Body Language Issue 67

dec/jan

67

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

HAIR TODAY THE LATEST NON-SURGICAL HAIR LOSS TREATMENTS ON THE MARKET

ANATOMY Dr Askari Townshend discusses best practice for safe injectable treatment

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FACE OF THE FUTURE Mr Rajiv Grover, Dr Nick Lowe, Dr Timothy Flynn and Dr Marina Landau offer advice

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FRESH FACED Dr Christoph Martschin examines hyaluronic acid skin boosters

body language I CONTENTS 3

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

7 NEWS

29 INJECTABLES

OBSERVATIONS

MESOTHERAPY AND ALOPECIA

Reports and comments

COMMISSIONING EDITOR David Hicks 020 7514 5989 david@face-ltd.com

14 MEDICAL

Alopecia can have a significant impact on a person’s life.

Dr Phillipe Hamida-Pisal summarises the use and effects of mesotherapy on alopecia

EDITORIAL ASSISTANT Arabella Tanyel 020 7514 5989 arabella@face-ltd.com SALES EXECUTIVE Monty Serutla 020 7514 5976 monty@face-ltd.com ASSISTANT SALES EXECUTIVE Simon Haroutunian 020 7514 5982 simon@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Dr Vishal Madan, Dr Nilofer Farjo, Dawn Forshaw, Dr Phillipe HamidaPisal, Toby Cobbledick, Richard Crawford-Small, Mr Rajiv Grover, Dr Nick Lowe, Dr Timothy Flynn, Dr Marina Landau, Dr Askari Townshend, Miss Zahida Butt, Mr Bijan Beigi, Dr Christoph Martschin ISSN 1475-665X The Body Language® journal is published six times a year by AYA Productions. All editorial content, unless otherwise stated or agreed to, is © AYA Productions 2014 and cannot be used in any form without prior permission. 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 5989. Editorial e-mail: editorial@ face-ltd.com Advertising: advertising@face-ltd.com Body Language can be ordered online at www.bodylanguage.net

ANDROGENETIC ALOPECIA TREATMENTS Dr Vishal Madan looks at the evidence base behind medical treatments for androgenetic alopecia

21 EQUIPMENT THE LIGHT SOLUTION Medications can be useful to treat pattern hair loss, however there are often issues with compliance and side effects.

Dr Nilofer Farjo discusses an alternative—low-level laser therapy

27 AESTHETICS MICROPIGMENTAION Scalp tattooing can be a successful way of disguising hair loss. Dawn Forshaw discusses how micropigmentation can benefit both men and women by offering a permanent solution for hair loss

32 PANEL Hair today There are many non-surgical cosmetic treatments for hair loss currently available—our expert panel debate the technique and benefits of PRP, micropigmentaion and mesotheapy

37 COSMETIC CONCEAL AND CONQUER Medicinal treatments alone may not always be the best course of action to treat hair loss.

Toby Cobbledick looks at the benefits of using cosmetics to support drug treatment

41 MARKETING DOES YOUR BUSINESS NEED AN APP? The way people interact with the internet has changed with

4 CONTENTS I body language

editorial panel

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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. 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.

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.

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.

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.

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.

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.

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.

Dr Raj Persaud FRCPsych is a consultant psychiatrist who has worked at the Bethlem Royal and Maudsley NHS Hospitals in London from 1994-2008, and as an honorary senior lecturer at the Institute of Psychiatry, University of London.

the proliferation of smartphones and tablets. Richard CrawfordSmall explains how you could boost your business by being tech-savvy

44 DEBATE FACE OF THE FUTURE Treatments to rejuvenate the face are ever evolving.

Mr Rajiv Grover, Dr Nick Lowe, Dr Timothy Flynn and Dr Marina Landau offer their advice on technique, product selection and results

FACIAL ANATOMY Understanding facial anatomy and good injection technique are vital for the provision of safe injectable treatments. Dr Askari Townshend offers his five key facts for best practice to avoid complications and achieve optimal aesthetic results

57 CASE STUDY THREAD LIFTS

ON THE MARKET

Miss Zahida Butt and Mr Bijan Beigi present a case report on the use of Silhouette Soft as a non-surgical option to treat facial nerve palsy

The latest products in aesthetic medicine

61 INJECTABLES

49 PRODUCTS

50 EDUCATION TRAINING A comprehensive course calendar for the industry

Dr Bessam Farjo MB ChB BAO LRCP&SI 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.He is a graduate of Guy’s and St Thomas’s Hospital, and trained at Johns Hopkins in the US and in Melbourne. He has a particular interest in the thyroid and menopause.

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, London, UK.

52 TECHNIQUE

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FRESH-FACED Dermatologist Dr Christoph Martschin examines the role of hyaluronic acid skin boosters in skin rejuvenation

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OPTIMAL

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INTEGRATION

Injectable Product of the Year 2013

1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150.

5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

BEL092/0314/FS Date of preparation: April 2014

Syneron Candela Launches Breakthrough Technology. Again.

Introducing PicoWay. PicoWay is a remarkably innovative dual wavelength picosecond laser from Syneron Candela, the most trusted brand in lasers. With both 532nm and 1064nm wavelengths, PicoWay can treat a very broad range of pigmented lesions and tattoo types and colors on any skin type.

PicoWay has the highest peak power and the shortest pulse duration of any picosecond laser for superior efficacy, safety and comfort. Proprietary PicoWay technology creates the purest photo-mechanical interaction available to most effectively impact tattoo ink and pigmented lesions, without the negative thermal effects of other lasers.

And, PicoWay has the reliability physicians want.

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Š2014. All rights reserved. Syneron and the Syneron logo are registered trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. PicoWay and Candela are registered trademarks of the Candela Corporation. PB85961EN

body language I NEWS 7

observations

MEDITERRANEAN DIET HAS POSITIVE LONG-TERM EFFECTS ON HEALTH Eating a Mediterranean diet and increasing exercise for only eight weeks still has measurable health benefits a year later, claims a new study Researchers at Sheffield Hallam University and the University of Lincoln showed that a combination of a Mediterranean diet and exercise improves blood flow in the endothelial cells in the inner lining of the blood vessels, even 12 months after completing an eight-week programme.

The study says improvements in endothelial cell function could reduce the risk of people developing cardiovascular disease.

The September 2014 study, published in the journal Microvascular Research, focused on healthy people aged between 51 to 59. Initially participants were split into two groups, one group ate a tradition Mediterranean diet consisting of vegetables, fruit, olive oil, tree nuts and fresh oily fish, and took up a moderate exercise programme. The other group only took up the exercise programme.

Both groups were assessed over an eight-week period.

The results showed health improvements over the eight weeks, however one year later, those health improvements could still be seen, even though the lifestyle changes during the study were no longer being followed. The improvements were greater in the group who also took on the Mediterranean diet than in the exercise only group, showing that nutrition plays a strong role in long-term health.

Researchers believe the lasting health benefits observed after such a short intervention could be due to molecular changes associated with the Mediterranean diet.

Lead researcher Dr Markos Klonizakis, a Research Fellow at Sheffield Hallam University, says, “Preserving a patient’s endothelial function as they get older is thought to reduce the risk of developing cardiovascular disease, so these findings are

very encouraging.

“Although exercise on its own can beneficial, other lifestyle factors such as nutrition play an important role as well. Considering the scientific evidence already out there that a Mediterranean diet offers health benefits, it made sense to examine how such a diet, when combined with exercise, could affect the small veins of our body due to their important role in our overall well-being, in the longer-term.”

Co-researcher Geoff Middle-

ton, Senior Lecturer in the School of Sport and Exercise Science at the University of Lincoln, adds, “With cardiovascular disease being on the rise, adding a huge burden to healthcare systems around the globe, it is important to find ways to reduce the number of cases.

Even a medium-duration intervention with a Mediterranean diet and exercise regime can promise longterm health benefits, especially in people at high risk of developing cardiovascular disease.”

8 NEWS I body language

events 29 JANUARY-1 FEBRUARY, IMCAS Annual World Congress 2015, Paris

DEC

Aesthetic & Clinical Conference, Orlando, Florida, USA W: orlandoderm.org

22 JANUARY, 8th Annual Oculoplastic 3-6 DECEMBER, Cosmetic Surgery Forum, Symposium, Atlanta, USA Las Vegas, USA W: sesprs.org W: cosmeticsurgeryforum.com 4-6 DECEMBER, The Cutting Edge 2014 Aesthetic Surgery Symposium, New York, USA W: thecuttingedgesymposium.com 4-7 DECEMBER, 12th International Darmstadt Live Symposium, Darmstadt, Germany W: live-symposium.de 5-6 DECEMBER, ICAM 2014, Dubai, United Arab Emirates W: antiageingme.com 6 DECEMBER, Aesthetics Awards 2014, London, UK W: aestheticsawards.com 9-13 DECEMBER, Journées Dermatologiques de Paris (JDP), Paris, France W: sfdermato.org 10 DECEMBER, International Lymphoedema Symposium, Neully sur Seine, Paris, France W: atoutcom.com 11-13 DECEMBER, Congrès annuel de la Société Française de Chirurgie Plastique, Reconstructrice et Esthétique (SOFCPRE), Paris, France W: plasticiens.org 11-13 DECEMBER, 5CC: Laser and Aesthetic Medicine, Hong Kong, China W: 5-cc2014.com 11-13 DECEMBER, International Conference of Regenerative Surgery, Rome, Italy W: regenerativesurgery.it 12-13 DECEMBER, International Live Surgery and Congress on Aesthetic Plastic Surgery, Amsterdam, Netherlands W: nvepc-livesurgerycongress.nl 12-14 DECEMBER, International SWAM AAAM Aesthetic Exhibition 2014, Jakarta, Indonesia W: swam-aaam.org 12-14 DECEMBER, Annual Meeting of the Japanese Society for Investigative Dermatology, Osaka, Japan W: jsid.org/english/

JAN

23-24 JANUARY, Fresh Cadaver Aesthetic Dissection Course on Facial Anatomy, Liège, Belgium W: dissectioncourse.com 23-25 JANUARY, 31st Annual Atlanta Breast Surgery Symposium, Atlanta, USA W: sesprs.org 24-25 JANUARY, Congrès de Médecine Morphologique et Anti-Âge, Paris, France W: sofmmaa.org 27-29 JANUARY, Big DiP 2015, London, UK W: bigdatapharma-europe.com 29 JANUARY-1 FEBRUARY, IMCAS Annual World Congress 2015, Paris, France W: imcas.com

FEB

6-7 FEBRUARY, 2eme Cours de Chirurgie de la Silhouette, Lyon, France W: imcas.com 12 FEBRUARY, South Beach Symposium 2015, Miami Beach, USA W: southbeachsymposium.org 12-14 FEBRUARY, 49th Annual Baker Gordon Educational Symposium, Miami, USA W: bakergordonsymposium.com 12-15 FEBRUARY, DERMACON 2015— National Conference of the Indian Association of Dermatologists, Venereologists and Leprologists, Mangalore, Karnataka, India W: dermacon2015.com 12-16 FEBRUARY, South Beach Symposium, Miami, Florida, USA W: southbeachsymposium.org/IMCAS 12-18 FEBRUARY, The American Brazilian Aesthetic Meeting, Park City, Utah, USA W: americanbrazilianaestheticmeeting.com 26-28 FEBRUARY, 6th ISDS Spring Meeting, Cartagena, Colombia W: isdsworld.com 26 FEBRUARY-1 MARCH, AESURG 2015 - Annual Conference of the Indian Association of Aesthetic Plastic Surgeons, Neemrana, India W: iaaps.net

14 JANUARY, Toxins 2015—Meeting of the International Neurotoxin Association, Lisbon, Portugal W: neurotoxins.org

27 FEBRUARY-1 MARCH, Study Group of Cosmetic Dermatology, Indonesia W: perdoski.org

16-19 JANUARY, Orlando Dermatology

Send event dates for consideration to arabella@face-ltd.com

STUDY FINDS REPEATED BOTOX USE TO BE SAFE Research shows continuous Botox treatments over many years is safe and effective At the 2014 American Society for Dermatology Sugery (ASDS) Annual Meeting, a new study by ASDS member Alastair Carruthers of Carruthers Derm Centre in Vancouver, was presented, concluding that using Botox to treat facial wrinkles over a prolonged period of time is safe and still effective.

The study, published in the Journal of the American Academy of Dermatology, also maintains that Botox is safe to use alongside other aesthetic treatments and that long-term patients are satisfied with the results.

Researchers interviewed nearly 200 patients treated with Botox for five or more continuous years between 1999 to 2012. Patients were an average age of 46 at the time of their first treatment and received at least one treatment each year for glabellar frown lines. Carruthers says, “Self-perception of age is a very simple way of judging results,” Carruthers said. “We found that the longer patients were treated, the younger they perceived themselves to look.”

Patients had 5,112 total treatment sessions, averaging two or more treatments each year over an average of nine years, although some has received treatment for as long as 16 years. Researchers reviewed the

records for the facial areas treated, number of treatments, dosage for each facial area, whether the patient had other facial aesthetic treatments and any Botox-related adverse events.

Although long-term patients were satisfied with the treatments, the researchers’ objective looked beyond happiness with the outcomes.

“We wanted to look at real life – how this treatment has been incorporated into patients’ lives and how treatments themselves have changed over time,” says Carruthers. “Doctors now use less Botox per treatment session to treat horizontal forehead lines. We are able to produce a more natural result.”

85 percent of the patients in the study group received soft-tissue filler treatments and many had other facial aesthetic treatments over time, including intense pulsed light therapy. Adverse effects from combining Botox with other treatments were infrequent and mainly mild, declining markedly over the first year of treatment.

Carruthers says “This retrospective provides extensive data on the progression of patients’ aesthetic treatments plus clinical trends during the period of widespread adoption of injectable aesthetic treatments to reduce facial lines and wrinkles. Over the years, we’ve learned to make our treatments better and more effective.”

Seeking an expert, such as a dermatologist or dermatologic surgeon, for wrinkle-relaxing cosmetic medical procedures is still incredibly important. “We say in our office, ‘Shop for your shoes, not for your face.’ This is where you live,” says Carruthers.

Botox has always had a number of medical uses and is now being used to treat conditions such as depression. “Botox keeps getting more and more interesting,” Carruthers says.

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body language I NEWS 11

ISAPS WARNS PATIENTS ABOUT UNLICENSED COSMETIC PROCEDURES The International Society of Aesthetic Plastic Surgery (ISAPS) issues a warning regarding unlicensed practitioners and medical tourism ISAPS have called for advocacy and changes to global legislation, warning people who go looking for inexpensive cosmetic surgical procedures, particularly abroad, to be aware of practitioners operating without board certification.

ISAPS is calling for worldwide changes after two UK citizens died having travelled abroad to have cosmetic procedure performed by uncertified practitioners. Their goal is to address these unnecessary deaths to ensure a higher level of patient safety.

“Cosmetic surgery abroad can be incredibly risky because the standards vary from one country to the next. It is essential that patients find boardcertified plastic surgeons, regardless of where they have a procedure performed,” notes Susumu Takayanagi, MD, President of ISAPS. “Patient safety is our highest priority.

ISAPS membership is exclu-

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sive to board-certified plastic surgeons who must be current members of their national plastic surgery society.”

The ISAPS symbol of patient safety was established over five years ago. It is represented by a diamond comprised of four factors, critical to safe aesthetic plastic surgery practice. These factors are: Procedure: Choose a procedure that is right for you. Do thorough research and have realistic expectations. If you’re having multiple procedures performed, make sure the surgery can be completed in a safe amount of time.

Patient: It is essential that your plastic surgeon conducts a medical screening to determine whether you are at risk for complications or are a poor candidate for aesthetic surgery. Disclose any health issues and/or previous procedures you’ve had.

Surgeon: Choose a plastic surgeon who is board-certified

second brief

CAMERA SHY According to a recent survey, 76% of people would be unhappy to have a photograph taken of them, due to dissatisfaction with their appearance.

The survey also uncovered that 66% of 30-39 year old respondants were unhappy with their appearance, and being unhappy with appearance prevented 32% of women from posting on social media, and 27% of men from going on a date.

Over a fifth of participants felt that appearing to have aged affected their confidence, and 69% stated that facial sagging and wrinkles aged a person the most.

However, 80% would not consider having surgery, mainly due to cost and safety concerns.

Source: Sinclair IS Pharma

with experience in performing the procedure you would like and who has an excellent safety record. Verify their training credentials with the medical board in the surgeon’s country.

Surgical setting: Standards vary among countries. If your surgery will be performed in a hospital, make sure that the hospital is certified or accredited. Ask for certification information and the name of the certifying body.

Michael C. Edwards, MD, chair of the ISAPS Patient Safety Committee and president of the American Society for Aesthetic Plastic Surgery says, “Patients fall prey to unlicensed physicians because of the misconception that anyone with an MD can safely perform any surgical procedure.

There is a need for countries to establish strict regulations controlling who can perform plastic surgery procedures and the surgical setting in which

they are performed in order to reduce surgical complications and deaths.”

Nigel Mercer, MD, president of the European Association of Societies of Aesthetic Plastic Surgery (EASAPS), deputy president of the British Association of Plastic Reconstructive and Aesthetic Plastic Surgeons, and former president of the British Association of Aesthetic Plastic Surgeons states, “Any patient who is planning to travel long distance for aesthetic surgery must be made aware that they are putting themselves at additional risk over and above the risks that they would face finding a certified surgeon closer to home.

“If they insist on traveling to another country, it is imperative that they choose a licensed surgeon who will provide them with service, post-operative care and advice, not just an operation. The only way to find board-certified surgeons internationally is on the ISAPS website. Patients should also be advised to ask the practitioner what insurance the surgeon carries in case they face complications following their procedure(s).”

12 NEWS I body language

PROCESSES OF CARE FOR BREAST RECONSTRUCTION IMPROVED BY CENTRALISATION Recent study shows that the centralisation of breast cancer care into a comprehensive breast centre (CBC) has a positive impact on care processes Published in the November issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS), the study suggests that centralised breast care in CBC’s can lead to more timely breast reconstruction for people undergoing surgery for breast cancer.

Albert H. Chao MD and his colleagues from Ohio State University reviewed their hospital before and after opening a CBC and found a significant improvement in the quality of care for women undergoing breast reconstruction after the CBC was opened. They said, “Access to breast reconstruction at our institution improved significantly after our CBC opened, with significant increases in internal referral rates and immediate reconstruction rates.”

The researchers evaluated postmastectomy breast reconstruction between 2009 and 2013, two years before and two years after the CBC was opened. The study compared 614 women treated for breast cancer before the CBC transition and 750 women treated afterward.

SURGEONS SHOULD PUBLISH SURGICAL OUTCOMES Sir Bruce Keogh calls for transparency to encorage surgeons to improve performance Sir Bruce Keogh’s has said that surgeons have a ‘moral responsibility’ for transparent operation results, as a website is launched which contains

After the CBC transition, patients were more likely to be referred to a plastic surgeon by a surgical oncologist for breast reconstruction and were referred more quickly. The referral rate increased from about 27 percent to 46 percent and “the time between surgical oncology consultation and plastic surgery consultation decreased from 10.5 days to 3.6 days,” say the researchers.

Patient care and outcomes are improved at CBCs by having highly specialised practitioners such as oncologists, plastic and reconstructive surgeons, all in the same place to provide coordinated breast cancer care. The researchers noted that their CBC approach was “financially sustainable” despite investments in resources.

With specialists working in tandem they found that the percentage of patients who saw that breast cancer surgeon and plastic surgeon on the same day increased from 6.5 percent before the CBC was opened, to 50 percent afterwards.

After the hospital took on the CBC approach the time between the plastic surgery visit and mastectomy/breast reconstruction decreased from about 42 days to 30 days. The rate of immediate breast reconstruction for women who underwent mastectomy also increased from about 40 percent to over 52 percent.

Improving processes of care such as having more patients see a surgical oncologist and plastic surgeon on the same day helps patients to move forward quickly but also reduces negative impacts on the patient. Dr Chao and colleagues write “A new diagnosis of breast cancer can be distressing for a patient, and every day that passes between the time the diagnosis is made and the time treatment is administered can increase a patient’s anxiety.”

They conclude, “In breast reconstruction, a comprehensive breast centre improves processes of care, and underscores the importance of plastic surgery involvement within these centres.”

data on outcomes for 5,000 surgeons.

This new website, called My NHS, allows patients to search for the results of their potential hospital and surgeon with data collected by the surgical associations themselves.

The data currently covers 10 of the 13 surgical specialities and will be updated to include all shortly. There were only three surgeons who had a lower outcome than what is considered normal.

John MacFie, president of the Federation of Surgical Specialty Associations, has said “There is now good anecdotal evidence that shows publishing this data has encouraged risk-averse

behaviour, which is not in the interest of patients. I believe that the data should only be published after any concerns in a surgeon’s performance have been investigated.”

However Keogh believes that publication will encourage surgeons to try to improve.

The Royal College of Surgeons president Clare Marx said “Patients and surgeons should have honest and open conversations about the likely outcome of their surgery and best treatment options available. Publishing consultant outcomes is just one step for ensuring that dialogue and trust is present.”

novacutis

14 MEDICAL I body language

Androgenetic alopecia treatments DR VISHAL MADAN looks at the evidence base behind medical treatments for androgenetic alopecia

B

roadly speaking alopecia is of scarring and non-scarring varieties. The scarring variety of alopecia is usually, but not always, irreversible whereas non-scarring variety of alopecia is usually, but not always, reversible. Of all the forms of non-scarring or noncicatricial alopecias, the androgenetic alopecia is the most common, making 95% of the cases.

The terminal hair shaft is usually around 60mm and the vellus hair, which is a finer hair, is around 30mm.

So there is usually a transition between

the terminal to the vellus hair and this process is called miniaturisation.

In men, as well as in women, this is facilitated by dihydrotestosterone (DHT) which is a hormone seen around the hair follicles. The normal ratio of terminal to vellus hair is around 7:1, but in androgenetic alopecia, it is reduced to 2:1.

Male androgenetic alopecia (MAGA) is perhaps one of the commonest causes of cosmetic concerns for men. It affects about 80% of men around the age of 70 years, so there is usually a bitemporal hair

loss in someone who’s in their 30s.

As you grow slightly older, you see that the hair loss becomes a bit more aggressive and it can involve the crown but spares the occipital scalp.

Why does this happen? Because miniaturisation is thought to be induced by the conversion of testosterone DHT by the enzyme 5Îą-reductase which works on androgen receptors which in turn are present in 30% more concentration in the frontal scalp as compared to the occipital scalp. So, higher 5Îą-reductase activity in the frontal

body language I MEDICAL 15

40% which is quite significant.

If it’s seen in teenage years, girls have a higher incidence of hair loss as compared to boys. When that happens, you’ve got to start investigating them endocrinologically and see if they have a late onset congenital adrenal hyperplasia.

The risks of depression are much higher in women as compared to men, but interestingly, if you treat the female pattern hair loss, the reverse is also true. More women will have uplifted mood after treatment as compared to men.

Evidence-based treatments include androgen-dependent and androgenindependent methods

scalp means higher the degree of frontal hair loss.

In female androgenetic alopecia (FAGA), there is a slight difference in the morphology in the form of progressive reduction in the hair density. It spares the frontal and the occipital but the parting and crown reduce in thickness.

As with men, the difference is in the five alpha-reductase, but there’s another enzyme at work called the aromatase. This converts the testosterone to oestrogen, or estradiol or estriol—the forms of oestrogen.

This means there is less of the testosterone available to be converted to DHT and so less hair loss in the frontal scalp.

Females have 3 to 3.5 times less 5α-reductase than men but aromatase levels are significantly higher in the hair follicles of women and also six times more in the frontal follicles and four times more in the occipital hair follicles, which may explain why women usually retain their frontal hairline in contrast to men with pattern hair loss.

The incidence of hair loss in women can be underestimated. In women over 70 it can be about 30-

Finasteride There are lots of treatments to mention but evidence-based treatments include androgen-dependent (dependent on the testosterone, the DHT, the five alpha-reductase and the aromatase), and androgen-independent methods.

One of the most common medications currently prescribed is finasteride, used for prevention or reversal of hair loss in men. This was the first drug that was approved by the FDA in 1997 for hair loss.

It works on the five alpha-reductase, but there are two isomers of five alpha-reductase—type one and type two. Type one is present in the liver, in the skin and the scalp and type two is present in the prostate, genitourinary tract and also in the skin. Finasteride blocks the type two five alpha-reductase which reduces the conversion of testosterone to DHT resulting in 70% reduction of DHT in serum.

What’s the evidence behind the efficacy? Two thirds of patients will experience some improvement in their hair loss and this can be quantitated to approximately 30% if you take finasteride 1mg for about one year. The efficacy can start appearing within four to six months, but the best effects are usually seen at around one year.

The vertex usually responds

better to this treatment, compared to the frontal parietal areas. After two years the crown area can gradually thicken, there is reversal of miniaturisation of hair in some patients.

What about use of finasteride in women? You would not want to use finasteride in women of childbearing age because there is potential for teratogenicity. There’s also a risk of feminisation of the male foetus and presence of ambiguous genitalia because it’s a very potent antiandrogen.

However, in postmenopausal women, if there is androgenetic alopecia associated with high androgen levels, there is good evidence of efficacy of finasteride. In these cases, one would have to increase the dose from the standard dose of 1mg to 2.5 or even 5mg.

You would usually advise patients to take 1mg tablet of finasteride with or without food. It’s metabolised through the liver, however there are no known interactions with other drugs which are metabolised through the liver. If someone’s got renal impairment, there is no need for dose adjustment.

There is no need for barrier contraception in pregnant women despite it being a very potent feminising drug as the amount secreted in semen, even on patients taking 5mg finasteride, is miniscule.

Men who are taking finasteride should not be donating blood and pregnant women should not handle crushed tablets or broken tablets.

Patients who would want to switch from minoxidil to finasteride should overlap drugs for a period of at least three to six months, otherwise they can see accelerated hair fall.

There are two formulations of finasteride available—1mg and 5mg.

Side effects One of the most worrying factors associated with use of finasteride

66 Male androgenetic alopecia is one of the commonest causes of cosmetic concerns for men—it affects about 80% of men around the age of 70 years 99

16 MEDICAL I body language

Oral medications can be prescribed for prevention or reversal of hair loss in men

are the adverse effect on the sexual health. According to the American Urological Association’s own guidelines, there is clear evidence of erectile dysfunction in up to 8%, of men, and loss of libido in up to 5% with high dose finasteride, but not with doses used in AGA where it is likely to be much smaller risk.

This is true with both finasteride and dutasteride.

The patient information leaflet was updated in 2011 to mention that there is difficulty in achieving an erection which continues up to three months after stopping the drug. Although these figures are pretty high with the higher dose finasteride such as that used in benign prostatic hypertrophy, the incidence is generally much lower with 1mg dose taken daily.

Other disorders such as testicular pain, ejaculation disorders and abnormal ejaculation volume are also side-effects associated with the use of finasteride.

One of the other major issues around finasteride was the fear that it can actually mask the signs of aggressive prostatic carcinoma. Finasteride is used for benign prostatic hypertrophy and recent studies have proven that actually it may have a protective effect on prostatic carcinoma.

What it does do, however, is reduce the PSA levels or the prostatespecific antigen levels which are used for monitoring BPH and for monitoring prostatic carcinomas. So if you are starting somebody on finasteride who’s older than 40 with a family history of prostatic carcinoma, it’s advisable to do serial PSA levels, maybe once every year. If someone has been on finasteride, you should

double the reference range for PSA in monitoring that patient.

Other side-effects include gynaecomastia. There was a fear about male breast carcinoma being induced by finasteride and studies have now shown that there are 50 worldwide case reports of breast carcinoma associated with use of finasteride.

However in these 50 cases, only three patients were on finasteride 1mg and it happened very soon after initiation of this treatment, so there is no causal relationship between the two. It would make sense, however, that if you have a patient on finasteride who complains of breast tenderness or abnormal mass, you are very swift in investigating that.

Dutasteride Dutasteride is a more potent inhibitor of 5α-reductase. So whilst finasteride is acting against type two, this is acting against type one and type two. Finasteride redues the DHT level in blood by 70%; dutasteride reduces it by 90%.

With regards to the efficacy, the standard dose of 0.5mg is equal to finasteride 1mg and 5mg and this is the one that’s been licensed for use in MAGA. Of the patients who are only taking finasteride, about 30% to 50% of them will have no improvement.

A study published online in June this year that showed that 35 Korean men who were on finasteride had no response. They started taking dutasteride at the recommended dose of 0.5mg per day and 24 out of the 31 who completed the study showed improvement (17 slightly, six moderately, one markedly. So

dutasteride may have a role to play in finasteride-resistant patients.

This is a drug which acts systemically, so how can you reduce the potential side-effects? You could formulate a topical solution, and inject as mesotherapy, but there are no convincing studies which suggest this is effective.

However, there is some evidence as to the effectiveness of this method.

Spironolactone Now we move onto the androgen receptor antagonists. These are drugs such as spironolactone, cyproterone acetate and flutamide.

Spironolactone is my preferred medication for treatment of androgenetic alopecia, and also patients with polycystic ovarian syndrome with hirsutism and acne. It’s the most commonly used, off-licence medication because we’ve got extensive experience of using this medication in hypertension.

It’s a potassium-spreading diuretic which is structurally an antagonist of aldosterone and has got a steroid-like structure so it works like aldosterone and also like testosterone. It’s recognised that spironolactone at a dose of 50 to 200 shows a good improvement.

There is a study which showed there was about 44% improvement in patients on long-term spironolactone.

The problem with spironolactone is because it’s a potassiumspreading diuretic, you have to monitor potassium levels and ensure that blood pressure’s maintained. There are also other issues such as liver problems.

In rat studies, there has been evidence of tumours, but this not transpired in human beings so far.

There is also a risk of menstrual abnormalities in these patients because it’s an antiandrogen.

Cyproterone acetate Another drug is cyproterone acetate, available as Dianne in the US and Dianette in the UK. Again, this is an inhibitor of the androgen receptor and reduces the testosterone levels by suppressing both the luteinising hormone, and the follicle-stimulating hormone.

This is a very good drug for patients who have polycystic ovarian disease, patients who have acne

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18 MEDICAL I body language

and patients who have hirsutism.

It’s been used on its own or in combination with ethinylestradiol for the treatment of FAGA. The recommended doses are 50 micrograms of ethinylestradiol and 2mg of cyproterone acetate. More often in the UK, it’ll be combined with ethinylestradiol as an oral contraceptive pill.

There are excellent case reports and studies which show that there is usually an improvement in the hair count in patients who go on Dianette. But the side effects are weight gain, mood disorders and deep vein thrombosis.

People who are on this medication for more than five to six years and have got a family history of DVTs need to come off it. They can get migraines, fluid retention and liver toxicity. Similar to the problems you can get with spironolactone.

Non-FDA approved topical hormonal agents Alfatradiol is a medication that has shown to increase the number of hair follicles, but in other studies it has reduced the number of hair follicles—the data is ambiguous.

Fluridil is available in some European countries and is also a topical anti-androgen and has had some reports of efficacy. Fulvestrant, a pure estrogen receptor antagonist used as an anti-estrogen therapy in patients with hormone receptorpositive metastatic breast cancer has also been evaluated.

Minoxidil Minoxidil works through an androgen-independent mechanism.

It’s one of the first topical agent licensed for use for male and femalepatterned alopecia.

This was an oral antihypertensive and one of the side-effects was that nearly everyone who took this medication had some degree of facial hair growth and scalp hair growth. For this reason it was quickly transformed into a topical preparation.

The way it works is still not very clear but there can be different mechanisms of action. It can open the ATPase–sensitive, potassium channels resulting in increased blood flow. It also stimulates the vascular endothelial growth factor, and promotes

growth promoters in the dermal papillae, which is where you want the hair follicles stimulated from.

It also acts on the prostaglandin endoperoxidase synthase, which leads to an increase the PGE2.

Manufacturers claim that it stimulates the hair follicles from arresting; that is the telogen to the anagen phase.

So minoxidil, like finasteride, can modulate the hair cycle by promoting the telogen hairs to go back into the anagen phase. Not only that—it also increases the length of time the hair will be in the anagen phase. They also claim that it reverses follicle miniaturisation bit this hasn’t actually been substantiated.

It’s available as two different formulations for use in male-pattern hair loss—2% and 5% solutions.

60% of men show some improve-

ment with the 5% formulation, and 40% show some improvement with the 2% formulation.

On the 5% formulation you will get about 12% increase in their hair growth. The patients who get a 40% increase on the 2% will get somewhere around 8% hair growth. So clearly the 5% solution is of higher efficacy than the 2% solution.

However, the 2% solution is the only one that’s been licensed for use for FAGA. There’s clear evidence of a statistically significant amount of hair growth in patients who are using a minoxidil for 24 weeks of treatment. You can quantify by the number of hairs per square centimetre, which in this case would be around 13-14.

The new formulation which is the 5% foam has distinct advantages because it doesn’t trickle

With regards to the female androgenetic alopecia, we know that the 2% solution is better than the 1% but we also know that the 2% solution is equal to the 5% solution—there’s little benefit in women using the higher potency minoxidil

body language I MEDICAL 19

down, so the risk of hypertrichosis on cheeks is lower. It also contains glycerin rather than propylene glycol which reduces the sensitivity on the scalp.

Practical considerations You should advise patients to use the drug at least two hours before they go to bed. The drug has to be in the scalp for at least four hours before they wash it off and it should be used on a dry scalp.

Patients should use 1ml of the lotion, twice a day. For people who want to be absolutely precise, it’s 25 drops. With the foam, it’s half a capful, twice a day. Patients may want instant results but you’ve got to warn them that the results may not come through by four to six months.

With regards to the female androgenetic alopecia, we know that the 2% solution is better than the 1% but we also know that the 2% solution is equal to the 5% solution.

So there’s little benefit in women using the higher potency minoxidil.

The 5% foam, however, is equal to the 2% solution. So again, the 2% solution is the best for women.

Patients also have to be warned that once they start using minoxidil, they will notice transient hair shedding in the first month. This happens because it’s synchronising the hair cycle. It’s pushing the telogen hair into the anagen phase.

The hair follicles which were at the last state of the telogen will fall off or shed, which can be quite alarming for patients. If you discontinue minoxidil, your hair, which you’ve noted an increase in, will fall off in four to six months’

time. Some of my colleagues who do hair transplant work will advise patients who’ve been on minoxidil that it’s advisable for them to stop the minoxidil two to three days before the procedure to prevent contact sensitivity.

Side-effects The most common is contact dermatitis and it’s likely to be irritant contact dermatitis rather than a proper allergy. If a patient has persistent problems, there are two things you can do. One is to send them for patch testing to someone like me.

If they are allergic to propylene glycol, then you can use butylene glycol, glycerin or polysorbate, which are less irritant than propylene glycol.

We already touched on facial hypertrichosis which can easily be treated by discontinuation of the drug and laser hair reduction. It’s something that works on the tachycardia and teratogenicity. We don’t know whether it actually causes problems with the foetus and therefore it’s best not to prescribe to patients and or be used by patients who are pregnant.

However the American Paediatric Society does not think that it’s something that should be stopped during breastfeeding because the amount excreted in the bloodstream or in the breast milk is very, low.

Prostaglandin analogues Prostaglandin analogues are the new kids on the block. They came about through the treatment of glaucoma, an eye condition with increased ocular pressure. Patients

started noticing increase in their eyelash numbers, thickened and darker eyelashes and eyebrows.

They started doing studies looking at the PGE2 and F2, which induce hair growth whereas the PGD2 actually reduces hair growth.

Ketoconazole, available as Nizoral is an imidazole antifungal drug. Why would it work for androgenetic alopecia? There are several theories. One of them is it’s an anti-inflammatory so that might help. It has probably got a local disruption of the DHT cycle but we’re not so sure.

There is certainly a synergistic effect if you use this drug along with minoxidil or finasteride. I’ve no experience of the use of melatonin but studies have clearly shown a lot of benefit in their patients. This has not reached the market so make what you will of this.

In summary, I think the best evidence in both MAGA and FAGA is with the use of topical minoxidil – 2% and 5% lotion and 5% foam, finasteride and dutasteride. I feel that combination therapy is the most effective, and there is clearly a place for these medications along with the surgical management of hair reduction.

Dr Vishal Madan is a Consultant Dermatologist, Laser and Dermatological surgeon at the Salford Royal Hospital NHS Foundation Trust and honorary senior lecturer at the University of Manchester.

W: manchester-dermatologist.co.uk References Sinclair R, Wewerinke M, Jolley D. Br J Dermatol. 2005;152: 466–73

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body language I EQUIPMENT 21

The light solution Medications can be useful to treat pattern hair loss, however there are often issues with compliance and side effects. DR NILOFER FARJO discusses an alternative—low-level laser therapy

The actual beam can be a continuous beam or a pulse beam, but the main difference between the lasers that have been developed is how they’re presented

T

he indications for treating pattern hair loss with non-surgical interventions include young patients, patients in the early stages of hair loss, female patients and also to prevent shock loss after surgery. Approved medications for this purpose fall into two categories; hair growth stimulators, such as minoxidil, and androgen modulators, such as finasteride.

However, the main problems that we get with patients and medication are the issues of compliance and side effects. This is either the actual worry of them or developing the side effects themselves.

So what about low-level light or laser therapy as an alternative?

There are a number of different terms that have been used, either in the media or in clinical papers such as cold laser therapy, laser biostimulation and phototherapy but they are all the same thing. The indications to use these lasers for pattern hair loss are the same as those you may treat with medications.

Cold lasers are all low-powered laser diodes and classed as 3R lasers. The wavelengths that we use for treating hair loss are usually in the region of 630nm to 670nm, although a wider range has been used

as well. The actual beam can be a continuous beam or a pulse beam, but the main difference between the lasers that have been developed is how they’re presented. So they can be constructed like a hood (similar to a salon hairdryer), a laser comb or a cap that has embedded lasers in it.

In the past, these lasers have been controversial because until the last couple of years, there were no controlled, blinded studies in their use in hair loss. Most clinics that were promoting them were using laser treatment in combination, either with minoxidil or finasteride, and getting good results.

But we didn’t know whether it was the medication or the laser that was actually producing these results.

Low energy lasers Looking at tissue response to lasers in general—if you use a high energy laser, you get ablation of tissue which is fully destructive. An example of this is the carbon dioxide resurfacing laser that a lot of dermatologists use for facial skin rejuvenation. Medium energy lasers create a thermal or heat effect and you get direct tissue effects as well.

An example of this is a pulsed dye vascular laser.

The low energy lasers, however, create a photochemical reaction which produces an indirect tissue effect similar to how photosynthesis acts via the mitochondria. Mitochondria are present in almost all cells in the body and they are the cellular power plants. Normal mitochondrial function is undoubtedly crucial in hair growth and inhibition of the normal mitochondrial function may play a role in hair loss.

Looking at the mechanisms of action, photobiology is based on photons that absorb the light from the lasers. The chromophores are the light-absorbing molecules in the mitochondria and they activate cytochrome c oxidase. This enzyme is part of the mitochondrial respiratory chain which produces transcription factors. The activation of these transcription factors can alter gene expression, either up-regulating or down-regulating.

It increases cell proliferation, cell migration and adhesion of cells and it decreases cell apoptosis or cell death.

The optimum treatment duration for the low level light therapy in hair loss still needs to be established.

It is possible that there is a biphasic dose response that happens, so

22 EQUIPMENT I body language

a little light can be good and a lot of light can actually be detrimental.

This has been established in studies that have been done in other applications of low-level light, like bone and wound healing.

Laser devices Some of the current devices are FDA cleared, and one of them is the HairMax laser comb. This has 12 lasers each illuminating between 4mm2 and 9mm2. They’re used as 15 minute treatments, which equates to about 225 movements of the comb, once every four seconds.

You get about a third of the scalp exposed to the light in about 15 minutes so the advice is to use it from the front to the back and move all over the areas that can go bald. It’s recommended to use it every other day, but it does mean that over a week each part of the scalp is only getting four seconds of laser exposure.

There is a published trial in the American Journal of Clinical Dermatology using the laser comb which studied 128 men and 141 women who were randomised into three treatment groups. They had different numbers of beams in the laser combs (seven, nine or 12 beams) and they also had a placebo group.

Patients used the combs three

times a week for 26 weeks and the measurements that were done in the study were terminal hair density, first at baseline and then at 16 and 26 weeks.

They concluded that there was an increase in terminal hair count, which was comparable to the shortterm trials of topical 5% minoxidil and 1% finasteride. However, they became less efficacious in longterm trials, with the medications showing better results.

Several helmet type devices have been studied against placebos, one in particular showed 47% in global photography (40 patients, 24 weeks, daily treatment for 18 mins) and another showed 35% increase in hair counts (44 males, treatment every other day, 16 weeks).

Another type of device is the laser cap. This is a device with 224 diodes which is fitted underneath a baseball cap so that it can be worn at any time of the day even when out jogging. There is currently a multi centre trial taking place with this device using the cap for 30 minutes every other day for six months. The results will be based only on global photography.

Although the trial is not yet complete, initial results indicate mild to moderate improvement.

In conclusion, basic science

pathophysiology and clinical evidence of efficacy is currently sufficient to justify selective adaptation of this technology in treating genetic hair loss. LLLT can be used either alone, in combination with medications or with surgery.

However the treatment duration and optimum wave length still do need to be established as people are using significantly different treatment modalities.

Devices on the market include laser hoods, combs, helmets and caps

Dr Nilofer Farjo runs The Farjo Hair Institute in Manchester and is past Editor of Hair Transplant Forum International.

References 1. Joaquin J. Jimenez, Tongyu C. Wikramanayake, Wilma Bergfeld, Maria Hordinsky, Janet G. Hickman, Michael R. Hamblin, Lawrence A. Schachner. Efficacy and Safety of a Low-level Laser Device in the Treatment of Male and Female Pattern Hair Loss: A Multicenter, Randomized, Sham Device-controlled, Double-blind Study. American Journal of Clinical Dermatology: April 2014, Volume 15, Issue 2, pp 115-127 2. Kim et al. Low-Level Light Therapy for Androgenetic Alopecia: A 24-Week, Randomized, Double-Blind, Sham Device–Controlled Multicenter Trial. Dermatologic Surgery 3. Lanzafame et al. The Growth of Human Scalp Hair Mediated by Visible Red Light Laser and LED Sources in Males. Lasers in Surgery and Medicine 45:487–495 (2013)

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24 ADVERTORIAL I body language

Automated FUE hair transplant DR FRÉDÉRIC MENU was one of the first doctors to propose the S.A.F.E.R./NeoGraft procedure in his clinic. He describes the features and benefits of the device

T

he S.A.F.E.R./NeoGraft patented medical device was developed by the French company MEDICAMAT, worldwide leader in automated hair transplant with an international experience of more than 20 years in the hair restoration field. I myself have more than 10 years of experience, and performed several hundreds of hair transplants surgeries using this device.

The main advantage of the system and its associated technique is to automate the manual follicular unit extraction (FUE) procedure.

This medical device performs both the extraction according to the FUE technique and the implantation. It offers three hand pieces powered by electro pneumatic controls.

The extraction hand piece It consists in an autoclavable hollow shafted contra angle on which is fixed a motorised punch with a rotation system (five diameters: 0.8, 0.9, 1, 1.25 and 1.40 mm), and a controlled pneumatic negative pressure to smoothly extract every single graft from the donor area, into a micro flask fixed on the hand piece.

The extraction hand piece su-

66 This medical device performs both the extraction according to the FUE technique and the implantation 99

perficially penetrates the patient’s skin, until the arrector pili muscle is cut ( ≈ ≡ 2mm deep). This superficial penetration avoids any risk of graft transection or trauma, allows a better quality (more cells around the graft) and a dramatic reduction of the time of surgery.

The implantation hand pieces It consists in a hollow needle (diameter 0.8mm and 1mm) surmounted by a piston allowing the operator to gently implant the grafts into the pre-made incisions in the bald area with extreme precision and without any ‘popping’ risk, using positive pneumatic pressure. The two implantation hand pieces connected to the device allow two operators to simultaneously plant, substantially reducing the duration of surgery.

Benefits of the S.A.F.E.R./ NeoGraft technique • Minimally invasive procedure, highly improving the accuracy of hair follicles harvesting • The device enhances the speed, efficiency and quality of hair transplant procedures • After mastering the device, I was able to reach a transection rate close to 0% • I am able to focus only on the aesthetic quality and naturalness of the surgery • I dramatically reduced the duration of my surgeries: more than half the time compared to manual FUE • Even though I work with an assistant to help me implant the grafts, it is possible to work alone.

Summary The device features allow me to concentrate all my efforts on the artistic quality and naturalness of

the final result for every patient. It also makes the patients and I save a lot of time and energy. The accuracy of the hair extraction and the results are so much better, patients are now able to reach their goal with less time in the procedure room or fewer FUE procedures. I think it was the breakthrough we were all waiting for in the hair restoration field.

Dr Frédéric Menu, member of the ISHRS and based in Cannes, France

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body language I AESTHETICS 27

Micropigmentation Scalp tattooing can be a successful way of disguising hair loss. DAWN FORSHAW discusses how micropigmentation can benefit both men and women by offering a permanent solution for hair loss

W

hen someone looses their hair scalp tattooing is an option to be considered.

The first choice for anyone if they are suitable and have the funds is a transplant. If they do not have enough hair then a combination procedure of transplant and tattooing can be considered.

Daily solutions are sprays and creams to stain the scalp or to wear a wig or a hairpiece.

More and more people are turning to scalp tattooing as the long term solution for hair loss.

Scalp tattooing offers a choice.

Much like semi-permanent makeup can balance and enhance facial features hair simulation tattooing can correct and disguise hair loss and fine/thinning hair.

In much the same way as

SPMU, or medical tattooing for camouflaging scars, a micropigmentation device is used to implant pigment into the scalp to replicate hair follicles or to stain the scalp.

It can offer a long term solution for men with male pattern baldness who wish to recreate a buzz-cut look.

It can offer answers for women with diffused hair by staining the scalp with pigment that gives the illusion of density, or can help infill thinning and receding hairlines with simulated It can offer answers for men and women who have lost their hair through accident, injury or post surgery. This is done by first dry needling the scalp to prepare the canvas for skin camouflage pigment followed by implanting replicated hair follicles.

All of the above offer long term

Process and before and after, showing results of micropigmentation treatment

solutions that do not wash off or need to be re-applied daily, which can greatly help boost a person’s confidence by knowing their hair loss problem will be less noticeable.

Anyone considering scalp tattooing must understand that it is treatment that offers a long term answer, not a permanent solution.

Colour adjustments, removal and adjustment as well as colour reboosting session once a year is all that is required to keep the look realistic and natural.

As with all micropigmentation procedures scalp tattooing treatment falls under the Tattooing of Minors Act, so certain regulations apply.

Tattooing a scalp is the hardest of all micropigmentation procedures for a trained specialist to learn. Combined skills from the worlds of transplantation, hairdressing and beauty must combine to ensure a specialist can offer their client realistic procedures for hairline placement for age appropriate hairlines to full head coverage and colour stability.

The scalp is on display 24/7 so there is no room for error.

Many good scalp tattooing procedures go unnoticed. Many bad procedures cause distress for the client and can damage what is a ‘growing’ industry.

Hair loss tattooing is not limited to the scalp. If a patient is missing hair anywhere on the body where they wish 24/7 coverage micropigmentation can offer them a solution. It can be offered as a procedural choice to patients with burns or scars who wish to camouflage an injury, or for men and women with alopecia to create realistic hair simulated eyebrows or infill sideburns.

Dawn Forshaw runs the Finishing Touches Group who provide training in medical tattooing, W: finishingtouchesgroup.com

SoMUK

Society of Mesotherapy UK

17th Annual Meeting

13th AMWC 2015

Aesthetic & Anti-Aging Medicine World Congress.

Annual congress 2015 Paris.

13th Aesthetic & Anti-Aging Medicine World Congress.

26 - 27 - 28 - March, 2015

January 29 - February 1

Monte-Carlo from 26 to 28 March 2015 and will be held under the High Patronage of H.S.H. Prince Albert II of Monaco.

T

he Society of Mesotherapy UK (SOMUK) has confirmed that it has become a partner of IMCAS Paris and Scientific Partner of AMWC Monaco.

The collaboration means that members of the society will be offered free registration to the Anti-Ageing Teaching Course. SOMUK confirmed that in 2015 they are also set to partner Euromedicom, Face2Face (Cannes) and AAAMC (Azerbaijan).

President of the society, Philippe Hamida-Pisal, explains that the SOMUK was created in December 2013 as an initiative to generate an academic

dialogue amongst practitioners interested in mesotherapy.

One of the Society’s principal aims is to incentivise academic institutions in the United Kingdom to include mesotherapy as a key alternative treatment in practitioners syllabus.

We have achieved this by becoming a partner or scientific partner of a number of important aesthetic congresses.

«Not only does this provide our members with an international reference and access to expert knowledge where the practice of Mesotherapy is more prevalent, but also benefits our members by providing access, at the reduced fee, to the respective congresses where the SOMUK is partner, improved networking as the Society grows from strength to strength, and access to expert advice through the society and network in the UK.»

The SOMUK next Annual Conference will be held on the 11th of April 2015.

partner

body language I INJECTABLES 29

A

lopecia is partial or total hair loss, or absence of hair. Hair is very important across cultures and in some religions - it can denote strength, success and sex appeal, so it can have a serious impact if a person starts losing patches of hair.

First some facts about hair - the number of hairs someone has will be between 80,000 to 150,000.

The diameter of a person’s hair is about 1mm and growth per month is1- 1.5mm. Hair has a lifespan of two to seven years and the resistance is 100g.

The density, shape and colour of hair is genetic. The average numbers of hair on a person’s head change depending on hair colour. Blonde is over 100,000, dark hair is roughly 100,000 and redhead’s have less than 100,000 hairs. These numbers depend on melanin as well.

There are 200 hair follicles per centimetre squared and we typically have between 80,000 to 150,000 hairs. They all grow by cycle and we normally lose 30 to 150 hairs per day as an average.

Hair growth cycle We see an increase in alopecia with age. In Caucasians, 70% to 80% of men and 40% of women show signs of baldness, frequent hair loss or alopecia. The most important way that we can understand when mesotherapy is beneficial, is by knowing the hair growth cycle.

There are three phases in the growth cycle—an active one, which is known as anagen and lasts two to six years. It comprised of 15 to 20 follicle cycles which grow 0.5 to 2cm per month. 85% to 90% of the follicles are in this stage.

The second phase, called catagen, is an evolutionary phase and lasts two to three weeks maximum.

Mesotherapy and alopecia Alopecia can have a significant impact on a person’s life. DR PHILLIPE HAMIDA-PISAL summarises the use and effects of mesotherapy on alopecia The final phase is called telogen.

It lasts between two to six months during which preparation is made for growing a new hair shaft. We know that the mesotherapies get to be very effective in this cycle.

First of all we eliminate the false hair loss and confirm the diagnosis.

We do a trichogram to pick some hair and to find out how many hairs we’ve got in each stage. If you don’t have any alopecia problems, we should have a maximum of 10% of the hair in a telogen phase - if there is more than 10%, there is a problem.

How do we diagnosis alopecia?

66 The average numbers of hair on a person’s head change depending on hair colour. Blonde is over 100,000, dark hair is roughly 100,000 and redhead’s have less than 100,000 hairs 99

Firstly we see a reduction in catagen or a total lack of hair. In the formation phase of the anagen phase, we’ve got the growth factors and nutrients—iron, protein, zinc and vitamin—and this where the mesotherapy works well.

The thyroid hormone promotes the growth of the hair follicle and this is what undergoes a perifollicular coagulation, linked to an enzyme called five alpha-reductase.

This metabolises it into a new anagen called dehydrogenase (DHG) which reduces size of the hair shaft.

Androgenic alopecia is the most common form of alopecia in males and females. We have androgen etiology in the form of hypothyroidism and less commonly, hyperandrogenism, which will be considered as alopecia if there are some older symptoms. When there is a nutritional deficiency—mainly iron but also all the nutrients—this can be one of the factors.

The classification of alopecia is the Ludwig scale for the women and Hamilton-Norwood scale for

One of the consequences of ageing is reduction of the length of the growth phase, reduction in hair shaft diameter, decrease in the elasticity and the growing of hair

30 INJECTABLES I body language

the men. The alopecia goes from stages three until seven.

What approach do we take? We have the same internal and external factors we have when we look at any anti-aging treatment for the skin.

The internal factors are genetic and the external factors are auxiliary, such as stress, sun exposure, smoking, using dyes, wavers, relaxers and more.

One of the consequences of ageing is reduction of the length of the growth phase, reduction in hair shaft diameter, decrease in the elasticity and the growing of hair.

Results of mesotherapy treatment

Is mesotherapy really effective?

It’s very effective for male and female androgenic alopecia when functioning hair follicles remain and for management of post-partum telogen effluvium.

Mesotherapy is far more effective than any conventional substance injected intramuscular or intravenous. Its goal is to prevent of the catagen phase and exogen of the anagen phase by using cytoprotective, an antecedent molecule.

In France, the combination substances used in mesotherapy are bepanthen, biotin, laroscorbine and multivitamin. We still get some disappointing results when there are external factors interfering, however we used NCTF 135 HA from Filorga.

This anti-ageing approach for treating dermal ageing allows androgenic alopecia to be considered as localised cellular ageing of the hair follicle in the dermis and subcutaneous tissue. This itself is undergoing a physiological slowing of cellular function. It’s exactly the same that we deal with skin ageing.

What other therapeutic options are available? We’ve got local treatment such as menoxidyl, vitamin,

placebo extract. These aren’t used in Europe but are popular in Russia and South East Asia. We’ve got general treatment like finasteride for men and antiandrogen tab, androcur and spirolactone for women. There are also obviously surgical treatments.

Mesotherapy represents an excellent technique in the treatment of alopecia. Fortunately we know how to ask the right question and this is very important. Like any treatment, we have to know the limitations of mesotherapy. It increases the blood flow in the scalp and allows the blood to nourish but the indication will depend on the sex, the age and the stage of alopecia.

For any treatment, we have to present the patient with a prognosis which is realistic and loyal. This means knowing our limitations.

For men, mesotherapy is only effective up to the stage four of Hamilton and for women, this is only up to stage two of the Ludwig. It’s also very effective for the postpartum effluvium which should be offered as a first treatment option.

Combining treatments The purpose of the treatment is to restore an effective local microcirculation and to provide an important nutritional intake. It also slows the process of programmed evolution of follicles. So there are mixtures we can use.

Vasodilators are very good for stimulating the microcirculation and we’ve proven their antiradical action. We’ve got vitamin H or biotin and vitamin B5 or bepanthen.

We’ve also got organic silica and lidocaine 1%.

How do we use this technique?

We inject either manually or with a gun—it’s often less painful with a gun. The technique will always be papilla exodermic, using all the

area of the alopecia. The frequency is once a week for four weeks, then once every two weeks for four weeks and then once to twice a month thereafter—roughly 12 sessions.

For protocol, the first consideration is asking the right questions.

We need examination, diagnosis and prescription of the trichogram to find out if we’ve got a patient with alopecia or not.

The second consideration is to confirmation the diagnosis and steps of the treatment. After one year we do a trichogram of control to find out if telogen percentage is going down or not. It’s really important to ask your patient to avoid washing their hair straight away and obviously to avoid aggressive products, such as hair dye, for 24 hours.

The follicle is generally improved in six sessions over 90% which is a very good result. In fact we’ve seen an improvement after just three sessions. The regrowth is seen over three months and the younger the patient more the more important the regrowth is.

In conclusion, Mesotherapy is a very good treatment for alopecia but can also be combined with other techniques to be even more effective—we have combined mesotherapy with LED and seen huge improvements.

It slows the effect of androgenic events which are scheduled and it’s an excellent accelerator for the regrowth of the effluvium postpartum.

Dr Phillipe Hamida-Pisal is a skin consultant for LEO Pharma in the UK , president of the Society of Mesotherapy of United Kingdom (SOMUK) and co-president of the Society of Mesotherapy of South Africa (SOMZA)

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32 PANEL I body language

Hair today There are many non-surgical cosmetic treatments for hair loss currently available—our expert panel debate the technique and benefits of PRP, micropigmentaion and mesotheapy

Q. Do you use anaesthesia on the scalp during platelet rich plasma (PRP) injections?

Dr Victoria Dobbie: If I’m using a medical needling technique, I give my clients Emla cream to apply before they come in to see me and most of them find it tolerable. However, I’ve recently switched to using the U225 machine and with this they don’t need any anaesthesia as it moves so quickly that they don’t feel it.

Q. Can micropigmentation be used when you have longer hair and will it look good then?

Dawn Forshaw: Yes and no. If the client has a large area of hair loss and wishes the end result to resemble that of a ‘buzz cut look’ the hair needs to be clippered or shaved so that the follicular tattoo implants blend in and look natural. If the client has diffused/thinning hair then the there

are two choices for the client.

You can offer scalp coverage by implanting hair simulated dots at the root of a hair follicle to create the illusion of thicker hair, or scalp rollering—which many women prefer, to put a permanent shadow or stain of colour onto the scalp.

This gives the illusion of scalp camouflage, much like the sprays which stain the scalp for a day, but with scalp tattooing this lasts 24/7.

body language I PANEL 33

All that is required is an annual colour boost.

Q. Isn’t there a critical length of hair in men where it looks a bit artificial?

Dawn Forshaw: Tattooing can look un-natural if the surrounding hair is longer than 2ml. Men need to make the decision to permanently shave their head to compliment their scalp tattoo.

Q. What about different shades to simulate shadowing?

Dawn Forshaw: Shading is difficult to offer on the scalp as the head will always be moving so the light and shadow will appear in different places.

Q. As the tattoos get older, what are the issues regarding the colours?

Dawn Forshaw: A shaved head is always grey so when the pigment colour fades the overall look can still look natural if a good quality pigment is used. New follicular tattoo implants can refresh the look.

An annual colour boost is essential to keep the overall look as realistic s possible.

Q. What depth does the tattooing needle go to?

Dawn Forshaw: For scalp tattooing super fine round needles are preferable, penetrating from 0.5mm to 1.5mm, depending on whether you are implanting into scar tissue, bony areas of the scalp or needling /rollering into spongy tissue.

People may elect a numbing agent prior to a procedure but as the implants are more superficial than regular cosmetic and medical tattooing the discomfort is minimal.

Combined treatments can offer enhanced results for patients

Q. Who can do micropigmentation training?

Dawn Forshaw: Anyone with a good eye and the ability to succeed, who is accepting that they may well loose a client to a more suitable hair loss answer, once a client has been informed of all hair loss choices. As scalp tattooing is a lifetime commitment it needs to be the right choice for the client, either in combination with transplantation, or as a stand

66 Tattooing the scalp is the hardest of all micropigmentation procedures to master— anyone thinking of offering this procedure must do their research 99 alone procedure for someone who wishes a 24/7 solution.

There are courses for medical professionals from transplant surgeons, to graft cutters and dermatologists, and courses for trained semi permanent makeup professionals and hairdressers.

Tattooing the scalp is the hardest of all micropigmentation procedures to master. It is not just a dot.

Anyone thinking of offering this procedure must do their research and choose their training school very carefully.

Q. Can you combine mesotherapy and PRP together?

Dr Philipe Hamida-Pisal: Yes, of course we can. There’s absolutely no problem at all.

Dr Victoria Dobbie: I haven’t seen any research that shows a combined treatment, though you could combine them. I’ve seen really good results just using PRP by itself, so I’m not sure what the benefit would be of a combination treatment.

Q. With PRP and androgenic alopecia—considering albumin is the primary protein in the serum, has anyone looked at whether we’re possibly concentrating testosterone in reinjecting it into the scalp?

Dr Victoria Dobbie: I haven’t seen any research along those lines.

Q. Have you had cases where it did not work or the people got worse on it?

Dr Victoria Dobbie: No. I’ve 100% satisfaction rate and that’s really unusual with any kind of aesthetic treatment.

Q. When you talk about

patient satisfaction, do you mean they’re happy with the treatment modality, or that they’re happy that they get a significant improvement?

Dr Victoria Dobbie: I mean that they’re happy that they see a significant improvement.

Q. From a technical point of view when you’re injecting a full scalp of thinning hair, is there a particular sequence pattern, within which you’re injecting, or is just random injection sites?

Dr Victoria Dobbie: It’s always tailored to the patient in front of me.

Q. Have you got any theories behind why you’re getting sustained effect with PRP and don’t need to continue ongoing treatment?

Dr Victoria Dobbie: Greco studies in America show that the results from one single treatment are better at eight months than at the four-month point and that’s without any further treatment. So, you do get a continuous improvement just with a single treatment.

But that’s an area that would be nice to see some further studies develop.

Q. Is it true that we don’t have any long-term data?

Dr Victoria Dobbie: No, I haven’t seen any data past 12 months.

Q. Do you have a target depth, at which you’re aiming to introduce the PRP? Dr Victoria Dobbie: With the mesotherapy gun, you can actually target right down to the follicle bulb at about 4mm, quite painlessly.

With the medial needling treatments, you’re probably looking at round about 1.5 mm.

34 PANEL I body language

66 With the mesotherapy gun, you can target right down to the follicle bulb at about 4 mm quite painlessly. With medial needling treatments, you’re probably looking at round about 1.5 mm 99 Q. Has anyone had experience with injecting minoxidil with mesotherapy?

Dr Philipe Hamida-Pisal: I don’t inject minoxidil. You can use it as a vacillator but I don’t think it’s available in the UK. Q. Using mesotherapy as a postpartum accelerator, have you got data to show the significance of improvement after mesotherapy, as opposed to just natural recovery?

Dr Philipe Hamida-Pisal: Yes we do. There is only one study about the effectiveness of mesotherapy, which is done by the French laboratory, Filorga. Patients recover their hair much quicker. It depends on the age and younger they are, better the result is.

Q. Is there any contraindication just to do some adjunctive mesotherapy or PRP with finestride?

Dawn Forshaw: No, the advan-

tage with using the mesotherapy is that combined treatment is always more effective. If you’re not going to carry on giving finesteride to your patient because of the side-effects, but you want a quick result, this the combination will do that. So you can stop your patient using finesteride and carry on with the mesotherapy.

You’ll get a better result without any side-effects.

Q. We see men who have been wearing hairpieces.

Very often, the method of attachment is glue or double-sided tape and in almost all of them, we see inflammation of the scalp and hair loss in patches at the point of attachment. Is that a consistent problem that you find?

Louise Wright: We tend to find this more in people who don’t come back regularly in between to have the hairpiece removed and washed properly. If they’ve kept it on for too long sometimes the adhesive is going to aggravate the scalp area.

Unfortunately, there’s no other way of attachment at the moment.

Q. I see people who have surgery but want to wait until the hair comes through before they get rid of their hair piece. Is it easy to design thinner pieces so the patient can gradually move away from their hair piece?

Louise Wright: Absolutely. They can have other pieces made for them

with less density of hair. They can get used to that as the hair starts to grow back again.

Q: Do patients prefer to have a local anaesthetic before having treatment?

Dr Victoria Dobbie: Most people feel it’s going to be uncomfortable so they wish to have anaesthetic and Emla replied for 30 minutes prior. If they have hair, we tend to try and talk them into not having anything anaesthetic because we want to make sure we’re implanting precisely, particularly on the eyebrow area.

If there’s no hair then they tend to just put up with it so we can get a better result. Our area is clear because numbing can blanche the area and also cause the follicles to open a little bit more. So we want to make sure our little dots are precise.

Dr Philipe Hamida-Pisal: I’ve noticed that a lot of practitioners are really concerned about painless procedures so are using Emla for this. We have to be careful about using too much numbing cream because there is a study now in France, regarding the stopping effect of fibeblasts, using too much lidocaine.

We know that PRP on the scalp, when you use the mesogun, is not painful and mesotherapy on the scalp, if you use a gun, is not painful. There is sometimes a little bit of pain so we shouldn’t consider that everything has to be painless—it won’t always go that way.

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body language I COSMETIC 37

Conceal and conquer Medicinal treatments alone may not always be the best course of action to treat hair loss.

TOBY COBBLEDICK looks at the benefits of using cosmetics to support drug treatment

T

he use of drugs either permanently or temporarily in hair loss treatment may not always be appropriate. One common reason for this is if the drugs are being contraindicated by other drugs that the patient takes. An obvious example is minoxidil— if you’ve got a patient on other high hypertension medication it isn’t a good idea to mix the two.

If a patient doesn’t want to take drugs you can give good advice about the percentage of risk versus the benefits, however there is always a percentage of people who won’t be convinced.

You might also not want to use drugs if the type of alopecia hasn’t actually been diagnosed yet. If you’re waiting for biopsy results, there’s some ambiguity about them, you may want to delay prescribing medication. You will also see patients with early stages of thinning hair, or who are just worried about hair loss in general.

These cases might not be diagnosable yet so you may not be able to prescribe a medicine.

Lastly, if drugs have been tried and haven’t worked for that particular patient then you need to consider other treatment options. Unfortunately there’s always a small percentage which can’t be helped by the medicinal options we have. Hopefully, the introduction of new medicines like Dutasteride will help close this gap, however when someone has been taking

tablets for six to 12 months with no result it can be impossible to convince them to continue with a different tablet.

Compliance No drug will work without compliance.

It’s the biggest issue with proven medications and the reason clinic patients don’t always get the same success rate that they do in clinical trials. Hair loss medications are all trialled with daily or twice daily application, so you have to take the treatment as often as you can in real life.

Compliance can be reduced by something as simple as absent-mindedness, but correcting this is not difficult. Most people don’t take tablets or apply lotions daily, so you’ve got to put the reminder

66 Compliance is the biggest issue with proven medications and the reason clinic patients don’t always get the same success rate that they do in clinical trials 99

into an activity they do every day. Successful options I’ve heard of are keeping the medication by your toothpaste or putting a shampoo from a hair loss brand in your shower.

We can also be a bit flexible in our prescriptions. Obviously, there is always an ideal time and way to take a tablet, however it’s much more important that somebody remembers to take it. So whilst evening might be the ideal time, a patient will get better results applying every morning if that’s when they remember, compared to applying in the evening but only once a week. Sometimes we have to compromise.

Side effects, even the very minor ones like scalp irritation, dandruff, or increased hair loss when patients start on minoxidil, slow visible results and can cause reduced compliance. It’s very hard to say to a patient, “I have the perfect answer for you, but you’re going to have to wait for six months before anything happens” particularly if the patient hasn’t done a lot of research into hair loss. It’s a difficult conversation to have. Offsetting these minor side effects creates a real difference to patient quality of life, compliance, and therefore success rates.

Topical Ingredients From a cosmetic perspective dandruff and irritation need to be considered. Most shampoos focus on the scalp or the hair and tend not to look at both together.

38 COSMETIC I body language

a patient to commit to six months’ treatment, giving them a quicker result within a month or so makes them much more likely to continue to whole treatment routine.

Before and after treatment with Nanogen thickening hair fibres

There are different options and ingredients in shampoos and conditioners to recommend. Salicylic acid is quite useful as it removes visible dandruff as well as helping preventing it, so you can get a faster cosmetic result. It’s also been shown in some studies to help reduce the inflammation that you get through contact dermatitis and dandruff as well, whereas other actives for dandruff don’t tend to.

Sodium lauryl sulfate (SLS) and sodium laureth sulfate (SLES) free products are an interesting topic. SLS and SLES can be irritating, but concentration is also important. Tests we performed at Nanogen showed some “natural” or “organic” shampoos can be more irritating than sulfate containing ones. So it isn’t that simple. Studies have shown that SLS can be irritating and even cause dermatitis when used alongside some organic solvents, so you might want to avoid it when patients are taking a topical treatment with an organic solvent in. This might be propylene glycol in some minoxidil products.

Some shampoos other organic solvents and SLS, so you need to consider what else your patient is using. It’s always very important to ask them about their rou-

tine, as the dandruff might not actually be coming from the medicine that you’re prescribing them. It could be coming from something else that they’ve changed or done.

There are a whole battery of other actives that you could potentially use, like beta-glucan and hyaluronic acid. These are both well known skincare ingredients that are rarely utilised for the scalp. It’s important to start looking at the scalp as skin and to treat like any other variety of irritated skin - not just a surface for hair to grow on.

Research At Nanogen we’ve reviewed two hundred minoxidil users who added a combination of a salicylic acid shampoo and a conditioner containing skincare ingredients to their routine. 90% said that their scalp felt more comfortable than before. Over 20% reported an immediate sense of irritation relief after the first time they used the products.

Improvements in hair thickness and condition were also reported by most people. That’s not important from a clinical perspective, but when you’re trying to get

Concealers Slow results are the biggest objection that we have to treatment. We recommend concealers as the best answer to this, you can shake dry keratin fibres onto hair for an instant thickening effect. They simply bind into the hair until you wash them out so can be used daily, or just for special occasions.

As dry fibres they are completely inert, they don’t block pores, they don’t interfere with a topical treatment and so they don’t have any effect on scalp condition whatsoever. This means you can give that instant result without interfering with a patient’s progress. Natural keratin is important as it looks and feels like hair and is non-irritating, whereas the ones made of rayon or nylon might irritate certain patients. Also, only some concealers are dermatologically tested so you know that they’re completely non-irritating.

Make sure that you ask a new patient whether they’re using a concealer because some concealers might cause other symptoms that you find. For example, if they’re using a coloured scalp spray every day it could have some effect on a treatment they apply afterwards, or their scalp condition.

Concealers have a wide variety of applications. If someone comes in and doesn’t have diagnosable hair loss, you can’t prescribe a medicine just because he or she feels that they need it. But concealers solve their problem. Alternative when you’re waiting for drugs to work or waiting to know what the right drug is, concealers provide and interim answer. They work in combination with transplants as well, if you’ve got quite a long consultation procedure and while waiting for implants to grow through. It’s all about giving patients something to work with in the meantime. Concealers work on all different hair colours, on frontal hair loss, and right on the crown.

Drugs are the first choice for treating patients. The role of cosmetics is to make sure that your patient feels good about the treatment, that they carry on long enough to see a result, and that you have a solution even when medicines aren’t an option.

Toby Cobbledick has a special interest in cytokine biochemistry and is Head of Brands at Pangaea

body language I MARKETING 41

Does your business need an app?

The way people interact with the internet has changed with the proliferation of smartphones and tablets. RICHARD CRAWFORD-SMALL explains how you could boost your business by being tech-savvy

A

pps are not just about technology, they can be used to improve processes and benefit businesses. Sometimes apps are expensive, sometimes they’re cheap, but there are certain things you can do in your own businesses to harness and work with them.

This is our world, whether we like it or not—life through an iPhone lens. You go and see a gig; no one’s watching whoever’s performing. Everybody’s looking at someone else’s iPhone, to get a better view.

What I’ve learned is that there is some fear, or lack of understanding, about what can be done and how to harness mobile technologies and apps to benefit from them. Before looking at what they are, we need to understand what they can do.

Facebook is the biggest app in terms of usage by a mile. It absolutely dominates the mobile landscape and a global survey showed over 50% of time on a tablet is spent on Facebook. After Facebook, the next most used apps were Twitter, Candy Cr ush, Instagram, YouTube and Angry Birds. You can gain an understanding about what people actually use apps for; communication, entertainment and some information. That said, not a single news site appears in the top five—and not even email.

So, why does Facebook dominate the the app landscape quite so much? It’s because the way that we interact with the internet has changed. A few years ago the main access point to the web was through a laptop or desktop and where you ended up, was more than likely going to be a Google homepage. Now, with mobile it’s different, your access point to the internet through mobile is Facebook. So, having a Facebook page set up for your business is a good start.

These are the main areas that apps cover; communication, infor-

mation, entertainment. Facebook is great for communication, you can play games through it so it’s entertaining, and you get your information through it. So, how do you break this into your businesses?

Three key challenges that we all face are patient or customer recruitment, patient or customer retention and the processes to achieve this.

It is important to remember that what gets measured gets done. We want to know why we’re being successful and what the mechanisms are that contribute. We also want to add value to the customer experience.

This is where branding and how you differentiate yourself is vital, as the aesthetics market is becoming hypercompetitive. The customer experience is part of your brand and apps can add value to that.

The patient journey Let’s take for example, a real world patient journey where we have an event; a barbecue perhaps or a fam-

ily wedding. A photo gets taken on a mobile phone, it gets uploaded onto Facebook, and the subject realises they are not happy with the way they look and want to seek treatment options. They look to the internet, go through Google, find your clinic and come in to be treated. Then you follow up with SMS or email marketing.

You hit all of the marketing touch points; word of mouth, SEO, telephone, consultation skills and follow up. Everything that we traditionally say are the factors to get right to ensure that patient flow works effectively.

However, if you use a mobile app, especially with Facebook as it’s something that you could implement tomorrow, it changes. This is how people are starting to digest information. So take the same event, the same family barbecue or wedding, the same photograph, the same realisation of the subject that they want treatment. That photo’s

This is our world, whether we like it or not—life through an iPhone lens

42 MARKETING I body language

If a potential patient is using a mobile device, they may find your clinic more easily via Facebook

gone on Facebook and the relationship can stay on Facebook because they’re asking their friends on Facebook—they’re linking in.

Instead of going to Google, they find your clinic via your Facebook page, and through the Facebook page then may join your clinic’s Facebook Group. You can communicate with them and they get notifications popping up on their iPhone saying this person’s added or commented on the Group.

Finally, the information is shared—or rather, the client shares the quality of the treatment on Facebook. I’ve noticed a trend increasing in the last six months with the clinics that I follow, where sharing before and after images is increasing. Obviously the patient’s permission on Facebook is really growing, and that’s what leads into word of mouth marketing. There’s a circle and it’s all carried out through the smart phone or tablet.

Setting up a Facebook page for your business is simple and instant.

You could then take it further, and set up a Group. You can invite your customers to join that Group, and when you begin communicating with them, the Facebook notifi-

66 I believe that the most valuable marketing real estate is on the front screen of a tablet or smart phone 99

cations will pop up on the home screen of their phone or tablet, and that’s when you can start engaging with your customers. It’s really simple, but very effective.

Apps If you want to dig a little deeper, and feel the need to have your own app and own it, you can do, but there are benefits and risks.

You could have an app that provides information on new treatments, so you’re communicating directly to your patients through their iPhone. You could have and app to organise bookings, so the amount of time you spend in your clinic registering patients and doing patient administration would be cut.

You could have a patient complete forms through their phone and have previous medical history to check through before they’ve even walked into the clinic. This leads into engagement and that’s mainly what social media is all about—generating engagement.

It’s not a blast, like SMS is, where away it goes, instead you want something back. You want patients to engage with you.

I believe that the most valuable marketing real estate is on the front screen of a tablet or smart phone because it’s instant and rich. Using SMS, you get some information, but not a massive amount. With push notification to an app you get detailed information.

If you do decide to go down the route of building your own app, there are three different platforms,

and you won’t want to develop for all. Take that from experience— don’t. Find one you like and stick with it.

HTML5 is essentially a website, compressed and packaged to put on the app store to be download.

It has great advantages in that it’s effectively a website, so the code is already known. It’s also very portable because it’ll work on a website, it’ll work on Android and it’ll work on IOS. They are quite cheap to develop because they don’t require difficult coding, so the development time is shorter.

The downsides are that they’re a lot slower than actual apps because they don’t draw on the power of the tablet, they draw on the power of the server. You can’t create push notifications, so communication is limited.

Android is interesting because it’s got huge market share on mobile devices—62% in 2013. There are many different options, and the devices are very price competitive, but from a developing point of view it’s a fragmented marketplace, with 40% of Android users using a version that was released in 2010, which is four years old. So developing a product is very difficult because there’s such a variation in the user-base.

It is also very easy to put malware on it—pop ups and such— that interfere with your app.

This leads me to IOS. I like IOS and have developed iConsult for it.

70% of the UK market is iPhone and iPad, so it is a good option. I also feel that the branding is important. If you’re using an iPad in a clinic, the first thing the patient sees is the Apple logo. If you swap that and use a Tesco Huddle for example, it’ll do the same thing, but the first thing you’re doing is pointing out to that patient that you’re cheap. Not a good move.

In terms of app stability and performance, they’re really solid and will work on all Apple devices. But the products do have a higher cost.

We’re still really scratching the surface of what apps can do in health care, and the aesthetics market. If you started today, you would still be an innovator.

Richard Crawford-Small is the Founder of iConsult Software Ltd

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44 DEBATE I body language

Face of the future

Treatments to rejuvenate the face are ever evolving. MR RAJIV GROVER, DR NICK LOWE, DR TIMOTHY FLYNN and DR MARINA LANDAU offer their advice on technique, product selection and results

Mr Rajiv Grover: I’d like to ask you what new tip have you picked up in the last year, that has really been of practical value in your practice? It could even be something that you have decided not to do.

Dr Nick Lowe: To improve atrophic scars, fillers often need to be combined with other treatments. It makes no sense to start treating deeper atrophic scars with lasers or radiofrequency until you’ve used subcision

for sub-dermal fibrosis. In deeper scars, use an appropriate filler such as Sculptra or an HA filler. After subcision and filler begin other procedures like Fraxel CO2, Fraxel Restore or micro-needle radiofrequency as skin tightening for the skin over and surrounding the atropic scars.

Mr Rajiv Grover: Recently it has been discussed that you can inject filler and massage it so it acts

like a sticky patch. Could this be a way to lift or suspend the brow and keep it up? Or are you injecting primarily for volume?

Dr Timothy Flynn: I like simple things, and in the last year the thing that’s impressed me the most is vibration. Viration decreases the pain of the needle stick and also smooths out fillers—we have shown this in our clinic and similar results are which is also mirrored in the litera-

body language I DEBATE 45

If you are stimulating sensory fibres, within the nerve there are C fibres as opposed to AB. C fibres are pain, they’re slow, and you close the gate in the spinal neuron as a result of stimulation

ture. For people who are pain sensitive, if you vibrate their skin beforehand with just a small ‘purse size’ vibrator, it will decrease the pain of the needle stick. Furthermore, for people who are receiving filler injections, there is a published study which shows if you vibrate the filler injections, there’s decreased pain associated with them.

We also dilute many of our fillers—particularly for deep injections such as with Radiesse, when injecting it deeply into the periosteum or around the deep fat pads—then we massage by hand and finish with a little vibration. I encourage you all to do this, particularly if you’re doing intra-dermal injections, because you’ll be amazed at the evenness.

We only use Belotero for intra-dermal injections (diluted with a small

amount of plain lidocaine) and it’ll smooth that right out.

Mr Rajiv Grover: There’s very good science behind this. A famous paper on pain relief, by Melzack and Wall, explains the gate theory of pain. If you are stimulating sensory fibres, within the nerve there are C fibres as opposed to AB. C fibres are pain, they’re slow, and you close the gate in the spinal neuron as a result of stimulation.

Dr Timothy Flynn: Of course, we struggled for years to try and call them something other than vibrators—medical stimulators, tissue devices—finally, in the end, we just threw in the towel and said, yes, it’s a vibrator.

Mr Rajiv Grover: Call a spade a spade. Marina—can you

follow that?

Dr Marina Landau: I have started to dilute my fillers in the last year for a number of reasons. First of all, I do not dilute with lidocaine, I dilute with preserved saline which has anaesthetic qualities as well.

I think that I get better cosmetic results, and it also creates a good anaesthesia.

Another remark, I have started to use the volumetric fillers and they give a good cosmetic result when the patients are at rest. When they smile, you can quite frequently see the demarcation between the filler and the untreated area.

Therefore, by diluting the volumetric fillers, you can create smoother transition areas between the treated and untreated areas.

Secondly, a study done in Russia

46 DEBATE I body language

66 Do not compete on price—compete on quality.

There will be always somebody who is cheaper than you are, so you deliver better treatment results 99 on calcium hydroxylapatite, showed very significant collagen stimulation by using hyper-diluted Radiesse.

They used 1ml of Radiesse to 3ml of lidocaine. I use preserved saline, and this option allows me to treat nonfacial skin, such as the neck, with no nodules or irregularities. It’s a very significant improvement. Hyperdiluted Radiesse is great filler for body skin.

Mr Rajiv Grover: I can imagine diluted Radiesse would work very well on the hands.

Dr Marina Landau: Yes. That is what you do with Radiesse on the hands— it creates better cosmetic results.

For the body, I use 1ml or 1.5ml Radiesse with 4.5ml preserved saline. You can add a 0.5ml of lidocaine first, then you need only 4ml saline, but preserved saline is an anaesthetic by itself, so it’s efficient for anaesthesia. For the hands, you don’t have to use hyper-diluted— you can dilute one to one.

Audience member: What’s the view on polycaprolactone and how does it compare to other available products?

Dr Marina Landau: It is considered to be a stimulatory filler, similar to Sculptra. I started to inject it very cautiously, as I do with every new filler. There is one study, which compared the efficacy of Ellansé against HA nasolabials. It showed less Ellansé was needed as compared to HA. I started with Ellansé S and according to the company claims, you need a small amount of filler—not more than 1ml, and again, diluted. I have limited experience, but you do have some stimulatory effect on collagen.

Dr Nick Lowe: Ellansé may prove to be useful, but I think all new dermal fillers need robust clinical safety studies.

Rajiv Grover: In your own practice, which filler is the one you

use the most, and why have you chosen that particular brand of filler?

Dr Nick Lowe: Hyaluronic acid fillers combined with local anaesthetic have been my main fillers.

The ones I currently use are the Emervel ‘family’ which I find very versatile and I can reduce or remove with Hyalase if needed. For diffuse atrophy of the cheeks I will often use Sculptra.

Mr Rajiv Grover: They talk about G prime and lifting capacity, do you think that these are an effect with some fillers?

Dr Nick Lowe: I think there are definitely different physical characteristics of the fillers. I think as important as that is how you inject them—the depth of injection and if you’re injecting onto the periosteum. These factors influence whether you’re getting lift, or as much lift as the next injection. It is related to technique as much as individual filler characteristics.

Dr Timothy Flynn: I end up doing a lot of very fine-line fillings that take a long time—the barcode on the lip, treating fine marionettes that have been undertreated, because nobody was doing the superficial lines efficiently. So Belotero is the only filler I use for this based on studies involving intradermal integration, and also Radiesse for deep filling. They work well together. I’m definitely using more Voluma, because of their longevity studies. We still use some of the Juvéderm family and also a little bit of Sculptra in the right people.

Dr Marina Landau: I don’t order all my fillers from one brand.

I have one filler with lidocaine, which is Perlane—my workhorse.

I then have one filler which is lidocaine-free called Princess, an Austrian filler. It is very similar to the original Juvéderm and I use it for any patient who claims to be

lidocaine-sensitive.

Then I use Radiesse, for injecting in the lower face, and for my male patients. For volumising cheeks, I use either Voluma or Teosyal Pure Sense.

Mr Rajiv Grover: From a business perspective, what one top tip have you got from your practice—maybe a USP—that made you successful?

Dr Nick Lowe: Employ my wife as my business manager.

Dr Timothy Flynn: My tip is to always do the right thing for the patient—put yourself in their shoes. Here’s a simple example that actually happened to me: a patient came back after a filler session and said, “Dr Flynn, you can do better.”

So I took a look at her and brought her in, and do you know what? I agreed with her. I could have done her fillers better. There were a couple of areas that I’d missed. She had some unevenness. The problem, I determined, was that she needed more volume replacement. I had a dissatisfied patient and I knew if I’d just used half a cc of, in this case, Juvéderm Ultra, I could fix the little depressed areas.

I didn’t charge her because I wanted to convert that unhappy patient, who’d already spend over $1,000 with me, into a happy patient. So I showed her I was going to take care of her, and do the right thing. That’s different to the person who comes in, three months after their botulinum toxin, and complains it’s not lasting that long—that’s clearly a person who’s working the system. I’m talking about something where you really agree with the dissatisfied patient and you want to help the patient because you’re disappointed in the results. Always do the right thing for the patient.

Dr Marina Landau: Do not compete on price—compete on quality.

There will be always somebody who is cheaper than you are, so you deliver better treatment results.

Mr Rajiv Grover: Very good advice. Don’t compete on price; compete on quality. Do the right thing for the patient. Keep your overheads down and have a skeletal staff. And put your wife in charge of the practice.

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body language I PRODUCTS 49

on the market The latest products in aesthetic medicine 2

1. iS Clinical have combined their “hero” skin essentials in the new Ultimate Skin Prep Kit, said to optimise skin health and maximise aesthetic treatment results.

The kit has been created for use in conjunction with face lifts and injectable treatments. Director Alana-Marie Chambers said “The new skin prep kit is designed to enable doctors to initiate treatment from as early as the consultation process”, allowing patients to “leave with the tools to start optimising their skin and preparing it for the treatment prescribed.” iS Clinical, W: isclinical.co.uk

1 3

4 3. Adoderm have launched a new generation of HYABELL dermal fillers, with pre-incorporated lidocaine (0.3%) to help reduce pain on injection. Adoderm say results of the filler for various indications in the dermis and subcutis is natural looking and long lasting, and HYABELL offers great elasticity and viscosity for ease of injection and optimal flow capability. Results of 12-month implantation tests demonstrated that HYABELL had a high tolerance and biocompatibility profile.

Adoderm, W: adoderm.com

2. Episciences Europe introduce their new Epionce Lytic Sport Tx, designed to help treat skin imperfections and improve the skin’s texture and tone for the more active lifestyle. The light-weight formula has been created specifically to treat very oily, problem adult and teenage skin by eliminating blackheads, whiteheads, pustules and inflamed blemishes, say Epionce.

Key benefits include a maximum strength, light-weight formula that helps treat acne, inflammatory conditions, and scaly skin diseases, leading to smoother skin contour and reduced pore and scar appearance.

Epionce say there is also improvement in reduction of redness, irritation and scaly growths and the product helps to regulate excess oil production and eliminate injurious bacteria.

Episciences Europe, W: epionce.co.uk

5. EVENSWISS is a professional cosmeceutical line, consisting of 10 selected products, all of which contain the patented Dermatopoietin peptide complex.

Dermatopoietin is said to affect deep skin structures without penetrating skin by triggering a cascade of reactions which propagates from the surface to the depth of skin, and promotes the production of collagen, elastin and several growth factors which supports the skin’s natural renewal process.

EVENSWISS say the range has been developed for specific skin problems and beauty needs and their blend of active ingredients helps to promote the natural regenerative process of skin to restore its youthful texture and appearance.

EVENSWISS, W: evenswiss.ch

5

4. Cambridge Medical Aesthetics has announced the release of its lidocaine containing hyaluronic acid based dermal filler, Uma Jeunesse Ultra. Uma Jeunesse Ultra is a global action product, designed to help correct medium to deep lines, lip augmentation, cheek and nose augmentation. Uma Jeunesse Ultra contains traces of lidocaine to help relieve pain during treatment and contribute to patient comfort and safety.

Uma Jeunesse Ultra is CE marked and is being released for global sales in the first week of December 2014.

Cambridge Medical Aesthetics, W: umajeunesse.co.uk

50 EDUCATION I body language

training TF

TOXINS AND FILLERS

11-12 December, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 13 December, Foundation Botox and Dermal Filler Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 15 December, Non-Surgical Facelift - Advanced Dermal Filler Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 16 December, Cheek Augmentation, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 19 December, Introduction to Toxins, Wigmore Medical, London W: wigmoremedical.com 8 January, Non-Surgical Facelift—Advanced Dermal Filler Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 9 January, Bespoke Botox and Dermal Filler Training—half day (am and pm), The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 13 January, Bespoke Botox and Dermal Filler Training—half day, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 14 January, Bespoke Botox and Dermal Filler Training—half day (am and pm), The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 21-22 January, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 24 January, Foundation Botox and Dermal Filler Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk

26 January, Botox and Dermal Fillers Refresher, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 30 January, Bespoke Botox and Dermal Filler Training—half day, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 30 January, Advanced Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 31 January, Foundation Botox and Dermal Filler Training, Essex W: cosmeticcourses.co.uk

I

INJECTABLES

8 December, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com 11 December, PRP Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 16 December, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 12 January, Microsclerotherapy Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 19 January, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com 26 January, Platelet Rich Plasma Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk

S

SKINCARE

1-3 December, ZO Medical Basic, Intermediate &

Advanced, Wigmore Medical, London W: wigmoremedical.com

Aesthetics, Essex W: edenaesthetics.com

9 December, Chemical and Physical Remodelling focusing on Acne and Rosacea, London W: skinmed.co.uk

29 January, Microdermabrasion Training, Eden Aesthetics, Glasgow W: edenaesthetics.com

10 December, Skincare and Peels, Wigmore Medical, London W: wigmoremedical.com

29 January, Agera Skincare and Peel Training, Eden Aesthetics, London W: edenaesthetics.com

15 December, Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com

29 January, gloTherapeutics, Wigmore Medical, London W: wigmoremedical.com

17 December, gloMinerals, Wigmore Medical, London W: wigmoremedical.com 12 January, Agera Skincare and Peel Training, Eden Aesthetics, Essex W: edenaesthetics.com 12 January, Agera Skincare and Peel Training, Eden Aesthetics, Warrington W: edenaesthetics.com 13 January, Epionce skincare and peel training, Eden Aesthetics, Essex W: edenaesthetics .com 13 January, Epionce Skincare and Peel Training, Eden Aesthetics, Warrington W: edenaesthetics.com 20 January, Skincare and Peels, Wigmore Medical, London W: wigmoremedical.com 27 January, Agera skincare and peel training, Eden Aesthetics, Glasgow W: edenaesthetics.com 27-28 January, ZO Medical Basic and Intermediate, Wigmore Medical, London W: wigmoremedical.com 28 January, Epionce Skincare and Peel Training, Eden Aesthetics, Glasgow W: edenaesthetics.com 28 January, Microdermabrasion training, Eden

L

LASER/IPL TRAINING

14-19 January, ITEC Laser / IPL Training, Scandinavian Skincare Academy, Gloucestershire W: scandinavianskincareacademy.co.uk/Laser-IPLcourse.aspx

A

AESTHETIC TRAINING

1-20 December, Silhouette Soft 1:1 Refresher Training, London, Midlands, Glasgow W: silhouette-soft.com 14 December, Mini Thread Training, Wigmore Medical, London W: wigmoremedical.com 15 December, 8 Point Face Lift Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 31 January, Mini Thread Training, Wigmore Medical, London W: wigmoremedical.com

If you have a training date or educational event that you would like to feature in Body Language Journal, send for consideration to: arabella@ face-ltd.com

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As 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 now a 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 the 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 also provides you with professional accountancy and legal advice.  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 will have access back issues of Body Language online which is a helpful time-saver, allowing you to re-read past articles by referring to them 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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Treatment approaches

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52 TECHNIQUE I body language

Facial anatomy Understanding facial anatomy and good injection technique are vital for the provision of safe injectable treatments. DR ASKARI TOWNSHEND offers his five key facts for best practice to avoid complications and achieve optimal aesthetic results

A

There are a few facial areas where important structures could be significantly damaged resulting in serious harm and knowledge of this is absolutely vital

DR RAJ ACQUILLA

s a specialism, nonsurgical aesthetics has developed greatly over the years. For example, having started with simply filling lines, we have learnt that changes in bone and fat affect volume and need to be carefully assessed and corrected. This assessment takes skill and experience and so training has become more important. In addition, authorities and the general public—quite rightly—expect and demand practitioners to be well trained and offer effective and safe treatment. Sir Bruce Keogh’s recent report on the regulation of cosmetic interventions indicated that there may be more regulation and training requirements on the horizon.

When discussing training, many instinctively think a good knowledge of facial anatomy is an absolute must to minimise the chance of complications with aesthetic injectable treatment. Of course, this knowledge is important and something that every injector should be familiar with.

However, facial anatomy is fantastically complicated and variable— the real question is how much should practitioners be expected to know? And how much is relevant to the reality of day to day injecting for practitioner and patients? I suspect that it is more likely a patient will suffer poor aesthetic outcome from inadequate assessment, treatment selection and technique.

There are a few facial areas where important structures could be significantly damaged resulting in serious harm and knowledge of this is absolutely vital. It is important that the pursuit of vast knowledge of facial anatomy for academic rather than practical

body language I TECHNIQUE 53

Area

Artery

Glabella

Supratrochlear a.

Nose

Dorsal and lateral nasal a.

Cheek

Infraorbital a.

Alar sulcus

Angular a.

Tear trough

Angular a.

Jaw

Where facial a. enters face

Temple

Superficial a.

reasons does not take the spotlight from this. More importantly, excellent knowledge of anatomy is of little help unless injection technique is safe and precise. Some (if not many) may disagree with this—if you are one of them, continue reading and you may be persuaded to agree with me. I believe that good injection technique is the most important factor in maintaining safety followed by the awareness of those areas of the face that require great care and caution.

1. Vessels—especially arteries—are the most important structures to avoid It is possible to hit bone with a needle and cause some minor trauma and discomfort but not serious harm. A patient will not thank you for hitting a nerve (especially the infraorbital nerve) but again, serious harm is not a concern as long as good “in out” injection technique has been used.

Fanning or great movement of large bore needles and cannulae could transect nerves and so this should not be done in areas where there are large important nerves.

Injecting into muscles is not desired but I am sure that it is done and often without consequence or even the knowledge of either patient or practitioner. There are other structures such as the parotid gland that should be avoided but simple knowledge of the anatomy of this area should be sufficient to avoid this and even if it was inadvertently injected, again it is unlikely that this would result in significant harm.

Tissue is at risk when its blood—and hence oxygen—supply is threatened. This can be via damage to arteries (supply) or veins (drainage). Compromise can be

internal (emboli from product or clot) or external (laceration or perhaps compression). Veins are larger and more distensible due to their thinner, weaker walls. Due to this, they are more likely to be damaged during injectable treatment but this is unlikely to result in more than a bruise or heamatoma.

The injection of even small quantities of thick or particulate materials into an artery can have devastating consequences such as tissue necrosis and even blindness.

These structures are by far the most important to be aware of and avoid when injecting.

2. Vessels are not always where you expect Having even the very best knowledge of facial anatomy won’t stop you from not puncturing vessels as there are variations in anatomy from patient to patient. Lohn et al dissected 201 cadavers and facial arteries. Branching patterns of this artery were found to be symmetrical in only 53%. Simply put, nearly half of the population may have different vascular anatomy on one side of their face compared to the other. In five of the cadavers (1 in 40), the facial artery was undetectable! In these cases, the transverse artery was dominant.

It is important to avoid injecting vessels at all times but as their

position is variable, every injection should be performed as if there is a vessel close by.

3. Puncturing a vessel needn’t be a problem, not realising you have will be It is impossible to avoid damaging vessels when injecting the skin, this is why the risk of bruising is included on consent forms. However, a small bruise is preferable to a large one or a haematoma. Not only is bruising unsightly and distressing for patients who may not want others to know they have had treatment, it also makes it difficult to assess the result of your work and ensure symmetry. When a vessel has been punctured, recognising this early ensures that action can be taken to minimise the size of the resulting bruise. Remember that blunt cannulae can also damage vessels when used vigorously.

Damage from a blunt cannula (a ragged hole rather than a clean slice from a needle) can be greater and so apply pressure to the area for a longer period of time.

Tips for safe injection: • Always aspirate in the same place as you plan to inject.

• In order to do this, stabilise your syringe; - Fingers holding it near the barrel to minimise movement

AMERICAN SOCIETY OF PLASTIC SURGEONS

Table 1: The most important arteries and areas to avoid damaging

54 TECHNIQUE I body language

Table 2: Red blood cell and needle diameter size comparison Needle (G)

Internal diameter (mm)

x larger than Red blood cell

26

0.260

32

27

0.210

26

30

0.159

19

32

0.108

13

Table 3: Summary of location of injections leading to blindness with hyaluronic acid filler Area injected

No of cases (n=17)

Nose

7

Scalp

3

Forehead

2

Glabella

3

Glabella & cheek

1

Temple

1

Table 4: Volumes of different sized vessels Length

Diam

Vol

5cm

2mm

0.16 mls

5cm

3mm

0.35 mls

6cm

3mm

0.42 mls

7cm

3mm

0.49 mls

of the needle.

- Use patient’s face to stabilise your hand.

• Avoid injecting near visible or palpable vessels.

• Watch for bruising, swelling or blancing during injecting.

• Listen to your patient during injection (does it feel different?).

• If you recognise a puncture, withdraw and apply pressure immediately for several minutes.

• Never continue to inject if you suspect you have caused vascular damage.

4. Aspirating before injection is always useful If you wish to minimise your chance of causing harm, do not believe anyone who tells you that you do not need to aspirate. Even a thick product can allow a flashback.

A red blood cell is up to 8 microns in diameter (0.008mm) and so even a standard 32G needle (as opposed to a thin walled version) has an internal diameter that is over 13 times larger. A grey 27G needle will accommodate more than 26 red blood cells side by side and so is certainly large enough to suck up blood if within a vessel. Of course,

a negative flashback does not mean that the needle is not in a vessel but it does add another layer of safety to your injection technique. If ever you did have a serious complication, it is also important to consider how the omission of aspiration would affect your medico-legal position but also your personal feelings about whether you did all that you could to avoid complications.

5. As little as 0.5mls of product injected to the glabella can reach the ophthalmic artery and potentially cause blindness When tissue does not receive enough oxygen via its blood supply, it becomes inflamed. If oxygen deprivation lasts long enough, cells die (necrosis). If the blood supply is restored quickly, it is possible that the damage is minor but if not, there can be significant tissue death and scarring, when skin is involved.

The ophthalmic artery (OA) is the first branch of the internal carotid artery (ICA) and gives off the central retinal artery which supplies all fibres that form the optic nerve. Prolonged occlusion of the central retinal artery results in loss of sight of the eye. Even though extremely rare, this is a complication that must be avoided at all costs.

Once the artery has been compromised there are approximately 90 minutes before irreversible blindness—even with swift action, the prognosis is very poor.

There are many communications between the internal and external carotid artery systems and anastamoses between vessels around the orbit, cheek and nose.

Intra arterial injection in any of these areas can result in compromise of the OA. Many are unaware of just how little product is required to reach this important anatomical danger zone.

An accurate calculation of this is difficult, as in reality vessels dilate when injected and there would be flow of product through communicating branches. However, for a simplified calculation, it is important to know the length of the artery and its diameter. The volume of a cylinder is given by the equation length x π x radius2. The distance to the OA from the gla-

bella is approximately 5cm and its diameter 2mm. A cylinder of this size has a volume of just 0.16mls.

As explained, in reality, the volume would be greater but even a vessel of 7cm length and 3mm diameter would have a volume of just 0.49mls. The main message is that a surprisingly small volume of product will fill a long length of a small diameter vessel and so caution must be observed when injecting even small aliquots.

Summary Knowledge of facial anatomy is vital for the provision of safe injectable treatments. However, as facial anatomy is complex and variable, good injection technique is just as—if not more—important. Areas at risk should be treated with particular care, especially those with shorter paths to the ophthalmic artery as even small volumes of product can cause compromise to this vital vessel. Any injection suspected of puncturing a vessel should be stopped immediately and pressure applied for several minutes to avoid haematoma or bruising. If vascular occlusion is suspected, this is an emergency and when using hyaluronic acid, should be treated with hyaluronidase. In addition, if vision is ever affected as a result of vascular compromise, transfer to a specialist unit should be arranged without fail.

Dr Askari Townshend is lead UK Sculptra trainer for Sinclair Pharma and the UK medical consultant providing support for Sculptra practitioners. He is currently teaching on an MSc course in Facial Aesthetics References 1. Lohn JW et al. The course and variation of the facial artery and vein: implications for facial transplantation and facial surgery. Ann Plast Surg. 2011 Aug;67(2):184-8 2. Dutton JJ. Arterial supply to the orbit. In: Clinical and Surgical Orbital Anatomy. Philadelphia, Pa: Saunders; 1994:68–71.

3. Lazzeri D et al. ‘Blindness following cosmetic injections of the face.’, Plastic Reconstructive Surgery, 129(4) (April 2012), pp.

995-1012.

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body language I CASE STUDY 57

Thread lifts MISS ZAHIDA BUTT and MR BIJAN BEIGI present a case report on the use of Silhouette Soft as a non-surgical option to treat facial nerve palsy

L 1. Before treatment 2. May 2014, after treatment with Silhouette Soft, Sculptra, Juvederm, Botox and brow lift 3. September 2014—stitches have been removed following brow lift surgery



ast October, a female patient presented for an initial consultation. She had a past medical history of left lower seventh (facial) nerve palsy following excision of left benign parotid adenoma in 2002.

This had been treated over the years, firstly with a left lower facial nerve graft in 2003 in London, and followed at a later date by endoscopic brow lift using an endotine implant. Unfortunately this did not make much difference.

Nerve conduction tests showed no response from the left facial nerve, which was therefore considered completely paralysed.

She was extremely traumatised by her previous repetitive surgery and had been recommended to see me for a non-surgical option. I advised her to have a couple of sessions with Sculptra to help volumise the left side of her face—which was



showing evidence of muscle and fat atrophy due to disuse—followed by non-surgical left mid and lower facial lift with Silhouette Soft.

I advised that Sculptra would help stimulate collagen in her left cheek area and this would help anchor the threads and therefore make the Silhouette Soft more successful in lifting her left lower face.

She also had evidence of left brow ptosis, left upper and lower lid retraction, giving her lagophthalmos (poor lid closure). In addition, the patient was keen on Silhouette Soft for a left brow lift but I did not feel this would give her a long term solution and also would pose a further risk of corneal exposure and ulceration because of her lagophthalmos.

I advised her a direct brow lift as a more permanent option in addition to a platinum weight for her left upper lid.



Method and results One vial of Sculptra was injected into the patients’ left temple and midface on the 7th November, 2013 and a second vial was injected into her mid face and lower face a month later on the 5th December. Then, on the 9th January 2014 she had 4x16 cone Silhouette Soft threads inserted into her left mid and lower face (each thread has 16 cones attached to it that help anchor the threads in the subdermal plane).

There were four exit points marked, the first point was 1cm lateral to the upper half of the nasolabial fold, the second point was 1cm lateral to the middle half of her nasolabial fold, the third and fourth points were 1.5 cms apart in the line between the corner of the mouth and the angle of the mandible.

This was tolerated very well and there were no postoperative problems.

58 CASE STUDY I body language

ward technique done as an outpatient in a clinic setting.

The Silhouette Soft thread and cones are made entirely from polyL-lactic acid which are entirely absorbable, leaving behind fibrotic tissue as it dissolves to help maintain the desired lift over a 12-18 month period and is easily repeatable.

Silhouette Soft suture

I saw her for review three months later in April, and she was extremely pleased with the results—her left side had lifted and looked significantly better. The corner of her left lower lip was still downturned slightly and I therefore suggested that she had some Juvederm Ultra 4 placed into her marionette lines, left side more than right to help improve this further. I also gave her four units of Botox into her left levator anguli oris muscle to complement the filler treatment.

Since then she has also undergone left direct browlift in addition to upper lid blepharoplasty under local anaesthetic on the 10th May this year. A platinum weight for the left eyelid was not deemed necessary as there was adequate eye closure and she had a good Bell’s phenomenon. Nine days later, her left eyebrow position was very good and her sutures were removed, she had made an excellent recovery and was very pleased with the outcome.

Her last check up was in June and her left brow position and left mid face and lower face are well maintained with adequate lift.

Discussion Facial nerve palsy is a feared complication of head and neck surgery and cancer. There are huge psychosocial and functional implications for the patient. Traditional options have included gold/platinum weights inserted into the upper eyelids, tarsorraphy, microvascular free tissue transfer, interposition grafts of the

facial nerve and hypoglossal facial nerve anastomosis. In patients who have already undergone significant surgery and have a complex surgical history already , further radical surgery in the form of free flaps or nerve anastomosis are often not warranted. Previous literature search shows that the Silhouette lift is an alternative solution to this difficult and often devastating condition, but so far there has not been any mention in the literature of using Silhouette Soft for this.

In the literature, facial rejuvenation and improvement of malar projection/jaw definition using non absorbable 3/0 polypropylene sutures with absorbable cones made of L-lactic acid and glycolide polymer has been published (Silhouette lift). The Silhouette lift has been used as a mid face and lower face lifting technique in suitable patients for both cosmetic reasons and for facial palsy patients.

The Silhouette lift is a surgical procedure whereby a surgical incision is made both at the entry and exit points where the suture is inserted and removed, necessitating sutures for closure. The entry point is a 2.5-3 cm incision in the temporal hairline and there are usually four exit incisions placed between the mid half of the nasolabial fold to the jawline. The Silhouette Soft technique that was used in this case, however, is entirely non-surgical, requiring only needle entry and exit points and therefore no sutures are required. This is a straightfor-

Summary My case report is the first nonsurgical option presented in the literature, using a combination of Silhouette Soft and Sculptra for lower seventh (facial) nerve palsy.

This should be considered for appropriate patients who want a nonsurgical and straightforward procedure which takes approximately 45 minutes to do. Post-operative complications are minimal in the form of bruising and swelling which is transient and settles within three to five days and antibiotic cream is used for three days over the entry and exit points.

Miss Zahida Butt and Mr Bijan Beigi are Consultant Ophthalmic and Oculoplastic surgeons and are Clinical Directors of The Norwich Cosmetic Clinic References 1. Aesthetic and Plastic surgery. April 2011, volume 2.

Facial rejuvenation and improvement of malar projection using sutures with absorbable cones: surgical technique and case series.

Javier de Benito et al 2. Journal of Dermatological Surgery. April 2009:35; 645-650. Novel specialised suture and inserting device for the resuspension of ptotic facial tissues, early results. Bisaccia E et al.

3. Clin Plastic Surg 2008: 35;481-486. Silhouette sutures for treatment of facial ageing: facial rejuvenation, remodelling and facial tissue support. Nicanor Isse.

4. The Journal of Cranio Facial Surgery. Volume 24, Number 1, Jan 2013. Suspension sutures in facial reconstruction: surgical techniques and medium term outcomes. Maschio F et al 5. The Annals of Plastic Surgery volume 62, number 5, 2009:62;478-481. Suture suspension technique for mid face and neck rejuvenation. Gamboa GM and Vasconez LO. 6. Clinical Otolaryngology, 2009:34;390-408.Silhouette lift for facial reanimation. Stephens J et al.

7. International Journal of Clinical Medicine, 2012:3;5559 Facial Asymmetry correction in Facial Palsy patients with Silhouette Sutures. Navarrete M et al.

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Date of preparation: August 2014 UK/SIPGEN/14/0001

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body language I INJECTABLES 61

Fresh-faced Dermatologist DR CHRISTOPH MARTSCHIN examines the role of hyaluronic acid skin boosters in skin rejuvenation

A

study published in the American Journal of Aesthetic Surgery in March 2006 revealed that the thinning of the dermis appears seven to eight years before sagging is actually visible. This means that structural changes in the skin appear years before the effects are visible to the naked eye. So the question is can hyaluronic acid be a tool to halt this thinning of the dermis and postpone the visible results of gravity?

Many years ago when I had just bought my first fractional laser and was very interested in treating everything possible with lasers, a colleague of mine, Uppsala based Dr Anders Strand, showed me a picture of a former co-worker who had been treated with Restylane Skinboosters.

She was treated with one ml, at three occasions, four weeks apart and I was really impressed with the difference it made—not only in the global volume of the face, but also the impressive gain in elasticity and the radiance of the cheek.

This is when I started working with skin boosters and I have not regretted it yet.

the hype around the collagen fragments—peptides, Matrixyl and others found in studies on wound healing. So whatever fracture there is of the extracellular matrix, it gives a signal to the fibroblast that there is a damage that needs to be repaired, so also hyaluronic acid.

Effects I hired a lady who’s very good at doing skin scans, and she works for a cosmetic company that promotes vitamin A based skincare. To prove the effect of the products, they carry out skin scans before and six months after the customer went onto the treatment regimen.

I asked one of my customers to be in a case study. This female was 43 years old, and before treatment was scanned. She had a dermal density index of 51. That is pretty good compared to what’s normal for her age. She was above average which isn’t a surprise, because most customers that come to our clinics are really well taken care of.

I injected her with Restylane Skin-

66 The key to successful treatment in my opinion, is good patient selection, good information about what can be achieved, regular maintenance and choosing the right product 99 HA and the skin I found a very interesting paper from 1988, showing that hyaluronic acid modulates proliferation of dermal fibroblasts in culture. Another publication in 2007 showed that the cross-linked hyaluronic acid in dermal fillers actually stimulates de novo collagen production.

This means there is more to it than simple hydration. Hyaluronic acid, or its fragments after the breakdown, attach to receptor fibroblasts and stimulate production of new collagen. Even more recently it is shown that even keratinocytes have a receptor for hyaluronic acid.

Cosmetic dermatologists know about

boosters, one ml, per treatment and three treatment sessions spaced four weeks apart. What happened at week four was a natural 8% increase in dermal density. At week four, however, the customer could not yet feel a huge difference.

At week nine her dermal density had increased by 14% and it was then the customer really noticed the difference in elasticity. She asked for the treatment because she was tired of the pillow-lines that traversed over her face every morning, but after the treatment she no longer had the wrinkles in the morning, so she was really happy with it.

However I was curious to see whether it

was that just a one hit wonder or whether it worked in all customers. I asked a younger customer, aged 32, to do the same thing and she started at a dermal density of 46, increasing by 9% after five weeks and a further increase up to 13% at week 10.

Again, at week four she wasn’t really sure if she could feel or see a difference, but at week 10 it was obvious. So in our experience it takes about eight to 12 weeks for the customer to really see and feel the difference.

Clinical studies One of the first studies on skin boosters was done by a German colleague, Dr Kirschner and published in Dermatological Surgery 2008. She investigated the effects of the physical parameters of Restylane Skinboosters. It is a prospective, single centre study including 19 female patients who underwent the traditional treatment schedule.

At the first visit they went through photography, measurement of cutaneous elasticity, surface roughness and skin density. Then they got their second treatment at week four, their third treatment at week eight, and then they had a follow up until week 24.

The method used for measuring skin elasticity is like a vacuum. It sucks up the skin a little and then it releases the skin measuring the time it takes for the skin to go back to its normal position. Then skin thickness was measured using the DUB 20, the same amperage I was using for my case study. The skin surface was analysed with the Visio-scan using both visible and ultraviolet light to bring out the skin microrelief.

The findings were really impressive and they also are in line with what I found in my customers. At the first visit to the second visit there was a measurable improvement, but it wasn’t really obvious to the customer. Then at around week eight and week 24, there was a visible and perceptive difference to the customer when it came to skin roughness.

Many customers report that their skin is smoother and gets a better glow. Skin elasticity also significantly improved. The interesting thing is that almost nine out of 10 patients are very happy with the

62 INJECTABLES I body language

Restylane Skinboosters

treatment, which is a good outcome for such a simple thing as injecting stabilised hyaluronic acid.

Treatment areas Hyaluronic acid does not only work on the face, it works really well on other locations on the body, like the hands and décolletage. I’ve been using it on the knees, on the skin above the elbow or wherever there’s a need for redensification and increase in elasticity.

Keep in mind it’s not only the thinning of the skin that gives us wrinkles and décolletage. It’s also the mechanical pressure during the night, so improvement depends a bit on the cup size and the stage at which you start the treatment.

As the décolletage is a large area we should be generous and use two ml at a time. We should also make the patient aware that they should start in autumn to have the perfect results next spring. An even distribution of the product is the key to beautiful results.

Technique Going back to the late 90s, when hyaluronic acid fillers were launched, some markets asked for a thinner product that was easier to inject and the injection technique was not that elaborate at the time.

It takes a while to bring out a new product and once the thinner product was launched, most injectors had adapted to the rather firm gels of the time.

Other markets really welcomed the product and used it in the same manner as they used mesotherapy products, so they traditionally used one syringe at three times, spaced four to eight weeks apart. My personal treatment scheme for the face is actually two ml, at two treatment sessions, spaced four weeks apart.

I find that very effective because in today’s busy lifestyle, many customers can’t find the time to come for three repetitive treatments and the follow ups inbetween. This extra ml also really gives the final boost for the face.

Of course, you can adapt this to specific needs. If you perform a preventive treatment, you might choose Vital Light and do one or two treatments to start with. You can also space the touch individually. I usually do a touch up every six to nine months.

The effect lasts nicely until week 36.

There’s still a huge improvement after week 36 but you don’t want to wait until the effect has fully vanished. You try to maintain it with regular injections and in that case one ml is usually enough.

The key to successful treatment in my opinion, is good patient selection and good information about what can be achieved. But it’s also about regular maintenance and choosing the right product, Restylane Vital or Vital Light, depending on the area and customers needs.

One of my own customers, a woman aged 46, came to me before Christmas and said that she wanted to look gorgeous for the holiday season. I told her we could put a little in her cheeks and work with the set corners of the mouth. But she said she wanted real improvement of her skin.

She could feel her skin start sagging and said it had lost its elasticity, so we decided to use skin boosters. At 12 weeks there was a noticeable difference after two plus two ml skin boosters.

I used pixel cannula for the injection.

I prefer the cannula because it offers the same benefits but with higher patient comfort compared to sharp needel. Restylane Skinboosters over time really gives a global increase in volume and dermal density. It also gives the impression of reduced sagging, but the skin is merely filled out and fine lines in the cheek are reduced.

Acne scarring Acne scars, for me, are sometimes a challenge to treat. Fractionated lasers for many of us are the first choice to treat acne scars, but some scars are still very persistent.

There are different types of acne scars.

Firstly the ice pick scar which is really narrow and deep and hard to treat.

Some people like to treat it with punch biopsy, followed up by laser treatment.

The second type is rolling scars that are anchored deeper down in the dermis that gives a rolling effect. Third there’s the boxcar shaped, cellular-like scar.

A recent study from Israel examined the use of Restylane Skinboosters as a second-line treatment after fractionated lasers in deeper scars with visible improvement and a lift of the scar being achieved after there had been reached a plateau with the laser.

In acne scars I prefer the sharp needle

and I use it to really loosen the fibrotic anchor and create a cavity for the product and then inject just a few droplets. With this technique you get a real difference after around 12 weeks.

For any remaining redness add on a v-beam or IPL. Sometimes, if it’s mainly rolling scars, skin boosters have become my first choice treatment because it has little downtime compared to more aggressive fractionated laser treatment and the results are good.

Cannula vs needle I prefer to use cannula for skin rejuvenation treatments but there are of course advantages and disadvantages with both.

If I work with acne scars, I like to use the sharp needle to really cut the space under the scar to fill it with the product and it’s easier to get an even distribution. You just space the micro-injections one to two centimetres apart from each other.

However, we need to consider the bleeding and bruising that it creates— many customers want to go back to work after treatment. In this case incisions with the micro-cannula are an improvement, if a bit more time-consuming. I am careful to place the product evenly, and the results are the same.

One of the secrets of a good treatment is to place the product evenly in small droplets and not hurry.

Dr Christoph Martschin runs his own dermatology practice in Stockholm. He also works as a consultant for Galderma and as a clinical investigator for Bristol Myers Squibb References 1. R.Groover, SR. Coleman, American Aesthetic Surgery Journal, February 2006 2. Yoneda M, Yamagata M, Suzuki S, et al. Hyaluronic acid modulates proliferation of mouse dermal fibroblasts in culture. J Cell Sci 1988;90(Pt 2):265–73.

3. Greco RM1, Iocono JA, Ehrlich HP. Hyaluronic acid stimulates human fibroblast proliferation within a collagen matrix. J Cell Physiol. 1998 Dec;177(3):465-73.

4. Wang F, Garza LA, Kang S, et al. In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Arch Dermatol 2007;143:155–63.

5. Kerscher M et al. Dermatol Surg 2008;34:1–7 6. Streker M et al. J Drugs Dermatol.

2013; 12(9):990–994 7. Halachmi S. et al. J Drugs Dermatol.

2013; 12(7):e 121-e 123.

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Now approved for crow’s feet lines

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU 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) and lateral periorbital lines seen at maximum smile (crow’s feet 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. Glabellar Frown Lines: 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. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. 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). Glabellar Frown Lines: 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, 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). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, dry eye. General disorders and administration site conditions; Common: injection site haemotoma.

Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. 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: August 2014. Further information 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 www.mhra.gov.uk/yellowcard 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. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251.

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. 1182/BOC/OCT/2014/LD Date of preparation: October 2014

PURIFIED1• SATISFYING2,3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins