Body Language Issue 69

march

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

PERIORBITAL REJUVENATION

Approaching treatment of the delicate eye area with fractional radiofrequency

FACE 2015

HYPERPIGMENTATION

EQUIPMENT

Conference agenda and exhibition preview

Dr Zein Obagi offers advice for treating darker skin types

Low level light for tackling acne and rosacea

* RESILIENT BEAUTY

*Resilient Hyaluronic Acid

WELCOME TO THE ERA OF DYNAMIC AESTHETICS

body language I CONTENTS 3

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contents EDITOR Helen Unsworth 020 7514 5989 helen@face-ltd.com ASSISTANT EDITOR Lousie Renwick 020 7514 5989 louise@face-ltd.com COMMISSIONING EDITOR David Hicks 020 7514 5989 david@face-ltd.com EDITORIAL ASSISTANT Arabella Tanyel 020 7514 5989 arabella@face-ltd.com SALES EXECUTIVE Monty Serutla 020 7514 5976 monty@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Prof Mukta Sachdev, Dr Matthias Aust, Dr Raj Persaud, Prof Kathleen Martin Ginis, Dr Zein Obagi, Dr David Eccleston, Dr Dianne Quibell, Dr Stephen Eubanks, Dr Carl Thornfeldt, Ms Shashi Gossain, John Castro, Sally Durrant, Gill Herrick, Elizabeth Raymond Brown 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 2015 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

14 DERMATOLOGY TREATING ACNE SCARS There are a myriad treatments available to help diminish acne scarring. Prof Mukta Sachdev discusses her preferred methods and the importance of managing patient expectations

19 EQUIPMENT BURN SCAR REJUVENATION

programme to keep you up to date with the latest developments in medical aesthetics

35 SKINCARE TREATING HYPERPIGMENTATION IN DARKER SKIN USING TOPICALS

Achieving improvement in burn scars can be tricky, however Dr Matthias Aust describes how medical needling can offer a solution

Dr Zein Obagi shares his advice on how to treat pigmentation using a step-by-step approach to reduce skin sensitivity, stabilise cells, control melanocytes and address the correct depth

23 PSYCHOLOGY

39 TECHNIQUE

BODY IDEALS

WIDE AWAKE

Are ‘hookups’ changing the way men and women view each other? Dr Raj Persaud and Prof Kathleen Martin Ginis look at the research

Dr David Eccleston considers the challenges of peri-orbital rejuvenation

26 CONFERENCE FACE 2015 Held at the QEII Centre in London’s Westminster on June 4th -7th, FACE 2015 will host a world-renowned speaker panel, delivering a complete educational

43 MEDICAL AESTHETICS FRACTIONAL LASERS FOR PERIORBITAL REJUVENATION Considering the bone structure of a patient, not just their skin is important when using fractional lasers around the eyes.

Dr Dianne Quibell guides us through her approach.

4 CONTENTS I body language

editorial panel

57

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.

47 PRODUCTS ON THE MARKET The latest anti-ageing and medical aesthetic products and services

48 EQUIPMENT 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.

LIGHT STIMULATION Dr Stephen Eubanks explores using low-level light to trigger a biologic response and effectively treat acne and rosacea

55 DEBATE 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.

HYPERPIGMENTATION Dr Carl Thornfeldt and Ms Shashi Gossain share their views on topical treatments

57 MARKETING 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.

PROMOTING YOUR CLINIC WITH SEO John Castro gives advice on how to use and implement Search Engine Optimisation (SEO) to market your clinic.

59 PANEL 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.

TRAINING AND ACCREDITATION Our expert panel debate training requirements and regulation in the medical aestheitc industry

61 EDUCATION 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.

TRAINING DATES A comprehensive course calendar for the industry

62 EXPERIENCE WORDS OF WISDOM

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.

Professor Mukta Sachdev chose to specialise in dermatology and completed her training in Bangalore. She shares her journey through the career she loves and her positive approach to treatment

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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

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body language I NEWS 7

observations

BAPRAS LAUNCHES ‘THINK OVER BEFORE YOU MAKEOVER’ CAMPAIGN Aimed at raising consumer awareness of safe and appropriate cosmetic surgery A new campaign—Think Over Before You Makeover—is being launched by the British Association for Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) to address the worrying lack of consumer awareness about how to choose safe and appropriate cosmetic surgery.

For Think Over Before You Make Over, BAPRAS conducted a major national study of attitudes and approaches to cosmetic surgery and found that thousands of people are at risk both physically and psychologically from poor or inappropriate cosmetic surgery.

Of the two million people in the UK considering or undergoing cosmetic surgery in the next year one quarter of these patients don’t check credentials of their surgeon, a fifth aren’t aware of the risks associated with the procedure and a further fifth aren’t even clear on the potential outcomes of the pro-

cedure before going ahead. Furthermore, a quarter are not aware if any aftercare is available should something go wrong.

The campaign provides a comprehensive range of advice on what everyone needs to know to make safe informed decisions. The public can access a range of materials including a range of free guides from expert BAPRAS plastic surgeon members, alongside patient case study stories and Q&As to help keep people safe if they are having surgery.

Nigel Mercer, BAPRAS President and Consultant Plastic Surgeon, said: “Cosmetic surgery is not something to be taken lightly and yet thousands of people are putting themselves at serious risk by rushing in to major procedures recklessly, without consideration for their own safety. In fact, many people spend more time choosing an

electrician than they do a surgeon.

Think Over Before You Make Over is not here to promote cosmetic surgery; we recognise that thousands of people will choose to have surgery this year and we want all these people to read our campaign advice so they can make informed choices and protect themselves from bad practice.”

“BAPRAS has been at the forefront of driving the highest standards of industry practices, demanding appropriate regulation and marketing of cosmetic surgery interventions. Think Over Before You Makeover builds on this commitment. We need an informed and empowered public, able to make active choices; we critically need people to think over before they make over, and we call on everyone to support this vital campaign.”

More information about the campaign, can be found at W: .bapras.org.uk/thinkover

8 NEWS I body language

events 1 MARCH, International Symposium of the Indian Society of Cosmetic Surgery, Cavelossim Beach, Goa, India W: iscs.in 6-8 MARCH, Annual Meeting of the Tennessee Society for Laser Medicine and Surgery, Nashville, TN, USA W: tnlasersociety.com 7-8 MARCH, ACE 2015, London, UK W: aestheticsconference.com 11-14 MARCH, Plastic Surgery at the Red Sea, Eilat, Israel W: redseaplastics2015.com 20-24 MARCH, Annual Meeting of the American Academy of Dermatology (AAD), San Francisco, California, USA W: aad.org 20-24 MARCH, Milano Masterclass Expo Edition, Milan, Ialy W: milanomasterclass.it 26-28 MARCH, 13th AMWC 2015, Monte-Carlo, Monaco W: euromedicom.com 26-28 MARCH, Paris Breast Rendez Vous, Villejuif, France W: parisbreastrendezvous.com

US SURVEY SHOWS SHIFTS IN USE OF COMPLEMENTARY HEALTH APPROACHES

28 MARCH, Advanced MACS Lift Course, Gent, Belgium W: coupureseminars.com 9-11 APRIL, Annual Conference of the Association of Cutaneous Surgeons of india (ACSI) - ACSICON 2015, Kolkata, India W: acsicon2015.com

Natural dietary supplements were most commonly used

10-12 APRIL, IMCAS China 2015, Shanghai, China W: imcas.com

Non-vitamin, non-mineral dietary supplements were the most popular complementary health approach used by Americans between 2002 and 2012 according to a complementary health questionnaire administered in the USA. Comparing trends in Americans’ use of selected complementary health approaches in 2002, 2007 and 2012 as part of the National Health Interview Survey (NHIS), showed that natural dietary supplements were the most commonly used complementary health approach at each of the three time points: 18.9% in 2002 and unchanged from 2007 to 2012 at 17.7%.

Fish oil was the top natural product among adults and adult use of fish oil, probiotics or prebiotics, and melatonin increased between 2007 and 2012. There was a decrease in adult use of glucosamine/chondroitin, Echinacea, and garlic in adults between 2007 and 2012. In 2012 fish oil was the most used product by children and melatonin was the second—it’s use increasing substantially from 2007 to 2012.

“While NHIS does not assess why shifts in use occur, some of the trends are in line with published research on the efficacy of

16-18 APRIL, 4th World Congress of Dermoscopy and Skin Imaging (IDS), Vienna, Austria W: dermoscopy-congress2015.com

natural products,” said Josephine P. Briggs, M.D., Director of NCCIH. “For example, the use of melatonin, shown in studies to have some benefits for sleep issues, has risen dramatically. Conversely, the use of echinacea has fallen, which may reflect conflicting results from studies on whether it’s helpful for colds. This reaffirms why it is important for NIH to study these products and to provide that information to the public.”

Complementary approaches recorded in the data set, aside from nonvitamin, nonmineral dietary supplements included use of acupuncture; Ayurveda; biofeedback; chelation therapy; chiropractic care; energy healing therapy; special diets; folk medicine or traditional healers; guided imagery; homeopathic treatment; hypnosis; naturopathy;; massage; meditation; progressive relaxation; qi gong; tai chi; or yoga.

Deep-breathing exercises—used either independently or alongside another approach were the second most commonly used complementary health approach in 2002 (11.6%), 2007 (12.7%), and 2012 (10.9%). People engaging in yoga, tai chi, and qi gong increased linearly from 2002 to 2012, with 80% of this related to yoga.

17-21 APRIL, Congresso Brasileiro de Cirurgia Dermatologica, Bahia, Brazil W: sbd.org.br 22-26 APRIL, Annual Conference of the American Society for Laser Medicine & Surgery (ASLMS), Kissimmee, Florida, USA W: aslms.org 20 APRIL – 2 MAY, Cosmetex 2015, Melbourne, Australia W: cosmetex.org 25-26 APRIL, Aesthetic Medicine Live, London, UK W: aestheticmed.co.uk 1-3 MAY, Middle East Congress on Rhinology and Facial Plastic Surgery (MERC), Tehran, Iran W: merc2015.com 6-9 MAY, Annual Meeting of the Society for Investigative Dermatology, Atlanta, Georgia, USA W: sidnet.org 8-9 MAY, Annual Conference of the Association of Scottish Aesthetic Practitioners (ASAP), Glasgow, Scotland W: imcas.com/en/worldwide-agenda 12-15 MAY, Skin Care 2015, Montreal, Canada W: spsscs.org Send events to arabella@face-ltd.com

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body language I NEWS 11

THE OVER 65S ARE LEADING A SURGE IN COSMETIC SURGERY IN THE UK Survey shows increase in older people seeking surgery In their first annual plastic surgery insight survey, almost two thirds (64%) of Nuffield Health surgeons—who between them carry out 1 in 10 UK cosmetic procedures—reported an increase in older people seeking surgery.

The total number of patients treated

by Nuffield Health over age 65 also increased 49% between 2007 and 2014 according to the organisation’s latest figures.

Four in five (82%) of the Nuffield Health surgeons reported a rise in men seeking cosmetic surgery in the form of rhinoplasty, eyelid lifts and ‘man boob’ removal. With surgery for men increasingly becoming ‘the norm’ in recent years—accounting for one in ten of all UK cosmetic procedures, this trend looks set to continue.

Mr Ian Whitworth, Consultant Plastic Surgeon at Nuffield Health Bournemouth, said, “I’m now seeing many more people in their 60s, 70s and even their 80s seeking plastic surgery as they not only want to remain fit and healthy into their old age but they want to look well too. I think this trend will continue as this is an expanding age group. They aren’t usually looking for radical work, normally facerejuvenation, and providing they are fit and healthy, we can use new techniques and technologies that are ideally suited to them. I also see many more men. 15 years ago surgery on men was very rare, now they make up around 10-15% of the people I see.”

A rise in the number of previously overweight or obese patients looking for surgery following dramatic weight loss was reported by 95% of surgeons.

Plus results showed a clear shift away from celebrity copycat procedures—for 75% of surgeons it was very rare to be asked to replicate a celebrity look—with 100% reporting people seeking a natural looking result and 57% the desire to rejuvenate rather than enlarge.

The desire to improve self-confidence was agreed by all surgeons to be the key motivator for most patients—greater than peer pressure, pressure from a partner, or the need to look good at work.

The surgeons, from 31 Nuffield Health hospitals across the UK also shared their predictions for the future. A 95% majority agreed that they would continue to see an increase in men and 82% believe they will be seeing increasing numbers of older people amongst their patients. Face transplants, light weight breast implants and mid-face lifts (which lift the middle segment of the face) were emphasised as new and innovative techniques that will become more commonplace over the coming years in the world of cosmetic or reconstructive surgery fol-

lowing accidents or injury.

Mr Whitworth, said “Plastic surgery is such an innovative speciality. In cosmetic surgery we are seeing much more integration between non-surgical and surgical procedures, combining fillers and Botox, and surgery where appropriate.

“The pioneering areas are in reconstructive surgery where surgeons in the UK are really pushing boundaries, particularly in their work with the armed forces. There are also incredible things happening with tissue engineering, where facial features, like a nose, can be rebuilt using other parts of the body”.

12 NEWS I body language

CEN PUBLISHES STANDARD ON AESTHETIC SURGERY SERVICES Expected to help improve the quality of services and enhance safety and satisfaction of patients and lower complications risk

APP IDENTIFIES SKIN LESIONS New application could help with the clinical detection of skin cancer A new app that could play a vital role in the clinical detection of skin cancer, is being offered free to practitioners, physicians and dermatologists in the United Kingdom, USA and Australia.

The app, which was launched on World Cancer Day, 4th February 2015, uses state-of-the-art image recognition software to offer the world’s first skin identification system. The simple inexpensive software system developed by Lūbax is designed to identify types of skin lesions by searching a database of over 12,000 diagnosed skin-lesion images and showing the user the most similar images and their associated clinical diagnoses. As the database grows over time the app will support health professionals by recognising and differentiating more skin-diseases.

“The Lūbax app could provide a major contribution in improving melanoma detection with its innovative technology.

As a primary care researcher I am keen to study its usefulness among generalists in different countries and with different thresholds for referral for specialist care,” said Dr Fiona Walter, a General Practitioner & Clinician Scientist from the Department of Public Health and Primary Care at the University of Cambridge. ”Mobile health apps and the power of the Internet have the potential to change the trajectory of premature deaths from cancer worldwide. We encourage all technology entrepreneurs to apply their skills and knowledge to global health issues, including cancer, to help us drive equitable access to information, awareness and early detection,” urges Cary Adams, Chief Executive Officer, Union for International Cancer Control (UICC). “Together with health experts we can create a pipeline of technology-driven solutions which will help all of us access these key levers to address cancer globally. We will let down future generations if we do not press forward exploring and testing new and exciting technology advances as they emerge.”

Feedback from health professionals can be sent to CustomerCare@lubax.com and more information about the app is available at Lubax.com.

The European Committee for Standardization, CEN has announced the publication of a new European Standard for Aesthetic Surgery services (EN 16372), which is hoped will help improve the quality of services, enhance the safety and satisfaction of patients, and reduce the risk of complications.

The new European Standard addresses requirements for surgical services provided to patients who wish to change their physical appearance. There are recommendations relating to services provided by aesthetic surgery practitioners concerning ethics and marketing, information provided to patients, competencies of the surgeons, the consultation procedure, requirements for clinical facilities and post-operative follow-up.

The Standard was developed by CEN’s Project Committee on ‘Aesthetic Surgery and Aesthetic Non-surgical Medical services’ (CEN/TC 403), which was set up in 2010. Having been formally approved by CEN in October 2014, this standard will be published by the end of June 2015 at national level by CEN Members in 33 European countries.

The Project Committee CEN/TC 403 is chaired by Plastic, Aesthetic and Reconstructive Surgery Specialist Dr Johann Umschaden from Vienna. According to him “The new European Standard defines a high level of quality for aesthetic surgery services and provides the basis for optimal patient safety”.

“Even if there are specific regulations in some EU Member States on aesthetic surgery, some of them are lacking in terms of hygienic, technical issues, or they don’t include a risk analysis. Recent reports on incidents in the context of Aesthetic Surgery emphasize the importance of this comprehensive European Standard, which was developed through an open, inclusive, multi-disciplinary and evidence-based process.”

Dr van Heijningen, National Secretary of the International Society of Aesthetic Plastic Surgery (ISAPS) in Belgium, who worked alongside Dr Umschaden and helped initiated the project said, “This European Standard is a landmark for health care services, especially considering the cross-border mobility of patients in Europe”.

“Whether they are being treated in their own country or abroad, patients expect to be treated by competent practitioners in a safe environment and to be informed about relevant issues related to their treatment, including risks. These expectations are addressed by the new European Standard for aesthetic surgery services,” continues Dr van Heijningen.

The CEN Project Committee on ‘Aesthetic surgery and aesthetic non-surgical medical services’ is currently developing a separate European Standard in relation to non-surgical medical procedures and will invite comments on this draft standard at the end of February 2015.

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14 DERMATOLOGY I body language

Treating acne scars There are a myriad treatments available to help diminish acne scarring. PROF MUKTA SACHDEV discusses her preferred methods and the importance of managing patient expectations

W

orking with darker skins is a constant challenge and in order to provide treatment efficacy with a high level of patient satisfaction and at the same time avoiding complications can keep one on their toes on a daily basis.

The incidence of acne scarring is studied with varying reports , but the key is to be sure what kind of a scar you’re treating—atrophic, hypertrophic, sclerotic, ice-pick, boxcar or keloidal. If a scar is keloidal you would not treat it with a procedure otherwise it can result in more keloid scars. Atrophic acne scars are by far the most common type.

The acne patient is a one of the commonest patients any dermatologist will see and a delicate handling of the patient is a basic requirement .

Take a detailed history before you start treatment- establish how much the scarring is bothering the patient and ask what the patient expects from the treatment. Take accurate pictures, measure the scars, and show the patient the progress throughout. This will enhance patient compliance and also reassure the patient that you are following up their treatment effectively.

Check if your patient has had any prior procedures, has any ac-

tive acne or has had isotretinoin. If the patient has had isotretinoin or is on recent isotretinoin there is definitely an increased risk of scarring, especially in darker skins.

One must also check if there is a history of keloids or a history of post-inflammatory hyperpigmentation (PIH).

When you are in an aesthetic or clinical dermatological practice it is important to be able to recognise the kind of a scar you’re dealing with and classify it. There are several grading scales available in the literature .One of them—the Goodman Grading for Scars is quite effective to use in practice.

body language I DERMATOLOGY 15

First clinically examine the scar, visually inspect, palpate, stretch and note whether there is active or inflammatory acne present as this is a contraindication for treatment

• Grade 1 is very mild, • Grade 2 has mild atrophy, • Grade 3 is moderate, cannot be covered up with makeup and can be flattened when you stretch the skin.

• Grade 4 is severe disease—the scarring is present and not flattened by manually stretching the skin.

It is recommended to first clinically examine the scar, visually inspect, palpate, stretch and note whether there is active or inflammatory acne present as this is a contraindication for treatment.

With this grading, if you stretch the skin you can distinguish between Grade 3 and Grade 4 scars, it can help determine whether the

66 Be sure what kind of scar you are treating— atrophic, hypertrophic, sclerotic, ice-pick, boxcar or keloidal 99 patient will benefit with a filler injection for the scar.

Treatment In the practice we use a range of treatments for scars—resurfacing procedures, dermarollers or micro needling and dermastamp/ pen , chemical peels, the CROSS

technique, dermabrasion, fillers, microdermabrasion, laser resurfacing, ablative and nonablative, and fractional lasers.

Some doctors now use autologous fat transfer for acne scars and punch evaluation, punch excision, elliptical excision and punch grafting.

Micro needling has its place for

16 DERMATOLOGY I body language

thelial wall and promotes dermal remodelling. You need to be extremely careful with this technique as you induce necrosis. Surround the areas to be treated with Vaseline for protection, and just touch the base of the scars. The most common complication is PIH. In Caucasian skins it works much, much better but it is an extremely skilled approach.

Darker skinsare at risk of post laser or post treatment hypo and hyperpigmentation—aggressive regular broad spectrum sun protection pre and post care are advised

darker skins but I have seen cases of PIH , in darker skins even with micro needling. The dermal vessels are wounded causing a cascade of events that includes platelet aggregation, release of inflammatory mediators, neutrophils, monocytes, fibroblast migration and collagen production. The improvement that you can get with rollers or lasers, depending on the depth of the scars, is 40% to 50% improvement after approximately six to eight sessions.

Erythema and bleeding are side effects of using a roller, and everything depends on the pressure of your hand. Results can be inconsistent care needs to be taken to avoid going deeper in some places and ensuring you are not tearing the skin. Even with automated devices such as the pen, no matter how controlled it is, if you are using too much pressure you can tear the skin and get PIH. Popular opinion seems to indicate that rollers and pens offer lower risks of PIH but I disagree.

In skin types 3, 4, 5 and 6 I think the risks are pretty much equal. I also think results can include a line of demarcation. If you are rolling some areas and leaving others, care must be taken. You need to cover the whole area otherwise if you do

Subcision Subcision which is subdermal incisionless undermining, is indicated for some acne scars and is a new technique. Subcision for depressed facial scars using a simple modification where the instrument is inserted and rotated, you can get improvement in the scar. It is a simple technique, and easy to do in the office.

Summary With darker skins, we always need to consider the risks of post laser or post treatment hypo and hyperpigmentation. I advise the use of aggressive regular broad spectrum sun protection pre and post care.

Over the years and with experience in using several techniques and technologies.

I firmly believe that combination treatments are the best way to achieve more beneficial and longer lasting results. Combining any of the treatments with topical treatment—whether you use a drug or a cosmeceutical—is definitely the future trend.

Each patients treatments need to personalised , tailor made and reevaluated at each visit and a flexible approach must be adopted.

There is definitely a psychological overlay with acne scarring as with a large proportion of the conditions in aesthetic dermatological practice and one must keep this in mind when evaluating and suggesting treatments for these patients.

One must make sure that you are going to be able to deliver the results your patient is expecting.

Recently we have been doing some work on body dysmorphic disorder in dermatology aesthetic practice , and discovered that 70% to 80% of patients have some element of body dysmorphic disorder. Make sure that the patient has clear expectations because that eliminates the unhappy patient ,ensures high patient satisfaction and ensures a happy physician.

The CROSS technique The CROSS technique uses 100% trichloroacetic acid (TCA) on a really sharp toothpick, localised on the scar to cause a necrotic reaction.

This high strength TCA placed in the base of the scars ablates the epi-

Prof Mukta Sachdev is a dermatologist and globally recognised skin of colour expert. She is also part of International Scar Guidelines Committee and runs a dermatology clinic and a research centre for skin of colour in Bangalore, India

four sessions on one cheek you will see a colour difference.

Evidence There are several studies which compare fractional erbium lasers with dermal rollers or micro needling.

The results have shown you can get nice results with micro needling and it does induce a large amount of collagen, comparable sometimes to the fractional erbium laser. In our practice we have integrated using a fractional laser first then four weeks later use a dermal roller, combining treatment for best results.

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body language I EQUIPMENT 19

Burn scar rejuvenation Achieving improvement in burn scars can be tricky, however DR MATTHIAS AUST describes how medical needling can offer a solution

T

here are many non-invasive and surgical procedures to treat scars. Many patients don’t want to go through surgery again, especially after burns, because they are concerned about long hospitalisation and questionable outcome. Therefore minimally invasive procedures such as dermabrasion, deep chemical peels and laser therapy have become more important.

All of these procedures though are ablative. Dermabrasion ablates the skin down to the basal membrane and a CO2 laser creates a wound, destroying the cells up to the basal membrane, leading to a thinner epidermis than before.

Also by removing the epidermis and cells—especially the melanocytes—you run the risk of dyspigmentation.

An ablative laser brings us more skin tightening than needling, because a tiny scar is created underneath the basal membrane in the papillary dermis, and a scar always contracts causing skin tightening.

However underneath, in ideal circumstances, you would want scar free healing and the stimulation of the body’s own growth factors.

One way to achieve stimulation of the body’s own growth factors is by skin needling. For burn scars, we do what is termed a “severe” needing and afterward the patient

will look bruised and swollen.

The needles puncture through the epidermis and set up bleeding underneath the basal membrane and even deeper. The needle then goes out of the epidermis again and the cells close. The epidermis remains intact with just puncture channels.

The reason for dyspigmentation involves the melanocyte as well as the keratinocyte. The melanocyte sits on the basal membrane and is a dendritic cell. If you perform an ablative procedure you remove some of these cells so you could end up with too few and create hypopigmentation, or the cells might overreact and produce too much leading to hyperpigmentation.

20 EQUIPMENT I body language

66

don’t have to send a patient away with active scarring—you can help improve the healing.

Any part of the body can be treated—it is simple wound healing 99 With a needle this risk is lessened by just bringing the cells out, and when the needle goes back, the cells go back together.

Postoperative treatment is simple because you don’t create an open wound, so no dressing is required. Importantly though, it doesn’t matter how long the needles are—avoid crusts. If you have crusts, underneath you can have bacteria and bacteria can lead to secondary wound healing which can end up scarring.

You can treat any part of the body, because it works so simply and is nothing more than simple wound healing.

You need a bleeding, and the reason you get long-lasting results with “severe” needling I believe, is because you have the bleeding. If you don’t have the bleeding it’s needle therapy, which will not bring long-lasting results but does avoid the downtime.

Scars need not be over a year old to be treated— good results can be achieved from needling scars two months after injury

Active scars When I was a young doctor I was trained not to touch a scar for one year after injury, let it heal. I now totally disagree. I have achieved good results from needling scars two months after injury. The scar would have improved by itself as it was an active scar, however you

Keloid scars I was also taught to avoid keloid scars, however, I now also disagree.

After treating almost 1,000 people with hypertrophic scarring we decided to try needling with keloid scars. Results have shown in some instances an improvement in elasticity—it can definitely help. You don’t get a result, but you certainly don’t make it worse. I would never promise my patients results when needling keloid scars, but I certainly recommend it is worth trying.

Side effects We’ve seen very few complications in terms of infections or long-lasting bruising and we have not seen any scarring, dyspigmentation, or photosensitivity.

You can get hyperpigmentation after needling, if the needle gets blunt with multiple usage and tears the skin, so you must be careful.

Research We have carried out research using rats. Histologies showed that eight weeks after needling, the epidermis increased in thickness. Also with needling, our research showed you have an increase of EGF, FGF and VGF, which are the body’s own growth factors for the epidermis, the fibroblasts and for new blood vessels.

We also examined the theory that needling promotes scar free healing. 24 hours postoperatively

there was no damage shown in the epidermis, just completely intact skin. The same with the connective tissue, it remained completely intact with no signs of damage, plus TGF-beta 3 was up-regulated in all control groups.

Hypopigmentation While you can improve scar with needling, unfortunately we didn’t see any improvement in big areas of hypopigmentation.

We can combine needling with another operation method, ReCell, a “skin in a spray”. You take a small skin sample and make a solution, which you spray onto a wound bed.

This optimises wound healing and improves cosmetic and functional results. It heals very quickly, and you can spray all living cell type— Langerhans cells, fibroblasts, melanocytes and keratinocytes.

The problem with ReCell is you need a wound bed, an open wound to spray the cells onto. I initially found this difficult to understand, because if you remove cells first with ablation, just to spray the cells on again, you take one step back, to go two steps further. This might not be a problem in healthy skin, but it is a problem in burn scars as the epidermis is thinner, so there is a risk of ablating too deeply. So we thought, maybe the puncture channels that we have after needling with a 3mm roller would be enough to get the cells in.

We have an ongoing study with 20 patients, with a one year follow-up for 10 of the patients. We measured scar areas bigger than 10 square centimetres and scars at least 12 months or older, which were hypopigmented. We evaluated them by pictures and questionnaire for the patient as well as for the doctor, and we evaluated the amount of melanin with a tool called a maxometre.

We needled the scars and then used ReCell and the results are showing improvement, we are looking to publish the results soon Dr Matthias Aust is a specialist in medical needling and is chief consultant for the Department of Aesthetic and Plastic Surgery at the Malteser Hospital in Bonn, Germany

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body language I PSYCHOLOGY 23

Body ideals Are ‘hookups’ changing the way men and women view each other?

DR RAJ PERSAUD and PROF KATHLEEN MARTIN GINIS look at the research

A

new study has found that the rise of ‘hookups’, or sex without commitment, could be having an unexpected impact, particularly on the way women assess men’s bodies.

This new research, on the type of ideal body men and women prefer in romantic heterosexual partners, also reveals surprising differences between what men and women are looking for in each other.

The study, from Kenyon College in the USA, examined body ideals that heterosexual college women and men choose for romantic partners, by comparing respons-

es to body silhouettes that vary in thinness, shape, and in women’s breast and men’s chest size.

Evolutionary theory predicts that what we are attracted to in the opposite sex is in some way genetically programmed in our brains.

Perhaps certain preferences had some kind of survival value in the ancestral environments we evolved in—for example, women might seek muscular men for ‘short-term mating’ because muscularity is linked with dominance, and dominant men might help protect women in dangerous environments.

Plenty of research has found that women rate their ideal body as significantly thinner than what

men selected as most attractive – likely influenced by the pervasive media representation of unrealistically thin women as attractive.

However, the authors of this latest study, published in the academic journal ‘Body Image’, conclude that it is difficult to say which gender was more critical in their assessment of the body of a romantic partner.

Women chose a body ideal for men larger, or more muscular than men’s actual bodies, while in contrast, men chose a body ideal for women quite close to women’s actual body size. Women’s ideal for men’s chest size was significantly larger than men’s actual chest size,

24 PSYCHOLOGY I body language

but women’s ideal for men’s chest size was smaller than the ideal men had for themselves. The ideal that men had for a female partner’s breast size was slightly larger than women’s actual rating, and it was significantly larger than the ideal that women had for themselves.

When considering thinness, the study found that a woman’s ideal for men’s thinness was slightly smaller than the ideal men had for themselves. The ideal that men had for the thinness of a woman partner was not significantly different from women’s actual rated thinness, yet women’s ideal for themselves was significantly smaller than men’s ideal for women. Women placed more importance on their own thinness than men did on women’s thinness. It was also possible to predict that men who viewed more sports on television and watched reality TV were likely to rate female body ideals and the size of breasts as important. Particularly interesting was that the more men were interested in ‘hookups’, and the more sexually permissive their peer culture, the thinner their choice of ideal woman.

‘Hookups’ appear to have overtaken committed relationships in popularity and priority amongst those of college age. But because ‘hookups’ emphasise the physical rather than emotional, young adults who participate in ‘hookup’ culture might be more likely to select partners based on physical features of attractiveness.

For women, ‘adversarial sexual attitudes’ emerged as the most important predictor of women rating body ideals as important for a male partner. Adversarial sexual beliefs are beliefs that heterosexual relationships between women and men are adversarial due to being opposite to one another. Those who subscribe to adversarial sexual beliefs endorse views such as “men and women cannot really be friends” and “men are out for only one thing”. They believe that men and women are out to “use” each other, and may be more likely to invest in body ideals that magnify the differences between women and men, a thin body for women

and muscular body for men.

The study, contends that women who participate in ‘hookup’ culture and who also have more adversarial attitudes about relationship, are more willing to judge men’s bodies, because they are part of a culture in which their own bodies are being judged.

Perhaps judging men by their bodies is considered “fair play.” Preferring ‘hookup’ culture to dating was also related to the importance of the chest ideal silhouettes as rated by women. Although women generally placed less importance on the ratings they chose for an intimate partner’s body, if they believed that men and women are adversaries in romantic relationships, they were more likely to do so.

So, the rise of ‘hookup’ culture might lead women to objectify men’s bodies in ways similar to what men already do with women’s bodies. The problem is that body dissatisfaction rates among both women and men are increasing in recent times.

The authors of the study, enti-

tled ‘Body ideals for heterosexual romantic partners: Gender and sociocultural influences’, point out that unrealistic, yet influential, images people are exposed to in the media means that recently the ideal image of women has become unrealistically thin, while the ideal image of men has become unrealistically muscular.

Perhaps we should try to encourage young people to value their bodies for what they can do, rather than what they look like.

Dr Raj Persaud is a consultant psychiatrist and joint podcast editor for the Royal College of Psychiatrists with a new free to download app entitled ‘Raj Persaud in Conversation’ which contains many interviews with mental health experts from around the world. Kathleen Martin Ginis is a Professor in the Department of Kinesiology at McMaster University in Ontario, Canada, the director of McMaster University’s Physical Activity Centre of Excellence and the founder and director of SCI Action Canada

The ideal image of men has become unrealistically muscular

body language I PROMOTION 25

New collagen for your skin Dermatopoietin is an innovative peptide complex that can boost collagen to replenish aged skin.

It is the principal component of Swiss cosmetic brand, EVENSWISS

C

ollagen is a major component of human skin –comprising more than 90% by dry weight. Collagen forms fibres and provides the mechanical strength of the skin. A network of regular collagen fibres forms a healthy environment for dermal fibroblasts, which produce the basic components of the skin including collagen, elastin, and hyaluronic acid.

The regular nature of the collagen fibres is vital for great skin appearance and ageing leads to collagen breakdown.

The accumulation of fragmented collagen lies at the core of age-related changes in the appearance of human skin. The skin of older people may contain four times more collagen fragments than younger skin, meaning there is a great need for collagen replenishment in aged skin.

Dermatopoietin is an innovative peptide complex capable of boosting collagen to the skin and is the principal component of Swiss cosmetic brand EVENSWISS. Dermatopoietin does not contain collagen and the formula does not even penetrate the skin. Dermatopoietin acts on receptors on the skin’s surface to send a signal to the deeper dermis of the skin to initiate collagen production by dermal fibroblasts.

Figure: Effect of Dermatopoietin on collagen (red fibres) and elastin (green fibres) in dermis of the aged skin. Skin layers and components shown on the images: Stratum corneum, at 5 µm; Stratum Spinosum and Stratum Granulosum, at 25-30 µm; Stratum Basale, at 50 µm; Dermis, at 70-80 µm.

Collagen replenishment with Dermatopoietin: a two-photon laser fluorescent microscopy in vivo study Test articles: Dermatopoietin or Vehicle.

Study performance: Neurotar Ltd. Helsinki, Finland.

Study design: Dermatopoietin was applied once daily for 28 days onto one forearm of healthy 63 year old male volunteer, while Vehicle was applied onto another forearm.

Collagen assesment: Levels of collagen were assessed by fluorescent microscopy in the skin dermis 28 days from the start of Dermatopoietin applications (see Figure).

Results: Dermatopoietin application results in increase of collagen in the skin dermis by 68% compared to Vehicle.

Conclusion: Dermatopoietin is effective as a fast collagen booster for aged skin.

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26 FACE 2015 I body language

Held at the QEII Centre in London’s Westminster on June 4th -7th, FACE 2015 will host a world-renowned speaker panel, delivering a complete educational programme to keep you up to date with the latest developments in medical aesthetics

F

ACE 2015 is already shaping up to be the UK’s largest and most focused conference dedicated to medical aesthetics. There will be more more agendas and concurrent workshops than ever before, and we will continue to offer something for anyone with an interest in aesthetics from seasoned veterans to new start-ups.

It is important that as new techniques are formed and new product launched, that a complement of complete scientific knowledge is placed on them. FACE 2015 will have more hours of lecture and workshops than any other conference dedicated to clear bespoke areas while also pioneering specialised lectures.

In addition to the regular SKIN, Business, and now HAIR seminars at FACE, the BODY Conference will also be coming to FACE 2015, creating a complete high-end educational aesthetic conference.

FACE 2015 promises an opportunity for those willing and wanting to learn more about the industry, promoting best practice and pa-

tient safety as well as cutting edge technology and treatments.

Advanced Masterclass FACE 2015 is proud to introduce an Advanced Masterclass course on Thursday 4th June which will be directed by Dr Ali Pirayesh.

Dr Pirayesh will present on all areas of the anatomy alongside a collection of the best aesthetic practitioners in the world of aesthetics.

Dr Pirayesh comments, “FACE 2015 will be the setting for an exclusive advanced edition of Scientific Aesthetics for Experts (SAFE) which was launched in Monaco this year.”

“It will be a masterclass of great magnitude, where world renowned experts will share their daily knowledge, tips and tricks for the aesthetic treatment of all facial regions. This includes topics on science and combination therapy with toxins, fillers and energy based devices, as well as decision making in the plethora of aesthetic modalities available today.”

“This event is the first of its

kind in the UK, providing a truly international interchange of the most valuable expertise necessary to take your advanced practice to the next level.”

For the first time ever we will also have a simultaneous video cast from across the world, meaning that the opportunity is not only available in the UK, but available in Singapore as well—a truly global event and something never before attempted in aesthetics conferences.

Please visit faceconference.com for all agenda updates, exhibitors and speaker profiles to identify which package and lectures are most suited for you.

The pre-conference Advanced Masterclass with Dr Ali Pirayesh will be live streamed to Singapore

body language I FACE 2015 27

Injectable agenda The core of FACE Conference, this agenda brings you up to date with the latest treatments and techniques using toxins, fillers, PRP, mesotherapy and fat transfer  INJECTABLES Friday through Sunday will host national and international lecturers to help delegates maximise results and minimise problems when using cosmetic injectables for total facial contouring. Different techniques, new treatment approaches and concepts will be explored alongside practical demonstrations.

GROUND FLOOR, CHURCHILL AUDITORIUM Friday/Saturday/Sunday

AGENDA HIGHLIGHTS

 The Advantages of

Introducing Controlled Trauma When Injecting Dermal Fillers Leslie Fletcher Friday 11.30 | 12.00

 The science behind injectable fat reduction, PRP and mesotherapy Dr Christopher Rowland Payne Friday 16.30 | 18.00

 Lip augmentation techniques Dr Ines Verner Saturday 09.30 | 10.00

 Bio-dermal restoration with a

new and advanced collagen— initial clinical results Mr Chris Inglefield Saturday 10.00 | 11.00

 New toxins, new data Dr Michael Kane Saturday 15.30 | 16.00

 Treating women across the ages 20s, 40s and 60+ Dr Raj Aquilla and Dr Frank Rosengaus Saturday 16.30 | 18.00  The “happy face” treatment— marionette lines and oral commissures Dr Frank Rosengaus Sunday 11.30 | 12.00

SPEAKER PROFILES

Dr Raj Aquilla Cosmetic Physician, United Kingdom One of the most skilled, experienced and trusted Cosmetic Physicians in the North West, member of the BACD.

Dr Frank Rosengaus Facial Plastic Surgeon, Mexico Recognised as a world renowned leader in cosmetic and aesthetic plastic surgery, with over 20 years experience.

Mr Chris Inglefield Consultant Plastic & Reconstructive Surgeon, UK Mr Inglefield has spent over a decade developing his private practice at London Bridge Plastic Surgery.

Dr Christopher Rowland Payne Consultant Dermatologist, United Kingdom Active in all areas of clinical dermatology, notably surgical dermatology, treatment of skin cancer and melanoma.

Dr Michael Kane Consultant Plastic Surgeon, United States Dr Kane has been a consultant plastic surgeon in private practice since 1992 and is based in New York City.

Dr Ines Verner Specialist Dermatologist, United Kingdom Internationally renowned specialist dermatologist working for over 15 years in aesthetic and cosmetic dermatology.

28 FACE 2015 I body language

Body agenda For the first time, FACE will host the BODY Conference with a full agenda featuring non-surgical treatments targeting all indications within this evolving sector  BODY As the BODY aesthetics market continues to grow with an ever increasing range of non-surgical solutions and indications, we will incorporate lectures on a wide range of treatment options into the traditional Equipment agenda sessions. The market is evolving with many platform systems having indications for both body and facial aesthetic treatments—and the BODY agenda will explore the latest concepts, practical tips and business models currently available.

4TH FLOOR, WESTMINSTER SUITE Friday/Saturday/Sunday SPEAKER PROFILES

Dr Ines Verner Specialist Dermatologist, United Kingdom Internationally renowned specialist dermatologist working for over 15 years in aesthetic and cosmetic dermatology.

Dr Dianne Duncan Plastic Surgeon, United States Dr Duncan runs a busy aesthetic practice, and travels and teaches internationally in the field of minimally invasive aesthetics.

AGENDA HIGHLIGHTS

 Pyroptosis of fat using

radiofrequency, vacuum and electrical impulse Dr Dianne Duncan Friday 12.10 | 12.30

 Resurfacing in 2015—where do we stand?

Dr Ines Verner Saturday 11.30 | 11.55

 Q switch lasers for pigmentation —the new darker skin tool Professor Mukta Sachdev Saturday 14.50 | 15.10

 Radiofrequency and microneedling—plus novel post-

procedure care for anti-ageing Dr Carl Thornfeldt Saturday 15.10 | 15.30

 Leg veins—where does aesthetics end and medicine begin?

Professor Mark Whiteley Saturday 16.55 | 17.20

Dr Maria Gonzalez Dermatologist, United Kingdom Dr Gonzalez as a leader and innovator in the teaching of dermatology winning awards for her contribution to the field.

Dr Syed Haq Consultant Physician, United Kingdom Dr Haq is the Founder of The London Preventative Medicine Centre and Clinical and Scientific Director of Daval International Ltd.

 The classic red face—how to

Prof Mukta Sachdev Professor of Dermatology, India Prof Sachdev runs a private cosmetic office practice and a clinical trial unit specialising in dermatology trials in skin of colour.

 Anti-ageing—hormones and IV

Dr Carl Thornfeldt Clinical Dermatologist, United States Dr thornfeldt has 30 years of skin research experience and multiple scientific publications in the treatment of skin conditions.

treat all skin types using new combination protocols Dr Maria Gonzalez Sunday 10.10 | 10.30

vitamins: science vs hype Dr Syed Haq Sunday 11.55 | 12.20

body language I FACE 2015 29

Skin agenda Skincare is at the centre of the medical aesthetic industry—topical products and combined approaches to treatment are explored in depth  SKIN With many different competing skincare lines, it can be confusing to establish which brands to choose. FACE provides a forum for practitioners to meet the true experts who understand ingredients, formulations and the arguments behind competing concepts and brands. This three day forum will focus on new topical approaches to preventing and treating signs and symptoms of ageing skin alongside the latest specific approaches to treating acne, rosacea and hyperpigmentation.

4TH FLOOR, ST JAMES’S SUITE Friday/Saturday/Sunday AGENDA HIGHLIGHTS

 Newer cosmeceuticals for

lightening—what can we use and where?

Professor Mukta Sachdev Friday 11.30 | 11.50

 Safer, more effective therapy for hyperpigmentation Dr Carl Thornfeldt Friday 11.50 | 12.10

 Tranexamic acid vs topical

meso lightening mixture using medical skin needling in the treatment of melasma Dr Rania Alsaied Friday 12.10 | 12.30

 Stem cells—explanation of stem cell science and its application to skincare Dr Charlene de Haven Saturday 16.30 | 16.50

 Combined approaches to dermatological skin conditions in aesthetic practice Dr Stephanie Williams 09.50 | 10.10 Sunday

 Combined IPL/peel treatment for refractory acne Dr Carl Thornfeldt Sunday 11.50 | 12.10

 Latest topical approaches to the treatment of acne Dr Rachael Eckel Sunday 12.10 | 12.30

SPEAKER PROFILES

Dr Charlene DeHaven Clinical Director of iS CLINCAL, United States Dr DeHaven is a board-certified physician in both internal medicine and emergency medicine, with an emphasis on age management and health maintenance.

Dr Rachael Eckel Cosmetic Dermatologist, Trinidad and Tobago Dr Eckel has trained under Dr Zein Obagi and Dr Michel Delune, two of the most influential and respected clinicians in cosmetic medicine and has perfected the most pioneering aesthetic techniques worldwide.

Dr Stephanie Williams Dermatologist, United Kingdom Dr Williams has a special interest in cosmetic dermatology. She has extensive clinical experience and her interest in cutting edge skin research has led her to receive a number of awards.

30 FACE 2015 I body language

Business agenda Marketing your practice is vital to secure success in a competitive industry. Our expert panel will guide you through, from social media to website development and PR  BUSINESS In an increasingly competitive market everyone needs to raise their game and FACE provides a unique two day forum for clinic owners, managers and marketeers to explore a wide range of topics related to the art of marketing.

Professional speakers including specialist marketeers, web designers, and social media gurus will give you the latest information on techniques that work specifically in the aesthetic market.

4TH FLOOR, HENRY MOORE ROOM Friday/Saturday AGENDA HIGHLIGHTS

SPEAKER PROFILES

Rosie Akenhead Manager of Local Business Outreach at Yelp, United Kingdom Rosie works directly with European businesses to identify best practice strategies for online reviewing, social media and reputation management.

Anouska Cassano Micro-Pigmentation Practitioner, United Kingdom Anouska Cassano specialises in the areas of scalp micro-pigmentation, aesthetic permanent makeup, medical and reconstructive, scar camouflage and reduction, chemical tattoo removal and correction.

 Website design, SEO and

marketing—the latest trends Adam Hampson Friday 11.50 | 13.00

 The value of a consistent consultation

framework and evidence based approach to patient assessment for aesthetic procedures Anouska Cassano Friday 14.30 | 15.00

 Use of PR and media in aesthetics Wendy Lewis Friday 16.30 | 17.15

 What are people saying about your practice online?

Rosie Akenhead Friday 17.40 | 18.00

 Promises: delivering and measuring and keeping what it is your clients lust after most of all Tony Gedge Saturday 10.00 | 11.00

 Aesthetic clinic marketing in the digital age Wendy Lewis Saturday 11.30 | 13.00

 Unity, direction, stability—the role of

the professional associations and overarching governance in self-regulation Andrew Rankin Saturday 16.30 | 16.50

Adam Hampson Creative Director of design and marketing agency H&P, United Kingdom H&P Design specialises in design and marketing services to cosmetic and medical clinics. H&P Design are best know for their unique websites and clever clinic branding.

Wendy Lewis President of Wendy Lewis & Co Ltd Global Aesthetic Consultancy, United States As the Knife Coach, Wendy Lewis sees private clients in New York, Palm Beach and London as the original independent cosmetic surgery and skincare expert.

body language I FACE 2015 31

Aestheticians agenda This agenda explores the latest advanced treatments for non-medically trained practitioners, providing a unique forum for therapists  AESTHETICIANS This event is tailored specifically to exploring advanced treatments that are performed by non-medically qualified practitioners with different skill sets, interests and backgrounds. The last 10 years has seen the role of beauty therapists, laser technicians and other practitioners working in the aesthetics market rapidly evolve and many of the lectures are delivered by therapists who have specialist expertise and experience in their chosen field, with FACE providing a dedicated forum to share knowledge and stimulate debate amongst therapists.

4TH FLOOR, ABBEY ROOM Friday/Saturday

 Cryotherapy induced lipolysis with

AGENDA HIGHLIGHTS

acoustic wave therapy Barbara Freytag Saturday 09.30 | 09.50

 Understanding the natural barrier function of the skin and its impact on skin health Sally Durant Friday 09.30 | 09.55

 Managing sweat From iontophoresis to microwaves Annie Eccleston Saturday 11.30 | 11.55

 PCOS and treatment of transgender Chris Hart Friday 11.55 | 12.20

 The implications of HEE recomendations to the clinical beauty therapist Sally Durant Friday 16.30 | 16.50

 Benefits of using a hyaluronic acid and succinic acid combination vs cream as post-laser care Maryam Borumand Saturday 11.55 | 12.20

SPEAKER PROFILES

Maryam Borumand Associate Director, Rederm Ltd, United Kingdom Maryam has a PhD in biochemistry and currently works as a scientist at Rederm with an interest in developing skincare products.

Sally Durrant Managing Director, Sally Durant Training, United Kingdom Sally Durant specialises in the field of, skin health, cosmetic dermatology and advanced skincare practice.

Annie Eccleston Cosmetic Nurse, United Kingdom Annie has a wide range of experience having worked as an intensive care nurse and as a specialist nurse in general practice.

Barbara Freytag Founder, Academy of Advanced Aesthetics United Kingdom Barbara is founder of the Academy of Advanced Aesthetics, which provides CIBTAC-endorsed training in aesthetics.

For further information on all lectures and new speakers as they are announced, visit faceconference.com. You can also explore exhibitor profiles, download the pre-programme and register.

32 FACE 2015 I body language

Hair agenda Androgenic alopecia and hair loss are common indications—learn about the latest treatments and techniques for effective restoration  HAIR With so many different non-surgical and surgical treatment options now available for the treatment of androgenetic alopecia, alongside growing demand for solutions to hair loss, FACE are hosting a special one day symposium devoted to exploring this sector of the aesthetic market. A panel of experts will explore in depth the different potential treatment solutions available.

Threads agenda A one day workshop to explore the latest thread lifts for facial rejuvenation  THREADS The concept of the use of different types of threads for facial rejuvenation has been in development since the late 1990s and now many threads are promoted to the aesthetic community. This special one day workshop will explore the latest data evaluating the efficacy and long term safety of threads for facial rejuvenation, alongside the technical issues of placing threads and the experience required to deliver these treatments in aesthetic practice.

AGENDA HIGHLIGHTS

 3D Facial Rejuvenation Using Threads and Dermal Fillers Dr Sarah Tonks Friday 11.55 | 12.20

DIAMOND SPONSOR: MERZ AESTHETICS

Exhibition With over 80 exhibitors and many exhibitor workshops, delegates can explore the latest medical aesthetic products and services 

This year delegates will be able to attend our largest programme of exhibitor workshops to date to learn about the latest products and services available to the industry. Workshops run for up to an hour and a half and can include lectures, presentations and live demonstrations as well as targeted Q&A sessions at the end.

For information about the exhibition, symposiums and workshops, visit faceconference.com

PLATINUM SPONSORS: SURFACE PARIS and WIGMORE MEDICAL

GOLD SPONSORS: GALDERMA and SKINCEUTICALS

SILVER SPONSORS: AESTHETIC SOURCE, CYNOSURE and SYNERON CANDELA

body language I INJECTABLES 33

JUNE 4TH - 7TH QEII CENTRE LONDON Twitter: @face_ltd Facebook: facebook.com/faceltd T: 020 7514 5989 E: info@face-ltd.com W: faceconference.com

Please complete the form, ticking the relevant boxes for attendance options and return to 2D Wimpole Street, London, W1G 0EB. To book via phone call 020 7514 5989 or visit faceconference.com to register online.

DELEGATE RATES

PASS 1: ADVANCED MASTERCLASS ONLY June 4th—one day course (includes lunch and refreshments)

 £300

PASS 2: FULL DELEGATE PASS INCLUDING ADVANCED MASTERCLASS June 4th, 5th, 6th and 7th—access to all lectures and advanced masterclass (includes lunch and refreshments) * Student certification will be required

 £699 Student*  £350

PASS 3: FULL DELEGATE PASS June 5th, 6th and 7th—access to all lectures (includes lunch and refreshments) * Student certification will be required

 £499 Student*  £250

PASS 4: SECOND TIER AGENDA PASS June 5th, 6th and 7th—access to main lecture programmes excluding injectables agenda (includes lunch and refreshments)

 £250

PASS 5: VISITOR PASS June 5th, 6th and 7th—workshops and exhibition only (does not include lunch and refreshments)

 £150

PAYMENT DETAILS PAYMENTS CAN BE MADE BY CARD OR BY CHEQUE MADE PAYABLE TO FACE LTD CHEQUE  VISA  MASTERCARD  SOLO  AMERICAN EXPRESS  CARDHOLDER’S NAME: CARD NUMBER: START DATE: EXPIRY DATE: ISSUE NO: SECURITY CODE: SIGNATURE OF CARD HOLDER 

* Student certification will be required.

All prices are inclusive of VAT. Cancellations received before May 24th, 30% of registration retained.

Cancellations received after May 24th, 100% of registration fee retained.

DELEGATE DETAILS NAME (inc. title): MEDICAL SPECIALITY: CLINIC/COMPANY: ADDRESS:

POST CODE: TELEPHONE: WEBSITE: EMAIL (MANDATORY) 

Confirmation will be sent by email, please write clearly

body language I SKINCARE 35

Treating hyperpigmentation in darker skin using topicals DR ZEIN OBAGI shares his advice on how to treat pigmentation using a step-by-step approach to reduce skin sensitivity, stabilise cells, control melanocytes and address the correct depth

H

yperpigmentation is caused by increased melanin production in hyperactive melanocytes present in affected areas of the skin.

Hormones, genetics, external elements, irritation and skin injury can induce melanocyte hyperactivity. ZO Skin Health principles, protocols and products, not only focus on treating the skin surface but also aim to reach the melanocytes to regulate and control their activity.

The concept of melanocyte stabilisation, one of the new principles of ZO Skin Health restoration has two main objectives. First—to increase melanocyte resistance (preventing their hyperactivity) to all the factors that can cause skin hyperpigmentation problems; and second—increasing keratinocytes ability to take any produced melanin in a horizontal fashion (to maintain or restore an even colour tone).

Each melanocyte provides melanin to 36 surrounding keratinocytes. Hyperpigmentation in an area is due to disruption of this horizontal melanin distribution and its replacement with abnormal vertical distribution, where few melanocytes can take most of the produced melanin, leaving many of the surrounding keratinocytes with little melanin (lazy keratinocytes that need to be activated to restore the horizontal distribution).

Hyperpigmentation due to this vertical distribution can be corrected only by stabilising the melanocytes to regulate and control their activity, and increasing

keratinocytes activity to enhance their uptake of melanin, thus evening out the horizontal melanin distribution.

Existing treatments focus on skin surface in skin hyperpigmentation, including melasma. Using hydroquinone or other bleaching agents, such treatments often fail, and over-bleaching (especially in dark skin) causes the skin to become unnaturally white and more photosensitive, which can cause more hyperpigmentation. In ZO Skin Health restoration and treatment, bleaching is recommended only for a short time at the beginning of the treatment, and then stopped. Along with bleaching, other principles are utilised: stabilisation (controlling melanocyte activity), blending (stimulation to restore melanin horizontal distribution), and exfoliation (to unload melanin deposits in skin). These principles are accomplished by using hydroquinone (used alone for bleaching), followed by exfoliation (glycolic acid and exfoliative peels), stimulation and blending (hydroquinone and retinoic acid), and stabilisation (retinol, antioxidants, and antiinflammatory agents).

One of the most common causes of treatment failure is the sebum level on the skin’s surface. Sebum is highly inflammatory and is the main element in inducing chronic skin inflammation. Sebum reduction is essential and can be accomplished by topical means (astringents) and systemic means (Isotretinoin 20 mg daily or every other day for one to two months).

Sebum acts as a barrier, reducing penetration of topical agents, and is a strong in-

TREATMENT STEPS The approach as created by Dr. Zein Obagi and accomplished with both systems of his products: ZO-Skin Health for non-medical problems and ZO-Medical for medical problems THE HYDROQUINONE APPROACH 1. Getting skin ready  Proper cleanser: AM and PM  Scrub: once daily  Sebum control: AM and PM 2. Bleaching (strong)  Melamin (hydroquinone): AM and PM 3. Exfoliation  Glycogent: AM 4. Stabilisation  C-Bright (vitamin C): AM  Barrier repair: PM 5. Stimulation and blending  Retinoic acid + hydroquinone: AM and PM THE NON-HYDROQUINONE APPROACH 1. Getting skin ready  Proper cleanser: AM and PM  Scrub: once daily  Sebum control: AM and PM 2. Bleaching  Brightalive (mild): AM and PM 3. Exfoliation  Glycogent: AM 4. Stabilisation  C-Bright (vitamin C): AM  Barrier repair: PM 5. Stimulation and blending  Brightenex: AM  Retamax: PM Important points when treating hyperpigmentation:  Treat any existing inflammatory disease, such as acne or rosacea, when treating melasma and post-inflammatory hyperpigmentation.  Try to eliminate sebum as much as possible.  Repair skin barrier function to make skin tolerant to the proposed treatment (eliminate skin sensitivity).  Avoid excessive bleaching, switch to blending (no bleaching effects) as soon as possible to restore even colour tone.  More chemical peels (ZO 3 Step Peel) when using the non-hydroquinone approach (to unload pigment).  Ochronosis is becoming more frequent due to illegal usage of prolonged use of hydroquinone.

Melasma and rosacea treated by stabilising the cells without hydroquinone, using the 3-Step Peel followed by retinol to stimulate rebirth to new keratinocytes and stabilise the melanocyte. After two to three treatments skin clarity is improved

DR ZEIN OBAGI

flammatory agent.

In treating melasma and post-inflammatory hyperpigmentation, the treatment must be aggressive to induce four to six weeks of acute inflammation, manifested by redness, sensation of dryness, and exfoliation. Such an approach is the only way to eliminate skin’s chronic inflammation. Without this elimination, the treatment will fail and melanocyte activity will not be controlled.

Acute inflammation can be induced by stimulation and blending (retinoic acid plus hydroquinone) applied twice daily as a part of a step-by-step approach.

The method begins with washing the face to eliminate sebum, and bleaching morning and night; then morning exfoliation; morning stabilisation and blending morning and night. Proper UV protection should be stressed to avoid the harmful effects of the sun. This approach should be continued for five months, keeping in mind that the bleaching step should be stopped in five months or sooner to prevent hydroquinone resistance and photosensitivity due to melanin elimination.

After patients are clear they must switch to non-hydroquinone immediately. Keeping them on hydroquinone for too long is dangerous because the skin builds resistance and you get rebound pigmentation, which in the long-term can create ochronosis.

Chemical peels (epidermal and dermal) can be performed when skin is tolerant (6 weeks after using the hydroquinone approach to prepare the skin). In ZO Skin Health the peels can be epidermal or dermal. An epidermal approach is a Zo 3-Step Peel whereby epidermal and dermal stimulation and exfoliation are achieved at the same time. Dermal is a controlled depth Blue Peel. It’s important to keep in mind that multiple peels may be needed to achieve the best results.

When the treatment for hyperpigmentation using the hydroquinone approach is completed, it is recommended to switch to a non-hydroquinone approach. This approach is also recommended when hydroquinone is contraindicated (allergy to hydroquinone or photosensitivity) or when the side effects from hydroquinone usage are encountered (ochronosis, rebound hyperpigmentation, or the development of resistance to the action of hydroquinone).

The steps of the non-hydroquinone approach are similar to the hydroquinone approach, with some changes in the topical agents used and in certain principles that are used.

You have to have multiple approaches for each condition and choose the right

DR ZEIN OBAGI

36 SKINCARE I body language

Uneven pigmentation had been treated long term with hydroquinone prior to treatment with Dr Obagi.

Hydroquinone was stopped, skin was submitted to the protocol of wash, scrub, oil control, barrier repair and Brightenex. More even colour tone has been restored.

one for your patient. When I created ZO system I addressed essential things. Some of the many important things are DNA repair, anti-inflammation, and elimination chronic inflammation. You have to eliminate sebum; you have to restore barrier function—that is how to stabilise the melanocyte. When the skin is tolerant, not sensitive, the melanocyte says, okay I’m not going to hurt; I’m not going to overwork. You have to address the problem point by point. If the skin is too oily, you reduce the oil. If it’s too sensitive or dry, you treat sensitivity and dryness.

Using hydroquinone in both bleaching and blending is called the hydroquinone approach, the preferred approach to start the treatment. After five months the hydroquinone bleaching should be stopped and a non-hydroquinone bleaching agent should be used. This will reduce melanin production, allowing skin to gradually reproduce melanin. On the other hand, hydroquinone blending can be continued for an extra one to two months and then stopped, and a non-hydroquinone blending treatment can be started.

Non-hydroquinone approaches I have used clinical non-hydroquinone approaches. I had a male client who looked like he had melasma, plus he had active rosacea. By treating the rosacea and treating the pigmentation, stabilising the cells without hydroquinone, he had what we call the 3-Step Peel, which is TCA—

glycolic acid, lactic acid combination, followed by retinol to stimulate rebirth to new keratinocytes and stabilise the melanocyte, and after two, three treatments his skin clarity improved dramatically.

Another client, a darker-skinned Indian lady who had uneven pigmentation had been treated long term with hydroquinone before she came to see me, and that’s wrong. We stopped hydroquinone, we did wash, scrub, oil control, then we did the barrier repair and the Brightenex, which has high dosage of retinol and anti-inflammatory agents with vitamin C complexes, and we have restored more even colour tone.

It’s important to stop hydroquinone when you see no further improvement after three, four months, no matter what. It must also be stopped completely if a patient has an allergy to it, and you have to be aware of the photosensitivity induced by hydroquinone.

Treating pigmentation is easy, but you have to understand the steps—you have to understand what caused pigmentation, you have to understand how to tackle pigmentation, you have to go step by step, reduce skin sensitivity, stabilise the cells, control the melanocyte, and address the issue at the right depth.

Dr Obagi is a dermatologist and the ZO Skin Health, Inc. medical director. He is responsible for the development of new skincare treatments, protocols and products.

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body language I TECHNIQUE 39

Wide awake DR DAVID ECCLESTON considers the challenges of peri-orbital rejuvenation

T

he skin around the eye is the thinnest on the face, and the thickness and elasticity and of this skin decreases with age and sun exposure.

With the eyelids in constant motion, blinking, squinting, smiling and laughing this extremely thin skin is being constantly creased— more than any other area of the body. Moving even while we are at rest in rapid eye movement sleep, it’s unsurprising that our eyes are the first area to show the early signs of ageing.

It can be said that the skin

66 Our eyes are the first area to show the early signs of ageing 99

around the eye has less of a ‘seal’ on it due to fewer sebaceous glands.

The ‘acid mantle’ is therefore less effective, and the upper and lower eyelid also become deeper set with age, due to fat pad loss, descent or both.

When considering relaxation with toxins, it is extremely important to first perform a detailed assessment of the eye area. The muscle around the eye, orbicularis oculi is supported by fatty tissue.

The posterior surface of the eyelid that sits on the globe itself is very smooth, so as not to cause irritation and pain. Even an eyelash or a small grain of sand behind the eyelid can cause considerable discomfort and distress.

Rejuvenation with fractional radiofrequency The concept of fractional radiofrequency is fundamentally different

from that of ablative and non-ablative fractional-type laser resurfacing. A small hole is created in the skin, but beneath the surface there is a larger area of damage, due to heat-induced tissue coagulation, leading to tissue contraction and neocollagenesis.

Photo-damage and loss of elasticity—common with ageing skin—results in the appearance of lines and wrinkles and an overall deterioration in skin tone and texture. The skin therefore needs to be tightened, and additional collagen is required. In order to stimulate the production of longer collagen bundles and to reawaken the fibroblast a certain degree of damage needs to be caused, which sets in place a healing system resulting in tightening, thickening and regeneration.

I have been using the eTwo device, a component of the Elos Plus

40 TECHNIQUE I body language

System, made by Syneron Candela, for nearly three years. The system now has a smaller replaceable 44 pin head, in addition to the original larger head, which allows much more accurate placement of the tip in the periocular area.

When treating, it is key to not allow the heat spots to be too close together, as the thermal coagulation columns spread out under the skin. This differs from fractional laser resurfacing, which dictates that the spots need to be more compact, as the columns of thermal injury are more vertical.

The principal of sublative rejuvenation is that an electrical current is passed from one electrode to another. There are four electrodes that create multiple channels of current. These pass through the superficial layers of the skin, generating heat. The eTwo machine accurately monitors the temperature attained for effective treatment, which makes the process easier for the operator and less painful for the patient. Additionally, the device monitors skin impedance (the resistance of the passage of electrical current) and gives a real-time reading. The results are consequently more reliable and predictable, as the optimum degree of heat is al-

ways being delivered to the treatment area.

The sublative rejuvenation process Firstly it is very important to cleanse the skin. The skin must be hydrated, so a HydraFacial prior to treatment can work well, but the skin must be clinically dry, or the current will not penetrate deeper than the surface. I recommend using acetone or witch-hazel to ensure there is no residual moisture on the skin’s surface.

Prior to treatment it is important to lift the skin away from the globe, using the bone as support underneath the soft tissues. This allows treatment delivery to the tissues that would normally be inside the orbital rim. A second pass is advisable, at a right angle to the first.

If there is a degree of lid ptosis present then it is also advisable to treat above the eyebrow. This can cause some contraction of the supraorbital skin, leading to a pleasing lift.

After treatment patients’ skin can feel hot and redden slightly, appearing similar to minor sunburn.

Approximately 12-24 hours later, small brown dots will appear which represent coagulation, and the skin may start to flake between 24 to 48

hours. After 48 hours there are few noticeable effects and makeup can be worn immediately after treatment.

Evidence and results An improvement can be seen in fine lines and wrinkles under the eye, as well as reductions in ‘crepiness’ and sagging. One patient who had additional treatment above the eyebrow presented a result comparable to an upper-lid blepharoplasty.

With the eyelids in constant motion, blinking, squinting, smiling and laughing this extremely thin skin is being constantly creased— more than any other area of the body.

Dr David Eccleston is an aesthetic doctor and clinical director of MediZen in Birmingham, W: medizen.co.uk

ADDITIONAL APPROACHES TO PERI-ORBITAL REJUVENATION  Chemical peels There are many benefits to chemical peels, but using them close to the eye can be fraught with hazards. Using peels immediately around the eye area is rarely practiced nowadays.  Topical retinoids These can be highly effective, but can be challenging to use around the eye area due to the common problem of causing irritation to the delicate tissues.  Toxins The use of toxins is an effective method for muscle relaxation, in particular a week or two prior to treatment with any fractional or resurfacing device, or when using fractional radiofrequency. The treated area can then remodel and repair without the creasing forces caused by periocular muscle contraction.  Dermal fillers These are not used for injecting into the eyelids themselves, but fillers can be useful for improving hollowing, both above and below the eye, and by lifting the tail of the eyebrow when injected underneath it.  Laser Ablation Full C02, fractional C02 and erbium laser-ablation are still popular, but the downtime is generally greater than with radiofrequency treatments.  Surgery Surgical treatment is still the benchmark, and sometimes all the different tools available in the armamentarium are no match for the skill of a good oculoplastic surgeon.

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body language I MEDICAL AESTHETICS 43

Fractional lasers for periorbital rejuvenation Considering the bone structure of a patient, not just their skin is important when using fractional lasers around the eyes. DR DIANNE QUIBELL guides us through her approach.

A

s we age, especially as women, the frontal bone recedes and flattens.

The orbital bone resorbs often resulting in hollowing, dark circles due to loss of volume and skin laxity. Changes to the face are not solely due to photo ageing, sun exposure and loss of elasticity of the skin, but also to structural alterations due to bone and volume loss. In the words of ophthalmologist Dr Jean Carruthers, ‘the table has become too small for the tablecloth.’ So, when considering fractional lasers for periorbital rejuvenation it is important to address changes in underlying bone and soft tissue in addition to tightening the overlying skin.

With regard to eye rejuvenation, it is also important to review the skin anatomy and thickness.

Eyelid skin is the thinnest skin on the body at only 350 microns, 50 of which are in the epidermis.

The old technologies Traditional resurfacing would treat 100% of the skin surface, not allowing any normal skin to remain available for wound healing. The old technology used ablative wavelengths with large zones of injury.

These treatments led to extensive injury, prolonged healing time and complications such as prolonged erythema and edema, permanent hypo-pigmentation, scarring and possible ectropion. In addition the open wound was susceptible to infection—bacterial, fungal and viral.

Fractional technologies Nowadays with a fractional injury, we get a fraction of the injury with microscopic columns of injury. We don’t have as big a wound, so the

complications are infrequent and the healing times are reduced. The down side is that patients will require more than one treatment for an optimal aesthetic outcome.

Patients and physicians prefer ‘partial’ or fractional treatments as the risks are low and the benefit is high, if patients understand a series of treatments are required.

The periocular skin must be approached delicately since the skin is extremely thin. The depth of treatment in this area should not be deeper than 100-150 microns or complications can arise.

The new non-ablative devices

contain optics that, regardless of wavelength, allow for deep penetration by adjustment of wavelength, the optical tip and energy.

With non-ablative technologies, the skin barrier is left intact and this closed wound is preferable to patients. Typically a patient will be prescribed three to five treatments at a monthly interval.

Ablative fractional resurfacing creates a greater wound with downtime but also offers better results in fewer treatments. Ablative lasers put microscopic holes in the tissue surrounded by a zone of coagulation. This type of wound offers

The periocular skin must be approached delicately since the skin is extremely thin.

44 MEDICAL AESTHETICS I body language

better remodeling of collagen and elastin and results can be achieved in one or two treatments.

Which wavelength?

Ablative lasers target water in the skin and raise the skin temperature over 100 degrees Celsius causing tissue vaporisation. Carbon dioxide has a wavelength of 10,600nm and absorbs coefficient of water equals to 1000 inverse cm2 . Erbium-YAG laser has a wavelength of 2940nm and absorbs water at 12,500 inverse cm2. So Erbium-YAG is 12.5 times more selective for water absorption, which is why it’s very good at ablating or removing tissue. CO2 has a greater zone of coagulation around the column of ablation, which is why it typically tightens skin more effectively than erbium-YAG alone.

It is essential to understand these wavelengths and properties when choosing a technology.

Non-ablative wavelengths are in the near infrareds region of the electromagnetic spectrum, utilising wavelengths from 1400 to 1,550nm. When these wavelengths target water in the skin, the tissue temperature reaches 60-80 degrees centigrade. This causes tissue coagulation and necrosis as collagen denatures at 63 degrees centigrade. In this reaction, no skin is vaporised so the barrier remains intact. The absorption coefficient for wavelengths 1400-1550 ranges from 26 inverse cm2 of water to 10 inverse cm2 of water repectively.

The microthermal zone of injury is non-ablative as the skin barrier remains intact. The skin can remodel zones as small as 100 microns and can tolerate up to about 350-400 microns without scarring. If the fractional injury is greater than 400 microns, this can cause bulk heating, leading to delayed wound healing and scarring. By choosing a particular wavelength, energy and optical delivery system on the laser we can control the depth and density across the treatment area.

Ablative lasers are extremely effective at allowing for enhanced drug delivery if applied to the treated area within two minutes of treatment. “LADS” or Laser Assisted Delivery of a Steroid” is a new concept used to deliver steroids transcutaneously to the target skin as in

66 Patients with darker skin are excellent candidates for non-ablative wavelengths. Employ caution conducting ablative therapies beyond Fitzpatrick Skin Type IV, but fractional non-ablatives can be safely used 99 a keloid or scar. Non-ablative technology can also help with LADS or other agents, but to a lesser degree given the absence of a vaporisation column or a “micro hole”.

Safety When considering the periocular rejuvenation, safety is essential.

When resurfacing around the eye I recommend treating over the orbital bone by retracting the skin and covering the eye with a standard external shield. However if treating the eyelid, it is critically important for safety to put a laser safe corneal shield in the eye.

Skin type Patients with darker skin are excellent candidates for non-ablative wavelengths. Employ caution in conducting ablative therapies beyond Fitzpatrick Skin Type IV, but fractional non-ablatives can be safely employed. I would recommend lowering the energy and the density to minimise adverse events such as post-inflammatory hyperpigmentation.

Infrared devices are very successful with ‘crepey’ textural skin.

Where there is not quite a wrinkle, just a bit of looseness in skin, such as often appears above the pretarsal muscle inside the orbital rim, or on the anterior neck. A series of treatments can improve tone, texture and tightening. Non-ablatives can also be safely used off the face alone or in combination with other devices in the same treatment session for optimal results.

When treating crows feet, I recommend pre-treatment with a neuromodulator such as toxin several weeks before the laser to relax the orbicularis oculi muscle under the skin wrinkle, so that when the collagen is remodeling over 3-6 months the skin on top will not fold. Wrinkles also have memory and they tend to recur so patients

need maintenance periodically.

Toxin migration Never use a toxin on the same day as a laser that’s going to cause inflammation. Many physicians have tried to treat within the same day or two and had problems with toxin migration, so I would suggest waiting for a minimum of one week optimally two, until the toxin has taken effect before considering a laser.

Depth Due to the new optics that are now available on contemporary laser devices, it is possible to treat at depth. With ablative lasers, it is easy to see the treated zones as they appear as a “white dot” on the skin representing the zone of ablation. A novel groove optic is available from one company and allows for higher density at the epidermis but decreased depth. This leads to quicker healing time and helps eliminate blotchy pigment in the epidermis or upper papillary dermis. This optic is ideal for the periocular area because it doesn’t go that deep.

Three dimensional approach In order to treat an individual effectively you can’t just think about the skin. Consider the changes to bone and soft tissue structures.

Think three-dimensionally under the skin considering re-volumising tissue where shadows occur. Utilizing tissue fillers one can augment supportive structures in the face that are changing. It is a essential to be clear about expectations with patients, including expected duration of benefit of treatment, and work with your patients treatment goals, timeline and budget.

Dr Dianne Quibell, MD is a Cosmetic Laser Surgeon, Vice President of the American Board of Laser Surgery, and Assistant Clinical Professor of Medicine at Harvard Medical School

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46 PROMOTION I body language

IMCAS 2015 The hugely successful IMCAS Annual World Congress in January 2015 showcased the best of the medical aesthetic industry. We review the highlights, and look forward to the 2016 event

IMCAS 2015

A

t the end of last January, 5500 attendees, including plastic surgeons, dermatologists and aesthetic practitioners from more than 80 countries worldwide descended on Paris to attend the IMCAS Annual World Congress 2015. Now in its 17th year, the IMCAS congress aims to offer an educational experience that bridges the gap between the fields of aesthetic surgery and cosmetic dermatology.

Throughout the four days 420 experts shared their knowledge regarding the latest developments in invasive and non-invasive aesthetic procedures and treatments in order to help other members of their profession to bring their skills and knowledge up to date. The 127 scientific sessions covered a vast array of subjects and focused on giving delegates practical advice and competencies that they could immediately apply to their everyday practice.

Alongside the scientific sessions the industry exhibition provided a great platform for the 165 exhibitors to show off their latest innovations. Aesthetic industry giants rubbed shoulders along with smaller companies whilst exhibiting their products and devices to the delegates.

Being one of the largest congresses of its kind in the world, the IMCAS Annual World Congress made the most of its international audience. Cultural differences abound in the field of aesthetics more so perhaps than in any other medical field.

Consequently, the exchange of knowledge and experience between practitioners of different cultures can be vital for the correct treatment of different morphological types. At IMCAS 2015, this was highlighted during the popular regional masterclasses: Friday was dedicated to practicing in the Middle East whilst Saturday saw Eastern Europe particularities take centre stage with great success.

The Injection Cadaver Workshop, now an IMCAS institution, remained as popular as ever, with many delegates claiming it as their highlight of the entire congress. It presented simultaneous live cadaver dissection alongside live injections on patients thus allowing attendees to gain a thorough understanding of the

anatomy of vital parts of the face and body. Experts, located not only on stage but also in the treatment room and at the famous Fer à Moulin Surgery School of Paris, delivered the six-hour program to a packed auditorium.

However, IMCAS 2015 was not only about the tried and tested but also about the new and innovative. This year saw the introduction of a number of new courses and sessions designed to offer delegates a better-rounded view of their practice.

The rapidly developing field of cosmeceuticals was explored during a one-day state of the art course. Delegates discovered the latest evidence-based information regarding cosmeceuticals and nutraceuticals and learnt how best to combine these new products with more traditional treatments such as lasers and injectables.

2015 also saw IMCAS expanding its frontier beyond aesthetics with a whole series of sessions dedicated to clinical dermatology. These sessions focused on the most recently developed treatments for some of the commonest dermatological indications such as acne, rosacea and psoriasis alongside the latest innovations in photodynamic therapy and radiation therapy.

Another new addition to this year’s program was a series of lunchtime talks, dubbed IMCAS Beyond, which provided an innovative vision of the future of aesthetic medicine. Charismatic speakers

took to the stage on a striking crimson carpet to deliver their insights regarding the future of aesthetic medicine and the use of technologies such as 3D printing and Google Glass in aesthetic medicine to an engrossed audience.

For many years now, the IMCAS Annual World Congress has also hosted an Industry Tribune that reports on the current state of the industry and reflects on future developments. This year, this economic forum was opened up to all delegates, allowing doctors as well as members of the industry to profit from the market analysis being proffered. It was reported that the global market for facial aesthetics was valued at approximately 3.7 billion USD (injectables—2.6 billion USD and cosmeceuticals—1.1 billion USD) in 2014, a figure that is due to rise to more than 5.6 billion USD by 2019.

It is certain that the IMCAS Annual World Congress 2015 proved to be bigger and better than ever before. The record number of attendees profited from high quality scientific content that covered a huge variety of topics relating to plastic surgery and cosmetic dermatology. There are, no doubt, many participants who are already booking their time off to attend again next year!

Reference: Sana Siddiqui Syed, Millenium Research Group

body language I PRODUCTS 47

on the market The latest anti-ageing and medical aesthetic products and services

 Dermedics CALM series Dermedics present their newly launched CALM series, designed to assist in calming the discomfort associated with weak, itchy, highly irritated or reddened skin. The series offers soothing properties that Dermedics say allow it to be applied to even the most delicate, demanding or sensitive skin conditions. The combination of products are intended for use by professionals pre and post beauty treatments that irritate the skin i.e. peels, waxing etc.

Comprising five different products—Instant Relief Eye Serum, Purifying Foaming Water, Concentrated Soothing Serum, Physiological Micellar Water and Cermide Creamy Cleanser—the CalmSeries range claim to calm inflammation, improve regeneration of the skin barrier and reduce oxidative stress caused by UV exposure.

Dermedics, W: dermedics.org.uk

 Exuviance Super Retinol Concentrate NeoStrata have launched their latest skin rejuvenation product, Super Retinol Concentrate, a night time formula which uses a 1% dose of retinol encapsulate to deliver 0.2% retinol into the skin. This is said to deliver lifting and firming results while also smoothing wrinkles. NeoGlucosamine, a patented ingredient from NeoStrata, works synergistically with the retinol in the formula, and is said to help boost results whilst also ensuring the product is delivered gradually into the skin via micro-encapsulation.

This delivery system has been designed to help minimise any potential irritation from the high strength formulation.

Exuviance Super Retinol Concentrate also uses optical brighteners along with glycerin to hydrate and bisabolol to calm.

Aesthetic Source, W: aestheticsource.com

. ZO Ossential Lash Enhancing Serum A blend of peptides have been combined to create Ossential Lash Enhancing Serum, said to enhance eyelash thickness and length and improve the appearance of thinning or sparse lashes and brows. Cosmetic dermatologist Dr Rachael Eckel, says “Ossential Lash Enhancing Serum employs cutting edge nourishing technology to safely optimise lash growth and fortify the health.

A potent meld of proprietary peptides targets all cellular stages of hair maturation to yield glossy eyelashes that are fuller, darker, and robust. With results seen in as little as two weeks, an easy to use applicator, and no side effects in clinical trials, Ossential Lash Enhancing Serum is a premier option for achieving visibly longer, stronger, healthier lashes.”

Wigmore Medical, W: wigmoremedical.com

 Dominant Flex Medela announce the launch of Dominant Flex, their new liposuction device. The high vacuum suction pumps are designed to provide adaptable flow rates to suit your needs, allowing for faster vacuum build-up or quieter operation. The functionality and design is said to meet the highest Swiss quality and reliability standards.

Other promoted benefits include optimised hygiene and reduced cleaning time due to intelligent construction, CleanTouch on/off buttons and a minimum number of easily accessible parts.

Medela, W: medela.co.uk

 Molecular Skincare Dr Gabriela Mercik announces the arrival of her molecular based facial skincare regime. The Advanced Molecular Face Mask and Magic Beauty Face Lift Serum have been formulated using Dr Gabriela’s ‘Molecular Care’ system to moisturise, hydrate and replenish skin.

Also within the range is Molecular Water, said to rehydrate, nourish and moisturise the skin, providing deep tissue hydration to help keep skin smooth.

Dr Gabriela, W: drgabriela.co.uk

48 EQUIPMENT I body language

Light stimulation DR STEPHEN EUBANKS explores using low-level light to trigger a biologic response and effectively treat acne and rosacea

T

here are many ways to treat acne and rosacea and several different classes of light and laser treatments, all designed to damage or treat the sebaceous glands—offering different ways of shrinking them.

Treatments include blue light and Levulan, 810 nm diode lasers, the use of 1450 nm Smoothbeam, 405 nm light with IPL blue light and also red light phototherapy.

There are also high power lasers— either 595, 755 or 1064 nm, used primarily to treat the vascular component. All of these lasers work by using the theory of selective photothermolysis. This theory combines a wavelength of laser that is attracted to a vascular target combined with a pulse that keeps the heat within the target. These concepts

are used to damage or destroys a vascular target. However, these are often not ideal because they are either painful, or not effective. Several other excellent approaches to treatment of these conditions exist, but let’s look specifically at the other options that use light and laser.

One of these approaches is bio stimulation—using some low-level laser light to trigger a biologic response—an approach that many people don’t believe in, but that I use to successfully treat both acne and rosacea.

An example of low-level light is to point a flashlight at your hand.

The light penetrates all through your hand, allowing you to actually see the bones in your hand. Low energy light that has a high number of photons, can penetrate the hand. You can use that low-level

body language I EQUIPMENT 49

laser light to gently heat a target— it doesn’t need high energy. In fact if you expose tissue to high energy this doesn’t happen, but if you expose it to low energy photons you can get bio stimulation.

Laser doctors say there’s no way this is going to work, that my laser doesn’t penetrate deep enough— only a millimetre—and that these low level laser light can’t work, but in my mind there are two different approaches: low energy bio stimulation and high-energy destruction.

This is a paradigm change in how I can approach work with lasers. I use a product called Regenlite Transform—a 585 nm pulse dye laser with a very short pulse of 350 microseconds. Unlike the original 450 microsecond Candela lasers that caused bruising, or what we call purpura, this new system can deliver multiple stacked pulses.

These are very low energy for each one, so you can get a cumulative amount of energy that never exceeds a purpuric threshold.

The 585 nanometre light, was the original light used in all pulse dye lasers, but not every company could use this because they couldn’t stabilise this wavelength. However, this wavelength is infinitely more absorbed by haemoglobin than 595 nm laser light. You can use lower fluences to get these same results.

The Regenlite can deliver two different types of pulses. One is a standard vascular treatment for treating blood vessels. We can still stack these pulses, so we have fewer problems with purpura, but most of the time when we’re treating vascular lesions at this higher type of pulse the purpura is unavoidable. A year ago I would never have done this because it would have caused too much purpura, but now with the stacking of pulses with the newest model you can treat the red vascular component of rosacea without causing purpura. Using biostimulation and using your body’s immune response to attack rosacea is much, much more effective.

The second pulse profile that Regenlite has is what they call a SmartPulse. The laser pulse comes out at high energy first, then tapers off —whereas the other meth-

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body language I EQUIPMENT 51

66 Rosacea is complicated and I still don’t think we completely understand all the mechanism or actions of what really causes it 99 ods are slow to rise and then drop off. The 585 nm laser light is still absorbed by blood vessels but it doesn’t have enough energy to destroy them. It heats them up which triggers an injury response. The damage stimulates the body to give a bio-stimulatory response. I use this SmartPulse in all my acne and rosacea patients. It’s a totally different approach to what I’ve done in the past.

I believe, despite the fact that most laser physicians today do not believe in low level laser light, that five years from now it will be equally as important as high energy laser light.

Rosacea is complicated and I still don’t think we completely understand all the mechanism or actions of what really causes it. The many triggers include sunshine and we see that almost everything patients do in regular life all make rosacea worse.

Remember that a trigger causes an immunologic response. Even if rosacea and acne are two different diseases, when you go beyond the clinical their immunologic responses what the body is doing are very similar.

With acne or rosacea there are three steps of the treatment and the disease. First you can try to treat the bacteria. There can be bacteria in rosacea, but there’s more in acne.

When treating Propionibacterium acnes you are trying to reduce the Propionibacterium, which lives primarily on fatty acids in sebum secreted by sebaceous glands in the follicles. Lasers can be used and light treatment, such as blue light where singlet oxygen damages the bacteria.

However, low-level light has been shown not to affect P. acnes.

The next thing to treat is the

damage that rosacea and acne both cause. There can be physical damage, to either the hair follicle spaces, or the overlying epidermis and you have to find a way to fix that.

Something with wound healing properties makes both these conditions better.

Finally there’s an anti inflammatory approach to treating both acne and rosacea. Regenlite can fix all three of these parts of the condition, however evidence shows it does not reduce the number of P acnes. Importantly, this reveals either that by itself the bacteria is not the primary culprit in either acne or rosacea, or that it doesn’t have to be removed.

With this low level 585 nm light, you dramatically increase the level of transforming growth factor beta. (TGF-β) TGF-β is one of what they call a super family of growth factors. It does many different things. It can control cell proliferation, it can control cell differentiation and it can control inflammation.

This factor is also associated

with cancer because cancer cells have the ability to disrupt the effect of TGF-β. But as far as we’re concerned TGF-β is involved with neo-cologenesis, which means it makes new collagen and with immuno-suppression. Many articles have been published that show how TGF beta makes new collagen.

Regenlite originally was created to treat wrinkles, now we know it builds new collagen. The repair of making new collagen is what we use to fix follicular structures that have been damaged either by acne or rosacea. So think of wrinkle repair and acne repair, it’s very similar because new collagen helps build new structures.

The most important and interesting part of this is the inflammatory effect of TGF-β. Patients with acne or rosacea have a long list of what we call cytokines—small proteins responsible for cell signalling in the body. You have probably heard of tumor necrosis factor (TNF-α), an immune cell regulator that’s associated with psoriasis for instance. Enbrel and Humira

Either bacteria by itself is not the primary culprit in either acne or rosacea, or it doesn’t have to be removed

52 EQUIPMENT I body language

injections are cytokines that affect TNF-α, and almost always they do bad things.

We’re looking at the inflammatory cytokines—so nuclear factor kappa B is one, TNF-α, IL-1, IL-10, IL-8 are all inflammatory cytokines. There is good evidence that TGF-β can reduce these cytokines within 48 hours of having a laser treatment. They reduce the inflammatory cytokines that are causing the inflammation from the rosacea or the acne.

Our latest finding is that TGF Beta also stimulates a class of Tlymphocytes called T-regulatory cells. T regulatory cells impart long-term anti-inflammatory

properties to the skin—potentially a lifelong anti-inflammatory to the acne-causing cytokines. This is why when we treat patients, they often stay clear.

I have patients now who have been symptom free for two years.

I do a series of four treatments two weeks apart. I have people who had horrible rosacea and nothing had worked for them. I have one patient whom I have given four treatments and 18 months later he’s still 100% clear. That we believe is because of the his T-regulatory response.

Can you get rid of redness? Absolutely. We treat redness still at the low level, at the stacking mode, but we also know that we’re giving

Q&A DR STEPHEN EUBANKS discusses treatment method for rhinophyma

Q: What would be the suggested pharmacological preparation of a patient for surgical treatment of rhinophyma?

A: Rhinophyma is a disease whereby you have a lot of oil production and you have textural irregularity. So my main focus is on changing texture and improving the texture, suppressing the disease, inactivating the disease before the procedure because if I do a procedure on active disease the disease is going to be worse afterwards because procedures activate oil glands.

In my practice I choose textural improving agents so I control oil. And we do things like beta-hydroxyl acid and azelaeic acid to do that. I use an exfoliating agent such as 10% lactic and glycolic acid to help with the texture and to improve the keratin turnover. And I use a 1% retinol product, the product I use in this circumstance is called Retin-A. So I’m preparing the skin for at least six weeks beforehand. Then I would do the procedure such as the CO2 fractionated laser once a patient’s skin has healed fully.

Afterwards I put them on the Accutane 20milligrams, to shrink the sebaceous

a long-term anti-inflammatory response. Another patient with acne on her chin for 10 years also had diffuse redness and everything she tried did absolutely nothing. We gave her two treatments and she has not had an outbreak for two years.

It’s amazing because something is happening immunologically.

Treatment for a full face takes three or four minutes and it’s painless, there’s zero down time. Hopefully this shows you that there are some alternatives and a new mechanism of action, a new approach to treating these diseases.

Dr Stephen Eubanks, is a dermatologist from Denver Colorado

glands permanently because after the procedure you get a reactivation of oil glands. So to prevent disease recurrence and the patient looking worse afterwards I introduce my Accutane then.

Q: How much further along the line with Accutane would you treat the patients. If you just treat them for a six month period with 20 mg, two years along the line sebaceous glands may start to produce oil so would you target it as a long term?

A: Accutane is a medication that’s been around for many, many years and the more that we learn about it the more we understand how to use it. To answer your question I do five months 20 milligrams once a day, so I do low dose Accutane, and at the end of that 50% improve and 50% don’t improve. So 50% have long term remission forever, and the other 50% don’t. Is that different to high dose?

High dose you have the exact same failure rate, so high dose if I use it based on your weight and I give you 40 - 60 milligrams of Accutane a day still at the end of the five months you’re going to have 50% improve and 50% don’t improve. So that’s why I go with the low dose, because it has the same success failure rate.

That 50% who don’t improve, when are they going to show signs of rosacea again?

I don’t know, it could be in five years time, it could be in 20 years time, I don’t know when they’re going to show the signs that it’s failed on them. If it happens to come back then I have a choice. I can either put

them on a second dose of 20 milligrams once a day for five months and then 50% will improve and 50% won’t improve, or a lot of times in my practice if it starts to recur I do continuous micro doses of Accutane. You can take ten milligrams once a day for the rest of your life, you can have 20 milligrams twice a week, three times a week, or you can pulse, you can do that for three months, take three months. Three months on, three months off. There are lots of different ways in the literature that you can play around with the drug.

Q: What about dangers of Accutane?

A: As dermatologists our role is to have a high index of suspicion and know the right questions to ask. So if somebody coming in is complaining of getting migraines, problems with nausea and seeing double vision, I have to know that there is a chance that you could have pseudo tumor cerebrii, which is a very rate thing that is associated with Accutane.

I must know about the side effects, the potential side effects, even if a lot of them are uncommon I must be able to know that when somebody comes in and complains of these things I know the right questions to ask. I know she needs to go to a neurologist, she needs to have a lumbar puncture, she needs to have an MRI. You have to have a high index of suspicion, yes there are risk, yes you need to know about depression, but that’s not going to be an absolute contra indication for me to put somebody on the medication.

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Agenda r a d n e l a c r u o y k r a M

IMCAS China

IMCAS ASIA

SHANGHAI

BALI INDONESIA

GOA

PARIS FRANCE

2015

2015

2015

2016

Apr 10 to

12

Jul 31 to

Aug 2

IMCAS

India

Nov

Annual World Congress

Jan 28 to

31

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body language I DEBATE 55

Hyperpigmentation DR CARL THORNFELDT and MS SHASHI GOSSAIN share their views on topical treatments DR CARL THORNFELDT Dr Thronfeldt is a practicing clinical dermatologist with 30 years of skin research experience, 21 US patents granted and multiple scientific publications in the area of treatment of skin diseases and conditions.

MS SHASHI GOSSAIN Ms Gossain is a pharmacist, cosmetic scientist, and MD of Pharmaclinix who has spent over 30 years in the skincare industry, researching the most effective treatments for skin types 3-6.

Q: Many of my patients have used over-the-counter or inadvisable products to combat pigmentation, with awful results.

Can you reverse the damage?

keeps those under control, then we have low rates of recurrence. I monitor patients for 36 months beyond initiation of treatment and instruct the patient of this on the first visit.

Ms Shashi Gossain: I would think they have been using hydroquinone at high strengths under no medical supervision.

You may only start seeing the damage years later, and then you have to reverse it. I spent six years in South Africa just doing that. I use Lightenex Gold to help combat the damage.

Q: What about for dermal components, for instance melasma that are harder to treat?

Q: Is there a place in your practice for chemical peels?

Dr Carl Thornfeldt: I do a lot of superficial and some mid-depth chemical peels in my clinic and have done for many years since we have the highest incidence of skin cancer per capita in North America. To build the strategy, consider what is happening in the melanocyte cell. When you look at skin cells under an electron microscope, including inflammatory cells, fibroblasts, keratinocytes, and melanocytes, you see an increased number and size of receptor sites. This leads to induction of excessive cell activity. To induce long-term remission, you must have those undergo disuse atrophy. That usually starts at about 18 weeks for inflammatory cells and longer for the other cell types. It may take as long as 18 months for these receptors to absorb, which induces remission.

When I achieve the desired result, I go into a pulse dose of the therapeutic regime, using it 2-5 times weekly. I want long-term remission, and to get the receptor sites reduced in size and back to the normal number. I will do that for an additional 18-month period afterwards to prevent rebound of hyperpigmentation.

As long as the regimen also targets barrier repair and inflammation and

Dr Carl Thornfeldt: It’s a lot slower and I caution patients it will take a lot longer.

I think that new technologies, such as the Pico laser and the nanosecond laser look pretty good, but we have to wait and see once long-term follow-up data is available.

Ms Shashi Gossain: Pigmentation occurs in several stages in different layers of the skin, and different ingredients work on hyperpigmentation within these different layers. You have to choose ingredients that are going to work in combination – no one ingredient will work for everyone. We have already done over twelve hundred Lightenex Max Peels at The Hyperpigmentation Clinic in Harley Street – in dark skinned individuals with at least 50% reduction in Melanosis after one treatment course, without using Hydroquinone. Dark blue grey dermal pigmentation has been successfully reversed with this peel.

Q: I see many patients who have been using hydroquinone for a very long time. How do you find the transition getting hydroquinone-free?

Dr Carl Thornfeldt: The FDA recommends that you only use eight-week pulses of hydroquinone-containing products and then you switch to something else. If patients come in and are using hydroquinone with good results, I don’t have them stop it completely, I have them taper off.

I will continue with eight weeks on, eight

weeks off, and use Epionce MelanoLyte Skin Brightening System between these hydroquinone pulses. I also use Epionce Renewal facial products with both depigmentation regiments to repair the barrier and control chronic inflammation.

This is expected to enhance the hydroquinone efficacy.

Usually, I find that after about six months the patient will say that their skin feels better on the non-hydroquinone, at which point if the patient wants to, you can try stopping using hydroquinone.

You have to remember though, that a lot of patients have had a good result with hydroquinone and when they have stopped in the past their symptoms have returned.

I respect that and believe most is due to damaged barrier and microscopic or mild irritation to hydroquinone, which is documented in clinical trials to occur in up to 83% of users. I don’t try to make them change. Instead they can continue the rotation that they’re on and then use the alternatives.

Ms Shashi Gossain: If hydroquinone was safe, I feel it would be freely available as there are dangers associated with its use.

Ochoronosis is a histological diagnosis and shows up on biopsy with the classical banana shaped bodies. Evidence of irreversible damage is seen under the microscope even before the visible signs show.

Therefore there tends to be complacency by users that they are fine. In addition addiction is also a problem. Rebound hyperpigmentation I always find is a problem with hydroquinone, especially in dark type 3-6 skins where it tends to become very resistant to any treatment. Treatment does not start and end in the clinic. Total sunblock and skin-brightening creams are what will suppress the production of melanin in the first place. Whatever damage has happened in the dermis is going to come to the epidermis and that’s when you start seeing the difference.

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JUNE

6 Advanced Toxins* (am) 6 Advanced Fillers-F* (pm) 8 Mini-Thread Lift* 10 glōTherapeutics 11 Advanced glōTherapeutics 16 Dracula PRP* 17 ZO Medical Basic 18 ZO Medical Interm.

19 ZO Medical Adv. 24 Skincare & Peels 24 ZO Medical Basic (Dublin) 25 ZO Medical Adv. (Dublin) 25 Intro to Toxins* 26 Intro to Fillers* 29 Microsclerotherapy*

9 Sculptra* 10 Advanced Fillers-TT* (am) 10 Advanced Fillers-CH* (pm) 11 Mini-Thread Lift* 13 CPR & Anaphylaxis Update 13 Medik8 Dermal Roller (pm) 20 Dracula PRP* 21 ZO Medical Basic 22 ZO Medical Interm.

28 Skincare & Peels 28 ZO Medical Basic (Dublin) 29 ZO Medical Interm. (Dublin) 29 Intro to Toxins* 30 Intro to Fillers*

8 Advanced Toxins* (am) 8 Advanced Fillers-LF* (pm) 9 Mini-Thread Lift* 19 Skincare & Peels 19 ZO Medical Basic (Dublin) 20 ZO Medical Interm. (Dublin) 20 Intro to Toxins* 21 Intro to Fillers* 26 ZO Medical Basic 27 ZO Medical Interm.

28 ZO Medical Adv. 30 Microsclerotherapy*

9 Skincare & Peels 10 Intro to Toxins* 11 Intro to Fillers* 12 Advanced Fillers-TT* (am) 12 Advanced Fillers-CH* (pm) 13 Mini-Thread Lift* 15 Dracula PRP* 16 ZO Medical Basic 17 ZO Medical Interm.

27 Microsclerotherapy*

* Only available to doctors, dentists and medical nurses with a valid registration number from their respective governing body.

All courses in London unless specified.

FOLLOW @WIGMORETRAINING ON TWITTER FOR THE LATEST UPDATES AND COURSE INFORMATION

Advanced Fillers sessions breakdown: CH = Cheeks/mid-face F = Forehead LF = Lower face TT = Tear troughs

body language I MARKETING 57

Promoting your clinic with SEO JOHN CASTRO gives advice on how to use and implement Search Engine Optimisation (SEO) to market your clinic.

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EO is a puzzle. There’s so much to it—keyword research, backlinks, competitor analysis, contents, metatags, social networks, blogging. But all those elements don’t have to be complicated, if they’re done properly and consistently.

SEO has continued to change dramatically with technology and customer demands and is now very social driven. Google’s objective is to give you the best result for whatever you’re searching for. If you’re looking for your local aesthetic clinic, they want to know which clinic to send you to. They do that by looking at how many people like that clinic by counting their Facebook likes, Twitter retweets, followers, Google Pluses—they’re counting everything.

Social media Social media, when used properly, does work and overall it will help your rankings.

35 plus is now the age of the Facebook audience. Youngsters just want quick clips or to post a picture telling the whole story on Instagram, they get bored easily. This means your audience is on Facebook.

High traffic websites don’t always have loads of likes for a really good article. But even with just 20 likes, those are 20 potential customers that you could PM. You can be really tactical about who you communicate with and you’ll be surprised the reaction you get.

Twitter is also good for aesthetic clinics although it can be a sensitive issue with cosmetic surgery. Twitter is good for less private conversations.

Another platform to look out for is Google Plus—Google’s social network, which although is not yet great, does have Google Plus local, which is a business page. Connecting interaction happening on that business page to your blogging is really going to help your SEO. Your reviews on Google Plus will show up in your Google search. So when you do show up on page one, you stand out. You look like an advert and you’ve got the image of the person who posted the blog and of course your location on Google Maps.

Content Content shouldn’t be random, it should be things people are actually interested in. If one client has a problem, chances are other

clients will have that problem too. If you’ve solved that problem, write about it, because it shows people the context in which you operate and how you can help them.

Linking It’s better to have your link or your website or be mentioned with a link back to you on a very high authoritative website for Google than it is anything else. So it’s not about the amount of links, it’s about the quality and the reputation of the sites you post links on.

With your linking, the site still needs to be relevant to you - if you are an aesthetics clinic, don’t post your link on a golf website. Get bloggers to blog about you, and link with people that get traffic or have a big Twitter following. Get them to post your blogs and articles for you.

For example, when you have been mentioned in another site or press—say local press—put the article on your social media because Google reads all of that. It reads who that social media account belongs to, they go to that article you’ve posted and they see that you’re linked on it. They know all of this in less than a tenth of a second.

Social, content and linking—these are the basics. If you do this consistently yourself it will take you some time, a good couple of hours a day, but you will see results.

What does this mean for you?

It’s so important to be personal today. In the internet boom, we wanted to know how to get stuff quickly. Now, consumers are actually going back to a time where they want a connection.

They want trust and they want a relationship—not just an injectable treatment. That’s just what you provide to them, so be really personal.

SEO isn’t just about getting to number one on page one anymore. It’s how much attention can you get on page one. It’s important to be looking at getting shares, likes, reviews and comments. We need to interact with people on social media—it can be a lot of work but it will benefit you greatly in the long run.

John Castro is the CEO and Founder of Websites for Cosmetics, a website agency that only focuses in cosmetic surgery and medical aesthetic businesses.

SALLY DURANT TRAINING AND CONSULTANCY Setting new standards in skin health education and clinical aesthetic training

 Training Excellence For the Medi-Spa Sector  Engaged by Leading Companies in the Global Aesthetic Market  Pioneering Level 4 Qualifications in Advanced Skin Study and Remedial Treatment  Courses accredited by OFQUAL Approved awarding body  Unique CPD Programme in Skin Health Management and Cosmetic Dermatology  Endorsed by leading Dermatologists and Aesthetic Practitioners

enquiries@sallydurant.com

www.sallydurant.com

01527 919 880

body language I PANEL 59

Training and accreditation Our expert panel debate training requirements and regulation in the medical aestheitc industry

Q: Do all laser technicians need to have a Level 4 laser or IPL qualification by 2016 in order to carry out treatment?

Gill Herrick: Due to under-qualified people using IPL and laser systems they have purchased from the internet and abroad, The British Association of Beauty Therapy and Cosmetology (BABTAC) were getting increased claims in this area for all skin types. So they decided that from 2016, any therapist insured with them must have a Level 4 Laser and Light qualification— whether in hair removal, rejuvenation, or a joint qualification.

Sally Durant: A lot of the time in our industry, certainly in the case of chemical peels and laser, we are being governed by the insurance companies because these treatments are not currently regulated by a qualification structure. I think the insurance companies, as much as we need them, have not been working in the best interests of the industry by broadly insuring

as many people as they can get premiums from, without adhering to a sufficiently stringent and specific criteria. I have encountered many people who think they don’t need training because they can get insurance without it.

Elizabeth Raymond Brown: We also have another vagary, which is with the laser and light therapies.

In London, Birmingham and Nottingham, clinics delivering lightbased therapies can insist—because there are special treatment licenses—that only practitioners who are NVQ Level 3 beauty therapists will be able to practice. The rest of the country won’t insist on that, so it’s difficult and frustrating.

66 A lot of the time in our industry, we are governed by the insurance companies 99

Q: Who should the Government be talking to?

There doesn’t seem to be agreement amongst the various bodies to nominate somebody who can speak on behalf of the industry.

that the cosmetic sector should be deregulated, so for cosmetic procedures there is no Government involvement and the local authorities have picked it up.

There is a certain mindset that will say what we need another high profile case, such as the PIP scandal, which brought about the Keogh report. Many cynical people will say we need a serious laser or filler scandal before we can bring the industry together and get the government involved. The government will feel it is too complicated and expensive for them to regulate, so will advise self-regulation, and everyone is aware how well selfregulation works.

Elizabeth Raymond Brown: The Government took the decision

Q: Would it be sensible to suggest to the Government

60 PANEL I body language

that there ought to be some minimum standards? If insurance companies would then support those basic minimum standards this would be a good step in the right direction.

Gill Herrick: We need to educate the public to look for the good practice, research qualifications and be discerning in whom they choose for treatment. Instead of selecting a practitioner on price, the patient should be looking for the right credentials, and we should enable the consumer to make the right choices.

Q: Do you think setting these standards would be expecting an awful lot from the Government, unless somebody helps them?

Elizabeth Raymond Brown: It won’t come from the Government—it will come from trade bodies. The Independent Healthcare Advisory Service (IHAS) for example, devised “treatments you can trust”—a voluntary register.

There is a cost to join though, and many practitioners may not see a reason to pay to join if they are happily running their practice.

The government is very hands off, they won’t regulate this sector, and so we’ve got to get our act together ourselves.

Q: It’s great that BABTAC is taking a lead, but is that going to go further?

Gill Herrick: BABTAC are working with some laser companies, of which Lynton are one, who will be voluntarily offering the laser and light qualification so that clinicians don’t have to go back to college. Instead, the practitioner can do a theory workbook, and case studies on the laser or IPL that they are using and then take a theory and practical exam. This is something that the Confederation of International Beauty Therapy and Cosmetology (CIBTAC) wanted to work. There are many good therapists in the industry who want to take qualifications voluntarily.

Sally Durant: I think that

BABTAC need to go a stage further and not just focus on laser qualifications, but qualifications across the spectrum of clinical skin care, in line with the commissioned review by HEE. I would like to see all insurance companies be more informed on each different element of particular treatments. Chemical peeling in particular needs to be looked at as it is so variable and the different levels of cover relating to peel agent strength, pH and therefore penetration should be made much clearer.

Q: What are the chances of BABTAC looking at the entire spectrum and applying the same reasoning that they will apply to IPL and laser to other disciplines, to create a common approach?

Sally Durant: I think we need to specify a point of entry—what level qualification do practitioners need to practice certain treatments and get away from the ‘supplier driven’ training which is sometimes very good, but often lacking in its educational quality and assessment of proficiency. The Government isn’t going to do this in the foreseeable future, so we as an industry have to self regulate by firmly setting our standards of accredited education and training for the clinical sector.

Q: Theoretically, if the manufacturers broadly speaking agree, the training bodies broadly agree and the insurance companies agree, some kind of guidelines could be created to present to the Government?

Sally Durant: Health Education England (HEE) is doing just that, having been appointed by the government to make recommendations for a qualification structure in the aesthetic sector. Originally the focus of the HEE was very much on looking at the more medical elements of aesthetics such as cosmetic surgery and injectables and the higher education recommendations relating to that. However, whilst the HEE standards has now

designed a degree course for medical practitioners to train in nonsurgical treatments, the structure of the qualification framework also encompasses the levels of occupational standards to be incorporated into qualifications for therapists at levels 4, 5 and 6 to become properly qualified in procedures such as chemical peels, laser, IPL and micro-needling. This is a great step forward in regaining the credibility of our industry and the safety of the public.

Gill Herrick: Toxins and fillers will always be down the medical route—in fact The Royal College of Surgeons have been asked to put together the training for that module. HEE have set up a working group for laser and light treatments and different levels have now been established, starting from level 4, going up to level 7 or 8 for lasers.

Hair and skin rejuvenation are level 4, tattoo removal is level 5.

HEE are looking at the moment for qualifications to be voluntary, but if there is a lot of take-up and interest they will perhaps legislate it. There is talk that other qualifications already available in the industry can be aligned with them.

Sally Durant: My hope is that if we don’t have compulsory qualifications, we can create a self-imposed standard that is not a question of paying membership. Instead it should be based on credentials, commitment to education, professional development and professional integrity. I think having a certain level of CPD every year, to make sure your skills are up to date is something to be incorporated.

SALLY DURANT Sally Durant established her training consultancy in 2009 offering the provision of post graduate training, practice development services and education programme design in the clinical aesthetics sector.

GILL HERRICK Gill is a clinical trainer for Lynton and has worked in the aesthetic industry for many years. She has extensive laser and IPL knowledge, and has been involved in developing training courses for various awarding bodies ELIZABETH RAYMOND BROWN Elizabeth authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies. She is director of education at LCS Academy Ltd.

body language I EDUCATION 61

training TF

TOXINS AND FILLERS

6 March, Advanced Botulinum Toxins (am) and Fillers—Forehead (pm), Wigmore Medical, London W: wigmoremedical.com 11 March, Hyperhidrosis Training, Honey Fizz, Newport W: honeyfizz.co.uk 21 March, Botox & Dermal Filler Training Foundation Course, The Paddocks Clinic, Birmingham W: cosmeticcourses.co.uk 21 March, Dermal Filler & Botox Training—Advanced Course, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 25-26 March, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 29 March, Botox & Dermal Filler Training Foundation Course, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 7 April, Basic Botulinum Toxin Training Day, Honey Fizz, Newport W: honeyfizz.co.uk 10 April, Advanced Fillers—Tear Troughs (am) and Cheeks (pm), Wigmore Medical, London W: wigmoremedical.com 11 April, Combined Basic Training – Dermal Filler and Botulinum Toxin, Honey Fizz, Newport W: honeyfizz.co.uk 21 April, Basic Botulinum Toxin Training Day, Honey Fizz, Newport W: honeyfizz.co.uk 29-30 April, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 2 May, Combined Basic Training Courses – Dermal Filler & Botulinum Toxin, Honey Fizz, Newport W: honeyfizz.co.uk 5 May, Advanced Botox & Azzalure Training, Honey Fizz, Newport W: honeyfizz.co.uk 8 May, Advanced Botulinum Toxins (am) and Fillers—Lower face (pm), Wigmore Medical, London W: wigmoremedical.com 20-21 May, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com

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OTHER INJECTABLES

8 March, Mini-Thread Lift, Wigmore Medical, London W: wigmoremedical.com 16 March, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com 28 March, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com

London W: wigmoremedical.com 30 May, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com

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SKINCARE

3 March, Micropigmentation Induction Day, Finishing Touches, West Sussex W: finishingtouchesgroup.com 3 March, Epionce Training Sessions, Eden Aesthetics, Glasgow W: edenaesthetics.com 4 March, Agera Training, Eden Aesthetics, Glasgow W: edenaesthetics.com 10-11 March, Basic and Advanced GloTherapeutics, Wigmore Medical, London W: wigmoremedical.com 12 March, Microdermabrasion Training, Eden Aesthetics, London W: edenaesthetics.com

9 April, Sculptra, Wigmore Medical, London W: wigmoremedical.com

16 March, Agera Training, Eden Aesthetics, Danbury W: edenaesthetics.com

11 April, Mini-Thread Lift, Wigmore Medical, London W: wigmoremedical.com

17 March, Epionce Training Sessions, Eden Aesthetics, Danbury W: edenaesthetics.com

20 April, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com

17-19 March, ZO Medical Basic, Intermediate and Advanced, Wigmore Medical, London W: wigmoremedical.com

9 May, Mini-Thread Lift, Wigmore Medical,

19 March, Agera Training, Eden Aesthetics, London W: edenaesthetics.com 24 March, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com 24-25 March, ZO Medical Basic and Advanced (Dublin), Wigmore Medical, London W: wigmoremedical.com 26 March, Epionce Microneedling Training, Eden Aesthetics, Liverpool W: edenaesthetics.com 26 March, Epionce Microneedling Training, Eden Aesthetics, Danbury W: edenaesthetics.com 31 March, Agera Training, Eden Aesthetics, Warrington W: edenaesthetics.com 1 April, Epionce Training Sessions, Eden Aesthetics, Warrington W: edenaesthetics.com 7 April, Micropigmentation Induction Day, Finishing Touches, West Sussex W: finishingtouchesgroup.com 13 April, Medik8 Dermal Roller (pm) , Wigmore Medical, London W: wigmoremedical.com 21-22 April, ZO Medical Basic and Intermediate, Wigmore Medical, London W: wigmoremedical.com 28 April, Skincare & Chemical Peels, Wigmore Medical, London

W: wigmoremedical.com 28-29 April, ZO Medical Basic and Intermediate (Dublin), Wigmore Medical, London W: wigmoremedical.com 5 May, Micropigmentation Induction Day, Finishing Touches, West Sussex W: finishingtouchesgroup.com 19 May, ZO Medical Basic (Dublin), Wigmore Medical, London W: wigmoremedical.com 19 May, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com 20 May, ZO Medical Intermediate (Dublin), Wigmore Medical, London W: wigmoremedical.com 26-28 May, ZO Medical Basic, Intermediate and Advanced, Wigmore Medical, London W: wigmoremedical.com

O

OTHER TRAINING

13 April, CPR & Anaphylaxis Update (am), Wigmore Medical, London W: wigmoremedical.com 9-10 March, Two Day Areola Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com 23-26 March, Four Day Scalp Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com Contact arabella@face-ltd.com to feature courses

62 EXPERIENCE I body language

Words of wisdom PROFESSOR MUKTA SACHDEV chose to specialise in dermatology and completed her training in Bangalore. She shares her journey through the career she loves and her positive approach to treatment

Prof Sachdev just after finishing her MD

I

have been working with skin of colour for close to two decades in the realm of clinical and aesthetic dermatology. Worldwide experience was initially limited with darker skin types, but as one of the first in India to work with lasers and cosmetic dermatology procedures I have witnessed not only a growth of world knowledge of how to work with this skin type alongside the development of newer treatments, but seen my own learning curve.

Dealing not only with the concept of body dismorphic disorder and unrealistic patient expectations, one also needed to be able to patiently deal with procedural induced post inflammatory hyperpigmentation which is a constant challenge with darker skin types.

Often people ask me why I chose dermatology as my speciality as today dermatology, particularly aesthetics, is one of the most sought after postgraduate training programmes.

As I lived in England, Saudi Arabia and India across my childhood, and studied medicine in India, I had global exposure and not a traditional Indian upbringing.

Having seen my mother who is a gynaecologist attend night calls and deliver babies late into the night for most of my childhood, I can honestly say that my choice was largely guided by the desire to have a work life balance, as the aesthetic field had not even really started when I began my post graduation.

So not only was my choice of my specialty confirmed, but the place I wanted to train was also Bangalore, India as by then I had decided to get married to my childhood sweetheart who I met in the 12th grade.

This then spurred me on to work extremely hard to get into the choice of my course for the competitive entrance postgraduate exam for a dermatology train-

ing programme in the prestigious military Air Force hospital in Bangalore.

After qualifying for the entrance exam and appearing for the interview, I was selected for the programme my Professor, guide and mentor, who suggested that in spite of being newly married I should intensely focus on the programme for three years without considering anything else. Despite some reservations this was sound advice when I topped the University in the postgraduate exam, and advice that has held me in good stead over the years.

I firmly believe that in spite of what we plan and do there is definitely a guiding force that steers ones life and path both professionally and personally. Over the years, I have come to realise that when one is happy and content with ones inner self and personal life and choice of profession, it is possible to be able to deliver realistic and kind advice to patients, which is taken by the patient in a positive manner. Today when a patient comes in and tells me that they are in my office and trust me to advise them for the right procedure so they are not over treated—which is a common occurrence today in the aesthetic world—I take the responsibility very seriously.

My only advice to upcoming dermatologists in this field, from my years in the speciality, is that if one treats the patient as one would like their own family member to be treated, it allows for a rapport and trust to be created with a long lasting patient physician relationship which is mutually satisfying.

Being married for 24 years now with a grown up son in university, I realise that having a supportive family who encourages you to do what you love is the secret to success. When I suggested to my son to perhaps consider medicine as a career option, he told me he didn’t think he had the patience to take care of people “all the time like you do”. When he subsequently chose and is excelling in a materials sciences engineering programme, I also realised that one must follow ones heart and liking as a work choice. I not only like, but actually love what I do and so going to the hospital and clinic is a pleasure everyday.

I can say, honestly that now when the clinic runs late into the night and work is completely unpredictable in terms of time, perhaps the reasons for my choice may not have been justified but I am absolutely sure that I made the right one!

Prof Mukta Sachdev Professor of Dermatology, India Prof Sachdev runs a private cosmetic office practice and a clinical trial unit specialising in dermatology trials in skin of colour.

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SKINCARE We offer a handpicked collection to suit all applications and benefit your practice

EQUIPMENT We provide a wide range of equipment to ensure practitioners stay ahead of the competition

INJECTABLES Our extensive range allows practitioners to tailor order products to best suit their patient

PHARMACY For the last 30 years we have supplied medical equipment and drugs to practitioners UK wide

TRAINING Unique courses combine leading expertise, intimate group sizes and hands-on training

Wigmore Medical The aesthetic industry’s preferred partner 23 WIGMORE STREET, LONDON, W1G 0EB I E: CUSTOMERSERVICES@WIGMOREMEDICAL.COM I W: WIGMOREMEDICAL.COM I T: 020 7491 0150

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