may
71 The UK and International Journal of Medical Aesthetics and Anti-Ageing bodylanguage.net
TREATMENT OUTCOMES
THE IMPORTANCE OF MEASURING AND REPORTING ON PATIENT’S RESULTS FOR OPTIMISING CARE
FACE 2015
SKIN COMPLAINTS
AWARDS
Conference agendas, speaker profiles and exhibition updates
How to treat common dermatological problems using multifactoral therapy
What does it take to win in a competitive industry
novacutis
body language I CONTENTS 3
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contents EDITOR Helen Unsworth 020 7514 5989 helen@face-ltd.com
07 NEWS
ASSISTANT EDITOR Lousie Renwick 020 7514 5989 louise@face-ltd.com
14 STUDY
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 Dr Ravi Jandhyala, Dr Stefan Cano, Dr Kimberley Taylor, Stephen Handisides, Dr Rachael Eckel, Dr Carl Thornfeldt, Dr Daniel Sister, Dr Zein Obagi, Dr Linda Eve, Dr Raj Persaud 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
OBSERVATIONS Reports and comments
Dr Ali Pirayesh as the Scientific Director on “Essential anatomy and techniques for aesthetic procedures”
QUALITY OF LIFE
28 INJECTABLE AGENDA
Dr Ravi Jandhyala talks about the methods to assess the impact of botulinum toxin type A on patients’ quality of life
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
19 PANEL TREATMENT OUTCOMES
29 BODY AGENDA
Dr Stefan Cano, Dr Ravi Jandhyala and Dr Kimberley Taylor discuss the importance of measuring and reporting on patients’ treatment outcomes for optimising patient care
For the first time, FACE will host the BODY Conference with a full agenda featuring non-surgical treatments to target all indications within this evolving sector
CONFERENCE 26 FACE 2015 Held at the QEII Centre in London’s Westminster on June 4th to 7th, FACE 2015 will host a world renowned speaker panel, delivering a complete educational programme
27 MASTERCLASS FACE 2015 will be hosting an advanced masterclass with
30 SKIN AGENDA Skincare is at the centre of the medical aesthetic industry— topical products and combined approaches to treatment are explored in depth
31 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
4 CONTENTS I body language
editorial panel
32 AESTHETICIANS AGENDA This agenda explores the latest advanced treatments for non-medically trained practitioners, providing a unique forum for therapists
33 HAIR AGENDA 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.
Androgenic alopecia and hair loss are common indications—learn about the latest treatments and techniques for effective restoration
34 THE EXHIBITION With over 80 exhibitors, a packed agenda of exhibitor workshops spanning three days and a choice of comprehensive exhibitor symposiums, FACE 2015 offers delegates every opportunity to explore the latest medical aesthetic products and services
37 MARKETING AWARD-WINNING In a competitive industry, winning an award can bolster your credibility and deliver a steady stream of new clients. Stephen Handisides offers his advice on how to enter, and what it takes to win
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.
38 INJECTABLES
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.
41 DERMATOLOGY
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.
48 PRODUCTS
TREATING ROSACEA WITH BOTULINUM TOXIN TYPE A Dr Rachael Eckel discusses how toxins can be used to reduce facial flushing and erythema
MANAGING COMMON SKIN DISEASES Dr Carl Thornfeldt discusses the multifactoral causes of skin diseases and how the best results are achieved using multifactoral therapy
ON THE MARKET The latest anti-ageing and medical aesthetic products and services
51 SKINCARE 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.
SKIN LIGHTENING
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.
54 EDUCATION
Treatments to reduce dark spots and lighten the complexion are often sought by patients worldwide. Dr Daniel Sister looks at the causes of pigmentation and ingredients that offer results
TRAINING DATES A comprehensive course calendar for the industry
57 SKINCARE 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.
ACNE PREVENTION AND TREATMENT Dr Zein Obagi describes his novel approach to preventing comedogenic acne and optimising a treatment plan
61 MEDICAL AESTHETICS 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.
MICRO-NEEDLING
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.
65 PSYCHOLOGY
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.
66 OBITUARY
Dr Linda Eve talks about the benefits of the micro-needling systems available and the newer techniques that have improved results for the benefit of patients
THE ‘SEXY SONS’ HYPOTHESIS Dr Raj Persaud discusses research exploring why women have better sex with men other women
DR FREDRIC BRANDT Pioneering dermatologist Dr Frederic Brandt, known as the ‘Baron of Botox’, and highly regarded as a cosmetologist has died aged 65
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body language I NEWS 7
observations
ANTIBODY THERAPY IMPROVES PSORIASIS SYMPTOMS Clinical trial sees improvement of at least 80% in most participants Many psoriasis sufferers showed significant recovery after just one dose of a human antibody that blocks an immune signalling protein crucial to the disease, reported The Journal of Allergy and Clinical Immunology. Nearly all 31 patients to receive treatment in the trial, carried out at Rockefeller University and seven other centres, saw improvement of at least 80%, if not total disappearance of their symptoms. Only a single treatment produced what the team describes as “rapid, substantial, and durable clinical improvement in patients with moderate-to-severe psoriasis.” In 2004, Krueger and colleagues suggested a dominant role for interleukin-23 in the disease, and research since then has supported this hypothesis. It appears that interleukin-23, a cytokine, triggers a cascade of interactions that leads to inf lammation in the skin and excessive growth of skin cells and dilation of blood vessels. The discovery of interleukin-23’s role has led to tests of a number of new antibody-based therapies that target
it, but the compound, known as BI 655066, stands out. BI 655066 is a human antibody that targets interleukin-23 and blocks it from binding to the receptors on cells that respond to it. “The striking result we achieved using a human antibody that targets the signal interleukin-23 suggests we are on the threshold of doing something very different from our current model
of treating psoriasis with immunosuppressive drugs throughout an adult lifetime,” says study author James Krueger, director of the Milstein Medical Research Program, D. Martin Carter Professor in Clinical Investigation and head of the Laboratory of Investigative Dermatology. “It raises the possibility of working toward long-term remission—in other words, a cure.”
BREASTFEEDING WITH IMPLANTS 20% of women with implants can’t or won’t breastfeed Research published in the Medical Journal of Australia claims one in five women who have had breast augmentation may subsequently be unable or unwilling to breastfeed their babies. Lactiferous ducts, glandular tissue or nerves of the breast may be damaged during surgery, or by pressure from the implants on breast tissue. Furthermore, complications of the surgery including capsular contracture, haematoma formation, infection or pain may reduce the ability or desire to breastfeed. “They may also fear, or have been told by their surgeon, that breastfeeding could undo a satisfactory augmentation result,” the report said. Another factor affecting a woman’s willingness to breastfeed could be fear they would transmit silicone or other implant materials into their breast milk and potentially harm their baby. The report concluded that their finding should be provided as part of informed decision making to women contemplating breast augmentation surgery.
8 NEWS I body language
events 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 14-19 MAY, Annual Meeting of the American Society for Aesthetic Plastic Surgery (ASAPS), Montreal, Canada W: surgery.org 22-24 MAY, SOFCEP Congress, Tours, France W: congres-sofcep.org 2-6 JUNE, Annual Meeting of the Canadian Society of Plastic Surgeons (CSPS), Victoria, Canada W: plasticsurgery.ca 4-6 JUNE, ISAPS Symposium, Nice, France W: isaps.org 4-6 JUNE, Congrès Annuel de la Société Française des Chirurgiens Esthétiques Plasticiens (SOFCEP), Nice, France W: chirurgiens-esthetiques-plasticiens. com
FACIAL REJUVENATION SURGERY COULD MAKE YOU SEEM MORE LIKEABLE Changes in personality perception can occur after surgery A new study published in JAMA Facial Plastic Surgery has found an increase in the perception of likeability, social skills, attractiveness, and femininity following facial rejuvenation surgery. The study, which evaluated and quantified the changes in personality perception that occur with facial rejuvenation surgery is the first study in surgical literature to measure and evaluate the broader outcomes of facial rejuvenation surgery. Procedures included rhytidectomy (face-lift), upper blepharoplasty, lower blepharoplasty, eyebrow-lift, neck-lift, and/or chin implant. The 60 photographs (30 preoperative and 30 postoperative) of these patients were split into six groups, each with five preoperative and five postoperative photographs. At least 24 individuals rated each photograph for six personality traits including aggressiveness, extroversion, likeability, trustworthiness, risk seeking, and social skills, as well as for
attractiveness and femininity. The intention of the study was not revealed to the raters. Of the eight traits that were evaluated, analysis revealed four traits with statistically significant improvements when comparing preoperative and postoperative scores: likeability (+0.36, P < .01), social skills (+0.38, P = .01), attractiveness (+0.36, P = .01), and femininity (+0.39, P = .02). Improvement in scores for perceived trustworthiness (+0.22, P = .06), aggressiveness (–0.14, P = .32), extroversion (+0.19,P = .14), and risk seeking (+0.10, P = .27) did not demonstrate statistically significant changes. The study concludes that facial plastic surgery changes the perception of patients by those around them. Traditionally, these interventions have focused on improvements in youthful appearance, but this study highlights the other dimensions of a patient’s facial profile that are influenced by facial rejuvenation surgery.
4-7 JUNE, FACE 2015, London, UK W: faceconference.com 4-7 JUNE, Non Surgical Symposium of the Australasian Society of Aesthetic Plastic Surgery (ASAPS), Melbourne, Australia W: asapsevents.org 7-11 JUNE, Annual Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons (SESPRS), Amelia Island Plantation, USA W: sesprs.org 8-13 JUNE, World Congress of Dermatology (WCD), Vancouver, Canada W: derm2015.org 17-19 JUNE, International Course on Plastic and Aesthetic Surgery, Barcelona, Spain W: clinicaplanas.com 18-21 JUNE, International Eurasian Aesthetic Plastic Surgery Course, Istanbul, Turkey W: eurasian2015.org 25-27 JUNE, 2nd ICAD BRAZIL, Sao Paulo, Brazil W: euromedicom.com 6-10 JULY, International Congress of the International Confederation for Plastic Reconstructive and Aesthetic Surgery (IPRAS), Vienna, Austria W: ipras2015.com 7-9 JULY, Annual Meeting of the British Association of Dermatologists (BAD), Southampton, UK W: bad.org.uk 8-9 JULY, Asia Sun Protection & AntiAgeing Skin Care, Hilton Singapore W: summit-events.com Send events to arabella@face-ltd.com
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body language I NEWS 11
FAT GRAFTING CAN IMPROVE RESULTS OF BREAST AUGMENTATION More natural looking cleavage achieved
BANDED AID: TWINNING PLASTIC SURGERY UNITS British female surgeon creates surgical charity to support surgical needs of developing countries Driven by her passion for treating life-altering injuries and disabilities, British plastic surgeon Barbara Jemec has set up BFIRST; the British Foundation for International Reconstructive Surgery and Training, which aims to twin every plastic surgery unit (circa 60) in Britain with one in the developing world. The foundation has already sent UK surgeons to Cambodia and is planning to work in other countries including Myanmar and Bangladesh to deliver training and surgical skills to local medics, ensuring that everyone has access to expert surgical care. Deformities and traumatic injuries can often result in social exclusion, poverty and destitution in a developing country. BFIRST not only trains surgeons on location, but also ensures that the training has practical longevity and is tailored according to the resources available, meaning that each country will have a unique package which best fits their needs and available resources. In three trips to Cambodia alone, BFIRST surgeons working alongside local teams have treated over 45 hand surgery cases including burns and trauma, congenital deformities, tumours and snake bites. The charity; which was launched at British Association of Plastic, Reconstructive and Aesthetic Surgeons’ (BAPRAS) Winter Scientific Meeting at the Royal College of Surgeons of England; recognises that the benefits of such a drive are mutual, with UK-based surgeons also learning valuable skills whilst at the location. BFIRST’s training packages also incorporate training for surgeons’ staff, such as nurses and therapists, enabling the medical and surgical team to provide holistic care for all patients. The charity is currently training a number of surgeons abroad, including three in Cambodia. Chairman of BFIRST Barbara Jemec says, “BFIRST equips surgeons with an array of key skills, allowing them to offer life-saving (and livelihood-saving) care. The vision for BFIRST is to provide surgeons in developing countries the skill set they require to continue using the techniques they have learned via our tailored training packages. Our longterm vision is to have most of the UK plastic surgery units twinned with a unit abroad, forging long-term friendships, collaboration and support.” BFIRST has also funded Fellowships, which involve surgeons from resource-poor countries visiting UK plastic surgery centres, where they are taught relevant surgical skills. One such surgeon is Dr. Rashedul Islam, who came to the UK in 2013 through BFIRST. Dr. Islam, a plastic surgeon from Bangladesh, stayed for six weeks to train, an experience he is very thankful for. BFIRST relies on donations to continue with its mission. Suggested amounts range from just £40, which can pay for gloves, antiseptic cleaning solution and dressings for fifteen patients, to £850, which can pay for a week’s plastic surgery training for a local doctor. Donations can be made on the BFIRST website: www.mydonate.bt.com/charities/bfirst
A fat grafting technique can be used to improve outcomes for breast augmentation patients, creating more natural cleavage and avoiding the appearance of separated breasts reports a study in the April issue of Plastic and Reconstructive Surgery. According to the report by Dr Francisco G. Bravo of Clinica Gomez Bravo, Madrid, who analysed the outcomes of breast augmentation surgery in 59 women, those treated using a combination technique, using breast implants plus “selective para-sternal fat grafting.” saw better results. Using a small amount of the patient’s own fat, harvested from elsewhere in the body—like thighs or abdomen, the fat cells were processed and placed along the medial borders of the breasts, to soften the “medial transition zone” between the sternum and implant edges and create a more natural shape. Bravo compared the results of women undergoing the two procedures by measuring the distance between the medial border of the breasts, or “vertical aesthetic line” (VAL). As measured on postoperative photographs, the average VAL was 2.26 centimetres in women receiving implants only versus 0.6 centimetre with fat grafting plus implants, supporting the concept that the VAL, as a measure of the distance between breasts, is a useful concept for plastic surgeons to consider in achieving a more attractive, natural appearance after breast augmentation. Dr Bravo believes his combination technique may be especially useful in preventing the “separated breasts” deformity.
12 NEWS I body language
FACIAL FAT INJECTIONS Two different fat grafting techniques have similar effects on facial rejeuvenation
RISE AND SHINE Night owls face higher risk of metabolic syndrome than early birds Night owls are more likely to develop diabetes, metabolic syndrome and sarcopenia than early risers, even when they get the same amount of sleep, according to a new study published in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism. The study which examined the difference between night and morning chronotypes, or a person’s natural sleep-wake cycle concluded that staying awake later at night is likely to cause sleep loss, poor sleep quality, and poor eating patterns, which might eventually lead to metabolic change. “Regardless of lifestyle, people who stayed up late faced a higher risk of developing health problems like diabetes or reduced muscle mass than those who were early risers,” said one of the study’s authors, Nan Hee Kim, MD, PhD, of Korea University College of Medicine. “This could be caused by night owls’ tendency to have poorer sleep quality and to engage in unhealthy behaviours like smoking, late-night eating and a sedentary lifestyle.” Sleeping habits and metabolism where examined in 1,620 participants between the ages of 47 and 59. Respondents sleepwake cycle, sleep quality and lifestyle habits such as exercising were also recorded and researchers took blood samples to assess participants’ metabolic health. In addition, the study subjects underwent DEXA scans to measure total body fat and lean mass, and CT scans to measure abdominal visceral fat. Based on questionnaire results, 480 participants were classified as morning chronotypes, and 95 were categorised as evening chronotypes. The remaining participants had a sleepwake cycle between the two extremes. Although the evening chronotypes tended to be younger, they had higher levels of body fat and triglycerides, or fats in the blood, than morning chronotypes. Night owls also were more likely to have sarcopenia and men who were evening chronotypes were more likely have diabetes or sarcopenia than early risers. Among women, night owls tended to have more visceral fat and a great risk of metabolic syndrome. “Considering many younger people are evening chronotypes, the metabolic risk associated with their circadian preference is an important health issue that needs to be addressed,” Kim said.
Using fat cell injections for facial regeneration gives the same result as the more time consuming fat-derived stem cell technique, reports a study in the April issue of Plastic and Reconstructive Surgery that compares the two approaches to fat grafting for regeneration of facial skin. The study, which included six middle-aged facelift surgery candidates who underwent fat grafting to a small area in front of the ear, found that facial rejuvenation results are the same with both approaches. One group of patients received fat-derived stem cells. Isolated and grown from their fat, these specialised cells have the potential to develop into several different types of tissue. The other group underwent injection of fat cells along with the stromal vascular fraction (SVF)—a rich mix of cell types, including stem cells. After injection of fat cells plus SVF, the skin samples showed reduced degeneration of the skin’s elastic fibre net-
work, or “elastosis”—a key characteristic of aging skin. Skin changes in patients receiving stem cell injection, were essentially identical. “This result seems to suggest that the effect of a fat graft is, at least in part, due to its stem cell component,” Dr Rigotti and coauthors write, also concluding that fat cells plus SVF are preferable to stem cell injection, since the fat processing step is less expensive and faster. Without the need for stem cell expansion the fat cells can be harvested, processed, and injected on the same day. Evidence suggests that the rejuvenating effects of fat grafting are also related to new formation of microscopic blood vessels, although further studies are needed to confirm this. Dr. Rigotti comments, “this is the first study presenting clinical evidence showing skin rejuvenation after fat grafting and highlighting the anatomical and structural changes that are the basis of this rejuvenation.”
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14 STUDY I body language
Quality of life DR RAVI JANDHYALA talks about the methods to assess the impact of botulinum toxin type A on patients’ quality of life
I
n 2013 I completed a piece of work that was published in the Journal of Clinical Aesthetic Dermatology, which examined the impact of botulinum toxin on patients’ quality of life following treatment of facial lines. The objective of the study was two fold—first, to understand whether or not botulinum toxin impacts on quality of life and second, to see whether there was a correlation between satisfaction scores and the quality of life. Satisfaction scores are extremely popular in studies where there is a cosmetic or an aesthetic intervention. This is partly because in a subject group that are in good health and not suffering from a disease, disorder, or dysfunction, an attempt must be made to justify these treatments and a satisfaction score, or ranking of how happy the subjects are after the aesthetic treatment is quite valuable. However, what I really wanted to understand is whether a satisfaction score could be used as a surrogate marker for quality of life.
Measuring quality of life In it’s own right quality of life is quite difficult to measure. As a result it is quite time consuming to understand and therefore largely ignored in aesthetic studies. Prior to this study, there was only one other investigation of quality of life in botulinum toxin use. I considered two methods of measuring quality of life. First, the tried and tested pre-emptive questionnaire method, which the previous study Dayan et al. used when they were investigating quality of life change with Onabotulinumtoxin and then second a more subjective evaluation. I was initially unconvinced that a questionnaire approach for something like aesthetics would be appropriate. Usually questionnaires are designed and validated in a specific disease area, so for cancer sufferers there would be a questionnaire that has domains that are relevant to cancer. I couldn’t really understand that we would have a similar setting in the aesthetics scenario, but after carrying out a litera-
body language I STUDY 15
BEST POSSIBLE
mm
THE WORST LIFE IMAGINBLE The downloaded case report forms contained a grid and a visual analogue scale as an attempt to gain a quick assesment of how that person feels their quality f life is at that particular time.
PS
E
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LIF
NS O LA TI
AL TH
AL SO
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mm
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CE S AN FIN
FA M
ILY
WORST POSSIBLE
THE BEST LIFE IMAGINBLE
ture search to understand if there are any other tools available for understanding quality of life impact, I found one published by the Royal College of Surgeons of Ireland. This was called the SEIQoL or Subject of Evaluation of Individual Quality of Life and it seemed to be exactly what I wanted. It seemed to understand that a human being has many facts. Quality of life of that human being would have many facets and not necessarily something that could be captured in a preemptive questionnaire. The study I set up examined 53 clients who presented at my clinic with mild to moderate facial wrinkles. Subjects had a median age of 39.5 years old, 87% were female and they were all naive to Botulinum toxin use. They were invited to present for two visits. First an initial screening where they underwent the SEIQoL interview, where we assessed how satisfied they were with their wrinkles at that particular time. Next, they received an appropriate treatment with Incobotulinumtoxin A and were brought back after 30 days where the SEIQoL interview was re-administered. Their satisfaction score related to the state of their winkles was recalculated or re-questioned and we then carried out our statistical analysis. Everything hinged on the SEIQoL-DW—a prescribed interview with a script associated with it. Everything was extremely carefully regimented in its application and when the subject was taken through it. The SEIQoL We asked our participants the following questions: What are the five most important areas of your life, the ones that make your life happy or sad, that ones that you feel influence the quality of your life? For me that is really what quality of life is all about, and I think this would be a valuable tool to assess the impact of all interventions. At least it would stimulate
the debate as to subjective versus objective measures of quality of life. When we downloaded the SEIQoL methodology or the interview pro forma from the internet, they provided us with some CRFs or case report forms. These contained a grid and a visual analogue scale at the bottom, which is a line running from left to right. The worst life imaginable on the left, to the best life imaginable on the right—and this is really an attempt to have a very quick assessment of how that person feels their quality of life is at that particular time. Clients made a mark on that depending on where they felt they were. From the graph we could see a number of different areas in each person’s quality of life and also differences as to how good they were. We measured the height of the bars in millimetres and also the distance from the left extreme margin to the visual analogue mark on their quality of life and then recorded this in the spreadsheet for the final analysis. This is only half the story. We need to understand the weighting element of it. So someone could have mentioned, for example, that health is really important to them and it’s actually very good. They’re enjoying good ‘health’ at the moment, but it may only be a very small amount of what contributes to their overall quality of life. For some people, ‘family’ would be quite a big proportion of what would contribute their quality of life. This pie chart is made up pieces of circular card of different colours that rotate over each other. Each colour is assigned a particular ‘domain’ which the patient provides. It is then possible for the subject to alter the size of each segment to try and relate how much weighting they would apply to each of these domains. This would reflect how much each domain would contribute to the patient’s ‘quality of life as a whole’.
16 STUDY I body language
TABLE 1: FREQUENCY OF NOMINATION AS AREAS OF IMPORTANCE Cue area
Visit 1
Visit 2
Family
96.2%
90.6%
Work
62.3%
69.8%
Finance
52.8%
58.5%
Relationships
52.8%
45.3%
Health
50.9%
60.4%
Appearance
43.4%
43.4%
Social life
35.8%
13.2%
Living conditions
34%
20.8%
Leisure activites
32.1%
13.2%
Marriage
13.2%
7.5%
Pets
13.2%
7.5%
Partner
11.3%
11.3%
Divorce
3.8%
1.9%
Religion
3.8%
0%
Education
1.9%
1.9%
Friends
1.9%
1.9%
Mother
0%
1.9%
Recording the Results To record the results from the questionnaire we divided the percentage by 100 and then multiplied that by the height of the bar for each cue to give us an index (see table 1). This was done for all five cues and then added up each of those indices to give us an overall SEIQoL index. We also made a mark, or a note of the VAS score for quality of life. The findings We found that the five most common areas of importance that were nominated by the subjects were ‘family’, ‘work’, ‘finance’, ‘relationships’ and ‘health’. Those are the ones that contributed to their quality of life. An important thing to take away is that quality of life is dynamic. It’s not static. It changes. By visit two we had differing numbers of the different cues as far as how often they were nominated by the population as a whole. We found that ‘family’ comprised a large percentage—96.2% of the overall cues put forward at the first visit and subsequently dropped to 90.6 at the second visit. The other interesting thing—remembering that these are clients that presented for treatment of facial wrinkles and one would assume that appearance would be quite important to them—is that less than half of them actually thought that appearance was one of their top five. This brings into question whether a simple questionnaire really is the best way of understanding quality of life impact of these types of treatments. When we moved over to the weighting element, we looked at the frequency of the cues, the areas of life that they nominated. We saw that there’s a difference between visit one and visit two and when we look at the mean weighting we also see here that there is a difference in the weighting between one and two. Considering appearance, we see that the mean weighting in visit one was 21.5% and then it went down to 18.2.
Quality of life is dynamic. It’s something that we need to respect as being something that we need to assess on that particular occasion and it’s really important if we’re trying to understand quality of life impact with cosmetic treatments in this regard. We know that people nominate different cues whether it be the first visit or the second visit. Where there was a subject that nominated different cues to their first visit we calculated the SEIQoL index for those new cues and also we repeated the exercise for the old cues, to try and understand whether that change in cues actually had an impact in their overall quality of life, or any improvement in their quality of life. Conclusions We saw that both for the VAS scores and also the SEIQoL indices that there was an overall improvement in quality of life, no matter which way we assessed the data. So the conclusions here are that IncobotulinumtoxinA improved quality of life versus baseline. The SEIQoL indices and the VAS scores both improved. The SEIQoL indices showed improvement despite changes in cues from visit one and visit two, and the quality of life improved whether or not appearance was one of the top five cues that were nominated. The important thing that I found here also, that almost dwarfs the other findings was the lack of correlation between satisfaction scores and quality of life. I could see a positive improvement in the quality of life. Satisfaction scores were a problem, partly because someone would show an improvement in their quality of life but their satisfaction score would be flat. Someone would show that their satisfaction scores are great and they’re really happy with their winkles, but their quality of life was either flat, or maybe showed a slight deterioration in one area. So we can’t forget about quality of life. We need to understand that satisfaction scores are great but they shouldn’t act as a surrogate marker for quality of life. Quality of life is something that we should strive to influence in a positive way, especially in light of the fact that these clients are not unwell. Dr Ravi Jandhyala is president of the UK Society for the Study of Aesthetic Medicine
66 Quality of life is dynamic. We should respect it as being something that we need to assess on that particular occasion. It’s really important if we’re trying to understand quality of life impact with cosmetic treatments 99
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FACE 2015 Booth 67
Saturday, June 6th, 2015 11:30 - 13:00 Speaker: Dr Raminder Saluja Sunday, June 7th, 2015 9:55 - 10:20
body language I PANEL 19
Treatment outcomes DR STEFAN CANO, DR RAVI JANDHYALA and DR KIMBERLEY TAYLOR discuss the importance of measuring and reporting on patients’ treatment outcomes for optimising patient care
Q: If you have a patient with depression who is on antidepressive medication, are you going to treat them? Dr Kimberley Taylor: I would treat them if they had been successfully treated for their depression and they had appropriate motivations for treatment. It’s not a contraindication to receiving treatment; it’s just something to be aware of, purely in the interests of patient protection. Q: If you have diagnosed a patient with body dysmorphic syndrome, would you completely, categorically deny that
patient treatment? Do you think that surgical treatment can help this group? Dr Kimberley Taylor: Firstly of course I wouldn’t be diagnosing body dysmorphic syndrome, but I may identify signs that this might be the case. If I were concerned about the psychological health of the patient I would refer them as appropriate and indeed would not undertake treatment at this point. With patients that have been diagnosed, given that there is little evidence to suggest a good probability of patient satisfaction with treatment outcome, I personally would be reluctant to treat them, as referral to the appropriate special-
ist would better meet their needs. For patients that have a history of body dysmorphic disorder, that has been successfully treated and is now well controlled, provided again they have appropriate motivations for treatment and realistic expectations of outcome, it may be appropriate to undertake aesthetic treatment. The key is to assess each case on an individual basis and manage them appropriately ensuring best interests of the patient are respected at all times. Q: What do you do with the patient who you don’t think is good for your surgery or for cosmetic treatment?
20 PANEL I body language
Dr Kimberley Taylor: I’ll go through the discussion process to find out why they want a particular treatment. Then depending again on their personality and how they’ve responded throughout the consultation process, I’ll sometimes say that I appreciate and respect their concerns but at this point that I don’t feel I’m the best person to help them. I’ll suggest that I may be able to put them in contact with somebody that may be in a position to be of assistance to them. Obviously, it would then depend upon their response as to whether they have insight into their issues, since some patients may not, but I think there’s absolutely nothing wrong in saying: sorry but I don’t think I’m the right person to provide you with the treatment at this point. Q: Would you recommend incorporating the FACE-Q, for example, in clinical daily practice when doing aesthetic procedures, or only for a specific percentage of patients? Dr Stefan Cano: I think it’s important to first of all decide what you want to measure and in whom. As one of its developers, I obviously have an interest in the FACE-Q. What we’ve done is to develop it to be used in clinical practice. We have based this idea on the BREAST-Q (our first PRO instrument of this type), which is used in routine clinical practice at Memorial Sloane Kettering Cancer Center, New York. I think the pattern in the UK (and even in the US) seems to be moving towards routine use of some sort of patient reported outcome instrument in clinical practice to be used to examine efficacy at some level. My advice to local (UK) surgeons, who were nervous about this sort of thing at the beginning of the UK PROMS initiative (2009), was to be proactive; choose the scales they wanted to use and to do what they thought would be useful locally. “Beat ‘them’ (the UK Department of Health) to the punch”. Start using the scales, and in that way they would have their own data. Before someone else
forced a scale on them, that they may have felt neither appropriate nor helpful. I would always say that the use of high quality PRO instruments is important. Hearing the positivity coming out from Memorial Sloane Kettering Cancer Center, especially from the patients, supports this. PRO instruments give the patient a voice. Dr Ravi Jandhyala: I used the Merz Aesthetic Scales in measuring informed consent and how informed the clients were around what to expect. And I think the take-home message was that compared to standard consent, the use of the Merz Aesthetic Scales in setting goals—with a joint discussion between the client and the person delivering the treatment—can help decide where the start point is and where a reasonable target should lie. The treatment would be administered, then the patient would be brought back and we would then assess how good we were at achieving that particular goal. Successful treatment should be hitting the mark, so you hit the mark that you have predefined in your goal setting exercise. You might have failed for one of two reasons. You might have fallen short, or you might have exceeded those expectations, but either of those two pieces of information are valuable because then you can understand how good you are using a particular product and how well that product actually behaves in the client. Goal setting and using the facial scales, I think is really valuable as part of the informed consent process, because as we know there are three main elements for informed consent. To be competent you need to have all the available information and you need to be free from duress or coercion. So, having enough information to understand exactly how you’re going to do, or what to expect from the treatment is really quite important. So scales fit in, in my mind, 100%. I use the Merz Aesthetic Scales every day in my clinic, and they’re fantastic as far as informing people as to what to expect, and also
weed out those people that aren’t going to get a benefit. There are young people that come in and say, oh, I’ve got this wrinkle, and we sit down with the scales, and say you’re actually a grade zero, so what would you like me to do for you? I think it’s only then when they’re presented with that stark reality that there is actually nothing to do but come back in 20 years, then that’s actually a compliment and not anything negative. So I’m a big fan of scales. Q: Some people in Dr Ravi’s research were slightly dissatisfied with treatment but had an improvement in their perception of
Successful treatment should be about hitting hte mark, so you hit the mark you have predefined in your goal setting exercise
body language I PANEL 21
quality of life. Would a placebo group have been an interesting study to see if it was a natural variation in perception? Dr Ravi Jandhyala: This is actually one of the criticisms. One of the limitations of the study that I conducted was that there wasn’t a
66 Goal setting and using the facial scales is really valuable as part of the informed consent process 99
placebo arm, and my justification at the time was that I didn’t want to understand whether or not botulinum toxin worked or not, or had an effect on reducing wrinkles—I knew that. What I wanted to understand is whether or not there was an improvement, or a change in baseline compared to the satisfaction score rating. If I were to go back again I would put in a placebo arm, but I think from my perspective, most post-authorisations studies do collect data in the way that I have, but those small groups of patients that you’ve highlighted – where there is an improvement in quality of life but a reduction or a flattening off of satisfaction scores—it’s actually
difficult to work out why there is such a disconnect overall. We could say that perhaps there is something else that’s influencing that person’s quality of life that hasn’t been captured in the tool, and that’s always something that we need to understand, that we may not understand everything about the subjects in our studies. But I think as long as we get to 90% there, then we can identify the small group of people that showed a flattening off of their satisfaction score, maybe a worsening of the satisfaction score, but improvement in their overall wellbeing as being perhaps a focus for the future. I think they are an interesting group of people in their own right.
body language I PANEL 23
The short answer to the question is I don’t know. The long answer to the question is I think we probably do need to spend a bit of time understanding more, and I would have put a placebo arm in, doing it again. Q: Would you do it automatically? Beck’s Depression Inventory is used in a similar kind of way. Is that something appropriate that could be incorporated into practice? Dr Stefan Cano: These are important considerations, and there’s always going to be a payoff. What we’ve tried to do is make these instruments (e.g. the FACE-Q) specific to the specific patient group. Our experience in breast surgery is that we’re able to target specific clinical areas or questions. You don’t need to use all 18 scales from the BREAST-Q. You can pick one or two BREAST-Q scales that you think are relevant. What we’ve been able to achieve—and we think it’s a good model—is that a patient comes into clinic, answers the BREAST-Q questions on an iPad (or some sort of handheld computer), and in real time this gets scored and electronically sent to the clinician together with clinically relevant information to help interpret the scores. Measuring patient experience is now a big thing. One of the problems with multi-item scales is their interpretability. In terms of clinical
outcomes research, this is where there’s a lot of ‘action’ is at the moment. For example, what does a score 23/100 mean? What does that mean for a patient? What does that mean for a clinician? What does it mean for a surgeon? What we’ve been able to do with the BREAST-Q is provide qualitative statements to say exactly what a score of 23 means. And also show how a patient who scores 23 compares to local normative data and national normative data. We’ve been very fortunate; the US Plastic Surgery Education Foundation funded this work and the BREAST-Q is now used routinely across a whole range of hospitals in the US. In terms of day-to-day practice, it’s about targeting the right scales to the right patient. Because you’re not going to ask everything, and you need to bear in mind what’s relevant to your clinical context. You must think about what you really want to know about. For example, do you want to know about satisfaction, appearance, depression or mood? What I’m very cognisant of, and this is a recurring theme in all the areas I work in, is that you’ve got enough to do as a day-to-day clinician. And people who look after patients are very busy. And none of us want to be sitting filling in forms. So the FACE-Q in particular is very short and very immediate and very clinical practice-friendly. You get a profile that includes
so-called ‘objective’ measurement and ‘subjective measurement’. It’s something that’s immediate and quick, and can be done in real time. I think part of the other challenges in terms of PROs is traditionally they’ve been developed by psychometricians, or statisticians, or psychologists—people apart and away from the clinician. I personally think that’s a huge mistake because the two key players in all these areas are the clinician and the patient. All the technical elements have an important part to play, but it’s not there to replace the patient clinician interaction. I’ve had conversations with some very high profile psychometricians who have told me that they believe interpretation should happen after the fact (i.e. after a PRO instrument is developed). I say ‘no’. I think it’s best to work out what’s clinically meaningful first, then try and measure it. And then I (as a psychometrician) can then tell you whether you’ve got something (i.e. a scale) that’s working (i.e. is psychometrically sound). You (i.e. the clinicians
People who look after patients are very busy and don’t want to be sitting filling in forms
66 In day to day terms, you need to target the right scales to the right patient—what is relevant to your clinical context 99
24 PANEL I body language
66 It’s going to become more important to collect this data— take control of it before someone takes control of you 99 and patients) are the substantive experts. And that’s where we have focused for the last ten years (i.e. in the development of the BREASTQ and FACE-Q). It’s been a dream for me to work with people on the ground and to try and craft these instruments and scales to as be specific and helpful as possible. Q: How would Face-Q change pre and post first consultation? Dr Stefan Cano: It depends. I think the danger here is that people just take scales off the shelf and (for example) give it to patients a month before and three months after treatment. I think what we’re able to do with these new types of instrument (such as the BREASTQ, which is electronically delivered, automatically scored and so on) is to be more precise about the timing of administration. For example, with botulinum toxin we want to administer the PRO instrument the day of the treatment. Because there’s less point giving it to the patient to fill in it two weeks before or four weeks before treatment. And then we want it two and a half, or three weeks later when the treatment is going to have at its maximum impact. You can tailor it, but I would suggest that the decision about when to administer the instruments is clinically driven. The instruments are just ‘rulers’. You have to decide when is the best time to get them completed. And also it’s important to be cautious about taking things off the shelf. Make sure they’re meaningful; if you can’t understand what the items are
trying to capture, then the patient’s not going to understand it either. Traditionally, a lot of the scales have been data driven. In other words you get a bunch of items that you’ve generated from patient interviews (or else picked from the literature), these are administered in a survey and the resulting data is analysed (e.g., a factor analysis or similar) and the resultant scales are named based on the findings (e.g. ‘symptoms’, ‘depression’, ‘quality of life’). We need to change that paradigm, because it’s wrong. And that’s what we’ve tried to do with the BREAST-Q and FACE-Q, because scale development is traditionally a very statistical psychometrically driven paradigm and it needs to be clinically driven a priori. Dr Ravi Jandhyala: I’ve had a little bit of experience with trying to encourage clinicians and people in this space to input data into registries—I’ve suffered it for the last four years. UKSSAM has a registry of use for collecting data on pretty much all aspects of botulinum toxin treatment, and we have 3,500 patients that we’re about to publish on. In my experience, it’s all well and good when the FDA tells somebody to collect pros and cons, but if that requirement hasn’t been mandated to the people in this room, then there’s very little likelihood of them actually taking it on board. We can do amazing things with this data. For example, I set up a facial mapping exercise four years ago was to try and understand how many units for different wrinkle severity should be administered to different parts of the face. That’s really quite valuable. We can gather that from this registry. But trying to encourage people to collect data when they don’t need to, or don’t have to is very difficult. Dr Stefan Cano: This is not uncommon, it happens everywhere. Though I believe, it’s going to become more important to collect this data, and my only recommendation would be to take control of that before someone takes control of you and tells you you have to use the Oxford Hip Score, or the Oxford Knee Score, for example. If
they come to me I’m going to say, the Oxford Hip Score is a very nice research tool but it wasn’t originally developed to make decisions about surgeons or patients. The UK PROMS initiative is in surgery now. It’s going into diabetes. It’s going into asthma. It’s going into stroke. This is going to be mandated across the board. Dr Ravi Jandhyala: But that’s within the NHS where someone’s looking. Nobody is looking at us, and that’s the problem. I think that the level has to be focused up. I’d like us to start looking now. Dr Stefan Cano: Every clinical area I work with, they say, we don’t need to collect data. What are we doing? The point here is this is a great tool and a great initiative, but if people are so busy, so what? I keep going back to the Memorial Sloane Kettering Cancer Center example. Where the BREAST-Q has had the biggest impact is they’ve been able to use it to measure expectations, outcomes, satisfaction and process of care. And they’ve been able to use that information to improve clinician–patient interaction though education programmes. Dr Kimberley Taylor: If you’re simplifying the process, then that’s going to remove some of the barriers to undertaking these questionnaires, isn’t it, and I do think that more guidelines will come in within private practice as well, and anything that optimises patient care I think it’s extremely valuable. Dr Stefan Cano Dr Cano is a chartered psycologist and associate professor of psychometrics. He is also director at ScaleReport Ltd, and has codeveloped the BREAST-Q, FACE-Q, BODY-Q and CLEFT-Q PROMs.
Dr Ravi Jandhyala Dr Jandhyala is a member of the Royal College of Surgeons, and is the president of the United Kingdom Society for the Study of Aesthetic Medicine. He has designed and implemented the BoNTA registry of use.
Dr Kimberley Taylor Dr Taylor is a cosmetic dentist with a particular interest in facial aesthetics. Her goal is to gain an insight into and individual’s perception of waht is aesthetic and predictably realise their vision.
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26 FACE 2015 I body language
Held at the QEII Centre in Londonâ&#x20AC;&#x2122;s Westminster on June 4th -7th, FACE 2015 will host a world-renowned speaker panel, delivering a complete educational programme FACE 2015 will be one of the largest conferences in the world dedicated to facial aesthetics and will continue to dominate the high end UK market of medical aesthetics. 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 highend educational aesthetic conference. We are also incorporating an Advanced Training course on Thursday 4th June which
will be directed by Dr Ali Piyaresh. The FACE 2015 weekend will be of a similar format to previous years for delegates and exhibitors with lectures across different agendas taking place throughout the day, along with exhibitor workshops and seminars. FACE 2015 will follow on from previous years by having a low-cost entry ticket allowing access to the exhibition area and exhibitor workshops which has proved very popular and successful
in encouraging new delegates/entrants into the market alongside a wider range of clinic personnel who may not normally attend the traditional scientific congress. With the marketing power of EuroMediCom and our 12 year heritage as a premier educational and scientific forum, this conference is on course to be the biggest and the best the UK has ever seen. A full list of confirmed speakers is available at faceconference.comâ&#x20AC;&#x201D;highlights below.
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 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.
Prof Mukta Sachdev Professor of Dermatology, India Prof Sachdev runs a private cosmetic practice and a clinical trial unit specialising in dermatology trials in skin of colour.
Dr Charlene DeHaven Clinical Director of iS CLINCAL, United States Dr DeHaven is a board-certified physician, with an emphasis on age management and health maintenance.
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 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.
Dr Diane Duncan Plastic Surgeon, United States Dr Duncan runs an aesthetic practice, travels and teaches internationally in the field of minimally invasive aesthetics.
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.
Dr Rachael Eckel Cosmetic Dermatologist, Trinidad and Tobago Dr Eckel has trained under Dr Zein Obagi, and has perfected pioneering aesthetic techniques worldwide.
Dr Frank Rosengaus Facial Plastic Surgeon, Mexico Recognised as a world renowned leader in cosmetic and aesthetic plastic surgery, with over 20 years experience.
Dr Greg Williams Plastic Surgeon, United Kingdom Dr Williams specialises in hair restoration and is the only BAAPS member performing hair transplants full time.
Dr Bessam Farjo Hair Transplant Surgeon, Iraq/United Kingdom Dr Farjo is a leading hair transplant surgeon and coFounding Director of the Farjo Hair Institute.
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 Stephanie Williams Dermatologist, United Kingdom Dr Williams has extensive clinical experience and a special interest in cutting edge skin research.
body language I FACE 2015 27
Pre-conference advanced masterclass FACE 2015 will be hosting an advanced masterclass with DR ALI PIRAYESH as the Scientific Director on ‘Essential anatomy and techniques for aesthetic procedures’
F
or the first time in FACE history, we will be running a Pre-Conference Advanced Training Masterclass on Thursday 4th June. Aimed at medical aesthetic practitioners across all levels of expertise, the course will be created with a view to keep the delegate in tune with non-invasive strategies and understand the key anatomy of the full face. Internationally renowned experts will share their “daily practice pearls” and tips and tricks on the most pertinent aesthetic medicine core and advanced topics. The SAFE and effective use of toxins, dermal fillers and energy-based devices will be covered with emphasis on essential anatomy and techniques. Clinically orientated presentations highly focused on practical aspects will include cadaveric anatomy videos, videos on “How I do it”, choice of products or devices and how to avoid and manage complications. By the end of the course, the delegate will be able to integrate and apply this information into their practice with confidence whilst improving and excelling in their clinical performance on aesthetic and rejuvenation procedures. Objectives This is a Masterclass catering for advanced physicians. The course content is established with the following objectives in order that the practitioner will be able to: Keep abreast of recent non-invasive rejuvenation strategies and related products and technologies Learn practical and clinical essentials of each treatment strategy Holistically understand the “Full face” approaches with patient-centered care Integrate and apply the learned information into their practice with confidence Improve and excel their clinical performance on (advanced) aesthetic and rejuvenation procedures Live stream to Singapore With CFA Singapore 2015 — Clinical Facial Aesthetics Singapore, taking place on the same day, for the first time ever FACE 2015 will be streaming live coverage of the Pre-Conference Advanced Training Masterclass all the way to our delegates and friends in Singapore.
09:30 I 11:20 SESSION 1: UPPER FACE 09:30 I 09:45 The total aesthetics package: blending surgical and non-surgical facial rejuvenation, Mr Chris Inglefield 09:45 I 09:55 Advanced anatomy: forehead and temples, Mr Colin Morrison 09:55 I 10:10 Toxins on upper face: tips and tricks for advanced natural results, Dr Kate Goldie 10:10 I 10:25 Temple injections and lateral brow, Dr Frank Rosengaus 10:25 I 10:40 Energy-based devices for facial rejuvenation, Dr Ines Verner 10:40 I 11:20 Live demonstration—upper face, Dr Tapan Patel and Dr Kate Goldie 11:20 I 11:40 REFRESHMENTS 11:40 I 13:20 SESSION 2: MIDFACE 11:40 I 11:50 Anatomy: tear trough, cheeks and nose, Dr Ali Pirayesh, Mr Colin Morrison and Dr Dario Bertossi 11:50 I 12:05 HA technology and characteristics: choosing the right HA for each location, Dr Ali Pirayesh 12:05 I 12:20 Tear trough: choice of filler and techniques, Mr Colin Morrison 12:20 I 12:35 Zygoma, cheeks and the Mona Lisa smile: choice of filler and technique, Dr Christopher Rowland-Payne 12:35 I 12:50 Nose: choice of filler and techniques, Dr Dario Bertossi 12:50 I 13:05 Filler complications and conservative management, Dr Patrick Treacy 13:05 I 13:20 Restoring major filler complications by facelifting and fat grafting, Dr Ali Pirayesh 13:20 I 14:10 LUNCH 14:10 I 17:30 SESSION 3: LOWER FACE & NECK REJUVENATION 14:10 I 14:50 Live demonstration—middle face, Dr Ali Pirayesh and Dr Kate Goldie 14:50 I 15:00 Anatomy: lips and perioral region, mandible, chin and platysma, Dr Ali Pirayesh and Mr Colin Morrison 15:00 I 15:15 Non HA fillers and threads—friend or foe? Henry Delver 15:15 I 15:30 Lips and perioral region: choice of filler and technique, Dr Tapan Patel 15:30 I 15:45 Jawline, chin, neck and decolletage rejuvenation with fillers and toxins, Dr Uliana Gout 15:45 I 16:05 REFRESHMENTS 16:05 I 16:20 Energy based devices and combination therapy for lower face and neck, Jean Louis Sebagh and Anne-Marie Olsen 16:20 I 16:35 Integrating PRP, cosmeceuticals and peelings in your practice, Dr Stefanie Williams 16:35 I 17:15 Live demonstration—lower face, Mr Chris Inglefield and Dr Uliana Gout 17:15 I 17:30 Q&A
28 FACE 2015 I body language
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
09:30 I 10:00 Preparing the skin for injectables, Dr Beth Briden
09:30 I 10:00 Lip augmentation techniques, Dr Ines Verner
09:30 I 10:00 Facial contouring with botulinum toxin, Prof Bob Khanna
10:00 I 11:00 Tissue stimulators; indications, evidence and techniques
10:00 I 11:00 Bio-dermal restoration with a new and advanced collagen—initial clinical results, Mr Chris Inglefield
10:00 I 11:00 The patient journey: tipping point from consumer to patient
11:00 I 11:30 REFRESHMENTS AND EXHIBITION 11:30 I 12:00 The advantages of introducing controlled trauma when injecting dermal fillers, Leslie Fletcher 12:00 I 12:30 Panel discussion—injection techniques, Dr Uliana Gout and Leslie Fletcher 12:30 I 13:00 The 15 minute nose job, Mr Ash Labib and Dr Alexander Rivkin
11:30 I 12:00 How HA fillers and botulinum toxin can slow down long term facial ageing: how to press the “facial pause button” Mr Rajiv Grover
11:30 I 12:00 The happy face treatment—marionette lines and oral commissures, Dr Frank Rosengaus
12:00 I 13:00 Facial contouring workshop—practical techniques and approaches
12:00 I 13:00 Dealing with complications of injectables, Dr David Eccleston and Dr Kate Goldie
13:00 I 14:30 LUNCH AND EXHIBITION 14:30 I 14:50 The ageing hand and the role of dermal fillers, Dr Uliana Gout 14:50 I 15:10 Dermal fillers for the feet, Dr Mark Hamilton
14:30 I 15:20 Male facial contouring workshop, Dr Raj Acquilla 14:30 I 15:30 Advanced facial injectable techniques workshop, Dr Kate Goldie and Dr Joan Vandeputte
15:20 I 15:45 Focused cold therapy for dynamic wrinkes—the latest data
15:10 I 15:30 Sexual regeneration with PRP: the p-shot and the o-shot, Dr Sherif Wakil 15:30 I 15:50 Casting light on “down under”, Dr Kathryn Taylor Barnes
PROVISIONAL AGENDA
15:50 I 16:00 Q&A
15:30 I 16:00 New toxins, new data, Dr Michael Kane
15:45 I 16:30 New treatments and trends—Expert debate: lipolytic injectables, microwaves, aesthetic gynaecology and more
16:00 I 16:30 REFRESHMENTS AND EXHIBITION 16:30 I 18:00 The science behind injectable fat reduction, PRP and mesotherapy, Dr Christopher Rowland Payne
16:30 I 18:00 Treating women across the ages 20s, 40s and 60+, Dr Raj Aquilla, Dr Frank Rosengaus, Dr Michael Kane and Dr Kate Goldie
16:30 I 17:00 Exhibition and Close
body language I FACE 2015 29
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. 4TH FLOOR, WESTMINSTER SUITE FRIDAY
SATURDAY
SUNDAY
09:30 I 09:50 Clinical standards and education in body sculpting, Dr Alexandra Chambers
09:30 I 09:55 Newer technologies for laser hair removal, Prof Mukta Sachdev
09:30 I 09:50 What we can do with newer technologies such as Hydrafacial, Geneo, Affinity and Delivery devices, Prof Mukta Sachdev
09:50 I 10:10 A closer look at cellulite and treatments to reduce its different grades
09:55 I 10:20 Advances in diode hair laser technology—is it really possible to effectively treat a back in four minutes? Lisa Mason
09:50 I 10:10 Tattoo removal—the latest technology
10:10 I 10:30 The role of nutrition in body contouring aesthetics, Kim Pearson 10:30 I 10:50 Body contouring—supplements, devices and wellness; the legal aspects
10:20 I 10:45 Paradoxical hair growth—the evolution of the hair removal market and its impact on the professional marketplace, Godfrey Town
10:50 I 11:00 Q&A
10:45 I 11:00 Q&A
10:10 I 10:30 The classic red face—how to treat all skin types using new combination protocols, Dr Maria Gonzalez 10:30 I 10:50 Dermabrasion with plasma for soft blepheroplasty, Dr Lebbar Noura 10:50 I 11:00 Q&A
11:00 I 11:30 Refreshments and Exhibition 11:30 I 11:50 The future of non-invasive fat reduction using multipolar non-contact radiofrequency
11:30 I 11:55 Resurfacing in 2015—where do we stand? Dr Ines Verner
11:30 I 11:55 Dendritic cells in anti-ageing and preventive medicine, Dr Stefan Lipp
11:50 I 12:10 Cryolipolysis—the latest clinical data
11:55 I 12:20 The benefit of internal and external temperature control in bipolar radiofrequency, Dr Diane Duncan
11:55 I 12:20 Anti-ageing—hormones and IV vitamins: science vs hype, Dr Syed Haq
12:10 I 12:30 Pyroptosis of fat using radiofrequency, vacuum and electrical impulse, Dr Diane Duncan
12:20 I 12:45 Pore refining with fractional diode laser, Dr Sharon Crichlow
12:20 I 12:45 Telomere testing, Dr Mark Bonar
12:30 I 13:00 Q&A
12:45 I 13:00 Q&A
12:45 I 13:00 Anti-ageing debate—what is the market for internal anti-ageing treatments? Dr Syed Haq and Dr Mark Bonar
13:00 I 14:30 Lunch and Exhibition 14:30 I 14:50 Advanced collagen remodelling and skin tightening using combined monopolar radiofrequency and HIFU ultrasound technology
14:30 I 14:50 Novel mixed technology—CO2 and non-ablative fractional resurfacing laser
14:50 I 15:10 Ultrasound for skin rejuvenation and tightening
14:50 I 15:10 Q switch lasers for pigmentation—the new darker skin tool, Prof Mukta Sachev
15:10 I 15:30 Non-invasive facial rejuvenation with hyaluronan delivered with piezoporation, Dr CesarArroyo Romo
15:10 I 15:30 Radiofrequency and micro-needling, plus novel post-procedure care for anti-ageing, Dr Carl Thornfeldt
15:30 I 15:50 The treatment of striae utilising the power of fractionated bipolar radiofrequency, Dr Ines Verner
15:30 I 15:50 Combining fillers with energy based devices, Dr Ines Verner
15:50 I 16:00 Q&A
15:50 I 16:00 Q&A, Prof Mukta Sachdev, Dr Carl Thornfeldt and Dr Ines Verner
PROVISIONAL AGENDA
16:00 I 16:30 Refreshments and Exhibition 16:30 I 16:50 Minimally invasive methods for vulva-vaginal rejuvenation—the latest approaches and techniques, Dr Evgenii Leshunov
16:30 I 16:55 Novel permanent microwave treatment for axillary hyperhidrosis, Dr Tsahi Vider
16:50 I 17:10 Non-invasive labia remodelling—live demonstration, Dr Kannan Athreya
16:55 I 17:20 Leg veins—where does aesthetics end and medicine begin? Prof Mark Whiteley
17:10 I 17:30 Carboxytherapy for vaginal rejuvenation, Dr Alessandra Scilletta 17:30 I 17:50 Threads for vaginal rejuvenation 17:50 I 18:00 Q&A
17:20 I 17:50 Treatment of fungal infections with lasers and light 17:50 I 18:00 Q&A
30 FACE 2015 I body language
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
09:30 I 09:55 Ageing mechanisms: The four major causes of ageing, Dr Charlene DeHaven
09:30 I 10:00 The art of camouflage make up, Jane Maier
09:30 I 09:50 Photodynamic therapy in aesthetic dermatology is also providing effective treatment for non-melanoma skin cancers or their precursors, Dr Daniel Sister
09:55 I 10:20 The detrimental effects of sugar on skin health and the role of the latest polyhydroxy acids in inhibiting damage, Dr Stephanie Williams
10:00 I 10:25 Post-treatment camouflage make up approaches
09:50 I 10:10 Combined approaches to dermatological skin conditions in aesthetic practice, Dr Stephanie Williams
10:20 I 10:45 A practical guide to skin fitness through skincare, Dr Sandeep Cliff and Mr Paul Banwell
10:25 I 10:50 Preventing the degradation of facial skin: environmental damage of cutaneous tissue, Prof Mark Birch-Machin
10:10 I 10:30 Dry skin—causes and treatment, Dr Charlene DeHaven
10:50 I 11:00 Q&A
10:30 I 10:50 Evidence based cosmeceutical herbs for skin conditions, Dr Carl Thornfeldt
10:45 I 11:00 Panel debate: Should we be advising patients to buy nutritional supplements as well as topical skincare?
10:50 I 11:00 Q&A 11:00 I 11:30 Refreshments and Exhibition
11:30 I 11:50 Newer cosmeceuticals for lightening—what can we use and where? Prof Mukta Sachdev 11:50 I 12:10 Safer, more effective therapy for hyperpigmentation, Dr Carl Thornfeldt 12:10 I 12:30 Tranexamic acid vs topical meso lightening mixture using medical skin needling in the treatment of melasma, Dr Raina Alsaied 12:30 I 12:50 Cosmetic claims substantiation, Dr Athanasia Varvaresou 12:50 I 13:00 Q&A
11:30 I 11:50 The fountain of youth, Dr Beth Briden
11:50 I 12:10 Retinoid and AHA double conjugate esters for acne and photodamage, Dr Joe Lewis
12:10 I 13:00 Panel debate: top tips on practical approaches to retailing and marketing skincare in your clinic, Lorna Bowes 13:00 I 14:30 Lunch and Exhibition
14:30 I 14:50 The importance of protection against UV, Dr Zein Obagi
14:30 I 14:50 Risk and returns of new product development, Dr Curross Bakhtiar
14:50 I 15:10 Transdermal delivery of cosmeceuticals—a new technique, Dr Tapan Patel
14:50 I 15:10 Delivery systems and new innovative ingredients, Dr Marc Ronert
15:10 I 15:35 TBC
15:10 I 15:50 TBC
15:35 I 16:00 Panel debate: skincare ingredients—which are the most effective and why for treating ageing skin, Prof Beth Briden
15:50 I 16:00 Q&A, Dr Curross Bakhtiar and Dr Marc Ronert
PROVISIONAL AGENDA
16:00 I 16:30 Refreshments and Exhibition 16:30 I 16:55 Using prescription medicine in conjunction with skincare treatments, Dr Zein Obagi
16:30 I 16:50 An explaination of stem cell science and its application in skincare, Dr Charlene DeHaven
16:30 I 17:00 Panel debate: Future topical and nutritional supplements for skin ageing—what is on the horizon? Eva Escofet and Prof Beth Briden
16:50 I 18:00 Panel discussion: Topical stem cells and growth factors and their use in aesthetics
11:30 I 11:50 Hormonal approach to acne treatment, Dr Terry Loong 11:50 I 12:10 Combined IPL and peel treatment for refractory acne, Dr Carl Thornfeldt 12:10 I 12:30 The latest topical approaches to the treatment of acne, Dr Rachael Eckel 12:30 I 12:50 Microbiome and acne 12:50 I 13:00 Q&A
body language I FACE 2015 31
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
09:30 I 10:00 Non-surgical vs surgical aesthetics—industry analysis of growth and trends, Constance Campion
09:30 I 10:00 Unlocking the power of cosmeceuticals—seven steps to doubling your clinic revenue and improving patient care, Alana Marie Chalmers
10:00 I 11:00 Mastering the marketing of aesthetics, Pam Underdown and Gilly Dickens
10:00 I 11:00 Promises: delivering, measuring and keeping what it is your clients lust after most of all, Tony Gedge
11:00 I 11:30 Refreshments and Exhibition 11:30 I 11:50 Business brand development, Gary Conroy
11:30 I 13:00 Aesthetic clinic marketing in the digital age, Wendy Lewis
11:50 I 13:00 Six expert web and Google tips to attract more clients, Adam Hampson 13:00 I 14:30 Lunch and Exhibition 14:30 I 15:00 The value of a consistent consultation framework and evidence based approach to patient assesment for aesthetic procedures, Anouska Cassano
14:30 I 14:50 Acne and rosacea: charity accredited clinic leads to major increase in aesthetic clientele for minimal cost, Prof Tony Chu
15:00 I 15:20 The anatomy of a claim, Eddie Hooker
14:50 I 15:10 Sweat smart centres—new niche marketing concept for the treatment of problem sweat, Martyn Roe 15:10 I 15:30 TBC
15:20 I 16:00 Social media workshop, Warren Knight
15:30 I 16:00 Debate: New business models and how to evaluate them 16:00 I 16:30 Refreshments and Exhibition
PROVISIONAL AGENDA
16:30 I 17:20 Use of PR and media in aesthetics, Wendy Lewis
16:30 I 16:50 Unity, direction, stability. The role of the professional associations and overarching governance in self regulation, Andrew Rankin
17:20 I 17:40 Getting the most from a clinic CRM system to develop business focus and planning, Charles Southey
16:50 I 17:10 European standards in non-surgical aesthetics—a progress report, Mike Regan
17:40 I 18:00 What are people saying about your practice online? Rosie Akenhead
17:30 I 18:00 Industry debate: self regulation—what impact can it really have? Sally Taber, Andrew Rankin, Brett Collins and Mark Regan
17:10 I 17:20 Save Face, Brett Collins 17:20 I 17:30 Treatments you can trust, Sally Taber
32 FACE 2015 I body language
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
09:30 I 09:55 Understanding the natural barrier function of the skin and its impact on skin health, Sally Durant
09:30 I 09:50 Cryotherapy induced lipolysis with acoustic wave therapy, Barbara Freytag
09:55 I 10:10 Skincare ingredients—which ones for which indications?
09:50 I 10:10 HIFU for fat reduction—the latest clinical information
10:10 I 10:30 Fillerina—the first no needle HA filler for at home use, Cassandra Brown
10:10 I 10:30 Radiofrequency for body contouring
10:30 I 10:50 Eyelash and eyebrow rejuvenation—the latest topical solutions, Amy Jackson
10:30 I 10:50 Weight management—the complete approach
10:50 I 11:00 Q&A
10:50 I 11:00 Q&A 11:00 I 11:30 Refreshments and Exhibition
11:30 I 11:55 Latest technologies for laser hair removal—what are they and how much difference do they make? Jo Martin
11:30 I 11:55 Managing sweat—from iontophoresis to microwaves, Annie Eccleston
11:55 I 12:20 PCOS and treatment of transgender, Chris Hart
11:55 I 12:20 Benefits of using a hyaluronic acid and succinic acid combination vs cream as post-laser care, Maryam Borumand
12:20 I 12:40 Practical demonstration on the treatment of “peach fuzz” facial hair, Sujata Jolly
12:20 I 12:45 TBC
12:40 I 13:00 Panel discussion: Avoiding and dealing with problems associated with hair removal, Jo Martin
12:45 I 13:00 Q&A, Maryam Borumand and Annie Eccleston
13:00 I 14:30 Lunch and Exhibition 14:30 I 14:50 Laser tattoo removal—the latest techniques and technologies, Jo Martin 14:50 I 15:10 Medical skin needling—an update, Dawn Forshaw 15:10 I 15:30 Thermolysis treatment for vascular and other blemishes, Elaine Stoddart
14:30 I 16:00 Panel discussion: skin rejuvenation—latest proven techniques and practical tips
15:30 I 16:00 Q&A, Elaine Stoddart, Dawn Forshaw and Jo Martin 16:00 I 16:30 Refreshments and Exhibition
PROVISIONAL AGENDA
16:30 I 16:50 The implications of HEE recommendations to the clinical beauty therapist, Sally Durant 16:50 I 17:10 Laser training—from core of knowledge to specific treatments, Jo Martin and Paul Stapleton 17:10 I 17:30 Insurance for beauty therapists and laser technicians—are you covered effectively? 17:30 I 18:00 Panel discussion: Insurance and accredited training; which courses should you buy? Paul Stapleton, Jo Martin and Sally Durant
16:30 I 17:30 Panel debate: the future role for aestheticians in medical aesthetic clinics
body language I FACE 2015 33
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.
SATURDAY 09:25 I 09:30 Chairman’s introduction, Dr Bessam Farjo 09:30 I 09:55 Alopecia awareness, Jackie Tomlinson 09:55 I 10:20 Shampoos and haircare, Carole Michaelides 10:20 I 10:45 Wigs and hair systems 10:45 I 11:00 Q&A 11:00 I 11:30 Refreshments and Exhibition 11:30 I 11:50 Cosmetics for concealing hair loss and scalp show-through, Jason Saks 11:50 I 12:10 Medical treatments, Dr Paul Farrant 12:10 I 12:30 Non-prescription supplements, Dr Greg Williams 12:30 I 12:50 Low level lasers to treat hair loss, Dr Nilofer Farjo 12:50 I 13:00 Q&A 13:00 I 14:30 Lunch and Exhibition 14:30 I 14:55 Mesotherapy 14:55 I 15:20 Platelet rich plasma 15:20 I 16:00 Hair transplant surgery, Dr Bessam Farjo 16:00 I 16:30 Refreshments and Exhibition 16:55 I 17:20 Promising science, Claire Higgins 17:20 I 18:00 Panel debate: the future of alopecia treatment, Dr Bessam Farjo, Claire Higgins, Gill Westgate, Dr Nilofer Farjo and Dr Greg Williams 17:20 I 18:00 Panel debate—the future of alopecia treatment, Dr Bessam Farjo, Claire Higgins, Gill Westgate, Dr Nilofer Farjo and Dr Greg Williams
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.
FRIDAY 09:30 I 09:55 A combined approach to facial ageing using aptos threads, Dr Albina Kajaia 09:55 I 10:20 TBC 10:20 I 10:45 New innovation in polydioxanone (PDO) threads for non-surgical face lifting, Dr Jacques Otto 10:45 I 11:00 Q&A 11:00 I 11:30 Refreshments and Exhibition PROVISIONAL AGENDA
11:30 I 11:55 Practical demonstration of threads for facial rejuvenation 11:55 I 12:20 3D facial rejuvenation using threads and dermal fillers, Dr Sarah Tonks 12:20 I 13:00 Panel debate: Avoiding and dealing with complications, Dr Sarah Tonks and Dr Jacques Otto 13:00 I 14:30 Lunch and Exhibition
PROVISIONAL AGENDA
16:30 I 16:55 Hair greying and ageing, Gill Westgate
34 FACE 2015 I body language
The Exhibition With over 80 exhibitors, a packed agenda of exhibitor workshops spanning three days and a choice of comprehensive exhibitor symposiums, FACE 2015 offers delegates every opportunity to explore the latest medical aesthetic products and services
BRONZE SPONSORS 3D Lipo stand #27 ABC Lasers stand #20 Academy of Advanced Aesthetics stand #38 Acne Clinic UK stand #44 Adare Aesthetics stand #19 AesthetiCare stand #75 Alfa Medical stand #16 Allergan stand #48 Anti Age Magazine stand #02 Asclepion Laser Technologies stand #40
DIAMOND SPONSOR: MERZ AESTHETICS
Avita Medical stand #46 BDR Advanced Skin Repair stand #38 Body Language Journal stand #82 Bottled Science stand #47 BTL Aesthetics stand #77 CCF Media stand #07
PLATINUM SPONSORS: SURFACE PARIS and WIGMORE MEDICAL
Care Quality Commission stand #03 Classys stand #10 Clinic Solutions stand #32 CoachHouse Medical stand #33 Consulting Room stand #55 Cutagenesis stand #25
GOLD SPONSORS: GALDERMA and SKINCEUTICALS
Device Technologies stand #18 Eden Aesthetics stand #70 Finishing Touches stand #59 Fusion GT stand #09 H&P Design stand #97
SILVER SPONSORS: AESTHETIC SOURCE, ALGENESS, BAUSCH & LOMB, CYNOSURE and SYNERON CANDELA
Hairmax stand #06 Hamilton Fraser stand #69 Invasix UK stand #64 iS Clinical stand #96 JMSR Europe stand #72 Just Care Medical stand #23 Laser Leap Technologies stand #08 LinLine stand #17 Lumenis stand #11 Lynton Lasers stand #45 Mapperley Park stand #05 Needle Concept stand #74 Oxygenetix stand #35 Phi 102 Ltd stand #34 Prollenium stand #28 Q Medical Technologies stand #01 Regenlab stand #39 Restoration Robotics stand #43 Rosmetics stand #94 Sinclair Pharma stand #92 Skinbrands stand #21 Tavger stand #63 Teoxane stand #49 TSK Laboratory stand #98 Venn Healthcare stand #26 Vida Health & Beauty stand #15 Viviscal stand #83 Wisepress stand #79 Zeltiq stand #14
body language I INJECTABLES 35
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
Save the Date!
Sat 7th November 2015 At the 5 Star InterContinental Hotel, London Park Lane The prestigious MyFaceMyBody Awards are back for the fourth year after the hugely successful 2014 event which was attended by the best in the industry and lots of celebrities. Feedback from the industry “It was the most prestigious event of the year.” “An awards that gives brands so much credibility and exposure.” “A glittering night in a fabulous setting and a must for everyone in the aesthetics industry.” The MyFaceMyBody Awards have been recognized all over the world with global brands entering their products and professionals travelling to attend the big event. Entries open 1st May 2015.
Register Now At www.GlobalAestheticAwards.com/uk/ thank you to our platinum sponsors
body language I MARKETING 37
Award-winning In a competitive industry, winning an award can bolster your credibility and deliver a steady stream of new clients. STEPHEN HANDISIDES offers his advice on how to enter, and what it takes to win
P
roudly displaying a trophy or certificate in your business reception is an obvious sign to clients old and new that you are great. You know you are amazing—so why shouldn’t should everyone else? There are many different industry awards offering multiple opportunities for entering, so do a bit of research, look at which categories you can excel in and go for it! Don’t underestimate how powerful it is being a finalist or even winning an award—especially on your website. Promoting your win on the homepage of your site creates great PR and boosts your credibility and reputation. Consumers are keen to look for indications of credibility and reputation when they visit your website so displaying endorsements and accolades - such as an awards’ badge will instantly mark you out as someone they can trust. Have you ever wanted the free publicity of appearing in your local news? There are great PR opportunities after winning an award - in the immediately aftermath of wining an award your local newspapers and radio will be keen to feature the story and a picture. Glamorous, news-worthy awards such as The MyFaceMyBody Awards also make the national news thanks to the prestigious nature of the awards and the celebrity guest list. This PR helps the awards’ winners because it generates about 400 pieces of press straight after the awards. Within 48 hours of The MyFaceMyBody Awards around 35,000 consumers visit the website to watch video, look at pictures and read about the winners—generating fantastic exposure for everyone involved.
Entry The MyFaceMyBody Awards do everything online and there are about 18 different categories, with criteria for each of them. Research which categories are best for you and write a concise and targeted entry piece. If you are not confident in writing you can get as visual as you like. In fact, the more visual you can be with your entry the better—send images of your team, or before and after treatment photos. With a number of awards you can also send in supporting evidence and research papers and findings. Mystery shopping Some of the awards involve you being mystery shopped. This is a fantastic way to find out how the staff are operating on a number of different levels because we look at many things from booking the consultation to the call handling to the consultation and beyond right up to the farewell. The professional mystery shopper will mark on criteria such as: Was the phone answered with a smile? Was the enquiry handled in a polite, enthusiastic matter? Were you able to get an appointment in one to two weeks? Was information given about what to expect on the day? Was the member of staff adequately informed about the treatments that were enquired about? Then the consultation will be also evaluated by the mystery shopper—was the practitioner well presented, did the practitioner clearly explain the procedure? Were they knowledgeable about your concerns, were you given a number of different treatment options?
Clinics operate in a very competitive space—there’s lots of practitioners out there offering very similar treatments and consumers are continually looking for the next ‘wonder treatment’. By winning an award you help them make decisions and by displaying trophies and badges which mark you out as a winner you help them avoid a bad experience. For yourself, winning an award will also represent a well-deserved pat-on-the-back—so why not go for it?! As tennis champion Stefi Graf once said: “There is no relief at it being over. There is the joy of winning it.” Stephen Handisides is the founder of MyFaceMyBody a TV and online resource for consumers considering cosmetic treatments W: myfacemybody.com
There are many different industry awards offering multiple opportunities for entering
38 INJECTABLES I body language
Treating rosacea with botulinum toxin type A DR RACHAEL ECKEL discusses how toxins can be used to reduce facial flushing and erythema
T
he etiology of rosacea is multifactorial; neurovascular dysregulation, inflammation, and hyperseborrhea all contribute to disease pathogenesis. Novel treatment techniques with botulinum toxin type A (BoNTA) are appealing. The neuromodulator comprehensively targets the three cardinal pillars of disease causation, reducing facial flushing and erythema. Q. How does it work for treating Rosacea? By targeting specific neurotransmitters (seretonin) and ion channels (transient receptor potential vanilloid 1 through 4) involved in disease pathology, BoNTA imparts benefit to the neuroinflammatory component of rosacea. It has also been shown to stabilise vascular hyperactivity, which may be tangential to its effect on minimising pore size and sebaceous gland output. Q. What evidence exists? For over 15 years BoNTA has been employed for its cosmetic benefits, yet we are only now beginning to investigate its potential therapeutic power. A simple search on PubMed will reveal a mere 4 studies describing the use of neurotoxins to remedy rosacea. The largest and most comprehensive of these publications (Dermatol Surg 2015 Jan), assessed erythema scores amongst rosacea subjects, following injections with BoNTA. Compared to baseline, a 45% mean erythema improvement occurred at the three monthly follow up. This statistically significant result allowed the authors to conclude that BoNTA is an effective therapeutic option for the treatment of facial erythema. This innovative approach must however be explored further with larger, randomised, blinded, placebo-controlled studies. Q. Does the treatment work on all patients with rosacea? In my clinical experience the treatment works well overall. However not everyone with rosacea will achieve success with
BoNTA. Response appears to be related to disease subtype, which is important to assess during the initial consultation. Phymatous and erythematotelangiectatic typologies typically confer more favourable results. Q. Can you tell us more about the technique? Treatment of the face is guided by anatomical affliction with erythema. Each area should be subdivided and injected with four to six intradermal blebs of BoNTA, 1cm apart. When reconstituting the neuromodulator I use a dilution of 7mls of saline per 100 units of incobotulinumtoxinA or onabotulinumtoxinA (label dosing for both requires 2.5 mls). A typical patient will require 10 to 15 units per area of with these products, or 20 to 30 units of abobotulinumtoxinA. These figures can be further adjusted depending on patient gender and size of the treated region. Endeavor to cover all apposite areas at a financially reasonable price. Q. Is this a safe method of treatment for rosacea? There have been no adverse events documented in clinical trials, but injection skill is seminal. To avoid unwanted muscle paralysis, product placement must remain superficial. It is also worth remembering that this is currently an off-label use of BoNTA and patients should be counseled accordingly. Q. When are benefits seen and is maintenance needed? Four weeks post-injection patients notice results, lasting between four and six months. Treatment with BoNTA must however be replicated lifelong, as rosacea is a chronic dermatosis. This can nonetheless be modified to suit disease aggression and relapse rate. It is postulated that repeated treatments will impart a cumulative effect on suppressing the neuroinflammatory process, thereby reducing
injection frequency over time. Q. Should it be used in isolation? Combination therapy yields optimum results for rosacea. Physicians should treat a disease using the standard of care, and explore new areas that are safe and scientifically tested. In this manner we can expand therapeutic options and improve our patientsâ&#x20AC;&#x2122; quality of life. Q. Can you tell us how you incorporate this treatment in your practice? I adopt a holistic approach to ameliorating rosacea. An important preliminary measure is educating patients about recognising and avoiding triggers. I also prescribe a ZO Skin Health topical programme focusing on sebum reduction, barrier restoration, inflammatory control, sun protection, and keratinocyte maturation cycle enhancement. Laser therapy can be appropriate when correcting texture (CO2 fractionated laser) or improving fixed erythema (flashlamp pumped dye laser). In patients who require the latter, I supplement BoNTA to maintain results. Should lasers to correct erythema not be permissible, due to oral isotretinoin treatment or long-term microdose therapy, neuromodulators can be a favourable alternative. They are also a valuable adjunct in those who flush and who cannot afford the social downtime associated with lasers or topical therapy. BoNTA is particularly effective at managing rhinophyma, especially after surgical debulking of the tissue. Dr Rachael Eckel is a Cosmetic Dermatologist, board certified by the American Board of Aesthetic Medicine, USA. A native of Trinidad and Tobago, Dr Eckel completed her medical training at the prestigious Royal College of Surgeons in Ireland.
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body language I DERMATOLOGY 41
Managing common skin diseases DR CARL THORNFELDT discusses the multifactoral causes of skin diseases and how the best results are achieved using multifactoral therapy
E
ndogenous and external factors activate multiple mechanisms of action in the skin, which produce the visible lesions of skin diseases or conditions. Research shows that 40% of adults will suffer a skin condition lasting more than a month, every five years, and it’s likely that their children will also carry the disease. Estheticians, medical assistants, nurses, nurse practitioners, physician assistants or primary care physicians are often the first to be asked about skin conditions or diseases. The incidence of dermatitis in children is now 15-30%, so when you’re consulting about procedures it’s vital not only to talk about the procedure, but to ask what’s going on in their family, because there are many ways we can help them also. Realising that several common skin diseases share two major similarities— destructive chronic inflammation and a disrupted barrier—we first started doing basic research in the stratum corneum and epidermis back in 1989, characterising the lipids and the barrier, plus how the stratum corneum is regulated. Because of their similarities, many skin diseases will respond to similar type of treatments. When you look at these diseases you’ll notice that some of the same things, not only skin ageing, but sun induced pre-cancers, melasma, are shown to have barrier abnormality, prostaglandin and induced inflammation – which is one reason why it recurs frequently. Core commonalities Destructive chronic inflammation and disrupted skin barrier characterise these conditions: visible skin ageing; dermatitis; winter itch; psoriasis (mild); sensitive skin; actinic keratosis; ichthyosis; PMLE ; melasma and follicular: acne, rosacea, keratosis pilaris. The latest UK data shows 52% of females and 38% of males complain of having sensitive skin and polymorphous light eruption, which is one of the main reasons why we started researching the barrier. Patients often burst out with itchy, red bumps after sun exposure in
the spring and then—regardless of my intervention—they all get better by about mid-summer. This phenomenon was my research stimulus, and with multiple biopsies we found that stratum corneum thickening causes spontaneous resolution and modulation of some of the inflammatory mediators. Acne treatment The newest data on acne, particularly in adults, shows that in 68% of adult females it’s driven by pityrosporum orbiculare. This was discovered by polymerase chain reaction two years ago. Also of interest is that 92% of these women also had a contact reaction to the pityrosporum, in the form of inflammation from a patch test. It’s only been in the last three years, despite me talking about it since 1996, that it has become accepted that acne is activated by an inflammatory response. Acne is problem primarily driven from the infundibulum. Accumulated tissue along the barrier is abnormal and activates the inflammation. A comedo is a response to try to protect that and close off that barrier, but because of the proximity
to the sebaceous gland the inflammation actually drives the sebaceous gland hyperplasia and the production of the atypical sebum. Three years ago, the American Academy of Dermatology set up a group studying that and we’re doing a lot more research in the area of inflammation and taking a complete new look on the way we treat acne. Having suffered from dermatitis over 99% of my body when I was a teenager I realised that dermatitis, as well as many of these other conditions, has multiple problems. Not only is there chronic inflammation and a damamged intra-follicular barrier, but we see microbial overgrowth and hyperproliferation as well, so it’s important to get the best result by treating the condition with multifactorial therapy. Realising that many treatments activate a series of problems we did a treatment with an interesting salicylate, azelaic acid, zinc pyrithione, menthol combination, which will kill all four microbe groups that are in acne. So that’s propionibacterium acne, pityrosporum orbiculare, the gram-negatives; we’ll often see pseudomonas or proteus, and then
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the staph aureus, the staph epidermidis and the strep pyogenes. We see a lot of patients with these other kinds of microbes. We did a study and compared a salicylic acid mix that with the benzoyl peroxide. In six days there was a statistical superiority in inflammation, but by 12 weeks it was dramatically better. There were also some other benefits from this – all the patients in this group had at least three actinic keratoses, all of those resolved visibly, and they also had a reduction of wrinkling by 42%. Combination topical therapies that have highest published success rates for acne treatment: Clindamycin 1.2% + tretinoin 0.025% Clindamycin 1.2% + benzoyl peroxide (BP) 2.5% Clindamycin 1.0% _ BP 5% 4% BP + Salicylic acid (SA) 1% 8% BP + SA 2% Adapalene 0.01% + BP 2.5% 5% BP + sulfur 2% 10% BP + sulfur 5% Sulfacetamide 10% + sulfur 5% Sulfacetamide 8% + urea 10% SA 2% + azelaic acid + zinc pyrithione + menthol
For most grade one acne patients you can use multifunctional single ingredients: azelaic acid 15 or 20%; coconut oil ; benzoyl peroxide; tretinoin, tazarotene,adapalene; retinol; salicylic acid; sulfacetamide; clindamycin and anti-inflammatory—dapsone Where I trained, at UC, San Diego, the number two dermatology programme in the United States, Dr Stoughton developed topical clindamycin for acne. I was on his research team at the time, and we chose that because it was a potent antiinflammatory as well as an antimicrobial. So all of these do have a multifunctionality, that’s why I like to use these particular agents. Peels Chemical peeling is effective, and what I found particularly beneficial in the adult acne is combining it with phototherapy. I presented a paper at ASLMS, the American Society for Laser Medicine last year, where we used a long wavelength IPL, 870-1,400 nanometre. This technique killed the yeast, worked on the inflammation, shrank the sebaceous gland—which is most responsive to 1,210 nanometre, as well as kill the variety of the microbes.
That, combined with the salicylate malic peel was extremely effective in women —we had 14 out of 16 completely clear. They had had uncontrolled disease for ten years and it failed the isotretinoin. The problem was that when we trialled a group of teenagers we had only about a 40% improvement—showing clearly different mechanisms involved in teenage acne compared to the adult acne. However, since 40% of women in America, aged 40, are suffering from some type of acne, I think these types of therapies are a really good adjunct. As far as the higher acne grades go, I do a lot of mid-depth peels and PDT. I find that with the mid-depth peels that they do best if we use a salicylate or a malic acid first, and then go with those peels. But that’s a ten-day downtime and so you must warn the patient. I really restrict that for those people who absolutely don’t want to use isotretinoin, have significant amount of scarring with the lesions, and a lot of comedos. Generally, with resistant grade two you will need orals. For cystic acne in grade three you will also require oral medication. But I can’t stress enough the importance of culturing those patients for yeast and also for bacteria, because you’d be surprised how many of the microbes are actually very resistant to the standard therapies, like the tetracycline and I can only pick that up with a culture. For some reason we see a lot of resistant organisms in the region that I’m based in the USA. Perhaps its because we’re a big agribusiness area where everybody eats a lot of meat that they raise, and huge use of antibiotics and so on, but about 30% of our patients will have multidrug resistance. Oral hormones For oral treatment, keep in mind the hormones. I find flutamide is about ten times more potent than spironolactone. Specifically, 5% and 10% topical flutamide lotion is very helpful. But with those you need to take them for about 18 months, so think about what’s going on with that receptor. When you look at that sebaceous gland receptor you find that there are increased numbers of receptors there and the receptors are much larger than normal. You don’t induce long-term remission until you start producing that disuse atrophy, and that usually takes 12 to 18 months, but the success rate is good. In a flutamide study, 88% of patients a year after they finished that 18-month therapy, were still cleared. So it appears you have some long-term benefit with that. In the UK you have access to a great-
er number of effective birth control pill hormones than we have in the US. I have data about the pityrosporum orbiculare playing a role. We use the azoles in a pulse dose, for example, itraconazole, 200 mg twice a day, two days a week for 12 weeks. This is because not only do you want to eradicate the microbe, but you also want the immune system to wake back up. Keep in mind that one of the problems with these chronic inflammatory diseases is that the inflammation will dampen down functionality of Langerhans’ cells and surveillance cells used to help detect. Plus there will be some relative suppression of cell-mediated immunity and so you want that to bounce back up. One of the things that I’ve found in the adult acne that’s been particularly effective is using the itraconazole at the weekends, and using the doxycycline on the weekdays. Sulfas There have been some studies about the sulfas, that warrant a mention. With Trimethoprim, when they examined the combination of the bactrim receptor, which is trimethoprim sulfamethoxazole, they found that the component that was working in acne was the trimethoprim. The component that was activating the sulfa allergy was the sulfamethoxazole. This means we can use the plain trimethoprim, 200 mg, once or twice a day. What’s also important about the sulfas is that of all the antibiotics that we tested it was found to be the most potent in inhib-
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iting matrix metalloproteinases. When we look at ageing skin, keep in mind that matrix metalloproteinases (MMPs) are the critical factor that will activate a whole series of problems, including increased inflammation and activating skin diseases. They will cause dysplasia that results in actinic keratosis. Where I live that’s a big issue because we have the highest incidence of skin cancer of any place in the United States—many of which are follicular tumours found in acne scars. In addition, it will also turn off the MMPs that are destroying collagen and elastin, which is an activator for the furrows and fine lines. So I find that the sulfas can be pretty good workhorses in that, particularly in the adult patient. Alternatives We’ve known for years that mint has antiinflammatory and antimicrobial effect and found that spearmint is particularly effective against the acne bugs, both the gram-negative and gram-positive, and had the most potent anti-inflammatory. A study, where patients consumed two cups of spearmint tea a day for a month found a 25% decrease in the number of inflammatory lesions. By the end of three months they had a 50% decrease in inflammatory lesions and a 25% decrease in non-inflammatory lesions. This is an interesting therapy that seems to have some good scientific background. Another natural remedy, coconut oil was presented two months ago at the
American Academy of Dermatology, in a study showing that it’s 94% effective in being cidal to staphylococcus aureus and 91% cidal to proteus, so there’s more research being done with that. A study done using coconut oil twice a day for a month, improved the acne lesions by 25% and had no irritation, so I think that’s something that’s interesting down the road. There was also a study using zinc picolinate, 25 mg three times a day, which showed significant benefit in acne. We’ve known for years that zine is effective but that the limitation with most of the acne forms was GI distress. In one study that was done 38% of the patients had such GI distress that they had to stop treatment early. Those people that could tolerate had some significant benefit, but it really caused a lot of problems there. So some very bright person decided to take picolinic acid—the ligand lining the GI tract that absorbs those minerals that are floating by, and then transport it into the blood stream—and combine the molecule itself to the zinc. So a 25 mg zinc picolinate equals 60 mg of elemental zinc and with the acne patients, we go with 50 mg, three times a day. We haven’t seen any GI problems because it’s also a component in wound healing. I do a lot of flaps and grafts, big cancer surgery and that’s one of my workhorses in the supplementation also for wound healing. Another interesting study that was presented two months ago at the American Academy of Dermatology was vitamin D, at 1,000 iu a day, if people notice that the acne flares during the winter. Many of you may use phototherapy and a home use device did show some statistical improvement, but in my experience there has been a problem with compliance. Patients will use it for a while, get pretty well clear, and they start backing off on
the treatment because it is one of those things that requires an every other day treatment. I’ve found that these things are helpful but cost becomes a big issue. Light One of the biggest failures I’ve ever seen is using blue light with ALA, because there are two big problems with how that blue light penetrates. One, is many of my patients developed a tan after treatment which will accelerate photoageing. This indicates that there’s UVA in there in the spectrum below 400 nanometres, even though the company said it’s only 415 nanometres. The second problem is it only penetrates through the epidermis and barely gets into the infundibulum. We know that the big problem with acne is down in the entire infundibulum, down to the sebaceous gland—so it doesn’t penetrate deep enough. With the blue light with ALA my and colleagues I had a success rate of 37%, so I confronted the company who had claimed 80% success rate, and discovered that their study wasn’t actually done with the same machine. We did try using some alternative wavelengths with more success. I also presented a paper where we used a longer wave-length—a 500-635 nanometre, with ALA, and we had very good results —a 76% success rate instead of 37%. Treating pre-cancers Actinic keratosis (AKs), are the sun induced pre-cancers identified by tingling or burning sites, or reddish or some fine, scaly spots. For patients still in the preliminary phase of hypertrophic AKs I’ll remove the carcinomas, and then I’ll use a mid-depth chemical peel or do aggressive photodynamic therapy. Where I live, more than 50% of peo-
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ple over aged 50 suffer from pre-cancers. Usually they will come in concerned about a tingly growth—particularly 2-20% progress into squamous cell carcinoma. If they’re very thick ones, then it’s a squamous cell carcinoma until proven otherwise. If you have one that has persistent pain, it’s cancer until proven otherwise and you must send him to a dermatologist to get those treated. Looking at the various therapies, if your patient has less then 20 lesions, commonly we use cryotherapy and cantharidin. However, the success with cryotherapy is only 62% and that’s not a great result. Cantharidin, salicylic acid and podophyllin has a 55% success rate. I use a combination of the two, so our success rate in treating 1,600 patients was 86.9%. For treating numerous lesions I use peeling agents and the photodynamic therapy. We did a trial on lesions that had failed with other therapies, using a salicylate, willow bark, onion, malic acid and we were able to have over an 80% success rate with three treatments. Jessner’s therapies have pretty good success rate. Studies from that range about 40% to about 65%. Our peel was up in that 85-90%. But I really like the photodynamic therapy using aminolevulenic acid activated by 750 nm IPL and LED lights There are a number of topicals that we’ve had pretty good results with. When you look at the data for 5-FU, there’s about a 55% success rate. Imiquimod has around a 72% success rate, but recurs after two years or so. My workhorse on that group is the Imiquimod, which re-programmes the cell-mediated immunities and makes those cells much more aware of what’s going on. I’ve been disappointed with diclofenac, and pleased with azelaic acid, overall. A study treating with with azelaic acids, salicylate and herbal anti-inflammatory in five clinical studies, saw 100% resolution of non-hypertrophic AKs on the foreheads and cheeks in three of the studies. And two studies where we had patients who’d had at least two cancers in the previous five years; 62% clearance in one, 83% clearance in the other. There are more studies pending on that. Sensitive skin The adage with sensitive skin is that 3050% of females are affected, depending on race. Occult type patients are pretty much sensitive to anything—when you biopsy and look at them, you find that their nerves are larger than normal and they also produce an excessive vascular response, so you have to consider the ae-
tiology of that. Most of the sensitive skin people may have some slight redness, some scaling or hives, they will notice burning with exposure to sunlight, water and change in humidity. This is most common when the seasons change—usually spring and autumn because the changes in the humidity has a bigger impact on the barrier. Particularly, in spring we see sensitive skin becoming really manifest because in the cold winter sebaceous gland production diminishes. Patients with sensitive skin have a really damaged barrier in the spring, which starts getting exposed to the light, to the pollutants. RIPT London is the 19th most polluted city in the world, so the most important aspect for patients here is to get their skin barrier repaired and make sure that all the products that you recommend for these patients have a Repeat Insult Patch Test (RIPT) test. It’s not required for cosmetic products, but in the cosmaceutical business, for every product I’m involved with, we do that test. It costs less than $4,000, it’s done on 50 patients and it’s a very good predictor of whether there’s going to be irritation and sensitisation. If the RIPT test is negative, your rate of sensitisation is going to be less than 0.5%. Last year at the American Academy of Dermatology, of the 38 skincare companies only five could claim any clinical trials, only six had done any RIPT tests. Patients with sensitive skin are very pH sensitive, so you must ensure that pH is above 2.5. For the patients who have sensitive skin and acne, 20% salicylic acid peels work well with an anti-inflamma-
tory and barrier at home topical regimen. We looked at all 130 herbs that in 1994 had been reported to be beneficial in human skin. We fractionated into six fractions with three different concentrations of each, and found ones that had measurable anti-inflammatory activity and ones that had barrier repairing activity. For sensitive skin patients I want products that will have one or more of each of those on them, because they generally ensure a good response. But I also advise them to be careful—to use a little hydration, put just some warm water on first and then put the products on. We begin doing it four times a day for the first month, and then start tapering down because they are exquisitely sensitive, even to many of the sunscreen ingredients. Seborrheic keratoses These can range from usually white, scaly bums on the legs to yellow-brown and even black spots. If a lot of them itch it can be associated with gastrointestinal cancer. So if a person comes in and says, I’ve got all these things and they’re starting to itch a lot, they need to get checked out by their regular doctor. If they have one or two that have a little bit of inflammation, maybe a little tenderness, maybe a little itching, they may be developing a pre-cancer in there and should be checked by a dermatologist. There’s absolutely no relationship between these and liver spots. I’m still stunned to see, in 2014, articles coming out in the natural literature saying that these are a marker for internal disease—that’s completely dis-proven. Unless seborrheic keratoses are really thick and catching on clothes, you want
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to gently thin those down over a period of time. I tell patients it’s going to take two to four months for those to melt away. They occurred because of injury to the barrier, so trauma rubbing and so on, and this is the body’s exaggerated response. If you just take it off you’re going to get some rebound effect so you want to take your time and gently get it planed down so that it doesn’t come popping back. But if they’ve got one that’s really bothering them a lot, I go with these more aggressive things right away to take it off. I follow with something lighter to keep it from coming back. A number of therapies are reported to be effective and have had fairly good outcomes for treating seborrheic keratosis these include: 100% pyruvic acid 70% glycolic acid 40% SA+ cantharidin + podophyllin Cryotherapy Curettage 40% urea paste 30% urea + 12% ammoniated lactate 5% SA + 5% coal tar 3% SA+ azelaic acid + zinc pyrithione
Dermatitis Derrmatitis can be broken down into specific types. You’ll see contact dermatitis in nurses, plus in hairdressers it’s also a real problem and they will often have scaly rashes. It’s characterised by areas of crusting, you’ll see fissures, you may see little blisters or pustules. I’ve found that 97% of these patients are infected with strep viridans or staph aureus, and
about 62% are infected with candida albicans. Studies have found that over 90% of those patients had a contact sensitivity to the staph aureus and to the candida. You’re dealing with a reaction to a particular agent, but also then the secondary invader, so it can be tough to treat. With the hand problems there are high numbers of plasma cells there, so once you get a clear there’s a very rapid rebound. You’ve got to go through a time where you’re doing a maintenance therapy again, so those excess receptors on those inflammatory cells, particularly those plasma cells, start shrinking away. It takes time, but it’s important to make sure you treat the underlying infection and then really focus hard on repairing the barrier, controlling the inflammation. Atopic dermatitis Atopic dermatitis is the itch that rashes. On adults usually it’s the antecubital fossas, popliteal fossas, neck, face. In children it would usually be over the extensor surfaces. The problems with this form are multiple-fold. Number one, they have leaky skin. Number two, they have excessive nerve activation and that’s what’s associated with the itching. Number three, they have a decreased cell-mediated immunity, so they get infected, and when they get infected they’re often times allergic to the infecting agents. Another alarming fact is the huge impact that atopic dermatitis has on metabolism. Studies were done in the UK and in Scandinavia, using twins, and treating one but not the other. At age 18 the untreated child had stunted growth, stunted IQ and stunted body of various kinds— not only height, but total body mass. We know that these things, untreated, have a huge impact because when you get this much flaring, the blood is flowing to the skin primarily. We also know that people who have more than 30% body involvement of uncontrolled dermatitis have a two and a half times increased risk of heart attack. Their risk of Alzheimer’s is doubled and their risk of kidney transplant for renal disease is tripled. Incidentally, the incidence of melanoma goes up 12 fold, so we know that there’s a direct correlation and how important it is to get these people under control. Again, you need to have a multifactorial effect. This is a problem that it’s rapidly increasing. The incidence in the United States has tripled in the last 20 years, and in children it’s increased five fold. When you’re working with your cosmetic patient, ask how the children are doing. If
their child has some dermatitis, then you need to encourage treatment. Keep in mind, this disease affects the entire family, including their sleep. A recent interesting dermatitis study includes using white water lily. We did research looking at neuropeptide activity for the neurogenic inflammation, which is that flush that occurs right after you carry out a procedure. The most potent in blocking that, of all the anti-inflammatories, was an extract of white water lily. Oral quercetin, which was initially looked at for cancer therapy, turns out to be one of the most potent inhibitors of histamine-1, plus broad spectrum anti-inflammatory and antitumour. N-acetylcysteine is also very potent in suppressing the mast cell. Those are three non-prescription things, that will augment the known prescription products as far as relieving an itch. In the one study, where they used a combination of oral quercetin and n-acetylcysteine, in six weeks they had the rash scores reduced by 75%, just by using those orally. It’s also important that you optimise the stratum corneum barrier. You need the cholesterol ceramide free fatty acids at a proper ratio, to form that barrier. You also need aquaporins in that and you need filaggrin proteins to basically reapply stratum corneum. That’s really critical for turning off the reactions. However, when I culture these people, they usually need antimicrobials for a month or so to get them under control. It’s now been shown that 80% of dermatitis patients in the United States have allergies to dust mite, dog, cat, grass or trees. So if we can use sublingual desensitisation we’re actually able to get much better results. The two biggest irritants to avoid are formaldehyde and dryer sheets’ fragrance. N-acetylcysteine and quercetin will control mast cells. I find quercetin is much better than those prescription ones and people like the fact that it’s naturally derived. When people tell me they don’t want to use any steroids I sit down and talk about it. When I was in San Diego in the 1970s I was on the research team for the Stoughton vasoconstrictor assay. I go through the amounts that will cause internal absorption and what the potential side effects are. But at the end of the day I make sure they know that if don’t treat a child he will be stunted, his IQ will be less, he will have reduced motor skills. The short-term effect of steroids is important for relief of the symptoms and you may have to go with that. But even if there’s a slight impact on that they will
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Rx: Dermatitis Stop itch with oral quercetin, N-acetyl-cysteine, cetirizine, fexofenadine, diphenlydramine, cyproheptadine, doxepin or topical doxepin, menthol, pramoxine, white water lily Optimise stratum corneum barrier and hydrate listed previously under sensitive skin Treat infection usually staphylococcus aureus, streptococcus Viridans, candida albicans with pulsed dose anti yeast agents (fluconazole two days/week) and anti-bacterial, antiinflammatories (minocycline five days/week) Avoid sensitisers—80% are aggravated by inhalant allergy to dust mite, dog, cat, grass, trees. Avoid irritants—fragrance, formaldehyde (dryer sheets) Control mast cells with montelukast or zafirlukast Topical corticosteroids—appropriate class for body site, patient age and body geography Topical macrolides—tacrolimus, pimicrolimus Infection prevention—probiotics
rapidly rebound. An interesting study was done at Oregon Health Sciences Centre, where they compared a high potency steroid, betamethasone dipropionate. Dermatitis patients were treated twice a day for six weeks and everybody got cleared. They compared it with a barrier repair product and at six weeks everybody was clear. They then stopped the beta dip, within four weeks everybody rebounded. With the barrier repair product it took eight and a half months before recurrence started. Why? It’s working on the underlying path of physiology and these are very effective tools, I use a lot of them. I’ve done a lot of work on alclometasone. They’re very good tools but they have a role and they don’t work on the underlying problem. Topical macrolides are beneficial, but I also like probiotics to help boost their normal immunity and prevent infection. Rosacea Patients with rosacea have extremely sensitive skin, they have the barrier abnormalities and abnormal inflammation, so I use combinations of orals and topicals on these patients, since working on the barrier and controlling inflammation is really important. In cases of perioral dermatitis usually we require anti-inflammatories to prevent patients rebounding as they come off steroids. Seborrheic dermatitis; in a minor case is dandruff. The big new thing with this is we’re seeing a lot related to rosacea. Many of the rosacea triggers, emotional stress, caffeine, chocolate, and alcohol are also driving this. In 92% they have malassezia for the pityrosporum orbiculare yeast, and they have an abnormal stratum corneum barrier. They tend not to have itching with it but once in a while it will start weeping and it’s infected usually with gram-negatives. To treat rosacea you can use anti-in-
flammatories, but it’s really critical to be using the anti-yeast agents. Miconazole and clotrimazole are non-prescription. I find ciclopirox and ketoconazole particularly effective and ketoconazole shampoo, which I use as a body wash because ketoconazole and ciclopirox are not only effective against yeast, they’re also good against gram-negatives and gram-positives too and to reduce the total microbial load on their skin. Again, I use the pulse dose fluconazole and itraconazole for 12 weeks on those patients. One of the dangers of rosacea can be a vascular problem. The big danger is that 20% of patients have eye problems. Often associated with seborrheic dermatitis, you have the increased demodex. The big concern is what came first? The demodex, because they had a decrease in cell-mediated immunity, or was it the rosacea that occurred first and the vascular abnormality that allowed it. Ivermectin is very helpful for this and there are four different types, the most common being papulopustular type. Psoriasis Psoriasis affects 2.4% of the population. When I see patients for the first time I always do some tape stripping and culture, because find that microbes are playing a role in these particular patients. Just like dermatitis, sufferers are 90% infected with bacteria when you do tape stripping, and 60% with yeast. Sadly sufferers have a 30% rate of arthritis and marked increase in morbidity. Psoriasis also triples the incidence of kidney transplant, increases the likelihood of heart attacks by two and a half times, doubles Alzheimer’s, doubles stroke, and increases malignancy by twelve fold. I prescribe a lot of pretty strong drugs, because when patients come to me they’re in pretty bad shape. But we’ve had very good adjunct with anti-inflammatory patients. Other therapies include narrow-
band UVB excimer laser (308 nm); biologics: antibodies adalimumab etanercept ustekinumab; anti-inflammatory antibiotics/antiyeast: doxycycline, fluconazole; and combinations of above. I’m a big believer in narrowband UVB light, I actually had the first device in the Pacific Northwest. My vice-chairman at UC, San Diego was one of the two inventors of PUVA. I also use the excimer laser a lot because it puts to sleep the psoriasis cells, but doesn’t kill them, so you don’t get all the atrophy, particularly over joints. But I’ve found also that anti-inflammatory, anti-yeast and antibiotics are really very helpful. It’s important to always take the history about whether there’s anything of infection going on, particularly sinus infections. Sinus infections and dental infections will really drive psoriasis. In males, prostate infections will also drive psoriasis. I had one 23 years old woman, who had been on two biologics over a period of years and had just not gotten as good results as she would like. And this was just doing the anti-inflammatory, antimicrobial, herbal preparation, barrier repairing three times a day. After four weeks she showed a very significant improvement. Psoriasis is often associated with physical and emotional stress, so it’s important to take history of patients. Keratosis pilaris Keratosis pilaris, is the bumpy skin that we see with young children, and many allergic people. Usually it appears on the arms and thighs and is basically an abnormality right at the follicle, so with topicals you need a combination of keratolytics to open up the pore, followed by hydrators and barrier repairing agents to turn the process off. I’ve also found that zinc is really helpful in these patients. Conclusion The conclusion is that multifactorial skin diseases require multifactorial therapies, many of which have been approved by the FDA in the United States. Orals and topicals are needed to achieve complete control and remission, though recent herbal products seem to have unique beneficial mechanisms of action, and are also available for you to use in your practice. Dr Carl R. Thornfeldt is a dermatologist and the CEO and founder of Episciences, Inc. He was awarded Innovator of the Year in Dermatology for 2014 at The Cosmetic Surgery Forum
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on the market The latest anti-ageing and medical aesthetic products and services Double Defence SkinCeuticals are launching the Double Defence packs in-clinic to support their Double Defence initiative. When used together, a skinceuticals antioxidant + broad-spectrum sunscreen are said to provide powerful protection against photoageing and the appearance of skin ageing. W: skinceuticals.co.uk
Medik8 Light Peel Medik8 have launched a new Light Peel, developed as a mild introduction to chemical peeling for those not ready to make the jump. Light Peel is said to dramatically improve mild skin concerns such as blemishes, scarring, photoageing, fine lines and dark pigmentation patches. It is designed to be so mild that it can be used all year around and is an advanced treatment suitable for all body parts including the eye contour, hands and feet. W: skinbrands.co.uk
Lipofirm Pro Advanced Esthetics Solutions have increased their Lipofirm brand with the launch of the new Lipofirm Pro, a non-surgical face and body platform utilising TriLipo and DMA technology for face and body contouring. Lipofirm Pro with TriLipo technology was designed for the specialist needs of aesthetic professionals. TriLipo combines two technologies (TriLipo RF and TriLipo Dynamic Muscle Activation) that are said to work simultaneously using a single applicator to deliver non-invasive fat removal and lymphatic drainage, as well as skin tightening and wrinkle reduction. The triple action fat reduction of TriLipo technology is said to consist of RF deep volumetric heating combined with internal muscle contraction and external mechanical force, which together yield maximum fat removal and lymphatic drainage as well as skin tightening. Lipofirm Pro offers two proprietary technologies and the use of three applicators: Trilipo RF, for skin tightening, cellulite reduction and fat reduction; TriLipo DMA, used on the body to clear released fat and on the face to “lift” the SMAS (Superficial Muscular Aponeurotic System); the small applicator: designed to treat delicate areas; the medium applicator: used for face, neck, arms and hands; the large applicator: used for treating the abdomen, flanks, thighs and buttocks. W: advancedestheticssolutions.co.uk
Vanquish Flex BTL Aesthetics have introduced their new Vanquish Flex applicator for use on the thighs and saddlebags. Harnessing the Vanquish RF technology for the abdomen, the non-surgical Flex hovers over upper legs and is said to deliver selective radiofrequency energy to heat the deep tissue layer. Vanquish Flex uses a two-panel system without touching the patient directly and is designed to offer patients a safe and comfortable treatment. BTL Industries say that full results are achieved in four to six weeks spaced about one week apart with continuous improvements seen over the next month or so. W: btlaesthetics.com
Pigment Lightening Gel This unique formulation combines the active brighteners butyl resorcinol, kojic acid and vitamin C, to help reduce the appearance of existing pigmentation and discourage new spots from forming. An AHA (alpha hydroxy acid) /PHA (polyhydroxy acid) blend helps to exfoliate skin and spots, while licorice extract enhances brightness. Skin should be left brighter, clearer and smoother. W: aestheticsource.com
body language I ADVERTORIAL 49
Keep hair from shedding Dermatopoietin is an innovative peptide complex which can keep hair from undesirable shedding— it is the principal component of Swiss cosmetic brand, EVENSWISS
S
hedding 50 to 100 hairs a day is normal. That is just hair going through its cycles, and there will arise a new one to replace it. Many factors like a stress can contribute to hair shedding at rates higher than normal ones even in the absence of medical conditions. Dermatopoietin is an innovative peptide complex capable of keeping hair from excessive shedding in healthy persons. It is the principal component of Swiss cosmetic brand EVENSWISS. Dermatopoietin does not penetrate the skin, but acts on receptors on the skin’s surface to send a signal to keep hair from shedding.
Daily hair shedding, %
Keeping hair from shedding with innovative peptide complex Dermatopoietin: a randomised doubleblind placebo-controlled study Test articles: Dermatopoietin or placebo. Study performance: Skin Test Institute, c/o Intercosmetica Neuchâtel S.A. 2008 Neuchâtel, Switzerland. Demographic data: Twenty six healthy volunteers, 45±12 years of age (18 to 63 years), females to males ratio 2:1, having average daily shed hair number less than 110. Study design: Volunteers were randomly assigned to Dermatopoietin group (n=14) or placebo group (n=12). Test articles were applied on the whole scalp once-a-day at evening for four consecutive days with a gentle massage. The course was repeated after ten days. Fallen hairs were collected upon combing and putted into blind envelopes by volunteers. Assessment of hair shedding: The number of fallen hairs during the daily normal hair shedding process was assessed by counting at baseline and at six count sessions during next three months. Results: Dermatopoietin application provides significant decrease of average daily hair shedding by 25% compared to Placebo for three months of the observations (see Figure). First positive results can be observed as early as two weeks from the start of Dermatopoietin applications. Conclusion: Dermatopoietin is fast and effective tool for keeping hair from shedding. Product line EVENSWISS products contain the unique and patented Dermatopoietin peptide complex. Using the hair-care products of the EVENSWISS line, you keep hair from undesirable shedding and achieve great hair appearance.
Daily hair shedding, % average for three months
For more information on the EVENSWISS line please visit, W: evenswiss.ch or unicos.ch
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body language I SKINCARE 51
Skin lightening Treatments to reduce dark spots and lighten the complexion are often sought by patients worldwide. DR DANIEL SISTER looks at the causes of pigmentation and ingredients that offer results
A
new trend has been observed recently. If people were looking for extreme suntan before, the new interest is in skin whitening. In Western culture tanned skin is the signature of vacation time, and is still considered desirable, but the increased risk of skin cancer due to sun exposure and subsequent press coverage is changing mentalities. In Eastern culture, beauty is associated with a bright, light complexion. In the past years we have seen an explosion of skin bleaching products without any consideration for the medical implications. As a result reports about the toxicity and carcinogenicity have been issued and in many parts of the world, ingredients such as corticoids, hydroquinone and mercury derivatives are banned in skin whitening formulations. Alternatives In medical literature there are mentions of vitamin A and C, citric acid, flavonoids, amino acids being suitable for skin lightening, however most are unstable and can be an irritant to the skin. Different facial skin abrasive techniques such as chemical peelings, laser and LED can be efficient but include down time. Skin colour Human skin colour is mainly regulated by the mechanism of the tyrosinase enzyme involved in melanin production. Melanin is produced by melanocytes cells in a melanogenesis process which involves small membrane-bound packages called melanosomes. Once they become full of melanin, they move into the slender arms of melanocytes from where they are transferred to keratinocytes. Under
normal conditions melanosones cover the upper part of keratinocytes in order to protect them from DNA damage occurred by sun exposure. The colour of normal skin is the result of a constitutive pigmentation and optional pigmentation (depending on the UV irradiation). It results from the superposition of four main colours: yellow carotenoids; red oxyhemoglobin of dermal capillaries; blue reduced hemoglobin from dermal venules; brown melanin present in keratinocytes The difference in skin colour between lightly and darkly pigmented skin is due to the quantity of eumelanin (brown black polymer) and pheomelanin (yellow to red hue). Tyrosinase is required to produce melanin pigment in melanocytes from the amino acid tyrosine. Ingredients Glutathione is a tripeptide consisting of cysteine, glycine, and glutamate and functions as a major antioxidant. It is synthesised endogenously in humans. Glutathione protects thiol protein groups from oxidation and is involved in cellular detoxification for maintenance of the cell environment. Reduced glutathione (GSH) has a skin-whitening effect in humans through its tyrosinase inhibitory activity. The problem is that glutathione is a big molecule and can’t penetrate the skin as a cream, gel or serum. Many foods we eat contain glutathione, however to achieve lighter, brighter skin it has to be injected. Mesotherapy is the best method of delivery, and I use Sur-
face White, injecting 0.02 ml to 0.05 ml of drug solution, perpendicular to the skin given a 4 mm deep injection with an interval of 5 mm between each injection. Another important ingredient is gamma-amino-butyric acid (GABA). It is the main whitening product in both Surface Serum and Surface Cream—part of the Whitebox treatment. It is a safer and more natural alternative to other bleaching agents which can have serious side effects. The GABA molecule is an amino acid naturally synthesised by the human body. Is has shown many positive effects on human health, and specifically on skin rejuvenation. Folic acid will also help to improve the skin tone and quality as proven by a study where topical application of a folic acid and creatine-containing formulation significantly improved firmness of mature skin in vivo. Treatment of
There are many treatments to improve skin tone and pigmentation
52 SKINCARE I body language
fibroblast-populated dermal equivalents with folic acid and creatine increased collagen gene expression and procollagen levels and improved collagen fiber density, suggesting that the in vivo effects are based on the overall improvement of the collagen metabolism. Superoxide dismutases Sometimes referred to as the “youth molecule” for its age-defying properties, superoxide dismutases (SOD) is believed to be one of the most powerful antioxidants known to science. SODs naturally exist in your body, but their numbers become depleted as we age. Researchers believe that much of the damage that occurs to skin, including sun damage, fine lines, wrinkles, age spots, and sagging, are caused by the continuous destructive action of free radicals. In 2004, researchers studied SOD on breast tissue. A total of 44 patients who had gone through breast radiotherapy for mammary cancer (radiation produces many free radicals) were treated with an ointment that contained SOD for 90 days. The ointment was found to reduce radiation-induced fibrosis—scarring. The SOD stopped the free radicals from damaging the skin connective tissues, resulting in a more normal regeneration of skin without scarring. In 2001, researchers studied SOD in the laboratory, observing its effect on myo-fibroblasts, which are key components in creating skin fibrosis, or scarring. After treating skin in the lab with SOD, researchers found that SOD seemed to reverse myo-fibroblasts into normal fibroblasts, resulting in a more normal, even skin structure. Whitebox results Dr Beilin in Paris conducted a study, using the Whitebox treatment system, which incorporates Surface White, a mesotherapy product containing glutathione, and Surface Cream and Surface Serum which contain 3% and 10% GABA complex respectively. Products were used twice daily with 20 women using GABA 3% and 21 women using GABA 10%, with once weekly mesotherapy ses-
10% GABA concentration Surface Serum
Results after four weeks
Results after eight weeks
Brighter complexion
95.2%
100%
Reduced irregular pigmentation
76.2%
76.2%
Reduction in yellowish appearance
71.4%
71.4%
Visibly fairer skin
85.7%
100%
More even skin tone
66.7%
76.2%
Visibly reduced dark spots
81%
81%
Refined skin texture
85.7%
95.2%
3% GABA complex Surface Cream
Results after four weeks
Results after eight weeks
More transparent complexion
80%
83.3%
Reduction in yellowish appearance
72.2%
70%
Smoother skin
77.8%
85%
Visibly fairer skin
83.3%
80%
Softer skin
90%
94.4%
Visibly reduced dark spots
65%
72.2%
Refined skin texture
70%
83.3%
sions for five weeks. She concluded that mesotherapy alone is efficient, and the Surface Whitening protocol also incorporating the dermal cosmetics with GABA complex, demonstrated significant results on skin whitening and on dark spots reduction. To optimise the facial skin whitening effect, mesotherapy for five weeks should be combined with two months of twice daily application of GABA complex. References 1. Bonniol JL, Beauté et couleur de la peau. Variations, marques et métamorphoses Communications, 60, Beauté, laideur,1995, p.185-204. 2. Findlay GH, Morrison JG, Simson IW. Exogenous ochronosis and pigmented colloid milium from hydroquinone bleaching creams. Br J Dermatol 1975; 93:613-22. 3. Mahé A, Ly F, Aymard G, Dangou JM. Skin diseases associated with the cosmetic use of bleaching products in women from Dakar, Senegal. Br J Dermatol 2003; 148(3):493-500. 4. ANSM-Evaluation des risqué lies à la dépigmentation volontaire, Oct 2011 ; http://ansm.sante.fr 5. Clin Cosmet Investig Dermatol. 2014 Oct 17;7:267-74. doi: 10.2147/CCID.S68424. eCollection 2014. Skin-whitening and skincondition-improving effects of topical oxidized glutathione: a double-blind and placebo-controlled clinical trial in healthy women.Watanabe
F. Hashizume E Chan GP, Kamimura A.Cohen M-G., Use of gamma-amino butiric acid as depigmenting agent, US 20090232757 A1, Sept 2009 6. Folic acid and creatine improve the firmness of human skin in vivo. J Cosmet Dermatol. 2011 Mar;10(1):15-23. doi: 10.1111/j.14732165.2010.00543.x.Fischer F, Achterberg V, März A, Puschmann S, Rahn CD, Lutz V, Krüger A, Schwengler H, Jaspers S, Koop U, Blatt T, Wenck H, Gallinat S. 7. Latha P., Vandana KR, Mesotherapy a review, International Journal of Advanced Pharmaceutics, 2011; I (1), 19-29. 8. Scholz RW. Graham KS. Gumpricht E. Reddy CC. Mechanism of interaction of vitamin E and glutathione in the protection against membrane lipid peroxidation. Ann NY Acad Sci 1989:570:514-7. Hughes RE. Reduction of dehydroascorbic acid by animal tissues. Nature 1964:203:1068-9. 9. Petit L, Pierard GE. Skin-lightening products revisited. International Journal of Cosmetic Science, 2003; 25, 169-181.
Results from Dr Beilin’s study using Surface Serum and Surface Cream
WIGMORE MEDICAL TRAINING YOUR COMPLETE TRAINING EXPERIENCE For over a decade, Wigmore Medical have been running competitively priced courses, including all the latest trends, products and techniques to ensure top quality training. Whether you are a newcomer to the medical aesthetic industry or an established practitioner, we feel there is always a training course or two that we can offer you. Wigmore Medical offer an extensive range of training courses to choose from, including toxins, fillers, chemical peels, Sculptra, Dermal Roller, platelet rich plasma and microsclerotherapy. All our hands-on training courses are run to a maximum class size of five delegates to ensure a quality learning environment. Unlike some training providers, we do not overfill the training room with delegates. Our training is doctor-led, medically-based and independent. Our courses focus on the skills you desire and all our trainers are extremely reputable within their field of expertise. The dedicated team has always taken pride in looking after all of its clients, with the added personal touch where needed. Please see below for our upcoming course dates and call us now to register your interest and benefit from our professional training and continuous support.
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MAY 8 Advanced Toxins* (am) 8 Advanced Fillers-LF* (pm) 9 Mini-Thread Lift* FB 10 Intro to Toxins* FB 19 Skincare & Peels 19 ZO Medical Basic (Dublin) 20 ZO Medical Interm. (Dublin) 20 Intro to Toxins* FB 21 Intro to Fillers* FB 23 Intro to Toxins* 26 ZO Medical Basic 27 ZO Medical Interm. 28 ZO Medical Adv. 31 Microsclerotherapy*
JUNE
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JULY
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AUGUST
2 Sculptra* 4 ZO Medical Basic 1 CPR & Anaphylaxis Update (am) 10 Mini-Thread Lift & Dermal Filler* 5 ZO Medical Interm. 1 Skinrölla Dermal Roller (pm) 11 Advanced Toxins* (am) 6 ZO Medical Adv. 8 Core of Knowledge—Lasers/IPL 11 Advanced Fillers-TT* (pm) 7 Advanced Fillers-TT* (am) 9 Skincare & Peels 13 Dracula PRP* 7 Advanced Fillers-LF* (pm) 10 Intro to Toxins* FB 13 ZO Medical Basic (Dublin) 8 Mini-Thread Lift & Dermal Filler* 11 Intro to Fillers* 14 ZO Medical Interm. (Dublin) 12 Core of Knowledge—Lasers/IPL 12 Mini-Thread Lift & Dermal Filler* 13 Mini-Thread Lift & Dermal Filler* 20 CPR & Anaphylaxis Update (am) 13 Neostrata by Aesthetic Source 20 Skinrölla Dermal Roller (pm) 18 Skincare & Peels 15 Dracula PRP* 21 Skincare & Peels 19 Intro to Toxins* 16 ZO Medical Basic 22 Intro to Toxins* 20 Intro to Fillers* 17 ZO Medical Interm. 23 Intro to Fillers* 18 Neostrata by Aesthetic Source 25 Microsclerotherapy* 23 ZO Medical Basic (Dublin) 24 ZO Medical Adv. (Dublin) 26 Mini-Thread Lift & Dermal Filler* 27 Microsclerotherapy*
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Advanced Fillers sessions breakdown: CH = Cheeks/mid-face F = Forehead LF = Lower face TT = Tear troughs
54 EDUCATION I body language
training TF
TOXINS AND FILLERS
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 8 May, Bespoke Botox & Dermal Filler Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 10 May, Intro to Toxins, Wigmore Medical, London W: wigmoremedical.com 16 May, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 23 May, Combined Basic Fillers & Toxins, Honey Fizz Training, Newport W: honeyfizz.co.uk 23 May, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Birmingham W: cosmeticcourses.co.uk 2 June, Basic Botulinum Toxin A Training, Honey Fizz, Newport W: honeyfizz.co.uk 8 June, Foundation Botox & Dermal Filler Training, Cosmetic Courses, London W: cosmeticcourses.co.uk 11 June, Introduction to Fillers, Wigmore Medical, London W: wigmoremedical.com 12 June, Advanced Fillers—Tear Troughs (am) and Cheeks (pm), Wigmore Medical, London W: wigmoremedical.com 13 June, Combined Basic Training Day—Dermal fillers and Botulinum Toxin, Honey Fizz, Newport W: honeyfizz.co.uk 13 June, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 16 June, Hyperhidrosis Training, Honey Fizz Training, Newport W: honeyfizz.co.uk 19 June, Advanced Botox & Dermal Filler Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 21 June, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Leeds W: cosmeticcourses.co.uk 4 July, Combined Basic Botulinum Toxin & Dermal Filler Training, Honey Fizz, Newport W: honeyfizz.co.uk 11 July, Advanced Botulinum Toxins (am) and Advanced Fillers—Tear Troughs (pm), Wigmore Medical, London W: wigmoremedical.com 22-23 July, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 7 August, Advanced Fillers—Tear Troughs (am) and Lower Face (pm), Wigmore Medical, London W: wigmoremedical.com 15 August, Combined Botulinum Toxin and Dermal Filler Training Day, Honey Fizz, Newport W: honeyfizz.co.uk 19-20 August, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.comn
I
OTHER INJECTABLES
W: edenaesthetics.com
8 May, Platelet Rich Plasma Training, Cosmetic Courses, Leeds W: cosmeticcourses.co.uk
5 May, Botox & Dermal Filler Training Refresher, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk
10 May, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com
6 May, Agera Skincare, Eden Aesthetics, Warrington W: edenaesthetics.com
21 May, Platelet Rich Plasma Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk
14 May, Dermaroller Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk
31 May, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com
15 May, Neostrata Chemical Peels, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk
12-13 June, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com
17 May, Advanced Facial, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com
15 June, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com
18 May, Agera Skincare, Eden Aesthetics, Bristol W: edenaesthetics.com
26 June, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com
19 May, Epionce Skincare, Eden Aesthetics, Essex W: edenaesthetics.com
27 June, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 29 June, Platelet Rich Plasma Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk
19 May, Epionce Skincare, Eden Aesthetics, Winchester W: edenaesthetics.com 19 May, Epionce Training Sessions, Eden Aesthetics, Winchester W: edenaesthetics.com
2 July, Sculptra, Wigmore Medical, London W: wigmoremedical.com
19 May, Epionce Training Sessions, Eden Aesthetics, Danbury W: edenaesthetics.com
10 July, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com
19 May, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com
13 July, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com
19-20 May, ZO Medical Basic and Intermediate, Wigmore Medical, Dublin W: wigmoremedical.com
25 July, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 8 August, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com
S
SKINCARE
5 May, Micropigmentation Induction Day, Finishing Touches, West Sussex W: finishingtouchesgroup.com 5 May, Epionce Skincare, Eden Aesthetics, Essex W: edenaesthetics.com 5 May, Epionce Skincare, Eden Aesthetics, Warrington
20 May, Microdermabrasion, Eden Aesthetics, Winchester W: edenaesthetics.com 21 May, Epionce Skincare, Eden Aesthetics, London W: edenaesthetics.com 26 May, Microdermabrasion, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 26-28 May, ZO Medical Basic, Intermediate and Advanced, Wigmore Medical, London W: wigmoremedical.com
O
OTHER TRAINING
8 June, Core of Knowledge Lasers/IPL, Wigmore
Medical, London W: wigmoremedical.com 23 June, Low Level Laser Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 5 May, Micropigmentation Induction Day, Finishing Touches, West Sussex W: finishingtouchesgroup.com 11-13 May, Three Day Medical Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com 15 May, Non-surgical Facelift Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 16 May, Ultrasound for Skin Rejuvenation (32 CPD), Academy of Advanced Aesthetics, Cambridgeshire W: academyofadvancedaesthetics.com 16 May, Infrared, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 17 May, Cryotherapy Induced Lipolysis (40 CPD), Academy of Advanced Aesthetics, Cambridgeshire W: academyofadvancedaesthetics.com 18-20 May, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 18-20 May, Radio Frequency, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 18-20 May, Pressotherapy, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 28-29 May, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 30 May, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 30 May, Fat Transfer & PRP Therapy, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 31 May, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 1 June, CPR & Anaphylaxis Update (am), Wigmore Medical, London W: wigmoremedical.com Contact arabella@face-ltd.com if you would like your course featured
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body language I SKINCARE 57
Acne
prevention and treatment DR ZEIN OBAGI describes his novel approach to preventing comedogenic acne and optimising a treatment plan
A
cne is often attributed to genetics or hormonal imbalance. Contributing factors, or acne triggers, may include lifestyle choices, such as diet, sleep pattern, hygiene, sun exposure, and stress. Some forms of acne require medical treatment, oral medication and/ or clinical procedures. Recommendations for topical acne skin care should be based upon the severity of acne, presence of discolouration, age of patient, and probability of scarring with acne. Acne is a common skin disorder that arises from pilosebaceous unit dysfunction, which consists of a hair follicle and its associated sebaceous gland. Acne typically first manifests at puberty, when increasing androgen levels activate the sebaceous glands which begin producing sebum. As androgen levels continue to rise, sebaceous glands become hypertrophic, and the amount of sebum greatly increases. Sebum is a powerful inflammatory agent that leads to the more severe forms of acne and scarring when produced in excess. Sebum also disturbs the maturation of keratinocytes (dyskeratosis) by inducing epidermal inflammation. These two factors—increased sebum production and the dyskeratotic keratinocytes—cause occlusion of pores and the subsequent appearance of whiteheads. When the trapped material in the pores oxidises and turns dark, whiteheads appear as blackheads. Blackheads are commonly seen in areas with enlarged pores, such as the nose. The immune system’s response to the excessive sebum on the skin surface, together with the trapped
sebum in the hair follicle and the bacterial flora (Proprionibacterium acnes), leads to the appearance of inflammatory cystic lesions that involve the dermis and lead to acne scars. The severity of inflammation leads to the spread of acne lesions and the formation of pustules, inflammatory nodules, and the formation of more cysts. Inflammation induced by the presence of increased sebum and P. acnes leads to variable degrees of scarring and post-inflammatory hyperpigmentation (PIH) in certain patients. Over time, the chronic inflammation with its destructive effects damages skin texture, producing rolling, boxcar and ice pick scarring. Occasionally hypertrophic scars and keloids can appear in predisposed individuals with severe acne. New approach to acne My approach is based on the belief that acne is preventable. Acne is preventable only if addressed at the initial stages, when whiteheads and blackheads begin to appear, but before sebum-induced inflammation can trigger the immune response. Every effort should be made to eliminate whiteheads and blackheads in the early, non-inflammatory acne lesions stage. They can be extracted with a comedone extractor that applies equal pressure circumferentially around the comedone and causes the sebum and follicular debris to be expelled outwards. Manual picking should be avoided, as it can push the sebum and follicular debris deeper and induce inflammation and cyst formation. Use of a good acne preventive
program, consisting of cleanser, scrub, and a sebum-lowering agent, can help eliminate whiteheads and blackheads in an early stage. If, however, some inflammatory acne form cysts appear, intralesional steroid injections (triamcinolone acetonide, diluted to a concentration of 2.5 mg/cc), should be used to prevent or arrest the focal inflammation early. Moreover, P. acnes does not directly cause acne. Rather, these bacteria play a secondary role in the condition. The complete pathophysiology of acne has not yet been elucidated, and the etiology appears to be multifactorial. Focusing on bacteria does not address the pathogenesis of the condition and, in practice, leads to high rates of reoccurrence and treatment failure. In actuality, sebum and the resulting inflammation are the main problems in acne, and the control of sebum may be the key to acne prevention and treatment. Acne treatment plan Acne treatment should comprise only a portion of the broader approach that aims to restore general ZO SKIN HEALTH ACNE REGIMEN These products help control oil, exfoliate dead skin cells, unclog pores, destroy bacteria growth and prevent acne eruptions Aknetrol Acne Treatment Cebatrol Oil Control Pads Glycogent Exfoliation Accelerator Ossential Daily Power Defense Offects Exfoliating Cleanser Offects Exfoliating Polish Offects TE-Pads Acne Pore Treatment Ossential Bio-Sulfur Masque Aknebright Acne Spot and Pigment Treatment
OBAGI SKIN INSTITUTE
58 SKINCARE I body language
Acne treated with ZO Skin Health regimen
skin health. Healthy skin is less susceptible to acne. Accordingly, the treatment objective should not be to only temporarily slow down sebaceous gland activity and dry up the pimples, but to restore skin health while correcting all of the contributing factors responsible for causing acne at the same time. The patient’s initial comprehensive consultation with the healthcare practitioner or skincare professional is especially important to set ground rules for optimising the treatment regimen. It should provide the patient and the practitioner with an idea of what is going on medically and what treatment options are available. This sets the stage for the formulation of both a long—and short-term treatment strategy. As such, the first consultation should include a thorough patient history and an in-depth physical examination. If an underlying systemic hormonal abnormality is suspected as contributing to the patient’s acne, he/ she should have appropriate blood tests ordered during the visit; a consult with an endocrinologist may also be appropriate in this setting. In female teenagers, certain birth control pills can help tremen-
ACNE TREATMENT STEPS Skin preparation Cleansing—am/pm Exfoliation—am or pm Sebum reduction—am/pm Stabilisation and correction AHAs for exfoliation—am Acne specific agents—alternative AHAs with BPO Barrier repair and stabilisation—retinol, antioxidants, anti-inflammatory agents
dously to regulate hormonal factors that play a major role in their acne condition. These include medications that counteract the androgens that drive sebum production. Additionally, other agents, such as spironolactone or insulin resistance agents, can be used. The physician must also determine whether or not systemic antibiotics or isotretinoin (RoAccutane) are indicated. The healthcare practitioner must determine the acne type (comedogenic, cystic/non-scarring, or severe (cystic/scarring) and, based upon the type, inform the patient and then discuss treatment options. Patient compliance with a daily treatment regimen is essential. The topical approach to treating acne, while at the same time improving overall skin health, includes the following: skin preparation, addition of disease-specific agents (if indicated), exfoliation and stimulation of epidermal renewal, barrier repair, Stimulation of the dermis (for deep repair), hydration and calming (only if needed for skin dryness), and sun protection. It should be noted that moisturisers, heavy foundations and camouflage makeup should be avoided, even if they are labeled ‘non-comedogenic,’ as these can alter skin barrier function and increase skin irritability, which can lead to inflammation and cystic acne. Treatment should begin with appropriate topical agents; systemic agents can be added when needed. Procedures, such as exfoliative peels and photodynamic therapy (PDT), with blue or red light, can be used to assist treatment, but never as the first line of treatment. For example, if PDT is going to be used, one should start with all essential and supportive topical agents. Once acne is somewhat controlled and skin is more tolerant (for example, after at least six weeks on a topical regimen containing essential topical agents), PDT sessions can be added to the overall treatment plan to accelerate and improve results. The topical photosensitising agent applied before PDT treatment collects preferentially in sebaceous glands, and the subsequent exposure to light of the appropriate wavelength destroys those glands.
Along with the discussion and planning that occurs at a patient’s first visit, the healthcare practitioner can take certain steps to resolve some of the patient’s most pressing acne issues during that same visit. These include extracting comedones, intralesional steroid injection into inflammatory acneform nodules, and initiation of a short course of oral steroids. Furthermore, to help unclog pores and dry cystic lesions faster, healthcare practitioners should use exfoliative procedures or products, including AHAs, beta hydroxy acids (BHAs), or exfoliative chemical peels after the first maturation cycle of treatment (six weeks) has been completed. This regimen may include: ZO Medical Invisapeel Non-irritating ZO Skin Health Ossential Exfoliating Polish once daily ZO Skin Health Ossential Advanced Radical Night Repair ZO Medical 3-Step Peel New acne classification Current acne classifications (mild, recalcitrant, severe; comedogenic, cystic adult acne (conglobata, necrotica, keloidae) are merely descriptive terms that do little more than confuse physicians and patients. Instead, I have developed the following suggested classification that provides more clear objectives and frees physicians from the restrictions that conventional wisdom imposes on proper treatment. Type 1 (Comedogenic Acne) can be prevented. 3 TYPES OF ACNE Comedogenic—comedones without cysts or scars Cystic, no scars—acne with cysts but no visible scars Cystic, with scars—cystic acne with visible scars
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body language I MEDICAL AESTHETICS 61
DR LINDA EVE talks about the benefits of the micro-needling systems available and the newer techniques that have improved results for the benefit of patients
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icro-needling is a well proven method of stimulating skin to make new collagen. Treatment is delivered in a basket weave pattern to achieve maximum collagen growth in the reticular and papillary dermis. Needling doesn’t just stimulate collagen growth but also stimulates new capillary growth—or angiogenesis, which also further improves the condition of the skin. It is effective for reducing acne and chicken pox scarring and can also reduce the appearance of stretch marks. The incidence of adverse events is very low and this includes mild erythema and occasional bruising and patients can be reassured by the excellent safety profile of quality needling. Unfortunately, as with many areas of the aesthetics industry there have been a lot of derma roller copies made across the world. The cheap ones are not made from high quality smooth steel needles and can cause dermal damage or even scarring of the skin. History As early as 1957, needles were being used to lift fibrotic depressed
scarring using a technique called subcision, which breaks up the fibrous tissue underneath the scarring. In 1997 patients who received tattooing, even without injection of pigment, were noticed to have an improvement in their skin quality simply through the tattooing which in itself is a form of needling. In the year 2000 the prototype of the first dermal roller was manufactured in Germany by Horst Liebl and since then it’s become increasingly popular and user-friendly. The UK released the first CE approved Genuine Dermaroller in 2005 and by 2008 a study by Fernandes showed that at least 60% to 80% of patients were showing noticeable improvement. Method Needling causes a wound healing response without scarring. By rolling over the skin and pricking it we cause inflammation, which sets up a cascade of effects due to the release of substances growth hormones TGF-B1/B2&B3. Tissue proliferation occurs and over a period of weeks to months we get a gradual maturation and re-modelling of the skin with the laying
down of new collagen fibres. It is important to remember that microneedling is not a “quick fix treatment” and that it normally requires several treatments to gain optimum results, which can be seen from about three months and even up to one year post treatment. When we look at the face immediately after treatment there is erythema. We tend to compare it to sunburn since it goes within about 24 hours, but unlike sunburn we get significant dermal regeneration repair. With good quality dermal rollers there is no removal of the epidermis, which stays absolutely intact, and there is no thermal damage and very minimal risk of pigmentation. It is essential to assess the Fitzpatrick type before treatment as there is a slightly in-
66 The incidence of adverse effects is very low and includes mild erythema and occasional bruising 99
62 MEDICAL AESTHETICS I body language
Stretch marks Recent clinical practice has also established micro-needling as an effective treatment for stretch marks. Although we’ve seen improvements in stretch marks, my female clients tend to be more worried about their faces. However for those with bad stretch marks and the budget to treat them I think it’s certainly something worth offering as an alternative to other treatments.
Pre, immediately post and one hour post eDS treatment
creased chance of hyper-pigmentation with darker skins. Scar reduction When you look at the results of scarring, research from Professor Niwat Polnikorn in 2009 showed over 75% of improvement. That was after just two micro-needling sessions—showing just how effective it is in breaking down the scarring and building up the collagen in between the pits of the scarring. There was initially some controversy over whether you should use needling in patients with active or historical keloid scarring, but there is increasing evidence now that it is very effective in hypertrophic post burn scars and inactive keloid scarring. Improvement in lines and pigmentation are also improved with micro-needling. It’s very effective for skin laxity; fine facial lines especially unsightly rhytids above the top lip. This is a delicate area where you may not want to put a light filler if it risks over volumising the area. I explain to patients that they won’t get a quick result but will gradually see an improvement in the areas treated as the skin slowly repairs itself.
Automatic systems We’ve moved forward from manual to automated skin needling methods which has made the treatment much more comfortable for the patients. There are a number of automated devices on the market all stating that they produce good results—I use the Aestheticare eDS machine. It is CE marked, reliable, lightweight and easy to use. The hand piece is very light and has a disposable head that holds six high quality stainless steel needles. Treatments with the eDS, following topical anaesthesia for approximately 30 minutes, is really painless because the intensity, depth of needle penetration and the speed can all be altered easily whilst doing the treatment. The entry speeds are 50-150 per second, which is 38% more than manual devices. For awkward areas like around the nose, which previously required a change to the derma roller size to fit the top lip area, the machine adds ease. Using larger handheld dermal rollers in this area or trying to put one on its side is difficult and can often hurt the patient’s nose. The needle plate on the eDS also tilts which makes it easier for treating uneven scarring and deep lines. The down time following the eDS treatment is also faster with return from erythema to normal skin tone in 12-24 hours. We carried out a split-face study of the Genuine Dermaroller versus the eDS system and found quite significant improvement in patient comfort with equally good results. Results A recent survey on eDS Skin Rejuvenation in the UK gave the following results: 100% of patients found their treatment much more comfortable, 100% of practitioners
said it was more controllable and 80% found it more intensive than manual skin needling. In my clinic we offer a package of three needling sessions in order to achieve good neo-collagenesis and each treatment is spaced four to six weeks apart to gain maximum benefit. Complimentary products We use a topical HA serum called CIT solution to complement treatment. It is a 1% (10mg/ml) pure hyaluronic acid which acts as a lubricant and helps the headpiece slide smoothly over the skin whilst greatly improving dermal hydration. We then place a cooling HA rich mask on the face after the treatment for 10-20 minutes, which helps reduce erythema and provides further HA absorption. There are other topical cosmeceuticals and anti-oxidants that will also enhance the results such as topical retinols and vitamin C products. Conclusion Skin needling has been greatly improved by the introduction of automated machines. We can stimulate skin regeneration and rejuvenation, reduce acne scars and other scarring, plus improve photo-damage. With the new automated devices offering variable speed and needle depth it is now possible for all physicians to offer safe, cost effective treatments with great patient satisfaction and results. Dr Linda Eve has over 25 years experience in GP practice and has worked in aesthetic medicine for 12 years at her clinic Evenlines in Bournemouth. References 1. Orentreich D S, Orentreich N. Subcutaneous incisionless surgery for the correction of depressed scars and wrinkles. Dermatological Surgery 1995 June; 21 (6): 543-9 2. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast Surg 1997; 21:48-51. 3. Fernandes D, Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin North Am. 2006;17:51–63. 4. Polnikorn, N Percutaneous collagen induction with Dermaroller TM for Management of atrophic acne scars in 31 Thai patients. Asian J Aesthetic medicine 2009; 2(1):1- 13. 5. Safonov I. Percutaneous collagen induction in correction of post-burn scars. FACE Mag. 2011;1:34–37
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body language I PSYCHOLOGY 65
The ‘sexy sons’ hypothesis DR RAJ PERSAUD discusses research exploring why women have better sex with men other women fancy
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team of psychologists from Oakland University, in the United States, have just published new research which showed that psychologists might be able to predict what kind of man a woman is more likely to achieve an orgasm with. The research, published in the academic journal, ‘Personality and Individual Differences’, explains why men found attractive by other women are more likely to deliver better sex, and this is because the study argues that women want to have sons who are also eventually found more desirable by the opposite sex. This theory is referred to as the ‘sexy sons’ hypothesis of sexual selection (within evolutionary theory), and explains a major yet hitherto hidden factor in women’s desire for certain men, and women’s experience of sex with these men. Evolutionary psychology argues that the female orgasm may have evolved as a sexual response designed for women to retain sperm during certain sexual encounters. The two main hypotheses about the evolutionary purpose of the female orgasm is that it is designed to increase relationship satisfaction (this is referred to as the ‘‘PairBond’’ Hypothesis) or to retain preferentially the sperm of men with higher genetic quality (‘‘Sire Choice’’ Hypothesis). The achievement of an orgasm, evolutionary psychologists contend, therefore makes it more likely that an egg will be fertilised. If this hypothesis about the sire-choice role of the female orgasm is true, then natural selection would have shaped the female body (and brain) to be more likely to achieve an orgasm during sex with a more desirable man. ‘Desirable’ in this context refers to evo-
lutionary desirability, which means that men whose genes women, consciously or unconsciously, chose to pass on to their sons for the son’s future reproductive success. It makes sense, from an evolutionary standpoint, that if women want their own genes to be successfully passed on through generations that they would be motivated to produce sons who are found physically desirable by the opposite sex. The more desirable these sons are, the more likely they are to be successful in the mating game, by either having sexual access to more women and/or securing higher quality mates—thus achieving evolutionary reproductive success. This new study is entitled ‘Female copulatory orgasm and male partner’s attractiveness to his partner and other women’, and involved recruiting 439 women, each in a committed, sexual, heterosexual relationship. Intriguingly, the study excluded 32 women from the analysis, because they were unsure or could not remember whether they had an orgasm the last time they had sexual intercourse with their partner. The authors of the study, Yael Sela, Viviana Weekes-Shackelford, Todd Shackelford and Michael Pham obtained women’s assessments of the sexual attractiveness of their male partners to other women. They found that women who perceive that other women find their partner to be more attractive, are more likely to report orgasm at last sexual encounter. What is most intriguing is that while assessments of how attractive the women themselves find their partner to be—perhaps unsurprisingly, predict how likely women are to achieve an orgasm during sex with their male partner, it is how attractive the women believe other women find their partner to be that appears to be a better predictor of how likely they are to have an orgasm. In other words, it is not so much how intensely you fancy your male partner that predicts how likely you are to achieve an orgasm, but more how much you think other women fancy your male partner which seems to predict orgasm during sexual intercourse with him. This is exactly what the ‘sexy sons’ hypothesis would predict.This hypothesis claims that women find certain men more
physically desirable because they possess markers of good genes (those which build a desirable man) which, if passed on to their sons, will contribute to these sons desirability to other women. Basically, this hypothesis argues that women are motivated to retain genes that build ‘sexy fathers’ in order to have ‘sexy sons’. One problem with the study and the theory behind it is that it seems silent on a ‘sexy daughters’ hypothesis. But perhaps that is because the theory might be arguing that the female characteristics a woman passes on to her daughters, has more to do with her herself, than the man she picks, whose male features are being chosen because these are going to end up being shown more in her sons. Another problem with this kind of evolutionary psychology argument is that it seems a bit stuck in the past—that it seems to endorse the view that men are, on average, less discriminating about mating opportunities than women. However, it does fit in with another well-known finding in attractiveness research, which is that when men find a woman physically desirable, they tend to be uninfluenced by the view of other men. So, for example, whether a man finds Megan Fox fanciable or not will be based almost completely on his own reaction to her, and very little on knowledge that she is found ‘hot’ by lots of other men. On the other hand we also know from psychology research on this topic that women’s assessment of how drawn they are to a man, is much more influenced by how desirable they notice other women find that man. The theory behind this finding is that for women, the assessment of a good quality male mate is more complex, and women therefore use the assessments of other women to guide their choice. Another way of putting it is that if people are like hotels, then women need ‘Trip Advisor’, or its equivalent, before making a choice, while men are happy to settle for bed and breakfast. 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’
66 OBITUARY I body language
Dr Fredric Brandt (1949–2015) Pioneering dermatologist DR FREDERIC BRANDT, known as the ‘Baron of Botox’, and highly regarded as a cosmetologist has died aged 65
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man from humble beginnings — self-described as a Jewish kid from Newark, New Jersey where his parents owned a sweet shop, Fredric Sheldon Brandt rapidly rose to the top of the world of dermatology. Following graduating from Rutgers University in New Brunswick, New Jersey in 1971, Brandt went on to Hahnemann Medical College in Philadelphia where he earned his medical degree. He completed his residency at the University of Miami in 1981 and set up his private practice there. Dr Brandt’s love of skincare started at Sloan-Kettering where he specialised in the research and treatment of leukemia. There he dedicated his studies to using natural elements to fight against the growth of cancer. Green tea, vitamin A and vitamin C became studied treatments under Dr Brandt’s expert eye, and would be the basis of his future skincare line. Brandt opened his Miami dermatology practice in 1982 and developed an expertise in injectable substances, including most famously, Botox. Much of his work involved running clinical trials for many other dermatology treatments. He opened his New York practice in 1998 and divided time between the two cities. When the FDA declared Botox safe to use for cosmetic procedures in 2002, Brandt led a new beauty revolution. He took botulinum toxin, or ‘bo’ as he called it, essentially a deadly nerve poison and made it a household name. His exceptional work attracted many celebrity clients who alongside his poking and pumping, will remember him for treating them while singing Broadway numbers, particularly “Younger than Springtime”. The internationally known lec-
turer, sought-after physician and innovative dedicated doctor, in practice for more than 20 years, was constantly called upon to provide his expertise in research, treatment and diagnosis regarding all issues of dermatology. Beyond this contribution to his field, Dr Brandt published numerous professional papers, conducted in-depth industry-wide research programs, was a Board Certified Member of the American Board of Internal Medicine and the American Board of Dermatology, and held membership in numerous prestigious organisations such as the International Society for Dermatologic Surgery, International Society of Cosmetic Laser Surgeons, American Medical Association, American Society for Dermatologic Surgery, Dermatology Foundation Leaders Society, Florida Medical Association, among others. Led by two core principals ‘never be content with the status quo’ and, ‘drive innovation based on the needs of women and not marketing opportunity’, Brandt saw himself not only as a physician, but also as an artist. He will be remembered by his patients for helping them sculpt the younger demeanor they sought with a variety of non-invasive procedures, many of which he pioneered or perfected himself— famously on himself. Brandt had a strict work ethic work ethic and adherence to his own beauty principles. He was up at six-thirty every morning for an hour and a half of yoga, followed by ten hours in the clinic. He also wrote two well-received books: “Age-less: The Definitive Guide to Botox, Collagen, Lasers, Peels, and Other Solutions for Flawless Skin”—launched in a New York nightclub where guests were told to wear only white to match the book’s sleeve —and “10 Minutes/10 Years:
Your Definitive Guide to a Beautiful and Youthful Appearance”. Touted as the “Skincare Svengali” by vogue Brandt established the Dermatology Research Institute, which currently has more than 200 patients involved in clinical studies of muscle relaxants and dermal fillers and is now one of the USA’s top resources for conducting clinical research studies and FDA trials for the cosmetic dermatology industry. Brandt, who never married, lived alone in his Miami home with the curtains permanently drawn to prevent sun damage to his artworks including pieces by Richard Prince and Damien Hirst. He leaves behind in Miami three adopted stray dogs and in New York his collection of modern art. The American Society for Dermatologic Surgery have set up two memorial funds in honour of Dr Brandt: The Fredric S Brandt, MD, Innovations in Aesthetics Fellowship Fund and the Fredric S Brandt, MD, Memorial Research Fund. If you wish to donate to these funds honouring Dr Brandt’s life and legacy, contact Tara Azzano at tazzano@asds.net
Brandt saw himself not only as a physician, but also as an artist. He will be remembered by his patients for helping them sculpt the younger demeanor they sought
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Now approved for crow’s feet lines
Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, dry eye. General disorders and administration site conditions; Common: injection site haemotoma.
Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1182/BOC/OCT/2014/LD Date of preparation: October 2014
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Botulinum toxin type A free from complexing proteins