Body Language Journal #74 by Body Language Journal

september

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

INJECTABLES COSMETIC INJECTABLE SPECIAL FOCUS: PREPARATION, TECHNIQUE, PRODUCTS & DEVELOPMENTS

TECHNIQUE

THE “HAPPY FACE”

PRE-TREATMENT

How using controlled trauma can enhance long term injectable results

Method for treating commissure and marionette lines and understanding anatomy

Tips to prepare the skin for cosmetic injectable treatments

novacutis

body language I CONTENTS 3

contents 07 NEWS

37 INJECTABLES

OBSERVATIONS

EXCITING SKIN

Reports and comments

Dr Askari Townshend talks about tissue stimulators

14 DERMATOLOGY PREPARING THE SKIN FOR INJECTABLE TREATMENTS

43 TECHNIQUE

Prof Beth Briden explains why there’s a lot more to preparing for aesthetic injections than an alcohol swab

Ms Leslie Fletcher explains a new technique in which controlled trauma stimulates new collagen

22 TECHNIQUE

ENHANCED HEALING POST TATTOO REMOVAL

THE “HAPPY FACE” TECHNIQUE Dr Frank Rosengaus explains his method for treating commissure and marionette lines and the importance of understanding facial anatomy

27 INNOVATION DEVELOPMENTS IN SAFER COLLAGEN Mr Chris Inglefield talks about bio-dermal restoration using advanced collagen

30 EQUIPMENT THE FUTURE OF RESURFACING Dr Ines Verner considers the evolution and revolution in our resurfacing technologies and techniques and where we stand in 2015

CONTROLLED TRAUMA

49 LASER Dr Raminder Saluja shares her experience using PicoSure’s Focus lens for rejuvenation after using PicoSure for tattoo removal

52 PRODUCTS ON THE MARKET The latest medical aesthetic products and services

55 PANEL FUTURE TREATMENT TRENDS Dr Vincent Wong, Dr Frank Rosengaus and Mr Taimur Shoaib discuss their personal experience with Aqualyx and Kybella

58 EDUCATION TRAINING A comprehensive course calendar

4 CONTENTS I body language

editorial panel Dr Jean Carruthers MD, FRCSC, FRC is clinical professor in the department of ophthalmology and visual sciences at the University of British Columbia in Vancouver. With her husband, Dr Alastair Carruthers, she has received the Kligman award from ASCDAS . Mr Ravi Jandhyala is a member of the Royal College of Surgeons of Glasgow, and a founding member of the UKBTGA. He is also a member of the Faculty of Pharmaceutical Medicine and is an expert in the science behind botulinum toxins for aesthetics.

Professor Syed Haq trained at Harvard Medical School, Massachusetts General Hospital and Tufts University, New England Medical Center. Professor Haq is Director of The London Preventative Medicine Centre, Harley Street.

Professor Andy Pickett has worked on botulinum toxins for over 23 years. Andy has lectured around the world on the products, translating the science into practical understanding for injectors. In 2011 Andy founded Toxin Science Ltd and is head of development at Q-Med.

Anthony Erian FRCS (Erg) FRCS (Ed) is an aesthetic plastic surgeon with more than 30 years’ experience. He is a member of the American Academy of Aesthetic and Restorative Surgery and chairman of the European Academy of Aesthetic Surgery.

Dr Stephen Bassett is medical director of the Aesthetic Training Academy and ShapeCYMRU Cosmetics. He is a Syneron luminary and member of the Merz academy. He is a barrister, fellow of the Society of Advanced Legal Studies and a legal consultant.

Elizabeth Raymond Brown, Phd, CRadP, MSRP authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies. She is now director of education at LCS Academy Ltd.

Dr Séan Cummings MBBS T(GP), DRCOG, DFFP, MRCGP, LLM is a cosmetic doctor practising in Harley Street. Dr Cummings has more than 20 years’ experience as a practitioner and has a masters degree in medical law. Dr Cummings works as an expert witness.

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

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.

EDITOR Helen Unsworth 020 7514 5989 helen@face-ltd.com ASSISTANT EDITOR Lousie Renwick 020 7514 5989 louise@face-ltd.com COMMISSIONING EDITOR David Hicks 020 7514 5989 david@face-ltd.com EDITORIAL ASSISTANT Arabella Tanyel 020 7514 5989 arabella@face-ltd.com SALES EXECUTIVE Monty Serutla 020 7514 5976 monty@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com

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.

CONTRIBUTORS Prof Beth Briden, Dr Frank Rosengaus, Mr Chris Inglefield, Dr Ines Verner, Dr Askari Townshend, Ms Leslie Fletcher, Dr Raminder Saluja, Dr Vincent Wong, Dr Frank Rosengaus, Mr Taimur Shoaib

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.

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

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BENEFITS FOR YOU High Patient Comfort - Emervel lips is very well tolerated by patients with mild to moderate swelling, with a mean severity rating of 0.8 on a scale of 0 (none) to 3 (severe).1 Long-lasting – Emervel’s Optimal Balance Technology ensures persisitance in the tissue resulting in long-lasting improved lip fullness when injecting with Emervel Lips.1 High Injection Comfort – Easy to inject2; the Ultra Thin Wall needle technology allows a very precise and well controlled injection using a 30G needle, as well as maximised patient comfort with the inclusion of lidocaine in every syringe.

Excellent tolerability and patient comfort Clinical studies with Emervel Lips demonstrates excellent tolerability. Mean ratings (injectors) Swelling

0.8

Bruising

0.2

Pain/Tenderness

0.2

All injection site reactions were assessed using a 4-point severity scale (0=none, 3=severe)1

Long-lasting improvement Emervel Lips is clinically proven to maintain longlasting improved lip fullness. 1.1

Mean improvement in LFGS

1.2

I’ve got the confidence to share the real me

HAPPY PATIENTS 86% of Emervel Lips patients want to be injected with the same product again1 The long-lasting, natural looking results with Emervel Lips provides high patient satisfaction with 83% of patients satisied/very satisied with the aesthetic outcome1 and 86% wanting to be retreated with the same product again1, to be ever ready for their close up. Emervel Lips is available from Wigmore, Med-Fx, Church Pharmacy as well as direct from Galderma. Contact your preferred distributor or your local rep for more information today.

1 0.8

0.8

Emervel Lips

0.4

72.

of lip fullness is maintained 6 months after treatment (measured with LFGS)

0 0

“I’M READY FOR MY CLOSE UP”

Week

Fig 6. Mean change in LFGS from baseline after 6 months according to 3-D measurements. Adapted from Cartier H et al. 2012.7 Subjects presented with a score of 0 (very thin) to 2 (moderately thick) on the Lip Fullness Grading Scale (LFGS )

References: 1. Cartier H et al. J Drugs Dermatol 2012;11(1 Suppl):s17–26 2. Segura S et al. J Drugs Dermatol 2012;11(1 Suppl):s5–8

EME/011/0513 Date of Prep: June 2013

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body language I NEWS 7

observations

RADICAL BIOLOGICAL AGEING DIFFERENCES Scientists have confirmed that despite our numerical age, we all age biologically at dramatically different rates Most research into human ageing looks at older adults, many with chronic disease, meaning little is known about how we age in our younger years. A New Zealand based study which measured biological ageing in young adults has found that the pace of ageing can be used to identify causes of ageing and evaluate rejuvenation therapies. A major study published in Proceedings of the National Academy of Sciences tracked the health and broader lives of around 1000 New Zealanders born in 1972 or 1973 in the town of Dunedin over 12 years. Researchers identified 18 biological markers of biological age, including kidney and liver function, immune function, periodontal, cholesterol levels, cardiovascular fitness and the lengths of teleomeres. The markers were then measured at three age intervals:

26, 32, and 38. The changes in these markers over time were ten compared to produce a “pace of ageing” figure—ie. a 38-year-old with a biological age of 40, has a “pace of ageing” of 1.2 years per year over the 12 year study. Biological ages of the 38-yearolds were found to vary dramatically from 28 to 61 as organ integrity was compared and obvious differences were found in the effect that the past dozen years had had on different bodies. “Even before they develop age-related diseases, their physiology shows signs, and there is great variation in how fast people aged in the past 12 years,” researcher Daniel Belsky said. The study revealed that already, before midlife, individuals who were ageing more rapidly were less physically able, showed

cognitive decline and brain ageing, self-reported worse health, and looked older. Using photographs of participants to compare how old people looked the researchers found that the images of the participants who were biologically older people were consistently rated as looking older than age 38, despite being the same age. The researchers hope that measured biological ageing in young adults can be used to identify causes of ageing and used a way to evaluate the effectiveness of rejuvenation therapies. The next step is to delve deeper into lives of the Dunedin participants to see how factors such as lifestyle, medical history, family circumstances, and stressful events might affect the speed at which people age. The researchers have called the study a “proof of concept” for using biological markers to measure the ageing process in people who are too young to have age-related diseases. An objective measure of biological age, could be used to assess whether new anti-ageing therapies work or not in a reasonable time frame. “What we need are measurements that can show whether these therapies are working, so we don’t have to wait 50 years to see if someone is still alive or not. We want a real-time barometer of how a person is doing, and whether the therapy is really changing their rate of ageing,” Belsky said. The ultimate goal is to target ageing instead of the multiple separate diseases that people are increasingly likely to develop as they age. “As we get older, our risk grows for all kinds of different diseases. To prevent multiple diseases simultaneously, ageing itself has to be the target.”

8 NEWS I body language

SUN DAMAGE TO DNA ILLUMINATED DNA damage to skin across full range of UV sun radiation documented for the first time. Scientists at Newcastle University have detailed the DNA damage that can occur to skin across the full range of ultraviolet radiation—providing an invaluable tool for sunprotection and sunscreen manufacturers. Testing on human skin cell lines, the study, published in The Journal of Investigative Dermatology, documents the action spectrum of ultraviolet damage in cells from both the dermis and epidermis. This information provides the manufacturers of sunscreen an invaluable tool developing and testing products so that they can provide protection to both layers. Constant exposure to sunlight UVA and UVB rays from the sun penetrates cells and increases the number of damaging free radicals, especially the reactive oxygen spe-

cies—too many of which can damage the DNA within our cells. Over time, this can lead to damage to cell mitochondria and speed up ageing by destroying the skin’s supportive fibres, collagen and elastin, leading to wrinkles. Studies strongly suggest the damage caused by reactive oxygen species may also initiate and exacerbate the development of skin cancers. Mark Birch-Machin, Professor of Molecular Dermatology at Newcastle University said: “Because we were able to analyse the full spectrum of UVA and UVB induced sunburnt DNA damage in the batteries of human skin cells this is an invaluable tool for the cosmetic and pharmaceutical industries and for anti-ageing studies.”

events 3-6 SEPTEMBER, 5CC: Laser and Aesthetic Medicine (Five Continent Congress), Cannes, France W: 5-cc.com 4-6 SEPTEMBER, Controversies, Art & Technology in Facial Aesthetic Surgery, Gent, Belgium W: coupureseminars.com 9-12 SEPTEMBER, Annual Meeting of the European Society for Dermatological Research (ESDR), Rotterdam, Netherlands W: esdr.org 18-19 SEPTEMBER, 8th Mediterranean Congress of Aesthetic Surgery - Focus on the Face Lift and the Face AntiAging, Montpellier, France W: isaps.org 18-19 SEPTEMBER, AMWC Eastern Europe 2015, Moscow, Russia W: euromedicom.com/amwc-easterneurope-2015/index.html 25-26 SEPTEMBER, Face 2 f@ce 2015 & Annual Meeting of the European Academy of Facial Plastic Surgery (EAFPS), Cannes, France W: face2facecongress.com 7-11 OCTOBER, Annual Congress of the European Academy of Dermatology and Venereology (EADV), Copenhagen, Denmark W: eadv.org 8 OCTOBER, 4th National Aesthetic Nursing Conference, Olympia, London W: aestheticnursingconference.co.uk 15-18 OCTOBER, Annual Meeting of the American Society for Dermatologic Surgery (ASDS), Chicago, Illinois, USA W: asds.net 16-20 OCTOBER, Plastic surgery 2015 The meeting of the American Society of Plastic Surgery (ASPS), Boston, USA W: plasticsurgery.org 22-25 OCTOBER, Annual Conference of the Australasian Society of Aesthetic Plastic Surgery (ASAPS), Sydney, Australia W: asapsevents.org 23-24 OCTOBER, 3rd Anti-aging Medicine European Congress, Paris, France W: euromedicom.com 4-8 NOVEMBER, 4th Annual DASIL Congress, Ho Chi Minh City, Vietnam W: thedasil.org

NEW ECZEMA TREATMENT Redness and itching reduced with arthritis drug An arthritis drug, which created a dramatic improvement in eczema in research could transform the standard care for the skin condition, a group reports in the Journal of the American Academy of Dermatology. Six people, whose moderate to severe eczema had not responded to conventional treatments and were given the rheumatoid arthritis drug tofacitinib citrate and reported a significant reduction in itch. Redness and thickening decreased in all patients’ skin,

alongside improvements in sleep. “These individuals were not only very happy with the results, they also expressed a tremendous sense of relief at being comfortable in their skin for the first time in many years,” explains Dr Brett King, senior author. “Eczema affects millions of children and adults in the United States. I’m hopeful we are entering a whole new era in treatment.” A larger study is needed to confirm safety and long-term effectiveness of the treatment.

5-8 NOVEMBER, World Congress of the International Academy of Cosmetic Dermatology (IACD), Singapore W: wcocd2015.com 12-15 NOVEMBER, World Congress of Aesthetic Medicine (WCAM), Miami, Florida, USA W: aaamed.org 14-18 NOVEMBER, World Congress of the International Academy of Cosmetic Dermatology (IACD), Rio de Janeiro, Brazil W: iacdrio2014.com.br 16-19 NOVEMBER, MEDICA, Dusseldorf, Germany W: medicamatch.com/en Send events for consideration to arabella@face-ltd.com

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body language I NEWS 11

second brief

POPULAR PROCEDURES

Over 20 million cosmetic surgical and non-surgical procedures were performed worldwide in 2014, according to the latest statistics from the International Society of Aesthetic Plastic Surgery (ISAPS). Botulinum toxin remains the most popular cosmetic procedure overall for both men and women. Breast augmentation is the most popular surgical procedure among women, while eyelid surgery is the most popular surgical procedure among men.

Leading cosmetic surgical procedures performed in 2014 Eyelid surgery 1,427,451 Liposuction 1,372,901 Breast augmentation 1,348,197 Fat grafting 965,727 Rhinoplasty 849,445

Leading non-surgical procedures performed in 2014 Botulinum toxin 4,830,911 Hyaluronic acid 2,690,633 Hair removal 1,277,581 Chemical peel 493,043 Laser skin resurfacing 480,271 Source: International Society of Aesthetic Plastic Surgery (ISAPS)

AN EFFECTIVE SHOCK TO THE SYSTEM Pulsed electric fields found to rejuvenate epidermal function and appearance A team at Tel Aviv University led by Dr Alexander Golberg of TAU’s Porter School of Environmental Studies and Harvard Medical School researchers has devised a non-invasive technique that harnesses pulsed electric fields to generate new skin tissue growth. According to their research, the novel non-invasive tissue stimulation technique, utilising microsecond-pulsed, high-voltage, non-thermal electric fields, produces scar-less skin rejuvenation and may revolutionise the treatment of degenerative skin diseases. “Pulsed electrical field technology has many advantages, which have already proved effective—for example, in food preservation, tumor removal, and wound disinfection,” said Dr Golberg. “Our new application may jumpstart the secretion of new collagen and capillaries in problematic skin areas. Considering that, in the modern era of aging populations and climate change, degenerative skin diseases affect one in three adults over the age of 60, this has the potential to be an healthcare gamechanger.” Current rejuvenation techniques tend to use various physical and chemical methods to affect cells and the extracellular matrix, but have the side effect of unsightly scarring. A pulsed electric field is different in that it affects only the cell membrane itself, preserving the extracellular matrix architecture and releasing multiple growth factors to spark new cell and tissue growth. By inducing nanoscale defects on the cell membranes, electric fields cause the death of a small number of cells in affected areas. The released growth factors increase the metabolism of the remaining cells, generating new tissue. “We have identified in rats the specific pulsed electric field parameters that lead to prominent proliferation of the epidermis, formation of microvasculature, and secretion of new collagen at treated areas without scarring,” said Dr Golberg. “Our results suggest that pulsed electric fields can improve skin function and potentially serve as a novel non-invasive skin therapy for multiple degenerative skin diseases.” The research team are currently developing a low-cost device for use in clinical trials, which will test the safety and efficacy of the technology in humans.

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body language I NEWS 13

PROTEIN-BASED GEL CREATED THAT MIMICS TISSUE A new hydrogel can mimic many of the properties of skin and blood vessels

FACIAL TREATMENT PREFERENCES Survey finds younger women more likely to seek treatment for upper face, while older women prioritise lower face Research published in Dermatologic Surgery, the official journal of the American Society of Dermatologic Surgery, revealed that while younger women seek aesthetic treatments to retain a youthful appearance, older women lean towards treatments to reverse the signs of ageing—such as facial lines, folds and loss of volume. A total of 603 women between the ages of 30 and 65 years old considering aesthetic treatments participated in an online research survey using Maximum Difference scaling. This revealed that crow’s feet are most likely to be treated first (82% of the first preferences), followed by the junction of the upper and lower lips (74%) and tear troughs (72%) A strong correlation was observed between facial areas creating the most concern and the likelihood that they received a high treatment preference. One exception was the tear trough, which was identified as a similar degree of concern to crow’s feet lines but was less likely to be selected for aesthetic treatment. Of the survey participants, 82% were married or living as a couple, “perhaps suggesting that women did not undergo treatment to attract a partner but rather to achieve their personal beauty goals or to retain their current partner,” according to the authors. The authors of “Facial Treatment Preferences in Aesthetically Aware Women” view their work as the first research study examining the preferences of women with the means to pursue treatments, arguing that “although individual physicians may have general perceptions of patient treatment preferences in their practices, there are no systematic data available that describe either the specific concerns that prompt women to seek treatments or their preferences for facial areas requiring treatment.”

A new protein-based gel, that when exposed to light mimics many of the properties of elastic tissue, such as skin and blood vessels has been developed at Brigham and Women’s Hospital (BWH). A paper published in Advanced Functional Materials reports on key properties of the new material—many of which can be finely tuned, plus results of using the material in preclinical models of wound healing. “We are very interested in engineering strong, elastic materials from proteins because so many of the tissues within the human body are elastic. If we want to use biomaterials to regenerate those tissues, we need elasticity and flexibility,” said Annabi, a co-senior author of the study. “Our hydrogel is very flexible, made from a biocompatible polypeptide and can be activated using light.” “Hydrogels—jelly-like materials that can mimic the properties of human tissue—are widely used in biomedicine, but currently available materials have limitations. Some synthetic gels degrade into toxic chemicals over time, and some natural gels are not strong enough to withstand the flow of arterial blood through them,” said Khademhosseini another researcher. The new material, known as a photocrosslinkable elastinlike polypeptide-based (ELP) hydrogel, offers several benefits. This elastic hydrogel is formed by using a light-activated polypeptide. When exposed to light, strong bonds form between the molecules of the gel, providing mechanical stability without the need for any chemical modifiers to be added to the material. Research shows that ELP hydrogel can be digested over time by naturally-occurring enzymes and the effect on living cells does

not seem to be toxic. It was also found that it was possible to control the materials strength and how much it swelled—indeed the ELP hydrogel could withstand more stretching than experienced by arterial tissue in the body. “Our hydrogel has many applications: it could be used as a scaffold to grow cells or it can be incorporated with cells in a dish and then injected to stimulate tissue growth,” said Annabi. “In addition, the material can be used as a sealant, sticking to the tissue at the site of injury and creating a barrier over a wound.” It was also discovered that the gel could be combined with silica nanoparticles to develop an even more powerful barrier to promote wound healing. “This could allow us to immediately stop bleeding with one treatment,” said Annabi. “We see great potential for use in the clinic. Our method is simple, the material is biocompatible, and we hope to see it solve clinical problems in the future.” Further investigation in preclinical models will be needed to test the material’s properties and safety before approval for use in humans.

14 DERMATOLOGY I body language

Preparing the skin for injectable treatments PROF BETH BRIDEN explains why there’s a lot more to preparing for aesthetic injections than an alcohol swab

roper skin preparation not only enhances the outcome of a treatment and minimises the complications, it helps to prolong the effects of the treatment, meaning a much happier patient. Injectables are among the most popular anti-ageing procedures.

The American Society of Plastic Surgeons report for 2014 showed a marked increase in injectable procedures, particularly toxins and fillers—up 6% and 3% respectively—with the total number reaching almost nine million procedures. Injections give immediate results, they’re minimally invasive, they have minimal risks of compli-

cations, and they are cost effective for the patient—no wonder they are so popular. With anything so popular, it’s vital that we know how to administer the injectables to get the best possible results; and since the effects aren’t permanent, it is the overall effect of the injectable along with the technique that keep patients coming back.

body language I DERMATOLOGY 15

Why prepare the skin? Using a little alcohol pad before inserting a needle really isn’t adequate preparation for an aesthetic injection. The most popular injectable procedures, such as toxins, fillers, lipodissolver, even liposuction and surgical procedures, such as the cosmetic surgery and non-ablative or tightening lasers, really don’t have any effect on the skin surface.

So no matter how well wrinkles, nasal labial folds and jowls are filled, if there is still dispigmentation and sallowness a rejuvenation effect won’t be apparent. Whether injecting a neurotoxin into the muscular layer, placing fillers in the dermal layer, or fat dissolvers into the fat layer, there is no effect on the epidermal layer. It’s this epidermal layer which is like the skin’s palette, so effect won’t

be as great if that isn’t addressed. Significant improvements in skin rejuvenation can be achieved with injectables. Virtually all wrinkles can be filled in and volume redistributed, but still there are limitations, which require adding additional procedures. Proper skin preparation can provide epidermal improvements that aren’t provided with injectable treatments. Skin can be smoothed, pigmentation

16 DERMATOLOGY I body language

How does Visia work? The Visia’s computerised analysis provides a numerical value or score for the fine lines and wrinkles, brown spots, and facial redness for each patient along with a print out of their photos and scores. I go over the print out with the patient to show the different areas that we can correct with various treatments, and then outline a plan. The rejuvenation plan can require multiple procedures and often, you can’t perform everything in one day. Also, they may not be able to afford everything right at once. We usually give options on how to start, with their skincare, the chemical peels, and move to the injectables, and if they need more, then the laser resurfacing. Thus, we have a comprehensive plan and then bundle the different procedures together. It works very well, but then you’ve got to make sure you actually provide significant improvements because the patients have their photos and their computer analysis with a numerical value so they can see their improvements.

evened, pore size reduced, and barrier function improved, so that the skin is more tolerant and less irritable and has a good, healthy glow. The risks of complications such as bruising and infections can also be reduced with proper skin preparation, and augment and even help maintain the effect of injectables. Step by step skin prep 1. The first step of skin preparation is to take a good medical history, and from this introduce patients to a good skincare regimen, because good, science based therapeutic skincare can greatly improve the epidermis and dermal matrix and

maintain the effects of injectables. Once they are on a good skin care regimen, additional procedures can be performed to deliver surface change, such as a superficial chemical peel, microdermabrasion, or perhaps lasers. IPL can be used on pigmentation in light skinned individuals and fractional lasering for large numbers of wrinkles that can’t be filled. Also, specific treatments can be used to help minimise bruising that can occur with injectables, such as applying topical arnica cream, recommending pineapple consumption for the bromelain effect, stopping use of any blood thinners, and sometimes even vitamin K, although that is not approved in the EU. In the medical history and consultation ensure that the patient does not have any allergies to substances that could be present in the injectable. Look at their medications carefully, have them stop any of the blood thinners, aspirin, fish oil, vitamin E, NSAIDs, if it’s medically appropriate in attempts to minimise bruising. Find out if clients are on any immunosuppressive agents, which could make them more prone to infections. Sometimes with injectables, biofilms can develop leading to chronic infections, and immunosuppression can make infections more likely to occur. Thus, you need to be extra careful in your skin prep to ensure a sterile procedure. Chemotherapy agents can also impede healing and increase the risk of infection. Nutritive supplements and vitamins should not be forgotten. Vitamin E and fish oil can make the patient more prone to bruising and you want to make them aware of that. Also, take a good history for any systemic diseases. Ensure they don’t have myasthenia gravis if you’re going to be injecting a neurotoxin, or collagen vascular disease, if you’re going to be doing the dermal fillers. If they have a history of cold sores or herpes simplex, you should premedicate with acyclovir, just to make sure that the trauma of the injection doesn’t precipitate an outbreak. Other important questions to

ask in the history include if they smoke and their sun exposure. Smoking impedes healing and could impede the vasculature, so smokers could be more likely to have vascular occlusion with an injectable treatment. Always ask about levels of sun exposure, but most importantly their expectations—because you’ve got to have realistic expectations and try to fulfil what the patient wants, to get the best results. 2. After taking an initial history, take series of photos and perform a consultation so you have a baseline to discuss what the patient would like to see improved and what improvements you can provide. Show your patient what they can expect to see improved on the photo to ensure realistic expectations of the treatment. I use a photography system called Visia which takes standardised photographs along with a computerised analysis comparing the patient’s scores to others their age. In terms of managing expectations, you just can’t assume what you think needs to be corrected is what the patient wants corrected. Some people like their moles, or a particular mark or spot, or they want to keep their crow’s feet, so you want to make sure that you know their expectations. What’s obvious to you may not be what the patient wants. 3. Outline their plan and create a timeline of procedures—because often it’s unwise to combine multiple procedures on the same day. Certain procedures can cause swelling of the dermis, for example tissue tightening lasers can cause marked dermal oedema, which may cause some of the neurotoxin to migrate and cause adverse reactions. With the IPL and perhaps a

66 Outline the plan and create a timeline for procedures because it is often unwise to combine multiple procedures on the same day 99

body language I DERMATOLOGY 17

66 The first step of skin preparation is to take a good medical history 99 filler, if there is redness or irritation you might not be sure what it’s from, so I recommend minimising any risks of complications by doing those treatments perhaps a week apart, or at least a day apart.

Resurfacing the skin is my starting point—helping to remove the excess dead stratum corneum, increase moisturisation, enhance cell turnover and disperse the pigmentation

Why bother with skincare? Creating a good skincare regimen is a simple thing for the patient to do and skincare products can provide a very uniform skin surface if they enhance cell turnover and disperse pigmentation to even out the skin tone. They can improve barrier function and reduce inflammation, and also help minimise the risks of bruising by plumping the epidermis from an atrophic skin to a nice, plump, firm skin. They can also help prevent and reverse signs of photo ageing. Using a sunscreen with some of the active ingredients will also help protect

from further photo-induced ageing changes. With scientifically tested and proven skincare products we can achieve nice rejuvenating results—enhancing cell turnover and stimulating new skin in the epidermis and the dermal compartments. A recent study by Mintel showed that 94% of consumers are using some type of skincare regimen, so it’s our job as physicians and skincare experts to try to direct them to the best products to help reverse their ageing or address their concerns, and there are some decent products out there that can help. Number one on my skincare regimen list is a sunscreen to help prevent hyperpigmentation from additional sun and prevent further photo ageing. For stimulating new skin growth and repair and for moisturisation, I prefer the alpha poly and bionic acids as they can be used by everyone. I will also add a retinoid if the skin is not too irritated, or barrier function is not compromised. There are some very effective dermal plumping agents, and

antioxidants that can help decrease inflammation and the MMPs that degrade the collagen and elastic fibres, helping to prolong the life of the treatment. Adding a pigmentlightening agent can also reduce the risk of post inflammatory pigmentation. The trauma from injections has been shown to help stimulate some new skin growth and repair, so we want to try to help enhance the growth by providing some of the substrates to enhance the skin repair. Where to start Resurfacing the skin is my starting point—helping to remove the excess dead stratum corneum, increase moisturisation, enhance cell turnover and disperse the pigmentation. Good skin care products for this are the alpha, poly and bionic acids, and a non-acid N-acetylglucosamine. Retinoids are also very effective, if the patient can tolerate these and not be too irritated. Chemical peels, microdermabrasion and fractional resurfacing are also other good treatments to help with this.

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body language I DERMATOLOGY 19

Several compounds have been shown to really help improve barrier function. There has been a big buzz in the past couple of years about the need to improve the skin barrier. The alpha, poly and bionic acids have been shown to improve the barrier function for over 20 years. Thus, the AHAs, PHAs and bionic acids are my mainstay for resurfacing and improving the barrier function. Barrier function In a 1997 study from the British Journal of Dermatology, Dr Berardesca measured transepidermal water loss as a measure of epidermal barrier function. In this study he took areas of the skin where he applied four different alpha hydroxy acids, glycolic acid, lactic acid, tartaric acid and gluconolactone, a second-generation polyhydroxy acid. There was an untreated site and a vehicle control site. Dr Berardesca treated these areas twice daily for four weeks and then applied sodium lauryl sulphate—a known irritant that disrupts the barrier, under occlusion for six hours. After removing that, transepidermal water loss was measured and all of the alpha and the polyhydroxy acid had improved barrier function. When colourimetry for the erythema and the transepidermal water loss was measured, compared to the non-treated and vehicle site there was no redness. The study showed the alpha, poly and bionic acids, can all improve the barrier function and sun damage, making a normal basketweave stratum corneum that becomes thinned out and more normal. They can also enhance epidermal proliferation and normalisation with a return of the rete ridges from the atrophic flattened epidermis. Thickening that gives us a little bit more play to apply our dermal fillers down in the dermis without having them show through with the Tyndall effect, and that will also help reduce some of the solar elastosis. Matrix building The dermal matrix of the skin is important in providing plumpness and firmness to the skin. Ingredi-

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ents available in skincare that build the skin’s matrix include: Aminofil, NeoGlucosamine, the polyhydroxy acids, multibionic and lactobionic, and some of the matrixyl peptides. The dermal matrix is comprised of acid mucopolysaccharides such as hyaluronic acid that bathe the collagen and elastic fibres. Aminofil Aminofil is a new product that has been on the market as a targeted treatment for over a year and recently introduced for use all over the skin instead of a targeted product for deep lines. Aminofil is an acetylated amino acid derivative of tyrosine, called N-acetyl Tyrosinamide. This has been shown to have marked plumping ability and to generate increased production of glycosaminoglycans, especially hyaluronic acid in the dermal layer. It increases the hyaluronic acid synthesis in fibroblasts and cell culture, also collagen expression of those fibroblasts, and it’s nonirritating and non-stinging. Clinical studies presented at the 2012 AAD meeting showed that the application of Aminofil twice daily for eight weeks, created an almost a four to fivefold increase in skin thickness just after 12 weeks. It has almost an immediate effect, plumping the skin dramatically, so this will help augment and maintain the effects of later treatments. NeoGlucosamine NeoGlucosamine is a novel agent that has multiple benefits. It is a natural component of our hyaluronic acid. If you combine NeoGlucosamine with the polyhydroxy acid DGlucoronic acid or gluconolactone, you have hyaluronic acid.

Hyaluronic acid in itself has not been able to penetrate through the epidermis to reach the dermal compartment where it’s needed, whereas the N-acetylglucosamine has been shown to penetrate through that epidermal barrier to place itself in the dermis where it’s needed. So it binds the water, helps plump the skin. It will help increase the formation and the volume and firmness of the skin. NeoGlucosamine also has some benefits from being a non-acid exfoliator, meaning it can be combined with retinols. Retinols, in formulation, cannot be in an acidic base, or they degrade and they lose their bioactivity. This product that can be combined with retinols or Retin-A and create a synergistic effect in terms of plumping the dermal glycosaminoglycans and collagen formation. It also inhibits the enzyme tyrosinase, so creates a pigment lightening effect by causing exfoliation, and by inhibiting new pigment production. Clinical studies show that there is a marked lightening and uniformisation of the pigment in the skin.

1&2: Aminofil Use test, periocular lines before and at eight weeks. It shows the reduction in fine lines and wrinkles. Even after neurotoxins, when a little crease remains, using these products will help eliminate and minimise those fine lines and wrinkles that we can’t really get to with the injectables. 3&4: Aminofil use test, glabellar lines before and at eight weeks. This shows how the forehead lines, the horizontal lines, and the crow’s feet have improved at just six weeks. This study was done by Dr Joel Schlessinger, showing that it even helped improve some of the fine lip lines and make them resolve faster, in addition to the injectables.

NeoGlucosamine  A natural component of human glycosaminoglycans (GAGs), glycolipids and membrane glycoproteins.  Hyaluronic acid = N-acetylglucosamine + D glucuronic acid (a PHA).  Binds water (1000 times its weight); used for cell migration/communication; skin plumping effects.  Amount of skin diminishes with age; increases with AHA, retinoid use.  NAG is a building block of hyaluronic acid.  A study to measure skin thickness after using NeoGlucosamine 8% twice daily for 12 weeks, showed results of a fivefold increase in the NeoGlucosamine treated site compared with the untreated site.

20 DERMATOLOGY I body language

1&2: Neurotoxin was used for the forehead and the glabellar, then lipodissolver under the chin and the jowls and then a little bit of filler in the nasal labial folds.3&4: Combination Rx— plasma resurfacing, lipodissolve, toxins and fillers.

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Third generation AHAs Another matrix building ingredient is poly and bionic acids, multibionic and lactobionic acid. These are the third generation alpha hydroxy acids, which apply many benefits to the skin. They’re very strong humectants to hydrate the skin. They’re very potent antioxidants to help prevent the breakdown of MMPs, matrix metalloproteinase, and also lipid peroxidase and heavy metal chelation—so they help preserve the skin. They have also been shown to help prevent ultraviolet induced pigmentation, and are very good anti-ageing ingredients. They will increase the plumpness of the epidermis and the dermal compartment by increasing collagen, hyaluronic acid and in new elastic tissue formation and are also very non-irritating. Multibionic acid is derived from corn sugar. Lactobionic acid

DR HELEN TOROK

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DR HELEN TOROK

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can be combined with retinol and alpha hydroxy acid to get a synergistic effect. They also help increase fibronectin and collagen to again give structural firmness to the dermal compartment. Necks are another area that we need to address, sometimes, with neurotoxins, and certainly fat dissolvers; there’s citric acid cream that has shown a very nice improvement in tightening and plumping the skin. Plus citric acid has been shown to increase collagen production and the glycosaminoglycans, so I like to use this in conjunction with the lipodissolver, the newer fat dissolvers.

is a natural component of the body. It’s used in organ perfusion baths because it is such a potent antioxidant and humectant. A study done at the AAD in Chicago, which showed the effects in studies on the multibionic and lactobionic acid over twelve weeks showed their plumping ability. Twice-daily application of multibionic acid, showing a marked 50% increase in thickness of the skin. The multibionic acid and lactobionic acid in a second generation alpha hydroxy gluconolactone has been shown to inhibit MMPs to inhibit the breakdown. A good skincare regimen will help prevent the breakdown with the use of collagenase and the hyaluronidase to help preserve that dermal matrix and the plumpness and firmness of our injectables. Matrix peptides these help improve collagen formation. They

Pre-injection In addition to your little alcohol pads I would strongly recommend using a surgical scrub and using a sterile procedure on this with sterile gloves, because, especially with the injectables, you can get a biofilm developing and there have been some incidences of infections and chronic infections occurring. Ensure that they don’t have any active, open sores and that they’re not a nasal staph carrier. You want to premedicate with Acyclovir if they have a history of herpes simplex, and, if possible, stop their blood thinners and nutritional supplements that can lead to additional bruising. Conclusion A good pre-treatment skin regimen is an essential part to my treatment protocol. My advice is to keep things simple—use just a couple of products, but include the hydroxy acids, the retinoids, peptides, antioxidants, and then a sun block, to try to improve that barrier function and thicken the epidermis and dermis. You must prepare the skin prior to the injection. Cosmeceutical peels are a good way to do this to enhance the results and the healing and minimise complications and help prolong the results. Professor Beth Briden MD is the founder, medical director and CEO of Advanced Dermatology & Cosmetic Institute in Edina, Minnesota. She is an international expert on skin rejuvenation.

22 TECHNIQUE I body language

The “Happy Face” technique DR FRANK ROSENGAUS explains his method for treating commissure and marionette lines and the importance of understanding facial anatomy

ommissure and marionette lines are very difficult to treat because irregularities, lines, folds, depressions and hyperkinetic parts of the muscle all need to be addressed to get good results. In October 2012, in a little convent next to Florence, Italy, archaeologists were digging in the catacombs for the remains of a woman called Lisa Gherardini who lived in 15th century. Lisa Gherardini was married to a very rich textile merchant who traveled frequently, so she decided that she was bored and

would take a lover. She found one as her neighbour, and he became so happy with her that he decided to paint her—her married name was del Giocondo. La Gionconda, or the Mona Lisa as you may know her has the most famous smile in Western civilisation, and it’s not even a smile, it’s a smirk. The corners of the mouth are looking upward and there is complete evenness and smoothness around the perioral region. That is my goal—I decided that these are two universal elements, no matter what your ethnicity, that all people

like; the corners of the mouth going upward and the smoothness. A modern version of that famous smile, is Mario Testino’s famous picture of Lady Diana which captures the same expression. The corners of the mouth are up and there is smoothness around the mouth. So, how can we get there? That’s the question. Anatomy We have been trained for the past 15 years to believe that on the upper face, all wrinkles are secondary to muscular hyperactivity, so

body language I TECHNIQUE 23

they should be treated with toxins preferably. On the lower half of the face, lines and folds are secondary to skin laxity and loss of volume, so we should treat with fillers. But what about the dynamic components of lines and wrinkles in the lower third of the face? Are the

66 We have been trained to believe that the upper face should be treated with toxins 99

muscles there part of the problem? If you look into it, you will find that there are many muscles that take care of this physiology of the mouth. Itâ&#x20AC;&#x2122;s not one or two or even threeâ&#x20AC;&#x201D;there are eight. All of them act together in a point called the modiolus, which is one centimetre away from the oral commissure. If we look at how they interact, all the movements of the muscles, especially the depressor of the angle of the mouth (DAO), are pulling all the time on the commissure and making the lateral vermilion follow a downward direction, plus causing

wrinkling of the area. Looking at a cadaver, we can see the labio mandibular ligament as the most anterior and superior part of the DAO attaching itself to the oral commisure. This ligament goes all the way from the commissure to the border of the mandible. When we do a CT scan in 3D, we can identify the components of the superficial fat pads. One is very importantâ&#x20AC;&#x201D;the jowl fat pad, and then there is the labiomental fat pad. In between there is a space. There is very little fat on the central part of the face, both upper and lower, and

24 TECHNIQUE I body language

the subcutaneous dissection medial to the sub mandible area. With this you are safe because you’re entering lateral to medial. You will never put the product where you shouldn’t put the product, which is in the fat of the jowl and make it worse. Safety is the number one priority. Be very careful and extra precise, exactly lower to the commissure. That’s where I draw my triangle. The subcision of dermal attachments allows for normal muscular mobility without the formation of deeper commissures, groups or wrinkles. I also design a space, I create the space necessary for the application of the filler, otherwise the filler just starts looking where to be.

Final outcome should achieve a smoother look—smoothness around the mouth and the position of the commissures going higher

especially around the labio mandibular ligament. Also, importantly in this area there are strong miodermal attachments—therefore skin and muscle are tightly united . Technique When I see my patients, I always explain what I will do. First of all, even if you have the most experience, you need to mark your patient. I do this by identifying the labio mandibular ligament, and marking the area that needs to be volumised. You are responsible for determining the area that needs to be filled and lifted—you design it. I specify in each patient how much they need and where they need it. Why do I think like this? Because as a surgeon we don’t have fillers, we have implants, and when we do implants—wherever they are, mental or mandibular—we create pockets and then put in the implant. The other consideration in this area in particular, is that it has a deep fat component. This is why we get jowling—it is one of the extensions of the buccal fat pad which is a deep fat compartment. If you add this to the fat on top of the jowl, then you get great volume in the lateral labiomendibular on top of the depressor but not the middle of

it. Push all that fat forward to the middle and see where it stops, then mark your patient there and make the space that you’ve assigned. I first see what tissue I need to lift, then I select the product, and then I select the tool. I do use cannulas and I prefer them because I don’t get complications clinical trials have offered clear outcomes that better results are achieved with a cannula, both from the patient and doctors point of view. The trend with cannulas has been the technology being used so you can use smaller and smaller ones. I don’t always want that though, I want something to help me actually separate the skin from the muscle, so I use the cannula as a subcision too. I make a lateral took entry point because then I can turn around and also do the nasolabial folds if I need to. I go through the ligament medially and I dissect, subcision and design the area. I use a precision microcannula (Softlift) of 25 or 23 Gs, and amazingly it’s painless. I didn’t think it was going to be painless but it is. I use the microcannula to do a dermal subcision, separate the labiomandibular ligament from the skin, continue with the sub commissure triangle and finally extend

Results I treated a patient who had wrinkling, irregularities, marionette lines and commissures going downward. I used my technique and the results offered smoothness and powerful improvement in the position of the commissures. You can elevate one, two or three milimetres and achieve the happy face that we want. What I want to achieve is for everything to be smoother, because we identify this as one of the main characteristics in the position of the commissures. This is the ideal outcome—smoothness around the mouth with the position of the commissures going higher. I also take care of the marionette lines on patients both young and old—the technique offers improvement for all. The disadvantages of this technique are that is does take longer to do, and after treatment the patient can have pain and inflammation around the oral commissure for the next 48 to 72 hours. Dr Frank Rosengaus is a Facial Plastic Surgeon from Mexico. He runs three hands-on training courses per year to teach the “ happy face” technique with cadaver dissection and live patient demonstrations in Mexico City. W: drrosengaus.com; T: +525552813133; E: frosengaus@ ultrabody.com.mx

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body language I INNOVATION 27

Developments in safer collagen MR CHRIS INGLEFIELD talks about bio-dermal restoration using advanced collagen

ll the changes that happen with ageing in the face are the effect of loss or break down of collagen and the loss of elasticity within that skin. This industry uses a lot of different techniques to try and restore collagen in the skin, to achieve rejuvenation. Everything from skin care, energy devices, toxins and fillers all work in different ways and there’s always been a desire to find an alternative, a better product. As we know, the skin is mainly collagen—85% of the dermis is type I to type III collagen, a small amount of elastin and very small amount of hyaluronic acid (HA). Collagen is not just lost as we age, there’s a fragmentation of the collagen fibres, a decrease in their length and viscosity. This occurs because of glycation, the crosslinking of that collagen makes those collagen fibres stiffer, less flexible and causes the collagen to become mechanically solid. Injectable collagen history The early injectable collagens, the first generation Zyderm or Zyplast were bovine or human collagen—a very fibrous product which was very difficult to use, needed pre-testing and even with pre-testing, caused a reaction in many patients. Because they were un-crosslinked, unstabilised collagens, their duration was quite short: just three to four months by today’s standards. Second generation collagens were cross-linked; these were por-

RPC pure-collagen—tissue

Hyaluronic acid—gel

cine collagen, therefore no skin testing was required. They were stabilised and lasted longer: nine to 12 months. I had Evolence, a second-generation collagen, injected into my nasolabial folds and it was there for two years with no problems. Some people said they were difficult to inject. I think they were a different concept to the hyaluronic acid injectables available at that time, but worked well.

bone, you replace bone. You don’t replace bone with muscle; you don’t replace skin with something else. From here this idea of injecting ageing skin with a rapid polymerising collagen was developed. It’s a pure type I collagen. It’s uncrosslinked, it’s sterile, it’s porcinederived. It’s stabilised with EDTA and it has mannitol added to it as an antioxidant to reduce free radicals. It’s a very smooth product to inject. RPC collagen is a low viscosity liquid product, not a particulate product. The collagen molecule assembles into collagen fibril and collagen fibres. When injected into water, within five minutes, it polymerises and you see the collagen— it’s a spontaneous polymerisation in the tissue. It becomes contour-stable within five minutes and histology reveals that it forms its natural 3D matrix within the tissue. It’s a real changing kind of concept that what you’re injecting is the building blocks and that the collagen fibrils are assembling within the tissue, so it’s quite different to what we normally use.

Rejeuvenation techniques Everything from skin care energy devices, to toxins and fillers all work in different ways. Intensive micro-needling has taken off as a huge rejuvenation technique and really taken over from fractional laser resurfacing, because it’s a much easier technique, it’s much better tolerated by patients and it’s about stimulating collagen – it stimulates type III collagen, but it doesn’t produce type I collagen. The present gold standard of using HAs is inflating the skin. The rules that were drummed into many of us growing up in plastic surgery were that you replace like with like. If you’re missing skin, you replace skin; if you’re missing

This shows an HA in the tissue and what the collagen looks like—native collagen and the product injected in it. You can see there’s vascular ingrowth and cellular ingrowth into it. Collagenase activity is completely suppressed by the presence of EDTA. The collagenase activity is dependent on calcium ions, so the reason for the EDTA is to absorb the calcium ions and therefore diminish the reactivity of collagenase. We see the RPC collagen, natural collagen and fibrils.

28 INNOVATION I body language

Before and one week post-injection with 1cc on each side

Before and six months after RPC treatment

Injection outcomes When you inject you get the normal polymerisation within the tissue and the normal banding that you would see in native collagen. Then you see the 3D matrix that occurs. Within two weeks, because of this open matrix that happens, there is vascular ingrowth and cellular migration into the collagen, so that the product becomes very easily bio-integrated into the tissue. Research We were involved in the first human pilot studies in the UK. In this small study of just eight patients we were looking at the safety of the product rather than efficacy. Injection site responses were first assessed by injecting male subjects into their lower back and looking for any allergy reactions. Those injection sites were then biopsied and if there was no reaction, treatment was given to the nasolabial folds, which were aimed at looking at the tissue reaction not an optimal correction. These were assessed by photographic review by an independent dermatologist as well as the patients’ own global aesthetic improvement scores. Statistical data didn’t show anything staggering, but the results were histologically completely neutral, no encapsulation, no cellular infiltration, with fibroblast migra-

tion into the implant. There was neocollagenesis within the implant and elastin fibre synthesis occurring. The reported scores of improvement, given by the patients, from the first to twelfth weeks, showed a good improvement. Patients would regularly report that they believed the product had gone because they could no longer feel it. A quick look at their pretreatment photographs would reveal that the area was still better. Even though these patients were not treated to optimal correction, since the maximum we were allowed to use was 1cc for each patient, they were just staggered that they couldn’t feel anything but yet they could see an improvement. This was a great learning experience, from our point of view. In this initial study, there were no implant site reactions. Physicians and subjects felt that there was good improvement and there were no adverse events reported and from this, the conclusion was that the product itself was safe. A clinical study followed, which involved two sites, 30 patients and used the Merz Aesthetic scales for scoring nasolabial folds. This treatment was achieve correction and then followed up out to 12 weeks. Again no adverse events were reported. The safety was certainly dem-

onstrated out to six months and the product performed as we expected really; the results were very natural and immediate. No patients showed any reaction, or redness and there was no swelling. Immediately post-treatment, within an hour, patients don’t feel anything at all and certainly by the next day, there’s nothing palpable. All patients are now up to sixmonth review and have maintained improvement. The patients who have achieved optimal correction—who started off at two or three on the Merz scale and we had got them down to zero—are currently being followed out to 12 months, to really assess the degradation of the RPC collagen. When you restore the integrity of the dermal collagen you create a much softer, more youthful appearance. This liquid injection is in-situ polymerisation; we’re talking about liquid tissue. This is a bio-dermal restoration. It’s not a filler, in the traditional sense of the word; it’s a very different product than an HA. It’s directly restoring dermal quality by using a natural collagen. The data has now been submitted to the regulatory authorities and however long that takes but the estimation is that there will be an EU launch in early 2016. Watch this space! Mr Christopher Inglefield BSc, MBBS, FRCS(Plast) was born in Trinidad, West Indies, and obtained his Medical Degree from the University of the West Indies in Jamaica and Trinidad in 1985. After attaining his Medical Degree he went on to complete his specialist surgical training in the UK passing the examinations for admission as a Fellow to the Royal College of Surgeons of England.

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30 EQUIPMENT I body language

The future of resurfacing DR INES VERNER considers the evolution and revolution in our resurfacing technologies and techniques and where we stand in 2015

ippocrates said that the natural forces within us are the true healers of disease. This is potent wisdom when we recognise that when we treat the skin, or tissues with energy-based devices we’re inducing the body’s natural wound healing mechanisms. This technology has changed in many ways in recent years Skin ageing leads to wrinkles, dyspigmentation, solar lentigines, rough skin surface, sagging, volumetric changes, solar keratosis and with time even skin cancer. Skin pathologies show that these changes are found mainly in the upper dermis and in the epidermis— which makes these changes amenable to skin resurfacing. There are many different methods to resurface the skin, from chemical peels to mechanical techniques like dermabrasion, or the use of laser and light technologies or radio frequency and ultrasound technologies. Problems with complete ablation When we consider ablative versus non-ablative, everything below 2,000 nanometres is non-ablative and everything above is ablative. When I entered into aesthetic dermatology in 1998 we didn’t have so much, just the completely ablative

CO2 laser and some deep chemical peels. We have learned a lot from complete ablative resurfacing such as chemical peels and have had great results, but today I don’t do them anymore. The reason being the risk for scarring and delayed hypopigmentation when you ablate the skin completely. Some of our problems included prominent hypopigmentation, plus despite fantastic results it was a very difficult procedure. Patients had to go through general anaesthesia, healing time was difficult, downtime was long, and there was of course a risk for scarring and hypopigmentation, which was mostly delayed and permanent. We’ve also learned that when we treat the skin to a certain depth, there is a certain tissue effect. If we just treat the epidermis with laser or peel, we’re doing a superficial treatment and we will always have regeneration and there will be no scar. But if we go deeper into the dermis, you might already have not only regeneration but also a kind of a scar formation, and we don’t want to be there. What we learned is that we don’t want to be so deep—we want to be only in the regeneration area so we can better regenerate tissue and not create so much scarring.

66 When we treat skin or tissues with energy-based devices, we’re inducing the body’s natural wound healing mechanisms 99

body language I EQUIPMENT 31

History Between 1998 and 2004 there were two main distinctive technologiesâ&#x20AC;&#x201D;ablative technologies which take off parts of the skin, mainly up to the mid-reticular dermis, to get an effect with wrinkles, or non-ablative technologies. The ablative technologies were extremely effective, but they had problems, including a long downtime, erythema for about three months, hyperpigmentation, and of course a very high risk for scarring. On the other hand, the nonablative technologies like the infrared devices and the IPLs, had fewer side effects but had limited efficacy on tissue tightening and tissue rejuvenation. Fractional technologies The revolution happened in 2004. Fractional technologies were introduced by Dieter Manstein. These are a photothermolysis process that involves treating columns of skin so the skin between the columns remains intact and tissue heals and regenerates. Using this technique creates tissue regeneration and no scarring even if we go deep. If we treat 25% of tissue in this way, the tissue effect is completely different. If we go deeper with ablation, cells migrate from the wound edges, or from the adnexa. That shows when we ablate with a peel or with a completely ablative laser, but in fractional resurfacing the cells will also migrate from the untreated areas so healing is much faster and tissue regeneration will be there. Cells migrate from the wound edge and also from the non-treated areas, which means faster healing, less risk of side effects and hopefully tissue regeneration. Our aim is to create new, younger skin and tissue that is completely healthy, without fibrosis, and with the adnexa as they were: younger, better, healthier skin. Comparing histologies After two days of fractional CO2 there is already a re-epithelialisation. With the ablative technologies we needed at least seven days to re-epithelialise the skin, but with the fractional resurfacing after two days the skin is re-epithelialised, which means that the risk for infec-

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body language I EQUIPMENT 33

tion is lower and the risk for scarring is lower. It’s interesting to note that there is neocollagenases after three months. Multiple studies have shown not only that new collagen formation occurs in the column area treated, but that after three months you can see also new collagen formation around that area, which means that all tissue around will also regenerate, but it will take a longer time. Any treatment with a fractional device—for instance, fractional laser or fractional RF —gives some immediate result, but after three months the result is much better, after half a year it’s even better, and this process will continue up to a year. I am able to achieve very nice resurfacing results with just five days downtime with this CO2 and there is a much lower risk for side effects, such as scarring and hypopigmentation.

the area where we want to be, and of course you can treat also other indications. Our clinic is very specified on aesthetic dermatology so we treat acne scars, a lot of sagging, wrinkles, and also skin cancer. At quite low energies of 25-30 millijoules, you’re already close to one-millimetre ablation. Most of the energy will go into the depth and very little of the energy will go to the lateral sites, meaning that you don’t have so much collateral heating and therefore you’re truly fractional. This means better tissue regeneration than when you heat laterally and a better effect on wrinkles and a little less tissue damage or collateral effect, which is good for some of these specific indications after even just a single pulse. It’s very important for fractional resurfacing to get some space between the columns, because if

When wound healing is complete, there is no inflammation so even when we treat with laser, we want the inflammation to be low 99

AcuPulse I use AcuPulse, which has a “SuperPulse” that enables skin resurfacing with a very good ablation/coagulation ratio. This is something you want to know because you need a one-millimetre ablation, 1,000 microns, to really get rid of wrinkles. Anything less and you don’t really get rid of the wrinkles. We had the same depth with ablative lasers and deep peels, so the one millimetre is

the heat is going laterally then you don’t get the fractional technology—you’re actually ablating or treating it all and then you don’t get the desired tissue regeneration. When there is less energy it’s less painful, there are less side effects, and the treatment is quite easy to do. There is a scanner within the device, like a computer programme, to ensure there is a cooling of the area, so you don’t heat

one after the other. It scans the area and alternatingly treats the skin. Problems If we only treat the skin with a fractional CO2, the problem is we don’t treat the surface, we don’t treat the epidermis. If you only treat in the deep mode you can improve the wrinkles, but you don’t really get rid of pigmentation, or surface abnormalities and the surface doesn’t get smooth or toned. To deal with this there is also a superficial mode, and when I resurface I combine the deep mode and superficial mode, to treat the wrinkles at the same time as improving pigmentation and surface irregularities of the skin so that the skin does look completely smooth. Inflammation In the past it was thought we needed to ablate everything and destroy a lot. I was a big believer of that because I did a lot of deep chemical peels and medium depth chemical peels. I was telling my completely swollen and red patients that it was good for them and that it would create a great result. Over years however, we’ve learned that it is not completely true, because although we do need a little bit of inflammation to get some matrix metalloproteinases and some collagen buildup and tissue regeneration and elastin—on the other hand, to achieve tissue regeneration we need as little inflammation as possible. When wound healing is complete there is actually no inflammation going on. So even when we’re treating with laser, or any other fractional technology, we want the inflammation to be low, not this horribly severe inflammation we

Before and after treatment of striae with ResurFX

34 EQUIPMENT I body language

ARIELLE KAUVAR MD

tion. Nowadays I’m also giving some topical corticosteroids directly after the laser, together with an antibiotic, to encourage quicker healing.

Before and three months after three treatment with ResurFX

thought we needed in the past. Considering the recent inverse correlation between the strength of inflammation and our ability to regenerate, I changed my approach to these resurfacing technologies, and I think this is also something new for us to consider and not to think that we need to destroy so much to achieve very good results. A severe immune reaction will lead to damage and impaired repair, so for scarless healing we need very low and minimal inflamma-

ResurFX I also use the 1565 nanometre is a completely non-ablative laser. With the ResurFX module, it’s possible to get it alone or it’s possible to get it inside a device, it also has universal IPL and an Nd:YAG and you can actually decide what you want. Why is 1565 such a good wavelength for nonablative resurfacing? The reason is that the absorption of melanin and haemoglobin is very low, so you will not get any side effects—it doesn’t actually go so much to the epidermis. On the other hand it is in the non-ablative wavelength range—it is at the high end so the absorption coefficient is quite high, but still you’re not ablating the skin, which means that you can get a very good tissue effect and a good depth of penetration. With 1565 you can get a good tissue effect, but it’s still non-ablative. In the past the nonablative technologies were not so effective, but if you are up in this spectrum on the high range of the wavelength you are in the very good part of the non-ablative range for getting enough tissue effect. All lasers below 2,000 are nonablative, and this 1565 laser is in the mid-infrared. There is less absorption by the intercellular water than the ablative lasers and therefore you’re able to treat completely non-ablatively. Treatment is also fractional, so there are columns of treatment and therefore the tissue will be able to regenerate, so you will have the deep effect—and it can go up to one millimetre. Due to the coagulation of columns, the tissue is able to expel the pigment and therefore, even though this effect is non-ablative there will be a clinical lightening and improvement of lentigines and possibly melasma. There is also an effect on the tissue tone because of the extrusion of pigment. And of course stratum corneum remains intact, and this is very nice because the patients, come in, they’re just a little bit red after treatment, they

put makeup on and can go out, and there’s almost no swelling. Histologies Histologies show that upper parts of the skin are intact; stratum corneum is intact and most of the epidermis. At 70 millijoules you’re already quite deep, so you can get to about 800, 900, up to 1,000 microns, which is very good if you want to treat wrinkles. Like the AcuPulse there is something like a scanner, so you don’t treat two points, one after the other directly, which is good for safety. It’s a very good scanning algorithm, and you can treat wrinkles, scars, striae and dyschromia. You can treat a face very quickly in maybe 15 or 20 minutes. Resurf X gives remarkable results immediately, but the best result will be seen later. As it is nonablative it will take even longer, so you need to treat a few times and then it will still improve even a year afterwards. Conclusion In conclusion, fractional technologies are revolutionary in my opinion, they’ve really changed our whole approach. Now, fractional CO2 laser will give us the possibility for safe ablative resurfacing with a shorter downtime and a lower risk for complications, and fractional 1565 laser will give us the possibility to resurface non-ablatively with remarkable results. Both technologies can effectively rejuvenate skin, improve laxity, improve tone and improve skin texture. And as Hippocrates said, healing is a matter of time, but it is sometimes also a matter of opportunity, so I think that we have to give our patients the opportunity to heal their skin because the damage that people have over the years we can actually treat it and let the tissue heal itself. Dr Ines Verner is an internationally esteemed Specialist Dermatologist working for over 15 years in Aesthetic & Cosmetic Dermatology. She has a Harley Street practice and is at the forefront of technology, treatment, teaching and research in the field of Aesthetic Dermatology.

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body language I INJECTABLES 37

Exciting skin DR ASKARI TOWNSHEND talks about tissue stimulators

ur body undergoes major changes from birth to old age. Bone remodelling occurs and as we age, we start to resorb more bone than we lay down, so we lose bony volume. There’s also muscle atrophy —which is important when using toxins—but in terms of revolumisation and biostimulation, it doesn’t play a huge part. However fat atrophy and the redistribution of fat is important, and these three things all contribute to volume loss. When we use hyaluronic acids (HAs) and biostimulators, volume loss is one major factor that we aim to correct. We also have issues with changes in collagen, and elastosis as we age and are exposed to the sun and toxins—I call these dermal changes. We can address volume loss with temporary fillers, permanent fillers, implants or fat transfer. For the dermal changes there are also many treatments we can offer. Interestingly, tissue stimulators can do both of these things—they can improve volume and improve the dermal thickness. Poly-L-lactic acid Sculptra has been around for many years now; it got its CE mark in 1999 and it’s still used in the NHS now under the name of NewFill. Another example is Polycaprolactone (PCL) under the brand name Ellansé and Radiesse also. These types of drugs are promoting neocollagenesis—improving or rebuilding the patient’s own collagen, which is great because it means results will be long lasting. It is versatile, but it does require very good technique because you can’t dissolve away a biostimula-

tor—you need to put it in the right place. If you don’t get the basics right, a year down the line that patient is still going to look unusual. Hyalase is a very last resort, and I’m proud to say that unless I’m correcting other people’s mistakes I think I’ve probably only ever used it two or three times in the last ten years or so. Using PLLA or Sculptra it can take 10-12 months to get your full results, but you should see changes within eight weeks.

time, and we know that PLLA can give you results for over two years. Polycaprolactone use was studied over 24 months and 40 patients in a randomised control study. Moers-Carpi et al looked at the two shorter acting Ellansé products S and M, which are a one-year and a two-year product respectively. Results showed that you will still see an improvement after a year, in the one-year product and an improvement after two years in the twoyear product.

Evidence With Sculptra you get type one collagen, not type three, which is the immediate, more fibrous type of collagen. These types of biostimulators can give results that last for a long

Cheeks Cheeks are fundamental. They’re the centre of the face—they hang the face. Imagine shirts or jackets are hung on those thin wire hangers from the dry cleaner—over time the

We have issues with changes in collagen and elastosis as we age

38 INJECTABLES I body language

hanger deforms and the cloth that is hanging over the top wrinkles. I see the same kind of analogy for the face and for the cheeks. Mid-face is like the arms of that hanger, and you need a strong mid-face structure to support the weight of the skin and the other soft tissues. By restructuring the mid face you’re going to be able to provide lift, to give the face better support, and this is where people look in terms of that quick half a second to decide whether somebody is looking fresh, or they’re looking young or not. Volume needs to live high, superiorly. We know that age and time is going to pull everything down, so placing volume lower down is counterintuitive because it’s going to get there anyway. I don’t have many straightforward rules but this is one of them: you can draw a line, across the nasal flares and inject the cheeks below this line, in order to increase volume. I need to have a really good reason to go above, and if you haven’t got a really good reason why, just don’t do it. You should always be above that line. Cheeks, on the surface, might be simple, but I think they’re quite tough because it’s very easy to get them wrong and when you get them wrong your patient might not necessarily know. They may be looking a bit better than they were at the beginning, but somebody who knows what they’re looking at is going to know that something is not quite right. If you keep doing it, few years down the line they will start to get people questioning what they’ve had done. Case study I think its tricky treating an older patient who has reasonable volume in the mid-face, but the volume is sometimes in the wrong place. I’m not a plastic surgeon and I don’t do fat transfer so when armed with just a needle, it can be difficult to treat. If you over volumise, the results will look unusual. You need to be extremely cautious, and less is always more. You can always put more in at any time. My first aim would be to recontour and correct the ogee curve—the curve that runs from the lateral flare

all the way up the cheekbone. Often we get a break, which happens when the fat that was once sitting higher up, is now sitting lower down if pressed and makes the nasolabial fold look more prominent. By injecting into the lateral area, we will start to correct the ogee curve. We will get a tent pole effect—in other words, when you put your tent up, as the pole increases in height it gathers the material around it. Creating an anterior projection will mean skin gathers around that, and will help relocate some of the fat that has prolapsed inferiorly. It’s vital not to be absolutely solid with your plan at the beginning, because things are always going to change and you’ll always be surprised. It might be that you put in a small amount of product and you get a bigger change than you had expected. It might be that you put in the amount you thought you needed, but actually you need a lot more, and you get to a stage where you think, hang on a second; I’m putting in more and more and more, but I’m not getting the change I want. If that happens please stop. Firstly, you’re wasting the patient’s money, you’re using product with no effect, but secondly, where on earth is the volume going? You may be revolumising an area that really doesn’t want it. If you look at the proportion of the face, the thirds should be fairly equal. You also need to consider the jowls, which are very tough to treat as they are formed by fat that is relocating. We have elastosis, soft tissues that are becoming more relaxed, and so to treat this you need to repin it—this is where surgical threads can be very useful. You can’t fix jowls with injectables but you can hide them by tricking eyes and playing with shadows and contours. I try to mould the beginning of the jowls into the rest of the jaw line so they look less apparent. If the mentalis appears as an island surrounded by a moat, the undulation casts shadows and gives the impression of the mentalis being quite separate from everything else. To correct this, you can fill in and smooth out the defect between

Shaw and Khan In California in 2007 Shaw and Kahn carried out CT scans on faces of patients who were coming in with query facial fractures or query sinusitis, and anybody who had a negative scan got entered into this study. They had 30 men, 30 women, from different age groups. They measured different angles of the skull— the glabellar angle, the piriform angle and the maxillary angle. These angles changed as people aged. Of all the angles measured, the maxillary angle was the only one that changed, statistically, between every age group, and between men and women. In everybody, man, woman, any age, this bone slowly erodes in this area more quickly than any other part. If you start there and you fix this, then you start to rebalance the face and give it support.

these two areas. It doesn’t need to be completely confluent but it will create a stronger jaw line with less shadow in the area, and look much better. Biostimulators like Ellansé, don’t go into the vermillion of the lips, stay well away from that area, and I think you need to give yourself a safety barrier as well. When I’m training I often tell people not to inject into the vermillion, and all of a sudden it turns into a competition of who can inject closest to the vermillion before actually getting into it. There are no prizes for that one. I always mark out a half centimetre or so, because you will get some spread of product. Approaching the parotid A lot of people get very worried about the parotid glands. The parotid lies in a deeper plane, with a thick parotid fascia over the top of it. If you’re starting to prang the parotid and inject into it without knowing about it, you need more training. Other important vessels in the area include the transverse facial artery—which you should watch out for. It’s not a huge artery, but you know it’s going to bleed. If it

body language I INJECTABLES 39

does, then apply pressure, but if you are kind and gentle with your technique there shouldn’t be a huge amount to worry about here. Remember though to be very aware of the superficial temporal artery— probably your closest really important artery. Don’t worry too much if, when you do treatments over the parotid area, they don’t look quite right in terms of being completely confluent initially. This is because it’s very near the masseter, and as the patient speaks, chews and sleeps over the next few days it will even out. It’s not an excuse for sending a patient home looking lumpy, of course. You never want to do that. Massage the area as best that you can, and don’t worry if you’ve done that and it’s not quite 100%, because it generally will even out. Q&A Q : What is the risk of vascular compromise with collagen stimulators, and if so how do you manage it? You are always at risk of vascular compromise. I don’t think is any different from any other product. However the difficulty with Ellansé is it’s quite a thick product, so like Radiesse, you can’t aspirate. I’m a big fan of aspiration, so unless you’re really confident and your technique is spot on, you need to consider using cannulae, because it’s much safer. Training and using Ellansé has taught me to become much more

66 Volume needs to live high superiorly. Age and time will pull everything down so placing volume lower is counterintuitive 99 aware of vascular compromise. Always look for blanching and look and listen for a patient that is in pain as intravascular injection can be quite painful. So if you start getting pain on injection you need to stop. I always start with a safe injection or something that I think is safe. I say to the patient that is how it should feel, and if feels anything different in the future then please let me know. And then it’s about slow injection. If you are injecting in the wrong place then you aren’t going to dump your entire syringe or a large amount in the wrong place. In terms of immediate complications, I’m not sure that it’s significantly greater, although of course you don’t have the reassurance of the flashback, so that’s important. In terms of later, I don’t think there are any. No one has ever described a big build up of collagen, which is then going to impinge on a vessel, I don’t think that’s possible. Q: If you suspect necrosis how do you manage this? With this product I inject slowly and I only ever inject aliquots of 0.2

mls, maximum, in one go in one place, so all of these things mean that if you were to have something terrible happen, your chance of it then turning into something really bad is much less. If even despite all of that, somehow you’ve got the magic bull’s eye and you placed your 0.2ml into a particular vessel, I think then you need to start going through the protocol that everybody should have about what to do with an intravascular injection. Try to vasodilate and refer them on to a tertiary centre because they need to move fairly swiftly. Ultimately you only have a few hours before you might start to get a breakdown, and then if that does happen, it’s about how you manage the wounds. It is important to have your fundamentals perfectly tuned so that you never get to that stage. I’ve used HAs for ten years and that is what I use mostly in my practice. The reality is if you injected a decent amount of HA into a vessel, the idea that you could then get your hyalase in there and exactly get it into the bit that you’d injected in and force it all the way up through the network is unlikely. We do know that if you inject you hyalase it can penetrate the vessels, so yes, you are going to get good effect if you try to blanket the whole area, but it certainly isn’t the panacea that some people think it is. Ultimately, never inject in a vessel. If you do, act very, very quickly. Q: How do you use your cannula? People always ask me which way should you use your cannula? Which direction should you go in? If you have a large fold and it’s originating at the place where you want to put your product, then, of course, why not go along the line of the fold? Because then you can withdraw and you can fill the defect as you come back. If you just have a particular place that you

40 INJECTABLES I body language

perpendicular because then it’s a bit easier to move the angle of the needle. If you’re using a very long cannulae you need to be aware of the superficial temporal artery that’s running way back, a centimetre or so in front of the tragus. Often you can palpate it. We all prang vessels. That is what happens when you put needles in skin. The problem is if you don’t recognise that you’ve pranged a vessel. So whatever you’re doing always be vigilant; always be watching. We have lost the old-fashioned art of just opening our eyes, plugging in some common sense and watching. That also means that when you’re injecting that you’re not covering the skin that you want to inject with your hand, because you’re not going to see if there’s any blanching or swelling. If there’s swelling that is not related to the product you’re putting in then of course there’s probably a haematoma or some bleeding that’s going on underneath the skin.

If you are comfortable, and have the skill, use a needle instead of a cannula as it is more specific in terms of getting to your target

want to fill then if you’re comfortable and you feel that you have the skill to do it, use a needle, because it’s much more specific in terms of getting to your target. If you are using a cannula and you just want to get to a specific place, then please just use the path of least resistance. Going between A and B in a straight line is always better than wiggling around. It always upsets me when I see somebody going through centimetres of tissue to get to a place that they could have accessed with a very simple injection very close to the area. With a cannula it’s important to decide what you’re going to do with it. Either you put your entry point in the direction of travel; if you want to access lots of different areas with your entry point then you should put your entry point

Q: Do you treat people who are anticoagulated? If people are on aspirin or blood thinners, I think that some practitioners are perhaps a little bit over cautious about this and they exclude large numbers of patients. I don’t mind treating people who are on aspirin. Of course, if possible, I do ask them to stop it a week or ten days beforehand but I wouldn’t deny somebody an important treatment for a wedding that they had in a couple of weeks’ time, because they were on 75 mgs of aspirin. In terms of warfarin I get a little bit more cautious, but it depends what their warfarin is for. I’ve got to be ultra cautious that if there are any issues then I’m well aware. It’s all about your skill level, what your comfort level is, and assessing the risks appropriately. If you’re new to this and you’re not very confident, then no. Don’t treat them. Send them on to somebody who has more confidence and experience than you. Q: What layers can you inject this product? The way that I treat Ellansé or any-

thing heavy like this is treat it as a heavy filler. You would not put a heavy filler in the dermis. This does not belong in the dermis, and in fact no biostimulator ever belongs in the dermis. Many of the problems that I see are down to poor placement of product. So they should always live deep. If you have fine lines, something really fine that you want to deal with, get a thin HA because that’s what it’s for. Please use your tools correctly; have a decent toolbox, but make sure that you’re using them correctly and not trying to put a heavy product into a superficial plane, and when I say superficial plane I mean in that dermal plane. You can of course sit beneath the dermis and that is fine. I always like to treat people in an upright position. I think that’s really important. Why? Because the tissues are going to come down with gravity; if you treat people lying down at 45 degrees, they sit up and everything comes down, and you don’t know exactly what you’ve been injecting. Another danger area is the facial artery that is coming in just in front of the masseter. If you ask your patient to clench their teeth you feel for the masseter—the front border, the anterior border. You run your finger down and there’s a little notch on the underside of the mandibular ramus there. There’s a little wiggly worm in there and that’s your facial artery and vein. They’re going to track superior and medially to the corner of the nose and become the angular artery. So when I’m treating this area I’m well away from that, but of course there are other vessels, the inferior labial vessels, which are going to split off from that facial artery and come across. Dr Askari Townshend has several years of injectable experience. He opened his first Aesthetic clinic in 2008, and he’s had the position of Director of Medical Services at one of the largest chains of clinics in the UK. He’s recently launched his new clinic, ASKINOLOGY —a new and different approach to offer skincare treatments. He’s also a trainer for several pharmaceutical companies.

body language I PROMOTION 41

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body language I TECHNIQUE 43

Controlled trauma MS LESLIE FLETCHER explains a new patented technique in which controlled trauma stimulates new collagen

rqueDerma is a patented technique that I developed for injecting hyaluronic acid and dermal filers into the dermis, using a modest subcuticular undermining effect with the needle that releases the dermal attachments. The separated, redundant tissue is then collected, redirected and stabilised upward. Approach There are three differentiating principles of the ArqueDerma technique, which simultaneously address the three signs of ageing:

volume loss, redundant tissue and deteriorated skin. The first principle is the ‘lost and found’ principle. ArqueDerma utilises the patient’s own tissue to replace and redirect into a hollow area. This also covers the second principle, the ‘less is more’ principle that addresses the patient’s redundant tissue. Instead of filling the hollow tissue in the face, we redirect and move the patient’s own redundant tissue into that area of hollow. The third principle is the ‘neocollagenesis principle’, which addresses deteriorated skin tissue. With a bit of undermining,

a controlled injury induces wound healing. The controlled trauma injection technique increases collagen synthesis and has a long-term anti-ageing effect on the quality of the skin. We use cannulas a lot in the USA—probably not as much as in the UK—but the whole point of a cannula is to create less trauma in the patient’s tissue. Sometimes a little bit of trauma can be good for establishing long-lasting results. Results can improve with time as the body creates collagen to stimulate and fill lines, even after the product has gone.

44 TECHNIQUE I body language

A patient with solar elastosis— ingrained etching that is crosshatched around the face—is hard to treat with fillers. I don’t have any lasers in my office, but this type of patient would definitely be a CO2 candidate, using the principle of heat causing some trauma and stimulating collagens. I don’t have that at my disposal, so I have developed a technique that uses hyaluronic acid injectables to produce a similar result to CO2 lasering on skin tissue. These results have shown the durability of endogenous neocollagenesis. Without reinjection, results are noticeable even years post treatment when the product is gone. What’s left is the body’s own collagen made in response to the trauma. Comparison There are various techniques used today that offer their own advantages. Conventional bolusing is very atraumatic; you go in, you place the product in and you come out. There’s not a lot of fanning, or movement with that needle. Another method is threading and fanning with a cannula, which creates collagen just by passing the instrument through the tissue. It does create a neocollagenesis, but using a needle ups the ante, as it is a sharp instrument that will cut through and create more controlled trauma. To up the ante even more, you can put increased tension on the needle when you’re in the tissue, splaying the needle to create undermining and subcision. It increases the neocollagenesis result, producing a longer-lasting result. The least amount of trauma that you produce for your patient, the least amount of neocollagenesis, the more trauma you can create the more organised neocollagenesis you will create. Controlled trauma The term subcision was trade-

marked by Dr Orentreich, a New York dermatologist, in 1994. His technique was developed for acne scars and he used an 18-gauge needle to break up the adhesions from their dermal attachments and pop the scar forward. He used no product, just a simple modality of needling and he had 97% patient satisfaction rate for the correction of defects. The concepts of using subcision to break up the attachments of the contour abnormalities to release the surface from deeper tissues is similar in ArqueDerma. However, it’s not using an 18-gauge needle as a separate treatment modality. ArqueDerma uses the injecting needle when placing the HA to create neocollagenesis and separate tissue, to create a pocket which keeps the tissue elevated until the collagen has a chance to form. So in this technique, the HA is actually used as a liquid glue as opposed to a filler. In Dr Orentreich’s work he speaks about the blood being a place-holder that holds the space open until the new collagen has a chance to form. With bruising that is gone within two to three weeks. I feel that it’s better to leave a little product behind—the hyaluronic acid (HA) is there to hydrate the area and is also used as a spaceholder or a potential separator to hold the tissue in place until the body has a chance to form its own collagen. This happens around four to six weeks later. Collagen Photoaged, aged or damaged skin has collapsed fibroblasts, because there is a decrease in healthy collagen putting pressure or tension on them. This creates a self-perpetuating cycle of degrading or fragmenting of its own natural collagen. Fragmented collagen is detrimental to the growth of new collagen because it takes up space. We want to get rid of as much of the fragmented collagen as pos-

66 Fragmented collagen is detrimental to the growth of new collagen because it takes up space 99

sible before we can start building the long, healthy collagen fibrils. Healthy, intact collagen attaches to the fibroblast and signals for it to stimulate even more collagen. We want full, intact collagen as much as we can under the skin because it holds the tissue up. It gives the skin an armature or a place to hold and suspend the area so that you’re not getting skin laxity. If you imagine a bowl of cooked spaghetti noodles; you’d pour out the water, and put the spaghetti on your countertop and put a paper towel on top of that. The paper towel will drape nicely over the cooked spaghetti noodles. But, if you take tiny, thin, chopped-up noodles, boil it, pour that on your countertop and put a paper towel on top, the paper towel’s won’t drape very well—it’s not going to be very supportive. Where you place the hyaluronic acid it swells due to the product’s hydrophilic nature—holding 1,000 times its weight in water. As the product swells, it puts pressure up against the fibroblasts, which signals those fibroblasts to create their own collagen. The ArqueDerma technique

A patient with solar elastosis, before and two years after one syringe per side only

body language I TECHNIQUE 45

ArqueDerma neocollagenesis schematic Thicker dermal/epidermal junction

Stratum corneum

Reticular dermis

INJECTABILITY INSTITUTE

Epidermis

Aged, damaged skin

places the HA in small, vectored strands, creating a synthesis of collagen, a breaking-down of old collagen, and a building-up of the new collagen over a larger area. You’re actually putting it throughout the whole face and having that same neocollagenesis process happening over a larger surface area. Every day our skin is in a process of ageing. We’re exposed to the sun, which releases matrix metalloproteinases (MMPs)—a proteinase that breaks down collagen. It breaks down those long spaghetti strands into tiny strands, which aren’t supportive for the skin tissue, and it also takes up space from longer ones forming. When longer strands can’t form, they can’t put pressure against the fibroblasts and the fibroblasts cannot create more collagen. It’s a cycle of ageing that occurs all day every day. To reduce ageing we have to do something to interrupt that cycle,

The wound healing cascade

Injected, healthy, hydrated skin

Improving, injected skin

and there are many things that we can do to stimulate the collagen including chemical peels and dermal injury with laser, needles or micro-needling. If you use microneedling, you create a change in the cycle when you are rolling, so when you’re injecting you can also change the cycle with your injecting needle, to increase creation of more collagen. An inflammatory phase occurs, where there is an increase of MMPs that break up unhealthy, broken collagen strands. It attacks these fragments first because they’re smaller. It breaks them down and macrophages them out and once they’re washed out space is created for healthy collagen to form. Growth factors are also released which stimulate the fibroblasts to produce more collagen. The long, healthy collagen strands put pressure up against the fibroblasts to create more collagen. It’s a good

thing to have this cycle change because we need to increase our amount of collagen production since we lose 1% of collagen a year after the age of 30. We have to do something to make up for this lost collagen, and it takes a lot of product to fill up what we’ve lost. What we can do though is stimulate the body’s own collagen which is free and use that as an adjunct to dermal fillers. The healing phase The inflammatory phase is the first three days—platelets release growth factors, neutrophils and macrophages are pulled into the wound, fibroblasts begin to be pulled into the wound and endothelial cells start to proliferate. Next there are three to 28 days of proliferation, or the fibroblastic phase. The keratinocytes and fibroblasts get involved and start producing more growth factors,

INJURY

REPAIR

PLATELETS RELEASE GROWTH FACTORS & CYTOKINES

Proliferation and fibroplastic phase 3-28 days

NEUTROPHILS & MACROPHAGES ENGULF BACTERIA & PRODUCE GROWTH FACTORS, CYTOKINES & PROTEASES

NEUTROPHILS & MACROPHAGES PULLED INTO WOUND

TGFb IL1 TNF

PDGF TGFa MMPs

FIBROBLASTS, KERATINOCYTES & ENDOTHELIAL CELLS PRODUCE GROWTH FACTORS

FIBROBLASTS EPITHELIAL & ENDOTHELIAL CELLS PULLED INTO WOUND

FGF IL-1 TIMP-1 VEGF

PDGF TGFa EGF HGF

Remodeling and maturitive phase 28 days-2 years

SYNTHESIS OF EXTRACELLULAR MATRIX & NEW CAPILLARIES

FIBROBLASTS PROMOTE REMODELING BY PRODUCING EXTRACELLULAR MATRIX MMP’s INJECTABILITY INSTITUTE

Inflammatory phase 1-3 days

46 TECHNIQUE I body language







 Before and after pictures show the small details of the fine lines and the etching have improved. 1&2: before and 2.5 years later three syringes total. 3,4&5: before, right after and 14 months after.

 which will move on to the synthesis of the extracellular matrix, and new capillaries form so there is also neo-vascularisation. Last is the remodeling phase, which lasts between 28 days and two years. It’s a continuation of growing collagen and the fibroblasts promote remodeling by producing extracellular matrix MMPs. This is an ongoing process lasting two years, and then after the two year period, the new collagen that’s been produced in the body has been speculated to last between four and seven years. Your patients aren’t going to perceive this as a treatment that will last for four to seven years, so I try not to quote that, because then they’re going to get upset at seven years if they don’t look like they did the day they left the office. The lift might be gone after a couple of years and patients do need to be re-injected to get that elevation of the tissue that they had initially. What does happen is the skin deterioration has changed over time—that lasts several years. I have no problem telling patients their results will last them two to four years. Perceived disadvantages There might be some perceived disadvantages with this technique.

One might wonder how creating trauma affects your patients – do they bruise? The answer is yes, most of the time they do. However, I take the time to educate my patients ahead of time on the advantages of the bruising and how that leaves the patient with some extra stimulation. Patients do get excited about it to the point where if they don’t bruise, they’ll call me and say, “Wait a minute, I thought you said I was going to bruise! Does this mean the technique won’t work?” The patients are very aware that there is social downtime. This is much more of a procedure than a basic fill, but I definitely like to give them the advantages. Some may say there’s an increased risk of occlusion over a cannula. This isn’t really the case, because you’re delivering micro-amounts, well under 0.1ml, sometimes less than 0.05ml with each pass and you’re always moving your needle—a moving needle is a safe needle. Another possible perceived disadvantage is the potential to have a decrease in sales because you use less product and patients take a lot longer to come back—this is just not the case. We’ve done a lot of follow with the people who take our courses and have been li-

censed in this technique, and their filler sales go up between 200% to 300% within the first few months. That’s due to word-of-mouth referrals because the results are so great. Additionally, the patients may spend a little extra money at their initial appointment to get the initial lift completed. Ms Leslie Fletcher is an Aesthetic Nurse Injector. She owns an international training company, InjectAbility Institute where she licenses out the ArqueDerma technique. E: info@arquederma.com References 1. Goodman (2001) Therapeutic undermining of scars (Subcision) Australasion Journal of Dermatology 2001 42, 114-117 2. Setterfield, L (2013) The Concise Guide to Dermal Needling, Expanded Medical Edition. Acacia Dermacare, Canada 3. Wang F. Garza LA Kang S Varini J Orriger IS Fisher GJ Voorhees JJ (2007) In vivo stimulation of de novo collagen production caused by cross linked hyaluronic acid dermal filler injections in Photodamaged human skin. Archives of Dermatology Vol. 143

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body language I LASER 49

Enhanced healing post tattoo removal DR RAMINDER SALUJA shares her experience using PicoSure’s Focus lens for rejuvenation after treating patients with PicoSure for tattoo removal

icopulsed laser is intuitivelyattractive because it’s pulsed in trillionths of a second, to create greater ink fragmentation and smaller particle sizes.We do also have a Q-switched laser in my clinic, but I primarily only use Picosure as pico pulsation can fragment particles better, and can target smaller sized particles that can be skipped by Q-switched laser. Picopulsed lasers also create a powerful photomechanical impact that can go through a fibrotic scar and reach the recalcitrant ink below. Reaching all colours The wavelengths utilised allows for the Alexandrite to clear away the stubborn greens, blues and blacks, and the 532 to better clear the reds and yellows. It is better than 1064, so it’s good to be able to have one laser to hit it all. FOCUS lens It is equally important when treating with picopulsed technology to note that the photomechanical wave can separate the epidermis from dermis, thus creating a blister. Typically this can occur in the first of several treatments as the ink density is higher then. After treating the tattoo, the area is then retreated with the FOCUS lens, which is a diffractive lens that redistributes light into highly focused microbeams, which are embedded in the low level energy. The microbeams magnify the

fluence by 20 times and this higher energy can change the permeability of the skin barrier to help diminish blistering in the post laser healing period. In addition, the FOCUS lens has been proven to stimulate collagen and elastin over time, therefore leaving the area treated with less

risk of textural irregularities that can be seen more frequently with Q-switched technology. When treating a tattoo, I treat with the straight pico, typically building up to 2.5 mm spot size, which equals a fixed fluence of 4.07 j/cm2. On distal appendages, I may start with 3mm spot

Research on picosecond wavelengths, 532 nm and 755 nm advantages. Before and after one treatment.

size which correlates to a lesser fluence and on subsequent visits when the ink is lighter increase it to 4.07 j/cm2. I recommend switching to the FOCUS lens on a 6mm handpiece and deliver about four passes over the treated area. This changes the skin barrier, allowing for egress of fluid from potential blister formation and stimulates collagen production as seen with revitalisation data, for smoother underlying skin. Acne scarring The FOCUS lens has also received clearance for acne scarring.There are many modalities to treat scarring including fractional non-ablative, fractional ablative and radiofrequency procedures. The aspect of PicoSure FOCUS that I love, especially for my teenagers, is that the downtime is really quite minimal. I use the 6mm handpiece with FOCUS, thus delivering 0.71 j/cm2 in background area, and 20 times higher energy through the microbeams, which allows for 10% of the tissue exposed to receive higher energy. This allows for minimal edema (essentially 2 hours of edema, typically on the lower cheeks) and anywhere from 2-24 hours of erythema. At the 24 hour mark, the erythema, if present is really imperceptible. This allows for students to return back to school without having to take time off. The present demand in cosmetic laser treatments is to give the “wow” result with “zero” downtime. Granted, this is an impossible request, but I find that Picosure FOCUS lens comes close in the

sense that the downtime is very manageable and the results (with three to six treatments) are visually significant. The FOCUS lens has received an additional FDA clearance for wrinkles. Once again, easy downtime which makes it appealing to the ever on-the-go cosmetic market Reducing melasma I have also used FOCUS for melasma/hemosiderin staining and to clear away PIH, especially in Fitzpatrick IV and V. We ensure that all patients use sun protection and we treat melasma every three to four weeks with around 40006000 pulses to the face. The dermal component of melasma will turn darker for five to six days and then begin to lighten. During consultation we discuss that three to six treatments may be needed and that there is no cure for melasma and that systemic and environmental issues contribute to the progression of melasma, this can return. For hemosiderin staining that can occur post sclerotherapy, one to three sessions with Picosure 6mm with the flat lens can help diminish the appearance of the brown coloration. Dr Raminder Saluja, is a board-certified ophthalmologist and fellowship trained in dermatologic cosmetic surgeon. Her many areas of cosmetic surgical expertise include, laser surgery and resurfacing, laser tattoo removal, IPL and PDL vascular treatment and rejuvenation, laser lipolysis and tumescent liposuction, dermal filling treatment, neurotoxin injections, sclerotherapy treatment of unwanted leg veins and photorejuvenation.

Case Study This shows a 16 year old male before and after treatment for acne scarring, both erythematous and rolling box car with PIH (post-inflammatory hyperpigmentation). The area was cleansed and external ocular shields were placed on patient. A Tx with 6mm handpiece with FOCUS lens was used to treat. The first pass was done horizontally and the 2nd pass vertically. Cool air was used at low level of 2-3 on smartcool. Around 4000-6000 pulses were applied and repeated at four to sixweeks for three to six treatments. The post care regimen for this patient was sunscreen only and we allowed him to return to topical retinoic acids that night. It was essential that the patient must not be tanned prior to treatment. The same type of settings can be used for revitalisation. If the skin is Fitzpatrick scale 4-5 I will sometimes use the 8mm or 10 mm handpiece, thus delivering 0.41 j/ cm2 or 0.25 j/cm2 respectively.

DR RAMINDER SALUJA

DR ROY GERONEMUS

50 LASER I body language

52 PRODUCTS I body language

on the market The latest anti-ageing and medical aesthetic products and services  Dermalogica Professional Additives Dermalogica announces the relaunch of three new and improved professional-use additives which are said to allow the skin care therapist to customise and enhance professional treatments. In tandem with the product re-launch, Dermalogica will be offering a new half-day class, “Targeted Neck and Shoulder Touch Therapy”. Dermalogica say that each concentrated, upgraded formulation now includes a new therapeutic oil with specific skin benefits. Combined with select essential oil blends, these products may be lightly pressed (four to six drops) onto the skin as part of the Dermalogica Pressure Point Massage, or applied to the skin prior to massage cream for a European-style massage. These intense botanical formulas are said to add a new dimension to the skin therapist’s repertoire, allowing for specific personalisation of every treatment based upon the individual needs of each client. W: dermalogica.co.uk

 Blemish Control Skin System SkinCeuticals have announced the launch of their new Blemish Control Skin System kit, which brings together three Blemish + Age products in a convenient package format, exclusively available to UK & Ireland clinics from August 2015. The kit includes: • Blemish + Age, Cleansing Gel: Decongests pores, removes impurities and softens skin. • Blemish + Age Solution: Removes surface cells and excess residue, decongests pores and primes skin. • Blemish + Age Defense: A lightweight and fast-absorbing oil-free serum which treats blemishes and damage to skin texture and tone. W: skinceuticals.co.uk

 Melanotech DMK have recently launched two new products, Melanotech Crème and Melanotech Drops, designed to prevent and treat hyperpigmentation. Melanotech products are designed to act as a powerful antioxidant to fight free radicals, revise pigmentation and brighten the skin. DMK say they are antimicrobial, anti-inflammatory and that Melanotech limits the production of melanin by interrupting the polymerisation process. W: dmk-uk.com

 Solution for Scars Designed to be applied as soon as the wound is closed, Solution for Scars is said to start actively reducing irritable skin by immediately controlling the irritation and redness, enhancing the skin’s reparative response and thus already minimising the appearance of the scar as it begins to develop. It was created follwing a study by scientists Dr Ardeshir Bayat and Mr Douglas McGeorge and uses active green tea extract. W: scienceofskin.com

 CoolMini Applicator ZELTIQ Aesthetics have announced a new addition to their innovative CoolSculpting range, the CoolMini applicator, which will be launching this September. Designed to treat smaller fat pockets, this non-invasive procedure uses Cryolipolysis, a patented process exclusively trademarked to ZELTIQ, which is said to eliminate fat cells by taking advantage of their natural vulnerability to the cold. ZELTIQ say results are noticable and lasting. W: coolsculpting.com

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body language I PANEL 55

Future treatment trends DR VINCENT WONG, DR FRANK ROSENGAUS and MR TAIMUR SHOAIB discuss their personal experience with Aqualyx and Kybella

Q: There’s seems to be very little difference between the safety level of Aqualyx and the danger level. How is it possible that it’s safe to use five or six vials, but above six is very dangerous? Dr Vincent Wong: The results of Aqualyx treatment does vary from patient to patient. We have to consider the patient’s lifestyle factors and metabolic rate for example. With repeated treatments you will get better results, and it also depends on how many vials you use per session. The number of vials is usually dependent on the size of the pinch test. If it’s 1.5cm, one vial will be enough for an area of 10cm by 10cm. If it 2.5cm, then I would use two vials, if it’s 3.5cm, then three vials in the same area. As far as I’m aware, according to the clinical trials, they have used over five vials per session without seeing any changes in terms of levels of patient

safety. It is more a precaution, to avoid people using too much. Dr Frank Rosengaus: We started using both deoxycholic and PTC, thinking that deoxycholic was what controlled the activity of PTC. However, studies by Dr Rotunda and Doris Duncan clinically proved that the active ingredient is deoxycholic. I’ve been using it for 20 years and have treated around 4,000 patients. The only problem that you will have is if you inject too superficially, which can cause problems with skin necrosis. Other than that, it’s very rare that I have problems with deoxycholic. Now we know that the PTC is actually what makes it less aggressive, with less redness, less pain and less inflammation—if you take that out, the pain Q: Is it true that Aqualyx can raise cholesterol levels very high and cause liver

damage—and this is why the 5-6 vial maximum was suggested? Dr Vincent Wong: It has been suggested by some doctors and the media that the use of Aqualyx can cause a raise in blood sugar levels and cholesterol levels. This is untrue and unfounded. No changes have been observed in the clinical trial. Diabetes and hypercholesterolaemia are complicated diseases. I think if your patient is healthy, the body will be able to cope with it. Dr Frank Rosengaus: I agree. Many years ago we carried out studies on our own patients, and then more clinical studies came out. If you go and read the pre-approval of the FDA from February 2015, you will also see that multiple studies were undertaken and there was no increase in cholesterol. Q: What do you think about using Aqualyx on lipomas?

56 PANEL I body language

good results. However nobody wanted to take on the expense of going through the process for FDA approval because it’s a synthetic of a natural substance, deoxycholic, so it’s not patentable. It took all these years for somebody to go through the process. I never used it for the eyelid—I saw it on the eyelids and thought it was dangerous. I use it on the jowl, and submental injection.

In the States, if you get approved treatment for one area you can use it off-label for other areas

Does it work, and if so, what’s your surgery-versusnon-surgical experience on this? Dr Vincent Wong: I have treated a few lipomas, especially on the back area, and Aqualyx has given very good results. Usually, with Aqualyx for lipomas, you will need about two or three sessions, but the results are fantastic. Dr Frank Rosengaus: We have used Aqualyx when patients don’t want a scar to be removed surgically. If used on the back and the shoulders that’s no problem, but in other areas it’s better to try first with a lipolytic injection. It does work, but I don’t think it goes all the way to 100%, because they are encapsulated and there’s a residual lump. If you want to remove the capsule completely with a lipoma, then you have to go surgically. Mr Taimur Shoaib: For deep lipomas that are greater than 10cm wide, which are through the deep facia or through the Scarpa’s facia, you should MRI them first, in case they are a sarcoma.

Q: In terms of using Aqualyx for body contouring, which areas is it suitable for? Dr Vincent Wong: It can be used anywhere, apart from periorbitally. Dr Frank Rosengaus: It can be used everywhere, but you don’t get the same results everywhere. If your patient wants treatment for “bra-fat” or anything on the back you will get excellent results. But the inner thighs for example are very difficult to treat because there’s a lot of laxity of the skin. You need to inform your patient about the possibility that there may be some residual lumps. Q: The injection of the eyelid fat was once used in Brazil, and for a while it was completely prohibited. Could you explain more about your experience, and why it was withdrawn? Dr Frank Rosengaus: A complication appeared, not on the eyelids but with skin necrosis. In Brazil it was then prohibited, but it stayed legal in Europe. People wanted to revive it because there were very

Q: Could you explain the Kybella FDA approval in more detail? Dr Frank Rosengaus: In the States, if you get approved treatment for one area, such as Kybella is for submental fat injection, you can use it off-label for other areas. Mr Taimur Shoaib: You can, but what you cannot do is tell your patients any information as to what the adverse effects are likely to be or what the expected result is going to be. If you treat something onlabel, you have the data to tell your patients, this is the expected result, these are the adverse affects, this is the risk profile. We use off-label drugs on a very regular basis. Botulinum toxin, and neuromodulators in particular are used outside of their licence, but so long as we tell our patients this, and inform them that we don’t know what the percentage risk is if they ask, then we have counselled our patients appropriately. Dr Vincent Wong is an Advanced Medical Aesthetics Practitioner and founder of La Maison de l’Esthétique. He specialised in nonsurgical treatment.

Dr Frank Rosengaus is a Facial Plastic Surgeon. With over 20 years of experience, he is recognised as a world renowned leader in aesthetic plastic surgery. Mr Taimur Shoaib is a Specialist Consultant Plastic Surgeon in Glasgow at La Belle Forme Clinic, and he has a special interest in facial surgery.

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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TRAINING

DATES

* Only available to doctors, dentists and medical nurses with a valid registration number from their respective governing body. FB - FULLY BOOKED All courses in London unless specified.

E: TRAINING@WIGMOREMEDICAL.COM

I T: +44(0)20 7514 5979

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

2 Surface Whitebox FB 3 Sculptra* 5 Microsclerotherapy* 10 Intro to Toxins* 11 Mini-Thread Lift & Dermal Filler* 12 Advanced Fillers-TT* (am) 12 Advanced Fillers-CH* (pm) 13 Mini-Thread Lift & Dermal Filler* 14 Dracula PRP* 16 ZO Basic (Manchester) 17 ZO Interm. (Manchester) 21 CPR & Anaphylaxis Update (am) 21 Skinrölla Dermal Roller (pm) 22 Skincare & Peels 22 ZO Medical Basic (Dublin) 23 ZO Medical Interm. (Dublin) 23 Intro to Toxins* 24 Intro to Fillers* 25 Mini-Thread Lift & Dermal Filler* 28 ZO Medical Basic FB 29 ZO Medical Interm. FB 30 ZO Medical Basic FB

3 Microsclerotherapy* 5 Non-Surgical Rhinoplasty 9 Advanced Fillers-TT* (am) 9 Advanced Fillers-CH* (pm) 10 Mini-Thread Lift & Dermal Filler* FB 11 Surface Whitebox FB 12 Dracula PRP* 15 Core of Knowledge—Lasers/IPL 18 Mini-Thread Lift & Dermal Filler* 20 Skincare & Peels 20 ZO Medical Basic (Dublin) 21 ZO Medical Adv. (Dublin) 21 Intro to Toxins* 22 Intro to Fillers* 26 ZO Medical Basic 27 ZO Medical Interm. 28 ZO Medical Adv.

2 Non-Surgical Rhinoplasty 6 Mini-Thread Lift & Dermal Filler* 7 Advanced Toxins* (am) 7 Advanced Fillers-LF* (pm) 9 Dracula PRP* 10 ZO Medical Basic 11 ZO Medical Interm. 13 CPR & Anaphylaxis Update (am) 13 Skinrölla Dermal Roller (pm) 17 Skincare & Peels 17 ZO Medical Basic (Dublin) 18 Intro to Toxins* 18 ZO Medical Interm. (Dublin) 19 Intro to Fillers*

1 ZO Medical Basic 2 ZO Medical Interm. 3 Core of Knowledge—Lasers/IPL 4 Advanced Fillers-TT* (am) 4 Advanced Fillers-CH* (pm) 5 Mini-Thread Lift & Dermal Filler* 6 Microsclerotherapy* 7 Dracula PRP* 8 Skincare & Peels 8 ZO Medical Basic (Dublin) 9 ZO Medical Interm. (Dublin) 9 Intro to Toxins* 10 Intro to Fillers* 11 Non-Surgical Rhinoplasty 14 Surface Whitebox

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

58 EDUCATION I body language

training TF

TOXINS AND FILLERS

3 August, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Leeds W: cosmeticcourses.co.uk 7 August, Advanced Fillers, Tear Troughs (am) and Advanced Toxins (pm), Wigmore Medical 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.com 22-23 August, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 24 August, Foundation Botox & Dermal Filler Training, Cosmetic Courses, London W: cosmeticcourses.co.uk 5 September, Combined Basic Training, Dermal Filler and Botulinum Toxin, Honey Fizz, Newport W: honeyfizz.co.uk 10 September, Intro to Toxins, Wigmore Medical, London W: wigmoremedical.com 12 September, Advanced Fillers, Tear toughs (am) and Cheeks and Mid Face (pm), Wigmore Medical, London W: wigmoremedical.com 12 September, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Birmingham W: cosmeticcourses.co.uk 14 September, Botox Training Course, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk 14 September, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Leeds W: cosmeticcourses.co.uk 23-24 September, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 3 October, Foundation Botox & Dermal Filler Training, Cosmetic Courses, London W: cosmeticcourses.co.uk 9 October, Advanced Fillers, Tear toughs (am) and Cheeks/Mid Face (pm), Wigmore Medical, London W: wigmoremedical.com 10 October, Hyperhidrosis Training, Honey Fizz Training, Newport W: honeyfizz.co.uk 18 October, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Leeds W: cosmeticcourses.co.uk 21-22 October, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com

OTHER INJECTABLES

5 September, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com

18 September, Microneedling training, Eden Aesthetics, London W: edenaesthetics.com

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

21 September, Skinrรถlla Dermal Roller (pm), Wigmore Medical, London W: wigmoremedical.com

14 September, PRP, Wigmore Medical, London W: wigmoremedical.com

22 September, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com

25 September, Mini Thread Lift, Wigmore Medical, London W: wigmoremedical.com

28-29 September, ZO Basic and Intermediate, Wigmore Medical, London W: wigmoremedical.com

3 October, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com

5 October, Non-Surgical Rhinoplasty, Wigmore Medical, London W: wigmoremedical.com

1-3 August, Low Level Laser Therapy, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com

10 October, Mini Thread Lift, Wigmore Medical, London W: wigmoremedical.com

11 August, Low Level Laser Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

12 October, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com

12 August, Core of Knowledge, Lasers/IPL, Wigmore Medical, London W: wigmoremedical.com

18 October, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com

15 October, Core of Knowledge, Lasers/IPL, Wigmore Medical, London W: wigmoremedical.com

SKINCARE

4-6 August, ZO Medical Basic, Intermediate and Advanced, Wigmore Medical, London W: wigmoremedical.com

LASERS/RF/ULTRASOUND

OTHER TRAINING

Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 1 September, Chemical and Physical Remodelling, SkinMed, Bristol W: skinmed.co.uk 2 September, Microdermabrasion, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 7-8 September, Advanced Skin Restoration, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 8 September, Chemical and Physical Remodelling, SkinMed, Burnley W: skinmed.co.uk 15 September, Chemical and Physical Remodelling, SkinMed, Birmingham W: skinmed.co.uk 15-16 September, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 17-18 September, Radio Frequency, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 18-20 September, Chemical Peels, Botox, Fillers & Lasers, American Academy of Aesthetic Medicine, London W: europeaestheticmedicine.com

1-3 August, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com

21 September, CPR & Anaphylaxis Update (am), Wigmore Medical, London W: wigmoremedical.com

1-3 August, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com

22 September, Chemical and Physical Remodelling, SkinMed, London W: skinmed.co.uk

14-15 August, Advanced Skin Restoration, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

5-6 August, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

23 September, Advanced Facial, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

18 August, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com

7-8 August, Radio Frequency, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

24-25 August, Surface Whitebox, Wigmore Medical, London W: wigmoremedical.com

11 August, Chemical and Physical Remodelling, SkinMed, Leicester W: skinmed.co.uk

25-27 September, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com

2 September, Surface Whitebox, Wigmore Medical, London W: wigmoremedical.com

12 August, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

13 August, Surface Whitebox, Wigmore Medical, London W: wigmoremedical.com

7 September, Agera skincare & peel training, Eden Aesthetics, Essex W:edenaesthetics.com 8 September, Epionce skincare & peel training, Eden Aesthetics, Essex W:edenaesthetics.com 9 September, Microdermabrasion training, Eden Aesthetics, Essex W:edenaesthetics.com 9 September, Microneedling training, Eden Aesthetics, Essex W: edenaesthetics.com/events.php

8 August, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com

15 September, Agera skincare & peel training, Eden Aesthetics, Glasgow W: edenaesthetics.com

1 September, Sculptra, Wigmore Medical, London W: wigmoremedical.com

16 September, Epionce skincare & peel training, Eden Aesthetics, Glasgow W: edenaesthetics.com

3 September, Sculptra, Wigmore Medical, London W: wigmoremedical.com

17 September, Microneedling training, Eden Aesthetics, Glasgow W: edenaesthetics.com/events.php

13 August, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 18 August, Chemical and Physical Remodelling, SkinMed, London W: skinmed.co.uk 25 August, Pressotherapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 25 August, Chemical and Physical Remodelling, SkinMed, Harrogate W: skinmed.co.uk 26 August, Beautiful Image, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 27 August, Ultrasound for Skin Rejuvenation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 1 September, Infrared, Academy of Advanced

25-27 September, Radio Frequency, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 25-27 September, Pressotherapy, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 28 September, Low Level Laser Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 29 September, Chemical and Physical Remodelling, SkinMed, Harrogate W: skinmed.co.uk 29 September, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 30 September, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 20 October, Chemical and Physical Remodelling, SkinMed, London W: skinmed.co.uk If you would like to submit details for medical aesthetic training courses to be featured in Body Language Journal and online, contact arabella@face-ltd.com



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

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

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

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

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

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

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The filler you’ll love 1. BEL-DOF3-001_1. Belotero® technology, March 2014. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI: 10.1159/000354384.