Body Language Journal #76

november

76

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

THREAD LIFTING WE EXAMINE THE INDICATIONS AND TECHNIQUES FOR FACIAL REJUVENATION USING THREADS

PDO THREADS

ANTI-AGEING

EQUIPMENT

Placement for skin rejuvenation and facial tissue anti-ptosis

A combined approach to facial ageing using Aptos threads, PRP, fillers and toxins

The myriad causes and treatments for the problem of cellulite

body language I CONTENTS 3

14

49

57

contents 07 NEWS Reports and comments

Dr Albina Kajaia takes us through a combined approach to facial ageing

14 MEDICAL AESTHETICS

41 MEDICAL AESTHETICS

MODERN TATTOO REMOVAL METHODS

TREATING CELLULITE

OBSERVATIONS

Dr Catherine de Goursac discusses the various methods of removal

21 TECHNIQUE POLYDIOXANONE THREADS FOR SKIN REJUVENATION AND FACIAL TISSUE ANTI-PTOSIS Dr Jacques Otto discusses the indications that can be treated by placement of PDO threads and his technique

27 TECHNIQUE ABSORBABLE THREAD LIFTING Dr Kwon Han Jin explains the benefits of thread lifting and his techniques for long lasting results

31 PRACTICAL THREAD LIFTING TREATMENTS Dr Sarah Tonks discusses the uses of thread lifting and how clinics should adopt it

35 TECHNIQUE THREADS AND AGEING

Mr Chris Inglefield delves into the myriad causes and treatments available for cellulite

45 INNOVATION MICRO-CHANNELLING Dr David Eccleston explains the technology behind Radara

49 SKINCARE DEMYSTIFYING THE USE OF STEM CELLS IN COSMECEUTICALS Dr Charlene De Haven demystifies stem cells in the cosmeceutical industry and how they can be effectively applied.

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

57 EQUIPMENT TAKE CONTROL OF THE AGEING PROCESS Dr Sharon Crichlow discusses treatment options, including the Clear + Brilliant laser system

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.

Dr Masud Haq BSc, MRCP, MD is a consultant in diabetes and endocrinology.He is a graduate of Guy’s and St Thomas’s Hospital, and trained at Johns Hopkins in the US and in Melbourne. He has a particular interest in the thyroid and menopause.

Fiona Collins and Marie Duckett are registered nurses and members of the Royal College of Nursing forum for nurses in aesthetic medicine. Their clinic, Fiona and Marie Aesthetics Ltd, is based in Harley Street, London, UK.

27 EDITOR Helen Unsworth 020 7514 5989 helen@face-ltd.com ASSISTANT EDITOR Lousie Renwick 020 7514 5989 louise@face-ltd.com COMMISSIONING EDITOR David Hicks 020 7514 5989 david@face-ltd.com EDITORIAL ASSISTANT Arabella Tanyel 020 7514 5989 arabella@face-ltd.com SALES EXECUTIVE Monty Serutla 020 7514 5976 monty@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Dr Catherine de Goursac, Dr Jacques Otto, Dr Kwon Han Jin, Dr Sarah Tonks, Dr Albina Kajaia, Mr Chris Inglefield, Dr David Eccleston, Dr Charlene De Haven, Dr Sharon Crichlow 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

LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE)

Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients.

In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis.

Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection Date of preparation: March 2013

site(s) or when the targeted muscle shows excessive weakness or atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection.

Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions.

Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

(twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to Galderma (UK) Ltd.

AZZ/021/0313

body language I NEWS 7

observations

WHICH DERMAL FILLER TO STICK TO? Researchers have developed a standard test for comparing the cohesivity of hyaluronic acid (HA) dermal fillers Realising that plastic surgeons are looking for evidence to help them choose the dermal fillers to give the best results for minimally invasive treatment of facial lines and wrinkles, Dr Hema Sundaram, a dermatologist in Rockville, Md; Samuel Gavard Molliard, a scientist in Geneva, Switzerland; and colleagues have developed a validated method for providing standard ratings of cohesivity.

In light of this, the researchers developed a standard test for comparing the cohesivity of HA dermal fillers. Samples of six FDA approved filler gels were dyed, added stirred into water.

An experienced panel of plastic surgeon and dermatologist specialists then rated each sample’s cohesivity on their self created five-point ‘Gavard-Sundaram’ scale.

Cohesivity was rated as high for one product, medium to high for three, low to medium for one, and low for one.

In the October issue of Plastic and Reconstructive Surgery Dr Sundaram and coauthors write that “Cohesivity... maintains gel integrity, contributes to tissue support with natural contours, and diminishes surface irregularities.”

However, the greatest cohesivity isn’t necessarily the best, so the goal of the ranking system is to “provide a scientific rationale

for the intuitive selection of different products for specific clinical objectives”, to help plastic surgeons choose the filler with properties that are most suited to the precise purpose for which it is being used.

Fillers with higher

cohesivity may be wiser for more superficial placement, or placement in mobile areas such as around the mouth or eyes. Products with lower cohesivity may be effective for use as “deep volumisers”, according to Dr Sundaram and co-

authors.

The researchers believe that comparative data on cohesivity and other rheologic properties, such as elasticity and viscosity is an advance that can make dermal filler procedures more sophisticated and successful.

8 NEWS I body language

events 4-8 NOVEMBER, 4th Annual DASIL Congress, Ho Chi Minh City, Vietnam W: thedasil.org 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 19-20 NOVEMBER, Abu Dhabi International Conference in Dermatology and Aesthetics (AIDA), Abu Dhabi, United Arab Emirates W: menaconf.com 27-28 NOVEMBER, Clinical Facial Anatomy Winter Session, Amsterdam, W: euromedicom.com 29 NOVEMBER – 2 DECEMBER, ENT Courses — 2nd Singapore Advanced Rhinoplasty Fresh Frozen Cadaveric Dissection Course, Singapore W: singaporeentcourses.com.

2-3 DECEMBER, The Cutting Edge 2015, New York, USA W: nypsf.org 2-5 DECEMBER, Cosmetic Surgery Forum, Las Vegas, USA W: cosmeticsurgeryforum.com 10-13 DECEMBER, Annual World Congress on Anti-Aging Medicine, Las Vegas, USA W: a4m.com

FAT GRAFTING FOR CALF AUGMENTATION

14-17 DECEMBER, AOCMF Course Principles in Craniomaxillofacial Fracture Management, Davos, Switzerland W: davos1215.aocmf.org

Fat grafting is revolutionising aesthetic body contouring and the treatment of soft-tissue, volume-related issues

15 – 18 JANUARY 2016, ODAC Orlando Dermatology Aesthetic & Clinical Conference, Florida, USA W: orlandoderm.org

A study published in the Aesthetic Surgery Journal, the official publication of ASAPS, showed that fat grafting for correction of slender calves—either for cosmetic purposes or for differences between legs due to deformities, infections, or trauma—is a viable alternative to traditional calf augmentation using implants.

“Autologous fat augmentation offers a number of advantages over calf implants, including liposuction in adjacent areas to improve calf contour, smaller incisions, additional augmentation through subsequent fat grafting, durable results, lack of foreign body reaction, and precise patient-specific adjustments not possible with off-the-shelf implants,” said Dr James E Vogel, corresponding author and

28 – 31 JANUARY, IMCAS Annual World Congress, Paris, France W: imcas.com/en

ASAPS member.

In the five year study, 13 patients received calf augmentation and reshaping with autologous fat grafting. Ten patients underwent bilateral calf augmentation, and three procedures were performed for congenital leg discrepancies. Fat was harvested from the abdomen, lateral thigh, medial thigh, waistline, flanks, axilla, upper back, and hips.

Irrespective of the fat harvest site, liposuction was also performed at the knee to improve contour.

“Local anesthesia was injected prior to fat transfer to utilise the smallest amount of effective anesthetic volume and to precisely place it into the muscle resulting in less sedation and more rapid postoperative recovery,” explains Dr Vogel.

11-14 FEBRUARY, South Beach Symposium 2016, Jacksonville, USA W: southbeachsymposium.org 30 MARCH – 2 APRIL, AMWC 2016, 14th Aesthetic & Anti-aging Medicine World Congress W: euromedicom.com 30 MARCH – 3 APRIL, ASLMS 2016, Annual Conference of the American Society for Laser Medicine and Surgery, Boston, USA W: aslms.org 27-30 APRIL, 32nd Annual American Academy of Cosmetic Dentistry Scientific Session, Toronto, Canada W: aacdconference.com Send events for consideration to arabella@face-ltd.com

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Approved for glabellar and crow’s feet lines

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection.

Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml).

Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection.

Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness.

Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, dry eye. General disorders and administration site conditions; Common: injection site haemotoma.

Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251.

2. Imhof, M & Kühne, U. A phase III study of incobotulinumtoxinA in the treatment of glabellar frown lines. J Clin Aesthet Dermatol 2011; 4(10):28-34.

3. Data on File: BOC-DOF- 012 Bocouture® - Convenient to use August 2015.

Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. BOC/6/SEP/2015/LD Date of preparation: September 2015

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body language I NEWS 11

60

second brief

AGEING GRACEFULLY

Women most likely to opt for cosmetic surgery at age 44 New research conducted by The Harley Medical Group found that women are most likely to undergo Cosmetic Surgery at the age of 44. Signs of ageing typically start to show around this age and the investigation showed that it’s at this phase of life that women are prompted to re-address their appearance.

1. Number one most desired surgery was a tummy tuck 2. Breast Augmentation was second most popular

Surgical aims are slight adjustments to make them look like ‘themselves on a really good day’ rather than recreating the body of a 20-something.

Understated surgery results are most desirable Almost 50% of women wouldn’t tell their family or friends about the procedure

50%

72% of women want minor changes that only they can notice

72%

DYING FOR A TAN Brits continue to ignore sun’s deadly risks Australia sun care company SunSense has produced a video to highlight the dangers of tanning, using powerful footage of their ‘Dying for a Tan’ campaign and live reactions to the UV camera. Over 1,200 participants were surveyed during the ‘Dying For a Tan’ tour, revealing that more than half of people believe it is safer to build a base tan before going on holiday and that nearly two thirds would overlook the long-term health risks for the sake of a sun-kissed appearance.

Using a UV camera, SunSense showed people the pigmentation changes, potentially caused by sun damage that are hidden deep in the layers of skin—invisible to the naked eye. Seeing the damage to their own skin had a positive impact on 70% of participants, with 25% saying they would now avoid unnecessary sun exposure and 45% that they may still sunbathe, but would use a higher factor sunscreen protection.

Dr Kerryn Greive PhD, Scientific Affairs Manager for SunSense comments: “There is no such thing as a healthy tan, but having one makes us feel good. Unfortunately, exposure to UV radiation from the sun and other sources, including sun beds, is a major cause of skin cancer.

“Despite this, it is difficult to get people to understand how bad a tan can be. A lot of people don’t believe that the sun is strong enough in the UK to do any real damage and even if they do, they consider skin cancer as something that happens to other people, or something that may happen in the future. But it’s the tan we are getting today that may cause skin cancer.

“Australia may be known as the skin cancer capital of the world, but it is also the first country in the world to see a reduction in skin cancer rates. This follows 30 years of public health campaigns which shows that if you are consistent with the message, you will see the benefit to people’s health.

“Skin cancer is also a serious problem in the UK and we believe that there is a lot that the UK can learn from Australia. We hope that the Dying for a Tan tour has helped to get the message across and provide the British public with the facts they need to make an informed decision about their health.”

In Australia, the advice is to combine a high factor sunscreen with sun-protective clothing, a hat that protects the face, head, neck and ears, shade and sunglasses. If people avoid unnecessary sun exposure and follow this advice when they are out and about, even on cloudy days, then the risk of premature ageing and skin cancer may be significantly reduced.”

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body language I NEWS 13

EXERCISE PILL New exercise pill being explored by scientists following increased understanding of molecular pathways

MICROFOCUSED ULTRASOUND Small study shows treatment is safe for patients with darker skin Microfocused ultrasound (MFU) treatment to tighten and lift face and neck skin was found safe for patients with darker skin types according to a report published online by JAMA Facial Plastic Surgery.

In a small study that resulted in only a few temporary adverse effects, a non-randomised trial in 52 patients demonstrated the safety of MFU for improving laxity of the skin in adults with Fitzpatrick skin types III to VI. Normal ageing means changes to skin and underlying connective tissue. A system that uses MFU together with ultrasound visualisation was developed to treat lax, ageing skin. Previous clinical trials have shown the system to be a safe and effective non-invasive aesthetic treatment, according to the study background.

The authors report only three adverse events—mild edoema or welts and moderately severe prolonged erythema with mild scabbing which all resolved after 90 days without complications.

“When performed by trained physicians, MFU is safe in patients with Fitzpatrick skin types III to VI,” the study concludes.

In the Journal Trends in Pharmacological Sciences, Ismail Laher, of the University of British Columbia in Vancouver, Canada, and Shunchang Li, of Beijing Sport University in China, claim increased understanding of the molecular pathways by which exercise benefits the body means an “exercise pill” is feasible.

“Regular physical exercise activates a number of molecular pathways in whole organ systems and reduces the risk of developing numerous chronic diseases,” the authors explain. “The signalling molecules activated by physical exercise are logically considered to be potent pharmacological targets for such exercise pills.”

One exercise-mimicking drug, AICAR, works by activating the protein AMPK, which plays a key role in maintaining the body’s energy balance, and also interacts with PGC-1x—a protein that the researchers say “induces mitochondrial biogenesis and fiber-type transformation in skeletal muscles.”

“Thus, treatment with AICAR activates AMPK, and AMPK then interacts, either directly or indirectly, with PGC-1x, inducing improved oxidative metabolism, mitochondrial biogenesis, and fiber-type transformation in skeletal muscle,” they

explain. “Taken together, this suggests that AICAR is capable of mimicking a broad spectrum of exercise-like adaptation in skeletal muscle.”

Dr Ismail Laher summed up these recent advances and said an exercise pill could be “an achievable goal”.

He explained that exercise is crucial for lessening the risks of certain diseases and cancers but for some people it was not a practical option.

He said: “a pill for people with spinal cord injury could be very appealing given the difficulties that these individuals face in exercising due to paralysis--in such patients, a large number of detrimental changes occur in cardiovascular and skeletal muscle function.”

The authors are positive about the future of exercise pills, but are realistic in acknowledging that drugs cannot act as a substitute for all benefits of physical activity.

“Clearly people derive many other rewarding experiences from exercise—such as increased cognitive function, bone strength, and improved cardiovascular function,” says Laher. “It is unrealistic to expect that exercise pills will fully be able to substitute for physical exercise—at least not in the immediate future.”

14 MEDICAL AESTHETICS I body language

Modern tattoo removal methods As tattoos continue to rise in popularity, so too does the business of tattoo removal. DR CATHERINE DE GOURSAC discusses the various methods to remove both medical and artistic tattoos

H

aving a tattoo is a way to decorate the body, as with permanent makeup. However, more and more people are regretting it, which means the tattoo removal market is growing fast. Tattoo removal refers to all the processes used to remove a tattoo or permanent makeup.

Nowadays, three main techniques exist to remove a tattoo: surgical removal procedure, laser or chemical alternative methods. These chemical methods have their place in the practice of tattoo removal because of the potential risks of the laser on the health, its inefficiency on some colours and its cost. However, none of the techniques are perfect.

Tattoos Nowadays, having a tattoo is fashionable, but we must distinguish the aesthetic tattoo from the artistic tattoo.

Doctors or aestheticians create aesthetic tattoos, permanent makeup or long-term makeup which concerns mostly the faceâ&#x20AC;&#x201D;lips, eyebrows, or eyes. The repairing or medical dermo-pigmentation can be suggested to redraw the mammary areola after a breast surgery further to a cancer or to hide scars.

Artistic tattoos are an indelible mark, made on the body by tattoo artists.These two techniques use a tattoo machine, an electrical device working on the basis of an up and down movementâ&#x20AC;&#x201D;the needle enters the skin and puts the ink in.

The difference between aesthetic and artistic tattoos is about the placement depth and the pigments used.

For long-term makeup, the tattoo machine implants the pigments superficially, at the limit of the epidermis and the dermis, which explains that the colour fades over time. The pigments are made in a

laboratory, have a CE marking and are part of an implantable medical device.

For an artistic tattoo, the pigment is implanted deeply in the dermis to get an irreversible drawing. The professional tattoo machine enables a dense, regular and deep application of the polychrome pigments, which make them resistant to the tattoo removal at the difference of the non-professional tattoos, which are generally more superficial and monochrome.

Nowadays, professional tattooists have a very large colour palette. Inks are made of coloured pigments, solvent (in general alcohol which enables the dispersion of pigments and the sterility of the ink) and additives to make the final product stable and homogeneous. Most of the actual pigments are metallic salts and azo dyesâ&#x20AC;&#x201D;chemical industrial prod-

body language I MEDICAL AESTHETICS 15

ucts to make red, yellow or orange inks. These azo dyes are likely to contain potentially carcinogenic aromatic amines or to free them through degradation (under laser shot). Their safety is not proved. In addition to classic ingredients, the professional artists can add their own ingredients to “customise” the ink. The chemical composition of inks used by tattooists remains very unclear.

The European regulation of January 2014 has listed the pigments prohibited for health reasons, and suppliers must be responsible for the compliance of these pigments. However, some grey areas remain about the health risks of

66 Three main techniques exist to remove a tattoo: surgical, laser and chemical 99

some authorised pigments.

A tattoo is not inoffensive and can lead to local or systemic cutaneous risks:  Risk of infection related to the skin (needles entering the skin, non-sterile inks, poor hygiene conditions).  Since 2008, a decree regulates the implementation of tattooing and makeup techniques by requiring the professionals to respect strict hygiene and health regulations, to reduce contamination risk. These infectious risks have become rare and have a favourable evolution.  Risks of allergic reactions related to tattoo inks, for instance, red coloured pigments can be responsible for numerous cases of allergic contact dermatitis, itches, oedema and red patches.  Toxicological risks related to the composition of the ink. Pigments made with metallic salts and organic dyes—sometimes

with additives—enter the dermis and remain in the skin.

They can have local or systemic side effects, in particular carcinogenic effects. However, their effect on the health is badly known.  A cicatricial reaction is possible from the hypertrophic scars to the keloids.

To remove a permanent tattoo from the skin is not without consequences in terms of healing, health, aesthetic or price. Histologically, the insoluble pigment is intracellular—in the macrophage of the dermis. It cannot be eliminated from the immune system and remains in the dermis. To remove a tattoo, the ink has to be rejected in the extracellular area (the immune system recognises it as a foreign body) or the cells charged in pigments.

Tattoo removal A doctor will carry out a preliminary consultation in order to dis-

16 MEDICAL AESTHETICS I body language

miss contraindications such as pregnancy, and then will establish criteria to determine the efficiency of tattoo removal:  Phototype.  Area of the tattoo.  Type of the tattoo: a non-professional tattoo is usually easier to remove than a polychrome professional tattoo.  The depth of the pigment: a non-professional tattoo made by the patient himself/herself can be deeply embedded (in the hypodermis).  The nature of the pigments (mineral, azo).  Quality of the healing of the patient.

Previous practices such as trichloroacetic chemical peeling (TCA) or dermabrasion (mechanical sanding of the skin with a grindstone) was used to remove a tattoo, but they were dropped because of the risks of hypertrophic scars or keloids after the procedure.

Modern methods of tattoo removal Nowadays, three therapeutic options are possible for tattoo removal: surgical removal and physical destruction through laser and chemical tattoo removal are considered as the standard treatments.

Surgical Tattoo Removal The surgery is to entirely remove the tattoo with a scalpel, under anaesthesia. This operation is made for small tattoos or low width linear tattoos. However, some scars will remain.

Laser Tattoo Removal Laser tattoo removal (meaning light amplification by stimulated emission of radiation) is a modern method based on physical destruction of the pigments. The light energy of the laser should have a specific wavelength to be absorbed by an ink colour. The first techniques using ablative lasers (CO2 Laser or Er:YAG laser) and including excision of the skin left ungraceful scars. Non-ablative lasers took over from these methods which led to an improvement of the results and a reduction of the cicatrical risks. The photothermal laser, QSwitched (with a wavelength of

532nm) makes very short impulses, expressed in nanoseconds (10 seconds), goes through the superficial part of the skin to divide to pigments of the tattoo by heating them to transform them into fine particles.

In 2013, a new generation of lasers appeared on the market, such as the PicoSure laser, 755 nm from Cynosure. It is a laser with a time of impulse expressed in picoseconds (10 seconds). These ultra-short impulses creates a photomechanical effect and divide the ink into tiny particles. They are more easily eliminated by the organism while minimising the thermal effect with the nanosecond laser and consequently the risk of burns.

The last generation of picosecond lasers combine two wavelengths 532 nm and 1064 nm in one device. Marketed under the name of PicoWay from Syneron Candela and Enlighten from Cutera. These new lasers are able to treat blue and green inks as well as colours which are particularly difficult to remove as red and yellow.

After a treatment with a picosecond laser, the healing is faster and it allows the patient to halve the number of sessions and their spacing—every four weeks instead of eight with a nanosecond laser.

Potential health risks When the laser hits the skin, the ink is divided into small particles and is spread in the body through the lymphatic system and the blood system. Azo dyes, industrially manufactured, are also divided and freed in the organism as chemical by-products (aromatic amines) known for their potentially toxic and/or carcinogenic properties.

The potential inherent toxicity of these compounds requires extensive research, because their mid or long-term effects could present some risks for the health unlike the chemical removal, which rejects the ink at the surface of the skin.

Laser complications After the session, the skin is erythematous and with oedema on the area of the treatment for some time. Even if side effects due to a laser treatment are rare and mostly temporary, a risk of dermatological

66 Laser tattoo removal is a modern method based on physical destruction of the pigments 99 complications still exists:  Pigmentation troubles are possible, from hypopigmentation to hyperpigmentation, especially for dark phototypes.  Changes in the skin texture: wrinkled appearance or slight effect of depth on the skin in the case of 3D tattoos.  Some light colours such as yellow or white can become dark.

This paradoxical darkening can lead to an aesthetic change.

These colours can be removed with other laser sessions.  A local infection is always possible but rare.  The risk of hypertrophic or keloid scars raises in certain situations such as tattoo removal on dark skin, pigments too deep into the dermis, post-treatment badly managed.  Incomplete, even impossible,

body language I MEDICAL AESTHETICS 17

elimination of all traces of tattoo ink. Polychrome tattoos, in particular pastel colour and yellow, can respond badly to the treatment. A phantom tattoo (residual traces) can be observed at the end of the treatment.  Having multiple colours requires several sessions and most of the time using different lasers to treat multicolour tattoos.

To get a full tattoo removal on the same area, it is necessary to use technical equipment with a polyvalent laser.  Laser tattoo removal is a strictly medical act which has to be performed by a qualified doctor.  Very expensive procedure.

When the laser hits the skin, the ink is divided into small particles and is spread in the body through the lymphatic system and the blood system

Chemical Tattoo Removal Anti-tattoo creams (Tat B Gone, Tattoo-OFF on the American market, or Belle&Nette in France) are presented as a simple, efficient, inexpensive and easy to use way to remove a tattoo, by the patient at home. According to the manufacturer, the person just has to apply the cream daily, during several months, to remove a tattoo or permanent makeup. This tattoo removal technique is not recommended. In fact, for a treatment

to act on the pigments, it needs to reach the dermis. A cream simply applied through a massage cannot destroy the pigments. The ingredients of those creams are either totally inefficient, or contain active ingredients as depigmenting agents made with highly toxic hydroquinone or TCA, highly irritating for the skin.

Chemical extraction methods The process of chemical tattoo removal frees the ink through the surface of the skin by the injection of an anti-tattoo liquid, without leaving any traces in the organism and without damaging too much the skin, to avoid the risks of scars.

Dr Variot developed the first process of chemical tattoo removal by the destruction of the pigments at the end of the 19th century, on some prisoners. His method consisted of pricking the skin with a needle soaked in a solution of tannin and then using a silver nitrate pencil for better healing. A pressure ulcer appears and falls off about fifteen days after, which does remove the tattoo. Recently, several chemical extraction methods of the pigments appeared, which led

to an evolution of Variot’s original method. All these methods use similar devices as for a tattoo and are based on the extrusion of the coloured particles at the surface of the skin. Instead of injecting ink into the skin, a special tattoo removal liquid is injected through the skin with needles.

The anti-tattoo solution reacts with the macrophages, that contain the ink. Then, these cells lose their structure and the pigments of the tattoos are released in the extracellular area. Pigments are identified by the defence system of the organism as foreign bodies and are directly rejected at the surface of the skin. As a result, an inflammatory reaction causes a healing process with a crust. This scab comes off taking with it the inks of the tattoo. A healing cream is prescribed at the end of the treatment to accelerate the process.

These alternatives to the laser treatment are less expensive, colour-blind and potentially safer procedures as the pigments are definitively out of the organism.

The current available methods are distinguished only by the composition of the tattoo removal product.

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body language I MEDICAL AESTHETICS 19

Rejuvi’s method The Californian Rejuvi Laboratory developed a chemical extraction method called e-raze, involving the introduction into the tattooed skin of a diverse metallic oxide in suspension. Its effectiveness in clinical practice has been demonstrated by publications.

Trans epidermal pigment release technology (TEPR) The TEPR technology presents the advantage to be based on the theory of partial healing of the skin. Injections are made point by point on the tattooed surface of the skin, regularly spaced by “bridges” of untreated skin. These injection points allow the introduction of a specific tattoo removal solution.

The area of healthy skin facilitates the healing.

Two techniques based on the TEPR method are the Tatt2Away marketed by an American company Rejuvatek Medical Inc, and Skinial born in 2011, in Germany. The anti-tattoo liquid is made with lactic acid. To my knowledge, no clinical study has been yet published about them. These methods are made for medical and non-medical professions, beauticians for instance.

TEPR technology is also used by an innovative device, named Magic-Pen, made only for doctors or under their supervision. The Magic-Pen is a device, designed and manufactured by BFP Electronique AAMS (Anti Aging Medical Systems), Montrodat, France, with a medical CE-marking.

For most tattoos, the session will be performed with an adhesive stencil applied on the tattooed skin, previously disinfected and dry. The stencilling is an indispensable tool for the treatment because small areas can be treated by point by point injections with the specific formulation of the Magic-Pen. It leaves the nearby areas untouched, untreated, and ready to start the healing process of the treated areas.

This “partial” treatment allows the skin heal faster than if the whole tattoo was treated in one session.

Once the treated areas are healed, the process is repeated on the adjacent untreated areas.

Only three to four sessions are necessary, spaced every eight

weeks, for the tattoo to be completely removed. However, it is recommended not to exceed a treatment surface higher than 15cm².

The Magic-Pen is used like a tattoo machine. The needle, equipped with very thin medical microneedles, is adapted to the patient and limits the formation of a scar, because it makes only micro-perforations into the tattooed skin and can easily reach the dermis to inject the TEPR soultion. The TEPR solution of the Magic-Pen is a natural, patented solution, made of 40% of lactic acid. The lactic acid is an alpha-hydroxy cid (AHA), in the form of lactate, which naturally occurs in dairy products, wine, some fruits and vegetables and in the muscles. It is the main organic compound found in the sweat. The lactic acid is one of the normal compounds of the human body, made from the degradation of glucose. Consequently, it is a natural biocompatible product and is biodegradable. In the field of medical aesthetics, soft peelings produced with lactic acid are currently made in application on the skin, but their intra-dermal effects are under study. Apart the aforementioned advantages of chemical extraction methods of the pigments, this new device limits the cicatricial risk.

However, in some rare cases, these chemical removal methods can have side effects too. Red patches on the injection point, small burns on the tattoo area, infection, scars and allergic reactions. These techniques are more contraindicated to remove an eyeliner, because of the risk of burn on the ocular surface.

Conclusion It is not easy to remove pigments fixed in the dermis. The improvement of tattoo techniques and especially the diversity of the colours used and the complexity of the pigments make their destruction difficult. The surgical excision of a small tattoo is topical. Laser tattoo removal is a must these last years, in particular with new picosecond devices which seem promising. But this technique is expensive, and not always efficient in particular on multicoloured tattoos and often requires several sessions with

different lasers, and can have some consequences such as healing disorders, even keloids. Possible risks for the health associated to the dispersion of pigments particles in the organism requires extensive studies. Tattoo removal with TEPR technology, will maybe compete with laser tattoo removal because it is a less expensive method, quick and without major risk of scars.

This method is efficient on all colours and the ink is rejected at the surface of the skin so it minimises health risk.

Dr Catherine de Goursac is an aesthetic medicine expert. She is a member of the French Association of the Board of Aesthetic Medicine, a member of the board of directors of the FSMEA, general secretary of the French Association Anti-Aging and a member of the SFME. She has authored numerous scientific publications and published numerous works for the general public. W: degoursac. com; esthetiquemedicale.com

It is not easy to remove pigments fixed in the dermis.

The improvement of tattoo techniques and especially the diversity of the colours used and the complexity of the pigments make their destruction difficult

body language I TECHNIQUE 21

Polydioxanone threads for skin rejuvenation and facial tissue anti-ptosis DR JACQUES OTTO discusses the many indications that can be treated by placement of polydioxanone (PDO) threads, and his technique for doing so

P

olydioxanone (PDO) has been in use for over three decades in tissue engineering and surgery. It’s safe and used on a daily basis in hospitals for wound closure. There are no problems with allergic reactions or long-term complications. Compared to other absorbable threads, PDO is the longest lasting. It takes about 130 - 180 days to be resorbed and replaced by fibrosis. The Korean FDA approved mono 6-0 PDO threads in 2011 for the following indications: (1) neo vascularisation, (2) collagen type 1 and 3 regeneration and (3) lipolysis. Platelet-rich plasma (PRP) also gives neo-vascularisation and collagen regeneration via growth factor release, so that’s why PDO threads combined with PRP gives an enhanced effect.

Histology A large number of fibroblasts infiltration around the pair of threads shows an increase in new collagen fibres and a reduction in the number of fat cells—that’s the lipolytic effect. It’s not a significant lipolytic effect though, so if lipolysis is desired then insertion of threads combined with a lipolytic agent such as Aqualyx can be used to enhance the effect. However, the patient must be warned to expect gross swelling of the treated area.

Fibrous bridging can be observed between the threads and the perimysium of the muscle and also between the threads and the dermis. So, fibrous bridging occurs in all directions and fibrosis is not confined to the immediate area around the threads. Two to three

months later, contraction (tightening) of the fibrous bridging takes place.

In summary, skin remodelling takes place because of more capillaries, more fibroblasts, more collagen and less fat cells.

How PDO threads work Spiral 3-D multi-direction 2-0 thickness barbed threads (cog threads) give an immediate mechanical lift and the lift will continue to take place via fibrosis and tissue contraction over the next three to four months—an instant lift as well as a delayed lift. Plain mono threads can’t give an instant mechanical lift.

The plain mono threads inserted into the dermis or sub-cutaneous tissue result in neo-collagenesis and neo-vascularisation. In the adipose tissue, the threads cause a minor degree of lipolysis, and when inserted into the muscle the effect is muscle relaxation (mechanotransduction—acupuncture effect).

If loss of muscle function is not desired (botulinum toxin type A effect) then plain mono threads can be inserted into the muscle, for example into the masseters or gastrocnemius muscles. In Korea and the Far East it’s very popular to decrease the calf muscle (gastrocnemius muscle) for cosmetic reasons.

In order to reach the desired effect, too much botulinum toxin type A may be required rendering the patient unable to walk normally, especially when wearing high heeled shoes. By using threads, or a combination of threads and botulinum

“SMOKER” LINES

Top Lip: Mono double or double screw 25mm or 38mm 6-0. Insertion level: dermis. 1st thread in vermillion border.

2nd thread 3mm from 1st thread. 3rd thread 3mm from 2nd thread. 4th thread 3mm from 3rd thread. 5th thread 3mm from 4th thread. Bottom lip: Mono double or double screw 25mm or 38mm 6-0. Insertion: same as top lip VERMILLION BORDER AND PHILTRIM

Mono double 25mm 6-0 in sub dermis.

1st thread from vermillion border to nostril. 2nd thread 1mm from 1st thread. 3rd to 5th threads into vermillion border.

Total two threads into each philtrim.

toxin type A, muscle function is preserved.

Mechanotransduction forms the basis of how acupuncture can lead to new collagen regeneration.

It is the ability of the cell to sense, process and respond to mechanical stimuli. If one inserts the needle into subcutaneous tissue and twists it twice, a cellular activation process takes place. After the rotations, the fibroblasts around the needle become activated resulting in neocollagenesis. In the Far East, there

Lip and peri-oral threads insertion

22 TECHNIQUE I body language

are many clinics that perform facial acupuncture facelifts. However, repeated acupuncture needling sessions are required.

Facial ageing The ageing process in the face involves a number of components that need to be addressed: loss of skin volume and skin laxity, redistribution of facial fat, connective tissue ptosis and muscle hypertrophy1. All of the components require PDO threads. Tissue laxity and redistribution of subcutaneous fat contributes to (1) accentuation of the nasolabial fold and the para nasolabial fold, (2) hollowness under the eyes and tear trough accentuation and (3) jowl formation.

However, other factors play a part in jowl formation such as platysmal hypertrophy.

Thus, all of the abovementioned factors in facial ageing have to be addressed: (1) elevation (antiptosis) of the connective tissue and adipose tissue, (2) tightening and rejuvenation of the skin and (3) muscle relaxation (platysma). The insertion of barbed threads alone are not going to have a long lasting effect compared with the combination of barbed threads and plain mono threads. The latter technique creates a crossed-hatched mesh network of threads leading to fibrous bridging between all of the threads.

Indications With PDO threads, one can contour the face, treat wrinkles, improve skin quality, reduce pores and tighten the skin, reduce the double chin (submental fat pad).

In the Far East, especially Korea and China, ladies don’t like the square jaw appearance, and prefer a V-shape. Patients as young as 20 years old have V-shape threads treatment, so threads are not only for people aged 40 years or more with skin laxity and other effects of ageing taking place.

Other indications are tissue healing, tendon trauma (tennis elbow, golf elbow), frozen shoulder, knee collateral ligament repair, fibro-myalgia and muscular relaxation (masseters, orbicularis oculi, gastrocnemius skeletal muscle).

Also, one can treat hypotrophic acne scars, but not hypertrophic

acne scars.

Contraindications Are the same as for most cosmetic treatments like fillers (HA etc.) botulinum toxin type A or any medical aesthetic treatment—one must take care. Patients with auto-immune connective tissue diseases must be excluded. Patients with high expectations are always of concern. Don’t sell the PDO thread treatments as a surgical replacement treatment or a treatment that is better than surgery. Patients who are Hepatitis B+, Hepatitis C+ and HIV+ pose more of a risk to the operator. Pregnancy is a contraindication and so is breastfeeding if any lidocaine is going to be used.

Anti-coagulant therapy (coumarin, etc.), existing infection in the treatment area and a history of keloid formation in the face and neck are contra-indications.

Precautions Be careful with patients taking aspirin—don’t terminate the treatment but warn them that they run the risk of bruising. Antibiotic prophylaxis is important in patients with bacterial endocarditis.

Prescribe acyclovir to patients who are prone to herpes simplex labialis.

Smoking has a detrimental effect on healing and tissue regeneration in general. Patients taking oral steroids or topical steroids on the PDO treatment areas can expect a less favourable end result.

Pre treatment procedure The medical history is important to identify exclusion criteria and one has to ensure that informed consent is obtained. Barbed threads insertion requires antibiotic prophylaxis such as Azithromycin 500mg one hour before the procedure followed by 500mg 24h and 500mg 48h later. Antibiotic cover is not necessary for superficial plain mono thread insertion. If the treated area becomes infected, especially if barbed threads were inserted, it’s going to be very difficult to treat the infection because there is a foreign body in-situ and the threads may have to be removed. In the presence of infected barbed threads, local anaesthesia may not be effective due to the acidity of the infected tissue

and the patient may require general anaesthesia.

The most important part of this whole treatment process is photography in order to establish preexisting asymmetry. Patients may come back accusing the operator of creating asymmetry by using the threads, so make sure during the consultation to point out for example that one cheek is bigger than the other cheek and have a photograph to prove it.

Technique: Five Point Face Lift The rationale behind the Five Point Facelift is that in my experience, Caucasian patients require less barbed threads, due to smaller facial features, than Asian patients.

Clean the treatment area very well with surgical spirits, betadine or chlorhexidine. Cover the patient’s hair with two caps and apply sterile drapes. Apply topical anaesthesia for dermal insertion of plain mono threads.

Mark the treatment area with a marker pencil. Put on sterile gloves.

For PDO barbed threads, inject 1.0ml of lidocaine plus 1:80,000 adrenaline (dental 2.2ml cartridge) into the insertion area. Then take a 1 ml syringe (with luer-lok) and aspirate 1.0ml of 3% lidocaine and connect it up to the thread cannula (Dr Irfan Mian’s technique).

During insertion of the cannula, if there’s any discomfort, inject 0.05 ml, wait for 30 seconds and continue to insert the cannula. This way there is no distortion due to a lot of tumescent anaesthetic and one can observe an immediate mechanical lift, and more importantly the patient can see it too!

Very importantly, superficial dermal or subcutaneous threads are inserted with a sharp needle but barbed threads have to be inserted via a cannula in order to reduce the risk of facial nerve trauma and

66 The most important part of this whole treatment process is photography to establish pre-existing asymmetry 99

body language I TECHNIQUE 23

5-POINT 90MM SPIRAL M-D BARBED AND MONO THREADS: MID AND LOWER FACE LIFT Ageing face

Step 1: Barbed thread insertion

Step 2: Mono double 50mm Entry point Zygomatic arch

Insertion level: connective tissue

Insertion level: dermis 5mm apart

Multi thread: 10 mono threads/cannula

Step 3: Mono double or double screw 38mm vertical from mandible

Step 4: Mono double or double screw vertical malar area

Insertion level: sub dermal

Insertion level: dermis 1cm apart

Insertion level: dermis 1cm apart

large blood vessel trauma (such as the facial artery). Extra care has to be taken in the region where the facial nerve is crossing the zygomatic bone because it runs very superficially in this region. Below the zygomatic bone, the facial nerve runs deep underneath the parotid glands so it’s a low risk area. When inserting deep barbed threads, don’t do it with a needle!

It is also important during the treatment that once the one half of the face is finished, to sit the patient up and take photographs to demonstrate the difference between the treated side and the nontreated side. It’s very important from the patient’s point of view to be able to see that there is an instant effect visible for we can forget very quickly how we looked like.

A single entry point for barbed threads insertion, where all the barbs come together, is important15 because it results in a lot of new collagen regeneration and fibrosis in the insertion area that is acting as an anchor and hold up the lift. The entry point is above

the zygomatic arch and the cannulas pass through the zygmatic retaining ligament superiorly and through false ligaments and connective tissue bands (septa) distally.

These structures provide ample anchoring points for maintaining the mechanical lift.

The first cannula passes through the malar region and importantly must pass through the nasolabial fold. This will achieve an instant nasolabial (N-L) lift—as good as any filler agent. For deep N-L folds, one can add additional fillers. If balancing of cheek volume is required then fillers can be combined with threads in the malar region.

The second end-point is near the corner of the mouth to elevate it.

The third cannula passes through the mandibular ligament and the marionette lines. There’s a special technique to pass the cannula through the ligament.

In the mandible and jowl area, the fourth and fifth barbed threads give an instant mechanical lift. It is important to also insert mono

threads in the dermis over the mandibular region in order to create a cross-hatched fibrotic mesh effect—fibrous bridging occurs between the skin, mono threads and the deeper barbed threads.

Compression and icepacks may be necessary if bruising is present due to dermal mono threads.

Barbed threads inserted via a cannula do not cause bruising!

Apply an antibiotic cream (Bactroban/Fucidin) to the entry point and cover it with a plaster for 24 hours. Clean the treated area with surgical spirits, betadine or chlorhexidine.

Aftercare An SPF 30 is advised to avoid postinflammatory hyperpigmentation (PIH), especially in Fitzpatrick skin types IV-VI. Avoid making long dental appointments for at least four weeks after treatment because mouth opening may be restricted. No facial massaging for two weeks and blood thinning herbs and vitamins like Vitamin E should be terminated seven days

24 TECHNIQUE I body language

NECK LIFT: BARBED 3-D SPIRAL M-D 90MM CANNULA Insertion level: sub dermal and above platysma Mandible Entry point

Entry point

Entry point

Entry point Epiglottis

PLATYSMA HYPERTROPHY

SUB-MENTAL FAT PAD

Insertion level: sub-dermal 38mm mono double or double screw Insertion level: dermal 25mm or 38mm mono double or double screw

Insertion level: platysma muscle bands 38mm mono double or double screw

BROW LIFT AND PERI-OCULAR THREADS INSERTION

Medial and lateral brow lift/forehead lines/crows feet Plain double mono 25mm needle 6-0 thread

Medial and lateral brow lift Barbed 90mm 2-0 spiral 2-D M-D Insertion point: hair line Insertion level: sub-dermal

Insertion level: dermal

End points medial brow lift: brow medial canthus and mid pupil lines End points lateral brow lift: brow mid pupil and lateral canthus line

before the treatment and for another seven days post treatment. For discomfort, paracetamol should be sufficient and NSAIDs like ibuprofen should be avoided because inflammation is necessary for fibrosis. No alcohol for three days post treatment and no sauna for seven days. Arnica (a herb) may be effective against swelling.

Complications Complications include swelling for a few days. Bruising is more likely when using a needle and may last for 10-14 days. Infection can occur due to the deep barbed threads . A foreign body reaction (granuloma)

Lateral canthus line Mid pupil line Medial canthus line

can occur in the epidermis if the plain mono threads are not inserted deep enough. Due to discomfort and restricted mouth opening the patient mustn’t book dental appointments.

The thread can migrate, especially with uni or bi-directional cogs. One has to be very careful when using bi-directional cogs— make sure that they are sufficiently embedded underneath the skin because they can migrate out of the insertion point. Barbed thread protrusion is possible if the threads are not cut short enough at the entry point. Facial nerve trauma is more likely when using a needle. Beware

Lower eyelids and tear trough Plain mono 27mm cannula 6-0 thread Insertion level: sub-dermal

of asymmetry. If the thread is visible, one can remove it by just using a green needle, and some local anaesthetic around the thread. Stick the needle in and hook it out—it’s easy to remove it but you must do it in the first two weeks.

Combination treatments One can combine threads with platelet-rich plasma, botulinum toxin type A, fillers and dermarollers.

PRP is usually injected during barbed threads insertion and it can also be combined with dermarolleing of the skin after threads insertion.

Don’t combine threads with heat generating devices such as la-

body language I TECHNIQUE 25

sers or RF before 12 weeks because the heat will cause distortion of the threads.

Patients treated with liquid PLLA treatment before have not presented with problems related to excess fibrosis. Similarly, no problems have been experienced in treating former facial surgery patients.

Results The threads will dissolve after about six to eight months, with maximum contraction at three to our months. Mechanical lift is only possible with cogs—it’s not possible with plain mono threads. In my experience, of over 450 patients, one has to place barbed threads to get a lift. Also, the duration depends on the age of the patient, lifestyle, quality of the tissues, medication and the general health and diet. I emphasise during the consultation

that PDO threads treatment is a continuous process and that regular additional threads are required at six to nine month intervals in order to maintain the effect.

New Equipment Up until the end of 2014, the only mono threads available were one thread per needle. However, new mono plain double or double screw threads are now available. Thus, for five needles inserted 10 threads are delivered (double thread). It is logical that more new collagen regeneration and skin remodelling would occur instead of a single thread.

The latest PDO threads innovation has been the introduction of the multi-thread (‘thread filler’).

This is a cannula that contains 10 mono plain 6-0 threads. Indications include N-L folds and marionette lines.

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“Electrospinning polydioxanone for biomedical applications”.

Acta Biomaterialia (Elsevier) 1 (1): 115–123. doi:10.1016/j.actbio.2004.09.003. PMID 16701785.

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3. Tiberiu Niță (Mar 2011). “Concepts in biological analysis of resorbable materials in oro-maxillofacial surgery”. Rev. chir. oromaxilo-fac. implantol. (in Romanian) 2 (1): 33–38. ISSN 2069-3850.

23. Retrieved 2012-06-06.(webpage has a translation button) 4. PDS (Polydioxanone Suture): A New Synthetic Absorbable Suture in Cataract Surgery A Preliminary Study. Bartholomew R.S. Department of Ophthalmology, University of Edinburgh, Scotland, UK Ophthalmologica 1981;183:81–85 (DOI:10.1159/000309144).

5. Jung-Hyun Yoon, Sang-Seop Kim, Dae-Il Kim. Skin Rejuvenation to make use of Absorbable PDO Thread in Regenerative Medicine.

MD World Medical Publishing Co., Niche Finders, ISBN 978-8991294-51-6.

6. Lifting effect with polydioxanone absorbable threads without anchors on face and neck. Llorca, V. MD Soyano, S. MD, PhD. 1 Hospital de Levante Benidorm. Unidad Antiaging. IMED Hospitales.

Spain. 2 Kanda Aesthetic Surgery Clinic. Japan. Vicenta María LLorca Pérez. Unidad Antiaging Hospital de Levante Benidorm.

Imed Hospitales. c/ Santiago Ramón y Cajal No 7. 03503 Benidorm.

Tel. 96 685 03 03 - Móv. 672329305. Mail: dr_llorca@vlift.org.

7. Rosenburg LZ, De la Torre Jorge I. Wound healing, growth factors. Updated Feb 17, 2006. eMedicine Plastic Surgery. 1-5 (http:// emedicine.medscape.com/article/1298196-print). Bone RC, Dantzker DR, George RB, et al, eds. Pulmonary and Critical Medicine. St. Louis, Mo: Mosby – Year Book; 1998.

8. G. Gabbiani, B. J. Hirschel, G. B. Ryan, P.R. Stratkov, G. Majno.

Dept of Pathology, University of Geneva, Geneva, Switzerland:

Another interesting product is the 30-gauge cannula thread for lower eyelid laxity and tear trough elevation. Injection of any filler in the lower eyelid region carries a risk, even when doing so with a 30 g cannula. Fine threads is safe and do not carry the risk of intravascular injection and blindness or chronic oedema due to the HA filler’s attraction of water.

Dr Jacques Otto is an Aesthetic Practitioner, highly experienced in the field of aesthetic treatments with a worldwide reputation as an innovator and trainer. His main interests include PRP, IV nutrition therapy (co-founder of IntraVita Ltd) and polydioxanone fine thread contouring (co-founder of Neocosmedix Europe Ltd). He was the first to introduce PDO multi-direction absorbable barbed threads into the UK cosmetic market.

GRANULATION TISSUE AS A CONTRACTILE ORGAN. A Study of Structure and Function. 1 Nov 1971.

9. Helene M. Langevin et al. Subcutaneous Tissue Fibroblast Cytoskeletal Remodelling Induced by Acupuncture: Evidence for a Mechanotransduction-Based Mechanism. J. Cell. Physiol. 207:767774, 2006.]

10. Arun K Gosain, Marc H Klein, et al., A Volumetric Analysis of Soft-Tissue Changes in the Aging Midface Using High Resolution MRI: Implications for Facial Rejuvenation. Plast. Reconstr. Surg. 115: 1143, 2005).

11. Dermatol Surg. 2015 Jun;41(6):720-5. doi: 10.1097/ DSS.0000000000000368. Outcomes of polydioxanone knotless thread lifting for facial rejuvenation.Suh DH1, Jang HW, Lee SJ, Lee WS, Ryu HJ 12. Murad Alam, Jeffrey S. Dover. Procedures in Cosmetic Dermatology Series: Non-Surgical Skin Tightening and Lifting p.44. By INC00265803. ISBN:978-1-4160-5960-8. 2009 13. Yuki Shimizu, Kanae Terase. Thread lift with absorbable monofilament threads (Journal of Japan Society of Aesthetic Plastic Surgery (JSAPS) 2013 Vol.35 No. 2) 14. M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, DOI 10.1007/978-3-642-21837-8_2, © Springer-Verlag Berlin Heidelberg 2012, p. 29 . P.M. Prendergast Venus Medical, Dublin, Ireland e-mail: peter@venusmed.com.

15. Otto, M.J. Non-surgical approach to facial ptosis – the PDO barbed absorbable thread 5-point facelift. PMFA News 2015 Vol 2, Issue 5, p. 17-18 16. Bryan C. Mendelson. Anatomic Study of the Retaining Ligaments of the Face and Applications for Facial Rejuvenation. Aesth Plast Surg (2013) 37:513–515 17. Sung Wook Parka, d, Se Joon Wooa, Kyu Hyung Parka, Jang Won Huhd, Cheolkyu Jungb, O-Ki Kwonc Iatrogenic Retinal Artery Occlusion Caused by Cosmetic Facial Filler Injections. American Journal of Ophthalmology Volume 154, Issue 4, October 2012, Pages 653–662.e1 (Accepted 24 April 2012, Available online 24 July 2012)

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body language I TECHNIQUE 27

Absorbable thread lifting DR KWON HAN JIN explains the benefits of thread lifting and his techniques for creating long lasting results

T

here are many surgical lifting options and threads available. I used a lot of Aptos threads about nine or ten years ago, and then polydioxanone (PDO) threads came to Korea.

The first time I introduced PDO threads, the thread was very thin and very short, so many of the doctors—especially plastic surgeons—laughed at me. They were not convinced that kind of thin thread could offer lifting. So, we upgraded and found a certain technique and layer, which gives fantastic lifting, even if the thread is thin. We don’t actually pull mechanically, but still it results in lifting.

Many devices such as lasers, radio frequency and ultrasound offer lifting but I explain to the patient, absorbable thread lifting results are in between plastic surgery and those devices. Some patients will ask if non-absorbable threads might give longer-lasting lifting, but, unfortunately the time results last is almost the same.

Nowadays, many patients are concerned about safety because they have been using non-absorbable or long-lasting fillers and they suffer from complications. In Ko-

rea, if you explain to patients that the threads are absorbable, then they feel safer and there are less complications and less downtime.

I have been involved in over 1,000 live demonstrations, and after ten minutes you can see lifting.

The lifting effect also continues— you don’t just get the initial lifting.

PLLA Threads After PDO threads, the poly-L-lactic acid (PLLA) threads were developed. They last for 16–18 months and are a fifth generation polymer suture, which is from plants—a sort of alpha hydroxy acid (AHA).

The PLLA material is sculptural, like some of the PLLA fillers, which are available in Europe so we know this material is safe. They also stimulate the collagen for a longer period, sometimes even up to 25 months.

There are other differences in comparison with PDO threads.

We placed PDO and PLLA threads under the skin and we tried to take them out after 50 days. We measured the diameter of the thread, and quite interestingly we found that the PLLA gives a little increase in volume. PLLA can work well in the teardrop lines due to the slight increase in volume effect.

66 Absorbable thread lifting results are in between plastic surgery and devices such as laser, radiofrequency and ultrasound 99

If you put PLLA threads in the muscle, it can cause some swelling so we don’t always recommend it.

If you explain this potential side effect to the patient though, they can be used in muscle. So these are some of the interesting points with the PLLA. Theory The basic science behind putting the thread under the skin is it will cause increased local circulation, increased activation of repair process, and simulation of collagen production. Nowadays, in Korea, we use threads instead of acupunc-

If you explain to patients that the threads are absorbable, then they feel safer

28 TECHNIQUE I body language

Dr Kwon Han Jin demonstrating his thread technique

ture—I call it six month-lasting acupuncture. If someone has a problem with their neck, then we place a thread and it will improve immediately as it causes an increase in the vascular plexuses.

Treatment If we want to treat the jawline with threads, we actually do not want to lift upwards too much.

Instead, we pull down to make the beautiful jawline, by placing two threads close to each other and one a little bit further away. Then it’s quite strange: the vector will move downwards.

For the mid-face, we place the thread every 1 cm, going upwards.

If we are using 1.0 or 2.0 thick thread, we can pull mechanically.

If we use 6.0—which is very thin, like a hair—we place the thread every 1 cm, and wherever you want to have most lifting, you can put threads a little closer. Immediately after and then after one and two months, you will see very natural lifting occurring due to the collagen stimulation surrounding the threads.

For the lateral side, we place threads 1 cm in front of the ear, and we put three lines—you will see the lifting already. You also need depth control—if you want to

achieve lifting upward, you put the thread a little bit deeper.

There is also a double-layer technique, putting threads up and down. Although the thread is very thin and absorbable, it will improve results if the threads contain any type of cogs, and avoid complications like dimpling asymmetry. In my experience, you have to be very careful, so I don’t pull very strongly mechanically, yet I still achieve incredible lifting.

Fishbone technique We also see some patients who are older and have more sagging. We cannot treat these type of patients with short threads, but instead use the 1.0 or 2.0 thread.

I use a fishbone technique, because no matter how thick the thread is in the beginning, it’s an absorbable thread.

The problem is the cog. Patients come back to you, saying in the beginning, the cog was so strong, they loved the lifting but after four months, it dropped down. This is a common complaint of the many patients in Korea after you use a thick cog thread. To solve this, after you use a thick one, you have to put a short one every 1 cm to fix it. No matter how thick, no matter how good you are, the cog will melt

and the lifting will come down. So, for me, I personally combine long and short threads together in a fishbone formation.

Combination We know that threads work very well, but sometimes the thread alone is not enough. When I treat eye bags, nasolabial folds and also double chins, I combine with radio frequency to enhance results.

I also use PRP in conjunction with threads. I use activated PRP at the same time together with the threads, to stimulate more collagen, more growth factors. We have a cold mechanical activator for PRP, so we pass through the thin tube and have activation similar to thrombin. We also use light activation of PRP and stem cells, using 13 wavelengths, four at the same time.

There is no limit to the amount of threads you can use. I don’t usually count, but I would say I use a minimum of 20 and a maximum of 80-100.

Dr Kwon Han Jin is an Aesthetic Dermatologist and Surgeon, and is Director of Dermaster clinic in Korea and President of Dermaster clinic (Indonesia, Malaysia, Vietnam, Hong Kong, United States)

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body language I PRACTICAL 31

Thread lifting treatments DR SARAH TONKS discusses the uses of thread lifting and how clinics should adopt it

I

have been a doctor in aesthetics for eight years and in the last couple of years I have been performing thread lifting. Recently there has been a big uptake in clients specifically requesting thread lifting because they believe it will give them a certain result.

It is a treatment that has had a big media push but there is a lack of knowledge about it in the public sphere, so it’s important that we understand realistically what threads can and can’t for our clients.

Often, what happens when people come in requesting threads is they end up getting a different treatment, because what they actually want in terms of outcome is something different from what threads can provide.

Case Studies An example of one client who got fairly medium results from thread treatment, had two pairs of PLLA bidirectional cones. One was in the malar region and one was along the jawline. Two to three weeks after treatment, there was some improvement in the position of her cheek and there was a slight

tightening along the jawline. This particular client was happy with the outcome, though best results appear a few months post procedure. I had a similar case where the results were better after two to three weeks, however I still felt that adding adjunctive treatments would give her an even better result. When clients pay for a treatment they often want to see quick results so that is something to consider when planning the treatment and you may want to add adjuncts such as dermal filler at the time of treatment with a thread.

This treatment can also be performed with 4D barbs. 4D barbs are mounted on a cannula whereas the regular barbs are mounted on a long needle however they are both types of PDO threads. A colleague of mine uses PDO threads. Their client had two sets of 4D barbs in the cheek region as well as regular barbs. She had very good results but again, they could have been better with additional treatments. I think it is important to let the patient know what would give them improved results even if it means staging the treatment due to cost.

Another of my colleague’s clients had some 31gauge monofilaments placed underneath the eye.

He gained tightening underneath the eye and the results were good, but again, they could have been better if we had added some dermal filler in addition to this.

Where threads can really help is when filler is not appropriate. One of my clients was unhappy with the jowling and sagging in her face.

However she had already had large amounts of filler placed elsewhere.

Her cheeks were incredibly overfilled when she smiled and adding more filler to her face would have been very tricky without making her look more unnatural.

We can put some filler in the angle of the mandible but that would be it. She is a good example who could benefit from thread lifting alone as it literally gives a lift

66 When clients pay for a treatment, they often want to see quick results 99

32 PRACTICAL I body language

rather than volumisation.

I also have clients who are adverse to using fillers. They believe they will look unnatural or fake.

For this type of clients thread lifting can be a nice alternative. I have done some monofilament PDO for clients like this, for skin tightness, and they have been pleased with the results. You can then also add some longer PLLA or PDO 4D barbs to further improve the results.

Combination treatments Thread lifting is just another colour in our artists pallet. It gives us more flexibility to treat more patients, so it is worth considering taking into your practice. Both PDO and PLLA threads can be used in slightly different ways, so it’s worth considering both.

Using fillers and thread lifting combined can be very beneficial for clients. As an example, I had a client who was 51. She felt she looked tired and wanted to look a bit fresher. She had an eight point lift which was some derma filler placed in the malar region, in the pre auricular area of the cheek, and also in the marionette region.

It looked fine but after we did threads it looked even better. She had some monofilament threads placed underneath her eyes on both sides and a couple of bidirectional sutures. One was along the jawline in the 90 degree pattern and then another one was in the malar region. I have recently changed how I am using these longer PLLA threads to insert them in a U shape rather than a V or a 90 degree angle, and Im getting much better results.

The results were very good but

if she hadn’t had the fillers done initially she would still not have got enough volume in her face for it to truly be a good natural result.

We need to consider that using threads is not as straightforward as using fillers. After patients have dermal fillers they can often go straight back to work or on holiday. However, with thread lifting you can sometimes get some bruising, asymmetry or rippling in the skin immediately afterwards. This means that people are sometimes uncomfortable going out in public.

I advise clients that they really will need a minimum of two weeks before they start to feel normal again.

You can use thread lifting in patients who have previously undergone a facelift. Sometimes, after ten years or so, people feel like they need a little lift again and thread lifting is useful for this.

A patient of mine who had undergone a facelift, had some bidirectional PLLA in the same region but we also did a little PDO as well. This consisted of a couple of barbs in the mid-face, just along the zygoma. She also had some cross linked derma filler placed in the vertical lip lines in the upper lip. She was very happy with the results and her jawline looked a lot tighter.

Using thread lifting If a client comes in for treatment and I feel like they could benefit from both threads and fillers, I’m often happy to do this in one go.

The rhetoric of aesthetics is to take things slowly, but if it is somebody I’ve seen before and they are happy to proceed, I’m happy to do it, as long as I can see them a few weeks

afterwards and do any tweaking that we might need to do.

I will often inject dermal filler first as it might be used for structure. For example I might do the malar region with dermal filler, then use a cannula and volumise the angle of the mandible to give a little bit more structure. I will then put some threads in afterwards.

I have also found no issues with placing the thread directly through the area where we have placed the dermal filler. Once this is done, they may well need to have some tweaking or adjustment after two to three weeks. The PDO threads are very good for this. If you have used the long PLLA before and the patient has a little bit of asymmetry on one side, you can add in a couple of PDO barbs on that particular side and it will be corrected.

If they are having botulinum toxin treatment I will do the thread lifting in a different treatment session. Botulinum toxin and the dermal fillers will come first and a couple of weeks later we’ll do any tweaks and add the threads in afterwards.

With threads you get an improvement in the skin quality and texture in a way that you don’t just using derma fillers. So we are giving the patient a more global enhancement rather than just spot treating. I believe this has a long term future in our industry but we need to understand what the patient needs and not just what they want, because they may not understand the benefits and issues of the treatments available to them.

Dr Sarah Tonks works at Omniya in Knightsbridge.

Before treatment, after fillers and after threads

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34 PROMOTION I body language

IMCAS 2016 Cultivate your instinct for learning at IMCAS Annual World Congress 2016

T

he well-established IMCAS Annual World Congress, now in its eighteenth year, will welcome delegates from around the world to Paris this coming January. In the French capital, participants will enjoy the combination of comprehensive scientific content, international key opinion leaders and exclusive networking opportunities that will help them to get ahead in their practice.

The four-day programme, put together by practising plastic surgeons and dermatologists, covers 16 principal themes in the domains of plastic surgery, cosmetic and clinical dermatology, practice management and the aesthetic medical industry. The structure of the congress is such that delegates can pick and choose which sessions they want to attend and thus create a tailor-made programme based on their interests and needs. With up to eight rooms at a time catering to the educational needs of participants, delegates will be truly spoilt for choice.

Acclaimed speakers from around the world including US facial plastic surgeon, Dr Steven Dayan, US dermatologist Dr Leslie Baumann, Argentinean dermatologist Dr Sergio Escobar, French plastic surgeon Dr Guy Magalon and Italian plastic surgeon Dr Daniel Cassuto will come to Paris to share their expert insights with more than 6 000 delegates.

Highlights Among the many highlights that participants can look out for is the Cadaver Workshop, taking place on the first day of the conference. This one-day workshop will present live dissections in parallel with live demonstrations and followed by interactive debates between experts in Paris, Tokyo and Taipei. Covering not only anatomy and techniques for injecting the face but also thread procedures and injection techniques and anatomy for other parts of the body, this workshop will offer a rare practical learning experience.

Another highlight will be the day of sessions dedicated to comparing the advantages and limitations of invasive, minimally-invasive and non-invasive pro-

cedures for rejuvenating the face, lips and neck. These sessions will not only offer insights into the efficacy of different procedures for different indications, but also into the ways in which surgical and nonsurgical interventions can be combined to obtain optimum results.

Invasive procedures will also be covered in sessions dedicated to facial bone reshaping, rhinoplasty, breast surgery and body contouring, to name a few.

More than three hours will be given over to lipofilling and regenerative medicine.

During these sessions, delegates will learn about the optimal techniques to employ when harvesting, purifying and grafting both small and large volumes of fat.

Alongside the medical and surgical curriculum, is the Marketing and Practice Management course, designed to help doctors to develop their business acumen and enable their private practice to flourish. From developing a business strategy to building a brand and retaining patients, this course will cover all of the key elements associated with managing a practice.

IMCAS continues to develop its interest in the cosmeceutical market too, with a day featuring all of the latest innovations in this sphere. Probiotics, prebiotics, nutraceutics and cosmeceutics will all receive their fair share of scrutiny as experts discuss the latest developments and the ways in which these products can be combined with other treatments for great results.

Exhibition IMCAS Annual World Congress is not only an educational conference; it is also a meeting place for the entire medical aesthetics industry. In 2016, exhibitors will come to Paris to present their latest innovations in the exhibition hall, during their symposia and through live demonstrations. Additionally, the World Industry Tribune will present market forecasts for the year ahead and will provide a platform for companies to offer insights into their strategies and approach to the market.

Networking Meeting peers and developing professional relationships is also an essential part of an event such as this. The informal Networking Cocktail will provide an informal environment for delegates and exhibitors to mingle and make new contacts. Meanwhile. The glamourous Gala Dinner will provide an evening of fine dining, entertainment and dancing at an exclusive Parisian venue.

With hundreds of lectures on all subjects relating to invasive and noninvasive medical aesthetic procedures, IMCAS Annual World Congress is a must-attend event for dermatologists and plastic surgeons looking to cultivate their instinct for learning.

Take a look at the full scientific program and register for the congress at imcas.com

body language I EQUIPMENT 35

Threads and ageing DR ALBINA KAJAIA takes us through a combined approach to facial ageing using Aptos threads, platelet rich plasma, dermal fillers and botulinum toxins

S

ince ancient times, people have always wanted to try and keep their youth and beauty for a long time. For example, the first plastic operations were performed in ancient Egypt and China, where noble persons used skincare tools. Nowadays aesthetic medicine is developing at a quick rate. There are more products, methods and devices to inhibit the ageing process than ever before.

According to data from the American Society of Aesthetic Plastic Surgery, the number of aesthetic procedures has been exceeding the number of surgical interventions for last several years. Even more of our patients are asking for non-invasive procedures, and accordingly our task is to give good results using injection methods and combination treatments.

Ageing In order to correctly apply different techniques, we must understand how the patientâ&#x20AC;&#x2122;s face ages. The basic ageing processes are turgor and skin elasticity, atrophy of subcutaneous fat, mimical wrinkles and ptosis of soft tissues.

There are a lot of ways to fight against each form of ageing. For example, we can use mesotherapy, PRP or biorevitalisation to improve the turgor and skin elasticity. We can also use toxin injections to remove mimical wrinkles, or apply fillers to fill the lipodystrophy zones. We can also successfully apply chemical peels in our own practice. Unfortunately though, all

of these methods are not enough to fight against facial tissue ptosis.

There is a need for mechanical transference of face tissues, which is not provided by any other procedures mentioned above. Previously, patients had to undergo a surgical operation for this but today there are methods to fight against ptosis without skin incisions. One of these methods is thread lifting, which has become especially popular among plastic surgeons and dermatologists.

Differences between threads There are three different thread methods that I have divided into groups. The first group, A, are small, ring sized threads where the thread lift is ten centimetres, USB 4/0, 5/0, 6/0. Group B is biorevitalisation, which is lifting with free fixation, with a thread lift more than ten centimetres, USB

66 The number of aesthetic procedures exceeds the number of surgical interventions 99 2/0, 3/0. Group L is skin soft tissue lifting, with points of fixation where the thread lift is ten centimetres and more, USB 0, 1/0, 2/0.

The last group is F, which is hard fixation of soft tissue with small threads, all with barbs, USB 0, 1/0, 2/0, 3/0 and 4/0.

The composition of thread types are either non-absorbable materialâ&#x20AC;&#x201D;mostly polypropylene or silicone, absorbable long material with a long-term duration (one to two years), based on polylactic acid and absorbable short material with a short-term duration (one to three months), which is PGO or polygly-

TYPES OF THREAD METHODS A

B

L

F

Armouring. Small sizes of threads.

Biorevitalisation.

Lifting with free fixation.

Skin soft tissues lifting with points of fixation.

Hard fixation of soft tissues and skin.

Surgical methods requiring skin incisions.

Thread length up to 10cm, USP 4/0, 5/0, 6/0.

Thread length more than 10cm, USP 2/0, 3/0.

Thread length 10cm and more, USP 0, 1/0, 2/0.

Smooth threads or with barbs, USP 0, 1/0, 2/0, 3/0, 4/0.

TYPES OF THREAD COMPOSITION NA

AL

AS

Non-absorbable material, mostly polypropylene or silicon

Absorbable material, long term duration (1.5 to 2 years), based on polylactic acid

Absorbable material, short term duration (1 to 3 months), PDO or polyglycolic acid

36 EQUIPMENT I body language

1.

3.

2.

4.

colic acid.

As a medical cosmetologist, I apply the following types of threads in my practice:  Absorbable material with a long-term duration—one and a half to two years—based on polylactic acid  Small sizes of threads for armouring  Lifting with free fixation for biorevitalisation.  Skin soft tissue lifting with points of fixation.

Product lines At the moment only one brand has all four size ranges—Aptos, antiptosis. According to patients’ age group Aptos offers different lines of absorbable threads. The first product line is intended for skin armouring, suitable for patients aged 25 years and above.

The Excellence line is intended for soft tissue lifting and bio-armouring. They are suitable to treat patinets aged 35 years and above, and a Light Lift line is also available for ‘true lifting’ allowing soft tissue and face skin to be transferred to a more aesthetically advantageous position.

Another product line refers to type A armouring. It consists of polylactic acid which biodegrades after one to one and a half years.

There are two basic products in the

5.

line—two smooth threads twisted among themselves and a spring leading the needle.

The application areas are horizontal forehead wrinkles, vertical wrinkles between eyebrows, lifting for broad tip, lipid dystrophy zone filling, correction of wrinkles around the eye area, teardrop wrinkle filling, skin turgor improvement, treating small wrinkles of neck and decollete, and removal of small wrinkles in the hand area.

The method is good for correcting nasolabial folds and marionette lines, performing the function of a filler. Even with such heavy tissues, you can see the results in two months and even more so in a year.

I perform this for patients who also want an injection of botulinum toxin.

The Excellence product line includes two products, Excellence Visage for treating the face, and Excellence Body.

This method offers more biorevitalisation, with biodegradation occuring in one and a half to two years. The products have threads with multi-direction barbs, allowing them to be fixed in the soft tissue.

This method is suitable for lifting of the brows, the middle and lower third of the face, treating ptosis, and neck and decollete area correction. For the body it is good for the humeral area and the inner

6.

surface of the thighs.

The Light Lift product line is intended for heavier tissues and adult patients, and the thread is manufactured from polylactic acid.

Application areas include the eyebrows, marionette lines, nasolabial folds, the mental area of the chin, submaxillary zone, correction of the nose and correction of the ear.

In my patients I have applied several products from Light Lift product line.

1&2: Aptos Excellence threads to treat nasolabial folds and marionette lines, before and one year after.

3&4, 5&6: threads in combination with botulinum toxin.

PRP Threads offer a very good result but we oftern use them in combination with other non-invasive asethetic procedures.

Threads only work for the skin structure, but we can use biorevitalisation as well. According my experience I use the procedure of biorevitalisation and PRP in combination with the threads. This decreases period of rehabilitation and provides with better aesthetic effect.

Plasma lifting is the same PRP method of tissue regeneration

66

Threads offer a very good result, but we often use them in combination treatments 99

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38 EQUIPMENT I body language

stimulation by local insertion of injection of thrombocyte auto plasma. We have developed two basic schemes of injection in our clinic.

The first scheme is “soft therapy”, where we perform three procedures of PRP. The first procedure is performed two weeks before thread lifting and the second procedure is performed on the thread lifting day. The third and last procedure is performed two weeks after placing the threads.

The second scheme is “hard therapy”. The principle is the same and the only difference is that we double the number of PRP procedures.

Dermal fillers We always correct platysma three to five days before a thread lifting procedure. After this, we find using threads with polylactic acid in combination with a hyaluronic acid, provide a complex solution for face, and offers good results.

When patients come to see us and we discuss what treatment they want, we look at what they

7.

10.

want the results to be. We do combinations with fillers because no one product can change the effect of botulinum toxins. That is why it is necessary to combine all types of procedures—even if only noninvasive options.

In recent years and even now, the procedure of bucco-malar area contouring and volumisation is still actual. Thread lifting does not always provide us with enough volume. In the middle third of the face some additional correction by hyaluronic acid fillers can be required. The correction should be performed three to four weeks before the thread lifting.

Toxins I find combining threads with botulinum toxins also offers better results. If you do not stop the muscle with botulinum toxins, the thread will not work well. This is very important for correcting zones such as platysma, m. frontalis, m. orbicularis oculi and m. corrugator supercilii.

With the combination of the threads and botulinum toxin, the botulinum toxin injections should be injected at least seven days before the thread lifting procedure.

This is very important to make sure the muscle does not spoil the fixed thread, especially in the eye area.

Conclusion Combination of non-invasive methods provides the possibility for a faster rehabilitation period, a complex approach and an aesthetically beneficial result for patients.

The key to cosmetic procedures and cosmetic outcomes is a very thorough assessment of the patient beforehand. Manipulating the face and seeing what can be achieved is essential.

The most important evaluation of the procedure is the satisfied beautiful faces of our patients.

Dr Albina Kajaia is Head of Department of Dermatology and Cosmetology at the plastic and aesthetic surgery clinic Total Charm.

9.

8.

11.

7,8&9: Thread lifting does not always provide enough volume in the middle third of the face, therefore some additional correction by hyaluronic acid fillers is required.

10&11: Biorevitalisation and PRP in combination with the threads.

novacutis

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body language I MEDICAL AESTHETICS 41

Treating

cellulite

MR CHRIS INGLEFIELD delves into the myriad causes and treatments available for the common problem of cellulite

I

f you look at the growth of nonsurgical procedures since 2004, you can see it is phenomenal.

Not only that but when you look at the value of these procedures for patients, non-invasive treatments are more valuable than breast surgery, or facial and neck surgery. So from an economic point of view there is a great drive for patients to spend their money on non-surgical procedures, versus surgery.

This is very similar to what is happening in the US. Skin tightening spend around the world has been growing steadily, and it is predicted to continue to grow into next year. Our industry is in a healthy place economically and if we do the right things, or we offer the right things to our patients, we will be financially sound.

What is cellulite?

Cellulite has many descriptive namesâ&#x20AC;&#x201D;orange peel syndrome, gynecoid, lipodystrophy etc. It is very

prevalent, so prevalent that a lot of things have been written about the fact that it cannot be pathological.

However, when I was training in breast surgery, that cystic disease of the breast was considered not a disease, because it was so common.

How do we define something thatâ&#x20AC;&#x2122;s pathological? For me the definition is about quality of life.

If something affects your quality of life, it then becomes pathological, even if it is very common. It becomes pathological because it is affecting how you function in society, how you do your job and how you interact with your friends and family.

Cellulite is not a female only disease either. Men also get cellulite if they have androgen deficiency syndromes, Klinefelter syndrome, or have been castrated because of prosthetic cancer get cellulite. Men with cirrhosis of the liver also get cellulite because they have androgen deficiency and they get high oestrogen levels.

Poor circulation is a big factor in the pathological cycle of cellulite. It causes oxidative stress and the release of free radicals. You get swelling of the adipocytes leading to inflammation, increased extra cellular fluid, and then the cycle continues.

The thickening of the fibrous septa is what causes the dimpling of the skin. The compression of blood vessels, lymphatics accentuate the relative ischaemia which is what perpetuates the free radical production, leading to excessive tissue swelling. It can occur at almost any site, especially in patients with pathological underlying conditions.

What causes cellulite?

There are many factors which are causative, hormonal, genetic, predisposing, and concerned with lifestyle. Oestrogen is one of the key factors, but also things like insulin, thyroxin, prolactin, noradrenalin, adrenalin. There are genetic fac-

Cellulite has many descriptive names including orange peel syndrome

42 MEDICAL AESTHETICS I body language

tors, such as identified genes for angiotensin converting enzyme.

Hypoxia-inducible factor 1-alpha (HIF-1a) has also been linked with the development of cellulite.

Predisposing factors are sex, as it is much more prevalent in women, race, fat distribution, underlying lymphatic disorders and vascular problems. A high stress lifestyle is linked with cellulite, probably because of the high levels of noradrenalin that circulates around, which leads to a relative ischaemia in the areas that are predisposed to cellulite.

Cellulite is graded. The most common grade is the Moulin Newberger scale, simple zero to three. Zero means there is no cellulite; Class one means there is no spontaneous dimpling, only pinch dimpling; Class two means there is dimpling while standing and class three is fairly severe with spontaneous dimpling while standing or lying. There is also the gynoid lipodystrophy scale, which is less commonly referred to in research papers.

Relative ischemia is much worse for the tissue than complete ischaemia, because relative ischaemia generates a huge amount of free radicals. You do not get free radical production in completely ischaemic tissue as you have to have some degree of oxygenation in order to produce free radical formation.

How to treat cellulite We need to improve lymphatic drainage, because what we want to do is decongest the area to allow better arterial inflow and better venous outflow. We want to improve adipocyte metabolism by improving the circulation and oxygenation and improve dermal-collagen, because we know that these patients, in these areas it tends to be a thinning of the overlying dermis, which makes appear worse than it is.

Then we want to treat the septi.

The septi are tight and fibrous, so we want to target the septi allow it to be more flexible and to move better with the underlying tissue.

There are also dietary treatments, external devices, internal and energy sources, and topical treatments which have been used quite extensively. Topical treat-

ments are much less effective despite the fact they are sold in huge amounts. Laser lipolysis has a very high level of evidence to support the results. Topical herbs and retinol are also shown to be very effective, along with carboxytherapy.

There are a lot of different modalities that have been tested to different levels of evidence and investigation. They range from everything, from all the topicals to non-invasive, to minimally invasive technology, to fully invasive such as liposuction in all its forms.

Perilipin A protein is a new development. It is located on adipocytes and controls adipogenesis and adipolysis. It is mediated via an oestrogen receptor, so investigation could lead to a better understanding of what is the initiating factor.

Is it a problem with the adipocytes

themselves, or is it a problem with the environment within which those adipocytes are residing? The more we understand the pathophysiology the more we are able to work out what the optimum treatments are for this.

External devices We have had the greatest experience with the VelaShape. The VelaShape III is six times more powerful on the

66 Cellulite is a huge problem.

As physicians, our role is to ensure that we provide the best treatment for our patients 99

body language I MEDICAL AESTHETICS 43

A high stress lifestyle has been linked to cellulite, probably because of the high levels of adrenelin which leads to a relative ischaemia in the areas predisposed to cellulite

RF. The RF is the device that really does the job, the rest of it augments the effect of the RF. The RF is a bipolar radio frequency for deep and sustained heating. The infrared provides superficial heating and the mechanical tissue manipulation helps with the circulation by decompressing the area and improving the oxygenation of the tissue. The thermal effects increase metabolism, stimulate fibroblast, get collagen shrinkage and collagen synthesis.

The vacuum effects help the RF to penetrate deeper and negative pressure improves the circulation. The important thing about the VelaShape III is the increased energy that you can deliver to the tissue. You get a faster heating of the tissue, and therefore a reduced number of sessions.

It ensures consistent energy delivery, so it is actively measuring the tissue impedance to ensure that the right amount of energy is being delivered into the tissue. There have been numerous peer reviewed articles on the VelaShape, starting all the way back from the VelaSmooth right up to the VelaShape III. But whatever technology you use, you have got to get to the right temperature point, you have got to be able to maintain that and you have got to control that end point for patient comfort.

Grade 3 plus cellulite is a real challenge and really needs combination therapy. We would combine liposuction in whatever form with the VelaShape III. A very popular device is Cellulaze, which is a 14/40 millimetre pulse laser. There has been some excellent work on

this, looking at the long term effects going out to 12 months, and two year follow-up. It shows very good improvement with the Cellulaze device. This is classed as a minimally invasive device.

The Cellulaze device is a laser fibre that is passed very superficially under the skin. It melts the fat as well as its breaking the fibrous septi which allows it to improve.

Some of the work that has been published on the original laser lipolysis, smart lipo, showed good effectiveness, but the results did not last very long. The conclusion was the heat that was put into the tissue at that time caused much more fibrosis compared to the Cellulaze, which is a much more controlled disruption of the fibrous septi. The conclusion of that was that the smart lipo was good at the lipo side of it, not very good at the cellulite side of it.

Cellulite is a huge problem. As physicians our role is to ensure that we provide the best treatment for our patients, because for many of these patients the effect on quality of life is not severe and it is not often a debilitating problem. Therefore the devices that we use must be safe and they need to be effective, because our patients are prepared to pay a fair amount of money, and spend a lot of their time having these treatments. This means when we look at what is available we really need to be very critical as to what these devices are purporting to do, and look at the level of evidence that has been published.

For mild and moderate grades we would expect with a non-invasive device to go down to one or two levels. For the severe grade, grade three, we really want to get them down to a one or a two with a combination of therapies. We use everything from standard liposuction, to VASER-assisted liposuction, to laser assisted liposuction in combination with the VelaShape.

This is because those severe grades have such a multi-factorial problem within the skin that one single technology is never going to get a good result.

Mr Chris Inglefield is Chief Surgeon at the London Bridge Plastic Surgery and Aesthetic Clinic.

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body language I INNOVATION 45

Micro-channelling DR DAVID ECCLESTON explains the technology behind Radara and how it can complement your existing treatment portfolio

T

he words ‘new’ and ‘innovation’ are often used in our industry—indeed, since I first began my career in aesthetic medicine almost twenty years ago the number of anti-ageing, restorative or regenerative treatment options has boomed exponentially. We now understand so much more about the science of skin ageing and the impact of aesthetic treatments—both alone and in combination—such as toxins, fillers, lasers and peels which make up the mainstay of our clinical portfolio. For me, it takes a lot for something to truly stand out from the crowd, but early this year, when I first heard about the unique micro-channelling skincare technology of Radara, I knew it was going to bring about a whole new treatment category for our industry.

As we know, micro-needling (or collagen induction therapy) is a well-established treatment option for skin rejuvenation, with the key benefits being neo-collagenesis, neo-vascularisation and stimulation of elastin. In addition, micro-needling can work as a successful adjunct to other topical or cosmeceutical skincare approaches

due to the piercing of the stratum corneum and delivery of active ingredients into the deeper dermis.

However, due to the invasive nature of the procedure, most current micro-needling devices require a topical anaesthetic before treatment and are associated with some degree of pain, bleeding and downtime for patients.

This is where Radara comes in—it is a non-invasive microchannelling regime, not a traditional micro-needling product.

Radara uses a combination technology of rejuvenating microchannelling patches and a high purity, naturally-derived hyaluronic acid (HA) serum. These unique, flexible patches are coated with microscopic plastic structures (not needles) less than 0.5mm in length which painlessly create two-thousand micro-channels into the skin upon each application, allowing for deeper penetration of the HA serum to restore natural elasticity, hydration and support. Designed for home use, the treatment restores skin quality and diminishes signs of ageing around the outer eye area—specifically the lateral canthal lines (crow’s feet). It repre-

sents a new category of treatments that we can offer patients—sitting in between full micro-needling and a topical cosmeceutical skincare regime. With a five-minute nightly application over the course of a month, patients should expect to see smoother, firmer skin and a significant 35% reduction in fine lines and wrinkles, with no pain or downtime.

Seamless Integration For me, I believe that there are two core patient groups in my practice who will benefit from Radara. The first are those patients who are just looking to ‘step up’ their normal skincare routine. They may be nervous or unsure about going for more advanced or invasive treatments such as injectables or peels, but are keen to address those early signs of ageing in a gentler, noninvasive way. As a home-use product, Radara can give these patients a sense of control and the non-invasive, quick and easy applications mean that it can be easily included into their existing skincare regime.

The second group are those patients who are already comfortable with a range of more advanced aes-

Radara uses a combination technology of rejuvenating micro-channelling patches and a high purity, naturallyderived hyaluronic acid serum

46 INNOVATION I body language

thetic treatments who are looking for a way to enhance and maintain the results of their treatment from home. These patients tend to be very excited about new advanced treatment innovations and keen to try the ‘next big thing.’ I know that I will get both groups of patients back into my clinic after their onemonth regimen is complete to evaluate their results and discuss their ongoing needs, giving another opportunity for me to connect with them and build their value to my business.

Development The aesthetics market is just the beginning for the Radara microchannelling technology. The product was created by Innoture Medical Technology—a multidisciplinary medical technology company specialising in next generation transdermal devices— working alongside the Institute of Life Sciences at Swansea University. The R&D teams developed and patented a proprietary manufacturing printing process that allows for the development of multiple microneedles to create micro-channels in the skin, allowing for the transport of various molecules—in this case, HA. This unique manufacturing process using a printing method means that there is huge scope for the creation of specialised patches to deliver products for different areas of the body, through different needle sizes on these flexible substrates which conform easily to the skin’s surface. This gives the potential for use across a variety of both aesthetic and therapeutic indications—clinical trials are in progress for pain management, dental anaesthesia, insulin delivery and glucose management.

However, it is for medical aesthetics that the technology has been first harnessed with this first-of-its kind micro-channelling product for gentle skin rejuvenation. The first key area of interest is tackling fine lines and wrinkles with HA— starting with the lateral canthal lines, but potentially looking ahead to addressing other common areas of concern such as the glabellar or mid-forehead lines. In the future, this technology could be adapted to address a variety of broader aes-

RADARA CLINICAL TRIAL RESULTS Radara underwent independent dermatologist-led testing at the renowned Dermatest facility in Germany.

• Study Design: 32 person split face study including control, among women aged 35-55.

Dermal filling of lateral canthal area with ergonomic 650um microneedle patch. 4 week application (8 week in total) T1, T2, T4 and T8wk with HA-based formula (0.2ml applications).

• Qualitative and Quantitative Assessment: Grading on Garnier scale by dermatologist and self. Questionnaire at 1, 2 and 4 week multiple aspect. Visia pictures and PRIMOS analysis Rz • Results: o Significant reduction in fine lines and wrinkles of up to 35% in four weeks, with noticeable improvements in just two weeks (depending on starting skin condition) o Radara patches and HA serum were almost twice as effective at reducing fine lines and wrinkles vs. serum alone o Radara continued to deliver results for up to four weeks post-treatment (improved skin quality, wrinkle reduction) o Treatment was well-tolerated, no reported adverse events

Before and after: Photo (Visia) performance candidate 18 T0, and T4wk

thetic skincare needs such as dark circles or pigmentation, scars and cellulite.

Conclusion As one of the first doctors in the UK to learn about Radara and the capabilities of this micro-channelling technology, I have been excited to see how it could be used to enhance our current aesthetic clinical practice. Despite not being a medical device, Radara has delivered compelling safety and efficacy results through independent testing and I believe it will be a valuable treatment addition for a broad range of my patients. I am looking forward to MediZen being among the first clinics in the UK to offer Radara to patients and will be waiting to what the next innovation will be in micro-channelling skincare.

Dr Eccleston is the Clinical Director and owner of MediZen, the leading cosmetic dermatology clinic in the Midlands. He has over 20 years’ ex-

perience in the use of lasers, botulinum toxin, facial fillers and other injectable aesthetic procedures and has personally trained over 1,000 doctors on injection techniques. He is passionate about safety in medicine and often provides commentary on core industry issues such as accreditation, patient safety and proper treatment techniques. E: info@radara.co.uk, W: radara.co.uk References 1. Innoture Aesthetics – Data on File. In vitro penetration studies and biocompatibility of microneedle array-based delivery systems. Project Report, Queens University, Belfast 2. Innoture Aesthetics – Data on File. Specialist dermatological report on the optical 3D-Measurement of the surface of the skin Quantitative evaluation of the roughness of the surface of the skin with the calculation of standardized skin roughness parameters according to DIN 4768ff.

Dermatest GmbH I Engelstrasse 37 I 48143 Münster

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body language I SKINCARE 49

Demystifying the use of stem cells in cosmeceuticals

DR CHARLENE DE HAVEN demystifies stem cells in the cosmeceutical industry and how they can be effectively applied.

S

tem cells are undifferentiated cells of an organism, which are capable of giving rise to indefinitely more cells of the same type.

All stem cells have two properties: self-renewal and differentiation. As well as the potential and ability for constant tissue regeneration as a stem cell divides and replicates it can also differentiate.

It differentiates into the various

tissue types that are found in the body, and that is where its great potential is found.

There is a hierarchy of stem cells beginning with totipotent. As one moves down the line of stem cells, less of the ability to differentiate into various tissue types is found. Totipotent stem cells occur in the embryo up to one week of gestation. Pluripotent stem cells are found in the embryo from one

week to birth. A newborn infant and an adult both have adult stem cells.

The adult type of stem cells are less versatile than totipotent or pluripotent. If an adult stem cell is harvested, that stem cell is only going to differentiate into a specific type of tissue such as skin, bone, cartilage or muscle.

For example if a bone adult stem cell is harvested, it will differ-

50 SKINCARE I body language

entiate into more bone tissue. If a fibroblast stem cell or adipose stem cell is harvested, it is already committed to differentiate into, respectively, another fibroblast or another fat cell.

Applications and limitations The more versatile totipotent or pluripotent stem cells enable the production of any tissue type desired. Neural tissue and pancreatic islet cells which make insulin are difficult to regenerate from stem cells but the potential is there, as it is with all other types of tissue.

The totipotent is the most versatile of the stem cells and is found in the single-cell embryo up to one week of gestation. It can differentiate into placenta and any type of embryonic tissue. Within a week, it is a little more limited. This pluripotent stem cell can no longer differentiate into placenta but can differentiate into embryo and any type of adult tissue, which means it is still very versatile.

Stem cells obtained at birth from umbilical in cord blood may be â&#x20AC;&#x153;bankedâ&#x20AC;? or stored in a frozen state for later use if the babyturned-adult develops a disease such as cancer. There are several companies that will store a babyâ&#x20AC;&#x2122;s umbilical cord blood for a monthly fee in case the high concentration of stem cells found within the cord blood are useful in later life.

Science has discovered how to convert adult stem cells which are already committed to a specific tissue type back into pluripotent stem cells which have the ability to differentiate into any tissue type. These are called induced pluripotent stem cells. Potentially one could then make a new knee, a new heart, a new liver, new skin, or any other tissue type that is desired. That was a very important advancement in terms of stem cell technology because previously useless adult committed stem cells, such as those from adipose tissue (fat) could be converted to induced pluripotent stem cells which then have the ability to differentiate into a wide number of extremely useful adult tissue types.

There are huge numbers of peo-

ple across the world needing organ transplants, and there are not enough donors. The advantages of

getting a real natural organ or body part, harvested through stem cell technology are amazing and this is

HIERARCHY OF STEM CELLS

Totipotent

Pluripotent

Blood Stem Cells

Red Blood Cells

White Blood Cells

Other Stem Cells Muscle

Nerve

Bone

Other Tissues

body language I SKINCARE 51

why the media and the public are so excited about stem cells.

Stem cell therapy is very much still in its infancy, although it is moving along rapidly. Stem cell therapy is being used in disorders like haematology where it is already an accepted therapy. Marrow transplants using harvested stem cells are fairly common in treating leukaemia and some types of anaemia.

Stem cells are also presently being used in burn therapy, bone grafting and in corneal plants. Stem cell technology in present development includes many diseases such as Parkinsonâ&#x20AC;&#x2122;s Disease for which we are

66 Stem cell therapy is very much still in its infancy, although it is moving along rapidly 99

actually very close to perfecting the science.

Some other neural diseases like Huntingtonâ&#x20AC;&#x2122;s chorea and even MI and heart attacks are being explored as potential targets for stem cell therapy.

Although the promises of stem cell therapy are impressive, there are also potential dangers. When adult stem cells are combined with a chemical to produce induced pluripotent stem cells they do become more versatile but we have also altered their DNA. This DNA is very long-lived and more versatile. In certain cases the unexpected could happen, such as the development of cancer, other diseases, or unwanted tissue types. Unfortunately, this process is not entirely understood at the present moment.

Stem cells in skin The skinâ&#x20AC;&#x2122;s stem cells are located

both above and below the DEJ as well as in the dermal papillae at the base of hair follicles.

Stem cell therapy in cosmeceuticals When we are detailed by companies about stem cell actives, there is a common communication and subsequent belief that the stem cells go in cosmeceutical products are delivered through the skin. But this is not what happens and is not possible.

Stem cells of any type placed on the skin will not penetrate because all cells are actually quite large structures. This would be analogous to trying to push a skyscraper through the skin; it is much too large. There are problems with getting peptides more than six to eight amino acids long through the skin barrier and cells are monumentally larger than short peptides.

52 SKINCARE I body language

WHAT ARE THE KEY STEM CELL ACTIVES THAT CAN AFFECT CHANGE WITHIN OUR OWN STEM CELLS? There actually are a large number of substances that are potential stem cell actives and that can talk to our own skin stem cells.

A few of these are: DNA protectants: The DNA within the stem cell is very important as it is what causes the division of the cell into daughter cells. Furthermore, DNA serves as the command centre of each cell, directing it in proper functioning. If we protect DNA, we can lessen the rapidity of ageing including the ageing of stem cells themselves. This means DNA protectants are very important potential stem cell actives and are “anti-senescence” agents for stem cells. Extremozymes, a subset of DNA protectants, are enzymes made by plants living in extreme environments.

Extremozymes are very effective DNA and protein protectants.

Growth factors: Growth factors are some of the most important the substances that message between stem cells. Growth factors are vitally important for any type of tissue growth and regeneration.

Wound healers: Substances that encourage wound healing must also up-regulate stem cells since their replication is involved in wound healing. Centella asiatica is an example of a botanical active that has been known and used since Ayurvedic times. It has also been investigated in the western medical literature and found helpful in the healing of burns, leprosy, venous stasis ulcers, and diabetic pressure ulcers, as well as a variety of other wounds.

Antioxidants and anti-inflammatories: Stem cells are also exposed to free radical damage and oxidative stress. They become senescent, they age, become less viable and less able to divide. If stem cells within the skin are protected with antioxidants, they remain more viable and more youthful.

Stem cell actives are special, but there are a large number of compounds that affect stem cells in a number of ways. There is no single type of ingredient that is entirely responsible for directing stem cell responses in healthy skin. A multi-tasking pharmaceutical-grade formulation with proven efficacy in achieving the specific goals of the patient is still ultimately key in the ongoing pursuit of anti-ageing and skin health.

Furthermore, a cell is a living thing. If you place it anywhere, it requires a nutrient supply; if it is a collection of cells, it must have a vascular supply. Delivering stem cells of any type through the skin requires a medical procedure.

They must be injected or an incision must be made in order to get stem cells into the internal part of the body.

Stem cell technology in cosmeceuticals In our industry we usually talk about using plant stem cells. Plants also have stem cells that are used for regeneration and repair of inured tissue after injury or for

growth. To obtain plant stem cell, the plant is first wounded. This begins the process of healing the wound, which causes stem cells to activate and divide.

The wounded area containing activated stem cells is removed from the plant and grown in a Petri dish with nutrient media and growth factors to encourage the

growth of the cells. Those cells divide, regenerate, and make more stem cells because self-renewal and differentiation are their two universal properties.

As these stem cells differentiate into healed tissue and replicate into more stem cells, they also message each other. Cells send messages via cytokines to tell each other to grow, in which ways to grow and to differentiate into adult tissue types. As stem cells send their cytokine messengers and growth factors back and forth, a significant amount of messaging molecules remain in the nutrient media. We can then separate the cells out from the nutrient media, also leaving the smaller molecules or “actives” in the media.

Those messenger substances are then removed from the nutrient media in concentrated form. These cosmeceutical “actives” are added to a number of other actives in the final formula which may be water or lipid-based. Delivery of the actives through the skin barrier to the site of action at stem cell locations must be achieved. These are each complex processes in formulation technology.

Furthermore, stability within the end-product bottle must be attained to give “shelf life”. Many cosmeceuticals that are very active will be in glass since actives often adsorb onto plastic surfaces thus making the product ineffective when placed on the skin.

Although stem cells cannot be delivered through skin without a medical procedure, stem cell actives in cosmeceuticals can affect stem cells located within the skin.

Stem cell technology within formulations to communicates and affects our own stem cells located within our skin.

Dr Charlene DeHaven is Clinical Director of iS Clinical Cosmeceuticals.

66 Delivering stem cells of any type through the skin requires a medical procedure. They must be injected or an incision must be made 99

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54 PRODUCTS I body language

on the market The latest anti-ageing and medical aesthetic products and services  Exuviance CoverBlend SPF20 Exuviance have reformulated their CoverBlend Skin Caring Foundation to now contain a physical sunscreen, protecting the skin with factor 20. The formulation is designed to visibly reduce signs of skin ageing, provide coverage and protect the skin from UVA and UVB rays. The range comes in 11 shades.

W: aestheticsource.com

 Reparative Moisture Emulsion iS Clinical present their new Reparative Moisture Emulsion, a multi-dimensional moisturiser designed to hydrate skin, reduce appearance of fine lines and improve skin health. It is formulated with pharmaceutical grade botanicals, peptides and antioxidants, and is said to combat photoageing and prevent DNA damage.

W: harpargrace.com

 Carbon Spectra Peel Treatment Lutronic Lasers have launched their new Carbon Spectra Peel Treatment, designed to target enlarged pores, pigmentation and skin ageing. The treatment uses the laser energy in two ways to break up melanin in the cells and heat the dermis to stimulate collagen.

The procedure begins with painting on a carbon-based lotion to the face, then laser energy is applied to remove the carbon particles, heat the dermis and lightly ablate the skin.

W: vennhealthcare.com  Radara Innoture Medical Technology Ltd have announced the launch of Radara—a microchannelling skincare system designed to restore skin quality and diminish signs of ageing. It is a one month regimen consisting of rejuvenating micro-channelling patches and a high purity, naturally derived hyaluronic serum, designed for use around the other eye area.

W: radara.co.uk

 DMK FibroMax C FibroMax C is a new formulation—a stablilised form of vitamin C. The product has been designed to work like mesotherapy, but without the syringe and is said to tone, tighten and brighten the skin. It is formulated to aid in prevention of acne scarring and encourage healing, and can also help treat fine lines, pigmentation, eczema and areas of skin requiring lifting and support. It can also help protect the skin against UVB damage, say DMK. W: dmk-uk.com

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body language I EQUIPMENT 57

Take control of the ageing process Skin ageing is a major concern for most patients, with contributing factors such as sun exposure.

DR SHARON CRICHLOW discusses treatment options, including the Clear + Brilliant laser system

O

ur perception of ageing is based on multiple factors, but texture has definitely been shown to be one of the first things to deteriorate. In terms of dilated pores, there are numerous factors which come into play. There are hereditary factors as we age, but there are also hormonal factors, menopause in women, acne, increased sebum production and of course sun damage, which destroys the support for the pores.

Sebum production is the most significant factor correlating with pore size, so treatments that focus on reducing that, as well as building up the dermal collagen surrounding the follicles, will be most beneficial in reducing the size of enlarged pores. Any reduction in photoageing would also help.

Anti-ageing skincare We know that the biggest factor in ageing generally is sun exposure.

There is actually a growing cosmetic significance of the enlarged pores among younger patients, who may not yet be exhibiting the full sequelae of photoageing but are nevertheless noticing changes in the texture of their skin.

The British Association of Dermatology recommends that at least a factor 30 be worn to guarantee protection against UV damage. In addition, the use of antioxidants, including vitamin C and vitamin E, will help to potentiate the effect of a sunblock by scavenging free radicals which are generated not only by sun damage but also by the body’s metabolism.

Regular cleansing and exfoliation with fruit enzymes, alpha or beta

hydroxy-acids and the regular use of tretinoin has been shown to increase the turnover of new cells and keep the skin looking luminous.

Moisturiser is also recommended, especially post procedure, since well-hydrated skin is known to age more slowly.

From here, you move on to the more targeted treatments such as peels, salicylic, glycolic, and treatments like derma-rolling and skin tightening devices. One direct photo-thermal effect of laser energy is a degree of shrinkage of the sebaceous gland, which may be effective in the longer-term reduction of both pore size and sebum levels.

Clear + Brilliant laser system Clear + Brilliant was developed by Bausch and Lomb in response to an unmet need from patients wanting to take control of the ageing process, and add a little glow to their skin, but who are not yet ready for something more aggressive or heavy duty.

It is a fractionated diode laser, which delivers energy with a wavelength of 1440 nanometres.

It creates microscopic holes in the

dermis, which then help with collagen remodelling. With the original hand piece, the energy is targeted at the dermis and it leaves the epidermis relatively untouched.

The machine can be used across all skin types, which makes it very useful, particularly because one of the problems with darker skin is a hesitation to use laser treatments. It offers the benefit of a more sophisticated laser treatment but with minimal downtime, fast recovery and natural looking results.

Imagine a line as a continuum of care; at one end you have at home products like sunblocks, glycolic acid peels and antioxidants, and you can offer patients peels, injectable, fillers. At the other end, you have the patients who are look for ablative and more powerful procedures, such as Fraxel and CO2 laser resurfacing, or who might even go so far as to have cosmetic surgery. There’s a gap in the middle, though, for people who simply want to maintain their radiance. They’re not ready for anything aggressive, they have a good at-home regime, but they want something that’s going to improve the tone and texture

The biggest factor in ageing generally is sun exposure

58 EQUIPMENT I body language

of their skin and restore the glow of their younger years. These are the people for whom Clear + Brilliant was developed.

The device received FDA approval in April 2012 for the coagulation of soft tissue and general skin resurfacing procedures. It has a patented intelligent optical tracking system, which is the same system used in the Fraxel device. In fact, Clear + Brilliant is sometimes referred to as “baby Fraxel” because it offers the same technology but is a lot less powerful.

Treatment The laser hand piece will only activate when it senses contact with the skin, proper hand piece movement and proper hand piece velocity, so it is very safe in that regard.

The device will notify you if you’re moving either too quickly or too slowly, and it will stop if it’s not in direct contact with the skin. This means that uniform delivery is created, and it’s also very hard for injuries to occur.

It’s focussed on minimising pore appearance, firmness and elasticity, and longer-term improvements through collagen remodelling. Microscopic damage is created in the epidermis but it leaves the stratum corneum intact, which leads to very good healing and virtually no down time. With the passage of time, there’s increased deposition of new collagen in the epidermis.

This can take a few months though so, while an immediate improvement is visible, there will also be sustained improvement in up to three to six months.

The device also has a Perméa hand piece, which increases treatment versatility and customisation. It is designed to enhancing tone and radiance whilst allowing greater permeability for topical treatments. The Perméa hand piece is a 1927 nanometre hand piece, which is not the same as the Fraxel 1927—this is 1 watt device diode as opposed to a fibre.

This creates more shallow lesions compared to the original hand piece, which disrupt the epidermis to some extent, creating what are known as micro pores in the upper epidermis. Each micro pore is a 3D structure that is individually capable of acting as a

reservoir for sustained delivery, retaining whichever treatment fluids you choose to put on the skin.

A previous study with SkinCeuticals C E Ferulic shows that the erythema was much reduced when the topical treatment was added compared to when the Perméa was used alone, thus demonstrating how the laser and topical treatments can potentiate each other.

Patients found that the dyschromia, radiancy and the overall appearance was much improved with the use of the Perméa along with a topical, as opposed to just the Perméa alone.

Hand pieces The two hand pieces complement each other, but the original is more focussed on maintaining and treating pores while the Perméa’s focus is increased radiance and permeability.

The machine has three settings—low, medium and high—so it can be adjusted depending on how aggressive you want to be.

Although the Fraxel Dual and the Perméa have the same wavelength, the Perméa is a diode whereas the Fraxel Dual has a fibre, and the wattage is also much different—1 W instead of 10 W. The energy delivered also varies drastically, which, consequently affects the maximum treatment coverage that can be achieved with each device.

Clear + Brilliant is not so much a treatment device as a maintenance device, but of course it is still helpful for getting rid of things like lentigines and discolourations. Although it’s not specifically targeted at reducing erythema, this is still something that can be achieved.

Evidence A small study presented at the American academy of Dermatology in 2012 looked at pore size and skin texture after using the Clear + Brilliant device. Twenty patients received three full-face treatments of eight passes at the highest tolerable energy level (4-9mJ), two weeks apart. The skin was analysed using the VISIA-CR imaging system and subjective measurements were recorded, both by the subjects themselves and by independent investigators, regarding pore appearance, skin texture and overall skin appearance. The improvements

Subjective improvement in pore size

Number of patients

Percentage of patients

None

2

10

Mild (1-25%)

9

45

Moderate (26-50%)

6

30

Marked (51-75%)

3

15

Very significant (76-100%)

0

0

were rated as either none (0%), mild (1-25%), moderate (26-50%), marked (51-75%) or very significant (76-100%). The average result after three treatments was a reduction in the average pore count in all three assessed views—right side, left side and front.

The investigators, meanwhile, were almost evenly spilt between mild and moderate—55 to 45— when assessing the improvement in pore appearance, but found that, when it came to skin texture, 70% were in the moderate category and 30% were in mild. The conclusion was that the non-ablative fractional 1440 nanometre laser reduces both pore count and pore size and improves skin appearance in all skin types. There’s very minimal discomfort during the procedure, and very transient oedema and erythema following the procedure.

Feedback In a small survey carried out in the clinic in St Albans, we found that all patients tolerated the treatment really well, including those treated without local anaesthetic. All patients reported that they would recommend the treatment to a friend. The downtime was very manageable, almost negligible, and the progression was predictable each time. All noted an improvement in the softness and texture of their skin, and four out of five noticed a reduction in pores after just one treatment. Although it wasn’t a full course of treatment, two of the five had reduction in redness and/or macular scars related to acne or rosacea.

Sharon Crichlow is a Consultant Dermatologist. She has a particular interest in dermatopathology (the microscopic evaluation of the skin), and offers a range of cosmetic dermatology treatments.

This was the 20 patients’ subjective improvement in pore size. The highest number of patients recorded a mild improvement, while three quarters of the group fell into either the mild or moderate categories. For skin texture, 55% of people recorded a moderate improvement, 35% mild and 10% marked.

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