Body Language Journal #77 by Body Language Journal

dec/jan

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

The art of eating well HOW TO INCORPORATE NUTRITIONAL SERVICES ALONGSIDE BODY CONTOURING PROCEDURES

WEIGHTLOSS

COMPLICATIONS

EXPECTATION

A complete approach: diet, therapy and contouring treatments

Potential adverse reactions from dermal fillers and how to manage them if they arise

The importance of legalities in body contouring and wellness

* RESILIENT BEAUTY

*Resilient Hyaluronic Acid

WELCOME TO THE ERA OF DYNAMIC AESTHETICS

body language I CONTENTS 3

contents 07 NEWS

39 BODY

OBSERVATIONS

WEIGHT MANAGEMENT

Reports and comments

Losing weight and maintaining it can be difficult. Bethan Coomber discusses her complete approach, involving diet, therapy and contouring treatments in order to help patients achieve lasting results

17 REPORT INDUSTRY NEWS Headlines and updates

20 INJECTABLES FACING COMPLICATIONS Dr Patrick Treacy discusses dermal filler complications and how to deal with them

45 LEGAL GREAT EXPECTATIONS

28 EQUIPMENT

Mr Andrew Andrews discusses the importance of legalities in body contouring and wellness

ELEVATING NON-SURGICAL FACIAL LIFTING

49 TREATMENT

Dr Roberto Pizzamiglio explains how Silhouette Soft sutures with bidirectional cones can be used for elevating facial tissue

PEACH FUZZ

34 DIET

52 PRODUCTS

NUTRITION FOR BODY CONTOURING

ON THE MARKET

Aesthetics clinics are increasingly incorporating nutritional services into their clinic offering. Kim Pearson highlights nutritional interventions that can work alongside body contouring procedures to optimise treatment results

Sujata Jolly talks about fitting treatment of vellus hair where photo-epilation often fails

The latest medical aesthetic products and services

54 EQUIPMENT PROPTOSIS OF FAT Dr Diane Duncan discusses the BodyFX treatment and how cell death mechanisms affect clinical results

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.

49 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 Patrick Treacy, Dr Roberto Pizzamiglio, Dr Leah Totton, Kim Pearson, Bethan Coomber, Mr Andrew Andrews, Sujata Jolly, Dr Diane Duncan 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

body language I NEWS 7

observations

MEDITERRANEAN DIET MAY PROTECT AGAINST BRAIN AGEING A diet rich in fish and vegetables with less meat may slow the loss of brain cells in older people The virtues of a Mediterranean diet have long been extolled and according to new research, this type of diet—rich in fish, vegetables and with less meat—may slow the loss of brain cells in older people, to the extent of equating to preventing five years of age related brain shrinkage. The US study monitored the eating habits of 674 people, with an average age of 80, who lived in Manhattan and did not suffer from dementia. The participants were divided into groups which reflected whether or not they followed a Mediterranean style diet —which involves consuming less meat and dairy products than average, and a light to moderate amount of alcohol. Researchers found that those who did, ended up with bigger brains and a slowing down of the age-

ing process, according to the study published in Neurology Journal. “These results are exciting, as they raise the possibility that people may potentially prevent brain shrinking and the effects of ageing on the brain simply by following a healthy diet,” said the main author, Yian Gu, of Columbia University in New York. Total brain volume was on average 13.11 millilitres greater in those who had closely followed a Mediterranean-style diet than that of those who had not done so. Grey matter volume was 5mm greater, and white matter 6.4mm greater, than those whose diet had not been predominantly Mediterranean foods. “The magnitude of the association with brain measures was relatively small. But when you consider that eating

at least five of the recommended Mediterranean diet components has an association comparable to five years of age, that is substantial,” said Gu. Regularly consuming fish and eating little meat was particularly effective. “Eating at least three to five ounces of fish weekly, or eating no more than three and a

half ounces of meat daily, may provide considerable protection against loss of brain cells, equal to about three to four years of ageing,” Gu added. The authors cautioned that their findings do not offer conclusive proof that the Mediterranean diet prevents brain shrinkage—it is merely an association.

FACELIFTS MAY DO LITTLE TO BOOST SELF-ESTEEM Study suggests patients exhibit a wide spectrum of psychological reactions after facelift surgery Thousands of pounds are spent each year by people going under the knife, in an attempt to not only look, but to feel better. However, this attempt to feel better could all be in vain, according to research carried out by eminent plastic surgeon Dr Andrew Jacono who has been studying the effect of surgery on patients’ self-esteem. Jacono used the Rosenberg Self-Esteem Scale (RSES) to correlate the outcome of rhytidectomy as perceived by the patient, to further understand the asso-

ciation of self-esteem and the results of aesthetic facial rejuvenation. His study concluded that patient’s self-esteem before surgery may partially determine the quality-of-life outcome after surgery. Patients with low preoperative self-esteem saw an increase in self-esteem after surgery, those with average preoperative self-esteem experienced no change, whilst those with high preoperative self-esteem experienced a decrease in self-esteem after surgery.

Self-esteem measurements did not correlate directly with the positive effect of the surgical outcome, as patients showed no mean change in self-esteem, but patients thought that they appeared on average of 8.9 years younger after their facelift surgery. Jacono’s findings highlight the complex nature of the human psyche as it relates to aesthetic surgery and shows that patients exhibit a wide spectrum of psychological reactions after facelift surgery.

8 NEWS I body language

TUMMY TUCK COMPLICATIONS Abdominoplasty has a higher risk of major complications than other cosmetic plastic surgery procedures, according to a new study The tummy tuck, which is carried out to remove excess skin and tissue from the abdomen and to create a smoother, firmer abdominal profile is the sixth most common cosmetic surgical procedure performed in the United States. A new study has revealed that complication risk is particularly high for the large proportion of patients combining the procedure with other work. According to data analyst Dr Julian Winocour of Vanderbilt University, Nashville, and colleagues, the figures show that, “Combined procedures can significantly increase complication rates and should be considered carefully in higher-risk patients.” The researchers assessed abdominoplasty complication rates and risk factors using the nationwide CosmetAssure database. CosmetAssure is an insurance

program providing coverage for complications related to cosmetic plastic surgery procedures, which are typically not covered by health insurance. The study reported in Plastic and Reconstructive Surgery, included nearly 25,000 abdominoplasties performed between 2008 and 2013—representing about 14% of all procedures in the database. Women accounted for 97% of these abdominoplasty patients and the average subject age was 42 years. Overall, major complications occurred in 4% of patients undergoing abdominoplasty—significantly higher than the 1.4% rate after other cosmetic surgery procedures. (The database omitted less-serious complications that can be managed in the clinic). Hematomas were the most common major complication, followed by infections,

venous thromboembolism and lungrelated problems. Sixty-five percent of patients underwent abdominoplasty combined with other cosmetic surgery procedures, something which increased risk levels of the procedure considerably—from 3.1% to up to 10.4% when abdominoplasty was combined with body contouring plus liposuction. After adjustment for other factors, the relative risk of major complications was 50% higher with combined procedures. Other risk factors for major complications included being male, an age of 55 years or older, and obesity. Risk was lower when abdominoplasty was performed in an office-based surgical suite, compared to a hospital or surgical centre. Dr Winocour comments, “Surgeons often refer patients with major illnesses, such as heart disease, to hospitals, which may be responsible for this observed trend in complications.” Diabetes and smoking—two major surgical risk factors—were not associated with a significant increase in complications after abdominoplasty. “That likely reflected Board-certified plastic surgeons’ practice of not offering abdominoplasty to poorly controlled diabetics and recommending strict smoking cessation for at least four weeks before and after surgery,” Dr Wincour adds. The study adds to previous evidence that abdominoplasty carries a higher complication rate than other cosmetic plastic surgery procedures. “Although the overall incidence of major complications is low, such complications can leave a potentially devastating cosmetic outcome and pose a significant financial burden on the patient and surgeon,” the researchers write. They draw special attention to the risk associated with multiple procedures— especially since nearly two-thirds of patients in the database underwent other cosmetic procedures combined with abdominoplasty. Dr Winocour and colleagues suggest that some patients at high risk of complications might be better off undergoing staged rather than combination procedures.

JUNE 16TH – 19TH

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FACIAL AESTHETIC CONFERENCE AND EXHIBITION

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 HAIR

 BUSINESS

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Register before February 29th 2016 to take advantage of our best Early Bird Prices on all Delegate Passes faceconference.com/register

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body language I NEWS 11

second brief

NO NEED TO BE SCAR-ED

Researchers commissioned by Science of Skin have delved into the psychological impact of vicible scars in men, and questioned 250 men with scars on their face, neck or hands. Nearly a third said they feel the need to change their behaviour when first meeting people, to counteract the ‘bad boy’ image or even play up to it. Results also revealed that older men are twice as likely to be secretly proud of a visible tattoo’s ‘tough’ connotations than their younger counterparts.

50%

50% ‘hardly ever think about’ their scars

31%

31% feel pressure to alter their behaviour when meeting people for the first time

15%

15% immediately joke about or explain their scars when meeting people, to ‘get it out of the way’

14%

14% feel aware of the negative impressions but ‘hope that people can see past it’ as they get to know them

07%

7% of 55+ year olds are secretly pleased with their tough image v only 3% of 25-34 year-olds

One tenth have felt judgment and discrimination, and feel the need to ‘work hard’ to counteract the negative image given by their scars

One in 15 felt secretly proud of their markings, of which a third (2%) confessed to actively playing up to the ‘bad boy’ image, by acting tougher than they are

ECZEMA PROGRESS The largest worldwide study on eczema has identified 10 new genomic regions in which common gene variants increase the risk of atopic dermatitis In the largest recorded genetic study on atopic dermatitis, in which more than 50,000 patients and 300,000 healthy individuals were examined, researchers sought to identify susceptibility loci for this complex disease. The addition of these ten new risk loci brings the total number of known atopic dermatitis risk loci to 31. Eczema affects up to 20% of children and 10% of adults worldwide, and has a huge impact not only on quality of life, but psychosocial well-being of patients and their families. Despite the precise causes not fully being known, it is firmly established that an inherited susceptibility is of supreme importance. The study looked at over 15 million genetic variants in 21,399 cases and 95,464 controls from populations of European, African, Japanese and Latino ancestry, followed by replication in 32,059 cases and 228,628 controls from 18 studies. The results which have now been published on the website of Nature Genetics show that the majority of the genes identified, play a role in balancing the immune system and its response to environmental exposures, and also affect risk of other inf lammatory diseases. According to study leader Weidinger, “results suggest that many people have an inherited susceptibility for inf lammatory diseases in general. In these people, other inherited or environmental exposures are then responsible for this susceptibility to be expressed in the skin.” The molecular mechanisms through which the identified genes increase the risk for eczema, coupled with their interaction with lifestyle and environmental factors have yet to be clarified. “Only then will we be able to develop tests which facilitate the prediction of disease risk and the development of improved strategies for prevention and treatment, or to apply existing treatments in a more targeted fashion”, says study leader Weidinger.

12 NEWS I body language

FULL FACE TRANSPLANT SUCCESS NYU Langone Medical Center have announced the successful completion of the most extensive face transplant to date, setting new standards of care in this emerging field The surgery—the first of its kind performed in New York State—began the morning of August 14, 2015 and concluded 26 hours later involving a team of more than 100 physicians, nurses, and technical and support staff—led by Eduardo D Rodriguez, MD, DDS, the Helen L Kimmel Professor of Reconstructive Plastic Surgery and chair of the Hansjörg Wyss Department of Plastic Surgery. The team worked in two adjoining operating rooms—in one room the donor’s face was procured (along with other donated organs), and in the other the recipient’s face and scalp burn was removed and the transplant took place. The recipient, volunteer firefighter Patrick Hardison, 41, of Senatobia, Mississippi, was injured in September 2001, when the roof of a burning building collapsed leaving him with disfiguring burns across his entire face, head, neck, and upper torso. Hardison lost his eyelids, ears, lips, and most of his nose, as well as his hair, including his eyebrows. After enduring more than 70 surgeries in Mississippi and elsewhere, he was still unable to return to a normal life. Dr Rodriguez, transplanted not only the face but also the entire scalp. Patrick’s surgery was pivotal in that the donor’s eyelids and the muscles that control blinking were transplanted—a significant milestone and a procedure that had not been previously performed on a seeing patient. Milestones achieved in Patrick’s surgery include: Transplantation of the ears and ear canals; transplantation of selective bony structures from the donor, including portions of the chin, cheeks, and the entire nose; advanced use of three-dimensional

modelling, computerised modelling, and three-dimensional printed patient-specific cutting guides designed from the recipient’s and the donor’s CT scans to provide the most precise “snap-fit” of the skeleton; and precise placement of patient-specific metal plates and screws to ensure the proper contour and symmetry of the transplanted face The transplantation of the donor’s eyelids and blinking mechanisms was particularly important to the surgery’s success, as Patrick was in danger of losing his sight and had been unable to perform independent daily tasks, such as driving. Within the final hours of surgery, signs of success were evident. Patrick’s new face, particularly his new lips and ears, were robust with colour, indicating circulation had been restored. The hair on his scalp, as well as the beard on his face, began growing back immediately. He was able to use his new eyelids and blink on the third day of recovery, after the swelling began to diminish. He was sitting up in a chair within a week. And now, just three months removed from surgery, swelling has greatly subsided and he is quickly returning to the routines of daily life independently. Patrick, like all transplant patients, will need to remain on anti-rejection medication for the rest of his life to prevent transplant rejection. Patrick will also rely on his family and friends—particularly his fellow firefighters in Senatobia—to support him in his recovery and his transition back to his hometown after he is discharged from the hospital. He will also have regular monthly checkups with Dr Rodriguez and the face transplant team.

LOW FAT DIETS DON’T WORK A major academic analysis, comparing diets of more than 68,000 people, has concluded that health advice to reduce fat intake has been wrong Researchers funded by the National Institutes of Health and American Diabetes Association, carried out a systematic review of 53 long-term studies carried out since 1960; seeking to determine whether low-fat diets contribute to greater weight loss than participants’ usual diet, low-carbohydrate diets, and other higher-fat dietary interventions, The findings published in The Lancet suggest that when compared with dietary interventions of similar intensity, evidenced Randomised Control Trials do not support lowfat diets over other dietary interventions for long-term weight loss. “There is no good evidence for recommending low-fat diets,” said lead author Dr Deirdre Tobias from Brigham and Women’s Hospital and Harvard medical school, Boston. “Behind current dietary advice to cut out the fat, which contains more than twice the calories per gram of carbohydrates and protein, the thinking is that simply reducing fat intake will naturally lead to weight loss. But our robust evidence clearly suggests otherwise.” Tobias confirms that whole fresh foods and real home cooking, rather than pre-packaged alternatives are the real key to creating a diet that is sustainable for life.

14 NEWS I body language

events 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 14-17 DECEMBER, AOCMF Course Principles in Craniomaxillofacial Fracture Management, Davos, Switzerland W: davos1215.aocmf.org 15 – 18 JANUARY 2016, ODAC Orlando Dermatology Aesthetic & Clinical Conference, Florida, USA W: orlandoderm.org

DRUG PROMISES ROBUST NEW HAIR GROWTH Hair growth can be restored by inhibiting a family of enzymes inside hair follicles that are suspended in a resting state, according to a new study In experiments with mouse and human hair follicles, Angela M Christiano, PhD, and colleagues at Columbia University Medical Centre found that drugs that inhibit the Janus kinase (JAK) family of enzymes promote rapid and robust hair growth when applied to the skin. The study raises the possibility that JAK inhibitors could be used to restore hair growth in forms of hair loss induced by male pattern baldness, and other types of hair loss that occur when hair follicles are trapped in a resting state. Two JAK inhibitors have been approved by the US FDA—one for treatment of blood diseases (ruxolitinib) and the other for rheumatoid arthritis (tofacitinib). Both are being tested in clinical trials for the treatment of plaque psoriasis and alopecia areata, an autoimmune disease that causes hair loss. “What we’ve found is promising, though we haven’t yet shown it’s a cure for pattern baldness,” said Dr Christiano. “More work needs to be done to test if JAK inhibitors can induce hair growth in humans using formulations specially made for the scalp.” The discovery was made serendipitously while Christiano and her colleagues were studying alopecia areata, a form of hair loss that’s caused by an autoimmune attack on the hair follicles. Christiano and colleagues reported last year that JAK inhibitors shut off the signal that provokes the autoimmune attack, and that oral forms of the drug restore hair growth in some people with the disorder. During those experiments, Dr Christiano

noticed that mice grew more hair when JAK inhibitors were applied to the skin than when the drug was given systemically—suggesting they may be doing something to the hair follicles in addition to stopping the immune attack. Hair follicles do not produce hair steadily, but cycle between dormant and active phases. A closer examination of normal mouse hair follicles, revealed that JAK inhibitors rapidly awakened resting follicles out of dormancy. Mice treated for five days with one of two JAK inhibitors sprouted new hair within 10 days, greatly accelerating the onset of hair growth. No hair grew on control mice within the same amount of time. “There aren’t many compounds that can push hair follicles into their growth cycle so quickly,” said Dr Christiano. “Some topical agents induce tufts of hair here and there after a few weeks, but very few compounds have this potent an effect so quickly.” The drugs also produce longer hair from human hair follicles grown in culture and on skin grafted onto mice. It’s likely that the drugs act on the same pathways in human follicles as they do in mice, suggesting they could induce new hair growth and extend the growth of existing hairs in humans. However, whether JAK inhibitors can reawaken the resting state of hair follicles because of androgenetic alopecia (which causes male and female pattern baldness) or other forms of hair loss is still unknown. Experiments to address hair follicles affected by hair loss disorders are under way.

28 – 31 JANUARY, IMCAS Annual World Congress, Paris, France W: imcas.com/en 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 19-22 MAY, 13th EADV Spring Symposium, Athens, Greece W: eadvathens2016.org/ 16 – 18 JUNE, 3rd ICAD Brazil – International Congress of Aesthetic Dermatology and Healthy Aging Medicine, Sao Paulo, Brazil W: v1.euromedicom.com/3rd-icadbrazil/index.html 16 – 19 JUNE, FACE 2016, London, UK W: faceconference.com

16 – 17 SEPTEMBER, AMWC Eastern Europe 2016 – 4th Aesthetic & AntiAging Medicine World Congress Eastern Europe, Moscow, Russia W: v1.euromedicom.com/amwc-eastern-europe-2016/index.html 23 – 27 OCTOBER, 23rd Congress of ISAPS, Kyoto-shi, Japan W: isapscongress.org Send events for consideration to arabella@face-ltd.com

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body language I INDUSTRY 17

industry news

AVITA MEDICAL HELPS BURN VICTIMS IN TAIWAN WITH RECELL Doctors in Taiwan have reported positive results from using ReCell to treat burn victims of June’s waterpark disaster A total of 12 people have died from burns sustained in the June 27 blast, triggered when a flammable starch-based powder ignited during a crowded music festival at the waterpark outside Taipei. The fire left 498 people with burn injuries, most of them teenagers, with the average wound size covering 43% of their bodies. Avita Medical donated 50 ReCell devices and sent a team to support Taiwanese medical personnel. All of these units, and a number of purchased devices, were distributed to 12 hospitals. To date, about 76 patients have been treated with ReCell and doctors contacted since the treatment began have now reported positive outcomes in their application of Regenerative Epithelial Suspension to both wounds and donor sites. Definitive conclusions around the impact of ReCell are difficult to draw in circumstances where multiple treat-

ments are being provided to meet the challenges of a mass casualty; however, when ReCell is part of care, it is reported that b e t t e r-t h a n- e x p e c t e d outcomes are often being achieved. “There was a great range and variation of burn wounds, so it is heartening to hear directly from the doctors that the regenerative healing mechanism has performed as we hoped it would,” said Adam Kelliher, CEO of Avita Medical. “Using ReCell was a new approach for the surgeons, and it was being applied in extreme circumstances, so we are pleased to be able to report benefits amongst these various anecdotal accounts.” One of the doctors contacted, Dr Yu-Ching Shih, a plastic surgeon at Taipei Veterans General Hospital, who said he had conducted four treatments with ReCell, and reported positive outcomes in healing and better-resulting skin

quality. He observed that the device is ‘important in accelerating healing, as we have seen that ReCell does help wound closure.’ Dr Shi said in one of the cases, donor skin shortages meant the patient could only receive ReCell on one thigh, while the other thigh was merely given a dressing. “After 14 days, we could see wound closure on the right [ReCell-treated] thigh and no progress of wound healing on the left [untreated] thigh,” Dr Shi said. “We will keep monitoring results in the coming months, and it will be of particular interest to see if Re-

Cell can help stop such typical scarring problems as contracture.” Dr Wen-Pin Kao, chief doctor of the plastic surgery department at Changhua Christian Hospital, said using ReCell in conjunction with other treatments such as grafts had boosted the survival rate of ‘skin islands’ within the wound bed by up to 90%. “The final result is better than we expected,” Dr Kao said. “ReCell is showing that it can enhance the survival rate of skin grafts. By using this, we are seeing that there is no need for another skin graft treatment.”

DR ARNOLD KLEIN DIES “Dermatologist to the stars” who pioneered the use of botulinum toxins Dr Arnold “Arnie” Klein, a man known as Hollywood’s “Dermatologist to the Stars” died on Thursday 22nd October in a Rancho Mirage hospital aged 70. Klein was a pioneer in the use of Botox and other injectable substances to improve personal appearance, but was probably better known to the public as a close friend of Michael Jackson. This was a relationship that helped reinforce his reputation as the go-to guy for stars such as Elizabeth Taylor, Dolly Parton

and Cher, powerful Hollywood executives, wealthy Beverly Hills socialites and even international royalty who wanted to look younger. Klein and Jackson met in 1983 when he treated him for a skin rash and Klein became the entertainer’s regular dermatologist, treating him for ailments including vitiligo. Attorney Garo Ghazarian, who represented Klein during the Jackson death investigation, called Klein a larger than

life figure who was engaging, outgoing, candid and funny. Actress Carrie Fisher once described Klein to the AP as a brilliant and ethical doctor who never would have misused drugs and who helped her immensely with her appearance and self-esteem. “It’s like he’s a painter but the brush is a needle,” she said. No cause of death was given by the Riverside County coroner’s office, and no investigation was planned.

18 INDUSTRY I body language

EARFOLD Northwood Medical Innovation Ltd have entered into agreement with Allergan for earFold, a medical device for teh correction of prominent ears

ALLERGAN - PFIZER MERGER Botox joins Viagra in a $160bn Allergan and Pfizer merger, creating the world’s largest drugmaker and healthcare group With a market value in excess of $320bn, the combined company, dubbed “Pfizergan” has overtaken rival Johnson & Johnson, valued at $277bn, as the world’s largest healthcare group. Annual revenues are predicted to be in excess of $65bn, drawn from drugs including Pfizer’s pneumonia vaccines, Viagra and the wrinkle smoother Botox, made by Allergan. The combination of Pfizer and Allergan will significantly increase the scale of Pfizer’s established business, and their complementary capabilities will maximise the combined established portfolio. The addition of Allergan’s Women’s Health and Anti-Infectives portfolio will add depth to Pfizer’s established business, and Pfizer will expand the reach of Allergan’s established portfolio using its existing commercial capabilities, infrastructure and global scale. In addition, Allergan brings topical formulation, manufacturing and its Anda distribution capabilities to the combined company. The deal has been criticised by US and UK politicians for allowing Pfizer to escape US taxes on more than $128bn US of overseas profits—possible by the company moving it’s domicile to Ireland. After completion the combined company will be renamed Pfizer and listed on the New York stock exchange. Pfizer plc’s board is expected to have 15 directors, consisting of all of Pfizer’s 11 current directors and 4 current directors of Allergan. The directors from Allergan will be Paul Bisaro, Allergan’s current Executive Chairman, Brent Saunders, Allergan’s current Chief Executive Officer (CEO), and two other directors from Allergan to be selected at a later date. Ian Read, Pfizer’s Chairman and CEO, will serve as Chairman and CEO of the combined company. Brent Saunders will serve as President and Chief Operating Officer of the combined company. He will be responsible for the oversight of all Pfizer and Allergan’s combined commercial businesses, manufacturing and strategy functions. “The combination of Allergan and Pfizer is a highly strategic, value-enhancing transaction that brings together two biopharma powerhouses to change lives for the better,” said Saunders. Pfizer boss Ian Read said: “Allergan’s businesses align with and enhance Pfizer’s businesses, creating best-in-class, sustainable, innovative and established businesses that are poised for growth,” adding the deal would enable Pfizer to pursue “business development opportunities on a more competitive footing within our industry.”

Prominent or protruding ears are thought to affect approximately 1-2% of the population—about 100 million people worldwide. Although current treatment options are limited, with the most conventional being surgical intervention for otoplasty or pinnaplasty, the International Society of Aesthetic Plastic Surgery (ISAPS), approximately 247,518 ear surgery operations took place across the world in 2014, making it one of the most common cosmetic procedures performed. However, many affected may choose to remain untreated due to the risks associated with these procedures, which include adverse reactions to general anaesthetic, infection, the development of keloid scarring and sometimes the need for re-do operations due to asymmetric outcomes or relapse. earFold is a small implantable medical device made from a short strip of nitinol metal alloy, which is specifically designed to retain a preset shape. Following injection of a local anaesthetic, it is carefully inserted under the skin using an introducer, and works by gripping the cartilage of the ear, enhancing or creating the shape of the anti-helical fold—thereby reducing the prominence of the ear. Including the initial consultation, the procedure takes about 15-20 minutes to complete and can be performed within an outpatient setting, reducing the risk associated with a general anaesthetic. Given the preset nature of the nitinol strip, treatment with earFold can deliver a consistently effective outcome. By contrast, otoplasty or pinnaplasty is a complex surgical procedure that requires a visit to a fully-fitted operating suite, requires a general anaesthetic and is associated with significant down-time post treatment. earFold has been studied in more than 400 patients with real world experience showing the benefit of providing patients with a rapid and predictable alternative to existing otoplasty techniques. “Following a complex outcome after a standard otoplasty procedure, early in my career, I was motivated to develop an alternative approach to correcting prominent ears,” says Norbert Kang, Consultant Plastic Surgeon and creator of the earFold™. “In my clinical practice, there are a significant number of patients who are reluctant to undergo surgery and so put up with accepting the social hindrance of prominent ears. The beauty of the earFold treatment system is that it offers an evidenced-based alternative to standard otoplasty surgery that may meet the needs of a wider range of patients, by delivering immediate and predictable results, without the risks associated with general anaesthetic.” On completion of this deal, Allergan will establish a standardised training programme for surgeons on the earFold treatment system, in order to bring this treatment option to more patients.

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20 INJECTABLES I body language

Facing complications DR PATRICK TREACY discusses dermal filler complications and how to deal with them

oft tissue augmentation with temporary dermal fillers is a fast-expanding field that has become an integral part of many aesthetic practices. According to the American Academy of Aesthetic Plastic Surgeons,

2,448,716 people received hyaluronic acid (HA) injections from plastic surgeons in 2013. These filler products are mostly safe, having a known incidence of mild and transient adverse events, but serious complications can also occur caus-

ing gross biofilm reactions or vascular embolism causing severe skin necrosis or even blindness. At present, thereâ&#x20AC;&#x2122;s a paucity of literature regarding both the prevention and management of serious events, despite the fact that

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The sales of dermal fillers are increasing at 15% per year, whereas botulinum toxin type A increases at 5% per year

these complications are the very things that patients and physicians both continually fear. Many physicians, (including myself), feel that corporate prefer not to address these issues and they are driven underground. Over the years, many of my colleagues have referred me their more serious problems and I consequently have developed a certain experience in this area. This insight into complications of der-

Botulinum Toxin Type A 6.3 million

Up 3% from 2012

Soft Tissue Fillers 2.2 million

Up 13% from 2012

Chemical Peel 1.2 million Laser Hair Removal 1.1 million Microdermabrasion 974,000

Up 3% from 2012

Down 4% from 2012

No change

The American Society of Plastic Surgeons 2013 Plastic Surgery Statistics

mal filler use will serve to highlight both of these problems and try to help one manage these complications if they should ever happen to you. The size of the problem Fortunately, most adverse reactions are mild and transient. Adverse events can be grouped into expected procedure-related events, such as bruising, erythema, and tenderness; events potentially related to improper technique, such as nodule formation; and reactions to the product, such as granuloma formation. We had a serious problem in both the UK and Ireland some years ago, with 168 different fillers being used in this marketplace. In comparison, the USA had effectively just three or four, which had been passed by the Food and Drug

Administration. Things are thankfully much better in Europe now, since most of the fillers that have survived the passage of time here, are ironically the exact same ones that were passed for clinical use in the USA. This also raises the question of whether we really require a similar vetting procedure regarding the safety of filler products in this jurisdiction. Specific problems Many minor side effects, like swelling, can easily be controlled by use of oral steroids. Bruising effects are mostly due to patients taking supplements including vitamin E or omega fish oils, aspirin, Lipitor or antidepressants prior to procedure. Moderate problems of dermal fillers are usually due to delayed onset nodules resulting in granuloma formation, inflammation and

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Case Study Example 1 I saw a patient last January in Dublin, who had as many as probably ten gross lesions six months after being injected with hyaluronic fillers. A diagnosis of generalised biofilm was made and her bacterial cultures showed evidence of streptococcus. Although the hospital wanted a plastic surgeon to remove the lesions, she was referred to me at Ailesbury. I tend to treat lesions medically, with a mixture of intralesional hyalase, dexamethasone and oral antibiotics. I also consider the possibility of mycobacteria being involved and often use Rifanah along with Ciprofloxacin. In this instance, I was able to bring this patient back to normality within a period of six weeks, though she still needed antibiotics for three months.

immune response. More serious adverse reactions include biofilm and vascular embolism leading to skin necrosis or blindness. Why are these problems occurring? There are many contributing factors. The first is that a corporate is driving sales, and as a consequence, the amount of product being used is increasing. The second is the continual introduction of new compounds and pharmaceuticals into our dermal fillers. The hyaluronic acid fillers started off fairly simple structures, but in recent years the addition of butanediol diglycidyl ethers (BDDEs) altered the chains and now different HA dermal fillers exist for different positions in the face, and consequently we have seen quite an increase in problems. Through the years, my experience of these higher molecular weight hyaluronic acids (SubQ, Voluma, Macrolane) is that they have tended to be problematic in terms of delayed onset nodules. I have long advised that Radiesse should not be injected in the perioral area or the vermillion border of the lips and question it’s use in the periocular area when we have other safer compounds to use. Bio-Alcamid has long been a

problem compound and I have treated many patients with the desire to remove this innocuous material from their face. It almost became the gold standard for treating patients with HIV lipodystrophy—in the days before less problematic antiretroviral drugs, when physicians had only Sculptra as an alternative. Luckily enough for most of the HIV lipoatrophy patients that I’ve treated, it comes out quite easily, because you can nick it, but unfortunately it does form abscesses up to ten years later. I also noticed that many patients who removed this compound tend to stay aesthetically normal because it has formed a collagen type capsulation to occupy the area where it was placed. Lidocaine dangers I’m not an advocate of lidocaine being included in every filler. This was largely done with our permission, often to aid nurses rather than doctors, and I’m certainly not being territorial about this. In my mind, lidocaine is possibly a dangerous drug to be unquestionably adding to dermal filler, because it of its potential to cause vasodilation. By using it widely and without proper recourse to its effects, we’re most probably setting up the arterial fa-

cial vessels like ducks in a row to be damaged by needles used by the unwary. I don’t remember seeing this level of complications prior to the widespread use of lidocaine, so whilst I can’t scientifically confirm it’s to blame, it’s definitely something we should now be considering. If we used lidocaine and adrenaline, the vessels would get smaller and they would be less easy to hit. For an ischemic event, you certainly don’t want adrenaline on board, but adrenaline only has an effect for about eight minutes, whereas lidocaine has an effect certainly in the region of two to four hours. Biofilm I have had several patients present to me with biofilm in recent years and have been able to successfully reverse these patients with hyalase, dexamethasone and in one instance 5-fluorouracil within three to four weeks. I have my own theories on the etiology of biofilm, which I’m fairly confident will be proven to be true. Primarily, I feel a lot of these biofilms are possibly mycobacteria. We like to think that the age of mycobacteria is long gone but it’s not—these organisms are present in many different environments around us, including in our

I have successfully treated patients presenting with biofilm, with hyalase, dexamethasone and in one instance 5-fluorouracil within three to four weeks

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What happens when a vascular accident occurs? Vascular problems begin with pain, and the skin launching into a livedo pattern, almost within a few minutes. This is followed in the next few hours by a blue-black discolouration, blister formation, skin breakdown, and within a few days—necrosis.

Effect of small ﬁller bolus A small bolus is usually carried downstream by blood flow and may cause limited obstruction that can be bypassed via abundant collateral vessels. Problem is region with restricted collaterals (eg, the glabellar region). Effect depends on the presence or absence of enough collateral circulation in the target tissues.

Distal branches Micro volume of filler does not completely obstruct blood supply

Collateral flow

Proximal branches

Effect of large ﬁller bolus When a large bolus of filler material enters a small or medium-sized vessel, the material may flow retrograde to the blood flow’s normal direction after it has filled in the distal segment, because there is nowhere else for the filler to go. If the filler bypasses a tributary during its retrograde flow, it may enter this particular pathway and be carried to distant areas. This is probably the pathophysiology responsible for injury sites distant to the original injection site.

water supply. We know that these specialist micro-organisms tend to form colonies, if not sub-colonies and we also know that ordinary antibiotics are largely ineffective in treating them. We know that when we take sterile cultures from biofilms, we usually grow nothing. However, if you can test for mycobacteria, quite a number of them are positive. You need to do a special PC test for mycobacteria and in the absence of this facility you’ll probably miss it. Hence, I would advocate starting the patient on

66 I am not an advocate of lidocaine being included in every filler, due to its potential to cause vasodilation 99

Distal branches

Supratrochlear a. Dorsal nasal a. Opthalmic a.

Angular a.

Facial a.

rifampicin and isoniazid as well as clindamycin. Biofilm is emerging more and more with the BDDE added to the HLAs, and as a consequence, these colonies actually migrate and form problems in other areas. When dealing with a colony of biofilm, three things need to be dealt with: The HLA in the middle; the collagen capsule around it; and the bacterial colonisation. I suggest that as many as maybe 10-20% of them are mycobacterium. I advocate using Hyalase (Hyaluronidase) to deal with the hyaluronic acid, dexamethasone to deal with the collagen, and antibiotics to deal with the infective commensals colonising the structure. One can’t be done without the other and if you give intra-lesional steroids alone, you’re probably creating a problem because you’re reducing the patient’s local immunity, and the infection will remain.

Retrograde flow

Internal carotid a. External carotid a.

What is the exact mechanism of vascular problems? While it is widely accepted that serious vascular compromise is caused by embolisation of filler material into part of the facial artery, I have dealt with some cases where the patient showed no clinical evidence of vascular compromise during injection, but presented some hours later with marked reticulation. I surmise that these patients may have sustained some venous compression due to hyaluronic acid swelling and considers the use of intravenous steroids in these patients. Vein illumination with AccuVein vein visualisation technology is a new technology that may reduce vascular embolic events by simply holding the device above the skin, and the vessels below are displayed on the surface of the skin. It is easy to use, and these vein finders may save valuable time

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for practitioners less familiar with facial anatomy. Hose-pipe theory The hose-pipe theory hypothesises that all vascular problems with dermal fillers resulting in skin necrosis or blindness are due to direct embolisation of the facial or temporal arteries or their collateral branches. Many physicians state the venous part of the system is not involved, because if you place a finger on the arterial system it will keep pulsing and supplying tissues.

Roundabout theory I advocate a slightly different vascular understanding, which for the sake of simplicity I shall call the roundabout theory. In my experience many patients present the next day, meaning they’re possibly presenting as a consequence of venous compression rather than embolism. Imagine the capillaries going into a small pressure system and the veins exiting the other side—if you block the veins, then nothing can go in on the arterial side. If we look at a small filler bolus, it’s usually carried downstream by blood flow, and that’s the classic embolism. That’s the sort of thing that we see for example in the labial artery. There’s no collateral circulation and if you damage the artery on the way in, then you’re going to cause a problem. Reversal protocol for retinal vascular occlusion Whenever a large filler bolus embolises a vessel, the consequence is retrograde flow to the blood’s normal direction, in a distal segment whenever the pressure is taken off the syringe. If you inject the temporal area, you can end up with

an obvious area of blanching, or at worse retinal vascular occlusion, and as a consequence unilateral blindness occurring within a short time. Are you confident you know what to do if this happens to you? First, don’t panic. You have to obviously discontinue the injection if it’s happening in front of your eyes. The first evidence of necrosis is pain and this happens even before blanching. Next massage the area and use heat packs on the area both as a means of dispersal and vasodilation. It’s most important to understand exactly why it has happened and in my mind to establish whether it’s arterial or venous. Is it reversible or not? If it’s hyaluronic acid, you have to use Hyalase (Hyaluronidase). I do this slightly differently to other physicians and use much higher doses than noted in the literature. I mix Hyalase (Hyaluronidase) with lidocaine because it burns like an acid. If you add lidocaine—and notice I’m saying lidocaine, not lidocaine-adrenaline— lidocaine will widen the embolised

66 I mix Hylase with lidocaine because it burns like an acid. Lidocaine will widen the embolised vessels 99 vessels. With the Hyalase—there are 1,500 units in the ampoule and I add 1ml of bacteriostatic saline, because it’s buffered so it’s not going to hurt the patient. I then draw out 0.2 ml—that’s 300 units of Hyalase (Hyaluronidase). I then mix the same amount with 2% lidocaine, and each 0.1ml of that is a nice controllable 75 units. Use as much as you have to, to save the patient’s face and inject in many different areas along the area of reticulation. Use up to 750 units twice daily or 375 units four times daily for smaller problems. I would even advocate the use of retro-orbital or even intra-orbital use of Hyalase (Hyaluronidase) in the case of impending blindness.  Case Study Example 2 This 37-year-old woman received an HA injection to the left nasolabial fold. The procedure was uneventful, but she reported back to the clinic with an erythematous reaction and some pain in the nasolabial and malar area the next day. In view of the vascular compromise, she was immediately treated with 150 units of hyaluronidase and nitropaste to the reticulated area. Because the patient presented 24 hours post procedure she was given 100mgs of cortisone IV and commenced on 4mgs of Dexamethasone PO. The patient’s symptoms and signs disappeared within a five-day period and two weeks later there was no evidence of any residual vascular deficit.

Many people inject some hyaluronic acid as a bee sting into the lower lip. Here we must remember that the inferior labial artery runs just posterior to the wet/dry zone of the lip on the inside. If you accidently inject it, you’re going to get a resultant vascular necrosis. If you examine a cadaver cross section through central third of lower lip, you will note the large size and superficial location of labial artery. Note the proximity of the artery to buccal mucosa, posterior to the wet-dry line of the lower lip. This area is commonly injected when trying to evert the red lip during augmentation with hyaluronic acid fillers. Anyone using hyaluronic acid fillers, must carry Hyalase in their fridge. If you don’t carry it, I would have to consider that you’re a dangerous doctor, because if a vascular event occurs you only have 24 hours to save your patient’s face. Most people reading this will in all likelihood send vascular accidents to their hospital colleagues who probably also don’t have no Hyalase in their pharmacy.

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Venous problems If it is considered venous, my way of treating the problem is also very different. In a case presenting the next day, I give 10 mg of dexamethasone IV stat as a bolus. This will be unproblematic because it will reduce the gross inflammatory response secondary to necrosis, even if it’s arterial. Note also that hyaluronic acid, absorbs water when it goes into the skin, and consequently increases in size by three to four times, so you’re going to reduce that that oedema also. Using vasodilatories Everybody says to use topical nitrates, but in my experience there are issues with this. Firstly, you can’t use them during the night time because the patient’s asleep and it requires hourly application; plus they’re very messy. I advocate the use of other vasodilatory

nitrates which are more long lasting and easier to find, especially Viagra, Cialis and Levitra. This may sound unconventional but I consider any sort of drugs that we use for erectile dysfunction are perfect for this. They’re going to cause vasodilation exactly the same as the other nitrates by increasing GMP, smooth muscle action. As a consequence, we get vasodilation. Summary To summarise the reversal protocol: discontinue immediately, massage the affected area, apply warm packs, bolus the dexamethasone, mix the Hyalase (Hyaluronidase)—don’t be afraid to use it—and consider the use of topical nitrates or Viagra. However, care should be taken when using the two together, as an older patient may be a cardiopath with pathology on board. They can also cause a syncopal episode, and I certainly know

66 If you’re a doctor who uses fillers, I would consider it essential to carry Hyalase (Hyaluronidase) and be very familiar with reversal protocol 99

one patient that was admitted to hospital some years ago as a consequence of getting topical nitropaste given liberally during a vascular event. If you’re a doctor who uses fillers, I would consider it essential to not only carry Hyalase (Hyaluronidase) in your fridge and be very familiar with your reversal protocol, but to be aware of which of your colleagues you could approach for assistance, should the need arise. It could save your patient’s face. Dr Patrick Treacy is Chairman of the Irish Association of Cosmetic Doctors and Irish Regional Representative of the British Association of Cosmetic Medicine. He is Honorary Board Member of the World Medical Trichologist Association and Honorary Ambassador to the Michael Jackson Legacy Foundation and the Haiti Leadership Foundation. Dr Treacy is a fellow of the Royal Society of Medicine and the Royal Society of Arts. (London). He is Chairman of the Ailesbury Humanitarian Foundation and is the driving force behind countless humanitarian efforts that has opened orphanages in both Haiti and Liberia the past year. Dr Treacy won the American Academy of Aesthetic Medicine award for his lecture on diagnosis and prevention of dermal filler complications. W: ailesburyhairclinic.com

To summarise the reversal protocol: discontinue immediately, massage the affected area, apply warm packs, bolus the dexamethasone, mix the Hyalase (Hyaluronidase) and consider the use of topical nitrates or Viagra

28 EQUIPMENT I body language

Elevating non-surgical facial lifting DR ROBERTO PIZZAMIGLIO explains how Silhouette Soft sutures with bidirectional cones can be used for elevating facial tissue

utures with bidirectional cones provide a non-surgical treatment option for aesthetic doctors to elevate tissue without surgery. Some plastic surgeons may be apprehensive about using the technique—because the skin elevation is less dramatic than the surgical results they are used to achieving. How-

ever an increasing number are using it as a transitional treatment where patients are not yet ready for a full face lift, are contraindicated, when they don’t want to have a general anaesthetic or countenance considerable down time. With the appropriate patient selection it is being used to achieve impressive results.

The Silhouette Soft Lift The Silhouette Soft Lift is a contemporary variation on the “traditional” thread lift, using specialised sutures which are introduced into the subcutaneous layer of the skin with a very fine needle, to lift tissue and improve skin texture. The idea is to “lift” the tissue with sutures interspersed with bi-directional

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fat compartment in the jaw drops, but we have retainer ligaments that maintain the aesthetic position of the jaw. Add to this a reduction of the bone and the relaxation of the tissue and the process brings about the changed look of our ageing jawline.

cones, in a minimally invasive fashion, and is most suited to patients with mild ageing characteristics. Application The ageing process brings about a three-dimensional change in the shape of the face. As we age, the

Structure The active parts of Silhouette Soft sutures are the cones, which act as an anchoring system. When the Silhouette Lift was introduced in 2006 as a surgical procedure, the cones were a hybrid permanent suture, with resorbable cones designed to grasp the tissue. A totally resorbable bidirectional suture has since been developed and was launched in 2013. This advance enabled the suture to be used without the need for surgery as this kind of suture can be inserted in the subcutaneous tissue, and not in the dermis. The cones remain the same, creating an anchor to facilitate the tissue lift, but also allow compression of the fatty tissue. The first sutures to be introduced featured eight bidirectional cones and two needles which were needed because the suture was inserted in two steps. The first insertion for the first half of the suture and first series of cones; the second needle to insert second half of the suture, from the same entry point. Silhouette Soft has undergone an evolution, and now also features 12 and 16 cone sutures to enable the whole face and neck to be treated effectively. However the difference is not only the number of the cones on the sutures, but also the length of the area which is grasped by the cones—the distance between the nodes has increased from 5mm to 8mm, allowing a larger area of subcutaneous tissue to be treated. The cones are fabricated from a mixture of polylactic acid and glycolic acid, and are absorbed by the body in around one year. The

The cones are fabricated from a mixture of polylactic acid and glycolic acid, and are absorbed by the body in around one year 99

suture material is also made from polylactic acid which is absorbed in around two years. The collateral effect of the polylactic acid is stronger fibrous tissue production. Polylactic acid stimulates type III collagen, which is a structural and solid collagen. This builds around the cones and when the cones are absorbed, fibrosis around the knot remains and maintains the support of the tissue. In terms of the “lift” effect, the suture does not produce a lift as such; it’s the movement and support of the tissue it brings about, which creates a fresher shape. For a patient who wants tightened skin, surgical intervention may be necessary as the suture procedure is designed to support the tissue in the appropriate position. Procedure When using an eight-cone suture the distance between the two entry points must be 10cms. From the first entry point, the first half of the suture is inserted into the subcutaneous layer of the skin, followed by the second needle from the same entry point, and the second half of the suture in the opposite direction. The technique is versatile, enough to be used in an angled part of the face—for example to create traction in the jawline and create better refraction and improved jaw definition. A longer suture would usually be used in a loop configuration rather than straight line. The 12-cone suture is 18cms and the 16-cone is 20cms. However, it is necessary to change from the bidirectional principle of the suture to the double unidirectional position of the suture because the cones work in the same direction. The technique for a longer suture is slightly different because two entry points are needed instead of one, but the way to insert the suture and the depth of the sutures remains the same. Probably the most frequently treated areas are the mid and lower face. When these areas are treated in a straight pattern it is recommended that two sutures with the eight-cones are used for each area. When using eight-cone sutures we suggest using a minimum of

30 EQUIPMENT I body language

two sutures to create enough support and compression of the tissue. Even in the jowl area of the lower face, two sutures can be used—for example one at an angle and one straight. These different vectors improve the jaw definition. Adopting the new ‘U’ technique Using a new advanced ‘U’ technique to configure the sutures provides several advantages. One advantage is that with one suture we can treat one area—for example just one suture can be enough to treat the jaw. The second is that the entry points are placed posteriorly, or sometimes behind or at the level of the hairline, so they are not visible. Using the ‘U’ configuration and the eight-cone suture, allows compression of the fatty tissue, so one can create more malar projection in the mid-face, if desired. The ‘U’ technique also produces greater elevation of the tissues and less projection when the tissue is sagging, so can be more useful to reposition it in the right place. It is possible to work horizontally, but generally we change the vectors according to aesthetic outcome we are seeking, so we can stay more vertical or even cross the vector. This technique can also create improvement of the upper part of the neck and better definition of the jaw. Whilst it’s not a neck ‘lift’ in the true sense, we can use the ‘U’ technique if skin tightening is required, or we can cross the midline when we have to support the platysmal bands. A 12-cone suture is useful here because of the dimen-

sions of the neck, and if the neck is bigger, a 16-cone suture can be used. The ‘U’ suture configuration also makes it possible to treat thicker skin successfully. The insertion technique starts with creating an entry point using an eightinch needle. The hole is the same diameter, more or less, as the base of the cone and then from that hole the first needle of the suture is inserted. To treat the brow, we work with two sutures—two eight-cone sutures in an ‘L’ rather than ‘U’ shape. The suture is inserted into the asymmetrical part of the brow because the distal cones have to grasp the soft tissue at the tail of the brow, and the proximal end of the suture goes to the temporal area and elevates the tail of the brow. Insertion To insert the sutures correctly it’s essential that the first needle remains vertical. The needle has a mark at the 5mm distance from the tip that disappears when the tip is 5mms into the subcutaneous tissue. With Caucasian skin the average of the thickness between the epidermis and the dermis is usually 2.8mms. With thicker skin—for example with Asian patients—it could be 4-5mm, so you have to go deeper to be sure of staying in the subcutaneous tissue. After inserting the suture, the tissue must be compressed. It’s a self-blocking suture—so doesn’t need to be fixed in any part—and the presence of the cones in the opposite direction collects the tissue

66 Using the new advanced ‘U’ technique to configure the sutures means just one suture can be enough to treat an area, for example, the jaw 99 over the centre of the suture. This increases the projection and the base of the cone will not release the traction. Staying a minimum of 5mm from the entry point, in the central part, ensures the suture is placed at the proper depth. The ‘U’ technique uses two entry points—created with the same needle at the same time. The eightinch needle can be inserted from the first point and can exit out of the second one, and we use the needle like a trocar. We can work in front of, or behind the hairline. Initially we suggest inserting in front to avoid fighting with the hair, but when one is more experienced behind the hairline so any puckering caused by the elevation of the skin—which lasts for one or two days—will not be visible. We insert the suture in the adipose tissues, we compress the tissue and create elevation through mobilisation or compression of the tissue. Danger Zones When inserting the sutures it is important to visualise the underlying position of the veins, arteries and nerves. A pinch to a vein can cause a hematoma and in the

The Silhouette Soft Lift uses specialised sutures which are introduced into the subcutaneous layer of the skin with a very fine needle

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The treatment is most suited to patients with mild ageing characteristics

temporal area we have an artery, so of course there’s a more serious risk of hematoma here. Nerves, especially the three branches of the facial nerve, can also be a danger spot. For this reason it is important to pay particular attention to the temporal branch of the facial nerve, which is very superficial and usually on top of the superficial parieto-temporal fascia, between the superficial and the deep temporal fascia. The mandibular part and the zygomatic branches however are really deep, so it’s impossible to create any injury to these nerves because of their depth.

How to check the patient Start by simulating the desired skin lift manually with your hands. If you see the anticipated result with a very moderate elevation of the tissue, it’s possible to obtain the same result by using the bidirectional sutures. Sometimes we want to treat the neck, but with the traction of the fingers we don’t see any result in the anterior cervical area. In this case, because of the fat, we would not achieve the desired results. If we have a fat problem, first we have to treat the fat and eventually after two to three months we can treat with the sutures.

Indications The indications for treatment of the face with bidirectional sutures range from the brow to the neck including the nasal area—for aesthetic or functional purposes or for nasal valve collapse. In fact, wherever we want to mobilise the tissue, we can use the sutures. In the mid face using eight-cone suture fat compression, we can bring about malar projection and usually, between two to four months we observe an improvement in the result due to the contraction of the capsule around the suture and then it remains stable. After one and a half years to two years the result is less marked and a repeat of the treatment is needed. In the neck we can achieve improvement of the cervical angle with the goal of creating better definition of the jaw, and this is more effective when treated in combination with the jaw area itself. We can also successfully treat the brow area. The only rule is to be sure to work 5mm deep vertically inside and to check where the tip of the needle is every time. This is the way you can ensure that you are in a perfect plane. The tip of the needle has to be mobile and free – if we can elevate the tip of the needle we are in a safe level, because if you can’t elevate the tip, you are under the fascia. A traction of the skin due to the tip of the needle, means we are in the dermis. Once the needle has been inserted under the skin it needs to be removed. The first four cones start to go into the tissue and we create a gentle contra-traction allow their correct positioning. Once the first four cones are embedded, we have to treat the second half, taking the second needle vertically by 5mm into the same entry point. Then we turn the needle to a horizontal position and we go through the proximal exit point, maintaining the same depth. Here we have less adipose tissue but we have to stay between the fascia and the dermis. If we can’t feel when the tip is near the exit point, it’s good to put the other needle on top of the skin and push down to see exactly where the tip is rather than going over the

32 EQUIPMENT I body language

exit point and potentially creating an injury to the vessels in the temporal area. By knowing where the tip of the needle is we know where the suture will be inside. When the second needle is inside the loop of the first suture is just visible, the first cones start to go in and we just have to perform the second contra-traction to allow the recession of the suture. Avoiding complications The best way to avoid complications such as breaks to the suture, dimples or bruising, infection or skin folds is to know which areas are contraindicated to treatment with sutures. The principal contraindication is the presence of fillers, but if you have any patient who has been treated with permanent filler and you feel the capsular, do

not put the suture in the same area. Pinching to the capsular can also cause an unpredictable reaction. Other minor complications might include hardness, pain or parestasia for a maximum of one to two days. Combination treatments In many cases suture treatment is not something we use to avoid doing something else, but in combination with other treatments. Most of the time when repositioning the tissues, we may also need to replace volume, so we can use the sutures as part of full-face non-surgical bio-revitalisation. We suggest combining treatments or using the bidirectional cone sutures a month before or after the volumisation procedure. This combination can give a notably more effective result compared with a single treatment alone.

Silhouette Soft case study Dr Leah Totton completed treatment with Silhouette Soft for the full face including the brow Patient profile: 64 year old Australian-born Jackie Genova was a high profile model in the 70’s, fronting campaigns for global brands such as coca cola and Levi’s before turning her hand at TV aerobics where she was known as the “Queen of Aerobics” throughout the 80’s. She wanted to refresh her appearance to restore her confidence but did not wish to go under the knife. Treating Doctor: Dr Leah Totton is a medical doctor and the 2013 winner of UK The Apprentice, her business plan was a doctor led cosmetic clinic which specialised in non-invasive treatments which give natural looking results with little or no downtime. She now co-owns Dr Leah cosmetic Skin Clinic with business partner Lord Alan Sugar and is one of the first UK doctors to be offering Silhouette Soft facelift for the full face and neck. Treatment: Silhouette soft thread lift is a non-surgical facelift treatment which involves placing dissolvable sutures under the skin to lift and enhance appearance. The treatment previously has been used to treat jowling but has recently obtained its license in the UK for use on the brow and neck, facilitating its use to transform the entire face and offering itself as an alternative to a full face and neck lift. Treatment was performed with local anaesthetic making it pain free, and takes approximately 1 hour to complete, with minimal downtime. Results last approximately 18 months. Dr Totton comments: “The neck, despite being one of the areas which patients most commonly note signs of ageing, is notoriously hard to treat non-surgically and a treatment which can improve this area is invaluable. Brow hooding is a similarly common presentation associated with ageing. This is another step forward in the innovative field of aesthetic medicine.”

Conclusion The advantage of bidirectional sutures is that we can perform a non-surgical skin lift in our clinic. The treatment can be minimally invasive, using local anaesthesia and can be used to treat the face or body using the position of the suture to achieve our goals. Dr Roberto Pizzamiglio has been Scientific Consultant and Teaching Course Director for Silhouette Lift since 2006 and more recently became the Director of Training for Silhouette Soft. He is considered to be a world expert in the Silhouette Soft procedure. Since 1997 he is has been based in Spain where he is Director of the Aesthetic Surgery Unit at the USP Hospital in Marbella. He is also a Professor of the postgraduate Masters in Cosmetic Surgery at the University of Padua.

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Nutrition

for body contouring Aesthetics clinics are increasingly incorporating nutritional services into their clinic offering. KIM PEARSON highlights nutritional interventions that can work alongside body contouring procedures to optimise treatment results

he non-surgical body contouring market has seen huge growth over recent years with the American Society for Aesthetic Plastic Surgeons reporting a 43% increase in treatments in 2014. There are various nutritional strategies designed to compliment non-surgical body contouring treatmentsâ&#x20AC;&#x201D;strategies that can work alongside treatments including cryolipolysis, infrared, low level laser, radiofrequency and ultrasound. Although some of the strategies may also be appropriate for use alongside surgical body contouring it should be noted that there are potential contraindications for certain nutritional supplements and surgery.

Why consider nutrition? Even when the best body contouring treatments are executed by expert therapists, treatment results can be compromised if a client is consistently consuming a suboptimal diet. Incorporating nutrition as part of your approach to body fat reduction can not only help to optimise treatment results, it can also set you apart from the many aesthetics clinics in this competitive marketplace. It ensures that you are providing a comprehensive service to the client and has the potential to generate additional revenue. Collaborating with a nutrition expert You may choose to collaborate with a qualified nutrition expert ena-

bling you to have a dedicated team member who can advise clients on a range of health and aesthetic concerns. Nutritionists and dieticians are trained to assess the health, diet and lifestyle of an individual and can put together tailored nutrition programmes based on the individualâ&#x20AC;&#x2122;s needs. However, providing such a service depends on the whole clinic team understanding the benefits of providing a client with nutritional advice and being actively involved in promoting the service. Providing basic nutrition guidelines Another option to consider is providing basic nutrition guidelines to work alongside the treatments that youâ&#x20AC;&#x2122;re delivering. You could devel-

body language I DIET 35

op a fact sheet, advising clients on the key considerations for reducing body fat. These might include macronutrient ratios—so the roles of proteins, fats and carbohydrates— and what forms and proportions they should ideally be consumed in, in order to support the reduction of body fat. You could also highlight the importance of micronutrient (vitamin and mineral) rich foods and considerations like adequate water intake and exercise. Specific weight loss programmes A third option is to integrate a specific weight loss programme into your clinic. This approach is more relevant for clients who want to focus on overall body fat loss, rather than clients who are coming wish to just reduce one localised pocket of fat. One strategy that I recommend to my clients and find to be highly effective, is a weight loss programme called the Protéifine Diet provided by Ysonut Laboratories. Proteifine is a sophisticated, evidence based protein based diet programme only available through nutritionists and medical doctors. It enables the client to lose body fat but retain their lean muscle mass, due to the optimised protein intake. One problem with many reduced calorie diets is that protein intake is often compromised. Suboptimal protein intake can lead to a reduction of muscle mass, and when muscle mass is reduced, so is the basal metabolic rate. Reduction

in basal metabolic rate can compromise long-term weight maintenance and result in a lifetime of yo-yo dieting. A protein based diet such as Proteifine also ensures the maintenance of healthy skin structure and function. Our skin is made from collagen and elastin. Collagen and elastin are proteins, and therefore adequate intake of dietary protein is essential for maintaining healthy skin. With any dietary approach it’s particularly important to not only consider helping a client achieve their target weight, but also ensuring that they maintain their results long-term. Proteifine provides a nutritional re-education programme, enabling you to educate clients in how to maintain their weight loss for good. Nutraceutical supplements The term “nutraceutical” was coined from “nutrition” and “pharmaceutical” in 1989 by Dr Stephen DeFelice, MD, founder and chairman of the Foundation for Innovation in Medicine. According to DeFelice, a nutraceutical can be defined as, “a food (or part of a food) that provides medical or health benefits, including the prevention and/or treatment of a dis-ease”. Nutraceutical supplements can be used alongside the above-mentioned dietary approaches but can also be used independently alongside body contouring treatments. Some clients may not wish to address their diet in order to optimise their treatment results, for these individuals supplementation can be a useful complementary therapy. Conjugated linoleic acid Conjugated linoleic acid (CLA) is a fat derived from omega 6 present in subtherapeutic levels in beef products, dairy and eggs. It has four primary mechanisms of action: it inhibits lipogenesis—the formation of new fat cells in the liver and the adipose tissue; it increases fat oxidation—promoting the burning of fat for energy; it promotes adipocyte apoptosis—encouraging programmed cell death of adipocytes; and it also supports the preservation of lean muscle mass.

CLA is one of the most well researched nutraceutical supplements for the reduction of body fat. One double-blind, parallel study published in the Journal of Nutrition studied 81 post-menopausal women supplemented with CLA over 16 weeks. Researchers supplemented 5.5 grams of CLA per day versus a placebo of olive oil, and it found that the CLA group had a 4% reduction in total fat mass compared with the control group, and a 7% less lower body fat mass than control. A 2007 meta-analysis reviewed the results from 18 eligible human trials on the efficacy of CLA in reducing body fat mass. Researchers found that CLA’s effect on body fat reduction was consistent for up to six months, but effects gradually tailed off as it reached the two-year mark. In terms of practical supplementation, the research shows visible results at the eight-week mark, but at the 12-week mark results becomes statistically significant. A dose of 3.2 grams of CLA per day is the optimal dose, preferably spread over three meals. Ysonut produce a CLA supplement that I recommend in clinic. Based on the research, I recommend that clients take two capsules, three times per day, at each main meal for the first month, and then after the first month reduce the dose to one capsule at each main meal. Thermogenic nutrients Thermogenic nutrients are another class of supplements that can be considered for use alongside body contouring treatments. Thermogenesis refers to the production of heat in the human body. Thermogenic nutrients work to increase heat and therefore increase energy expenditure above the basal metabolic rate, so increasing the body’s calorie burning effect. Well researched thermogenic agents include green tea, black tea, capsaicin (taken from the red chili pepper) guarana and caffeine. In a study researching the effects of green tea on weight reduction in obese Thai people, 60 subjects consuming a 2000 calorie, typical Thai diet, were enrolled onto the study. At week four versus the placebo the green tea group had

36 DIET I body language

Phaseolamin could be an appropriate supplement for client’s to use ad hoc prior to carbohydrate-rich meals. It could be used in scenarios such as eating out or when on holiday in order to prevent weight rebound following treatments.

Green Tea Green tea is of particular interest to us in the medical aesthetics industry for a number of reasons. Not only can it help with the reduction of body fat mass, it is a powerful antioxidant known to improve skin quality. Research demonstrates that, if supplemented at high enough doses, green tea polyphenols can exert antioxidant effects within skin cells and can even protect from sun damage.

lost 2.7kg, at week eight, 5.1kg, and week 12, 3.3kg. No dietary modifications were made demonstrating a significant impact of green tea on weight reduction. Results were believed to be due to the synergistic effect of polyphenols and caffeine present in the green tea. Ysonut have a thermogenic complex that combines some of the most effective thermogenic nutrients. These include green tea, black tea, guarana and yerba mate as a source of caffeine. These nutrients are combined with chromium and l-carnitine to support blood sugar levels and promote the transport of fat into cells to be utilised as energy. Ysonut Ysonut understand the needs of medical aesthetics clinics. They provide nutraceutical supplement protocols to work alongside many of the treatments clinics offer. These include protocols to compliment injectable treatments, four protocols for the different grades of cellulite, as well a range of protocols for a variety of aesthetic and health concerns. Phaseolamin Phaseolamin is a natural enzyme present in white beans. It works to inhibit alpha-amylase—an en-

zyme present in saliva and released from the pancreas into the gastrointestinal tract—which converts starch into glucose. Starch in the diet is converted to glucose, which enters the bloodstream and is then either used for energy immediately, or it’s transported into the muscle cells or the liver cells to be stored. However, if there’s a significant amount of glucose in the bloodstream it’s likely to be stored as fat in the adipocytes leading to weight gain. It is this that we are looking to prevent. Interesting findings emerged from a recent study conducted on standardised Phaseolamin extract and it’s effect on body composition. The study was carried out on 60 slightly overweight individuals who continued to eat their normal diet. Phaseolamin was supplemented prior to the consumption of carbohydrate-rich meals in order to prevent conversion of starch into glucose and subsequently into body fat. Results showed a reduction in body weight, BMI, body fat mass, and waist, hips and thigh circumference. Phaseolamin supplementation is potentially beneficial to those clients who have a carbohydrate rich diet but who do not wish to make any changes to their diet.

Conclusion Since every client is unique, no one approach fits all. It is important to tailor your approach to the individual depending on theirs goals, their commitment and their lifestyle. Consideration of these factors can ensure and the implementation of the right nutritional strategy will ensure clients achieve the results they are coming to you for. Integrating a nutrition offering into your clinic can ensure you are providing clients with the most comprehensive and results driven approach to body contouring. It enables you to offer a unique service to clients, allowing you to set your clinic apart from competitors. Implemented in the correct way, a sophisticated nutrition service has the potential to generate significant additional revenue for any medical aesthetics clinic. Kim Pearson qualified in 2008 from the Institute for Optimum Nutrition. She works in clinical practice within the medical aesthetics industry and her areas of speciality are weight loss, skin health and healthy ageing. References 1. Auvichayapat P, Prapochanung M, Tunkamnerdthai O et al. (2007) Effectiveness of green tea on weight reduction in obese Thais: A randomized, controlled trial. Physiology & Behaviour. 2008 Feb 27;93(3):486-91 2. Celleno L, Tolaini MV, D’Amore A et al (2007) A Dietary supplement containing standardized Phaseolus vulgaris extract influences body composition of overweight men and women. Int J Med Sci. 24;4(1):45-52. 3. Ekta K. Kalra. (2003) Nutraceutical—Definition and Introduction. AAPS PharmSci. 5(3): 27–28 4. Heinrich U, Moore CE, De Spirt S, (2011) Green tea polyphenols provide photoprotection, increase microcirculation, and modulate skin properties of women. J Nutr. 141(6):1202-8. 5. Steck SE, Chalecki AM, Miller P, et al (2007) Conjugated Linoleic Acid Supplementation for Twelve Weeks Increases Lean Body Mass in Obese Humans. The Journal of Nutrition. 137(5):1188-93. 6. Whigham LD, Watras AC, Schoeller DA. (2007) Efficacy of conjugated linoleic acid for reducing fat mass: a meta-analysis in humans. Am J Clin Nutr. 85(5):1203-11.

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body language I BODY 39

Weight management Losing weight and maintaining it can be difficult. BETHAN COOMBER discusses her complete approach, involving diet, therapy and contouring treatments in order to help patients achieve lasting results

have worked in the aesthetic industry for about ten years, but I can honestly say the happiest time I’ve had at work is when I’ve been working with patients to help them achieve their weight loss goals. The most successful treatments are the ones where you can help a patient through all the different elements of losing the weight. It’s not about simply shedding fat and getting healthy, it’s about the patient feeling confident and relaxed whilst they’re going through treatment. At Alevere, our doctors have designed a three-part programme that we call the “complete” approach. This includes a medical diet, contouring treatments and stabilisation & education. Patients are supervised by the doctors throughout to help them feel confident in what’s happening, and with patients that have an excessive amount of weight to lose, generally they come to us with health concerns. It’s not very often you see a patient who is clinically obese yet everything else is fine, so it’s important that they’re medically supervised and monitored throughout a weight loss programme. People don’t want down time, they want to be able to have a treatment and follow a plan that achieves results without it affecting their life. If we’re going to work hard and help someone become healthy and feel confident in their body, we have to educate them in order to keep that body shape. Education is an important part of

the process. We also need to treat body confidence to help patients keep the weight off and feel confident in the body they’re left with. With this in mind, we have designed a combination therapy that transforms the body shape and size—without surgery. Consultation We start with a doctor’s consultation, where we go through the patients’ medical history and take a comprehensive blood test to allow the doctor to see if the patient is healthy enough to start the programme. More serious underlying health issues would need to be addressed first, but we do take patients with diabetes, high blood pressure, high cholesterol, weight-related joint pain and reduced mobility. We have found with some type 2 diabetic patients, when you resolve their body weight problems they can stop their medication. High blood pressure and cholesterol, and joint pain also often resolve themselves when people get down to a healthy weight. We often hear “exercise more”, but that’s not always suitable for patients with joint pain or mobility problems related to their weight. If you can put them on a programme that helps them lose some weight first and then guide and educate them into a healthier lifestyle this will be a lot safer and more effective. Metabolic rate We also take a computerised metabolic rate test—this is a breathing

test. With this measurement the doctor can calculate how quickly the patient will lose the weight. The medical foods that a patient will eat on the programme, cause the body to go into rapid weight loss where all of the calories being burnt come from existing fat

Patients initially go onto a prescribed diet, which includes fruit, vegetables and a medical grade protein to get them into rapid fat loss

40 BODY I body language

stores. With the metabolic rate test the doctor can determine at what weight that patient should be every four weeks throughout the programme until they reach their target weight. This helps patients because they have monthly goals to achieve that are unique to their own metabolism. Body composition Most people are familiar with body mass index (BMI), and whilst it’s accurate for most people, for some people it’s better to use more medical testing to see exactly how the body is built. A body composition test gives the doctor results on how much protein in kilos, lean muscle mass, how much fat and how much water is on the body. We can repeat this test throughout the programme to help determine how effectively it is working. I have had patients in the past who haven’t followed the programme exactly as they should; however, they’re still losing weight so they still think they’re achieving their goals. Body composition testing has found that what they’ve actually lost is a little bit of muscle mass, so they’re not seeing the contouring shape. This is why it is crucial for patients to follow the plan exactly as prescribed by the doctor. Showing the results to a patient and explaining the consequences of not following the programme correctly is really powerful. You have the tools in your arsenal to help patients understand not just what you’re doing to help them, but what they can do to help themselves. You begin the process of educating your patients on how to look after their bodies, and what’s happening on in the inside. Diet Patients initially go onto a prescribed diet, which includes fruit, vegetables and a medical grade protein to get them into rapid fat loss. Alevere custom-formulated nutritional supplements supply all the protein the body needs in order to maintain lean muscle mass during the programme, as well as a full complement of additional vitamins and essential fatty acids. Patients are also prescribed supplements

and minerals, so that they aren’t depleted and to maintain optimum health. Therapy We also provide weekly wellness monitoring with our therapists. Therapists are probably one of the most important parts of our company as they act as the bridge between the patient and the doctor. Patients have monthly medical reviews with the doctor, but if anything happens in between, the therapists are there to take that information to the doctor. Also, when you have someone who’s clinically obese they need to feel comfortable and relaxed— particularly if they need to expose parts of their body that they’re not confident about. It is the therapist’s job to make that person feel confident, comfortable and relaxed during treatment. Contouring We all know that exercise is fantastic for helping reduce fat, tone up muscle and increase metabolism. We encourage our patients to perform low impact cardio exercise as soon as they feel confident enough. It’s definitely going to help them and will also help educate them to maintain the weight lost afterwards—but it doesn’t tighten skin. There’s no muscle in skin so exercise cannot tighten it or target specific areas. You can do as many sit-ups as you like, and it will not give you a flat stomach unless you also burn fat. You have to do cardio to burn fat, and people who are clinically obese don’t necessarily want to (or is it medically advised in some cases) go jogging straight away. Often, even when people exercise there are areas of the body that we they would like to target, that are resistant to diet and exercise— pear shapes want to get rid of their bums, apple shapes want to flatten their stomachs. Subcutaneous fatty deposits often respond poorly to diet, because poor circulation in these areas prevents the release of their contents into to the blood stream. It’s for this reason we use a high frequency ultrasound treatment first to help break down the

diet-resistant fat stores. The ultrasound device is medically certified and the therapy is delivered using a special concave handpiece. The therapist follows the contour of the patient’s body, targeting fatty tissue layer that is one to five centimetres below the surface of the skin. Two beams of ultrasound energy combine to heat subcutaneous fat and the connective tissue. This promotes fat cell mobility and encourages the body to metabolise, drain or reabsorb excess fluids, redistributing fat and encouraging blood circulation. The “micromassage” effect produced by the ultrasound energy also causes heating of the fat cells, causing a thermogenic effect in the skin. When the therapeutic temperature range is achieved and maintained during treatment there is a stimulation of collagen and elastin production, as well as collagen contraction; thereby improving the result, by locally tightening the skin. Aside from fat loss skin tightening is every important factor. When people finish the programme they must feel confident with the results if they are to be encouraged to maintain the loss. This is why we use a combination therapy weekly, where ultrasound is used in combination with skin tightening treatment, to achieve the best possible contour at the end of the programme. Hopefully not

Before and after—patients have monthly goals to achieve until they reach their target weight

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28/08/2012 14:42:22 28/06/2012 18:21 28/08/2012 14:42:22 28/08/2012 14:42:22 28/06/2012 18:21 28/06/2012 18:21

42 BODY I body language

only a healthier contour, but a contour the patient feels confident in and encouraged to maintain. I’ve seen patients who have lost weight in the past, and admitted to deliberately putting it all back on because they didn’t feel confident in the body they were left with. One lady told me she felt like a fraud because she had to tuck an overhanging apron of skin into her underwear in the morning. She had deliberately put ten stone back on as she felt more confident with excess fat than excess skin. She joined the programme so that she could have contouring treatments as she lost weight. We find that if you improve the cosmetic results of weight loss, you encourage people to keep the weight off. It improves self-confidence and gives them a body they feel proud of and want to look after. Combination In addition to the ultrasound therapy we use endermologie, which is beneficial because it tightens the skin all over the body gradually throughout the programme. It also benefits patients by increasing the drainage of toxins, and again promotes fat cell metabolism by redistributing fat and encouraging improved circulation. When you’re improving the circulation and draining toxins, you treat cellulite. This is fantastic for when people are losing weight, as they produce a lot of toxins that need to be drained out of the body. Combining the medical ultrasound technology to break down and mobilise the fat, with endermologie immediately afterward to allow that fat to be drained into the lymph and improve circulation, produces end results that have found to be even better than when both therapies are used alone. Hunger Hunger is the biggest cause of people stopping diets or weight loss programmes. By providing protein supplements, you can help stabilise patients’ blood sugar levels and reduce hunger. This is combined with the ultrasound treatment to release the fat that the patient would be using for energy. If you’re not hungry because you feel full

from the protein supplement, and because your treatment has released fat that you can use for energy, you don’t get irritable. Therefore patients don’t tend to grab something on the run as a convenience food, and they don’t get low energy levels—this increases patient compliance. If people are hungry they will eat whatever they can and this is a slippery slope. Yo-yo dieting The yoyo effect of dieting happens due to a misunderstanding of the basic principle of losing weight: eat less and exercise more. The problem is how much less and how much more is different for everyone. With rebound weight gain, when you eat fewer calories you train your body to survive on less calories. You lose weight quickly and then it plateaus because your body is now trained to survive on 1,000 calories a day. Often people will say they just look at food after that kind of diet and the weight goes straight back on—it’s because now their metabolism is slower. Another metabolism reducing effect of dieting is lean muscle loss. This is down to not eating enough protein daily, which the body then needs to find a resource for. When diets like this are followed people will often lose weight but not inches, this is because they are burning lean muscle. If patients aren’t calorie restricted and lean muscle loss is prevented, they have less of a reduction in their final resting metabolism. The programme achieves this by providing the patient with medical grade protein meals regularly spaced throughout the day, as well as a selection of very specific low carbohydrate fruits and vegetables. When a patient follows the diet correctly, all of the calories their metabolism needs comes directly from their fat stores. This is an unlimited supply in the initial stages of the program until the patients reach goal weight; it is then that more carbohydrates are gradually introduced. To prevent the weight going straight back on, you need to very gradually reintroduce foods that patients’ haven’t been able to eat for a long time. This allows us to edu-

cate patients about portion size, allowing them to have the tools they need when they finish to be able to keep the weight off. At the end of our programme, we carry out the metabolism test again, and patients have a detailed consultation with the doctor, who will advise on how to maintain the weight loss. The metabolism test will reduce slightly from the beginning, because someone who is 19 stone compared to someone who’s 10 stone will need fewer calories just to carry that mass around. It’s important we do this measurement so that patients know how many calories they need per day to survive and maintain that weight. The reduction seen at the end of the programme is not due to muscle loss or a starvation diet. A complete approach We see the obvious results that you get from treating the person as a whole: improved health—which you will always get with weight loss—and dramatically improved body shape and contours. Patients look younger and have boosted confidence, and this leads to dramatic and life changing results. They are educated in eating more healthily and are motivated to live a healthier life. Bethan Coomber is a trainer and an aesthetic therapist at Alevere

Before and after—we find that if you improve the cosmetic results of weight loss, you encourage people to keep the weight off

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body language I LEGAL 45

Great expectations MR ANDREW ANDREWS discusses the importance of legalities in body contouring and wellness

atient expectations and demands can often be unrealistic, and if these impractical expectations are not identified at the outside, disappointment—which very often turns to irritation—is inevitable. Patients as individuals have autonomy and the right to self-determination, and may on occasions make what we perceive to be an unwise decision, because the bottom line is they know what is best for them. However, part of your role as a clinician is to work in partnership with your client to educate and empower that individual, to make balanced informed decisions for themselves. We should remind ourselves though, that ultimately in the eyes of the law—you must be able to clinically justify every intervention. Clinical Responsibilities It’s not for the patient to dictate how you will discharge your clinical responsibilities for them. Patients have a choice when they opt to have a procedure, but they cannot determine how you will discharge your clinical responsibilities to them. Many find it very difficult to understand that they cannot direct how you discharge your legal duty of care, which rests with you as a matter of professional clinical judgement. As a practitioner on a professional register, you cannot plead superior orders. It’s no good saying, my boss told me to, I was persuaded to, my colleagues thought this would be for the better, it’s what the client wanted, or I was just following policy. The only justification for action is that you used your professional and clinical judgement. I would like to cite an interesting case: two women, both NHS patients who wanted elective caesarean sections for social reasons.

The first woman said she needed to be delivered so she and her husband could go off on their expensive holiday and leave her new baby with her mother. The second woman wanted an early caesarean section to prevent unnecessary weight gain and possible future loss of figure. In both cases their consultants agreed. Post-operatively they were left with very rare, but recognised complications of that intervention. One of the women is unable to have more children; the other has continuing problems with dysmenorrhea. They both acknowledge they knew of and accepted those risks. They had not thought to challenge the quality of surgeon, but they have both sued their consultants alleging negligence—saying that as experienced clinicians, the consultants knew that there was no clinical justification for that intervention. They claimed that had the consultants discharged their professional responsibilities—as they ought to have—and refused to carry out the procedure and acted in that professional way, the women would have been saved from the consequences of their procedures. Both women won their cases. In the UK National Health Service, practitioners write the menu, patients can accept or reject what is on offer. In the case I just shared with you, clearly that c-section should not have been on offer, because for something to be available in the NHS there must one—be a therapeutic benefit, and two—a reasonable prospect of success. If those two criteria are not met, it’s not on offer. Interestingly, in the private sector, there is more leeway and instead of therapeutic benefit it’s for welfare and wellbeing of the individual. So provided that threshold is met—welfare and wellbeing, plus reasonable prospect of success, you could have it on offer. Ironi-

cally, in the above case, had those two women gone to the private sector and paid, it would have ticked the box for welfare and wellbeing and they’d have no redress. Let this be a reminder that with anything you offer, you must to be satisfied that it is for the welfare and wellbeing of the individual and there is a reasonable prospect of success. That’s why, the NHS does very little in the way of plastic surgery—it’s limited to post-operative, post-trauma, psychiatric, psychological. If a woman wants to enhance her appearance, it’s not available on the NHS, patients must go to the private sector and buy that. It’s vital to make that distinction—will the procedure increase the client’s welfare and wellbeing? If it doesn’t meet that criterion, or there is no reasonable prospect of success, it’s not something you will offer that individual. What you offer has got to be based on your professional and clinical judgement. And of course, when you make an offer, you’ve also got to ensure that you have shared with that individual the risks and bene-

Ultimately in the eyes of the law— you must be able to clinically justify every intervention

46 LEGAL I body language

fits of what is proposed. When you think about consent, this is simply the individual’s agreement to what is proposed. To make a balanced, informed decision, they also need to know the risks, benefits of intervention, alternatives or possibly non-intervention. Explaining Risks An individual will want to know what your track record is like with the intervention they have are seeking. So when you share the risks, how do you explain likelihood? I know there are practitioners who use percentages, but that can be confusing for some people. I know one practitioner who would say there’s a one in 20 chance of this happening, and clients’ response was “oh don’t like the sound of that”, yet when he translated that to a 5% risk, suddenly that was ok. Isn’t that interesting? That 5% seems more acceptable; one in 20 makes you stop and think. I’d never say 50/50, I’d say every other person, because that’s something to which the individual can easily relate. If there are catastrophic risks—so something which is irreversible, or may adversely affect the quality of life—then you need to be very clear that you put that in context and that you’ve raised it with the individual. What you don’t want is someone to say they were tricked into agreeing and had they known what they have since found out they would never have agreed to proceed. Informed Consent Informed consent is a North American concept—and one I am certainly not an advocate of. It means that you will share with that individual every conceivable risk and outcome, no matter how unlikely, or how remote. That’s fine if you want to do it, but just to give you an example, a friend of mine in Massachusetts needed fairly urgent surgery to remove his appendix. They wouldn’t proceed until he assured them that he read and understood a 48-page booklet with all the possible risks. When he signed that off they brought another six sheets of risks that had been identified since that leaflet was published. The problem I see with informed consent is that after con-

firming disclosure of every conceivable risk and outcome, no matter how unlikely or remote—and you presumably do a weekly literature search to ensure the information is up to date—should that individual do a web search and find things you haven’t mentioned, the consent is not valid. We want patients to make an informed decision but we need their agreement. UK law says you share with the individual the nature, purpose and likely outcome of what is proposed, not every conceivable no matter how unlikely or how remote, but those which are material to the individual. So please talk about consent, but if you want to put a word with it, use valid or effective consent, not informed consent. And obviously, if there are catastrophic risks, you put them in context. As I said to a patient, just visualise a Wembley stadium packed, double that, one of those people is likely to experience an adverse outcome to what I’m talking about. So you can put it in context so they’re not unnecessarily frightened. Clinical Evidence If a clinical case goes to court, what matters in court is proof, or evidence. Cases are won and lost on the quality of the documentation. In an ideal world the consent process would involve simply taking the individual through a preprepared consent leaflet and script. This would allow you to document that you’ve taken the patient taken through leaflet, given the leaflet, that they’ve agreed to proceed etc. So, that leaflet saves an enormous amount of documentation because you simply say, I always take the individual through, deal with their questions in context and they had the leaflet to keep, and that’s all documented. Safeguarding Remember while adults can make unwise decisions, children cannot, and the role of trustees is to safeguard the basic rights of the child, their life, health, education and protection and if a trustee is not fulfilling that role the State will intervene. The Children Act says the views of the child shall be taken into account, having due regard

66 Ask yourself, can I justify my decisions and actions to my professional colleagues? 99 to age and understanding. So the child has a right to be heard, but not a right to self-determination. The UK law allows a 16 year old to give their own consent, but it doesn’t invalidate the legal position of someone with parental responsibility. So from age 16 to 18, two consents are possible—either the young person or someone with PR (Parental Responsibilty). With consent, either can say yes, but neither has a power of veto. So if a young person agrees, the parent cannot veto, conversely, if the parent has agreed, the child cannot veto because the law takes the view you wouldn’t be offering anything which wasn’t in the child’s best interest and you don’t want the child therefore to be denied that best interest option. Below age 16 we also have the concept of Gillick competence, where a child can say I don’t want my parents involved. If you raise the question of whether a 15 year old would like mum and dad involved and they say no, then you’ve got to be satisfied that they have the capacity to make that decision and that you believe it’s in the child’s best interest. And if those three criteria are met, you can proceed on the basis of the child’s consent without involving the parents. Conclusion The bottom line is—no matter where you are—ask yourself, can I justify my decisions, my actions to my professional colleagues? Or put another way, will the profession endorse what I have decided to do? I hope this has given you an insight into this legal perspective. Remember that law, morals, ethics and professional considerations will all pull you in different directions, it’s up to you to resolve that tension and then decide how best to proceed. Andrew Andrews MBE is a Barrister and Director of Health and Social Care

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body language I TREATMENT 49

Peach fuzz SUJATA JOLLY talks about fitting treatment of vellus hair where photo-epilation often fails

nwanted facial hair can cause embarrassment and can lead to anxiety and depression. It can make women feel unfeminine, freakish, self-conscious and depressed. Excessive facial hair can have an impact on confidence in professional and social situations. Causes of unwanted hair Excessive hair on the face is a common problem for many people. Around 40% of women will suffer from unwanted hair at some point. Causes include: • genetic predisposition and ethnicity • hormones: excessive hair growth due to androgen over-production occurs most commonly with polycystic ovarian syndrome (PCOS) • side effects of medication for epilepsy, hypoglycaemia, high blood pressure, endometriosis • anti-ageing supplements containing DHEA • reaction to chemotherapy Types of unwanted hair There are three types of unwanted hair found in adults—hormonal,

terminal and vellus. Hormonal hair growth usually occurs due to elevated androgen levels; this may be from medication, menopause or HRT. Terminal hairs develop from vellus hair during puberty and are thick, long and dark. Vellus hair is mainly short, fine, light or translucent with low density of melanin, and unlike terminal hair, vellus hairs are not affected by hormones. Generally, vellus hairs are located at the upper dermal level of the skin and are not associated with sebaceous glands. Typically, vellus hair or “peach fuzz” is evident on most women’s face and neck. Hair removal considerations At present, the most popular method of treating unwanted hair is photo-epilation—laser and IPL. Both need a conduit for the energy—this is the melanin within the hair. However, vellus hair presents two major issues: • there is little or no melanin in light coloured hair • there is a lack of density of melanin in darker hair Dark hair has a much thicker cortex with abundant melanin, i.e.

dense pigment, whereas lighter hair has a thinner cortex with relatively little or no melanin. Whilst it is accepted that blonde, white, grey and red hair cannot be treated successfully with photo-epilation, it has also been observed that dark vellus hair is also less likely to respond due to lack of density of pigment. For example, a client with Fitzpatrick skin type IV - VI will usually find laser and IPL treatments relatively unsuccessful on vellus hair; this is because the systems have difficulty differentiating hair colour from skin tone. Paradoxical hypertrichosis Paradoxical hypertrichosis was first described by Moreno-Arias et al in 2002, but the aesthetic industry

Before and immediately following the treatment—all vellus hair is removed leaving the skin completely hair free, smooth and radiant

50 TREATMENT I body language

because paradoxical hypertrichosis is either not recognised or goes unreported.

Hair V Go case study At the FACE Conference 2015, I demonstrated the Hair V Go treatment on Nel—a typical polycystic ovary syndrome (PCOS) patient. One in five women suffer from PCOS and makes up a large proportion of the hair removal market. Nel is a typical example of someone who had unsuccessfully tried a variety hair removal methods. She told the audience “By 12 years old, I had a beard like a man. As soon as lasers were legal in South Africa, I started using them and then did this for a couple of years. Then I had electrolysis on my chin and it did reduce a lot of thicker hair.” Nel has had epic journey of various hair removal treatments and whilst we can address the hormonal issue on the chin with electrolysis or laser, these treatments have limited success for blonde and vellus (peach fuzz) hair.

To illustrate how Hair V Go reduces hair growth, I showed a sequence of a client’s hair growth over 43 days following one treatment.

is only just beginning to take talk about it. Paradoxical hypertrichosis manifests itself in two ways - either the hair being treated gets stronger, or hair growth is stimulated in an adjacent untreated area. Published data of patients with normal hair growth who underwent photo-epilation treatments observed that after five sessions hair growth became stronger and thicker. Reported figures have shown that only 10% of patients have experienced the paradoxical hair growth, but my experience and anecdotal evidence from practitioners and other experts in the industry suggests it is much closer to 20%. I suspect this is

Alternative treatments Vellus hair requires a different treatment methodology. My research led to the conclusion that the most effective way to treat vellus hair is to use a high-pH formulation. My development, Hair V Go, works using a pH between 12.212.4 which breaks down the bonds that hold the hairs’ cells together. It works by dissolving the lipid bonds across the hair shaft and going down into the hair shaft. So it works in two ways meaning that you will get penetration across the hair shaft and down the hair follicle. By travelling down the follicle, the formulation begins to disable the stem cells within the bulge. These stem cells are responsible for creating the hair follicle and regenerate not only the follicle but also the epithelial layer. Therefore, unless we can disable or destroy the stem cells, hair will continue to grow. Hair V Go progressively disables stem cells within the bulge which reduces their activity, hence hair reduction is achieved. Treatment Protocol As we are using an alkaline formulation it is essential the acid mantle of the skin is not disrupted prior to treatment; this means that the skin should not be cleansed even if the client is wearing makeup. For this reason, I have adopted a belt and braces approach in order to leave the practitioner with no worries or concerns. Step one: application of paste mixed from Hair V Go Treatment Powder and Activator Solution. This breaks down the lipid bonds in the hair and is left untouched for 8 to 10 minutes. Step two: wash off all traces of

the paste and cleanse with pH Reset Cleanser. Step three: reinstate skin’s barrier function with application of Acid Mantle Mist. Step four: the treatment is finished with a specially formulated Hair V Go Hair Reduction Treatment Cream which contains a mixture of key botanical hair growth inhibitors, including gymnemic acids, which further helps to slow down hair growth. Post-treatment aftercare includes the same hair reduction treatment cream to be used by the client for the next seven days. I recommend that treatments are initially carried out every three weeks. Then, as hair growth decreases the period between treatments is increased to four weeks, five weeks and so on. Eventually the client will require just three or four management sessions a year. Sujata Jolly, founder and medical director of UK-based Clinogen Laboratories, has 46 years experience in scientific research and development. She is renowned for being on the cutting edge of R&D and specialises in medical aesthetic treatments using oxygen therapy for treating skin disorders and advanced hair removal. Her latest work includes advanced wound healing and scar reduction. References 1. Moreno-Arias G, Castelo-Branco C, Ferrando J. Paradoxical effect after IPL photoepilation. Dermatol Surg 2002;28:1013-6. 2. Moreno-Arias GA, Castelo-Branco C, Ferrando J. Side-effects after IPL photodepilation. Dermatol Surg 2002;28:1131-4. 3. Radmanesh M. Paradoxical hypertrichosis and terminal hair change after intense pulsed light hair removal therapy. Journal of Dermatological Treatment. 2009; 20:1; 52–54

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52 PRODUCTS I body language

on the market The latest anti-ageing and medical aesthetic products and services  ACTIVE GOLD COLLAGEN MINERVA Research Labs Ltd introduce their reformulated Active Gold Collagen, a liquid beauty supplement for men and women with busy lifestyles. It is specifically formulated to promote younger and healthier looking skin, hair and nails whilst looking after muscles, joints, bones and overall wellbeing. ACTIVE GOLD COLLAGEN is composed of hydrolysed collagen which is said to activate the collagen producing cells to create plump and healthy skin with reduced wrinkles and lines whilst hyaluronic acid boosts skin hydration and smoothness and vitamin C creates an even skin tone. L-Carnitine is included to support the health of bones and joints along with glucosamine, vitamin D and new chondroitin as well as reduce fatigue with vitamin B6. W: gold-collagen.com

 DMK Festive gift sets DMK have introduced four seasonal gift sets to offer your skin clients. The Festive Lift gift, the Klear Skin gift set, the Super Eyez gift set and the TransGenesis Amplified gift set. For full information on the contents of the sets, see contact information below. W: dmk-uk.com

 Tebiskin SkinMed have recently launched a new addition to the Tebiskin range, a clinic only spray designed to be used by the client at home for treating their chest and back acne. The key ingredients are designed to kill acne bacteria faster than prescription combinations and restore the skin’s lipid balance. Tebiskin OSK does not contain antibiotics, benzoyl peroxide or retinoids and helps reduces inflammation rapidly. It can be used in combination with EnerPeel 30% Salicylic acid Chest and Back. W: skinmed.co.uk

 Lightfusion Skinbrands have introduced a new cost effective way to deliver clinically proven, non-invasive, photo facials in a matter of minutes. Lightfusion is a new device that can be used as a standalone facial therapy or a course of treatments, or can be combined with Vitage or proprietary skincare and existing treatments such as micro-needling and peels for global skin rejuvenation, including hydration and reduction in pore size, wrinkles and pigmentation. W: skinbrands.co.uk

 ALMA Accent Ultrasound Handpiece ALMA Accent have introduced a new hand piece for body contouring, said to be the only RF treatment platform that can target 60cmsq in one go. This new hand piece is designed to provide tailored solutions for different skin types and conditions and new capabilities including unique depth control for shorter treatment time and more powerful, longer lasting results. The hand piece utilises patented ultrasound selective resonance that uses cold and hot ultrasonic waves which selectively resonate with and destroy fat cells, while leaving surrounding tissue unharmed. The selective sound waves are said to disrupt fat cell membranes leading to the gradual breakdown and release of stored fat through the lymphatic system and to help improve the appearance of cellulite. W: almaaccent.com

WIGMORE MEDICAL TRAINING YOUR COMPLETE TRAINING EXPERIENCE  For over a decade, Wigmore Medical have been running competitively priced courses, including all the latest trends, products and techniques to ensure top quality training.  Whether you are a newcomer to the medical aesthetic industry or an established practitioner, we feel there is always a training course or two that we can offer you.  Wigmore Medical offer an extensive range of training courses to choose from, including toxins, fillers, chemical peels, Sculptra, Dermal Roller, platelet rich plasma and microsclerotherapy.  All our hands-on training courses are run to a maximum class size of five delegates to ensure a quality learning environment. Unlike some training providers, we do not overfill the training room with delegates.  Our training is doctor-led, medically-based and independent. Our courses focus on the skills you desire and all our trainers are extremely reputable within their field of expertise.  The dedicated team has always taken pride in looking after all of its clients, with the added personal touch where needed.  Please see below for our upcoming course dates and call us now to register your interest and benefit from our professional training and continuous support.

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DECEMBER 1 ZO Medical Basic 2 ZO Medical Interm. FB 3 Core of Knowledge—Lasers/IPL 4 Advanced Fillers-TT* (am) FB 4 Advanced Fillers-CH* (pm) FB 5 Mini-Thread Lift* FB 6 Microsclerotherapy* 7 Dracula PRP* 8 Skincare with NeoStrata 8 ZO Medical Basic (Dublin) 9 ZO Medical Intermediate (Dublin) 9 Intro to Toxins* FB 10 Intro to Fillers* FB 14 Surface Whitebox* FB

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FEBRUARY

1 CPR & Anaphylaxis Update (am) 19 ZO Medical Basic 1 Skinrölla Dermal Roller (pm) 20 ZO Medical Interm. 2 glō minerals 21 Sculptra* 3 glō therapeutics 23 Non-Surgical Rhinoplasty 8 Dracula PRP* 24 Microsclerotherapy* 9 ZO Medical Basic 25 Dracula PRP* 10 ZO Medical Interm. 26 Skincare with NeoStrata 11 ZO Medical Adv. 26 ZO Medical Basic (Dublin) 13 Microsclerotherapy* 27 ZO Medical Intermediate (Dublin) 14 Non-Surgical Rhinoplasty 27 Intro to Toxins* 16 Surface Whitebox* 28 Intro to Fillers* 16 ZO Medical Basic (Dublin) 29 Advanced Toxins* (am) FB 29 Advanced Fillers-TT* (pm) FB 17 ZO Medical Intermediate (Dublin) 23 Skincare with NeoStrata 30 Mini-Thread Lift* 24 Intro to Toxins* 31 Mini-Thread Lift* 25 Intro to Fillers* 26 Sculptra* 27 Advanced Toxins* (am) 27 Advanced Fillers-CH* (pm) 28 Mini-Thread Lift*

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MARCH 7 CPR & Anaphylaxis Update (am) 8 ZO Medical Basic 9 ZO Medical Interm. 12 Microsclerotherapy* 13 Non-Surgical Rhinoplasty 15 Skincare with NeoStrata 16 Intro to Toxins* 17 Intro to Fillers* 18 Advanced Toxins* (am) 18 Advanced Fillers-F* (pm) 19 Mini-Thread Lift* 21 Dracula PRP* 22 Surface Whitebox* 24 Sculptra*

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

54 EQUIPMENT I body language

Pyroptosis of fat DR DIANE DUNCAN discusses the BodyFX treatment and how cell death mechanisms affect clinical results

hen we talk about ways to destroy fat, we loosely use the terms necrosis and apoptosis because these are the mechanisms that are most commonly known. Here I’d like to highlight the importance of bearing in mind the particular way in which a cell dies. Consideration of how the cell dies and how this mechanism of death will affect the clinical outcomes is an important and somewhat overlooked premise. Ways to kill fat Until recently we’ve only thought of the two polar opposites of ways to kill fat. Apoptosis is really silent cell death and this is what happens when our cells die in order keep the total population of cells stable. About 100,000 cells per second undergo apoptosis in a human because our cells also divide and undergo mitosis. A balance must be kept. As you know embryos tend to have a tail, and it’s apoptosis that makes the cells of that tail disappear without a scar. If we didn’t

have programmed cell death we would be massive creatures. By definition there’s no inflammation at all when an apoptotic process occurs. Necrosis, on the other hand, is severely inflammatory, but it is not the ideal mechanism for fat reduction either. Necrosis causes an instant demise of the affected cell. The cell membrane ruptures, causing the release of lysozymes into the surrounding tissue and the involved cells undergo significant swelling. Another word for the process is “oncosis”, as necrosis is more correctly used as identifying the cell when it is dead. Necrosis and apoptosis Why is neither necrosis nor apoptosis an ideal mechanism when contouring the face, neck, or body? In apoptosis there is no inflammation, and in necrosis, the swelling and bruising cause significant down time. Controlled inflammation is desirable, as with time, the body loses its support system for soft tissue (figure 1). A 23 year old

CELL DEATH Apoptosis is a normal, always ongoing process in humans that programs cells to die in order to offset the number of new cells created by mitosis. Necrosis is immediate, sudden, and very inflammatory, so patients treated with a necrosis inducing regimen—such as injection lipolysis—will see a lot of swelling and bruising. Both necrosis and pyroptotic-like mechanisms are pro-inflammatory. One has poration and one does not. One has cell shrinkage and one is characterized by cell wall rupture. Apoptosis and necrosis are not the only mechanisms of cell death; others include autophagy, pyroptosis, caspase independent apoptosis, paraptosis, Wallerian degeneration, cornification and anoikis.

has a thick, sturdy fibrovascular network that holds the fatty layer together and binds it to the underlying fascia and overlying skin. A 44 year old has lost about 50% of this support network, allowing regions of fat to become pendulous and quite saggy. By age 60, about 85% of the fibrous tissue binding fat cells together has eroded away. When we use the term “skin laxity”, we are actually talking about a combination of the skin and adipose layer. The loss of attachment to the underlying fascia, plus the loss of a scaffold that is knitting the fatty layer together, cause the flabby character of ageing skin and soft tissue. In many cases, the nature of the soft tissue is actu-

body language I EQUIPMENT 55

scar tissue formation. A desired outcome would be restoration of the youthful fibrovascular support system to the adipose layer. This would require a fractional and somewhat uniform response—layers of tendrils of collagen that are interspersed within the fatty layer. A multilevel response would be needed, and the response would need to be able to be controlled—more fibrous support in some areas, like the jowl or lower abdomen and a bit less in areas that do not tend to be pendulous, like the cheek, or outer thigh. The fibrous support response alone can be generated with a moving external radiofrequency device like Forma or Plus.

ally more important than that of the skin. Soft Tissue Contouring The ideal mechanism for soft tissue contouring would be somewhere between apoptosis—with no inflammation, and necrosis’ rampant

Results and temperature I did a study in which I looked at serial scanning electron microscopy sections of fat, treated over time with Forma at different maximum temperatures: 40, 41, 42, and 43 degrees Celsius. We looked at adipose cells immediately following the eighth weekly treatment, at one month following treatment cessation, and again at three months following treatment cessation. We had two questions: one, could moving RF alone kill fat? And two, does a hotter temperature which may not be well tolerated by the patient create a better tissue response? Figure 2 shows a matrix of SEMs showing tissue response over time at different temperatures. Temporary cell deformation increases with higher temperatures. If you read the thermal literature, fat must get to about 55 degrees Celsius in order to cause necrosis. It is extremely difficult to create that level of heat transcutaneously with external RF alone. Interestingly, at one month and three months, all adipocytes had recov-

23 years old

44 years old

60 years old Figure 1: Young adipose tissue has a strong fibrovascular support framework. Middle aged tissue has lost part of the binding and structural tissue. Older tissue has retained very little remaining connective tissue, allowing the soft tissue to appear lax and pendulous

ered, and no fat death was noted with Forma treatments. Contrary to the belief that bulk heating, especially radio frequency bulk heating, doesn’t work, I have proof that it does. However, the level of fibrous ingrowth into the adipose layer did not vary as significantly with temperature level as originally thought. We’ve been instructed to get the tissue as hot as possible, however even at 40 degrees, there was a significant tissue response in treated areas. Patients tend not to come back to repeat painful experiences. Clinical results are just as good with lower temperatures and longer treatment times.

Figure 2: Effect of temperature difference on fibrous tissue response at three months post treatment with moving external RF only. All tissue has fibrous and vascular ingrowth. More cell deformation is present at 43 degrees. If tissue support and molding is the goal, keeping the temperature at 42 degrees or below may be best, as a small amount of fat may die at higher temperatures.

56 EQUIPMENT I body language

Repeated Measures ANCOVA

Before treatment Mean/ SD

After 1 month Mean/ SD

After 3 months Mean/ SD

US @ 0 degrees

2.63+/- .283

1.74 +/- .202

1.68 +/- .218

US @ 90 degrees

2.83 +/-.160

1.57 +/- .164

1.55 +/- .188

US @ 180 degrees

2.60 +/- .249

1.71 +/- .184

1.76 +/- .204

US @270 degrees

2.82 +/- .237

1.49 +/- .150

1.57 +/- .179

* p=<.05 The standard for statistical significance **p=<.001 Stronger statistical significance The repeated measures analysis (ANCOVA) has been adjusted for age and height

Tissue tightening and fat reduction A device like BodyFX also has moving external radiofrequency. The handpiece is suction-coupled, which means that the target tissue is firmly held so that heat can better get to it. The depth of energy penetration is also controlled this way. However, the secondary electrical impulse is the secret ingredient that makes the fat die. One of the recent advances in medicine is reversible electroporation, which is used to introduce small molecules into a cell, cause cell fusion, or enable genetic alteration. This causes temporary relaxation of the pores in the cell membrane of target cells, so that medicine or other “genetic directions” can get through. A newer and rapidly growing field, especially in the arena of cancer treatment, is irreversible electroporation. With reversible electroporation, cells can be altered, but none die. With irreversible electroporation, the holes in the pores cannot be reversed, and the cells are programmed to die over time.

The importance of death over time Most people understand that the inflammatory process in humans takes time. There is about a sixweek healing process after surgery and the strength of the repair of a surgical incision gains about 10% per month. This is a process that cannot be hurried. If adipose cells die over time, there is no discomfort, no swelling, no bruising, and no down time. With simple external RF heat, the pattern of fibrous infiltration has barely begun at the end of the eighth treatment, is stronger one month following treatment cessation, and has become quite visible at three months. A similar process is seen with the Body FX; fat takes at least three months to optimally remodel. Fractional cell death is seen; that means not all of the fat cells in a given region die, but a significant number do. Fibrous support is restored, and fat layer thickness is reduced by an average of 40% as measured by high-resolution ultrasound (figure 3). With the BodyFX, the external RF heat is only the introduction— it sensitises the adipocyte and

Figure 4: Tissue treated with external RF plus vacuum but no high voltage pulses shows no adipocytolysis at three months. Cells appear similar to tissue treated with external RF alone.

Figure 3: High resolution ultrasound fat thickness measurements Multivariate ANCOVA : 53.25% fat thickness reduction at three months post last treatment

lowers the poration threshold. It doesn’t really cause induction of fat death—we treat anywhere between 40°C and 43°C—but it does cause the induction of fibrous response. Different devices that claim fat loss with only moving RF are not very likely to work, given this research. I’ve done a lot of scanning of what happens when tissues are heated using scanning electron microscopy, SEM, which is much easier for people to understand than histology. Adipocytes are notoriously difficult to fix and cut in histologic sections as the cells can easily fracture with processing. The SEM doesn’t have those artefacts. What you see with electron microscopy cannot be manipulated. Using an SEM I have studied pieces of tissue as a control (figure 4) that have been treated with heat and vacuum alone without the high voltage pulses. These high voltage pulses are the a third step and the patient will feel this as a thump, since a feeling of an electric shock would really be an adverse stimulus. Mechanically the large size of the fat cells is what makes them more susceptible to injury. Their blood supply is poor, so they are

Figure 5: Adipocytes treated with Body FX including high voltage pulses, effect at three months. Note lipid droplet egress continues. Critical volume loss has occurred

body language I EQUIPMENT 57

How do apoptosis, necrosis and pyroptosis differ? In looking at the apoptotic process, you can see some cellular budding and eventual separation of these buds (apoptotic bodies). Macrophages will clean up cellular debris. By definition, there is no inflammation. The mechanism is caspase mediated. With necrosis, immediate swelling and bursting of cells causes significant inflammation in the affected area. It is not caspase mediated. Pyroptosis is caspase mediated, which explains why early researchers thought the Body FX mechanism was apoptotic. Also, apoptosis occur over time, so the slow response with no down time was assumed to be apoptotic. With pyroptosis, poration causes the cell to become “leaky”. Cell biology literature notes that when a cell cannot repair the damage to its membrane, it will go on to die.

more easily damaged than other smaller cells. SEM images (figure 5) show how tissue looks over time after treatment with the BodyFX device with the high voltage pulses. The lipid droplets leak out, or leave the cell through these membrane defects. In looking at thousands of treated cells, we note very few have actual membrane rupture. The membrane has many micro-injuries—and there must be enough, of a degree that cannot be repaired by the cell, in order to cause permanent cell death. Pyroptosis Originally discovered by Brad Cookson in 2001 pyroptosis is a pro-inflammatory mechanism. Cookson discovered pyroptosis

while looking at people who had infection with salmonella and shigella and observing that the cell creates little pores in the cell membrane. Some of the cytosol then leaks out, cells shrink and then cytokines signal the cell to die. Pyroptosis is the current best model to help explain what is going on in the Body FX process, but the process is not identical. In order to see the whole picture I took some control samples of fat tissue injected with saline, but no mechanical or electrical impulses, to illustrate what a normal area of fat cells look like for comparison. The early effect of the BodyFX is totally different than anything that we’ve seen before. You can see some early cracks in the cell membrane, which is interesting because

you can see the fibrocyte trying to mend that crack so the cell won’t die. In breaking down the mechanics of cell death we know that if the fibrocyte can mend that tear then the cell won’t die—but that it can’t survive with many tears and a lot a lipid droplets that egress, or significant volume loss. The current gold standard in fat reduction is liposuction. Liposuction removes some, but not all of the fat, so that the tissue that remains behind still acts like “soft” tissue. After liposuction, the remaining tissue can glide over underlying structures, the surface ideally remains smooth, and the fatty layer is reduced. With Body FX, a similar response is seen; fat reduction occurs, but it may not be as significant as with liposuc-

58 EQUIPMENT I body language

Figure 6: Adipocyte size reduction 6 weeks post cryolipolysis. Average adipocyte size varies from 50- 200 microns, with a mean size of 100 microns. Most adipocytes in this field of treated tissue measure less than 100 microns; all appear viable.

Figure 7: Four months following cryolipolysis, viable fat cells show persistent size reduction in the treatment region, although it is less uniform. 100 microns is the average adipocyte diameter. Note extensive fibrosis in this patient, control untreated tissue appears on the left.

tion. However, there is not a lot of residual scar tissue, and tissue lift can clearly be seen. Cryolipolysis As another control study, I looked the mechanism of action of cryolipolysis because I wanted to compare it to that of RF. The officially agreed mechanism of cryolipolysis is apoptosis. However, by comparing the tissues under the SEM it becomes apparent that his cannot be true. The mechanism appears to be mechanical in the early stages. In early SEMs you can see little crimps of folds in the cell wall, most likely due to a combination of the vacuum and the freezing that creates a crystalline structure within the cell. You get some membrane peeling, probably due to the massage performed immediately following treatment, but there’s no poration. The lipid droplets don’t really come out of pores in cryolipolysis. At four months posttreatment with cryolipolysis, no cell death was seen in these SEM specimens. A uniform reduction of adipocyte size is clear (figure 6). Fibrosis is also evident, which can clinically translate as improvement of tissue pendulosity and a firmer character (figure 7). These two new mechanisms are

really interesting and we’re barely on the verge of understanding them. The radio frequency-induced mechanism is pyroptosis-like. Currently we call it “poroptosis” because the mechanism appears to be irreversible poration that doesn’t have any real relationship with the infectious process of Cookson’s. The cryolipolysis mechanism of action is clearly not inflammationfree; it’s not apoptosis, but it’s not necrosis either. We didn’t see a single ruptured cell in our SEMs. Cryoptosis has a very different mechanism of action than anything we’ve seen before. Age differences There are age-related differences as well as ethnic variations in tissue type. You can see at age 23 you have a lot more inherent fibrosis or fibre support of the fat tissue, at age 44 there are patches where the support tissue is gone. By age 60 the fat cells are barely held together with little threads of fibrotic tissue. Darker skin type patients tend to have more fibrotic soft tissue, which explains the lesser effect of transcutaneous treatments such as cryolipolysis and radiofrequency at lower settings; the adipose tissue is insulated from both heat and cold by the extra amount of fibrous tissue. By knowing these things, we can optimise the clinical outcome. Fat reduction plus tissue lift, I think, gives the best outcome in most patients. In looking at before and after images from the BodyFX, you can see some definite tissue lift as well as fat reduction. This is great for older patients who don’t have a lot of fibrotic tissue remaining; they get top results because there is a new collagen scaffold that’s built up. Paradoxically, with this treatment, middle aged and older patients may see more results than youthful patients with firm tissues. Conclusion The ideal mechanism inducing adipose cell death is not necrosis, because there’s too much down time and possible subsequent scarring. Nor is it apoptosis, because if you don’t get any inflammation at all you won’t get any correction of soft tissue and overlying skin laxity. Poroptosis is fractional which is

ideal, as some, but not all of the fat is affected. There is some inflammation, and I believe this is a good way of inducing fibrous scaffold restoration. However, cryolipolysis is also very interesting because this is also pro-inflammatory. We’re just beginning to study both of these mechanisms and clearly more work needs to be done. Diane Duncan is a Board Certified Plastic Surgeon and has been in practice in Colorado for over 26 years. She specialises in facial enhancement, breast surgery, and body contouring and teaches new surgical and nonsurgical techniques around the world.

Top: 52 year old before and three months following eight Body FX treatments. Weight gain was one pound. Bottom: 63 year old before and three months following eight weekly treatments. Fat reduction and soft tissue laxity correction has occured.

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