march
79 The UK and International Journal of Medical Aesthetics and Anti-Ageing bodylanguage.net
Hair transplants A JOURNEY TO THE ROOT OF CUTTING-EDGE HAIR TRANSPLANT SURGERY
ALOPECIA
HAIR REMOVAL
THREADS
More than just hair— cause and effect, plus available support
How has permanent hair removal using electricity changed throughout the years
Facial lifting and rejuvenation with reabsorbable sutures
New for 2016, 3Juve combination skin treatment fights against the 3 key signs of ageing.
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body language I CONTENTS 3
07
34
contents 24
07 NEWS OBSERVATIONS Reports and comments
18 CONFERENCE FACIAL AESTHETIC CONFERENCE AND EXHIBITION
and cytokines in wound healing has stimulated research to uncover the evolving benefits of growth factors in skin rejuvenation. Dermatologist Dr Zein Obagi explains the science
FACE 2016—the UK’s premier medical aesthetic conference returns to the heart of London this summer showcasing an expanded lecture programme, hands on training and FACE rewind
51 TECHNIQUE
24 TECHNIQUE
ON THE MARKET
FOLLICULAR HARVEST Expert Dr Bessam Farjo takes us to the root of hair transplant surgery
34 HAIR LOSS MORE THAN JUST HAIR Jackie Tomlinson, trustee at charity Alopecia UK talks about alopecia awareness
38 MEDICAL AESTHETICS ELECTRICAL PERMANENT HAIR REMOVAL Dr Catherine de Goursac explores how permanent hair removal using electricity has evolved over the last 140 years.
47 DERMATOLOGY THE ROLE OF TOPICAL GROWTH FACTORS The role of topical growth factors
STIMULATION AND REGENERATION Dr Joseph Choukroun discusses platelet rich plasma and platelet rich fibrin
55 PRODUCTS The latest medical aesthetic and anti-ageing products and services
57 EQUIPMENT LIFT AND REJUVENATE The ageing face can benefit from the use of toxins and fillers, however the use of of reabsorbable sutures with biodirectional cones can offer better results for some indications, explains Dr Kuldeep Minocha
61 EXPERIENCE A JOURNEY FROM THERE TO HAIR Dr Greg Williams outlines his path to becoming a Plastic Surgeon—from Jamaica via Canada and ultimately to London to specialise in hair transplant surgery
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.
38 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 Bessam Farjo, Jackie Tomlinson, Dr Catherine de Goursac, Dr Zein Obagi, Dr Joseph Choukroun, Dr Kuldeep Minocha, Dr Greg Williams 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 2016 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
Deening success 24% reduction in stubborn fat • Works on any skin type • Over 90% patient satisfaction rate • Comfortable and well-tolerated treatment • Can be used in skin types I-VI • The 1060 nm wavelength’s speciic afinity for adipose tissue
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www.teoxane.co.uk 1. TEOXANE Laboratories crosslinking method is a patented process. 2. TEOSYALŽRHA keeps its mechanical properties on a large range of strain or stress constraints (dynamic G’) Report Rheological characterizations of hyaluronic acid gels. Rheonova (University of Grenoble, France). Data on file - Patent pending
body language I NEWS 7
observations
NEW APPROACH TO FACIAL FEMINISATION SURGERY OFFERS MORE THAN GOOD COSMETIC OUTCOMES Full facial feminisation surgery offers psychological, social and functional benefits to patients according to new research A new stepwise approach to facial feminisation surgery (FFS) for gender dysphoric patients, leads not only to good cosmetic outcomes for patients undergoing male-to-female transformation—it offers psychological, social, and functional benefits according to new Italian research. The six-month process not only offers ‘excellent cosmetic results’, but alongside psychotherapy, hormone treatment, and gender reassignment surgery is an important part of the treatment plan for some patients with gender dysphoria. Full FFS targets gender specific facial characteristics and may include forehead remodeling, surgery to change the appearance of the nose and chin, thyroid surgery to reduce the “Adam’s apple,” and voice alteration procedures. Dr Tommaso Agostini and colleagues of the Face Surgery Centre in Parma, Italy, report high patient satisfaction rates using their standardised protocol for male-tofemale FFS. “The reduction of gender dysphoria has psychological and social benefits and significantly impacts patient outcomes,” the researchers write in the February issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).
From 2003 to 2103, Dr Agostini and colleagues performed FFS in 33 patients, aged 19 to 40. About half of the patients had previously undergone breast augmentation, while one-fifth had undergone genital surgery. For some patients, genital and FFS procedures were overlapped, speeding up the overall gender reassignment results. The patients underwent a total of 180 surgical procedures for FFS, with no major complications. Most completed FFS in six months. The process was longer and the order of the pro-
cedures was different for patients who also required orthodontic treatment. In follow-up surveys, the patients reported significant improvements in quality of life, including physical, mental, and social functioning. More than 90% of patients “very much” or “completely” agreed that they liked the appearance of their face and that it appeared feminine. On evaluation of postoperative photographs, independent surgical specialists rated the cosmetic results as “very much improved” in 88% of pa-
tients, and “significantly improved” in the rest. “Both frontal and profile views achieved a loss of masculine features,” the researchers write. Dr Agostini and colleagues conclude, “The result was a high degree of patient satisfaction, since FFS was approached as a unified process.” They believe their approach leads to excellent cosmetic results of FFS as part of male-to-female transformation, providing patients with a more feminine facial appearance and improvement in key aspects of quality of life.
8 NEWS I body language
LIPOFILLING DOESN’T INCREASE RECURRENT BREAST CANCER RISK Using a patient’s own fat cells to assist with breast reconstruction after cancer surgery does not increase recurrent breast cancer risk, according to new research For women undergoing breast cancer surgery, a technique called lipofilling – using the patient’s own fat cells to optimise the results of breast reconstruction – does not increase the risk of recurrent breast cancer, reports a study in the February issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS). Lipofilling is a fat grafting technique that is increasingly used to optimise the cosmetic results of breast reconstruction. In a 2013 survey, more than 60% of ASPS member surgeons said they used fat grafting as part of breast reconstruction. However, some plastic surgeons may still be reluctant to use lipofilling because of concern that it might affect the risk of primary or recurrent breast cancer. This new study of breast cancer recurrence risk associated with lipofilling is the first to use a control group of women who underwent breast reconstruction without lipofilling. In the research, more than 1,000 partial or total mastectomies followed by breast reconstruction with lipofilling were analysed. About 30% of cases involved risk-reducing mastectomy in women at high genetic risk of breast cancer. Rates of recurrent or new breast cancers were then compared with a similar group of women who underwent mastectomy followed by
breast reconstruction without lipofilling. For women who underwent mastectomy for breast cancer, overall recurrence rates were similar for reconstruction with versus without lipofilling. The rate of locoregional recurrence (in the breast and surrounding area) was not significantly different between groups: 1.3% for women who had lipofilling versus 2.4% in those who did not. Rates of systemic (distant) cancer recurrence were also similar: 2.4% with lipofilling versus 3.6% without. None of the women undergoing preventive mastectomy developed initial (primary) breast cancer. In most patient subgroups, breast cancer recurrence risk was similar with or without lipofilling. The sole exception was women receiving hormone therapy, for whom lipofilling was associated with a small but significant increase in locoregional recurrence risk: 1.4 versus 0.5%. The results show no increase in the risk of locoregional or systemic recurrence in women with breast cancer who undergo breast reconstruction with lipofilling. The study also finds no evidence that lipofilling affects the risk of initial breast cancer for the growing number of high-risk women undergoing “preventive” mastectomy. “Our results provide new evidence
that lipofilling, used as part of breast reconstruction, is a safe procedure that does not increase the risk of recurrent or new breast cancer after mastectomy,” ASPS member surgeon Dr Steven J. Kronowitz of Kronowitz Plastic Surgery, Houston, lead author of the new report comments. While highlighting the need for further research, the researchers hope their findings will encourage more plastic surgeons to use lipofilling to provide the best possible results of breast reconstruction for their patients undergoing breast cancer surgery.
SELFIES MAKE YOU LOOK OLDER Women over the age of 40 look up to seven years older in a typical selfie According to plastic surgeon and head of the President of the British Association of Aesthetic Plastic Surgeons (BAAPS) Rajiv Grover, the ubiquitous self-portraits taken with smartphone cameras are making us appear older than our years. In an interview with the UK Telegraph, London plastic surgeon Rajiv Grover said 17% of his clients mention selfie culture as the reason for their interest in undergoing cosmetic surgery, a phenomenon he says comes down to selfie images accentuating features people don’t normally want to highlight. “[A] phone’s 28mm camera lens does exactly what time does to your face, enlarging the front of your face so that it looks bigger, as well as amplifying the features that get larger as you age,” he told the publication.
“Add to that the fact that you tend to look down at your phone, which makes the skin on your neck and jowls look saggy.” According to Grover—a photographer in his spare time—a typical selfie adds seven years to the appearance of a woman over 40, and he suggests adding distance or a different angle to change what’s highlighted in your picture. “A shot from above looking up stretches the neck, defines the jaw and distributes your soft tissue in your face (if you are 40 plus) more peripherally so that your face appears more balanced like it does in youth (less inner cheek and jowl volume and more fullness over the cheekbone and angle of the jaw),” Grover said. Using a selfie stick can also help, or you could of course just give the camera to someone else.
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body language I NEWS 11
60
second brief
ON THE UP
Over 51,000 Britons underwent cosmetic surgery in 2015, showing that the public’s love affair with surgical enhancement is far from over. As more celebrities open up about the odd nip or tuck, it’s likely that this increased acceptance and de-stigmatising of aesthetic enhancement, is leaving patients feeling encouraged by their positive admissions and attractive results.
13%
The number of cosmetic operations in 2015 grew 13% overall since 2014 All procedures increased in demand The top surgical procedures for men and women combined in 2015:
Breast augmentation 9,652—up 12% from 2014 Blepharoplasty 8,689—up 12% Face/Neck Lift 7,419—up 16% Breast Reduction 6,246—up 13% Liposuction 5,551—up 20% Rhinoplasty 4,205—up 14% Fat Transfer 3,261—up 3% Abdominoplasty 2,933 – up 8% Browlift 2,110—up 7% Otoplasty 1,074—up 14% 2015 data from the British Association of Aesthetic Plastic Surgeons baaps.org.uk
WOUND HEALING Seaweed offers solution to stem cell transport and wound treatment Stem cells from seaweed have been put into plasters and bandages to help heal wounds thanks to a new technique developed by scientists at Newcastle University. A wealth of scientific evidence shows that stem cells from fatty tissue (adipose-derived mesenchymal stem cells) can be used to improve wound healing by reducing inflammation and speeding up wound closure. However, until now the problem has been that these stem cells have had to be stored and handled by experts under specialised conditions—limiting their practical use. A simple and effective new solution to extending stem cells life has been found by researchers at Newcastle University—rather than keeping them at 37 degrees Celsius, in atmospheric oxygen and 5% carbon dioxide —encasing them in an alginate gel prolongs their life for up to three days at ambient temperatures. Alginate is a natural material extracted from seaweed that is used in cosmetics, food manufacturing and more recently in healthcare. Alginate on its own without stem cells is used in wound dressings to keep burns moist. The study found that after three days at a range of temperatures (between 4 and 21 degrees C) up to 90% of the stem cells were still viable and available for healing. Medically, 70% viability is considered acceptable. The team believe that the alginate encapsulation offers a degree of protection from the environment, acting like a corset and preventing the stem cell from expanding and being destroyed—a process known as lysing, which would normally occur within a day when unprotected cells are stored in their liquid state. “The stem cells are grown from the standard frozen form and then mixed into the alginate solution. This is extracted from a type of brown algae, a seaweed commonly used in food and medical applications, “ explains Dr Stephen Swioklo, research assistant at the Institute of Genetic Medicine. “This can either be dropped into a vial of calcium chloride, which forms cross-links making the alginate set, forming tiny beads. Or the gel can be placed into a mould to form a film, which sets in a couple of minutes. We have used this to make plasters and bandages.” The ‘Stem-gell’ bandage offers many exciting opportunities for therapeutics, for ease of transport, in cell printing, in improving the results with injections of stem cells and for wound healing. Professor of Tissue Engineering Che Connon, said “With this new technology we are able to put stem cells directly onto an open wound with a stem cell bandage. The gel retains the cells so that they don’t leave the bandage—it’s the chemicals these cells make that actually do the healing.
12 NEWS I body language
IDEAS OF SMILE PERFECTION EVOLVING A leading London dental clinic has seen a 30% rise in patients wanting treatment to look better in self-portrait pictures Dentistry trends are evolving due to smartphone selfies. The craze isn’t just driving demand for teeth whitening and other cosmetic work, but according to London Smile Clinic, the unique photographic features of these close-up images have changed the types of smile patients are asking for. As selfies become the most popular way for people to appraise their looks—even regularly used in lieu of compact makeup mirror—the quest for the previous generation of blinding ‘piano key’ grins of TV stars has fallen by the wayside. A centre of excellence in both cosmetic and restorative dentistry, the London Smile Clinic reports that the new ‘selfie smile’ sought by patients is a novel aesthetic that benefits, rather than suffers, at the hands of the typically centre-widening, periphery-narrowing properties of smartphone cameras. Although youthful appearance seekers may have been previously south out larger teeth—not worn down with age, this look is now shunned; even by those who naturally have a white and even smile. “The problem with a selfie is that the picture is taken quite closely, so the image can be distorted. Teeth often look more protruding than they are in real life and appear ‘horse-like’, which can also be emphasised by the unflattering light of the flash” reports Tim Bradstock-Smith, Clinical Director and Cosmetic Dentist at the London Smile Clinic—who has recorded a dramatic increase in the number of people with complaints specific to selfies. “As teeth are at the centre of the image, people are increasingly, and understandingly, driven to make them look nicer. Whilst these photos will undeniably exaggerate defects, they can also be misleading. We have seen a 30% rise over 5 years in the number of patients sending in selfies through the website with concerns about the look of their front teeth, yet when the patients come in person, often the teeth don’t look too bad at all. We dissuade approximately two to three patients now each week from treatment and for many others will recommend simple alignment of front teeth with clear aligners instead of major intervention work.”
Although the clinic is offering clients tips on taking better photos as a response the growing increased demand for work to the front teeth, there are some with problems that cannot be filtered away. For these, Tim has tailored treatments to help achieve the new ‘selfie smile’ aesthetic. He explains: “It’s always been thought that the two front teeth look good being a little more dominant with a step in length between these and the next two. It creates a ‘smile curve’ and it’s a highly aesthetic, natural, feminine, youthful appearance. However if your selfies are taken too close it can be distorted and exaggerate the size of the two front teeth. We will take some undistorted photos to see what’s really going on before diving into treatment but selfies have caused an increase in demand for a reduction in this natural dominance of the front two teeth.
If someone has very mild crowding of the front teeth this can also make the teeth look really wonky in a distorted selfie. In this instance however we don’t recommend waiting for things to get worse. Teeth move throughout life and mild crowding always worsens, often causing uneven wear and gum health problems that can be expensive to sort out later. So we do recommend early intervention to straighten and then retain crowded teeth to improve aesthetics and avoid long-term problems.” “Another issue raised by many is that they feel the smile looks too gummy in selfies. If this is a genuine problem, rather than just a distorted photo, I tend to look at the pink-to-white ratio –the pink can be exaggerated in a selfie. Possible solutions, depending on the size and shape of the teeth can include gum lifts and gum contouring.”
14 NEWS I body language
events MARCH 16 - 19, AAFPRS: Facial Rejuvenation Meeting, Beverly Hills, USA W: embers.aafprs.org 31 MARCH - 2 APRIL, AMWC 2016, 14th Aesthetic & AntiAging 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 30 MARCH - 2 APRIL, AMWC 2016, 14th Aesthetic & AntiAging Medicine World Congress, Monte-Carlo, Monaco W: euromedicom.com 28 APRIL, British Association of Sclerotherapists 2016 Annual Meeting, The Ark, Basingstoke, UK W: bassclerotherapy.com
FIRST TOPICAL TREATMENT FOR BENIGN SKIN LESIONS
27-30 APRIL, 32nd Annual American Academy of Cosmetic Dentistry Scientific Session, Toronto, Canada W: aacdconference.com
An investigation into the molecular mechanisms responsible for the most common type of benign skin lesion may lead to the first nonsurgical treatment seborrheic keratoses
16 - 18 JUNE, 3rd ICAD Brazil – International Congress of Aesthetic Dermatology and Healthy Aging Medicine, Sao Paulo, Brazil W: euromedicom.com
A paper by Massachusetts General Hospital (MGH) researchers, published online in the Journal of Investigative Dermatology, reports that blocking the action of a specific signaling enzyme leads to the death of cultured seborrheic keratoses (SK) cells and the breakdown of SK lesions. “Our paper is the first to show that SKs are dependent on an enzyme called Akt for survival,” says Dr Victor Neel, director of Dermatologic Surgery and lead author of the paper. “Inhibition of this enzyme in SK cells causes rapid cell death while having no effect on normal skin cells. We are confident that this paper heralds the development of an effective, topical treatment for SKs.” Sometimes called “senile warts,” “barnacles” or “liver spots,” SKs vary in colour from tan to black, can be flat or raised, and range in size from quite small to an inch or more across. They become more common with aging; most individuals over 40 are likely to have a few, and some can have hundreds scattered across the torso and face. While SKs have some microscopic features in common with their malignant counterpart squamous cell carcinoma and most
have mutations in genes known to be involved in cancer, SKs never become malignant. Previous research by members of the MGH team identified increased expression in SKs of growth factor receptors and other genes thought to be involved in skin cell differentiation and in skin cancer development. Neel explains, “We still don’t know why SKs resist malignant transformation but we think studying SKs will help us identify factors that prevent benign lesions from becoming malignant. The MGH team identified conditions that permit SK cells to be cultured, opening up an array of opportunities for studying their biology. Cultured SK cells were exposed to a panel of specific kinase inhibitors, confirming that the development and maintenance of SK cells requires the presence of activated Akt. One particular Akt inhibitor, called A44, was by far the most efficient at inducing the death of cultured SK cells. Small doses of A44 initiated apoptosis. The researchers also found that applying A44 to intact SK lesions that had been excised from patients’ skin and maintained in culture caused the lesions to die through apoptosis.
19 - 22 MAY, 13th EADV Spring Symposium, Athens, Greece W: eadvathens2016.org
16 - 19 JUNE, Facial Aesthetic Conference & Exhibition—FACE 2016, London, UK W: faceconference.com 1 - 3 JULY, IMCAS Americas 2016, Cancùn, Mexico W: imcas.com 29 - 31 JULY, IMCAS Asia, Taiwan W: imcas.com 16 - 17 SEPTEMBER, AMWC Eastern Europe 2016 – 4th Aesthetic & Anti-Aging Medicine World Congress Eastern Europe, Moscow, Russia W: euromedicom.com 23 - 27 OCTOBER, 23rd Congress of ISAPS, Kyoto-shi, Japan W: isapscongress.org 3 - 5 NOVEMBER, 3rd AMWC Latin America, Medellin, Columbia W: euromedicom.com 24 - 26 NOVEMBER, ICAD 2016, Bangkok, Thailand W: euromedicom.com Send events for consideration to arabella@face-ltd.com
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body language I INDUSTRY 17
industry news
NEW SUNSCREEN DOES NOT BLOCK VITAMIN D New product developed with different filter compositions to maximise pre-vitamin D3 production A typical sun lotion with a sun protection factor (SPF) of 30 might protect against harmful UVA rays, but it also reduces the skin’s capacity to produce vitamin D by 97.3%. However, a new product developed by an Australian company, promises to change that with Solar D—a lotion shown to allows the body to produce up to 50% more vitamin D than a sunscreen with the same SPF. Low level of vitamin D can lead to a host of problems including rickets, osteoporosis, diabetes, and memory loss. With rising skin cancer fears increasing amounts of sunscreens—which also block vitamin D—are applied by many, particularly parents—leading to an estimated 40% of children and 60% of adults becoming deficient in the ‘sunshine vitamin’. Sunscreen use is the major cause for the vitamin D epidemic worldwide according to Dr
Michael F. Holick, an endocrinologist at the BU School of Medicine who told the journal PLOS ONE that, “Solar D was designed with differing filter compositions to maximise pre-vitamin D3 production while maintaining its sun protection.” Dr Holick added, “During sun exposure the skin produces vitamin D3 which is metabolised in the liver and kidney to 1,25(OH)2D3 or it can undergo a variety of metabolic steps in the skin producing several novel secosteroids that exert
antiproliferative, prodifferentiation and antiinflammatory effects on cultured skin cells.” Widespread sunscreen use has been implemented to protect skin from the cancer causing UVA rays, however was not fully appreciated was that sunscreens are designed to efficiently absorbed radiation in the UVB range. Several chemical compounds that are typically used in a sunscreen efficiently absorb varying wavelengths of UVB radiation. Solar D is designed with compounds with differing filter composi-
tions to maximise previtamin D3 production while maintaining its sun protection for reducing erythema. “Based on our previous observations the in vitro results can be directly translated to what would be expected when the sunscreens are used on human skin” says Holick. “Therefore we have proof of principal that a sunscreen can be produced for optimising previtamin D3 production while retaining its sun protection factor for reducing erythema.’
BREAKTHROUGH IN ACNE TREATMENT Topical gel formulation evenly delivers lower doses of antibiotic to the source of the acne Pharmaceutical company BioPharmX’s unique formulation of minocycline— BPX-01, may offer a breakthrough in acne treatment because it may not cause the systemic toxicities commonly associated with current use of the orally administered antibiotic according to new research. “Our preliminary studies in animals indicate that minocycline delivered by BPX-01 is efficiently absorbed into the skin, reaching the epidermis and the pilosebaceous region where acne develops,” said Kin F. Chan, Ph.D., executive vice
president of research and development at BioPharmX Corporation. “The results suggest that lower doses of the antibiotic may be used to provide a treatment that is superior to higher-dose topical formulations and oral therapies.” Minocycline, the antibacterial and anti-inflammatory medicine most commonly prescribed to treat acne, is typically administered orally because an effective minocycline-based topical medication is yet to exist. BPX-01 is the first and only stable hydrophilic topical gel formulation with fully solubilised minocycline, that
effectively delivers the antibiotic to the source of the acne. Its hydrophilic BPX01 formulation distributes evenly, is not sticky and does not occlude or irritate the skin, an advantage in acne treatment. Results from a preclinical toxicology study demonstrate that both systemic exposure and peak plasma concentrations of minocycline are minimised by topical administration, which eliminates the risk of unwanted side-effects associated with oral minocycline, including diarrhoea, nausea and dizziness that can discourage usage.
18 FACE 2016 I body language
Facial aesthetic conference and exhibition FACE 2016—the UK’s premier medical aesthetic conference returns to the heart of London this summer showcasing an expanded lecture programme, hands on training and FACE rewind
JUNE 16TH – 19TH 2016
F
ACE 2016 marks the 14th year of the UK’s premier aesthetic conference in the heart of London. With the strategic partnership and alliance with EuroMediCom and Informa—the organisers behind a host of international medical aesthetic conferences and events including AMWC in Monaco—FACE is constantly creating changes to the conference experience, allowing more content to be seen by more delegates every year. FACE 2016 sees the regular INJECTABLES, BODY, SKIN, HAIR and THREADS Agendas take place across three days in their own dedicated rooms and lecture theatres. Changes to the Agenda for FACE 2016 include a Live BUSINESS Agenda taking
place within a new section of the Exhibition Hall located on the 1st Floor. This will enable access for all delegates and exhibitor representatives to participate in our ever popular and interactive business talks which have proven to be key for everyone working within the medical aesthetics industry. Also new to FACE 2016 is the addition of Advanced Hands-On Training Courses, which will run throughout the event focusing on injectable treatments. Each session will consist of five to 10 delegates. The Sunday schedule will also be enhanced for 2016, as running alongside the Injectables Agenda, will be a ‘FACE Rewind’ lecture programme. This will take place across two rooms, and will repeat some of the most popular talks
from the weekend which delegates might not have been able to see in their first few days of attendance. FACE 2016 will—for the first time—host a Sexual Aesthetics Agenda. Over the last few years there has been an explosion in the number of treatments targeted at both aesthetic and functional improvement of the genital area. From fillers, PRP and threads, to lasers and radiofrequency; research and development investment and clinical experience has grown significantly. This session aims to explore the evidence behind different modalities and their potential combined uses, alongside practical tips from experts pioneering the use and promotion of these treatments in their clinics.
FACE 2016 is held at the QEII Centre in London’s Westminster
body language I FACE 2016 19
MASTERCLASS Provisional international faculty includes: Dr Raj Acquilla, Cosmetic Physician, UK Dr Ali Pirayesh, Consultant Plastic Surgeon, Netherlands Dr Frank Rosengaus, Consultant Plastic Surgeon, Mexico Dr Alek Nikolic, Cosmetic Physician, South Africa Dr Ton Van Eijk, Cosmetic Physician, Netherlands Dr Uliana Gout, Cosmetic Physician, UK Prof Mukta Sachdev, Consultant Dermatologist, India Dr Kate Goldie, Cosmetic Physician, UK
Pre-Event “FACES of the World” Advanced Injectables Masterclass Due to the incredible popularity of our first pre-event injectables masterclass delivered in 2015, Thursday at FACE will once again host an Advanced Pre-Course agenda. The concept of “total facial contouring” with fillers/toxins and threads continues to become increasingly appealing to an ever wider audience of both men and women of all races and backgrounds around the world. However, for practitioners living in cosmopolitan areas, the technical challenge of delivering excellent results safely is enhanced when dealing with patients of different ethnicities and cultural backgrounds. This unique one day masterclass will be headed by an expert panel who will explore these challenges and provide personal insights into the cultural differences of aesthetics and beauty alongside variations in technical approaches required to ensure that patients are treated safely and effectively with the outcomes that they desire. Subjects covered in this unique workshop include: Anatomy: With a special focus on ethnic differences and anatomical variations Concepts in Beauty: What are the differences in ideals between women from different continents. Safety: Recommendations in altering techniques in facial contouring for different indications dependent upon ideals and ethnicity Adverse events: Exploring any differences in complication rates and how to deal with them when dealing with people from different ethnic backgrounds
In addition, there will be a number of live demonstration sessions delivered by our expert faculty highlighting the practical variations required in terms of facial assessment, consultation techniques, and facial rejuvenation approaches. Facial Injectables Agenda A host of national and international lecturers, trainers and clinical trialists will feature, providing scientific updates and practical insights to help you maximise results and minimise problems when using cosmetic injectables for total facial
contouring. Different techniques, new treatment approaches and products will be explored alongside practical demonstrations. The latest clinical data and thoughts on toxins, fillers, PRP and other cosmetic injectables will be reviewed and debated by some of the world’s most experienced practitioners. If you are passionate about cosmetic injectables then FACE 2016 is the event that you must reserve in your professional education diary. You won’t find a better industry focused event anywhere in the world this year.
INJECTABLE AGENDA Confirmed speakers and topics include: Professor Nick Lowe: The Evolution of injectables over the last 20 years Dr Raj Acquilla & Dr Alek Nikolic: Injectable masterclass workshop Dr Christopher Rowland Payne: Eyebrow ptosis—universal destiny? Causes and solutions Dr Maria-Angeliki Gkini & Dr Mario Goisis: A preliminary study comparing nanograft plus PRP vs hyaluronic acid plus PRP for the correction of facial wrinkles Mr Ash Labib: Non-surgical nasal contouring Dr Raj Kanodia: Enhancement of the cheek vector by lifting vs filling Dr Frank Rosengaus: Rheology and how to choose the right filler Dr Uliana Gout: Lip and peri-oral complex treatment with toxins and fillers Dr David Eccleston: Doing toxins well; tips and tricks for upper and lower face Dr Kate Goldie: Dealing with complications workshop Mr Chris Inglefield: Rapidly polymerising collagen—study on its use for lip augmentation Professor Bob Khanna: The art of the aesthetic consultation
20 FACE 2016 I body language
BODY AESTHETIC EQUIPMENT AGENDA Confirmed speakers and topics include: Dr Mark Taylor: The comprehensive treatment of acne scars Dr Welf Prager: Intralesional cryotherapy for keloid and hypertrophic scars Dr Jean Paul Meningaud: Multifractional microablative laser with space modulated ablative (RecoSMA) technology for facial skin rejuvenation Dr Sweta Rai: Complications associated with body contouring Dr Barbara Hersant: Multifractional microablative laser with space modulated ablative (RecoSMA) technology to treat stretchmarks Dr Klauss Hoffman: Picosecond laser for tattoo removal Dr Francois Michel: Wellbeing effect of photobiomodulation Dr Christine Dierickx: Vascular laser update Dr Rahul Pillai: Whats new in laser hair removal for the treatment of ethnic skins Dr Stephen Mulholland: Mesocaine technique for more aggressive singles session fractional RF and laser resurfacing
BODY Aesthetic Equipment Agenda Growth in research and development in this section of the market has produced a raft of new technologies in recent years that have opened up whole new business models. From microwaves for the permanent reduction of excessive axillary sweating, to specially designed fractional ablative approaches for vaginal atrophy—the high tech equipment market continues to surge forward. Delivered by an international panel of experts in their particular fields, this two day agenda allows delegates the opportunity to explore and compare the latest equipment based technologies and treatment protocols for a wide range of different indications. BUSINESS Agenda With the ever increasing range of effective treatments that can now be added to the service menu of a medically led aesthetic clinic comes the challenge of ensuring that you can effectively market and promote them to ensure profitability. Marketing body contouring treatments or laser hair removal requires a different approach to building a facial injectable business, especially when you need to ensure a quick return on investments from capital expenditure on equipment. In addition, in an increasingly competitive market everyone needs to ensure that they continuously review pricing models and points of differentiation to ensure that they continue to grow turnover and profit. FACE provides a
unique three day forum delivered by professionals from the field of web design, digital marketing, PR and social media that can help to ensure your strategies are up to date and effective. This is yet another unique opportunity for clinic managers, marketeers and aesthetic business owners to learn from respective marketing
experts in their fields, and network and share ideas with peers to maximise profitability in their business. SKIN Forum—Topical Treatments With so many different competing skincare lines, it can be challenging to draw conclusions about which brands to invest in using the
BUSINESS AGENDA Confirmed speakers and topics include: Norman Wright: Safety in aesthetics Dr Uliana Gout: Tips and tricks to maintaining competitive advantage Dr Kate Goldie: Social styles Wendy Lewis: The S-Factor: How to keep the ‘social’ in social media For aesthetic practitioners Dr Ross Perry: What makes the best CRM/practice management software in 2016 ? Charles Southey: How to grow your business with clinic management software Susan McNeece: Retail strategies for increasing retail sales in a medical clinic Glenda Bailey Bray & Jo Martin: The value of training in an unregulated industry Adam Hampson: Secrets of a successful clinic website
body language I FACE 2016 21
advice of company representatives and promotional literature alone. FACE provides a forum for practitioners to meet the real industry experts who truly understand ingredients, formulations and the arguments behind competing concepts and brands. As cosmeceuticals and medical retail skincare lines continue to be an important aspect of providing a complete approach to anti-ageing, this two day forum will help practitioners to review new topical approaches to preventing and treating signs and symptoms of ageing skin alongside the latest specific protocols for treating acne, rosacea and hyperpigmentation in skin of colour. SKIN FORUM Confirmed speakers and topics include: Chiza Westcarr: Inflammation and accelerated skin ageing (inflammaging) Dr Charlene de Haven: Ageing facts and myths; Pigmentation process of skin; Cancer treatments and the skin Professor Liudmila Korkina: Active ingredients of meristem plant cells for skin rejuvenation: myths and reality Professor Nick Lowe: The changing face of acne Elliot Isaacs: Topical anti-ageing cosmeceuticals Susan McNeece: Peels and pigmentation—how to make peels effective Dr Sandeep Cliff: Peeling to induce increased skin thickness Dr Rodrigo Arroyo Sanchez: Deep peeling—the science of TCA and phenol Dr Uliana Gout: Chemical peels workshop
HAIR Agenda The demand for effective nonsurgical and surgical treatment options for hair loss continues to grow, and newer technologies including the use of LED, PRP and hair transplant robots have encouraged more practitioners to consider incorporating a treatment service for this indication in their clinics. Dr Bessam Farjo, one of the UK’s leading hair transplant surgeons, will be chairing and lecturing alongside a panel of experts who will explore in depth the latest scientific data for the different potential treatment solutions available. If you’re already involved in this exciting market segment, or are looking to add this to your treatment menu, the HAIR agenda will provide you with the latest expert views and information on the effective treatment of hair loss that can be offered in a private clinic. THREADS Agenda The use of threads for face and body indications in the UK has exploded in the last few years following their launch in the late 1990s when prolene APTOS threads were invented by Russian Cosmetic Surgeon, Dr Marlen Salaminidze. Professor Bob Khanna, one of the UKs leading trainers on facial rejuvenation will be chairing and lecturing a special one day seminar dedicated to reviewing the latest scientific information, practical tips and expert views on avoiding
and managing complications in this dynamic section of the market. If you’re considering adding threads to your treatment menu, or if you would like to learn more about different types of threads and newer indications for their use, this agenda will provide you with access to the experts who have the answers.
SEXUAL AESTHETIC Agenda For the first time in the UK, FACE will host a dedicated Sexual Aesthetic Agenda on Sunday the 19th of June, chaired by Dr Sherif Wakil. Sexual rejuvenation is becoming one of the fastest growing areas in the aesthetics industry for men and women. This is due to the development of advanced technology and a variety of non-surgical treatments
22 FACE 2016 I body language
delegates to treat as well. For delegates to qualify and attend one of these courses, they must provide proof that they are a practicing Doctor, Dentist or Nurse.
The FACE 2016 Summer Reception will be held on June 18th at The Skyloft
that are available. The public have recently started to hear and see in various media publications the benefits of these treatments. Many clinics are now seeing patients actively seeking out solutions to intimate concerns that they once thought were untreatable or as the alternative to having a surgical procedure with considerable less downtime. Dr Wakil promises delegates a unique opportunity to hear from a hand selected elite team of speakers and practitioners from around the globe. They have been chosen for their outstanding contribution to these exciting procedures. Delegates will be able to discuss all of the subjects with the panel, who will cover the latest cutting edge topics in this field including PRP (O Shot and P Shot), threads, fillers, hormones and patient selection as well as training and marketing in these procedures. This agenda will be suitable for aesthetic practitioners who are already performing some of these treatments and are looking to advance on their knowledge or new practitioners interested in adding these life changing procedures into their clinics. All delegates will also be invited to watch a live demonstration of one of the latest vaginal rejuvenation machines on stage. This is an exciting opportunity for practitioners to be part of the latest advancements and procedures in sexual aesthetic medicine.
Dr Wakil has more than two decades of experience in the health care industry, and has performed more than 19,000 procedures. He has introduced a number of new treatments to the UK and Europe, including the P-Shot and the OShot (sexual rejuvenation with PRP) the vampire breast lift and the “soft surgery” concept. HANDS-ON Training New to FACE 2016 are Advanced Hands on Training Courses which will run for half a day and will consist of five to 10 delegates per session. The delegates will be led by one of our expert aesthetic practitioners and speakers from FACE 2016 and will be focussing on one particular area of facial aesthetics. Models will be provided for the
FACE Summer Reception Join speakers and peers for an evening of networking and socialising on Saturday June 18th, at The Skyloft—a unique venue providing in the sky, offering 360 degree views of London’s famous skyline. Tickets are £40 per person, and include beer, wine and soft drinks all night. There will be a snack bar at 23:00 offering late night snacks and food, and reserved Lounge Seating Areas for up to 10 guests for you and your company are also available with prices starting from just £500. FACE REWIND New to FACE 2016 is ‘FACE REWIND’. If as a delegate, you have missed certain talks throughout the Friday or Saturday sessions (because you simply cannot be in more than one lecture theatre at any given time), we will repeating highlighted lectures and presentations from the BODY, SKIN, THREADS and HAIR Agendas on the Sunday. For detailed agendas updated daily, or to register for FACE 2016, visit W: faceconference.com. An Early Bird discount applies if booking before March 31st. For more information, call 020 7514 5989.
QEII Centre, London I 16-19 June 2016
THE UK’S PREMIER MEDICAL AESTHETIC CONFERENCE & EXHIBITION
INJECTABLES AGENDA BODY AGENDA SEXUAL AESTHETICS SKIN AGENDA PRE-COURSE HAIR AGENDA BUSINESS AGENDA THREADS AGENDA WORKSHOPS
EARLY BIRD DISCOUNT Available until March 31st
We are delighted to invite you to join us at FACE 2016. Once again being held in the heart of London, FACE 2016 is on course to being the biggest and best conference to date. FACE 2016 sees the INJECTABLES, BODY, SKIN, HAIR and THREADS Agendas take place across three days, with some new additions: Live BUSINESS Agenda for all delegates and exhibitor representatives. Advanced Hands-On Training focusing on Injectable treatments. ‘FACE Rewind’ lecture programme repeating the most popular talks from the weekend which delegates might not have been able to see.
twitter.com/face_ltd facebook.com/faceltd W: FACECONFERENCE.COM T: 020 7514 5989 E: INFO@FACE-LTD.COM
24 TECHNIQUE I body language
Follicular harvest Expert DR BESSAM FARJO takes us to the root of hair transplant surgery
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wo types of hair transplant surgery exist today. The difference between them is the method of harvesting from the donor. FUE, which stands for follicular unit extraction, can either be done manually, mechanically,
or it can be automated and robotassisted. FUE involves extracting grafts or small units of hair individually using very small drill bits. The second more traditional technique, is the strip or follicular unit transplantation (FUT) technique, where a block of skin or graft is re-
moved from the back of the scalp and then it’s microscopically dissected into the individual grafts. FUE FUE uses punches that are between 0.7 and 1.2 mm in diameter. It can be done manually—the punch is
body language I TECHNIQUE 25
attached to a handle and can be manually spun. It’s very controlled, but very labour-intensive. It can also be done mechanically in the same way. In the majority of cases the back and sides of the scalp will need to be shaved for the surgery. The tiny round wounds will ultimately heal in the form of very small dot scars scattered amongst the hairs. The alternative to the manual spin, is to do it robotically. After reading the fiduciary readings or grid readings, a robotic arm automatically finds the grafts, while the surgeon manually oversees it, or manually controls it. The robot
has a camera system that detects the hairs, calculates angles, and calculates the appropriate depth to extract these grafts. The surgeon can look at a grid on a screen, watching the action on magnification. All the other readings on the screen are essentially various vari-
able parameters, from depth of the punch, to the angle of entry and so on. Essentially, it is a roboticallyassisted variation of follicular unit extraction. FUT Strip Harvesting In the FUT strip harvesting
66 Two types of hair transplant surgery exist today—follicular unit extraction (FUE) and follicular unit transplantation (FUT). The difference is the method of harvesting 99
26 TECHNIQUE I body language
2.
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1. A patient who’s had a robotic FUE procedure; immediately after the surgery on day one, a week later, and two weeks later. Healing is pretty fast and the scars are reasonably undetectable. 2. A strip harvesting. 3. Part of a strip that’s removed. 4. The trichophytic closure, forcing hairs to grow through the incision line. 5. Scars from strips. 6. A magnified dissection of the strip. Dissection of the strip cutting into a plane, produces these slivers. Slivers are one individual follicular unit wide, carefully doing that under the stereoscopic microscope.
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method, a narrow but long strip is removed from the back of the scalp. The patient has a wound that’s either sutured or stapled. Then the harvested strip is microscopically dissected into the individual grafts. Usually this procedure needs a bigger team and a more elaborate, more involved set-up. For strip harvesting, the area is marked and only the part that needs to be removed is shaved. The strip is removed, carefully dissecting in the subcutaneous fat, preserving the roots. This technique relies on the scalp being reasonably elastic. A trichophytic closure could be used, where epidermis is removed from one edge, to be overlapped by the other edge in order to force hairs to grow through the cut—to further disguise the obvious linear scar that the patient will end up with as a result of this surgery. Obviously, the hair will cover it up either way. Once the strip has been removed, a technical team prepares
6.
the strip into individual grafts, dissecting in two different planes under dissecting stereoscopes. The result is grafts that would have otherwise been obtained directly using the FUE method. After slivers are produced in one plane (see fig 6) any excess of fat is trimmed and then and dissection is carried out in the opposite
plane and the individual groupings separated. Sometimes there are two hairs, three hairs, or even one hair, and sometimes four or five hairs. The idea is to preserve them the way they are, minimising the amount of tissue there, so that the transplant is mainly hairs, rather than skin.
ADVANTAGES AND DISADVANTAGES OF THE STRIP FUT METHOD Advantages Less time-consuming for the surgeon and therefore cheaper for the patient. A higher number of grafts in the one sitting is achievable quite quickly. Only a small amount of shaving is necessary, so the patient can comb the hair down and hide what they’ve had done. The view of the hairs is much clearer, because the dissecting is taken place outside the body, on the microscopes. Disadvantages The patient will end up with a linear scar running across the back of the head. With an extremely short haircut, the scar may be visible. More moderate post-op pain because there’s a wound at the back. If somebody doesn’t have elastic enough scalp, then you cannot remove enough tissue.
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Influences on procedure choice I recommend a strip-type operation over the FUE if the patient is unwilling to have the back of their head shaved. In order to drill the hairs out in the FUE method, the hairs need to be shaved to a grade one. If a patient is unwilling to shave the entire back of their head, we cannot do enough work. For those unwilling to shave their head, the strip gives them an alternative way for this operation to be done. If the donor area at the back is of limited size and only the very centre of that area can be utilised, then it’s a good way of getting high numbers of grafts. Perhaps the patient has a financial issue and this operation is cheaper. The strip is popular in women, because although the FUE procedure is possible, the patient has to grow the hair long to hide the shaved bit. Most women in my experience, would be unwilling to have their head shaved for this operation and they would be happier with this strip method. Who chooses FUE procedure? Some patients have a preference for FUE because they’ve read about it and this is the way they prefer to have it done. I may recommend it because of their hair character—
people with hair that is spiky and coarse in nature or where the hair comes out at obtuse angles, no matter how long they keep their hair, the scar will always be at risk of being visible with a shorter cut and therefore FUE is a more suitable operation. It also appeals to men who like to have their hair short or cropped all the time. If the patient has a history of unattractive looking scars, it’s advisable to avoid giving them a linear scar. FUE is also preferable if the patient has a tight scalp. Young men, with an uncertain future of hair loss, may wish to have the option to have their hair short and they may not necessarily need to have further transplants in the future. FUE gives them that option and that freedom. Implanting Regardless of the method of harvesting these grafts need implanting. Once harvesting has been done, what follows after that is the same; whether you’re doing the strip method or the FUE. Most practices, like to create implant incisions first. These are recipient sites that are going to receive the grafts. They can be made with blades or hypodermic needles of a variety of sizes—controlling angles and controlling direction—
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ADVANTAGES AND DISADVANTAGES OF FUE Advantages When the grafts are removed individually the patient will not end up with a line scar. The scars are tiny, little dots scattered over the entire head and they’re much more subtle. Not linear wound at the back, means minimal post-op pain Patients don’t use any painkillers after the operation. Scalp elasticity is not an issue in FUE. It doesn’t matter if the scalp is tight. There’s less donor dissection and preparation involved and therefore the technicians tend to play a smaller role. Disadvantages More time-consuming and therefore more expensive. Many foreign countries are marketing FUE in medical tourism and doing this kind of operation very cheaply. However, costs are saved by using lower paid, non-medical personnel, which is likely unsafe. Because the grafts spread over the entire head, you may end up with a lesser number of grafts that’s obtainable per session. A large operation may take two consecutive days. Because dissecting into the tissue is done blind, there’s probably a higher rate of transection of the hairs and potential damage.
that will then be followed by inserting the grafts. It’s important to test these grafts to see if the incisions made are of suitable size. If they’re not of suitable size, after about ten or 20, the size of that blade can be made smaller or larger as needed. Since some of the grafts have one hair, some of them have two, three or four, they should be replanted in specific locations where deem most suitable. For work on somebody’s hairline, it’s best to put single hairs first, followed by dou-
7. Positioning depends on number of hairs in the graft. 8. A feathered front hairline. 9. A graft being placed. 10. The incisions made before placing any hairs.
30 TECHNIQUE I body language
ble hairs on the hairline, and threeand four-haired grafts further back. When working on the crown, this many change to three and four-hair grafts near the top and middle of the crown and double hairs near the lower part and the whorl. It’s possible to create incisions at different angles and in different ways so that you can simulate the growth of the hair in the natural direction. In contrast to the dense areas further back, it’s important to keep hairlines looking natural and feathery in order to simulate a natural hairline. A transplant will not look natural if the hair follows a line that’s too straight or a line that’s too thick. The angle is also
important in order to avoid planting hair that grows straight up or growing in the wrong direction. When inserting a graft, a variety of tools and forceps can be used to insert. Smooth forceps cause the least damage to the graft. The biggest problem with the grafts is that they can easily get dehydrated and the most likely cause of damage to the grafts is dehydration. Different zones of the scalp have different importance. At the hairline, it’s important to pay attention to the part line where the patient going to lose further hair, so that if they do lose hair, that edge look feathery to simulate natural hair loss. At the very back, if the pa-
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tient has been left with a bald area behind, it’s important to feather it out so it looks like they’re balding naturally, rather than having a sudden partition line. Transplanting for women There are important considerations when it comes to women. Women can have hair transplant surgery by either method, but it’s important to remember, women have a more diffuse pattern of loss behind the hairline. Very rarely do women go completely bald, so it’s necessary to work amongst the existing hairs and pay much more attention to avoid trauma to these hairs. On initial consultation it’s vi-
11. This patient had multiple surgeries to correct trauma after a road accident—FUE was the operation of choice. 11a. It’s difficult to see any evidence of the surgery. 12. This patient has had 2,684 grafts done and this is his result 18 months later. 12a. This shows what his scar looks like when the hair is combed upwards. 13. This patient received FUE using the ARTAS robot. 14. The feathered hairline of a patient with 3,500 grafts, and the scarring.
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32 TECHNIQUE I body language
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tal to exclude various conditions, when determining why the hair is being lost. Only when you actually establish that the loss is actually female pattern hair loss is surgery the answer. Women tend to be thinner on the parietal areas. The good donor area tends to be restricted to the very back, so harvesting sites are more limited in numbers. For some reason, women have tighter scalps, which means it may be necessary to remove a thinner piece, or perhaps do FUE. It’s essential to warn women that because you’re working amongst existing hair, it’s possible they may get traumatic loss because of the surgery. So they may end up with a worse situation a month or two after surgery, before their hair grows back and the result of the transplant comes through. Another area that can be treated, especially in women, is patients with a naturally high hairline. Care is needed if a man asks for intervention at the hairline, because obviously a man is more likely to lose hair through androgenetic alopecia in the future. A woman who has a naturally high hairline and no evidence of female pattern hair loss, could achieve a lower hairline with a hair transplant. A hairline lowering or forehead reduction procedure could do that as well, but that gives a scar around the hairline, which can then easily be disguised with a hair transplant procedure. Other applications of hair transplant surgery For eyebrows, transplants work extremely well. A lot more attention
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to the angles and growth direction is needed and it’s also necessary to warn patients that the hair is taken from the scalp and therefore the hair will grow like scalp hair— they need to trim their eyebrows possibly every week, maybe every two weeks. As yet, I’m yet to treat a patient who thought that was a problem. This isn’t just a solution for over-plucking, it’s possible that as a result of trauma or burns, this kind of procedure could also be called for. The same principle can be applied to beards. I recently treated a patient who had a trauma to the chin area as well as the beard on the side from a dog bite. I often get asked if transplanted hair can grow very well in scar tissue, if certain precautions are taken. Obviously not all scars are the same, but in general, it responds reasonably well. In face-lift surgery patients, hair can be lost in front of the ear if the lift was a bit aggressive, where it’s also possible that a scar becomes exposed. These are both things that can be tackled with hair transplantation. Triangular alopecia, congenital areas of loss like that, usually on one side, can be treated perfectly with hair transplantation. Traction alopecia, much more common in Afro-Caribbean women, also can be treated. Sometimes it can require two operations but it can work reasonably well as well. Patients who have had radiotherapy and the hair was lost and did not grow back can be treated similarly. Caution is needed in cases of scarring alopecia, or cicatricial alopecia like lichen planopilaris.
It’s vital to ensure that the condition is dormant on biopsy and certainly, clinically, for a minimum, of two or three years. Patients must be warned that the condition can come back and if it does, then the hair will possibly fall out. There are certain conditions for which a transplant is not probably a good idea, like lupus and frontal fibrosing alopecia. Success is extremely variable with those kind of conditions. Summary Today’s hair transplant surgery offers alternative techniques to suit different stages of hair loss and different desired hairstyles and lifestyles in healthy men and women. All round skill and expertise by the surgeon offers the patient the solution that is in their best interest. Dr Bessam Farjo is a fellow of the International College of Surgeons (FICS); A Diplomate and Past Board Director of the American Board of Hair Restoration Surgery (ABHRS); Past President, Ambassador & Fellow of the International Society of Hair Restoration Surgery (ISHRS); Founder Member and Past President of the British Association of Hair Restoration Surgery (BAHRS); Fellow and Medical Director of the Institute of Trichologists and Founder Member of the Trichological Society. He has numerous hair-related peer reviewed publications and has clinics in London & Manchester exclusively dedicated to medical & surgical hair restoration. Joint recipient of the 2012 ISHRS Platinum Follicle Award for ‘outstanding contribution to hair research’.
15. A patient who had a mild area of hair loss right behind her hairline, before and after her hair transplant surgery. 16. This patient was treated nearly 20 years ago. He burnt his face as a child, and had skin grafts from his thighs on his face. Grafts were taken from the back of his head and built his beard. He only had a small moustache area in the middle, otherwise he couldn’t grow hair anywhere else. Transplant enabled him to grow a beard and not be conscious about the appearance of his face.
body language I PROMOTION 33
Automatic artifical hair implant The new automatic artificial hair implant offers an alternative or complement to other treatments. DR MANAL SHETA explains the product and the procedure
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he problem of alopecia affects both sexes and all ages with sometimes significant psychological sequelae. Along with androgenetic alopecia, there are forms of alopecia of various origin: traumatic, surgical, pharmacological and others. Along with the main surgical techniques for solving the problem of baldness, today the automatic implant of biocompatible fibres is available. Treatment The Biofibre automatic hair implant procedure is not in competition with any other hair restoration technique, but it is good alternative or complementary treatment for the patients. It is a soft surgery technique which is performed under local anaesthesia by an innovative automatic device that enables an immediate aesthetic result without pain, scars or hospitalisation. This modern technique is indicated to treat diffuse hair loss or hair thinning both for men and for women at any baldness stage. Biofibre automatic hair implant is suitable for patients with a healthy scalp but poor donor area. It is also ideal for patients who cannot shave their head or who cannot wait a shaved head to regrow after the FUE or FUT medical transplant, where immediate result are required. It can also be used if needed to increase volume of a patients hair following normal hair transplant procedure.
Biocompatible fibres The Biofibre hair meets all the biocompatibility and safety requirements established by international standards for medical devices. It is available in 21 colours, with different lengths—15, 30 or 45 centimetres and in various shapes— straight, wavy, curly and afro. It is also available in the new high density version of Biofibre that allows each implant to have three hairs. That fibre is used for crown area only, meanwhile for the front line a single Biofibre is suggested. Advantages Using the Biofibre Implant offers high hair density within a very short time, with natural aesthetic result and the related physiological and physical wellness for the patient. The implant is a simple and virtually painless outpatient procedure, which it is safe for the patients because it uses biocompatible material. The use of this technique allows the patient to lead an active lifestyle even soon after the implant procedure. The artificial hair also will not age, and will not turn whiter. Disadvantages One disadvantage of this technique is that it requires patients to have suitable hygiene of the scalp and aftercare, so we have to select patients. The treatment is not recommended for patients suffering from scalp diseases or infections like psoriasis, certain types of der-
matitis and some autoimmune diseases like lupus. Additionally small yearly implant sessions are needed to maintain the results. Post-procedure Immediate post-implant requires use of betadine and saline spray by the patient alternatively for three days, and to wash using ketaconazole shampoo. Antibiotics systemic coverage is recommended for one week after implant and LED application or laser hair combs are useful to maintain a healthy scalp. Dr Manal Sheta is an Egyptian Cosmetic and Dermatological Physician specialising in hair restoration and aesthetic laser surgeries. She is the owner of Al-Mansour Hospital in Kuwait city, and trains physicians on the Biofibre hair implant and surgical threads
Use of artificial hair implants can be an alternative treatment for male and female baldness
34 HAIR LOSS I body language
More than just hair JACKIE TOMLINSON, trustee at charity Alopecia UK talks about alopecia awareness
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air is ingrained within aesthetics in our society. Hair is a conversation starter and the first thing you notice just before you look at someone’s face or body. We judge people by their hairstyle; by their hair colour and the amount of product used or not used. Throughout history, people have made hair and it’s styling an important method of not only indicating status, but making religious and social statements about themselves and others. Opinions are formed concerning a person’s health, wealth, social status, beauty and sexual desirability. A full head of luxurious beautiful hair smooth and silky hair is marketed as sexuality – the adverts on TV tell us this several times during a commercial break. Whilst outrageous
hair styles are often perceived as overtly conveying a message of non-conformity or having a big personality. What is alopecia? Alopecia is the medical terminology for hair loss and there are many different types that are either scarring and non scarring. For example, the autoimmune disease alopecia areata is termed as non scarring, as the hair follicle bulb is intact, and means localised areas of hair loss usually presenting as patches. Alopecia areata has subgroup classifications: Totalis, the loss of hair on the head, Universalis, total loss of all head and body hair and Barbae, patchy loss of hair from the beard. Alopecia areata affects men, women and children, all ethnicities and can happen at any age.
The function of hair The primary function of the hair is to insulate the human body, which it does in two ways. Hair serves as a physical barrier between external cold air and the skin, and also traps warm air between the skin and the hair keeping the body warmer. Hair on the head guards the scalp from injury and offers some protection from the UV rays. It also decreases heat loss from the scalp. Eyelashes protect the eyes from foreign particles, as does the external ear canal hair. Nose hair filters away small particles and pollen, and helps to regulate temperature of inhaled hair. Eyebrows help to divert sweat away from the eyes and also aid non-verbal communication. Hair also serves as a buffer against friction, and is one of the reasons why it is present in the places which we all work so hard
body language I HAIR LOSS 35
to remove—on the legs, genitals and underarms. It soaks up sweat for easy evaporation so that sweat is not stuck to the body during physical activity. Touch receptors associated with the hair follicle are activated whenever they are lightly touched and serve as a function in sensing touch. Disease causes In my experience many individuals dealing with alopecia areata do not want to acknowledge that they have a skin disease, but it is abnormal pathophysiology. Multifactorial triggers are cited from inflammatory stress response, autoimmune response, genetics, immunisation, environment, diet and lifestyle. The scientific community continues to research the causes from the release of neuropeptides by the follicular nerve, T lymphocytes, cytokine-related genes, hypoxic signalling, genetic versus immunology. More recently, genetic laboratory re-testing is finding a strong association on chromosome six and the CTLA4 gene, that links with other autoimmune diseases like type one diabetes, rheumatoid arthritis, psoriasis, multiple sclerosis and coeliac disease. Research into treatment Although researchers are slowly finding the answers and developing new treatments for all types of hair loss in the long term, research by its nature is slow and there is a distinct lack of funding for all types of hair loss research. There is no shortage of research questions to answer but there is a shortage of funds and researchers. Within the UK, there are only a small group of clinicians and researchers who are dedicated to answering the complexities of the hair follicle. What can be done in the short term? Do we eat this or avoid that or how about rubbing on some of this product that is guaranteed? If only it was that simple otherwise more of us would have regrown our hair, or sustained our hair regrowth. Psychosocial affects As with other physically visible conditions, the emotional distress
ALOPECIA UK Jackie Tomlinson discusses Alopecia UK Alopecia UK is a charity with a vision to improve the lives of those with alopecia with aims focused on support, awareness and research. The charity started in 2004 when, there was a real lack of information available in the public domain and on the Internet. In the past decade there has been a huge change in internet and social media, there is a wealth of information available at our fingertips now and a challenge of knowing who and what to trust and what treatments to believe. How did you start? The charity’s growth and direction is a direct result of the people who have contacted us for advice and support. It has not been easy over the past ten years and until recently the charity was solely voluntarily led. At times it has been a struggle with just a handful of volunteers working for us on top of their full-time jobs, families, the demands of life – and also dealing with their own hair loss issues. The more we do, the more awareness it raises and, in turn, the more resources we need to provide support and improve services to individuals. I personally have a type of hair loss called alopecia universalis and have no hair on my head or body. I lost my hair 15 years ago and it has made very little attempt to regrow. I have volunteered for the charity for 7 years as a Trustee and help with the governance side of the charity, as well as, raising awareness within different industry sectors, healthcare professionals and researchers. What does the charity offer? Although the main focus of Alopecia UK is alopecia areata, the charity also provides insight and support to people with androgenetic alopecia and scarring forms too, as the psychological and social stigma issues are very much the same. We are a passionate group taking on all sorts of challenges to raise awareness. Alopecia UK may be a charity, but it also offers a community. At our last event, many speakers gave talks about the research and medical side of alopecia, which we think is really important for the future, but we believe that the community is just as important. Events are a chance not only for social interaction but to also share information about hair systems or how to tie a head-scarf or discuss coping methods. We also bring groups of people together to provide support in a fun and positive normal way and do activities that people with hair loss would typically avoid such as swimming, sports and or visiting theme parks. We find that when individuals access their GP or dermatologist, how the healthcare professional interacts on an interpersonal level makes a big difference when there are no treatments or when the treatments that are offered have not worked. If we can raise awareness of alopecia with healthcare professionals it can make a huge difference, as many are dismissive with a ‘it’s just hair’ attitude. I personally want to raise awareness about respecting the psychosocial aspect of hair because it is so much more than ‘just hair’.
36 HAIR LOSS I body language
SCARED The acronym SCARED can be used to develop awareness of how someone may react. They may feel: Self-conscious Conspicuous Angry Rejected Embarrassed or Different. They may behave in a: Shy Cautious Aggressive Retreating Evasive and Defensive in manner. This model is taken from our friends at Changing Faces on providing counsel to others.
of dealing with an altered body image can affect personal, social and work-life balance. The ability to cope will depend on an individual’s coping mechanism and social support. Those who struggle will find themselves at a higher risk of depression, social phobia and anxiety disorders. Quotes from Alopecia UK discussion forum demonstrate this: “I had a total breakdown when I was in my 30s, I would not leave the house and it cost me my job and my marriage.” “I have been job hunting but have been turned away for several jobs and been told sorry you are not suitable because your condition.” “The way you look is not an image we wish to portray“ Those words sent me into a very dark depressing time...” “It’s difficult, frustrating and makes you feel powerless and depressed.” “I’ve spent most of my life crying.” This highlights a real need for greater awareness about hair loss and the devastation it brings as well as to challenge societal norms. If left unchecked, it can affect people’s marriages and their jobs. We see this daily with people contacting the charity, as hair loss can lead to emotional distress and an altered body image. The harsh words of others said in ignorance or jest,
or on purpose, especially when directed at children and young people, can be particularly damaging and can evoke severe psychological distress, low self-esteem and poor body image. For children with alopecia, activities such as sport that were once part of day-to-day life become something that are avoided. The management of the hair loss can be more challenging than the activity itself. Children also fear that their hair loss will be exposed, or be subjected to teasing or bullying and this can lead to problems with the development of their self-identity and also their body image. This, in turn, can lead to poor mental health and a decline in their wellbeing. Taking part in normal activities, regardless of age, from sports or eating out, to jam making or shopping with friends encourages the development of self-esteem, confidence and a better self-image, which is the essential component for healthy, happy adults and children. Coping strategies Hair systems and wigs are a good coping strategy but they range from £50 to £5,000 upwards and depends on the type of synthetic material or the quality and the ethical sourcing of human hair to how the cap is constructed. For many, avoidance is easier than social participation—as many people do not feel at ease discussing or disclosing. A fear of social interaction and exposing your medical condition fits with a fear avoidance hypothesis that determines how a person will cope. This is based on five aspects: • life events • personality • history of change experienced up until that point • coping strategies and a fear of a changed body and/or the reaction of others It is usually the last point that is the hardest one to manage. Limited options We need to be honest, empathetic, and acknowledge people’s
thoughts and feelings and explain that it’s normal to hide away and conceal hair loss. Encouraging people to talk to others with the same experience may also help with the practical advice and help them cope with other people’s reactions, for example, like building up an internal question and answer bank. However, even I get caught out every now and then— most recently, at my dentist, who has never known me with hair for the past 12 years asked if my cancer treatment had permanently damaged my hair? Understandably there is an awkwardness that follows, but this encourages me to raise awareness and to challenge societal norms, to promote dignity, respect and equality. A great deal of awkwardness could be lifted if someone said, “do you have cancer or alopecia?” If we can educate and raise awareness together this all is possible. Future goals for the charity are to have access to psychological services and equal wig provision. Unfortunately, getting past a clinical commissioning group for a human hair wig for a child or an adult in some parts of the UK is impossible. Lastly of course, we need more research, as well as funding to develop the range of support that we offer, because the community deserves more people working on this full-time. Jackie Tomlinson is a Trustee for Alopecia UK and Dermatology Nurse at Cambridge University Teaching Hospital NHS Foundation Trust. W: alopecia.org.uk References 1. MacFarlane, M 1993: The Complete Guide to Growing new hair. Carnell Limited. 2. Picardi, et al., 2003: Psychosomatic factors in firstonset alopecia areata; Psychosomatics. 2003 SepOct;44(5):374-81. 3. Hunt, N. & McHale, S. (2005b): Reported experiences of persons with alopecia areata. Journal of Loss and Trauma, 10, 33–50. 4. Cartwright, et al., 2008: Illness Perceptions, Coping and Quality of Life in Patients with Alopecia. The British Journal of Dermatology. 2009;160(5):1034–1039. 5. Regan & Chambers 2014: Alopecia uncovered. Blurb.
body language I PROMOTION 37
IMCAS 2016 We reflect on the resounding success of IMCAS Annual World Congress 2016, and look forward to the exciting contribution IMCAS Asia and India will offer the ever-evolving medical aesthetic world later this year
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he medical aesthetic industry has now become accustomed to beginning its year with the annual IMCAS World Congress in Paris. As well as being the first event in the 2016 medical aesthetic calendar, the 6,500 attendees, 520 speakers, 180 exhibitors and 140 scientific sessions also made the January World Congress what is likely to be the biggest industry gathering of the year to come. This year’s scientific programme confirmed IMCAS’ reputation for providing a truly diverse approach to learning in the field, with sessions ranging from professional business and industry insights to plastic surgery and clinical dermatology. Attendees could also take advantage of manufacturers’ symposia and an extensive exhibition of products. Now in its 18th year since its conception IMCAS now receives delegates from no less than 85 countries across the world. This kind of international reputation and attendance has only been achieved by providing tailored content that is as diverse as this global medical community and the patients they treat. This year IMCAS gave special attention to the specific issues pertinent to aesthetic medical practice in three chosen regions: the Middle East, Eastern Europe and China. Representing three of the biggest consumer markets in the industry, it is now essential to provide bespoke learning opportunities for delegates working in these regions. Across each day attendees were able to benefit from sessions on topics such as pigmentation and vascular disorders, aging particularities and a comparison in lasers and EBD in China and Europe. This recognition of the diversity of global hu-
man morphology and the need for equally diverse approaches to medical aesthetic procedures is what makes IMCAS a truly standout learning event. The demand for male procedures has also shown a large rise according to the American Society of Plastic Surgeons, increasing by more than 70 percent since 2000. To reflect this, IMCAS dedicated several sessions to male treatments. Topics were tailored to male patients across the program, including sessions on the biological specificities of male skin, penile surgery and the male mind. The Minimally-Invasive Cadaver Workshop was the opening session of the congress and has now become IMCAS’ signature event, drawing in physicians each year for a unique insight into anatomy, procedures and techniques that remains without comparison. Delegates flocked to all sessions in the eight-hour workshop for the opportunity to see live procedures performed in tandem on patients and cadavers, transmitted via satellite link from the world-renowned Fer à Moulin Surgery School of Paris. As well as showcasing expert knowledge and groundbreaking research each year, the IMCAS World Congress also provides a stage for the industry’s foremost business experts to evaluate the market from an economic standpoint. This year’s World Industry Tribune panel revealed that the growth of the medical aesthetic market shows no sign of slowing down, estimating that its value will increase at a rate of 8.9 percent annually to reach €10.49 billion by 2020. Keeping its gaze fixed firmly on the future of this growing industry, the Paris World Congress also saw the IMCAS Beyond series take place for the second time. Each
66 This year’s scientific programme confirmed IMCAS’ reputation for providing a truly diverse approach to learning 99 lunchtime delegates were given the opportunity to listen to industry experts discuss the relationship between digital technology and the medical aesthetic world. David Blair, Head of Industry for Health at Google and Tom Seery, CEO of RealSelf.com, brought their expertise to the fore in a discussion on how the latest innovations can be harnessed to bring patients and doctors, consumers and brands closer together. It was fitting that this 2016 World Congress, with its topical focus on technology in the industry, also saw the launch of an e-learning platform designed specifically for plastic surgeons and dermatologists: IMCAS Academy. Subscribers can now access all IMCAS content online, making it easier to browse lectures, refresh skills and read abstracts than ever before. The platform breathes life into learning: as each congress passes, the IMCAS Academy will expand to create an unrivalled learning platform for medical professionals in the field. Having achieved such success and innovation at this early stage of the year, you would be forgiven for thinking that IMCAS may stay quiet until its next World Congress. However, due to journey to Taiwan and India later this year, it is certain that IMCAS is set to make even more exciting contributions to the medical aesthetic world in 2016.
38 MEDICAL AESTHETICS I body language
Electrical permanent hair removal DR CATHERINE DE GOURSAC explores how permanent hair removal using electricity has evolved over the last 140 years.
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he removal of superfluous hair by the electrolytic action of galvanic current began in 1875 when Dr Charles E Michel of St Louis Missouri, re-
ported his findings to the medical profession. Galvanic electrolysis is basically a chemical process, the substance that is formed in the follicle, is sodium hydroxide (lye). This highly caustic procedure is an
effective way to destroy hair, however the needle must remain in the follicle for three to 20 seconds depending on hair thickness. Finding this modality too slow, Paul Kree, from New York,
body language I MEDICAL AESTHETICS 39
The removal of superfluous hair by the electrolytic action of galvanic current began in 1875
developed the “multiple-needle technique” in 1916. However, this technique is no longer used. During the twenties, Dr Henri Bordier from Lyon France, developed a new method of permanent epilation using RF (radio frequency). This new method promised greater speed and better results over the galvanic method. The system became popular during the 1940’s. Blending techniques The evolution of electrolysis produced the “blend” technique : Henri E St Pierre of San Francisco—a pioneer in electrolysis—uses both galvanic and radio frequency for permanent hair destruction. For difficult cases, such as coarse hair or distorted follicles, he uses a galvanic unit and when needed, a short wave unit for
work rapidly. His desire for combining the efficiency of the galvanic, with the speed of the high frequency method led him to investigating the possibility of blending both at the same time. The “blend’’ technique was born. It was at this time that Arthur Hinkle, a service engineer for the General Electric X-Ray Corporation in collaboration with St Pierre, began work on superimposing the two currents. Their first unit was called “Electro-Blend”. These older techniques were efficient however very painful. The latest innovation in the development of permanent hair removal—“vectorial’’ technology —consists of modulated sequences that vary current intensities and time while the probe is inside the
follicle. These modulations increase energy sent to the follicle while decreasing pain. This technology deceives pain receptors by sending, for a very short duration, a very high intensity burst to the follicle, followed by downward cascading modulations that eradicate all hair growing cells. These modulations can be used with Thermolysis and combined techniques. Permanent electrical epilation For over 20 years, hair removal, using laser and intense pulsed light (IPL) has continued to improve and satisfy both users and patients. Laser and IPL destroy pigmented hair in the anagen phase including hair that is not yet visible. Electrical permanent epilation
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body language I MEDICAL AESTHETICS 41
66 Electrical permanent epilation consists of inserting a fine disposable needle-shaped probe inside the hair canal to precisely catheterise the pilo-sebaceous follicle 99 destroys hair in the anagen phase regardless of its colour It enables: • Treating hair not suited for laser IPL: (red, white, grey or very fine hair). • Treatment when laser/IPL is contraindicated. • Completion of laser/IPL treatments: treats stubborn regrowth. • Treatment of light or white hairs and darker skin. • Correction of paradoxical hair growth problems. • Treating areas contraindicated for laser or IPL. • Treating all body areas, skin colour, hair, hair sizes and shape, men or women. • Reduction of post treatment problems and precautions (sun exposure). Electrical permanent epilation consists of inserting a fine disposable needle shaped probe inside the hair canal to precisely catheterise the pilo-sebaceous follicle, without piercing it, without bleeding, and without pain. The hair guides probe insertion. The objective is to obtain selective coagulation of the pilo-sebaceous follicle by using low frequency vectorial modulations while avoiding damaging surrounding tissues. The treated hair is removed without any resistance by using small forceps. This technique ensures complete destruction of the hair growing cells located in the dermal papilla and in the bulge. Since hairs must be treated individually, this technique is preferred for treating smaller areas and stubborn regrowth. Galvanic current When electrical permanent epilation is carried out using galvanic current (direct current), it is applied to tissue using 0.7 mA inten-
sity. An electrochemical action is induced producing destructive lye. It has long been understood that the application of direct electrical current to a solution of salt water produces a reaction causing salt and water to break into their constituent parts. These parts quickly rearrange themselves to form an entirely new substance, sodium hydroxide (lye), hydrogen and chloric gas. The newly manufactured lye remains in the follicle a few seconds, causing a chemical decomposition of the hair growing cells in the papilla and germinative tissue in the bulge. Used alone, this technique is very slow and time consuming (requiring about 20 seconds for a medium size hair) as well as painful. Therefore, this method is no longer used.
A galvanic current does not generate any heat. Thermolysis or thermocoagulation current Thermolysis—also called thermocoagulation method—uses a highfrequency current (13.56 MHz is the frequency mostly used by manufacturers), constantly changing polarity to generate heat and destroy the hair follicle by electrocoagulation. During thermolysis procedures, high frequency radio energy is emitted (mostly) from the tip of the needle probe, inserted into the hair follicle. The high frequency energy vibrates hair growing cell molecules. This energy field pushes and pull electrons back and forth, creating heat through vibration, to the level of permanent tissue destruction. This destruction is referred to as electrocoagulation. The needle probe remains cold Tissue protein inside the follicle coagulates, dries out and is destroyed During thermolysis, two techniques are used according to hair size: 1. Thermo-Coagulation • Slower technique- 4/10th to 2
Permanent electrical epilation can be used on areas contraindicated for laser or IPL treatment
42 MEDICAL AESTHETICS I body language
1/100th to 9/100th of a second. • Tissue temperature: 100 C. • Intensity: high to very high. • Efficient for fine and very fine hair.
Different factors influence hair regrowth The operator: • Using the wrong technique. • Inaccurate insertion, not following the angle and direction of the hair. • Wrong estimation of follicle depth , too deep or too shallow. • Inaccurate positioning of the probe (needle). Choice of treatment parameters: • Insufficient power, electrical current too weak. • Insufficient timing, current duration too short. Treatment difficulty • Distorted hair or follicles, difficult to destroy because of previous temporary depilation mode. • Hair not treated in Anagen stage. • Considerable keratin deposit in the follicle. Regrowth is generally atrophied, very fine, very weak or depigmented What appears to be hair regrowth: • Hair that was not treated due to lack of maturity. • Lanugo becoming terminal hair for various reasons (hormonal, medications etc).
seconds. • Tissue temperature: 53 C • Intensity: low to medium. • Efficient for medium to coarse hair. 2. Thermo-Desiccation • Rapid technique—flash technique: 1/10th to 2/10th of a second—super flash technique
Blend technology The blend technique is a combination and simultaneous use of galvanic and thermolysis techniques. This combination method alleviates the shortcomings of each technique, while bolstering its advantages. Minimum time is required to produce reaction in the follicle. The high frequency current increases the efficacy of the galvanic lye production. The caustic effect is increased by heating lye. The advantages of both technologies results from the union of both currents. With new technologies, it is not necessary to use blend technique when working on fine, very fine and medium size hair. The blend technique is useful when working on coarse and very coarse hair as well as distorted or curved follicles, stubborn regrowth and white hair. Vectorial technology This technique deceives pain perception by first applying a very high intensity impulsion in an excessively short time. The following impulsions are modulated in a vectorial pattern using a decreasing current intensity to destroy germinative hair growing cells. The current shape and strength supports the highly effective use of 6.78 megahertz. This method is used with thermolysis techniques (thermo-coagulation and thermo-desiccation) or with combined modulated currents (blend). Vectorial technology is very effective with blend, enabling use of stronger intensities while reducing duration and pain detection (treatment is therefore more comfortable). The 6.78 MHz frequency optimises current stability, safety, efficiency, and ease of use. Focused frequencies The most used frequency for permanent hair removal is 13.56
MHz, a reasonable choice considering high frequency at high levels, experiences an altered HF signal, sacrificing stability and results. The needle holder cable is similar to an antenna with energy waves concentrating on the needle tip (peak effect). The cable needs to be insulated and calibrated (according to length and resistivity). That is why lower frequencies (6.78MHz) are preferred. Probes Different probes (needles) with different lengths and diameters are available (from one to five—one being the smallest and five the biggest): • Insulated (for thermolysis technique). • Non-insulated (for blend/combined currents). Their size and shape will influence the electrical current flow and precision of insertion. Probes are chosen according to depth and coarseness of the hair. (length and diameter). Non-insulated needles are used with the blend technique to ensure sufficient lye production in the follicle, along the entire probe. Once treated, hair is removed from the follicle, without any resistance using forceps (or tweezers). To ensure safe depilation during treatment, never treat hairs closer than 3mm to each other. Hair growing cycles The hair follicle has intermittent activity. It produces an abundance of keratin within a few months or years, eliminating and renewing it after a certain period (cyclic activity proper to different areas) Histologists divide the growth cycle into three stages : anagen (period of active growth), catagen (retrograde morphogenic transformation) and telogen (period of rest). Hair on the body renews itself through cycles. All hairs have their own cycles, shedding and replacing regularly. Old hairs in the telogen stage are replaced by new hairs in the anagen stage. Many successive hair stages co-exist. The hair growth cycle varies from six months (for upper lips) to six years (for the scalp).
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Available Nationwide Visit radara.co.uk to find your nearest stockist. * 8-week trial, independently assessed by clinical dermatologists. Data on File, Innoture Medical Technology Ltd.
44 MEDICAL AESTHETICS I body language
Treatment is performed the following way • Sanitise the area to be treated. • Identify hair to be removed first (the ones most apparent). • Choose technique and select appropriate probe. • Setting intensity and current duration. • Holding skin taught. • Selecting a follicle and verifying correct angle for insertion. • Inserting probe, activating current, removing probe. • Adjusting current if necessary (intensity and duration). • Using forceps to remove treated hair, it should slide out effortlessly. • Repeat insertion procedure on different follicles as needed taking into consideration patient tolerance and areas to be treated. • Sanitise treated areas. • Consider using Cataphoresis with a healing gel (calming, anti-inflammatory, germicidal, vasoconstrictor properties or penetration of positively charged products).
Within a same location, mosaic in nature, several hair growth cycles co-exist. This is why several sessions, at regular intervals, are needed to treat different areas. Electrical permanent depilation of a complete area can take up to two years (one year actual plus one year maintenance treatments) according to: • Patient age. • Methods used for previous hair removal. • Hair growth, when hair first appears (hair growth cycle activity). • Time between sessions (regular appointments). • Duration of each session (patient tolerance and sensitivity), number of treated hairs (between 800 to 1500 hairs per hour for experienced electrologists). Treatments performed during the anagen stage, are more successful. Hair regrowth Following treatment hair regrowth varies between patients. It can reach up to 30% when using high frequency currents (thermolysis), and 20% when using combined currents (blend). New hair, depending on the patient, is more or less rapidly, in constant development. This may leave the impression that treatment is not permanent, so explaining the causes of hair regrowth reassures the patient of professional competence. It is necessary to treat regrowth the usual way and to schedule regular maintenance sessions. Factors which influence treat-
ment results include how regular the treatment schedule is, what other depilation methods are used while following treatments, and the use of certain medications. Consultation Patient consultation is a very important step in establishing confidence between electrologist and patient. It should be used to: • Gather patient information (skin and pilosity evaluation). • Obtain medical information and identify general or local contraindications. • Establish treatment protocol according to individual pilosity. • Explain treatment procedures. • Plan ideal treatment outcome. Procedure Regardless of the technique being used, the treatment procedure remains the same, with current intensity and duration (timing) parameters being the only variables. Treatment session time will vary according to patient pilosity, skin sensitivity and tolerance threshold. Patient budget and tolerance to prolonged periods of immobility are also factors. We prefer working on hair previously shaved or depilated (a few weeks before treatment). Treatment session can last from 10 minutes to one hour and can be repeated weekly or monthly. Side effects Whitening of the skin around the probe and minor scabbing disap-
pearing within 24 hours can occur. Scabs may appear that are difficult to disappear, with a longer healing time requiring healing cream. Hyper or hypo pigmentation is possible but is quick to disappear. Pain is a consideration. Prior to treatment, apply a numbing cream (or use cooling device). After treatment, if there is any rednessoedema, apply soothing or healing cream. For any folliculitis, use a local antibiotic treatment. These side effects are caused mainly by using intensities that are too strong or too long in duration. They are also caused by to shallow or deep insertions. Dr Catherine de Goursac is an aesthetic medicine expert. She is a member of the French Association of the Board of Aesthetic Medicine, a member of the board of directors of the FSMEA, general secretary of the French Association Anti-Aging and a member of the SFME. She has authored numerous scientific publications and published numerous works for the general public. W: degoursac.com; esthetiquemedicale.com References 1. Hair structure and chemistry simplified, by A.H. POWITT, B.SC., A.S.T.C.,1972 ; 15-35,41, 66-68, 70, 83 2. Electrolysis Exam Review by John Fantz, R.E., Former State Examiner, 1988 ; 13, 38, 46, 61, 83 3. Real World Electrology, the blend method by Michael Bono,1994 ; 15, 45, 63 4. Cosmetic and medical electrolysis and temporary hair removal, A Practice Manual and Reference Guide , R.N. RICHARDS M.D., G.E.MEHARG R.N.- 1991 ; 15, 55, 87, 151, 193, 237 5. Principles of electrology and shortwave epilation (Edited by Arthur Y. Mahler, Compiled by Harold C. Mahler)- 1983 ; 19, 183, 236, 259 6. Electrolysis, Thermolysis and the Blend : The principles and practice of permanent hair removal, HINKEL & LIND, 1968 ; 127, 150, 172, 199, 241 7. L’épilation par courants combinés (blend), Ministère de l’éducation de Québec, GAUDREAU G. & FREYNETTE-ROY J., 1995 ; 1-6 8. L’épilation par électrolyse, Ministère de l’éducation de Québec, GAUDREAU G. & FREYNETTE-ROY J., 1995 ; 1-6 9. L’épilation par thermocoagulation, Ministère de l’éducation de Québec, GAUDREAU G. & FREYNETTEROY J., 1995 ; 1-5 10. BORDIER H, Technique de l’épilation diathermique. Le monde médical, 1932 ; 78-81
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46 PROMOTION I body language
Reshaping the nose profile DR EDUARDO RODRÍGUEZ MIELES discusses how the procedure and technique for remodelling the nose using Liquidimplant
T
he range of anatomic areas which can be injected with hyaluronic acid (HA) fillers has gone far beyond the initial and classical indications, like the nasolabial sulcus. Different and challenging indications—not necessarily risky if techniques are adequate—evolved with time and experience, like the tear through, the temporal hollow, the depression of the middle third of the face, and of course, the nose. One of the new alternatives in the market is Liquidimplant, (Nova Cutis Inc., Miami, USA), a monophasic, non animal-based, cross-linked HA filler gel. Treating the nose The term “medical rhinoplasty” was first described by Braccini and Ehrenfest in 2008. It consists in the injection of dermal fillers in the external or internal nasal area to modify or improve aesthetics or functionality. This technique is especially suitable for patients with minor aesthetic orfunctional concerns like the so called “ kyphosis” of the dorsum of the nose. Also, certain surgical sequelae of a rhinoplasty can be “camouflaged” with this technique. Some rhinoplasty patients end up with a notorious notch, particularly visible from a side view of their nasal profile. A review of the anatomy of the nose, in particular, the arteries involved in its irrigation is of upmost importance. To ensure safety, the use of blunt tip cannulas is highly recommended. The dorsum of the nose offers the advantage of very
loose skin. Because of that fact, and considering the softness of Liquidimplant Labium, the possibility of causing a compartment syndromelike in this area is remote, in comparison to the tip of the nose, where the skin is tightly bound to deeper planes. Procedure After disinfection of the dorsum of the nose with isopropilic alcohol, we apply anesthetic cream for a period of 20-30 minutes—this procedure is almost completely painless! After removing the anesthetic cream, again with isopropilic alcohol, we outline the depressed zone to be filled using a surgical pen. For the comfort of the practitioner—considering the concavities of the areas to be injected—it is necessary to bend the 27 G cannula about 30 degrees in order to get the necessary angled direction for entrance in the skin, although the cannula is flexible. We drill little holes for entrance of the cannula using sharp 27 G needles. And we retroinject along vertical trajects in the outlined depressed zone to be filled. Sometimes it will be necessary to place couple of horizontal injection trajects. The injection itself must be slowly performed, little by little, with the practitioner standing lateral to the patient, constantly visually inspecting the profile of the nose, in order to not overcorrect. Something remarkable about this anatomic indication is the little volume of Liquidimplant Labium required: no more than 0.5 ml per
average patient. The volume spent will depend on the severity of the defect to be treated, but in general, this technique requires little volumes of HA. One of the highlights of this technique, and this anatomic indication, is the long lasting result: on average it is two years before the need for re-injection. In experienced hands, Liquidimplant Cutis or Liquidimplant Subcutis can be used, with the logical extended duration of the results. It is wise however to remember that a learning curve is required to make the move to more viscous presentations of Liquidimplant. This technique has become more requested by patients, because it is safe, effective, long lasting, and even comfortable due to the lack of pain involved. Dr Eduardo Rodríguez Mieles is a dermatologist Omni Hospital Staff Member, Guayaquil, Ecuador President, Ecuadorean Association of Dermatology and Allied Sciences References 1. Braccini F, Dohan Ehrenfest DM. Medical rhinoplasty: rational for atraumatic nasal modelling using botulinum toxin and fillers]. Rev Laryongol Oto Rhinol (Bord). 2008;129(4-5):233-8. 2. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S. 2012. Blindness following Cosmetic Injections of the Face. Plastic and Reconstructive Surgery 129(4): 995- 1012. 3. Carle MV, Roe R, Novack R, Boyer DS. 2014. Cosmetic Facial Fillers and Severe Vision Loss. Journal of the American Medical Association Ophthalmology 132(5): 637- 639.
body language I DERMATOLOGY 47
The role of
topical growth factors The role of topical growth factors and cytokines in wound healing has stimulated research to uncover the evolving benefits of growth factors in skin rejuvenation. Dermatologist DR ZEIN OBAGI explains the science
G
rowth factors are proteins that regulate cellular growth, proliferation and differentiation under controlled conditions. They play a critical role in maintaining healthy skin structure and function. Growth factors are secreted by all cell types found in the epidermis and dermis, including keratinocytes, fibroblasts and melanocytes. Numerous growth factors are involved in complex and synergistic combinations to stimulate collagen, elastin, and glycosaminoglycans (GAGs). They are also involved in regulating epithelial proliferation, differentiation, and other cellular functions. TGF-α (transforming growth factor- α) is involved in the regulation of systemic inflammation, including the pro-inflammatory condition psoriasis. The use of topical growth factor agents has been demonstrated to speed the healing of open wounds. Furthermore, when used in conjunction with cosmetic procedures including chemical peels, laser and
HUMAN GROWTH FACTORS AND THEIR RESPECTIVE FUNCTIONS IN THE SKIN Growth Factor
Function in Skin
Fibroblast Growth Factor (bFGF [FGF-2], FGF-4, FGF-6, KGF [FGF-7], FGF-9)
Angiogenic and fibroblast mitogen.*
Transforming Growth Factor (TGFβ1, TGFβ2, TGFβ3)
Keratinocyte migration; chemotactic for macrophages and fibroblasts.
Platelet Derived Growth Factor (PDGF AA, PDGF BB, PDGF Rb)
Chemotactic for macrophages and fibroblasts; fibroblast mitogen and matrix production; macrophage activation.
Vascular Endothelial Growth Factor (VEGF)
Influences angiogenesis and vascular permeability to improve tissue nutrition.
Placental Growth Factor (PGF)
Promotes endothelial cell growth (member of VEGF family).
Insulin Like Growth Factors (IGF1, IGFBP1, IGFBP2, IGFBP3, IGFBP6)
Endothelial cell and fibroblast mitogen.
Hepatocyte Growth Factor (HGF)
Strong mitogen; wound healing and three dimensional tissue regeneration.
Table adapted from: Mehta RC, et al. J Drugs Dermatol. 2008 and Sundaram H, et al. J Drugs Dermatol. 2009. *Mitogen = induces cell mitosis (replication) and transformation/differentiation.
light based treatments, growth factors can also be effective in minimising downtime and optimising outcomes. Essential agents for healthy skin I classify topical agents in terms of falling into the categories of Es-
66 Numerous growth factors are involved in complex and synergistic combinations to stimulate collagen, elastin, and glycosaminoglycans (GAGs). 99
sential and Supportive. Essential agents are fundamental for restoring skin health. These have been scientifically validated as having beneficial activity, and they are the only known substances that can return the skin to its best possible original state. Topical agents in the essential category must offer one or more of the following features: intracellular activity, therapeutic effect, antiinflammatory benefit, activation of cellular function, and/or improvement of the barrier function. The products, which are crucial to achieving Skin Health Restoration and successful maintenance include: vitamin A derivatives (treti-
48 DERMATOLOGY I body language
Skin Health Ossential Growth Factor Serum Plus This lightweight gel was formulated to help strengthen skin, support skin repair and protect against future signs of ageing. It is easy to tolerate for all skin types, even the most sensitive skin. This unique formula contains the following advanced ingredients that offer extensive skin health benefits: • Disodium acetyl glucosamine phosphate and fermented red ginseng extract: Stimulates cellular regeneration, collagen production and synthesis of glycosaminoglycans (GAGs) • Retinol: Stimulates epidermal renewal and collagen production, and helps even skin tone • Hydrolysed sericin: Enhances production of collagen and hyaluronic acid • Dipeptide diaminobutyroyl benzylamide diacetate: Minimises the appearance of expression lines • Buddleja stem cell: Helps prevent future signs of ageing by protecting against cellular damage and collagen degradation • DNA repair and protection complex: Enhances DNA repair and protects DNA from future damage • Beta glucan and angelica polymorpha sinensis root extract: Calms and soothes irritated skin
noin and retinol), hydroquinone (HQ), antioxidants, DNA-repair agents, anti-inflammatory agents, and growth factors Growth factors are chemical messengers between cells to turn on or off specific cellular activities
such as cell proliferation, chemotaxis, and extracellular matrix formation. Topical application of growth factors also reduces signs of photoageing by promoting fibroblast and keratinocyte proliferation, and inducing extracellular
matrix formation. Growth factors can be derived from several sources including epidermal cells, human foreskin, placental cells, colostrum, recombinant bacteria, yeast, and plants. Growth factors can also be produced synthetically. The use of human-derived growth factors in topical skin care products is controversial. Although human growth factors have been shown to repair photodamage through the induction of cell proliferation and differentiation, the associated increase in angiogenesis (secondary to excessive VEGF exposure) has also been shown to be a critical step in the transition of dormant tumours to malignancies. Furthermore, various types of melanomas have receptors for growth factors (e.g., VEGF). Therefore, alternate, non-human sources of growth factors have been sought out to offer the same cutaneous benefits as the humanderived growth factors, but without the potential for stimulating skin cancers. Animal derived growth factors, such as one derived from a mollusk, have been shown to be effective substitutes in repairing photodamage. Kinetin, a plant derived topical growth factor, has similarly shown promise in repairing photodamage. Synthetically-produced growth factor, composed of lipopeptides (the main active portions of growth factors, composed of small-chain amino acid sequences), has shown great potential in terms of providing the building blocks necessary for fibroblasts to produce collagen and elastin. These synthetic lipopeptides are one of the main ingredients in the best-selling ZO Ossential Advanced Growth Factor Serum. Since no human or animal product is directly applied to the skin when synthetic growth factors are used, their safety profile is enhanced. Dr Zein Obagi is a board certified dermatologist in Beverly Hills, California, and the Medical Director of ZO Skin Health and is responsible for the development of new skincare treatments, protocols and products to achieve healthy skin. W: zoskinhealth.com
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The Cellenis™ PRP and PRF medical device enables the clinician to concentrate platelets and growth factors between 1.8 - 10 fold over whole blood base line.
Cellenis™ PRP and PRF are prepared using the latest, advanced gel filtration technology. This method is superior to the old buffy coat means of separation. Cellenis™ special patented gel filtration system is the only preparation system that eliminates undesired erythrocytes, which have been shown to significantly decrease fibroblast proliferation and augment apoptosis in vitro1. The Cellenis™ system virtually eliminates granulocytes as well, which are considered not beneficial in terms of the regeneration process, and may contribute to a catabolic effect by secreting catabolic mediators, including metalloproteinases2. Cellenis™ platelet harvest is at least 90%.
All desired white blood cells (i.e. mono nuclear cells) and peripheral blood stem cells are included at a concentration between 2.5-5 over the concentration in the whole blood.
Recognised Quality Cellenis™ is CE Class IIb certified and and USFDA 510K class II approved and cleared. Both Cellenis™ PRP and Cellenis™ PRF are now available in different size blood draw tubes. 1 Red Blood Cells Inhibit Proliferation and Stimulate Apoptosis in Human Lung Fibroblasts In Vitro Fredriksson K et al. Scand J Immunol. 2004 2 Growth Factor and Catabolic Cytokine Concentrations Are Influenced by the Cellular Composition of Platelet-Rich Plasma. Sundman et al. Am J Sports Med. 2011
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body language I TECHNIQUE 51
Stimulation and regeneration DR JOSEPH CHOUKROUN discusses platelet rich plasma and platelet rich fibrin
G
rowth factors are routinely used in reconstructive and regenerative therapies. They can be derived from human tissue, or recombinant DNA can be used, but the simplest method is to extract growth factors from the blood’s platelets. Platelet concentrate technique uses centrifuge to separate the blood’s components, with the goal of increasing the platelet count. Clotting is essential because the platelets release their growth factors only after clotting, and it is from there that their use can be determined. It’s possible to use growth factors to simulate tissue stimulation undergoing regeneration, or to regenerate tissue. Stimulation needs only platelets, with or without leukocytes. Regeneration requires a scaffold, and then fibrin matrix, platelets and leukocytes.
PRP and PRF Both PRP (platelet rich plasma), and PRF (platelet rich fibrin) can be extracted using centrifuge. For PRF, there is no anticoagulant added during the spin, the clotting is physiological and the spin creates a clot, which contains platelets, white cells and fibrin. PRF is not injectable, it’s a gel. The enrichment of platelets is not the same. For PRP, the platelets are enriched two to four times and there are few white cells. In the PRF, there are all platelets, 50% of white cells and all the fibrin of the blood. The role of the fibrin is very specific, it’s a recipient of growth factors and this recipient will allow very specific release of growth fac-
tors, very slowly and continuously over a time period of more than one week. It’s not the amount of growth factors that’s the most important, but it is released into the site. To treat severe infection, antibiotics can be injected drop by drop in an IV perfusion, ensuring that a stable concentration is maintained. This is the same in PRF biology— to obtain the most important function a stable concentration must be maintained. The best is a drop-bydrop infusion. The clinical use of the PRF in dermatology and aesthetics By using PRF as a matrix, it can be used to promote healing in an infected wound—for example in a diabetic foot, after amputation. The concept is to inject the fibrin, and this fibrin will release over a few days. By leaving the wound un-
touched for four to five days, a very fast vascularisation can be achieved without any anti-infectious threat. If vascularisation can be achieved on the surface, the healing is very easy, because the vessels are doing the job by slowly infusing the growth factors. Ulcers in the diabetic foot can also be treated with the same technique. Fibrin is put on the wound, covered with a plastic sheet, or an aluminium sheet and then in four to five days fast healing is achievable. To regenerate tissue we need a scaffold. We can use fat, but the most efficient scaffold in the body is fibrin. When I carry out cervico-facial lifting, I mix fat and the PRF, because fibrin provides an excellent scaffold to first get a new vascularisation, but then also new collagen. This fibrin is very impor-
Fat and PRF can be mixed because fibrin provides an excellent scaffold to get new vascularisation and new collagen.
52 TECHNIQUE I body language
tant if we want to get the growth factors and with those factors we can achieve the new vascularisation and healing. The healing always begins with formation of a provisional matrix. All the products are active, but in the beginning, we need the platelets and the white cells. The objective is to create homeostasis and inflammation. After five days granulation tissue begins to form and the matrix deposition becomes visible because the endothelial cells and the fibroblasts start to work, and after ten days collagen forms on this tissue. The provisional matrix is the most important, because when fibrin is introduced to into the site new vascularisation is immediately created. Cell biology Plasma protein is necessary to create collagen synthesis. White cells are also necessary, because inflammation is needed for the recovery. At an injury site, the endothelial cells immediately separate themselves and then the white cells squeeze through the gaps and then by chemotaxis they move through the injury site, and begin to release the pro-inflammatory interleukins. This is the sort of inflammation that causes activation of monocytes into macrophages. The macrophages dominate the inflammatory phase, and then they start to release growth factors and BNPS. Stem cells are necessary alongside white cells in order to achieve a smart blood concentrate and regenerate new tissue. White cells influence the quality of the PRP, so enriching the PRP in white cells creates greater tissue augmentation and a significantly higher proliferation of mesenchymal stem cells. Spinning to create PRP, PRF, i-PRF and A-PRF In PRF the white cells are in the bottom of the clot. If blood is spun at too high a G force, a lot of cells are lost, but with a reduced RPM (revolutions per minute) and lower G force, this can be altered. The advanced PRF is the clot and the i-PRF is the injectable PRF,
which is liquid. With the advanced PRF, the RCF (relative centrifugal force) is low : 200 G force—in order to get more white cells. This is not done in a lab—reducing G force simply increases white cells. An eight minute spin is needed to create A-PRF. Increasing the white cells, increases both vascularisation and release of growth factors. By increasing vascularisation, the vessel density and the percentage of vascularisation can also be increased. i-PRF is different. To obtain an injectable PRF, requires a very, very
low G force—60 only—followed by the same protocol, with no additive and no anticoagulant. This is the concept of the i-PRF. There is a high concentration of white cells, plus fibrinogen, plasma protein and it clots spontaneously after the injection. Nothing additional needs adding into the wound to get the clot and to get the platelet to release growth factors. Comparing the white cells between PRP and i-PRF, shows that i-PRF has over 20 times more white cells. Interestingly, the level of the platelets is the same in the
body language I TECHNIQUE 53
1-2% of these cells are mesenchymal stem cells. It’s possible to produce many thousands of stem cells in just three minutes, by getting the blood in a tube and spinning with a low force. If we compare the concentration of the mesenchymal stem cells in the iPRF, in the PRP, we can see the difference of using a low spin speed. A separate specific manufactured device to produce mesenchymal stem cells isn’t needed. We need only to get blood, draw the blood and to spin it doing three minutes in the iPRF tube, without any additive, without any anticoagulant. It’s that simple. Applications of iPRF I’m not a dermatologist, I have my own pain clinic in Nice, and I have many patients with arthritis in the knee. I discovered it is possible to regenerate the cartilage with the stem cells from the iPRF, reduce inflammation and reduce pain. Applying iPRF to the scalp with microneedling can improve the hair when the patient has alopecia. iPRF can also be used in the lips—we know that if we want to augment lips, we need to create new tissue, and for that, we need a fibrinogen to get collagen in the future. PRF can also be used to treat the mouth and regenerate the gingiva around the teeth.
White cells influence the quality of the PRP
three techniques; it seems that reducing the G force does not reduce the platelet enrichment. Injectable-PRF can be created by spinning for only three minutes. Spinning for four minutes, decreases the quality a little, but is fine because more spinning creates more liquid. The best concentration of the stem cells is spinning only for three minutes. More blood can be used to create more liquid. Research In recent research, my objective was to try to extract stem cells
from the blood. We did a flow cytometry to analyse the mesenchymal stem cells into the iPRF. Using information from the International Society for Cell Therapy, we knew we needed to find cells that are CD 34- and 45-, and CD44+, CD73+, CD90+ and CD105+ positive, since those are the characteristics of the mesenchymal stem cells. So we did an elimination of all the cells, and we found that in the iPRF we have from 1 to 2% of mesenchymal stem cells. When we analyse the IPRF we have a quantity of cells.
Conclusion The best results are the ones created the most simply. When we follow nature and our body’s natural biology it makes sense to be safe and avoid any manufactured additives. Using this method of using RCF and controlling the RPM, we not only get more cells, we can get a lot of stem cells very simply, naturally and at a low cost. I believe we are at the beginning of developments with the iPRF and that the future will be very exciting. I also believe we can use iPFR to improve the HA injection, because with the iPRF, we can create more collagen and create perfect stability. Dr Joseph Choukroun is a MD, Anesthesiologist and Pain clinician
www.wigmoremedical.com I 020 7491 0150 | Tel 0207.514.5975 Stand 68 Benjamin Britten Lounge | www.wigmoremedical.com
body language I PRODUCTS 55
on the market The latest anti-ageing and medical aesthetic products and services Discovery Pico Lynton introduces the new Discovery Pico system, a next generation picosecond laser said to deliver unprecedented power and versatility. Discovery Pico combining the efficacy and speed of picosecond pulses with the proven safety profile of nanosecond Qswitched pulses at 1064 & 532nm. W: lynton.co.uk THE INViSIBLE NEEDLE TSK Laboratory is launching THE INViSIBLE NEEDLE, the first needle of its kind and the thinnest needle available to date. technology advancements have made it possible to make this needle 33% thinner than a 30G needle and 14% thinner than the TSK 33G needle. W: tsklab.com Triple Lipid Restore 2:4:2 Ageing skin is increasingly susceptible to lipid depletion: the loss of natural compounds in skin’s surface, present in the form of ceramides, natural cholesterol, and fatty acids. This lipid loss compromises skin’s natural protective barrier, resulting in visible signs of accelerated aging, as skin loses its ability to effectively self-repair. Triple Lipid Restore 2:4:2 is formulated with a maximised concentration of reparative lipids: 2% pure ceramides, 4% natural cholesterol, and 2% fatty acids. This anti-ageing lipid correction cream is said to contain the first cholesterol-dominant ratio to restore skin’s external barrier and support skin’s natural hydration process to reduce the appearance of signs of ageing. Skinceuticals say that Triple Lipid Restore 2:4:2 has been clinically proven to improve skin’s smooth feel, laxity, pore appearance, and overall radiance. W: skinceuticals.co.uk
Body Profile Environ is now offering a new toning gel, Body Profile, in a 100ml size, perfect for travel. The gel is designed to address the dreaded lumpy, bumpy skin that afflicts many of us, whether slim or overweight. W: iiaa.eu GOLD COLLAGEN HYDROGEL MASK Minerva Research Labs launch their first ever topical product, a hydrogel mask designed with a unique water soluble bio-matrix that fits like a second skin. W: gold-collagen.com
Agera Nano Eye Lift Kit This kit contains Nano Eye Lift (10ml) and a free Eye Makeup Cleanser (60ml) and is said to be an ideal take-home treatment to compliment toxin treatments. Agera say that growth factor peptides found in their Nano Eye Lift enhance cell, collagen and dermal production to increase and maintain skin thickness, helping to reduce the appearance of fine lines, wrinkles and dark circles. It is said to be formulated with an ultra-smooth texture that allows for an even application and matt finish. Agera have also launched their Deep Hydration Gel Cream and Oxygen Infusion Kit. W: edenaesthetics.com
NOW APPROVED FOR USE IN BROW AND NECK
Creating the
Silhouette effect
“I couldn’t be happier with the result” Gillian Taylforth
Help your patients rediscover a more defined facial outline that’s both natural and discreet with SILHOUETTE SOFT®. Using innovative technology, SILHOUETTE SOFT® sutures both lift and provide volume for an immediate and long lasting effect. Bidirectional cones provide traction to support and lift the subcutaneous tissues, while polylactic acid stimulates progressive restoration of lost collagen. SILHOUETTE SOFT® Training Workshops are available to GMC/GDC registered professionals, e-mail: silhouettetraininguk@sinclairpharma.com For more information, visit www.silhouette-soft.com Sinclair IS Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. www.sinclairispharma.com Date of preparation: September 2015 UK/SIPSST/15/0003
body language I EQUIPMENT 57
Lift and rejuvenate The ageing face can benefit from the use of toxins and fillers, however the use of of reabsorbable sutures with biodirectional cones can offer better results for some indications, explains DR KULDEEP MINOCHA
TREATED TREATED AREAS AREAS – RECOMMENDED – RECOMMENDED TECHNI TE
T
here is a limit to what can concept of a totally reabsorbable line or neck? With all the best will using a combisuture with bidirectional cones, in the world no amount ortreated. ative ing aims marking to determine aims betoachieved determine the position theand position the direction and the of direction the sutures of theon sutures the areas onofthe tofiller be areas to be treated. nation of botulinum toxin forming the basis of Silhouette Soft toxin is going to produce this effect and dermal fillers alone to technology. The concept of pro- without surgery. help combat the signs of facial age- viding both a mechanical lift and The cone technology pioneered ing. The currentENTRY trend of continutissue regeneration through typeEXIT by Kolster, owner of KMI Inc, CoPOINTS ENTRY POINTS POINTS EXIT POINTS ing to add volume to the mid-face 1 collagen formation, without re- rona, CA in 2005 has been the real is beginning to significantly alter sorting to surgery, appeared to be breakthrough in the development of 1&2: The mid-face the way our clients look. This has an ideal solution for those who had suspension threads. The 360-degree and jaw line can be treated using not gone unnoticed by the media crossed the injectable threshold. surface of the hollow cone (1.0mm straight pattern, or and is having a negative effect on How often have we seen clients x 2.5mm) creates a strong anchor- combined straight the aesthetic industry. who gently pull up sagging skin ing effect on the fibrous soft tissue. and angle pattern. 3. The “U” techIn 2012, as an aesthetic physi- on their face to soften the jowl and Collagen begins to form as early as nique 4. Silhouette cian, I was first introduced to the improve the contour of their jaw day eight, in and around the hydro- Soft suture
MID FACE MIDAND FACEOR AND JAW ORLINE JAW LINE
1
1
2
1.
2
2.
TREATED AREAS – RECOMMENDED TECHNIQUES TREATED AREAS – RECOMMENDED TECHNIQUES
Preoperative marking aims to determine the position and the direction of the sutures on the areas to be treated.
PRESENTATION
Preoperative marking aims to determine the position and the direction of the sutures on the areas to be treated.
ENTRY POINTS
ENTRY POINTS
EXIT POINTS
MID FACE AND OR JAW LINE MID FACE AND OR JAW LINE
3. 1 Straight patterns Straight patterns 1
EXIT POINTS WHAT IS SILHOUETTE SOFT®? Silhouette Soft® suture is made of Poly-L-Lactic Acid while its cones are made of Lactide/Glycolide (82% Lactide 18% Glycolide). These components are totally resorbable, biocompatible and biodegradable (10).
4. 2 Combined Combined patterns straight patternsand straight angle and angle 0.5 cm length for 8-cone suture 0.8 cm for 12 and 16-cone sutures
2 cm length
2
NECK NECK
3
23G needle 12 cm
Straight patterns
3
Straight patterns
NECK 3
Combined patterns straight and angle
4
4
Combined patterns straight and angle
NECK 3
4 4
PRODUCT
0.5 cm length for 8-cone suture 0.8 cm for 12 and 16-cone sutures
SOFT 8 CONES
SOFT 12 CONES
30 cm
27.5 cm
USP DESIGNATION LENGTH
SOFT 16 CONES
3.0 26.8 cm
On each suture, there are two series of cones. Each series has the same number of cones, which face in opposite directions towards the extremity of each suture, hence the term « bidirectional ». The cones are separated by tied knots, placed at 0.5 cm (SMS 22 or 8 cones) or 0.8 cm (for SMS 23 (12 cones), and SMS 25 (16 cones)) intervals from each other, free
patient inserted (Fig. 2), stop the When traction and cone start with Then turn the (Fig. needle horizontally and it throughcones the isindications. enter in the adipose tissue. the last subcutaneous tissue 1) until the black lineguide disappears. patientwill indications. the insertion of the second half of the suture. subcutaneous tissue. Depth may be adapted according to Then turn the needle horizontally and guide it through the 1is inserted (Fig. 2), stop the traction and start with 2 patient indications. 58 EQUIPMENT language Extract the of needle through thesuture. first exit point. Insert the point ofI body the first suture perpendicularly insertion the second half of the subcutaneous tissue. Depth may needle be adapted according to the Gently pull it and by way of traction, the first series of the skin through the entry point to a depth of 5mm into the patient indications. subcutaneous tissue (Fig. 1) until the black line disappears. cones will enter in the adipose tissue. When the last cone Then turn the needle horizontally and guide it through the is inserted (Fig. 2), stop the traction and start with subcutaneous tissue. Depth may be adapted according to the1 insertion of the second half of the suture. 2 1 2 patient philic indications. cones when placed in vivo. clinician with a range of treatment
The fibrous reaction around the modalities to improve the signs of 1 2 cones creates a solid support within facial ageing in the most artistic 1 2 the soft tissue, ensuring no migra- way. tion or extrusion. It was Dr Nicanor 1. Isse who had the idea of inserting The Ideal Patient 3 Introduce the needle located at the second end of the suture, re-absorbable cones between retain- Choosing the ideal patient for the perpendicularly to the skin in the same entry hole, respecting the 1 knots on a 3/0 polypropylene procedure is important. This ing is 2not depth of 5mm into the adipose tissue. Proceed in the direction suture, leading to the development a face lift, although it does provide of the second exit point (Fig. 3). of Silhouette Lift, approved by the repositioning of displaced fat and FDA in 2006 and soon after obtain- volume restoration. Patients with 3 Introduce the needle located at the second end of the suture, 3 ing the CE mark. excessive skin in the mandibular Introduce2.the needle located at the second end of the suture, perpendicularly to the skin in the same entry hole, respecting the Since 2006, Silhouette Lift su- region associated with thick skin, perpendicularly to the skin in the same entry hole, respecting the 3 tures Introduce have had numerous those excessive skin todepth ad- of 5mm into the adipose tissue. Proceed in the direction the needleapplicalocated at the with second end of thedue suture, depth of 5mm into the adipose tissue. Proceed in the direction 3 the second tions perpendicularly including liftingto ofthe theskin midvanced ageing and respecting thin skin would of point (Fig. 3). skin at exit the pre-established exit point (Fig. 4). Extract the needle, w in the sameend entry the Introduce the needle located at the second ofhole, the suture, Prick of the second exit point (Fig. 3). tissue face and jowl, in the treatment of be unsuitable for the procedure. are inserted in the tissue (Fig. 5). The entire sutureSubcutaneous has now been implanted depth ofto 5mm into in the adipose tissue. Proceed in the direction perpendicularly the skin the same entry hole, respecting the facial of nerve palsies leading to paExcessive skin in the mandibular Repeat these actions with each suture, then on the other side. the second point (Fig. 3).Proceed in the direction Subcutaneous tissue depth of 5mm into theexit adipose tissue. ralysis, and with 2/0 sutures, to lift region but with hypertrophic type ofthe the adipose second exit point 3). tissues in (Fig. the gluteal ageing as well as patients with 3ex3. Introduce the needle located at the second end of the suture, area. Fundamental to its success cessively thin skin with lack ofPrick fat the skin at the pre-established exit point (Fig. 4). Extract the needl perpendicularly to the skin in the same entry hole, respecting the Prick the skin at the pre-established exit point (Fig. 4). Extract the needl was the secure anchoring of the su- tissue would also not get such good inserted in the tissue (Fig. 5). The entire suture has now been implan Subcutaneous tissue depth adipose tissue.results. Proceed in the direction 4 are are inserted in the tissue (Fig. 5). The entire suture has now 5been implan ture of to 5mm stronginto deepthefascia, placing Repeat these actions with each suture, then on the other Prick the skin at(Fig. the 3). pre-established exit point (Fig. 4). Extract the needle, with a gentle pull so the second seriesside. of cones ofthis the procedure second exit point Repeat these actions with each suture, then on the other side. within the realm of Suitable patients would include are inserted in the tissue (Fig. 5). The entire suture has now been implanted (Fig. 6). Cut thread leaving the free ends Prick the skincolleagues. at the pre-establishedthose exit point (Fig. 4). ptosis, Extractloss theofneedle, with a gentle pull so the second series of cones long. our surgical with mid-face Repeat these actions with each suture, then on the other side. are inserted in the tissue (Fig.any 5). The entire suture been As a physician evaluating malar volume, jawhas linenow ptosis, neckimplanted (Fig. 6). Cut thread leaving the free ends long. Repeat these actions with each suture, then onand thebrow other side. new treatment, the safety profile relaxation ptosis. 4. Subcutaneous tissue 4 5 of a product is paramount. SilOne way of evaluating the po4 5 Prick the skin at the pre-established exit point (Fig. 4). Extract the needle, with a gentle pull so the second series of cones houette Soft sutures are made of tential effect of the procedure is by 100% poly-lactic (PLLA) are inserted tissue (Fig.and 5). The entire has now been implanted (Fig. 6). Cut thread leaving the free ends long. lifting thesuture tissue by approximately 5 4 in theacid the cones a mix of poly-lactic acid 1cmthen withon your Repeat these actions with each suture, thefingers other placed side. prox4 5 (82%) and glycolic polymer (18%). imally (i.e. at the insertion 6point) Subcutaneous tissue We know that PLLA has been used and checking to see if there is a Subcutaneous tissue in medical devices and implants for significant difference made to the 5. Subcutaneous decades and that the degradation tissue distally (i.e. at the exittissue point). 4 5 ratio of PLLA compared to other If this produces a positive effect the Subcutaneous tissue 6 materials used in the production patient should do well with the Sil6 of sutures is much slower, there- houette soft procedure. fore its 6 benefits are longer lasting. The formation of type 1 collagen Technique 6 Subcutaneous tissue in response to PLLA has been long Key to the technique being suc6. established. cessful is the initial vertical insertion made at the entry point with Indications an 18G needle prior to the injec- excessive dimpling of skin at the Insertion of the 6 suture, Fig 1-6 Redefining the jaw line and reduc- tion of local anaesthesia. This al- entry point. ing the jowl are some of the most lows easy passage of the smaller Proceed in the direction of the common indications. Enhancing 23G needle, with attached thread second exit point (Fig 4), extract anterior malar projection, soften- and cones, to the correct depth in the needle and with a gentle pull 13 ing of the naso-labial and mario- the subcutaneous fat of approxi- the second series of cones are innette folds using a variety of vectors mately 5mm (Fig 1). serted in the tissue (Fig 5). The 13 has proved to be very successful usThe needle is turned hori- entire thread has now been iming this unique technology. The zontally through 90 degrees and planted (Fig 6). Next is the modaddition of the CE mark for its guided through the subcutaneous elling phase of the treatment. brow and neck lift in July 2015 has tissue. Extract the needle through With the fingers of one hand, 13 officially extended the licensed in- the first exit point. Gently pull it apply slight pressure on the tisdications. and by way of traction, the first sue. At the same time, pull first The use of Silhouette Soft as series of cones will enter the adi- on one end of the exposed suture, an adjunct to muscle-relaxing in- pose tissue. When the last cone and then on the other, which enjections (usually performed two is inserted (Fig 2), stop traction sures that the cones are in contact weeks prior to thread insertion) and start inserting the second half with the tissue and that a certain and dermal fillers or collagen stim- of the suture, by introducing the degree of compression is mainulators (can be injected before or needle vertically in the same entry tained. after thread insertion) provides the hole (Fig 3). This is vital, to avoid Once adequate compression
body language I EQUIPMENT 59
has been achieved, cut the exposed ends of the sutures at the level of the exit points (Fig 6). A variety of sizes of threads and cones are available, including 8,12 and 16 cone threads. Using a combination of straight, angled and/or U technique insertion patterns the clinician is able to lift, support and sculpt descending facial tissues. Red indicates entry points and blue indicates exit points.
Before and after treatment with Silhouette Soft
After-care Post-treatment advice includes avoiding physical exercise, dental surgery, facial massage and use of saunas for two to three weeks.
Patients are advised to sleep in a supine position and elevated on pillows for the first three nights as well as refraining from excessive facial movements such as yawning in the first week. Complications Careful explanation to patients about what to expect immediately after their procedure is an important part of the pre-treatment consultation. Entry point depressions and puckering or folding of the skin are all normal sequelae and resolve within days. Bruising and occasional haematomas may occur. Rates of infection are very
low, with only a dozen cases being reported worldwide to the International Medical Advisory Board, despite there being over 385,000 threads inserted worldwide. Contraindications As with most aesthetic treatments it is unadvisable to insert Silhouette soft sutures in the presence of acute or skin chronic diseases, permanent fillers, autoimmune diseases, pregnancy and breast-feeding, patients under 18 years of age or those sensitive to the materials used in the components of Silhouette Soft. Training Since being brought under the Sinclair IS Pharma umbrella, structured and supported training has been the hallmark of introducing this new technology to clinicians. Full day workshops are organised for hands on practical advice and demonstration. Delegates are also encouraged to attend the World Expert Meeting in Barcelona every October. A record number of 1500 delegates from all over the globe attended in 2015 for an educational event at the Javier De Benito Institute. The two day conference is devoted solely to the Silhouette Soft procedure and includes in depth anatomy lectures as well as numerous practical demonstrations of the latest techniques being used all over the world. Conclusion Introducing Silhouette soft threads into my practice as an adjunct to my existing treatment portfolio has certainly provided with me with a broader range of options to treat more challenging areas of the face and neck. The results continue to improve over three to four months as Type 1 collagen is produced and can last for 18 months. From the patient’s perspective offering a tailor-made treatment, under local anaesthesia, which produces natural looking results and can be performed in less than 60 minutes is immensely appealing. Dr Kuldeep Minocha is a trainer for Sinclair IS Pharma and lead Aesthetic Physician at Absolute Aesthetics based in London and Surrey.
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body language I EXPERIENCE 61
A journey from there to hair DR GREG WILLIAMS outlines his path to becoming a Plastic Surgeon—from Jamaica via Canada and ultimately to London to specialise in hair transplant surgery
I
was born in Kingston, Jamaica to a blond French mother and an olive skinned Jamaican father of mixed White/Indian/ Black ethnic background so I feel I embody the Jamaican national motto ‘Out of Many One People’. I went to a primary school where I was considered to be financially privileged and light skinned and then to a boarding school in Toronto, Canada where I was considered the under-privileged dark skinned kid. This gave me an interesting perspective on socio-economic and racial issues from an early age. I had decided by the time I was 11 years old to be a doctor so my academic direction was clearly focused and university followed at McGill in Montreal, Canada studying anatomy. It was only in my teens that I realised how lucky I was to be from the Caribbean. As a child, I rarely went to the beach other than with my family for the annual summer holiday on the island’s north coast. At boarding school in Canada, and especially during winter, it became apparent that much of the rest of the world worked hard to afford the luxury of sun destination holidays, and I began to appreciate what had always been on my doorstep. Perhaps it was for this reason, or perhaps it was having been away from home for so long, that I was keen to set up my medical practice in Jamaica. I was also advised that, whilst it is easy to train in medicine in a third world country and practice in the first world, the reverse
was not so true so I applied to, and was accepted at, the University of the West Indies to study medicine. Six years later with a medical degree under my belt, the realities of practicing medicine where few can afford the price of basic medications caused me to change my mind, and I looked to emigrate somewhere that I could be the kind of white coat-wearing doctor I had imagined I would be. A chance meeting with a British tourist couple who suggested I move to England and stay with them whilst I found my feet led me to London, and a series of fortunate coincidences landed me with a surgical rotation rarely offered to an outsider. I had chosen plastic surgery as my preferred specialty during my medical school elective in Toronto when I was awed by the surgeon I was assigned to moulding an ear from a patient’s costal cartilage to treat a congenital microtia. Incidentally, I also met my wife through mutual friends whilst on this medical elective and I consider these two events to be the most pivotal turning points of my life. Once again, lady luck shined on me and I was offered a plastic surgery training rotation in London without having done any research. I was later told that the offer was made to me over better qualified candidates based on my bursting enthusiasm at interview. A good lesson for others who think the hill is too steep to climb. Plastic surgery encompasses so much more than is commonly per-
ceived by the public. In the NHS, it is much less about beauty than about reconstruction and my training encompassed managing hand, craniofacial and general trauma, cancer excision and reconstruction, congenital deformity management and much more. However it was burn surgery that caught my eye and in which I sub-specialised. I went on to lead the Burn Centre at Chelsea and Westminster Hospital in London and in fact, for many years, I was the only substantively appointed NHS Burns Consultant in London. I became the Clinical Director for Burns in London and the South East of Eng-
Dr WIlliams came to London after a chance meeting with a British tourist couple
62 EXPERIENCE I body language
land, and co-authored the UK national documents for Burn Major Incidents, Burn Advice to National Trauma Networks and Thresholds for Admission to Burn Services. After reaching the pinnacle of my NHS career, I started thinking about a more relaxed way of life that did not entail getting up at 3am whilst on call, working long weekend shifts, and being away from my family on Christmas Day. In my pre-Consultant training days I was fortunate enough to have been accepted on what was then, London’s only Aesthetic Training Fellowship. There, I assisted and learned from the best of the best, but I felt that if I was going to be good at facial aesthetics, breast surgery or body contouring I would have to dedicate more time than was available to me as a busy Burns Consultant so I did not pursue a career in aesthetic surgery. I fact, I have never given a botulinum toxin injection nor administered a dermal filler—rare for a Plastic Surgeon! I was however, instructed on how to perform full thickness hair bearing skin grafts and pedicled hair-bearing flaps for eyebrow burn scar alopecia by my burn surgery mentors, the results of which seemed very rudimentary to me for the 21st century. I researched where I thought the best hair transplant practitioners were and travelled to Brasil and
66 I know that I am changing lives 99
North America to learn from them. For many years I believe I was the only doctor in the NHS performing follicular unit hair transplants. This skill was the same as that used to treat genetically-determined male and female pattern hair loss and I built up a respectable parttime private practice in this area. It was therefore not a difficult step to move into full time private practice especially since the opportunity arose to join forces with like-minded doctors at the Farjo Hair Institute, who not only have the same high clinical standards but are also dedicated to research and education. I often smile wryly when I think that one of the reasons I chose to leave the NHS was that I was weary of the politics and yet I have taken on many of the same leadership roles in the private sector. I have been the President of the British Association of Hair Restoration Surgery (BAHRS) since 2013 and represented the Association on the Health Education England Advisory Group developing the Qualification Requirements for Delivery of Cosmetic Procedures: Non-surgical Cosmetic Interventions and Hair Restoration Surgery. I have taken a strong stance in the development of Clinical and Professional Standards for Hair Transplant Surgeons but there is much work still to be done around the development of Patient Related Outcome Measures and in data collection. This commitment has been recognised by the International Society of Hair Restoration Surgery (ISHRS) and I have been asked to chair that Society’s Bylaws and Ethics Committee.
I was also very privileged to be awarded the Fellow status by the ISHRS which recognises senior hair transplant surgeons around the world. There are only three in the UK and currently less than 100 globally. The award recognises leaders in the field in terms of leadership, education and medical publication. I have always felt that hair transplant surgery is different from those aesthetic procedures that aim to turn back the clock because not everyone loses hair as they get older. I think of it more as a medical disorder with a surgical treatment. For those who are unfortunate enough to have lost their hair through burns or trauma, hair restoration can lead to the regaining of lost confidence. The surgery can be expensive and unaffordable to some so I have worked along with my colleagues and the Katie Piper Foundation to establish a pro-bono partnership to offer hair restoration surgery for free to suitable and eligible patients. I may no longer be saving lives but I know that I am still changing lives. As I look at where I am now, it has been a path with several forks in the road. I would not have imagined in the past that I would be doing what I am now but I remain professionally fulfilled and wake up every day knowing I am doing good in the world. What more can a man ask for and what better example can one set for one’s children? Dr Greg Williams is a Plastic Surgeon and the lead Hair Transplant Surgeon at the Farjo Hair Institute’s London clinic W: farjo.com
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