Body Language #81

may

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

Advances in dermal fillers DEVELOPMENTS IN MONOPHASIC TECHNOLOGY FOR HYALURONIC ACID DERMAL FILLERS

VEIN CARE

FACE CONFERENCE

MANE EVENT

The technique of sclerotherapy and how to manage results

The premier medical aesthetic conference and exhibition returns to London on June 16th -19th

The fundemental issues surrounding hair care today

LIFT, CONTOUR & REJUVENATE 1,2

with sustained collagen stimulation2

RAD/7/SEP/2015/DS Date of preparation: September 2015

Adverse incidents should be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents should also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143.

The Lifting Filler

1. Sundaram H. J Drugs Dermatol. 2012 Mar; 11(3): S44-S47 2. Yutskovskaya Y, et al. J Drugs Dermatol. 2014; 13(9): 1047-1052

Call Merz Aesthetics Customer Services now to find out more or to place an order

Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com www.radiesse.co.uk

The Lifting Filler

body language I CONTENTS 3

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24

contents 32

07 NEWS OBSERVATIONS Reports and comments

17 REPORT INDUSTRY NEWS Headlines and updates

18 CONFERENCE 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

24 INJECTABLES ADVANCES IN HYALURONIC ACID DERMAL FILLERS Mrs Alexandra Mills Haq and Professor Syed Haq discuss monophasic technology

30 PRODUCTS

Mr Philip Coleridge Smith explains the technique of sclerotherapy and how to manage results

40 HAIR THE MANE EVENT Trichologist Carole Michaelides, highlights some of the fundamental issues surrounding hair and unravels the language of hair care today

47 INJECTABLES RHA AND SMOKER’S LINES Visible signs of ageing in the periorbital area can have a significant impact on self confidence. Dr Kieren Bong explains how to treat vertical rhytids with a combination of resiliant hyaluronic acid and botulinum toxin

53 EDUCATION TRAINING Medical aesthetic course diary

ON THE MARKET

55 INJECTABLES

The latest medical aesthetic and anti-ageing products and services

FILLING SKIN OF COLOUR

32 VEIN CARE MANAGEMENT OF RETICULAR VEINS AND TELANGIECTASES

Prof Mukta Sachdev, Dr Keerthi Velugotla and Dr Archana Samynathan share their approach to using injectable dermal fillers in skin of colour

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.

40 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 Simon Haroutunian 020 7514 5976 simon@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Mrs Alexandra Mills Haq, Professor Syed Haq, Mr Philip Coleridge Smith, Carole Michaelides, Dr Kieren Bong, Prof Mukta Sachdev, Dr Keerthi Velugotla, Dr Archana Samynathan 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

Preserve the identity of your patients with natural-looking results.1 Azzalure is proven to reduce the severity of glabellar lines.2 It provides fast onset of action (median 2-3 days)2 and long-lasting efficacy (up to 5 months)2, and almost 90% of patients felt the results “surpassed” or “met” their expectation.1 References: 1. Molina B et al. J Eur Acad Dermatol Venereol. 2015;29(7):1382-1388. 2. Azzalure Summary of Product Characteristics.

Actual Azzalure user. Fictional model name. Results may vary.

Azzalure Abbreviated Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection) Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to Galderma (UK) Ltd. Azzalure and Galderma are trademarks owned by Galderma S.A Date of preparation: February 2016 AZZ/003/0216

intervals/higher doses can increase the risk of antibody formation.

Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation.Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE) Legal Category: POM Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: March 2013

body language I NEWS 7

observations

PERIORBITAL TRANSPLANTATION MAY PROTECT VISION IN FACIAL TRANSPLANT New USA based research has concluded periorbital tissue transplantation is feasible to protect eyesight in selected patients Transplantation of the periorbital tissues has been found as a "technically feasible" alternative to protect a functioning eye in some patients being considered for facial transplant.

The "periorbital subunit”—including the eyelids, underlying neuromuscular structures, and supplying blood vessels— may be transplanted as an isolated procedure or as part of a full facial transplant, according to new USA based research led by Eduardo D. Rodriguez, MD, DDS, Chair of the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Medical Center.

The study published in Plastic and Reconstructive Surgery—Global Open, details an approach that Rodriguez and colleagues have trialled on five patients being evaluated for face transplantation due to extensive destruction of the facial tissues— caused by a gunshot, animal attack, thermal or chemical burns, or cancer. All patients had at least one functional eye, which was considered at high risk of deterioration due to loss of the eyelids and associated structures that protect the eye. The researchers explored the "indications and anatomic feasibility" of periorbital transplantation—transplanting the periorbital subunit alone or as part of a full face

transplant.

"The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimise aesthetic outcomes."

Writes Rodriguez.

After thorough evaluation and surgical planning, the researchers attempted transplantation of six periorbital subunits in all five patients (including both eyes of one patient). Four patients underwent partial facial transplant including the periorbital tissues; the other patient underwent periorbital transplantation as part of a full facial transplant.

Transplants including critical periorbital tissues—such as the eyelids, tear ducts, and associated facial nerve branches—were obtained from deceased donors. In five out of six periorbital subunits, the surgeons were able to achieve a dual vascular supply to maximise the chances of tissue survival.

In four out the five patients, periorbital transplantation was successfully performed, reconstructing the lost tissue while restoring critical functions, such as voluntary and reflexive blinking. In the fifth patient, complications occurred.

While still controversial and performed at a small number of medical

centres around the world, face transplantation has become an option for carefully selected patients with full or partial destruction of the facial tissues. Patients with intact eyes are at high risk of progressive deterioration due to loss of blinking and other protective functions.

"Periorbital transplantation (isolated or total face) is technically feasible," Dr. Rodriguez and coauthors conclude.

They acknowledge some important limitations of their initial experience— especially the limited

range of cases encountered in their single-hospital series.

The authors propose an approach to classifying the types of tissue loss that may be reconstructed by periorbital transplantation, and highlight key technical considerations involved in these complex procedures. They suggest, "Those patients with retained orbits, orbital nerve function, and early vision changes should be considered optimal candidates for allotransplantation in an effort to reverse the progression to blindness."

8 NEWS I body language

SKIN WITH HAIR FOLLICLES AND GLANDS GROWN IN LAB Complex skin tissue has been sucessfully grown by scientists in Japan, using reprogrammed iPS (induced pluripotent stem) cells Japanese scientists were then able to implant these three-dimensional tissues into living mice, and the tissues formed proper connections with other organ systems such as nerves and muscle fibers. This work opens a path to creating functional

skin transplants for burn and other patients who require new skin.

Research into bioengineered tissues has led to important achievements in recent years—with a number of different tissue types being created—but there are still obstacles to be overcome. In the area of skin tissue, epithelial cells have been successfully grown into implantable sheets, but they did not have the proper appendages—the oilsecreting and sweat glands—that would allow them to function as normal tissue.

To perform the work, published in Science Advances, the researchers from the RIKEN Center for Developmental Biology (CDB) in Japan have, along with collaborators from Tokyo University of Science and other Japanese institutions, took cells from mouse gums and used chemicals to transform them into stem cell-like iPS cells. In culture, the cells properly developed into an embryoid body (EB)—a three-dimensional clump of cells that partially resembles the developing embryo in an actual body. The researchers created EBs from iPS cells using Wnt10b signaling and then implanted multiple EBs into immune-deficient mice, where they gradually changed into differentiated tissue, following the pattern of an actual embryo. Once the tissue had differentiated, the scientists

transplanted them out of those mice and into the skin tissue of other mice, where the tissues developed normally as integumentary tissue—the tissue between the outer and inner skin that is responsible for much of the function of the skin in terms of hair shaft eruption and fat excretion.

Critically, they also found that the implanted tissues made normal connections with the surrounding nerve and muscle tissues, allowing it to function normally.

One important key to the development was that treatment with Wnt10b, a signaling molecule, resulted in a larger number of hair follicles, making the bioengineered tissue closer to natural tissue.

According to Takashi Tsuji of the RIKEN Center for Developmental Biology, who led the study, “Up until now, artificial skin development has been hampered by the fact that the skin lacked important organs, such as hair follicles and exocrine glands, which allow the skin to play its role in regulation. With this new technique, we have successfully grown skin that replicates the function of normal tissue. We are coming closer to being able to recreate actual organs for transplantation, and also believe that tissue grown through this method could be used as an alternative to animal testing.”

IMPROVING BARRIER FUNCTION New study demonstrates topically applied cross-linked resilient HA improves skin barrier function A new study has demonstrated that topically-applied crosslinked resilient hyaluronic acid (RHA) is superior to non-crosslinked (linear) low and high molecular weight hyaluronic acid in increasing water content of the skin, maintaining skin integrity and improving skin barrier function.

“This is an exciting study, featuring state-of-the-art analytical techniques. It’s the first study to reveal important differences between specific

types of HA, and points to a key role for topical RHA in skin rehydration and rejuvenation,” says lead study author Dr. Hema Sundaram. Dr. Sundaram is a Washington, DC area dermatologist who collaborated on the publication with Swiss-based TEOXANE Laboratories.

“RHA was originally developed by TEOXANE as the primary component of their injectable dermal fillers line, indicated for the aesthetic treatment of skin wrinkles and

facial contours. Its proprietary crosslinking confers longevity and enhances mechanical characteristics. Our latest research shows that crosslinking may also be beneficial in a topical HA formulation.

If we effectively address the skin’s fundamental hydration needs, it may tolerate and respond better to other topical treatments and cosmetic procedures.”

The study was conducted to evaluate the effects of crosslinked RHA vs. lin-

ear, non-crosslinked low molecular weight (LMW) HA and high molecular weight (HMW) HA using human skin explant surfaces. In the study, researchers found that RHA was a more efficacious humectant than LMW HA and a more efficacious occlusive moisturiser than HMW HA. Furthermore, topical crosslinked RHA significantly improved the skin barrier structure and function by helping to better retain moisture in the skin.

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• Individualised treatments with the world’s broadest portfolio of HA fillers • Established safety profile based on over 2 decades of experience • High patient satisfaction with more than 28 million treatments world wide

For more information on the Restylane portfolio please contact your local Galderma product specialist.

www.restylane.co.uk RES/026/0316a Date of Prep: March 2016

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body language I NEWS 11

ULTRASONIC SURGERY REDUCES TRAUMA AFTER GENIOPLASTY Plastic and reconstructive surgery could benefit

SUN LOVERS MAY LIVE LONGER BUT ARE AT RISK OF SKIN CANCER Swedish study reveals longer life expectancy among those with active sun exposure habits New research is investigating the paradox that women who sunbathe are likely to live longer than those who avoid the sun, even though sunbathers are at an increased risk of developing skin cancer.

A study involving 29,518 Swedish women who were followed for 20 years, revealed longer life expectancy among those with active sun exposure habits and showed a relation between this and a decrease in heart disease and noncancer/non-heart disease deaths, causing the relative contribution of death due to cancer to increase.

It is impossible to determine whether the positive effect of sun exposure demonstrated in this observational study is mediated by vitamin D, another mechanism related to UV radiation, or by unmeasured bias, therefore, additional research is warranted. However, it is very possible that women who spend more time in the sun may be more active and therefore healthier overall.

"We found smokers in the highest sun exposure group were at a similar risk as non-smokers avoiding sun exposure, indicating avoidance of sun exposure to be a risk factor of the same magnitude as smoking," said Dr. Pelle Lindqvist, lead author of the Journal of Internal Medicine study. "Guidelines being too restrictive regarding sun exposure may do more harm than good for health."

For patients undergoing plastic surgery of the chin, the use of ultrasonic piezosurgery equipment has been found to reduce trauma, pain, and swelling, when compared to traditional surgical drills, according to reports a study in the The Journal of Craniofacial Surgery.

"Piezosurgery may be a viable alternative to traditional osteotomy technique, as it reduces the degree of inflammation, pain, swelling, and morbidity, improving satisfaction and patient comfort," according to the report by Dr. Gilberto Sammartino of University of Naples Federico II, Italy, and colleagues.

Complications after genioplasty performed using piezosurgery devices were compared with those from using traditional rotating drills. This relatively new approach uses ultrasonic energy, rather than conventional surgical instruments, for cutting of bone. "Several studies have demonstrated that bone healing using piezosurgery is more rapid than other techniques using drills or burs, thanks to a lower inflammatory bone response," Dr. Sammartino and coauthors write.

Sammartino’s study included 40 patients scheduled for genioplasty, as a primary procedure or after corrective jaw surgery. Patients were randomly assigned to undergo genioplasty using either piezosurgery, or traditional drills. Pain, healing, and complications were compared from one to 15 days after surgery.

The results showed lower pain scores for patients undergoing piezosurgery, although the difference was significant only on the third and seventh day after surgery. Swelling also seemed to be reduced with piezosurgery, compared to cutting drills.

Both groups experienced reduced sensation in the chin area throughout the first 15 days after surgery, mainly due to nerve stretching. Sensation normalised within six months for all patients in both groups, plus pain and swelling were also completely resolved.

Previous studies show that piezosurgery leads to better control of the inflammatory bone response induced by surgery. Less cell damage also leads to increased bone remodelling after surgery. Dr. Sammartino and colleagues conclude, "Bone undergoes less stress during surgery and thus less pain and swelling postoperatively, which is in agreement with the results found in our trial: pain and discomfort were minimal compared to the traditional technique (saw and drills) especially in the immediate postoperative period of healing (within three days)."

12 NEWS I body language

FUTURE 3D PRINTING COULD FIX DAMAGED CARTILAGE IN KNEES, NOSES AND EARS Researchers at Wallenberg Wood Science Center in Sweden have found a way to produce cartilage tissue by 3-D bioprinting an ink containing human cells Having successfully tested the cartilage tissue in an in vivo mouse model, Swedish researchers believe that the development could one day lead to precisely printed implants to heal damaged noses, ears and knees.

“Three-dimensional bioprinting is a disruptive technology and is expected to revolutionise tissue engineering and regenerative medicine,” says Paul Gatenholm, Ph.D. “Our team’s interest is in working with plastic

surgeons to create cartilage to repair damage from injuries or cancer. We work with the ear and the nose, which are parts of the body that surgeons today have a hard time repairing. But hopefully, they’ll one day be able to fix them with a 3-D printer and a bioink made out of a patient’s own cells.”

Gatenholm’s team first had to develop an ink with living human cells that would keep its shape after printing, as previously printed materials

would collapse into an amorphous pile.

To create a new bio-ink, polysaccharides from brown algae and tiny cellulose fibrils from wood or made by bacteria were mixed with human chondrocytes, which are cells that build up cartilage. Using this mixture, the researchers were able to print living cells in a specific architecture, such as an ear shape, that maintained its form even after printing.

The printed cells also pro-

duced cartilage in a laboratory dish.

“Under in vitro conditions, we have to change the nutrient-filled liquid that the material sits in every other day and add growth factors,” Gatenholm says. “It’s a very artificial environment.” Tells Gatenholm. So the next step was to move the research from a lab dish to a living system.

Printed tissue samples were implanted in mice where the cells survived and produced cartilage. To then boost the number of cells – another hurdle in tissue engineering – the researchers mixed the chondrocytes with human mesenchymal stem cells from bone marrow. Previous research has indicated that stem cells spur primary cells to proliferate more than they would alone.

Preliminary data from in vivo testing over 60 days show the combination encourages chondrocyte and cartilage production.

Further preclinical work needs to be done before moving on to human trials and Gatenholm is working is currently working with a plastic surgeon to anticipate and address practical and regulatory issues.

In addition to cartilage printing, Gatenholm’s team is working with a cosmetic company to develop 3-D bioprinted human skin. Since cosmetic companies in Europe are now prohibited from testing cosmetics on animals, it’s hoped this printed skin can be used to try out makeup, anti-wrinkling techniques and strategies to prevent sun damage.

W ELCO M E TO TH E ER A O F DY NAM I C AES TH E TI C S The first resilient hyaluronic acid1 dedicated to facial dynamism2.

N E

1 TEOXANE Laboratories crosslinking method is a patented process. 2 TEOSYALÂŽ RHA keeps its mechanical properties on a large range of strain or stress constraints (dynamic Gâ&#x20AC;&#x2122;) Report Rheological characterizations of hyaluronic acid gels. Rheonova (University of Grenoble, France). Data on file - Patent pending.

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14 NEWS I body language

events 19 - 22 MAY, 13th EADV Spring Symposium, Athens, Greece W: eadvathens2016.org 24 MAY, Value in Healthcare Congress, Manchester, UK W: valuecongress.hsj.co.uk 3-4 JUNE, Global Academy for Medical Education’s 6th Annual Summit in Aesthetic Medicine, Newport Beach, United States W: globalacademycme.com 3-4 JUNE, Journées Parisiennes du Laser, Paris, France W: congres-medical-congress.com 10 JUNE, Oculoplastic@Bordeaux 2016, Bordeaux, France W: congres-medical-congress.com

SOME SUNSCREEN INGREDIENTS MAY AFFECT FERTILITY

16 - 18 JUNE, 3rd ICAD Brazil, International Congress of Aesthetic Dermatology and Healthy Aging Medicine, Sao Paulo, Brazil W: euromedicom.com

Chemicals could interfere with human sperm cells Many ultraviolet (UV)-filtering chemicals commonly used in sunscreens interfere with the function of human sperm cells, and some mimic the effect of the female hormone progesterone, a new study has found.

“These results are of concern and might explain in part why unexplained infertility is so prevalent,” said the study’s senior investigator, Niels Skakkebaek, MD, DMSc, a professor at the University of Copenhagen and a researcher at the Copenhagen University Hospital, Rigshospitalet.

Although the purpose of the chemical UV filters is to reduce the amount of the sun’s UV rays getting through the skin by absorbing UV, some UV filters are rapidly absorbed through the skin, Skakkebaek said. UV filter chemicals reportedly have been found in human blood samples and in 95% of urine samples in the US, Denmark and other countries.

Skakkebaek and his colleagues tested 29 of the 31 UV filters allowed in sunscreens in the U.S. or the European Union (EU) on live, healthy human sperm cells, from fresh semen samples obtained from several healthy donors. The sperm cells underwent testing in a buffer solution that resembled the conditions in female fallopian tubes.

Specifically, the investigators evaluated calcium signalling, which is signalling inside the cell

brought on by changes in the concentration of calcium ions. Movement of calcium ions within sperm cells, through calcium ion channels, plays a major role on sperm cell function, according to Skakkebaek. CatSper is a sperm-specific calcium ion channel that he said is essential for male fertility. This channel is the main sperm receptor for progesterone, a potent hormone attractant for human sperm cells.

Binding of progesterone to CatSper causes a temporary influx, or surge, of calcium ions into the sperm cell, controlling several sperm functions necessary for fertilisation.

The researchers found that 13, or 45%, of the 29 UV filters tested induced calcium ion influxes in the sperm cells, thus interfering with normal sperm cell function. “This effect began at very low doses of the chemicals, below the levels of some UV filters found in people after whole-body application of sunscreens,” Skakkebaek said.

Furthermore, nine of the 13 UV filters seem to induce this calcium ion influx by directly activating the CatSper channel, thereby mimicking the effect of progesterone. This finding suggests that these UV filters are endocrine disruptors, Skakkebaek said. In addition, several of the UV filters affected important sperm functions normally controlled via CatSper, such as sperm motility.

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 6-8 JULY, AFPSS 7th Functional Septorhinoplasty Course in conjunction with 7th Asian Facial Plastic Surgery Society Congress, Singapore W: entfortnight2016.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 19-23 OCTOBER, DASIL—Dermatologic Aesthetic Surgery International League, Dubai, United Arab Emirates W: thedasil.org 21 OCTOBER, AMEC 2016 - 12th Aesthetic & Anti-aging Medicine European Congress, Paris, France W: congres-medical-congress.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 6-16 NOVEMBER, 11 Days of Plastic Surgery 2016 — 3rd Singapore Advanced Rhinoplasty Fresh Frozen Cadaveric Dissection Course, Singapore W: singaporeentcourses.com.sg 16-19 NOVEMBER, 2nd EPSC 2016 - Middle East — 2nd Emirates Plastic Surgery Society Congress 2016 - Middle East, Dubai, United Arab Emirates W: epsc.ae/ 24 - 26 NOVEMBER, ICAD 2016, Bangkok, Thailand W: euromedicom.com Send events for consideration to arabella@face-ltd.com

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industry news

PATIENT SAFETY IS PARAMOUNT Healthcare profession takes strides in protecting non-surgical cosmetic intervention patients Five prominent healthcare groups have collaborated to improve safety for patients undergoing non-surgical cosmetic interventions.

With support from the Department of Health (DoH), the joined forces have created the Clinical Standards Authority for Non-Surgical Cosmetic Interventions (CSA) and the Joint Council for Cosmetic Practitioners (JCCP).

These two groups will work collaboratively to ensure patient safety in the specific area of nonsurgical interventions, which includes dermal fillers, Botox injections and cosmetic laser therapies. This area is largely unregulated and although many of these treatments

are carried out by doctors, nurses and dentists – who are covered by their own professional codes of conduct—there are also a large number of treatments carried out by nonregulated practitioners.

The associations currently involved are: • The British Association of Aesthetic Plastic Surgeons (BAAPS) • The British Association of Cosmetic Nurses (BACN) • The British Association of Dermatologists (BAD) • The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) • The British College of Aesthetic Medicine (BCAM) These bodies will

work together to protect patients by improving and enforcing clinical standards and training, and by maintaining a register of practitioners.

The CSA and the JCCP have already started on these key tasks with the objective of fully launching in April 2017.

Professor David Sines, CBE, has been appointed as the Interim Chair of the JCCP and his first task has been to bring together the key professional medical associations involved in delivering non-surgical services followed by other professional associations and stakeholders.

This news swiftly follows the recent publication of the ‘Guidance for Doctors who offer

cosmetic interventions’ by the General Medical Council (GMC), which both the CSA and the JCCP welcomed.

Professor David Sines, Interim Chair of the JCCP, said: “In 2013 the Keogh ‘Review of the Regulation of Cosmetic Interventions’ found that the regulatory framework had not managed to keep up with the growing cosmetic intervention industry. Sections of the non-surgical cosmetic interventions industry remain largely unregulated, however healthcare professionals have made important strides in improving patient safety. The formation of the CSA and the JCCP is an important step forward.”

THE ASSOCIATION OF PDO THREADS UK The increase in supply and application of PDO threads necessitated professional guidelines With concerns over the legitimacy of CE certificates growing, leading clinicians in the field of aesthetics and cosmetics have formed the Association of PDO threads UK, to ensure that best practices are adhered to in the use of polydioxanone thread in the UK. With their aim to consolidate the science, technology and clinical practice in this expanding field, one of the main objectives of the Association will be to focus on education, clinical trials, training and peer development using an evidencedbased approach. Importantly, The Association has engaged with and is working closely with a number of regulatory bodies including the MHRA (Medicines & Healthcare products Regulatory Agency) and several insurance companies.

"The aim of the Association of PDO threads UK is to set and uphold minimum standards of excellence in polydioxanone threads education and training

practitioners and CE Mark regulation in collaboration with the MHRA. In addition, an important function of the Association is the provision of information to the public in terms of safety and the legal aspect of PDO threads and where to find accredited practitioners. The explosion in the supply and application of PDO threads in the UK has necessitated the need for a professional organisation guide and support the development of the practice of PDO threads to the highest professional standards." says Dr Jacques Otto, who is the Association of PDO threads UK’s board member responsible for Education and Accreditation Standards.

Many practitioners are unaware of the risks of buying PPDO Threads from countries such as Korea and China – such as packaging with fake CE certificates.

The MHRA is currently investigating all PDO suppliers in the UK and will name and shame those that do not have the cor-

rect CE markings amongst other serious consequences.

The Association will offer help and guidelines for members including information on all threads available in the UK and their CE status. Distributors will be invited to hand in their CE certificates to be scrutinised by an expert working for the MHRA. The MHRA will then approve the CE status of the product or warn the association that it is a fake.

Findings will be published the Association website and members warned.

Members of the Association of PDO Threads UK will be offered numerous benefits beyond this safety reassurance.

PDO level one, level two, level three and trainer level classes will be offered to members with a 25% discount. Select members based on their skills will be invited to classes exploring new techniques and patented threads not available in the UK market.

body language I PROMOTION 17

The hybrid experience Light-based technology has been taken to the next level with Nordlys by Ellipse

A Nordlys by Ellipse—more than light The most versatile vascular and rejuvenation platform

fter decades of clinical experience and engineering expertise, Ellipse introduces the latest in premier medical devices—the Nordlys. Built on unrivalled engineering each component of the Nordlys has been rethought specifically with the user in mind. A virtually silent system with a sleek ergonomical design ensures a calm atmosphere which benefits both the practitioner and the client.

Nordlys allows for greater ease of use, yet still achieving the clinical results Ellipse is renowned for.

Receiving both FDA and CE Mark clearance, the researchers and scientists at Ellipse have taken light-based technology to the next level by introducing an innovative sub-millisecond pulse, resulting in superior versatility and improved clinical outcomes.

In addition to the intuitive and clinical intelligence of the Nordlys, Ellipse is always pushing boundaries to enable new capabilities—this was achieved with the new and unique fractional non-ablative laser Frax 1550.

66 The new shorter Ellipse pulses now enable me to successfully manage conditions that previously were only treatable with pulsed dye lasers Professor Peter Bjerring, MD, Head of Department of Dermatology, Molholm Private Hospital

99

Frax 1550 The Frax 1550 has been clinically designed for treatments of wrinkle reduction, stretch marks, skin resurfacing and other fractional non-ablative laser treatments. Ellipse designed an entirely new unparalleled mechanism with the Frax 1550, while still integrating the unique Ellipse SoftCool system to ensure greater comfort. All while being engineered for as much energy efficiency as possible.

 Better clinical performance than pulsed dye laser, without the running costs  Selective waveband technology with powerful narrowband sub-millisecond pulse for vascular treatments  Wide treatment possibilities including fractionated 1550 and pain free Nd:YAG laser  Unparalleled operator erganomics and silent operation

Sub-millisecond pulse Nordlys offers the user a truly unique short pulse. Effective short pulses were previously previously only available with Pulsed Dye Laser, but Nordlys combines a powerful short pulse, with narrowband light (535-750nm or 555-950nm) and 4 applicators. It is now possible to achieve better clearance on microtelangiectasias, rosacea and pink port wine stains, than with PDL, and without the running costs.

Clinical intelligence Unique Ellipse clinical intelligence ensures effective treatment and reduces the risk of side effects. Nordlys chooses the appropriate settings based on the operator’s evaluation of patient parameters (e.g. vessel size and colour) and automatically adjusts the spot size, energy level and pulse length.

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

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 andprocedures 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 just six delegates per session. The delegates will be led by Dr Frank Rosengaus, a world renowned facial plastic surgeon, and will be focussing on one particular area of facial aesthetics. Models will be provided for the 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.

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.

6-1 MASTERCLASS COURSE ON FILLERS Small group practice sessions with Dr Frank Rosengaus

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FACE Conference will be hosting three highly personalised and VIP hands-on training sessions, reviewing all the different facial areas in order to obtain a "Full Face Balance". The sessions will include a short preview of the most advanced and sophisticated concepts and procedures, with emphasis on facial anatomy and correct clinical assessment to gain amazing results and avoid complications. The course will be practical with constant supervision during application.

Techniques like rhinoscuplting, “The Happy Face Treatment” for oral commissures and marionette lines and “3D volumisation + vector lifting” for the midface will be addresed.

Numbers are limited to six delegates per session, and delegates must provide models. Each session costs £1000 to attend, and includes VIP access to the FACE Conference for the day in question. Sessions take place on: Friday 09:00 – 13:00, Friday 14.30 – 18.30 and Saturday 14.30 – 18.30 Visit faceconference.com to book

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24 INJECTABLES I body language

Advances in hyaluronic acid dermal fillers MRS ALEXANDRA MILLS HAQ and PROFESSOR SYED HAQ discuss monophasic technology

H

yaluronic acid (HA) is a natural, high molecular weight repetitive disaccharide macromolecule that exhibits no species or organ specificity in its natural form. It is composed of two key subunits; D-glucuronic acid and N-acetylD-glycosamine monosaccharides.

The average human body contains 15 g of HA, 50% of which is located in the skin (primarily dermal).

In its natural form HA is highly soluble, not immunogenic and has a rapid turnover through enzymatic and free radical degradation with a half-life of 24hr in vivo. Immunological tolerance and hygroscopic properties render the HA molecule an excellent candidate for volumising the skin therefore.

The development of stabilised forms of HA dermal fillers has expanded exponentially over the past decade, with cross-linking

technology providing an important bridge in aesthetic medicine for non-permanent facial augmentation. Cross-linking HA macromolecules by intermolecular bonds stabilise the superstructure, which would otherwise be a linear macromolecule. The Avian derived form of HA filler, synthesised from rooster combs are less commonly used now due to allergic reactions and increased sensitisation from repetitive use. Many current

body language I INJECTABLES 25

importantly are currently manufactured in combination with Cohesive Polydensified Matrix (CPM) technology which is characterised by variable densities of cross-linked HA zones. This ensures optimal spreading of the gel into surrounding tissue allowing larger spaces to be filled with denser parts of the gel and finer pericellular tissue spaces to retain low-density gel.

HA fillers are derived from streptococcus or staphylococcus equine bacterium biofermentation using the cross-linking binding agent, 1,4-butanediol diglycidyl ether.

The principal reason behind this is due to the higher purity, reduced immunogenicity, viscosity and non-animal origin.

66 The development of stabilised forms of HA dermal fillers has expanded exponentially over the past decade 99

Classification HA dermal fillers can be classified into two main groups: cohesive (monophasic) or non-cohesive (biphasicâ&#x20AC;&#x201D;NASHA technology [Restylane]) depending on the method of development. The cohesive (monophasic) fillers are composed of a single phase of HA, which may be cross-linked once as seen with the monodensified form [Juvederm]) or continuously as with the polydensified series [Belotero]). The cohesive monodensified filler is characterised by a highly cross-linked smooth gel that results from homogenisation of the manufacturing process. A series of the cohesive polydensified fillers

Monophasic vs biphasic One of the increasing trends seen in the production of HA fillers is in the use of higher concentrations of HA which equates to a longer duration in situ. The general consensus is that 20mg/g of HA is considered to be the optimal concentration in dermal fillers though HA dermal fillers with higher concentrations are currently being used in a monophase.

Importantly some manufacturers have described the monophasic versus biphasic debate as â&#x20AC;&#x153;semanticsâ&#x20AC;?. It is true that all HA gel fillers are monophasic when in a syringe in vitro, however they are not when placed in an in vivo environment.

Particle size does matter, uniformity of size can be an advantage but also a disadvantage as uniformity on a macroscopic level in the dermis of the skin does not exist, so variation in size could provide a biological and clinical advantage under certain circumstances and certain anatomical considerations are taken into account, though this question needs further investigation.

Analysis An example of a comparative analysis was exemplified by the elucidation of the cellular behaviour of HA fillers in vivo in human skin samples by Tran et al. 2014 using monophasic versus biphasic fillers.

Histological analysis of the skin samples harvested from points overlying the iliac crest were used from 15 subjects and taken at 8 and 114 days. These samples demonstrated that the tested HA fillers showed specific characteristic biointegration patterns in the reticular dermis. Observations under the optical and electron microscopes revealed morphological conservation of cu-

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body language I INJECTABLES 27

taneous structures. Immuno-histochemical results confirmed absence of inflammation, immune response and granuloma. The monophasic and biphasic dermal fillers show an excellent tolerability and preservation of the dermal cells and matrix components. Their tissue integration was dependent on their viscoelastic properties. Interestingly, Tran et al., 2014 concluded that the cohesive polydensified filler when investigated showed the most homogeneous integration with an optimal spreading within the reticular dermis, which was achieved by filling even the smallest spaces between collagen bundles and elastin fibrils, while preserving the structural integrity of the latter. Of note comparable clinical efficacy was observed in this study together with one conducted by Buntrock et al., 2013 who found that irrespective of whether the dermal filler was monophasic or biphasic in nature, the resulting clinical readout was comparable as defined by an analysis of the wrinkle severity rating scale at 2, 4 and 48 weeks in pa-

tients treated with a single injection into the naso-labial fold.

Advances Further advances have taken place in dermal filler monophasic HA technology with the introduction of non-particulate, non-CPM based derivatives. TEOXANE Laboratories of Geneva, Switzerland currently use a new range of monophasic non-animal based HA product. Two formulae exist - TEOSYAL 27 G and 30 G—each with monophasic cross-linked hyaluronic acid macromolecules—25 mg/ml. The primary characteristic is that the HA is formed as a strong ribbon using a patented manufacturing protocol (Figure 1) which does not create any particulate matter, this provides high viscosity and elasticity properties (which creates a less elastic (lower G’—elastic modulus) and highly cohesive filler (high cohesive index) with resistance to degradation and migration. The product in vivo lasts between six to nine months. In a study by Nast et al., 2011, a split face trial with correction of moder-

ate to sever nasolabial folds using either the Teoxane monophasic versus a commonly used biphasic filler showed that in general comparable results were observed, though there was a trend in the double-blind randomised controlled trial which favoured the monophasic filler in terms of wrinkle severity rating

Figure 2 DermoRestructuring Complex

DNA synthesis and cell protection Role in tissue restructuring and the healing process

ISOLEUCINE LEUCINE VALINE

ZINC COPPER

Figure 1 Monophasic Ribbon Technology developed through the creation of a controlled uniform temperate environment leading to a homogenous medium

Energy production for cell metabolism VITAMIN B6

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28 INJECTABLES I body language

scale, global aesthetic improvement scale and a reduced volume requirement for reinjection correction.

Formulation TEOXANE have gone further with their scientific development by creating a universally unique formulation that combines high concentrations of free HA (15mg/g) integrated with a patented Dermo-Restructuring Complex (Figure 2). The net effect of this is to create of what I term a s a “gain of function” dermal filler that maximises spreading potential in the midst of tackling dermal deep rehydration and redensification.

The TEOSYAL. PureSense Redensity Dermo-Restructuring Complex combines natural components involved in redensifying the dermis and providing antioxidant protection from three potent antioxidants, two minerals, one vitamin and eight amino acids. The Patented DermoRestructuring Complex fortified the restructuration of the dermis with cellular regeneration as defined by increased collagen IV and fibrillin-1. The improved cutaneous hydration was due to 15x fold increase in acidic GAGs deposition in the epidermis with an overall reduction in photo-oxidant damage.

Particulate vs nonparticulate What of the question particulate versus non-particulate? Are

they all created equal. In essence the answer is no with the key difference between particulate and non-particulate HA fillers based on newer technological advances with non-particulate (gel) fillers claiming that they are either multicross-linked, double cross-linked or monophasic. In reality the gels are single cross-linked with an ether bond in a two stage manufacturing process; with the first stage creating BDDE cross-links between HA long chains, and the second stage involving bonds between shorter HA chains.

Clinical consideration The sum effect of intrinsic ageing and long-term environmental exposure to ultraviolet and infrared radiation, together with pollution, and the underlying individuals genetic makeup define the severity and rate of development of wrinkles in our skin over time.

Characteristic changes develop that reflect the level at which the anatomical layers within our skin and subcutaneous tissue become damaged.

Macro-pathological features such punctate dyschromia, diffuse hyperpigmentation, tissue atrophy, telangiectasia, skin laxity and rhytides are examples of such changes.

Much emphasis has been place upon gaining an increasingly youthful and refreshed appear-

ance through the use of facial rejuvenation treatments with practitioners often neglecting an area that has been dogged by ineffective and/or short-term methods of addressing the skin around the neck and chest (décolletage) areas. Patients are increasingly aware of the transition between the look that they are able to achieve in their face, which often starkly contrasts what they see in the summer months over their chest and neck areas. These changes highlight photo-ageing of the décolletage, resulting in frequent requests for cosmetic enhancement of the said areas.

Multiple modalities can be used either as a stand alone or combined treatment for the rejuvenation of the décolletage, from injectables, neurotoxins, chemical peels, sclerotherapy, photodynamic therapy, intense pulsed light, micro-focused ultrasound with visualisation, qswitched lasers, non-ablative fractionated lasers, and ablative fractionated lasers.

The use of wrinkle scales in aesthetic medicine has allowed the field to better evaluate patients and determine treatment outcomes through objective and standardised methods of assessment. The Fabi-Bolton (F-B) chest wrinkle scale for example was developed as a 5-point scale photonumeric wrinkle assessment scale

Before and followup pictures of the décolletage area of a 58-yr old female patient treated with TEOSYAL Redensity II with 1mL, four weeks apart (total volume used 2 mL) using serial puncture and retrograde threading injection techniques.

The follow-up picture was taken three months from the time of the first treatment session.

body language I INJECTABLES 29

using standardised photographic methodology to obtain reference photographs that grades chest wrinkle severity from grade 1 to grade 5. The full spectrum of chest wrinkle severity were accordingly selected when creating the scale and classified as follows: 5-point wrinkle scale (1 = wrinkles absent; 2 = shallow but visible wrinkles; 3 = moderately deep wrinkles; 4 = deep wrinkles, with well-defined edges; 5 = wrinkles very deep with redundant folds).

The F-B chest wrinkle scale can be used as a simple clinical device for objectively grading rhytid severity prior to treatment together with allowing the clinician in being able to monitor patient outcomes longitudinally (Fabi et al., 2012 and Vanaman et al., 2015).

With the advent of more advanced formulations in HA dermal technology my colleague and I AMH focused our attention on the use of such fillers to address rhytides of the décolletage and to carry out a natural lip augmentation. We chose TEOSYAL Redensity II to augment the décolletage and the new formulation TEOSYAL KISS as part of the case studies.

TEOSYAL Redensity II has a HA concentration of 15mg/ml, contains 0.3% lidocaine and is a mixture of non-cross-linked and cross-linked HH containing the Dermo-Restructuring Complex.

We chose this to carry out one of the two case studies to examine whether we could successfully rejuvenate the décolletage area naturally. In addition we used TEOSYAL KISS which has a HA concentration of 25mg/ml, 0.3% lidocaine and is composed exclusively of BDDE cross-linked HA. All patients underwent a clinical history, were consented and photographs taken before and after the procedure. A topical anaesthetic was used in each case prior to administration of the HA filler. Importantly, it should be noted that in Caucasian patients, the epidermis and dermis have been reported to be 39–44 μm and 1319–1400 μm thick, respectively in the décolletage area.

The chest also demonstrates variable distribution of subcutaneous fat and decreased pilo-sebaceous units compared with facial skin, as a direct result particular care needs to be used when injecting this area.

Conclusion The rate of change of formulations has been every increasing in the development of HA dermal fillers.

As the technology grows continues the next installment will likely see further additional synergistic component will likely be merged with the underlying HA platform, as seen with the Dermo-Restructur-

ing Complex. This will no doubt have a positive impact with longer lasting, more visco-elastic, cohesive and integrated HA fillers which will deliver natural results (case studies 1 and 2) with a skilled practitioner in the future.

Acknowedgments Alexandra and I would like to take this opportunity in dedicating this article to our family and friends both past and present, with particular reference to Mr William Mills and Dr Sayyid Azizul Haq.

Before and after pictures of the lip area of a 27-yr old female patient treated with 0.4mL of TEOSYAL KISS using standard tower and retrograde threading injection techniques to the vermilion and body of the lip.

Mrs Alexandra Mills Haq is a Nurse Practitioner, and Founder of AM Aesthetics Belmont Road Belfast E: aigburth@me.com Professor Syed Haq is a is a Consultant Physician and Founder of The London Preventative Medicine Centre. E: info@invictushumanus.com; W: professorhaq.com References 1. Buntrock H, Reuther T, Prager W, Kerscher M. Dermatol Surg. 2013 Jul;39(7):1097-105.

2. Fabi S, Bolton J, Goldman MP, Guiha I. J Cosmet Dermatol. 2012 Sep;11(3):229-34.

3. Nast A, Reytan N, Hartmann V, Pathirana D, Bachmann F, Erdmann R, Rzany B.Dermatol Surg. 2011 Jun;37(6):768-75.

4. Tran C, Carraux P, Micheels P, Kaya G, Salomon D. Dermatology. 2014;228(1):47-54.

5. Vanaman M, Fabi SG. Plast Reconstr Surg. 2015 Nov;136(5 Suppl):276S-281S

30 PRODUCTS I body language

on the market The latest anti-ageing and medical aesthetic products and services

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 UNIVERSKIN UNIVERSKIN is the scientifically formulated skincare line, which uses medical-grade ingredients, and has a unique personal questionnaire and clinical consultation to tailor these ingredients. This unique approach is said to allow UNIVERSKIN to effectively treat conditions from acne and ageing, to rosacea and pigmentation.

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 ULTRAFORMER II & III ULTRAFORMER II & III from Classys, are said to be effective in-clinic, ultrasonic devices that utilise focused ultrasound energy to provide both immediate and long-lasting lifting and tightening effects on the face and body.

The device is designed to work deep below the skin rather than on the surface, providing optimal lifting effects that last up to one year.

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 Believa Believa is a new, natural skincare range scientifically formulated for sensitive skin, eczema, dermatitis and psoriasis. Originating in Germany, Believa combines nature and science, using only natural ingredients that are safe and effective for adults, babies and pregnant women.

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 Oxynergy Paris Oxynergy Paris have launched a new generation of personalised and interactive skincare designed to respect and meet each person’s skin type and condition, targeting specific skin concerns. To create personalised skincare, Oxynergy Paris have developed an application aid which can be downloaded to any mobile device. By answering eight questions, the app determines the right combination and concentration of active ingredients to deliver a personalised formula specific to skin type and skin condition.

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32 VEIN CARE I body language

Management of reticular veins and telangiectases MR PHILIP COLERIDGE SMITH explains the technique of sclerotherapy and how to manage results

V

aricose veins is a common problem in westernised countries, affecting up to a quarter of the adult population. Reticular veins and telangiectases occur more frequently in perhaps half the population.

Reticular veins (blue veins) are dilated, bluish sub-dermal veins, usually 1 to 3 mm in diameter.

Telangiectases (thread veins) are collections of dilated intradermal venules less than 1 mm in calibre.

The main complaint by the pa-

tient is usually the appearance, but symptoms may also arise. In the Edinburgh Vein study the highest frequency of symptoms (heaviness, swelling, aching and cramps) was present in patients with both telangiectases and varicose veins.. The main indication for treatment is a requirement for cosmetic improvement. Few significant complications arise from this type of vein.

Assessment of patients with telangiectases and reticular varices.

In patients with venous disease, history taking, clinical examina-

tion and duplex ultrasound examination are recommended by many authors.

The European Guidelines for Sclerotherapy in chronic venous disorders recommends this strategy in most patients. In some patients, these guidelines indicate that continuous wave (CW) Doppler examination may be sufficient to evaluate the venous system. Most phlebologists consider that treating incompetent saphenous veins and varices is essential before successful management of the telan-

body language I VEIN CARE 33

giectases can be achieved. Where previous varicose veins surgery has been done, residual sections of saphenous vein or varicose tributaries may remain and contribute to the development of telangiectases.

These should be identified and can be managed by ultrasound guided sclerotherapy during the treatment of the telangiectases.

66 Varicose veins are a common problem in westernised countries, affecting up to a quarter of adults 99

Technique of sclerotherapy Several papers in this field emphasise the importance of treating all venous disease including saphenous veins, tributaries, reticular varices and telangiectases in order to obtain a satisfactory outcome.

The sequence of treatment starts with the largest varicose veins (where these are present), continuing with smaller tributaries and reticular varices and concluding with telangiectases. Injection of telangiectases alone will not lead to a satisfactory outcome since the reticular varices contain venous blood at a high pressure that will lead to early recurrence of telangiectases.

The European Guidelines on Sclerotherapy note that needles

with a size of 27 â&#x20AC;&#x201C; 32g are used for the treatment of reticular varices and telangiectases. These are usually combined with small syringes with a capacity of 1 â&#x20AC;&#x201C; 3 mL. Numerous different methods of injection are advised though most practitioners hold the skin and underlying veins with one hand to immobilise them and manipulate the syringe with the other. In the UK a method of using a sclerotherapy injection set in which a 30 g needle is attached to the syringe using a flexible tube, in a similar design to a butterfly needle, is also used.

The European Guidelines recommend a maximum volume of sclerosant injected in any one vein of up to 0.2 mL when treating tel-

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angiectases and up to 0.5 mL when treating reticular varices. The maximum total amount of sclerosant which may be injected in any one session depends upon the sclerosant. Different manufacturers recommend different maximum doses of the sclerosant.

Sclerosant drugs used in the management of telangiectases and reticular varices.

The two most widely used sclerosant drugs for the management of varicose veins are polidocanol (Aethoxysklerol, Kreussler, Germany; Sclerovein, Resinag, Switzerland) and sodium tetradecyl sulphate (Fibrovein, STD Pharmaceuticals Ltd, UK). In most European countries, at least one of these drugs is licensed for the treatment of varicose veins. Both are also licensed in the United States. These drugs are detergents and achieve their effects by the lysis of cell membranes.

Both have been used for more than half a century in the management of varicose veins.

Fibrovein is licensed in the UK at a concentration of 0.2% for the management of reticular varices and telangiectases. The maximum volume recommended to be injected by the Summary of Product Characteristics (SPC) in one session is 10 mL. Polidocanol is unlicensed in the UK but fairly widely used despite this. The SPC indicates a maximum dose of 2 mg/kg

per day. The European Guidelines calculate that this would allow up to 28 mL of 0.5% polidocanol solution in a 70 kg patient in one day.

The manufacturers recommend that treatment is avoided during pregnancy, lactation and in patients taking oestrogen treatment.

A double-blind comparison between polidocanol and sodium tetradecyl sulphate has been undertaken by Goldman. He found that, when used at the recommended concentrations both drugs had similar efficacy in clearing telangiectases and reticular varices with a similar incidence of adverse events.

Management following sclerotherapy The management of the limb following sclerotherapy of telangiectases and reticular varices varies greatly between different practitioners. Kern has investigated the efficacy of compression in managing the outcome of sclerotherapy for telangiectases and reticular varices. In a randomised clinical trial he compared the outcome following three weeks compression with class two medical compression stockings, worn during the day, to a control group who wore no compression. He found that photographic assessment at 52 days following treatment showed a superior result in the compression group compared to the control sub-

jects. Nevertheless, some phlebologists do not advise the use of compression. This is often influenced by the climate since compression stockings are poorly tolerated in hot climates. In the UK, most sclerotherapists recommend the application of compression using bandages or stockings following treatment.

Most authors recommend a series of treatments for the management of telangiectases. Intervals between treatments vary from two to eight weeks but this is not based on any detailed research. Following sclerotherapy of reticular varices as

Sclerotherapy set with 30g needle

Canulation of reticular vein with successful aspiration of blood to check that the needle is in the vein. The same vein immediately following injection of sclerosant.

36 VEIN CARE I body language

Table 1: A simplified algorithm for the management of reticular varices and telangiectases 1. Evaluate the venous system of the lower limbs by clinical examination and ultrasound imaging.

2. Treat incompetent saphenous trunks and tributaries (if present) using thermal ablation or foam sclerotherapy.

3. Commence by injecting the reticular varices. Use a maximum volume of 0.5 mL of 0.2% STS liquid per injection until all veins have been injected. Polidocanol 0.5% can also be used but is unlicensed in the UK. 4. Inject all remaining telangiectases in the treated area with 0.2% STS liquid with a maximum volume of 0.2 mL per injection. Polidocanol 0.5% can also be used but is unlicensed in the UK. 5. Conclude the session when all veins have been treated or the maximum recommended volume of sclerosant has been reached.

6. At the end of the session apply a class two medical compression stocking to the limb (including the thigh) for a period of up to three weeks.

7. Review after two to eight weeks and treat residual reticular varices followed by telangiectases.

Reapply compression and review after a further two to eight weeks. Treat remaining veins as from step 3 above.

8. If telangiectatic matting occurs, check for underlying veins with duplex ultrasound imaging and inject these. Review after one to three months and continue treatment from step 3 above.

9. One to three months after conclusion of a course of treatment, most or all veins will have been successfully treated and reabsorbed.

An example of embolia cutis medicamentosa following sclerotherapy of reticular veins

well as telangiectases, some veins remain after each treatment and these can be addressed in future sessions leading to an improved outcome. I have summarised a simplified strategy for the management of reticular varices and telangiectases in table 1.

Events after sclerotherapy for telangiectases and reticular varices.

Immediately following a session of sclerotherapy, an acute inflammatory reaction is provoked by intravenous injection of sclerosants.

This includes a central swollen region surrounded by a red flare and comprises Lewis’s Triple Response to any noxious stimulus to the skin.

This is short lived and resolves in one to two hours after treatment.

This reaction is followed by some bruising of the skin in regions which have been injected which will resolve in about one to two weeks. After this many veins appear dark in colour where thrombus has occluded the veins.

Some reticular veins appear brown in colour, others become bluegreen which distinguishes them from untreated veins. One problem that may arise is that the retained thrombus leads to pigmentation of the skin. It has been shown that evacuation of the thrombus from occluded veins results in a reduction in skin pigmentation.

In my own practice, I review

patients two weeks following the previous session when it is clear which veins have been successfully occluded by thrombus and which require further treatment.

Excess thrombus can be removed by aspirating with a 25 g needle, and residual reticular varices and telangiectases can be injected. The

occluded reticular veins will usually resolve in one to three months depending up their size.

Occasional patients experience protracted skin pigmentation, especially those of Mediterranean origin. Unfortunately, there appears to be no treatment or manoeuvre which will resolve this problem more rapidly—but all skin pigmentation following sclerotherapy will fade and usually resolve completely after an extended period.

Skin pigmentation may occur with excessive strength of sclerosant or the injection of too large a volume.

However, some patients are especially susceptible to skin pigmentation.

Complications of sclerotherapy The most common adverse events after liquid sclerotherapy include: • Thrombophlebitis • Skin pigmentation • Residual veins • Minor skin necrosis Telangiectatic matting (formation of a pink region comprised of fine telangiectases in the region of treatment).

Rare complications include: • Embolia cutis medicamentosa

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38 VEIN CARE I body language

through the skin. In general, lasers are much less effective than sclerotherapy in the management of reticular varices and telangiectases of the lower limb.

(inadvertent intra-arterial injection of a skin arteriole, figure 4) • Skin rashes due to allergy • Anaphylaxis Minor skin necrosis needs simple dressings and perhaps antibiotic treatment if clinical evidence of infection arises. Telangiectatic matting may arise in a region of previous treatment which has been subjected to vigorous treatment.

These veins will resolve without intervention over a period of about three months. However, if the affected region still contains untreated veins, it is suggestive of resistance to treatment in the patient concerned.

Use of larger volumes of sclerosant or greater concentration will simply worsen the matting. A strategy has been suggested by SchullerPetrovic which is commonly used amongst phlebologists. Using a high frequency ultrasound transducer, as search is made for underlying veins and perforators. These can be very small, typically 0.5 – 2 mm in diameter. Ultrasound guided sclerotherapy with liquid can then be used to ablate these veins. Any incompetent saphenous trunks or tributaries which are also found should be treated as well. Several sessions of this type of treatment may be required if resistant telangiectases are widespread.

This ultrasound guided strategy is effective at clearing telangiectases where sclerotherapy guided by eye is not.

Inadvertent intra-arterial injection (embolia cutis medicamentosa, Nicolau syndrome) is a rare complication of sclerotherapy. This

most frequently arises following visually guided sclerotherapy since ultrasound imaging usually identifies the arteries so that injection of these is avoided. The result is a very painful region around the point of injection with a dark purple or blue discolouration. Current recommendations include high dose steroids combined with anticoagulation but some tissue damage may arise despite these measures.

Severe allergic reactions (anaphylaxis) require immediate treatment with adrenaline given via intravenous or intramuscular routes, in accordance with nationally published guidelines for management.

In some countries, the use of steroids is also advised. Intravenous fluids and inhaled oxygen are also recommended.

Sclerotherapists should have a plan of action should this very rare complication arise.

In the longer term, patients who develop reticular veins and telangiectases continue to grow more veins even when the correct treatment has been provided. Occasional further treatments will maintain a satisfactory outcome and cosmetic appearance which is the main aim of most treatments of this type.

Alternative treatments for telangiectases Lasers are sometimes recommended in the management of telangiectases of the lower limb. In contrast to sclerotherapy, the only veins which this can ablate are the most superficial and smallest veins which are usually pink in colour.

Reticular veins are too large to be destroyed by a light beam passed

Conclusions Sclerotherapy for the management of varicose veins has long been established as a means of treating reticular varices and telangiectases in the lower limb. Clinical and ultrasound examination is required to identify all components of the venous disease present in the limbs of patients with reticular varices and telangiectases. Any saphenous varices are treated first. Sclerotherapy for small veins commences with reticular varices and proceeds to telangiectases, usually over a number of sessions. Compression of the limb following treatment using a class two medical compression stocking has been shown to improve the outcome. Resistant telangiectases can be treated with the help of ultrasound guided injection of underlying perforating and tributary veins. Complications of treatment are few and most are readily managed by simple means.

Mr Philip Coleridge Smith is a Consultant Vascular Surgeon and Reader in Surgery and is the President of the British Association of Sclerotherapists.

E: p.coleridgesmith@adsum-healthcare. co.uk References 1. Ruckley CV, Evans CJ, Allan PL, Lee AJ, Fowkes FG. Telangiectasia in the Edinburgh Vein Study: epidemiology and association with trunk varices and symptoms.

Eur J Vasc Endovasc Surg. 2008; 36:719-24.

2. Rabe E, Breu F, Cavezzi A, Smith PC, Frullini A, Gillet J, Guex J, Hamel-Desnos C, Kern P, Partsch B, Ramelet A, Tessari L, Pannier F. European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2013; 29: 338-354.

3. Goldman MP. Treatment of varicose and telangiectatic leg veins: double-blind prospective comparative trial between aethoxyskerol and sotradecol. Dermatol Surg. 2002; 28: 52-5.

4. Kern P, Ramelet AA, Wütschert R, Hayoz D. Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study. J Vasc Surg. 2007; 45: 1212-6 5. Schuller-Petrović S, Pavlović MD, Schuller S, Schuller-Lukic B, Adamic M. Telangiectasias resistant to sclerotherapy are commonly connected to a perforating vessel. Phlebology. 2013; 28: 320-3

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40 HAIR I body language

The mane event Trichologist CAROLE MICHAELIDES, highlights some of the fundamental issues surrounding hair and unravels the language of hair care today

O

ur hair can make our day or ruin it. It plays a huge role in our confidence; we use it to express our personalities, to draw attention to ourselves and to attract a mate. We spend more time and money taking care of our hair than we do on the rest of our body. In 2014 in the UK, we spent £1.3 billion on hair care, and the global haircare market is forecast to reach £60 billion by the end of 2016. It’s estimated that over an average lifetime in the UK, we spend as much as £28,000 on haircare, and that’s not including salon visits.

Hair structure The hair’s most important attribute is its elasticity. If hair didn’t stretch it would break every time you put a comb or brush through it, and no one could have long hair. Elasticity is made possible by the coiled polypeptide chains within the cortex—the main part of the hair shaft—and the imbricated design of the cuticle, which is the protector of the fibrous cortex underneath. This structure allows hair to stretch and retract without breaking.

The strands of protein are bonded together with both soluble and insoluble bond—water soluble

salt and hydrogen links, and insoluble disulphide bonds. The soluble bonds dissolve in water whenever you wet your hair, and reform again once it dries. This makes it possible to style hair because we can wet it, alter its shape, then dry it and the bonds will reform into their new shape, which hold until the next time the hair gets wet— hence why styles tend to drop out in humidity.

The very strong disulphide bonds are difficult to break, but heat and cosmetic processing such as colouring and so on will cause oxidation of these bonds and eventually wear down the hair structure. To maintain the elasticity of hair, it’s vital to protect the outer coat, which in turn protects the inside of the hair, thus the hair structure will stay intact. Hair absorbs water all the time from the atmosphere, so to keep a style we can use one of the many products that have been designed to reduce this in order to maintain the hair style, including mousses, setting aids, hairsprays and so on.

Choosing hair care can be difficult—language such as normal hair, damaged hair, dry hair and so on, does not really help us as these descriptions can apply to all hair types. Normal is a particularly common theme, but one per-

son’s normal can be very different from another’s and hair may well cross over many of these categories. Therefore is this language helpful? How can we differentiate and help our clients find appropriate hair care?

Hair types Hair can range from completely straight to tight, wiry curls, from fine and flyaway to coarse, heavy and frizzy. Our hair type is inherited and depends on the race or the mixture of races it comes from—but defining the hair type

body language I HAIR 41

The hair’s most important attribute is its elasticity

is the key to giving good advice on haircare.

Hair shapes 1. African-Caribbean hair, will bend and twist because of its shape 2. Oriental hair is symmetrical and will hang very straight 3. Caucasian hair is elliptical and it will typically have waves Hair texture The diameter of typical human scalp hair ranges from as little as 40 microns to as much as 110 or more microns, almost three times

the thickness. Those whose hair diameters are mainly around 40 microns—very fine textured—usually want to increase the volume and make more of it. Those whose hair diameters are mainly 100 microns

or more— coarser textured—usually want to control it; to make it smoother and sleeker. It’s interesting to note the difference in the surface of the hair as we look from fine to coarse. Fine hair will automatically

66 Elasticity is made possible by the coiled polypeptide chains within the cortex—the main part of the hair shaft—and the imbricated design of the cuticle 99

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body language I HAIR 43

be oiler because it doesn’t absorb sebum so well—it will sit on the cuticle or outer layer. Coarse textured hair is automatically much more porous and therefore loses moisture easily, so it is drier. Once you identify the shape and the texture of the hair you can begin to advise on how to get the best individual haircare.

Of course there are important variables to consider such as hair length, condition and the level of processing—whether its coloured, heat styled and so on.

Hair care When considering which hair care products to use, shampoo and conditioner are at the top of the list, both a must for nearly everyone.

We all need to wash our hair and most of us—aside from those with very short, unprocessed hair, benefit from conditioning our hair.

Then there are treatment products, dry shampoos, mousses, serums, volumising products, styling gels, waxes, heat protectors, and all sorts of other things as well.

It can help to think about hair care in layers, in a similar way to facial care. We cleanse our faces regularly, we might use toners, we often use some moisturiser, and women will perhaps apply foundation, a sweep of eye makeup, some blusher, a little dash of lipstick—it’s a case of layering things up. Hair care can be thought of in exactly the same way— first hair is washed and, conditioned; then perhaps it needs some extra moisturising in the form of a serum or a leave-in conditioner. Finally add styling products such as mousse or volumising spray to add body and hold; gels and waxes for creating definition. There is wide range of products to help get the best result.

Products And there are hundreds of product ingredients. As consumers it’s

impossible to know what all of the functions of these ingredients are, so we have to rely on the cosmetic scientists. But key words can help us when we’re trying to identify a product that will do the job that we are looking for.

Common ingredients include cleansers (such as the now infamous sodium laurel sulphate), as well as proteins, silicones, moisturisers, alcohols. We tend to think of alcohols as drying, but alcohol is in lipsticks and moisturising creams and is used a lot in haircare.

Quaternary ammoniums are very useful, especially in products for fine textured hair, as they are substantive but not too heavy. And nowadays they are often combined with proteins and silicones to give an even better result. Because of the INCI (International Nomenclature for Cosmetic Ingredients) laws we must refer to all ingredients by their chemical names— hence tocopheryl acetate instead of plain old Vitamin E! Sunscreens are now commonly used in haircare formulations—this along with antioxidants such as Vitamin E, can help protect against the breakdown of disulphide bonds from oxidative stress.

Surfactants (cleansers in shampoos and shower gels) are mostly made from palm oil, which is similar to coconut oil. And it’s worth noting that sodium lauryl sulphate can be made from either oil—just like other cleansers.

Matching hair and products The shampoo has to fit the job.

It has to provide foam, or it won’t work. Fine textured hair needs adequate foam to remove the sebum, usually achieved with a mixture of surfactants that can boost foaming without being harsh, so the hair isn’t left limp. Shampoo for coarse textured hair generally needs less

66 The current trend towards naturals and organics has some benefits—oils such as olive oil and almond oil have long been used in hair care 99

Medulla

Cortex

Cuticle

foam and more moisturiser, especially African-Caribbean hair.

Organics The current trend towards naturals and organics has some benefits.

Oils such as olive oil and almond oil have long been used in hair care and while we know the value of them, it’s easy to forget that like everything in nature, they are also ‘chemical’. There are certainly no safety advantages for so called natural ingredients, and they should not escape the rigorous testing applied to synthetic ingredients just because of the assumption (untrue) that natural means safe. The regulations cover all the things that go into the bottles and a natural cosmetic product might contain unmodified natural ingredients like olive oil, or Moroccan argan oil, or chemically modified ingredients

Hair structure—to maintain the elasticity of hair, it’s vital to protect the outer coat, which in turn protects the inside of the hair

44 HAIR I body language

1

2

3

Oriental hair is symmetrical and will hang very straight

Caucasian hair is elliptical and it will typically have waves

African-Caribbean hair, will bend and twist because of its shape

that have been naturally derived, like guar and other nature-identical ingredients. There’s a lot of mythology around this subject and I think we need to be a little wary of the ‘natural myth’.

Shampoo frequency Washing frequency is often talked about. Just like our clothes, our hair comes with us everywhere. And just like the collar of a white shirt in London it can look a bit grimy by the end of the day. Scalp hairs trap dirt particles easily, and hair has a propensity for hanging on to dirt particles because of the coating of sebum. In today’s society you certainly don’t want hair to look greasy.

There is also debate over whether to shampoo dry hair frequently. Using a face analogy—if your skin is greasy would you imagine that not washing it for a week would make it less greasy? If it is dry would you believe that not washing it for a week could moisturise it? The same is true for hair—and with hot water on tap and pH adjusted cleansers that do not require acidic rinses such as vinegar or lemon juice as in days gone by, as well as excellent conditioning

products, we can shampoo our hair as often as we want to achieve the look we desire.

The idea that hair gets used to the same shampoo is another myth. The same shampoo used on the same hair type under the same circumstances will give you the same result. People change products because they are simply dissatisfied - they’re searching for that miracle that will magically transform their hair type and make their straight hair curly or their curly hair straight and so on. Of course something might change that warrants a different hair care routine—starting to colour your hair for example.

Conditioners Conditioners contain a number of things—cuticle smoothing agents, emollients, anti-statics, de-tanglers, moisturisers and so on. They help to limit damage from the weather, the sun, and all the other things that cause wear and tear.

Heat styling Use of high temperature implements on hair causes a lot of dam-

age. Styling products can be used to provide some protection, but there’s a limit to what they can do.

As a trichologist I always encourage people to turn the heat down—I see so much damage to hair these days from overly hot hair dryers and styling tools. They have got hotter and hotter in recent years.

Matching ingredients and hair types Those with fine hair usually want more volume. This can be achieved by frequent shampooing and using lightweight conditioners without oils, but with ingredients such as quaternary ammoniums and hydrolysed proteins instead. Styling products with copolymers will add body and hold, and small amounts added of lightweight oils and silicones, proteins and antioxidants all give added benefits of protection, manageability and shine. The same ingredients can be used for medium textured hair, but with more moisturising waxes and humectants added. Serums with silicones and glycols help give smoothness and gloss. Coarse hair and AfroCaribbean hair requires the most moisturising, with ingredients such as lanolin, and oils like the now popular Moroccan or argan oil, olive oil, avocado oil, castor oil and so on. Proteins are included in all haircare and are very useful functioning additives that help to prevent ongoing weathering in the hair. Sunscreens are useful in hair care for all hair types to help reduce oxidation damage from sunlight.

Carole Michaelides has been a member of the Institute of Trichologists since 1971, and has been practicing at the Philip Kingsley Clinic for over forty years. From 1992 to 2004 Carole was responsible for the Trichology Clinic in the Harrods Hair and Beauty Department, and as well as focusing on clinical practice, she gained a wider understanding of retail hair care and retail product training. She is also a member of several other organisations including the Society of Cosmetic Scientists and the European Hair Research Society.

She was awarded a Fellowship of the Institute of Trichologist in 2013.

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body language I INJECTABLES 47

RHA and smoker’s lines Visible signs of ageing in the periorbital area can have a significant impact on self confidence.

DR KIEREN BONG explains how to treat vertical rhytids with a combination of resiliant hyaluronic acid and botulinum toxin

F

acial ageing is a hot topic in cosmetic medicine, with widespread discussion of the effects of ageing on facial morphology and the use of surgical or non-surgical correction.

One of the main reasons patients seek non-surgical facial aesthetic correction is to address ageing of the perioral region, specifically the formation of vertical rhytids, commonly known as “smoker’s lines”. Vertical rhytids, which I shall refer to as smoker’s lines in this article, are more prevalent on the upper lips.

Smoker’s lines are small lines that etch the lips and, in some cas-

es, extend vertically from the lips.

They are sometimes referred to as “barcodes” or “lipstick lines”, as they are usually first noticed when lipstick starts to ‘bleed’ out of the vermilion border.

The lips and surrounding softtissue play a key role in non-verbal communication, through smiling or grimacing, for example. As such, visible signs of ageing in the perioral area can have a significant effect on a person’s self-perception and confidence in interpersonal relationships.

Intrinsic and extrinsic ageing Successful correction of smoker’s lines necessitates a thorough un-

derstanding of the underlying perioral anatomy and detailed knowledge of ageing related changes in the region.

Ageing is a multifactorial process, involving a complex interplay of intrinsic and extrinsic factors. Intrinsic factors consist of genetic components, which play a predominant role in this process, while extrinsic factors include sun exposure, smoking, alcohol intake, stress and depression.

Although smoking does not necessarily cause smoker’s lines, it can predispose a person to develop vertical rhytids and/or accelerate their formation. This is due in part to the repeated pursing of the lips

48 INJECTABLES I body language

Natural HA

Natural HA

BDDE = covalent and irreversible bonds

BDDE = covalent and irreversible bonds

‘Typical’ HAs

RHA

 Mostly short/fragmented chains  5-10% BDDE crosslink  Hard/rigid gel

Natu and mob bond

 Mostly long chains

highgel dy high dynamism of the  Natural and dynamic bonds provide stablisation  Reinforced 2-4% BDDE crosslink  More dynamic properties

 Softer, more resiliant gel with better integration

tented by Teoxane Laboratories the and lip border. The use RHAs have a good 66 ® lines resiliency, ideal TEOSYAL RHA – RESILIENT HYALURONIC ACID TEOSYAL® RHA – RESILIENT HYALURONIC ACID of HA presents a non-invasive, cost for treating the We typically treat smoker’s lines with a effective means of treatment with perioral region a proven safety record. For best combination of hyaluronic acid dermal results, I recommend a combinafillers and botulinum toxin type-A tion of HA and botulinum toxin 99 type-A. Botulinum toxin type-A helps

to draw from the cigarette, as well as patho-physiological effects of smoking, such as hypoxia and/or microvascular changes in the skin that adversely affect the integrity of elastin and collagen.

decrease in subcutaneous tissue in the perioral region which, along with repetitive bunching of skin and soft-tissue from muscular activity, leads to the formation of smoker’s lines.

The development of smoker’s lines As we age, the external white skin (skin between the nose and top lip) lengthens and sags. This is mostly due to decreased skin elasticity, which is a normal part of ageing.

Decreasing volume of the facial skeleton is also a typical part of ageing, with this loss of volume seemingly caused by decreased osseous support and atrophy of the soft-tissue. This results in decreased support and projection of the soft-tissue.

In addition, there is a marked

Effective treatment We typically treat smoker’s lines with a combination of hyaluronic acid (HA) dermal fillers and botulinum toxin type-A. The choice of treatment depends on the depth of the lines and extent of puckering, with HA providing the most effective non-surgical method for treating smoker’s lines.

Treatment with HA can lead to impressive, natural-looking correction of smoker’s lines, usually requiring only a very small volume of the product to be injected at a precise depth at locations along

to relax the strength of the muscular contracture, thereby relaxing the rhytids, while HA helps to soften any permanent etching that may have occurred. Patients can realistically expect to see improvement in the puckered look, as well as softening of the furrowed lines.

Not only does the combination of HA and botulinum toxin type-A offer superior benefits, this regimen can result in longer-lasting effects.

Additional lip enhancement is also worth considering to address contracture of the lips. Adding some bulk to the lips with HA can have a positive effect on the smoker’s lines by further elongating the lip.

Choice of HA fillers HA fillers are typically formulated for use in static areas of tissue. As the perioral region is a very mobile

body language I INJECTABLES 49

part of the face, it is essential to choose an HA filler with the correct biochemical specifications to work with dynamic tissue.

Due to their resiliency, I favour the use of Teosyal’s latest range of HA fillers—RHA (resilient hyaluronic acid)—for the perioral region. This range of fillers has been formulated to be able to stretch with movements while resisting compression and other constraints in order to offer results which are both natural and long-lasting.

RHA is available in four grades, each of which is dedicated to the different dynamic areas of the face.

The grades differ in HA concentration and the percentage of crosslink. RHA is unique because for the first time, the long HA chains are preserved during the manufacturing process. This, coupled with the preservation of the intrinsic and dynamic bonds which only exist between long HA chains, affords this filler dynamic properties best suited for mobile areas of the face.

For the perioral area, I recommend using RHA grade 1, which contains 15mg/ml of partially

crossed linked HA (rate of 1.9%).

This formulation is ideal for treating fine lines and wrinkles where the HA filler needs to flow freely, be subtle, soft and smooth. The unique formulation of RHA and the preservation of long chains also mean that the product integrates very well into the soft-tissue. Results can last up to one year.

Techniques Two injection techniques are useful when treating smoker’s lines: retrograde linear threading and serial punctures. Both techniques are carried out with the use of a hypodermic needle, with the target injection depth in the superficial dermis.

Some practitioners believe it virtually impossible to inject precisely in the dermis due to the girth of the needle being thicker than the dermal layer. While this may be true if one uses a 30G needle, the unique formulation of RHA1 allows it to glide through the lumen of a 32G needle without any difficulty. As such, a 32G needle is my preferred choice of instrument for treating smoker’s lines with RHA1.

The retrograde linear threading technique can be carried out either pointing the tip of the needle caudally or cephalically. In the case of a cephalic approach, the needle should be inserted at the junction of the rhytid and the lip, oriented along the course of the rhytid. Using the thumb and second finger of the non-dominant hand, guide the needle into place and apply gentle pressure to inject the product.

I prefer the serial puncture technique because it affords superior accuracy. Again, precise injection into the superficial dermis is the key to success. Following the injection, firm pressure should be applied to smooth out the filler and ensure that it softens. This helps to avoid overcorrecting the smoker’s lines, which is a common mistake that results in a series of bumps replacing the rhytids.

Adverse Events Adverse events are not common with the use of HA to correct smoker’s lines. In my experience, when adverse events do occur they are typically a result of inappropriate product choice, poor technique

66 Two injection techniques are useful when treating smoker’s lines: retrograde linear threading and serial punctures 99

50 INJECTABLES I body language

Conclusion Treating smoker’s lines with HA fillers can be technically challenging, but the unique formulation of Teosyal’s latest range of HA fillers, RHA, has made treatment of the perioral area much easier. Teoxane’s patented method of preserving the long HA chains during the manufacturing process gives RHA unique properties that make it a superior product for this dynamic area of the face.

This range of fillers has been formulated to be able to stretch with movements while resisting compression and other constraints

or a combination of the two.

Lumpiness or surface irregularity can occur with any HA filler, although it is more prevalent with high viscosity HA fillers. The risk can be minimised with the use of non-particulated HA fillers of low viscosity and appropriate technique to avoid overcorrection.

I have found that transient side effects such as injection site inf lammation, including erythema and discomfort, typically resolve within one or two days. ‘Tyndall effect’ may occur with too superficial a placement of HA and is more commonly observed when particulated HA fillers are used in this region.

This presents as a bluish hue just beneath the skin and can be corrected very easily with the injection of hyaluronidase.

Infection is possible with any injection, but the risk is low and can be minimised through judicious use of antiseptic prior to the treatment and observing a strict protocol for infection control.

Cutaneous necrosis is a rare but clinically significant complication. This may present as vascular interruption at the treatment site with subsequent localised tissue necrosis.

Bacteria-derived HA fillers are generally considered nonimmunogenic, although there is a theoretical risk of hypersensitivity against any impurities that remain after the purification of HA. Patients who have previously experienced an immune response to HA should not be considered candidates for this type of treatment.

Dr Kieren Bong is a Cosmetic Doctor, trained in both medicine and surgery. He is the clinical director of the Essence Medical Cosmetic Clinic in Scotland, and combines his creative talents with his scientific, medical aptitude to provide excellent natural and refined aesthetic results for his patients.

Internationally, Dr Bong has an outstanding reputation as a leading lecturer, trainer and expert in aesthetic medicine, having carried out training master classes and workshops in over 25 countries. Dr Bong is the pioneer of the ‘Two-Point Eye Lift’ and ‘3D Ultimate Lift’ techniques for effective peri-orbital rejuvenation and advanced facial contouring and sculpting with dermal fillers.

References 1. Gregor F. Raschke, ‘Perioral Aging—An Anthropometric Appraisal’ Journal of Cranio-Maxillofacial Surgery, 2014; 42:312-317.

2. Leveque JL, ‘Influence of Age on the Lips and Perioral Skin’ Dermatology, 2004;208(4):307-13.

3. Gregor F. Raschke, ‘Perioral Aging—An Anthropometric Appraisal’ Journal of Cranio-Maxillofacial Surgery, 2014; 42:312-317.

4. Cornelis Kennedy, ‘Effect of Smoking and Sun on the Aging Skin’ Journal of Investigative Dermatology, 2003; 120:548-554.

5. Ezure T, Hoshoi J, Amano S et al. ‘Sagging of the Cheek is Related to Skin Elasticity, Fat Mass and Mimetic Muscle Finction’ Skin Res Technol, 2009;15:299-305.

6. David Funt, ‘Dermal Fillers in Aesthetics: An Overview of Adverse Events and Treatment Approaches’ Dove Press Journal: Clinical, Cosmetic and Investigational Dermatology, 2013; 6:295-316.

7. Airan LE et al, ‘Nonsurgical lower eyelid lift’, Plast Recons Surg, 2005; 116:1785-1792.

8. Indy Chabra, ‘Severe site reaction after injecting hyaluronic acid based soft tissue filler’, http://www.cosderm.com/fileadmin/qhi_archive/ArticlePDF/CD/024010014.pdf.

9. Busso M et al., ‘Reengineering Injectable Hyaluronic Acid Fillers: The Science ‘, PRIME North America 2014; 2(2): 42-8.

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body language I EDUCATION 53

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LASER/RF

23 May, An Introduction to Vascular and Pigmentation, Lynton Clinic, Cheadle W: lynton.co.uk 24-26 May, Advanced Skin and Laser Applications (in conjunction with University of Manchester), Lynton Clinic, Cheadle W: lynton.co.uk 6 June, Clinical Update Training, Lynton Clinic, Cheadle W: lynton.co.uk 22 June, Core of Knowledge (in conjunction with the University of Manchester), Lynton Clinic, London W: lynton.co.uk 27 June, An introduction to Tattoo Removal, Lynton Clinic, Cheadle W: lynton.co.uk Contact arabella@face-ltd.com if you would like your course featured

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

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* Only available to doctors, dentists and medical nurses with a valid registration number from their respective governing body.

FB - FULLY BOOKED All courses in London unless otherwise specified.

E: TRAINING@WIGMOREMEDICAL.COM

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MAY

JUNE

JULY

AUGUST

4 CPR & Anaphylaxis Update (am) 6 Algeness* 7 Microsclerotherapy* 8 Advanced Toxins* (am) FB 8 Advanced Fillers-TT* (pm) FB 11 Intro to Toxins* FB 12 Intro to Fillers* 13 Mini-Thread Lift* 14 Mini-Thread Lift* 14 ZO Medical Basic (Glasgow) 14 ZO Medical Interm. (Glasgow) 16 Dracula PRP* 17 ZO Medical Basic (London) 18 ZO Medical Interm. (London) 22 Advanced Toxins* (am) 22 Advanced Fillers-CH* (pm) 24 glo minerals 25 glo therapeutics 27 Sculptra*

1 CPR & Anaphylaxis Update (am) 1 Skinrölla Microneedling (pm) 2 Non-Surgical Rhinoplasty* 3 Algeness* 7 ZO Medical Basic (Manchester) 8 ZO Medical Interm. (Manchester) 9 ZO Medical Basic (Dublin) 10 ZO Medical Interm. (Dublin) 11 Microsclerotherapy* 21 Skincare with NeoStrata 22 Intro to Toxins* 23 Intro to Fillers* 24 Advanced Fillers-CH* (am) 24 Advanced Fillers-TT* (pm) 25 Mini-Thread Lift* 28 ZO Medical Basic (London) 29 ZO Medical Interm. (London) 30 ZO Medical Adv. (London)

8 Algeness* 12 ZO Medical Basic (London) 13 ZO Medical Interm. (London) 14 Sculptra* 15 Advanced Toxins* (am) 16 Microsclerotherapy* 18 Dracula PRP* 19 Skincare with NeoStrata 20 Intro to Toxins* 20 ZO Medical Basic (Dublin) 21 ZO Medical Interm. (Dublin) 21 Intro to Fillers* 22 Advanced Fillers* 22 ZO Medical Basic (Manchester) 23 ZO Medical Interm. (Manchester) 25 CPR & Anaphylaxis Update (am) 30 Mini-Thread Lift*

5 Algeness* 9 ZO Medical Basic (London) 10 ZO Medical Interm. (London) 11 ZO Medical Adv. (London) 12 ZO Medical Basic (Dublin) 13 ZO Medical Interm. (Dublin) 23 Skincare with NeoStrata 24 Intro to Toxins* 25 Intro to Fillers* 26 Mini-Thread Lift* 27 Advanced Fillers*

FOLLOW @WIGMORETRAINING ON TWITTER FOR THE LATEST UPDATES AND COURSE INFORMATION

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

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Filling in skin of colour PROF MUKTA SACHDEV, DR KEERTHI VELUGOTLA and DR ARCHANA SAMYNATHAN share their approach to using injectable dermal fillers in skin of colour

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olume replacement and soft tissue augmentation are the key components of anti-ageing procedures and hyaluronic acid fillers with lignocaine are the most commonly used. In India there is rapid increase in patients who are interested in minimally invasive aesthetic treatments. Filler injections comprise a significant number of these treatments, either alone or in combination with chemical peels, neuromodulatory toxin injections and lasers. Aesthetic treatments in skin of colour require expertise in foreseeing complications and managing specific issues.

When compared to the western population, knowledge of the cultural practices and local perception of traditional beauty and attractiveness are critical in deciding the technique and placement of filler injections. In a global community it is necessary to understand the aesthetic perception and cultural differences to manage and meet the patient’s expectations.

Indications of dermal fillers Unlike toxin injections, which are treatment of choice for dynamic lines, the key indications of fillers are static lines, wrinkles and volume augmentation.

Aesthetic indications: • Nasolabial folds • Forehead lines • Glabellar lines • Tear trough rejuvenation • Nose reshaping • Augmentation of chin, cheek, breast, buttock, temporal fossa • Marionette lines, perioral, periocular lines • Prejowl sulcus

• Lip augmentation and reshaping • Décolleté rejuvenation • Hand, neck rejuvenation • Ear lobe plumping, ear lobe ptosis Therapeutic indications include improvement of scars—post acne, post traumatic; dermatological diseases—scleroderma, AIDS associated lipodystrophy etc, and cushioning effect to treat corns and calluses Contraindications Contraindications include having a history of hypersensitivity to filler or its components; keloidal tendency; patients with unrealistic expectations or body dysmorphic disorder; pregnancy, lactation; infection at the site of injection; patients with platelet or bleeding disorders, or taking anti-platelet medication; patients with auto-immune disorders and patients with herpes facialis.

Tempory fillers—collagen Collagen forms the major structural protein of dermis and is responsible for the tensile property of skin. Loss of collagen as the skin ages, results in wrinkles. Degradation of collagen can be collagenase

mediated, which is produced as a result of UV exposure and antioxidant stress. The available injectable forms of collagen are bovine collagen, bioengineered human collagen and cadaveric collagen.

Concentration levels differ in each of these forms.

Hyaluronic Acid HA is the most commonly used filler agent worldwide. It forms the predominant component of the extracellular matrix. It has a very short life in human tissues as it is degraded by native hyaluronidase in tissues. To prevent this degradation and stabilise the molecule the chains must be cross-linked.

The unique property of hyaluronic acid is it’s ability to absorb water— hence the volumising and hydrating property of it when injected in tissues. Based on cross linking it can be monophasic or biphasic.

Crosslinking can be further managed to manufacture particulate (based on the particle size to increase the volumetric lift and span) and non-particulate forms (higher degree of crosslinking to proportionately increasing the volume). Research is underway to

CLASSIFICATION OF DERMAL FILLERS Dermal fillers can be classified in a number of ways: • Based on source: biodegradable (collagen, hyaluronic acid, autologous fat, fascia, poly-Llactic acid), non-biodegradable (calcium hydroxyapatite crystals, polymethylmethacrylate).

• Based on longevity: temporary (collagen, hyaluronic acid), semipermanent (poly-L-lactic acid), and permanent (silicon, polymethylmethacrylate ).

• Based on site of placement: dermal (collagen, hyaluronic acid), subdermal (poly-L-lactic acid), supraperiosteal (calcium hydroxyapatite crystals).

• Based on origin of filler material: heterograft, allograft, auto graft (fat, fascia), synthetic material.

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determine the best possible level of crosslinking, where the hyaluronic acid molecule loses its biocompatibility and hydrophilic nature thereby leading to rejection, encapsulation and granuloma formulation. Trials proving the efficacy with the recently innovated 0.3% lidocaine addition to the filler have been done, concurrent end results and safety profiles with the added benefit of pain relief were observed.

Semi permanent fillers Temporary fillers can be created from various sources—some natural, and some synthetically produced in a laboratory.

Autologous fat Using patient’s own fat for augmentation of defects elsewhere is the oldest method of soft tissue augmentation. Introduction of tumescent anaesthesia has enhanced the use of autologous fat transplantation.

The most popular method of fat transplantation is microlipoinjection, which involves use of aspirated fat globules in augmentation of facial tissues.

Poly-L-lactic acid (Sculptra) This promotes the production of new organised collagen in the dermis. It is utilised in the form of a sub dermal injection dispersed in sodium carboxymethylcellulose gel. PLA is approved by USFDA for the treatment of HIV associated lipoatrophy, however volume augmentation is it’s off label indication.

Calcium hydroxyapatite (Radiesse) The advantage of this filler material is its availability as microspheres which are dissipated into the tissue for a long time slowly up to two years. The FDA approved indications being HIV associated lipoatrophy, facial rhytides, and vocal cord augmentation. It is not known to cause granuloma formation.

Permanent fillers These are less commonly used and include polymethylmethacrylate (PMMA) (Artefill), silicone and polytetrafluoroethylene. Associated drawbacks include hypersensitivity, high incidence of immediate post treatment edema and bruising.

The major drawback is the permanent nature of the fillers—as the patient ages there will be changes in the skin and the cosmetic acceptability of the filler may change.

Pre-procedure care Patient selection and counselling play a pivotal role in any aesthetic procedure. Detailed medical history including previous experience of the patient with fillers, drug intake history (eg. aspirin, thrombolytics, anti platelet drugs), keloidal tendency in the patient and family has to be taken. Counselling of patient is important regarding the procedure, expenditure, complications

body language I INJECTABLES 57

and aesthetic outcome. Detailed informed consent and pre-procedure photographs are mandatory for future reference. Ideally it is advisable to evaluate the patient, provide basic information to the patient regarding dermal fillers, and schedule the procedure on another day.

Anaesthesia Injection of dermal fillers is a minimally invasive technique and anaesthesia is generally not required.

However in apprehensive patients and in treatment of areas with high pain sensitivity (lips, periorbital) anaesthesia may be required. Anaesthesia may be topical (Lidocaine cream under occlusion or ice), nerve block (infraorbital or mental nerve block), or use of fillers that contain anaesthetic agents. Newer filler injections are being available in the market that contains local anaesthetic molecules that alleviate the pain.

Injection techniques

Choice of technique is at the discretion of the clinician and will vary depending on the type of filler used and anatomical site to be injected. Techniques include: • Linear threading technique • Fanning technique • Cross hatching technique • Depot technique • Serial puncture technique • Push ahead technique • Sandwich or layering technique • Fern technique

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Post procedure care Application of ice immediately after the procedure and intermittently during the day is advised to alleviate the pain if any and to reduce the risk of bruising. Patients of skin of colour have a high risk of post inflammatory hyper-pigmentation. Therefore it is necessary to emphasise the importance of use of sunscreen. Other equally important instructions include: • Avoid excessive massaging the area treated.

• Avoid strenuous activity the next six to eight hours.

• Avoid exposure to extreme cold or heat.

• Analgesics can be prescribed to alleviate pain and discomfort.

• Anti-bruising creams containing vitamin K can be prescribed.

• Adverse reactions, if any, should be reported immediately.

Complications Complications of fillers vary in skin of colour. Though the high melanin content in the skin is protective against photo damaging, it may be responsible for complications like post-inflammatory hyper- or hypo-pigmentation. Due to the high level of dermal fibroblasts in individuals of skin of colour they are more prone to develop keloids or hypertrophic scars.

Complications may be immediate, such as pain, hypersensitivity or anaphylaxis. Other early complications include: • Injection site reactions: erythema, odema, ecchymosis, pruritus, tenderness.

• Skin discolouration: erythema, cyanosis, blue appearing papules (Tyndall effect of superficially placed fillers), blanching of skin.

• Infection: erythema, edema, pain, fluctuant mass, systemic symptoms.

• Tissue necrosis and venous congestion secondary to vascular compromise.

• Nodules: Due to inappropriate placement of filler.

Late complications include: • HSV activation: Itching, burning, erythema, edema, vesicles, pustules.

• Granuloma formation: palpable, visible nodules.

• Clumping and migration of filler.

• Aseptic abscess or biofilm reaction.

Permanent complications could include: scarring; persistent discolouration and hyper-pigmentation.

Reversing treatment Though reversal of hyaluronic acid filler action is not an FDA approved indication of hyaluronidase, it is advisable to have it in office to deal with the over correction, to manage impending tissue necrosis and the Tyndall effect. Hyaluronidase must be reconstituted with normal saline before use. It’s application is contraindicated in patients with hypersensitivity to hyaluronidase or injection components.

It is also contraindicated in patients with an allergy to hymenoptera stings and thiomersal.

procedures, have gained popularity and are the most commonly undertaken aesthetic procedure. Factors such as detailed understanding of facial anatomy, proper patient and product selection for the anatomical site, preparation and injection techniques determine the outcome.

In view of the high risk of post inflammatory pigmentation in skin of colour it is better to undertake techniques such as linear threading to minimise the number of punctures. Coloured skin specific issues such as hypersensitivity, keloidal tendency, bad scarring, dyschromias have to be considered in patient selection as well as filler and technique selection.

Conclusion Dermal fillers, both alone or in combination with other aesthetic

Prof Mukta Sachdev, Dr Keerthi Velugotla and Dr Archana Samynathan Manipal Hospital, Banga-

References 1. Naoum C, Dasiou-Plakida D. Dermal filler materials and botulin toxin: Review. International Journal Dermatology 2001; 40:609-21. Level B 2. Matarasso SL, Carruthers JD, Jewell ML. Restylane Consensus group, Consensus recommendation for soft tissue augmentation with non animal stabilised hyaluronic acid (Restylane).

Plastic Reconstruction Surgery. 2006;117:3S-34S; discussion 35S-43S. 3. Baumann L, Blyumin M, Saghari S. Dermal fillers. Baumann L. Cosmetic Dermatology: Principles and practice, 2nd edition. Tata McGraw-Hill; 2011;191-211.

4. William J Lipham. Cosmetic and clinical applications of botox and dermal fillers; chapter 9; second edition 2008.

5. Vedamurthy M. Standard Guidelines for the use of dermal fillers; Indian Journal Dermatology; Venereol Leprol 2008:74, Suppl Si:23-7 6. Beasley KL, Weiss MA, Weiss RA. Hyaluronic acid fillers a comprehensive review. Facial Plastic Surgery 2009; 25:86–94. A good biotechnological review of hyaluronic acid fillers.Bray D, Hopkins C, Roberts DN. A Review of Dermal Fillers in facial plastic surgery. Arch Facial Surgery 2007; 9: 130-136.

7. Bergeret-Galley C. Choosing Injectable treatments according to treatment area: the European experience. Facial Plastic Surgery 2009; 25:135–142.

8. Weinkle SH, Bank DE, Boyd CM, et al. A multicenter, double-blind, randomised controlled study of the safety and effectiveness of JUVE´DERM1 injectable gel with and without lidocaine.

Journal Cosmetic Dermatology 2009; 8:205–210.

9. Wahl G. European evaluation of a new hyaluronic acid filler incorporating lidocaine. Journal Cosmetic Dermatology 2008; 7:298–303 10. Vedamurthy M. Dermal fillers; Khunger N, Sachdev M. Practical Manual of Cosmetic Dermatology And Surgery,1st edition. Mehta Publishers; 2010; Chapter 27, 368-376 11. Steven H. Dayan, MD; and Benjamin A. Bassichis, MD. Facial Dermal Fillers: Selection of Appropriate Products and Techniques. Aesthetic Surgery Journal 2008; 28:335–347.

12. Vedamurthy M. Soft Tissue Augmentation: Hyaluronic Acid Fillers In: Mysore Venkataram ACS(I) Textbook on Cutaneous & Aesthetic Surgery. Jaypee publications; 2010;634-645.

13. Coleman KR and Carruthers J. Combination therapy with Botox and fillers; the new rejuvenation paradigm. Dermatology Therapy 2006; 19:177-188 14. Lowe, NJ, et al. Adverse reactions to dermal fillers: Review. Dermatology Surgery 2005;31: 1616-25.

15. Derek Jones Injectible Fillers, Wiley Blackwell chapter 10: 121-139 16. Hirsch RJ, Cohen JL, Carruthers JD. Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and a proposed algorithm for management with hyaluronidase. Dermatological Surgery Journal. 2007; 33:357

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

Not all HA dermal fillers are created equal.

OPTIMAL

Cohesive Polydensified Matrix® (CPM®) Technology1,2

I N T E G R AT I O N 2

Optimal tissue integration2

TISSUE

Intelligent rheology design

BEL/37/MAR/2016/LD Date of preparation: March 2016

Adverse incidents should be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents should also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143.

The filler you’ll love

Contact Merz Aesthetics NOW and ask for Belotero Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com 1. BEL-DOF-003 V2 Belotero® technology, June 2015. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI: 10.1159/000354384.

www.belotero.co.uk

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