Body Language #83

september

83

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

Picture perfect BEFORE AND AFTER—THE SECRET TO GOOD CLINIC PHOTOGRAPHY AND VIDEO IS REVEALED

GROWTH FACTORS

P-SHOT & O-SHOT

LAUGHTER LINES

The impact of growth factors on the future of aesthetic medicine

The pioneering use of PRP to treat male and female sexual dysfunction

Step by step guide to treat nasolabial folds with the 3Lift technique

body language I CONTENTS 3

27

41

contents 07 NEWS

41 TECHNOLOGY

OBSERVATIONS

MODERN TREATMENT EDUCATION

Reports and comments

18 DERMATOLOGY GROWTH FACTORS Dr Ahmed Al Qahtani discusses growth factors and their impact on the future of aesthetic medicine

24 NON-SURGICAL NATURAL VOLUME Algeness offers treatment versatility with a unique highly biocompatible formulation, offering patients well-tolerated and long lasting volumising results

27 INJECTABLES

43 PRODUCTS ON THE MARKET The latest in anti-ageing and medical aesthetic products and services

47 EQUIPMENT THERMO-THERAPEUTICS Dr Ariel Haus discusses the success of ultrasound use for body reshaping

LIFTING LAUGHTER LINES

50 DENTAL

Dr Keiren Bong explains the 3Lift treatment for the nasolabial folds

COSMETIC DENTISTRY

30 NON-SURGICAL THE P-SHOT AND O-SHOT Dr Sherif Wakil outlines his pioneering use of platelet rich plasma for the effective treatment of male and female sexual dysfunction

39 TECHNOLOGY 30

Tim Molony discusses how to educate modern day patients often misinformed by the internet

Suzanne Valance discusses changes in cosmetic dentistry, and which treatments are most suitable for a range of dental concerns

55 HAIR LOSS FEATHERLIKE FINISH Karen Betts guides us through brow microblading

PICTURE PERFECT

57 INTERVIEW

Dr Emmanuel Elard exposes the secrets of good clinical photography and video

LIPOSUCTION Q&A Dr Foued Hamza answers questions about fat removal

4 CONTENTS I body language

PRODUCTION 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 PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Dr Ahmed Al Qahtani, Dr Keiren Bong, Dr Sherif Wakil, Dr Emmanuel Elard, Tim Molony, Dr Ariel Haus, Suzanne Valance, Karen Betts, Dr Foued Hamza ISSN 1475-665X The Body Language® journal is published ten 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

Dear Body Language Reader, Welcome to the September edition of Body Language. We hope that the changes coming over the next few issues will continue to support your professional development as we endeavour to become your closest partner in aesthetics.

Body Language has always maintained the high calibre of scientific content, featuring editorial from international figureheads in aesthetics. Alongside this ethos, we want to incorporate the other side of the industry—featuring the manufacturers and service providers. They are the backbone within the aesthetic community and for the first time Body Language will not only tell the story from the clinic table, but from the teams that make it all possible. Scientific content mixed with up-to-date product news and concepts will keep you abreast of everything aesthetic.

Raffi Eghiayan, Publisher, Body Language

47

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body language I NEWS 7

observations

ALMOST HALF OF HIGHLY RATED SUNSCREENS DO NOT MEET AAD GUIDELINES Most effective absorbers and nicest fragrances do not adhere to American Academy of Dermatology (AAD) guidelines Regulating skin exposure to ultraviolet (UV) light is the most effective way to reduce the risk for all skin cancer types, and the ADD The American Academy recommend protecting skin with daily use of a sunscreen over SPF 30 that offers broad-spectrum protection against UVA and UVB rays.

Consumer reviews on websites such as Amazon can often give a good insights into a product.

However, results from an article published online by JAMA Dermatology questions if sometimes consumer reviews can do more harm than good.

Shuai Xu, MD, MSc, of Northwestern University Feinberg School of Medicine in Chicago, IL, and co-authors searched the keyword "sunscreens" on the US retailer Amazon.com in December 2015.

The team then selected the top one percentile of sunscreen products according to an average consumer review of four stars or greater. They also collected descriptive data including SPF strength, price, and active ingredients, in addition to the top five most helpful and critical comments for each product.

Of the 6,500 products that were categorised as "sunscreens," the top 65 were chosen for analysis.

For those top 65 sunscreens, Xu and colleagues

looked at how well they met American Academy of Dermatology minimum recommendations —that they are at least SPF 30, broad spectrum and resistant to water and sweat—and were surprised to find that 40 percent of these popular sunscreens were deemed insufficient.

A total of 40% of the highest rated sunscreens on Amazon.com did not adhere to A AD guidelines, mostly due to lack of water and sweat resistance.

The study also found that the price of sunscreen varied greatly—from 68

cents an ounce to $23.47 —but that price wasn’t related to SPF number.

Sunscreens that were water-resistant tended to be more pricey, and creams were more expensive than lotions, and lotions more than sprays.

The article suggests that "Dermatologists should balance the importance of cosmetic elegance, cost, and AAD guidelines for sun protection in making their recommendations to consumers."

Most of the products analysed claimed additional product features in addition to sun protec-

tion. The authors note that consumers should be advised that labels such as 'safe for sensitive skin,' 'preservative free,' or "noncomedogenic" are marketing mechanisms and are not performance standards, such as SPF, that are regulated by the Food and Drug Administration (FDA).

"Dermatologists should counsel patients that sunscreen products come with numerous marketing claims and varying cosmetic applicability, all of which must be balanced with adequate photoprotection," the study concludes.

8 NEWS I body language

FIRST RETINOID APPROVED FOR OVER-THE-COUNTER USE The US FDA has approved Differin Gel 0.1% (adapalene), a once-daily topical gel for the over-the-counter (OTC) treatment of acne, for use in people 12 years of age and older Differin Gel 0.1% is the first in a class of retinoids to be made available OTC for the treatment of acne, and contains the first new active ingredient for acne treatment for OTC use since the 1980s. The gel was originally approved in 1996 as a prescription product for the treatment of acne vulgaris in patients 12 years of age and older.

“Millions of consumers, from adolescents to adults, suffer from acne,” said Lesley Furlong, M.D., deputy director of the Office of New Drugs IV in the FDA’s Center for Drug Evalua-

tion and Research. “Now, consumers have access to a new safe and effective over-the-counter option.”

Differin Gel’s safety and efficacy were initially established based on five clinical trials in people with mild to moderate acne. To support approval for OTC marketing, the data accrued from 1996-2016 on post-marketing safety, data from consumer studies (a label comprehension study, a self-selection study, and an actual use trial), and data from a maximal use trial were submitted.

SCROTAL LIFTS Gynaecomastia and beard transplants move aside—men are looking further for another part of their anatomy to modify Scrotoplasty could be the next trend in male grooming, predicts The Telegraph, and with the British Association of Aesthetic Plastic Surgeons showing that the number of men undergoing cosmetic procedures has more than doubled in the past ten years (to over 4,500 a year), there could be some truth in this.

The ‘P shot’ of Dr Sherif Wakil has been hugely successful in altering the shape, size and function of the penis, but aside from that—little exists in the world of aesthetic medicine for addressing the

appearance of the penis or scrotum beyond hair removal.

The lifting of low hanging scrotal sacks with a scrotal uplift is, according to a Tunbridge Wells based surgeon Dr Nakhdjevani, set to be a rising trend. The minimally invasive procedure which can improve the appearance and discomfort caused by lax scrotal skin, which occurs as a result of time, trauma and genetics, is carried out under local anaesthetic. Excess skin is removed and scars are hidden in the natural grooves of the two halves where the scro-

tums join in the midline. The ‘lunch time’ procedure is performed in under an hour uses absorbable sutures that will dissolve.

Aside from general discomfort and swelling for three to five days, daily activities can resume within in a week. In addition to the cosmetic appeal of this procedure, Dr Nakhdjevani also cites the functional benefits for men who regularly engage in cycling or other sports where the scrotum can get caught in clothing or become uncomfortable. The procedure at Bellavue is a snip at just £2,800.

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body language I NEWS 11

GMC URGES PATIENTS TO QUESTION THEIR DOCTORS Guide published to help potential patients

LIGNIN FROM PLANTS BOOSTS EFFECTIVENESS OF SUNSCREEN Natural ingredient could boost product performance A major waste product of the paper industry – Lingin—may one day be used to enhance the effectiveness of sunscreen report scientists who have published their findings in the ACS Sustainable Chemistry & Engineering.

As consumer trends move towards natural ingredients consumers are searching for better product performance that comes from natural rather than chemical sources to protect themselves from sun damage. As a step toward meeting this demand, scientists have added compounds from a variety of sources, including green coffee, soy and papaya to sunscreens. Shiping Zhu, Xueqing Qiu and colleagues wanted to test different kinds of lignin for their potential as an enhancer.

The researchers showed that out of five types of lignin tested, organosolv lignin improved the sun protection factor (SPF) of sunblock the most.

Sunscreen containing just one percent of this compound had double the lotion’s original SPF—it went from 15 to 30%. A lotion with 10% organosolv lignin increased SPF even further, from 15 to almost 92, but excessive amounts of hydrophilic lignin such as lignosulfonate caused the product to start separating. More work is needed, but the results represent a promising first step toward the development of lignin-containing sunscreen, say the researchers.

People thinking of having a cosmetic procedure are being urged to question their doctors before going ahead with treatment, in new advice issued by the General Medical Council.

As tough standards for doctors carrying out cosmetic practice come into force—covering everything from fillers to face lifts – the GMC has published a guide to help potential patients research and receive safe, high quality cosmetic care.

The following advice has been given to those considering a cosmetic procedure: Consent: The doctor who will carry out your procedure must speak to you personally and get your consent.

Openness: Your doctor must be open and honest about their skill, experience, fees and any conflicts of interests.

Safety: Your procedure must take place in a safe and suitable environment.

Marketing: Your doctor must market themselves responsibly and be clear about the risks involved.

Experience: Your doctor should have experience of carrying out the procedure you’ve asked for, and be able to tell you what it involves and how long it takes.

Time: Your doctor must give you enough time to make your decision. You should never feel pressured or rushed into having a procedure.

Information: Your doctor must give you clear information, including details about aftercare and who to contact if you’re worried.

Costs: Your doctor must explain the costs clearly, including details of any fees you need to pay for any potential additional procedures.

The advice, contained in full in the GMC’s leaflet What to expect of doctors who carry out cosmetic procedures, also explains what to do if people have any concerns or doubts about a cosmetic procedure, or if they experience any problems after work has been carried out.

GMC Chairman, Professor Terence Stephenson said, ‘People choosing to undergo a cosmetic procedure have the right to expect safe, high quality care and treatment. While doctors offering cosmetic interventions now have tough standards they must follow, this shouldn’t deter potential patients from asking questions about any aspect of their care, treatment and support.

The new COSMETIC acrostic accompanies its new guide What to expect of doctors who carry out cosmetic procedures. The GMC is asking private cosmetic clinics across the UK to display these materials to help inform and support potential patients.

12 NEWS I body language

NEW DRUG CLEARS PSORIASIS IN CLINICAL TRIALS Group of studies show promising results for psoriasis sufferers Approximately one-third of patients on a new psoriasis drug, ixekizumab, had clear skin after three months using the drug which targets interleukin 17A (IL-17A), which is a cytokine involved in inflammation. Clinical trial results for two other drugs targeting IL-17, brodalumab and secukinumab were released earlier this year.

Eli Lilly, ixekizumab's manufacturer, has published results of three separate clinical trials involving 3,866 patients, which tested the safety and effectiveness of the drug. Trials were held in 21 countries, including sites in North America, South America, Asia, Europe and Australia. The results of these phase III trials were compiled in a paper pub-

lished in the New England Journal of Medicine.

"This group of studies not only shows very high and consistent levels of safety and efficacy, but also that the great majority of the responses persist at least 60 weeks," said Dr Kenneth Gordon, a professor of dermatology at Northwestern University Feinberg School of Medicine and first author of the paper.

In one trial, called UNCOVER, patients were assigned to take either ixekizumab or a placebo. The other two trials, UNCOVER-2 and UNCOVER-3, compared ixekizumab with Enbrel (etanercept). Enbrel (etanercept) is a biologic medication that targets another cytokine called tumor necrosis factor-alpha

(TNF-alpha).

According to the research, 78-90% of the patients taking ixekizumab experienced at least a 75% improvement in their psoriasis after twelve weeks, as measured by the Psoriasis Area and Severity Index (PASI 75). Of these patients, 31-41% achieved 100% improvement (PASI 100) after twelve weeks, which is clear skin.

In comparison, only 5-7% of patients taking Enbrel achieved PASI 100, the statement reports. UNCOVER, the study testing ixekizumab against a placebo only, kept patients on the drug for 60 weeks. Throughout the entire study period, patients maintained "high levels of response," according to the press release.

The most common side effects for ixekizumab were colds and infections around the site of the injection, and in the trials comparing ixekizumab with Enbrel, the frequency and severity of side effects were similar for the two drugs, according to the release.

"Based on these findings, we expect that 80 percent of patients will have an extremely high response rate to ixekizumab, and about 40 percent will be completely cleared of psoriasis," Gordon said. "Ten years ago, we thought complete clearance of this disease was impossible. It wasn't something we would even try to do. Now with this drug, we're obtaining response levels higher than ever seen before."

body language I NEWS 13

events 8-10 SEPTEMBER, London Breast Meeting 2016, London, UK W: londonbreastmeeting.com/home 9-10 SEPTEMBER, F.A.C.E.2f@ce, Cannes, France W: face2facecongress.com/en/ 16 - 17 SEPTEMBER, AMWC Eastern Europe 2016 – 4th Aesthetic & Anti-Aging Medicine World Congress Eastern Europe, Moscow, Russia W: euromedicom.com 16-19 SEPTEMBER, Aesthetic Medicine Symposium, Scottsdale, United States W: aestheticmedicinesymposium.com/ 17 SEPTEMBER, BACN Autumn Aesthetic Conference, ICC Birmingham, UK W: bacn.org.uk/events 18 SEPTEMBER, Aesthetic Medicine North, Exchange Hall, Manchester Central, UK W: aestheticmed.co.uk/e/north16/site/home/ 23-24 SEPTEMBER, The International Society of Aesthetic Trichology, Warsaw, Poland W: is-at.org/konferencja/index.php?lang=en 30 SEPTEMBER – 2 OCTOBER, VISAGE, Nice, France W: v1.euromedicom.com/visage/index.html

SLEEPING POSITION AFFECTS WRINKLES Study shows stomach and side sleeping positions cause facial distortion and wrinkles over time A new study published in the Aesthetic Surgery Journal, indicates that compression, tension, and shear forces applied to the face during sleep cause facial distortion when people sleep on their sides and stomach, leading to the development of sleep wrinkles over time.

"Sleep wrinkles form in response to distortion created when the face is pressed against any sleep surface. They tend to worsen over time due to repetition combined with thinning of the skin and decreased elasticity as we age," explains lead author, Dr Goesel Anson.

Sleep wrinkles are also influenced by the amount of time spent in various positions. While our initial sleep position is a conscious decision, we change positions throughout the night unconsciously. The number of shifts decreases as we age from 27 to 16 per night, with an average of about 20 position shifts. The lateral (side) sleep position is the most common

in studies averaging 65%, with the remaining 30% in the supine (back) position, and 5% in the prone (stomach) position. While some sleep wrinkle patterns can reinforce facial expression lines, most sleep wrinkles tend to be perpendicular to expression wrinkles.

Most sleep wrinkles can be seen on the forehead, lips and cheeks.

Unlike facial expression wrinkles caused by muscle contractions, sleep wrinkles that are formed because of mechanical compression during sleep can't be eliminated using botulinum toxin.

Dr Anson notes, "One way to minimise sleep wrinkles is to limit facial distortion during sleep. If you can stay on your back, that's ideal. There are several specialty pillows available to help achieve that. Dermal fillers can temporarily improve wrinkles of any type however neurotoxins won't have much effect on these wrinkles since they are not caused by muscle contractions."

6-7 OCTOBER, CCR Expo, London Olympia, UK W: ccr-expo.com 6-9 OCTOBER, International Society of Plastic & Regenerative Surgeons, Marseille, France W: ispres-congress.org 7 OCTOBER, Breast Cancer Conference, London, UK W: royalmarsden.nhs.uk/breastmeeting 12-14 OCTOBER, Aesthetic Medicine, Saint-Petersburg, Russia W: aestheticmed.ru/ 19-23 OCTOBER, DASIL—Dermatologic Aesthetic Surgery International League, Dubai, United Arab Emirates W: thedasil.org 21-22 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, 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—2nd Emirates Plastic Surgery Society Congress 2016, Dubai, United Arab Emirates W: epsc.ae/

24 - 26 NOVEMBER, ICAD 2016, Bangkok, Thailand W: euromedicom.com 30 NOVEMBER – 3 DECEMBER, Cosmetic Surgery Forum 2016, Las Vegas, USA W: cosmeticsurgeryforum.com/ Send events for consideration to arabella@face-ltd.com

www.wigmoremedical.com I 020 7491 0150 | Tel 0207.514.5975 Stand 68 Benjamin Britten Lounge | www.wigmoremedical.com

body language I NEWS 15

FRUIT AND VEG GIVE YOU THE FEEL-GOOD FACTOR Research finds psychological wellbeing benefits within two years of an improved diet Eating more fruit and vegetables can substantially increase people’s later happiness levels, according to a University of Warwick study to be published in the American Journal of Public Health. The study is one of the first major scientific attempts to explore psychological well-being beyond the traditional finding that fruit and vegetables can reduce risk of cancer and heart attacks.

Happiness benefits were detected for each extra daily portion of fruit and vegetables up to eight portions per day.

The researchers concluded that people who changed from almost no fruit and veg to eight portions of fruit and veg a day would experience an increase in life satisfaction equivalent to moving from unemployment to employment. The wellbeing improvements occurred within 24 months.

The study followed more than 12,000 randomly selected people, who kept food diaries and had their psychological wellbeing measured. The authors found large positive psychological benefits within two years of an improved diet.

Professor Andrew Oswald said: “Eating fruit and vegetables apparently boosts our happiness far more quickly than it improves human health. People’s motivation to eat healthy food is weakened by the fact that physical-health benefits, such as protecting against cancer, accrue decades later. However, well-being improvements from increased consumption of fruit and vegetables are closer to immediate.”

The work is a collaboration between the University of Warwick, England and the University of Queensland, Australia.

The researchers found that happiness

increased incrementally for each extra daily portion of fruit and vegetables up to eight portions per day. The study involved an examination of longitudinal food diaries of 12,385 randomly sampled Australian adults over 2007, 2009, and 2013 in the Household, Income, and Labour Dynamics in Australia Survey. The authors adjusted the effects on incident changes in happiness and life satisfaction for people’s changing incomes and personal circumstances.

Dr Redzo Mujcic, research fellow at the University of Queensland, said: “Perhaps our results will be more effective than traditional messages in convincing people to have a healthy diet. There is a

psychological payoff now from fruit and vegetables—not just a lower health risk decades later.”

The authors found that alterations in fruit and vegetable intake were predictive of later alterations in happiness and satisfaction with life. They took into account many other influences, including changes in people’s incomes and life circumstances.

The academics think it may be possible eventually to link this study to current research into antioxidants, which suggests a connection between optimism and carotenoid in the blood. However they argue that further research is needed in this area.

PLASTIC SURGEON BROADCASTS ON FACEBOOK Natural ingredient could boost product performance After Miami plastic surgeon Dr Michael Salzhauer gathered one of the largest followings on Snapchat by using it to document procedures, another US doctor has taken things one step further by broadcasting graphic videos of his operations not only on Snapchat, but on Facebook Live.

Dr Thomas Jeneby, from San Antonio, Texas streams videos

of breast augmentation, liposuction and tummy tucks online.

The surgeon claims his videos are often watched by more than 24,000 people a day—and says he uses them to promote his practice and not only reassure people that the operations are safe, but give him an opportunity to speak with commenters watching the videos who are interested in having surgery themselves.

16 NEWS I body language

RESEARCHERS DEVELOP NEW FRAMEWORK FOR HUMAN NUTRITION Scientists call for a radical rethink through a new 'nutritional geometry' framework Existing models for measuring health impacts of the human diet are limiting our capacity to solve obesity and its related health problems, claim two of the world's leading nutritional scientists in their newest research.

In the latest volume of Annual Review of Nutrition, Professor David Raubenheimer and Professor Stephen Simpson from the University of Sydney's Charles Perkins Centre call for a radical rethinking of human nutrition science through a new framework called 'nutritional geometry'—the culmination of more than 20 years of research in the field.

'Nutritional geometry' considers how mixtures of nutrients and other dietary components influence health and disease, rather than focusing on any one nutrient in isolation. It is hoped this new model will assist health professionals, dietitians and researchers to better understand and manage the complexities of obesity.

"Our framework throws down the gauntlet to the whole field of human nu-

trition. It shows that the prevailing focus on single nutrients is not able to help us understand complex chronic diseases, and that an approach based on nutrient balance can help solve the problem," said Professor Stephen Simpson, Academic Director of the Charles Perkins Centre.

Human nutrition science has historically focused on a single-nutrient approach, which is predicated on a lack of resources or micronutrient deficiency.

For instance, the absence of vitamin C in human diets is a known cause of scurvy.

But this traditional approach is no longer useful in the face of modern nutrition-related diseases, the authors argue, which are driven by an overabundance of food, an evolved fondness for foods containing particular blends of nutrients, and savvy marketing by the packaged food industry which exploits these preferences.

"Conventional thinking which demonises fat, carbohydrate or sugar in isolation as causes of the obesity crisis— dubbed the single nutrient approach—

has now run its course. We've provided a framework for not only thinking about but also experimentally testing issues around dietary balance," said Professor Simpson.

"Our new approach provides a unique method to unify observations from many fields and better understand how nutrients, foods and diets interact to affect health and disease in humans," said Professor David Raubenheimer, who heads the Nutrition Theme at the Charles Perkins Centre.

"The 'nutritional geometry' framework enables us to plot foods, meals, diets and dietary patterns together based on their nutrient composition, and this helps researchers to observe otherwise overlooked patterns in the links between certain diets, health and disease."

The new model enables complex problems like obesity to be viewed from a variety of perspectives, from the impacts of nutrients on metabolism and the health of individuals, through to the sustainability of global food systems.

"Although at face value more complex than the single-nutrient model, our 'nutritional geometry' framework can simplify the study of human nutrition in the long run by helping to identify those subsets of factors and their interactions that are driving negative health and environmental outcomes in our rapidly changing environments," said Professor Simpson.

To illustrate the power of the approach, Professor Raubenheimer and Professor Simpson plotted data for the composition of 116 diets, compiled from previous published studies examining macronutrient ratios (carbohydrate, fats and protein) and energy intake in humans.

Their model shows that protein was the strongest driver influencing diet, regulating the intake of fat and carbohydrate. This finding is consistent with the previously observed 'protein leverage' phenomenon, in which the strong human appetite for protein leverages the intake of fats, carbohydrates and total energy.

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18 DERMATOLOGY I body language

Growth factors DR AHMED AL QAHTANI discusses growth factors and their impact on the future of aesthetic medicine

I

n 1986, Dr Rita Levi-Montalcini and Stanley Cohen were awarded the Nobel Prize in Physiology or Medicine for their discovery of nerve growth factor (NGF). In 2002, Gail Newton and her group—of which Dr Fitzpatrick was one, got the first patent in producing growth factors and using them in aesthetic medicine. We now know them as Chemedica—who were bought out

by Arjun in 2014. In 2013, I came up with a patent after having discovered how to produce growth factors, and how to characterise

and generate them. In 2014, I also patented the application of specific types of growth factors for ocular and eye treatments..

What are growth factors?

Growth factors are chemical messengers, which allow the cells to communicate. This is extremely vital for any cellular functions and variability, since cells will not thrive if they cannot communicate with their environment, or with other cells. This is how cells search for help when they need it. If cells are damaged, they communicate

via growth factors to call for help.

Growth factors also have the ability to turn a function on and off. When they were first discovered, proteins were placed in a dish and cells started growing—hence the name growth factors. However, the name 'growth factors', is not really the best name. These particular factors allowed the cells to grow, but we now know that there are more than 370 different growth factors and not all can cause cell growth.

In the same cell, growth factors have the ability to change the

body language I DERMATOLOGY 19

physiology of the cell; they are involved in the production and proliferation of blood vessels, collagen production, distribution, elastin and so forth. When we consider using a platelet derived growth factor (PDGF)—if you want to carry out a function, if you want to construct a product, you can just go to

a growth factor, list functions, and then just pick it out. It is just like cooking a meal.

Growth factors are very unique.

They are signalling molecules that require a ‘lock and key’ and they cannot cross species. If your patients are humans, then you will need to use growth factors that are

66 Growth factors are very unique—they are signalling molecules that require a 'lock and key' and they cannot cross species 99

derived from humans. If your patients are apples or oranges, then you need growth factors from apples or oranges.

Growth factors for treating necrosis Dr de Melo is a Portuguese plastic surgeon based in Dubai. He has been using growth factors for the last five years in his practice and has been working on a clinical case that is expected to publish soon.

Clinical evidence #1 A 37-year old female patient was presented to Dr de Melo for a breast reduction operation. She was

20 DERMATOLOGY I body language

a heavy smoker, so oxygen content in her blood and blood platelets had become sticky and aggregated.

After the breast reduction, she returned having developed total necrosis in the areolas of the nipples.

A blood surgeon would deal with this by bringing a vessel from below, connecting it up and cutting where the necrotic tissue is.

Knowing this woman did not wish to have more surgical interventions, Dr de Melo’s approach was to treat her with ‘recovery’—a very high concentration of growth factors designed to repair; hence the name. She came in every three days to change the dressing and after 26 days, the whole nipple and areola was restored.

From my experience, healing and restoring are two different concepts.

This woman’s wound was healed in 26 days—you would have never known there was a trauma before.

Sensation was recovering, showing the nerves were starting to reconnect. Testing nerve sensation can be done not just by sensation, but also by checking reflexes as well—seeing if the nipple shows erectile response after stimulation. That happened at 40 days. The treatment not only restored the tissue, it was also repaired without scarring. Furthermore, function was restored. This amazing communication comes from growth factors.

Improving wound healing— clinical evidence #2 A 62 year old female patient with type 2 diabetes was presented at a clinic in California. She had a very poor medical history. She had lost both her eyes, had a heart problem, and had fallen and injured her knees. After six months of standard and ineffective treatment for chronic wounds, she was open for any new clinical trials of some drugs that could help her. The scar formation was particularly interesting as there was really minimum scar formation. In a 62 year old diabetic patient, you can expect very slow healing and a lot of scarring, but this was not the case.

Growth factors changing orthopaedics Another area where growth fac-

RECOVERY The AQ Recovery Serum in conjunction with micro needling works to tighten the skin as the serum targets fibroblast cells that are responsible for providing a backbone for the skin. It has been used by dermatologists, cosmetic surgeons, and even orthopedic surgeons who use it before dressing. This serum is a pharmaceutical grade product containing the highest concentration of natural growth factors, proteoglycans, and glycosaminoglycans on the market. The AQ Recovery Serum is designed to enhance the skin’s natural process of regeneration and repair by promoting collagen production, promoting healthy circulation, and encouraging cellular renewal. This system of producing growth factors is easier, more convenient, and even safer than other conventional methods. It improves the appearance of ageing, damaged and postprocedure skin with a highly concentrated formula that transforms skin cells to a younger state and fortifies the skin's ability to repair DNA damage that causes the signs of ageing.

The serum is ideal for post-operative care and post-spa procedures, as well as a wrinklereduction agent used in conjunction with skin resurfacing modalities like lasers, chemical peels or dermastamps. It is great after clinical procedures for shortening down time, speed healing and improves end results. This especially applies to post wound care for orthopaedic surgery procedure. The AQ Recovery Serum soothes irritation from bruising after cosmetic procedures, reduces the appearance of broken capillaries, and greatly decreases post-procedural redness.

tors are changing the landscape of scarring is in orthopaedics.

Females who undergo knee surgeries often dislike the scarring that comes after it, so surgeons have trialled something new using growth factors. After inserting the pin, ‘recovery’ is applied on top of it—which is really the growth factors.

It is now possible for women to feel confident while wearing a skirt

after knee replacement surgery, so it has become really a model for advertising. No scar formation, quick healing and fast recovery keeps patients satisfied.

Combining growth factor with micro-needling Now, combining micro-needling with growth factors has been certified in the USA as a treatment. It is difficult to get the growth factor

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22 DERMATOLOGY I body language

THE IMPORTANCE OF SKINCARE IN CLINICS Many procedural doctors are not focused on skincare and underestimate the importance of skincare in their clinics.

Skincare gives an easy income and can support a clinic, but it cannot be just any old skincare—it is vital to be strategic. A patient visiting a doctor or a professional can expect a scientific based product that is scientifically sound and has copious amounts of scientific basis.

Simultaneously, the product has to carry an intellectual property and contain an IP patent. It is madness to compete with pharmacies outside of your clinic because if patients can select, more people would choose a pharmacy over your clinic. Therefore, you need to have something that is scientific and has intellectual property, so nobody can duplicate or have another similar line, with the same ingredients.

Look for a product that has been manufactured with GMP—which is good manufacturing practices. You will be surprised to hear that 90% of the products are produced in a manufacturing process where there is an absence of control. If you are going to give something to a patient, be sure that these products are being manufactured with good manufacturing practices.

If you cannot sell the product to a patient, you can use it in your therapies.

If you use laser, IPL or any other therapeutic procedures, you can use this product to enhance your results. Products that can be combined with clinical procedures will give you an income, and can be used in combination with a therapy—for example ‘recovery’ is specifically for a professional; the patient cannot access it. It is only sold to doctors and professionals, but they can use it with their separate treatments so it acts as another income for them. Look for a product that is strictly dispensed for physicians.

through the tissue, so a modality to get that growth factor in is needed.

After using micro-needling and growth factors, staining and biopsy can be used to see if growth factors are delivered.

Treating hair A paper published in 2011 by Global Penn State found that PDGF stimulates the stem cells around the papilla of the hair and promotes hair growth. I can testify to this because I did the treatment in 2010 and I still have my hair.

Hair growth case study Growth factors are signalling molecules, so the growth factor found in the recovery is different from the growth factor that is used for hair growth. With an aim to discover what growth factor combination could communicate with the targeted hair cells, I was involved with research that was carried out on a mouse head. The mouse was shaved, and growth factor was applied to one side and water was applied to the other side. Like hair, fur is different, but we followed up to see whether there was growth. We

Dr Paola Sjoqvist, Oslo, Norway, performing growth factor induce therapy for rejuvenation

body language I DERMATOLOGY 23

Dr Paola Sjoqvist, Oslo, Norway, performing growth factor induce therapy for rejuvenation

knew that both sides were going to grow, but wanted to see if the communication message that we sent is actually getting there.

After 21 days the side with the growth factor grew almost 45% faster “than the normal hair”.

This shows that the growth factors we chose “for this purpose” are actually communicating with the papilla.

Using a device with specific software that measures the area and the new hair that grows, the number of hairs being produced was calculated, alongside the coverage. Although we are concerned with how much hair is growing, since we are interested in the aesthetic, it is also necessary to know how it is going to cover. The correct distribution is important, and 2,000 follicles transplanted all onto one side of the head will not work.

Safety There is no research to date to indicate that growth factors are bad. Growth factors are found naturally in the human body and often times, growth factors are not like hormones; they do not have negative reactions. Applying growth factors does not mean the body will stop producing them.

Usually, there is no receptor in the cells to take the growth factor—it just gets disseminated.

Growth factors mostly act locally and trigger cell receptors. Once they go in, they only attach to the receptors, so they are untraceable in the blood stream. Usually the by-product, or breakdown of the growth factor, will have side effects. In this case, the body is used to dealing with growth factors so there will not be any breakdown or by-product of them. They are also safe enough for the US FDA

to allow growth factors to be used in cosmetics.

Dr Ahmed Al Qahtani is a National Institutes of Health (NIH) scientist for numerous NIH grants in research and development. He is accredited with numerous scientific publications. A longstanding member of the American Association of Immunologists, Dr Al-Qahtani has spoken and presented research at congresses around the world. He started AQ Skin Solutions through extensive work in the medical applications of growth factors for healing wounded tissue and creating artificial skin grafts. As a researcher in immunology, he applied his knowledge and experience in GF biotechnology to develop a process for producing the highest quality GF media available, which contains growth factors that have been identified to be the most effective for rejuvenating skin.

24 NON-SURGICAL I body language

Natural volume Algeness offers treatment versatility with a unique highly biocompatible formulation, offering patients well-tolerated and long lasting volumising results

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lgeness is now wellknown for its uniqueness and versatility for it is 100% all-natural, biodegradable and mouldable filler with immediate volumising and shaping for a more defined youthful look.

Algeness is highly purified polysaccharide which does not contain any protein fractions, a source of contamination for most bacteria, making it highly biocompatible.

Formulations of agarose form stable gels with small amounts of material (1% of agarose and 99% sterile saline water. Being free from toxicity to micro-organisms and free from impurities, Algeness is well tolerated within the human body and is clinically proven safe natural filler available in Europe, Asia, Middle East, and South and Central America.

Totally biocompatible and fully absorbable, Algeness has no crosslinked synthetic chemicals (BDDE or PEG) required by hyaluronic acid (HA) fillers, thus it is all natural.

Advanced training The fulfilment of patients’ requirements and provision of excellent outcomes can be challenging when the result must be achieved immediately and safely, with a more defined natural look. This is why AAT Inc, developed a highly focused training dedicated to doctors injecting Algeness. This programme—“Master Your Results—is a credentialing training course, consisting of theoretical and hands-on workshops to advance practitioners’ knowledge, experience, and technique using Algeness for anatomical correction.

Specifically, we instruct practitioners in the art of the technique to maximise the unique properties of Algeness for consistent excellent outcomes that are achieved imme-

diately with little to no migration over time.

Led by experienced Master trainers, Master Your Results programmes are held monthly in countries serviced by our exclusive distributors.

To attend a session, please contact us at algeness.com or the aesthetic distributor in your country.

Scientific and clinical research Algeness has been well studied in animal studies and in post-market comparative clinical studies since 2006.

Wake Forest University in the United States performed animal studies which were completed in 2013 and 2014 with the 2.5% Algeness VL and the 3.5% Algeness DF compared to Restylane, Juvederm and Radiesse. The Wake Forest comparative study showed that after six months 2.5% and 3.5% performed better compared to the other fillers, showing Algeness lasted longer, did not show unpredictable changes due to inflammatory reactions or water absorption, and exhibited less migration.

Four clinical studies were conducted in Italy and Denmark in 2006/2007 where Algeness performed well with minimal side effects and no adverse events were reported. The effects of Algeness lasted a minimum of six months but was not compared directly to other filler materials. These studies demonstrated the safety and efficacy of Algeness fillers. Algeness HD was extensively studied in the lips and was found to be very effective with no reports of adverse reactions.

Dr Giovanni Montealegre, Professor of Plastic Surgery at the National University of Colombia, in Bogota, completed a 50 subject study to evaluate the safety and efficacy of Algeness for the correction of nasolabial folds in comparison to Juvederm. Both Juvederm and Al-

geness have similar and comparable effects on safety and duration. Algeness offers excellent tolerability and biocompatibility, is safe, natural and has a negligible immunological reaction. Over the first six months of observations, the results are comparable with Juvederm.

In 2016 a 30 subject study of the volumising and lifting effects of Algeness and Juvederm Voluma will commence in Belgium with Dr Joan Vandeputte, in Italy, Dr.Giovanni Salti, and in Germany with Dr Tatjana Pavicic.

Also starting in 2016, is a prospective, randomised, within-subject controlled study of the effectiveness and safety of Algeness VL 2,5% Natural Agarose Subdermal Filler Injectable Gel versus Restylane Perlane Injectable Gel, for the correction of moderate and severe nasolabial folds.

The principal investigator is Nicolo Scuderi, MD, Professor at University la Sapienza of Roma.

For more information W: algeness. com; E: vgitto@algeness.com THE BENEFITS • Hydrocolloid gel 100% biocompatible and biodegradable.

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• Free of solvents and chemicals; all natural.

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• Non allergenic; Algeness offers excellent tolerability and biocompatibility with a negligible immunological reaction.

• Minimal irritation and inflammation due to the absence of foreign body reactions.

• Extremely low migration, the product stays where it has been injected with excellent persistence.

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body language I INJECTABLES 27

Lifting laughter lines DR KEIREN BONG explains the 3Lift treatment for the nasolabial folds

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rinkles should merely indicate where smiles have been. This now common saying is especially apt in regard to the nasolabial folds (NLFs)—the two skin creases that run from each side of the nose to the corners of the mouth.

Deepening of these creases is one of the key signs of ageing in the face. As such, softening these lines results in a rejuvenated appearance and a fresher, more youthful look.

Many techniques are available for reducing the prominence of the NLF and as is the case with many areas of aesthetic medicine, this multitude of therapeutic options suggests that we are yet to develop the perfect treatment for these laughter lines, or smile lines. It is true that current treatments each have their own limitations, but with care and practice, it is possible to address deep NLFs and lessen their impact in terms of an aged appearance.

The 3Lift is a new approach demonstrating significant promise for NLF treatment. This technique uses Teosyal’s latest range of hyaluronic acid (HA) dermal fillers – resilient hyaluronic acid (RHA) – for rejuvenation and contouring.

The structured approach of the 3Lift focuses on softening the appearance of the NLFs and the treatment protocol is individualised to each patient using Teosyal’s RHA3 with lidocaine and, in some cases, RHA4 with lidocaine or PureSense Ultra Deep with lidocaine.

Anatomy of the NLF A thorough understanding of facial anatomy underpins effective treatment. Treating the NLF is no different.

The NLF courses diagonally in the mid-face from the nasal ala toward the corner of the lip. The crease is accentuated by smiling

because the muscles of facial expression that draw the upper lip in a supero-lateral direction—primarily the zygomaticus major, the zygomaticus minor, and the levator labii superioris—have dermal insertions on the upper lip. Smiling draws the upper lip under the malar fat pad as the pad bulges forward. The lateral nasal artery is in close proximity to the NLF, 2-3mm superior to the alar groove and it is the main vascular supply for the nasal tip and ala.

Ageing and the NLF At birth and in early childhood the NLF is absent while the face is at rest. With ageing, the fold becomes visible even when the face is in repose. This change is due to multiple age-related factors including facial volume loss, ptosis of the malar fat pad, atrophy of dermal collagen, and increased skin laxity. The presence of the NLF is also dependent on some baseline tonic activity of

ADVANTAGES OF 3LIFT  Suitable for patients of different morphotypes  Natural result  Virtually no downtime

the muscles of facial expression, as demonstrated by the disappearance of the fold in patients with paresis of the facial nerve.

Rejuvenation techniques using hyaluronic acid (HA) dermal fillers in the mid-face and NLFs address some of these underlying causes.

Volume restoration An approach which I’ve designed to reduce prominent NLFs uses volume restoration, either in the NLF alone, or in conjunction with mid-face volume replacement. This approach uses Teosyal’s latest range of HA dermal fillers—RHA—to address the dermal atrophy, associated with ageing, that contributes

Deepening of the nasolabial folds is one of the key signs of ageing

28 INJECTABLES I body language

to the development of the NLF. Restoration of contour and volume in the mid-face creates an upward lift, thereby softening the prominence of the NLF. RHA dermal filler has been the prototypical filler since 2014, with clinicians able to choose the viscosity and degree of cross-linking of the product. In general, and depending on the choice of product, this filler is injected just medial to the NLF but in the mid- to deep-dermal layer. RHA incorporates an anaesthetic agent for patient comfort.

RHA RHA dermal fillers integrate very well into the ground substance of the dermis and into tissue in general. This is due to the unique molecular structure of RHA dermal fillers, which results from the use of Teoxane’s patented technology during the manufacturing process.

The process preserves HA long chains, allowing the formation of a mobile 3D network and giving the HA its viscoelastic capacities.

Thanks to these properties, the HA

is capable of maintaining tissue architecture, volume and hydration.

In practice, the unique molecular structure of RHA fillers affords superior resilience in withstanding the constant, repetitive stretching and contortions of facial musculatures during facial expressions. The longevity of effects for RHA fillers is typically six to 12 months, or even longer in some cases.

Patient selection When using RHA filler, consider the quality of the patient’s skin, the depth of the fold, the patient’s goals regarding degree and longevity of correction and the patient’s risk tolerance. Facial assessment involves objective grading of volume loss in the mid-face and NLF, in addition to their structure, symmetry and proportion. Taking pictures prior to formulating a treatment plan is an effective tool for educating a patient on their facial features and appearance. It also helps you in explaining the rationale for the treatment plan to the patient.

Patients with mild and moderate NLFs are suitable candidates for the 3Lift. Patients presenting with severe NLF, especially with excess skin laxity and hanging skin folds require surgical intervention. The goal of this treatment is to achieve a reduction of NLFs without full effacement.

With ageing, the NLF becomes more visible even when the face is in repose

Practical guide • For mild midface volume loss, mild NFL, use RHA3 in NFL. • For mild midface volume loss, moderate NFL, use RHA4 in midface and RHA3 in NFL. • For moderate midface volume loss, moderate NFL, use Ultra Deep and RHA4 in midface, and RHA3 in NFL. RHA4 is injected in superficial fat compartments, Ultra Deep injected in deep fat compartments.

Injection protocol The 3Lift has been designed to be used with a blunt-tipped microcannula.

The NLFs prominence and any concurrent mid-face volume loss

Injecting into deep fat compartments creates upward lift in the mid-face, lateral lift is achieved through linear threads in the midface

body language I INJECTABLES 29

treatment to review results. Visible correction of NLFs using RHA dermal filler typically lasts nine to 12 months after treatment, although longevity of HA dermal fillers is influenced by many factors.

Further consultation at six to 12 months is advisable to establish any need for additional enhancement.

Draw an imaginary line between lateral canthus and oral commissure 1st bolus—on the line, on maxilla 2nd bolus—1cm laterally, on zygoma 3rd bolus—1cm laterally, on zygomatic arch

Using the same entry point, inject along the zygoma and zygomatic arch three linear threads Injections are made in the superficial fat compartments

Inject three linear threads in the NFL Injections are made in the mid to deep dermis

Injections are made in the deep fat compartments

Sequence of injection—three injection sites, three boluses, three linear threads

The volume of product injected in each area will vary from patient to patient

will determine the correct injections site for dermal filler. When evaluating potential areas to inject, it is important to remember that contour and volume restoration in one area may lead to improvement in the adjacent area.

For instance, treatment in the maxillary and zygomatic (cheek) areas may improve the appearance of the NLF. This is especially true in patients who have mild to moderate volume loss in the mid-face with minimal or no translocation of mid-face fat pads.

Sequence of injection Injections in the deep fat compartments create an effective upward lift in the mid-face. Lateral lift is achieved through the linear threads in the mid-face. More often than not, this sequence of injections alone improves the appearance of the NLF.

Choice of RHA filler • For deep fat compartments, use the bolus technique with RHA4 or PureSense Ultra.

• For superficial fat compartments, us retrograde linear threading with RHA4.

• For nasolabial folds, use retrograde linear threading with RHA3.

Instead of PureSense Ultra Deep, clinicians may use PureSense Ultimate Volume of product The volume of product injected in each area will vary from patient to patient, taking account of the following factors: the severity of mid-face volume loss (with or without translocation of fad pads); bone structure; the patient’s desired outcome and the prominence of the NLF. Review and subsequent treatments Teoxane recommends inviting patients for follow-up two weeks after

After care instructions 1. Avoid deep tissue massage for two weeks 2. Avoid application of make-up until the following day 3. Minimise touching of injection sites 4. Contact the attending clinician for advice if there are any concerns Dr Kieren Bong is a Cosmetic Doctor and Founder and Director of the Essence Medical Cosmetic Clinic in Glasgow. He is trained in both medicine and surgery, and will be training the 3Lift technique throughout the UK in the first quarter of 2017 with Teoxane UK References 1. Clemente Anatomy – A Regional Atlas of the Human Body, 4th edition.

2. Gilchrest BA. Cellular and molecular changes in aging skin. J Geriatr Dermatol 1994;2:3–6.

3. Stern R, et al. Hyaluronan in skin: aspects of aging and its pharmacologic modulation. Clin Dermatol. 2008;26(2):106-22.

4. Anderedd U, et al. More than just a filler – the role of hyaluronan for skin homeostasis. Exp Dermatol. 2014;23(5):295-303.

5. Gilbert E. et al. J Drugs Dermtol.

2012;11(9):1059-1068.

6. De Maio M. [abstract]. In: Programme and Abstracts. Beauty Through Science. International Aesthetic Symposium Stockholm. 2012.

7. Steven H. Dayan. Facial Dermal Fillers: Selection of Appropriate Products and Techniques.

Aesthetic Surgery Journal 2008;28:335–347.

8. De Maio M. [abstract]. In: Programme and Abstracts. Beauty Through Science. International Aesthetic Symposium Stockholm.

2012.

9. Monheit GD. & Rohrich RJ. Dermatol Surg 2009;35 Suppl 2:1598-1604.

30 NON-SURGICAL I body language

The P-Shot and O-Shot DR SHERIF WAKIL outlines his pioneering use of platelet rich plasma for the effective treatment of male and female sexual dysfunction

S

exual dysfunction is a major public health concern with sexual health issues having a significant impact on interpersonal relationships and quality of life for both men and women. It's estimated that one in 10 men has a problem related to having sex, such as erectile dys-

function with men over the age of 75 have a staggering 77.5% chance of suffering from erectile problems.

While issues pertaining to male sexual dysfunction are more commonly talked about, sexual health issues also affect a surprising number of women.

According to the Sexual Ad-

vice Association, sexual problems such as Hypoactive Sexual Desire Disorder (HSDD), Female Sexual Arousal Disorder (FSAD), Female Orgasmic Disorder (FOD) and Dyspareunia (pain that interferes with sex), impacts around 50% of women, however, very few women discuss the sexual issues they are

body language I NON-SURGICAL 31

with either calcium chloride or calcium gluconate.

It is imperative that PRP is injected within 10 minutes of activation otherwise it will clot. Various growth factors i.e. transforming growth factor (TGF), platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF) and insulin-like growth factor (IGF) are secreted from the alpha-granules of concentrated platelets activated by aggregation inducers. These factors are known to regulate processes including stem cell migration, attachment, proliferation and differentiation as well as to promote extracellular matrix (ECM) accumulation by binding to specific cell surface receptors. It has been shown that PRP may induce the synthesis of collagen and other matrix components by stimulating the activation of fibroblasts, this in turn rejuvenates the skin.

having with a physician. In fact, the percentage of women who do speak about it is as low as 14%, according to the American statistics, which also states that almost 40% of women suffer from one or more type of FSD to the point that is causing them psychological distress. Added to this is the fact that, although there are various treatments for erectile dysfunction in men, there are no virtually no FDA-approved treatments for sexual dysfunction in women.

The only exception is Flibanserin, sold under the trade name Addyi, a medication which was recently approved for the treatment of premenopausal women with HSDD. With a demand for safe and effective treatments in this field for

both sexes, a new revolutionary, non-surgical treatment modality utilising PRP is opening up new and exciting possibilities. These treatments are known as The OShot and the P-Shot.

What is PRP? Platelet rich plasma, usually referred to as PRP, has been used in various fields of medicine including cardiothoracic surgery, plastic surgery, sports injuries, wound healing, and rejuvenation with satisfactory results. Injections of PRP have also recently shown to be effective in treating sexual dysfunction. PRP is obtained from patient’s blood by high speed and sophisticated centrifugation. The resulting PRP can be activated

Centrifuge—single spin vs dual spin Not all PRP is created equally.

The quality of the PRP will depend on a number of factors, one being the type of centrifuge used.

In terms of centrifuges we often talk about ‘single spin’ and ‘dual spin’, although we can also think about it in terms of ‘separation’ versus ‘concentration’ techniques.

In order to truly concentrate the platelets a dual spin centrifugation system is needed. The initial spin removes the red blood cells from the plasma, resulting in a mixture of platelet rich plasma (PRP) and platelet poor plasma (PPP), which contains a relatively small number of platelets. A second spin is then necessary to create a finer separation which removes the PPP, leaving a higher concentration of platelets and resulting in PRP that falls within beneficial levels (six times baseline). The most effective solution should be no less than four to six times the concentrate.

The P-Shot The P-Shot is named after the Greek god of fertility, Priapus. It is indicated for erectile dysfunction, improvement in sensation and function, Lichen Sclerosus and Peyronie’s disease. It also helps

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Table 1: Erectile dysfunction over the age of 40—a global study of sexual attitudes and behaviors —Prevalence of ED for the entire study Age range

Prevalence rate

40-49 years old

5%

50-59 years old

9%

60-69 years old

15%

70-80 years old

22%

Entire study

10%

40% Vascular 30% Diabetes 15% Medication 6% Pelvic Surgery, Radiation or Trauma 5% Neurological Causes 3% Endocrine Problems 1% Other

Causes of erectile disfunction

increase size and girth when combined with an approved pump.

Causes of erectile dysfunction: Erectile dysfunction can be caused by ageing, psychological conditions (such as anxiety), depression, neurological disorders (such as Parkinson’s disease), pelvic surgery and endocrine disorders e.g. diabetes and interactions with prescribed drugs. In 40% of the cases, the cause is atherosclerotic disease.

Treatment options Treatment modalities for treating erectile dysfunction include: • Psychological support e.g. counselling • Pharmacological e.g. Phosphodiesterase type 5 (PDE-5) inhibitors which are usually the recommended first-line treatment for ED • Testosterone replacement therapy for cases of androgen insufficiency • Vacuum constriction devices • Vasoactive drug injection therapy • Surgical treatment: surgical implantations of penile prosthesis, which can either be inflatable or malleable.

All of the above could have risks and complications which vary in severity. These encompass side ef-

fects from PDE inhibitors such as headaches, flushing, dyspepsia and nasal congestion, unsatisfactory results from vacuum restriction11 and risks of complications from surgery.

The P-Shot procedure Lasting approximately 40 minutes, the P-Shot procedure is quick and easy to perform. Local anaesthetic, preferably lidocaine, is applied to the glands and shaft of the penis.

Around 60ml of the patient’s blood is taken under proper aseptic precautions and placed in a special high-speed centrifuge to obtain 10ml of PRP. After sterilising the penis, the PRP is activated with a few drops of calcium chloride to trick the platelets in the plasma into thinking the body has been injured—by initiating fibrinogen cleavage and fibrin polymerisation—so they release growth factors. The harvested PRP is then injected into the corpus cavernosum in a very specific way according to the P-Shot protocol. Treatment can be tailored according to patient’s complaint and indication of the treatment.

The growth factor-rich plasma will lead to an initial increase in size. Growth factors trigger stem

cells to increase blood flow and generate healthy tissue growth, which will continue for about three months. It will also help in regaining the sensitivity in diabetic patients by regenerating CN. If combined with an approved penis pump, treatment helps patients gain an increase in length and girth. Patients usually see an increase in the flaccid position within four to six weeks and in erect position in four to six months of continuous use of the pump following the P-Shot treatment. Some patients could have the P-Shot repeated in one year or less, since it is not ‘an antibiotic course’ and, as such, no limit exists to the number of treatments that should be given.

Referring to it as a ‘vitamin shot’ for their penis, patients also report increased pleasure during sex, increased ability to achieve an erection and maintain it for longer.

Downtime and aftercare The P-Shot has the advantage of carrying no downtime and zero to little discomfort. Patients can even exercise and have sexual intercourse on the same day. Typically, there are no side effects (except from a few drops of blood from the injection site and mild soreness). Rarely, bruising is reported or lumps are formed which tend to resolve themselves or with nonsteroidal anti-inflammatory drugs.

As this procedure uses the patient’s own blood, and is all natural, there is little risk of allergic reaction.

Usually one injection is sufficient, however, some patients might need top-ups for sustained results or if their disease is severe. This usually depends on the patient’s age and lifestyle factors such as whether or not they are a smoker, or heavy drinker.

Results The following results have been reported by patients following PRP injection into the penis (The PShot) for male sexual dysfunction: • Increased erection quality • Heightened sensation and pleasure • Increased firmness of erection • Improvement to the symptoms of Lichen Sclerosus • Improvement in Peyronie’s Dis-

34 NON-SURGICAL I body language

ease • Increased sexual stamina • Healthier appearance • Increased blood flow and circulation • Increased length and girth when combined with the penis pump.

Most patients report an immediate increase in girth, which, as described above, is due to the injected plasma. This may slowly reduce over the next week as the plasma is reabsorbed by the body but will usually increase again over the next three to four weeks, due to the growth factors initiating the regenerative process. Firmness and strength of erection is noted after about four weeks and will continue to improve over the next three months. Immediate improvement in sexual function has been reported, which I believe may be in part due to psychological factors, however, optimum results are seen four weeks later. The effects of treatment continue to improve for up to three months and may last for 12 to 18 months.

Measurements of results There are various ways to evaluate the effectiveness of treatment. The measurement of nocturnal penile tumescence and rigidity (NPTR) is a safe method of defining erectile function. Electro diagnostic methods include penile nerve conduction test, bulbocavernosus reflex responses and pudendal somatosensory evoked responses. Penile biothesiometry is promising for evaluation of penile sensation.

The erection hardness score is also a good way to assess improvement as well.16 0—Penis does not enlarge.

1—Penis is larger, but not hard

Fibrous plaque on corpus restricts symmetrical erection acts like a tether causing curvature Soft centre

Firm outer casing where plaque forms (Peyronie's disease) Corpus

2—Penis is hard, but not hard enough for penetration 3—Penis is hard enough for penetration, but not completely hard 4—Penis is completely hard and fully rigid These scales can be utilised to quantify the improvement in sexual function.

The O-Shot Many women suffer in silence about the issues they are experiencing in terms of low desire; low levels of sexual arousal or lack of feeling; difficulty in achieving orgasm and even more difficultly in achieving vaginal orgasm (orgasm from vaginal intercourse without clitoral stimulation); urinary incontinence or pain during sex, brought on by child-birth, the menopause and other factors.

Recently the first FDA-approved drug aimed at female sexual dysfunction was released. The drug

Corpus

is known as Flibanserin (sold under the trade name Addyi), but only targets one type of FSD—hypoactive sexual desire disorder (HSDD) in pre-menopausal women. HSDD is only one small factor that effects women with FSD. While taking Flibanserin may help with this one aspect, it does not address any of the other issues and, as such, is like filling a car with gas when the engine and cables do not work. There are also some undesirable sideeffects attached to the drug, such as syncopal attacks as well as some inconvenience e.g. the patient is not allowed to drink alcohol during the period she is receiving the treatment.

Peyronie's disease

Other treatment options for FSD Calcium hydroxyapatite crystals can be used to treat USI, but they could have some side-effects, such as urinary obstruction, erosion and

Before and after the O-Shot. Dr Wakil also injected the PRP inside the labia to regain the contour and help remoulding aging labia and loss of fat.

body language I NON-SURGICAL 35

A patient with Lichen Sclerosus before treatment (left) and two months after the P-Shot injection, courtesy of Dr Sherif Wakil (right)

granuloma formation. Injections of hyaluronic acid to enhance orgasmic sensitivity lack data to support its use. Vaginal oestrogen and transdermal testosterone patches have been tried but testosterone can lead to side-effects such as acne, hirsutism and virilisation.

The O-Shot is an all-natural procedure with a safer side-effect profile than previously offered treatments.

It is for these reasons and more that I believe in the benefits of the O-Shot.

The O-Shot, or ‘Orgasm Shot’ was invented in 2010 by Dr Charles Runels, MD (Alabama, USA) and is a method of injecting the vagina with PRP in a bid to regenerate the vaginal tissues and regain sensation.

The O-Shot is suitable for treating the following: • Urinary stress incontinence (USI) • Reduced sensation • Decreased arousal • Anorgasmia • Vaginal dryness • Reduced sexual desire • Dyspareunia • Lichen sclerosis • Fissures post episiotomy The O-Shot procedure The O-Shot is a pioneering new non-surgical technique, which offers a quick, safe and simple solution for a variety of concerns associated with female sexual dysfunction. A strong topical anaesthetic cream is applied to the anterior vaginal wall and the clitoris after retracting the clitoral hood.

The injection is then performed, according to the O-Shot protocol, which we have modified quite a few times to date in order to achieve the best results. With the

experience that we have gained in injecting thousands of women, we do change the protocol according to each individual complaint and needs, so injecting a patient when the desired outcome is to increase sensation is different from injecting a patient with Lichen Sclerosus.

Both of these techniques are also different from the way in which we would inject a patient with urinary incontinence and so on. For example, in the latter, we aim to change the vesicourethral angle with the volume injected in the anterior vaginal wall.

Following the treatment, there is no downtime. The patient can even resume sexual activity almost immediately after the procedure.

From my experience, there is often an immediate improvement in sexual dysfunction and arousal, due to the volume effect of the PRP, which increases the friction during penetration. This may dissipate over a few days but then slowly improves again over the next three to five weeks, with full effect often achieved at around three months.

Potential side-effects may include (as with any injection) spot bleeding, bruising, tenderness, a warm or burning sensation in the area (this usually settles within minutes/hours), temporary localised numbness (due to the local anaesthetic effects) and hypersexuality or increased arousal, especially in younger women with previously normal or close-to-normal sexual function.

Evidence A pilot study of the effect of localised injections of autologous PRP for the treatment of female sexual

dysfunction was published in 2014.

11 females, aged 24-64, presenting with complaints associated with female orgasmic disorder, hypoactive sexual arousal disorder, anorgasmia or dyspareunia, participated in the study. After receiving the O-Shot seven of the women treated (64%) demonstrated some degree of improvement (Table 1). Five of the seven women who started with elevated levels of sexual distress in the FSDS-R, in which the threshold of distress is defined as a score of 11 or more, dropped their scores to less than 11. Therefore, according to the test criteria, 71% of the women improved from being ‘distressed’ to being 'not distressed' after the procedure.

The effectiveness of PRP for the treatment of vulvar lichen sclerosus has been established by a study of nine patients with the disorder.

Two patients were lost to followup. Of the remaining seven, four had decreased inflammation on post-treatment biopsies, one had no change, and two had ‘minimal’ increase in inflammation.

Another study demonstrated that PRP injections lead to decreased inflammation in vulvar lichen sclerosus without the potential side-effects associated with topical or systemic immunomodulators. King et al at the Center for Vulvovaginal Disorders, Washington, DC published an exploratory study designed to evaluate the efficacy and safety of autologous PRP injections for the treatment of vulvar lichen sclerosus. They concluded that the effectiveness of PRP is based on its high level of growth factors such as PDF, TGF-β, and EGF. These growth

36 NON-SURGICAL I body language

factors are important in modulating mesenchymal cell proliferation, and extracellular matrix synthesis during healing.

The vast majority of published literature shows that autologous PRP has minimal risk of scar tissue formation or serious adverse events.

The results of this exploratory study suggest that PRP injections decreased histopathologic inflammation in women with vulvar LS without the potential side effects associated with topical or systemic immunomodulators.

sults of the O-Shot and P-Shot look promising. Being autologous, PRP is safe with minimal side-effects.

It is good to know that now there is something substantial available in the ever-demanding field of sexual aesthetics. However, proper training of how to administer the O-Shot and P-Shot is of upmost importance for patient safety. As well as this, ongoing collection of data, which I am continuously involved in, is mandatory to provide the patients with the best care and achieve the optimum results.

Conclusion With more than 30,000 procedures performed worldwide, the re-

Dr Sherif Wakil is the founder and medical director of DrSW Clinics. He has more than two decades

References 1. Laumann EO, Paik A, Rosen RC. Sexual Dysfunction in the United States: Prevalence and Predictors. JAMA. 1999;281(6):537-544. doi:10.1001/jama.281.6.537 2. http://www.nhs.uk/livewell/goodsex/pages/malesexualdysfunction.aspx 3. http://www.healthcentre.org.uk/pharmacy/erectile-dysfunctionstatistics.html 4. UK Health Centre, Statistics on Erectile Dysfunction (2015) http:// www.healthcentre.org.uk/pharmacy/erectile-dysfunction-statistics. html 5. V Cerveli, I Bocchini, C Di Pasquali, B De Angelis, G Cervelli, C B Curcio, A Orlandi, M G Scioli, E Tati, P Delogu, Pietro Gentile, P.R.L Platelet Rich Lipotransfert: Our Experience and Current State of Art in the Combined use of Fat and PRP (2013) 6. Runels CE, Melnick H, Roy L, DeBourbon E, ‘A Pilot Study of the Effect of Localized Injections of Autologous Platelet Rich Plasma (PRP) for the Treatment of Female Sexual Dysfunction’, J Women’s Health Care, 3:4 (2014) 7. Maria J H Nagata, Michel R Messora, Flavia A C Furlaneto, Stephen E Fucini, Alvaro F Bosco, Valdir G Garcia, Tatiana M Deliberador and Luiz G N de Melo, Effectiveness of Two Methods for Preparation of Autologous Platelet Rich Plasma: An Experimental Study in Rabbits (2010) 8. Wyllie MG. The underlying pathophysiology and causes of erectile dysfunction. Clin Cornerstone 2005;7:19–27 9. NHS, Erectile dysfunction (impotence)—Treatment, (2015) 10. Brian Wu, Will Zialin Z-Strips Treat My Erectile Dysfunction?

(2015) http://www.healthline.com/health/erectile-dysfunction/zialinz-strips-and-ed 11. J Yuan, A N Hoang, C A Romero, H Lin, Y Dai, R Wang, Vacuum Therapy in Erectile Dysfunction 0 Science and Clinical Evidence, (2010) <http://www.medscape.com/viewarticle/725873_2> 12. Kenneth R Hirsch, Erectile Dysfunction Complications, (2014) <http://www.healthline.com/health/erectile-dysfunctioncomplications#Treatments2> 13. P Borrione, A D Gianfrancesco, MT Pereira, F Pigozzi, Plateletrich plasma in muscle healing (2010) Am J Phys Med Rehabil 89 (10): pp. 854–61 14. Charles Runels, Official Priapus Shot Home Page, (ND) http:// priapusshot.com 15. Report of the Therapeutics and Technology Assessment

of experience in heath care and has worked in leading hospitals in the UK and Middle East, including The Royal London Hospital NHS Trust and is now based on London’s Harley Street. Dr Wakil has performed more than 20,000 procedures and has introduced a number of new treatments to the UK and Europe, including the P-Shot and the O-Shot and the Vampire Breast Lift early 2014, He is the only trainer for these procedure in Europe and the Middle East.For the past few years Dr Wakil has been at the forefront of the non-surgical sexual aesthetics arena with his new sexual rejuvenation treatments and cutting-edge machines—so much so that he has been named 'Dr O'.

Subcommittee of the American Academy of Neurology December 1995, 45:12 2287-2292; doi:10.1212/WNL.45.12.2287: 1526632X 16. Parisot, J., Yiou, R., Salomon, L., de la Taille, A., Lingombet, O. and Audureau, E. (2014), Erection Hardness Score for the Evaluation of Erectile Dysfunction: Further Psychometric Assessment in Patients Treated by Intracavernous Prostaglandins Injections after Radical Prostatectomy. Journal of Sexual Medicine, 11: 2109–2118. doi: 10.1111/jsm.12584 17. Alijotas-Reig, Jaume MD, PhD, ‘Foreign-Body Granuloma After Injection of Calcium Hydroxylapatite for Treating Urinar Incontinence’, Obstetrics & Gynecology, 118(5) (2011), pp. 1181- 1182 18. American Congress of Obstetricians and Gynecologists, ACOG Committee Opinion: Vaginal“Rejuvenation” and Cosmetic Vaginal Procedures (US: American Congress of Obstetricians and Gynecologists, 2007),http://www.acog.org/Resources-And-Publications/ Committee-Opinions/Committee-on-Gynecologic-Practice/VaginalRejuvenation-andCosmetic-Vaginal-Procedures 19. Davis SR1, van der Mooren MJ, van Lunsen RH, Lopes P, Ribot C, Rees M, Moufarege A, Rodenberg C, Buch A, Purdie DW. ‘Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo-controlled trial.’ Menopause, 13(3) (2006), pp. 387-96 20. Michelle King, MSc, Hillary Tolson, Charles Runels, MD, Meghan Gloth, MD, Richard Pfau, MD, Andrew T Goldstein, MD. Center for Vulvovaginal Disorders, Washington, DC. Autologous Platelet Rich Plasma (PRP) Intradermal Injections for the Treatment of Vulvar Lichen Sclerosus. Journal of Lower Genital Tract Disease, Volume 19, Number 3, Supplement 1, July 2015 21. Journal of Lower Genital Tract Disease:July 2015 - Volume 19 Issue 3 - p S1–S25 doi: 10.1097/LGT.0000000000000121 Abstract ISSVD 2015 Abstracts 22. Zhonghua Yi Xue Za Zhi. 2008 Sep 23;88(36):2578-80., [Effect of platelet rich plasma on the regeneration of Cavernous nerve: experiment with rats]., [Article in Chinese, Ding XG, Li SW, Zheng XM, Hu LQ, Hu WL, Luo Y.Department of Urology, Zhongnan Hospital, Wuhan University, Wuhan 430071, China.

23. http://www.omicsgroup.org/journals/a-pilot-study-of-the-effectof-localized-injections-of-autologous-platelet-rich-plasma-prp-forthe-treatment-of-female-sexual-dysfunction-2167-0420.1000169. php?aid=27349

body language I MEDIA 37

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body language I TECHNOLOGY 39

Picture perfect DR EMMANUEL ELARD exposes the secrets of good clinical photography and video

T

he most perfect before and after pictures have the patient in an identical position and an identically lit environment prior to and after the procedure—so it’s understandable that as clinicians, taking photos of patients is probably one of the least favoured part of a consultation.

Some delegate the job to assistants in a dedicated room, others more adventurous and more professional take pictures by themselves with varying degrees of success. But how can we improve what we do?

How do we create the perfect pictures?

Clinicians are not professional photographers, so an average photo taken on the clinic camera is unlikely to do justice to a procedure.

There are many mistakes that are made, but one of the most common mistakes is the use of flash, creating a distorted reality. Other things to regulate as a photographer are white balance, patient positioning and light.

Mastering white balance White balancing is a camera setting that adjusts for lighting in order to make white objects appear really white on the photo. Most of

the time, when two pictures shot at two different moments don’t show the same colour, it is because ambient light is not the same and the sensor of the camera is tricked.

The only way to make white objects appear white in the picture is to use a white card that you need to put in front of the camera. This card will tell the sensor that “what he is seeing is white” Patient positioning Once white balancing is mastered, next it’s important to think about

We can trick reality by only modifying a little detail. Here the angle of the face can create an impression of something that doesn’t really exist in real life. We can play with the before and after picture, rotate the angle a little and without touching anything have opened the nasolabial angle and apparently corrected the nose

setting up the patient positioning. This must be exactly the same on the before and after picture. It could be wise to mark places to stand on the floor in your office, or lines on a wall for patients to stand between in order to create consistency.

Lighting One of the most important parameters that we need to master is lighting. Aesthetic injectors all know that we need to restore the balance between lights and shadows. Light alone can change our perception of the reality. If you want to get two pictures perfectly comparable, ambient lights must be always the same.

The reality of video Everybody can be a photo-shopper today. So nobody trusts a picture of a before and after conversion.

I recently treated a patient with high intensity focussed ultrasound (HIFU) using ultherapy to lift her jawline. Despite wonderful results, when I showed her picture to my

One of the most important parameters that we need to master is lighting

40 TECHNOLOGY I body language

Next Motion Video Capture After creating patient’s profile in the app, the patient sits down in the centre of the machine and we pair the machine and smartphone. Once it is done, the app will help to calibrate patient’s positioning and white balancing and video recording can commence. The machine moves around the patient as the light stays at the exact position on the face—meaning that lights and shadows are exactly at the same position before and after the procedure.

During the recording, a patient can be asked to smile, to kiss or give any other facial expressions needed, depending on the selected procedure. Dynamic results can then be show to a patient, which are better and convenient for some procedures like botulinum toxin than a photo, since it is only the work of the aesthetic practitioner that will change the perception of the face after the procedure.

For the after video, ghost mode is used to ensure the patient makes the same movements as in the before shooting. With that technique the head remains in exactly in the same position for before and after pictures. Exactly the same expressions can be requested from patients, it takes less than three seconds to create. The background can be removed or replaced with colour desired before one click exports the video. It’s also possible to extract still images from the video of the patient from any angle.

other patients very few of them trusted me when I tried to convince them the benefits of HIFU. I replaced photo with video and it changed totally the perspective that a potential patient can have and the work that I am proposing to them.

It is possible to cheat with a photo, but it’s impossible to do the same with a video. My observations about mastering all these photog-

raphy parameters like light, white balancing, patient positioning and the video concept of not being able to cheat, pushed me to create a tool that allows creation of standardised videos of patients really easily in less than one minute—Next Motion. This is really powerful because with a video you can see the emotion of the patient. You can see the patient kiss, smile, doing some positive or negative expression that

they would do in everyday life.

A motorised device piloted

by Bluetooth allows the camera to make a video while traveling around the patient. Using only the ambient light in your office is adequate—no additional light is necessary. Traveling movement is really important because it is the only solution that allows light and shadows on the face of the patients to be exactly the same before and after the procedure.

A smartphone is plugged on the frontal arm and steers the machine

by Bluetooth. Via an app it records the before and after video and it adds a final mounting.

This is a complete solution. The heart of the platform is the smart phone, but basically you buy a machine that does the travelling around you, and you have the full system via your iPhone & Android app to steer the machine, record your before/after videos, manage your products. An iPad pro app can be used to display and sign consent forms, display your before and after videos. A powerful backend (webpage), similar to a CRM that allows you (or your assistants) to manage your patient’s files and optimise your workflow Summary Knowing that we can now standardise with this tool, I think we can go further. I see the potential for leading larger studies with, involving many doctors, to show the reality and the efficiency of all treatments. With that I think it is possible to improve the image of our work and to improve the transparency of the work we do with all of our patients.

Dr Emmanuel Elard is a medical doctor specialising in aesthetic medicine. In addition, he is an entrepreneur, founding Next motion, a doctor-friendly solution of standardised before and after video creation, editing and sharing, with a digital management system to share with his peers. Dr Elard is a holder of a state Diplomas (IUD) in mesotherapy, in morphological medicine, anti-ageing and injectable techniques. He is a member of several scholarly communities, including the AFME, SoFMAA, SFM and LED Academy.

Modern treatment education TIM MOLONY, founder of Comparethetreatment.com, discusses how to educate modern day patients often misinformed by the internet

"Comparethetreatment.com is the Ronseal for patient information—it does what it says on the tin. The concept—developed by some very clever and passionate people—aims to improve knowledge and increase trust.

This can only be a great tool for the British public" Dr Husein K. Salem, Precious Cells

T

here is little doubt the expectations of patients have changed tremendously in the last 10 years, fuelled by an increased exposure to celebrity lifestyles, treatments and makeovers—all accessed via the multitude of digital channels. Our 21st-century lifestyle is increasingly focused on aesthetics and a desire to look younger longer and, as more of us live longer, so the age range of patients seeking cosmetic treatments widens. The ‘selfie’ phenomenon is helping to drive down the age of those seeking cosmetic procedures to include millennials, of which there are 13.8 million in the UK. Conversely, research from The Independent Pensions Advisory Service reveals that pensioners are now looking to splash their cash, too, on cosmetic procedures. And so, as the profession develops and adapts to meet these elevated—and expanding—expectations, it is important to educate patients so they understand what can be achieved and, more importantly, what cannot. Without this education, it is easy to see how the number of medico-legal challenges increases if expectations are not met.

GMC guidelines The new GMC guidelines for cosmetic procedures goes some way to reassuring the public of safe surgery. Designed to help patients

make safe and informed choices, it bans any aggressive marketing tactics such as ‘two-for-one’ offers on surgery and also insists on a ‘cooling off’ period for patients, who must also be made aware of any risks. Consent, the guidelines suggest, should be obtained by the doctor carrying out the treatment.

Additionally, an empathetic, friendly and honest approach will work to mitigate any risks that come with more complex treatments. Shared decision-making can also have a positive effect on satisfaction and the perceived quality of outcomes, with consent revisited regularly throughout the course of treatment.

Internet education It’s been estimated that only 15% of demand for aesthetic treatments is currently being met. For a patient, knowing they need help but unable to find the right advice or clinician is one of the most challenging aspects of seeking treatments.

Due to the plethora of information (good and bad) found on the internet, patients can arrive in the surgery having already made the first steps towards treatment education.

Sometimes, this may mean unpicking ‘bad’ knowledge—an increasingly challenging step in the consent process for many practitioners.

Having identified this need for reliable patient education and information, Comparethetreatment. com is the first UK based interactive platform that enables aesthetic practitioners to share their expertise and engage with millions of potential patients. Its aim is to help those 85% of people who know they have some form of body issue, but don’t know where to start. And, unlike traditional directories that list surgeons, Comparethetreatment.com works with you to help grow a private base of patients through education.

It is the only treatment-led website serving patients at all stages of the treatment journey—from early stage research through to booking a consultation and offers expert advice, patient experiences and practice reviews. Aesthetic practitioners can upload treatment advice and clinical cases, so patients can identify—and have confidence in—their treatment choice. There is also a panel of medical experts who can advise patients and offer a professional explanation of all available options. It boasts an open and transparent community, with 92% of people taking notice of peer reviews, with the objective to give consumers greater confidence in their treatment and practitioner choices. The disparity between patient expectation and the final result is what leads to an unhappy client if they haven’t been supplied with the correct information. The cost of treatment is, of course, immaterial if the patient’s expectations are ultimately not met.

Patients are arriving in surgeries seeking aesthetic treatments with information gleaned from the internet

3 MONTH FREE TRIAL If you are a leading aesthetic practitioner and you wish to promote your expertise and grow your online reputation through Comparethetreatment.com we are offering a 3 month free trial, offer ending 30th September. To sign-up or find out more please visit comparethetreatment.com/freetrial

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body language I PRODUCTS 43

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

BABOR The DOCTOR BABOR PURITY CELLULAR range is said to act like a highly effective problem-solver when faced with blemished skin, even when it is stress related.

The multi-action D-Actryl 360° complex is designed to tackle blemishes at every stage of their development. Babor say that it combats acute inflammations quickly and effectively, while minimising new irritations early on, with long-lasting effect. Enantia chlorantha extract obtained from the bark of the African moambe jaune tree is said to reduce sebum production. Meanwhile, an extract of Poria cocos, a fungus that is also used in traditional Chinese medicine, is said to decrease the tendency of the sebaceous glands to become irritated as a result of stress by rebalancing the responsible neuropeptides and curbing sebum production.

W: babor.co.uk

PERK Introducing Perk, Edge Systems’ latest innovation in skincare technology to rejuvenate lips, eyes and skin in just 10 minutes.

Perk is said to offer a comprehensive approach to skincare, merging a professionally delivered exfoliation service, using a patented roller-flex technology to deliver immediate results and long-lasting benefits, with an advanced daily application of take home products.

W: wigmoremedical.com

DMK LIMITED DMK Skin Co announces the arrival of their new luxury retail skincare range. This range includes Mediterranean Pearls, a foaming cleanser gel with vitamin B enriched microshperes that are said to wash away any impurities; Wetter than Water, an instant hydrating emulsion; Firmatrix, a skin recovery serum containing powerful botanics said to utilise bio-homeostasis technology to rebuild the epidermal matrix; A 2 Z, revitalising tinted day crèmes packed with nutrients from aqua to zinc; Elevate, a neck and decollété crème with revitalising bio-energy ingredients and a warming thermogenetic effect; as well as the new TransGenesis, an age management crème that has been reformulated and is said to target cell renewal, elasticity and moisture retention.

W: dmk-uk.com

DERMALOGICA Dermalogica announces the launch of its new IonActive System and IonActive Power Treatment, a collection of professional products and 45-minute skin treatment developed for the experienced, serious skin therapist who wants to achieve advanced results in the treatment room. This powerful system is said to address a growing need in skin care centres for rapid, highlyefficacious ways to manage predominant skin concerns such as acne, dehydration, hyperpigmentation and skin aging, and offers multiple opportunities for treatment personalisation.

W: dermalogica.co.uk

EXUVIANCE Exuviance announces the launch of two new products—The Bionic Body Polishing Masque, to refresh and invigorate, and the Retexturing Treatment, to restore smooth, radiant skin. The new Exuviance Bionic Polishing Masque is said to be an indulgent exfoliating, hydrating and smoothing treatment for the body. The new Exuviance Retexturing Treatment on the other hand is a lotion designed to resurface dull, rough skin on the body, treat keratosis pilaris and restore silky softness to arms and legs.

W: exuviance.co.uk

44 PRODUCTS I body language

REVITATROL This advanced, dual-purpose formula is designed to deliver essential hydration and calming for post-procedure, compromised and severely dry or irritated skin. It is also said to support the skin's natural regenerative process for skin renewal and improvement in the appearance of fine lines and wrinkles. The formulation's rich hydrators are said to replenish lipids and restore the skin’s barrier while branched beta glucan helps reduce the appearance of redness.

W: zo-skinhealth.co.uk

 NEXT MOTION Next Motion is a complete solution that allows Doctors to create, edit and share videos thanks to a motorized equipment run by a mobile and tablet application. It offers both 180 o and 360 o face and body videos, generates the correct consent forms and stores them, sends your patients their video and information in one tap, provides eastyto-use professional editing tools, can be easily personalised with your website and business card, generates a treatment plan with your patient and their picture, ensures traceability of your products and is stored on a secured cloud that is reachable from any device at any time.

W: nextmotion.net

 ROSALIEVE Jan Marini announce the arrival of their new lotion—Rosalieve, designed to reduce the appearance of facial flushing. RosaLieve is an innovative formula with azelaic acid, an anti-redness peptide, and multiple antioxidants and extracts shown to calm the skin and reduce the appearance of redness and visible flushing.

W: janmarini.co.uk

 GOLD COLLAGEN RX Minerva Research Labs launches new Gold Collagen RX, a unique oral liquid collagen beauty supplement. This high impact professional product is designed to boost the production of natural collagen, elastin and hyaluronic acid in the dermis, targeting the visible signs of ageing associated with collagen loss.

W: gold-collagen.com

LA ROCHE POSAY La Roche Posay announces the launch of the new Effaclar BB Blur that offers multi-benefit oil-absorbing coverage for blemish-prone skin. This product is available in two shades providing medium coverage for an instantly flawless complexion that lasts all day. It can be Applied the morning after cleansing and moisturising, as the final smoothing and illuminating step, and is suitable for sensitive skin. The Effaclar range has been formulated and clinically proven to help fight imperfections, reduce inflammation, soothe and clarify, without stripping skin of its natural oils. Whilst some blemish treatments can leave skin feeling tight, dry or irritated, all La Roche-Posay products are specifically designed for sensitive skin to ensure it is left feeling cleansed, fresh and moisturised, without any intolerances, as part of a daily regime.

W: laroche-posay.co.uk

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body language I EQUIPMENT 47

Thermo-therapeutics DR ARIEL HAUS discusses the success of ultrasound use for body reshaping

U

ltrasound has various uses in medicine, both diagnostically and thermo-therapeuticallyâ&#x20AC;&#x201D;but for reshaping the body in aesthetic medicine our interest lies in its mechanical therapeutic capabilities.

Focussed ultrasound

Treating fat You can remove fat by either heating it, freeze it, or breaking it down with sound waves.

Ultrasound treatment uses the peaks and dips in the pressure created by sound waves to alter body tissue. Maximum pressure is found

at the peaks and the minimum at the dips.

Technology has changed a lot since the first devices I was using some 15 years ago when there was no focus ultrasound, and wave penetration only occurred in the more superficial fatâ&#x20AC;&#x201D;not deeper the epidermis or the dermis, where the latest technology can treat.

Today, using a focused ultrasound, the energy can go quite deep, and once it penetrates deeper into the subcutaneous fat, not only can the intensity can be increased, certain areas can be targeted with greater precision.

Using a 200khz device, features such as pulse mode allows the user to control the temperature.

This offers an important element to treatment and contrast to continuous mode, which can cause the tissues very close to the transducer to overheat, which can cause the patient pain and other side effects.

Focused ultrasound energy can penetrate up to 1.5 centime-

48 EQUIPMENT I body language

attest to having had this treatment done on me and feeling no pain and having no side effects.

Reshaping procedure First the area to be treated is mapped.

A device such as Ultrashape Power can calculate and track how many pulses are needed for an area, so it’s very precise. Many different areas can be treated, including abdomen, flanks, thighs, inner thighs, arms, and glutes.

Ultrasound can be used to treat those with a BMI above 28 with great success. In terms of the satisfaction, 94% of the patients feel happy with the treatment, and over 93% feel pain free when this treatment is carried out well.

Before and after 3 cm reduction

tres without discomfort, because it uses intermittent pulse waves, which causes no overheating. It’s a mechanical effect, and it’s a permanent immediate effect, that only targets the fat cells, while key blood vessels and the connective tissue are preserved.

When we treat with ultrasound, the fragile membrane of the adipose sites can be broken by the sound waves to release the fat. The connective tissue, blood vessels and skin is preserved, which for me this is an important part of choosing to use this technology. When ultrasound is used to break down the membrane and release the fat, 50% occurs very quickly, and then the body’s metabolism acts on the rest to eliminate it in natural ways. Depending on the depth, treating with high intensity focussed ultrasound can create tissue tightening, does not create fibrous tissue and can only destroy fat.

Evidence Many clinical papers and peer reviews exist on this technology, showing studies with amazing data, including circumference reduction of up to 6.3cm.

In a recent study I looked at 43 patients, skin type one to five, 41 female and two male. My protocol was three treatments, two weeks apart and the result was an improvement for all the 43 patients in the study. At the 12 week follow up, the improvement was 32.3%; while in terms of circumference re-

duction at 12 weeks follow up this was 2.62 centimetres. Over 80% of the patients showed improvement just after the first treatment.

It’s important to note that the pain level in this case—which was rated between zero and 10—was 0.68, which means pain free. The treatment is very comfortable. I can

Conclusion Ultrashape Power is the most effective and safe device for non-invasive long lasting fat destruction.

Dr Ariel Haus offers a variety of non and minimally invasive treatments from his Harley Street clinic, in the NHS and by arrangement in Rio de Janeiro.

Immediate selective fat cell destruction—control DESTROYED FAT CELLS

INTACT CONNECTIVE TISSUE Immediate selective fat cell destruction—treated

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50 DENTAL I body language

Cosmetic dentistry SUZANNE VALANCE discusses changes in cosmetic dentistry, and which treatments are most suitable for a range of dental concerns

B

efore undergoing cosmetic dental treatment many patients report being self-conscious about their appearance and the impact of this low confidence on personal and professional lives is surprising. A 2016 study by the British Dental Association revealed that 77% of respondents felt that visibly decayed teeth, missing teeth or bad breath would hinder a candidate’s chances of securing employment in public or clientfacing roles, and six in 10 believe tooth decay could impede their

promotion prospects. These views were reported alongside the overall belief of that white teeth increases attractiveness by 20%.

In the face of this dental anxiety, cosmetic dentistry has never been so popular. With a variety of treatments available, it’s important that the correct choice for each patient’s individual needs are met. The most effective cosmetic treatments available are changing as technology advances, so it’s vital that dental practices are moving with technology to create an improved clinical environment for patients.

Cosmetic dentistry Cosmetic dentistry varies from small treatments that will improve a patient’s oral health and make their mouth look clean and well cared for, to improving tooth alignment and enhancing the appearance of their smile. These cosmetic procedures can make a huge difference to a patient’s appearance, although every mouth requires different treatment and there is no one size fits all answer when it comes to dental solutions.

For those who have concerns about the way their teeth look,

body language I DENTAL 51

when meeting new people, smiling and interacting with their peers.

This may be having a psychosocial impact on society that goes beyond vanity as patients will do almost anything to achieve the whitest shade of teeth possible.

Reputable suppliers Sourcing products from a reputable supplier is vital for practitioners reputation and patient safety. It’s been reported that in Warwickshire, the LGA seized more than 15,000 "dangerous"' teeth whitening products between May 2015 and February 2016. These kits contained up to 33% hydrogen peroxide, which is shockingly high in comparison to the legal limits of 0.1% for public use, or 6% for professionals.

Patients should be advised that The British Dental Association warns against buying whitening kits over-the-counter or on the internet. Home kits are not the best option for teeth whitening as they may not fit the patients mouth exactly and bleaching isn’t always advised for patients with gum disease or crowns. whether it is chipping, colouring, or straightness, there are varying dental treatments available that can make them feel more confident about their appearance. Cosmetic treatments vary and any professional dentist generally provide the following cosmetic treatments: • Teeth whitening • Dental implants • Teeth straightening (Invisalign) • Dentures • Inman aligner orthodontics • Crowns • Veneers Teeth whitening A simple clean may be all that’s needed in order to lift the colour of some patients teeth. Regular professional cleaning removes plaque and tartar by using tools to remove this from above and below where the tooth and gums meet.

Teeth whitening is a great next step for patients who are looking to restore their smile without surgery.

The whitening product is applied to the teeth using a specially fitted

mouth guard. As the active ingredient—typically hydrogen peroxide or carbamide peroxide—is broken down, oxygen gets into the enamel on the teeth and the tooth colour lightens. The treatment typically takes around 30 minutes to one hour Teeth whitening is only legal if carried out by a dentist, dental hygienist, dental therapist, or using an at home kit containing less that 0 .1% hydrogen peroxide, according to EU legislation. Although tooth whitening at home is increasing in popularity, a dental professional is highly trained to understand the complex ways in which the mouth works and the way the treatment will affect it— plus can recognise problems such as cancer of the mouth and gum disease, which would contraindicate treatment.

Research is showing that one third of teenagers and adults suffer from tooth discolouration and that this is causing them to feel less confident about there appearance

Crowns and veneers Dental porcelains are used to create replicas of natural looking teeth for both veneers and crown fabrication. The tooth is prepared by removing a layer of the outer surface using a chamfer bur on a hand piece drill, this can also be done with another preferred bur.

Once the tooth is prepared, the dental team will begin to take an impression. The impressions are then transferred over to the dental technician, along with personal information about the patients shade of teeth.

By putting the patient under local anaesthetic this procedure should feel no different from a filling for the patient, however, in some cases if the tooth does not have a nerve, and a post crown is being prepared, a local anaesthetic may be unnecessary.

Veneers and crowns are perfect for a patient who wants a subtle change made to their mouth.

The secret to fitting the perfect crowns and veneers is that the

52 DENTAL I body language

implants do not rely on adjacent teeth.

Reliability As the more modern treatment, dental implants are stronger and are the most reliable and comfortable form of tooth replacement.

A titanium dental implant bonded with the jawbone

work should be imperceptible.

The dental implant debate Dental implants are ideal for patients who have lost teeth to injury or oral disease. This treatment is beneficial as implants can be fitted either individually or as a whole set.

Dental experts at Berkeley Clinic recommend that dental implants should be safe, strong and durable for them to be more effective than dentures. Dental implants are made from titanium—a biocompatible material that the body will not reject and that provides a strong foundation for replacement teeth. The natural bone fuses to the implant—in the process of osseointegration. These new teeth could last a lifetime if they are looked after appropriately.

Media coverage of celebrity culture has boosted the attractiveness of dental implants as superstar patients are looking for first class dental care from trusted physicians.

Dental implants vs dentures In recent years the popularity of dental implants over dentures has grown increasingly, though den-

tists should consider a variety of personal preferences before advising a cosmetic treatment for their patient.

Application Dental implants are applied to patients while they are under general anaesthetic. To secure the implant into the patient's jawbone they are drilled in. The titanium implant then acts as a new tooth root whereas partial dentures are secured with wings to adjacent teeth.

Comfort Many denture wearers complain about the comfort of the appliance and how it affects eating and drinking. Dental implants are fixed firmly to the gums which eliminates any risk of slippage, as the implants are attached. Partial denture appliances can loosen and slip out of place, which may cause the user distress.

Impact on oral health Partial dentures depend on adjacent teeth for support and in many cases this can damage the lining of the patient’s natural teeth. Dental

The future of cosmetic dentistry With technology comes choice and the last 15 years has seen the world of cosmetic dentistry full of new options for patients, including CADCAM dentistry that allows single visit crowns, veneers and ceramic reconstructions.

Computer Aided Design and Computer Aided Manufacturing are now used to assist with dental restoration—specifically dental crowns, veneers and dental implants. This modern technique allows dentists to treat heavily broken teeth in as little as one visit and in reduced appointment times.

This has benefits both dentists in the form of higher patient volumes and for patients who can be seen sooner.

With the rise of clear brace applications like Invisalign that only take a matter of months to straighten teeth, it appears that, in the future, state of the art technology will enable dentists to fix teeth without an impression, without temporaries, and without metal.

Suzanne Valance is an industry writer for cosmetic dentistry, she represents the Glasgow Dental Clinic, Berkeley Clinic, an award winning practice in Glasgow, Scotland.

References 1. http://www.dailymail.co.uk/ femail/article-2307430/Whiteteeth-make-look-younger-employable-Holly-Willoughby-enviedsmile-say-dentists.html 2. ICM Research conducted amongst a nationally representative sample of 2041 UK adults, 2729 April 2012, Source: dentistry. co.uk 3. http://www.itv.com/news/201604-02/teeth-whitening-diy-kitsare-dangerous-councils-warn/

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body language I HAIR LOSS 55

Featherlike finish Karen Betts guides us through brow microblading

T

he brow design process is complex and depends on the desires of the client, their face shape, facial features and skin tones. The technician can use a number of tools such as cotton thread, a ruler, measuring callipers, or the Karen Betts Brow Guides and their own personal experience to achieve symmetry and a design that suits the client.

The microblading tool As part of the KB PRO treatment, KB have launched a patent pending microblading tool, which is like no other hand tool available in the industry and available exclusively for KB PRO. The tool features a removable depth guard for safer, easier and faster treatment, sharper needles which deliver the finest stroke lines. The micro needles implant pigment (in a colour tailored to suit the client) to the brow in a “featherlike” hair stroke technique which mimics the growth of natural hair and results in natural, flawless looking brows.

Very little pigment is used—only a couple of ml at most per treatment.

KB PRO microblades control the depth of the pigment and the outline achieved in the design process will control where it is applied. The KB PRO Glider is dipped into the pigment before gliding through the skin where it deposits the pigment.

After all the hair strokes are channelled KB PRO advises a ‘colour bath’. This simply involves pigment being applied over the skin using a micro brush so the skin absorbs as much pigment as possible.

The hardest thing about microblading is depth control and fluidity, unlike using a machine you get no vibration or feedback with a hand tool. To eliminate technicians going too deep, the KB PRO Glider has a specially designed

depth guard and ergonomic shape for more control and less fatigue.

Protocol Be sure to patch test your client, conduct a thorough consultation discussing shape, colour and expectations and take your client through the appropriate aftercare.

Microblading is not a technique that can be mastered in one day and it is recommended that a client does their research, checks training credentials, views the artist’s portfolio and not be afraid to verify that the work is that of the artist and not courtesy of the company they have trained with.

Discomfort and healing time There’s a tiny amount of discomfort but it wouldn’t be regarded as pain—rather the feeling of small

surface scratches. A topical anaesthetic cream can be applied to numb the area. Aftercare advice is given on an individual basis after each treatment, but a soothing balm that we produce and give to our clients to apply post treatment can assist with the healing.

Contraindications Contraindications are as per any invasive treatment—the client should not be pregnant or breast feeding or have any medical conditions which may be affected by the application of a permanent cosmetic treatment.

Karen Betts is a pioneer in permanent makeup and medical tattooing with over 20 years’ experience. She is the Managing Director of Nouveau Beauty Group.

IDENTITY RECOVERED Alopecia sufferer Alison Beaty shares her experience of KB PRO eyebrow microblading In 2010, at the age of 42, I lost all of my hair due to alopecia.

First the hair on my head and then within six months, every hair on my body. After a few years, the majority of my lashes returned but I still had to draw in eyebrows. I got by, but was always conscious of rubbing them out, having them sweat off, or washing them off in a swimming pool. When the offer of a KB. PRO micro-blading treatment with Karen Betts was presented to me via Alopecia UK, I plucked up the courage and headed to Karen’s London clinic. The expectation of a little discomfort was slightly off-putting but my bigger concern was that my new brows would be in some way bigger, darker, or in a different shape to what I’d become accustomed to. Karen mixed a colour to compliment my skin tone, but explained that despite an initial darkness, the colour would fade by up to 50% over the first couple of weeks, to give a more natural shade.

The procedure was neither painful, nor completely without discomfort. The sensation was like a series of gentle scratches. The hair-like effects are so realistic, and the most significant observation is the wonderful difference the brows have made to my face.

Alison would like to thank Karen Betts Clinics, Alopecia UK and Alex Silver PR for this opportunity.

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Dosage and Administration: Should be applied to the affected area twice daily, at least eight hours apart. Application should be limited to the face and under the chin. Maximal applied doses used safely in clinical trials were up to 30 grams per month. Improvement in the condition may be noticed within eight weeks and continued treatment may result in further improvement and is necessary to maintain beneficial effects.

Discontinue if no beneficial effects are noticed within four months of commencing therapy. Patients may need to continue to use hair removal methods (e.g. shaving or plucking) in conjunction with Vaniqa. Application of Vaniqa should be no sooner than 5 minutes after use of other hair removal method, as increased stinging or burning may occur. A thin layer of the cream should be applied to clean and dry affected areas. The cream should be rubbed in thoroughly. The medicinal product should be applied such that no visual residual product remains on the treated areas after rub-in. Hands should be washed after applying this medicinal product.

For maximal efficacy, the treated area should not be cleansed within four hours of application. Cosmetics (including sunscreens) can be applied over the treated areas, but no sooner than five minutes after application.

The condition should improve within eight weeks of starting treatment.

Paediatric populations: The safety and efficacy of Vaniqa in children 0-18 years has not been established. Hepatic/renal impairment: caution should be used when prescribing Vaniqa. Consult SmPC for further information. Contraindications, Warnings, etc: Contraindications: Hypersensitivity to eflornithine or to any of the excipients. Warnings & Precautions: Excessive hair growth can result from serious underlying disorders (e.g. polycystic ovary syndrome, androgen secreting neoplasm) or certain active substances (e.g. cyclosporin, glucocorticoids, minoxidil, phenobarbitone, phenytoin, combined oestrogen-androgen hormone replacement therapy). These factors should be considered in the overall medical treatment of patients who might be prescribed Vaniqa. For cutaneous use only. Contact with eyes or mucous membranes (e.g. nose or mouth) should be avoided. Transient stinging may occur if applied to abraded or broken skin. If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. If irritation continues, treatment should be discontinued and the physician consulted. Contains cetostearyl alcohol and stearyl alcohol which may cause local skin reactions (e.g. contact dermatitis) as well as methyl parahydroxybenzoate and propylparahydroxy-benzoate which may cause allergic reactions (possibly delayed). Interactions: No interaction studies have been performed. Pregnancy and lactation: Women should not use Vaniqa whilst pregnant or breastfeeding. Ability to drive and use machines: Vaniqa has no or negligible effects on

UKEFL3585b(1) Date of preparation: August 2016.

the ability to drive and use machines. Adverse Effects: These are ranked under heading of frequency using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Very common: acne. Common: pseudofolliculitis barbae, alopecia, stinging skin, burning skin, dry skin, pruritus, erythema, tingling skin, irritated skin, rash, folliculitis. Uncommon: bleeding skin, furunculosis. Rare: rosacea, skin neoplasm, skin cysts, vesiculobullous rash. Consult SmPC in relation to other adverse effects. Legal Category: POM. Marketing Authorisation Number(s): EU/1/01/173/003. NHS Cost: (excluding VAT). Tube containing 60g – £56.87. Marketing Authorisation Holder: Almirall, S.A. Ronda General Mitre, 151 08022 Barcelona, Spain.

Further information is available from: Almirall Limited, 1 The Square, Stockley Park, Uxbridge, Middlesex, UB11 1TD, UK. Tel: (0) 207 160 2500.

Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk.

Date of Revision: 10/2015. Item code: UKEFL3336

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 Almirall Ltd.

For more information please go to: www.medicines.org.uk/emc/medicine/21243

body language I INTERVIEW 57

Liposuction Q&A DR FOUED HAMZA answers questions about fat removal

Q A

How does liposuction work to treat localised fat deposits?

Liposuction removes the deep fat cells in the area that requires treatment and can be performed with an adapted cannula linked to a medical aspirator. This enables the doctor to suction the fat through the tube as it is moved around under the skin and sculpt the body to achieve the desired results. A trustworthy practitioner should first arrange for a thorough consultation to determine the risks and assess the feasible outcome for each individual.

Q

Which indications do you typically treat with liposuction rather than surgery and are there any areas you would not treat and why?

The use of liposuction is very effective to deal with areas where there are excessive fatty deposits that mis-shape the body but the procedure can’t be used to deal with areas where there is just an excess of skin, which may have come about through weight loss. Areas of the body which this operation is not suitable include the forearm

A

or the back of the thighs because there is little fat to remove and these zones tend to be packed with tendons, muscles, nerves, arteries and veins so underlying structures might be damaged.

Q

Can you explain your technique for treating each area that you would use liposuction for?

All areas of the body will be treated with the same protocol. Personally, I use the wet technique, which implies injecting the same amount of saline solution mixed with xylocaine and adrenaline, as the amount of fat that needs to be removed. I recommend this procedure because it can help reduce bleeding and post operation discomfort. Following this, we would aspirate the fat with a cannula linked to a medical aspirator. This tool allows us to adjust the size of the cannula based on the area and amount of fat to remove as this prevents a rippling effect. For the abdominal area, we use a 4mm cannula, for the calves we use a 3mm one and for the neck area, the most suitable size is a 2mm cannula. Depending on the size and location of the

A

66 Depending on the size and location, we would opt for an incision in a hidden area 99

area, we would always opt for an incision to be performed in a hidden area, which allows us to access the fatty deposit easily.

Do you use RF to tighten and remove fat?

I prefer to avoid using RF equipment as, although in the first stage this could induce fibrosis under the skin and help

Q A

58 INTERVIEW I body language

The use of liposuction is very effective when dealing with areas where there are excessive fatty deposits

with its retraction, when performing a second liposuction procedure on the same area, this might cause problems due to the bruised tissue and could lead to skin burns. The indication of RF use should be limited to areas that really require it, like the arms. Every cosmetic procedure performed in our practice is designed to be the least invasive and aggressive to the skin as possible so this tool is not part of our portfolio. Our patients are very pleased with the results from the classic wet technique so we’ll continue providing this service to them until there are future cosmetic technological advances for us to consider.

Do you use liposuction in conjunction with any other treatments?

Q A

I combine over 90% of my liposuction cases with fat transfer procedures to offer the best contours to a patient’s silhouette. Treating the whole shape of the body implies removing the fat from some areas and carefully placing it into other parts of

their body to create a harmonious shape. In general, with age, pregnancy and successive dieting, we accumulate fat in the waist and lateral thigh and lose the shape in the buttock area, so we use these mixed techniques to address this process i.e. remove fat from the waist or the tummy and add it to the lateral thigh and buttocks.

What is the expected downtime?

Patients should be able to return to their day-to-day activities after a week to 10 days, depending on the extent of the liposuction procedure.

Are there any contraindications?

The ideal candidates for this procedure are those in good health, with no blood coagulation problems or anaemia, but we would always do a thorough assessment of a patient to check their suitability before performing any operation.

Are there any side effects? What is your pre-

Q A Q A Q

ferred aftercare procedure?

The side effects from liposuction are similar for each surgical procedure. Patients might have an allergic reaction to the anaesthesia, or the quality of their skin might decrease. These risks can be lowered by ensuring that an indepth screening of the candidate is performed before the surgery. The aftercare process only involves wearing a garment for at least four weeks, until the patient makes a full recovery.

A

Q A

Who does your practice attract?

The common denominator is their need and desire to get into shape with the help of modern medicine. We receive liposuction requests from both men and women, of different ages, however the legal age to perform surgery is 18 and over.

Dr Foued Hamza, is a cosmetic surgeon, practising at the Queen Anne Street Medical Centre off Harley Street, London.

W: drhamza.co.uk

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

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UPPER FACIAL LINES The first and only aesthetic neurotoxin approved for combination treatment of Upper Facial Lines including: • Horizontal Forehead Lines • Crow’s Feet Lines • Glabellar Frown Lines

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Botulinum toxin type A free from complexing proteins Bocouture® (incobotulinumtoxinA) 50 units Prescribing Information M-BOC-UK-0007 Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults below 65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: Intramuscular injection, the recommended total dose range is 10 to 20 units, a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50 units/1.25mL). Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome).

Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with aging or photodamage). In this case, patients may not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia

and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia).

Frequency of adverse reactions by indication is defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Upper Facial Lines: Very common: Headache.

Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma.

For a full list of adverse reactions, please consult the SmPC. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany.

Date of Preparation: July 2016. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143

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

Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

1. Bocouture® 50U Summary of Product Characteristics (SPC).

April 2016. Available from: https:/www.medicines.org.uk/emc/ medicine/23251 2. Carruthers A et al. Multicentre, Randomized, Phase III Study of a Single Dose of IncobotulinumtoxinA, Free from Complexing proteins, in the Treatment of Glabellar Frown Lines. Dermatol Surg. 2013:1-8 3. Prager W, et al. Comparison of Two Botulinum Toxin Type A Preparations for Treating Crow’s Feet: a Split-Face, DoubleBlind, Proof-of-Concept Study. Dermatol Surg. 2010 Dec; 36 Suppl 4:2155-60 4. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 5. BOC-DOF-012 Bocouture® Convenient to Use, August 2015 BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC--0002

Date of Preparation August 2016

PURIFIED1• EFFECTIVE2, 3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins