Body Language #85

november

85

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

20 YEARS OF INJECTABLES A SHOT OF HISTORY—DR NICK LOWE GUIDES US THROUGH RECENT INJECTABLE INNOVATIONS

TREATMENT Histology and the latest approaches to diminish stretch marks

EQUIPMENT

PSYCOLOGY

Skin tightening & scalpel-less non-excisional face and neck lifting

The importance of pre and post-procedure patient support

NOW APPROVED FOR

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

body language I CONTENTS 3

18

25

contents 07 NEWS

36 TREATMENT

OBSERVATIONS

STRETCH MARKS: THE CHALLENGE OF TODAY

Reports and comments

15 INDUSTRY NEWS MEDICAL AESTHETICS News round-up

18 INJECTABLES A SHOT OF HISTORY Professor Nick Lowe guides us through 20 years of injectables

25 EQUIPMENT

49 EDUCATION NEOSTRATA SKINCARE TRAINING Caroline Gwilliam shares benefits of attending AestheticSource's training courses

RF NON-EXCISIONAL FACE AND NECK LIFTS

53 PRODUCTS

Dr Stephen Mulholland explores the concept of skin tightening and scalpel-less non excisional facelifting

The latest products and services in medical aesthetics and anti-ageing

33 TRAINING

Q&A

DRACULA PRP THERAPY TRAINING

07

Dr Catherine De Goursac discusses the histology and available treatments for stretch marks

PRP is a powerful treatment that can be used in many areas of aesthetic medicine. Dr Daniel Sister talks us through his comprehensive training course and how you can use PRP to benefit your practice

ON THE MARKET

55 PANEL DEBATE Prof Mukta Sachdev and Dr Rahul Pillai discuss laser hair removal

59 BUSINESS PRE AND POSTPROCEDURE SUPPORT Norman Wright discusses the importance of psychological support for patients

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 Prof Nick Lowe, Dr Stephen Mulholland, Dr Daniel Sister, Dr Catherine De Goursac, Caroline Gwilliam, Prof Mukta Sachdev, Dr Rahul Pillai, Norman Wright ISSN 1475-665X The Body LanguageŽ journal is published ten times a year by AYA Productions. All editorial content, unless otherwise stated or agreed to, is Š 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 November edition of Body Language.

We hope that you are all able to use Body Language as a guide to identify the next course of action for your practice regarding treatments, products and concepts in our ever changing world of aesthetics.

Our aim is to continue to support your professional development as we endeavour to become your closest partner in aesthetics.

In this issue, Professor Nick Lowe discusses the evolution of injectables, delving into the last 20 years of use and how we apply fillers and toxins today.

Dr Catherine De Goursac explores the myriad treatments available for treating stretch marks and Dr Stephen Mulholland elaborates on how the FaceTite can benefit your patients.

You can also catch up on all the latest industry news as well as medical aesthetic and anti-ageing product releases.

Please enjoy your copy of Body Language, and we look forward to helping continue your professional development.

Raffi Eghiayan, Publisher, Body Language

55

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The visible improvements provide high levels of patient satisfaction and the progressive treatment approach provides the opportunity to guide your patients in a consultative partnership helping to deliver attentive, personalised care and long-lasting results.

Kelly’s Story

A Restylane Skinboosters patient shares her experience Forehead area

“Before trying Restylane Skinboosters, I had never done an injectable treatment of this type – but I had been told what the treatment could do and was very hopeful that I would see some of these results for myself!

My practitioner explained that the results would appear over time, and that I would continue to see improvement even after my third treatment. I couldn’t wait to get started.

The procedure itself was better than I expected. It wasn’t too painful; I felt just a few small pinpricks, and my practitioner was very gentle.

I loved that I could go back to my normal, everyday activities right after treatment.

I really started to notice a difference after my second treatment. My skin started to glow, and felt so much fresher. I could feel that the structure of my skin had improved as well, and my face felt softer. I also had fewer fine lines around my cheeks and mouth.

I am so pleased with the results of my Restylane Skinboosters treatment that I would recommend it to any of my friends. The results are subtle and natural-looking but everyone tells me I look refreshed and that my skin is radiant. I can see and feel the same effects myself, and I feel younger! The treatment has even made a difference to me on the inside - I feel happier, and I feel good about myself.

Crow’s feet Cheek area Smile lines

Peri-oral lines

Neck area

Hands

Décolletage

All thanks to Restylane Skinboosters!”

A versatile treatment suitable for a wide range of age groups and skin types

www.restylane.co.uk RES/041/0516 Date of preparation May 2016

HENTIC AUT Micro-Focused Ultrasound with Visualisation

Only from

An evolution in aesthetics treatment1 • Scientifically proven*1-4 • Lift that can last for over a year3,5 • Treatment takes between 60-90 minutes6

ULT/180/2016/MAY/2016/SS Date of preparation May 2016

• No patient downtime2,3,5

Contact Merz Aesthetics NOW and ask for Ultherapy® Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com

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Before

After

Before and after imagery: all patients have had their Ultherapy® treatment line counts tailored to their individual needs by their practitioner. These line counts may differ from those recommended in the Instructions For Use.

*stimulates new collagen and elastin which can reverse the signs of ageing References: 1. Ulthera System Instructions for Use, 1001393IFU Rev H 2. Sasaki GH & Tevez A. JCDSA. 2012; 2: 108-116 3. Alam M, et al. J Am Acad Dermatol. 2010;62:262-269 4. Lee HS, et al. Dermatol Surg. 2011;1-8 5. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202 6. ULT-DOF-003 Ultherapy Treatment Duration. Merz - July 2015 7. http://www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed May 2016 8. CE Certificate 3808396CE01, DEKRA April 2012 Adverse incidents must be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents must also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143

www.ultherapy.co.uk

body language I NEWS 7

observations

NEW COSMETIC SURGERY INFORMATION FOR PATIENTS Royal College of Surgeons launches new patient resources around cosmetic surgery The Royal College of Surgeons (RCS) is urging people to 'think carefully before cosmetic surgery' by adding new independent information and resources to their website.

The aim of this information drive is to give patients unbias advice they can trust, in the face of more underhand marketing methods used by some private companies.

Mr Stephen Cannon MBE is Vice President of RCS and chaired the Cosmetic Surgery Interspecialty Committee, which was set up to improve standards in cosmetic surgery.

He said: “The cosmetic surgery industry is booming, but due to the aggressive marketing and ruthless sales tactics of some unscrupulous companies, it can be very difficult for patients to find independent, trustworthy information which gives them a clear idea of what an operation would entail.

In the wake of the PIP breast implant scandal, the 2013 Keogh Review found that there was a clear need to improve regulations of both surgical and non-surgical cosmetic practices in the UK. Following this, the Department of Health asked the RCS to produce patient resources and set up a certification system.

Mr Cannon remarks: "The vast majority of

cosmetic surgery is carried out in the private sector and many people do not realise that the law currently allows any qualified doctor – surgeon or otherwise – to perform cosmetic surgery, without undertaking additional training or qualifications."

The resources on the RCS website are there to counteract this lack of knowledge, offering patients and those seeking cosmetic surgery handy checklists and short animated films. It also provides information on choosing the right hospital and surgeon, and explains the risks and complications that can be associated with undergoing surgery.

According to an audit by the British Association of Aesthetic Plastic Sur-

geons of its members, last year alone over 51,000 cosmetic surgery procedures were performed in the private sector in England. It's therefore imperative that these patients understand the surgery and procedures they are undergoing, and are able to choose a surgeon with confidence.

In the coming months, the RCS will also publish a register of ‘certified surgeons’ in different cosmetic surgical procedures. This will allow patients to look for a surgeon who has provided evidence that they have the appropriate training, experience and insurance to practise in the UK. Consultant plastic surgeon and BAAPS President Michael Cadier said: “The British Asso-

ciation of Aesthetic Plastic Surgeons; which represents the vast majority of NHS-trained plastic surgeons in private practice; is delighted to hear that ... the Royal College of Surgeons of England is launching a new patient portal providing accurate information on cosmetic procedures and advice on how to choose a surgeon.

For the last three years BAAPS has worked both closely and exhaustively with the RCS to develop not only this patient portal but also implementing mechanisms to ensure that cosmetic surgeons are appropriately trained and competent, and to develop measures to monitor the outcomes of cosmetic surgery – and, crucially, to make these resources available online to the public."

8 NEWS I body language

STRESS CAN NEGATE THE BENEFITS OF 'GOOD' FAT New research shows that the benefits of eating healthier fats disappear when we're stressed People are becoming more and more aware that fats are not to be avoided, and that certain dietary fats are in fact good for us. However, a recent study from researchers at The Ohio State University suggests that stress can cause the benefits of healthier fats to disappear.

The study, published in the Molecular Psychiatry journal, measured unhealthy markers in the bloodstream in women who ate a breakfast with high saturated 'bad' fat and women who ate a breakfast with monosaturated 'good' fat.

The team controlled factors within the groups that could skew the outcome, such as age. Both groups had meals that contained 930 calories and 60 grams of fat, but one group had a breakfast high in saturated fat from palm oil, and the other had a breakfast high in monosaturated fat from a sunflower oil high in oleic acid.

The women were asked to fill in

questionnaires which measured stressful events the day before. They found that the women who ate the breakfast with saturated fat had a higher level of unhealthy markers in their bloodstream than the women who ate the breakfast with monosaturated fat. However women who experienced stress before eating the 'good' fats in their breakfast had the same level of unhealthy markers as those who ate 'bad' fats.

Jan Kiecolt-Glaser, lead author of the study who directs the Institute for Behavioral Medicine at Ohio State’s Wexner Medical Center said, “It’s more evidence that stress matters.” Although it is known that stress and diet are linked to inflammation, this study was conducted to find out more about how these factors work together.

Interestingly, no matter what stressors were experienced by the group who had a breakfast with 'bad' fat , their unhealthy

markers did not go up or down.

The women's blood was drawn multiple times during their visits. The researchers looked at two markers of inflammation – C-reactive protein and serum amyloid A. They also evaluated two markers called cell adhesion molecules that could predict a greater likelihood of plaque forming in the arteries.

Food that's high in oleic acid is known to be anti-inflammatory. Health problems, including heart disease, diabetes and rheumatoid arthritis are linked to chronic inflammation, so this study paves the way for more research into stress, fat sources and other healthy diets, such as those high in fibre, fruit and vegetables.

The message from the researchers is not that it doesn't matter what you eat when you're stressed, rather that you should aim for healthier choices every day so that you're in a better place when you do experience stress.

HIGH FACTOR SUNSCREEN REDUCES MELANOMA RISK Using a high factor sunscreen instead of a low factor sunscreen can decrease the risk of melanoma by a third.

The Department of Biostatistics at the University of Oslo recently carried out a study to assess the risk of melanoma, comparing high factor sunscreens to low factor sunscreens.

The study, which was published in the Journal of Clinical Oncology, found that high factor sunscreen can decrease the risk of melanoma by 33%.

Researchers looked at 143,844 women aged 40-75, and followed them for an

average of 10 years, with 722 cases of melanoma. They found that people who used an SPF of factor 15 or higher had a decreased risk of melanoma.

This large study was conducted by a research group that had access to data from the NOWAC study merged with data from the Cancer Registry of Norway.

The results showed that sunscreen users actually reported more incidences of sunburn than non-sunscreen users. They

also reported to take more sunbathing holidays and were more likely to use tanning machines.

This research come at an important time where cases of melanoma have increased year on year across Europe. There are around 2,000 new cases each year now in Norway. According to Cancer Research UK, in the last decade incidences of malignant melanoma have increased by nearly half in the UK.

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

W: WIGMOREMEDICAL.COM/EVENTS I

TRAINING

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E: TRAINING@WIGMOREMEDICAL.COM

I T: +44(0)20 7514 5979

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1 CPR & Anaphylaxis Update 1 Skinrölla Microneedling (pm) 2 Mini-Thread Lift* 5 Microsclerotherapy* 6 Adv. Toxins and Fillers* 7 Dracula PRP* FB 8 ZO Medical Basic (London) 9 ZO Medical Interm. (London) 10 Sculptra* FB 10 ZO Medical Basic (Manchester) 11 ZO Medical Interm. (Manchester) 11 Non-Surgical Rhinoplasty* 12 Algeness* 15 ZO Medical Basic (Dublin) 16 ZO Medical Adv. (Dublin) 22 Skincare with NeoStrata 23 Intro to Toxins* 24 Intro to Fillers* 25 Adv. Toxins and Fillers* 26 Mini-Thread Lift* FB 30 CPR & Anaphylaxis Update

1 Adv. Toxins and Fillers* 3 Microsclerotherapy* 6 ZO Medical Basic (London) 7 ZO Medical Interm. (London) 8 ZO Medical Adv. (London) 9 Core of Knowledge (pm) 13 ZO Medical Basic (Dublin) 13 Skincare with NeoStrata 14 Intro to Toxins* 14 ZO Medical Interm. (Dublin) 15 Intro to Fillers* 16 Adv. Toxins and Fillers* 17 Mini-Thread Lift* 19 Algeness*

17 Skincare with NeoStrata 18 Intro to Toxins* 19 Intro to Fillers* 20 Mini-Thread Lift* 21 Adv. Toxins and Fillers* 23 Dracula PRP* 24 ZO Medical Basic (London) 25 ZO Medical Interm. (London)

2 Skinrölla Microneedling (pm) 2 glo minerals (am) 3 glo therapeutics 9 Sculptra* 10 Non-Surgical Rhinoplasty* 11 Microsclerotherapy* 13 CPR & Anaphylaxis Update 14 Skincare with NeoStrata 15 Intro to Toxins* 16 Intro to Fillers* 17 Mini-Thread Lift* 20 Dracula PRP* 21 ZO Medical Basic (London) 22 ZO Medical Interm. (London) 24 Adv. Toxins and Fillers* 27 Core of Knowledge (pm)

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body language I NEWS 11

60% OF BRITS SUFFER WITH SKIN DISEASE

© FEATUREFLASH PHOTO AGENCY

The British Skin Foundation reveals statistics on skin disease and sunburn

RISING DEMAND OF THE 'BRAZILIAN BUTT LIFT' A doctor takes to Instagram to share his techniques on this popular procedure According to The Independent, social media and the popularity of celebrities such as Kim Kardashian and Nicki Manaj may be responsible for the rise of gluteal augmentation.

They report that Dr Siamak Agha, a plastic surgeon in Florida, is building a following on Instagram by showing the 'before' and 'after' pictures of his 'Brazilian Butt Lifts'. In 2015 there was a huge increase in the number of buttock augmentations, showing the rise in popularity for a larger posterior.

The procedure involves transferring fat, inserting implants, or a combination of both to get the desired effect. Dr Agha transfers people's unwanted fat using liposuction, processing the fat and then injecting it back into the patient's buttocks. He shows this to his followers using hashtags like #buttockslift.

The International Society of Aesthetic and Cosmetic Surgery has reported that there has been almost a 30% increase in buttock augmentations since 2014, with almost 320,000 carried out worldwide in 2015. While the American Society of Plastic Surgeons also released a report stating that buttock implants were the fastest growing type of cosmetic surgery in the US in 2015.

Popular celebrity posteriors and growing popularity of the procedure on social media, may see this procedure continue to see a rise in numbers in 2016-2017.

A new survey, conducted by the British Skin Foundation, has found that 60% of British people have at some point in their lives suffered from a skin disease, and a huge 85% admit to getting sunburnt.

Revealed at their 20 years of Research Conference on 13th October in London, the survey covered all sorts of skin conditions from the common to the potentially life threatening.

According to the survey, seven in ten people have visible scars or visible skin conditions, with 72% saying it affects their confidence. 14% of people saying they feel uncomfortable if they see a visible skin condition or scar. 28% of the population also suffer with acne and 39% struggle to find ways of handling the skin disease.

“Statistics like this remind us just how much skin conditions and scars can affect everyday life by crushing people’s confidence... our goal is to fund as much research as possible to try and help those with skin issues,” explains Lisa Bickerstaffe, British Skin Foundation spokesperson.

While 85% of people admitted to being sunburnt, one in ten people confessed that they don’t wear SPF 30 or more when abroad. Over a fifth of people also forget to reapply sunscreen after swimming or at two hours intervals.

Consultant Dermatologist, Dr Emma Wedgeworth warns, “Sunburn isn’t just a nuisance, it’s a warning. We know that just five or more sunburns in your life can double your risk of melanoma... Regular reapplication of sun cream, seeking shade and covering up can all significantly reduce the risk of sun damage and skin cancer.”

The British Skin Foundation is the only UK charity that funds research into all types of skin disease and to date has raised over £15 million.

This survey into British skin health comes as the charity celebrates 20 years of raising money for research.

Matthew Patey, British Skin Foundation CEO says “Our survey has shown that a high percentage of people are affected by skin disease during their lifetime, telling us that our work is just as essential today as it ever was twenty years ago. It illustrates that more research is needed to help people with all kinds of skin problems.”

12 NEWS I body language

COLD PLASMA CAN TREAT NON-HEALING WOUNDS Treating cells with cold plasma can lead to regeneration and rejuvenation.

Treating patients with non-healing wounds effectively can be difficult. New research, published in in the Journal of Physics D: Applied Physics demonstrates that cold plasma can be used to regenerate cells and therefore develop a plasma therapy program for patients with non-healing wounds.

Researchers at the Moscow Institute of Physics and Technology (MIPT), the Joint Institute for High Temperatures of the Russian Academy of Sciences (JIHT RAS), and Gamaleya Research Centre of Epidemiology and Microbiology used two types of cells in this study – viz. fibroblasts (connective tissue cells) and keratinocytes (epithelial cells).

The purpose of the study was to establish the influence of cold plasma treatments on the physiological characteristics of both these cells – each are an important part of wound healing.

Researchers used three regimes of plasma application: a single treatment, double treatment with a 48 h interval, and daily treatments for 3 days.

In single plasma application and double plasma applications, there was a 42.6% and 32.0% cell increase, respectively.

No DNA-breaks were found during the application of plasma, however they did detect an increase in the accumulation of cells in the active phases of the cell cycle. This shows that the plasma application seems to promote regeneration.

The activation of proliferation also correlated with a decrease in the level of β-galactosidase enzyme, a senescence marker. The researchers concluded this could be due to cell renovation after plasma application.

The proliferation of cells that had been treated daily over a period of three days (group C) was reduced by 29.1 % relative to the controls. Keratinocytes did not show noticeable changes in proliferation.

This shows great promise for plasma therapies for non-healing wounds, which can be caused by immune system failure or damage to blood vessels. These are currently very hard to treat using conventional methods.

The scientists are planning to continue their studies this area, including the molecular mechanisms underlying the effects of plasma on cells.

BROWN ADIPOSE TISSUE ACTIVATES FAT AND CARBS METABOLISM Brown adipose tissue secretes signaling factors that activate the fat and carbohydrates metabolism Brown adipose tissue (BAT) is known to help burn calories in the body, but according to an article published in Nature Reviews Endocrinology it also has an endocrine function which can activate the body's lipid and glucidic metabolism.

Researchers at the Department of Biochemistry and Molecular Biology at the University of Barcelona and CIBER of Physiopathology in Obesity and Nutrition (CIBERobn) of the Institute of Health Carlos III are looking at BAT as an endocrine organ. Some of the first BAT-derived endocrine factors to be identified were Fibroblast growth factor 21, IL-6 and neuregulin 4. The secretory capacity of BAT is where their interest lies.

BAT is the organ that generates the most heat in the body and when it is activated there is high oxidation in metabolism products. According to researchers it then also sends a series of biochemical signals to the entire body, activating the global oxidizing metabolism. The release factors are called batokines and these are the factors that researchers are trying to identify. Some of the known batokines target organs are the liver, heart and possibly the brain and pancreas.

This means that BAT does much more than just burn calories in the body. The study paves the way for future therapeutic targets to treat pathologies like obesity and diabetes. The team are attempting to move this research into the clinical field, de-

veloping in vitro human cells of brown adipose humans in population that allow verifying in human physiology the obtained results in mice.

body language I NEWS 13

events

MEDICAL TATTOOING CAN IMPROVE QUALITY OF LIFE FOR HEAD AND NECK PATIENTS Patients with scarring and skin grafts see improvements in their appearance and quality of life after dermatography

GIRLS AS YOUNG AS 15 SEEK GENITAL COSMETIC SURGERY A recent study has found that 35% of GPs who get requests for female genital cosmetic surgery, see girls younger than 18 This world-first survey, published in the British Medical Journal, found that over half of GPs in the UK had seen women requesting female genital cosmetic surgery (FGCS). A massive 97% of GPs had been asked by women of all ages about genital normality, suggesting that this is a growing concern for women.

This study is the largest so far to examine GP knowledge, attitudes and practice in this relatively little explored area. Overall, 75% of GPs rated their knowledge of FGCS as inadequate. Of those who had seen patients requesting FGCS, nearly half reported they had insufficient knowledge of the risks of FGCS procedures and 35% has seen requests from girls younger than 18.

According to The Guardian, lead author of the study, Dr Magdalena Simonis from the University of Melbourne’s department of general practice, decided to

conduct the survey after her own patients began asking about labiaplasty.

The Australian online survey of GPs was conducted over a 10week period, starting before and ending two weeks after a Women’s Health seminar held in Perth in 2015.

Just over half of the GPs felt that women should be counselled before making a referral for FGCS. More than half the GPs also suspected psychological disturbances in their patients requesting FGCS such as depression, anxiety, relationship difficulties and body dysmorphic disorder.

The study concluded that GPs see women of all ages presenting with genital anatomy concerns.

GPs often suspected a range of mental health difficulties in those who request FGCS. There is a need for greater education for GPs to thoroughly support their patients who request FGCS.

JAMA Facial Plastic Surgery has published an article online stating that head and neck patients who undergo dermatography procedures perceive improvements in their appearance and quality of life.

The study, published by Rick van de Langenberg, M.D., Ph.D. and coauthors, analysed the effect of dermatography - medical tattooing - on the subjective perception of patients at the Netherlands Cancer Institute at Antoni van Leeuwenhoek Hospital, Amsterdam.

Medical tattooing is often used to recreate the areole in patients who are undergoing breast reconstruction after a mastectomy or a breast reduction. However, the team undertaking the research stated that it is often an overlooked procedure to improve colour mismatch on the skin in head and neck patients. They also found no prior evaluation of the effects on patients’ perceptions and quality of life after this procedure.

The study involved 56 patients who completed two questionnaires evaluating a visual analog scale score and multiple questions on a 5-point scale focusing on satisfaction with appearance and quality of life.

Patients were asked questions about the appearance of their scars and skin grafts, and their quality of life before and after their dermatography treatment.

It found that patients’ subjective perception of their scar and skin graft appearance and overall quality of life improved after dermatography, suggesting that this is an effectual procedure for head and neck patients.

The study concludes "...the use of dermatography is warranted in the routine workup of patients with problematic scars and skin graft pigments after head and neck surgical procedures."

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body language I INDUSTRY NEWS 15

MATA LAUNCHES NEW LEVEL 7 INJECTABLE THERAPIES AND LEVEL 5 LASER & LIGHT ACCREDITED QUALIFICATIONS Leading aesthetic training academy MATA, will be launching a suite of Level 5 laser and light based therapy qualifications and courses this month, as well as a comprehensive Level 7 Postgraduate Certificate in the Principles and Practice of Clinical Injectable Therapies (botulinum toxin and dermal fillers).

The qualifications reflect the latest HEE guidelines, is awarded by EduQual, and endorsed by an Ofqual-recognised organisation.

The new blended-learning qualifications offer theory and practice combining distance and face-to-face teaching, with hands-on treatments on volunteer patients and clinic-based assessments. Qualifications will be available in London and around the country led by experienced clinical practitioners and tutors.

The qualification suite includes: • Advanced Professional Certificate in Laser and Light Hair Reduction (Level 5).

• Advanced Professional Certificate in Laser Tattoo Removal (Level 5).

• Advanced Professional Certificate in Laser and Light-Based Therapies (Level 5) – offering optional units of vascular & pigmented lesions, non-ablative & ablative rejuvenation, hair reduction and tattoo removal - allowing Learners to customise the qualification to their specific needs and treatment applications.

• Advanced Postgraduate Certificate in The Principles and Practice of Clinical Injectable Therapies (Level 7).

Units from the qualifications are also available as stand-alone accredited short courses, offering learners the opportunity to build ‘credits’ whilst gaining valuable training and experience in safe practice

of cosmetic therapies, in line with HEE recommendations.

As one of the first training academies to offer a portfolio of bespoke qualifications, MATA founder and director, Mr Faz Zavahir, wanted to provide rigorous but flexible training and education opportunities in a sector that needs to set high standards of treatment delivery and patient care: “I’m very pleased we are able to offer an entire suite of qualifications and courses from which learners can choose to meet their own training needs—all within one academy. Ensuring our qualifications reflect the latest HEE guidelines was vital, but we also want to ensure our qualifications and courses are open to those wanting to learn and train to a high standard. Our Level 5 and Level 7 qualifications are demanding, expecting high standards in clinical knowledge and skills, but they are also immensely

rewarding in both personal and professional development. Only by developing qualifications and courses that offer competence based training will this sector see an improvement in standards of care and patient safety”— Mr Faz Zavahir, MATA founder and director The Level 5 laser and light qualifications are open to beauty therapists (Level 3/4 qualified), tattoo removal practitioners, healthcare professionals and those with suitable prior experience/learning and/or able to demonstrate an ability to study at Level 4 or higher.

The Level 7 Injectable Therapies qualification entry requirements* are degree holding (Level 6) doctors, dentists, nurses, independent nurse prescribers and a valid GMC, GDC, or NMC number.

For the latest information including dates and fees for this exciting new range of accredited qualifications, please visit matacourses.com

CYNOSURE’S NEW 1064 NM LASER DELIVERY SYSTEM Cynosure announces a new FDA approved Delivery System for PicoSure, the world’s first aesthetic picosecond laser. Together with the FDA cleared 532nm and 755 nm wavelengths, Cynosure’s new 1064 nm Laser Delivery System is said to improve the multi-wavelength laser technology for removing the full colour spectrum of tattoo inks in fewer treatments. Cynosure say this makes PicoSure the first true 3-wavelength platform.

Engineered to complement the highly versatile 755 nm wavelength and the FOCUS Lens Array, the 1064 nm and 532 nm Laser Delivery Systems are said to enhance PicoSure’s ability to

remove tattoos and treat a range of dermatologic conditions including wrinkles, acne scars and pigmented lesions.

Cynosure’s Product Manager says, “Science shows us that 755 and 1064 are equally absorbed by black ink and that 755 is also a highly efficient picosecond wavelength for broad skin revitalisation indications and multi-colour tattoo removal. As the leader in picosecond technology, Cynosure is releasing the 1064 for customers seeking a complementary wavelength (to 755 nm) to add versatility to treatment plans for their darkest skin type patients.”

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body language I INDUSTRY NEWS 17

DR SABRINA SHAH-DESAI LAUNCHES NEW OCULO-FACIAL AESTHETIC ACADEMY (OFAA) ANATOMICAL BASIS OF PREVENTION AND MANAGEMENT OF DERMAL FILLER COMPLICATIONS Date: Sat. 15th October 2016 Location: West Midlands Surgical Training Centre, Coventry.

ANATOMICAL BASIS OF RESTORATION & REJUVENATION OF THE FACIAL PROFILE USING NON–SURGICAL INJECTABLE TREATMENTS

Oculo-Facial Aesthetic Academy (OFAA) was founded by Mrs. Sabrina Shah-Desai (MS, FRCS), an Aesthetic and Reconstructive OculoPlastic Surgeon, with more than a decade of experience in aesthetics, and a career spanning over 20 years collectively in the specialty, Mrs. Shah-Desai is a highly sought after industry trainer working globally to educate professionals on behalf of brands such as Galderma.

OFAA courses are CPD accredited and designed to provide a ‘hands on’ fresh cadaver wet-lab training, with the aim of promoting safe and evidence based aesthetic practice amongst medical professionals. Led by a faculty of international and national clinical and anatomical trainers, who are highly ex-

perienced Industry recognised educators, the courses have been developed to provide expert training, based on how to avoid and manage complications from poor technique, inappropriate product and patient selection. Created to enhance your knowledge and confidence to launch or improve your practice, the course offers cadaver based skills learning that are recognised as one of the best ways to impart training before attempting these on a live patient and support you in being recognised as a safe practitioner.

Mrs Sabrina Shah-Desai will be running the following courses in October / November 2016 and invites you to visit facialaesthetictraining.com for more details or to book a place now.

Date: Sat. 12th November 2016 Location: Dissecting Room, Anatomy Department, Kings College London, 2nd Floor, Hodgkin Building, Guys Campus, SE1 1UL ANATOMICAL BASIS OF RESTORATION & REJUVENATION OF THE PERI-ORBITAL & PERI-ORAL AREA USING NON–SURGICAL INJECTABLE TREATMENTS Date: Sat. 26th November 2016 Location: Dissecting Room, Anatomy Department, Kings College London, 2nd Floor, Hodgkin Building, Guys Campus, SE1 1UL www.facialaesthetictraining.com T: 0800 0016959

VIVEVE ANNOUNCES FDA 510(K) CLEARANCE FOR THE VIVEVE SYSTEM IN THE U.S. Viveve Medical, Inc. ("Viveve"), is a women's health company passionately committed to advancing new solutions to improve women's overall well-being and quality of life. The Viveve System has received regulatory approval in 45 countries throughout the world and is available through physician import license in Japan.

The Viveve team are proud to announce that the Viveve System has received 510(k) regulatory clearance from the U.S. Food and Drug Administration (FDA). In the United States, the Viveve System is now indicated for use in general surgical procedures for electrocoagulation and hemostasis.

"FDA 510(k) clearance for the Viveve System represents a major milestone in our efforts to bring this safe and effective

technology to patients in the United States who can benefit from it," said Patricia Scheller, chief executive officer of Viveve.

"We are grateful to all of the clinicians and researchers who have supported the development of the Viveve System over the past several years, and to all of the members of the Viveve team who played a vital role in helping us achieve this goal."

"This clearance represents the first step in our U.S. regulatory strategy," Scheller added. "In September 2016, we announced that the company filed an Investigational Device Exemption (IDE) to the FDA, for authorisation to begin the Viveve Treatment of the Vaginal Introitus to Evaluate Efficacy (VIVEVE II) study."

For more information, please visit viveve.com

18 INJECTABLES I body language

A shot of history PROFESSOR NICK LOWE guides us through 20 years of injectables

tions, but the other indication for volumising fillers by derma­tologists and skin physicians, is for managing patients with atrophic scarring and lipodystrophy of the face.

I

njectables have revolutionised aesthetic treatments over the last 20 years. Looking at aesthetic procedures that have been used since 1997 (recorded by the American Plastic Surgery Society), botulinum toxins outpaced the frequency of use of the other categories of injectable.

Why injectable fillers?

One rationale of using injectable fillers is to restore the ageing face to the contours of youth. This is one of the most frequent indica-

Recent history of temporary tissue augmentation This started with the advent of bovine collagen in the 1970s and 1980s when Collagen Corporation in California developed bovine collagen. The start of the hyaluronic acid fillers came in the mid-1990s, with avian-derived hyaluronic acid, Hylaform (HA).

The next development was non-animal-derived hyaluronic acids, called NASHA hyaluronic acids. Several studies including some of our own showed that these produce much less allergy than the animal-derived HAs. Many HAs are now available.

Neocollagenesis fillers with polymerised lactic acid was developed in response to HIV related facial atrophy. In the USA there are far fewer fillers than in the rest of the world, and as a result fewer complications. Only a relatively small number of fillers have been thoroughly researched to FDA requirements, which cannot be said for the UK and the rest of the world where—in my opinion—we have far too many fillers.

The other thing that's popularised fillers more recently is knowing what else they can do. Fillers don’t just fill, with strategic placement of the fillers you can achieve useful lifting, volumisation and facial contouring changes. Years ago Bill Hanke and Gerhardt Sattler described the Tower method of injecting

Non-surgical procedures; Dermatologists, Plastics ENT, 1997, 2001, 2010, 2015, USA

BTX-A 1997 2001

Soft Tissue Fillers

2010 2015

Peel 0

2

4

6

8

The soft tissue fillers have increased steadily, chemical peels increased but then plateaued. I predict there will be a further increase in fillers because we have new filler categories. However, it is the botulinum toxins that have really led the popularity of this whole area.

body language I INJECTABLES 19

YOUTHFUL FACE

AGEING FACE

AS WE AGE

Shape

Shape Hollows, deep rhytides, sagging

Facial volume loss

This is what I do and I will select some areas for injection with needles and I'll select other areas for the cannulas.

Over-simplifying where to place these fillers can be misleading because every patient's face, as we know is quite different.

You have facial asymmetry, facial anatomy differs, the patient desires differ and faces change considerably with age and weight.

Individualised placement I think using both cannulas and needles makes an enormous amount of sense. There are definite advantages to cannulas in some locations, vascular risk areas. For periosteal placement I think needles are more accurate, and for large areas of volume replacement cannulas are more logical. In a recent audit study at Cranley Clinic we showed that cannulas create less bruising than needles, and there are certain areas where you can use the cannulas to safely deliver correcting volumising filler and you can use them in combination with needles.

In my clinic we try to reduce the incidence of bruising by using a vascular viewing laser, which we find extremely useful. I mark out the vascularity; this laser picks up veins, adjacent veins and many arteries, so by marking these areas carefully we can target and avoid hitting those vascular areas. This is a very common area for bruising with fillers, and it's these vascular areas in this area.

Swelling from fillers Certain areas swell more than others—the lips area may swell more than other areas with some fillers than with others. We carried out a study where we injected 1.5cc of a hyaluronic into the upper and lower lips and measured the volume immediately afterwards. That increased volume was 2.8cc, which equates to almost as much oedema and swelling as the amount of filler. We found there can be a difference from one filler to another in the amount of immediate lip swelling.

LIFT AND FILL POINTS Lift –Tower method Bartus C, Sattler G Hanke W., 2011 , J D Derm

Needle

Which fillers?

I will usually use three types of HA filler: a high G-prime for upper face and lifting, a volum-ising filler for the midface and atrophic scars, a lower viscosity filler for shallows in the perioral area. There are many fillers out there, so you need to find ones you can trust and probably just stay with those.

HA fillers with needles, and others have proposed variations on this. My own approach is I use needles for some areas to lift and I will use cannulas for other areas to volumise.

Polymerised lactic acid These have an important part to play for volumisation of the face, the correction of atrophic scars, facial asymmetry and lipodsytrophy. Polymerised lactic acid was used for this for years and in a study using three dimensional imaging, we proved that improved volumisation does occur after a series of polymerised lactic acid injections. One problem with polymerised lactic acid is that there are certain areas where it has a higher incidence of nodule formation. You can overcome this with increased dilution techniques.

Polymerised lactic acid also requires a series of treatments – usually about three to five – to get the maximum volumisation.

Many of my patients don't want to come for all those treatments.

More recently I’ve been using another neocollagenesis filler, polycapralactone fillers.

Marking up I can't over-stress the importance of planning your injection sites for each patient. We can have patient do facial “grimacing” as well as static marking, to enhance the placement of these agents.

Polycapralactone Polycapralactone progressive re-volumises as the polycapralactone beads dissolve and create this progressive neocollangenesis.

I've started using this for atrophic faces, hands. As yet haven't

Fill by cannula

20 INJECTABLES I body language

Different Botulinum Neurotoxins approved in Europe and USA

Product

Toxin Type

Molecular Weight (kD)

pH

Approved Europe, Forehead lines

Approved for Hyperhydrosis Europe, USA

Approved for medical indications e.g. Cervical Dystonia Blepharopasum

Botox

A

900

~7

Yes + USA

Yes

Yes (+USA)

Dysport

A

500-900

~7

Yes + USA

No

Yes (+USA)

Xeomin

A

150

~7

Yes

No

Yes

Myobloc/Neurobloc

B

300-500

~5.6

No

No

Yes (+USA)

Polycapralactone fillers case studies

1. This is one example of a patient who I had previously treated with polymerised lactic acid several years before and she came back and we treated with the polycapralactone filler. Here she is about four months after that treatment.

Post Acne Atrophic Scars, Ellanse M

seen any serious complications.

Filler Summary Fillers are not a replacement for face-lifting surgery, but they can be used in a very valuable way for treating facial atrophy, asymmetry, atrophic scars, nasolabial folds, and modest facial lifting.

I advise always having hyalase available in your emergency filler tray to dissolve overcorrection. Nodules and papules can be permanent with non-HA fillers.

I'm wary of injecting some fillers too superficially, because some can give a bluish Tyndall effect, and also wary of reactions, with previous permanent fillers, if you inject near a previous filler there can be a problem with delayed reactions.

Necrosis is obviously a major potential problem but I feel there is much less risk of necrosis with cannulas because they tend to push vascular structures aside rather than piercing them.

With use in the periorbital and nasal areas there is a small but tragic number of cases of reported blindness.

Early history of botulinum toxins The innovative work of the American ophthalmologist Dr Alan Scott, using botulinum toxin for the correction of strabismus, initially in primates and then in humans began human use.

Drs Alistair and Jean Carruthers noticed that patients treated with strabismus showed improvement in some of their periorbital wrinkles. That led to development stud-

ies with the botulinum toxins from the 1990s onwards.

A series of double blind studies resulted in the modern use of the botulinum toxins. In the 1990s and early 2000s there were two botulinum toxins: type A Botox – the American-derived toxin from the Fort Detrick warfare station in Maryland in the United States; then Dysport, named after Porton Down, the biologic warfare station on Salisbury Plain in the UK. The approved uses have gradually expanded, initially blepharospasm, cervical dystonia, strabismus, cerebral palsy, hemifacial spasm, and moving to the treatment of glabellar lines and hyperhidrosis and numerous other indications.

From 1996 onwards, clinical evidence was gathered of botulinum toxin A in glabellar lines. I was a participant in early double blind controlled placebo studies, BotoxTM was eventually approved for use for glabellar lines in the United States in April 2002. In some patients we noticed that in addition to improving the mid-forehead frown lines we also saw significant brow lifting which led to a series of observations and uses based on strategic placing of BTX-A. The whole concept of brow lifting with the botulinum toxins, is now very firmly established; the key is knowing where to place toxin, otherwise you'll get brow drop and heaviness of the brows.

As the treatments evolved, we realised that some heavily muscular, heavy brows, particularly males, needed more botulinum toxin units, above the 20 units of the approved dosage. Fortunately we can use it outside of the indicated doses. From 2006 onwards, other botulinum toxins became available and we have now three available at the moment in Europe and the USA. Treatment rations Units of BTX-A with the botulinum toxins are not interchangeable, they are quite different. Different formulations have dif-

66 Only a relatively small number of fillers have been thoroughly researched to FDA requirements, which cannot be said for the UK and the rest of the world where—in my opinion— we have far too many fillers.

99

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22 INJECTABLES I body language

66 Botox resistance occasionally occurs, although it's more common in larger does for neurologic use 99 ferent protein loads and different delivery – there are key differences pharmacologically between the botulinum toxins. In my clinic we use Botox to Dysport with roughly a 1:2.5 unit conversion. With Xeomin there's been some really interesting studies around levels of glabellar strain suggesting 1 unit of Xeomin has less duration than 1 unit of Botox.

Crow's feet was the next area researched. I did the first study in 2002, which was a pilot study. Our dosages were confirmed by a large multi-centre study. I use between 12 and 18 units of Botox units, or the equivalent times 2.5 Dysport units for each crows feet area.

An important use of botulinum toxins is for hyperhidrosis.

There is greater diffusion of botulinum toxins in subcutaneous tissue than in muscle. Several factors govern diffusion – e.g. dilution and volume. Injecting in a dense, bulky muscle it diffuses less than into subcutaneous tissue.

Botox resistance This occasionally occurs; in general it’s much more common in the larger dosages for neurologic use. We have seen a group of patients who have developed resistance to type A toxins. I see about two patients a year, with acquired type A resistance from aesthetic use and a few more with hyperhidrosis. The reason, for this is when one type A is resistant they all are. The enzyme targets are different – there's a snap 22 target for the type A and there's a different one for type B, so they're all working through the different synaptic proteins.

There are problems with type B botulinum toxin too. It is more expensive, unless you modify the pH it gives a lot of injection pain, and also it doesn't last nearly as long as BTX-A for muscle activity. Interestingly, although it doesn't last as long in muscles, it may last longer against hyperhidrosis.

Reducing BTX Bruising A few patients get bruising after botulinum toxins, particularly in the crow's feet area, which led us to use a vein viewing near infrared laser system to identify the vascular elements, mark the vascularity, and then make a point of where to inject the toxin.

For anybody that we think is at risk for bruising we will use this routinely, and I think it is useful for both toxins as well as fillers.

Other side effects There are side effects from Botox, but fortunately relatively few when it is injected, some lower eyelid oedema, and facial asymmetry from an over-action in some areas compared to the others.

Occasionally we also see diplopia. There have been reports of using too much botulinum toxin in the cervical area and resulting dysphagia and dysphonia. Very rarely, hypersensitivity reactions, have been reported.

Combining BTX with other treatments Combination treatments of botulinum toxins with appropriate fillers can lead to good results. If you use botulinum toxins in association with lasers or pulse lights, my advice is do the botulinum toxin at least a week before or after. I tend not to do them

at the same time because of an increased bruising and diffusion risk. You certainly can inject BTT the same time as fillers.

The future of botulinum toxins A topical botulinum toxin developed in the USA has been reportedly abandoned recently. There are acetylcholine inhibitors that could be promising for the control of hyperhidrosis. Time and effort may lead to new alternative treatments.

Professor Lowe is a Consultant Dermatologist at Cranley Clinic, London, and Clinical Professor of Dermatology at UCLA School of Medicine, Los Angeles. He is Fellow of numerous societies and Colleges, including the Royal College of Physicians, American Academy of Dermatology, American College of Physicians, American Society of Laser Medicine and Surgery, Royal Society of Medicine and is a past President of both the Pacific Dermatology Association and the Cosmetic Dermatology Group of the British Association of Dermatology. Prof Lowe is a prolific author, with over 450 clinical and research publications, 15 scientific and five educational books for the public. He is on a number of editorial boards is a reviewer of International Journals and is founding editor of the Journal of Cutaneous and Laser Therapy. Over the last 30 years he has undertaken clinical research and treatment of general dermatology, acne, ageing skin, laser skin therapy, photo protection, phototherapy, psoriasis and skin rejuvenation procedures.

Botulinum toxins

Early Double Blind Placebo study, Botox,20 u. J.Am.Acad.Derm 1996 ,35,569,Lowe N. et al

Botox resistance

This patient developed a complete type A resistance. On the one side you can see that after three different type A toxins he was still resistant, and on the other side injecting the type B toxin neuroblock he achieved a good result.

body language I INJECTABLES 23

BTX– A and BTX – B References 1 Scott AB. Development of Botulinum toxin therapy. Dermatol Clin 2004;22:131-3 2. Scott AB, Rosenbaum A, Collins CC. Pharmacologic weakening of extraocular muscles.

Invest Ophthalmol 1973;12: 924-7.

3. Scott AB. Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. Ophthalmology 1980;87:1044-9.

4. Keen M, Blitzer A, Aviv J, et al. Botulinum toxin A for hyperkinetic facial lines: results of a double-blind, placebocontrolled study. Plast Reconstr Surg 1994;94:94-9.

5. Lowe NJ, Maxwell A, Harper H. Botulinum A exotoxin for glabellar folds: a double-blind, placebo-controlled study with an electromyographic injection technique. J Am Acad Dermatol 1996;35:569-72.

6. Carruthers JA, Lowe NJ, Menter MA, et al, for the BOTOX Glabellar Lines I Study Group. A multicenter, doubleblind, randomized, placebocontrolled study of the efficacy and safety of Botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol 2002;46:840-9.

7. Carruthers JD, Lowe NJ, Menter MA, et al, for the BOTOX Glabellar Lines II Study Group. –Double-blind, Placebocontrolled study of the safety and efficacy of Botulinum toxin type A for patients with glabellar lines. Plast Reconstruc Surg 2003;112:1089-98.

8. Lowe NJ, Ascher B, Heckmann M et al, for the Botox Facial Aesthetics Study Team.

Double-blind, randomized, placebo-controlled, doseresponse study of the safety and efficacy of Botulinum toxin type A in subjects with crow’s feet.

Dermatol Surg 2005;31:257-62.

9. Flynn TC, Carruthers JA, Carruthers JA, Clark RE II. Botulinum A toxin (BOTOX) in the lower eyelid: dose-finding study.

Dermatol Surg 2003;29:943-50.

10. Lowe NJ, Yamauchi PS, Lask GP, et al. Botulinum toxin types A and B for brow furrows: pre-

liminary experiences with type B toxin dosing. J Cosmet Laser Ther 2002;4;15-8.

11. Lowe N.J., Campanati A, Bodokh J et al The place of Botulinism toxin in the treatment of focal hyperhydrosis. Br. J. Dermtaol 2004 151. 1115-1122.

12. Heckmann M, Plewig H, for the Hyperhidrosis Study Group.

Low dose efficacy of Botulinum toxin A for axillary hyperhidrosis: a randomized, side-by-side, open-label study. Arch Dermatol 2005;141:1255-9.

13. Kranz G etal. Long teerm efficacy and potencies of Botulinum Toxin type A and B.Br.J.Dermatology 2011.164.1.176-181.

14. Matarasso A., Matarasso. S., Brandt F.S., Bellman B., Botulism A exotoxin for the management of Platysma bands. Plastic and Reconstrutive Surg 1999. 103.

645-652.

15. Ascher B, Zakine B, Kestemont P, et al, A multicenter, randomized, double-blind, placebocontrolled study of efficacy and safety of 3 doses of Botulinum toxin A in the treatment of glabellar lines. J Am Adad Dermatol 2004;51:223-33.

16. Lowe P, Patnaik R, Lowe N. Comparison of two formulations of Botulinum type A for the treatment of glabellar lines: a double-blind randomized study. J Amer Acad Dermatol 2006;55:975-80.

17. Lowe N.J. When and how to combine treatments In Textbook of Facial Rejuvenation Ed. Lowe N.J. et al. Ch. 28. 322-325. Pub. Martin Dunitz Taylor and Francis 2002.

18. Yamauchi P., Lowe N.J., Lask G.L. Botulinum toxin plus Erb Yag Laser for periorbital lines, J. Cos. Laser. Ther 2004 6.3.

145-148.

19. Carruthers J., Carruthers A. Maberly. D. Deep Resting Glabellar Rhytides respond to BTX-A and Hylan B D. Dermatol. Surg.

2003. 29. 539-544.

20. LoweN.J., Shah A., Lowe P.L., Journal of Cos. and Laser Therapy, Dosing, Efficacy, Safety and Computerized Photography of Botulinum Toxins. 2010, 12.

2. 106-111.

21. Sattler G.,et al Non inferior-

ity of Incobotulimun toxin-A, compared with another BTX-A. J.der.Surg.2010.36.2146-2154.

22. Maas.C,et al One Botulinum Toxin slightly better than another for crow’s feet. Arch.

Facial.Plast.Surg.Dec19.2011 23. Brandt et,F., et al efficiency and safety evaluation of novel Botulinum toxin topical gel for the treatment of lateral canthal lines. J.Derm.Surg.2010.36.2112118 24. Lowe P., Lowe N J., Botulinum Toxin type B; pH change reduces injection pain, retains efficacy J.Derm. Surg.

2014.40.1328-1333.

Filler References 25. Lowe NJ. Temporary Dermal Fillers - European Experiences. In Lowe NJ, ed. Textbook of Facial Rejuvenation. Martin Dunitz/Taylor and Francis, London. 2002. pp 177-188 26. Klein AW. Collagen Substances. Facial Plast Surg Clin N Am 2001; 9: 205-218 27. DeLustro F, Condell RA, Nguyen MA et al. A comparative study of the biologic and immunologic response to medical devices derived from dermal collagen. J Biomed Material Res. 1986; 20: 109-120 28. DeLustro F, Smith ST, Sundsmo J et al. Reaction to inject able collagen in human subjects. J Dermatol Surg Oncol 1998; 14 (suppl1): 49 29. Patel MP, Talmor M, Nolan WB; Botox and collagen for glabellar furrows: advantages of combination therapy. Ann Plast Surg. 2004 May; 52(5): 442-7 30. Lowe NJ, Maxwell CA, Patnaik R. Adverse reactions to fillers a review. J Derm Surg 2005, 31,1616-75 31. Andre P., Lowe N.J., Parc A et. al. Adverse Reactions to dermal fillers: a review of European Experiences. J. Cosmet. Laser Ther. 2005. 7. 171-176.

32. Lowe N.J., Maxwell CA., Lowe P., et al. Hyaluronic acid fillers; adverse reactions and skin testing J. Am Acad Derm 2001, 45. 930-933.

33. Alam M., Yooss., Technique for calcium hydroxylapatite injection for correction of nasolabial fold depressions. J. Am. Acad

Dermatol 2007 56. 285-289.

34. Valantin M.A., Aubron-Oliver C. Ghosn J., et al Polylactic acid (New-Fill) to correct facial lipatrophy in HIV infected patients: results of the open-label study VEGA. AIDS, 2003; 17.

2471-2477.

35. Lowe NJ. Appropriate use of Poly-l-lactic Acid and clinical considerations. J.E.A.D.V. 2006.

20. 2-6.

36. Beer, K. A single center, Open-label study on the use of injectable Poly-L-Lactic acid for the treatment of Moderate to Severe Scarring from Acne or Vaincella. J. Dermatol. Surg.

2007. 33. 159-167.

37. Lowe N.J., Lowe P.L., Patnaik R., Clair Roberts J.St. A phase 1 study of 1CX-Rhy, a suspension of allogeneic human dermal fibroblasts J.I. Derm. 2007. 127.

5157. S.I.D. Abstract. 254.

38. Donofrio. L. Panfacial Volume Restoration with fat. J. Derm. Surg. 2005. 31. 14961505.

39. Lowe N.J., Lowe P.L., Patnaik R. Polymerised Lactic Acid; Volumetric improvement assessed with 3D photography for nasolabial folds. J. Cos. Las. Ther. In Press 2011.

40. Moers-Carpi .M.M. and Sherwood. S. Polycaprolactone for the correction of nasolabial folds: A 24 month, prospective randomized, controlled clinical trial. J.Derm.Surg.2013.39:457463 41. Weiss. A, Goodman. J, Lowe. P, Lowe.NJ. New and Novel Fillers. In Soft Tissue Augmentation 3rd Edition. 53-61, 2013. Edited Carruthers. J and.

A. Published Elseviler. London.

New York. 2013 42. Sclafani A.P. Platelet Rich Fibrin Maifrix for improvement of deep nasolabial folds. J.Cos. Dermathol. 9.66-71.2010.

43. Roberts S.A.I., Arthurs BP. Blindness from Periorbital Poly L-lactic Acid. Opth.Plast.Reconstrutice.Surg. 28-5.2012.

44. Blindness due to Fillers.

Literature search review. Opth.

Plast.Reconstrutice.Surg.

129.995-1012.2012.

45. Review of Blindness from fillers Seoul review. Am.J.Opthalmol.154.653-662.2012.

The new shape of energy-based body contouring SculpSure offers convenient, comfortable contouring for any body and skin type. It’s a noninvasive, light-based energy device that treats stubborn fat in just 25 minutes.

• Flexibility with 4 individual non-suction applicators • Treat more than 1 area during a 25-minute session Simp hands-free treatment • Simple, • Lower cost of ownership for your practice

body language I EQUIPMENT 25

RF non-excisional face and neck lifts With two to three times more of his patients presenting for non-excisional experiences than those opting to go under the knife, DR STEPHEN MULHOLLAND explores the concept of skin tightening and scalpel-less non excisional facelifting

W

e know ageing causes 3D changes to the skin; deflation, deterioration and descent, changing the face from an oval shaped and to become more jowly and a bit dowdy as we lose the form and shape of youth. There are many technologies and techniques that work to improve this, but RF techniques that result in optimal remodelling and tightening, without an excisional experience are increasing in popularity and, performed properly, with adjunctive techniques, can approach the results seen with mini surgical face lifting.

For a non-surgical restoration—

whether plasma, exeresis, fractional resurfacing or sub-dermal heating—there has to be some thermal or non-thermal mechanism that causes skin to remodel in very significant way. The secret to success is in the treatment modality, combination therapy and, most importantly, how you choose to remodel the skin.

There has been huge progress in skin and dermal remodelling technologies over the last 15 years, starting from the epidermal rejuvenation through peels and micodermabrasion, to remodelling the full thickness of the dermis from the “inside-out” and “outside-in”.

These trans-epidermal, total dermal remodelling techniques can

include laser, HIFU and radio frequency (RF). Typically the problem has been accessing the dermis the energy that tightens without over heating or injury excessively the epidermal-dermal junction, which can result in hypopigmentation, hyperpigmentation and scaring. This “epidermal sparing effect” is now possible by using HIFU (Ulthera) or, more effectively a silicon coated RF needle device. In the spectrum of modern facial repositioning, the patient can now choose a Facelift for the best results, a suture suspension technique (Threadlifts) for noticeable lifting and then sub-dermal and transdermal heating techniques, with or with out neuromodulators

26 EQUIPMENT I body language

and soft tissue fillers for non excisional tightening.

Presenting RF The modern concept in non-excisional thermal face-lifting is to heating from below the skin under and within the deep reticular dermis, called “inside-out” heating and then, synchronously heating from the “outside-in” preferably with relatively epidermal sparing technologies for deeper papillary and mid-reticular heating and then, finally tailoring the epidermal-dermal remodelling with more superficial thermal fractional technologies. This “Sandwich Lifting” relies in technologies that can heat under the skin, RF or laser fibers and electrodes and then transdermal, generally fractional laser or RF technologies RF, or radiofrequency energy, has become the most commonly deployed energy form for bulk heating the skin. RF is high frequency, rapidly oscillating electrical current. Unlike a laser, RF does not look for a target, or chromphore, but rather the rapidly oscillating electrical current, positive to negative and back, oscillates all

molecules in its path and the intermolecular motion caused by this oscillation leads to thermal energy and the resulting heat leads to the inflammation needed for remodelling. The designing the size and shapes of the electrodes between which the current flows, the RF can be ablative and necrotic, or non ablative in nature.

In achieving the best non excisional facelift using skin tightening technology, you will need to select an energy based platform that will allow direct heating under the skin, or sub-dermal heating, which is coagulative AND then, transepidermal fractional remodelling which should be ablative and non ablative which also offers relative epidermal thermal sparing features for treating the deeper papillary and reticular dermis. In the past, to achieve this kind of energy profiling, a physician would need at least two technology purchases, a internal laser fiber stimulaton using Smartlipo or an internal monopolar RF probe like ThermiRF (both of which work, but are ineffience with radiant heat loss, heat tissue under the probe and offer no epidermal thermal control) and

then, a second purchase such as a fractional CO2 or Erbium (both a non epidermal thermal sparing) or a fractional RF resurfacing system.

This “inside – out” and “outsidein” sandwich Energy based, non excisional lifting is now possible using a single RF platform, on the InMode RF, which offers the physician interested in a non surgical facelift and skin tightening the Facetite for internal heating and the Fractora, for strong fractional RF resurfacing, with a epidermal thermal sparing mode in one technology purchase.

FaceTite FaceTite, offers temperature, impedance and contact controlled Radiofrequency Assisted Lipocoagulation, or RFAL and is a skin tightening device produced in Israel, used worldwide and was recently approved in the USA. This technology is a one-time use, disposable and affordable RF applicator that offers Bipolar RF energy for simultaneous sub-dermal coagulative heating and transepidermal non ablative tightening.

The FaceTite is a silicone coated, 1.2 mm microcanula, 14 cm long

Figure 1. The FaceTite is Biploar RF skin tightening applicator. The internal RF probe is inserted under the skin and RF flows to the external RF electrode that slides over the skin. The RF energy internal heats to 70 degress and the temperature and RF flow is controlled by an internal thermistor near the tip. The external electrode heats gently to 38-42 degrees and is also controlled and but off by the external electrode thermistor. The equistely contolled devices heats and tightens the skin from the inside out and outside in, features “thermal containment”, internal thermistor control and external electrode thermal, contact and impedance automated controls and cut offs.

body language I EQUIPMENT 27

Figure 2. FaceTite is a temperature, contact and impedance sensed and controlled bipolar RF skin tightening system. RF release internally heats to 70 degrees and coagulates and tightens soft tissue and the RF flows up the the external electrode that heats the skin non ablatively. The FaceTite offers thermal containment and exquisite safety controls of internal and extermal simultaneous thermal control, external contact control and low and high impedance sensing and and RF cut off controls. Studies show that FaceTite and RFAL can result in up to 40% area contraction at one year.

Bipolar applicator (Figure 1.) The end of the internal Electrode is silicone capped to prevent end dermal thermal hits, and the RF energy is emitted from the uncoated portion between the cap and the coated probe. (Figure 2.) RF then flows from the internal electrode to the external electrode and back.

Within 0.5cm of the electrode the RF current and temperatures are strong, coagulative and ablative in nature, while the RF energy from the external electrode is gentle and heats the papillary and reticular dermis non-ablatively. For safety, there is a thermistor within the internal electrode that allows the physician to set cut offs for the RF energy when the therapeutic thermal end point, is reached and this is most commonly set by the user at 70 degrees Celsius.

Under local anaesthesia, the internal electrode is inserted under the skin in the superficial subcutaneous adipose, with the external electrode on the skin and the hand piece is moved slowly back and forth in the skin region to be tightened. The external electrode slides over the skin, in parallel with the internal electrode, using a thin layer of sterile ultrasound gel. The RF flows from the internal to external electrode accounting for the extreme thermal coagulative efficiency of the system (gets to end

point within 1 second). Not only is this bipolar RF configuration efficient, (at 20 watts you get a lot of energy and you can heat the subdermal space to 70 degrees in about a second) , but is also much safer due to â&#x20AC;&#x153;thermal containmentâ&#x20AC;?, meaning RF only flows between the electrodes and not significantly below the internal electrode, making the use of this device much safer in the face and around the facial nerve. Many mono polar RF probe technologies (tThermiRF) and laser probes (Smartlipo) do not

have thermal containment and can heat the facial nerve, allow radiant energy to dissipate (are then slower) and have no epidermal thermal safety cut-off features.

The FaceTite heats and tightens strongly using ablative coagulation from the inside out and heats gently from the outside in â&#x20AC;&#x201C; think of it as a moving Thermage. FaceTite is coagulative internally and nonablative externally. The temperature can be controlled externally and internally, with automated thermistors that cut RF energy off

Figure 3. Sequential vertical treatment of the fatty and lax areas, such as the sub-mentum, can can deliver fat reduction , as well as FSN mediated skin contraction.

28 EQUIPMENT I body language

mis, as the goal is soft tissue tightening not fat reduction. However, when used in off face fatty areas, like the sub-mentum and neck, several layers of fat can be coagulated and then aspirated to ensure contour correction (aspiration) and simultaneous tissue tightening. (Figure 3). Studies show that FaceTtie alone can result in 25% contraction at 6 months and up to 35-40% area contraction at 12 months.

Figure 4a. Fractora is a fractional RF needle resurfacing device that comes with the FaceTite on the InMode RF platform. The RF needles, which come in different lengths and densities, are positively charged and deliver an RF ablative crater and injury very much like CO2.

However, unlike CO2, which is summation of ablative craters, the Fractora, at the end of the ablative cycle and crater, sends the RF from the positively charged needle and ablation to the negatively charge side electrodes creating a rich, deeper dermal non ablative tightening that summates with the ablative effects.

a end points set by the physician.

For added safety, there is also an external contact sensor as well as high and low impedance controls.

Inside-Out The FaceTite moves back and forth, heating the FSN (Fibroseptal network) and adipose tissue to 70 degress (fat and adipose tissue

Figure 4b Upper

coagulates immediately at temperatures over 60 degrees) leading to soft tissue contraction. Simultaneously, the device heats the dermis to 40-42 degrees leading to nonablative dermal remodelling and tissue tightening. When using the FaceTite on the face, lower lid, cheek or jawline, the internal electrode is place very close to the der-

Outside IN The FaceTite will deliver a simultaneous gentle non-ablative RF hearing from the outside in and additional skin tightening. However for additional dermal tightening, after the FaceTite, I will pass over the same skin with an ablative RF fractional resurfacing device called Fractora.

Fractora Is a needle array based fractional RF resurfacing system. The RF flows from the positively charged pins to the negative charged side electrodes. The RF pins create an RF ablative fractional injury, similar to CO2 and then, the RF current flows from the tip of the RF ablative pin tip, up to the negatively charged side electrodes to create a unique RF ablative and non ablative dermal papillary and reticular dermal tightening experience.

There is a whole family of Fractora

Figure 4B lower

Figure 4b Upper and Lower. There are a number of Factora RF needles configurations one can use. (upper) The most common for tightening is silicone coated, where the proximal 2000 microns is coated thus protecting the epidermal-dermal junction from excessive thermal injury, while targeting the deeper dermis with coagulative injury with the distal uncoated needle RF thermal injury (lower). This allows aggressive targeting of the deeper dermis and then a uncoated tip for milder treatment superficially.

Invasix present InMode, the unique multi-disciplinary machine that offers everything from radio frequency for facial and body contouring, IPL for skin rejuvenation to laser hair removal.

With five non-invasive options available, this machine allows practitioners to offer their patients multiple in-demand aesthetic treatments in just one machine.

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/ Mini

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THE COMPLETE BODY MAKEOVER

30 EQUIPMENT I body language

Figure 4c. For maximal non excisional skin tightening, the physician can combine the Facetite, Fractora 24 pin coated and finally, the 60 pin uncoated more superficially for the targeting multiple soft tissue, layered coagulation and non ablative superficial skin tightening.

pin configurations for flexible and designer dermal remodelling options, but the 24 pin coated tip is very commonly uses for non excisional skin tightening, as it will drive a lot of ablative energy deep into the reticular and papillary dermis with thermal epidermal sparing. (Figure 4).

Research evidence Thermal coagulation and contraction occurs at 60-70 Degress internally and non ablative dermal tightening at 38-42 degrees transepidermally. Significant area contraction of 30-40% occurs on the table. (1) In Diane Duncanâ&#x20AC;&#x2122;s study published in the ASJ, reproduces

Barry DiBernardoâ&#x20AC;&#x2122;s study, where he showed Smartlipo resulted in 17% contraction 3 moths after thermal stimulation. Dr Duncan, used RFAL and Facetite and att six months, area contraction was about 25% and by one year the contraction had stabilised at 34%, compared to 8% with subdermal stimulation and no thermal contraction. (1-4) The procedure The FaceTite and Fractora non excisional face lift (skin tightening) can easily be performed in the side office under local anaesthesia.

After infiltrating the sub-dermal space with dilute Lidocaine, the

Figure 5. Facial and body areas that can be treated with FaceTite and Fractora skin tightening.

Facetite is inserted under the skin through a port created by a 16 gauge needle. The sub-mentum, jawline, peri-nasolabial folds, under eye, upper lid and brow can all be treated. The Faceite is moved slowly back and forth in a stamping and then moving technique until the thermal end points of 70 degrees sub-dermal and 38-42 degrees epidermal are achieved. Each area is treated till the end points under all areas where tightening is treated. Following the Facetite the sub-mentum can be aspirated (fat is non usually removed from the face, with the occasional exception of the jowl) and then the Fractora is used. The 24 pin coated is used first for deep dermal fractiona RF ablation and non ablative tightening followed by lower energies and the uncoated 6o pin tip. A full face and neck takes approximated 30 minutes. Figure 5.

Following a full face and will be swollen for 5-7 days and a supportive wrap is worn and topical aquphor is applied to the skin.

The results Patients can expect significant skin tightening with the FaceTite and Fractora combination, as well as wrinkle reduction and improvement in texture and dyschromia.

30-50% of a mini open facelift can be achieved in a single treatment and results can last five or more years.

FaceTite and RFAL is an excellent adjunct to primary liposuction to ensure skin tightening is optimised after Lipoaspiration.

FaceTite is used to tighent he FSN

body language I EQUIPMENT 31

Conclusion Thermal, contact and impedance controlled RF rejuvenation is here to stay. Getting to the therapeutic end point to optimise contraction and ensure safety requires thermal, impedance and contact monitoring and RF - temperature automated feed back control. I like FaceTite for its elegant safety and efficiency

Dr Mulholland is a board-certified plastic surgeon and a Fellow of the Royal College of Physicians and Surgeons of Canada. During the period of time Dr Mulholland had an aesthetic practice in Los Angeles, California, as well as Toronto, he was also certified by the American Board of Plastic Surgery (1999-2009). Dr Mulholland is one of the few plastic surgeons in North America and the only Toronto Plastic Surgeon that has truly dual-certified specialty training in advanced Otolaryngology, Ear Nose Throat Surgery— Head and Neck Cancer, as well as being board certified in plastic surgery, facial plastic Surgery, micro-vascular surgery, auto-tissue transplantation and adult craniofacial trauma.

Non excisional Facelifts

DR MULHOLLAND

design features. I have been using FaceTite and Fractora for several years as my “go to” non excisional thermal skin tightening and contraction technology and my patients have been happy with the non excisional skin tightening.

Figure 6. Before and after treatment with FaceTite and Fractora used on the submentum, jawline and cheeks.

DR MULHOLLAND

and optimised area contraction.

Facetite is also valuable in treating secondry liposuction irregularities and lax skin. When I work with patients who have had previous liposuction, I simply coagulate through the fibrous septal network and try to stimulate these FSNs and get contraction. Then I take a very small microcanula, usually 1.8-2 mm and do a little bit of micro-lypo on these secondary areas. They usually do not have a lot of fatous contour derangement basically and try to correct these little contra defects all through a 16 gauge.

Figure 7. Before and after treatment with FaceTite and Fractora under the eye, cheek, jawline and neck.

DR MULHOLLAND

Body Contouring: primary liposuction and RFAL or secondary contouring

Figure 8. Patient with two previous liposuctions and post contouring irregularities, before and after treatment with FaceTite and micro aspiration to improve contour.

References 1. Duncan, DI. Non excisional tissue tightening: creating skin surface area reduction during abdominal liposuction by adding radiofrequency heating. Aesth Surg J. 2013. 33(8); 1154-1166.

2. Paul, M et al. Three-dimensional radiofrequency tissue tightening: a proposed mechanism and applications for body contouring. Aesth Plast Surg. 2011;35(1); 87-95.

3. Paul, M and Mulholland RS. A new approach for adipose tissue treatment and body contouring using radiofrequency assisted liposuction. Aesth Plast Surg. 2009;33(5);687-694.

4. Mulholland, RS. Non-excisional, minimally invasive rejuvenation of the neck. Clini Plastic Surg 2014 41:11-31.

body language I TRAINING 33

Dracula PRP therapy training Platelet Rich Plasma (PRP) is a powerful treatment that can be used in many areas of medicine, including aesthetics, dentistry, periodontal implants, hair loss, wound care, sports medicine, orthopaedics and much more. DR DANIEL SISTER discusses how this makes it an excellent addition to the treatment list of any doctor, nurse or dentist

P

RP is not a new treatment, but one that dates back to the 1950’s when growth factors were first discovered by Dr Stanley Cohen and Dr Rita Levi-Montalcini. These doctors were subsequently awarded a Nobel Peace Prize for their work and since then many thousands of medical studies have been published proving the effectiveness of PRP. How does it work?

A small amount of blood is drawn from the patient into a sterile tube in the exact same manner as a standard blood sample. The tube containing a patient’s blood is placed into a centrifuge and spun to separate the plasma and platelets from the other blood components.

After a few minutes, the plasma and concentrated platelets are removed from the tube and re-introduced into the patient at the site of injury, scars, skin, obvious lines or wrinkles. Using a small sterile needle, the PRP is injected in and around the desired site. The treatment lasts 30 to 45 minutes and can be applied to any skin type or colour.

What’s unique about this treatment is that it is autologous – meaning it only contains material from the patient’s own blood, with nothing added. Not only does this mean it is impossible for a patient to be allergic to treatment, it also makes it suitable for professional

athletes, as it does not contravene anti-doping regulations.

What’s included in the course?

This one-day training course begins with a lecture from myself where I detail the history, development and future possibilities of this treatment. I then provide a demonstration, followed by a hands-on practical session where delegates will have the opportunity to draw

blood, create PRP and inject a patient themselves while under my supervision.

During the course I will detail my experience of PRP combined with mesotherapy or dermaroller, as a standalone treatment or post ablative laser; mixed (or not) with dermal filler, vitamins, amino acids and antioxidants.

Training takes place in groups no larger than 10 delegates, to allow enough individual time myself.

Platelet increase presence of high platelet counts in the blood

34 TRAINING I body language

prp-therapy.com, contact Dr Sister directly by emailing info@drdanielsister.com and should you wish to register for the next training course, please contact the Wigmore training department on 020 7514 5979 or by emailing training@wigmoremedical.com

Platelet rich plasma treatment has been praised by journalists

Only medical professionals can take part in the training, including doctors, nurses and dentists and we require GMC/GDC/NMC Registration Numbers to establish qualifications. I am very proud to run this one-day course at Wigmore Medical around once a month.

On going support After completion of the course delegates have the opportunity to purchase a centrifuge and Dracula PRP kits, which enables them to practice the treatment under the trademark of Dracula PRP Therapy and benefit from the branding and promotion this provides.

There is also a closed Facebook group available to discuss techniques and queries with other Dracula Therapy practitioners. I am available via email or telephone for support and to answer specific questions.

What the press say about Dracula PRP Therapy Metro: “My complexion has never

been clearer, my skin is still glowing and the pink scars have finally faded. I’ve never had so many compliments about my skin.”

Daily Mail: “The lines between nose and mouth and on my forehead vanished.”

Huffington Post: “My skin is simply rejuvenated” Antonia Mariconda: “I don’t see this treatment declining anytime soon” What past delegates have said about the PRP training course Claudia McGloin: “I wouldn’t hesitate in recommending Dr Sister’s Dracula PRP Therapy training course. Having researched online, I was drawn to this particular course for its wide range of content and I wasn’t disappointed. The course excelled in every way and increased my knowledge and understanding of the body’s ability to heal and repair itself naturally.”

For more information you can visit drdanielsister.com or dracula-

About Dr Sister Dr Daniel Sister’s has a reputation for meticulous research and keeping patient care and safety paramount when developing and introducing new treatments. Having practiced medicine since the 1970’s, Dr Sister was the first to introduce PRP to the UK. He has used his extensive experience to develop his own unique system, Dracula Therapy, which requires a unique treatment protocol, injecting technique and specific kit, which has gained a reputation as the best available worldwide. Dr. Sister has travelled the world lecturing and training PRP, he contributes to many professional publications worldwide and is often quoted in the mainstream press.

Dr. Sister has been an advisor to The Safety in Beauty Campaign for the past 12-months, promoting good practice within aesthetics and providing both advice and comment specifically around the subject of PRP. He was recently awarded a Diamond Award for his dedication and excellence in Safety in Beauty.

Earlier this year, Dr. Sister’s book PRP; Platelet Rich Plasma, A New Frontier in Regenerative and Aesthetic Medicine, the first medical textbook on PRP

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Stretch marks: the challenge of today Stretch marks can cause psychological distress for many. DR CATHERINE DE GOURSAC discusses the histology and available treatments

Good skin vs skin with stretch marks

S

tretch marks are benign cutaneous lesions that form in lines across certain parts of the body.

Although these lesions are harmless, their appearance is often unwanted, and can lead people to seek treatment.

Recently, a better understanding of the skin's physiopathology has opened up interesting therapeutic prospects for stretch marks.

Histology and physiopathologies The dermis is a layer of skin between the epidermis and hypodermis and plays a fundamental role in the skin’s regeneration. It is a connective tissue made up of collagen fibres and elastic fibres surrounded by an extracellular matrix (ECM).

Fibroblasts, the dermis’s main population, are cells that synthesise (collagen, elastin, ECM).

The histological aspect of stretch marks depends on their development stage. In more recent marks, the epidermis is still normal but the dermis is infiltrated with inflamed cells (lymphocytes, monocytes/macrophages) and collagen bundles are disorganised. Elastin fibres are stretched and thinned, but a new elastic fibre set develops on the outskirts of each mark with thick and tortuous fibres.

In older marks, the epidermis is atrophied and is thinner than in healthy skin. In the dermis, bundles of thin collagen fibres are stretched parallel to the skin surface due to the mechanical constraint imposed, as opposed to the perpendicular direction found in healthy skins. There is little to no lymphocyte infiltration, unlike recent stretch marks. Elastic fibres are split into a stack of small-diameter

fibres, and fibroblasts are inactive and cannot initiate fibrillogenesis.

Stretch mark physiopathology is complex and almost unknown to the scientific sphere, but we do know that there are factors of an inflammatory, mechanical and hormonal nature, as well as a function corruption in fibroblasts of the dermis.

• Inflammatory factors: stretch marks go through an initial inflammation phase, where mast cell degranulation plays an important part.

• H ormonal factors: glucocorticoids are involved in the formation of stretch marks, so are sexual hormones (such as oestrogen).

• L ocal mechanical factors: such as stretching or distension.

• A lteration of the dermis’s chief cellular type: the fibroblast.

Discovery of the dysfunction of

body language I TREATMENT 37

dermic fibroblasts is a major discovery of the past years and has helped us understand and greatly improve the care for this benign affliction.

Fibroblasts are mechanically sensitive cells (i.e. reacting to mechanical stress), which play a central part in the healing process, primarily by turning into myofibroblasts. Myofibroblasts are fibroblasts with contractile properties to reduce the affected surface area, that can synthetise ECM. Stretch marks go through two phases: an initial inflammatory phase, where dilated blood vessels give them a red-violet and erythematous appearance. Then the chronic phase where the now hypopigmented marks have fewer vessels, are less visible and take a pearl white colour. These marks are permanent.

In more recent stretch marks, the pressure caused by inflammation mediators is triggered by tissue damage. Fibroblasts in the dermis turn to a myofibroblastic phenotype in order to synthetise an ECM and tighten the damaged area. This area gradually becomes inactive when marks start healing.

When scars appear, the skin has reached an irreversible and permanent state.

Resting fibroblasts are then incapable of producing the components that are necessary for a healthy skin. This reduces the skin’s ability to resist attacks and stretch properly. When weakened, it tears more easily and the healing process does not prevent further stretch marks from appearing.

Causes and risk factors • P uberty: during puberty, people (girls more often than boys) experience fast growth sometimes associated with excessive weight gain. This period of time is also a time of high cortisol production.

• S ome endocrinal diseases: such as Cushing’s syndrome – when an unusually high level of cortisol is detected in the blood (endogenic hypercorticism).

• Iatrogenic hypercoticism: caused by excessive intake of corticoids, topically or orally.

• Pregnancy: gravidic stretch marks occur extremely frequent-

•

•

ly, especially where rapid weight gains are experienced around the abdomen, thighs, hips, breasts and bottom. This period of time is particularly favourable to stretch marks as two main factors are combined: ¤ A hormonal factor: women’s hormone production increases heavily in order to ensure the proper development of the foetus. ¤ A mechanical factor associated with skin distension, particularly around the abdomen.

Lightening creams with de pigmenting agents: Usage of this type of cream is frequent in both women and men who want to lighten their skin. The two main active ingredients are cortisol and hydroquinone, which both increase the risk of developing stretch marks. Sale of creams containing the latter is now prohibited in most European countries but it can still easily be found in shops specialising in ‘afro’ products or online.

H ereditary diseases of the connective tissue: ¤ Ehlers-Danlos syndrome: hyper-elasticity of the skin often

associated with stretch marks ¤ M arfan syndrome: horizontal stretch marks in the lumbar region are symptoms of this disease • Significant weight changes: Stretch marks can be the result of obesity, rapid weight gain but also excessive weight loss, often associated with anorexia.

• H igh-level athletes, mainly men who practice weight-lifting, body-building or take anabolic steroids in order to increase their muscle mass.

• G enetic or constitutional predispositions • E thnic factors: Interracial differences in the depth and severity of stretch marks were observed

by Elbuluk et al. This study, involving 48 women, concludes that Afro-American women are more severely affected than white American women.

Diagnosis and pre-treatment consultation Pathological stretch marks require a complete medical examination in order to identify a potential organic etiology (e.g. Cushing’s syndrome) and to prevent it from get-

Macro stretch marks of skin on the thigh

38 TREATMENT I body language

affect patients’ psychological wellbeing, which can be the case for women as well as men.

Contraindications – Pregnant and breastfeeding women, to be safe, – Patients that are undergoing corticosteroid therapy or taking blood thinners, – If there’s an evolving skin disease on the treatment area, – If the patient has a history of keloid scars or scars that do not heal easily.

Inform patients During this interview, doctors may inform patients on operating conditions, available techniques, expected results and potential side effects.

Carboxytherapy

ting worse.

Standard stretch marks are far more common. These skin lesions are widespread and benign and therefore require no urgent treatment as they do not constitute health hazards. They do, however, raise aesthetic concerns and may have an impact on patients’ wellbeing.

Just as for any aesthetic treatment, an initial medical consultation is mandatory.

This consultation will have several objectives Confirming diagnosis The diagnosis of stretch marks relies quite simply on medical history data and a clinical evaluation of the skin.

Their shape: They often look like parallel streaks.

Their size: Their length, width and depth are variable.

Their surface: Smooth and oedematous when they are relatively new, but become more crumpled when the healing process is over.

They are hairless with no sebaceous or sweat secretion.

Their colour: They are initially purplish-red (striae rubra), then turn to a pink colour before going to white (striae alba). They may gain pigments on the long term.

Their quantity: They come in a high number, usually parallel and symmetrical.

Their localisation: While on women they appear mainly on the abdomen, breasts, buttocks and thighs, on men, they will be more likely to appear on the back and shoulders (most often because of body-building), and sometimes on the abdomen and buttocks. On black skins, we may find them in more unusual locations (shoulders, the inside of the arm).

Their duration: Their red colour dissipates with time, but pearl white marks are permanent.

Their symptoms: Although they are usually asymptomatic, a small percentage of patients may experience localized, sometimes pruriginous, redness when the area is inflamed.

Complications: Although physically benign, stretch marks can have an impact on body image and

Establish a personalised treatment protocol Deciding on the best treatment for a patient may depend on several factors: – The reason for stretch marks’ emergence (pregnancy, growth, weight gain), – Their age, – The patient’s skin phototype using the Fitzpatrick scale, – The patient’s expectations, – Cost – cosmetic treatments are rarely covered by insurances, – The patient’s availability, as several sessions are required for a clear result.

At the end of this consultation, the practitioner may hand a personalised quote to the patient including the number of sessions and fees depending on the affected zones and the patient’s willingness to undergo these treatments.

Therapeutic care for stretch marks Stretch marks are essentially scarred dermis. There is currently no known treatment that can entirely erase them, but it is possible to reduce and attenuate them, including their colour, length, width and depth, using a wide array of medical treatments.

Even though their physiopathology is not yet fully understood, it is currently assumed that they are connected to a dermis fibroblast disorder. There are therefore two

40 TREATMENT I body language

objectives: – To reduce visible consequences of stretch marks, including improving the mark’s surface and reducing the erythema (in recent marks), – To reactivate local fibroblasts in order to boost collagen and elastin production.

Preventive action, hygiene and dietary rules The only way of minimising stretch mark emergence is to avoid or limit their triggering factors: – Have a stable weight and avoid yo-yo diets, – Avoid excessive weight gain during pregnancy and moisturise high-risk zones daily, – Avoid stress - chronic stress states induce excessive cortisol production, – Eat a healthy, balanced diet with plenty of water in order to avoid any deficiencies, – Exercise frequently but not excessively, – Avoid excessive exposure to the sun without appropriate protection (solar elastosis), – Stop smoking, – Avoid using cortisol-based creams unless specifically prescribed, – Cosmetic products against stretch marks can be suggested in order to prevent their emergence during specific propitious times such as pregnancy.

However, even when all these guidelines are followed, stretch marks can still appear.

Over-the-counter nonmedical cosmetic creams There are two types of cosmetic methods: – Those that aim to temporarily hide these marks with pigmented creams (make-up or fake tan), – Those that aim to prevent or reduce the unsightly appearance of stretch marks. These usually take the form of oils, creams or lotions and can be sold in pharmacies or online. It is the only soft treatment that can be done directly by the patient, and is relatively cheap and painless.

Their action is mainly based on their moisturising property.

They are most effective when

used frequently on very recent stretch marks, but their effect still depends on skin quality and the origin of these stretch marks.

These anti-stretch mark creams play an important part in therapeutic care, prevention and management of stretch marks, especially gravidic ones. Some of these products (such as Centella asiatica, a herbal medicine), are permitted during pregnancy and breastfeeding but they do not have any proven effects. All other medical treatments are avoided in these cases.

There is no non-medical topical treatment that is proven by wellconducted clinical trials to prevent or heal stretch marks.

Prescription medical remedies Creams or lotions containing vitamin A acid are widely used to treat acne and keratinisation disorders.

These products can also be prescribed against stretch marks but they have yet to be authorised on the market.

A visible effect has been proven only when a 0.1% tretinoin cream has been applied once a day for 6 months on recent marks. However, these results are uncertain as the study covered a small number of patients, and histological data from this study is lacking.

Vitamin A acid acts on the skin by attacking it in order to regenerate it and homogenise its surface by facilitating its epidermis desquamation. Treatment takes time and has a significant number of side effect, including skin irritation and dryness, which may require a compensatory daily moisturiser application. The skin should be well protected from the sun throughout the treatment (photo-sensitising agents).

It is a relatively light treatment for recent stretch marks, however, its components are teratogenic and therefore strictly prohibited in the case of pregnancy, breastfeeding, or with women of child-bearing age that do not use sufficiently reliable contraception.

body language I TREATMENT 41

osmetic medical treatments C These treatments aim to attenuate existing stretch marks in order to improve patients’ quality of life, as there is currently no technique capable of completely removing them.

This is not an exhaustive list and often combinations of treatments get a synergic effect as shown later.

Stretch marks on woman's stomach

Chemical Peeling This medical action consists of applying a chemical (most often acid) on the skin to exfoliate its outermost layer and regenerate it.

A study compared the effect of two topical treatments: glycolic acid (20%) with tretinoin (0.05%) versus glycolic acid at a 20% concentration with ascorbic acid at 10%. Results showed that both treatments had a positive impact on stretch marks’ appearance.

A more recent double blind test was produced to evaluate the effect of a peeling with 70% glycolic acid on 40 patients with both red and

white stretch marks. Results confirmed that glycolic acid induced skin texture modifications that were perceived by patients.

Trichloroacetic acid (10 to 35% TCA) has also been used to treat stretch marks but data is insufficient to draw reliable conclusions.

Microdermabrasion This technique carries out a mechanical exfoliation under a local anesthetic, using a machine that projects aluminium oxide microcrystals and aspires them back alongside skin debris.

Abdel et al have reported results that show this could be a useful therapeutic option, as it potentially has a stimulating effect on collagen formation of type I. A recent prospective study compared superficial dermabrasion and topical tretinoin application. 32 women with erythematous marks were randomised and treated with either the former or the latter (0.05% cream) for 16 weeks. Evaluation, through objective criteria (measurement of stretch mark size) and subjective ones (the practitioner’s and patient’s opinions) have shown relatively equal results with a better tolerance for superficial dermabrasion. This study, however, did not include a control group.

Laser treatments Laser emits a monochromatic light (a single wavelength corresponds to a single colour) that converts into heat when reaching the target. The chosen wavelength determines the penetration depth into the skin or other target. Some devices may combine several wavelengths to obtain better results. Specific precautions are necessary to handle these lasers and only properly trained laserists will know how to select the right settings for each application.

The types of lasers used for cosmetic applications have their differences: – Ablative lasers (CO2 or ErbiumYAG) destroy the epidermis and the upper dermis by photothermolysis within one session, which triggers a neocollagenesis of the lower dermis with fairly heavy aftereffects.

– Micro-ablative (with both an ab-

lative and thermic effect) or non micro-ablative (purely thermic effect) fractional lasers are less aggressive than conventional ablative lasers and lead to the remodeling and retightening of the skin by boosting collagen production. Fractioning the treated zone will preserve intervals of healthy skin in between laser impacts at each session.

This will cause the scars to heal faster and be better tolerated by patients. However, several sessions are required to treat the surface area in its integrity.

– Vascular lasers (KTP or pulsed dye laser) are used to treat skin redness. They target only hemoglobin, a component of red cells and blood vessels.

Choice of laser will therefore depend on the stretch marks’ development stage.

– For red and recent marks, vascular lasers should be chosen as they cause the coagulation of dilated blood vessels. Their effectiveness was shown by Jimenez et al.

– W hite marks should be treated with ablative fractional lasers.

However, non-ablative lasers are becoming more popular by virtue of their limited side effects.

Of the available range of stretch mark treatments practitioners can use, laser treatment is best documented. However, conclusions found in literature often diverge, especially when it comes to white mark treatment.

Intense Pulsed Light Unlike standard lasers, flash lamps emit polychromatic light that penetrates the skin on a range of depths. This technique uses short wavelengths to act on the vascular element (redness) of the stretch mark by targeting oxyhemoglobin found in dilated blood vessels, and longer and more penetrating wavelengths to induce dermis regeneration through thermic action.

Flash lamps have undesirable side effects on dark skins and should therefore be avoided.

In another study, Al-Dhalimi and Abo Nasyria compared the effect of two different wavelengths from a flash light to treat red marks on 20 patients over a treatment pe-

42 TREATMENT I body language

LED lights are everywhere nowadays—screens, home lighting

riod of five sessions with two week intervals. It showed that flash light was a good therapeutic method, indicating that the 590nm wavelength was more efficient.

Bedewi and Khalafawy studied the efficiency of IPL in treating stretch marks on 24 patients. Using infrared micro-spectroscopy by synchrotron radiation, they have shown that IPL stimulates dermic fibroblasts and leads to increased collagen production. They concluded that this therapeutic method was promising in terms of efficiency and lack of side effects.

In 2016, El Taieb and Ibrahim published the results of their randomised comparative study on fractional CO2 laser and IPL for the treatment of mature stretch marks on 40 women. According to the publication’s authors, these two treatment conditions were both efficient for the treatment of stretch marks and had few side effects.

However, fractional CO2 laser seems to be better than IPL, with the same treatment period but with fewer sessions.

Aldahan et al have conducted a literature review in order to examine all the available data on the use of lasers and light to treat stretch marks. Their conclusion was that both methods are efficient treatments and can significantly im-

prove the physical aspect of both types of stretch marks: recent ones (red) and older ones (white). Recent ones, however, respond better to treatments, regardless of the technique used. “ Cold” light emission, or LED photomodulation LEDs are everywhere nowadays— screens, home lighting. NASA were the first to notice how wounded astronauts healed faster when exposed to LED during infrared therapies. Nowadays, this technique is widely accepted in dermatology, cosmetic medicine and anti-ageing for its anti-inflammatory, analgesic and healing properties.

It is a monochromatic cold light that penetrates the skin to shorter or longer depths depending on its wavelength and acts directly on skins sells. Red and yellow LED light, for example, have a healing and anti-inflammatory effect.

LED efficiency depends not only on light colour but also skin colour.

LED light stimulates mitochondria (intracellular organelles that are responsible for energy production) within fibroblasts, and boosts collagen and elastin production, leading to the progressive regeneration of altered connective tissues.

This effect is highly beneficial to the improvement of the area’s cos-

metic aspect.

The advantages of this technique are that it’s entirely safe, non invasive, painless, it can be repeated as often as desired, has no side effects, can be applied on all skin types and does not impose temporary social restrictions.

A biological and clinical study was carried out in 2006 at the Pitié-Salpêtrière hospital in Paris on 20 women, all with mature stretch marks. The chosen wavelength was between 600-650nm (orange to red) for all patients. The study showed a clear improvement of the marks’ aspect after 15 20-minute sessions. The same study was carried out on five patients in five 40-minute sessions and the outcome was equivalent.

Micro-needling Micro-needling refers to a new cosmetic technique, which consists of producing micro-perforations on the skin using a medical electric pen. This pen is made of extremely thin single-use needles, of which practitioners can set the penetration depth and diameter. In practice, the doctor will go over the same area several times in order to reach different depths and treat all layers of skin. This activates fibroblasts, leading to a higher collagen and elastin production, and heals microscopic

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44 TREATMENT I body language

wounds (self-regeneration process).

Medical needling is a nonablative procedure, easy to carry out and safe. It has a beneficial effect on acne scars as well as stretch marks. According to a study by Khater et al, this therapy would produce better results than fractional CO2 laser.

Microchannels resulting from this technique will also facilitate the penetration of active ingredients (multivitamins, hyaluronic acid etc) usually stopped by the epidermal barrier.

This technique has a double action on the treated area: mechanical stimulation (multiple micropricks) and skin bio-revitalisation (supplying various active ingredients). Sessions can be painful and it is advised to apply an anaesthetic cream one hour before the act.

Radiofrequency Radiofrequencyâ&#x20AC;&#x201D;most commonly using bi- or multipolar devicesâ&#x20AC;&#x201D; warms up the dermis using electromagnetic waves that circulate between the handheld deviceâ&#x20AC;&#x2122;s electrodes and the skin. This practice heats up the skin to a precise temperature only where it is in contact with the device, allowing for a very precise treatment.

This local skin temperature rise first triggers the contraction of existing collagen fibres, which has an immediate tensing effect. It also activates fibroblasts to boost their collagen and elastin fibre synthesis, leading to a visible effect a few weeks later.

During this session, patients should only feel a light heat sensation on the skin. This non-invasive treatment has no side-effect and

produces a targeted and controlled effect of dermis production and healing process revitalisation.

Nowadays, technological advances allow us to apply these radiofrequency directly into the skin through micro-needles. Intradermal fractional radiofrequency (IFR) delivers RF energy right into the skin using non-isolated goldplated needles with modular penetration depth. The synergy of the micro-ablative effect due to skin micro perforation, and the thermic effect due to needles heating up, have a positive impact on collagen fiber contraction and also triggers neo-collagenesis.

Carboxytherapy Carboxytherapy has been used for decades in the Royat Spa in France to treat vascular, venous and arteri-

Micro-needling perforates the skin activating fibroblasts

body language I TREATMENT 45

cream may be suggested to the patient before the session.

Results obtained by Pinheiro et al suggest that RF is more efficient than carboxytherapy for the stimulation of collagen production.

Galvanopuncture In galvanopuncture, needles are implanted into the skin and discharge electric current in small quantities and low tension to stimulate dermis fibroblasts.

In 2016, a Brazilian prospective, monocentric study - carried out on 32 women, all with white marks and different skin types - demonstrated this technique’s safety, efficiency and patient satisfaction after 10 sessions.

Combining different techniques Technique combinations are common nowadays as they combine superficial treatments with more in-depth treatments for optimal results. Experience in cosmetic medicine tells us that combining treatments in one session, or alternating techniques, often leads to the best possible results.

al pathologies, and has proven both efficient and innocuous. However, it has only recently made its way to cosmetic medicine. It relies on subcutaneous injections of CO2 (a sterile gas) using a very thin needle.

This gas is very soluble and therefore diffuses easily into skin tissues, bringing positive effects to the skin: – Improvement of microcirculation, – A n increased release in oxygen in-situ, by reducing haemoglobin’s oxygen binding affinity (Borh effect), – The skin’s texture, thickness and flexibility are improved through dermis fibroblast stimulation.

CO2 is often well-received, but passing gas can give an uncomfortable sensation to the patient due to skin unsticking. An anaesthetic

LED and RF A study was carried out on 103 patients with stretch marks of all ages.

Treatment was done in three steps: a bipolar RF session, then 70% glycolic acid peeling, and finally LED (pulsed 645 nm red light and continuous 855nm infrared light).

This amounted to 16 sessions in total at a rate of two sessions a week.

88% of results were deemed good to excellent. There was a significant improvement stretch mark aspect and a notably more tonic skin on the treated area, regardless of the skin type but more efficient on younger marks. LED phototherapy combined with bipolar radiofrequency was shown to have a significant positive impact on stretch mark size and quality(34).

IFR and CO2 fractional laser The synergy stemming from the conjoined use of RFI and CO2 fractional laser was shown in a recent study on stretch marks and then confirmed with a histological analysis. This study was comparative, non controlled and non ran-

domised, and sampled 30 Korean women, all with phototype IV(35).

Results of a study by Naeni et al also confirmed this. On 48 pairs of white marks on 6 Iranian women, treated randomly by IRF for one group or with a laser and IRF combination for the other, the combination proved to be more efficient than simple micro-needle radiofrequency.

Ultrasounds, fractional RF and retinoic acid A 2013 study on old stretch marks on a small number of volunteering women, was made up of three successive therapeutic stages: ablative fractional radiofrequency to produce skin micro-perforations, followed by a 0.05% retinoic acid topical application on the perforated skin area and then ultrasounds to enhance vitamin A cream penetration into the skin. The clinical evaluation has shown a significant improvement on atrophic white marks for all treated women. This therapeutic combination proved to be both safe and effective.

In a nutshell, we can say that the combination of cosmetic medical actions can notably reduce stretch marks. There are, however, currently no methods capable of completely erasing them.

The best results are often obtained when stretch marks are still appearing and erythematous. Still, at this healing stage, considered to be the most stable one, no treatment is capable of making them disappear entirely.

Therapeutic perspectives Novel treatments such as autologous platelet rich plasma (A-PRP) injections, on their own or combined with another therapy, are under study. PRP is a platelet concentrate, obtained by centrifugation of autologous blood, i.e. blood taken from the patient themself, which means this product is 100% biocompatible and natural. This PRP is then directly re-injected or applied externally (on a wound, for example). These platelets will then release growth factors in the damages site, thus stimulating fibroblast proliferation and tissue healing. PRP has has anti-infectious and healing properties and has

46 TREATMENT I body language

Male stretch marks

been used for a number of years with positive results in medicine (rheumatology, sports medicine) and care surgery.

A few studies are starting to show promising results on stretch marks.A prospective study by Kim et al has shown the beneficial effect of PRP combined with intradermic RF on a small cohort of 19 Asian patients with mature stretch marks.

In 2015, Ibrahim et al have compared PRP with microdermabrasion in the treatment of stretch marks. This randomised study had a sample size of 68 patients, split into three groups. The first one was treated with PRP injection, the second group with microdermabrasion and the third with both PRP and microdermabrasion in one session. Each pa-

tient underwent six sessions on a two-week interval. PRP alone was more effective than microdermabrasion alone, but the combination of both was seen as highly preferable as a more effective and quicker way to produce results.

The histopathological examination has shown a clear increase in collagen and elastin inside the dermis at the end of the treatment. It was generally well accepted.

Progress in associative treatment: In many cases, the chosen treatment calls for a combination of different techniques either simultaneously or successively in order to adapt it to the patient and the stretch marksâ&#x20AC;&#x2122; known physiopathological factors. A few new combinations are under clinical investigation. Based on personal experience with a dozen of pa-

tients with white stretch marks, six months after the treatment we are in favour of micro-needling followed with a 15% TCA peeling and multipolar radiofrequency during the same session. This treatment improves their crumpled aspect and their pearl white colour. The sensation of vacuity when touching the skin also disappears, thanks to skin retightening.

Patients are satisfied after at least six sessions.

Finding preventive care against the emergence of stretch marks would be ideal, but it is currently impossible.

Doctors nowadays tend to combine several therapies over one session to act cumulatively on the skinâ&#x20AC;&#x2122;s surface and depth and produce synergic results. Stretch mark care is moving towards more physiopathological treatments that target dermic fibroblasts to activate them, boost local collagen and elastin production and retighten the affected skin areas. Nevertheless, several regular sessions are essential to reach satisfactory results, depending on their size, age, patient phototype and budget (these techniques are generally expensive).

Stretch marks are most often a consequence of pregnancy but unfortunately, all these techniques are prohibited on pregnant women.

Stretch mark treatments, especially those of the white kind, remain a major challenge for doctors, who face this issue daily.

As a result, there is a constant need for new techniques and combinations to treat these scars more efficiently. A high number of comparative clinical studies are still necessary in order to identify the best therapeutic protocols and ideal parameters, that will be both effective and well-received.

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

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Vaniqa 11.5% Cream eflornithine Prescribing Information. (Please consult the Summary of Product Characteristics (SmPC) before prescribing). Active Ingredient: eflornithine 11.5% (as hydrochloride monohydrate). Indication: Treatment of facial hirsutism in women.

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 EDUCATION 49

NeoStrata skincare training CAROLINE GWILLIAM shares the benefits of attending AestheticSource's comprehensive training courses at Wigmore Medical

A

estheticSource is your complete Skin Fitness partner and we are delighted to partner with Wigmore Medical to provide an initial training course for NeoStrata.

At AestheticSource we have a team of trained and experienced colleagues to ensure you are fully confident with the technologies, ingredients, products, peels and treatments available. We believe that the initial training course is the start of your learning journey with us, along with pre course reading and follow up support. We aim to provide a great learning experi-

ence, a successful business partnership and ultimately happy clients.

The AestheticSource team is extremely proud of the heritage and success of the brand and we endeavor to impart this enthusiasm on the course. NeoStrata has consistently won UK industry awards over the years and in 2015 was the first brand ever to win both Aesthetic industry awards for ‘Best Cosmeceutical Range’. We can of course provide you with the awards badges for your own marketing.

The founders of NeoStrata, Dr Van Scott and Dr Yu hold over 200 patents, have published over 200 journal articles and have an enviable

cabinet full of international awards and accolades. All this is driven from a simple passion to improve people’s skin.

Your course trainers also have a passion for skin. Our Director at Aesthetic Source, Lorna Bowes RGN NIP, has been passionate about skin care since her first NHS post in dermatology in the 1980’s.

Lorna joined the aesthetics arena in the 1990’s with her own clinics before working across the industry in sales, training, management and business development.

Lorna has trained many doctors, nurses and dentists in dermal fillers, toxins, dermal roller and

NeoStrata product range

50 EDUCATION I body language

66 We take you through the science and clinical data that underpins the brand 99

Facial treatment

peels and lectures regularly on aesthetic procedures as well as aesthetic business management. Lorna is a founding committee member of the British Association of Cosmetic Nurses and former editor of the Journal of Aesthetic Nursing and frequently writes for various professional journals and lectures at many aesthetic medical conferences and at beauty shows.

When Lorna is lecturing elsewhere, we invite Anna Baker BN RGN INP PGCert—Applied Clinical Anatomy, Facial Anatomy Teaching Co-ordinate and Assistant Tutor to run our courses. She is a Cosmetic and Dermatology Nurse Practitioner who has been running nurse led clinics alongside a plastic

surgeon for several years. Anna also runs Topical Photodynamic Therapy Clinics to treat types of non-melanoma skin cancers. She is part of the Editorial Board for the Journal of Aesthetic Nursing and a Specialist Nurse Advisor for PMFA News and contributes anatomical articles to a number of aesthetic journals. Anna has used many cosmecuetical brands over the years so is in a perfect position to discuss her results with NeoStrata as well as present the in depth science behind the brand and run the practical demonstrations.

As the Sales and Business Development Manager for London and the South East, I also attend the course with my case of NeoStrata products and some amazing selling tips and tricks to give you the essential ‘know how’ to get the most out of the brand.

My experience and successes—winner of ‘Best Sales Representative’ last year at the Aesthetic Awards and nominated again this year for both awards—will also

help you to develop the brand in your clinic with marketing, creative promotions and ongoing support and training that is second to none.

When you book your NeoStrata course you will have the option to receive an email with pre reading and a glossary to give you a nice introduction to the brand and some of the key ingredients.

On the training day you will receive a training folder and all the marketing materials that you will need to take the brand forward in your own practice. We take you through the science and clinical data that underpins the brand and we give you the chance to observe and demo each and every product in the range. After lunch we run the practical demonstrations for the AHA peels with plenty of opportunities to perform and receive one of the famous and original NeoStrata “lunchtime peels”. Another guaranteed benefit of attending the course is that you will leave with glowing skin!

NeoStrata Best Cosmeceutical Range/ Product of the Year 2015 Aesthetics Awards NeoStrata Skin Active Best Cosmeceutical Range 2013, 2014 and 2015 MyFaceMyBody Awards

An example of one of NeoStrata’s clinically proven products:

Fight age. And win.

NeoStrata Skin Active Triple Firming Neck Cream Best Anti Ageing Product 2015 MyFaceMyBody Awards Triple Firming Neck Cream includes three powerful clinically proven ingredients to help reverse visible signs of aging in Before **

the neck and décolletage.

• NeoGlucosamine® helps increase hyaluronic acid* and even pigment • NeoCitriate® targets new collagen* to lift and firm • Pro-Amino Acid increases pro-collagen* to help diminish wrinkles

8 Weeks** • Lifts and firms sagging skin • Plumps to rejuvenate jawline contour • Targets uneven pigmentation

16 Weeks**

* in vitro test ** Poster, 73rd AAD Meeting, San Francisco, March 2015

NeoStrata ProSystem Peels Highly Commended 2015 Aesthetics Awards A complete peel system for your clinic Call us on 01234 313130

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body language I PRODUCTS 53

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

DMK Three gift sets are now available from DMK Skin Co as a special treat this Christmas. The DMK Limited gift set contains the brand new DMK LIMITED Elevate crème and comes with a free cellerator tool (designed to aid product absorption), a cosmetic mirror and bag hanger; the Super Eyes gift set contains the DMK Eye Tone and Super Serum and comes with a free herb and mineral spray and cosmetic bag; and finally, the Holiday Lift gift set contains the DMK Foamy Lift Masque, Exoderma Peel and Deep Pore Cleanser and comes with a free cosmetic bag, mixing bowl and masque brush.

W: dmk-uk.com

LYNTON LASERS Introducing the launch of Lynton Lasers' 'next generation' picosecond platform designed for the removal of all treatable tattoo colours, including notoriously hard to treat, green and blue pigments. With the new addition of a Ruby 694nm laser wavelength, Lynton claim the PICO SERIES transcends all other picosend devices through its unique ability to combine the efficacy and speed of picosend pulses with the proven safety profile of nanosecond Q-switched pulses at 1064nm, 532nm and 694nm. The PICO SERIES also comes with the new FraxTip lens attachment, designed for skin rejuvenation.

W: lynton.co.uk UNIVERSKIN The newly launched Universkin fullbody is designed to treat stretch marks, cellulite, loose skin on arms and legs, décolleté damaged by the sun, age spots and wrinkles on hands, etc. through a topical, fully customised skincare programme. Universkin Body uses a cosmetic formula that is said to minimise postoperative skin inflammation and optimise skin healing.

W: schuco.co.uk

MURAD The new Eye Lift Firming Treatment is the first in the Murad Professional collection, designed to deliver younger looking eyes in an instant. This formula features surfacefilling spheres that are said to reduce the appearance of fine lines and wrinkles and deliver filler-like results. It is also said to use a unique firming technology to instantly lift, firm and tighten the skin around the eyes. Murad Professional is a range of professional-strength formulas, traditionally used by Dr Murad in his world-renowned dermatology practice, now available for athome use and said to offer immediate and long-term results without any downtime.

W: murad.co.uk

ESTHECHOC Introducing the new, limited edition Esthechoc Advent Calendar. Said to be the world's first youth boosting 'smart' chocolate with powerful skin ingredients, Esthechoc combines festive tradition with optimum skin health.

W: esthechoc.com

ALUMIER Introducing the new broad spectrum sunscreen line from Alumier, said to be created using only active ingredients with proven safety records and a specific combination of antioxidants to protect skin from damaging free radicals caused by UV rays. Alumier MD sunscreens are free from parabens and available in various tints to suit different skin tones.

W: alumiermd.co.uk

EXUVIANCE The Exuviance Body Tone Firming Concentrate has just been launched as the new secret weapon to lift, tone and firm the skin. Said to use a unique trio of powerful, patented ingredients—NeoGlucosamine, CitraFill and Aminofil, this triple firming complex is then combined with a handy built-in massaging applicator. Designed to be used as an at-home treatment, it gently massages the skin and stimulates circulation, vital for improving cellulite, while delivering high potency ingredients to hydrate and tone the skin.

W: exuviance.co.uk

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body language I PANEL DEBATE 55

Q&A PROF MUKTA SACHDEV and DR RAHUL PILLAI discuss laser hair removal

Q D o you use more than one laser technology in the same area?

Mukta Sachdev: Absolutely, I would switch technologies, although I wouldn’t do it in the same sitting.

I don’t believe in hitting the same area over and over again, so what I have been doing so far is using different technologies at different sessions. I’ve been switching and rotating, but I think that it’s brilliant that it’s now possible to use a machine like the Alma Soprano Ice platinum with the Trio hand piece with 3 different wavelengths of 755nm, 810 nm and 1064 nm coming together in one hand piece.

Q W ho’s making Alexandrite and who’s using them in this country?

Mukta Sachdev: I know Alma have an Alex in motion and Alma and the e-motion Alex from DEKA are both available in the UK. They can be used on all skin types and I believe these are the only two companies using this technology.

Fifteen years ago, Alex was the go to laser for fair skins, and long pulse Nd:YAG was the choice for darker skins. Today there’s resurgence in a similar technology, yet with the modern machines, much of the hard work is done by the machine. In fact, the skill of the person using the machine is as, if not more important than the machine itself. There are so many people using lasers in darker skins worldwide, we don’t have to reinvent the wheel anymore. Some 20-25 years ago there was no experience, but today the settings have been done for you and the success is basically handler dependent. Anyone can get a burn with any machine if they’re doing it wrong.

Q A re you using a combination of IPL and radio frequency?

Mukta Sachdev: I have the Elos technology which combines IPL and radio frequency. All devices work, but each practitioner must make their own personal choice because success is dependent on

so many things—your distributor, your contracts, your breakdown contracts, your AMCs—maintenance contracts and your pricing.

In my opinion there’s not a number one or a best, in any device for any indication.

Q

an Q switch laser also be used C for hair removal?

Mukta Sachdev: I don’t use it for hair removal. I know it’s documented but I have no personal experience. Q switch is more for pigmentation. It’s a photoacoustic mechanism, not really one of the preferred choices for hair removal, as far as I’m aware.

Q I n countries like India, where patients have many skin types, what lasers would you advise as a start up purchase of one or two lasers?

Mukta Sachdev: If I had an option for a combination, I would choose a combination, but it depends on your budget. There’s no one de-

Laser Epilation Treatment

56 PANEL DEBATE I body language

contact cooling. All the machines I work with have contact.

I think cooling is mandatory. I don’t think it’s optional anymore.

You’ve got to cool the skin with any laser technology, especially darker skins.

vice that I can give a 100% recommendation for. We’re in a global world now, so I don’t think it has to be chosen based on suitability for Indian skin—I would look at efficacy. Safety’s paramount, but everything is safe if you do it right.

Q Would IPL be your first choice?

Mukta Sachdev: IPL is not a first choice. I would make a conscious educated choice for a wavelength.

IPL is a very wide range, so I wouldn’t go with an IPL as a first choice.

Q W ith 3-beam technology do the three beams come out in one pulse?

Mukta Sachdev: Yes, they’re preset and your areas are pre-set, and the makers have already done all of those calculations that in this skin type and in this area, this is the best combined fluence. So they’ve actually combined all three in one piece with contact cooling. There are different targets in the hair follicle and these 3 wavelengths act at different levels and different modalities of action so the combined effect should ideally be superior to a single wavelength.

This is quite a device, since it’s very rare that somebody goes out and buys all three different technologies. You’ll buy one and then you’ve found it hasn’t worked, and then you look at buying another one. Here all the work has now been done for you. We’ve had hair removal for 20 plus years. So long as you know what works on different colours, and you can adjust those settings to get what depth you want or what safety you want.

Q A re you getting applicators that have laser pulses and RF? Mukta Sachdev: Yes, it’s possible to blend all three—Alex, diode and long pulsed ND;YAG in the same hand piece, but you also get three different hand pieces. So you also get an attachment of an Alex or an Nd:YAG or a diode if you want.

It really depends on what you’re looking for, although studies have found that if you combine it, you’ll use less numbers of treatments, and you’ll be able to achieve efficacy and safety.

Q C an you say anything about the cooling system?

Mukta Sachdev: All of them have

Rahul Pillai: I would like to add one thing to this debate. Diode has been considered Gold standard for hair removal and it has been so for more than a decade. The physics based on chromophore that is Melanin, is that Nd-Yag penetrates more but absorbs less energy, while Ruby penetrates less but absorbs more. Because of this, a Diode which is somewhere in between, was considered ideal for treating darker skin types. If you look in the market all new lasers are Diode lasers with a handpiece similar to Nd-Yag or Alexandrite, but its still a Diode. The platform is a single Diode platform not two lasers integrated into one. So one should not confuse them as three different lasers into one laser as its three different technologies firing different wavelength from the same Diode laser. I still feel the physics remains the same—chromophore is the same, so Diode in my opinion is still the gold standard. Any additional wavelength options or handpieces are a luxury which you surely can have if you can afford and have a multi-ethnical crowd walking in for treatment.

Prof Mukta Sachdev, Dr Keerthi Velugotla and Dr Archana Samynathan Manipal Hospital, Bangalore, India and MS Skin Centre, Bangalore, India. Prof Sachdev Prof Sachdev has two decades of clinical experience in medical, aesthetic and cosmetic dermatology, and is a skin of colour expert.

Dr Rahul Pillai completed his MD in General Medicine from Moscow Medical Academy Russia, and his MD in Dermatology, Venereology and Leprosy, from Pondicherry University, India,where he was the rank holder and gold medallist. Now he is Medical Director of KKRIS Skin Care Centre and Laser Llinic, Kochi. He is a speaker, trainer and course conductor at various International conferences and workshops and specialises in laser technologies.

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body language I BUSINESS 59

Pre and postprocedure support NORMAN WRIGHT discusses the importance of psychological support for patients

Any procedure will have psychological impacts on your patients.

P

re and post procedure support, PaPPS in short, is something not only of benefit to patients; it also has benefit to your employees and your business. Psychological support for patients can reduce patient complaints, lawsuits, and more importantly, enhance the patient experience.

As clinicians, practitioners, and clinics, it is also just as important to appreciate how your own emotional, relational, and psychological wellbeing impacts on and is affected by, what you do.

As an integrative psychotherapist with the last four years work-

ing in the aesthetic and cosmetic industry, what has come to my attention, is that patient supportâ&#x20AC;&#x201D; not just physical but emotional, relational and psychological is an absolute necessity. Given the pressured, hectic and quickened lifestyle and expectations that leave people being so busy, less time is available to appreciate these factors and those practitioners, clinics, and clinicians that are actually supporting their patients, sometimes in an unconscious way, as part of the work they do.

In principle it is important that patient health, safety, and wellbeing are addressed. Though one

of the questions that I am often asked, at the end of the discussion with people agreeing that ERP impacts and needs are considered by users of cosmetic procedures and aesthetic treatments, is who is going to pay for itâ&#x20AC;&#x201D;thatâ&#x20AC;&#x2122;s always the bottom line.

Why patients complain Today we are getting an insight into why patients complain, how to reduce litigation, learning about and gaining a deeper understanding of the person behind the patient. As an expert witness and medico-legal expert in an increasing litigious society, I am in a unique position

60 BUSINESS I body language

Emotional, relational and psychological support is an absolute necessity.

to give the clinics and clinicians I work with the opportunity to understand and look at patient health, safety and wellbeing within their businesses. Much of my expertise comes from experience delivering PaPPS, preparing reports for court, and working with patients who have had their aesthetic or cosmetic procedure that has not quite gone according to plan, or the patients have been dissatisfied with them, for whatever reasons.

Although I am speaking from a British perspective (and as a member of the BSI), I am a strong believer in the need to introduce medical aesthetics standards across Europe. This has come about as a consequence of the PIP scandal and a desire from the Government for the cosmetic and aesthetic industries to tighten up, to begin to self-regulate, to take some responsibility and to introduce their own standards. I suspect that if we do not do that, then the Government might step in, as in introducing regulation like in Scotlandâ&#x20AC;&#x201D;introducing certain standards that they want clinics to adopt. There is a regulatory process starting to be introduced and the Scottish clinics have got three years in which to become registered.

Mental health One in four of the population will experience a mental health issue in any one year. This speaks volumes about the kind of society that we live in, and how more and more people are experiencing mental health difficulties. The implication of this statistic, rates of body dysmorphic disorder, domestic abuse and sexual violence in the UK and across both genders, the chances are, you are going to have someone that walks through your doors who will be experiencing some level of psychological distress is high. Also, if they are not, it is possible the treatment and/ or procedure that they might be getting from you could be a trigger for psychological disharmony. That sometimes happens.

It is almost certain that you will have patients who will have underlying mental health issues and concerns. I know that in many cases, these issues and concerns are neither inquired, discussed nor recognised by some professionals.

However, when you work with a client, often alongside acting as the patientâ&#x20AC;&#x2122;s aesthetician or clinician, you act as their counsellor as well, as they share their issues and concerns.

What you do as clinicians is already extremely complex, already very taxing and demanding. By inviting a specialist who is an expert in PaPPS to work with your practice, you as experts in your chosen area can be freed up to do your work and to know that there are other people taking care of other aspects of your patients. This also sends out a message to your clients and to your competitors, that you see more than just the pounds behind the patient; you see a person behind the patient.

Industry facts There are shocking statistics about the experiences of women, who make up something like 80% of your caseload. In England, women are more likely than men to have common mental health problems and are almost twice as likely to be diagnosed with anxiety disorders.

In 2013, a Europe-wide survey revealed horrendous statistics about how many women are going to experience sexual violence this year, and how many women wouldâ&#x20AC;&#x2122;ve experienced sexual violence since the age of fifteen.

In the context of your clients, this indicates some of the things they might be carrying with them,

body language I BUSINESS 61

which may not be an issue for many people, may be triggered through your contact with them.

In 2015 the cosmetic and aesthetic treatments industry generated over £3.6 billion and it’s due to rise. Non-surgical cosmetic and aesthetics procedures made up 75%, and of these treatments, their popularity is increasing daily.3 Over 50,000 cosmetic surgery procedures took place in private clinics last year, 65% of those who had cosmetic surgery procedures in the last five years said that they regretted it.

Outside of the cost, the top reason cited was fear stemming from horror stories, the PIP scandal, and botched treatments in the media, followed by weariness of the results looking unnatural, and not knowing which practitioners are qualified to perform these procedures.

The fear of unhappy clients One surgeon, who I work closely with, told me that opening a letter from an unhappy client is one of his worst nightmares. He is very aware, through talking to his colleagues, of the impact of having one of those letters—and how many hours of valuable time is spent, contacting their insurance

company, solicitor, going through patient records, speaking with staff, other people, and the ensuing rise in stress levels.

Business does not get put on hold when you are dealing with a complaint—you have your full case load, a busy clinic, and whilst all of these things are going on, you have to find the time to deal with this complaint. With the influence of social media there is the potential for a patient to post something public about their experience, or the fact that they are going through a lawsuit, that is against you and your clinic. If your family and your colleagues see, it is natural to worry how this will affect these relationships, your lifestyle, and your business. If you are found to be negligent, the costs almost do not bear thinking about; your premiums will go up, your risk and the reputation of being solid, not necessarily in a negative way has a negative impact.

Secondary trauma No matter the level of impact, this kind of experience is going to have an impact upon your mental health, how you feel, it will affect the relationships that you have with yourself and your clinic, the people that work in your clinic,

and at home. Any procedure will have psychological impacts on your patients and because every patient that walks through your door is vulnerable and loaded with the things they come with, also makes you vulnerable.

RCS Professional Standards for Cosmetic Surgery is asking you to consider and talk with your patients about the potential adverse physical and psychological impact of the treatment or procedure going wrong, failing, or not meeting their expectations. You must have that discussion when you discuss treatments and procedures, and their options with a patient—you must consider the vulnerabilities and psychological needs.

It is fair to say that patients’ vulnerabilities and psychological needs could be as long as a piece of string in many ways. I have pioneered a method and an approach that helps to get all the questions that you need to know answered so that your clients are ready to have this procedure and that they are doing it for the right reasons.

I encourage clinicians and practitioners to consider duty of care first of all. You have that as soon as clients contact you, either by phone, email, text, or whatever it

Psychological injury could go on for a long time.

62 BUSINESS I body language

and your clinic and your staff— everybody is now vulnerable.

Norman Wright

might be, you have a duty of care at that point. I am interested in enabling you to monetise that, because you would have spent in the region of £200 attracting an aesthetic patient to your clinic, through your marketing campaign, and about £500 for a cosmetic patient.

Your website, design, and money spent, marketing and publicising is an investment that you have made, so you need to work out how you capitalise on that investment and keep clients. I encourage you to develop and maintain those relationships that are now established with your clients, even if they are not ready, I never say never, rather I encourage you to say, maybe not now.

What are the risks with no support?

There are considerable risks to you and your business when you are not supporting your patients. Remember that a quarter of the population are suffering from mental health problems, and that a proportion of those people are coming through your doors.

Patients complain for a number of reasons, firstly because their expectations are sometimes not met, or are not clearly understood, or if they do make an initial complaint, it’s not dealt within a timely fashion. Sometimes clinics, clinicians, practitioners get scared when somebody has made a complaint, so they avoid it and do not pick the phone up, screen their phone calls or choose to simply ignore the complaint.

When this happens you have put yourself as a clinician and as a practitioner in a vulnerable place;

Psychological injury I have noted in medico legal reports that it is always about the psychological injury where clinicians and clinics come unstuck. Yes, there are times when it is about the expected outcome and what it is that the client has perceived as being inadequate, but very often it’s not about the procedure that patients complain about.

And at very best it is 50/50, and one leads to the other. Someone not happy about their nose and the way it’s turned out, which has affected the way that they think and feel about themselves, and they believe it has affected all of their relationships. They feel inadequate and even worse than before. Psychological injury could go on for a long time – you do not know when the healing is going to take place. Or that they do not feel as their concerns, experience and perception is not heard, understood and taken seriously.

Emotional relational and psychological support ERP Support, is a bespoke method and approach that is issue focussed – so it is only about the procedure that the client has elected to have.

It is brief and focal, that means it is short-term, three sessions, one before, two afterwards and that’s it. In the focus on the client’s procedure of choice, it is making sure that the client has given due consideration to their decision—making sure that they are doing it for themselves and not for somebody else or the practical support needed pre and post procedure for effective healing to occur, as examples.

It gives the patient an opportunity

to address their ERP wellbeing in regard to their treatment, but more importantly, it does not only benefit and manage the expectations of your patients, it helps you too, as practitioners and clinicians. It gets you to appreciate your own emotional, relational, and psychological functioning, wellbeing, in a very stressful, high intensity role, job, and responsibilities that you have.

When I work with clinics in the realm of ERP, I make a bespoke configuration, that fits around your clinic, fits around your needs.

Training around the specific ERP factors for your client group helps you get a deeper understanding of your patients ERP and wellbeing and facilitates you in understanding the ERP wellbeing of the clinician, your team and your clinic.

For example, It is often the quiet, cautious patient that often requires more ‘attention’, ones that you need to watch out for actually more than anything else. I offer assessment tools and a 24-hour practitioner support line once you have undertaken the training. It is about preparing you and your clinic to meet the emotional, relational, and psychological needs of your patients.

Norman Wright is an Integrative Psychotherapist with sixteen years in Private Practice. Norman is a medico legal expert working with law firms preparing and writing reports about psychological injuries due to clinical and medical negligence.

Norman represents the UKCP as one of the CH/403 BSI committee members helping to set standards across the UK and Europe. Norman has pioneered and developed his award winning PaPPS support and PaPPS Training, July 2016 W: papps.org. uk; thewrightinitiative.com

References 1. 2012/13 CSEW and Psychosocial predictors, assessment and outcomes of cosmetic interventions A systematic rapid evidence review. March 2013 2. Raconteur Cosmetic Surgery report 2016 3. Source Aesthetics Journal 4. http://www.aestheticmed.co.uk/news-and-feature/fears-continue-togrow-around-aesthetics-sector/#sthash.3gwFoICW.qnFjBt6B.dpuf 5. The Guardian newspaper 8th January 2012

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

EQUIPMENT We provide a wide range of equipment to ensure practitioners stay ahead of the competition

INJECTABLES Our extensive range allows practitioners to tailor order products to best suit their patient

PHARMACY For the last 30 years we have supplied medical equipment and drugs to practitioners UK wide

TRAINING Unique courses combine leading expertise, intimate group sizes and hands-on training

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

NEW

A DERMAL FILLER TO CONTOUR1 & DEFINE1

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M-RAD-UKI-0030 Date of Preparation September 2016

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2015

NEW

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Ready-to-use, premixed with 0.3% lidocaine2

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Favourable rheological properties to create contours, shape & definition1

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Enhanced patient comfort when compared with Radiesse® non-lidocaine3

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New 27G Terumo needle

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

1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. Instructions for Use (IFU) Radiesse® 3. Schachter D, et al. Calcium Hydroxylapatite With Integral Lidocaine Provides Improved Pain Control for the Correction of Nasolabial Folds. Journal of Drugs in Dermatology. August 2016; Volume 15. Issue 8. 1005-1011 4. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ deviceapprovalsandclearances/pmaapprovals/ucm439066.htm

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

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

CONTOUR & DEFINE