Body Language #86

dec/jan

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

TREATING ROSACEA THE LATEST UNDERSTANDINGS BEHIND PATHOPHYSIOLOGY AND CUTTING EDGE COSMETIC CHEMISTRY

PLANT CELLS

CONSULTATION

HAIR CARE

The use of cultured meristem plant cells in cosmetics for skin

How to increase patient satisfaction by transforming the consultation process

Introducing hair into your cosmetic practice; the long and short of it

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

27

52

contents 07 NEWS OBSERVATIONS Reports and comments

15 INDUSTRY NEWS MEDICAL AESTHETICS

40 TREATMENT

News round-up

INTRODUCING HAIR INTO YOUR COSMETIC PRACTICE

18 DERMATOLOGY ROSACEA Dr Rachael Eckel discusses how to effectively treat rosacea, by coupling the latest understandings behind its pathophysiology with cutting edge cosmetic chemistry advances

25 PRODUCTS

Dr Greg Williams goes into the long and short of it

45 SKINCARE GLOâ&#x20AC;&#x201D;THE ULTIMATE REVOLUTIONARY SKINCARE KERRIE SMYTHE discusses how glo minerals and glo therapeutics can benefit your patients and your practice

ON THE MARKET

49 EQUIPMENT

The latest medical aesthetic and anti-ageing products and services

SOFT SURGERY

27 MEDICAL AESTHETICS LEAP OF FAITH Dr Ravi Jain recounts his experience of increasing patient satisfaction and success by transforming the consultation process 18

Prof Liudmila Korkina discusses the use of cultured meristem plant cells in cosmetics for skin rejuvenation

33 SKINCARE MERISTEM PLANT CELLS IN COSMETOLOGY

Dr David R Jack outlines the concepts and applications of the Plexr device, and recounts his own experience of using this technology

52 DERMATOLOGY TOPICAL OXYGEN Dr Mark Rubin shares his ideas about where topical supersaturated oxygen emulsions could be helpful in your practice

4 CONTENTS I body language

PRODUCTION EDITOR Helen Unsworth 020 7514 5989 helen@face-ltd.com ASSISTANT EDITOR Lousie Renwick 020 7514 5989 louise@face-ltd.com COMMISSIONING EDITOR David Hicks 020 7514 5989 david@face-ltd.com EDITORIAL ASSISTANT Arabella Tanyel 020 7514 5989 arabella@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Dr Rachael Eckel, Dr Ravi Jain, Prof Liudmila Korkina, Dr Greg Williams, Kerrie Smythe, Dr David R Jack, Dr Mark Rubin ISSN 1475-665X The Body Language® journal is published ten times a year by AYA Productions. All editorial content, unless otherwise stated or agreed to, is © AYA Productions 2016 and cannot be used in any form without prior permission. Printed by Buxton Press Ltd. Enquiries, orders and all other mail should be addressed to Body Language, 2D Wimpole Street, London, England, W1G 0EB. To contact Body Language by telephone, please call us on +44(0)20 7514 5989. Editorial e-mail: editorial@face-ltd.com Advertising: advertising@face-ltd.com Body Language can be ordered online at: www.bodylanguage.net

33 Dear Body Language Reader, Welcome to the December/January 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, Dr Rachael Eckel discusses the latest advances in treating rosacea and Dr Ravi Jain explains how he has increased patient satisfaction by transforming the consultation process.

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

CORRECTION: In Body Language issue 85, page 20, "A shot of history" by Professor Nick Lowe, the above images of pre and post treatment were swapped in error.

SKINBOOSTERS ™

Radiant Skin, Radiant Patients Restylane® Skinboosters™ are clinically proven to deliver progressive, long-lasting improvements to the skin condition of your patients.

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

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

The only noninvasive lift US FDA cleared7

EU CE mark certified8

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

BAAPS BELIEVES IN CLEAN CUT FOR AESTHETIC SECTOR The British Association of Aesthetic Surgeons believes the UK's exit from the European Union provides the chance to set better standards and regulations New data has found that 90% of surgeons have recorded a dramatic rise in patients being dangerously misinformed about cosmetic surgery over the past three years.

This figure, unveiled at the British Association of Aesthetic Surgeons’ Annual Scientific Meeting for 2016, is of particular concern given the extensive Government review, the emergence of new forprofit agencies claiming to regulate the cosmetic sector and the launch of online educational resources for the public.

However, as the UK makes its move from the European Union, whether individual members were ‘Remainers’ or ‘Leavers’, the BAAPS as a whole stands together in the belief that the impending exit presents a unique opportunity to finally clean up Britain’s role in a sector long described as the ‘Wild West’.

With the UK free to set their own required standards of regulation and training, businesses can be forced to meet quality levels and to employ surgeons trained to a UK-defined standard, and who are appropriately covered by UK or UKequivalent indemnity insurance.

According to consultant plastic surgeon and BAAPS President Michael Cadier; “Whilst individuals may have widely differing

opinions on whether the UK should or shouldn’t have chosen to leave the European Union, the fact remains that Brexit is offering a brilliant opportunity to implement very straightforward changes that can ensure what the BAAPS has long been battling for: safe and effective aesthetic plastic surgery for the British public.”

A straw poll of the BAAPS Council demonstrated that nine out of 10 surgeons have seen a rise over the last three years—on average by 31%—in patients being wildly misinformed about aesthetic plastic surgery.

The top three reasons for unsuitability; in descending order; were the

treatment sought not being appropriate for the patient, Body Dysmorphic Disorder and medical history making the procedure risky or unfitting.

Two out of five surgeons have seen problems with unregulated facial injectables (dermal fillers) in the same period, all of whom asserted the problems would have been avoided should such treatments be prescription only. Two out of five surgeons have continued to see a rise in problems stemming from cosmetic surgery abroad, with 60% of those recording an increase by as much as a 25%.

Although Brexit is unlikely to impact on UK patients seeking cheap procedures abroad, one

of the BAAPS’ proposals calls for foreign hospitals to be invoiced for the necessary reconstructive— and often life-saving— treatment undertaken by the NHS once these patients come home.

The BAAPS also proposed for dermal fillers— injectables previously described as ‘the next PIP implant crisis waiting to happen’—to finally be classed as Prescription-Only Medications (POM). This classification would mean practitioners using them would be limited only to those with appropriate medical training, and their advertising to the public would automatically become restricted.

Michael Cadier concluded; “Our clear-cut proposals should be seriously taken into consideration by the Government —at the BAAPS we have spent decades doing our best to educate the public and warn them away from unethical offers and procedures performed by untrained practitioners.

Yet as our internal survey has proven, many people are still vulnerable and far from well-informed.

Now we have a chance to truly change the landscape of cosmetic surgery in Britain and not only ensure safety for the tens of thousands of patients who seek procedures every year, but also remedy for our Health Service hospitals treating victims of surgical tourism.”

8 NEWS I body language

NEW BREAST AND COSMETIC IMPLANT REGISTRY BAPRAS and BAAPS launch registry to better regulate the use of implants in cosmetic surgery The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), Association of Breast Surgery (ABS) and the British Association of Aesthetic Plastic Surgeons (BAAPS) have launched the Breast and Cosmetic Implant Registry— to safeguard the health of patients with cosmetic implants.

The registry, which will record the details of any individual who has breast or other

implant surgery, so that they can be traced in the event of a product recall or other safety concern, was developed by a steering group as one of a number of new initiatives to better regulate use of implants for cosmetic surgery and breast reconstruction after breast cancer – with the aim of both improving outcomes and reducing risk.

Commenting on the launch, Health Secretary Jeremy Hunt

said, "We want the NHS to be the safest healthcare system in the world and anyone who chooses to have a cosmetic procedure has the right to safe care.

The PIP breast implant scandal in 2010 affected thousands of people which is why we asked NHS Digital to develop a new register which will allow people to be traced swiftly if that is ever needed".

The registry’s establishment is in response to recom-

mendation 21 in Sir Bruce Keogh's Review of the Regulation of Cosmetic interventions, which called for a cosmetic implant registry "to provide better monitoring of patient outcomes and device safety".

The registry is expected to record more than 20,000 cases of implant surgery annually.

Reporting of data will be done by the provider, via an online portal.

LIPOSUCTION PROCEDURES ON THE RISE Global survey results from ISAPS show that the number of liposuction surgeries worldwide has grown by 1.4% between 2014 and 2015 Liposuction is increasingly showing as the fat reduction treatment choice for the bodies of overweight patients, who have exhausted the do-it-yourself method of diet and exercise are want to remove stubborn fat and improve their self esteem.

The global survey results of the ISAPS show that not only does the U.S. have the most liposuction surgeries, but that number has grown worldwide by 1.4% between 2014 and 2015.

Despite public awareness of the need for healthy diet and exercise regimes, this popular surgery continues to grow— comprising 14.5% of the total surgical procedures globally performed by plastic surgeons. Women make up 84.7% of this figure and men 15.3%.

The USA performed the most liposuctions—at 17.2% of the countries' total procedures or 240,565. Brazil was second with 182,765 procedures and 13.1% of

their total surgeries.

It is evident that as liposuction techniques have become more refined, and networks of ISAPS accredited surgeons have grown, men and women frustrated by stubborn fat feel ever confident in liposuction being a safe and proven solution. However, it remains to be seen how newer non-invasive techniques such as cryolipolysis will shape market in future.

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

DATES

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

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

E: TRAINING@WIGMOREMEDICAL.COM

I T: +44(0)20 7514 5979

DECEMBER

JANUARY

FEBRUARY

MARCH

1 Adv. Toxins and Fillers* FB 3 Microsclerotherapy* 6 ZO Medical Basic (London) FB 7 ZO Medical Interm. (London) FB 8 ZO Medical Adv. (London) FB 10 Adv. Toxins and Fillers* 13 Introduction to Skincare & Peels 14 Intro to Toxins* FB 15 Intro to Fillers* FB 16 Adv. Toxins and Fillers* 17 Mini-Thread Lift* 18 Intro to Toxins* 19 Algeness*

16 ZO Medical Basic (Dublin) 17 ZO Medical Interm. (Dublin) 17 Introduction to Skincare & Peels 18 Intro to Toxins* 19 Intro to Fillers* 19 ZO Medical Basic (Manchester) 20 ZO Medical Interm. (Manchester) 20 Mini-Thread Lift* 21 Adv. Toxins and Fillers* 23 Dracula PRP* 24 ZO Medical Basic (London) 25 ZO Medical Interm. (London)

2 glo minerals 2 glo therapeutics 2 Micro Needling 9 Sculptra* 10 Non-Surgical Rhinoplasty* 11 Microsclerotherapy* 13 CPR 14 Introduction to Skincare & Peels 15 Intro to Toxins* 16 Intro to Fillers* 17 Mini-Thread Lift* 17 ZO Medical Basic (Edinburgh) 18 ZO Medical Interm. (Edinburgh) 19 ZO Medical Adv. (Edinburgh) 20 Dracula PRP* 21 ZO Medical Basic (London) 22 ZO Medical Interm. (London) 24 Adv. Toxins and Fillers* 27 Core of Knowledge

6 CPR 8 ZO Medical Basic (Manchester) 9 ZO Medical Interm. (Manchester) 10 ZO Medical Adv. (Manchester) 11 Microsclerotherapy* 13 ZO Medical Basic (Dublin) 14 ZO Medical Interm. (Dublin) 14 Introduction to Skincare & Peels 15 ZO Medical Adv. (Dublin) 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) 23 ZO Medical Adv. (London) 24 Adv. Toxins and Fillers*

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

10 NEWS I body language

BREAST IMPLANT SIZE SELECTION SYSTEMS REVIEWED Using clinical guidelines could provide better outcomes When it comes to breast augmentation, researchers are suggesting that dismissing patients’ or surgeon’s preferences and using clinical guidelines to determine optimal breast implant dimensions—may provide better outcomes.

In research published in the November 2016 issue of Plastic and Reconstructive Surgery, researchers in the USA carried out a "data-driven review" of methods used by plastic surgeons to select the appropriate implant size for breast augmentation surgery.

The implant size selection systems used were divided into three groups: A group who used no breast measurements and implants were chosen based solely on the patient's or surgeon's preference; second which used dimensional analysis systems with implants chosen in order to establish a desired result, with measurements performed to determine the implant needed to achieve that result; and a final one using tissue-based planning (TBP)—breast tissue measurements used to set "clear and narrow boundaries" for implant selection based on clinical guidelines, with limited to no flexibility.

The review identified 33 articles on implant sizing systems.

Studies evaluating TBP sizing systems were of higher quality than those in the other two categories.

"The top ten studies based on methodological quality all used patients' breast dimensions before selecting final implant dimensions, and this should now be considered standard of

practice based on our analysis," Drs. Adams, of University of Texas Southwestern Medical Center, Dallas, and Daniel McKee of McMaster University, Hamilton, Ont., Canada write. The TBP studies reported low rates of repeat surgery, compared to industry standards and accepted research values.

The researchers emphasise some major limitations of the available evidence on implant sizing systems. Just four out of 33 studies reported clinical outcomes that could be compared to any standard, while none of the studies compared two or more sizing systems. Overall, 60%of studies scored zero on the quality rating scale used—including some popular sizing systems that were "not grounded on any published data or evidence."

The topic of implant selection can be an emotional one, with tension between the plastic surgeon's roles as "Artist" versus "Engineer." The researchers note that some TBP systems with the highest quality of evidence take a "middle-of-the-road" approach—based on measurements, but also considering the patient's aesthetic desires.

Based on their data, Drs Adams and McKee are evaluating a new "implant-specific" TBP system designed to guide the surgeon to a selection of manufactured implant styles and models.

"Going forward," they write, "new published systems should [use] rigorous quantitative methods so that comparisons can be made in terms of patient outcomes."

PSORIASIS LINKED TO DEPRESSION Results of study show that patients with psoriasis have a higher risk of depression A new finding that patients with psoriasis face a higher risk of major depression, could lead dermatologists to alert patients with the condition and even screen them for mental health issues.

In the recent study, which appears in the January 2016 issue of JAMA Dermatology, Dr Ho and colleagues found that 16.5% of psoriasis patients met criteria for major depression. After researchers controlled for various factors, patients with psoriasis were twice as likely to experience (OR, 2.09 [95% CI, 1.41-3.11], P<.001) major depression.

It's not clear how psoriasis and depression are linked, however "psoriasis patients should be counselled that psoriasis, a treatable disease, may place them at an elevated risk of depression," says study co-author Roger S. Ho, MD, MS, MPH, an assistant Professor of Dermatology with the New York University School of Medicine/Langone Medical Center. "However, many patients may

not be cognisant of their own depression symptoms. As a result, dermatologists should be aware that all patients with psoriasis may benefit from depression screening."

There was no significant connection found between the severity of psoriasis and the risk of major depression and researchers could not discern if psoriasis causes or worsens depression–or vice versa–or if other factors may explain the apparent link. However, it's possible that "some unifying factors or mechanisms common to both psoriasis and depression might predispose a patient to both psoriasis and major depression," says study coauthor Dr Ho. "Or psoriasis or major depression might set off a cascade of events that make a patient more vulnerable to the other entity."

In regard to a specific mechanism, psoriasis and depression may affect each other, possibly when stressful life events disrupt the body's autonomic and immune responses. Indeed psoriasis patients face a higher risk of immune disorders— like diabetes and inflammatory bowel disease—and conditions related to the autonomic system such as heart disease.

body language I NEWS 11

BARRIERS TO CLEFT LIP AND PALETTE SURGERY IN LMICS REVEALED Survey reveals a wide range of financial, structural and cultural barriers to cleft care

HIGH PROTEIN DIET Research shows protein-rich foods affect appetite and weight Researchers have shed light on the underlying mechanisms of the association that a diet high in protein can aid weight loss—research which may open the door to new preventive and treatment strategies for obesity.

In a new pilot study, researchers from Imperial College London revealed that phenylalanine—an amino acid produced by the digestion of protein— boosts levels of a hormone that tells us when we are full, leading to reduced food intake.

Marianna Norton's three part study involved a series of experiments on rodents to test the effects of phenylalanine, an amino acid produced in the gut after consumption of foods rich in protein.

Mice and rats given phenylalanine showed increased levels of the hormone GLP-1, which suppresses appetite, but reduced levels of the hormone ghrelin, which increases hunger. Phenylalanine was also found to reduce rodents’ food intake and increased weight loss. Rats that received the amino acid also more active, which the team notes may have contributed to their weight loss.

Next, regular doses of phenylalanine were given to mice with diet-induced obesity over a seven day period and when compared with mice that were not treated with phenylalanine, they showed a reduction in weight.

A final experiment which revealed the mechanisms by which phenylalanine affects levels of GLP1 and ghrelin involved applying phenylalanine to gut cells in a petri dish. The team found that the amino acid targets a receptor called the calciumsensing receptor (CaSR), and it is this receptor that increases GLP-1 levels and lowers levels of ghrelin.

Over 80% of cleft lip and cleft palate surgeries in Vietnam are performed by charitable organisations—a figure that reflects the complex and persistent barriers to surgical care in low-to-middle-income countries (LMICs).

Facing structural, financial, and cultural barriers to cleft lip and palate surgery, "Patients rely on charitable care outside the centralised healthcare system," according to a report by Dr William Magee III of University of Southern California and colleagues published the November issue of Plastic and Reconstructive Surgery. "As a result, surgical treatment of cleft lip and palate is delayed beyond the standard optimal window compared to more developed countries." The average age of Vietnamese children at time of initial cleft surgery was 3.25 years—later than the recommended age for cleft lip and palate repair surgery of between three and 18 months.

Around 450 Vietnamese families seeking cleft lip and/or palate repair surgery for their affected child at four medical missions sponsored by Operation Smile, Inc were interviewed and parents were asked about their perceptions of the barriers to surgical and medical care for their child's condition.

Although for most, a local hospital was more accessible than the Operation Smile mission, cost restricted many parents from obtaining cleft treatment there. About 40% said that without the charitable mission, they would not have had access to any surgical or medical treatment for their child's condition.

The survey revealed not only in financial, but also a wide range of structural and cultural barriers to cleft care. Structural barriers included lack of trained medical personnel, equipment, and medicine. Financial barriers were identified as not only the cost of the surgery, but the cost of travel to obtain care. Cultural barriers included family members' opinions/permission and lack of trust in the medical system/personnel.

The study suggests that charitable missions remain a critical source of access to surgical care in LMICs, even in countries with near-universal health insurance. Based on their findings, Dr. Magee and colleagues propose a new "Surgical LMIC" model to give a more complete picture of the unique barriers to accessing surgery in resource-poor countries—especially for conditions that require multiple operations, as is often required in reconstructive surgery.

Dr Magee and coauthors write. "Plastic surgeons are uniquely positioned to lead the surgical community in addressing the need for improvements in global surgical access and care, given our history of missionbased work, access to multicultural patients and dedication to education systems within global surgery."

12 NEWS I body language

SLEEP DEPRIVATION LINKED TO HIGHER CALORIE CONSUMPTION Study shows sleep deprived people consume on average an extra 385 kcal per day Sleep deprivation may result in us taking in a higher number calories the next day, according to a systematic review and meta-analysis led by researchers at King’s College London.

The team found that sleep-deprived people consumed an average of 385 kcal per day extra—equivalent to the calories of about four and a half slices of bread.

The study combined the results of 11 studies with a total of 172 participants.

The analysis included studies that compared a partial sleep restriction intervention with an unrestricted sleep control and measured the individuals’ energy intake over the next 24 hours.

A small shift was also found in the consumption pattern of sleep-deprived people—they had proportionately higher fat and lower protein intakes, but no change in carbohydrate intake.

The study published in the European Journal of Clinical Nutrition found that partial sleep deprivation resulted in a large net increased energy intake of 385 kcal per day. If long-term sleep deprivation continues to result in an increased calorie intake of this magnitude, it may contribute to weight gain.

Dr Gerda Pot, senior author from the Diabetes & Nutritional Sciences Division at King’s College London and Vrije Universiteit Amsterdam said, “The main cause of obesity is an imbalance between calorie intake and expenditure and this study adds to accumulating evidence that sleep deprivation could contribute to this imbalance. So there may be some truth in the saying ‘early to bed, early to rise, makes a man healthy and wise”.

“Reduced sleep is one of the most common and potentially modifiable health risks in today’s society in which chronic sleep loss is becoming more common. More research is needed to investigate the importance of long-term, partial sleep deprivation as a risk factor for obesity and whether sleep extension could play a role in obesity prevention,” she continued.

A previous small study in 26 adults found partial sleep deprivation resulted in greater activation of areas in the brain

associated with reward when people were exposed to food. A greater motivation to seek food could be an explanation for the increased food intake seen in sleepdeprived people in this study, the authors suggest. Other possible explanations include a disruption of the internal body clock affecting the body’s regulation of leptin (the ‘satiety’ hormone) and ghrelin (the ‘hunger’ hormone).

The authors suggest further studies over longer periods and in everyday life are needed into the effect of increased sleep duration on weight gain and obe-

sity, as most of the studies included in this analysis were in controlled laboratory conditions over periods of one day to two weeks.

Haya Al Khatib, lead author and PhD candidate at King’s College London, said: ‘Our results highlight sleep as a potential third factor, in addition to diet and exercise, to target weight gain more effectively. We are currently conducting a randomised controlled trial in habitually short sleepers to explore the effects of sleep extension on indicators of weight gain.’

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14 INDUSTRY NEWS I body language

industry news

AWARD-WINNING WIGMORE MEDICAL Wigmore wins two prestigious awards at MyFaceMyBody 2016 Wigmore Medical was presented with two highly regarded awards at the MyFaceMyBody award ceremony on Saturday 12th November 2016, winning Best Home Use Product or Device for Radara and Best Skin Tightening Treatment for the ZO Controlled Depth Peel.

The awards were attended by leading figures in the UK aesthetic industry and are dedicated to showcasing the most innovative, game-changing brands which are shaping the future of the aesthetic medicine landscape.

“We are delighted to see that the truly unique scientific innovation of Radara has been recognised by the aesthetic community, and are very pleased to accept this prestigious award” says Ken Jones, CEO of Innoture–the manufacturers of Radara. “Radara has had a highly successful and exciting first year and we are looking forward to bringing yet more innovation to the market in the future.”

Radara is a new category of anti-ageing treatment which uses 3D printing technology to create unique micro-channelling patches.

These patches deliver a speciallyformulated HA serum deep into the lower layers of the skin. Radara works by repairing, rejuvenating and replenishing the skin around the eyes, diminishing wrinkles for a smoother, firmer feel. In just four weeks, Radara is clinically proven to reduce fine lines and wrinkles by an average of 35% - with no pain, no needles and no downtime.

The ZO Controlled Depth Peel won best Skin Tightening Treatment due to its incredible, longlasting results. It is a highly advanced, in-office-only procedure, recommended for use when scarring, severe laxity, severe texture damage and advanced melisma are of concern.

“Wigmore Medical is very happy with the continued success of the ZO Medical and Skin Health brands, and to be acknowledged for its excellence by a selection of judges, practitioners and the public is always an honour” says Kerrie Smythe, Wigmore trainer and aesthetician. “This robust peel from ZO has proven to be very popular as it provides excellent dermal and

epidermal stimulation with fast recovery and excellent results, allowing physicians to precisely tailor treatment for a wide range of skin conditions.”

ZO products, founded by Dr Zein Obagi, MD, are unique because of the use of the Medical and Skin Health lines together to provide unparalleled results. ZO Skin Health is a comprehensive array of at-home products that maintain the results of therapeutic treatments and support daily skin health and protection from the environment.

Continuous adjustment and product development is at the core of ZO Skin Health, capitalising on the latest advances in cosmetic engineering that help optimise results and provide continuous skin health for all skin types.

We have always found the MyFaceMyBody awards, including the first-class entertainment and dinner, to be a highly prestigious and enjoyable affair. Whether you are a winner or not, it is a great opportunity to network and mingle with some of the best names in the industry.

Wigmore would like to thank all our team members for their hard work in supporting these innovative skincare solutions and a huge congratulations goes out to the other award-winners, as well as the organisers for putting together such a spectacular industry event.

body language I INDUSTRY NEWS 15

JOINT COUNCIL FOR COSMETIC PRACTITIONERS UPDATE Timetable for launch of the JCCP and CSA agreed for June 2017 The JCCP is a regulatory body for the non-surgical sector that was formed in January 2016 following the publication of the HEE Final Report on ‘Qualifications framework for the Non-Surgical Sector in England’. Professor David Sines, CBE was appointed Interim Chair and a development group was established.

Since that date huge progress has been made. Over 70 stakeholders have been seen and consulted and a new sister body called the Clinical Standards Authority (CSA) has been established with the specific remit of developing an agreed set of clinical and practice based standards for the nonsurgical sector. In addition, the JCCP has established major working parties to look at the establishment of a new ‘Voluntary Register for Practitioners’ and a list of recognised education and training providers, the processes for education, training and accreditation and a new group to look at the issues involved with non-medical practitioners carrying out non-surgical treatments within the HEE framework (primarily advanced beauty therapists).

These various groups—including the Register Working Party, the Education, Training and Accreditation Working Party and the Aesthetic Practitioners Working Party—are independently chaired by

major industry figures and contain wide representation.

These groups have all agreed membership, remit and key tasks to be completed.

The basic timetable for the launch of the JCCP and CSA has been agreed for June 2017. Between now and then, a number of major stakeholder events are planned to keep all industry stakeholders informed, the first of which will be held in early February 2017.

This is a highly complex task and should be seen as the start of a process for regulation of the non-surgical sector in England. There are many other processes taking place at the same time including premises regulation, now in place in Scotland, proposals being considered for this in Wales and a continuing debate over the role of the CQC in inspecting premises providing only non-surgical treatments.

It should also be noted that all of the major medical professional associations have and will still campaign for mandatory and statutory regulation of the nonsurgical sector in England even though this has been refused at this time by Government. It is hoped that with the development of the JCCP and CSA, the industry can come together on the principle of regulation and start to collect and

analyse evidential data and therefore be in a better position to campaign for statutory regulation.

Finally, it is very important to note that both the JCCP and the CSA are in the process of being established as not-forprofit bodies, eventually with charitable status and with the overriding remit of delivering patient safety. This will be reflected in the proposals coming forward for the governance of those bodies.

Professor David Sines–Interim Chair of the JCCP said “It was a privilege to lead the HEE stakeholder process looking at this vital sector and to be the Interim Chair of the new body leading regulation is a highly challenging position. However, I have been amazed at the level of support I have received during this development phase from all sides of the industry from practitioners, to educationalists/trainers, pharma suppliers, insurers and service providers. This is not going to be easy but there is huge consensus on the need for an agreed set of standards and for a process of registration that recognises a person’s competence and proficiency against these standards. How we get there will be complex but we are all working hard to achieve our ultimate goals of patient safety and awareness.”

LEARNING TO LASER A growing number of professionals are seeking out ways to learn this valuable skill Delegates attend laser courses for a variety of reasons, from those who are completely new to the sector, through to experienced practitioners who wish to broaden their knowledge. Mapperley Park Training Academy in Nottingham provides training in Laser and Light Therapies from industry experts, welcoming practitioners of every level from all over the UK and worldwide. In the last two years in particular, they have seen demand for their courses almost double.

These courses offer delegates the opportunity to develop their knowledge and understanding of lasers and light and how it reacts with the tissue in a variety of treatments, as well as core knowledge in; hair removal, tattoo removal, non ablative water targeting, and vascular treatments. But where are these skills being used?

From specialist units in hospitals to private clinics and beauty salons, qualifications in laser are in demand across the aesthetics industry. We spoke to a leading national clinic chain who said laser hair removal is by far their most popular treatment.

The courses in Laser and Light available at Mapperley Park combine theory with practical demonstrations. Entry requirements vary by course, but there are no specific qualification re-

quirements for the Level 4 courses, which are suitable for all.

Mapperley Park is currently the only training academy able to offer a progression route for BTEC qualifications in Lasers and Light Therapies enabling learners to progress to a BTEC Level 5 Certificate.

For further information, visit mapperleypark.co.uk

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18 DERMATOLOGY I body language

Rosacea DR RACHAEL ECKEL discusses how to effectively treat rosacea, by coupling the latest understandings behind its pathophysiology with cutting edge cosmetic chemistry advances

R

osacea is an inflammatory dermatosis, with a marked neurovascular component. It is a multifactorial condition heavily influenced by sebum, but genetics, hormonal fluctuations, and lifestyle all play contributing roles. Certain factors may exacerbate rosacea (e.g. emotional stress), but UV-radiation is the principle trigger in 81% of patients. The underlying diagnosis for patients with rosacea is a disease of sebaceous glands, therefore it is common for it to present in the early thirties, when a surge in sebum production and growth in sebaceous glands occur. Sadly, rosacea is a chronic, lifelong disorder, meaning that it only disimproves with time. The reasoning behind this is due to the ongoing intractable sebaceous gland hypertrophy that occurs with disease progression. Remembering that sebum is a pro-inflammatory substance that degrades the skinâ&#x20AC;&#x2122;s architecture, increasing deposition leads to cutaneous mayhem and an escalating inflammatory response.

Rudimentary sebaceous glands Sebaceous glands are adnexal skin structures that are remnants from our primate evolutionary epoch.

Oil glands represent a sack of preformed cytokines attached to a hair follicle. The gland empties its contents (sebum) into the neighbouring canal for intended upward transfer onto the external hair follicle. Here it is meant to lubricate the shaft and repel water.

As we evolved from a primitive form, we shed the excess hair of our ancestors, and retained the large sebaceous glands. Oil serves no purpose to the skin; it causes

detriment and disease due to its pro-inflammatory nature. Acne and rosacea are two of the most commonly encountered sebaceous gland disorders. What distinguishes their clinical appearance is the inflammatory response: in acne it is focal, but with rosacea it is generalised.

Rosacea explained In rosacea, the patientâ&#x20AC;&#x2122;s ever-ballooning sebaceous glands produce excessive amounts of destructive oil, with an altered chemical composition that is noxious. In some patients the oil glands concentrated in a particular area grow exponentially, leading to a ruinous, bulbous

body language I DERMATOLOGY 19

blast activity including less natural moisturising factors and glycosaminoglycan production (dryness).

Furthermore, they often have colour or perfume additives, which are both irritating and photosensitising

Rhinophyma can result from oil glands concentrated in one area

facies such as rhinophyma.

Cutaneous inflammation from surplus oil alters the permeability of skin, and weakens the epidermal barrier function. This generates clinical sensitivity and irritation due to sebum’s disruption of the delicate water-lipid-protein balance. The chronic background inflammatory hubbub, also aggravates melanocytes leading to a non-specific discolouration of skin. Additionally, if a disease of pigment coexists in parallel (e.g. melasma), the condition is made worse by the superfluous oil. Successful treatment and long-term management of the pigment disorder will therefore hinge on controlling sebaceous gland activity and the associated chaos.

In response to the excessive inflammation, the body mounts a defensive response by dilating blood to the skin’s surface resulting in redness. For patients in their thirties—when rosacea is in its infancy—said redness is discreet and intermittent (e.g. flushing in response to a stimulus). However, due to the progressive nature of the disease, this appearance later transmogrifies into a fixed, dramatic redness that includes telangiectasia from vascular destruction. Sebum also degrades texture and elasticity, which means that large pores and rough skin is a common presentation. Sebaceous gland hyperplasia

may also occur adding to the textural distortion.

Sebum plugs pores, which in some patients generates pustules (more common) and papules.

Clogged pores in conjunction with barrier dysfunction give rise to a false sense of dryness prompting patients to use moisturisers.

Moisturiser misuse further accelerates rosacea causing thinning of the epidermis (tissue fragility), an accumulation of dead surface keratinocytes (dullness, rough appearance, acniform lesions), barrier dysfunction (sensitivity, dryness, inflammation), and reduced fibroSIGNS AND SYMPTOMS Discrete | Variable - Large pores - Sebaceous gland hyperplasia - Comedomes - Seborrheic dermatitis - Papules + pustules - Erythema - Telangiectasia - Non-specific discolouration

Identifying rosacea Rosacea is a common cutaneous condition, but one that is frequently overlooked. As a result of its multifarious nature and characteristic relapses and remissions, diagnosis is complex.

Rosacea at its onset is a discreet and variable condition. This is because there are multiple presentations (e.g. granulomatous, ocular), and each of these may look different amongst varying ethnicities and ages. Some of the unmistakable signs such as textural damage do not appear at the onset, but quickly emerge if the disease is not controlled.

Currently, clinicians are primarily identifying the advanced, more obvious forms of rosacea. In practice, however, milder states prevail, and their soft markers may include sensitivity, patulous follicles, dyschromia, sebaceous gland hyperplasia, and/or a soupçon of erythema. It is therefore critical that the skin is thoroughly perused by the clinician before the condition can be outruled. Seborrhoeic dermatitis is another disease indicator, occurring five times more

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body language I DERMATOLOGY 21

Factors

Percent Affected

Sun exposure

81%

Hot weather

79%

Emotional stress

75%

Wind

57%

Heavy exercise

56%

Alcohol consumption

52%

Hot baths

51%

Cold weather

46%

Spicy foods

45%

Humidity

44%

Indoor heat

41%

Certain skincare products

41%

commonly in patients with rosacea.

Ocular symptoms (e.g. conjunctival hyperaemia, photosensitivity) can also prompt the clinician to rosacea. In darker ethnicities these may occur in conjunction with post-inflammatory hyperpigmentation around the eyes due to the chronic inflammation and pruritus from enlarged meibomian glands.

Triggers Heat (e.g. warm showers, heavy exercise) and sunlight are the foremost triggers when it comes to rosacea. In fact 87% of patients who use daily sunscreen notice an improvement in their rosacea. Initial treatment measures should revolve around helping the patient to identify their relevant triggers, and cautioning them about elimination or protection (e.g. sunscreen).

Rozatrol clinical trial The author was recently afforded the opportunity by ZO Skin Health to trial Rozatrol, a novel prototype developed to topically correct and control all features of rosacea. My aim was to assess its efficacy potential over six weeks, in minimising both the signs and symptoms of rosacea.

The study was executed in the Caribbean, specifically Trinidad, under guidance of Dr Zein Obagi (Medical Director, ZO Skin Health) and Rick Woodin (Vice President of Research and Development, ZO Skin Health). Trinidad is a challenging environment for rosacea due to the high levels of UV-radiation, humidity, and air pollution. In fact, the island

has the second highest air ozone pollution levels per capita, due to fossil fuel production. Specific to rosacea, air pollution is a formidable foe as it compromises barrier function and drives the condition.

Elevated sunlight and humidity levels also add to this tumult, by further increasing sebum output and inflammation.

When the study protocol was prudently developed, it was decided to aggressively eliminate excess surface sebum and pollution due to their negative effect on product penetration. Even the most transformational topical will fail to show itâ&#x20AC;&#x2122;s prowess without a clean canvas to set forth. In order to holistically cleanse the skin and prepare it for Rozatrol, we employed a 3-step process that included: 1)

Washing the face for 60 seconds bidaily (Oilacleanse), 2) Mechanically exfoliating for 60 seconds once daily (Exfoliating Polish), 3) Toning the skin twice daily (Cebatrol). Rozatrol (1 pump) was then applied bi-daily and rubbed into the skin adequately.

The five-star approach Drawing from the latest understanding of rosaceaâ&#x20AC;&#x2122;s pathogenesis, Rozatrol was custom engineered to holistically stymie the condition.

Affording a multi-modal benefit platform with a 5-tiered system, its mechanism of action to correct and control all features of rosacea is as follows: 1. Suppress sebum output and modify the chemical composition to be less inflammatory.

2. Provide a keratolytic system that is non-acidic to avoid irritation and user disdain.

3. Modify the hyper-vascular response to control neuro-inflammation while also repairing telangiectasia.

4. Generate a comprehensive system of inflammatory modulators.

5. Repair the defective neurogenic signals and restore the health of cutaneous neurons by removing end plaque.

Study method Rozatrol was applied by subjects bi-daily for a cumulative assess-

Drawing from the latest understanding of rosaceaâ&#x20AC;&#x2122;s pathogenesis, Rozatrol was custom engineered to holistically stymie the condition

22 DERMATOLOGY I body language

Weekly totals comparison Sign/Symptom

Week 0

Week 1

Week 2

Week 3

Week 4

Week 6

Week 7

Erythema

0

0.85714286

1.85714286

2.16666667

2.33333333

2.5

3

Telangiectasia

0

0.25

1.16666667

2.42857143

2.5

2.5

2.71428571

Texture

0

2.125

2.57142857

2.33333333

2.83333333

2.875

2.85714286

Discolouration

0

1.5

2.14285714

1.5

1.2

1.375

1.42857143

Sebum

0

1.75

2.14285714

2

2.5

2.71428571

1.42857143

Swelling

0

0.75

0.83333333

1.2

1

1.2

1.66666667

Nodularities

0

0

0.71428571

2.5

2.66666667

2.8

2.75

Red patches

0

0.42857143

0.8

1.33333333

2.75

2.25

2.5

Desquamation

0

0.25

0.8

1

2

2

1.75

Overall signs

0

1.5

2

2.16666667

2.28571429

2.5

2.71428571

Lesion count

40

37

24

13

23

13

12

Stinging/burning

0

0.71428571

1.2

2.5

2.66666667

2.75

2.5

Flushing

0

0.625

1.28571429

2.2

2

2.25

2.14285714

Dryness/tighness

0

0.33333333

1.4

2

3

2

1.66666667

Overall symptoms

0

1.75

2.28571429

2

2.5

2.875

2.71428571

ment period of six weeks; the main objective being to assess its efficacy potential. Specifically, its ability to minimise the signs and symptoms of rosacea were evaluated, and any adverse events documented.

A total of nine panellists with moderate to severe rosacea of varying subtypes were assessed. Their ages ranged between 32 and 78, with an absence of any other visible skin diseases except rosacea.

Clinical photographs (frontal, oblique) were obtained at the onset, and weekly thereafter for baseline comparison.

The study author assessed a va-

Rozatrol by ZO Skin Health showed excellent ability to improve and control all features of rosacea over a six week period

riety of signs specific to rosacea.

Each was graded weekly according to their change (-1 = disimprovement, 0 = no improvement, 1 = minimal improvement, 2 = moderate improvement, 3 = significant improvement). An overall score was then generated for the observed changes in signs each week.

The patient was simultaneously asked to grade changes in their symptoms weekly. This was scored according to change (-1 = disimprovement, 0 = no improvement, 1 = minimal improvement, 2 = moderate improvement, 3 = significant improvement). A total figure was generated for the changes in symptoms each week.

Results All patients showed significant improvement in their rosacea over the six week period. Signs improved to an overall score of 2.5/3, and symptoms to 2.9/3.

The signs with the greatest improvement were texture (2.9/3), nodularities (2.8/3), sebum (2.7/3), erythema (2.5/3), telangiectasia (2.5/3), red patches / seborrheic dermatitis (2.3/3), desquamation (2/3), discoloration (1.4/3), and swelling (1.2/3).

The symptoms with the greatest improvement included stinging / burning (2.8/3), flushing (2.3/3), and dryness / tightness (2.0/3).

Rozatrol had a dramatic improvement on overall lesion count.

At baseline, there were 40 lesions

tallied amongst all patients. By week six, this has reduced to 13, representing a 68% improvement.

While ocular rosacea assessment was not built into the original study, all patients with this disease subtype showed improvements in their symptoms (2.9/3) and signs (2.4/3). These included conjunctival hyperaemia, pruritus, burning, dryness, photosensitivity, lid inflammation, and peri-orbital oedema.

Of note, no signs or symptoms of rosacea deteriorated throughout the clinical study, and there were no dropouts.

Discussion Rozatrol showed an excellent ability to improve and control all features of rosacea over a six week period. The following points are worth considering, to enhance performance of the topical in a clinical setting.

Dosage The original Rosacea Prototype protocol advocated the use of one pump applied to the entire face.

All patients were commenced on said dose. However, upon review at week one, most patients volunteered that the product amount was too sparse, and they were unable to cover the entire face. A dosage adjustment was made by the study executor based on facial size.

Smaller faces were advised to use two pumps, and larger ones three.

All patients showed significant improvement in their rosacea over the six week period

body language I DERMATOLOGY 23

The patients and study author remained content with this dosage until study completion.

Rosacea subtype Remembering that rosacea occurs along a spectrum, patients who displayed more erythematotelangiectatic, phymatous, and ocular features received most benefit. Where the patient had a greater tendency towards the papulopustular subtype, improvement was lesser, especially in relation to overall lesion count. Perhaps this category requires more aggressive exfoliation, and a chemical exfoliant (e.g. lactic acid, glycolic acid) would be an appropriate addition.

Before and after Rozatrol following six week trial protocol

UV Radiation It is well documented that UV radiation is the premier trigger of rosacea in 81% of patients. Not unexpectedly, 88% of rosacea patients report a decrease in flares when they apply sunscreen.

Sunscreen use was mindfully omitted from this study, so as not

WeekWeek 6 6

to skew the Rozatrol results. It is however worth remembering, that the trial was carried out in Trinidad, the warmest Caribbean island. Furthermore, it was executed during the islands most arid period—the dry season.

While Rozatrol demonstrated superb results independently, all patients were still exposed to significant amounts of daily UV radiation throughout the study. This generated ongoing inflammation, barrier function disruption, and melanocyte activation amongst others. Naturally, this would limit the cumulative benefits of the Rozatrol, as it was continually playing “catch-up” to the sun’s ill effects.

In order to limit the UV confounding factor, future protocols should include an inorganic sunscreen. This category is ideal for rosacea due to its levels of inertness.

Conclusion Rosacea is an ominous sebaceous gland disorder. It enlists the inflammatory cascade to ruin the

facies by triggering an undue neurovascular response. Current treatment options are antiquated with little benefit, as they fail to address the multifaceted nature of the disease.

Rozatrol represents a paradigm shift for effectively managing rosacea, due to its masterful ability to correct and control all features of the disease. Not only does it draw from the latest understanding of rosacea’s pathogenesis, but also affords a multimodal benefit platform with a 5-tiered system to holistically stymie the condition. In execution, Rozatrol’s results are dramatic and rapid, imparting high patient and clinician satisfaction.

Dr Rachael Eckel is a cosmetic dermatologist based in Trinidad and Tobago in the Caribbean. She is also chair of Dr. Obagi’s ZO Skin Health International Faculty.Rozatrol by ZO Skin Health, will be available for purchase in the UK and Ireland in March of 2017.

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body language I PRODUCTS 25

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

EXUVIANCE The new Exuviance Deep Hydration Treatment is an intensely hydrating overnight moisture mask with a unique water-gel formula that melts into the skin overnight and also protects skin from environmental damage. Applied overnight, Exuviance’s Deep Hydration Treatment contains Prodew, a unique ingredient that infuses skin with crucial amino acid building blocks, increasing the level of amino acid in the skin to restore skin’s natural moisture levels. The blend of PHA bionics and evening primrose oil strengthen the skin’s protective barrier for a stronger, more resilient complexion, whilst the inclusion of an antioxidant complex neutralises the effects of pollution and environmental damage that can break down collagen and threaten to dehydrate, weaken and age the skin. After cleansing, bathe skin in Exuviance’s Deep Hydration Treatment at night to reap the rewards of plumped, youthful, radiant skin in the morning.

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BRUISE MD Presenting Bruise MD, the only clinically proven medical device available to prevent and treat the incidence of bruising and speed up the recovery time following non-surgical treatments such as facial injections. Bruise MD has a unique formulation containing water and glycerol which penetrates the cell walls in skin and hydrates the tissue preventing the bruise from forming, or if the bruise has already formed it will hydrate the skin and mask the bruise on the skins surface.

Shuna Adamson RGN from Elixir Skin Clinic in Southport shares her experience, saying “As a Clinic Owner I am always keen to provide the best experience for my patients as I can and with one of the main concerns being bruising I was very interested in trying Bruise MD. I tried the formulation on several patients and found the results were unquestionable and the feedback from my patients very positive, particularly those who bruise regularly. I like the smooth consistency of the serum and the pleasant light menthol aroma, which I am told is very relaxing after treatment. I stock Bruise MD in my clinic now and use it on every patient following injectable procedures".

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TEOXANE Introducing the new RHA Hydrogel Mask, an intensive care mask designed for the face and neck, for a global anti-ageing regimen. Composed of sulfated D-galactose and natural polymers—polysaccharides that constitute the cell walls of various red seaweed—and more than 90% water, this mask creates a filmogenic gel that spreads the active ingredients to the cutaneous tissue. The advantages include a tightening effect, immediate freshness, better penetration of active ingredients, a second skin effect, no need to rinse off and it is absolutely non greasy, compared to other masks' texture. Teoxane's RHA resilient hyaluronic acid creates a matrix on the skin, which is more resistant to degradation. It creates a lifting and repulping effect with RHA, HA low molecular weight and Osilift, a sugar based tensor ingredient, and also contains aloe vera and Fucogel for a soothing and hydrating effect. Ideal as a booster treatment when skin has been exposed to stress or is showing signs of fatigue, this mask is designed to visibly soften lines, hydrate, soothe and lift skin and restore luminosity and a refreshed appearance. The mask can be used both after a procedure or as part of an at-home protocol.

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body language I MEDICAL AESTHETICS 27

Leap of faith DR RAVI JAIN recounts his experience of increasing patient satisfaction and success by transforming the consultation process

F

rom a background in general practice, I've now been practicing aesthetic medicine for the past ten years. My experiences and mistakes of the last 10 years have shaped my clinic, Riverbanks to be what it is today and I truly believe that if you get it right, you can have more successes than just financial.

Market penetration With only 2% of the general population taking up aesthet-

ics, you can imagine the huge growth potential. Over the next four years, the dermal filler market is predicted to double and part of growing the market has to come from changing perceptions of the remaining 98% of the public about what we do. In my experience people don’t really understand what we do—in fact, many think we’re not really doctors or real nurses. But that means there’s a lot of potential, particularly if we get focussed on patient education.

Building rapport Nowadays, we’re seeing more and more patients who know exactly what they want, because they’ve seen it on social media. What they don’t understand is that their face isn’t that person’s face. That’s what we have to educate, so we have to adapt the consultation style not to be defensive and aggressive and dismissive; we have to work with them and show them.

Once you’ve shown the patient that you are on their wavelength, you will have a loyal patient, you

28 MEDICAL AESTHETICS I body language

will have a patient who trusts you, and likely a successful business because they will refer their friends.

Referrals to your business are all about trust.

Customer service is also of huge importance. The website you. gov, commissioned a survey which showed that 53% of consumers would spend more with you if you provided good customer service.

That’s not delivering results; that’s making their patient journey a positive experience. A study commissioned by Galderma, showed that one of the most important drivers to referrals is customer satisfaction with service, not with results.

Creating an aesthetic consultation tool Around five years ago Galderma asked me if I’d like a consultation tool that would increase patient satisfaction and help improve my business. My arrogant reaction was that it wasn’t going to be possible to create one. However, in 2011 I was invited to sit on a task force board, where we created a consultation tool. We involved international global key opinion leaders from all over the world, from Sweden, Brazil, France, Italy, Germany, US and Australia, and plastic surgeons, dermatologists and most importantly the psychological counsellor. She was critical to the whole process of devising the consultation tool, because she managed to flip all of our insights as medics around— to considering what a patient would want.

What we created was the most comprehensive aesthetic consultation tool that’s ever been developed.

It allows us as healthcare professionals to consistently provide high quality patient-centred aesthetic consultations. As a result patient satisfaction has dramatically enhanced and business is enhanced.

But it’s that way around. I've spent

the last four years launching the service and teaching clinicians all over the world and I'm happy to say it’s been a success.

Initial consultation We have one page where we ask a patient to fill out the form them self, ideally not in front of us.

It asks questions about whether they’ve seen someone before and if so, who? If it was a dermatologist, aesthetic doctor, nurse, counsellor, osteopath, beautician, they mark it. You ask them to disclose what treatments they’ve had before. It gives you a chance to understand

66 What we've created is the most comprehensive aesthetic consultation tool that's ever been developed 99

what they understand. It’s not just looking at a history and ignoring it, you talk through their responses and begin to educate them, showing them your expertise, earning their trust.

They tick those areas that they have concerns over—such as pain or scarring. Again, you’re asking them in a form, but you address it during the consultation. What this is showing to the patient is that you’re interested in them. It’s not about asking for a few hundred quid and then seeing the next person, which some believe most of us are about.

The next thing is to find out why have they decided to come to see you today. Of all days in their life, they came to see you today.

Why? Have you ever asked your patients that? Answers vary from— I want to appear slightly younger and refreshed, to I want to feel less self-conscious.

Facial mapping— patients draw on the diagram what they are concerned about (reproduction of a real patient's notes)

body language I MEDICAL AESTHETICS 29

We could ask if they find themselves worrying about their appearance every day. Is the answer never—or 20 times a day? If they don’t answer we can modify and ask about selfies. If anyone is taking selfies more than 20 times a day, clearly there’s an issue going on. Are you going to fix that, or do you want to? You have to decide.

One of the most important questions asks patients to circle

66 One of the most important questions asks patients to circle how they have felt over the last few weeks 99 how they have felt over the last few weeks. This is like a condensed version of the HADS scale, the hospi-

tal anxiety and depression scale, in five smileys.

If they’ve circled a sad face or a not so happy face, they’ve opened up to you and said they’re feeling bad, and if you haven't even questioned it, you’ve ruined all the hard work you’ve done before.

The time it takes to fill this form out is not taken out of the appointment time. This is filled out in the waiting room or at home. It takes me about one minute to read the form as I’m going to collect the patient. Like an ECG would take you when you first look at them about 15 minutes to work out, this takes you a second now.

Facial mapping Next we do a facial mapping. Patients draw on a piece of paper on a diagram what they’re concerned about. Sometimes you see the whole face. It could be the patient that’s got acne or dermatological skin conditions. It could be they really have got a low self-opinion of themselves.

TYPICAL CONCERNS WITH ADOPTING HARMONY Concern: I don’t have time for this.

Solution: Because you’ve done a good consultation at the beginning and given them a treatment plan, you don’t have to resell to them every time.

Concern: I'm not a salesman, I can’t sell this stuff.

Solution: You don’t have to—just give them the treatment options. You take the history, do the examination, give them a treatment plan. That’s all it is.

Concern: My patients won’t spend that much.

Solution: Not at once perhaps, but they know the plan, and eventually they do want it all.

But you have to earn their trust.

Concern: How successful is this in business?

Solution: We noticed that there was 131% increase in new patient spend between before Harmony and after Harmony. That’s a huge change Concern: How do you monitor patient satisfaction?

Solution: There’s various ways. Word of mouth, surveys, conversion rates, re-booking rates.

Examination When we examine in medicine, we get feedback from a patient about whether things hurt. You examine and work through the range of movements of whatever you’re examining. What we’re doing here is assessing their skin, rather than using a computer that’s going to take a photo and make pores look huge and lines look like crevices and canyons. You’re going to do this together.

Ask patients what they think about their skin. I ask them, about hydration, how they would describe it, how smooth they would say it is, how elastic. Ask them about their wrinkles, how deep or powerful they are and how much they bother them. Address volume loss, perhaps they won't know what volume loss is, so you ask them, if they feel their face is

30 MEDICAL AESTHETICS I body language

sagging. Then you educate them about why sagging occurs and move on to talking about asymmetry. This has given us a guided assessment where they’re involved in their scoring. I'm contributing to it and guiding them as well.

What happens at the end is we come up with a plan.

Principles of treatment planning When you have any treatment plan, patients need to understand the key topics. First of all, we’re going to try and relax parts of the face, we can then start to restore the face, bring it back to its former glory; that’s what we do most of the time. Then I tend to refresh the skin and that’s when I'm using skin boosters. Restoration is with volumisation to the correct level; refreshment is with Restylane skin boosters. Then maybe they want a bit of subtle enhancement.

Procedure At a consultation, I always start with the skin and I make sure the patient’s face is clear of makeup.

If you give someone good-quality

skin with skin boosters, they feel so much better. Before I worked this out through Harmony, I had no one taking on skin boosters in my practice. I started using Harmony and jumped from nothing to 100 patients in the first year.

Looking after patients On the Harmony facial map, ask them to explain their drawings to you. In the consultation room, I ask patients what they’re trying to say. That’s their opportunity to speak to you and share their concerns. Studies have shown that, on average, it takes the patient 90 seconds to tell you everything. But the doctor typically interrupts at 19 seconds.

It is critical to involve the patient. Involvement in their assessment helps them accept the treatment plan you’ve created for them. Rather than you telling them what’s wrong with their face, they’ve actually told you what they’re concerns are and understood any issues and what improvements could be made. The two-year treatment plan I give patients to take home isn’t pages and pages. It is one page and when they

take it home, they can relate to it.

Summary Harmony has transformed my practice and when done properly, it will transform yours. It does take some adjustment in consultation style but it really works and you know your patient is really on board.

This chart shows our referral rates: before and after Harmony. There’s a huge change in referral rates because patients are happier with the overall service they received.

Dr Ravi Jain has 10 years experience in the industry, specialising in aesthetic medicine for the face and body. Dr Jain leads the medical team at Riverbanks Wellness which is registered with the Care Quality Commission, has accumulated five aesthetic medicine awards and been voted Best Clinic in the UK on several occasions. His aesthetic apprenticeship was served under one of the world's pioneers in botulinum toxin and fillers.

References: 1. Millennium Research Group, Fam Med. 2001 JulAug;33(7):528-32.

2. Galderma IMPACT STUDY 3. . Rhoades DR1, McFarland KF, Finch WH, Johnson AO. Speaking and interruptions during primary care office visits .

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body language I SKINCARE 33

Meristem plant cells in cosmetology PROF LIUDMILA KORKINA discusses the use of cultured meristem plant cells in cosmetics for skin rejuvenation

T

he false idea that cultured plant stem (meristem) cells provide an absolute miracle—due to substitution of human stem cells, or specific growth factors facilitating skin cell growth and extracellular matrix regeneration—is one that’s currently being pushed a lot on to aesthetic medicine experts and laymen.

Many speculations and aggressive advertisements have appeared recently, proposing the magic role of plant stem cells in human skin rejuvenation. As a molecular and cellular biologist, working for 15 years with these plant meristem cells at the Italian St. Mary’s Dermatology Institute in Rome, my opinion is that these statements discredit the entire brilliant perspective of meristem plant cells in cosmetology and dermatology.

My laboratory aims to evaluate mechanisms of meristem biological activity, to provide a solid sci-

entific background for their use in aesthetic medicine and dermatology. Having published more than 70 papers on the matter, I want to share my own experience with meristem plant cells and discuss their active components and how they interact with human skin promoting its rejuvenation.

History Some 40 or 50 years ago, we started seriously re-considering ancient approaches to treating human pathologies and ageing processes, using products of completely natural origin. For example, about 50% of existing anti-inflammatory drugs are either extracted from natural sources, or inspired by nature. The development of fully “biologic” cosmetics and food supplements as adjuvants to therapies and promoters of health is fast and steadily growing. Dermatological problems with unmet therapeutic needs, alongside broadening public de-

sire for efficient skin rejuvenation, are at the front line of the intense search for natural remedies.

Moving away from using animal-derived products, experts in aesthetic medicine began to discuss the feasibility and clinical efficacy of plant-derived products. Plants, unlike humans and animals, don't have immune, nervous and endocrine systems to protect themselves against the unfriendly environment, infections, wounding, herbivores, insects, tumours, and rival species. In the course of evolution, plants evolved just one extremely efficient mechanism to protect themselves from these biotic and abiotic stresses—they synthesise so-called secondary metabolites.

Secondary plant metabolites These are among the most common biologically active components of food, spices, aromas, fragrances, propolis, wines, essential oils, beer, and traditional medicine.

34 SKINCARE I body language

Simple polyphenols (phenolic acids, alcohols and esters

Glycosylated Phenylpropanoids [GlyT]

Curcuminoids [CuS]

Stilbenoids [SS]

Flavonoids, Isoflavonoids [ChS]

Suberin [PPx]

Proanthocyanidins (Condensed tannins) [PPx]

Lignins [PPx]

Cinnamic acid [PAL] Phenylalanin Shikimic acid

Figure 1. Plantderived secondary metabolites derived from the amino acid phenylalanine with a potential for cosmetic industries.

With the numerous essential roles of secondary metabolites in plant physiology, these compounds have attracted great interest in the last decades, especially for medicinal use as natural antioxidants, UV screens, anticancer, chemo-preventive, anti-virus, anti-inflammatory, wound healing, and antibacterial agents. Great interest in secondary plant metabolites has been recently shown by cosmetic and perfume industries.

Secondary metabolites are small molecules like non-protein hormones, neurotransmitters or mediators of immune response in human beings. Their parent molecule is amino acid phenylalanine. The same amino acid is a parent molecule for human neurotransmitters and hormones, such as adrenalin, noradrenalin, serotonin, thyroid hormones, oestrogen's, androgens, etc. Due to this unique parent, definite secondary plant metabo-

lites are highly available to human cells binding to the same parts of human cellular membranes (receptors) as the molecules of human origin. They are also perfectly metabolised in human cells through the same enzymes and metabolic pathways (high compatibility). Secondary plant metabolites can imitate numerous biological actions of human regulatory molecules thus exerting enhanced biological effects on human cells.

Industrial production The industrial production of secondary plant metabolites are limited by a number of factors: (1) low abundance in natural sources; (2) seasonal variations in plant harvesting; (3) contamination of plants by environmental pollutants (e.g. heavy metals, oil- and gas-derived toxic hydrocarbons, pesticides, aflatoxins, mycotoxins, and other organic and non-organic

hazardous compounds); (4) complex and expensive procedures for the extraction and purification of the actives from the grown plant tissues; (5) poor standardisation of the final product due to unavoidable variations in soil, water, weather conditions, and fertilisers used for the plant growth. Moreover, as the demand for secondary metabolites derived from medicinal plants for pharmaceutical and cosmeceutical industries is growing at a very fast pace, the existence of these plants is increasingly threatened and many of them have become endangered species. In an attempt to find out valid alternatives to production of desirable natural compounds, plant cell culture technologies have been developing as a valuable source of high-quality plant-based medicinal/cosmetic ingredients.

Meristem plant cells as a source for secondary metabolites At some point, the pharmaceutical and cosmetic industries suddenly remembered a 19th century discovery about the cultivation of meristem plant cells. Meristem cells have been used for more than hundreds of years for different purposesâ&#x20AC;&#x201D;reproduction of different cultivars, genetic modification of plant species, preservation of extinct species, production of virus-free plants, evaluation of plant metabolism and physiology, and so on. Only 15-20 years ago, did we come to understand that these meristem cell cultures could be used as a source of very precious active components for cosmetics and for pharmacy.

Plant in vitro technologies have been known for more than a century. Meanwhile, meristem plant cells have become increasingly attractive and cost-effective alternatives to classical approaches for the sustainable mass production of precious plant-derived secondary metabolites (so-called â&#x20AC;&#x2DC;green cell factoriesâ&#x20AC;&#x2122; concept). Plant meristem culture is the only economically feasible way of producing some high-value metabolites from rare or threatened plants.

Plant cell cultures exposed to appropriate stimulators (elicitors) become a unique and valuable

body language I SKINCARE 35

source of â&#x20AC;&#x153;perfectâ&#x20AC;? modulators of oxidative state (free radical scavengers, direct and indirect antioxidants), UV protectors, chelators binding heavy metals, anti-bacterial or anti-inflammatory agents.

By a very simple procedure, the meristem cells are taken either from shoots, flowers or roots, then cultivated under different conditions to produce specific secondary metabolites that are needed.

For example, by UV irradiation of plant cell cultures one can induce biosynthesis of secondary metabolites against UV irradiation. As a result, these substances will have very good SPF against UVB and excellent UVA protection.

It's important to note that secondary metabolites produced in plant meristem cultures are easily available in the cultivation medium due to their penetration of outer cellular membrane. To obtain secondary metabolites hidden inside cultured plant cells, thin cell membranes could be disrupted mechanically without addition of toxic solvents or long-time boiling usually used to extract secondary metabolites from parts of grown plants, such as roots, cork, leaves, seeds, fruits, or flowers.

Collectively, the yield of desired specific secondary metabolites

Meristem cell stimulation

Industrial amounts of second metabolite-producing cells

Isolation, purification and identification of chemical structure, quantity and biological activity

from cultured plant cells stimulated by an appropriate elicitor is sometimes hundreds of times higher than from a grown plant. These active raw materials for cosmetic industry use are completely deprived from toxic solvents and undesired environmental admixtures.

It is a concentrate of active plant metabolites, activities of which have not been diminished by high temperature.

HYPOTHESES OF SKIN AGEING hair shaft

epidermis dermis eccrine gland

external root sheath aporcine gland

arrector pili muscle sebaceous gland internal root sheath hair

{

cuticle cortex medulla matrix

blood vessel

Cell cultivation and selection

connective tissue papilla

GENETIC; STEM CELL; EPIGENETIC; IMMUNE; FREE RADICAL; METABOLIC Figure 3. Relevant current hypotheses of skin ageing

Action of meristem-cell produced active substances on mechanisms of skin ageing.

Cosmetic preparations could feasibly interact with and positively affect several recognised human skin seeing mechanisms, namely, to protect from skin age-accelerating solar irradiation, to maintain normal redox (oxidative/reductive) balance in the skin, to normalise cutaneous microbiota thus preventing age-related deterioration of skin-located immune system, to regulate epigenetic machinery responsible for proper gene functioning (cycles of induction and suppression) to promote skin regeneration, and to control metabolic processes in skin cells and extracellular matrix. Our current knowledge brought us to the assumption that active secondary metabolites produced by meristem plant cultures could finely tune all the above mentioned mechanisms of skin ageing while promoting skin structure and functions characteristic for a young skin.

However, cosmetics cannot change skin genetics to make it less prone to ageing. They also cannot affect stem cells by definition of cosmetics, which must not interfere with vitally important properties and functions of the skin. Moreover, stem cells being a unique stor-

Figure 2. Schematically, a biotechnological process of meristem cellbased secondary metabolite production

36 SKINCARE I body language

EFFECTIVE UV PROTECTION BY SECONDARY METABOLITES OF MERISTEM PLANT CULTURES  Broad band (UVB + UVA) and photo-stable sunscreens  Free radical scavengers and direct antioxidants to break UV-induced chain reactions  Rescuers of sacrificing cutaneous antioxidants to maintain redox barrier  Indirect antioxidants to induce endogenous antioxidant and detoxifying systems  Modulators of inflammation to control UVinduced inflammatory response of skin cells  Modulators of skin metabolism to control UV-induced metabolic response and diminish risk of carcinogenesis

Figure 4. Positive features of meristem cell metabolites in the photo -protection of human skin

age and a propagation centre of genetic material are very well protected in our body, so they cannot be easily reached by either chemical agents or physical power. In experiments on cultured human epidermal stem cells, it has been clearly shown that these cells could not be easily transformed into tumour stem cells. Therefore all claims that meristem plant cells could affect or “substitute” human epidermal stem cells are senseless and untrue.

Protection against solar UV irradiation There are various excellent effects of concentrated secondary metabolites from meristem plant cells. Solar ultraviolet irradiation, UV-B and UV-A alike, is considered as a major cause of premature skin ageing. Secondary metabolites produced by meristem plant cultures stimulated by UV irradiation (mainly, glycosylated polyphenols) possess extremely high potency of

physical, chemical, and biological protection of human skin. As physical screens, these molecules can effectively absorb both UV-B and UV-A light, therefore they have very high SPF-B and SPF-A, respectively, comparable and often greater than those of conventional chemically synthesised sunscreens.

Furthermore, these metabolites are not destroyed by UV-B and particularly by UV-A light and they belong to photo-stable sunscreens, which allow protecting skin for a durable period of time. The great majority of secondary metabolites are very effective antioxidants and can break down chain reactions induced by UV irradiation in the lipids of skin cell membranes. Some of these photo-stable sunscreens produced by meristem cell cultures exposed to UV elicitation, protect endogenous skin-located antioxidants, such as tocopherol alpha and coenzyme Q10, from photo destruction induced by UV. They are safe due to the lack of photo toxicity and photo allergenic properties.

Biological protection by secondary metabolites is remarkable and has a broad range of positive effects: (a) they attenuate inflammatory responses of the skin to UV radiation; (b) they prevent suppression of immune cells residing in the skin (attenuate UV-associated immune depression; (c) they reduce metabolic responses of skin cells to UV exposure, thus attenuation the risk of photochemical activation of pro-carcinogens into carcinogens. Different meristem cell metabolites exert differential action as preventive, sun-screen or post-sun curative substances. Meristem cell-derived active substances have been extremely effective in the protection of human skin keratinocytes, fibroblasts and blood vessel endothelial cells from cell death caused by UV irradiation.

Secondary metabolites from meristem cell cultures protect natural endogenous antioxidant barrier of the skin. Young human skin is a perfect barrier for environmental free radicals formed in the polluted air as a result of interaction between UV irradiation, dust particles, organic toxins, and heavy metals. This multilayer

barrier includes lipid antioxidants (tocopherol alpha and coenzyme Q10), which are essential part of skin surface lipids. Skin epidermis and dermis contain large amounts of ascorbic acid, uric acid, and glutathione, which are non-enzymatic antioxidants of the skin. Skin is rich in antioxidant enzymes, which neutralise free radicals within skin cells and extracellular matrix.

On the other hand, skin cells are sources of free radicals themselves.

All types of skin cells produce free radicals to protect skin and entire organism against microbial invasions, to metabolise toxins, drugs, skin care products applied to the skin, and to perform intracellular signal transduction. In the healthy and young organism both parts of redox skin barrier are balanced to maintain the tissue and organism homeostasis. In the ageing or ailing organism the balance could be altered and shifted to one or another side. Secondary metabolites from meristem cells restore normal balance of free radicals and antioxidants in the skin, inducing either free radical-generating systems or endogenous antioxidant defence.

Secondary metabolites don't need to be direct antioxidants, they may have the power to induce your own antioxidant systems through nuclear factor Nrf2, and then the skin’s own antioxidant enzymes start working and the skin will be well protected against an excess of free radicals arrived from outside or produced inside the organism.

Advances and limitations We should admit that this seemingly ideal source of active principles for cosmetics and skin care products has several evident limitations. For example, it is still rather difficult to achieve stable and reproducible production of desired secondary metabolites from meristem cultures due to their genetic and metabolic instability and obstacles in their up-scaling to industrial quantities. Due to these current pitfalls, these active ingredients have comparatively high costs. However, with fast development of modern combined biotechnologies, metabolic engineering, and improvement of plant cell

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BEFORE

WWW.BTLAESTHETICS.CO.UK I INFO@BTLAESTHETICS.CO.UK +01782 579 060

AFTER 4 TREATMENTS

38 SKINCARE I body language

Figure 5. Stimulating or inhibiting actions of secondary meristem cell metabolites towards human keratinocytes are shown by red and green asterisks, respectively. It is clearly seen that they could affect numerous molecular pathways orchestrated functions of which are essential to maintain skin structure and functions.

eliciting, more plant meristem lines are becoming available for stable industrial production of their active metabolites with targeted and selective mechanisms of interaction with skin cells.

In parallel, technological processes to develop stable cosmetic preparations ensuring skin penetration, transportation, and targeted delivery of these active principles to different skin cell types and cutaneous layers are urgently needed. Of utmost importance, clinical safety and efficacy of the cosmetological or skin care products containing actives from meristem cells should be duly confirmed in randomised placebo-controlled clinical studies using final product for topical administration.

Several cosmetic lines containing active ingredients of Leontopodium alpinum, Buddeleja davidii, Centella asiatica, Gardenia jasminoids, and Echinacea angustifolia meristem cell concentrates have been developed and commercialised recently. The use of these particular cell lines was defined by solid background research that had been carried out and published in

leading peer reviewed international journals. These publication have shown impressive and long-lasting aesthetic effects improving skin appearance due to rejuvenation of both skin cells and extracellular matrix. The rejuvenation effects were more evident when the meristem cell-containing cosmetics were used in combination with conventional methods of skin rejuvenation, such as fractionation laser, collagen mask, fruit acid peeling, and radio frequency treatment. Cosmetic effects were confirmed by instrumental measurements of skin hydration, elasticity, and sebum production.

Furthermore, administration of the products to facial skin resulted in the protection of lipophilic skin antioxidants in the surface skin lipids, decreased levels of oxidation of squalene and proteins, and normalisation of skin microbiota.

Conclusions and perspectives Meristem cell cultures derived from medicinal plants seem to be a unique source of biologically active, bioavailable, biocompatible, and highly concentrated secondary

metabolites targeting practically all known so far molecular pathways of human skin ageing. These cultivated plant cells produce large quantity of easily isolated and uncontaminated precious metabolites with UV protective, anti-inflammatory, skin cancer chemo-preventive, healing, skin immune system normalising, skin metabolism and redox balancing properties.

The industrial development of active ingredients based on meristem cell metabolites for anti-age cosmetics is toxicologically, ecologically and ethically sustainable since it does not affect plant biodiversity while rather maintains extinguishing species; it overcomes problems with plant metabolite preservation and difficulties of their extraction from grown plants; it allows to avoid contamination with environmental pollutants and to better standardise the raw material. Advances in cosmetic technology using appropriate vehicles with targeted delivery of meristem cell-derived metabolites to definite skin layer/cell types will facilitate development of topical preparations with high and durable clinical/aesthetic efficacy.

Professor Liudmila Korkina, is a Russian Academic and Full Professor in Biochemistry & Biophysics.

She is presently a CEO and Founder of the Centre for Innovative Biotechnological Investigations, Moscow, Russia. Prof Korkina was a Head of Tissue Engineering Department of Dermatology Institute (IDI IRCCS) in Rome, Italy from 1998 to 2013. She is a R & D consultant for a number of pharmaceutical/ cosmetic industries. Prof Korkina is the author of 20 patents, of more than 300 peer-reviewed articles, and of 20 chapters in the books on the effects of free radicals and antioxidants towards skin physiology and pathology. She is a Guest Editor of Current Drug Metabolism and Oxidative Medicine & Cellular Longevity and of Current Medicinal Chemistry journals. She is currently a member of Editorial Board of Advanced Wound Healing Journal. She is a Board Member of European Society of Anti-Ageing Medicine (ESAAM).

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40 TREATMENT I body language

Introducing hair into your cosmetic practice DR GREG WILLIAMS goes into the long and short of it

B

y the age of fifty, 50 % of men in the UK will have hair loss, which often begins in their early twenties, but can even start in their teens. For women, hair deterioration usually starts a little later around age twenty-five and 50% of women

over the age of sixty-five will suffer from hair loss. Over six million women in the UK suffer from hair loss—and of course, for females, menopause is a contributing factor to hair deterioration.

If you add to those numbers the people who have dry scaly scalp— be it seborrheic dermatitis or just

dandruff—and poor hair quality, there’s a whole spectrum of options of how you can introduce hair into your practice.

Psychology of hair loss As a responsible practitioner it is vital to understand the enormous psychological morbidity that goes

body language I TREATMENT 41

The first consideration when making the decision to get involved with hair is whether to offer products and therapies to both men and women

along with hair problems. This is an extremely vulnerable patient group, who are very susceptible to exploitation. Unfortunately hair myths are widespread, and exist alongside a huge range of treatments and cures that people are promised will work, despite an absence of researched evidence.

Treatment considerations The first consideration when making the decision to get involved with hair is whether to offer products and therapies to both men and women. The requirements are overlapping, but they each have some unique needs. Services to consider include products on the shelf, hairstyle management, hair and scalp care, hair and scalp disorder diagnosis, non-invasive and minimally invasive treatments, as well as invasive treatments.

Products There are a plethora of products available so if you are going to supply nutritional supplements, do you just offer them or do you endorse them? Before endorsing them, it might be advisable that you have had personal experience with the product or that there is strong research evidence. Another option is to make your own brand—putting your name and reputation behind the product you have on the shelf.

There is a huge range of camouflage products for hair loss that are quite successful. They generally come in three categories, scalp dyes, microfibers and coloured hair sprays. Many patients don’t know about these products so having a bespoke service for demonstrating the effects that can be achieved creates a self-sustaining market. Patients can come in with

thinning hair and be transformed in a few minutes to an appearance of fuller hair.

If you are the sort of practitioner that only wants to put products on your shelf where there is evidence, then consider Regaine for men and women which is proven by good quality reproducible research to be effective in treating hair loss.

Hairstyle management The range of salon services that you might want to offer, and how wide the range is up to you. But if you already have a brand within your clinic that is about the feel good look, then it’s worth considering that without good hair, overall a patient isn’t going to feel good about themselves and their look. Hair systems vary from offthe-shelf extensions, weaves, wigs, to bespoke hair pieces and hair re-

42 TREATMENT I body language

FACT In Hippocrates’ time, pharmacists created mixtures of cumin, pigeon droppings, horse radish, beetroot and nettles to treat hair. Today in pharmacies you will still find cumin and nettles as a common component of hair treatments.

placement systems. If you are going to consider offering hair cutting, styling and colouring then a hair salon environment is required.

Hair and scalp care What you can offer depends on what your training is, but it only takes a small hand-held dermatoscope or folliscope to better visualise the scalp and the hairs. This not only allows you to see what’s going on in a more magnified view, but if connected to a computer screen also allows the patient to do so as well. It is possible to look at whether or not the hair is miniaturising, but also if there is any inflammation or disease of the scalp.

If you’re going to give hair and scalp advice, it’s possible to do it without a medical or a nursing degree. You can either employ a trichologist or you can train to be one. The Institute of Trichologists defines trichology as the science of the structure, function and diseases of the human hair, and it is the largest provider of trichology training in Europe. They offer a two-year training course.

If a medical diagnosis is required this is the remit of a medical degree, delivered by a doctor, and

takes into account a proper history, performing an examination, all the investigations, blood tests and biopsies that will go towards confirming a diagnosis from a differential diagnosis. Medical treatment requires monitoring and follow up.

Types of non-medical and medical treatments One of the lowest risk non-medical treatments is low level light therapy (LLLT) which can be delivered in static, clinic based equipment or portable home use devices.

Next are minimally invasive techniques. Although there isn’t a great deal of evidence for it, there are people who use a dermaroller on the scalp for hair stimulation.

Mesotherapy, which involves the injection of pharmaceuticals, vitamins or drugs into the scalp, may also be something to consider.

Platelet rich plasma (PRP) which is becoming a very popular treatment that is being offered to patients does not yet have a solid research evidence base but has an increasing amount of level 4 anecdotal support.

There are several pharmacological treatments available for hair loss in men and women that require

drugs to be prescribed, some of which need blood tests to monitor.

For more invasive treatments, such as hair transplant surgery it is necessary to have an operating theatre environment which needs to be Care Quality Commission (CQC) regulated. Depending on the technique that is offered, you may need one or two assistants, or you may need quite a large team.

The most sophisticated hair restoration technique involves using robotic technology.

Building a hair transplant business If you’re considering introducing hair transplantation into your practice, you are going to have to make a significant investment in your equipment, your training, your staff, and your environment.

Careful market research is vital to ensure that this is something that is really going to be financially feasible for you and you may wish to start with some of the non-surgical consultations or procedures, to get a feel for your patient population.

When you start to offer hair transplant surgery, it’s wise to start with small cases. It takes a long time to build up the skills to do large procedures so consider offering surgery to the smaller cases, and refer on the larger cases to colleagues to start with.

Summary Female pattern hair loss and male pattern hair loss are extremely common and there is a definite opportunity for many clinicians to augment their current practice with something hair related. However, it is a field that should be approached with sensitivity because of the vulnerability of this patient population. The market is full of offerings that are not research proven, and what you don’t want to do is add to the empty promises that many of these patients will already have explored and been disappointed by.

Dr Greg Williams is a Plastic Surgeon who has specialised in hair restoration. He is the only member of the British Association of Aesthetic Plastic Surgeons who performs hair transplant surgery as a full time practice.

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.

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body language I SKINCARE 45

gloâ&#x20AC;&#x201D;the ultimate revolutionary skincare KERRIE SMYTHE discusses how glo minerals and glo therapeutics can benefit your patients and your practice

T

he most effective products and training programmes are proudly provided by glo professional. The products are uniquely formulated with innovative technology, cutting edge science and nourishing vitamins and antioxidants to deliver radiant beauty for healthy glowing skin, continually creating new product

lines, technologies and treatments to keep up with the growing demand of the aesthetic industry. glo therapeutics glo therapeutics is a revolutionary breakthrough incorporating home care programmes and chemical exfoliation treatments. Our systematic approach is based on established research combined with new scien-

tific discoveries. glo therapeuticsâ&#x20AC;&#x2122; unique and advanced formulations provide potent concentrations with high levels of active ingredients to offer the ultimate revolutionary skincare. glo therapeutics can progress your clinic to the next level of skincare treatments and help you provide faster and effective results to your customers. Skincare

46 SKINCARE I body language

products are suitable for treating multiple skin concerns, including premature ageing, sun damaged skin, dull, dehydrated, fine lines, wrinkles, pigmentation, oily, acne prone and scarred skin types in addition to pre and post chemical exfoliation treatments. The products are created using unique formulations with peptides, antioxidants, amino acids, retinols, phyto stem cell technology, growth factors, healing botanicals and many other advanced ingredients and all products are paraben free.

Our professional chemical exfoliation treatments provide customised programmes for each individual, helping them achieve subtle, gradual or astonishing transformations. This will give you the opportunity to tailor more advanced and effective treatments for each and every one of your patients. Patients are amazed at the results from the home care products, noticing dramatic differences following home care use of in clinic chemical exfoliation treatments, which can range from superficial peels to medium depth peels and bring a new concept to your treatment menu. glo therapeutics course content In depth product knowledge including product selection for all skin types and targeted concerns, hands on practical experience of the skin peels including superficial enzyme and lactic peels and, where applicable, peel layering using glycolic and salicylic acid, as well as the medium depth modified jessner peel. Skin analysis and consultation techniques will also be covered during the course. glo mineral make-up is formulated for skin care professionals and their patients. Created by dermatologists, these advanced formulations combine pharmaceutical grade ingredients, natural highly pigmented minerals, nourishing vitamins and the power of antioxidants, without using any parabens, perfumes or gluten derived ingredients. The result is clinically advanced mineral make-up that covers, corrects and protects. glo minerals helps to protect and enhance the results of any clinical

treatment, camouflaging naturally.

Our formulations deliver unsurpassed coverage, broad spectrum UV protection and assist in combating free radical damage, whilst being suitable for the most sensitive of skin conditions including acne and rosacea. glo minerals glo minerals offer innovative new products in a rich colour palette along with timeless classics. Our clinical skincare is embraced by dermatologists, plastic surgeons and skin care professionals around the world and it is ideal for use after chemical, injectable and laser procedures. glo minerals helps to heal the skin post procedure and is perfect for everyday use to maintain a healthy luminous complexion. glo minerals have a powerful antioxidant blend of vitamins A, C, E, green tea extract, zinc oxide and titanium dioxide. Applied to your skin, this blend provides nutrients that are vital for maintaining the health of your skin while protecting it from further environmental damage.

We used only the finest ingredients and micronised minerals in a triple milled process, ensuring that every application provides even coverage that lasts. Compared to traditional make up, glo professional uses no talc and therefore the make-up does not clog the pores, nor does it accentuate any wrinkles or imperfections. By sitting on the surface of the skin the bases allow the skin to breathe and function normally. glo minerals course content During the course you will learn how to prime the skin for flawless make up application, how to colour match, selecting the correct foundation base for your patient, camouflage techniques, as well as contouring to enhance facial structure and achieve cat walk looks of the current season.

Trainerâ&#x20AC;&#x201D;Kerrie Smythe Kerrie Smythe is an aesthetician with more than 20 years of experience as a skincare specialist in the aesthetics industry. Having been a consultant and the UK trainer

for glo professional for the past eight years, Kerrie has worked with many different skin care brands and trained many doctors, nurses, dentists and aestheticians in various peel systems, including ZO Skin Health by Dr Zein Obagi, Neostrata and Medik 8. Previously working within a clinical environment, she understands from a business perspective how important it is to have a full knowledge of any skincare brand to ensure patient safety and therefore dedicates time to learning new procedures and protocols thoroughly before sharing with her delegates. Kerrie has recently won an award for her work with ZO at the MyFaceMyBody Awards and is a finalist at the Aesthetic Awards.

Further to attending one of the glo professional workshops you will receive continued support from the Wigmore medical sales team with continued product updates and further on-site training if required.

Training workshops during 2017 will be held at various locations throughout the UK. For further information, please contact training@wigmoremedical.com.

Kerrie Smythe, trainer for glo professional

A PA R T N E R S H I P T H AT R E A L LY W O R K S LASER HAIR REMOVAL + VANIQA ® The hair-removing combination more effective than laser alone*

VANIQA® is licensed for the treatment of Female Facial Hirsutism *Complete or almost complete hair removal was achieved in 93.5% (29/31 subjects) in eflornithine-laser treated sites vs 63.9% (21/31 subjects) in placebo-laser treated sites.1

Available from Wigmore Medical Limited

Reference: 1. Hamzavi I et al. J Am Acad Dermatol 2007; 57(1): 54-59.

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 EQUIPMENT 49

Soft surgery DR DAVID R JACK outlines the concepts and applications of the Plexr device, and recounts his own experience of using this technology

T

he non-invasive reduction of tissues without incisions, sutures or scarring—‘soft surgery’—originated in Italy and includes the use of electrosurgery, radio frequency and a new treatment modality, plasma energy.

The latter concept, pioneered

by Prof Giorgio Fippi of the Italian Society of Aesthetic Medicine and Non Invasive Surgery, utilises the fourth state of matter, plasma, (the others being solid, liquid and gas) to reduce tissue simply and effectively without having to reach for a scalpel or create dermal scars.

The first device to reach the market utilising this technology was Plexr, by GMV. In addition to Plexr, GMV also produces a device named Vibrance, which uses an electrostimulation technique to create a controlled injury and fibrous tissue deposition with volume increase, and O.F.F., which delivers a monopolar frequency of 1230kHz via a needle for ablation of fat cells and telangectasia. In addition to these devices by GMV, the realm of ‘soft surgery’ could be considered to include other ablative radiofrequency, HIFU and laser devices and techniques which tighten and lift the skin and soft tissues without excision.

Plexr Plexr is in the form of a set of three hand held ergonomic devices, which are able to generate a strong electromagnetic field between the skin and the tip of the hand piece to create a very small beam of plasma (ionised gas) in a voltaic arc between a surface (the skin) and the device. This narrow beam relies on no contact between the tip and the tissue to provide a space of gas to be ionised.

When the gas is ionised and the plasma beam is created, the area of skin directly below the narrow plasma beam undergoes a process described as ‘sublimation’, where the tissue exposed to the plasma beam is vaporised, with a solid core of skin being converted into gas and the surrounding proteins denatured, with no bleeding due to the high local temperature generated.

This process of tissue injury induces a repair response with an initial inflammatory response, with later wound contracture and restructuring and reduction in the surface area of the area of skin treated. As a result, this technology has been indicated for treatment of eyelid ptosis as a possible alternative to surgical blepharoplasty and in treatment of perioral rhytides.

To date, very little substantial or thorough research has been done in this area, despite the high level of clinical interest in these devices.

Most documentation of the potential results of such techniques is from the observations of individual practitioners with experience of using these devices and no randomised studies have been performed as yet.

Techniques of tissue reduction using Plexr Non-surgical tissue reduction is a significant area of interest in the world of aesthetic medicine. The ability to reduce tissue volume and skin surface area has a wide number of applications, so devices offering this ability could potentially transform this industry and that of cosmetic surgery.

In my own experience, I have had some success in performing Plexr to reduce the volume of skin of the upper lids producing what some may describe as a non-surgical blepharoplasty.

Other techniques for reduction of skin volume of the lateral face, in effect producing a ‘mini-lift’, and resurfacing of acne scars and removal of benign lesions without scarring add to the vast range of potential applications that this flexible device offers.

The use of Plexr to reduce the skin volume of the upper eyelids is probably the most well known application of this device. This technique involves the creation of multiple small controlled plasma injuries on the surface of the upper lids whilst leaving small bridges of normal skin between the injuries (similar to other resurfacing techniques) to allow healing of the skin.

There are several suggested patterns of injuries, such as the ‘triangle’ technique, which is believed to create maximal lifting of the skin in particular areas. The controlled injuries are generally placed on

The use of Plexr to reduce the skin volume of the upper eyelids is probably the most well known application of this device

50 EQUIPMENT I body language

substantial. Similarly, for perioral rhytids, the deep creases seen with advancing age, created by the pull of the orbicularis oris on the skin surface can be treated by creating Plexr injuries on either side of the creases, using the tension created by the subsequent wound contracture response to stretch the creases and soften the radiant lines seen around the mouth.

For larger areas of skin excess the technique is identical, indeed, lifting of the jawline may be created by treating a larger area in the lateral cheek, and some practitioners have even been able to lift sagging skin around the umbilicus using these principles.

Benign skin lesions such as skin tags and intradermal naevi may also be treated with Plexor and other plasma devices using a spray technique, where the device is used to ablate the surface in a layered patter, vaporising the lesions, creating a flat bed for wound healing to occur from the normal skin on the margins of the lesion.

Dr Jack performing a Plexr treatment to the upper eyelids

the crest of skin folds rather than in the bases of the creases, to reduce the excess tissue rather than deepen a skin crease. In this way, if injuries are created on the crests of skin folds at either side of a crease, when wound contracture occurs, the crease is effectively stretched from either side and the depth of the crease is reduced, in addition to reduction of the surface area of the fold of skin.

When these injuries are created in this pattern on the upper lid, the lifting of the tissues can be

Drawbacks and pitfalls In my own experience, Plexr is generally safe and the outcomes are satisfactory. Treatments are generally easily performed with minimal discomfort using topical anaesthesia for at least 30 minutes. In some cases, injection local anaesthesia may be required. Post-treatment there is generally a predictable sequence of erythema, oedema and crusting for the first seven to 10 days, with complete healing usually around day 14.

Occasionally these effects can be prolonged and in some cases, similar to that with other resurfacing techniques such as fractional carbon dioxide laser, erythema can be prolonged long after superficial skin healing for several months.

In these cases, it is suggested that treatment with zinc oxide creams such as Sudofed or even treatment with IPL or other light based treat-

ments may reduce this extended period of inflammation.

To date, there have been no studies investigating the outcomes of Plexr treatments in darker skin types, in particular associations with post-inflammatory hyper/ hypopigmentation cannot be commented on. I therefore cannot advocate the use of these techniques in patients with darker skin types or history of Post-inflammatory pigment changes.

Plexr is very much an operator dependent device, with outcomes dependent on the experience and technique of the individual practitioner, this is perhaps more the case than for any other resurfacing technique on the market today.

Summary The concept of ‘soft surgery’ is an exciting development in the field of aesthetic medicine, which could potentially transform this industry and substantially augment the spectrum of treatment capabilities available to the aesthetic practitioner.

The number of applications of using plasma energy techniques to create controlled injuries and tissue volume reduction are immense, including upper eyelid skin reduction, the ‘non-surgical blepharoplasty’. Currently there is very little research being done in this area, despite the great requirement for this. As with any new medical technology, it may take some time and research to iron out any issues and adverse effects, but my own and my colleague’s experience of this technology so far has been largely positive.

Dr David Jack is a London based aesthetic doctor who has been working in his own thriving Harley Street clinic for several years. Fully qualified in the administration of advanced facial aesthetics including Botox, Dermal Fillers and Laser Dr Jack was featured in Tatler’s Beauty and Cosmetic Surgery Guide in 2016.

References 1. Scarano, A. Andria, D, Fippi, G, Di Carlo F, Carinic E, Lauritano, D Treatment of perioral rhytides with voltaic arc dermoabrasion, European Journal of Inflammation (2012) 10(1) (S2) 25-29 2. Sotiris TG, Nikolaos G, Irini G, Plexr: the revolution in Blepharoplasty Pinnacle Medicine & Medical Sciences (2014) ISSN 2360-9516 pp1-5

www.swisscode-uk.co.uk

52 DERMATOLOGY I body language

Topical oxygen DR MARK RUBIN shares his ideas about where topical supersaturated oxygen emulsions could be helpful in your practice

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he body and the skin love oxygen. It is vital for our health and cellular function to be surrounded by oxygen.

Regardless of our health, the levels of oxygen inside our body and also our skin decrease as part of the ageing process, meaning less effective cell functioning.

Oxygen plays a very specific role not only in anti-ageing but also in wound healing and topical antiageing products are formulated to promote collagen synthesisâ&#x20AC;&#x201D;the building of thickness in the skin, and epithelialisation.

Faster healing times for any injury are desirable not only to reduce the risk of infections, but to reduce

post-inflammatory hyperpigmentation. Oxygen is also anti-microbial. When dealing with anaerobic bacteria like P acnes, an increase of oxygen in that area can kill anaerobic bacteria, although traditional bacteria will also be killed because of a neutrophil mediated type of microbial killing.

We need oxygen for ATP pro-

body language I DERMATOLOGY 53

duction, which is part of every cell’s function, and most vitally we need oxygen for epithelialisation and healing. Over the years many products have claimed to increase the oxygen levels of the skin. However, it’s really not possible to create a product that contains oxygen at a level greater than ambient air, or into a container, unless the oxygen is pressured. In fact most oxygenating products on the market that aren’t pressurised have the same amount as what you have when you’re breathing and therefore have limited effectiveness.

A perfluorodecalin emulsion with oxygen Perfluorodecalin is a product that’s been used for years as a blood substitute in the military. It’s a liquid

that solubilises very large amounts of gas—in this case oxygen. When this is done under pressure, it’s possible to drive ten atmospheres of oxygen into a can with perfluorodecalin, and then apply that to the skin and very slowly outgas oxygen over the course of four or five hours. We have shown this supersaturated oxygen emulsion can increase the amount of oxygen in the skin by 200-300% and maintain that elevated level for hours.

With this knowledge, Cutagenesis have created two different products containing Perfluorodecalin, both of which have over 10 atmospheres of oxygen in. One of them is a very light feeling topical moisturiser, called CutaVive— a cosmetically elegant hydrating emulsion. The other, Cutagenix,

is a more occlusive, heavier base to use post-injury or post procedure when the injured areas requires a more significant amount of hydration and occlusion.

How does skin acquire oxygen?

Although the majority of our oxygen for our organs, including our skin, comes to us through our blood, the very top layer of skin, the first 250-400 microns, including the epidermis and superficial papillary dermis, gets the majority of its oxygen externally by diffusion from the atmosphere.

The depth of 250 to 400 microns, is important, because many dermatological interventions are in that range, whether it’s very superficial fractional type lasering or mi-

54 DERMATOLOGY I body language

OXYGENATED PFD EMULSION ANIMAL STUDIES Partial thickness wound healing

Second degree burns

 Eight pigs each received 80 partial thickness wounds 10 x 7 x 0.3 mm deep using an electrokeratome

 Eight pigs each received 100 burn wounds using a hot cylindrical brass rod

 Cutagenix applied twice daily for five days and once daily thereafter until complete epithelialization

 Burns were randomly assigned to treatment with PFD emulsion or exposed to air and untreated

 By day six, all (100%) Cutagenix treated wounds healed (complete epithelialization) compared to 8% of the control (air treated wounds).

 Burns were treated twice daily with Cutagenix for five days

 Statistically significant (P < 0.001) results are observed for days three to seven

 100% of the Cutagenix treated burns completely healed by day ten compared to 25% of the untreated burns  Burns treated with Cutagenix demonstrated an upregulation of collagen I, II and VEGF production

2nd degree burn healing 120

120 100 80 60

% of wounds healed

% of wounds healed

Partial thickness wound healing

Cutagenix

40 20 0

Control 3

4

5

6

7

100

8

Days after wounding

80

Cutagenix

60 40

Control

20 0 7

8

9

10

11

12

13

14

Days after burn

Topical oxygen emulsion, Davis, SC, Cazzaniga, AL, et al., Arch Dermatology, Oct 2007, Vol 143, No. 10, pp1252-1256

croneedling, which is at that level as well.

One of the concerns that people have when using very occlusive products like petrolatum, post laser resurfacing is that these greasy products can actually create a barrier which makes it more difficult for oxygen to penetrate into the skin.

Skin has a natural barrier function and is built to keep what’s out, out, and what’s in, in, so when you put a topical ingredient on the skin, it is often difficult to get it to penetrate in a significant amount Perfluorodecalin is a way to do this quite well.

Cutagenix efficacy We carried out a study using the Cutagenix product and using a radiometer to measure the amount of oxygen that would diffuse through a one millimetre thick piece of animal skin. Within 20 minutes of ap-

plying Cutagenix, we could document a 300% increase of oxygen that had diffused through that one millimetre thick piece of tissue.

A millimetre is 1,000 microns, so this shows that the oxygen is moving into much deeper layers of skin. After two hours our study showed there was absolutely no drop off in diffusion level, and we have data that shows even at four hours there’s no drop off. So we know we can drive oxygen into the skin by using perfluorodecalin.

Uses of topical oxygen products Topical oxygen can be used for wound healing, laser resurfacing, the treatment of photo damage, photodynamic therapy and for vascular occlusion events when you’re doing injectables and you have an arterial blockage. Other areas of use include radiation dermatitis, acne and rosacea.

Evidence from the University of Miami’s wound healing centre proves that applying high levels of oxygen to the skin actually does speed up and improve wound healing. Their research published in the Archives of Dermatology in 2007, shows that using this supersaturated oxygen technology increased healing in two different types of wounds created in pig skin. One study was done with a keratome where they created a 300 micron deep injury to the skin, and the other trial examined wound healing from second degree thermal burns.

This evidence of the Miami team showed that by the end of day six 100% of the animals that were treated with Cutagenix had completely reepithelialised, and only 8% of the control wounds had reepithelialised. The degree of reepithelialisation was speeded up tremendously by topical oxygen in

The blue line is the Cutagenix—we can compare the rate of epithelialisation versus the control in a keratome injury.

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56 DERMATOLOGY I body language

ADVERSE EVENTS—CUTA MAKES IT HEAL WITH LESS COMPLICATIONS CUTA Aftercare

Shamsaldeen

Nanni and Alster

Adverse event

Number

%

Number

%

Number

%

No. of patients or treatments

99

100

490

100

500

100

Milia

1

1.1

0.0

11.0

Acneiform eruption

0

0.0

26

5.3

15.0

Infections (total)

0

0.0

27

5.5

8.4

HSV

0

0.0

11

2.2

7.4

Bacterial

0

0.0

11

2.2

0.0

Yeast

0

0.0

6

1.2

<1.0

Hyperpigmentation

2

2.0

6

1.2

37.0

Prolonged erythema

0

0.0

4

0.8

100.0

Contact dermatitis

0

0.0

4

0.8

11.0

Scarring

0

0.0

0

0.0

0.0

Hypopigmentation

0

0.0

0

0.0

1.0

Erythema

100.0

Acne exacerbation Total adverse events

15.0 3

3.1

68

13.9

The use of a perflurocarbon emulsion as a post laser aftercare Duplechain, JK; Rubin, M ASLMS E poster 2012. Nanni C A, Alster T S. Complications of carbon dioxide laser resurfacing. An evaluation of 500 patients. Dermatol Surg. 1998;24(3):315–320. [PubMed]. Shamsaldeen O, Peterson J D, Goldman M P. The adverse events of deep fractional CO(2): a retrospective study of 490 treatments in 374 patients. Lasers Surg Med. 2011;43(6):453–456. [PubMed]

that type of a wound.

Burns heal slower, however observation of the animals that were treated with second degree burn injuries reveals that 100% of them were completely healed by day ten, treated with the oxygen product, versus 25% that were untreated. So there was also a significant increase in healing from the topical oxygen Reducing acneform and infection In 2012 we took 100 patients and treated them with CO2 resurfacing, and then treated them afterwards with topical oxygen in the Cutagenix product. We looked at the rates of complications with that, and then went back and studied existing research. In some very large studies done by Nanni and Ulster or Shamsaldine 490 patients who used Aquaphor or petrolatum after their resurfacing were studied. This research showed that acneiform eruptions are extremely high—5% to 15%—with these greasy products. The rate of acneiform eruptions in the topical oxygen product was zero.

Infection rates with topical oxygen product was zero in this research and with the greasier Aquaphor petrolatum based, somewhere between 5% and 8%. Looking at contact dermatitis, which is an is-

sue after resurfacing—a lot of these patients are very reactive and they don’t do well with products that you apply in their immediate healing phase. Using Cutagenix we have a 0% contact dermatitis rate, versus anywhere from about a 1% to 10% with the other products. So not only do the patients heal faster, but they have less problems, less adverse events afterwards.

Wrinkle reduction About 20 years ago a study was published where topical products with perfluorodecalin and different levels of oxygen were applied to the skin for 28 days and wrinkle reduction was measured. They showed a direct linear correlation between the amount of oxygen supplied to the skin and the amount of wrinkle reduction. So, 20 years ago they knew that oxygen was effective in reducing wrinkles, and this was before we had our current technology to put larger amounts of oxygen in PFD by pressurising it.

We took the non-occlusive lighter topical oxygen product, CutaVive and used it on 20 patients with photo damage. The patients applied the product to their skin twice a day for six weeks—carrying out a biopsy on them before and afterwards. We found about a 50% improvement in multiple

parameters—texture, colour, wrinkling, blotchiness, dryness, pores and other factors—within three weeks. Then at the end of six weeks the degree of improvement had continued to increase beyond that seen at three weeks, Since the skin responds rapidly to this product, patients only have to wait three weeks or a month before they’d expect to look in the mirror and see some positive changes in their skin.

And if we look at the biopsies to try and understand what makes those patients look better wrinklewise, we see an increase in the thickness of the epidermis, the papillary dermis and in the deeper dermis as well. If we look at new collagen deposition with a trichrome stain, we see some very significant increase in collagen at the end of six weeks, not just in the Grenz zone, but actually even deeper than that.

There is also a significant increase in the amount of elastic tissue in skin treated with Cutavive.

Photodynamic therapy This is a very popular treatment for actinic keratosis in the US and in UK and Europe also very popular for treatment of basal cells.

We studied ten patients who had multiple actinic keratosis, treating them with ALA and incubating them for two hours with that

body language I DERMATOLOGY 57

a more normal appearance than is expected in an area of radiation. That inflamed skin which is breaking down from the radiation, can be saved from healing with secondary intention and scarring by the use of supersaturated oxygen emulsion.

Fully ablative laser resurfacing at day 5. Patient treated with Aquaphor on right and Cutagenix on left. You can see the patient is not completely reepithelialised in the periorbital area on the Aquaphor side. She has significantly more erythema and some increased oedema on this side, compared to the other. At the end of five days, the side treated with Aquaphor still had some peeling, still has some oedema and erythema. Using Cutagenix on these patients not only makes them more comfortable but also reduces healing time.

This patient was injected with an HA filler in the forehead and presented clinic three days later with this area of early necrosis; he was treated with topical Cutagenix four times a day.

on their skin. The ALA was then washed off and they were put under blue light for 16 minutes—which is the traditional protocol in the US to treat actinic keratoses. We then took one half of the face and put Aquaphor on that, and Cutagenix on the other side. Within two minutes the Cutagenix side had a dramatic reduction in pain, burning, stinging, and over the course of several days the patients had significantly less redness and oedema from continued use of Cutagenix.

At the end of six months there was no difference in efficacy on either side of the face with these patients, so although the topical oxygen was able to reduce the inflammatory component of PDT, it didn’t reduce the efficacy.

Radiation dermatitis For patients who are going through radiation therapy, one of the big

problems is a lot of microthrombi.

All the superficial blood vessels close off, creating ischaemia, so the patients are uncomfortable, they have a lot of skin breakdown, and most patients don’t really have any effective topical therapy to use.

Some use Aquaphor or a petrolatum or Aloe vera—but until now there’s really no great topical products that could make a difference with this.

I have worked with patients undergoing radiation therapy, who have developed radiation dermatitis. These patients have damage to their superficial blood vesssels and a lowered oxygen level in their skin. We have seen that patients who have applied Cutagenix to their radiated skin, had a significant improvement in their discomfort as well as having far less tissue breakdown. After radiation therapy is over, the skin has

Other applications There is the potential to use the supersaturated oxygen emulsion for many different clinical applications. It appears to be helpful in many patients with rosacea and even with perioral dermatitis.

We have done some small pilot trials documenting improvement in acne with the oxygen product.

This makes sense since P. acnes, the bacteria associated with acne, is an anerobic bacteria that doesn’t survive well in areas of high oxygen content. Additionally there’s a multitude of potential areas for using high levels of oxygen to treat diseases.

When treating patients with severe burns, with Reynaud’s disease, gangrene, vasculitis—any where you have areas of tissue loss because of poor perfusion, if you can oxygenate that tissue you can enhance healing. Hyperbaric oxygen therapy is great for these problems if you have that available, but it also means the patient has to sit in a hyperbaric oxygen chamber multiple times—which is time consuming and costly.

By treating them topically with a product like Cuatgenix, it’s possible to rescue some of that tissue with impending necrosis—it’s fairly impressive.

You can also use it on traditional injuries to speed epithelialisation. We have used it routinely to treat lacerations that have been sutured. The patients heal a bit faster but they also have a better cosmetic result with their scar.

58 DERMATOLOGY I body language

This is a patient going through radiation therapy: at the start of Cutagenix use you can see skin breakdown and necrotic tissue.

Caption: By day seven, a fairly profound improvement, and by day 17, completely healed

This is a thermal burn with hit liquid on the anterior thigh. The patient took this photograph, presented at the clinic three days later, started applying the Cuta, and by day ten completely reepithelialised.

Tattoo removal Two years ago Dr Rox Anderson and his group at Wellman labs at Massachusetts General Hospital came out with a new clinical protocol to improve the effectiveness of laser tattoo removal. This protocol, called R20, consisted of lasering the tattoo, waiting 20 minutes, and then lasering them again. Patients would be treated up to four times in one sitting, and they showed that they could get profoundly better results with tattoo removal by doing that vs just treating the tattoo once and waiting several weeks for the next

Day 1

treatment. The difficulty with R20 is that you have to wait at least 20 minutes between treatments, because when you treat a tattoo with Q-Switch lasers, a microcavitation type of gas bubble forms in the skin created by the laser, which creates whitening. If you try and laser them again while that area is white, the opacity of the white prevents the laser from penetrating very well.

As previously stated, PDF soluabilises gas very effectively. When it is applied to the area of whitening from laser tattoo removal, the PFD soluabilises the gas in the air bub-

Day 3

ble within a minute and the white opacity disappears. This allows a second laser treatment within a minute or two, rather than having to wait the traditional 20 minutes between treatments. Three laser passes within ten minutes is possible with those patients. So you can still treat them and achieve the effectiveness of R20 but they donâ&#x20AC;&#x2122;t have to spend hour and a half in your clinic.

DeScribe is a product recently launched in the USA, it is a clear patch that has perfluorodecalin in it. When applied over a tattoo, the laser treatment can be applied right through the patch and the PFD will speed up the resolution of the whitening from the laser. This patch costs US$40 to use one time on a patient. You can achieve similar results with Cuatgenix because of its high levels of PFD, but it only takes about $3 worth of Cutagenix to treat an area of tattoo. So it is a very cost effective way to speed up tattoo removal.

Dr Mark Rubin is a founding member of Cutagenesis, the maker of Cutagenix and CutaVive, which are distributed in the UK through Wigmore Medical. Dr Rubin is a boardcertified dermatologist. He currently practices at the Lasky Skin Center in Beverly Hills. His practice there is limited to cosmetic dermatology. In addition, he is an Assistant Clinical Professor of Dermatology at the University of California, San Diego.

Day 10

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