Body Language Journal - Issue 62

mar/apr

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

FACE FACIAL AESTHETIC CONFERENCE AND EXHIBITION

PREVIEW INSIDE

COSMECEUTICALS A NEW LIGHT I SKINCARE PRODUCTS I ROSACEA Alternatives to hydroquinone

Our expert panel provide their recommendations

A comprehensive skincare regime

LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE) site(s) or when the targeted muscle shows excessive weakness or (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients.

In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis.

Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection Date of preparation: March 2013

atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection.

Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions.

Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

<1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013

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

Adverse events should also be reported to Galderma (UK) Ltd.

AZZ/020/0313

body language I CONTENTS 3

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contents Contributors Mr Chris Inglefield Dr Mukta Sachdev Dr Beth Briden Dr Joe Lewis Dr Zein Obagi Dr Carl Thornfeldt Julie Brackenbury Cliff Betton Mr Shailesh Vadodaria Eddie Hooker Mike Murphy Per-Arne Torstensson John Castro Dr Timothy Corcoran Flynn

Editor Helen Unsworth 020 7514 5981 helen@face-ltd.com COMMISSIONING Editor David Hicks 020 7514 5989 david@face-ltd.com Editorial Assistant Arabella Tanyel 020 7514 5989 arabella@face-ltd.com Sales Executive Monty Serutla 020 7514 5976 monty@face-ltd.com Assistant Sales Executive Simon Haroutunian 020 7514 5982 simon@face-ltd.com Publisher Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com ISSN 1475-665X The Body Language® journal is published six times a year by FACE Ltd. All editorial content, unless otherwise stated or agreed to, is © FACE Ltd 2014 and cannot be used in any form without prior permission. The single issue price of Body Language is £10 in the UK; £15 rest of the world. A six-issue subscription costs £60 in the UK, £85 in the rest of the world. All single issues and subscriptions outside the UK are dispatched by air mail. Discounts are available for multiple copies. 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

7 OBSERVATIONS

29 DERMATOLOGY

ANALYSES

In a new light

Reports and comments

Hydroquinone is the controversial gold standard for skin lightening but there are a number of newer alternatives on the market. Dr Mukta Sachdev discusses current and emerging treatment options

13 REPORT Regulation of cosmetic interventions Since the 2013 Keogh Report set out recommendations to improve safety for non-surgical cosmetic surgery patients, progress has been disappointing. Organisations and product suppliers must therefore focus on providing training and accreditation to raise standards of care, writes Mr Chris Inglefield

16 CONFERENCE FACE 2014 The UK’s premier medical aesthetic conference and exhibition returns on June 20th—22nd at the QEII Conference Centre, London

22 FORUM

34 SKINCARE Rosacea Dr Zein Obagi describes the four main subtypes of rosacea and how a comprehensive skincare regime can help to treat mild to moderate cases

36 SKINCARE Skin barrier repair Chronic, itchy skin conditions and inflammation can result from compromised stratum corneum function. Dr Carl Thornfeldt discusses the importance of barrier repair and optimisation, and his research behind the Epionce skincare range

Skincare products

40 HEALTH

Our expert panel provides recommendations on a range of skincare products for different indications, including sunscreens, growth factors and antioxidants

What’s in your emergency bag?

Julie Brackenbury discusses the incidence of medical emergencies in aesthetic practice such as

4 CONTENTS I body language

editorial panel Dr Jean Carruthers MD, FRCSC, FRC is clinical professor in the department of ophthalmology and visual sciences at the University of British Columbia in Vancouver. With her husband, Dr Alastair Carruthers, she has received the Kligman award from ASCDAS .

Mr Ravi Jandhyala is a member of the Royal College of Surgeons of Glasgow, and a founding member of the UKBTGA. He is also a member of the Faculty of Pharmaceutical Medicine and is an expert in the science behind botulinum toxins for aesthetics.

Professor Syed Haq trained at Harvard Medical School, Massachusetts General Hospital and Tufts University, New England Medical Center. Professor Haq is Director of The London Preventative Medicine Centre, Harley Street.

Professor Andy Pickett has worked on botulinum toxins for over 23 years. Andy has lectured around the world on the products, translating the science into practical understanding for injectors. In 2011 Andy founded Toxin Science Ltd and is head of development at Q-Med.

Anthony Erian FRCS (Erg) FRCS (Ed) is an aesthetic plastic surgeon with more than 30 years’ experience. He is a member of the American Academy of Aesthetic and Restorative Surgery and chairman of the European Academy of Aesthetic Surgery.

Dr Stephen Bassett is medical director of the Aesthetic Training Academy and ShapeCYMRU Cosmetics. He is a Syneron luminary and member of the Merz academy.

He is a barrister, fellow of the Society of Advanced Legal Studies and a legal consultant.

Elizabeth Raymond Brown, Phd, CRadP, MSRP authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies.

She is now director of education at LCS Academy Ltd.

Dr Séan Cummings MBBS T(GP), DRCOG, DFFP, MRCGP, LLM is a cosmetic doctor practising in Harley Street. Dr Cummings has more than 20 years’ experience as a practitioner and has a masters degree in medical law.

Dr Cummings works as an expert witness.

Dr Raj Persaud FRCPsych is a consultant psychiatrist who has worked at the Bethlem Royal and Maudsley NHS Hospitals in London from 1994-2008, and as an honorary senior lecturer at the Institute of Psychiatry, University of London.

Dr Bessam Farjo MB ChB BAO LRCP&SI is a fellow International College of Surgeons, founder member British Association of Hair Restoration Surgeons and president of the International Society of Hair Restoration Surgery.

Dr Masud Haq BSc, MRCP, MD is a consultant in diabetes and endocrinology.He is a graduate of Guy’s and St Thomas’s Hospital, and trained at Johns Hopkins in the US and in Melbourne. He has a particular interest in the thyroid and menopause.

Fiona Collins and Marie Duckett are registered nurses and members of the Royal College of Nursing forum for nurses in aesthetic medicine. Their clinic, Fiona and Marie Aesthetics Ltd, is based in Harley Street, London, UK.

48

necrosis and anaphylaxis, and how practitioners can prepare for them

42 REVIEW Call to account The new Cosmetic Regulation requires that all cosmetic products sold in the EU meet specific criteria and that a ‘responsible person’ must be designated to legally ensure their safety. Cliff Betton runs through the implications of the EU Cosmetics Regulation

45 SURGICAL

Target destruction while minimising damage to surrounding tissues during photothermal treatments relies on the theory of thermal relaxation. But the concept focuses on target cooling rather than destruction, write Mike Murphy and Per-Arne Torstensson, leading to poor results and repeat treatments

55 PRODUCTS On the market The latest products in aesthetic medicine

Prominent ears

59 MARKETING

Ear deformity is a common aesthetic complaint among children and adults. Mr Shailesh Vadodaria describes the nonsurgical and surgical treatment options for correcting prominent ears

Secrets to a successful blog

48 INSURANCE Protect your practice Eddie Hooker discusses the pitfalls of medical malpractice insurance, how to prevent claims occurring and how to deal with complaints for elective procedures

51 LASERS Thermal relaxation times

A blog can be a useful addition to your website, providing users with relevant and up-to-date information and building trust with potential clients. John Castro explains how blogging can help your business grow

61 EXPERIENCE Pancakes, or how I became an aesthetic dermatologist Dr Timothy Corcoran Flynn recalls the childhood inspirations who led him down the aestheticallypleasing—and moss-covered— path to dermatology

READY • AUTHENTIC • MY BUSINESS

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 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 vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age 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. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, LambertEaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. 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. 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 observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency 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). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis),vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin.

Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. 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 revision of text: FEB 2012. Full prescribing information and further information is 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 medical.information@merz.com or on +44 (0) 333 200 4143.

1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456.

3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154.

4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58.

5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1134/BOC/NOV/2013/LD Date of preparation: November 2013

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body language I NEWS 7

observations

Government “paying lip service” to sector warnings Patient safety high on industry agenda Nearly a year after the publication of the Keogh report, the Government has responded to the report and its numerous recommendations. However, the reaction from the industry to the response has been less than enthusiastic, with many believing that the Government wasted an opportunity to implement safeguards into the market, particularly in relation to medical devices such as dermal fillers.

The Keogh report was launched following the scandal into PIP breast implants. Following its review of regulation in the cosmetic interventions sector, the group behind the report made 40 recommendations for the industry—in particular, highlighting dermal fillers as a cause for concern.

The Government backed the majority of the recommendations and has even begun to make some headway in their implementation.

The Royal College of Surgeons has established a cosmetic surgery interspecialty committee and “work is underway”, new advertising guidelines on cosmetic interventions have been published, and the Health Education England is undertaking a “call for evidence” and held a round table to develop training and accreditation programmes.

In addition, there is recognition that recommendations concerning record-keeping are good practice or statutory in the medical field.

However, the two recommendations that many believed were key to reigning in “Wild West” cowboy practitioners—a registry of practitioners and making medical devices such as dermal fillers prescription only—were rejected by the Government.

The Government believes that a registry would be an unnecessary duplication as nurses, doctors and dentists would already be on their respective registers and that patient safety would be better served by improving clinical standards.

However, there is no explanation as to how it expects non-healthcare professionals to be accredited and regulated, although it states that legislative options are still being explored.

While the Government says it supports “the principle that dermal fillers and other non-surgical cosmetic products should be prescription only”, it says it is hamstrung

by EU law which defines the products as medical devices.

There are currently proposals to bring dermal fillers and the like under the EU framework for medical devices but this is unlikely to come into legal effect until 2015 at the earliest.

This may require manufacturers to seek authorisation for products before they can enter the EU market, but there is no indication that it will lead to dermal fillers be-

ing prescription only in the UK. Mr Rajiv Grover, president of The British Association of Aesthetic Plastic Surgeons, says the association is appalled at the lack of action taken so far.

“This review…represents yet another thoroughly wasted opportunity to ensure patient safety.

With all the evidence provided by the clinical community, choosing not to reclassify fillers as medicines with immediate effect or setting up any kind of compulsory directive beggars belief.

“Legislators have clearly been paying only lip service to the sector’s dire warnings that dermal fillers are a crisis waiting to happen.

It’s business as usual in the Wild West and the message from Government is clear: roll up and feel free to have a stab,” Mr Grover says.

Sir Bruce Keogh, while welcoming the Government’s response to his eponymous report and noting the benefits that training and clear standards will bring, highlighted that “…this is the beginning of a journey, not the end.”

8 NEWS I body language

training & events W: wigmoremedical.com MAR 1 March, Botox & Dermal Fillers Foundation, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk 3 March, Level 4 Award in the Physiology and Practice of Chemical Skin Peeling, UK W: sallydurant.com 4 March, Level 4 Award in the Physiology and Practice of Dermal Rollering, UK W: sallydurant.com 5-6 March, Level 4 Award in the Physiology and Practice of Non-Surgical Blemish Removal (Advanced Electrology), UK W: sallydurant.com

29 March, Botox & Dermal Fillers Foundation, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk

APR 1 April, Sculptra (Day 1 of 2), Wigmore Medical, London W: wigmoremedical.com 2 April, ZO Skin Health, Wigmore Medical, London W: wigmoremedical.com 2-6 April, Laser 2014, Phoenix, USA W: aslms.org

6 March, Sculptra (Day 1 of 2), Wigmore Medical, London W: wigmoremedical.com

3-5 April, 12th AMWC, Monte Carlo, Monaco W: euromedicom.com

6-9 March, California Society Of Facial Plastic Surgery 9th Annual Winter Symposium, Truckee, USA W: csfps.org/winter-symposium

7-8 April, ZO Medical Basic and Intermediate, Wigmore Medical, London W: wigmoremedical.com

8-9 March, Aesthetics Conference & Exhibition, London, UK W: ace2014.co.uk 10 March, Mesotherapy for hair and face, Dorking, UK W: vidahealthandbeauty.com/mesotherapy-training-courses 10 March, BACN Workshop - Super Secrets of Business Success, Royal College of Obstetricians and Gynaecologists, London W: cosmeticnurse.org/events/ 10 March, BACN Workshop, Super Secrets of Business Success, London, UK W: cosmeticnurse.org/events 10-11 March, Skinsynergy seminar, Aestheticare, London W: aestheticare.co.uk 11 March, Mesotherapy for body, Dorking, UK W: vidahealthandbeauty.com/mesotherapy-training-courses 13 March, Advanced Fillers, Wigmore Medical, London W: wigmoremedical.com 14 March, Medik8 Dermal Roller courses, Wigmore Medical, London W: wigmoremedical.com 15 March, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 19-20 March, ZO Medical Basic and Intermediate, Wigmore Medical, London W: wigmoremedical.com 21-23 March, ISAPS Course, Cape Town, South Africa W: isaps.co.za 24 March, Platelet Rich Plasma (PRP), Wigmore Medical, London W: wigmoremedical.com

10 April, Advanced Toxins & Fillers, Wigmore Medical, London W: wigmoremedical.com 14 April, Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com 24–25 April, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 24-30 April, ASAPS/ASERF Annual Meeting, San Francisco, USA W: surgery.org 2­ 6 April, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 28 April, Platelet Rich Plasma (PRP), Wigmore Medical, London W: wigmoremedical.com

MAY 6-7 May, ZO Medical Basic and Intermediate, Wigmore Medical, London W: wigmoremedical.com 12-13 May, Skinsynergy seminar, Aestheticare, London W: aestheticare.co.uk 17 May, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 19 May, Platelet Rich Plasma (PRP), Wigmore Medical, London W: wigmoremedical.com 20 May, Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com 27-31 May, AAFPRS 11th International Symposium, New York, United States W: aafprs.org

25-29 March, American Burns Association 46th Annual Meeting, Boston, USA W: ameriburn.org/46thAnnualMeeting. php

29-30 May, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com

27-28 March, Intro to Toxins and Fillers, Wigmore Medical, London

Email training and events dates to arabella@face-ltd.com

Health benefits of fruit juice questioned Sugar content underestimated by consumers Members from the Institution of Cardiovascular and Medical Sciences at the University of Glasgow have questioned whether fruit juice should still be promoted as an accepted serving of fruit and vegetables as part of the “five-a-day” guidelines, when it has more in common with fizzy drinks and other artificially sweetened beverages.

Published in The Lancet Diabetes & Endocrinology, article authors Jason MR Gill and Naveed Sattar explain that despite the similar energy density and sugar content in a typical glass of apple juice and cola, the former is widely-held to be the healthier option.

The researchers carried out a survey on over 2000 UK adults, asking them to estimate the amount of sugar in a range of non-alcoholic beverages.

Results showed the sugar content in fruit juices and smoothies was underestimated, on average, by 48% by consumers.

While fruit juices contain vitamins and minerals that sugar-sweetened beverages are lacking, this nutrient content is unlikely to be sufficient to offset the negative metabolic consequences of high fruit juice consumption. For example, a randomised trial involving the daily consumption of half a litre of grape juice by overweight adults for a period of three months, led to increased insulin resistance and larger waistlines.

The article highlights that while there is a public health consensus to limit consumption of sugar-sweetened beverages, including suggestions for increased taxation on such drinks, there is currently no similar drive to limit the consumption of fruit juice, despite the similarity of sugar content.

The association with the “five-a-day” guidelines continues to promote fruit juice as the healthy choice.

As well as calling for more explicit labelling on packaging, the authors note that in this modern age of rising obesity, public health authorities should move to include fruit juice in any debate regarding reducing consumption of sugar-sweetened drinks.

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body language I NEWS 11

60

second brief

Bioengineered skin grafts reduce scarring and pain Autologous skin contains blood and lymphatic capillaries Recent research from the University of Zurich is paving the way for a breakthrough in skin grafting. Current grafting methods include removing healthy skin from one area of the body to another, or engineering skin from patient skin cells, both of which have their own limitations. The former by size—removing the healthy skin leaves a new wound—and the latter by quality, as the skin does not contain blood or lymphatic capillaries, pigmentation, hair follicles or nerves.

As reported in January’s Science Translational Medicine, the team from Zurich have, for the first time, engineered full-thickness skin with both blood and lymphatic capillaries. When this bioengineered, autologous, dermo-epidermal skin graft was transplanted onto nude rats, it anastomosed to the rat’s lymphatic plexus and supported fluid drainage.

Commenting on the findings, one of the lead authors of the study said: “The lymphatic capillaries collected and transported tissue fluid; hence they were functional. We assume that skin grafts with lymphatic and blood capillaries will, in future, both prevent the accumulation of tissue fluid and ensure rapid blood supply of the graft.”

This will go some way to reducing scarring and pain associated with skin grafts. Further clinical trials are expected to take place later this year.

On the rise According to statistics released by the American Society for Dermatologic Surgery, nearly 22% more medically necessary and cosmetic procedures were performed in 2013 by the Society’s members than 2012. Over three million of these involved skin cancer treatments, due in part to increasing awareness among consumers to have suspicious lesions investigated.  Over 9.5 million treatments performed in 2013, compared with 8 million in 2012  Treatment for skin cancer rose 13% from 2012, with over 3 million procedures carried out last year Of these, nearly 190,000 were for melanoma  Laser/light/energy-based procedures went up 34% to 2.25 million  Wrinkle relaxing injections increased by 20% in 2013, rising to 1.8 million  There were nearly 1 million soft tissue filler treatments carried out, a rise of 8.6% over 2012 Source: The American Society for Dermatologic Surgery

Rhinoplasty can change voice quality Could have impact on professionals who rely on their voice A recent study from the Ferdowsi University of Mashhad in Iran reports that patients who undergo rhinoplasty may also experience changes to the characteristics of their voice. The report, published in the February 2014 issue of Plastic and Reconstructive Surgery, suggests that because the nasal cavity is a key component in voice production, the narrowing of that cavity by rhinoplasty affects the quality of the patient’s voice following surgery.

The researchers studied 27 patients undergoing rhinoplasty before and five months after the surgery using three modalities to

evaluate voice: self-assessment, trained listener assessment and software-based assessments.

The results showed that subtle changes to voice quality do occur following rhinoplasty, which can be perceptible to patients, although these changes “do not appear to interfere with patients’ lives”.

However, as the research concludes, surgeons should discuss these changes before surgery with patients, particularly those who rely on their voice for professional reasons.

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EME/021/1013 Date of prep: October 2013

References 1. Rzany B et al, Dermatol Surg 2012;38: 1153â&#x20AC;&#x201C;1161 2. Cartier et al, J Drugs Dermatol. 2012; 11 (1)(Supp): s17-s26 (*Results taken from a mean value across all treatments performed in study) 3. Farhi D et al, J Drugs Dermatol 2013; 12: E88-E93

body language I REPORT 13

Regulation of cosmetic interventions Since the 2013 Keogh Report set out recommendations to improve safety for nonsurgical cosmetic surgery patients, progress has been disappointing. Organisations and product suppliers must therefore focus on providing training and accreditation to raise standards of care, writes MR CHRIS INGLEFIELD

T

he government response to Professor Sir Bruce Keogh’s Review of the Regulation of Cosmetic Interventions has been rightly criticised for its failure to act on key recommendations for mandatory registration of all practitioners and, nearly a year after the Review was published, there is little sign of much needed training and accreditation requirements for providers of non-surgical interventions.

Despite government talk of support for the principles of Keogh’s recommendations, it is clear that little concrete progress has been made and there are widespread fears that opportunities for change are being lost.

At the Merz Aesthetics Partnership in Practice conference (MAPPCon) held in September 2013, three quarters of delegates felt that government inertia over the Keogh recommendations would open the door to inadequately trained individuals entering the facial aesthetics business.

They felt that the best way to protect patients would be to ensure that only doctors, dentists or nurses can offer toxin and filler treatments, but they were also critical of healthcare professionals (HCPs) who offer these non-surgical procedures after just a few hours of training.

They suggested that, just as HCPs must now undergo continuing medical education (CME) and regular appraisals to ensure they keep up to date with clinical prac-

tice, similar requirements should be in place for those offering nonsurgical aesthetic procedures.

In response to the Keogh recommendations, Health Education England (HEE) established a project to develop minimum standards of educational qualifications, values and attitudes for safe and effective provision of non-surgical cosmetic procedures. The range of practitioners to be considered included plastic surgeons, dermatologists, dentists, aesthetic nurses, other HCPs and beauty therapists.

The HEE is due to complete its work by April 2014, but the inclusion of beauty therapists in its remit is at odds with the widely held view that medical, dental or nursing training are essential for a good understanding of the clinical aspects of aesthetic procedures.

Reclassification of fillers In the consumer press, much has been made of the government’s failure to make dermal fillers pre-

scription-only medicines (POMs), as proposed in the Keogh Review.

However, as delegates at the MAPPCon meeting concluded, POM status would not make fillers any safer and it would be unlikely that its implementation would take them out of the hands of poorly trained therapists.

They pointed out that botulinum toxin is already a POM, but that has not stopped it being widely used at beauty clinics and parties, without supervision from a qualified doctor, nurse prescriber or dentist.

Reclassifying dermal fillers as POMs would make them unavailable to many highly skilled and experienced non-prescribing nurses who would adhere to legislation.

But it would have little impact on the so-called “cosmetic cowboys” for whom legislation acts as no constraint.

Dermal fillers produced by leading aesthetic companies are manufactured and marketed under strict

14 REPORT I body language

EU controls and conform to EU legal requirements for CE Class III products—those generally considered high-risk. The Keogh Review estimated that there are between 140 and 190 dermal filler products available in the UK (including CE marked and non-CE marked products) with no restrictions on who can purchase them.

In the USA, all dermal fillers are regulated by the Food and Drug Administration (FDA) under a more restrictive system of regulation than in the EU and, as a result, only 14 different dermal fillers are permitted for sale.

Reclassifying dermal fillers as POMs would delay innovation and increase costs, and make it illegal to promote filler treatments to the public. Once again this would be more likely to adversely affect the business of aesthetic practitioners who work according to best practice and abide by advertising restrictions for POMs, than those who advertise services regardless of legislation.

Practitioners have a choice of dermal filler suppliers and they may prefer to work with the large reputable pharmaceutical companies, such as Merz, Allergan and Galderma. It is legislation that ensures that all their products are tested and manufactured according to highest standards of pharmaceutical practice.

Some companies have already met the requirements for FDA approval of dermal fillers in the USA, so practitioners who only want to use evidence-based products with the clinical data to support the claims made for them, may prefer to use only FDA-approved brands.

Pharmaceutical companies that take their responsibilities seriously for ensuring the efficacy, safety and quality of their products are also the ones that are most committed to educational support for aesthetic practitioners and high quality information for patients.

Media coverage of the Keogh report suggested an epidemic of complications arising from misuse of non-surgical treatments.

We know that this is not the case, but we cannot ignore the fact that adverse events do happen. Recent expert guidance includes informa-

tion on potential complications of injectable products and how they can be prevented and treated. It is therefore essential for practitioners to update consent documentation to ensure that patients are fully informed about the risks of complications, however small.

Price incentives Offers of cut-price injectable treatment are widespread. A survey reported at last year’s scientific meeting of the British Association of Aesthetic Plastic Surgeons showed that time-limited deals and financial incentives for toxin and filler treatments were commonplace.

Procedures were offered at shopping centres, gyms and parties and, all too often, patients were offered little information about treatment providers and their qualifications.

Whether the revised “Help Note” on marketing of cosmetic interventions, issued by the Committee on Advertising Practice (CAP) and the Broadcast Committee of Advertising Practice (BCAP) in October 2013, will have any impact remains to be seen.

Keogh called for time-limited deals and financial inducements to be prohibited, but the CAP/BCAP guidance advises only that time limits should not pressurise consumers to take up offers and that promotions should not encourage consumers to undergo unnecessary or unwarranted interventions.

Good medical practice already dictates that doctors should not accept any inducement to prescribe, so price should never be a factor References 1. Department of Health.

“Government Response to the Review of the Regulation of Cosmetic Interventions.”

February 2014 2. Department of Health.

“Review of the Regulation of Cosmetic Interventions”. April 2013.

3. Health Education North West London. “Cosmetic nonsurgical interventions Update.”

December 2013 4. Carruthers J, Fournier N, Kerscher M et al. “The convergence of medicine and neuro-

in a patient’s decision to go ahead with toxin or filler treatment.

Delegates at MAPPCon were in agreement that decisions about treatment should be based entirely on clinical assessment and therapeutic need.

Price should only ever be considered after recommendations about treatment have been made.

Date-limited offers that encourage patients to make quick decisions about treatment in order to benefit from price reductions cannot be justified, though restrictions are hard to police.

Moving forward In the absence of legislation to ensure that only qualified practitioners provide toxin and filler treatments, it is incumbent on professional organisations and suppliers to support education and accreditation initiatives aimed at raising standards of care.

Not forgetting that insurers also have a role, by restricting indemnity to those with proven expertise attained through accredited training programmes.

By working together, we can not only raise the bar for standards of care in non-surgical aesthetic practice but we can enable our patients to approach their treatment with a greater understanding of the quality of service they have a right to receive.

In this way, we can build a bright future for our profession, secure in the knowledge that we are meeting the highest expectations for best practice.

toxins: a focus on botulinum toxin type A and its application in aesthetic medicine—a global, evidence-based botulinum toxin consensus education initiative. Part II: Incorporating botulinum toxin into aesthetic clinical practice.” Dermatol Surg 2013;39:510–525 5. Bailey SH, Cohen JL, Kenkel JM. “Etiology, prevention, and treatment of dermal filler complications.” Aesthet Surg J. 2011 Jan;31(1):110-21 6. British Association of Aesthetic Plastic Surgeons Annual Scientific Meeting.

“Cosmetic surgery: not perks and recreation.” Accessed at: http://www.baaps.org.uk/ about-us/press-releases/1740cosmetic-surgery-not-perksand-recreation 7. Help Note. Committee of Advertising Practice (CAP)/ Broadcast Committee of Advertising Practice (BCAP).

Marketing of Cosmetic Interventions, October 2013 8. Good medical practice (2013). Accessed at http:// www.gmc-uk.org/static/documents/content/GMP_2013. pdf_51447599.pdf

16 CONFERENCE I body language

FACE 2014 The UK’s premier medical aesthetic conference and exhibition returns on June 20th—22nd at the QEII Conference Centre, London

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ith so many medical aesthetic events running every month in the UK and overseas, it can be difficult to plan which ones to attend. FACE has grown from a small local meeting in 2003 to a three day event that is unique on the international stage attracting expert speakers, practitioners and clinic owners from all over the world.

FACE has always focused on the main driving forces of growth in the aesthetic industry—namely non-surgical injectables, aesthetic equipment and topical treatments designed for facial rejuvenation with an emphasis on the quality and depth of topics covered in the scientific agenda.

This year FACE will provide unparalleled CPD approved learning with over 170

national and international speakers, a total of 14 days of educational content spaced over seven separate agendas— plus exhibitor workshops and an exhibition devoted to the facial aesthetic market.

FACE uniquely has dedicated agendas for different

interests with separate injectable, equipment, cosmeceutical, business and aesthetician agendas. This allows clinicians interested in the latest techniques and information related to cosmetic injectables to focus on their learning requirements, whilst a clinic

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Facial Injectables Agenda A host of national and international lecturers, trainers and clinical trialists will feature, providing scientific updates and practical pearls to help you maximise results and minimise problems when using cosmetic injectables for total facial contouring. Different techniques, new treatment approaches and concepts will be explored alongside practical demonstrations. The latest clinical data and thoughts on toxins, fillers, PRP and other cosmetic injectables will be reviewed and debated alongside a special session devoted to different ways of objectively measuring and recording patient outcomes. Little discussed techniques including earlobe rejuvenation, a new procedure for dealing with forehead lines and a treatment demonstration for facial hyperhidrosis will also be featured. If you are passionate about cosmetic injectables then FACE 2014 is the event that you must reserve in your professional education diary. You won’t find a better industry focused event anywhere in the world this year.  faceconference.com/agenda/injectable

manager or marketeer would attend the business section, and an aesthetician working in a clinic may want to attend the dedicated aestheticians agenda.

Whatever your medical speciality, or size of business, FACE provides learning for doctors, nurses, surgeons, dentists, aestheticians, therapists, clinic managers and marketers working full or part-time in the aesthetic industry. FACE is the one event for anyone or any business involved in facial rejuvenation that you must attend in 2014 to gain knowledge about the latest treatments, procedures, scientific data, practical treatment tips, and marketing and business strategies-all delivered by leading national and international experts in their respective fields.

SKIN FORUM—COSMECEUTICALS AND PROBLEM SKIN Cosmeceuticals and medical retail skincare lines are an important aspect of providing a complete approach to anti-ageing, alongside the treatment of specific skin conditions, and can provide a robust additional revenue stream for aesthetic clinics. With so many different competing skincare lines, it can be confusing to draw conclusions about which brands to choose from company representatives and promotional literature alone. FACE provides a forum for practitioners to meet the true experts who understand ingredients, formulations and the arguments behind competing concepts and brands. This two day forum will focus on new topical approaches to preventing and treating signs and symptoms of ageing skin alongside the latest specific approaches to treating acne, rosacea and hyperpigmentation in skin of colour.  faceconference.com/agenda/skincare

body language I CONFERENCE 17

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Facial AESTHETIC EQUIPMENT Agenda The use of lasers, radio frequency, ultrasound and other aesthetic equipment for facial rejuvenation continues to grow, providing new approaches to the treatment of skin lesions and skin ageing.

Clinics embracing the right equipment can significantly enhance revenue streams by providing complementary approaches for skin rejuvenation alongside cosmetic injectables. This two day agenda allows delegates the opportunity to explore and compare the latest equipment, protocols and treatment approaches to a wide range of different skin problems.  faceconference.com/agenda/equipment

FACE offers excellent flexibility when booking. You can register as a full delegate to be free to attend all agendas on all days of the conference, or just on the day of your choice. You may also select to only attend the most relevant agenda for you, or mix and match to give great value for money.

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HAIR Agenda With so many different non-surgical and surgical treatment options now available for the treatment of androgenetic alopecia, alongside growing demand for solutions to hair loss, FACE are hosting a special one day symposia devoted to exploring this sector of the aesthetic market. Dr Bessam Farjo, one of the UK’s leading hair transplant surgeons, will be chairing and talking alongside a panel of experts who will explore in depth the different potential treatment solutions available. If you’re already involved in this exciting market segment, or are looking to add this to your treatment menu, the HAIR agenda will provide you with the most up to date views and information on the effective treatment of hair loss that can be offered in a private clinic.  faceconference.com/ agenda/hair

BUSINESS Agenda Anyone owning their own aesthetic business, or involved in the marketing and management of a clinic or salon understands the critical importance of customer service and developing a steady and continuous stream of new clients. In an increasingly competitive market everyone needs to “raise their game” and FACE provides a unique 3 day forum for clinic owners, managers and marketeers to explore a wide range of topics related to the art of marketing. We have a wide range of professional speakers including specialist marketeers, web designers, and social media gurus giving you the latest information on techniques that work specifically in the aesthetic market. In addition we have a specialist session including lawyers, an expert witness and representatives from the insurance industry exploring important aspects related to risk management to ensure that you effectively minimise potential problems from clients who have poor outcomes or who are not satisfied with your service. FACE provides yet another unique opportunity for clinic managers, marketeers and aesthetic business owners to learn from respective marketing experts in their fields, and network and share ideas with peers to maximise profitability in their business.  faceconference.com/agenda/business

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AESTHETICIANS Agenda Last year we announced a new two day event tailored specifically to exploring advanced treatments that are performed by non-medically qualified practitioners with different skill sets, interests and backgrounds. This proved extremely popular as the last 10 years has seen the role of beauty therapists, laser technicians and other practitioners working in the aesthetics market rapidly evolve, enabling them to work alongside medical practitioners or expand their own skillset in salons or their own businesses. Many of the lectures are delivered by therapists who have specialist expertise and experience in their chosen field, with FACE providing a dedicated forum to share knowledge and stimulate debate amongst therapists.  faceconference.com/ agenda/aestheticians

The FACE website for 2014 has now launched and allows you to browse the entire lecture programme for all agendas, as well as our world-renowned speaker panel and all exhibitors and exhibitor workshops. If you would like to register online you can do so, by visiting faceconference.com/register and if you would prefer to register by telephone, please call 020 7514 5989. We are also happy to answer any queries via email on info@face-ltd.com and can offer advice on the best booking options for you and your team. If you register before March 31st as a full delegate for all three days, you will receive a 20% discount.

18 CONFERENCE I body language

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THREADS WORKSHOP The concept of the use of different types of threads for facial rejuvenation has been in development since the late 1990s when prolene APTOS threads were invented

by Russian cosmetic surgeon, Dr Marlen Salaminidze.

Since then, the Contour Lift, Thread Lift, Silk Lift, Russian Lift, Feather Lift, Scarless Suture Lifting, Suture Suspension Face Lift, Curl Lift and many other other types of threads have been actively promoted to the aesthetic community.

This special half day workshop will explore the latest data evaluating the efficacy and long term safety of threads for facial rejuvenation, alongside the technical issues of placing threads and the experience required to deliver these treatments in aesthetic practice.  faceconference.com/workshops

LECTURE HIGHLIGHTS Injectable agenda  Botulinum toxin for facial hyperhidrosis—practical tips and demonstration, Dr Sandeep Cliff  FACE of the future—hot topics, panel discussion, Dr Timothy Flynn, Mr Rajiv Grover, Dr Michael Kane and Dr Marina Landau  Brow and temple rejuvenation using toxins and HA fillers, Dr Raj Aquilla Hair agenda

 Modern artificial hair transplant, Dr Manal Sheta  Private hair loss treatment—the market potential, Dr Bessam Farjo Business agenda

 The unhappy patient—strategies for damage limitation, Ms Liz Bardolph  SOCIAL STATUS Workshop, Ms Wendy Lewis  Advertising—what you can and cant say, Mrs Lorna Jackson Aestheticians

 Peels—which peels for which indication? Ms Sally Durrant  How to maximise retail skincare sales, Ms Lorna Bowes  Practical tips for getting the most out of your laser/IPL system, Ms Jo Martin Equipment agenda

 Treatment of scars in Asian skin—using microneedling and other approaches, Professor Mukta Sachdev

 Avoiding and dealing with complications caused by light and energy based aesthetic treatments, Professor Harry Moseley

 Fractional radiofrequency for the treatment of pigmentation, Dr Diane Duncan Skincare agenda

 Cosmeceutical treatment and avoidance of pigmentation in patients with skin types 3 to 5, Mrs Shashi Gossain

 Camouflage make-up, Ms Liz Allen  Treatment of rosacea using lasers and light, Dr Stephen Eubanks Open plenary session

 Review of Bruce Keogh cosmetic surgery report and CEN European standards for cosmetic surgery update, Mr Rajiv Grover and Mr Mike Regan

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AN EVENING WITH DR MICHAEL KANE Once again FACE has the pleasure of hosting another evening lecture session and in 2014 we have the esteemed pleasure of welcoming Michael Kane MD to the stage, to offer us his insights into the aesthetic community, how he made his way to the top of the pile and the methods he uses to stay there.

Dr Kane has been practicing out of New York City for over 15 years performing a wide variety of cutting edge cosmetic procedures, facial rejuvenation and injections, while also taking time to develop techniques, lecture across the world and teach others to practice at the top level. This evening session is geared for a lighter approach towards the concept of facial aesthetics and the journey of one particular individual who has helped the process of pioneering the facial aesthetic market place. There will be a drinks reception prior to this lecture.  faceconference.com/evening

In February we saw the long awaited response by the Department of Health to the Review of the Regulation of Cosmetic Interventions in England, published by NHS Medical Director Professor Sir Bruce Keogh and his team in April 2013. The government noted that it agreed with the overwhelming majority of the review’s findings and recommendations. However, sentiment of solid action is sadly lacking from the points made within the response, and the industry has been less than enthusiastic.

Overlying this we have a separate agenda being led by CEN—the European Committee for Standardisation (cen.eu) with input from representatives from the UK and the rest of Europe looking at harmonising standards for cosmetic surgical and non-surgical treatments across the European community.

FACE will play host to the key parties involved in takings recommendation forward from the Keogh report and those involved in European standards to explore the practicalities of how we can improve quality of treatment in the UK aesthetic market.

To view the full lecture programme for any of the above please visit our website faceconference.com

FACE

20%

FACIAL AESTHETIC CONFERENCE AND EXHIBITION

Save £100 on the price of a full delegate pass and pay just £399 if you book by March 31st. The pass entitles full access to all agendas across all three days of the conference, as well as a place at An Evening With Dr Michael Kane, and access to the exhibition and exhibitor workshops throughout the whole event.

To take advantage of this time-sensitive offer, book today by visitng our website faceconference.com or by calling 020 7514 5989. Our website includes the most up to date information on all agendas, exhibitors and speakers attending the UK’s premier medical aesthetic conference and exhibiton—FACE.

 INJECTABLES

 HAIR

 BUSINESS

DISCOUNT WHEN BOOKING A FULL DELEGATE PASS BEFORE MARCH 31ST 2014

 AESTHETICIANS

faceconference.com/register

Follow FACE Ltd on twitter @face_ltd and on Facebook facebook.com/faceltd for the latest updates

 EQUIPMENT

 SKINCARE  WORKSHOPS

FACE SOCIAL A night in Rio

Carnival fever will hit London in June, and we invite you to join us on Saturday 21st for a brand new event in 2014—the FACE Social.

With the added attraction of a small sports tournament —the World Cup hosted in Rio—medical aesthetic practitioners can enjoy a night of samba and caipirinhas at the newly opened One Embankment in the heart of London. On a warm summer’s evening, you can relax and network in a light hearted atmosphere to conduct some of the most important business of the FACE weekend.

 RESERVE YOUR PLACE NOW BY VISITING FACECONFERENCE.COM/FACESOCIAL OR CALL 020 7514 5989 

body language I CONFERENCE 21

The Exhibition at FACE As the FACE Conference has expanded in recent years, so too has the Exhibition. In 2014 FACE will host over 80 international exhibitors and is the largest medical aesthetic exhibition in the UK

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ver the past decade, the demand from exhibitors to utilise the FACE Conference as a platform to promote their products and services has increased year after year. So much so, that one of the key factors for FACE changing venue from the Royal College of Physicians to the QEII Conference Centre last year, was so that all companies could be accommodated. From 47 exhibiting companies in 2012, to 80 in 2013, FACE has expanded to include not only a huge scientific agenda across three days, but also a grand medical aesthetic exhibition to go with it.

FACE now hosts the largest medical aesthetic only exhibition in the UK which includes all leading manufacturers and distributors supplying clinics for a wide range of facial rejuvenation products and ancillary business support services. With very few stands remaining for the 2014 event, please visit faceconference.com/exhibitors for more information on how to book a stand.

Exhibitor workshops Over the years, Exhibitor sponsored Workshops have grown in popularity. Workshops give companies a platform and opportunity to deliver a product or service specific lecture and or demonstration over an hour long period. Companies will use their highly acclaimed KOL’s to reach out to the FACE delegates and present to them why their products and services can be an integral part of their clinic and practice. 2014 is no different with many of the Exhibitors already booking their Workshop slots. Please see below a list of companies who will be running a Workshop over the FACE weekend.  Adare Aesthetics  Aesthetic Source  Aqtis Medical  Coachhouse Medical  Galderma  Healthxchange  Invasix UK  Merz Aesthetics  Needle Concept  Solta Medical  Syneron Candela  Wigmore Medical—ZO SkinHealth European Symposium  Zeltiq

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EXHIBITION ONLY PASSES ARE AVAILABLE FOR JUST £50 PER DAY

The pass allows entry into the exhibition and exhibitor workshops on the chosen day. To book, visit faceconference.com/register or call 020 7514 5989

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INJECTABLES

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HAIR

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AESTETICIANS

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EQUIPMENT

PLATINUM SPONSOR  Merz Aesthetics, stand 77 GOLD SPONSORS  Galderma, stand 76  Wigmore Medical, stand 78 SILVER SPONSORS  Aesthetic Source, stands 11 and 12  SkinCeuticals, stand 36 and 39  Solta Medical, stands 45 and 46  Syneron Candela, stands 81 and 82 EXHIBITORS 3D Lipo, stand 27 Adare Aesthetics, stand 20 Aestheticare, stands 70 and 71 Allergan, stands 57 and 61 AQTIS Medical, stand 54 Avita Medical, stand 44 Body Language, stand 2 Biofibre Hair, stand 50 BTL Aesthetics, stand 9 Clinogen, stand 37 Coachhouse Medical, stand 24 Consulting Room, stand 1 Cytomedix, stand 73 Dermalux, stand 51 Dermaquest, stand 16 Device Technologies, stand 13 Eden Aesthetics, stands 65 and 66 H&P Design, stand 88 Hamilton Fraser, stand 64 Healthxchange, stands 79 and 80 Institut Hyalual, stand 75 Invasix UK, stands 4 and 5 IS Clinical, stand 3 JMSR, stands 67 and 68 Lifestyle Aesthetics, stand 41 Lumenis, stands 47 and 48 Lynton Lasers, stands 42 and 43 Magic Needle, stand 69 Meda Pharma, stand 19 Pharmaclinix, stands 52 and 53 Rosmetics, stand 86 Schuco, stand 56 Spectrum Technology, stand 21 Tavger, stand 38 TSK Laboratory, stand 89 Wesbites for Cosmetics, stand 10 Zeltiq, stand 7

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SKINCARE

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WORKSHOPS

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EXHIBITION

22 FORUM I body language

Skincare products Our expert panel provides recommendations on a range of skincare products for different indications, including sunscreens, growth factors and antioxidants

Anti-Ageing Q: What are your top three products on the market for anti-ageing, and why?

Dr Carl Thornfeldt: The difficulty we have in recommending products to patients, particularly in the US, is price point. If they want a product that has some measurable benefit but price is an issue, I’ll recommend a NeoStrata-type product, something with a primary alpha hydroxy acid (AHA) and a retinol-containing product. There are several on the market. If they want the best product on the market—the one, in my eyes, that has the most efficacy and has beaten all the prescription products—I would always choose Epionce.

Dr Joe Lewis: First of all, I’m not a doctor. I’m a chemist. For any anti-ageing skin care regimen, at the very base of my anti-ageing skin pyramid is skin protection.

You have to have a great SPF and antioxidant for DNA repair. That’s fundamental. If you’re not going to do that, you’re wasting your time with the rest of the regimen. That’s a consumer must-have.

What the consumer needs is a combination of a retinoid and AHA. These two ingredients have been the absolute pillar of dermatology for the last 30 years and for good reason. They really work and they really have an effect on the epidermis to decrease the appearance of lines and wrinkles. At the top of the pyramid are the “new age” ingredients, peptides and growth factors. You can get all of these ingredients in Priori or PrioriMD products.

Dr Beth Briden: I agree with the skin care model of retinoids, AHAs, antioxidants and sun protection. My top product is Skin

Actives—this combines all ingredients in only two specific creams.

There is a double-blind placebo-controlled study published in Drugs and Dermatology Journal in 2012 showing the clinical and histologic effects of this regime.

The product contains alpha, poly and complex poly (bionic acids) along with 1% retinol. The active ingredients are used synergistically and combined with N-acetyl glucosamine (NAG)—the main building block of hyaluronic acid.

When retinol is combined with the NAG, it increases collagen production dramatically.

The products also contain potent oxidants including Chardonnay grape seed extract, which is more potent than C and E combined on the ORAC scale, as well as a broad spectrum SPF 30 in the morning product.

The products have all been formulated to ensure maximum compatibility and effectiveness. Each

individual ingredient was tested scientifically and in a clinical study by itself and then together to ensure its effectiveness. I think it’s easier to use one or two products, such as morning and night creams, to get all the anti-ageing benefits rather than picking three or four differently-branded products to layer on without knowing if they’re compatible or if they’re cancelling each other out.

Dr Zein Obagi: We have to consider multiple factors when we address ageing. We have to make sure the product contains not only retinoic acid, retinol and a fruit acid, but also an anti-inflammatory agent. Ageing is an inflammatory process and if you cannot repair damaged DNA, the cells will not function.

If you don’t suppress inflammation, the cells will not function optimally and the anti-ageing benefits of any topical agent will not work.

I use retinol as a hero and retinoic

Ageing is an inflammatory process and if you don’t suppress inflammation, cells will not function optimally

body language I FORUM 23

Dr Beth Briden

Dr Joe Lewis

Dr Zein Obagi

Dr Carl Thornfeldt

acid as a therapy. Anti-ageing is not only using a substance; you have to know how it’s formulated, how much to use, when to use it and the synergistic effects. Retinol alone will not work if you don’t also load the skin with an anti-inflammatory agent and an anti-oxidant.

In terms of products, ZO Skin Health uses retinoic acid and retinol. I advise patients to load the skin with antioxidants in the morning, and to load the skin with retinol at night as a preventative measure. If you are doing therapy, fruit acid facilitates the penetration of certain retinoids which helps these products address damaged DNA and inflammation.

It seems like the same retinols and technology have been used for the last 20 years and there has been no development of treatment. New investment in skincare is going away from retinols.

Dr Joe Lewis: There is a huge amount of clinical support for the efficacy of AHAs and retinoids.

You can say both ingredients plump the epidermis, which pushes out fine lines and wrinkles. However, they do it by different mechanisms of action. With AHAs, we have a huge increase in glycosaminoglycans in the skin and more water— the raisin and grape effect. The raisin has no water so it shrivels and has wrinkles. If you pump water into it, it plumps up and you have a grape. This is how AHAs work.

But retinoids increase the number of cells in the epidermis, so increased epidermal volume comes from increased cellular mitosis.

The increased epidermal volume from AHA comes from increased moisture content, so the two together make a great marriage. But peptides and growth factors are the new thing. We now know the cell membrane is the brain of the cell—effector proteins and receptor proteins transfer messages to the DNA, deciding what’s transcribed and what proteins you make. We’re all protein machines, making 100,000 proteins that runs everything in our body, so all this is important too.

Q: Which growth factors do you think are the most effective?

Dr Joe Lewis: One of the problems with growth factors is delivery.

I’ve been involved with a lot of drug delivery technologies and the big question is how do we deliver these growth factors to have the maximum benefit? Does it work through a second messenger system? Is it being selectively absorbed at the follicle because the layer of stratum corneum is at its thinnest as you go into the follicular orifice?

We know there are benefits to their use but is it really worth the price for what you’re getting and do we really understand how they work?

Until we have a good, solid delivery system and corresponding explanation for it, I’m very sceptical of growth factors. The reason AHAs and retinoids have been used for so long is because there is such a huge body of evidence supporting them. Nobody doubts they work.

Also, how do we get the best result? We found in basic research at UC San Francisco that the driver for skin ageing is the damaged stratum corneum barrier which activates chronic, not acute, inflammation. The way to attack that is to optimise barrier function and reverse chronic inflammation with ingredients that deliver at therapeutic concentrations to the cell at the site you want to modulate.

Sunscreens Q: What are your top three choices of sunscreen products?

Dr Carl Thornfeldt: My three choices are all anti-inflammatory sunscreens: Epionce Ultra Shield SPF 50, which was the first antiinflammatory sunscreen on the market; Aveeno SPF 60 for babies; and the Neutrogena Full Spectrum 100. All three are among the other four anti-inflammatory SPF50 or higher sunscreens. A review in 2012 published in the Journal of American Academy of Dermatology showed that three or less anti-oxidants added to sunscreen provide no additional benefit; however, when seven anti-oxidants and antiinflammatories were added, there was additional benefit.

Dr Joe Lewis: I disagree with that evaluation. In that particular study, we clearly demonstrated the addition of antioxidants to a sunscreen had added benefit.

Another study I’ve worked on combined SPF 50 and an antioxidant—in this case, 1% chlorogenic acid—and the addition of DNA repair enzymes at various concentrations to show the cumulative effect in the prevention of cyclobutane pyrimidine dimers (CPD) and 8-oxo-guanine (8OG) lesions.

These are the primary cause of cell ageing, leading to mutation and skin cancer.

You can also now get great sunscreens in mineral formulations, such as CoffeeBerry and a PrioriMD formulation based on chlorogenic acid.

In terms of SPF, after you get past SPF 30, you really need an antioxidant and DNA repair. The SPF 50 used in most studies originated from a FDA council recommendation of a maximum number.

But Neutrogena markets the SPF 100 and it’s a good product.

Dr Beth Briden: I like to distinguish between facial and body sunscreens, for daily use, and for activities. For facial sunscreens I like Revision Intellishade. It has a green tea antioxidant plus a broad spectrum sunscreen. It’s tinted so patients don’t have to use a self-tanner to have some colour. SkinCeuticals has a nice physical mineral block and Skin Actives has a daily SPF with potent antioxidants for daily use.

For the body, I like a waterproof broad spectrum, UVA, UVB sunscreen with a sun protection factor of 30 or more. In the US, all sunscreens are regulated so brands aren’t as important as they all had to prove their sun blocking ability.

I agree that sunscreens containing antioxidants are more effective, but, they are also more expensive, and cost can be an issue when covering the whole body. Neutrogena is probably one of my favourite brands as they have a great variety of products from gels, creams and sprays with a broad range of SPF factors. For the body, I like the waterproof spray sport versions of Coppertone and Banana Boat as they’re lighter and easier to apply

24 FORUM I body language

with a quick spray. You just have to apply enough sunscreen to give the benefit.

Dr Zein Obagi: Sun damage and skin cancer are the most problematic skin problems we face.

They are on the increase, no matter how high the SPF. I do not agree that antioxidants don’t make a difference—they will make a big difference. But you have to distinguish how to apply sunscreen in two steps; first, load the skin with antioxidants and then apply sunscreen with SPF 30 and natural melanin.

ZO Skin Health Oclipse Sunscreen + Primer SPF30 is a sunscreen that addresses inflammation and the antioxidant issue. We don’t use chemical products; we use natural melanin, titanium dioxide and zinc oxide for broad-spectrum UVA/UVB production. We want to lengthen the sunscreen’s efficacy.

There are two Oclipse products—a tinted sunscreen oxidised melanin and a non-tinted fractionated melanin version. If you apply a sunscreen, no matter how high the protection, the SPF will come off in an hour and a half. The melanin is a very important issue, to protect the melanocytes from a negative response to UV exposure.

Dr Beth Briden: There is also an oral sunscreen for patients who are out every day in the sun. Heliocare capsules with the fern extract polypodium leucotomos, a very potent antioxidant to help protect against UV damage. But as this is taken as a daily supplement, you still need to use topical sunscreens as well.

Q: How would you advise to apply sunscreen?

Dr Joe Lewis: The key is you’ve got to put on a lot. When the FDA does a study, they apply about two decilitres per square centimetre which is a really thick layer. It’s been shown that if you reduce that, the reduction effect is exponential.

You put on one quarter of that amount and your benefit is only one-ninth of the original number.

Your SPF 33 is only giving you a protection factor of 4.5.

The amount you put on is really critical. So you put enough on so you can just see it, wait about half an hour for cool, dry skin, put an-

other amount on and that second application should be 30 minutes before you actually get your exposure because it needs to have enough time to bind to the stratum corneum and to bind down in the orifice of the follicle. If you put it on when you’re already hot and sweaty, it’s not going to work.

Dr Carl Thornfeldt: I agree with Dr Lewis. Few people apply sunscreen correctly. The average person applies only 25–40% of the recommended amount.

Dr Zein Obagi: You need to wash your face before you apply sunscreen because if your skin is clean and dry, the sunscreen will stay on better. If your skin is oily, you need to eliminate the oil that prevents the sunscreen from sticking to your skin.

As skin produces oil throughout the day, use the astringent from ZO Skin Health TE-Pads. If you have too much oil, you need to wipe the oil off.

Having oil on your face during the day is not disastrous, if you cleanse in the morning and at night. But if you don’t wash the excess oil off at night, that sebum is going to kill your skin.

Dr Joe Lewis: The key for making these product decisions is understanding the physiology of what you’re trying to do. Some of these new advances are intriguing and moving towards good results but the fact is, when we look at percentages of improvement, we’re still in

the 80–90% success rate. So why aren’t we at 100%?

No patient ever comes in and wants inadequate results. They want 100% success rate. Getting that rate is dependent on understanding the path of physiology and then modulating all those pathophysiological processes.

Q: Is it better to have an antioxidant in your diet as opposed to applying it topically?

Dr Joe Lewis: All of the above. You need a combination of oral and topical antioxidants.

Dr Zein Obagi: The dietary factor of an antioxidant may play a role, but is so far not proven because all the supplements that people are buying are not regulated. We don’t know if they are absorbed, therefore we don’t have any idea whether they work or not.

So a healthy diet is important— eat many different colours of vegetables, between 20–50 colours if you can, because each one is an antioxidant. But when it comes to delivery to the skin, the brain, the muscles and everything else comes first. Whatever antioxidant is left to reach the skin is not in sufficient quantity which is why I believe that topical application is essential.

Dr Joe Lewis: In our sunscreen study, we didn’t measure the inherent antioxidant content of the skin of the subjects in the study so we

body language I FORUM 25

A healthy diet is important when it comes to antioxidant intake, but topical antioxidant application is essential

just applied topical antioxidants.

We could clearly delineate that the topical application of coffeeberry had a tremendous effect. However, I’m not discounting internal consumption of antioxidants. Obviously you need that.

Dr Zein Obagi: We can’t forget that antioxidants play a role in inflammation. We need to address that. The body is bombarded with chronic inflammation, so a supplement of antioxidants is essential in a healthy diet. But applying antioxidants topically is not going to be sufficient for the body.

Antioxidants have a very short lifespan. Once you apply it to the skin, within about seven to eight minutes it becomes deactivated and is gone. It’s no longer in the skin and it doesn’t go into the cells, so the effect is not helpful for the body.

Dr Joe Lewis: The untreated skin shows the inherent amount of antioxidants that we have. In the study, we saw in all cases a tremendous increase in CPD and 8OG lesions post-UV exposure. After applying the antioxidant, you reduce those lesions so it must be from the topical antioxidant you apply.

The inherent level in the skin is from what you’ve been eating.

That is the control; untreated skin.

There are huge levels of CPD and 8OG lesions in untreated skin.

Maybe these subjects hadn’t eaten any antioxidants, but when we topically applied the antioxidant, we

reduced the problem. So the topical application and effect was proven.

Q: In terms of the link between sunscreen usage and vitamin D deficiency, are you making any alterations in your prescriptions?

Dr Carl Thornfeldt: This is a real issue. Dr Pearl Grimes is a leading expert in pigmentary disorders in the US—she spoke to the Academy of Dermatology two years ago about when she developed acute respiratory distress syndrome because her vitamin D levels were very low.

You have to look at vitamin D from two aspects. One, it’s affecting calcium metabolism and the level published in normal range is the effect on calcium. The problem is, for immune benefit and anti-tumour effect, you have to be above the median which in the US labs is around 65 units.

So the goal is not just to get to the bottom of normal range of 30 units, you need to be above the midpoint of about 65 to have the immune benefit and reduction of infection. The key with vitamin D is to get high enough levels.

However, if you look at all the nutrients out there, the number one for nutrient toxicity is vitamin D, in terms of more side-effects, frequency and severity, such as atrial fibrillation, and I often see people sent from a GP who have been given 50,000 units a week but the

patient has decided more is better and they’re taking 50,000 units a day. Then they end up ill.

So you have to be very careful.

The key is to titrate it so you’re at the mid-level of that range to get the immune benefit.

Dr Beth Briden: Coming from Minnesota—the northern latitude, where we don’t get much sun and a short summer vitamin D deficiency is a concern with using sunscreens—I tell patients to go out in the sun for ten minutes without a sunscreen and then to make sure they apply the sunscreen. Also, if they’re concerned I ask them to have their vitamin D level checked and then get appropriate oral supplementation.

Dr Zein Obagi: I would recommend to patients that while using sunscreen, they should expose their skin to the sun at a good time— like 8 o’clock in the morning—for 15 minutes. One of the studies I have participated in collected data from around the world and found that people who have been exposed to the sun, even in Africa, have low vitamin D levels in their blood. So supplementation of vitamin D is essential, on top of sun exposure.

Lightening agents Q: What are your top three product choices for lightening agents?

Dr Carl Thornfeldt: Epionce Melanolyte Skin Brightening System is my top choice, with MelanoLyte Tx and our new MelanoLyte Pigment Perfecting Serum. Secondly, La Roche Posay Biomedic Pigment Control.

Dr Joe Lewis: My first is methyl gentisate, which is a 1-3 benzoquinone so it’s very similar to hydroquinone but has shown to have no cytotoxic side-effects. Secondly, idebenone—the core of the idebenone molecule is a 1-4 benzoquinone and hydroquinone. It has also a de-pigmenting effect which is not cytotoxic. Finally, CoffeeBerry is full of depigmenting agents like chlorogenic acid, ferulic, caffeic and quinic acid. All three ingredients can be found in Priori and PrioriMD products.

Dr Beth Briden: I still like TriLuma. It has been off the market

26 FORUM I body language

for a few years in the US but it contains a retinoid, 4% hydroquinone and cortisone. In terms of cosmeceuticals, I’ve had excellent results from Enlighten. It’s by NeoStrata and contains 12 botanical lightening agents including chlorogenic acid which inhibits UV induced melanogenesis and a turmeric extract which has been shown to be as effective as 4% hydroquinone without the toxicity. Enlighten inhibits every pathway from the inflammation-causing hyperpigmentation to the tyrosinase-related protein and the packaging of the melanosomes and has been proven to be very effective.

Dr Zein Obagi: ZO Skin Health has Daily Power Defence that includes a highly stable retinol, antioxidants, and DNA repairing enzymes to help minimize UV oxidative damage and uneven pigmentation. If patients use Daily Power Defence on their face every day and at night, as well as the 1% retinol concentration in our ZO Ossential Radical Night Repair Plus, skin will become brighter and have a more even tone and colour.

Under-eye creams Q: Which under-eye products would you recommend for dark circles and wrinkles?

Dr Carl Thornfeldt: Epionce Intense Defense Serum provides all the key macro-nutrients and vitamins and nutrients required for the skin for it to function properly.

The Epionce Renewal Eye Cream has anti-inflammatory and barrier repair components to it.

Dr Joe Lewis: Any of our Priori eye serums under our HA line.

Otherwise, you can apply a little caffeine to reduce the puffiness, a mild AHA because the eye area is delicate and a low concentration of retinol. Ceramides, essential fatty acids and cholesterol are all important in barrier repair.

Dr Beth Briden: I do like the Skin Actives eye cream because it has N-acetyl glucosamine which is the building block of hyaluronic acid and can penetrate the skin.

It also contains the polyhydroxy acids that are non-irritating to further plump the dermis and provide

antioxidant/anti-infammatory effects to the skin. Unlike the plain AHA creams, it has caffeine and some optical brighteners to mask the darker circles. It also has a double-blind clinical study that was published showing its effects.

Dr Zein Obagi: My first choice for the eye area is ZO Medical Hydrafirm. It contains antioxidants, shea butter, enzymatic vasodilators, and caffeine. Retinol in low concentrations is useless. You have to go above 0.3 to 0.6 to have an effect.

However, I would not use too much retinol around the eyes. We have a very thin epidermis and once you screw up the barrier function, sensitivity under the eye will create inflammation and make pigmentation worse.

I recommend using antioxidants heavily under the eye and on the face. Within three or four weeks you will see reduction in wrinkles and pigmentation, and you will have a normal-looking lower eyelid.

Dark circles are not only pigmentation. If there is hollowness under the eye, it creates a shadow.

It is important not to make that mistake.

If you stretch the skin and see blood vessels under the eye, that also creates darkness under the eye.

So you have to address all three elements before you choose a topical agent.

Q: Do you prefer to use alpha hydroxy or polyhydroxy acids? Or beta hydroxy acids?

Dr Beth Briden: I like AHA’s, PHAs and bionic acids better than the beta hydroxyl acids.. Beta hydroxy acids would include salicylic acid which is fairly dehydrating to the skin and it is more irritating. So I would rather go with the alpha and poly hydroxy acids.

Alpha hydroxyl acids provide greater exfoliating effects but, may be irritating to some people with sensitive skin. I like to use them to provide a resurfacing effect to the skin.

The polyhydroxy acids and bionic acids are a great alternative as they are non-irritating and provide gentle exfoliation to restore the

skin. They are great for sensitive and dry skin.

Dr Joe Lewis: The absolute AHA of choice is lactic acid. It is the cell signal AHA in the human body.

We have discovered that lactic acid binds to the CD44 glycoprotein on the cell membrane in the fibroblast and sends the message that says we need to make hyaluronic acid. Hyaluronic acid is the natural moisture retention substance in the epidermis and dermis and you need lots of it.

You get great moisture retention and that’s how you plump out the lines and wrinkles. Lactic acid does this better than any other AHA. Dr Carl Thornfeldt: I agree with Dr Lewis. The activity of the lactic acid is very potent. Others that we’ve found that are very effective are malic acid and the BHA salicylates. The salicylates can be formed to have increased activity with decreased irritation.

We conducted research into the salicylates, combining salicylic acid with linoleate and a key signalling ion for barrier function—we had much faster and better penetration and produced a better cosmetic result.

In the double-blind prospective controlled trials combined with anti-inflammatory barrier repairing Epionce Renewal Facial Cream, this combination was statistically superior to the Renova which is emollient Tretinoin 0.05% cream in reversing photoageing.

Dark circles under the eye are not only pigmentation—if there is hollowness it creates a shadow

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body language I DERMATOLOGY 29

In a new light Hydroquinone is the controversial gold standard for skin lightening but there are a number of newer alternatives on the market. Dr Mukta Sachdev discusses current and emerging treatment options

I

n India, I generally work with Fitzpatrick skin types IV,V and VI. Contrary to the Western culture’s desire for tanned skin, there is a strong aspiration for a fairer skin complexion in many parts of the world. Across Asia— particularly in India, Japan and China—light or fair skin represents beauty, youth and affluence.

Tanned skin has long been associated with a lower socioeconomic status and regarded as a result of manual labour and working in the sun for long hours.

In the Asia-Pacific region, it’s estimated that $13 billion is spent annually on skin lightening products and these figures are rapidly changing. Around 15% of the world’s population invests in skin lightening products and Asia is the largest market. In India alone, $432 million was spent on skin lightening creams as of a recent survey.

A global survey showed that 33% of Chinese women use a lightening product daily or weekly, 62% in India, 55% in Japan, and 22% in Taiwan, Senegal, Mali and South Africa.

An Indian survey revealed that 80% of Indian men use lightening creams; this would once have been unheard in India but now it’s become common practice for men to choose a lightening agent as part of their daily skin care routine.

Safety We are constantly looking for safer and effective lightening agents.

Pigmentation is one of the most common complaints dealt with in both a clinical and an aesthetic dermatology outpatient practice.

I personally work both in a large private corporate hospital where the common conditions treated include psoriasis, eczema and bullous

diseases and run a private aesthetic dermatology office practice. In both settings, pigmentation is the commonest problem.

Hydroquinone is the platinum standard for treating pigmentation.

However, as dermatologists we are aware that it has its limitations and potential complications .While it is banned as an over-the-counter (OTC) agent in Europe and other parts of the world, the product is available by prescription so there is a misconception is that hydroquinone is a banned and dangerous; that we shouldn’t use it. Physicians worldwide continue to regularly prescribe it and, quite frankly, no other skin lightening product can compare to hydroquinone and the triple combination products.

The incidence of exogenous ochronosis is on the rise. The Journal of the European Academy of Dermatology and Venereology published an article saying that ochronosis is vastly underreported. It can often be misdiagnosed as melasma or hypermelanosis, but a simple skin biopsy confirms this condition.

Ochronosis is a definite potential side-effect of prolonged topical hydroquinone usage, so what are our treatment options?

Patients can stop the hydroquinone-containing products and use alternative lightening agents. However, unless ochronosis has been confirmed, it is a challenge to stop using hydroquinone—the product is almost universally recommended as induction treatment for facial melanosis, melasma or any form of hyperpigmentation.

Many physicians do not perform a diagnostic facial skin biopsy. Patients are often reluctant for this procedure, but it is now advocated for diagnosis. A two to three millimetre punch from the affected area provides a confirmed clinical diagnosis of the condition which one is treating and helps not only

30 DERMATOLOGY I body language

from a diagnostic and therapeutic perspective but also a prognostic significance.

Alternative agents Depigmenting agents target different steps in the production of melanin, most commonly inhibiting tyrosinase. The evidence-based agents are hydroquinone, azelaic acid, kojic acid, arbutin and certain liquorice extracts.

Other agents include retinoids, mequinol, ascorbic acid, niacinamide, n-acetyl glucosamine and soy, all of which have papers published and evidence to back them.

Certain procedures can also be effective in the treatment of postinflammatory hyperpigmentation.

However, there isn’t any one specific product or procedure for skin lightening. We have to combine our treatment modalities and often a combination of topical and procedures in now a routine regimen for the management of hyperpigmentation.

Cosmetic camouflage using make up has a place for the management of skin pigmentary disorders both in hyper and hypopigmentation. Melasma and other pigmentary disorders can be emotionally distressing and quality of life is seriously affected. If cosmetic camouflage is advised and patients are counselled this will have a significant benefit and the patients automatically become more compliant with medication. Cosmetic camouflage should always be included as part of the first line initial

treatment regimen or protocol.

The key thing to remember is that when you’re using a lightening agent, you are using it more often than not to target pigmentation.

Pigmentation is a dynamic process and will keep coming back, so it is important to adequately counsel the patient.

Topical mequinol has been tried and there is evidence to back it up.

Topical retinoids also have significant evidence to show they are effective for pigmentation. Topical azelaic acid works but there can often be significant irritation in darker skins.

In India, there is no problem with the availability of topical kojic acid and it is an effective therapy as a lightening agent. It is banned in certain countries, but many OTC products contain the ingredient. It definitely has its place in the management of hyperpigmentation, albeit in the maintenance phase of therapy rather than as an initial treatment option.

Vitamin C is effective but stability can be an issue so one needs to choose products where the stability is proven to ensure effectiveness of the active. However, in India, products containing vitamin C, particularly serums, tend to be more expensive. This can therefore become a constraint for patients.

Arbutin, liquorice, soy, glycolic acid formulations and hydroxy acids work very well. The percentage of active ingredients needs to monitored and often one needs to change the prescription according

Evidence-based depigmenting agents are hydroquinone, azelaic acid, kojic acid, arbutin and certain liquorice extracts

to seasonal variations, as even the topical hydroxy acids can cause slight irritation.

Mulberry and liquorice extracts can work well. Liquorice contains glabridin and licochalcone A, which both inhibit tyrosinase activity. Glabridin is also anti-inflammatory so it has a dual function. Liquiritin is the other active ingredient commonly being included in many lightening formulations. It does not inhibit tyrosinase but causes depigmentation through melanin dispersion.

Nicotinic acid, niacinamide and resorcinol also help—they’re not as effective as the gold standard, but they are definitely beneficial.

However, we are working in an era of evidence-based medicine, and most of the products available combine multiple actives. On average, any given lightening product contains between three and six lightening agents, with limited evidence to back them as they are mostly included in the cosmeceutical category where regulatory is less rigorous as compared to drugs.

The enzyme lignin peroxidase is one of the newer ingredients which has found a place in pigmentation treatment for hydroquinone-intolerant patients—especially for those with sensitive skin and who require maintenance therapy.

As most lightening products contain a list of active ingredients, we often don’t know which active is really working. There are not always clinical trials to support any independent active ingredient, depending on individual country regulations. In clinical practice, one should use a chromameter or mexameter and imaging system to document any improvement but how do we know which active is working?

When you’re evaluating a product, read the clinical trials. Has a chromameter been used? Has a Mexameter been used? What imaging has been performed?

If the study is carried out on six patients, this isn’t enough evidence to put it out on the world-wide market and say, “This is brilliant.”

We’re practising evidence-based medicine, so we, as physicians, have to make intelligent choices when prescribing for our patients in clinical practice.

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Emerging products Several oral and topical formulations are now available. There has been some interest about grape seed extract and pycnogenol—a trial in the Philippines involved the use of oral pycnogenol on 35 patients.

Topical ingredients include ellagic acid, resveratrol, linoleic acid, green tea extracts and mulberry tea extracts. Melanostatin is a new peptide available for topical use.

Tranexamic acid is generating a lot of interest in India, as regulation tends to be a little more relaxed. It is being used for the treatment of melasma, and there is now evidence in the worldwide literature supporting a potential benefit. There are now several ongoing controlled studies. However the drug has a number of side effects, including renal complications and needs to be evaluated thoroughly for this indication.

Trends seem to be favouring more aggressive treatments for lightening or when treating pigmentation. Home use peels are very much on the market and prescribed in stronger concentrations—many of the home use products contain 15–20% glycolic acid. This concentration is almost as strong as one performed in an office—and patients have access to this.

Natural ingredients are always of interest and currently include turmeric, tomato, tamarind and pomegranate. These are gaining popularity and generating a lot of interest in India. Tamarind is used extensively as a cooking ingredient and hair powder in India, and has garnered much interest for newer cosmeceuticals.

Fuller’s earth is also used for lightening in India and can be found in most households. It is easily available and people apply it regularly as a homemade face mask for fairness. Turmeric, or haldi powder, is a daily use Indian spice, mainly used in cooking and most Indian women will have, at some point, have applied it to their face for lightening.

cific habits, lifestyles and cultural traditions, it is extremely helpful in identifying and actually eliminating a lot of the causes. Pigmentation is therefore not just a melanocyte problem.

We now need to think out of the box for the medical management.

Studies examining the benefits of combining a vascular laser with a Q switch laser for melasma are ongoing, depending on the aetiology, and combination treatments for rosacea are now aimed at treating pigmentation.

Lastly, in order to effectively treat hyperpigmentation, it is imperative to try and make an accurate diagnosis. Pigmentation is a sign of ageing in darker skins.

An older Asian woman might come in with blotchy pigmentation—she may have freckles, or lentigines, and these are signs of ageing. They may not display wrinkles or deep nasolabial folds, but they will have pigmentation so we need to treat that. As a dermatological expert, counsel and educate your patients as to what you’re really capable of delivering in terms of benefit. Counsel and prescribe, because you need compliance.

Skin lightening actives are here to stay. The market is increasing rapidly and an informed educated physician has a range of treatment choices of active ingredients in their therapeutic armamentarium.

Combining treatments Combination therapies are the order of the day. Physicians worldwide are combining topicals with peels, lasers or other aesthetic procedures. However, there can be complications with darker skins when physicians combine treatments and the risks become higher with more potential skin damage.

Patient education is a critical part of our pigmentation management protocol—we regularly see patients who have applied topical home remedies, such as lemongarlic juice or toothpaste for acne, which has caused post-inflammatory hyperpigmentation persisting for six months post-application.

Recently a patient came to our outpatient with pigmented lesions on the nose and cheeks. On detailed history and examination she was found to have a habit of wiping her face because she was regularly exposed to cooking or heat, thereby developing frictional melanosis.

This emphasises the fact that when you are treating darker skins, it is important to keep in mind certain cultural or religious habits which the patient may not tell you about.

If you are aware of these spe-

Dr Mukta Sachdev is a Professor of Dermatology and Senior Consultant Dermatologist at Manipal Hospital, Bangalore, India and is also runs a private clinical practice and dermatology clinical research centre.

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Rosacea Dr Zein Obagi describes the four main subtypes of rosacea and how a comprehensive skincare regime can help to treat mild to moderate cases

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osacea is a chronic skin condition that tends to be common in fair skin types and is often referred to as “The Curse of the Celts”. It affects both men and women, most notably between the ages of 30 and 60, and typically begins as redness on the central face across the cheeks, nose or forehead.

In some cases it can also affect the neck, chest, ears, and scalp.

This chronic inflammatory disease of the skin can have devastating effects on an individual’s quality of life. Patients often show signs of depression and avoid social situations due to feelings of embarrassment and low self-esteem. Just a small fraction of the millions of individuals who suffer from rosacea are aware of this condition and seek treatment. An even smaller fraction of these individuals receive optimal treatment, which helps them cope with anxiety and other social stigma.

Symptoms Rosacea is a heterogeneous skin disorder. Flushing and persistent

Subtype 1: Facial redness, flushing, visible blood vessels • Flushing and redness in the centre of the face.

• Visible broken blood vessels or thread veins.

• Swollen skin.

• Skin may be very sensitive.

• Skin may sting and burn.

• Dry skin, roughness or scaling.

• Tendency to flush or blush easily.

redness are the most common early signs of the skin disorder. For some individuals, symptoms may only include mild, intermittent facial redness and flushing. For others, symptoms may be more severe and persistent such as redness, pustules, papules and telangiectasias, thickened, rough skin (rhinophyma) as well as ocular manifestations.

Many rosacea patients also report skin sensitivity and facial dryness.

Rosacea is cyclic, and flares may last for weeks to months after which symptoms typically abate.

Its progression can vary substantially from one patient to another.

It is a progressive condition with no cure, but it can be controlled and healthy skin can be maintained, often by using topical creams alone.

For more severe cases, oral medication or photodynamic therapy is occasionally required.

Long-term medical supervision is the best approach to treating rosacea. Delay of treatment may result in skin damage. As a skin disease, rosacea requires medical consultation and proper treatment

Subtype 2: Acne-like pustules • Acne-like breakouts, usually where the skin is very red.

• Flare-ups.

• Oily skin.

• Skin may be very sensitive.

• Skin may burn and sting.

• Visible broken blood vessels.

• Plaques.

from a qualified skin care professional Many patients present having used over-the-counter products to treat the condition with no improvement. These patients require medical care.

Rosacea is an inflammatory process, the specific cause of which is still unknown. Other factors that play a role in rosacea aetiology include hormonal fluctuations and genetics. In addition, hyperactive oil glands lead to increased sebum production. Increased sebum, in turn, irritates the skin to cause the inflammation and sensitivity that occur with the condition.

While there is no cure, effective treatment regimens do exist and can be tailored to individual symptoms and rosacea severity.

An important component of any rosacea treatment involves recognising and avoiding triggers.

These tend to vary by individual, but often include extreme temperatures, sun exposure, alcohol, spicy food and stress. Keeping a diary can help patients identify rosacea triggers.

Subtype 3: Thickening skin This subtype is rare but when it does occur, the patient often presents with signs and symptoms of another subtype of rosacea first. The signs of this type may include: • Bumpy texture to the skin.

• Skin begins to thicken, especially common on the nose, as in rhinophyma.

• Skin may thicken on the chin, forehead, cheeks and ears.

• Visible broken blood vessels.

• Enlarged pores.

• Oily skin.

Subtype 4: Eyes are affected Rosacea can also occur in the eyes with one or more of the following symptoms: • Watery or bloodshot appearance.A gritty feel, often feels like sand in the eyes.

• Eyes burn or sting.

• Eyes are very dry.

• Eyes itch.

• Eyes sensitive to light.

• Blurry vision.

• Visible broken blood vessels on an eyelid.

• Cyst on the eyelid.

• Loss of vision.

body language I SKINCARE 35

Subtypes Rosacea presents in many forms, so four subtypes typically identify it.

Redness, involuntary flushing or blushing, red capillaries over the cheeks and nose, rough texture due to large oil glands, large pores, oily skin, discolouration, acne-like cysts and nodules and dry flaky skin are all signs of dermatological rosacea.

Ocular rosacea often occurs simultaneously in the eyes and can affect lashes and eyelids.

Some patients may have more than one rosacea subtype at the same time. Each subtype also requires different treatment regimen.

Treatment The way I treat rosacea depends on the appearance of the skin and the stage of the condition. For milder cases, in which there may only be mild inflammation and no acne-type lesions, I recommend a daily skincare regimen to soothe and calm the skin and repair the skin barrier.

For moderate to severe cases, with redness, irritation and weak-

ened, oily skin, I prefer a combination of therapeutic treatments and daily at-home use of anti-redness products. The right combination of therapies, controlled peels and retinol products can improve the signs and symptoms of rosacea and restore skin to optimal health.

Dermatologists and skincare professionals should evaluate a patient’s skin condition before recommending therapy. More severe rosacea cases marked by telangiectasias, enlarged pores, papules and pustules often require a more aggressive treatment approach. For severe cases of rosacea, oral medicine or photodynamic therapy including intense pulsed light or vascular lasers may be indicated.

However, in most cases, rosacea can be well controlled and skin can look healthy with consistent use of a regimen of topical creams alone.

Dr Zein Obagi is a board certified dermatologist in Beverly Hills, California and Medical Director of ZO Skin Health, Inc.

Top: Before and six months after treatment with the Rosacea System Middle: Before and four months after treatment with the Rosacea System Bottom: Before and five months after treatment with the Rosacea System and 20mg oral isotretinoin

6-Step ZO Medical Treatment Process  Use ZO Medical Oilacleanse every morning and evening to exfoliate and cleanse skin and remove oil and other impurities that contribute to skin inflammation.  ZO Skin Health Offects Exfoliating Polish exfoliates dead skin cells and increases epidermal turnover. Patients should use two to three times a week in the morning or more often if skin is oily. This polish is replete with antioxidants Vitamins A, C, E, and C-Esters to help maintain skin barrier function.  ZO Medical Cebatrol oil control pads should be used twice a day.

These exfoliating pads contain an emollient complex to soothe skin and reduce redness. Mandelic acid helps reduce inflammatory agents that cause irritation and triclosan provides additional antibacterial benefit.  Patients can apply two or three pumps worth of ZO Skin Health Ossential Daily Power Defense to their face and neck each morning.

Including retinol, antioxidants and DNA-repairing enzymes that work around-the-clock, this therapy restores skin function and elasticity.  Nightly treatment with ZO Skin Health Ossential Radical Night Repair Plus or tretinoin. The Ossential product comprises a full 1% concentration of retinol to stimulate new cell activity and collagen production for strengthening and building skin tolerance.  Judicious use of a non-irritating sunscreen such as Oclipse-C SPF 50 or Oclipse SPF 30. Daily sun protection is important for all patients, but rosacea patients should be especially vigilant. Sun exposure is considered a major trigger for rosacea flares.

Other steps in this regimen are optional, including the use of prescription metronidazole gel 1%. Metronidazole decreases the redness, but is not a cure for rosacea. When using this regimen, it should be applied before ZO Ossential Radical Night Repair Plus for best results. ZO Ommerse Overnight Recovery Crème can be applied before ZO Ossential Radical Night Repair Plus or after tretinoin in the evening.

36 DERMATOLOGY I body language

Skin barrier repair Chronic, itchy skin conditions and inflammation can result from compromised stratum corneum function. Dr Carl Thornfeldt discusses the importance of barrier repair and optimisation, and his research behind the Epionce skincare range

M

y goal as a dermatologist has always been to achieve what I desired for my own chronic skin condition—to become clear and itchfree, and stay clear. When I began private practice, I believed people did not get better because the physician wasn’t intelligent enough or diligent enough to leave no stone unturned in searching for the cause of the disease. Within the first two years of practice, I realised how foolish this thought was.

Two diseases in particular were conundrums—polymorphous light eruption (PMLE) and asteatotic dermatitis (ASD). Both magically appeared and then resolved at specific times each year. This was unexplained by our understanding of skin function and structure.

PMLE is commonly known as “sun allergy”. The condition presents with itchy red bumps or hives, or dermatitis patches occurring at any sun-exposed site on the body, usually starting in the spring.

It is more common in patients who have allergies and sensitive skin. Despite our treatments, most PMLE patients completely cleared by early August.

ASD or “winter itch” would start during the winter holidays with itchy dermatitis, usually on the lower legs before spreading to the feet, hands and trunk. After months of battling this disease, ASD would spontaneously clear by mid-April. Moreover, our treatment success for completely clearing the common chronic scaly inflamed skin diseases like psoriasis and dermatitis was modest, but keeping them clear had a poor success rate.

Stratum corneum As I pondered these therapeutic dilemmas, I considered the facts.

PMLE resolved when the stratum

PMLE resolved when the stratum corneum thickened in response to solar radiation in summer

corneum was thickened in response to solar radiation as summer progressed. ASD resolved when the ambient humidity and warmth increased, causing the fractured, dehydrated stratum corneum to become supple and thickened.

In a scientific epiphany, I realised that in both cases, chronic inflammation resolved after the stratum corneum barrier was strengthened and thickened and that the inflammation and itchy dermatitis must also follow a compromise of the stratum corneum barrier. This made sense—the poorest barrier occurs at the sites of lowest sebum production, such as lower legs, and is also deficient in those with atopy.

This was also a partial answer for the treatment of chronic inflammatory scaly skin diseases and maintaining their remission. The standard treatment of corticosteroids was effective in reducing inflammation, but induced further

barrier thinning and disruption, allowing pollutants, radiation, microbes and chemicals to penetrate through to a greater degree.

Corticosteroids also stimulated the growth of these pro-inflammatory microbes—when the corticosteroid treatment was stopped, chronic inflammation roared back.

It also provided an explanation for Koebner response, where injury to the skin activates diseases like psoriasis.

The skin barrier compromise was therefore usually intertwined with the chronic inflammation that is critical in a significant number of skin disorders and conditions.

Dr Albert Kligman and Dr Robert Lavker reported that inflammation played a role in extrinsic skin ageing in 1988. But the question remained—how did the stratum corneum barrier and the chronic inflammation respond differently to their seasonal insults?

Twenty-five years ago, the epi-

body language I DERMATOLOGY 37

dermis was considered to be like a cellophane wrap of dead and inactive cells. I believed more scientific investigation in all physiologic aspects of skin barrier and cutaneous inflammation, including their regulation, was warranted.

That led to the scientific hypothesis: if we could optimise the structure and function of the skin, can we treat disease and conditions better and prevent them from flaring or rebounding? Moreover, could these morphologic adjustments impact visible skin ageing and even skin cancer incidence?

Barrier disruption Epidermal skin biology research carried out with Dr Peter Elias two decades ago resulted in the understanding of the brick and mortar skin barrier structure and destructive chronic vs. healing acute cutaneous inflammation.

We found that a variety of environmental exposures damage the skin by disrupting the skin barrier, inhibiting its repair which then activates multiple inflammatory cascades that damage existing cutaneous structures.

Damage can be caused by not only pollution, sunlight, smoking and poor diet, but also X radiation, heat, premature or elderly age, humidity extremes, high testosterone, low oestrogen, severe emotional and physical stress, ingestion of lipid-lowering medications, insufficient consumption of “good” fats, excess consumption of “bad” fats and sugars and exposure to heavy metals in diet and contacting in workplace.

A number of compounds used in therapeutic products for skin diseases and conditions—including propylene glycol, lactic acid, retinoic acid, as well as preservatives formaldehyde, quaternium 15 and sodium lauryl sulfate—not only induced barrier disruption, but activated inflammation by releasing tumour necrosis factor alpha.

Further research showed that skin conditions and diseases characterised by chronic inflammation coupled with a compromised permeability barrier, include visible skin ageing and also sensitive skin; all dermatoses (eczema), including atopic, seborrheic, chronic contact

and asteatotic; most types of ichthyoses, keratosis pilaris, rosacea, PMLE, certain types of psoriasis and premalignant actinic keratoses.

The foundation for the most effective treatment and longest lasting remission of these diseases therefore rests upon optimising barrier function and safely reversing and preventing destructive chronic inflammation.

Inflammation Chronic inflammation is activated in the epidermis and dermis by persistent or recurrent barrier disruption of any cause in two ways. First, protective endogenous inflammatory pathways are activated by the release of biologic response modifiers sequestered in granules within the deepest stratum corneum corneocytes—released when these cells extrude the granules that are disrupted with stratum corneum injury.

Secondly, pro-inflammatory insults penetrate at a much greater amount and depth that magnifies its inflammatory effect.

We have discovered that five pathways of inflammation are activated with stratum corneum barrier damage from any cause.

The first four include the release of cytokines, such as interleukins and tumour necrosis factor alpha, growth factors such as transforming growth factor beta, histamine and nuclear receptors such as PPAR and LXR. All these paths ultimately upregulate matrix metalloproteinase enzymes (MMPs) that destroy cutaneous structures inducing micro scars that progress to wrinkles, dysplasia that progresses in to skin cancer and sensitive skin.

Bacterial and yeast invasion that is increased with barrier damage also upregulates inflammation via toll-like receptor activation.

Two other cutaneous inflammatory pathways not related to barrier disruption include glycation reaction and the upregulation of arachidonic acid synthesis, a group of pro-inflammatory molecules Acute inflammation is characterised by polymorphonuclear leukocytes infiltration, proliferation and chemotaxis which is necessary for protection and initiating repair.

It converts into chronic inflamma-

tion 12–20 days after the skin is damaged.

Chronic inflammation, on the other hand, is characterised by lymphocytic cell infiltrate and upregulation of MMPs. With frequent, recurrent or prolonged insult, accumulation of excessive amounts of MMPs results in excessive damage of collagen and elastin fibres and glycosaminoglycan ground substance.

Reversing and preventing this destruction is needed with therapeutic ingredients focusing on chronic inflammation, while at the same time attempting to slam the incompetent skin barrier shut.

A variety of environmental exposures damage the skin by disrupting the skin barrier, including excess consumption of “bad” fats and sugars

Repair Barrier repair utilises five pathways that lead to increased keratinocyte proliferation then to enhanced differentiation into the corneocytes— protein bricks of the barrier—with rejuvenation of lipid lamellae mortar located between these cells.

The normal stratum corneum barrier requires the key physiologic lipids, cholesterol, ceramide and free fatty acids, in a specific molar ratio to maximise repair and optimise barrier function.

Many different ratios were tested but the ratio ultimately found to be most effective to accelerate barrier repair nearly 2.5 fold over any other ratio was cholesterol 3; ceramide 1; and linoleic acid 1.

Our research also found that it was not possible to produce chemically and visually stable results us-

38 DERMATOLOGY I body language

insult patch test, which tests for irritant and allergic contact reactions. Neither was induced by this formulation.

The key test to determine if a product is effective is a double blind prospective controlled clinical trial graded by third party investigators with enough human subjects to determine statistically significant value. It is the marketed, final formulation that should be tested for true efficacy.

This type of study is not required to market a cosmeceutical, but there is no other scientifically valid method to determine the effectiveness of a product. As a physician, I felt it was critically important that any new products claiming to be effective for any skin condition should adhere to this standard for efficacy and safety.

I settled on a barrier repair formula based on extracts of safflower, mountian rose, avocado and flax

ing known synthetic ingredients at that time. Our search therefore turned to herbal extracts that each had multiple biological functionalities within the skin.

In nature, these herbs contain stable but biologically active molecules that perform many different functions for the plant. After years of research, I settled on a barrier repair formula based on extracts of safflower, mountain rose, avocado and flax to achieve the optimum ratio of barrier lipids and their precursors.

This product accelerated barrier repair more than twice as effectively as 100% petrolatum and four times better than any commercially available moisturiser product used by the dermatology community.

Additionally, an anti-inflammatory formulation was created based on extracts of date, meadowfoam, apple, flax and avocado, all of which were more potent than grape, olive, teas and soy, respectively. This product inhibited chronic inflammation 2.5 fold better than 1% hydrocortisone.

The barrier repair and antiinflammatory components were formulated together and tested for safetyâ&#x20AC;&#x201D;patients expect products to be effective and safe, just as those determined for procedures and prescriptions. This test was a repeat

Study These barrier repairing (BR) products that also reverse and prevent chronic inflammation (AI) have been tested against six different prescription products and were superior to all six. Initially, retinoid induced contact dermatitis was effectively treated to a statistically significant degree that was superior to mometasone.

This BR product was used twice daily with a once daily comedolytic, anti-inflammatory (AI/C) product. It was compared to emollient tretinoin (ET) 0.05% once daily combined with a moisturiser containing lactic acid twice daily, to assess impact upon visible photoageing.

In a six-month trial on 25 subjects, the BR/AI/C regimen was numerically superior in reducing tactile roughness, fine lines, wrinkles, clarity and visible actinic keratoses while ET was numerically superior in reversing mottled hyperpigmentation and laxity.

But histologically, the combined BR/AI and AI/C products statistically significantly (p<0.05) increased epidermal glycosaminoglycans by 13.3%, double that of ET. On dermal ultrasound, BR/AI/C produced a highly statistically significant (p<0.001) doubling of the dermis, by 20.8%, measured by density versus ET. No subjects experienced true contact dermatitis to BR/AI and

AI/C with 20% noting only transient eyelid erythema. The ET product subjects experienced frank contact irritant dermatitis in 40%.

To prove a concept is valid, a second formulation (BR/AI/C) with different ingredients but same mechanisms of action for the concept is required. This related product contains potato and yeast peptides to further increase barrier repair and an anti-inflammatory triterpenoid that also realigns elastin fibres (ursolic acid) was formulated with a low concentration of azelaic acid.

A 12-week study against the most potent antioxidant product on the market at that time containing idebenone was conducted.

After six weeks of use, this related BR/AI/C product was statistically superior (p<0.05) in reducing shallow wrinkles, triple the efficacy of idebenone and twice as effective in reducing laxity and hyperpigmentation. It was also superior in reducing roughness and improving clarity.

One third of the idebenone patients dropped out of the study after the six-week time point because of moderate to severe contact irritant reactions. When compared to the ET trial, BR/AI/C improved dermal density by a highly statistically significant 19.4% at 12 weeks as measured by extensibility twice as fast as in the ET study.

One BR/AI/C subject dropped out from eyelid irritation. This was the only subject using BR/AI products based to drop out of any of the 15 blinded clinical trials that included 390 subjects.

Since this project began, a total of 15 blinded clinical trials have been performed with BR/AI, AI/C and BR/AI/C products. These products were designed to focus on the foundational mechanisms of skin diseases as skin ageing, which includes repairing and optimising barrier function while reversing and preventing inflammation.

The data shows that this concept is not only novel, but has become a valid cosmeceutical offering superb safety and efficacy for treating photoageing.

Dr Carl Thornfeldt is a dermatologist and founder of Episciences, W: epionce.com

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40 HEALTH I body language

What’s in your emergency bag?

Julie Brackenbury discusses the incidence of medical emergencies in aesthetic practice such as necrosis and anaphylaxis, and how practitioners can prepare for them ing and Alexiades-Armenakas, the FDA received 930 post-marked reports of adverse events between 2003 and 2008, of which 823 were deemed severe and 638 required medical treatment and follow-up.

M

ost injectable fillers used in medical aesthetic treatments have a low risk of systemic reaction. However, local anaesthesia can cause anaphylactic reactions—although this is rare— and it is possible for patients to collapse due to circulatory imbalance.

One example could be treating the upper lips with insufficient local anaesthetic. We know that anaphylaxis can present in many ways and is crucial to be aware of the reactions that can occur. These include: cutaneous reactions such as erythema, pruritis, uticaria, angioedema and swelling; changes in the oral mucous membrane, respiratory changes and respiratory

obstruction due to oedema of the larynx and epiglottis.

Anaphylaxis is a severe, lifethreatening, hypersensitivity reaction to the release of histamine and other inflammation mediators by mastocyte and basophil cells following antigen stimulation within the body. Anaphylaxis may also occur as a reaction to commonly prescribed medications such as antibacterials, aspirin and other nonsteroidal anti-inflammatory drugs and vaccines. In rare cases, some patients may have a severe allergy to latex.

Although aesthetic treatments with injectable dermal fillers are considered to be safe, adverse events can occur. According to Luebberd-

Necrosis The most severe and early onset complication requiring immediate medical attention is impending necrosis. Injection necrosis is rare, but a potential clinical complication caused by interruption of the vascular supply to the area by compression, injury and/or obstruction of the vessel or vessels. The glabella is a particular danger zone for injection necrosis, regardless of the type of filler used.

The difficulty is that most dermal fillers have not been the subject of well-designed studies. Also, the management of both acute and systemic reactions is often difficult and requires inflammatory and, occasionally, immunosuppressive therapy. Nevertheless, intravascular injections and infection may not be entirely technique-dependent and must be managed swiftly and effectively.

There are few reports about hypersensitivity or allergic responses due to aesthetic botulinum toxin type A (BoNTA) treatments. Serious adverse events are more likely to be reported for therapeutic than for cosmetic use, which may be related to higher doses, complicated underlying diseases or both.

Numerous departures from FDA-approved recommendations for drug dose, dilution, handling, site of injection, and storage have been noted in previous reports.

Conversely, in 2005, Li et al reported that the first death documented with BoNTA was associated with BoNTA-lidocaine mixture given to a female patient for chronic neck and back pain. Based on the medi-

body language I HEALTH 41

Adult basic life support UNRESPONSIVE?  Shout for help  Open airway  NOT BREATHING NORMALLY?  Call 999  30 chest compressions  2 rescue breaths 30 compressions

cal records, autopsy and laboratory findings, the cause of death was determined to be anaphylaxis to the BoNTA-lidocaine mixture.

Although the anaphylaxis cannot be definitively proven to be caused by BoNTA alone, this case warns of an adverse reaction in a drug that has become trivialised in medical aesthetics.

To avoid reactions, it is important to note that those who have had an allergic reaction to the tetanus immunisation should refrain from having BoNTA. In addition, patients with egg allergies may have an increased likelihood of an allergic reaction since the BoNTA molecule is stabilised by human albumin, a protein similar to egg albumin. BoNTA is contraindicated for patients with known hypersensitivity to any ingredient in the formulation, including albumin.

Medical history It is widely taught that a diagnosis is revealed in the patient’s history.

“Listen to your patient—they are telling you the diagnosis” is a much quoted aphorism and the same applies to obtain any allergy history.

During consultation, some patients will admit to being allergic to certain medications. The question is: if you are consulting what you perceive to be a highly atopic patient, would you treat them? If in doubt, don’t treat them and inform them why.

Advise them that they are at high risk of a reaction and, if they are to seek an aesthetic consultation elsewhere, it is imperative they must inform the practitioner. Un-

fortunately, in some cases, patients are not always transparent in their past medical history. However, it is crucial they are made aware of the allergic risk upon them.

Aesthetic practitioners all have a duty of care, which includes identifying and managing risk to their patients. The principle of “duty of care” was established by Donoghue v Stevenson in 1932, where Lord Atkin identified that there was a general duty to take reasonable care to avoid forseeable injury to a “neighbour”.

Failing to provide a duty of care is the most common reason to be sued for negligence. What must be acknowledged is that those working in aesthetics owe their patients a duty of care by ensuring that the correct emergency drugs and equipment are to hand.

Knowledge The most serious reactions can be reduced through a greater understanding of the area being treated.

Injection necrosis in the glabellar region may be prevented through knowledge of the local anatomy and an understanding of its pathophysiology, and then treated with a suggested protocol.

Practitioners should be aware of early intervention and treatment options, should impending necrosis become apparent. So why are nonhealthcare practitioners even being discussed in the recent government’s response to the regulation of cosmetic interventions? All of these treatments require training and experience. The policy is supposed to protect patients from avoidable harm and is therefore contradictory.

Thankfully, emergencies do not regularly occur in aesthetic practice, but it could be argued that staff may regard preparing for them as a low priority. There may also be a general lack of confidence in dealing with them.

Human nature dictates that we may be less prepared to deal with emergencies due to their rarity and discount the importance of the problem and need for preparation.

Do not wait until you have a problem before considering how you will manage it.

Each aesthetic skillset is vari-

able, so there will never be a tailored, standardised kit. Risk assessment should reflect the level of competency. So, if you do not have a medical emergency kit that is tailored to your practice and competencies in conjunction with appropriate protocols, or have not updated your annual accredited basic life support training, now is the time to do so. This will also ensure that future revalidation checks may go more efficiently.

Miss Julie Brackenbury is an aesthetic nurse specialised based in the South West and is a board member for the British Association of Cosmetic Nurses. E: julie@jbcosmetic.co.uk References 1. De Maio, Mauricio, Rzany B. “Botulinum toxin in aesthetic medicine”. 2009 Springer 2. Ackaoui A. “Treatment of anaphylaxis: EpiPen, Twinject, or another autoinjector?” Can Fam Physician 2011 57(3):273-4 Joint Formulary Committee. British national formulary. ed. 2013 Vol. 65. Pharmaceutical Press 3. Lee A. Adverse drug reactions. 2006 Pharmaceutical Press.

4. Wade J. “Care of the type 1 latex allergy patient.”

Australian Nursing Journal: ANJ, The 2012 19.9 : 30 5. Luebberding S, Alexiades-Armenakas M. “Safety of dermal fillers”. Journal of drugs in dermatology: JDD 2012 11.9: 1053-1058.

6. Glaich et al. “Injection Necrosis of the Glabella: Protocol for Prevention and Treatment After Use of Dermal Fillers Dermatologic Surgery”. 2006 32: 276–281 7. Dayan S. “Complications from Toxins and Fillers in the Dermatology Clinic: Recognition, Prevention, and Treatment.” Facial plastic surgery clinics of North America. 2013 21.4: 663-673.

8. Alijotas-Reig et al. “Inflammatory, immune-mediated adverse reactions related to soft tissue dermal fillers”.

Seminars in Arthritis and Rheumatism. 2013 43: 2 241–258 9. Cote et al. “Botulinum toxin type A injections: Adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases”.

Journal of the American Academy of Dermatology 2005 53: 3 407–415 10. Braun et al. “Botulinum toxin type A injections: Adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases”. Journal of the American Academy of Dermatology 2005 53.3 11. Li et al. “Fatal case of BOTOX-related anaphylaxis?”

Journal of Forensic Sciences 2005 50.1 169-172 12. Bitar et al. “Botulinum Toxin for Facial Rejuvenation”. Advanced Surgical Facial Rejuvenation. 2012 Springer Berlin Heidelberg 219-229 13. Sibson, L. “A duty of care”. Journal of Paramedic Practice 3. 2011 11: 601-601.

42 REVIEW I body language

Call to account The new Cosmetic Regulation requires that all cosmetic products sold in the EU meet specific criteria and that a ‘responsible person’ must be designated to legally ensure their safety.

Cliff Betton runs through the implications of the EU Cosmetics Regulation

I

n July 2013, the EU Cosmetics Regulation (EC No. 1223/2009) came fully into force, replacing the existing national laws based on the EU Cosmetics Directive (76/768/EEC), which covered companies manufacturing and marketing cosmetics across the EU. Companies now have to ensure compliance with the new requirements for both cosmetic and medicinal products.

To work out if a product is a cosmetic or a medicine, the Medicines and Healthcare products Regulatory Agency (MHRA) provides definitions for cosmetic and medicinal products and has the final say in any cases of doubt: the various regulations define cosmetics as focusing on cleaning and changing the appearance, while medicines protect against and prevent disease. All products sold in the EU will come under one or the other of these two regulations, but not both.

The MHRA provides guidance for “borderline products”—those that may contain pharmacologically active substances or make medicinal claims and are therefore difficult to distinguish from medicines. Unfortunately this guidance can be confusing. For example, the product statement “protects against” is considered as a medicinal claim. A sunscreen can protect against sunburn, so does that make it a medicine? According to the law, it’s regulated as a cosmetic but clinically, this protection implies a medicinal claim.

Clinical trials imply a medicinal claim.

However, most of the products advertised as cosmetics would be medicines if following that aspect of MRHA guidance.

Only products that comply with the Cosmetics Regulation can be placed on the EU market.

Responsible person Under the new regulations, a designated “responsible person” within the EU must take control of, and legal responsibility for, all aspects of product safety. Previously, if you were marketing, importing or selling a cosmetic, you were automatically responsible. You can now however, by written mandate (or contract), pass

Role of the responsible person

that legal responsibility onto a third party, who then has to ensure compliance.

So who is the responsible person? If you’re manufacturing, shipping the product out and somebody else is bringing it back into the EU, the importer becomes the responsible person—something could have happened to it outside. If you’re a trader, importing the product into the EU, or a distributor taking a product already on the market and doing something to it—even just changing the name on the label—you then become the responsible person. As a basic rule of thumb, the company with their name on the product is the Responsible person.

Responsibilities All aspects of safety, from choosing the raw materials and their specifications and putting them together in the factory, to how the factory operates, is the responsibility in Law of this person. The management of labelling claims, testing and

safety of a product is a complex and specialised task. The responsible person also has to monitor and resolve any negative findings such as customer complaints, skincare issues and adverse events related to the product.

The responsible person needs to work with all parts of the supply chain. Everybody involved in the process of making a cosmetic product has some involvement with the responsible person to ensure that the product is safe, that it complies with the various articles of the regulation and, if anything goes wrong, they can do something about it.

There also has to be an up-to-date file of information—the Product Information File or PIF—that includes all complaints related to a product and what action has been taken to resolve them, for a period of ten years following the last sale of the product; not from the day it’s put on the market, but for ten years after it has finished being sold. The PIF can be

body language I REVIEW 43

kept electronically—there is a set amount of data has to be included and it must be in a language that’s easily understood by the competent authority in the country where the file is located. However, you only have one PIF and Registration for the whole EU. The responsible person gets involved with every aspect of product safety, not just from the specification of the raw materials right through to customer complaints, but also with the wording of marketing materials.

With respect to product claims, if you are saying that a shampoo cleans hair, you do not have to be able to prove that claim. If, however, you make a claim that a product makes consumers look ten years’ younger, such a claim must be substantiated by scientific study; it is no longer acceptable under the Regulation to extrapolate from results in-vitro for an ingredient, claim substantiation must be proven for the product.

The responsible person must also carry out a safety assessment. The product must be made to good manufacturing practice, which involves auditing factories. There is an online EU portal for registering products, following registration as an individual or a company on a separate website.

Restricted substances In the Regulations, restricted substances and prohibited materials are shown in the Annexes. Carcinogens, mutagens, reproductive toxins and nano-materials are specifically excluded unless they are approved by an EU committee called the Scientific Committee on Consumer Substances (SCCS), which produces opinions and reviews three or four times a year.

This is a continual upgrading and monitoring process that you also have to do if you’re manufacturing or importing cosmetics into the EU. What was allowable

in July may be prohibited in August so constant vigilance is necessary.

There is a complete ban on animal testing of products and ingredients, so product safety is assured on the basis of a professional assessment of available data.

Animal testing hasn’t been allowed in the UK since 1995. However, the practice is common in other countries and there is misunderstanding about this issue.

The law says you cannot test on animals for the purposes of ensuring cosmetic safety according to the regulation. This means that if you are required by another Law to do animal testing for another purpose, such as selling in China where it’s mandatory to carry out animal testing, or Compliance with the REACH Regulation in Europe, it does not mean you cannot sell a product in Europe. You just have to provide a statement declaring why testing was carried out. You need to be aware of that differentiation particularly as some retailers have a policy of “no animal testing” when, in reality, historical testing has been done for most ingredients and is mandatory for new substances.

You are also required to give public access to some product information. You have to be able to tell the authorities what is in the product. You also have to survey the market constantly and liaise with authorities if something goes wrong.

Product safety A safety assessment is required, including instructions for safe use and disposal of the product and how many times a day the product is used. You don’t have to conduct the tests yourselves; other people can carry out testing as long as you make sure that they’re suitably qualified. There could be a potential conflict between the views of someone ensuring safety and the manufacturer, who says: “No, we want to sell it and make lots of money.” However, the responsible person has legal responsi-

bility for these things, and it is they who could end up in court, not necessarily the manufacturer.

Factories should be audited, on average, once every two years. If it’s a factory with a long history of good performance, it might be every three years. If there have been problems, it might be every three to six months until you decide they’re improving or to go somewhere else.

Samples need to be taken off the production line and sent away for analysis. It needs to be proven that key ingredients are what the supplier says they are. As the responsible person, you have to do this in such a way that the supplier is aware that you’re doing it as it will keep them honest.

Information on where the product is manufactured and where it’s first imported is distributed by the EU to all the countries where it’s sold. Each EU member state will have its own regulatory authority who will look after things in their country—they then liaise with their equivalent in another country if something goes wrong.

Cliff Betton is a zoologist by training and Founder of Delphic HSE Solutions Ltd. References REGULATION (EC) No 1223/2009 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 30 November 2009 on cosmetic products.

COUNCIL DIRECTIVE of 27 July 1976 on the approximation of the laws of the Member States relating to cosmetic products (76/768/EEC) GUIDANCE ON TOPICAL PRODUCTS FOR ANTI-BACTERIAL, ANTISEPTIC, ANTIMICROBIAL, GENERAL DISINFECTION AND CLEANSING OF SKIN Details about the work of the Medicines Borderline Section can be found under letter “B” in the A – Z search facility. At www.mhra.gov.uk

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body language I SURGICAL 45

Prominent ears Ear deformity is a common aesthetic complaint among children and adults. Mr Shailesh Vadodaria describes the non-surgical and surgical treatment options for correcting prominent ears

A

prominent ear is classified as the absence or poor formation of the anti-helical fold. A prominent ear can also have an obtuse concho-mastoid angle behind the ear so that it protrudes away from the head. It is an aesthetic deformity and doesn’t affect the function of the ear.

Prominent ears occur in approximately 1–2% of the UK population. The condition is often passed down through a family and can occur in only one ear or both ears. In India, prominent ears are considered to be a sign of good luck and the larger the ear lobes a person has, the greater their intellect is.

Many parents therefore choose not to correct their child’s prominent ears. However, in countries like Africa, prominent ears are considered a sign of bad luck and so parents would want to fix their child’s prominent ears as soon as possible. A prominent ear can be known by different names in other countries, such as “elephant ears” in Eastern countries or “jug ears” in the Western world.

Indications There are many reasons why a person may choose to correct their prominent ears. A child with prominent ears will have ears close to adult size when they are six years old, making the abnormality more noticeable. This can lead to bullying and teasing.

Some adults have said that the name-calling has had an effect on their self-esteem and so makes them shy around people.

It can also affect their behaviour at family functions and make

A child with prominent ears will have ears close to adult size at six years old

it unlikely for the person to want to take any pictures to remember the event. It can also make it harder for those in certain professions to do their job—a builder, for example, wouldn’t be able to hold a pencil behind their ear.

The operation is performed under general anaesthesia in children.

In adults and young adults the operation can be performed under local anaesthesia, but a patient can choose to have it under general anaesthesia instead.

There are some advantages for an adult having the operation done under local anaesthesia—the procedure is safe, simple, cost effective and time efficient. The patient is awake and aware so finer refinement can be possible at the end of the procedure and the bandage is

easier to wrap around the head of the patient.

Techniques There are different approaches as to how to correct a prominent ear.

One non-surgical approach for children is referred to as “moulding”. A mould is made to gently reshape the child’s ear cartilage which is softer and mouldable for a short time after birth.

These moulds would have to be worn by the baby all day and every day for the first few months. Although it is a non-invasive technique, it may not correct prominent ears in all children.

It can be very demanding for parents and may not be very comfortable for children. Children who did not have the benefit of mould-

46 SURGICAL I body language

ing during childhood or the moulding was unsuccessful can have surgical correction of prominent ears after five or six years of age.

The operation, called a pinnaplasty, can utilise various surgical approaches. The most frequently used procedure is where a dumbbell-shaped incision is made behind the ear and skin is removed.

The cartilage is pinned down with permanent stiches to allow it to bend backwards towards the head.

Sometimes it is necessary for a small part of the cartilage to be removed to complete the procedure.

Dissolvable stiches are then used to suture skin. A dressing is placed to keep the ear comfortable and in place. The operation usually takes between one to two hours.

The suture technique is safer than scoring as it is less invasive and there is minimal danger of conchal cartilage infection. It is also easier to revise if the suture technique is used instead of scoring.

Postoperative care The dressing is kept on for up to seven days as it is important to keep the ear in place following surgery.

It is necessary for the ear to remain undisturbed so the site must not be scratched. After the dressing is removed, patients are given a headband to wear for six to twelve weeks at night only. Swimming and contact sports should be avoided for four to six weeks.

As with any operation under general anaesthetic, there is a risk of complications related to a patientâ&#x20AC;&#x2122;s heart or lungs. There is also a minor risk of infection but the surgeon will prescribe a course of antibiotics and pain control medication. There is a small chance of keloid scars formation, but these can be addressed with a minor procedure at a later date.

Rarely, the ear might begin to protrude after the surgery so the operation will be performed again.

There are also possibilities of bleeding, undercorrection, overcorrection and asymmetry, which may require revisional surgery.

Mr Shailesh Vadodaria is a consultant aesthetic, plastic and reconstructive surgeon based in Harley Street

Before and after surgery on a female patient for an obtuse concho-mastoid angle behind the ear

Below: The absence of the anti-helical fold is a common aesthetic deformity in those seeking surgical correction

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48 INSURANCE I body language

Protect your practice Eddie Hooker discusses the pitfalls of medical malpractice insurance, how to prevent claims occurring and how to deal with complaints for elective procedures

M

any things can go wrong in all types of cosmetic procedures—poor patient selection, treatments not being fully explained or possible complications not being mentioned.

The majority of complaints and unsatisfactory outcomes tend to arise from elective patients in comparison to medical patients due to higher expectations for a treatment they will be paying a considerable amount of money for.

Over the last ten years within the aesthetic industry, many more experimental procedures have been introduced, and existing products and treatments are being used for different areas of the body. There are a lot of adverse outcomes with these pioneering treatments, some of which go away quickly, some of which can linger, but the whole purpose of aesthetic medicine these days is to offer much more of a temporary procedure. Most of the initial side effects do wear off, but practitioners aren’t always explaining this correctly to their patients. Complaint management is probably one of the biggest areas where we see things going wrong, complaints are made and the practitioner doesn’t know how to deal with them.

Aftercare is another area which in many cases is pretty poor and could do with improving. There is a growing problem with the quality and composure of patient notes by the practitioner. This may sound surprising as you would not imagine medical professionals would make poor notes, but this is the area where most claims end up being worse than they should be.

Consent Consenting, consulting and talking with your patient are probably

the most important things to do to avoid a claim. However, even if you do consent, and do it properly, it doesn’t necessarily mean you won’t lose a lawsuit if it’s brought against you, or that a claim won’t occur just because you’ve had the correct conversation with your patient. It’s the quality and the depth of the consenting that is important.

Informed consent is fundamental. Without consent you will have no defence. We can’t defend you, the lawyers can’t defend you and the defence bodies can’t defend you. You will need to provide evidence, so the rule of thumb is: if it isn’t written down, it never happened—that’s very, very important to remember.

Some tips for taking consent: • Practitioner and patient guide each other between information.

Make sure that the patient isn’t overloaded with information, but that enough information is provided, so that they can make an informed decision.

• Don’t use technical language—most of your patients are going to be everyday people, so use terms that are easy for them to understand.

I know it’s difficult sometimes, but try and keep it as simple as possible. Make sure that the patient can comply with the necessary aftercare. For example, if they’re going on holiday to a hot country and they’ve had some laser work done,

Informed consent is fundemental— without consent you have no defence

body language I INSURANCE 49

they shouldn’t be going in the sun.

Try to avoid patient disappointment. Make sure that you understand what effect they’re looking for, and why they are having these treatments, and then you can manage their expectations.

Use diagrams where possible and ask the patient if they’ve got any specific concerns, if there’s anything worrying them.

Some of the best consenting happens when the patient goes home, so make sure that the consenting doesn’t happen on the same day as the actual treatment. They should have an opportunity to go home and think about things. Also, remember a lot of patients will research on the internet and will probably think they’re an expert before they’ve even turned up at the clinic, so make sure that you’re explaining everything to them.

Dos and don’ts  Listen to your patient. Keep detailed and updated notes. If you get a complaint, remember that not all complaints go to a claim.  If someone doesn’t turn up to an appointment, especially after it’s onto their second course of treatments, then give them a call and make sure everything’s alright.  If there is any discussion on refunds of money, ask why the patient wants a refund. If anyone asks for patient notes, make sure that you understand whether they are going to pursue you for something or not.  Never admit liability. Never say: I’ve actually done that wrong—always respond with sorry, that’s never happened to me and I’ll ring my insurance company straight away.

You can always deal with a complaint by saying: I’ve never seen that happen before, or: Leave that with me and I’ll come back to you.  Make sure that you give yourself a bit of breathing space and you can take some advice. Never offer a refund or complimentary treatment without asking your insurance company for permission. That can actually sometimes be seen as an admission of guilt, even though you don’t intend it to be.  Don’t indicate you have insurance, because that always puts the cost of a claim up in my experience. And don’t ever put your head in the sand and pretend it’s all going to go away, because generally it doesn’t.

Ensure that consent is clearly documented and well evident.

Make sure that the patient understands what you’re writing down and understands what you’re telling them.

Aftercare leaflets are important too, rather than just telling them to go home and put various products on, show them what these treatments actually do and provide them with leaflets on their particular procedure or manufacturer.

Before and after photos are very, very important. Make sure that you take before photos, so if anything goes wrong after the event you’ve got something to compare to, and then make sure any concerns which the patient has are documented with your response to them. It seems straightforward, but in the heat of the moment, when you’re actually doing those treatments, a lot can get missed.

Over the last four or five years, the vast majority of the claims we have taken relate to laser, body contouring and other fat reduction treatments. Around 18% of our claims concern hyaluronic acid fillers and 14% relate to botulinum toxins. So between them, more than a third of our claims are now coming from the non-invasive treatments.

Cost of a claim The most expensive claims we see relate to laser and body contouring treatments. The cost of claims, similarly to the cost of defence, is rising quite rapidly at the same time as premiums and costs and there’s a struggle for the industry on what to do with that.

Let us consider a case study involving a body contouring procedure. The treatment cost £2,800 —not an unsubstantial amount of money for anybody to spend. The defendant was a registered doctor.

He did consent with the patient and he did provide leaflets and documents relating to the procedure and potential side effects.

On the face of it, he did everything quite correctly, but then something went wrong—the patient developed scarring on her thighs following the procedure.

She alleged negligence, as there was an indentation remaining—a

5cm by 3cm mark left on her left thigh. She then claimed for psychological effects, which is natural.

If you think about the motor insurance industry, whiplash is the big issue. With cosmetic treatments you get the psychological issues: I can’t go out, I can’t wear short skirts, I can’t wear my bikini. The patient became embarrassed and self-conscious about her appearance.

The defence was that the doctor claimed the indentation was a natural side effect—a seroma—which was created and would subside over a period of days and weeks.

A big consideration with any type of claim like this is that if it ends up going to court and getting into serious litigation, expert opinion will be sought by the defence lawyers.

In this particular case, they used a plastic surgeon, so a step above the normal practitioner for these types of treatments.

He disagreed with the defence saying that the surgery was badly performed and the note-taking and consenting was well below the standard expected for this type of treatment.

The message here is that the more expensive and complicated the treatment, the better the consenting and the more detailed the note-taking will need to be.

In this case, the note-taking and the evidence that the doctor provided, wasn’t good enough. The outcome was £32,000 damages. £14,000 claimant’s costs, defence costs, and our defence costs were just over £3,000. The total cost was £50,000, for a £2,800 treatment.

The insurance cost for that doctor was somewhere in the region of £2,000 to £2,500. It doesn’t take a genius to establish that the claim will affect his performance going forward and presumably causing him considerable stress by going through the process.

These types of claims do occur, and the recent claims that we are seeing coming though are getting more and more expensive as the years go on.

Eddie Hooker is the CEO at Hamilton Fraser Insurance W: hamiltonfraser.co.uk

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body language I LASERS 51

Thermal relaxation times Target destruction while minimising damage to surrounding tissues during photothermal treatments relies on the theory of thermal relaxation. But the concept focuses on target cooling rather than destruction, write Mike Murphy and Per-Arne Torstensson, leading to poor results and repeat treatments

L

asers and IPLs have long been used to treat a range of unwanted blemishes on the skin. The theory of selective photothermolysis was devised in 1981 by Anderson and Parrish and was based on the pulsed laser technology of the day. This idea involved heating the target tissues without over-heating the surrounding tissue, by restricting the time in which laser energy was applied, thereby minimising collateral damage and scarring.

They applied the heat diffusion equation to a cylinder (to approximate for a blood vessel). A short energy pulse heats a cylinder then cools. Anderson and Parrish surmised that as long as the total pulse duration was less than the cylinder’s “relaxation time”, then no significant damage to adjacent tissues would occur outside the vessel.

By careful choice of wavelength and fluence, the selected targets could be successfully targeted and selectively destroyed. A major part of this theory was the concept of thermal relaxation time (TRT).

This is defined as the time taken “for the central temperature of a Gaussian temperature distribution with a width equal to the target’s diameter to decrease by 50%”. TRT is calculated, in cylinders as a first approximation, as the following; where d is the target diameter (in mm) and α is the tissue diffusivity (mm²/s): TRT = d² / 16 α This definition describes the cooling time of the target. It is only dependent on the size of that target and the local heat conduction properties. By choosing pulse durations less than the TRT of the target, it was believed that a successful outcome would be produced without damaging

adjacent tissues. While this is essentially true, there is a significant problem with this idea. To explain this we need to reexamine the basic physics and biology behind the light-tissue interactions.

Target destruction The purpose of delivering light energy and, hence, generating localised heat energy in a target tissue, is to selectively destroy that target. To achieve this goal, the target must be irreversibly denatured.

If the target is not damaged sufficiently, there is the probability that the tissue will simply regenerate. Consequently, the important goal is to damage the target such that it cannot regrow.

This is extremely important since it is the basis for many treatments. The TRT simply describes the target’s cooling time.

It has no relevance in terms of denaturing or destroying it. While the TRT may be important in minimising collateral damage, it ignores the most important task— to destroy the main target.

The key problem with this approach has been observed in poor clinical results with short-pulsed lasers and the treatment of aberrant blood vessels. Consequently, many treatment programmes were abandoned once a “plateau” in the results had been reached. Recent developments with IPL technology have improved clinical outcomes resulting from the longer pulsewidths available from these devices.

Arrhenius Damage Equation To consider how much damage a target sustains during the heating process, we need to consider the Arrhenius Damage Equation. The amount of tissue damage, Ω, at any point can be calculated as: Ω = A δt exp(-E a /RT)

where A is the frequency of decomposition of the molecules (or damage rate factor, s-¹), Ea is the activation energy per mole between the native and the denatured states of tissue (J/mole), δt is the time that the energy within the target tissue is at or above the activation energy, T is the tissue temperature (in degrees Kelvin) and R is the molar gas constant (8.314 J/mole K).

This model is based on the tissue molecules absorbing an amount of energy at or above E a followed by decomposition of the molecules at a rate determined by A. The terms Ea and A are generally known as the Arrhenius parameters.

The equation shows that the amount of tissue damage, Ω, is exponentially proportional to the temperature, T, attained by those cells and linearly with the time, δt, maintained at that temperature. Note that the time, δt, is not necessarily the same time as the pulse duration of the energy—it is the time the tissue is at, or

Energy

52 LASERS I body language

Ea Denatured state

Original state (native)

The activation energy required to denature tissue molecules

above, the temperature corresponding to the activation energy, or E a.

The activation energy of any tissue differs according to the molecules in question and the denaturation pathways.

This is the energy required to break molecular bonds within the tissues and is often referred to as the barrier energy.

It induces a change of state from “native” to “denatured” (see “The activation energy required to denature tissue molecules”).

In essence, E a determines the temperature at which denaturation of the tissue proteins begins, while the frequency factor, A, dictates the rate at which that denaturation occurs.

The determination of tissue damage was calculated by Diller and Pearce as the logarithm of the relative concentration of un-denatured tissue.

The level of damage may be calculated by the ratio of the concentration of native tissue, ct, at the end of the thermal insult, at time t¹, to the concentration of

native tissue prior to any denaturation, c0, at time t0.

Diller and Pearce showed that the logarithm of the relative concentration of undenatured collagen is the same quantity as Ω in the equation above.

The accumulated damage is defined by the dimensionless parameter Ω with the threshold for irreversible damage at a point being defined as Ω = 1. The quantity ct / c0 represents the proportion of undamaged tissue at the end of the applied thermal energy. This, therefore, dictates that the proportion of damaged protein may be found as follows: Ω = - loge(ct / c0) = 1 i.e. ct / c0 = 0.368 Therefore, the proportion of damaged protein, (1 – ct / c0), is 63.2% of the initial concentration. Hence the threshold for irreversible damage, or tissue necrosis, is assumed to occur in tissue when 63.2% of the target tissue has been denatured by

Below: Variation of % damaged tissue versus damage level Ω

95 85

% Damaged Tissue

75 65 55 45 35 25 15 5 0.1

0.5

1

1.5

2

Damage Level

2.5

3

4

7

the thermal process.

With the definition of Ω = 1 being the threshold for irreversible protein denaturation, it is worth considering what happens when Ω is greater or less than one (see “Variation of % damaged tissue versus damage level Ω”). This shows the relationship between as Ω and the percentage of denatured proteins.

The chart below clearly shows that an Ω of one corresponds with a 63.2% damage level, while a value of three is required to achieve 95% damage. Diller and Pearce suggest that values of Ω above one are essentially meaningless since irreversibility has already been achieved in that tissue.

Interestingly, Takata et al suggest an Ω of 10,000 is equivalent to “third degree burns”, yet calculations show that an Ω of only seven will result in 99.9% tissue damage. However, this definition is purely arbitrary. There is no clinical or histological evidence available in the literature to confirm that this assumption is accurate.

It may be that an Ω of two (equivalent to 86.5% denaturation), three (95.0%), four (98.2%) or somewhere else in that range, may actually be necessary to prevent sufficient protein re-naturation or regrowth of the existing structure occurring. We shall continue with the accepted definition of the onset of irreversible denaturation (ID) at an Ω value of one.

However, it may be that total denaturation is not required to induce the desired response. In the case of generating new collagen growth, it appears that the existing collagen merely needs to be stimulated by the application of external heat.

Our calculations reveal that the actual amount of level of damage, Ω, may be as low as only 0.1 to 0.2. Yet, even this low damage level appears to be sufficient to stimulate the fibroblasts to produce neocollagenesis.

Irreversible denaturation It is clear that the target cells must attain a temperature, T, which must be maintained for a minimum time, t, to achieve ID (Ω = 1). Consequently, it is not sufficient to simply describe a desired temperature to ensure a successful treatment outcome. The associated time for that temperature must also be indicated.

The temperature-time combination is a “coupled pair”—quoting one without the other is meaningless.

So, what are the typical (T,t) combinations required to achieve ID in hair or blood vessels? These depend on the Arrhe-

body language I LASERS 53

Eª

A

(J/mole)

(s-¹)

Bulk Skin

3.27 x 105

1.8 x 1051

Blood

4.55 x 105

7.6 x 1066

Arrhenius Parameters for bulk skin and blood (data from Diller and Pearce). The activation energy for blood is higher than that for ‘bulk skin’, but once it is achieved blood will denature at a much faster rate than bulk skin.

nius parameters for the tissue in question.

These parameters must be found through experiment; they cannot be calculated.

Many researchers have carried out such experiments for a wide range of human tissues but the data produced by Diller and Pearce will be used in this article.

The graph below shows the temperature-time combinations required to achieve ID for bulk skin and blood. The curves shows the thresholds for ID where the volume of tissue denaturation reaches 63.2% (Ω = 1).

The areas above each curve therefore show all the temperature-time combinations that will induce ID for each tissue.

Any temperature-time pairing which lies within those areas will exceed the damage threshold of 63.2% and render the tissue necrosed. The areas below the curves represent Ω < 1 and, hence, may result in tissue re-growth.

Higher temperatures require less time to induce ID compared with low temperatures. Note that the time axis in the graph below is logarithmic.

It is clear from the Arrhenius Damage Equation that the desired goal of most photothermal treatments is the attainment of irreversible denaturation. If

this does not occur then tissue regrowth is possible. The time required to achieve this state is entirely dependent on the temperature achieved in the tissue. The cooling time, or TRT, is essentially irrelevant. There is no direct link between the denaturation time and the relaxation time—they describe two completely separate processes.

The Arrhenius equation shows the relationship between time and temperature.

Simply achieving a desired temperature in tissue to induce a particular response is not sufficient. That temperature must be maintained for the appropriate time to achieve the desired end result. If either the temperature or the time is not attained then the response will fall short of what is clinically required, leading to poor results or excess repeat treatments.

Most importantly the equation shows that the damage achieved, Ω, due to denaturation of proteins by heat is, for any given tissue: linearly dependent on time (i.e. pulse duration); and exponentially dependent on temperature (i.e. input energy/fluence). Therefore, as long as sufficient energy has been deposited into the target then damage to the proteins can be controlled by careful selection of ex-

Thresholds of irreversible damage for “bulk skin” and “blood” (Ω =1) as functions of temperature and time. The areas above each curve show the temperature-time combinations which will ensure ID. Combinations below the curves will result in less than 63.2% tissue destruction.

105 10 4

δt (ms)

103 102 10 1 10 -1 10 -2 10 -3 64

68

72

76

80

84

88

Temperature (˚C) Bulk Skin

Blood

92

96

100

posure time. Denaturation will not occur in the tissue proteins until the activation energy has been input; thereafter, a small increase in energy density (fluence) will have a major effect on the rate of the denaturation process. This strongly indicates that careful control of tissue damage is more easily achieved by judicious choice of pulsewidths, as this will result in a linear progression of denaturation.

Mike Murphy is chief technology officer at Clinical Lasers plc, 145 – 157 St John Street, London, EC1V 4PW. E: mike.murphy@virgin.net. Per-Arne Torstensson is CEO of Photonova AB, Gothenburg, Sweden. E: pa.torstensson@photonova.com References 1. Anderson RR, Parrish JA. “Microvasculature can be selectively damaged using dye lasers: a basic theory and experimental evidence in human skin.” Lasers Surg Med. 1981;1(3):263-76.

2. Anderson RR, Parrish JA. “Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation.” Science 1983; 220:524-527.

3. Lanigan SW. “Port-wine stains unresponsive to pulsed dye laser: explanations and solutions.” Br J Dermatol.

1998;139:173-177.

4. Hellbrügge G, Stockmeier M, Henschel R, Drosner M. “Port wine stains : Comparison of intense pulsed light and pulsed dye laser.” Abstract from the 24th Annual Meeting of the American Society for Laser Medicine and Surgery (ASLMS) in Dallas, March 31–April 4, 2004 5. Barikbin B, Ayatollahi A, Hejazi S, Saffarian Z, Zamani S. “The use of intense pulsed light (IPL) for the treatment of vascular lesions.” J Lasers Med Sci. 2011; 2(2):73-81 6. FC Henriques and AR Moritz. “Studies of thermal injury, 1. The conduction of heat to and through skin and the temperature attained therein. A theoretical and an experimental investigation.” A.J. Pathol., vol. 23, 1947, 531-549.

7. AR Moritz and FC Henriques. “Studies of thermal injury, 2. The relative importance of time and surface temperature in the causation of cutaneous burns.” A.J. Pathol., vol. 23, 1947, 695-720.

8. Kenneth R Diller and John A Pearce.

“Issues in modelling thermal alterations in tissues.” Annals New York Academy of Science, vol. 888, 1999, pp 153-164.

9. Takata AN, Rouse J, Stanley T. “Thermal Analysis Program.” IIT, Chicago, 1973.

Stand 68 Benjamin Britten Lounge | www.wigmoremedical.com www.wigmoremedical.com I 020 7514 5975 | Tel 0207.514.5975

body language I PRODUCTS 55

on the market The latest products in aesthetic medicine, as reported by Helen Unsworth 1. Epionce was recently voted "Best AntiAgeing Skincare Line" at the US Aesthetics Awards. MelanoLyte Pigment Perfecting Serum has just been introduced to the range, and is a night treatment to target unwanted dark spots and help achieve a more even complexion with minimal to no iritation.

Episciences Europe LLP, T: 01245 227788; W: epionce.co.uk

1

2. Med Contour is a non-surgical body contouring treatment which uses ultrasound and cavitation technology to break down fat cells in problem areas without damage or scarring to the skin. Recently awarded "Best Non-Surgical Body Contouring Treatment" at the US Aesthetics awards.

Med Contour, T: 0207 734 7113; W: med-contour.co.uk

3

2

3. Scandfit have launched a range of designer underwear for breast augmentation patients. They offer a white label service to provide clinics and surgeons with a signature colour.

Scandfit, T: 07989947247; W:scandfit.com

4

6

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4. Skinade is a 150ml drink, formulated to maintain hydration and skin function from within. Skinade say it delivers collagen and micronutrients in liquid form, to promote healthier younger looking skin.

Skinade, T: 07702 490 300; W: skinade.co.uk 5. Instant Demake is a Micellar water formula make-up remover and deep cleanser.

It is ideal to use in-clinic pre-treatment to cleanse the face and remove patients' make-up and daily impurities effectively.

The formula is alcohol free and comes in two formulationsâ&#x20AC;&#x201D;one for sensitive skin and one for combination skin.

Skin Matrix, T: 0845 505 9800; W: skinmatrix.co.uk 6. Monolith Quattro is a new treatment from Tekno Surgical which uses cryolipolysis for fat reduction. Up to four non-invasive applicators can be used to deliver controlled cooling to target fat. Procedures last sixty minutes and there is no down time.

Tekno Surgical, T: 00 353 16754842; W: tekno-surgical.com

7

7. PreCleanse from Dermalogica is now available in packs of 20 pre-moistened biodegradable wipes. They are for use as part of the "double cleanse" routine advocated

by Demalogica and help dissolve excess sebum, products, make-up and pollutants on the skin before cleansing.

Dermalogica, T: 01372 363600; W: dermalogica.co.uk

56 dIRECTORY I body language

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Body Language is a bi-monthly journal aimed at all medical practitioners in medical aesthetics and anti-ageing. It is full of practical information written by leading specialists with the intention of helping you in your pursuit of best practice.

Assisting professionals in medical aesthetics, Body Language has taken stock of developments and investigates the methods of experienced practitioners around the world, commissioning experts to pass on their knowledge in our editorial pages. Our editorial provides you with professional accountancy and legal advice that alone can save you thousands of pounds.

You can also help yourself to continuing professional development (CPD) points. You can determine how many within the CPD scale that our articles are worth to you and self-certify your training.

As a subscriber, you can access back issues of Body Language.

You will be emailed your own code to enable you to read articles online. That in itself is a big time-saver. Rather than have to track down a misplaced issue from six, nine or 14 months ago to reread an article, you can refer to it online in seconds.

Body Language continues to be at the forefront of publications in the medical aesthetics sector. Its leading position owes much to it being a practical journal that puts theory into practice and assists you to do your job as best as you can.

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body language I MARKETING 59

Secrets to a successful blog A blog can be a useful addition to your website, providing users with relevant and up-to-date information and building trust with potential clients. John Castro explains how blogging can help your business grow

T

he most popular website blog, The Huffington Post, benefits from 105 million unique visitors per month.

In 2013 they saw a 20 million unique visitor increase to the previous year, which was 85 million.

This is an extreme example, but demonstrates the ever-growing need for regular information and the desire to receive it in “real time” is growing at a fast pace—a pace few are keeping up with.

Using such an example as The Huffington Post may seem unusual, as they are a news company. However, their website is simply a blog. It’s a place they add blog posts to daily and they are blogging the right way.

We must understand that users are fed up of seeing and receiving junk online, which has been around since the Internet was created. The growth of junk across the web has even encouraged Google to change how they rank websites on their first page.

Within the next year, there will be no website on the first page of Google results that does not have a blog or recent news area. A blog has become a must, even when putting together a Google Search Campaign.

Today the Internet gives us so much information and, in many cases, we use this information to make buying decisions. A blog gives us the opportunity to supply relevant and up to date information that, in turn, will support buying from you.

Trust Aesthetic businesses have an opportunity. Your primary aim is to build trust through your online marketing activity.

Do not spam potential clients with offers and deals—especially with recent debates based around the Keogh report.

Set the standard now and not later.

Setting up and running your own blog can help do this.

I use the word running, as most people think blogging will be one more

thing they need to dedicate a substantial amount of time to. However, this isn’t the case. A blog doesn’t require the attention and effort some may think—we are not trying to be The Huffington Post.

Within the medical aesthetic industry, blogging gives website visitors more opportunity to trust you, engage with you and interact with you. This is our intention—to gain trust.

There are three main reasons to start blogging to help your aesthetic business bring in new potential clients.

Become the trust agent The real task for any aesthetic businesses is to gain the trust of potential new clients. Most practitioners are experts when it comes to trust building, but require a face to face consultation to do so. It is possible to gain clients trust beforehand, so that consultations merely relate to treatments.

Blogging will show you are putting in that little bit extra to give potential clients as much value as you can. It helps because when someone visits your website they can see that it’s up to date with relevant and new information about your industry, treatments, client experiences and industry events.

As human beings we love more, so give more to your website visitors and start blogging.

Engagement delivers Engagement is so undervalued. We use the word “engagement” in relation to commitment. I encourage you to look at a blog the same way. A blog engages your audience and has them commit to you for a specific period of time. They have taken time to read your information and that is commitment.

You gain their interest by providing them with content that no one else does.

Do this regularly and you will begin to see how your blog posts play a big part in generating new leads to your aesthetic business from your website.

Interact and you will attract One of the most difficult parts in any blogger’s agenda is to get the users to interact but if you get this right, you are on to a real winner. Interaction with the user encourages enquiries—you are asking them to take a specific action related to your blog post, meaning you have all their attention and they are listening to you.

The best way to get interaction is mix it up in blogs by adding videos, Facebook “like” buttons, share buttons for social media and comment boxes for them to leave their thoughts on your blog.

All of these get the reader interacting and if you keep your blog posts interesting, informative and up to date, website visitors will encourage their community— more potential clients—to read by sharing them. Get this right and people will return repeatedly to your website and will start sending more potential clients your way.

Blogging can play a major role in the ability of your website to generate new client enquiries. Internet users today want new information daily and the more you can supply them with, the more they will consider coming to you or telling people about you.

Be informative and creative when writing blogs. Two to four posts per month is enough—don’t think you need to bombard your readers by posting daily.

John Castro is the CEO at Websites for Cosmetics. W: websitesforcosmetics.com; E: jc@ websitesforcosmetics.com

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body language I EXPERIENCE 61

Pancakes,

or how I became an aesthetic dermatologist Dr Timothy Corcoran Flynn recalls the childhood inspirations who led him down the aesthetically-pleasing—and moss-covered—path to dermatology

I

was fortunate to have a great first year teacher. Every fouryear-old needs to go to school and be taught by Miss Mildred Painter. She made every child feel special and we all knew she really loved us. Warm and friendly, she had a huge smile. It didn’t matter that there was usually food retained between her irregular yellowed teeth.

Most days you could get over that, unless she had eaten a typical American lunch. We would all sit at our desks and spend a few minutes identifying the hamburger, lettuce and tomato bits next to yellow cheese wads snuggled in the crypts and crags of her upper dentition.

Then it would become a game of “Find the French fry” or “What’s in her moustache?” You had to make sure you were out-of-range should she recite “Peter Piper”.

Her personality was kind and big, but her body was even bigger.

She wasn’t just large; she was fullon fat—so plump, you thought that when she took a shower, her feet never got wet. We all worried that if you were to run to her with arms wide open to give her a hug, you might never come out. Or, that she might accidentally sit on two kids who would be stuck to her rear end, squashed like pressed raisins.

She had one style of dress—a tent that hung from her shoulders, made out of a large drapery and covering her ample chest and chubby tummy. I wondered if she was smuggling a Volkswagen under it. One mother said there was so much fabric she had to iron it on the driveway.

We never saw her shoes and I’m not sure she did. I suspect that they had been flattened into the shape of

inflatable lifeboats. If she’d ever had them polished, she’d have to take the shoe shine man’s word for it.

She was like the most wonderful grandmother (make that three grandmothers)—so nurturing, but to whom nature hadn’t been kind.

If only she could have been nicerlooking.

Elegance and pancakes The next year, my teacher was Mrs Jack Morgan. One look at her and I knew we were going to get married.

She was a perfect beauty and after coming home, I told my mother just how gorgeous she was. My mother agreed with me, telling me that she was not just pretty; she was elegant. After explaining elegance, she told me that Mrs Morgan was married and her husband worked at the university.

I was not about to let that get in my way. Mr Morgan could be there on Saturday morning when I fantasised that Mrs Morgan would be making me pancakes while wearing a nice red skirt and frilly white apron. I’d even let Mr Morgan watch cartoons with me.

Mrs. Morgan started it all. She was my “aesthetic angel”—she made me appreciate beauty. At two o’clock naptime, I’d roll out my little cotton mat and lie down positioned so I could look at her. Her face was wonderfully symmetrical and lipstick so wonderfully red.

She had a perfect Cupid’s bow; and one of Cupid’s arrows had certainly struck me.

She had the type of skin that seemed to glow in the dimmed lights of the classroom, like the windows of the passenger car of my electric train. Her hair perfectly framed her face and it never seemed

to grow; it was always perfectly styled and naturally placed. She was really quite beautiful and at times, I couldn’t hear what she was saying because I was looking at her face, her fingers or her feet, thinking about what made her so pretty.

Mrs Morgan lived near our house, which was great because I wouldn’t have to leave our neighbourhood when I moved in with her. I would see her out walking and she seemed to flow, rather than ambulate. Some women walked with purpose—including my mother, who walked as if she were a draught horse pulling a wagon, not to be slowed down by anything.

62 EXPERIENCE I body language

She had energy and determination but Mrs Morgan simply floated.

I recall noting how movement was a component of beauty and of elegance. I began looking at other beautiful women out walking.

There was Mrs Sam Nelson with long auburn hair, wonderful facial bone structure and height. Mrs Gay McDonald—quite beautiful.

She gave me swimming lessons and had superior grace and form (as much as anyone could in a rubber swim cap with yellow floppy flowers adorning it).

Moreover, my classmate Lisa’s mother had poise and manners, gorgeous big brown eyes and a rich smile with just a touch of adventure in it. Fortunately, my mother agreed that these were all attractive ladies and did not even mention any thoughts about why I was so interested in them, the Oedipus complex or a need for psychotherapy.

Moss-scaping Throughout my childhood, I learned that beauty is found throughout nature and not just among older women walking around town. Many scientists can pinpoint the times they became acutely interested in research and I recall the afternoon in which nature’s beauty exploded.

It did not involve the music of Pink Floyd or smoking anything, for I was eight and lying out in the woods examining moss just four inches from my face. How perfect that moss was, and how varied. There were patterns to it and a wonderful structure. There was colour and form in that soft, green bed and its beauty invited me to lay my head down on it, like the bosom of Mother Earth.

I felt the coolness of the earth and took in the rich earthy odours.

The beauty of the moss was inviting and captivating. I started to think about how that mossy pillow could be made better, by removing the twigs and acorn caps from it, and perhaps trimming it a little bit. Moss-scaping might be needed.

If only that tuft had more volume, those creases would be smoothed out.

Beauty is anatomy and good anatomy is wonderful. Like most children, I was interested in anatomy at an early age. One’s anatomy

The author (far right), learning human anatomy

produced intestinal gas. It was fun and funny, so much so that laughter could not be avoided. When an audible eruption occurred in the classroom, the laughter could be painful. No matter how many times the teacher whacked us with the ruler, the giggles could not be suppressed. Sometimes the farts were appropriately termed “tear gas” because of how hard we howled.

Perhaps related to a curiosity about the anatomy of the intestines, a few students and I managed to get some anatomy training in summer school. We studied the eye, the brain, the skeleton and the muscles. While we never made it to the large colon and didn’t come near the anus, the anatomy of the human body seemed beautiful to me.

Some have termed the years at university “anatomy lab”, and it certainly led to a further interest in the body. Great learning occurred, and beauty was investigated and appreciated. While not at the forefront of my thoughts, I wondered what makes one college girl more attractive than another.

It’s not just that Mary’s father owns a liquor store while Martha’s dad sells insurance. Personally, intelligence and style play a role, but we always seem to consider anatomy and the many different

variations. Sometimes the anatomy is perfect, which can lead to the irrational behaviour called love.

However, even when in love, one can’t help thinking about how to improve your beloved.

So, fast-forward to training in dermatology. Here, we could actually improve appearance and increase beauty. Wrinkles could be relaxed and lines could be reduced.

Noses could be reshaped and made more pleasant to look at. I was so excited. I thought I would never again have to hear my mother’s memorable comment made about a girl I went out with once in college: “Beauty is but a light switch away.”

A few injections here, a bit of light energy there, some steel and suture and symmetry and elegance approached. How very exciting to be able to improve someone’s anatomy and make them feel better.

I thought back to Mrs Jack Morgan—her beauty and movement, her smile and radiant skin—and realised whoever will be making my pancakes will look better with just a few well-placed injections and a bit of light energy.

After all, no one is perfect.

Dr Timothy C Flynn is a dermatologist and medical director at the Cary Skin Center in Cary, North Carolina. T: 00 (1) 919-363-7546

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Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 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 vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age 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. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, LambertEaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. 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. 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 observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency 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). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis),vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin.

Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating

vertical lines between the eyebrows (glabellar frown lines) and other indications. 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 revision of text: FEB 2012. Full prescribing information and further information is 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 medical.information@merz.com or on +44 (0) 333 200 4143.

1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456.

3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154.

4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58.

5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1133/BOC/NOV/2013/LD Date of preparation: November 2013