PRIME Journal May/June 2023

NON-SURGICAL RHINOPLASTY INDICATIONS AND TREATMENTS

AGEING AND THE BRAIN

THE IMPACT OF GLYCATIVE STRESS

Clinical pearls for optimising safety in

NON-SURGICAL RHINOPLASTY

WELCOME TO THE MAY/JUNE ISSUE OF PRIME JOURNAL. IN THIS edition, we bring you some exciting features on the latest trends and innovations in medical aesthetics. Covering topics such as the current products and devices that doctors are excited about, the fifth anniversary of Crown Aesthetics’ SkinPen® Precision and the launch of BIOJUVE™, as well as private equity in aesthetics.

In our first feature, we celebrate the fifth anniversary of Crown Aesthetics’ SkinPen® Precision, an innovative microneedling device that has been a game-changer in the industry. As Crown Aesthetics looks to expand its portfolio with the launch of BIOJUVE™ in Europe, we take a closer look at the company’s success and what’s in store for the future.

One of the most fascinating aspects of the aesthetic industry is the rapid pace of innovation. In our second feature, we dive into what aesthetic doctors are excited about right now. From new injectable fillers to advanced laser technology, we explore the latest treatments and procedures that have doctors buzzing. You can read the full story from page 18.

Another hot topic in the industry is private equity in aesthetics. With private practice in decline, many established physicians are now looking for partners to help them reach their life goals. In this edition, Rosalind Hill speaks to physicians who have sold their practices to understand more about the motivations behind the decision and to industry experts about what it means for the future of aesthetics.

Ensuring safety in non-surgical rhinoplasty is of utmost importance. In this edition, Alexander Z. Rivkin, MD, unveils his Universal Injection Safety Precautions (UISP) that aim to ensure injectors can perform non-surgical rhinoplasty safely without compromising on results. We also dive into the most common indications for non-surgical rhinoplasty and the treatment benefits over surgery with Onir Spiegel.

The impact of glycative stress on the brain and the role it plays in the pathogenesis of Alzheimer’s disease is another topic that we explore in this edition. Yoshikazu Yonei and Masayuki Yagi explain the impact of glycative stress and melatonin on amyloid-β clearance. These experts provide valuable insights into this field, which has the potential to revolutionise the way we approach ageing.

As always, we strive to provide our readers with the latest and most informative articles on aesthetic and anti-ageing treatments. We hope that the articles in this issue will not only educate you but also inspire you to explore new treatment options.

Our partnership with AMWC means we will be present at an ever-increasing number of Aesthetic and Anti-ageing events around the world, including AMWC Japan, AMWC China, and for the first-ever AMWC India, which takes place in September 2023. If you would like to attend any of the AMWC events in person, and I highly recommend you do, be sure to book your place at euromedicom.com. In addition, Aesthetic Multispecialty Society Premium Members will receive 20% off their delegate pass to all shows paid for during their membership as well as further enhanced benefits, and you can sign up here: multispecialtysociety.com.

Balraj Juttla Editor, PRIME balraj.juttla@informa.com

With private practice in decline, many established physicians are now looking for partners to help them reach their life goals.

International Journal of Aesthetic and Anti-Ageing Medicine

Informa Australia, Level 4/24 York St, Sydney, NSW, 2000, Australia

ISSN 2159-8908 (print)

ISSN 2159-8916 (online)

Editor Balraj Juttla balraj.juttla@informa.com

Art Director David ‘Spike’ McCormack spike@spikedesigns.co.uk

Digital Marketing Manager Slim Hakimi slim.hakimi@informa.com

Production & Ads Department balraj.juttla@informa.com

Please send your manuscripts and press releases to: balraj.juttla@informa.com

All submitted manuscripts are evaluated on the basis of scientific quality, originality, appropriateness, contribution to the field and style. Suitable manuscripts are subject to peer-review. Manuscripts and accompanying files should be prepared in accordance with our Author Guidelines, which are available via www.prime-journal.com.

All content © 2023 Informa UK Ltd Images © Stock.adobe.com, unless otherwise stated

OVER THE PAST 20 YEARS, FACE HAS GROWN TO BE ONE OF THE WORLD’S leading aesthetic conferences, offering an unparalleled scientific programme curated for physicians and practitioners who share our passion for aesthetics. From June 31st to July 1st we celebrate our 20th edition at the InterContinental, London, UK. With 75% of all aesthetic medicine practices in the UK based in London, it is the go-to destination to do business and network.

With 20 years of experience, FACE is the only conference in the UK — and one of the few in the world — to have in-depth agendas focussed on core segments of the non-surgical aesthetic marketplace.

Physicians can expect to receive high-level scientific content from true experts on a variety of topics, including Injectables, Regenerative Medicine, Threads, Skin, Equipment, Genital Rejuvenation, Hair, and more.

FACE’s programme bridges the gap between the current level of academic training, and the pioneering advancements constantly arising within the aesthetics and dermatology field. With both UK and international leading practitioners contributing to the programme, you can be confident in the depth and quality of scientific research available at FACE.

FACE scientific committee members and experts represent every discipline within our field and have contributed for many years to the education of doctors and to the advancement of aesthetics.

No matter where you are in your aesthetic journey— looking to kick-start your career, gain confidence in a discipline, or upscaling your practice — everyone has something to gain at FACE. Through a vast array of plenary sessions, live demonstrations, and tutorials our experts will present the latest clinical and scientific advances as well as offer practical life hacks to bring your practice to the next level.

The UK market has an insatiable desire for minimally invasive aesthetic procedures with an estimated value of £3 billion. FACE will place your brand at the forefront of this market and present your company with the unique opportunity to connect and engage with a targeted audience of aesthetic professionals. Sponsor scientific sessions to align your brand with the key values of your prospects and exhibit to acquire valuable leads and solidify meaningful relationships.

SUBSCRIPTION RATES

UK: £180

Europe: €180

Rest of world: US$180

FACE Scientific Committee London, UK

PRIME JOURNAL EDITORIAL BOARD

BOARD MEMBER SPECIALISM COUNTRY

Dr Claude Dalle Anti-ageing & aesth. medicine France

Dr Wilmar Accursio Endocrinology Brazil

Dr Firas Al-Niaimi Dermatology & laser surgery UK

Dr Ashraf Badawi Dermatology

Dr Janethy Balakrishnan Aesthetic & anti-ageing medicine

Dr Lakhdar Belhaouari Plastic surgery

Egypt & Canada

Malaysia

France

Dr Anthony Benedetto Cosmetic Dermatology USA

Dr Philippe Berros Oculoplastic surgery Monaco

Dr Dario Bertossi Maxillofacial surgery Italy

Dr Pierre Bouhanna Dermatology – Hair surgery

Dr Fahd Benslimane Plastic Surgery

Dr Claude Chauchard Anti-ageing medicine

Dr Christophe de Jaeger Geriatrics

France

Morocco

France

France

Dr Gerd Gauglitz Aesthetic Dermatology Germany

Prof Ilaria Ghersetich Dermatology

Italy

Dr Michael H. Gold Dermatology USA

Dr Kate Goldie Aesthetic Physician UK

Prof Eckart Haneke Dermatology Germany

Dr Steven Hopping Plastic surgery USA

Prof Andreas Katsambas Dermatology

Greece

Dr Mario Krause Anti-ageing medicine Germany

Dr Marina Landau Dermatology Israel

BOARD MEMBER SPECIALISM COUNTRY

Dr Gustavo Leibaschoff Cosmetic Surgery USA

Dr Sohail Mansoor Dermatology UK

Prof Leonardo Marini Dermatology Italy

Dr Sly Nedic Aesthetic & anti-ageing medicine South Africa

Prof Daniel Pella Cardiology Slovakia

Dr Chariya Petchngaovilai Dermatology Thailand

Prof Ascanio Polimeni Neuro-endocrinology Italy

Dr Herve Raspaldo Facial plastic surgery France

Dr Christopher Rowland-Payne Dermatology UK

Dr Neil Sadick Dermatology USA

Dr Hema Sundaram Dermatology USA

Dr Pakpilai Thavisin Dermatology & Anti-ageing medicine Thailand

Dr Patrick Treacy Aesthetic surgery Ireland

Dr Mario Trelles Plastic surgery Spain

Dr Ines Verner Dermatology Israel

Dr Octavio Viera Anti-ageing medicine Spain

Dr Jean-Luc Vigneron Aesthetic dermatology France

Prof Bernard Weber Genetics Luxembourg

Dr Sabine Zenker Dermatology Germany

Catherine Decuyper Industry expert & consultant France

Wendy Lewis Industry expert USA

Christophe Luino Industry expert & consultant France

Sahara Star

Mumbai, India

September 15-16

2023

12 42

NEWS

11 New Restylane survey insights reveal common misconceptions about fillers

12 Gender pay gap in primary care narrowing: Medscape report

INDUSTRY INSIDER

14 What aesthetic doctors are excited about right now Wendy Lewis interviews 6 top doctors from around the world to find out

18 Private equity in aesthetics: a new market model for physicians

The benefits of setting up on your own very often do not outweigh the costs, and many established physicians are now looking for partners to help them reach their life goals. Rosalind Hill spoke to physicians who’ve sold their practices to understand more about the motivations behind the decision and to industry experts about what it means for the future of aesthetics

COMPANY PROFILE

24 Crown jewels: Crown Aesthetics celebrates five years of innovation in medical aesthetics

SkinPen® Precision celebrates fifth anniversary as Crown Aesthetics looks to expand portfolio with BIOJUVE™ launch

AESTHETIC FEATURES

32 Clinical pearls for optimising safety in non-surgical rhinoplasty

Alexander Z. Rivkin, MD, unveils his Universal Injection Safety Precautions (UISP) that aim to ensure injectors can perform non-surgical rhinoplasty safely without compromising on results

36 Impacts of glycative stress and melatonin on amyloid-β clearance

Yoshikazu Yoneim, MD, and Masayuki Yagi explain the impact of glycative stress on the brain and the role it plays in the pathogenesis of Alzheimer’s disease

42 Finesse and applications for non-surgical rhinoplasty Onir Spiegel discusses the most common indications for non-surgical rhinoplasty and the treatment benefits over surgery

18 | CONTENTS

PRIME PROMOTIONS

48 A review of the XB-49 Tip: A new and improved tool for microneedling

50 VELOCE Intense Pulsed Double Light for active acne, post-acne scars, and skin lifting

EVENTS

A round-up of news stories in the aesthetic and anti-ageing medicine industry

NEW RESTYLANE SURVEY INSIGHTS REVEAL COMMON MISCONCEPTIONS ABOUT FILLERS

According to a new global survey sponsored by Galderma and Restylane, there are many misconceptions and stereotypes facing the aesthetics industry. The survey found that 40% of respondents would discourage others from using facial injectables, while 34% believe the results of such treatments look fake and unnatural. However, when shown a range of images of people who had undergone filler treatments, 4 out of 5 people could not identify them as having received filler. Restylane patient feedback data also shows that 96% of people who used fillers felt their treatment exceeded expectations, and 95% maintained or enhanced the naturalness of their facial expressions after treatment.

The perceptions surrounding the use of temporary fillers stand in stark contrast to those around the use of permanent beauty treatments such as tattoos, body piercings and dental corrections. Tattoos and body piercings are primarily seen as a positive form of self-expression (30% of respondents agreed for tattoos, and 24% for body piercings). Teeth

straightening is viewed by 47% of respondents as a great way to enhance your appearance. Meanwhile, over a third of respondents (35%) believe fillers create unrealistic beauty standards and ideals, while 26% feel they can easily become addictive and 24% say they are an extreme option.

However, Restylane patient feedback data shows that 96% of people who used fillers felt their treatment exceeded expectations, and 95% of patients had maintained or enhanced the naturalness of their facial expressions after treatment.

The prevalence of societal judgements and the impact they have on how people behave are

laid bare in the study. Only 11% of respondents said they would be supportive if a friend or family member told them they were considering using fillers. In contrast, according to Restylane patient feedback, 99% of those who have received treatment would recommend Restylane to a friend.

Media leads in debunking misconceptions

The results also reveal that people see the media as more progressive in its views about aesthetic treatments. 27% of respondents said the media portrays injectables as empowering, while just 13% would personally describe them this way. Adult Gen Z7 respondents displayed a more open-minded attitude toward aesthetic procedures and were more likely to see treatments of this nature as empowering (19% in this age group agreed versus 13% overall). They were almost three times more likely to feel positively toward fillers than those over 55 years old, only 7% of whom agreed. Younger consumers also feel that people seeking injectable treatments are inherently more confident.

RENUVION® RECEIVES FDA CLEARANCE FOR USE AFTER LIPOSUCTION

Apyx Medical Corporation, the manufacturer of Renuvion®, announced that it has received 510(k) clearance from the US FDA for the use of its APR Handpiece in procedures for coagulation of soft tissues following liposuction.

‘We are thrilled to announce this newest clearance, making Renuvion the only device cleared to be used after liposuction procedures,’ said Todd Hornsby, Executive Vice President. ‘This is the fourth 510(k)

clearance we have received from the FDA in the past 11 months and highlights our commitment to providing evidence-based outcomes and clearances to further demonstrate the safety and efficacy of our Renuvion technology.’

Already cleared by the FDA for the treatment of neck laxity, facial renewal procedures, and the contraction of soft tissue, Renuvion’s latest 510(k) clearance allows physicians to set a new standard for

liposuction results when it comes to minimally invasive body contouring. Liposuction removes fat volume, leaving behind empty space that may increase excess or loose skin. Renuvion goes beneath the surface and applies precise energy directly to the source of the loose skin. This energy contracts the collagen fibres and pulls the skin down, closer to the muscle, for a more contoured appearance. By adding Renuvion to these procedures, physicians have

another tool to help them obtain optimal liposuction results.

‘Renuvion is a game changer in the field of plastic surgery,’ said board certified plastic surgeon Dr. Matthew J. Nykiel. ‘Using Renuvion after liposuction allows patients, with minimal to moderate skin redundancy, to attain high-definition results that were once only available with skin excision. Renuvion and liposuction is the gold standard for amazing body contouring results.’

GENDER PAY GAP IN PRIMARY CARE NARROWING: MEDSCAPE REPORT

PLASTIC SURGEONS AMONG HIGHEST PAID SPECIALTIES IN 2022

The gender pay gap among physicians has narrowed for the first time in five years, with primary care seeing the most significant change, according to the 2023 Medscape Physician Compensation Report. While physician salaries overall continued to rise, women in primary care earned an average of $239,000 compared to $286,000 for male physicians, resulting in a 19% pay difference, compared to 25% in 2018. Disparities also decreased within specialties, from a 36% difference in 2018 to 31% in 2022. For specialists, men earned an average of $415,000, while women earned an average of $327,000. The racial disparity gap, however, remained unchanged, with African American and Black physicians earning 13% less than white physicians, as seen in previous reports.

Highest and lowest salaries, by specialty and region

The report surveyed over 10,000 U.S.-based physicians across 29 specialties and found that the highest paid specialties were plastic surgery ($619,000), orthopedics ($573,000), cardiology ($507,000), and urology ($506,000), while the lowest paid specialties were infectious disease ($262,000), family medicine ($255,000), pediatrics ($251,000), and public health and preventive medicine ($249,000). The highestearning physicians were located in Wisconsin, Indiana, Georgia, Connecticut, and New Jersey, while the lowest salaries were in Maryland, Colorado, Virginia, Massachusetts, and Arizona.

The average physician salary was $352,000, up about 4% from the previous year and over 17% higher than in 2018. Specialty salaries also increased, from $368,000 in 2021 to $382,000 in this year’s report. The rise in physician incomes is partly due to a physician

40% OF BRITS SUNBURNT IN 2022’S HEATWAVE

shortage exacerbated by retirements and burnout, leading more physicians to make career shifts, including reduced shifts, shift work, and a move to virtual care.

Satisfaction, challenges, competition

While 52% of physicians are satisfied with their salary, the report showed growing concern with reduced insurance reimbursements, notably from Medicare and Medicaid, and competition from allied health professionals. Additionally, 27% of doctors said they would not choose medicine as a career if they could do it all over again, citing industry issues (rules and regulations, long hours), frustrating patients, and insurance reimbursement. One in four physicians reported that the most significant competition for patients came from allied healthcare professionals, including nurse practitioners and physician assistants, as well as alternative practitioners such as chiropractors and naturopaths.

The report’s Senior Director, Leslie Kane, stated, ‘While there is more work to be done, the progress on gender pay disparities was a positive development in this year’s report. That said, the issue of physician burnout, fueled by long hours and bureaucratic burdens, continues to have an impact on how physicians view their careers, their satisfaction with pay, and other aspects of medicine.’ The survey was conducted from October 7, 2022, to January 14, 2023, and the margin of error was +/0.98% at a 95% confidence interval. To view the full report, click here: www.medscape. com/2023-compensationoverview.

40% of people in Great Britain reported a least one case of sunburn in 2022, with this percentage rising to more than half (56%) of young people (aged 18-34), according to a survey carried out by YouGov on behalf of the British Association of Dermatologists (BAD).

2022 saw the UK’s highest recorded temperature, but also many consistently sunny days. Data supplied by the UK Health Security Agency shows that, with the exception of the most northern parts of Scotland, between a third and half of days in the UK in 2022 had a maximum UV index** of at least 3, the level at which sun protection is recommended for people with lighter skin tones (see notes below for more information). The data also shows that the summer isn’t the only time that people should be using sun protection, with the BAD recommending that people should be aware of the risk of sun damage between April and September.

People in Great Britain are quick to take advantage of sunny days, with 76% of people saying that they would spend at least some time in the sun on a sunny day if they were not working. 29% would aim to sunbathe at least some of the time, with 7% saying that they would sunbathe as much as possible.

Sunbeds are only used by a small minority of people (3%) and usage remains low even in younger age groups (18-24-year-olds: 5%). Artificial tanning products are more popular (7%), particularly among women (11%).

The UV index is the best measure available to show the risk of sun damage on any given day, however, 57% of people said they would either rarely or never check the UV index if in the UK during April–September, with only 19% of people often or always checking it.

The latest skin cancer figures show that there are 16,700 new melanoma skin cancer cases in the UK every year and more than 200,000 keratinocyte skin cancers (also known as non-melanoma skin cancers). The BAD recommends people regularly check themselves for signs of skin cancer.

While physician salaries overall continued to rise, women in primary care earned an average of $239,000 compared to $286,000 for male physicians, resulting in a 19% pay difference, compared to 25% in 2018.

Embrace the confidence of biorevitalised, healthy hair with Pluryal Hair Density

78% of patients showed improvement in hair growth after 4 months of treatment with Pluryal Hair Density*

↗ of hair thickness*

↗ anagen phase (growing phase) compared with telogen phase*

↘ of Hair loss*

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*Clinical study on 20 patients, pending publication conducted by AyatollahiA, FiroozA, SamadiA., KashaniMN., Safety and efficacy assessment of PLURYAL ® Hair Density intradermal gel for treatment of male and female pattern androgenic alopecia.

Wendy Lewis interviews 6 top doctors from around the world to find out

NLESS YOU HAVEN’T ATTENDED ANY OF AMWC’s recent global congresses, you surely know the scope of new technologies and products that have been launched so far in 2023.

WHAT AESTHETIC DOCTORS ARE EXCITED ABOUT RIGHT NOW U

From novel technologies to innovative topicals, practitioners have a lot of new options for optimising their treatment menu in their clinics.

of Dermatology,

Tehran University of Medical Sciences, Iran

PLURYAL® Hair Density, MD-SKIN SOLUTIONS

email wl@wendylewisco.com

PLURYAL® Hair Density formulation is an injectable intradermal gel consisting of 15 mg (7.5 mg/ml) polynucleotides that targets hair loss. It is a stimulator that strengthens the scalp, nourishes hair follicles, and increases the duration of the anagen phase of hair growth. So, patients rapidly experience a reduction in hair loss and gradually an increase in hair thickness and scalp coverage by hairs.

It is very unique in that it uses polynucleotides to stimulate hair follicles. With an innovative package design, it is prefilled and easy to use. The package contains an extra needle change during the injection, which makes the injection process easier and less painful for the patient. The improvement in hair growth will be visible within 4 weeks, including a decrease in hair shedding, an increase in hair thickness, and improved scalp coverage. It is safe and well-tolerated by patients.

Professor Alireza Firooz MD Professor

WENDY LEWIS is Founder/ President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy since 1997, author of 13 books, Editor in Chief of beautyinthebag.com, and frequent presenter on the international stage. Her first textbook, Aesthetic Clinic Marketing in the Digital Age (CRC Press) will debut a second edition in 2023.

for the treatment of male and female pattern androgenic alopecia in 10 injection sessions. For month 1, I perform four injections at 1-week intervals for a total of four injections. For months 2, 3, and 4, I perform one injection every 2 weeks for a total of six injections. With this treatment, I have seen a better efficacy profile in male pattern alopecia. In addition, based on its amazing effects on reducing hair shedding and increasing the trend of anagen phase duration, this can also be an effective treatment for hair loss due to telogen effluvium.

Wendy E. Roberts, MD, FAAD Dermatologist, Rancho Mirage, CA, USA

ZO SHEER FLUID

SUNSCREEN SPF 50 & ZO

GEL SUNSCREEN BROAD SPECTRUM SPF 50, ZO SKIN HEALTH

The new sunscreens from ZO Skin Health are very efficacious and have many unique features. ZO Sheer Fluid Sunscreen SPF 50 makes your face look amazing as a standalone product. This truly innovative, elegant zinc oxide formulation is instantaneously moisturising. It is slightly tinted and goes on like an essential oil with some sheer coverage. Superb functionality in a handy sporty size bottle slips right into the side pocket of your gear during sports or a run and my patients go protected and glowing. It features high efficacy and is water resistant and all the UV, IR and HEV filters needed for my potent photoprotection. I recommend it to my patients for use

on the face, neck and hands, and it is excellent for drier mature skin.

ZO Gel Sunscreen Broad Spectrum 50 is a true sunscreen formulation breakthrough. This formula is a non-greasy SPF that is ideal for kids, as well as women and men who have oily skin. With three proven UV filters, it gives a high level of water resistance and photoprotection. The product’s non-greasy texture helps with patient compliance. It is very user-friendly with a packable pump that you can put right into your handbag, golf bag, tote, or in your purse to protect your hands from the UV lamps used in nail salons, or anytime patients don’t want to use an oily formulation for sun protection. My patients like this sunscreen because it is non-oily and can be effectively applied to the face, neck, and hands.

Jane Yoo, MD, Dermatologist

New York City, NY, USA

ULTRAPULSE ALPHA, LUMENIS

The Ultrapulse Alpha is Lumenis’ newest CO2 laser that combines the best-in-class CO2 laser technology with an easy-to-use platform to safely treat a wide range of dermatological conditions. With this technology, I can treat patients with the deepest penetration and the lowest amount of energy. It enables ultra-short pulses per energy level so we can deliver superior results using minimal excess heating.

Lumenis’ Ultrapulse Alpha is truly versatile in my practice. I address facial resurfacing, deep rhytides, rhinophyma, ice-pick acne scars as well as traumatic scars. Some physicians even use it to perform nonsurgical blepharoplasty. However, I am interested in utilising this device for full facial rejuvenation, scars on any part of the face and body and thoughtfully utilising the laser in my skin of colour patients.

Lumenis has included some impressive new technology into this system, including CoolScan technology for enhanced patient comfort, and a BrushFX scanning mode helps to blend different anatomical subunits. In the SCAARFX mode, there is up to 4 mm penetration depth in a single pulse which makes it ideal for treating deep, thick lesions.

ZO

Wendy

The user-friendly, intuitive graphical interface allows me to create presets to enter the settings for each patient. It will save those settings so you can easily access them when the patient comes in for a follow-up treatment. The laser beam is transmitted through a scanner to control the delivery of energy. The scanner regulates the configuration of energy delivered

ZO Gel Sunscreen Broad Spectrum 50 is a true sunscreen formulation breakthrough. This formula is a nongreasy SPF that is ideal for kids, as well as women and men who have oily skin.

E. Roberts, MD

Gel Sunscreen Broad Spectrum 50, ZO Skin Health

The improvement in hair growth will be visible within 4 weeks, including a decrease in hair shedding, an increase in hair thickness, and improved scalp coverage.

Alireza Firooz MD, PhD PLURYAL Hair Density®, MD-SKIN Solutions

onto the skin, which can range from covering the entire treatment area or just a fraction of it. You can perform ablation and coagulation, full or fractional.

What I like most are the numerous options I have with this device that improves ROI. This is a powerful laser that can be utilised in many ways, including ablative skin resurfacing, which results in dramatic improvement of the signs of ageing, improvement of deep periorbital and perioral rhytides, and lifting and tightening of eyelid skin, to improvements in skin texture, laxity and skin tone. With this device I can also help improve the appearance of pitted acne scars, treat rhinophyma, as well as benign lesions such as syringomas with a safe, non-scarring method. Finally, it provides for advanced treatment of traumatic scars, which can have life-changing effects for some patients. It is truly a game-changer for my practice.

Pablo Naranjo, MD, PhD, MBA, Aesthetic Doctors, Elite Laser

Clinic, Madrid, Spain

REVERSO, INDIBA®

Reverso is the evolution of deep fractional radio frequency, the new generation that implements cutting-edge technology to achieve more effective skin resurfacing and remodelling, less painful, less downtime and faster treatments. When the electric energy penetrates the skin through an array of tiny needles, it is converted into heat, causing controlled local thermal destruction, including tissue ablation and protein coagulation. The natural healing processes of this thermal induction will result in skin remodelling and rejuvenation from the stratum corneum to the dermis. The inflammation that subsides will enable the

release of several growth factors as Epidermal Growth Factors (EFF), Fibroblast Growth Hormone (FGH), Cytokines, Interleukins, and similar proteins. These growth factors stimulate the formation of collagen, elastin and other proteins that will stimulate dermis regeneration.

Reverso incorporates several technological innovations intended to guarantee skin-tailored treatment and optimal aesthetic results while maintaining the highest level of safety with this very easy to use and delegable technology. The frequency used by Reverso (460 kHz) enables this technology to create more effective heating. The large tips and short electric pulses allow the doctor to perform a quicker treatment. The combination of more powerful technology, up to 10W/pin and very sharp metal edge pins (VSP) facilitates penetration to the dermis up to a depth of 1 mm and enables the achievement of more effective treatments. The decreased pain sensation and significantly lower risk of post-inflammatory hyper-pigmentation with this technology compared to the previous generations of deep fractional radio frequencies can be justified by way of delivering the energy sequentially in every electrode (scanning mode). One of the most important technological innovations is the Variable Pulse Profile (VPP) that allows Reverso to be a unique fractional radio frequency device where users can select the electric pulses shape (flat pulse, super pulse, double pulse and parallel scanning to decrease pain sensation), based on the treatment parameters.

We are using Reverso in our clinic for eight different applications: skin rejuvenation, tissue remodelling, acne scars improvement, fine wrinkles improvement, facial contour definition, skin firming, hyperpigmentation improvement and stretch marks. The range of treatments with this technology is very large (men/women, young/ old patients, different skin colours, face/body, summer/ winter), which makes it a very profitable technology.

Michael Gold, MD Dermatologist, Gold Skincare Center, Nashville, TN, USA

TARGETCOOL, COOL HEALTH

As we all know, cosmetic patients in particular are interested in minimally invasive treatments that are effective and fast, with little to no downtime. They also expect to have a comfortable experience. Cool Health’s TargetCool offers us a new way

Reverso incorporates several technological innovations, intended to guarantee skin-tailored treatment and optimal aesthetics results, while maintaining the highest level of safety with this very easy to use and delegable technology.

Pablo Naranjo, MD, PhD, MBA Reverso, INDIBA®

Lumenis’ Ultrapulse Alpha is truly versatile in my practice. I address facial resurfacing, deep rhytides, rhinophyma, ice-pick acne scars as well as traumatic scars.

Jane Yoo, MD Ultrapulse Alpha, Lumenis

to administer topical cooling that is simple to use, safe and effective for patients.

It uses compressed CO2 cryogen that is modulated digitally, IR sensors, and a calibrated nozzle to deliver rapid cooling to the skin. The system provides accurate and efficient temperature control before and during treatments. With this device, it is easy for my nursing staff to control the patient’s skin temperature to a precise temperature between 10 degrees Celsius (ºC) and 5 degrees Celsius (ºC) for whatever duration we need to complete the treatment.

Another benefit of this technology is that it does all the work for us. It is very easy to use, so

your staff can input the precise temperature and time into the device, point and spray where cooling is needed, and TargetCool can precisely cool the skin temperature to the level you want for each individual patient. This makes it a very simple and versatile device that can be used for many or most of the treatments aesthetic doctors and dermatologists offer in their practices. We find TargetCool to be particularly useful to pair with any energy-based devices to keep the patient comfortable and calm during the treatment. It can also serve to reduce bruising and swelling post procedure.

Having the ability to easily deliver a more comfortable and efficient experience for patients can also help you do more treatments and attract more patients. In fact, search through any review site and you will find that ‘discomfort’ and ‘painful treatment’ are among the most common complaints aesthetic patients post online. Happy patients are the ones who will come back to your practice for more procedures and refer their friends and family.

Nimrod Friedman, MD

Plastic surgeon, Israel, STYLAGE®, VIVACY

I’m using the full range of VIVACY STYLAGE® products for wrinkle improvement, skin rejuvenation, and for volume enhancement.

I like the products a lot for several reasons. The first is their extremely low rate of complications. I have not encountered one case of granuloma or other complications throughout all my treatments with these products.

The second reason is I know with confidence the STYLAGE products will give me excellent lifting. So whenever I need a good lifting above the bone, like the cheeks, the chin and

other parts, especially if I’m treating an older patient and men, then the range of XL and XXL are the best products in the market, in my opinion.

But this is not the whole story because, besides that, it is also the best syringe on the market today. And this is important not just for the patient but also for the doctor. If you’re a doctor that injects a lot, then having a syringe that will keep your hand safe while also giving you the opportunity to inject many syringes without getting tired or without having any fatigue or pain in your hand is very important. This is something that is crucial for doctors who are performing a lot of injections.

So the combination of the best syringe on the market, together with an excellent safety profile and a unique product like the XXL, for me, means that the product is the best on the market up to now.

Cool Health’s TargetCool offers us a new way to administer topical cooling that is simple to use, safe and effective for patients.

Michael Gold, MD TargetCool, Cool Health

I’m using the full range of VIVACY STYLAGE® products for wrinkle improvement, skin rejuvenation, and volume enhancement.

Nimrod Friedman, MD, STYLAGE, VIVACY

PRIVATE EQUITY IN AESTHETICS A NEW MARKET MODEL FOR PHYSICIANS

Private practice is in decline. The benefits of setting up on your own very often do not outweigh the costs, and many established physicians are now looking for partners to help them reach their life goals. Rosalind Hill spoke to physicians who’ve sold their practices to understand more about the motivations behind the decision and to industry experts about what it means for the future of aesthetics

THERE’S NO DENYING AESTHETIC medicine is an expensive business — and not just for consumers. If you’re setting up in private practice today, you’ve likely already racked up hundreds of thousands — be it dollars, pounds or euros — on office space, a website, and marketing and that’s before you’ve even thought about investing in a skincare line, injectables or a laser. And when you do finally set-up shop and start welcoming patients, you might need to consider hiring staff to run your practice and support your work. So, in addition to being a doctor, you’re already a CHRO, a CEO, a CMO and more besides. After all that, what time is left for patients? And therein lies the dichotomy that many doctors in the aesthetic industry are faced with: serving their patients— their vocation— versus building and operating a successful business.

It’s no surprise then, that the business of aesthetics is

changing. While a large proportion of clinics in both the US and UK remain sole practitioner practices (over 80% of practices in the UK alone, according to PRIME’s sources), more physicians are now looking to join a partnership. And while private practice isn’t dead just yet, it’s definitely not the lure it used to be.

‘Solo practice as a business model has long been on life support,’ said industry expert Wendy Lewis. ‘It is costprohibitive to open a dermatology or plastic surgery practice today when you calculate all the costs involved: rent, staffing, software, computers, equipment, laser and light-based technology, skincare, malpractice insurance, plus marketing and social media management. And for doctors who are looking for an exit strategy, are getting closer to retirement, or overwhelmed by the advent of more and more competition in their market, it makes good sense to look around at other options. The choices are simple: join another practice, bring in a partner to offset the costs of running the practice, or sell your practice to private equity (PE) or another medical group. Many doctors I know are very interested in exploring the PE options in their markets.’

Time to wake up to the trend

Private investment into the healthcare market and services is by no means new, particularly not in the US, where the very nature of access to healthcare has made it ripe for private companies to build, operate and invest in end-user services. Dermatology, gynaecology and more services have long piqued the interest of investors, with whole tower-blocks of multi-specialty healthcare providers cropping up in some of the larger cities. However, our experts agreed that medical aesthetics has been a little late to jump on the bandwagon, with dermatology really only seeing such levels of investment in the last 5–10 years.

‘The investment community has been sleepy on medical aesthetics and have just woken up,’ said Dominic Mazzone, CEO and Founder of MedSpa Partners, one of the consolidation platforms currently growing in the US and Canada. ‘Before I founded MSP with my partner Persistence Capital Partners (PCP), there was only one other small platform out there trying to do this. Almost every doctor and every PE fund told me it was impossible, and the idea of MSP was dead about four times. In the first year of raising capital, we had to tell the story a lot. In the second year, we were still performing through COVID, and the story became a lot more exciting. By year three, you could see that the industry was noticing what we and others were doing and that medical aesthetics held an interesting niche in the retail healthcare space due to its attractive growth rate, being private pay primarily without insurance reimbursement, and recession resilient.’

contact missrosalindh@gmail.com

It is cost-prohibitive to open a dermatology or plastic surgery practice today when you calculate all the costs involved: rent, staffing, software, computers, equipment, laser and light-based technology, skincare, malpractice insurance, plus marketing and social media management.

ROSALIND HILL is a freelance journalist and content strategist. She was the launch editor for PRIME Journal in 2011.

In fact, the consolidation machine in aesthetics is moving so quickly that it is likely to become the norm in the US — and not least because of the spiralling costs of practice overheads and physician time spent away from patient care. While only approximately 5–6% of practices are part of a larger entity at this point, with up to 9000 medical spas and 14,000 aesthetic practices in the market, there is a lot of business to be done.

Drew Fine, Chief Commercial Officer at Advanced Medaesthetic Partners, touted as an alternative to private equity consolidation firms, agrees. ‘It’s very early in the trend, but I think it is going to continue, especially because the US aesthetics market has proven pretty resilient. And I think the reason that we’re seeing our growth is because when you’re a small business owner, you have to deal with everything, and it’s hard to be an expert at everything. Medical practitioners don’t love making sure the payroll runs every week; they don’t love making sure their accounting is organised; and they don’t love having to deal with marketing agencies on figuring out digital marketing.’

And that’s precisely the offer of consolidation platforms like AMP and MSP: they will bring the HR expertise, the payroll expertise, the marketing expertise, and the management professionalisation so that the physician can get back to their calling. And not only that, but they have the funds to invest in clinics to further drive profitability.

‘This is the future of aesthetics as we know it in 2023,’ said Lewis. ‘There are numerous roll-ups and chains popping up all over the US and EU now as well. These well-funded medspa chains present stiff competition for solo practitioners in the marketplace. They are much less expensive to manage and run because they have buying power for supplies, products, lasers, injectables, equipment, etc. They also offer savvy direct-to-consumer marketing programmes that resonate with today’s aesthetic patients. I think it will change the face of this industry exponentially. Aesthetic medicine is not the only target private equity groups have their eye on. We have seen roll-ups across medical specialties, from gastroenterology to OB-GYN, infertility, dentistry, podiatry and more. The next frontier for those who can afford it is concierge medicine.’

Selling up doesn’t mean losing autonomy

From her small office space based in Midtown, New York, Dr Doris Day has been running her practice for the best part of 25 years, and has become an internationally renowned and well-respected physician.

‘I’ve never worked for anybody; I’ve always done my own thing and been my own boss,’ she told PRIME. ‘I’ve been fortunate over the years to have had excellent

growth, but my office is too small to have an HR department or a marketing department. But that means I am it, and I have to do it all: I am HR. I am IT. I am marketing, and it all takes a lot of time. As I’ve gotten older, and I have added projects that I’m excited about doing, I found that it’s harder for me to get to all the things that I love and want to do because I have to do a lot of the admin side, which is often tedious and time-consuming. And also, I have ideas for expansion and growth that I don’t have the time to fully invest in and build on my own.’

Dr Day, along with Drs Shino Bay Aguilera and Steve Dayan, has joined MedSpa Partners.

‘What’s important to me is to maintain my autonomy, and feel like I run my day-to-day operations, my hours, who works in my office, and how many patients I see,’ she said. ‘But I also have people now when I need something— I have an HR department, a marketing team, and they respond quickly, so now I can go home and focus on the things that I want.’

Chicago-based plastic surgeon Dr Dayan agreed: ‘I was managing every aspect of the business. HR law in Chicago is tough and that became a full-time job in itself, especially through COVID. It was non-stop, and I wasn’t enjoying managing those issues.’

In fact, Dr Dayan has often spoken candidly of the sacrifices he’s made throughout his career as he has built his practice. Writing in Modern Aesthetics last year, Dr Dayan shared his story of missed soccer games, dance recitals and family barbecues while putting his heart and soul into building a viable business1. ‘It’s very difficult to go into private practice— I was in debt for so long that I didn’t get my real first paycheck until I was in my 40s. Unless you’re independently wealthy or willing to take the financial burden, then it’s just not viable to set up practice today. That’s not to say that private practice is totally over, but you do have to be willing to accept the sacrifices that come with it.’

But for those not willing to accept the sacrifices, unable to afford the costs of setting up privately, or looking at different priorities and life events, the alternative option is becoming more attractive. And perhaps most importantly, the patient experience has not been compromised in the name of increasing productivity and profit, as one might expect from private investors.

‘I no longer stress about the need to increase the volume of patients in order to offset the ever-increasing prices of injectable fillers, toxins, and energy devices,’ said Dr Aguilera. ‘This allows me to spend more time with my patients, which is very important for me. It also allows me to have a lower level of stress, and my visits with my patients are very personable and enjoyable.’

Likewise, Dr Michael A. Fiorillo, a New York-based board-certified plastic surgeon, who has joined Advanced Medaesthetic Partners, has been grateful for the gift of time. ‘I can now more effectively focus on the things I love — my patients, mentoring the other providers in my practice, looking for growth opportunities — because I don’t have to

Unless you’re independently wealthy or willing to take the financial burden, then it’s just not viable to set up practice today.

spend as much time on the operational day-to-day,’ he said.

And for others, it’s been thinking about an ‘exit strategy’ — what happens to that hard-earned practice that you’ve built up for decades when you’re ready to retire, and if family haven’t followed in your footsteps?

Georgia-based Dr Steven F. Weiner told PRIME: ‘I was at a place in my life and practice where I wanted to make sure my employees and staff were taken care of for the long run. I also love aesthetics and wanted to be part of something bigger to leave a memorable footprint on the industry for years to come. I love the access I now get to the bestin-class experts with the company. We could do some amazing things before, but now we get access to the scale benefits that come from the larger organisation to help us grow more effectively and support all my providers.’

The view from the UK

While the UK market, in terms of private investments in healthcare and aesthetics in particular, isn’t quite as advanced as the US, with some experts putting its maturity at least 10 years behind, there are early signs of a similar trajectory. The Sk:n clinic chain was acquired by private equity group TriSpan for a reported £35 million in 2019; The Cosmetic Skin Clinic was similarly acquired by Blue Gem Capital; and firms such as KKR Capital, which acquired Laser Clinics Australia in 2017, are now rapidly expanding into the UK and Europe.

However, one key challenge with the UK market is its fragmentation. Max Taylor, Associate at Mansfield Advisors, a boutique healthcare consultancy in the UK with a special interest in the aesthetic industry, told PRIME: ‘It’s a very different market to the US. On the surgical side, I think private equity investors want a market that isn’t there yet, and that’s because there is a perception that the surgical cosmetic market is growing and that is simply not the case. Data from BAAPS on the volumes of cosmetic surgeries shows that it’s been pretty stagnant for years now. Conversely, on the non-surgical side, there is limited data because it’s such a complicated and fragmented market. But anecdotally, non-surgical volumes are increasing.’

That said, Taylor told PRIME that there is certainly more activity in the UK market than there was 10 years ago, and it may well be the case that the UK follows where the US leads in this regard.

‘It’s definitely a growing market and it remains to be seen where it goes. PE investors care about getting it right and having the right clinically qualified people to do it. They have to set higher prices to achieve this and therefore limit their customer base because people will go elsewhere to the cheaper options, especially for toxin and fillers. Also, investors want to roll up and take on more clinics so they can build a large platform to sell privately. There’s multiple arbitrage, so if you’re a larger group, you can sell for a higher price. The other part of that is you can also create synergies when you have

have more bargaining power in what you buy; you reduce your cost base and keep a larger portion of the profit. That’s why private equity-acquired clinics seek to acquire more clinics and build a more profitable platform.’

In the UK, private investment in healthcare is perhaps more common in specialisms such as IVF, which as a market, has matured and structured itself more formally over the years. And the prime reason that investors like it is because it’s self-pay — precisely the offer of the aesthetics industry. But on the flip-side, there’s a lot of competition and in the UK in particular, the current lack of regulation likely has prospective investors feeling a little anxious.

Advice for others

If you’re weighing up whether joining a partnership is the right route for you, it definitely shouldn’t be rushed and finding an acquiring partner that’s the right fit is the most important decision.

‘All platforms are not created equal,’ said Dr Aguilera. ‘If you just want money, that’s one thing, but having a partner that you actually have a fit with that isn’t going to treat you like just a number is what’s most important to me. I have created a wonderful place where the vibe is

If you’re weighing up whether joining a partnership is the right route for you, it definitely shouldn’t be rushed and finding an acquiring partner that’s the right fit is the most important decision.

loved by all employees and patients. I didn’t want someone to come and destroy what I’ve built; it would have been like selling my soul to the devil.’

Dr Dayan agreed: ‘Choose the group that’s the best fit and has the most potential–infrastructure, track record, like-minded physicians, who’s on the board, the vision for the future, and how much control/equity you’ll have are all important things to weigh up.’

Along with that, the experience of the partnership also means a lot — do they have experience in the aesthetic industry? What can they offer you beyond monetary support? What’s their model? Are you able to tailor it so that it satisfies what you’re looking for in your career, your life?

‘Look carefully at the leadership team, the financial track record, and the strategy of the company,’ said Dr Fiorillo. ‘If those three things align with your goals, you likely have found a great partner. It’s important that whoever you partner with is going to steward the amazing business you have built with the same care,

appreciation and consideration you did.’

‘Make a list of what’s important to you and know your value,’ Dr Day advised. ‘Talk to more than one group and to colleagues you trust in those groups before you sign with anybody, and be willing to walk away. It doesn’t matter if you’re about to sign; even at the very last second, just be willing to walk away. If you’re willing to walk away from a deal that you don’t feel is right for you, you’ll know that you’re going to make the right deal when it’s time. There’s no perfect deal or perfect practice, but if you follow your list and then follow the instincts that helped you build your successful practice, you will be happy with the deal you make.’

Conclusions

Private investment and partnership consolidations in aesthetics certainly aren’t going anywhere, and if PRIME’s experts are right, then this will become the predominant market model for the aesthetic industry, and not just in the US. With spiralling overheads and set-up costs for all practices now the norm, private equity roll-ups offer a more efficient business model for anyone and allow physicians to get back to what they do best and what they love — caring for their patients.

Even for newly qualified physicians just getting started out, unless you’re independently wealthy, then joining a group is the most practical solution. And with that, the face of healthcare will undoubtedly change.

‘I think aesthetic doctors must acknowledge the current trends in the industry and accept the fact that the model they may have started out with is not practical today,’ said Lewis. ‘They have to at least look at their options and have a well-thought-out plan for future growth and success. Even young physicians just starting out should consider all options. Many young doctors may join a PE-backed group practice set up early in their careers. It does not necessarily mean that they will spend their entire life in medicine in that mode. The industry is in constant flux, and new opportunities will arise all the time. Aesthetic medicine is a very fast-paced and exciting space to be part of. It certainly keeps me on my toes.’

(accessed 24 April 2023)

I have created a wonderful place where the vibe is loved by all employees and patients. I didn’t want someone to come and destroy what I’ve built; it would have been like selling my soul to the devil.

CROWN JEWELS

CROWN AESTHETICS

CELEBRATES

FIVE YEARS OF INNOVATION IN MEDICAL AESTHETICS

SkinPen® Precision celebrates its fifth anniversary as Crown Aesthetics looks to expand its portfolio with BIOJUVE™ Launch

WITH A GROWING PORTFOLIO OF PRODUCTS, INCLUDING their flagship SkinPen Precision, an exciting new launch, plus a unique niche in regenerative science, Crown Aesthetics is staking new ground in the cosmetic research space globally.

Crown Aesthetics is a division of Crown Laboratories, Inc. which is a privately held, fully integrated global skincare company. It has been listed on the ‘Inc. 5000 Fastest Growing Privately Held Companies’ for nine years and counting. To date, the company has expanded its distribution to more than 42 countries around the world and is growing by leaps and bounds.

‘We are extremely proud of our journey into aesthetics over the past 5 years. We believe there is still a tremendous opportunity for us in the aesthetic market, and we expect to continue to expand our portfolio meaningfully in the years ahead,’ says Jeff Bedard, founder, President and CEO of Crown Laboratories, Inc.

SkinPen Precision turns five

The company’s hero device, SkinPen Precision, was acquired from Bellus Medical in September 2018. SkinPen Precision was the first microneedling pen to score US Food and Drug Administration clearance in 2018 for acne scars and again in 2021 for the treatment of neck wrinkles, also referred to as ‘Tech Neck.’

According to Joe Proctor, founder of SkinPen Precision, ‘We are extremely proud of the tremendous success of SkinPen, which is ringing in its fifth birthday this year. To date, close to three million SkinPen Precision treatments have been performed across the globe as the market continues to grow and become a must-have technology in aesthetic practices.’

The multi-tasking device received three new approved indications — to address surgical scars, stretch marks, and enlarged pores on all areas of the body— in the European Union, the United Kingdom, Australia, New Zealand, KSA, Colombia, and Israel. By all accounts, it’s getting better with age. SkinPen Precision recently announced an

WENDY LEWIS is Founder/ President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy since 1997, author of 13 books, and frequent presenter on the international stage. Her first textbook, Aesthetic Clinic Marketing in the Digital Age (CRC Press) will debut a second edition in 2023. email wl@wendylewisco.com

upgrade to its signature Treatment Kit: a new Premium Biocellulose Masque. The Masque was developed to help soothe and calm the skin following any minimally invasive treatment that causes discomfort, including SkinPen Precision, MicroPen EVO, and other skin rejuvenation procedures and energy-based technologies.

‘Another unique benefit of the SkinPen Precision system compared to other devices is how the microneedles penetrate the skin’s surface, triggering the skin’s natural wound healing process to increase blood flow and activate the creation of new tissue,’ says Dr Brian C. Jones, PhD, VP Medical Affairs, Pharmacovigilance, and Biomedical Innovation at Crown Aesthetics. ‘The needle cartridge reaches the maximum safe needle penetration depth and provides validated needle sharpness for up to 80 minutes of use.’

‘Additionally, tissue remodelling of new dermal tissues rich in collagen and elastin proteins form. These proteins improve skin quality, visibly reducing facial acne scars and neck wrinkles, leaving skin more smooth, radiant, and younger-looking,’ adds Dr. Jones.

The micro-channels created by SkinPen Precision are rebuilt with new granulation cells that include collagen and elastin for skin remodelling.

New indications expand the role of SkinPen Precision for practitioners

SkinPen Precision maintains the distinction of being the first globally approved microneedling device with FDA clearance, in addition to a C.E. mark and I.S.O. certification*.

To date, it is currently available in the EU, the UK, Australia, New Zealand, Canada, Hong Kong, South Africa, UAE, Bahrain, Kuwait, Oman, Qatar, South Africa, Colombia, Israel, and Saudi Arabia.

‘SkinPen® Precision has been my go-to treatment for some years,’ shares Dr Ana Mansouri, Medical Director of the Dr Ana The Skin Clinic in Birmingham, UK. ‘It remains the most popular option among my patients for collagen induction, thanks to its minimal discomfort and downtime, while providing impressive results.’ She is excited about the new indications for Europe, including the treatment of surgical scars and stretch marks.

‘Crown Aesthetics remains at the forefront of the aesthetic industry, given their device’s safety and efficacy profiles,’ Dr. Mansouri says. ‘This is particularly impressive and helpful to my clinical practice thanks to the high calibre of clinical studies and data conducted, as well as their evidencebased clinical protocols, providing me with the confidence to implement these in my clinical practice.’

Sonja Sattler, MD, CEO of Rosenpark Klinik in Darmstadt, Germany, agrees. ‘Innovation, maximum safety, organic results with little to no downtime is what our patients want, [and] therefore, we have been using

the SkinPen Precision for several years with very high patient satisfaction,’ she says.

‘I introduced the SkinPen Precision medical-grade device into my clinic in 2019, and it has been one of the best investments for my patients and me,’ adds Beatriz Beltrán, MD, the General Manager of Clínica BB in Barcelona, Spain. ‘The feedback has been fantastic. SkinPen microneedling treatments have enabled me to drive patient results further by creating excellent skin tone and texture, treating acne scars, fine lines, and with safety and efficacy at the forefront.’

A A

B B

LEADING THE WAY AS THE MICRONEEDLING PIONEERS, DRIVING THE MOST ADVANCED TECHNOLOGY

Unparalleled commitment to safety and proven results

Industry-setting standard of education

Only available to physician-directed practices

Physician Finder feature to help new patients find you

Marketing Resources to help build your SkinPen Precision practice

Figure 3 Female patient presenting with acne scars. (A) Before and (B) after six treatments with SkinPen. Courtesy of Cathy A. Presnick, Licensed Aesthetician, A Perfect Complexion, LLC, Melbourne, FL.

Crown Aesthetics remains at the forefront of the aesthetic industry, given their device’s safety and efficacy profiles.

Figure 2 Female patient presenting with solar lentigines. (A) Before and (B) after 4 treatments with SkinPen. Courtesy of Rosenpark Research, Dr. Sonja Sattler

SKINPEN KEY BENEFITS INCLUDE

All-natural: Ability to jumpstart new collagen

Quick: Treatment time of less than 30 minutes

Little to no downtime

Safe

Effective Visible results in one to three sessions*

Versatility: Ability to treat all skin tones and types year-round

*Results may vary

Balancing the skin microbiome with BIOJUVE™

Following their reputation as being first to market in the industry, the buzz behind Crown’s cutting-edge new product introduction is growing louder and louder.

It came out of the gates strong in the US in early 2023 with a robust media tour and a huge presence at the annual meeting of the American Academy of Dermatology in New Orleans in March. Next on the horizon, Crown is planning a robust Fall 2023 launch for the BIOJUVE line in Europe.

BIOJUVE taps into one of the hottest areas of skin research: the human microbiome. The brand’s living microbe technology, called Xycrobe™ Technology, aims to optimise the overall skin biome for healthier, youngerlooking skin.

Xycrobe Technology is derived from an isolated strain of Cutibacterium acnes subspecies defendens (C. acnes defendens) to improve the health and appearance of the skin by curating and supporting the right strain within the existing microbiome.

‘Crown Laboratories, Inc., is pioneering the “skin biome care” category with our extensive research into the skin biome,’ says Dr. Thomas M. Hitchcock, PhD, Chief Science Officer, Crown Laboratories, Inc., who literally wrote the

book on skin biome care and along with his small team of scientists created both BIOJUVE and its Xycrobe Technology.

He co-authored, ‘Rebooting the Biome: How Properly Caring for Your Skin Biome Can Do More for Your Health and Beauty Than Any Skincare Ingredients’ with New York City dermatologist Doris Day.

‘We aim to continue to invest in exploring the relationship between the microbes that live on and in the skin, and how this new philosophy of formulating topicals to holistically consider the skin biome may change how we care for the skin,’ says Dr. Hitchcock.

The excitement among leading dermatologists around this new concept in professional skincare has been impressive.

According to Crown’s research, BIOJUVE produces significant improvements in the appearance of texture, tone, fine lines, wrinkles, and photodamage1

Steeped in research and science

Their team of researchers looked at how specific strains of C. acnes, such as XYCM42 cells and their ferment affect human skin cells and tissues including keratinocyte and fibroblast monolayers, human peripheral blood mononuclear cells (PBMC), and skin explants. They found that XYCM42 and its ferment filtrate have the potential to provide benefits to the skin via antioxidant, anti-inflammatory, and select antimicrobial activities.

Next, researchers performed an 8-week pivotal study using XYCM42-based topical regimens designed to deliver and support the engraftment of live XYCM42 cells in 121 subjects. Of these, 32 subjects were enrolled for an in-clinic portion for efficacy evaluation, with clinic visits occurring at baseline, week 1, week 4, and week 8. They found that the daily regimen supports a healthy skin environment, promotes increased skin hydration, decreases redness, regulates sebum production, and reduces the appearance of signs of ageing, such as fine lines and photodamage. The study is published in the Journal of Cosmetic Dermatology1

Participants in this 8-week study used a 5- or 7-point Likert-scale (agree/neither/disagree) over a two-month evaluation period. Agreement responses at the 90th percentile or higher included (improved) skin texture, tone, healthy, natural appearance, felt conditioned, radiant, and vibrant, the study showed.

‘I’m happy to have options that are more holistic to help my patients have clearer, healthier, and more beautiful skin,’ says Dr. Day.

‘I got firsthand information as he did the basic science research behind this product line and saw the amount of strong research and science behind the ingredients and products, and that impressed me,’ she says.

As such, Dr. Day was an early adopter of the BIOJUVE line, namely the serum and the activating spray. ‘I have my patients wash with a salicylic acid cleanser at night or a gentle cleanser, and then follow that with the serum and activating spray, and have them use other products during the day,’ she says.

She typically recommends the whole line or may mix-

I think products like BIOJUVE, combined with other ingredients will be a game changer for skin health.

Figure 3 SkinPen® Precision features & benefits

and-match different products during the day. ‘I am careful to not combine the night BIOJUVE with other products so we don’t disrupt the probiotics,’ she says. ‘I believe that the future of skincare is going to be next level skincare, based on curating and protecting our natural skin biome, rather than trying to annihilate it as some of the current products and treatments now do. I think products like BIOJUVE, combined with other ingredients, will be a game changer for skin health.’

Dr. Deirdre Hooper, a dermatologist in New Orleans, LA, agrees. ‘I am so intrigued and hopeful to see what we as dermatologists can achieve as we harness the power of a healthy microbiome,’ she says. She has witnessed powerful results among people who struggle to tolerate topicals due to sensitive skin, especially those with underlying inflammatory conditions such as rosacea, seborrheic dermatitis, and perioral dermatitis.

‘Another group of early adopters are my patients who are looking for more natural products,’ she says. ‘The BIOJUVE product is lovely to use and seems to give a kind of immediate “glowy” look that has been well received by patients.’

What’s next for Crown?

According to Michael McKenna, General Manager of Crown Aesthetics, their main focus is on science that delivers innovative aesthetic solutions to their practices and partners. They are also proud to be selling exclusively to physician-directed providers.

‘As the premier medical aesthetics company, the Crown team is dedicated to working with practices around the world to grow their businesses. We are committed to investing in innovative non-invasive products to market that will drive revenue for our customers. The three pillars of our business model are to excel with our technology, offer educational opportunities for our customers to learn and grow, and

provide best-in-class service to all of our customers,’ he says.

‘As we expand our portfolio of game-changing products for the aesthetic industry, we are focused on continuing to set industry standards for efficacy and safety.’

*CE Mark - Medical device Class II a. In the European Union, UK, Australia, New Zealand and Colombia: Medical Purpose: SkinPen Precision Microneedling System is a medical device intended to treat facial acne scars in adults aged 22 years or older; Aesthetic Purposes: SkinPen Precision Microneedling System is also intended to help improve the cosmetic appearance of fine lines, wrinkles, stretch marks, surgical scars, enlarged pores and pigmentation conditions (dyschromia)

References

The BIOJUVE product is lovely to use and seems to give a kind of immediate ‘glowy’ look that has been well received by patients.

1. Rhee, MS, Alqam, ML, Jones, BC, Phadungpojna, S, Day, D, Hitchcock, TM. Characterization of a live Cutibacterium acnes subspecies defendens strain XYCM42 and clinical assessment as a topical regimen for general skin health and cosmesis. J Cosmet Dermatol. 2023; 22: 1031- 1045. doi: 10.1111/jocd.15510. Available at https:// onlinelibrary.wiley.com/doi/10.1111/jocd.15510

Figure 4 Results from the BioJuve clinical study on a Female patient, 57 years of age, Fitzpatrick skin type I. (Left to right) Results shown at baseline, week 1, week 4, and week 8.

Figure 5 Results from the BioJuve clinical study on a Female patient, 56 years of age, Fitzpatrick skin type IV. Results shown at baseline, week 1, week 4, and week 8.

The continuing rise in popularity of nonsurgical rhinoplasty (NSR) demands that injectors develop a firm understanding of needed safety precautions so that outcomes are not only elegant and beautiful but also safe.

CLINICAL PEARLS FOR OPTIMISING SAFETY IN NON-SURGICAL RHINOPLASTY

Alexander Z. Rivkin, MD, unveils his Universal Injection Safety

Precautions (UISP) that aim to ensure injectors can perform non-surgical rhinoplasty safely without compromising on results

ABSTRACT

The demand for non-surgical rhinoplasty (NSR) is surging globally, in part because the procedure can be life-changing for patients. However, the nose is the most dangerous area of the face to inject filler, and while rare, adverse events (AEs) can be devastating. Thus, the successful NSR injector must be an

experienced injector with a detailed understanding of nasal anatomy, a nuanced appreciation of nasal aesthetics, and a thorough knowledge of best practices in prevention, recognition, and treatment of AEs. Key to prevention is adoption of and diligent adherence to Universal Injection Safety Precautions for safe injection, described in this manuscript.

WHEREAS THE INJECTION OF FILLERS IS A RELATIVELY SAFE procedure, adverse events (AEs), including serious ones like vascular compromise and ischemic complications, do occur. Complications from filler injection can occur anywhere on the face, but the nose poses a higher risk than anywhere else. The continuing rise in popularity of non-surgical rhinoplasty (NSR) demands that injectors develop a firm understanding of needed safety precautions so that outcomes are not only elegant and beautiful but also safe.

Injection safety in the nose hinges primarily on preventing and managing ischemic complications. Although bruising, erythema, tenderness, and swelling may occur, these are transient and treatable with over-the-counter medication and vascular lasers. In addition, moderately serious AEs like granuloma and delayed onset nodule formation that occur with filler injection in other areas of the face have not been reported after using US FDA-approved fillers in the nose1

Overall, the principles that govern safe injection in the face can be applied to ensure safety in NSR; however, following those principles meticulously is of paramount importance with nasal injections. The nose is the most dangerous area in the body to inject with filler, and complications can be catastrophic. There are numerous reviews and reports of filler-related blindness and tissue necrosis, which illustrate this point all too well 2. Injectable filler vascular complications happen when the tip of the needle or cannula is inside an artery, and a large amount of material is injected under high pressure, obstructing critical blood supply to the skin or the eye. The only exception to this rule is in the tip of the nose or the alar area, where ischemia can occur because too much filler compresses the small vessels in a tight space, causing a compartment syndrome-like effect. Preventing complications, therefore, hinges on preventing the confluence of these factors.

ALEXANDER Z. RIVKIN, MD is a facial aesthetic specialist (aesthetic surgeon) in Private Practice in Los Angeles, California. He is also Assistant Clinical Professor at the David Geffen UCLA School of Medicine. Dr. Rivkin is a member of the International Society for Aesthetic Competence - a leading consortium of global aesthetic experts devoted to safety

email: arivkin9@gmail.com

KEYWORDS

Non-surgical rhinoplasty, liquid rhinoplasty, non-surgical nose job, injection safety, fillers

Is there a way to make sure that the tip of the needle or cannula is not inside an artery?

Unfortunately, the short answer to that question is — no. Until ‘smart’ needles that provide some signal upon passage into a blood vessel are widely available, we will be inherently injecting blind. Although aspiration is a widespread practice, there is no definitive evidence showing effectiveness in preventing complications. In fact, there is a growing consensus among expert injectors that aspiration is not only unreliable but actually decreases safety3,4. It is unreliable because the test is only assessing the exact spot where the tip of the needle is located during aspiration, not necessarily where the product is injected. This manoeuvre assumes that the injector’s hand has remained perfectly still through the performance of aspiration and subsequent injection. If the tip of the needle moves, even by a millimetre, the test is rendered useless. As demonstrated by a recent ultrasound study, it is physically impossible to aspirate a viscous gel, like those used for facial filling, without moving the tip of the needle several millimetres during the procedure the size of the vessels to be avoided, this distance is clearly far too large to assure safety during product placement. Of note, some have argued that aspiration without motion is possible if the needle is resting on bone. While this may be true for a brief suction time, it is very unlikely true for the extended times suggested by the aspiration literature as necessary for a reliable test, especially when using the highly viscous fillers needed for good NSR outcomes6. False negative findings with aspiration are common enough7,8 to suggest the practice itself creates a false sense of security for injectors, which could lead to the placement of large amounts of filler under high pressure inside a patient’s artery. Until technology provides a way to detect arterial puncture, one must inject assuming that their needle or cannula is always inside a vessel.

If we cannot control needle location, how do we inject safely?

Before discussing techniques to improve safety, it is important to dispel the myth that an expert level of anatomic knowledge reduces injection risk to zero. Anatomy will indicate the areas or depths that are relatively higher or lower risk; however, individual variability in the course and depth of facial vessels is such that one can never be certain that a given area or

plane of the face is completely safe. Fang et al. recently published an article describing positive aspirations at all depths, including the supra-periosteal plane9

If we cannot know whether a needle is in a vessel, what can be done to ensure safe

Though there are no randomized clinical trials on the subject, there are evidencesupported practices which can reduce risk. First, one must do everything possible to limit the volume of filler deposited in any one injection point. Because one must assume that the needle tip is always in a dangerous place, injecting a large bolus filler is an unsafe practice under any circumstance. Admittedly, this stance is in contrast to many of the recommendations and techniques popular today, and it is not uncommon to read claims that bolus injections on periosteum or perichondrium are ‘safe’. The literature on anatomic variability, however, provides clear evidence that doing so is unwise. Given the absence of any true ‘safe plane’ for injection, and the stakes at hand, it is best to take appropriate precautions. The sections below describe a set of protocols developed by the author, Universal Injection Safety Precautions (UISP). These principles should be applied in combination with adequate training and knowledge of anatomy.

Universal Injection Safety Precautions (UISP) relevant for all treatment areas

■ Continuous retrograde motion as filler is moving through the needle. Constant motion limits the amount of filler deposited in any one place to a very small amount. This practice is more reliable than aspiration because, even if the needle is inside a vessel, it will exit the vessel before enough material has been deposited to cause an AE. If the injection is placed as a vertical column, this practice also improves tissue lift because expanding multiple tissue planes leads to more efficient and precise projection.

■ Slow, low-pressure injections give the injector time to react if early signs of ischemia present. This type of injection also will not overcome systolic blood pressure, which is required for a filler to move retrograde through an artery.

■ Injectors should use the smallest gauge needle possible. A small needle gauge encourages small injection volumes and enhances patient comfort.

Constant motion limits the amount of filler deposited in any one place to a very small amount.

Figure 1 51 year old male undergoing facial feminization with a history of 3 rhinoplasty surgeries, last 1 year prior to consultation with the author, wanted to turn up their nasal tip with Bellafill. (A) 0.25cc Bellafill was injected into their tip using a backloaded 0.5cc 28 gauge insulin syringe. (B) A 1cm area of duskiness developed on their tip 10 minutes after injection that was concerning for compressive ischemia. (C) Asprin was given and massage and warm compress were administered for 15 minutes. The area was still dusky afterwards, so the patient was started on a Medrol dose pack and given NO gas, nitropaste, hyaluronidase injection (50u) and continued receiving massage and heat. They left the clinic after an hour improved, but presented (D) the next morning with a nasal tip that was very concerning for developing necrosis. They were given nitropaste and NO gas for an hour and injected with 30u more of hyaluronidase. They were then sent for hyperbaric oxygen treatment. Their tip began to improve (E) and the next day (F) they were treated with hyperbaric oxygen a second time. Throughout this period, the patient was using aspirin, nitropaste, warm compresses, massage and Medrol dose pack at home. After the second HBO treatment (G), the patient showed clear signs of improvement and by day 5 after procedure their nasal tip skin recovered completely.

Cannulas should be 25 gauge or larger. Sizes smaller than 25G can pierce vessels, but this must be balanced against the fact that larger cannulas can compromise precision, which is especially important for good outcomes in the nose.

■ Diligent cleansing of the skin with alcohol, chlorhexidine or hypochlorous acid is important because the fillers can remain under the skin for several years. We want to prevent the formation of an environment likely to harbor chronic infections.

Universal Injection Safety Precautions (UISP) specific to non-surgical rhinoplasty

■ Ice the skin of the nose prior to injection. This will shrink the vessels and decrease the risk of perforation. One exception is patients who have had rhinoplasty in the past, as their dermal blood supply is already compromised. For these patients, icing may increase the risk of ischemia.

■ Use 0.3 or 0.5 cc insulin syringes backloaded with filler. These syringes come with smaller needles (28 to 31 gauge) and permit the precise deposition of tiny (0.01 to 0.03 cc) amounts of product. Insulin syringes improve safety by limiting the amount of product injected per spot. The outcome is improved because of an increase in precision. They also improve patient comfort. Aspiration is not possible with these syringes due to needle size and syringe construction.

Additional suggestions to improve safety for nasal injections include:

■ Place most injections at the midline, as the major vessels of the nose mainly run on the lateral aspects. That being said, there are vessels in the midline, and anatomic variability dictates that some people will have a dorsal nasal artery which runs down the middle of the dorsum. Thus, careful adherence to UISP rules is necessary, even in the midline. Of note, advanced NSR injectors will regularly inject outside of the midline, because correction of many asymmetries and cases of cartilage collapse require filling of the nasal sidewall.

■ Pinch compress the dorsal nasal and

supratrochlear vessels during radix injection to prevent inadvertent cannulation.

The goal of UISP and the other effective safety precautions is not to prevent our needle or cannula from entering a vessel. We enter vessels all of the time when we inject filler, as is obvious from the frequency with which we cause bruising. The goal is to make sure that, no matter where the tip is, we never inject enough filler to cause an ischemic AE.

Which patients are most at risk from complications with NSR?

In a retrospective review of my first 2400 NSR cases, patients who had undergone previous rhinoplasty surgery had a 50% higher risk of AEs10. Blood supply to the nasal skin of a post-rhinoplasty patient is inherently compromised, increasing the risk of compressive ischemia and necrosis. Post-operative scar formation can fixate vessels, limiting their ability to roll away from a needle or cannula and thereby increase the risk of an embolic event. These patients should only be treated by the most senior NSR experts, and particular precautions should be implemented both pre- and post-injection.

Of the nasal subunits, we found that the tip, sidewall, and alar areas had the highest frequency of adverse events. Of note is that our analysis included minor adverse events such as prolonged erythema, tenderness, and ischemic AEs. The increased risk at the tip and alar areas are most likely due to the relative lack of redundant blood supply in these areas, as well as the relatively small and tight potential space due to the disordered arrangement of fibrofatty tissue and muscle. Unlike the rest of the nose, the tip, ala, columella and radix do not have a classic five-layer structure. The increased risk at the sidewall is due to the presence of large vessels, such as the angular and dorsal nasal arteries and veins and their respective branches. These can cause significant bruising or embolic ischemia when perforated.

Which fillers are safest to use in NSR?

Every beginner- and intermediate-level NSR injector should use hyaluronic acid (HA) fillers exclusively for NSR. The reversibility of HAs is a critical safety advantage when injecting a high-risk area like the nose. Of the US

In a retrospective review of my first 2400 NSR cases, patients who had undergone previous rhinoplasty surgery had a 50% higher risk of adverse events.

FDA-approved HA fillers, JUVÉDERM® VOLUMA®, JUVÉDERM® Volux™ (Allergan, Irvine, CA, USA) and Restylane® Lyft (Galderma Laboratories, Irving, TX, USA) are best for NSR due to their longevity, low water absorption, and ability to project tissue. Viscous fillers like these are relatively more cohesive and, therefore, able to hold their shape and avoid spread over time. This quality is essential for sculpting tip-defining points, dorsal edges, and performing the kind of precise contour adjustment necessary for successful NSR. After many years and thousands of patients, I have incorporated poly methyl methacrylate — collagen gel (PMMA, Bellafill; Suneva Medical, Inc., San Diego, CA, USA) for NSR. Most patients choose to do one session of HA for the peace of mind that reversibility confers and to be certain of satisfaction with the results. At the recommended touchup session, however, they have the option of switching to PMMA. Every patient is informed of the risk of using a non-reversible filler and the inadvisability of having rhinoplasty surgery at any point after PMMA injection. In my experience, PMMA is an effective filler for NSR with an unmatched duration of effect and an excellent safety profile if injected in the deep dermal to subdermal layer under UISP11

Fillers not recommended for use in the nose include:

■ Silicone. This material was used extensively in the 1980s but was abandoned because of devastating inflammatory reactions. A few expert injectors use a microdroplet technique effectively in the nose for carefully selected patients, but the material itself is accompanied by too much risk for broader use.

■ Calcium Hydroxyapatite (CaHA; Radiesse; Merz Pharmaceuticals GmbH, Frankfurt, Germany). Despite a superior G’ (a measure of stiffness), CaHA duration of effect in the nose is quite variable once the carboxymethyl cellulose carrier is absorbed10 Given this limitation, the negative impact of irreversibility on the safety profile makes NSR injection with this filler undesirable.

■ Other poor choices for NSR include soft and/or hydrophilic HA fillers, fat, and poly-L-lactic acid (PLLA [Sculptra, Galderma, Irving, TX, USA]). These agents are not able to lift tissue sufficiently and tend to

spread and swell after injection, giving unpredictable and poorly defined NSR results. Additionally, fat and PLLA are not reversible.

What should I do if I suspect an ischemic event?

The safe performance of NSR hinges on a thorough understanding of adverse event prevention, as outlined above; however, there are additional requirements. The safe NSR injector must also be fully capable of recognizing and managing adverse events. The first sign of ischemia in the nose is often a painless blanching that is slow to resolve. If ignored, this can proceed to pain and mottled duskiness with slow capillary refill in the surrounding area. The competent NSR injector must be able to easily differentiate the solid, well-demarcated color of a hematoma from the mottled appearance of ischemic livedo reticularis. They should also know exactly what to do if ischemia is suspected, with the understanding that timely action is the only way to prevent progression to necrosis. Steps to be taken immediately include:

■ Stop injecting!

■ Massage the area vigorously

■ Apply heat in the form of a warm compress

■ Give the patient 325mg of aspirin.

Figure 2 Pictured are the components of the author’s crash cart. Gummy bears and ammonia for vaso–vagal recovery; warm compresses, aspirin and assistant’s hand for massage of early ischemia; methylprednisolone, nitroglycerine ointment, hyaluronidase, nitrous oxide gas for persistent ischemia; flashlight, timolol and 1.5 inch 25 gauge cannula for visual loss event recovery

The first sign of ischemia in the nose is often a painless blanching that is slow to resolve.

In over twenty years of experience with NSR at my practice, countless cases of early ischemia have been resolved in seconds when steps 1 and 2 above were performed immediately. Based on clinical experience, intense massage of the area for a minute or so appears to stop vasospasm and normalize blood flow, especially in post-surgical noses. Vasospasm accompanies and significantly complicates ischemia12. I believe that vasospasm often causes a feed-forward loop of ischemia and tissue damage that leads to necrosis if not resolved right away. If ischemia resolves with massage, a warm compress should be applied for 10 minutes, and a dose of aspirin should be given. If the area appears pink at this time, no further steps are necessary aside from the patient sending a photo of their nose in a few hours to ensure no delayed effects are manifesting.

If massage does not resolve blanching and/or the area in question looks dusky or mottled after the first compress, further measures should be instituted. The injector should have a ‘crash cart’ with all of the below emergency supplies easily accessible:

■ Hyaluronidase. Inject with enough hyaluronidase to cover the entire surface area involved, not just the

injection point. The usual dose in the nose for this situation ranges from 50 to 300 units or more. Repeat hyaluronidase treatment hourly until capillary refill and skin color normalize. This recommendation applies irrespective of the filler used.

■ Nitroglycerin paste. Apply 2% nitroglycerin paste (NitroBid, Fougera, Melville, NY, USA) after hyaluronidase injection for 20 to 30 minutes. Although controversial, I have found this treatment to be beneficial. There is a theoretical concern that dilating vessels could worsen ischemia by permitting filler particles to move to smaller arterioles, but there is no empirical evidence to support this hypothesis, and I have not seen evidence of this happening in my patients.

■ Steroids. Start a five-day steroid taper with the first dose administered in the treatment room. It is important to keep steroids on hand rather than providing a prescription. Patients may change their minds about taking steroids once they leave the office, a decision which could worsen outcomes.

■ Nitrous oxide. If available, nitrous oxide should be administered via inhalation while the patient waits

Non-surgical rhinoplasty is a life-changing procedure for patients. For this reason, although it is a complex and risky procedure to perform, it is immensely rewarding for the injector.

for hyaluronidase and nitro paste to take effect.

■ Additional medication. Other medications that could also be helpful for increasing blood flow include sildenafil, tadalafil, and vardenafil.

If the patient’s skin improves after steps 1–5 are performed, they should be observed for fifteen minutes and sent home with instructions to take aspirin (325 mg bid) and use warm compresses, periodic massage, continued steroids, and nitroglycerin paste (one hour on, one hour off). The patient should send photos of the area every 12 hours and should return to the clinic for reevaluation the next day. Hyperbaric oxygen (HBO) treatment should be instituted if there is any doubt that the skin will fully recover. The earlier HBO treatment is initiated, the more effective it is.

If the area in question does not improve despite all the measures taken, including HBO treatment, or if the injector is not notified before necrosis has set in (two or more days after the original injection), wound care protocol should be initiated. The skin should be kept well hydrated with topical emollients and dressings, antibiotics or antivirals should be considered, and the patient should be referred to a wound management expert for further care.

What if the patient has vision changes?

Every aesthetic practitioner must be aware and prepared for the remote but devastating possibility of injectable filler causing visual compromise. NSR injectors especially so, since the glabella and nose are well known to be the areas at greatest risk2. If visual compromise is suspected, the injection should cease at once, and the function of each eye must be immediately documented. NSR injectors should make sure they are practised at administering these tests quickly.

■ Ability to read a Snellen chart

■ Ability to read a newspaper or magazine

■ Count fingers and perceive hand motion

■ Extra-ocular motion

■ Pupillary response to light evaluation.

If there are indications of stroke, such as unilateral weakness, severe headache, confusion, sudden speech difficulties or dizziness, the patient must be immediately transported to the nearest emergency room, and the rapid response stroke team must be alerted.

If stroke is not suspected, a retinal specialist should be summoned emergently. Each NSR injector should establish a relationship with a retinal specialist in

References

1. Wang JV, et.al. Utility of preinjection aspiration for hyaluronic fillers: a novel in vivo human evaluation. J Cutan Med Surg. 2020; 24(4): 367- 371.

2. Beleznay K et.al. Update on avoiding and treating blindness from fillers: a recent review of the world literature. Aesthet Surg J. 2019; 39(6): 662- 674.

3. Rivkin AZ. Aspiration: I don’t do it and neither should you. J Cosmet Dermatol. 2021 Apr;20(4):10421043

4. Goodman GJ et.al. Aspiration Before Tissue Filler-An Exercise in Futility and Unsafe Practice. Aesthet Surg J. 2022 Jan 1;42(1):89-101.

5. Lin F, et.al. Movement of the Syringe During Filler

Key points

The nose is the most dangerous area of the face to inject with filler, but also the most rewarding

Aspiration is not a reliable safety maneuver in the nose

Universal Injection Safety Precautions should be scrupulously followed with every procedure in the nose

The NSR injector must be expert at preventing, recognizing and quickly treating vascular adverse events

The NSR injector must be prepared for any emergency with a well stocked crash cart and established relationships with HBO centers and retinal specialists in their area who are willing to see patients urgently if necessary.

Aspiration: An Ultrasound Study. Aesthet Surg J. 2022 Sep 14;42(10):1109-1116.

6. Kapoor KM et al. Factors influencing pre-injection aspiration for hyaluronic acid fillers: a systematic literature review and meta-analysis. Dermatol Ther. 2020;e14360.

7. Torbeck RL et.al. In Vitro Evaluation of Preinjection Aspiration for Hyaluronic Fillers as a Safety Checkpoint. Dermatol Surg. 2019 Jul;45(7):954-958.

8. Van Loghem JA et.al. Sensitivity of aspiration as a safety test before injection of soft tissue fillers. J Cosmet Dermatol. 2018 Feb;17(1):39-46.

anticipation of this possibility. In the meantime, the injector must act, as irreversible damage can occur within 15 minutes of the onset of visual symptoms. The practitioner should inject several hundred units of hyaluronidase into the area that was being treated, as well as into the supratrochlear and supraorbital foramina. Several hundred more units should be injected into the retrobulbar or peribulbar area. There is little concrete evidence to show that these injections work to reverse ischemic blindness, but the potential benefits far outweigh the risks13. Other techniques that may help include:

■ Breathing into a paper bag can lead to carbogen dilation of the retinal vasculature

■ Retinal massage. Gently pressing and releasing the eye twice per second for an hour or two may dislodge the emboli and improve vision14

■ Topical Timolol and oral Acetazolamide. These medications decrease intraocular pressure and should be in every NSR injector’s crash cart.

Is it worth it to become an advanced NSR injector?

Non-surgical rhinoplasty is a life-changing procedure for patients. For this reason, although it is a complex and risky procedure to perform, it is immensely rewarding for the injector. The successful NSR injector must know the anatomy of the nose, be aware of nasal aesthetics (as well as important differences between ethnicities), and be an expert in the safe and effective use of all of the injectable fillers on the market. Safety must always be the first priority in the nose with diligent adoption of robust and evidence-based precautions, such as UISP, as well as thorough preparation for any and all adverse event possibilities.

Declaration of interest Dr. Rivkin is a speaker and ad board consultant for Galderma, Allergan, Suneva Medical, and Merz; and a principal investigator for Allergan, Suneva and Galderma.

9. Fang WT et.al. Descriptive Analysis of 213 Positive Blood Aspiration Cases When Injecting Facial Soft Tissue Fillers, Aesth Surg J, Vol 41, Issue 5, May 2021; 616–624

10. Rivkin A. Nonsurgical Rhinoplasty Using Injectable Fillers: A Safety Review of 2488 Procedures. Facial Plast Surg Aesthet Med. 2021 Jan-Feb;23(1):6-11.

11. Rivkin A. PMMA-collagen Gel in Nonsurgical Rhinoplasty Defects: A Methodological Overview and 15-year Experience. Plast Reconstr Surg Glob Open. 2022 Aug 19;10(8):e4477

12. Murray G, et.al. Guideline for the Management of Hyaluronic Acid Filler-induced Vascular Occlusion. J

Clin Aesthet Dermatol. 2021 May;14(5):E61-E69. Epub 2021 May 1.

13. Jones, D et.al. Preventing and Treating Adverse Events of Injectable Fillers: Evidence-Based Recommendations From the American Society for Dermatologic Surgery Multidisciplinary Task Force. Dermatologic Surgery 47(2):p 214-226, February 2021.

14. Rommel F et.al. Evaluating Retinal and Choroidal Perfusion Changes After Ocular Massage of Healthy Eyes Using Optical Coherence Tomography Angiography. Medicina (Kaunas). 2020 Nov 26;56(12):645.

Figures 1–2 © Dr. Rivkin

IMPACTS OF GLYCATIVE STRESS AND MELATONIN ON AMYLOID-βCLEARANCE

Yoshikazu Yonei and Masayuki Yagi explain the impact of glycative stress on the brain and the role it plays in the pathogenesis of Alzheimer’s disease

ABSTRACT

Glycative stress refers to the tendency of the body to form carbohydrate- and fatty acid-derived shortchain aldehydes as a result of diabetes, high-fat diets, and excessive alcohol intake. Short-chain aldehydes are highly reactive to carbonylate lysine and arginine residues in proteins. Further reactions produce advanced glycation endproducts (AGEs). In brains rich in high lipid content, lipid peroxidation produces lipid-derived aldehydes, i.e., methylglyoxal (MGO) and acrolein. In the amyloid-β (Aβ) cascade involved in the pathogenesis of Alzheimer’s disease (AD), these aldehydes promote polymerization via glycative modification of Aβ and cross-link formation, leading to deposition in the brain

and increased neurotoxicity. Furthermore, Aβ becomes persistent, and Aβ clearance is reduced. We measured Aβ phagocytosis using primary cultured rat microglia and fluorescence-labelled TAMRA-Aβ (Cosmo-Bio, Otaru, Japan) and compared phagocytosis ability against MGO-treated glycated Aβ to examine the effect of glycative stress and melatonin addition to examine the effect of sleep quality. The results showed that Aβ phagocytosis of microglia was impaired by glycative stress and, conversely, was enhanced by melatonin addition. This suggests that the impaired phagocytosis is one of the mechanisms underlying the decrease in Aβ clearance induced by glycative stress. Even with modern medicine, it is difficult to treat advanced AD

with widespread disruption of the neural network. Rather, proactive preventive measures from an early stage are important. On the other hand, melatonin can be expected to prevent lipid peroxidation and inhibit the formation of fatty acid-derived aldehydes by its antioxidant potential and also to contribute to AGE clearance by its ability to promote AGE degradation in the brain. In AD strategies, we have entered an era in which a paradigm shift should be made toward maintaining Aβ clearance homeostasis by practising a lifestyle with two pillars: prevention of Aβ glycation and promotion of AGE degradation through measures against glycative stress and improvement of sleep quality to promote melatonin secretion.

The major components of senile plaques and PHFs have been identified as amyloid-β protein (Aβ) and hyperphosphorylated tau protein.

THE NUMBER OF PATIENTS WITH dementia worldwide is expected to increase from an estimated 57.4 million in 2019 to an estimated 152.8 million by 20501. The number of patients over 65 years old with dementia in Japan is estimated to be about 6 million (as of 2020), and it is predicted that about 7 million (about 1 in 5 elderly) will have dementia by 20252. Efforts to prevent and treat dementia will become increasingly important in the future.

Dementia is classified into four types: Alzheimer’s disease (AD), vascular dementia (VD), dementia with Lewy bodies (DLB), dementia due to other Dementia with Lewy bodies (DLB), and dementia due to other diseases.

The neuropathological features of AD include atrophy of the hippocampus and cerebral cortex in the brain, as well as extensive deposition of neuronal loss, senile plaques and neurofibrillary tangle (NFT)3. NFTs are unique fibre bundles called paired helical filaments (PHFs), as seen in electron microscopy images. The major components of senile plaques and PHFs have been identified as amyloid-β protein (Aβ) and hyperphosphorylated tau protein. Tau protein is a protein bound to microtubules, which have a molecular weight of approximately 50,000 and are present in nerve axons and functions to promote and stabilize microtubule polymerization. Microtubules form a cytoskeleton and function as a transport rail for intracellular proteins and intracellular organelles. Phosphorylation of tau protein causes destabilization of microtubules, leading to an impairment in the intracellular transport mechanism.

Senile plaques, which are deposition sites of Aβ, are more specific for AD than NFT. Diffuse senile plaques, characterized primarily by nonfibrotic Aβ deposition, are the earliest lesions in AD brains. Polymerized Aβ aggregates are neurotoxic. These features suggest that Aβdeposition in the brain precedes tau protein in the pathogenesis of AD and is closely related to the aetiology of AD4

Complications of diabetes include neuropathy, retinopathy, nephropathy, and cardiovascular lesions. The incidence of dementia is known to be higher in diabetic patients5. A core mechanism linking diabetes and complications is glycative stress.

Glycation may be involved in the onset and progression of dementia in terms of protein denaturation by the generation of advanced glycation end products (AGEs), enhancement of cross-linking, and induction of inflammation via RAGE6. The accumulation of AGEs in the skin of 226 Anti-Aging Dock checkup subjects was measured by the AGE Reader (Diagnoptics, Netherlands), and the subjects with a measured value of 2.27 or higher had a higher rate of mild cognitive impairment (MCI) than those with a measured value of less than 2.27 (Figure 1)7

Glycative stress

The concept of glycative stress is shown in Figure 2 Causes of glycative stress include

■ blood glucose spikes (diabetes and insulin resistance)

■ a high fat/animal fat diet (high triglyceride and LDL cholesterol levels), and

■ excessive alcohol consumption.

Common to all three is aldehydes. Many people experience postprandial hyperglycemia of 140 mg/dL

YOSHIKAZU YONEI, PHD, Doshisha University Faculty of Life and Medical Sciences

Graduate School of Life and Medical Sciences

1–3 Tatara Miyakodani

Kyotanabe, Kyoto, Japan; MASAYUKI YAGI, Anti-Aging Medical Research Center and Glycation Stress Research Center, Graduate School of Life and Medical Sciences, Doshisha University, Kyotanabe, Kyoto Japan

email: yyonei@mail.doshisha.ac.jp

KEYWORDS

Alzheimer’s disease, amyloid-β clearance, microglia, amyloid-β phagocytosis, glycative stress, melatonin

or higher, even if their fasting plasma glucose is normal. Such postprandial hyperglycemia is called ‘blood glucose spikes’, and it is now known to be a risk factor for the progression of atherosclerosis and the pathogenesis of various age-related disorders, i.e., cerebral and cardiovascular events.

Typical carbohydrate-derived aldehydes that induce glycation are glyceraldehyde (GA), glycolaldehyde, acetaldehyde, 3-deoxyglucosone (3-DG), glyoxal (GO), and methylglyoxal (MGO). In the lipid-rich brain, fatty acid-derived aldehydes8, i.e., acrolein (Acro), malondialdehyde (MDA), 4-hydroxynonenal (4-HNE) and MGO play an important role. Although the reaction with aldehydes is generally referred to as ‘carbonylation’, the process of subsequent complex and multi-pathway reactions to produce a wide variety of AGEs is also often referred to as ‘glycation’.

Impacts of high animal-fat diets on the brain

Among high-fat diets (HFDs), excessive animal-fat diets (HAFDs) have recently attracted attention from the viewpoint of addiction; HAFDs reduce the effects of the adipocyte-derived hormone leptin (leptin resistance), resulting in weight loss difficulties9,10. In the hypothalamus, the arcuate nucleus is the main nerve centre that regulates the hormonal and autonomic homeostasis of appetite (metabolic hunger regulation system).

Typical carbohydratederived aldehydes that induce glycation are glyceraldehyde (GA), glycolaldehyde, acetaldehyde, 3-deoxyglucosone (3-DG), glyoxal (GO), and methylglyoxal (MGO).

HAFD induces hypothalamic inflammation and cellular stress, i.e., ER stress and oxidative stress, thus paralyzing the metabolic hunger regulatory system. As a result, the individual’s brain is unable to correctly

determine the necessary caloric intake. In HAFD-fed mice, inflammation-inducing activated microglia infiltrate the hypothalamus for a short period of time, causing progressive brain damage and leukocyte migration, and eventually, the brain enters a state of chronic inflammation9. This inflammation is ameliorated by regular exercise in morbidly obese mice. We hypothesize that the mechanism by which HFD/ HAFD induces ER stress in neurons involves fatty acidderived aldehydes and subsequent protein modifications. In animal studies, HFD induces increased oxidative stress and impaired GAPDH activity in hepatocytes, resulting in increased GA and MGO in plasma8,11. Oxidative stress increases fatty acid-derived aldehyde production from the lipids, rich in brain tissue, resulting in an increased aldehyde supply.

Glycative stress and AD

Neuropathological features of the brain in AD patients include brain atrophy, senile plaques, and neurofibrillary changes. Senile plaques are composed of Aβ, a peptide (Aβ40, Aβ42) with a molecular weight of 4,300–4,500 consisting of approximately 40 amino acids. Aβ is cleaved from amyloid-beta precursor protein (APP) by the action of βand γ-secretases (Figure 3)6,12

Aβ is normally degraded and excreted within a short period of time as a metabolite in the brain (Aβ clearance). However, once the structure of Aβ is modified by oxidative stress or glycative stress and abnormal Aβ is generated, insoluble fibres are formed and deposited13,14 In particular, when proteins form cross-links with each other due to glycative stress, Aβ binds to each other and abnormal Aβ polymers are formed. The formation of abnormal Aβ polymers induces persistent degradation, increased neurotoxicity, and impaired Aβ clearance. Furthermore, when Aβ is not excreted, it accumulates and deposits in the brain, forming Aβ senile plaques (amyloid pathology). When highly neurotoxic abnormal Aβ clings to the periphery of previously healthy neurons, it affects the neurons. This triggers the formation of neurofibrillary tangles, in which tau protein, one of the microtubule-binding proteins, fibrillates and aggregates in the cytoplasm. This results in gradual brain atrophy and the progression of Alzheimer’s disease. A concept that adds glycation stress to the ‘amyloid cascade hypothesis’ has also been proposed15-17. The importance of Aβ clearance is emphasized in these concepts.

Prevalence of MCI was analyzed using the tertile method (n = 226); SAF, skin auto fluorescence measured AGE Reader (Diagnoptics, Groningen, Netherlands); Existence of MCI, SAF ≥ 2.27, odds ratio 6.402, 95%Cl, 1.590 ~ 25.773, p = 0.009. The figure is quoted from Reference 7. MCI, mild cognitive impairment; 95%CI, 95% confidence interval.

Glycative stress has a major impact on the Aβ cascade. It is triggered by an increase in short-chain aldehydes, including ring-opened glucose. These aldehydes, as carbonyl stresses, induce protein carbonylation and further produce AGEs, which contribute to neurodegeneration in AD. Aβ amyloid protein, glycated by aldehydes, is considered a morphological change with increased toxicity.

MGO is involved in the development of AD; MGO increases the size of Aβ aggregates18. The concentration of MGO in CSF of AD patients is higher than that in

Figure 1 Analysis of MCI prevalence by participant’s profile index

healthy subjects19. There are also more MGO-derived hydroimidazolone compounds in the CSF of AD patients20

Regarding the progression of dementia, it has been reported that higher serum MGO levels are associated with greater cognitive decline21

On the other hand, Acro is also involved in the pathogenesis of AD. Acro is produced by lipid peroxidation and polyamine metabolism and is highly nucleophilic and reactive, causing Michael addition reactions with nucleophilic amino acids such as cysteine, lysine, and histidine to induce protein carbonylation. Oral administration of Acro to rats (2.5 mg/kg/day, intragastrically for 8 weeks) resulted in cognitive decline and hippocampal atrophy22. Clinically, Acro is increased in the hippocampus and temporal lobe of AD patients23 and Acro-binding protein in plasma and spinal fluid is higher than in healthy subjects24. It is also involved in the onset and progression of AD25

Aβ is glycated and formed into AGEs (AGE-Aβ) when incubated in the presence of glucose. The Aβ amino acid sequence has lysine residues (Lys; K) at the 16th and 28th sites and arginine residues (Arg; R) at the 5th site, and these amino acid sequence sites are involved in glycation18 Also, AGE-Aβ may be contributing as a ‘seed’ to accelerate the aggregation of Aβ since Aβ clumps together when incubated in the presence of glucose18. AGE formation by Aβ glycation alters Aβ aggregation potential26. Aβ glycation significantly delays β conversion to mature fibres, and toxic forms, i.e., oligomers, are more likely to remain18,27

Studies on the effects of Aβ morphological changes are scarce; glycated Aβ created by MGO treatment has been reported to be highly toxic, inducing increased RAGE expression and GSK-3 (glycogen synthase kinase-3) activation28. Therefore, we examined the effects of glycative stress and sleep quality on phagocytosis using primary cultured microglia (Figure 4)12. We prepared glycated Aβ by MGO treatment and examined the effect on microglial phagocytosis and found that phagocytosis was markedly impaired for glycated Aβ. In contrast, the addition of melatonin, a hormone involved in sleep quality, enhanced Aβ phagocytosis.

The importance of Aβ clearance in the Aβ cascade has become more apparent in recent years, and this is an important finding that suggests that glycative stress decreases Aβ clearance and melatonin associated with improved sleep quality may ameliorate Aβ clearance. Furthermore, one of the mechanisms by which glycative stress reduces Aβ clearance is through impaired microglial phagocytosis for glycated Aβ

Sleep quality and glycative stress

Approximately 40% of diabetic patients with high glycative stress have sleep disturbances. Sleep apnea syndrome (SAS), in which sleep quality is markedly impaired, is frequently complicated by obesity and diabetes29. In other words, sleep and glucose metabolism have a bidirectional relationship. To reduce glycative stress, it is important to consider the prevention and

Figure 2 Concepts of glycative stress

Glycative stress

HFD/HAFD DM/Insulin resistance

Alcohol overdose

Acetaldehyde

Fatty acid-derived aldehydes

Glucose spikes

MDA, Acro, MGO GA, 3DG, GO, MGO

Carbonylated protein Glycated Aβ

Carbohydrate-derived aldehydes

AGEs

Aldehyde sparks

Figure

A

cascade and actions of glycative stress and sleep quality/melatonin

treatment of both disorders of glucose metabolism and sleep concurrently.

Melatonin is a hormone secreted from the pineal gland and has antioxidant effects30 and homeostatic effects on glucose metabolism31. Whereas poor sleep quality and circadian rhythm disturbances are known to increase the risk of developing AD32, melatonin is attracting attention as a factor linking these events33. Melatonin acts in an inhibitory manner on APP processing and Aβ

3

β

KEY AGEs, advanced glycation endproducts; DM, diabetes mellitus; HFD, high-fat diet; HAFD, high-animal fat diet; GA, glyceraldehyde; 3DG, 3-deoxyglucosone; GO, glyoxal; MGO, methylglyoxal; MDA, malondialdehyde; Acro, acrolein.

KEY Aβ, amyloid beta; APP, amyloid precursor protein.

Figure 4 Aβ phagocytic activity of microglia: Fluorescence microscopy images. (A) Aβ addition, (B) MGO-treated Aβ addition, (C) Aβ addition with melatonin (100 µM). Red-stained cells indicate Aβ-phagocyted microglia. Red-fluorescencelabeled Aβ (TAMRA-Aβ) and rat-derived primary microglia (Cosmo Bio, Otaru, Hokkaido, Japan) were used. The bar indicates 200 µm. Aβ, amyloid beta; MGO, methylglyoxal (10 mM). The figure quoted from Reference 12.

A B C

Key points

It is important not to decrease Aβ clearance to prevent AD.

generation by modulating the regulatory network of secretase expression34

Melatonin inhibits Aβ aggregation35,36, ameliorates neurotoxicity37,38, and improves lymphatic drainage through lymphatic vessels, thus promoting Aβ clearance through the blood-brain barrier (BBB) transport and degradation pathways39. We have confirmed that melatonin suppresses blood glucose spikes40 and promotes AGE degradation41. If AGEs in the brain are reduced by melatonin-induced degradation, AGE uptake into glial cells will be reduced, resulting in the alleviation of ER stress. Similarly, a reduction in the ER stress load on microglia may have a positive effect on the homeostasis of cellular functions, i.e., phagocytosis. This point awaits further validation.

Conclusions

Aβ plays an important role in the onset and progression of AD, whereas its physiological role is unknown. As

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10. Masuzaki H, Kozuka C, Okamoto S, et al. Brown rice-specific γ-oryzanol as a promising prophylactic avenue to protect against diabetes mellitus and obesity in humans. J Diabetes Investig. 2019; 10(1): 18-25.

11. Martin-Morales A, Arakawa T, Sato M, et al. Development of a method for quantitation of glyceraldehyde in various body compartments of rodents and humans. J Agric Food Chem. 2021; 69(44): 13246-13254.

12. Yonei Y, Taira T, Otaka S, et al. Amyloid beta clearance and microglia: Effects of glycative stress and melatonin. Glycative Stress Res. 2022; 9(3): 135-145. https://doi. org/10.24659/gsr.9.3_135

13. Barage SH, Sonawane KD. Amyloid cascade hypothesis: Pathogenesis and therapeutic strategies in Alzheimer’s disease. Neuropeptides. 2015; 52: 1-18.

14. Cline EN, Bicca MA, Viola KL, et al. The amyloid-β oligomer hypothesis: Beginning of the third decade. J Alzheimers Dis. 2018; 64(s1): S567-S610.

15. Frisoni GB, Altomare D, Thal DR, et al. The probabilistic model of Alzheimer disease: The amyloid hypothesis revised. Nat Rev Neurosci. 2022; 23(1): 53-66.

16. Woltjer RL, Maezawa I, Ou JJ, et al. Advanced glycation endproduct precursor alters intracellular amyloid-beta/A beta PP carboxy-terminal fragment aggregation and cytotoxicity.　J Alzheimers Dis. 2003; 5(6): 467-476.

17. Barić N. Role of advanced glycation end products (AGEs) on the reactive oxygen species (ROS) generation in Alzheimer’s disease amyloid plaque. Glycative Stress Res. 2015; 2(3): 140-155. https://doi.

Diabetes, high-fat diet, and alcohol consumption increase aldehyde production in the brain, producing glycated A.

Glycated Aβ is difficult to phagocytose by microglia and causes decreased Aβ clearance

Melatonin promotes Aβ phagocytosis by microglia and improves Aβ clearance

The keys to AD prevention are ‘glycative stress reduction’ and ‘sleep quality boost by melatonin’

org/10.24659/gsr.2.3_140

18. Vitek MP, Bhattacharya K, Glendening JM, et al. Advanced glycation end products contribute to amyloidosis in Alzheimer disease. Proc Natl Acad Sci USA. 1994; 91(11): 4766-4770.

19. Kuhla B, Lüth HJ, Haferburg D, et al. Methylglyoxal, glyoxal, and their detoxification in Alzheimer’s disease. Ann N Y Acad Sci. 2005: 1043: 211-216.

20. Ahmed N, Ahmed U, Thornalley PJ, et al. Protein glycation, oxidation and nitration adduct residues and free adducts of cerebrospinal fluid in Alzheimer’s disease and link to cognitive impairment. J Neurochem. 2005; 92(2): 255-263.

21. Beeri MS, Moshier E, Schmeidler J, et al. Serum concentration of an inflammatory glycotoxin, methylglyoxal, is associated with increased cognitive decline in elderly individuals. Mech Ageing Dev. 2011; 132(11-12): 583-587.

22. Huang YJ, Jin MH, Pi RB, et al. Acrolein induces Alzheimer’s disease-like pathologies in vitro and in vivo. Toxicol Lett. 2013; 217(3): 184-191.

23. Dang TN, Arseneault M, Murthy V, et al. Potential role of acrolein in neurodegeneration and in Alzheimer’s disease. Curr Mol Pharmacol. 2010; 3(2): 66-78.

24. Waragai M, Yoshida M, Mizoi M, et al. Increased protein-conjugated acrolein and amyloid-β40/42 ratio in plasma of patients with mild cognitive impairment and Alzheimer’s disease. J Alzheimers Dis. 2012; 32(1): 33-41.

25. Chen C, Chen Y, Lu J, et al. Acrolein-conjugated proteomics in brains of adult C57BL/6 mice chronically exposed to acrolein and aged APP/PS1 transgenic

already mentioned, polymerization of Aβ due to glycative stress results in increased neurotoxicity, persistence, and brain deposition, resulting in impaired clearance of Aβ (Figure 3). In contrast, improved sleep quality/increased melatonin secretion acts in the direction of inhibiting Aβ polymerization, alleviating neurotoxicity, and ameliorating Aβ clearance. Treatment of completed AD is difficult, and restoration of lost mental function is not expected. Concurrently, Aβ elimination therapy at a stage when the physiological role of Aβ is unknown involves risks. Therefore, there is an urgent need for a paradigm shift in AD countermeasures to maintain homeostasis of the Aβ cascade and clearance, with measures to counteract glycative stress from the early stages, with the improvement of lifestyle habits, i.e., eating habits and ‘quality of sleep’ as primary prevention as the main focus..

Declaration of interest

We received a scientific research grant from JSPS KAKENHI (#26350917, #17K01880, 20K11593).

AD mice. Toxicol Lett. 2021; 344: 11-17.

26. Alghamdi A, Forbes S, Birch DJS, et al. Detecting beta-amyloid glycation by intrinsic fluorescence: Understanding the link between diabetes and Alzheimer’s disease. Arch Biochem Biophys. 2021; 704: 108886.

27. Emendato A, Milordini G, Zacco E, et al. Glycation affects fibril formation of Aβ peptides. J Biol Chem. 2018; 293(34): 13100-13111.

28. Li XH, Du LL, Cheng XS, et al. Glycation exacerbates the neuronal toxicity of β-amyloid. Cell Death Dis. 2013; 4(6): e673.

29. Otake K, Sasanabe R, Hasegawa R, et al. Glucose intolerance in Japanese patients with obstructive sleep apnea. Intern Med 2009; 48: 1863-1868. doi: 10.2169/ internalmedicine.48.2465.

30. Hardeland R, Pandi-Perumal SR. Melatonin, a potent agent in antioxidative defense: Actions as a natural food constituent, gastrointestinal factor, drug and prodrug. Nutr Metab (Lond). 2005; 2: 22.

31. Watanabe K, Katagiri S, Hattori A. Melatonin and glucose metabolism. Glycative Stress Res. 2020; 7(1): 105-109. https://doi.org/10.24659/gsr.7.1_105

32. Wu H, Dunnett S, Ho YS, et al. The role of sleep deprivation and circadian rhythm disruption as risk factors of Alzheimer’s disease. Front Neuroendocrinol. 2019; 54: 100764

33. Li Y, Zhang J, Wan J, et al. Melatonin regulates Aβ production/clearance balance and Aβ neurotoxicity: A potential therapeutic molecule for Alzheimer’s disease. Biomed Pharmacother. 2020; 132: 110887.

34. Shukla M, Govitrapong P, Boontem P, et

al. Mechanisms of melatonin in alleviating Alzheimer’s disease. Curr Neuropharmacol. 2017; 15(7): 1010-1031.

35. Rebelo S, Vieira SI, Esselmann H, et al. Tyrosine 687 phosphorylated Alzheimer’s amyloid precursor protein is retained intracellularly and exhibits a decreased turnover rate. Neurodegener. Dis.2007; 4: 78-87.

36. Balmik AA, Chinnathambi S. Multi-faceted role of melatonin in neuroprotection and amelioration of Tau aggregates in Alzheimer’s disease. J Alzheimers Dis. 2018; 62(4): 1481-1493.

37. Hoppe JB, Frozza RL, Horn AP, et al. Amyloid-beta neurotoxicity in organotypic culture is attenuated by melatonin: Involvement of GSK-3beta, tau and neuroinflammation. J Pineal Res. 2010; 48(3): 230-238.

38. Ionov M, Burchell V, Klajnert B, et al. Mechanism of neuroprotection of melatonin against beta-amyloid neurotoxicity. Neuroscience. 2011; 180: 229-237.

39. Pappolla MA, Matsubara E, Vidal R, et al. Melatonin treatment enhances Aβ lymphatic clearance in a transgenic mouse model of amyloidosis. Curr Alzheimer Res. 2018; 15(7): 637-642.

40. Ogura M, Okuda F, Hattori A, et al. Effect of melatonin intake on postprandial blood glucose in the breakfast. Glycative Stress Res. 2018; 5(2): 75-81. https://doi. org/10.24659/gsr.5.2_75

41. Takabe W, Mitsuhashi R, Parengkuan L, Yagi M, Yonei Y. Cleaving effect of melatonin on crosslinks in advanced glycation end products. Glycative Stress Res. 2016; 3(1): 38-43. https://doi.org/10.24659/gsr.3.1_38

Figures 1–4 © Dr Yonei

Aβ plays an important role in the onset and progression of AD, whereas its physiological role is unknown.

FINESSE AND APPLICATIONS FOR NON-SURGICAL RHINOPLASTY

Onir Spiegel discusses the most common indications for non-surgical rhinoplasty and the treatment benefits over surgery

ABSTRACT

We suggest the following seven guidelines as a systematic approach to non-surgical Rhinoplasty. Of course, just as treating the nose provides the opportunity to make meaningful changes to a highly visible facial feature, so

too are injections in this area fraught with the possibility for serious complications. It is necessary to have advanced injectable knowledge prior to undertaking NSR to achieve precise results. Our system details the following seven categories: 1) Dorsal hump or dorsal bump, 2) Bulbus tip,

RHINOPLASTY IS AMONG THE MOST common facial plastic surgery procedures but requires a recovery period during which the patient will likely have bruising, swelling, and nasal congestion, in addition to needing to wear a surgical cast and tape on the nose for a week or more. In experienced hands, the cost can be high, and while 2-D and 3-D modelling techniques are available to demonstrate the potential outcome, there is no great way to know how the face would look before moving forward.

Facial fillers have seen great popularity over the past several years. From the initial indications to blunt the nasolabial folds and improve superficial rhytids, the utility of these minimally invasive injectable fillers has expanded to lip shape and volume enhancement, facial balancing by augmentation of the chin and jaw, and rejuvenation of the ageing face with application to the cheeks, tear troughs, and temples. Though highly technique dependent and not for the novice, tear trough injections have greatly reduced the number of transconjunctival (‘scarless’) lower lid blepharoplasties being performed as blunting between the lid and the cheek is a more natural correction in many cases than removing lower lid periorbital fat.

More recently, the use of injectable fillers has expanded further to the nose. Non-surgical rhinoplasty (NSR) has become celebrated among people of all ages as a quick

3) Depressed, beak-like, nasal tip/down turned nasal tip, 4) Twisted Nose, 5) Enhanced nasal dorsal definition to mask a wide, flat nose, 6) The overly resected, overly ski-sloped, or saddle nose dorsal ridge, 7) Flattened or retracted columella.

way to obtain a meaningful change in nasal appearance without surgery. As an office procedure that takes only minutes, it is desirable for individuals seeking a solution that requires little downtime away from work and family obligations to those who want to ‘test the water’ and see what they could look like with less time and financial investment. Interestingly, it is also desirable for those who have had a rhinoplasty but desire some further modification or improvement without undergoing a full revision surgery. For all these reasons and more, NSR is unquestionably among the hottest procedures in facial aesthetics. At The Spiegel Center in Newton, Massachusetts, NSR is among the highest requested procedures for filler aesthetics and a frequent reason for referral from other injectors and area plastic surgeons. Rhinoplasty is widely considered to be the most difficult plastic surgery procedure to perform well and the hardest to master. The nose is a complex threedimensional structure in the centre of the most visible part of the face, so there is a small margin of error. Furthermore, there are many anatomical features on the nose that create important shapes and shadows critical for an attractive appearance. Facial plastic surgeons spend years learning to evaluate a nose to determine the proper intervention.

With over 200 cases performed in the last 3 years, we have developed a systemised approach to non-surgical rhinoplasty based on seven frequent anatomic diagnoses. By using this guideline, the injector will be

email: onir@drspiegel.com

KEYWORDS

MFU-V, CaHA, Neck rejuvenation

ONIR SPIEGEL, DDS, PHD, Director of Aesthetics Services at The Spiegel Center, Advanced Facial Aesthetics, Newton, MA, US

Non-surgical rhinoplasty (NSR) has become celebrated among people of all ages as a quick way to obtain a meaningful change in nasal appearance without surgery.

better able to deliver consistently beautiful and safe results. Of course, just as treating the nose provides the opportunity to make meaningful changes to a highly visible facial feature, so too are injections in this area fraught with the possibility of serious complications. It is necessary to have advanced injectable knowledge prior to undertaking NSR to achieve precise results. One must be well-trained and experienced in the use of facial fillers and have extensive knowledge of nasal anatomy, including nasal vasculature. That said, here are the seven most common nose deformities that can be corrected predictably with non-surgical rhinoplasty, including fillers and energy devices.

Dorsal hump or nose bump

The dorsal hump is likely the most common reason for patients to seek a non-surgical rhinoplasty, or surgical rhinoplasty for that matter. The appearance of a dorsal hump can be caused by the overgrowth of the nasal bones and cartilages, a result of trauma, or appear due to an excessively deep radix — the concavity at the top of the nose beneath the forehead and between the eyes, right below the corrugators and procerus muscles.

For small bumpy noses, I may only use tiny drops of filler that can be delivered through a small needle, typically a 30-gauge needle, for direct droplet injection. This gentle and precise placement of filler can fill in the area of depression, creating improved symmetry of the nose from the forehead extending to the ridge of the nose. The injections should be placed deep into the skin beneath the ‘SMAS’ layer of the nose just above the nasal

bone or cartilage.

For larger imperfections and more significant bumpy noses, I often choose to deliver filler with a cannula, which can further decrease the potential for bruising, the most common, but still rare potential undesired sequela of NSR. To penetrate with a 30-gauge cannula, I numb the area with 0.1 cc of Lidocaine with 1:100,000 epinephrine at the injection site. After a 1–2-minute wait, I make an entry point for the cannula with a 22-gauge needle. The cannula is inserted through, and the filler is applied in a retrograde (injection while pulling back) motion. I prefer to use a surface vibration device adjacent to the cannula tip to help with sensitivity. The vibration device can be further used to meticulously spread the filler to smooth and refine filler deposition. Importantly, one should pay attention to avoid any displacement of the filler in a lateral direction to the sides of the nose. This can create an abnormally widened or ‘T-shaped’ appearance to the nasal dorsum. In the event of such an occurrence, apply immediate pressure to the side of the lateral nostril to quickly push the filler back to its intended place on the nasal dorsal ridge (Figure 1).

Bulbous tip

Often, if the nose looks like an inverted ice cream cone with an excessively bulbous tip, the problem can be a lack of balance due to a narrow bridge of the nose near the root. This area may also look narrow due to a hollowed extension of the tear trough from beneath the lower eyelid. In this situation, we need to pay particular attention to the precise area leading to the narrow

I add small drops of hyaluronic acid filler through the smallest needle (30 or 32-gauge) to the tip of the nose extending upward to the bridge of the nose in a gradated fashion to create a new tip-defining (most projected) point.

appearance and treat it carefully and accurately. Again, gentle and precise placement of filler with a 30-gauge needle will provide excellent results. The injector must be well-versed in the anatomy of the area to avoid arterial occlusion, as this is known to be the ‘danger zone’ in NSR correction. Only tiny aliquots of filler should be placed, again utilising a round vibration device to help spread the filler smoothly in the area.

Depressed, beak-like, nasal tip/downturned nasal tip

Some people are born with a downward projection of the tip of the nose that can become more pronounced when smiling. The nose seems to point down like a parrot beak, hence the descriptive term ‘beak-like’ for the tip. Here our goal is to create a new tip-defining point so that the overall appearance looks balanced rather than downward facing. To achieve this, I add small drops of hyaluronic acid filler through the smallest needle (30 or 32-gauge) to the tip of the nose extending upward to the bridge of the nose in a gradated fashion to create a new tip-defining (most projected) point. The filler must give the nose an attractive shape in an upward and outward direction.

Commonly you will need to continue these small hyaluronic acid filler injections for an additional definition to the dorsal ridge of the nose as well as inject filler to the chin for better facial balance. Lifting and reprojecting the nasal tip can create a facial imbalance which is improved with the deposition of filler into the chin. For the chin, we have several options regarding the type of filler used. In most cases, when a small amount is required to obtain symmetrical balance with the nose, I will use the remainder of the hyaluronic filler used for the NSR. However, if more filler is required to obtain this correction, I prefer a calcium-based filler such as Radiesse®.

Twisted nose

Vertical asymmetry or a C-shaped curve to the nose is another common problem for which people seek nonsurgical correction. The key to adjustment of a twisted nose is to recognise that it represents, typically, a central area of volume deficiency on one side with higher and lower areas of volume loss on the contralateral side. Unless the twist is very severe, this can be readily corrected with a non-surgical rhinoplasty/liquid rhinoplasty. By filling in the concave areas, the contour is smoothed, and you gain a straighter nose projection. This is also a great treatment following a prior rhinoplasty if something didn’t heal just right. This is a perfect example of a situation where two minutes in the office can replace two hours of surgery. But keep in mind that this is one area where adding filler will make the nose appear wider and may be better treated with a surgical rhinoplasty. Here again, remember to layer small aliquots of hyaluronic acid filler through the smallest needles, often a 30-gauge needle, just to the areas of the nose that are concave and hollow to get more symmetry. I find it important to counsel patients that we are seeking

improvement and rarely expect perfection (even if we sometimes achieve it). As before, I employ a vibration device during injection to help with sensitivity and meticulously spread the filler to smooth any filler protrusions.

Enhanced nasal dorsal definition to mask a wide, flat nose

Many persons of African or Asian descent have softer and/or wider nasal cartilages and thick skin. This creates the appearance of a wide, flat nose with large nostrils. Enhancing the nasal dorsal ridge with enhanced projection and outward protrusion will add definition to a nose with widened nostrils. Increasing the projection of the dorsum extending from the radix area to the tip of the nose will balance wide nostrils. In this case, we inject hyaluronic filler extending from the tip of the nose to the root of the nose to increase ridge definition and thus mask a widened nose. The key here will be to prevent lateral spread of the filler as a high and central dorsal ridge is important to balance the width and lack of support. In addition, we have found that energy devices such as Morpheus8 (Inmode, Irvine, CA USA) radiofrequency may contribute to further shrinkage of the nasal skin and, thus, further improve tip definition (Figure 2).

The overly resected, overly skisloped, or saddle nose dorsal ridge

Saddle nose deformity can be a birth defect, a result of overzealous prior rhinoplasty where too much bone and/or cartilage was removed during surgery, or occur following nasal trauma, or drug use with loss of the

For larger imperfections and more significant bumpy noses, I often choose to deliver filler with a cannula, which can further decrease the potential for bruising.

Figure 1 (A) Before dorsal hump or dorsal bump corrected with NSR (B) after, in a female patient.

Figure 2 Enhanced nasal dorsal definition used to mask a wide, flattened nose dorsum. (A) Before (B) after.

A B

nasal dorsum or an overly scooped nasal dorsum, particularly on profile view. This creates an unattractive nose slope which can cause breathing problems and interfere with the proper use of eyeglasses. In severe or long-standing cases, only surgery is indicated as the skin can be contracted (particularly if the cause was nasal inflammation from an autoimmune disorder or drug use) and is unlikely to expand well with a soft filler. However, in more mild cases, the dorsum can be recreated similarly to that performed with an ethnic rhinoplasty but being very specific to identify the start and end of the depressed area so that only the hollow areas are augmented (Figure 3). Augmentation above or below the true depressed region can exacerbate the problem. Again, the use of the vibration device is adequate to help with injection sensitivity as well as aid in ensuring that the filler stays in the precise area of injection and does not flow to the sides of the nose ridge.

Flattened or retracted columella

Appropriate columellar show on a profile view is 3–5 mm for most women. The proper projection of the columella can be beautiful and very feminine, while a flattened or retracted columella can seem more masculine. The columella is the small strip of skin and tissue between your nostrils when you look at the base of the nose. It looks like a small column, hence the name columella, and it is very important for the proper balance and beauty of the nose. If this area is flat, too high, or seems retracted within the nose, adding filler to that area extending the columella downward can be attractive and, in some cases, improve symmetry when there is some degree of caudal septal deviation. Care must be taken not to overfill the central part of the columella laterally, as the medial crura cartilages within the columella should have a gentle curve to be wider at the nasal footplates, and an overly wide columella will look unnatural. The use of the vibration device, in this case, helps but may not be adequate to help with injection sensitivity as this is a particularly tender region for injection.

Non-surgical rhinoplasty (NSR) can smooth and straighten noses to complement facial balance and

Key points

We suggest an approach for correction of nose deformities with non-surgical rhinoplasty

Listing seven categories that enable correction of nose deformities with filler injections

Findings based on 200 non-surgical rhinoplasties performed at our centre

harmony. However, non-surgical rhinoplasty cannot make a nose smaller or thinner; although, with filler camouflage, the nose may appear smaller as the light reflection of a narrower dorsal ridge, even with a wide nose, will make the nose appear smaller. Additionally, a straight nose will reflect light in a way that makes it look smaller than a crooked nose. Of course, liquid rhinoplasty is not likely to help with breathing problems, nasal congestion, snoring, or other sleep disturbances. These can only be addressed with a surgical rhinoplasty procedure.

Conclusions

Non-surgical rhinoplasty is a very powerful procedure that can result in high patient satisfaction. As always, potentially serious complications can occur, and these must be discussed in advance, including bruising, vascular occlusion, blindness, tissue necrosis, nasal deformity, and others. I recommend using a three-way mirror during patient evaluation and specifically underpromising the results you are likely to produce for your patient. Once you have mastered these techniques, you should find them to be extremely rewarding. In my experience, patient satisfaction with NSR is higher than with any other non-surgical aesthetic procedure. We are currently gathering data and plan to publish patient satisfaction data on NSR compared to surgical rhinoplasty as well as patient retention and patient conversion from NSR to surgical rhinoplasty rates. Non-surgical rhinoplasty is a non-invasive and reversible approach to nasal shaping which can substantially improve facial appearance. It has been a great addition to my practice and among my most favourite procedures.

Declaration of interest

None

Figure 3 (A) Before and (B) after correction of an overly resected, ski-sloped nose dorsal ridge from a prior surgical rhinoplasty.

Figures 1–3 © Dr Onir Spiegel

I recommend using a three-way mirror during patient evaluation and specifically under-promising the results you are likely to produce for your patient.

A REVIEW OF THE XB-49 TIP: A NEW AND IMPROVED TOOL FOR MICRONEEDLING

Gee Bum Kim, MD, discusses the benefits of the new XB-49 Tip for the SYLFIRM X microneedling device

SYLFIRM X HAS LONG been a solution for improving a range of skin issues. However, the use of a linear step motor in pursuit of precise procedure results can often lead to a reduction in treatment speed. With the release of the new XB-49 Tip, I would like to discuss its benefits based on my experience.

The indications for the XB-49 Tip are not significantly different from that of existing Sylfirm X tips, including melasma, rosacea, postinflammatory hyperpigmentation (PIH), skin tightening and lifting, and more. Notably, the XB-49 Tip can treat a bigger area in a single shot, reducing treatment time.

Compared to the commonly used XE-25 Tip, the XB-49 Tip has a reduced distance between the needles, maximising the delivery of drugs when used in conjunction with microneedling and lowfrequency ultrasound equipment. Additionally, compared to the old treatment, the pain experienced during the procedure has been reduced, resulting in an increase in patient satisfaction.

Shorter treatment time

With the XB-49 Tip, a full-face treatment can be performed in approximately 5 minutes. With the increased treatment area per needling, significantly less time is required for the same procedure. Shortened treatment time is a major advantage for both users and patients,

Minimised pain

Another advantage of the XB-49 Tip is that it causes less pain than previous treatments, allowing patients to be more comfortable during the procedure. This benefit is expected to make the procedure approachable for more patients.

Enhanced microneedling and drug delivery effects

Recently, more clinics have been combining RF micro-needling with skin boosters. Our clinic also uses various skin boosters combined with the new XB-49 Tip, resulting in reduced pain and treatment time and maximising drug delivery effects. The additional number of needles for the radiofrequency needling procedure creates numerous micro-holes, increasing the absorption rate of the skin boosters. When combined with lowfrequency ultrasound procedures, more effective skin regeneration and remodelling effects can be achieved.

While I already have been consistently using SYLFIRM X, the three additional benefits through XB-49 Tip have increased the usage of the device even more.

When using the XB-49 Tip, there is an adjustment in the depth setting. I set the target depth slightly deeper and use the same power setting as the provided parameter. For melasma treatments with the XB-49 Tip, I use PW2, 5-Level, 0.5mm, and 2 Passes (Provided parameter for melasma treatment is PW2, 5-Level, 0.3mm, and 2 Passes). With the

XB-49 Tip, applying less physical force and increasing depth makes performing the procedure easier. Also, even with deeper depth settings, patients did not experience any increase in pain during the procedure in comparison to the old procedure. The same power parameter is used as before. In particular, I recommend not adjusting the power during melasma treatment, as tissue reactions can change.

The launch of the XB-49 Tip is expected to increase satisfaction not only for existing SYLFIRM X users but also for new users with shortened treatment times and higher efficacy. I look forward to discovering better treatment methods through continuous parameter exploration and sharing new findings with other users.

For more information, visit www.violmedical.com

Figure 1 XB-49 Tip

DR. GEE BUM KIM, Korean Association of Laser, Dermatology and Trichology (KALDAT), Korea

VELOCE INTENSE PULSED DOUBLE LIGHT FOR ACTIVE ACNE, POST-ACNE SCARS, AND SKIN LIFTING

VELOCE WAS USED to treat 9 patients, addressing active acne, post-acne scars, and loss of skin tightness through the use of intense pulsed double light. Each patient received treatment in a designated area, with the first treatment being the same for all patients. Throughout the tests, the patients’ skin reactions, recovery time, and treatment effects were closely monitored and observed.

VELOCE uses the Square Pulse technology, producing fast pulses through a double tube, emitting up to 320 homogeneous pulses continuously for a maximum of 16 seconds. This technology allows for the treatment of various indications.

Treatment

During the research, the NT-800 filter was primarily used for acne treatment and skin tightening, which heats collagen fibres with high light energy, leading to their contraction and improvement of skin texture. This technology also stimulates dermal fibroblasts’ synthesis of proteins in the extracellular matrix, partially restoring lost dermal volume due to ageing.

For patients with active acne, the study applied pulsating light with parameters of 120 IU and filters 420-5J and 100 ms, destroying the blood vessels supplying sebaceous glands, reducing sebum production, and destroying Propionibacterium acnes. The treatment also stimulated the formation of free oxygen radicals

through the absorption of porphyrins produced by Propionibacterium acnes, resulting in a bactericidal effect and destruction of sebaceous glands.

Patients who were struggling with acne inflammation, acne scars, and uneven skin structure received a treatment using an 800NT filter, where over 50,000 joules were applied to the face and chin area with treatment parameters of 120 IU and filters of 420 - 5J and 100 ms. After the treatment, a clear thickening, tension, and lifting of the skin were noticed, and there was a fading of acne-related changes. Patients who were experiencing regularly occurring active changes reported positive results. The skin calmed down after the treatments.

Patients with adipose tissue problems on their face were also observed. Treatment was performed with an 800NT filter, delivering over 40,000 joules to the face and chin area, significantly thickening the skin, and improving the skin tone, providing

a refreshed and radiant look. After three sessions of VELOCE treatment, all patients showed significant improvement, with the best results observed in patients with acne problems. The treatment is non-invasive and requires minimal convalescence time. Patients experienced only pleasant warmth on the skin, with no side effects observed.

Conclusion

Overall, VELOCE technology has a significant effect on skin density, making it a comfortable and pleasant option for patients seeking to reduce active acne, post-acne scars, and loss of skin tightness. The technology also provides noticeable results for patients with adipose tissue problems, temporarily providing tension and preventing noticeable flaccidity.

For more information, visit eng.ilooda.com

Elżbieta Zielińska, MD, explains why Veloce’s device has been proven to be an effective treatment for active acne, post-acne scars, and skin lifting

Figure 1 VELOCE treatment resulted in fading of acne and clear thickening, tension, and lifting of the skin. (A) Before, (B) after.

ELŻBIETA ZIELIŃSKA, MD, Aesthetic Medicine Clinic Ostrołęka, Poland; NATALIA JEROMINEK, M.Sc. of Nursing

Winners

In partnership with the Aesthetic Multispecialty Society (AMS), the 2023 AMWC Awards judged over 1000 applications from 60 countries, competing for Best Products & Devices in the industry and for Best Clinical Cases.

After reviewing and shortlisting the applications, 100 were selected as finalists and were open for voting. A jury composed of renowned

physicians in aesthetics and anti-aging medicine assessed the final cases, in addition to nearly 9,500 unique votes from peers.

Winners from the 22 categories were announced during a ceremony at the prestigious AMWC Monaco conferences on March 31 and April 1, 2023.

www.euromedicom.com

BEST PRODUCTS & DEVICES WINNERS

BEST REGENERATIVE AESTHETIC MEDICINE

HY-Tissue PRP | Fidia - Aesthetic Care

HY-TISSUE is a regenerative medicine portfolio that consists of PRP and Nanofat kits, providing high-quality, safe and effective autologous biological solutions.

www.aesthetics.fidiapharma.com

BEST COSMETICS

ASCEplus HRLV | ExoCoBio

A one step hair & scalp solution offering the best synergistic results. It is the first commercialized exosome in lyophilized type for topical use. It improves problematic scalp, hair loss and thinning hair, and it normalizes the hair cycle for hair growth and graying hair.

www.asceplus.com

BEST AESTHETIC DEVICES

NANOSOFT® | FillMed Laboratories

Composed by 3 microneedles with 0,6 mm in length, it allows for injections that are very accurate and standardized, making the procedure easier for the doctor even in delicate areas such as eye contour, neck, and décolleté. For patients, it guarantees an effective and near-painless procedure.

nctf.fillmed.com

BEST NON-INVASIVE BODY SHAPING TECHNOLOGIES

Emerald Laser | Emerald Laser - Erchonia

The non-thermal laser delivers more energetic photons and is coherent, collimated, and monochromatic. Level One (510k)multicenter clinical studies on 30-40 BMI patients who fitted the study criteria lost an average of six inches over a course of 12 treatments with no lifestyle changes or adjunct therapies in the space of six weeks.

www.emerald-emea.com

BEST SUSPENSION THREADS

Aptos | Aptos Thread Lifting Methods

Minimally invasive threads and methods for face and body lifting, contouring, and rejuvenation.

www.aptos.global

BEST ANTI-AGING SUPPLEMENTS

Vild Nord Collagen Gold | Vild Nord

We have combined collagen from the wild caught North Atlantic cod with the clean, lifegiving ingredients of the Nordic countries. We provide consumers with a daily beauty ritual that is easy and enjoyable.

www.vildnord.com

BEST LASERS, LIGHTS & ENERGYBASED DEVICES

DuoGlide | Deka Innate Ability

A PLLA (POLY-L-LACTIC ACID) collagen stimulating injectable filler for the face and body that contours, reshapes, volumises, and activates the production of natural collagen for natural-looking results. It can be used for the face, buttocks, upper arms, hands, neck, décolleté, cellulite, and thighs.

www.dekalaser.com

BEST INJECTABLES BODY FILLERS

LANLUMA | Lanluma - Sinclair

A one step hair & scalp solution offering the best synergistic results. It is the first commercialized exosome in lyophilized type for topical use. It improves problematic scalp, hair loss and thinning hair, and it normalizes the hair cycle for hair growth and graying hair.

www.lanluma.com

BEST INJECTABLES FOR SKIN REVITALIZATION

NCTF® 135 HA | FillMed Laboratories

An injectable poly revitalizing solution, composed of free hyaluronic acid and a complex of 59 essential ingredients with vitamins, amino acids, minerals, coenzymes, nucleic acids, antioxidants, and others. In only 3 sessions, NCTF® 135 HA induces a 360° revitalisation of the skin with immediate results, plus a long-term activation.

nctf.fillmed.com

BEST INJECTABLES DERMAL FILLERS

HArmonyCa™ | Allergan Aesthetics

The dual-effect Hybrid Injectable combines hyaluronic acid (HA) with calcium hydroxyapatite (CaHA) in one ready-to-use syringe. It can improve skin architecture by providing an immediate and long-lasting lift from HA and sustained lifting effect from new collagen production associated with CaHA.5,6.

www.allerganaesthetics.fr

Watch a replay of the Awards Ceremony on the AMWC website

www.amwc-conference.com

BEST CLINICAL CASES WINNERS

Dr. Francisco LLANO Mexico

Post surgical chronic open wound in the head optimal resolution

BEST INTEGRATIVE MEDICINE & WELL-BEING

Dr. Alexandra DOROBANTU Romania

Treatment of superficial infantile hemangioma using pulsed-dye laser and 4% Propranolol Gel

BEST ENERGY-BASED TREATMENTS

Dr. Vívian de Carvalho AMARAL Brazil

Reduction of exposure of hypertrophied clitoris by implant of gestrinone, with indication of clitoroplasty, through filling with hyaluronic acid in the labia majora

BEST GENITAL REJUVENATION

Dr. Roberto CHACUR Brazil

Advanced cellulite treatmentGoldincision method

BEST NON-SURGICAL BODY SHAPING

Dr. Marcio CRISOSTOMO Brazil

Corrective hair transplant for advanced baldness in a male patient with a previous juri flap (Fronto-ParietoOccipital) surgery

BEST HAIR RESTORATION

Prof. Dr. Pietro GENTILE Italy

Breast hypoplasia treated with autologous fat grafting

BEST SURGICAL BODY SHAPING

Dr. Arthur YU USA

Relay PDO Thread facelift using a bi-laminar approach

BEST THREADS TREATMENT

Dr. Sebastian TORRES Chile

Costal cartilage nasal reconstruction for rejuvenation of the center of the face in patient with binder syndrome

BEST SURGICAL FACIAL REJUVENATION

Dr. Vincent MCGINNISS USA

Basal cell carcinoma of the left lower eyelid resulting in large full thickness defect

BEST CONDITION IMPROVMENT TREATMENT

Dr. Mohsen NARAGHI USA

Non-surgical secondary rhinoplasty in severe inverted V deformity: The marriage of the art and the science

BEST NON-SURGICAL FACIAL BEAUTIFICATION

Dr. Massimo VITALE Italy

Extravasation and pigmentation post iron infusion: How I gave my patient a new arm

BEST SKIN ENHANCEMENT & SCAR TREATMENT

Dr. Arash JALALI Canada

Cocaine nose reconstruction

BEST NON-SURGICAL FACIAL REJUVENATION

EUROPE

Industry events in 2023 for the aesthetic and anti-ageing market

NORTH AMERICA

REST OF WORLD

1–3 JUNE 2023

Beauty through Science

Stockholm, Sweden

www.btsstockholm.com

1–4 JUNE 2023

5-CC Word Congress

Lisbon, Portugal

www.5-cc.com

30 JUNE – 1 JULY 2023

FACE 2023

London, UK

www.euromedicom.com

31 AUGUST – 2 SEPTEMBER 2023

ISAPS Olympiad Athens World Congress 2023

Athens, Greece

www.isapsathens2023.com

28–29 SEPTEMBER 2023

BAAPS 2023

London, UK baaps.org.uk/

11–14 OCTOBER 2023

EADV 2023

Berlin, Germany eadvcongress2023.org/

19–20 OCTOBER 2023

CCR 2023

London, UK

www.ccrlondon.com/about-ccr/

17–18 NOVEMBER 2023

VISAGE 2023

Monte Carlo, Monaco www.euromedicom.com

7–10 JUNE 2023

Vegas Cosmetic Surgery 2023

Las Vegas, NV www.vegascosmeticsurgery.com

6–9

JULY 2023

The Aesthetic Show

Online and Las Vegas, NV www.aestheticshow.com

20–23 SEPTEMBER 2023

AAFPRS Annual Meeting

Las Vegas, NV

www.aafprs.org

15–16 SEPTEMBER 2023

AMWC India

Mumbai, India

www.euromedicom.com

7–8 OCTOBER 2023

FACE ASEAN

Bali, Indonesia

www.euromedicom.com

18–19 NOVEMBER 2023

AMWC Japan

Tokyo, Japan

www.euromedicom.com