PRIME January/February 2024 by IM-Aesthetics

The BB8 Technique

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Dual Wavelength Laser

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Biotherapy

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AMWC Awards

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Industry News

January/February 2024 ❙ Volume 14 ❙ Issue 1

Jan/Feb 2024 Volume 14 Issue 1

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INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE

POINT-OF-CARE ULTRASOUND

GUIDELINES FOR MEDICAL AESTHETICS

A NEW HA FILLER

TO TREAT THE LIPS AND NASOLABIAL FOLDS

GEN Z AND SOCIAL MEDIA

IMPACT ON AESTHETIC DEMANDS

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FACIAL REJUVENATION with threads and HA

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| EDITORIAL

HAPPY NEW YEAR TO YOU ALL, AND WELCOME TO OUR FIRST ISSUE of 2024. Looking back across 2023, it feels like we live in unpredictable times, so it is reassuring some things continue to follow old trends: the aesthetic and anti-ageing industry continues to grow and reach new demographics, researchers and physicians continue to push the science forward, and new products make treatments more accessible, faster and with fewer side effects. The ultimate result is that consumer numbers continue to grow in this ever-expanding market. Thanks to pioneering individuals within the industry, we see this upward projection and greater adoption by consumers around the world. So it’s only fitting we take the time to celebrate their achievements and all that they have done. During the annual congress on March 27th, AMWC will host the 10th edition of the AMWC Aesthetic Awards in Monaco. The Awards aim to recognise diverse achievements and cover a wide range of categories, including the best energy-based treatment, non-surgical body shaping, complication management, suspension thread, injectable dermal filler, and much more. The credibility of the AMWC Aesthetic Awards is upheld by its jury. Comprising leading experts and th luminaries in aesthetic medicine, the jury members collectively bring decades of experience and expertise to the evaluation process. You can read more about the Awards in our coverage on page 10. Much like the AMWC Awards, the rest of the issue covers a wide range of categories, but one certainly to note is our look at the future of lasers. It’s been four decades since Anderson and Parrish put lasers on the aesthetic map, and we ask whether their glory days are behind them or if the best is yet to come? You can read the full feature from page 14. Switching gears to fillers, Drs. Jamel Fares, Jenny Simancas, Carlos Vivas, and Carlos Arguedas share the results of their multicentre clinical study on the safety and efficacy of Fillderm® HA filler with lidocaine. Discover how this innovative filler is proving effective for nasolabial folds and lip correction from page 24. Lastly, Dr Nitin Sethi and Naina Dhawan shed light on the influence of social media on the aesthetic demands of Gen Z. Through their work they are able to offer an insight into the economic implications on aesthetic practices as a new generation, influenced by online perfection, steps into the realm of aesthetic procedures.

On March 27 , AMWC will host the 10th edition of the AMWC Aesthetic Awards Affiliated partners:

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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 Digital Marketing Manager Slim Hakimi slim.hakimi@informa.com Production & Ads Department balraj.juttla@informa.com

Cover image Stock.Adobe.com Retouching Pio Blanco

The BB8 Technique

❚

Dual Wavelength Laser

❚

Biotherapy

❚

AMWC Awards

❚

Industry News

Jan/Feb 2024 Volume 14 Issue 1

❙

INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE

POINT OF CARE ULTRASOUND

GUIDELINES FOR MEDICAL AESTHETICS

A NEW HA FILLER

TO TREAT THE LIPS AND NASOLABIAL FOLDS

GEN Z AND SOCIAL MEDIA

IMPACT ON AESTHETIC DEMANDS

FACIAL REJUVENATION with threads and HA

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

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| CONTENTS

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NEWS

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Chimeric antigen receptor (CAR) T-Cells identified as potential key to anti-ageing American Society of Plastic Surgeons break down demographic surgery trends AMWC AESTHETIC AWARDS 2024

ooking ahead to the 10th edition of the AMWC Aesthetic L Awards, taking place in Monaco on March 27th 2024

The aesthetic laser— powerhouse of the past, focused on the future It has been four decades since Rox Anderson and John Parrish published the landmark paper that put lasers on the map for aesthetic medicine. Since then, we have witnessed a constantly evolving flood of energy-based devices, and the aesthetic world has never looked back. Are the laser’s better days behind it?

INDUSTRY INSIDER

CASE REPORT

BioReTherapy: much more than peeling Drs Angela Capponi and Francesca Nicolucci explain how BioReTherapy is efficient and safe to treat extrafacial melasma

GentleMax Pro Plus®: A Multitude of Treatment Possibilities in a Single Platform Dr Firas Al-Niaimi explains why he trusts in the latest dual-wavelength platform from Candela

AESTHETIC FEATURES

Facial Rejuvenation with a new generation of combined poly-L-lactic acid and polycaprolactone threads with HA Albina Kajaia describes the results from a 12-month study on the effects of the fourth-generation of Aptos threads A new Hyaluronic acid filler with lidocaine for nasolabial folds and lip correction Drs Jamel Fares, Jenny Simancas, Carlos Vivas, and Carlos Arguedas share the results of their multicentre clinical study evaluating the safety and efficacy of the latest Fillderm® HA filler with lidocaine BB8 Technique: An innovative approach to deliver diluted Belotero ® Balance (BB) to treat infraorbital hollows and skin quality Siew Tuck Wah reveals the results of his study on how diluted Belotero Balance HA filler can transform infraorbital hollows, offering safe and effective rejuvenation with enhanced skin quality

Guidelines for the use of ultrasound in medical aesthetics With point of care ultrasound gaining popularity, Humzah Dalvi, Elizabeth Raymond-Brown, and Telisha Jenkinson share their guidelines to raise the standard of education, training and use of ultrasound in aesthetic medicine Gen Z and the impact of social media on aesthetic demands Dr Nitin Sethi and Naina Dhawan take us through the results of their cross-sectional study on the impact of social media on aesthetic demands of Gen Z patients and the economic implications on their aesthetic practices

PRACTICE PEARLS

PRIME PROMOTIONS

50 The right concept for thread lifting: classification and effect of thread injection methods 54 Neck rejuvenation: low molecular weight hyaluronic acid combined with six amino acids to counteract skin ageing of the neck 58 Tear trough rejuvenation using a PDLLA+HA hybrid biostimulator EVENTS

round-up of the major industry events happening A around the world over the next 12 months

prime-journal.com | January/February 2024

NEWS |

news

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

CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELLS IDENTIFIED AS POTENTIAL KEY TO ANTI-AGEING RESEARCHERS REPROGRAMME T-CELLS TO FIGHT INFLAMMATION CAUSING CELLS

old Spring Harbor Laboratory (CSHL) Assistant Professor Corina Amor Vegas and colleagues have discovered that T cells can be reprogrammed to fight ageing, so to speak. Given the right set of genetic modifications, these white blood cells can attack another group of cells known as senescent cells. These cells are thought to be responsible for many of the diseases we grapple with later in life. Senescent cells are those that stop replicating. As we age, they build up in our bodies, resulting in harmful inflammation. While several drugs currently exist that can eliminate these cells, many must be taken repeatedly over time. As an alternative, Amor Vegas and colleagues turned to a ‘living’ drug called CAR (chimeric antigen receptor) T cells. They discovered CAR T cells could be manipulated to eliminate senescent cells in mice. As a result, the mice ended up living healthier lives. They had lower body weight, improved metabolism and glucose tolerance, and increased physical activity. All benefits came

without any tissue damage or toxicity. Amor Vegas says: ‘If we give it to aged mice, they rejuvenate. If we give it to young mice, they age slower. No other therapy right now can do this.’ Perhaps the greatest power of CAR T cells is their longevity. The team found that just

one dose at a young age can have lifelong effects. That single treatment can protect against conditions that commonly occur later in life, like obesity and diabetes. Amor Vegas explains: ‘T cells have the ability to develop memory and persist in your body for really long periods, which is very different from a chemical drug. With CAR T cells, you have the potential of getting this one treatment, and then that’s it. For chronic pathologies, that’s a huge advantage. Think about patients who need treatment multiple times per day versus you get an infusion, and then you’re good to go for multiple years.’ CAR T cells have been used to treat a variety of blood cancers, receiving FDA approval for this purpose in 2017. But Amor Vegas is one of the first scientists to show that CAR T cells’ medical potential goes even further than cancer. Amor Vegas’ lab is now investigating whether CAR T cells let mice live not only healthier but also longer. If so, society will be one step closer to the coveted fountain of youth.

MINIMUM GUIDELINES FOR HAIR TRANSPLANT SURGERY ISSUED The British Association of Hair Restoration Surgery (BAHRS), the British Association of Aesthetic Plastic Surgeons (BAAPS), the British Association of Plastic, Reconstructive and Aesthetic Plastic Surgeons (BAPRAS) and the Turkish Society of Plastic, Reconstructive and Aesthetic Surgeons (TSPRAS) understand and recognise that there will always be patients from different countries who will seek medical and surgical treatments abroad; however,

multiple reports have highlighted concerns that our four national societies share regarding minimum standards of patient care. The four organisations strongly urge anyone from the UK considering travelling to Türkiye for hair transplant surgery to consider the following: Patients should have a consultation with the doctor who will be performing the surgery and make the recommendation on harvesting method, number of

January/February 2024 | prime-journal.com

follicular units/hairs required, and hairline/transplant design. Patients should be given two weeks to consider the doctor’s recommendation and the proposed consent form before making any form of payment for surgery. Patients should be informed at the initial consultation if it will not be a doctor operating on them by making skin incisions to harvest the donor hair or implant it, including whether this will be a technician.

The interim progress and final result of the hair transplant should be assessed by the doctor who performed the surgery and patients should have the opportunity to voice any grievances they have as well as any complaints. Systems should be in place for complications to be dealt with by the clinic during and outside of working hours, such as assessing skin necrosis, infection, cysts, and supplying antibiotics.

NEWS |

AMERICAN SOCIETY OF PLASTIC SURGEONS BREAKS DOWN DEMOGRAPHIC SURGERY TRENDS THE STUDY ALSO REVEALS THE CURRENT PLASTIC SURGERY LANDSCAPE AND LATEST SURGEON FEES

he American Society of Plastic Surgeons (ASPS), the world’s largest plastic surgery organisation, representing 92% of all board-certified plastic surgeons in the United States, has released supplemental data to its 2022 procedural statistics. The newest study breaks down data by age, gender and surgical fees. ‘Looking deeper into the trends that are driving the data in the 2022 study, we’re continuing to see patients prioritise comfort and selfconfidence above all,’ said ASPS President Steven Williams, MD. ‘Alongside the increasing interest in plastic surgery, and as new techniques, products and trends continue to emerge, it is imperative to ASPS that the pursuit of beauty and comfort remains rooted in safety, authenticity and wellbeing.’

Generational Trends Across age groups, Generation X (age 40–54) accounted for 45%, and Baby Boomers (ages 55–69) accounted for 30% of total cosmetic procedures, while Millennials (ages 30–39) accounted for 16% and Generation Z (ages <19 to 29) accounted for 6%. Patients over age 70 accounted for 3%. Gen X specifically accounted for 35% of cosmetic surgeries and 46% of minimally invasive procedures. In reference to the total number of procedures performed in 2022, Gen X accounted for Costs can fluctuate the following: depending on the surgeon, ■ 48% of all tummy tucks ■ 51% of all buttock lifts procedure and region, yet, ■ 43% of all breast implant on average, surgeon fees for removals some popular procedures ■ 57% of all neuromodulator injections either decreased in cost or ■ 50% of all hyaluronic acid rose less than inflation in fillers. 2022. In reference to the total

January/February 2024 | prime-journal.com

number of procedures performed in 2022, other generations accounted for the following: ■ 50% of total facial procedures were accounted for by Baby Boomers ■ 35% of breast augmentations were accounted for by Millennials ■ 41% of buttock augmentations with fat grafting were accounted for by Millennials ■ 37% of rhinoplasties were accounted for by Gen Z ■ 25% of cheek implants were accounted for by Gen Z.

Men and plastic surgery Men have increasingly invested in their looks, with over 1.5 million male patients seeking plastic surgery, specifically minimally invasive cosmetic surgeries. In 2022, over 1.4 million male patients took advantage of the shorter recovery time and more immediate results that minimally invasive surgery offers, resulting in a staggering 253% increase since 2019. Top procedures included neuromodulator injections, commonly called ‘Brotox,’ and dermal fillers, which jumped 65% and 70% in male patients, respectively, since 2019. Sclerotherapy, the most common treatment for improving the appearance of varicose and spider veins on the legs, saw a rise of 54% in male patients from 2019. As it pertains to surgical cosmetic procedures, male patients accounted for 88,876 of the 1.5 million procedures in 2022, a 4% decrease from 2019. Yet, there were some procedures that grew in popularity in 2022 among male patients. Men accounted for the following in comparison to the overall total number of surgeries: ■ 12% of all eyelid surgeries ■ 39% of ear surgeries ■ 19% of cheek implants, an 80 percent jump from 2019 ■ 36% of chin augmentation, a 32 percent jump from 2019 ■ 10% of lower body lifts, a 61 percent surge jump from 2019

Surgeon fees Despite high inflation in a post-pandemic economy, people continued to spend and invest in themselves through plastic surgery. The average surgeon’s fees for minimally invasive procedures are also lower than most surgical procedures, ranging from $530 to $1,800. The surgeon’s fee for cosmetic surgeries can range from $3,000 to $10,000. In 2022, patients spent upwards of $26 billion on both minimally invasive and surgical procedures in the U.S. Costs can fluctuate depending on the surgeon, procedure and region, yet, on average, surgeon fees for some popular procedures either decreased in cost or rose less than inflation in 2022. More demand has led to more supply, and, in some cases, decreasing costs since 2019. While inflation in 2022 was almost 7%, the surgeon’s cost for surgeries such as cheek implants, chin augmentation and ear surgery increased only between 3 and 4%. Average fees for a few of the top overall procedures dipped, including: ■ Eyelid surgery dropped by $900 ■ Breast augmentation dropped by almost $500 ■ Noninvasive fat reduction dropped by almost $260 ■ Nonsurgical skin tightening dropped by $476 To learn more about the American Society of Plastic Surgeons and these statistics, visit: PlasticSurgery.org/Stats2022.

12-13 J U LY 2024

BUSINESS DESIGN CENTRE, LONDON, UNITED KINGDOM

Under the scientific super vision of the Aesthetic Multispecialt y Societ y (AMS)

WWW.FACECONFERENCE.COM

EXPERTISE EVIDENCE

EXCELLENCE ENGAGEMENT

27-28-29 MARCH 2024 MONTE-CARLO, MONACO GRIMALDI FORUM

Under the High Patronage of H.S.H. Prince Albert II of Monaco

Under the scientiﬁc supervision of the Aesthetic Multispecialty Society (AMS)

WWW.AMWC-CONFERENCE.COM

| MEETING PREVIEW

THE AMWC AESTHETIC

AWARDS 2024

Looking ahead to the 10th edition of the AMWC Aesthetic Awards, taking place in Monaco on March 27th 2024

N THE EVER-EVOLVING WORLD OF aesthetics, where innovation and artistry continually redefine beauty, it is vital to honour the individuals and establishments that push the boundaries of this dynamic field. The AMWC Aesthetic Awards, now in its 10th edition, epitomise the pursuit of excellence in aesthetic medicine. In this article, we will explore the high standards upheld by the AMWC Aesthetic Awards, highlight the diverse award categories, and shine a spotlight on the esteemed jury, which comprises an impressive 76-member panel. The AMWC Aesthetic Awards are synonymous with maintaining impeccable standards. The event has earned a reputation for its rigorous evaluation processes and its unwavering commitment to celebrating exceptional achievements in aesthetics. Year after year, these awards spotlight the highest standards in aesthetic medicine, innovation, and patient care. Every entry undergoes meticulous

scrutiny to ensure that the procedures and treatments submitted adhere to the highest ethical and safety standards. This commitment to patient well-being ensures that the awards honour not just exceptional results but also responsible and ethical practices.

Award categories: recognising diverse achievements The AMWC Aesthetic Awards encompass a wide range of categories, ensuring that all areas of aesthetics receive the recognition they deserve. Some of the noteworthy award categories include: ■ Best energy-based treatment ■ Best non-surgical body shaping ■ Best complication management ■ Best suspension thread ■ Best injectable dermal filler.

Standout cases and innovative products and devices The AMWC Aesthetic Awards serves as a

platform to acknowledge remarkable achievements, be they clinical cases or new products and devices, that epitomise the pinnacle of aesthetic excellence. Noteworthy cases illustrate the transformative potential of aesthetic procedures, the prowess of practitioners, and the positive influence on the lives of their patients. Year after year, these awards shine a spotlight on these accomplishments, igniting inspiration and establishing fresh standards within the field. Moreover, the recognition of cutting-edge products and devices that advance the aesthetics field highlights the role of technology in shaping the future of aesthetic medicine.

The esteemed jury: guardians of excellence The credibility of the AMWC Aesthetic Awards is upheld by its distinguished jury. Comprising leading experts and luminaries in the field of aesthetic medicine, the jury members

prime-journal.com | January/February 2024

MEETING PREVIEW |

collectively bring decades of experience and expertise to the evaluation process. Their unwavering commitment to maintaining the highest standards ensures that only the most deserving candidates are crowned winners. With an impressive panel of 76 members, the awards benefit from a diverse array of

perspectives and expertise. These esteemed jurors come from various corners of the globe. Each jury member is meticulously chosen based on their extensive contributions to the field of aesthetic medicine. Their selection includes a thorough review of their professional

AMWC Aesthetic Awards 2024 Jury Panel

records, ensuring that only the most qualified individuals serve as guardians of excellence in the AMWC Aesthetic Awards.

In summary The AMWC Aesthetic Awards 2024 promises to be a celebration of excellence

VIVIAN AMARAL, Cosmetic Dermatologist, Brazil

CHYTRA ANAND, Dermatologist, India

VLADLENA AVERINA Dermatologist, Ukraine

ASHRAF BADAWI Dermatologist, Canada

CINTIA CUNHA, Dermatologist, Brazil

CLAUDE DALLE Anti-aging Physician, France

KRISTINA DAVIDOVIC, Radiologist, Serbia

STEFANIA DE FAZIO, Plastic Surgeon, Italy

CHRISTOPHE DE JAEGER Geriatrist, France

TOM DECATES Aesthetic Physician, Netherlands

HENRY DELMAR Plastic Surgeon, France

SIMONE DOREIAN Aesthetic Physician, Australia

AIKATERINI GKOUVI Dermatologist, Greece

ALEKSANDAR GODIC Dermatologist, UK

ULIANA GOUT Aesthetic Physician, UK

BRITTANY HOWARD Facial Plastic Surgeon, USA

ARASH JALALI Aesthetic Physician, Canada

NICOLE KANARIS Aesthetic Physician, South Africa

MARTINA KERSCHER Dermatologist, Germany

JACK KOLENDA Facial Plastic Surgeon, Canada

NATALIA MARKOVA Dermatologist, Czech Republic

ELENA MARTIN Plastic & Reconstructive Surgeon, Romania

VINCENT MCGINNISS Facial Plastic Surgeon, USA

SOPHIE MENKES Aesthetic Physician, Switzerland

ANA MITROVIC JOVANOVIC Gynecologist / Obstetrician Serbia

NIKOS NAOUM Cosmetologist, Greece

PATRICIA OGILVIE Dermatologist, Germany

TATJANA PAVICIC Dermatologist, Germany

TODD SCHLESINGER Dermatologist, USA

JULIETA SPADA Dermatologist, Argentina

NENAD STANKOVIC Aesthetic Physician, Serbia

JESPER THULESEN Oculoplastic Surgeon, Denmark

TUNC TIRYAKI Plastic Surgeon, UK

PATRICK TREACY Aesthetic Physician, Ireland

MATHIAS TREMP Plastic Surgeon, Switzerland

OLEKSANDR TURKEVYCH Dermatologist, Ukraine

January/February 2024 | prime-journal.com

| MEETING PREVIEW in the field of aesthetic medicine, encompassing not only exceptional procedures and practices but also innovative products and devices. With a steadfast commitment to maintaining the highest standards in aesthetic practice and technology, diverse award categories that

include the full spectrum of aesthetic achievements, and an esteemed jury comprising an impressive panel, the awards continue to lead the way for those who strive to elevate aesthetic medicine and advance technology to new heights. As the field evolves, these awards serve as a

reminder of the transformative power of aesthetic medicine.

NICOLAS BERRENI Gynecologist / Obstetrician, France

THIERRY BESINS Plastic Surgeon, France

PAOLO BONAN Dermatologist, Italy

R. GLEN CALDERHEAD Research Scientist, South Korea

GABRIELA CASABONA Dermatologist, Brazil

NACI CELIK Plastic Surgeon, Turkey

YATES YEN-YU CHAO Dermatologist, Taiwan

VICTOR GABRIEL CLATICI Dermatologist, Romania

JEANINE DOWNIE Dermatologist, USA

KAPIL DUA Hair Transplant Surgeon, India

CLEO EDWARDS Aesthetic Physician, Netherlands

BESSAM FARJO Hair Transplant Surgeon, UK

FERNANDO FELICE Plastic Surgeon, Argentina

KLAUS FRITZ Dermatologist, Germany

HASSAN GALADARI Dermatologist, UAE

PIETRO GENTILE Plastic Surgeon, Italy

PETER C. KONTUREK Internal Medicine, Germany

ALEKS LETNIKOVS General Physician, Latvia

TING SONG LIM Aesthetic Physician, Malaysia

FRANCISCO LLANO Anti-aging Physician, Mexico

LUIS LOPEZ TALLAJ Plastic Surgeon, Spain

NAVNEET MAGON Gynecologist / Obstetrician, India

THEODORA MANTZOURANI Anti-aging Physician, UK

LEONARDO MARINI Dermatologist, Italy

JENNIFER PEARLMAN Aesthetic Physician, USA

ALI PIRAYESH Plastic Surgeon, Netherlands

THOMAS RAPPL Plastic Surgeon, Austria

ALEXANDRE REBELOMARQUES Sports Medicine Physician, Portugal

ALEXANDER RIVKIN Plastic Surgeon, USA

STEFANIA ROBERTS Aesthetic Physician, Australia

FRANK ROSENGAUS Facial Plastic Surgeon, Mexico

AURA RUIZ Aesthetic Physician, Colombia

JANI VAN LOGHEM Aesthetic Physician, Netherlands

JOAN VANDEPUTTE Plastic Surgeon, Belgium

PETER VELTHUIS Dermatologist, Netherlands

INES VERNER Dermatologist, Israel

RUNGSIMA WANITPHAKDEEDECHA Dermatologist, Thailand

STEVEN WEINER, MD Facial Plastic Surgeon, USA

GREG WILLIAMS Plastic Surgeon, UK

SABINE ZENKER Dermatologist, Germany

prime-journal.com | January/February 2024

INDUSTRY INSIDER | LASERS |

THE AESTHETIC LASER

POWERHOUSE OF THE PAST, FOCUSED ON THE FUTURE

The laser is the quintessential energy-based device—or rather, it was. It has been four decades since Rox Anderson and John Parrish published the landmark paper that put lasers on the map for aesthetic medicine. Since then, we have witnessed a constantly evolving flood of energy-based devices, and the aesthetic world has never looked back. Are the laser’s better days behind it? 14

January/February 2024 | prime-journal.com

| LASERS | INDUSTRY INSIDER

ASERS HAVE BEEN A MAINSTAY OF and potassium titanyl phosphate (KTP) lasers, for aesthetic medicine for decades. Although example — and key technologies such as Q-switching they have been around a bit longer, their emerged. Creative clinicians in the field also drove ubiquity was ushered in by the advent of innovation with new treatment protocols. ‘Visionary injectable botulinum toxin, which made thinkers in the field devised myriad ways of applying the aesthetic medicine accessible to the technologies they were presented with and pushing the masses. The roots, however, go deeper, according to South envelope of what could be done,’ continued Dr. Niaimi. Korea-based laser- and light-therapy pioneer Dr. R. Glen Calderhead, with the work of Leon Goldman at the Technological advances University of Cincinnati in the 1960s. ‘Dr. Goldman is really The advent of fractional laser technology changed the the godfather of lasers in dermatology,’ he said. ‘He laid the game again. ‘The landmark 2004 paper by Manstein and groundwork for some of the most popular laser colleagues2 demonstrated how scanner technology procedures today, such as laser hair reduction and tattoo developed for lasers by Coherent Medical could be removal. He also introduced the ruby laser, argon laser harnessed to create a pattern of microwounds, rather than and the ubiquitous neodymium:yttrium-aluminium full surface ablative resurfacing, which could improve skin garnet (Nd:YAG) laser. He moved the argon laser, for conditions without the wholesale damage of full-field example, from ophthalmology into dermatology.’ Lasers, resurfacing. This would theoretically reduce risk and it seemed, could be of great use to the aesthetic downtime, but also with less improvement, with the tradepractitioner. ‘This whole thing was underpinned by a off being worth it for many laser surgeons,’ Dr. Bernstein delving into and growing understanding of laser physics, said. biophysics, and laser-tissue interaction.’ This concept caused an explosion of fractional lasers The real leap forward for aesthetic laser medicine of various types and wavelengths, and the concept was the work of Anderson and Parrish1 with the of fractional delivery of energy was applied to theory of selective photothermolysis in 1983. other energy-based devices as well. Many The basic concept was that repeated laser laser platforms of today offer fractional pulses targeting an ideal chromophore delivery capabilities in addition to fullcould selectively heat a target without field resurfacing options. ‘Fractional causing undue spread of that heat to technology has transcended the laser surrounding tissue, according to by this point and revolutionised the Pennsylvania-based dermatologist way we practice device-based Dr. Eric F. Bernstein. ‘You could therapies,’ Dr. Al-Niaimi added. reach into the skin and destroy ‘Anything that brings visible results tattoo pigment or a blood vessel, with lower risk and downtime, and for example, without hurting faster healing is a positive response surrounding tissue, by selecting to that trend among patient the specific wavelength absorbed expectations. For lasers it meant a by a particular target and the viable alternative for those who appropriate pulse duration for the were afraid of undergoing traditional size of the target,’ he explained. Dr. CO2 resurfacing because of the side Bernstein actually owns a signed copy effects, and much of what happened of this seminal paper. afterward in device-based aesthetic The juggernaut began chugging forward, medicine was exactly that—proliferating gaining momentum. Dermatologist Dr. Firas competing alternatives for the many Al-Niaimi practices in London, U.K. ‘For a while, it conditions we are presented with every day.’ was a single wavelength treating a specific Al-Niaimi also lauded the more recent harnessing pathology, but competing and creative of picosecond lasers — less impactful in the Western Much of what we will see world but strong in Asia because they transformed engineers battling to gain market share in the coming years will not be the treatment of pigment (as well as tattooing) in coordinated with researchers in the field to explore what could be done, and we began to Asian skin. ‘The therapeutic injury caused by novel, but more of a see an evolution gaining momentum which has lasers has a unique and profound effect refinement of what we already picosecond yet to cease,’ he added. ‘As we went through the on tissue; it has also been fractionated, which have. We may see more eighties, the CO2 laser gave us full-field provides another unique effect.’ resurfacing, which we still do some form of ‘The picosecond laser,’ Dr. Calderhead added, evolution of lasers and lowtoday; it had quite a lot of downtime and ‘creates thermally-produced plasma causing a level lasers or LED light for recovery associated with it but the outcomes cavitation effect, forming zones of laser-induced convincing and reproducible optical breakdown (LIOBs). This technology is very are great. It was there that we began to achieve hair growth rather than the kind of improvements in the aesthetic useful for pigment and was especially promising in appearance of the skin, moving away from Asian skin.’ reduction. treating pathology alone.’ As Dr. Al-Niaimi shared, exponential growth in Dr Firas Al-Niaimi Specialised wavelengths — the pulsed dye the energy-based device market stands on the

prime-journal.com | January/February 2024

INDUSTRY INSIDER | LASERS |

groundwork laid by lasers. ‘Much of what we will see than your typical erbium laser with a much faster in the coming years will not be novel, but more of a repetition rate, creating unique applications of this refinement of what we already have. We may device.’ The 2,910 nm wavelength is very see more evolution of lasers and low-level similar to the 2,940 nm Er:YAG wavelength, lasers or LED light for convincing and right on the peak absorption of water, but reproducible hair growth rather than instead of 10 or 20 pulses a second, it reduction.’ delivers about 5,000. ‘In superficial As a result, according to the mode,’ Dr. Bernstein continued, ‘it’ll experts, it’s not that lasers are falling make a series of superficial donuts by the wayside; in fact, it’s quite the on the skin, and each one is opposite. They’re still relevant, actually made of 33 little laser they still work, and they still do pulses approximated in such a things other devices can’t. They way that the shoulders of the have simply become one more beam overlap, creating a very technology in a rapidly evolving uniform treatment pattern. It’s and increasingly diverse space. extraordinary. Healing is rapid. But they aren’t going anywhere. In my office, I use it for ‘Even with the proliferation of rejuvenation, acne scarring, and energy-based therapies, lasers are exploring laser coring for other still the mainstay of my dermatology applications. This laser has practice,’ said San Diego-based dramatically changed the way I treat dermatologist Dr. Arisa Ortiz. ‘The trend patients; it can be combined with a with lasers, which has translated to all vascular laser in the same treatment energy-based devices, is less invasive, less session.’ pain, less downtime, less hassle. Patients want to ‘The 2910 nm Er:glass fibre laser has been get things done but they don’t want completely transformational for my anyone to know about it. This is laser resurfacing practice,’ said especially true with men, who are a Nashville-based facial and oculoplastic The trend with lasers, which has growing segment of the patient surgeon Dr. Brian S. Biesman. ‘It delivers population. This was harder with energy in such a way that treatments translated to all energy-based devices, is less lasers in the past but is much easier invasive, less pain, less downtime, less hassle. are tolerated far better by patients while now, with all the advancements in still producing outstanding results. I Patients want to get things done but they don’t have performed CO resurfacing for technology and treatment protocols.’ 2 want anyone to know about it. This is especially nearly 30 years and there are still rare Current disruptors occasions on which I will choose CO2 true with men, who are a growing segment of ‘We’re in a really good spot as far as over the 2910. I typically perform the patient population. lasers are concerned,’ added aggressive CO2 resurfacing in the Nashville-based dermatologist Dr. operating room under anaesthesia for Dr Arisa Ortiz Michael H. Gold. ‘Beyond lasers the sake of patient comfort. In contrast, I themselves, look at the technology that supports them, such perform even the most aggressive 2910 nm Er:glass fibre as better computers, intuitive graphical user interfaces, and laser treatments in the office under topical anaesthesia, better cooling when we need it. They’re safer and much typically in conjunction with cold air and sometimes with more user-friendly. They treat more rapidly — I can do things the aid of oral anxiolytics.’ in much less time than I could twenty years ago. We have In addition to superior patient comfort during treatment, dialled in the treatment of skin of colour, which opened up a the 2910 nm laser offers faster recovery times and a shorter whole new patient base, especially outside of the United duration of postoperative erythema while still producing States. The laser companies have gotten those things right. outstanding clinical results, according to Dr. Biesman. ‘The So when I’m asked about the state of the laser business in 2910 nm laser is also very versatile, allowing for extremely aesthetic medicine, it’s as healthy as ever, but we’re always superficial intraepidermal treatments, full ablative on the lookout for disruptive technologies.’ resurfacing, fractional ablative resurfacing for scarring and These days the disruptive technology is the fractional skin rejuvenation, a novel treatment referred to as laser 2,910 nm Er:glass fibre laser, which was the immediate coring and surgical mode. The risk profile is also highly answer given by almost every physician interviewed for this favourable relative to CO2. We can now treat skin of colour article. Dr. Bernstein is Chief Medical Officer of Acclaro without worrying nearly as much about pigmentary Medical, Inc. (Smithfield, R.I., U.S.A.), manufacturer of the 2910 changes. It’s really expanding the spectrum of patients who nm laser platform known as UltraClear. ‘It is a vastly different are potential candidates for resurfacing, as well as making laser with drilling, superficial and laser coring modes. When the patient experience better overall.’ it drills holes in the skin in drilling mode, it uses four pulses ‘I still use my CO2, and there remains a niche for it,’ in very rapid succession to create very small-diameter Dr. Biesman continued, ‘but I use the 2910 nm Er:glass fibre channels. The fibre itself is the laser, so it’s lower powered laser for the vast majority of my resurfacing. Let’s be clear:

January/February 2024 | prime-journal.com

| LASERS | INDUSTRY INSIDER patients on the most extreme end of the photoaging spectrum still need CO2 because the Er:glass fibre laser doesn’t provide the same degree of thermal effect that can be required to achieve best outcomes in those cases. While the 2910 nm Er:glass fibre laser in its native mode provides less thermal effect than CO2 due to software engineering, it can also deliver variable amounts of heating and tissue coagulation.’ An advancement that isn’t getting a lot of traction, according to Dr. Ortiz, is lasers for basal cell carcinoma. ‘It’s not life-threatening. I don’t think a lot of surgeons are openminded about it, but there’s about a decade of very promising research showing that you can get around 90% clearance, and if something doesn’t clear, you can just cut it out. More interesting is research by Benson, Hibler, Kotliar and Avram3 that suggests that patients treated with nonablative fractional lasers may exhibit reduced risk of subsequent keratinocyte carcinoma, and increases the timeline if there’s a recurrence. So we may see not only the treatment of the appearance of ageing skin, but as prophylaxis for skin cancer.’ Calderhead has been at the forefront of low-level laser therapy (LLLT) for some time, and that technology is transforming rapidly. ‘Photobiomodulation is only now beginning to get the respect it deserves, but those who have adopted LLLT love it. LLLT has been looked at as hocus-pocus but there’s a good scientific base developing, with evidence at the subcellular and molecular levels, that appropriate wavelengths with appropriate fluencies may provide wonderful adjunctive approaches for the aesthetic surgeon,’ he detailed. ‘By cutting the healing time almost by half, it accentuates outcomes and also acts as prophylaxis against scarring. It’s a winwin situation, but this is undervalued at the moment. Also, we’re currently transitioning from lasers to LED light in this field.’

Looking to the future According to Dr. Ortiz, the future for lasers is more increased safety and ease of use. ‘Between imaging technologies, A.I., and robotics, we will see devices that are much, much easier to use safely. Those kinds of technology will help flatten the learning curve, fine-tune safe automation and reduce human error,’ she explained. ‘We haven’t seen as much of this in lasers yet, but I think that’s what’s coming if they can find a way to do it credibly and costeffectively.’ This is a big issue because safety is a bit more challenging with lasers than other energy-based technologies; in fact, it has driven the way other energybased therapies have evolved. ‘They are still operatordependent, and you should know a lot about lasers and how they interact with tissue before you treat anyone. The growing base of non-core providers has impacted overall safety. I see so many complications working out of a university; it sometimes seems like the Wild West out there, but it’s not because of poor technology. Patients should be mindful of where they’re going for any treatment but especially laser treatments. Providers with a weekend of

We clinicians can make or break these technologies, so companies must do the right thing price-wise and in terms of support. We’re here to help them but we need to be partners, and if that happens it can all work out. Dr Michael Gold

training can cause a lot of damage and it brings the entire field down.’ ‘I believe A.I. technology will find its way into laser devices quickly to measure various parameters of the skin and optimise treatment parameters based on in vivo analysis,’ Dr. Al-Niaimi opined. ‘Combined with in vivo imaging, we may achieve new levels of visualisation and analysis. We treat vascularity and pigmentation but we don’t actually visualise them. It would be a major advancement to be able to visualise the effects during treatment, and there may be a role for A.I. in that realm.’ Dr. Gold shared advice for those entering the field. ‘When a physician considers buying a new laser box, you’re always looking for something that treats many indications safely with good science behind it — I want to see controlled trials and substance, not hype. Also, know what you want to do and be sure what you go for can do that thing well, before you’re bamboozled by versatility and capability.’ Bearing in mind the limitations of lasers and all energybased devices, a key limitation is cost. ‘These platforms are expensive and the world economy isn’t what it used to be,’ Dr. Gold stated. ‘Interest rates have skyrocketed. Cost is becoming prohibitive and the industry has to figure out a way to keep costs down. A company may have a great device but must be price-conscious in order to succeed, and that not only involves the capital equipment but the disposables as well. If they don’t set it all up correctly, they’re going to suffer no matter how good the technology is, so it is incumbent upon them to find the best way to bring the technology to the industry but make it accessible so all can benefit.’ As per Dr. Gold, the bottom line is that the market and applications for laser- and all energy-based devices is still strong. ‘Companies can build on this strength or they can shoot themselves in the foot. We clinicians can make or break these technologies, so companies must do the right thing price-wise and in terms of support. We’re here to help them but we need to be partners, and if that happens it can all work out. Some companies are doing exceptionally well and others are struggling. There are also a lot of companies out there, so I see an era of consolidation in the coming years. The ones who do this right will end up owning the ones that don’t.’ Written by Kevin A. Wilson

References 1. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220(4596):524527. 2. Manstein D, Herron GS, Sink RKH, et al. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal

injury. Lasers Surg Med. 2004;34(5):426–438. 3. Benson TA, Hibler BP, Kotliar D, Avram M. Nonablative Fractional laser treatment is associated with a decreased risk of subsequent facial keratinocyte carcinoma development. Dermatol Surg 2023 Feb;49(2):149-154.

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AESTHETIC FEATURE | THREADS |

FACIAL REJUVENATION

WITH A NEW GENERATION OF COMBINED POLY-L-LACTIC ACID AND POLYCAPROLACTONE THREADS WITH HA Albina Kajaia describes the results from her 12-month study on the effects of the fourth-generation of Aptos threads ABSTRACT A polylactic acid and polycaprolactone (P(LA/CL) copolymer monofilament thread coated in a shell comprising nano- and microparticles of hyaluronic acid (HA) has recently been introduced by Aptos using the latest NAMICA (NAnoMIcroCApsules) technology. NAMICA, which utilises particles consisting of unstabilised (noncross-linked) HA surrounded by P(LA/CL) nanofibres securely fixed to lifting threads, is thought to provide longlasting biostimulating and rejuvenation effects. This study evaluates the 12-month-long skin quality improvement and lifting effects of the P(LA/CL)-HA threads produced with NAMICA technology on the middle and lower third of the face.

Research design and methods: 26 patients, women and men aged 30-65 years, underwent mid and lower face lifting using the 4th generation of Aptos P(LA/CL)-HA threads created with NAMICA technology. The threads were applied symmetrically on the right and left sides, with five threads on each side of the face. Patients’ satisfaction and facelifting were assessed at study follow-ups. Main outcome measures: Skin quality improvement, midface lift and patient satisfaction with the procedure outcome overall, and specifically, satisfaction with facial appearance, skin, cheekbones and cheeks, lower face and jawline were explored at 4, 9 and 12 months after the procedure and compared with the scores given at enrolment.

T ALBINA KAJAIA, MD, Head of Dermato-Cosmetology Department, Clinic of Plastic and Aesthetic Surgery and Cosmetology ‘Total Charm Vake’, Tbilisi, Georgia email: dr.kajaia@tcc.ge

KEYWORDS Facelift, Midface lifting, Aptos threads, P(LA/CL)-HA threads, NAMICA technology, Face rejuvenation

HE PROCESS OF FACIAL AGEING manifests as structural deformities to the skin and hypodermis1. Primary visual markers of facial ageing, such as wrinkle formation, sagging of facial soft tissue, and distortion of the oval contour, are more sharply expressed in the middle zone of the face2. Midface rejuvenation is a developing field in aesthetic medicine, and there is great patient demand for minimally invasive treatments to have a short recovery period, quicker functioning time and longlasting satisfactory results3. Nowadays, in the majority of cases, aesthetic treatments are combined with other procedures to obtain the desirable rejuvenating effects, such as eliminating sagging skin through mechanical lifting and repositioning of skin and subcutaneous tissue, as well as skin quality improvement. For such goals, aesthetic practitioners can combine thread lifting and hyaluronic acid injections. Face-lifting with barbed threads has been gaining popularity in recent years. Various facelifting threads are currently present on the market.

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COVER STORY

Results: Our results demonstrate that the NAMICA technology provides a significant skin quality improvement and facial lift that is preserved for 12 months after treatment. Improvement in skin quality parameters such as wrinkles, evenness, and redness were observed 12 months after thread implantation. The procedure is well-tolerated in all studied subjects, with no adverse effects or undesirable symptoms at later follow-ups. Patient satisfaction scores were high for all measured parameters. Conclusions: This study supports the use of fourth generation P(LA/CL)-HA threads with NAMICA technology to achieve and preserve an improvement in skin quality, meaningful facial lift and patient satisfaction for at least 12 months post-treatment.

Polydioxanone (PDO) threads, poly-L-lactic acid (PLLA) threads, and PLLA/polycaprolactone (PLC) threads are predominantly used. New generations of threads are thought to reduce side effects, extend the functioning time, improve satisfaction, and promote skin surface reparation4,5. Threads developed by Aptos (Aptos LLC, Georgia) are composed of the copolymer poly-L-lactic acid (PLLA) and polycaprolactone (PCL), providing this product — P(LA/CL) — with a long-lasting biostimulating effect through the slow and gradual release of PLLA, which is a potent stimulator of collagen production (Figure 1)5,6. As a result, the patient not only experiences an instant improvement in the shape of their face but also a faster rejuvenating and long-lasting biostimulation effect with thicker, glowing skin. In parallel to facelifting, the application of dermal fillers is becoming increasingly popular for skin rejuvenation purposes. Hyaluronic acid (HA) is known to be involved in primary biological functions, such as regulating cell adhesion and motility, manipulating cell differentiation, and cell proliferation and degrading as the body ages. HA-based fillers have launched quickly

and widely because of their biocompatibility, nonteratogenicity, safety, durability, ease of application, and good cost/benefit ratio. Due to its hydration and bio-stimulative effect, hyaluronic acid injections are widely used in aesthetic medicine for skin rejuvenation purposes. However, there are challenges that are faced in aesthetic medicine for hyaluronic acid treatment methods. In vivo, HA is rapidly degraded by enzymes and radicals that exist in the human body7. HA in dermal fillers must, therefore, be modified to increase its resistance to degradation once injected8. The modification includes cross-linking HA polymers — chemically stabilising the HA molecules. The cross-linking prevents it from degrading too quickly. However, the chemical stabilisation of HA molecules has its disadvantages and causes complications in HA injections9. Both non-cross-linked and cross-linked HA-fillers have been utilised in aesthetic centres. Nevertheless, hygroscopicity and overall effectiveness are more apparent in unstabilised, i.e. non-cross-linked molecules of HA10. Recently, Aptos LLC has introduced a new generation of threads in which P(LA/CL) copolymer threads are surrounded in a coating of unstabilised (non-crosslinked) HA molecules encapsulated in a P(LA/CL) copolymer shell embedded in the net of P(LA/CL) nanofibres around the core P(LA/CL) monofilament thread. This technology, named NAMICA (NAnoMIcroCApsules), is believed to provide longlasting skin rejuvenation and tissue lifting. The goal of this study was to evaluate the 12-month rejuvenating, skin quality improvement and midface lifting effects of Aptos threads produced with NAMICA technology.

Patients and methods Twenty-six subjects undergoing midface thread lifting procedures in the Total Charm Vake aesthetic clinic, Tbilisi, Georgia, from April 2022 to December 2022, were involved in this prospective study. The study was carried out in accordance with the guidelines laid down in the Declaration of Helsinki and the study protocol approved by the local Ethics committee. Informed consent was obtained from every study subject. The selected patients had facial ageing graded between 10– 100 points according to the visual scales. All included patients had Fitzpatrick skin phototype I–VI. The age of the women and men included was 30–65 years. Exclusion criteria were any previous use of facial threads or previous facial aesthetic surgery, use of permanent fillers or hydroxylapatite fillers, pregnancy, allergy and autoimmune diseases, complicated chronic illnesses, and skin infections. Collected demographic data included age, gender, race, weight (kg), and height (m). Other baseline/screening data included general medical history.

Treatment technique After clinical examination, all patients underwent a thread-lifting procedure in accordance with the

Midface rejuvenation is a developing field in aesthetic medicine, and there is great patient demand for minimally invasive treatments to have a short recovery period, quicker functioning time and long-lasting satisfactory results. prime-journal.com | January/February 2024

AESTHETIC FEATURE | THREADS |

Nano- and microcapsules are composed of hyaluronic acid particles enclosed in P(LA/CL) polymer shell • Non-stabilized (non-cross linked) hyaluronic acid molecules are encapsulated by biodegradable P(LA/ CL) copolymer microfibres • The capsules with hyaluronic acid and nanofibres are securely fixed to lifting threads • Hyaluronic acid weight reaches 5% of the total weight of the threads

In P(LA/CL) coating

Figure 1 NAMICA utilises particles consisting of unstabilised (non-cross-linked) HA surrounded by P(LA/CL) nanofibres, securely fixed to lifting threads

on each side of the face. Next, entry points were injected with 1% lidocaine mixed with epinephrine. The skin was punctured so that an anaesthetic solution could infiltrate along the pre‑marked location for each thread placement. Subsequently, 190 mm of absorbable threads with multidirectional barbs comprised of P(LA/CL)-HA (NAMICA Technology) were pre-loaded into a 21G round tip cannula (Figure 2). Cannulas were pulled through so that the threads were placed in subcutaneous tissue. Both sides of the face were treated with five P(LA/CL)HA threads, with three threads implanted in the midface area and two in the lower face area. Implanted threads were compressed, cannulas were removed, and the puncture was closed using a medical strip. Patients were provided with post-treatment recommendations.

Data assessment Calibrated and stereoscopic images of the patients’ faces were acquired with a passive stereovision LifeViz Mini (Quantificare S.A., Biot, France) digital camera and its Quantificare 3D Viewer plus surface reconstruction and analysis. This equipment was used for skin quality parameters (wrinkles, evenness, oiliness, redness) and lifting level assessment. Skin quality parameter (wrinkles and evenness) measurement values using this method of assessment are scored from -10 to +10, for which -10 is the worst case (for example, for wrinkles, it is many deep wrinkles) to +10 is the best case (no wrinkles). Redness improvement was assessed blinded via visual assessment by physicians of images analyzed by LifeViz® software and compared post-procedure with baseline images. Lifting was measured in millimetres. All patients accepted the reproduction of their recognisable photographs. Subject-reported outcomes were assessed using the validated FACE-Q questionnaires (satisfaction with the procedure, satisfaction with facial appearance, satisfaction with skin). All patients were asked to complete the correspondent Face-Q patient-reported outcome questionnaire (FACE-Q© 2020 Memorial Sloan-Kettering Cancer Center, all rights reserved) at D0 and 4 months, 9 months, and 12 months after the procedure. The areas reported in the Face-Q questionnaire were satisfaction with facial appearance, skin, cheeks, and cheekbones; adverse effects: skin, cheeks, lower face and jawline; appraisal of lines: overall, nasolabial folds, and marionette. GraphPad Prism software was applied for the

Figure 2 P(LA/CL)–HA view The thread with length 190 mm placed inside the needle 20G x 150mm. The package of such thread contains 10 threads laced into a needle; 1 needle is 23G x 80mm for infiltration, and 1 needle is 18G x 40mm for puncture out

Manufacturer’s Instructions for Use. Five threads were applied to each half of the face (one package of the product containing 10 threads were used in total for one patient) with the entry point on the line from the lateral canthus to the tragus at 1–1.5 cm from the hairline. This point will be in the projection of a cluster of strong fibrous cords linked with the periosteum of the zygomatic arch. Once the areas to be treated were disinfected and cleaned with an antiseptic solution, local anaesthesia was applied. Anaesthesia was performed symmetrically

Table 1 Skin quality score for wrinkles, evenness and red spots at each timepoint: 4, 9, and 12 months Skin quality parameters

Improved % (no)

No change

Worsened

Improved

No change

Worsened

Improved

No change

Worsened

Wrinkles

100% (26)

96.2% (25)

3.8% (1)

Evenness

92.4% (24)

7.6% (2)

92.4% (24)

7.6% (2)

96.2% (25)

3.8% (1)

Red spots (redness)

100% (26)

96.2% (25)

3.8% (1)

92.4% (25)

7.6% (2)

4 months

9 months

January/February 2024 | prime-journal.com

12 months

| THREADS | AESTHETIC FEATURE Figure 4 Evenness

4.9

4.3

MEAN SCORE

Figure 3 Wrinkles

3.8

0.3 Baseline

4 months

9 months

12 months

4 1.15 Baseline

4 months

TIMEPOINTS

Results Skin quality scores for wrinkles and evenness were improved significantly at each timepoint: 4, 9, and 12 months (Table 1). Wrinkles improved in 100% of patients (26) at 4 and 9 months and in 96.2% (24) at month 12. The mean baseline score for wrinkles was 0.3 and increased to 4.8 at month 4, 4.2 at month 9, and 3.8 at month 12 (Figure 3). The mean baseline score for evenness was 1.15 and increased to 4.0 at month 4, 4.42 at month 9 and 5.46 at month 12 (Figure 4). Redness improvement was assessed blinded by three evaluators and deemed improved in 100% (26) of patients at month 4, in 96.2% (25) at month 9, and in 92.6% (24) at 12 months. Meaningful changes in facial lifting were effectively measured using 3D surface imaging techniques at 4, 9, and 12 months post-treatment, separately on the right and left side of the face. The lifting effect peaked at month 4 and was maintained to month 12. Subject-reported outcomes were assessed using the validated FACE-Q questionnaire. Subjects completed the questionnaire at the time of enrollment and 4, 9, and 12 months post-treatment. Mean scores are based on a satisfaction scale: 1=very dissatisfied, 2=somewhat dissatisfied, 3=somewhat satisfied, and 4=very satisfied. All questions garnered scores between 3 (somewhat satisfied) and 4 (very satisfied) by all patients, and there were no significant differences between 4 months, 9 months, and 12 months, meaning that 100% of patients expressed meaningful satisfaction with the procedure through 12 months. It is worth noting that no adverse effects or undesirable symptoms were raised at any follow-ups.

9 months

12 months

TIMEPOINTS

Wrinkles were assessed by a stereophotographic 3D system (LifeViz® Mini). Scores: -10 (worst case— many deep wrinkles) to 10 (best case — no wrinkles)

statistical analyses. The chi-squared test was used to evaluate facial lift, and the Wilcoxon signed-rank test was employed to evaluate differences in the total mean surface area of facial lift. The scale questions were summed up based on the Face-Q recommendations. Differences at three time intervals were compared using the Wilcoxon signed-rank test. A p-value of less than 0.05 was considered statistically significant.

5.46

4.42

Evenness was assessed by a stereophotographic 3D system (LifeViz ® Mini). Scores: -10 (worst case — rough skin) to 10 (best case — smooth skin)

Patients’ satisfaction with their facial appearance was analysed using scores for the symmetrical, balanced, well-proportioned, fresh and rested look, as well as morning and night-time satisfaction with their appearance, profile look, and appearance in photos. The scores were statistically significantly elevated at all follow-up time points (4, 9, and 12 months) compared to the baseline and remained consistent through 12 months.

Figure 5 Procedure satisfaction scores

4 months 9 months 12 months

The result is miraculous The result is fantastic I am surprised at how good I look in the mirror The result was just as I expected The result turned out great I am pleased with the result

Mean subject FACE-Q procedure satisfaction scores collected at 4, 9, and 12 months. Responses to each of the 6 listed questions (y-axis) are shown; mean scores are based on a satisfaction scale (1=Very dissatisfied; 2=Somewhat dissatisfied; 3=Somewhat satisfied; 4=Very satisfied)

Figure 6 Facial appearance satisfaction scores

Enrollment 4 months

9 months 12 months

How your face looks under bright lights? How your face looks when you first wake up? How your face looks in photos? How your profile (side view) looks? How rested your face looks? How fresh your face looks? How your face looks at the end of your day? How well-proportioned your face looks? How balanced your face looks? How symmetric your face look?

Mean subject FACE-Q Facial appearance satisfaction scores collected at enrollment and 4, 9 and 12 months. Responses to each of the 10 listed questions (y-axis) are shown; mean scores are based on a satisfaction scale (1=Very dissatisfied; 2=Somewhat dissatisfied; 3=Somewhat satisfied; 4=Very satisfied). significance is indicated (NS = non-significant, *p≤0.05, **p≤0.01, ***p≤0.001).

prime-journal.com | January/February 2024

AESTHETIC FEATURE | THREADS |

Figure 7 Skin satisfaction scores

Enrollment 4 months

9 months 12 months

How even-coloured your facial skin looks? How your pores look? How the tone (colour) of your facial skin looks? How radiant your facial skin looks? How your facial skin looks when you first wake up? How hydrated your facial skin looks? How refreshed your facial skin makes you look? How clear your facial skin (complexion) looks? How smooth your facial skin looks? How attractive your facial skin makes you look? How healthy your facial skin looks? How your facial skin looks at the end of your day?

Discussion 1

Mean subject FACE-Q Facial appearance satisfaction scores collected at enrollment and 4, 9 and 12 months. Responses to each of the 12 listed questions (y-axis) are shown; mean scores are based on a satisfaction scale (1=Very dissatisfied; 2=Somewhat dissatisfied; 3=Somewhat satisfied; 4=Very satisfied). significance is indicated (NS = nonsignificant, *p≤0.05, **p≤0.01, ***p≤0.001).

Importantly, the skin rejuvenation effect is the added value of a P(LA/CL)-HA facelift. Evaluation of patients’ satisfaction with their skin appearance was high at all follow-up time points (Figures 5, 6, 7). The results for the Face Q scores for satisfaction with the procedure showed that 100% of patients were pleased with the results at all time points by 12 months.

Figure 8 A 59 year old female patient underwent midface lifting using the Aptos 4th generation of barbed P(LA/CL)-HA threads (NAMICA Technology). Photos for the following timelines: (A) & (C) Before the procedure; (B) & (D) 12 months after the procedure.

The results were great for 92.31% of patients at 4 months and 100% at 9 and 12 months. The results for Face Q scores for satisfaction with their skin showed 100% of patients were very satisfied at 4, 9, and 12 months for the following skin characteristics: skin appearance at the end of the day, skin refreshed appearance, skin smoothness, skin hydration, skin even coloured. Photographs of the patient before the procedure and 12 months after treatment with NAMICA are shown in Figure 8.

January/February 2024 | prime-journal.com

The allure of human beauty is intricately linked to the state of one’s skin, with flawless skin emerging as a universally appreciated trait. Underscoring the significance of maintaining healthy and high-quality skin is a key focus in our discourse on aesthetic medicine. Numerous studies emphasise the substantial influence of skin quality on emotional well-being, general quality of life, self-perception, and interpersonal relationships, highlighting the pivotal role of healthy skin in our narrative of well-being within the realm of aesthetic medicine. Data from this study supports the use of P(LA/CL)-HA threads produced with NAMICA technology to achieve and preserve a meaningful skin quality improvement combined with facial lifting and overall rejuvenating effect and patient satisfaction for a sufficient period of time post-treatment. In our study, all subjects were treated on the right and left side symmetrically, applying five threads per side: the first thread to the lower jaw on the border of the jowl fat compartment, the second thread to the projection of the mandibular cutaneous ligament, the third thread to the mouth angle, the fourth thread to the middle part of the nasolabial fold without crossing it, and the fifth to the nose alar angle. While similar studies describe the treatment of patients with 3 to 4 sutures in the midface, accumulating evidence suggests that optimal results are achieved with a holistic approach that most often includes four sutures in the midface, one to two sutures in the jowls or jawline, and two sutures in the upper neck, per side. Various studies describe the implantation of up to eight sutures per side11-13. Therefore, the selection of an adequate number of sutures is critical for ensuring that there is sufficient support for repositioned tissue and abundant volumisation to provide facial recontouring. Our data show significant improvement in skin quality and a lifting effect through the 12-month period, indicating tissue repositioning taking place around the treated area. Of importance, tissue repositioning and skin quality improvement have a crucial role along with hyperkinetic muscle relaxation, skin resurfacing, and tissue revolumisation to achieve a durable rejuvenating result. Most often, patient demand for skin quality improvement along with thread lifting is supported by their desire for greater facial recontouring together with rejuvenation that other treatment modalities such as fillers, toxins, or energy-based devices can provide. In our study, skin quality improvement was assessed

| THREADS | AESTHETIC FEATURE based on score changes before and after the procedure. The amount of lift was calculated based on changes in the projection of the skin’s surface in comparison with the baseline projection, which is an important supplement to the subjective data from patient satisfaction scores for facial appearance, skin, and the procedure overall. Our data, reporting the dynamics of skin quality parameters and face lifting up to 12 months posttreatment, provides important information for aesthetic practitioners about the window where retreatment might be considered. Importantly, some authors even suggest that there is no need for patients to lose the lifting effects completely; rather, additional sutures can be placed at certain timeframes to maintain and/or further improve results11. P(LA/CL)-HA threads used in our study were demonstrated to provide facial skin quality improvement and facial lift preserved through the study duration of 12 months. It is also noteworthy that the procedure was well-tolerated in all studied subjects, and no adverse effects or undesirable symptoms were recorded at later follow-ups. In addition, the vast majority of subjects gave satisfactory responses to all questions, evaluating their satisfaction with the procedure. These findings suggest that the 4th generation of P(LA/CL)-HA threads with NAMICA technology is a unique, adaptable, safe, and minimally invasive approach for the combined result of skin quality improvement and tissue lifting and repositioning. Besides skin quality improvement and face-lifting, assessing subject-reported outcomes revealed the meaningful rejuvenating effects from P(LA/CL)-HA threads. Patients have mostly provided ‘somewhat satisfied’ or ‘very satisfied’ responses to the questions measuring their satisfaction with their facial appearance and skin. As demonstrated by the range of various absorbable suspension sutures, they provide a unique result by repositioning, lifting and recontouring. The 4th generation of P(LA/CL)-HA threads demonstrated wrinkle and evenness improvement, along with the above-mentioned effects. Consistent with the inclusion and exclusion criteria for this study, the ideal patient has strong bony projections and skin that is mobile and pliable and of

Key points Midface rejuvenation is a developing field in aesthetic medicine, and there is great patient demand for minimally invasive treatments to have a short recovery period, quicker functioning time and long-lasting satisfactory results NAMICA, which utilises particles consisting of unstabilised (non-cross-linked) HA surrounded by P(LA/CL) nanofibres securely fixed to lifting threads, is thought to provide long-lasting biostimulating and rejuvenation effects Our results demonstrate that the NAMICA technology provides a significant skin quality improvement and facial lift that is preserved for 12 months after treatment

Besides skin quality improvement and face-lifting, assessing subjectreported outcomes revealed the meaningful rejuvenating effects from P(LA/CL)-HA threads.

sufficient thickness to avoid palpability of the sutures. However, most often, the patients have facial skin redundancy and visible nasolabial folds and/or marionette lines. These patients, although not ideal candidates, might still benefit from such treatment. Several reports strongly argue that the best aesthetic result is reached by combining fillers and threadlifting14-16. Other studies underline the benefits of either treatment depending on clinical indications and demands, while also suggesting avoiding the application of multiple procedures, each having notable side-effects and recovery period. The recent comparative study by ElMesidy et al. evaluated the efficacy of filler injection vs. thread lifting, reporting statistically significant improvement in GAIS favouring the filler14. Importantly, however, an argument about the benefits of threads for patients desiring an oval, less wide face shape is also proven14. Now, with the 4th generation of P(LA/CL)-HA threads, the suspension suture technique can be easily considered as the method providing the combined effect of facelift and rejuvenation through skin quality improvement. Longer-scale studies with larger populations are warranted to better explore the elements of the combined effect of lifting and skin quality improvement.

Conclusions NAMICA technology ensures meaningful facial rejuvenation expressed by a well-observed improvement in skin quality, mid and lower-face laxity, and patient satisfaction with the procedure for at least 12 months. Declaration of interest None Ethical Statement The study protocol and consent form used for the study were approved by the Ethics Committee of the Clinic of Plastic and Aesthetic Surgery and Cosmetology ‘Total Charm Vake’, Tbilisi, Georgia. Written consent to reproduce their recognisable photographs, use anonymised clinical data for analysis and consent for publication was obtained from every study subject.

References 1. Sulamanidze M, Sulamanidze G, Sulamanidze C. Elimination of Aesthetic Deformations of the Midface Area, Our Experience. Aesthetic Plast Surg 2018;42(3):774-90. 2. Rezaee Khiabanloo S, Jebreili R, Aalipour E, Saljoughi N, Shahidi A. Outcomes in thread lift for face and neck: A study performed with Silhouette Soft and Promo Happy Lift double needle, innovative and classic techniques. J Cosmet Dermatol 2019;18(1):8493. 3. Ilankovan V. Erratum to: recent advances in face lift to achieve facial balance. J Maxillofac Oral Surg 2017;16(1):134. 4. Aitzetmueller MM, Centeno Cerdas C, Nessbach P, et al. Polydioxanone Threads for Facial Rejuvenation: Analysis of Quality Variation in the Market. Plast Reconstr Surg 2019;144(6):1002e-9e. 5. Sulamanidze GM, Sulamanidze MA, Sulamanidze

KM, Kajaia AA, Giorgadze SG. The Subcutaneous Tissue Reaction on Poly (L-lactide-co-caprolactone) based Threads, Case Report. Int J Clin Exp Dermatol 2018; 3(2)1-9. 6. Stein P, Vitavska O, Kind P, Hoppe W, Wieczorek H, Schurer NY. The biological basis for poly‐L‐lactic acid‐induced augmentation. J Dermatol Sci 2015;78(1):26-33. 7. Park S, Park KY, Yeo IK. Investigation of the Degradation-Retarding Effect Caused by the Low Swelling Capacity of a Novel Hyaluronic Acid Filler Developed by Solid-Phase Crosslinking Technology. Ann Dermatol 2014;26(3):357–362. 8. Tezel A, Fredrickson GH. The Science of Hyaluronic Acid Dermal Fillers. J Cosmet Laser Ther 2008;10(1):35-42. 9. Fakhari A, Berkland C. Applications and Emerging Trends of Hyaluronic Acid in Tissue Engineering, as a

Dermal Filler, and in Osteoarthritis Treatment. Acta Biomater 2013;9(7): 7081–7092. 10. Da Costa A, Biccigo DGZ, de SouzaWeimann ET, et al. Durability of Three Different Types of Hyaluronic Acid Fillers in Skin: Are There Differences Among Biphasic, Monophasic Monodensified, and Monophasic Polydensified Products? Aesthet Surg J 2017;37(5):573-81. 11. Nestor MS. Facial Lift and Patient Satisfaction Following Treatment with Absorbable Suspension Sutures: 12-Month Data from a Prospective, Masked, Controlled Clinical Study. J Clin Aesthet Dermatol 2019;12(3):18-26. 12. Bohnert K, Dorizas A, Lorenc P, Sadick NS. Randomized, Controlled, Multicentered, Double-Blind Investigation of Injectable Poly-L-Lactic Acid for Improving Skin Quality. Dermatol Surg 2019;45(5):71824.

13. Kalyan R, Rafiq N, Wong V. The Efficacy of Polycaprolactone Threads in Zygomatic and Mandibular Lifting: Consecutive Study from a Single Practitioner’s Experience. Int J ClinExplDermatol 2017;1(1):1-3. 14. El-Mesidy MS, Alaklouk WT, Azzam OA. Nasolabial fold correction through cheek volume loss restoration versus thread lifting: a comparative study. Arch Dermatol Res 2020;312(7):473-80. 15. Tepavcevic B. Satisfaction of Patients and Surgeons with Combined Aptos Thread Lifting Treatment, Fat Grafting and Laser Treatment. Aesthetic Plast Surg 2022. 16. Goel A, Rai K. Non-surgical facelift-by PDO threads and dermal filler: A case report. J Cosmet Dermatol. 2022;21(10):4241-4

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AESTHETIC FEATURE | INJECTABLES |

JAMEL FARES, MD, Plastic Surgeon, Academia Internacional Dermo Cosmiatria, Brazil; JENNY SIMANCAS, MD, Aesthetic Doctor, Centro de Rejuvenecimiento Dra. Jenny Simancas, Venezuela; CARLOS VIVAS, MD, Plastic Surgeon, Aesthetic Doctor, Plasticenter Clinic, Dominican Republic; CARLOS ARGUEDAS, MD, Aesthetic Doctor, Academia Internacional Dermo cosmiatria, Costa Rica

Every professional must have a thorough knowledge of facial anatomy and adequate experience to evaluate the patient and make the correct treatment recommendations. 24

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| INJECTABLES | AESTHETIC FEATURE

A NEW HYALURONIC ACID FILLER WITH LIDOCAINE FOR

NASOLABIAL FOLDS AND LIP CORRECTION Drs Jamel Fares, Jenny Simancas, Carlos Vivas, and Carlos Arguedas share the results of their multicentre clinical study evaluating the safety and efficacy of the latest Fillderm® HA filler with lidocaine

ABSTRACT The use of dermal filling techniques for soft tissue augmentation has greatly increased in recent years. Hyaluronic acid is one of the most used temporary dermal fillers in the treatment of facial wrinkles, furrows, and folds due to its effectiveness and safety. Objective: To evaluate the efficacy and

safety of Fillderm®, a new hyaluronic acid filler, for nasolabial folds and lip correction. Methods: Open, multicentre study comprising 80 women. The Global Aesthetic Improvement Scale and the Wrinkle Severity Rating Scale evaluated efficacy. Efficacy was evaluated through observation and the reporting of side effects.

Results: One week after the filler injection, improvement in nasolabial folds and lips was observed in 89% and 86% of the women, respectively. Mild or moderate transient inflammatory reactions and ecchymoses occurred in 15% and 9% of patients, respectively, mainly in nasolabial folds. Two patients presented labial herpes

RINKLES ARE THE MOST apparent sign of facial ageing; they are dermo-epidermal depressions caused mainly by the sun (photoageing), intrinsic ageing, and the influence of factors such as gravitational force, repeated muscle movements of mimicry, disorganisation of collagen and elastic fibres and by the progressive loss of glycosaminoglycans1. At present, several treatment methods can be indicated according to the degree and type of patient ageing defined using the ageing classifications described in the literature (i.e. Fitzpatrick, Glogau). Depending upon the degree of ageing on the patient’s face, we can find lines, wrinkles, folds, grooves, hyperchromias, hypochromias, flaccidity, and premalignant and malignant lesions. All of these are typical during the ageing process, which can converge and form difficult, complex indications for treatment.

Ageing evaluation The Glogau classification continues to be very useful for diagnosing the severity of ageing (Types I, II, III, IV). ). As patients increasingly adopt preventive measures, their physical appearance may not necessarily reflect their actual age2. Consequently, it is important not to rely solely on chronological age when diagnosing ageing. Instead, a comprehensive clinical evaluation should consider the specific changes observed in each individual. In all facial aesthetic treatments, the objective is to

KEYWORDS Hyaluronic acid, skin, wrinkles

simplex after treatment of the lips. The good results were maintained in 85% and 70% of women for nasolabial folds and in 80% and 65% of women for lips after 6 and 8 months, respectively. Conclusion: Fillderm® was effective and safe for these indications.

restructure the face and improve the so-called triangle of youth (open angle of the lateral and orbital wall, full cheek volume and the definition of the mandibular contour.) There are limits to what facial fillers can do, which is directly related to: ■ Type of skin ■ Degree of ageing ■ Type of wrinkle ■ Skin flaccidity ■ Profile of the patient (diet, physical activity, habits, profession, diseases) ■ Age. As there are several possible combinations causing the changes produced by ageing, it is recommended to combine filling techniques with one or more of the following treatment options: surgical procedures, peeling, laser, pulsed light, carbon dioxide, long wave, radiofrequency, infrared, and other procedures. Every professional must have a thorough knowledge of facial anatomy and adequate experience to evaluate the patient and make the correct treatment recommendations. In our experience, patients with a round face shape and/ or oily or acne-prone skin usually have poorer results or may have complications such as prolonged inflammatory processes, danger of infection by purulent lesions, or reactivation of intradermal cysts. Procedures based on the use of filling materials are indicated in all patients, regardless of their age, that display marked signs of ageing in the region of the upper lip, lower lip, flattening of the upper lip with alteration of the pillars

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AESTHETIC FEATURE | INJECTABLES |

Figure 1 (A) Before and (B) after injection of Fillderm in the nasolabial folds

When referring to the best facial filling material, we can firmly say that it is one that complies with the specific parameters described above and effectively fills the depressed region, be it a line, a wrinkle or a groove, and that also favours or does not intervene in the cutaneous metabolism. The filling material should not alter the mobility of the mimic musculature. We often observe that permanent materials change the region’s movement, limiting and altering the normal ageing process. Generally, when performing rhytidoplasty in patients in whom this type of permanent filling has been used previously, a fibrous process occurs that interferes with the surgical procedure, limiting the mobility of the facial structures. Currently, several commercial injectable preparations are combined with lidocaine, which significantly increases the fluidity of the filler material. This combination allows for the product to pass more easily through fine gauge needles. The gentle pressure exercised by the plunger allows the injector to be very precise with the amount to be injected, in addition to offering comfort to the doctor and less discomfort for the patient.

Materials and methods For the development of this clinical study, we used a product called FILLDERM®. FILLDERM® is a range of dermal fillers consisting of biphasic gel formulations of hyaluronic acid (HA) with special patented double-cross link (DCL) technology, using no animal-stabilised HA. The FILLDERM® (Eye contour, Derm, Deep, Face Shape, Body Shape) range of products consists of a soft gel with high flexibility that integrates into the tissue. The product comes in a SCHOTT syringe, along with Terumo needles and cannulas to reduce adverse effects.

Study design

Figure 2 (A) Before and (B) after injection of Fillderm for volume in the cheeks and cheekbones

of the philtrum, nasolabial folds (SNG) and labial commissures (CMS), with or without alterations to the mandibular contour. These signs appear especially in patients in grades I, II and III of the Glogau Standard. In ageing grades III and IV, when surgery is prescribed, it may also accompany filling techniques in these regions. Presently, no optimum filling material possesses all the properties and characteristics necessary to treat all signs of ageing successfully. Instead, what exists are specific parameters we look for when we choose a product: ■ Non-allergenic ■ Non-pyrogenic ■ Not teratogenic ■ Does not migrate ■ Does not require a previous test ■ Has a duration of between 8 to 18 months ■ That is not permanent.

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The study is designed to evaluate the safety, effectiveness, and durability of FILLDERM® with lidocaine for injection in the nasolabial folds to correct wrinkles, lip augmentation, and to reduce the pain associated with such treatments. FILLDERM® was assessed through an open clinical evaluation across Panamá, Costa Rica, Venezuela, and the Dominican Republic, and the data collected for this study was collected from January 5, 2018, to December 5, 2018, and included 80 patients.

Inclusion and exclusion criteria Inclusion criteria

Healthy females between 20 and 50 years of age, with an indication for filling in the nasolabial folds.

Exclusion criteria ■ Use of medication that could interfere with coagulation (acetylsalicylic acid, anticoagulants, ginkgo biloba, vitamin E) ■ History of hypersensitivity or allergy to the components of the product ■ Presence of autoimmune diseases, pregnancy, or lactation.

| INJECTABLES | AESTHETIC FEATURE Efficacy and tolerance Table 1 Efficacy in nasolabial grooves (40 cases)

Results were evaluated immediately by the doctor, as well as at 4 and 8 months, according to the patient’s photographs. Three follow-up visits were scheduled on days 0, 120 and 240. The immediate efficacy was not observed; however, considering that there was no limit to the quantities used, it was deemed satisfactory in all cases. The volume to be injected was chosen not only based on economic criteria but also on aesthetic criteria shared by the doctor and the patient. Over-corrections were avoided. The volumes used in each patient were noted, and an average volume was calculated per indication. Finally, each patient performed their own evaluation of efficacy and tolerance at days 0 and 240.

Evaluation

240 days

Very good

30 (75%)

28 (70%)

Good

10 (25%)

Average

—

2 (5%)

Low

— —

Table 2 Lip augmentation (10 cases) Evaluation

Number and description of cases

Results

Very good

— —

Good

6 (60%)

8 (80%)

Average

3 (30%)

1 (10%)

Low

1 (10%)

Evaluation

Immediate and late tolerance was not a problem. The efficacy at 120 days was very satisfactory in 30 cases and satisfactory in 10 cases. After 240 days, it was very satisfactory in 28 cases, satisfactory in 10 cases, and average in 2 cases.

Lip augmentation (10 cases) Immediate and late tolerance was not a problem. The efficacy at 120 days was satisfactory in 6 cases, average in 3 cases, and low in 1 case. After 240 days, it was satisfactory in 8 cases, average in 1 case, and low in 1 case.

The treatment of nasolabial folds, lip augmentation and cheek volume are the most frequent applications of hyaluronic acid-based fillers. The addition of lidocaine to

Key points Increasing the middle part of the face to adjust facial proportions can create a more pleasing aesthetic and facial appearance. FILLDERM® added fullness to the left and right cheeks, providing significant results for at least 8 month. This study confirmed that FILLDERM® is safe and effective for patients looking for augmentation of the middle part of the face

Time 120 days

240 days

Very good

25 (83%)

21 (70%)

Good

5 (17%)

7 (23%)

Average

—

2 (7%)

Low

— —

Nasolabial folds (40 cases)

Discussion

240 days

Table 3 Increase of volume in cheeks and cheekbones (30 cases)

The three most important criteria for evaluating an aesthetic filler are its tolerance, effectiveness as a volumiser, and its duration.

Immediate and late tolerance was not a problem. The efficacy at 120 days was very satisfactory in 25 cases and satisfactory in 5 cases. At 240 days, it was satisfactory in 21 cases, average in 7 cases, and low in 2 cases. A multicentre, non-randomised, prospective, observational study was conducted by 4 clinics in the countries of Panama, Costa Rica, Venezuela, and the Dominican Republic for the intervention of FILLDERM® facial filler. The inclusion and exclusion criteria were categorised, and the patients signed the consent forms free and informed.

Time 120 days

Eighty cases were collected among the four clinical centres: 40 for nasolabial folds, 10 for lips and 30 for more extensive indications of volume deficiency, such as cheeks and cheekbones, in addition to the nasolabial folds.

Increase of volume in cheeks and cheekbones (30 cases)

Time 120 days

the hyaluronic acid formula results in a more practical product in its use by incorporating a topic anaesthetic. This trial confirmed that FILLDERM® is safe and effective for patients looking for augmentation of the middle part of the face. FILLDERM® added fullness to the left and right cheeks, providing statistically significant results and clinically relevant visible aesthetic results for at least 8 months. Declaration of interest The authors have consulted for Fillderm Figures 1–2 © Dr Fares

References 1. Hachach-Haram N, Kirkpatrick WN. Midface-lifting: evolution, indications, and technique. Facial Plast Surg 2013;29:289–94. 2. Bertucci V, Lin X, Axford-Gatley RA,

Theisen MJ, et al. Safety and effectiveness of large gel particle hyaluronic acid with lidocaine for correction of midface volume loss. Dermatol Surg 2013;39:1621–9.

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AESTHETIC FEATURE | INJECTABLES |

BB8 TECHNIQUE AN INNOVATIVE APPROACH TO DELIVER DILUTED BELOTERO BALANCE® (BB) TO TREAT INFRAORBITAL HOLLOWS AND SKIN QUALITY

Siew Tuck Wah reveals the results of his study on how diluted Belotero Balance HA filler can transform infraorbital hollows, offering safe and effective rejuvenation with enhanced skin quality ABSTRACT Facial ageing in the infraorbital hollows (IOH) is challenging to treat due to the area’s complicated periorbital anatomy, thin dermis, and its accompanying dangers and risks. Minimally invasive hyaluronic acid (HA) dermal fillers effectively restore support to the periorbital region hollow, thus rejuvenating it and alleviating the IOH. Belotero Balance (BB) is a dynamically

cross-linked, cohesive, homogeneous sodium hyaluronate gel with properties that confer a unique viscoelasticity to facilitate its homogeneous intradermal distribution, and is an excellent filler for IOH. To prevent the development of adverse events (AEs), BB can only be injected deep into the orbicularis oris muscle. To provide specific skin quality improvements, I have developed the novel

T SIEW TUCK WAH, MBBS, Radium Medical Aesthetics, Singapore email: siew.tw@radiumaesthetics.com

KEYWORDS Hyaluronic Acid, dermal filler, Belotero Balance, infraorbital rejuvenation, skin quality

‘BB8 technique’ to allow the effective injection of HA (at a concentration of 12.5 mg/ml) in the IOH area. The BB8 protocol is especially efficacious in the upper face area, with patients reporting improvements in forehead wrinkles, infraorbital fine lines, and tear troughs for up to 12 months, as well as skin quality improvements for up to 9 months, with mild and minimal AEs. To date, the BB8

HE FIRST SIGNS OF FACIAL AGEING are visible in the infraorbital hollows (IOH)1,2, where facial volume loss causes wrinkles and folds3,4 and exaggerates the natural curvilinear depressions beneath the eyes, creating shadows2,5 and causing a tired or sad appearance1,6,7,8. The periorbital or infraorbital area is comprised of the mid-cheek, palpebromalar and nasojugal grooves, as well as the tear trough9. Facial ageing atrophies the skin, fat, and underlying periorbital structures, exacerbating the medial canthal depression and emphasising the tear trough and lid-cheek junction10. In turn, orbital fat herniates, and the shadowing worsens, often along with undesirable skin texture and pigment changes. Unfortunately, the inherently complicated periorbital anatomy, especially the superomedial aspect of the tear trough hollow, consists of a thin dermis and little subcutaneous fat11, and the accompanying dangers and risk of complications12 make it a challenging area to treat10,13. Both surgical (e.g., lower eyelid blepharoplasty with fat transposition or injections) and nonsurgical

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protocol has been used in over 500 infraorbital areas with no adverse events or complications, including no swelling, lumps, or ‘sausage’-like protrusions due to overfilling. Thus, using BB HA filler diluted with normal saline, we effectively and safely improved the IOH and infraorbital skin quality, leading to rejuvenation of the entire infraorbital area in a safe and effective manner.

alternatives (e.g., dermal fillers, treatments using lasers, light and radiofrequency, or chemical peels and topical agents)13, 14 are effective, routinely offered treatments for this indication. Minimally invasive, hyaluronic acid (HA) fillers have repeatedly been shown to effectively restore support to the periorbital region hollow11 by restoring volume in its pre-periosteal plane, thus rejuvenating it and alleviating the IOH1, 2, 7, 10, 15-18. HA fillers create a natural appearance and offer high and long-lasting levels of patient satisfaction13. Importantly, they have favourable safety profiles, are dissolvable with hyaluronidase if needed9, 14, 19-23, and avoid the inconvenience and risks associated with surgery9, 14, 19. However, inadvertent adverse events (AEs), including nodules, swelling, and inadequate corrections, are common5,24. Belotero Balance (BB; Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany)3 is a dynamically crosslinked, cohesive, homogeneous sodium hyaluronate gel (22.5 mg/mL) manufactured using Cohesive Polydensified Matrix (CPM) technology and suspended within a physiological phosphate buffer containing 0.3%

| INJECTABLES | AESTHETIC FEATURE Minimally invasive, hyaluronic acid (HA) fillers have repeatedly been shown to effectively restore support to the periorbital region hollow by restoring volume in its pre-periosteal plane, thus rejuvenating it and alleviating the infraorbital hollows.

of lidocaine hydrochloride. CPM technology leads to a gel with areas of more or less cross-linking25. Gel areas with higher cross-linking density have higher filling and expanding functionality, while areas with less crosslinking density can enter smaller tissue gaps to fulfil the same filling and expansion functions3. These CPM gel properties thus confer a unique viscoelasticity that facilitates the homogeneous intradermal distribution of BB1,3,26-30. BB was recently approved31 by the U.S. Food and Drug Administration for US FDA approval for the improvement of infraorbital hollows. HA fillers have a long history of use for facial rejuvenation. One emerging, sought-after indication is skin quality improvement. Due to its properties mentioned above, BB is an excellent filler for this area. However, to prevent the development of AEs, BB can only be injected deep into the orbicularis oris muscle. To provide specific skin quality improvements, I have developed a novel BB injection technique in which 1 mL of BB is prepared by dilution with 0.8 mL of normal saline for an effective HA concentration of 12.5 mg/ml. This procedure has thus been named the ‘BB8 technique’.

Material and methods Patients included in this study were those requesting improvement of the infraorbital area or facial rhytids, and all were photographed before and after treatment to allow evaluation of treatment outcomes and followed up at 2 weeks, 4 weeks, 3 months, and 6 months posttreatment. Treatment outcomes were also assessed through patient satisfaction and evaluated using photographic scales for dark eye circles as previously published32. The infraorbital area was addressed through a cannula-delivered BB wash, while skin quality and wrinkles were addressed through the injection of droplets with a 31G needle. The BB8 protocol is thus comprised of the two phases described below.

Infraorbital rejuvenation A 25G blunt-tip cannula is inserted 5 mm above the intersection between a vertical line from the lateral cantus and the Zygomatico-cutaneous ligament, and advanced superficially into the infraorbital region for placement of small volumes of BB into the IOH, medially and laterally. Because it is diluted, BB can be delivered

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AESTHETIC FEATURE | INJECTABLES |

in a ‘wash’ fashion where the filler is spread out across the target treatment area. Volumes of BB used per side vary between 0.05ml to 0.2 ml, depending on the severity of hollowing or skin quality.

Skin quality improvement The face was divided into the upper face (forehead, temples, and upper eyelid) and the left and right lower face (infraorbital, cheeks, lateral face, and jowls). BB8 was introduced into the target treatment area using a 33G needle inserted superficially into the mid-dermis and injected in tiny droplets (0.02 ml) with an average total of 1 ml of BB8 per facial area. Areas with rhytids were injected more superficially, with blanching.

Figure 1 Patient A Treated with Belotero® Balance Using the BB8 Protocol. Patient (A) before and (B) 3-months and (C) 6-months post-treatment. Clear improvements in IOH and skin quality are visible for at least 6 months.

Results Our goal was to demonstrate the effectiveness and safety of BB delivered using our novel, simple and straightforward BB8 protocol to improve IOH and facial rhytids. The BB8 protocol is especially efficacious in the upper face area, with patients reporting improvements in forehead wrinkles, infraorbital fine lines, and tear troughs for 6 to 12 months (Figures 1 and 2). Skin quality (hydration and texture) in the upper and lower face also improved for at least 6 to 9 months (Figures 1 and 2). Patient satisfaction (data not shown) was high. AEs were mild and minimal, and observed at 2–4 weeks. These included bruising and, in exceptional cases of very thin-skinned patients, excessive swelling. As the main aim of the BB8 protocol was to reduce AEs associated with fillers in the infraorbital area, these low rates were unsurprising. To date, the BB8 protocol has been used in over 500 infraorbital areas with no adverse events or complications, including no swelling, lumps, or ‘sausagelike’ protrusions due to overfilling.

Discussion

Figure 2 Patient B Treated with Belotero® Balance Using the BB8 Protocol. Patient (A) before and (B) 3-months and (C) 9-months post-treatment. Clear improvements in IOH and skin quality are visible for at least 9 months.

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The BB8 technique, in which a viscoelastic, biphasic HA filler (BB) is pre-mixed with 0.8 mL of lidocaine, is a novel and improved delivery technique for IOH treatment. The IOH area is challenging to treat and often results in nodules and uneven results, especially for less experienced injectors. Moreover, the tear trough is an anatomically complex area comprised of critical blood vessels and nerves, overlaid by thin skin, and frequently affected by hyperpigmentation, thus complicating the injection of dermal fillers10. Treatments here require a thorough grounding in facial anatomy as well as experience with injection techniques. Diluting BB, which already has lidocaine, with an additional 0.8 mL of normal saline improves the rheology of the filler so that it is easier to handle, thus reducing the incidence of unevenness, enhancing the natural results of BB, and improving overall patient outcomes. As we did not perform objective evaluations of skin quality, future studies should include device-based skin quality assessments for parameters such as texture and hydration. The BB8 protocol would also be suitable for superficial injections into the dermis in other parts of the face and

| INJECTABLES | AESTHETIC FEATURE neck to improve skin quality and texture and reduce the appearance of wrinkles and fine lines. We now use the BB8 protocol for all patients requiring fillers in the infraorbital or upper eyelid area, for lines in the forehead, neck, and lateral canthal area, and as a skin quality booster. As the skin in the infraorbital region is very thin and unforgiving, and fillers often absorb water or cause a Tyndall effect, the use of diluted BB is ideal as it can be placed superficially, and its CPM nature enhances tissue integration33 so that the Tyndall effect does not occur. In the nasolabial fold, BB with lidocaine provided better improvements in wrinkles3, pain sensation, and satisfaction than Restylane, in agreement with other studies of similar outcomes between HA fillers with and without lidocaine3,34-36. Furthermore, lidocaine readily dissolves in the filler’s gel matrix without changing its properties or concentration, thus facilitating the reduction of intraprocedural pain without reducing the product’s effectiveness37. At a dilution of 1:0.8 with normal saline, the filler becomes less hygroscopic and, therefore, more suitable for superficial placement, even in the delicate infraorbital area, with minimal AEs. Its rheology also becomes ideally suited for mild volume replacement and skin hydration, as is often required to improve the infraorbital area. In our clinic, BB is used superficially in the infraorbital region, in the upper eyelids, for wrinkles especially forehead lines and neck wrinkles — and for long-lasting skin quality improvement. Restylane Vital was previously used for this infraorbital region, and although effective, outcomes were less natural, and the Tyndall effect occurred in some patients. Together with

Key points Infraorbital hollows (IOH) are difficult to treat Minimally invasive hyaluronic acid (HA) dermal fillers, such as Belotero Balance (BB), effectively restore support to the periorbital region hollow, thus alleviating the IOH The novel ‘BB8 technique’ rejuvenates the entire infraorbital area in a safe and effective manner

BB, the BB8 protocol therefore improves infraorbital skin quality, reducing fine lines, and effectively improving dark eye circles. Injectors should be aware of the general, routine difficulties associated with IOH injections, including uneven results, overfilling, Tyndall effects, and lumps. These AEs occur because HA filler is most commonly delivered into the IOH and infraorbital area using deep injections, but this often leads to suboptimal outcomes2,7,10,11,38,39. Additionally, filler is often introduced deep in the tear trough, another difficult area given that the orbicularis oculi is very adherent to the bone in the medial infraorbital area, resulting in filler often being placed intramuscularly. This itself causes problems with lumps, inconsistent results, and filler migration. These events can be mitigated with the BB8 protocol.

Conclusion Using BB HA filler diluted with normal saline, we effectively and safely improved the IOH and infraorbital skin quality, leading to the rejuvenation of the entire infraorbital area in a safe and effective manner.

Injectors should be aware of the general, routine difficulties associated with IOH injections.

Declaration of interest Funding for the preparation of this manuscript was provided by Merz Asia Pacific Pte. Ltd to Dr Shawna Tan, Medical Writers Asia. No conflict of interest was reported. Figures 1 & 2 © Dr Siew Tuck Wah

References 1. Iera M. Treatment of infraorbital skin depressions using the hyaluronic acid filler VYC-15L based on the MD codes approach: a retrospective analysis. J Clin Exp Dermatol Res. 2020;11(4):526. 2. Hall MB, Roy S, Buckingham ED. Novel Use of a Volumizing Hyaluronic Acid Filler for Treatment of Infraorbital Hollows. JAMA Facial Plast Surg. 2018;20(5):367-372. 3. Li W, Li B, Hofmann M, Klein G, Xie H. A Multicenter Noninferiority Study Comparing Safety and Effectiveness of Hyaluronic Acid Fillers for Correction of Nasolabial Folds in Chinese Subjects. Plast Reconstr Surg Glob Open. 2023;11(2):e4810. 4. Coleman SR, Grover R. The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthetic surgery journal. 2006;26(1_ Supplement):S4-S9. 5. Sharad J. Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes. J Cutan Aesthet Surg. 2012;5(4):229-238. 6. Haddock NT, Saadeh PB, Boutros S, Thorne CH. The tear trough and lid/cheek junction: anatomy and implications for surgical correction. Plast Reconstr Surg. 2009;123(4):1332-1340. 7. Niforos F, Acquilla R, Ogilvie P, et al. A Prospective, Open-Label Study of Hyaluronic Acid-Based Filler With Lidocaine (VYC-15L) Treatment for the Correction of Infraorbital Skin Depressions. Dermatol Surg. 2017;43(10):1271-1280. 8. Siperstein R. Infraorbital Hyaluronic Acid Filler: Common Aesthetic Side Effects With Treatment and Prevention Options. Aesthet Surg J Open Forum. 2022;4:ojac001. 9. Lee JH, Hong G. Definitions of groove and hollowness of the infraorbital region and clinical treatment using soft-tissue filler. Arch Plast Surg. 2018;45(3):214-221. 10. Trinh LN, Grond SE, Gupta A. Dermal Fillers for Tear Trough Rejuvenation: A Systematic Review. Facial Plast Surg. 2022;38(3):228-239. 11. Shah-Desai S, Joganathan V. Novel technique of non-surgical rejuvenation of infraorbital dark circles.

J Cosmet Dermatol. 2021;20(4):1214-1220. 12. Peng PH, Peng JH. Treating the tear trough: A new classification system, a 6-step evaluation procedure, hyaluronic acid injection algorithm, and treatment sequences. J Cosmet Dermatol. 2018;17(3):333-339. 13. Woodward J, Cox SE, Kato K, Urdiales-Galvez F, Boyd C, Ashourian N. Infraorbital Hollow Rejuvenation: Considerations, Complications, and the Contributions of Midface Volumization. Aesthet Surg J Open Forum. 2023;5:ojad016. 14. Lipp M, Weiss E. Nonsurgical Treatments for Infraorbital Rejuvenation: A Review. Dermatol Surg. 2019;45(5):700-710. 15. Diwan Z, Trikha S, Etemad-Shahidi S, Alli Z, Rennie C, Penny A. A Prospective Study on Safety, Complications and Satisfaction Analysis for Tear Trough Rejuvenation Using Hyaluronic Acid Dermal Fillers. Plast Reconstr Surg Glob Open. 2020;8(4):e2753. 16. Fabi S, Zoumalan C, Fagien S, Yoelin S, Sartor M, Chawla S. A Prospective, Multicenter, Single-Blind, Randomized, Controlled Study of VYC-15L, a Hyaluronic Acid Filler, in Adults for Correction of Infraorbital Hollowing. Aesthet Surg J. 2021;41(11):Np1675-np1685. 17. Morley AM, Malhotra R. Use of hyaluronic acid filler for tear-trough rejuvenation as an alternative to lower eyelid surgery. Ophthalmic Plast Reconstr Surg. 2011;27(2):69-73. 18. Rzany B, Cartier H, Kestermont P, et al. Correction of tear troughs and periorbital lines with a range of customized hyaluronic acid fillers. J Drugs Dermatol. 2012;11(1 Suppl):s27-34. 19. Stutman RL, Codner MA. Tear trough deformity: review of anatomy and treatment options. Aesthet Surg J. 2012;32(4):426-440. 20. Rohrich RJ, Hanke CW, Busso M, et al. Facial Soft-Tissue Fillers Conference: Assessing the State of the Science. Plastic and Reconstructive Surgery. 2011;127:22S-122e-S. 21. Philipp Dormston W, Bergfeld D, Sommer B, et al. Consensus statement on prevention and management of adverse effects following

rejuvenation procedures with hyaluronic acid‐based fillers. Journal of the European Academy of Dermatology and Venereology. 2017;31(7):1088-1095. 22. Cohen JL, Dayan SH, Brandt FS, et al. Systematic review of clinical trials of small- and large-gel-particle hyaluronic acid injectable fillers for aesthetic soft tissue augmentation. Dermatol Surg. 2013;39(2):205231. 23. Carruthers JD, Glogau RG, Blitzer A. Advances in Facial Rejuvenation: Botulinum Toxin Type A, Hyaluronic Acid Dermal Fillers, and Combination Therapies–-Consensus Recommendations. Plastic and reconstructive surgery. 2008;121(5):5S-30S. 24. Collier H. Management of tear trough complications post lower eyelid rejuvenation. Journal of Aesthetic Nursing. 2014;3(Sup8):S6-S12. 25. Sundaram H, Fagien S. Cohesive Polydensified Matrix Hyaluronic Acid for Fine Lines. Plast Reconstr Surg. 2015;136(5 Suppl):149s-163s. 26. Prasetyo AD, Prager W, Rubin MG, Moretti EA, Nikolis A. Hyaluronic acid fillers with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature review. Clin Cosmet Investig Dermatol. 2016;9:257-280. 27. Micheels P, Sarazin D, Tran C, Salomon D. Effect of Different Crosslinking Technologies on Hyaluronic Acid Behavior: A Visual and Microscopic Study of Seven Hyaluronic Acid Gels. J Drugs Dermatol. 2016;15(5):600-606. 28. Pavicic T. Efficacy and tolerability of a new monophasic, double-crosslinked hyaluronic acid filler for correction of deep lines and wrinkles. Journal of Drugs in Dermatology: JDD. 2011;10(2):134-139. 29. Tran C, Carraux P, Micheels P, Kaya G, Salomon D. In vivo bio-integration of three hyaluronic acid fillers in human skin: a histological study. Dermatology. 2014;228(1):47-54. 30. Hertz-Kleptow D, Hanschmann A, Hofmann M, Reuther T, Kerscher M. Facial skin revitalization with CPM®-HA20G: an effective and safe early intervention treatment. Clinical, Cosmetic and Investigational Dermatology. 2019:563-572. 31. Communications BM. Merz Aesthetics’ Belotero

Balance (+) receives FDA approval for Infraorbital Hollows. 2023 [Available from: https:// modernaesthetics.com/news/merz-aestheticsbelotero-balance-receives-fda-approval-forinfraorbital-hollows?c4src=news%3Afeed 32. O’Mahony MM, Sladen C, Crone M, et al. A validated photonumeric scale for infraorbital dark circles and its application in evaluating the efficacy of a cosmetic treatment product in a split-face randomized clinical trial. Int J Cosmet Sci. 2021;43(1):48-56. 33. Micheels P, Sarazin D, Besse S, Sundaram H, Flynn TC. A blanching technique for intradermal injection of the hyaluronic acid Belotero. Plast Reconstr Surg. 2013;132(4 Suppl 2):59s-68s. 34. Baumann L, Weiss RA, Grekin S, et al. Comparison of hyaluronic acid gel with (HARDL) and without lidocaine (HAJUP) in the treatment of moderate-tosevere nasolabial folds: a randomized, evaluatorblinded study. Dermatologic Surgery. 2018;44(6):833840. 35. Lee J-H, Kim S-H, Park E-S. The efficacy and safety of HA IDF plus (with lidocaine) versus HA IDF (without lidocaine) in nasolabial folds injection: a randomized, multicenter, double-blind, split-face study. Aesthetic plastic surgery. 2017;41:422-428. 36. Kwon HJ, Ko EJ, Choi SY, et al. The efficacy and safety of a monophasic hyaluronic acid filler in the correction of nasolabial folds: A randomized, multicenter, single blinded, split face study. Journal of Cosmetic Dermatology. 2018;17(4):584-589. 37. Hedén P, Fagrell D, Jernbeck J, et al. Injection of stabilized hyaluronic acid based gel of non animal origin for the correction of nasolabial folds: comparison with and without lidocaine. Dermatologic Surgery. 2010;36:775-781. 38. Chundury RV, Weber AC, McBride J, Plesec TP, Perry JD. Microanatomical Location of Hyaluronic Acid Gel Following Injection of the Temporal Hollows. Ophthalmic Plast Reconstr Surg. 2015;31(5):418-420. 39. Wendy WL, Alexandra EL. Periocular rejuvenation with neurotoxin and dermal filler. Plastic and Aesthetic Research. 2018;5:43

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AESTHETIC FEATURE | ULTRASOUND |

GUIDELINES FOR THE USE OF

ULTRASOUND IN MEDICAL AESTHETICS With point-of-care ultrasound gaining popularity, Humzah Dalvi, Elizabeth Raymond-Brown, and Telisha Jenkinson share their guidelines to raise the standard of education, training and use of ultrasound in aesthetic medicine 32

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| ULTRASOUND | AESTHETIC FEATURE management of medical aesthetic complications, i.e., the identification and avoidance of arteries when injecting and for assessing post-procedural complications such as oedema and abscess formation. At present, there are no standards to support practitioners using ultrasound in aesthetics. Therefore, guidelines are required in order to provide evidencebased guidelines and benchmark standards for aesthetic practitioners who wish to use POCUS within their scope of practice. As there are no nationally or internationally agreed protocols or standards of practice for the use of ultrasound examinations in aesthetics at this time, it is anticipated that guidelines will act as a basis for service and training providers when creating assessment and examination frameworks. In some countries, there is little regulation in regard to the provision of aesthetic interventions, which poses a potential risk to patients. Similarly, without any guidelines for POCUS in aesthetics, this may lead to issues in the future.

ABSTRACT With the increasing use of ultrasound in aesthetics, it would be reasonable to expect standards to be available to implement the use of Point of Care Ultrasound (POCUS) in clinical aesthetic practice. An abridged version of the UK Guidelines for the use of diagnostic ultrasound in aesthetics is presented to consider as a way to raise the standard of education, training and use of ultrasound in aesthetic practice.

At present, there are no standards to support practitioners using ultrasound in aesthetics. Therefore, guidelines are required in order to provide evidence-based guidelines and benchmark standards for aesthetic practitioners who wish to use POCUS within their scope of practice.

EDICAL AESTHETICS IS A rapidly growing sector internationally; the advent of injectable procedures since the early 1980s has resulted in a significant increase in the availability and acceptability of these interventions, and in 2022, there were over 9 million botulinum toxin injection procedures and over 4 million injectable hyaluronic acid cosmetic procedures performed internationally by plastic surgeons (ISAPS Global Aesthetic Trends 2022)1. The accuracy and outcome of procedures such as BBL are improved when performed under ultrasound guidance2. As a consequence, practitioners are seeking to access or are using ultrasound devices. Many practitioners use point-of-care ultrasound (POCUS) in relation to diagnostic processes for the prevention and

We have been working in close collaboration with The British Medical Ultrasound Society (BMUS), which already has well-established and respected professional practice guidelines for specific user groups3. Together, we developed The Guidelines for Professional Diagnostic Ultrasound Practice in Aesthetics with the aim of raising the standard of education, training, and use of ultrasound in aesthetics. The format and structure of these guidelines are based on those used for medical diagnostic ultrasound and underpin good medical practice4.

Guideline principles The complete Guideline is freely available for all practitioners and was developed to support aesthetic practitioners with a medical background to make them safe and familiar with using ultrasound in aesthetics. We present an abridged outline of the guidelines in this article. While ultrasound is considered a ‘safe’ imaging technique, compared with ionising radiation, it is operator-dependent and, therefore, should ideally be performed by practitioners who: ■ Can select ultrasound systems, optimise images, recognise artefacts, and adjust equipment settings and techniques to mitigate the risk of misdiagnosis ■ Are able to recognise normal anatomical structures and differentiate between the appearance of normal and abnormal ultrasound images ■ Understand the limitations of ultrasound and its role in aesthetic practice

HUMZAH DALVI, MD, Consultant Plastic Surgeon Beechwood House Clinic, UK; Elizabeth Raymond-Brown, Laser Education Ltd, Lincoln, UK; Telisha Jenkinson, Beechwood House Clinic, Wolverhampton, UK email: pdsurgery@live.co.uk KEYWORDS Ultrasound, Imaging, Guideline, POCUS

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AESTHETIC FEATURE | ULTRASOUND |

The BMUS guidelines are based on requirements to which those performing diagnostic medical ultrasound in the UK must adhere, in particular for ultrasound provision in aesthetics: Practitioners must be committed to providing a quality ultrasound service with due regard to the legislation and codes of practice related to healthcare provision Practitioners must identify limitations in their practice and request training and support to meet their needs Practitioners will take all reasonable opportunity to maintain and improve their knowledge and professional competency in keeping with the code of conduct of healthcare professionals. All those using ultrasound must ensure that their professional activities are covered by professional indemnity insurance or equivalent. The medical indemnity providers will be able to offer specific advice on appropriate professional medical cover if required. Within this framework, medicolegal aspects should be considered, particularly in relation to practitioner-patient communications, consent, image acquisition and reporting. Professional areas of clinical standards, audit, and continued professional development (CPD/CME) should also be considered from the practitioners’ perspective in relation to the use of POCUS in aesthetics. The type of CPD activity should be considered carefully as not everyone will be properly trained and could well be sharing poor practices. As this is a new area in the use of ultrasound in aesthetics, several new sites are being developed.

Safety of ultrasound

■ Can implement treatment protocols and manufacturers’ guidance to ensure that the ultrasound scan is accurate and reproducible ■ Work within their scope of practice and know how and when to seek further advice and support when necessary.

Clinical governance Clinical governance forms the basis of all clinical practice, and these concepts need to be considered when guidelines are produced. All practitioners should follow their professional codes of conduct, and this code will make clear the professional’s responsibility to the patient, the profession, and their colleagues.

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The safe use of ultrasound relates both to the user and to the ultrasound devices; users must be aware of the potential hazards of ultrasound. In the head and neck, due to the proximity of tissues to the cranial bones, it is recommended that the Thermal Index safety values for cranial setting (TIC) is used. Ultrasound use to image the eye should only be performed by specifically trained users. In the UK, it is the responsibility of the aesthetic practitioner to be aware of and apply the safety standards and regulations with regard to bioeffects, such as thermal and mechanical changes. In some countries, there are no regulatory limits on acoustic output from ultrasound scanners; hence, a knowledge of these safety issues is important.

Images and reports It is recommended that storing correctly annotated images is useful for ongoing patient treatment and is

| ULTRASOUND | AESTHETIC FEATURE valuable if further scans are required for follow-up comparison or for further procedures. The images should ideally be stored in DICOM (Digital Imaging and Communications in Medicine) format and securely on a local hard drive or a picture archiving and communication system (PACS). The storage of images on an ultrasound system’s hard drive or mobile device should be avoided. Local guidelines on information handling and security should be adhered to.

Infection prevention and control/ equipment maintenance Hand hygiene and the use of appropriate personal protective equipment (PPE) should be demonstrated before and after any contact with a patient. The examination table on which the patient lies during the scan should be protected prior to the patient’s arrival and cleaned immediately after and in accordance with clinical requirements5. Good infection prevention and control processes are essential for safe ultrasound examinations, and it is important to follow departmental protocols but also individual manufacturer’s instructions when cleaning machines — in particular, transducers and built-in ultrasound system filters. A ‘post patient’ daily, weekly and monthly cleaning schedule for the transducer is recommended. Only recommended transducer disinfection products (nonalcoholic) should be used to avoid any damage to the transducer. Cleaning and disinfection processes will be different for different procedures, so it is essential that practitioners understand their role in infection prevention and control6.

Water-based gel or water-based sterile gel should be used as a coupling fluid. Repeated use of alcoholic spirits on an unprotected transducer can lead to the rubber/plastic surface membrane perishing and potential electrical safety issues.

The ultrasound examination Water-based gel or water-based sterile gel should be used as a coupling fluid. Repeated use of alcoholic spirits on an unprotected transducer can lead to the rubber/plastic surface membrane perishing and potential electrical safety issues. Alcohol may be required as a coupling fluid for sterile interventional procedures and critical care patients, but only when a suitable transducer cover has been applied. The use of ultrasound gel on aesthetic patients should follow the principles laid out by the UK Health Security Agency7, as many aesthetic patients will be undergoing invasive procedures immediately following an ultrasound scan. The recent introduction of non-alcohol based antiseptic gel may be considered.

Key points Use of ultrasound in aesthetic practice is increasing Procedures for maintenance and clinical governance must be applied as for any new technology or equipment in medical aesthetic practice Utrasound images must be treated as confidential patient notes and stored appropriately Training sessions using models also need specific consents Knowing the safety limits of ultrasound and tissue interactions is mandatory

Training programmes Before using diagnostic ultrasound in aesthetics, it is recommended that practitioners receive training in the basics of ultrasound physics, image interpretation, relevant settings used, and safety aspects in the use of ultrasound. When ultrasound training is undertaken on ‘well’ patients, teaching staff or attendees, written informed consent must be obtained from the ‘model’ who understands the processes put in place to support onward referral should an abnormality be detected or suspected during a training programme8.

Summary Aesthetics is a rapidly evolving specialty which is being accessed by an increasing number of patients internationally. The outcome of many aesthetic procedures are significantly improved if performed under ultrasound guidance; therefore, support for aesthetic practitioners acquiring appropriate ultrasound skills is essential. We anticipate these guidelines on POCUS in aesthetics will provide direction towards best practice, which in turn will support their service delivery, improve patient/client outcomes and improve patient safety. These guidelines are not prescriptive but aim to support the use of POCUS in aesthetic practices. The Guidelines for Professional Diagnostic Ultrasound Practice in Aesthetics are freely available to all practitioners at www.bmus.org. Declaration of interest The authors wish to thank the British Medical Ultrasound Society (BMUS) for their advice, support and assistance with the guidelines. Comments and feedback are also very welcome and will assist us in the further development of these guidelines. Please contact us at www.bmus.org

References 1. ISAPS, 2023. ISAPS Global Survey 2022. [Online] Available at: https://www. isaps.org/media/a0qfm4h3/ isaps-global-survey_2022.pdf Accessed 28 October 2023]. 2. BAAPS, 2022. Superficial Gluteal Lipofilling. [Online] Available at: https:// baaps.org.uk/about/news/1865/ bottoms_up/ [Accessed 28 October 2023]. 3. BMUS, n.d. The British Medical Ultrasound Society. [Online] Available at: https://www.bmus.org/ [Accessed 28 October 2023]. 4. Humzah, M. D., Raymond-Brown, E. & Jenkinson, T., 2023. Guidelines for Professional Diagnostic Ultrasound Practics in Aesthetics. [Online] Available at: https://www.bmus.org/media/ resources/files/Guidelines_for_ Professional_Diagnostic_Ultrasound_ Practice_in_Medical_Ae_LnvgPk1.pdf [Accessed 28 October 2023]. 5. Manual, N. I. C. a. P., 2023. NICPM. [Online] Available at: https://www. england.nhs.uk/national-infectionprevention-and-control-manual-nipcmfor-england/ [Accessed 28 October

2023]. 6. Decontamination, U. T., n.d. Ultrasound Transducer Decontamination. [Online] Available at: https://www.bmus.org/policiesstatements-guidelines/professionalguidance/guidance-pages/ ultrasound-transducerdecontamination/ [Accessed 28 October 2023]. 7. UKHSA, 2022. Ultrasound gel: good infection prevention practice. [Online] Available at: https://www.gov.uk/ government/publications/ ultrasound-gel-good-infectionprevention-practice [Accessed 28 October 2023]. 8. BMUS, 2018. Guidelines for the management of safety when using volunteers and patients for practical training and live. [Online] Available at: https://www.bmus.org/static/uploads/ resources/Glines_for_the_mgment_of_ safety_when_using_volunteers__ patients_NOV_2018.pdf [Accessed 28 October 2023].

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AESTHETIC FEATURE | GEN Z AND SOCIAL MEDIA |

The individuals in this generation are extremely diverse and cannot be described by only one or two adjectives.

January/February 2024 | prime-journal.com

| GEN Z AND SOCIAL MEDIA | AESTHETIC FEATURE

GEN Z

AND THE IMPACT OF SOCIAL MEDIA ON AESTHETIC DEMANDS Dr Nitin Sethi and Naina Dhawan take us through the results of their cross-sectional study on the impact of social media on aesthetic demands of Gen Z patients and the economic implications on their aesthetic practices ABSTRACT Over the years, aesthetic procedures have gained immense popularity. Clinics catering to these procedures have always had a high footfall of patients above 30 years of age. However, in recent years, younger generations, specifically Gen Z, have begun to show a keen interest in aesthetic procedures for themselves. As a very online-savvy

generation, Gen Z is strongly influenced by social media platforms. They are exposed to images that promote a certain physical perfection, which attracts them towards aesthetic procedures. In the present article, we investigated the factors that influence Gen Z to desire such procedures and whether social media plays a role. We also investigated whether there has been any financial impact

EN Z, GENERATION Z, POSTmillennials, or the iGeneration are terms used to describe individuals born during the late 1990s and early 2010s. The individuals in this generation are extremely diverse and cannot be described by only one or two adjectives. This generation was the first to grow up completely in the digital age and are often referred to as ‘digital natives,’ owing to their easy access to the internet, social media, and gadgets from a very young age. Unlike previous generations, social media has seamlessly integrated into the lives of Gen Z. 98% of Gen Z own a smartphone, according to Forbes1. Statistics released by Statista2 in February 2022 analysed the average

on the practices of physicians in the past 5 years. We sought these answers via surveys and video interviews. The results indicated that social media is the biggest driving force for Gen Z to approach aesthetic practices. This downward shift in the age category demanding physical perfection has greatly impacted the practices of dermatologists and plastic surgeons.

amount of hours spent by different generations on social media. While boomers and Gen X averaged 1 and 1.5 hours, respectively, Gen Z averaged 3 hours. The social media platforms with the largest Gen Z user base include Snapchat (49.5 million), TikTok (37.3 million) and Instagram (33.3 million). According to Digiday3, ‘The unique thing about Gen Z is that while millennials have grown up with social media, Gen Z has grown up with “video-first” social media.’ Celebrities and influencers with substantial following and power on such platforms play a significant role in shaping the societal mindset. A study conducted by

NAINA DHAWAN, MD, The Shri Ram School Aravalli, Delhi, India; NITIN SETHI, MD, Additional Director Plastic & cosmetic surgery, Fortis Hospital; Director, Aura Aesthetique, Ludhiana, India email: drnitinsethi@gmail.com

KEYWORDS Gen Z, social media, aesthetic treatment

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AESTHETIC FEATURE | GEN Z AND SOCIAL MEDIA |

this is the need of the hour. This research was conducted with specific questions and surveys in the hope of establishing a correlation between social media and Gen Z, which could, in turn, affect the practices of aesthetic physicians.

Figure 1 Most requested aesthetic procedures by Gen Z 60% 50% 40% 30%

Materials and methodology

20% 10% 0% HAIR QUALITY

SKIN QUALITY

NOSE

DOUBLE CHIN

BODY CONTOURING

LIPS

FACIAL CONTOUR

(NON-SURGICAL)

Figure 2 Factors influencing the selection of aesthetic procedures for Gen Z 60% 50% 40% 30% 20% 10% 0% SOCIAL MEDIA, CELEBRITIES, CURRENT TRENDS, INFLUENCERS

BASED ON MOOD

TREATMENTS THAT IDENTIFY WITH YOUR PERSONALITY

Dr Victoria Rodner, The University of Edinburgh in 20224, concluded that cosmetic procedures are portrayed as effortless and normal on social media — such as fillers being as typical as a The unique thing manicure. This mindset, along with data on the impact of face filters and digitally about Gen Z is that while enhancing apps, helps us understand the millennials have grown up effect of image-based platforms such as with social media, Gen Z Instagram on consumer’s decision-making. Thus, it is prudent to explore if this videohas grown up with ‘videofirst social media is potentially the primary first’ social media. reason for Gen Z seeking aesthetic treatments. Other factors that could influence Gen Z’s aesthetic wants are the cost of the procedure, affordability, and parental consent in the younger cohort. In line with the assumption that Gen Z is influenced by social media to desire aesthetic procedures, it leads us to explore the potential impact this has on the aesthetic practices of dermatologists and plastic surgeons. In 2021, a global survey from the International Society of Aesthetic Plastic Surgery (ISAPS)5 reported an increase of 19.3% in surgical and non-surgical procedures. The report showed an increase of 54.4% in non-surgical procedures in the last 4 years. In 2020, Drs Sandeep Arora and Gulhima Arora6 published an article citing the need to make dermatology training more inclusive towards aesthetic dermatology as

January/February 2024 | prime-journal.com

The study is a double-blind study that was conducted in two parts. The first part was a survey of closed-ended questions for the age group between 12 and 26 years, and the second part was in-depth video/phone interviews with aesthetic physicians. The survey was conducted with the objective of evaluating what the Gen Z patient is seeking in terms of aesthetic outcomes and what factors determine the same. It was conducted through online channels over a span of 3 months. Inclusion criteria included people born between 1995 and 2012, living in urban areas, and having access to aesthetic centres and services. A total of 212 people fitting into this inclusion criterion were surveyed. For ethical reasons, their identities were undisclosed. Firstly, we inquired about their familiarity with aesthetic treatments. Another crucial aspect we investigated was the influence of social media on their desire to undergo these treatments. Identifying the most desired aesthetic treatment among this generation was another key objective. To achieve this, we inquired about their preferences and what factors contributed to their attraction to a particular treatment. We also questioned them to understand the role of friends and family in influencing their decision to undergo these treatments. Lastly, we assessed whether cost was a concern for this generation. This involved understanding if the cost of aesthetic treatments played a significant role in their decision-making process and if they would be more inclined to undergo a treatment if it were more affordable. By posing these questions in a neutral and non-leading manner and gathering responses from a diverse group of Gen Z individuals, we gained valuable insights into their attitudes, preferences and motivations related to aesthetic treatments. The results of the survey were analysed using two measures of central tendency, namely mean and median. Pie charts and bar graphs were used to represent the data. The second part of the study involved conducting telephonic and video interviews with dermatologists and plastic surgeons from across India. Criteria for selecting these doctors included doctors practising in urban areas, having a prominent aesthetic practice and having an average footfall of over 40 patients daily. The questions were designed to evaluate whether there has been any change in the age of clients visiting their practices, the reasons they desire

| GEN Z AND SOCIAL MEDIA | AESTHETIC FEATURE

aesthetic treatments and if there has been any economic impact on the aesthetic practices in the last 5 years. These questions were open-ended in order to allow the doctors to express their views freely.

Results At the end of the data collection, 212 stakeholders participated in the survey. The survey questions aimed to ascertain whether Gen Z desired aesthetic treatments, which physical attribute they wanted to change the most, what were the influencing factors, and whether the cost of treatments influenced their decision to proceed. 57% of the respondents said skin quality was the one feature they most desired to change. 37% desired an improvement in hair quality. Nose and double chin were other features that some respondents wanted to improve (Figure 1). With regard to what influences Gen Z to desire aesthetic procedures, a startling 53% stated that they were influenced by celebrities, social media and influencers. 39% of individuals wanted treatments that aligned with their personalities, while 37% claimed to be influenced by their moods (Figure 2). Most respondents sought parental consent before undergoing any aesthetic treatment (Figure 3), and the majority were concerned about the cost of treatment (Figure 4). For the second part of the study, 20 aesthetic physicians participated in a video questionnaire. The questions aimed to assess if there was any increase in footfall of Gen Z clients in their practices, what influenced them to desire aesthetic work, what was the area they

With regard to what influences Gen Z to desire aesthetic procedures, a startling 53% stated that they were influenced by celebrities, social media and influencers.

most wanted to improve and whether this has had any financial impact on the practice. We also tried to understand if the doctors have invested in social media marketing for their practices to take advantage of changing trends. The open-ended questions allowed the doctors to express their opinions freely, allowing us to better understand the wave of change in their practices.

Change in the number of patients between the age of 12–26 in the practice and their primary aesthetic concerns 83.3% of the surveyed doctors claimed there was an increase in patients between the ages of 12 and 26 years desiring aesthetic procedures. Of these, the vast majority, if not all of the patients, wanted to improve their skin quality, as well as a majority stating they desired hair quality improvement. According to the doctors, the other areas that concerned this generation were lip and periorbital areas, thus the increase in demand for lip fillers and undereye fillers.

Factors that influence these younger patients to want aesthetic procedures All the surveyed doctors believed that social media, influencers and watching videos of celebrities each played a role in driving Gen Z to desire aesthetic changes in their physical appearance. 58.3% of doctors felt that peer pressure and self-consciousness were other causes of discontentment with their bodies. Some doctors also opined that unrealistic and modified reality shown online influenced youngsters to try to be picture-perfect like them.

prime-journal.com | January/February 2024

AESTHETIC FEATURE | GEN Z AND SOCIAL MEDIA |

Figure 3 Involvement of parents and relatives in the decision-making process with regard to aesthetic treatments

Figure 4 Influence of cost on decision to undergo aesthetic treatment 50% 40%

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The cost of treatment is a concern for this younger generation, and the involvement of parents and relatives in their decision-making With regards to whether affordability is a concern for this generation and if parents are involved in their decisionmaking, 91.67% of doctors agreed that affordability is a concern for this age group. It was interesting to note that some doctors who disagreed with this trend reported that members of this generation are so determined to undergo aesthetic treatments that they emotionally manipulate their parents into supporting and funding their procedures. Additionally, some individuals prioritise aesthetic work to such an extent that they proactively save up money to cover the costs of the treatments themselves. This indicates a strong desire and commitment among specific individuals within this age group to pursue aesthetic enhancements.

Steps taken by doctors, if any, to make aesthetic procedures more affordable for these patients. 58.3% of doctors said they create packages to make procedures more affordable, while some offer student discounts and an option of interest-free EMIs.

Influence of current trends on social media on doctors in advising certain popular procedures to this clientele. 80% of doctors said they do not make treatment recommendations based on trends. They implied that even though they are aware of existing trends, they advise on the basis of what they feel is needed for the client rather than what the client desires. Some said that

January/February 2024 | prime-journal.com

ALWAYS/VERY FREQUENTLY

OCCASIONALLY

RARELY

VERY RARELY/ NEVER

they inform the Gen Zs of the trending treatments to avoid risking the client thinking that the doctor failed to suggest all treatment options but eventually emphasise what they feel are ethically correct treatments for that particular age group.

Whether there has been a financial impact on their practice in the last 5 years due to greater interest from Gen Z clients. 100% of doctors have seen a growth in their practice in the last 5 years, with the average increase being 20%.

Attempts to increase their social media presence 41% of doctors said that they have invested in social media marketing in order to promote deals and packages in their practices and to raise awareness about some key treatments being offered.

Discussion The results indicate Gen Z’s inclination towards aesthetic procedures and that social media and videos of celebrities play a significant role in influencing them. As the literature suggests, Gen Z spends a significant part of their day on social media, which could hence lead to them being influenced by the content they watch. The data collected in this study indicates this relationship. The

According to the doctors, the other areas that concerned this generation were lip and periorbital areas, thus the increase in demand for lip fillers and undereye fillers.

| GEN Z AND SOCIAL MEDIA | AESTHETIC FEATURE analysis of the results also suggests that skin and hair quality are the features Gen Z most desire to improve. The data also suggests that cost is a significant deciding factor while undergoing these procedures, and considering that a significant age category of Gen Z is underage, parental consent plays a significant role, too. The questionnaire for the doctors revealed very insightful results and analyses. The study demonstrated a clear relationship between increasing demands for aesthetic procedures by Gen Z and a subsequent change in clientele in aesthetic practices. There was also a significant increase in the revenue and financial performance of the doctors’ aesthetic practices in the past 5 years. A possible hypothesis for this could also be the post-COVID era of video calls and conferences. PostCOVID-19 saw a major boom in Zoom calls and other video conferencing apps, during which people were constantly seeing themselves online and assessing and judging their facial flaws. This could certainly lead to a desire to visit an aesthetic practice. This assumption merits further research on changes in aesthetic demands post-COVID-19. In accordance with the survey of the Gen Z cohort, the doctors’ questionnaire also revealed that social media and celebrities were the most common influencing factors on this generation. This further substantiates the hypothesis that since social media has been ‘video first’ for this generation, it is most likely to influence them to trend towards body image issues and to desire a change in their physical appearance. The analysis also supports the fact that Gen Z is cost-conscious, and this can be explained by the fact that part of this generation is underage and not financially independent and also that even the adult Gen Z is still new in their professional lives and most aesthetic procedures are not very affordable at this age. It was interesting to note that this generation is so keen to undergo aesthetic changes that they coerce their parents to support this need and pay for their treatments. Even though the doctors interviewed belong to different age categories and are extremely busy in their professional lives, it was interesting to note that almost all doctors were aware of the aesthetic procedures that are trending online. A possible explanation for this is that the aesthetic demands of the younger generation that is visiting their practice is forcing them to keep up with their awareness of the current online trends. It was heartening to learn that even though the physicians offer all aesthetic services in their practices, they still choose not to come under the pressure of patient demands and only advocate for the aesthetic procedures they feel are ethically right for that particular age category. Lastly, all doctors claimed to have experienced an upward trend in the revenue of their practices in the last 5 years, with an average increase of 20%. This is in line with the analytics given by the Times of India in 2022, which predicted an annual increase of 10–15% in the financials of the aesthetic businesses. McKinsey research in 2021 also shows that the global aesthetics injectables market could grow by 12 to 14% a year over the next five

Key points Social media is a potential influencing factor in driving gen z towards aesthetic practices Social media is the most potent influencing factors driving gen z to aesthetic practices There is been a significant increase in the economic dynamics of aesthetic practices of physicians in the last 5 years

years if manufacturers and providers capitalise on the underlying trends11. The study is limited by the fact that only 20 physicians were surveyed. Future studies with a larger sample size are advised. The study can also be conducted with a differentiation of the needs of males and females.

Conclusion As social media becomes increasingly central to young people’s everyday lives, it is crucial to comprehend its impact on their perception of beauty standards. The presented data clearly indicates that social media plays a significant role in normalising aesthetic procedures for Gen Z, making them more accepted as a norm rather than an exception. Consequently, this trend has a substantial and possibly ongoing influence on the practices of aesthetic physicians. These findings provide valuable insights to aesthetic physicians about the evolving trends and demands of the younger generation. To effectively cater to this techsavvy and well-informed cohort, physicians must adapt their skills and knowledge of aesthetic procedures according to their ever-changing aesthetic needs. Developing new treatments to fulfil the unmet requirements of this generation becomes imperative. While it may be tempting to recommend various aesthetic procedures to younger clients, it is crucial for physicians to act ethically and wisely. They should suggest only age-appropriate treatments and counsel their patients against mindlessly following all or any social media trends. Encouraging a balanced and informed approach to aesthetic enhancements will ensure the well-being and satisfaction of their younger clientele while safeguarding their long-term health and self-esteem. Declaration of interest None Figures 1–4 © Dr Sethi

References 1. Kastenholz, C. (2021, May 17). Council Post: Gen Z And The Rise Of Social Commerce. Forbes. https://www.forbes.com/sites/ forbesagencycouncil/2021/05/17/gen-z-and-the-rise-of-socialcommerce 2. U.S. Gen Z daily time spent social media 2022 | Statista. (n.d.). Statista. https://www.statista.com/statistics/1385608/ us-gen-z-daily-time-spent-on-socials/?gclid=CjwKCAjwlJimBhAs EiwA1hrp5ttlnQEsenLbLF9X4Rm_58XLLvQ8mR_ G8mbiEp7rdXTx29ZJWpOD7xoCUjMQAvD_BwE 3. Barber, K. (2021, June 23). Digiday Guide: Everything you need to know about Gen Z’s media consumption habits. Digiday. https://digiday.com/media/digiday-guide-everything-you-needto-know-about-gen-zs-media-consumption-habits/ 4. Social media aids quest for beauty perfection. (2022, December 2). The University of Edinburgh. https://www.ed.ac. uk/news/2022/social-media-aids-quest-for-beauty-perfection 5. Global Survey 2021: Full Report and Press Releases. (n.d.). Global Survey 2021: Full Report and Press Releases | ISAPS. https://www.isaps.org/discover/about-isaps/global-statistics/ reports-and-press-releases/global-survey-2021-full-report-andpress-releases/ 6. Arora, Sandeep & Gulhima, Arora. (2021). Recognizing “medical aesthetics” in dermatology: The need of the hour. Indian Journal of Dermatology, Venereology and Leprology. 87. 1-2. 10.25259/IJDVL_678_20.

7. From extreme to mainstream: The future of aesthetics injectables. (2021, December 20). McKinsey & Company. https:// www.mckinsey.com/industries/life-sciences/our-insights/ from-extreme-to-mainstream-the-future-of-aestheticsinjectables 8. News, A. (2001, July 29). Botox users getting younger after a year of Zoom meetings, doctors say. ABC News. https://abcnews. go.com/Health/botox-users-younger-year-zoom-meetingsdoctors/story?id=78800168 9. Shauly O, Marxen T, Goel P, Gould DJ. The New Era of Marketing in Plastic Surgery: A Systematic Review and Algorithm of Social Media and Digital Marketing. Aesthet Surg J Open Forum. 2023 Feb 28;5:ojad024. doi: 10.1093/asjof/ojad024. PMID: 37033450; PMCID: PMC10078152. 10. Hopkins ZH, Moreno C, Secrest AM. Influence of Social Media on Cosmetic Procedure Interest. J Clin Aesthet Dermatol. 2020 Jan;13(1):28-31. Epub 2020 Jan 1. PMID: 32082468; PMCID: PMC7028372 11. Leclerc O, Peters N, Scaglione A, Waring J. From extreme to mainstream: The future of aesthetics injectables. McKinsey & Company, December 2021. Available at: https://www.mckinsey. com/industries/life-sciences/our-insights/from-extreme-tomainstream-the-future-of-aesthetics-injectables [last accessed 14 December 2023]

prime-journal.com | January/February 2024

CASE STUDY | PIGMENTATION |

BIORETHERAPY MUCH MORE THAN PEELING Angela Capponi, MD, and Francesca Nicolucci, MD, explain how BioReTherapy is efficient and safe for treating extra-facial melasma ABSTRACT Extra-facial melasma is a new entity common in post-menopausal women. It appears related to hormones, family history, and personal history of facial melasma. It could involve mainly the neck, neckline, and forearms¹. Melasma treatment for the body, as for the face, is a real challenge. BioReTherapy is a revitalising, antioxidant, and moisturising treatment for the face and body, including treatment and post-treatment care. We suggest using the specific formulation body dedicated to treating extra-facial melasma.

ANGELA CAPPONI, MD, is a Dermatologist, Latina, Italy email angelacapponi@gmail.com

ELASMA, AN ACQUIRED REFRACTORY PIGMENTED SKIN disease, is a complex multifactorial disorder, and its pathogenesis is not yet well understood. Risk factors include a genetic predisposition, sun exposure, stress, medications, and pregnancy². We usually consider melasma as a typical facial manifestation; however, in recent years, we have recognised a new type of melasma involving the body, mainly the neck, décolleté and arms, defined as extrafacial melasma. This kind of melasma is not described well in scientific literature, and it appears to be related to menopause, family history, and personal history of facial melasma. It seems more common in older patients and especially in post-menopausal women on supplementary oestrogen therapy. The pigmentary change is macular and may be confluent or speckled. As for facial melasma, there is a sharp line of demarcation at the margins. Histopathology revealed a similar pattern to facial melasma, with signs of solar degeneration and a similar number of melanocytes; exactly as in facial melasma, it seems to have vascular involvement¹. During menopause, due to the lack of oestrogen, the skin loses its thickness, experiences a decrease in blood supply, and can seem tired and pale. In some cases, we could also have hyperpigmentation, like post-menopausal melasma; considering all these factors, we need a tool able to renovate the skin and simultaneously reduce subclinical inflammation and remove melanin stains³.

Mechanism of action

KEYWORDS Melasma, Extra-facial Melasma, Peeling, Biostimulation, BioReTherapy

BioReTherapy is a revitalising, antioxidant and moisturising treatment for both the face and body, including treatment and post-treatment care. The focus of this treatment is a patented biphasic technology product based on 35% to 50% trichloroacetic acid, which allows for safe and effective redermalisation and skin rejuvenation. This therapy is indicated for different skin conditions but is specified to treat face and body chrono and photoageing. It is available in a specific formulation for the body, which includes 50% TCA. Other ingredients are lactobionic acid, salicylic acid, tartaric acid, citric acid, glycine, proline, hydroxyproline, arginine, vitamins C and B2, gamma-aminobutyric acid, squalene, and isopropyl myristate. The innovative patented biphasic formulation brings room temperature stability

January/February 2024 | prime-journal.com

| PIGMENTATION | CASE STUDY

without TCA oxidation, darkening or any product degradation. In detail, the lipophilic action has a stabilising and protective effect on the chemical formulation and facilitates the movement of the active ingredients, as well as reducing trans-epidermic water loss (TEWL). The hydrophilic effects play the primary active role in the dermis through its biostimulating and revitalising actions on fibroblast activity. Considering its properties, this product is appropriate for all Fitzpatrick types and can be used in all seasons, as the treatment is non-ablative and the product doesn’t cause any skin photosensitivity.

Objective To recommend the use of this protocol in extra-facial melasma, we present a patient affected by symmetrical melasma on their forearms, resistant to topical treatments, managed successfully with BioReTherapy.

Case Report A 53-year-old Caucasian female presented with several years history of extra-facial melasma, localised symmetrically on the forearms, previously managed by topical treatments with partial and transitional improvement (Figure 1).

To recommend the use of this protocol in extra-facial melasma, we present a patient affected by symmetrical melasma on their forearms, resistant to topical treatments, managed successfully with BioReTherapy. prime-journal.com | January/February 2024

CASE STUDY | PIGMENTATION |

evaluation 1 month after the last body treatment. The patient applied BioReHydra® post-treatment serum once per day for the entire period of treatment.

Conclusion

Figure 1 (A) Before and (B) after four treatments with BioReTherapy Body

In her medical history, it was reported that when she was approximately 30 years of age, she was affected by mild facial melasma, which spontaneously disappeared after some years. We performed a Wood’s light evaluation on the forearms’ hyperpigmentation, which revealed mixed melasma.

After the treatment was performed, the skin was bright and firm with a significant reduction in hyperpigmentation. Overall, we witnessed a real skin quality improvement.

Materials and method The patient was treated with BioReTherapy Body (50% TCA) according to the following protocol. After shaking the ampoule, we applied 2 ml of the solution on the left forearm with nitrile gloves, massaging until it was completely absorbed. We performed the same on the right forearm, using another 2 ml of biphasic peeling; it is preferable to execute the method in stages since the product will return to the initial biphasic state after a few minutes. After 8 minutes from the initial application, we carefully cleaned the area with water and applied BioReHydra® post-treatment serum, containing ocean extracts, micronised hyaluronic acid, vitamins, GABA and amino acids, to accelerate skin restoration. We completed four sessions every 15 days and performed a new clinical

January/February 2024 | prime-journal.com

Dyschromia is a leading cause for cosmetic consultation, and melasma is the most difficult kind of dyschromia to treat due to its complex pathogenesis and frequent recurrences. Extra-facial melasma is a new entity, very common in post-menopausal women, and appears related to hormones, as well as family history and personal history of facial melasma. It involves mainly the neck, neckline, and forearms. Combined therapy involving laser/light and topical treatments could actually be the most efficient, safe, and effective long-term option to manage melasma4,5,6. However, it has some important limits, such as requiring a specific (and often really expensive) medical device and the extensive knowledge and experience to treat it using these devices. However, when the laser/light systems are not available, or when we prefer a gradual but efficient approach, we can choose BioReTherapy for extra-facial localisation using the specific and authorised formulation for the body with 50% TCA. In order to support our opinion, we presented a clinical case showing a significant improvement for extra-facial melasma, localised symmetrically on the forearms, after four treatments with BioReTherapy Body. After the treatment was performed, the skin was bright and firm with a significant reduction in hyperpigmentation. Overall, we witnessed a real skin quality improvement. The patient declared herself very satisfied with the results achieved on hyperpigmentation and, in general, skin quality; she also appreciated that the chosen treatment was well tolerated, painless, and didn’t require special care post-treatment. In conclusion, BioReTherapy Body could be considered a real alternative to available treatments for many clinical situations and also for extra-facial melasma: it’s affordable, safe and convenient for the physician, well-tolerated for the patient, and performs well for both. Declaration of interest None Figures 1–2 © Angela Capponi

References 1. CG Ritter et al. Extra-facial melasma: clinical, histopathological, and immunohistochemical case-control study. J Eur Acad Dermatol Venereol 2013 Sep;27(9):1088-94 2. B. Sofen, G. Prado, J. Emer. Melasma and Post Inflammatory Hyperpigmentation: Management Update and Expert Opinion. Skin Therapy Lett 2016 Jan;21(1):1-7 3. M. Daroach et al. Extrafacial Melasma: A Scenario Less Explored Indian Dermatol Online J 2022 Jun 24;13(4):484-486

4. Jiarong Yi et al. A Meta-analysisBased Assessment of Intense Pulsed Light for Treatment of Melasma. Aesthetic Plast Surg 2020 Jun;44(3):947-952. 5. Lisa Zaleski, Sabrina Fabi, Mitchel P Goldman. Treatment of melasma and the use of intense pulsed light: a review J Drugs Dermatol 2012 Nov;11(11):131620. 6. G. Zoccali, D. Piccolo, P. Allegra, M. Giuliani. Melasma treated with intense pulsed light. Aesthetic Plast Surg 2010 Aug;34(4):486-93.

Joint meeting with

11th congress

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PRACTICE PEARLS | DUAL WAVELENGTH LASER |

GENTLEMAX PRO PLUS®

A MULTITUDE OF TREATMENT POSSIBILITIES IN A SINGLE PLATFORM Dr Firas Al-Niaimi explains why he trusts in the latest dual-wavelength platform from Candela

HE GENTLEMAX PRO PLUS (GMPP) IS A PLATFORM FROM CANDELA that is the result of innovations and advances from the original platform produced some years ago. It is a solid, stable dual-wavelength platform of both the 755 nm Alexandrite and the 1064 nm Nd:YAG wavelengths. The platform is globally recognised as the gold standard for laser hair removal, offering not only optimal wavelengths but also versatility for various treatments. The unique features and reason for its status as the best epilation laser in the world will be explained in detail below.

Unique features of the GMPP FIRAS AL-NIAIMI, MSC, MRCP, EBDV, is a highly experienced consultant dermatologist and laser surgeon practicing in Central London. In addition, he is the group medical director of sk;n clinics UK; the largest skin and laser clinics in the UK. He is the first doctor outside the USA to have worked with the Vbeam prima and is the author of 160 scientific publications email: firas55@hotmail.com

KEYWORDS Candela, GentleMax Pro Plus, hair removal, vascular laser, port wine stains

The GMPP is a dual wavelength platform having two solid state wavelengths of the 755 nm Alexandrite and the 1064 nm Nd:YAG. This means the platform can offer a variety of treatment sessions given the action of the wavelengths on melanin, haemoglobin and tissue water. It has high power and multiple spot sizes ranging from 1.5 mm to 26 mm. The smaller spot sizes (1.5, 3, 3x10, and 6 mm) are typically used for vascular lesions, whereas the larger spot sizes above 12 mm are suitable for laser epilation. This is because a larger spot size will penetrate deeper and will also have a larger coverage area for faster treatment time. Typically, spot sizes 8, 10, 12 and 15 mm are used for pigmentation. The GMPP has multiple pulse durations from microseconds in the Nd:YAG to longer millisecond pulses, which will enable us to treat smaller structures that require a short pulse duration as well as larger structures that require a longer pulse duration. The frequency is 3 Hz, which means that three shots can be fired in a second, resulting in very fast treatments if the larger spot sizes are used. Importantly, for laser epilation with the larger spot sizes, the GMPP has a 2 ms pulse duration, which is particularly useful in the treatment of fine hairs. The GMPP has a dynamic cooling device (DCD), which is efficient in cooling the surface of the skin to protect the epidermis, and both the spraying and delay time can be adjusted. The GMPP is the latest version of several advances from the previous Gentle series, which has led to this evolution.

January/February 2024 | prime-journal.com

| DUAL WAVELENGTH LASER | PRACTICE PEARLS

Laser epilation Laser epilation, or hair removal as it is commonly known, remains one of the most in-demand aesthetic and laser treatments worldwide. As such, despite the growth in all aspects of laser rejuvenation treatments, this modality will continue to be one of the most popular applied treatments. Therefore, it is important to have a solid and stable laser epilation system that can treat all different skin types and hair thickness sizes. The GMPP has the advantage of a large spot size enabling deep penetration, a high frequency speed of 3 Hz as well as high power to enable high fluence levels in a large spot size. As the treatments progress and the hair shaft becomes thinner and finer, it is important to use a very short pulse duration to effectively achieve long-term hair reduction, and the GMPP can get down to 2 ms, which will be particularly useful for fine, thin hairs. This is a major differentiating factor compared to many other systems, in particular the diode lasers. There are regional laser epilation guidelines and recommendations, although worldwide there is a degree of variation in terms of interval and parameters. In

Laser epilation, or hair removal as it is commonly known, remains one of the most in-demand aesthetic and laser treatments worldwide.

general, treatment is initially suggested at intervals of 4 to 8 weeks, increasing as the treatment progresses and the hair cycle slows down1. It is recommended to start with a minimal spot size of 12 mm and keep the handpiece in direct perpendicular contact with the treated area with around 20% overlap. The DCD should be adjusted based on skin type and fluence but is typically 30:20 or 40:20. Blonde, white or red hairs typically do not respond to laser epilation. It is my opinion that the GMPP is the best platform to achieve stable, long-term hair reduction with little regrowth when measured at 6, 9 and 12 months postlaser epilation treatment.

Hair follicle-related disorders In addition to laser treatment of hirsutism or unwanted hair for aesthetic reasons, the Nd:YAG laser has been used in a number of follicle-related disorders with or without combination treatment with favourable outcomes. These conditions include hidradenitis suppurativa, pilonidal sinus (particularly post-surgery), dissecting cellulitis, keratosis pilaris, and pseudofolliculitis barbae2.

prime-journal.com | January/February 2024

PRACTICE PEARLS | DUAL WAVELENGTH LASER |

parts of the vessels since only the upper part of some vessels were in interaction with the shorter wavelength of 532 nm5. The parameters of the Nd:YAG in leg vessels depend on the size and depth of the leg vessels, with typically smaller vessels requiring a smaller spot size and a shorter pulse duration, and larger vessels requiring a slightly larger spot size and a longer pulse duration. The clinical endpoint, which is the vessel’s colour change, spasm or disappearance, is important. In the GMPP, the linear elliptical 3x10 mm is particularly suited for such linear vessels on the legs (on the face, too, but with a degree of caution).

Alexandrite for pigmentation The 755 nm is a wavelength that is strongly absorbed by melanin and can, therefore, be used to treat benign epidermal pigmentation in lighter skin types. Despite nano and picosecond lasers being much better at targeting pigmentation with little collateral damage, the GMPP can have a short pulse duration (2 ms in the large 10–15 mm spot sizes and the microsecond 6 mm spot) which will get closer to the thermal relaxation time of melanocytes and melanosomes. Typically, cryogen cooling is turned off to allow for the use of lower fluences in achieving the clinical endpoint of pigment darkening. Therefore, common parameters for diffuse lentigines are a spot size between 8–12 mm, 7–10 Hz, and a fluence between 6–12 joules with the cooling off. Lighter pigments require higher fluences, while darker pigments need lower fluences. Typically, a few pulses are performed until the clinical endpoint of pigment darkening and mild perilesional erythema is achieved3.

Figure 1 Venous lake on the lower lip (A) before and (B) after treatment with the Nd:YAG laser

Unlocking the potential of Nd:YAG laser technology, this wavelength proves to be a powerhouse in targeting skin chromophores effectively. Operating at shorter microsecond wavelengths, it focuses on water absorption, contributing to wrinkle treatment through repeated sessions. Seamlessly integrated with other procedures, such as injectables, it utilises common parameters like an 8 mm spot size and a frequency of 7-10 Hz. Meanwhile, for onychomycosis, Nd:YAG offers an alternative to systemic treatment, showing effectiveness in studies with short pulse durations and monthly intervals. The preference for microsecond pulse duration underscores its efficacy in these innovative treatments6.

Conclusion The GMPP is a dual-wavelength multipurpose platform with two wavelengths and multiple applications. It has a large spot size of 26 mm and a short pulse of 2 ms with a speed of 3 Hz, which will make laser hair reduction particularly effective in all skin types and hair thicknesses. Furthermore, it has multiple applications in rejuvenation (defined as the treatment of pigmentation, vascularity, and wrinkles), vascular and benign epidermal pigmentation, and onychomycosis.

Vascular uses The Nd:YAG wavelength is absorbed by haemoglobin, which is why this laser can be used in a number of vascular conditions in dermatology. In particular, venous lesions respond preferentially to the Nd:YAG compared to the shorter vascular wavelengths (such as the 595 and 532 nm) as they are located deeper in the skin and are rich in deoxyhaemoglobin, which is absorbed well by the Nd:YAG wavelength. The combination of these two characteristics makes this wavelength the first choice for venous lesions such as leg veins, venules on the face, and thick or hypertrophic parts of haemangiomas and port wine stains3. Venules on the face respond well to the Nd:YAG and are safe to treat using a small spot and starting with low fluences, given the risk of atrophic scarring when a large spot size and high fluences are used. In one study comparing both the Nd:YAG laser against the pulsed dye laser (PDL) for nasal vessels, it was found that the small red telangiectasia responded better to the PDL, whereas the blue venules responded better to the Nd:YAG laser, an observation agreed with by all laser experts4. A study on the comparison between the Nd:YAG longpulsed against the 532 nm vascular laser in leg vessels showed that the longer penetration of the Nd:YAG wavelength was superior to the 532 nm laser given the deeper uniform heating, which will address the lower

Wrinkles and onychomycosis

Key points GMPP is the world’s most powerful and practical laser hair removal platform The ability to have high power with a short pulse duration allows for effective treatment of even very fine hairs The Nd:YAG laser can be used in many aesthetic and medical applications in addition to hair removal The microsecond pulse in the Nd:YAG allows for further uses such as rejuvenation The Alexandrite laser can be used in some resistant vascular cases such as portwine stains

January/February 2024 | prime-journal.com

References 1. Casey AS, Goldberg D. Guidelines for laser hair removal. J Cosmet Laser Ther. 2008 Mar;10(1):24-33. 2. Aleem S, Majid I. Unconventional Uses of Laser Hair Removal: A Review. J Cutan Aesthet Surg. 2019 JanMar;12(1):8-16. 3. Trafeli JP, Kwan JM, Meehan KJ, Domankevitz Y, Gilbert S, Malomo K, Ross EV. Use of a long-pulse alexandrite laser in the treatment of superficial pigmented lesions. Dermatol Surg. 2007 Dec;33(12):1477-82. 4. Kwon WJ, Park BW, Cho EB, Park EJ, Kim KH, Kim KJ. Comparison of efficacy between long-pulsed Nd:YAG laser and pulsed dye laser to treat rosaceaassociated nasal telangiectasia. J

Cosmet Laser Ther. 2018 Oct;20(5):260264. 5. Ozden MG, Bahçivan M, Aydin F, Şentürk N, Bek Y, Cantürk T, Turanli AY. Clinical comparison of potassiumtitanyl-phosphate (KTP) versus neodymium:YAG (Nd:YAG) laser treatment for lower extremity telangiectases. J Dermatolog Treat. 2011 Jun;22(3):162-6. 6. Ma W, Si C, Kasyanju Carrero LM, Liu HF, Yin XF, Liu J, Xu Y, Zhou B. Laser treatment for onychomycosis: A systematic review and meta-analysis. Medicine (Baltimore). 2019 Nov;98(48):e17948.

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Continuing Our Legacy of Excellence Candela has long been known for industry-leading innovation, and our Gentle Pro Series™ of devices have contributed to practices’ success for over 25 years. Now, with Candela’s GentleMax Pro Plus® system, we bring enhanced features for patient comfort, faster throughput and amazing results. Ready to experience the Power of Plus for yourself? Scan the QR code and contact us today!

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THE RIGHT CONCEPT FOR THREAD LIFTING:

CLASSIFICATION AND EFFECT OF THREAD INJECTION METHODS Yongsu Ahn, MD, a board-certified plastic surgeon, discusses his approach to effective tissue repositioning using PDO threads

YONGSU AHN, MD, is a board-certified plastic surgeon and director of ONYOO plastic surgery, Seoul, Republic of Korea

INIMALLY invasive lifting procedures using PDO threads are fundamentally and conceptually different from traditional lifting surgery. Unlike lifting surgery, where the skin, subcutaneous tissue, and SMAS layer are dissected and pulled, these structures are not being pulled in thread lifting. Consequently, it’s not possible to create the same changes commonly achieved through surgical lifting. When lifting is achieved by extensively hanging the SMAS layer with PDO threads, the relocation of the SMAS layer may cause subcutaneous fat to shift, potentially leading to the formation of unwanted wrinkles. Additionally, if the uneven areas on the skin caused by this fat shifting are immediately relieved, the lifting effect could be insignificant. In my opinion, thread lifting should focus on the slight relocation and fixation of the tissue, as well as the changes that can occur between the ligaments. Creating structural support through traction, fixation, volume relocation, and collagen formation are possible physical changes to the face that can be achieved with thread lifting. I believe that with traction and fixation, slightly lifting the soft tissue or overlapping the SMAS layer are changes that can be achieved in the inter-ligamental space.

January/February 2024 | prime-journal.com

Figure 1 illustrates the structure of epiticon® ORIGINAL. Each unit performs a dual action of traction and fixation

Types of lifting threads and thread selection Depending on their purpose, there are threads for traction, fixation, and volume creation. There are also remodelling threads that are injected into the dermal or subdermal layers to create a tissue reaction. epiticon® ORIGINAL 18 G (Total length: 187 mm, length with cogs: 92 mm, manufactured by JETEMA Co., Ltd., Republic of Korea) can simultaneously perform traction and fixation functions. Typically, PDO threads vary in function depending on the type, so clinicians may use various types. However, I prefer using epiticon® ORIGINAL 18 G threads exclusively, applying them with multiple techniques. The epiticon® ORIGINAL 18 G has a repeating single unit that performs both traction and fixation, allowing insertion from any direction without considering the thread’s orientation. Extensive tissue gathering, volume creation or reduction, and tissue relocation can all be implemented when aiming for traction and the fixation of tissues. For correcting volume loss in areas like the sub-zygomatic and anterior malar areas, and nasolabial folds, coiled threads such as epiticon® JAMBER are exceptionally effective.

They can reduce the need for fillers or fat grafts, creating a lighter and more elastic appearance.

Depth of thread insertion and layer to avoid injection Threads can be placed in a number of layers. Thin threads, like mono threads, are often inserted into the skin or subcutaneous layer. The epiticon® ORIGINAL 18 G is suitable for insertion into the subcutaneous fat layer, SMAS layer, or platysma. Personally, I avoid thread insertion in areas with facial expression muscle movements, such as the nasolabial folds, mouth wrinkles, and the area between the eyes. I also avoid areas with dimples due to true ligaments and areas with thin subcutaneous fat where the thread might be visible.

Classification and effect of fixation methods I classify thread insertion into three categories: line fixation, plane fixation, and three-dimensional (transitional) fixation. Each fixation method is selected and implemented based on the patient’s condition. Line fixation is the most commonly performed procedure. This procedure is executed by inserting the thread in

“The epiticon® ORIGINAL 18G has a repeating single unit that performs both traction and fixation, allowing insertion from any direction without considering the thread’s orientation.”

the direction in which the cogs should be fixed, either forward or in reverse. Plane fixation involves creating two or more vectors on a single plane to fix the surface. There’s a risk that a V-shape method with a narrow vector width may cause protrusions at the vertices if it is strongly fixed in reverse. To prevent these protrusions from being palpable, the vertex can be shaped more gradually, or several V-shapes can be used to distribute the force across multiple threads. This approach avoids palpable sensations while creating solid support and fixation. In methods like the U-shape or triangular shape, where the width narrows at the end, the supporting part beneath is a line. Therefore, it’s beneficial to create a more gradual loop shape. The triangular shape method, pulling volume towards the centre of the triangle, is effective for volume formation, particularly below the cheekbones or at the front cheekbones. Transitional fixation is a threedimensional fixation that passes through two or more layers. Transitional fixation procedures that pass from the subcutaneous layer to the SMAS layer and then back to the subcutaneous layer are akin to a skewer going through multiple layers. This can create results similar to those of SMAS plication facelift procedures. To create a distinct angle at the jawline, sagging skin can be fixed by inserting a thread from the platysma to the subcutaneous fat layer. In the case of the chin, if the malar fat pad has moved downward through caudal rotation, threads can be used to improve asymmetry with a favourable prognosis. Here, a

thread can be fixed to the arcus marginalis or nearby septum using a V or W-shape transitional fixations. Threads can be inserted directly above the nasolabial fold or accessed through the conjunctiva.

Facial analysis before procedure It is important to analyse the face before the procedure. Every factor in the table below, including skin laxity, elasticity, bone shape, asymmetry, occlusion, soft tissue location, and volume is analysed through photographs, palpation, and CT measurements. It’s important to clearly communicate to patients what changes are possible and what is not through procedures or surgery. Among the modifiable aspects, we often select procedures that can synergistically enhance the effects of thread lifting. It is crucial to understand the limitations of thread lifting, especially in comparison to surgical lifting. Thread lifting alone may not achieve significant changes. Therefore, it is often necessary to perform it in conjunction with other procedures. This integrated approach is key to maximising changes in anatomical location and tissue volume, thereby achieving more comprehensive and satisfactory outcomes.

Case review In this case, involving a 23-year-old female with prominent cheekbones and jawlines, an assessment revealed a significant amount of subcutaneous fat, identified through palpation and CT measurements. This assessment led to the conclusion that using lifting thread traction alone might not yield

optimal results. A comprehensive treatment plan was recommended for this patient. This plan included liposuction of the cheeks, jawline, and submental area to reduce overall facial volume. Additionally, deep cheek removal

prime-journal.com | January/February 2024

PROMOTION

THE RIGHT CONCEPT FOR THREAD LIFTING:

CLASSIFICATION AND EFFECT OF THREAD INJECTION METHODS Before

(continued)

After

Figure 2 A 23-year-old woman’s image before and 3 months after the procedure

surgery was advised for further volume reduction. An injection of botulinum toxin was also proposed to decrease the masseter muscle volume. For the thread-lifting procedure, PDO threads were specifically employed on

the cheeks. The technique involved creating two reverse V-shape fixations in the subcutaneous layer, using one thread for each V-shape, resulting in a total of two threads. This method was intended to tighten the facial line through the combined effect of traction and fixation. Moreover, a reverse direction linear fixation using two threads and a forward direction V-shape fixation with one thread was performed from the side trough, amounting to five threads on each cheek in total. Furthermore, to achieve a tightening effect along the jawline, one thread was inserted into the platysma through the subcutaneous layer.

Procedures performed on the patient ■ Liposuction — on the cheeks, jawline, submental area, and deep cheek ■ Botulinum toxin injection — square jaw (masseter muscle) ■ Thread lifting — five threads in the cheek, one thread in the jawline (for each side).

Conclusion Figure 3 Threads entry point and insertion path

Thread lifting, in contrast to surgical

January/February 2024 | prime-journal.com

lifting, can be an excellent tool for enhancing facial contours and supporting or fixing loose tissue. It complements the limitations inherent in both surgical lifting and thread lifting. For achieving the best results, the choice of material is critical. I specifically recommend the epiticon® ORIGINAL 18G threads. These threads are advantageous because, unlike others where the vector is directed in a single direction, they allow clinicians to employ various techniques. This versatility is due to the unique cog shape of each unit, where all four sides can effectively serve as fixation points. This design facilitates natural and stable results. Critical to patient satisfaction is a thorough pre-procedure analysis of the patient’s face. It’s essential to identify treatment methods that are compatible with thread lifting and can enhance its effectiveness. The key to success lies in performing the treatment safely and effectively, ensuring that patient expectations are met and satisfaction is achieved. For more information, contact global@jetema.com

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PROMOTION

NECK REJUVENATION:

LOW MOLECULAR WEIGHT HYALURONIC ACID COMBINED WITH SIX AMINO ACIDS TO COUNTERACT SKIN AGEING OF THE NECK Elena Fasola, MD, and Concetta Santoro discuss the results of their clinical study using the novel new injectable Sunekos Performa

T ELENA FASOLA, MD, MICROSURGEON, is General Secretary of the Italian Association of Aesthetic and Functional Gynecology (AIGEF), Italy

HE NECK IS A VERY attractive area and is considered to be one of the areas where ageing occurs relatively early, as well as an anatomical area that undoubtedly reveals a person’s true age. Ageing of the neck is characterised by the definitive appearance of laxity, wrinkles (or by the worsening of previously present horizontal wrinkles called Venus rings), skin dyschromia, telangiectasia, loss of the mandibular contour, widening of the cervico-mental angle, accumulation of submental fat and volume loss of the platysma muscle, which leads to the visual prominence of the platysma muscle bands1. Many medical aesthetic procedures exist to counteract these changes with personalised management, but there is still little literature about efficacy with a single, easy, minimally invasive, and relatively inexpensive procedure. Ageing of the neck is a multifactorial and complex process that compromises the thickness and health of the dermis (extracellular matrix [ECM] impairment related to skin laxity and dyschromia), volume change (dystrophy of adipose tissue) of the submental fat, and volume reduction to the platysma muscle. Rejuvenation of the neck often requires a combined approach to address these multiple ageing factors. The signs of photo and

January/February 2024 | prime-journal.com

chrono-ageing are often more evident on the neck than in other anatomical areas. Generally, most patients’ initial requests for antiageing remedies are concentrated on the face, which is therefore treated for a longer period and much earlier; for this reason, the ageing of the neck, when it appears, is more evident2. Aged skin in healthy patients demonstrates structural modification of collagen and elastin molecules related to fibroblast dysregulation as well as their reduction in number. It is estimated there is a 35% reduction in collagen by age 80 compared to people in their 20s3, with a consequent decrease in neocollagenesis, reduction of prompt gene expression for the synthesis of new collagen, and adequate neo-elastin genesis. Clinically, this change manifests itself with the appearance of wrinkles and laxity4. Along with the physiological intrinsic ageing process (chronoageing), photoaging should be considered — chronic ultraviolet exposure causes elastosis, dyschromia (hyper and hypopigmentation), solar lentigines, telangiectasias, and poikiloderma of Civatte5. For patients undergoing certain therapies chronically or acutely (ongoing or finished), all pharmacological factors that promote skin ageing (as with isotretinoin, amitriptyline or after chemotherapy) or counteract skin ageing (as with HRT) and/or atrophy of the dermis should also be

considered. This topic deserves a separate discussion considering its importance in a society like ours that does not tolerate skin diseases, even if benign, which impact the aesthetic appearance and which are often treated aggressively (such as acne, for example) or in an increasingly older society, therefore subjected to multiple therapies in general or in a society in which the women live more than a third of their life in menopause, which highly impacts the health of the ECM. Several approaches have been adopted to improve the appearance of the neck6; one such approach is the injection of hyaluronic acid (HA), which is a widely used method to restore skin appearance because it is demonstrated to be safe and effective7. However, it is important to review and understand how the different molecular weights of HA contribute to the restoration of the ECM8.

Aim/objective of the clinical trial The study aims to evaluate the effectiveness of a pre-mixed injectable combination of non-crosslinked low molecular weight (LMW) hyaluronic acid (defined as between 50–250 KDaltons) added to six specific amino acids (HY6AA formula, Sunekos Performa by Professional Dietetics SpA, Italy) to improve laxity and the signs of chrono- and photo-ageing of the skin on the neck through a minimally invasive injectable procedure. The study was

“This new formula is able to reduce hyaluronidase activity by 40%, improving the stimulation of collagen and elastin production and increasing the effect of injected HA supporting the regeneration of the ECM.”

conducted on 16 caucasian female, healthy patients in both perimenopausal and postmenopausal age ranges (46 to 66 years of age).

Mechanism of the action of the HY6AA formula The formula (HY6AA) by Sunekos Performa is a 3.5 ml premixed solution containing a specific mixture of low molecular weight hyaluronic acid (LMWHA 200 kDa) and six amino-acids (glycine, L-proline, L-lysine MHC, L-leucine, L-valine, and L-alanine). This new formula is able to reduce hyaluronidase activity by 40%, improving the stimulation of collagen and elastin production and increasing the effect of injected HA supporting the regeneration of the ECM. An in vitro study on cultured human fibroblasts exposed to an HY6AA formula showed that oxidative stress decreases along with UV exposure damage. In conclusion, the HY6AA formula appears to support the restoration of ECM homeostasis in ageing8–9.

Materials and methods The open-label clinical pilot trial was conducted on 16 healthy female caucasian patients at two medical centres; 1.8 ml of HY6AA formula was injected three times at intervals of 2 weeks per patient. The GAIS (Global Aesthetic Improvement Scale) questionnaire and patient photos were used to evaluate the visual aesthetic improvement; furthermore, elasticity improvement was assessed using the Pinching Test following the 3-point scale below: ■ 1. very good elasticity — immediate skin relaxation

Figure 1 HTP for neck rejuvenation: 18 injection points in the deep Dermis with a 30–32 G needle (4–13 mm) into the medium to deep dermis, perpendicular to the folding lines; 1 session every 2 weeks for 3 or 4 sessions

Figure 2 66 year-old patient (A) before (T0–baseline) and (B) after (T3–8 weeks after third injection)

■ 2. medium flexibility — relaxation less than 10 seconds (approximate number of seconds) ■ 3. lack of flexibility — relaxation time over 10 seconds. Efficacy evaluations by iPhone photo and Pinching Test were performed prior to each injection treatment and 8 weeks after the third injection. GAIS questionnaires were completed by patients at T1 (before the second injection), at T2 (before the third injection) and at T3 (8 weeks after the third injection).

Technique The technique used was the high-performance technique (HPT) specifically designed for the treatment of the neck dermis. The

HPT exploits the traction forces orthogonal to the Langer lines (folding lines of the soft tissues). It consists of a multipoint technique, specifically of six equidistant injection points along the anterior edge of the sternocleidomastoid muscle (from mandible angle to jugulus) and three points bilaterally along the medial bands of the platysma muscle (Figure 1). At each point, 0.1 ml of the HY6AA formula was injected into the deep dermis or just under the dermis for a total volume of 0.9 ml (0.6 + 0.3 ml) per side, and 1.8 ml injected in total, sufficient to treat the entire surface of the neck dermis. A slight swelling appeared immediately after treatment at all injection sites; these were mild and transient and would disappear spontaneously within 30 minutes.

prime-journal.com | January/February 2024

PROMOTION

NECK REJUVENATION:

LOW MOLECULAR WEIGHT HYALURONIC ACID COMBINED WITH SIX AMINO ACIDS TO COUNTERACT SKIN AGEING OF THE NECK

Figure 3 54 year-old patient (A) before (T0–baseline) and (B) after (T3–8 weeks after third injection)

Results The iPhone photo analysis has proven the significant effectiveness of the HY6AA formula (Figures 2–3): the visual improvement of texture, elasticity and appearance of the skin is excellent, considering the minimal invasiveness of the treatment and the relatively short time to achieve the result.

Conclusions Medical aesthetic treatments are very popular10, especially because the population is increasingly older; women are living a third of their life in menopause, a period in which the depletion of endogenous estrogen hormones (highly related to collagen and elastin balancing) begins to accelerate (it is estimated 1% decrease in collagen per/year after

35 yo and 3% per/year after menopause). Skin collagen and elastin peak around 30 years of age, which corresponds to the peak in estrogen production. In this regard, several reports suggest positive correlations between circulating estrogen levels and perceived age, attractiveness, enhanced skin health, and facial colouration in women11. From about 40 years of age, the appearance of the female neck begins to undergo some slow but inexorable changes: a deepening of the ‘Venus rings’, the skin thins, and it becomes lax12, some signs of photo-ageing begin to appear such as telangiectasias, and sometimes ruby angiomas, skin discolourations and poikiloderma of Civatte. Non-cross-linked HA is one of the most widely used agents to treat the

(continued)

above ageing manifestations13. Our purpose was to demonstrate the efficacy of a mixture of the new patented HY6AA formula, with a new ratio between HA and AA, adapted to counteract chrono- and photo-ageing of the neck in peri-menopausal and postmenopausal women. The GAIS questionnaire and visual analysis observed excellent preliminary results on appearance. Also, the improvement in skin elasticity witnessed thanks to the pinching test was more than encouraging. These results were obtained using a minimally invasive procedure and after just three injections of a relatively small amount of product in a short time. In the future, it would be interesting to analyse the efficacy of this powerful mixture on a greater number of patients and also by collecting data using instrumental methods, as has been previously done on the face14, further involving those women for whom skin atrophy has occurred due to pharmacological reasons. For more information, visit www.professionaldietetics.com

Further Reading 1. Vanaman M, Fabi SG, Cox SE. Neck Rejuvenation Using a Combination Approach: Our experience and a Review of the Literature. Dermatology Surgery: May Supplement 2016; s94-s95 2. Sturm A, Shokri T, Ducic Y. Nonsurgical Rejuvenation of the Neck. Facial Plast Surg Clin North Am, 2022 Aug; 30(3):407-417 3. Zorina A, Zorin V, Kudlay D, Kopnin P. Age-Related Changes in the Fibroblastic Differon of the Dermis: Role in Skin Aging. Int J Mol Sci. 2022 May 30; 23(11): 6135. doi: 10.3390/ijms23116135 4. Fisher GJ, Varani J, Voorhees JJ. Looking older: fibroblast collapse and therapeutic implications. Arch

Dermatol 2008; 144:666–72 5. Katoulis AC, Sgouros D, Bozi E, Pappa G, Theotokoglou S, Konstantinou MP, Voudouri A, Voudouri M, Theofili M, Tzima K, Hofmann-Wellenhof R. Diagnosis and Differential Diagnosis of Poikiloderma of Civatte: A Dermoscopy Cohort Study. Dermatol Pract Concept. 2023 Jan 1;13(1): e202307. doi: 10.5826/ dpc.1301a7. 6. Jeon H, Kim T, Kim H, Cho SB. Multimodal approach for treating horizontal neck wrinkles using intensity focused ultrasound, cohesive polydensified matrix hyaluronic acid, and IncobotulinumtoxinA.

Dermatologic Surgery, vol. 44, no. 3, pp. 421–431, 2018 7. Sparavigna A, Bombelli L, Giori AM, Bellia G. Efficacy and Tolerability of Hybrid Complexes of High- and Low-Molecular-Weight Hyaluronan Intradermal Injections for the Treatment of Skin Roughness and Laxity of the Neck. Scientific World Journal, 2022 Sep 17 2022: 4497176 8. Fasola E. Sunekos Injectables and the High-Performance Technique. PRIME Journal March/ April 2023, vol 13, iss 2: primejournal.com 9. Tedesco L. A designer mixture of six amino acids promotes the extracellular matrix gene

January/February 2024 | prime-journal.com

expression in cultured human fibroblasts. Bioscience, Biotechnology, and Biochemistry, 2022, Vol. 86, No. 9, 1255-1261 10. Donath AS, Glasgold RA, Glasgold MJ. Volume loss versus gravity: new concepts in facial aging. Current Opinion in Otolaryngology & Head and Neck Surgery, vol. 15, no. 4, 243 pages, 2007 11. Lephart ED, Naftolin F. Menopause and the Skin: Old Favorites and New Innovations in Cosmeceuticals for EstrogenDeficient Skin. Dermatol Ther (Heidelb). 2021 Feb; 11 (1):53-69. doi: 10.1007/s13555-020-00468-7. Epub 2020 Nov 26.

12. Farkas JP, Pessa JE, Hubbard B, Rohrich RJ. The science and theory behind facial aging. Plastic and Reconstructive Surgery Global Open, vol. 1, no. 1, pp. 1–8, 2013. 13. Robin S, Fanian F, CourderotMasuyer C, et al. Efficacy of a Biorevitalizing-Filler Solution on all skin aspects: 10 years approach through in vitro studies and clinical trials. J Cosmet Dermatol Sci Appl. 2021; 11: 18-37 14. Fasola E, Kutera EA. Pilot Study evaluating the therapeutic effects of a new pre-mixed injectable product of low molecular weight (LMW) hyaluronic acid added to six amino acids (HY6AA + Formula) in facial skin aging. JDC, August 2022

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PROMOTION

TEAR TROUGH REJUVENATION USING A PDLLA+HA HYBRID BIOSTIMULATOR Inmaculada González Fernández, MD, applauds JUVELOOK as the ideal product for tear trough and periorbital treatment What is your opinion on the advantages of biostimulators compared to HA filler, the current aesthetic trend, and the future of biostimulators in Europe?

INMACULADA GONZÁLEZ FERNÁNDEZ, MD, Founder of CiSiG Clinic, Barcelona; Master’s Degree in Aesthetic Medicine from the University of the Balearic Islands(UIB); Graduate in Medicine and Surgery from the Central University of Barcelona, Spain

The advantage of biostimulators over HA fillers is their mechanism of action. Unlike HA filler, polymer fillers such as polylactic acids mainly restore natural volume by generating collagen type I and type III through the body’s own collagen production. Additionally, biostimulators leave no aesthetic imprint on the skin, and there are no residues of cross-linking particles, which decompose into water and CO2, minimising the residue. This is especially true of poly-D, L-lactic acids (PDLLAs), the main components of JUVELOOK, which tend to decompose more easily into lactic acid thanks to their short shelf life, making them more biodegradable and biocompatible.

Within the PDLLA particle of JUVELOOK, D-form and L-form lactic acids are linked randomly, maximising the area of contact surface involved in collagen production. They provide a greater size of scaffold on which immune cells and extracellular materials adhere to produce collagen and elastin. I believe that the future of aesthetic medicine is biostimulators, among which the safest will receive the most attention. Studies show how JUVELOOK reverses skin ageing, improves skin texture and pigmentation, and redensifies the dermis by increasing collagen and elastin. In the future, natural-looking results and the safety of procedures will play a larger role in aesthetic medicine.

What are your tear-trough treatment protocols? In my clinic, the demand for tear-

Figure 1 A female patient (A) before and (B) after two sessions of JUVELOOK treatment on the tear trough

January/February 2024 | prime-journal.com

trough depression treatment has recently increased among young patients. As the skin of eyelids ages, wrinkles, hyperpigmentation, and telangiectasias are observed. The technique consists firstly of making a diagnosis and evaluation of the collapse of the tear trough. Next, it involves evaluating the palpebromalar cavity and the lack of volume in the deep fat pad in the middle area of the cheekbone. I inject 1.0–1.5 cc per tear trough. Even a small amount of PDLLA can effectively improve ageing under the eyes. LENISNA, the bigger particle size of PDLLA, can be injected to create natural volume in the cheek if there is volume loss in the middle fatty compartment. First, treat the volume loss in the medial fatty compartment supporting the orbitomalar ligament and then treat the medial palpebromalar cavity or lateral SOOF (suborbicularis oculi fat) at a deeper level with LENISNA. Finally, treat the lacrimal groove with JUVELOOK with a double layer injection; first, inject in the lacrimal groove with a cannula touching the periosteum and then redirect the cannula through the orbitomalar ligament to leave small linear deposits in the shape of a fan from the entry point to the lacrimal groove. If necessary, you may treat the palpebromalar groove as well. The entry point of the cannula coincides with the line between the eye’s outer canthus and the zygomatic bone’s midpoint (between the upper and lower border) and the intersection with the nasojugal groove.

“I believe that the future of aesthetic medicine is biostimulators, among which the safest will receive the most attention.”

From here, we are going to direct the cannula to the nasojugal fold and leave small fan-shaped linear deposits in retrograde until the palpebromalar sulcus. We then work on it again in a more superficial plane without removing the cannula.

What makes JUVELOOK interesting to you? What makes JUVELOOK unique from the other polymer fillers? The most intriguing aspect of JUVELOOK is its mechanism of action, which resolves the underlying causes of the signs of ageing. The primary mechanism of JUVELOOK induces the polarisation of M2 macrophages and the expression of the interleukin IL-10. IL-10 induces the senescence of adipose-derived mesenchymal stem cells (ASC) and increases their proliferation, which leads to an increase in new fibroblasts. On the other hand, the polarisation of M2 macrophages reduces the expression of NF-kB and MMP2/3/9, preventing the degradation of collagen and elastic fibres. Among other biostimulators, JUVELOOK gives more natural and plumping results, and I have never had an adverse effect. Before learning of JUVELOOK, I used to perform HA injections on the tear trough, but I always had to end up dissolving the material with hyaluronidase. Lately, many younger patients have come to my clinic to prevent or treat the first symptoms of ageing. With JUVELOOK, I can reverse their ageing signs more physiologically with natural results satisfying the patient’s expectations.

How do you see the future of JUVELOOK in the market? Based on the steadily increasing demand for natural beauty, the future

Figure 2 Skin rejuvenation in aged skin1

trend will be using products that leave zero aesthetic imprints and reverse ageing more physiologically, which is why the future is Regenerative Medicine with autologous material (such as autologous fat transfer) or with regenerative biomaterials such as collagen inducers. Just like JUVELOOK and LENISNA. The PDLLA particle of JUVELOOK has a porous surface and reticular structure inside. While the porous surface remains intact and protects the internal structure from damage, the dermal cells permeate the particles through the pores and form

collagen and elastic fibres along the internal mesh structure. As the particle slowly decomposes from the inside, pH change in the surrounding environment is minimised, and over-inflammation is prevented. As mentioned, the future is to reproduce the repair mechanisms of the dermis itself and reverse ageing naturally and safely, without excesses or overtreated faces. That is why I opt for this latest generation of polylactic acid (JUVELOOK) for dermal biostimulation and tear trough treatment on young patients and LENISNA for volume loss and older patients. For more information, visit https://juvelook.com/ or scan the QR code above right Figure 3 The JUVELOOK PDLLA particle has a porous surface and reticular structure inside. The porous surface protects the internal structure from damage, while the dermal cells permeate the particles through the pores and form collagen and elastic fibres along the mesh structure

Mechanism of Action — JUVELOOK

References 1. Oh S, Seo SB, Kim G, Batsukh S, Park CH, Son KH, Byun K. Poly-D,L-Lactic Acid Filler Increases Extracellular Matrix by Modulating Macrophages and Adipose-Derived Stem Cells in Aged Animal Skin. Antioxidants (Basel). 2023 Jun 1;12(6):1204. doi: 10.3390/antiox12061204. PMID: 37371934; PMCID: PMC10294940.

prime-journal.com | January/February 2024

PRODUCT NEWS |

product news APTOS

4th Generation threads with hyaluronic acid Application Threads for non-invasive facial rejuvenation Aptos, a leader in medical aesthetics, has introduced the revolutionary 4th Generation threads with Hyaluronic Acid (HA), utilising advanced NAMICA technology. This innovation represents a significant advancement in non-invasive facial rejuvenation techniques offering patients a more effective and longer-lasting option for facial rejuvenation. Key features of the 4th generation P(LA/CL) HA threads include targeted delivery, ensuring that HA is precisely applied without loss and controlled release of HA at the application site, ensuring a consistent distribution of HA. They are designed with variably sized encapsulated particles that release HA at different timepoints. This results in an immediate reduction of the inflammatory response followed by a gradual biostimulatory effect. This process significantly increases collagen production, stimulates microvascular development, and enhances nutrition to the subcutaneous fat and dermal layers. These threads offer up to six months of active HA and visible results for more than a year.

Contact Aptos ● a.chikobava@aptos.ge

JETEMA

e.p.t.q.® Lidocaine Application Hyaluronic acid 24mg/ml plus lidocaine 0.3% injectable treatment e.p.t.q.® (epitique) is a monophasic hyaluronic acid filler with lidocaine. 2CM Technology utilises physical crosslinking in addition to chemical crosslinking to minimise the addition of BDDE in order to create the optimum viscoelasticity while securing the utmost safety. With ZEEP (Zero Endotoxin and BDDE Entire Process) technology, e.p.t.q.® keeps endotoxin levels below 0.1EU/mL and residual BDDE at a ‘not detected’ level to minimise the various side effects that may occur after the procedure. Lastly, the Downing Process creates uniform and fine particles of e.p.t.q.®, which result in even extrusion force to yield control and precision during injection.

Contact Jetema ● global@jetema.com

January/February 2024 | prime-journal.com

| PRODUCT NEWS The latest product news and technologies for the aesthetic and anti-ageing market

FOTONA

SP Dynamis® Nx line Application Over 100 treatment options across aesthetics, dermatology, gynecology and surgery The SP Dynamis Nx Line represents the next generation in multi-application laser technology. With a powerful combination of gold-standard Nd:YAG and Er:YAG laser wavelengths, this versatile device delivers outstanding results across a wide range of applications. Its user-friendly interface is highly intuitive, featuring customisable memory presets that enable practitioners to work more efficiently. With over a hundred treatment options, including popular new non-invasive facial and body treatments, it delivers natural-looking results that clients love. Moreover, the SP Dynamis Nx Line boasts advanced features such as eco-friendly CoolMist™ skin cooling and MatrixView® thermal sensors integrated into its handpieces. Its extensive range of state-of-the-art accessories and easy upgrades for surgical and gynecological procedures ensure that your clinical options are almost limitless, making it the ultimate revenue-generating device for modern practices.

Contact Fotona d.o.o. ● www.fotona.com

VAIM GLOBAL

JUVELOOK & LENISNA Application Hybrid-biostimulator injectables for skin rejuvenation JUVELOOK and LENISNA are advanced next generation hybrid-biostimulators. JUVELOOK is injected into the dermis layer and applied for skin rejuvenation, fine wrinkle removal, atrophic scars, stretch marks, and tear trough treatment. LENISNA is injected in the subcutaneous, producing a greater amount of collagen. It is applied for deep wrinkles, deep scars, nasolabial folds, body/facial contouring, and natural volume augmentation. The main ingredients are PDLLA (poly-D, L-lactic acids) and Hyaluronic acid. PDLLA particles produce new collagen and elastin by stimulating adipose stem cells, resulting in greater proliferation of neo-fibroblasts. Those newly formed fibroblasts restore natural volume in the sunken area with new collagen and elastic fibres. Instead of CMC, hyaluronic acid is utilised as a biocompatible gel carrier. It provides an immediate hydrating effect on the injection site.

Contact Vaim Global ● official@vaimglobal.com

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5-CC World Congress 2024

London, UK

Lisbon, Portugal

www.aestheticsconference.com/

www.5-cc.com

27–29 MARCH 2024

12–13 JULY 2024

AMWC 2024

FACE 2024

Las Vegas, NV

Mumbai, India

www.vegascosmeticsurgery.com

www.amwcindia.com/

27–30 JUNE 2024

18–20 OCTOBER 2024

Monte Carlo, Monaco

London, UK

www.euromedicom.com

www.faceconference.com

16–18 MAY 2024

26–27 SEPTEMBER 2024

EADV Symposium

BAAPS 2024

St Julian’s, Malta

London, UK

eadv.org/symposium

baaps.org.uk/

30 MAY – 1 JUNE 2024

25–29 SEPTEMBER 2024

Beauty Through Science 2024

EADV 2024

Stockholm, Sweden

Amsterdam, Netherlands

www.btsstockholm.com

eadv.org

Industry events in 2024 for the aesthetic and anti-ageing market

January/February 2024 | prime-journal.com

Miami, FL

Taipei, Taiwan

www.amwcamericas.com

www.amwc-asia.com

30 MAY – 1 JUNE 2024

24–25 AUGUST 2024

Vegas Cosmetic Surgery

AMWC India 2024

The Aesthetic Show

AMWC China

Las Vegas, NV

Chengdu, China

www.aestheticshow.com/en/home.html

en.amwcchina.com/

FEBRUARY 22-24, 2024 MIAMI BEACH CONVENTION CENTER

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Continuing Our Legacy of Excellence

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AMWC Awards

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Industry News

January/February 2024 ❙ Volume 14 ❙ Issue 1

Jan/Feb 2024 Volume 14 Issue 1

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INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE

POINT-OF-CARE ULTRASOUND

GUIDELINES FOR MEDICAL AESTHETICS

A NEW HA FILLER

TO TREAT THE LIPS AND NASOLABIAL FOLDS

GEN Z AND SOCIAL MEDIA

IMPACT ON AESTHETIC DEMANDS

prime-journal.com

FACIAL REJUVENATION with threads and HA