PRIME July/August 2023

ENLARGED PORES

WELCOME TO THE JULY/AUGUST ISSUE OF PRIME JOURNAL IN THIS edition, we’ll be covering topics such as treatment options for enlarged pores, radiofrequency for skin tightening and rejuvenation, and a non-invasive approach to jawline contouring. We’ll also be taking a look at the impact ChatGPT may have on aesthetic practices and how you can wield it to your benefit.

We kick off the issue by delving into the topic of enlarged pores and the integrative and holistic approaches to their treatment. Dr Victor Gabriel Clatici takes us on a comprehensive journey through the multifactorial nature of enlarged pores and explains why a holistic approach yields the best results. By addressing factors such as sebum production and cutaneous ageing, Dr Clatici guides us through the current treatment modalities, including diet and sun protection, topical retinoids, chemical peels, oral antiandrogens, and laser and energy-based devices. This article provides valuable insights to help you select the most appropriate and effective treatment strategies for your patients.

Next, we delve into the world of skin rejuvenation with a new bipolar multi-channel radiofrequency device. A panel of Chinese experts recently held a seminar to reach a consensus on the clinical application of Sinclair’s Reaction bipolar multi-channel radiofrequency device. This expert consensus aims to provide physicians and experts with references and suggestions for the clinical use of this innovative technology.

We also address a common concern among practitioners — how to increase the duration of botulinum toxin effectiveness. Dr Klaus Fritz offers valuable guidance on overcoming one of the limitations of neuromodulators and enhancing the longevity of treatment results.

Furthermore, we explore a non-invasive approach for jawline contouring. Dr Noura Lebbar shares her expertise in using focused ultrasound technology to achieve natural and effective jawline contouring.

In addition to these features, I’m delighted to announce that PRIME will be distributed at three upcoming events — AMWC India, AMWC China, and AMWC Japan. These conferences offer unparalleled opportunities to connect with experts, learn about the latest advancements in the industry, and explore a wide range of exhibits. I hope to meet many of you there and learn more about aesthetic medicine in each of these diverse markets.

If you would like to attend any of the events mentioned above, take note that Aesthetic Multispecialty Society Premium Members will receive 20% off their delegate pass to all shows paid for during their membership as well as further enhanced benefits, and you can sign up here: multispecialtysociety.com.

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

delighted to announce that PRIME will be distributed

International Journal of Aesthetic and Anti-Ageing Medicine

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WE ARE THRILLED TO ANNOUNCE THE HIGHLY ANTICIPATED FIRST edition of AMWC India, set to take place on September 15–16, 2023. This prestigious event, held under the scientific supervision of the Aesthetic Multispecialty Society (AMS), promises to be an extraordinary gathering of medical professionals, researchers, and industry leaders in the field of aesthetics and anti-ageing medicine.

The scientific committee, comprising top dermatologists and experts, have meticulously crafted a content-driven congress programme that will provide fresh perspectives on the latest advancements, case studies, insights, and technological trends in aesthetic medicine. Renowned speakers from around the world will share their expertise, offering invaluable insights into their groundbreaking research and innovative techniques.

Discover the Latest Trends: With more than 100 reputable companies in attendance, you will have the opportunity to witness product launches, experience live demonstrations, and learn about the latest advancements in bio-hormone products, dermal fillers, lasers, slimming devices, skincare, and much more. The vibrant exhibit hall will bring together leading brands, fostering a collaborative and informative environment.

Connect and Network: At AMWC India, you will have the chance to connect and network with like-minded professionals from various disciplines in the aesthetic and anti-ageing field. This conference provides an ideal platform to build relationships, share knowledge, and forge partnerships with seasoned physicians from around the world. Expand your network and gain insights from diverse perspectives.

Leading industry experts, carefully selected by the Scientific Advisory Board, will present sessions covering a wide range of aesthetic medicine disciplines. From aesthetic dermatology and minimally invasive surgical procedures to anti-ageing medicine and practice management, the programme caters to practitioners of all backgrounds.

Live demonstrations and interactive workshops will further enhance your learning experience, providing practical insights and guidance. Gain first-hand knowledge from experts in the field and refine your skills to offer the best possible outcomes for your patients.

Save the date — September 15–16, 2023 — and join us at the Hotel Sahara Star in Mumbai, India. Immerse yourself in a world of innovation, knowledge, and professional growth. Experience the energy of over 100 industry speakers, engage with 100+ reputable companies, and unlock the future of aesthetic and anti-ageing medicine. We look forward to welcoming you at AMWC India 2023. For registration and further information, please visit the official AMWC India website.

SUBSCRIPTION RATES

UK: £90

Europe: €90

Rest of world: US$90

AMWC India Scientific Committee Mumbai, India

PRIME JOURNAL EDITORIAL BOARD

BOARD MEMBER SPECIALISM COUNTRY

Dr Claude Dalle Anti-ageing & aesth. medicine France

Dr Wilmar Accursio Endocrinology Brazil

Dr Firas Al-Niaimi Dermatology & laser surgery UK

Dr Ashraf Badawi Dermatology Egypt & Canada

Dr Janethy Balakrishnan Aesthetic & anti-ageing medicine Malaysia

Dr Lakhdar Belhaouari Plastic surgery

France

Dr Anthony Benedetto Cosmetic Dermatology USA

Dr Philippe Berros Oculoplastic surgery Monaco

Dr Dario Bertossi Maxillofacial surgery

Dr Pierre Bouhanna Dermatology – Hair surgery

Dr Fahd Benslimane Plastic Surgery

Dr Claude Chauchard Anti-ageing medicine

Dr Christophe de Jaeger Geriatrics

Italy

France

Morocco

France

France

Dr Gerd Gauglitz Aesthetic Dermatology Germany

Prof Ilaria Ghersetich Dermatology Italy

Dr Michael H. Gold Dermatology USA

Dr Kate Goldie Aesthetic Physician UK

Prof Eckart Haneke Dermatology Germany

Dr Steven Hopping Plastic surgery USA

Prof Andreas Katsambas Dermatology

Greece

Dr Mario Krause Anti-ageing medicine Germany

Dr Marina Landau Dermatology Israel

BOARD MEMBER SPECIALISM COUNTRY

Dr Gustavo Leibaschoff Cosmetic Surgery USA

Dr Sohail Mansoor Dermatology UK

Prof Leonardo Marini Dermatology Italy

Dr Sly Nedic Aesthetic & anti-ageing medicine South Africa

Prof Daniel Pella Cardiology Slovakia

Dr Chariya Petchngaovilai Dermatology Thailand

Prof Ascanio Polimeni Neuro-endocrinology Italy

Dr Herve Raspaldo Facial plastic surgery France

Dr Christopher Rowland-Payne Dermatology UK

Dr Neil Sadick Dermatology USA

Dr Hema Sundaram Dermatology USA

Dr Pakpilai Thavisin Dermatology & Anti-ageing medicine Thailand

Dr Patrick Treacy Aesthetic surgery Ireland

Dr Mario Trelles Plastic surgery Spain

Dr Ines Verner Dermatology Israel

Dr Octavio Viera Anti-ageing medicine Spain

Dr Jean-Luc Vigneron Aesthetic dermatology France

Prof Bernard Weber Genetics Luxembourg

Dr Sabine Zenker Dermatology Germany

Catherine Decuyper Industry expert & consultant France

Wendy Lewis Industry expert USA

Christophe Luino Industry expert & consultant France

NEWS

9 Galderma receives FDA approval for its latest HA filler Restylane® Eyelight

10 Plastic surgeons in the UK and Türkiye Issue joint statement

AESTHETIC FEATURES

12 Enlarged pores: the integrative and holistic approaches: from diet and skin care to lifestyle and laser

Victor Gabriel Clatici, MD, takes an in-depth look at this common skin concern and explains why a holistic approach is the best form of treatment

18 Skin rejuvenation with a new bipolar multi-channel radiofrequency device

Expert consensus on the use of the Reaction Bipolar Multi-channel Radiofrequency with Combined Vacuum device

COMMENTARY

22 How to increase the duration of botulinum toxin effectivity

Klaus Fritz, MD, explains how to overcome one of the limitations of using neuromodulators and enhance the duration of treatment results

CASE REPORT

24 A non-invasive approach for the jawline contouring

Noura Lebbar, MD, discusses her experience using focused ultrasound technology

PRACTICE MANAGEMENT

26 My love affair with ChatGPT

Wendy Lewis shares her infatuation with OpenAI’s firstto-market chatbot

PRODUCT NEWS

30

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

PRIME PROMOTIONS

32 The New Face of Polycaprolactone: Gouri

Anti-ageing specialist Katarzyna Grudzień, MD, shares why deep skin rejuvenation treatment GOURI has become the treatment of choice in her practice

EVENTS

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

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

GALDERMA RECEIVES FDA APPROVAL FOR ITS LATEST HA FILLER — RESTYLANE® EYELIGHT

AIMS TO IMPROVE THE APPEARANCE OF UNDEREYE HOLLOWS FOR UP TO 18 MONTHS

Galderma has announced the U.S. Food and Drug Administration (FDA) approved Restylane® Eyelight for the treatment of undereye hollows, also known as dark shadows, in adults over the age of 21. Restylane Eyelight, an undereye hyaluronic acid (HA) dermal filler, is the first and only product in the U.S. formulated with NASHA® Technology for volume loss under the eyes, giving patients natural-looking results.

For millions of Americans, dark circles can make individuals feel older, tired and stressed. Dr. Carolyn Jacob, a board-certified dermatologist based in Chicago and a lead investigator in the clinical trial of Restylane Eyelight sees first-hand how undereye concerns are top of mind for consumers.

‘Many of my patients seek treatment for hollows under the eyes, and topical products such as creams, concealers and undereye masks just aren’t able to solve the problem and provide the long-lasting results they are seeking. I’m pleased to see that Restylane Eyelight offers a safe, effective and natural-

looking outcome that enables my patients to achieve their aesthetic undereye goals, with results that last up to 18 months with optimal treatment.’ Said Dr Jacob.

This FDA approval is supported by efficacy and safety data from a randomised, evaluatorblinded, parallel group, no-treatment controlled, multi-centre Phase 3 study to evaluate the effectiveness and safety of Restylane Eyelight for correction of volume

loss under the eyes.

Lack of volume and volume loss in the undereye region can create shadows and emphasise dark circles, leading to the appearance of tiredness and/or ageing. In the Phase 3 study, 87% of patients had reduced undereye hollowness at 3 months, and Restylane Eyelight was found to be well tolerated under the eyes. At 3 months, 92% of patients were pleased with their results, and 84% were still pleased through 1 year. The study also yielded high satisfaction, with 93% of patients expressing interest in receiving treatment again after 12 months.

Restylane’s legacy with safety continues with this Phase 3 trial where most patients (87%) did not experience adverse events related to treatment with Restylane Eyelight.

The most commonly observed side effects for undereye injection are swelling, redness, tenderness, pain, bruising, itching, and lumps or bumps at the injection site. Most adverse events were mild in severity (75%) and none were severe. There was no incidence of Tyndall effect (blue discolouration) after treatment with Restylane Eyelight.

ESPRAS CALLS FOR SPECIALIST TRAINING STANDARD ACROSS EUROPE

The European society that represents all national associations in plastic surgery across Europe has issued a call-to-action for a comprehensive approach to protect patients from under-trained ‘beauty surgeons’, some of whom are not certified plastic surgeons and only trained in special regions of the body or not trained in surgery at all.

The European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) ensures that all

member plastic surgeons have advanced multi-year training in plastic surgery, however, in most European countries there is no law to stop medical doctors without specialisation calling themselves ‘aesthetic surgeons’ or ‘beauty doctors.’ Shockingly, often even paramedics can take on these titles with just basic knowledge acquired over weekend courses or short plastic surgery attachments. On the flip side, board-certified surgeons

meet the highest degree of qualification; have multi-year specialisation, work rotations in ICU and emergency care, undertake research and teaching, are required to demonstrate a catalogue of operations, and sit a final exam.

ESPRAS conducted a survey across 23 European countries to assess levels of education/ specialisation in plastic surgery. The results demonstrated a high level of training required for board

certification, further driving home the need for the public to be made aware of the dangers of opting for a practitioner who is not trained to this standard. Such a move is the first step to ensuring quality of training, with patient safety taking precedence over financial gain, ESPRAS claims in its position paper. ESPRAS is working to support national legislation to provide clear regulation of aesthetic surgery Europe-wide.

PLASTIC SURGEONS IN THE UK AND TÜRKIYE ISSUE JOINT STATEMENT

IN RESPONSE TO RISING COMPLICATIONS FROM COSMETIC TOURISM

The significant increase in the number of patients travelling abroad for aesthetic plastic surgery has been linked with consequent serious complications and even deaths. According to the British Association of Aesthetic Plastic Surgeons (BAAPS) Annual Cosmetic Surgery Audit complications rose by 35% in 2022. BAAPS and the Turkish Society of Plastic Reconstructive and Aesthetic Surgeons (TSPRAS) have made an unprecedented joint statement due to concerns for patient welfare and safety.

BAAPS and TSPRAS understand and recognise that there will always be patients from different countries who will seek medical and surgical treatments abroad. There are a variety of reasons this may be so, but multiple reports have highlighted concerns that our two national societies share regarding standards of patient care. Undergoing any form of surgery risks experiencing a complication, no matter who the surgeon is or where it is performed, however, what these reports have highlighted is poor practice, unnecessary risk taking and potentially avoidable harm to patients.

President of BAAPS Marc Pacifico said, ‘Whilst in the United Kingdom recognised surgeons can be checked on the GMC Specialist Register and hospitals and clinics are regulated by the CQC, this is not the case in other countries.’

‘BAAPS and TSPRAS have come together to draw up some advice and guidance for patients seeking surgery in Türkiye (Turkey), which has a large cosmetic tourism industry. The aim of this guidance is to help to protect patients from harm and ensure that they are aware of standards of care (both before and after surgery) that they should expect as a minimum.’

The two organisations strongly urge anyone from the

SKIN OF COLOUR SOCIETY’S 20TH ANNIVERSARY

UK considering travelling to Türkiye for cosmetic surgery to consider the following points:

■ Any Turkish surgeon seen should be a member of TSPRAS (the Turkish Society of Plastic Reconstructive and Aesthetic Surgeons)

■ Your surgeon in Türkiye should have Turkish board certification you should be able to see their certificate on request

■ EBOPRAS membership (the European Board of Plastic Reconstructive and Aesthetic Surgery) is desirable in your surgeon

■ Your surgeon should have been in practice in Plastic Reconstructive and Aesthetic Surgery for at least 5-years (as training is different in Türkiye)

■ Your surgeon should offer you an aftercare plan

■ You should know the name of your surgeon and how to contact them if there is a problem

■ It is advisable to ask how long your surgeon has been working with their clinic at least 3-years is recommended

■ Informed consent— it is compulsory in Türkiye to have a comprehensive consent form completed ahead of travel— if this does not happen it should raise concerns

■ Please double-check your surgeon about his/her specialty. In Türkiye— there are practitioners who claim to be plastic surgeons who are not, and other surgeons working outside their areas of training and specialty

■ We recommend that your surgeon performs your surgery in a fully recognised hospital, which might be, in Türkiye, identified by having at least 30-beds

President of BAAPS

Marc Pacifico added:

‘We hope that these guidelines will help patients with their research into surgeons and clinics in Türkiye and urge anyone to think carefully before considering surgery

As the world’s leading professional organisation dedicated to skin of colour dermatology, the Skin of Colour Society (SOCS) marks its 20th anniversary milestone with several signature programmes and groundbreaking initiatives underway that help bring greater diversity to dermatology, reduce healthcare disparities, advance muchneeded research, expand training and mentorship opportunities for dermatologists, and amplify patient education.

Founded in 2004 by dermatology leader Susan C. Taylor, MD, FAAD, SOCS is flourishing with unprecedented growth and expansion in recent times, making seminal contributions to the field of dermatology. Highlights from its most active and innovative year in history include:

■ Leading the way with skin of colour patient and dermatology educational videos

■ Advancing Diversity in Dermatology Clinical Trials

■ Supporting Much-Needed Research in Skin of Colour Dermatology

■ The SOCS Foundation Institutional Research Fellowship (IRF) Programme

■ The SOCS Dermatology Research Award

■ SOCS Career Development Awards

■ The SOCS Early Career Innovations Award

■ Mentoring the next generation of dermatologists

■ Presenting the latest skin of colour research.

‘As we reach our 20th anniversary, we are indebted to many skin of colour dermatology pioneers, whose contributions led to tremendous advances in the field. As we face a very promising future, we are thankful for and strengthened by many SOCS leaders, members, supporters and collaborators who are helping us continue our work toward achieving true diversity, equity and inclusion in dermatology,’ comments Dr. Andrew F. Alexis, MD, MPH, FAAD, SOCS President.

The aim of this guidance is to help to protect patients from harm and ensure that they are aware of standards of care (both before and after surgery) that they should expect as a minimum.

ENLARGED PORES THE INTEGRATIVE AND HOLISTIC APPROACH FROM DIET AND SKIN CARE TO LIFESTYLE AND LASER

Victor Gabriel Clatici, MD, takes an in-depth look at this common skin concern and explains why a holistic approach is the best form of treatment

ABSTRACT

Physiologically speaking, pores are defined as apertures from the surface of a tegument (animal, vegetal) that ensure the input or output of gases or fluids.

Dermatologists often face challenging questions from their patients or customers about the presence of large or enlarged skin pores and the practical possibilities to alleviate such undesired aspects. Although not a medical concern, enlarged pores are a cosmetic concern for a large number of individuals. This obsession has even led dermatologists to coin the term ‘porexia’ for those with neurosis about their pores.

Many endogenous and exogenous factors are known to cause enlarged pilosebaceous pores. Sex, genetic predisposition, ageing, chronic ultraviolet light exposure, comedogenic xenobiotics, acne, and seborrhoea. In female patients, additional hormonal factors, such

PEOPLE OFTEN DESIRE TO MAINTAIN a youthful and healthy appearance indefinitely. However, our fears of death, rejection or abandonment, and failure can sometimes hinder us. The fear of rejection is often linked to our appearance, while the fear of failure is often tied to our competence.

The skin has multiple functions, including defence against mechanical, physical, and chemical aggressions, microorganisms, and solar radiation. It also regulates temperature, acts as a barrier to prevent loss of water and electrolytes, serves as a reservoir for stem cells, provides immunologic function, and functions as a sensory organ that can detect pressure, temperature, and touch.

The health of our skin affects our self-esteem, mental state, and the way we interact with others. Essentially, our skin health plays a vital role in determining our quality of life1. The condition of our skin plays a vital role in our overall well-being and how we are perceived in terms of health and beauty2

as menstrual cycles, affect the pore size. Pore size was significantly increased during the ovulation phase.

Because various factors cause enlarged facial pores, it might be helpful to identify the underlying causes to select the appropriate treatment. Enlarged facial pores are challenging to treat due to the multifactorial nature of their pathogenesis. They are primarily treated by addressing associative factors, such as increased sebum production and cutaneous ageing.

Treatments for enlarged facial pores primarily aim to decrease sebum production, rejuvenate skin, remove hair, and/or decrease follicular size.

In this paper, I review the current treatment modalities for enlarged or dense facial pores, including diet and sun protection, topical retinoids, chemical peels, oral antiandrogens, and lasers and energy-based devices (EBDs).

because good-looking skin with an even tone, clarity, and radiance is a sign of health, well-being, and fertility. Therefore, taking care of our skin and maintaining its appearance is essential.

The level of attractiveness of a person’s face is a significant social characteristic. It is often regarded as a factor that helps determine social and intellectual abilities, including selecting a partner and earning potential4,5. The face is crucial for human social communication, as it provides the primary source of information for social perception. Even slight imperfections can significantly affect mental health and quality of life6,7. Research has shown that the texture and colour of female facial skin can impact how people judge their age, health, and attractiveness8,9. This is true even when taking into account the influence of facial shape.

KEYWORDS

Pores, Skin quality, skin texture, laser therapy, Energy-based devices, EBDs

Desmond Morris3, a Zoologist, made an interesting statement about our skin. He said that having flawless skin is something that is desired universally. This is

Having a ‘camera-ready’ face is crucial for social media10, and making a good first impression is crucial, as research shows that you only have 100 milliseconds to do so and you won’t get a second chance11. The colour and texture of a person’s facial skin significantly impacts their perceived attractiveness, according to studies12,13. As a result, these factors are considered when evaluating facial attractiveness14,15

VICTOR GABRIEL CLATICI, MD, is a Senior Dermatologist, Sanador Floreasca, 165 Calea Floreasca, BUCHAREST, ROMANIA, 014459 email: claticiv@yahoo.com

Pores: definition and impact

The word ‘pore’ comes from the Greek word ‘poros,’ which means ‘a passage or way’16. The adjective ‘porous’ is commonly used to describe surfaces with small spaces or interstices. In simple terms, pores are openings in the skin or surface of an animal or plant that allow gases or fluids to enter or exit17

‘Skin pores’ refer to the openings of the pilosebaceous follicles that are visible topographic features on the skin surface. They can become more visible and enlarged under specific circumstances.

Patients or customers frequently ask dermatologists, cosmeticians, and aestheticians about the appearance of large or enlarged skin pores and how to reduce them. It can be a complex issue to address, but practical options are available17. Patients who have been affected by these pores have been complaining about a cosmetic issue commonly referred to as the ‘orange peel skin’ effect and are seeking treatment18. While not harmful, they can cause concerns about appearance and may be seen as indicators of ageing skin by many17

Enlarged or dilated pores refer to the visible features on the skin’s surface that correspond to larger openings of pilosebaceous follicles19. Different studies have varying

definitions of enlarged pores. According to Kim et al.20 , visible skin pores range from 0.1 to 0.6 mm2, while enlarged skin pores are between 0.3 and 0.6 mm2

What do these changes in the patient’s topography mean? Will it affect their texture, general appearance, and makeup results, or will it have any psychological effects?

Several factors, including proportionate contours, consistent skin tone, and a smooth skin surface, influence the appearance of the face. Scars can make the skin look rough, but enlarged or dilated pores can make the skin surface appear uneven21. Enlarged facial pores are a major aesthetic concern for many women, and they have been identified in the literature as a potential consequence of photo-ageing18

According to new research22 conducted among over 2,000 adults in February 2014 by Harris Poll on behalf of L’Oreal Paris, found that:

■ Nearly half of women (45%) wish they could change the size of their pores

■ Almost one in three women (28%) are more concerned about their pore size than wrinkles. This obsession has even led dermatologists to coin the term ‘porexia’ for those with neurosis about their pores.

On the other hand, a growing number of young

The condition of our skin plays a vital role in our overall well-being and how we are perceived in terms of health and beauty.

adults visit the dermatology clinic to address enlarged pores, which are not necessarily linked to other signs of ageing skin18

Individuals with enlarged skin pores often experience low self-esteem, hindering their ability to interact socially and decreasing their overall quality of life. Additionally, attempts to conceal the pores using cosmetic products can be ineffective due to the uneven texture of the skin and product buildup in the pore openings23

Enlarged pores: causes and risk factors

Enlarged facial pores are a dynamic and multifactorial condition. Several non-modifiable risk factors for its development have been identified. One of the most important aspects to discuss and to communicate with our patients is the dynamic nature of the pores, which is determined by the dynamic nature of the factors involved.

Various internal and external factors can cause enlarged pilosebaceous pores. These factors may include gender, genetic traits, ageing, prolonged exposure to ultraviolet light, comedogenic substances, acne, and seborrhea24. Seborrhea, loss of skin elasticity and tension, and hair follicle size are most clinically relevant to the pathogenesis of enlarged pores. In addition, chronic recurrent acne, sex hormones, and skin care regimen can affect pore size25 During the ovulation phase of the female menstrual cycle, there is a significant increase in sebum output and pore size. This is most likely due to increased progesterone affecting the activity of sebaceous glands24, 25

Facial pore development is mainly associated with increased sebum production and reduced skin elasticity. Studies have found that there is a negative correlation between skin elasticity, tensile strength, and facial pore size and density when measured visually and mechanically20. Other authors confirm that the enlarged pore counts correlate with wrinkle severity and found the correlation varies depending on the location on the body26

The skin surface around noticeable pores underwent structural changes that included both concave and convex structures, with inner skin structures also changing27. I want to highlight the importance of structural changes and their impact on the surface and depth of the skin. These changes are caused by factors involved in the development of dilated pores.

According to some authors, there is a connection between the appearance of a pore and the characteristic

feature at the epidermal-dermal junction. In crosssectioned images of large pores, it is often noticed that the epidermal-dermal junction around the pore’s opening is strongly undulated28

There was a significant correlation between the serum level of IGF-1 and the total pore area, as well as with the severity of impairment of epidermal architecture around facial pores and sebum output levels21

It’s worth noting that our skin can look different depending on the season. For instance, pores may appear more prominent during the summer months compared to winter29. It’s also important to remember the effect that lifestyle can have on our skin. Even just one night of sleep deprivation can make our pores look worse and decrease skin hydration, elasticity, brightness, and translucency30

Several internal and external factors can contribute to the enlargement of pores. These factors include prolonged exposure to the sun, hormones, sebum production, being male, age, and genetic predisposition. When the skin’s structural components around the pores, like collagen and elastin, are damaged, the pore

Enlarged pores: principles of therapy

Our patients require a programme that includes clear and established events. These events should trigger multiple synergistic processes, which will be carried out according to a set schedule. Our actions should be systematised and based on an individualised plan. The purpose of a programme is to alleviate decision fatigue by knowing what tasks need to be done, why they are essential, how to do them correctly, and when they need to be completed. The goal of the programme is to save time, money, and energy.

Enlarged facial pores can be caused by various factors, but the three major contributors are increased sebum secretion, reduced skin elasticity around pores, and increased hair follicle volume, particularly with thick hair31

Our next step is identifying the specific factors contributing to each cause and determining actionable steps. To manage sebum secretion, we can modify diet and lifestyle, address hormonal imbalances (including hormonal drugs), use retinoids, and use energy-based devices and laser treatments. We should implement lifestyle measures, utilise laser therapy, and use appropriate skincare to maintain skin elasticity.

My personal point of view regarding treatment is it should be:

■ holistic and integrative

It’s also important to remember the effect that lifestyle can have on our skin. Even just one night of sleep deprivation can make our pores look worse and decrease skin hydration, elasticity, brightness, and translucency.

■ personalised and individualised

■ modulated and adapted

■ complete and complex

■ sequential and continuous.

If your patient is concerned about enlarged pores, there are several approaches they can take to address the issue. First, they can consider lifestyle factors such as diet, skincare routine, photoprotection, smoking habits, stress levels, and sleep patterns. Additionally, there are both local and general treatments available, as well as energy-based devices such as laser, IPL, and radiofrequency, which may be effective options to explore.

Although many therapies have been reported, currently, there is no universally approved or effective treatment for enlarged facial pores. Given the different possible causes for enlarged pores, therapeutic modalities should be individualised for each patient. In fact, it is possible that multiple factors orchestrally affect the pore structure of an individual. Therefore, multiple treatment modalities focusing on different modes of action may be applied for better and long-lasting outcomes20,25. Because of its multifactorial nature, treatment of enlarged facial pores has proved to be challenging as they tend to recur after discontinuation of treatment interventions25

For treatment and maintenance, laser technology is recommended. However, in analysing text and dynamic pore layout, it’s important to note that obtaining ‘definitive results’ is not possible due to the dynamic nature of pore sizes and the factors involved, as well as lifestyle and external conditions.

Other treatment options for enlarged facial pores include chemical peeling, topical retinoic acid, oral isotretinoin, antiandrogen therapy, botulinum toxin type-A injections, chemical peeling, lasers, radiofrequency, ultrasound devices, microdermabrasion, photorejuvenation, laser skin resurfacing, and fractional laser treatments, each yielding variable results25, 32–37

There are several benefits to using combined treatments for skin problems. These treatments are fastacting and minimise the risk of adverse reactions. Additionally, they provide therapy on multiple skin levels and address several issues simultaneously, such as enlarged pores, seborrhea, pigmentation spots, tonus, texture, and laxity. Essentially, combined treatments target multiple mechanisms involved in skin problems at the same time.

Enlarged pores: holistic approaches

To improve facial skin characteristics, such as pore size, and reduce the severity of impairment of epidermal architecture around facial pores, it is essential to develop strategies to lower levels of IGF-1. We must take action regarding the patient’s diet and make necessary adjustments to reduce sugar intake, high glycemic index foods, and milk.

Vitamin A derivatives, known as topical retinoids, are effective in treating the changes that occur in the skin due to ageing and sun exposure. Tretinoin, isotretinoin,

and tazarotene are examples of these treatments that have been shown to improve skin rejuvenation in various ways, such as reducing facial pores, wrinkles, hyperpigmentation, skin sagging, and excessive oil production38

Chemical peels are utilised in skin rejuvenation and have been found to be effective in reducing enlarged facial pores. These peels temporarily break down and regenerate healthier cells at either the epidermal or dermal level, resulting in an improved skin matrix39

The most commonly used oral therapies to treat enlarged pores include antiandrogens, such as spironolactone, combined oral contraceptives, and cyproterone acetate. These medications modulate sebum production by targeting androgen receptors within the sebaceous glands40

Some authors have studied how seborrhea and excessive sebum production contribute to enlarged pores. A new study has found that injecting botulinum toxin type A (BoNT-A) directly into the skin can effectively reduce enlarged pores and seborrhea for up to four months. This was shown in a controlled, split-face study41 The underlying mode of action on the decrease in sebum level was hypothesised to be the neurologic modulation and vascular regulation of BoNT-A on sebaceous activity42, 43

Enlarged pores: energy-based devices

Let me point out that lasers (and other EBDs) are part of the puzzle but not the only one, and this approach needs support. Laser treatment must act on at least one of the primary mechanisms related to the sebaceous gland (if it does not act on the sebaceous gland — it must be complemented by a treatment on the sebaceous gland and hair follicle).

Ongoing research has been conducted to explore the effectiveness of different types of laser devices and EBD procedures as potential solutions for enlarged facial pores44–53

Several lasers and EBDs work by inducing collagen remodelling, which is an effective way to improve the appearance of enlarged facial pores. Numerous devices have been documented in the literature to target the various pathophysiologic factors that cause the formation of large skin openings based on their unique mechanisms of action20, 24, 25, 54

The 1064 nm Nd:YAG laser has been widely used in cosmetic laser dermatology for the removal of unwanted hair, tattoos, and pigmented and vascular lesions and more recently in dermal remodelling for the treatment of wrinkles55, 56

In recent years, studies on laser treatments for facial pores have been gradually increasing due to good efficacy and few adverse reactions. The long-pulsed 1064-nm Nd:YAG laser (LPNY) has been widely used for facial rejuvenation. LPNY has been demonstrated in many studies to reduce facial wrinkles and improve skin elasticity57, 58. Researchers have utilised it successfully to treat enlarged pores50, 59, 60

During the ovulation phase of the female menstrual cycle, there is a significant increase in sebum output and pore size. This is most likely due to increased progesterone affecting the activity of sebaceous glands.

The use of 1064 nm Nd:YAG lasers to treat enlarged pores has been studied extensively due to their ability to induce neocollagenesis44. Several trials have focused on optimising parameters, such as pulse duration and energy density, to achieve the best clinical results46, 48, 50, 60

A previous study conducted by Roh et al.,50 found that the use of Q-switched and quasi-long-pulsed 1064 nm Nd:YAG lasers resulted in a significant reduction in pore size and sebum output when compared to the untreated control. The authors suggested that the reduction in pore size could be attributed to the new dermal collagen deposition in the perifollicular area, while the direct effect of the laser was responsible for maintaining the reduced pore size and sebum level over a long period of time.

In contrast, the efficiency of using a carbon-suspended lotion was demonstrated in a separate study using a Q-switched laser with micropulse settings46

As previously discussed, enlarged pores are caused by various factors and can change over time. Laser treatment may not be able to fix all the causes of this condition20,25

A recent study was conducted to compare the effectiveness of two laser treatments for reducing facial wrinkles and enlarged pores. The picosecond 1064 nm Nd:YAG laser using a microlens array (MLA) and the quasi, long-pulsed 1064 nm Nd:YAG were both found to produce significant improvement in skin rejuvenation and pore reduction after five treatment sessions at 2-week intervals51

Using the concept of combining multiple approaches to address the different factors that influence enlarged

Key points

Having enlarged facial pores can be a major concern when it comes to aesthetics

Enlarged pores can be caused by a variety of factors, both internally and externally

The first step is a thorough consultation, with the evaluation of the lifestyle and the skincare process, as well as establishing the indications and contraindications for various types of EBD interventions

My personal point of view about treatment is Holistic and Integrative, Personalised and Individualised, Modulated and Adapted, Complete and Complex, Sequential and Continuous.

pore appearance to achieve better outcomes, Cho et al.45 investigated the efficacy of combined laser modalities with the expected sebaceous injury effect of a 1450 nm diode laser, tightening effect of a Q-switched and quasi long-pulsed 1064 nm Nd:YAG, and the smoothening effect of a 10,600 nm carbon dioxide (CO2) laser. Four months after the final treatment, the condition of the patient’s pores were rated to have improved by 51–75%. However, the recovery time spent, the risk of adverse effects, and the cost of treatment must be taken into account with the benefit of using these multiple treatment modalities.

Other EBDs have been proposed as effective treatments, such as intense focused ultrasound (IFUS)49 , fractional radiofrequency devices47, and broadband light52

Theoretically, RF is another EBD that aims to manage several possible causes of enlarged pores47,61,62. The simultaneous thermal effect on s-urrounding tissues and/or the pilosebaceous unit due to tissue impedance to electrical currents aims to stimulate neocollagenesis for pore tightening and reduction of sebum secretion62, 63

A recent study using broadband light suggested its potential as an effective treatment for enlarged pores by improving skin laxity, epilation of facial hair, and decreasing sebum production52

Conclusions

Enlarged pores are difficult to treat, in part due to a lack of knowledge of the pathophysiology37, and many endogenous and exogenous factors are known to cause enlarged pilosebaceous pores24

In light of the changing world, we require a new

approach. This entails developing first evaluation, medium-term, and long-term strategies and utilising combined therapies.

It’s essential to consider the experience of the end user, specifically the patient. This includes factors such as pain, the time needed for preparation, the intervention, and post-intervention, as well as downtime in social, professional, familial, and personal areas. This experience is ongoing throughout the year and all day long as patients balance their job with clinic visits. Additionally, we must consider the results of the service, whether they are instant, complex, or an ongoing process. Finally, we need to consider our service’s price and value.

There is no one-size-fits-all solution for skin care. Skin is a dynamic organ that requires a balance between effectiveness, safety, social downtime, and pain perception. Therefore, we need to approach skin care

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When addressing enlarged pores, taking a holistic approach is vital. This involves considering lifestyle factors like diet, skincare, sun protection, smoking habits, stress levels, and sleep quality. Both local and general treatments may be necessary to achieve desired results. Energy-based devices like lasers, IPL, and radiofrequency can also be effective options.

Declaration of interest

None

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Skin is a dynamic organ that requires a balance between effectiveness, safety, social downtime, and pain perception.

SKIN REJUVENATION WITH A NEW BIPOLAR MULTICHANNEL RADIO FREQUENCY DEVICE

Expert consensus on the use of the Reaction Bipolar Multi-channel Radiofrequency with combined vacuum device

ABSTRACT

In April 2023, renowned Chinese experts held a seminar to reach a consensus on the use of Reaction (Sinclair (Shanghai) Co., Ltd) before its launch with foreign experts in Chongqing, China. At the seminar, experts discussed and reached a consensus on the clinical application of the Reaction Bipolar Multichannel Radiofrequency Combined Vacuum Device in facial rejuvenation. The Consensus is aimed at providing clinical physicians and experts with references and suggestions on the clinical facial rejuvenation applications for the device.

products, attracting the public’s attention and becoming a focus of studies in skin beauty and treatment.

MEDICAL ADVISOR BOARD EXPERT TEAM

OVER THE YEARS, AS LIVING standards have significantly improved, people now have higher expectations for facial rejuvenation treatments driven by rapid technological developments. The accelerated population ageing in China has pushed up the demands for anti-ageing services and

There are diverse techniques to treat the ageing face, including Botox injection, chemical peeling, lasers and surgery, which face significant limitations in clinical application due to the associated risks of trauma, hyperpigmentation, scars, poor post-treatment stability, and aesthetic results 1. In fact, when it comes to facial rejuvenation, people tend to prefer minimally invasive or non-invasive treatments. Being first applied in the field of skin rejuvenation from the beginning of the 21st century 2-3, radiofrequency (RF) is a non-invasive treatment technique that has been extensively applied in facial rejuvenation. A non-invasive cosmetic

PROFESSOR WU YAN, PHD, Peking University First Hospital, China

PROFESSOR YAO MIN, PHD, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, China

DR INNA BELENKY, MD, Clinical Director of Sinclair, Vice Director, Marketing and Clinical Affairs Department

PHYSICIAN CHAN JAMES K.M, MD, Expert of Cosmetic Medicine and Anti-aging, Hong Kong, China

PROFESSOR ZHAO XIAOZHONG, PHD, President of Beijing Laserking BeauCare Clinic, China

medicine technology, such as RF, is a common aspiration for all physicians and patients.

Features of the device

By adjusting different electromagnetic wave frequencies that include 0.8 MHz, 1.7 MHz, and 2.45 MHz, the Reaction Bi-Polar Multi-channel can be set to precisely lock a penetration depth from 3.9 mm to 18.6 mm and treat the superficial dermis, deep dermis, and subcutaneous adipose tissue layer by layer for more accurate positioning. The device penetrates all layers of skin from shallow to deep under the Fourth Dimension Channel Mode as well as penetrates and heats layer by layer by applying the First, Second and Third Dimension Channels to

achieve a comprehensive therapy 4. Meanwhile, the device can raise the dermal temperature to 40~50°C while maintaining the skin temperature at 39~42°C thanks to its electronic cooling function. The device also stimulates collagen production in fibroblasts 5–7

For the first time, the Reaction Bipolar Multichannel Radiofrequency Combined Vacuum Device makes integrating RF and the negative pressure systems of three frequencies possible. Different electromagnetic wave frequencies enable the device to target specific layers from shallow, middle, to deep for accurate positioning. Integrating with the vacuum system, the device improves action in areas between the two electrodes and expands the penetration scope and depth of RF energy, thus improving blood microcirculation and increasing lymphatic drainage. The bipolar arrangement effectively avoids adverse reactions, such as pain and burning commonly found in monopolar devices. The distribution of RF current in the tissue can be controlled by constraining the distance between the two electrodes, making the device safer. In most cases, the device can heat the target tissue rapidly to distribute the heat more evenly for a better treatment outcome 4

The patented Channeling Optimized RF Energy (CORE) technology enable diverse different treatment parameters, so that the physician can customize device settings for each patient considering specific treatment scheme. RF energy intensity, RF penetration depth and mechanical vacuum suction strength are controlled to achieve the optimal treatment effect in different treatment areas.

KEYWORDS

Sinclair, Reaction, Skin rejuvenation

The accelerated population ageing in China has pushed up the demands for anti-ageing services and products, attracting people’s attention and becoming a focus of studies in skin beauty and treatment.

PROFESSOR SU GONGMIN, PHD, Senior Cosmetic Medicine Training Specialist in Taiwan, China

DR QIAN HUI, MD, Huashan Hospital, Fudan University, China

Clinical application of Reaction in facial rejuvenation

The device may be set with different frequencies and RF intensities to penetrate and heat layer by layer, thus achieving a comprehensive therapy. It stimulates the fibroblast to produce including extracellular matrix (ECM) and collagen. With noticeable treatment effects in facial and skin rejuvenation, the device can improve fine lines and sagging skin, tighten the skin, and comprehensively improve the facial contour, especially mild to moderate wrinkles and mild laxity accompanied by facial fat accumulation. Moreover, it is a comfortable experience for the patient, with a high safety and reliability profile. It can also deliver personalised and diversified treatments to cater to different skin qualities and the cosmetic demands of patients.

Treatment methods and effects

The device offers four different RF treatment modes for physicians. These modes are based on the following integrated technologies:

■ Frequency Mode I — Low RF 0.8MHz (applicable for deep layer treatment)

■ Frequency Mode II — Medium RF 1.7MHz (applicable for middle layer treatment)

■ Frequency Mode III — High RF 2.45MHz

(applicable for superficial treatment)

■ Frequency Mode IV — Integration of the three frequencies described above (applicable for multilayer treatment).

In terms of the hand tools, the skin tightening (ST) device is suitable for the treatment of the face, neck, jaw, shoulder and neck or other small areas. The facial contouring (FC) device is suitable for the treatment of sensitive areas, such as the lower jaw and underarm.

Safety and efficacy

Having undergone basic experiments and clinical studies at home and abroad, the Reaction Bipolar Multi-channel RF has proven to be effective and safe for anti-wrinkle, anti-ageing, and facial contouring. Inna Belenky et al. conducted studies on skintightening with Reaction in Israel. Sixteen subjects aged 37~66 with severe wrinkles and/or lax, sagging skin received Reaction treatment once every 3 weeks for a total of 3 times. Each treatment lasted 25 minutes on average (fibroblasts in each area were all heated for at least 4 minutes). Results show that 50% of subjects had moderate improvement, and 31% of subjects had significant improvement. Lax and sagging skin was clearly improved. The device was approved for registration by the National Medical Products Administration of China in 20154

Figure 1 Pictures of Jawline after being treated with Reaction Facial Contouring (FC) hand tool to tighten jawline contour for a more V-shape face. (A) Before treatment, (B) after 1 time treatment, and (C) after 3 times treatments. Professor Yao Min.

Discussion

Lax, sagging skin is the primary manifestation of facial ageing. The causes of lax skin include reduced skin elasticity, dull skin, coarse pores, and skin wrinkles under the combined action of internal factors (e.g. natural ageing, estrogen, heredity, etc.) and external factors (e.g. long-term UV exposure, increase in oxygen free radicals, smoking, etc.). Frequent facial expressions and gravitational pull will also result in dynamic facial wrinkles. Change in the facial skeleton with ageing is also a contributing factor8

All these factors together will result in loss of facial soft tissue volume and sagging soft tissues, which will further lead to fat accumulation in lacrimal grooves, nasolabial folds and jawline, as well as sagging mouth. Ageing of lateral eye brows, obscured jawlines and accumulation of fat in the submental region are also common manifestations of facial ageing.

The treatment efficiency of RF in the field of facial anti-ageing has been extensively recognised. RF emits electromagnetic waves that act on the dermis, resulting in a vast amount of heat to the targeted skin, which in turn stimulates structural modification and regeneration of collagen and elastin. The increase of collagen and elastin then increases the thickness and density of the dermis and enables a more compact

Key points

Patented multi-channel optimized RF enable the penetration depth more than 10mm and optimize parameters for different clinical indications

The Device with vacuum suction can obviously improve fine lines and sagging skin, tighten the skin, and comprehensively improve the facial and body contour

It offers comfortable experience, high safety and reliability.

distance between the two electrodes, making the device safer. Moreover, such a controllable RF device can directly act on the skin dermis to heat the collagen without damaging the epidermal tissue.

It is generally recognised that there will be a corresponding reaction between collagen and fibroblasts if the temperature is maintained at 40°C~43°C for 10 minutes14. The Device is used for anti-ageing treatment in a moderate yet comfortable manner. The generation of heat is related to local characteristics and resistance of the tissue, which varies between patients and areas targeted.

Conclusion

Having undergone basic experiments and clinical studies at home and abroad, the Reaction Bipolar Multichannel RF has proven to be effective and safe for antiwrinkle, anti-ageing and contouring treatments. The integration of multi-channel RF technology and vacuum brings diverse precise treatment schemes that feature effective treatment, fewer side effects, high safety and no downtime. It offers physicians and patients a new option for its highly comfortable treatment experience. With proved treatment effect in facial rejuvenation, the Device can improve the texture, elasticity and gloss of the skin, lighten wrinkles, tighten and lift lax tissues in jawline, lighten nasolabial folds, tighten the midface, and comprehensive improve the facial contour15-16

Acknowledgements

This consensus was discussed and approved by Wu Yan, Yao Min, Inna Belenky, Su Gongmin, Chan James K.M., Qian Hui and Zhao Xiaozhong at the Reaction Experts Consensus Seminar in April 2023. Note-taker: Wu Li

tissue arrangement, thus achieving facial rejuvenation9-13

The Reaction device creatively integrates heat and vacuum, giving rise to mechanical pressure that improves the microcirculation of blood and stimulates lymphatic drainage. The bipolar configuration effectively avoids adverse reactions such as pain and burning commonly found in the monopolar configuration. The distribution of RF current in the tissue can be easily controlled by constraining the

References

1. HUANG J YU WY, ZHANG Z et al. Clinical and histological studies of suborbital wrinkles treated with fractional bipolar radiofrequency [J] Rejuvenation Res. 2018. 21( 2) : 117-122

2. Jensen SL,Deutch SR,Olsen BS,et al. Laxity of the elbow after experimental excision of the radial head and division of the medial collateral ligament.Efficacy of ligament repair and radial head prosthetic replacement:a cadaver study[J].J Bone Joint Surg Br,2003,85(7):1006-1010.

3. Kokolakis G,Von Eichel L,Ulrich M,et al.Kinetics and tissue repair process following fractional bipolar radiofrequency treatment[J].J Cosmet Laser Ther,2018:1-5.

4. Inna Belenky,Exploring Channeling Optimized Radiofrequency Energy: a Review of Radiofrequency History and Applications in Esthetic Fields.Adv Ther (2012) 29(3):249-266

5. WAKADE DV, NAYAK CS, BHATT KD. A study glycolic acid peels in facial rejuvenation of aging skin u- sing histopathology and ultrabiomicroscopic sonography ( UBM ) —an evidence based study [J]. Acta Medica ( Hradec Kralove). 2016. 59( 1) : 14-17

6. RIVLIN D SKINNER DR, STEINMETZRODRIGUEZC Y et al. Novel modality for neck rejuvenation: aprospective multicenter trial of percutaneous radiofre- quency ablation of the cervical branch of the facial nerve [J] Dermatol

Surg 2018. 44( 2) : 209-217

7. JONES IT, GUIHA I, GOLDMAN MP, et al. A randomized evaluator-blinded trial comparing subsurface monopolar radiofrequency with microfocused ultrasound for lifting and tightening of the neck[J] Dermatol Surg 2017. 43( 12) : 1441-1447

8. Bryan Mendelson, Chin-Ho Wong Changes in the Facial Sketleton With Aging: Implicatons and Clinical Applications in Facial Rejuvenation. Aesth Plast Surg (2012)36:753-760

9. Kinney BM,Sadick NS,Gentile RD. Radiofrequency technology in face and neck rejuvenation[J]. Facial Plast Surg Clin North Am,2018,26(2):123-134.

10. Thanasarnaksorn W, Siramangkhalanon V, Duncan DI, et al. Fractional ablative and nonablative radiofrequency for skin resurfacing and rejuvenation of Thai patients[J].J Cosmet Dermato 2017, 17(2): 184-192.

11. 鲁楠,李青峰.妊娠纹的研究及治疗进展 [J].中国美容医学,2008, 17(2):302-304.

12. Iennet C,Bride J,Cohen-Letessier A,et al.Mechanical behavior of fibroblasts included in collagen lattices [J].J Soci Biol,2001,195(4):427-430.

13. Zelickson BD,Kist D,et al.Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: a pilot study[J].Arch Dermatol 2004. 140(2): 204-209

14. Fukumi Hiragami. Heat Shock-Induced Three-Dimensional-Like Proliferation of Normal Human Fibroblasts Mediated by Pressed Silk Int. J. Mol. Sci. 2009, 10, 4963-4976; doi:10.3390/ijms10114963

15. Andrea T.Kassim,Assessment of the safety and effi cacy of a bipolar multi-frequency radiofrequency device in the treatment of skin laxity.Journal of Cosmetic and Laser Therapy, 2013; 15: 114–117

16. James K. M. Chan, Bi-Polar RF, Still the Gold Standard for Non-Invasive Fat Volume Reduction. Journal of Cosmetics, Dermatological Sciences and Applications, 2015, 5, 247-253

Figure 1 © Sinclair Pharm

Having undergone basic experiments and clinical studies at home and abroad, the Reaction Bipolar Multi-channel RF has proven to be effective and safe for antiwrinkle, anti-ageing and contouring treatments.

HOW TO INCREASE THE DURATION OF BOTULINUM TOXIN EFFECTIVITY

IT IS A FACT THAT BOTULINUM TOXIN HAS become a staple in our portfolio of solutions due to all the indications it can treat and its amazing performance. However, it takes a few days to act, and the duration remains limited, especially compared to dermal fillers. The duration of the treatment effect is considered an unmet need within existing neuromodulators.

Manufacturers are also putting a lot of effort into further enhancing its efficacy, and we have various strategies to improve the onset and duration of botulinum toxin effects.

The best-known approach uses higher doses of botulinum toxin. Up to a certain amount of toxin helps to achieve faster outcomes and slightly longer duration of results; however, the duration is limited and can only be achieved up to a maximum of receptor saturation, beyond which there is no more increase in effectivity. Side effects, however, can also increase as the quantity of toxin increases and limits the use of ever higher doses.

For doses between >20 U–80 U of Onabotulinumtoxin A, studies1 have demonstrated a longer duration of response and higher patient-reported satisfaction versus the on-label 20-U dose with no apparent impact on safety variables. In another trial, the median duration of the IncobotulinumtoxinA effect was 175 days for the 20 U group but 215 days for the 100 U group. Also, AbobotulinumtoxinA dosed at 50, 75, 100  or 125 U tended to demonstrate elevated response rates and longer duration of effects.

In more than 2700 individuals with approximately 4200 treatments, there was a 6-month median duration, and some individuals maintained their results at 9 months.

Klaus Fritz, MD, explains how to overcome one of the limitations of using neuromodulators and enhance the duration of treatment results

Another approach3 used botulinum toxin type A reconstituted in 1% lidocaine hydrochloride with epinephrine 1:100,000. The addition of lidocaine was believed to achieve an immediate paralysing effect on the injected muscles, and the addition of epinephrine was hypothesised to minimise diffusion to adjacent muscles. In total, 58% of participants reported being more satisfied with BTX-A reconstituted in 1% lidocaine with epinephrine 1:100,000, with 85.7% of these participants reporting that the immediate results made the formulation superior; 35.7% (56/157) were indifferent, and 6.4% (10/157) reported that the modified formulation did not work better. The injection of BTX-A reconstituted in 1% lidocaine with epinephrine 1:100,000 presented no increased adverse effects (AEs), no decrease in pharmacologic potency, immediate feedback to the clinician, and higher satisfaction for the participants.

Newly approved formulations of botulinum toxin claim to be effective for longer

Alluzience® (liquid botulinum toxin type A) — claims to be effective for up to 6 months4. However, there was also a difference in the way the study was conducted compared to previous studies. In previous studies on other botulinum toxins, the evaluation was limited to less than 6 months, while with Alluzience, patients were monitored for longer, and the study documented what experienced injectors knew from other toxins: the effects can remain for longer in a small number of patients.

DaxibotulinumtoxinA has been approved by the FDA for frown or glabellar lines5-6. In more than 2700 individuals with approximately 4200 treatments, there was a 6-month median duration, and some individuals maintained their results at 9 months. The results were also seen as early as 1 day after treatment. It was well tolerated and achieved high patient satisfaction. The peptide in the formulation increases the affinity of the toxin for neural membranes facilitating increased internalisation of the toxin.

Swiss-based biotech, Fastox, is preparing for a phase I/II clinical trial with FTP-501, a proprietary formulation which, when combined with botulinum toxin products (BoNT), demonstrates faster onset, increased efficacy, and longer duration of action based on faster and higher internalisation of molecules without saturation on a cellular level. The Fastox research team discovered a unique way to enhance botulinum toxin’s activity with no effect on the fundamental properties of BoNT.

Fastox technology works on all BoNT/A tested and is

References

1. Joseph JH, Maas C, Palm MD, Lain E, Glaser DA, Bruce S, Yoelin S, Cox SE, Fagien S, Sangha S, Maltman J, Lei X, Brin MF. Safety, Pharmacodynamic Response, and Treatment Satisfaction With OnabotulinumtoxinA 40 U, 60 U, and 80 U in Subjects With Moderate to Severe Dynamic Glabellar Lines Aesthetic Surgery Journal 2022, 1–10 /doi.org/10.1093/asj/sjac157

2. Kerscher M, Fabi S, Fischer T, Gold M, Joseph J, Prager W, Rzany B, Yoelin S, Roll S, Klein G, Maas C. IncobotulinumtoxinA Demonstrates Safety and Prolonged Duration of Effect in a Dose-Ranging Study for Glabellar Lines. J Drugs Dermatol. 2021 Oct

Figure 1 Muscle paralysis duration after injection of Botox vs FTP-501 and Botox combination

Mean DAS (n=12)

+50% duration with combo

+100% duration with optimised combo

MUSCLE PARALYSIS AFTER INJECTION OF BOTOX OR FTP-501 COMBOS

+ Rats were injected in the tibialis anterior muscle with a dose of Botox resuspended with either FTP-501 or saline + Muscle paralysis was measured in time using the Digit Abduction Score (DAS)

proven in two validated animal models7-8

Preclinical work has validated the use of FTP-501 with the key BoNT products marketed worldwide. It follows a completely different mechanism of action and has the potential to be more effective than high dose alone and DaxibotulinumtoxinA. The combination with any of the toxins at their standard dosage increased the duration up to 50%, and the combination at increased doses achieved a 100% longer duration. This new approach will be the next significant step in botulinum toxin development.

KLAUS FRITZ, MD, PHD, Dermatology and Laser Center Reduitstraße, Landau, Germany email: drklausfritz@drklausfritz. com

Due to its innovation, Fastox was awarded as the winner of two major aesthetic meeting awards: in February 2023 by the IMCAS Innovation Tank and in April 2023 at the Aesthetic Innovation Summit, Miami.

Declaration of interest

Figures 1 © Dr Fritz

None

KEYWORDS

botulinum toxin, neuromodulators

1;20(10):1052-1060. doi: 10.36849/JDD.6377. PMID: 34636520.

3. Kim A, Jung J, Pak A. Botulinum toxin type A reconstituted in lidocaine with epinephrine for facial rejuvenation: results of a participant satisfaction survey. Cutis. 2013 Jul;Suppl:13-8. PMID: 24308152.

4. Ascher B, Rzany B, Kestemont P, et al. Liquid Formulation of AbobotulinumtoxinA: A 6-Month, Phase 3, Double-Blind, Randomized, Placebo Controlled Study of a Single Treatment, Ready-to Use Toxin for Moderate-to-Severe Glabellar Lines. Aesthet Surg J. 2020;40(1):93–104

5. Bertucci V, Solish N, Kaufman-Janette J, Yoelin S, Shamban A, Schlessinger J, Snyder D, Gallagher C, Liu Y, Shears G, Rubio RG. DaxibotulinumtoxinA for Injection has a prolonged duration of response in the treatment of glabellar lines: Pooled data from two multicenter, randomized, double-blind, placebo-controlled, phase 3 studies (SAKURA 1 and SAKURA 2). J Am Acad Dermatol. 2020 Apr;82(4):838-845. doi: 10.1016/j.jaad.2019.06.1313.

Epub 2019 Nov 29. PMID: 31791824.

6. Solish N, Carruthers J, Kaufman J, Rubio RG, Gross TM, Gallagher CJ. Overview of DaxibotulinumtoxinA

for Injection: A Novel Formulation of Botulinum Toxin Type A. Drugs. 2021 Dec;81(18):2091-2101. doi: 10.1007/ s40265-021-01631-w. Epub 2021 Nov 17. PMID: 34787840; PMCID: PMC8648634.

7. Botulinum Toxin Type A Duration Enhancement by Mu-Conotoxin CnlllC. Presentation at Toxins 6th International conference 2022 New Orleans

8. Machicoane M, Onillona P, Stazib M, Tonellatob M,Crosa C, Pirazzinib M, Rossettob O, Le Doussala JM. Botulinum Toxin Type A Duration Enhancement by Mu-Conotoxin CnIIIC Toxicon Volume 214, Supplement 1, July 2022, Pages S38-S39

Noura Lebbar, MD, discusses her experience using focused ultrasound technology

A NON-INVASIVE APPROACH FOR JAWLINE CONTOURING W

ITH THE INCREASING NUMBER OF MILLENNIALS presenting to our practice, our aesthetic treatments have changed and now involve more contouring and profiloplasty than in previous years. Jawline contouring is increasing in popularity, but should we always inject fillers? We have all witnessed in the media that plastic surgery and medical aesthetics procedures are causing unnatural-looking results; are we really giving the patients a better version of themselves by exaggerating their contours?

Prior to injecting fillers, especially in patients with increased laxity, we should consider treating their skin, working to achieve neocollagenesis and neoelastinogenesis and treatment of the SMAS. With the right preparation, we can achieve excellent results and, in some cases, avoid fillers.

The objective of the study

What we propose is an innovative approach for treating the skin and redefining the contours of the face, using focused ultrasound rather than fillers. Focused ultrasound has been available for a number of years and is now a popular treatment. However it is not without its downfalls, which include:

■ It can be a painful procedure

■ Some patients were unable to finish the treatment or treatment course

■ In some patients, there was unwanted permanent fat loss from the face

■ It is a longer procedure, typically ranging from 1 hour to 1 hour and 30 minutes in length

■ Very costly to the doctor and patient.

Material and methods

So how can we overcome the negative aspects of focused ultrasound? One device I have seen success with in my practice is the CFU-Èlife (BIOTEC ITALIA SRL). A highintensity focused ultrasound that involves:

KEYWORDS

Ultrasound, CFU, jawline, contouring

■ EASYFLOW application technique using up to 10Hz that allows random coagulation points making the procedure faster < 30 minutes, safer and painless. The EASYFLOW technique can be used all over the face without limitation and with no risk of neuropraxia.

NOURA LEBBAR, MD, Cosmetic Surgeon, Anti-Aging Medicine, Milan, Italy

■ A virtually painless procedure

■ A centreless transducer for more precise coagulation points

■ By modifying the pulse duration together with a centreless transducer, we can avoid fat loss from the areas where fat loss is unwanted

■ Constant water flow within the handpiece ensures handpiece longevity. Offering approximately 2500 treatments without changing handpieces is a lot more cost-effective

■ Ability to work on seven different depths, ensuring effective treatments on the face and body.

We have treated patients aged 35–70 years of all skin types and ethnicities, with skin laxity on the jowls, nasolabial folds, and marionette lines, desiring a noninvasive lifting and tightening of the midface.

We excluded patients who underwent a previous face lifting surgery or HA filler surgery in the previous 6 months.

Patient assessment was performed using the Croma jawline sagging assessment scale, and photos were taken at 1 and 3 months following the treatment. Patients with severe sagging had three treatments, two treatments for moderate sagging, and just one treatment for mild sagging.

We used three depths (4.5, 3.0, and 1.5 mm) at 4MHZ, pulse duration 50 ms, emission frequency 5–10 Mhz and energy 0.8–2 J. 1000–3000 coagulation points were performed using each depth for a total of 5000–8000 points with the three depths used. No topical anaesthesia was required.

Results

All the patients were evaluated 1 and 3 months after the treatment. The results were all extremely satisfying; 95% of patients were very satisfied with the results. No side effects were observed post-treatment. The maximum result of skin tightening and jawline contouring was achieved 3 months after the treatment.

Conclusion

I will usually treat the face and the neck in the same session. Often combining the treatment with a non-crosslinked hyaluronic acid skin booster. To achieve the best result for the jaw-line definition, I will incorporate a botulinum toxin treatment to deliver a ‘Nefertiti lift’ immediately after the focused ultrasound but never before.

Skin tightening is immediate with better jawline

definition, while the definitive result is visible 3 months after the treatment due to the collagen and elastic fibre synthesis in the 3 months following the ultrasound procedure.

I will propose two sessions a year to the patient unless the results are not satisfactory in terms of jawline contouring and lifting of the lower face.

The new generation of ultrasound technology allows us to achieve excellent contouring of the jawline, occasionally from the first session. As the treatment is painless, fast and very safe, we can also propose it to younger women from 35 years, avoiding the need to fill the jawline with an excessive quantity of filler, which is fast becoming a fashionable trend. The treatment is safe, very fast, painless and extremely effective. In the opinion of the author, CFU appears to be actually the most effective non-invasive medical lifting method on the market.

Declaration of interest

Figures 1–2 © Dr Noura Lebbar

Figure 1 (A) Before and (B) after treatment for jawline contouring with CFU Elite

Figure 2 (A) Before and (B) 3 months after treatment for mid-face lifting

What we propose is an innovative approach for treating the skin and redefining the contours of the face, using focused ultrasound rather than fillers.

MY LOVE AFFAIR WITH ChatGPT

Wendy Lewis shares her infatuation with OpenAI’s first-to-market chatbot

CHATGPT AND I MET OUT OF MY SHEER

curiosity in April 2023, and we have been inseparable ever since. ChatGPT stands for ‘Chat Generative Pre-trained Transformer’. It is an AI chatbot that was built on a family of large language models (LLMs), collectively known as GPT-3.

Fast forward to July 2023, and I keep my ChatGPT open on my desktop on a daily basis. I have moved on from ChatGPT to ChatGPT+ (the paid version), and from ChatGPT-3 to ChatGPT-4.

ChatGPT-4 is only available to paid subscribers of ChatGPT+, which as of this writing, costs $20 USD per month. It is OpenAI’s most advanced system that they claim ‘produces safer and more useful responses.’

In its own words, ChatGPT is ‘a friendly and intelligent robot’. ChatGPT can do way more than you think and probably more than any of us will ever need to use it for.

In case you are interested, ChatGPT is also available as an app and on IOS in some countries.

Where it all began

Created in November 2022 by OpenAI, ChatGPT was the first to market. However, it didn’t take long before we had AI-wars as more players entered this exciting and potentially game-changing category.

According to techradar.com, ChatGPT is now the fastest-growing consumer app in history, hitting 100 million users in only two months. It is rapidly morphing into new and improved models, which makes it even more confusing for lay people (aka non-engineers) to get our heads around. In fact, Microsoft uses a form of it in its Bing search engine and Microsoft Edge browser and is

also an investor in OpenAI.

Not to be outdone, Google launched its own chatbot model called Google Bard, which is referred to as an ‘experimental conversational AI service.’ From my perspective, Bard is useful since it lives on Google, which is open on my MacBook all day long. It also claims to draw on information from the internet to provide what Google calls ‘fresh, high-quality responses.’

ChatGPT is not connected to the internet in the same way. In my experience, the most significant glitch in ChatGPT is that, to date, it does not have the ability to help if I need information on anything that occurred after September 2021. The disclaimer reads like this: ‘As an AI language model, I don’t have access to real-time information or future developments beyond my knowledge cutoff in September 2021.’

This means that this AI cannot share anything or respond to any query about something that occurred in the past 22 months, at least as of the time of this printing.

More AI players

The next giant to launch its own AI version was Microsoft’s Bing. The Bing chatbot is integrated with the Bing search engine to retrieve relevant information. It uses machine learning algorithms to match the input

with predefined intents or categories. A benefit is that it can be integrated into other messaging platforms or applications and interfaces with Microsoft Teams, Facebook Messenger, and Skype.

In April, Snapchat announced their own chatbot called ‘My AI’, which operates on the latest version of OpenAI’s technology.

Another newcomer aiming to compete with ChatGPT was created by Anthropic, a self-proclaimed ‘AI safety and research company.’ Going by the name Claude, like ChatGPT, it doesn’t access the internet, and its training only goes up to the spring of 2021. Claude has two versions; ‘Claude’, which is referred to as ‘a state-of-the-art high-performance model’ and ‘Claude Instant’, which is defined as ‘a lighter, less expensive, and much faster option.’

According to TechCrunch, Google pledged $300M US in Anthropic for a 10% stake in the company.

What ChatGPT can do for you

ChatGPT can do way more than you think and probably more than any of us will ever need to use it for.

OpenAI’s GPT-4 model can understand and generate human-like answers to text prompts because they’ve been trained on huge amounts of data. For example, ChatGPT’s original GPT-3.5 model was trained on 570 GB of text data from the internet, which OpenAI says included books, articles, websites, and even social media.

Because it has been trained on hundreds of billions of words, ChatGPT can create responses that make it seem almost human. ‘Almost’ is the operative word here, as

CREATING MY FIRST PROMPT

This was the first prompt I posed to ChatGPT-4: ‘How can ChatGPT-4 help me manage my consulting business?’

ChatGPT-4 can be an invaluable tool in managing a consulting business, providing a variety of ways to streamline operations, communicate effectively, and make informed decisions. Here’s how:

Client Communication: Use it to automate responses to frequently asked questions, manage email correspondence, and generate draft responses to client inquiries.

Content Creation: It can assist in creating business proposals, reports, and other written content, including blog posts and articles. Research: ChatGPT-4 can help gather information about competitors, market trends, potential clients, and industry updates.

Project Management: It can remind you about

deadlines, keep track of project milestones, and even help to define project scopes based on provided details.

Data Analysis: ChatGPT-4 can interpret complex data, giving insights into financial metrics, sales statistics, or client demographics, which can guide your strategy.

Training: It can be used to create training materials for your team, aiding in the onboarding process or when learning new software or techniques.

Brainstorming Sessions: You can use ChatGPT-4 as a creative tool, suggesting ideas for problemsolving or enhancing your services. Scheduling: ChatGPT-4 can help manage your calendar, scheduling client meetings or team sessions.

Bookkeeping: With some basic inputs, ChatGPT-4 can help manage basic financial bookkeeping

and generate financial

ChatGPT-4 can be programmed to provide CRM-like functions such as managing customer interactions and following up

Process Optimization: It can analyze your existing operations and suggest potential improvements or efficiencies.

AI can generate an understanding of the legal language and help ensure your business is complying with relevant laws and regulations.

Remember, while ChatGPT-4 is a powerful tool, it should be used in conjunction with other tools and practices specific to your business needs and should not replace professional advice in areas like legal or financial matters. Also, please ensure all uses comply with OpenAI’s use-case policy and respect privacy and confidentiality agreements.

Because it has been trained on hundreds of billions of words, ChatGPT can create responses that make it seem almost human.

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

DRAFTING PROMPTS THAT DELIVER RESULTS

I went right to the source; this is how ChatGPT Plus explains it: ‘Here are a few examples across different scenarios:

• Writing Assistance: “Write a short story about a detective solving a mysterious crime in a small town.”

• Creative Idea Generation: “Provide me with ideas for a unique and innovative business start-up.”

• Learning and Knowledge Query: “Explain the concept of gravitational waves in physics and their significance.”

• Decision Making: “Help me weigh the pros and cons of buying a car vs. using public transportation.”

• Opinion or Debate: “What are the advantages and disadvantages of genetically modified organisms (GMOs)?”

Remember, the quality of the response you receive will depend on the clarity and specificity of your prompt. The more precise and detailed your instructions are, the better the AI model can understand and generate a relevant and accurate response.’

5 CAVEATS FOR CREATING PROMPTS

1

Be direct, clear, and as precise as possible. Avoid language that may be too vague or confusing to an AI.

2 Avoid giving the AI a very narrow scope which may limit the information it is able to pull. If the response you get is too vague, try again with more detail.

3 Try to create prompts that are neutral and unbiased. Avoid giving the AI any hints that you want a specific outcome.

4 Provide the most important information and some context but don’t overwhelm the AI with mixed messages.

5 Keep it simple stupid. Don’t try to outsmart the AI. It’s still early days, and they don’t have an unlimited amount of data to pull from.

answers around three times quicker than the free version. The most valuable benefit to date, from my viewpoint, is ‘priority access to new features and improvements.’ For example, the experimental ‘Turbo’ mode is said to boost response times even further, and I am keeping watch for when it is ready for the masses.

How to pick your prompts

According to ChatGPT, ‘prompts are like guideposts that direct the conversation or inquiry with a language model like ChatGPT-4.’ Language models, or LLMs, are what all these AIs are. The more specific your prompts are, the better responses you can achieve and the less time it will take to get there.

Prompts are not just about asking a question to get an answer. Rather, they need to be designed to solicit the precise information you are seeking in the fastest and most direct way. Keep in mind that we are dealing with robots who didn’t go to medical school.

the content it spits out is not particularly engaging. In Open AI’s own words, ChatGPT is ‘a friendly and intelligent robot’. Personally, I have yet to see any sign of its ‘friendly’ side.

According to OpenAI, ChatGPT Plus subscribers get ‘faster response times’, which translates to getting

Note the legalese language in ChatGPT-4’s response above. Since I started on this adventure, the disclaimers have been rapidly expanding as more and more users are joining these platforms. I get the sense that the rise of AI is happening so fast that armies of white shoe lawyers are coming on board to protect these start-ups from potential legal jeopardy, as these technologies have the potential to cause harm.

Prompts are not just about asking a question to get an answer. Rather, they need to be designed to solicit the precise information you are seeking in the fastest and most direct way.

product news

PROFESSIONAL DIETETICS SuneKOS CELL 15

Application Cellulite treatment

SuneKOS CELL 15 is the new discovery from Professional Dietetics and the beginning of a new era in cellulite treatment: rebuilding rather than destroying.

The synergy of the Hyaluronic Acid plus a patented Amino-Acid compound with an Alkaline Solution that modifies and improves the structure of ECM (Extra Cellular Matrix) through the physiological induction of three precise mechanisms:

• Re-equilibrium of the inflammatory situation of the ECM (Alkaline Solution), helping to neutralise the acidosis in latent inflammation present in all the stages of cellulite.

• Optimisation of the turnover of the protein structures of the ECM (HA+AA) targeting the fibroblast to induce an optimal neo-synthesis of collagen and elastin.

• Reduction of the slackness and resistance of the treated dermis to minimise the bulging caused by the underlying fat cells.

It is the ideal treatment for summer as Sunekos Cell 15 contains the only patented formula to counteract acidosis and to restructure the ECM, for a successful non-invasive treatment of cellulite.

Contact Professional Dietetics ● www.professionaldietetics.com

IBSA

PROFHILO® BODY KIT

Application Body skin laxity

The only injectable treatment specifically intended for the treatment of body skin laxity and particularly recommended for the brachial area, abdomen and areas most affected by this condition. PROFHILO® BODY is characterised by high and low molecular weight Stable Cooperative Hybrid Complexes (HCC) of high concentration Ultrapure Hyaluronic Acid, produced using a unique and innovative thermal production process patented by IBSA, the NAHYCO® Technology.

The Body Kit Contains two PROFHILO® BODY injectable treatments, one pack containing four patches of PROFHILO® FIGURA BODY PATCH and one bottle of 150 ml PROFHILO® FIGURA BODY CREAM.

Contact IBSA ● www.ibsaderma.com

CMED AESTHETICS

BioReTherapy

Application Chemical peeling BioReTherapy is a complete medical peeling line based on BioRePeelCl3® exfoliating power and post-treatment solutions, BioReHydra® Serum and BioReLift Cream, specifically developed for normal, combination, dry and oily skin.

BioRePeelCl3® FND promotes a marked exfoliating action on dead cells that amplifies the antioxidant and moisturising effects of amino acids, vitamins and GABA. The action of amino acids, vitamins and GABA is also assisted by the lipophilic phase thanks to its filming and moisturising action.

4EVER is a universal pre-treatment kit developed to be associated with our BioRePeelCl3® protocol and more generally with any type of medical aesthetic or dermatological procedure, with electro-medical instruments and photo stimulation, whenever an epidermal preparation is required.

The latest product news and technologies for the aesthetic and anti-ageing market dermamelan®

Thanks to the exfoliating action, it promotes cellular turnover by removing the outer corneal layer cells with selective action on corneocytes’ junction bonds. The active ingredients’ dermofunctionality contributes to a profound stimulation of skin replication and biosynthetic processes, essential to counterbalance the effects of skin ageing and oxidative damage induced by UV radiation and pollution.

Contact CMed Aesthetics S.r.l. ● www.cmedaesthetics.com

Application Depigmenting topical solution dermamelan® intimate is the medical depigmenting method especially indicated for the external intimate area, inner thighs, and groin. Unique for its dual corrective and regulatory action, it reduces the pigmentary imperfections in the short and long term, and improves the quality, turgor, and appearance of the intimate area.

The dermamelan® intimate method consists of a two-phase protocol: intensive depigmentation in consultation followed by a home treatment to regulate hyperpigmentation.

Contact Mesoestetic ● www.mesoestetic.com

THE NEW FACE OF POLYCAPROLACTONE:

GOURI

Anti-ageing specialist Dr. Katarzyna Grudzień shares why deep skin rejuvenation treatment GOURI has become the treatment of choice in her practice

GOURI HAS BEEN clinically applied as an injectable for tissue augmentation, but it also functions as a skin tissue stimulator. It debuted in Europe as liquid polycaprolactone and found its use as a skin-firming, smoothening, and rejuvenating agent.

All the currently available injectables present an evolutionary continuum, starting with collagen, through non-cross-linked hyaluronic acid as well as cross-linked, to collagen stimulators. This advancement has resulted in increased product safety, cosmetic effect magnitude, and durability. The latest step in the development was made by utilising the CESABP (Collagenesis-Enabled Solubilised Active and Biodegradable Polymer) technology, which provided the means to create the first fully liquid collagen stimulator, making the treatment even more safe and easy.

Most collagen stimulators face limitations posed by PCL or PLLA-based compounds enclosed in 25-50 μm microspheres, the size of which allows these chemicals to avoid phagocytosis and short-term biodegradation in order to induce long-term collagen production. This solution comes with its own set of challenges: it is unavoidable that

different-size particles move unevenly under the pressure exerted by the syringe plunger, sometimes clogging the lumen of the injection needle. Furthermore, such products need to be painstakingly massaged into the tissues to assure their even spread, otherwise an injection can result in long-term lumps. A rare, but serious adverse effect of occlusion, induced by damaging the endothelium of adjacent blood vessels, is also a potential risk to remember when using products like this.

What makes Gouri stand apart from its competitors are its:

■ Contents ready-to-use fully solubilised polycaprolactone

■ Effect mostly long-term dermal rejuvenation

■ Application liquid form allows the injector to cover large areas of skin with minimum effort

■ The time when the effect begins to be visible about 2 weeks post-treatment

■ Safety maximised, no serious adverse effects reported up to date.

Before conducting the Gouri treatment, two important points need to be communicated to the patient. Firstly, before the injection, the patient needs to take Cetirizine (an H1 receptor blocker) 0.5–1 hr beforehand. Secondly, the patient needs to avoid exposure to heat, sun, water, and alcohol ingestion for at least 24 hours following the procedure.

The protocol for injecting Gouri is quite intuitive and easily replicable. General guidelines state that our injection target is the deep dermis. Injections are retrograde linear using a cannula. Most patients get great results with just one treatment, but if necessary, 1–2 additional treatments 3–6 months apart can be applied.

Gouri is a truly innovative product, characterised by its increased safety of use and far better cosmetic outcomes in skin rejuvenation. It requires a sort of diligence on the operator’s part and the patient’s engagement in the treatment process, but it rewards these qualities by exerting a tremendous reversal effect to the senescence-process.

For more, visit: gorgeousgouri.com

KATARZYNA GRUDZIEŃ, MD, LiftMed hospital, Rybnik, Poland; KACPER GRUDZIEŃ, Medical Student LiftMed hospital, Rybnik, Poland

“Gouri is a truly innovative product, characterised by its increased safety of use and far better cosmetic outcomes in skin rejuvenation.”

Industry events in 2023/24 for the aesthetic and anti-ageing market

EUROPE REST OF WORLD NORTH AMERICA

28–29 SEPTEMBER 2023

BAAPS 2023

London, UK

baaps.org.uk/

5–7 OCTOBER 2023

AGORA 2023

Milan, Italy

www.congressomedicinaestetica.it

11–14 OCTOBER 2023

EADV 2023

Berlin, Germany eadvcongress2023.org/

19–20 OCTOBER 2023

CCR 2023

London, UK

www.ccrlondon.com/about-ccr/

17–18 NOVEMBER 2023

VISAGE 2023

Monte Carlo, Monaco

www.visagecourse.com

17–19 NOVEMBER 2023

SCARS 2023

Berlin, Germany

www.scars-meeting.com/

15–16 MARCH 2024

ACE 2024

London, UK

www.aestheticsconference.com/

27–29 MARCH 2024

AMWC 2024

Monte Carlo, Monaco

www.euromedicom.com

20–23 SEPTEMBER 2023

AAFPRS Annual Meeting

Las Vegas, NV

www.aafprs.org

26–29 OCTOBER 2023

Plastic Surgery: The Meeting Austin, TX www.plasticsurgerythemeeting.com

22–24 FEBRUARY 2024

AMWC Americas

Miami, FL

www.amwcamericas.com

15–16 SEPTEMBER 2023

AMWC India

Mumbai, India

www.amwcindia.com

7–8 OCTOBER 2023

FACE ASEAN

Bali, Indonesia

www.euromedicom.com

18–19 NOVEMBER 2023

AMWC Japan

Kyoto, Japan

www.amwc-japan.com/en