PRIME May/June 2024 Issue

How would you like to have the most advanced 3D imaging technologies in your hands?

Find out how

PERIORAL PIGMENTATION AETIOLOGICAL FACTORS LIP AUGMENTATION WITH THE HYBRID BIO-LIPS TECHNIQUE REVOLUTIONISING POSTPARTUM RECOVERY WITH HIFEM AND RF

STEM CELLS Clinical preconditioning for

IWANT TO BEGIN THIS ISSUE BY CONGRATULATING LONG-TIME PRIME contributor Wendy Lewis on the release of her latest book, Aesthetic Clinic Marketing in the Digital Age (CRC Press). With over 25 years of experience in medical aesthetics, Wendy shares her deep understanding of the challenges aesthetic clinics face in marketing their products and services, managing patients, and increasing profits.

This second edition comes with additional chapters, more tips and easy to read charts and up to date strategies for success. It is the definitive guide written specifically for healthcare professionals to present best practices and actionable strategies for mastering digital marketing, social media, branding, and the advent of AI. It is a must-read for aesthetic practitioners to keep up with the latest developments they need to manage their businesses effectively. PRIME readers can grab their copy at www.routledge.com with a 20% discount using the code ACM23.

At the recent AMWC congress in Monaco, I had the pleasure of speaking to Dr Jiajie Li, a maxillofacial surgeon from China and the first recipient of the Young Physician Medical Research competition awarded by the AMWC China Scientific Advisory Panel. The award celebrates young innovators and researchers who look to push the boundaries of aesthetic medicine. She won the award for her research on DNA nanotechnology, which she believes will play a pivotal role in anti-ageing in years to come. You can learn more about Dr Li, the Chinese aesthetic market and AMWC China on page 16.

Affiliated partners:

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

Please send

There’s still time to book your spot at FACE London, taking place on July 12–14th, from its new venue in the heart of London. The programme has been redesigned into four unique agendas: Advanced Injectables, Multispecialty Aesthetics, Aesthetics Open Stage, and Industry Workshops. The agenda has been thoughtfully designed to make FACE more accessible to the whole aesthetic medicine community. It features 8 multidisciplinary sessions that are ideal for both MD and non-MD delegates at all experience levels. Topics that will be explored by the over 150 UK and international speakers include PRP, threads, injectables, combined treatments, business, lasers, peels, complications, and skin care.

Both the open stage and industry workshops are free to attend, while full passes start at £149. You can book your place at www.faceconference.com. You can also receive an additional 20% off your delegate pass by signing up to become an Aesthetic Multispecialty Society Premium Member. AMS Premium members will enjoy the extra discount off their delegate passes 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

May/June 2024

AviClear’s laser technology delivers long-term acne relief for all skin types

Non-melanoma skin cancer deaths continue to rise INDUSTRY

Aura’s instant 3D facial analysis technology is changing the face of aesthetic and skincare consults AMWC

Celebrating young innovators in aesthetic medicine COMMENTARY

The longevity factor

Jennifer Pearlman, MD, explores the biological foundations and lifestyle factors shaping women’s path to longevity CASE

Revolutionising postpartum recovery with HIFEM and RF technology

Hannah Lo, MD, shares her experience using high intensity focused electromagnetic energy with radiofrequency to treat diastasis recti

The hybrid bio-lips lift technique

Noura Lebbar, MD, discusses her preferred product choice and technique when performing lip augmentation

AESTHETIC FEATURES

Clinical preconditioning for stem cells

Ivan Ibáñez, MD, provides insights into the role of hormesis, intermittent fasting and senolytic supplements for enhancing stem cell function

Clinical-observational study in 50 Indian female patients with perioral pigmentation

Dr Janani Palanivel explores the aetiological factors behind persistent perioral pigmentation

PRACTICE MANAGEMENT

Get smart: investigating AI’s role in plastic surgery and dermatology

Wendy Lewis speaks to some top doctors to share how they are using AI tools in their practices and how they are not…yet

LENISNA’s special role in acne scar treatment: the prolonged stimulation of collagen

Evaluating the skin repair efficacy and tolerability of a facial night mask in Chinese females

The body toning revolution: high energy inductive therapy with Z Tone®

news

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

AVICLEAR’S LASER TECHNOLOGY DELIVERS LONG-TERM ACNE RELIEF FOR ALL SKIN TYPES

Armed with its breakthrough, award-winning technology, and effective light-based approach, AviClear by Cutera reinvents the journey to achieving long-term, acne-free skin. It’s the first and original FDAcleared energy device for the treatment of mild, moderate, and severe acne. With impressively high patient satisfaction where 9 out of 10 of patients were ‘satisfied’ or ‘very satisfied’ after treatment, AviClear achieves outcomes that redefine what’s possible.

The first of its kind, AviClear is an efficient and powerful in-clinic treatment developed to finally get acne under control. It significantly reduces active, inflammatory acne and helps prevent future breakouts by treating acne at the source without side effects or the need for medication or downtime. This can be achieved after three 30-minute sessions spaced 4 weeks apart.

It’s a state-of-the-art laser treatment that has been engineered with its unique 1726 nm wavelength which works to safely deliver laser energy into the skin to selectively target sebaceous glands and suppress sebum production.

Unlike most treatments for acne, AviClear’s cutting-edge technology makes it a safe and effective treatment for mild to severe acne. From hormonal to cystic acne, the treatment is suitable

for all skin types and tones and can be used on both adolescent and adult patients all year round.

The results continue to improve over time, resulting in clear skin. In AviClear’s clinical study, 92% of patients treated with AviClear saw at least half of their acne resolved at 12 months after the final treatment session.

Its precise technology prevents injury to the skin’s surface and makes AviClear a safe and effective acne treatment for all skin types and tones, eliminating the risk of hyperpigmentation previously associated with laser acne treatment for people with deeper skin tones.

Acne is one of

the world’s most widespread skin conditions affecting around 742 million people globally that’s almost 10% of the Earth’s population whose daily life, mental wellbeing and confidence are at risk of being impacted by the effects of acne. Following extensive research, AviClear found that: ‘Nearly 80% of moderate to severe acne sufferers admit acne holds them back from doing what they want. In fact, more than 1 in 4 moderate to severe acne sufferers have missed over 10 important moments due to

AviClear’s new campaign ‘Missed Moments’ is an ode to acne suffers worldwide who continuously worry about the past, present and dream of the future, encouraging them to embark on the journey to clear skin, giving them the freedom and power to ‘live in the moment.’

To discover the next-generation solution for acne treatment with your nearest AviClear dermatologist or aesthetic professional, find a provider who’s lighting the way to clear skin here: www.aviclear. com/en-uk/locations/.

PIONEERING SUPERFICIAL FAT RESTORATION IN AESTHETIC MEDICINE

Profhilo® announces the launch of Profhilo® Structura, an advanced injectable treatment designed to specifically target and regenerate superficial facial fat in the midface. Launching to the industry on June 4th in London, the European debut of Profhilo® Structura comes nearly a decade after UK and Ireland

distributor HA-Derma unveiled Profhilo, the eponymous hyaluronic acid bioremodeling treatment.

Developed by IBSA using the patented NAHYCO® technology, Profhilo® Structura represents a notable breakthrough in aesthetic medicine. It is the first injectable treatment specifically designed for

adipose tissue restoration, clinically proven to help reposition superficial fat to its natural state. This addresses critical concerns including pronounced facial hollows, skin laxity, and altered facial contours resulting from midface fat loss.

Profhilo® Structura is injected in the preauricular area using a

protocol that evaluates facial structure, including midface projection, hollows, laxity, and skin density. The treatment involves two sessions, typically one month apart, with minimal downtime, allowing patients to continue their daily activities immediately posttreatment.

NEW The Acne Revolution Is Here

The first and original FDA-cleared energy device for the treatment of mild to severe acne.

BECOME A PROVIDER

NON-MELANOMA SKIN CANCER DEATHS CONTINUE TO RISE

RESEARCH PREDICTS THEY WILL SOON OVERTAKE MELANOMA DEATHS

Recent research shows that non-melanoma skin cancer deaths are on track to overtake melanoma deaths in England and Scotland for the first time.

Non-melanoma skin cancer (NMSC) is currently the most common type of cancer in the UK. Most NMSCs have a high survival rate in comparison to melanoma, and awareness of them is lower. However, recently published research suggests that based on current trends, the number of NMSC deaths will overtake melanoma deaths in years to come, through the sheer number of people they affect.

There are two types of NMSCs, basal cell carcinoma and cutaneous squamous cell carcinoma. It is estimated that there are around 250,000 new cases every year, with basal cell carcinoma making up around 180,000 of these cases. While less common than basal cell carcinoma, cutaneous squamous cell carcinoma is more deadly.

Current research and trends

Dermatology researchers looked at data from 6 countries with more than 1,000 skin cancer deaths annually and high-quality mortality data, including England and Scotland. In all these countries, deaths from melanoma reduced or remained static between 2010 and 2019, due to advances in melanoma care. In the same period, NMSC deaths increased.

‘A shift in how we view non-melanoma skin cancer is long overdue. While non-melanoma skin cancer does have a high survival rate, it is becoming so common that the number of people it kills each year is beginning to overtake more deadly cancers, including melanoma. We estimate that there are around a quarter of a million cases a year in the UK compared to under 17,000 melanoma cases. While awareness of melanoma skin cancer is still very important, we would urge people to educate themselves on the signs of non-melanoma skin cancer as well.

‘Like melanoma, non-melanoma skin cancers are often caused by excessive sun exposure. They are particularly common among older people and the increase in cases that we have seen in recent years is in part due to the ageing population in the UK.’

Improving awareness

Dr Zoe Venables, Dermatology consultant and clinical lead at the National Disease Registration Service, who led the research, said: ‘Huge leaps, particularly in the form of immunotherapies, have been made in how we treat melanoma skin cancer in the last decade. This research provides analysis of deaths from both melanoma and nonmelanoma skin cancers in England, and we hope our findings will support future research and result in greater awareness of non-melanoma skin cancers to improve prevention and early detection.’

If current trends continue, non-melanoma skin cancer deaths will soon overtake melanoma in these countries, first in Scotland (2028), then in the US (2031), Australia (2033), and England (2038).

If current trends continue, NMSC deaths will soon overtake melanoma in these countries, first in Scotland (2028), then in the US (2031), Australia (2033), and England (2038).

As an example, in England, over the last decade deaths attributed to NMSCs have increased by 42%, an increase which is higher than many other cancers.

Dr Chris Bower, Clinical Vice-President of the British Association of Dermatologists, said:

The best way to check for skin cancer is to carry out regular skin self-examinations, ideally once a month. Early detection can help to reduce the risk of developing a larger, more serious skin cancer that may need extensive surgery or treatment. The British Association of Dermatologists has created a useful guide to skin cancer, which you can find by visiting: www.bad.org.uk.

IBSA LAUNCH TWO NEW DIETARY SUPPLEMENTS

IBSA USA announced that its Syrel™ (selenium + BioPerine®) and Thirodium™ (iodine) brands are now available in the U.S. Manufactured and marketed by IBSA, Syrel and Thirodium are select dietary supplements that contain two vital micronutrients for thyroid support: selenium and iodine, respectively.

‘Syrel and Thirodium are the latest innovations from IBSA, a company whose name is synonymous with high-quality prescription drugs for thyroid care,’ said Michael Scully, Head of Commercial Operations, IBSA USA. ‘Unlike other manufacturers who market a broad line of nutritional supplements, we are only offering a select line of products. These products’ micronutrients are necessary for healthy thyroid function. They’re healthcare provider-focused and backed with high-quality scientific studies.’

Syrel, a selenium-containing dietary supplement, combines the benefits of selenium and BioPerine. BioPerine is a black pepper extract that has been demonstrated to improve the absorption of key nutrients such as selenium. Thirodium, an iodine-containing supplement, is designed to enhance total dietary intake of the nutrient. Both Syrel and Thirodium are soft gel formulations made with IBSA’s unique PEARLtec technology for enhanced absorption.

Syrel and Thirodium will be supported by healthcare provider detailing, professional samples, and scientific studies. Both are available for purchase on Amazon. Syrel is offered in a strength of 100 mcg of selenium/5 mg of BioPerine per capsule. Thirodium comes in two strengths: 100 mcg and 225 mcg of iodine per capsule. Both products are packaged in blisters in 30-count cartons.

IBSA plans to add to its IBSA Care line of select dietary supplements by introducing other products later this year. Like Syrel and Thirodium, they will also be supported by healthcare provider promotion and will feature novel formulations. More information about Syrel, Thirodium and the IBSA Care line of dietary supplements can be found at www.IBSACareUS.com.

With over 25 years of experience in medical aesthetics, Lewis shares her deep understanding of the challenges aesthetic clinics face to effectively market their products and services, manage patients, and increase profits. This updated text is the definitive expert user’s guide written specifically for healthcare professionals and medical spa managers to present best practices and actionable strategies for mastering digital marketing, social media, branding, and the advent of AI. It is a must-read for aesthetic practitioners to keep up with the latest developments they need to manage their businesses effectively in this highly competitive field. April 2024 • Hb: 9780367405656 • Pb: 9780367405182 • eBook: 9780429356742 www.routledge.com/9780367405182

on hot topics you need to know

tips, charts, tables, and resources

The Aura 3D imaging system applies proven technology from Hexagon and successfully applies it for the face, the most demanding landscape Hexagon ever captured in 3D.

— Simon Mark, Vice President Innovation, Hexagon

PICTURE PERFECT

Aura’s instant 3D facial analysis technology is changing the face of aesthetic and skincare consults

HEXAGON’S TECHNOLOGY HAS ALREADY HAD A MAJOR IMPACT on factories, farms, mines, industrial facilities, cities, and nations by combining sensors, software, and autonomous technologies to drive productivity and quality.

Now, the Swedish multinational company is set to disrupt aesthetics with the Aura 3D Imaging System.

Aura captures a photorealistic 3D digital twin of a patient’s face and neck with a single shot. The system then delivers cutting-edge artificial intelligence (AI)-based insights and precise dimensions and details of a patient’s face and neck to the practitioner’s device for real-time, comprehensive analysis. Aura generates a full report on patients’ skin, including wrinkles, pores, red areas and brown spots, and skin texture, as well as before-and-after images of the digital twin to model what is — and isn’t — possible with aesthetic procedures.

This allows for a shared visual language during the consultation process and sets the stage for bespoke, tailored treatment planning.

‘The aesthetics industry offers a hugely exciting opportunity for Hexagon to apply our innovative digital twin technology, most commonly applied to buildings and manufacturing, to the most complex landscape of all: the human face,’ says Burkhard Boeckem, Hexagon’s Chief Technology Officer.

The company worked with dermatologists, aesthetics doctors, and plastic surgeons across the globe to develop the Aura system. ‘It’s a product from practitioners for practitioners,’ says Mr. Boeckem. ‘Aura has been designed to enhance the consultation process and create a shared visual understanding between practitioners and patients.’

Aura goes global

After a successful launch at AMWC in Monaco, the company is now rolling out the Aura technology globally.

Each facial element, including wrinkles, pore size, redness, pigmentation, and skin texture receives a score across different facial areas. A customizable filter option allows practitioners to select the score they want to focus on during the consultation. Aura measures angles and distances to clarify the potential for enhanced symmetry, allowing for a more balanced and harmonious facial appearance.

The technology can analyze results from soft-tissue injections or fat grafting, highlighting volume loss or gain in easy-to-review colors. The software also calculates these variations, providing an evidence-based understanding of the actual effects of treatment.

Practitioners can effectively demonstrate the progression of their patients’ skin and appearance over time with Aura, showcasing the tangible improvements resulting from their treatment plan. This bespoke approach has been shown to increase patient satisfaction with their outcomes.

WENDY LEWIS is Founder & President of Wendy Lewis & Co Ltd since 1997, a strategic marketing communications group in New York City. Their clients include healthcare, skincare, medical devices, dermatologic brands, start-ups, as well as aesthetic practices and medspas. A frequent speaker at conferences globally, she is the founder of the LinkedIn group, Global Aesthetics Professionals, with over 10,000 members. The second edition of her textbook, Aesthetic Clinic Marketing in the Digital Age: From Meta to AI, was published by CRC Press. @wendylewico.

Aura has been designed to enhance the consultation process and create a shared visual understanding between practitioners and patients.

— Burkhard Boeckem, Chief Technology Officer, Hexagon

‘The Aura 3D Imaging system captures the patient in one instance and provides the aesthetic practitioner with a photorealistic 3D visualization with skin analysis features as well as volume comparison and vector analysis of before and after captures,’ says Hexagon’s Vice President Innovation Simon Mark.

‘In contrast, other systems may need to do 3-4 photos to capture all features, while Aura only requires one capture. The Aura 3D imaging system applies proven technology from Hexagon and successfully applies it for the face, the most demanding landscape Hexagon ever captured in 3D,’ he says.

Aura in practice

Sophie Shotter, MBChB, an aesthetic doctor in London, incorporates Aura through her patients’ journeys.

‘It’s such a useful tool during consultations, as patients never see themselves in three dimensions,’ she says. ‘It allows me to show patients things that they may not be able to perceive in a mirror, which shows them a two-dimensional image of themselves. As they say, a picture tells a thousand words.’

The technology also allows her to track the progress of treatments. ‘It takes our

BURKHARD BOECKEM, Chief Technology Officer, Hexagon

SIMON MARK, Vice President Innovation, Hexagon

SANDRA TOBLER, Product Manager, Hexagon

Aura sets a new standard with its efficient and streamlined singlecapture process.

– Sandra Tobler, Product

SOPHIE SHOTTER, MBCHB, Aesthetic Doctor, London, UK

CLAUDIA BETTINA RÜMMELEINS, MD, PHD, CEO and Medical Director of Hautwerk AG in Zurich, Switzerland

MAURIZIO CAVALLINI, MD, Plastic Surgeon, Milan, Italy

perception of results from not just being subjective but being objective and measurable,’ she says.

Claudia Bettina Rümmeleins, MD, PhD, CEO and Medical Director of Hautwerk AG in Zurich, Switzerland, considers it a plus that Aura allows for an enlarged examination of the skin, and the ability to record the skin’s condition both macroscopically and dermoscopically. ‘They also enable me to review these images with patients, enhancing their understanding of their diagnosis and treatment.’ She tells PRIME.

Another plus is that the images allow doctors and patients to evaluate therapy outcomes, including those from laser treatments, during follow-up visits. ‘This advancement is immensely beneficial in everyday clinical

practice and is highly valued by my patients,’ says Dr. Rümmelein.

She worked with Hexagon to develop and perfect the Aura technology. ‘It is extremely valuable to me to contribute to the development of a system that not only enhances our diagnostic capabilities but also enriches the dialogue with the patient,’ she says.

Maurizio Cavallini, MD, a plastic surgeon in Milan, Italy, consulted in the design process for the Aura 3D Imaging System. ‘We show our patients … the real improvement that they have with a lot of treatments that we normally perform,’ he says. The technology also allows patients and doctors more insights and to see details such as vectors.

‘AURA system could give us a comparison between before and after for coloration, wrinkles, lines, and volumes,’ Dr. Cavallini continues. ‘It’s important for aesthetic medicine to be evidence-based.’

He believes other systems can’t provide the same depth and breadth of information that the AURA system does.

‘Aura sets a new standard with its efficient and streamlined single-capture process,’ agrees Hexagon Product Manager Sandra Tobler. ‘Its 3D reconstructions are remarkably precise, capturing intricate details down to the neck. Moreover, Aura offers unparalleled skin analysis, revealing pores, wrinkles, pigmentation, red areas, and skin texture with exceptional clarity.’

Elevating aesthetic care

Practitioners report that they are finding that here’s no learning curve with Aura. Only minimal training is required to operate the system, so clinic staff, assistants, associates, or technicians can operate Aura, which boosts office efficiency.

Another benefit is that Aura is portable, allowing physicians to take it from room to room or office to office seamlessly. ‘The hardware itself is also completely unique, and it combines so many cameras into a single, lightweight, portable device [which] makes the Aura significantly less cumbersome than alternative devices,’ Shotter says.

Marketing Aura has been easy for Shotter. ‘I find having the Aura on my desk intrigues patients who ask, “Wow, what’s that!” It looks so different compared with other imaging devices, and so it markets itself,’ she says.

‘The Aura System elevates aesthetic and dermatological care, analyzing key skin aspects with precision.’ She continued. ‘It’s easy to use and encourages direct patient interaction, elevating our clinical communication. Practical as well as high performance, it will be a valued asset in any modern skincare practice.’

For more information, visit aurareality.com or visit the Aura stand at the 5CC Lisbon conference.

Left and far left: Brown spots and skin texture images.

Above left: The Aura 3D Imaging System.

In collaboration with the Aesthetic Multispecialty Society (AMS), the 2024 AMWC Awards meticulously evaluated more than 1000 submissions hailing from 38 countries, contending for top accolades in categories across Best Products & Devices and Best Clinical Cases. Following an exhaustive review and shortlisting process, 237 standout entries emerged as finalists, ready for evaluation. The final round was judged by a distinguished panel of physicians specializing in aesthetics and anti-aging medicine, alongside over 20,500 votes from industry peers. The ultimate winners across the 25 categories were unveiled at a prestigious ceremony held at AMWC Monaco on March 28th, 2024. Discover all finalists and winners on the AMWC website: www.amwc-conference.com

www.benev.com

ASCEplusTM IRLV is the world’s first exosomebased regenerative product for vaginal rejuvenation. With a dual mechanism of regeneration and anti-inflammation, it addresses multiple common concerns such as vaginal dryness, and chronic infections like lichen sclerosus.

Activ’ anti-wrinkle ultimate is a high-quality food supplement specifically developed for the skin. It contains a unique active ingredient with clinically proven efficacy: DermboostTM, which reduces wrinkles. Clinical results prove it: +63% hydration, -22% wrinkles.

www.dekalaser.com

4th Generation Thread belongs to innovative NAMICA technologyUnique composition of P(LA/CL) thread with non-crossed Hyaluronic Acid coating. This is the new era of Solid Biostimulators which is the only product analogue on the global aesthetic market providing triple results.

Make results more visible with the 3D LifeViz Mini Pro and LifeViz Neo software. Elevate consultations with a 3D facial aesthetic camera. Let AI and facial recognition manage image upload and organization. Achieve impactful B/A results. Now exclusively with 3D pictures on mobile and connectivity.

Our clinically proven intensive dual-action post-care optimizing balm is designed to quickly absorb into the skin delivering the concentrated power of exosomes and intensive hydrators to optimize treatment results and reduce downtime.

The Novel Onda PRO by DEKA maximizes the Coolwaves® effect through the new PGWPrecision Gigawave Technology in noninvasive face and body remodelling, firming and lifting.The energy of microwaves is managed by technological solutions to be effective and safe on fat, cellulite and laxity.

Laser, Light And Energy-based Device

www.dekalaser.com

Tetra Pro | DEKA Best Aesthetic Products & Device Integration

The novel TETRA PRO CO2 laser performs innovative fractional photo rejuvenation and even CoolPeel. TETRA PRO is effective for treating aging skin and for real improvement in wrinkles, fine lines, skin laxity, and skin texture. TETRA PRO is also appreciated in skin surgery and for scars improvement.

Skin Regen MD - Radiance | Dermoaroma Best Injectables For Skin Revitalization

www.dermoaroma.com

Radiance addresses uneven skin tone and dark spots, preventing melanin production and resulting in a significantly improved skin complexion, decreases activated T cell and increases anti-inflammation effect, resulting in dramatically improved skin tone.

www.skinboosters.com

Best Injectable Dermal

Filler

Best Integrative Medicine

Dr Pablo Gonzalez Isaza Colombia

Sclerous lichen combined approach with pulsed Co2 laser and exosomes from periumbilical fat

Best Energy-based Treatments

Best Genital Revujenation

Dr Ernesto Delgado Cidranes Spain

Exosomes: New solution in female genitalia regeneration.

Best Non-surgical Body Shaping

Restylane® Skinboosters™ | GALDERMA Best

Stimulate | NEAUVIA

www.neauvia.com

Restylane(R) Skinboosters(TM) is the original and only HA skin quality injectable clinically proven to provide 6 key skin quality benefits for healthy glowing skin for up to 15 months.

Neuromodulator

Alluzience® | GALDERMA

www.galderma.com

Dr Jaqueline Barreto Rodrigues Brazil

Treatment of sagging skin without scars: technology in favor of aesthetics

Best Hair Restoration

Ken Anderson, MD United States

Gender-affirming Hair Restoration Surgery

Alluzience® (abobotulinumtoxin A) is the first ready-to-use liquid neuromodulator in Europe, temporarily reducing moderate to severe glabellar lines. Onset of effect in 24 hours, up to 6 months of duration*.

Best Skin

Stimulate is a biodegradable hyaluronic acid hydrogel crosslinked with PEG and enriched with CaHA, Glycine and L-Proline. Neauvia hydrogels are based on PEGDE crosslinking technology which appears to have better biocompatibility, excellent bio integration, and optimal rheological characteristics.

Tightening

/ Resurfacing

Device

Youlaser Prime | Quanta System

www.quantasystem.com

Youlaser Prime is a fractional resurfacing and dermatologic surgery device based on powerful CO2 and fiber laser sources. It is the evolution of the first combined ablative and non-ablative laser, designed and launched by Quanta System in 2013, capable of emitting both wavelengths at the same microp

Best Threads Treatment

Dr Hüray Hügül Turkey

Combined Thread Lifting & Filler Application For Face & Neck Lifting & Rejuvenation

Best Surgical Body Shaping

Dr Alain Michon Canada

Exosomes: New solution in female genitalia regeneration.

Best Surgical Facial Rejuvenation

Adam Rubinstein, MD United States

Total body and breast makeover after weight loss

Dr Cécile

Winter

Turkey

Combined Thread Lifting & Filler Application For Face & Neck Lifting & Rejuvenation

Best Complication Treatment

Dr Hagai Betzer

Israel

Six-Day Challenge: Successfully Resolving Vascular Occlusion 6 Days Post Hyaluronic Acid Filler Using Ultrasound Guidance

Best Non-surgical Facial Beautification

Dr Simone May

Austria

Combined treatments to achieve a beautification after a severe lip injury

Best Condition Improvement Treatment

Dr Yaryna Turkevych Ukraine

Improvement of the Quality of Life and Medical Conditions in the patients who are victims of injuries and burns

Best-non Surgical Facial Rejuvenation

Dr Fernando Felice

Argentina

Facial Rejuvenation with hybrid fillers taking into account the ligament line, virtual spaces and specific deep fat pad compartments.

Best Skin Enhancement & Scar Treatment

Dr Massimo Vitale

Italy

Management of Mixed Melasma on Fitzpatrick phototype V: a new and safe laser therapy treatment

AMWC CHINA

CELEBRATING YOUNG INNOVATORS IN AESTHETIC MEDICINE

PRIME speaks to the winner of the Young Physician Medical Research competition, which was held at AMWC China 2023 in Chengdu

AMWC CHINA 2023 WAS held to great acclaim at the Chengdu Tianfu International Convention Centre on October 20–22, 2023. Boasting a conference and exhibition area of 10,000 square metres, accommodating more than 200 exhibitors and over 180 speakers, the conference played host to over 4,800 professional delegates over the three days who came to learn and network with their peers.

AMWC is a conference based on the concept of international academic openness. That’s why, last year AMWC China held the first AMWC Young Physician Medical Research Competition. The competition aimed to bring together rising stars in the field of medical research and provide them with a unique platform to showcase their excellence.

Through its unique competition format, participants had the opportunity to share their research results, demonstrate their medical insights, and interact with their peers. It was a cross-border gathering of ideas and innovation

and encouraged young medical researchers to think eclectically and integrate inspiration from different fields into aesthetic medicine research.

The Young Physician Medical Competition was an outstanding success and welcomed exceptional young medical researchers from all over the world to showcase their wisdom and innovation. The submissions were judged by the AMWC Global & China Scientific Advisory Panel, with 60 submissions handpicked to be displayed as poster presentations at AMWC China. Of these, 10 were shortlisted for the final round where the candidates were asked to present their research on stage in front of the Scientific Advisory Group.

Dr Jiajie Li, a maxillofacial surgeon from China, was awarded the first-place prize, which included a flight, accommodation, and a full Dr Jiajie Li

pass to AMWC Monaco, where PRIME caught up with her to share her thoughts on winning the competition.

‘This is my first visit to Monaco, and it’s so beautiful. I’m very glad to be here and to be invited to attend the AMWC. It’s a very good opportunity for me to meet with pioneers of aesthetic medicine. To learn from them and exchange ideas with the many speakers and delegates attending.’ Said Dr Li.

What was the topic for your winning submission to the AMWC Young Physician Medical Research competition?

It was research presented on DNA nanotechnology, what we call Tetrahedral framework nucleic acid (tFNA). My team and I focused on its potential in various biomedicine applications. TFNAs offer a good opportunity in regenerative medicine, as they can provide the cells and the tissues to repair and regenerate. So we hope that tFNA can be a future star in regenerative medicine and be used in aesthetic treatments around the world.

What does it mean to you to win the competition?

It means a lot to be recognised for my research. I have always believed that basic research goes on to find its way into clinical practice. So, this platform is a great way to showcase our research, and I really hope that my research will lead to others interested in DNA nanotechnology to continue looking at its application in aesthetic medicine.

Many people outside of China have little information on the Chinese aesthetic market. Can you tell us what procedures are popular in China and the major differences to other markets?

The most popular procedures in China are facial rejuvenation, body contouring and skin whitening is really important. After that, I would say breast augmentation is also popular. In terms of differences, I’m surprised that we actually have the same aesthetic training. All of the speakers and physicians I talk with speak of less invasive treatments and having a natural look. That’s different to what my concept of European Aethetic trends was before I came here.

Are there any products you are really excited about?

Yes, it’s fillers. There are so many brands and different types of fillers here in Europe. We do not have that much choice in China, so it has

been good to learn more about them here in AMWC Monaco. The government is currently working on industry regulation, so maybe we will have more in the future, maybe.

What insights have you gained from your time at AMWC China and Monaco that you will be incorporating into your practice?

Yes, I have learnt a lot over the past two days. I have listened to many great lectures and a new concept that I really support is health is beauty but beauty isn’t equal to health. So we need to be careful in our clinical practice that

we are looking after all concerns of the patient and not just the surface.

What are the main reasons why other young physicians should attend AMWC China?

There are a number of reasons for young doctors to attend AMWC China. The first is to learn the latest techniques, and to gather a more comprehensive knowledge of aesthetic medicine. They also have the chance to meet other doctors, to exchange ideas because people want to know what’s going on in China and how we treat patients if there are differences or if they’re similar to other markets. It’s great for networking and sharing with people not just from China but also from around the world and finding ways to collaborate in the future. It is even beneficial to look for what business opportunities exist with the companies exhibiting at the congress. It’s a great platform for young doctors to share their experiences and talk with the top physicians.

Photos

THE LONGEVITY FACTOR

Jennifer Pearlman, MD, explores the biological foundations and lifestyle factors shaping women’s path to longevity

JENNIFER PEARLMAN, MD, is the founder and Medical Director of PearlMD Rejuvenation, a leader in women’s health and regenerative and cosmetic medicine. Dr Jennifer Pearlman is a renowned expert in women’s health, hormones and ageing.

email: drpearlman@ pearlrejuvenation.com

KEYWORDS longevity, ageing, telomeres

WOMEN ARE BORN WITH UNIQUE biological advantages favouring longevity. I have coined this phenomenon the ‘Female Longevity Factor’. However, offsetting these advantages are potential risks related to lifestyle and environmental exposures. By proactively addressing the so-called epigenetic effects, a proactive approach to ageing can be achieved to live longer younger.

The longevity gender gap refers to the extra seven years that women, on average, live longer than men. The added years of life too often fail to translate into extended health spans as women often experience disease and disability in their last decade of life. Healthcare gender inequities exist throughout the biomedical system, from research to diagnosis to treatment of disease. Too often, women are mis- or under-diagnosed, untreated or mistreated, and the unique risk factors that predict disease in women are too often unrecognised. For example, cardiovascular disease is the most common cause of death in women,

accounting for more deaths than all other causes combined. However, women are often misdiagnosed when presenting with a heart attack and are too often denied lifesaving interventions. Hormonal milestones pose unique risks to women, and experiencing pregnancy-related high blood pressure, early menopause, or severe hot flashes and sweats are all unique cardiac risk factors for women.

Hallmarks of ageing

Ageing is not hardwired in our DNA. While scientists have discovered several longevity genes, the vast majority of our ageing is under our control and influenced by our life choices.

Twelve hallmarks of ageing have been identified. These are both drivers and markers of biological age and affect women differently than men. The hallmarks include genomic and epigenomic changes, telomere loss, mitochondrial exhaustion, inflammation and nutritional factors. Furthermore, oestrogen exhibits geroprotective effects throughout a woman’s lifetime and exerts influence on nearly all hallmarks of ageing.

Genomic gifts

Studies of ‘super-agers’, those that live into their ninth decade and beyond with physical and cognitive vitality, have revealed over 200 longevity genes.

Women have an innate genomic advantage with an extra X chromosome. There are over 1000 genes encoded on the X chromosome and these X-linked traits include brain, bone, neurological and immune function. Men on the other hand lack a second X chromosome and instead have a Y chromosome, with fewer than 80 genes mostly coding for secondary male characteristics. The second X chromosome serves as a genomic advantage for women with an age-dependent contribution to longevity.

A science-based approach to live longer younger

The tale of telomeres

Within each of our chromosomes lies an additional source of the female longevity advantage. Telomeres are the non-coding protective caps of our chromosomes that shorten over our lifetime.

Telomere loss, like damaged ends to our shoestrings, can be considered a biological limit to our lifespan. Telomere length is extended under the influence of an enzyme, telomerase, which repairs shortened or damaged telomeres. Short telomeres predict disease, ageing, and mortality.

Women are born with longer telomeres than men. However, these longer telomeres are more susceptible to the harmful effects of stress and oxidative damage. Oestrogen is telomereprotective as it upregulates telomerase. At menopause, with the decline of oestrogen, women experience a rapid shortening of telomeres, and age acceleration ensues.

Epigenetic influence

tissues like the thyroid, adrenals, and ovaries that produce their effects throughout the body. Oestrogen is critical throughout a woman’s lifespan and binds cell membranes and nuclear receptors, affecting both cellular activity and genomic expression. Oestrogen is geroprotective as it positively impacts the hallmarks of ageing. The menopausal loss of oestrogen triggers accelerated ageing in women. In fact, during the years that saddle a woman’s final menstrual cycle she will age three-fold faster than any other time in her life.

A lifestyle for longevity

Ageing is not inevitable. Your DNA is not your destiny. Although your genes may load the gun, a poor diet and unhealthy lifestyle can pull the trigger. So does a longevity diet exist? Studies of the longest-living populations in the world, referred to as the ‘Blue Zones,’ reveal that the secrets to living longer can be found in the unique diets and lifestyles of these diverse populations.

The Okinawa islands off the mainland of Japan boast the longest-living women in the world. These women eat a plant-based diet, nearly void of refined sugars and processed foods and remain active into their final years. The Okinawan diet differs from that of mainland Japan. Instead of a rice-based diet, they consume large amounts of Japanese sweet potato, which contains high yields of hyaluronic acid, a sort of elixir of youth. Hyaluronic acid is used to treat ageing skin, eyes, joints and vaginal dryness in women after menopause. Indeed, these women may have discovered a diet for longevity.

The vast majority of our ageing is considered to be influenced not by genetics but by gene-environment interactions, referred to as epigenetics. Epigenetic factors arise from our lifestyle, life choices, environment and exposures. Poor nutrition, environmental toxins and psychological stress are important epigenetic factors.

Women are more susceptible than men to epigenetic ageing, and with epigenomic alteration to the germ line, this risk can be passed on to future generations. Epigenetic imprinting through maternal exposure is transgenerational. For instance, a maternal grandmother’s diet that is low in protein can lead to adverse outcomes in her granddaughter. Epigenetics confirms that our health and ageing are very much under our control. And with the impacts being passed on to future generations, women are truly a gateway to the health and longevity of their family tree.

Pearls of wisdom for healthy ageing

Hormonal factors

Hormones are vital life signals secreted by glandular

The vast majority of our ageing is considered to be influenced not by genetics but by gene-environment interactions, referred to as epigenetics.

Beauty is more than skin-deep

Skin is our largest organ and receives, on average, 7% of our blood flow. Looking young is a sign of slow biological ageing, and the beauty span can predict a longer health span. There are more options than ever to look and feel our best with little to no downtime, pain, or risk.

A personalised approach

We are each born with a unique set of risks and advantages when it comes to health and ageing. The key is understanding our individual needs and addressing the hallmarks through a personalised health lens that evolves over time.

Ageing well is a choice, but there is not a one-size-fitsall approach. By addressing our individual needs, preferences, and goals inside out, a proactive plan for healthy ageing can be formed. Ageing while achieving optimal health and vitality is the key to living longer and younger.

REVOLUTIONISING POSTPARTUM RECOVERY WITH HIFEM AND RF TECHNOLOGY

Hannah Lo, MD, shares her experience using high-intensity focused electromagnetic energy with

Pradiofrequency to treat diastasis recti

OSTPARTUM BODY IMAGE CAN INDEED HAVE A SIGNIFICANT impact on a mother’s self-confidence. The physical changes that occur during and after pregnancy, coupled with societal expectations and pressures, can contribute to a complex range of emotions that affect how a woman perceives herself.

Pregnancy brings about profound changes in a woman’s body, including weight gain, stretch marks, and alterations in breast size and shape. These changes can sometimes lead to feelings of discomfort, self-consciousness, or dissatisfaction with one’s appearance, impacting self-confidence.

Mental health

Negative body image is closely linked to mental health, and conditions such as postpartum depression and anxiety can amplify feelings of self-doubt and low self-worth.

Impact on intimacy

Changes in body image can affect a woman’s comfort and confidence in intimate relationships. This shift may strain the emotional connection with a partner, further impacting self-esteem.

Perceived lack of control

The physical changes during pregnancy and postpartum recovery can sometimes make mothers feel a lack of control over their bodies. This loss of control can contribute to feelings of frustration and decreased self-confidence.

Negative body image is closely linked to mental health, and conditions such as postpartum depression and anxiety can amplify feelings of self-doubt and low self-worth.

It’s crucial to recognise that every woman’s postpartum journey is unique. Supportive measures, such as seeking professional help, joining postpartum support groups, and fostering open communication with partners and loved ones, can play pivotal roles in addressing postpartum body image concerns and rebuilding self-confidence.

KEYWORDS

Postpartum body recovery, negative body image, HIFEM technology, diastasis recti, HIFEM with RF Technology

However, one of the biggest challenges that we encounter in the Asian culture is the lack of awareness to seek help during the postpartum period. It’s true that many mothers may underestimate the importance of postpartum recovery and may inadvertently neglect their health during the crucial ‘golden period’ that typically

HANNAH LO, MD, LCP board certified aesthetic physician, Clique Clinic Bangsar, Kuala Lumpur, Malaysia

Figure 1 A 39 year-old female presented 8 months post-partum, normal vagial delivery. They received 6 sessions of HIFEM with RF at 2 weeks interval, further enhanced with RF with Shockwave during the first 4 visits. (A) Before and (B) 3 months following completion of treatment course (C) 12 months following completion of treatment course A B C A B C

A

A B B C C

further enhanced with RF with Shockwave during the first 4 visits. (A) Before and (B) 3 months following completion of treatment course (C) 12 months following completion of treatment course

spans from 3 to 12 months after giving birth. Other factors that contribute to the challenges mothers face in prioritising postpartum recovery during this time include the new mother’s responsibilities, as the demands of caring for a newborn can be overwhelming.

Understanding diastasis recti

Diastasis recti is a condition in which the rectus abdominis muscles, separate along the linea alba, the connective tissue that runs down the midline of the abdomen. This separation is a normal part of pregnancy as the abdominal muscles stretch to accommodate the growing uterus. However, in some cases, the separation persists postpartum, leading to a weakened core and various associated issues, affecting both appearance and functionality.

Who is at most risk?

Some of the risk factors for diastasis recti include:

■ Having twin pregnancies/larger babies

■ Pregnancy in petite women

■ Poor abdominal muscle tone

■ Obesity/being overweight

■ Pregnancies being close together.

Gynaecologists primarily focus on the medical aspects of women’s reproductive health, including prenatal care, childbirth, and postpartum care. While some gynaecologists may not specialise in managing postpartum body image concerns, they play a crucial role in supporting

While some gynaecologists may not specialise in managing postpartum body image concerns, they play a crucial role in supporting overall postpartum body image and offer guidance or refer mothers to appropriate professionals.

overall postpartum body image and offer guidance or refer mothers to appropriate professionals.

HIFEM with RF technology

High-intensity focused electromagnetic energy (HIFEM) with radiofrequency (RF) energy has recently gained popularity in the treatment of diastasis recti, especially amongst the postpartum population. During a HIFEM treatment session, electromagnetic energy is delivered to the muscles, causing rapid and intense contractions. These contractions engage the entire muscle structure, stimulating deep layers of the muscles that are often challenging to activate through conventional exercise. The intense muscle contractions lead to the remodelling and strengthening of the abdominal muscles over time.

Radiofrequency technology is known for its ability to heat the skin’s deeper layers, promoting collagen production and tightening the skin. This can contribute to improved skin tone and texture.

Benefits of HIFEM in diastasis recti treatment

Focused and efficient: HIFEM technology precisely targets the muscles affected by diastasis recti, providing a more concentrated and effective treatment compared to general exercise routines.

Non-invasive: Unlike surgical interventions, HIFEM treatments are non-invasive, eliminating the need for incisions or downtime.

Time-Efficient: HIFEM sessions typically last around 30

Figure 2 A 34 year-old female presented 4 months post-partum, normal vagial delivery. They received 6 sessions of HIFEM with RF at 2 weeks interval,

A B B C C

minutes, making it a convenient option for busy mothers who may find it challenging to commit to lengthy exercise routines.

Visible results: Clinical studies have demonstrated improvements in abdominal muscle separation, core strength, and overall appearance after a series of HIFEM treatments.

Clinical evidence

Research studies have shown promising results in the use of HIFEM technology for diastasis recti treatment. Patients have reported significant reductions in abdominal muscle separation, improvements in perceived core muscle strength, and reductions in waist circumference.

Case 1: A 39-year-old mother presented 8 months following a natural delivery birth. She completed six sessions of HIFEM with RF at 2 week intervals, further enhanced with RF with Shockwave during the first four visits. Photos were taken at baseline, 3 months and 12 months following completion of the treatment course.

Case 2: A 34-year-old mother presented 4 months following a natural delivery birth. She completed six sessions of HIFEM with RF at 2 week intervals, further enhanced with RF with Shockwave during the first four visits. Photos were taken at baseline, 3 months and 12 months following completion of the treatment course.

Case 3: A 32-year-old mother with twin pregnancy presented to the clinic nine months after her twins were delivered via cesarean section. She completed six sessions of HIFEM with

Clinical studies have demonstrated improvements in abdominal muscle separation, core strength, and overall appearance after a series of HIFEM treatments.

RF at 2 week intervals, further enhanced with RF with Shockwave during the first four visits. Photos were taken at baseline, 3 months and 12 months following completion of the treatment course.

There was a marked improvement in abdominal muscle tone and core muscle strength and a reduction in waist circumference. In this case, the patient was advised to continue another course of HIFEM with RF for further improvement.

Conclusion

As technology continues to advance, HIFEM combined with RF emerges as a game-changer in postpartum care, offering an effective, non-invasive solution to address diastasis recti. With its ability to target and stimulate deep abdominal muscles, HIFEM technology provides new hope for mothers seeking a non-invasive and more efficient path to postpartum recovery. As this innovative approach gains popularity, it is crucial for healthcare professionals (gynaecologists, aesthetic physicians and general practitioners) to stay informed and guide their patients toward evidence-based solutions for optimal postpartum health and well-being.

Declaration of interest None

Figures 1–3 © Hannah Lo

Figure 3 A 32 year-old female presented 12 months post-partum, twin pregnancy, caesarean section. They received 6 sessions of HIFEM with RF at 2 weeks interval, further enhanced with RF with Shockwave during the first 4 visits. (A) Before and (B) 3 months following completion of treatment course (C) 12 months following completion of treatment course

THE HYBRID BIO-LIPS LIFT TECHNIQUE

Noura Lebbar, MD, discusses her preferred product choice and technique when performing lip augmentation

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

email dott.noura.lebbar@gmail.com

THE SHAPE AND FULLNESS OF THE LIPS PLAY A SIGNIFICANT ROLE in facial aesthetics and outward appearance. The patient’s corrective needs can range from a subtle enhancement to a complete recontouring, including correction of perioral rhytides. Injectors must have a comprehensive understanding of the lower face anatomical features and injection site techniques. Likewise, the choice of filler material contributes to the success of the injection techniques and facilitates a safe, effective, and naturallooking result.

When we assess a patient before a lip augmentation, we need to respect her natural lip shape unless the patient makes a special request. There are six basic lip shapes: straight, bow, heart, rosebud, Cupid’s bow, and downturned. When performing lip augmentation, it is important to respect the lip proportions. We believe that the most attractive lip shape has an upper-to-lower lip ratio of 1:2. However, lips are most desirable in different shapes and forms for different people—with many preferring a 1:1 ratio where the lips are completely symmetrical and evenly full.

The anatomy of the lips is complex as they have many functions and are formed from different tissues. The edges of the lips are covered with reddish skin called the vermillion. The vermillion is a transition layer between the outer, hair-bearing tissue and the inner mucous membrane. As far as lip proportions are concerned, the lower lip vermillion should be three times greater than the upper vermillion. However, that ratio can vary dramatically depending on ethnic background and even from individual to individual within the same ethnic group.

The orbicularis oris muscle is a broad, elliptical muscle around the mouth. Its lateral fibres join the modiolus, a chiasma of facial muscles held together by fibrous tissue.

The orbicularis oris consists of two distinct parts, the pars marginalis and pars peripheralis, which differ in location and function. Anatomical studies have shown that pars peripheralis fibres decussate at the midline and insert themselves into the contralateral philtral ridge, whereas pars marginalis fibres form a continuous band from modiolus to modiolus.

Lip filling should always be used sparingly to maintain the patient’s elocution, which is the orbicularis muscle’s primary function.

The lip blood supply is provided by the superior and inferior labial arteries that arise from the facial artery. They are located 1 mm posterior to the mucocutaneous border or white roll. The labial arteries lie deep to the orbicularis oris muscle and anastomose with each other to form an arterial ring.

KEYWORDS Lip filler, HA, hybrid bio lips

Here are some anatomical variances I have witnessed using ultrasonography image analysis in relation to the positional relationship of the superior and inferior labial artery:

the superior labial artery is located in 30% of cases on the intramuscular layer, 4% in the dry submucosa layer, and 47% in the wet mucosae layer. The inferior labial artery is located in 7% of cases in the intramuscular layer, 19% in the dry mucosae layer and 43% of the time in the wet submucosae layer. Accordingly, using a needle while injecting the superficial dry mucosal lower lip layer may still cause an arterial embolisation of the inferior labial artery in 19 % of cases.

Objectives

This review will highlight the benefits of using the hybrid bio-lips lifting technique to obtain safe and natural results.

Material and methods

The hybrid bio-lips lift uses two techniques. The first is the Russian lips technique with a 30 G, 13 mm needle, followed by the second technique with a 23 G, 50 mm blunt cannula.

Usually, to achieve perfect lip volumisation, we need to use a large amount of HA filler (more than 1 ml). In order to obtain a natural result, the filler should be injected into the submucosa layer. However, this poses vascular risks due to the presence of the superior and inferior labial arteries.

I believe the chances of injecting into a blood vessel and other vascular risks increase with the volume of filler injected and decrease when a blunt cannula is used rather than a needle.

Additionally, the more HA filler we inject, the greater the risk of long-term post-inflammatory effects, and a high volume of HA is also associated with a higher risk of

In order to obtain a natural result, the filler should be injected into the submucosa layer. However, this poses vascular risks due to the presence of the superior and inferior labial arteries.

Figure 1 Blunt cannula insertion point

Figure 2 Lip anatomy and filler placement with the Russian Lips technique

Canine arc

White roll

Vermillion border Philtrum

A A B B

granuloma. Based on this knowledge, product choice for lip augmentation is crucial.

That is why I have chosen hybrid bio-linked technology, which uses a new method of cross-linking. It allows me to be extremely safe with less than 0.1 ppm BDDE residue, ensuring maximum safety without a post-inflammatory reaction.

Combining a biodegradable component with the BDDE allows me to ensure the highest biocompatibility and adaptability of the HA filler. What is more, lidocaine integration is crucial to the comfort of the patient and the practitioner.

I have treated two patients. The first patient is 53 years old. She has never undergone lip filling in the past and desired a natural-looking result.

I have used Hyalure Lips (Rome, Italy) (hybrid bio-linked technology) lidocaine 20mg/ml 0.4 ml in total, with a 23G, 50 mm blunt cannula with two entry points in the modiolus. This approach allowed me to treat the upper and lower lips using the same entry point. I performed local anaesthesia, injecting 0.1 ml in each entry point using 2% lidocaine with epinephrine to ensure maximum comfort to the patient. I also applied topical anaesthesia containing 10% lidocaine and 5% prilocaine on the entire lip.

I then performed the Russian lips technique using 0.4 ml of Hyalure Lips with a 30 G needle 13 mm in length. My entry points were 1 mm above the vermillion, and I entered every 2 mm with my needle until I covered the entire area of the upper lip beginning from the Cupid’s bow and ending at oral commissure. The needle was directed vertically at a 10-degree medial angle. In the dry mucosa, the injection

layer should be very superficial. The objective of using the Russian lip technique is to define the vermilion, create a younger and fresher lip appearance, and increase the upper and lower lip projection.

The result was very natural; we noticed a significant improvement in the smoker’s lines (although they haven’t been filled) and a meaningful reduction in the nasolabial distance.

The second patient is a 45-year-old smoker. Performing the Russian lips technique as described above, I used 1 ml of Hyalure Lips (hybrid bio-linked technology). The needle was kept vertical, but the direction was medial due to the patient’s wide lip shape. The medial direction of the needle ensured a more narrow shape (similar to a heart shape) (Figure 1), while a lateral needle direction provides a wider shape. The result of the Russian lips technique is a meaningful reduction to the nasolabial space, giving a fresh and younger appearance and significantly improving the smoker’s lines.

One advantage of using the blunt cannula technique to fill the lips is that it allows me to reshape the oral commissure and elevate the oral angle, giving a younger and happier appearance.

Accordingly, the Russian lips technique allows me to inject the minimum filler quantity while obtaining the maximum volumisation and lip projection. The superficial injection used in this technique makes it safe for the patient as the labial arteries run deeply in the wet mucosa or in the orbicular muscle. In conclusion, my choice of Russian lip technique has two main advantages: the first is getting maximum lip projection using the minimum HA volume, and the second is its safety profile.

For the above treatments, I used 0.4 ml of Hyalure Lips and 20 mg lidocaine using a 30G, 13 mm needle, performing many entry points 1 mm above the vermillion, injecting small drops in a retrograde technique. The rheological characteristics and bio-adaptability of Hyalure Lips lidocaine allow me to inject superficially, avoiding any granuloma and injecting a minimum quantity for maximum efficiency. The choice of lidocaine is mandatory when using the Russian lips technique to ensure maximum patient comfort.

Conclusion

One advantage of using the blunt cannula technique to fill the lips is that it allows me to reshape the oral commisures and elevate the oral angle, giving a younger and happier appearance.

Both the technique and HA filler choice, in addition to excellent knowledge of lip anatomy, are prerequisites to obtaining the most natural-looking and safe result in lip enhancement.

The hybrid bio-lips lift technique is a revolutionary technique that allows for significant lip volume enhancement as well as excellent lip contouring and shaping, which is safe and results in natural-looking lips.

Declaration of interest None

1–4 © Dr Noura Lebbar

Figures

Figure 3 Patient 1 (A) before and (B) after treatment

Figure 4 Patient 2 (A) before and (B) after treatment

CLINICAL PRECONDITIONING FOR STEM CELLS

Ivan Ibáñez,

MD,

provides insights into the role of hormesis, intermittent fasting and senolytic supplements for enhancing stem cell function

ABSTRACT

During the transplant of autologous stem cells, one of the main problems is the poor capacity of the transplanted cells to survive due to the change in environment. In addition, the final implantation zone is an altered tissue with low blood flow, oxygen and nutrients. Hormesis is defined as an adaptive response of cells and organisms to moderate and usually intermittent stress. Many studies have shown cells display a ‘hormetic effect’; a low stimulation dose could have a beneficial effect, and a high dose causes inhibitory or toxic effects.

Preconditioning is an emerging therapeutic strategy that consists of small doses of a harmful agent that the body can accept (hormetic doses) to create resistant organisms. Vaccines, physical exercise, intermittent fasting, intermittent hypoxia-hyperoxia are some examples.

Using this concept, we have created a preconditioning programme for patients who are candidates for stem cell transplantation; with that, the stem cells are more resistant in different environments and with nutrient deficiency, so we can increase their survival and improve the viability and efficiency of stem cell therapy.

Lately, a prescription of senolytic supplement (Fisetin) has been incorporated into preconditioning to reduce the number of senescent stem cells.

IN ANTI-AGEING MEDICINE, CELLULAR REGENERATION AND THE USE OF stem cells are increasingly important. However, the main problem with stem cells is that they are often found in areas of the body where there is very little exposure to oxygen. Hence, stem cells are very vulnerable to oxidative stress, so they reside in hypoxic areas and are well protected from free radicals. One of the hallmarks that explains the complex ageing process is the ageing of stem cells and mesenchymal cells. It is vitally important for physicians to perform clinical preconditioning of these mesenchymal stem cells before their transplant and niche change since when they are removed from their comfort zone, they may lose their function and their ability to regenerate tissues1

Method

A literature review was conducted using the PubMed database, examining the role of hypoxia, intermittent fasting, and senolytics in stem cell function. Practically all body tissues have stem cells, but two organs, the central nervous system and the heart, are almost devoid of them, so their regenerative capacity is almost zero.

Most stem cells exist in subcutaneous fat tissue and bone marrow. Knowing this, three strategies based on hormetic stimuli2 enhance the regenerative capacity of mesenchymal stem cells. The first is hypoxia-hyperoxia training; another is intermittent fasting, and finally, supplementation with senolytic supplements.

Hormesis

The hormesis phenomenon is defined as a stimulus that causes adaptive changes for survival or, in other words, what does not kill strengthens.

There are many hermetic agents, which can be very beneficial if we know how to use them and their therapeutic window. Some of these stimuli are exposure to cold, exposure to extreme heat, some toxins, physical exercise, intermittent fasting, exposure to hypoxia, or moderate stress.

IVAN IBÁÑEZ , MD, Medical director of Eternal Medical Group, Prof. and Director of Anti-Aging and Longevity Medicine, Barcelona, Spain

email: dr_ivan18@yahoo.es

The hormesis phenomenon is defined as a stimulus that causes adaptive changes for survival or, in other words, what does not kill strengthens.

As discussed, the main problem of cell transplantation is that by separating stem cells from their environment and their niche they are exposed to high levels of oxygen and many of them die. That’s why stem cells are usually taken from the body and put into a bioreactor, where they are grown in a hypoxic environment and try to increase their number3

Humans are actually more physiologically prepared to survive in oxygen-poor environments rather than in a state of excess supply of oxygen (hyperoxia). Normal arterial oxygen saturation in the population is usually between 95% and 100%. The usual oxygen saturation in the fetus is 65%, and during birth, through the birth canal, it can reach 35% saturation.

Over the years, the tolerance to hypoxia as the body ages is lost, and the main goal of hypoxic preconditioning is to create resistant tissues to low partial oxygen pressure

KEYWORDS

Stem cells, hormesis, intermittent

Senescence

Cells age until they stop dividing, but they do not die.

Over time large numbers of aged or senescent cells accumulate in the tissues. They do not become functional and are called ‘Zombie’ cells. They release harmful proinflammatory substances that injure neighbouring cells. They play a role in developing cancer and other diseases. 1 2 3 4

Senomorphics

Agents that modulate the secretory phenotype (SASP) by preventing senescent cells from releasing inflammatory substances ‘without causing apoptosis’.

Senotherapy

Early-stage basic research field for the development of potential therapeutic agents & strategies to target specifically cellular senescence, an altered cellular state associated with ageing and age-related diseases.

Senolytics

Substances or agents that eliminate senescent cells.

situations. For example, as we climb up a mountain and are exposed to higher altitude. Partial oxygen pressure at elevations is usually lower than partial oxygen pressure at sea level. In 1985, Dr. Jordi Ibáñez performed the first simulated altitude experience in mountain athletes in Barcelona, Spain. He designed the first hypobaric chamber in the Spanish state, and a new area of research was created at the University of Barcelona in the field of hypobaria. In 2005, we started using hypoxia generators where the patient breathes in low oxygen concentrations through a mask and does not need to enter a hypobaric chamber. It has been shown that using the hormetic effect to stimulate stem cells with hypoxia, arterial oxygen saturation must be between 75% and 85%.

● Although contradictory, another effect of cellular senescence is tumour growth. This deleterious consequence can be attributed to age: while cellular senescence in young organisms protects against tumours, in older organisms it induces tumour spread.

Cells in the human body have a maximum division capacity of 60 copies, when a cell has been divided 60 times it is called a ‘senescent cell’ and is no longer functional.

saturation is between 75% and 85%, the body releases a substance called HIF-1 (Hypoxia Inducible Factor). And it has the ability to increase red blood cells by erythropoietin stimulus, it stimulates angiogenesis due to increased VEGF (vascular endothelial growth factor), there is vasodilation by nitric oxide release, improvement of aerobic metabolism, anaerobic metabolism, and iron uptake.

In addition, hypoxia exposure inhibits cardiac progenitor cell apoptosis and increases the regenerative potential of mesenchymal cells4,5

On the other hand, exposure to hypoxia decreases blood pressure, increases diuresis, an increase in catecholamines improving beta-oxidation, increases biogenesis, mitochondrial density and function, improves endogenous antioxidant capacity, decreases total and LDL cholesterol, decreases leptin, increases serotonin, and increases GLUT4 and insulin sensitivity6–9

In general, the protocol that we are using to achieve these benefits requires the patient to participate four days a week for 45 minutes each session, and the patient must be in hypoxia for five minutes and then one or two minutes in hyperoxia. In addition to the benefits mentioned, there are studies that show that these changes in the partial pressure of oxygen increase the length of the telomeres, as there is also an increase in exosomes and intercellular communication10

Intermittent fasting

With ageing itself, stem cells also become senescent. This has been seen in muscle stem cells, central nervous system, intestinal and hematopoietic stem cells.

Caloric restriction, intermittent fasting, a rich in monounsaturated and polyunsaturated fat diet, and ketogenic nutrition enhance the function and regeneration of those stem cells, demonstrated in vivo and in vitro. Religious fasting has been shown to improve endothelial progenitor stem cells too11–13

When a person breathes low amounts of oxygen, and their arterial oxygen

Senotherapeutics

On an integrative level, anti-ageing medicine is based on nutrition, intermittent fasting, elimination of bad habits, brain training, stress management, predictive medicine, preventive medicine, physical exercise (strength, power, flexibility, balance, endurance) and also the use of senotherapeutics (senolytics and senomorphics).

Cells in the human body have a maximum division capacity of 60 copies, when a cell has been divided 60 times it is called a ‘senescent cell’ and is no longer functional. Now, the ageing of senescent cells release inflammatory substances such as proinflammatory cytokines as interleukin-6 and TNF-alpha. What is called an inflammatory secretory phenotype or SASP. Senotherapeutics, considered senomorphics and senolytics, help to remove senescent cells and inhibit the secretory phenotype.

A senomorphic supplement inhibits the secretory

Figure 2 Clinical preconditioning approach in stem cells therapy

30 DAYS BEFORE

SENOLYTIC SUPPLEMENT (Fisetin FITOSOMADA)

INTERMITTENT FASTING 16:8

phenotype, and a senolytic agent removes the senescent cell (Figure 1).

Two well-studied senomorphics are metformin and trans-resveratrol. Quercetin, too, has a level of senomorphic and senolytic capacity. Rapamycin and fisetin have senolytic activity, and of course, physical exercise also encourages senolytic activity. Nicotinamide adenine nucleotide (NAD) has also been found to have the ability to renew existing stem cells and repair broken DNA, thereby prolonging the life of the mesenchymal cells.

In terms of caloric restriction, it increases VEGF and decreases IL-6 and mTOR. NAD reduces levels of IL-6, TNF-alpha, and IL-2. It also increases the autophagy and expression of SIRT1, while also reducing together with trans-resveratrol the levels of beta-galactosidase, a marker of senescent cells14,15. Curcumin also reduces the senescent cell secretory phenotype, thereby decreasing the inflammatory response16

The application of senolytics in organ transplantation is already under investigation. The donor’s organ or graft

References

1. Anne Brunet, Margaret A Goodell, Thomas A Rando. Ageing and rejuvenation of tissue stem cells and their niches. Nat. Rev. Mol. Cell. Biol. 2023 January; 24(1): 45-62. doi: 10.1038/s41580-022-00510-w.

2. Mahmood S Choudhery. Strategies to improve regenerative potential of mesenchymal stem cells. World J Stem Cells. 2021 Dec 26; 13(12): 1845–1862. doi: 10.4252/wjsc.v13. i12.1845.

3. Sun H. Peck., Justin R. Bendigo., John W. Tobias., et al. Hypoxic Preconditioning Enhances Bone Marrow–Derived Mesenchymal Stem Cell Survival in a Low Oxygen and Nutrient-Limited 3D Microenvironment. Cartilage. 2021 Oct; 12(4): 512–525. Published online 2019 Apr 11. doi: 10.1177/1947603519841675

4. Rongfeng Xu., Yuning Sun., Zhongpu Chen., et al. Hypoxic Preconditioning Inhibits Hypoxia-induced Apoptosis of Cardiac Progenitor Cells via the PI3K/Akt-DNMT1-p53 Pathway. Sci Rep. 2016 Aug 4:6:30922. doi:

10.1038/srep30922.

5. Jianyang Liu., Jialin He., Yan Huang., et al. Hypoxiapreconditioned mesenchymal stem cells attenuate microglial pyroptosis after intracerebral hemorrhage. Ann Transl Med. 2021 Sep; 9(17): 1362. doi: 10.21037/atm-21-2590

6. Bushra Bahir., Mahmood S., Choudhery., et al. Hypoxic Preconditioning as a Strategy to Mantain the Regenerative Potential of Mesenchymal Stem Cells. Journal of Regenerative Medicine, 2020. doi: 10.5772/ intechopen.93217

7. Effectiveness of three short intermittent hypobaric hypoxia protocols: Hematological responses. Casas H, Casas M, Ricart A, Rama R, Ibáñez J, Palacios L, Rodríguez FA, Ventura JL, Viscor G, Pagès T (2000) Journal of Exercise Physiology Online, Vol. 3(2), April 2000 [http://www.css.edu/ users/tboone2/asep/JEPCasa. html].

8. Rodríguez FA, Casas H, Casas M, Pagès T, Rama R, Ricart A, Ventura JL, Ibáñez J, Viscor G.

15 DAYS BEFORE

HYPOXIC TEST with ECG & BP O2 Sat = 80% (5’) & Hyperoxia (2-3’) during 45-50’

THERAPY

DAY

STEM CELLS THERAPY

is removed and placed in a container where the senolytic is inoculated, thus reducing the ageing cells of the organ, and when the organ is more rejuvenated, it is implanted in the recipient17-18

Conclusions

So, for everything mentioned above, we can consider that exposure to intermittent hypoxia, the use of intermittent fasting, and supplementation with transresveratrol, NAD, curcumin, quercetin, metformin, and phytosomes fisetin greatly helps the regenerative power of the body’s stem cells19 (Figure 2).

Intermittent hypoxia application training is necessary, as otherwise the technique may have pernicious effects.

Declaration of interest None

Intermittent hypobaric hypoxia stimulates erythropoiesis and improves aerobic capacity. (1999) Medicine and Science in Sports and Exercise 31(2): 264-268.

9. Ibáñez J, Casas H, Casas M, Rama R, Ricart R, Ventura J.-L, Palacios L, Pages T, Rodriguez FA, Viscor G. L’exposition intermittente à l’hypoxie en caisson hypobarique : Effets physiologiques et applications. (2000). Médecine du Sport 74(2): 32-34

10. Cheng-Yu Mao., Tian-Tian Zhang., Dong-Jiu Li., et al. Extracellular vesicles from hypoxia-preconditioned mesenchymal stem cells alleviates myocardial injury by targeting thioredoxininteracting protein-mediated hypoxia-inducible factor-1α pathway. World J Stem Cells. 2022 Feb 26;14(2):183-199. doi: 10.4252/wjsc.v14.i2.183.

11. Kevin Spehar, Andrew Pan, Isabel Beerman. Restoring aged stem cell functionality: Current progress and future directions. Stem Cells. 2020 Sep; 38(9):

1060–1077. doi: 10.1002/ stem.3234

12. Jesse S.S. Novak, Sanjeethan C. Baksh, Elaine Fuchs. Dietary interventions as regulators of stem cell behavior in homeostasis and disease. Genes Dev. 2021 Feb 1; 35(3-4): 199–211. doi: 10.1101/gad.346973.120

13. Valter D. Longo, Maira Di Tano, Mark P. Mattson, Novella Guidi. Intermittent and periodic fasting, longevity and disease. Nat Aging. 2021 Jan; 1(1): 47–59. doi: 10.1038/s43587-020-00013-

3

14. Selim Chaib, Tamar Tchkonia, James L. Kirkland. Cellular senescence and senolytics: the path to the clinic. Nat Med. 2022 Aug; 28(8): 1556–1568. doi: 10.1038/s41591-022-01923-y

15. Sprick JD, Mallet RT, Przyklenk K, Rickards CA. Ischaemic and hypoxic conditioning: potential for protection of vital organs. Exp Physiol. 2019 Mar;104(3):278294. doi: 10.1113/EP087122.

16. Matsunaga T, Iske J, Schroeter A, Azuma H, Zhou H, Tullius SG. The potential of

Senolytics in transplantation. Mech Ageing Dev. 2021 Dec;200:111582. doi: 10.1016/j. mad.2021.111582.

17. Iske J, Seyda M, Heinbokel T, Maenosono R, et al. Senolytics prevent mt-DNA-induced inflammation and promote the survival of aged organs following transplantation. Nat Commun. 2020 Aug 27;11(1):4289. doi: 10.1038/ s41467-020-18039

18. Shuaifei Ji, Mingchen Xiong, Huating Chen, Yiqiong Liu,. et al. Cellular rejuvenation: molecular mechanisms and potential therapeutic interventions for diseases. Signal Transduct Target Ther. 2023; 8: 116. doi: 10.1038/s41392-023-01343-5

19. Fisetin in Cancer: Attributes, Developmental Aspects, and Nanotherapeutics. Rachna M. Kumar., Hitesh Kumar., et al. https://doi.org/10.3390/ ph16020196. Published: 28 January 2023 in Pharmaceuticals

1 MONTH AFTER

Key points

Stem cells, crucial for anti-aging therapies, face vulnerability to oxidative stress

Hypoxic training, intermittent fasting, and senolytic supplementation emerge as key strategies to enhance mesenchymal stem cell regenerative potential

Exposure to intermittent hypoxia triggers adaptive changes via HIF-1 induction, fostering angiogenesis, vasodilation, and improved metabolic function

Integrative anti-ageing approaches encompass nutrition, intermittent fasting, stress management, physical exercise, and the use of senotherapeutics to combat cellular ageing and enhance regenerative potential

Figure 1-2 © Dr Ibanez

CLINICAL-OBSERVATIONAL

STUDY IN 50 INDIAN FEMALE PATIENTS WITH PERIORAL PIGMENTATION

Dr Janani Palanivel explores the aetiological factors behind persistent perioral pigmentation

ABSTRACT

Chronic pigmentation around the mouth poses a common challenge in Indian clinics, frequently causing emotional distress among patients due to its persistent nature and resistance to treatments. Isolated perioral pigmentation presents clinicians with diagnostic and management challenges. In response to this, we conducted an observational study aimed at comprehensively unravelling the plausible etiological factors and clinical patterns associated with perioral pigmentation. Our investigation seeks to enhance the understanding of this common pigmentary condition which is not discussed in the literature.

CHRONIC ISOLATED PIGMENTATION AROUND THE MOUTH IS A prevalent issue observed among South Indian female patients. Frequently classified as a subset of conditions such as melasma, seborrheic dermatitis, or acanthosis nigricans, this condition poses challenges due to its persistent nature and often leads to emotional distress among affected individuals1. The long-lasting nature of the problem adds complexity, making histopathological examination challenging due to concerns about scarring in the affected area.

Despite its common occurrence and impact on patients’ well-being, the literature on perioral pigmentation remains limited. A PubMed search using terms like ‘perioral pigmentation’ and ‘pigmentation around mouth’ produced only two results, both referencing it as a subset of acanthosis1,2. Interestingly, there is a notable absence of articles recognising chronic perioral pigmentation as a distinct clinical entity.

Given its prevalence and the cosmetic concerns it raises in clinical settings, our study aims to unravel the patterns of complaints associated with perioral pigmentation and comprehensively understand its aetiological factors. Through this study, we propose possible factors that could influence skin pigmentation and could be the focus of future research.

Methods

Fifty female patients in the age group of 18 to 35 years were included in the study. All the patients presented with a characteristic long-standing demarcated pigmentation around the mouth.

The exclusion criteria were:

■ Patients presenting with other associated pigmentary skin disorders like acanthosis or melasma

■ Patients on long-term systemic medications

■ Pregnant and breast-feeding women

■ Patients presenting with additional skin symptoms such as dryness, acne or itching on the area of presentation.

Although an initial questionnaire was not part of our plan, we noted distinct histories in the first few patients, such as the onset of the problem post-menarche and symptom exacerbation related to menstrual cycles and diet. Recognising the significance of these complaints, we subsequently developed a structured questionnaire for the remaining participants. This questionnaire explored aspects like onset, the relationship with menstrual cycles, and factors exacerbating symptoms, including dietary habits. In addition to the questionnaire, a thorough clinical evaluation of BMI and waist

JANANI PALANIVEL, DD, MSC DERM, is an Aesthetic Physician and Medical Director at Derme Cure Skin & Cosmetic Clinic, Chennai, India email: drjananiap@gmail.com

KEYWORDS

Perioral pigmentation, skin pigmentation, hyperandrogenism, sex hormone-binding globulin

Given its prevalence and the cosmetic concerns it raises in clinical settings, our study aims to unravel the patterns of complaints associated with perioral pigmentation and comprehensively understand its aetiological factors.

Table 1 Questionnaire on clinical complaints

CLINICAL HISTORY IN N=50 YES NO NOT KNOWN OR NOTICED

Noticed/started after puberty 42 (84%) 8 (16%)

Present for more than 2 years 50 (100%)

Prominent on and off 37 (74%) 13 (26%)

Correlation with menstrual cycles 28 (56%) 12 (24%)

H/o irregular menstrual cycles 26 (52%) 24 (48%)

Exacerbation with diet 12 (24%) 38 (76%)

H/o intake of high glycaemic foods 45 (90%) 5 (10%)

H/o increased intake of dairy products

H/O increased intake of meat

43 (86%) 7 (14%) (vegetarian)

41 (82%) 9 (18%) (vegetarian)

Any positive response to treatments 50 (100%)

Current treatment modalities for perioral pigmentation include topical depigmenting agents such as hydroquinone, azelaic acid, alpha-arbutin, Vitamin C, tranexamic acid, kojic acid or retinoids.

Table 2 Clinical evaluation and blood investigations in the study group

EVALUATION N=50

BMI

1

Below 18.5 = 0 18.5-24.9

Waist circumference Below 80cm (31.5 in) = 0 80-88cm (31.5-34.6 in) = 18 (36%) >88cm (34.6 in) = 32 (64%)

Fasting lipids Triglycerides >150

Normal = 37 (74%)

High = 13 (26%)

HBA1C 4-5.9 = 33 (66%) 6.0-6.4 (prediabetes) = 17 (34%) >6.5 = 0

Serum free testosterone (0.2 to 4.1pg/ml)

Sr. Sex hormone binding globulin (18-144nmol)

Sr. DHEAS (65-380 mcg/dl)

No. of USG done before visiting us (n=22)

circumference were established. Further blood investigations were conducted, which included HbA1c, fasting lipids, serum free testosterone, serum sex hormone binding globulin and serum DHEAS.

Results

84% of the patients noted the onset of symptoms postmenarche, suggesting a correlation with hormonal

A

Normal = 45 (90%) >4 = 5 (10%)

Below 25 = 44 (88%)

Above 200 (within normal range) = 21 (42%)

Below 18 = 4 (8%)

Below 200 (within normal range) = 29 (58%)

Normal = 15 PCOS = 7 (32%)

Above 25 = 2 (4%)

Abnormal = 0

changes. Additionally, 56% observed an exacerbation of symptoms corresponding to their menstrual cycles, further indicating a hormonal influence on skin pigmentation. Similarly, 28% reported symptoms worsening with specific dietary factors, particularly sugary and fatty foods (Table 1). Interestingly, 76% of participants were not aware of dietary effects on pigmentation. However, about 90% of the study group predominantly

B

Figure

Pictures of individuals with perioral pigmentation

consumed high-glycemic foods, meat, and dairy products (Table 1).

The effects of diet were substantially noticed during clinical evaluation, which revealed that around 64% of the group were overweight and had a waist circumference of >88cm. Though only 34% were identified as prediabetic, it emphasises a possible relationship between diet, body composition, and glycemic control in perioral pigmentation (Table 2).

With further blood investigations, it was established that serum total testosterone and serum DHEAS were within the normal range in most individuals in the group. However, sex hormone-binding globulin (SHBG) levels were in the lower range in 88% of patients with perioral pigmentation, indicating a predominant state of hyperandrogenism. Thus, this indicates that there is a potential link between androgen levels and the manifestation of perioral pigmentation (Table 2).

Discussion

The above results highlight that hormones, diet, and lifestyle are potential aetiological factors for chronic isolated perioral pigmentation. When assessing patients with associated symptoms like darkening of the skin around the neck, dryness, or itching in the affected area, it is crucial to consider differentials such as acanthosis or seborrheic dermatitis. However, if the patients present with distinct, chronic pigmentation around the mouth, it becomes imperative not to overlook the possibility of hyperandrogenism. It is plausible that perioral pigmentation could serve as an initial indicator of hyperandrogenism, emphasising the importance of a complete clinical evaluation, dietary history, and menstrual history for early identification.

The role of sex hormone-binding globulin (SHBG) as an early biomarker of hyperandrogenism has been extensively studied3,4. Produced primarily by hepatocytes, SHBG exhibits a high affinity for testosterone and a low affinity for estradiol, influencing the concentration of testosterone in plasma. With only 1–2% of testosterone existing in its free form, 65% is bound to SHBG, and the remaining to albumin. Consequently, low

SHBG levels can lead to elevated bioavailable and free testosterone5

Although a detailed exploration of the role of SHBG is beyond the scope of this article, it is crucial to recognise that SHBG has emerged as a biomarker associated with conditions such as metabolic syndrome and polycystic ovary syndrome (PCOS). In addition, low SHBG may precede biochemical abnormalities of androgens in PCOS4,5

Drawing parallels with SAHA (seborrhea, acne, hirsutism and alopecia) syndrome, which summarises skin manifestations of hyperandrogenism6, there is a compelling possibility that distinct perioral pigmentation may manifest as an initial sign of hyperandrogenism.

Based on our observations, we propose the inclusion of chronic isolated ‘perioral pigmentation’ as a distinct clinical entity within the SAHA syndrome spectrum. We expect more clinical studies on perioral pigmentation in individuals with skin of colour. Similarly, more studies are required for a better understanding of the role of androgens in hyperpigmentation, which is still uncertain.

Due to the resistant and relapsing nature of perioral pigmentation, selecting an appropriate treatment option is often a challenge. Current treatment modalities for perioral pigmentation include topical depigmenting agents such as hydroquinone, azelaic acid, alpha-arbutin, Vitamin C, tranexamic acid, kojic acid or retinoids. These topical agents along with photoprotection, will help to reduce the pigmentation significantly. Procedural treatments such as chemical peels and laser technology such as the Q-switched or the Pico lasers, will serve as an effective adjuvant treatment method. While these treatment modalities will diminish skin pigmentation, combining lifestyle and dietary modifications will provide a better clinical outcome in patients with chronic and resistant perioral pigmentation.

Declaration of interest None.

Key points

Predominantly affecting South Indian females, chronic perioral pigmentation presents challenges due to its persistent nature and limited literature recognition

A study involving 50 female patients aged 18 to 35 revealed a correlation between hormonal changes, menstrual cycles, and dietary habits with the onset and exacerbation of symptoms

Results indicated that 84% of patients experienced symptoms post-menarche, with 56% reporting exacerbation corresponding to menstrual cycles and 28% to dietary factors

Blood investigations suggested a potential association between low sex hormone-binding globulin (SHBG) levels and hyperandrogenism, indicating perioral pigmentation as a possible indicator

References

1. Sarma N, Chakraborty S, Bhattacharya SR. Acquired, Idiopathic, Patterned Facial Pigmentation (AIPFP) Including Periorbital Pigmentation and Pigmentary Demarcation Lines on Face Follows the Lines of Blaschko on Face. Indian J Dermatol. 2014 Jan;59(1):41-8. doi: 10.4103/00195154.123492. PMID: 24470659; PMCID: PMC3884927.

2. Shah VH, Rambhia KD, Mukhi JI, Singh RP, Kaswan P. Clinicoinvestigative Study of Facial Acanthosis Nigricans. Indian Dermatol Online J. 2022 Mar 3;13(2):221-228. doi: 10.4103/idoj. IDOJ_855_20. PMID: 35287408; PMCID: PMC8917481.

3. Li L, Feng Q, Ye M, He Y, Yao A, Shi K. Metabolic effect of obesity on polycystic ovary syndrome in adolescents: a meta-analysis. J Obstet Gynaecol. 2017 Nov;37(8):1036-1047. doi: 10.1080/01443615.2017.1318840. Epub 2017 Jun 28. PMID: 28657375.

4. Chen MJ, Yang WS, Yang JH, Hsiao CK, Yang YS, Ho HN. Low sex hormone-binding globulin is associated with low high-density lipoprotein cholesterol and metabolic syndrome in women with PCOS. Hum Reprod. 2006 Sep;21(9):2266-71. doi: 10.1093/humrep/del175. Epub 2006 Jun 6. PMID: 16757555.

5. Qu X, Donnelly R. Sex Hormone-Binding Globulin (SHBG) as an Early Biomarker and Therapeutic Target in Polycystic Ovary Syndrome. Int J Mol Sci. 2020 Nov 1;21(21):8191. doi: 10.3390/ijms21218191. PMID: 33139661; PMCID: PMC7663738. 6. Orfanos CE, Adler YD, Zouboulis CC. The SAHA syndrome. Horm Res. 2000;54(5-6):251-8. doi: 10.1159/000053267. PMID: 11595813.

Figure 1 © Dr Palanivel

GET SMART: INVESTIGATING AI’S ROLE IN PLASTIC SURGERY AND DERMATOLOGY

Wendy Lewis speaks to some top doctors to share how they are using AI tools in their practices and how they are not… yet

IN 2023, I WROTE ‘MY LOVE AFFAIR WITH ChatGPT’ in the July/August issue of PRIME. Fast forward to Q2 2024, and artificial or ‘augmented intelligence’ has grown by leaps and bounds across all fields. It now dominates the way we work and communicate, whether we like it or not. It’s like a runaway train and there is no stopping it now.

AI has made a significant difference in our day-to-day lives. In particular, AI is changing the way doctors diagnose diseases, plan surgeries, choose medications, boost inclinic productivity (and profits), promote their practices, and more.

How much of an impact is AI having on aesthetics and dermatology? I asked ChatGPT4 to weigh in (see panel below right).

This answer, which was generated in under 10 seconds, reflects some of what I have heard from so many physicians in various parts of the U.S. and abroad.

AI in action: simplifying presentations, patient intakes

‘I’ve been playing around with generative AI, a category of AI that enables you to create new experiences with text, images, videos, and audio,’ says New York City-based dermatologist Jane Yoo, MD. She uses Canva to create marketing material, handouts, and newsletters.

worth thousands of dollars sitting unused on our shelves, some of it expiring.’ She recalls, ‘This was aggravating because toxin and filler are expensive, not to mention laser and device consumables.’

But that was then. Managing inventory is one of the features of her practices’ proprietary Residen technology. ‘Using automated sensors, our system continually tracks inventory,’ she explains. ‘Taking this data, along with numerous other data points, the system then uses a type of AI called prescriptive analytics to determine what products to order and how much.’

AI has made a significant difference in our day-to-day lives. In particular, AI is changing the way doctors diagnose diseases, plan surgeries, choose medications, boost in-clinic productivity (and profits), promote their practices, and more.

Since implementing this system, inventory is in line with patient needs, she says. ‘We only have on hand what we need in the short term,’ she says. ‘It’s much more accurate than staff eyeballing and guesstimating what to order. It removes human error and also identifies missed shipments and theft.’

AI also allowed Dr. Wu to reduce her rent costs. ‘I recently built out a new office and decided I only needed a very small waiting room. Instead, I fit in another procedure room,’ she says.

‘Although my new office is 800 square feet larger, my new waiting room is less than a quarter of the size of my previous one.’ AI tech continually scans her schedule and adjusts it according to patient and doctor data. ‘Patients don’t need to wait, so [there’s] no more need for a large waiting room that isn’t generating income,’ she

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

Dr. Yoo also uses AI to help with upcoming podium presentations. ‘Microsoft Copilot in Word can write, edit, summarise, and PowerPoint can help create presentations based on prompts, but they are very basic and are not sophisticated enough to have the technical detail that is needed,’ she says.

Dr. Yoo is currently working with the American Academy of Dermatology (AAD) on a pilot programme with an app called the Suki AI Assistant, which uses AI, natural language processing, and machine learning to help physicians create clinically accurate medical notes and complete administrative tasks, such as retrieving patient information from the electronic medical record (EMR) system using their voice. ‘The programme makes up some information during the patient interaction and transposes it to the electronic medical record,’ she explains. ‘It is not perfect as there are some major hiccups—including AI hallucinations, and I am worried about the privacy/HIPPA issues involved.’ In case you are not up to speed, AI hallucinations are incorrect or misleading results that AI generates.

AI in action: maximising efficiency, cutting costs

Dr. Jessica Wu, a dermatologist in Los Angeles, is the Founder of RESIDEN, which uses technology including AI to improve efficiencies.

Dr. Wu sees 25 to 30 patients a day. ‘Before AI, sometimes we’d run out of products; other times, we’d have products

Question posed to ChatGPT-4:

‘How much of an impact is AI having on aesthetics and dermatology?’

‘AI is significantly impacting both aesthetics and dermatology, offering innovative solutions and enhancing both fields.

In aesthetics, AI is being used for facial recognition and analysis to suggest personalised beauty and skincare routines. By analysing thousands of skin-related datasets, AI can recommend products or treatments tailored to individual skin types and conditions. Furthermore, AI-driven tools can simulate makeup or hair styles, allowing clients to visualise changes before they commit.

In dermatology, AI is transforming the way skin conditions are diagnosed and treated. AI algorithms, trained on vast datasets of dermatological images, can assist in identifying skin cancers, psoriasis, eczema, and other skin disorders, often with accuracy comparable to dermatologists. This can lead to early detection of skin cancers and other conditions, potentially improving outcomes. AI also supports telemedicine by enabling remote diagnosis and monitoring, which is particularly beneficial for patients in underserved regions.

The integration of AI in these fields is ongoing, and as the technology advances, its impact is likely to become more profound, aiding in research, developing personalised treatments, and improving patient care.’

THE AI INVASION

What started out in November 2022 with ChatGPT (now up to the ChatGPT4 version) has morphed into a plethora of others, each with its nuances and features. I dabble with them all for different applications, but ChatGPT4 and Claude 3 are my preferred choices at the time of this printing.

Note: All of these have free and paid versions to tap into :

• ChatGPT (OpenAI)

• ChatSonic.pro (Writesonic)

• Claude.ai (Anthrop/ic)

• Google Gemini (formerly Bard)

• Microsoft Copilot (formerly Bing Chat)

• Perplexity.ai (Aravind Srinivas, Denis Yarats, Johnny Ho, Andy Konwinski) - self-proclaimed as the ‘world’s first answer engine.’

says. ‘Our Residen system also detects if/when a doctor will be late and how late, and this information is sent to patients and is automated, so it doesn’t require a staff member to call each patient. Again, lessening the need for a large waiting room that doesn’t generate income.’

In addition, Dr. Wu uses AI to perform more rote tasks, which frees up staff to do more valuable activities. ‘For example, our system checks patients in, then directs patients where to go and which type of room to seat them in.’ There’s no need for a receptionist, which is a big cost savings,’ Dr. Wu says.

This is all true, adds Jason Pozner, MD, plastic surgeon and founder of Sanctuary Medical Aesthetic Center with practices in Boca Raton and Fort Lauderdale, FL.

‘We look at AI today as having the potential to significantly improve the way we practice. We don’t see it as a threat, but more like a tool to save time, improve efficacy, and help us to take better care of patients and produce superior outcomes,’ he says. For example, AI helps doctors make evidence-based decisions based on hard data, he says. ‘There is no doubt that AI will continue to be used in all facets of medicine and surgery. It is here to stay, so we need to embrace it while proceeding with a dose of caution.’

The Holy Grail: integrating AI in EMR and PM software

Karol Gutowski, MD, a Chicago based plastic surgeon who also manages a thriving Medspa brand, Afresh Medspa, isn’t all-in on AI yet. ‘Right now, AI seems to be a buzzword that is being used to describe predictive technology,’ he says.

He has experimented with ChatGPT, Bard, Microsoft Copilot, Microsoft AI, and Claude for general plastic surgery questions. ‘The answers were very general without the specifics that I can include myself,’ he says.

‘AI models can help in interpreting medical images, and lab results, but I am not aware of any AI that is integrated in

AI models can help in interpreting medical images, and lab results, but I am not aware of any AI that is integrated in electronic medical record (EMR). If that happens, it would be a game changer.

electronic medical record (EMR). If that happens, it would be a game changer,’ he says.

Unless AI can integrate with EMR or practice management software, the information transfer gap is a problem, he says. Other ethical concerns remain as well: ‘Is AI HIPPA compliant? If AI is given real patient information, will the AI platform capture it, store it, and use it elsewhere?’

His bottom line? ‘AI is not a substitute for human interaction, but rather it is a tool to improve efficiency for the patient’s benefit.’

Gregory A. Buford, MD, a plastic surgeon in Denver and Lone Tree, CO, is a self-proclaimed newbie when it comes to using AI. He has found AI to be a good jumping-off point for writing papers and presentations. ‘At this point, I am finding it extremely useful as more of an adjunct versus a replacement for blood, sweat, and tears and the normal creative process,’ he says. ‘I am using it in a number of ways to either begin my thought process on a topic — source the topic and go from there — or often to refine a process that I have already started.’

But it’s ‘writer beware’ as essays completely generated by AI have a very distinct look, tone, and feel and literally scream that they have been written by a bot. ‘As an assistant to my own creativity, they often allow me to often go in directions to which I had not ventured and to build more layers and depth upon my initial foundations.’ He uses ChatGPT and Claude, and often goes back and forth between the two to effectively evaluate and compare their differing voice, inflections, and direction.

Dr. Gutowski agrees, noting that AI may appear to be a

timesaver when writing articles or papers for journals, or clinical studies, but most reputable medical journals will not accept AI-derived manuscripts. ‘I suppose an author could use AI to start with a template but not sure if that will save time or not,’ he says. ‘AI may have the potential to compose some aspects of a research grant, but many researchers probably know their subject matter better than AI so would still need to review the content.’

Uses in dermatology

Peter Lio, MD, a clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine and a partner at Medical Dermatology Associates of Chicago, has published several papers on the role that AI may play in dermatology.

In one study that appears in the August 2023 issue of Pediatric Dermatology, Dr. Lio and colleagues looked at the potential effect of AI on anxiety levels in parents of children with atopic dermatitis (AD). For the study, researchers compared the answers to commonly asked questions in AD from ChatGPT-3.5 and the most updated version of Google. When the apps were asked, ‘Why can’t my child stop itching? What should I do?’ ChatGPT responses recommended seeing a healthcare professional. By contrast, Google provided a ‘snippet answer.’ When asked, ‘Will my child grow out of eczema? Are there any serious consequences to long-term eczema treatment?’ ChatGPT provided a more medically complex, detailed answer compared to Google, which could induce parental anxiety. ‘We worry that the ease of asking ChatGPT medical

questions combined with incomplete reference verification has the potential to result in misinformation and unnecessary concern among parents of children with AD,’ they conclude. ‘A clinician’s awareness of ChatGPT’s answers can be instrumental in guiding parental counselling by dissuading unnecessary restrictive diets and providing parents with reliable, evidence-based online resources such as the Society of Pediatric Dermatology patient handout, the AAD, and the National Eczema Association.’

He uses AI to help draft letters and has shown his staff how they can use it to help them draft letters of medical necessity. ‘We stress that it can only be a draft and explain that it is prone to errors, so every word must be checked carefully,’ he says. ‘Still, it can be timesaving and helps to ensure that all the pieces of the puzzle are present.’

His current go-to is also ChatGPT-4. ‘I will say that Perplexity.ai is quickly becoming my favourite as it does much more with real-time web integration, which I think is the future.’ Dr. Lio is also looking forward to experimenting more with Google Gemini and rumour has it that Apple is working on a big AI announcement as well.

Indeed, according to numerous tech experts, the iPhone 16 family will include generative AI, both locally and in the cloud, and this will be introduced at Apple’s upcoming Worldwide Developer Conference that takes place in June 2024. Stay tuned because this could be a game changer for the whole category.

How AI is influencing consumer expectations

According to numerous tech experts, the iPhone 16 family will include generative AI, both locally and in the cloud, and this will be introduced at Apple’s upcoming Worldwide Developer Conference that takes place in June 2024. Stay tuned because this could be a game changer for the whole category.

AI is also revolutionising consumer experiences, changing the way people engage with aesthetic services, treatments, and bespoke recommendations.

Steven R. Feldman, MD, PhD, a professor of dermatology, pathology and social sciences and health policy at Wake Forest University School of Medicine in Winston-Salem, NC, works with Perfect Corp to do research studies validating their AI tool, which assesses facial characteristics. As such he is on the front lines of AI in beauty.

In one study, Dr. Feldman and colleagues compared Perfect Corp’s AI Skin technology to both physician assessments and a high-end, standard imaging device and found that AI Skin had a good correlation with assessments done by a physician and the clinical imaging system with dedicated hardware and camera.

‘In these studies, we’ve documented the severity of patients’ acne, pores, spots, wrinkles, and a host of other characteristics,’ he says. ‘The AI tool lets us use a simple iPad to rapidly assess patients before and after dermatological treatments.’

Perfect AI is ‘low cost, superfast (just seconds to capture the image and get the data), and forgiving of different lighting conditions,’ he says.

Boston-based plastic surgeon Samuel Lin, MD, an associate professor of surgery at Harvard Medical School, uses AI to manage patient expectations.

‘Visual filters that patients may use on themselves before surgery can affect their expectations for surgery, and our group has studied the degree of effect as well as taken

this into consideration during patient counseling,’ he tells PRIME

‘In addition, we have used ChatGPT in our efforts to develop code being used to analyse large patient datasets in research efforts to study best surgical practices and lowering complications.’

In the future, Dr. Lin anticipates using AI as a medical scribe in clinic visits, using Otter’s powerful speech-to-text capabilities to lower the burden of surgeons to make records of patient visits. ‘We anticipate using AI in the future to help facilitate diagnosis and treatment planning, and surgical simulation for resident training as well.’

‘The integration of AI into our practice is not meant to replace the expertise of a plastic surgeon,’ he says. ‘The first step to adoption is understanding the capabilities of each open-source AI platform and how it can add to your practice without sacrificing patient experience or patient safety,’ Dr. Lin explains. ‘When utilised correctly, AI can make certain aspects of plastic surgery more efficient.’

He and his colleagues, Drs. Vikas Bommineni, Daniela Lee, and Massoud Sharif, were the recipients of the Dean’s Innovation Awards sponsored by the Harvard Medical School Dean’s Office, for their paper, ‘The 900 images project: Minimising post-scar sequelae via image generation for patients with diverse skin tones.’

Dr. Lin also suggests outlining the areas where AI could help and setting standardised techniques with associated training for the team. ‘In addition, full transparency with the provider team as well as with patients regarding how AI is being used is essential,’ he says. ‘Disclosures on AI use help maintain trust in the physician-patient relationship and among the healthcare group.’

What’s coming next with AI?

AI continues to make tremendous advances that can help improve efficiency and productivity in ways we may not have even thought about yet.

‘While AI algorithms may one day independently learn

While AI algorithms may one day independently learn to read CT scans, identify skin lesions, and provide medical diagnoses, the low-hanging fruit is in improving physician efficiency,

and de-tethering clinicians from the computer.

to read CT scans, identify skin lesions, and provide medical diagnoses, the low-hanging fruit is in improving physician efficiency, and de-tethering clinicians from the computer. This should be embraced by the healthcare industry now,’ write Anthony M. DiGiorgio, DO, of the University of California-San Francisco, and Jess M. Ehrenfeld, MD, MPH and Medical College of Wisconsin in Wauwatosa, WI. What’s more, they note that AI that improves physician workflow should require less regulatory oversight than algorithms that make diagnoses, recommend treatments, or impact clinical decision-making — a bonus.

AI could seamlessly integrate to provide predictive text for physician notes too, they suggest. As this takes place, the AI could start filling out orders, selecting ICD codes, and gathering pertinent clinical history. ‘Instead of clicking through endless reams of clinical documentation, a physician could have an AI-generated relevant patient history that can be quickly verified with the patient,’ they write.

Dr. Wu says current AI applications are just the tip of the iceberg. ‘Right now, most medicine is using AI as a tool to address current conditions or to treat those who are already symptomatic, but those at the forefront will be using AI on currently healthy people who have earlier or more severe signs of ageing, sun damage, or sagging,’ she predicts. ‘AI may be able to identify and track markers and predict who’s going to have earlier or more severe signs of ageing, sun damage, hair loss, sagging breasts and suggest interventions earlier,’ she tells PRIME. She believes AI will also take on a bigger role in diagnostics by analysing digital images instead of glass slides for the pathology of skin biopsies.

One thing is clear: AI is here to stay and as Kara Swisher notes in her new book Burn Book — A Tech Love Story, ‘We are the crash test dummies of the digital age.’

1-2-3 OCTOBER 2025

LENISNA’S SPECIAL ROLE IN ACNE SCAR TREATMENT:

THE PROLONGED STIMULATION OF COLLAGEN

Yu Dong-Kee, MD, describes his combinational approach using PDLLA

fillers Juvelook and Lenisna to treat acne scars

There are numerous techniques available for treating acne scars. These treatments typically involve deliberate physical damage or stimulation of the dermal layer using methods such as fractional lasers, microneedle radiofrequency, and picosecond lasers. This stimulation triggers an inflammatory response, activating dormant fibroblast cells beneath the skin through the secretion of growth factors. Subsequently, activated fibroblast cells produce new collagen, constituting the fundamental principle in scar restoration.

Lately, there has been a surge in procedures involving the injection of polymer-based biostimulators, like polylactic acid, into the skin layers to improve acne scars. Unlike conventional methods, which utilise machines or chemical substances like trichloroacetic acid (TCA) to induce intentional scarring and activate fibroblast cells, these bio-stimulators with polymer components trigger fibroblast cells via suitable inflammatory responses, eliciting a foreign body reaction in the immune system rather than causing scars.

The principal distinction here is that, following laser treatment, collagen generation by fibroblast cells peaks right after the

procedure and then diminishes rapidly over time. In contrast, Poly-D, L-lactic acid (PDLLA) biostimulators degrade slowly within the skin, fostering collagen production for an extended period, leading to a sustained effect. When comparing the duration of results between these two approaches, PDLLA treatments demonstrate a notably longer-lasting impact. I’ve personally observed collagen formation and scar recovery persisting for up to 3–6 months following a single treatment (Figures 1–2).

The laser or TCA alone cannot fill enough volume within the boundary of the acne scar. So, most of the time, I combine JUVELOOK or LENISNA in the combination treatment as the primary solution because these products effectively elevate the dull skin surface left after acne. Both products contain PDLLA and HA and allow direct injection into the dermis.

If your goal is simply to refine skin texture and minimise pores, JUVELOOK is the go-to option. However, for acne scars that are deeply pitted enough to be noticeable at a glance, I recommend using LENISNA to elevate the sunken area. When addressing these pitted scars, deep injection of PDLLA offers significant advantages. LENISNA (50-60 μm, 200mg) is composed of PDLLA particles twice the size and four times the concentration compared to JUVELOOK.

YU DONG-KEE, MD, Dermatologist and Founder of Irvine Dermatology, Seoul, South Korea. Master’s Degree in Medical Science from Seoul National University

Figure 1 Case 1. (A) Before and (B) 6 months after the first session

PDLLA can be injected into the dermis because it gradually induces a milder immune response compared to poly-l-lactic acid (PLLA). PDLLA, as particles with an amorphous structure, triggers a mild immune response due to its smooth characteristics. The foreign body reaction occurs more strongly with increasing hardness of the external substance (antigen), so PLLA is more likely to cause an excessive immune response. The ability to inject PDLLA into the dermis signifies the possibility of collagen formation within the dermis. On the other hand, PLLA with harder particles is more likely to cause firm nodules when injected into the dermis.

Key mechanism of PDLLA in collagen synthesis

Vaim Global has recently discovered another key underlying mechanism for collagen production of its uniquely structured PDLLA particle through clinical trials. When PDLLA is injected into the dermis or subcutaneous layer, it not only increases the survival rate of adipose stem cells through the M2 polarisation response but also stimulates their differentiation, leading to the generation of new fibroblasts. While the new fibroblasts produce collagen, restoring the sunken area or scar with new volume, the cytokine IL-10 secreted from M2 inhibits the breakdown of collagen by downregulating the expression of NF-kB and MMP2/3/9, thus preventing collagen degradation (Figure 3). NF-κB activation can lead to the production of pro-inflammatory cytokines, such as tumour necrosis

“In essence, addressing acne scars necessitates a multifaceted approach for

practitioners.

optimal

results that satisfy

both

patients and

Here, LENISNA emerges as a valuable asset, complementing the shortcomings of traditional acne scar treatments centred around lasers or chemical injectables.”

factor-alpha (TNF-α) and interleukin-1 (IL-1), which can stimulate matrix metalloproteinases (MMPs) production. MMPs degrade connective tissue by destroying the extracellular matrix (ECM), resulting in reduced dermal thickness and elasticity and skin wrinkles.

Integrating LENISNA into the treatment of acne scars

Given the diverse types and shapes of acne scars, a variety of treatment combinations are employed, tailored to each individual’s condition. Often, combining different procedures proves more effective than relying solely on one solution. In essence, addressing acne scars necessitates a multifaceted approach for optimal results that satisfy both patients and practitioners. Here, LENISNA emerges as a valuable asset, complementing the shortcomings of traditional acne scar treatments centred around lasers or chemical injectables.

For effective acne scar treatment, the following process must be meticulously carried out for each lesion.

1. Shouldering: Using Er:YAG or CO2 lasers, meticulously shave the boundaries of the lesion. For boxcar acne scars, an Er:YAG laser is used to trim the edges. If the edges of the scar are steep at 90 degrees, trimming both the edges and the surrounding normal skin together will reduce the depth of the scar as new skin fills in, and the number of treatments needed will decrease as well.

2. Subcision: Utilise the subcision technique to sever fibrous bands beneath depressed areas.

3. TCA injection Inject TCA to create space between the tightly bound collagen fibres at the base of the scar.

4. LENISNA injection: Inject LENISNA (PDLLA, collagen stimulator) into each lesion. Administer LENISNA into both

Figure 2 Case 2. (A) Before and (B) after the second session

LENISNA’S SPECIAL ROLE IN ACNE SCAR TREATMENT: THE PROLONGED STIMULATION OF COLLAGEN (continued)

particles1

the subcutaneous fat layer and the dermis layer using a dual-plane technique with needles. The choice of needle is crucial due to the thinness of the dermis layer within the acne scar boundary, necessitating precise injection at the correct depth. Furthermore, needles are ideal for meticulously treating narrow areas with individual attention to each scar.

5. Combination with Energybased device: Administer needle RF or pico-high laser treatment across the entire face.

Other indications of LENISNA

LENISNA is already being widely used for various indications requiring volume regeneration besides scar treatment. It is widely employed for deep wrinkles such as nasolabial folds and marionette lines, volume augmentation of the forehead and face, skin laxity, and body contouring, including décolleté and hip dips.

Patented PDLLA particles for safe, balanced collagen synthesis

JUVELOOK and LENISNA stand out from other polymer fillers due to their unique patented structure, ensuring maximum safety for dermal injection and promoting balanced collagen synthesis. VAIM Global’s PDLLA particle possesses a distinctive porous surface and reticular internal structure.

“LENISNA is already being widely used for various indications requiring volume regeneration besides scar treatment. It is widely employed for deep wrinkles such as nasolabial folds and marionette lines, volume augmentation of the forehead and face, skin laxity, and body contouring, including décolleté and hip dips.”

This design shields the internal structure from damage while facilitating the permeation of dermal cells through the pores, fostering collagen and elastic fibre formation along the internal mesh (Figure 4). Moreover, the gradual decomposition of the particle minimises drastic pH changes in the surrounding environment, mitigating overinflammation. Additionally, by utilising HA as the biocompatible gel carrier instead of CMC, immediate hydration post-treatment is ensured while averting unnecessary inflammation reactions associated with the latter chemical compound.

For more information, visit https://juvelook.com

References

antiox12061204. PMID: 37371934; PMCID: PMC10294940.

Figure 3 Mechanism of skin rejuvenation with PDLLA

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/

Figure 4 Patented reticular structure of VAIM Global’s PDLLA particle

EVALUATING THE SKIN REPAIR EFFICACY AND TOLERABILITY OF A FACIAL NIGHT MASK IN CHINESE FEMALES

EltaMD® shares the results of a new study conducted on 34 patients with sensitive facial skin

SKIN IS THE LARGEST and outermost organ in humans and forms a barrier to protect the body from countless external elements, including the environment or climate. Consumers often use cosmetic products to help improve this natural protective barrier and keep their skin in good condition. While much of the research has focused on those of European descent, very little research has been conducted on those of Asian and Chinese descent1. Chinese females with sensitive facial skin are reported to have more visible erythema and a poorer skin barrier than those who do not have sensitive skin2; this was the target population for the current study.

The clinical study was designed to demonstrate the skin barrier repair efficacy of a facial night mask on the cheeks of selfperceived sensitive skin Chinese females with naturally-occurring facial skin damage. The facial night mask contains a proprietary amino acid complex (AAComplex) known to reduce skin irritation and redness.

The cheeks were chosen as the measurement location because these sites are reported to have lower hydration and higher TEWL values than other facial skin sites3 and are where skin issues such as redness and sensitivity occur4. The

Tewameter TM300 (Courage + Khazaka, Germany) was used to evaluate the skin barrier function via transepidermal water loss (TEWL) and product tolerability on the whole face was evaluated by the study dermatologist. All parameters were evaluated before (D0) and after product application once daily at night, following product label instructions for a period of twenty-eight days (D28). The subjects continued using their usual sunscreen and daily facial regimen products, avoiding sun exposure as much as possible during the course of the study.

ISABEL DIAZ is Director of Dermal Clinical Research at Colgate-Palmolive, Co. and has 20+ years of experience in the cosmetic testing industry.

Figure 1

“In

the present study, we demonstrated that daily use of a facial night mask with AAComplex helps repair (improve) the facial skin barrier and reduce visible facial redness in Chinese females with self-perceived sensitive skin over 28 days with good skin tolerability.”

Methods

Participants

Thirty-four (34) females who signed an informed consent form were screened and enrolled in the study.

Test product

The test product was an EltaMD® Skin Recovery Night Mask provided with subject use instructions.

Study design

The study was conducted at the Guangzhou Landproof Testing Technology Co. Ltd, Guangzhou, Guangdong, China, between August 30 and September 28, 2021. The study followed a monadic design in which all subjects applied the Facial Mask to their entire face once at night for 28 days.

Testing parameters and biophysical instrumentation

The specific area of the face used for evaluations is illustrated in Figure 1, with site one representing the location where the TEWL measurements were made and site two where the skin redness (a*) was measured using the VISIA-CR + IPP (Canfield Scientific, Inc.) on facial images captured under Standard 2 Light Mode and Red Area Mode5

All testing parameters were evaluated at baseline (D0), 14 days (D14) and 28 days (D28) post once-daily product application (Table 1).

Adverse event (safety) evaluation

Evaluations were performed by the study dermatologist. The subjects were also requested to indicate whether they had experienced any kinds of adverse events.

Ethics

The study protocol and informed consent were approved by the Ethics Committee of Guangdong Daily Chemical Industry prior to the initiation of the study. The study followed the requirements of the Declaration of Helsinki and Good Clinical Practice.

Statistics

Analyses of the differences between the baseline value (D0) and the values at D14 and D28 were performed by a repeated measures ANOVA test for TEWL and for a*. SPSS 21.0 was used for data analysis. A two-tailed test was used for statistical analysis with statistical significance defined as p ≤ 0.05.

2 TEWL values at D14 and D28 are statistically significantly different from D0 (p ≤ 0.001). Percentages represent the decrease in TEWL post product use as compared to baseline (D0).

Results

The results are based on the thirty-two subjects who completed the study. TEWL decreased (Table 2) from 17.04 g/m2/h at D0 to 16.08 g/m2/h at D14 to 13.88 g/m2/h at D28. These decreases resulted in statistically significant decreases of 5.60% (D14) and 18.52% (D28) as compared to D0 (Figure 2).

After 28 days of product use, the red area mode images demonstrated reduction in facial redness in the cheek area (Figure 3). The skin’s a* value was

Figure

Table 1 Testing Parameters

Table 2 Tewameter (TEWL) & VISIA CR (a*)

EVALUATING THE SKIN REPAIR EFFICACY AND TOLERABILITY OF A FACIAL NIGHT MASK IN CHINESE FEMALES (continued)

Figure 3

Representative facial images as captured by VISIA-CR indicating overall decreases in skin redness. Top image: Subject 2 (Right view). Middle image: Subject 3 (Front view). Bottom image: Subject 21 (Front view).

Figure 4 a* value at D14 is statistically significantly different from D0 (p ≤ 0.05) with a numerical decrease by D28 (p>0.05). Percentages represent the change in a* values post product use as compared to baseline (D0).

measured on the same spot in the cheek area throughout the study. As shown in Table 2, a* values had an increase from 16.19 on D0 to 16.48 on D14 followed by a decrease to 16.09 on D28. This 1.8% increase in a* at D14 was statistically significant when compared to D0; however, on D28, the a* value had returned to D0 values since the decrease of 0.63 was not statistically different from the D0 value (Figure 4). The test product demonstrated good skin tolerability and was deemed safe. There were no product-related adverse events observed by the study dermatologist or reported by the subjects.

Discussion

In the present study, we demonstrated that daily use of a facial night mask with AAComplex helps repair (improve) the facial skin barrier and reduce visible facial redness in Chinese females with self-perceived sensitive skin over 28 days with good skin tolerability. The AAComplex technology contains taurine, arginine, and glycine, which have previously been reported to reduce skin irritation and repair skin damage6

The TEWL reductions were statistically significant (p<0.05) at both 14 days (5.60%) and 28 days (18.52%) of product use, signaling significant improvement of skin barrier function at both time points after daily use of the facial night mask.

The VISIA-CR images of the whole face demonstrated visual improvement of skin redness after 28-days of daily use of the facial night mask. Quantification of skin redness (a* value) on a selected spot on the cheek using the Image Pro-Plus (IPP) software showed a slight increase in a* at D14, which was then reduced back to baseline values by D28. The

observed increase in a* values on D14 was not corroborated by either the VISIA-CR images, the study dermatologist, or the subjects, none of which reported any problems with product tolerance or adverse events at either D14 or D28. This single-point measurement may not be representative of the entire face, while the study dermatologist, the subjects, and the VISIA-CR evaluated the entire face.

The facial night mask was safe and demonstrated good skin tolerability based on the dermatologist’s assessments.

Conclusion

This clinical study supports the repair efficacy and skin tolerability of the EltaMD® Skin Recovery Night Mask on healthy Chinese females based on bio-instrumental measurements and study dermatologist evaluations.

For more information, visit www.eltamd.com/

Further Reading

1. Pan Y, Ma X, Zhao J, et al. The Interaction of Age and Anatomical Region Influenced Skin Biophysical Characteristics of Chinese Women. Clin Cosmet Investig Dermatol, 2020, 13: 911-926. doi: 10.2147/CCID.S286402.

2. Ding DM, Tu Y, Man MQ, et al. Association between lactic acid sting test scores, self-assessed sensitive skin scores and biophysical properties in Chinese females. Int J Cosmet Sci, 2019, 41(4): 398-404. doi: 10.1111/ics.12550.

3. Voegeli R, Gierschendorf J, Summers B, et al. (2019). Facial skin mapping: from single point bio-instrumental evaluation to continuous visualization of skin hydration, barrier function, skin surface pH, and sebum in different ethnic skin types. Int J Cosmet Sci, 2019, 41(5): 411-424. doi: 10.1111/ics.12562.

4. Pan Y, Ma X, Song Y, et al. Questionnaire and Lactic Acid Sting Test Play Different Role on the Assessment of Sensitive Skin: A Cross-sectional Study. Clin Cosmet Investig Dermatol, 2021, 14: 1215-1225. doi: 10.2147/CCID.S325166

5. Ly BCK, Dyer EB, Feig JL, et al. Research Techniques Made Simple: Cutaneous Colorimetry: A Reliable Technique for Objective Skin Color Measurement. J Invest Dermatol, 2020, 140(1): 3-12.e1. doi: 10.1016/j.jid.2019.11.003.

6. Diaz I, Namkoong J, Wu JQ, et al. Amino acid complex (AAComplex) benefits in cosmetic products: In vitro and in vivo clinical studies. J Cosmet Dermatol, 2021, Oct 25. doi: 10.1111/ jocd.14544. Online ahead of print.

THE BODY TONING REVOLUTION: HIGH ENERGY INDUCTIVE THERAPY WITH Z TONE®

Dr Hans Bayer explores body shaping with electromagnetic pulses

DR. MED., HANS BAYER, is a specialist in dermatology and venereology. After 10 years as a senior physician at the University Hospital in Freiburg, he is now a partner in Hautmedizin Bad Soden and works independently with a private practice in Freiburg i. Breisgau, Germany

Physical fitness is very much at the forefront of current health trends. At the same time, many people no longer have the time or the energy to focus on their physical fitness. Treatment with electromagnetic impulses provides us with a new, highly effective and pain-free treatment option in the field of body toning to support physical fitness in a time-effective manner.

The Z Tone® from Zimmer Medical Systems® enables muscle hypertrophy of up to 20% after just six applications. At the same time, fat reduction of up to 15% contributes to the success of the non-invasive revolution in body toning. The innovative device is characterised by its design, effectiveness and durability.

The history of muscle stimulation in medicine goes back a long way and is characterised by an ongoing search for new methods to treat muscle injuries and improve the musculature in general1. In ancient times, electric fish were used to relieve pain and stimulate muscles. In the 18th century, Luigi Galvani discovered that electrical stimulation could trigger muscle contraction, which was an important milestone in the development of electrotherapy. In the mid-1950s, electromagnetic stimulation (EMS) was introduced. The mode of action of EMS is based on the fact that electrical impulses stimulate motor neurons, which in turn innervate the muscles. In order to transmit electromagnetic pulses, electrodes must be placed on the skin over the

muscles to be stimulated. The patients often have to wear corresponding vests or other special clothing for this purpose, which are not optimal in terms of hygiene and comfort.

HEIT technology

Body shaping through the use of high-energy inductive therapy (HEIT) electromagnetic impulses is the logical next step in the development of EMS. While the motor nerve fibres are stimulated in EMS, with HEIT, the electromagnetic impulses are delivered directly to the muscle tissue to induce muscle contractions. This allows for up to 32,000 muscle contractions within 25 minutes. This is accompanied by lipolysis and muscle hyperplasia, i.e., an increase in muscle tissue has been demonstrated. Interestingly, a regression of rectus diastasis after weakening due to pregnancy in the area of the straight abdominal muscles could also be shown2 Another new feature of HEIT therapy is the possibility of strengthening the pelvic floor muscles, which also brings medical indications, such as incontinence or sexual dysfunction, into the focus of treatment3. In addition, HEIT does not require electrodes to be applied to the skin. This makes the treatment much more pleasant, hygienic and accessible. HEIT can be used almost ubiquitously, with the exception of the pectoralis muscle, due to the risk of cardiac arrhythmia.

Mechanism of action

The mode of action of the Z Tone® from Zimmer Medical Systems® is

based on HEIT technology. Highenergy electromagnetic impulses specifically stimulate the muscle tissue. The special features of these ‘supramaximal’ muscle contractions and how they can lead to consecutive lipolysis and even muscle hyperplasia are explained below.

The principle of using induction current through rapidly changing magnetic fields is widely used today. A typical example is charging a smartphone without a cable using magnets. The Z Tone® from Zimmer Medical Systems® produces a strong, rapidly alternating magnetic field in two independently usable pads. The resulting electromagnetic impulses, or the induction current that flows, are used to trigger a direct muscle contraction.

The HEIT treatment has some special features. First, as part of a physiological muscle contraction, there is a short refractory period after each muscle contraction, a ‘non-excitability’ of the muscle. The reason for this physiological refractory period is that the resting potential, the excitability, has to be built up again via the motor nerves. As the electromagnetic impulse in HEIT therapy directly addresses the muscle and not the nerve, this refractory period is eliminated. This allows for 25,000–32,000 muscle contractions in a treatment cycle that lasts for 20–25 minutes. In addition, muscle contraction due to the external magnetic field is much stronger than voluntary muscle tension. We, therefore, speak of ‘supranormal or supramaximal contractions’. However, since there is

no injury to muscle fibres, the treatment does not lead to muscle soreness. This is also a special treatment feature, which patients see as particularly positive.

Another special feature is lipolysis, which is induced through the treatment with electromagnetic fields. On the one hand, the supranormal and enormously numerous contractions signal via a negative feedback loop that the muscle needs energy. This energy is mainly obtained through ketogenesis, which also leads to fat loss4. We therefore assume that a low-carb or ketogenic diet can also support the Z Tone® treatment. The rapid metabolisation of stored fat also releases blood lipids and triglycerides for a short time. The increase in triglycerides leads via a negative feedback mechanism to fat cells being driven into programmed cell death, i.e., going into apoptosis4 Fine tissue analyses have shown that apoptotic fat cells develop on the abdomen due to HEIT treatment. The reduction in fat through programmed cell death is, therefore, permanent and does not involve inflammation.

Finally, the supramaximal contraction of the muscles is so sustained that the muscle cells not only increase in cross-section but can even multiply5. This is why HEIT technology is now also used by professional sports clubs for regeneration after sports injuries.

In summary, 25–32,000 supramaximal muscle contractions are generated in 20–25 minutes. This leads to sustained muscle growth (muscle hypertrophy and hyperplasia) and a permanent reduction in fatty tissue (fat cell apoptosis).

“In summary, 25–32,000

supramaximal muscle contractions are generated in 20–25 minutes. This leads to sustained muscle growth (muscle hypertrophy and hyperplasia) and a permanent reduction in fatty tissue (fat cell apoptosis).”

Figure 1 Result in male patient 21 years. (A) before and (B) after six sessions of Z Tone® abdominal

Figure 2 Result in female patient 33 years. (A) before and (B) after eight sessions of Z Tone® abdominal

THE BODY TONING REVOLUTION: HIGH ENERGY INDUCTIVE THERAPY WITH Z TONE® (continued)

Treatment procedure and special features

For electromagnetic therapy, no electrodes are attached, and no special clothing is required. On the contrary, the treatment pads should not come into direct contact with the skin for reasons of hygiene. The two pads, which contain the magnetic coils responsible for generating the inductive magnetic field and thus the rapidly alternating currents, are fixed over the muscles to be treated using a Velcro strap.

The device can be used to control the treatment of the abdominal muscles, gluteal region, and upper and lower extremities using presets. The pads can be used individually, doubled, and coupled or decoupled. A special feature of the Z Tone® pads is that they are oil-cooled and, therefore, outperform competitors in terms of durability.

A separate chair is necessary for treating the pelvic floor, but this can be connected to the Z Tone® and does not require a separate device, as with other products.

Another special feature is that the treatment with the Z Tone® can be carried out in three training stages. Depending on the selected level, the Z Tone® works with different frequencies and thus controls different muscle groups. The treatment always starts at level 1 and is gradually increased to level 3 over the course of the sessions. Within the individual levels, work is carried out with different intensities between 0-100%.

A total of six sessions are recommended in a treatment cycle, which can be conducted at a maximum of twice a

week. Several sessions per week should be avoided due to the risk of rhabdomyolysis. More than six sessions can also be carried out, or these can continue to be carried out regularly at specific intervals; however, the benefit of this has not yet been proven. Our group is currently investigating this question, i.e., whether up to 10 sessions provide additional benefit for the subject, as part of a randomised study.

The contraindications to HEIT treatments are few. The most important contraindications are certainly its use around the heart, for pregnant women and febrile patients, or wounds in the treatment area. Use by individuals with medical implants and patients with active epilepsy should also be avoided. Finally, patients with an IUD with copper components must have the position of the IUD checked by a gynaecologist after treatment and should refrain from treatment during menstruation if they have menstrual problems.

Summary

The HEIT treatment of body muscles and the pelvic floor with the Z Tone® from Zimmer Medical Systems® has revolutionised body toning. With only six treatments, we can achieve a significant increase in muscle, which is sustained in the long term due to the associated muscle hyperplasia. The stimulation of ketogenesis and triglyceridaemia triggers lipolysis, especially in the abdominal area. Due to the underlying apoptosis, this process also sustainable. The two

pads can be used to control both the extremities and the trunk. Due to the oil cooling, the pads are more durable than comparable medical products. Six treatments are currently recommended, and the effect of 10 treatments is presently being investigated.

Because it is pain-free, hygienic and easy to use and, in particular, because of its fast and effective results, HEIT treatment with Z Tone® from Zimmer Medical Systems® is a real asset in the field of body contouring and body toning. Non-aesthetic indications include the treatment of rectal diastasis postpartum and muscular urinary incontinence.

For more information, visit zimmer-aesthetics.de/en/ztone/

Further Reading

1. D. E. Kent and C. I. Jacob, “Simultaneous Changes in Abdominal Adipose and Muscle Tissues Following Treatments by High-Intensity Focused Electromagnetic (HIFEM) TechnologyBased Device: Computed Tomography Evaluation,” J Drugs Dermatol, vol. 18, no. 11, pp. 1098–1102, Nov. 2019.

2. C. I. Jacob and B. Rank, “Abdominal Remodeling in Postpartum Women by Using a High-intensity Focused Electromagnetic (HIFEM) Procedure: An Investigational Magnetic Resonance Imaging (MRI) Pilot Study,” J Clin Aesthet Dermatol, vol. 13, no. 9 Suppl 1, pp. S16–S20, Sep. 2020.

3. J. B. Samuels, A. Pezzella, J. Berenholz, and R. Alinsod, “Safety and Efficacy of a Non-Invasive High-Intensity Focused Electromagnetic Field (HIFEM) Device for Treatment of Urinary Incontinence and Enhancement of Quality of Life,” Lasers Surg Med, vol. 51, no. 9, pp. 760–766, Nov. 2019, doi: 10.1002/lsm.23106.

4. D. J. Goldberg, “Induction of fat apoptosis by a combination of synchronised radiofrequency and HIFEM technology: Human histology study,” J Cosmet Dermatol, Jan. 2024, doi: 10.1111/jocd.16197.

5. D. Duncan and I. Dinev, “Non-invasive Induction of Muscle Fiber Hypertrophy and Hyperplasia: Effects of High-Intensity Focused Electromagnetic Field Evaluated in an In-Vivo Porcine Model: A Pilot Study,” Aesthetic Surgery Journal, vol. 40, no. 5, pp. 568–574, Apr. 2020, doi: 10.1093/asj/sjz244.

The Z Tone® from Zimmer Medical Systems®

experiencethedifference

THOUSANDS OF MUSCLECONTRACTIONS THROUGH ELECTROMAGNETIC PULSES

The High Energy Inductive Treatment with Z Tone is performed using electromagnetic pulses and is able to contract the muscles. Electromagnetic elds can penetrate cells, tissues, organs and bones without deformation or loss, activate the electrochemistry of tissues and improve the function of cells and cell membranes. The magnetic eld consequently stimulates nerve cells, muscles and blood vessels.

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NORTH AMERICA

27–30 JUNE 2024

The Aesthetic Show Las Vegas, NV www.aestheticshow.com

1–4 AUGUST 2024

AAD Innovation Academy Seattle, Washington www.aad.org

17–20 OCTOBER 2024

ASDS Annual Meeting Orlando, Florida www.asds.net

REST OF WORLD

28–29 SEPTEMBER 2024

AMWC India 2024 Mumbai, India www.amwcindia.com/

18–20 OCTOBER 2024

AMWC China Chengdu, China en.amwcchina.com/

10–11 NOVEMBER 2024

AMWC Japan Tokyo, Japan www.amwc-japan.com/en