The UK Journal of Medical Aesthetics and Anti-Ageing www.bodylanguage.net
BOTULINUM TOXIN ADVANCES REVIEWED THE POWER OF PEPTIDES
Fillers and men INJECTION POINTS AND QUANTITY VITAL FOR TOP RESULTS
Your partner in injectable facial aesthetics
BOCOUTURE does not require a cold chain. ®
Transport and storage does not require refrigeration prior to reconstitution.
Unopened BOCOUTURE® vials can be stored at controlled room temperature ( 25°C) for up to 3 years.
Botulinum toxin type A free from complexing proteins
BOCOUTURE® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for BOCOUTURE are not interchangeable with those for other preparations of Botulinum toxin. Reconstitution with 0.9% sodium chloride unpreserved for intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units) injected into each of the 5 injection sites: 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Use a thin sterile needle (e.g. 30 gauge). Intervals between treatments at least 3 months. Not recommended for use in patients over 65 years or under 18 years of age. Use immediately after reconstitution. Superior and medial alignment of the needle should be maintained during the injection. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Injections into the corrugator muscle should be done in the medial portion of the muscle, and in the central portion of the muscle belly. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions BOCOUTURE should only be used for one patient for one session. Should not be injected into a blood vessel. Patients may experience exaggerated muscle weakness. Not recommended for patients with a history of dysphagia and aspiration. Seek immediate medical care if swallowing, speech or respiratory disorders arise. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution if bleeding disorders of any type occur. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Caution in targeted muscles which display pronounced weakness or atrophy. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Use during lactation cannot be recommended. Has a minor or moderate influence on the ability to drive and use machines. Interactions No interaction studies have been performed. Theoretically Botulinum neurotoxin may be potentiated by aminoglycoside antibiotics or other medicinal products that interfere with neuromuscular transmission e.g. tubocurarine-type muscle relaxants. Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Localised muscle weakness, blepharoptosis,
localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose Increased doses of Botulinum neurotoxin type A may result in pronounced neuromuscular paralysis distant from the injection site. Symptoms of overdose are not immediately apparent post-injection and may include general weakness, ptosis, diplopia, speech difficulties, paralysis of the respiratory muscles and swallowing difficulties which may result in an aspiration pneumonia. BOCOUTURE may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Prescriber should consult the SmPC for full information regarding side effects. Legal Category: POM. Basic NHS Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: June 2010. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to email@example.com or on +44 (0) 333 200 4143. 1047/BOC/JAN/2011/JH. Date of preparation: Jan 2011. BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA.
body language number 48 14
CONTOURING THE MALE FACE Dr Derek Jones passes on his experience of treating men with an array of fillers
18 TECHNIQUE TURN UP THE VOLUME Injecting a good amount of filler at the right points can fill in wrinkles and address volume in large facial areas, writes Dr Koenraad De Boulle
Designer Helen Unsworth 020 7514 5981 firstname.lastname@example.org
21 CLINICAL NEEDLEPOINT Micro-needling skin rejuvenation doesn’t involve ablation or thermal injury and can be performed by all medical aesthetic practitioners and their trained personnel. Combination treatments are the way forward, writes Dr Robin Stones
25 RESEARCH PEER PRESS REVIEW Dr Rohit Kotnis surveys academic and association journals to report on advances in research in medical aesthetics and related fields
Classiﬁed Sales Simon Haroutunian 020 7514 5982 email@example.com Publisher Head of Sales Raffi eghiayan 020 7514 5101 firstname.lastname@example.org Contributors Dr Derek Jones Dr Koenraad De Boulle Dr Robin Stones Dr Rohit Kotnis Dr Timothy Flynn Dr Raj Persaud Dr Beatriz Molina Mr Rajiv Grover Barbara A Green RPh Ronni Weinkauf PhD Kim Pearson Dr Nick lowe Dr Sangeeta Punjabi Dr Aamer Khan Martin Murray Dr Sheldon Pinnell
ANALYSES Reports and comments
14 COVER STORY
Editor David Williams 01273 606 799 email@example.com Assistant Editor Helen Twinam 01273 606 799 firstname.lastname@example.org
HITTING NEW TARGETS The growth of aesthetic medicine can be traced to the rise of injectables, particularly botulinum toxin. Dr Timothy Flynn discusses papers that have investigated effects of the new formulations and how they have combined with fillers
30 PSYCHOLOGY THROUGH THE LOOKING GLASS We all know that cosmetic surgery can improve appearance, often with outstanding results. But does surgery improve self esteem? Dr Raj Persaud reviews the literature
33 FILLERS FILLER UP With an increasing variety of dermal fillers on the market, which one do you choose? Dr Beatriz Molina runs through their key characteristics
56 ISSN 1475-665X The Body Language® journal is published six times a year by FACE Ltd. All editorial content, unless otherwise stated or agreed to, is © FACE Ltd 2011 and cannot be used in any form without prior permission. The single issue price of Body Language is £10 in the UK; £15 rest of the world. A six-issue subscription costs £60 in the UK, £85 in the rest of the world. All single issues and subscriptions outside the UK are dispatched by air mail. Discounts are available for multiple copies. Printed by Buxton Press Ltd. Enquiries, orders and all other mail should be addressed to Body Language, 2D Wimpole Street, London, England, W1G 0EB. To contact Body Language by telephone, please call us on +44(0)20 7514 5982. Editorial e-mail: email@example.com Advertising: firstname.lastname@example.org. Body Language can be ordered online at www.bodylanguage.net body language www.bodylanguage.net
37 INJECTABLES IN GOOD SHAPE Dr Derek Jones, Dr Tim Flynn and Mr Rajiv Grover discuss permanent versus resorbable dermal fillers for a range of indications
41 SKIN POWERFUL PEPTIDES Small, biologically active peptides can help slow facial ageing, reduce dark circles under the eyes and lighten unwanted spots, write Barbara A Green RPh, MS and Ronni Weinkauf PhD
editorial panel Dr Jean Carruthers MD, FRCSC, FRC is clinical professor in the department of ophthalmology and visual sciences at the University of British Columbia in Vancouver, where she specialises in facial cosmetic surgery. With her husband, Dr Alastair Carruthers, she has received the Kligman award from ASCDAS . Rohit Kotnis MRCS (lon), Dip SeM (ed) practises from clinics in Oxfordshire and Buckinghamshire and is a trainer in advanced botulinum toxin and dermal filler applications. He has published extensively in musculoskeletal and trauma research journals and specialises in sports and soft tissue injuries. Professor Syed Haq trained at Harvard Medical School, Massachusetts General Hospital and Tufts University, New England Medical Center. Professor Haq is Director of The London Preventative Medicine Centre, Harley Street. Syed is an honorary consultant at the Chelsea and Westminster Hospital NHS Foundation Trust. Professor Andy Pickett has worked on botulinum toxins for over 23 years. Andy has lectured around the world on the products, translating the science into practical understanding for injectors. In 2011 Andy founded Toxin Science Ltd and is head of development at Q-Med.
Fiona Collins and Marie Duckett are registered nurses and members of the Royal College of Nursing forum for nurses in aesthetic medicine. Their clinic, Fiona and Marie Aesthetics Ltd, is based in Harley Street. Anthony erian FRCS (erg) FRCS (ed) is an aesthetic plastic surgeon with more than 30 years’ experience. He is a member of the American Academy of Aesthetic and Restorative Surgery and chairman of the European Academy of Aesthetic Surgery. Mr Erian practices in Cambridge and Harley St. Dr Stephen Bassett is medical director of the Aesthetic Training Academy and ShapeCYMRU Cosmetics. He is a Syneron luminary and member of the Merz academy, focusing on RF facial procedures. He is a barrister, fellow of the Society of Advanced Legal Studies and a legal consultant. elizabeth Raymond Brown, Phd, CRadP, MSRP authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies. She is now director of education at LCS Academy Ltd in Milton Keynes. Dr Séan Cummings MBBS T(GP), DRCoG, DFFP, MRCGP, llM is a cosmetic doctor practising in Harley Street. Dr Cummings has more than 20 years’ experience as a practitioner and has a masters degree in medical law. Dr Cummings works as an expert witness and has sat on GP disciplinary hearings Renato Calabria MD is part of the voluntary faculty of the Department of Plastic Surgery at the University of Southern California, Los Angeles. He is a member of the American Society of Plastic Surgery, and the International Society of Plastic Surgery. Dr Calabria practises in Beverly Hills, Milan and Rome. Dr Bessam Farjo MB ChB BAo lRCP&SI practises hair restoration at his clinics in Manchester and London. Dr Farjo is a fellow International College of Surgeons, founder member British Association of Hair Restoration Surgeons and president of the International Society of Hair Restoration Surgery.
body language number 48
43 NUTRITION MICRONUTRITION AND IMMUNITY The best offence to bolster the immune system is a strong defence, writes Kim Pearson
45 PRODUCTS ON THE MARKET The latest products in aesthetic medicine, as reported by Helen Twinam
48 RESEARCH EVIDENCE-BASED PRACTICE Practitioners must combine clinical expertise with independent research. Dr Nick Lowe reviews the effectiveness of current study protocols and the importance of data-based evidence
50 DERMATOLOGY ATOPIC ECZEMA The prevalence of eczema is rising, caused by genetics and environmental factors. Dr Sangeeta Punjabi discusses treatment and patient management
53 PEER TO PEER UNDER THE SKIN In this issue, our panel of experts discuss dermatological issues and skin treatments, as well as the best hyaluronic acid techniques for facial rejuvenation
56 DERMATOLOGY FOLLOW THE LIGHT As well as being an effective skin cancer treatment, photodynamic therapy can be a useful addition to your armamentarium for conditions such as acne and rosacea. Dr Aamer Khan describes the procedure and aftercare
59 ACCOUNTANCY STRUCTURAL INTEGRITY With the onset of the 50% tax rate and potential loss of personal allowances, Martin Murray outlines the pros and cons of financial structures available to cosmetic practitioners
61 ANTIOXIDANTS UNDER THE SUN The sun may have set on the British summer but our skin is still under attack. Dr Sheldon Pinnell explains why topical antioxidants may provide skin protection that is not possible with sunscreens
66 COMMENT CONCLUSION Letter from the Editor, cartoon
Dr Masud Haq BSc, MRCP, MD is a consultant in diabetes and endocrinology who practises at Tunbridge Wells and 10 Harley Street. Dr Haq is a graduate of Guy’s and St Thomas’s Hospital, and he trained at Johns Hopkins in the US and in Melbourne. He has written for numerous publications and has a particular interest in the thyroid and menopause.
body language www.bodylanguage.net
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BEL023/0411/JH Date of preparation April 2011
www.belotero.com Merz Pharma UK Ltd 260 Centennial Park, Elstree Hill South Elstree, Hertfordshire, WD6 3SR Tel: +44 (0) 333 200 4140
Tax would cause more harm than good, say critics HMRC says proposals simply clarify current legislation. Helen Twinam reports Government plans to introduce VAT on cosmetic surgical procedures have been blasted by the industry. The proposal, called the “boob tax”, would raise an estimated £500m per year, raising prices of procedures such as breast enlargements, facelifts, liposuction and abdominoplasties by around 20%, the current rate of VAT. Minor procedures, such as injectables and facial peels, are subject to VAT. But cosmetic doctors performing surgery will have to register for VAT and pass the charge on to their patients, unless they can prove the procedures are for medical reasons. Guidelines issued by the HM Revenue and Customs (HMRC) state that services are VAT-exempt only if the purpose is to “protect, maintain or restore the health of the person concerned”. The guidance says that, while cosmetic treatment may make a person feel more confident about their appearance, this is not sufficient to make the treatment exempt. Patients with psychological conditions, such as body dysmorphic disorder or those having corrective surgery, will not be affected by the proposal. The British Association of Aesthetic Plastic Surgeons (BAAPS) claims the move will present an “ethical minefield” and drive patients abroad for cheaper surgery deals. “The subjective proposals being put forward by HMRC will potentially harm large numbers of patients. They imply that, by definition, any procedure that corrects appearance rather than
function is not a medical need. There has been no meaningful discussion with the professional bodies involved,” says BAAPS president Mr Fazel Fatah. “We can only hope that common ground can be found that protects the well-being of patients while balancing the obvious need to increase tax revenues. With surgery, we are dealing with human lives," Mr Fatah says. A similar 5% levy on elective cosmetic procedures in the US, dubbed the “Bo-tax”, was proposed under President Obama’s healthcare reforms in 2009. But the move was dropped in favour of a 10% tax on tanning bed users. The UK move has initiated debate on whether the government is acting to profit from the success of the industry, which has an estimated value of £2.3bn a year, and the difficulty in determining whether a surgical procedure can be classed as ‘therapeutic’. Consultant plastic surgeon Douglas McGeorge says: “The amount of money HMRC will make out of this is astonishing. Should prominent ear correction in children be taxed? What level of asymmetry or abnormality is required to justify breast surgery? “Our role is to make sure patient needs justify treatment. Any justification to HMRC of our decisions on VAT will be impossible unless patient confidentiality is breached,” Mr McGeorge says. The potential invasion of patients’ privacy is also a contentious issue. Dr Samantha Gammell, president elect of the
“Justification to HMRC of decisions on VAT will be impossible unless patient confidentiality is breached” Douglas McGeorge, consultant plastic surgeon 6
British Association of Cosmetic Doctors, says that the aggressive stance taken by HMRC will discriminate against vulnerable women, some ethic groups and sufferers of disfiguring dermatological conditions. “When patients seek out care from doctors, they expect to be treated without judgement or prejudice, putting the maintenance of their health as our primary concern. “We are appalled that HMRC inspectors in Wales are demanding to review confidential patient records for proof of their medical needs. It is an obscene invasion of privacy based on a ridiculous premise that a doctor, having taken on a duty of care, could do otherwise than protect the health of their patient,” Dr Gammell says. “The public should not be put off seeking the help that they need. There is simply no legal basis for the HMRC’s approach and we will continue to fight for patients’ rights.” However, HMRC maintains that the new tax is simply clarifying current guidance set out in a 2007 document. A statement issued by the HMRC says that, while it reviews its guidance in consultation with relevant trade bodies, there are no plans to change the VAT liability of cosmetic services. “Medical care provided by registered health professionals in hospitals or clinics is, and will continue to be, VAT-free along with cosmetic services performed for therapeutic purposes. Medical treatment for purely aesthetic reasons has been, and continues to be, liable to VAT at the standard rate.” HMRC adds: “We will generally accept that cosmetic services are exempt where they are undertaken as an element of a health care treatment programme. Where services are undertaken purely for cosmetic reasons, they will be standard rated.”
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South-east Asia is a medical tourist hot spot Lower prices, well-trained staff and beaches and warm weather lure Western consumers The UK aesthetic medicine’s fears that more consumers will be lured to other countries because of the imposition of VAT on procedures is a distinct possibility. South-East Asia and India in particular has shown large growth in patients travelling from abroad to have aesthetic surgery. Hospitals from India to Singapore and South Korea treat more than one million foreign patients a year, lured by cutprice surgery, no waiting lists, cutting-edge technology, and highly trained doctors. Industry experts predict medical tourism in Asia will grow at a rate of 15–20% a year. American patients swell the numbers most, saving 40– 50% on domestic costs. The fastest growing visitor numbers are from China.
Kim Byung-gun, a plastic surgeon at the BK DongYang Plastic Surgery Clinic in Seoul, says medical tourism is going to be “one of the growth engines of the South Korean economy”. He attributes the growth from China to the “Korean Wave”, which is popular Korean culture that is popular in China. CLSA Asia-Pacific Markets estimated that China will account for 60% of the rise in high net-worth individuals' wealth in Asia over the next five years. In 2007, fewer than 8,000 medical tourists travelled to South Korea. By 2020, the South Korean government envisages one million medical tourists a year. India's government says its medical services are cheaper than those in southeast Asia,
Letters to the editor Problems with awards
I just read your “Conclusion” at the back of Sept/Oct Body Language, and I just wanted to write to commend you on this. I entirely share your views that giving “awards” and trophies to clinics is an impossible, not to mention thankless task—apart, that is, from the person receiving it! I know that other cosmetic publications offer these routinely, however, I have always frowned upon these (as much as Botox will allow me of course—LOL) for the reasons that you have succinctly pointed out. Although I know that the commercial pressures may be great upon you but I do hope you will be able to uphold your thoughts and withstand having such awards in the future. Mr Alex Karidis Plastic surgeon London
Body Language on iPad please!
In addition to the paper version, could we have Body Language available on the iPad please. Dr David Varghese Hampshire Does BL on iPad suit your reading preferences? Email david@ face-ltd.com if this is something you would like to see. Or do you prefer good, old-fashioned paper. You can send your letters to the editor by email: email@example.com body language www.bodylanguage.net
and identifies its Englishspeaking doctors as providing a "major comfort factor". It has even introduced a special visa category to cater for the growing number of medical tourists. Thailand sells itself as dual purpose destination where medical treatment can be combined with a cheap recuperative holiday. The Singapore healthcare industry positions itself as a "premium" centre. Among its patrons have been many of Malaysia's sultans, as well as other high profile political figures and celebrities from Asia and the Middle East. By next year, Singapore aims to treat one million foreign patients a year, generating about $3 billion for the economy, the Singapore Straits Times has reported.
Its area of expertise includes cancer treatments, cardiology and other specialised care. Like South Korea, it sees China, as well as India, as being the catalysts for growth, Neighbouring Malaysia, attracted nearly 400,000 medical tourists last year, and aims to increase that number to 1.9 million by 2020, mainly by way of undercutting Singapore. A health official said costs in Malaysia are 30 percent cheaper than the city-state to the south. The Philippines also sees itself as a cut-price destination, and is projecting the number of medical tourists to hit one million by 2015, generating at least $1 billion in revenue. It targets patients from the United States, Canada, Taiwan and Japan.
Nanotechnology in breast implants reviewed Material could help cancer treatment A review published in Wiley Interdisciplinary Reviews: Nanomedicine and Nanobiotechnology is investigating whether nanotechnology may improve the safety of breast implants. While groups have campaigned for their abolition on safety grounds, results from six ongoing post-approval studies on silicone implant safety and performance have shown no increased risk of breast cancer or connective tissue disease. The US Food and Drug Administration ended its 14-year ban on silicone-filled breast implants in 2006 but the actual silicone rubber shells were never called into question and silicone rubber implants filled with saline were never withdrawn from the market. Lead review author Judit E Puskas, PhD ME of the University of Akron and researchers
surveyed the literature on breast implants from the perspective of material science to determine how nanotechnology may enable the future development of safer breast implants. By reducing the size of the components in nanostructured materials, “unprecedented properties can be achieved”, they say. The authors are developing an alternative nanostructured material to silicone rubber that they say will minimise complications. They say the new material will be able to deliver cancer drugs locally to improve the efficacy of treatment and minimise side-effects associated with chemotherapy. There is potential for countless materials and devices to be developed for a range of applications but issues have been raised concerning toxicity, particularly when used in medicine. 9
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Signals from stem cells may spur hair growth Finding could lead to baldness treatments Researchers at Yale University have found that molecular signals from stem cells within the skin’s fatty layer are necessary to generate hair growth in mice. The finding could lead to new treatments for baldness, according to a study published in the September issue of Cell. When hair dies, the scalp’s fatty layer shrinks, then expands as hair growth begins— a process known as adipogenesis. The Yale researchers found that the stem cells involved in the creation of new fat cells— adipose precursor cells—were
needed for hair regeneration, and that these cells produce platelet-derived growth factors. Lead author of the study, Valerie Horsley, says: “If we can get these fat cells in the skin to ‘talk’ to the dormant stem cells at the base of hair follicles, we might be able to get hair to grow again.” To test whether the signalling applies to humans, research is needed to identify other signals produced by the scalp’s stem cells and how these may help regulate hair growth, and whether they are required for human hair growth
BACN offers bursaries for prescribing course Nurses must apply now for 2012 The British Association of Cosmetic Nurses (BACN) is offering members bursaries for its V300 nurse prescribing course. Completion allows cosmetic nurses to prescribe within their area of competence drugs such as botulinum toxin following a face-to-face consultation. The V300 course can cost more than £1500. The BACN is offering £800 per member towards the full prescribing course, and £200 towards a pre-assessment course. Applicants can choose either, but not both, and payment will be made directly to the chosen university. Nurses can apply for bursaries now, in preparation for the January 2012 intake. The first awards will be made on 5 December 2011. Further awarding dates will take place in 2012, or until all money has been allocated. To be eligible, applicants must be a BACN member, have been practising in aesthetics for at least a year, hold current
registration as an adult nurse on the NMC register, obtain written support from a line manager or referee, submit an end of year final report to the BACN management board, and have been a UK, Channel Islands or Isle of Man resident for four years. Applicants must write a 500-word supporting statement on how the course would benefit them and their patients, as well as a two-page CV and references. More information can be found on the BACN website at www.cosmeticnurses.org.
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SELLING POINTS How does online marketing of UK and US aesthetic clinics compare? A study presented at the British Assocation of Aesthetic Plastic Surgeons annual meeting evaluated the marketing practices of 100 top clinic websites offering cosmetic surgery—50 in London and 50 in New York. Results showed that more US-based practitioners take advantage of social media networking and interactive website features than UK surgeons
Accreditation 94% vs 64%: Nearly all US websites list surgeons’ accreditation, such as board certification, compared with only two-thirds of British websites The remaining 36% don’t include qualifications, are not on the specialist register or even listed with the GMC. Prices 24% vs 10%: One-quarter of British clinics provide price lists and indicative prices, compared with only 10% of US clinics Photography 100% vs 46%: US websites are much more likely to contain pre- and post-operative photographs of patients who have undergone specific procedures, compared with less than half of their British equivalent Media 66% vs 26%: American websites are more likely to feature video clips (and 72% animated graphics) online than UK clinics (56% graphics) 72% vs 30%: US-based practitioners are more likely to feature press and media coverage of their work compared with UK doctors Social media 58% vs 16%: More than half of American websites feature a blog, compared with only 16% of UK clinics 36% vs 6%: Over a third of US clinics have a link to a Facebook page (and 28% Twitter), compared with only 6% of UK websites (10% Twitter) Competitions 26% vs 12%: British clinics are more than twice as likely than US clinics to offer financial incentives such as prize draws, BOGOF offers and multi-procedure discounts Source: Aesthetic Surgery Journal/BAAPS
training & events NOVEMBER
9th November Stem Cells and Growth Factor Technology in Cosmetics, Melia White House Hotel, London W: skingeeks.co.uk; 01865 338 046
12th January 5th Annual Oculoplastic Symposium, Atlanta W: sesprs.org
10th - 12th November 8th British Academy of Cosmetic Dentistry Annual Conference, Hilton London Metropole Hotel, London W: bacd.com 12th - 13th November Advanced Toxins & Fillers and Advanced Dermal Fillers Training Courses, Wigmore Medical, London W: wigmoremedical.com; 0207 514 5979
13th January Healthxchange Obagi Training Workshop, Manchester W: obagi.uk.com; 01481 748063 18th January Dental Block Training, Heather Irvine Aesthetics Academy, Bradford, W. Yorks W: heatherirvineaestheticsacademy.co.uk; 0844 324 9199
15th - 16th November SkinBrands Medik8 Training Courses, Cheshire W: skinbrands.co.uk; 05603 141 956
18th January Lynton Lasers Core of Knowledge Course, Lynton Clinic Training Centre, Cheadle W: lynton.co.uk; 0845 612 1545
22nd November The Future for UK Cosmetic Surgery: Creating a Safe, Successful Industry Seminar, Guoman Charing Cross Hotel, London W: inside-health.co.uk; 0845 666 0662
19th-21st January 15th Meeting of the European Dermatology Forum, Interlaken, Switzerland W: euroderm.org
23rd November Eden Aesthetics Agera, DermaFrac and Microdermabrasion Training Course, Manchester W: edenaesthetics.com; 01245 227752
19th - 21st January International Congress in Aesthetic Dermatology 2012, Bangkok W: euromedicom.com
24th November DNC Skin Microneedling Training Course, London Docklands W: wellnesstrading.co.uk; 01746 718123
24th January BACN Managing Complications for Nurse Prescribers, London W: cosmeticnurses.org
28th November Advanced Botulinum Toxin Training, Heather Irvine Aesthetics Academy, Bradford, West Yorkshire W: heatherirvineaestheticsacademy.co.uk; 0844 324 9199
26th January BAD Medical Dermatology Meeting, Royal College of Physicians, London W: bad.org.uk
30th November British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) Winter Scientific Meeting, Royal College of Surgeons, London W: bapras.org.uk
26th - 29th January International Master Course on Aging Skin (IMCAS) 2012 Annual Meeting, Paris, France W: imcas.com
27th - 28th January British Academy of Aesthetic Dentistry Annual Scientific Conference, Stoke Park, Bucks W: baad.org.uk
1st - 3rd December 6th International Congress of Psoriasis: from Gene to Clinic, QEII Conference Centre, London W: psoriasisg2c.com
28th - 29th January Innomed Basic Botulinum Toxin and Dermal Fillers Courses, Greater Manchester W: innomedtraining.co.uk; 02380 676733
2nd - 3rd December Hyperhidrosis and Intermediate Botulinum Toxin and Advanced Dermal Fillers Training Courses with Dr Brian Franks, North London W: drbrianfranks.com; 07973 558595
31st January - 4th February 8th IACD World Congress of Cosmetic Dermatology, Cancun, Mexico W: wcocd2012.com
6th - 7th December SkinBrands Medik8 Training Courses, London W: skinbrands.co.uk; 05603 141 956 3rd December Dermis Deep Foundation Botox and Dermal Fillers Courses, Birmingham W: ddassist.com; 01675 625007 7th December Mapperley Park Core of Knowledge Course, Nottingham W: mapperleypark.co.uk/training; 0115 969 0111 7th December Lip Master Class Training, Heather Irvine Aesthetics Academy, Bradford, W. Yorks W: heatherirvineaestheticsacademy.co.uk; 0844 324 9199 8th - 10th December 19th Annual World Congress on Anti-Aging Medicine and Biomedical Technologies, Las Vegas, Nevada W: a4m.com 12th December Healthxchange Obagi Training Workshop, London W: obagi.uk.com; 01481 748063
FEBRUARY 1st - 4th February International College for Maxillofacial Surgery Congress, Gran Canaria W: icmfs.com 8th February Mapperley Park Core of Knowledge Course, London W: mapperleypark.co.uk/training; 0115 969 0111 9th-11th February 46th Annual Baker Gordon Educational Symposium, Coconut Grove, Florida W: bakergordonsymposium.com 27th February Healthxchange Obagi Blue Peel Training Workshop, London W: obagi.uk.com; 01481 748063 28th February Interventional Cosmetics: New Treatments & Management of Complications, Royal Society of Medicine, London W: rsm.ac.uk
13th - 14th December If you have an item you would like included SkinBrands SkinCeuticals Training Courses, London in Training & Events, send it for consideration W: skinbrands.co.uk; 05603 141 956 to firstname.lastname@example.org
Synthetic collagen shows promise for regeneration Too early to predict whether it is viable alternative Researchers at Rice Universi- similar way to native collagen, ty, Houston have developed a but we start with shorter pepmethod for creating synthetic tides,” says Hartgerink. collagen, which may aid tisThe researchers say that it is sue and organ regeneration too early even to predict whethfrom stem cells. er the synthetic collagen will be Lead author Jeffrey Hart- a viable substitute. gerink says: “Our final product Tests have shown, however, more closely resembles native that the enzyme that is responcollagen than anything that’s sible for breaking down napreviously been made, and tive collagen breaks down the we make that material using synthetic material at a similar a self-assembly process that is speed. remarkably similar to processes Future tests will determine found in nature.” whether cells can survive in the It has so far been difficult new material. to recreate collagen because of its complexity. Collagen fibres are constructed from millions of peptides, and the fibres can form hydrogels to trap water. “Our supramolecules, fibres and hydrogels form in a CAD can aid the creation of a mould
Architect technology used for breast reconstruction Potential boon for tissue engineering Scaffolds for personal breast tissue reconstruction have been produced using computer-aided design (CAD) to create an accurate mould of the breast as a visual aid during tissue reconstruction. Three female breast cancer patients in a study published in a physics institute journal were scanned by a 3D laser and the images fed into CAD software to create a single image representing the patient’s breast and thorax. The image was printed to form a 3D mould used as an operative aid for surgeons carrying out autologous tissue reconstructions. Patients reported higher satisfaction of surgical outcome compared with a control group. CAD particularly shows
promise for tissue engineering in the creation of a mould for scanned tissue with the ability to tailor the porosity and pore size. This is essential to the seeding and diffusion of cells within the structure and is limited by modern technologies. Professor Dietmar Hutmacher, co-author of the study, says: “The development of a clinically translatable method of engineering adipose tissue for soft tissue reconstruction requires investigation of several components. There must be coordination between all key aspects of tissue engineering, including the selection of cell source, scaffold material, cellular environment, and means of device delivery for the engineering of tissue to be successful.”
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R OYA L CO L L E G E O F PHYSICIANS LONDON
15th – 17th June 2012 3 DAY CONFERENCE PROGRAMME Hear the world’s leading facial aesthetic experts speak on the latest developments in Facial Aesthetics. As with 2011 FACE will include many parallel lectures to allow all topics within facial aesthetics to be covered with even more Exhibitor Workshops and Specialist Meetings. ADVANCED TRAINING Opportunities to learn new and advanced techniques from leading practitioners in this limited space full day training course. EXHIBITION A concurrent exhibition and exhibitor workshops help you keep up to date with leading-edge products with over 50 of the industry’s key manufacturers and distributors. FACE OF THE CLINIC A concurrent business meeting providing an invaluable opportunity for you to invest in quality education for key personnel within your business. 2012 will see also much more focus on the marketing of your clinic as well as day to day managment. AN EVENING WITH... This will be the 4th incarnation of an evening with and once again we will have one of the industry greats explain the methods used to have a thriving clinic and a healthy business model. ALTERNATIVE AGNEDA FOR 2012 As in the last four years FACE has always created the need for delegates to see and hear more and 2012 will be no different. With the prospect of more than 4 parallel conferences on each day FACE 2012 will undoubtedly be the biggest conference yet.
REGISTER NOW: WWW.FACECONFERENCE.COM
THE UK’S PREMIER MEDICAL AESTHETIC CONFERENCE AND EXHIBITION Celebrating 10 Years of FACE In 2012 FACE will be celebrating 10 years of being the UK’s premier medical aesthetic conference. From the first 5 hour evening meeting in 2002, FACE has grown into a congress with over 70 hours of lectures held by some of the worlds best practitoners and pioneers in facial aeshtetics. The growth has been consistent and over the next few years we expect to see even more developments for the FACE Conference. Wendy Lewis, Beauty Consultant “FACE is the most important aesthetics congress in the UK and an absolute must for any vendor doing business in the region.” Dr Daniel Goldberg, Clinical Dermatologist “One of the most dynamic and exciting cosmetic meetings I have ever lectured at.” Dr Tess Mauricio, Clinical Dermatologist “Face has been wonderful, able to bring together world leaders in aesthetics. Definitely the conference to go to.” Dr Aamer Khan, Cosmetic Doctor “FACE is the pinnacle of our industry, educates and brings people together.”
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cover story Dr Derek Jones
Contouring the male face Dr Derek Jones passes on his experience of treating men with an array of fillers
start every filler lecture with anatomical slides of high-risk structures, and that is vascular anatomy. Anyone picking up a filler syringe must know it inside and out, like the back of your hand. The facial artery supplies the blood to the face, breaking off on the lower lip, into the inferior labial artery, into the superior labial artery, travelling up along the course of the nasolabial fold. All of these present high-risk for vascular occlusion. This network connects the dorsal nasal artery to the supratrochlear artery. If you inject your filler into any point along this and occlude the vessel, you can get a watershed vascular occlusion that affects a portion of or the entire network, manifested an an immediate white blanching of tissue followed by a retiuculated purple-blue erythema. There are increasing case reports secondary to intravascular occlusion with fillers; that’s why we have to know where these vessels are, where they run, and we have to be respectful of them so that we don’t create any mischief. We have much data on Restylane, Juvederm and Belatero. Studies show that when you reach optimal correction with hyaluronic acid and retreat in 6–12 months, you need less volume for optimal correction, and the corrections start to persist for
longer periods—often 18–36 months. HAs are long-lasting with repeat treatments. HAs are “erasable”. I use many fillers—they all have a role— but I particularly like hyaluronic acid because I sleep well at night. If I have a problem I know I can erase it with hyaluronidase. If I have an unfortunate intravascular accident, which can happen to even the best of us, I have hyaluronidase in my cabinet that I can use to flood the area and resolve it. We use Vitrase in the USA; the one common here is Hylase. When using hyaluronidase, you need to have some awareness of the difference between fillers. It takes more Vitrase to dissolve Juvederm than it does Restylane. That doesn’t mean one product persists longer than the other. But if you’re using Juvederm and you’re trying to erase it, it’s going to take twice as much hyaluronidase than Restylane. From my clinical experience, each tenth of a cc of Juvederm that I estimate I want to dissolve, I use 10 units of Vitrase; and for each tenth of a cc of Restylane that I estimate that I want to dissolve, I use five units. The hyaluronidase works well and breaks the cross links immediately. You often see the hyaluronic acid fading away before your eyes. HAs are great for male lips. You must be careful not to overbody language www.bodylanguage.net
cover story Dr Derek Jones
volumise them. I ing as you pull back, you have much less chance of injecting never use calcium straight into an artery. hydroxylapatite or Cannulas are becoming much more popular these days. I’m polylactic acid. Lips still mostly a needle injector, but I would certainly seek experiare for hyaluronic ence with cannulas when injecting Radiesse because it may be acid only; it’s a less risky. Never inject it into the lips; never inject it into the much softer, more glabella, which is a high risk area for necrosis; and never inject it supple product and into the tear trough. you can erase it. Sculptra is a subtle volumiser. HAs work nicely You have to do multiple treatments and I would say do not for tear troughs. inject this product superficially. It is not an intra-dermal injecMany practitioners tion, it’s a SubQ injection. You want to make sure that you rewant to treat tear constitute with 5cc or more using a linear threading technique. troughs, but they I’ve done a significant amount of work with the HIV lipoatroare the most techni- phy community. I was among a group of authors who published cally complex area data on 77 patients treated with liquid injectible silicone using to treat. I get many micro-droplet technique, 2cc per treatment at monthly intervals, referrals because until we got optimal correction. (Derek H Jones MD, Alastair Carruthers MD, David Orentreich MD, Harold J Brody MD, Know your anatomical danger zones. Avoid of my experience facial artery branches, infraorbital nerve and with hyaluronidase. Mei-Ying Lai MS, Stanley Azen PhD, Gregory S Van Dyke MD, parotid gland Most people come PhD. “Highly Purified 1000-cSt Silicone Oil for Treatment of to my clinic with an over-volumised tear trough. Human Immunodeficiency Virus-Associated Facial LipoatroI inject on a deep plane through this area, going in at a 90-de- phy: An Open Pilot Trial,” Dermatologic Surgery, Vol 30, Iss gree angle with, generally, a 32-gauge half-inch needle. You don’t 10, pp 1279–1286, Oct 2004.) The treatment worked beautifulwant to put it too superficially. You need to go just a little infe- ly. You have to go slowly with the micro-droplet technique using riorly to the trough into the sub-orbicularis oculi fat and place it highly purified 1000-cSt silicone. I do find this to be absolutely properly, usually in an epiperiosteal location. the best treatment for HIV facial lipoatrophy. If there’s any mid-facial atrophy in the cheek, you have to adWe have recently followed up with about 135 of these padress this before you treat the tear trough; otherwise you’ll create tients. Extremely good results were evident at five years or more. a sausage effect that is basically buttressing out over a hollow We have had four patients who have developed some subcutacheek, and that’s a no-no. Often by just restoring cheek atrophy, neous induration, which is expected with any permanent filler. you can make eyes look better. Luckily we’ve been able to treat it quite nicely with intralesional HAs can treat the ear lobes. One patient had a little line in cortisone with 5-flourauracil. the ear that bothered him. I put .4 ccs of HA in each ear lobe and he was thrilled. Dr Derek Jones is an associate professor of dermatology at UCLA I always pay attention to what bothers patients. I give them and director of the Skin Care and Laser Physicians clinic of Beverly the mirror and ask them. I may have all sorts of ideas about what Hills. W: skincareandlaser.com I want to do, but I really try to incorporate their primary complaint foremost, without doing any harm. Radiesse is a one-year filler, and we have histologic studies showing that. Calcium hydroxylapatite is visible in CT and X-ray and does not obscure underlying structures or pathology. It is FDA-approved for the nasal labial fold in HIV facial lipoatrophy. HIV facial lipoatrophy patients can take much volume. For more advanced stage two lipoatrophy, the average optimal correction using Radiesse is about 13cc; our silicone stud- A 42-year old male injected with filler into lips before (left); at two weeks, 12 weeks, 24 weeks, ies suggest about the same. You’re not go- 36 weeks and 48 weeks ing to make patients happy with a smaller amount. Part of what we need to do as good cosmetic injectors is to be able to estimate how much volume someone will need. Radiesse is a robust product. There are probably a disproportionate number of vascular accidents with Radiesse because novice injectors are using it and injecting it too rapidly, getting into vascular structures. I use a lot of it in my own practice. Inject it very slowly. I use a linear retrograde technique, using a long needle. If you’re inject- An HIV patient before Silikon-1000 injections and after 11 at monthly intervals body language www.bodylanguage.net
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technique Dr Koenraad De Boulle
Turn up the volume Injecting a good amount of filler at the right points can fill in wrinkles and address volume in large facial areas, writes Dr Koenraad De Boulle
evolumising the face can make patients look so much younger. Those who have seen me inject know I use the bolus technique. I check that I'm not in a vessel, that I'm not scraping the periostium and that I am on the bone. My old adage is always “stab quickly, inject slowly”. On average, for a cheekbone enhancement, I need anywhere from 0.25–0.75cc. I follow up with a little massaging of the area. I get my patients to smile so that I can assess volume, then I inject one side, and ask to smile again as to assess the other side. I inject the requisite volume for an even look. Then I feel whether everything 18
is in the right position, For the mid-face I make a single injection into the deepest point. If I can have the tip of my needle around that area, then I know the maximum amount of product will be delivered there for maximum lift. As I pile up the filler like a pyramid, I can squeeze it so that it goes perfectly into place. Vessel I check that I'm not in a vessel—if I am in a nerve the patient will definitely tell me. If I am in a vessel, the aspiration test will tell me that. I put my finger where I feel the orbital rim and inject very softly. I will have close to 0.75cc in this area
if it is not mixed with lidocaine. Then I will look at both sides. Typically, I may inject 0.75 to 1cc in the cheekbone and around 1cc per side in the mid-face. I do not use icepacks on a regular basis, especially when fillers containing lidocaine are used. Once during a demonstration, the injectors were using a filler containing lidocaine and afterwards they put icepacks on the patient. Later I saw the patient, who was due for another treatment. She had frostbite, because the doctor didn’t see any signs of too much cooling and the patient did not complain because she could not feel anything. For the temple area, if you see a vessel, body language www.bodylanguage.net
technique Dr Koenraad De Boulle
don't stab into it. I often use a 27-gauge so that the filler really flows easily. Again, I check whether there is not the odd vessel that runs in this area and then I put in the product, building a little pyramid. After the injection, sometimes you can see that vessels around that area become a little inflated, become more voluminous. It's a trauma, and so the body reacts by getting all the fluids and the blood there to control it. Also a little oedema might develop immediately after the injection due to the trauma. I will do this in one bolus technique. I put in something like 0.5 to 1 cc maximum. You will see a little lump of product. I smooth it out and ask the patient to look up. If I still see little lines, I will add a little bit more product. For remaining lines in the lateral frontal area, don't use botulinum toxin because you may end up with a lateral brow drop. Fill them—not the lines as such because this will make them look like a ridge. Fill the whole area. For people who are skinny and a little older, it’s a nice procedure to do. I may use a cannula. I will add a drop of lidocaine and then drill a little hole with a needle—not that much smaller than the cannula, otherwise you have to stab again. Then I put in the cannula, such as a 27-gauge, 1-inch cannula. You can fan out the product, first putting it in one place, as I do with the bolus technique. I feel if everything is okay and then massage the area for a while Closing words Over time, with repetitive treatments following a treatment plan, your patients’
overall facial features will hardly age and may even improve. We are not injecting fillers only for the filling aspect of their properties. The stretching of the fibroblast induces neocollagenesis. Complications can arise. The stimulation of fibroblast is ongoing—the fibroblasts do not have a little switch that stops it at the critical point. One patient had polylactic acid and presented with what appeared to be a granuloma, but was an ongoing fibrosis. The gentleman was not happy with his continuing neoformation of collagen. A steroid injection was the solution. Complication issue number two is bacterial infection. You need to cleanse the patient carefully. Always wear gloves. I’ve seen practitioners demo without gloves, putting a cannula against the chin or cheek to show where they were going to inject and then inject with the same cannula. That is asking for trouble, because you can easily introduce your bacteria into those areas. In the so-called homogenous gels, there is a constant exchange of water with surrounding tissues. These are, by definition, excellent growth media for bacterial infection. HAs are slightly acidic, which helps to prevent infection. If you’re dealing with an infection, use antibiotics to start with. If the area is a bluish or violet colour, it is most probably a granuloma. If it is red and swollen, tender, sometimes with a fever, it is most likely an infection. Dr Koenraad De Boulle is a dermatologist and director of Aalst Dermatology Clinic, a private dermatology clinic in Aalst, Belgium
In one session the mid-face and cheeks were filled using the bolus technique. Juvéderm Voluma was used—1cc per side, mid-face; 1cc per side, cheek —overall 4cc. Fanning was with a 25G cannula after local anaesthesia was used for the stab entry. The after photo was taken 3.5 weeks later body language www.bodylanguage.net
Follow-up questions Q: What proportion of your practice has changed more towards contouring and volume compared with filling lines and wrinkles? A: I'm not injecting the nasolabial area with filler anymore. Filling changed so dramatically with the filling of the midface—I don't think it’s necessary. If there is a remaining part that I can’t treat midface, then I will fill. Q: If you have a patient with frown and forehead lines who doesn’t want a toxin, would you inject fillers in the glabellar area and indeed the frontalis, and if so at what level would you inject? A: First, if they don't want any botulinum, you can definitely use fillers in the central frontal area, as toxin is not that important there. Glabellar is another issue. Products in superficial layers are fine. In deeper layers, you need to be aware that if you put in a large quantity you can block an artery. This can result in an occlusion or a vascular compromise. Q: How can you differentiate between a granuloma and infection? A: If it has a bluish/violet colour, this is most probably a granuloma. If it is red and swollen, tender, sometimes accompanied with a fever, this will be an infection. For granuloma, with people who have been injected with multiple products, you need to ascertain which is the culprit. Even if you're precise, cleansed and the procedure goes wrong you may think you are to blame. But it may have been the stabbing that led to a reactivation in the deeper layers. So you may need to do a biopsy to determine the culprit. If you are dealing with an infection, don't start steroids, but antibiotics, high-dose, long-term. Q: One of my patients was injected with a toxin in the crow's feet and the result was not that good. How do you fill this area? A: Crow's feet can be way too deep for a toxin. Think of a deflated balloon with a wrinkled surface. If you inflate it, it becomes stretched, and so we don't have to inject anymore toxin there. Just enhance the area with a little volume.
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clinical Dr Robert Stones
Micro-needling skin rejuvenation doesn’t involve ablation or thermal injury and can be performed by all medical aesthetic practitioners and their trained personnel. Combination treatments are the way forward, writes Dr Robin Stones
icro-needling is not a new concept. The Carruthers were using needles subcutaneously to divide adhesions under full thickness in grafts on the nose before micro-injections of fat as a levelling procedure. In 1995 the Orentreichs in New York described their use of a tri-bevelled needle under the skin, again to cut the deep attachments from fibrotic scarring. This is a process that became known as subcutaneous incisionless surgery, which we now call subcision. Many of us use this technique routinely when we’re treating depressed fibrotic scars. What I want to focus on is microneedling in a perpendicular plane to the skin—rather than underneath it—to stimulate collagen formation. Dr Des Fernandes in South Africa in 1996 devised a needle stamp to treat upper lip lines. It was a crude device that he had body language www.bodylanguage.net
some success with, but the design and mechanism would limit its widespread use due to pain and peripheral damage. In 2005, the advent of a medical device, the Dermaroller from Dermaroller GmBH, enabled the use of micro-needles in an easy to use, patient comfortable device. A landmark study, by Dr Martin Schwarz in 2006, looked at the histology of what happened following microneedling. Dr Schwarz demonstrated that a micro-needling procedure would lead to the formation of new collagen in the middermis. A much larger series of patients in a study published by Dr Aust in 2008 with data taken six months after a single micro-needling procedure showed a 60– 80% improvement in treated conditions. The mechanism of action similar to other technologies: fractional lasers, fractional RF. As the needles cause a multiplicity of tiny micro-wounds and we
wound the skin, we get a wound-healing response. Initially, we’ll get an inflammatory response and release of inflammatory mediators from monocytes and platelets. Fibroblast growth factor and transforming growth factor, which will initiate the proliferative phase, lead to the production of collagen and elastin, enhancing the extracellular matrix and angiogenesis. This will be followed by maturation and remodelling of collagen, with resulting contraction and tightening, collectively leading to a significant enhancement in the appearance of the skin. One of the key differences of medical micro-needling leads to wound-healing without scar tissue formation, as there is no ablation and the mechanically induced needle columns naturally close, which is clearly important for some of the indications of this technique. TGF Beta 1 and 21
clinical Dr Robert Stones
Beta 2 induce collagen synthesis, but the wound-healing occurs with a fibrotic scarring response. Micro-needling has been shown to up-regulate TGF Beta 3, which facilitates wound-healing without scarring, and the new collagen that’s been laid down will be in a normal lattice-like pattern, which will rebuild normal skin architecture. Every procedure has contra-indications. In micro-needling it is any form of active infection, active inflammatory dermatosis, skin cancer, keloid scars, systemic retinoids and anti-coagulants. As usual, patients must have a consultation and give proper informed consent. The procedure is simple to perform. It’s done under topical anaesthesia—the one of your choice—30-40 minutes with or without occlusion is normally adequate for this procedure, followed by the rolling, done in a vertical/horizontal plane and the two diagonals.
If I don’t get much pin-point bleeding, I don’t feel as though I’ve caused enough stimulation, and wounding down to the mid-dermal plexus with pin-point bleeding will give a good wound-healing response. You can wipe blood away immediately with antiseptic, or leave and clean at the end of the procedure. Bleeding does not continue post treatment, and one is left with erythema, which will normally resolve in 24–48 hours. The skin will return to normal within 24 hours, and most patients find that they can return to work. They will notice some increase in exfoliation in the first week, and from a week onwards, improvement in the texture and tone. From three weeks, pigmentation can start to improve. The main collagen effect will be evident six weeks and onwards. Six weeks is the chosen interval between treatments. There are a number of devices avail-
able. A 1.5mm needle length is best for most facial work. For sun-damaged skin or pigmentation, a course of three or four micro-needling treatments at six-weekly intervals should be adequate. For scarring of any type, I usually start with four treatments, but this can be extended. If there is clear improvement on an ongoing basis, there’s no limit to how many treatments you can carry out. Where the dermis is much thicker— the back, the buttocks, or where there isn’t anything firm beneath to roll against, such as the abdomen for stretch marks—a longer needle length of 2–2.5mm is probably better. Very short needle versions are designed for patients to use at home two or three times a week between the medical micro-needling sessions. Micro-needling generates a woundhealing response and new collagen, but there’s no ablation, no removal of epidermis, no thermal damage… it creates
DR ROBIN STONES DR DAVID ECCLESTON
DR MATTEO TRETTI CLEMENTONI
Stretch marks before and after a course of five 1.5mm microneedlng treatments. After photo taken seven months after final treatment
A 54-year-old woman before and after two Dermaroller treatments five months apart. Nerve blocks were used for surgery and treatment with Tretinoin 0.05% for two months before and two months after the surgical sessions.
Immediately after a micro-medical skin-needling procedure with 1.5mm needles 22
DR IGOR SAFONOV
DR ROBIN STONES
Before and after three 1.5mm needling sessions
Before and after 1.5mm treatments body language www.bodylanguage.net
clinical Dr Robert Stones
purely a physical injury. The downtime is minimal and it has an excellent safety profile for all skin types. The most widely published data records treatment of acne scars and I find that I can get as good a result with a single Dermaroller microneedling session for acne scarring as with a single fractional erbium laser treatment. A study of 350 patients and satisfaction in the micro-needling treatment of wrinkles used a visual analogue scale of 0–10. Ten was completely satisfied and zero was completely dissatisfied. The average pre-operative score, following a single micro-needling procedure, was 8.5. In addition, a survey by the Consulting Room showed that 91% of practitioners used this technique for skin rejuvenation. Half reported very good results, and a third reported excellent results. Combination therapies Combination therapies using micro-needling are becoming more popular. I favour an LED device. We know, from use of the Omnilux device, that there’s much evidence over years for the effects of its light wavelengths on the skin. The blue is obviously a photodynamic effect for acute inflammatory acne from the bacterial porphyrins. The red light at 633 has been shown to have a specific healing effect. It’s been used for years to treat leg ulcers and nonhealing surgical wounds. The infrared 830 wavelength also stimulates fibroblastic activity. There are various protocols. I keep mine simple. Immediately after microneedling, I put the patient under the Omnilux Red infrared lamp for 20 minutes. Other practitioners use micro-needling in combination with the red light before and after. In non-fractionated RF, there are ways of ways of focusing the energy into different layers of the skin and the subcutis, and this could present good combinations with micro-needling. A collagen stimulation from hyaluronic acid products, possibly from a stretching effect of the dermis, does seem to generate activity of fibroblasts and production of collagen. Potentially we could combine the deeper layer filling procedures with the microneedling surface procedure. Low molecular wight and less crosslinked HA products are also candidates for combination therapy. I know of one practitioner who uses four Dermaroller treatments interspersed with Restylane Vital, showing good and rapid responses. So the HA hydrates and gives a fast result body language www.bodylanguage.net
while waiting for the collagen maturation to take effect. A logical extension to that thought process is: HAs are by injection, so if we’re doing micro-needling, which is going to breach our normally protective stratum corneum and epidermis, why do we need to inject the HA under the skin? Why don’t we just apply it topically? Will it work if we do that and then carry out a micro-needling procedure? Well, the answer is, yes, it does. Study A study by Dr Martin Schwarz, a plastic surgeon, and the dermato-pathologist Dr Laaff, both from Germany, applied HA topically to the skin, which was rolled in using a Dermaroller medical device. They showed that not only was the HA present in the needle channels, but also in the dermis around it. They postulated that it may be travelling within the lymphatic channels This leads us to consider all the mesotherapy techniques, because there are many topical agents that mesotherapy practitioners apply to the skin. Work is being conducted on combining microneedling and topical agents, but it is in its early stages. Finally, I want to mention the home needling device that is available and has been shown to be beneficial. It doesn’t cause any bleeding. It’s designed for two or three times a week use, and it’s really designed for use with the longer needles used in the medical micro-needling procedure. If you’re using a roller device, get one that is approved as a CE-marked sterile single-use medical device. There are many cheap alternatives available on the internet. Avoid them. I use the genuine Dermaroller device manufactured by Dermaroller GmBH. I now apply a topical HA serum before rolling. Afterwards, I apply a calming cream, put them under the Omnilux Red light, and get them to use a topical HA product between the six-weekly Dermaroller sessions. Micro-medical skin needling is established now. We do have evidence for various applications. There are some interesting areas that can be looked at in the future for which we don’t yet have the proper evidence, but may well come with time. Dr Stones is co-medical director of Court House Clinics and has worked in private cosmetic practise for the past 13 years and in NHS dermatology practice for 25 years
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peer press review
Peer press review Dr Rohit Kotnis surveys academic and association journals to report on advances in research in medical aesthetics and related fields
Botulinum Toxin A Treatment of Raynaud’s Phenomenon: A Review Iorio ML, Masden DL, Higgins JP. Semin Arthritis Rheum. 2011 Aug 23.
Botulinum toxin A has conventionally been used in the upper extremity to treat spasticity resulting from stroke, paraplegia and dystonia. In this study, an Ovid MEDLINE search from 1950 to September 2010 was performed to identify reports on the use of botulinum toxin in the treatment of Raynaud’s disease or associated vasoconstrictive disorders. Since 2004, there have been five studies that have evaluated the use of botulinum toxin A for the treatment of Raynaud’s. In each study, patients received a range of botulinum toxin injections (10-100 units) in their fingers and hands. The studies have many limitations, such as lack of controls, variable severity of disease and variability of dosing, but all report favourable clinical results. All showed improvement in patient pain and a reduction in soft tissue ulceration. Initial reports on the use of botulinum toxin A for Raynaud’s phenomenon are promising. Larger controlled trials with improved study design are warranted. Botulinum toxin treatment in upper limb spasticity: Treatment consistency Papavasiliou AS, Nikaina I, Bouros P, Rizou I, Filiopoulos C. Eur J Paediatr Neurol. 2011 Aug 19.
The study assessed treatment consistency of botulinum toxin administration in spastic upper limbs through stability of dosages
and between injections intervals. Over eight years, 153 children (81 with bilateral spastic cerebral palsy, 72 with unilateral) were treated according to accepted, experience-based guidelines with Botox and Dysport. Treatment response was based on assessment of spasticity and attainment of pre-determined goals at three, six and 12 months post treatment. Mean age at treatment onset was six years four months and median follow-up was 2.5 years. The number of injection sessions ranged between 1–10 and few had more than six sessions. In 106 children, more than one anatomic region of the limb was injected. Most (56.2%), had at least two injection sessions with a median time interval between the sessions of nine months. Children over four years old at the first treatment had longer intervals between sessions (25.8%) compared to younger ones. The mixed effects models demonstrated that botulinum toxin dosage was stable over subsequent visits and that intermediate intervals for subsequent visits were similar to the first one. This is a useful article illustrating a common application for botulinum toxin in conventional medical circles. Patients enquire about the safety of the treatments cosmetically—this study can give the practitioner information on the use of the product in children which can be explained to a new client. Extensive necrosis after injection of hyaluronic acid filler: case report and review of the literature. Kassir R, Kolluru A, Kassir M. J Cosmet Dermatol. 2011 Sep;10(3):22431.
The use of dermal fillers for soft tissue augmentation has become an integral part of aes-
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thetic practices. Dermal fillers temporarily remove the appearance of rhytids and reduce the depth of skin folds. But even with the most experienced of injectors, adverse effects can occur, ranging from mild bruising to severe injection necrosis. Physicians should be able to treat the severe complication of vascular necrosis and detect impending necrosis after injection of a dermal filler, especially with hyaluronic acid fillers. This case report followed a patient for six months from time of hyaluronic acid injection to complete healing of the wound. Complete wound healing was achieved with early recognition and institution of treatment. The study concludes that early recognition of vascular necrosis with specific protocol for treatment after injection necrosis with hyaluronic acid fillers improves the outcome of wound healing. Cosmetic procedures in children Curr Opin Pediatr. Aug;23(4):395-8
Many cosmetic procedures are being performed on children for aesthetic reasons and for the management of dermatological conditions such as psoriasis and vitiligo. Recent developments in laser technology have improved our ability to treat paediatric cutaneous disorders. Most of these technologies were first developed for aesthetic dermatology in adults. Collagen-stimulatory agents such as poly-L-lactic acid were first approved for lipoatrophy associated with human immunodeficiency virus. Poly-L-lactic acid and dermal fillers have potential therapeutic applications in children with atrophic disorders such as lipoatrophy and morphea. Injection of botulinum toxin is
very successful in the treatment of hyperhidrosis in adults and can improve quality of life in children with the condition. The field of cosmetic dermatology is evolving quickly, with limited safety and efficacy studies in the paediatric age group. Children may benefit from thoughtful application of these technologies. Tissue engineering, regenerative medicine, and rejuvenation in 2010: the role of adipose-derived stem cells Beeson W, Woods E, Agha R. Facial Plast Surg. 2011 Aug;27(4):378-87. Epub 2011 Jul 26.
There is a wide variety of dermal fillers for facial rejuvenation and many more are in development. Over the past few years, the study of adult-derived stem cells has become an active area of research. Adult stem cells are an attractive option for volume restoration and facial rejuvenation. Adult stem cells are isolated from adipose tissue-adipose derived stem cells and have mesodermal, ectodermal, and endodermal potentials. Adipose-derived stem cells could conceivably be an alternative to pluripotent embryonic stem cells and could play a critical role in the rapidly expanding fields of tissue engineering and regenerative medicine. This article reviews the history of soft tissue augmentation using adipose tissue grafting and the advent of adipose-derived stem cells. State-of-the-art stem cell isolation techniques as well as anticipated future therapeutic indications are also addressed. Reviewing the peer press is Rohit Kotnis (Lon), Dip SEM (ED). Rohit is an advanced tutor at Dermis Deep, Birmingham and a member of the Body Language editorial panel
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injectables Dr Timothy Flynn
g n i t t i H w e n targe ts The growth of aesthetic medicine can be traced to the rise of injectables, particularly botulinum toxin. Dr Timothy Flynn discusses papers that have investigated effects of the new formulations and how they have combined with fillers
eurotoxins have revolutionised our practices. Patients have a Botox or neurotoxin treatment, can’t believe the results, and say they wish they had done it earlier. Times have moved on since Botox was the only toxin available. We now also have Azzalure, (Dysport) and Bocouture (Xeomin). We also have a type B toxin (Neorobloc). Five units of these products can change how people feel about themselves. For example, I had a patient who I treated for a gummy smile. She said she hated having her picture taken because her smile was all teeth. Five units of Bocouture later and her smile looks normal. The toxin structures are all composed
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of heavy chains and a light chain, which is the active toxin. But some of the toxins have complexing proteins. The questions that have arisen over the past few years are: what is their role and do we really need them? We now understand that they are less important than originally thought. At a physiologic pH, the active compound— the 150 kDa portion —actually dissociates. At a pH of 6.6, which is what the Vistabel is placed in the vial at, the complex is associated. As the pH increases, the active complex separates from the other surrounding proteins. Once it is in the patient, you have only the 150 kDa complex at work, and this dissociates quickly. The half-light of the complex at a pH of 7.27.4 is virtually
none, in other words, it instantly dissociates so that the effective release of the active compound from the complexing proteins occurs in less than a minute. Bocouture has much less toxin protein—it does have a little more human serum albumin, but this is a stable compound. All the toxins are stable, but Bocouture can be stored at room temperature for 36 months. You can virtually heat this up to 60°C for a long period and you do not lose any effectiveness. It has a very stable molecule. Also, at cool temperatures, reconstituted Botox has been proven to be stable for six weeks when refrigerated. In the US we have many FDA-approved indications for Botox. Using it for prophylaxis of headaches in a patient with chronic migraine won’t work for everyone, but a decrease in intensity and frequency is usually evident. Beware patients asking to try if for non-cosmetic indications. 27
injectables Dr Timothy Flynn
Another issue that has arisen is an apparent immunity to toxins at cosmetic doses. Typically, this is when a patient has repeat treatments and the toxin stops working. When the person honestly says that it didn’t work this time, what’s the most common reason? Most likely not enough units were used, but there have been six case reports in the literature of true secondary non-responders. There have been no cosmetic secondary non-responders reported to date for Bocouture, but Bocouture simply has not been available for long. We have to be prudent and say that in another 10 years we might have some Bocouture secondary non-responders. You can treat someone with type A resistance with type B, however, many of these people later develop this resistance, but this is in therapeutic cases. What about dosage? In an article by Sattler, which A Carruthers and I participated in, we tested 360 females aged 18– 50 years with moderate glabellar lines. All were injected with 24 units of Xeomin or Botox, using a standard injection pattern, and were monitored for 12 weeks. Instead of doing equal numbers, we injected more subjects with Xeomin than Botox, because we have more Botox data. We looked for differences in results and complications. Patients had to have one point improvement on the four-point facial wrinkle scale. They were rated by the investigators and also by a blinded independent panel of three experts who looked at glabellar lines. The blinded independent panel—people who were sitting in rooms looking at slides all day—judged results as equivalent after 12 weeks and one month. The investigators’ and the patients’ global assessments of their own lines were the same. The toxins has equal effectiveness. When we looked at adverse events,
both toxins produced the same low degree—this includes headaches, injection pains, and the like. For related adverse events, such as eyelid ptosis, Xeomin has none and Botox one, but this is statistically insignificant. How many people see ptotic eyelids anymore? Hardly any. A smaller study of 21 patients by Prager in Germany looked at the two toxins. He injected 12 units of either Botox or Xeomin in crow’s feet and had exactly the same results. When we look at interchangeability of Vistabel versus Azzalure—these toxins are dosed at different rates, there’s no clear dosage pattern. Some people use these in different ways, but the average is about 2.5 Azzalure to one Botox unit. Anecdotal evidence There are some anecdotal reports of a more rapid onset action with Dysport. Many studies ask patients to write down in their journal when they first noticed a result. I may be biased towards my own research, but reports and the literature have the onset of both Vistabel and Azzalure within 24 hours. In an old study of Botox versus Myobloc, the type B toxin, a comparison was made by injecting patients with Botox on one side, and Myobloc on the other. The subjects were photographed every day. The type B toxin was seen to act faster than the type A toxin. Most likely all toxins can show an onset as early as 24 hours noticeable by controlled photography. Is there a difference in diffusion between toxins? A study by Lee in 2009 showed no difference in the diffusion when injected into mouse legs. The objective was to investigate the transfer of toxin from one muscle group to another, and he found no significant diffusion. Recent papers examining new uses for the toxins include a study on topical botulinum toxin. This incorporates an agent
that can transfer large proteins across the stratum corneum and down through the epithelial cells that affect the underlying muscular trim. Toxin was rubbed on subjects’ crow’s feet. The study showed a decrease in lateral canthal lines—around a two-point improvement. But the study observed only lines at rest and did not comment on lines in motion. Does toxin around the mouth plus a filler work better in combination? Carruthers et al studied three groups of 30 subjects: one group had Botox plus Juvederm around the mouth, another group just Botox around the mouth, another group just Juvederm around the mouth. The Botox doses were six units administered periorally—in the little lines around the lips. The Juvederm was injected for optimal correction. When we’re working on the perioral area, we can get improvement with Botox—we can get better improvement in terms of how it looks with the Juvederm—but when you use them together we get an even better response. Basically the conclusion was that they are safe and effective, and when combined are superior than used alone. Doctor Schim et al in Korea used three-dimensional laser scans to see how much volume is lost in the lower face. They injected 15 patients in the lower and lateral masseter with 25 units of Chinese toxin called Lanzhou. The reduction in the masseter occurred maximally at 12 weeks. So when we’re reducing the size of large muscles, we don’t look at them at two weeks, we have to wait out for three months to treat the so-called “Korean square face”. Dr Timothy Flynn is a consultant dermatologist and medical director of the Cary Skin Center. He is also clinical professor at the department of dermatology, University of North Carolina at Chapel Hill
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psychology Dr Raj Persaud
looking glass We all know that cosmetic surgery can improve appearance, often with outstanding results. But does surgery improve self esteem? Dr Raj Persaud reviews the literature
suspect I am not alone in being impressed by the slides my aesthetic colleagues show at conferences, demonstrating impressive before and after results. But I wonder, if those smiling faces could talk, what would they say about how they feel after treatment? They might look, in our opinion, better than before—but has it actually made a difference to their lives? This is more difficult to assess than simply observing physical change. In polite society, it’s not customary to make detailed comment, however accurate, on another’s appearance. So how do we confirm how we look? The issue isn’t just how we look to ourselves, but how we appear to the outside world. The issue of appearance is such a taboo—everyone knows everyone else is busy giving compliments but maybe thinking something else entirely. Anyone who has treated sufferers of body image disorders such as imagined ugliness syndrome, or body dysmorphic disorder, will be aware of how much these patients have chosen to infer from subtle, or entirely imagined, feedback. This group, although at an extreme end of the spectrum, shares with cosmetic surgery patients the tendency to regard appearance as important. They also have a clear evaluation of how they compare to others on this front. This crucial combination of scoring high on ‘body image orientation’ (how important it is in life) combined with low evaluation (low satisfaction with personal appearance) delivers the motivation to seek an alteration. Scientific research has been performed to fill the gap in this area and provides useful feedback to cosmetic professionals about the psychological impact of their work. The study, conducted by a team led by Dr Skilleborg based in Norway, used a questionnaire to study 155 female cosmetic surgery patients. The investigation was published in the Journal of Plastic, Reconstructive and Aesthetic Surgery, and compared responses before surgery to six months after. A representative sample of over 800 Norwegian women with no cosmetic surgery experience also completed the questionnaire. Procedures undertaken included breast enlargements, breast lifts, liposuctions, abdominoplasties and eyelid operations. Results revealed high scores on satisfaction with the actual procedures, with 91% reporting post-operatively, that they would still choose to have surgery if they had to make the choice again. There were no differences between the comparison non-surgery group and those having surgery in prevalence of psychological problems. This is interesting given the stubborn public perception, in some quarters, that to opt for a procedure is a sign of something problematic psychologically.
Intriguingly however, those who had surgery but scored high on psychological problems before the procedure, ended up being much less satisfied than average with surgical results. Those without psychological problems before surgery ended up with a more positive change in body image evaluation and raised selfesteem post-surgery. Overall, self-esteem went up following surgery, but psychological problems remained. This result confirms that surgery is not a solution for deeper psychological problems. The issue here is that the simple low self-esteem that those who go for cosmetic surgery appear to suffer could be confused with deeper problems, which really aren’t there. Normal The key take home message from this study is that the increase in body image evaluation in the operative group was such that patients after surgery no longer differed from the ‘normative’ sample—in other words, the surgery made them feel ‘normal’ again. Many people undertaking cosmetic surgery are not so much vain or seeking some kind of unfair advantage in appearance, they simply want to feel normal or like the rest of us. If, as a surgeon, you want your patients to end up scoring high on satisfaction post-surgery, you need to keep your eye on those who score high on psychological problems beforehand. This group are much less likely to end up feeling positive about the results. It was also notable that the study showed no statistically significant differences between different kinds of surgery in terms of positive body image and satisfaction with outcome. But there was a trend for breast augmentation to be associated with more positive body image evaluation post-surgery. It is important to note that rhinoplasty did not feature in this study. Cosmetic surgery did improve the patients’ self-esteem, but it was a relatively small change. But, on average, there was a definite improvement in satisfaction with appearance. Post-operative measures of appearance satisfaction, self-esteem and psychological problems did not differ from the comparison sample. Surgery appears to make people feel normal again rather than making them feel better than normal. Perhaps this indicates that this desire for more superior results than average for cosmetic surgery may be an ominous predictor of a less than satisfactory outcome in the longer-term. Dr Raj Persaud FRCPsych is a consultant psychiatrist working in private practice at 10 Harley St, London W1 body language www.bodylanguage.net
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fillers Dr Beatriz Molina
Filler up With an increasing variety of dermal fillers on the market, which one do you choose? Dr Beatriz Molina runs through their key characteristics
here are over 100 fillers on the market, providing us with a great deal of choice. So what is the difference between them, and which one do we choose? All are different when you look at their physical properties. This allows us, as physicians, to choose different products for age, skin type and desired outcome. One of the key differences is the concentration of HA and degree of cross-linking in the product. This will provide different characteristics, producing a softer or harder gel. But we need to work out how this extrusion force will affect injecting the filler in the dermis. Characteristics Molecular weight ranges from 500–6,000kDa. In terms of concentration, 10mg/ml is usually the best—any less and the product will disappear quickly from the skin. Even if the filler is nice to inject, it won’t last more than two to three months. Restylane and Juvéderm are 20mg/ml and 24mg/ml, which have done well clinically. Optimal concentration is between 18–24mg/ml, but some companies choose to go slightly below to get different characteristics. In terms of skin tolerability, an uncrossed-linked product is unlikely to cause any reaction but it will give no lifting capacity. So there needs to be a balance to give the filler the physical properties we need. The more cross-linking there is in the product, the more the G-prime will increase, therefore causing more inflammation. A product with a low G-prime will cause minimal inflammation. But the higher the G-prime goes, the more severe the reaction body language www.bodylanguage.net
is. Manufacturers have to balance the concentration and crosslinking for the optimal effect. All HAs will cause some swelling. They are hydrated by water, so a fully-hydrated filler has reached its equilibrium and there will be less swelling in the dermis. Non-equilibrium gels will have more swelling post-injection. A non-cross-linked HA has no lifting capacity, so we need to cross-link them. The two most common functional groups are carboxylic acid and hydroxyl with alcohol. These cross-links will try to improve the bio-chemical properties while ensuring it is still compatible with the body. The total degree of modification will be a percentage of the cross-link, plus the non-cross-link, or pendant agents. An increased cross-link will result in increased hardness or stiffness of the gel. Swelling will make the product degrade quicker, and only cross-linked HAs will resist degradation in the body. The gel texture will be modified by the cross-linking, which is hard to measure and it is therefore difficult to get these measurements from manufacturers. Indirect approaches involve measuring the mechanical characteristics of the product, or a rheological analysis. So we have the G measurement, which is the elastic modulus, and the G-prime which is the viscous modulus. The ratio of these is the most reliable information we can get regarding crosslinking and how the material reacts in the skin. We know that the more cross-linked the product, the closer it is to a solid and therefore is a much stronger gel. It will be harder to manipulate and more resistant to higher forces. So you will probably use it in deeper places or nasolabials when you 33
fillers Dr Beatriz Molina
want a lot of movement. If the product is less cross-linked, it is closer to a liquid and will dissolve more in the tissue and spread more easily. Most HA fillers will be visco-elastic. We need that combination of elasticity and viscosity to give us the total effect. Gels with a higher G will be stiffer, with more ability to resist dynamic forces. Those with a low G will be used for more static and superficial wrinkles or the lips. Particles Once a product is cross-linked, it needs to be particulated, or we end up with a lump of gel. Particle sizing is very important to how it will be injected into the skin. A gel needs to be calibrated in the tissue to prevent too much spread—perhaps you want the product to stay in the same place, or you want to calibrate it in a different way to make it more malleable. Ultimately, when we inject the product, we want minimal pain for the patient, less swelling or reactions and a smaller extrusion force. Particles have to be small enough to go through very small needles. If you want to reduce the extrusion force by reducing the particles’ average, you need to make the sizes very even—if there are bigger particles mixed with smaller particles, the flow will not be continuous and you will have a blockage in the needle. Firm gels will have a higher ability to resist deformation so they must have small particles. The distribution has to be narrow so that the flow is smooth. They also have an easy way to spread so we will be more superficial with them. Particle size alone affects the extrusion force of the filler. But without knowing the rheological properties, such as the modulus, then we don’t know how the product is behaving. The total degree of modification will be a combination of cross-linked and uncrossed-linked HA, the concentration and the degree of hydration—all of which will affect the rheological properties. A firm gel with a high G will provide the best resistance to formation, but will be harder to push with a higher extrusion force— a needle with a larger diameter may be needed. A soft gel will feel more natural and can be injected more superficially on the skin. All these ingredients provide an optimal balance for a product. But depending on the patient’s age, skin colour, nature or depth of wrinkles, we will use different products in different areas.. We need a bigger calibration and more cross-linking when we want to go deeper in the skin, or it won’t last and won’t lift. But we need to avoid too much cross-linking or we get too much swelling and the product will dissolve too quickly. We need to calibrate the gel depending on the needle we inject it through. Clinical results will not only depend on these characteristics but also on the response of the biological host, or patient. A product that gives you fantastic results may suddenly not achieve the result in a particular patient. The same filler in different people will react differently— unfortunately, this is something you will learn through clinical experience and so you may choose a slightly different concentration or calibration on different patients. The depth of injection technique will afG1 G2 fect the hydration and inflammatory response we create.
The higher the G prime, the more inflammation there will be. (G1) Restylane G=350 whereas (G2) Puragen G=1000, with noticably more inflammation 34
Dr Beatriz Molina is a cosmetic physician and medical director at Medikas Medispa in Somerset
History of dermal fillers 1890s: Fat was extracted from a patients arm and injected into their faces. Early 1900s: Paraffin was used as a skin filler but a high incidence of foreign body granuloma formation was discovered 1940s: Highly refined injectable silicone was used as a dermal implant with excellent cosmetic results. But it had high abuse potential and problematic adverse effects from contaminated composites. It has since been banned 1970s: Injectable bovine collagen was approved by the FDA in 1981 as Zyderm I, Zyderm II, and Zyplast. As of the end of 2010, all collagen fillers are no longer available in the US, as they have been voluntarily withdrawn from the US market. 1980s: Reconstituted human serum product was introduced, which worked by forming clots. In the face of the AIDS epidemic and a concern for blood-borne diseases, it was taken off the market. Autologous collagen processed from harvested fat presented an alternative. Aquamid, an injectable water-based polyacrylamide gel (2.5% polyacrylamide, 97.5% water) was launched. 1996: Hylaform, an FDA approved hyaluronic acid (HA) obtained from rooster combs and then highly purified through a vigorous filtering process is launched. Despite being animal-derived, it does not require a skin test. Its effect lasts 4–5 months as the product is naturally reabsorbed by the body. 1998: Restylane comes to the market. The HA is a glycosaminoglycan disaccharide composed of alternately repeating units of D-glucuronic acid and N-acetyl-D-glucosamine. 1999: Sculptra, injectable poly-L-lactic acid, is launched. It is a dermal filler indicated for the restoration and/or correction of the signs of facial fat loss, or lipoatrophy. 2001: Aquamid gains approval in Europe 2002: Isolagen, or autologous cell therapy (ACT), the process of using the body’s own cells to help repair trauma and ageing, arrives in the UK in late 2002. 2003: Cosmoderm and Cosmoplast, or "injectable bioengineered human collagen implant”, are introduced. Both products contain 35mg/mL of human-derived collagen in phosphate-buffered physiological saline containing 0.3% lidocaine. Cosmoderm is not cross-linked and is used to treat superficial lines and wrinkles. Cosmoplast is cross-linked with glutaraldehyde and can be used for deeper wrinkles. Bio-Alcamid is launched. It is a gel polymer with several networks of alkyl-imide groups and 96% nonpyrogenic water. 2004: Radiesse, launched in the US in 2000 as Radiance FN, is introduced to Europe in June 2004. It consists of synthetic calcium hydroxylapatite (CaHA) microspheres suspended in a gel carrier—an aqueous gel that contains sodiumcarboxymethylcellulose, glycerin and high purity water. Evolence luanched. This is a naturally occurring collagen filler derived from porcine tendons. It is voluntarily removed from the US market in 2009. Reviderm Intra is an injectable implant with flexible dextran microbeads. Dextran is a carbohydrate complex of 40–60 microns in size. The microbeads are evenly suspended in a non-animal HA. 2009: Novabel is launched. It is a colourless dermal filler composed of cross-linked alginate, a natural and biocompatible polysaccharide extracted from marine algae. The extracted alginate undergoes an intensive purification and stabilisation process to become smooth, microscopic, three-dimensional gel spheres called Geleons. Merz Pharmaceuticals GmbH issues a field safety notice in 2010), advising practitioners to stop using the product.
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injectables Jones, Flynn & Grover
Dr Derek Jones, Dr Tim Flynn and Mr Rajiv Grover discuss permanent versus resorbable dermal fillers for a range of indications
In good shape Dr Derek Jones is a consultant dermatologist and founder of the Skin Care and Laser Physicians of Beverly Hills I have conducted a considerable amount of research with liquid injectable silicone, specifically for HIV-associated facial lipoatrophy. I use liquid silicone only for this one indication. In 2004, we published a study in the Journal of Dermatologic Surgery treating 77 patients with Silikon 1000—a highly purified silicone oil. It is FDA-approved for injection into the globe of the eye for tamponade in retinal detachment. We can use it legally on and off label. With silicone, we use a microdroplet serial puncture technique. We inject 1/100th of a cc of Silikon 1000 into the subcutis at 2–4 mm intervals. Our protobody language www.bodylanguage.net
col calls for no more than 2cc in a given treatment visit. We wait one month then re-inject and continue injecting until we achieve optimal correction. The initial 2004 report showed that it takes 12cc on average to achieve optimal correction. Studies by Carruthers et al. investigating the amount of Radiesse (calcium hydroxylapetite) it takes for optimal correction for HIV lipoatrophy showed around the same amount—12–13cc. I have treated over 700 patients with with liquid silicone for HIV fat loss in my Los Angeles clinic. I presented an abstract in 2010 at the American Society of Dermatologic Surgery looking at the long-term follow-up of these individuals at five years. I’ve been impressed with the results and have seen nothing better than liquid injectable silicone for this specific indication. In that long-term follow-up, we’ve had about five adverse events of note. Two were complaints of over-correction. One
gentleman had gained 30lb in weight so this may have been the cause of his overcorrection in the face. The other was slight and improved over time. Three patients developed subcutaneous induration and firmness. We expect this in a certain subset of individuals who have permanent fillers, especially silicone. But the consensus is that if you’re injecting a highly purified material with the microdroplet technique, you should not have too many cases. In these three patients, I took the lead from the Carruthers’, who treated a number of Artecoll-induced granulomas in Canada. They used 40mg/cc of a high potency triamcinolone intralesionally. I used this in these individuals and it worked well. The cumulative doses were not very large over time; about 1cc of material. Two these patients had signs of adrenal insufficiency and fatigue, which prompted me to get an endocrine consult. Both had AM cortisol results that 37
injectables Jones, Flynn & Grover
were zero. The endocrinologist who has a lot of experience with this population told me adrenal insufficiency due to exogenous cortisone is very common in HIV patients. So I recommend not using high doses of intralesional cortisone in an HIV-infected host. Since then, I have injected 50mg/cc 5-fluorouracil (5-FU) mixed with 10–20% of 40mg/cc triamcinolone and results have been good with no adverse effects. I will not use a permanent filler in non-HIV patients—while not serious, those who experience adverse events will probably have them for life. HIV facial atrophy is a unique condition that takes a lot of volume and large volumes of a durable material will work best. In terms of resorbable fillers, I’m a huge fan of hyaluronic acids (HAs) because they are reversible. They can also last a lot longer than 12 months with repeat treatment. Literature shows this on Restylane, Juvederm and Belotero products. We need to rethink this class of fillers in terms of longevity. Dr Timothy Flynn is a consultant dermatologist and medical director at the Cary Skin Center in Cary, North Carolina Particularly in our legal climate in the US, it can be difficult to inject silicone. It’s an off-label use. If you get complications, it could be permanent. Non FDA-approved silicone has been used for anything from deep filling to tiny acne scars. I have seen a few patients who got treated 20 years ago and have small bumps—the silicone elicits a collagen response which keeps going, resulting in a lump. The only way to get rid of it is to cut it out. In the States, we don’t yet have a great HA deep filler—products from the Juvederm, Esthélis and Belotero ranges do a good job. But when we want deeper filling, we’re looking for robustness and longevity so I tend to use calcium hydroxylapatite, or Radiesse, instead. It only takes one intravascular injection or vascular occlusion to wish for HAs for all indications. When you see the blanching that occurs immediately after injection, you know exactly what could be happening. Literature reports a case of complete alar necrosis requiring reconstruction following an intravascular occlusion, so it can be very serious. So I love the reversibility idea. We 38
always have hyaluronidase in the clinic. When I had my first intravascular occlusion, I was glad I had hyaluronidase. It occurred while injecting Radiesse, but the patient had a large amount of HA present around the nasolabial folds so I could dissolve the extra pressure from the HA. We got return of good blood flow and typical venous stasis on the outside, but no cutaneous or mucosal necrosis. Mr Rajiv Grover is a consultant plastic surgeon at King Edward VII Hospital and practices privately in Harley Street I don’t have much experience with silicone or permanent fillers. If I was using a permanent product in large volumes, I’d generally use fat. In terms of temporary fillers, I’m a big fan of HAs. I like the deep volume aspect. In the lower face, HAs can be quite heavy. Some patients have very thin skin here so if you want to build up a small amount of volume, I find Sculptra very useful. Some patients are not suitable or ready for a facelift, so you can build them up using Sculptra to give them good volume. Dr Tim Flynn There is still an opinion that HA fillers only last six to twelve months. I injected the nasolabial fold in one of my patients. She was around 50 years old and pleased with the results. About 18 months later, she came back with a basal cell carcinoma (BCC) above the area we injected. We used the Mohs technique to remove the BCC and found large pools of Restylane in the subdermal plane that we’d injected 18 months earlier. So they’re evidently more durable. These HAs can also stimulate collagen. With repeat treatments, our patients are returning to us less often than we expect. Dr Derek Jones One study on Restylane found that it lasted around 36 months after repeat treatment. Repeat treatment studies on Juvederm and Belotero prove a similar increased duration after repeat treatment and we often see it in our clinics. Patients come back in for Botox and request more filler—they think that because they need one, they need the other. Yet they often have optimal correction after a handful of HA treatments and don’t
require retreatment.. I was recently involved in a debate looking at the five year safety data on polymethylmethacrylate, under the trade name of Artefill in the US. It does not share a large percentage of the marketplace as many people are afraid of it. The five-year data is good and the long-term complications are just a fraction of 1% when used properly. It’s a good product, yet many of us are reluctant to use it because of its permanent nature. Dr Tim Flynn First of all, we have the reversability of HA and the success of injectable crosslinked hylauronic acid. Faces change and as people gain or lose weight, or have bone resorption, you have to change your treatments with the patients as they change. I’m a little nervous about a product that stays in there for such a long time. Physicians may also be influenced by the early Artecoll complications— also methylmethacrylate but in a different carrier and the spheres are different shapes. I’m having great success with HA and patients are happy with results so I’m happy to stick with it. Mr Rajiv Grover When SubQ first launched in 2003, it was designed for use with a cannula. It required a small incision which not everybody was keen to do and occasionally leaves a small scar. So there was a search for how it could be used without the small incision. So the needle became more popular. But one of the things to avoid is the presence of blood. If you have blood in the cheek, you’re not only going to get bruising but it will lead to an inflammatory response. Avoiding this results in a more controllable, more reliable recovery. I find using a cannula more helpful. The pixel cannula is much finer than the original 18G cannulas marketed for SubQ. You do have to make a small hole with a green needle—have the pixel cannula in your hand so that when you take the needle out, you can put the cannula straight in. The pixel cannula also has a little arrow on the hub, pointing to the opening. I find this valuable because I tend to treat the cheek laterally. I want that opening to be pointing downwards so that when I’m injecting, on withdrawal, I’m putting the product into the body of the cheek fat pad and not around the junction of the lid and cheek. If you get product above that junction, it shows as a small bleb. body language www.bodylanguage.net
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