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The UK Journal of Medical Aesthetics and Anti-Ageing www.bodylanguage.net

Topical antioxidants

EXPERT ADVICE ON THE PREVENTION AND TREATMENT OF SKIN AGEING

AESTHETIC SYNERGY I AFTERCARE I MOULDING SOFT TISSUE Restoring ideal facial proportion

Increase patient satisfaction

Non-surgical procedures with minimal downtime


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a Galderma Division

Date of Preparation: February 2012 RES/004/0212(2)

NEW RESTYLANE FOR LIPS. IRRESISTIBLE SOFTNESS.


contents

body language number 54 14

ANALYSES Reports and comments

14 COVER STORY Topical and systemic antioxidants Professor Syed Haq and Dr Masud Haq discuss the role of naturally-occurring antioxidants in protecting against free radical damage and how advances in technology can aid their effect

Guest Editor David Hicks 020 7514 5989 david@face-ltd.com Production Editor Helen Unsworth 020 7514 5981 helen@face-ltd.com Sales Executive Monty Serutla 020 7514 5976 monty@face-ltd.com

20 SKINCARE

20

Assistant Sales Executive Simon Haroutunian 020 7514 5982 simon@face-ltd.com

Topical combinations Developing a topical antioxidant product is a complex process, involving considerations such as formulation balance, ingredient conflicts and delivery mechanisms. Susan McNeece elaborates

23 FORUM Head to head With an array of topical antioxidants available to practitioners, a panel of experts discuss the benefits of the products they use or helped develop

Publisher Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com Contributors Professor Syed Haq Dr Masud Haq Susan McNeece Dr Mervyn Patterson Elliot Isaacs Sally Durant Lorna Bowes Dr Tapan Patel Dr Beatriz Molina Dr Simon Poole Dr Hema Sundarem Catherine Quinn Charles Southey Mr Yannis Alexandrides Dr Diane Duncan Wendy Lewis Eddie Hooker Dr Sabine Zenker Dr Shimon Eckhouse

7 OBSERVATIONS

31 NUTRITION

38

Essential Oil The Mediterranean diet, featuring a medley of fresh vegetables, fruits, cereals and fish, is widely promoted for its health benefits, writes Dr Simon Poole. Its components are rich in antioxidants and an increasing body of evidence extolls the virtues of its star ingredient—olive oil

34 INJECTABLES AESTHETIC SYNERGY When treating the face, every practitioner’s aim is to restore ideal facial proportions. Dr Hema Sundarem summarises combinations of toxins and fillers and how rheology can help us understand the science behind their efficacy

38 AESTHETIC MEDICINE

47 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 2012 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: editorial@face-ltd.com Advertising: advertising@face-ltd.com Body Language can be ordered online at www.bodylanguage.net body language www.bodylanguage.net

AFTERCARE Ground-breaking cosmetic procedures are at the forefront of a successful clinic, but Catherine Quinn discovers why good aftercare brings incredible results

44 WEB MARKETING ONLINE PRESENCE Having an appealing website with informative content is the most effective way to influence and gain customers, writes Charles Southey

47 NON-SURGICAL BODY SHAPING Mr Yannis Alexandrides elaborates on how high intensity focused ultrasound can be used for measurable non-invasive fat reduction

3


body language

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 .

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66

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.

4

50 PRODUCTS ON THE MARKET The latest products in aesthetic medicine, as reported by Helen Unsworth

53 LASERS MOULDING SOFT TISSUE With more patients seeking minimal downtime, there is much value in non-surgical soft tissue shaping. Dr Diane Duncan describes radio-frequency shaping using the Invasix BodyTite

57 MARKETING À La Carte Creating the right menu of products and services for your clinic is essential. Wendy Lewis discusses best practice to compose the ideal mix of treatments

60 INSURANCE COSMETIC CLAIMS With more practitioners entering the medical aesthetics sector, Eddie Hooker discusses how to handle complaints and claims

63 FILLERS

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.

PLATELET RICH PLASMA Platelet rich plasma can provide a natural alternative to standard fillers for volumisation. Dr Sabine Zenker discusses her injection technique

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.

66 EXPERIENCE THE MAN BEHIND THE MACHINE 20 years after the original intense pulsed light technology was developed, the creator Dr Shimon Eckhouse looks back on its origins body language www.bodylanguage.net


Your partner in injectable facial aesthetics

Belotero® now approved by the FDA • One of only 3 HA fillers approved by the FDA currently promoted in the US • Optimal integration1 for superior evenness2 • Minimal local inflammation3 for sustained patient satisfaction4

BEL050/1111/JH

Call Merz Aesthetics Customer Services now to find out more or place your orders: Tel: +44(0) 333 200 4140 Fax: +44(0) 208 236 3526 Email: customerservices@merz.com 1 Histological examination of human skin (eyelid dermis layer). Courtesy Dr. J. Reinmüller, Wiesbaden, Germany 2 Prager W, Steinkraus V. A prospective, rater-blind, randomized comparison of the effectiveness and tolerability of Belotero Basic versus Restylane for correction of nasolabial folds. Eur J Dermatol 2010;20 (6):748-52. 3 Taufig A, et al. A new strategy to detect intradermal reactions after injection of resorbable dermal fillers. J Ästhetische Chirurgie 2009; 2: 29-36 4 Reinmüller J et al. Poster presented at the 21 World Congress of Dermatology, Buenos Aires, Argentina, Sept 30 – Oct 5, 2007. Thereafter published as a supplement to Dermatology News: Kammerer S. Dermatology News 2007; 11: 2-3.

www.belotero.uk.com Merz Pharma Uk Ltd 260 Centennial Park, Elstree Hill South Elstree, Hertfordshire, WD6 3SR Tel: +44(0) 333 200 4140


Azzalure® Abbreviated Prescribing Information Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP) IRE 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: January 2011.

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Galderma (UK) Ltd.

Azzalure® is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when the severity of these lines has an important psychological impact on the patient.

The passage of time

A secret to reveal beauty

Azzalure® is a Botulinum Toxin Type A for aesthetic use. • Fast onset of action (median time to onset 2-3 days)1 • Long duration of action (up to 5 months)1 • High level of patient satisfaction (93% after 6 months, following one treatment session)2

References 1. Azzalure® Summary of Product Characteristics. 2. Ascher B et al. J Am Acad Dermatol 2004; 51: 223-33. Azzalure® is a registered trademark of Galderma. Date of preparation: February 2012 AZZ/005/0212

an aesthetic choice


observations

Plastic surgeons submit evidence to Government review Measures proposed include re-classification of dermal fillers as medicines For the last two months the cosmetic surgery review being undertaken by the Department of Health, led by NHS Medical Director Professor Sir Bruce Keogh, has been calling for evidence from both the profession and patients. The British Association of Aesthetic Plastic Surgeons (BAAPS) have revealed the main points they have put forward to assist in the inquiry. Measures proposed by BAAPS to help protect the public include the re-classification of dermal fillers as medicines; defining who should be allowed to perform cosmetic procedures (both surgical and non-surgical); establishing a compulsory register for practitioners; requiring surgeons from abroad to have UK-based indemnity insurance; severely restricting advertising; and making legal claims histories part of revalidation, among others. BAAPS president and consultant plastic surgeon Mr Rajiv Grover says: “The call for evidence by the Keogh review has given our sector an ideal platform to air issues that have long been concerning many of us. The PIP implants crisis demonstrated beyond a shadow of a doubt that there are clear failures in the system, as well as

vulnerable people being taken advantage of. Mr Grover says that while it may not be possible to prevent criminal activity in the future, safeguards can be put in place to protect the public. “It is of paramount importance that the growing area of largely unregulated dermal fillers be controlled and we have put forward for consideration the simple measure of reclassifying these injectables as medicines.” The association suggests “killing three birds with one stone” by regulating which fillers come on the market,

body language www.bodylanguage.net

banning their advertising and defining who is qualified to dispense them. BAAPS are also calling for the term “surgeon” to be legally protected, for practitioners to be audited and listed on a compulsory register run independently and for an insurance scheme to help protect patients. Mr Grover says, “We propose as well that overseas surgeons who operate in Britain have UK-based indemnity insurance, and—if it cannot be outright banned—for cosmetic surgery advertising to be severely restricted to protect the young and vulnerable.”

Suncare app raises awareness With the rise of the smartphone, La Roche-Posay have developed an app designed to raise awareness of the damaging effects of UVA and UVB rays to the skin. While health campaigns have ensured the general public are more aware of the sun’s harmful effects, many do not apply sunscreen correctly, if at all—potentially leading to wrinkles, premature ageing and skin cancer. Compatible with the iPhone, the My UV Alert app can be used to generate a recommended skin protection regime against UV rays based on a personalised skin profile generated within the app. It can also provide location-specific notifications to advise the user when UV levels are high. Users will then be alerted to remind them to reapply sunscreen. The free app also offers practical tips and advice on ways to keep skin protected and stay safe when outdoors in the UK.

The app generates personalised skin profiles

7


observations

60

second brief

BODY HANG-UPS Unsightly tummies and excess weight are the top two body dislikes for both men and women in the UK. In a YouGov SixthSense survey of over 2000 adults, women were found to be unhappy with their body shape, while men were concerned with the appearance of their teeth. Of those who would not consider a cosmetic procedure, women cited outcome, risk and cost as potentially off-putting reasons.

Women tend to be more self-critical, with around 67% disliking their stomach, and 57% unhappy with their weight, compared with 45% and 38%, respectively, for men.

42% of women were also found to dislike their hips, 47% disliked their thighs, and 46% are dissatisfied with their body shape in general. Men in the UK were also found to be unhappy with their teeth, with 31% saying they dislike them, 24% saying they would seriously consider having their teeth whitened, and 12% that they would consider having them straightened. When it comes to reasons why people would not consider having a cosmetic procedure more women than men have specific concerns. 48% of women are concerned that they might look too fake, 30% are worried that something might go wrong, and the cost of the procedure is an inhibiting factor for 28% of women. Among those consumers who have had a facial cosmetic procedure 38% said they did so because they were dissatisfied with the way they looked. 32% had undertaken a procedure in order to make them feel more comfortable, and 23% wanted to look more attractive. Overall, 40% would consider any form of facial cosmetic procedure. Source: YouGov SixthSense Surgical and Non-Surgical Cosmetic Procedures Report, 2012

8

PDT shows clinical promise for acne Red light penetrates deeper dermal structures The use of photosensitising agents and light in photodynamic therapy (PDT) is noted for the treatment of acne but its benefits have not been widely supported with clinical trials. A study conducted by Dr David Pariser, pastpresident of the American Academy of Dermatology, has found that PDT can provide results in the treatment of acne. Patients involved in the double-blinded, prospective, randomised study suffered with moderate to severe acne—featuring at least 25 facial inflammatory lesions. Subjects were treated with methyl aminolevulinate (MAL) and 632nm red light over four sessions spaced two weeks apart. Previous clinical trials have been unable to show that PDT is any more effective than using the light source alone, says Dr Pariser. “Acne is one of those indications where PDT has been tried with different combinations of photosensitis-

ers and light sources. Theoretically, it should work,” he says. The study showed that 12 weeks post-treatment, subjects experienced a statistically significant reduction in inflammatory lesion counts and improvement in investigator global assessment scored versus control-group patients. A 2011 study showed that a combination of 5-aminolevulinic acid (ALA) and blue light could be effective off-label for actinic keratoses, with a mean lesion reduction of 58% among treated patients. But the MAL and red light PDT combination is able to penetrate further into the skin, says Dr Parisier. “MAL penetrates more deeply than ALA because it’s more lipophilic. “Blue light is a more efficient PDT activator than red light but it only penetrates through the dermis and does not reach the deeper structures. This makes red light a better choice for sebaceous glands and skin cancers,” Dr Parisier says.

Echinoderms able to change collagen elasticity Sea urchin peptides may aid understanding of ageing A study published online in PLOS One and General and Comparitive Endocrinology journals suggests that marine creatures such as sea urchins and sea cucumbers (echinoderms) could help our understanding of the way skin ages. The research, carried out at Queen Mary, University of London, investigated DNA sequences of genes in the purple sea urchin (Strongylocentrotus purpuratus) and the edible sea cucumber (Apostichopus japonicus) and found genes for messenger molecules—or peptides. According to project leader

Professor Maurice Elphick, these peptides cause rapid stiffening of collagen in the body wall of sea cucumbers. “As we get older, changes in collagen cause wrinkling of our skin, so if we can find out how peptides cause the body wall of a sea cucumber to quickly become stiff or soft, then our research might lead to new ways to keeping the skin looking young and healthy,” he says. Researchers also found that sea urchins have a peptide similar to calcitonin—a hormone that regulates human bones to keep them strong.

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≤ 25°C

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). 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. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. 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 Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. 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. 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. Interactions 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 observed within the first week after treatment. 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 May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture ® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category POM. List 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 FEB 2012. 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 yellowcard.mhra.gov.uk. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1084/BOC/JUN/2012/JH

Date of preparation June 2012

Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA.


observations

training & events Bariatric surgery seen NOVEMBER

DECEMBER

1 - 4 November, 1ST IPRAS International Trainees’ 1 December, Microsclerotherapy & Facial TelangiMeeting & 10th IQUAM Consensus Conference, ectasia, Wigmore Medical, London Royal Olympic Hotel, Athens, Greece W: wigmoremedical.com/events W: ipras.org 1 December, Botox Training, KT Training, 3 November, Microsclerotherapy & Facial Telangi- Swindon ectasia, Wigmore Medical, London W: kttraining.co.uk W: wigmoremedical.com/events 2 December, Dermal Fillers Training, KT Training, 3-4 November, Body Conference, Royal Society Swindon of Medicine, London W: kttraining.co.uk W: bodyconference.co.uk 4 December, CPR & Anaphylaxis Update, Wig5-6 November, Introduction to Medik8 Dermal more Medical, London Roller & Glo Therapeutics Advanced Courses, W: wigmoremedical.com/events Wigmore Medical, London W: wigmoremedical.com/events 4-7 December, BAPRAS Winter Scientific Meeting, Royal College of Surgeons of England, London 6 November, Advanced Skin-Laser Applications, W: bapras.org.uk The Lynton Clinic Training Centre, Manchester W: lynton.co.uk/training 5 December, Introduction to Skincare & Peels, Wigmore Medical, London 7 November, Intermediate Toxins & Fillers, W: wigmoremedical.com/events Wigmore Medical, London W: wigmoremedical.com/events 6-7 December, Introduction to Botulinum Toxins & Introduction to Fillers Courses, Wigmore Medi8 November, VI Peel, Wigmore Medical, London cal, London W: wigmoremedical.com/events W: wigmoremedical.com/events 9-10 November, 26th Congress Laser Medicine, Auditorium St Apollonia, Firenze, Italy W: laserflorence.eu

6-8 December, Controversies in Reconstructive Microsurgery, Marmara Hotel, Istanbul, Turkey W: controversies2012.org

9 - 11 November, Ultimate Skin Health Symposium, Montage Hotel, Beverly Hills, USA W: ultimateskinsymposium.com

8 December, Foundation Botulinum Toxin & Dermal Fillers Training Course, National Training Centre, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk

10 November, Foundation Botulinum Toxin & Dermal Fillers Training Course, National Training Centre, The Paddocks Clinic, Bucks W: cosmeticcourses.co.uk

10 December, Introduction to Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com/events

10-11 November, Weekend Combined Botox/ Dermal Filler Training Course, Aesthetic Training Academy, Devon W: aesthetictrainingacademy.co.uk

12-13 December, International Symposium in Plastic Regenerative & Aesthetic Surgery, Crocus Expo Centre, Moscow, Russia W: russiansymposium2012.com

11 November, Advanced Botox and Dermal Fillers, KT Training, High Wycombe W: kttraining.co.uk

13-15 December, International Winter Consensus Conference, Kitzbuhel, Austria W: iwc-conference.com

14 November, Introduction to Skincare & Peels, Wigmore Medical, London W: wigmoremedical.com/events

14 December, Foundation Botulinum Toxin Part I, Watford, Hertfordshire W: drbrianfranks.com

16 November, Introduction to Fillers, Wigmore Medical, London W: wigmoremedical.com/events

15 December, Foundation Dermal Fillers Part I, Watford, Hertfordshire W: drbrianfranks.com

17&19 November, Sculptra Courses, Wigmore Medical, London W: wigmoremedical.com/events

JANUARY 2013

19–23 November, BTEC AWARDS, London Medical, London W: mapperleypark.co.uk/training 20 November, Biomimetic Mesotherapy Workshop, London W: dermagenica.co.uk/events 22 November, Advanced Toxins & Fillers, Wigmore Medical, London W: wigmoremedical.com/events 23-24 November, The International Congress in Aesthetic, Anti-Aging Medicine & Medical Spa, Habtoor Grand Beach Resort, Dubai, UAE W: euromedicom.com/icaam-2012/index.html 24 November, Combined Botox/Dermal Filler Training Course, Aesthetic Training Academy, Birmingham W: aesthetictrainingacademy.co.uk 28 November, Fractional Laser Masterclass, The Lynton Clinic Training Centre, Manchester W: lynton.co.uk/training

8 January, Core of knowledge, Mapperley Park Training Centre, Nottingham W: mapperleypark.co.uk/training 14-18 January, BTEC AWARDS, Mapperley Park Training Centre, Nottingham W: mapperleypark.co.uk/training 24-26 January, International Congress in Aesthetic Dermatology, Bangkok Convention Centre, Bangkok, Thailand W: euromedicom.com 31 January - 3 February, IMCAS annual meeting, Paris, France W: imcas.com FEBRUARY 16 February, Cosmetic News Expo 2013, Business Design Centre, London W: cosmeticnewsuk.com 24 February - 1 March, IPRAS World Congress 2013, Espacio Riesco Convention Centre, Santiago, Chile W: www.ipras.org

If you have an item you would like included in Training & Events, send it for consideration to helen@face-ltd.com

body language www.bodylanguage.net

as ‘quick fix’

Calls for improvements to pre-surgery counselling Obesity rates are among the highest in Europe, with costs to the health economy estimated at £5bn per year. Bariatric surgery is an option for those suffering from severe obesity, but research suggests the procedure is considered by too many as a ‘quick fix’ to addressing obesity problems, rather than considering dietary alternatives. A report conducted by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has found that many patients undergo bariatric operations without a proper understanding of the risks involved. The report investigated the care provided to 381 NHS and private adult patients over a three-month period, from referral through to six months post-treatment. Only a third of those received psychological counselling before being referred for surgery and the same amount did not receive adequate follow up following the procedure— around 44% of patients had their first follow up appointment over six weeks after discharge. Surgical bariatric procedures, such as gastric bypass or gastric bands, increased by 70% between 2008 and 2010, according to the report. Around 7,200 procedures were carried out between 2009–2010 compared with only 4,200 the previous year. NCEPOD chairman Mr Bertie Leigh says surgery is not a panacea and can only be part of the solution. “Both the private sector and the NHS offer a surgical solution to people suffering from an extreme disorder of diet without involving the dietician. A clinician treating the problems of a patient needs to understand them at an individual level,” says Mr Leigh. Poor consent procedures

were highlighted in the report, with many patients providing consent on the day they are admitted for surgery. “This means there is no time for patients to reflect on their choices and have the opportunity to ask further questions about the risks and benefits of surgery before committing themselves to an operation,” says report co-author Mr Ian Martin. Of those who did not receive adequate follow up after surgical procedures, nearly a fifth had to be readmitted for treatment within six months, with some requiring further surgery. Weight loss surgery is a radical procedure with risks as well as benefits, and shouldn’t be undertaken without full patient support, continues Mr Martin. “When we reviewed cases, we found examples of inadequate processes from start to finish—even the basics, such as giving patients dietary advice and education before decisions to operate were taken, were lacking,” he says. The report found that 80% of bariatric patients were women and nearly half of all patients paid privately for their weight loss surgery. Recommendations made by the organisation include a greater emphasis on psychological assessment early in the care pathway, a two-stage consent process for patients to better understand risks involved and a code of conduct for weight loss advertisements. 11


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cover story Professor Syed Haq & Dr Masud Haq

Topical and systemic

antioxidants

Professor Syed Haq and Dr Masud Haq discuss the role of naturally-occurring antioxidants in protecting against free radical damage and how advances in technology can aid their effect

A

n antioxidant is a molecule that is capable of inhibiting or slowing down the oxidation of other molecules. Antioxidants have a protective effect against free radical damage. Normal bodily functions such as breathing or physical activity and other lifestyle habits such as smoking produce free radicals that attack healthy cells. When these healthy cells or their genetic material are damaged, they become more susceptible to disease and certain types of cancers. Classification of antioxidants Types of antioxidants

Hydrophilic or hydrophobic Extracellular or intracellular Metabolites

Uric acid Ascorbic acid Carotenes Glutathione Melatonin a-tocopherols Lipoic acid and ubiquinone

Enzyme systems

Superoxide dismutase Catalase Thioredoxin (CXXC)/gluathoine

Naturally occurring (polyphenols, caratenoids, Vitamins E and C)

14

Free radicals come in many shapes, sizes, and chemical configurations. What they all share is a ravenous appetite for electrons, “taking” them from nearby substances that will yield them. This electron shift can radically alter cellular function. Free radical damage can, for example, change the instructions coded in a strand of DNA. They can make a circulating lowdensity lipoprotein (LDL, sometimes called “bad cholesterol”) molecule more likely to get trapped in the intima of the arterial wall. Alternatively free radicals can alter a cell’s membrane. It must be noted that balance is key with free radicals playing an important part in immune surveillance. It is when there is excess of free radicals that we run in to problems. We are not defenseless to free radical damage and on a daily basis extract free-radical scavengers from food. These substances are often collectively assigned the description of acting as “antioxidants.” They work by generously giving electrons to free radicals without turning into electron-scavenging substances themselves. In this article we highlight some of the groups of antioxidants that we derive from food, our own internal protective redox system and describe new methods in the form of nanotechnology that allows us to gain greater benefit from the pre-existing source of antioxidants. Antioxidants per se can come in all shapes and sizes. They may be found in or outside a cell, or can be part of a complex system of enzyme reactions, a metabolite or can be naturally-occurring (exogenous) in nature (see “Classification of antioxidants”). body language www.bodylanguage.net


cover story Professor Syed Haq & Dr Masud Haq

Classification of antioxidants We all produce natural metabolites which can act as antioxidants on a daily basis including uric acid, vitamin C, carotenes, glutathione and melatonin. Melatonin is an interesting peptide that has a diverse array of functions. It is found in the pineal gland and controls the sleep centre, diurnal rhythm, controls a variety of hormone levels throughout the day and acts as an antioxidant. Alpha-tocopherols, vitamin E and its various derivatives: alpha, beta, gamma, as well as lipoic acid and ubiquinone, superoxide dismutase, catalase and the thioredoxin glutathione system work in concert as part of a complex redox system that exists in the mitochondria of cells.

Figure 1: Vitamin E redox system, aiding skin defence

The cutaneous redox system This naturally occurring redox system exists and forms part of the skin defence system. It exists in both the dermis and epidermis. In the stratum basale of the epidermis the components of this redox system (see Figure 1) are found to be more concentrated with an abundance in the deep epidermis and the dermis. Vitamin E (reduced form—alpha tocopherol) acts as a key antioxidant in the skin as well as other tissues. It does this by acting as a peroxyl radical scavenger preventing the generation of free radicals in tissue by reacting with free radicals to form a tocopheryl radical. This tocopheryl radical is then oxidised by the transfer of a hydrogen ion from ascorbic acid or ubiquinol to exist in a reduced form (tocopherol). Meanwhile the dehydroascorbate is later reduced by a sequence of redox reactions that involve glutathione and lipoic acid. Superoxide dismutase (SOD2) Superoxide dismutase (SOD) binds to copper and zinc ions and is one of three superoxide dismutases (SOD-1, -2, and -3) that are responsible for destroying free superoxide radicals in the

Figure 2: Superoxide dismutase-2 and H2AX body language www.bodylanguage.net

body. The encoded isozyme is a soluble cytoplasmic and mitochondrial intermembrane space protein, acting as a homodimer to convert naturally occurring, but harmful, superoxide radicals to molecular oxygen and hydrogen peroxide. SOD2 is normally ubiquitously expressed and is found in the mitochondria of cells. It is a key player in maintaining oxidant potential. The example defined in Figure 2, taken from mouse skin cells, shows in the top panel a Western blot of increased protein expression of H2AX (the core histone involved in cell division) in the cells lacking SOD2 [SOD2 -/-]. H2AX is normally wrapped in DNA. However when the DNA is damaged, due to increased susceptibility to free radicals, the core histone H2AX becomes exposed and later undergoes further injury. The increased “exposure” of H2AX is further noted in the lower panel immunostains which show increased levels of H2AX in the absence of SOD2. Naturally-occurring dietary antioxidants  Proanthocyanidin (OPC) works as a DNA mutation inhibitor. It blocks elastases which maintain the integrity of elastin in the skin and act synergistically with both vitamin C and E, protect and replenish them. OPC in cream form is effective against the effects of UV light. OPCs exert a solo antioxidant effect at a level of potency on a par with vitamin E, protecting different polyunsaturated fatty acids from UV light-induced lipid peroxidation. Grape seed proanthocyanidins are potent antioxidants, free radical scavengers and have been shown to inhibit skin tumour formation in mice.  Resveratrol belongs to a class of polyphenolic compounds called stilbenes. Resveratrol is a fat-soluble compound that occurs in a trans and a cis configuration. Resveratrol is a naturallyoccurring polyphenolic phytoalexin that acts as an antioxidant, anti-inflammatory and anti-mutagen. Topical application of resveratrol in animal models results in inhibition and delayed formation of UVB-induced tumours. Foods known to contain resveratrol are limited to grapes, wine, grape juice, cranberries, cranberry juice and peanuts. The roots of the weed polygonum cuspidatum constitute one of the richest sources of resveratrol. The Chinese have used resveratrol as a potential anti-cancer and anti-atherosclerotic agent in remedies for centuries.  The most common flavonol in the diet is quercetin. Quercetin has anti-inflammatory and antioxidant effects and acts as a immunomodulator. A diet rich in quercetin has been reported to inhibit the development of carcinogen-induced rat mammary cancer, colonic neoplasia, oral carcinogenesis and latterly in skin tumour formation when administered topically. It is present in various common fruits, vegetables, beverages and herbs with the highest concentrations found in onion. Quercetin and rutin have been tested as potential topical sunscreen factors in humans and were found to provide protection in the UVA and UVB range.  Silymarin is a flavonoid compound found in the seeds of milk thistle (Silybum marianum). Silymarin consists of three phytochemicals: silybin, silidianin, and silicristin. Silybin is the most active phytochemical. Topical silymarin has been shown to have an antitumour effect and reduces UV-induced sunburn cell formation and apoptosis.  Curcumin (diferuloylmethane) is a yellow odourless pigment isolated from the rhizome of turmeric (Curcuma longa). Curcumin possesses anti-inflammatory, antitumour and antioxidant properties.  The antioxidant vitamin E (α-tocopherol) may protect both animal and plant cell membranes from light-induced damage. Topical application of these antioxidants to the skin has been 15


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cover story Professor Syed Haq & Dr Masud Haq

Naturally-occurring dietary antioxidants Active Ingredient

Natural Sources

Effects

Pelargonidin

Strawberry, banana, red radish, potato

Antioxidant—cell membrane protection from lipid oxidation, neutralise enzymes, repair damaged tissue and proteins

Cyanidin and Delphinidin

Blackcurrant, gooseberry, red cabbage, purple carrot

Repair damaged tissue and proteins

Delphinidin

Passion fruit, pomegranate, aubergine

Antioxidant—blocks lipid peroxidation and repairs tissue

Cyanidin and Peonidin

Cranberry, plum

Antioxidant—blocks lipid peroxidation and repairs tproteins

Proanthocyanidin

Grape seed, white pine, horse chesnut, witch hazel, apples, barley, chocolate, rhubarb, rose hip, hawthorn

DNA mutation inhibitor, block elastase breakdown, free radical scavenger

Resveratrol

Grapes, wine, grape juice, peanuts, (Vaccinium species—cranberries, blueberries bilberries)

Antioxidant, antimutagenic, anti-inflammatory

Silymarin

Milk thistle

Anti-inflammmatory, antioxidant, antitumourigenic, UV induced sunburn

Quercetin

Evening primrose oil, onion, tea (Camelia sinensis), sunflower, cranberry and apple (Malus domestica)

Anti-inflammatory, antioxidant, immunomodulator, inhibits tumour formation, and potential sunscreen

Curcumin

Tumeric (Curcuma longa)

Anti-inflammmatory, antioxidant—free radical scavenger, antitumorigenic

Apigenin

Citrus fruits, peppermint, cumin (Cuminum cyminum), marigold, parsley, argimony, arnica (Arnica Montana), purple coneflower (Echinacea purpurea)

Prevention of UVA and UVB carcinogenesis, anti-inflammatory

shown to reduce acute and chronic photodamage. Topically applied, only the natural forms of vitamin E—alpha-tocopherol and tocotrienol—effectively reduce skin roughness, the length of facial lines, and the depth of wrinkles. Topically-applied vitamin E increases hydratation of the stratum corneum and increases its water-binding capacity. Triticum vulgare (wheat germ) oil is particularly rich in vitamin E and offers excellent antioxidant promise in topical anti-ageing formulations. It also nourishes and prevents loss of moisture from skin.  Vitamin C (L-ascorbic acid) is the body’s most important body language www.bodylanguage.net

intracellular and extracellular aqueous-phase antioxidant. Vitamin C provides many benefits to the skin—most significantly, increased synthesis of collagen and photoprotection. Photoprotection over many months allows the skin to correct previous photodamage, the synthesis of collagen and inhibition of metalloproteinases-1 has been proven to decrease wrinkles, and inhibit of tyrosinase and in depigmenting solar lentigines. Importantly, vitamin C is found in active form and substantial quantities in Rosehip seed extract or oil.  Dietary carotenoids from a healthy, unsupplemented diet accumulate in the skin and their level significantly correlates with sun protection. Eating large quantities of fish oil appears to provide a sun protective effect, in some cases up to an SPF of 5, and may reduce the UV-induced inflammatory response by a lowered prostaglandin E2 levels (a mediator in the arachidonic acid cascade for inflammation). In human fibroblasts, lycopene, β-carotene, and lutein were all capable of significantly reducing lipid peroxidation caused by UVB. A 12-week oral study of supplementation with a combination of lycopene, lutein, β-carotene, α-tocopherol, and selenium has been shown to significantly improve skin thickness, density, roughness, scaling and reduce sunburn. Naturally-occurring topical antioxidants  Tea (Camellia sinensis) is commonly used as a home remedy for sunburn. The Chinese recommend applying cooled black tea to the skin to soothe sunburn. The tannic acid and theobromine in tea can help remove heat from sunburns. Other compounds in tea called catechins help prevent and repair skin damage and may even help prevent chemical and radiation-induced skin cancers. The complex polyphenolic compounds in tea provide the same protective effect for the skin as for internal organs. They have been shown to modulate biochemical pathways that are important in cell proliferation, inflammatory responses, and responses of tumour promoters. Green tea has shown to have anti-inflammatory and antioxidant effects in both human and animal skin. Animal studies provide evidence that tea polyphenols, when applied orally or topically, ameliorate adverse skin reactions following UV exposure, including skin damage, erythema, and lipid peroxidation. Topical green tea applied to human skin provide a photoprotective effect, reduce sunburn, protecting epidermal Langerhans cells from UV damage, and reduce the DNA damage that formed after UV radiation. Green tea has been found to decrease melanoma cell formation with topical and oral administration in mice. Most cosmeceuticals products containing tea extracts or phenols have not been tested in controlled clinical trials, but these substances have shown compelling evidence for antioxidant, anti-inflammatory, and anti-carcinogenic activities.  Aloe vera or Aloe barbadensis has been scientifically proven for all forms of burn, be it radiation, thermal or solar. The plant is mainly used for its soothing and cooling effect; however, the plant is useless if used at less than 50% and is recommended to be used at 100% to ensure a beneficial effect. The polysaccharides, mannose-6-phosphate, and complex anthraquinones all contribute synergistically to the benefits of this material. The natural chemical constituents of aloe vera can be defined as containing: amino acids, anthraquinones, enzymes, lignin, minerals, mono- and poly-saccharides, salicylic acid, saponins, sterols, and vitamins. Aloe vera is a uniquely effective moisturiser and healing agent for the skin.  Walnut extract is made from the fresh green shells of English walnut, Juglans regia. The aqueous extract has been shown to be particularly effective as a self-tanning sunscreen agent. Its 17


cover story Professor Syed Haq & Dr Masud Haq

Naturally-occurring topical antioxidants Herbal source of extract

Effects

Green tea

Photoprotective; soothes sunburn, repairs skin, anti-inflammatory, anti-oxidant, protects dermal langerhan cells, reduces DNA damage

Aloe vera

All forms of burn, soothing and cooling effect, heals skin and accelerates collagen production

Walnut extract

Self-tanning, UV protection

Rhatany root extract

Antioxidant, photo-protection, free radical scavenger

Borage oil

Skin regeneration and skin cell activity

Evening primrose oil

Soothe’s skin and anti-inflammatory

Avocado oil

Natural suntan, soothe and protects skin

Tea tree oil

Antiseptic, fungicide, relieves sunburn

most important component is juglone (5-hydroxy-1,4- naphthoquinone), a naphthol closely related to lawsone (2-hydroxy-1,4naphthoquinone). Juglone is known to react with the keratin proteins present in the skin to form sclerojuglonic compounds. These are coloured and have UV protection properties  The antioxidant/photoprotective potential of a standardised Krameria triandra root extract (15% neolignans) has been evaluated in different cell models, rat erythrocytes, and human keratinocytes cell lines, exposed to chemical and physical (UVB radiation) free radical inducers. In cultured human keratinocytes exposed to UVB radiation, Krameria triandra root extract dose-dependently restrained the loss in cell viability and intracellular oxidative damage. The cytoprotective effect of the extract was confirmed in a more severe model of cell damage.  Researchers have found that some plant oils contain natural sunscreens. Sesame oil resists 30% of UV rays, whereas coconut, peanut, olive, and cottonseed oils block out about 20%. Although mineral oil does not resist any UV rays, it helps to protect skin by dissolving the sebum secreted from oil glands, thus assisting evaporation from the skin.  Borage oil (Borago officinalis) stimulates skin cell activity and encourages skin regeneration. It contains high levels of gammalinoleic acid (GLA), making it useful in treating all skin disorders, particularly allergies, dermatitis, inflammation and irritation. Borage penetrates the skin easily and benefits all types, particularly dry, dehydrated, mature or prematurely ageing skin.  Evening primrose oil (Oenothera biennis) has a high GLA content that promotes healthy skin and skin repair. It is usually yellow in colour. It soothes skin problems and inflammation, making it a good choice for people with eczema, psoriasis or any type of dermatitis. Evening primrose skin oil discourages dry skin and premature ageing of the skin. The role of nanotechnology Nanotechnology can be applied to increase the delivery of antioxidants to the skin. This can be tailor-made to focus on the area in question without systemic toxicity. Nanotechnology is a system where a microenvironment—a micelle, for example—can be administered to the skin that allows greater bio-compatibility or better permeation of the active ingredient. For example, the physical and chemical properties of the naturally-occurring form quercetin mean that it is highly insoluble in water, creating in effect an emulsion that does not permeate skin efficiently. 18

Quercetin When quercetin is placed in a nanoparticle-based vehicle, its properties change to allow it to become more water soluble. This loaded particle is held within a micelle in association with lecithin which are lipids, positively charged chitosan (glycosaminoglycans), D-α-tocopheryl polyethylene glycol succinate (TPGS). The nanoparticle acts as a polycationic-attracting agent that allows more loading “entrapment” of quercetin. Results demonstrate that nanoparticles can significantly promote the accumulation of quercetin in skin, especially in the epidermis. The nanotechnology allows significant permeation that is limited to the epidermis and reduces the risk of systemic buildup of the active agent over time. In Figure 3, microscopic pictures taken from skin of mice treated with a quercetin propylene glycol solution, quercetinloaded nanoparticles reveals a slight change in the compacted corneocyte layer (Fig 3B) compared to the untreated skin (Fig 3A). Importantly, the presence of the nanoparticle suspension results in the skin becoming swollen with increased overall thickness of the stratum corneum, loosening of the cellular junctions and increased intercellular spacing (Fig 3C). The changes may be due to the positive charge of chitosan, the hydration of D-α-tocopheryl polyethylene glycol succinate (TPGS) altering the barrier function of the skin, mixing of the lecithin component of the nanoparticle with endogenous cutaneous lipids. The effect of these changes would facilitate topical drug permeation. In summary, there is a multiplicity of examples of antioxidants which have a fundamental role in health. The key question with the advancement of technology is how best to increase our ability to extract these beneficial effects from such molecules in a way that is efficient and site direct as seen here in the skin. The next few years should see greater efficacy from the current available crop of cosmeceuticals. I dedicate this article to my late father Dr Sayyid A. Haq, my mother Mrs Fazilatun N. Haq and family. Dr Masud Haq is a consultant endocrinologist and Professor Syed Haq is a consultant physician at the London Preventative Medicine Centre, 10 Harley street. Both physicians are on the editorial board of Body Language 

1. Chemical hydrocarbon structure of quercetin 2. Crude quercetin as an emulsion when mixed with water 3. Quercetin in a nanoparticle based vehicle becomes more water soluble

Figure 3: Microphotograph (200x) of vertical section of mouse skin after haematoxylin eosin (H&E) staining (A) untreated skin, (B) skin treated with quercetin propylene glycol solution, and (C) skin treated with quercetin-loaded nanoparticles. body language www.bodylanguage.net


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skincare Susan McNeece

Topical combinations Developing a topical antioxidant product is a complex process, involving considerations such as formulation balance, ingredient conflicts and delivery mechanisms. Susan McNeece elaborates

T

he role of antioxidants in the prevention and treatment of ageing skin is a broad topic and an emerging field. There are so many new technologies and we have only scratched the surface as to their true applications and their clinical efficacy. How are antioxidants driving results from a topical application in clinic? Ingredients like vitamin A (prescrip20

tion and non-prescription retinoids), vitamin C—whether lipid soluble ascorbyl palmitate, or water soluble L-ascorbic acid —and vitamin E, are the most widely recognised and studied antioxidants. Research, data and clinical validation have demonstrated that they work and have an impact on the skin, whether from collagen synthesis, stimulation of fibroblast activity, increase in glycosaminogly-

cans, prevention of lipid peroxidation, or other anti-inflammatory benefits. There is little doubt as to the value these vitamins bring to the overall quality of the skin. It’s documented; they work. What is interesting is the range of new technologies emerging with antioxidants, and their impact. When we review raw ingredient data, we have to be a little cautious—most body language www.bodylanguage.net


skincare Susan McNeece

are isolated raw ingredients. Whether it is green tea, or dimethylaminoethanol (DMAE), how does that apply to topical formulations? If it’s an in vitro study, how well does this convert to in vivo application and usage, or in animal studies, how does its efficacy compare between the skin of a mouse and the skin of a human being? When talking about systemic versus topical application, many ingredients such as DMAE have been discussed from a systemic approach but not necessarily from the topical viewpoint. DMAE is an ingredient originally analysed in Alzheimer studies as a precursor to acetylcholine. Being an analogue of choline, it was studied for the ability to enhance cognition, memory and learning. However, a number of changes to body language www.bodylanguage.net

the skin were observed, so topical studies were then conducted . These trials have examined how DMAE creates a contraction at the neuromuscular juncture to cause a lifting and firming of the skin. In one study, a 3% solution of DMAE was applied topically for six weeks before suspending use of the product. Two weeks after treatment ended, there was no loss in results.

making it cosmetically elegant, and preventing the formulation from separating while remaining efficacious. When you try to prove the benefits of a single ingredient versus a topical formula, it becomes much more challenging. The whole formula is very different to any one of its components. You have to look to the clinical validation of the overall formula.

Topical formulation Ingredients should hypothetically provide results but topical formulations are complex and delivery mechanisms become important in suspension in a solution. When ingredients are combined, they perform differently. Taking individual ingredients and performing studies on them is not the same as taking a combination in a topical solution and applying it for clinical efficacy and results. There is 100% of a solution in a jar. In any non-silicone based solution, there will be around 50-75% water so there is a limited amount of space available for the rest of the ingredients—this limits the number of ingredients that can be combined in a product if they need to be at higher percentages for true efficacy.

Anti-inflammatory The anti-inflammatory benefits of antioxidants in relation to cosmetic and aesthetic procedures has become very interesting. Whether it be chemical peels or laser procedures, these treatments cause intentional wounding to the skin. So how can we use antioxidants in combination with peptides and growth factors to enhance our treatments? In clinical evaluations of applications of Jessner’s solution peels, an antioxidant product will assist in reducing redness, erythema and inflammation in the skin, to reduce the downtime and increase patient satisfaction. Dr Ian Carlisle in Australia has been conducting similar research and studying topical application in relation to reduction of inflammation post-Fraxel non-ablative procedures. Studies show a reduction in downtime of up to 32%. Anti-inflammatory benefits can also be seen in the reduction of irritation and acclimation issues in topical solutions. Using a full 1% retinol, which is a 10-1 conversion into retinoic acid within the skin, equals the 0.1% prescription tretinoin. That is the highest concentration of vitamin A that you can get, and one of the common problems with it is compliance due to skin irritation. But if you combine 1% retinol with antioxidants to reduce irritation, you can reach twice-daily application much more quickly. You can reduce the acclimation and irritation issues and achieve faster results within a short timeframe. People want quick results. Patients are looking for value for their money and this is one way of using antioxidants in combination for anti-inflammatory benefits. From the point of view of your practice, you must determine its goals and needs so you can then decide how to best utilise topical antioxidants in your overall treatment strategy to enhance clinical outcomes.

Efficacy In terms of varying the pH, L-ascorbic acid needs to be at around 2.25pH to be efficacious whereas ascorbyl palmitate should be around 7pH. Retinols need a pH of around 5.5 near the skin’s acid mantle. When ingredients are combined, there will be loss efficacy of one or multiple ingredients depending on the overall pH of the formulation There are also stability issues; some ingredients don’t combine. A good example is a retinol with a benzoyl peroxide in a single chamber. When oxygen is created with one ingredient, which is then combined with another that is sensitive to light and air, the efficacy of the retinol will be affected. The combination of ingredients in a single chamber can alter the formula, making it less effective. Delivery mechanisms By trying to penetrate the lipid barrier, what is the level of penetration with water soluble ingredients? How do you combine them and how well will they penetrate into the epidermis? What delivery mechanism can be utilised in the formula to increase penetration? Other considerations are the base of the solution forming a cream or a serum,

Susan McNeece is the senior director of Global Education at Jan Marini Skin Research, San Jose, CA 21


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forum

Head to head With an array of topical antioxidants available to practitioners, a panel of experts discuss the benefits of the products they use or helped develop

Dr Mervyn Patterson is a cosmetic doctor practicing at Woodford Medical and is medical director at Eden Aesthetics, distributor of Epionce skincare

Epionce is a botanical range which optimises skin health, using a synergistic blend of proven botanical formulas that help address all the pathways that trigger the activation of chronic inflammatory factors. Dr Carl Thornfeldt and his team in Boise Idaho have developed this product range over the last ten years. He has 25 years practice as a dermatologist, and has pioneered work in barrier repair and the inflammatory mechanisms in the skin. Chronic inflammation is a damaging process to the skin. When external factors penetrate the skin, an inflammatory cascade is activated which makes the skin more vulnerable and affects its ability to repair its own barrier. When left untreated, this damaging cycle of events intensifies. Epionce attempts to repair and improve the quality of the skin barrier, giving better protection against the external environment, dampening down the inflammatory process and allowing the skin to recover, regenerate and look after itself. To achieve results, products must be active, stable, with concentrations great enough to produce an impact and the delivery body language www.bodylanguage.net

system must work without causing irritation. Individual synthetic antioxidants only block one or two aspects of the inflammatory pathway, so Epionce favour a combined approach, using multiple anti-inflammatories derived from the plant kingdom to give a broader impact on the chronic inflammatory process. Epionce have attempted to find the best possible herbal extracts that when combined have the greatest effect. Date palm for instance, has a very high antioxidant activity, greater than blueberry, blackberry and green tea. Flax oil has a very potent anti-inflammatory effect, meadow foam is a rich source of an omega-3 type, and apple extract is a very high natural source of quercetin. The Epionce skincare line is supported by fourteen independent clinical trials using the finished product so clinicians can see the results on the product they are selling to clients. Clinical trials demonstrated for the first time that a botanical ingredient could outperform prescription strength Renova with no irritation. In all the parameters used, from tactile roughness to fine lines, wrinkles, clarity and skin lapse and actinic keratosis, Epionce Renewal Facial Cream and Epionce Lytic Tx were equivalent to prescription-strength Renova. It was further shown that Epionce outperformed Renova in terms of the production of epidermal glycosaminoglycans and dermal density. In a second independent clinical trial, a 12-week controlled study using Epionce Renewal Facial Cream showed reduced tactile roughness by a mean value of 56%, improved clarity by 53%, reduced fine lines by 27% and wrinkles by 19%. Last year Epionce introduced a hyperpigmentation range to control the pigmentation process. The aim was to create an effective treatment without irritation, with prolonged results even after the product was withdrawn. The product had to be safe for long-term use and free of hydroquinone and parabens. 23


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A wide range of herbal extracts, including licorice root, crithmum maritimum algae, peppermint, mallow, pea, paper mulberry and white water lily were selected, backed up by other key Epionce ingredients which have barrier repair and chronic inflammatory effects. A study comparing Epionce products with the Obagi Nu-Derm system—which comprises hydroquinone 4% and prescription strength Retinol—found the two were similar in their pigment-reducing effect. However, some sideeffects were experienced with the Obagi regime, including erythema, scaling, redness and some subjects found it irritated the skin. When all active products were discontinued, a rebound of pigmentation was seen in the Obagi group, but not in Epioncetreated subjects—this effect is caused by barrier dysfunction remaining after the bleaching agent is removed from the skin.

Elliot Isaacs is the founder and medical director of Pangaea Laboratories, the company behind the international Medik8 skin brand

Medik8’s CE-Thione contains a “network antioxidant system” which mimicks the skin’s own redox cycle. This helps keep the vitamin C stable in the packaging and ensures it is stable, or “highly potent”, on the skin. Medik8 are marketing the oil-free technology as “Rechargable Vitamin C”. CE-Thione serum is the product of three years’ research and development by Medik8 to ensure the product has an elegant feel, pleasant fragrance and excellent penetration and stability data —95% after two years at room temperature. The serum contains 15% L-ascorbic acid, 1% Dalpha vitamin E and 0.5% L-glutathione amongst other active ingredients. Aesthetic feel is something which can be lacking in a quality stabilised vitamin C serum because the appropriate carrier and stabilising agents for vitamin C are—by their nature—greasy and chemical smelling. This has been a compromise users have been prepared to accept given the great results from vitamin C. Medik8 biochemists were set the task of keeping the potency while ditching the poor aesthetics. Professionals know that vitamin C is a great antioxidant— soaking up free-radical particles. Less well known is that vitamin C is an essential coenzyme for the synthesis of collagen. It also is necessary for the transportation of collagen into the extracellular matrix, and it disrupts melanin synthesis so it’s important for reducing pigmentation. The problem with vitamin C is that it’s highly unstable in aqueous solutions. There are several factors which affect the stability of L-ascorbic acid; ionic strength or pH, temperature the product is kept at, the presence of oxygen, UV radiation, transition metal ions, viscosity or thickness of the solution, the solvents and carrier vehicles that you use in the product, and the presence or absence of other stabilising antioxidants. For example, if the pH is over four, the vitamin C molecule becomes negatively charged, making it less stable. From an efficacy point of view, the lower the pH, the greater the efficacy. From a penetration point of view, at a low pH the lipid mem24

brane is disrupted, allowing for easier penetration of molecules into the skin. However if the pH is too low, the product becomes irritating with continued use. We say the ‘goldilocks’ pH is about three, giving a stable, efficacious, and not too irritating product which is able to penetrate. The same level of consideration is applied to each component making up CE-Thione. From the use of nitrogen blanketing to remove oxygen in the headspace of the serum bottle, to adding special metal chelators to remove transition metal ions. The redox system comprises a natural vitamin E molecule which does a good job of stabilising vitamin C, but the reverse is not true. Therefore the vitamin E which is in place to stabilise the vitamin C will eventually “run out”. A better recycler of vitamin C is L-glutathione, which is the reason we add it in—to help the vitamin E. We have three other patent pending stabilisers, and all six stabilisers work in harmony to produce excellent stability resulting in a completely self-sustained product—this is why it stays stable in the bottle and for two minutes in the skin. Once the product has been opened we have shown that our product has 95% of L-ascorbic acid remaining after 90 days at room temperature, which is double the amount of time that you would expect a user to have the product, and 81% after 12 months accelerated. The product has a shelf life of two years.

Sally Durant has a specialist knowledge of skin science and runs a corporate training and consultancy business, engaged by many high profile companies including SkinCeuticals

SkinCeuticals have extensive technical and clinical support from a scientific team, dermatologists, biochemists and Professor Sheldon Pinnell—dermatologist and head of Duke University, Colorado. Professor Pinnell pioneered research into the topical use of pure water-soluble vitamin C to address photoageing of the skin. In 1997, the first stabilised form of Lascorbic acid was discovered to effectively penetrate the skin. This research has paved the way in the use of cosmeceutical vitamin C serums in addressing ageing, pigmentation and collagen regeneration. Antioxidant therapies form the cornerstone of SkinCeuticals. Unless practitioners send clients home with an antioxidant and a sunscreen, they are wasting their patient’s money, as ultraviolet light will generate damaging free radicals which negate the benefits of other anti-ageing treatments. It is a well-established fact that sunlight is degrading to dermal tissue and the epidermis, causing oxidative stress leading to skin dysfunction, ageing and disease. Around 95% of photo ageing is caused by sunlight, yet ultraviolet light is only 7% of the electromagnetic spectrum and 54% of that spectrum is infrared. Research carried out by Dr Ramy Shaat shows that 65% of the infrared A rays—which are between 790–1500nm—actually penetrate deeper into the dermis than UVA. Therefore, it is not only UVA light which causes premature ageing of the skin. Infrared rays also cause free radical damage continued on page 27  body language www.bodylanguage.net


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and the upregulation of the matrix metalloproteinases(MMP). This leads to degradation of collagen and elastin leading to loss of dermal integrity and the formation of Thymine Dimers showing implications of cancerous change. The P53 gene is also upregulated and can indicate the degree of penetration of light rays into the skin and the subsequent issue of apoptosis. In vitro and in vivo studies have proven this link with photo ageing to be not only ultraviolet but also infrared. Our science and products, in terms of antioxidant therapies, become inherent to everyday life. People are somewhat resistant to feel that ultraviolet protection is necessary in the UK, but as skin health professionals we know that that is still a very pertinent danger. In relation to transdermal penetration of antioxidants, we can facilitate the absorption of vitamin C, vitamin E, ferulic acid, and the SkinCeuticals patented antioxidant from apples— Phloretin. In order to penetrate the skin, vitamin C has to be L-ascorbic acid, un-ionised, of a pH between 2.1 and 3.5, at a concentration of at least 10% and it has to be stable. SkinCeuticals serums sit at 2.3 with our gel serums—designed for the more sensitive skins— at 3.2 to give optimum penetration at lower acidity. In a study carried out with applications of between 5% and 30% L-ascorbic acid of pH 2.3, very good penetration occurs at 10% and 15%. 20% has a very high penetration level, but it is highly unstable, so we combine the efficacy and penetration at 10% and 15% with the stability that those percentages give us. In terms of the kinetic study, we know that our antioxidants can have a reservoir effect. After three days the levels of the antioxidant showed to be saturated with 20 times more content of L-ascorbic vitamin C in the skin, and indeed the washout at testing showed that this saturation continued for up to four days after the product had been applied. Phloretin has become one of our bestselling and most efficacious antioxidant serums. It has a true broad spectrum capacity and contains 10% L-ascorbic acid, 0.5% ferulic acid, and 2% Phloretin. Studies were done on this formulation using Fitzpatrick Type II and III subjects. Four sites were localised on the lower back of each participant and each were exposed to UV light. One site had Phloretin CF applied for four days and this was compared to a second site that had a vehicle applied. A third area was exposed with nothing applied to the skin and the fourth area had no exposure to UV. The control erythema was significantly greater than the skin which was irradiated after four days having been dosed with Phloretin. We also measured the prevalence of sunburn cells, which showed significant reduction. Thymine dimers—particularly showing in the generation of non-melanoma skin cancers—had almost total reduction occurring in the Phloretin treated skin. In addition, studies also showed reduction in MMP-1 and MMP-9, reducing the degradation of the extracellular matrix. Damage to the Langerhans cells by the free radical issue was also reduced, meaning that we can help to inhibit the UV immunosuppression and the IR immunosuppression that can occur on a daily basis when exposed to sunlight. The studies Dr Shaat then completed on infrared light were reflective of these issues with antioxidants on UV. He conducted a study on 13 individuals aged 18–45, exposing them for ten days to CE Ferulic which is 15% L-ascorbic acid. Having exposed the areas of skin after ten days’ treatment with the infrared parameter of 790–1450nm, he showed 100% reduction in MMP at uppregulation—significant progress in terms of not only addressing antioxidant and free radical issues in the skin but also preventing the active degradation of the dermal tissue that sunlight, as a whole, can cause to our skins. body language www.bodylanguage.net

Lorna Bowes is an aesthetic nurse with an interest in dermatology and cosmeceuticals. She is managing director of Aesthetic Source, distributor of NeoStrata in the UK

NeoStrata antioxidants use a complex of ingredients offering distinct antioxidant mechanisms, as well as other active benefits. I will focus on one product—the newly launched NeoStrata Skin Active Antioxidant Defense Serum. In the 1970’s alpha hydroxy acids—glycolic acid in particular—were discovered by Dr Van Scott and Dr Yu, owners of the NeoStrata Company Inc, who were looking for something to help break down the over production of stratum corneum cells in lamellar icthyosis. Alpha hydroxy acid—alpha being one, hydro being water—are small molecules which penetrate quickly and resurface the skin. Towards the end of the 1980’s the doctors at NeoStrata developed poly hydroxy acids—poly being multiple—many more hydroxyl groups; four hydroxyl groups for example for gluconolactone which gives it more humectant capacity. Bionic hydroxy acids have moved on further and have eight hydroxyl groups. NeoStrata Skin Active Defence serum contains maltobionic acid, a complex bionic hydroxy acid to trap oxidation-promoting metals, and help with the metal chelation. It works with lipid peroxidation, preventing the oxidated damage to lipids and the cell membrane, and preserves the dermal matrix by inhibiting matrix metalloproteinases which, in turn, will inhibit the breakdown of collagen and glycosaminoglycans. Another ingredient in the serum is gluconolactone—a polyhydroxy acid. It inhibits the elastin promoter gene and creates both an antioxidant effect and reduces the breakdown of elastin. It also contains citric acid, which has much evidence relating to its antioxidant capacity as a free radical scavenger. Another antioxidant within this product is phytostem—a lilac leaf cell culture extract which contains an active ingredient called verbascoside. Verbascoside contains caffeic acid which a popular antioxidant. Verbascoside also has an anti-inflammatory effect which is important for our patients. Comparing antioxidants we should look at two different things. First, the trolox equivalent antioxidant capacity (TEAC) value, one of several measures of antioxidants along with the oxygen radical absorbance capacity (ORAC) score. We have verbascoside measured on the TEAC score comparing to ascorbic acid and resveratrol, showing it has potent antioxidant capacity. The ORAC score for verbascoside against peroxyl radicals, hydroxyl radicals, superoxide anions, comes to 28,000—a very high ORAC score. Teavigo EGCG extract is another ingredient, all in the same Skin Active Antioxidant Defense Serum. This is a polyphenol flavonoid antioxidant that protects DNA against oxidative damage and also protects against inflammatory mediators. The last ingredient in this NeoStrata product is Chardonnay grape seed extract. This Crodarom Chardonnay extract is taken from the seeds of the white burgundy, Chardonnay, immediately after harvesting and before fermentation. If you take the antioxidant immediately before fermentation, you’re able to save 80% 27


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of the oligomeric proanthocyanidins (OPCs). If you look at the measure of ORAC with different ingredients, vitamin E has been shown to have an antioxidant ORAC score of just over 1,000. Vitamin C been shown to come in at 5,000, the Crodarom Chardonnay extract measures nearly 8,000 and the ORAC score of verbasocide is 28,000.

Dr Tapan Patel is a cosmetic doctor specialising in non-surgical treatments. He is medical director at the VIVA Clinic in London and is an international trainer for Obagi Medical

Multiple factors contribute to extrinsic ageing, one of which is free radical damage. Free radicals are reactive oxygen species induced by ultraviolet radiation, which induces thymine dimers which attack the DNA and cell walls. We have endogenous antioxidants within the skin but this supply becomes rapidly depleted and often the dietary oxidants that we ingest are either not present in high enough a concentration, or don’t reach the skin to the level that we need for the protection. This is where the topical antioxidants have a place in protecting us from the effects of UV-induced skin damage. There are many different antioxidants and the Obagi range uses L-ascorbic acid. Essentially, there are at least six areas where antioxidants have an effect on the skin: collagen stimulation; reducing inflammation; pigmentation suppression; improving the barrier function; enhancing UV protection; and replenishing other antioxidants Observational studies have found that 12 weeks after daily application of topical L-ascorbic acid there is a decrease in the appearance of wrinkles, decreased roughness, increased collagen content and interestingly, a reversal of the age-related changes seen at the epidermal-dermal junction. The ideal antioxidant must be as potent as possible. It needs to penetrate the skin to the desired level and it has to confer protection and most importantly—it must be stable. Obagi Medical Products produces an antioxidant called ProC Serum, using L-Ascorbic acid as the active ingredient. The available strengths are 5%, 10%, 15% and 20%. Other products may claim good penetration of L-ascorbic acid into the skin, but they are actually referring to the total L-ascorbic acid—what is important is the penetration of bioavailable L-ascorbic acid. Clinical studies have been carried out to investigate the properties of this product and one study showed that compared to a leading competitor, there was significantly better penetration in both the epidermis and the dermis using 20% concentration. There was almost five times better absorption over a 24 hour period. Further testing showed that at 40˚–45˚ temperature which mimics the shelf-life, at three months there was nearly 50% better shelf-life for the Obagi product compared to the leading competitor. Antioxidant preparations play a small part in the overall skin care regime and should not be relied on as mono-therapy. Ideally they would be combined with an appropriate cleanse, exfoliating product, retinoid and sunscreen. 28

Dr Beatrice Molina is a cosmetic doctor and owner of the Medikas Clinic in Somerset. She is a key opinion leader for Image Skincare

As a doctor , my first interest is lines and wrinkles and what we can do about them. We could send patients to the surgeons for a facelift, but that sometimes doesn’t give the results we expect. What I can offer in my practice is a range of botulinum toxins, fillers, lasers and also topical products. It is very important to remember that when we perform procedures we need to advise patients of a good skincare regime. It still happens that people have laser resurfacing treatments and then leave without even a sun-block. It is about correction, prevention and nutrition. The main ingredient in the Vital C range from Image, is triple C complex. Within this triple C complex is BV-OSC, a stable soluble vitamin C Ester (Stay C-50). BV-OSC has two main properties—an anti-ageing effect and a whitening effect. The anti-ageing effect is due to the metabolic activation (by cell activation and acceleration of collagen synthesis) and antioxidation, preventing cell damage, lipid peroxidation and prevention of UV cell damage. The whitening effect is a depigmentation by inhibition of tyrosinase activity and melanogenesis. The MAX range, and Daily Defense from Image also contain this BVOSC component along with Vital C range. The second antioxidant ingredient we use is the vitamin C Ester (Stay-C 50) and we know that its capacities of antioxidation are very high. Vitamin C has been under-used due to stability hurdles of straight ascorbic acid, but has moved to the centre of interest with the availability of ascorbic acid derivatives such as the more stable and easy to handle Stay C50. Photo-damage of skin including premature skin ageing, is largely caused by reactive oxygen species (ROS). Their generation and the quenching of ROS in living skin can be quantified and visualised. UV filters protect against UV-induced ROS generation, but this first line of defence is not complete. In vivo, antioxidants Stay-C 50 and vitamin E acetate were shown to provide an additional quenching effect of ROS of almost 50% to a standard sunscreen formulation of SPF 8. Stay-C 50 not only reduces the level of damaging free radicals but also helps to increase the skin firmness. This in vivo effect was supported by the additional finding that Stay-C 50 promotes the synthesis of collagen I and III in human fibroblasts. Vitamin C and some derivatives have been traditionally used as active ingredients to brighten the complexion because they are known to inhibit the formation of melanin. Studies have shown that Stay-C 50 reduces the melanogenesis in primary human melanocytes by 57%. A three month in vivo study on Asian skin has also shown that regular use of a cream with Stay-C 50 resulted in a reduced colour intensity of facial age spots. The overall skin lightening effect of Stay-C 50 was assessed as 25% by dermatological reading, and The Japanese Ministry of Health has approved Stay-C 50 as a quasi drug (Q/D) for skin whitening products. body language www.bodylanguage.net


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nutrition Dr Simon Poole

The Mediterranean diet, featuring a medley of fresh vegetables, fruits, cereals and fish, is widely promoted for its health benefits, writes Dr Simon Poole. Its components are rich in antioxidants and an increasing body of evidence extolls the virtues of its star ingredient—olive oil

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Essential oil

n 2005, the New York Times cited an article in the New England Journal of Medicine which asserted that, for the first time in two centuries, the current generation of children in America may have shorter life expectancies than their parents. This was attributed largely to the effects of long-term illness and obesity associated with poor diet and lifestyle. The science of nutrition has provided us with an increasingly sophisticated understanding of the dietary patterns which lead to poor health and premature death. A recent review by Parkin attributing 40% of cancers to lifestyle causal factors provides just one example of the significance of the problem in our society. While there are intriguing developments in the study of genetic and physiological factors which predict such outcomes and advances in pharmacological and surgical techniques designed to mitigate the consequences of lifestyle choices, we also have a wealth of evidence providing insight into dietary patterns most associated with longevity, good health and weight management. Traditional diets, such as the Mediterranean diet described by Oldways, which are rich in vegetables, fruits, legumes, wholegrain cereals, nuts and fish have shown an association with significantly reduced levels of chronic disease. Gianluca Tognon, one of the authors of the “H70 Study” published in Age, reported that older people who eat a Mediterranean diet live an estimated two to three years longer than those who do not. An earlier study involving a broader description of healthy lifestyle features in 120,000 participants from Maastricht University showed that female non-smokers who eat a Mediterranean diet, exercise and keep a healthy weight could live up to 15 years longer. Men who follow a similarly healthy regime could add eight years to their lifespan. Using a rather different approach for their study “Centenarians and diet”, Vasto and colleagues observed a strong correlation between Sicilian centenarians and greatest adherence to the traditional Mediterranean diet. There are now thousands of observational, intervention and RCT publications demonstrating significant benefits to health

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when adopting a Mediterranean style diet—the methodology and standardisation of the system to score such diets has become much more uniform. The common features of such dietary patterns include low consumption of saturated fat and salt, with relatively higher levels of monounsaturated fats, low glycaemic index (GI) carbohydrates and fibre. Strong cultural associations with communal dining, an active lifestyle and an emphasis on fresh, seasonal, local produce are also important. The role of antioxidants The characteristics of a low GI, high fibre, low cholesterol and low saturated fat diet relating to likely health benefits are widely known. However, there is increasing interest in the micronutrient composition of many of the composite ingredients of the Mediterranean diet. These components of natural and traditional diets are often rich sources of antioxidants. The role of oxidative stress in relation to the ageing process was described by Soren Denim in Body Language 49—in the same issue, Green and Weinkauf cited evidence of the protective effects of topical antioxidants specifically in relation to skin ageing. The abundance of antioxidants in the traditional Mediterranean diet may be an important contributing factor in the protective characteristics of the lifestyle. The widespread presence of different varieties of naturally-occurring antioxidants in the fruit, vegetables, herbs, spices and wine we commonly associate with the diet may create a beneficial effect to reduce chronic inflammation, cellular damage and other aspects of the ageing process and chronic illnesses. Olive oil is at the heart of the diet and can be a rich source of antioxidants, especially in countries such as Greece where average consumption is 70ml per day. Cretian subjects who participated in the Seven Countries Study enjoyed diets relatively high in fat—up to 40% of intake—and were considered to be the healthiest population, where 80% of the fat was represented by olive oil. 31


nutrition Dr Simon Poole

The ubiquitous presence of olive oil, a “not from concentrate fruit juice”, not only provides a healthy source of monounsaturated fat, but differs distinctly from the animal fats and seed oils more prevalent in Western Europe. The antioxidants include not only Vitamin E, but varieties of polyphenols such as hydroxytyrosol, secoiridoids (oleuropein, the aglycone of ligstroside, and their respective decarboxylated dialdehyde derivatives) and lignans [(+)-1-acetoxypinoresinol and pinoresinol]. Olive oil and health The virtues of olive oil have been described since ancient times in its value as a food and as an essential oil found in skin care preparations and cosmetics. Contemporary writings describe olive oil as part of the beauty regimen of Cleopatra and Homer writes, “Odysseus was bathed, and, when he came from the bath, rubbed with olive oil he looked hale and strong.” Hippocrates not only extolled its virtues for everyday health as a food, but also recommended its inclusion in medicines and ointments. Now, of course, there is a need to demonstrate with greater rigour the health benefits of olive oil. An extensive body of evidence exists which describes such effects, much of which appears to be attributable to the antioxidant composition rather than the healthy monounsaturated fats. It is often impossible to identify the influence of individual components of a diet in relation to measurable advantageous outcomes and olive oil has become almost unique in this regard. Numerous studies cite the antioxidant effects of extra virgin olive oil, with in vitro and in vivo research finding extensive health benefits. As long ago as 2000, the 12th International Symposium on Atherosclerosis stated the evidence that “Olive oil improves blood lipid profiles, protects against atherosclerosis, decreases risk of atherothrombosis, improves blood vessel endothelial function and clears post prandial apolipoproteins”. More recent reviews, such as a study by Covas into the effect of polyphenols in olive oil, have described links with a reduction in risk of cardiovascular disease and also of some cancers. European food labelling Food health label claims have, on occasions, been misleading, confusing and sometimes based on dubious scientific evidence. In recent times, the European Food Safety Authority (EFSA) has been tasked with producing guidance to support member countries in health claims legislation aimed at introducing greater rigour, reliability and credibility in such claims. We will, as a result, see far fewer misleading health claims in the future as the food industry comes to terms with new expectations to justify such marketing. References 1. S. Jay Olshansky. “Potential Decline in Life Expectancy in the United States in the 21st Century”, N Engl J Med 2005; 352:1138-1145 March 17, 2005 2. D M Parkin. “The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010”, Br J Cancer 105: S2-S5; doi:10.1038/bjc.2011.474 3. “The H70 Study”, AGE 2011; 33(3): 439–450. http://oldwayspt.org/resources/ heritage-pyramids/mediterranean-dietpyramid

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The EFSA has looked at over 3,000 submitted claims to date, and while it has upheld many widely-accepted generic claims relating to broad categories of nutritional patterns—such as low salt, low saturated fat and high monounsaturated fat—only a handful of individual food products or ingredient claims have been accepted by the examining committee. One such food is olive oil. The studies submitted for scrutiny included work on the role of olive oil polyphenolic antioxidants in reduction of LDL oxidation, with a beneficial effect on cardiovascular health. The panel concluded that “a cause and effect relationship has been established between the consumption of olive oil polyphenols (standardised by the content of hydroxytyrosol and its derivatives) and protection of LDL particles from oxidative damage”. In effect, an extra virgin olive oil may carry a health claim, for example, to assert a role for 20ml consumed per day in maintaining a healthy heart. But this claim must be certified with a high level of polyphenolic antioxidants to reflect the evidence that there was measurable benefit conferred only by high antioxidant olive oil. An observation consistent with the local ethos and traditional characteristics of the Mediterranean diet is that the wholesale industry, which relies on oil derived from many sources, is unlikely to be able to guarantee the characteristics of oils and therefore may not be able to seek to promote their antioxidant qualities. While the antioxidant concentration of olive oil varies with harvesting methods, storage and variety, a significant influencing factor is the amount of irrigation. Therefore large producers seeking to maximise yield are often mass producing oils with much reduced levels of natural antioxidants. Polyphenols, which are so beneficial to our health, are likely to be present in greater quantities and with the least variation where the olive trees are require a protective response to the challenging dry and hot environment in which they have adapted over millennia to thrive. Homer and Hippocrates would have recognised the value of such olive trees, so much part of the health and wealth of early empires, clinging to the side of the dry and sun baked hills of the Mediterranean coastline. In the scientific world of the 21st Century we are able to add to that understanding, and we discover that traditional ways of eating and of agriculture are not only best for our modern environment, but are also demonstrably better for health. Dr Simon Poole is a GP, author and recognised authority on the Mediterranean diet. He is the first to have successfully applied a European Health Claim in relation to a commercially available extra virgin olive oil.

4. Piet A van den Brandt. “The impact of a Mediterranean diet and healthy lifestyle on premature mortality in men and women” Am J Clin Nutr September 2011 ajcn.008250 5. Vasto S, Rizzo C, Caruso C. “Centenarians and Diet”, Immun Ageing. 2012 Apr 23;9(1):10. 6. Denim S. “Oxidative Stress”, Body Language Journal, Jan 2012 Issue 49 7. Green, Weinkauf. “Combined Power”; Body Language Journal, Jan 2012 Issue 49 8. Keys, A. “Seven Countries: A Multivariate Analysis of Death and Coronary Heart

Disease”, Harvard University Press 1980. ISBN 0-674-80237-3. 9. Homer. “The Adventures of Odysseus and the Tale of Troy part 2”. 10. Covas MI. “The effect of polyphenols in olive oil on heart disease risk factors: a randomized trial”, Ann Internal Medicine 2006 Sep 5;145(5):333-41. 11. “Scientific Opinion on the substantiation of Health Claims related to the polyphenols in olive oil”, EFSA Journal 2011;9(4):2033 [25 pp.]. doi:10.2903/j. efsa.2011.2033

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injectables Dr Hema Sundarem

Aesthetic synergy When treating the face, every practitioner’s aim is to restore ideal facial proportions. Dr Hema Sundarem summarises combinations of toxins and fillers and how rheology can help us understand the science behind their efficacy

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ome years ago I wrote an article for Prevention entitled “Small Fixes, Big Payoffs”— the premise being that we are increasingly looking for better results but with as little recovery time as possible. And what holds true then holds true even more now. With so many advances in the field of volumetry, toxins and lasers and light, at this point we stand at a very different stage in our evolution as far as aesthetics are concerned. We are familiar with the concept of 34

the “Four R’s of non-surgical rejuvenation”. We can re-contour with fillers or lipolysis, we can relax or re-balance with toxins and resurface or re-drape with lasers and light. We can think in terms of building a house: we have to build from the foundation up and we have to remember to put the roof on. Ageing is multiplanar, so rejuvenation should be as well. When we are assessing patients we need to think about the ideal, which is to have a more prominent upper- and midface, tapering to a less prominent lower face. So the question is, what treatment

modality or combination can we use to restore more ideal facial proportions? Toxins When skin elasticity is good, we may be able to perform facial reshaping with toxin treatment alone. The strategy here is to target and correct resting muscle panfacially, rather than focusing on relaxing in animation. Toxins available to us in Europe, in alphabetical order, are: abobotulinumtoxin A (Dysport or Azzalure), incobotulinumtoxin A (Bocouture or Xeomin) and onabody language www.bodylanguage.net


injectables Dr Hema Sundarem

ly into the pretarsal orbicularlis oculi. We should never do this if there’s skin laxity or a bulging pretarsal orbicularlis oculi, or we can get sclera show and both aesthetic and functional impairment. But in the right patient, it lowers the ciliary margin by a fraction of a millimetre and produces an aesthetically pleasing effect. A nice add-on is to treat bunny lines in addition to what we do for the glabella. The supero-lateral orbicularis oculi— the lateral brow depressor—can be weakened with a small dose of toxin in order to get some brow elevation. We can’t use the brows as a landmark because they vary so much, especially in women. We have to go by muscular activity. In the face and lower neck I try not to overtreat and I’m mindful of the fact that I can always add to an area subsequently to the first treatment session. My epiphany for toxins has been to realise that patients don’t view themselves frowning, raising their eyebrows, smiling or pulling down the corners of their mouths. They view themselves in repose. If we can rebalance resting muscle tone and create a more rested and youthful appearance, they are going to be very happy with the results. For example, the “Nefertiti neck lift” can be performed by targeting the uppermost fibres of platysma. The eyebrows can be repositioned, the eyes opened up, the angle of the mouth turned up and, overall, the patient will look more rested and perhaps a bit younger. botulinumtoxin A (Botox or Vistabel). We should consider that the ideal brow differs from men to women. For women, it’s higher arched and has been compared to a seagull’s wing. For men it’s lower set and flatter. This is so subliminally imprinted in our consciousness that when the eyebrows sit a little too low for a woman or a little too high for a man, it doesn’t look quite right and unbalances the face. Brow shaping is one of my favourite treatments to perform, both solo or in combination with other modalities of therapy. It’s all about the complex interplay between the frontalis, which is the brow elevator, and the lateral and medial brow depressors. If we weaken the lateral and medial brow depressors, the frontalis will be relatively unopposed and able to elevate the brows more effectively. In appropriately-selected patients, eyeopening is performed by injecting a small dose of toxin at the mid-pupillary line at the lower ciliary margin, very superficialbody language www.bodylanguage.net

Fillers When it comes to fillers, we have many choices. We can divide them into calcium hydroxylapatite (CaHA); high concentration cross-linked hyaluronic acid (HA), which will be partially hydrated and potentially pull in more water after implantation; the lower concentration HA which is fully hydrated prior to implantation; and poly (l-lactide) acid (PLLA) and poly (methyl methacrylate) acid (PMMA). With these choices we’ve moved from wrinkle-chasing to three dimension volumetry. One of my passions and research interests is rheology—the study of the science of fillers. We measure G prime or elastic modulus and viscosity of the fillers. Simply speaking, a filler with a high G prime is firmer and will have more resistance to applied force, but it will also be more palpable in tissue. A low G prime filler is softer and has less tissue lifting effect. G prime measurements for various fillers is not a ranking system. All these

products are excellent. Rather, the measurements help us understand that CaHA and the non-animal stabilised hyaluronic acid (NASHA) fillers are going to be firmer and have more lifting effect, and that cohesive polydensified matrix HA and Hylacross HA are softer and less lifting. Turning to viscosity, high viscosity products spread less. They are CaHA and NASHA fillers. The Hylacross family and cohesivepolydensified matrix (CPM) HAs are lower viscosity and more spreading. Viscosity parallels elasticity. So is there any evidence that this is of clinical utility? Actually, there is. We can implant these fillers dermally and then take biopsies and examine them microscopically. Restylane, the high viscosity product, stays as a bolus so we can infer from that it’s going to be good for vectoring. Belotero Basic, the lower viscosity product spreads most homogeneously through the dermis and so it’s going to have great tissue integration properties. This is a visual depiction and manifestation of viscosity that we measure in the lab and it correlates with the structural alterations we see in the dermis. Tan delta There is one final rheologic parameter we can calculate, which is tan delta. Products with high tan delta like Belotero Basic and Intense are more fluid and suitable for flowing superficially through the dermis or the superficial subdermal plane. A product with lower tan delta such as Radiesse or Restylane will be more elastic and suitable for deeper implantation. Rheology is helpful because it predicts how calcium hydroxylapatite will behave during and after injection. And we have the concept of rheologic tailoring—selecting the right product for the right application. In particular we can provide volume efficient lifting for patients, that will give them cost effective results and stay within their budgets. We can refine our strategies with current products and can potentially shorten the learning curve with new products if we know their rheologic specifications. We talk metaphorically about the palette of fillers, selecting the right combination of fillers for each patient, just as a painter selects the right combination of paints to make a beautiful picture. Each patient’s needs may be different because of age, ageing patterns and skin type. We’ve moved to a concept of multiplane ‘sandwich’ volumetry which is very exciting. We can place high G Prime and 35


injectables Dr Hema Sundarem

little bit of sheeting round there. For the lower eyelid, I’ll often do a combination with a blunt cannula. My insertion hole is made in order to avoid the infraorbital neurovascular bundle which will lie typically about 7mm or so in the mid pupillary line below the orbital rim. Another entry point could be laterally. I lay down the filler below the muscle supraperiosteally and then go back and do some sharp injection intradermally to layer in a multiplane fashion to tighten up the skin. We are advancing very rapidly in our understanding of the forehead. Very often I’m balancing my filler and toxin. For fillers I use a superficial blanch technique when it’s appropriate.

The Tyndall Effect occurs when a filler with prominent particulate component is implanted superficially and scatters back the light of the shortest wavelength, which is blue light, resulting in a bluish discolouration of the skin.

viscosity products deeply, subcutaneously or supraperiosteally for deep lifting volumetry. We also have lower G Prime and viscosity products that don’t cause the Tyndall Effect, which we can place superficially for superficial ‘flow’ volumetry. So why do we conceive both NASHA products and Hylacross products as being subdermal? If we examine them microscopically, we see Restylane, Perlane and Juvaderm products all have particles. For that reason they are better placed below the dermis so as not to cause contour irregularities and the Tyndall Effect. This occurs when a filler with prominent particulate component is implanted superficially. It preferentially scatters back the light of the shortest wavelength, which is blue light, resulting in a bluish discolouration of the skin. It’s the same reason that the sky, which in reality is colourless, actually appears blue to our eyes. Cohesive polydensified matrix (CMP) HA (Belotera Basic and Soft) doesn’t cause the Tyndall Effect. Superficial volumetry is new to the United States because CPM HA has just been approved. The areas where it can be useful include the lower and upper eyelid, where I like to perform multi-plane layering, fine rhytids and nasolabial folds in order to avoid that unattractive simian look when we’ve puffed out the area with too much subdermal filler. Layering is a much better way to go. We can get precise vermillion border definition that will synergise with submucosal lip filling. So we can now start listening to our patients and determine what strategy is going to be the best. I only need to lay 36

down about 0.1mm at each injection point to achieve effective mid-face revoluminisation. This is subcutaneous and supraperiosteal—there is a lack of tissue when we inject appropriately. Another good use of CaHA is the pre jowl. Here I use retrograde technique, inserting the needle, pulling it back and laying down the filler in the tunnel formed by the needle supraperiosteally. It gives a nice definition to the jaw line. And then we can come back and inject NASHA (Restylane) subcutaneously to the nasolabial folds, and what we end up with is layered subdermal volumetry. We can add toxin treatment for further improvement. We want patients to look naturally rejuvenated, not ‘done’. The key is to use high G Prime, high viscosity products for maximal lift. For patients who have fine rhytids and also need lift, we can perform classical sandwich volumetry with intradermal injection of CMP HA (Belotero Basic) and subdermal injection of hydroxylapatite (Radiesse) via a combination of blunt and sharp volumetry. This is not new to Europeans but is to Americans. The needle and the hub of the syringe graze the surface of the skin. As we inject we see a blanching because this is being injected intradermally. You can see tenting, you can almost see the silver grey of the needle through the skin. This is counterintuitive—not how we would inject Restylane or Juvaderm but it’s how we need to injectBelotero Soft and Belotero Basic. We will see this little blanch for a few minutes afterwards. Periorally it’s a similar thing; we can do a

ePrime What do you do with a patient who needs fillers but doesn’t want fillers? A good option is to treat with bipolar radio frequency with microneedling (ePrime) inserting a parallel array of ten 32G needles into the reticular dermis and directly delivering the bipolar radio frequency. This stimulates the production of new collagen, elastic tissue and hyaluronic acid. As with other technologies, the longer-term the studies, the better the understanding will be of what we can do for our patients. This is not a completely non-invasive treatment. It requires nerve blocks and a little local anaesthetic. The needles heat the reticular dermis to 70 degrees Celcius in four seconds. It’s a novel technology because its delivering the radio frequency not through the skin surface but directly into the reticular dermis. For aesthetic synergy, bipolar radio frequency can be combined with toxin —for example, to the masseters and the platysma for the “Nefertiti neck lift”. As an overview, radio frequency is regenerative. We cause less ablation, more structural restoration and synergising with injectables. Fractional bipolar radio frequency produces sublative rejuvenation, targeting the dermis with relative sparing of the epidermis because the dermis has higher conductance. This achieves very nice results for patients. A scientific understanding of the various treatments I’ve discussed allows us to combine them to address individual patient needs and to achieve a more restorative type of rejuvenation. Dr Hema Sundaram is a dermatologist specialising in cosmetic surgery and is the director of Sundaram Dermatology, Cosmetic and Laser Surgery Center body language www.bodylanguage.net


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A BTEC award expresses professionalism. It sets you apart from the unskilled as one of the few Healthcare or Beauty Professionals to formalise their expertise through Qualification. Most laser and ILS training is through distributor’s instruction, often to a very high standard. Qualification is different, measuring knowledge and understanding and at Mapperley Park, through small-group, round-the-laser workshops. This is a degree-level qualification, independent of any particular laser or light interest, run by Jo Martin and Paul Stapleton. Jo has run the Clinic – and a daily clinic list - since setting it up in 1993. We have delivered more than 200,000 treatments in 20 years of practice - and more than 7,000 training places over the last 10, with clinical delivery now central to the training process. This Autumn, Mapperley Park begins a new programme of structured Laser Training designed to build on your current knowledge and experience – however great or small. Qualification evidences your expertise against defined criteria, using the widest range of essential equipment in laser dermatology. We have London and Nottingham venues but the advantage is on our home ground, where we have £1million of equipment already emplaced across 6 treatment rooms and a minor ops facility. The London premium covers the extra cost of delivery away from home.

The BTEC awards... Level 4 qualifications in lasers and light for medical professionals and others. This is 5-day, equipment based delivery, based on small-group workshops against the entire range of cosmetic laser/light/ devices in a programme using our own 12 platform suite - plus equipment from top manufacturers. Tutorial and lecture content is delivered in short units by recognised industry experts, providing all the experience that you need across the widest range of laser and light expertise.

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New to the BTEC team... ...we are delighted to welcome Dr Tapan Patel. Dr Tapan Patel will be concentrating on the use of ablative and non-ablative lasers and other energy sources in the targeting of water based structure in epidermis and dermis. He has extensive experience on the treatment of acne, acne scarring and pigmentary disorders. He has spoken at educational conferences both in the UK and abroad. In addition to performing treatments, Dr Patel has a keen academic interest in medical education. Dr Patel will work alongside Jo Martin in the delivery of a full day of lectures, discussions and hands-on training sessions against CO2/Erbium/Near infra-red/RF devices in whole, fractional and needle modes.

For those of you who have already sat the course... …we will be running a series of conversion workshops so, if you are not one of the 300 but have already sat the course, come and join us for a workshop day and complete the qualification.

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Call 0115 969 0111 or Email: training@mapperleypark.co.uk mapperleypark.co.uk/training Mapperley Park Clinic is registered and therefore licenced by the Care Quality Commission to provide a range of medical services as Provider ID; 0000026452.


aesthetic medicine Catherine Quinn

Aftercare Ground-breaking cosmetic procedures are at the forefront of a successful clinic, but Catherine Quinn discovers why good aftercare brings incredible results

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s every cosmetic surgeon knows, quality practice and procedures are key to excellence. But the latest wisdom has seen the focus expand to beyond the treatment itself. Clinics who focus on best aftercare are seeing a significant rise in customer satisfaction. “I would estimate aftercare to be 50% of the battle,” says Dr Anthony Maquillan, an aesthetic surgeon at the Spire Bristol Hospital. “Even with a technically perfect procedure the patient outcome is likely to be diminished with adequate post-operative and on-going aftercare. It is crucial to the success of any cosmetic procedure.” Surgical outcomes are not the only result to be maximised by aftercare. The all-important-issue of customer satisfaction— that Holy Grail which goes far beyond clinical data—can often be made or broken on service provided after a procedure has taken place. “The satisfaction rate following cosmetic procedures is far higher with correct aftercare,” confirms Dr Ayoubi, an international plastic and laser surgeon, and medical director of the London Medical & Aesthetic Clinic. “In my Harley Street practice I have seen a lot of patients who’ve been overseas, or to cheaper clinics in London. This results in a higher complaint rate because they don’t have the adequate aftercare needed.”

body language www.bodylanguage.net

So with aftercare so crucial, what can you do post-surgery or procedure to set your service apart? Aftercare products Of growing interest to the cosmetic industry is the use of products and supplements to aid aftercare. The growth of beauty supplements—nutrients which aid skin formation—are beginning to merge with aiding healing of cosmetic procedures and the results are exciting. Clinics who administer botulinum toxins will be interested to discover that new out this year is a supplement which has been specially developed to extend the life of the injections. Zytaze has been engineered using expert knowledge of how toxins break down within the skin, and acts to slow this process by a third. “For botulinum toxins to be effective, each of its molecules must bind with a molecule of zinc within the human tissues after being injected,” explains US cosmetic surgeon Dr Soparkar. He innovated Zytaze and now distributes the product in the UK with Eden Aesthetics. “If a person has inadequate zinc in their tissues, then the toxin will have a significantly diminished effect,” continues Dr Soparkar. “The biggest culprits responsible for zinc failing to be absorbed are phytates, found in whole grain breads, whole-wheat 39


aesthetic medicine Catherine Quinn

products, many cereals, soy, oats, legumes, beans, corn, nuts and rice. Zytaze is formulated with a more absorbable form of zinc along with phytase—an enzyme that neutralises phytates.” In-clinic results have been impressive. The supplement has been shown to increase the lifespan of botulinium toxin treatments by up to a third in patients, and several UK clinics now advise Zytaze is taken after injections. “I have used Zytaze with some of my regular clients and have found that they have had an enhanced experience for the duration of the treatment,” confirms Dr Hillary Allen who runs the Woodford Medical Aesthetics chain of clinics. “My clients also found the toxin took impact within a couple of days rather than the usual two weeks,” she adds. Naturally many cosmetic specialists are extremely excited by the possibility of supplements which can extend results of treatments. And others have been launched which help scar tissue recovery and wound healing. Biocorrex, for example, has been launched in the UK as an all-round cosmeceutical. The product consists of a boxed pack of five supplements, each with different benefits to skin health. What the manufacturers have discovered, however, is an unexpected additional sales potential amongst those recovering from cosmetic operations. “Biocorrex offers a new approach to the healing process following invasive procedures,” confirms Kate Davenport, Business Development Manager at Biocorrex. “The inter-repair capsule provides a potent, and correctly dosed, range of skin healing ingredients. Resveratrol, Circumin, zinc and Calendula promote wound-healing and help to actively diminish the appearance of post-procedure scars.” With a range of interesting products to help wound-healing now emerging, aesthetic specialists could find themselves in a win-win situation. Not only will patients recover faster and better, but clinics can also make an attractive mark-up on products. Biocorrex, for example, offers a 50% mark-up for clinic, and retailing at a £69 for month’s supply, this represents a reasonable extra revenue stream for no extra time and minimal investment from the clinic. Communication But good aftercare doesn’t have to rely on pills. In fact the markers of good aftercare can often be surprisingly simple. And effective communication—particularly with the surgeon performing the operation—is crucial to patient satisfaction. “The personal mobile and details of the clinic must be available to the patient,” advises Dr Ayoubi. “So, should anything

Deep Oscillation and supplements like BioCorrex can help speed up recovery post-treatment 40

A US study showed that a one minute call to a patient postsurgery, increased patient satisfaction by 85%

happen, he or she has a direct link with the surgeon involved, and with the hospital or clinic. Even the most minor concerns for a patient can develop into something more alarming if they are not reassured by their surgeon.” Dr Ayoubi also ensures that his patients have an alternative contact available in case his clinic is not open. “I make sure they have the number of an out of hours emergency care with another surgeon at another hospital,” he says, “and I make sure that hospital is familiar with the procedure.” Aside from allowing patients to easily get in touch with any questions, Dr Ayoubi also makes a reassuring telephone call to his patients soon after the surgery has taken place. “There was a US study on plastic surgery patients called the ‘One-minute post-surgical procedure phone call’”, he explains. “If made by the surgeon post-treatment, it increases patient satisfaction by 85%, and reassures the patient no end.” For most clinics, an 85% increase in satisfaction for a minute of the surgeon’s time is a no-brainer. Encouraging compliance Unfortunately, good aftercare is not just about getting the best result for the patient. Every procedure comes with a degree of risk. And no clinic wants to run the risk of a patient contracting an infection. So how can you manage patient compliance to guard against complications? According to plastic surgeon Dr Jonquille Chantry, spotting tricky patients is half the battle. “I’ve found ways to identify patients who may have more trouble complying with aftercare than others,” she explains. “Patients that fail to return for follow-up, jump from practitioner to practitioner or do not give an honest history of previous treatments can be difficult to manage. I’ve also found that patients who do not listen to the importance of aftercare and refuse to take some degree of accountability for it are particularly difficult to manage.” In the case of challenging patients, clinics should take a two-pronged approach—proper written aftercare, and carefully managing recovery expectations before any treatment takes place. The patient should know all possible side effects, complications from the procedure, both verbally and in writing. body language www.bodylanguage.net


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aesthetic medicine Catherine Quinn

Good Aftercare Practice

Five Top Tips

 Always follow up verbal advice in writing Written aftercare advice is essential. Patients often don’t take everything in when instructed verbally and will refer back to aftercare instructions. Advice should be clear and within specific timeframes—for example, avoid alcohol for four weeks. Where possible the reasons for any restrictions should be explained clearly to aid compliance.

 Make aftercare as personalised as possible If the patient feels that aftercare advice is formulated just for them they are more likely to comply. This means avoiding a generic aftercare instruction sheet which applies to many procedures.

 Ensure the patient has a mobile or direct number for their surgeon Patients often have questions which they forgot to ask pre- or post-surgery. If they’re unable to directly contact an expert they may not be able to get the right advice soon enough to put it into practice. Patients also often have minor concerns following surgery—unexplained lumps or bruising, for example—which can lead to panic if not addressed.

 Talk to the patient about their family support networks The clinic shouldn’t be acting in isolation to provide proper aftercare. Ideally the patient should have their own support networks of family and friends. Talk to the patient about who might be available to help care for them if their surgery comes with a long recovery time. It might be appropriate to suggest a private nurse visit their home.

 Encourage good nutrition and hydration The patient’s general health will impact enormously on how well they heal following any procedure. A good diet, supplements if necessary, and plenty of fluids will all ensure good woundhealing. Nutrition has long been downplayed in conventional medicine, but in the field of aesthetics it can make a significant difference to outcome.

“Setting out the likely recovery time is essential,” confirms Dr Ayoubi. “Face-lifting, for example, is a major plastic surgery procedure, but not everyone understands what this will involve post-surgery. It is essential that expectations are managed and patients know when they’ll be able to go back to work or be generally active. Otherwise there could be unexpected issues that could alarm the patient post-surgery.” Non-surgical procedures So what about non-surgical procedures? Interestingly these can often be more challenging in terms of aftercare, since patients expectations are different. According to Dr Raina Adami of The Aesthetic Virtue Clinic, patients often underestimate the aftercare needed for treatments such as fillers or chemical peels, making it doubly important the right protocol is emphasised. “With procedures such as dermal fillers, complications can easily result if good aftercare is not adhered to,” explains Dr Adami. “This tends to be primary factor causing a negative effect on the long and short term results of treatments with fillers, so everything should be done to avoid these.” “Fillers often cause lumps and bumps in the first two weeks after treatment,” she adds. “These are usually small bruises that don’t necessarily show up in colour. Patients are often tempted to massage them, but doing so will only make them bigger—the same goes for biting or sucking on them.” Clinicians should also make doubly clear the effects of an anaesthetic on the lips after treatment. Numb areas can be all too easy to burn or infect since the patient can’t feel the usually sensitive mouth area. Extra special aftercare So if you’ve taken care of advising patients and covered yourself in the case of misbehaviour, what’s next? In the ever-expanding field of treatment clinicians could certainly look to emerging products which lower the need for extensive aftercare. At the moment, fillers and laser surgeries are likely to fulfil this need ever-more successfully. “The new generation injectable products has led to improved product integration into tissues, with less swelling, redness and overall downtime for the patient,” says Dr Jonquille Chantry, “although the need for good aftercare advice such as sterility and hygiene post treatment is still likely to feature for some time to come.” With increased understanding of the immune and lymphatic response to injury, however, the aesthetic field is also seeing some break-through products on the horizon. Deep Oscillation is a new form of deep post-aesthetic surgery massage treatment which has seen some good results in clinical trials and may speed recovery from swelling and bruising. Involving a deep oscillation machine, the technology is currently available from Physiopod in the UK and has been used to great effect in the aesthetic sector. Other breakthroughs involve the development of Cellentine—a patented ingredient which supports the formation of scar tissue directly after surgery and has been clinically proven to reduce post-surgery scars. The treatment is available this year as SkinMedica Scar Recovery gel, and is already gaining acclaim amongst surgeons and patients. Whilst break-through treatments and products are ever on the horizon, however, the old-fashioned approach is often worth just as much as the right lotions and potions. So for clinics looking to provide optimal aftercare, that all-important patient-surgeon relationship is still the most important thing to get right. Catherine Quinn is a nutritioist and freelance journalist

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Online presence Having an appealing website with informative content is the most effective way to influence and gain customers, writes Charles Southey

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our website is your most valuable asset when it comes to marketing a business. If your website isn’t your biggest source of new business, you’re either doing something wrong or not doing it at all. The internet is the first place people turn to when considering new options, whether it’s purchasing, researching or creating something. A scroll through a website has become an extension of the thinking process, particularly now that we have the appendage of the smart phone offering constantly accessible internet. If your website offers the solution to a problem the internet user was considering, there is likely to be a satisfying outcome for both parties. With technology at the forefront of everyday and business life, it is essential to have a website. It is often the first point of contact a customer or client will have with your business.

Start blogging What better way to guarantee ‘expert’ status in your marketplace than to provide those seeking expertise with useful and relevant articles? Blogging is an opportunity to hand out features packed to the rafters with your expert knowledge. You’ll gain the trust of potential customers who have acquired valuable information from your blog and this will put you on the road to increased conversion and increased sales. Being seen as an expert in your field builds trust with your audience and gains customers. Your website can and should help you to be seen as an expert. On an ever-more crowded internet, there is constant need to make you and your business stand out amid the multitude of search engine results. An effective way of doing this is to blog, allowing people to take notice your industry expertise. Blogs are another simple and effective way of offering content to potential customers or clients that might not otherwise have found it, and crucially from them you can redirect to your main point of business—your principal website. If an internet user searches for a specific phrase and you have included that in your blog, it is very likely that they will 44

be directed to that page. Further to this, as the blog is constantly updated and offers continually expanding content, the search engines are increasingly likely to send clients to you, your reach becoming broader with every post. Finally, a blog offers a means of informing clients and customers of news or updates as they happen, with no delay. They are kept abreast of all changes and improvements, new products and new information. Blogs offer a constant and residual awareness of a company’s activities and products, and are a great influence in the online battle for business. In a recent Financial Times article, “Web nerds are now part of the family”, founder and executive editor of hodinkee. com Benjamin Clymer noted, “The digital space is a much stronger influencer of buying habits than print,” emphasising why, if one is to benefit in an internetdriven consumer market, one must blog. Content When scoring the effectiveness of a website, content is crucial. Great content can compel potential customers to buy, and also builds the foundations for a strong search engine optimisation strategy. Make sure the words on your website sell the benefits of your products, not just the features. People want to know more about how your product will help them and less about how big, small or techno-

logically advanced it is. Including certain words in your content can make the difference between being top of the search engine results or bottom—this is search engine optimisation. But further to increasing the likelihood of being clicked on by a potential client or customer, the website must maintain interest once accessed. To maintain interest there must be relevant and, crucially, informative content to engage and educate the visitor. Good content will encourage a visitor to remain on your website, and the longer they remain, the more likely they are to develop an interest in your products and services. The effectiveness of the content on your page determines whether browsing is transformed to buying, and if it is the sort of company a client wants to transact with. People feel at ease with more information, and are likely to trust you to provide the services they require. Good website content is perhaps the most important way of making your business stand out, and is the most effective way of influencing customers. They want to know what you do, how you do it, and why they should choose you. Your informative and accessible website content is the means of showing them. Charles Southey is Operations Director at Digital Results, T: 01920 444797, E: charles@digital-results.com body language www.bodylanguage.net


promotion La Roche-Posay

Multi-purpose skincare La Roche-Posay introduces Cicaplast Baume B5—a balm to help soothe, protect and repair even the most sensitive skin. Suitable for all ages

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a Roche-Posay, the sensitive skin specialist, brings you their latest dermatological innovation—Cicaplast Baume B5—a soothing and repairing balm that has taken Europe by storm. Recommended by dermatologists worldwide, La Roche-Posay is well recognised as the brand that takes your patient’s skin seriously thanks to its condition-led range of clinically proven skincare. Cicaplast Baume B5 is a multi-repairing, multi-tasking product which has been tolerance tested under dermatological and paediatric supervision making it suitable for all ages and all kinds of skins—even the most sensitive. Skin repair The skin is our first level of protection against every-day aggressors and we rely on it to protect us. In a clinical environment the demand on the skin to perform becomes even more extreme; whether a patient is suffering from dryness, hypersensitivity, contact dermatitis, or whether the skin function has been com-

promised following aesthetic procedures. Cicaplast Baume B5 is paraben free, non-perfumed and lanolin free and its versatility makes it the essential soothing, repairing balm for a wide range of skin irritations including minor epidermal wounds such as grazes and burns. Powerful ingredients Cicaplast Baume B5 continues to support the La RochePosay pledge of providing a better life for sensitive skin by combining minimal yet efficacious ingredients to bring your patients a product that is soothing, repairing, antibacterial and nourishing. All La Roche-Posay product formulations begin with the soothing and softening thermal spring water from the town of La Roche-Posay, renowned for its dermatological efficacy. The next key ingredient of Cicaplast Baume B5 is Panthenol—a biologically stable form of pro-vitamin B5 and Cicaplast Baume B5 consolidates one of the highest doses of Panthenol achieved in a dermo-cosmetic product. This active ingredient is

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used for its effectiveness in helping to: • Reduce signs of skin irritation (dryness, roughness, flaking, itching, redness and cracks following use). • Alleviate itching and feelings of discomfort—antiinflammatory. In topical application, Panthenol plays the role of a moisturiser—improving hydration in superficial layers of the skin, reducing water loss and helping maintain skin elasticity. It also helps soothe irritated and compromised skins. Once the compromised skin has been soothed it is important to begin the repairing process and madecassoside, another key ingredient in Cicaplast Baume B5 plays that role. Derived from a plant renowned for its skinrecovery properties, madecassoside helps accelerate epidermal repair for faster healing, bringing comfort to the skin and helping to improve the aesthetics of the healing process. When combined with the copper, zinc and magnesium elements in this product, madecassoside also has an antibacterial action to help prevent bacteria proliferation and any further deterioration of already weakened skin. The final action of Cicaplast Baume B5 is to nourish the skin so that it is more supple and disposed to the healing process. Shea butter and glycerine, contained within Cicaplast Baume B5, act to replenish and moisturise in order to help restore the skin barrier function. Cicaplast Baume B5 brings you all of these ingredients formulated in an ultra-nourishing texture with a nongreasy finish, combining efficacy with pleasure of use.

The Cicaplast range  Cicaplast Baume B5 – Multi-Purpose Repairing Balm for sensitive, irritated skin Indications: Irritations (chapping, dry patches). Everyday minor injuries Texture: Rich, soothing and repairing balm, non-greasy finish Size: 100ml  Cicaplast – The post dermatological procedure repair expert Indications: Post-laser, postpeeling, post dermatological procedures Texture: Invisible isolating texture, dressing effect Size: 30ml

Cicaplast Baume B5’s smooth texture means it can be easily applied to both small and larger areas—making it ideal for use on all kinds minor epidermal lesions. Clinical efficacy In an observational study covering 2440 patients, carried out by 313 dermatologists and 99 paediatricians, 96% of users rated product satisfaction as excellent or good with 98% rating the tolerance as excellent or good. All the subjective symptoms evaluated—burning, tingling, pain and itching—were significantly reduced between the two visits—spaced by an average of 22 days. Whatever the epidermal lesion at the inclusion, the percentage of patients with clinical objective signs of erythema, dryness and/or cracks was also significantly reduced between the two visits. For more information on La Roche Posay products call 020 7491 0150 or visit larocheposay.co.uk 45


Wigmore Medical 020 7514 5104 invasix@wigmoremedical.com


non-surgical Mr Yannis Alexandrides

Mr Yannis Alexandrides elaborates on how high intensity focused ultrasound can be used for measurable non-invasive fat reduction

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Body shaping

rom the point of view of a plastic surgeon, there are a great many tools which can be used to address fat reduction and body contouring. Most of them are surgical procedures with very effective— sometimes dramatic—outcomes, and predictable results. However these procedures are also considered invasive, and they demand a relatively long downtime

body language www.bodylanguage.net

before the patient can go back to normal activities. There are also some fairly new approaches for less invasive—or less demanding procedures—such as laser assisted liposuction, ultrasound-assisted liposuction or even injectables that can be used to dissolve localised fat which is then extracted or left in place to be metabolised. Although less invasive than

traditional liposuction or tummy tucks, these procedures still demand downtime and patient care after the procedure, and also involve dedicated facilities, staff and time. In most practices, there is a tendency to see patients who want non-invasive procedures with minimal downtime and good results in targeted fat reduction, body contouring and circumferential reduction. Under scrutiny, appropriate technology for non-invasive lipolysis should offer: •  Substantial clinical studies with histological, biochemistry and clinical documented efficacy •  A standardised protocol •  Non-invasive treatments with no downtime •  Efficacy after a single session •  Skin tightening in addition to fat reduction One such device which I use, is the Liposonix, an energy delivery device which uses high intensity focused ultrasound (HIFU) to disrupt subcutaneous 47


non-surgical Mr Yannis Alexandrides

Swine tissue histology after HFIU treatment

adipose tissue and provide a non-invasive approach to body contouring and fat reduction. The HIFU energy is concentrated in a focal point 1.3cm under the skin, creating an area of intense heat that will permanently destroy the fat cells. An ultrasound transducer can scan the area under treatment, creating a volumetric disruption of fat tissue of about 4.6cm x 4.6cm x 1cm. Multiple passes and selective distribution of treatment sites allows for custom contouring of localised fat deposits. Once the fat cells are destroyed, the body, by inflammatory response, is in charge of removing lipids and cell debris via the lymphatic system, so the treated area is removed within 8-12 weeks. The intense heat applied in these deep layers of subcutaneous fat also creates denaturation and subsequent contraction of the collagen fibres in the fibrous septae, creating more compacting by skin tightening in the treated area. HIFU has been evaluated clinically with more than 200 subjects with no adverse effect related to the treatment reported. Part of this study was an extensive series of blood testing, including lipid panels at day one and seven and at 1, 4, 8, 12 and 24 weeks following the treatment to identify if a substantial increase on blood lipids is caused. The result was that no relevant changes were detected in any case. The ideal patient for HIFU would be someone with localised fat pockets or stubborn fat deposits that cannot be reduced or eliminated with diet and exercise. A good candidate should have enough subcutaneous fat tissue to ensure that the focal point of the HIFU hits 48

fat. This minimal amount of fatâ&#x20AC;&#x201D;about 2cmâ&#x20AC;&#x201D;can be measured by diagnostic ultrasound or by a simple pinch of the area to be treated. Patients with non-realistic expectations, obese patients or any patient that will see better benefits with a surgical or any other invasive procedure are not ideal candidates for HIFU because they will not be content with the results. Instead, HIFU is indicated for patients in relatively good shape who follow a healthy eating and exercise plan, yet need help to lose stubborn fat in the abdomen, flanks, love handles, buttocks, thighs or legs. One of the most interesting characteristics of HIFU is the flexibility of areas which can be treated. The areas are not limited to the size of a cup or treatment transducer, and can be selected to be as small or as large as desired. The default area of the transducer can be used full or can be used partially, selecting edges and corners that allows for treatment patterns which are more appropriate for the typically rounded shapes of localised fat pockets. In the case of the treatment for the abdomen, there is an specific pattern that allows for treatment over the umbilicus.

This pattern does not deliver energy in the centre as the umbilicus is scar tissue and will not benefit from a HIFU treatment but can be uncomfortable. The main difference between HIFU and other devices that utilise ultrasound as a means to destroy fat cells, is that HIFU generates heat, which is responsible for the fat cell membrane disruption. Other technologies rely on a mechanical disruption of the cells or on a cavitation process (formation of gas bubbles by effect of ultrasound). An example of this would be Proslimelt, a low frequency ultrasound technology from Italy. Cryolipolysis on the other end uses cold to disrupt fat cell membranes and their main limitation is the fact that the area treated is restricted to the tissue that is placed inside the cooling cup or between two cold plates. This technology does not allow for custom contouring or personalised treatment patterns. HIFU is a proven technology used for years in other medical applications such as cancerous tumour destruction and the result of over 10 years of investigation for specific fat applications. Mr Yannis Alexandrides is a plastic surgeon based in Harley Street, London

Liposonix uses high intensity focused ultrasound which generates heat to disrupt the fat cell membrane

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LoveLite Ice have developed Lipoglaze a new found celebrity secret for both Men and Women delivering fast results! • Futuristic treatment, more advanced than liposuction • Safe and effective way to target stubborn areas • Cools and reduces localised deposits to reshape body contours • Can destroy 26% fat in the treatment area • Better than Radio Frequency, ultrasound and cavitation • Much more affordable than liposuction

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products

market On the

The latest products in aesthetic medicine, as reported by Helen Unsworth

under the microscope Olluminate Intense Eye Repair Often the eyes can be the first part of the face to show signs of ageing as the skin is so thin. With this in mind, ZO Skin Health— developed by Dr Zein Obagi—have created Olluminate Intensive Eye Repair as part of their new Skin Health range. As a recent convert to using eye treatments for combating the ageing process and to reduce dark circles, I adhered to the instuctions and gently applied Olluminate both morning and evening following cleansing. The product uses stabilised retinol and advanced peptides to strengthen the skin and decrease fine lines and wrinkles. It also uses optical diffusers to reduce dark circles and helps to reduce puffiness and discoloration with antioxidants and anti-inflammatory ingredients. I found the cream particularly nourishing and soothing on the skin, and after a week of use, my eye area looked brighter. I will certainly continue using Olluminate in the hope that my dark circles keep on improving in appearance. Key ingredients in Olluminate Intensive Eye Repair are:  Retinol: A pure derivative of Vitamin A, clinically proven to be the most effective anti-ageing ingredient to decrease the appearance of fine lines and wrinkles, even skin tone and increase epidermal thickness.  Mica and Titanium Dioxide: Proven to be the most effective minerals to diffuse light and create radiant skin.  Vitamin E: An antioxidant to fight free radicals and repair damaged skin cells. Wigmore Medical 020 7491 0150; W: wigmoremedical.com

OVERNIGHT REPAIR SERUM

Dermalogica’s Overnight Repair Serum for ageing skin is designed to firm and restore the skin’s barrier capacity to maintain suppleness and moisture levels. It contains active ingredients to address collagen loss and lack of luminosity. Dermalogica 01372 363600; W: dermalogica.co.uk

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LIPOGLAZE

Lipoglaze is an FDA approved, non-surgical fat reduction treatment which kills off fat cells in one 50-minute session. The treatment targets fatty areas in the tummy, arms, legs, and thighs with fast results, no scaring and no pain and is being launched in the UK by beauty spa treatments company LoveLite. The Lipoglaze Cryogenic Lipo machine works by first gently heating and then rapidly cooling the target area. This causes the fat cells to crystallise and permanently destroys up to a third of fatty deposits per session. The body then naturally eliminates this waste tissue over the next few weeks. It is an ideal treatment to selectively target and diminish stubborn fat deposits on the tummy, arms, legs, bottom and thighs that some patients find hard to shift even with a good diet and exercise. For patients with more than one problem area, a set of treatments can be carried out, although it is recommended the practitioner leaves a week between sessions to allow the body time to metabolise the dead fat cells. LoveLite 0845 505 0805; W: loveliteuk.co.uk

PORTRAIT NEOGEN

Energist have unveiled their latest system—Portrait NeoGen—a unique technology which delivers controlled pulses of nitrogen plasma energy to tissue. Portrait NeoGen is a new approach to restoring and regenerating the skin’s natural architecture and has the added benefit of enabling treatment of the upper and lower eyelids. Clinical trials have shown that Portrait stimulates a natural regenerative process of the skin—recovery time is minimal and there is little or no risk of complications. Plasma energy produces a unique thermal response at and below the skin’s surface. This stimulates significant remodelling of the skin’s architecture, replacing old damaged collagen with significant amounts of new collagen and replacing the damaged elastin tissue. This is key to longlasting and simultaneous improvements to deep wrinkles, skin laxity, skin texture, acne scars, pore size and surface discoloration. It has been noted that Portrait can provide treatment outcomes similar to those seen with CO2 resurfacing but with significantly reduced downtime. Energist 01792 798768; W: energistgroup.com

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MICROPEEL

SkinCeuticals Micropeel 20 and 30 are new clinical grade peels in a graduated strength containing 20% and 30% unbuffered glycolic acid with a pH of 1.4. 20%-30% glycolic peels are measured as “clinical” chemical peels of a superficial epidermal depth nature and will generally show minimal post treatment sheathing of the skin with downtime of two or three days. They address sun damaged, prematurely aged skin and help reduce appearance of fine lines and wrinkles, whilst brightening the appearance of overall skin tone. Skin must be primed prior to receiving a peel and nurtured following the treatment to ensure an even result and the optimum recovery. SkinBrands 05603 141956; W: skinbrands.co.uk

PROMAXLIPO

PromaxLipo is a multi-functional device that can treat all areas of the body, as well as the face, having been designed to offer the three most popular body treatments: cellulite reduction, inch loss and skin tightening. Dr Samantha Hills, Lynton’s Clinical and Training Manager, says “The system is compact, non labour intensive and extremely versatile. There are six different applicators which allows treatments on every area of the body, including the arms, thighs, tummy, hips, knees, ankles and the face.” Proma x Lipo uses radiofrequency, ultrasound and vacuum massage to achieve immediate results, with best results achieved after six to 10 sessions. Lynton 01477 536975; W: lynton.co.uk

FUSION

Fusion—the newest addition to the Chromogenex product line-up—combines the bio-stimulation of cold low level laser therapy (LLLT) with the aesthetic benefits of hyaluronic serum. The treatment is non-invasive, pain free and the system is easy to use and portable. This combination of LLT, which stimulates the natural rejuvenation process of the skin, and hyaluronic serum, produces noticeable improvements to the appearance of the skin after one treatment, however a course of six treatments is recommended resulting in long-term aesthetic improvement. Chromogenex 01554 755444; W: chromogenex.com MARINI PHYSICAL PROTECTANT 45

This sunscreen utilises purely physical filters for broad spectrum UVA and UVB protection to decrease the risk of premature skin ageing. It features a universal tint and microscopic sponges for oil control with a sheer matte finish and is enhanced by the anti-inflammatory, antioxidant and skin conditioning benefits of green tea extract, alpha-bisabolol and CoEnzyme Q10. It has been created to meet the needs of professionals and for consumers who require a physical sunscreen or a minimum SPF of 45. JMSR Europe Ltd 020 8868 4411; W: jmsreurope.com

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brushstrokes  GRAHAME GARDNER have launched two ranges of garments—Urbane Scrubs and Vitality, The Designwear Collection. Urbane Scrubs represents a more stylish approach to scrubwear, whilst Vitality, The Designwear Collection is tailored towards beauty therapists. Grahame Gardner 0116 2556326; W: grahamegardner.co.uk

 CACI have introduced the CACI MICROLIFT, an at home facial toning device which uses low frequency electrical impulse technology to “re-educate” facial muscles and combat the signs of ageing. The handheld device targets the entire face and is a quick 10 minute treatment. CACI International 020 87315678; W: caci-international.co.uk

 EXILIS – PROTÉGÉ has been launched by BTL Aesthetics, and offers a non-invasive form of treatment for the reduction of wrinkles, skin rejuvenation and tightening to the face, neck and hands. The system offers quick treatment times from only four minutes per area. BTL Aesthetics 01279 408170; W: btlmed.co.uk

 ENLIGHTEN is the new range of cosmeceutical products to reduce pigmentation and promote a brighter, more even skin tone from NeoStrata. The range contains high performance active ingredients and can tackle unwanted pigmentation and melasma as well as dull skin tone, fine lines and wrinkles. Aesthetic Source 01234 313130; W: aestheticsource.com 51


Itâ&#x20AC;&#x2122;s not only your clients that will love the Energist feeling. You get state of the art laser, pulsed light and plasma systems featuring the latest technology, all backed by outstanding customer care. Your clients get the exceptional aesthetic treatments and results they desire. Fantastic! Visit www.energistgroup.com for the full story, email us at enquiries@energistgroup.com or call us on 01792 798768


lasers Dr Diane Duncan

Moulding

soft tissue With more patients seeking minimal downtime, there is much value in non-surgical soft tissue shaping. Dr Diane Duncan describes radio-frequency shaping using the Invasix BodyTite

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any practitioners may look for treatments beyond toxins and fillers to help patients achieve their goals of looking better without surgery. There are some techniques that you can offer patients to give visible and often dramatic results with high patient satisfaction, that are minimally invasive to non-invasive, low-risk and cost-effective. There is a great deal of value in tissue shaping and, instead of cutting out skin and pulling the skin tightâ&#x20AC;&#x201D;which can give a distorted effect, more patients are requesting shaping the ageing tissue to give a natural result. I like to shape soft tissue without surgery by looking for depressions to fill, and adding more volume than you can do costeffectively with fillers alone. I also shrink the laxity of the skin and soft tissue layer, as a lot of people lose some definition of their face, mostly to skin laxity and soft tissue atrophy with time. Tools of the trade When a patient comes in for a facial consultation, I tend to look first at achieving volume using a fat grafting procedure which, when performed well, gets great results. I also use some laser, liposuction and external ultrasound. I still provide injection lipolysis, but I particularly like radiofrequency shaping devices. One device in particular is the BodyTite by Invasix, which I have used for over three years. I first used it to perform liposuc-

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tion with less resistance, but found that there was a nice skin contraction and soft tissue tightening side effect. One application of BodyTite is the FaceTite, which is a device I use exclusivelyâ&#x20AC;&#x201D;even for body areas. The cannula width is less than 2mm, so you can use an entry poke of the 18G needle. There is no stab incision and therefore no need to close an opening. It is a good way to create lift in the face and neck without taking out skin. A fairly resistant area to improve with face-lifting or any of the other energy-based devices is the nasolabial fold marionette line. This is a difficult area to treat, even with fat grafting, but you can get a nice improvement with the FaceTite. One of the new areas I am focusing on is the definition of obscured landmarksâ&#x20AC;&#x201D;improving angles, jaw line, jowls and chin. My target is the fibre supply network, which I believe is a relatively new target. We are not really treating skin or fat, but instead looking at the stromal tissue that supports the adipose network. If you tighten the fibre supply network, you get several effects: tightening of the tissue; tightening of the skin, because the overlying skin accommodates; and re-adherence of the loose flabby tissue to the underlying fascia. Heat When delivering radio-frequency assisted liposuction, there is some benefit with adding heat. The effect of adding heat is 53


lasers Dr Diane Duncan

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DR DIANE DUNCAN

Dr Diane Duncan is a consultant plastic surgeon based in the United States

Before and after one session of treatment with FaceTite

DR STEPHEN MULHOLLAND

Fractora Many people with Scandinavian or UK-type heritage seem to suffer with “granny skin”—fairly thin, crêpey and wrinkly. It is loosely attached to the underlying fascia—frequently sun damaged and marred by pigmentation. Laser resurfacing is universally recognised as an excellent treatment, but a lot of people are discouraged by the down time. The Invasix platform also offers Fractora, which is a resurfacing alternative—it gives you a minimum temporary deformity— you can have from 20 to 60 and now 126 pins. One downside is that you may need to perform several treatments. But the upside is that because there is virtually no visible deformity, patients can go back to work the next day and look fine—there is very little down time. And the one thing that I really like: it is pain free. I had a patient who looked amazing without makeup, but she didn’t like the fact that she had some hyperpigmentation, a bit of puffiness around the corner of her mouth and a little bit of a jowl. In this case, the only treatment I would recommend is Fractora. After two treatments her hyperpigmentation was gone, and the puffy areas and the slightly more lax areas were much better. If you have high-demand patients like this, who want just a small amount of correction and you want something that’s riskfree, I think it’s a great device. You can get the Fractora Firm or the Fractora Firm Plus for

treating the neck and body areas, which is a heating device. I usually start at about 30 millijoules and heat about to 41° centigrade. This may sound quite hot, but an advantage of the Firm is that it starts at skin temperature and it feels very comfortable and the gradual heating is pain free. I use fairly slow strokes to get some heating of the subcutaneous tissue, but not so much heating that you cause fat atrophy. However, it can be used with the intent of producing fat atrophy in the region of the jowls or the neck. I prefer to slowly get up to the optimum temperature and stay there for about two minutes. I like to use Fractora for the neck because healing can be fairly slow with laser treatments, and the Fractora heals quite quickly. You will have to carry out more than one treatment, but you don’t have the downtime. For most of my patients who come in and want comprehensive facial rejuvenation, my best combination is fat grafting and some type of resurfacing along with a radio-frequency neck lift for the flabby neck, jawline and perioral features using Facetite. We should look beyond toxins and fillers—it’s the smart thing to do. My new tool is radio-frequency tightening of the fibre supply network because I know if I target this network, I’ll get a lot of improvement. It can be minimally or non-invasive and has very high patient satisfaction.

Before and after resurfacing and skin tightening with Fractora

DR STEPHEN MULHOLLAND

achieving three-dimensional tightening—it’s not only horizontal or vertical but also oblique. It pulls the tissue in and re-adheres it to the underlying fascia. One problem patients may present with is the pendulous hang of tissue, especially in the arms. I had a 63-year-old patient who wanted some improvement of her arms, but didn’t want a brachioplasty and was very strict about avoiding scars. Six months after radio-frequency treatment with heating to her upper arms, there was a dramatic improvement in the pendulous hang of the arm. She still had a little laxity in her elbows but it was quite an improvement for a lady who would otherwise have had empty bags of hanging skin with liposuction alone. Patients may also present with a pendulous hang over a Csection scar or the suprapubic area. I treated a 53-year-old woman who had had three C-sections and wanted some improvement of her abdomen but flatly refused a tummy tuck. She participated in a study where her left side was treated with suction assisted liposuction (SAL) plus radio-frequency heating and the right side was treated with SAL alone. While it had improved, the results showed some residual overhang in the SAL side, but there was no hang at all on the radio-frequency treated side. So how does this translate to facial treatments? These, I believe, are a “home run” because the region is smaller. You can treat under local anaesthesia and it is easier to get a good result in difficult areas. A tough facial problem to treat, which we all struggle with, are depressions. If you have a patient with very strong and pronounced depressions—for example, the nasolabial folds or the marionette lines—adding fillers to them will often make the fold less prominent but unless you lift the sagging skin, you won’t get complete correction. One way to treat this would be with radio-frequency assisted liposuction, which heats the tissue above and below, and fat grafting in a linear manner along the depression to get a smooth correction of the depression that lasts long-term.

Before and after six sessions of treatment for neck and chin with Fractora Firm body language www.bodylanguage.net


Exilis

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marketing Wendy Lewis

À la carte Creating the right menu of products and services for your clinic is essential. Wendy Lewis discusses best practice to compose the ideal mix of treatments

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inding the most effective mix of products and services for a clinic is a strategic decision that should be based on a thorough analysis of your customer base. If you want to provide patients with products and services they need and are willing to spend money on, you must first understand their spending habits, preferences and limitations. Take a close look at your patient population. In what neighbourhoods do they live? Where do they work? How affluent are they? Even without doing extensive research, simply asking yourself these questions will help to identify the price segment in which your clinic operates. Staying in sync with your price segment will allow you to determine how much your patients are willing—and able—to pay for your services and products. Position your clinic as where you want to be within this segment: either bargain basement, good value for money, or exclusive. However, there are other considerations that may help finesse your clinic’s ideal positioning. What is your clinic best known for? What are your areas of expertise? What do you specialise in? Every clinic should have a four to five sentence mission statement that describes how it wants to be perceived. The positioning of your clinic will serve as a fundamental blueprint for all management and marbody language www.bodylanguage.net

keting decisions, as well as adding new services in the future. Defining your concept It is important to have a concept for your clinic that is clear and understandable. This should be described in your mission statement. Your concept should identify the type of service program you are offering, who will purchase these services and at what quality level. Note that quality or value is not the same as price. Price and value are two different things. Price is not determined by value; rather it is determined by supply and demand. Your customers determine value by determining what they are willing to pay for your services and products. Therefore you need to know your customer and what they consider important. Understanding this will help you to be more competitive in the marketplace. Differentiation It is critical that you differentiate your clinic from your competition. If there are a dozen other clinics in your region or city, consider why a customer should select yours over the others? Without specific differentiators you may get lost in the clutter of the competition, and it will be difficult to capture your share of the market. One clear way to differentiate your clinic is by offering 5-star service and a winning patient experience. As medical

aesthetics becomes more competitive, you need to ensure that the customer experience and services you provide are of the quality level that you communicate to the marketplace. Your quality should match the expectations you build through your marketing vehicles that communicate your clinic’s key messages. Product selection When it comes to dispensing products, consider the three major effects this will have on your clinic. First of all, dispensing drives reputation, as the reputation of the brands you sell will transfer to your own reputation. Secondly, selling additional products can drive growth by creating additional revenue streams. Finally, dispensing drives repeat business and customer loyalty as patients appreciate all-inone solutions. The selection of products and services offered is very important. Make sure that your products are compatible with both your treatments and your positioning. You will sell them only if they go along with your specialisation as a clinic, as well as your patients’ needs and spending capacity. If you are just starting out with building your clinic’s reputation, stick with well-established brands. Your patients will recognise them and feel more comfortable and confident with the products and technologies you recommend. The good reputation of the endorsed 57


marketing Wendy Lewis

brand will also help you to enhance your own reputation. Larger companies tend to offer marketing support including onsite staff training, brochures, samples, public relations and promotions. If your clinic already has a well-established reputation and a solid patient base, you can endorse less well-known products, or even be the first to introduce a new brand. This can be a good strategy to distinguish your clinic from competitors. Many clinics effectively implement being the first in their market to have the newest technology as part of their overall strategic positioning. It also can help to demonstrate your expertise and specialisation in a certain field. Customers who are early responders and are always seeking the latest and greatest thing on offer will seek out your clinic It is also vital to do your research to maintain your ethical standing as a physician or healthcare practitioner before you bring something new into your clinic. Only choose products with proven results and sufficient clinical data and testing. Look for large-scale studies and articles published in peer-reviewed journals. Ask to see a range of before and after photos, and ask hard questions. You should also be convinced that there is a sound reason for you to bring this particular product or brand into the clinic. For example, does it address an unmet need for your patients? Is it faster, safer or more effective than something else you may already have? Consider whether you currently have enough customers who will be interested in having this new treatment and willing to pay the price you will need to get to turn a profit. Marketing Training your staff is the first step in marketing your services and products.

Make sure that all your employees are familiar with everything you are promoting in your clinic. They should be able to explain with ease the details, what the benefits are, and the basics of how every treatment is performed. Receptionists and front desk staff should be able to answer routine questions from callers looking to book a consultation or come in for a treatment. If they are unable to respond to questions with a degree of credibility, patients may question the quality of your clinic. It is not reassuring to get responses like, “I’m not sure about that,” or putting the call on hold by saying, “I’ll have to ask someone.” Similarly, they should be able to answer questions correctly. Giving patients the wrong information is equally detrimental to your clinic’s reputation. Do not train your clinic staff to sell services and push products, but rather to provide patients with a positive and educational experience, or a “soft sell” approach. It is important that they are good listeners, are attentive to patients’ needs and can offer personalised advice. Trust is a vital element in running a successful medical aesthetics clinic. Consider how your clinic presents the products and services on offer, including product display, merchandising, and promotional materials. Products need to be placed attractively in patient areas to attract attention, encourage patients to ask questions. Signage in the form of posters, brochures, and before and after photographs should be displayed appropriately. Do not leave it up to patients to find out what you offer—communicate with them via eblasts, newsletters, an updated website, blog, Facebook page and Twitter. Many clinics schedule open house seminars to introduce new products or treatments to their patients. These can be done in your clinic waiting room, or

Most Popular Aesthetic Treatments Depending on your positioning and your customer base, it is important to offer treatments that address all or most of the following for facial areas; lines and wrinkles, sun damage, brown spots, discolouration, redness and rosacea, thread veins, volume restoration, sagging, scars, acne, lifting, and firming. The next areas to consider are off-face applications, including chest, arms, hands, legs, and body. To address these concerns, fat reduction, cellulite therapies, hair removal and vein treatments top the list. Selection of services should include a range of dermal fillers, neurotoxins, light based and laser technologies, and topical agents.

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If you are just starting out, stick with well-known brands but if your clinic has an established reputation, it could be a good strategy to introduce new brands

include treatment rooms so guests can watch a treatment being performed, ask questions of the staff and doctors, and meet other patients who can speak about the treatments they have had. In some cases, you may have one or more speakers with a PowerPoint presentation and before and after photographs to explain how a procedure works in more detail. Staying on trend As new technologies and techniques are launched to increase the level of results that can be achieved, your clinic must stay current and keep up with the trends. Consumers are exceedingly well versed in the latest and most popular procedures on offer. They do their homework, go online to research devices and products, seek out reviews and ratings, and generally know a bit about your clinic before they walk through the door. Consumers today are seeking the best and safest treatments on the market to accomplish the results they want to achieve. They are willing to pay more for superior service, better results, less pain and downtime, and faster, more efficient treatments. Top clinics continually identify new trends, and are constantly seeking the next big wave of procedures and products to meet their customer demands. By implementing new services that you have vetted as being safe and effective, your customers will be less likely to seek out services elsewhere. Position your clinic as a source of information so your patients will come to you first to find out what’s new. Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, author of 11 books, and founder/Editor in Chief of beautyinthebag.com. E: wl@wlbeauty.com body language www.bodylanguage.net


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insurance Eddie Hooker

Cosmetic claims I

n the last two years Hamilton Fraser Cosmetic Insurance has experienced an increase in both the frequency and severity of claims. There are various reasons for this increase. Firstly, there has been a significant rise in the number of practitioners entering the cosmetic market place and consequently a higher number of treatments are being performed. Naturally, the probability of a claim is increased. The most common type of claims notified to Hamilton Fraser Cosmetic Insurance are: • 21% fat reduction (including laser/ radio rrequency/ultrasound assisted liposculpture treatments) • 20% laser (including facial rejuvenation and hair removal) • 18% hyaluronic acid dermal filler • 14% botulinum toxin • 14% other (including chemical peels, medical needling, general beauty treatments) • 13% other dermal fillers Since cosmetic treatments, in the main, are elective procedures, consumer expectation is increased leading to a higher risk of complaint and call for compensation. Couple this with the increase in ‘no win no fee’ solicitors and the cur-

With more practitioners entering the medical aesthetics sector, Eddie Hooker discusses how to handle complaints and claims rent financial climate has led to patients pursuing claims they may have previously ignored. The visibility of cosmetic treatments in the media has allowed treatments to be more socially acceptable. Whereas before, patients would be reluctant to admit they had elected for cosmetic procedures, patients are now not as apprehensive about reporting or discussing a claim. However, it is important that cosmetic practitioners recognise there is a difference between a complaint and a claim. A claim will only take place if the practitioner has caused bodily injury, mental stress or a financial loss to the patient as a result of their negligence. A claim would need to be notified to your insurer immediately so that they can take action and ensure the claim is dealt with satisfactorily. In comparison, a complaint can be dealt with by the practitioner. An example of a complaint may be that the treatment doesn’t meet the patient’s expectations or the patient has a grievance with the style or behaviour of a practitioner. It is advised that cosmetic practitioners have a complaints procedure in place for how to deal with them. Of course if you are unsure of how to deal with a com-

Always keep detailed notes, as if a claim does occur they will form part of your evidence

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plaint then you should contact your insurance provider who will be able to help. There are some simple dos and don’ts that cosmetic practitioners should follow to mitigate the possibility of a claim. Firstly, you need to ensure you have a thorough face to face consultation with your patient. Give the patient time to assess the potential risks and costs and make sure that they understand the style and length of treatment. Do not be scared of managing expectations. Always make sure you keep detailed notes. If a claim does occur your notes will form part of your evidence. The better your notes the better your defence will be. Remember, most claims involve who said what, when and where. When defending a claim the burden of proof lies with you and if something is not written down it is hard to prove that it actually happened. If an incident does occur when you are performing a treatment never admit liability to the patient either verbally or in writing. That is not to say that you cannot apologise but make sure you do not accept fault. It is also recommended that you do not make an offer of a refund or complimentary treatment before consulting with your insurers as this could be seen as an admission of liability. If you receive a letter of complaint from your patient, or any third party, you should notify your insurance provider immediately and pass on all correspondence unanswered together with the patient notes and your proposed response. Your insurer will be able to advise you on how you should deal with the complaint and ensure you are not placed in a vulnerable position. Never try to deal with the claim yourself. Eddie Hooker is chief executive officer of Hamilton Fraser Cosmetic Insurance body language www.bodylanguage.net


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21ST-23RD J U N E 2 0 1 3 THREE DAY CONFERENCE PROGRAMME Hear the world’s leading facial aesthetic experts speak on the latest developments in Facial Aesthetics. 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. Advanced training will include injectables, lasers and skincare taking place through out the weekend.

EXHIBITION A much larger platform for the exhibitors at the QEII will allow delegates to see more than 70 key manufacturers and distribuotrs in the industry and any product specific workshops available through the weekend.

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.

SKIN Skin is the most visible organ affected by ageing and a variety of common skin diseases. 2013 will see lectures devoted to treating ageing skin, treating common skin diseases and dealing with the unique problems associated with treating skin of colour.

HAIR With widely publicised celebrity hair transplants, the market for treatments that increase the thickness and density of hair is more buoyant than ever. We will examine the non-surgical and surgical options for the treatment of pattern baldness. www.faceconference.com info@face-ltd.com 020 7514 5989

NEW LOCATION FOR FACE 2013 FACE Conference has provided over 3000 delegates the chance to see some of the most enterprising speakers, treatments and topics in aesthetic medicine. In 2012 FACE celebrated 10 years and has eveloved with the very industry it serves. FACE 2013 will be moving to the QEII in Westminster, London to help accommodate the growing lecture programmes. With over 70 exhibitors and 100 hours of lectures by the worlds best practitoners and pioneers in facial aesthetics, FACE 2013 promises to be larger than ever. “The FACE Conference is without doubt the premier facial aesthetic meeting in the UK. The unique contribution from all subspecialties makes FACE the best way to keep up to date.” RAJIV

GROVER, CONSULTANT PLASTIC SURGEON

“One of the best, most enjoyable, informative aesthetic meetings in the world.” DR TIMOTHY FLYNN, COSMETIC DOCTOR “The FACE Conference brings together National and International leaders within the cosmetic and aesthetic industry and year-on-year represents the ultimate forum for practitioners who wish to expand their knowledge base and practical skills.”

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fillers Dr Sabine Zenker

Platelet rich plasma Platelet rich plasma can provide a natural alternative to standard fillers for volumisation. Dr Sabine Zenker discusses her injection technique

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hile every individual ages differently, we all share two factors—skin ageing and the fact we have blood. Platelet rich plasma (PRP) has been shown to enhance wound healing, whether it’s used topically, for healing ulcers, in bypass surgery as a fibrin clot, as fibrin glue or even in dentistry to help implants take root. When using PRP as a volumiser, the platelets release growth factors. They make their way to the designated tissue and perform the action we need in the area we need it. A fibrin scaffold is also activated at the injection site, which provides a structure for thrombocytes to release the growth factors, to stabilise and to produce collagen. Before injecting, we need to think about the purity of the solution. This depends on how well the gel within the kit separates platelets from the red and white blood cells. We need to work out many spins are needed, how many platelets the patient has available and how much volume is needed. We also need to consider the platelet recovery rate. There has been much discussion on how high the platelet count should be. There should be a stable recovery rate—the availability and number of growth factors differ, which can impact the final outcome. Red blood cells are not desirable because they produce hemosiderin, which can cause hyperpigmentation and free radicals. White blood cells may inhibit the healing process. When you isolate the PRP, you must stop the coagulation process to be able to inject. We use anticoagulants with a low pH. While this can burn, it’s better to have a more physiological pH to limit the sensation while injecting. There has been some debate around activation of the PRP before injecting. We do have an endogenous process with the collagen in our skin, but we can control this by adding calcium chloride. When adding calcium chloride, fibrinogen becomes a fibrin and forms the matrix needed to act as a scaffold for the thrombocytes. There is some evidence that the effects of calcium and thrombin body language www.bodylanguage.net

on the growth factor release from PRP has an impact on growth factor efficiency. In one PRP, growth factor release after injection can be sustained for up to seven days. PRP within a fat transfer has shown longer survival rates and more vascularisation. Technique The PRP injection can be slightly more painful—as with mesotherapy in general—than an intradermal injection as we hit the epiderm so often with the needle. You can use a 30G needle, which you would use for any HA fillers. We have to deal with some leakage on injection, as the area can bleed, so we tend to overcorrect by 20% in any site. Injecting into the tear trough, you don’t have to worry about lumpiness as it will be resorbed. I treat until the clinical endpoint of 20% over correction, so a patient can leave with some puffiness around the tear trough. For the mesotherapy technique, I use nappage, with a micropapular or perpendicular technique using a 30/32G, short needle (4mm). When filling, I use a linear threading fanning or crosshatch injection technique, using 30/32/34G sharp needles to limit pain and the liquid PRP can be easily extruded and placed.

To avoid too much loss of the liquid during injection, you can control its flow while drawing the syringe plunger with the 4th and 5th finger as the needle comes out of the skin. You can even use cannulas where appropriate, such as the lips, lateral wrinkling on cheeks or tear trough. Over the years, I have used many different products with many clinical outcomes. In terms of PRP, we have to train ourselves to be more attentive to which kit we use based on the end result to enhance treatment outcome. Few kits provide controlled activation, particularly the platelet rich fibrin matrix which builds the scaffold for sustained growth factor release. Red and white blood cells are a contamination and we don’t need them. We need consistent rates of platelets in the final product. While there is reproducible proof for superficial and deep dermal stimulation of collagen and angiogenesis, there are many more studies we can do. The treatment is safe, but we can learn much more to increase the effectiveness of PRP injections. Dr Sabine Zenker is a consultant dermatologist and founder of the Dermatology Surgery Clinic in Munich, Germany 63


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Medical aesthetics is at your fingertips. Body Language passes on the knowledge of leading practitioners, who will help you with your technique. july/aug july/aug 2011

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s new procedures, products and services are launched and patients’ demands intensify, your own knowledge needs to keep up with change. Whether you wish to know about the efficacy and contraindications of a new filler or borrow tips from a master injector of toxins, you can rely on Body Language to keep you informed and up to date. Body Language is a bi-monthly journal aimed at all medical practitioners in medical aesthetics and anti-ageing. It is full of practical information written by leading specialists with the intention of helping you in your pursuit of best practice. Assisting professionals in medical aesthetics, Body Language has taken stock of developments and investigates the methods of experienced practitioners around the world, commissioning experts to pass on their knowledge in our editorial pages. Our editorial provides you with professional accountancy and legal advice that alone can save you thousands of pounds. You can also help yourself to continuing professional development (CPD) points. You can determine how many within the CPD scale that our articles are worth to you and self-certify your training. As a subscriber, you can access back issues of Body Language. You will be emailed your own code to enable you to read articles online. That in itself is a big time-saver. Rather than have to track down a misplaced issue from six, nine or 14 months ago to reread an article, you can refer to it online in seconds. Body Language continues to be at the forefront of publications in the medical aesthetics sector. Its leading position owes much to it being a practical journal that puts theory into practice and assists you to do your job as best as you can. You cannot afford to be without Body Language.

SUBSCRIBE UK subscription £60 for one year  UK subscription £110 for two years  Name: Company Name: Address:

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experience Shimon Eckhouse

The man behind the machine 20 years after the original intense pulsed light technology was developed, the creator Dr Shimon Eckhouse looks back on its origins

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t takes courage to overcome the hurdles faced by all great inventors and entrepreneurs; perhaps it is more challenging in the competitive world of medical devices. One man who has made an impact on the rapid development of the non-invasive aesthetic market is Dr Shimon Eckhouse, who, some 20 years ago, developed the first intense pulsed light (IPL) technology. This was a cornerstone in the growth of the medical aesthetics market, and today Dr Eckhouse has 20 registered patents and has published more than 50 published papers. “I thought about IPL as a way of using a form of light energy that has a much higher degree of flexibility then lasers and enables the safe and effective treatment of a wider range of aesthetic problems. In addition, I believed IPL can also be developed so that it can be used by a wider range of professionals and even by consumers which is indeed one of the most exciting development seen in the last few years in which millions of consumers around the world are using IPL technology to treat themselves and enhance their aesthetic appearance. “I felt that there are better ways of treating patients for aesthetic problems than using only lasers which was the status of the technology in the early 90’s. Lasers are one of the most sophisticated devices ever invented by physicist but have important limitations in using them in aesthetic medicine.” Dr Eckhouse formed a small company 66

in 1992 called ESC. His initial tests were carried out on his wife, who still remembers the burns. “There were a lot of risks (when developing the original IPL technology) because the whole idea of IPL was to put a flash lamp very close to the surface of the skin and to use it at a very high temperature.” From this first flash lamp prototype known as Photoderm VL, ESC obtained FDA clearance in 1995 and working with an all star team of US dermatologists including Dr Goldman, Dr. Fitzpatrick and Roy Geronemous to name but a few, introduced the world to IPL technology “The biggest applications for IPL were either hair removal or vascular lesions and now it is commonly used for facial rejuvenation taking care of blemishes, redness and even melasmas.” As IPL developed, Dr Eckhouse continued his quest to find the most effective methods to optimise results. A relatively little-used energy, radio frequency was introduced to create elōs technology, taking the IPL a stage further. “The invention of elōs by Syneron is a great example of how not only using a different form of energy (RF) but by using a combination of energies (RF and light applied simultaneously to the skin) enables us to treat a much wider range of aesthetic problems. Similarly, new forms of energy such as ultrasound energy are now used in various ways and enhance our ability to treat aesthetic problems. These successes and the continuous demand of patients

drive us, scientists and engineers in coming up with even better and safer ways of treating aesthetic problems and making people feel more happy with themselves and the way they look.” So what is this great pioneer doing today? He is not just sitting back enjoying his success, and though he is a dedicated family man, he is still working actively within Syneron in the capacity of Chairman, where he is known as a person that never gives up. He remains at the forefront of the research and development in this industry sector, and now when Dr Eckhouse has a new concept or idea the industry listens intently. “I feel that the huge success of using energy in non-invasive aesthetic treatments as well as the explosive growth of patient awareness and demand for these treatment is creating an exponential growth in technology developed for these applications. “This interest and awareness will be great drivers for the development of more exciting technologies that will be introduced to the market at an ever increasing pace. Energy-based technology based treatments jump started by the introduction of intense pulsed light will keep on growing at the speed of light in the next 20 years.”

Dr Shimon Eckhouse is a Physicist and is Chairman of the Board at Syneron body language www.bodylanguage.net


Wigmore Medical Driving the medical aesthetic industry The longest established aesthetic distribution company in the UK, Wigmore Medical have over 30 years of industry experience • All your aesthetic supplies from one company • Free next day delivery on orders over £500 • Same day delivery within London on orders placed before 3pm • Always at the forefront of the market, introducing new and exclusive product ranges • In the heart of London in close proximity to Harley Street • Walk-in pharmacy for face-to-face personal advice • Exceptional Customer Service advisors with extensive product knowledge • We offer tailor-made product solutions, providing training on product ingredient to enable a mix and match range, making your practice unique whilst increasing revenue. • Leading laser specialists on hand to advise with over 12 years experience

Extensive product range available including: • Skincare • Dermal Fillers • Botulinum Toxins • Laser/IPL • Microdermabrasion • Consumables • Chemical Peels • Medical Equipment

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