55 The UK Journal of Medical Aesthetics and Anti-Ageing www.bodylanguage.net
A brief history of toxins Stem cells and aesthetic medicine
HAIR TRANSPLANT SURGERY The latest treatments available
RESTYLANE LIP VOLUME
RESTYLANE LIP REFRESH
Indicated for lip volume enhancement
Indicated to restore hydrobalance and improve deﬁnition, without a great change in lip volume.
Q-Med, a Galderma Division Meridien House, 69-71 Clarendon Road, Watford, Hertfordshire WD17 1DS Phone +44 (0)1923 208950 • Fax +44 (0)1923 208999 • Email firstname.lastname@example.org
a Galderma Division
Date of Preparation: February 2012 RES/004/0212(3)
NEW RESTYLANE FOR LIPS. IRRESISTIBLE SOFTNESS.
body language number 55 14
ANALYSES Reports and comments
14 MEDICAL AESTHETICS STEM CELLS Stem cell research is an ever-evolving field, but more evidencebased studies are needed to rely on functional outcomes in aesthetic medicine, writes Dr Ali Ghanem
Guest Editor David Hicks 020 7514 5989 email@example.com Production Editor Helen Unsworth 020 7514 5981 firstname.lastname@example.org Sales Executive Monty Serutla 020 7514 5976 email@example.com
18 COVER STORY
Assistant Sales Executive Simon Haroutunian 020 7514 5982 firstname.lastname@example.org
HAIR TRANSPLANT SURGERY Confidence and self esteem can be greatly affected by hair loss, both in men and women. Hair transplants have seen a surge in popularity in recent years—Dr Bessam Farjo discusses the treatments available
25 INJECTABLES A BRIEF HISTORY OF TOXINS Botulinum toxins are the bread and butter of every aesthetic practice. Dr Nick Lowe runs through their history and types of toxins available, as well as their indications and side effects
Publisher Raffi Eghiayan 020 7514 5101 email@example.com Contributors Dr Ali Ghanem Bessam Farjo Dr Nick Lowe Ravi Jandhyala Mr Omar Durrani Mr Kambiz Golchin Catherine Quinn Dr Anil Shrestha Dr Raj Persaud Dr Kathleen Martin Ginis Dr Pablo Nuranjo Charles Southey Dr Raj Kanodia
29 RESEARCH PEER PRESS REVIEW Ravi Jandhyala surveys academic and association journals to report on advances in research
32 SURGICAL PERI-OCULAR REJUVEATION Ocular plastic surgeon Mr Omar Durrani discusses surgical periocular, or eyelid, rejuvenation, and the art of achieving a good aesthetic result while ensuring the eyes remain healthy
37 AESTHETICS BEYOND PRP Mr Kambiz Golchin highlights current debates around platelet rich plasma biotherapies and discusses the introduction of regenerative biotherapies into clinical practice, from a clinician’s perspective
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 2013 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: firstname.lastname@example.org Advertising: email@example.com Body Language can be ordered online at www.bodylanguage.net body language www.bodylanguage.net
BEAUTY FROM WITHIN Anti-wrinkle pills and sweets which act as internal deodorant? Catherine Quinn investigates whether the world of nutraceuticals is proven and profitable
47 DENTAL DENTAL TREATMENTS IN FACIAL AESTHETICS The teeth are often overlooked when rejuvenating the face. Dr Anil Shrestha illustrates the importance of integrating dental analysis with aesthetic facial procedures
50 CONFERENCE FACE 2013 The UK’s premier medical aesthetic conference and exhibition moves venue for the biggest event to date 3
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 .
Mr Ravi Jandhyala is a member of the Royal College of Surgeons of Glasgow, and a founding member of the UKBTGA. He is also a member of the Faculty of Pharmaceutical Medicine and is an expert in the science behind botulinum toxins for aesthetics. He is the president of the United Kingdom Society for the Study of Aesthetic Medicine. 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.
WHAT WOMEN WANT The latest psychological research finds women don’t care what men want when it comes to bust size. Dr Raj Persaud and Dr Kathleen Martin Ginis discuss the findings
Elizabeth Raymond Brown, Phd, CRadP, MSRP authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies. She is now director of education at LCS Academy Ltd in Milton Keynes.
Dr Séan Cummings MBBS T(GP), DRCOG, DFFP, MRCGP, LLM is a cosmetic doctor practising in Harley Street. Dr Cummings has more than 20 years’ experience as a practitioner and has a masters degree in medical law. Dr Cummings works as an expert witness and has sat on GP disciplinary hearings
Renato Calabria MD is part of the voluntary faculty of the Department of Plastic Surgery at the University of Southern California, Los Angeles. He is a member of the American Society of Plastic Surgery, and the International Society of Plastic Surgery. Dr Calabria practises in Beverly Hills, Milan and Rome. Dr Bessam Farjo MB ChB BAO LRCP&SI practises hair restoration at his clinics in Manchester and London. Dr Farjo is a fellow International College of Surgeons, founder member British Association of Hair Restoration Surgeons and president of the International Society of Hair Restoration Surgery. 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.
ON THE MARKET The latest products in aesthetic medicine, as reported by Helen Unsworth
HAIR REMOVAL Removing hair can be achieved using a wide range of devices. Dr Pablo Nuranjo disusses some of these, and how to improve results in patients who are poor responders
63 MARKETING DIGITAL MARKETING Introducing payment options to your website and working on your online social media presence can result in considerably more sales, writes Charles Southey
66 EXPERIENCE A NOSE FOR AESTHETICS Rhinoplasty specialist Dr Raj Kanodia describes his 40-year professional journey in aesthetics, from an internship in Chicago to practising in Beverly Hills
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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
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: firstname.lastname@example.org 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.mhra.gov.uk/yellowcard. 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
Filler complication rates double in three years Renewed calls from aesthetic bodies for regulation and reclassification When news of the Poly Implant Prothèse (PIP) scandal broke last year, a spotlight targeted the aesthetic industry. Both media and government were overrun with calls for tighter regulation and enquiries delved into surgical and non-surgical practices. One review in particular, carried out by NHS medical director Sir Bruce Keogh, has been deemed the ‘ideal platform’ to highlight failures within the system, particularly concerning the safety of dermal fillers. A recent survey carried out by the British Association of Aesthetic Plastic Surgeons (BAAPS) shows that cases with filler complications seen by the association’s surgeons have doubled in the last three years. The same survey released in 2009 showed only 23% of members were seeing problems with permanent fillers; the 2012 equivalent has seen these figures rise to 49%. In a 2012 paper published in Opthalmic Plastic & Reconstructive Surgery, surgeons at the University Hospital Coventry and Warwickshire NHS Trust reported serious migration of a permanent dermal filler in the forehead, 10 years after treatment. The female patient complained of a bluish swelling around the left brow, temple and glabella, which appeared on an MRI to be a vascular malformation. But after further investigation, it was revealed she had received a permanent polyalkylimide filler in the glabella 10 years previously. Following surgical intervention, the gel and granulomas were removed and the patient made a good recovery. But the authors emphasised that while this is a rare occurrence, a detailed patient history is vital. Around 69% of surgeons polled have seen problems stemming from temporary fillers—of these, 57% saw one to three patients with complications, while 12% saw between 4–6. Over a quarter of surgeons reported between one to three of these cases in the last year required surgery to correct the damage. Commenting on the findings, BAAPS president Mr Rajiv Grover says that while many surgeons do not provide filler treatment, they are increasingly dealing with the consequences of botched procedures. “Although it is known that plastic surgeons are not the main providers of cosmetic injectables—in fact, a considerable number of respondents in our survey clarified they did not perform them at all—it is surgeons who are called upon to deal with body language www.bodylanguage.net
problems when they do arise,” he says. Patients requiring corrective surgery or who were deemed “untreatable” because of the damage caused by fillers were seen by 41% of those surveyed and surgeons voted the top reason for filler complications being “unqualified practitioners administering fillers incorrectly”. Filler treatment is currently unregulated and can be administered by anyone upon completion of a short training course. “The growing popularity of these non-surgical treatments has clearly led to complacency regarding how they are performed and by whom,” says Mr Grover. “As shocking as these figures may appear to the public, none of us in the profession are actually shocked by the results of this survey. What I would find surprising is if anyone was still able to maintain, in good conscience, that fillers should not be reclas-
sified as medicines,” he says. Almost all BAAPS members responded that fillers should be treated as a medicine when undergoing approval, as it is by the US Food and Drug Administration (FDA). They are currently classed as a medical device, which receives a CE mark—indicating that while the product meets the requirements of EU legislation, it does not have to undergo scientific tests. In response to the PIP implant scandal, Sir Bruce Keogh launched an enquiry into cosmetic procedures earlier this year, which will take into account regulation and safety of products used in cosmetic procedures, as well as regulation of those who carry out procedures. In August, the review group called for evidence from the profession and public, and the review process ended in October. Conclusions are set to be published by March 2013. 7
TEENS UNDER THE KNIFE
Cosmetic surgery among under-18s is a growing trend—a UK survey released by cliniccompare.co.uk, a website providing advice and information on cosmetic procedures, asked 2,000 parents their views on children undergoing cosmetic surgery. While the majority of parents were against allowing under18s to have surgery, bad self-esteem and negative peer attention were cited as reasons for allowing teenagers to undergo cosmetic procedures.
While 87% of parents agree that young people should not consider surgery until they are over 18... ...1 in 10 mothers and 14% of fathers would allow their child to undergo cosmetic surgery to stop them feeling insecure Almost 50% of pro-surgery parents would let their child have surgery to avoid bullying or harrassment Around 6% of parents say 16-18 year olds should be allowed to make the decision to have surgery While 7.2% say under-16s should have the same choice, 2% of those surveyed say pre-teens should be able to choose whether or not they want cosmetic surgery Top procedures for under-18s: Ear pinning (31%) Nose surgery (25%) Weight loss surgery (16%) Breast reduction (10%) Liposuction (7%) Breast enhancement (5%) Source: cliniccompare.co.uk
Reverse craniofacial planning for transplants Approach applied to facial transplantation Principles of craniofacial surgery can benefit the planning and performance of facial transplants, according to a paper published in the Journal of Craniofacial Surgery, allowing surgons to compensate for missing bony or soft tissue landmarks. The authors state that in patients with extensive facial defects, this approach can help restore normal facial relationships. Most patients undergoing facial transplant have soft tissue loss only, such as skin, muscle, blood vessels and nerves. But some have underlying bone defects, requiring restoration of the structure of the craniofacial skeleton. Reconstructive craniofacial surgeons have developed an understanding of the relationship between soft tissue and supporting bones in the face, and design “bone movements that translate into a desired change of the attached soft tissues,” say the authors.
But facial transplants require a reversed approach— soft tissue transplantation and degree of injury dictate the ‘osteosynthesis’ of the craniofacial skeleton. The paper’s authors have developed a planning technique to enable correct positioning on the skull base and occlusal plane, by applying normative data on facial landmarks and compensating for missing facial features. Along with appearance, function enables patients to eat and breathe properly. The authors highlight the importance of proper transplant placement, emphasising that “positioning of the hard tissues of the allograft is the fundamental starting point for functional and aesthetic restoration”. While donor selection focuses on immunological factors, the paper suggests that donor assessment may soon include craniofacial matches between donor and recipient.
Spider silk reduces side effects in breast implants Implant coating more biocompatible One of the issues with silicone breast implants concerns side effects relating to immune response. An implant coating derived from spider silk has been developed by AMSilk, an industrial producer of biomaterials, to minimise immune system reaction. Initial tests in rats, conducted jointly with the University of Bayreuth and the University of Wuerzburg, Germany, showed that silicone implants coated in the thin layer of recombinant spider silk proteins were accepted better than implants without the coating, with reduced incidence of capsular fibrosis and inflammation at the
tissue border. A one-year follow up study, completed this year, showed that capsule formation around the implant differed significantly from controls. This resulted in a thinner, more flexible and translucent capsule which reduced inflammation markers, say the authors. Some markers, as well as fibroblast infiltration, were found to be at lower levels 12 months after surgery. Study author Dr Philip Zeplin says, “This new technology offers a real option for further improving current implants and can be used for nearly all silicone-based products.”
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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 email@example.com or on +44 (0) 333 200 4143.
Date of preparation June 2012
Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA.
training & events Facial palsy charity to JANUARY 8 January, Core of Knowledge, Mapperley Park Training Centre, Nottingham W: mapperleypark.co.uk/training 9 & 10 January, Basic Dermal Filler & Botox Training Courses, Newport, S. Wales W: honeyfizz.co.uk 10 January, Medical Dermatology 2013, Royal College of Physicians, London W: bad.org.uk 12 & 13 January, Advanced Botox & Dermal Filler Training Courses, Newport, S. Wales W: honeyfizz.co.uk 14–18 January, BTEC AWARDS, Mapperley Training Centre, Nottingham W: mapperleypark.co.uk/training 16 January, Glo Minerals Workshop, Wigmore Medical, London W: wigmoremedical.com 22–24 January, Introduction to Skincare & Peels, Toxins and Dermal Fillers Courses, Wigmore Medical, London W: wigmoremedical.com 24–26 January, International Congress in Aesthetic Dermatology, Bangkok Convention Centre, Bangkok, Thailand W: euromedicom.com 25 & 26 January, BAAD Annual Scientific Meeting, Stoke Park Club, Bucks W: baad.org.uk 26 January, Smart Ideas Seminar, Radisson Blu Manchester Airport, Manchester W: smartseminar.co.uk 29 January, Sclerotherapy Training Course, Newport, S. Wales W: honeyfizz.co.uk 31 January–3 February, IMCAS annual meeting, Paris, France W: imcas.com FEBRUARY
24 & 25 February, Professional Beauty 2013, ExCeL London W: professionalbeauty.co.uk 24 February–1 March, IPRAS World Congress 2013, Espacio Riesco Convention Centre, Santiago, Chile W: ipras.org 25 & 26 February, Basic Botox & Dermal Filler Training Courses, Newport, S. Wales W: honeyfizz.co.uk MARCH 2 March, Microsclerotherapy & Facial Telangiectasia Training, Wigmore Medical, London W: wigmoremedical.com 3 March, Advanced Toxins & Fillers, Wigmore Medical, London W: wigmoremedical.com 7 & 8 March, Basic Dermal Filler & Botox Training Courses, Newport, S. Wales W: honeyfizz.co.uk 8 March, PRP Training, Wigmore Medical, London W: wigmoremedical.com 11–15 March, Dermaroller, Introduction to Skincare & Peels, Toxins, Dermal Fillers and Laser/ IPL Courses, Wigmore Medical, London W: wigmoremedical.com 13 March, Sclerotherapy Training, Newport, S. Wales W: honeyfizz.co.uk 22 & 23 March, Mesotherapy Training, Wigmore Medical, London W: wigmoremedical.com 23 & 24 March, Basic Dermal Filler & Botox Training Courses, Newport, S. Wales W: honeyfizz.co.uk 24 March, Laser/IPL Training, Wigmore Medical, London W: wigmoremedical.com APRIL
4–6 April, AMWC, Monte-Carlo, Monaco 1 February, CPR & Anaphylaxis Training, Wigmore W: euromedicom.com Medical, London 6–8 April, Microsclerotherapy & Facial TelangiecW: wigmoremedical.com tasia, Intermediate Toxins & Fillers, CPR & Anaphy2 February, Microsclerotherapy & Facial Telangiec- laxis Courses, Wigmore Medical, London W: wigmoremedical.com tasia Training, Wigmore Medical, London W: wigmoremedical.com 11–16 April, Aesthetic Meeting 2013, Javits 2 & 3 February, Basic Dermal Filler & Botox Train- Convention Center, New York ing Courses, Newport, S.Wales W: surgery.org W: honeyfizz.co.uk 15–16 April, BAPRAS Advanced Cosmetic Breast 7 February, PRP Training, Wigmore Medical, Surgery Meeting, Manchester Conference Centre London W: bapras.meeting.org.uk W: wigmoremedical.com 15–18 April, Dermaroller, Introduction to Skincare 8 & 9 February, Mesotherapy Training, Wigmore & Peels, Toxins and Dermal Fillers Courses, Wigmore Medical, London Medical, London W: wigmoremedical.com W: wigmoremedical.com 11–14 February, Dermaroller, Introduction to Skincare & Peels, Toxins and Dermal Fillers Courses, Wigmore Medical, London W: wigmoremedical.com 14–16 February, WCAM 2013 – 19th Congress of Aesthetic Medecine, Cape Town, SA W: cvent.com/events 16 February, Cosmetic News Expo 2013, Business Design Centre, London W: cosmeticnewsuk.com 22 & 24 February, Laser/IPL Training, Wigmore Medical, London W: wigmoremedical.com
improve quality of care Treatment classed as ‘cosmetic’ by NHS While more than 100,000 people in the UK suffer from the effects of facial palsy, little funding is allocated to its treatment, as it is classed as a ‘cosmetic’ problem. But Facial Palsy UK—the first UK charity dedicated to facial paralysis—aims to educate sufferers on advances and development in treatments. According to a survey undertaken by the charity, fewer than 50 consultant surgeons in the UK offer treatment for facial paralysis, and patients take an average 5.6 years to specialist referral. Mr Charles Nduka, consultant plastic surgeon and chairman of Facial Palsy UK’s medical advisory board, says there is little awareness of advances in care. “Despite facial paralysis being widely misunderstood as just a ‘cosmetic’ problem, our surveys show that not being able to express emotion easily is considered the most frustrating aspect of the condition by a small percentage of sufferers,” Mr Nduka says. “In comparison, four out of ten cite functional issues as being the most problematic, such as not being able to close their mouth or one eye properly.” He emphasises the importance of early treatment—according to their statistics, over a third of patients have been told no treatment is available, leading to anxiety and depression in sufferers.
The charity hopes to spread knowledge that facial palsy is a functional, not cosmetic, problem, and educate about developments in treatment. Patients can undergo “smile transplants”, or smile re-animation surgery—involving transplanting a functioning muscle, such as the temporalis, to recreate a smile. Platinum chains can help to close the eye, the function of which can be impaired in facial palsy sufferers. A gold weight was historically implanted in the eyelid, but a ‘platinum chain’ implant is smaller, resulting in fewer complications. When the facial muscles are paralysed, rehabilitation can be a long and difficult process. Patients can also undergo neuromuscular training, combining surface electromyography with botulinum toxin, to relax overactive muscles. Some consultants providing treatment for facial palsy have trouble providing care—surgical procedures often require special permission and lengthy appeals. The charity aims to improve early diagnosis and show professionals which patients require specialist treatment. “We also aim to raise funds to support clinical and basic science research in the hope that one day everyone suffering with facial palsy can be given back their smile,” says Mr Nduka.
18 & 19 April, Basic Dermal Filler & Botox Training Courses, Newport, S. Wales W: honeyfizz.co.uk 27 April, Smart Ideas Seminar, Radison Blu Portman Square, London W: smartseminar.co.uk 27 & 28 April, Basic Dermal Filler & Botox Training Courses, Newport, S. Wales W: honeyfizz.co.uk 29 & 30 April, Basic and Advanced Glo Therapeutics Workshops, Wigmore Medical, London W: wigmoremedical.com
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medical aesthetics Dr Ali Ghanem
Stem cells Stem cell research is an ever-evolving field, but more evidence-based studies are needed to rely on functional outcomes in aesthetic medicine, writes Dr Ali Ghanem
here is ever-increasing public and scientific interest in the field of stem cells. The words “stem cells” appeared across medical domain infrequently until the 1980’s. The concept was then popularised after Sir Martin Evans and Matthew Kaufman successfully cultured mouse embryonic stem cells and established the concept of “stemness” in the lab. Since then, knowledge and expansion in stem cell research has proliferated exponentially. But what is the truth about aesthetic applications of stem cells—are we there yet? Concepts and biology The only consensus from the scientific community is that there are three characteristics which define a stem cell. Firstly it must be a cell which is able to self renew—produce after each division at least one daughter stem cell with all genetic and functional properties of the mother stem cell. Secondly, this ability of selfrenewal must be indefinite. This property is difficult to prove literally—it means
that this self-renewal property should continue for a long time when stem cells are maintained and expanded in cultured conditions, as should be the case in living organisms. Thirdly, this ability to maintain stem cell self-renewal should happen without changes in genomic stability such as malignant transformation. There are many more properties and characteristics described for stem cells but these are all open to variation of type and stage of the cell, and are not in the consensus definition. As a result, if we subject much of what is clustered in scientific and public domain to this strict definition, we would find ourselves mostly facing stem cell-like cells rather than true stem cells. Another important concept related to stem cell science is potency—the ability of a cell to differentiate into various cell types. There are three important terms to be aware of here: totipotency, pluripotency and multipotency. A totipotent cell is only associated with the fertilised egg and the very few cells after its initial divisions. These cells are called totipotent because they are able
to produce a whole embryo. If we take the two daughter cells resulting from the first division of the fertilised egg and separate them, each will give rise to an intact, complete twin embryo. These cells are therefore totipotent cells. At some stage of early cell division, totipotency is lost and cells become pluripotent. This means that they are able to give rise to most of the cells of the body but they cannot generate whole embryos. Later in embryo development, when we have more specification, cells lose their multipotency and become multipotent, which means they can produce only a few types of cells—two, three or more— but not all derivatives of our main three germ layers. Now, and with increased understanding of the molecular basis of “stemness” regulation, these terms are less demarcated and even mature and finally differentiated cells can be induced to become pluripotent by introducing a number of transcription factors that will reprogram the cell into an earlier embryonic-like stage; a finding that would award its pioneers Sir John Gurdon and body language www.bodylanguage.net
medical aesthetics Dr Ali Ghanem
Dr Shinya Yamanaka the Nobel Prize in Physiology and Medicine in 2012. Biomedical applications Two main areas of stem cell research exist—one is concerned with embryonic stem cells and the other with adult stem cells. Adult skin, hair, gut, bone marrow and every tissue type have many stem cells that exist to replace lost or damaged cells. These two domains overlap in many areas, but it is adult stem cells that have attracted more attention in the last few years. This is because of the potential for development of regenerative medicine products and the immunological, cancerous and ethical issues surrounding embryonic stem cell research. The boundaries are blurring more each day with new insights gained from research as, with molecular genetic modifications, adult stem cells (or even somatic cells) can be made to acquire characteristics which were thought to be specific to embryonic stem cells. We now understand that, for example, blood stem cells can be interconverted to produce neurons and liver stem cells can be stimulated in a certain way to differentiate into insulin-producing cells in what is known as transdifferentiation. Even as adults we—as a multi organism—undergo huge morphological changes during our lifetime. The reason why changes happen on an organism level are merely the changes happening on a single cell level which, in turn, are caused by differential gene activity. Our understanding of this change is increasing rapidly. Only a few years ago scientists were excited at being able to change the programme of cells encoded in their nucleus by the process of nuclear transfer. A well-known example is Dolly the sheep, in which the nucleus of an
adult cell was used to replace the nucleus of a fertilised egg, which then was left to develop to become a clone of the original adult. That was reproductive cloning. If the resulting nuclear transfer cell was grown in the dish rather than the womb to produce a particular tissue type which matches the adult from which the nucleus was taken in its genetic and immunological properties, we then have regenerative cloning. But this is old-fashioned research already! In stem cell science, we now know that there is a group of basic transcription factors, namely Oct-4, SOX2 and Nanog, which control the stem state “switch” of the cell. By altering these transcription factors alone—or the activator and repressor factors working on them—we can now manipulate and decide cells’ specific fate. This understanding allows us to manipulate and “direct” stem cells in the lab to differentiate into a specific cell type with a handful of factors. This constitutes the key concept in tissue engineering employing stem cell technology for tissue replacement and regeneration. Thanks to these insights, we can now understand very complex processes that used to be obscure when observed in fast growing embryos. Furthermore, in biotechnology we can now use cells taken from specific patients, say with a particular genetic disorder, and try to target the defective gene in these cells. We can then design a very specific individual drug to correct the fault then reintroduce the cells back to the same individual to achieve cure as summarised in Figure 1. The same principles are used when planning and designing a stem cell product for therapy. First, stem cells are obtained from an individual patient. The cells are then subjected to manipulation in the lab, to either purify or expand
Figure 1: Defective genes can be targeted in stem cells to develop drugs to correct the fault
them, or to prepare them for the desired clinical outcome. Having achieved that, the cells are then delivered back to the same individual or another individual in the specific tissue where the desired result is sought. This process is no longer science fiction. Real examples ranging from simple manipulated stem cell therapies such as genetically modified bone marrow transfer, to a more stem cell tissue engineered product are now reality. Claudia Castillo was was the world’s first patient to receive an airway transplant using an organ grown from her own stem cells. Claudia suffered from tuberculosis, which damaged her left bronchus leading to the possibility she may have had to have the whole left lung removed. Bone marrow mesenchymal cells were taken from her iliac crest, which were then differentiated into cartilage cells around a matrix made from decellularised donor bronchus. The resulting product was lined by cells taken from her right bronchus and the resulting tissue-engineered left bronchus was surgically transplanted into the defected area. Claudia continues to live well ventilating both lungs without the need for immunosuppression and no signs of transplanted organ rejection. The wonder of mesenchymal stem cells does not end with its differentiation potential. These cells are considered a biological pharmacy for anti-inflammatory factors, angiogenesis, and tissue repair and regeneration. They are able to produce a huge quantity of cytokines and growth factors making these cells important for therapeutic exploitation for both structural and pharmacological effect. In plastic and reconstructive surgery, replacing like with like is an important principle. Autologous tissue has therefore been used as the gold standard to repair and reconstruct damaged tissue. With adipose tissue emerging as a rich reservoir of mesenchymal stem cells (MSC), regenerative cell-based strategies started to show potential for soft tissue augmentation in aesthetic applications. The use of such strategies has fast passed the preclinical and animal studies and gone into the clinical trial domain with promising reports emerging in aesthetic literature. Anti-ageing treatments There is plenty of anecdotal evidence to suggest that the skin above areas treated with fat transfer improves in quality. This anti-ageing effect is believed to occur due to the adipose-derived stem cells (ADSC) producing anti-ageing antioxidants, growth factors and cytokines that work
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medical aesthetics Dr Ali Ghanem
on epidermis cells and dermal fibroblasts. Subcutaneous injection of ADSCs was shown to increase collagen synthesis and density, and so increase dermal thickness. This anti-ageing effect has been attempted to be transferred into cosmoceutical products in the form of creams, gels or mesotherapy injectables based on one or more stem cell secreted factors. Stem cell creams, serums, emulsions and lotions which claim to reduce ageing facial lines have invaded the consumer market worldwide, yet none have been clinically evaluated objectively. Effective factors of these products tend to be stemcell-secreted peptides or enzymes that have been implied in stem cell biology, such as epidermal growth factor and telomerase. To have any effect, these factors would have to remain stable for weeks at room temperature (given they are mostly polypeptides and proteins), get past the epidermal layer, go into the right cells, and execute the desired outcome. An original effect may have been shown in experimental models in cell-cells interaction, but unless those ingredients can get past the epidermal layer and be evaluated clinically with valid outcome measures, any effect of such ingredient continues to be an unverified claim. For example, the producers of Amatokin claim its ability to stimulate stem cell markers’ expression in the skin with no peer-reviewed evidence. The UK’s Advertising Standards Authority (ASA), however, concluded in July 2008 that claims implying a physiological effect were not supported by product-specific evidence and could mislead consumers. On the basis of its findings, the ASA asked Basic Research-owned Voss Laboratories to remove the challenged claims from its Amatokin advertising in the UK. Another example is RéVive, which has telomerase, a fibroblast growth factor and “Nobel Prize winning” epidermal growth factor as its main effective ingredients. It claims that it “converts resting adult stem cells to newly-minted skin cells”. The identification of epidermal growth factor did indeed win its co-discoverers the Nobel Prize in Physiology and Medicine in 1986. RéVive president and founder Gregory Bays Brown also published numerous articles in the 1980s and early 90s supporting the benefits of bioengineered epidermal growth factor in treating chronic wounds and second-degree burns. What has not yet been proven is whether such in vitro benefits of these factors may extend to reverse the ageing process on the skin layers. Another strategy of action is to acti16
vate and induce stem cells resident in the skin to accelerate their regenerative antiageing effect. Again, we find some cosmoceutical products launched in the market under this category such as L’Oreal’s “Absolue”. This cream contains an apple extract claimed to alter the stem cell niche—the “microenvironment” that surrounds epidermal stem cells. It is claimed that this product then would lead to reactivation of sluggish endogenous stem cells to produce new epidermal cells resulting in plumper, younger-looking skin. If this claim is true, this product would cease to fall under the cosmetic category and would instead be considered a “drug”, necessitating evidence based verification and relevant regulation by governmental and other pharmaceutical regulation agencies such as the FDA. Most manufacturers of stem cell related cosmetics try to word their marketing to avoid such a consequence and carefully build definite boundaries and limits into their products. Facial rejuvenation The first report of using stem cells in the face goes back five years to when Dr Kotaro Yoshimura from Tokyo University treated two small groups of patients suffering from facial lipoatrophy from lupus erythematosus, profundus or ParryRomberg syndrome with fat grafts. In the first group he used conventional Coleman’s structure fat graft and in the other he used cell assisted lipotransfer (CAL), in which the fat graft was enriched with adipose tissue derived stem cells. The average volume of lipoinjection was 100ml and the cell-processing procedure took 90 minutes. He reported that in the CAL treatment group, patients showed a better clinical improvement score. But the difference was not statistically significant and the sample size was too small to draw any meaningful conclusion. Since then, more than 100 patients were treated with adipose tissue derived stem cell assisted lipotransfer, with variable clinical results without any significant adverse reaction or complications. It is clear that the use of stem cell enriched fat grafts for aesthetic applications of the face has passed the proof of concept stage. That said, any other product claiming to originate from stem cell related technology is not supported by good evidence. It is important to note that stem cells come with warnings and limitations that need to be addressed before wider and reliable applications can be made possible. So far—judging by the available reports—stem cells continue to be a poorly-defined group of heterogeneous
cell populations and their differentiation progenies are equally heterogeneous. In preclinical and animal research this fact is often ignored, as positive results are put in the focus of any insight gained. This, however, could not be overlooked when such cells are to be used for human medical applications. The potential for tumour formation and immunogenic adverse reactions remain controversial potentials that cast a heavy shadow on the safety of using of stem cell technology. There is also the issue of questionable functional outcomes. We may introduce cells into a patient in the hope of a particular result that these cells will achieve but cells might not work in the live tissue the way they demonstrated in the petri dish. For example, dopamine-producing neural cells transplanted into the brains of sufferers of Parkinson’s disease failed to produce consistent results in all patients treated so far, despite heavy investment and investigation of this area. Although the proof of concept has been demonstrated long ago, the process still lacks efficacy and sustainability and is therefore still considered far from standard medical treatment. All these considerations are applicable to the use of stem cells in aesthetic applications. Although there is a marked paucity of well-designed, controlled clinical trials to demonstrate its efficacy and safety, emerging clinical data on the use of bone marrow or adipose tissue derived MSCs in wound healing and inflammatory disorders indicates that the safe and effective use of these cells in a wider range of applications, including aesthetics and reconstruction, can be realised in the foreseeable future. The priority now seems to lie in specifying the cluster of MSCs that have a particular functional effect, and unveiling the immunologic and neoplastic properties of these cells to facilitate wider commercial exploitation. The industry of stem cell based cosmoceuticals will continue to grow. And despite its slim evidence base, new products based on novel discoveries will keep emerging, pushing for new approaches to anti-ageing and skin rejuvenation. The next decade will witness a real push for translational research in which the fundamental discoveries made in the lab will be transformed into clinical and cosmetic tools, affecting all areas of regenerative medicine, reconstructive and aesthetic surgery. Dr Ali Ghanem is an honorary lecturer in plastic, reconstuctive and aesthetic surgery and has a PhD in developmental and stem cell biology body language www.bodylanguage.net
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cover story Dr Bessam Farjo
Hair transplant surgery Confidence and self esteem can be greatly affected by hair loss, both in men and women. Hair transplants have seen a surge in popularity in recent years—Dr Bessam Farjo discusses the treatments available
have been performing hair transplants for 19 years—I don’t practice anything else. The current gold standard in hair transplantation is the follicular unit. Historically, grafts were cut down to the required size without paying attention to the natural configuration of hairs in the scalp. Follicular units are normally produced using stereoscopic dissecting microscopes at 5–10 times magnification. The most popular way of doing this is using a single strip of skin taken from the occipital, the parietal or both. One advantage of sticking to the concept of the follicular unit is
that you achieve a more natural cosmetic result. The recipient area heals rapidly because there is a minimal amount of tissue surrounding the bulb. It is easier to transplant among thinning hairs, as they are more easily fitted due to their small size. More donor is available through efficient use of the donor hair, because of the use of microscopes. Similarly, because of the small size of these grafts, you get higher survival in scar tissue and, if you’re transplanting to areas like the face, the eyebrows and eye lashes, a more natural result.
However, because the average size of a follicular unit is 2.2–2.3 hairs each, you need to transfer a large number of these grafts in the one sitting to give the patient a decent result—usually between 2,000 and 4,000. In some cases you can transplant even more, so you need to have enough staff and a suitably customised operating environment. Back in the 1990s, 1,000 grafts were seen as a large number. Nowadays, anything over 2,000 grafts is considered a large number and, in my practice, 3,000 is considered a large session. I usually plant at a rate of 25–50 of these grafts in body language www.bodylanguage.net
cover story Dr Bessam Farjo
Strip technique procedure
each square centimetre per operation in the recipient’s scalp and they can go home without any bandages. From a staffing point of view, it’s time consuming and labour intensive, requiring well trained and skilled technicians. The strip technique There are two ways you can remove the grafts from the back of the head. One is called the strip technique—the most popular method—and the second is follicular unit extraction (FUE). Using the strip method, we remove a rectangular or oval shaped piece of scalp from the back of the head, usually around the occipital protuberance to the front above the ear. Usually you end at a vertical line, in line with the external auditory meatus. You take scalp from the “permanent area”—the area where the patient is not expected to lose hair from in the future. To close, you can suture but I prefer to use staples. The most important principle when removing the strip is to minimise the body language www.bodylanguage.net
1. Donor hair needs to be prepared, the area shaved and anaesthetic injected—usually using 1% lignocaine. The proposed donor sites are then measured up. Use lignocaine on its own without adrenalin to begin with, because it’s less acidic and more comfortable for the patient, followed by concentrated adrenalin into the incision lines to achieve vasoconstriction. 2. Use normal saline to produce tumescence, staying away from the deep fat lining the neurovascular bundle. Once the surface is firm, the incision can be made—a superficial incision at the lower edge and the upper edge, using hooks to separate the edges. Sometimes the blade may need to be used to cut in the plane between the hairs to avoid transection. 3. The strip is removed avoiding any vessels—incisions are usually made inside the subcutaneous fat. 4. Next is the trichophytic step. Create a ledge, scoring a 1mm—or one follicular unit—wide area, and cut out the epidermis. This will probably remove part of the dermis, but try and remove as thin a piece as possible. This ensures you remain above the bulge where the stem cells lie. If the cut is too deep, the new hairs may not come through. 5. The slivering process involves producing a slice of the strip one follicular unit wide. Ensure all technicians are getting complete follicular units, as opposed to random hairs within a piece of skin. 6. Once the slices have been removed, trim any unnecessary excess fat, leaving a small amount of fat underneath to protect the bulb—you don’t want it to become naked. This process continues until grafts are produced from the entire sliver. 7. In the meantime, the donor site is closed. Staples line up the incision better and are easier to remove. 8. Next, design the area for the graft. In the case of the crown, preserve the natural whorl. I use a 0.8mm custom-made blade, making incisions at particular angles to match the existing hairs. Make around 20 incisions then test the grafts being produced, to ensure the graft fits snugly into the incision. If it’s too tight, switch to a larger blade. If you try to force a graft into an incision that’s too tight, you may get compression of the graft, resulting in an unnatural look. If the incisions are too big, switch to a smaller blade—grafts placed in incisions that are too large may move within the incision, causing them to grow at an unintended angle. 9. Once happy with the size of the graft, continue to make the rest of the incisions and decide where each graft goes. I use a 21 or 22 gauge needle to make smaller incisions to receive the single haired grafts.To create incisions receiving larger three and four haired grafts, I use a 19 gauge needle. Switch the orientation of the needle to make an incision perpendicular to the hair direction (coronal) to help spread the hairs. 10. Put 1% methylene blue dye on the skin and wash it off. Some of the dye remains in the incisions, but washes off the skin, making the placing process easier. 11. Bandage up the donor area temporarily whilst working and put a cushioning pad on the donor site to help the patient feel comfortable while lying back.
cover story Dr Bessam Farjo
Before and after approximately 2200 grafts in one operation
Before and after approximately 3200 grafts in one operation
Before and after eyebrow restoration
Before and after hairline dense packing
transection of the follicles, trying to keep the bulbs intact as much as possible by performing a blunt dissection. You use skin hooks to separate the edges—rather than use a sharp instrument—so that you can end up with as many of the bulbs intact in the subcutaneous fat. In recent years when closing the donor area, we have used the trichophytic method. This involved removing the lower edge epidermis. Some use the upper edge, but when we’re exposing a cut hair, approximating one edge to the other, the cut hair will grow through the scar, further minimising the appearance of the scar. This enables the patient to have a much shorter haircut, if they desire. Once the strip is removed from the back of the head, it’s moved to a technical area where it becomes separated. The first step in dissecting the strip is “slivering”. Very thin slices of the strip are removed—about a millimetre wide— sticking to the principle that they are one follicular unit wide. The sliver is then moved to another part of the operating room, where it is separated into the individual follicular units that could be anywhere between one to four hairs each. Follicular unit extraction The alternative method of removing the grafts from the back of the head is FUE. This process has been popularised by celebrities such as Wayne Rooney. The method uses punches or drill bits between 0.7mm–1.0mm to extract individual units from the back of the head, rather than remove them en masse. One advantage of FUE is that there will be no linear scar at the back of the head, so theoretically the patient could have a very short haircut. There is minimal post-operative pain, because there’s no traction. Scalp elasticity is not an issue because you’re not moving any scalp, and there is less donor dissection so potentially fewer staff are required to perform the procedure. However there are disadvantages and it is more time consuming. The doctor has to remove each individual graft, so it can be more expensive for the patient. As you are spreading these grafts all over the scalp, you can extract lower numbers per operation. Generally we remove around 2,000 grafts or more using the strip technique, but to remove the same number of grafts by FUE, you need an area about three or four times as large. This often means you go into areas that are not considered permanent—in trying to avoid that you can end up with fewer grafts per operation. The patient will body language www.bodylanguage.net
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cover story Dr Bessam Farjo
After over 4500 grafts—a record for Dr Bessam Farjo
therefore need more operations to achieve a particular result. Additionally, because you are drilling blind—you can’t see through the skin— you may get a higher rate of transecting these follicles. To remove large numbers of grafts, the patient has to shave their head, so depending on the circumstances, it may not be convenient. If you don’t shave the whole head, you can shave thin strips and let the hairs in between camouflage them. However, by doing this you are further restricting the number of grafts that you could remove. In an ideal treatment, you may hardly be able to see where the grafts were taken from, but not everybody responds this way. If the patient has dark skin, the scars may be more visible. The future for FUE lies in further automation. There are a number of machines becoming available, such as the NeoGraft—a suction-based extracting device. There is also a machine which usess a computerised robot (ARTAS) that extracts the grafts for you. At the moment, the robot is quite slow but further models in the future should speed up—however, these machines are very expensive. Whichever method you choose to extract the grafts, you still have to look after them to ensure their best survival. They must be kept chilled and hydrated in a graft holding solution. We isolate the grafts that have one hair from those that have two hairs, or three or four hairs. That way you can plan the operation to keep the result looking at natural as possible. With regards to the recipient site, we use instruments—usually blades or nee-
dles—of various sizes depending on the size of the graft. Once we have controlled angles and directions, and made all the incisions, we start placing the grafts. The most important part of the recipient site is the design, which is mostly reflected in the hairline. It’s important to keep this feathery and irregularly irregular. Sometimes you may end up creating patterns. It is important that once you’ve created a pattern, you go back and disturb that pattern, producing peaks and troughs in an irregular way so that you are unable to identify one particular design. You need to follow the existing direction of the hair, and know when the hairs are supposed to curve to one side or the other, or whether the angle is changing from 30 degrees to 40 degrees to 45 degrees. If a patient is bald at the back, or they may lose hair there in the future, you need to create a feathery zone at the back. They need to look like they’re naturally balding into the bald area, so avoid having a sudden wall of hair in an unnatural way. Treating women Around 10–15% of our consultations are women, but they account for only 5% or less of our surgeries—fewer women are suitable for surgery than men. Women lose hair in a diffuse manner across the top, but the hairline usually stays intact. This is the most crucial area in women. If you can only restore hair in that area, with styling and colouring, patients can usually achieve excellent camouflage. Transplants in women are more limited. Usually 1,200 to 2,000 grafts is the maximum I can provide in one operation.
Women who undergo female pattern hair loss get a lot of thinning in the parietal area, making it less ideal to extract hair from without making the situation worse. Women’s scalps also tend to be tighter than in men, which means you can remove a narrower piece from the occipital area. Another complication that happens commonly in women is shock loss. This is essentially anagen effluvium—caused because you are operating on an area that does have some hair. You may get shock hair loss in the month or two after surgery, so the patient feels like they got worse after the operation. Usually the patient will improve, but as hair loss was traumatic enough in the first place, further hair loss due to surgery can be very upsetting. The reason for this loss may be mechanical and/or chemical. Mechanical, because of the action of the surgery— maybe you’re cutting across hairs—but also due to inflammatory reaction of the body. The body views the surgery as a kind of trauma, so we always warn patients at consultation that might happen. I don’t have scientific evidence for it but anecdotally, I feel that pre- and post-operative Minoxidil can help prevent that from happening. We also advise patients about camouflage products such as Nanogen. Other than female pattern hair loss, women may have a transplant because of hairline lowering. Some women have naturally high foreheads, where the hairline is located behind the curve of the forehead, making them feel self conscious. You could perform transplantation, providing they have no history of genetic hair loss. There are other non-androgenetic applications for hair transplantation, such ass scarring or cicatricial alopecia. Providing this has been dormant for at least two to three years, you can treat it with surgery. Women who have face lifts can get a complication where the hairline is lost in front of their ear, or they have visible scarring. You can reconstruct the area with transplantation, as long as you only use single and double hair grafts. Traction alopecia—most commonly in Afro-Caribbean women who do a lot of braiding or hair extensions—can be treated as well with hair transplantation. Dr Bessam Farjo is a hair transplant surgeon and co-founder of the Farjo Medical Centre in Manchester and London
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onfidence is Reliable1,2 Rewarding3 Performance4,5 BOTOX® is licensed for the treatment of moderate to severe glabellar lines Delivers long-lasting patient satisfaction, time after time2,3 Has been used for over 20 years in over 26 million treatment sessions worldwide6 Is the world’s first and most studied botulinum toxin*7
BOTOX® (botulinum toxin type A) Abbreviated Prescribing Information Presentation: Botulinum toxin type A (from clostridium botulinum), 50 or 100 or 200 Allergan Units/vial. Indications: Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar lines), in adults <65 years, when the severity of these lines has an important psychological impact for the patient. Dosage and Administration: See Summary of Product Characteristics for full information. Do not inject into blood vessels. Doses of botulinum toxin are not interchangeable between products. Not recommended for patients <18 or >65 years. Use for one patient treatment only during a single session. Reconstitute vial with 1.25ml of 0.9% preservative free sodium chloride for injection (4U/0.1ml). The recommended injection volume per muscle site is 0.1ml (4U). Five injection sites: 2 in each corrugator muscle and 1 in the procerus muscle: total dose 20U. Contraindications: Known hypersensitivity to any constituent. Infection at proposed injection site(s). Warnings/Precautions: Relevant anatomy and changes due to prior surgical procedures must be understood prior to administration. Do not exceed recommended dosages and frequency of administration. Adrenaline and other anti-anaphylactic measures should be available. Reports of side effects related to spread of toxin distant from injection site, sometimes resulting in death. Therapeutic doses may cause exaggerated muscle weakness. Caution in patients with underlying neurological disorder and history of dysphagia and aspiration. Patients should seek medical help if swallowing, speech or respiratory disorders arise. Clinical fluctuations may occur during repeated use. Too frequent or excessive dosing can lead to antibody formation and treatment resistance. The previously sedentary patient should resume activities gradually. Caution in the presence of inflammation at injection site(s) or when excessive weakness/ atrophy is present in target muscle. Caution when used for treatment of patients with peripheral motor neuropathic disease. Use with extreme caution and close supervision in patients with defective neuromuscular transmission (myasthenia gravis, Eaton Lambert Syndrome). Contains human serum albumin. Procedure related injury could occur. Interactions No interaction studies have been performed. No interactions of clinical significance have been reported. Theoretically, the effect may be potentiated by aminoglycoside antibiotics or other drugs that interfere with neuromuscular transmission. Effects of administering different botulinum toxin stereotypes simultaneously, or within several months of each other, is unknown and may cause exacerbation of excessive neuromuscular weakness. Pregnancy: BOTOX® should not be used during preganancy unless clearly necessary. Lactation: use during lactation cannot be recommended. Adverse Effects: See Summary of Product Characteristics for full information on side effects. Based on controlled clinical trial data, the proportion of patients that would be expected to experience an adverse reaction after treatment is 23.5% (placebo: 19.2%). In general, reactions occur within the first few days following injection and are transient. Pain/burning/stinging, oedema and/or bruising may be associated with the
injection. Frequency By Indication: Defined as follows: Very Common (> 1/10); Common (>1/100 to <1/10); Uncommon (>1/1,000 to <1/100); Rare (>1/10,000 to <1/1,000); Very Rare (<1/10,000). Infections and infestations. Uncommon: Infection. Psychiatric disorders. Uncommon: Anxiety. Nervous system disorders. Common: Headache. Uncommon: Paresthesia, dizziness. Eye disorders. Common: Eyelid ptosis. Uncommon: Blepharitis, eye pain, visual disturbance. Gastrointestinal disorders. Uncommon: Nausea, oral dryness. Skin and subcutaneous tissue disorders. Common: Erythema, Uncommon: Skin tightness, oedema (face, eyelid, periorbital), photosensitivity reaction, pruritus, dry skin. Musculoskeletal and connective tissue disorders. Common: Localised muscle weakness, Uncommon: Muscle twitching. General disorders and administration site conditions. Common: Face pain, Uncommon: Flu syndrome, asthenia, fever. The following other adverse events have been reported since the drug has been marketed: dysarthria; abdominal pain; vision blurred; pyrexia; focal facial paralysis; hypoaesthesia; malaise; myalgia; pruritus; hyperhidrosis; diarrhoea; anorexia; hypoacusis; tinnitus; radiculopathy; syncope; myasthenia gravis; erythema multiforme; dermatitis psoriasiform; vomiting and brachial plexopathy; rash; psoriasiform eruption; anaphylactic reaction (angiodema, bronchospasm); alopecia and madarosis. Adverse reactions possibly related to spread of toxin distant from injection site have been reported very rarely (exaggerated muscle weakness, dysphagia, or aspiration pneumonia which can be fatal). NHS Price: 50 Units: £77.50, 100 Units: £138.20, 200 Units £276.40. Marketing Authorization Number: PL 00426/0074 Marketing Authorization Holder: Allergan Pharmaceuticals (Ireland) Ltd., Westport, Co. Mayo, Ireland. Legal Category: POM. Date of preparation: November 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 Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026. References: 1. De Almeida A et al. Dermatologic Surgery 2007;33:S37–43. 2. Carruthers A et al. J Clin Res, 2004;7:1–20. 3. Stotland MA et al. Plast Reconstr Surg, 2007;120:1386–1393. 4. Beer KR et al. J Drugs Dermatol, 2011;10(1) :39–44. 5. Lowe et al. Am Acad Dermatol, 2006;55:975-980. 6. Allergan data on file. BOTGL/001/SEP 2011 7. Allergan Data on File VIS/006/JUL2011. *Allergan botulinum toxin type A. Global figures. Launched in 1989 in the US. UK/1010/2011 Date of Preparation November 2011
injectables Dr Nick Lowe
Botulinum toxins are the bread and butter of every aesthetic practice. Dr Nick Lowe runs through their history and types of toxins available, as well as their indications and side effects
A brief history of toxins
he term “botulism” comes from botulus—the Latin for sausage. This was described by a German physician in the late 1800s, as he was aware of Justinus Kerner’s work describing the syndrome of botulism from sausages. In 1895, the Belgian bacteriologist Émile von Ermengem, isolated the bacteria—Clostridium botulinum. Early in the 1920s, scientists in California tried to purify botulinum toxin A but it wasn’t until the Second World War that this research accelerated because they wanted to develop an antidote for what was planned as a potential weapon of biological warfare. US researchers crystallised the structure of type A botulinum toxin at a military establishment in Maryland. In 1949, in London, scientists showed for the first time that botulinum toxins block the release of acetylcholine, thereby reducing muscle power. In the 1970s Alan Scott, an ophthalmologist from San Francisco, was looking for a non-surgical way of correcting strabismus in children. His work with monkeys showed that you could selectively paralyse muscles and correct strabismus with botulinum toxin. He then proceeded with this work in humans, for strabismus as well as blepharospasm, yet it wasn’t until the early body language www.bodylanguage.net
90s, that its benefits were noted within the aesthetic arena. There are several different serotypes which influence different synaptic-controlling proteins. This may be one mechanism by which the efficacy of the different toxins are different and the duration is different. For example, we know that type A toxin has quite a different pharmacologic activity to type B toxin. Approval in Europe We have four approved botulinum toxins—three type A and one type B. These are the appropriate names for the different toxins: onabotulinum toxin A, abobotulinum toxin A , incobotulinum toxin A and rimabotulinum toxin B. The differences are mainly that incobotulinum toxin A has a very low protein content. The type B toxin also has different dosing characteristics and an acid pH with more injection pain and shorter duration than type A toxins. We must acknowledge the work of Jean and Alastair Carruthers as the first to identify the effects and the benefits of botulinum toxins in regard to reduction of facial wrinkle lines in the early 1990s. They published their first study in the Journal of Dermatologic Surgery, which began an interesting area of re25
injectables Dr Nick Lowe
search that I was involved in. Initially, a small group—comprising dermatologists, plastic surgeons, and head and neck specialists—worked on the use of type A toxin in facial wrinkles. The first controlled studies were published between 1993 and 1995, and then further placebo double-blind controlled larger scale studies in other areas, including crow’s feet, were performed later. In one of our early studies, we controlled the delivery with a recording electromyogram (EMG) to ensure we were delivering the toxin where we hoped it needed to be delivered to reduce the forehead lines. EMG is still is useful in certain situations, such as for training or with gross facial asymmetry and you need to closely target a specific muscle. In 1994, I opened my clinic in London—as my other clinic was in Santa Monica, I was able to perform some comparative studies with Botox and Dysport. Dysport was not yet available in the USA. We continued over the subsequent several years, with a variety of different dosing and pivotal studies that led to aesthetic approval of both Botox and Dysport in most countries. In Europe and the US, we only have one approved aesthetic indication for botulinum toxin Type A—for glabellar frown lines. For other aesthetic purposes, we use toxins off-label. While this could be regulated in the future, physicians and surgeons are currently allowed to use drugs for off-label purposes. Dosage One unit of Botox is not equivalent to X units of Dysport or X units of Xeomin. These are all different toxins and should be considered as totally different drugs. We must learn to use each different toxin as a separate drug. We have, however, carried out a study where we compared 30 units of Botox and 75 units of Dysport in severe glabellar facial lines and there were no statistical differences between the efficacies. It depends, rather, what dose you use, what dilution you use and which muscle groups you are treating. In terms of safety—diplopia, ptosis and so forth—Dysport and Botox were found to be exactly the same. Neither produced any problem safety-wise but interestingly, certainly at this dose, Dysport outperformed Botox. However, had we reversed doses and injected a higher dose of Botox, we may have seen a reverse effect, as effects are dose dependent. I tend to use a dilution that I can use the same volume for each toxin and use both Botox and Dysport in our clinic. If I am treating hyperhidrosis for example, I use much more diluted dosages than for muscle injection. You also need to get your doses right for the patient. What’s good in some countries is not good in others—a totally “frozen” face may be desirable in Beverly Hills, but may not be in London, where patients prefer perhaps a more natural look. In terms of type B toxin, you might need to use this if a patient has become resistant to type A toxin. There are also some rare instances where people are resistant to type A from the start. This is thought to be because of a mutation in the enzymes that control the snare proteins. But Type B toxin is not that easy on the patient. It is a very painful toxin, because it has an acid pH. The other problem is that even when you go up to relatively high dosages, you rarely get the efficacy beyond two or three months, so they need more frequent injections. Recently there has been a report to suggest that type B toxin for hyperhidrosis was as effective as type A. Incobutulinum toxin A does not contain much protein. In one of the first studies on the toxin, Gerhard Stadler in Ger26
Botulinum toxin A, molecular model
many compared Xeomin and Botox with a 12-week followup and found equivalent efficacy for glabellar lines. You need a little bit more Xeomin to get equivalence. I would say, if I were using 20 units of Botox, I might use about 25–30 units of Xeomin to get equivalence. Efficacy and safety I feel that people injecting botulinum toxin, which is a prescribed drug, should be sufficiently-trained clinicians. The patient needs a full medical history taken and a medical examinabody language www.bodylanguage.net
injectables Dr Nick Lowe
lift, I may choose to use Dysport. I can achieve a smoother, more natural effect using multiple small unit injections of Dysport. You should caution patients that they may need to come back for adjustment afterwards, sometimes a little sooner after Dysport than Botox in regards to the speed of onset. Sometimes after you’ve successfully treated glabellar lines, you may get supraorbital lines from the action of lateral frontalis, which usually need one or two units of Botox or two or three units of Dysport. If you’re starting off with toxin treatments, you really need to be aware that men are not ideal candidates to treat. There are a couple of reasons for this: firstly, if you elevate their brows too much, most men don’t like it; they also need much more toxin than women because their muscle bulk is much greater. You need a higher targeted toxin. Crow’s feet can really benefit from BTX-A. I always get patients to scrunch their noses because you’ll find that those paranasal muscles actually produce an increase of the infraorbital lines. I don’t inject much infraorbital Botox because it tends to add to post-Botox oedema. The other critical thing for crow’s feet to ensure you do not hit any veins. It’s difficult to avoid but it can be done with excellent lighting and needle placement. A European study showed that the optimum dose range— at least with Botox—in the lateral crow’s feet is usually 12–18 units. A Botox versus Dysport study using a 1:3 ratio, from San Francisco, with an increased benefit favouring Dysport, got equivalent efficacy statistically. You can measure crow’s feet scientifically with appropriate measuring cameras. The study results demonstrated that Botox showed a 50% reduction at about five days, whereas Dysport showed 79% at five days. There is no doubt that Dysport starts working more rapidly. But duration for both can actually last much longer than we originally thought—there was still efficacy as long as six months afterwards for both Botox and Dysport.
tion of the relevant areas. You need to decide if the patient is a candidate for botulinum toxin and the face needs to be examined very carefully at rest and at maximum muscle action. Consent forms need to be read. Photographs need to be taken and careful documentation is vital. Very importantly, you need to note the presence of asymmetry before you start treating the patient—if you first notice it or make a note of it after you’ve treated the patient, it’s your fault. Select the appropriate toxin in the appropriate dose and record very accurately injection sites, doses and toxins. Use of toxins If I wish to achieve a good brow lift, I want to have the toxin remain very focused in the brow depressor muscles—corrugator and procerus. At some dilutions, Botox does tend to stay more in the injection site. On the other hand, if a patient does not need much of a brow body language www.bodylanguage.net
Side effects We’re all going to see side effects—the more toxin treatments you do, the more side effects you are going to see. You’re going to give bruising sometimes—you just cannot avoid it. You can ask patients to avoid fish oils, nonsteroidals, aspirin and you’ll still get some bruising. You can get lower eyelid oedema, particularly with periorbital Botox. You can get brow and facial asymmetry as with some patients, it’s hard to judge. There are some less frequent but important side effects and it is very important to take a careful drug history. For example erythromycin and related macrolide antibiotics can increase BTX-A potency. The lower face, for example the depressor anguli oris and mentalis muscles, can be injected but can also give unexpected lower face asymmetry. I have become much more cautious in this area. There have been cases where overly enthusiastic treatment of platysmal bands have resulted in patients being admitted for artificial ventilation. One of the most exciting things coming out of California is the topical botulinum toxin from Revance, which uses a special percutaneous delivery system for botulinum toxin Type A. Studies have shown its efficacy for facial lines and hyperhidrosis by Rick Glogau from San Francisco. So we should keep an eye on topical therapy for the future. Dr Nick Lowe is a consultant dermatologist and teaches at UCLA School of Medicine as a clinical professor of dermatology. 27
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peer press review
Peer press review Ravi Jandhyala surveys academic and association journals to report on advances in research Subjective rating of cosmetic treatment with botulinum toxin type A: do existing measures demonstrate interobserver validity? Conkling N, Bishawi M, Phillips BT, Bui DT, Khan SU, Dagum AB. Ann Plast Surg. 2012 Oct;69(4):350-5.
This study explores the validity of subjective qualitative measures historically used to assess efficacy of botulinum toxin type A (BoNT-A) for aesthetics, making particular reference to the Facial Wrinkle Scale (FWS) and Subjective Global Aseessment (SGA). These measures are able to define whether BoNT-A has provided improvement versus baseline in the treatment of facial wrinkles. Botulinum toxin injections were performed for the aesthetic indication in six patients recruited as part of an institutional review board-approved investigation. Subjects were photographed at rest and during animation—raising eyebrows, frowning and blinking—before treatment and at one, two, four weeks and monthly, with follow-up to six months. Standardised digital 8″×10″ prints were scored using the FWS by board-certified plastic surgeons (n=5), general surgery residents (n=3) and medical students (n=4). Photographs at each time point were then compared to baseline using the SGA. Statistical analysis of observer data was performed using SPSS v19. Cohen κ (FWS) and Spearman ρ (SGA) were calculated for each pairwise comparison of observer data, with a conservative α of 0.01. The FWS observer scores for the upper face were generally in agreement, with no negative κ values. Distribution, even among members of a sin-
gle group, was highly variable. Agreement among plastic surgeons was the greatest (κ, 0.1940.609). Resident concordance was moderate and medical students displayed the most variable agreement. Spearman ρ for SGA scores was much higher, with surgeons approaching excellent agreement (κ, 0.4430.992). In comparisons between members of different groups, agreement was unpredictable for both the FWS and SGA. Comparisons using scores from individual areas of the face were the least concordant. The FWS and SGA represent the current standard of cosmetic outcomes measures. However, when subjected to scrutiny, they display relatively
body language www.bodylanguage.net
unpredictable agreement even among plastic surgeons. Compared to the FWS, the SGA has a more acceptable user concordance, especially among plastic surgeons accustomed to using such scales. The inter-observer variability of FWS and SGA scoring underlines the need to explore objective, quantitative cosmetic outcomes measures. This paper highlights the shortcomings of qualitative versus quantitative assessments in clinical studies. The findings are interesting for botulinum toxins, as these will have demonstrated their efficacy over placebo using subjective, qualitative ratings in their phase III studies. There should be no doubt that BoNT-A’s do work
for the treatment of glabellar lines as well as other areas of the face. However, the question this paper raises is: should FWS and SGA have been used to measure changes in wrinkles pre- and post-treatment in pivotal studies if is there is such variability between observers within the same group and also between groups? Would selecting a different group of observers influence the overall outcome of the study? The alternative—a quantitative, objective measurement—would still suffer from a degree of error but would be very small in comparison. The reality is that quantitative wrinkle depth measurement may have been viewed as a
peer peer peer to press review
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Date of Preparation: January 2012 UK/0023/2012
good, compared with sunscreens,and at prowith natural is extremely more complicated, cumbersome changed topical rules in ‘Which 2000, they botulinum toxin A was more theand safety istry were collected fromproducts consequently one tecting against sunburn. But we’reanot important. product than has gone and ultimately unnecessary told us that because the product conona botulinum totalre-of 1256 subjects. Unless theeffective should I choose?’ ally talking about oxygen radical protecthrough rigorous blinded or a tained endpoint prior to this study. If toxin Aplacebo in achieving responsemore than On analysing the responses, 10% natural as products, These questions, well as tion when we speakcontinue about sunburn—it’s prescription trials, I theystudcurrent regulators to the study found defined in the included that therecontrolled were as clinical were nothe longer going to regulate that. competitive environment more of an inflammatory would label the difnaturalies. claims as voodoo be satisfied with the use ofresponse. the no statistically However, the scale of this between manufactures, have significant Q What dofuelled Most the oxidative ultra- between science.inco Companies youwas to sell FWS andofSGA, the overallstress im- and advantage not clinically thinktheabout thearound fact that ferences botuli- wanting debate the violet lightbecomes from UVA which product have to prove it works pact may an academic one.light,num meaningful. Ofand 11 clinical and relative toxin Atheir and ona botulinum the pendulum has potency shifted so that of much inco botuisThis obviously important is safe. to physician preclinical studies identified is a good exampletoofprotect the against. toxin A relating we are getting patients D linum toxin Awith andvitamin ona botuSo it’s astruggle bit radical at this point and but subject my satisfaction, A review dosages was carriedcomparing out by Dr Pinnell eternal between qualiinco botulinum deficiencieslinum because protecting toxinweAare since the UK own is that sunscreens 2006,experienced. that discussestoxin the difficulty tativefeeling and quantitative methods are A and with ona botulinum andgood adversein effects ourselves from sunofdamage? launch inco botulium toxin for protecting yourself against excessive delivery of these typestoxin of agents. You’re of assessment. A directly, the weight of APinnell: Both botulinum toxin type A Dr Sheldon I think solution in 2010. Since the then, bench sunThe exposure. I always come to the being to sell a lotevidence of products with that small numbers of ob-backpreparations suggested there were asked well tolerated to the problem is potentially studies using the simple—diemouse LD 50 point I’m astudy guy, may and also guys don’t use many serversthat in this differenceare in thetary relative and effective in thedifferent treatmentingredients. of was no Patients supplementation vitamin assays haveofgiven way D. to Even more sunscreens because we’re not usedupper to hav-facialexpecting youtotolow tell them what’s safetwo andproducts. have contributed to the variabilpotency of the Asit doesn’t lines. Due though a lot of exposure clinical take assessments of their ing things onbut our the face.statistical treatment numbers, effective abo for botulithem. In such, one screen we should did continue ity reported, clinicians to make therelative daily potency. amount of vitamin D certainly, can to use antioxisix vitamin C products, only one testsBut used have beenyou selected to consider the had formulations to need Prager’s num toxin of A was not included studyskin, adopts a questhat you on exposed we’ve got dants which feel at all.in We’re measurable UVB-induced minimise thisyou as a don’t confounder. be equipotent until clinical evi-so protected, the statistical analysis.benefit against tionnaire-based retrospective people even in places where talking half theconsider population, Overall and erythema, the specific reaction that we they Overall, about one should to the contrary becomes study findings of dence review approach. The don’t get exposure, that it’scombined possible ifthewerating can get them use antioxidants to were looking in human skin. scale usedto when in- this retrospective available. analysisforconcases collected was that we are number creating of a vitamin D deficient protect themselves, that would a big terpreting clinical studies and be firm the results of prospective population.impressive and the multi-centre QbyIndemonstrating advantage. the US, the FDA has come forComment accept a degree of both inter- clinical trials approach a longof way in In America, aboutgoes one third people ward to regulate you Each of theDo three commercially and intra-observer variability that, in daily practice, inco bot- sunscreens. reassuring the findings get blood studies that us arethat vitamin D defiQ There are some sunscreens there toxin think thisona might in thetoxins—inco supple- cient available botuliwhen subjective measures are out ulinum A and botu-happen not of a single observer. so howwere do you decide what the minthat aretoxinment used. contain antioxidants. What linum A areworld? used at a 1:1 num toxin A, ona botulinum The statistical imal daily requirement is in thosemodelling circumyour thoughts on that combination? Dr display Carl Thornfeldt: thinkA there is a botulinum and abo dose ratio and compara- Itoxin in my vitamin study supstances. Butundertaken even with dietary D Dr Sheldon Pinnell: that it will, astoxin well A—are as somedistinct, cos- supplements, Botulinum toxin I don’t type have A any not only ports bleprobefficacy chance and safety. the still overall of people aren’tfinding drinking lem with a combination product, as long meceutical regulation.inI their was structure glad to see treatment to the upper but inortheconsuming way Prager and products other authors on the dairy or there’s as it works. There areanalysis lots of antioxidant the FDA come out with final ruling, something Relative potency of inco face: retrospective theya are manufactured. Regu- wrong subject,with showing thatthat incowe’re botthe test products out there but they use ingredibecause lot of require researchthat hastheydoing botulinumparticularly toxin A vs ona a lators of daily practice are not ulinum toxin A was or our understanding of it.expected I think ents don’t etknow how to getIn-intobotulinum skin— shown criticalconsidered aspect for the deWelf IPrager al. Clin Cosmet toxin that A: athe metasame it’s product to problem outperform a serious thatona we botulinum shouldn’t some incredibly antioxidants, so ofvelopment of skin cancer is sunburn different cell ignore vestig are Dermatol. 2012;good 5: 53–58. analysis key evidence. by requesting prodtoxin A, the based on all the assoavailjust because dermatology the comparisons you2012 usually see are, “My R.damage a variety ofuct other signals thatonlyciations Published online June Jandhyala J Drugsand Dermatol. names. So not are they say able The ‘but’ here is that thatdata. it’s not important. antioxidants are 21 better than yours.” we look at. 2012But Jun;11(6):731-6. Physicians from Germany‘different’ in the eyes of the reg- the difference in FWS modelled their to paper do reviews The the correlation just but protecting evidence ofulators based clinical centres trials were have askednothing to This their units Q areI’ve cal- started was 4% of a single on a taking bloodgrade samples with getting the product through straagainst erythema not enough. De-Each from a different angle to Prag-wasculated complete questionnaires based the differently. wrinkleIscale. is a clinically ofmanuevery patient see,This which include tum doesn’tfiles get through, struction occurs in the skin atuses sub-eryer’s 2012 study. The study comon ancorneum; inspectionifofitsubject facturer their ownvitamin way of Dundetectable difference my studies. Around 90%and have it’s in the thema doses theredefining are a lothow of differreviewand of the for dead subjects 18 water. years of age or prised a systematic many units there low final conclusion remained showed levels. Even my staff, that inDr Carl I’d at like to second Dr supporting ent effects that cells. literature, the can twooccur over, whoThornfeldt: had received least arein inaffected a 50 or 100 unit vial. The me, theshowed two products are expected cluding to be deficient so Pinnell screened ourand involving But the FDA is somewhat budg- we all toxins a specially two, butonnotthat. moreWhen than we three, onlybound directbyhead-to-head ranto achieveDthe same outcome if had vitamin shots. botanicals, of whichwith were reported issuesmodel and has been as aggressive constructedetary statistical to notdomised consecutive many treatments clinical studyDr carried used at the samesome doses. Carl Thornfeldt: With aspects of to lighteners toxin and depigmenters, wewhich in of thethesupplement they the two toxins, arena incobebotulinum A, ona explore out asforI think the aesthetics indicavitamin D issue, the jury is still out. could not gettoxin high enough be.would I would to see morenon-inferiority regu- The FDA Mr Ravi Jandhyala is a memrandom, be liketion botulinum A, or concentrations abo if chosen atshould found at recently changed the vitamin D of many botanicals have any at to lation incredible claims made berto of 600IU. the Royal College Surexpected achievebecause a better of outbotulinum toxin Atowithin a impact 24 units of each. In effect, RDAthis only up This was of shockall in the melanocytes. without credible clinical proof.that at those doses, a founding member 12-month period in the previ- come. means ing tono thosegeons of us and involved with traditionthatsubcould impact of our early products UKsee Botulinum Toxinpatients Group The paperOne demonstrated ousThe twodoses years.required Data on product we’d is anytaken worse than the ofwho al medicine a lot of those the produced such high through phase there two clinical forhistory. Aesthetics. He is also on the thatrates at a dose of 24 units, ject melanocytes and physician satisfaction, other.trials Thisand is awere different queswith a cancer of irritation.intervals, So the formulation chemthe FDA Body Languageinvolves editoriala panel a 94% preparing likelihood for thatphase inco three. treatment dosages was tionWhen to ‘which one is better?’ My patient population huge
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surgical Mr Omar Durrani
rejuvenation Ocular plastic surgeon Mr Omar Durrani discusses surgical periocular, or eyelid, rejuvenation, and the art of achieving a good aesthetic result while ensuring the eyes remain healthy
ne of the questions I often get asked is, “What is oculoplastic surgery?” Oculoplastic surgery is the surgery of the eyelids and surrounding area of the face—the eyebrows, forehead, cheek and mid-face. An oculoplastic surgeon is an ophthalmologist or an eye doctor who has undergone additional advanced training in dealing with problems of eyelids and the surrounding area of the face. When dealing with eyelids, it is important to understand that it’s not just a bit of skin, but a complex anatomical structure that has a key function in protecting and lubricating the eyes. The blink reflex physically protects the eyes and spreads tears across the surface of the eye. 32
Tears form the perfect optical surface on the eye that is essential for good vision. When eyelid function is reduced or damaged, vision can be compromised and the eyes can become dry, sore and gritty. The eyelid skin is the thinnest skin in the body and surgical trauma causes lot more swelling and bruising. The complexity of tissues in the eyelids and the periocular region is due to the presence of fascias and sheets of muscles that either open or close the eyelids. The inferior and superior oblique muscles—eye movement muscles—sit just behind the lower and upper eyelids at the eye socket rim. You also have tear ducts and the tear sac in the inner corner of the eye. In addition to periocular plastic surgery, body language www.bodylanguage.net
surgical Mr Omar Durrani
an oculoplastic surgeon is a trained eye consultant and aims to achieve a good aesthetic result whilst ensuring that the eyes remain safe and healthy. Facial ageing We all understand that ageing is about volume loss—the effects of gravity and environmental factors such as sun exposure, smoking, diet and hydration. There are also changes to the bony skeleton that have an impact on the facial soft tissues. Over time the smooth facial curves become valleys, hills and furrows and this is what we try to address with rejuvenation therapies—toxins, fillers and lasers—with surgery being one of the many options. Eyelids are continuous with the eyebrows above and cheek below, so when considering eyelid rejuvenation we must think more broadly to include the cheek and the brow during clinical assessment and planning of surgery. Therefore, good eyelid rejuvenation is actually “periocular” rejuvenation. The aim is to achieve natural results with a minimally invasive treatment, as most patients don’t want to have weeks of downtime. The brow shape itself can change with fashion from relatively flat to high and arched. Generally, if you look through the ages, a young brow tends to be relatively flat with the outer third of the brow being slightly higher than inner part of the brow. Ageing changes tend to affect the outer one third of the brow. The reason for this is anatomical. The middle two-thirds of the brow is supported by the frontalis muscle. The outer one-third doesn’t have that support and the obicularis oculi fibres—the muscle that closes the eyes—in that area actually produce a vertically downwards pull on this outer third of the brow. Assessment for surgery When assessing the periocular region, the upper eyelids, eyebrows and forehead are considered a single unit. The lower eyelids and the cheeks/mid-face are also assessed as a single unit. With the assessment of the upper eyelid, there are many different things to look for, such as brow height in relation to the superior orbital rim and the distance between the lower limbus (junction between the white and dark part of the eye) and the brow—a fairly static lower point to measure from. If you use any other point it can be quite variable. Another important measurement is the amount of skin between the lash line or the lashes to the lower end of the brow where the natural hair of the brow would be, and not the plucked area. Also look for subtle changes and signs such as loss of brow tissue volume, orbital fat protrusion and drooping of the eyelid (ptosis). When assessing the lower eyelids one must look beyond the usual features like excess skin, eye bag formation (fat prolapse) and give due attention to the position of the outer corner of the eye in relation to the inner corner, laxity of the eyelid and the prominence of the lower orbital rim and cheek bone Ageing changes in the cheek mid-face area result in the sagging of the fat pads from the malar prominence (cheek bone) towards the naso-labial fold. This results in the apparent lengthening of the lower eyelid. When combined with the loss of skin volume, this results in formation of a hollow or tear trough deformity between the lower lid and the cheek. A recent paper showed that there is shrinkage of the facial bones with age, showing that there are anatomical changes to the skeleton and loss of bone. So eventually—when we learn how—real rejuvenation will start with the bone. We’re not there yet, so we’re dealing with the soft tissue changes that occur partly because of the anatomical bony changes. body language www.bodylanguage.net
Before surgery: Upper eyelid hooding and brow droop
After: Upper eyelid blepharoplasty and trans-bleph (no scar) endotine brow lift
Before: Upper lid hooding, lower lid bags and severe mid-face volume loss
After: Upper and lower blepharoplasty and trans-bleph endotine midface lift 33
surgical Mr Omar Durrani
Before surgery. Note Upper lid hooding, lower lid bags and micro ptosis (drooping of eyelid) After surgery. Patient underwent upper and lower blepharolplasty, cheek lift and micro ptosis repair. The micro ptosis repair enhances the overall results and brightens the eyes
Surgical technique A key point to remember when performing surgery around the eyes is that less is often more. For the upper eyelids to function and close properly, there must be at least 20mm of skin between the roots of the lashes and the lower margin of the brow. One of the most challenging groups of patients that I deal with are those who have undergone upper eyelid blepharoplasty surgery previously, where too much skin has been removed. The patients are unable to close their eyes fully which results in symptoms of irritation, soreness and grittiness due to dryness of the eye surface. A skin graft may be needed to correct the problem so itâ€™s always best to be cautious. The key to great outcomes in upper lid blepharoplasty is the correct placement of the skin crease, contouring of the orbital fat pockets and repositioning of the brow fat pad. Micro-ptosis must be identified and corrected during the blepharoplasty In patients with heavy brows, it is often necessary to perform a brow lift in combination with eyelid rejuvenation. This can be performed endoscopically from behind the hairline or through the upper lid blepharoplasty incision so there is no need for additional incisions in the hairline. The endoscopic procedure is more suitable for patients with heavy brows whilst the transblepharoplasty procedure provides good results for most other patients. Lower eyelid rejuvenation aims to restore a single smooth surface between the lower eyelid and the cheek. In patients with prominent fat pockets or eyebags without excess skin, the blepharoplasty can be performed from inside the eye (transconjunctival) without a skin incision. Prominent hollows or tear troughs can also be corrected by performing an additional septal reset procedure at the same time. In patients with excess skin, the incision is made just below 34
the eyelashes and runs outwards from the outer corner of the eye for about 10mm. Skin removal is usually quite conservative, especially in the vertical vector below the lashes. The key to great results is to perform a resuspension of the orbicularis muscle and the mid-face, where appropriate. The septal reset procedure involves involves redistribution of the prolapsed orbital fat of the eyebags as well as repositioning of the orbital septum, which is a fibrous membrane just behind the orbicularis muscle. This changes the little bump or hill of the lower lid in to a smooth curveâ€”thatâ€™s what patients love. In patients with significant loss of cheek volume or displacement of the fat pads, a cheek or mid-face lift can be performed through the lower lid blepharoplasty incision. The lift is performed either with special stitches or the endotine cheek lift device. The cheek lift when combined with a lower lid blepharoplasty gives amazing results but patients have to be made aware that full recovery can take several weeks. So, what are the risks of ocular plastic or periocular rejuvenation? Most of the problems are minor and settle down by themselves. These include bruising, swelling, transient blurring of vision and dry eyes. Double vision can occur due to entrapment of the inferior oblique muscle in the scar tissue, which can require additional surgery to correct. Extremely rarely, lower lid rejuvenation surgery can cause loss of vision because it is a very vascular area. Very occasionally you can get an alteration in the eyelid position called ectropion, where the eyelid is pulled down and away from the eye. Most patients have natural looking results and are quite satisfied by what is achieved. Mr Omar Durrani is a consultant ophthalmic plastic and reconstructive surgeon at the Birmingham & Midland Eye Centre body language www.bodylanguage.net
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aesthetics Mr Kambiz Golchin
Beyond PRP Mr Kambiz Golchin highlights current debates around platelet rich plasma biotherapies and discusses the introduction of regenerative biotherapies into clinical practice, from a clinician’s perspective
he “vampire face lift” is currently a hot topic in the media, with people clamouring to find out more about a natural, nonsurgical approach for skin rejuvenation. This excitement has led to a growing interest amongst clinicians to learn more about the indications and applications of autologous platelet rich plasma (PRP) therapies and how best to integrate these biotherapies into clinical practice. The consumer hyperbole surrounding PRP therapies presents the clinician with a conundrum—should we use PRP or not? If so, for what clinical conditions and should it be used as a stand-alone treatment or as part of a combination therapy? We are approaching a tipping point in bio-regenerative therapies, fuelled by demand from an increasingly sophisticated consumer seeking a minimally invasive, natural approach to aesthetics. Simultaneously, clinical applications of autologous bio-regenerative therapies available for clinical applications are expanding rapidly. So before embarking on the bio-regenerative pathway, we need to consider the following: body language www.bodylanguage.net
• Which conditions will be treated with PRP biotherapies? • What skills and equipment are required? • What is the safety profile of the biotherapies and consider the supporting scientific and clinical evidence? • How do we incorporate such treatments into our clinical practice, taking into account the learning curve and weighing up the return on resources? • What is the cost benefit to the patient—and to the clinician—versus other treatments? First and foremost, understanding the science of bio-active therapies is essential in ascertaining the scope and limitations of autologous PRP therapies. There were three critical criteria I considered before considering PRP biotherapies: what I wanted to achieve with the introduction of biotherapies into my practice; the scientific rationale aligned with the clinical safety and efficacy; and the technologies available. The scientific rationale for the use of concentrated PRP is both elegant and intriguing. The mechanism of action is
based upon the release of a cocktail of growth factors from the α granules of the platelets to stimulate tissue regeneration and enhance healing. The scientific rationale Described by Marx et al. in 2004, platelets contain seven fundamental groups of protein growth factors, which are released to initiate wound healing. They include three isomeres of platelet derived growth factors (PDGFαα, PDGFαβ, PDGFββ), transforming growth factor (TGFβ1 and TGFβ2), vascular endothelial growth factors (VEGF), transforming growth factors and insulin-like growth factors (IGF). These growth factors are involved in the intricate regulation of cell migration, attachment, proliferation and differentiation, combining to form an extra-cellular matrix formation by linking to specific cell receptor sites. Cell adhesion molecules, such as fibrin, fibronectin and vitronectin also play an important role in this matrix formation. The concentrated platelet rich plasma (cPRP) is used to stimulate cell prolifera37
aesthetics Mr Kambiz Golchin
tion and initiate the re-modelling of the extra-cellular matrix, which is particularly beneficial in the rejuvenation of aged and photo-damaged skin. Though the scientific rationale for the use of PRP biotherapies is sound, researching the clinical literature was like opening Pandora’s box, revealing a burgeoning amount of literature littered with variable results, reflective of the wide variety of technology, equipment and techniques employed for the production and applications of PRP. Scientific debate is centred on a number of issues: the classification of PRP; the optimal concentration level of platelets that will provide the best results; the role of leucocytes and fibrin; and how to reduce variability in clinical results. Upon investigating the data, it revealed that PRP is actually a misnomer and often used as a broad generic term that belies the spectrum of a broad and complex range of biotherapies and formulations. Research suggests that it is not just about the quantity of the platelets but emphasis should also be placed on their quality Scientists and clinicians suggest that PRP therapies should be differentiated and defined by their bioactive nature, which is based upon platelet concentrations and leucocyte levels. Increasingly, they are designed and formulated for their intended clinical application—the emergence of “condition specific” biotherapies and the ability to design a unique biotherapy according to a patient’s specific clinical condition. We are already seeing this trend with the emergence of “premium” PRP skin regeneration therapy, offered by the Seish-
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en Institute for Regenerative Medicine, which has significant experience in PRP biotherapies. While debate on optimal platelet concentration continues, increasing scientific research supports the concept of platelet dose related tissue response. A 2006 study by Eppley et al, published in the American Journal of Plastic & Reconstructive Surgery, stated, “In vitro, there is a dose–response relationship between platelet concentration and the proliferation of human adult mesenchymal stem cells, the proliferation of fibroblasts, and the production of type I collagen.” Understanding the PRP mechanism of action allows the clinician to design the appropriate biotherapy for the patient and their uniquely individualised treatment requirements, with clinical safety and efficacy as the critical measurement tools. Expanding the debate about what technologies to choose, in 2010 Castello described evidence of “significant difference in platelet capture efficiency” indicating how some technologies and equipment significantly out-perform others in their ability to process platelets and maintain the bio-integrity of the growth
Technology drives the formulation of the biotherapies 38
factors and clinical effectiveness. Choice of PRP technology Investigating the plethora of PRP technologies available was a revelation—pity the clinician faced with such extensive choice, ranging from the basic centrifuge, which uses small amounts of blood and a single spin cycle, to the fully automated blood processing systems, dual spin cycle. I required a system that would provide a range of autologous biotherapies for different applications, including: • Combination laser and PRP injections plus autologous fibrin gel, applied post-laser for non-surgical face lifts— my so “Angel Face Lift” technique. The PRP injected into key areas and the autologous fibrin sealant sprayed over the lasered area is yielding significant results. • Mixing PRP with fat grafts, a technique defined as BEAT (Bio Engineered Adipose Tissue Graft). • Skin rejuvenation with PRP and autologous thrombin mix, to provide a filler effect, particularly in the difficult to treat tear trough areas. The uses for an autologous fibrin gels and PRP combination are expanding rapidly and colleagues are also using the fibrin sealant technique for abdominoplasties. My choice of technology was based upon the need for a whole blood processing system that can be used in the hospital setting. I also needed it to be used at point-of-care and able to provide a range of high quality PRP biotherapies, using state-of-the-art technology and sterile conditions. I use the Cytomedix Angel Blood Processing System, which is backed by clinical data and used globally and in UK hospital settings for various disciplines including orthopaedics, advanced wound care and osteoarthritis. The main reason I use this system is the results—particularly in terms of processed yield of concentrated PRP and growth factors. continued on page 40 body language www.bodylanguage.net
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aesthetics Mr Kambiz Golchin
1. Platelet at rest with alpha granules 2. Activated platelet releasing the growth factors, chemokines and cytokines
For clinical effect you have to achieve a platelet concentration that is at least twofold the patient’s own baseline. The Angel System is fully automated and can be programmed to deliver a range of different platelet concentrations from 1x baseline up to 18x baseline. Using a double spin, it yields high concentrations of growth factors, progenitor cells-HSC, and MSC. PRP in practice When I started working with PRP about seventeen months ago, I did a pilot study to convince myself the technology worked. I used two sets of identical twins—one twin was injected with PRP and the other just with saline injections, neither knowing exactly what they were having injected. In the first few weeks nothing really happened. Initially, I was a little disappointed but then realised I’d been looking at this technology in the wrong way. It doesn’t work like a dermal filler or botulinum toxin injection—both have very immediate, predictable results. What I have seen with PRP is that, over time, the skin quality measurably improves in both texture and tone and fine lines will disappear. In my own experience, my first patients are still recording satisfaction with their results. 40
PRP works as an effective treatment in isolation, but recently I’ve been combining it with other treatments such as laser skin resurfacing with excellent results. With the laser I’m treating the epidermal level of the skin, stimulating the fibroblast layer. Fibroblasts lie dormant in the skin but when stimulated, they produce collagen, which depletes as we age. The laser stimulates the fibroblasts very effectively but when you combine with PRP combined with the use of the autologous fibrin gel topically, the healing process is much more improved and you also decrease the side effects of the laser treatment. One of my concerns about the field of aesthetic medicine—and this does not just relate to PRP—is that when a new machine or new treatment concept is successful, the market is quickly flooded with cheaper, less effective and, sometimes, less safe copies. Then patients either don’t get the results they have been promised or, worse, complications and side effects occur. Clinical practice now has access to technologies and equipment, previously the exclusive reserve of hospitals and clinics. We are still very much in the early days of PRP therapies and technology but I believe it’s the future of aesthetic medicine.
Mr Kambiz Golchin is a consultant ENT and facial plastic surgeon based at the Beacon Face and Dermatology Clinic, Dublin. T: 020 7788 7828 for more information on the Cytomedix Angel Blood Processing System REFERENCES Marx, R.E. et al. “Platelet Rich Plasma: Evidence to support its use.” Journal of Oral Maxillofacial Surgery 2004. Vol. 62:489-496. Ehrenfest, D.M., Rasmusson, L., Albrektsson, T., “Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF)” Trends in Biotechnology 2009. Vol 27 No 3 ; p160 Eppley, B. L., Pietrzak, W.S., Blanton, M. “Platelet-Rich Plasma: A Review of Biology and Applications in Plastic Surgery.” American Journal of Plastic and Reconstructive Surgery November 2006 pp. 147e-159e Castillo, T.N., Pouliot, M.A., Kim, H.K., Dragoo, J.L. “Comparison of Growth Factor and Platelet Concentration From Commercial Platelet-Rich Plasma Separation Systems”. American Journal of Sports Medicine November 2010.
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evitacare is the facial rejuvenation product range that can achieve both in-depth and onsurface action to prevent, correct and reduce all signs of skin ageing. The range provides three different concentrations of non-cross linked hyaluronic acid—2mg,16mg,32mg—to suit individual skin needs. Special features • Contains CT50 rejuvenation vitamin and trance elements complex that can restore skin’s youthful healthy glow. • Treats indications including: crow’s feet, perioral folds, fine-lines, wrinkles, uneven skin tone, loss of skin elasticity ,dry and dull skin, reduction and correction of most skin ageing signs plus prevention of skin ageing. • Revitacare can be injected using filler injection techniques, nappage, point by point and cross-hatching technique. It can also be administered with a dermal roller or other transdermal systems.
• Revitacare has achieved 96% satisfaction rate among patients and practitioners in a panel of 35 patients in two independent trial centres as regards the hydration, radiance and filling effect as well as the comfort level during the treatment. Specific action Revitacare products work on both fibroblasts and keratinocytes, enabling in-depth and on-surface synergic action leading to the densification of the dermis. The range is proven to have optimised hyaluronic acid (HA) hydrating and antioxidant power thanks to its brilliant and unique combination of HA and CT50 in comparative studies with similar products. Guaranteed quality Revitacare products are manufactured by Revitacare laboratories—a French company with more than 15 years of experience and which has received a certified authorisation by French Health Products Security Agency(AFSSPS). The manufacturing process is monitored during each step to ensure the quality and safety of the production.
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nutraceuticals Catherine Quinn
Beauty from within Anti-wrinkle pills and sweets which act as internal deodorant? Catherine Quinn investigates whether the world of nutraceuticals is proven and profitable
hen collagen marshmallows first launched in Japan, they were thought an eccentric product in the West. Seven years later and the notion of “nutraceuticals”—foods and supplements which confer genuine cosmetic benefits—has sky-rocketed. With attractive products now in on the market, it could be worth considering some ranges for your clinic. Particularly since this year has seen the launch of everything from deodorant candies to age-spot reducing juice drinks. “Beauty and food industries have always overlapped substantially,” explains nutritionist Sam Paget of Nutrition Consultancy Paget & Coles, “but the last few years have seen a revolution in nutraceuticals. Clients now understand that ingestible products can confer cosmetic benefits, and that benefits can be more substantial than those derived from creams and lotions.” According to Sam, this change has partially been driven by improvements in the products themselves. “A few years ago we saw things like collagen marshmallows sell in Harvey Nichols,” she explains, “but they were more of a cute gimmick than an ongoing cosmetic benefit. Now we see clinically proven collagen supplements, and antioxidant drinks which have real scientific weight behind them.” body language www.bodylanguage.net
Edible cosmetics In terms of food products, the US are leading the trend with big brands like Borba launching Skin Balance GummiBears, and anti-acne skin chocolates by Genuine Health. But this year the UK has launched some products with genuine clinical acclaim, including an anti-age-spot smoothie. AS10 is a fruit drink initially developed by NASA to protect astronauts against radiation. Since it’s been found to reduce age damage and sunspots, the smoothie is now selling by the bottle for cosmetic purposes. With a price tag of £120 a bottle it’s not a cheap option, but for clinics offering age-spot reduction treatments, this could be a highly effective addition. Other products which would make good counter-top impulse purchases are a new range launched by BeautyIn. Coming to clinics and gyms this year, BeautyIn have a range of flavoured collagen waters, collagen beauty bars and vitamin enriched sweets. The brand might not have the clinical credentials of products like AS10, but as a grab and go range they’re an attractive option for those looking to sell snacks and drinks. More on the novelty side, are Alpi’s deodorants sweets which are big sellers in Europe, and are launching in the UK this year. The sweets come in rose and vanilla flavours, and a pack a day 43
nutraceuticals Catherine Quinn
Combination Ranges For clinic sales nutraceuticals also make a good choice for selling in combination. And several product ranges exist which combine topical products with nutraceuticals. The advantage of these products if they’ve been developed to work together, so the topical and internal benefits should be amplified. Jane Scrivner’s rose hip oil can come sold in a pack with an wrinkle-reducing oil for the skin. Whilst Caudalie have an impressive range of similarly proven creams and lotions to go alongside their supplement. BioBees also have skin-cream to complement their royal jelly range, and all of these products make an attractive shop-front when stocked together.
is claimed to produce scent from the inside out. Using the same principle as garlic, the sweets contain an undigested scented compound which is passed out through sweat. Borderline nutraceuticals are now hitting mainstream supermarkets, suggesting customers are more receptive than ever to these products. “We’ve seen a boom in specialist juices like beetroot and cherry,” says Samantha Paget, “and these drinks are being sold as having specific pharmacological effects as well being generally ‘good for you’.” Supplements While food products are more of a novelty for the time-being, however, nutraceutical supplements are growing into a booming industry. For both scientists and consumers, they’re often easier to understand in terms of clinically trialled results. Clinical breakthroughs have identified key ingredients which are proven to reduce age spots, aid collagen production, thicken the dermis and reduce wrinkles. Many of these findings are now finding their way into attractively packaged and proven products. Antioxidants Antioxidants are key for reducing age-spots—they can also help with skin firmness and reducing fine lines. The current favourite is lutein, an antioxidant derived from green leafy vegetables and part of the vitamin A family of carotenoids. At a dose of 6mg a day it has a proven antioxidant effect, and can even form a kind 44
of “internal sunscreen” if taken regularly. Other proven compounds include French Pine Bark, green tea extract and grape seed extract, and products which feature these ingredients are likely to be well-researched. Resveratrol— a compound derived from grape skins—has a compelling evidence base for wrinkle reduction. Seven Seas are currently launching three new age-targeted products as part of their Ilumina range, all of which carry the proven 6gm dose of lutein alongside fish oils, green tea and lycopene—an antioxidant derived from tomatoes. Colladeen Visage by Nature’s Best comes with evidence it will work as a sunscreen. As well as green tea extract and lutein, the product uses a proprietary blend of anthocyandins— a type of flavonoid. Their clinical trials suggested the product improved skin firmness, reduced wrinkle depth and provided a natural SPF of 15 after a twelve week course. Another antioxidant product with heavyweight clinical credentials is Imedeen. Their range of age-targeted products also use lycopene and lutein, as well as their own patented fish extract. A year’s trial of the product found a daily dose reduced signs of ageing by 48% and improved dermal density by 122%. The product also improves collagen production. Resveratrol is gaining ground, based on research surrounding the “French paradox”—the idea that the French derive antioxidant benefits from red wine consumption which aids health and longevity. Resveratrol supplements vary in their dosage, and the current leader for well-researched products is Caudalie who have their own patent on a resveratrol blend “Vinexpert”. Their results are very impressive—after three months on Vinexpert, wrinkle surface had decreased by 53% and dermis density increased by 17%. Supplement 27 by ME SkinLab also uses a clinically proven dose of resveratrol, alongside an herb extract shown to increase collagen. French pine bark is also attracting a lot of attention. This pine derivative has antioxidant properties, and has also been shown to help vascular health—ideal for preventing varicose veins and a healthy blood supply to the skin. Masqueliers has a supplement with a proven 50mg of French pine bark alongside their own patented flavonoid blend. Other companies add it as an ingredient, but often at a lower dose than trials suggest is effective. body language www.bodylanguage.net
nutraceuticals Catherine Quinn
Skin oil Besides antioxidant protection, the right kind of oil is crucial to healthy cellular skin production, and a plump, flexible skin matrix. With this in mind several nutraceuticals now deliver a clinically proven dose of various plant extract and fish oils. The idea of internally lubricating the skin may seem fairly basic. But in fact, ingested oil alter inflammatory pathways in the body and can either lower or increase inflammatory reactions which contribute to skin conditions like rosacea and eczema. So besides providing components to skin cells, the right kind of oil will also lower inflammation throughout the body. Products formulated for the beauty market include Jane Scrivener’s Rose Hip Oil, whilst Viridian have developed a range of Beauty Oils which can be taken by the spoon or drizzled over food. However, a basic Omega oil, can be considered a value purchase with cosmetic benefits. Other ingredients So what should you be looking for? Key antioxidants and skin health oils are part of the picture. But other ingredients show a nutraceutical is likely to be effective. Cosmetic surgery and Beauty Coach Antonia Mariconda recommends CoQ10, hyaluronic acid and Royal Jelly have highly beneficial results, alongside antioxidants. Royal Jelly has attracted some controversial findings, but emergent research backs the claims that it is a powerful immune modulator, reducing inflammation and aiding the immune response. Good quality Royal Jelly can be hard to find, as the process of extraction and preservation is vital to an effective product. For clinics looking for a proven format, BioBees has a range of fresh products.
Other ingredients are still emerging and the use of amino acids looks set to be promising. These compounds are part of proteins and, used in isolation, have been shown to have various effects on the body. New this year is Youth by BeautyWorksWest, which have combined specific amino acids with superoxide dismutase—a kind of supercharged antioxidant. The amino acids in the pills are associated with better digestion and muscle repair. Looking to the future we are also likely to see the food and tablet market blur even more, with pills developed from more unadulterated superfoods. The use of spirulina, for example by Vitalize’s new ProFerm, covers off a mixture of antioxidants in one, rather than individual extractions. With such a wide range of products to choose from, knowing which can genuinely complement your offering can be difficult. The good news is that most antioxidant supplements will deliver a benefit which your customers will see on their face as a healthy glow. The less good news is that unlike many other cosmetic treatments, these results take far longer to achieve. In the clinical trials most of the impressive findings have been between three months and up to a full year of taking a product. And as most clinics know, many customers looking for cosmetic benefit are after far faster results. But the clear advantages of nutraceutical foods and supplements is that the benefits seen on the skin is usually a sign of better overall health. So unlike a cream or a lotion, the glowing complexion is derived from the body functioning better as a whole. And as a reason to add a bottle of juice or a packet of pills to a cosmetic treatment, that should be an easy sell. Catherine Quinn is a nutritionist and freelance journalist
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dental Dr Anil Shrestha
The teeth are often overlooked when rejuvenating the face. Dr Anil Shrestha illustrates the importance of integrating dental analysis with aesthetic facial procedures
in facial aesthetics
he face is often the focus of attention when we form our initial impressions of someone. The teeth are a central part of the face and are often overlooked by medical aesthetic practitioners. However, it is important to integrate dental treatment with the holistic care of patients undergoing facial aesthetic treatments. Harmony The same aspects of facial aesthetics that make for an attractive faceâ€”despite cultural differenceâ€”also apply in dental aesthetics. These principles of symmetry, proportion and position are equally important and applicable in dentistry. However, more importantly than just subjective opinions, objective mathematical models for an attractive, harmonious appearance of teeth can be applied. For example, the theories of golden proportion have been the basis on which early studies of smile design were founded. In addition, specific micro-engineering and biological principles have been acutely developed in the prosthetic reconstruction of teeth and dental hard tissues, from the specific design of crown preparations to the modern use of dental implant treatments. A working knowledge of dental material science is an integral part of predictable reconstructive treatment planning, from centuries-old hard and soft tissue reconstruction using removable dentures, to cranio-facial reconstruction and restoration of the dento-facial skeleton and individual teeth using modern CAD/CAM technology. It may not be apparent to some aesthetic practitioners that the teeth are an integral and central part of the maxillofacial scaffold upon which the soft tissues of the face hang. The loss of teeth and the dento-alveolar complex often leads to loss of soft tissue support and signs of premature ageing and wrinkling. body language www.bodylanguage.net
The skills of a good dental surgeon can quite often restore soft tissue support and can obviate the need for the use of facial fillers in the perioral area. For example, eversion of the lips, the elimination of naso-labial folds and circumoral creasing following tooth extraction can be restored with the restoration of the dentition and alveolar bone which supports the hard tissues. Even a simple removable denture on its own can restore face height and soft tissue support. A contemporary alternative would be the use of bone grafting and dental implants to provide a non-removable and more appealing definitive result for the patient. Classical dentistry has always been important to overall facial aesthetics and how far we have come with contemporary dental treatments, all of which serve to
enhance the overall holistic care of our aesthetic patients. Understanding the science of ageing of the dentition is a sub-science of dentistry itself known as gerodontology. I would argue that the study of tooth-wear and dento-facial atrophy, both natural and premature following tooth loss, is as important to the understanding of dental aesthetics as an understanding of pathology is to the study of physiology. As the population ages cross-culturally, many patients see medical and dental practitioners for the restoration of their youthful appearance. A sound knowledge of the ageing process and the ever expanding limits of techniques in our armamentarium are essential for treatment planning and execution of predictable, restorative dental treatments. 47
dental Dr Anil Shrestha
leading to recent changes on 31st October 2012 prohibiting all non-dentists from carrying out bleaching of teeth. If mastered though, it can produce highly predictable and consistent results to combat discolouration and produce an appealing central focus of the face. Dental tooth wear is a common and insidious deterioration in the youthful appearance of our patients. Quite often the subtle changes in incisal levels, asymmetric wear patterns and overall loss of tooth structure can cause a confusing lack of youthful appearance in the smile of even the most beautifully enhanced facial treatments. This can stem from the simplest flattening of the biting edges of the incisor and canine teeth, removing central dominance and soft contours of what would otherwise be a youthful and healthy appearance, to pathological tooth surface loss from the effects of eating disorders such as anorexia and bulimia, or from tooth grinding habits or dental neglect. The latter group of patients quite often require some of the most complex, high precision reconstructive work otherwise known as full mouth rehabilitation.
on their teeth alone. With an increasing knowledge base and an appreciation of the importance of facial aesthetic treatments not including dentistry, dentists are now becoming acutely aware of the importance of other facial aesthetic treatments to integrate with dental treatments—hence the increasing number of dentists carrying out treatments with facial injectables. Dentists are extremely well-placed to understand head and neck anatomy as well as principles of symmetry and facial harmony through the mathematical engineering principles of dentistry. I hope that an increasing number of aesthetic practitioners—as well as dentists—will begin to appreciate the importance of dental treatments in facial aesthetics and that this appreciation will be reciprocated by their dental colleagues.
Dental implants The modern use of dental implant treatments, including associated oral surgical procedures, has advanced dramatically over the last twenty years. This has now become a sub-speciality in dentistry and a treatment modality to definitively restore from single teeth to complete dentitions in as little as one day. I would argue that the rejuvenation of the dento-oral complex, improved function to that of normal teeth, improved appearance and overall enhancement of quality of life as a result can be the most dramatic of aesthetic and functional treatments above all other facial aesthetic treatments. Finally, to emphasise the integration of several disciplines of dentistry of the overall management of complex cases, examples of combined multi-disciplinary specialist treatments, co-ordinated by the author and utilising the sub-specialities of orthodontics, cranio-facial surgery, prosthodontics, endodontics and periodontics will be illustrated. These often result in dramatic improvements in the function and aesthetics of patients referred for specialist and aesthetic dental care.
Enhancements Dental bleaching is possibly regarded as one of the simplest forms of enhancing the appearance of a patient’s smile. It is, in fact, quite complex and can be dangerous,
Dr Anil Shrestha is a registered specialist in prosthodontics and the Clinical Director and owner of Lister House International Centre of Excellence (ICED), Wimpole Street, London.
Before and after multi-disciplinary full mouth rehabilitation
I have been deeply involved in writing and teaching MSc and other postgraduate programmes in cosmetic dentistry and firmly believe in mastering the fundamentals of science as well as mastering an excellent knowledge of contemporary treatments. Without understanding how the natural hard and soft tissues can deteriorate and fail prematurely and with age, effective restorative techniques cannot be appropriately utilised. In my opinion, the over-used and often inadequately understood concept of “smile design” and “smile makeover” treatments has been a damaging aspect of modern dental care in the last decade. Poor analysis, treatment planning and execution all compound to produce sometimes disastrous results and have been shown to increase the proportion of litigation cases carried out against dentists involved in this. Quite often, patient expectations are not adequately managed or reached, as the patients are often concerned with the holistic improvement in their facial appearance, whereas the dentist has focused 48
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Wigmore Medical 020 7514 5104 email@example.com
conference FACE 2013
21–23 June, QEII Conference Centre, London
ver the last decade, the FACE Conference and Exhibition has provided over 3000 delegates the opportunity to meet the world’s leading experts in the field of facial rejuvenation. As this unique event has grown in size and popularity, FACE 2013 will be moving to the larger QEII Conference centre, situated opposite the Houses of Parliament in Westminster, London. This move offers a vast exhibition area and greatly extended conference and seminar room facilities, allowing for a programme with over 150 hours of lectures by the worlds leading practitioners and pioneers in facial aesthetics. FACE 2013 will build on its heritage as the premier scientific forum devoted to facial aesthetics by combining the lecture programme with the largest dedicated medical aesthetics exhibition ever seen in the UK.
Save the date For aesthetic practitioners and clinic owners FACE is regarded as a most important date in the diary. Mark 21st–23rd June in the diary to be entertained by the most respected speakers from the UK and internationally, bringing their knowledge and new techniques to the aesthetic industry in what will be the 11th Annual FACE Conference. Whether you are a sole practitioner, aesthetician, clinic manager or marketer working in an aesthetic clinic, FACE will be the one event that you must attend in 2013 to learn about the latest treatments, procedures, scientific data, practical treatment tips, and marketing and business strategies—all delivered by leading experts in their respective fields. Three days of unparalleled choice FACE will once again be a three day conference but with even more lectures available for delegates to attend. Parallel
lectures throughout the three days will provide something for everyone with an active role in aesthetics. Lecutures in the main audotorium will focus on facial injectables for the duration of the conference. Alongside this will be a surgical lecture programme—introduced for the first time at FACE 2013. The “Face of the Clinic” meeting will return in 2013, but will be enhanced to include a three-day series of lectures covering all aspects of the marketplace for clinic owners focusing on both macro and micro foundations that effect the aesthetic business. Analysis on how to grow your clinic and how to maintain substantial growth will be key in this seminar with the application and reasoning. SKIN will return in two parts in 2013. The first part will focus on cosmeceuticals and the second part will look at the dermatological and disease orientated aspects of skin conditions and treatments. Lasers are becoming even more intebody language www.bodylanguage.net
conference FACE 2013
“The FACE conference has been the premier facial aesthetic meeting in the UK for many years and following a decade of success is now one of the best in Europe. It brings together international speakers from all disciplines to provide a unique program of evidence based lectures, panel discussions on hot topics and live demonstrations. The FACE conference is the best way to keep up to date with the latest techniques and sharpen your practical skills in facial aesthetics” Mr Rajiv Grover, Consultant Plastic Surgeon “There is a good balance of evidence based aesthetics. I truly believe what FACE 2012 has achieved is the next level and surpassed all of my expectations” Professor Syed Haq, Consultant Physician “We all learn from each other and it becomes a collaborative effort. FACE has become a great platform to exchange ideas and to be able to learn from each other with our goal being able to help our patients in a better way” Dr Raj Kanodia, Plastic Surgeon
gral to our clinics and with that FACE 2013 will have three days of lectures dedicated to laser equipment and the treatment protocols available—including a roundtable product vs product discussion. In 2013, FACE will also be introducing the Aesthetician’s Forum—a two day aestheticians conference for therapists. Other lectures through the weekend will include a focus for aestheticians as well as countless workshops from some of the largest manufacturers and distributors within the industry. A first for FACE FACE 2013 will feature a more flexible pricing structure, including a low cost delegate day rate of just £50 which will allow access to the exhibition area and exhibitor workshops. Aesthetic Industry Summer Ball FACE wouldn’t be the same without a networking event rivaling the best in body language www.bodylanguage.net
the world of aesthetics to break up the lectures, and 2013 will be no different. After the great success of last year’s Summer Ball held in Madame Tussauds, the ante will be upped for 2013 with a new venue in the heart London—The Brewery. The Ball will take place on Saturday 22nd June and once again, all proceeds will go to charity. We hope that you will be present to enjoy a summers evening of fine dining and entertainment. Register Ensure that you register for this year’s premier aesthetic conference which will deliver the most comprehensive scientific and marketing forum that you will find anywhere in the world devoted specifically to the dynamic facial aesthetics market. For more information on FACE 2013 visit W: faceconference.com T: 020 7514 5989 or follow FACE Ltd on Twitter: http:// twitter.com/face_ltd
“The people who come to FACE are from all over the world with a high degree of expertise in very different areas. The ability to hear from them and then speak to them afterwards in a fairly intimate environment is great” Dr Shlomit Halachmi, Consultant Dermatologist “FACE has become a truly great global event rather than just a domestic one” Dr Raj Acquilla, Cosmetic Doctor “I really like FACE because there are split sessions. You get basic courses for some of the beginner level attendees to more complex ideas that are out there” Dr Michael Kane, Consultant Plastic Surgeon “An excellent meeting! I’ve really enjoyed being a participant as well as a faculty member. The audience are always excited to learn about new developments and also get to see the techniques” Dr Tim Flynn, Consultant Dermatologist
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psychology Dr Raj Persaud and Kathleen Martin Ginis
What women want
n one of the largest psychological studies ever conducted, an intriguing difference between male and female views on what is attractive has emerged. The study was recently published in the academic journal Aesthetic and Plastic Surgery and was conducted by cosmetic surgeon Lukas Prantl and psychologist Martin Grundl from the University of Regensburg in Germany. Until now, researchers had found women were very good at anticipating what female body shape men found attractive. There is a psychological theory that it makes sense for women to correctly estimate what men ﬁnd desirable, and for men to calculate accurately what women like. This allows both genders to assess their own relative attractiveness with respect to the “competition”, and correct estimation permits better matching. Prantl and Grundl argue that in Western cultures both sexes tend to agree a smaller female waist and relatively lower weight is more appealing. The main difference between men and women on the best female body shape has now been found, by this latest research, to be opinions about the ideal bust size. Prantl and Grundl quote previous research which found over two decades, models in Playboy magazine, who would be selected for male appreciation, had a much larger breast size in comparison to waist measurement, than models in Vogue, who would be chosen for female admiration. Another study found ‘pinup’ girls in adult magazines for men in Japan, the United States, and Germany sported larger breast sizes relative to waist measurements, than models and display mannequins, who should be designed to appeal to women. In their experiment, Prantl and Grundl used a web-based interface which allowed participants to manipulate the appearance of a woman’s photographed ﬁgure by adjusting ﬁve sizes and shapes including weight, hip width, waist width, bust size and leg length. By clicking on a button, the photograph of the female ﬁgure changes its dimensions. Participants adjusted the woman’s features until
body language www.bodylanguage.net
The latest psychological research finds women don’t care what men want when it comes to bust size. Dr Raj Persaud and Dr Kathleen Martin Ginis discuss the findings it matched their own beauty ideal. A total of 34,015 participants—16,686 men and 17,329 women aged between 15 and 98 years took part. The majority of men and women were found to prefer female ﬁgures of medium or low body weight with medium-sized hips and a narrow waist. However, a striking gender difference emerged over breast size, with 40% of men preferring a large bust size, in comparison to only 25% of women. Prantl and Grundl argue that this difference between men and women is surprising because women theoretically ought to have the same beauty ideal as men. Men and women seeing eye to eye on what is attractive, allows them to judge their own relative desirability levels with respect to other men and women, and so match with the correct prospective mate. Prantl and Grundl point out a woman with a large-sized bust who considers medium size as more eye-catching, naturally underestimates her own attractiveness to men, and hence ‘undervalues’ herself. It logically follows she will tend to be settle with a man of lower league desirability, so she is throwing away her advantages in the ‘mating market place’. One theory as to why women believe smaller breast size is more attractive, is that there appears a widespread prejudice that women with larger breasts are less intelligent and competent, and it could be women are keen to avoid this label. Prantl and Grundl contend various previous studies have found the female curvaceousness ideal amongst women has declined, as more women entered the workforce, put greater store on careers compared to marriage and pursued further education. The authors argue that women today favour a more androgynous ﬁgure, or smaller breasts, since this might create an impression of career-relevant qualities such as intelligence and competence. Women also seem to not mind being so sexually attractive to men as they become more economically independent. Another theory is women may prefer a medium-sized bust because they think that they are less likely to be ogled if they don’t have big breasts, but a study using
eye-tracking software found men spent just as much time looking at mediumsized as large breasts. The experiment produced another intriguing finding. Only 11% of participants preferred a regular leg length in women, whereas 54% favoured a leg extent that in the case of a body height of 170cm would correspond to a leg lengthening of 6cm. This difference corresponds with the height of fashionable high-heeled shoes. Prantl and Grundl point out that we already know models tend to have very long legs and, second, that high heels, which visually lengthen legs, are widely deployed by women to increase attractiveness. However, a longer leg length in relation to the torso is also associated with various important health outcomes, for instance, reduced risk of coronary heart disease, diabetes resistance, low blood pressure, better cardiovascular proﬁles and considerably reduced risk of cancer. This last result adds fuel to the debate over why we tend to find particular features of a body attractive. Evolutionary psychology argues that we are driven by an evolutionary imperative to disseminate our genes as much and as widely as possible—so we are attracted to mates who look fit, because fitness on the outside suggests physical resilience and survival value. By mixing genes with the strongest DNA, we give our progeny the best chance of survival. This theory suggests that when you find yourself drawn to someone, you may think you are the victim of falling in lust or love, but in reality, beneath conscious awareness, your genes are busy running cold calculations on who is hot, and who is not. Dr. Kathleen Martin Ginis is a professor of health and exercise psychology at McMaster University’s Department of Kinesiology where she is also the director of the Physical Activity Centre for Excellence. Dr Raj Persaud is a Consultant Psychiatrist who has been a Consultant at The Bethlem and Maudsley Hospitals for 14 years and is now in private practice in Harley Street. 53
PALAIS DES CONGRèS
31JAN 03 FEB
I n t e r n a t i o n a l
M a s t e r
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A g i n g
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Celebrating 15 years of diversity, dedication and scientific innovation in aesthetic surgery and cosmetic dermatology
« The epitome of international learning and dialogue in aesthetics. A unique and unforgettable experience. » Dr Hema Sundaram, Dermatologist, USA
4 4 500
160 exhibiting companies
« Above all in the world of the plastic surgery. It is really very impressive. » Dr Ricardo Baroudi, Plastic Surgeon, Brazil
« The most illuminating and up-to-date conference on aesthetics that one can attend. An absolute MUST. » Dr Hugo Kitchen, Cosmetic Surgeon, United Kingdom
« Splendid and professional. » Dr Ali Al Tukmatchy, Dermatologist, United Arab Emirates
of the best international
Benjamin ASCHER, Plastic Surgeon, FRANCE Olivier GERBAULT, Plastic Surgeon, FRANCE David J. GOLDBERG, Dermatologist, USA Philippe KESTEMONT, Facial Plastic Surgeon, FRANCE Anne LE PILLOUER-PROST, Dermatologist, FRANCE Ali MOJALLAL, Plastic Surgeon, FRANCE Bernard MOLE, Plastic Surgeon, FRANCE Serge MORDON, PhD, Research, FRANCE Bernard ROSSI, Dermatologist, FRANCE
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The leading subjects on aesthetic surgery and cosmetic dermatology
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market On the
The latest products in aesthetic medicine, as reported by Helen Unsworth
ZOOM DAYWHITE 6%
Philips have recently acquired Zoom—a brand renowned for its tooth whitening products—and have launched Zoom DayWhite 6%. This product differs significantly from any other home whitening system available because it contains Amorphous Calcium Phosphate (ACP), which combines with fluoride and bonds with tooth enamel to provide advanced protection, improved luster and shine, with reduced sensitivity when compared with teeth whitened without ACP. Crucially, Zoom DayWhite 6% HP with ACP is compliant with the new European Commission regulations preventing the sale of whitening products containing more than six percent hydrogen peroxide. An additional benefit is the dispensing dual-barrel syringe system developed by Phillips, which provides greater gel stability without the need for refrigeration. Phillips T: 0800 0567 222; W: sonicare.co.uk/dp
under the microscope PURE GOLD COLLAGEN Developed by Minerva Research Labs and European scientists Pure Gold Collagen combines a unique blend of hydrolysed collagen and active ingredients that work from the inside out. Minerva Reserch Labs say that once absorbed in the small intestine, Pure Gold Collagen is distributed through the blood vessels to the deeper layer of the dermis resulting in the multiplication and stimulation of fibroblast cells to produce more collagen and hyaluronic acid in the dermis. According to clinical trials, results have been seen in eight weeks for skin hydration, and twelve weeks for improvement in wrinkes. Pure Gold Collagen contains hydrolysed collagen (5000mg), borage oil, N-acetylglucosamine, hyaluronic acid and vitamins C,E and B6, formulated for maximum absorption and bioavailability. Our tester found Pure Collagen Gold pleasant to drink once a day as recommended and is looking forward to seeing the long term results. Minerva Research Labs T: 020 3137 7731; W: gold-collagen.com
eyeSlices—a global first in cryo-gel technology—are cooling and soothing eye gels that target puffiness, dark circles, tiredness, redness and wrinkles. Made with natural and organic extracts from the Swiss Alps, they can be used during or after many aesthetic treatments. During laser treatments they can be placed over your client’s eyes, post toxin treatments around the eyes they can be applied to soothe and calm the skin. Post peel treatments eyeSlices can be used as an aftercare product for their soothing and restoring properties. With aloe ferox to heal and pentavitin to hydrate, eyeSlices lock in moisture for up to 72 hours. Calla Distribution Ltd T: 01635 749749; W: calladistribution.co.uk
body language www.bodylanguage.net
Primcogent Solutions have announced the launch of Lunula Laser—a clinically proven, low level laser therapy for onychomycosis. Lunula Laser can help patients suffering from fungal nail infections, providing treatment of onychomycosis in two 12-minute treatments. Lunula Laser uses Low Level Laser Technology (LLLT). It combines two different wavelength lasers—one at 405 nm for direct fungicidal activity and one at 635 nm to stimulate a natural immune response— to provide effective clearing of the nail bed within three months. In a recent study of 105 toenails, clinicians observed a mean percentage change in clear nail bed of 30.4 percent, or 5mm. Furthermore, 62 percent of toenails treated achieved at least a 25 percent increase in clear nail after three months. The Lunula Laser has been specifically designed for use by physicians and their staff, requiring very little setup time and no operator intervention, creating a complete walk-away treatment thanks to preset dosage times and output energies. Primcogent Solutions T: 01235 841590; W: primcogent.com
Zytaze is a nutritional supplement formulated with organic zinc along with phytase, and can enhance results of toxin treatments and extend the treatment’s effects by up to a third. The recommended dosage is two capsules each day for four days prior to and on the day of receiving toxin injections. Results of a study show that in seventy-seven patients, 92% of subjects with zinc 50 mg and phytase experienced an average increase in toxin effect duration of nearly 30%, and 84% of participants reported a subjective increase in toxin effect. The clinical trial showed that only the correct dosage of zinc and phytase could boost toxins effects. Eden Aesthetics T: 01245 227752; W: zytazeonline.co.uk
Obagi Hydrate is a new facial hydrator which uses Hydromanil technology to capture and assimilate water into the skin immediately and lastingly due to an advanced multi-capillary process. Hydromanil matrix molecules remain on the surface of the stratum corneum reducing water loss, while water-bearing 3D matrix captures and retains water, continuously reducing hydrating compounds within the skin, say Obagi. Healthxchange T: 01481 736837; W: healthxchange.com
brushstrokes SilDerm have recently launched a Scar Gel and Scar Spray to prevent and repair unsightly scars caused by surgical operations such as Caesarean section, trauma injury, wounds or burns, using clinically proven, safe ingredients. SilDerm T: 01260 271666; W: sildermgroup.com
Silkann cannulas—manufactured by Sterimedix—are supplied either as cannulas alone or with pre-hole needles included and offer distinct and unique features. Sterimedix T: 01527 501280; W: sterimedix.com
DermaPeach Growth Factor Systems and Serums are based on biotechnological research of growth factors focusing on skin healing and anti-ageing. DermaPeach products all contain epidermal growth factor and fibroblast growth factor to replenish the skin’s supply of crucial proteins and fight visible signs of chronological and sun-induced ageing. BHR Pharmaceuticals Ltd T: 02476 3677210; W: bhr.co.uk
TSK Laboratory has launched a newly designed cannula—the STERiGLIDE. The STERiGLIDE cannula will have ultimate gliding characteristics helping practitioners introduce the cannula into the skin with more ease and allowing for more controlled guidance. TSK Laboratory T: +31499 769 009; W: tsklab.com
ThermaVein uses Veinwave technology— not laser, IPL or epilation but “thermocoagulation” for the removal of facial veins. The treatment works in a different way to alternatives and is safe, instant and effective—the user will see the veins disappear as they administer the treatment. In most instances just one 15 minute treatment is required. ThermaVein T: 0845 62 62 400; W: thermavein.com
Six Month Smiles is an orthodontic treatment which allows the correction of crooked teeth within six months. It uses clear brackets and tooth coloured wires which are low-force so treatment is comfortable. Six Month Smiles T: 0207 935 5332; W: aquadentalspa.com
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lasers Dr Pablo Naranjo
Laser hair removal Removing hair can be achieved using a wide range of devices. Dr Pablo Nuranjo disusses some of these, and how to improve results in patients who are poor responders
here are many different systems on the market for hair removal. It is possible to divide them in two different groups—absorption and transmission lasers. The absorption devices—ruby, alexandrite and 810 nm diode lasers—have high absorption by melanin and lower by haemoglobin and water. The transmission lasers—neodymium-YAG and 915 nm diodes—have high penetration in the tissue and coagulate directly the bulge and the surrounding vessels. Lastly, there are IPL devices which can help with hair removal. The target is to destroy the stem cells that are on the hair shaft and dermal papilla. They are colourless which makes them difficult to be targeted by light devices, so we need to coagulate and thermally destroy the keratinocytes surrounding the stem cells at the bottom of the hair shaft and dermal papilla to be able to hit them. To achieve this you need to use a minimum temperature of 65 degrees Celsius at a depth of one to four millimetres in order to achieve good coagulation and thermal destruction of the stem cells. By doing this, lower part of the hair shaft and dermal papilla are destroyed permanently. We say permanently but not definitively, because after the hormonal changes in the body during puberty, 15–20% of hair follicles will not have created hair shafts in the body and more than 30% on the face and neck. Therefore it is impossible to destroy all the hair we have—we can only destroy the hair that has been not in a “sleeping” situation, as they cannot be destroyed until they receive vascularisation to create a new hair shaft. It is important to know the different phases of hair growth—anagen, catagen and telogen. Interaction in the anagen phase is likely to give better results in fewer treatment sessions. Challenging treatments When carrying out hair removal treatment, we will be exposed to certain challenges—treating patients with a high phototype and tanned skin, treating sensitive areas, treating complex anatomical areas and getting unexpected poor results. When treating a patient with a high phototype or tanned skin, the absorption lasers–alexandrite, ruby and 810 nm diode lasers–have a high absorption by melanin on the hair shaft and epidermis. Those devices may be the gold standard to treat dark, thick hair on white skin but should not be used on phototype IV, V, VI and phototypes I, II, III with very thin, light hair because it’s too risky. The light doesn’t know where to deposit the energy and it is likely to cause burns or postinflammatory hiperpigmentation. It is vital to thoroughly evaluate patients to avoid complications. Never treat a patient who has had sun exposure in the last few days. You need to wait a minimum of four weeks before treating with an alexandrite ruby or 810 diode laser and a minimum of seven days when using a Neodymium-YAG laser or 915nm diode laser. Talk with the patient, take a good clinical history and ask about sun exposure—not just on the beach but daily exposure in the last two to four weeks. Alternatively we can use devices that give us information 58
about the quantity of melanin and quantity of redness on the body. Those devices are very low cost and give realistic information about melanin in the skin. You need to obtain measurements of melanin in a patient’s skin by evaluating the “real” phototype from the wrist—an area which does not get much sun exposure. Then measure the phototype in the area you want to treat and if the quantity of melanin is multiplied by two or more, treatment is too risky. Even if you reduce the energy with an alexandrite laser to 12 joules per centimetre square, if a patient is recently tanned and doesn’t tell you or you don’t take measurements, you can burn the patient. Another way to prevent secondary effects is to cool the skin. By cooling the skin you reduce the risk of burning when applying high energy. You may apply high energy if you feel the hair shaft does not have enough colour compared to the epidermis to receive the energy selectively. So when you treat thin, light hair it is important to cool the skin because you will need to use higher energies. To treat a patient with a high phototype or recently tanned skin, you can select a wavelength with less absorbtion by melanin–a transmission laser, 915 nm or 1064 nm. If you only have a regular diode or alexandrite laser, you would have to increase the pulse duration of the laser, but doing this you sacrifice the effectiveness of the treatment. Pulse duration is not related to the phototype of the patient—pulse duration is related with the thickness of the hair. Thinner hair needs shorter pulse duration, larger hair needs larger pulse duration. If you enlarge your pulse duration on thin hair, you are sacrificing the effectiveness. Devices During the last years we have been considering other ways of treating patients with high phototypes or tanned skin. Apogee Elite from Cynosure is a device combining two wavelengths— Neodymium-YAG and Alexandrite on a blend mode. One after the other—milliseconds apart—you can shoot with Neodymium-YAG and then Alexandrite. This protocol reduces the energy needed for each one of the wavelengths and decrease the risk of superfitial burns by a half. A study which took place in IML Clinic in Madrid demonstrated that 54% of Neodymium-YAG plus 46% of Alexandrite, one just before the other, was the best combination, but the efficacy obtained was exactly the same as one shot of Alexandrite. Another device that can be used on patients with high phototypes is the 810 nm diode laser with high repetition rates and low energy—the first such device was the Soprano from Alma Lasers. This is not a regular diode laser—it has the regular mode with the high energy pulse and different pulse durations but also has the ability to work with dynamic epilation using low fluence and eight repetition rates—ten shots per second. Soprano hair removal efficacy can not be explained by photothermal theory like other devices, but yes by the fact that the accumulation of heat on the dermis after each pass of the laser would destroy the body language www.bodylanguage.net
lasers Dr Pablo Naranjo
stem cells on the hair shaft and dermal papilla. This dynamic epilation is less painful, although when you increase the number of passes on the same area you increase the heat and this increases pain sensation. The last pulses are going to be much more painful than the first ones, but it can be considered as a less risky and less painful technique. The gradual increase of heat in the dermis justify the lower risk of superfitial burns of this technique and the ability to treat higher phototypes and long lasting tanned skin. It’s an interesting device but very technically dependent. You need to move the handpiece correctly: if you move too quickly, you don’t increase enough the energy and if you move too slowly, you can burn the skin. A problem with these device is that you cannot set the pulse duration you want. You have pre-fixed pulse duration and pre-fixed energies. You have limitations as you cannot adjust duration and energy separately, and you cannot use very short pulse durations which is needed for very thin hairs. eLase Another similar device on the market which uses this same theory of accumulated heat, is the eLase from Syneron-Candela. It works in exactly the same way with pre-fixed pulse duration and pre-fixed energy. The difference is that the eLase needs less power as it uses ELOS technology—a combination of radio frequency (RF) and light. Radio frequency is not selective to any chromophore. It doesn’t look to the melanin and is only influenced by resistance—the electrical impedance of the tissue. If the device delivers RF before the light of the 810 nm diode laser, the dermis will be pre-heated and the fluence needed to achieve a coagulation threshold will be less. The temperature delivered by RF will specifically increase in the part surrounding the hair shaft and dermal papilla as this is the most resistant structure we have in the dermis. You will increase the vasilodilation and the extravasation of the plasma. If you apply RF and light simultaneously, light will be selective and RF will be deposited in the area with highest resistance. You can decrease the energy of the light because we have the synergy of the electrical current and light both creating heat. The electrical current and light together increase the temperature to 55–65 degrees. This is why RF is
used, as it is less risky than the light especially for patients with tanned skin and high phototypes. Avoiding unexpected results Areas such as the ears, nose, and the upper lip are complicated to treat using a diode laser. It is very difficult to place the sapphire or quartz crystal of a diode laser in a perpendicular and covered position, so it is easier to use an Alexandrite, or NeodymiumYAG laser. It is important not to angulate the handpiece to prevent bad results on hair removal that can be justified by partial coagulation of the hair shaft and dermal papilla. Also take care with excess refrigeration. It can reduce the effectiveness of the Neodymium-YAG laser—which has absorption by haemoglobin—because it decreases the diameter of the vessels feeding the dermal papilla if skin is cooled too much. We can have problems on hair regrowth when trying to treat a delimitated area or just one hair. While you may see one hair, the patient can have many “sleeping” hairs in the area and if you treat with a laser, you create a scattering effect-heat not just in the area being treated, but in the surrounding areas. This heat has been proven to create neovascularisation, vasodilation and increase the blood flow to the bulge area of “sleeping” hair. This situation can justify regrowth of those follicles. Don’t treat outside of the pre-treated areas, don’t treat individual hairs and don’t treat with low energy in large spots because you increase the scattering effect. Make sure you always refrigerate the surrounding areas to prevent this unwanted effect. Bad results on areas like the nasolabial area can also be explained by a bad stretch of the skin. Sometimes we have patients who don’t get good results: patients who have undergone up to ten sessions in an area which is easy to treat, without any apparent problems—no hormonal problems. We have recently started a study at the King Juan Carlos University in Madrid, Spain, to try to clarify those situations and problems related to oestrogen receptors of the dermal papilla can be part of the explanation of those bad results. Dr Pablo Naranjo is a cosmetic doctor and medical director of Elite Laser, Madrid, Spain
The growth cycle of a hair
body language www.bodylanguage.net
knowledge is power from exhibitor workshops to business seminars and the aesthetics conference, the 2013 cosmetic news expo is all about value for money education and cpd points
They say that “knowledge is power” and that is why education has always played a key role at the Cosmetic News Expo. Now in its fourth year, the Cosmetic News Expo and adjoining Aesthetics Conference will take place at the Business Design Centre in Islington on February 16-17, 2013.
The Aesthetics Conference is an excellent opportunity to gain CPD points and hear from the very best UK and international speakers, discussing the latest topics and demonstrating the most up-to-date techniques. This year the conference not only has a new look and a new name but, for the first time, is being organised by an independent consultant with years of knowledge and experience of the aesthetics industry to make it even more cutting edge. Because the event is now also taking place on the earlier dates of Saturday February 16 and Sunday February 17, 2013, the Cosmetic News Expo and Aesthetics Conference will now be the first key professional meeting in the UK aesthetics calendar and is the first chance for you to hear what is new in 2013 on home soil. And because tickets for The Aesthetics Conference are a fraction of the cost of other industry events, this is one opportunity you cannot afford to miss.
cosmetic news the uk’s largest trade aesthetics exhibition and conference
exhibition and conference
1 6 th a n d 1 7 th f e b r u a r y
The SoCial neTwork
There is no doubt about it, one of the best ways to grow as a business is by networking with fellow aesthetic professionals and sharing ideas. The Cosmetic News Expo and Aesthetics Conference are centered around making peer-to-peer networking a priority. With long breaks in between lectures, to allow you to browse the exhibition and catch up with fellow delegates, and with all delegates receiving a VIP invite to our exclusive Japanese themed after show party at The Chapel bar on the evening of Saturday February 16, the Cosmetic News Expo is the ideal place to make contacts and get your face seen in the industry. The party is attended by all the speakers from the day as well as exhibitors and the Cosmetic News team. This always proves to be a highlight of the event and is something that adds incredible value to the price of a ticket.
Tickets for the 2013 conference cost £49 for one day or £85 for both days, if you book in advance, or £75 per day/£150 for both days if you pay on the day. A complimentary lunch will be incorporated into the delegate package, with refreshments provided throughout the conference breaks. You will also receive a VIP invite to the after show party. To book your place visit www.cosmeticnewsuk.com or call Carly on 01268 754 897. If you are booking tickets for more than two people from the same organisation you will receive a 20% discount. Quote booking reference BL123 when you book for one day or BLW123 when you book for two days. We also offer a discount of 10% for members of the British Association of Cosmetic Nurses. Please quote reference EX123 when booking. cosmetic news expo is sponsored by: gold sponsor
s i lv er s p on so r
b r o n ze spo n so r
h o spita l it y s p o n s o r
Speaker SpotlightS: here are juSt a few of the SpeakerS confirmed for the 2013 aeStheticS conference dr raj acquilla Dr Raj Acquilla has developed a deserved reputation as one of the most skilled, experienced and trusted cosmetic physicians in the UK and is a recognised Key Opinion Leader in the field of non-surgical facial aesthetics. miSS jonquille chantrey Miss Chantrey has more than nine years of plastic surgery experience. She has published articles in various peer-reviewed journals including The Lancet and presented at international conferences. She is also recognised as an expert and trainer in VASER liposuction, Macrolane and Sculptra.
dr galcerán montal Dr Galcerán Montal has worked as medical director in some of the most prestigious anti-ageing clinics in Barcelona, including Clínica Virtalia, Oxycell, Elixir Clinic and Revital. He is also the medical director of Mesoestetic Pharma Group. dr kate goldie Dr Kate Goldie is the founder of Medics Direct (Europe) Ltd, one of the largest and most successful Medical Cosmetic training companies in the UK and is renowned in the industry as an expert in non-invasive facial restructuring.
dr ariel hauS Dr Ariel Haus has carried out advanced training in dermatology and cosmetic medicine and has a special interest in anti-ageing medicine. He has clinics in Harley Street and Ipanema in Rio de Janeiro. mr dalvi humzah Mr Dalvi Humzah is a consultant plastic reconstructive and aesthetic surgeon and is the medical director of Plastic and Dermatological Surgery and BUPA Cosmetic’s clinical lead. He has been the STEP® Tutor for the Royal College of Surgeons of England and is an examiner
for the Intercollegiate MRCS for the Royal College of Surgeons of Glasgow. mr chriS inglefield Chris Inglefield has worked as a consultant plastic and reconstructive surgeon since 1998. He has written several papers and contributed to many specialist books and journals within the field of plastic and reconstructive surgery and has lectured at national and international meetings. dr gabriela mercik Dr Gabriela Mercik is medical director of Hebe Anti-Ageing and Aesthetic Medicine
Clinics and Dermagenica Ltd. She is an advanced aesthetic trainer in biomimetic mesotherapy, dermal fillers and toxins. dr tracy mountford Dr Tracy Mountford is the founder and medical director of The Cosmetic Skin Clinic. She has over 21 years experience in advanced non-surgical facial rejuvenation techniques and won the accolade of ‘Speaker of the Year’ at the 2011 Aesthetic Awards.
Book T o d ay !
01268 754 897
aeStheticS conference 2013 conference programme S ATurDAy FE B r uAry 1 6
S u N D Ay F EB r u A ry 1 7
MORNING SESSION - Chaired by Mr Dalvi Humzah 9.45-10.20
MORNING SESSION – Chaired by Mr Chris Inglefield
Managing the Versatility of Dermal Fillers – Dr Kate Goldie
9.45 - 10.15
Introduction to Lasers in Cosmetic Practice
This session will analyse the facial indications for fillers as well as looking at treatment plans and key matrices for dermal fillers.
10.15 - 11.00
Multi-Application Lasers – Dr Ariel Haus This session will explain the value of a multi-application laser and how it can benefit your bottom line while offering your patients the best results with the least downtime.
New Trends in Fillers Including Facial Volumising and Lip Shaping and Live Demonstration – Dr Raj Acquilla and Miss Jonquille Chantrey New techniques are being developed all the time. This masterclass session will focus on the latest treatments with emphasis on anatomical placement and risk management using the most effective products and techniques.
11am-11.30am Coffee Break 11.30 - 12.15
How to Treat the Tear Trough Area: From Injection Techniques to Managing Complications (Including Live Demonstration) – Dr Patrick Trevedic
New Innovations and Advancements in Platform Technology Dr Robin Stones This session will look at the latest combination of light and laser based technologies that provide total anti ageing and skin rejuvenation solutions for all skin types
11.30am-12pm Coffee Break 12.00-1.00
gET cp d poI NTS
12.15 - 1.00
The eye area has always been notoriously difficult to treat. This session will cover treatment and management of this delicate anatomical area using dermal fillers.
Advanced Body Shaping and Skin Tightening: Obtaining the Best Results Using Radio-Frequency and Ultrasound Technology. – Mr Jan Stanek There is much new technology for skin tightening and body shaping - but do these devices work? This session will present the findings of clinical practice.
1pm-3pm Lunch Break/Exhibition Viewing
1pm-3pm Lunch Break/Exhibition Viewing
AFTERNOON SESSION – Chaired by Dr Tracy Mountford 3.00 - 3.40
Treatment and Maintenance of Redness and Inflammation - Dr Stephanie Williams and Mr Chris Inglefield
AFTERNOON SESSION - Chaired by Dr Tapan Patel 3.00 - 4.00
A presentation of a study based around rosacea/redness and the effects it has on skin ageing. To include new findings around triggers, symptoms and treatments for the skin condition to ensure correct diagnosis and treatments for sufferers.
3.40 – 4.20
A Topical Approach To Wrinkles - speaker tbc
Find out how the latest cutting-edge mesotherapy technology can enable quick, non-invasive solutions for many different indications including skin brightening, hair restoration, rejuvenation, and lipolysis.
4.00 - 5.00
Synopsis: Confused by cosmeceutical ingredients? Covering both well established and novel ingredients this session will provide you with all the facts you need to make informed choices about cosmeceutical skin care that will meet your patients needs.
4.20 - 5.10
The Impact of the Menopause on Ageing Skin – Dr Tracy Mountford and Dr Nick Pannay
During the menopause the skin undergoes significant changes due to the hormonal imbalance. The collaboration of gynaecologist and skin specialist is an exciting partnership to improve care for this group of women.
st in class
dr nicholaS panay Dr Nicholas Panay is a e award winning system for ED BODY SHAPING consultant obstetrician and gynaecologist and sub-specialist IGHTENING... in reproductive medicine and surgery. he Best Skin Tightening He is the chairman of the British ard TAS 2012”, Las Vegas Menopause Society and The National Association for Premenstrual Syndrome.
mr jan Stanek
Mr Jan Stanek has lectured across the world, published more than 20 articles in journals on surgical procedures and written a number of books. He is well known as the resident surgeon on TV’s 10
ssex CM19 5QE
s.com www.btlaesthetics.co.uk firstname.lastname@example.org
Years Younger and featured in the ground breaking Channel 5 series ‘Plastic Fantastic’. dr robin StoneS
Dr Robin Stones is the Court House Clinic medical director for the North of England and director of non-surgical business for Surgicare. He is a national trainer for doctors interested in the use of lasers in dermatology and holds a BTEC Advanced Award in Lasers, Light and Associated Aesthetic Applications.
Mesotherapy with Biomimetic Nano-Peptides: A New, Quick, Injectable Treatment for a Wide Variety of Indications - Dr Gabriela Mercik
dr patrick trevidic
Dr Patrick Trevidic is a plastic reconstructive aesthetic surgeon. He has published more than 50 scientific articles in periodicals and international journals. He is also director of the Anti-Ageing Medicine World Congress and Face2Face. dr Stefanie williamS
Dr Stefanie Williams is a dermatologist with special interest in cosmetic dermatology. She is an international speaker, lectures at university and has published more than 100 scientific articles.
Medical Devices for Intradermal Injections and the Use of Mesotherapy Techniques for Rejuvenation – Dr Galcerán Montal Mesotherapy has been used widely in Southern Europe but with little uptake in the UK. Now, as techniques and results improve, we are seeing an upsurge in treatments. Dr Galceran Montal is an expert in his field and this session will focus on the treatment of the hands and neck as well as other problem areas that have previously been very difficult to treat.
Book T o d ay ! £49 for one day or £85 for both days, if you book in advance, or £75 per day/£150 for both days if you pay on the day.
for updates on the conference programme and speakers visit cosmeticnewsuk.com
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Courses in Central London Intro to Skincare – 22nd January, 12th February Intro to Toxins – 23rd january, 13th February Intro to Fillers – 24th January, 14th February Intermediate Toxins & Fillers – 3rd February Advanced Toxins & Fillers – 3rd March Microsclerotherapy – 2nd February, 2nd March Sculptra – 5th February Sculptra Refresher - 15th February Medik8 Dermal Roller – 21st January (Afternoon), 11th February (Evening) CPR & Anaphylaxis – 1st February glōTherapeutics Basic – 28th January, 25th February glōTherapeutics Advanced - 30th April Business Development - 4th February PRP - 7th February, 8th March Mesotherapy - 8th & 9th February Laser/IPL - 22nd & 24th February
Tel: 0207 491 0150 Tel: 01234 313130 email@example.com firstname.lastname@example.org .com Medical Training, 21 Wigmore Street, London, W1U www.wigmoremedical.com www.wigmoremedical www.aestheticsource.com Wigmore 1PJ email@example.com, www.wigmoremedical.com Twitter: @wigmoretraining
marketing Charles Southey
Digital marketing Introducing payment options to your website and working on your online social media presence can result in considerably more sales, writes Charles Southey
igital marketing is a hugely important part of all business operations, whether you provide a service, a product or offer consultation. Companies that fail to embrace the online world will inevitably see their business suffer, as competitors who have developed effective digital marketing strategies advance. It is no exaggeration to say that digital media is the most important development in marketing for many years—ignore it at your peril. As the first point of access for many customers, the effectiveness of your website has a direct correlation with conversions and sales. Therefore, if you are interested in enhancing the digital marketing of your business, the first and most crucial step is to increase the effectiveness of your website. Further to this you must also consider the importance of social media. Perhaps the fastest growing method of advertising, social media is an interactive way to communicate with consumers. Your online presence is greatly increased by partaking in the social media phenomenon—it is surprisingly easy to do and hugely effective. Now you can buy online Have you thought about selling some or all of your products directly from your website? Online purchasing is a sure-fire way of increasing customers. We all shop online and it is faster and easier to make a purchase with a business that is optimised for digital retail. In the fast-paced modern world, many customers simply do not have the time or inclination to visit a shop or place an order over the telephone. In terms of the buying process, the simpler the better. If your company offers ease of access and purchasing for consumers, your sales will increase and any competitors who do not offer such services will be left behind. If you consider one of the world’s biggest retailers, Amazon, one of the key elements of their success is the easy purchase and payment. As further proof of the effectiveness of a simple purchasing method, they have created a “1-click” buying option, allowing consumers to buy with literally one click. With consumers who feel ever more pressed for time, such buying options are popular, and emphasise the fact that in the digital world there is a “need for speed”. Another benefit to online sales is that there is immediate cash flow. There is no delay due to invoicing. A product is purchased, a payment is taken—it really is as simple as that. It’s easier if you sell physical products but it can work if you’re a service provider too. A good example would be medical practitioners who can allow patients to book and prepay for an appointment online. Setting up online payments can be complicated so to get it right it’s usually best to gain the help of a digital agency that provides e-commerce services. Social media Your activity and level of following on social media channels like Facebook and Twitter is said to positively impact your ranking on search engines like Google. It’s essential to have a social media strategy, even if you’re not convinced that your audience is active on Facebook, Twitter and other such websites. Social
body language www.bodylanguage.net
media is a crucial marketing tool for your website. It is an effective way of interesting people in, and directing people to, your website. Similarly, your website must direct people to your social media, allowing you to have a continued presence even when they have left your site. The beauty of digital media, including your primary website, is that each aspect is able to feed into and enhance the other. Here are three tips to get you started in social media: Create a Facebook page and ask your friends to like it. Fill your page with interesting content. Once you’re happy with it, invite all of your friends to ‘Like’ the page to gain a bit of early momentum. Integrate social media into everything you do. Add buttons saying ‘Like us on Facebook’ and ‘Follow us on Twitter’ on your website, email signatures, business cards, brochures, letterhead and anything else you can think of! Spend 10 minutes each day engaging. Maintain momentum by spending just 10 minutes every day to post something interesting, share a useful link, reply to messages and follow useful people. The more you get involved in social media the more you will gain from it, so try and increase this 10 minutes over time. Create and share interesting content. You will start to gain a following on social media channels if you build a reputation for creating and sharing interesting content. The more you give to the social community the more of a following you’ll get. Crucially you must make sure that all social media links back to your website, enabling you to benefit from a bigger online presence with increased sales. The key word to remember with digital media is “interconnectedness”. Each aspect of your online marketing must be integrated to form a whole cohesive package. The social media that you partake in directly affects the number of visitors to your website. Similarly, if you are able to direct customers already on your website to follow you on social media, the chances of returning custom are greatly increased. Charles Southey is Operations Director at Digital Results T: 01920 444797; E: firstname.lastname@example.org 63
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NEW Obagi Hydrate
01481 736837 email@example.com www.healthxchange.com www.obagi.uk.com
V300 University Challenge The BACN recognises that many nurses in aesthetics, who are not prescribers, are facing up to the challenges (and expense!) of providing Botox on the treatment menu. Also employment opportunities are limited these days for non-prescribing nurses in aesthetics. The winds of regulation are also blowing clearly in the direction of prescribing nurses - and we don’t want our members to be left out in the cold, particularly when we have all worked so hard to establish ourselves and have loyal clients who trust and depend upon us. With this in mind we are providing, with the support of sponsors, an opportunity for aesthetic nurses to attend events around the country to find out about the V300 Non-Medical Prescribing course – have your questions answered by university lecturers and nurses who have undertaken the course. Let us address your fears, and see if we can’t get you past the barriers you perceive, real or imagined. The agenda What is The V300? An introduction by a University lecturer The Role of the DMP A nurse’s experience of the course Q&A—Put your questions to the University panel
LONDON – 24th January EDINBURGH – 29th January BIRMINGHAM – 31st January MANCHESTER – 5th February BRISTOL – 7th February
For more information and to book your place (for £50 deposit, refundable upon attendance) contact Liz on 01749 836328
Read, learn and apply
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
The UK Journal of Medical Aesthetics and Anti-Ageing
The UK Journal of Medical Aesthetics and Anti-Ageing
FA iAl pRe CE vieW
correcTing oTHer PrAcTiTioners’ MisTAKes
BL46 covers.indd 7
Breast implants post PiP
THE POWER OF PSYCHOLOGY
volume 13 issue 4 number 46
OUR GOLDEN ISSUE
volume 14 issue 2 number 50
Shadows of Beauty
volume 12 issue 3 number 39
volume 12 issue 5 number 41
Brighten dark circles
HydroxyAcids for AnTi-Ageing sKincAre
Beauty over time
I N M E D I C A L A ES T H E T I C S 03/07/2009 10:17:21
HoW Toxins HeAl WoUnds PeriorBiTAl MelAnosis
volume 11 issue 4 number 34
volume 13 issue 3 number 45
How to shape rear ends
BL34 Cover.indd 1
COMMAND OF HINDQUARTERS
FAciAl reJUvenATion wiTh ThreAdS expert reveals his techniques deFAMATion on The inTerneT What do you do?
the t he uK Journal of medical aesthetics m and anti-ageing
The heaT is on
the role of
Toxin’s effecT on sKin qUAliTy
sociAl MediA And yoUR pRAcTice
The UK Journal of Medical Aesthetics and Anti-Ageing
The UK Journal of Medical Aesthetics and Anti-Ageing
The UK Journal of Medical Aesthetics and Anti-Ageing
BL50 covers.indd 7 Cover Images.indd 3
27/02/2012 14:09:24 27/02/2012 13:56:56
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 Dr Raj Kanodia
A nose for aesthetics Rhinoplasty specialist Dr Raj Kanodia describes his 40-year professional journey in aesthetics, from an internship in Chicago to practising in Beverly Hills
orty years ago, my journey to the United States started with a oneway ticket from India to Chicago on a tourist visa. My dream was to become the best plastic surgeon in the world, and my passion and dedication to surgery afforded me the rare opportunity to train at McNeal Hospital (internship) and The University of Illinois (residency). In the early 1970’s, surgical residency was rarely—if ever—given to foreigners like myself, but despite this, I was fortunate enough to pursue my dreams in facial plastic surgery with one of the greatest rhinoplasty teachers of all time, Dr Eugene Tardy. My obsession with facial beauty narrowed, and my focus became the centre of the face—the nose—and thus began my quest to become the best nose doctor in the world. Throughout my residency, my ultimate goal was to observe, assist and perform as many rhinoplasties as I possibly could. The Eye and Ear Infirmary at the University of Illinois was the best breeding ground for the “rhinoplasty endeavor” with Dr Tardy at the helm. As the consummate rhinoplasty surgeon and teacher, Dr. Tardy was very inspiring and encouraging in my pursuits. After five years of training in Chicago, I vowed to leave the windy city for a warmer climate and ultimately landed in Los Angeles. Even with all my training and experience in Chicago, I still did not feel that I was good enough to take a pretty 18 year old girl and refine her nose in the most artistic way. I sought out a more intense, one-on-one experience with the greatest rhinoplasty surgeon of that time. The American Academy of Facial Plastic Surgery had a list of these mentors and on the top of the list was Dr Morey Parkes in Los Angeles. It was a miracle moment that out of the 30 candidates who applied for this coveted fellowship, I was selected. The one year fellowship was an incredible experience and it got even better when Dr Parkes extended my learning experience to four more years as a junior partner, with the condition that I continued to assist him with the rhinoplasties he would be performing.
As I began to perform rhinoplasties on my own patients, I realised the challenges of various steps of executing this intricate millimeter by millimeter surgery. It was like me humming along with Michael Jackson when the radio was playing his song, and then suddenly the radio stopped, and I had to sing on my own. Those four years perfecting rhinoplasty on my patients and assisting Dr Parkes enabled me to zero in on the difficulty of various maneuvers and perfect them. Dr Jack Sheen was another one of the rhinoplasty stalwarts who I was very fortunate to observe frequently during these first five years of my ongoing journey in Los Angeles. Approximately 12 years ago, with the advent of Botox and hylauronic acid fillers, came the facial rejuvenation revolution, with Dr Jean Louis Sebagh at the forefront. Once again, I was very fortunate to spend time observing him. It was inspiring how he was evolving with the new injectables, as the collagen era was very limiting. This opened up a whole new chapter where I could artistically refine and rejuvenate the rest of the face, in addition to focusing on the centre of the face—the nose. As the population ages, preservation of a youthful face is in even more demand. We as injectors have to constantly
evolve and stay extremely subtle and artistic in our endeavour to continually restore and rejuvenate the face. Consider the way a photographic image is made. Light falling on the subject is reflected from its contours and features through the lens of the camera. It is this reflected light that is photographed. I look at the face as if through a lens. The contours of a tired, wrinkly face do not reflect light in a harmonious, coherent way so I “adjust the light” until I am able to establish the youthful vectors in the face. The resulting “photograph” becomes my model. My work is not to endow the face with qualities it never possessed, but to bring out those qualities of beauty that are intrinsically its own. Now, 33 years into my rhinoplasty and injectables practice, I still pursue perfection in my endeavour to be the best at finesse closed rhinoplasty—my motto is to refine noses and not change them. I hope that closed rhinoplasty does not become an extinct art and that every nose is altered using the open approach.
Dr Raj Kanodia is a leading plastic surgeon based in Beverly Hills body language www.bodylanguage.net
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