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56 The UK Journal of Medical Aesthetics and Anti-Ageing

 LASER TATTOO REMOVAL Banishing unwanted ink

 TRUE COLOURS Food rich in antioxidants

Breast aesthetics




Booster A patented cutting-edge solution utilizing cycloastragenol, growth factors, peptides and antioxidants for dramatic age defying results proven through independent studies. Regeneration Booster is a cutting-edge anti-aging powerhouse proven through independent studies to significantly improve the appearance of aging skin. Maximum results are delivered through a concentrated combination of advanced ingredients including cycloastragenol, TGF Beta-1, coenzyme Q10, multiple beneficial growth factors and peptides and antioxidants.

Features & Benefits In an independent 12-week study conducted by Robert Weiss MD, Regeneration Booster showed significant improvement in the appearance of each of the eight measured categories of aging skin. Measured categories included the appearance of wrinkles, texture, pore size, elasticity, skin colour / clarity, erythema, hydration and overall skin quality.

Study highlights included: • 100% of subjects noted improvement in overall skin quality. • 100% of subjects noted in at least 3 or more categories with an average improvement in 6.7 of 8 categories. • 100% of individuals noted positive user experience (ease of use, smell, texture, feel). • Significant improvement in 100% of measured categories. • Visible results after just 2 weeks of use • 0 cases of sensitivity, acclimation or irritation.

Skin Types Recommended for all skin types. Pump dispenser in presentation box 30ml Ingredients: See our website for details.

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ANALYSES Reports and comments

Guest Editor David Hicks 020 7514 5989

14 COVER STORY In search of the ideal breast implant After a chequered past, polyurethane coated silicone implants are showing positive long-term results. CC Kat details the benefits of using these implants over their traditional silicone counterparts, presenting data from her own two-year study

Production Editor Helen Unsworth 020 7514 5981 Sales Executive Monty Serutla 020 7514 5976 Assistant Sales Executive Simon Haroutunian 020 7514 5982


 19 Post-pregnancy breast rebalancing Mr Raj Ragoowansi and Mr Jonathan Britto describe the features and causes behind post-partum breast problems, and how breast and body reshaping can be combined to provide overall rejuvenation following pregnancy  22 Autologous breast augmentation The use of autologous fat for aesthetic breast enlargement can provide natural results, with an added benefit of shaping from liposuction. Dr Amin Kalaaji, Cecilie Bergsmark Bjertness and Dr Kjell Olafsen describe their study comparing machine and manual centrifuge fat grafting methods for breast augmentation

Publisher Raffi Eghiayan 020 7514 5101 Contributors CC Kat Mr Jonathan Britto Dr Amin Kalaaji Cecilie Bergsmark Bjertness Dr Kjell Olafsen Dr Daniel Sister Catherine Quinn Mr Shailesh Vadodaria Dr Dennis Hurwitz Dr Luiz Toledo Dr Riccardo Frati Mr Basim Matti Mr Barry Jones Mr Raj Ragoowansi Mr Nick Percival Mr Alex Karidis Mr Andy Batchelor Mr Shiva Singh Diana Talaue Dr Jose Miguel Garcia Mr Ravi Jandhyala Dr Simon Poole Dr Anil Shrestha Dr Raj Persaud Dr David Edwards Dr Mark Hamilton Charles Southey Professor Syed Haq


 25 PRP for the breast The ‘Dracula’ platelet rich plasma technique can provide effective correction for problems encountered following surgical breast augmentation. Dr Daniel Sister elaborates


 28 BREAST ISSUES Patients can present with a number of problems owing to previous breast surgery, whether augmentation or reduction. Mr Shailesh Vadodaria presents a myriad of examples for our panel to discuss the treatments they would recommend

37 LASERS LASER TATTOO REMOVAL As tattoos become more prevalent among the younger population, so does ‘regrettable ink’ and the need for tattoo removal. Dr Jose Miguel Garcia runs through the process of removal using a Q-Switched Nd-YAG laser



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: Advertising: Body Language can be ordered online at body language

PEER PRESS REVIEW Mr Ravi Jandhyala surveys academic and association journals to report on advances in research in medical aesthetics and related fields

44 NUTRITION TRUE COLOURS Colourful fruits and vegetables are rich in antioxidants and nutrients, and can form a healthy, low calorie starting point for those seeking to improve their diet, writes Dr Simon Poole

48 CONFERENCE FACE 2013 The UK’s premier medical aesthetic conference and exhibition moves venue for the biggest event to date 3

body language

editorial panel Dr Jean Carruthers MD, FRCSC, FRC is clinical professor in the department of ophthalmology and visual sciences at the University of British Columbia in Vancouver, where she specialises in facial cosmetic surgery. With her husband, Dr Alastair Carruthers, she has received the Kligman award from ASCDAS .

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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. 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 Dr Raj Persaud FRCPsych is a consultant psychiatrist who has worked as a consultant at the Bethlem Royal and Maudsley NHS Hospitals in London from 19942008, and as an honorary senior lecturer at the Institute of Psychiatry, University of London—the premiere research and training institutions for psychiatry in Europe. 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.


51 DENTAL WEAR AND TEAR It is easy to underestimate how ageing of the dento-facial complex can affect facial aesthetics. Dr Anil Shrestha discusses the science behind the process, also known as gerodontology

55 PSYCHOLOGY DOES SIZE MATTER? The role of sexual intercourse as a form of communication may be a far more important discussion in evolutionary terms than the size of the male member, contrary to press reports on recent research. Dr Raj Persaud and Dr David Edwards review the latest studies

56 INJECTABLES BACK ON YOUR FEET High heels can cause a number of painful problems for the feet, one of which can be effectively treated with dermal filler injections. Dr Mark Hamilton describes his injection technique for metatarsalgia, or pain in the ball of the foot

59 MARKETING DIGITAL SUCCESS Search engine optimisation and email marketing are key marketing tools, writes Charles Southey

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

62 EXPERIENCE HIGHWAY TO HEALTH Professor Syed Haq describes his passage through healthcare, science and aesthetics, with a focus on addressing the rising obesity issue body language

A NEW VISION FOR THE GALDERMA AESTHETIC PORTFOLIO TO BE THE FIRST TO EXPERIENCE POSITIVE TRANSFORMATION Register for the Q-Med Academy day on the 15th March now at Date of Preparation February 2013 RES/004/0213

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

voted as The Best by our customers in 2011 and 2012

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


Gold Standard Customer Services



Is Facebook changing our faces? Surgeons report that unflattering photos on social media are driving a boom in facial procedures

This year heralded some surprising data for the cosmetic industry. In 2012, several popular procedures took an unexpected tumble and surgeons found that demand for body shaping—such as tummy-tucks and liposuction—had fallen significantly. But despite a double-dip recession, patients were choosing surgical facial operations over noninvasive equivalents. The reason? Many surgeons report that social media, with its propensity for showcasing unflattering camera angles, is to blame. So can Facebook and other social media really be driving an increase in invasive facial surgery? The statistics certainly make a case. Data released by the British Association of Aesthetic Plastic Surgeons (BAAPS) showed that body-altering surgery—with the exception of breast augmentation—dropped by up to 14%. And instead of tummy tucks and fat removal, patients were opting for anti-ageing surgeries on the face. Face and brow lifts rose by 14% and 17% respectively, while eyelid surgery and fat transfer rose by 13%. The reason for this shift in focus from body to face is thought to be, at least partially, down to social media images. Surgeons report that a large number of patients looking for facial rejuvenation and surgery, appear in-clinic brandishing photos from forums such as Facebook and Instagram. The social media phenomenon seems to have affected patients in several key ways. Firstly, a plethora of phone camera devices mean that more un-posed and unedited body language

pictures are in circulation. This means that would-be patients see themselves in a less flattering light. Secondly, this ‘papped’ style of photography means that different facial angles are highlighted, than might otherwise be seen. So a patient with a bump in her nose, gets to see a profile she wouldn’t ordinarily witness in the mirror. Imperfect images can also be readily accessed by all. So as well as providing a ‘shame factor’ which could prompt a desire for surgical intervention, patients can provide surgeons with an image on exactly what they would like changed. Nor is this trend limited to the UK. In America, similar statistics have been reported by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Surgeons across the pond have also seen body modifying operations (aside from breast augmentation) drop, and fa-

cial procedures significantly increase. The AAFPRS have also polled the reason for this, and found that the number of patients claiming social media images informed choice of surgery, rose by 31% last year. This is a huge increase, and suggests that UK data also owes a large number of facial operations to forums like Facebook. It may also be the case, that social media is paring back gender differences when it comes to facial surgery. Last year saw a huge increase in male facelifts and browlifts, both in the UK and US. And while men are still far behind women with cosmetic enhancements, the real-life social media environment could be something of a leveller. In any case, the cosmetic industry can likely expect the ‘Facebook face’ trend to continue, with ever more patients choosing surgery, because of social media images.

Non-invasive procedures gain recognition under European standards Non-surgical techniques, such as botox and fillers, are to be officially recognised as part of wider aesthetic surgery practices. Following last year’s public consultation for the European standard for Aesthetics Surgery Services, it has been decided that non-invasive procedures deserve recognition. With the enormous growth of non-surgical techniques, which are used alongside surgical aesthetics, significant feedback from the consultation, claimed the market has shifted. As a result, the title of the standard has been changed from ‘Aesthetic surgery services’ to ‘Aesthetic surgery and aesthetic non-surgery medical service’ to account for the broader scope of treatments now commonly practised.




second brief

AESTHETIC RESEARCH Desire to spend money on cosmetic enhancements seems to be on the up, according to website traffic statistics realeased by The Consulting Room. Over the course of 2012, just over 1 million unique visitors visited, in line with figures from 2010 after a dip in 2011. This increase in traffic suggests patients are still keen to fork out on aesthetic treatments, despite government talk of continued widespread recession

These were the 15 most popularly researched treatments in 2012, based on 700,000 visitors viewing the treatment and product FAQ pages:

1. Laser/IPL hair removal 2. Radiofrequency for facial rejuvenation 3. Penile augmentation surgery 4. Laser tattoo removal 5. Dermal fillers 6. Vaginal surgery 7. Fractional laser skin resurfacing 8. Microdermabrasion 9. Ultrasonic body contouring 10. Specialist skin cream 11. Laser and IPL skin rejuvenation 12. Chemical peels 13. Radiofrequency for cellulite and fat 14. Medical skin needling 15. Umbilicoplasty Source:


Firmer breast implants launch in the US New breast implant gains preliminary FDA approval US cosmetic surgeons will soon have access to another kind of silicone-gel implant. The Natrelle 410 Highly Cohesive Anatomically Shaped Silicone-Gel Filled Breast Implant has passed a key approval stage with the US Food and Drug Administration (FDA), meaning the implants can now be used by cosmetic surgeons. Allergan, who have developed the implants, claim the silicone used is of a different nature to other implants. The linking structures within the collagen are more numerous, resulting in a firmer gel. Currently, the FDA licenses the implants for use in women over the age of 22 undergoing breast augmentation surgery. They have also been approved for use in breast reconstruction. However, the implants are still under trial and the FDA have made it clear that licensing comes with several con-

straints. The implants have the same broad complications as other gel implants—namely, issues in their implantation and removal and risks of infection. However, Natrelle 410 has also exhibited a novel “gel fracture”, where fissures appear in the implants—unique to this product. The FDA’s conditions include monitoring 3500 women who receive the implants for five years after surgery. A further study, following 2000 women for ten years, will assess longer term risks. The FDA have also stipulated that risk assessment for common breast diseases be carried out. The FDA claim that direct safety comparison with other silicone-gel implants is difficult. As Natrelle 410 is a unique product, no direct comparisons have been made so no data will be available on whether this new gel-implant is safer or less safe than competing implants.

New nutritional protocol suggested for acne Sugar, white bread and dairy associated with acne Medical nutritional therapy has been suggested for the treatment of acne, according to the results of a new literature review. The study, published in the Journal of the Academy of Nutrition and Dietetics concludes that the connection between diet and acne is significant and that nutritional advice is key to treatment. The review of a number of leading trials and studies has found key links between dairy products, as well as food with a high glycemic index. The latter includes white bread, white rice, potatoes and sugars. Acne is traditionally treated

using high-strength antibiotics, or steroid cream, both of which have serious long-term side effects. In this study, researchers conclude that dietary advice— to cut down on dairy and high glycemic index foods—could have an effect equal to, or better than, conventional drugs, with no side effects and overall benefits to long-term health. Researchers pin-point a “rise in the diet and acne myth”, where medics were encouraged to dismiss the possibility of diet in the treatment of acne. They conclude that although diet doesn’t cause acne, it can strongly aggravate or influence its development.

body language


onfidence is Reliable1,2 Rewarding 3 Performance 4,5 BOTOX® is licensed for the treatment of moderate to severe glabellar lines Delivers long-lasting patient satisfaction, time after time 2,3 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. Serious adverse events including fatal outcomes have been reported in patients who had received off-label injections directly into salivary glands, the oro-lingual-pharyngeal region, oesophagus and stomach. 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. Pneumothorax associated with injection procedure has been reported. 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 pregnancy 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. Adverse reactions possibly related to spread of toxin distant from injection site have been reported very rarely (exaggerated muscle weakness, dysphagia, constipation or aspiration pneumonia which can be fatal). Rare reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. Rare reports of serious and/or immediate hypersensitivity (including anaphylaxis, serum sickness, urticaria, soft tissue oedema and dyspnoea) associated with BoTox use alone or in conjunction with other agents known to cause similar reaction. Very rare reports of angle closure glaucoma following treatment for blepharospasm. New onset or recurrent seizure occurred rarely in predisposed patients, however relationship to botulinum toxin has not been established. Needle related pain and/or anxiety may result in vasovagal response. 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: December 2012.

Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to Allergan Ltd. 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/0008/2013 Date of Preparation: January 2013

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 Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to or on +44 (0) 333 200 4143.


Date of preparation July 2012

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


training & events Bioengineered ears MARCH 4 March, Obagi Workshop, Obagi Medical, Manchester W: 9 March, Advanced Toxins & Fillers, Wigmore Medical, London W: 12–15 March, Introduction to Skincare & Peels, Toxins, Dermal Fillers and Laser/IPL Courses, Wigmore Medical, London W: 13 March, Sclerotherapy Training, Newport, S. Wales W: 16 March, Botulinum Toxin & Fillers Advanced, The Paddocks Clinic, Bucks W: 18 March, Obagi Workshop, Obagi Medical, London W: 21&22 March, Botulinum Toxin and Dermal Fillers Part 1, Dr Brian Franks, Watford, North London W: 22–23 March, Mesotherapy Training, Wigmore Medical, London W:

– a major development

25&26 April, Botulinum Toxin and Dermal Fillers Part 1, Dr Brian Franks, Watford, North London W:

Scientists create life-like human ears

26 April, ZO training, Wigmore Medical, London W:

Bioengineers have pioneered a major breakthrough in the development of prosthetic ears. Using cutting edge techniques in both cell cultivation and 3D printing, scientists have produced the first bio-ears, which are almost impossible to distinguish from real human ears. Researchers at Cornell University, New York, undertook a study in the ground-breaking techniques, which was published in online journal PLOS One. The bioengineers combined several technologies in the development of life-like prosthetic ears. Firstly, 3D printing technology allows a highly accurate mould to be made, using a real-life human ear as a template. This computer-generated mould is then filled with a specially-developed collagen gel. This substance forms a scaffold, onto which cartilage can grow, meaning the ear will become a fully integrated piece of living tissue after it is implanted. After removal from the mould, the ear is trimmed, and left to culture for a few days, to allow cellular growth to continue after transplant. The entire process takes less than a week in total. The resulting ears are life-like and functional, providing a natural alternative to thousands of children born with a deformity which leaves them without an external ear. Microtia, which affects between one and four in every 10,000 births, leaves the internal ear canal intact. But the lack of sound channelling exterior creates hearing problems. Currently, Styrofoam-like prosthetics are the main solution. However, these imperfect substitutes offer fairly poor performance, since they have no capacity to regenerate if damaged, and fail to grow with the

27 April, Smart Ideas Seminar, Radison Blu Portman Square, London W: MAY 10&11 May, PRP and Microsclerotherapy & Facial Telangiectasia training, Wigmore Medical, London W: 14 May, Obagi Workshop, Obagi Medical, Glasgow W: 17–19 May, Summit in Aesthetic Medicine 2013, Dana Point, USA W: 18 May, Botulinum Toxin & Fillers Foundation, The Paddocks Clinic, Bucks W: 20–23 May, Dermaroller, Introduction to Skincare & Peels, Toxins and Dermal Fillers Courses, Wigmore Medical, London W:

23&24 March, Basic Dermal Filler and Botox Train- 23&24 May, Botulinum Toxin and Dermal Fillers ing Courses, Newport, S. Wales Part 1, Dr Brian Franks, Watford, North London W: W: 24 March, Laser/IPL training, Wigmore Medical, London W:

29–31 May, Beauty Through Science, Stockholm, SWEDEN W:

25&26 March, Botulinum Toxin and Dermal Fillers Part 1, Dr Brian Franks, Watford, North London W:

31 May, CPR & Anaphylaxis Update, Wigmore Medical, London W:

27 March, Core of Knowledge, Nottingham W:

31 May, Dermaroller training, Dr Brian Franks, Watford, North London W:

APRIL 3–7 April, American Society for Laser Medicine and Surgery Annual Meeting (ASLMS) Boston, Massachusetts, USA W: 4 April, Business Development training, Wigmore Medical W: 4–6 April, AMWC, Monte-Carlo, Monaco W: 6–9 April, Microsclerotherapy & Facial Telangiectasia, Intermediate Toxins & Fillers, CPR & Anaphylaxis and Sculptra courses, Wigmore Medical, London W:

JUNE 1&2 June, Microsclerotherapy & Facial Telangiectasia and Intermediate Toxins & Fillers training, Wigmore Medical, London W: 6–8 June, Esthetic Education, Crimea, Ukraine W: 10–13 June, Dermaroller, Introduction to Skincare & Peels, Toxins and Dermal Fillers Courses, Wigmore Medical, London W: 14 June, Business Development training, Wigmore Medical, London W:

11–16 April, Aesthetic Meeting 2013, Javits Convention Center, New York W:

14 June, Obagi Workshop, Obagi Medical, London W:

12 April, PRP Training, Wigmore Medical, London W:

21–23 June, FACE Conference, London W:

15–16 April, BAPRAS Advanced Cosmetic Breast Surgery Meeting, Manchester Conference Centre W:

26–28 June, Aesthetics China 2013, Beijing, China W:

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patient. Other solutions, using harvested rib or other cartilage, involv painful and challenging operations for young children. In contrast, these bio-ears can be made in a few days and transplanted with minimal surgical invasion. It then takes three months for natural cartilage to begin to grow over the collagen scaffold, after which, the flexible ears are virtually indistinguishable from the real thing. Joint authors of the study are Lawrence Bonasser, associate professor of biomedical engineering at Cornell, and Dr Jason Spector, director of the Laboratory for Bioregenerative Medicine and Surgery and associate professor of plastic surgery at Weill Cornell in New York City. Both scientists have collaborated for some time on the development of cartilage replacements, and are delighted with the development. They believe that five years of age would be the ideal time for an ear transplant and that the prosthetics could also be used in cases where ears had been lost to accident or cancer. Although the processes are still in development, the scientists believe we could be seeing the bio-ears in real use within three years.


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cover story CC Kat

In search of the ideal

breast implant

After a chequered past, polyurethane coated silicone implants are showing positive long-term results. CC Kat details the benefits of using these implants over their traditional silicone counterparts, presenting data from her own two-year study


y 2010, I had completed ten years of private practice and it was an ideal time to critically review my breast implant results. In that same year, I heard a talk by Dr Daniel Fleming, a cosmetic surgeon from Australia. He presented his experience over a five year period of more than 500 polyurethane coated silicone breast implants. His message was convincing and it stimulated me to look further into the evidence behind these implants. 14

After reading the relevant clinical papers, I was able to convince myself of its safety and efficacy. I started using these implants from May 2010 in secondary breast implant patientsâ&#x20AC;&#x201D;those who have had problems such as capsular contracture with traditional silicone implants. As my experience increased with using these implants, I progressed to using them in primary procedures as well. I analysed the results of my first 189 patients. Based on these results, poly-

urethane coated silicone breast implants are now my implant of choice in primary and secondary cases, for both cosmetic and reconstructive surgery patients. History Polyurethane coated silicone implants are only a little older than traditional silicone implants. Silicone implants appeared on the market in 1962 and the first polyurethane coated silicone implants appeared in 1968. By all accounts, they body language

cover story CC Kat

were very popular. Users of these implants reported a very low capsular contracture rate. Unfortunately in the late 80’s and early 90’s, in vitro research found that one of the breakdown products of polyurethane—2,4-TDA—when injected into cancer-prone rats, caused cancer. Further research found traces of 2,4-TDA in the urine of women with polyurethane implants. Although there was never a direct link between polyurethane itself and cancer in humans, the manufacturer voluntarily withdrew polyurethane coated silicone implants from USA and UK markets. However, the implants continued to be popular in other parts of the world, especially South America. Further research by the US Food and Drug Administration (FDA) in conjunction with several prominent clinicians provided evidence for the safety of polyurethane coated silicone implants. It was found that the breakdown product 2,4TDA does not exist in human blood. A small proportion of women were found to have 2,4-TDA in their urine, but this was both in the control as well as the polyurethane coated implant group. The conclusion and advice given by the FDA was that it was not necessary for women with polyurethane coated silicone implants to have the implants removed. The risk of the implants causing cancer in humans was in the order of 1 in a million (compare with the risk of breast cancer in women—one in 10). Over the past 30 years this has been borne out by the fact that there has not been a single adverse event reported relating to polyurethane coated silicone implants. In 2010, the MHRA in UK re-examined the evidence and approved the use of polyurethane coated silicone implants in the UK.

quoted papers for polyurethane coated silicone implants: Handel, over a ten year period showed a 2% capsular contracture rate; and Vasquez showed a 1% capsular contracture rate over a period of 15 years. Daniel Fleming in his more than 500 cases had a zero capsular contracture rate.  An implant migration/rotation rate of close to zero, versus up to 10% in standard silicone implants. The implant has a ‘Velcro’-like effect on breast tissue. As a result, I have increased my use of teardrop shaped implants which suits a larger proportion of women who want to have a more naturally shaped breast.  The Silimed polyurethane range is the only implant range with a conical shape, which is ideal for slightly droopy breasts. It has a higher projection whilst maintaining a natural shape. It helps to avoid a formal mastopexy, or uplift, in a significant proportion of women.  An excellent range of 20 different shapes and projections for every implant size, to suit any body frame.  A high grade cohesive gel which is safer in the event of an implant rupture and it gives a more predictable stable outcome in terms of breast shape. The German Polytech implants are a little softer than the Brazilian Silimed implants and this gives the flexibility of choosing the right consistency implants for different breast types.  The two companies are the only ones to date that give the ‘D’ dimension of the breast implants. This is the distance between the maximum projection and the lower edge of the implant. This should fit quite accurately into the breast just below the nipple areola complex and the breast crease. Having this dimension allows more accurate selection of implants for the patients. Other implant companies are starting to put this measurement into their catalogues as well.

Advantages Having used the implants for over two years, I feel that the following are advantages over traditional silicone implants:  Capsular contracture rate of 1% vs up to 20% in standard silicone implants. In 2011, the core clinical US studies of Allergan and Mentor implants analysed between 2000–2010 were published. This confirmed that with the normal textured and smooth implants, the capsular contracture rate in cosmetic augmentation was up to 20% and the re-operation rate was 40%. In reconstruction there was a capsular contracture rate of up to 25% and re-operation of 70%. Comparing this with the two most

Results Between May 2010 to September 2012, I used the polyurethane coated silicone implants selectively in 189 patients. Initially, it was only used in secondary procedures but towards the end of the study period, I started to use the implants in primary augmentations as well. The ages ranged from 18–35 (median 35). The procedure types were: •  118 primary augmentations: (62%) •  Three primary reconstructions •  18 primary augmentation-mastopexy (10%) •  45 capsulectomy and change of implants, five of which were PIP (24%) •  Five mastopexy and change of im-

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Correction of capsular contracture with round 485cc extra high profile implants

Correction of capsular contracture with round 435cc extra high profile implants 15

cover story CC Kat

Primary breast augmentation with short height anatomical implants 435cc extra high profile

Primary augmentation of slightly asymmetrical ptotic breasts with conical implants 380cc extra high profile

Primary breast augmentation of moderately ptotic breasts with conical implants 435cc extra high profile

plants , two of which were PIP. The implant types were: conical (20%); round (31%); anatomical normal height (35%); anatomical short height (14%); and anatomical full height (one implant). The overall complication rate was 2.6%, with one instance of each of the following: visible rippling, implant sitting high, seroma, infection, stitch abscess. There were no instances of capsular contracture or implant migration/rotation. All complications were minor and treated conservatively. Both the patient with the visible rippling and the patient whose implants I felt were sitting a little too high were satisfied with the result and did not want further surgery.

I have progressed from using these implants only in patients who need replacement for capsular contracture to all patients who require breast implants, both in aesthetic and reconstruction cases. Prior to 2008, only Brazil made these polyurethane coated implants (Silimed), hence the popular term ‘Brazilian implants’.   With the exponential rise of its popularity, Brazil has not been able to keep up with demand. The German partner Polytech has taken over it’s own production in Germany to meet the market demands. I visited the Brazilian factory in Rio de Janeiro last year to satisfy myself that the implants were of the highest quality before committing to using them almost exclusively. I visited the factory in Frankfurt, Germany this year to do the same. It is everything that I expected of a German product. Every single implant is hand made with meticulous attention to safety and quality. Adding the polyurethane foam requires another time-

consuming step to ensure that the foam sits smoothly over the implant surface. This explains the additional cost of these implants. In conclusion, polyurethane coated silicone breast implants are now my implant of choice in both primary and secondary breast implant surgery. There is strong clinical evidence of its lower capsular contracture and implant rotation rate. I am able to achieve superior stable aesthetic results due to the wide range of shapes available and the high cohesive gel. The unique conical shape is ideal for the slightly droopy breast and avoids a formal uplift in a significant number of patients. I want patients to feel safe in having implants that are of the highest quality, with the least risk of possible complications, as well as giving them the best aesthetic outcome.

Conclusion Although the follow up period for these patients was short, the data has cemented my belief that these implants have superior aesthetic results with significantly reduced complication rates.

References 1. Ashley F. L. “A new type of breast prosthesis; preliminary report” PRS 45 : 421 – 424 1970 2. Chan et al. “Detection of TDA in the urine of a patient with a PU covered breast implants.” Clin Chem 37; 756, 1991 3. Hester et al. “Measurement of 2-4 TDA in urine and serum samples from women with the meme and replicon breast implants.” PRS 100:1291-1298, 1991.


Mrs Chien C Kat is a consultant plastic, reconstructive and aesthetic surgeon with her own clinic CC Kat Aesthetics W:

4. FDA: Update of study of TDA released from PU foam covered breast implants, June 1995 5. FDA update on the safety of silicone gel-filled breast implants, June 2011 6. Handel et al. “A long term study of outcomes, complications and patient satisfaction with breast implants.” PRS 117: 757 2006 7. Vasquez and Pellon. “Polyurethane coated silcone gel breast implants used for 18 years.” Aesth. Plastic Surgery 31:4 p3306, 2007

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cover story Mr Raj Ragoowansi and Mr Jonathan Britto

Post-pregnancy breast rebalancing Mr Raj Ragoowansi and Mr Jonathan Britto describe the features and causes behind postpartum breast problems, and how breast and body reshaping can be combined to provide overall rejuvenation following pregnancy


uring pregnancy, complex biochemical mechanisms lead to expansion and proliferation of the breast ducts, stromal elements and supporting fat. These features clinically manifest as enlarged, swollen breasts which can expand up to 2–3 cup sizes from their original size. At birth, prolactin levels increase with a concomitant decrease in the progesterone levels—the ductal elements expand further and milk production commences within the alveoli. The suckling reflex allows expression of this milk out of the nipple. During weaning, the prolactin levels gradually decrease and progesterone levels increase. The stromal elements and ducts then contract. The hypertrophied fat cells, stretched ligaments and expanded skin envelope shrink to a lesser degree. Typical features of the post partum breast are: •  The skin is lax, excessive and dermal thinning may manifest as stretch marks; •  The gland undergoes atrophy and, together with involution of stromal elements and attenuation of the ligaments, descends from the pectoralis fascia; •  The nipple-areaola complex (NAC) undergoes ptosis and its border with breast skin becomes less defined and; •  With descent of the breast, the inframammary crease effaces.

The severity or grade of these deformities vary between individuals and are more pronounced in multiple pregnancies.

A 31 year old patient, with one child not breast-fed, underwent breast augmentation with 290cc, sub-pectoral anatomical implant of moderate height and full projection

A 39 year old patient with three children all breast-fed, underwent a three-pedicled mastopexy, pictured before and 18 months postoperatively

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Causes The aetiology of ptosis is multi-factorial. Multiple pregnancies, mothers of an older age group, large bra cup size pre-pregnancy and weight loss are all established causes. Breast feeding is purported to be involved in causation but there is some evidence to suggest that prolactin production during feeding induces contraction of the ductal and stromal elements. This, to a certain degree, may lend to tightening and stability during the weaning phase. Upper body exercises are proven to tighten the pectoralis fascia and the supporting ligaments which extend to it from the skin provide some degree of protection against ptosis. Following accurate assessment and in conjunction with patient’s general health and physique, a strategy for rebalancing is drawn. The quality of the skin and position of the NAC are salient parameters upon which a surgical treatment plan is established. Ideally, if further pregnancy is contemplated, treatment is postponed. An appropriately-shaped and measured bra can minimise or temporise against the problem of ptosis and loss of breast balance. With glandular atrophy—usually in the superior pole—


cover story Mr Raj Ragoowansi and Mr Jonathan Britto

A 33 year old patient, one child not breast-fed, underwent a singlestage 265cc round sub-glandular augmentation with a superior-pedicled mastopexy

without descent, in the presence of reasonable skin quality and minimal or no NAC ptosis, a simple breast augmentation can suffice. My preferred option is anatomical implant, placed in the sub-glandular plane or in the sub-muscular/dual plane in the presence of significant parenchymal atrophy (<2.5 cm parenchymal thickness). In the presence of glandular atrophy with moderate breast ptosis and a supple skin envelope, an augmentation with an anatomical implant is a reasonable option. This strategy delivers a degree of nipple ascent, fullness of the medial pole and a smooth and natural take-off the chest wall. The over-riding benefits of the anatomical implant are volumetric support and projection of the lower pole, as well as better control of the height/width ratio. However, they do carry the additional burden of precision with placement and risk of turning in the early post-operative period. In patients with excess skin and heavy gland ptosis, a mastopexy is indicated. I routinely deploy the three-pedicled mastopexy—the superior pedicle to support the NAC, the inferior pedicle to augment the superior pole (and upper abdominal lift/ tightening), and a lateral pedicle inset into the medial pole to restore fullness, thus re-establishing a cleavage. Occasionally, the post-partum breast may persist with glandular hypertrophy and its descent. My preference in this scenario is to carry out a routine superior-medial pedicle breast reduction/mastopexy to restore comfort and harmony. For moderate to severe parenchymal atrophy, glandular and NAC descent and loss/attenuation of breast base or foot-plate, a mastopexy augmentation can be performed. My preference is to carry out this as a single stage procedure—a mastopexy is relatively easier to conceptualise and plan when the breast base and volume have been restored. Combination procedures Since commencing independent practice in 1995, I have treated 228 patients with post-partum breast sequelae, of which 97 have undergone combination procedures with abdominal wall recontouring or liposculpture at the same sitting. The average length of these combination procedures is six hours, an average hospital stay of two days and a six week recovery period (as opposed to 2–3 weeks for the breast procedure alone). Complication rates (2-5%) of these breast and body contouring combined procedures are no higher than if the procedures are carried out separately. Post-pregnancy breast reshaping is ideally carried out after child-bearing to ensure a favourable, durable result. Breast rebalancing strategies, alone or in combination, are carried out after accurate assessment of individual breast components against a backdrop of the patient’s chest dimensions, body habitus and preference or lifestyle.

A 32 year old patient, with three children all breast-fed, underwent a superio-medial pedicle breast reduction

References 1. Birkenfeld A, Kase NG. “Functional anatomy and physiology of the female breast”, Obstetrics and gynecology clinics of North America 21.3 (Sep 1994): 433-44. 2. Brian Rinker, Melissa Ven-


eracion, Catherine P. Walsh. “Breast Ptosis”, Ann Plast Surg 2010; 64; 579-584. 3. Spear, S, carter, ME and Ganz, JC. “The correction of capsular contracture by conversion to dual- plane positioning: Techniques and outcomes.”

Mr Raj Ragoowansi and Mr Jonathan Britto are consultant plastic surgeons, and directors of Millimetre Perfect clinic at the London Chambers of Plastic and Cosmetic Surgery: W: Plast Reconstr Surg. 118(7 Suppl.): 103S, 2006. 4. Bernard S. Alpert and Donald H. Lalonde. “MOC-PS CME Article: Breast Augmentation”. Plast. Reconstr. Surg. 121: 1, 2008. 5. Ragoowansi R, Britto JA.

“The ‘three-pedicled’ mastopexy – indications, technique and early results”. In preparation 6. Spear SL. “Augmentation/ mastopexy: ‘surgeon, beware’”. Plast. Reconstr. Surg. 2003; 112 (3): 905-906

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cover story Dr Amin Kalaaji, Cecilie Bergsmark and Dr Kjell Olafsen

Autologous breast augmentation The use of autologous fat for aesthetic breast enlargement can provide natural results, with an added benefit of shaping from liposuction. Dr Amin Kalaaji, Cecilie Bergsmark Bjertness and Dr Kjell Olafsen describe their study comparing machine and manual centrifuge fat grafting methods for breast augmentation


uch progress was made in the field of medicine during the Greco-Roman period, documented in ancient texts which were disseminated throughout civilisation. It was during this period that Roman medical writer Aulus Cornelius Celsus wrote De Medicina, which described surgical methods for reconstructing ears, lips and noses. The first nasal reconstructions using a forehead flap were performed by Sushruta in India between 600–700 BC. During the early Byzantine era, Oribasius compiled a compete medical encyclopedia entitled Synagogue Medicae. This 70-volume work contained numerous passages dedicated to reconstructive techniques to repair facial defects. A fifteenth century Islamic text by Serafeddin Sabuncuoğlu, Imperial Surgery, was largely based on Abulcasis’ 10th Century work Al-Tasrif. However, Sabuncuoğlu introduced many innovations of his own, including material on maxillofacial surgery and eyelid surgery, as well as a protocol for the treatment of gynaecomastia. This is believed to be the foundation for the modern method of surgical breast reduction. Around the time of World War I, surgeons began to fully realise the potential influence that one’s personal appearance could exert upon the degree of success experienced in his or her life. Because of this understanding, aesthetic surgery began to take its place as a more respected aspect of plastic surgery. In 1907, Dr Charles Miller penned the first text specifically written on cosmetic surgery, entitled The Correction of Featural Imperfections. The text, while ahead of its time in some respects, was nonetheless criticised and denounced as “quackery” by many general surgeons. Unfortunately, this attitude was prevalent among the medical community, who largely tended to view cosmetic surgeons, including Dr Miller, as charlatans or “quacks”.

Fat grafting In 1895, surgeon Vincenz Czerny carried out the earliest breast augmentation/reconstruction when he used the patient’s autologous adipose tissue, harvested from a benign fatty lumbar lipoma, to repair the asymmetry of the breast from which he had removed a tumour. The use of autogenous abdominal fat to correct deficits in the malar area and chin was reported in 1909. Throughout the early part of the 20th century, attempts were made to correct other conditions, including hemifacial atrophy and breast defects, but modern fat grafting did not develop until the early 1980s with the popularity of liposuction. In 1984, Dr Yves-Gérard Illouz reported the transfer of liposuction aspirate fat and in 1986, Dr Richard Ellenbogen used free pearl fat autografts in atrophic and post-traumatic facial deficits. Fat grafting has become popular for a variety of problems including facial scarring, lip augmentation and facial rhytides—such as the nasolabial fold and glabellar furrows. Dr Sydney Coleman has since developed the technique of fat grafting, and also invented the so called Coleman injections canulaes which carried his name, particularly for facial treatments. Fat grafting is now a well-known clinical method for reconstruction of small defects and has recently been applied to the face, but to lesser extent for breast reconstruction and only recently to aesthetic breast augmentation as an alternative to breast implants. Since 2008, the Oslo Plastikkirurgi Clinic in Norway has carried out 49 breast enlargements in 43 patients with fat grafting to treat hypoplasia mammae, asymmetry and in combination with other procedures like abdominoplasty and mastopexy. Patients need to fulfill five criteria to become a candidate for surgery. The patient must not want a foreign object to be

Before & after photos of a 31-year old patient with moderate hypoplasia and slight asymmetry, resulting in the right breast being smaller than the left. Fat was harvested from the thigh. A total of 175ml of fat was grafted in the right side and 150ml in the left. A,B: Front view before and after. C,D: Right view before and after. E,F. Left view before and after

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cover story Dr Amin Kalaaji, Cecilie Bergsmark and Dr Kjell Olafsen

used; they must have existing fat to be corrected, not just a donor site—no hunting for fat. The patient must also have realistic expectations of breast volume increase. A result from fat grafting will never be as voluminous as with breast implants. There must be no breast cancer history and the patient must have a normal ultrasound or MRI before the operation, and agree to have another examination one year post-surgery. Methods Of the 49 enlargements performed at the clinic, we carried out a study comparing machine and manual centrifuge for fat grafting. In the first group (28 enlargements), the fat was machinecentrifuged for three minutes, while a manual centrifuge was used on the other group of patients (21 enlargements). Fat was usually harvested from the abdomen, thigh, buttocks or knee and was grafted in intersecting and parallel canals through small incisions using Coleman’s cannulas. In the machine-centrifuged group, the fat was treated with 3000 rounds per minute. The fat was then separated from the liquids and oil, and filled in 10ml syringes. Using a 1.5–2ml Coleman cannula, the fat was mostly injected subglandularly. In the manual group, we used a manual centrifuge rotated by hand, usually carried out by the nurse. The fat was sampled in a 60ml syringe and rotated around a spine for three minutes. This method has 15G gravitational force, compared to 1200G for the machine centrifuge. It is thought that this method is less distracting for the fat than the machine method. The procedure is performed under total intravenous anaesthesia (TIVA) and local anesthesia corresponding to the standard concentration used in liposuction. Using 3–4 ml cannulae for harvesting the fat and avoiding maximal pressure when injecting the local anaesthesia are important factors, as we are trying to avoid injuring the fat cells. A local anesthetic is also used when undermining the breast area where the fat is to be grafted. Areas of liposuction, as well as the amount of extracted and injected fat, should be agreed with the patient before the procedure. We also advise patients not to lose weight after the operation. A loose bra is used postoperatively and there should not be any pressure on the injected side of the breasts—this will increase absorption and compromise the circulation to the fat. Results In the machine-centrifuged group, the average follow up time was 15 months and for the manual group, one year. Average injected fat in the machine and manual groups was 206ml and 229ml respectively in the left breast, and 204ml and 234 ml in the right. Resorption rate was less than 50% in the main part of patients in both groups (72% of the patients in the machine group and 83% in manual group). Ten patients were not satisfied because resorption was more than 50%—seven in the machine group and three in the manual. New injections were performed on six patients.


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Three patients chose to have breast implants following the procedure because there was not enough donor fat and/or because their expectation of breast volume with this method was not fullfilled. One patient was surprised with the expected breast volume but was interested in gaining even more volume with implants. Two small cysts were treated easily and one minor fat necrosis was observed in a mastopexy case along with the scar. According to Khori, fat grafting can be characterised by the four S’s farmer analogue of sowing seeds in a field: seeds (harvesting of fat cells), soil (preparing the breasts), sowing (grafting technique) and support (post-operative care). Each step is rate limiting and the weakest link could determine the outcome. Patients should be aware about overcorrection of the breast which, along with swelling, gives the impression of being bigger than normal. To avoid disappointment, patients should be informed that overcorrection and swelling—seen directly after the operation—is not the final result and that they should always compare pre-operative photos with results. In our study, patients obtained a natural feeling, more fullness in desired areas, such as the upper side of the breast, correction of asymmetry, and removal of unwanted fat and corrected areas. There is also no risk for capsular contractions, which we see in breast implants. However, far from all patients obtained the desired volume. Furthermore, it is difficult to calculate gained rest volume. Vectra 3D imaging is used to determine the breast volume, but this is still in the establishment phase. Factors like centrifugation, local anaesthetics, cannulas used, preoperative expansion and the injected fat amount still have an unclear interaction on the result. Stromal vascular fractions and adipose derived stem cells (ADSC) are explosive research areas, which could affect the outcome of fatgrafting. The BRAVA expansion device invented by Khori could also be used, especially in the severe hypoplasy, though it is essential for breast reconstruction. Providing strict patient selection is carried out, this method could be a good alternative for breast enlargement for patients who never want implants, for correction in asymmetry, Poland syndrome, in combination with other procedures like abdominoplasty, and even as a composite augmentation together with implants. This is tissue engineering. It is strongly not recommended for non-plastic surgeons and definitely not for beginner plastic surgeons. This technique is reserved only for experienced plastic surgeons with experience of handling tissue, bearing in mind the armamentarium of treatment. Failing to do so would risk undermining results and the technique as a whole. However, a longer follow-up time and multicentre studies should be performed before final conclusions can be made. Dr Amin Kalaaji, medical student Cecilie Bergsmark Bjertness and Dr Kjell Olafsen practice at the Plastikkirurgi Clinic in Oslo, Norway. W: E:

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cover story Dr Daniel Sister

PRP for the breast The ‘Dracula’ platelet rich plasma technique can provide effective correction for problems encountered following surgical breast augmentation. Dr Daniel Sister elaborates


ith our constantly-evolving industry, we as practitioners always need to be on the lookout for innovative, safe and efficient treatments; the first lesson in medical school is “do not harm”. Following these criteria, I have been fortunate enough to introduce to the UK: the Polaris laser; carboxytherapy, two chemical peels—the VIpeel and the Rouge peel; three dermal fillers (Radiesse, Ellanse and Amalian); Aqualyx-Intralipotherapy; MELT (1, 2 and 3); and the “Dracula” platelet rich plasma (PRP) therapy system. Platelet Rich Plasma PRP defines a high concentration of blood platelets in a small volume of plasma and is developed from autologous blood, so is therefore inherently safe. Plasma—which comprises 55% of blood fluid—is mostly water (90% by volume) and contains dissolved proteins, glucose, mineral ions, hormones, carbon

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dioxide, blood cells and platelets. Platelets are small, being only two micrometres, but are powerful. They contain three types of internal vesicles, lysosomal vesicles, dense vesicles and alpha vesicles. They also contain a variety of small molecules also known as cytokines that interact with the local cells and send signals that initiate a variety of important events, such as cell division and migration. The concentration of platelets delivers an increased number of growth factors in their biologically determined ratios that distinguish PRP from recombinant (not native) growth factors. To release the growth factors and pre stem cells, these platelets must be activated. In 1986, the Nobel prize for medicine was attributed to Stanley Cohen and Rita Levi-Montalcini for their 1950s discovery of the first growth factors—NGF (nerve growth factor) and EGF (epidermal

growth factor). Their research proved a polypeptide chain was able to stimulate the cell’s growth, like a biochemical signal activating a membrane receptor. In the 1970s, Professor Marx in Miami published his treatment with PRP on receding gum and maxillary bone strengthening to fix dental implants. From there, multiple applications were discovered—sports medicine, surgery, post laser therapy, veterinary and cosmetic/aesthetic applications—as well as important knowledge concerning preparation methods and growth factors. Alpha vesicles store and release growth factors which promote tissue healing and bio-cellular regeneration. Treating a wound generates new cells and vascularisation, similar to skin rejuvenation. This explains why these growth factors have interesting applications in antiageing medicine. In addition, the activated thrombocytes have on their surface a multitude of signalisation molecules: 25

cover story Dr Daniel Sister

PDGF (Platelet Derived Growth Factors): - Chemo attractive to mesenchymal stem cells and endothelial cells. - Differentiation for fibroblasts and osteoblasts. - Up regulates effects of other growth factors on cells such as macrophages. - Mitogenes of mesenchymal stem cells promote the synthesis of the extra cellular matrix TGF (Transforming Growth Factors alpha and beta): - Promotes cell mitosis - Significantly increases type I collagen production in the tendon and favours the synthesis of collagen. - Sheath fibroblast - Stimulates DNA synthesis, proliferation of various types of cells. VEGF (Vascular Endothelial Growth Factor): - Stimulates angiogenesis, chemo attractive for osteoblasts EGF (Epidermal Growth Factor): - Has an important role in the regulation of cell growth, proliferation and differentiation by binding to its receptor EGFR - Induces epithelial development and promote angiogenesis - Stimulates proliferation and differentiation of epidermis cells, co-stimulating angionegesis. IGF 1 and 2 (Insulin like Growth Factors): Stimulates the proliferation and differentiation of osteoblasts.

CD9, CD-W17, CD41, CD42a-d, CD51, CD-W60, CD61, CD62P and CD63. The alpha-vesicles also contain cell-adhesion molecules and are involved with vitronectin, fibronectin and fibrin. For treatments involving the breast, we are not concerned with the osteoblasts but more with type 1 collagen and fibroblasts. Dracula breast improvement In light of the PIP implant scandal and the removal of Macrolane for breast augmentation, women were left with two options for breast augmentation—either do nothing or have surgery using reliable implants. But some patients cannot afford surgery, are afraid of the complications or do not require such an invasive treatment. By using PRP, we can correct three types of problems using this non-invasive technique. So what can we do for a woman who had a breast reduction which left her with two asymmetrical breasts? One of my patients had this problem and was not keen to undergo surgery again to add what had been removed. Post surgery, her left breast was rounder, bigger, fuller and hung lower than the right breast. By injecting a mixture of PRP and hyaluronic acid, I was able to correct the flat area and re-create some symmetry. Post-treatment, there was no bruising, scar formation or downtime and no special care was needed. The second area PRP can help with are problems with skin stretching and irregularity following breast implant surgery. A female patient was presented to me who had implants which were too large for her, resulting in skin problems. The weight 26

from the implants was too great and, on one side, was pulling the skin down. One breast was round and the other appeared flatter, and her cleavage was wrinkly and damaged by the extra weight. I worked with Dr Charles Runnels on this case and, using PRP mixed with hyaluronic acid, the correction was almost immediate without down time. Thirdly, you can treat patients with PRP who do not need or want breast implants but would like to improve only the cleavage. When a woman wears a bra, it pushes the breasts up and in to create the cleavage. The same technique, right under the cleavage would improve it—a subtle, easy modification that would not have been accessible before.

It is very easy to inject under the skin, and by mixing PRP with HA, we do not need to inject as much dermal filler. The region is filled up with a very supple mixture, without any risk of lumps, bumps or granuloma. The results and the feeling are totally natural. Technique Technically the preparation for PRP/ Dracula is classic: 20ml of a patient’s blood centrifuged for eight minutes at 1800 RPM to separate the red cells and the plasma. We then harvest the totality of the plasma—PRP and PPP (platelet poor plasma). Using a two way connector, it is simple to mix 2ml HA with the plasma. The injection(s) are performed using a cannula or 30G needle, just under the skin and within the area we want to correct or improve. In contrast to Macrolane, PRP is not injected into the mammary gland but instead sub-dermally, without penetrating the breast itself. Therefore there is very little risk and no modification on mammograms. As it is an autogenous preparation, PRP is inherently safe and free from concerns over transmissible diseases such as HIV, hepatitis, West Nile fever and Cruetzfeld-Jacob disease (CJD). The PRP growth factors never enter the cell or its nucleus, are not mutagenic and they act through the stimulation of normal healing, just much faster. Therefore, PRP has no ability to induce tumour formation and never has done. Dr Daniel Sister is a cosmetic surgeon practicing in London and Paris.

Before and 30 minutes after having PRP and hyaluronic acid injected into the right breast to regain symmetry

Weight from overly large implants was pulling skin down and causing wrinkling, correction achieved using PRP mixed with hyaluronic acid body language

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Mr Shailesh Vadodaria is a consultant plastic surgeon who is on the specialist register of the GMC

Dr Dennis Hurwitz is a cosmetic surgeon and is director of the Hurwitz Center for Plastic Surgery in Pennsylvania, USA

Dr Luiz Toledo is a consultant plastic surgeon, originally from Brazil, now practicing in Dubai

Dr Riccardo Frati is a plastic surgeon who recieved his clinical fellowship in cosmetic surgery with Prof Gaspatotti

Mr Basim Matti is a consultant plastic surgeon, a member of BAAPS and is the UK secretary for ISAPS

Mr Barry Jones is a consultant plastic surgeon, craniofacial surgeon and past president of BAAPS

Mr Raj Ragoowansi is a consultant plastic, reconstructive and aesthetic surgeon practising in London

Mr Nick Percival is a consultant plastic and cosmetic surgeon with a special interest in aesthetic breast surgery

Mr Alex Karidis is a consultant plastic surgeon who runs his own private practice in central London

Mr Andy Batchelor is a consultant plastic surgeon and is a member of BAPRAS and BAAPS

Mr Shiva Singh is a plastic surgeon based in central London, with a special intrest in aesthetic breast surgery


Breast issues Patients can present with a number of problems owing to previous breast surgery, whether augmentation or reduction. Mr Shailesh Vadodaria presents a myriad of examples for our panel to discuss the treatments they would recommend Issue 1: Size dissatisfaction following bilateral breast reduction Mr Shailesh Vadodaria: The first case is that of a 66-year-old patient who had received a badly done liposuction elsewhere and requested a bilateral breast reduction. We performed the surgery and, six weeks down the line, she complained the size was too small and that she would like a breast augmentation. I advised her I would not carry out any further surgery for one year, for maturation of scar and then we could revisit the situation. A year has now passed, how would you now manage this patient? Firstly as a patient—not relating to technique—and second, following mutual agreement with the patient and if anything needs to be done, what would you do? Dr Dennis Hurwitz: With a patient who has a larger body type, it can be difficult

to get small enough breasts that are comfortable and don’t hang. For minor issues, I have sometimes used lipo-augmentation to fill out the upper breast. Many people are rightly concerned about putting an implant in and getting sagging, so I’ve treated some patients with 200cc of fat as a reasonable and low cost alternative. Dr Luiz Toledo: I had a case with a similar patient. She had an abdominoplasty and breast lift. She didn’t want smaller breasts but wanted them lifted because she had had four children. The first thing she said when she came to the consultation was “I’m a very difficult patient.” I told her exactly what I could do, and insisted on taking preoperative pictures. During the operative procedure—predicting potential difficulties in future—I took full photographs of the procedure. Then, post-operatively, I took pictures of the skin excess that I had removed from the breasts, without any gland in it, and a picture of the patient on the table immediately after the procedure. body language

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gested, I would ask a colleague to give a second opinion and pay the fee. I would also give the patient copies of her notes, and write a detailed letter to her GP and send a copy to the patient.

Issue 2: A young female patient requesting correction of pectus excavatum and mastopexy following implantbased breast augmentation performed in the past elsewhere

At the one month follow up, she said her breasts were too small and wanted them back to the size they were. I was able to produce the pictures demonstrating that no breast tissue had been removed. She decided she did not want to increase breast size, but if she had, I would probably have put in an implant. As it was, I insisted she sign an agreement to state she would no longer be my patient and there could be no complaint in future. Dr Riccardo Frati: Scientifically speaking, I would use a fat graft because this would enable me to correct the asymmetry. The patient would also feel that the lost volume was being replaced with something from her own body. But, hearing the background of this patient, I think the percentage of her being satisfied is too low, and I would therefore not operate further on her. Mr Basim Matti: Every patient who comes to me must pay two weeks before any procedure. If the patient pays for the treatment, in general they’ll be very happy. But if they haven’t paid, there is always a reason for them not to. I refuse to operate if they have not paid one week before— this seems to settle the issue. If I had to operate again on this patient, I would first ask her to see a colleague of mine to get another opinion. I would pay for the consultation and then would agree that if I had to operate further, it would be an implant. However, I would be very careful with a patient like this. Mr Shailesh Vadodaria: As Basim sugbody language

Mr Shailesh Vadodaria: The next patient is a 21-year-old lady, who had a pectus excavatum and breast implants in the past. She now wants a mastopexy. There are two problems. One is correction of the skeletal deformity on the sternum. Another is the issue of mastopexy—would you perform this simultaneously? What would you do about the pectus excavatum? Dr Luiz Toledo: Fat grafting would be a good solution for the pectus excavatum and this could probably be done simultaneously with a mastopexy. Dr Dennis Hurwitz: I’ve been pleased with the results from fat grafting for moderate to mild deformities. But you would probably need a couple of treatment sessions and the patient should be made aware of that. As Luiz says, do a mastopexy. I am getting more wise in warning patients about potential drops of their breasts. I would probably ‘two-stage’ her—I don’t know how big the implants are, but I would remove them and put a small implant in a year later. Mr Basim Matti: I have problems with this kind of pectus excavatum, especially with asymmetry. I had a patient who had an implant in front of the muscle, so one side of the chest was more vertical, while the other was more horizontal. After a year, the patient became upset because the implant slid on the vertical side. I had to operate on her and learned that you have to build behind the muscle as it acts as a barrier for the implant to slide down. In my experience with this kind of pectus excavatum, I would not treat the patient immediately as they are. I would do the mastopexy first and the implant later on. I would not use fat first as I don’t think the patient would be happy. Mr Barry Jones: One of the most important things here is to manage expectations. If you talk to the patient about open chest surgery, she’ll almost certainly say no. In this case, you could explain how fat grafting could be used but the

disadvantages are X, Y and Z. If the patient has reasonable expectations of what can be achieved—which is actually not a very good outcome however clever you are—then you’re fine. But you should at least ask or give the patient opportunity to discuss it with a chest doctor. Mr Shailesh Vadodaria: In this case, we actually performed an autologous fat transfer in two stages and she was happy with the result. Mr Barry Jones: Dennis, if you were to forget about the pectus and do a mastopexy on this patient—particularly looking at the left side—what kind of mastopexy technique would you use? Dr Dennis Hurwitz: I’m not sure what proportion of this patient’s breast is implant, but assuming it’s a third, we have something to work with. If there is some bulk, it would be similar to a Pitanguy vertical technique—with the inferior flap continuing from the aureole down, as a de-epithelised enhancer, sutured up to the chest wall and the two pillars come from side to side. Owing to the suturing to the chest wall, there would be no room for an implant, nor do I want that dynamic in such a patient. But I think that inferior pull could be readily used and pushed up—it looks like the whole footprint of that breast is too low. I could even use a Wise pattern technique and suture the T-portion up to the second rib as a double suspension. She should be informed about the inverted T keyhole pattern and resulting scars—you’re going to need a tremendous amount of skin and reshaping. Mr Shailesh Vadodaria: In the end, I performed a two-stage autologous fat transfer and she is at present quite happy with the results. But if we were planning to do any kind of mastopexy, would you use the

Issue 2: Correction of pectus excavatum using autologus fat transfer in two stages


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de-epithelised skin, based on intercostal perforator to augment the concavity of the pectus excavatum by inserting the soft tissue into the subcutaneous pocket? Mr Raj Ragoowansi: The lateral pedicle can be de-epithelialised and raised. You don’t have to see the perforator, you can raise it as a wide-based pedicle. This can then be carried over and inset into the medial pole and even into the pectus excavatum so that you are dividing the pectum deformity in half. On the right side, one half of the pectum is being filled by the right lateral pedicle distal portion and then the left side in a similar manner. I think strategic use of pedicles with whatever breast tissue remains is a good option. I probably perform this as a twostage procedure—the mastopexy first and then an implant if needed. Dr Riccardo Frati: Principally it is a good idea but in this case you are at risk of having the aureole too high up. The flap would never get to the midline. Otherwise you would have the aureole too medially with your flap.

Issue 3: A patient in her late 60s requesting larger implants, following augmentation performed 40 years ago Mr Shailesh Vadodaria: The next case is that of a 67-year old patient who has had implants for 40 years and would like replacements with larger implants. She explained she had bad capsular contracture, which she would like managed at the same time. The patient had significant tethering—how would you manage this before taking the patient to theatre? She also has a calcified capsule on the right side with a ruptured implant—how would you treat this? Mr Barry Jones: Firstly, would you do any investigations before operating on her? Dr Dennis Hurwitz: The patient would need an ultrasound or even an MRI. You want as much information as you can get in a patient of this age—there could be a ductal carcinoma. Dr Luiz Toledo: I would do an MRI. As she wants bigger breasts, the solution will be easier than if she wanted smaller breasts. If she wants only one size bigger, then we would have to deal with scars. Mr Basim Matti: If there is calcification behind the nipple, I would do nothing apart from exploring that calcification to see if it is cancer. That’s number one. If the implant has been calcified for many years, it could be that the implant is stuck body language

Issue 4: Correction of capsular contracture by removal of implants from behind muscle and replacement into the subglandular plane

to the nipple and is pulling it down. I would not operate until I had explored what the calcification is, ensuring it’s not cancer. I would do an MRI scan and then refer the patient to a general breast surgeon as I would not be happy to operate. Dr Riccardo Frati: I would first get her examined by a breast surgeon, by MRI or ultrasound. Was the implant sub-muscular or sub-glandular? Mr Shailesh Vadodaria: Sub-glandular. Dr Riccardo Frati: She would therefore have little glandular tissue. You would therefore have a problem with the protection, or cover. After excluding any malignancy, I would perform a capsulectomy and put the implant under the muscles to provide some cover. Dr Dennis Hurwitz: Patients want a simple, easy solution, such as just changing the implant. But there may be capsule contracture, rippling or worse, so there is no simple solution. This would be like a breast reconstruction case. Patients have incredibly high expectations which you have to manage because you can’t offer a simple operation.

Issue 4: Painful capsular contracture in the right breast following breast augmentation four years ago Mr Shailesh Vadodaria: The next case is that of a 27-year-old woman. I performed a bilateral breast augmentation four years ago and she returned with capsular contracture on the right side. Now she has pain in her right breast and would like revisional surgery. She has also asked if I could upgrade the implant size. This patient had a dual plane augmentation with a round implant, and we also have to tackle the capsule contracture. Would you perform a capsulectomy? Would you change the plane? And if the patient requests a bigger implant, what size and shape would you recommend? Mr Basim Matti: This is a very difficult

case. If she wants too large an implant, I would send her to a specialist. Otherwise I would use a polyurethane implant behind the muscle and increase the size using a conical implant. Mr Shailesh Vadodaria: Would you perform a capsulectomy? Mr Basim Matti: It depends on the thinness of the skin. I would make the decision during the procedure. There are purists who would say remove the capsule, but you must consider the circulation of the skin. If the circulation is good and the tissue thickness is very thin, I would remove the capsule. If I am not able to do that, I would excise the capsule. If I was in a difficult situation, I would leave the capsule—the circulation of the patient is most important to me. Mr Nick Percival: If you’re going to put in a polyurethane implant, you have to remove the capsule. This would be a silicone implant covered in polyurethane foam. If you want to get the beneficial effect of not getting capsular contracture, then you must remove the capsule. I don’t see a problem with removing the capsule because this is a sub-muscular implant. Mr Alex Karidis: I would create a new pectoral pocket, which reflects the anterior portion of the capsule back so you don’t have to touch the one on the base of the ribs. You’re creating a fresh pocket that accommodates your polyurethane implant. It doesn’t matter if you leave the posterior aspect of the capsule. I would use an extra high profile because she has quite a narrow base if she wanted bigger breasts. I don’t have any issues with the viability there. Mr Barry Jones: So this seems like a good indication for polyurethane. Dr Dennis Hurwitz: Polyurethane implants are not available in the US so we would probably use Stratos implants. There seems to be some impediment to recurring capsule contracture. Mr Nick Percival: I only use polyurethane implants for difficult cases with recurrent capsular contraction. I don’t use them all the time as, from a technical point of 31

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to take the implant out. Mr Alex Karidis: I recently removed a polyurethane implant from a patient who I had put the implants in two years ago. She was perfectly happy with them in terms of encapsulation—there weren’t any grade one capsules—but she wanted to be bigger. I went in through the same incision and the foam covering was intact. It came off the capsule easily but what I was left with was a very thick capsule, albeit not contracted. Normally when you exchange an implant, you find a very thin capsule, perform a capsulotomy and insert a bigger implant. To get the effects of a polyurethane implant re-established, you have to go back and take out the old capsule. Effectively I had a bigger operation on my hands—if I have patients coming in for bigger implants, I have to have to take out the capsule entirely again, creating a bigger operation for myself. Mr Barry Jones: One of the interesting things about the PIP implants—not that I’ve ever used them, but I have taken some out—is that there is no capsule. There is free silicone around the implant but there is no capsule. Mr Shailesh Vadodaria: There is an increasing trend of using polyurethane implants. Is there any evidence that if you use a polyurethane implant it has a better outcome with less capsular contracture compared to other textured implants for primary breast augmentations? Personally speaking, whenever I have to remove a polyurethane implant with capsular contracture, it’s a nightmare. The capsule is thick and virtually stuck to the skin—it’s then very likely it could damage the skin. Dr Dennis Hurwitz: I also don’t routinely use polyurethane implants. When I first heard about them, they were sold as a good implant that wouldn’t cause capsular contracture.

Frankly, I don’t have a major issue with capsular contracture, so why would I want to introduce a new element into my practice, something that could have problems later on? Perhaps capsular contracture has been overstated to make the polyurethane implants seem better. I would, however, use them in the handful of patients who come back to my practice with recurrent contracture. Mr Shailesh Vadodaria: I think we are creating two issues by introducing polyurethane implants without evidence. Firstly, they increase the chance of asymmetry because of malposition and secondly, if revision surgery is required, it would be difficult. Mr Barry Jones: The problem is that there are no proper controlled trials going on in Europe, and there should be. Then we can maybe answer those questions.

Issue 5: Thoughts on ethics and risk factors when taking on post-operative care of patients who have had operations abroad—what should the upper size or volume limit be of implants? Mr Shailesh Vadodaria: Consider, for example, a patient who had received very large implants for bilateral breast augmentation in the US—no UK surgeon was prepared to perform the procedure with large volume implants. Surgery has been performed through a sub-areola approach, sub-muscular or possibly a dual plane. Would you take this patient on for minor issues with wound healing? And what is the general thought process about implant size, what should the upper size limit be? Mr Basim Matti: Firstly, I would take care of the wound and give her antibiotics. I wouldn’t have continued on page 35 

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Date of Preparation: January 2013 UK/0008/2013a

view, they are more difficult to use than pure silicone implants. They’re unforgiving in terms of position and most surgeons find, when they start using them, they tend to place the implant slightly too high and they don’t shift. I’ve also got one or two concerns about their shape. I find they tend to be rather broad and flat in comparison with the Nagor silicone implants that I normally use. However, we should start thinking about using conical shaped implants because these seem to avoid many of these problems. Dr Dennis Hurwitz: Twenty years ago, we were using MEME and Replicon implants. Within seven or ten years, capsular contracture occasionally occurred and when patients came back, there was no polyurethane left around the implant and sometimes even a little seroma. That put me off somewhat. I take it this has not been the experience here? Mr Nick Percival: The polyurethane foam and silicone implant detach from each other so you can then, if needed, perform revisional surgery. I don’t know if there’s a long-term problem with seroma formation in these implants. I’m not aware that this is an issue, but the polyurethane foam does detach from the implant. So after six months you’re technically left with a silicone implant. You do have a capsule around it but it seems not to contract in the same way that the capsule does from a normal silicone implant. If you need to carry out revision surgery with polyurethane implants, you must wait some time because the implant is stuck to the foam coating. It takes three to four months for separation to occur. If you try and remove the implant following malpositioning, the best option is to take the patient straight back to theatre in the first week or so. Once that foam is incorporated, it is difficult to remove. But once the silicone has separated from the polyurethane, it’s pretty straightforward

10/01/2013 12:38

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It is more important that a patient is happy with the look of the implants prior to surgery, rather than focusing on cup size

done that operation myself. Mr Barry Jones: The problem is that once she becomes your patient, she becomes your problem. If you treat her, she then becomes your duty of care. Mr Andy Batchelor: In the UK, the framework is simple. If you don’t do it with the consent, assent and cooperation of the general practitioner, then you look after that patient’s total care until the clinical episode is finished to her satisfaction. You are responsible for all her general medicine. What you should do is smile graciously and explain that the problem is outside your experience and she deserves treatment from a specialist. Mr Barry Jones: I would agree—tell the patient, “This is out of my field of expertise and there’s no charge.” Mr Basim Matti: If the patient has a good aesthetic result, but does have a wound problem, this should be treated on a humanitarian basis. However, I’m wiser after what I have heard. Dr Riccardo Frati: Direct treatment is a very important issue. I would send her to her GP to take care of this as it is a general problem. Regarding size, I think it’s deplorable that there are no limits for implant size. It’s not a good argument to say if I don’t do it then someone else will. Mr Shiva Singh: The maximum volume available in the UK is 1500cc and that would be a customised implant. Up to 800cc is available off the shelf. There are a small number of patients who want these implants—some are models, some have psychological issues. I recently had 10 or 12 patients from across Europe who were mature, married women. Many of these patients already had 600cc implants but wanted bigger. I don’t feel that I’m causing any future problems by offering bigger implants apart from the effect of gravity, which is explained to the patient. I do not yet have a long-term follow up which I can quote, but in the first two years I have never had any problems with a larger implant. Dr Luiz Toledo: The biggest implant I have put in was for an American patient. body language

She was in the entertainment business and already had a 600cc implant. After five years, the implanted breast started dropping and she wanted to make them bigger. I used a 700cc implant—which, at the time, was custom made—and she was very happy. So 700cc would be my limit. Diana Talaue: We need to respect what we personally consider to be beauty. I have few patients working in the entertainment industry but to me, excessive breast size means that the person is not satisfied with themselves. They want to be outside the normality of beautiful results and I would probably decline the patient. Dr Dennis Hurwitz: In the US, you can’t get an implant larger than 800cc or custom made implant, so this patient probably had an over-expanded saline implant. I have seen patients who have sagging from 700cc implants and want 1,200cc and I have performed the surgery. They’re usually pleased and there are no problems.

Issue 6: How do we determine the volume of breast implants—patient choice, surgeon choice, sizers or 3D imaging? Mr Shailesh Vadodaria: Finally, two questions. Firstly, how would you determine with the patient the size and shape of the implant during your initial consultation? And secondly, would you use any kind of breast sizers during the operation? Dr Dennis Hurwitz: Mentor has a new, more realistic, sizing system. I have also used the Axis Three 3D imager sizer, which is pretty accurate and very helpful. With a little care, through using sizers and 3D imaging, I have only had one implant size exchange in the last three years. Dr Luiz Toledo: I have a box of implants in the office that the patients can try on, which I think is the best way. We have special bras for these and I tell patients to come in wearing a t-shirt for the fitting. I also have the mirror image programme

that I can show patients and some cohesive implants that are cut in half so patients can see what they look like inside. Mr Alex Karidis: Many patients come in with a predetermined notion about what size they want to be. I also have a box of implants, special sports bras and a tight fitting top, and ask patients to look in the mirror and see what the implants are like. The first question patients always ask is “what size does this make me?” I would say it is irrelevant what size it is. What is important is that if the patient likes the look, ignore the cup size. If you tell them it’s going to be a D cup or an E cup, they will hold you to that. They’ll then say, “I went to my bra fitter and he said it was a C cup or a D cup.” So forget about size— it’s what it looks like that is important. Dr Riccardo Frati: At the start, I take some measurements from the patient and ask about expectations. This guides me to suggest a range of three sizes of implant. Then we go to the sizer and try implants with a loose bra and allow the patient to evaluate the look in a mirror. It’s important not to give them all the implant sizes because the patient will get confused, as will you. I also use 3D simulation, but it costs a lot of money and can make false smaller sizes. I prefer patients to try the implants as I don’t believe the 3D simulation systems are accurate. Mr Shiva Singh: I use the same system. The basic measurement is the base weight and I try to stay within it. I do give them implants and use the bras, but I do then tell them it’s not going to look exactly the same. Bra cup sizes vary from shop to shop so nobody can guarantee the final size—it’s on my consent form that a cup size has not been guaranteed. Invariably, using the base weight and keeping within one centimetre of the width of the breast will give a good result. Then I use my own imagination about projection; whether to go for medium, high or low profile implants. Dr Luiz Toledo: If a patient is undecided between a 300cc and a 350cc implant, I tell them to go for the 350cc—I’ve never had a patient coming back and asking for a smaller implant, but I do have patients wanting a bigger one. Dr Dennis Hurwitz: I advise the patient that I am here to tell them what’s best for them and what’s realistic. If a patient has a small, narrow chest and wants an implant, you have to guide them away from one that is too big. If they insist and choose a bigger size than their body can handle, then they have to understand the repercussions of that. If a patient selects a size that I think is too big, I would say so. 35

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lasers Dr Jose Miguel Garcia

Laser tattoo As tattoos become more prevalent among the younger population, so does ‘regrettable ink’ and the need for tattoo removal. Dr Jose Miguel Garcia runs through the process of removal using a Q-Switched Nd-YAG laser


attoo removal is unknown territory for most of us. If we had a gadget that could take a picture of a tattoo, analyse it and tell us what we are dealing with, our job would be much easier. Laser tattoo removal is becoming increasingly popular, but there are still problems associated with its use. Other modalities of tattoo removal, such as injections of acids, can be particularly aggressive but I am not keen on these—while they cause some degree of removal, they leave unsightly scar tissue. The influence of famous role models, such as David Beckham, on the younger generation is producing a lot of tattoos. They are very fashionable. Tattoos are a way of using their bodies as a permanent reminder of a moment of madness, or a parbody language

ticular event in their lives. But this is often followed by regret. Regrettable ink has created a business opportunity. This year has been difficult for many clinics and the market seems to be changing. Hair removal is becoming a beautician’s market with cheap equipment. Tattoo removal is now being carried out in tattoo parlours, again with cheap equipment. Those performing these treatments are unlikely to be offering best practice or care so there is an opportunity for serious medical practitioners to offer their services in a more scientific way and look after these patients to a medical standard. A 2006 study by the American Academy of Dermatology (AAD) revealed 24% of Americans between 18–50 years old are tattooed. In the younger segment of this group, 36% have at 37

lasers Dr Jose Miguel Garcia

least one tattoo. Around 20% of these people were dissatisfied with their tattoos but only 6% of them wanted to have them removed. Another 5% took the route of having their tattoo covered with another tattoo, carrying on their lives with something they prefer. Laser tattoo removal is currently the fastest growing area of dermatology in America. On The Patients Guide website, it was estimated that this sector of the market grew by 32% between 2011–2012. This website carries out regular polls of many clinics with a database of many thousand patients and should be a reliable indication of the current market. Reasons So why do people want to have tattoos removed? The majority want them removed for employment reasons—the tattoos may be visible on their face, neck, hands or arms. If unsightly, these can be a barrier to their career path or even prevent them from obtaining employment. My practice has recently received several requests for the removal of tattoos to hands, as requested by employers or potential employers. The British Association of Dermatologists carried out a similar survey to the AAD in 2012. Results were similar—about 20% of the UK population have tattoos and among the younger generation, this rises to 29%. Around 9% of over 60’s have a tattoo, but this group never seeks removal; they have had the tattoo for a long time and are quite happy with it. Around 45% have their tattoos done between the ages of 1825. They probably don’t realise the implications of having a tattoo on the forearms, face or neck for future career progression. Almost one third of these regret their tattoo. Men are less likely than women to regret their tattoo, particularly those tattooed in their early years. In the UK, it is illegal to tattoo anyone under the age of 18 but research has discovered youths tattooed at 15 or 16. We do

There are two peaks of pulse energy with a Q-Switched laser, but the energy is dispersed into the skin in a very controlled manner

The technology delivers a very flat beam with no hot spots., therefore not hitting one area of the tattoo harder than the others 38

have requests from patients the day after having their tattoo. They wake up with a hangover and a sore arm, and want the tattoo removed straight away. Unfortunately, if they are 16 or 17, we have no licence to treat under-18’s. In the UK, fewer than half the people who regret their tattoos will have them removed, but this is a higher proportion than the US. To translate these percentages into numbers, England has a population of 53 million, of which 35 million are adults between the ages of 18 and 65. Seven million will have tattoos and, of these, 2,300,000 will regret them. The potential market for tattoo removal is around a million people. They will not all come to us at the same time, it will happen over years. But we are not currently servicing this market—we should be offering a reliable, safe, non-invasive treatment for tattoo removal. When choosing your machine, research carefully. I chose a Q-Switched Nd-YAG which could also carry out other procedures. In the present market, I cannot justify buying a machine that only does one type of treatment. Q-Switched lasers usually work with a photo-mechanical effect—when a tattoo is hit with a one of these lasers, the beam is so fast it produces a shockwave which shatters the ink. Firing ten times a second, there is also a mild photothermal effect. Nanosecond pulses happen in one billionth of a second. Because these pulses are so short, there is no heat build up on the skin, offering a very safe and effective treatment. We can offer fast treatment of large areas because we have high fluence on bigger spot sizes, and the beam penetrates much deeper in the skin. The technology delivers a very flat beam, which does not have any hot spots. You therefore do not hit one area of the tattoo harder than the others. Tattoo process The creation of a tattoo involves injecting ink into the skin to create a permanent design. Many histological processes occur in the first few weeks of the ink being on the skin. The ink is initially placed between the epidermis and dermis. The dermoepidermal junction and basal membrane are destroyed and take a few weeks to recover. As recovery happens, fibrosis on the papillary dermis pushes the ink down into the reticular dermis. After two to three months, the ink is found on the dermal fibroblast, distributed in the perivascular regions and surrounded by layers of fibrosis. In some areas the ink quite thick and in others it’s very, very thin—even using a microscope, it’s very difficult to see the capsule of fibrosis around the ink. In the past, many pathologists thought it was not encapsulated into anything, but we now know it stays in place because it is surrounded by this fibrosis, hence why the tattoo stays on the skin. The process of ink degradation is very slow. Some migrates naturally to the lymph glands. Heavily tattooed people will naturally have a lot of ink in the regional lymph glands, which can be a problem. In melanoma cases where the lymph glands are removed, tattoo ink can turn these glands dark in colour, which can be a cause of concern to the surgeon. Unfortunately, tattoo ink is not regulated. We don’t know what is in the ink and it can have an unpredictable behaviour. In mainstream medicine, we have to take consent for what we inject, explaining allergic reactions and side effects. Tattooists could be injecting mercury, copper, lead or cadmium, yet there is no requirement for informed consent. In terms of treatment, the gold standard is the Q-Switched laser. The first laser used for tattoo removal was the Ruby laser but this can produce severe hypopigmentation. This was folbody language

lasers Dr Jose Miguel Garcia

lowed by the Alexandrite and YAG lasers, with the YAGs producing fewer hypopigmentation and textural problems. Side effects As well as hypopigmentation, problems with laser tattoo removal include scarring and allergic reactions, particularly when heating red dyes. There are reports that these allergic reactions have occasionally required hospitalisation for treatment with intravenous steroids. Other problems include ink darkening and resistance. We don’t really know why this happens. Two chemicals are involved in tattooing—ferrous oxide which is jet black and titanium oxide. These tend to lump together into much larger-sized particles which are difficult for the body to remove. We need to wait until the body restarts the process of degrading those large particles, so treatment involves waiting a few months before hitting the particles again. Destruction of the ink occurs with the shock wave and fast thermal expansion. Temperatures can reach between 1,400– 2,000+ degrees Centigrade and the ink gets shattered into small particles for the macrophages and neutrophils to take to the lymph nodes. Removal is carried out by the immune system; we only facilitate the process. It is impossible to predict the number of treatments needed for each individual. The closest tool we have is the Kirby-Desai scoring system which is based on Fitzpatricks skin type allocation. Factors include ink density, location of pigmentation, the colours used, the presence of scarring and the layering of the tattoo. You can download the paper online and build into a spreadsheet, which can be used to counsel your patients regarding the number of treatments likely to be required. The R20 method, which involves multiple laser passes in one session promises faster removal, but I have found results to be disappointing, and there is a risk that we may be causing more fibrosis making removal more difficult. So there is a large market for laser tattoo removal and many people need a serious effective removal. This may be for work reasons, to correct wrong spellings, to remove evidence from a previous life or a regretted tattoo. Tattoos can now be treated in a serious and safe way with very little blistering or scarring. As a profession, we should be offering this service and it is very likely to complement other treatments that you offer to your patients. Dr Jose Miguel Garcia is a cosmetic doctor and member of the British Medical Laser Association and European Laser Association. He is the medical director and principal practitioner at Discover Laser.

References Laumann A, Derick A. “Tattoos and body piercings in the United States: A national data set”, J Am Acad Dermatol 2006;55:413-421 2006 report. American Society of Dermatological Surgery A Aslam and C Owen. “Fashions change but tattoos are forever: time to regret”, Burnley General Hospital, Burnley UK. Study released at the British Association of Dermatologists’ Annual Conference. Birmingham, 3rd to 5th July 2012. Kilmer S. et al. “Tattoo Lasers”. eMedicine. Medscape Reference. November 2011 Kaur R. et al. “Cutaneous allergic reactions to tattoo ink”. Journal of Cosmetic Dermatology. 2009. Vol 8, 295-300 Kent K., Graber E. “Laser tattoo removal: a review”. Dermatological

body language

A green tattoo just after laser treatment. The epidermis is intact—there is swelling and purpura but no blistering. This will resolve 48 hours post treatment without scarring, blistering or scabbing

A professional multicoloured tattoo before treatment. This tattoo is not layered or scarred, with a score of 13 on the Kirby-Desay scale.

After 15 treatments there is some transient hypopigmentation and an absence of scar tissue.

Surgery (2012), (1): 1-13 Ross E., et al. “Tattoo darkening and non response after laser treatment: a possible role for titanium dioxide”. Archives of Dermatology (2001), 137(1): 33-37 “Laser treatment of pigmented lesions and tattoos. Lasers in Aesthetic Surgery.” Edited by Keller G., et al. Theime Medical Publishers (2001); 245-250 Kirby W., et al. “The Kirby-Desai scale: a proposed scale to assess tattoo-removal treatments.” Journal of Clinical and Aesthetic Dermatology (2009). Vol 2 (31): 32-37 Kossida T., et al. “Optimal tattoo removal in a single laser session based on the method of repeated exposures.” Journal of the American Academy of Dermatology, (2012); 66(2): 271-7


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A er  

A er 7 treatments 

peer press review

Peer press review Mr Ravi Jandhyala surveys academic and association journals to report on advances in research in medical aesthetics and related fields Efficacy and safety of a novel botulinum toxin type A product for the treatment of moderate to severe glabellar lines: a randomized, double-blind, active-controlled multicenter study. Won CH, Lee HM, Lee WS, Kang H, Kim BJ, Kim WS, Lee JH, Lee DH, Huh CH. Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea. Dermatol Surg. 2013 Jan;39(1 Pt 2):171-8.

The aim of this study was to compare the efficacy and safety of NBoNT (Korean BoNTA) and OBoNT (Onabot) for moderate to severe glabellar wrinkles. This was a double-blind, randomised, active-controlled, phase III study. A total of 314 patients were randomised at a 1:1 ratio to receive 20U of toxin. The primary end point was the responder rate according to the investigator live assessment, at maximum frown at week four. Secondary end points were responder rates with frowning and at rest at weeks eight, 12 and 16, with photographic assessment by a panel of blinded raters four weeks after injection. Subjective satisfaction scores were also evaluated. Four weeks after treatment, responder rates for maximum frown were 93.7% in the NBoNT group and 94.5% in the OBoNT group. For secondary end points, there was no significant difference between the two groups for any variable at any time point. Non-inferiority of NBoNT was confirmed. There were no serious adverse effects reported with either toxin. The study authors con-

cluded that NBoNT is equally as effective as OBoNT for the treatment of glabellar frown lines and that both toxins were well tolerated. This study was carried out using the Korean BoNT-A, marketed as Neuronox, Botulift, Siax and Meditoxin. This product is currently not approved in the EU but has been approved for therapeutic indications in 22 countries, mostly in Asia, since 2006. It has been approved by the Korean FDA for treatment of glabellar frown lines. Unlike incobotulinumtoxin A—a pure neurotoxin, free of complexing proteins and which can reasonably be described as ‘novel’—the structure of this BoNT-A appears identical to onabotulinumtoxin A in the authors description: “Both are composed of 100U of botulinum toxin, 0.5 mg of human serum albumin and 0.9mg of sodium chloride, which allows physicians to use both products in a similar manner.” It would be difficult to see any real differentiators between this BoNT-A and Onabot. The study has proven non-inferiority in the treatment of glabellar frown lines, but the product appears to be a copy of one of the older BoNT-A’s. It would be interesting to see how this paper can support an inevitable application in the EU for glabellar wrinkles. If performance of the product convinces the EU to grant it a licence, the next important consideration would be its cost-effectiveness in relation to the other, currently marketed, BoNT-A’s. I am sure the aesthetics com-

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munity will be monitoring its progress through the local regulatory process. Comparative study of the diffusion of five botulinum toxins type-A in five dosages of use: are there differences amongst the commercially-available products? Costa A, Pegas Pereira ES, de Oliveira Pereira M, Calixto dos Santos FB, Favaro R, Stocco PL, Fávaro de Arruda LH. Pontifitial Catholic University of Campinas, Campinas/SP, Brazil. Dermatol Online J. 2012 Nov 15;18(11):2.

This study evaluated and compared the largest diameter of diffusion halos of five different doses of five commercially available BoNT-As—twentyfive adult female volunteers were involved. Products with 100 units (UI) and the product with 500 UI were reconstituted in a ratio of 1:2.5. The BoNT-A products were applied in five concentrations (1 U/2.5 U, 2 U/5 U, 3 U/7.5 U, 4 U/10 U and 5 U/12.5 U) and, after 30 days, a starchiodine test was conducted to obtain the largest diameter of each halo. For all BoNT-As, the study found that the higher the number of units used, the larger the diameter of the diffusion halo. Statistically significant differences (p<0.05), were observed between: the North American and Chinese BoNT-As for the three lowest doses; between the Korean and German BoNT-As for all doses; between the French and Chinese BoNT-As for the four highest doses; between the French and German BoNT-As for all doses; between the Chi-

nese and German BoNT-As for the four highest doses; and between the North American and German BoNT-As for all doses (p<0.01). Confusingly, the authors chose to refer to the products not by their product name, but by the country in which their manufacturer resides. This may be because the Korean and Chinese toxins have yet to be granted FDA approval and are still referred to by the generic name of “Clostridium Botulinum neurotoxin type A”. This use of the parent country of manufacturer’s origin appears to be the only way of differentiating each of the five from each other. The observations are interesting and directly contradict previous findings where Abobot was found to move further than Onabot. This study found no difference between the diffusion halos. However, as before, little or no plausible explanation is given in the paper to account for the findings. The authors infer that spread may cause off-target muscles to be affected and raise the possibility of adverse events as a result. The use of the upper back as a test area may confound those wishing to extrapolate the finding to the forehead or the face. The thickness of skin in the upper back allowed the authors to standardise an injection depth of 3mm—simply not possible in the face. The use of anhidrotic halos for spread of each toxin cannot be used as surrogate marker for muscle activity. However, It would be interesting to compare these two markers of spread in a future study. 41

peer press review

A standardised, objective means of setting treatment goals and measuring the success of BoNT-A procedures is lacking.

A consistent finding was that the halos increased with increasing dose for each of the products. This is a more straightforward finding to explain using simple diffusion down a concentration gradient and greater volume of product resulting in a wider halo to reach equilibrium. Interestingly, the German BoNT-A appeared consistently to be the product that migrated the least, having the smaller diffusion halos. Again, no explanation has been offered for this finding. Overall, an interesting paper which has yielded some new data on the newer toxins whilst challenging a previously held idea on migration of the French toxin. It would be good to see this comparison in the forehead at single doses Also, if this paper is to be of value to aesthetic practitioners, off-target adverse events need to be collected in parallel with the other toxins when used for the aesthetics indication. It can be argued this is only endpoint of relevance to those at the cold face. OnabotulinumtoxinA: a meta-analysis of duration of effect in the treatment of glabellar lines. Glogau R, Kane M, Beddingfield F, Somogyi C, Lei X, Caulkins C, Gallagher C. Department of Dermatology, University of California at San Francisco, CA, USA. Dermatol Surg. 2012 Nov;38(11):1794-803.

In this paper, phase III clinical trials with similar designs were identified and their data pooled to ascertain duration of clinical effect of onabotulinumtoxinA in glabellar muscles. Duration was calculated using the Kaplan-Meier meth42

od for investigator-rated Facial Wrinkle scale (FWS) scores and subject global assessment (SGA) of glabellar lines. Responders were determined according to FWS score at maximum contraction and at repose 30 days after injection. Data from four trials with 621 onabotulinumtoxinA-treated (20  U) subjects were analysed, 523 of which (84.2%) were identified as day-30 responders on the FWS at maximum contraction. Pooled median duration of effect for day-30 responders was 120  days for FWS at maximum contraction and 131  days for FWS at repose. Higher day 30 SGA scores were correlated with a greater duration of effect on dynamic, but not static lines. Treatment of glabellar lines with 20  U of onabotulinumtoxinA resulted in sustained clinical benefit for four  months in more than 50% of responders—subject satisfaction increased with duration of effect. This publication focuses on the duration of action of Onabot in the treatment of glabellar frown lines. The official data sheet on Onabot states: “Improvement of severity of glabellar lines generally occurs within one week after treatment. The effect was demonstrated for up to four months after injection.” Initial reading of this data sheet implies that the effect of Onabot in the average patient treated for moderate to severe glabellar frown lines will last only four months, and frown lines would return to baseline beyond this point. Interestingly the pooled analysis published in this

study shows that half the subjects continue to have a benefit from their treatment at four months. It might be interesting to see how statistical modeling might show a comparison between the different products in this respect. Improving Consent Procedures and Evaluation of Treatment Success in Cosmetic Use of IncobotulinumtoxinA: An Assessment of the Treat-to-Goal Approach. Jandhyala R. The Jandhyala Institute, Banbury, Oxon, UK. J Drugs Dermatol. 2013 Jan 1;12(1):72-8.

Despite an increasing number of patients undergoing aesthetic BoNT-A procedures, a standardised, objective means of setting treatment goals and measuring the success of treatment is lacking. Treat-ToGoal (TTG) is a new approach to consent that uses the Merz Aesthetics Scale to set objectively defined start points and treatment goals, to better inform the consent process and provide a means of measuring the success of treatment. The aim of this study was to evaluate the TTG approach versus standard consent procedures in terms of patient understanding of the risks and benefits of treatment. It was undertaken in two phases among consecutive patients presenting for BoNT-A treatment. Phase one consisted of a crossover comparison of patient satisfaction with standard consent versus the TTG approach (n=20). Patient understanding of the likely outcomes and risks associated with treatment following consent and their overall preference were assessed using 10-point visual analogue scales (VAS). Phase two assigned patients to receive no treatment (n=10) or treatment with BoNT-A (n=54) following consent with the TTG approach. Patients were followed up 28 days later to assess whether the goals defined during consent had been met. The TTG approach sig-

nificantly improved patient understanding of outcomes of BoNT-A treatment compared with standard consent (P=.004 when standard consent assessed first and P=.002 when TTG assessed first). All patients assessed preferred the TTG approach (median VAS score in favour of TTG: 7.0, P<.0001). Target improvements were successfully met or exceeded in at least one treatment area (forehead, glabellar lines or crow’s feet) in all patients treated with BoNT-A. In contrast, none of the untreated patients met their target improvements unless the target was defined as “no change”. The TTG approach represents an improvement over standard consent in terms of the information provided to patients. Further investigation of this concept is warranted. Essentially, this approach asks the practitioner to explore how well mutually agreed goals to the treatment can be achieved. This recognises that, as medical professionals, we aspire not only achieving any improvement but one that we intended to achieve. It should therefore be possible to define this at the consent stage itself using the validated Merz Aesthetics Scale. This also gives the client absolute clarity on what they can expect from the treatment. Informed consent is crucial ahead of any procedure. My TTG approach shows that using the scales at this stage provides the client with more information and consequently means they are more informed as to what can be achieved compared to a simple standard consent. The paper also offers a good guide as to number of grade improvement that can be achieved in the different areas of the face with Incobot. Mr Ravi Jandhyala is a member of the Royal College of Surgeons and a founding member of UK Botulinum Toxin Group for Aesthetics. He is also on the Body Language editorial panel

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Minimise redness SkinCeuticals add Redness Neutralizer to their range of advanced, professional skincare


lobally, around 45 million people suffer with a form of redness, with one in 10 people suffering from the condition

Finally, as the appearance of redness can be an unwanted side effect of a range of aesthetic treatments, Redness Neutralizer can also be used to help address this. By using Redness Neutralizer following aesthetic procedures such as non-ablative lasers, chemical peels, microdermabrasion and medical needling, erythema will be effectively reduced whilst the zinc glutonate and vitamin E will help further assist the skin in the overall healing process.

in the UK. The appearance of redness is exacerbated by a wide range of aggressors, from environmental triggers like ultraviolet (UV) light and extreme weather, to the intake of spicy food and alcohol or emotions such as stress and anxiety. These triggers stimulate the sensory nerve endings in the skin, causing the onset of flushing, burning and overall discomfort for sufferers. In addition, these environmental aggressors can also impair the skin’s natural barrier function, leaving the skin feeling rough, tight and irritated and further susceptible to redness. Redness Neutralizer is the latest addition to the Correct franchise of products, helping to reduce the appearance of redness and flushing by up to 30%. Formulated with the patent-pending NeuroMed Complex, Redness Neutralizer protects against redness associated with environmental triggers by interrupting the inflammation cascade in the skin, while helping to protect the skin’s barrier. Innovative formulation The NeuroMed Complex is a combination of biomimetic peptides and natural actives to help combat vasodilation, the appearance of flushing and redness, and overall skin discomfort. The NeuroMed Complex is comprised of palmitoyl tripeptide-8 and eperua falcata bark extract —a synergistic combination that effectively works to reduce the inflammation cascade within the skin and diminish an increase in skin temperature often seen through vaso-dilation. Redness Neutralizer also contains ingredients such as bisabolol, zinc glutonate, glycerin, squalene and shea butter to help soothe, hydrate, cool and calm irritated skin. This high-performance formulation, with no fragrances, parabens, alcohol silicones or dyes, has also been tested to meet the needs of patients with very sensitive skin. Patient profiles For a patient with rosacea, Redness Neutralizer can be used alone, or alongside body language

prescription medications, to help to restore the skin’s natural barrier function and reduce overall appearance of redness. It will also help to sedate the sensory nerve endings, preventing the inflammation cascade at the source. The compromised barrier function often seen in a rosacea patient also frequently results in a lipid dry and dehydrated skin. The squalene and glycerin content within Redness Neutralizer will therefore also help to hydrate the skin and aid in reinforcing the water and lipid barrier. Similarly to patients with rosacea, patients with generally very sensitive or reactive skin are often affected by environmental aggressors, which again have a tendency to impair the skin’s barrier function and leave the skin feeling rough, tight, irritated and further susceptible to the appearance of redness. Redness Neutralizer will help to reduce the reaction to further aggressors by helping to reinforce the natural barrier function of the skin.

Clinical efficacy A single-centre, 12 week clinical trial of 48 subjects was conducted by a boardcertified dermatologist to validate the efficacy of the product. Female participants with mild-moderate rosacea (three-four inflammatory pustules) applied Gentle Cleanser, Redness Neutralizer and Physical UV Defense SPF30 twice daily and were clinically evaluated at baseline, week two, week four, week eight and week 12. Further evaluation included a dermospectrophotometer for redness, objective and subjective assessment and a consumer self-assessment. Overall, redness was reduced by 30% in 12 weeks and flushing was also reduced by 30% in 12 weeks. Skin smoothness improved by more than 55% in 12 weeks and skin radiance improved by more than 30% in 12 weeks. Furthermore, 96% of users reported immediate overall satisfaction after first using the product, with 98% identifying that their skin felt immediately smoothed after application. 87% of users also stated a reduction in the appearance of their redness in just 12 weeks. A small observational study is also on-going, conducted by plastic surgeon, Mr Christopher Inglefield using the Visia Complexion Analysis Machine to scientifically quantify any improvement that Redness Neutralizer has provided. Initial results show a patient with a severe redness level of 2% improving to a level of 21% after using the products for four weeks. The patients level of UV damage also improved by 23% over the same period. Redness Neutralizer is available now in retail and professional sizes. T: 05603 141 956 W: @ SkinCeuticalsUK 43

nutrition Dr Simon Poole

True colours

Colourful fruits and vegetables are rich in antioxidants and nutrients, and can form a healthy, low calorie starting point for those seeking to improve their diet, writes Dr Simon Poole


rofessionals in the fields of medicine, nutrition and dietetics are often asked for simple solutions to address problems of weight maintenance or to provide easy steps in supporting patients to improve their nutrition and diet. There is a wealth of nutritional advice, much of which is based on robust evidence. But there is also a considerable market for the promotion of novel dietary patterns or ingredients, often with little basis in science. These may attract celebrity endorsement and perhaps enjoy periods of popularity. We can advocate the importance of a truly healthy diet and weight in relation not only to prevention of chronic disease and


premature ageing, but also in areas as diverse as promoting psychological well-being and improving post-operative recovery. We should therefore perhaps devote more time and energy to ensuring that good nutritional counselling is a fundamental part of our job. Yet we live in a world where all too frequently the â&#x20AC;&#x153;medical modelâ&#x20AC;? of care and commercial interests promote expectations of cures in the form of pills and supplements. Supposedly healthy forms of food are promoted in ways which frequently focus on what they contain less of rather than any added value. It is therefore gratifying to see evidence that despite global trends towards convenience, over 55% of respondents in Euromonitorâ&#x20AC;&#x2122;s body language

nutrition Dr Simon Poole

international trend survey reported preparing a daily meal from scratch, using fresh ingredients. There are clearly numerous strands to promoting healthy eating. From the benefits of low GI carbohydrates in reducing the risk of diabetes or obesity, to salt reduction and promoting the benefits of monounsaturated fats as well as the right balance of exercise and calorie intake. There is increasing understanding in the role of colourful micronutrients, or phytochemicals, in plants which may possess powerful antioxidant activity, protecting against the potentially harmful effects of cellular oxidative damage. Introducing colourful cuisine is a simple way to encourage individuals to access generally low calorie yet high nutritional value vegetables and fruits which have been associated with significantly lower rates of disease. The potentially damaging effects of oxidising free radicals in our environment are as much a problem for plants as they are for mammals. Elegant evolutionary hypotheses suggest that while plants have evolved colourful fruits to attract animals to consume, fertilise and deposit their seeds, this also ensures that phytochemicals support the fruit through antioxidant effects. They promote a longer lifespan and protect the plant from the harmful effects of UV light and damaging chemical reactions which can induce cellular damage, decay and rancidity. body language

Science and supplements For those hopeful of a â&#x20AC;&#x153;magic bulletâ&#x20AC;? for reasons of convenience or commercial interest, the science behind the effects of antioxidant supplements is, at the very least, somewhat disappointing. This was best illustrated by a landmark study which demonstrated a possible increased risk of lung cancer in smokers who took beta carotene supplements. There has been some recent publicity surrounding yet to be published research suggesting, for example, that a derivative of lycopene might have demonstrable effects on improving endothelial function. But there is a paucity of data to support the routine use of supplements in all but very specific medical circumstances such as pregnancy or conditions of deficiency. It seems that there is much in the observation by Fito in his paper, Effect of a Traditional Mediterranean Diet on Lipoprotein Oxidation, that lifetime consumption of the complex mixture of antioxidants in foods is more effective than large doses of a single antioxidant given for a finite period. This is consistent with the received wisdom that the benefits of any dietary pattern are likely to arise from the sum of all its positive parts, perhaps enhanced by methods of preparation and cooking. This is illustrated by the observation that the bioavailability of some fat-soluble plant antioxidants and vitamins is significantly increased when vegetables are cooked in healthy fats 45

nutrition Dr Simon Poole

The science behind the effects of antioxidant supplements is disappointing

such as extra virgin olive oil, and similarly that of the enhanced nutritional profile of wine when consumed with food. While science may sometimes be viewed as dispassionate in relation to the benefits of foods and the commercial interests in supplement manufacture are criticised for promoting products without evidence to support their use (see Ben Goldacre’s book Bad Science). But perhaps we should instead celebrate the suggestion that the food is best placed to provide true health and wellbeing rather than “quick-fix” pills created by industry. As purported by Peter Jackson’s film The Hobbit, we might consider that, “if more of us valued food and cheer and song above hoarded gold, it would be a merrier world”. Or, as Kristal describes the current position in the 2009 paper Nutritional Prevention of Cancer: “The prospects for cancer prevention through micronutrient supplementation have never looked worse”. Reds and blues Tomatoes have been given the rather ill-defined status of “superfoods”, due in part to the presence of the chemical lycopene—a carotenoid shown to have powerful in vitro antioxidant effects. Tomatoes, although not originally indigenous to the Mediterranean region, have become synonymous with the Mediterranean Diet, which in totality describes a combination of foods associated with significant health advantages. Lycopene was included in the 2008 review of possible anticancer effects of dietary antioxidants by Naghma Khan et al. However, it is acknowledged that more research is required, particularly since early suggestions of a preventative role in prostate cancer have been apparently refuted. More recently however, interest has been further generated into the effects on blood vessel epithelium, perhaps supported by research describing a reduction in ischaemic stroke . The way we produce our food seems also to have an effect on the physiological value of the produce. It seems that tomatoes grown in greenhouses rather than direct sunlight or ripened in storage rather than on the vine to maximise yield are not subject to the same conditions which promote maximum levels of antioxidants. We see lower levels of important micronutrients when 46

using more intensive methods of farming which may be highly significant for human health, yet are rarely considered. Other red pigments such as capsanthin are contained in peppers, while the purple skin of aubergines are rich in anthocyanins. Grapes and blueberries are similarly rich in similar forms of antioxidants and are the subject of research to more fully establish their role in scavenging free radicals and preventing disease. Flavonoids in red onions and wine are also considered to be important in human health. Yellows and greens The most common chemical constituents which give colour to vegetables and fruits such as carrots, sweetcorn, pineapples, apricots and yellow peppers include the carotenoids. Beta-carotene is another example of a highly effective antioxidant of this class which showed promise in studies as a chemotherapeutic agent to inhibit cancer formation. The evidence still supports the assertion that a diet rich in these micronutrients, in the context of a healthy lifestyle, is likely to have a beneficial effect on health, despite the aforementioned capacity for harm from the supplement form in studies of smokers at risk of lung cancer. “Eating up your greens” are of course words of wisdom we associate with traditional knowledge of eating healthily. Certainly isothiocyanates and indoles in cruciferous vegetables have been known to have potential anticancer effects. Other green vegetables and fruits can be included in salads with high polyphenol extra virgin (“not from concentrate fruit juice”) olive oil as part of the powerfully healthy combination. Encouraging patients and clients to seek out a wide variety of colourful fruits and vegetables as a daily experience is a simple way to educate and provide an understanding of important nutritional factors which can promote health and wellbeing. Rich in antioxidants, as well as high in fibre and other nutrients and minerals, such coloured fruit and vegetables form the basis of an attractive and palatable diet, low in calories and consistent with modern understanding of what constitutes the healthiest of lifestyles. Dr Simon Poole is a GP, author and recognised authority on the Mediterranean diet. References 1. Euromonitor International—2011 Annual Study of Global Consumers 2. Tim Byers. “Nutrition and Lung Cancer: Lessons from the Differing Effects of Foods and Supplements”. Am J Respir Crit Care Med. 2008; 177: 470-47 3. Fito et al. “Effect of a Traditional Mediterranean Diet on Lipoprotein Oxidation.” Arch Int Med 2007. 167(11) 1195-203 4. Ben Goldacre. Bad Science. 2008 Fourth Estate 5. JRR Tolkien. The Hobbit 6. Kristal et al. “Nutritional Prevention of Cancer”. J Nat Cancer Inst. 2009 101 363-5 7 .Sofi et al. “Adherence to Mediterranean Diet and Health Status: Meta-Analysis.” BMJ 2008 337:a1344 8. Naghma Khan, Farrukh Afaq, Hasan Mukhtar. “Cancer Chemoprevention Through Dietary Antioxidants: Progress and Promise Antioxidants & Redox Signaling”. March 2008, 10(3): 475-510. doi:10.1089/ars.2007.1740. 9. Cancer Epidemiology, Biomarkers Prevention Cancer. May 2007 16; 962 10. Neurology October 9, 2012. Vol. 79 no. 15 1540-1547

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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   “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


FACE 2013 O

ver the last decade, the FACE Conference has provided over 3000 delegates the opportunity to meet world leading experts in the field of facial rejuvenation. As this unique event has grown in popularity, we will be moving to the QEII Conference Centre, opposite the Houses of Parliament in Westminster, London. This move offers a vast exhibition area and greatly extended conference and seminar 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, combining an outstnading 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 im-

portant 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 receptionist 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. Lectures in the body language

conference FACE 2013

21–23 June

QEII Conference Centre, London main auditorium will focus on facial injectables for the duration of the conference which will include head to head debates on various technologies and treatments. Alongside this will be a surgical lecture programme—introduced for the first time at FACE 2013. The Business Agenda will return, but 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 condition and treatment lectures will be present, day one focussing on cosmeceuticals and the second day a more dermatological and anti-ageing focus. Lasers are becoming even more integral to clinics and with that FACE 2013 will have three days of lectures dedicated to laser equipment and the treatment probody language

tocols 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. With workshops from some of the largest manufacturers and distributors within the industry there is plenty to see at FACE 2013. A first for FACE FACE will feature a more flexible pricing structure, with delegate rates from as low as £50/day. Ensure that you register today 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 to the dynamic facial aesthetics market. Aesthetic Industry Summer Ball FACE wouldn’t be the same without a networking event rivaling the best in

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. Visit our newly relaunched website, to browse through the full conference programme, search our international speaker list and view the full list of exhibitors at FACE 2013. 49

Wigmore Medical 020 7514 5104

dental Dr Anil Shrestha

Wear & tear It is easy to underestimate how ageing of the dento-facial complex can affect facial aesthetics. Dr Anil Shrestha discusses the science behind the process, also known as gerodontology


very ten years, the Adult Dental Health Survey confirms that the UK and Ireland population are keeping more of their natural teeth as they age. This is a reflection of overall improvements in dental health and diet. This also places demands on dentists to be able to carry out more complex restorative dental treatments than merely extracting the teeth and placing full dentures, as was the norm as early as one generation ago. Modern dental treatments allow the most complex and beautiful restorative dental treatments to be carried out to provide function and improvement in aesthetics for the ageing population. This also brings the predictable increase in patient expectations with respect to dental rejuvenation and fulfilling the patient’s desire to look younger in their senior years. Aesthetic surgeons must also take into account the need to improve the dentition of patients, producing an overall holistic enhancement of aesthetic facial treatments. The relatively recent trend of TV makeover programmes and established media interest in programming of cosmetic procedures has clearly heightened public interest in and awareness of aesthetic facial and dental treatments. Our patients have a good understanding of available procedures, which is causing increased—and not always realistic—expectations that need to be carefully managed. The most successful dental surgeons performing cosmetic dental procedures, like their aesthetic surgeon counterparts, will be able to establish what their patients like and dislike about their own appearances before advising and treating them. This is crucial in successfully managing patient expectations for what can become complex and protracted dental treatments, sometimes taking three to four years to complete for multi-disciplinary cases. Understanding the science of ageing of the dento-facial complex (also known as gerodontology) is as important to the understanding of dental aesthetics as an understanding of pathology is to the study of physiology. Ageing affects the teeth, the periodontium and facial skeleton that support the teeth, and the soft tissues—including the skin—that drape these hard tissues. body language

Ageing changes Facial aesthetic treatments that do not account for the restoration of aged teeth and the dento-facial skeleton do not produce the best long-term, holistic results in facial rejuvenation. The focus for most aesthetic practitioners is on mid-facial ageing when considering restoration of the aged dentition, whereas the focus for dental surgeons is usually on the lower third of the face— around the peri-oral region, base of nose and chin. Established degenerative changes due to age, usually from the middle of the fourth decade, include cranio-facial bone remodelling, gravitational effects on soft tissues, atrophy of fat deposits and skin deterioration. These can all be exaggerated by degenerative changes of the teeth (tooth wear and tooth loss) and surrounding hard tissues. Loss in face height due to tooth loss and wear can exaggerate all of these and if not accounted for or understood by the aesthetic surgeon, can lead to inappropriate and ineffective use of fillers and other treatments in or around the peri-oral area. The loss of face height can be exaggerated by the complete or partial loss of a significant amount of teeth and can add ten or more years to a person’s facial age. The face height decreases as a result of this tooth loss due to the mandible effectively overclosing. This produces a characteristic increase in vertical lines in the lips as the chin rotates forward. There is a decreased angle at the corner of the lips, thinning of the upper lip due to poor lip support, loss of muscle tonicity in the circum-oral region, longer appearance of the upper lip resulting from gravity and loss of muscle tone, deepening of the naso-labial grooves and an increase in the naso-labial angle that can make the nose appear larger. Muscle attachments to the jaws as the bone atrophies can cause tissue to sag along the lower jaw line, enhancing the jowl effect and causing the chin to appear prominent. A good aesthetic practitioner not versed in dentistry will have an eye for beauty and harmony. They will also be able to immediately tell if a patient’s dentition is a pleasing full smile or is potentially the missing part in his jigsaw for the facial rejuvenation treatment they are planning. 51

dental Dr Anil Shrestha

From the sixth decade, atrophy and involution of the midface begins and is more commonly observed in women than men. Soft tissue support is lost as the inferior orbital rim remodels and loses anterior projection, with the mid-face losing vertical height. Similar changes occur in the lower-third face, which are enhanced by physical loss or wear of teeth. A reduction in face height, especially in the maxilla and mandible, is strongly correlated with tooth loss. Tooth loss causes atrophy of cortical bone thickness and alveolar ridge volume that continues throughout life, enhancing signs of aging in the later decades. In general, loss of teeth has a greater atrophic effect on the mandible than the maxilla and more bone loss is observed in women than men. The imbalance between osteoclastic and osteoblastic activity in old age is exacerbated by the withdrawal of oestrogen during the menopause. There is also an age-related decrease in the circulatory levels of hyroxylated vitamin D3 and greater crosslinkage of the collagen matrix. All of these changes contribute to the atrophy of the bony structures of the oral cavity. Soft tissue changes include reduction in muscle mass, and loss of isometric and dynamic muscle strength, all of which are exacerbated in edentulous (toothless) patients. The salivary glands have a diminution in function with age, with lower volume and quality of saliva being produced causing, at its extreme, xerostomia (dry mouth). The main functions of saliva are lubrication, buffering and protection of oral hard and soft tissues, and its diminution can have disastrous effects in terms of dental caries and oral disease. Many of our elderly patients that present for aesthetic treatments will be on a polypharmacy of medication. It has been estimated that 75% of the drugs listed in the British National Formulary exert some degree of depression on the salivary system. For example, most anti-depressants and anti-hypertensive agents have a marked hypo-salivatory effect, which can initiate or exacerbate oral diseases, including tooth decay. Tooth wear Tooth wear—correctly termed tooth surface loss—is rarely due to one single etiological factor. Usually it is a combination of more than one of the known following causes: erosion from a chemical effect such as citrus fruits or carbonated drinks; attrition, from tooth-to-tooth contact; or abrasion due to mechanical wear. The effect of tooth surface loss on appearance can be a dramatic reduction in the proportion of the dentition that shows in every day function and over-closing of the mouth due to loss of face height resulting in exaggerated peri-oral skin folds. The reconstruction of extensive tooth wear can be complex and demanding in a procedure called ‘full mouth rehabilitation’. This involves initially assessing the cause of loss and ensuring it has been eradicated before embarking on the various stages of treatment, which can involve raising the bite to create space for restorations (the Dahl effect), followed by various stages of provisional and definitive crowns and implant work, as appropriate. Tooth wear can be a natural process as the ageing population retains its teeth for longer or, more tragically, can affect very young adults due to psychological problems, such as anorexia nervosa or bulimia nervosa. Aesthetic doctors could recognise the effects of these eating disorders in patients asking for correction of peri-oral ageing effects due to wear or loss of their teeth. These patients can be extremely difficult to treat due to their altered perception of their own bodies and their all-consuming desire to attain a dysmorphic view of perfection. 52

During my final year of postgraduate training at the Eastman Dental Institute in London, I spent six hours rebuilding by hand the 70% tooth loss of a 25-year-old anorexic woman to my understanding of the ideal shape and dimensions of her natural teeth. The end result restored the original appearance of her teeth beautifully from study models and photographs of her at the age of 18, prior to her eating disorder. Her initial reaction to the finished treatment was to burst out crying because the restored teeth initially appeared huge to her, as she had become used to the reduced size of her worn down teeth. Thankfully, with the reassurance of friends and family, she soon overcame her initial shock and was extremely happy that she had regained her original, beautiful smile. This emphasises the need to appreciate the potential impact of rejuvenation procedures in an holistic way, and underlines the importance of assessing accurately and managing patient expectations. 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.

Premature toothwear in 24 year old having restored dentitions with crowns and veneers

Mutulated dentition and tooth wear causing collapse of perioral structure treated to full mouth rehabilitation and improved tissue support body language

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psychology Dr Raj Persaud and Dr David Edwards

Does size matter? The role of sexual intercourse as a form of communication may be a far more important discussion in evolutionary terms than the size of the male member, contrary to press reports on recent research. Dr Raj Persaud and Dr David Edwards review the latest studies


he Daily Telegraph newspaper recently reported an investigation by Richard Lynn from the University of Ulster, researching penis size measurements across the world and the racial differences which emerged. What the press didn’t relate was the importance of these findings; that these results might reveal how our ancestors varied in the evolution of monogamy during sexual relationships. Lynn reports a variety of data, including a 113-nation study where penis length is found to be greatest in ‘Negroids’ (16.07cms), intermediate in ‘Caucasoids’ (13.89cms) and smallest in ‘Mongoloids’ (10.66cms). Since male sexual organ size is linked to body proportions such as height, feet and hand dimensions, it’s no surprise racial variations exist. But Lynn’s paper reports an evolutionary argument as to why penis size should consistently vary between races, based on the ‘survival of the fittest’ theory—that our biology and psychology exists to maximally disseminate our genes to future generations. According to this argument, longer penises evolved to displace semen left by other males in the female reproductive tract. There is, apparently, an evolutionary advantage in having a longer penis under ancient conditions of intense competition for women. In these ‘caveman’ circumstances, so the theory goes, males can’t be sure that the females aren’t mingling their genes with other men as well. Lynn reports theories that races migrating thousands of years ago from equatorial Africa into colder, tougher environments of Europe and Northeast Asia no longer faced so much inter-male competition. Everyone was too preoccupied trying to survive from freezing, rather than enjoying the luxury of sleeping around. Loyalty, and therefore paternity, became more assured and linked to ‘provisioning’. These theories remain controversial. But a more established view is that modern men’s sexual organ size is disproportionately linked to how good they feel about their whole bodies, including how much they like their own face and assess overall physical attractiveness. Researchers have found almost 50% would prefer body language

to have a bigger penis. Is this some kind of evolutionary competitive hangover? However, if size is about evolutionary advantage, one study suggests a correlation between penis size and disease. The study surveyed 1,065 men who have sex with men and found a significant association between those with an above average size penis and infection with Human Papilloma Virus and Herpes Simplex Virus. “The Association Between Penis Size and Sexual Health Among Men Who Have Sex with Men”, contends that one possibility for this disproportionate number of viral skin-to-skin sexually transmitted diseases is that size may play a role in condom slippage and/or breakage. Despite there being some disadvantages to bigger size, the paper also explains that previous research reports 84% of women claim to be very satisfied with the size of their partner’s penis. However, the more the subject is researched, the more the findings don’t appear quite so straightforward. For example, Weijmar Schultz led a team of researchers from the University of Groningen in the Netherlands, surveying sexually active women. The study, “What Importance Do Women Attribute to the Size of the Penis?”, reported that when it comes to sexual function, 20% of women declared length to be important and 1% very important; 55% and 22% reported length to be unimportant and totally unimportant respectively. The data also suggests that for women, length is less important than girth. Roughly a third rated girth important while only one fifth assessed length similarly. The authors conclude that a large proportion of women attach substantial significance to size, in terms of sex. Russell Eisenman from the University of Texas-Pan American confirms this

finding in his study entitled ‘Penis size: Survey of female perceptions of sexual satisfaction’ published in BMC Women’s Health. Fifty sexually active female undergraduate students were asked which dimension was more important for sexual satisfaction. None reported either they didn’t know or that width and length were equally satisfying. The majority—45 of 50—verified width was more important. Edwin Bowman, retired professor of Obstetrics and Gynecology at Louisiana State University, published an argument in the academic journal Archives of Sexual Behaviour which seems to suggest this preoccupation with size is missing the point. His more recent comment on Richard Lynn’s study is that of course there are racial differences in penis size, which follow ethnic contrasts in vaginal depth. Bowman’s original paper, ‘An Explanation for the Shape of the Human Penis’, states that the foreskin is highly absorbent, as evidenced by the increased susceptibility of the uncircumcised male to HIV. Over 40 studies have indeed established that male circumcision significantly protects against HIV infection. It is possible, Bowman argues, that the primary function of the foreskin is to absorb “behaviour-modifying chemical messengers” from the female. Bowman believes that future research on vaginal secretions, particularly of an ovulating female, is likely to show a surfeit of neuropeptides, which enhance pair bonding and protective behaviour in the male. He concludes that sexual intercourse is a medium of communication older than language itself. It may be that sex as a form of communication has been somewhat overshadowed by how much sheer size has loomed over the subject, as evidenced by the way the press reported Richard Lynn’s research. So, then, it’s not all about size after all? Dr Raj Persaud is a consultant psychiatrist in private practice at 10 Harley Street and in Surrey. Dr David Edwards is president of the British Society of Sexual Medicine. He also combines part-time family medicine with a specialism in male and female sexual dysfunction. 55

injectables Dr Mark Hamilton

Back on your feet High heels can cause a number of painful problems for the feet, one of which can be effectively treated with dermal filler injections. Dr Mark Hamilton describes his injection technique for metatarsalgia, or pain in the ball of the foot


here has been much anecdotal evidence about people injecting materials into the feet with varying degrees of success in recent years, but the treatment isn’t generally promoted within the industry. We can use dermal fillers to provide volume and create cushioning in the feet. We are always looking at ways to innovate— this procedure has developed over the past year but it isn’t the most popular treatment in my practice. Footwear Killer heels are killer by name and killer by nature. There’s no doubt that women love wearing heels, but if you ask them at the end of the night, they’ll admit that their feet feel ‘dead’. So why do women want to wear heels when they cause so much discomfort? Women gain a certain amount of confidence wearing heels. Their posture seems to improve, height is increased, legs look better, calves look thinner and heels are always in fashion. To quote shoe designer Christian Louboutin, “There’s no doubt that heels have never been as high as they are currently. No one is forced to buy my shoes or wear them.” 56

High heels are now an integral part of a woman’s outfit. However, the balls of the feet are taking abuse like never before, yet women refuse to step into flats. We need to get to the base causes of foot pain before beginning treatment. Plantar fasciitis, arthritis in the joints of the feet, corns and calluses, gout and neuromas are all contributing factors. Metatarsalgia is the issue we can offer improvement for. Correct diagnosis is vital—metatarsalgia is pain in the ball of the foot. Body weight is transmitted through the metatarsal joint and a high heeled shoe causes constant pressure through the joint with inadequate cushioning. When the distal metatarsal joint is flexed into a high angled position, the fat pad of the foot is displaced posteriorly and it no longer cushions the area it’s meant to. The most sensible option to gain relief in this area of the foot is to change footwear, but many women are reluctant to do this. Ironically, changing from high heels into flat shoes can be a trigger for plantar fasciitis, the pain of which can be slightly relieved by wearing a slight heel. Gel cushioning inserts are an option that most women have

injectables Dr Mark Hamilton

tried, but they change the fit of the shoe and can cause pressure and friction elsewhere in the foot. A lternatively, dermal fillers can provide constant cushioning by attempting to recreate the fat pad that occurs naturally in the foot. Injecting dermal fillers in the foot involves a simple technique, with minimal downtime and it’s a relatively safe procedure. Dermal fillers There is no published material in peer reviewed journals on the use of dermal fillers in the foot. One case report was published in the November 2010 issue of Journal of Foot and Ankle Surgery, which reported failed relief of metatarsalgia with collagen dermal filler, but I don’t believe collagen is the ideal filler for the feet. The distal metatarsal joint bears the brunt of pressure when forced into a high heeled shoe. The small sesamoid bones, often forgotten about, sit just below the distal metatarsal head. Interfering with these, resulting in misalignment, can cause a great degree of discomfort. When injecting, we cannot do anything with the bony anatomy. Instead, we target the subcutaneous tissue. The thickness of the skin is very different on the sole of the foot than the skin on the rest of the body. It is much thicker and lacks hair, pigmentation, sweat pores or sebaceous glands, and is a very sensitive area to treat. The subcutaneous fibro-fatty chambers are where we want to target our treatment. These are surrounded by thick connective tissue which resists pressure and gives the fat pad cushioning. We need to be aware of the deep intrinsic and extrinsic muscles of the foot, and we don’t want to have any interference with them. When I inject the sole of the foot, the most important factor is a thorough foot assessment. If you don’t make the correct diagnosis of foot pain before commencing treatment, you will be treating the wrong patients and are not going to get a satisfactory outcome. I first take a foot impression in some foam, which gives me an idea of where the pressure is being transmitted through the foot. I then do some antiseptic preparation with the foot using a mixture of topical and local anaesthetic and continue to the subcutaneous deposition of hyaluronic acid filler with a little moulding. Post-treatment, I ask the patient to wear comfortable sports shoes for 24-48 hours to let any transient swelling subside. They can take oral analgesia if they want—simple paracetamol or cocodamol if necessary, but usually this is not required. Then it is a common-sense approach with a slow introduction back into high heels, with comfort dictating the speed at which the patient makes progress. Some patients find they are able to wear high heeled shoes again in a short space of time. Technique Firstly I mark the major weight-bearing region of the foot—the distal metatarsal head is where you want to target most of your filler. The foam impression that I take of my patients allows me to see the major pressure and weight-bearing regions of the foot. The sole of the foot is incredibly sensitive so I inject some local anaesthetic and use topical anaesthesia on the skin. I tend not to use a regional block, because patients aren’t able to walk properly afterwards. The sole of the foot is quite a vascular area so I use 2% lidocaine with adrenalin to help vasoconstriction of the area and reduce bruising and haematoma. I use some alcohol foot prep and palpate the foot to feel where body language

the metatarsal head is. You often see calluses on the feet where the weight-bearing regions are and can feel where the tissue seems thin, indicating a loss of supporting tissue. However, this can be misleading because when forced into that high heel, the fat pad will slip posteriorly. I prefer to use Belotero Basic instead of a more robust filler like Sculptra PLA or Radiesse. In this weight-bearing region of the foot, you want to create immediate comfort and a thicker, harder product will quite uncomfortable until it is fully integrated with the tissue. Belotero Basic spreads throughout the tissue so you don’t get any localised lumps and bumps in the area, which is key for immediate and short-term relief of the pain in this region. You could use a filler such as Juvederm with integrated local anaesthetic, but in my experience the patient is more comfortable if local anaesthetic is injected before the dermal filler for this procedure, as the sole of the foot is so sensitive. Using a short needle [is there a specific needle?], I slowly push 2ml of the filler into the ball of the foot, keeping it quite superficial. Using this quantity, you should give the patient six months of benefit. If you see calluses in other parts of the foot, you can infiltrate other areas such as the sides of the toes. Application is straightforward and you can feel an immediate cushioning effect. Complications There are some pitfalls to dermal filler injection in the feet. If you inject too much in one session, there will be too much pressure. Too much volume in the foot can cause a lot of pain. Using the wrong filler—one that is too firm to be injected into this cushioned part of the foot—is the biggest mistake you can make. This is a high pressure area with a lot of mobility in the region and a great deal of pressure is transmitted through it. What we try to do in aesthetics is replicate what the body naturally provides. So considering the fibro-fatty cushioning tissue, if we use a product that is firm, hard and lumpy, it will make things worse. You must make sure you use a soft filler. It is vital to never inject very deeply. There is a risk of intraarticular injection and sepsis, but by confining injections to the skin and subcutaneous tissue, you increase the safety of the procedure. Incorrect patient selection is also a potential pitfall—you must ensure the patient has the correct foot discomfort you can treat. High patient expectations also need to be managed. If you claim this treatment will banish all foot pain, patients will be unhappy. It is better to project a modest expectation of pain relief and patients will be pleased with the outcome. Botulinum toxins can also be of benefit for foot pain. I do not carry out toxin procedures in the feet, but it has been shown to reduce foot pain. This mechanism is not completely understood, but we know toxins can benefit patients who suffer from migraines. While slightly different in the feet, a 2009 University of Taipei paper was published in Neurology, reporting the treatment of patients suffering from nerve pain with botulinum toxin injections into the skin of their feet. It showed significant reduction in pain at 12 weeks and 44% showed a three point reduction in pain. So there is some evidence to suggest that toxins can provide an analgesic effect in the sole of the foot. Mark Hamilton is a cosmetic doctor specialising in facial aesthetics, and is the director of the Hamilton Face Clinic, Ireland 57







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

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marketing Charles Southey

Digital success Search engine optimisation and email marketing are key marketing tools, writes Charles Southey


mail marketing and search engine optimisation (SEO) will make your online marketing strategies more effective. These are perhaps two of the most crucial and fundamental aspects of online marketing, each encouraging growth in the number of internet-users directed to your business. They are basics in making sure your company stands out above the rest and are considered vital to any online marketing scheme. You have mail! Email is still one of the most effective marketing platforms, particularly if you have a strong database of contacts. It is direct marketing, straight to the customer or potential customer. If you have a strong database of contacts, the trickiest part of email marketing is avoided—carefully conceived and designed, emails will produce new leads. Design, as in all things marketing, is key. The reader must be drawn in, informed and called to action. It’s important to think carefully about the design of the emails you send to your contacts— distributing poorly designed email marketing campaigns could damage your brand. Remember that these emails are a direct reflection of your company so should have the maximum effort and thought put into them—often not the case in email marketing. Similarly, the reader will be pre-disposed to ignore marketing emails but if yours offers something new and exciting and stands out from the rest, it will receive the attention email marketing requires from the customer. To aid you in your email marketing campaign hire a digital agency to get: body language

•  Emails coded in HTML format, so you can customise the design and include images. •  Spam testing, which will help you avoid the ‘Junk Folder’ and reach the ‘Inbox’. •  Clear calls to action to gain maximum reaction from your message. All of which can be pitfalls when commencing an email marketing campaign. With expert help you will avoid these, and enable your emails to be as effective as possible, reaching as many people as they can, and being converted into sales. Building a database of email users can be the most difficult aspect of email marketing. Use your website to encourage customers and potential customers to sign up to receive your email newsletters. This way you will build up a database of people who you know are interested in your product. The more relevant people that receive your emails, the better the response you’ll get. Finally, remember to use email in moderation and avoid alienating customers or potential customers by sending them too many emails. Nobody likes to be bombarded and embarking upon a campaign which could irritate rather than entice the customer. It is always important to keep in mind the associations which a marketing campaign will produce for the customers with your business, as crucially you do not want these to be negative in any way. Search engine optimisation Just as an effective email campaign can encourage customers to visit your website, so too can SEO. Without SEO, your website may get lost among the multitude of

websites that are competing with yours. Users are far more likely to click on a link at or near the top of the page and this is the basic concept behind SEO. It’s important to gain a strong position on search engines to reach a larger number of internet users. Most people will head to Google when they’re researching a product or service and SEO is the process by which you make your website more visible and gain higher positions on search engines. To explain the process in its simplest terms, SEO is a host of techniques used to make your website more accessible to search engines. It’s also about proving your authority on a certain topic. You can make quick and easy improvements to your website such as including keywords and phrases (that people are likely to search for you on search engines) in the text content of your website and gaining links from other websites. The good news is that these two things will get you on the way to improving your website’s SEO. The bad news is there’s a lot more to it than that! If you’re serious about improving your search engine position but don’t have the time to spend several hours a day on SEO, get in touch with a digital agency that provides SEO services to help you. SEO should be done properly, rather than clumsily adding key words and phrases to your website, randomly dotted about. A digital agency will enhance your website by performing SEO with no detrimental effect to its aesthetics or functionality. SEO can take weeks to take effect and is rarely an overnight process. If you have no time to wait, look into pay-per-click (PPC) advertising which can help you get to the top positions on search engines within a matter of minutes. In an ideal world, you would run PPC campaigns until SEO has taken effect. Both effective email marketing and SEO offer new opportunities to reach customers and clients. They are fundamentals of online marketing campaigns, and as such must be considered carefully and undertaken properly. Charles Southey is Operations Director at Digital Results T: 01920 444797; E: 59


market On the

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

under the microscope SYNCHROVIT C The superoxide free radical cannot be neutralised by antioxidants so can cause damage to collagen, elastin and hyaluronic acid fibres, damaging cells and leading to skin problems such as thread veins, pigmentation, age spots and visible sun damage. Superoxide eventually converts to the weaker free radical, hydroxyl, and only then can it be neutralised by antioxidants, say Skinmed the distributors of Synchrovit C. Synchrovit C is a clinic only enzyme treatment containing Super Oxide Dismutase (SOD) combined with L-ascorbic acid and zinc. SOD forces superoxide to convert immediately to hydroxyl allowing the ascorbic acid to neutralise it. The zinc triples the activity of ascorbic acid and boosts the performance of SOD. Synchrovit C comes as six bottles with vacuum sealed containers in the caps that contain the key active ingredients in pure 100% active powders which are released on opening to ensure maximum activity of ascorbic acid and enzyme. Skinmed T: 0870 190 9369 W:


Advanced Nutrition Programme is launching a patent-pending supplement Skin Accumax, designed to help those who are occasionally unhappy with their skin, as well as those who have ongoing concerns. Skin Accumax contains a combination of vitamins A, C and E, which support skin health, plus DIM (diindolylmethane), an active nutrient complex found in broccoli. These ingredients have been formulated in a specific ratio to work in synergy for maximum results for problem skin sufferers, say the manufacturer, iiaa. As Skin Accumax works from the inside, the skin on the chest, back and shoulders should also see improvement, not just the face. The recommended initial intake is four capsules a day, with a meal, reducing to two capsules a day once skin starts to improve. Skin Accumax is ideally taken for a minimum of 14 weeks and can be discontinued once the user is happy with the results achieved. iiaa T:020 8450 2020 W:


L.C.E. Regard is the latest addition to the Cebelia range of products and combines a covering formula with intensive care. This total care product corrects dark circles, bags, fine lines and imperfections. The applicator is easy to use everywhere, and the product is perfume and preservative free. Cebelia skincare products have been developed to optimise aesthetic medical practices in providing them with efficient and long-lasting complementary treatments for use pre or post aesthetic medical treatments. Cebelia T: 00 33 1 48 78 21 13 W:



Allergan have recently announced the launch of JUVÉDERM VOLBELLA with Lidocaine—a new treatment for the lips and peri-oral area and the latest addition to the JUVERDERM range of hyaluronic (HA) dermal fillers. It was designed for gently restoring natural-looking lip volume, but also for defining lip contours, treating oral commissures, smoothing fine “barcode” lines around the lips and supporting the “marionette” lines down to the chin. Developed using Allergan’s proprietary VYCROSSTM technology, JUVÉDERM VOLBELLA with Lidocaine is formulated with a combination of low and high molecular weight technology, to improve the cross-linking efficiency of HA chains. This more effective crosslinking allows for a lower concentration of HA to be used, resulting in less swelling say manufacturer, Allergan. Allergan T: 01628 494444 W:

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Lynton are launching the Q-PLUS C—a unique laser platform offering what are considered to be the three most effective wavelengths for multi-coloured tattoo removal. This powerful combination of QSwitched Nd:YAG at 1064/532nm and Ruby Laser at 694nm is a world first. The three output wavelengths allow all treatable tattoo colours to be effectively removed, as well as pigmented lesions. Treatment time can vary from one to six sessions for removal of an amateur tattoo, and up to 12 sessions to treat a professional tattoo. Lynton T: 01477 536977 W: lynton.

Medik8 introduces three new porerefining products to its cleansing range. True to the Medik8 concept these new cleansing products are pH balanced, free from pore-blocking sulphates, soap and parabens with a fresh and uplifting fragrance. After use, skin will appear clearer, softer and refreshed, free from dirt, oils, impurities and pollution. The range includes a poreCleanse Gel, a dailyScrub and a clayMask Skinbrands T: 05603 141956

brushstrokes  Soprano ICE from Alma Lasers is based on patented SHR technology—a clinically proven method of effective and virtually pain free hair removal that combines low fluence, short pulses, and a high repetition rate. Alma Lasers T: 00 9724 627 5357; W: almalasers. com

 The Cool Peel promises to rejuvenate skin while caring for the epidermis. The new ptotocol developed by Dr Des Fernandes adresses lines, photo damage and problem skin. iiaa T: 020 8450 2020; W:


The Multi-function Clinic Treatment Chair from PJS Direct offers a four motor, completely electric and simple to operate treatment couch. The PJS-2235D model can be moved into various positions from seated to flat. An important feature is the ability to tilt the chair allowing for greater positioning flexibility during treatment, especially around the clients head or feet. Upholstery is finished in waterproof marine vinyl for durability and padded for comfort. PJS Direct T: 01634 292032 W:

 Stylage is now available with Lidocaine. A clinical study conducted by French plastic surgeon Dr Bernard Mole confirms that the efficacy of the hyaluronic acid is not compromised by the addition of Lidocaine. Stylage has a 12 to 18 month longevity. Stylage T: 02380 676733; W:


The NeoStrata Enlighten products contain a unique combination of high performance, active ingredients to get to the heart of pigmentation by not only inhibiting tyrosinase but also reducing inflammatory cytokines, blocking the melanin transfer to melanosomes and therefore limiting transportation to the keratinocytes and by exfoliation. The three products in the range provide an effective anti-ageing skin treatment programme. Aesthetic Source T: 01234 313130 W:

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 Venus Freeze is an FDA approved, non-invasive solution for body contouring, cellulite reduction, wrinkle reduction and skin tightening for the face neck and body. The technology uses magnetic pulses and multipolar RF. Venus Concept T: 00 1888 907 0115; W: 61

experience Professor Syed Haq

Highway to health Professor Syed Haq describes his passage through healthcare, science and aesthetics, with a focus on addressing the rising obesity issue

Healthy diet and physical activity should be the norm


was born in Scotland, the son of Indian immigrants from a region south of Kolkata. Life in Glasgow was bliss until my father decided to move the family, to my horror, to London. I didn’t enjoy moving down to London at seven years of age. My strongest recollection at such a young and impressionable age was that of unpalatable water, bullying and the race riots. During my time at boarding school in South East London, I was a bit of a bookworm, excelling as an academic but enjoying lighter pursuits such as singing in the choir. I was inspired to become a doctor by observing the local GP, my father, who was the most committed, compassionate man, that was truly loved and revered by all of his patients. Studying at Guys’ Hospital Medical School in my first year was traumatic. Everyone was so competitive! It wasn’t until I was exposed to seeing patients that I really enjoyed the idea of becoming a doctor. Soon after I qualified, my father tragically passed away which led to an unbridgeable void. I later became immersed in the competitive rat race of medicine trying to achieve, winning awards and moving to Boston in the USA, to study at Harvard Medical School and Massachusetts General Hospital. Everything was so different—from the food, weather, accents and people. The city was a cauldron of students from all four corners of the world. My experiences there defined me as a doctor, scientist and person. I realised what was important in life and career, and that was making a change that would impact on many. Returning to London, I noticed so


much had changed. The NHS was unrecognisable. Throughout my time in the US and in London, I was continually drawn to addressing the growing challenges of the epidemic of obesity. I realised that its impact to health, economies and development in society would be one of the major issues facing clinicians in all sectors. The issues are certainly daunting and pose one of the most serious public health concerns today. The prevalence of obesity has risen threefold in the last 20 years, with half of all adults and one in five children being overweight. Being obese or overweight contributes to an increased risk of non-communicable diseases, a foreshortened life expectancy and an adverse quality of life. The trend is particularly alarming in children and adolescents, thus passing the epidemic into adulthood and creating a growing health burden for the next generation. The effect on socioeconomic development is clear, with up to 6% of healthcare expenditure in Europe going towards treating patients with weight problems. This does not, however, include indirect costs due to loss of life, productivity and related income, which would lead to an overall figure of up to 12%. Factors such as a reduction of physical activity, changing dietary patterns, increased consumption of energy dense nutrient food and beverages, in combination with insufficient consumption of fruit and vegetables are culminating in this appalling situation. It is simply not acceptable to lay the blame on genetic predisposition. Obesity is no longer restricted to wealthy societies and, in fact, is more dominant in developing countries and

those with economies in transition. Sadly no Western country has yet managed to bring this epidemic under control. So what are the solutions? It is possible to reverse the trend and this can be done by targeting the root of the problem. My vision is to shape societies where healthy lifestyles related to diet and physical activity are the norm, where health goals are aligned with those related to the economies, societies and culture and where healthy choices are made more accessible and easy for individuals. Political will, government commitment, investment in our young, better education, increased accountability by our food producers, increased physical activity and greater responsibility by individuals of their own health issues are key. Cultural differences also have an impact. Cross-border intervention from the local, sub-national and national, at both microand macro- levels, will certainly make a difference. Understanding what we are eating has become even more important over the past weeks following the horsemeat contamination debacle. The UK aesthetic medicine industry is no longer focusing purely on looking beautiful and maintaining ones external youthful appearance. A more integrated approach is being adopted by progressive thinking practitioners, where screening, hormone balance and weight management are becoming a feature of day-today clinical practice. Here in the UK, we are certainly taking a leading role in Europe. A few years after returning to the UK, I became the chief scientific officer and clinical director of a biopharmaceutical company. We are now at a crossroads, and I believe in the next year we will be able to conclusively show that a biologic drug will have an impact on obesity, autoimmunity and Alzheimer’s disease. The implications of this and the changing practices of many will as a collective have a better outcome on “age management” and obesity in today’s aesthetic and cosmetic industry. Professor Syed Haq is a consultant physician based in the UK body language

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

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

“The aesthetic industry’s favourite partner” Email for aesthetic orders: Wigmore Medical, 23 Wigmore Street, London, W1U 1PL Tel: 020 7491 0150 Fax: 020 7491 2782 Email: Web:

Gold Standard Customer Services voted as The Best by our customers in 2011 and 2012



Volume enhancement for a youthful appearance ■

Immediate result due to elastic gel-matrix

Prolonged effectiveness due to CaHA-induced collagen production

Comprehensive studies confirm a robust safety profile

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For more information, please contact Merz Aesthetics Customer Services Phone: 0333 200 4140, Fax: 0208 236 3526,

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