Body Language Journal #75

october

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

LIP REJUVENATION

PRACTICAL ADVICE ON USING COSMETIC INJECTABLES TO AUGMENT AND REJUVENATE THE LIPS

VEIN CARE

MESOTHERAPY

HAIR GROWTH

Where does aesthetics end and medicine begin when treating veins?

The evidence base for clinical efficacy when using mesotherapy for anti-ageing treatment

How has new equipment influenced paradoxical hair growth

novacutis

body language I CONTENTS 3

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27

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contents 07 NEWS OBSERVATIONS Reports and comments

14 INJECTABLES LIP AUGMENTATION Dr Ines Verner talks through lip rejuvenation, lip augmentation and gives some tips and tricks and common mistakes seen after lip enlargement

Mr Ash Labib, Dr Alexander Rivkin and Ms Leslie Fletcher draw on their wealth of experience to offer advice on optimum delivery of cosmetic injectables

43 EQUIPMENT PARADOXICAL HAIR GROWTH

22 MEDICAL AESTHETICS

Dr Godfrey Town enlightens us on paradoxical hair growth, the evolution of hair removal home use devices and their impact on the professional marketplace

MESOTHERAPY FOR ANTI-AGEING

50 PRODUCTS

Dr Philippe Hamida-Pisal discusses the evidence base for clinical efficacy of mesotherapy

ON THE MARKET

27 TECHNIQUE

53 EQUIPMENT

TREATING VEINS

VULVO-VAGINAL REJUVENATION

Professor Mark Whiteley discusses where aesthetics end and medicine begins

34 INDUSTRY REGULATION Kelly Harding discusses the aftereffects of deregulation for laser and IPL devices, and the importance of education

37 PANEL INJECTION TECHNIQUE

The latest medical aesthetic products and services

Dr Kannan Athreya explains the management of hormonallydependent vaginal atrophy and vaginal relaxation syndrome, which offer therapeutic as well as aesthetic benefits

57 RADIOFREQUENCY MONOPOLAR RADIOFREQUENCY Ms Marie Duckett discusses how she uses the Exilis Elite

4 CONTENTS I 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. With her husband, Dr Alastair Carruthers, she has received the Kligman award from ASCDAS .

Mr Ravi Jandhyala is a member of the Royal College of Surgeons of Glasgow, and a founding member of the UKBTGA. He is also a member of the Faculty of Pharmaceutical Medicine and is an expert in the science behind botulinum toxins for aesthetics.

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.

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.

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.

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.

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.

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.

Dr Raj Persaud FRCPsych is a consultant psychiatrist who has worked at the Bethlem Royal and Maudsley NHS Hospitals in London from 1994-2008, and as an honorary senior lecturer at the Institute of Psychiatry, University of London.

Dr Bessam Farjo MB ChB BAO LRCP&SI 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.

37

EDITOR Helen Unsworth 020 7514 5989 helen@face-ltd.com ASSISTANT EDITOR Lousie Renwick 020 7514 5989 louise@face-ltd.com COMMISSIONING EDITOR David Hicks 020 7514 5989 david@face-ltd.com EDITORIAL ASSISTANT Arabella Tanyel 020 7514 5989 arabella@face-ltd.com SALES EXECUTIVE Monty Serutla 020 7514 5976 monty@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com

Dr Masud Haq BSc, MRCP, MD is a consultant in diabetes and endocrinology.He is a graduate of Guy’s and St Thomas’s Hospital, and trained at Johns Hopkins in the US and in Melbourne. He has a particular interest in the thyroid and menopause.

CONTRIBUTORS Dr Ines Verner, Dr Philippe Hamida-Pisal, Professor Mark Whiteley, Kelly Harding, Mr Ash Labib, Dr Alexander Rivkin, Ms Leslie Fletcher, Dr Godfrey Town, Dr Kannan Athreya, Ms Marie Duckett

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, London, UK.

ISSN 1475-665X The Body Language® journal is published six times a year by AYA Productions. All editorial content, unless otherwise stated or agreed to, is © AYA Productions 2015 and cannot be used in any form without prior permission. 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 5989. Editorial e-mail: editorial@face-ltd.com Advertising: advertising@ face-ltd.com Body Language can be ordered online at www.bodylanguage.net

COMPOSED • CONFIDENT • MY CHOICE

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Approved for glabellar and crow’s feet lines

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU 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) and lateral periorbital lines seen at maximum smile (crow’s feet 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. Glabellar Frown Lines: 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. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. 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. Should not be used during breastfeeding. 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). Glabellar Frown Lines: 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, 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). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, dry eye. General disorders and administration site conditions; Common: injection site haemotoma.

Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. 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: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251.

2. Imhof, M & Kühne, U. A phase III study of incobotulinumtoxinA in the treatment of glabellar frown lines. J Clin Aesthet Dermatol 2011; 4(10):28-34.

3. Data on File: BOC-DOF- 012 Bocouture® - Convenient to use August 2015.

Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. BOC/6/SEP/2015/LD Date of preparation: September 2015

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Botulinum toxin type A free from complexing proteins

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body language I NEWS 7

observations

MELANOMA IN RELATION TO MOLE COUNT People with fewer moles may have a tendancy to be diagnosed with more agressive melanoma People with more than 50 moles have an increased risk of developing melanoma, but those with fewer than 50 moles should still look out for this form of skin cancer.

According to new research presented at the American Academy of Dermatology’s 2015 Summer Academy Meeting in New York, people with fewer moles may have a tendency to be diagnosed with more aggressive melanoma than those with many moles.

Research from dermatologist Dr Caroline C Kim, director, pigmented lesion clinic, and Beth Israel the associate director, cutaneous oncology programme and Deaconess of Medical Center Department of Dermatology, Harvard Medical School, shows that in treating advanced-stage melanoma cases, patients with fewer moles tended to have more aggressive melanoma

than those with many moles.

The study looked at records of 281 melanoma patients who visited BIDMC in 2013 and 2014. Eightynine of these patients had more than 50 moles, while the remaining 192 had fewer than 50 moles. Moles were found to be thicker and more aggressive in those with fewer melanoma than those with many moles.

Thinner, less aggressive melanoma were seen in patients with both a high number of moles and atypical moles—another melanoma risk factor. Additionally, those with more than 50 moles had a higher chance of diagnosis of melanoma at a younger age than those with fewer moles.

Dr Kim says the results of her research could be attributable to several factors, including patients with more than 50 moles being identified earlier as being at risk for melanoma and educated regarding that risk.

These patients may have then seen a dermatologist for regular skin exams, allowing for earlier detection of their melanoma, when it is thinner and less aggressive.

Biological difference between patients may also have a role to play Dr Kim says. “We already know that melanomas are not all the same genetically,” she says. “It’s possible that there are different pathways that drive melanoma in these two patient groups, resulting in different degrees of aggressiveness. If patients with fewer moles are more prone to aggressive melanoma, then we need to make sure that they are also being educated and screened, in addition to patients with many moles.”

Additional large-scale studies will be necessary to confirm the results of Dr Kim’s research and further investigate the biology of melanoma in these two patient groups.

8 NEWS I body language

WATER BEFORE FOOD TO AID WEIGHT LOSS Study finds drinking water before meals can lead to greater weight loss for obese adults Drinking 500 ml of water 30 minutes before meals led to greater weight loss for obese adults compared with those who did not, according to a study published in the Journal of Obesity.

Benefits of water consumption including removing toxins from the body, transporting nutrients and oxygen to cells, lubricating joints, regulating body temperature, improving brain performance and protecting the body’s organs and tissues have been demonstrated in previous studies.

This study looked at how water consumption affected eating habits. A group of 84 obese adults who were randomised to one of two groups—one who ‘pre-loaded’ their stomach with 500 ml of tap water 30 minutes before breakfast, lunch and dinner—

every day for 12 weeks, and the remaining ‘control group’ who were asked to imagine having a full stomach prior to eating.

All participants received a consultation on weight management and advised how to increase physical activity and improve their diet, plus a follow-up telephone consultation two weeks later.

Preloading subjects lost an average of 1.3 kg more in weight than control subjects, an average of 4.3 kg over the 3 months, compared to control subjects’ average loss of 0.8 kg.

The researchers say their findings provide “preliminary evidence” that drinking water prior to main meals can aid weight loss, and note that it is a simple strategy health care professionals could easily promote for overweight or obese patients.

events 7-11 OCTOBER, Annual Congress of the European Academy of Dermatology and Venereology (EADV), Copenhagen, Denmark W: eadv.org 8 OCTOBER, 4th National Aesthetic Nursing Conference, Olympia, London W: aestheticnursingconference.co.uk 15-18 OCTOBER, Annual Meeting of the American Society for Dermatologic Surgery (ASDS), Chicago, Illinois, USA W: asds.net 16-20 OCTOBER, Plastic surgery 2015 The meeting of the American Society of Plastic Surgery (ASPS), Boston, USA W: plasticsurgery.org 22-25 OCTOBER, Annual Conference of the Australasian Society of Aesthetic Plastic Surgery (ASAPS), Sydney, Australia W: asapsevents.org 23-24 OCTOBER, 3rd Anti-aging Medicine European Congress, Paris, France W: euromedicom.com 4-8 NOVEMBER, 4th Annual DASIL Congress, Ho Chi Minh City, Vietnam W: thedasil.org 5-8 NOVEMBER, World Congress of the International Academy of Cosmetic Dermatology (IACD), Singapore W: wcocd2015.com 12-15 NOVEMBER, World Congress of Aesthetic Medicine (WCAM), Miami, Florida, USA W: aaamed.org 14-18 NOVEMBER, World Congress of the International Academy of Cosmetic Dermatology (IACD), Rio de Janeiro, Brazil W: iacdrio2014.com.br 16-19 NOVEMBER, MEDICA, Dusseldorf, Germany W: medicamatch.com/en 19-20 NOVEMBER, Abu Dhabi International Conference in Dermatology and Aesthetics (AIDA), Abu Dhabi, United Arab Emirates W: menaconf.com 27-28 NOVEMBER, Clinical Facial Anatomy Winter Session, Amsterdam, W: euromedicom.com

‘ON THE GO’ EATING MAY LEAD TO WEIGHT GAIN Research finds dieters who eat ‘on the go’ may increase food intake Researchers from the University of Surrey have found dieters who eat ‘on the go’ may increase their food intake later in the day, which could lead to weight gain and obesity.

The study, published in the Journal of Health Psychology showed that eating while walking triggered more overeating compared to eating during other distractions such as watching TV or having a conversation. 60 dieting or non-dieting females were given a cereal bar to eat under three different conditions:

watching a TV clip, walking, or sitting having a conversation. Afterwards, participants completed a questionnaire and a taste test involving four different bowls of snacks which they were invited to consume as much as they wished of. Dieters ate more snacks at the taste test if they had eaten the initial cereal bar whilst walking around and most interestingly, consumed five times more chocolate.

“Any form of distraction, can lead to weight gain” said lead author Professor Jane Ogden.

29 NOVEMBER – 2 DECEMBER, ENT Courses — 2nd Singapore Advanced Rhinoplasty Fresh Frozen Cadaveric Dissection Course, Singapore W: singaporeentcourses.com.

2-3 DECEMBER, The Cutting Edge 2015, New York, USA W: nypsf.org 2-5 DECEMBER, Cosmetic Surgery Forum, Las Vegas, USA W: cosmeticsurgeryforum.com 10-13 DECEMBER, Annual World Congress on Anti-Aging Medicine, Las Vegas, USA W: a4m.com 14-17 DECEMBER, AOCMF Course Principles in Craniomaxillofacial Fracture Management, Davos, Switzerland W: davos1215.aocmf.org Send events for consideration to arabella@face-ltd.com

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body language I NEWS 11

DESK EXERCISE Pedal device could improve employees concentration, promote weight loss and reduce illness

Inspiring office employees to be active at work could be as easy as pedalling a desk bike says a new study from the University of Iowa published in the American Journal of Preventive Medicine.

Growing evidence shows that people who sit all day— even if they’re active outside of work—are at increased risk for serious health conditions such as multiple chronic diseases, poorer cognitive function, and mental distress. In an attempt to increase physical activity of sedentary workers Lucas Carr, assistant professor of health and human physiology and member of the Obesity Research and Education Initiative at the UI, provided desk workers in his study with a pedalling device.

The study found that workers who pedalled more were more likely to report weight loss, improved concentration while at work, and fewer sick days than co-workers who pedalled less.

“We wanted to see if workers would use these devices over a long period of time, and we found the design of the device is critically important,” Carr says.

Aside from the device being comfortable to use, an essential component to successful use was privacy. Place a high-end exercise bike or treadmill desk in the hall as a shared device, and very few employees will use them, Carr says. Carr’s 16-week pilot study was the third and longest in a series of studies he has conducted testing portable pedal machines among workers with sedentary jobs. Carr says providing an employee with an option to be active right at their desk could be an effective way to improve the health of employees who are reluctant to exercise and reduce health care costs for employers.

In his most recent study, 27 employees volunteered to have an activeLife Trainer pedal device placed under their desk. An activity monitor connected to the pedalling devices tracked each participant’s daily pedal time, which averaged 50 minutes a day over 16 weeks.

In addition, participants were sent three emails a week, providing them with tips for how to move more at work and reminders to shift their posture and stand on a regular basis.

At the end of the study, 70% of participants chose to keep their pedalling device—an unexpected response that gives Carr hope of people engaging in healthy behaviours that can be sustained over the long term.

“SAFE” LIMITS FOR LIPOSUCTION Study proposes ‘relative liposuction volume threshold’ based on BMI The “safe” amount of fat to remove in patients undergoing liposuction depends on the patient’s body mass index (BMI), according to a report in the September issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

“Our study shows that liposuction is associated with a very low complication rate, with major complications occurring in less than 1 in 1,000 patients,” comments ASPS Member Surgeon John Y.S. Kim of Northwestern University, Feinberg School of Medicine, Chicago.

“It also calls into question the concept of simple absolute thresholds for lipoaspirate volume—the amount of liposuction that can be performed safely seems to depend in part on how much fat content a person begins with.”

Current ASPS guidelines define five litres as “large-volume liposuction” potentially associated with a higher risk of complications.

But the guidelines acknowledge there is no scientific data to support an absolute cut-off point.

Dr Kim and colleagues analysed data on more than 4,500 liposuction patients, drawn from the ASPS’s “Tracking Operations and Outcomes for Plastic Surgeons” (TOPS) database. Relationship between liposuction volume and complication risk—including interactions with the patient’s BMI was analysed.

Patients with complications had larger liposuction volumes—average 3.4 litres—and higher BMIs. Patients undergoing “large-volume” liposuction of more than five litres had a higher overall complication rate: 3.7 versus 1.1%– almost entirely from an increase in seromas.

There was also a significant interaction between liposuction volume and BMI: when patients with higher BMIs had a greater liposuction volume, the complication rate was somewhat lower.

“Obese patients may tolerate larger lipoaspirate volumes without an increased risk of complications,” tell the researchers, while by contrast, patients with lower BMIs experience a “more exponential increase in risk” at higher liposuction volumes. This relationship between a patient’s pre-existing fat content and “safe” liposuction volumes had not been previously shown.

Dr Kim and colleagues introduced the concept of a “relative liposuction volume threshold” based on BMI. Dr Kim and co-researcher Dr Karol Gutowski emphasised that this provides a relative threshold where complications start to increase, but does not imply an absolute limit on liposuction volumes. Other considerations such as length of surgery, adjunct procedures, and the patient’s overall health status are also important to consider when evaluating liposuction risk.

“Our risk assessment tool can further aid shared decision-making between the surgeon and patient by linking BMI and liposuction volumes,” adds Dr Kim.

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body language I NEWS 13

AVOIDING COMPLICATIONS Adding panniculectomy to hysterectomy does not increase complications

ALTERNATIVE PROCEDURE TO RADICAL MASTECTOMY A revolutionary single-stage procedure has been developed A pre-medical student at Florida Atlantic University, together with Hilton Becker, MD, a plastic and reconstructive surgeon, and affiliate professor in FAU’s Charles E Schmidt College of Medicine and Jeffrey Lind II, MD, have authored a publication describing a revolutionary procedure developed by Becker that is an alternative to radical mastectomy.

Today’s breast reconstructions are generally a twostaged procedure—an expander is placed in the submuscular position followed by exchange for an implant several months later after the tissue has expanded.

Sometimes, in the appropriate patients, a single-stage reconstruction is performed placing the implant in the sub-muscular position at the time of the mastectomy.

The current issue of Plastic and Reconstructive Surgery Journal details the new, above the muscle, singlestage procedure developed and studied by Becker, which preserves the nipple, areola and surrounding skin.

This technique, in which Becker uses a vertical mastectomy incision, a dermal flap for coverage, and a definitive adjustable smooth saline implant “addresses the complications related to sub-pectoral implants and traditional expanders currently used in mastectomies,” he says.

“There are numerous advantages to using a vertical incision over a horizontal incision. From the surgical perspective, it allows for ease of access, and from an aesthetic perspective this incision leads to a better cosmetic result with a scar that resembles that of a breast lift procedure. The procedure is minimally invasive as no new tissue planes are opened after the general surgeon has completed the mastectomy.”

Thirty-one patients with an average age of 51 underwent this single-stage breast reconstruction in the preliminary study and were followed over the course of four and a half years. Results have shown a low complication rate and implant loss.

Having “hanging” abdominal fat and skin removed during the same surgery does not increase the risk of complications reports Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

At some hospitals, plastic and gynecological surgical procedures are commonly performed together. But some surgeons may be concerned that performing panniculectomy and hysterectomy together might increase the risk of complications. Few previous studies have evaluated the safety of this combination of procedures.

This new study supports the safety of this combined approach.

“Our study indicates that there is a similar complication rate between women who chose to undergo a combined panniculectomy and hysterectomy as compared to those who had hysterectomy alone,” says Dr Forte. “However, these patients should be counseled to expect to stay longer in the hospital after combined procedures.”

“Our findings do not end the conversation about risks associated with combined procedures, but provide more data to help patients and providers make informed decisions,” Dr Forte adds According to lead author Dr Antonio Jorge Forte. “This is among the best evidence to date regarding 30-day risk profiles, and the data suggests that the complication rates are comparable for patients undergoing combined hysterectomy and panniculectomy versus hysterectomy alone.

In other words, patients may elect to benefit from the convenience of multiple procedures in a single stage associated with the peace of mind of documented safety.”

The study identified 25,000 women who underwent hysterectomy between 2005 and 2012. Of these, 174 underwent panniculec-

tomy at the same operation. Thirty-day complication rates were compared for matched groups of women undergoing hysterectomy plus panniculectomy versus hysterectomy alone.

Overall, women undergoing hysterectomy plus panniculectomy had a higher rate of venous thromboembolism (VTE): 3% versus 1%. Women in the combined group were also more likely to stay in the hospital for three days or longer: 48% versus 29% However, when comparing patients with similar characteristics, no significant difference in VTE risk was found and there was also no difference in wound complications, surgical site infections, medical complications, or total complication rate.

“The significant differences in complications initially identified in our unadjusted analysis were not found after matching patients from both groups,” Dr Forte emphasises. “This highlights the critical importance of patient selection for avoiding complications in combined procedures.”

14 INJECTABLES I body language

DR INES VERNER talks through lip rejuvenation, lip augmentation and gives some tips and tricks and common mistakes seen after lip enlargement

Lip augmentation L

ips are the central hallmark of the lower face and when they are full and well-defined, they impart youth, health, attractiveness and sexuality. Wider, fuller curved lips with a high vermillion and a short up-

per white lip are all signs of female attractiveness. One of our greatest challenges is to achieve natural results after lip augmentation, because we and our patients are aware of plenty of patients who have had augmentation and look terrible.

Anatomy and structure To achieve natural results we need to be acutely aware of the lip anatomy, of the desired lip structure and what we would like to achieve after the augmentation; and of course of possible deviations.

body language I INJECTABLES 15

The basic structure of the lip has the wide cutaneous lip, the area below the nose. There is the red mucosal lip, which is also called the vermillion, and the junction is the vermillion border. The perfect lips should be curved, well-defined, with a really well-defined cupid’s

66 To achieve natural results, we need to be acutely aware of the lip anatomy 99

bow—we really like to see this structure. Very importantly, the lower lip should be 1.6 times thicker than the upper lip—so about a third thicker than the upper lip— and it’s a very common mistake for us to see this the other way round.

The lower lip should also be longer than the upper lip, because if you take a line from the corners of the mouth along the lower lip, it should be longer than the one taken from the corners along the upper lip. The mouth corners should be at least straight and preferentially maybe slightly elevated due

to the emotions that we suggest when they are a bit elevated. Something that goes to perfection is the distance between the nose and upper lip. The desired distance should be somewhere between 18 and 20 millimetres, while the distance from the lower lip or vermillion border to the chin should be twice as large, about 36 to 40 millimetres in length.

We must look at the profile of the patients whose lips we treat when we evaluate them. This is really essential because people don’t see themselves from a profile, so

16 INJECTABLES I body language

they can’t evaluate and we really need to evaluate them from the profile. The line that I like to use when I’m doing lip injection or lip augmentation is the Steiner line— the line from the mid-nares to the chin. When you take this line from the mid-nares to the chin, the lips should just barely touch it. So if they just barely touch it, they don’t protrude too much and if they don’t touch it, then you know that you can augment the lip and push it a little further forward.

An important point to check when augmenting the lips is the nasal labial angle and this angle should be somewhere between 85 and 105 degrees. Another very important point is the concavity of the upper lip. There should be a “ski-jump”, so a slight elevation at the border, at the vermillion border of the upper lip and this point is called the Glogau-Klein point. It’s also something to check when you fill the lips, so as not to overfill and not to destroy this structure.

Asiatic lips are a little bit different from Caucasian. They have a

relatively fuller upper lip, but when we think about beauty, the lower lip should be a little bit thicker. We rarely have male patients coming for lip augmentation, although it’s becoming more common. Males actually have thinner lips than females and Caucasian males have the thinnest lips. Thin lips are actually considered masculine— males with fuller lips, will look a little bit more feminine, so mostly males do not desire lip augmentation. It’s just not a characteristic of male beauty.

Rejeuvenation As we age our lips become thin and they lose their curves. The upper lip becomes flat and elongated and actually obscures the maxillary teeth, which is very important for the smile. We get radial lip wrinkles—a lot of barcode lines. There is loss of lip definition and the lips become less defined. The lower lip will become shorter than the upper lip, and the lower lip and chin area lose height. The lips go downwards and the mouth descends, exposing

66 As we age our lips become thin and they lose their curves.

The upper lip becomes flat and elongated and obscures the maxillary teeth 99 the mandibular teeth. When you compare younger people and older people smiling it’s very important to see the upper teeth, the maxillary teeth. If you see the mandibular teeth, the smile is not so beautiful anymore and the mouth corners turn down.

When a patient comes to our clinic with a desire for lip augmentation, we have to consider both which problems of the lips we would like to address and of course their desires.

While they’re holding the mirror, I tend to explain their anatomy to them and their problems. I also tell them what should be done to correct these problems, but also what

body language I INJECTABLES 17

should not be done and what cannot be achieved. It’s very important to have the right expectations because some patients will come with pictures of models, to have lips like a certain model, which is an unrealistic expectation of course. They may want larger lips; younger patients many times desire very large lips, which may look very unnatural on a certain face.

The other group of patients are afraid of lip injections so this is also a very big group. They come to your clinic and you tell them you would like to augment their lip a little bit, but they’re afraid of you working on their lips, as they are afraid of unnatural results. Now, many of our patients will have vermillion border definitions with some perioral wrinkles, they will have atrophic lips, or some will have a good lip shape and just want more fullness. I think that most of our patients are actually in that group.

Injection techniques When we evaluate a patient, one of the most important parameters,

is the proportion between the upper and the lower lip. That is really very essential. The lower lip should be one third thicker. Another very important evaluation is the sideby-side symmetry. When the face or the lip is very asymmetric, of course it will bother our eye when we look at it. The other things to evaluate are fullness and also lip projection, so this is a very common problem.

A common problem is loss of lip definition with barcode lines on the upper lip. Arnie Klein described a few of the methods to augment the lips and he described a technique that is very commonly used—vermillion border injection from the lateral side towards the centre of the lip. You put the needle on the lateral side of the upper vermillion border, you just push the filler and where it stops, where you get resistance, you stop and you go to the next point into this potential vermillion space. That is a very common technique and the filler material will flow into that space along the vermillion border and of course we move at a point of resistance. This can be very good for lip definition and also for a little bit of stretching of the barcode lines.

Another technique that I use a lot is really filling up the white lip, because many times injecting the vermillion border may not be enough and you need to inject the whole area. So I go from the lateral side and inject under the wrinkles and then you can also inject into the wrinkles – though I don’t like to inject into the wrinkles so much because it’s very hard to really achieve nice results. You have to use a relatively low G filler for that, which is possible, but it’s better first to fill in the white lip from the side and then, if some wrinkles are left, to go into the wrinkles.

Another technique that has been used in the past a lot is the Paris lip technique, but this is something that I think we use less now. It’s a technique that covers mostly the central part of the lip and that is its problem because it doesn’t pay attention to the lateral sides. Again you inject

TIP: Viscosity of fillers When considering the viscosity of the filler that we use for the lips, I like the lower viscosity or the lower G prime fillers.

The vermillion border is much better defined when the viscosity of the filler or the G prime of the filler is lower. So if you inject the vermillion border, it’s better to take a lower G prime so as to achieve sharper lip definition because lip definition is sharper.

So a tip for this is to use low to medium viscosity filler to also avoid lumps, but also to achieve a sharper lip definition.

TIP: When you’re injecting wrinkles on the white lip, take care not to overcorrect, as this may lead to lumps and also thickening of the white upper lip. This is also an extremely common mistake when the upper lip becomes convex instead of concave due to overfilling. When it’s convex instead of concave you lose the right lip structure when you overfill. It can also be due to ageing, but many times after lip augmentation this is a mistake that you see, so you really have to take care not to overcorrect the upper white lip. It’s better to have a little bit of wrinkles but not to have a convex upper lip.

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body language I INJECTABLES 19

from the sides of the lip to the vermillion border, first the upper lip, then the Cupid’s bow area, and then the lower lip. Of course there are some problems here because only the central portion of the vermillion border is actually treated here.

An interesting problem is that these injection techniques are quite old and when collagen was introduced in the US and it was approved by the FDA, the approval was for vermillion border augmentation and therefore some of the injection techniques were actually always talking about the vermillion border. In Europe we do not have these restrictions and can inject a filler into the red lip and also in the perioral area. So the problems here were there was no attention to the corners of the mouth and of course you have to pay attention to that as they shouldn’t stay turned down, and this is also another common problem. The corners of the mouth should be straight and, if possible, even a bit elevated. Also, we should be careful not to over inject the central lip. The cupid’s bow, the central upper and lower lip should not be over injected.

Volume Atrophic lips can be either genetic or acquired due to ageing, and they of course can be in the lower and upper lip, and also there can be asymmetry. We lose a lot of volume in the lips when we age and we have upper lip elongation. So when we want to achieve a little bit of more volume, what should we do? To achieve more volume the best way is to inject into the red lip because that’s the part that we want to be a little bit more full. You can do it from the sides towards the centre, and you can inject in the sub vermillion border or at the area of wet and dry border.

There are possible problems here in nodules or too superficial

injection. A very common problem is that the material is injected too superficially and then you can actually feel it, or see it when people move, smile, talk. High viscosity fillers will of course lead to more nodules, so in my opinion it’s better to use lower G prime fillers.

Clumping of the filler is also a very common problem due to movement. So you inject the filler, the patient goes out, you massage it, it’s completely soft and then they come in two weeks later and tell you they feel bumps. This is very common on the lips because there is quite a lot of movement, so the filler actually clumps. It’s also easy to treat it because if you just massage it out, it’s possible to get rid of this lump within a few minutes.

Treating the lower lip The lower lip is essential, but many times a lot of attention is paid to the upper lip and how to inject it, but not so much to the lower. The lower lip also has a very important structure for beauty. It has protuberances and areas of higher and lower levels, so when I inject the lower lip I divide the lip in four imaginary parts by imaginary lines. I inject each quarter of the lower lip separately. So in this way, I always control the volume and it’s also very symmetrical. I also pay attention to the structure of the lower lip, where it is, so not to get just a straight line but to really get the right lip structure.

For most of our patients we actually need to combine all the different injection techniques. Of course you can also use a cannula, but I like to use a needle on the lip, because you can be very precise and inject exactly the same quantities in each part of the lip, and know exactly where the filler is going. I use all these different techniques, depending on the problem of the patient.

66 For most of our patients, we actually need to combine all the different injection techniques 99

Treating the upper lip You can inject the sub vermillion or the vermillion, or you can inject in the wet and dry border. This depends on where the lack of volume is—in some patients they lack volume in the wet and dry border and the other ones will have it in the sub vermillion area—I would inject where the volume is missing.

Corners of the mouth It’s also essential to consider the corners of the mouth—to pay attention to the marionette lines and the corners. Of course you can have the perfect lip, but if the area around the perioral area looks terrible, then it’s even worse because then the lip attracts the attention to the terrible decent of that area. So it’s essential to pay a lot of atten-

Before and after volume replacement in the lips

20 INJECTABLES I body language

tion to the perioral area and to treat marionette lines and the midface if it is needed. Sometimes patients come and they want a lip augmentation and they don’t want to treat the area around, and I won’t do it because I think they really need to get the whole area treated. It’s also very essential to look at the whole face to really get a whole approach to a patient because one little drop in the sea may not be enough.

Treating other areas of the face I like to use botulinum toxin in the perioral area. Often I do the filler first, in the same session, and most often I will inject just one cc—almost never more than that. I will go around and treat with botulinum toxin a little if I see that there is some muscle contraction—I will inject the orbicularis oris and I will inject the depressor anguli oris and also the mentalis because these muscle contractions really affect also how it looks; the cosmetic result will be much better.

By using botulinum toxin in the same area, we can prolong the durability of the filler.

Longevity One complaint is that hyaluronic acid may be short-lived on the lip.

So I treat gradually. I use one cc, we will see the result, and if they want more, then only in the next session, or one month, or two months, or even three months later we can augment more until we achieve the desired result. Maybe the first time you inject the lip the results will stay for about half a year, but after a few injections, after a few times, they come again after half a year, you inject the lip again. The next time it will be eight to nine months or maybe ten months, and the time after that it will be a year, and the next time you correct it again maybe it will be two or three years. I have a very large group of patients that I’ve injected three times for something like that, it’s not the same, it’s a little bit variable, and then they don’t need any augmentation for many years after.

You must also remember that when we age our faces become smaller so we actually need a little bit of a smaller lip to fit the face, so it’s good that there is some absorp-

66 Always consider the desired anatomy before injecting.

Master an atraumatic injection technique and inject low volumes at a time 99 tion and actually it is a long-term result after a few injections.

In conclusion, always consider the desired anatomy before injecting. Use only low to medium viscosity filler in the lip. Master an atraumatic injection technique and inject low volumes at a time so as not to overcorrect, and follow up and inject more if it is needed.

Dr Ines Verner is an internationally esteemed Specialist Dermatologist working for over 15 years in aesthetic and cosmetic dermatology. She has a Harley Street practice and is at the forefront of technology, treatment, teaching and research in the field of aesthetic dermatology.

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22 MEDICAL AESTHETICS I body language

Mesotherapy for anti-ageing DR PHILIPPE HAMIDA-PISAL discusses the evidence base for clinical efficacy of mesotherapy

I

n aesthetic medicine mesotherapy can be defined as a non surgical technique aimed at diminishing problem areas in the skin such as cellulite, stretch marks, excess weight, body contouring, and face and neck rejuvenation, to name a few. It is administered via numerous microinjections that contain various types of CE approved medicines, vitamins and minerals. This technique was developed in France in the 1950s, and it was recognised by the French Academy of Medicine in 1987.

Indications Aesthetic mesotherapy addresses skin rejuvenation, cellulite, sun damage, scar reduction and alopecia. There are various indications for mesotherapy, including pain management and aesthetic mesotherapy. For pain management there is a different field of mesotherapy, where this technique is used to relieve rheumatism, arthritis and muscle pain and sports

injuries, amongst many other. Another uses include smoking cessation, allergy and ophthalmological pathology.

In the aesthetic field, the concern is primarily the effectiveness of the poly-revitalising solutions employed in mesotherapy and what happens in skin when those solutions are used.

To treat using mesotherapy, a solution containing small amounts of various substances such as vitamin C, vitamin A, vitamin E, vitamin B in nearly all its forms, amino acids, minerals (like calcium, phosphorous and magnesium), nucleosides, coenzymes, antioxidants, and hyaluronic acid is injected. This solution is injected into the epidermis and the dermis using three injection techniques. It is also possible to use micro needling or a meso-gun.

Both young skin and more aged skin can be targeted. In aged skin the treatment aids hydration, reduces the anti radical action and fights against the effective of oxi-

COMPOSITION OF POLY-REVILING SOLUTIONS USED IN MESOTHERAPY  Vitamin C, as we all know, is an antioxidant. It has antioxidant effects, and regulates, and speeds up the DNA synthesis and it’s essential for collagen synthesis.  Vitamin A is retinol, which is an antioxidant as well, that increases its action when combined with the vitamin C, and that regulates the epidermis regenerations and amino acid activities. It also controls all gland activities.  Vitamin E has a high level of antioxidant activity. It controls skin’s physiological regeneration and starts repair processes in the case of skin damage.  Vitamin B is very important as an antioxidant, but also to release the energy necessary for the fibroblasts to work with efficacy.

dative stress. Radiance can also be achieved, improving the density, the tone of the skin, and its tonicity. The results of mesotherapy are progressive and accumulative and the advantage is that it is non-invasive and non-traumatic.

Ageing skin Beautiful skin tends to be defined as smooth, even coloured and tone, radiant, firm and plump, with small pores, no wrinkles, no blemishes, no sagging, and no hyperpigmentation. Everyone desires luminescent, glowing, hydrated skin; a skin that is neither too dry, nor too oily, and would like to keep it this way forever. However, unfortunately the ageing process catches us all.

After the age of 30, it’s common to see that the eyebrows begin to descend. In our 40s, we may have excess eyelid skin, the glabella frown lines start to show and the nasal brow will fall also. By the 50s, forehead wrinkles start to show, the glabella becomes more pronounced and there is excess skin and vertical lines in the perioral region. When we arrive in our 60s, things get a bit worse. There are perioral and neck wrinkles, the nose begins to droop and the glabella becomes even more pronounced. By the age of 70 these developments become more visible as the skin thins even more.

We also note a reduction in facial fat and a loss of volume. Muscular hyperactivity is a further reason of skin ageing.

Ageing factors There are internal and external factors affecting ageing. Internal fac-

There are internal and external factors that affect skin ageing

body language I MEDICAL AESTHETICS 23

tors include genes, time, evolution and expression. When we look at external factors we find smoking, sun exposure, lifestyle, and pollution. For instance, those living in London are likely to age quicker than those in Cornwall.

So what happens to the skin?

The epidermis thins, and the rate of cell renewal decreases. Photo ageing causes thinning of the epidermis with abnormal keratinocyte differentiation and dryness of the stratum corneum, which is due to the lack of hyaluronic acid.

When the junction between the dermis and epidermis thins, the ageing process becomes more pronounced in the dermis. A quan-

66 We have been trained to believe that the upper face should be treated with toxins 99

titative and a qualitative change occurs in collagen types I and III and changes to the fibroblasts â&#x20AC;&#x201C; the extracellular matrix and collagen, the structural framework for human tissue.

The role of fibroblasts Understanding the ageing process and the importance of fibroblasts is the key to understanding how mesotherapy works.

The fibroblasts are concerned primarily with maintenance and tissue metabolism and their correct functioning is responsible for structural and biochemical alterations, change in perception, permeability and capacity of scar formation. Fibroblasts make collagen, glycosaminoglycans, reticular and elastic fibres, glycoproteins found in the extracellular matrix, and cytokine TSLP. They also represent the major skin type in the dermis and are responsible for producing and maintaining the extracellular

connective tissue, which gives the skin its youthful look.

However, as time passes, fibroblasts stop being able to keep the skin looking youthful. The exact reason why remains unclear, but what we do know that there is an important reason for this change in the dermisâ&#x20AC;&#x201D;perhaps an age related increase in oxidative stress, due to alteration in the balance between production and elimination of reactive oxygen.

Each of the components used in mesotherapy solutions such as NCTF HA has a physiological effect on the skin cells. The main principle is that ageing skin is supplied with various substrates that are key to the adequate functioning of the fibroblasts. These include vitamin, mineral element, amino acid, nucleotide, coenzyme and antioxidant as well as hyaluronic acid.

Fibroblasts will work more efficiently if they are provided with the nurturing environment in which

24 MEDICAL AESTHETICS I body language

they can function properly, and the substrate substance looks after creating such an environment.

Putting all these multiple components together is not enough to guarantee the actual efficacy, as they need to maintain the stability and integrity in the formulation. It is very important to note that the formulation is sterilised by double filtration and not autoclaving, because those substrates are very sensitive to the heat.

Poly-reviling solutions In terms of ingredients, we have vitamin C, vitamin A, vitamin E, and the whole range of vitamin B. Amino acids represent a substrate required to build the extracellular matrix protein, mainly the collagen. The three main minerals found in mesotherapy solutions are calcium, phosphorus and magnesium. Calcium is the main iron used to regulate cell homeostasis.

Phosphorus is essential for cell wall regeneration and all the biological membranes. And magnesium is required to maintain more than 180 normal enzymatic reactions.

We also have some nucleosides—five which are necessary to replicate DNA for fibroblast fission. Then, co-enzymes which are biochemical reaction catalysers.

There are also some other antioxidants, such as the tripeptide glutathione which is among the most

efficient endogenous antioxidants, and finally we have hyaluronic acid, which has an anti-inflammatory action. It is antifungal and it also attracts 1000 times its weight in water (which maintains and improves the hydration of the skin).

Evidence Preclinical and some clinical trials evidence is available to support the effectiveness of mesotherapy treatments, as well as long-term international experience in the clinical use of such preparations.

Studies of mesoneedling show that the formation of new collagen and elastin after passing a needle has an increase of 206%.

Studies looking at a simulation of cell multiplications on young skin and on aged skin, show 147% for young and 148% on more aged skin. New collagen stimulation shows an increase of 166% intracellularly and 256% extracellularly, and protection against oxidative stress can increase up to 90%.

I have studied patients in Paris and London, who showed amazing results after just five sessions of mesotherapy—which is standard amount we recommend. The results varied in each individual case, but in general we can say that the quality of the skin improved overall, including reductions of crow’s feet as well as nasolabial fold, and an evident reduction of pigmenta-

Q: What technique do you use?

A: In mesotherapy, we always use all three techniques: the epidermic technique, papula and nappage. The epidermic technique is superficial and it is sometimes referred to as the Parkinson technique.

Papula is when we target the fine lines, and nappage is when we target the deep dermis. Using the three techniques enables us to target the different depths of the skin hydrating them individually.

Q: How many sessions do you deliver?

A: We recommend five sessions, two to three weeks apart, but some patients, want to have quicker results. For them, we can do one session per week and within three sessions, we will notice a huge difference. After completing the five sessions, we always recommend two sessions per year to maintain the results. Most of the times my patients have such good results that they come and have one session per month.

Q: Would you combine PRP with mesotherapy, or instead of the list of vitamins, would you sometimes use PRP? A: It depends on the patients and their requirements. It is possible to mix PRP and Mesotherapy together, especially for alopecia,

tion. Applied on a regular basis, mesotherapy reduces sun damage, and we see this when we use such solutions for ageing hands, where loss of firmness and sunspots are clearly improved.

Possible side effects Short-term side effects, such as mild pain, redness, swelling, and bruising are relatively common and an expected consequence of the injections themselves, but true complications are rare. Occasionally, small lumps, bruising, swelling and discomfort may also occur. Disinfecting the skin before the treatment is important to avoid possible infections.

Conclusion The goal of the poly-revitalising solutions is to create a favourable micro-environment for more optimal fibroblast activity. These solutions help fibroblasts work effectively.

Mesotherapy in the aesthetic field is one of the safest existing techniques if it is done accordingly.

Dr Philippe Hamida-Pisal is the owner and Managing Director of PHP Aesthetic and PHP Wellness, Divisions of PHP Health First, a London based aesthetic treatment provider specialising in aesthetic treatments and bespoke skin care for model agencies. He is Founder and President of The Society of Mesotherapy of United Kingdom “SoMUK”.

where we have a very good combined treatment.

Q: Apart from combining mesotherapy with PRP, do you combine it with any other aesthetic methods?

A: I combine mesotherapy with peel, with fillers, or with mechanostimulation when I target cellulite (or when I want to reshape someone’s body). When doing a peel combined with mesotherapy, we would always do the peel first followed by mesotherapy. We will always do mechanostimulation first and then mesotherapy, because the mechanostimulation improves the blood circulation, and when we perform mesotherapy, we will have a better absorption of the solution, which will lead to better results.

We can have very good results, when treating cellulite with mesotherapy, but we need to know what our limits are, just like with any other treatment. For instance, mesotherapy for cellulite can provide very good results on its own. However, when combined with mechanostimulation, it gives even better and quicker results. But when we have clients asking for mesotherapy for weight loss, we have to be careful; with mesotherapy we can reduce cellulite, but not weight. It is important to be clear about what we can and what we cannot achieve.

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body language I TECHNIQUE 27

Treating veins PROFESSOR MARK WHITELEY discusses where aesthetics end and medicine begins

O

ur understanding of the venous system and venous treatments, including thread veins treatments and venous surgery, is constantly changing. Many people think they know all about varicose veins and venous disease, because they were taught about them when they trained. However, thanks to modern duplex ultrasound diagnosis, knowledge of this topic is ever evolving and things we thought we knew can be redefined just over the course of one week. Treatment of the veins by merely treating what is visible, is about 15 years behind the curve and in the majority of cases is probably incorrect. Understanding the actual underlying pathophysiologies of this problem is of paramount importance if one wants to get the correct treatment for each individual case.

Veins When thinking about treating veins, the most important consideration is the location of the offending veins in relation to the heart. When veins are above the heart, there are fewer concerns because the blood is draining away naturally due to gravity. Thus on the face, laser, intense pulsed light (IPL) and radiofrequency can be used for thread veins treatments, as there is no risk of an underlying feeding vein. Conversely, blood

in the leg veins below the heart, does not flow upwards against gravity and so it has to be actively pumped. This requires movement and functioning valves to make the blood flow one way. If any valves fail and blood falls back down the veins (venous reflux) it can feed into varicose veins or surface veins keeping them open. Hence if we want to treat visible leg veins successfully, we have to understand if there is venous reflux or not before even thinking about treating visible veins.

Prevalance Thread veins, spider veins or broken veins are correctly termed as Telangiectasia. According to the research published by Professor Vaughan Ruckley’s group in Edinburgh, they affect 88% of women and 79% of men. That’s a huge prevalence of thread veins and hence a huge potential market.

However to succeed in that market, you have to understand what you are dealing with.

The prevalence of varicose veins today is 15 to 20%. However, a venous duplex ultrasound will reveal a prevalence of venous reflux in the leg veins of twice this—about 3040%. That means that for every person who knows they’ve got varicose veins—because they can see them—there’s another person who doesn’t think they have varicose

66 When thinking about treating veins, the most important consideration is the location of the vein in relation to the heart 99

veins, but they have! I named this problem “hidden varicose veins” in 2009 to try to help people understand it. Hidden varicose veins are a big problem because they can cause problems, such as visible thread veins or spider veins on the surface, but their presence cannot be identified without a venous duplex ultrasound.

Hidden varicose veins can cause visible thread veins or spider veins on the surface, but can only be identified with a venous duplex ultrasound

28 TECHNIQUE I body language

CEAP classification The CEAP classification is used by vein surgeons and people treating veins. The CEAP clinical score is the most widely used, ranging from C0 - C6. In the aesthetics world, might think you only need to know about the minor levels of vein disease, C1 and C2. However if you are going to start treating patients with leg veins, you need to understand the whole system as they’re all connected and your patients may progress from one classification to another.

Typical telangiectasia of a C1 manifests as spidery red and purple clusters of veins.

C2, are varicose veins. If varicose veins are asymptomatic, they’re C2A. If the patient has any symptoms, such as swelling of any sort, or any tenderness or aching, then it’s C2S or more.

C3 represents the presence of venous oedema. This may not be immediately visible, but might be noted by measuring the ankles or looking for the indentation in the skin after wearing socks. Do remember you can’t always compare the two because you might have the same oedema on both sides. Luckily venous duplex ultrasound identifies oedema very easily.

C4 is skin changes due to venous reflux. These skin changes are usually in the lower leg, under the calf muscle. Such skin changes may be venous eczema, red itchy skin, lipodermatosclerosis, hard red skin, or haemosiderin, which is the permanent brown staining, indicating progression towards leg ulceration.

C5 is when there has been a venous leg ulcer which has healed.

Venous leg ulcers often heal temporarily with dressings only to come back again, if the underlying vein problem has not been identified and treated. If there has been a venous ulcer which is currently healed and not active, then the clinical score is C5.

C6 is a venous leg ulcer, which is an “open sore” where the skin has broken down and will not heal as a normal wound would. Leg ulcers should not be assessed by size as many leg ulcers look larger than they actually are due to the effect of dressings. Traditional leg ulcer

dressings keep the moisture from the leg ulcer inside the dressing next to the skin. This causes the normal skin around the ulcer to macerate and break down, looking like the leg ulcer itself. The correct way to treat the majority of venous leg ulcers nowadays is not to dress and bandage them, but to use a venous duplex scan to identify the underlying cause and then to treat that. Once the underlying hidden varicose veins have been treated, the ulcer will usually heal despite any bandages or dressings.

CEAP criticisms There are several criticisms of the CEAP score. Firstly, it’s not linear.

You obviously do not go from C0 to C1 to C2 to C3 to C4 to C5 to C6. A patient with normal looking legs and “hidden varicose veins” (clinically C0), can suddenly get a leg ulcer (C6) without ever having any visible problem—so can jump from C0 to C6. Most of the vein problems can’t be seen on the surface and so finding out what is actually going on inside the leg is only possible if you’ve got a venous duplex ultrasound.

It’s also impossible to go from C4 to C5 to C6, because you can’t get a healed ulcer (C5) before you’ve had the ulcer in the first place (C6). So you have to go to C6 before you can go back to C5.

Hence it is important that we know that the CEAP Clinical score is a way of communicating the severity of a leg with venous disease at any one time and is not a direct measure of disease a progression.

NICE guidelines The National Institute of Health and Clinical Excellence (NICE) published Clinical Guidance on Varicose Veins (CG 168) in July 2013. Although NICE is UK based, Europe tends to follow NICE guidance and interestingly the clinical guidance is virtually the same as that produced for doctors in the USA. Although the NICE guidelines do not actually mention the CEAP classification, the explanation of the signs and symptoms of varicose veins and the problems that they can cause map directly to the clini-

CEAP CLASSIFICATION C0—normal, nothing wrong

C1—telangiectasia and reticular veins

C2—varicose —varicose veins: split into asymptomatic and symptomatic

C3— — venous oedema: swelling due to varicose veins

C4—skin —skin damage

C5—a —a healed ulcer

C6—an —an active ulcer

body language I TECHNIQUE 29

NICE DEMANDS FROM CLINICIANS  Explain what varicose veins are.  Explain the causes, the likelihood of progression and any potential complications including deep vein thrombosis.  As a proper clinic you must have an out-of-hours service to protect and look after people at risk of DVT.  Explain all of the treatment options, which now include Endovenous laser, Radiofrequency, glue and ClariVein (MOCA), foam sclerotherapy.  Offer different options, because it has been proven that the most appropriate treatment depends on the thickness of the vein wall and the diameter of the vein. Remember there is no one size fits all treatment for veins.  Give advice on weight loss and physical activity.  Tell patients the benefits but also explain about the recurrence risks of your procedure.

Clinical guidance on veins was published by NICE in 2013

cal score of CEAP. Interestingly, the NICE guidelines do not cover C1 (telangiectasia) and C2A varicose veins with no symptoms, as these are not considered as “medical” varicose vein problems. NICE only provides clinical guidelines for patients with varicose veins causing symptoms (C2S) or damage to the lower leg (C3, C4, C5 and C6).

Beware of thinking that because NICE now approves some varicose vein treatments that this allows you to treat leg veins in aesthetics clinics. Most people who go to aesthetics clinics are C1 or C2A and so are not covered by the NICE guidelines.

If your clinic does treat varicose veins with and symptoms at all, or with any swelling or skin damage, or has a doctor who pops in with his duplex scan to do a bit of RF or laser, it’s vital to know what the NICE guidelines say so that you don’t fall foul of the regulations.

The guidelines state that these patients need a full medical consultation, a duplex ultrasound, and should be treated by a multidisciplinary team not just a single doctor in a room by themselves doing their own scans and treatment.

In other words, you really need a 30 minute consultation and a scan done by a proper vascular technologist or radiologist.

So you cannot treat these patients like the normal aesthetics patients where you assess them by looking at them, write a few brief notes or fill in a “tick sheet” and manage expectations. To do so would not fulfil the requirements of the NICE guidelines.

NICE approved treatment Options NICE specifies that for varicose veins with venous reflux, the preferred option is endothermal ablation. Endothermal ablation means you are going to stick something into someone and heat it up. I believe what this guideline should say is endovenous thermal ablation, because the device needs to be put inside the vein and then the vein is heated and destroyed.

If endovenous thermal ablation is unavailable or the vein is unsuitable, then you can use ultrasoundguided foam sclerotherapy. If that is unavailable or the vein in unsuitable, you can then offer stripping.

However it must be remembered that most veins grow back again after stripping and so this is not a good option.

Stockings have not been considered to be a treatment for varicose veins since 1993 and should never be prescribed as a treatment. You can use them to make the patient feel better while waiting for venous surgery; but it is unacceptable for a GP, insurance company or the NHS to advise a patient to just wear stockings instead of having curative surgical treatment.

Anyone with a leg ulcer must be referred for proper assessment if it hasn’t healed within two weeks.

66

Research has shown that compression bandaging is not a cure in the majority of cases and is only something to do whilst waiting for proper treatment. Patients should only have compression as a treatment option if they have been shown to be incurable by a venous specialist, which is only about 15% of venous ulcers.

Patients with C2S to C6 must be referred to “vascular service”. If you have a clinic and you want a doctor to come in and treat varicose veins, they are breaking NICE guidelines unless they set up a full “vascular service” in your clinic. This is defined in the clinical guidelines as a team of healthcare professionals who have the skills to undertake a full clinical and duplex ultrasound examination and are able to offer the full range of venous treatments.

It is now not acceptable to use a handheld Doppler to assess veins in the legs, as this does not identify which vein is being listened to and so venous duplex ultrasound is essential. As the full range of treatments must be available, you need a minimum of one method of endothermal ablation, the ability to perform ultrasound guided foam sclerotherapy and ambulatory phlebectomy.

Aesthetic treatment for leg veins As we have discussed above, C1 telangiectasia or thread veins, and C2A varicose veins are not covered by the NICE guidelines and can therefore be thought of as “cosmetic” or “aesthetic”. However, that does not mean to say the assessment or treatment is any less demanding or is easier. If you are a doctor or nurse, you must act in accordance with good practice and within your own professional competencies, and patient safety must come first. If you are not a doctor or nurse but work clinically in an

If endovenous thermal ablation is unavailable or the vein is unsuitable, you can use ultrasound-guided foam sclerotherapy 99

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body language I TECHNIQUE 31

66 Doctors and nurses learn that varicose veins come from valves failing in the great and/or small saphenous vein— this is incorrect 99 aesthetics clinic, you will have your own guidelines and insurance.

Your insurance company will also expect the same high standards for treating patients.

By definition, every patient with C2A varicose veins will have underlying venous reflux. This means 100% of them must have a venous duplex ultrasound scan to find out what treatment is right for them.

A study presented in 2013 in New York at the VEITH conference showed that if a doctor does their own quick scan, they will miss a minimum of 30% of the underlying causes of the varicose veins and so any treatment planned will be incomplete. Hence venous duplex ultrasound must be performed by a specialist vascular technologist as part of the team approach.

Published research in 1993 shows that 89% of telangiectasia have got underlying feeding veins that you cannot treat unless you know they’re there. More importantly, 40% of these people have underlying truncal reflux in one of the major veins such as the great saphenous, small saphenous or anterior accessory saphenous veins.

In addition, 15% of patients with thread veins have incompetent perforator veins feeding into them.

Such a patient visited me recently.

She had found a cheap clinic online offering endovenous treatment and had gone along to have her veins treated. However after treatment, she found her veins were still there and more were appearing. The scan performed by my vascular technologist revealed a good closure of the great saphenous vein, but the anterior accessory saphenous vein,

which was causing all of the problem, hadn’t been touched! Neither had several incompetent perforating veins located down at the bottom of the leg. That patient had spent a couple of thousand pounds to get her leg looking nice and then had to spend even more again for it to be done properly.

Which veins to treat?

Doctors and nurses learn in their training that varicose veins come from valves failing in the great saphenous vein and/or the small saphenous vein. However we now know that’s incorrect. Fewer than 15% of my patients have one of those two vein as the cause of their varicose veins. With good venous duplex ultrasound we now know that there are many causes for leg varicose veins including the anterior accessory saphenous vein in the front of the thigh, bifid sections of the great or small saphenous veins, the Giacomini vein (or intersaphenous vein) in the back of the thigh as well as varicose veins from the

pelvis.

In addition there can be incompetent perforator veins and research has shown that 40% of everyone with varicose veins have incompetent perforators. Most doctors and even vascular surgons still don’t treat perforators and so they don’t even look for them—and this is one of the major causes of recurrent varicose veins after surgery. The treatment of incompetent perforator veins is not easy. In the 1950s, it was a very long hospital stay with a big scar down the back or side of the lower leg, needed in order to tie them off. In 1983, Hauer invented a keyhole technique called SEPS— but this was superseded 2000 by TRLOP. TRLOP technique My colleague, Judy Holdstock, and I invented the TRLOP technique to close incompetent perforator veins in 2000. However, in the USA, a doctor “re-invented” the operation in 2007, calling it PAPS. It is now the standard

A

B

C

D

A&B: Pelvic varicose veins emerging into leg varicose veins. C&D: Recurrent varicose veins one year after treatment at a cheap vein clinic— missed AASV and perforators

32 TECHNIQUE I body language

technique for closing perforators in varicose vein surgery. TRLOP is performed through one needle hole under ultrasound control.

The laser is passed into the incompetent perforating vein and is closed under local anaesthetic as a walk-in, walk-out procedure. As it only uses a needle hole, there isn’t any need for stitches and it is about 95% successful in our hands now.

Pelvic vein reflux Pelvic vein reflux has become a real problem to many people trying to start a varicose vein or thread vein practice, because most vein surgeons, even in vascular units or vein clinics, either don’t know about this or ignore it. We starting publicising it in 2000 after I had a female patient come to see me who has had three children by normal vaginal delivery. She had previously had stripping on two occasions by a famous London vein surgeon, but her varicose veins kept returning. She came to see me as a second opinion. On close examination of

her legs, she had veins on the inside of her thighs, coming down the inside of the leg and around the back of her buttock.

This isn’t uncommon. Since the year 2000 we’ve been researching this and have found that it’s not only the ovarian veins in the pelvis, but also the internal iliac veins in the pelvis that cause this.

One in five women (20%) of those who have had children and who have varicose veins, have pelvic veins as the cause of their leg varicose veins.

We’ve recently published research in the USA showing that pelvic veins are a major cause of leg varicose veins recurring after traditional surgery. We showed that if the women had previously had children, and had not had a hysterectomy, and who got recurrent varicose, then the second most common cause is because the doctor missed the pelvic varicose veins.

More importantly, neovascular tissue caused by the old fashioned stripping was the only commoner cause of recurrence, and so now we

don’t strip veins any more. Missing pelvic varicose veins is likely to become the most common reason women get recurrent varicose veins after vein treatments.

The importance of scanning Use of duplex ultrasound scan is essential. We’ve just published a study in the European Journal of Vascular and Endovascular Surgery proving that you can’t use MRI, CT or anything fancy for this, because when you are lying down, you can’t tell if a vein is varicose or not. Consider phlebitis, atrophic segments, neovascularisation, strip-track recurrence, incompetent perforators—all of these cause symptomatic varicose veins and telangiectasia and if you are not doing a 45 minute venous duplex

66 Pelvic vein reflux has become a real problem to many people starting a practice 99

body language I TECHNIQUE 33

Everyone with veins, even telangiectasia, has got a systematic problem that is affecting their circulatory system on the venous side

ultrasound scan, you are not going to find them.

As an aethetician it’s important that you can distinguish the difference between a client who is systemically well, but is coming to you for toxins or fillers to look nice, and someone who is a patient with a medical problems affecting one of the systems in the body—and look passed the obvious visible effects on the surface. Everyone with veins, even telangiectasia, has got a systemic problem that is affecting their circulatory system on the venous side and almost always have a lot more going on than can be seen on the surface. If you treat them like a client with a cosmetic problem and only treat what you can see, as you do with most aesthetics patients, you will get it very wrong.

Taking precautions Thorough clinical assessment is vital. All aesthetic practices use a visual assessment. In leg vein practice, if you do that, you will miss almost all of the pathology. You must have venous duplex ultra-

sound and someone who is trained to use it for veins. The success or failure in your aesthetics practice is usually determined on whether your patient is happy or not. However for a leg vein practice, you have to use various quality assurances and to make sure you are not causing complications that can be serious or even dangerous. In addition to checking the patient is happy, you should check that the VCSS has improved, that there is no problem that is going to make the patient unhappy at a later date (such as early recurrence) and you have to make sure there’s no deep vein thrombosis as this can be life changing. If you are treating telangiectasia or sclerotherapy, you must have out of hours cover and be able to diagnose and treat deep vein thrombosis and thrombophlebitis when you cause it, which can complicate any sclerotherapy treatment.

If you want to treat telangiectasia, I advise getting a vascular service in your clinic or to form a link with a local vascular service. If you want to be a varicose vein centre, now you don’t have an option and you must become a vascular service with all the services and regulations that are required to do so. Now that NICE has published the varicose veins guidelines, you could wind up in serious trouble if you treat leg varicose veins and get any problems, and you haven’t followed the published guidelines.

Remember, varicose veins patients have a systemic circulatory disorder and you must not treat telangiectasia or varicose veins if you don’t understand venous reflux.

I’ve produced a little book which explains venous reflux in simple terms, and it is now recommended reading for medical students and junior doctors in teaching hospitals in a couple of countries.

You need to have venous duplex ultrasound and a proper SVT trained vascular technologist working with a doctor who can interpret it. Hence it is essential to have the required technologies and team, keep up with the regulations and law and keep up with the latest research into veins and vein treatments.

Summary Remember venous conditions are systemic and cannot be treated visually. Mistakes are likely when treatment is based on a visual assessment alone. Practice is the key to success. Consider training as a phlebologist and joining The College of Phlebology so you can provide and excellent service, safely for your patients.

Professor Mark Whiteley performed the first endovenous operation in the UK in March 1999, founded The Whiteley Clinic in 2001 and is a visiting Professor to the University of Surrey. He has over 80 peer reviewed publications, has written the book for Understanding Venous Reflux and founded the College of Phlebology.

He founded the Leg Ulcer Charity and writes and lectures widely to try and get people interested in veins.

He’s won several national and international research prizes, including the National Prize for Veins at the Venous Forum of The royal society of Medicine for the last two years.

References 1. Pelvic Venous Reflux is a Major Contributory Cause of Recurrent Varicose Veins in More Than a Quarter of Women; Whiteley AM, Taylor DC, Dos Santos SJ, Whiteley MS. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2014:Vol 2(4);411–415) 2. Ovarian Vein Diameter Cannot Be Used as an Indicator of Ovarian Venous Reflux; Dos Santos SJ, Holdstock JM, Harrison CC, Lopez AJ, Whiteley MS. Eur J Vasc Endovasc Surg. 2014 Nov 22. [Epub ahead of print] 3. Understanding Venous Reflux—The Cause of Varicose Veins and Venous Leg Ulcers. Mark S Whiteley. ISBN: 978-1908586001 Links NICE CG168 for Varicose Veins: https://www.nice.org.uk/guidance/cg168/ The College of Phlebology: www.collegeofphlebology.com The Leg Ulcer Charity: www.legulcercharity.org

34 INDUSTRY I body language

Regulation KELLY HARDING discusses the after-effects of deregulation for laser and IPL devices, and the importance of education

I

n February 2008, The Department of Health made the surprising announcement that, following the abolition of The Healthcare Commission (HCC), and the introduction of its replacement, The Care Quality Commission (CQC), all non-healthcare related use of lasers and intense pulsed light devices were to be deregulated.

The common treatments that were to “fall out” of regulation were hair removal, vascular and pigment treatments and skin rejuvenation.

The only laser service to remain regulated, was laser lipolysis, which must be carried out by a plastic surgeon.

Initial consequences The deregulation came into force on October 1st 2010, sparking a complete mix of opinion within the medical and nonmedical aesthetic industry. In place of this regulation, local authorities would issue “special treatment licences” to try to keep some control over who could use lasers and IPL. When the decision to deregulate was confirmed, I was running a successful aesthetic practice that was registered with the CQC, and had previously been registered with the HCC. I was one of the many practitioners and clinic owners that had jumped through the hoops to gain this certification, which was not only an accomplishment for me, but served as a comforting reassurance to my patients, who could see that a widely recognised organisation, had approved the clinic as a safe environment for these treatments.

As a fiercely ethical practitioner, I was exceptionally worried that this decision would not only cheapen this fantastic industry, but also put many misinformed patients at risk.

During the months and years following the deregulation, I noticed a sharp increase in the amount of clinics opening using unknown equipment, and treating conditions that they had no background qualifications to treat. This resulted in

an increase of patients coming to my own clinic with adverse events caused elsewhere, after having treatments they were not suitable for, or were not properly informed about.

The current situation The dust has now settled, and local authorities are much more strict in checking suitability of practitioners before issuing them with a special treatment licence.

The geographical confines of the areas that these local authorities govern has also increased, protecting a larger area of the UK, and not just London.

The positive side to the deregulation, has been an increased level of care from the reputable laser manufacturers. In my current role of clinical department manager for Cynosure UK, a large part of my time is taken up supporting practitioners who carry out aesthetic treatments. I never assume that just because someone has the funds to purchase a laser, that they should be using that laser to treat conditions that they are not familiar with.

Education If a customer comes to us and wants to get into the field of aesthetics, I help guide and support them through the relevant BTEC courses, to ensure that they are working safely and effectively, and within the guidelines of their mal practice insurance. The customer then undergoes several sessions of individually tailored training that focuses on specific aspects of laser treatments, the science behind these treatments, and how to safely get the most effective results for their patients, using an ethical approach.

Only after that practitioner has satisfied all of the science, safety and practical aspects to training are they able to freely treat patients unsupervised.

I also ensure that my knowledge of this rapidly evolving industry is kept up to date, by attending conferences to further my skills, and be able to offer the very latest information to our customers.

I recently attended the American

Society of Laser Medicine and Surgery (ASLMS) conference in Florida, which is by far one of the biggest meetings in the industry. Surprisingly though, I was one of only a few attendees from UK-based laser manufacturers.

This event is educationally focused, and is filled with the industries very best dermatologists and surgeons. The conference showcases over 250 presentations, on the subject of laser treatment and opened my mind to new and evolving techniques that will ultimately benefit the customers that I am training or supporting. The ongoing support and commitment to education excites and motivates practitioners into striving to be the best at what they do.

Ethos My ethos has always been to do the very best for my customers, whether they are patients, or future practitioners. It is difficult to remain true to that ethos when you cross over to the manufacturing side of the industry, which is often a sales hungry environment that is not aware or sensitive to the needs of the practitioner’s education, or the often overwhelming process of starting up a new business.

I am privileged to work for a company which shares this very same ethos.

The customers’ needs come first, and we work together to provide support through big changes like deregulation, new clinic start-ups and investment in new technology. A large amount of time is invested to ensure that every laser treatment—from hair removal to laser lipolysis—is carried out with care, with an innovative approach, and with their patients best interests in mind.

Kelly Harding is the clinical department manager, for Cynosure UK. After completing studies in anatomy and physiology, she completed several qualifications in the use of aesthetic lasers, including the nationally recognised BTEC in laser and light. She has worked in many high profile medical aesthetic clinics in London’s Harley street, as well as running a successful practice for six years.

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body language I PANEL 37

Injection technique MR ASH LABIB, DR ALEXANDER RIVKIN AND MS LESLIE FLETCHER draw on their wealth of experience to offer advice on optimum delivery of cosmetic injectables

Q: Can, you give your top tips for safe and effective injections?

Ms Leslie Fletcher: I’m a firm believer in a moving needle. If I’m ever stationary, I always aspirate, and when I aspirate, I retract and I count to five. I’ve seen a flashback that came delayed a couple of times with Voluma, and I was glad I waited. There was nothing and then all of a sudden there was something.

So I aspirate, hold for five seconds and then inject, if I’m bolusing.

Other than that, I don’t aspirate when I’m retrograde threading.

Mr Ash Labib: I know that some people wonder whether aspiration is a good thing to do. I aspirate all the time, I inject very slowly. I check any skin changes or blanching, and I deal with it swiftly.

Dr Alexander Rivkin: I agree, my needle is always moving and I

inject slowly and softly, however, I do not generally aspirate. I do not think that you can accurately say that the needle is in the same place when you are pulling back as it is when you are pushing filler through it. Especially with viscous fillers. I don’t inject boluses very much, I usually inject in vertical columns and that’s generally given me very good results.

Q: Considering cannulas versus needles, why and where do you use them?

Dr Alexander Rivkin: I don’t use a lot of cannulas, I have to admit. I mostly use a lot of needles. With my injection technique for the nose, I really focus on precision by injecting tiny bits of filler into lots of little spots on the nose. But for the rest of the face, I have a technique where I insert the needle

perpendicular to the skin, and raise columns of filler by injecting as I withdraw the needle. I find that to be most efficient in terms of filler use for augmentation, and I find I’m doing multiple puncture sites and so I’m using needles mostly.

Mr Ash Labib: I use both.

Though specifically I use cannulas for tear trough treatment, to build cheek hollowing and carotid area hollowing, and lately for the marionettes.

We used to use a very small amount of injection left in the syringe when treating marionette

66

Some people wonder whether aspiration is a good thing to do 99

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body language I PANEL 39

lines. It’s an area where you have to treat it very respectfully. I put on an entry point of the cannula, and I fan out and I fill the whole area, with maybe half a ml of whatever I use. I treat it with respect, and that’s the area where I use a cannula quite a lot.

Ms Leslie Fletcher: I’m more of a needle user than a cannula user, but in the tear trough area, I feel it’s much safer to use the cannula and so I do use it in the tear trough area, or any area that doesn’t need additional stimulation—so sometimes in the temples, I’ll use the cannula.

Q: Moving on to pan facial injection techniques, do you work superior, inferior, or the other way up? Lateral medial or mediolateral?

Ms Leslie Fletcher: I work superior to inferior, I feel that you can get a lift on the jaw line, once you lift up the superior lateral part of the face, it can actually pull up the jowls, and even the neck, due to the fact that it’s all one piece of fabric. I personally work lateral to medial as well, for the same rationale.

Mr Ash Labib: I work top to bottom, always. Don’t get into the trap of somebody saying to you, “I don’t like my jowl lines”, and you go and put a heavy one syringe of Voluma with that, dealing with the top part of the face. That is adding

66

gravity and it will cause problems.

Top to bottom, temple hollows, cheekbones, mid face and then lower face.

Q: Can you give your opinion on giving moulding massage post treatment?

Dr Alexander Rivkin: Sure, I generally do that. I find that the fillers we have available mould nicely, and it’s a great way to make sure that your results are as natural as possible, so I do that quite often.

Mr Ash Labib: We are in the habit of moulding and massaging and pressing on products, and trying to make it disappear, and then you end up using more products.

When I do the eight-point face lift, I put certain injections in certain points, and I can see a little bit of a blip, and I want to keep it there. It’s almost like erecting a tent. Don’t keep pushing and massaging too much, because you lose the product. It will absorb water, it’s hydrophilic and in two week’s time, it will look even better. So, don’t worry about a little bit of a bumpiness, because that is desirable to lift the skin up.

Ms Leslie Fletcher: I don’t do a lot of massage. I think part of my technique is injecting in multiple vectors at multiple depths, so with massage you almost lose some of that lift, by flattening out the vectors. Having said that, I never want

I work top to bottom always— temple hollows, cheekbones, mid-face and then lower face 99

to send a patient out concerned, so I will tap or hold in mould, as opposed to pushing it through, just to soften the island, so that it’s not quite as aggressive for the patient, but I know within a couple of days, it will integrate into the tissue just fine.

Q: Do you subcise when you do injections? Do you open up the fourth ligaments with your cannulas, perhaps?

Mr Ash Labib: Yes, with cannulas in certain areas, you can. I think if you are to build a nasal dorsum in maybe an Asian nose, you can use Voluma. I’m very conscious of using Voluma in the tip. I think the tip is a very confined area and Voluma can be quite thick and quite compressive on vessels. This is me. I think safer to go something like Juvederm Three or maybe Juvederm Volift.

Q: How do you correct a rotated tip of the nose?

Mr Ash Labib: We inject a small amount in the dome of the tip, between the cartilages, and that will add a bit of rotation, and also by opening the angle between the nose and the lip, that will add further rotation. To correct an up tip you use your vision, it’s like sculpturing, you are actually filling a defect, either on the lateral side of the nose.

Q: How do you correct a deviated tip laterally?

Mr Ash Labib: You can compensate for the bulge on the one side by injecting slowly to compensate for that and make it look regular and

I think part of my technique is injecting in multiple vectors at multiple depths

40 PANEL I body language

cartilage, to stop the dilator muscle from working. I work slowly and try to avoid multiple injections, because that will create more chance of bleeding and also necrosis, if that’s something you’re trying to avoid.

MR ASH LABIB

MR ASH LABIB

Q: Have you ever used filler to narrow the alar?

Mr Ash Labib: I did that a few times, but what I want to do as well, functionally, if you have an alar collapse, when you breathe I inject the dome of the inside of the nose to support that, and that will stop that influx of the nasal alar, to help breathing. It’s a functional reason to do the fillers in that area.

Before and after correction of the nose

symmetrical.

Dr Alexander Rivkin: Because, a deviation is due to an imbalance in terms of volume. On the one side, there is more volume than the other side, so that makes it look deviated. You add to the contralateral side, to make that side more symmetric with its opposite and it generally works out quite nicely. I like to go directly perpendicular to the skin, but I think it’s whatever you’re comfortable with. I think it’s important to actually put the material where you want it, and you know that the most lift you’re going to get is if you’re injecting the actual tip. I say this to contrast with the technique of lifting the tip by injecting the columnella. I go deep enough to get to the perichondrium and inject softly and slowly for safety.

Q: When you define the Aline, do you do that just by rotating, or do you actually inject?

Dr Alexander Rivkin: I actually inject, but very, very carefully, because that’s, as we saw on that case, that’s the point where you can really run into a lot of trouble. The blood supply to the skin in that area is not that strong, and so that’s where you can really get some vessel compression and run into problems, so yes, but I approach it gingerly.

Q: Do you do A Line dilation, do you treat that area, the flare with toxin?

Dr Alexander Rivkin: Yes. Mr Ash Labib: Yes, I do, I just inject a very, very small amount— one unit each side, in one spot, very superficially around the alar

Q: What products are best for longevity?

Mr Ash Labib: I think longevity is very variable, and you can’t set an exact length of time. We say up to two years, but sometimes they come after nine, 12 months and you start seeing the hump again, depends on the metabolic rate, and how quickly they break down the products. I don’t believe that there’s one product that will last longer. We all use hyaluronic acid, and the body will break it down gently over the next 12 to 18 months normally. That’s with Juvederm Three.

Dr Alexander Rivkin: With Radiesse, on average, I see nine, ten months but a minority of people come back six months later and the filler has faded significantly.

One of the reasons I like Voluma, is that I get a lot more duration out of it, and that’s why I use it so much.

The duration of Voluma is also variable, so I give them an average, and I tell them that everyone’s body is different.

Hyaluronidase is useful no matter what kind of filler you’re using.

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body language I EQUIPMENT 43

Paradoxical hair growth DR GODFREY TOWN enlightens us on paradoxical hair growth, the evolution of hair removal home use devices and their impact on the professional marketplace

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aradoxical hair growth is the stimulation of hair growth in areas on, or adjacent to areas treated with hair removing laser, or intense pulsed light (IPL) devices. In a recent study with Peter Bjerring, I examined published reports of par-

adoxical hair growth, and reviewed the published scientific studies to identify any link between low fluence and the stimulation of paradoxical hair growth.

After entering the market in 2004, home use devices are now well established. One of the first—

a laser and an IPL which was for use in the home—came from the British company, Dezac Group.

This has progressed to IPLs and laser devices being available in Boots’ main stores, department stores and online. For hair removal, the majority in the UK are IPLs, although

44 EQUIPMENT I body language

there is one very well known laser device apart from the Dezac product, which is the Tria Beauty laser.

Technicalities People always assume that home use devices are low fluence. In fact, if you look at the parameters for the Tria Beauty laser, you’ll see that the range of fluences claimed by the manufacturer is 6-24 joules per sq. cm. Comparing that to the Lumenis Light Sheer ET professional laser, which was a very popular diode laser for several years—the range there is 10-40 Joules per sq. cm. When I compared the Asclepion MeDioStar with the Lightsheer ET in a study a few years ago, we were using fluences in our trials of 23 Joules per sq cm—a typical user fluence for a professional diode and what’s now achievable even with a home use device.

Ron Wheeland has published two prospective studies and produced very good data. He even managed to treat Fitzpatrick skin types five and six, and of course found that, he observed very strong reactions and a lot of hyperpigmentation. As a consequence of this research, he was able to say which consumers shouldn’t be allowed to treat themselves with these home use laser devices. Even in the absence of blinded controlled studies, we can conclude that the Tria Beauty home use device is clinically effective.

Research into paradoxical hair growth Paradoxical hair growth has been attributed to low fluence at or near the periphery of the treatment area.

In my research with Peter Bjerring, we first examined established scientific knowledge about the absorption and the scattering of light in tissue to test the theory. Then we examined scientific studies to see whether low fluence was the most probable cause of unwanted hair growth. Beginning with Igarashi’s very well-known diagram describing forward scattering of light in turbid tissue, the predominant direction of light going into tissue is forward scattering, and the majority of useful light does not travel laterally in tissue very far outside the contact area with the tissue.

Some of the work in my PhD examined distribution of light in mathematical simulations and this also confirmed that even when you apply very high concentrations of photons of light in the tissue, the majority of the light is forward scattering. Very little light moves laterally beyond 2 mm from the edge of the treatment area that is likely to have a biological impact, including stimulation of hair growth.

However, it should be noted that perilesional erythema and oedema is very commonly seen well outside of the 2 mm periphery of the treatment area, and it seems to be one of those cases where the answer is probably staring us in the face, but we’re not really looking at

the most logical cause.

I performed some measurements on IPLs which all have a very large divergence angle of about 135 degrees. If you calculate the exponential loss of stray light energy from these devices, even using a high fluence IPL with a large spot size of 4.5 sq. cm., the energy at 5 cm distance away from that light source would be of the order of 0.5 mJ/cm2. One eminent researcher in the area of

66

It is important to look at all causes for stimulation of hair regrowth 99

body language I EQUIPMENT 45

After light-based therapy hair regrowth could be down to a number of factors, potentially unrelated to the treatment itself

low level laser therapy pointed out to me that you’d need at least 80,000 times more energy than that to stimulate hair growth—so it’s a very, very low figure, and unlikely to be a cause of stimulation for hair growth 5 cm away.

I don’t deny that paradoxical hair growth exists. I’m just questioning whether or not it’s most likely cause is by low fluence light energy rather than some other origin.

Examining other causes It’s important to take time to look at all causes for stimulation of regrowth of hair after light-based therapy, including other factors, completely unrelated to the treatment itself. These include seasonal

variation in hair growth patterns, increases of hair growth with age, paradoxical effect of androgens, endocrine disorders, idiopathic hirsutism, stress, medications, use of anabolic steroids, food supplements, use of Minoxidil and exposure to UV light. All of these things can cause hair growth without it being related to the treatment by laser or IPL and most importantly, in the literature there are many references to acquired hypertrichosis associated with post-inflammatory traumatic and burn injury reactions. So we know that there are lots of reasons why we should be thinking about post-inflammatory reaction as a likely primary cause of this hair growth.

Evidence In our literature review we looked at the Thaysen-Petersen paper from 2011, where he found one controlled and six uncontrolled trials on home use devices looking at three different IPL sources and the diode laser. We also undertook a further search in 2014, and we performed a retrospective analysis of our own clinical study files—to try and identify published studies reporting paradoxical hair growth following professional and at-home treatments. We found no published studies documenting paradoxical hair growth from home based light based treatments. That doesn’t mean it doesn’t happen, but there’s nothing published so far.

We also know that there are recent studies showing that very low laser fluences are effective in hair reduction. I know that the published papers on the use of in motion technique using the diode laser talks about an average fluence in the order of 5-7 Joules per sq cm.

That’s a fairly low fluence and we can’t say that those devices don’t work. It’s not logical to think those sort of fluences are going to be suitable for stimulating hair growth because they do produce stable hair growth reduction.

The Moreno-Arias paper, reported on paradoxical hair growth in five out of 49 females with polycystic ovarian syndrome following IPL photoepilation and skin rejuvenation treatment, and mentioned being about 5 cm away because he’d only treated the sideburns and the chin area of that patient, so there is classic paradoxical hair growth. I think we’d all agree that’s what it is. What’s causing it is the big question.

I don’t have the answer, but I’m trying to exclude unfounded excuses that could be made by professionals looking for reasons for advising clients not to buy one of those “cheap toys” from Boots, because “they don’t work and they can cause paradoxical hair growth”—which is what started this study in the first place. Although, I believe home use devices are more of an adjunctive or companion treatment, rather than any threat to professional treatments.

46 EQUIPMENT I body language

classic paradoxical hair growth.

These authors very clearly said that there was a significant relationship between the hair induction that they saw and single episodes of severe erythema, hyperpigmentation or crusting. Once again, that was the main conclusion about the possibility of the cause of this paradoxical hair growth.

Barcaui had similar comments about his studies. He said suboptimal fluence was an unlikely cause, while heat-induced inflammatory response to treatment may have played a role. Willey et al. had some interesting findings. They observed this paradoxical hair growth problem and made some suggestions about controlling it, including extensive use of cooling gel packs all around the treatment area. It may look rather strange for hair removal in an aesthetic clinic, but he did find that by chilling the surrounding tissue it prevented paradoxical hair growth from occurring. This is clearly preventing the erythema response, so I think probably we’re going down the same track with those suggestions.

It’s unlikely that hair growth several centimetres or more way from the irradiated skin surface can be attributed to scattered or stray optical radiation, the science doesn’t hold up for that. The incidence of true paradoxical hair growth is probably limited to darkIn 2002 Vlachos & Kontoes also found terminal hair growth several months after therapy. In these cases the cause of hair transformation to terminal hair could be explained by the inflammatory response. The paper makes an obvious point—it’s possible that inflammatory response would be a good reason for expecting that to happen.

In 2005, Kontoes also performed a retrospective study, looking back at 750 subjects out of a total of 4,374 treatments with an Alexandrite laser. All of these were quite dark-skinned type— Fitzpatrick three to four. Hair induction was recorded in 4% of the cases, and this hair regrowth, 3-24 months later, was noted after at least three treatments.

Several of the reviewed studies were retrospective, asking clients about hair growth or examining photographs after the event, then deciding afterwards whether they’re seeing paradoxical hair growth and then trying to extrapolate backwards whether they could have been caused by low fluence.

When we’re considering possible causes or paradoxical hair growth following laer or IPL treatment, I also think it’s very difficult when you’re treating people with PCOS. Hormones change and even if they had no treatment at all, they might have exhibited this kind of hair growth without having any laser or IPL treatment whatsoever.

Marayiannis et al. basically came up with the same thing—

66 It is very difficult when you’re treating patients with PCOS— hormones change 99 er skin photo types of specific ethnic origin. Typically it’s found in females of Middle Eastern or South Asian extract, clinically obese with evidence of underlying hormonal disorders and middle-aged PCOS, and there may be other androgen hormone irregularities, including, of course inflammatory sequelae.

Causes of stimulated hair growth In our opinion, the observed per-

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48 EQUIPMENT I body language

66 Several devices that didn’t initially get FDA clearance in the States for use on the face have subsequently been cleared for sale for treatment below the nose 99 ilesional inflammatory response is the most likely cause of hair growth stimulation. Certainly limited terminal hair growth reoccurring on the same body area treated previously with low fluence can hardly be seen at the same time as both the cause of subsequent extended hair growth delay and terminal hair regrowth. The two things just don’t hang together. And paradoxical hair growth does remain a rarely reported event.

Home use devices Launched back in 2004, there are probably two or three million of these devices now in use worldwide. Europe is behind the USA and behind Asia in the use of these products, growing at about 16-18% per annum, whereas Asia is growing at over 30% per annum.

These devices have been developed with a whole range of safety features built into them: safety switches, capacitance sensors, low initial settings; and safe parameters for skin types are also determined by skin tone sensors. When placed on the surface of the skin, they read the melanin content in the skin in the area to be treated before you can fire the device. So not only can you not fire the device in free space, it will also evaluate the skin type for safe use.

It won’t work on a small body because of capacitance sensing, so the manufacturers have gone a long way to try and make these devices fool proof and child proof, and they’ve done that for a very simple reason—self-protection—they don’t want to be sued. So far there has only been one letter to the editor of the JADV Journal which has reported a single case of hyper pigmentation from somebody using one of these devices at home. There have been no other cases reported in the literature of adverse inci-

dents, which is pretty incredible for several million devices sold already.

Safety features Several devices that didn’t initially get their FDA clearance in the States for use on the face have subsequently been cleared for sale for treatment below the nose. Outside of the USA they’ve been used on the face as well as the body since they were first launched.

Because of the safety features built into these devices, safety glasses are unnecessary—because you can’t fire them in free space, your eyes can’t be exposed to hazardous laser or IPL energy.

In 2014 there was a new edition of the IEC 60825 laser classification standard, which introduced the idea of a Class 1C laser—whereby you can embed a laser of higher class in a device whilst making that device effectively a Class 1 laser. Use of that standard is not possible however, unless there’s a corresponding vertical standard i.e. a product standard, to go with it. The first product standard recently passed into the final draft international standard (FDIS) stage. The international standard will be published

by December 2015 and we shall see publication of that first standard in Europe by February 2016.

This product standard contains the test methodology required that the manufacturers will have to follow.

The ones I’ve mentioned have all been embodied in that standard so providing it’s adopted worldwide, hopefully we will not see any unsafe devices being launched.

From the manufacturers’ point of view they don’t want to “rock the boat” with the profession. They see these devices as a huge opportunity for partner products with existing treatments that professionals are carrying out e.g in hair reduction, after a series of six or eight treat-

ments when there are a few rogue hairs that grow back and the patient returns, the availability of a device like this for top-up treatments at the end of their course means that they could do that treatment themselves.

Dr Godfrey Town is a registered clinical technologist and RPA2000 certificated laser protection adviser specialising in the comparative measurement of laser and IPL devices.

References 1. Wheeland RG, Consumer use of a batterypowered, hand-held, portable diode laser (810 nm) for hair removal: A safety, efficacy and ease-of-use study. Laser Surg Med. 2007; 39:476-493.

2. Wheeland RG, Permanent Hair Reduction With a Home-Use Diode Laser: Safety and Effectiveness 1 Year After Eight Treatments. Laser Surg Med. 2012; 44:550-557.

3. Thaysen-Petersen D, Bjerring P, Dierickx, Nash JF, Town G, Haedersdal M. A systematic review of light-based home-use devices for hair removal and considerations on human safety. J Eur Acad Dermatol Venereo.l 2012; 26(7):799-811.

4. Royo J, Urdiales F, Moreno J, Al-Zarouni M, Cornejo P, Trelles MA. Six-month follow-up multicenter prospective study of 368 patients, phototypes III to V, on epilation efficacy using an 810-nm diode laser at low fluence. Lasers Med Sci. 2011; 26:247-255.

5. Halachmi S, Lapidoth S. Low-fluence vs. standard fluence hair removal: A contralateral control non-inferiority study. Cosmet Laser Ther. 2012; 14:2-6.

6. Moreno-Arias GA, Castel-Branco C, Ferrando J. Paradoxical Effect after IPL Photoepilation. Dermatol Surg 2002; 28:1013-1016.

7. Vlachos SP, Kontoes PP. Development of terminal hair following skin lesion treatments with an intense pulsed light source. Aesthetic Plast Surg 2002 Jul-Aug; 26(4):303-307.

8. Kontoes P, Vlachos S, Konstantinos M, Anastasia L, Myrto. Hair induction after laser-assisted hair removal and its treatment. J Am Acad Dermatol 2006; 54:(1):64-67.

9. Marayiannis KB, Vlachos SP, Savva MP, Kontoes PP. Efficacy of long- and short pulse alexandrite lasers compared with an intense pulsed light source for epilation: a study on 532 sites in 389 patients. J Cosmetic & Laser Ther 2003; 5:140-145.

10. Barcaui CB. Localized Hypertrichosis after Intense Pulsed Light Treatment for Tattoo Removal.

Dermatol Surg 2007; 33:621-622.

11. Willey A, Torrontegui J, Azpiazu J, Landa N. Hair Stimulation Following Laser and Intense Pulsed Light Photo-Epilation: Review of 543 Cases and Ways to Manage It. Lasers Surg Med 2007; 39:297301.

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 Hydroloc Crème Hydroloc Crème from DMK is an improved version of their Hydrophilic Crème, now delivered in an air pump dispenser. It is a nourishing fomulation, designed to lock moisture in the skin and prevent trans-epidermal water loss. Ideal for tired and inflamed skin.

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Non-Surgical Rhinoplasty training course with ENT surgeon Mr Ash Labib FRCS DLO MBCHB

Advanced Fillers sessions breakdown: CH = Cheeks/mid-face F = Forehead LF = Lower face TT = Tear troughs

body language I EQUIPMENT 53

Vulvo-vaginal rejuvenation DR KANNAN ATHREYA performs radiofrequency assisted labial re-modelling and fractional CO2 vaginal ablation. He explains the management of hormonally-dependent vaginal atrophy and vaginal relaxation syndrome, which offer therapeutic as well as aesthetic benefits

I

began work in this area when I invested in the Exilis Elite from BTL, as I had seen the great results achieved with fat reduction and skin tightening. I was not aware at the time that this versatile little machine also reliably used its precise RF delivery to remodel the labia. From the very first time I started treating women, the improvement was remarkable—not only the aesthetic improvement, but also in the way patients felt afterwards-noticeably tighter. The introital tightening that one can achieve dramatically improved sexual enjoyment for both partners.

Very soon I began to get many more enquiries, purely by word of mouth, which is always the best indicator of satisfaction.

At the same time, I began to look into lasers, primarily for dermatological management in which I have an interest. It was whilst I was researching this I was made aware of the use of fractional ablation of the vagina using a CO2 laser—The MonaLisa Touch—for the treatment of post-menopausal vulvo-vaginal atrophy and vaginal relaxation syndrome. I spent some time in Italy training and watching the treatment being performed routinely by the research team led

by Professor Stefano Salvatore.

There were women in the third and fourth year of follow up treatments who reported a return to pre-menopausal vaginal function, giving them a new lease of life. The treatment to them seemed as routine as a smear test, and so it convinced me to adopt the procedure to my practice.

The results again have been quite remarkable. Once patients overcome the initial fear of treatment with a laser device, the first

thing they’ll notice is that it’s painless. No anesthesia is involved, and no downtime—they get the treatment and can go home straight away. Three treatments over three to four months is optimum, and though improvement begins almost after the first treatment, it is after the second people really do notice the difference.

The wonderful thing is how suddenly the rejuvenation occurs, such as the return of a natural physiological discharge.

Urinary incontinence tends to be improved as well. It can be emotional for women, because something they’d feared talking about—atrophic symptoms, incontinence, things we don’t like to mention in this country—have improved along with their sex life, and thus confidence is improved. Confidence is sexy, and I think if we can achieve that for ladies, it’s a good thing.

Q: Do you have any experience with injection of carboxytherapy to the labia minora or majora?

I haven’t, but I have read about it over recent months. For me, I achieve such good results with the Exilis and the Mona Lisa Touch,that I’m not too sure how carboxytherapy would improve it. Having said that, I understand the philosophy behind it, and the promising rejuvenation achievable with the vasodilatation and revascularisation of atrophied tissue. I can see a place for the synergistic use of these therapies.

Q: What are your treatment protocols with Exilis, a mono polar RF device?

You would treat each labial area,

majora and minora, for six to eight minutes, about half an hour to 45 minutes in total. I also treat the perineal area, to encourage rejuvenation and plumping of supporting structures which would help tighten the vagina. The treatment is pretty much painless- just the heat sensation. The aim is to maintain a surface temperature of 42-44oC to allow for the collagen remodeling.

In terms of improvement, even as they get off the couch, they will immediately notice a tightening.

The treatment is known as protégé intima—in terms of using radiofrequency in this area, it’s an established approach to management. We know what heat does to collagen, and therefore know how we can manipulate the effect of RF on the tissues to get the required result.

Q: Which laser do you use?

I use the DEKA Smartxide2 DOT/RF CO2, and distributed in the UK by 10 Laser limited. The machine is powerful and fast, and

Please note, this feature contains explicit images overleaf that some readers may find sensitive

The Mona Lisa Touch from DEKA

54 EQUIPMENT I body language

employs a specific pulse for safe and effective treatment of the vulvo-vaginal area. My treatment parameters using the vaginal probe is 40w Power, DP (DEKA Pulse) modality, pulse duration of 1000µs, and a dot spacing of 1000µm It’s become a recognised treatment now, and I believe from the results that I’ve seen with my patients, it’s going to be gradually accepted as a valid alternative to hormonal management of postmenopausal atrophy. Certainly, even though we know that HRT therapy does work, it’s not without its controversy. Both doctors and patients are nervous of treatmentthere is uncertainty as to how long to give treatment for, although I believe it is quite safe if we choose the right type of hormone and mode of delivery. Certainly when it comes to management of atrophy for breast cancer survivors, where for most people, estrogen may be contraindicated, it is a very good, viable alternative which works well, is effective and safe.

DR KANNAN ATHREYA

Intima results— pre-treatment, post second treatment and post fourth treatment

Q: What kind of healthcare professional should be doing this type of treatment?

I do not see any reason why therapists and nurses as well as doctors could not technically perform these treatments with the right training.

Whilst I am aware that the Protégé Intima treatment is performed by all those practitioners currently I believe that it is only doctors that have been trained to perform the Mona Lisa Touch. Even within that group I only know of gynecologist’s and GP’s. Given the novel nature of the procedure in the UK and the need to observe explicit safety protocols with laser use, I feel that

doctors should routinely be involved with the laser treatments at the moment.

Q: How much does the treatment cost the patient?

For the radiofrequency labial reduction, I tend to charge about £300 an hour. It takes roughly four treatments, which is not too expensive, when you consider labiaplasty can be in the thousands. For the fractionated laser therapy, I’ll charge £1,000 per treatment, and typically it’s three treatments over three months. Both treatments do require a yearly top up.

Q: Is it just the anterior wall and the lateral walls that you treat, or do you treat the posterior wall of the vagina as well?

It’s a circumferential treatment of the vaginal canal.

Q: How do you prevent damage to the urethral opening and to the more superficial structures?

The probe itself is intra-vaginal, so you’re not near the urethra.

Secondly, the cervix is protected because the laser fires through the probe, reflects off a mirrored end piece, and then radiates in 360 degree around the vaginal mucosa.

There is no laser energy that is incident on the cervix, also the DP (DEKA Pulse) has been especially designed to be an ablative pulse but with a controlled thermal diffusion, it converts in a much safe and efficient laser therapy.

Q: Are there contraindications to your treatment—prolapse for example?

Of course. The use of RF would of course be contra-indicated for those to whom passage of current may be dangerous, eg patients with pacemakers or metal implants near the area of treatment.

For the fractional laser ablation, prolapse not greater than grade one is suitable for treatment, but not grade two or three. Additionally to this, I ensure that smears are up to date, and there are no symptoms or signs of any possible un-diagnosed neoplasia or infection, and would offer antiviral prophylaxis prior to treatment to those with known HSV infection. I always offer my patients the opportunity to be seen and assessed by a gynecologist should they wish, to ensure that they do indeed have atrophy, and have any other questions answered before I commence my treatment of them. Going forwards, I feel confident that this step may not be necessary as it should be well within the expertise of a GP. Q: How much success have you had with incontinence?

Patients do report an improvement with incontinence with the Mona Lisa Touch. Incontinence typically has a combination of neurogenic, ligament and muscular etiologies.

When you go ahead and treat this area, you’re going to improve the structure and have an effect of supporting the urethra as it emerges from the bladder. There is an improvement, but I wouldn’t say it’s going to improve severe stress incontinence. However, having recently trained in the O-Shot procedure, using platelet rich plasma in the anterior vaginal wall does seem to dramatically improve stress incontinence, and I am extremely excited to commence the first clinical experience of using the O-Shot and Mona Lisa Touch in combination in the UK to evaluate the sustained response to this very problem. The future is very exciting for nonsurgical aesthetic and therapeutic gynecology.

Dr Athreya has worked as an NHS GP for over 18 years, but now practises independently from his private clinic in Brentwood, Essex

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after 4 treatments

body shaping before

after 4 treatments

volume reduction before

after 2 treatments

before

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body language I RADIOFREQUENCY 57

Monopolar radiofrequency MS MARIE DUCKETT explains how she uses the Exilis Elite to treat fat, lax skin and cellulite

T

he Exilis Elite is a monopolar radio frequency machine which offers treatment of fat, of lax skin and of cellulite. It has little or no downtime—little because, similar to after a facial treatment, clients have difficulty applying makeup immediately because they’re red and hot.

How does it work?

It works very simply, by delivering heat without discomfort. We try and keep our patients somewhere between 8.5 and 9/10 on a comfort level. It seems to be the easiest way of establishing where they are on that score. The utilisation of the cooling tip gives a lot of flexibility when fat busting sufficient temperature is needed to bust fat cells. The constant monitoring of the temperature being achieved is very important for the treatment outcome. Clinically-proven neocollagenesis, tightens the skin and creates the contouring that we require. The treatment can be used on the face using the device’s small facial head and on the body – for example on the stomach, using the body head.

We found that the optimal number of treatments for the average under 50 for skin tightening and contouring is four. We will do six on someone over age 50. The device can be used for body con-

touring, or fat busting, using the large body head and using cooling to get to the right level to burn the fat away.

Ten degrees cooling is the coolest setting and this will penetrate down into the deep fat layers. With increases in the temperature you work more superficially, so at 25 degrees in much more superficial layers of fat.

With the cooling setting off, the treatment is to the dermis—so this is skin tightening as opposed to fat busting. The beauty of being able to switch between the two when treating patients is that very often, a reduction to fat content increases skin laxity in that area. So, a fat busting treatment can be immediately followed by a skin tightening treatment to make sure the skin is kept looking sufficiently taut.

There are two applicators: the body piece, which has an extremely useful inbuilt thermometer or temperature monitor. Your treatment opportunities lie between 40 degrees Celsius and 43.2, which is regarded as the mean temperature for the pain threshold. Below 40 degrees, apoptosis does not occur and nor does skin tightening. Maintaining a 40-degree temperature for at least five minutes is necessary—so to know what temperature your patient is at is really important.

The body piece is used pre-

IMPORTANCE OF HYDRATION From our experience, we’ve discovered the absolute importance of hydration. If the patient is not well-hydrated then they tolerate the heat far less. Our clinic has scales which monitor the water content of the patient, and if they are not hydrated, we refuse treatment because you’re wasting their money and our time. We always send out a reminder the day before treatment telling them drink at least a litre and a half to two litres of extra water, the day before the treatment, the day of the treatment and the day after treatment.

Before we did this we suspected that some patients were not always telling the truth about how much they had drunk. They would have a poor tolerance to the heat and we knew this would impact on their results.

dominantly for the larger area. The facial applicator doesn’t have a temperature monitor on it, so we now have a laser thermometer that we use. This has proved to be very interesting. You set up your machine to allow sufficient time to get the treatment area up to the optimum temperature. I now check the temperature with 5 minutes left on the clock. If they have not reached 40 degrees, I add more time in order to get the best results.

For the décolleté, we will often use the body piece for skin tightening because it’s a nice, large area, particularly large on some ladies. It gives it an ease of movement on a larger area.

Treatment areas Exilis works by remodelling collagen. In the simplest terms, the heat causes the unravelling of the collagen fibres. The body recognises this unravelled collagen and is stimulated to produce new col-

The Exilis Elite works by delivering heat without discomfort

58 RADIOFREQUENCY I body language

66 An absolute hate amongst many women is “fat back syndrome” and overhanging bra lines—we can create lovely results 99 At 12 weeks post-the fourth or sixth session, depending on how many that they have, is when optimum results are visible. However, one of the first things that patients notice is an improvement in the quality of their skin before they notice the improvement in the tightness and the tone and the firmness of their skin. The larger the area, the more sessions needed. So doubled up sessions may be needed to cover the required area.

An absolute hate amongst so many women is the “fat back syndrome” and the overhanging bra lines and we can create really lovely results here. This is closely followed by bingo wings, where even on somebody with a high degree of laxity there is a distinct improvement following the treatments.

It’s also possible to treat excessive fat in the male breast, and although it wasn’t originally thought that it would treat cellulite it’s now proving to be extremely useful in its treatment. In fact, it is now FDA approved for this treatment and it makes a lot of sense – Exilis tightens the skin and improves the tone. Young people respond better, because they produce better collagen and more collagen than people who are significantly older.

It’s a great treatment around the eyes. It’s a quick treatment—just make sure you ensure patients remove all their eye makeup. I tighten above the brow, across the brow and then under the eye, so it’s three passes backwards and forwards under and three passes backwards and forwards over.

Before and after— results with the Exilis Elite

lagen. The device promotes neocollagenesis and then remodels that collagen, in order to create good, strong, young collagen again and give clients back the skin firmness and tone that’s been lost.

The Evidence We have plenty of evidence to show that dermal remodelling and the neocollagenesis can make a significant difference. There is a thickening of the dermis, which is obvious and the evidence of the subcutaneous interstitial collagen, which is also improved greatly. The fat cell reduction is evident after just one

treatment, and following the fourth treatment that’s even more obvious.

Anywhere there’s skin, you can tighten skin and you can improve the skin.

Lower jaw and neck can be treated together as one treatment area, so that you get the pull between the two areas and you get that beautiful re-establishment of the jawline.

I treated one lady in her 60s who showed a distinct improved—you could actually start to see her jaw line and a reduction in her skin laxity and a great improvement in her neck. Very often they do double treatments in America rather than doing four single treatments—so one treatment and then a treatment immediately after. Our preference is to do a single treatment once a week.

Two-week intervals just makes it a lot longer before they get their final result, which is always a pity.

Summary Results with Exilis are dependent on two factors. One is the right choice of patient; if you feel you have a patient who is not going to be compliant and drink the amount of water that you want them to drink, then don’t even entertain it. You won’t get the results and you will just waste many hours of your time. Your own expertise is the other really crucial factor.

When you first start using this machine—or any machine—your first 20 patients, are probably going to be a big learning curve for you. The more competent you are and the greater the co-operation you insist on from your patient, the greater the likelihood that you will get the results that both you and your patient want.

Ms Marie Duckett is a Registered Nurse and has a wealth of experience in the area of medical aesthetics specialising in facial rejuvenation using dermal fillers and skin care. She currently runs a successful clinic in London’s Harley Street.

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The filler you’ll love 1. BEL-DOF-003 V2 Belotero® technology, June 2015. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI: 10.1159/000354384. 3. Aesthetics Awards Supplement, December 2014. Injectable product of the Year, pg 5.

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