Body Language Journal #80

april

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

Female intimate rejuvenation THE HISTORY, METHODS AND LATEST TRENDS IN FEMALE SEXUAL AESTHETICS

EYE BOOST An innovative new treatment for the tricky tear trough area

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body language I CONTENTS 3

24

46

contents 40

07 NEWS OBSERVATIONS Reports and comments

17 REPORT INDUSTRY NEWS Headlines and updates

18 CONFERENCE FACIAL AESTHETIC CONFERENCE AND EXHIBITION

Mrs Sabrina Shah-Desai shares her understanding of the tear trough and her innovative new treatment

46 DERMATOLOGY SKIN REJUVENATION Dr Zein Obagi discusses designing a treatment plan for optimal results

FACE 2016—the UK’s premier medical aesthetic conference returns to the heart of London this summer showcasing an expanded lecture programme, hands on training and FACE rewind

51 HAIR LOSS

24 SEXUAL AESTHETICS

58 PRODUCTS

FEMALE INTIMATE SURGERY

ON THE MARKET

Dr Evgenii Leshunov reviews the present literary data on the history, methods and trends in female intimate surgery

The latest medical aesthetic and anti-ageing products and services

35 TECHNIQUE PRIVATE PATHOLOGY Dr Alessandra Scilletta discusses carboxytherapy as an option for vulva-vaginal rejuvenation

40 INJECTABLES EYE BOOST

MEDICAL TREATMENT FOR HAIR LOSS Dr Paul Farrant discusses licensed and unlicensed products for the treatment of male and female pattern hair loss

61 NON-SURGICAL INJECTION LIPOLYSIS Although surgery remains the most effective way of fat reduction there is an increasing need for and success of non-surgical facial and body fat reduction treatments.

Mr Taimur Shoaib reports on his research and results.

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.

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.

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.

61 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 Simon Haroutunian 020 7514 5976 simon@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Dr Evgenii Leshunov, Dr Alessandra Scilletta, Mrs Sabrina Shah-Desai, Dr Zein Obagi, Dr Paul Farrant, Mr Taimur Shoaib 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 2016 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

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body language I NEWS 7

observations

SCIENTISTS MAKE SIGNIFICANT ANTI-AGEING BREAKTHROUGH Scientists at Newcastle University have identified that the activity of a key metabolic enzyme found in the batteries of human skin cells declines with age The discovery that the activity of mitochondrial complex II significantly decreases in older skin, brings experts a step closer to developing powerful anti-ageing treatments and cosmetic products which may be tailored to counteract the decline in the enzyme’s activity levels.

Findings may also lead to a greater understanding of how other organs in the body age, which could lead the way for drug developments in a number of age-related diseases, including cancer.

Mark Birch-Machin, Professor of Molecular Dermatology at Newcastle University, who led the pioneering study with Dr Amy Bowman from his research group said, “As our bodies age we see that the batteries in our cells run down, known as decreased bio-energy, and harmful free radicals increase.

“This process is easily seen in our skin as increased fine lines, wrinkles and sagging appears.

You know the story, or at least your mirror does first thing in the morning!

“Our study shows, for the first time, in human skin that with increasing age there is a specific decrease in the activity of a key metabolic enzyme found in the batteries of the skin cells.

“This enzyme is the hinge between the two important ways of mak-

ing energy in our cells and a decrease in its activity contributes to decreased bio-energy in ageing skin.

“Our research means that we now have a specific biomarker, or a target, for developing and screening anti-ageing treatments and cosmetic creams that may counter this decline in bio-energy.

“There is now a possibility of finding anti-ageing treatments which can be tailored to differently aged and differently pigmented skin, and with the additional possibility to address the ageing process elsewhere in our bodies.”

Complex II activity was measured in 27 donors, aged 6-72 years.

Samples were taken from a sun-protected area of skin to determine if there

was a difference in activity with increasing age.

Using cells from the skin’s dermis and epidermis activities of the key enzymes within mitochondria that are involved in producing the skin cell’s energy were measured.

Complex II activity was found to significantly decline with age, per unit of mitochondria, in the cells derived from the lower rather than the upper levels—an observation not previously reported for human skin.

The reason for this was cited as a reduction in the enzyme protein. This decrease was only observed in those cells that had stopped proliferating.

Dr Bowman, Research Associate at Newcastle University’s Institute of

Cellular Medicine, said: “Newcastle University is pioneering research into ageing as it has long been thought that mitochondria play an important role in the ageing process, however the exact role has remained unclear.

“Our work brings us one step closer to understanding how these vital cell structures may be contributing to human ageing, with the hope of eventually specifically targeting areas of the mitochondria in an attempt to counteract the signs of ageing.”

More research is required to fully understand the functional consequences in skin and other tissues, and to establish methods to assess anti-ageing strategies in human skin.

8 NEWS I body language

WOUND HEALING GENE IDENTIFIED Researchers at Ohio State University have pinpointed a human gene product that helps to regulate wound healing and may control internal post-surgery or post-injury scarring The discovery of Protein MG53—which helps the body repair injuries to the skin, heart, lungs, kidneys and other organs without causing scarring—could help heal open wounds, decrease post surgery recovery time and reduce the spread of infections.

“A massive scar on your skin may look bad, but imagine you have a heart attack and get a scar on your heart—that could be lethal,” says Jianjie Ma, a physiologist at Ohio

State and co-author of the presentation.

All animals carry this gene, he said, and it’s almost identical across all species.

MG53 repairs the cell and tissue damage that occurs during everyday living. Even simple every day activities like writing or walking may cause injuries to the body, but usually this is usually unproblematic because MG53 can make repairs before there’s any serious harm.

Experiments with genetically engineered MG53-deficient mice showed that mice lacking MG53 had difficulty recovering from injury, because of their compromised repair capacity and their heart function was reduced under stress conditions.

MG53 works in tandem with TGF Beta, a type of “cytokine” protein that also heals wounds, but creates healing so quickly that scarring occurs. Research shows that higher amount of TGF Beta in the bloodstream than MG53, creates easy scarring.

Ma’s goal is to develop a therapy that will inhibit TGF Beta and promote MG53, helping medical professionals to promote quick, scarless healing. His next step is to identify a small compound that can do this and eventually test whether it has the desired effect in human trials.

PROTEIN MAKES US FEEL FULL New study confirms the evidence stacks up Eating protein-rich meals is commonly believed to make dieters feel fuller, although surprisingly, this idea hadn’t been tested on a large scale.

In a new study featured in the Journal of the Academy of Nutrition and Dietetics, researchers conducted a systematic review of the evidence on the effect of protein intake on perceived fullness and confirmed that protein does indeed make us feel fuller.

Low-carb, high-protein diets’ popularity can partially be attributed to feelings of fullness from high protein intake, even if calorific intake is lower overall. “A good deal of evidence suggests that protein activates satiety hormone release and so should be most strongly tied with fullness ratings,” said lead investigator

Richard D. Mattes, MPH, PhD, RD, Distinguished Professor, Department of Nutrition Science, Director of Public Health, and Director of the Ingestive Behavior Research Center at Purdue University, “but individual studies are often conducted in small populations or with different approaches that can make interpretation of results challenging. Our study combined multiple experiments to confirm the presence of an effect.”

Mattes and his team used a variety of statistical approaches to make sense of the data, including a quantitative metaanalysis and a secondary directional analysis using a vote counting procedure. Both approaches indicated that higher protein loads have a greater effect on fullness than lower

protein loads.

However, the team remind us that although protein may help dieters feel fuller, it is by no means a guaranteed weight loss solution.

“The exact amount of protein needed to prolong fullness as well as when to consume protein throughout the day is not resolved, and our study did not determine this,” said Heather Leidy, PhD, Assistant Professor, Department of Nu-

trition & Exercise Physiology at the University of Missouri.

“Though this study did not specifically evaluate dieters, feeling fuller could help to reduce food intake, an important factor when dieting,” concluded Dr Mattes. “If these effects are sustained over the long-term - and our study only looked at short-term effects—increased protein intake may aid in the loss or maintenance of body weight.”

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body language I NEWS 11

60

second brief

BOTTOMS UP!

Derriere dominates surgical growth Since the year 2000, overall cosmetic procedures growth has risen 115%. A whopping 15.9 million surgical and minimally-invasive cosmetic procedures performed in the United States in 2015.

But it’s not just the volume that’s increasing—the types of procedures patients are choosing are changing according to new ASPS statistics.

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Buttock lifts, went up 252% (4,767 in 2015, up from 1,356 in 2000) and buttock implants were the fastest growing type of cosmetic surgery in 2015.

There was a buttock procedure every 30 minutes of every day, on average.

Top procedures related to the bottom in 2015: 1. Buttock augmentation with fat grafting (14,705 procedures, up 28% from 2014 to 2015) 2. Buttock lift (4,767 procedures up 36% from 2014 to 2015) 3. Buttock implants (2,540 procedures up 36% from 2014 to 2015) Source: American Society of Plastic Surgeons (ASPS)

3D ANALYSIS AND CAD/CAM TECHNIQUES ADVANCES SURGERY Plastic and reconstructive surgery could benefit 3D planning and CAD/CAM techniques—used mainly in craniofacial reconstruction until now—have the potential for advances in practically every area of plastic and reconstructive surgery a review by doctors at Yale university has found.

“When properly implemented, virtual surgical planning and CAD/ CAM technology enhance efficiency, accuracy, reproducibility, and creativity in aesthetic and craniomaxillofacial plastic surgery,” write authors Drs Miles J. Pfaff and Derek Steinbacher who provide an overview of VSP and CAD/CAM technology and its emerging applications in plastic and reconstructive surgery.

These powerful techniques—originally developed in the automotive and aerospace industries - are already being used to help surgeons solve complex problems in craniofacial reconstruction through analysis, planning, virtual surgery, 3D printing, and evaluation of surgical results. CT scan data can be manipulated by surgeons to create a digital 3D model— used for virtual surgical planning. A patient’s specific defect can be studied by a surgeon in detail from every angle, aiding in developing and comparing a range of reconstructive approaches. Surgeons can even perform simulated 3D procedures to “run through multiple treatment strategies to determine the most optimal approach.”

Combining the 3D digital information with CAD/CAM technology, 3D printing, and other advanced manufacturing techniques can be used to create biocompatible implants, splints, or treatment guides.

“As access to CT and 3D photo imaging improve, VSP and CAD/ CAM procedures will become the standard of care,” the authors write.

“When properly implemented, VSP and CAD-CAM technology enhances efficiency, accuracy, reproducibility, and creativity in aesthetic and craniomaxillofacial plastic surgery.”

While most applications so far have been in the area of skull, face, and jaw reconstruction, Drs Pfaff and Steinbacher foresee growing use in complete reconstructions of the head and neck, trunk, and limbs.

Although they acknowledge that these new and emerging techniques can’t replace the surgeon’s clinical judgment or technical skill, nor guarantee perfect results, their future vision for surgery is one where VSP is used to provide lifelike simulations of a wide range of plastic surgery procedures—enhancing outcomes and providing better communication between the surgeon and patient.

12 NEWS I body language

PATIENT CARE COULD BE UNDERMINED WITHOUT MORE FEMALE SURGEONS Society and the medical profession must do more to attract women into surgery The President of the Royal College of Surgeons, Clare Marx has warned that the quality of care patients receive could be affected - unless society and the medical profession do more to attract women into surgery.

According to Marx, a Consultant Orthopaedic Surgeon, the latest figures show around 57% of doctors in training are women, but only 30% of surgical trainees and 11% of consultant surgeons are female.

Speaking at an event to mark International Women’s Day, the Women in Surgery (WinS) conference at the Royal College of Surgeons, Miss Marx, who became the first trauma and orthopaedic female trainee in London in 1981 and went on to be elected the first female President of the RCS in 2014, said, “Surgery used to be one of the most sought-after medical specialties. Yet our failure to attract sufficient and growing female trainee numbers is a factor behind why we are now attracting fewer overall candidates into surgery.

“Unless we can reverse that trend and encourage and support more women to access surgery as a career, we risk reducing our choice from the talent pool.

Eventually that has the potential of reducing the quality of care that patients receive.”

Referring to recent analysis published in BMJ Careers, Miss Marx highlighted that while surgery has traditionally been one of the most popular medical careers, in 2014, it was not possible to fill every training post for the 10 surgical specialities.

Although the selection process was as competitive as ever, the ‘fill rate’ for core surgery fell short of other areas of medicine, including: acute care common stem, anaesthesia, clinical radiology, ophthalmology and public health.

Miss Marx continued “I strongly believe that a major factor behind this [fall in the fill rate] is the increasing numbers of women in medicine for whom surgery is still not a popular career option.

“As my surgical colleagues have made clear [in the BMJ study], if surgery con-

tinues to be seen as a male dominated discipline and women choose not to apply, we really will be fishing in an increasingly small pond.”

To attract more women into the profession, Miss Marx called for several interventions from the profession including: to talk positively about the benefits of a career in surgery for women; challenge the perception that a surgical career makes greater demands on your work/life balance than other postgraduate careers and supporting men and women in less than full time training so they can balance their work, social and family commitments; She also called for ‘all male short lists’

for interview panels and conferences to be banished and encouraged and applauded men and women who sponsor their female peers in surgery.

“In my own career, I am extremely grateful for the guidance and mentoring that I received from men, and I wouldn’t be standing on this platform with you today if it wasn’t for the courageous male and female leadership and support that I have experienced to date.

“That is exactly what we are aiming to do with our emerging leaders group at the College and through the fantastic work of Women in Surgery. These national actions should be promoted and replicated on a local basis as well.”

14 NEWS I body language

events 28 APRIL, British Association of Sclerotherapists 2016 Annual Meeting, The Ark, Basingstoke, UK W: bassclerotherapy.com 27-30 APRIL, 32nd Annual American Academy of Cosmetic Dentistry Scientific Session, Toronto, Canada W: aacdconference.com 19 - 22 MAY, 13th EADV Spring Symposium, Athens, Greece W: eadvathens2016.org 24 MAY, Value in Healthcare Congress, Manchester, UK W: valuecongress.hsj.co.uk 3-4 JUNE, Global Academy for Medical Education’s 6th Annual Summit in Aesthetic Medicine, Newport Beach, United States W: globalacademycme.com 3-4 JUNE, Journées Parisiennes du Laser, Paris, France W: congres-medical-congress.com 10 JUNE, Oculoplastic@Bordeaux 2016, Bordeaux, France W: congres-medical-congress.com

SURGEONS USE YOUTUBE AS EDUCATIONAL TOOL

16 - 18 JUNE, 3rd ICAD Brazil, International Congress of Aesthetic Dermatology and Healthy Aging Medicine, Sao Paulo, Brazil W: euromedicom.com

Learning new techniques helped by online resources A small survey of American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members found that when is comes to keeping skills current, online streaming media (i.e. YouTube) has been used by members at least once to learn a new technique, which has then been used in practice.

Anita Sethna, M.D., of the Emory University School of Medicine, Atlanta, and co-authors surveyed all 2600 AAFPRS members and received 202 responses. Although this represented just 8% percent of the AAFPRS membership, the results of which were published online by JAMA Facial Plastic Surgery.

Meetings, journals and discus-

sions with colleagues were found to be the most popular sources for staying up to date with technical and non-technical findings. However 64.1% of respondents said they had used online media at least once to learn a new technique, especially in the areas of rhinoplasty and injectable procedures, and 83.3% had subsequently used those techniques in their practice. Less experienced surgeons were more likely to have used online streaming media than more experienced surgeons.

“The enthusiasm is not unbridled, however. The Internet’s ease of access has raised concerns regarding the quality of these sources,” the authors note.

1 - 3 JULY, IMCAS Americas 2016, Cancùn, Mexico W: imcas.com 6-8 JULY, AFPSS 7th Functional Septorhinoplasty Course in conjunction with 7th Asian Facial Plastic Surgery Society Congress, Singapore W: entfortnight2016.com 29 - 31 JULY, IMCAS Asia, Taiwan W: imcas.com 16 - 17 SEPTEMBER, AMWC Eastern Europe 2016 – 4th Aesthetic & Anti-Aging Medicine World Congress Eastern Europe, Moscow, Russia W: euromedicom.com 19-23 OCTOBER, DASIL—Dermatologic Aesthetic Surgery International League, Dubai, United Arab Emirates W: thedasil.org

AD CRACKDOWN Unscrupulous marketing is targeted by BAAPS New guidelines from BAAPS which will protect consumers from aggressive cosmetic surgery marketing will come into force this April.

In a serious message to doctors offering procedures through discounts, time-limited deals, refer-a-friend offers, gift vouchers,

16 - 19 JUNE, Facial Aesthetic Conference & Exhibition—FACE 2016, London, UK W: faceconference.com

loyalty cards, or as a prize, the new rules view that such advertising trivialises serious procedures and is unscrupulous.

Those found to be in serious or persistent breach could be referred to a public tribunal or suspended from the medical register.

21 OCTOBER, AMEC 2016 - 12th Aesthetic & Anti-aging Medicine European Congress, Paris, France W: congres-medical-congress.com 23 - 27 OCTOBER, 23rd Congress of ISAPS, Kyoto-shi, Japan W: isapscongress.org 3 - 5 NOVEMBER, 3rd AMWC Latin America, Medellin, Columbia W: euromedicom.com 24 - 26 NOVEMBER, ICAD 2016, Bangkok, Thailand W: euromedicom.com Send events for consideration to arabella@face-ltd.com

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body language I INDUSTRY 17

industry news

SESDERMA LAUNCHES IN THE UK Award winning clinical skincare and aesthetics company Sesderma has launched in the UK, boasting an innovative portfolio anti-ageing products Already established in over 40 countries in Europe and South and Central America and with over 25 years of immense success, Sesderma’s longestablished expertise in the dermo-cosmetic sector is led by its founder Dr Gabriel Serrano.

The high quality formulation of Sesderma

products utilises unique nanotechnology that facilitates a deep level of skin penetration and results in extremely effective products. Sesderma’s portfolio of products is extensive, from skincare to medical grade products. The medical product line, Mediderma, offers a wide range of

specialised products that treat an array of conditions from acne to sun spots. A number of innovative products will be launching throughout the forthcoming 12 months including Retiage, Sesgen 32, Factor G and C-Vit. Dr Serrano says “Sesderma is delighted to launch in the British Aesthetics Industry. We fully respect the committed stance that our British medical aesthetic colleagues embrace when selecting clinically proven skincare products, and our clients will find Sesderma an exciting new addition to their existing portfolio of treatments and products�.

The overriding

principle of Sesderma —“Listening to your skin�—is made possible through the use of integral dermatology which combines technical innovation with valued customer feedback.

Sesderma’s mission is clear—to focus on the development, manufacturing and distribution of dermo-cosmetic products that will satisfy the needs of customers and end users. Joanne Briggs UK Sales Manager says: “Sesderma has taken a new scope, expanding its presence in the top international markets. The United Kingdom represents for us a unique opportunity to offer high-quality tailor-made treatments for the end consumers�.

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THE BRITISH ASSCOCIATION OD SCLEROTHERAPISTS MEETING -PQYP HQT MGGRKPI QPG UVGR CJGCF YKVJ OKPKPIHWN KPPQXCVKQP Sesderma IKXG The must-attend meeting for allKPUKIJVU KPVQ DGCWV[ RTGFKEVKQPU HQT VJG HWVWTG sclerotherapists takes place on April 28th Although unsightly thread veins affect 50% of the population, the NHS offers no treatment. Most GP’s have little knowledge of possible treatments and cannot confidenty refer patients privately because of the lack of established standards. The British Association of Sclerotherapists’ objective is to address this.

To date there are no set standards of training, professional development or practice for treatment in the UK, but The British Association of Sclerothera“Retinoids: Topical vitamin pists (BAS) are anticipating the emerthatofboost gence of Aa derivatives distinct group individuals FROODJHQ WR UHGXFH ÂżQH OLQHV with a particular interest in venous disspeed turnover ease—asand in the rest cell of the world. to even out discolouration and The BAS is formed of a body of exVPRRWK VNLQ 3UHVFULSWLRQ perts whose commitment is to agree on retinoids include tretinoin best practice and inform and educate and tazarotene; the over-themembers,FRXQWHU UHWLQRLG LV UHWLQRO 7KH the public and allied health professionals to ensure high standards of QHZ IXWXUH RI UHWLQRLGV ZLOO treatment.

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tunity for vascular surgeons and aesthet- will present his highly popular ‘top tips’ ic doctors and nurses wishing to broaden and invite questions from the audience. or update their sclerotherapy skills, the Further information is on the BAS BAS annual conference will be held at website bassclerotherapy.com. the Ark Conference Centre in Basingstoke on 28th April 2016. At this lively and stimulating event, eminent experts in the field of phlebology and sclerotherapy will give presentations, and live demonstrations will include both foam and liquid sclerotherapy.

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18 FACE 2016 I body language

Facial aesthetic conference and exhibition FACE 2016—the UK’s premier medical aesthetic conference returns to the heart of London this summer showcasing an expanded lecture programme, hands on training and FACE rewind

JUNE 16TH – 19TH 2016

F

ACE 2016 marks the 14th year of the UK’s premier aesthetic conference in the heart of London.

With the strategic partnership and alliance with EuroMediCom and Informa—the organisers behind a host of international medical aesthetic conferences and events including AMWC in Monaco—FACE is constantly creating changes to the conference experience, allowing more content to be seen by more delegates every year.

FACE 2016 sees the regular INJECTABLES, BODY, SKIN, HAIR and THREADS Agendas take place across three days in their own dedicated rooms and lecture theatres. Changes to the Agenda for FACE 2016 include a Live BUSINESS Agenda taking

place within a new section of the Exhibition Hall located on the 1st Floor. This will enable access for all delegates and exhibitor representatives to participate in our ever popular and interactive business talks which have proven to be key for everyone working within the medical aesthetics industry.

Also new to FACE 2016 is the addition of Advanced Hands-On Training Courses, which will run throughout the event focusing on injectable treatments. Each session will consist of five to 10 delegates.

The Sunday schedule will also be enhanced for 2016, as running alongside the Injectables Agenda, will be a ‘FACE Rewind’ lecture programme. This will take place across two rooms, and will repeat some of the most popular talks

from the weekend which delegates might not have been able to see in their first few days of attendance.

FACE 2016 will—for the first time—host a Sexual Aesthetics Agenda. Over the last few years there has been an explosion in the number of treatments targeted at both aesthetic and functional improvement of the genital area.

From fillers, PRP and threads, to lasers and radiofrequency; research and development investment and clinical experience has grown significantly. This session aims to explore the evidence behind different modalities and their potential combined uses, alongside practical tips from experts pioneering the use and promotion of these treatments in their clinics.

FACE 2016 is held at the QEII Centre in London’s Westminster

body language I FACE 2016 19

MASTERCLASS Provisional international faculty includes: Dr Raj Acquilla, Cosmetic Physician, UK Dr Ali Pirayesh, Consultant Plastic Surgeon, Netherlands Dr Frank Rosengaus, Consultant Plastic Surgeon, Mexico Dr Alek Nikolic, Cosmetic Physician, South Africa Dr Ton Van Eijk, Cosmetic Physician, Netherlands Dr Uliana Gout, Cosmetic Physician, UK Prof Mukta Sachdev, Consultant Dermatologist, India Dr Kate Goldie, Cosmetic Physician, UK

Pre-Event “FACES of the World” Advanced Injectables Masterclass Due to the incredible popularity of our first pre-event injectables masterclass delivered in 2015, Thursday at FACE will once again host an Advanced Pre-Course agenda.

The concept of “total facial contouring” with fillers/toxins and threads continues to become increasingly appealing to an ever wider audience of both men and women of all races and backgrounds around the world. However, for practitioners living in cosmopolitan areas, the technical challenge of delivering excellent results safely is enhanced when dealing with patients of different ethnicities and cultural backgrounds.

This unique one day masterclass will be headed by an expert panel who will explore these challenges and provide personal insights into the cultural differences of aesthetics and beauty alongside variations in technical approaches required to ensure that patients are treated safely and effectively with the outcomes that they desire.

Subjects covered in this unique workshop include:  Anatomy: With a special focus on ethnic differences and anatomical variations  Concepts in Beauty: What are the differences in ideals between women from different continents.  Safety: Recommendations in altering techniques in facial contouring for different indications dependent upon ideals and ethnicity  Adverse events: Exploring any differences in complication rates and how to deal with them when dealing with people from different ethnic backgrounds

In addition, there will be a number of live demonstration sessions delivered by our expert faculty highlighting the practical variations required in terms of facial assessment, consultation techniques, and facial rejuvenation approaches.

Facial Injectables Agenda A host of national and international lecturers, trainers and clinical trialists will feature, providing scientific updates and practical insights to help you maximise results and minimise problems when using cosmetic injectables for total facial

contouring. Different techniques, new treatment approaches and products will be explored alongside practical demonstrations. The latest clinical data and thoughts on toxins, fillers, PRP and other cosmetic injectables will be reviewed and debated by some of the world’s most experienced practitioners. If you are passionate about cosmetic injectables then FACE 2016 is the event that you must reserve in your professional education diary. You won’t find a better industry focused event anywhere in the world this year.

INJECTABLE AGENDA Confirmed speakers and topics include: Professor Nick Lowe: The Evolution of injectables over the last 20 years Dr Raj Acquilla & Dr Alek Nikolic: Injectable masterclass workshop Dr Christopher Rowland Payne: Eyebrow ptosis—universal destiny?

Causes and solutions Dr Maria-Angeliki Gkini & Dr Mario Goisis: A preliminary study comparing nanograft plus PRP vs hyaluronic acid plus PRP for the correction of facial wrinkles Mr Ash Labib: Non-surgical nasal contouring Dr Raj Kanodia: Enhancement of the cheek vector by lifting vs filling Dr Frank Rosengaus: Rheology and how to choose the right filler Dr Uliana Gout: Lip and peri-oral complex treatment with toxins and fillers Dr David Eccleston: Doing toxins well; tips and tricks for upper and lower face Dr Kate Goldie: Dealing with complications workshop Mr Chris Inglefield: Rapidly polymerising collagen—study on its use for lip augmentation Professor Bob Khanna: The art of the aesthetic consultation

20 FACE 2016 I body language

BODY AESTHETIC EQUIPMENT AGENDA Confirmed speakers and topics include: Dr Mark Taylor: The comprehensive treatment of acne scars Dr Welf Prager: Intralesional cryotherapy for keloid and hypertrophic scars Dr Jean Paul Meningaud: Multifractional microablative laser with space modulated ablative (RecoSMA) technology for facial skin rejuvenation Dr Sweta Rai: Complications associated with body contouring Dr Barbara Hersant: Multifractional microablative laser with space modulated ablative (RecoSMA) technology to treat stretchmarks Dr Klauss Hoffman: Picosecond laser for tattoo removal Dr Francois Michel: Wellbeing effect of photobiomodulation Dr Christine Dierickx: Vascular laser update Dr Rahul Pillai: Whats new in laser hair removal for the treatment of ethnic skins Dr Stephen Mulholland: Mesocaine technique for more aggressive singles session fractional RF and laser resurfacing

BODY Aesthetic Equipment Agenda Growth in research and development in this section of the market has produced a raft of new technologies in recent years that have opened up whole new business models. From microwaves for the permanent reduction of excessive axillary sweating, to specially designed fractional ablative approaches for vaginal atrophy—the high tech equipment market continues to surge forward. Delivered by an international panel of experts in their particular fields, this two day agenda allows delegates the opportunity to explore and compare the latest equipment based technologies and treatment protocols for a wide range of different indications.

BUSINESS Agenda With the ever increasing range of effective treatments that can now be added to the service menu of a medically led aesthetic clinic comes the challenge of ensuring that you can effectively market and promote them to ensure profitability.

Marketing body contouring treatments or laser hair removal requires a different approach to building a facial injectable business, especially when you need to ensure a quick return on investments from capital expenditure on equipment.

In addition, in an increasingly competitive market everyone needs to ensure that they continuously review pricing models and points of differentiation to ensure that they continue to grow turnover and profit. FACE provides a

unique three day forum delivered by professionals from the field of web design, digital marketing, PR and social media that can help to ensure your strategies are up to date and effective.

This is yet another unique opportunity for clinic managers, marketeers and aesthetic business owners to learn from respective marketing

experts in their fields, and network and share ideas with peers to maximise profitability in their business.

SKIN Forum—Topical Treatments With so many different competing skincare lines, it can be challenging to draw conclusions about which brands to invest in using the

BUSINESS AGENDA Confirmed speakers and topics include: Norman Wright: Safety in aesthetics Dr Uliana Gout: Tips and tricks to maintaining competitive advantage Dr Kate Goldie: Social styles Wendy Lewis: The S-Factor: How to keep the ‘social’ in social media For aesthetic practitioners Dr Ross Perry: What makes the best CRM/practice management software in 2016 ?

Charles Southey: How to grow your business with clinic management software Susan McNeece: Retail strategies for increasing retail sales in a medical clinic Glenda Bailey Bray & Jo Martin: The value of training in an unregulated industry Adam Hampson: Secrets of a successful clinic website

body language I FACE 2016 21

advice of company representatives and promotional literature alone.

FACE provides a forum for practitioners to meet the real industry experts who truly understand ingredients, formulations and the arguments behind competing concepts and brands.

As cosmeceuticals and medical retail skincare lines continue to be an important aspect of providing a complete approach to anti-ageing, this two day forum will help practitioners to review new topical approaches to preventing and treating signs and symptoms of ageing skin alongside the latest specific protocols for treating acne, rosacea and hyperpigmentation in skin of colour.

SKIN FORUM Confirmed speakers and topics include: Chiza Westcarr: Inflammation and accelerated skin ageing (inflammaging) Dr Charlene de Haven: Ageing facts and myths; Pigmentation process of skin; Cancer treatments and the skin Professor Liudmila Korkina: Active ingredients of meristem plant cells for skin rejuvenation: myths and reality Professor Nick Lowe: The changing face of acne Elliot Isaacs: Topical anti-ageing cosmeceuticals Susan McNeece: Peels and pigmentation—how to make peels effective Dr Sandeep Cliff: Peeling to induce increased skin thickness Dr Rodrigo Arroyo Sanchez: Deep peeling—the science of TCA and phenol Dr Uliana Gout: Chemical peels workshop

HAIR Agenda The demand for effective nonsurgical and surgical treatment options for hair loss continues to grow, and newer technologies including the use of LED, PRP and hair transplant robots have encouraged more practitioners to consider incorporating a treatment service for this indication in their clinics.

Dr Bessam Farjo, one of the UK’s leading hair transplant surgeons, will be chairing and lecturing alongside a panel of experts who will explore in depth the latest scientific data for the different potential treatment solutions available.

If you’re already involved in this exciting market segment, or are looking to add this to your treatment menu, the HAIR agenda will provide you with the latest expert views and information on the effective treatment of hair loss that can be offered in a private clinic.

THREADS Agenda The use of threads for face and body indications in the UK has exploded in the last few years following their launch in the late 1990s when prolene APTOS threads were invented by Russian Cosmetic Surgeon, Dr Marlen Salaminidze.

Professor Bob Khanna, one of the UKs leading trainers on facial rejuvenation will be chairing and lecturing a special one day seminar dedicated to reviewing the latest scientific information, practical tips and expert views on avoiding

and managing complications in this dynamic section of the market. If you’re considering adding threads to your treatment menu, or if you would like to learn more about different types of threads and newer indications for their use, this agenda will provide you with access to the experts who have the answers.

SEXUAL AESTHETIC Agenda For the first time in the UK, FACE will host a dedicated Sexual Aesthetic Agenda on Sunday the 19th of June, chaired by Dr Sherif Wakil. Sexual rejuvenation is becoming one of the fastest growing areas in the aesthetics industry for men and women. This is due to the development of advanced technology and a variety of non-surgical treatments

22 FACE 2016 I body language

delegates to treat as well. For delegates to qualify and attend one of these courses, they must provide proof that they are a practicing Doctor, Dentist or Nurse.

The FACE 2016 Summer Reception will be held on June 18th at The Skyloft

that are available. The public have recently started to hear and see in various media publications the benefits of these treatments. Many clinics are now seeing patients actively seeking out solutions to intimate concerns that they once thought were untreatable or as the alternative to having a surgical procedure with considerable less downtime.

Dr Wakil promises delegates a unique opportunity to hear from a hand selected elite team of speakers and practitioners from around the globe. They have been chosen for their outstanding contribution to these exciting procedures.

Delegates will be able to discuss all of the subjects with the panel, who will cover the latest cutting edge topics in this field including PRP (O Shot and P Shot), threads, fillers, hormones and patient selection as well as training and marketing in these procedures.

This agenda will be suitable for aesthetic practitioners who are already performing some of these treatments and are looking to advance on their knowledge or new practitioners interested in adding these life changing procedures into their clinics.

All delegates will also be invited to watch a live demonstration of one of the latest vaginal rejuvenation machines on stage.

This is an exciting opportunity for practitioners to be part of the latest advancements and procedures in sexual aesthetic medicine.

Dr Wakil has more than two decades of experience in the health care industry, and has performed more than 19,000 procedures. He has introduced a number of new treatments to the UK and Europe, including the P-Shot and the OShot (sexual rejuvenation with PRP) the vampire breast lift and the “soft surgery” concept.

HANDS-ON Training New to FACE 2016 are Advanced Hands on Training Courses which will run for half a day and will consist of five to 10 delegates per session. The delegates will be led by one of our expert aesthetic practitioners and speakers from FACE 2016 and will be focussing on one particular area of facial aesthetics.

Models will be provided for the

FACE Summer Reception Join speakers and peers for an evening of networking and socialising on Saturday June 18th, at The Skyloft—a unique venue providing in the sky, offering 360 degree views of London’s famous skyline.

Tickets are £40 per person, and include beer, wine and soft drinks all night. There will be a snack bar at 23:00 offering late night snacks and food, and reserved Lounge Seating Areas for up to 10 guests for you and your company are also available with prices starting from just £500.

FACE REWIND New to FACE 2016 is ‘FACE REWIND’. If as a delegate, you have missed certain talks throughout the Friday or Saturday sessions (because you simply cannot be in more than one lecture theatre at any given time), we will repeating highlighted lectures and presentations from the BODY, SKIN, THREADS and HAIR Agendas on the Sunday.

For detailed agendas updated daily, or to register for FACE 2016, visit W: faceconference.com. An Early Bird discount applies if booking before March 31st. For more information, call 020 7514 5989.

QEII Centre, London I 16-19 June 2016

THE UK’S PREMIER MEDICAL AESTHETIC CONFERENCE & EXHIBITION We are delighted to invite you to join us at FACE 2016. Once again being held in the heart of London, FACE 2016 is on course to being the biggest and best conference to date.

FACE 2016 sees the INJECTABLES, BODY, SKIN, HAIR and THREADS Agendas take place across three days, with some new additions:  Live BUSINESS Agenda for all delegates and exhibitor representatives.  Advanced Hands-On Training focusing on Injectable treatments.  ‘FACE Rewind’ lecture programme repeating the most popular talks from the weekend which delegates might not have been able to see.

INJECTABLES AGENDA BODY AGENDA SEXUAL AESTHETICS SKIN AGENDA PRE-COURSE HAIR AGENDA BUSINESS AGENDA THREADS AGENDA WORKSHOPS

FACE VIP Access all areas, plus the exclusive FACE VIP lounge For full details visit faceconference.com

twitter.com/face_ltd facebook.com/faceltd W: FACECONFERENCE.COM T: 020 7514 5989 E: INFO@FACE-LTD.COM

24 SEXUAL AESTHETICS I body language

Female intimate surgery DR EVGENII LESHUNOV reviews the present literary data on the history, methods and trends in female intimate surgery

P

rocedures aimed at correcting appearance and restoring functions that are carried out in the female urogenital area are customarily referred to as intimate plastic surgery (IPS). This surgery includes traditional methods of correcting vaginal prolapse and looseness of the vaginal vestibule, and also aesthetic correction of the vulva. The boundary between medical and aesthetic indications for the performance of procedures is blurred, and nowadays many operations are carried out with both objectives in mind.

A major contribution to the development of this sphere in the world is provided by cooperation between gynaecologists, urogynaecologists and reconstructive surgeons. Unfortunately in Russia we see a lack of mutual understanding

between specialists engaging in “sexual medicine”, so that it is not possible to talk of the quality of the results of intimate plastic surgery or of sexual wellbeing as a whole.

At the first interview with a prospective patient, a gynaecologist or surgeon should be able to provide a patient who is looking to have intimate plastic surgery with a full and informed explanation concerning all the options and the potential for correction in the urogenital area. The patient should, in addition, be examined by a psychologist to check for dysmorphophobia.

It is important to be sure that the woman is taking the decision independently, without any coercion or pressure from her sexual partner.

Historical information The previous history of female intimate surgery is associated with

genital surgery—ritual manipulations that date back deep into antiquity and have distinct ethnic characteristics. Some approaches and methods used in modern-day sexual surgery have however been assimilated specifically from these rituals. One particular aspect of this surgery is that operative intervention is, in a number of cases, carried out not because of medical indications, but in connection with the patient’s dissatisfaction with her sex life.

Female genital mutilation is an operation that consists in the removal or resectioning of parts of the female genitalia, up to and including removal of the tip and part of the body of the clitoris (clitoridectomy) and the labia minora, performed without medical indications. As things stood in 2008, between 100 and 140 million women had under-

body language I SEXUAL AESTHETICS 25

gone this operation, mainly in Africa (in Egypt, Sudan and Ethiopia, more than 80% of women have this operation), and also in Saudi Arabia and Indonesia. With time, it was female ritual circumcision that served as a prototype for female intimate cosmetic surgery.

To begin with, female intimate cosmetic operations were common among commercial sex workers, nude models, bathing suit models, actresses who appeared naked and certain categories of women suffering from such diseases as urinary incontinence, congenital sex organ development defects or birth-related injuries.

Articles about female intimate plastic surgery first began to appear in North American journals in 1978, and the first article describing a method of correction of the female urogenital area appeared in 1984. When Gary Alter presented the results of his own labiaplasty, vaginoplasty and G-spot enlargement work in 1998, there was a change in world opinion concerning intimate surgery. Although operations to tighten the vagina had been carried out earlier, the difference in the new methods was that they incorporated aspects of plastic surgery, and concentrated on the appearance of the vulva.

Intimate filling as a method appeared at the end of the 1990s, and did not begin to be actively used until after 2000. When the method first began to be practised, various fillers were widely used to augment the tissues of the anogenital area, and on occasion some of these did not meet safety requirements. In the USA, for example, numerous complications were seen that were linked to the use of implants based on bovine collagen and liquid silicone. For a long time a leading role in intimate plastic surgery was taken by lipofilling, often in combination with liposuc-

66 Boundaries between medical and aesthetic indications for the performance of procedures are blurred 99

tion of the pubic region and the inside surfaces of the thighs. The first experience of lipofilling of the anogenital area was described by E Hernandez-Prez in 1996. Following the commencement of use by cosmetologists of hyaluronic acid based products, doctors performing intimate zone correction also began to take a closer look at these.

The first publications concerning the safe and effective use of products containing hyaluronic acid in sexual surgery appeared in 2003.

In 2006, the Italian plastic surgeon A. Alessandrini was the first to familiarise a Russian audience, at a congress in Moscow, with intimate filling methods. Since 2006, Professor Ya.A.Yutskovskaia and her colleagues have been engaged in the development and introduction of intimate filling methods for correction work in the anogenital area.

In discussing sexual medicine generally, mention must be made of the role played by professional medical societies. The International Society of Cosmetogynecology (ISCG) is the first, and the world’s largest, association of specialists in aesthetic gynaecology and intimate surgery. It was founded in 2004 by Marco A. Pelosi II and Marco A. Pelosi III, and takes in over 700 members and more than 30 countries. The society was set up with the aim of consolidating academic knowledge in the sphere of female intimate aesthetics and of making changes to gynaecological practice.

Moreover the organisers appreciated that doctors working on sexrelated problems enter into unique relations with patients, which provides an opportunity for fuller aesthetic control.

It is important to make the point that as medical activities become increasingly commercialised, the market for services on offer in the sphere of sexual medicine will grow, while the lack of a legal field in this area enables these services to be licensed in the certification register for a variety of types of medical activity. So perhaps specialists engaged in sexual medicine, be they urologists, gynaecologists or cosmetologists, will not run up against ethical/legal problems, but by the same token patients can anticipate strictly medical problems

of quality control for the provision of medical services.

Intimate surgery—women’s views Women go to a doctor both for aesthetic correction and because of functional disorders, including pain during the sex act or while engaging in sport, frequent irritation, vulvalintertrigo and discomfort while wearing underwear or clothing.

Women aged 18-44 prefer to undergo epilation in the bikini zone, which makes for better visualisation of the vulva. In 2008, D. Herbenick and colleagues carried out a study in which 2 500 women took part.

The extent of the practice of pubic hair removal was investigated, and the ways in which it was done, and the influence of pubic pilosis on the quality of one’s sex life. The study results gave rise to the conclusion that a complete absence of pubic hair is linked to a higher FSFI (sexual function index) level.

Konig and colleagues discovered that 78% of 482 women questioned had learned about labiaplasty through the media, while 14% thought that their own labia minora looked abnormal. A feeling of awkwardness, “changing-room syndrome” and problems with sex life are also commonly adduced as reasons for wanting intimate correction. Bearing in mind the possibility of congenital deformations of the vulva, psychological problems may occur during the early adolescent period.

Possible dysmorphophobia should be borne in mind: one way or another it is the media who are to blame for this, by giving coverage to it in women’s magazines, alongside fashion and the accessibility of pornography on the Internet. Meanwhile the rise in the popularity of the procedures has spawned TV reality shows, where the subject of the ideal appearance of female external sex organs has been actively pursued. Michala and colleagues described a study of 16 girls (average age 14.5) who went to a clinic to have their labia minora (LMin) reduced in size. Six girls were worried about LMin asymmetry, while 10 complained of protrusion of the labia minora, regardless of their normal size.

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body language I SEXUAL AESTHETICS 27

The concept of ideal external sex organs among women in Western countries differs from that among women in other countries.

In Rwanda and Mozambique, for example, extended labia minora are considered attractive, whereas in Japan the most attractive vulva is considered to be one shaped like a butterfly.

Doctors’ views Traditionally, it has been gynaecologists who engaged in surgical correction of the vagina and vulva.

Since growing numbers of urologists and plastic surgeons are carrying out labiaplasty, intimate filling and cosmetic vaginal operations, the need for correction of complications following interventions is steadily increasing. Most surgeons perform intimate plastic surgery without having had any training in aesthetic vaginal surgery. This gives rise to complications such as nonaesthetic appearance, functional incompetence of the vulva and sexual dissatisfaction. Increasing numbers of patients come to us for correction of such complications as asymmetry, excessive tissue removal, loss of sensitivity and pain in the vulvar area. Around 10% of interventions in the urogenital area that are performed at our centre arise out of unsuccessful operations.

In general, cosmetic surgery on the vulva does not require medical indications. According to the results of the consensus adopted in 2007 by the American College of Obstetricians and Gynecologists, the medical indications for intimate surgery are: • the need to reconstruct the vulva following circumcision; • asymmetry and hypertrophy of the labia minora; • sclero-atrophic processes in the vulva; • hypertrophy of the clitoris as a result of an excess of androgens.

Most surgeons, however, perform intimate plastic surgery with aesthetic objectives or to improve the quality of sex life of the woman and her partner. In a multi-centre, retrospective study, 76% of 258 women had an operation for functional reasons; 53% underwent an operation for cosmetic reasons and 33% to improve self-esteem.

Fifty four percent of women who underwent vaginoplasty/perineoplasty and 24% of those who had the combined procedure, including vagino-/perineoplasty, labiaplasty and plastic surgery on the hood of the clitoris, did this to increase their partner’s sexual satisfaction.

Methods—vaginoplasty Vaginoplasty is an intravaginal operation. Vaginoplasty is not intended to eliminate defects in the pelvic floor, but this reconstructive procedure is a modification of traditional colporrhaphy and is often carried out in conjunction with reconstruction of a pelvic floor prolapse.

Classically, the vaginoplasty procedure involves anterior or super-posterior colporrhaphy, modified by the use of plastic surgery methods, excision of the lateral wall of the vaginal mucosa, and also a combination of these methods. Practical experience has shown that, in contrast to other methods, lateral colporrhaphy is less often complicated by a scar process. Ablation or excision of strips of the mucosa from the lateral walls of the vagina enables the diameter of the vagina to be perceptibly narrowed, looseness of the vestibule to be eliminated and the quality of the sex life of the woman and her partner to be improved, but may not be used with prolapse of the pelvic floor. This operation is currently used to treat “vaginal relaxation” syndrome. To achieve a better result, the procedure may be combined with perineoplasty and labiaplasty. We have improved on the classical vaginoplasty method, so we can carry out some of the procedures under local anaesthesia.

Thus instead of a scalpel we make use of a latest-generation Surgitron radio-frequency device (Ellman International, USA) which enables us to make incisions with exceptional precision and the minimum of trauma. The procedure takes about 60 minutes, and the rehabilitation period 10-15 days.

Complications following an operation to tighten the vagina include dyspareunia, a defect in the mucosa which takes a long time to heal and stress urinary incontinence. In Goodman and colleagues’ study, 16.6% of women reported compli-

cations, including poor healing of wounds, dyspareunia, post-operative haemorrhaging, pain, excessive constriction of the vestibule and injury to the intestine or bladder with the creation of fistulas.

Lasers have been in use for over 20 years for the correction of agerelated changes in the vaginal area.

Examples include venereal warts and colpectasia and scars from episiotomies and perineotomies.

They are also used to treat precancerous diseases of the vulva, kraurosis (sclero-atrophic lichen) and afflictions of the neck of the womb. We and our patients often notice changes to the appearance of the vulva that happen following laser treatment: elimination of hyperpigmentation, and a taut and aesthetically pleasing appearance.

At Professor Yutskovskaia’s Clinic we use laser rejuvenescence of the vagina to treat vulvar kraurosis. The intervention protocol includes treatment with an ablative erbium laser and the use of autoplasma (PRP) and non-stabilised hyaluronic acid.

Use of a fractional erbium laser supports collagen regeneration and enables the skin to be smoothed out and scars to be reduced in size, with no injury to surrounding tissues. Laser vaginal and vulvar rejuvenescence are performed under local anaesthesia. The procedure lasts between 15 and 30 minutes, and the rehabilitation period is five to seven days.

In the past, patients with a high risk of haemorrhage and low regenerative capacity used to undergo vaginoplasty using neodymium, diode or CO2 lasers. Nowadays CO2 and erbium lasers are universally used. The action of the laser is aimed at the submucosal layer, where a thermal impact is used to begin remodelling of the extracellular matrix, which in turn has the effect of increasing the elasticity

Vaginal rejuvenation is the surgical procedure performed to fix the medical diagnosis known as vaginal relaxation

28 SEXUAL AESTHETICS I body language

of the vaginal wall and tightening of the vagina. A. Gaspar and colleagues assessed the impact of two fractional laser systems—CO2 and erbium lasers—in conjunction with the topical use of plateletenriched plasma and pelvic floor exercises. An improvement in the condition of the vaginal wall and a tightening of the vagina were observed in both groups, but more complications were recorded in the patient group on which a CO2 laser had been used. Complications following the use of a CO2 and an erbium laser include a burning sensation and excessive tightening of the vagina.

Women with vaginal relaxation often complain they no longer feel the same amount of friction during intercourse. The patient will often describe vaginal looseness and often a decrease in a woman’s ability to attain vaginal orgasms. The main component of the lack of friction is the relaxation of the inner vagina as well there is usually a component of relaxation at the vaginal opening . A patient has internal vaginal enlargement as well as enlargement of the vaginal opening.

At our clinic we use a sixthgeneration erbium laser made by Asclepion (Asclepion Laser Technologies GmbH, Germany). The MCL-31 laser system was first used for a gynaecological operation in December 2013. A provisional analysis of the results of the first 15 procedures supports our view that the level of efficacy and safety of this laser system is high. The rehabilitation period takes three to five days, depending on the individual characteristics of the woman. Protocols are currently being drawn up for procedures with a variety of changes to the vagina.

There are separate reports concerning the use of lipofilling and hyaluronic acid gels with the aim of tightening the vagina. In our view, fillers are not suitable for use in this procedure, and we would like to warn that this procedure is still in the experimental stage.

Despite a lack of studies meeting the requirements of evidencebased medicine, following aesthetic vaginoplasty patient satisfaction is high as regards both medical and functional results and also

psychological results. It is not clear whether some kind of ablative or non-ablative laser technology will be developed, or an ultrasound or radio-frequency system, which could be used to address the problems of pelvic floor muscle prolapse. The existence of undesirable events means that lengthy monitoring is needed to analyse long-term efficacy and safety.

Perineoplasty Perineoplasty is the surgical procedure that restores a torn perineal muscle, which can make the vaginal opening wider than normal, also known as gaping introitus, epsiotomy damage, perineoplasty damage.

Gaping introitus (enlarged vaginal opening) is usually the result of giving birth, however patients may have enlarged vaginal openings without ever giving birth. Patients have a separation of the transverse perineal muscles, which causes the base of the vagina to widen. These are the muscles that are often torn as an extension of an episotomy (a cut made in the perineum made by the obstetrician to widen the vagina to facilitate the delivery of a child) or are torn. This enlarged vaginal opening can also occur do to a dehiscence or breakdown of a perineoplasty repair performed by a gynecologic surgeon. This condition gives the patient an “open” feeling and also may cause some lack of friction during intercourse.

Most plastic surgeons who carry out vaginoplasty actually perform a perineoplasty as a simpler method of correcting the anterior part of the vagina. Perineoplasty is often combined with labiaplasty and super-posterior colporrhaphy.

The following indications for a perineoplasty may be listed: • existence of scarring to the perineum; • looseness of the vaginal vestibule; • low position of the perineum; • kraurosis.

The performance method comprises excision of a rhomboid area on the perineum above the anus and within the confines of the vaginal vestibule. The lateral boundaries are the remnants of the hymen.

The bulbocavernous and superficial transverse muscle of the peri-

1.

2.

neum are identified, and these are subsequently sutured to create the effect of a tightening of the vaginal vestibule, raising the edges of the vestibule and restoring the structural integrity of the perineum This procedure is carried out under local anaesthetic with excision of scar tissue using radio-frequency or laser technologies. Use of an erbium laser enables the removal of rough edges and surplus skin, resection of skin neoplasms, enhancement of skin elasticity and elimination of skin hyperpigmentation.

Labiaplasty The dimensions of the LMin are individual for each woman and change during the course of her life. In the anterior part, the widest part when spread, the breadth of the LMin is on average from 2 to 4 cm. During the course of life, under the influence of endogenous (hormones) and/or exogenous (injury or wearing of underwear) factors, there is a change in shape and loss of function in the LMin, and such changes are known as involution.

Hypertrophy of the labia minora comes as an increase in the size of the LMin, leading to a decrease in the erectility and sexual hypoaesthesia both of the LMin themselves and of the tip of the clitoris.

Elongation of the labia minora is a lengthening of the LMin by more than 5 cm in their peak state of extension. Most women think that the ideal length of the LMin should be within 1 cm in a nonextended state.

1. Perineoplasty procedure to restore torn perineal muscle. 2. Labiaplasty— usually carried out when there is lengthening or asymmetry of the LMin

body language I SEXUAL AESTHETICS 29

3. Diagram of performance of marginal (amputational) labiaplasty.

4. Diagram of performance of outline resection.

5. Diagram of performance of de-epithelisation labiaplasty.

3.

Protrusion of the labia minora is when the LMin protrude from the sexual cleft, whereas they should be fully concealed by the labia majora (LMaj).

Besides elongation and hypertrophy of the LMin, a distinct, to a greater or lesser extent, asymmetry in them is a common enough observation, linked to anatomical idiosyncrasies and constituting a version of normal development of the external sex organs. Asymmetrical labia usually give women greater discomfort than labia that are evenly enlarged.

Labia minora reduction is the surgical procedure performed to fix the medical diagnosis known as labia minora enlargement (aka labia hypertrohpy) Labia minora enlargement is one of the most common or the most common cosmetic problems that present to our doctors for potential surgery. Doctors in our clinic never suggest to a patient their condition is a problem, it is only a problem if the patient believes it is problem for them personally. This condition can cause both functional and cosmetic issues.

Patient functional and aesthetic issues include: • Pain, discomfort, irritation • Pain during intercourse • Physical protrusion wearing certain clothing (underwear, bathing suits) • Poor genital/body image Labiaplasty is usually carried out when there is lengthening (elongation) or asymmetry of the LMin. Any non-malignant formations (e.g. papillomas and condylomas) of the LMin may also serve as a reason for surgical intervention. When labiaplasty was being developed, its objective was to reduce the size of the LMin and to remove pigmentation and excess wrinkles, so the main method was 4.

considered to be marginal (linear) resection. But this method has serious deficiencies associated with loss of sensitivity and of the natural appearance of the vulva. At many clinics, however, this method is used because it is simple to perform.

Outline resection is carried out according to the canons of plastic surgery, using W-Y- and Z-plasty elements. There is virtually no risk of complications when this is done.

When the intervention is carried out, it is best that intradermic sutures are used. One drawback of the method is a lack of efficacy with very distinct pigmentation of the urogenital area.

The de-epithelisation method entails the creation of an elliptical de-epidermised area on the surface of the LMin while maintaining the integrity of the underlying tissues. This is the least destructive method, but still has a number of drawbacks, the most fundamental of which is the lack of potential to use the method with hypertrophy of the LMin to over 4 cm, since in this case their thickness is significantly increased. At the current stage of development of labiaplasty, a combination method is most commonly used, which means outline resection with elements of the de-epithelisation method.

There are dozens of ways and methods of performing this operation, but they all have their own advantages and drawbacks. We have come up with a unique algorithm for selection of a method individually for each patient.

The advantages of the “laser scalpel” over the surgical one come down to a more accurate incision line, absolute sterility and a lack of sutures and scars. The operation time and rehabilitation period are significantly curtailed. LMin correction using a surgical laser is ba5.

sically carried out using a CO2— and Nd:YAG-laser. We also make use of a radio-frequency method to perform labiaplasty. Following a resection, an intradermic cosmetic suture is usually applied. At the end of the operation, a long-lasting local anaesthetic is introduced into each LMin, which enables the patient to return home with no problem on the day of the operation. Since the area of the genitalia features a good blood supply, the mucosa heals quite quickly and no perceptible scars are left behind.

Following the operation, the recommendation is to apply antiseptic agents to treat the wound margins (five to six times a day) for seven days. For two to three weeks it is best not to go to gyms, swimming-pools or saunas. Sexual contacts are ruled out for up to three weeks. The patient will not have any social life for just one to two days. Complications are encountered extremely rarely when a labiaplasty is performed, and they are mainly linked to individual idiosyncrasies of the body. The commonest complications are haemorrhaging lasting more than three hours and the formation of haematomas, which sort themselves out within no more than four days.

We conducted a retrospective analysis of 130 patient outpatient cards following surgical labiaplasty.

Complications were encountered in 12% (15 patients), and these included pain in the area of the postoperative wound that lasted more than three days for 20% (three patients), and LMin hypaesthesia in 46% (seven patients). There was also hyperpigmentation in the post-operative suture zone in 34% of cases (five patients). Through a prospective assessment of the patients’ sexual function before and after the operation, conducted using the Female Sexual Function

30 SEXUAL AESTHETICS I body language

Before and after correction of the hood of the clitoris

Before and after labia majora augmentation

Index (FSFI) questionnaire, we established that the procedure undergone had had a positive impact on the women’s sexual health.

Plastic surgery on the hood (extreme tip or mantle) of the clitoris.

An enlargement of the LMin in the upper third is commonly accompanied by an enlargement of the hood of the clitoris, which leads to an aesthetically unsatisfactory appearance, sexual hypaesthesia and a diminution in sexual satisfaction. Genetics, hormonal changes and the nature of the woman’s sex life may introduce substantial changes into the way the clitoral area looks. A poorly performed labiaplasty, not taking into account surplus skin in the clitoral area, may give rise to a disruption of the structure of this area.

Clitoral hood lift Patients with elongated clitoral hoods benefit from a clitoral hood lift.

The prepuce or the clitoral hood is located directly over the clitoris and acts as a protective barrier to the clitoris. Excess prepuce is actually excessive clitoral hood and is not a second layer but the same original clitoral hood, which is just excessive. It is not a second structure just an abundance of the same structure and usually helps to completely cover the clitoris.

Excess prepuce is not usually removed but only reduced so the patient can have easier access to the clitoral gland for stimulation. The reduction of the excessive prepuce is called “clitoral hood reduction or clitoral hoodectomy.” Most of-

ten this procedure is performed for functional reasons.

At our clinic we carry out surgical correction of folds of skin to the side of the clitoris. At the same time as this procedure, correction of the frenulum of the clitoris is carried out to fix the head of the clitoris in a sexually advantageous position. The clitoris and its nerves are not directly involved in this. The procedure of surgical correction of the hood of the clitoris takes place under outpatient conditions, under local anaesthesia. The procedure takes 30 minutes and the rehabilitation period is seven to 10 days.

Correction of the hood and frenulum of the clitoris using hyaluronic acid products. With congenital developmental anomalies or aggressive surgical intervention in the LMin area, it is possible for a situation to arise where the head of the clitoris is not covered by the hood, as it should normally be.

This leads to constant difficulty when wearing tight underwear, discomfort and a fall in the number and quality of clitoral orgasms.

In this situation the performance of a surgical operation is not possible because of the complexity of the reconstructive techniques and the need for a lengthy rehabilitation period. To correct an existing defect we use high-viscosity gels based on hyaluronic acid which have been specially developed for intimate filling. The procedure takes place under local application anaesthesia and rehabilitation takes three days.

Correction of involution lesions of the labia majora An enlargement of the LMaj may be associated with loss of elasticity and surplus skin, and also with local fatty deposits. Such an enlargement of the LMaj may, when the woman is wearing trousers, bathing costumes and tight-fitting underwear, look like an unaesthetic convexity, and may also cause discomfort associated with enhanced perspiration in the external sex organs. The LMaj may be enlarged from birth, and they may also change after childbirth or with age.

In many women quite large and wrinkled labia are observed following major weight loss, and es-

pecially following bariatric surgery.

To achieve the optimum aesthetic result, a half-moon-shaped flap of skin is excised on the inside of the labia, and the margins are sutured using a cosmetic suture which is concealed between the labia minora and majora. LMaj plastic surgery is carried out at our clinic under local anaesthesia, and the procedure takes 60 minutes.

Another important problem is deformation of the inferior commissure of the LMaj, which in turn gives rise to looseness of the vaginal vestibule and the entry of intestinal microflora into the vagina—the main cause of recurrent infections of the vagina, urethra and bladder.

Labia majora convergence surgery is performed in women who feel that their labia majora diverge away from the clitoris or away from the perineal body.

When viewing a picture or medical illustrations of patients with this problem, they often complain that their labia majora diverge away and don’t come together. This can occur anteriorly above the clitoral hood and posteriorly below the vaginal opening at the perineum.

Surgery can be performed to pull the majora towards the midline to give a more aesthetically appealing contouring of the majora both above and below the vaginal openings.

Labia majora augmentation surgery is actually performed in a similar manner as the lip augmentation of the face. Injectables are used to puff up the area underneath the stretched skin so the wrinkles will be stretched and thus disappear.

The most common injectable is the patients own fat which has been transferred from another area of her body. This is sometimes called an antilogous fat transfer.

To correct the volume of the LMaj, a subcutaneous injection of various fillers is carried out. This is known as intimate filling. Earlier the “gold standard” for LMaj augmentation was lipofilling.

This method entails preliminary liposuction and subsequent introduction of aspirated fatty tissue into the area where correction is intended. Purified fat is gathered from areas of local fatty deposits such as the knees, stomach and thighs, and is then treated by pass-

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32 SEXUAL AESTHETICS I body language

ing it through a system of filters.

Syringes with a volume of 10-20 ml with a Luer-Lock type lock and blunt-ended 14G cannulas are used for the injections. For stabilisation of it and improvement of its regenerative properties, the collected fat is mixed with autologous plateletenriched plasma (PRP) at a ratio of 4:1. Experience in the use of lipofilling in other areas of aesthetic medicine has revealed the negative properties of this method, such as low plasticity, lack of predictability of its effect, and frequent instances of the formation of lipogranulomas and filler migration. The mean frequency of complications when this method is used is 6.6%.

In the available literature there is information on the use of liquid silicone, bovine collagen and a polyurethane biopolymer for LMaj augmentation. The authors themselves, however, mention the high risk of complications, associated primarily with the high level of toxicity of the materials and their capacity to migrate and cause aseptic inflammation.

To achieve the desired aesthetic result and to lower the risk of complications developing, a search was made for a bio-compatible filler with optimal physical and chemical properties. A visco-elastic hyaluronic-acid-based gel that is well known to doctors working in aesthetic medicine turned out to be a suitable candidate. There are numerous products now on the cosmetology market which could be used for plastic surgery to shape face and body. As creators of an original method for intimate filling, we recommend the use of the only filler that is currently legitimate—Bellcontour GVISC (HyalIntertrade S.A. Swiss), which we have been actively using since 2005. The lack of immunogenic properties and migration, lengthy biodegradation and unique rheological properties make this the optimal product for intimate filling. All procedures are carried out under local application anaesthesia, and the procedure time is 20 minutes.

At Professor Yutskovskaia’s Clinic we were the first in Russia to make use of the Pelleve radiofrequency apparatus (Ellman International, USA) for intimate plastic

surgery. This procedure may primarily be of assistance to patients suffering from unsightly enlarged LMaj which have lost their tone.

Patients who previously used to suffer from the so-called “camel toe” (swelling of the LMaj when wearing skintight clothing) may now avoid plastic surgery on the LMaj by undergoing a 30-minute non-invasive procedure.

One question that is under discussion is the use of thread lifting to correct involution lesions to the vulva. We use various Aptos thread systems for this purpose. To correct a loose vestibule and perineum height, the Thread 2G system is used, and the NanoVitis and Excellence Elegance systems (Aptos, Russia) for modelling of the labia minora and majora. Work is currently under way to create a protocol for the performance of this procedure.

G-spot enlargement The G-spot (lip of the urethra, G point, “12 o’clock zone”, G zone, Gräfenberg spot (zone), internal trigger) is the point of projection of the female prostate onto the anterior wall of the vagina, pressure on which may be a way to achieve erogenous stimulation. G-Shot (enlargement of the G-spot) is a trademark registered in 2001 by David Matlock. This is a low-invasive method of tissue augmentation in the anatomical area to increase sexual excitation during coitus. For quite some time, the legitimacy of this procedure was questioned in scientific reports. When on 18 October 2008 the Federal International Committee on Anatomical Terminology (FICAT), based on studies conducted by M. Zaviacic, included the term “female prostate gland” in its Glossary of Terms, all doubts were resolved.

The G-Shot is a painless office procedure performed in our office under local anesthesia. The actual injection usually takes less than eight seconds and the total time in the examination room is usually less than 10-15 minutes. A specially designed speculum is used to assist in the deliver a specified amount of human engineered collagen directly into the G-Spot after local anesthesia. The G-Shot aug-

ments (enlarges) the G-Spot. This results in a G-Spot about the size of a quarter in width, and one fourth of an inch in height (meaning the projection into the vagina). Thus, bringing the woman more in tune with her own sensuality.

The effect can last for up to four months. In a pilot study, 87% of women surveyed after receiving the G-Shot reported enhanced sexual arousal/gratification. Results will vary.

Hyaluronic acid gel is introduced into the submucosal layer in the G-spot area and the gap between the anterior vaginal wall and the urethra, using a drop, linear-retrograde or “fan” technique.

The volume of product introduced is 0.5-3.0 ml. A 25-27G needle is used. This leads not only to an enlargement of the G-spot projection zone, but also to a certain diminution in the volume of the vagina, which is particularly marked during sexual contact at the time of formation of what is known as the “orgasmic cuff”. As a result of the intervention, the G-spot projection zone becomes the most protruding part of the anterior vaginal wall, and more accessible to tactile impact, which increases its sensitivity and thus improves the quality of sexual relations.

The introduction of other fillers, such as autologous fatty tissue, or collagen may lead to unpredictable results and culminate in complications such as descent of the vaginal wall, stress urinary incontinence, bleeding and infection.

One question that is under discussion is the use of thread lifting to correct involution lesions to the vulva

The G-Shot uses HA to enlarge the G-spot

body language I SEXUAL AESTHETICS 33

Conclusion The objective of intimate surgery is to alleviate psychological and/or physical suffering caused by aesthetic or functional deficiencies of the genitalia. Although the number of surgeons engaged in intimate plastic surgery is rising, the increase in patient numbers is being promoted by media activity. Some gynaecologists are unable to comprehend the attitude taken by a woman to her own vulva/vagina. It is becoming clear that modern women have a psycho-biological need to obtain sexual satisfaction as a support for their self-esteem and self-respect.

Modern girls and adult women who perform bikini zone epilation have a clear picture of the perineum, its References 1. Honore LH, O’Hara KE. Benign enlargement of labia minora: report of two cases. Eur J Obstet Gynecol Reprod Biol 1978;8(2):61–64.

2. Hodgkinson DJ, HaitG. Aesthetic vaginal labioplasty. Plast Reconstr Surg 1984; 74(3):414–416.

3. Alter G. New technique for aesthetic labia minors reduction. Ann Plast Surg 1998;40:287–290.

4. Hern ndez-P rez E, Machado A. Fat transplants in male and female genitals.

Am J Cosmet Surg 1996;13:109–111.

5. Kim JJ, Kwak TI, Jeon BG, et al. Human glans penis augmentationusing injectable hyaluronic acid gel. Int J Impot Res 2003;15: 439–443.

6. V International symposium of aesthetic medicine. Moscow, Russia 16–18 February 2006.

7. Yurteri-Kaplan LA, Antosh DD, Sokol AI et al. Interest in cosmetic vulvarsurgery and perceptions of vulvar appearance. Am J Obstet Gynecol 2012;207:428. e1–e7.

8. Herbenick D, Schick V, Reece M, et al.

Pubic hair removal among women in the United States: Prevalence, methods and characteristics. J Sex Med 2010;7:3322– 3330.

9. Konig M, Zeijlmans IA, Bouman TK, van der Lei B. Female attitudes regarding labia minora appearance and reduction with consideration of media influences.

Aesthetic Surg J 2009;29:65–71.

10. Jothilakshmi PK, Salvi NR, Hayden BE, Bose-Haider B. Labial reduction in adolescent population—a case series study. J Pediatr Adolesc Gynecol 2009;22:53–55.

11. Michala L, Koliantzaki S, Antsaklis A.

proportions and beauty standards for it. Intimate images that are actively dispersed via the Internet and other media are helping to consolidate an ideal “image” in women’s awareness—a narrow vestibule and delicate labia minora.

Surgeons performing intimate plastic surgery and having a conflict of interests may unintentionally discredit intimate surgery with modern scientific society and potential patients. It is not worth performing procedures on girls who are subsequently planning to become pregnant and who have not yet achieved sexual maturity. Women wishing to have intimate plastic surgery performed should be made aware of all the possible options for correction of

Protruding labiaminora: abnormal or just uncool? J Psychosom Obstet Gynaecol 2011;32(3):154–156.

12. Essen B, Johnsdotter S. Female genital mutilation in theWest: traditional circumcision versus genital cosmetic surgery. Acta Obstet Gynecol Scand 2004;83(7):611– 613.

13. Scholten E. Female genital cosmetic surgery—the future. J Plast Reconstr Aesthet Surg 2009; 62(3):290–291.

14. Goodman MP, Placik OJ, Benson RH et al. A large multi-center outcome study of female genital plastic surgery. J Sex Med 2010;7:1565–1567.

15. Pardo JS, Sola VD, Ricci PA, et al. Colpoperineoplasty in women with a sensation of a wide vagina. Acta Obstet Gynecol Scand 2006;85(9):1125–1127.

16. Adamo C, Corvi M. Cosmetic mucosal vaginal tightening (lateral colporrhaphy) improving sexual sensitivity in women witha sensation of wide vagina. Plast Reconstr Surg 2009;123(6):212e–213e.

17. Goodman MP, et al. Female cosmetic genital surgery. Obstet Gynecol 2009;113(1):154–159.

18. Gaspar A, Addamo G, Brandi H. Vaginal fractional CO2 laser: a minimally invasive option for vaginal rejuvenation.

Am J Cosmetic Surg 2011 28(3):156–162.

19. Gaspar A. Comparison of two novel laser treatments inaesthetic gynecology. J Lasers and Health Acad 2012;Supplement(1);S10.

20. Brambilla M. Intramuscular-submucosal lipostructure for the treatment of vaginal laxity. Paper presented at: Congresso Internazionale di Medicina Estetica; October 10/2008; Milan, Italy.

the vulva and vagina and examined to see whether they have any pelvic disorders for which proven treatment methods are available. The ethical duties of surgeons in respect of a patient include professional honesty, prevention of any conflict of interests and carrying out the wishes of the patient.

Dr Evgenii Leshunov is a Urogynecologist, genital surgeon, “Clinic professor Yutskovskaya” Moscow, Department of Urology GBOU DPO RMAPO. He is also Scientific coordinator of the International Association of Gender Medicine. The methods of performance of the procedures are described in this article considering the reports of surgeries made in the clinic of Prof Yutskovskaia.

21. Rouzier R, Haddad B, Deyrolle C, et al.

Perineoplasty for the treatment of introital stenosis related to vulvar lichen sclerosus.

Am J Obstet Gynecol 2002;186(1):49–52.

22. Tepper OM, Wulkan M, Matarasso A. Labioplasty: anatomy, etiology, and a new surgical approach. Aesthet Surg J 2011;31(5):511–518.

23. Rezai A, Jansson P. Clinical techniques: evaluation andresult of reduction labioplasty. Am J Cosmetic Surg 2007;24(2)242–247.

24. Alter G. Labia minora reconstruction using clitoral hoodflaps, wedge excisions, and YV advancement flaps. Plast Reconstr Surg 2011;127(6):2356–2363.

25. Choi HY, Kim KT. A new method for aesthetic reduction oflabia minora (the deepithelialized reduction of labioplasty).

Plast Reconstr Surg 2000;105(1):419–422, discussion 423–424.

26. Felicio YA. Labial surgery. Aesthet Surg J 2007;27(3):322–328.

27. Vogt PM, Herold C, Rennekampff HO. Autologous fat transplantation for labia majora reconstruction. Aesthetic Plast Surg 2011;35(5):913–915.

28. Kilchevsky A, Vardi Y, Lowenstein L, Gruenwald I. Is the female G-spot a distinct anatomic entity? J Sex 2012;9:719–726; 29. ZaviacicM, ZaviacicT, AblinRJ, et al. The human female prostate: history, functional morphology and sexology implications.

Sexologies 2001;11:44–49.

30. Юцковская Я.А., Лешунов Е.В. Женская пред-стательная железа. Современные возможности малоинвазивной коррекции сексуальных дис-функций. Пластическая хирургия и косметоло-гия 2013;2:307–315

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body language I TECHNIQUE 35

Private pathology DR ALESSANDRA SCILLETTA discusses carboxytherapy as an option for vulva-vaginal rejuvenation

F

emale sexual dysfunction is age-related, progressive and highly prevalent in 30-50% of women.

Whilst there are emotional and relational factors related to female sexual response and functionality, female sexual dysfunction is a result of organic vascular and hormonal pathologies.

Vulva vaginal atrophy is a common and under-reported condition associated with decreased eostrogenisation of the vaginal tissue. It can occur at any time of the woman’s life, but is even more common during the postmenopausal phase in up to 50% of women. In situations other than menopause, vulva vaginal atrophy may result spontaneously, although lactation is another cause of hypo-estrogenic states. This has interesting implications when we consider that child bearing age for many women is in their mid thirties. We must also remember that hormonal decrease can begin at 35 years old—so at 40 years old the first sign of atrophy is noticeable, especially in the labia majora.

You may think that most patients are ladies of 60 or 70 years old, but many women present to me in their forties.

Symptoms Dyspareunia, dryness, irritation, soreness and post-coital bleeding are just some of the symptoms women are finding that we have to investigate. A lot of women have post-coital bleeding but they are

ashamed to address this with a gynaecologist or their doctor.

Often when we examine we can see the presence of the pale and dry mucosa, with petechiae. There is visible change to the external genitalia in the vulva, as a result of the connective tissue and fat deposits under the skin reducing and causing a shrinkage of the vulva. The labia majora becomes less pliant, looser and the hood of skin covering the clitoris retracts.

Treament options Many treatments are possible, including laser, radiofrequency, fillers, surgery, botox and bio stimula-

tion, but the most common given is vaginal lubricants or hormonal replacement. Similar to treating the face, we aren’t limited to selecting just one type of treatment for the vulva—as aesthetic practitioners we can integrate and combine techniques to give the best results in terms of naturalness and function. The choice of therapy depends on the severity of the symptoms, the effectiveness and the safety of therapy for the individual patient and of course their preference. Part of this decision-making also has to include the patient’s economic situation, because since this is a functional problem—not

36 TECHNIQUE I body language

1a

1b

1a: This lady is 48 years old with between third and second degree atrophy. The atrophy is not bad, but the clitoris position is out of the labia majora. 1b: The stimulation of carboxytherapy can induce the collagen and give this kind of result.

2a

2b

2a and 2b: This patient received five carboxytherapy sessions. The initial result is lifting effect, which is then followed by increased volume. To increase and improve the vaginal introits more is possible fill with hyaluronic filler in the lower part.

merely an aesthetic one—there are many ladies seeking help who have a reduced budget.

How does carboxytherapy work?

Carboxytherapy is the transcutaneous administration of medical carbon dioxide for therapeutic purpose, using very tiny 30 gauge needles. It’s not a new treatment, but it’s application for vulva vaginal refreshment is. Carbon dioxide is a colourless, odourless gas that represents the final product of our organic metabolism. We exhale carbon dioxide in every minute of our life, and since its always present in our blood, we know it’s non-toxic.

It does not cause embolism, thanks to the carbonic anhydrase enzyme that combines the carbon dioxide with the water to produce bicarbonate and proteins.

The first effects noticeable after CO2 injections are strong vasodilatation, blood flow increase and higher pO2 in the treated area. The

Bohr effect describes the tendency of haemoglobin to have less affinity for oxygen, when CO2 blood concentration is increased. This lower affinity leads the haemoglobin to release oxygen better in superficial tissues and muscles and so even induce the release of vascular endothelial growth factor (VEGF), endothelial proliferation, vascular permeability, angiogenesis and the vasodilatation, as demonstrated in a very important publication.

Why use carboxytherapy?

We know that there are several causes of female sexual dysfunction besides the decreased levels of oestrogen and the atrophy of female hormones. Vasodilation, angiogenesis, vascular endothelial growth factor stimulation, and even the vascular pathology are contributory factors. Dysfunction can also be caused by pelvic floor blood flow reduction, due to arteriosclerotic pathologies of the ilio hypogastric and pudendal arterial

bed (blood supply to lower limbs), causes vaginal fibrosis and clitoris muscle fibrosis. Futhermore, surgical or post-partum traumas or diabetes, can lead to vaginal orclitoris vascular insufficiency with consequent sexual dysfunction.

For women who have had an episiotomy there is also the problem of the surgical and the postpartum trauma of cutting that muscle. Plus several recent studies show that menopausal and elderly women who don’t receive hormone replacement therapy have a reduced blood flow, leading to thinning of the vagina and all associated problems of sexual dysfunction.

66 The first effects noticeable after CO2 injections are strong vasodilatation, blood flow increase and higher pO2 99

SC LE A ER TH RO CPD Thursday 28th April, The Ark Conference Centre, Basingstoke

Venue The 2016 BAS annual meeting will be held on Thursday 28th April 2016 at the Ark Conference Centre, Basingstoke.

10 minutes from the M4 or Basingstoke train station, 40 minutes from Southampton airport.

Programme The day will include a full programme of eminent speakers and a variety of interesting demonstrations, and will offer opportunities to network—we hope to see you there!

Accommodation There will be an optional dinner the previous evening, and overnight accommodation can be arranged nearby.

Registration Registration will open at 9am for a 9.45am start, and the meeting will end at 4pm, followed by the members only Annual General Meeting.

Don’t miss the premier CPD event of the year for sclerotherapy practitioners Eminent speakers from the field of phlebology and sclerotherapy include Mr Philip Coleridge Smith, Dr Stephen Tristram, Dr Martyn King and Dr Savita Rangarajan among others. Topics include:  Compression after sclerotherapy  Complications of foam and liquid sclerotherapy, and how to avoid them  Should I be worried about DVT in my patients?  The best technique for sclerotherapy of telangiectases and reticular varices  Effective marketing for your business  Demonstrations of foam and microclerotherapy, with ample opportunity to question the experts

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38 TECHNIQUE I body language

For the external genitalia, five or six micro-injections of carbon dioxide can be used to stimulate and replenish the blood supply, improving circulation in the area and reactivating the closed capillary mechanically. This activates the draining process and also the metabolic process, thanks to the Bohr effect. The effects are cumulative.

Technique The technique for the external genitalia is very simple. In many countries carboxytherapy has a very bad name for being painful—and it certainly is with the old devices that use cold gas, so I don’t recommend trying to treat genitalia with these. The new devices, which heat the gas to 43 degrees, should be used on a low flow, in small quantities. I recommend giving six to eight sessions in total, with no more than one session each week.

3a

Generally we suggest one session every three months.

Evidence In an interesting report from a group of gynaecologists, led by Adrian Gaspar1, he carried out treatment on two groups of ladies—40 treated with local hormonal replacement and 40 treated with endovaginal carboxytherapy. The biopsy carried out on all the ladies before and after, showed clear improvement of the symptoms of vaginal atrophy and proliferation of mucosal epithelium.

If the ladies are young and not in menopause, carboxytherapy can be used alone, or in combination with laser or filler or radiofrequency, but for older women a combination will certainly be necessary.

Summary Carboxytherapy, is a procedure that improves not only cosmetic appear-

ance, but improves vaginal function and even the sensation. This is a lunchtime procedure that you can combine, as you want, with other techniques, because when you improve the micro circulation you improve the results of even other techniques.

Dr Alessandra Scilletta has a degree in medicine and surgery and a postgraduate diploma in plastic and reconstructive surgery. She has cooperated in the writing of various scientific publications and is currently the medical director of a private surgical practice and the International scientific consultant at Maya Beauty Engineering Reference 1. Elias J, Gaspar A.: Carboxytherapy local treatment of vaginal mucosa atrophy or hypotrophy of vaginal mucosa at menopausa and postpartum.

International Journal of Gynaecology and Obstetrics 119 (2012) s:563-564

3b

3a: This client presented with atrophy. I proposed lipo filling and she refused the surgical procedure because she had a very low budget and wanted only hyaluronic filler. In this case I needed a minimum of 3 or 4 ml of hyaluronic acid, so we did five sessions of carboxytherapy. 3b: One month later this was the change that the vulva had during the month. And on this basis I injected only one syringe of filler, thanks to the stimulation of the carboxy.

4a

4b

4a: This woman was treated with carboxy to stimulate her own collagen. She was in a post oncological phase, breast cancer free for eight years, but treated with tamoxifen. I had to use a lubricant for the treatment because she was very dry. Note the paleness of the internal mucosa. 4b: After this patient was treated with endovaginal laser I did two sessions of carboxytherapy to restore and improve the micro-circulation of the area. And after hyaluronic acid – not filler – I used bio stimulation to improve the appearance and the functionality of the introitus.

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40 INJECTABLES I body language

Eye Boost MRS SABRINA SHAH-DESAI shares her understanding of the tear trough and her innovative new treatment

A

s an ophthalmic plastic reconstructive surgeon, trained in facial plastic surgery relating to the eyes, the periorbita and the central face, my aim has always been improving aesthetic outcomes for patients who have disfiguring conditions/ disease, congenital anomalies, and skin cancers.

When patients come to me seeking out treatment for under eye dark circles or puffy eyes, the common denominator is understanding the causative factor for an individuals tear trough deformity, in order to optimise the outcome. The tear trough is not forgiving and it’s certainly not as forgiving compared to other facial areas. There’s a risk of blindness, granulomas, swelling and Tyndall to name a few.

I have developed a new treatment called the Eye Boost, based on my experience managing tear trough complications and reflecting on experience with patients who seek more natural looking results. Poor techniques using large boluses of one type of filler, typically “sausage” when you animate as they lie at a confluence of the three muscles which are being constantly used when talking/smiling.

Eye boost, uses Restylane Vital light, which works well alone or in combination with deep tear trough filler treatments, to give natural looking results.

What is the tear trough?

Historically, the tear trough was described in 1961 by greats like Duke Elder and Wybar who were essentially describing the medial concavity at the border of the eye-

body language I INJECTABLES 41

The tear trough is not forgiving and it’s certainly not as forgiving compared to other facial areas

lid and the cheek, but they called it the nasojugal groove. The term tear trough was coined by Loeb and Flowers in 1969 and once again referred to the medial one third of the periorbital hollow. The concept was that the tear trough hollow formed at a confluence of three muscles; the levator labii superioris alaeque nasi, the levator labii superioris and the orbital portion of the orbicularis muscle.

In 2009 Haddock and his group carried out dissections and reported that involutional changes in the

66 I always inject with the patient sitting up and looking up—so that the entire tear trough is unmasked and the location of the fat pads is obvious 99 tear trough were occurring at a biplanar level, a deep sub muscular plane, (mainly soft tissue involutional changes involving descent and deflation of the sub orbicularis

oculi fat pad, malar fat pad, the cheek fat pad), and a subcutaneous plane (between the skin and orbicularis muscle).

It was only in 2012 that the tear trough anatomy was formally described. The trough ligament extended from the medial canthus to the medial border of the pupil and then it continued onto the lid and cheek in a bilaminar structure called the orbital retaining ligaments.

The tear trough ligament is a true osteocutaneous ligament, running from the skin through the orbicularis muscle and attaching to the orbital rim. It is only during the last five years that we’ve really had a clear understanding of the anatomy of the tear trough and understood that along the tear trough, the orbicularis muscle is attached directly to the bone. Along the lid/ cheek junction, the attachment is ligamentous by means of the orbicularis retaining ligament, which has implications on the plane of filler placement.

Technique As the anatomical causes of a tear trough deformity are multiplanar, I often use different techniques and fillers to volumise different parts of the tear trough/lid-cheek junction in the same patient. I prefer to use the needle, rather than cannula, as in my hands this gives precise augmentation where it’s required. I inject supraperiosteally, using a light touch. The key message is—less is more.

I always inject with the patient sitting up and looking up—so that the entire tear trough is unmasked and the location of the fat pads is obvious. I look at the pre-aponeurotic fat pads and try and blur the demarcation lines between the eye socket rim and fat pads. These are supra-periosteal injections and I’m careful not to go post-septally, be-

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Before treatment, after Eye Boost, and after lid-cheek junction deep filler

cause this could worsen the appearance of any puffiness.

For a type 2 trough—I use a retrograde injection technique, and for a type 3 trough I use a 3 point injection technique and retrograde injection. I often use a layered technique—Perlane/Emervel deep for the lid-cheek junction and Restylane Lido/Emervel classic for the medial tear trough.

Tear trough treatments are technically the most challenging because this area is fraught with capillaries, blood vessels and the vital anatomy of the eyeball underneath. Precise volume augmentation becomes extremely challenging because the instant the injection has been delivered, there’s the chance of bruising or swelling.

It’s very easy to want to over-inject and erase the concavity and it’s very easy not to understand the product you’re using. I see a lot of patients who’ve had overfilled tear troughs and then they come to me for dissolution.

Skin Something that we all ignore is skin. When you have really thick, smooth skin in the under eye area with minimal or no skin pigmentation, then you achieve the best results from your tear trough treatment.

Eyelid skin is different anatomically. Although we talk about the tear trough and we focus on tear trough ligament and the deformity, what we forget is the eyelid skin. It’s the thinnest skin in the human body, has virtually has no subcutaneous fat, is low on oil glands, but sadly very high in pigment cells. That pigmented

Tear trough classification In order to better describe the clinical types of tear trough deformities, Hirmand published a classification in 2010. I use this clinically to guide my decision making as regards the type of filler to be used, the plane of injection and to estimate the volume of filler required.

1.

Class 1—a medial volume loss with a mild flattening.

2.

Class 2—a much more defined tear trough. The volume loss involves the medial and the lateral cheek and some moderate central flattening.

3.

Class 3—full depression, medial to lateral with advanced volume deficiency between medial and central cheek, and malar eminence. These are the kind of patients that would benefit from six point lifts rather than class 1 and 2 tear troughs.

44 INJECTABLES I body language

1a

eyelid skin meeting the cheek skin, which is not that pigmented, worsens a visual appearance of a tear trough. Because the skin is already thin and it’s low on oil, it’s much more prone to photo ageing than anywhere else.

Eye Boost I’m often approached by women in their mid-30s, who’ve had babies and sleepless nights and have fat prolapse adjacent to a thin tear trough skin. This will not be resolved with one tear trough injection and this is what led me to start developing the Eye Boost technique. This involves a very gentle hydra rejuvenation of the tear trough skin using a skin booster, which is Restylane Vital Light.

There is evidence to show that Vital Light improves hydration, improves the skin structure, improves fine lines and volumises.

It’s been used on the décolletage and on the back of the hands. Vital Light contains only 12mg per ml of hyaluronic acid and it has a smooth formulation—so it’s really fine particles and this is important because the tear trough area is so unforgiving, especially if the skin is very thin and you really don’t want to inject thick particulate material into it.

My guide for patient selection for highest success for this treatment, based on my experience, is young patients in mid 20s to early 40s with thin infra-orbital skin.

Procedure Just like any surgical procedure this is a completely sterile injection technique. The Eye Boost technique is multiple subdermal injec-

1b

tions, 10 microlitres per point. I use the SmartClick of Restylane Vital, so I’m not really watching the syringe, I’m just watching the blebs but I’m hearing the click. In a total, I would give anywhere from 0.1ml to 0.5ml per tear trough, just subdermally.

This technique is very safe, there’s no theoretical risk of blindness from vascular injury. However bruising is expected, as the injections are just sub-dermal, between 5 to 30 points over the area of the thin skin.

Precautions with injection technique Be sure to keep injections to stay within the thin eyelid skin and not inject into the thick skin of the cheek. Don’t inject just under the medial canthus because you’ve got the lacrimal sac (or the tear drainage sac) and the angular vein and artery.

Side effects Bruising lasting a couple of days is an unavoidable side effect of this treatment. All patients get swelling, lasting a few days, during which time I tell them to apply ice to the lid. However, it is important to counsel your patients about visible bumps for up to a week, which settle with gentle massage.

Conclusion Vital Light has a promising future to address thin under eye thin skin, which can worsen the illusion of under eye hollows or puffy eyelids. It restores the hydro balance, improves the structure of skin. My patients report that their skin looks radiant and they don’t need to wear

1c

heavy makeup, or thick concealer for their dark circles. Patient selection is key, this is not appropriate for all patients, and certainly won’t erase pigment in the skin.

However it is an exciting new tool in the toolbox, to rejuvenate a challenging under eye area.

Mrs Sabrina Shah-Desai is an leading UK accredited Consultant Ophthalmic Plastic Reconstructive surgeon, with private practices in London and in Greater London.

1a: Lady in early 30’s with under eye “eye bags” seeking non surgical rejuvenation. 1b: Immediately after 0.5ml of Restylane Perlane in central and lateral tear trough and 0.5 ml of Restylane in medial tear trough.

1c: Four weeks after Restylane Vital Light in the lower eyelid skin.

References 1. Duke-Elder S, Wybar KC. The eyelids. In: DukeElder S, editor. System of Ophthalmology: Anatomy of the visual system. Vol. 2. St Louis, MO: C V Mosby CO; 1961.

2. Loeb R. Naso-jugal groove leveling with fat tissue. Clin Plast Surg. 1993;20:393–400.

3. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg.

1993;20:403–15.

4. Plast Reconstr Surg. 2009 Apr;123(4):1332-40 tear trough and lid/cheek junction: anatomy and implications for surgical correction. Haddock NT1, Saadeh PB, Boutros S, Thorne CH. 5 The Tear Trough Ligament: Anatomical Basis for the Tear Trough Deformity Wong, Chin-Ho. Plastic & Reconstructive Surgery: June 2012, Volume 129, Issue 6, p 1392–1402.

6. Anatomy and Nonsurgical Correction of the Tear Trough Deformity, Haideh Hirmand, M.D. Plast Reconstr Surg. 2010; 125:699–708).

7. A comprehensive examination of topographic thickness of skin in the human face. Chopra K, Calva D, Sosin M, Tadisina KK, Banda A, De La Cruz C, Chaudhry MR, Legesse T, Drachenberg CB, Manson PN, Christy MR. Aesthet Surg J. 2015 Nov;35(8):1007-13 8. J Drugs Dermatol. 2013 Sep;12(9):990-4. Stabilized hyaluronic acid-based gel of non-animal origin for skin rejuvenation: face, hand, and décolletage.

Streker M, Reuther T, Krueger N, Kerscher M.

46 DERMATOLOGY I body language

Skin rejuvenation Dr Zein Obagi discusses designing a treatment plan for optimal results

T

he popularity of skin rejuvenation procedures has increased exponentially over the past decade as a result of increased patient interest and technological advancements.

Patients are becoming better educated and more aware of different treatment options for skin rejuvenation via the Internet and media coverage. In addition, more practitioners are now offering skin rejuvenation procedures of varying degrees in clinics, malls, salons and spas, and on the High Street.

This convergence has resulted in consumer confusion about which treatments and products are safe and most effective, and how to sort through the myriad options on offer.

Skin rejuvenation redefined Skin rejuvenation is not just about selecting a cream to improve the skin’s surface. Nor is it about one type of procedure, such as a laser or other energy-based device, a chemical peel, dermal filler or neurotoxin injections. It is also not just about undergoing invasive surgery, such as a facelift, blepharoplasty or browlift.

My philosophy of skin rejuvenation is a comprehensive treatment plan with a combined approach.

This includes the art of transforming skin to its original state through use of: • Topical agents that restore general skin health.

• Topical agents to treat existing disease (acne, rosacea, actinic keratoses, etc.) when they are present.

• Procedures (lasers, energy-based devices, chemical peels, fillers,

and/or neurotoxins) when topical agents alone do not completely restore skin to its original state.

Restoring and maintaining skin in its optimal original state is the main objective of skin rejuvenation.

This is accomplished by designing an appropriate topical protocol and overall treatment plan that is appropriate for each patient’s needs.

The optimal plan should be based on selecting: • Topical agents that restore general skin health and treat any concurrent skin disease.

• When indicated, adding an appropriate procedure, based upon its mechanism of action and the desired result.

• When choosing a procedure, identifying the safe depth of penetration for a particular skin type, to ensure maintenance of skin integrity and a natural appearance.

After classifying the patient’s skin and making the diagnosis, the practitioner should formulate a comprehensive treatment plan that includes both short and longterm goals. The plan must clearly inform the patient of the reason for each part of the overall plan.

Monitoring patient compliance with short-term treatment recommendations, for example, assessing the patient’s daily use of a comprehensive topical regimen, allows the practitioner maximal control over the entire process.

Preventing photodamage Photodamage is a universal problem that can affect any skin type. It starts at an early age (two to three

66 My philosophy of skin rejuvenation is a comprehensive treatment plan with a combined approach

99

years old), and is undetectable initially. However, as a person experiences more sun exposure over the years, damage becomes clinically significant, as localised and generalised pigmentation increases, and texture (wrinkling, loss of elasticity) become apparent.

Unfortunately, many skin care professionals as well as consumers

The best way to address photodamage is not to have it occur in the first place

body language I DERMATOLOGY 47

7 STEPS OF SKIN REJUVENATION TREATMENT PLANNING  Classify the patient’s skin (according to colour/ethnicity and thickness)  Diagnose condition(s to be treated  Treat any active disease  Maintain the objective of restoring skin health while initiating a plan for skin conditioning with daily topical products prior to any planned procedures  If one or more rejuvenation procedures are indicated, choose them based upon the procedure’s mechanism of action to the depth of the condition being treated  Have a clear plan for expediting recovery, minimising potential for post-procedural complications, and for treating them if they do occur  Establish a comprehensive, effective post-procedure maintenance regimen

do not recognise sun damage until it becomes severe and extensive, for example when actinic keratoses and skin cancers appear. Thus they ignore the early signs of photodamage that are more easily corrected, such as tanning, freckles, and lentigines.

Recognising and treating photodamage in its earliest stages will help patients avoid the more severe and clinically challenging types of photodamage, and perhaps, more importantly, to prevent all photodamage, which is our ultimate goal.

The best way to address photodamage is not to have it occur in the first place. This requires going beyond basic sun protection, and incorporating my four Key Principles of Skin Health Restoration that are imperative to teach your patients: 1. Avoid tanning—skincare professionals must educate consumers so they know that tanning reflects DNA damage and a host of unhealthy skin changes that can have major consequences over time.

2. Do not rely on sunscreens alone—regardless of how high the sun protection factor (SPF), chemical and physical sunscreens wear off after one to two hours.

Research shows consistently that people under-apply sunscreen and fail to reapply it often enough.

3. Practice sun avoidance—wear protective clothing (wide-brimmed hats, long pants and sleeves); pursue outdoor activities before 10 AM or after 4 PM, with adequate sunscreen and protective clothing.

4. Adopt a healthy skin protection programme as part of a daily routine: • Load the skin with antioxidants (four to six types) in a proper formulation that also provides DNA protection and repair agents • Enhance skin barrier function by using appropriate concentrations of retinol and AHAs daily, and before applying sunscreens.

• Increase the skin’s ability to repair and renew itself by following a skin care program that provides effective stabilization of the epidermis (keratinocytes and melanocytes) and the dermis (fibroblasts).

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48 DERMATOLOGY I body language

 ZO SKIN HEALTH OLLUMINATE INTENSE EYE REPAIR Targeted to help repair and prevent signs of ageing for all skin types and intended to be used in the AM and PM. The formula contains Retinol (vitaine) to stimulate epidermal renewal and collagen production and even skin tone, along with vitamin E, potent peptide Matrixyl 3000 to promote collagen and elastin production, MDI complex that mimics glycosaminoglycans to restore hydration and inhibit matrix metalloproteinase enzymes to prevent the breakdown of collagen.  ZO MEDICAL HYDRAFIRM EYE BRIGHTENING REPAIR CRÈME Hydrafirm is specifically designed for the delicate eye area to minimise puffiness, discolouration and fine lines and support skin elasticity that diminishes with age.

Key ingredients include retinol and hydrolyzed sericin for collagen stimulation, kojic dipalmitate to target pigment production, saccharomyces lysate extract, carnitine, coenzyme A, and caffeine to promote microcirculation to reduce puffiness, as well as shea butter and squalane for skin lipid and barrier replenishment.

skin from HEV light. Iron oxides and mica offer a unique pressurerelease colour system for customisable skin tone, and tetrahexyldecyl ascorbate is incorporated to promote pigmentation inhibition.

Eyelid rejuvenation treatments The delicate eyelid area is one of the first places that signs of ageing tend to appear, mainly due to prolonged sun exposure. Brown spots, fine lines and wrinkles, sagging, herniated orbital fat are among the age-related changes that affect the eyelids and patients complain about most.

Skin discolouration is caused by cumulative sun exposure and sun spots often begin to appear in the mid-30s just below the eyes.

Fine lines form around and below the eyes that are exacerbated by

sun exposure. Dynamic wrinkles caused by repetitive facial movements are also related to ageing; for example, parallel vertical lines that form between the eyebrows in the glabella, crow’s feet in the lateral corners of the eyes, and horizontal wrinkles that run across the forehead. Under eye bags are caused by a combination of loose skin and protruding pockets of fat.

With advanced age, the muscles of the lower eyelids tend to weaken, skin becomes lax, and more fatty deposits get stored that bulge forward and become more visible.

In addition, hollow grooves may develop under the eyes in the tear troughs that create the appearance of dark shadows.

Treatment options for eyelid rejuvenation include neurotoxin injections to soften dynamic lines and wrinkles, dermal fillers and fat

to plump hollows, TCA peels, lasers and light based treatments to improve skin laxity and discolouration. Older patients may also benefit from upper and lower blepharoplasty to remove excess skin and fat if needed, and tighten loose muscles. Another commonly used technique is fat transfer where fat is repositioned from the lower lid to fill in the groove.

Selecting a treatment plan for your patients must also include topical agents to maintain a youthful and healthy skin condition.

We have developed two essential eye treatments in the ZO range to target the key components of eyelid ageing.

Dr Zein Obagi is a board certified dermatologist in Beverly Hills, Calif. and the Medical Director of ZO Skin Health (zoskinhealth.com) and is responsible for the development of new skincare treatments, protocols and products to achieve healthy skin.

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ZO Skin Health, Inc. and Dr. Obagi have no business relationship with Obagi +1 949 988 7524 www.zoskinhealth.com r. Obagi have no businessMedical relationship with Obagi Products, and Obagi Medical Products does not sell or endorse using +1 949 988 7524 www.zoskinhealth.com agi Medical Products doesZO not sell or endorse using Inc.“ZO” and DrisObagi have no business relationship withHealth, Obagi Medical anySkin ZOHealth, product. a registered trademark of ZO Skin Inc. Products, and Obagi Medical Products does not sell or endorse using any ZO product. “ZO” is a registered trademark of ZO Skin Health, Inc. registered trademark of ZO Skin Health, Inc. 28/08/2012 14:42:22

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DAY 0

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PATENTED DERMA-AESTHETIC SKINCARE

body language I HAIR LOSS 51

Medical treatment for hair loss DR PAUL FARRANT discusses licensed and unlicensed products for the treatment of male and female pattern hair loss

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e’re all familiar with typical male pattern hair loss, the bitemporal recession, the thinning over the crown and then the balding over the vertex. The pattern in women is probably slightly less well recognised.

Characteristically, there’s a preservation of the frontal hairline. There may just be broadening of the part line initially and then thinning

over the vertex but this is usually incomplete loss.

What they have in common is miniaturisation of the hair fibre.

So, instead of nice, thick terminal hairs, they become much finer.

Everyone has some fine vellus hairs like the ones on young babies, and with ageing the numbers of fine hairs increase again. But when is it recognised as a problem? Some variability of hair fibres is normal but greater than 20% miniaturised

66 What male and female pattern hair loss have in common is miniaturisation of the hair fibre—instead of nice, thick terminal hairs, they become much finer 99

hairs is considered abnormal. These tiny little hairs don’t really contribute to the density of the scalp.

The old model of how hairs were arranged, was a single hair follicle with the fibre, single arrector pili muscle and a single sebaceous gland as standalone units.

It’s now known, largely from working with hair transplantation, that hairs grow in follicular units and that gatherings of hair follicles may share an arrector pili muscle and sebaceous glands. What’s different in pattern hair loss is a decrease in the number of hairs that are growing together in follicular units.

Some of those thicker hairs start to be lost and hairs become arranged in clusters of one and two hairs, rather than a nice, thick four or more hairs per unit. It’s been postulated that when this progresses,

52 HAIR LOSS I body language

the fine hairs become disassociated from the arrector pili muscle and it’s not really clear what the function is of that. However, it’s also been suggested that this then leads to those hairs being irretrievable from medical therapies—so you can’t then make those bigger.

Hair lifecycle The dermal papilla is really key for the size of the hair fibre; the bigger the dermal papilla, the bigger the hair fibre that results. That’s largely due to the matrix, which sits on top of the dermal papilla—the rapidly dividing cells that produce your hair fibre.

Most hairs will spend the majority of their time on the scalp in a

growing phase. This is the anagen growth phase, and on the scalp will last five, six or more years. When hairs reach the end of their growing phase, the hairs will regress, and enter into the telogen phase, where not a lot happens for a couple of months until the old hair is shed, in what’s called exogen. Now what also sits in that timeline is a phase where the follicle can remain empty, called kenogen. The major difference in pattern hair loss is that the growth phase becomes much shorter, so the anagen growth phase may only last a few months, not years. More hairs are going to be in the regression phase, and moving into telogen, so there’s an increase in shedding. The other

difference is that hairs will spend more time in empty kenogen phase.

What is driving this change in hair life?

It’s been known for many decades that the process in men is largely driven by testosterone, and particularly it’s product dihydrotestosterone or DHT, and that is driven by the enzyme 5-alpha reductase.

Changing levels of testosterone doesn’t have to be excessive for hair change to occur. There may be an increased sensitivity in susceptible patients. It’s been shown that there is an increase in the androgen receptors in the dermal papilla in balding areas on the vertex of the scalp, as compared with non-bald-

The dermal papilla is really key for the size of the hair fibre; the bigger the dermal papilla, the bigger the hair fibre that results

body language I HAIR LOSS 53

sible to try and prolong the anagen growth phase.We can also alter the amount of DHT by stopping it being produced from testosterone. In the future, I envisage research into trying to activate those stem cells that are still present during the thinning stage.

Minoxidil This was first developed in the 70s as an antihypertensive, minoxidil has been around for a number of decades now. Initially it wasn’t a very reliable antihypertensive, but lots of patients developed hypertrichosis (excess hair growth) at generalised body sites, so research was done from here to develop something that would be useful for balding. It got converted into a lotion at 2% strength in the 1980s and then subsequently, a 5% lotion in the 90s, and now a foam.

It works in both sexes, in all ages and it works for the majority of patients. What Minoxidil is doing is holding the hairs in the anagen growth phase and it is more effective in stopping hairs becoming miniaturised, rather than reversing them so the key here is treating early. The 2% is licensed in women, and the 5% is in men, because their skin is generally less sensitive.

The 5% is thicker, more sticky and more irritating, but can be used by women.

Patients must be warned that when they start minoxidil, they can get a temporary hair shedding ing areas. The DHT binds to the androgen receptor and then there’s a cascade, that ultimately leads to the decrease in the anagen growth phase in the finer hair.

Recently it’s been shown that men that are balding have the same number of stem cells in the balding areas as the non-balding areas.

But with further study it emerged that they had much less of the progenitor cells—the daughter cells of stem cells—which then produce more and more cells. So, something is holding back the stem cells from their normal replication.

Following microarray gene analysis, the same researchers found that prostaglandin D2 synthase was markedly elevated and it’s thought

that prostaglandin D2 being elevated in balding scalps is holding back those stem cells.

For women, testosterone is certainly less relevant. It may be of some relevance in younger women, and the presence of prostaglandin D2 as far as I’m aware, has not yet been studied, or certainly not been published.

Medical management options The medical options, in terms of managing this are not great— things aren’t as good as we would like them to be, as yet—but there are a couple of main strategies though. Looking back to that anagen phase being very short, it’s pos-

Fine vs thick hairs

54 HAIR LOSS I body language

many pages and forums of very angry people, who will put lots of side effects down to being on Finasteride. However most patients tell me that they don’t even know they’re taking anything and when you talk to hair experts they don’t experience problems with any alarming frequency but of course all drugs have the potential to cause side effects.

This female patient was treated with minoxidil alone for generalised thinning. You can see the part line initially much more visible, now filled in. The whole density and the hair is much more luscious

over the first six to eight weeks, as the hairs are pushed through the hair cycle. If they are not warned about this, they’ll start using it, the hair will start to come out more, and they’ll stop straightaway.

Minoxidil is dissolved in propylene glycol and that’s what makes it irritating. Patients who experience irritation may benefit from converting to the foam because that doesn’t contain propylene glycol.

Very rarely, someone can become allergic to the minoxidil chemical, a type four hypersensitivity, and if that happens, then they can’t have any minoxidil products.

There is a dose-related benefit. There is very little published evidence that all the extra ingredients that get added to minoxidil make a big difference, so I recommend caution about the cost of any products over regular minoxidil, because these are products people have to use lifelong, if they want to maintain hair thickness. If usage stops, the hair goes back to where it started.

Prostaglandin E2 and F2 Analogues These agents were traditionally thought to prolong the anagen phase, but they may now link in with the stem cell story. Glaucomabased treatments added to the eye, were shown to cause increase in eyelash length and thickening.

Another recent publication has shown success in using Prostaglandin E2 and F2 to treat this in idiopathic hypertrichosis and

in chemotherapy patients during the regrowth phase, accelerating regrowth of lashes. They are yet to be fully investigated on the scalp, so what we don’t know as yet, is whether they have any extra benefit over minoxidil. Currently they’re not licensed, nor available in a size or preparation that makes them easy to use.

Treatment for men In terms of altering male hormones, there are two main drugs that are 5-alpha reductase inhibitors and only one is licensed for male pattern hair loss. Finasteride is most commonly used, with Propecia being the best know brand.

This drug stops testosterone being converted to the highly active dihydrotestosterone. It’s very effective in preventing further hair loss and does that in the majority of men. About two thirds of men will get a very modest thickening. There are some potential side effects, including loss of libido (less than 5% men) and impotence (less than 1%), but this is reversible when drug use stops. A Google search of side effects of Finasteride, or Propecia, reveals

Dutasteride Dutasteride works against both 5-alpha reductase inhibitors. As with any drug, it’s important to question each client’s individual benefit, compared to the profile of side effects. It may be worth trialling in men, if they have had a very poor response to finasteride.

Is targeting male hormones in women relevant?

The consensus is, it’s probably useful to trial in premenopausal women. In women of child bearing age taking an antiandrogen product, has the ability to feminise a male foetus so women taking these medicines need to take measures to prevent pregnancy. The use of antimale hormone medications is probably not relevant in the older age groups (60-plus) and the benefit is unclear in the perimenopausal group—there may be some benefit but we don’t really know and a trial may be justified.

In younger patients combined pills can have benefit, as can HRT in the postmenopausal group and that’s due to the oestrogen component. Oestrogens are generally good for female hair growth and they can be combined with some progestogens. Some progestogens have an antiandrogenic property, in particular, cyproterone, drospirenone and desogestrel. Combining oestrogens in a pill that contains one of those progestogens is

66 In terms of altering male hormones, there are two main drugs that are 5-alpha reductase inhibitors and only one is licensed for male pattern hair loss 99

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56 HAIR LOSS I body language

a good idea, although it’s probably best to avoid progesterone-only products because there’s no oestrogen benefit.

Drugs for women Cyproterone acetate probably has more antiandrogenic propertiesby decreasing androgen production and increasing the testosterone clearance. It can be given at low doses, combined with an oestrogen as a pill or can be given in much higher doses for ten days of the cycle. This is used, predominantly, as a treatment for hirsutism and it’s very effective. It is used in female pattern hair loss but there’s actually little evidence that it causes regrowth of hair in women. The biggest side effect women will complain of with antiandrogen therapy is weight gain. There is also concern that as a combined contraceptive pill it has a slightly higher risk of thromboembolic events such as deep vein thrombosis (DVT) and pulmonary embolus (PE). For patients with risk factors, such as smoking, obesity, or family history, it should be used with caution or avoided.

Another commonly used drug is spironolactone, which is a potassium-sparing diuretic and has a number of different properties that are all antiandrogenic. Doses should usually be started fairly low, although, this is quite a high dose for its blood pressure indications.

A typical starting dose may be25 mg or50 mg, building up to 100 mg, once or twice a day, probably morning and lunchtime, so they don’t create diuretic effects in the evening. Side effects are menstrual irregularity, occasional mood swings and changes to potassium balance. Neither finasteride or dutasteride are licensed in women at all, however, they do have a potential role in treating younger women, providing you give them adequate counselling and take the pregnancy prevention side of things seriously.

Can we reactivate stem cells?

Trying to stop the enzyme PGD2 synthase, or block it having an ef-

fect on a receptor is a possibility.

There were drugs that were developed for rhinitis and asthma to block this receptor but they didn’t work so they got abandoned at phase 2. However, it is thought that these drugs may have a role in reactivating stem cells.

Summary In men, minoxidil is very well tolerated, finasteride is pretty well tolerated, and together they can hold hair or allow some modest regrowth. If there’s a very poor response, Dutasteride and oral minoxidil, are alternatives.

In premenopausal women, minoxidil combined with a hairfriendly contraceptive pill is a very good starting point and then if there’s still thinning problems, adding in spirolactone or 5-alpha reductase inhibitors under specialist supervision is an option. In post-menopausal women, minoxidil is the only option. If women are on HRT, then switching to a hair-friendly HRT like Angeliq is possible.

Medical therapies are only one component of managing pattern hair loss. Light devices, camouflage and alternative therapies may also play a role. Our understanding of hair biology offers new insights and the potential to new therapies.

Dr Paul Farrant is a consultant dermatologist working in Sussex with clinics in Brighton and Hove and Haywards Heath. His main clini-

cal interest is hair disorders.In 2011, Dr Farrant set up the British Hair and Nail Society to bring together dermatologists and allied professionals interested in treating patients with hair loss. The Society aims to improve information for the public, enhance education and training for dermatologists, develop UK clinical research and provide a forum for dialogue between specialists and scientists to further our understanding of hair conditions.

This man had a lot of early changes bitemporall, before and two years in. Although the change is not huge, with two years of progression in a premature hair loss patient, you would expect this to be getting worse and it’s holding.

References 1. Sci Transl Med. Author manuscript; available in PMC 2012 Apr 5. Published in final edited form as: Sci Transl Med. 2012 Mar 21; 4(126): 126ra34. doi: 10.1126/ scitranslmed.3003122 2. Prostaglandin D2 Inhibits Hair Growth and Is Elevated in Bald Scalp of Men with Androgenetic Alopecia Luis A. Garza,1,* Yaping Liu,2 Zaixin Yang,1 Brinda Alagesan,1 John A. Lawson,3 Scott M. Norberg,1 Dorothy E. Loy,4 Tailun Zhao,1 Hanz B. Blatt,1 David C. Stanton,5 Lee Carrasco,5 Gurpreet Ahluwalia,6,† Susan M. Fischer,7 Garret A. FitzGerald,3 and George Cotsarelis1,‡ 3. Johnstone MA. Hypertrichosis and increased pigmentation of eyelashes and adjacent hair in the region of the ipsilateral eyelids of patients treated with unilateral topical latanoprost. Am J Ophthalmol. 1997;124:544– 547.

4. Cohen JL. Enhancing the growth of natural eyelashes: the mechanism of bimatoprost-induced eyelash growth. Dermatologic Surgery 2010; 36:1361-1371.

5. Glaser DA, Hossain P, Perkins W, Griffiths T, Ahluwalia G, Weng E, Beddingfield FC. Long-term safety and efficacy of bimatoprost solution 0·03% application to the eyelid margin for the treatment of idiopathic and chemotherapy-induced eyelash hypotrichosis: a randomized controlled trial. British Journal of Dermatology 2015; 172(5): 1384-94

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58 PRODUCTS I body language

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body language I PRODUCTS 59

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body language I NON-SURGICAL 61

Injection lipolysis Although surgery remains the most effective way of fat reduction there is an increasing need for and success of non-surgical facial and body fat reduction treatments. MR TAIMUR SHOAIB reports on his research and results.

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here is an ever-increasing demand for treatments with minimal recovery.

Busy people want to come in for a short time frame, have their treatments, go home, and see the results. Those who want more of a result are happy to have more treatments as necessary, and patients keen to consider non-surgical alternatives to treatments or conditions that have been traditionally treated with surgery are happy to return several times for a course of treatment.

Fat reduction is no different.

Injectable fat reduction treatments have a history of success. In terms of energy based treatments, there are contact radiofrequency devices on the market including Vanquish, Indiba, Accent, Endymed, Exilis, amongst many others, which will perform lipolysis to a mild to moderate degree.

There are also non-contact methods of radiofrequency such as using the Vanquish machine and there are also cryolipolysis and ultrasound cavitation based

methods for performing medical fat reduction.

In terms of fat reduction injectables, phosphatidylcholine was used in the past. Aqualyx is currently available, and in the US, the FDA has recently approved Kybella for fat reduction.

VASER treatment can have a dramatic effect for clients at the submental region and in the jawline. Radiofrequency treatment has a mild to moderate effect in both lifting, and in fat reduction—it would be very difficult to achieve such dramatic results from most non-surgical treatments. When performing gynaecomastia treatments with VASER, a visible skin tightening effect and a reduction in fat that is surrounded by glandular hyperplasia is apparent.

Phosphatidylcholine Phosphatidylcholine was first used in 1988, to help treat xanthelasma, the fatty deposits seen in the eyelid region. It was subsequently used off label for fat reduction for pockets of fat that were resistant to diet and

exercise in places like the flanks, the double chin region and in the abdomen. It was also used for the treatment of fat emboli, following surgical treatments.

Insurance companies were happy for doctors to be using Lipostabil, (phosphatidylcholine) about ten years ago. However, the MHRA website, now states that the off label use of lipostabil, particularly for cosmetic fat reduction will be looked upon unfavourably. Effectively that is the end of phosphatidylcholine as a fat reduction method. Patients doing their research, may come across this MHRA information about Lipostabil online and see that it is not something that we would want to use.

Aqualyx Aqualyx works as a detergent as an emulsifying agent, disrupting the fat cell membrane. Injection into the fat is followed by ultrasound to mobilise the fat, and to allow it to enter into the extracellular matrix, and for transport and metabolism.

62 NON-SURGICAL I body language

This patient was treated with liposuction and a facelift, because there was excess skin that needed to be tightened.

However, because it’s a medical device, not a drug, it has a CE mark not a drug licence.

Aqualyx contains desoxycholan acid, which releases fat content from the cell into the extracellular fluid, by disrupting the cell membrane. Two thirds of patients say it is worth it, but that is only based on 11 reviews over 24 months on the RealSelf website.

However, since it is a medical device, it has not gone through some of the more rigorous testing processes that drugs will go through.

Kybella Kybella, is a new drug that has been recently approved, as deoxycholic acid—for the improvement and the appearance of moderate to severe convexity or fullness associated with submental fat in adults, though other sites are not recommended.

Kybella is available in the USA for injection into the double chin region, and is a cytolytic drug—it destroys the cell membrane, the fat is then released into the extracellular matrix, and the fat is released and transported and subsequently metabolised by the liver. It is a bile salt, and bile is excreted in our faeces, so I fear to ask their source!

FDA drug approval means much more information is available about complications and

the mechanism of action, and the method of injection. Drugs are much more heavily regulated than medical devices. We know that there is a 4% risk of marginal mandibular palsy, with an average six week return to function, in all patients that suffer weakness or an asymmetric smile after the treatments. There may also be some difficulty in swallowing.

We can say that 72% of patients will have bruising, or haematoma and that it’s exceedingly common to have swelling and numbness, erythema and indurations. Obviously, it’s contraindicated in the presence of infection, as are most of our cosmetic injectables, and injections that are too superficial may lead to skin necrosis.

We can say that 96% of patients will have an injection site reaction of some kind, and 10% of these will last more than a month.

Treatment with Kybella Treatments are given are with 0.2 ml injections based 1.0 cm apart and the practitioner can give up to 50 injections, (a total of ten ml) which is one vial of the drug.

The recommendation is six treatment sessions, a month apart, which is six-month’s worth of treatment. The manufacturers claim that the results will be mild to moderate improvements, for

moderate to severe convexity in the area.

As with any treatment, the relevant anatomy and the associated neuromuscular structures must be understood. The location of lymph nodes and the submandibular gland must be considered, plus where the marginal mandibular gland is, and if the patient has had surgery before, or has had any treatment to the submandibular area with another treatment either surgical or non-surgical. It’s essential that any alterations to the anatomy is understood prior to giving this drug.

As a surgeon, I still tell clients that better results are possible with surgery. If there is excess skin that needs to be tightened, it can be done either with surgery in terms of the facelift, or with non-surgical treatments, like radiofrequency. The disadvantage of invasive treatment is scarring although three to four weeks after a facelift, and submental liposuction, this will fade.

Conclusion An FDA approved product for mild to moderate improvements in the double chin now exists. Although the results are mild to moderate improvement, it is nevertheless a non-surgical solution for something that was traditionally treated with surgical solution in the past.

The information from Kybella is a lot more than the information that we have from Aqualyx. Drugs are tested far more extensively than a device, and I think that’s good for the industry. I hope to see the arrival of Kybella into the UK, fairly soon.

Mr Taimur Shoaib is a specialist consultant plastic surgeon on the General Medical Council’s specialist register for plastic surgery. He is a former Consultant in the NHS at the Glasgow Royal Infirmary, a Consultant at the Glasgow BMI and Nuffield private hospitals, a consultant at La Belle Forme Clinic in Glasgow, an Honorary Senior Clinical Lecturer in the Faculty of Medicine at the University of Glasgow and a Faculty Member of the Allergan Medical Institute.

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OPTIMAL

Cohesive Polydensified Matrix® (CPM®) Technology1,2

I N T E G R AT I O N 2

Optimal tissue integration2

TISSUE

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BEL/37/MAR/2016/LD Date of preparation: March 2016

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The filler you’ll love

Contact Merz Aesthetics NOW and ask for Belotero Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com 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.

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