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The UK Journal of Medical Aesthetics and Anti-Ageing















SKIN HEALTH MELANOMA EPIDEMIC Patient education and prevention strategy


LIFESTYLE AND AGEING The effect of diet on skin ageing processes



GREATER WORKING COMFORT The syringe feels light in the hand, with a more comfortable finger grip and thumb rest1 Comfortable grip and thumb rest

SmartClick™ system

STURDY AND SECURE CONSTRUCTION Secure Luer lock system for robust needle and cannula attachment Tamper-proof seal for patient and clinician security ERGONOMIC FLOW Low extrusion force, comparable to equivalent systems on the market2


Restylane Skinboosters give great results when small amounts are distributed evenly3 The new SmartClick system audible dosage indicator delivers ~10 µL microdroplets for every subtle click Lets you focus on your injection technique rather than the amount injected

Restylane® stands for innovation as the original nonanimal HA dermal filler. With over 20 million treatments worldwide, we are now injecting even more innovation: new delivery systems for Restylane and Restylane Skinboosters™ that are designed to give you improved comfort, control and precision. To find out how smarter tools can help in your daily practice contact your local Galderma representative today.

Easily switch the dosage indicator on and off, for added treatment versatility THE TWO NEW DELIVERY SYSTEMS ARE COMPATIBLE WITH: Thin walled needles for improved flow rates and lower extrusion force2 pix’L flexible microcannulas for minimally invasive treatments4, 5 References: 1. Galderma Restylane fillers Data on File (4) 2. Galderma Restylane fillers Data on File (5) 3. Streker M et al. J Drugs Dermatol 2013;12(9):990-994 4. Galderma Restylane Skinboosters Data on File (6) 5. Galderma Restylane fillers Data on File (3)

RES/016/0414 Date of Preparation April 2014

body language I CONTENTS 3




contents Contributors Dr Timothy Flynn Dr Stefanie Williams Dr Carl Thornfeldt Dr Mervyn Patterson Dr Hema Sundaram Dr Mukta Sachdev George Cotterhill Will Cotterhill Dr Dennis Wolf Dr Daniel Sister Dr Kambiz Golchin Dr Fraser Duncan Dr Alain Gondinet Dr Xavier Abad Dr Ines Verner Mike Murphy Per-Arne Torstensson

Editor Helen Unsworth 020 7514 5981 COMMISSIONING Editor David Hicks 020 7514 5989 Editorial Assistant Arabella Tanyel 020 7514 5989 Sales Executive Monty Serutla 020 7514 5976 Assistant Sales Executive Simon Haroutunian 020 7514 5982 Publisher Raffi Eghiayan 020 7514 5101 ISSN 1475-665X The Body Language® journal is published six times a year by FACE Ltd. All editorial content, unless otherwise stated or agreed to, is © FACE Ltd 2014 and cannot be used in any form without prior permission. The single issue price of Body Language is £10 in the UK; £15 rest of the world. A six-issue subscription costs £60 in the UK, £85 in the rest of the world. All single issues and subscriptions outside the UK are dispatched by air mail. Discounts are available for multiple copies. Printed by Buxton Press Ltd. Enquiries, orders and all other mail should be addressed to Body Language, 2D Wimpole Street, London, England, W1G 0EB. To contact Body Language by telephone, please call us on +44(0)20 7514 5989. Editorial e-mail: Advertising: Body Language can be ordered online at

7 OBSERVATIONS ANALYSES Reports and comments

13 Communication How to improve consultations Employing an attentive and reassuring approach to your patients can increase retention and build confidence. Dr Timothy Flynn describes the tricks and techniques that can help to build a successful doctor-patient relationship

17 Nutrition Lifestyle and ageing By cutting out the healthy fats needed for optimal skin function, many low-fat diets can cause accelerated skin ageing. In the first of a two-part series, Dr Stefanie Williams investigates the effects of diet on skin ageing processes, particularly oxidative stress, glycation and inflammation

23 Dermatology The melanoma epidemic With skin cancer rates quadrupling in the last 40 years,

patient education and a daily prevention strategy could help to slow the incidence of malignant melanoma, write Dr Carl Thornfeldt and Dr Mervyn Patterson

31 Injectables Growth opportunity Skin actives are an increasingly popular component of skin rejuvenation treatments, providing a cascade of collagen stimulation and wound healing. Dr Hema Sundaram describes the benefits of topical and injectable treatments, involving growth factors and platelet-rich fibrin matrix

37 Equipment Transdermal drug delivery The barrier function of the stratum corneum is vital to protect the skin and underlying structures, but it can serve as a barrier for topical aesthetic treatments. A combination of radiofrequency and ultrasound can help increase skin permeability and allow for topical product penetration, writes Dr Mukta Sachdev

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.

40 Conference The UK’s premier medical aesthetic conference and exhibition returns to London on June 20th — 22nd

Fractional radiofrequency for skin rejuvenation and tightening, as well as for scars and stretch marks, can offer minimal complications for skin of colour, writes Dr Ines Verner

53 Marketing

69 Lasers

Showcase your clinic

Thermal energy levels

Using video content on your website is the ideal way to engage prospective clients, improve your Google rankings and build trust. George and Will Cotterhill explain why it is the marketing choice for the future

Heating of the skin triggers different processes at different temperatures, resulting in a variety of outcomes. Mike Murphy and Per-Arne Torstensson discuss the effects of heat shock proteins and collagen denaturation when treating the skin at variable temperatures

FACE 2014

57 Forum Platelet rich plasma

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.

An expert panel aims to demystify the often perplexing topic of platelet-rich plasma therapy systems, and offers their recommendations for obtaining optimal results

65 Devices Sublative rejuvenation

72 Products On the market The latest medical aesthetic products and services

76 Training Thirst for knowledge Courses and seminars for medical aesthetic practitioners 57


Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or

rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: November 2013. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2012 September Available from: URL: 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1139/BOC/NOV/2013/LD Date of preparation: March 2014



Endocare® contains SCA Biorepair Technology the unique snail derived growth factor complex sourced from nature and refined by science to clinically rejuvenate visibly aged skin*: Reduction of lines & wrinkles  Increased elasticity & tightness  Enhanced texture, tone & luminosity 


The Skin; anatomy & physiology, functions & mechanisms, ageing & problem conditions


Evidence based skincare ingredients and products


Client consultations and evidence based regimes



© AesthetiCare® 2014 6593/04.14


*Gold et al, Journal of Drugs in Dermatology, 2013

body language I NEWS 7


NEw BoDY coNtouRiNg commiSSioNiNg guiDE Guidance addresses “unfair” postcode lottery for weight loss patients In March, the British Association of Plastic Reconstructive and Aesthetic Surgery (BAPRAS) and the Royal College of Surgeons (RCS) published a new commissioning guide on body contouring to address the ‘postcode lottery’ of care faced by patients who have lost significant amounts of weight. Massive weight-loss, whether through a health regime or via bariatric surgery, often results in excessive, sagging fat and skin, as the tissue lacks the elasticity to bounce to the reduced body size. Research has shown that patients who undergo body contouring to remove and/or tighten the redundant skin, demonstrated significant benefits to their all-round wellbeing over those who had not, with improvements to physical function as well as emotional state and body image satisfaction. In developing this guide, BAPRAS and RCS are attempting to address the regional variation and inconsistency faced by patients in England highlighted in recent studies. For example, one paper showed that 23 out of 67 Primary Care Trusts excluded all postbariatric surgery body contouring; another that 38% of patients approved for post-bariatric body contouring in Scotland would not have met the requirements to receive the treatment in Leeds. With morbid obesity on the increase, there will be more people undergoing drastic weight loss. But without access to body contouring, these patients are more likely to endure physical and mental discomfort, as well as a greater risk of regaining the weight. The guide recommends that

body contouring be offered to those who had a starting BMI of above 40 (or above 35 with co-morbidities), a current BMI of 28, weight stability of 12 months and a significant functional disturbance. Current smokers will be excluded from treatment, as well as those with active psychiatric or psychological conditions who would benefit from treatment prior to a referral. The guide contains an extensive questionnaire for both the patient and clinician to help assess whether a patient should be referred for the major reconstructive surgery. The guide makes clear that a psychological assessment would be part of any referral process. The new guide concludes with future recommendations, including a request for central funding for body contouring and the development of a compulsory register of operations and complications. Mark Soldin, BAPRAS specialist in body contouring surgery and

consultant plastic surgeon says: “I’ve seen many patients whose lives have been transformed through receiving body contouring reconstructive plastic surgery. However, there are many other people who, simply due to their postcode, are denied this procedure and are left to deal with the huge physical and psychological problems caused by excess skin. “We are calling on commissioners and GPs to use this carefully researched, NICE accredited guidance to put an end to people living in limbo, and enable them to live healthy happy lives.” Paul O’Flynn, Consultant ENT surgeon and Council Lead for commissioning at the RCS says: “We hope that this guide will help to create equality in provision of body contouring surgery for patients across England and stop unfair postcode lotteries which are denying patients desperately in need of treatment.”

8 NEWS I body language

events May 7-10 May, 10th European Association of Dermato-oncology (EADo) congress, vilnius, Lithuania w:

11-13 juNE, Spanish Society of Aesthetic, plastic and Reconstructive Surgery 49th congress, granada, Spain w: 17-19 juNE, 36th Asia pacific Dental congress, Dubai, uAE w:

8-11 May, Australian Society of Aesthetic plastic Surgery Non-Surgical Symposium, Sydney, Australia w:

18-22 juNE, 10th Annual vegas cosmetic Surgery, Las vegas, uSA w:

9-11 May, FaceEyesNose, coventry, uK w:

20-21 juNE, 1st AmEc DAcH, Berlin, germany w:

15-17 May, 22nd Annual world congress on Anti-Aging, Regenerative & Aesthetic medicine, orlando, Kissimmee, uSA w:

20-22 juNE, faCE CoNfErENCE aNd ExhibitioN, loNdoN, uk W: faCECoNfErENCE.CoM

17-18 May, iApAm Aesthetic medicine Symposium, Scottsdale, Arizona w:

24-25 juNE, genotoxic impurities, Berlin, germany w:

22-24 May, AmcSA, cSiR, pretoria, gauteng, South Africa w:

24-28 juNE, 68th Annual meeting of the canadian Society of plastic Surgeons, montreal, canada w:

22-24 May, French Society of Aesthetic plastic Surgeons 17th congress, tours, France w:

25-28 juNE, 14th world congress of Endoscopic Surgery, paris, France w:

22-25 May, 11th EADv Spring Symposium, Belgrade, Serbia w:

28-29 juNE, Advances in medicine, Hong Kong, china w:

27-31 May, AAFpRS 11th international Symposium, New York, united States w: 29-31 May, European Association of plastic Surgeons 25th Annual meeting, Lacco Ameno, ischia, italy w:


4-6 juNE, Rome Breast Surgery Symposium, Rome, italy w: 5-7 juNE, Beauty through Science, Stockholm, Sweden w: 6-7 juNE, Summit in Aesthetic medicine, St. Regis, Dana point, uSA w: 6-8 juNE, ohio valley Society of plastic Surgeons 57th Annual meeting, west virginia, uSA w:


6-11 july, 12th Quadrennial congress of the European Society of plastic, Reconstructive and Aesthetic Surgery (ESpRAS), Edinburgh, uK w:

BREASt LiFtS oN tHE RiSE Augmentation procedures in US show slower annual growth The American Society of Plastic Surgeons (ASPS) has recently released statistics showing that while breast augmentation is still the most performed cosmetic surgery on women, breast lifts have been growing at twice the rate. In 2000, fewer than 53,000 breast lifts were performed, while by 2013, there were over 90,000; an increase of 70%. Breast augmentation operations, however, have only grown 37% since 2000, although 290,224 were performed in 2013. A breast lift, or mastopexy, is requested to combat droopy breasts; a common legacy of motherhood, weight-loss and ageing. The surgeon performs the reshaping procedure by removing pleats of skin underneath the breast rather than

inserting an implant as with augmentation, creating a firmer and tighter breast. The nipple is also repositioned at a higher level so that it sits on the point of the ‘new’ breast. A lift will not significantly change the size of the breast nor will it round out or fill the upper part of the breast, but lifts can be performed in conjunction with implants, increasing the fullness of the breast above the nipple. Alongside the increase in numbers of patients seeking breast lifts, there have been improvements in methodology leading to less scarring following the procedures and a reduction in recovery times. ASPS President Dr Robert X Murphy says many women are seeking a procedure using the tissue they already have. “The ideal candidate for a breast lift is a women who has a good amount of breast tissue left, who doesn’t necessarily want to have implants. “Many women aren’t sure if they are a candidate for this type of surgery, but a simple pencil test can tell them if they are. If the breast tissue holds the pencil in place against the chest that implies that there’s a hanging nature to the breast that can fixed with a lift.”

10-11 july, medical Devices Summit west, Newark, uSA w: 26-31 july, pain Review course, San Antonio, uSA w: 29 july – 3 auGuSt, Australasian Society of Aesthetic plastic Surgeons 37th Annual conference, Hobart, Australia w: 31 july – 3 auGuSt, imcAS Asia, Hong Kong, china w: Send events for consideration to arabella@

3D pRiNtiNg uSED to REpAiR cRASH victim’S FAcE Pioneering technique offers hope for trauma patients Maxillofacial surgeons at Swansea’s Morriston Hospital in Wales have been able to reconstruct the face of a 29-year-old patient with the help of 3D printing. Stephen Power suffered horrific injuries following a motorcycle crash in September 2012 including breaking both his arms, his right leg, both cheek bones, both eye sockets and upper jaw, as well as fracturing his skull. Surgeons were unable to repair his left cheek and eye socket to avoid doing further damage to his eye. The team, led by consultant maxillofacial surgeon Mr Adrian Sugar, spent eight months virtually planning how to repair Mr Power’s face. The team printed 3D models of Mr Power’s cranium from scans and were able to create precise guides as to how they would cut and reposition the bones and plates to hold the bones in place. The team also printed the medical grade titanium implants that were used in the eight-hour surgery. According to Mr Sugar, the technology allowed the team to be far more accurate than they would have been if working ‘freehand’, leading to better results for the patient.

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body language I NEWS 11

FiLLER gEL ActS AS iNcuBAtoR FoR BActERiA Subcutaneous lumps caused by infection rather than allergic response Recently published research by the Department of International Health, Immunology and Microbiology at the University of Copenhagen, has shown that subcutaneous lumps which may occur in patients following dermal fillers are caused by bacterial infection rather than allergic or auto-immune reactions as previously thought. Filler injections are now the second most popular non-surgical cosmetic procedure in the USA, and are growing in popularity across the world. But as popularity increases, so does the number of adverse events, such as stubborn, tender lumps or lesions which can lead to permanent disfigurement. The research was conducted using tissue from patients and mouse

models and showed that not only are disfiguring lesions following dermal filler injections caused by bacteria but also that the fillers themselves act as incubators for infections. Once the bacterial material, known as biofilm, has developed, antibiotics are ineffective. The research also showed that that the sustainability of the bacterial infections depended on the longevity of the filler itself; the less permanent the gel, the less the bacterial growth. Associate Professor Thomas Bjarnsholt says that many cosmetic practitioners refuse to accept that filler side effects are caused by bacteria, so treat the problems with steroids. “This is actually the worst possible treatment because steroid injections exacerbate the condition and give the bacteria free reign. “Fortunately, many of the filler producers have now become aware of the risk of bacteria and recognise that the gel can act as a bacterial incubator,” Professor Bjarnsholt says. The team estimate that between 1:100 and 1:1000 patients, depending in the type of filler used, will develop a bacterial infection following a filler injection. However, there does appear to be a silver lin-

ing. Morten Alhede, a postdoc on the team, says: “[t]he good news is that infections can be prevented by prophylactic antibiotic treatment, i.e. injecting antibiotics together with the filler itself during the cosmetic treatment process. Our new research emphasises how important it is for all practitioners to follow this procedure to prevent unwanted complications.” The results of the research have been published in April’s issue of Pathogens and Disease.

iNJEctABLES FAvouRED ovER NoN-BREASt AEStHEtic impLANtS Less invasive treatments preferred for natural results A report by Medtech 360 entitled “US Markets for Nonbreast Aesthetic Implants 2014” has found that the US market for non-breast aesthetic implants—such as facial and body contouring implants— will decrease as patients choose non-surgical alternatives such as facial injections or fat transfer. The findings by the market intelligence group highlight that many patients now prefer facial fillers over implants, not only because the latter is more invasive, but because the former is temporary and facilitates more natural facial

movement, leading to a better aesthetic outcome. Similarly, fat transfers are more requested than body contouring implants as the results are more natural looking. The frequency and severity of complications associated with implants, such as malposition or displacement and capsular contracture, may be pushing patients away from implants. Negative media coverage of other augmentation procedures, such as gluteal injections with unapproved materials, are often confused with implants, potentially deterring patients.

LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE) site(s) or when the targeted muscle shows excessive weakness or (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection Date of preparation: March 2013

atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

<1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013

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


body language I COMMUNICATION 13

How to improve consultations Employing an attentive and reassuring approach to your patients can increase retention and build confidence. Dr Timothy Flynn describes the tricks and techniques that can help to build a successful doctor-patient relationship


osmetic patients need special attention because they are different from medical patients. They’re often busy, successful people. You have to respect their time and you have to be understanding when they are more demanding of you. You are there to advise and assist them to look better. These patients want a streamlined, first-class visit. Providing lots of personal attention is helpful—consider their own little waiting area. Make them feel special and valuable. Encourage your staff to spend extra time with them, to talk to them and make them feel that they are the most important person in the world. The most important person in your office So, if the patient is the most important person in the world, who is the most important person in your office? It’s your telephone receptionist. This is your practice interface. This person reflects you. Make sure you have somebody in place who speaks well, who is intelligent and who has been well-trained. We’ve heard stories of patients who are experiencing vascular compromise from fillers. They get home, call the receptionist and say, “I have a purple mark over my lip.” If the receptionist doesn’t know what they’re doing, they’ll dismiss it, saying, “It’s just a bruise. Don’t worry about it.” Your staff need to know the right questions to ask, such as: “Have you had fillers before? Have you ever had this kind of bruising before? Is it painful? Does it seem to have a pattern? Does it go away from the area that it was injected?” If there is a possible impending vascular problem, this person must know how to deal with the complication. It’s about your reputation

Make your patients feel special and valuable

and the patient’s end result. Our waiting area has an openplan architecture and we have a young, smiling person who is willing to greet patients. We do not have a sliding glass window at the desk, where a hand juts out and an disinterested voice asks you to sign a form. We want to make people feel comfortable and welcomed. Cosmetic patients are looking for a great experience and a great result; and they are willing to pay for it. They want excellence. Some are looking for bargains, of course. But do you want those people as your patients? No, because they’re always looking for a “deal”. You could treat them once and perhaps give them a little something extra, or discount their first treatment. But then they’ll be on to the next freebie from another provider. Using discount sites such as Groupon for cosmetic treatments is a bad idea—people looking for bargains will buy that single coupon and then wait for the next Groupon deal from somebody else. This is not a way to build a practice. Great patients are friendly and likable, and they have a sense of humour. You need to make sure they’re trying to improve their appearance and not other aspects of their life: “My husband is having an affair. What can you do for me?” Keep an eye out for the warning signs of difficult patients.

Listen, listen, listen There are some simple tips on how to interact well with your patients. Think of interviewing the patient; listen to their concerns and complaints, and address their fears. We’ve learned that fear of pain is a huge barrier to people getting cosmetic treatment. The number one thing you can do is listen to the patient. The act of listening builds a therapeutic bond, which increases their confidence in you as the injector and, later, provides patient satisfaction. It helps the patient clearly dictate what their goals are and then you can help them. Listening helps you determine who’s a good patient and who’s a really great patient. You want a great patient. They are people who express themselves well. Sometimes, when consulting with a patient, you ask them, “What can I help you with?”, and they say “Well, it just looks so… it’s… you know.” You offer them a mirror. When you ask, “Can you show me?”, they reply, “No. I hate to look.” You therefore don’t know what that person is after. They don’t know what they’re after. They’re feeling rather bad and they’re not there for a specific reason. You have to get them to express themselves. You want a patient who has realistic expectations. They might say, “My problem is this particular frown line that my mother had,

14 COMMUNICATION I body language

that I am now developing and I hate it. What can you do about it?” They’re open to your suggestions. We’ve all had people who come in, stating they need Botox for the treatment of nasolabial folds. You try to assure them that they need a filler, but they’re adamant they want Botox; they’re not listening and they’re not valuing you. You probably can’t make them happy. One tip on how to listen well is to position yourself equal to or lower than the patient. You make them feel empowered. You’re also looking carefully at their eyes and, at the proper distance, you can also watch how their face animates. They’re aware that you’re listening to them, which builds confidence. Another trick is to set down your pen or shut the screen on your laptop. The motion of stopping what you are doing shows that you’re paying attention. It’s a time marker, and tells them that you are going to focus and listen to them. Practice “the pause”. Your patient tells you about their problem or concern. You start talking about how to help, then pause, and then resume conversation—they’re anticipating that you’re thinking about their situation. A pause also allows them to elaborate, giving you valuable information. A mirror is a great tool, too. Have the patient hold a mirror and a cotton bud, and have them point out to you exactly what they’re talking about. Repetition is a simple technique, but very useful. Tell the person exactly what they have just told you. If they say, “I really don’t like

my crow’s feet,” you say, “So, what you’re saying is, you really don’t like your crow’s feet.” They don’t hear the repetition. They think, “He understands, he’s going to help me.” You’ve established a connection with your patient.

A mirror provides an effective way for the patient to explain their problem

Understanding beauty You also want to reassure the patient that you understand iconic and modern beauty. Subscribe to women’s magazines and read the beauty section. What are the beauty editors thinking about and talking about? That’s what your patients are reading about. Know it. You want to show the patients you understand irreducible beauty elements—clarity, symmetry, harmony and colour. Use words like “flawless skin” and “even-toned complexion” when you’re talking about clarity. For a patient with some asymmetry, discuss restoring symmetry. Restore harmony and address colour. You have to remove dyschromia in the skin to achieve beauty because it’s part of the full package. Tell the patient you can use bleaching agents, minor peels or laser; and they certainly need a sunscreen. A medium-depth chemical peel for sun damage is very quick and easy to do. You can improve the way their skin looks. Have the nurse show your actual before and after pictures. There is nothing wrong with showing an imperfect result. You can show the patient that while you didn’t achieve what you wanted here— this person needs more volume, for example—flip the page and show them what you really can do for them. Show them the results from combination treatments and you can get a patient who wanted something simple and they then say, “Let’s do a combination approach. I’d like to see how I’d look.” Freebies Should you sometimes give a little extra, for free, for your patients? The positive argument is that these are good customers and everybody likes a little something extra. Pay a little more attention to them; the simple rules for human interaction. But the negative is that the patient may expect the freebie every time.

You have to make very clear what you’re giving away and what you’re not. If you live in a very demanding environment or you’ve had a lot of patients who are always looking for a bargain, you may want to avoid that. On the other hand, it can be very helpful for patient retention. We use the Merz Aesthetics Scales regularly in the clinic. The lip fullness scale is particularly helpful—somebody might want their lips augmented but they have a difficult time telling you how much they want. If you pull out the scale, which is derived from reallife lips, you can show them what is achievable and what isn’t. You have to educate them. One thing to remember is that many people do not understand the proper orientation of the lip. They may ask why you need to treat the lower lip in addition to the upper lip. It’s because of their anterior projection. Not many people look in the mirror at their anterior projection, but the world sees in three dimensions. Lips look strange if you don’t get the correct balance. You also want to emphasise that your current approach addresses beauty elements and proportions. I tell my patients that I “don’t do funny-looking”. That may sound odd but by that, I mean that I’m not going to make them look unnatural. You want to tell people that you understand “looking better”. You could tell them that you’re seeing a lot more people getting treated with cosmetic procedures. Tell them about surveys and data; top treatments and top areas for those treatments. Patients appreciate that you know what you’re talking about. If you consult correctly with the the cosmetic patient, listening to them and paying attention to their needs, you’ve got a great future and you will have a great practice. Dr Timothy Flynn is clinical professor of the Department of Dermatology, University of North Carolina at Chapel Hill. He is also Medical Director of the Cary Skin Center in Cary NC, USA, and immediate past President of the American Society of Dermatologic Surgery

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1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150. 5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

BEL092/0314/FS Date of preparation: April 2014



Indicated for painful topical treatments on large surface skin areas up to 900cm2*

Effective pain control from 30 to 60 minutes*

Well tolerated with low incidence of erythema†



PRESCRIBING INFORMATION LMX4 Lidocaine 4% w/w Cream is a topical anaesthetic containing 4% w/w Lidocaine in a liposome base. Indication: Venous cannulation or venipuncture: Adults including the elderly and children over one month of age. Local anaesthetic for topical use to produce surface anaesthesia of the skin prior to venous cannulation or venipuncture. Dose and method of use: Apply 1 to 2.5g of LMX4 Cream to the area of the skin where the procedure will occur. No more than 1g of cream should be applied to children under 1 year of age, 1g of cream equates to approx. 5cm of cream squeezed from the 5g tube or approximately 3.5cm of cream squeezed from the 30g tube. The LMX4 Cream should remain undisturbed on the skin and can be covered with an occlusive dressing to prevent disturbance. Adequate anaesthesia should be obtained after 30 minutes, but the LMX4 Cream can be applied for up to 5 hours under a dressing. Shortly before starting the procedure the LMX4 Cream should be removed with clean gauze and the procedure site prepared in the usual manner. Maximum application time for 1 year and above should not exceed 5 hours. Maximum application time for 3 month up to 12 month infant should not exceed 4 hours and maximum application time for 1 month up to 3 month infant should not exceed 60 minutes. Indication: Painful topical treatments on larger surface areas of intact skin: Adults, including the elderly. Local anaesthetic for topical use to produce surface anaesthesia of the skin prior to painful topical treatments on larger surface areas of intact skin. Apply approx. 1.5g to 2g LMX4/10cm2 of skin up to a maximum of 900cm2. Apply until response is achieved which is generally between 30 to 60 minutes. Typical estimated quantities are 30-40g/200cm2 (approx. © AesthetiCare® 2014 6593/04.14

10cm x 20cm or covering a face), 45-60g/300cm2 (approx. 10cm x 30cm or covering an arm), 135g-180g/900cm2 (approx. 30cm x 30cm, or covering torso or back). The LMX4 Cream should be applied evenly at the specified dose with a uniform thickness across the area where the treatment will occur. Measures may be taken to ensure the cream remains undisturbed. Shortly before starting the topical treatment the LMX4 cream should be removed and the site for treatment prepared in the usual manner. Contraindications: Hypersensitivity to Lidocaine, or any of the amide-type local anaesthetics, or any of the excipients. Precautions and warnings: For external use only. Do not apply to irritated skin or if excessive irritation develops. Avoid contact with eyes. Do not use in large quantities or for longer times than those recommended. LMX4 Cream should not be applied to wounds, mucous membranes, or on atopic dermatitis as there is no clinical data relating to its use on such areas. Lidocaine should not be used in any clinical situation in which its penetration or migration beyond the tympanic membrane into the middle ear is possible. Repeated doses of Lidocaine may increase blood levels of Lidocaine. Patients with severe hepatic disease are at greater risk of toxic plasma concentrations of Lidocaine. Production of surface anaesthesia can block all sensations in the treated skin and trauma to the treated area such as exposure to extreme temperatures should be avoided until complete sensation returns. Interactions: Lidocaine should be used with caution in patients receiving Class 1 anti-arryhthmic drugs. Pregnancy and lactation: LMX4 should be used during pregnancy only if clearly necessary. Caution should be exercised when LMX4 is administered to a nursing mother.

Undesirable effects: Application of Lidocaine can cause transient local blanching followed by transient erythema and other effects can include irritation, redness, itching or rash of the skin. In rare cases local anaesthetics have been associated with allergic reactions including anaphylactic shock. Systemic toxicity is unlikely but signs of systemic toxicity are blurred vision, dizziness, difficulty breathing, trembling, chest pain or irregular heart beat. Basic NHS Price: LMX4 5g £2.98, LMX4 30g £14.90. Legal classification: P MA number and holder: PL 20685/0034, Ferndale Pharmaceuticals Ltd, 12 York Place, Leeds, LS1 2DS. Prescribers should consult the Summary of Product Characteristics for further information. Date of revision: July 2013. Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to Ferndale Pharmaceuticals Ltd. contact details below Ferndale Pharmaceuticals Ltd, Unit 740 Thorp Arch Estate, Wetherby, West Yorkshire, LS23 7FX, Phone: 01937 541122, Fax 01937 849682, email

REFERENCES * LMX4 Summary of Product Characteristics (Date of Revision 28 June 2013) † Taddio et al, CMAJ 2005;172(13) 1691-1695 Date of preparation: July 2013 Item code: LMX4ACare0713

body language I NUTRITION 17

Lifestyle and ageing By cutting out the healthy fats needed for optimal skin function, many low-fat diets can cause accelerated skin ageing. In the first of a two-part series, Dr Stefanie Williams investigates the effects of diet on skin ageing processes, particularly oxidative stress, glycation and inflammation


ur desire to look young has deep evolutionary roots, as scientific evidence confirms a connection between inner health and outer youthfulness. Perceived age has been proven in studies to be a good estimate of general health. It has also been shown that the younger we look, the more likely we are to live a long life. However, things we do or are unknowingly exposed to on a daily basis may speed up the ageing process and diminish the chance of reaching our full age potential. Lifestyle choices have a significant influence on how well our skin ages. Well known lifestyle habits with negative influence on skin ageing are smoking and excessive sun exposure. More recently, urban pollution has gained increasing interest. However, one greatly underestimated lifestyle aspect with influence on skin ageing is diet. But beliefs are changing and what has been considered a ‘healthy’ diet over the last 30 years—namely low-fat, high-carbohydrate eating—might be ageing our skin much quicker than need be! Oxidative stress Oxidative stress and inadequate clearance of material damaged in the process is acknowledged as one of the key mechanisms in ageing; not only in our skin, but in all major systems of our body. One of the main aims of any anti-ageing strategy, therefore, should be to reduce free radical production and increase antioxidant levels in the body and skin. Studies have confirmed that good dietary habits are a major determinant of our body’s anti-

oxidant status and oxidative stress level. We can raise our internal antioxidant levels significantly by eating antioxidant rich foods such as vegetables. An interesting skin study by Nagata et al confirmed that a greater intake of green and yellow vegetables is associated with decreased skin wrinkling in the crow’s feet area. Another study revealed that increased vegetable and fruit intake benefits our skin colouration in a way that makes us look more attractive to other people. This had an even greater impact than tanning. Most intriguingly, there are now several studies which clearly show that high vegetable consumption is associated with longer telomeres, and therefore lower biological age. Glycation Glycation is also a very important mechanism of ageing. It refers to a process where sugar molecules such as glucose and fructose attach themselves to other molecules in our body, including collagen in our skin, to form tissue-harming crosslinks called advanced glycation end

products (AGEs). These cross-links prevent collagen from performing its optimal function as a major supporting structure in our skin. Glycation also causes other destructive reactions in our skin, including free radical formation, oxidative stress and inflammation, all of which accelerate ageing. Each of these changes creates an environment that supports degradation of collagen and compromises integrity and regeneration of our skin. Some degree of glycation occurs all the time—which is fine—but the extent of glycation in our skin is greatly increased by consuming a high sugar diet. We can significantly reduce the rate of glycation by reducing the amount of sugary foods we eat on a daily basis. It’s worth noting that fructose, such as Agave syrup, is even more active in generating AGEs than conventional sugar. Interestingly, glycation in our skin is increased after excessive sun exposure. Another study confirmed that long-standing hyperglycemia impairs skin barrier function including protection against bacteria. The same study also confirmed

Studies show that high vegetable consumption is associated with lower biological age

18 NUTRITION I body language

accelerated skin ageing in people with high blood sugar levels. Not surprisingly, the acceleration of skin ageing processes was found to be in direct proportion to the duration of hyperglycaemia. High blood sugar levels have also been shown to reduce growth factor release including human growth hormone (HGH), which has skin-rejuvenating properties. A scientific study confirmed that higher blood sugar levels correlate with higher perceived ages. In other words, people with higher blood sugar look older. It is also known that familial longevity is associated with better blood sugar control. Sugar storage The message to reduce sugar consumption is something the media are increasingly catching onto. However, an often-neglected fact is that carbohydrates in starch (amylose and amylopectin) are simply long strings of sugar molecules. Starch is essentially nature’s storage form of sugar. After eating starchy carbohydrates such as bread, pasta, rice or potatoes, our body ultimately breaks these linear or branched sugar strings down into individual sugar units. Eventually every 4g of starchy carbohydrates will result in one teaspoon of sugar in our blood. Most starches do this at a slower pace than sugar. But some, like cornflakes breakfast cereal or a plain baguette—and even supposedly healthy foods such as roast parsnip or baked potato—can have a worse effect on our blood sugar level than pure table sugar. That’s why a diet relying largely on easily digestible, processed carbohydrates is disadvantageous for long-term skin health and our longevity. In addition to AGEs being generated in our skin, there are also preformed AGEs present in many of the foods we consume on a daily basis. The exact levels depend on the type of food and how it is prepared. Processed foods generally contain higher contents of preformed AGEs than natural foods. Most of the pre-packaged, processed food in supermarkets also contain many other unwelcome sugars in various forms—soy pro-

tein, modified starches and unstable polyunsaturated vegetable oils—so are best avoided in favour of natural, unprocessed foods. Inflammation As nature intended, acute inflammation with redness, heat and swelling can be a useful process for our body. However, too much of a good thing can become a bad thing, and that’s clearly the case with chronic inflammation. In today’s world, bad dietary habits and other modern lifestyle aspects such as chronic stress can lead to lowgrade, chronic inflammation. A number of factors can contribute this condition, including high blood sugar and insulin levels, and oxidative stress. This invisible form of inflammation smoulders silently in the body, often for decades without obvious symptoms. However, all along it accelerates ageing. As we age, our skin is unable to produce important proteins such as collagen and elastin as well as it used to. To make matters worse, it also degrades them quicker via group of enzymes called matrixmetallo-proteinases (MMPs). Certain environmental and lifestyle factors further induce MMPs in our skin. The more oxidative stress and inflammation we have in our skin, the higher the rate of collagen and elastin degradation. Telomere length Telomeres maintain the integrity and stability of our genetic material by protecting our chromosomes. Every time a cell divides, the telomere takes the brunt and shortens a little to protect the vital genetic information between them. Therefore telomere length is an important piece of information when judging our ‘real’ cell age, as opposed to our chronological age. Shorter telomeres have been linked to increased cancer risk and even a shortened life span. Skin cells have been described as being particularly susceptible to accelerated telomere shortening because of their high proliferation rate and exposure to DNA-damaging influences such as oxidative stress. However, we now know that telomere shortening can happen at

different rates and that we can influence the rate of telomere shortening with our lifestyle choices. Telomere shortening and consequent cell ageing is accelerated by any sort of cellular stress. The more free radicals that are present in our tissues and the greater the oxidative stress our cells are exposed to, the faster our telomeres shorten. High levels of blood sugar, low-grade inflammation and obesity have also all been linked to telomere shortening. Positive lifestyle interventions, on the other hand, are able to improve telomere length. Ageing hormones The sugar-regulating hormone insulin, secreted in the beta cells of our pancreas, is one of our pro-ageing hormones. While insulin is our friend at optimal levels, clearing away excess sugar from the blood stream, excess insulin release has

body language I NUTRITION 19

sugar levels throughout the day. The repeated ups and downs of glucose and insulin are very stressful for our body. It responds by releasing pro-ageing stress hormones such as cortisol, which encourage collagen breakdown. Eventually, these continuous waves of sugar intake, blood sugar spikes and insulin hikes will make our cells less responsive to insulin, thereby creating ‘insulin resistence’. A good sensitivity of our cells to insulin, however, is very important for optimum ageing and superior insulin sensitivity has been connected to familial longevity. A typical Western diet is often highly insulinaemic and with low-fat, high sugar and starch eating habits, insulin greatly accelerates the skin’s ageing process. We should try and moderate our insulin secretion for optimal antiageing benefits. Measures include avoiding sugar-containing foods and cutting down on foods that are broken down into sugar molecules in your body.

Contrary to popular belief, consuming sufficient amounts of fat is crucial for maintaining skin elasticity and reducing wrinkling

been shown to contribute to free radical generation, oxidative stress, inflammation and striking acceleration of skin ageing. Insulin also interferes with other hormones. For example, it leads to a decrease in the levels of testosterone, didehydroepiandrosterone (DHEA) and other anti-ageing sex hormones, which are known to decline with age. Insulin also increases the level of sex-hormonebinding-globulins, which keep sex hormones bound and therefore inactive. Not all the effects of insulin are so subtle. After a high carbohydrate meal, there is an insulin spike, making our blood sugar level plummet a couple of hours later and leaving us ravenous for more sugar and other carbohydrates. Giving in to the renewed hunger creates a vicious circle, leading to fluctuating high and low blood

Building blocks Protein provides crucial building blocks for our body and forms muscle, hair, skin and connective tissue. As some amino acids are essential—the body can’t produce them itself—we need to ensure we ingest complete protein with our food. As our body has little capacity to store protein, we should provide it with sufficient amounts on a daily basis. We also need to forget the lowfat brainwashing of the past 30 years. Our body and skin need fat. Lipids form a vital component of our cell membranes and help maintain cell structure and function. Fat is also important for optimal hormone production. Studies confirm that higher intakes of total fat—monounsaturated and saturated—are significantly associated with increased skin elasticity and decreased wrinkling of the skin. Fat intake therefore makes our skin more elastic and less wrinkly. Therefore, consuming sufficient amounts of fat is crucial to maintaining healthy and beautiful skin as we age. There is another reason to avoid falling into the low-fat trap. When the food industry creates a low-fat

food product, the removed fat has to be replaced with something. In the vast majority of cases, refined carbohydrates are added. Many supposedly ‘healthy’ lowfat products are stuffed with processed carbohydrates, which increase your level of insulin, glycation, oxidative stress and create chronic inflammation, all of which have an adverse effect on skin health. Healthy fats on the other hand support optimal skin function. The consumption of chemically altered, highly processed, omega-6 rich fats such as unstable polyunsatured vegetable oils has led to all fats being viewed as a villain. But eating good amounts of monounsaturated fats such as olive oil and avocados and saturated fats— such as coconut oil and animal fats, which are very stable and therefore suitable for cooking—is beneficial for our skin and for overall health. Olive oil’s monounsatured fats have, for example, been shown to be associated with a lower risk of severe sun-induced skin ageing in both men and women. Omega-3 fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have also been shown to be beneficial for our skin as they are anti-inflammatory, antioxidant and help protect telomere length. In one study, individuals in the highest omega-3 quartile experienced the slowest rate of telomere shortening. Supplementation with omega-3 rich fish oil has also been shown to support long-term skin health by preventing sun-induced changes in our skin and improving collagen metabolism. In a study by Fortes et al, it was shown that regular consumption of fish can even be protective against melanoma skin cancer. However, we should remember that omega-3 fatty acids as polyunsaturated fatty acids are inherently unstable and need to be treated with care. There is true hysteria surrounding saturated fats. However, they are not as evil as their reputation. They actually have many advantageous properties such as their stability. Saturated fatty acids are an integral part of our body and constitute at least 50% of our cell membranes.

20 NUTRITION I body language

They help prevent oxidative damage to cells and are an important part of cell biology, both in the skin and throughout the entire body. Thankfully there seems to be a gradual rethinking about saturated fat intake and general health. A meta-analysis stated, “there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of cardiovascular disease”. A British Heart Foundation funded meta-study also recently concluded, “current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats”. I am looking forward to further studies in this area, as for our skin saturated fats are highly beneficial. Boosting cell repair Another interesting way to support our body and skin staying youthful is intermittent fasting (IF). There are a variety of different approaches. One of the most popular ways is to fast for 24 hours twice per week—for example, don’t eat from dinner the previous day

until dinner the next day. Many people currently do this for weight management in the UK, without realising that IF is also highly antiageing. Intermittent fasting promotes healthy autophagy. Autophagy is a cellular process with which cells get rid of problematic content. This not only applies to infectious agents, but also to its own damaged, malformed or dysfunctional cell components. Autophagy also ensures the turnover of aged cellular components. When digesting this cellular ‘junk’, the cell breaks it down into constituent parts, such as fatty acids, amino acids and sugar. These are then reused by the cell—a true recycling process. When fewer ‘building blocks’ become available via food, such as during fasting, autophagy is increased. This means that when fasting, our cells ramp up the process of tidying up, because they are trying to find cellular ‘junk’ they can dismantle in order to obtain building blocks needed. A study confirmed that promoting autophagy can extend lifespan by as much as 50%.

References 1. Anlasik T, Sies H, Griffiths HR, et al. “Dietary habits are major determinants of the plasma antioxidant status in healthy elderly subjects.” Br J Nutr. 2005; 94(5):639-42. 2. Avery NC, Bailey AJ. “The effects of the Maillard reaction on the physical properties and cell interactions of collagen.” Pathol Biol (Paris). 2006; 54(7):387-95. 3. Boukamp P. “Skin aging: a role for telomerase and telomere dynamics?” Curr Mol Med. 2005; 5(2):171-7. 4. Buckingham EM, Klingelhutz AJ. “The role of telomeres in the ageing of human skin.” Exp Dermatol. 2011; 20(4):297-302. 5. Chowdhury R, Warnakula S, Kunutsor S, et al. “Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis.” Ann Intern Med. 2014; 18;160(6). 6. Danby FW. “Nutrition and aging skin: sugar and glycation.” Clin Dermatol. 2010; 28(4):409-11. 7. Epel ES, Lin J, Wilhelm FH, et al. “Cell aging in relation to stress arousal and cardiovascular disease risk factors.” Psychoneuroendocrinology. 2006; 31(3):277-87. 8. Farzaneh-Far R, Lin J, Epel ES, et al. “Association of marine omega-3 fatty acid levels with telomeric aging in patients with coronary heart disease.” JAMA. 2010; 303(3):250-7. 9. Fortes C, Mastroeni S, Melchi F, et al. “A protective effect of the Mediterranean diet for cutaneous melanoma.” Int J Epidemiol. 2008; 37(5):1018-29. 10. Galluzzi L, Morselli E, Vicencio JM, et al. “Life, death and burial: multifaceted impact of autophagy.” Biochem Soc Trans. 2008; 36(Pt 5):786-90. 11. Gunn DA, de Craen AJ, Dick JL, et al. “Facial appearance reflects human familial longevity and cardiovascular disease risk in healthy individuals.” J Gerontol A Biol Sci Med Sci. 2013; 68(2):145-52. 12. Latreille J, Kesse-Guyot E, Malvy D, et al. “Dietary monounsaturated fatty acids intake and risk of skin photoaging.” PLoS One. 2012;7(9):e44490. 13. Marcon F, Siniscalchi E, Crebelli R, et al. “Diet-related telomere shortening and chromosome stability.” Mutagenesis. 2012; 27(1):49-57. 14. Mays PK, McAnulty RJ, Campa JS, Laurent GJ. “Age-related alterations

IF has also been shown to increase insulin sensitivity and decrease oxidative damage. During fasting, secretion of human growth hormone—one of our ‘skin youth’ promoting hormones—also increases. What we eat on a daily basis has a significant impact on your skin’s ageing process. The current Western low-fat obsession with over-reliance on starchy, grain-based and sugary foods, together with constant grazing throughout the day, doesn’t do our skin any favours. With an improved way of eating, however, we are able to reduce oxidative stress, inflammation, glycation and telomere shortening, while encouraging a more youthpromoting hormonal homeostasis. Dr Stefanie Williams is a dermatologist and medical director at European Dermatology London W: eudelo. com. Further information can be found in Dr Williams’ book “Future Proof Your Skin – Slow down your biological clock by changing the way you eat”. In the next edition of Body Language, Dr Williams will be looking at the connection between skin ageing and stress.

in collagen and total protein metabolism determined in cultured rat dermal fibroblasts: age-related trends parallel those observed in rat skin in vivo.” Int J Biochem Cell Biol. 1995; 27(9):937-45. 15. McDaniel JC, Massey K, Nicolaou A. “Fish oil supplementation alters levels of lipid mediators of inflammation in microenvironment of acute human wounds.” Wound Repair Regen. 2011; 19(2):189-200. 16. Nagata C, Nakamura K, Wada K, et al. “Association of dietary fat, vegetables and antioxidant micronutrients with skin ageing in Japanese women.” Br J Nutr. 2010; 103(10):1493-8. 17. Noordam R, Gunn DA, Tomlin CC, et al. “High serum glucose levels are associated with a higher perceived age.” Age (Dordr). 2013; 35(1):189-95. 18. Park HY, Kim JH, Jung M, et al. “A long-standing hyperglycaemic condition impairs skin barrier by accelerating skin ageing process.” Exp Dermatol. 2011; 20(12):969-74. 19. Piccardi N, Manissier P. “Nutrition and nutritional supplementation: Impact on skin health and beauty.” Dermatoendocrinol. 2009; 1(5):271-4. 20. Pilkington SM, Massey KA, Bennett SP, et al. “Randomized controlled trial of oral omega-3 PUFA in solar-simulated radiation-induced suppression of human cutaneous immune responses.” Am J Clin Nutr. 2013; 97(3):646-52. 21. Polidori MC, Praticó D, Mangialasche F, et al. “High fruit and vegetable intake is positively correlated with antioxidant status and cognitive performance in healthy subjects.” J Alzheimers Dis. 2009; 17(4):921-7. 22. Schalkwijk CG, Stehouwer CD, van Hinsbergh VW. “Fructose-mediated non-enzymatic glycation: sweet coupling or bad modification.” Diabetes Metab Res Rev. 2004; 20(5):369-82. 23. Shen J, Terry MB, Gurvich I, et al. “Short telomere length and breast cancer risk: a study in sister sets.” Cancer Res. 2007; 67(11):5538-44. 24. Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. “Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease.” Am J Clin Nutr. 2010; 91(3):535-46. 25. Tiainen AM, Männistö S, Blomstedt PA, et al. “Leukocyte telomere length and its relation to food and nutrient intake in an elderly population.” Eur J Clin Nutr. 2012; 66(12):1290-4. 26. Vellai T. “Autophagy genes and ageing.” Cell Death Differ. 2009; 16(1):94-102.

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References 1. Rzany B et al, Dermatol Surg 2012;38: 1153â&#x20AC;&#x201C;1161 2. Cartier et al, J Drugs Dermatol. 2012; 11 (1)(Supp): s17-s26 (*Results taken from a mean value across all treatments performed in study) 3. Farhi D et al, J Drugs Dermatol 2013; 12: E88-E93

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body language I DERMATOLOGY 23


melanoma epidemic With skin cancer rates quadrupling in the last 40 years, patient education and a daily prevention strategy could help to slow the incidence of malignant melanoma, write Dr Carl Thornfeldt and Dr Mervyn Patterson


t the age of 16, CB was a vibrant, champion track star when she went to spend a summer in California with her grandparents. As she dove into the swimming pool one day, her grandfather noticed a crusted black spot on her back. Her grandparents immediately called my office to arrange an appointment and flew her several hundred miles to see me. The spot turned out to be a malignant melanoma (MM) skin cancer, 0.25mm thick. Despite being a young, healthy athlete with a university track scholarship prior to her diagnoses, after two radical surgical procedures including chemotherapy treatment, CB died before her 18th birthday from metastatic melanoma. In 2010, around 12,800 people in the UK were diagnosed with malignant melanoma and in 2011, there were 2,209 deaths from the cancer. Melanoma is the fifth most common cancer in the UK, but lies 18th in the rankings for deaths from cancer reflecting high survival from the disease. Melanoma incidence Incidence rates have more than quadrupled since the mid-1970s. Age distribution differs from other cancers—there is a relatively high incidence in younger people—but 45% of cases are still diagnosed in the over-65s. The European age-standardised incident rates for males are significantly higher in Wales compared with England, Scotland and Northern Ireland. There is no such variation between


Increase of Risk

History of melanoma; risk of second


Fair skinned (Fitzpatrick I)


Sibling afflicted


Indoor tanning


History of basal or squamous cell cancer


History of 2 or more blistering sunburns in childhood


Red hair/blue eyes


1-5 Atypical (dysplastic) nevi


≥6 Atypical nevi


≥25 nevi


≥100 nevi


the countries for females. Malignant melanoma incidence in the UK is strongly inversely related to deprivation. It is one of the few cancers where incidence rates are lower for more deprived men and women and there is a clear trend of decreasing rates from the least to the most deprived. Lifetime risk of developing malignant melanoma is one in 55 for men and one in 56 for women. The mortality rate per 100,000 is 2.9% in Wales, 2.6% in England, 2.4% in Scotland and 2% in Northern Ireland. Survival for melanoma is improving—in men, the five year age-standardised relative survival for malignant melanoma in England increased from 46% during the early 1970s to 84% between 2005–2009. In women, five year survival increased from 65% to 92% over the same time periods, respectively. If lymph nodes are present and the MM thickness exceeds 4.0mm, the five-year survival rate drops

to 40%. The death rate in darker skinned minorities is 250% higher than in Caucasians because 70% of those lesions involve palms, soles, genitalia and mucosal surfaces. When found in these sites, MM metastasises when the thickness of the lesion is smaller. When MM is discovered in Caucasians, 12% has already metastasised to other parts of the body while in African-Americans, 26.4% has metastasised and in Latinos, 17.6%. Only 0.5% of MM afflicts African-Americans and 3.1% afflicts Latinos. One-third of those who survive a MM diagnosis will develop a second cancer, with another melanoma occurring in one in five melanoma survivors. Secondary cancers occurring to a greater degree include lymphoma, breast, thyroid, basal cell and squamous cell carcinomas. The eleven major risk factors for MM each increase the risk by at least 200%. The highest risk fac-

Malignant melanoma risk factors







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tor increases MM to nearly 1000%. The risk of a second MM in one already afflicted has the greater risk of 6.5-fold. Other factors include fair skin type (Fitzpatrick I), red hair and blue eyes, history of another type of skin cancer and having a sibling affected with a melanoma. If an individual experiences two or more blistering sunburns in childhood or uses a tanning bed—even only once—the risk of MM is doubled or higher. Moles There is a relationship between MM and nevi (moles), which are pigment cell growths. One to five atypical, or dysplastic, nevi increase melanoma risk by 3.8 times. Six or greater atypical nevi increase risk by 6.3. Twenty-five or greater number of even normal-looking nevi increase MM risk by 4.4 times and 100 or more increases the risk by 9.8 times. It has been found microscopically that 22–50% of MMs have nevus cells indicating they arose in nevi. The nevus, also known as the “ugly duckling”, is the most sensitive marker for a risk of being an MM. Invisible UVB induces nonmelanoma basal cell and squamous cell skin cancers. UVA not only induces wrinkles, but suppresses protective immunity, thereby increasing all types of skin cancers and it especially activates MM. Both UVA and UVB are linked to DNA damage and cell mutations even before a visible redness (erythema) or tan appears. It is imperative to note that tanned skin is injured skin. In other words, there is no safe tan. In a convenience survey conducted on 100 random beachgoers in the summer of 2007, 87% of those polled believed that skin cancer, including MM, is linked to tanning. The study also noted that 81% of those asked still believe that tanned skin looks better than pale skin. The Sun Exposure and Teen Study conducted by the American Academy of Dermatology reported in 2008 that 63% of teens believe they look better with a tan. Onethird of teen respondents claimed

to “always” use sun block, with nearly the same number of teens declaring that they “never” use sun block. It’s not just on sunny, summer days that sunscreen application is needed. UVA rays penetrate though clouds and windows and are reflected off concrete, tarmac, snow and grass. These rays are present from sun up to sun down, all year round. Tanning beds Indoor tanning beds, also referred to as “fake-bakes” or “cancer-ina-can” in the US, are considered the new nicotine—both the World Health Organization and the US Department of Health and Human Services designated UVA and UVB as proven carcinogens, equal to tobacco smoke. Seventy-one percent of tanning salon patrons are females, aged between 16–29 years old. About onefifith of American females have admitted to using a tanning bed, with a third claiming they use it to medicate anxiety and depression. Additionally, about one-third of people who use tanning beds develop a psychological and psychiatric dependency, or addiction, to tanning. The majority of those suffer withdrawal symptoms when tanning is stopped. In my practice, only about 20% of melanoma patients who were using tanning beds prior to their diagnosis will actually stop this practice. The tanning bed industry touts “safer rays” in tanning beds, but any tan is a sign of damage to the skin. It was published in 2003 that 95% of tanning customers received more than the recommended dose of UV radiation, after studying people attending 50 tanning facilities. Tanning beds can expose an individual to four times the amount of UVA and two times the amount of UVB as a similar period of sunlight exposure. We do not feel a sensation of the UVA rays on our skin, but they contribute most to skin ageing and skin cancer. UVA rays inhibit the function of the surveillance cells (Langerhans cells) which detect damaged cells and send white blood cells to destroy the damaged

Any growth that looks or feels different than other growths (also known as an “ugly duckling.”) Any new growth, if you are 25 or older Any growing of width at base Any bleeding of a bump or nodule Any changes in sensation: itchy, tender, red or painful, lasting more than 2 weeks Any spread of pigmentation beyond its border Any change in a lesion present since birth Any growth that concerns you by your intuition (it just “feels” wrong)

cells, usually before they move from premalignant dysplastic cells into cancer cells. These UV wavelengths also damage the protective skin barrier, while UVL and visible light stimulate skin barrier thickening to increase protection. These wavelengths are absent in tanning beds. The table above lists the eight new criteria to diagnose MM, which have an accuracy rate of around 90%. It is especially effective in diagnosing early, thin MM that are considered to be the most curable. The previous A-B-C-D-E criteria allowed the MM diagnosis in about two-thirds of patients but many were advanced when these criteria were met. A dermoscope is the dermatologist’s new weapon in the fight against MM. It is a hand-held cross-polarising microscope that increases accuracy in finding these cancers and their precursors by 82% for a trained user. Melanoma prevention There are four components for an effective MM prevention strategy, beginning with daily use of sunscreen as the first line of defence. Sunscreen use is as important as brushing your teeth. SPF 30 or higher is proven to reduce the number of MMs, premelanoma dysplastic nevi, actinic keratoses and squamous cell carcinomas. Men over the age of 60 report the lowest usage of sunscreen, yet have the highest incidence of MM. In this demographic, the rate of melanoma is increasing so fast that a man of this age diagnosed with a head or neck melanoma has twice the death rate of other demographics.

Eight criteria for recognising melanoma

26 DERMATOLOGY I body language

MMETRY ASYMMETRY ASYMMETRY MMETRY ASYMMETRY a: aSyMMEtry nign mole is his mole isis MMETRY hisbenign benign nign mole ismole ASYMMETRY mmetrical. MMETRY ot asymmetrical. this benign mole is his benign mole is ASYMMETRY not asymmetrical. nign mole is mmetrical.




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of sunscreen to the protection ratio

DER ORDER BORDER DER b: bordEr BORDER gn mole has benign mole has DER A benign mole has gn mole has A benign mole has BORDER h, even DER mooth, even A benign mole has BORDER mooth, even gn mole has smooth, even h, even

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C: Colour R OLOR COLOR R most benign moles COLOR enign molesmoles Most R benign Most benign moles are all one color— enign moles COLOR one color— R re one Most moles COLOR reall allbenign one color— color— often a single shade


enign moles one color— single shade ften a single shade re allcolor— color— Most benign moles often aone single shade of brown. enign moles one Most benign moles single shade wn. f brown. ften a single shade re allcolor— one color— of brown. one single shade re all one color— wn. fften brown. a single single shade shade wn. ften a single shade f brown. wn. f brown.

d: diaMEtEr METER DIAMETER DIAMETERBenign moles METER DIAMETER molesmolesusually have a enign METER Benign moles moles DIAMETER have ahave METER sually enign molesasmaller diameter DIAMETER usually moles have ahave a


rsually diameter maller diameter have a malignant ones. enign than diameter moles have amoles enign moles rmaller diameter alignant ones. han malignant maller diameter sually have a ones. han malignant have a ralignant diameter sually have a ones. ones. han malignant ones. maller diameter r diameter alignant ones. maller diameter han malignant alignant ones. ones. han malignant ones. E: EvolviNG


VING VOLVINGcommon, benign EVOLVING VING moles look the same EVOLVING on, benign ommon, benign VING Common, benign over time. Be on the on, benign EVOLVING ook the same VING moles look the same ommon, benign EVOLVING moles look the same on, alert when a mole ookbenign the same



me. Belook onbenign the ver time. Be on the moles the same ommon, over time. Be on the on, benign ook the same starts to evolve or ommon, benign me. on the hen alook mole ert Be when athe mole ver time. Be on the moles same lert when a mole ook the same me. Be on the change in any way. moles look the same hen a mole o evolve or artsBe to evolve or lert when a mole ver time. Be on the tarts to evolve or me. on the hen a mole ver time. Be the o or on inevolve any way. hange in any way. tarts to evolve or lert when a mole hange in any way. hen a mole o or lert when a mole inevolve any way. hange any tarts toin evolve or oinevolve or way. any tarts to way. evolve or hange in any way. in anyin way. hange any way. Figure 1: ABcDE of melanoma

If youIfdraw a line a line you If youdraw draw a line If youthrough draw line protection, while one to three addthrough thisadraw mole, this If you line through thisamole, mole, If you draw amole, line through this the two halves will the two halves will ed antioxidant ingredients show no through this mole, If you draw a line the two halves will If you draw a line through this mole, If you draw a line the two will if you draw ahalves line not match, meaning not match, meaning the two halves will photo protection. through this mole, not match, meaning through this mole, increase the two halves will through this mole, not match, meaning through this mole, it is asymmetrical, itnot asymmetrical, match, meaning the two halves will itisis asymmetrical, the halves will not match, meaning two halves will the halves will it is two asymmetrical, a two warning sign for athe warning sign for it is match, asymmetrical, not meaning a warning sign for not match, meaning it is asymmetrical, not match, meaning not meaning a match, warning sign for melanoma. melanoma. Sunscreen application a warning sign for it is asymmetrical, melanoma. it is asymmetrical, a warning sign for it is asymmetrical, it is asymmetrical, melanoma. melanoma. a warning sign a warning sign It for is important to keep in mind melanoma. a warning for for asign warning sign for melanoma. melanoma. melanoma. melanoma. that the applied amount, or dose,

All colours of skin, regardless of race, should be using sunscreen. Naturally darker Fitzpatrick types have a lower incidence of skin cancer, but when MM is discovered in darker skin it is more advanced than on lighter skin, producing 2.5 times higher rates of death. Sunscreen protection is measured by SPF for UVB and UPF for UVA. SPF is a multiple of the time UVB needs to induce skin erythema. For example, if one develops visible redness in five minutes of sun exposure without wearing sunscreen, a SPF 50 will provide 50 times five minutes of protection, or 250 minutes. SPF is not a percentage of blockade of the sun’s rays. UPF is measured on a one to four star system, based on multiple

provides 4.4 protection factor. So it is best to use SPF with 50 or higher, that contains multiple Having a variety of Having aavariety of Having variety of Having a another variety of anti-inflammatory colorscolors is is another ingredients. Having a variety of colors is another Having a variety of A variety of colors is another warning signal. A warning AAof colors is another Having asignal. variety warning signal. Having a variety of Examples of sunscreens that meet colors is another colours is another Having aofvariety of warning signal. Adifferent number of different number warning signal. A colors another number colors isof another warning signal. Adifferent warning signal. A is colors isof another these criteria include Banana Boat number different shades of brown, tan shades of brown, tan of different warning signal. A tan shades of brown, warning signal. A number of different number ofnumber different warning signal. A shades of brown, tan or black could appear. or black could appear. SPF115, Neutrogena Full Spectrum shades of brown, tan number of different or black could appear. number of different shades ofcould brown, tan shades ofnumber brown, of different or black appear. A melanoma may A melanoma may or black appear. shades ofcould brown, tan Aveeno for Babies SPF60, Aof melanoma may brown, tan SPF100, orormelanoma black could tanshades black could shades ofappear. brown, tan A may also become red, also become red, A melanoma may or black could appear. also become red, ormelanoma black could appear. A may appear, as well as or black could appear. Epionce Ultra Shield Lotion SPF50 also become red, whitewhite ormelanoma blue. or blue. also become red, A may white or blue.may A white melanoma may also become red, red, ormelanoma blue. A white or blue. and Thinksport Livestrong SPF50. white or blue. also become also become red, red, white or blue. also become red, or blue. Sunscreens that maintain the white white or blue. white or blue. Melanomas usually are are Melanomas usually Melanomas usually labeled protection factor after 80 Melanomas usually are are larger inare diameter melanomas larger in diameter Melanomas usually larger in diameter Melanomas usually are aresubmersion in a whirlpool minutes’ larger insize diameter than the of the usually larger in dithan the size of the larger insize diameter Melanomas usually than the of Melanomas usually arethe are larger inthe diameter Melanomas usually are than the size ofpencil the eraser on your ameter than size eraser on your are considered very water resistant, than the size ofpencil the larger in diameter eraser on your pencil larger insize diameter than the of the larger in diameter eraser on your pencil (¼ inch or 6mm), but of a pencil eraser (¼ (¼ inch or 6mm), but eraser on your pencil than the size of the (¼ inch or 6mm), but than the size ofsize the to which Epionce Ultra Shield Loeraser on your pencil than the of the (¼ inch or 6mm), but they may sometimes inch or 6mm), but they may (¼ orsometimes 6mm), but eraser on your pencil they may sometimes eraser on your (¼ inch orinch 6mm), but eraser onpencil your pencil tion SPF50 and Livestrong SPF50 they may sometimes bemay smaller when first they sometimes be smaller when first they may sometimes (¼ or 6mm), but beorinch smaller when (¼ inch 6mm), but first may sometimes (¼ inch or 6mm), but Regular usage of an SPF be smaller when first detected. bethey smaller when detected. comply. be smaller when they may sometimes detected. they may sometimes be smaller when first first they may sometimes detected. first detected. detected. be smaller first be smaller when when first 30 or higher reduces the incidence detected. be smaller when first detected. detected. detected. of premalignant actinic keratoses WhenWhen a mole aais mole and isis atypical nevi, as well as squaWhen Any change—in When a mole ismole evolving, see a see doctor. evolving, mous cell carcinoma. When a mole isaadoctor. evolving, see doctor. size, shape, colour, When a mole evolving, seeisa size, doctor. Any change—in Any change—in evolving, seeisa size, doctor. When a is mole Any change—in size, elevation, When aormole For best protection, apply sunevolving, see a doctor. When a mole is Any change—in size, shape,shape, color, elevation, color, elevation, Any evolving, see a size, doctor. another trait, orchange—in any shape, color, elevation, evolving, see a size, doctor. Any change—in evolving, see a or doctor. shape, color, elevation, screen twice in the morning to cool, or another trait, or any or another trait, any shape, color, elevation, Any change—in size, new such or another trait, or any Any change—in size, shape, color, elevation, Any change—in size, or symptom another trait, or any new symptom such as new symptom such as clean, dry skin, waiting at least 30 or another trait, or any shape, color, elevation, as or bleeding, itching new symptom such as shape, color, elevation, another trait, or any shape, color, new symptom such as or bleeding, itching orelevation, bleeding, itching new symptom such as or another trait, or or new crusting—points bleeding, itching orany or another trait, or any symptom such as or another trait, or anybetween applications and bleeding, itching orminutes to crusting—points to bleeding, itching or as new symptom such to crusting—points danger. crusting—points to new symptom such as bleeding, itching orat new symptom such as crusting—points to least danger. danger. crusting—points to bleeding, or 30 minutes prior to going danger. bleeding, itchingitching or crusting—points to bleeding, itching or as recommended by worlddanger. outside, danger. crusting—points to crusting—points to danger. crusting—points to danger. danger. wide dermatologist organisations. danger. criteria; including prolonging time Sunscreen is always the last step for skin to increase pigmentation before foundation make up, but apand the average, or critical, wave- plied after a barrier repair skin care length blockaded by the sunscreen. product since sunscreen ingrediIn order to be considered “broad- ents bind to the stratum corneum. spectrum,” a sunscreen must have This binding is prevented if one is an SPF of at least 30 with UPF already perspiring. Wearing make of three-stars, according to the up with SPF does not provide adUS Federal Drug Administration equate coverage, but it does, none(FDA). Only four ingredients are theless, provide an extra layer of FDA-approved for broad-spectrum protection. designation, including zinc oxide, titanium dioxide, Avobenzone Skin barrier (Parsol 1789) and Mexoryl SX The second line of defence against (ecamsule), which are all available MM is a healthy, well-functioning worldwide. skin barrier. The two major skin A clinical study published in abnormalities known to induce 2011 showed that six or more anti- skin cancer and visible ageing, as inflammatory and antioxidant in- well as many common skin disgredients added to marketed sun- eases, include: screens do provide increased photo Compromised stratum cor-




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28 DERMATOLOGY I body language

neum barrier function due to excessive dryness, cold, wind, or having fair, sensitive skin, or suffering from hay fever and/or asthma. Activation of damaging chronic inflammation due to exposure to pollutants, exfoliating skin care products and preservatives. Truly healthy skin is characterised by optimum barrier function without chronic inflammation. A normal skin barrier is necessary to maximise epidermal defence. When the skin is injured, for example through sunburn or tanning, the first response after erythema is to increase the synthesis of three groups of specific oils (lipids) to repair the skin barrier permeability function. These three key physiological lipids include cholesterol, free fatty acids and ceramide. The next event required for repair is to speed up the proliferation of epidermal cells. Chemical peels and microdermabrasion both accelerate this cell turnover. The third line of defence against MM includes additional adjuncts, such as wearing clothing such as a UPF-rated cloth hat with a 3–5” brim, UV blocking sunglasses and/ or sunshades, and UPF protective

clothing. Mineral makeup also provides additional sun defence, as do sun protective laundry additives. The fourth, and last, line of defence includes a healthy diet, incorporating anti-inflammatory foods, eating low-fat, low-sugar and low starch, with six or more daily servings of fruits and vegetables, oily fish and photoprotective foods. Green tea, pomegranate, grape seed and chocolate containing more than 55% cocoa (not including milk or white chocolate) are also very beneficial. Photoprotective supplements include golden fern (polypodium leucotomos), quercetin and melatonin. Skincare professionals are often asked about spray tans and selftanning agents. These options can provide minimal protection, with the active ingredient in spray tanning solutions giving a SPF value of around two. This is a service that my office provides. Dyhydroxyacetone is safe unless inhaled into the lungs, so avoid enclosed spray tanning booths. Education Not all is lost when educating your clients about MM, since it is docu-

All colours of skin, regardless of race, should be using sunscreen

mented that education does have impact. A study conducted in Dallas and Houston, Texas, involved 210 junior high and high school students aged between 12 to 18 and tested their general knowledge of sun exposure and MM. After the first exam was completed, the students were then provided with correct answers with detailed explanations for each test item. The participants were then given a second exam to measure the effect of the educational piece on future sun exposure practices. It was concluded that students between 12 to 15 years old were significantly more likely to change future behaviour after learning about skin cancer, including MM prevention. Skin care professionals are in a life and death battle for clients with the scourge of malignant melanoma. It has been documented in Australia—the country with the highest incidence of MM per capita—that education and protection can slow the increasing incidence of this colour blind killer. Skin care professionals must seize this incredible opportunity to educate their client population about the dangers of sun exposure, and the importance of protecting their skin with the four lines of defence daily. Additionally, we must try to shift the attitude to that of pale skin, rather than tanned skin, is the real look of healthy beauty. Dr Carl Thornfeldt is a dermatologist and founder of Episciences, W:

References 1. June K, Robinson, Kim J, Rosenbaum S, Ortiz S. “Indoor Tanning Knowledge, Attitudes, and Behavior Among Young Adults From 1988-2007.” Arch Dermatol. 2008;144(4):484488. 2. “Skin and Aging,” December 2008. p12 3. Whitworth L. “Legislators combat melanoma, restrict teen tanning.” Journal of the National Cancer Institute, Vol. 98, No. 22, November 15, 2006. 4. Wang SQ, Osterwalder U, Jung K. “Ex vivo evaluation of radical sun protection factor in popular sunscreens with antioxidants.” J Amer Acad Dermatol, 2011;65(3):525-530. 5. Thornfeldt C, Bourne K. “The New Ideal in Skin Health: Separating Fact from Fiction.” Allured Books, Carol Stream, Illinois; 2010, p149. 6. Lucci A, Watts Citro H, Wilson L, Debakey M. “Assessment of knowledge of melanoma risk factors, prevention, and detection principles in Texas teenagers.” Presented at the Annual Meeting of the Association for Academic Surgery, Tampa, Florida, November 2–4, 2000.




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body language I INJECTABLES 31

Growth opportunity Skin actives are an increasingly popular component of skin rejuvenation treatments, providing a cascade of collagen stimulation and wound healing. Dr Hema Sundaram describes the benefits of topical and injectable treatments, involving growth factors and platelet-rich fibrin matrix


n terms of skin ageing pathways, there are extrinsic and intrinsic ageing mechanisms. Extrinsic largely involves UV exposure, while intrinsic ageing is unavoidable—it involves our oxidative metabolism. There are a number of key antiageing actives that can remediate or prevent these mechanisms from occurring. Growth factors play a particularly important role, helping to reverse the detrimental imbalance that causes reduction in dermal collagen. They can prevent the suppression of synthesis of procollagen —the precursor for collagen—and can also prevent collagen degradation. We can combine growth factors with cytokines, and other anti-ageing actives for a synergistic approach to skin rejuvenation, including VEGF, PDGF, TGF-ß1 and TGF-ß2 and TIMP. Supplemental growth factors can help the multiplication of cell growth and provide wound healing, ramping up fibroblast activity. It’s important to note that it isn’t actually essential to get down to the dermis, or deeper, to get these effects because there is a cascade. Keratinocytes have receptors for growth factors and cytokines.

If we’re injecting these actives superficially into the skin, or even applying them topically, we can potentially get an impact on the keratinocytes and initiate a cascade, leading to activity in the dermis. Topical growth factors Topically-applied growth factors include human-derived, animalderived and plant-derived, and also recombinant growth factors. One example of animal-derived growth factors is SCA, which stands for secretion of cryptomphalus aspersa. The secretion, or slime, is harvested from the cryptomphalus aspersa snail. The snail’s secretion contains a growth factor complex that is secreted at times of stress and tissue damage. It also contains glycosaminoglycans and enzymatic antioxidants. Initial studies showed that SCA can regenerate damaged tissue in less than 48 hours so it has been developed for topical use. These studies involved radiation therapy—a challenging situation—and showed good results in acute conditions. The ingredient has been used in Europe for over 15 years to treat radiation dermatitis. From an evidence-based point of view, the growth factor increases

Secretion harvested from the cryptomphalus aspersa snail contains growth factors and antioxidants that can regenerate damaged tissue

fibroblast proliferation and stimulates fibroblast replication. It also optimises form and function so they’re in an active state. The greater the concentration, the greater the proliferation of fibroblasts. An open label, double-blind study published in the Journal of Drugs and Dermatology involved the application of 8% SCA cream and 40% serum on patients with lighter Fitzpatrick skin types. Validated scales were used for the general ageing assessment, along with silicone impressions around the periocular region and punch biopsies. Following application of the cream in the morning and the serum at night, there was a significant decrease in wrinkles (p<0.05). There was an increase in the elasticity of the skin in all patients by day 19, dryness and roughness resolved and sallowness also was shown to be improved. There was also an increase in microangiogenesis—the area occupied by the micro vessels—a and a reduction in epidermal thickness. It is important for these studies to be vehicle-controlled—we can compare the effect from lubricant or moisturising activity with the active ingredient. Endocare Tensage includes the SCA complex and has been through rigorous testing, particularly for a cosmeceutical—there is still a grey zone for cosmeeuticals as far as evidence is concerned. Results are good for a topically applied treatment. Injectables So can we facilitate healing and synergistically augment the results through growth factors in autologous injections? Platelets possess all the elements that are essential for tissue regeneration. Platelet-rich fibrin matrix, or PRFM (Selphyl),

32 INJECTABLES I body language

Platelet rich fibrin matrix can improve dark circles, skin tone and texture, and provide a superficial volumising effect for hollowing in the tear trough

is a fibrin matrix scaffold. It essentially allows us to have a sustained and controlled release of growth factors and cytokines. It’s very important that the platelets should be viable. Platelets are complex cells, and a number of growth factors and cytokines are associated with platelet function. These growth factors and cytokines provide tissue repair, cell growth, collagen production, angiogenesis, keratinocyte growth and generation as well as the promotion of wound healing—all important factors when dealing with ageing skin. Platelets release growth factors, which stimulate angiogenesis, and stimulate the migration of fibroblasts and stem cells. The fibrin matrix, which is unique to PRFM, provides a scaffold that can support the sustained, controlled and predictable release of growth factors and cytokines. Ultimately, the aim is to achieve the formation of new collagen and extracellular matrix in the dermis. PRFM and PRP So what’s the difference between PRFM and platelet-rich plasma (PRP)? The PRFM has minimal red cells in the plasma, which reduces the risk of hemosiderin staining. While that’s important all over the face, one of the areas we’re injecting PRFM the most is the tear troughs. Many patients who come in for tear trough treatment already have an issue with hemosiderin, deposition which is one of the main causes of dark circles. We certainly don’t want to put any more there. Minimal white cells in the plasma have been reported to reduce the risk of impaired tissue healing

and remodelling. It’s a complex process that includes the activation of matrix metalloproteinases which break down collagen. It’s a non-traumatic procedure; the PRFM injects as a liquid but then remains in place and provides a sustained effect from the fibrin matrix. The closed system, with minimal user interaction, minimises contamination. The physiological platelet concentration is only two to three times the platelet concentration in blood. This is important—as it has been shown in some Asian studies that the manipulation and superconcentration of PRP may cause some side effects. Benign tumours in connective tissue have been reported anecdotally. The closer we are to what’s physiologically occurring in the body, the safer we may be. If this complex array of growth factors and cytokines is kept in the same proportions as those present in the blood—just concentrated slightly—we have a physiological balance. Treatment process The treatment is available as a closed kit with labelled tubes. The first step is to draw blood from the patient, then invert the tube gently and place it into the centrifuge. The machine spins for six minutes and, when it comes out, it is now platelet rich plasma. Once this gets transferred into a tube with calcium chloride, it becomes platelet rich fibrin matrix. The entire preparation takes around 20 minutes which, up to this point, can be performed by ancillary staff. Then we go ahead and inject.

There are a number of potential applications. Core applications include fine lines and wrinkles, superficial volumetry, facial rejuvenation and improvement in skin tone, texture, colour and quality. I prefer to use a multi-level superficial technique with PRFM. When injecting the tear troughs, for example, I use a blunt cannula in the superficial subdermal plane. Over-correction is not a concern as the liquid PRFM is very forgiving. After this deeper injection with the cannula, I then use a sharp needle for intradermal layering of the PRFM. Typically, I use a 30 or 32 gauge needle. This combined cannula and needle protocol minimises tissue trauma and resultant bruising. Treatment of the tear troughs with PRFM or PRP can be combined with hyaluronic acids to the lower face to provide additional volumisation if needed. The synergy with PRFM provides improvement in dark circles, skin tone and texture. The procedure also provides a superficial volumising effect for hollowing, tear trough depth can be decreased and tissue quality can be improved after three months. This is a safe, well-tolerated treatment that can yield significant improvement in some patients. Studies have shown that it can induce angiogenesis and fat cell synthesis. Combining PRFM and PRP with other fillers and autologous fat provides an effective combined treatment approach. Ageing is multimodal so we need to think of multimodal means of rejuvenation. Dr Hema Sunderam is a fellowshiptrained board certified dermatologist, and the Founder and Director of her aesthetic dermatology practice in suburban Washington, D.C. Her new paper in collaboration with Dr Sabrina Fabi in Facial Plastic Surgery, “The Potential of Topical and Injectable Growth Factors and Cytokines for Skin Rejuvenation”, serves as an educational guide to this topic in conjunction with American Academy for Facial Plastic & Reconstructive Surgery International Symposium.

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body language I PROMOTION 35

Resveratrol bE SKiNcEuticALS introduce their first antioxidant night concentrate


o help target accumulated signs of visible skin ageing caused by free radical damage, the skin requires a multi-pronged antioxidant approach for protection and correction. Supplemental antioxidant formulations—often containing L-ascorbic acid—need to be applied in the morning to help reinforce the skin’s natural protection against damaging free radicals generated from environmental sources, including UVA, UVB, infrared radiation, and pollution. As the skin cannot naturally produce or store vitamin C, this may be applied topically through a broad-spectrum formulation, proven to absorb within the skin. However, even the most potent formulations are not able to help protect the skin against all free radicals. Additional protection is needed. The skin is able to produce its own natural internal antioxidants to help defend itself against accumulated free radical damage. Regulated by the NRF-2 protein, this system mediates the expression of 200 cytoprotective molecules responsible for neutralising excessive free radical damage and promoting skin’s self-repair. However, with age and on-going environmental aggressions, the skin’s natural protective mechanisms can lose efficiency, rendering skin vulnerable to the cumulative effects of free radical damage and the subsequent appearance of skin ageing. Now, new science has shown that certain ingredients can work to influence and support these internal mechanisms. reservatrol Resveratrol is a potent polyphenol antioxidant found in grapes, various berries, nuts, and other plant sources. Over the past 10 years resveratrol has garnered the reputation as the “longevity molecule,” owing to the role it has been found to play

in determining species longevity and healthspan. It is believed that resveratrol works as an intracellular effector to modulate the signaling pathways responsible for age-related deterioration and functional decline. Resveratrol has been scientifically shown to boost skin’s endogenous antioxidant defense via the NRF-2 pathway. By boosting this defense system, skin enhances its natural self-repair and rebuilds defenses against new damage. introducing resveratrol bE Resveratrol BE is SkinCeuticals’ first night-time ‘PREVENT’ formulation that helps to support the skin’s natural, endogenous defence system against free radical damage, to help repair the appearance of accumulated skin ageing. It also helps to strengthen skin’s functionality to help diminish the visible signs of accumulated skin damage. Resveratrol BE combines our highest concentration of 1% pure, stable resveratrol—one of the highest levels available in a skincare formulation on the market today. Known to be difficult to stabilise within an aqueous solution, Resveratrol BE has been formulated with hydrotopes to ensure optimum absorption of the active ingredient. This is then synergistically enhanced with 0.5% baicalin and 1% alpha tocopherol. Suitable for all skin types, Resveratrol BE should be applied at night after cleansing and is suitable to help target a wide variety of indications including signs of photodamage that have accumulated over time, overall loss and skin firmness and loss of skin radiance, poor elasticity and fine lines and wrinkles. Resveratrol BE can also be recommended for use alongside invasive or non-invasive clinical treatments such as tightening and volumising procedures including radiofrequency or injectable treatments.

Clinical improvements In a dermatologist controlled 12week clinical trial conducted on 55 females with mild to moderate lines and wrinkles, Resveratrol BE was proven to be effective. Over the 12 weeks, different indicators of ageing were evaluated as improved vs the baseline, including skin radiance, skin firmness, skin smoothness, skin’s elasticity and skin density. Subjects applied Resveratrol BE once daily at night. As shown by an ultrasound measurement, Resveratrol BE was also shown to help increase skin’s epidermal thickness by 18.9%. discover more SkinCeuticals will be exhibiting at this year’s FACE conference. Visit SkinCeuticals at stand 36-39 to find out more, or listen to an exclusive symposium ‘The latest developments within topical antioxidant formulations’ on Friday 20th June on the SKIN agenda. Resveratrol B E will be available to order direct from SkinCeuticals, and from Wigmore Medical, from June 2014.

Reference: Silvie t. et al (2012). Aging 4:146-158; Fontana, L. et al (2010); Science 328:321-326.

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body language I EQUIPMENT 37

Transdermal drug delivery The barrier function of the stratum corneum is vital to protect the skin and underlying structures, but it can serve as a barrier for topical aesthetic treatments. A combination of radiofrequency and ultrasound can help increase skin permeability and allow for topical product penetration , writes Dr Mukta Sachdev


e all know that if we can push an active deeper into the dermis, the lower epidermis or the upper dermis, the results are going to be more effective. In an era of evidence-based medicine—it is important to understand the science behind any procedure and have proof of the same. The stratum corneum acts as a barrier and for the past 20 years, many studies have reported that ultrasound can improve the penetration

of drugs. In spite of that, we haven’t really understood the mechanism. Recently, ablative fractional lasers have been shown to increase the skin permeability, following up the laser with a cosmeceutical. We can also use a dermaroller and then apply a cosmeceutical. This is trans-epidermal drug delivery. Enhanced delivery Publications have shown that radiofrequency (RF) creates channels. Topical aminolevulinic acid (ALA)

delivery has been enhanced by an erbium laser. Topical 5 -Fluorouracil can be enhanced with lasers as can topical delivery of methotrexate using the erbium YAG laser. Transdermal and trans-epidermal drug delivery is a potential method for enhancing treatment efficacy. So the new thinking is that the use of these devices can enable us to penetrate the stratum corneum. Cosmeceuticals and topical agents currently in development are using newer technologies, such as nanospheres and different delivery systems. These are designed to enhance delivery and therefore allow products to penetrate deeper into the skin—if we cannot get past the stratum corneum, then it will be difficult to have an enhanced effect. We need to get to the lower epidermis or the lower dermis to make a difference. The newer treatment , known as the Legato is a combination treatment involving RF to achieve thermal damage followed by an impact technology. We use a unipolar fractional ablative technology, delivering the energy in a fractional manner. When this interacts with the skin, we create a micro-channel. The RF creates holes are 100– 150µm (micrometres) in depth and a width of 80–120µm. Micro-channels When we have an open microchannel and apply a topical drug, we have a better chance of penetration. We can use an ultrasound technology and push the drug into the epidermis. Looking at this theoretically, it makes a lot of sense. We’ve made a channel and whether we push hydroquinone, topical retinoic acid or hyaluronic acid, the product is getting deeper and hav-

38 EQUIPMENT I body language

The treatment can be used for acne scarring and provides good improvement in the texture on the face

ing some effect. The ultrasound works through a thermal, cavitational and an acoustic streaming effect. High acoustic pressure and sonophoresis help force the product down. I use the Alma Legato, which has a sonotrode which tends to improve product distribution under the skin. While the science behind this delivery works, we have to be careful of the active we’re using. None of the actives which have been developed or studied are meant for intradermal use. For example, mesotherapy products have not been developed for intra-dermal use. But, as far as I can foresee, the only possible complication would be a potential reaction to the vehicle of the topical. But if we’re performing any kind of mesotherapy or dermaroller, we’re already providing a form of transepidermal delivery. The only difference is when you use a device such as a laser—we’re then providing controlled, reproducible results. Indications With this technology, we can target anti-ageing, rejuvenation, scars and

stretch marks. I find the treatment most beneficial for stretch marks— we see good results Medicines used include glycolics, hyaluronics, Vitamin C, hydroquinone and kojic acid. We’ve also used peptides; any of the active topicals that you would prefer in a particular indication can be used. During the procedure, there is some amount of burning sensation—it is an RF treatment after all. We use topical anaesthesia for at least 45 minutes because they can’t tolerate the pain of the RF. The pain progressively reduces over 12 hours. Once you apply the topical and you’re using the ultrasound probe, the patients tend to say they feel better. The whole treatment takes around 15–20 minutes. We can see significant erythema which looks really painful, but it’s not usually as bad as it looks. Patients tend to have three to four days of downtime following the procedure. For stretch marks, we’re looking at around a 30–40% improvement. If we look at the underlying etiology of striae, the skin has been

stretched, torn and damaged. We can’t repair the whole thing, but we can improve the appearance. We can also use the treatment for acne scars. It can provide a good improvement in the texture on the face. New scars show better improvement than old scars. In general, we aim for a 20–30% improvement for scarring. Melasma will improve temporarily—it’s not a permanent treatment for melasma. But it’s an adjunctive treatment for melasma; the condition is dynamic and does come back. But this technique can be used as an adjunctive therapy. Trans-epidermal delivery is kickstarting a new generation of treatment devices in dermatology, focused on combination therapies. We want to combine procedures and topicals for more effective results. Dr Mukta Sachdev is a professor of dermatology and practising senior consultant dermatologist and runs her own dermatology consulting firm. She specialises in lasers and aestheteic dermatology in skin of colour


FACE has always focused on the main driving forces of growth in the aesthetic industry—namely non-surgical injectables, aesthetic equipment and topical treatments designed for facial rejuvenation with an emphasis on the quality and depth of topics covered in the scientific agenda. This year FACE will provide unparalleled CPD approved learning with over 170 national and international speakers, a total of 14 days of educational content spaced over seven separate agendas—plus exhibitor workshops and an exhibition devoted to the facial aesthetic market. FACE uniquely has dedicated agendas for different interests with injectable, equipment, cosmeceutical, business and aesthetician agendas. Whatever your medical speciality, or size of business, FACE provides learning for all medical aesthetic practitioners. For detailed agenda information and to book visit or call us on 020 7514 5989





JUNE 20TH – 22ND


FACE 2014 is the one must-attend event for anyone involved in facial rejuvenation to gain knowledge about the latest treatments, procedures and business strategies

Follow FACE Ltd on twitter @face_ltd and on Facebook for the latest updates  EQUIPMENT



body language I CONFERENCE 41


FAcE brings together a world-renowned speaker panel to deliver lectures you won't want to miss



Dr Raj Acquilla is an expert in medical aesthetics, facial contouring, volume replacement, dermatological surgery including facial skin cancer and undergraduate/postgraduate clinical education. He runs busy private clinics in Cheshire, London and Ibiza in addition to his own Facial Aesthetic Academy.

Wendy Lewis founded Wendy Lewis & Co Ltd, Global Aesthetics Consultancy in 1997. As the "Knife Coach", she sees private clients in New York, Palm Beach and London as the original independent cosmetic surgery and skincare expert with a client list of women and men all over the world. In 2008 she founded



Sandeep CliďŹ&#x20AC; has a clinical interest in the use of combination procedures and cosmeceutical skincare to produce a natural, more youthful look in his patients. He undertakes an extensive range of non invasive rejuvenation procedures including advanced botulinum toxin, non permanent fillers and both ablative and non ablative lasers.

Dr Zein Obagi has achieved international renown as a leading authority on skin rejuvenation. He is the ZO Skin Health Inc. founder and medical director and is responsible for the development of new skincare treatments, protocols and products to achieve healthy skin. He is a researcher, innovator, scientist and board-certified dermatologist.



Dr Flynn served as the 2012-2013 President of the American Society for Dermatologic Surgery, the largest sub-specialty organisation in US dermatology. He is currently Medical Director at the Cary Skin Center in North Carolina and Clinical Professor of Dermatology at the University of North Carolina. He is the author of over 145 publications.

Dr Tapan Patel specialises in non-surgical treatments. Dr Patel founded the London based vIvA clinic in 2003 and works full time as the Medical Director. His main area of interest is in the use of light and laser technology and has extensive experience on the treatment of acne, acne scarring and pigmentary disorders.



Mr Rajiv Grover is the President of the British Association of Aesthetic Plastic Surgeons (BAAPS). He works as a Consultant Plastic Surgeon at London's King Edward vII Hospital as well as running a Private Practice in Harley Street. Rajiv has published over 60 book chapters and journal articles in the UK and USA.

Dr Mukta Sachdev is Professor and Head of the Dept of Dermatology in Manipal Hospital, Bangalore, India. She also runs a private cosmetic oďŹ&#x192;ce practice and a clinical trial unit specialising in dermatology trials in skin of colour. She is regarded as one of the international experts in the field of cosmetic dermatological procedures and lasers in skin of colour.

42 CONFERENCE I body language

UNPARALLELED CHOICE Experience CPD approved learning with over 170 speakers and 14 days worth of educational content spaced over seven seperate agendas devoted to the facial aesthetics market 

Facial Injectables Agenda

A host of national and international lecturers help you maximise results and minimise problems when using cosmetic injectables for total facial contouring. Different techniques, new treatment approaches and concepts 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 alongside a special session devoted to different ways of objectively measuring and recording patient outcomes.


With many different competing skincare lines, it can be confusing to establish which brands to choose from company representatives and promotional literature alone. FACE provides a forum for practitioners to meet the true experts who understand ingredients, formulations and the arguments behind competing concepts and brands. This two day forum will focus on new topical approaches to preventing and treating signs and symptoms of ageing skin alongside the latest specific approaches to treating acne, rosacea and hyperpigmentation in skin of colour.


The use of lasers, radio frequency, ultrasound and other aesthetic equipment for facial rejuvenation continues to grow, providing new approaches to the treatment of skin lesions and skin ageing. Clinics embracing the right equipment can significantly enhance revenue streams by providing complementary approaches for skin rejuvenation alongside cosmetic injectables. This two day agenda allows delegates the opportunity to explore and compare the latest equipment, protocols and treatment approaches to a wide range of different skin problems.

HAIR Agenda

With so many different non-surgical and surgical treatment options now available for the treatment of androgenetic alopecia, alongside growing demand for solutions to hair loss, FACE are hosting a special one day symposia devoted to exploring this sector of the aesthetic market. Dr Bessam Farjo, one of the UK’s leading hair transplant surgeons, will be chairing and talking alongside a panel of experts who will explore in depth the different potential treatment solutions available.


In an increasingly competitive market everyone needs to raise their game and FACE provides a unique three day forum for clinic owners, managers and marketeers to explore a wide range of topics related to the art of marketing. Professional speakers including specialist marketeers, web designers, and social media gurus will give you the latest information on techniques that work specifically in the aesthetic market. We have a specialist session including lawyers and representatives from the insurance industry to explore risk management.


This two day event is tailored specifically to exploring advanced treatments that are performed by non-medically qualified practitioners with different skill sets, interests and backgrounds. The last 10 years has seen the role of beauty therapists, laser technicians and other practitioners working in the aesthetics market rapidly evolve and many of the lectures are delivered by therapists who have specialist expertise and experience in their chosen field, with FACE providing a dedicated forum to share knowledge and stimulate debate amongst therapists.


The concept of the use of different types of threads for facial rejuvenation has been in development since the late 1990s and since then many other other types of threads have been actively promoted to the aesthetic community. This special half day workshop will explore the latest data evaluating the efficacy and long term safety of threads for facial rejuvenation, alongside the technical issues of placing threads and the experience required to deliver these treatments in aesthetic practice.

body language I CONFERENCE 43







09:25 | 09:30 Conference introduction

09:25 | 09:30 Conference introduction, Dr Carl Thornfeldt

09:25 | 09:30 Conference introduction

09:30 | 10:00 20 years of botulinum toxin Dr Martina Kerscher and Dr Michael Kane

09:30 | 09:50 A new topical formulation for the treating hyperpigmentation Dr Tapan Patel

10:00 | 10:50 The safety of polycaprolactone and my personal experiences with polycaprolactone Dr Pierre Nicolau

09:50 | 10:10 Hyperpigmentation treatments for Asian and African skin types Ms Shashi Gossain 10:10 | 10:30 TBA, Dr Carl Thornfeldt

10:50 | 11:00 Q&A

10:30 | 11:00 Expert panel debate Dr Tapan Patel, Ms Shashi Gossain and Dr Carl Thornfeldt



11:30 | 12:20 Expert panel debate

11:30 | 11:50 Photo ageing and DNA damage Dr Charlene DeHaven 11:50 | 12:10 Ingredients that affect glycation Dr Beth Briden

12:20 | 13:00 Nefertiti lift and marionette line treatment with toxins

12:10 | 12:30 Pollution and skin damage, TBA 12:30 | 13:00 Expert panel debate Dr Charlene DeHaven Dr Beth Briden

09:30 | 11:00 The profit hunter Mr Andy McDougall

COFFEE BREAK & EXHIBITION 11:30 | 11:50 Does my business need an app? Richard Crawford Small

11:50 | 13:00 TBA




14:30 | 15:00 Skin rejuvenation and HA Dr Christoph Martschin

14:30 | 14:50 The next generation of antioxidant formulations Julien DeMaude

14:30 | 15:00 Avoiding litigation Ms Flora McCabe

15:00 | 15:20 PRP overview Mr Kambiz Golchin

14:50 | 15:10 TBA

15:20 | 15:40 PRP injection workshop Mr Taimur Shoaib

15:10 | 15:30 TBA

15:40 | 16:00 TBA

15:30 | 15:50 TBA

15:30 | 16:00 The unhappy patient Ms Liz Bardolph

16:00 | 16:20 Stem cells for facial rejuvenation Dr Ali Ghanem

15:50 | 16:10 TBA

16:00 | 16:20 Insurance—what to buy and how to work with insurers

16:20 | 16:45 PRP and HA for skin rejuvenation Mr Kambiz Golchin, Dr Christoph Martschin, Mr Taimur Shoaib and Dr Daniel Sister

16:10 | 16:45 Expert panel debate Dr Charlene de Haven, Dr Zein Obagi, Dr Carl Thornfeldt and Dr Beth Briden

16:20 | 16:45 Panel debate and Q&A session

15:00 | 15:30 Avoiding litigation in practice Dr Natalie Blakely and Ms Mandy Luckman

16:45–17:15 Drinks and Canapés FOLLOWED BY 17:15–19:00 An Evening with Dr MICHAEL KANE

Once again FACE has the pleasure of hosting another evening lecture session and in 2014 we have the esteemed pleasure of welcoming Michael Kane MD to the stage, to offer us his insights into the aesthetic community, how he made his way to the top of the pile and the methods he uses to stay there. Dr Kane has been practicing out of New York City for over 15 years performing a wide variety of cutting edge cosmetic procedures, facial rejuvenation and injections, while also taking time to develop techniques, lecture across the world and teach others to practice at the top level. This evening session is geared for a lighter approach towards the concept of facial aesthetics and the journey of one particular individual who has helped the process of pioneering the facial aesthetic market place.

44 CONFERENCE I body language







09:25 | 09:30 Chairman’s introduction

09:25 | 09:30 Chairman’s introduction

09:25 | 09:30 Chairman’s introduction, Dr Mukta Sachdev

09:30 | 09:55 Drug based topical and oral treatments for alopecia Dr Vishal Madan

09:30 | 09:50 Fractional lasers for eye rejuvenation Dr Dianne Quibell

09:55 | 10:20 Non-drug based topical and oral treatments for alopecia Mr Eliot Isaacs

09:50 | 10:10 Fractional radiofrequency for peri-orbital rejuvenation Dr David Eccleston

10:20 | 10:45 Light based treatments for alopecia Dr Nilofer Farjo

10:10 | 10:30 Nitrogen plasma for peri-orbital rejuvenation Dr Jose Miguel Garcia

10:45 | 11:00 Q&A

10:30 | 11:00 Expert panel debate Dr David Eccleston, Prof. Mukta Sachdev, Dr Dianne Quibell and Dr Jose Miguel Barcia




11:30 | 11:45 Impact of botulinum toxin type A on the quality of life Dr Ravi Jandyhala

11:30 | 11:50 Hair micropigmentation treatment Ms Dawn Forshaw

11:30 | 11:50 Ultrasound non-invasive skin tightening/lifting Dr Sabrina G. Fabi

11:45 | 12:15 Patient assessment in clinical practice

11:50 | 12:10 Injectable treatments

11:50 | 12:10 Radiofrequency for skin tightening

12:15 | 12:30 Facial assessment scales in clinical practice Dr Stefan Cano and Dr Anne Klassen

12:10 | 12:30 Platelet rich plasma Dr Victoria Dobbie

12:10 | 12:30 Combined radiofrequency and ultrasound for skin tightening Mr Martin Coady

09:30 | 10:10 Botulinum toxin for facial hyperhidrosis Dr Sandeep Cliff

10:10 | 11:00 Facial contouring workshop Dr Marina Landau and Dr Kate Goldie

12:30 | 13:00 Expert panel debate Dr Stefan Cano, Dr Ravi Jandyhala, Dr Anne Klassen and Dr Stefan Cano

12:30 | 12:50 Wigs and weaves Ms Jane Kelly 12:50 | 13:00 Q&A

12:30 | 13:00 Expert panel debate Mr Martin Coady and Prof. Mukta Sachdev




14:30 | 15:00 TBA

14:30 | 14:55 Evolution of hair transplant surgery Dr Greg Williams

14:30 | 14:50 Microneedling systems Dr Linda Eve

14:55 | 15:20 How to achieve great results using the latest techniques Dr Bessam Farjo

14:50 | 15:10 Treatment of scars in Asian skin Prof. Mukta Sachdev

15:20 | 15:45 Using robotic devices Dr Edward Ball

15:10 | 15:30 Fractional radiofrequency in combination therapy Dr Diane Duncan

15:45 | 16:10 Modern artificial hair transplant Dr Manal Sheta

15:30 | 15:50 Combination of needling and recell for regeneration and repigmentation of burn scars Dr Matthias C. Aust

16:10 | 16:30 Panel debate and Q&A Dr Greg Williams, Dr Bessam Farjo, Dr Edward Ball and Dr Manal Sheta

15:50 | 16:30 Expert panel debate Dr Matthias C. Aust, Dr Diane Duncan, Prof. Mukta Sachdev, Mr Elliot Isaacs and Dr Linda Eve




17:00 | 17:30 Finessing facial volume with fillers Dr Nick Lowe

17:00 | 17:25 Private hair loss treatment

17:00 | 17:30 Avoiding and dealing with complications caused by light and energy based aesthetic treatments Prof. Harry Moseley

15:00 | 16:00 Peri-orbital injection workshop session Dr David Eccleston

16:00 | 16:30 TBA Mr Rajiv Grover

17:30 | 18:15 FACE of the future Dr Timothy Flynn, Mr Rajiv Grover, Dr Michael Kane, Dr Marina Landau and Dr Nick Lowe

17:25 | 17:50 Surgical hair transplant 17:50 | 18:15 Q&A

17:30 | 18:15 Laser controversies debate Prof. Harry Moseley

body language I CONFERENCE 45

pLAtiNuM SpoNSoR





09:25 | 09:30 Chairman’s introduction

09:25 | 09:30 Chairman’s introduction


09:30 | 10:00 Lasers/IPL and RF for skin rejuvenation

09:30 | 11:00 Pay per click marketing and Google myths—exploring page one psychology, Google+ and Google reviews Mr John Castro and Mr Adam Hampson

10:00 | 10:20 Radiofrequency for skin tightening 10:20 | 10:40 Ultrasound for skin tightening 10:40 | 11:00 Expert panel debate


14:30 | 15:00 TBA

14:30 | 14:50 Peels - which peels for which indication? Ms Sally Durrant

17:00 | 17:40 What are you trying to build and why? Mr Martyn Roe 17:40 | 18:15 Expert panel debate Mr Martyn Roe


14:50 | 15:10 Key ingredients—what should your skincare line contain?


15:30 | 15:50 Using digital skin analysis systems in consultations

SKINCEUTICALS, STANDS 36 – 39 15:50 | 16:10 How to maximise retail skincare sales Ms Lorna Bowes 16:10 | 16:30 Expert panel debate




15:10 | 15:30 Eyelash enhancement treatments

15:00 | 16:30 Social status workshop Ms Wendy Lewis


12:00 | 12:30 Practical tips for getting the most out of your laser/IPL system Ms Jo Martin

12:30 | 13:00 Expert panel debate Ms Jo Martin LUNCH & EXHIBITION


COFFEE BREAK & EXHIBITION 11:30 | 12:00 Latest laser/IPL devices for hair removal

11:30 | 13:00 Search engine optimisation workshop Mr John Castro and Mr Adam Hampson




17:00 | 18:15 How do you train to be an aesthetician? Ms Barbara Freytag


46 CONFERENCE I body language







09:25 | 09:30 Chairman’s introduction

09:25 | 09:30 Chairman’s introduction

09:25 | 09:30 Chairman’s introduction

09:30 | 09:50 TBA

09:30 | 09:50 Pulsed DYE laser for vascular lesions Dr Maria Gonzalez

09:50 | 10:10 Treating hyperpigmentation in dark skins using topicals

09:50 | 10:10 Copper bromide multi-wavelength laser for vascular lesions Mr Ian Franklin

10:10 | 10:30 Treating hyperpigmentation in dark skins using peels

10:10 | 10:30 Intense pulsed light for vascular lesions

09:30 | 10:00 Chin reshaping and lower face refinement Dr Kate Goldie

10:00 | 11:00 Dealing with adverse events from cosmetic injectables Dr Chris Inglefield, Dr Gertrude Huss, Dr Stefanie Williams and Marie Duckett

10:30 | 10:50 Grid fractional treatment lasers in darker skins Prof. Mukta Sachdev




11:30 | 11:50 Intralesional cryotherapy for hypertrophic and keloid scars Dr Tapan Patel

11:30 | 11:50 Fractional radiofrequency for the treatment of pigmentation Dr Diane Duncan

11:30 | 11:50 Warts, moles, lumps and bumps in aesthetic practice

11:50 | 12:10 Lasers and IPL for the treatment of pigmentation

12:10 | 12:30 Management of common skin diseases in an aesthetic practice Dr Carl Thornfeldt

12:10 | 12:30 TBA

12:30 | 13:00 Expert panel debate

12:30 | 13:00 Expert panel debate Dr Diane Duncan




14:30 | 14:50 Avoiding nerve damage when administering cosmetic injectables Mr Riccardo Frati

14:30 | 14:50 Acne treatment using topicals/peels

14:30 | 14:50 Choosing Equipment for facial rejuvenation Dr Mark Tager

14:50 | 15:10 Acne treatment using lasers and light Ms Jane Lewis

14:50 | 15:10 Advances in mixed wavelength laser tecnologies Dr Samantha Hills

15:10 | 15:30 Treatment of rosacea using topicals Dr Rachael Eckel

15:10 | 15:30 Mole excision by radio wave Dr JJ Masani

11:30 | 12:00 The art of non-surgical nasal contouring Mr Raj Kanodia

12:00 | 13:00 Brow and temple rejuvenation using toxins and HA fillers Dr Raj Aquilla and Dr Tapan Patel

14:50 | 15:10 Botox bring bliss? Dr Raj Persaud 15:10 | 15:30 Plumping up an erogenous zone Dr Kathryn Taylor Barnes 15:30 | 16:10 TBA

10:50 | 11:00 Expert panel debate Prof. Mukta Sachdev

10:30 | 11:00 Expert panel debate Dr Maria Gonzalez and Mr Ian Franklin

15:30 | 15:50 15:30 | 15:50 Treatment of rosacea using lasers and light Dr Steve Eubanks

15:50| 16:10

16:10 | 16:30 Q&A

15:50 | 16:30 Expert panel debate Dr Steve Eubanks, Mc Jane Lewis and Ms Julie Brackenbury

16:10 | 16:30 TBA




CLINIC DISCOUNT Discount 1: Three Full Delegates from the same clinic—pay for two full price passes and recieve a 50% discount on the the third pass Discount 2: Four Full Delegates from the same clinic—pay for three full price passes and receive the fourth pass free of charge Discount 3: Buy three mix and match passes for any agenda’s for delegates from the same clinic, and receive 10% off the total cost Discount 4: Buy four mix and match passes for any agenda’s for delegates from the same clinic, and receive 15% off the total cost

body language I CONFERENCE 47





09:25 | 09:30 Chairman’s introduction

09:25 | 09:30 Chairman’s introduction 09:30 | 09:50 Peels for the treatment of acne 09:50 | 10:10 Topical treatment approaches to the management of acne

09:30 | 11:00 Market to prime of life women Mr Tony Gedge

10:10 | 10:30 Hydradermabrasion & LED

10:30 | 11:00 Expert panel debate



11:30 | 11:50 Advertising—what you can and can’t say Mrs Lorna Jackson

11:30 | 11:50 Medical needling techniques

11:50 | 12:10 How to sell skincare Ms Lorna Bowes

11:50 | 12:10 Using lasers safely in darker skins

12:10 | 12:50 Great Team Training Dr Mark Tager

12:10 | 12:30 Ablative and non-ablative fractional radiofrequency

12:50 | 13:00 Q&A

12:30 | 13:00 Expert panel debate



14:30 | 14:50 Success is based upon creating a great first impression Ms Gilly Dickons

14:50 | 15:10 Industry awards Mr Stephen Handisides

15:10 | 16:10 Ten top tips on recruiting staff Roger Thomson 16:10 | 16:30 Q&A EXHIBITION & MEETING CLOSE

 Full Delegate three Day pass £499  Full Delegate two Day pass £375  Full Delegate one Day pass £225

14:50 | 15:10 Radiofrequency treatment demonstration for body contouring 15:10 | 15:30 Ultrasound lipo-cavitation for fat reduction and cellulite Ms Barbara Freytag 15:30 | 15:50 Cryolipolysis for fat reduction



 Equipment Agenda two Day pass £180  Equipment Agenda one Day pass £99


 Hair Agenda pass £99 SKiN pASSES

 Skin Agenda two Day pass £180  Skin cosmeceuticals Agenda Friday pass £99  Skin Anti-Ageing Agenda Saturday pass £99


 Aesthetician Agenda two Day pass £99  Aesthetician Agenda one Day pass £50


 Exhibition and workshop one Day pass £50

 15:50 | 16:30 Expert panel debate


 Business Agenda weekend pass £250  Business Agenda two Day pass £180  Business Agenda one Day pass £99

14:30 | 14:50 Cellulite treatment demonstration with velaShape


EvENiNg witH

 An Evening with Dr michael Kane £50


 FAcE Social Saturday Evening £75 please note that agendas may change prior to the event due to circumstances beyond our control

48 CONFERENCE I body language

EXHIBITORS Attend the largest medical aesthetics exhibition the UK has ever seen 3D Lipo, stand 27 ABC LASERS, stand 25 Adare Aesthetics, stand 20 ADVANCED BIOTHERAPIES, stand 73 Aestheticare, stands 70 and 71 Aesthetic Source, stands 11 and 12 AESTHETIC TECHNOLOGY LTD, stand 51 Allergan, stands 57 and 61 AMBICARE, stand 54 ANEVA NUTRACEUTICALS, stand 60 AQTIS Medical, stand 83 Avita Medical, stand 44 Body Language, stand 02 BOTTLED SCIENCE, stand 34 BTL Aesthetics, stand 09 CHROMOGENEX, stand 59 Clarisonic, stand 35 Coachhouse Medical, stand 24 Consulting Room, stand 01 CYNOSURE, stands 62 and 63 Cytomedix, stand 73 Dermalux, stand 51

Dermaquest, stand 16 Device Technologies, stand 13 Eden Aesthetics, stands 65 and 66 ENERGIST, stand 72 EQUIPMED, stand 50 EUROMEDICAL SYSTEMS, stand 14 Galderma, stand 76 H&P Design, stand 88 Hamilton Fraser, stand 64 Healthxchange, stands 79 and 80 Invasix UK, stands 04 and 05 IS Clinical, stand 87 JMSR, stands 67 and 68 KOREESA GROUP, stand 23 La Roche-Posay, stand 40 Lifestyle Aesthetics, stand 41 LIRA UK, stand 55 Lumenis, stands 47 and 48 Lynton Lasers, stands 42 and 43 Meda Pharma, stand 19 Merz Aesthetics, stand 77 MYOSCIENCE, stand 06

NEEDLE CONCEPT, stand 69 Neocosmedix Europe, stand 58 Pharmaclinix, stands 52 and 53 REDERM, stand 75 Rosmetics, stand 86 Schuco, stand 56 SILHOUETTE SOFT, stand 17 Sinclair IS Pharma, stands 84 and 85 SKINBRANDS@COSMECEUTICALS, stand 26 SkinCeuticals, stands 36 and 39 Solta Medical, stands 45 and 46 Spectrum Technology, stand 21 Sterimedix, stand 49 Syneron Candela, stands 81 and 82 Tavger, stand 38 THERMAVEIN, stand 74 TSK Laboratory, stand 89 UKAAP, stand 22 Wesbites for Cosmetics, stand 10 Wigmore Medical, stand 78 Zeltiq, stand 07

EXHIBITOR WORKSHOPS This year delegates will be able to attend our largest programme of exhibitor workshops to date Friday 20th June Chaucer Room 11:30 I 13:00 Lumenis 14:30 I 16:00 Invasix UK, Introduction to InMode, Dr Dianne Duncan, Dr Hela Goran, Simon Davies 16:00 I 17:30 Invasix UK, My Way With InMode, Dr Dianne Duncan, Dr Nicola Willis Keats Room 16:00 I 17:30 Healthxchange, Refining Localised Fat Reduction—a new injectable technique. Not all Radiofrequency treatments are as they seem. When only the best will do—Skincare from Obagi Wordsworth Room 16:00 I 17:30 Galderma

Smarter Tools For Smarter Working, Dr Christoph Martschin Saturday 21st June Chaucer Room 09:30 I 11:00 Invasix UK, Facial Aesthetics with BodyTite, Dr Dianne Duncan, Dr Hela Goran, Dr Rupert Gabriel 11:30 I 13:00 Invasix UK, Combination Treatments With InMode, Dr Aamer Khan, Dr Dianne Duncan 14:30 I 16:00 Solta Medical, Synergistic effect of combining Thermage and Fraxel treatments: the “1 + 1 = 3” effect, Dr Afschin Fatemi 17:00 I 18:30 Needle Concept, U225: The amazing painless mesotherapy System, Scientific Basis, Injection

& Microneedling in face and Alopecia treatment using vitamin cokctailand PRP, Jean-Paul Ben Keats Room 09:30 I 13:00 Aesthetic Source, The Science Of Healthy Skin, Dr Elizabeth Briden, Dr Sandeep Cliff, Dr Bianca Toebben, Deborah Forsythe, Sally Durant, Lorna Bowes 14:30 I 16:00 AQTIS Medical, Lifting with Ellanse. The Secret To Longer Lasting Results, Mrs Sharon King NIP and Dr Martyn King 17:00 I 18:30 Zeltiq Shelley Room 09:30 I 11:00 Sinclair IS Pharma, Sculptra: Needle v Cannula, Dr Linda Eve & Dr

Askari Townshend 11:30 I 13:00 Pharmaclinix 14:30 I 16:00 Ultherapy, Ultherapy— the only non-invasive procedure FDA-cleared to lift skin, Dr Sabrina Fabi 17:00 I 18:30 Rederm, Redermalisation: A New Approach To Face and Body Skin Rejuvenation using Needle and Cannula Techniques, Dr Joshua Berkowitz & Dr Rikin Parekh Wordsworth Room 09:30 I 11:00 Cynosure 11:30 I 13:00 Galderma 14:30 I 16:00 Galderma, Emervel—

The Broadest Range of Soft Gel Textures, Dr Med. Said Hilton 17:00 I 18:30 Lifestyle Aesthetics, Non-Surgical Rhinoplasty, Dr Ahmed Haq and Dr Vincent Wong Sunday 22nd June Chaucer Room 11:30 I 13:00 Silhouette Soft Keats Room 11:30 I 13:00 Adare Aesthetics, Knowing your Anatomy, Needles v Cannulas and Deep Injections using VARIODERM HA Dermal Fillers, Dr Aref Al Soufi Wordsworth Room 11:30 I 13:00 Syneron Candela Check online at for additional workshops

body language I CONFERENCE 49

MERZ WORKSHOP Viewing the patient’s ageing process over years shows us how facial shape and skin quality changes with environmental influences and natural ageing. Certain treatments may ‘slow the clock’ and others help to give the appearance of ‘turning back the clock’. In a two part workshop Merz Aesthetics present world leading opinions on the processes of ageing, approaches to anti-ageing and treatments that will have the greatest impact on the visual signs of ageing. Friday 11.30 to 1pm: Pickwick Suite Merz Aesthetics Workshop One This workshop demonstrates the anatomical and physiological changes of the naturally ageing face focusing on skeletal, muscular and dermal changes over time. Understanding how, over time, the ageing face becomes a changing landscape and considerations for safe treatment techniques need to be adjusted.

MEET DR CARL THORNFELDT Epionce is a comprehensive and innovative skin wellness line designed to optimise the appearance and health of the skin by working at the core of the skin’s own protective and reparative systems. This results in a stronger healthier barrier that can help defy the effects of ageing, giving you smoother, more radiant skin that functions at its optimum. Come meet and listen to Dr Carl Thornfeldt, creator of Epionce on Saturday 21st June 2014 2.30pm in the Thames room. Dr Carl Thornfeldt will be discussing:  Theory and science behind the Epionce skincare line  How to incorporate Epionce with other treatments  European launch of the new MelanoLyte Pigment Perfecting Serum  Practical demonstrations using the Epionce Peel System  The importance of clinical studies

Saturday 11.30 to 1pm: Pickwick Suite Merz Aesthetics Workshop Two This workshop showcases the treatments options and various techniques best employed for treating the ageing face. Demonstrating specifics of anatomical and physiological changes and how to select products and techniques that will target various needs of treatment outcomes to ensure best long-term patient commitment to treatment and satisfaction. After you have registered to attend FACE you can reserve your space at these symposia by contacting

ZO SKIN HEALTH SYMPOSIUM Wigmore Medical are proud to host the second annual ZO Skin Health Symposium at FACE 2014. The most exciting range of skincare in the aesthetics industry is constantly improving and the European symposium will focus on effective ageing prevention and treatment by comprehensively addressing aesthetics strategy for external appearance and applying anti-ageing medicine for internal wellbeing. The session will feature a “Be Ready for the Future” theme and emphasise not only the importance of keeping up with knowledge and technology and world-

wide practices but also on preparing the participants to meet the challenges of the changing world. Dr Zein Obagi and his key International and domestic faculty will identify the best products and techniques for treatments available within the ZO SkinHealth range and focus on how the effective use of the product portfolio will be able to generate longer lasting results and even more patient satisfaction. When you have registered for FACE 2014 please reserve your place at the European Symposium, or to just register your interest please email the team at

50 CONFERENCE I body language

VENUE For the second year running, FACE will be held at the QEII Conference Centre in the heart of London’s Westminster


s a location, Westminster speaks for itself. As one of the world’s great capital cities, London’s cosmopolitan blend of culture, history, vibrancy and modern offers an exhilarating mix for professionals looking to stimulate their imagination. The award-winning Queen Elizabeth II Conference Centre has stunning panoramic views of Westminster Abbey and Big Ben. Westminster boasts superb transport links, with easy access to five International airports, including Heathrow. In addition the Eurostar terminal at St. Pancras International Station is just a short journey from Victoria, providing instant access to Brussels, Paris and the rest of Europe. The Centre is also within walking distance from three mainline and two underground stations making it a suitable option for those arriving by train from elsewhere in the UK. Accommodation Should you need accommodation, a discounted rate for FACE delegates and exhibitors has been arranged at the Park Plaza Hotel, Westminster Bridge.

How to book: • Go to Park Plaza reservations Enter City (London) and then Country (United Kingdom) • Enter check in and check out dates • Select the desired number of rooms and guests • Enter promotional code 190614 • Click “Find Hotels” Park Plaza Westminster Bridge London will be displayed • Click “Book Now” and then follow the booking procedure • Alternatively, call +44 844 415 6780 to book by phone quoting the reference 190614GROO At the time of booking, credit card details will be required. Superior room, single occupancy—£169 per room + VAT. Superior room, double occupancy—£179 per room + VAT. Travel By tube Westminster Station is 0.1 miles away and is served by the Circle, District and Jubilee lines. St. James Park Station is also 0.1 miles away and is served by the Circle and District lines. Victoria Station is 0.7 miles away, and is served by the Circle, District and Victoria lines. By bus, the 11, 24, 53, 77a and

88 all stop at Parliament Square. The Centre is just to the west of the square, directly opposite Westminster Abbey. By train, there are three mainline rail stations within a mile of the Centre. These are Charing Cross, Victoria and Waterloo. To plan your travel from the other mainline terminals in central London (St Pancras International, King’s Cross, Paddington, Liverpool Street, London Bridge) use the Transport for London journey planner on

Take advantage of a discounted room rate available for FACE delegates at the Park Plaza Hotel, Westminster Bridge

body language I DERMATOLOGY 51

FACE SOCIAL A night in Rio

Carnival fever will hit London in June, and we invite you to join us on Saturday 21st for a brand new event in 2014—the FACE Social. With the added attraction of a small sports tournament —the World Cup hosted in Rio—medical aesthetic practitioners can enjoy a night of samba and caipirinhas at the newly opened One Embankment in the heart of London. On a warm summer’s evening, you can relax and network in a light hearted atmosphere to conduct some of the most important business of the FACE weekend.



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The Skin; anatomy & physiology, functions & mechanisms, ageing & problem conditions


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© AesthetiCare® 2014 6593/04.14


body language I MARKETING 53

Showcase your clinic Using video content on your website is the ideal way to engage prospective clients, improve your Google rankings and build trust. George and Will Cotterhill explain why it is the marketing choice for the future


ideos are a very effective way of getting your message across in a simple and engaging manner. They allow you to deliver a message with high impact and attentiongrabbing visuals, allowing you to stay in the mind of your potential customers and stand out from your competition. Video as a marketing form can create a connection unlike any other type of marketing. Combining audio and visual content allows viewers to see your practice and business in the same way they would if they came in, spoke to you and saw it in person. This personable approach puts the customer and the viewer at ease. It also creates an element of trust between the viewer and the business which no other form of marketing can. Whatever message you want to get across, video creates a lasting impression on the viewer because it’s an effortless format—all you have to do to get the information is press play. You don’t have to read through text or scroll through images, so the viewer can focus directly on the video content which increases retention of information. Google loves video content. One reason for this is that Google owns YouTube so they like to direct traffic towards YouTube and get revenue from advertising. More importantly though, Google loves video content because it is information-dense. You can get a lot more information into a one-minute video than you can on a page of text. Uploading Before you can can get your videos recognised on Google you have to get them on the Internet itself, and

there are a couple of options. Google is the number-one search engine in the world, but what not many people know is that YouTube is the number-two. Therefore it is a great way of getting your videos online because of the analytics and insights these videos can provide you. Not only can you see how many people have viewed your video, you can see which countries and formats they viewed it in. You could also use Vimeo to upload your videos, which is very similar to YouTube. We prefer using Vimeo for certain types of video because of the interface it gives you. There are no adverts popping up and it’s a clean, clear interface which means the focus is purely on

Video content makes a lasting impression on the viewer, creating an element of trust

your video and the content. Thumbnails are vital, especially when you embed a video into a website because it’s what entices the viewer to press play. Vimeo allows you to choose your best thumbnail from the video, which makes people want to watch it. Website Once you have your video content on the Internet, you can then put it on your own website. Putting a video on your landing page is ideal as visitors can press play on a one minute video where they can learn about your business, what you’re about, who the people are and what you do. It is a brilliant idea to use videos on your FAQ pages. If you have five

54 MARKETING I body language

or six questions that people regularly ask about your practice you could answer them using short one minute videos as a more personable way to reach your audience. On average, visitors only stay 40 seconds on a website, but if you have a video on your website this increases to three or four minutes. Videos not only keep people on your website looking at your content, but Google then ranks it higher. The longer people stay on your website, the more Google think they are getting the information they require, so your site goes up in the rankings. Style and process Rather than producing one large video, it is better to create five or six small videos which directly answer questions people may come to you and ask. This works well for many reasons. It improves your search engine optimisation due to multiple videos being better than one, and it keeps the viewer engaged for longer. These shorter videos may be split into a brief overview about the practice, the people who work there, why use your services, what sets you apart from competitors and what services you offer. Cost of treatment may be a frequently asked question, but it may be difficult to offer pricing without having a consultation with the patient. To get round this, a video response to this question can explain exactly that. For any practice testimonials and before-and-afters are vital to build trust. It allows potential cli-

ents to see people who have made the decision to have treatment, see results and that the patients are happy. We see a lot of testimonials now that appear staged and scripted, which can appear insincere. The more natural the testimonials are, the better. The client should be talking informally in their own words. You can offer a few points that you would like to be forthcoming in the testimonial and then in a relaxed environment record the client talking about their treatment and edit accordingly. The message will be delivered in a more sincere manner. You can then edit these short videos and testimonials into a short overview video to go on your landing page, which is then what people will watch when they first come to your website.

short and produce a series rather than one. Stay on track. Keep the content of your video relevant to the title of the video. Don’t start talking about other products you offer and other services you provide; keep on topic. Do a separate video to answer different questions as this helps prospective patients trust you more. They will feel like they’re getting what they want for each video and are more likely to watch your other videos. Finally, know your audience. This can be a bit difficult because it’s not in your control, but use your own marketing data to relate to your video production. If you already have videos on YouTube, you can look at the demographics and the people who watch them and then design your video to suit these people.

Production points. One of the key points is to try and educate people first—don’t hardsell. Tell prospective patients about your practice, and let them learn in order to decide whether or not they want the services you are providing. Don’t put offers in your videos and get your message across early. Peoples’ attention spans are decreasing, and you have a 15-second window at the start of a video to get someone hooked, either through visuals or answering their questions in the right away. Consider the length of the video—around one minute is optimum. You’ll be surprised at how much information you can actually cram into one minute. Keep videos

future marketing By 2015, video traffic will more than quadruple and the Internet will be made up of two-thirds’ video content, which makes it even more important that the video you’re producing has quality content. Anyone can point and shoot with a smartphone, throw something together and upload it straight to YouTube, but people won’t watch that content. If the production level isn’t good quality, it will reflect badly on your practice. George and Will Cotterhill are the directors of Rhoda Pond Productions, a video production company based in the West Midlands. W:

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Client consultations and evidence based regimes



© AesthetiCare® 2014 6593/04.14


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body language I FORUM 57

Platelet Rich Plasma An expert panel aims to demystify the often perplexing topic of platelet-rich plasma therapy systems, and offers their recommendations for obtaining optimal results

Tropocells Dr Dennis Wolf: The Tropocells kit comes with a 15ml blood collection tube that draws 10ml blood. The tube contains a precision measured anticoagulant and a separating gel. The anticoagulant is pH balanced making it more comfortable for the patients. A butterfly blood taking set is used to aspirate and perform the venipuncture. Once we have drawn the blood into the tube, gently agitate it to mix the anticoagulant with the blood and then insert it into the centrifuge. A RCF of 1500g is required for 10 minutes. After centrifuging, the sample will have separated into three distinct layers—red blood cells with granulocytes at the bottom; a gel layer and the plasma. At this stage, the platelets are sitting on the gel leaving an increasingly platelet poor plasma higher in the tube.

Some of the platelet-poor plasma can be aspirated from the top of the tube to concentrate the platelets. After which, a gentle agitiation is created to resuspend the platelets that are on the gel. Once resuspended, we then insert a filter funnel into the top of the tube. The plasma is pushed up through the membrane at the bottom of the filter funnel and into the internal part of the funnel. We end up with platelet-rich plasma in the filter funnel which we can then extract through the cap of the filter funnel with a syringe. We can use the same 1ml syringes to extract the solution that we will use to inject into the patient. I prefer to provide items such as syringes and needles from my clinic stock. This PRP system provides only the parts unique to the system. Dracula Therapy Dr Daniel Sister: The Dracula kit

is different from many others—it still extracts platelet-rich plasma, but instead works like a cafetiére. Some systems have no separation between the red cells and the plasma, while others have a buffer that separates them. With a cafetiére, you push the plunger and the coffee goes through. Similarly, we push the plunger and the plasma goes through while the red cells are separated, so we end up with pure PRP and PPP. It’s very important to use the whole plasma, not just the PRP. When drawing the blood, it should be taken as slowly as possible to ensure we don’t damage the platelets. There is no point in rushing to take the blood and when we harvest the plasma, it’s better to have system that takes it slowly than one which would create turbulence and destroy the platelets and growth factors. When the solution is centri-

The use of PRP therapy is controversial, but evidence for its efficacy is growing

58 FORUM I body language

fuged at a specific, low speed for eight minutes, we have a separation of the plasma and the red cells. By pressing on the plunger, the red cells are pushed down and we have our plasma—20cc in one manipulation. After that, we use a two-way connector to extract into a 1ml syringe if it’s easier to use or to mix it with hyaluronic acid. We get the plasma without any chemical separation and no need for human or bovine thrombin. I want the PRP to be totally autologous unless I want to mix it with hyaluronic acid. Angel Lift System Dr Kambiz Golchin: Rather than dealing with tubes, I like to use a fully-closed, automated system that does the job very simply. With the Angel system, we extract around 52ml of blood and push the plunger in, which then and it’s going to goes into a reservoir bag. The system then makes the PRP automatically, depending on the settings that we give it. We can choose the amount of red or white blood cells, and adjust the volume so we can generate less or more, depending on need. The 2012 Cochrane Review stated that there is no clear evidence that PRP works. So why are we using it? Contrary to the Review, we know that there is evidence that it works. A systematic review in the Journal of Plastic & Aesthetic Surgery shows clearly that PRP works in fat grafts. There is some evidence in wound care for diabetic foot ulcers. However, these are different indications and they need different formulas. So we can’t use the same PRP for all treatments and get great results; it just won’t work. PRP is not a filler, so we’re not going to get a filling effect from it. As there are different indications, we have to be specific with formulations. Aesthetic indications require different settings, for example white cells do something different, as do platelets. Selphyl Dr Hema Sundaram: The Selphyl system produces Platelet Rich Fibrin Matrix (PRFM), a unique

type of PRP that has a fibrin scaffold from which there is gradual, controlled release of growth factors and cytokines. One of the important features is that the PRP is free of red blood cells—it’s pure yellow. If you’re looking at bringing PRP into your practice, look at two or three different systems and figure out what’s going to work for you and your patients. I just published a new peer-reviewed scientific paper. The Potential of Topical and Injectable Growth Factors and Cytokines for Skin Rejuvenation in the special issue of the journal, Facial Plastic Surgery that is in conjunction with the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) International Symposium. It provides an evidence-based update on PRP, with a comprehensive review of the available data and explanation of the different formulations. With the Selphyl system, I’ve developed a two-layer technique to optimize results and minimize recovery time. I use a 27 gauge blunt cannula to inject PRFM into the superficial subdermal plane, for a nice, even distribution. This is non-traumatic to the skin. Patients who have a tendency to get swelling after HA filler injections often ask for PRFM. By making the procedure as non-traumatic as possible, as a general rule, my patients can walk out of my clinic with no bruises at all. I then use a sharp 30 or 32 gauge needle for precise intradermal injection of PRFM. This dual plane injection technique achieves superficial volumising, with a subsequent skin boosting effect. It’s notable that the Selphyl system allows a full 10-minute window period between the formation of the PRFM and time of injection. Injection of PRFM into the dermis can dramatically improve light reflectance of the skin, which is very helpful for dark circles under the eyes and to restore skin radiance. It isn’t just about volumising and generating collagen; to alter skin reflectance is a significant benefit. Does PRP work? Dr Fraser Duncan: PRP is not one

single substance and the clinical evidence for its use is controversial. There are four main questions for anyone considering using PRP. The first is how pure is it and is it sterile? How much does it cost to set up and use? How easy is it to use? And does it work? Dr Daniel Sister: In 1950, two doctors were awarded the Nobel Prize when they discovered a growth factor in plasma. In 1970, Marx proved that he helped to treat receding gums and peripheral bone structure and since then, more than 6,000 studies have been published. So there is hard evidence that PRP works. From my own experience, we are currently reviewing over 700 treatments I’ve performed and we have over 70% satisfaction rates. When people say PRP is not a filler, I agree. It’s not a filler but because it helps to generate type 1 collagen, regenerate more vascularisation and helps all the cells to function, there is a filling effect—not as much as if you were to use a filler, but there is a filling effect. PRP is totally natural and autologous, so you can mix it with any other treatment. You can mix it with fractional laser, hyaluronic acid or with any other treatment to have a stronger or longer-lasting filling effect with fewer side-effects. It is definitely the most versatile and efficient treatment. Dr Kambiz Golchin: I truly believe in PRP—I quoted the Cochrane Collaboration which looks at all the evidence that has been published. The National Institute for Health and Care Excellence have a report on the subject as well. The reason for all the confusion is because of the differences in PRPs. What is the definition of PRP? There are differences in the definition—is it just superphysiological or does it have to be at least two-fold? There is no consensus on what the correct definition is. I agree that growth factors are key to the effect of PRP but growth factors are not directly related to platelet count. Dr Alain Gondinet: We need to go back to the basics and to FDA approval. According to the FDA’s definition, when we use a medical device kit, we need to have a

PRP is natural and autologous, and can be combined with other treatments for longerlasting effects

body language I FORUM 59

or a blood bank. The definition exists but there is currently no indication for PRP approved by the FDA. We wait for studies of PRP acting on the filling of nasio-labial folds, but it will come. We can’t be pessimists. At RegenLab, we have a lot of studies in progress with the FDA and currently carrying out the 510(k); the file for the FDA approval. We are also starting to do the ATS-2 for thrombin. It’s not a filler—it’s “filler-like”. In regards to thrombin, we create a gel, but we don’t want to fill with the gel. We already have a filler, such as HA. But we do want to regenerate. Dr Fraser Duncan: We have many different PRP systems but no specific evidential base for its use in aesthetics. There are almost as many peer-reviewed evidential papers that show PRP does not work as there are to say PRP does work Dr Hema Sundaram: I couldn’t agree with that more. From an evidence-based perspective, there are evidence gaps with all PRP technologies. It’s very important to understand evidence levels and anything in vitro is evidence level five. We have to then connect the dots through to clinical outcomes. It’s an incredibly intriguing field that we all should be looking at getting into. But we shouldn’t fall in the trap of mistaking promotion and marketing for science.

minimum of 250,000 platelets per microlitre and a minimum of 50% of living cells. The FDA also states that we have to use the PRP within four hours. We have to take the blood through the centrifuge and inject within a maximum of four hours—we are not haematologists

Plasma purity Dr Fraser Duncan: I’m a huge a fan of PRP and am using it extensively. However, I’m slightly concerned that we may potentially be extending its use into aesthetics too quickly. We could be killing that golden solution that may lay a beautifully golden egg for us. Posing a question to the panel; how pure is the plasma fraction that these systems are producing in terms of erythrocytes, leucocytes and any substance which is likely to be allergenic? Dr Alain Gondinet: With the ReGen system we don’t add anything to the PRP; we only have the blood. We don’t add calcium. We add the calcium when we carry out alternative wound care with topical application when we want

to produce coagulum for stomalogy or when we want to produce membranes for orthopaedia. But for aesthetic applications, it’s better to avoid using calcium, particularly calcium chloride. It’s better to use calcium gluconate. We also have between 80–90% of living cells. Dr Hema Sundaram: In my scientific paper, I’ve reviewed data from studies showing that there is significant variability between different batches of PRP produced by the same automated system, and even between two blood draws from the same patient. Purity may be defined as the percentage of the PRP that comprises platelets. With the Selphyl system, there is 74% purity—the platelet component is 74%. There are no erythrocytes because we don’t want haemosiderin, and there are no known external allergens. In my opinion, there isn’t enough evidence to say what kind of calcium is advantageous or not. We need to wait until we have peerreviewed publications, not promotional studies from companies, so the jury is still out. Dr Kambiz Golchin: As the Angel is a fully-automated system, there are optical sensors which can detect the platelets, red cells and the plasma. This gives very accurate and consistent results. Dr Fraser Duncan: In clinical practice, we give both calcium chloride and calcium gluconate in many patients for the same reason; to potentially increase their blood pressure in high infusion of blood. Both are completely safe in clinical practice. Dr Xavier Abad: PRGF-Endoret protocol was tested by Harvard Medical School when we obtained FDA approval. Endoret doesn’t have red or white cells. Platelets have been activated before the treatment, so that’s the reason that we are using calcium. I don’t agree that the calcium chloride is more harmful than calcium gluconate— there are specific warnings about the use of calcium gluconate for some applications but no warnings about calcium chloride. Dr Daniel Sister: The Dracula system is very simple. There is no chemical buffer so the solution is

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totally pure; all plasma. There are no red cells. Growth factors and around 37 cytokines in plasma work for bones, skin, hair regrowth and cartilage. The body is clever enough to take what it needs from the plasma to do what it wants. Dr Fraser Duncan: There is some clinical evidence in the literature, that leukocytes in this situation may be catabolic. It may actually negate the anabolic effect from cytokines and other growth factors. Dr Daniel Sister: I agree but with the Dracula system, when we push the plunger, we get the plasma and platelets, but no red cells, no leucocytes and no chemical buffer in the middle. Dr Dennis Wolf: Tropocells gives us a yield of higher than 80% of functional viable platelets. I can also create a four to five-fold increase in platelet concentration. The gel locks all red blood cells and granulocytes beneath the gel layer so you don’t have any contamination—no release of metalloproteinases once injected as well, which obviously has a beneficial effect. The filter also contributes to purity. So there is no risk of drawing up gel when you use a needle to extract the plasma. This PRP system is used worldwide and in the UK for orthopaedics with published papers. It is also used for wound healing. In this case, the PRP is activated with calcium chloride before topical application. There is published evidence on the benefits for wound healing. Dr Hema Sundaram: I have discussed this in my scientific paper. There Is no consensus regard-

ing leukocytes. Some researchers are concerned about neutrophils becuase they upregulate the activity of matrix metalloproteinases, which are collagenases. Contamination Dr Fraser Duncan: The one thing that would worry me is that apart from the potential for infection of taking blood—which is universal using aseptic technique—are your systems closed, semi-closed or open? Is infection a potential risk in a clinic situation rather than a hospital situation? Dr Alain Gondinet: With the ReGen system, everything is closed so you have no risk of oxygen contamination or oxidation of the plasma. But, of course, if the tube is opened, there may be a risk. Dr Hema Sundaram: The Selphyl system is closed and sterile in its entirety. The needle that is ensheathed with it is also part of the closed system and is sterile. Dr Kambiz Golchin: When you talk about sterility in microbiological terms, there is a term called the sterility assurance level (SAL)—you can’t get absolute zero. For test tubes, the SAL is 1–1000. The Angel system is 1–1,000,000 which means that the system is actually cleared to be used in an operating room; for orthopaedics and for stem cells. You can use the system knowing that as it is a fully closed system, there is no multiple penetration into test tubes with different needles. The collection is just made into a sterile syringe and you can use it straight away. Dr Xavier Abad: With Endoret

technology, we perform the blood extraction in the closed system, then open the system for the fractioning. We tested this protocol with 150 patients at Harvard Medical School and more than 700,000 patients over 15 years. We also published two scientific papers when we have bacteriostatic potential of the plasma with the platelets, so we avoid any kind of contamination. Dr Daniel Sister: When we move the blood from the centrifuge to the syringe with the Dracula system, it’s a closed process with no contamination. Dr Dennis Wolf: Tropocells is a semi open system. Blood is taken directly into the tube maintaining a closed environment and the tube is opened only for PPP removal and resuspension of platelets. The filter sleeve facilitates PRP complete harvest and keeps PRP in a closed environment. Importantly, each component of the system is packed in its own sterile pouch, maintaining sterility until used. Tropocells also has a closed system. Calcium and thrombin Audience member: How are thrombin and calcium used in forming PRP and PRFM? Dr Fraser Duncan: In the US, there are more than 20 systems available and far fewer than that in UK. Globally, there are many systems which purport to give exactly the same substance, but they don’t. They do not produce the same PRP substance. The matrix in the Selphyl and the Endoret systems is activated using calcium. This forms the matrix—the sug-

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gestion is that within this matrix, the platelets are trapped so it’s an artificial clot which is injected and which sets. There’s also the potential of a thrombin clot which offers another substance. So PRP is not a uniform substance and can have as many variations as there are manufacturers of systems generating it. Dr Alain Gondinet: However, it’s not as simple as that. In the blood we have fibrinogen. Fibrin needs the thrombin as a coagulating enzyme and the calcium is a coactivator of the thrombin. So, with the autologous thrombin, you activate the fibrinogen into fibrin and the fibrin will embed the cells and then you have the matrix. Audience member: Where does the thrombin come from? Dr Alain Gondinet: The thrombin comes from a tube without anticoagulant. When you centrifuge the blood and separate the red cells, you end up with a fibrin clot. When you destroy the clot, you have thrombin. You then mix the thrombin with the anticoagulant PRP, and obtain a gel. The thrombin is natural; autologous. There is therefore no risk of coagulation when we inject it. Dr Xavier Abad: The release of growth factors when using thrombin is different to the release of growth factors when using calcium. Dr Alain Gondinet: Absolutely. This is why PRFM is only fibrin and a small number of platelets and growth factors—the platelets are embedded and are not able to release the growth factors. So you have to centrifuge the anticoagulated blood first to release the growth factors and after that, you can activate with the calcium. Audience member: Is calcium required or not? Dr Kambiz Golchin: The reason we need the calcium is because we anticoagulate the blood so we don’t get a clot instantly. The calcium reverses the anticoagulation. So, yes, we do need calcium but it is not absolutely essential for different indications. We do not need to activate the platelets every time—thrombin and calcium aside, there are other things that activate platelets, such as damaged collagen. For example, when we’re mixing it with fat, we

don’t need to actually activate it. Dr Hema Sundaram: Calcium chloride is needed to make platelet-rich fibrin matrix which gives the controlled, sustained release of growth factors and cytokines. There are peer-reviewed scientific data on the Selphyl system showing clinical efficacy for wound healing and skin rejuvenation, such as papers by Sclafani and colleagues in respected plastic surgery journals. But we still need to keep studying the safety and efficacy of various PRP systems. Dr Dennis Wolf: No additional chemicals are added to Tropocells and for aesthetic purposes, no activator. Activation occurs naturally in the skin when used for skin rejuvenation. Platelets are viable for up to four hours after preparation. Audience member: Do you use in vitro diagnostic tubes? Dr Alain Gondinet: No. They are cheap but they are not produced for therapeutic injections. They are just produced for diagnostics; that’s it. If you do PRP with IVD, you will not be covered by your insurance. Dr Kambiz Golchin: That’s absolutely correct. This is why the Angel system does not use tubes. It’s a disposal closed kit, so it’s as pure as you’re going to get. Dr Xavier Abad: The reason is because of the presence of endotoxin. You have to have a very low level of endotoxin in these tubes. Dr Alain Gondinet: You need to have pyrogen-free tubes by law. Dr Dennis Wolf: The tubes are FDA approved for therapeutic injections, are non-coated and comply with regulatory law. Improving results Audience member: How would you look at your results in terms of improvement and client satisfaction? Dr Alain Gondinet: Biology is biology. This means everybody will react differently because it depends on age, the renewal of the cells and the number of stem cells. Sometimes we have very nice results and sometimes we have less good results. Sometimes we have to repeat the session because when we inject living cells, they do what they want. Dr Kambiz Golchin: Depending

on how you look at your results, the results do look a bit “soft” if you’re just looking at PRP in aesthetic use on its own. But you do get a glow and an improvement in texture. The value of PRP is in combination treatments; the results are so much better. Dr Xavier Abad: It’s very important not to give wrong expectations to the patients. This is not a standard filler. We know that we improve the quality of the skin and we have measured that. We have more hydration and a better pH. There are different parameters that we can measure but it’s not for changing the expression. It’s not Botox and it’s not a hyaluronic acid. Dr Daniel Sister: Of the 700 treatments we’re currently reviewing for the London School of Medicine, the total number of patients is around 300. So some came for one treatment, some for two and others for more than two. Obviously, if they have come back for another treatment, it’s because they’ve seen a difference. I have over 80% of our patients return without booking them another treatment straight away. I never tell patients they have to come back for a second or third treatment. I say, “If you like the results, come back and see me”. Dr Dennis Wolf: In my aesthetic practice, I use PRP both on its own and as an adjunct. I use it in conjunction with laser, IPL, hyaluronic acids and toxins. Dr Hema Sundaram: I agree with the use of PRP as an adjunct with synergistic potential. Again, we have to distinguish data from marketing. There is variability in patient response to PRP. Those who respond well are very happy. References 1. Castillo TN, Pouliot MA, Kim HJ, Dragoo JL. Comparison of growth factor and platelet concentration from commercial platelet-rich plasma separation systems. Am J Sports Med. 2011;39(2):266–271 2. Sclafani AP, Saman M. Platelet-rich fibrin matrix for facial plastic surgery. Facial Plast Surg Clin North Am. 2012;20(2):177–186. 3. Sclafani AP. Platelet-rich fibrin matrix for improvement of deep nasolabial folds. J Cosmet Dermatol. 2010;9(1):66–71. 4. Fabi S, Sundaram H. The Potential of Topical and Injectable Growth Factors and Cytokines for Skin Rejuvenation. Facial Plast Surg. 2014;30:156–170. (AAFPRS International Symposium Special Issue). 5. Sundaram H, Carruthers J. Volumetric approach to the lower eyelid and midface. Clin Plast Surg. 2014; in press.

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Sublative rejuvenation Fractional radiofrequency for skin rejuvenation and tightening, as well as for scars and stretch marks, can offer minimal complications for skin of colour, writes Dr Ines Verner


eople with darker skins age differently, developing volume loss and a loss in laxity, with less surface wrinkling than Caucasians. Ageing indicators include melolabial folds, neck folds and pigmentation. Skin tightening is extremely difficult to document, to photograph and to show results—even with the best of imaging. This is especially difficult in skin of colour. The current industry focus is to use combination approaches. We’re using toxins, fillers, peels, dermabrasion and cosmeceuticals. So if you’re looking for one single device that works brilliantly for everything, it doesn’t exist. However, we can’t afford five devices in our office. We need to make intelligent choices to provide a gradual and complete rejuvenation. A device also depends on many things—distributor, technology, cost to you and cost to the patient. Radiofrequency Fractional lasers have revolutionised the industry. With their patterned microscopic thermal wounds in the skin while the surrounding tissue is spared, we see much less downtime and fewer complications than with traditional CO2 resurfacing. I’m a big fractional laser user. I use the CO2 laser, particularly for working with lighter skin types. For darker skin types, I prefer to use fractional radiofrequency (RF) technologies which better address the problems that darker skins pose, such as sagging, mild surface irregularities and dyspigmentation. Additionally, there is virtually no risk of complications. So what is the concept behind fractional laser or fractional RF? We’re leaving behind healthy tis-

sue to speed up the healing process. When light is used to rejuvenate the skin, high energies are needed to achieve optimal results. For patients with lighter skin, this is not so much of a problem. But in the darker skin types, there is a much greater risk for complications. As RF can give us remarkable results of tightening and rejuvenation even at lower energies, we can safely and easily use this technology in darker skin types. With

RF—even at low energies—we see gradual skin tightening and lifting with simultaneous improvement of surface irregularities. There’s a huge amount of clinical data available and it’s one of the newer treatments for darker skins. Sublative rejuvenation Devices such as the E2 by Syneron Medical have two treatment heads. The sublative rejuvenation head provides bulk heating in the der-

Radiofrequency provides a safer alternative for skin tightening and rejuvenation at lower energies

66 DEVICES I body language

tarily adjusts the delivered energy to the skin. In this way the amount of delivered energy is always right.

mis while also fractionally heating the epidermis. The other treatment head is called Sublime, and combines RF with infrared light for even deeper and more pronounced heating of the tissue. Sublative RF is a unique approach as it offers us a mild approach to rejuvenation. Following treatment, patients are only red for a day or two; they can apply make up and leave the house. After three to five treatments, remarkable clinical results can be seen. This is due to optimal dermal stimulation of new collagen production, with the energy delivered through multi-electrode pins. As only around 5% of the epidermis is disrupted with this treatment, the risk of post-inflammatory hyperpigmentation (PIH) is very low, even with darker skin types. Also, we’ve got more dermal impact and less epidermal impact which leads to tissue tightening. There is also a higher tolerability as the treatment is not painful and a great safety profile. There is very

little risk of complications. As device physicians, we need to understand the mechanisms of action. Just because we bought a laser three years ago, it does not mean we don’t need to upgrade our clinic or buy a new technology. The machine I use now has pins and electrodes, and delivers RF in a homogeneous fractional manner. It’s a very controlled treatment and easy to operate. As with all of the new technologies, they have smart-screens and do most of the work. But when we’re working with darker skins, we have to choose our energies. This is critical—ask yourself, “Can I delegate this treatment?” Yes, you can. In my experience, the E2 from Syneron is a very safe technology and can be delegated. However, I do check the energy settings before each treatment in my clinic. Impedance is a new term associated with RF. It’s the resistance in our skin to electrical energy. The device measures the tissue impedance during treatment and momen-

Sublative RF reduces the risk of post-inflammatory hyperpigmentation in darker skin types

Combination treatments Almost every practitioner is using combination treatments in one way or another. There are a lot of people performing microneedling, with controlled studies documenting its use. Transepidermal delivery systems are gaining interest, as well as using under-eye devices with cosmeceuticals for home use. The newer approaches for skin tightening are now all combination devices. The E2 uses a combination of infrared and RF, so it has two technologies combined in one. Manufacturers are trying to create a channel, trying to go deeper and trying to protect the epidermis. There are good results, but we do have to be cautious with our treatments. The choice of treatment is based on many variables. What is your patient requirement? What is your skill? What device do you already have in the office? Choose something to augment or change. Don’t get carried away and buy something very similar. Look at going into a completely new area. Think about the budget. This is often overlooked. We’re all living in a utopia where patients arrive with their credit card and say, “Do what you want.” I don’t have those kinds of patients. It’s vital to be able to give a viable economic treatment. We have to consider four to eight sessions of these treatments, so we have to price them appropriately. We have to be realistic about tightening and rejuvenation. This is more pertinent to darker skins— results seen in Caucasians are brilliant, but in darker skins we are at a disadvantage. It’s an individual combination regimen because skin of colour is a challenge. But we’re in an era of new technology, so we can explore new devices. It’s about being open-minded and aiming to really make a difference. Dr Ines Verner is a Dermatologist & Immediate Past President of the Israel Society of Dermatologic Surgery. She is manager & owner of The Clinic of Dermatology & Aesthetics in Tel Aviv, Israel


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Thermal energy levels Heating of the skin triggers different processes at different temperatures, resulting in a variety of outcomes. MIKE Murphy and Per-ARNE Torstensson discuss the effects of heat shock proteins and collagen denaturation when treating the skin at variable temperatures


t is a fundamental law of physics that electric current always seeks the path of least resistance. So when radiofrequency (RF) probes are placed on the skin surface, the current will ‘seek’ a path which offers the lowest possible resistance, regardless of the distance between electrodes. The stratum corneum is mostly composed of dead, flat skin cells, lipids, air pockets and very little moisture. It therefore has a very high electrical impedance (or resistance to an AC current), potentially up to 100,000 ohms. Wet skin, either due to external water or perspiration, will have a much lower impedance. In skin, the path of least resistance is most likely a direct route from the emitter electrode through the stratum corneum to the epidermis—which has a much lower impedance compared to the stratum corneum—along the top of the epidermis, then back through the stratum corneum to the collecting electrode. As electric current flows through these tissues, heat is generated due to the resistance to the current flow. The amount of heat generated is directly proportional to the tissue impedance, the power applied and the time for which it is applied. Radiofrequency The heating that takes place using typical non-invasive RF systems in the low megahertz region (0.5 – 5MHz) with skin contact electrodes is known as Joule heating. The temperature rise results from purely resistive heating resulting from electrons colliding with ions within the tissues. Dielectric heating is also possible, as a result of friction losses from the rotation of dipole molecules induced by magnetic and or

electrical field oscillations. Dielectric heating is typically an order of magnitude smaller than Joule heating in the above frequency range. Dipole heating is proportional to the field frequency and also proportional to the tissue permittivity. At frequencies greater than 10MHz, dielectric heating is no longer negligible in human tissues. The absorbed electrical energy is converted into thermal energy in resistive tissues according to the following equation: E avg = I2rms Z t E avg is the heat energy (J) averaged over a number of cycles, Irms is the root mean squared current (amps), Z is the tissue impedance (ohms) and t is the current application time in seconds. Clearly high impedance tissues will generate higher temperatures per unit current. The electrical impedance of the dermis is typically around 290 ohms while that of fatty tissue is almost 7.5 times that, at around 2180 ohms. Hence any current flowing through the fat layer will generate more heat than the dermal tissue above and so RF energy may also be used to induce lipolysis. RF current typically generates relatively low temperatures in the skin compared to high energy lasers and IPL systems. Since the heat is generated through electrical impedance, the colour of the tissue is irrelevant. If the heat is sustained for a sufficiently long period, collagen fibres can contract and thicken during the procedure. Further tightening is enabled from the inflammatory wound healing response which triggers new collagen synthesis. The fibrous septa, which separate the fat lobules in the subcutaneous layer, are also preferentially heated due to

the higher impedance of that layer. This results in a contraction of the fatty layer tissue which is evident as an immediate tightening reaction to the treatment. A prolonged wound-healing response lasting for more than three months may also occur, leading to dermal remodelling and the formation of new collagen fibre bundles. The ultimate result is an improvement in skin laxity and texture and an increase in dermal bulk. Wiley et al found around a 90% satisfaction rate with their patients at the three- and six-month follow-ups after RF treatments. Clinical and histological studies have shown an increase in type I and type III collagen in addition to newly synthesised collagen. Levels of collagen were observed to have further increased over a three month period which resulted in statistically significant improvements in skin tightening, skin texture and rhytides. Reports suggest that a low-energy, multi-pass, multi-treatment protocol results in consistently good results with minimal discomfort to the patients. Another study using a fractional bi-polar RF unit showed both neocollagenesis and neoelastogenesis in addition to an increase in dermal cellularity and deposition of hyaluronic acid. This study also found a 28-fold increase in the level of the heat shock protein, HSP47.

The path of least resistance for RF current is through the stratum corneum to the epidermis, generating heat as it passes through

70 LASERS I body language

thermal denaturation Below around 50ºC, HSP expression dominates over collagen de-

collagen denaturation HSp expression 37ºc







heat shock proteins Regardless of the method of heat generation in the dermis—by RF, lasers or IPLs—the heating process affects dermal collagen in at least two ways. For dermal temperatures between 43–50ºC, the heat generated within the dermis triggers a response from the heat shock proteins (HSP) resulting in molecular changes in the damaged collagen. HSPs reside within cells in the dermis and help to prevent irreversible cell damage under stressful conditions. They are responsible for the synthesis, transport and folding of proteins as part of a damage-control response to excess heat. These changes include structural rearrangement of the collagen proteins through folding and unfolding activities resulting in contraction and thickening of the collagen. It has been shown that such thermally-damaged collagen can be completely replaced with new collagen through an active remodelling process mostly due to the collagen chaperone HSP47. Many anecdotal reports discuss the ‘painless’ sensation during RF treatments. This indicates that the temperatures achieved in the dermis are probably below 40ºC—the threshold temperature at which the pain nociceptors are activated. Thermal pain is typically triggered between 40º and 45ºC, so the clinical results from such low temperatures must be due to the HSP repair processes. However, HSP expression increases significantly at around 43ºC, suggesting that a modest level of pain might lead to a better clinical outcome. The low-energy, multi-pass and multi-treatment regime now appears to make more clinical sense since the accumulated thermal stimulation will result in further HSP expression. In particular, elevated levels of HSP47 result in the promotion of collagen synthesis, while recent research appears to indicate the role of HSP70 in determining those cells which are deemed irreversibly damaged.

pain threshold Base Skin temperature

thermally altered collagen is repaired—fibres are contracted and thickened

naturation. However, above this temperature the denaturation process is too rapid for HSP repairs to be maintained and collagen breaks down more rapidly. This is evident in treatments where higher energies are typically applied and where energy is applied directly into the dermal tissues via micro-needles. For those cases where temperatures exceed 50ºC, we can apply the Arrhenius Rate Equation. In such situations the temperature applied, coupled with the time for which it is applied, is critical in determining the amount of collagen denaturation, Ω: Ω = Aδt exp(–Eₐ/RT) where A is the frequency of decomposition of the molecules (or damage rate factor, sˉ�), Eª is the activation energy per mole between the native and the denatured states of tissue (J/mole), T is the tissue temperature (in degrees Kelvin, K), R is the molar gas constant (8.314 J/mole K) and δt is the time for which the temperature T is maintained. It is important to note that the amount of tissue damage, Ω, is linearly dependent on time but exponentially dependent on temperature (which is directly proportional to the absorbed energy). Studies indicate that more readily observable results are achieved at higher temperatures. Berube et al found that the increase in collagen volume was almost three times greater at 75ºC compared with 65ºC. This is entirely in keeping with the above theory, since a small increase in temperature results in an exponential increase in tissue

collagen is denatured increasing exponentially with temperature. Neocollagenesis dominates

denaturation and consequently more neocollagenesis over time. Therefore, the level of collagen damage is very sensitive to the local temperature. However, even with relatively low temperatures (<40ºC) applied for sufficient periods of time, it is evident that an immediate contraction of collagen fibrils occurs, leading to significant improvements in the skin’s textural appearance. activation zones It is clear that the heating of skin induces a number of reactions, including HSP expression and tissue denaturation. These processes are triggered at different temperatures and result in various outcomes at various rates. In addition to the wound-healing response and vasodilation, at least four heat-related processes are evident: immediate collagen fibril

graph demonstrating different temperatures triggering reactions at different rates.

Below: Results immediately following a ten minute RF session on the right hand side of the face—around the eye and forehead.

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pHoto cREDitS: Lynda v price/XXY photography

Left: Before and after one application of RF energy to a 68 year old female’s neck Below left: Results showing immediate improvement in the neck of an 89-year old female following one RF treatment.

contraction; HSP expression; collagen denaturation; and fibroblast stimulation The rate of collagen denaturation depends exponentially on the temperature—for low temperatures, the rate is slow and the HSP expression dominates. As the temperature increases, the rate of denaturation becomes too fast for the HSP processes to repair the damage and the collagen breakdown process dominates. Clinical results Treatment was carried out using Omniface RF—a non-ablative, bipolar system and a multi-tip, fractional bi-polar system in one unit. The author, Dr Murphy, received treatment on the non-ablative, non-fractional setting at 2MHz in a continuous mode at a power of 14W over a period of less than ten minutes (see image on opposite pag). A sweeping motion was employed on the skin surface to deliver current and heat the underly-

ing tissues. No pain was felt during the procedure indicating relatively low temperatures (<40ºC). There were no visible signs of erythema or oedema, yet instantaneous skin tightening was evident around and above the right eye. A 68 year old female patient received one session of non-fractional treatment to her neck. A continuous power of 22W at 2MHz was applied in a continuous sweeping motion over a 30 minute session. The immediate tightening of the dermal collagen was evident with a noticeable reduction in the appearance of the wrinkles. While this is a relatively shortterm improvement, the fibroblasts in the reticular dermis will also have been stimulated. This will result in neocollagenesis in the following weeks and months. Fibroblasts typically take around six weeks before reaching the peak of collagen synthesis but can continue this process for up to nine months post-treatment. The neck of an 89 year old female patient was treated with a continuous 19W and 2MHz for 20 minutes. There was immediate improvement in the recessed area at the base of the neck, in addition to a significant improvement in the appearance of the deep wrinkles. Further treatments will improve the appearance over subsequent months. RF energy may be applied to the skin resulting in instantaneous collagen shrinkage, collagen denaturation, neocollagenesis and dermal remodelling. At low energies the results are mainly due to HSP expression, while higher energies cause more thermal damage and tissue denaturation. However, good clinical results are obtainable

using both processes with different levels of pain and outcomes. Mike Murphy is chief technology officer at Clinical Lasers plc, 145 – 157 St John Street, London, EC1V 4PW. E: Per-Arne Torstensson is CEO of Photonova AB, Gothenburg, Sweden. E: References 1. Hollmig St, Hantash Bm. “Radiofrequency in cosmetic Dermatology: Recent and Future Developments.” Cosmet Dermatol. 2011;24:565-574 2. El-Domyati m, El-Ammawi tS, medhat w, moawad o, Brennan D, mahoney mg, uitto J. “Radiofrequency facial rejuvenation: Evidence-based effect.” Journal of the American Academy of Dermatology, volume 64, issue 3, march 2011, pages 524-535. 3. wiley A, Kilmer S, Newman J, “Elastometry and clinical results after bipolar radiofrequency treatment of skin.” Dermatol Surg. 2010, 36:877-884. 4. Jacobson Lg, Alexiades-Armenakas m, Bernstein L, geronemus Rg. “treatment of nasolabial folds and jowls with a noninvasive radiofrequency device.” Arch Dermatol 2003; 139, 1371-2. 5. Sukal SA, geronemus Rg. “thermage: the nonablative radiofrequency for rejuvenation.” Clin Dermatol 2008; 26:602-7. 6. Hantash Bm, ubeid AA, chang H, et al. “Bipolar radiofrequency treatment induces neoelastogenesis and neocollagenesis.” Lasers Surg Med, 2009;41, 1-9. 7. morimoto Ri. “cells in Stress: transcriptional Activation of Heat Shock genes.” Science, New Series, vol. 259, No. 5100, mar. 5, 1993, pages 1409-1410 8. mayer mp, Bukau B. “HSp70 chaperones: cellular functions and molecular mechanism.” Cell Mol Life Sci, 62(6);670-684. 9. Sajjadi AY, mitra K, grace m. “Expression of heat shock proteins 70 and 47 in tissues following short-pulse laser irradiation: assessment of thermal damage and healing.” Med Eng Phys. 2013 oct;35(10):1406-14. doi: 10.1016/ j.medengphy.2013.03.011. Epub 2013 Apr 12. 10. Dubin AE, patapoutian A. “Nociceptors: the sensors of the pain pathway.” J Clin Invest, Nov 1, 2010. 120(11), 3760-3772. 11. widmer c et al. “molecular basis for the action of the collagen-specific chaperone Hsp47/SERpiNH1 and its structurespecific client recognition.” July 2012. doi/10.1073/pnas.1208072109. 12. murphy mJ, torstensson p. “thermal Relaxation times.” Body Language Journal, vol 16, issue 2, Number 62, mar/Apr 2014. 13. murphy mJ, torstensson p. “thermal relaxation times: an outdated concept in photothermal treatments.” Lasers in Medical Science, october 2013. 14. Berube D, Renton B, Hantash Bm. “A predictive model of minimally invasive bipolar fractional radiofrequency skin treatment.” Lasers in Surgery and Medicine, volume 41, issue 7, p473–478, September 2009.

72 PRODUCTS I body language

on the market The latest products in aesthetic medicine, as reported by Helen Unsworth 1. galderma is launching two new syringe delivery systems. the Restylane filler syringe offers greater comfort and has been developed to increase security and accuracy. it has a tamper proof seal and new Luer lock providing robust needle and cannula attachment. the Restylane Skinboosters syringe offers audible dosage control with Smartclick, so practitioners can focus on injection technique rather than amount injected. Galderma, T: 01923 208950; W:




2. the Belotero + range with lidocaine is now available. Belotero is manufactured by randomly linking HA strands creating a variable density gel which allows for filling different shapes and sizes of dermal space. merz Aesthetics say this provides far greater tissue integration and reduced incidence of inflammatory reactions post-treatment. Look out for the newly named Belotero Balance +, formerly known as Belotero Basic. Merz Aesthetics, T: 020 8236 0000; W:


3. proSystem peels from NeoStrata— launching at FAcE 2014—provide the skin rejuvenation benefits of three alpha hydroxy acids in one system. practitioners can tailor treatment plans to help improve rough skin texture, fine lines, wrinkles, discolouration, blemishes, keratosis, pilaris and pseudofolliculitis barbae. Aesthetic Source, T: 01234 313130; W:


4. Safe Sun is a new range of sun protection products offering high uvA and uvB protection from the institute Hyalual. these professional creams contain organic and natural filters to protect skin from sun damage. the formulation also helps to repair the skin and relieve irritation and inflammation. Rederm, T: 020 3651 1227; W: 5. Lifestyle Aesthetics have launched iRejuvenation, an ipad application to share patients’ cosmetic timelines from first injection to ongoing treatment plan. the app, available in the Apple App Store, offers high precision recording and is a reliable solution for patient reporting. Lifestyle Aesthetics, T: 0845 070 1782; W: 6. the mesohyal range offers 11 injectable products to administer as mesotherapy for helping to correct skin ageing and figure concerns. the products can be used alone or in combination “cocktails” as needed. Mesoestetic, T: 01746 718 123; W: 7. Lynton are launching the Duetto mt, a new laser treatment for hair removal. it allows practitioners to use the mixed technology (mt) mode to mix Alexandrite (755 nm) laser and Nd:YAg (1064 nm) for ultimate treatment flexibility and possibilities. Lynton, T: 01477 536 975; W:




neva_Derma_A4-Poster.indd 1

body language I PRODUCTS 73

8. Scarlet RF combines radiofrequency and needling for skin rejuvenation and improvement of elasticity and acne scarring. it provides heating to the dermis and epidermis with precise control of RF and needle penetration say the manufacturers, vioL. Adare Aesthetics, T: +353 (0) 1 676 9810; W:


9. the Affinity system has been developed for intra-follicular delivery of liquid solutions such as peeling agents. plastic tipped nozzles guide moderate pressure jets and upon contact with an open pore orifice, the follicular space is sprayed with the infused solution. more efficient absorbtion is said to occur, leading to lower concentration of peeling agents being required and offering greater effects. Tavger, T: 00 972 527322302; W:

10 8

10. Density platelet gel pRp has launched as a non-invasive procedure using growth factors from patientsâ&#x20AC;&#x2122; own blood to help to regenerate ageing and damaged skin. it is said to offer long lasting results and improve the skin tissue. Koreesa, T: 01204 770 985; W:


11. isolaz 2 is a device that combines vacuum, broadband light and topical skincare products to treat acne. Solta medical say results are fast and side effects are lessened. A treatment tip uses vacuum to lift impurities, broadband light is then applied to destory bacteria and slough oil and dead skin away. then with profusion technology, the vacuum stretches skin cells so that topical products can be applied into the intercellular spaces in the skin offering improved results. Solta Medical, T: 00 31 206 653 7080; W:


12. A new neutraceutical skin beverage, Aneva Derma is now available, containing arthred hydrolysed collagen and hyaluronic acid alongside zinc, vitamin c, grape seed extract, green tea extract, alpha lipoic acid, copper and manganese. these ingredients are said to work from within to boost collagen production and skin hydration. Aneva, T: 0203 368 3001; W:



11/04/2014 09:36

13. iS clinical have launched Sheald Recovery Balm, designed to address the needs of post procedure and compromised skin. it is formulated to calm, sooth and hydrate skin as well as helping to prevent scarring. it contains kave kava for its anaesthetic properties, ceramide blends and cell signalling technology to optimise skin recovery. iS Clinical, T: 07779 112 225; W: 14. Dermaquest uK has relaunched with a refreshed identity and eight skincare collections for aestheticians, physicians and at home use. Dermapure, T: 0845 620 2020; W:

74 DERMATOLOGY I body language

classified FoR SALE

SyNEroN CaNdEla fraCtioNal Co2 rESurfaCiNG SyStEM, (Co2rE) £30,000 includes safety glasses, additional parts and manual. Laser vac can be included for an additional £1,500 contact: Rekha tailor t: 01252 820690 01252 820690

SoPraNo xl bluE laSEr hair rEMoval £36,000 the machine is in excellent condition and the skin tightening head has been hardly used contact: Adeboye oloritun Bloom Healthcare t: 01908 693400 m: 07760 788822 E:


alMa aCCENt rf xl £7,500 in good condition, six years old contact: Amanda Stokes t: 01708 225555 E:

lPG Endermologie Cellu M6 keymodule £6,695 Never used, includes bed, marketing and manuals. we can deliver. contact: Amanda Stokes t: 01708 225555 E:

PaloMar vECtuS diodE laSEr £39,000 Brand new machine with full manufacturers warranty. Available immediately, training included. pre-purchase demonstration available. contact: paul Edwards t: 01245 227752 E:

ChEriShEd NuMbEr PlatE aNd audi ttS £50,000 (ono) Brownish grey colour, in very good condition with less than 21K miles. Full black leather interior with Bose sound system. we will consider selling the number plate (B8toX) separately. contact: Susan Judodihardjo t: 07796017018 E:



medical TRAINING

DATES * Only available to doctors, dentists and medical nurses with a valid registration number from their respective governing body. All courses in London unless specified.





2 CPR & Anaphylaxis Update 6 ZO Medical Basic 7 ZO Medical Interm. 8 ZO Medical Adv. 8 ZO Skin Health 14 ZO Medical Basic (Dublin) 15 ZO Medical Interm. (Dublin) 17 Microsclerotherapy* 18 Advanced Toxins* (am) 18 Advanced Fillers-TT* (pm) 19 Platelet Rich Plasma (PRP)* 20 Medik8 Dermal Roller 21 glōTherapeutics 28 Skincare & Peels 29 Intro to Toxins* 30 Intro to Fillers*

1 Platelet Rich Plasma (PRP)* 2 ZO Medical Basic 3 ZO Medical Interm. 5 Sculptra(Day 1 of 2) 5 ZO Medical Basic (Dublin) 6 ZO Medical Interm. (Dublin) 6 CPR & Anaphylaxis Update 10 Medik8 Dermal Roller 12 Advanced Toxins* (am) 12 Advanced Fillers-LF* (pm) 14 Microsclerotherapy* 15 Sculptra Refresher 16 glōMinerals 25 Skincare & Peels 26 Intro to Toxins* 27 Intro to Fillers* 29 Advanced Fillers-TT* (am)

1 ZO Medical Basic 2 ZO Medical Interm. 4 Angel PRP* 7 Platelet Rich Plasma (PRP)* 8 ZO Medical Basic (Dublin) 9 ZO Medical Interm. (Dublin) 10 ZO Medical Adv. (Dublin) 10 Advanced Fillers-TT* (am) 10 Advanced Fillers-CH* (pm) 11 CPR & Anaphylaxis Update 12 Microsclerotherapy* 14 glōMinerals 15 glōTherapeutics 21 Medik8 Dermal Roller 23 Skincare & Peels 24 Intro to Toxins* 25 Intro to Fillers*

1 Sculptra(Day 1 of 2) 4 ZO Medical Basic 5 ZO Medical Interm. 18 Medik8 Dermal Roller 19 Advanced glōTherapeutics 20 Skincare & Peels 21 Intro to Toxins* 22 Intro to Fillers* 30 Microsclerotherapy*

CH = Cheeks/mid-face F = Forehead LF = Lower face TT = Tear troughs

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

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body language I COURSES 77

training Toxins and Fillers 3 May, Foundation Botulinum toxin course, Swindon, Wiltshire W: 10 May, Lip course (Dermal Fillers Part II), Watford, Hertfordshire W: 10 May, Basic Botox Training, Newport W: 11 May, Basic Filler Training, Newport W: 17 May, Foundation Botulinum toxin course, Harley Street, London W: 18 May, Advanced Toxins (am) & Fillers - Tear Troughs (pm), Wigmore Medical, London W: 22 May, Advanced Botulinum Toxin Part II, Watford, Hertfordshire W: 23 May, Advanced Dermal Fillers (Volumising) Part III, Watford, Hertfordshire W: 24 May, Botulinum Toxin in Facial Aesthetics, London W:

Harley Street, London W:

25 May, Dermal Fillers in Facial Aesthetics, London W:

26-27 June, Introduction to Toxins and Fillers, Wigmore Medical, London W:

29-30 May, Introduction to Toxins and Fillers, Wigmore Medical, London W:

29 June, Advanced Fillers-Tear troughs (am) and Forehead (pm), Wigmore Medical, London W:

5 June, Sculptra (Day 1 of 2), Wigmore Medical, London W:

10 July, Advanced Fillers -Tear toughs (am) and Cheeks (pm) , Wigmore Medical, London W:

5 June, Foundation Botulinum Toxin Part I, Watford, Hertfordshire W:

12 July, Basic Botulinum Toxin A Training, Newport W:

6 June, Foundation Dermal Fillers Part I, Watford, Hertfordshire W:

13 July, Filler Training, Newport W:

7 June, Advanced Botulinum Toxin (lower face, neck, hyperhidrosis), London W: 7 June, Basic Botulinum Toxin A Training, Newport W: 8 June, Advanced Fillers (facial contours, lip refinements, skin-hydration), London W: 8 June, Filler Training, Newport W:

16 July, Advanced Botulinum Toxin A Course, Newport W: 24-25 July, Introduction to Toxins and Fillers, Wigmore Medical, London W: 30 July, Advanced Dermal Filler or Lips Masterclass Training Day, Newport W:

Other Injectables

12 June, Advanced Toxins (am) and Fillers – Lower face (pm), Wigmore Medical, London W:

4 May, Mesotherapy for localised fat, cellulite & skin rejuvenation, London W:

14 June, Foundation Botulinum Toxin course, Harley Street, London W:

17 May, Microsclerotherapy, Wigmore Medical, London W:

15 June, Sculptra Refresher, Wigmore Medical, London W:

19 May, Platelet Rich Plasma, Wigmore Medical, London W:

18 June, Advanced Botulinum Toxin A Course, Newport W:

1 June, Platelet Rich Plasma, Wigmore Medical, London W:

19 June, Foundation Botulinum Toxin course,

14 June, Microsclerotherapy, Wigmore Medical, London W: 4 July, Angel PRPa Biotherapies - focus on hair, Wigmore Medical, London W:

Centre, Windsor, Berks W: T: 01628 674 644 20 May, Medik8 Dermal Roller, Wigmore Medical, London W:

7 July, Platelet Rich Plasma, Wigmore Medical, London W:

20-21 May, Dedicated Brand, Science and Product Knowledge, Skinceuticals Training Centre, Birmingham W: T: 0208 762 4860

12 July, Microsclerotherapy, Wigmore Medical, London W:

21 May, gloTherapeutics, Wigmore Medical, London W:


22 May, Advanced peel Training, Skinceuticals Training Centre, Birmingham W: T: 0208 762 4860

3 May, Chemical Peel Systems & Medical Skincare, London W: 6-7 May, ZO Medical Basic and Intermediate, Wigmore Medical, London W: 6-8 May, ZO Medical Basic, Intermediate & Advanced, Wigmore Medical, London W: 8 May, ZO Skin Health, Wigmore Medical, London W: 9 May, Dermaroller (includes nutrition and topical skin products), Watford, Hertfordshire W: 10 June, Medik8 Dermal Roller, Wigmore Medical, London W: 12-13 May, Skinsynergy seminar, Aestheticare, London W: 14-15 May, ZO Medical Basic & Intermediate (Dublin), Wigmore Medical, London W: 19 May, Systematic Approach to Treating Acne & Related Problems, Clinogen Aesthetic Training

24-25 June, Dedicated Brand, Science and Product Knowledge, Skinceuticals Training Centre of Excellence, London W: T: 0208 762 4860 27-28 May, Dedicated Brand, Science and Product Knowledge, Skinceuticals Training Centre of Excellence, London W: T: 0208 762 4860 28 May, Skincare & Peels, Wigmore Medical, London W: 29 May, Advanced Peel Training, Skinceuticals Training Centre of Excellence, London W: T: 0208 762 4860 2-3 June, ZO Medical Basic and Intermediate, Wigmore Medical, London W: 5-6 June, ZO Medical Basic and Intermediate (Dublin) , Wigmore Medical, London W: 10 June, Systematic Approach to Treating Acne & Related Problems, Clinogen Aesthetic Training Centre, Windsor, Berks W: T: 01628 674 644 16 June, gloMinerals, Wigmore Medical, London W:

78 COURSES I body language

25 June, Skincare & Peels, Wigmore Medical, London W: 26 June, Intermediate Peel Training, Skinceuticals Training Centre of Excellence, London W: T: 0208 762 4860 30 June, Systematic Approach to Treating Acne & Related Problems, Clinogen Aesthetic Training Centre, Windsor, Berks W: T: 01628 674 644

29-30 July, Dedicated Brand, Science and Product Knowledge, Skinceuticals Training Centre of Excellence, London W: T: 0208 762 4860

24 June, Advanced Hair Removal Techniques for Vellus Hair & Light Hair, Clinogen Aesthetic Training Centre, Windsor, Berks W: T: 01628 674 644

31 July, Advanced Peel Training, Skinceuticals Training Centre of Excellence, London W: T: 0208 762 4860

26 June, Lecturer Workshop, Sterex Electrolysis International Ltd, Birmingham W:

Hair removal

30 June-1 July, Advanced Cosmetic Procedure Course (Part II), Sterex Electrolysis International Ltd, Birmingham W:

1-2 July, ZO Medical Basic and Intermediate, Wigmore Medical, London W:

6 May, Refresher Advanced Cosmetic Procedures, Sterex Electrolysis International Ltd, Birmingham W:

8-9 July, Dedicated Brand, Science and Product Knowledge, Skinceuticals Training Centre, Birmingham W: T: 0208 762 4860

14 May, Advanced Hair Removal Techniques for Vellus Hair & Light Hair, Clinogen Aesthetic Training Centre, Windsor, Berks W: T: 01628 674 644

8-10 July, ZO Medical Basic, Intermediate and Advanced (Dublin), Wigmore Medical, London W:

19-20 May, Advanced Electrolysis (Part I), Sterex Electrolysis International Ltd, Birmingham W:

10 July, Intermediate Peel Training, Skinceuticals Training Centre, Birmingham W: T: 0208 762 4860

28-29 May, Advanced Electrolysis (Part I), Sterex Electrolysis International Ltd, Leeds, West Yorkshire W:

14-15 July, gloMinerals and gloTherapeutics, Wigmore Medical, London W: 15 July, Systematic Approach to Treating Acne & Related Problems, Clinogen Aesthetic Training Centre, Windsor, Berks W: T: 01628 674 644 21 July, Medik8 Dermal Roller, Wigmore Medical, London W: 23 July, Skincare & Peels, Wigmore Medical, London W:

2 June, Advanced Hair Removal Techniques for Vellus Hair & Light Hair, Clinogen Aesthetic Training Centre, Windsor, Berks W: T: 01628 674 644 9 June, SXB Product Knowledge Course, Sterex Electrolysis International Ltd, Birmingham W: 9-10 June, Electrolysis Refresher, Sterex Electrolysis International Ltd, Birmingham W: 16-17 June, Advanced Electrolysis (Part I), Sterex Electrolysis International Ltd, Birmingham W:

14 July, Advanced Hair Removal Techniques for Vellus Hair & Light Hair, Clinogen Aesthetic Training Centre, Windsor, Berks W: T: 01628 674 644 14-15 July, Advanced Electrolysis (Part I), Sterex Electrolysis International Ltd, Hastings, Sussex Coast W: 18 July, Refresher Advanced Cosmetic Procedures, Sterex Electrolysis International Ltd, Birmingham W:

Cheadle W: 3-8 June, LASER THERAPIST PRACTICAL HANDSON TRAINING (Affiliated with NCLC), Institute of Medical Aesthetics, Dubai, UAE W: T: +971 4 369 50 23 23 June, Tattoo Removal, The Lynton Clinic, Manchester W: 1 July, Advanced Skin Laser Applications, The Lynton Clinic, Manchester W: 7 July, Clinical Update Training, Lynton Clinic, Cheadle W: 13-18 July, Fellowship in Aesthetic Medicine (A4M), Institute of Medical Aesthetics, Dubai, UAE W: T: +971 50 655 8684

Other Training

28-29 July, Advanced Electrolysis (Part I), Sterex Electrolysis International Ltd, Bridgend, Wales W:

1 May, Treating the Lip & Perioral Area, Wigmore Medical, London W: T: 01923 216 013


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

3-8 May, LASER THERAPIST PRACTICAL HANDSON TRAINING (Affiliated with NCLC), Institute of Medical Aesthetics, Dubai, UAE W: T: +971 4 369 50 23 14 May, Skin laser applications, The Lynton Clinic, Manchester W: 2 June, Hair removal Masterclass, Lynton Clinic,

22 May, Introduction to Skinboosters, Wigmore Medical, London W: T: 01923 216 013 23 May, Volumisation with Emervel, Wigmore Medical, London W: T: 01923 216 013 27-31 May, AAFPRS 11th International Symposium, New York, United States W: 4 June, Introduction to Skinboosters, Wigmore Medical, London W: T: 01923 216 013 6 June, CPR & Anaphylaxis Update, Wigmore Medical, London W: 11 June, Volumisation with the Emervel Range, Wigmore Medical, London W: T: 01923 216 013 30 June, Volumisation with the Emervel Range, Wigmore Medical, London W: T: 01923 216 013 11 July, CPR & Anaphylaxis Update, Wigmore Medical, London W:

Webinars Botulinum Toxin—upper and lower face Peri-orbital rejuvenation Brow and temple Injection rhinoplasty Injection facelift Lip and peri-oral beautification Chin and jaw line lift Facial mapping and surface anatomy W:

If you would like to have your course dates published in Body Language Journal, please send for consideration to

The aesthetic industryâ&#x20AC;&#x2122;s preferred partner Wigmore Medical has been at the forefront of medical aesthetics for over 15 years and with the industry growing each year, the modern clinic needs to be maintained at the highest possible level.

Skincare Skincare is fast becoming the most important aspect of medical clinics, and Wigmore Medical have handpicked a collection to suit all applications and benefit your practice

We are the market leader in product distribution, with a comprehensive range of injectables, chemical peels, skincare and equipment coupled with consistent training, development and product awareness. Wigmore Medical can provide your practice with premium solutions for your patients.

Equipment Offering a variety of treatments is vital in a clinic, and Wigmore Medical provide a wide range of equipment to ensure practitioners can keep up with competition and expand their practices


Training Wigmore Medical Training continually adds new course titles and combines leading expertise, intimate group sizes and handson training to keep delegates at the forefront of the industry

Wigmore Medical has distributed the major injectable product ranges across the UK for over a decade. Our extensive range allows practitioners to tailor order products to best suit their patient

Doctors Dispensary The doctors dispensary has been a division of Wigmore Medical for the last 30 years, supplying medical equipment and drugs to hospitals, private doctors and dentists all over the UK


Not all HA dermal fillers are created equal. Intelligent manufacturing technology creates a variable density gel1 resulting in... Optimal tissue integration2 Greater dermal compatibility3 Superior cosmetic results4 High patient satisfaction5 Contact Merz Aesthetics NOW and ask for Belotero.

Tel: +44 (0) 333 200 4140 Email: OPTIMAL



Injectable Product of the Year 2013

1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150. 5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

BEL092/0314/FS Date of preparation: April 2014

Profile for Body Language Journal

Body Language Journal 63  

Body Language Journal 63