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Chronicle of


Medicine + Surgery Light and shadows in aesthetic medicine

Cosmetic medicine: 2015 clinical forecast

Getting the best from your fractional laser devices

Microneedling for skin rejuvenation

Mid-face treatment refreshes the whole face

Documenting informed consent on risks

From the publishers of The Chronicle of Skin & Allergy: Visit Volume 5 Number 1

June 2015

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Discover XEOMIN® COSMETIC The new Botulinum Toxin Type A, free from complexing proteins


Copyright © 2014 Merz Aesthetics, Inc. All rights reserved. Merz Aesthetics and the Merz Aesthetics logo are trademarks and XEOMIN COSMETIC is a registered trademark of Merz Pharma GmbH & Co. KGaA.

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Editors Sheetal Sapra, Oakville, Ont. Nowell Solish, Toronto

Guest Editor Shannon Humphrey, Vancouver

National Editorial Board Sheldon V. Pollack, Toronto (Chairman) Scott Barr, Sudbury, Ont. Arie Benchetrit, Montreal Vince Bertucci, Woodbridge, Ont. Yves Hébert, Montreal Frances Jang, Vancouver Julie Khanna, Oakville, Ont. Mark Lupin, Vancouver Mathew Mosher, Vancouver W. Stuart Maddin, Vancouver William McGillivray, Vancouver Kent Remington, Calgary Jason K. Rivers, Vancouver Arthur Swift, Montreal Jean-François Tremblay, Montreal Fred Weksberg, Toronto

Industry Advisors Ann Kaplan, iFinance, Toronto Roxane Chabot, RBC Consultants, Montreal/Miami Publisher Mitchell Shannon Editorial Director R. Allan Ryan Senior Associate Editor Lynn Bradshaw Assistant Editors John Evans Emily Innes Sales & Marketing Sandi Leckie, RN Production & Circulation Cathy Dusome Comptroller Rose Arciero

Published four times annually by the proprietor, Chronicle Information Resources Ltd., from offices at 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont. M9C 2Y3 Canada. Telephone: 416.916.2476; Fax 416.352.6199. E-mail: Contents © Chronicle Information Resources Ltd, 2015, except where noted. All rights reserved worldwide. The Publisher prohibits reproduction in any form, including print, broadcast, and electronic, without written permission. Printed in Canada. Subscriptions: $59.95 per year in Canada, $79.95 per year in all other countries, in Canadian or US funds. Single copies: $7.95 per issue. Subscriptions and single copies are subject to 13% HST. Canada Post Canadian Publications Mail Sales Product Agreement Number 40016917. Please forward all correspondence on circulation matters to: Circulation Manager, Dental Chronicle, 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont. M9C 2Y3 Canada. E-mail: ISSN 1927-4955 Cover image: © sherrie smith| Dreamstime Stock Photos

From the editors Dr. Shannon Humphrey on why a multi-disciplinary approach is recognized as superior for ensuring more natural-looking outcomes ..............................................4 Options in CME: Stay home, or hit the road Dr. Jaggi Rao pioneers a stay-at-home option, while Dr. Yves Hébert seeks knowledge in distant Malaysia............................6 Cosmetic Update: On the leading edge of research, discoveries and new clinical findings in aesthetic medicine. Nutraceutical may offer improvement in female hair loss, &c. ......8 Getting the best benefits from your fractional laser devices Dr. Mathew Avram advises on the best way to think about treatment approaches for your patient 10 Cosmetic medicine: 2015 clinical forecast Minimizing potential for complications is necessary to maintain a reputable image for aesthetic medicine ..........................14 Mid-face treatment can refresh the whole face Know your patient and understand the geometry of the eye, recommends Dr. Dimitrios Motakis ....................................19 Light and shadows in aesthetic medicine

Dr. Kent Remington says these elements need to be considered in lifts and filling procedures with reflation and contouring ..........23

Micro-needling an effective tool for skin rejuvenation Percutaneous collagen induction does not ablate the skin or cause scarring, according to Dr. Matthias Aust ..24 Group pre-consultation sessions for breast reconstruction

shown to help improve decision making in presentation at Toronto Breast Surgery Symposium ......25

The business of cosmetic medicine

Dr. Steven Bellemare on legal issues to consider when delegating care to non-physicians ......................................................................26 Celebrating 20 years of Ideas in the Service of Medicine. Publishers of: The Chronicle of Skin & Allergy, The Chronicle of Neurology & Psychiatry, Pediatric Chronicle, The Chronicle of Healthcare Marketing, and Linacre’s Books

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More natural-looking outcomes  Dr. Shannon Humphrey,



Commentary and opinion on current topics of interest in aesthetic medicine

A multi-disciplinary approach is recognized as superior for ensuring the best patient care—and this is particularly true in the case of cosmetic medicine. The best way to guarantee the safest and best results for our patients is by sharing expertise and knowledge with physicians from all specialties and by ensuring our patients receive their cosmetic treatments from the most expert and skilled physicians. In recent years in cosmetic medicine, I have, thankfully, observed an increase in this multi-disciplinary approach and collegiality. In this very issue we have so much to share with colleagues of different medical specialties. Toronto’s Dr. Dimitrios Motakis, a plastic surgeon in private practice, is featured with his approach to rejuvenating the peri-ocular region and mid-face including pearls on avoiding overcorrection. Dr. Mathew Avram, a laser and cosmetic dermatologist from the Massachusetts General Hospital in Boston, shares his mastery of laser physics with a feature on fractional laser devices, how to choose the best device and set-

NOTE TO READERS This month, the publishers of THE CHRONICLE OF COSMETIC SURGERY + MEDICINE have launched an international mobile information and social-networking portal, at Introduced at the 23rd World Congress of Dermatology in Vancouver, is your source for breaking clinical news in the skin sciences, continuing medical education, and the opportunity to share opinions and experiences with peers the world over, in an entertaining environment. It’s “Where Dermatology Lives™.” Please have a look and let us know what you think.


tings for the task at hand, and some new indications. Edmonton’s Dr. Jaggi Rao, also a dermatologist, highlights the obvious benefit of multidisciplinary knowledge-sharing as he develops an interactive webinar format to educate general practitioners in aesthetic dermatology continuing medical education. Dr. Rao also shares his experiences with the use of online tools for referrals and consultations. On the business side of practice, Dr. Steven Bellemare, a Physician Risk Manager at the Canadian Medical Protective Association (CMPA), provides advice on what to keep in mind when considering delegating aspects of patient care to non-physicians in your own practice. I am hopeful that as we look toward an exciting and rapidly evolving future for Canadian cosmetic medicine the spirit of multi-disciplinary collegiality and knowledge-sharing will continue to flourish–both for the benefit of our patients and for ourselves as we enjoy much more productive and satisfying careers. The other theme that became clear as I edited the manuscripts for this edition of THE CHRONICLE OF COSMETIC MEDICINE + SURGERY reflects a trend that has been rapidly gaining momentum in recent years. This is the demand for and obsession with achieving natural-looking outcomes. This trend signifies the pendulum swinging swiftly away from the infamous “duck lip” and “chipmunk cheeks.” In fact, on a daily basis, cosmetic providers hear the request: “I just want it to look natural.” In this edition there are some pearls that we can use to achieve that outcome for our patients. Oakville, Ont.-based dermatologist Dr. Sheetal Sapra (a founding editor of this publication) focuses on the foundational role that cosmeceuticals play in the full anti-aging approach. Dermatologist Dr. Vince Bertucci of Toronto and Dr. Arie please turn to page 28— Benchetrit, a The Chronicle of Cosmetic Medicine + Surgery

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solabial folds and the rejuvenation of the hand. After injection, patients may experience redness, bruising, swelling or other local side effects. Most side effects of treatment resolve within a few days. More rare side effects may include swelling that lasts longer, side effects.orMost side in effects of treatment resolve within few days.there Moremay rarebeside effects may include swelling that lasts longer, unevenness firmness the area injected, and as with anyainjection, a risk of infection. unevenness or firmness in the area injected, and as with any injection, there may be a risk of infection.

Please see instructions for use for full list of warnings and precautions. Please see instructions for use for full list of warnings and precautions. RADIESSE is indicated for subdermal implantation for the correction of moderate to severe facial wrinkles and folds, such as na1. Data on file 2. Moers-Carpi M, et al. Dermatol Surg. 2007 Dec; 33 Suppl 2: S144–51. MAE-044 solabial the rejuvenation of the hand. injection, patients may experience redness, bruising, swelling or other local 1. Data onfolds file 2.and Moers-Carpi M, et al. Dermatol Surg. 2007After Dec; 33 Suppl 2: S144–51. MAE-044 side effects. Most side effects of treatment resolve within a few days. More rare side effects may include swelling that lasts longer, unevenness or firmness in the area injected, and as with any injection, there may be a risk of infection.

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New options in medical educatio o Interactive format saves participants the time and cost of travel  by John Evans OF THE CHRONICLE

On the leading edge of research, discoveries and new clinical findings in aesthetic medicine


A pilot project to bring aesthetic dermatology CME to general practitioners using the popular “GoToMeeting” web platform has garnered a lot of interest and will be expanded, says Edmontonbased Dr. Jaggi Rao, the driving force behind the project. The software is popular in the medical community, particularly the U.S., for holding online meetings in order to save everyone involved the time and expense of travelling to meet face to face, says Dr. Rao, clinical professor, and former program director for the Dermatology Residency Program, at the University of Alberta. Dr. Rao is also CME director for the Canadian Association of Aesthetic Medicine (CAAM). “If you have a computer monitor, a camera and a microphone, we can often hold meetings like this across the world, let alone across the country,” he says. This led him to the idea that GoToMeeting could be used to hold webinar CME sessions, he says. With the help of a web enabled camera, the CME presenter is visible to all participants. The presenter can also show images, PowerPoint presentations, and videos, all of which he can point to on screen as easily as he could in a lecture hall, says Dr. Rao. As well, the platform allows for questions to be taken during the presentation without interrupting it. “The way I do it is I have a moderator. Typically someone who is not the speaker, who will come into the webinar and take questions,” says Dr. Rao. Doctors attending the webinar have their microphones muted so the presenter can still be heard clearly. “During the time that the speaker is present-

ing the moderator will assemble questions into different types,” says Dr. Rao. “Some of them might not be pertinent, some might be duplicates.” At the end of the presentation, the moderator can announce to the audience that questions have been asked and can then address the questions to the presenter. “So there is some degree of anonymity there, so people are more inclined to ask questions,” he says. “It has worked out to be a fantastic thing,” in the assessment of Dr. Rao. “And the great thing is we can record this entire presentation so that later we can archive it, and if people

Distant CME: Why I attennd The International Society of Hair Restoration Surgery (ISHRS), which has more than 1,000 members in 60 countries, provides education and tools for the treatment of hair loss and restoration to specialists and their patients worldwide. Shortly after Montréalbased aesthetic physician Dr. Yves Hébert returned from the 22nd annual ISHRS scientific meeting in Kuala Lumpur, Malaysia, he spoke with THE CHRONICLE’s assistant editor John Evans. What would you say were the most valuable things you learned at this meeting? For years we were just doing extraction with the strip technique. Then in the last few years it was all about follicular unit extraction to the point that new doctors in this field were learning just follicular unit extraction. But now the tendency is to make sure that you learn both, because there are indications for both techniques, or a combination of both techniques. Doctors who limit themselves to just one technique miss a lot of opportunities. I think that was the biggest message I took The Chronicle of Cosmetic Medicine + Surgery

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tion: Stay home, or hit the road want to watch it they are free to do so.” Feedback for the pilot CME webinars has been good, Dr. Rao says. “People really like them. I’d like to expand this across the country.” FP/GP accredition Getting the webinar accredited with the Canadian College of Family Practitioners was not difficult, he says. “We picked a date whenever we wanted to do a CME program. For example, we did one [Oct. 14, 2014], then we submitted the proposal to the Canadian College of Family Practitioners. They do have pretty stringent requirements [for CME programs]. The material we do has to go through one of their

advisory boards. It can’t have proprietary information. If we’re talking about medications it has to be generics. You can’t be promoting a particular medication.” “We have to have it reviewed by them. [The program] has to have good learning value, which it always does. Then you just tell them which day it is, and that we’re doing it by webinar, and they typically approve it for a Class M1 credit, so that goes toward the family doctors’ accreditation,” says Dr. Rao. Dr. Rao says he would like to see the project expand to incude webinars created on behalf of CAAM with procedural videos, as part of a training program.

tended global hair restoration society meeting in Malaysia away from the conference—to keep doing the strip technique because it’s good, but at the same time make sure I can provide my patients with good technology or good technique for follicular unit extraction. One other thing that came out [during the meeting] is there has been this approach to do 4,000, 5,000 follicular units in one mega-session. I think that is exaggerated. We should limit ourselves to much smaller numbers of grafts to protect the donor area, and to not deplete the donor area too much if you do those mega-sessions, particularly in younger patients. Were there any techniques that were presented at the conference that you are planning to adopt or try in your practice? Sometimes you see performed techniques that are very easy, so you ask yourself why you didn’t think of it first. For example, regarding anesthesia, a lot of patients who have had surgery in the past say they don’t want to have another surgery because it is painful. There was a doctor who was using cannulae—the cannulae we use for fillers—to infiltrate under the skin. I used that technique for the first time this morning. This was the patient’s third session, and he said ‘I didn’t feel a thing this Volume 5 Number 1

time.’ On a scale of one to ten, it was probably a two on the pain level. So this is something I’m going to adopt and use on a regular basis. You use robotic assistance in your hair transplant procedures. What is new on that front? There is a new upgrade coming soon [for the ARTAS system from Restoration Robotics], probably in the next few months. They call it the Hair Studio. The robot will be able to make the slits [for inserting transplanted follicles]. For now, the only the thing the robot does is the extraction of the follicles. Eventually, down the road a few years from now, the robot will be able to actually transplant. It takes more time for the robot to make the slits than I would do. But at the same time I see the value for someone who is not familiar, or as comfortable as I am, with the design and the pattern of the insertions.

skin smoothing body



Worth the long trip to Kuala Lampur? We don’t have any hair restoration meetings in Canada. The International Society is really the only society that covers all the topics in hair restoration. Most times, I find there is significant value for me to go there.



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 Cosmetic Update Improving the face lift, after significant weight loss  In patients who have experienced massive weight loss, several techniques can improve the results of face lifts, according to a paper published in Plastic & Reconstructive Surgery (Feb. 2015; 135(2):397405). A retrospective chart review was conducted on face lift patients from a 25-year database of 1,089 patients at a single clinic, including data on patient age, body mass index (BMI), surgical techniques used (when available), and intra- and post-operative complications. From the database, 22 face-lift patients who had experienced massive weight loss were identified, of which 15 were women and seven were men (average age at time of face lift was 52.7 years, ranging from 41.0 to 67.0 years, and average BMI was 26.0). Primary face lifts were performed in 19 cases, and three were secondary lifts. No intraoperative complications were seen, and the postoperative complications included one hematoma, which responded to drainage. Some 19 patients (86%) host volume in their midface and nasolabial grooves, and 13 (59%) lost volume periorally and had skin excess and reduncancy in the jowl and submental region. Platysmal bands were documented in 18 (82%). SMASectomy was performed in 20 (91%) patients, and all patients received fat augmentation, with on average almost twice the fat as is used in non-massive weight loss patients (22ml vs. 12ml). —Read more at

3D liposculpture: 20 years of good results  A review of 20 years of three-dimensional liposculpture of the hips, flanks, and thighs confirms the procedure can provide satisfying outcomes safely and reliably, according to a paper published in Plastic and Reconstructive Surgery – Global Open (Jan. 2015; 3(1):e291). The authors reviewed 4,000 patient charts, looking at preoperative, intraoperative, and postoperative management of patients scheduled to undergo lipo-


The Chronicle of Cosmetic Medicine + Surgery

suction of the hips, flanks, and thighs. Of those, 50 patients experience postsurgical seroma that resolved after syringe aspiration, and one patient had a major mycobacterial infection that resolved with antibiotics. Minor asymmetries were reported by 20 patients, and corrected six months posttreatment under local anesthesia. Another 18 patients reported minor skin irregularities, which lipofilling improved. Hyperpigmentation lasting six to 12 months was seen in six cases before the suction drainage of large adiposites in patients with light skin, and there were two cases of transient parasthesia lasting eight and ten months. There were no cases of skin necrosis, deep vein thrombosis, or death. —Read more at

Nutraceutical may offer improvement in female hair loss  A nutritional supplement regimen including omega 3 and 6 fatty acids and antioxidants appears to mitigate the effects of hair loss in women by improving hair density and reducing telogen percentage and

the proportion of miniaturized anagen hair, according to research published online in Journal of Cosmetic Dermatology (Jan. 8, 2015). A group of healthy female subjects (120) were enrolled in a six-month, randomized comparative study, which looked at changes in hair density on standardized photographs, as well as changes in telogen hair percentage and diameter distribution of anagen hair— more than 40μm vs 40μm or less—compared to controls. Overall hair density and diameter changes were measured via trichometer and subject self-assessment. After the treatment period significantly better improvement was seen in the treatment group (p<0.001). Telogen hair percentage was significantly reduced (p<0.001) in the active group, and the proportion of nonvellus anagen hair was increased, compared to controls. As well, trichometer index increased in the supplemented group, while it decreased in the control group. A large majority of active group subjects reported a reduction in hair loss (89.9%) and improvements in hair diameter (86.1%) and density (87.3%) at the end of the six months of treatment. —Read more at

Imaging tool measures neurotoxin efficacy  A 3D imaging technique called digital image correlation may be a useful tool for dynamically assessing rhytid activity and neurotoxin efficacy, and therefore may aid research into dynamic aging and neuromuscular disorders, investigators write in Plastic and Reconstructive Surgery (May 2015; 135(5):869e876e). The authors used a dual-camera system to carry out a three-dimensional optical analysis to evaluate 14 subjects. Anatomic regions including the glabella, the forehead, and the total face were identified and highlighted in each face. Then tissue strain—either compression or stretch—was measured in these regions across 36 image frames while the patients furrowed their brows. These measurements were taken both before and two weeks after injection of 20 units of onabotulinumtoxin-A in the glabella, with average stretch and compression in the treated areas analyzed across all available frames and the results compared using a Wilcoxon signed rank test. Researchers found that after the injections the average vertical stretch in the glabella during brow furrowing was reduced from 2.51% to 1.15% (p<0.05), and in the forehead from 6.73% to 1.67% (p<0.05). Horizontal compression was reduced from 9.11% to 2.60% in the glabella (p<0.05) and from 4.83% to 0.83% in the forehead. As well, total major facial strain decreased from 4.41% to 3.05% (p<0.05) while total facial minor strain dropped from 5.01% to 3.51% (p<0.05). —Read more at

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Getting the best benefits from your  by John Evans

Fractional advantages While ablative lasers are the gold standard for resurfacing, due to pain, long re-epithelialization time and complicated wound care associated with them, Massachusetts General Hospital has for the most part stopped performing resurfacing procedures with these devices, says Dr. Avram during a presentation at Cosmetic Update in Toronto. On the other hand, non-ablative devices such as IPL and infrared lasers produce inconsistent, often subtle results so the hospital rarely uses them as standalone therapies anymore. Fractional lasers produce a precise pattern of damage, Dr. Avram said, creating “thousands of microscopic wounds that are completely surrounded by vital tissue for rapid healing. With non-ablative devices, these are columns of thermal coagulation, there is no ablation and these protect the surrounding corneum completely.” Non-ablative devices include medium-depth laser and radiofrequency (RF) devices and more recent superficial devices such as the new 1927 nm thulium lasers.

is associated with adverse side-effects of being more aggressive is the density. As you treat more and more skin you are going to have more erythema, more swelling, more hyperpigmentation and more of a chance for adverse side effects.” With the increased rate of adverse events associated with more aggressive, higher density laser patterns, it would be hoped there was a worthwhile improvement in outcomes that went with it, but Dr. Avram says it is unclear if this is so. “To the extent that it has been looked at— which has mostly been in scars—typically at best we can get the same results with more side-effects at the higher densities than we do at more moderate densities.” If patients have a history of herpes simplex, Dr. Avram recommends antiviral prophylaxis. For local anesthesia during fractional procedures, cold-air cooling is appropriate for most applications and patients, Dr. Avram said, along with some combination of topical lidocaine or tetracaine. If considering injecting lidocaine, particularly into scars, practitioners might want to wait a short time before proceeding with the laser treatment as there is some evidence that injected lidocaine produces a thermal instability in the skin that could lead to ulceration after laser irradiation. If the patient’s concern is melasma, fractional lasers are not the best choice, says Dr. Avram, noting that while the patient may see some improvement, what will typically happen is that six to eight months after treatment when the patient is sun exposed again, the melasma will return, possibly worse than it was before the laser treatment.

Pre-treatment considerations “The best way to think about treatment approach for your patient is to think like a pathologist,” said Dr. Avram. “What are you treating? Are you treating superficial pathology or are you treating deeper pathology?” The clinician’s decisions are how deep does the laser need to treat—which is controlled by pulse energy—and how aggressive the treatment needs to be—which is controlled by the density of the fractional pattern primarily, he said. Moderate depth devices penetrate between approximately 442 microns and 1359 microns into the skin, and beam density—the percentage of the skin area the fractionated beam is affecting—can range from 5% to 48%. It is a common misconception among doctors to associate pulse energy with aggressiveness of treatment, Dr. Avram said, but that factor simply determines how deep into the skin you are treating. “What really

Scar treatment “For scars, it’s best to treat the erythema and the scar texture with two lasers in the same session if you can,” Dr. Avram said. After using an IPL device for the erythema, the texture of the scar can be treated with either an ablative or non-ablative fractional laser as appropriate. “If you are doing ablative fractional you can put the little drops of Kenalog on top because you are going to have the channels that are open to get deeper penetration into the scar.” Higher energy settings are also recommended for scars for treating deeper in the skin, Dr. Avram said. “And if you keep your density down you can treat for skin types four to six with fractional lasers.” “One of the things that we do is punch excisions prior to the first treatment if there are ice pick scars,” Dr. Avram said. “Then do the five or six fractional treatments because the fractional treatments are going


Fractional laser resurfacing—whether with an ablative or a non-ablative device—is a versatile approach for producing good results in an evergrowing range of indications. It is a good therapeutic midpoint between the efficacy of full ablative lasers and the safety of intense pulsed light (IPL) devices, says Dr. Mathew M. Avram, a laser and cosmetic dermatologist at Massachusetts General Hospital in Boston.


The Chronicle of Cosmetic Medicine + Surgery

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fractional laser devices The best way to think about treatment approach for your patient is to think like a pathologist, suggests Dr. Mathew Avram

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 Laser surgery to help if there is any scar remaining from the 2 mm punch.” Photodamage and photoaging Using multiple laser devices in a single session is also a viable approach for photodamage and photoaging, Dr. Avram noted. “Because we are going to have the downtime anyway, this is a good way to have people getting more of the wow factor when they leave your office or within a few weeks of leaving your office.” Beginning with a pulsed-dye laser, Q-switched laser or similar device for erythema and telangiectasias, that can then be followed by an ablative or nonablative fractional treatment. “This will address the erythema, telangiectasia, lentigines, texture and tone, all in one treatment and they are going to be much more satisfied than if you treated them afterwards because they are going to see a bigger difference,” he added. “In terms of dermatoheliosis or background sun damage the fractional devices and the IPL are far more effective than the Q-switched devices or picosecond devices, because you are treating a broad background area,” he said. “But when you want to treat individual lentigenes, due to their own physiology, it is the Q-switched lasers and the picosecond lasers that are going to be more effective.” Skin resurfacing With ablative devices, clinicians are creating channels into the skin surrounded by coagulated tissue. As a result, says Dr. Avram, these treatments “are characterized by pretty dramatic immediate postoperative picture. You can see significant swelling and bleeding after the treatment.” Interestingly, in contrast to the non-ablative treatments patients don’t really feel like their skin is warm after treatment, Dr. Avram said. “And the extent that they do might be an indication that something wrong is happening. So, if the patient has lidocaine after the treatment, or complications after the treatment, check to see if there was some kind of problem.” Ablative fractional lasers can be better than non-ablative fractional devices in terms of obtaining a good resurfacing result with a single treatment, improving skin laxity, pigmented lesions, and vascular issues non-selectively targeting blood vessels with a significant reduction in downtime compared to traditional ablative procedures. New indications “Ablative fractional resurfacing actually does a nice job on tattoos. We had a case with a patient [who was] allergic to ink,” and using traditional Q-switched lasers to remove the tattoo can cause the ink which is the patient’s allergen to spread into his system and cause anaphylaxis, said Dr. Avram. To treat this patient, Dr. Avram and his team used an erbium laser, which produces less coagulation and more bleeding to get the ink to extrude out of the skin. “By using these channels we could get the ink out without getting so much of a systemic allergic reaction.” Another indication that Dr. Avram said he expects to become common in the next five to 10 years is drug delivery. “This is an incredible means to get things into the skin that wouldn’t normally go transcutaneously,” he said. “You are creating ablative channels and this is giving topicals the ability to get into the skin in ways they couldn’t before.”


Fractional laser treatment can dramatically impact burn scars, he noted. “This was learned in San Diego by the navy, in patients coming back from Iraq and Afghanistan who had horrific hypertrophic scars. What’s being found is that with these ablative fractural treatments not only are their scars getting better but their mobility is getting better as well. This is actually now pretty well established. It is amazing how these technologies can take on new uses. But even I have seen patients who have had median sternotomy scars who were able to breathe better after treatment because they feel that they are less constricted.” 1927nm Thulium Laser Among the most recent devices to enter the market are 1927 nm Thulium lasers, said Dr. Avram. This wavelength is strongly absorbed by water, so it targets a superficial region. “The thulium device goes from 196 to about 204 microns [deep], so it’s far more superficial. “It’s going to target dermatoheliosis, actinic keratosis, lentigines and this is great for patients with light

“I don’t do neurotoxins at the same visit for fractional lasers.” Dr. Mathew Avram

skin phototypes,” he says. “This is less painful than the deeper penetrating fractional devices, so you don’t need the topical anesthesia for quite as long.” Cautions “One thing I would caution is the use of fractional lasers with neuromodulators,” said Dr. Avram. Not only can this result in some edema, but Dr. Avram reported that several doctors have told him that when they have done neuromodulator and fractional laser treatments in the same area on the same visit, the neuromodulator diffused into unintended areas and patients developed ptosis and other side effects. “So I don’t do neurotoxins at the same visit for fractional lasers,” he says. “I did for a number of years, but I am hearing [of those adverse events] more and more and I think it’s probably not a good idea to do [the two treatments together].” The Chronicle of Cosmetic Medicine + Surgery

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Special Report

How to Treat Your Patients’ ACNE SCARS PMMA-collagen dermal fillers one option for these patients cne scars can lead to significant patient unhappiness, and good management results of these scars are most often achieved through a combination of approaches, including the use of PMMA-collagen dermal fillers, says Dr. Sheldon V. Pollack. The variety of approaches to treating acne scarring is important because of the diverse nature of the scars, says Dr.


noted, and are not suitable for rigid fibrotic or ‘ice pick’ scars. However, the choice of filler is important, he says, as many fillers may just flow around the scar, resulting in the formation of a donut. PMMA-collagen fillers have gone through several generations of refinement over the years, with better elimination of contaminants and improvements in manufactur-

point improvement in the Acne Scar Rating Scale (ASRS) scores for at least 50% of their scars, which was considered successful treatment. By contrast, successful treatment was achieved by just 33% of those in the control group. Adverse events (AE) occurred in 17% of the PMMA-collagen group and 13% of controls, of which the most common were injection-site pain, injection-site tenderness, swelling, influenza, and nasopharyngitis. The rate of AE

placed using a microdroplet technique followed by immediate massage to smooth any irregularities. Applying pressure after the treatment can also help to minimize bruising, he says. Using this technique to address acne scars with PMMA-collagen fillers, Dr. Pollack says he has not encountered any necrosis or granulomas for this indication. Combining scar management through subcision and filling with a chemical peel is something Dr.

Pollack, Associate Professor of Medicine in the Division of Dermatology at the University of Toronto, and immediate past president of the Dermatologic & Aesthetic Surgery International League (DASIL). Acne scars can display a variety of features, even on the same face. They may be tough and sclerotic or soft, atrophic or hypertrophic, distensible or not, and are generally classified in three loose groups: narrow but deep ‘ice pick’ scars, starkly edged ‘boxcar’ type, and the softeredged ‘rolling type.’ Treatment approaches can include raising atrophic scars through subcision and fillers, and resurfacing the skin using microneedling, directed energy or chemical peels, and encouraging collagenesis, Dr. Pollack says. Yet no single treatment approach results in improvement rates higher than 20% to 50%, so he recommends the combination approach. Dermal fillers are most suited for soft, distensible scars with gently sloping or rolling edges, Dr. Pollack

ing that allow for rounder, smoother microspheres of a more uniform 30 to 50 μm diameter and a reduced negative charge. Current-generation PMMA-collagen filler products, such as Bellafill, offer a number of advantages for the management of acne scars in cases where fillers are appropriate, says Dr. Pollack. With the correct technique, these fillers are easy to use due to their slow extrusion, and produce good cosmetic results, he says. A double-blind, controlled study of suspended PMMA microspheres as an acne scar treatment in 147 individuals also supports their efficacy and safety in this application. In this trial, patients with at least four moderate to severe rolling, atrophic scars were randomized to receive injections of either PMMA-collagen or saline. Each participant had one or two sessions, and was followed up for six months with treatment efficacy evaluated for each scar using a validated scale. In the study group, 64% of the PMMA-collagen group had a two-

between the active and control groups were not significantly different. Only five severe AE were recorded, none of which were related to treatment. When treating distensible atrophic acne scars using PMMA-collagen fillers, Dr. Pollack notes, patients will likely need two to four total treatment sessions spaced at least six weeks apart to achieve best results. If the scar is bound down, he subcises as he goes along, he says, to free the base of the scar and also to create a pocket where he can inject the PMMA-collagen. Subcision is typically done with a 20 gauge needle, and the patient will likely experience bruising for one to two weeks. Dr. Pollack says the usual location of the PMMA-collagen injections is between 1/8 and ¼ inches outside the rim of the scar. Since the filling effect with PMMA-collagen products is immediate, doctors should aim to correct to 100%, rather than under-filling and expecting the product to bulk up later, says Dr. Pollack. The filler should be

Pollack also does in his practice. In terms of chemical peels, Dr. Pollack puts trichloracetic acid directly onto the scar using a cotton swab. He also offers a series of superficial peels with glycolic acid, done in a series of 12 treatments spaced three to four weeks apart, for one year. Acne scars tend to worsen with age, says Dr. Pollack, as collagen production in the skin decreases. For this reason he recommends supporting acne scar revision with topical retinoids before and after the filler treatments. Other options that have been suggested for encouraging collagenesis include vitamin C before and after procedure, rollers for at-home use, and needling.

Supplement to The Chronicle of Cosmetic Medicine + Surgery, June 2015. Chronicle is an independent medical news service that provides educational updates regarding medical developments around the world. Views expressed are those of the participants and do not necessarily reflect those of the publisher or sponsor. Support for distribution of this report was provided by Suneva Medical, Inc. through an unrestricted educational grant without conditions. Information provided in this report is not intended to serve as the sole basis for individual care. Printed in Canada for Chronicle Information Resources Ltd., 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont. M9C 2Y3.Telephone 416.916.2476; facsimile 416.352.6199; e-mail: Copyright 2015 by Chronicle Information Resources Ltd., except where noted. All rights reserved. Reproduction in any form is expressly prohibited without written permission of the publisher.

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his year physicians can look forward to numerous new developments in the field of cosmetic medicine, according to Canadian clinicians. Patients who have concerns about the impact of aging on the skin will look to topical cosmeceuticals to fight the effects of the aging process, says Dr. Sheetal Sapra, a dermatologist from Oakville, Ont. “There are more cosmeceuticals in skin care,” said Dr. Sapra, a founding editor of THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “More and more companies are developing cosmeceuticals, and [the manufacturers] are introducing active ingredients such as growth factors and peptides, etc., [in those cosmeceuticals].”

Another advance in fillers is that Radiesse, a volumizing filler, will be offered in a more convenient formulation that contains lidocaine. “It will make injections easier because it will be pre-formulated with lidocaine,” suggested Dr. Vince Bertucci, a Toronto dermatologist and presidentelect of the Canadian Dermatology Association. An additional trend is that some clinicians who offer aesthetic medicine are combining injections of HA with platelet-rich plasma (PRP) with an aim to improve revitalization of skin tissues, noted Dr. Yves Hébert, medical director of Médecine Esthétique in Montreal and a past president of the Canadian Association of Aesthetic Medicine.

PRP Tx option for hair restoration, skin rejuventation New line of HA fillers “I think we are approaching PRP with a new eye,” said Dr. Hébert. “We are using Regarding fillers, Canadian clinicians can look forward to the availability of a it for skin rejuvenew line of nation and also hyaluronic acid using it for the (HA) fillers that purposes of hair have been avrestoration. ailable in EurSometimes hair ope. Emervel transplants are fillers will be not an option available in D r. Benchetrit Dr. Bertucci Dr. Hébert Dr. Sapra Dr. Weksberg because patients Canada this

2015 clinical forecast Minimizing potential for complications is necessary to maintain a reputable image for aesthetic medicine

year. The addition to the array of HA fillers will allow for greater differentiation in the marketplace, noted a plastic surgeon based in Pointe-Claire, Que. “The fillers have various properties,” said Dr. Benchetrit. “For volumizing, use of stiffer fillers appears to be more effective, and for the lips or tear trough, softer products seem better.”


 by Louise Gagnon FOR THE CHRONICLE

don’t have sufficient density for hair grafts or transplants. Overall, the use of PRP is becoming more mainstream.” Some studies have investigated PRP injections to treat hair loss in males and females (Journal of Cutaneous and Aesthetic Surgery Apr. 2014;7(2): 107–110 and Dermatologic Surgery Sept. 2014 ;40(9):1010–1019). Another technology that please turn to page 22—

The Chronicle of Cosmetic Medicine + Surgery

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Mid-face treatment can refresh the whole face

Knowing your patient and understanding the geometry of the eye lets you keep your patients looking good and age-appropriate  by John Evans


Peri-ocular rejuvenation can keep patients looking great into their 70s, often with just non-invasive techniques. It is important to balance a patient’s desires and budget with what is possible based on their facial geometry, while avoiding overcorrection, said , speaking at the 2014 annual meeting of the Canadian Association of Aesthetic Medicine in Toronto. No two eyes are the same, says Dr. Motakis, a plastic surgeon in private practice in Toronto, but beautiful eyes share some common features. “Features of a beautiful eye include a fullness in the infrabrow area, the fullness of the cheekbone, a nice smooth eyelid/cheek transition, and a mild concavity in the medial part of the eye,” says Dr. Motakis. He says he has seen many cases where that medial concavity has been overfilled. Volume 5 Number 1

“We often look at the beautiful people and how they age in Hollywood. We can see that many of them look age appropriate and elegant with rejuvenation. Some of them have more lines, some of them less,” Dr. Motakis says. “I tell my patients that looking great is a range. We know who looks distorted, and we know who looks weathered. But looking good is not a fixed point, it is a range. I’ve always tried to figure out, first of all where in that range my patient would like to fall.” The face ages through a combination of deflation—corrected with volume—skeletal changes that can change the shape and size of the eyes, and descent, says Dr. Motakis. “Descent is lateral,” he says. “We don’t move down on the medial canthus. We don’t move so much near the nose. We move laterally. The brow comes down, the cheek comes down, dragging the tissues down laterally.” Know your patient A clinician needs to know what endpoints a patient desires, how much downtime they are comfortable


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 Mid-face treatment with, if they are even interested in an invasive procedure, if they are willing to schedule the repetition that some treatments require, and what their budget is, he says. Then the clinician has to determine what it is possible to accomplish with the patient’s facial structure, says Dr. Motakis. Can the clinician impact the patient’s skin texture, colour and translucency? Can volume be introduced and lines corrected? Is there so much fat and skin that the patient requires a surgical intervention, or will non-invasive modalities provide results that meet the patient’s expectations? Some of his patients have had past blepharoplasties and have refused further surgery because they do not want the downtime, says Dr. Motakis. Other individuals, such as balding men, were not candidates for surgical brow lifts because of the scar left by the procedure. These patients can be treated by non-invasive modalities. Restoring volume and lift “One of my favourite non-invasive things to do is to use volume, because I think if it is done correctly it really rejuvenates the eye in very natural way,” says Dr. Motakis. He has, however, seen many cases where too much volume has been placed in certain areas, he says. “I feel that an overcorrected tear trough, though it may look good in pictures, and people want to look like the pictures in those touched up images in Vogue magazine, is not a human feature. We used to make the same mistake with nasolabial folds.” A wiser course is to inflate the cheek and lift the lateral face and brow, which will as a consequence soften the tear trough and reduce any hollowness around the eye, says Dr. Motakis. He says his own approach is to first determine the patient’s budget for filler, then assess the temples and brow, and then to begin volumizing the lateral cheekbone and orbital rim when there is a depression in that area. The junction of the orbital rim and the cheekbone “is probably where you get most of the lift, but again, an area that is often over-volumized. You don’t want to have a cheek that juts out from the face. You want to just blend it in,” he says. After that, Dr. Motakis progresses to add volume medially while retaining a bit of concavity on the inner part of the upper and lower anatomy. When adding volume around the eye specifically, Dr. Motakis says he uses three canula points of entry. “One to lift the medial brow, another point to lift the lateral brow and also to address the orbital rim show, and another from the cheek to volumize the nasojugal groove. At the very end I’ll introduce some volume medially at the tear trough using the same entry point.” Neurotoxins, too, play a role in raising the brow and thereby rejuvenating the peri-ocular area, says Dr. Motakis. “This is one of the first tools we go to,” he says of neurotoxins. “Why? Because it is almost a guaranteed success—90 to 95 per cent of the time you are


going to get improvement of the crows feet, you’re going to get improvement in the glabellar lines. In my books, more importantly, you’ll get the structuring of the brow. You’re going to shape that brow to lift up.” This lift, he says, gives his patients a more rested, fresher look. Excess skin and fat To treat droopiness, not hollowness, around the eyes, Dr. Motakis says that radiofrequency and ultrasound modalities can tighten skin. He does find that the results can be unpredictable so he is very particular about which patients he will recommend these modalities to, usually those who are adamant about not having surgery or are at the very early stages of descent. The removal of fat from the lower lid is quite satisfactory, says Dr. Motakis, but he cautions doctors to be aware they will likely need to fill in the area as well, to blend the bone of the lower orbital rim into the cheek. Skin quality Regarding skin quality, some patients in his practice seem to benefit from the use of retinoids under the eye, says Dr. Motakis. “Some patients cannot tolerate them. I try and introduce them in a slow manner in dilute forms.” He says he also recommends growth factor serums, high concentration vitamin C, and sun protection around the eyes. Ablation can also improve skin quality around the eyes but not all methods are appropriate, says Dr. Motakis. His modality of choice is radiofrequency ablation, enabling the surgeon to get right down to the lid margin. Platelet rich plasma with microneedling is another effective form of treatment used around the eyes, which provides a very satisfying result. Combining procedures Different peri-ocular procedures can also complement each other, says Dr. Motakis. For example, he says upper blepharoplasties are low-complication, high satisfaction, procedures with very short down time, but don’t actually correct the position of the brow. Fillers, neurotoxins, or, where indicated and within the patient’s desires and budget, a surgical brow lift, can build on the improvements from the blepharoplasty, he says. It is better to stagger different interventions over many visits rather than doing all the procedures on the same day, so the practitioner can see the results of one intervention and then build on it, says Dr. Motakis. “Make sure it looks good, and then make plans for the next step. I explain to my patients that it is a process.” Once the patient is satisfied with the change, the physician now has a ‘recipe’ of treatments for that patient’s face that can be repeated for years to come. “Of course, there comes a time when maybe more dramatic interventions such as surgery are needed,” he says. The Chronicle of Cosmetic Medicine + Surgery

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SPECIAL REPORT Ce Cosmec an‐aging ingredients link to cellular bioenergecs in vitro bioen llular e n e r g e r g et i c s i ze respons skin se

Certain ingredients can help combat look of skin aging

An amino peptide complex of ingredi‐ ents contained in Olay Regenerist Micro‐Sculpting Cream not only hy‐ drate the skin, but utilize skin energiz‐ ing technology to help accelerate skin’s responsiveness to anti‐aging, clinicians reported during a round‐ table discussion at the Canadian As‐ sociation of Aesthetics Medicine 11th Annual Conference in Toronto. During the presentation, the clini‐ cal findings and benefits of cellular bioenergetics (Olay Regenerist)—which includes a complex of ingredients such as niacinamide (Vitamin B3), Pal‐KTTKS (Palmitoyl moiety‐lysine‐threonine‐ threonine‐lysine‐serine), Olivem (olive‐ derived fatty acid ethoxylates) and Lys’lastine V (dill seed extract) were re‐ viewed by Dr. Charles Lynde and Dr. Kucy Pon. Dr. Pon said that there are five dif‐ ferent classes of cosmeceuticals that clinicians should take note of including vitamins, botanicals, hydroxy acids (AHAs, BHAs), depigmenting agents and peptides and growth factors. “The term cosmeceuticals was coined by the late Dr. Albert Kligman in 1984 and it refers to products ap‐ plied topically that claim to reduce signs of aging and maintain a youthful appearance,” said Dr. Pon, Assistant Professor of Dermatology at the Uni‐ versity of Toronto. “[We must keep in mind that] cosmeceuticals are in between drugs and cosmetics; therefore, they do not have to go through government regu‐ latory approval from the FDA or Health Canada. They do, however, un‐ dergo tests to determine safety, but the testing of any claims made is not mandatory.” Given that cosmeceuticals are not regulated, Dr. Pon said that there are important questions clini‐ cians must consider before recom‐ mending a cosmetic product to patients. The questions that should

be reviewed include:  Can the active ingredient pene‐ trate the skin in sufficient con‐ centrations?  Does the active ingredient have a known biochemical mechanism of action in the skin?  Are there peer‐reviewed, statisti‐ cally significant clinical trials to substantiate claims? It is important for these questions to be answered when deciding on a spe‐ cific product to recommend to pa‐ tients, Dr. Pon emphasized. “In the case of products like Olay Regenerist, for example, there is sci‐ ence, research and development be‐ hind the product, which makes me quite confident to recommend it to my patients,” said Dr. Lynde, Associate Pro‐ fessor, Department of Medicine and Assistant Clinical Pro‐ fessor at the Univer‐ sity of Toronto. Dr. Lynde Dr. Lynde added that data published in the British Journal of Dermatology suggests that niacinamide, Pal‐ KTTKS peptide, Olivem and Lys’lastine V are promising bioactive candidates for inclusion in cosmetic formulations (Aug. 2013; 169(2):32–38). He noted that these in‐ gredients can all be found in Olay Re‐ generist. Overall, the findings of the British Journal of Dermatology study indi‐ cated that the complex of niacinamide, Pal‐KTTKS and Olivem, especially with addition of Lys’lastine V, increases the NAD(+)/NADH bioenergy level of adult skin fibroblasts in parallel with in‐ creased expression of skin structure biomarkers in vitro to levels similar to those in younger fibroblasts. Niacinamide has been found to restore NADPH levels and increase collagen production in human fibrob‐ lasts in cultures, said Dr. Lynde.

“The clinical benefits of using moisturizers containing niacinamide have shown that it improves the skin’s texture, reduces fine lines and wrinkles, prevents sallowness, improves skin bar‐ rier function, improves hyperpigmenta‐ tion, improves acne and reduces surface sebum,” Dr. Pon said. Research has shown that KTTKS (lysine‐threonine‐threonine‐lysine‐ serine) stimulates collagen production and has a potential utility in wound healing (J Biol Chem 1993; 268(14) 9941– 9944). Pal‐KTTKS (Palmitoyl moiety) im‐ proves skin delivery, stimulates collagen production, and improves wrinkle ap‐ pearance, reported Dr. Lynde. In a further discussion about Pal‐KTTKS, Dr. Lynde referenced the results of an eight‐week dou‐ ble‐blind, vehi‐ cle‐controlled, split‐face, ran‐ domized (left‐ Dr. Pon right) study aimed at assessing the use of moisturizer containing 3 ppm Pal‐ KTTKS among Caucasian women, 36 to 66 years of age with moderate to se‐ vere facial crow’s feet wrinkles. The findings of the eight‐week study, according to Dr. Lynde, revealed that use of moisturizer containing 3 ppm Pal‐KTTKS significantly reduced the appearance of crow’s feet wrin‐ kles as measured by FOITS (wrinkle volume and depth) compared to baseline and the concurrent moistur‐ izer vehicle control product. “Olivem has also been found to help boost cellular metabolism by in‐ creasing the production of collagen, elastin, and hyaluronic acid in vitro,” said Dr. Lynde. He added that protection from acute UV down‐regulation are key pro‐ tective oxidative response genes by Olivem in an ex vivo human skin model. “Olivem increases expression of genes/enzymes related to anti‐oxidative protective mechanisms,” Dr. Pon said.

With regard to the benefits of a moisturizer containing Lys’lastine V, Dr. Lynde reviewed the results of a 12‐week double‐blind, vehicle‐controlled full‐ face, randomized study that evaluated Caucasian women between 43 and 56 years of age who had facial wrinkles/fine lines and reduced skin elasticity. Findings of this Lys’lastine V study demonstrated that twice daily use of moisturizer containing 1% Lys’lastine V significantly improved facial skin elastic‐ ity by instrumental evaluation (Cutome‐ ter), compared to both baseline and the concurrent moisturizer vehicle control product. Data also showed that there was significantly improved elasticity as determined by clinician grading as per visual and touch assessments, com‐ pared to baseline and control product. After Dr. Lynde and Dr. Pon re‐ viewed data related to the ingredi‐ ents included in Olay Regenerist, Dr. Lynde commented that he is glad to have a product available to recommend to his patients that has statistically significant clinical trials to substantiate the efficacy claims. As an added benefit, Dr. Lynde is also pleased that the price of the product is more economical compared to some other cosmetic products on the market. Supplement to The Chronicle of Cosmetic Medicine + Surgery, June 2015. Chronicle is an independent medical news service that provides educational updates regarding medical developments around the world. Views expressed are those of the partici‐ pants and do not necessarily reflect those of the publisher or sponsor. Support for distribution of this report was provided by Procter & Gamble through an unrestricted educational grant without conditions. Information provided in this re‐ port is not intended to serve as the sole basis for individual care. Printed in Canada for Chronicle Infor‐ mation Resources Ltd., 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont. M9C 2Y3.Tele‐ phone 416.916.2476; facsimile 416.352.6199; e‐mail: Copyright 2015 by Chronicle Information Re‐ sources Ltd., except where noted. All rights reserved. Reproduction in any form is ex‐ pressly prohibited without written permis‐ sion of the publisher.

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 Clinical forecast is develop—continued from page 14 ing a niche role in hair transplantation is the ARTAS Robotic Hair Transplant, which does not leave a scar or pattern in the donor area, explained Dr. Hébert. “It’s appealing for male professionals [who want a hair transplant] because they are able to keep their hair short because they are not left with a scar that is visible in the donor area,” Dr. Hébert said. New neuromodulator available to treat glabellar frown lines, forehead wrinkles Studies of a new neuromodulator, known as PurTox, a purified botulinum type A neurotoxin, which is free of complexing proteins, may present another option to smooth the appearance of glabellar frown lines and forehead wrinkles. An energy treatment that is garnering much attention from Canadian physicians who focus on aesthetic medicine is micro-needling with RF, according to , medical director at Project Skin MD in Vancouver. “The radiofrequency energy reaches two to three times deeper into the dermis than traditional lasers,” said Dr. McGillivray. “Micro-needling delivers the energy in a more gentle way [and it] shows great promise in treating acne scars and skin types five and six,” Dr. McGillivray added. Micro-needling technologies can include rollers with wheels of needles and pins. The slight injury triggers collagen growth, thereby enhancing the appearance of skin that is scarred, explained Dr. Fred Weksberg, owner and medical director of the Weksberg Centre for Cosmetic Dermatology and the Toronto Vein Clinic in Toronto. Micro-needling represents a novel method of improving topical drug therapy, according to Dr. Bertucci. “By creating small channels within the skin, it may be a way of improving drug delivery,” said Dr. Bertucci. “By improving product delivery, it may ultimately improve drug effecacy.”


The ubiquity of social media and the popularity of ‘selfies’ is attracting patients to cosmetic dermatology to improve their look, observes Dr. Fred Weksberg. ‘Looking at photos of themselves [on social media], people are more critical of themselves’

Picosecond technology has signified progress in lasers that are very effective in tattoo removal, and more firms will offer lasers that feature the technology. Observers predict more competition in the marketplace will bring down the price point for the technology, making it more accessible for purchase by clinicians. In body contouring, some existing technologies such as cryolipolysis, known by the brand name CoolSculpting, feature new hand pieces, which can be applied to sites such as the outer thighs, noted Dr. Hébert. “There is a flat applicator designed to treat the saddlebags that can develop on the outer thighs,” said Dr. Hébert. One target zone in facial shaping is the recognition that there is loss of volume in the temples of the face over time, said Dr. McGillivray. “Overall facial shaping is relatively new,” he noted. The ubiquity of social media and the popularity of “selfies” is attracting patients to cosmetic dermatology who have familiarity with cosmetic interventions to improve their look, observed Dr. Weksberg. “Looking at photos of themselves [on social media], people are more critical of themselves,” said Dr. Weksberg. “There is more awareness about cosmetic procedures.” Minimizing the potential for complications is necessary to maintain a reputable image for aesthetic medicine, so physicians like Dr. Weksberg are taking extra steps to avoid complications. Threats of infection have been a concern with entities like biofilm. “My infection rate has dropped dramatically since I began using chlorhexidine to clean the skin,” said Dr. Weksberg, emphasizing an aseptic technique is required. “Using alcohol to clean the skin and then proceeding with injections is not up to the standard of care. We need to do more than just that.” “Because it is elective, we can plan our surgery, and that reduces the risk [of complications] for most patients,” said Dr. Benchetrit. “Also, we mostly deal with healthy patients who don’t have significant risk factors.” The Chronicle of Cosmetic Medicine + Surgery

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and shadows

in aesthetic medicine

The shadows facial features cast are critical to perception of youth and freshness, so managing them needs to be included in the plans of any lifts or filling procedures with reflation and contouring  by John Evans OF THE CHRONICLE

The highlights and shadows of the face are crucial to the perception of youthfulness and beauty, said Dr. Kent Remington, speaking at Cosmetic Update in Toronto on Dec. 5, 2014. Failing to take into account the face’s natural shadows during rejuvenation procedures can produce unnatural looking results, but restoring young-looking shadows can produce a highly aesthetically pleasing result by re-creating youthful facial highlights. Study light and shadow deliberately, not just intuitively

“We’ve known for a long time that light is the language of photography,” said Dr. Remington, founder of the Remington Laser Dermatology Centre in Calgary, noting that cosmetic physicians have a great deal of experience in seeing how light falls on and defines facial features from taking patient photographs, not all of them are as experienced working with shadows. “You cannot have facial shadows without light, and you can’t have highlights without shadows. So what gives us trouble with facial issues is we end up not only filling deflated shadows, but also filling the youthful shadows.” Inflating youthful cheek shadows creates the pillow face we see so much in Hollywood, he says. While a sagging jowl may cast a shadow on the neck, a full cheek bone and jaw also create a hollow between them, but the latter is natural in a youthful face. Beautiful faces, said Dr. Remington, have light and shadow in the right ratio and in the right locations. “Shadows help create the third dimension, they create form and structure of the face.” In the past when HA fillers first came onto the market, some practitioners did not pay attention to the natural form shadow—the darker side of an object away from a light source—of the cheek, said Dr. Remington. They filled the whole cheek, erasing a natural, youthful, shadowed hollow that helps create the highlight at the top of the cheek, he said. “If you look at all your photos, in patients that have had really good results [from filling], [the good results are] because you have intuitively stayed away from the youthful shadows and not injected those. The aim with reflating deflated cheeks is to focus on the aging shadows of the cheeks. The same thing is true with the occlusion shadow on the angle of the jaw,” said Dr. Remington. Crisp shadows convey youthfulness

“The post-jowl, the pre-jowl, those areas create an uneven shadow. You want to create a nice brisk occlusive shadow —Please turn to page 27 Volume 5 Number 1


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needling an effective tool for skin rejuvenation

Commonly used in Europe, percutaneous collagen induction does not ablate the skin or cause scarring  by Emily Innes OF THE CHRONICLE

Percutaneous collagen induction therapy—also known as micro-needling— has been proven to be a safe and effective technique to rejuvenate skin in conditions such as scars, wrinkles, sagging skin, and stretch marks, according to a leading expert in the field who spoke during Cosmetic Update in Toronto. , a specialist in plastic and cosmetic surgery practicing in Bad Wörishofen, Germany, said there are many options to tighten and rejuvenate the skin such as face lifts and botulinum toxin fillers, but “all these operation methods have one thing in common—they do not really change the skin texture, they do not really rejuvenate the skin by itself,” said Dr. Aust. As a result, he said that ablative procedures, such as fractional lasers, have increasingly become more popular. The problem with these procedures, Dr. Aust noted, is that they cause a thinning of the epidermis, which can over time lead to dyspigmentation of the skin and scarring. Needling leaves the epidermis intact “What you do not achieve is a real rejuvenation of the skin,” said Dr. Aust. “Under ideal circumstance, you


should repair the epidermis and you should not remove it . . . The major difference between skin needling and ablative procedures is that the needle penetrates through the epidermis into the dermis. The cells of the epidermis get wide and the needle gets out and the cells grow back again. You do not damage or ablate any cells. We believe that this medical instrument [the needling roller] brings us closer to this ideal.” Dr. Aust said needling has become popular in Europe, particularly as a “lunchtime procedure.” If the physician uses a shorter needle, 1 mm, only topical anesthesia is required, and the downtime is minimal. He describes the patient’s post-operative appearance as resembling a slight sunburn. No dressings are required so the patient can immediately go back to work. Without bleeding there are no results “[The physician] rolls the roller over the surface and tries to create as many puncture channels and needle holes as possible,” said Dr. Aust. “The goal is to get small bleeding spots. If you do this technique and you do not achieve any bleeding it is a waste of time. Without bleeding you do not get any results.” When longer needles, 3mm, are used, the patient will experience more swelling intraoperatively and some bruising. There is still no downtime in hospital and no dressings are required, Dr. Aust said. The needle length, according to Dr. Aust, will depend on the patient’s desires. If the patient wants the maximum results in the shortest amount of time and does not mind if they have more swelling then a

longer needle can be used. He noted that most of his aesthetic patients prefer the shorter needles with repeat visits. The longer needles are usually reserved for keloids and hypertrophic scars. The post-operative regime, according to Dr. Aust, is simple and just requires patients to avoid getting crusts. Crusts can lead to bacteria growth, which can cause scarring. “We tell all our patients for the first day to wash their face every three hours and to oil it with a high dose vitamin A oil to enhance the results,” said Dr. Aust. It is possible with needling to treat any part of the skin and a variety of different conditions. Dr. Aust said that traditionally fresh scar burns are not treated for at least one year, but it is possible to use needling immediately. One of Dr. Aust’s patients had a fresh burn scar three months after a barbeque. “The patient came to us and he asked us specifically not to wait because he did not want to live with that,” said Dr. Aust. “So we needled him in the very early phase and we have seen at one year to two years post-op tremendous improvement. “I am not saying that the scar by itself would not improve by waiting. But, I just want to point out that maybe we now have a tool to improve scars from the early phase on.” While needling has become a widely accepted practice in Europe, when Dr. Aust first introduced the concept in meetings, he said his colleagues had a high level of skepticism. Through a series of studies with both rats and human subjects, Dr. Aust and his colleagues were able to demonstrate true skin rejuvenation without dyspigmentation, and that needling is a safe procedure (Plast Reconstr Surg April 2008; 121(4):1421–1429). Dr. Aust and his colleagues also found that the needling rejuvenated collagen levels, epidermal growth factor, fibroblast growth factor, and vascular endothelial growth factor (Plast Reconstr Surg June 2010). Any needle type product will do the trick When it comes to selecting the type of needle—as a member of the audience pointed out that there are numerous devices now appearing on the North American market—Dr. Aust said “at the end of the day a pin prick is a pin prick.” However, he did say he prefers using a roller because it can cover large surfaces quickly. He said the pen-like needle is also a good tool for when a patient requests an area requiring precision, such as the upper eyelid or under the eyes. “I am not saying [needling] is . . . able to treat everything. But I am saying that regarding the skin condition it is a very, very safe and powerful tool,” said Dr. Aust concluding his talk. The Chronicle of Cosmetic Medicine + Surgery

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 by Emily Innes OF THE CHRONICLE

Residents of the University of Toronto’s (U of T) Division of Plastic Surgery have developed a breast reconstruction pre-consultation model that has allowed patients to feel better informed and perceive greater involvement in their care. U of T resident Dr. Jennica Platt presented her study about an improved breast reconstruction pre-consultation workshop—selected the best resident paper—during the 14th annual Toronto Breast Surgery Symposium last April. Dr. Platt and her colleagues acknowledge that many factors go into deciding what type of breast reconstruction a patient might undertake following a mastectomy, including personal desires, past medical history, history of cancer, and the availability of donor sites. The patients are also getting their information from a variety of sources such as the Internet, other patients, online chat groups, or the lay media, noted Dr. Platt. “We may not always ask patients what are their preferences or what are their values. . . We might not always ask them where they are getting their information [and] is the information that they are gathering correct. [Also] how is that information being used to inform their decision?” said Dr. Platt. “However, research has shown that the best types of decisions, or the higher quality decisions, are those which patients have adequate information about all the different treatment options and they are making a decision that is congruent with their own personal values and preferences.” Information sessions held Dr. Platt and her team used the Shared Decision Making (SDM) tool that was introduced by the Institute of Medicine in 2001 as the basis for developing their pre-consultation program. SDM focuses on decision-making that is respectful of and responsive to the individual patient preferences, needs, and values. It was cited in a New England Journal of Medicine (2012;366:780–781) editorial as being “the pinnacle of patient-centered care.” In a pilot study, conducted at the University Health Network, four information sessions were held with each having five patients and another five that were randomized to receive a routine education program, the current standard of care. The group session was held from 8 A.M. until 10 A.M. and then the patients met with their surgeon individually for a half-hour surgical consultation from 10 A.M. to 12:30 P.M. The intervention, according to Dr. Platt, is divided into four components with the first being a session with the surgeon regarding the different surgical breast reconstruction options, followed by a clinical Volume 5 Number 1

nurse specialist who talks about pre- and post-operative care and the recovery period, followed by a question and answer period with both the surgeon and the nurse. Next, a social worker goes through a Values Clarification Exercise where the patients are asked to rank their own personal values and preferences regarding different components of care in each of the different types of reconstruction. Lastly, the participants have the opportunity to discuss breast reconstruction experiences with two patient volunteers who previously had breast reconstruction. “What is unique about our session, in addition to the fact that we have multiple different types of information provided by different multidisciplinary healthcare providers like the plastic surgeon and the nurse, [is that] we also have the patients undertake the Values Clarification Exercise where they have their new, accurate information and they can consider this, consolidate that to develop their own values and preferences that can then be implemented as a decision or a choice for their breast reconstruction,” said Dr. Platt. Participants were pleased with the workshop, according to Dr. Platt, and they uniformly said the presentation by the surgeon was “tremendously informative” and that they also enjoyed interacting with the experienced breast reconstruction patient. The most common critique was wanting more time for discussion. Powerful opportunity for patients to engage in process “Patients said that this was a very powerful thing for them in terms of really making a decision, and feeling very informed and engaged in the process,” said Dr. Platt. “Interestingly they said it was really good to learn that breast reconstruction might not be for everyone and that your mind might change based on what you thought coming into this session after you learn enough information to be able to develop preferences.” Using the Decisional Conflict Scale (DCS) to measure patient’s uncertainty with a medical choice, such as implant based or autologous breast reconstruction, Dr. Platt said patients who participated in the group session had a reduction in their DCS of 37 points compared to those who did not attend the workshop; they had an average reduction of 24 points. “We think that patients found our intervention to be acceptable and that our pilot [study’s] preliminary results would suggest that Decisional Conflict is lower, that patients perceive that they are more involved in their care, and lastly, that patients’ choices may change when they become well involved, well informed, and had the opportunity to consider their values and form some preferences,” said Dr. Platt. “Ultimately, we think in the context of a positive definitive trial that we would like to see implementation of these workshops into routine clinical practice.”

Group preconsultation sessions for breast reconstruction helps improve decision making


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 The Business of of Cosmetic Medicine

Legal issues to consider when delegating care to non-physicians Essential to document informed consent on potential procedural risks  by Lynn Bradshaw OF THE CHRONICLE

Clinicians must be cautious when they decide to delegate aesthetic procedures and care to non-physicians because it could result in serious legal implications in the event of a lawsuit, said Dr. Steven Bellemare. “Just because your college does not have a policy on delegation and supervision does not mean you should not take notice and be cautious, because the buck stops with you as a physician,” said Dr. Bellemare, a physician risk manager at the Canadian Medical Protective Association. “Ultimately, as a clinician you may be held responsible for what your staff do in your practice, especially, in cases where litigation arises,” he said during a presentation at the Canadian Association of Aesthetic Medicine sessions in Toronto. Difference between medical directive, delegated medical function It is important for clinicians to be aware of the difference between a medical directive and delegated Medical Act function, Dr. Bellemare emphasized. A medical directive, he explained, essentially allows a clinician to write an order to appoint another healthcare professional to conduct a procedure that falls within their scope of practice under a certain set of conditions and supervision requirements. On the other hand, a delegated medical act function consists of a physician delegating a medical function to a non-physician employee who does not have the statutory right to carry out a procedure that falls under the medical act. “Ultimately, if something goes wrong when you delegate a medical act function to a nonphysician then you could be held responsible for their actions because essentially you have asked someone to do something on your behalf,” he said. Dr. Bellemare commented on an overarch-


ing theme among a majority of Colleges of Physicians and Surgeons of various provinces regarding their view on delegating medical act functions. He indicated that the stance of most college policies regarding medical delegated functions suggest that delegation has to be done with the best interest of the patient in mind; for example, for the purpose of enhancing medical care. “Your decision to delegate could be problematic if you are delegating medical act functions to nonphysicians simply for the purpose of increasing income generation to your practice,” said Dr. Bellemare. In the event of litigation, Dr. Bellemare explained that you have to be willing and able to defend your reasoning for delegating a procedure that is considered to be a medical act function. You will be expected to clarify your reasoning for delegating to a judge or representatives of the College of Physicians and Surgeons in your particular province. “It is a good idea to be cautious in the first place and decide on how you would defend your delegation decision before you decide to delegate medical act functions.” For instance, Dr. Bellemare said, it is important to set up policies and procedures, training, certification of ability to do the delegated task, and periodic recertification as appropriate, as part of demonstrating your diligence around delegation. Dr. Bellemare explained that most college regulations prescribe that you as a clinician have to be able to demonstrate that you were supervising the delegated acts. He added that the method chosen for supervision is up to the individual clinician, with the supervision chosen based on individual circumstances and on employee experience. “You have to be able to prove that you are often diligent about supervising your staff. For example, you should be able to provide details

about how you train your staff, how you supervise them on a regular basis, and how you conduct quality control,” he said. Documentation of patient discussion encouraged As a point of caution, Dr. Bellemare recommends that clinicians document patient consent to delegation in situations where a non-physician may conduct procedures. “Patients must be informed and understand about how much you as a physician are or are not involved in procedures that happen within your practice,” he said. “Failure to provide patients with an informed consent opportunity could result in patients alleging that you fraudulently or neglectfully misrepresented what you were doing.” Dr. Bellemare says that it is important for clinicians to document that they had a discussion with their patients not only regarding potential procedural risks, but also about other people who will be involved in providing treatment—especially in cases where a nonphysician such as nurses or technicians are going to do procedures without your direct supervision. “If you have a note on file detailing that you had a conversation with a patient about the fact you delegate some procedures to physician extenders then our lawyers can work with that and it may help us convince the judge that you had the conversation with your patient and that the patient was informed and not mislead,” he said. Medical act function delegation considerations Another point to consider about delegation of medical functions is that, generally, a physician is only allowed to delegate an act in an area in which he or she is trained, said Dr. Bellemare. “So, you cannot just have someone else do a procedure for you if you do not know how to do it yourself, because you have to be able to manage complications,” he said. “[Honestly], it would be difficult to stand up in front of college representatives or a judge and indicate that you were supervising a procedure that you do not know how to do yourself.” “As a clinician, you are not expected to not have any complications, but you are expected to make reasonable educated decisions, under reasonable circumstances.” The Chronicle of Cosmetic Medicine + Surgery

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Light and shadow —continued from page 23 [along the jaw line]. The occlusion shadow becomes very important, along with the form shadow of the chin.” Doctors should avoid trying to prevent or correct natural facial structures that block the light and cast healthy shadows, he said. “Young adults have that nice occlusive jaw angle shadow, and those that are aging do not,” Dr. Remington noted.

image courtesy Dr. Remington

Avoiding over-correction does not mean avoiding filler use in shadow-casting parts of the face, it means restoring a structure through various treatments that casts the right shape of shadow in the right place. “If you do just a few little things, then you can make her [a patient] more youthful without making her look done,” said Dr. Remington. “You re-establish that occlusive shadow on the jaw angle by a little bit of filler and by shrinking her parotid with a n e u r o m o d u l a t o r. ” Example of how shadows typically fall against Similarly in the upper facial contours face, small adjustments can be made to the brow while being careful to not obscure the face’s natural form shadows, he said. As with the jaw line, physicians can get an unwanted cast

shadow along with the natural form shadow in deep naso-labial folds, said Dr. Remington. “We don’t want to eliminate [the naso-labial fold shadows]. We try to just reduce them some so that they look better.” Filling and revolumizing are not the only procedures where a lack of care can remove the face’s natural shadow and produce an unnatural looking result, said Dr. Remington. “Face lifts are even a little more difficult. In a really good face lifts where all the fat is undermined, it’s hard to find where that cheek form shadow is,” said Dr. Remington. “Then you start to say, ‘How am I going to lift this up and try to keep that form shadow?’” Proper photographic lighting to define and identify facial contours While it can be challenging to identify where the form shadow of the cheek should naturally fall, says Dr. Remington, the task can be simplified with the aid of good digital photogra-

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phy, he says. But doctors need to have the right set up to take high quality, consistent photographs. “If you don’t have a Rembrandt [lighting] set up in your photography room, then the cast shadows become your enemy,” because uneven shadows from your lighting can obscure how ambient light naturally falls on the patient’s face, said Dr. Remington. With a uniform lighting setup “you can have reproducible results to look at and it helps us all understand what to do.” Once Dr. Remington has properly taken photos with all the poses and degrees of animation, “I often convert my photos into black and white images because [it] often shows shadows better,” he said. As well, importing the images into image editing software and using some of the software’s built-in filters can make shadows and highlights more prominent and easier to study, he added. Having your patients provide you with a photograph of themselves in their prime will also help you understand where highlights and shadows naturally fall on their face, Dr. Remington said.

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More natural-looking outcomes â&#x20AC;&#x201D;continued from page 4

Canadian Laser and Aesthetic Specialists Society 2015 ANNUAL SYMPOSIUM

Invited Guest Speakers Dr. Doris Hexsel: Cellulite Update Full Face Injections of botulinum toxins Dr. Mark Dupere: Surgical and Non-Surgical Approach to the Male Face Dr. T. Zmijowskyj: CMPA - Risk Mitigation Strategies in the Digital Age

plastic surgeon based in Pointe-Claire, Que., highlight advances in soft tissue fillers with optimized rheologic profiles that allow for the most natural-looking results possible, as well as describing new products pre-formulated with lidocaine. Dr. William McGillivray, medical director at Project Skin MD in Vancouver, and Torontoâ&#x20AC;&#x2122;s Dr. Fred Weksberg, owner and director of the Weksberg Centre for Cosmetic Dermatology, discuss new treatments under development that may stimulate collagen production in a natural-looking way, including radiofrequency microneedling. Of particular interest is new insight from veteran Calgary-based cosmetic surgeon Dr. Kent Remington into how the interplay of light and shadow convey youthfulness and age in a face, and how understanding them can help clinicians produce very natural-looking outcomes. Each of these articles boils down to the conclusion that a common sense approach, a deft grasp of facial anatomy, and a careful combination and selection of treatments will allow us to provide the most natural-looking outcomes for our patients. Please enjoy the excellent features in this issue of THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. I look forward to many multidisciplinary collaborations and a focus on natural-looking outcomes for our patients. Dr. Humphrey is director of CME and clinical assistant professor, Department of Dermatology & Skin Science, University of British Columbia, Vancouver

Saturday, November 7, 2015 Toronto, Ontario



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The Chronicle of Cosmetic Medicine + Surgery

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Pearls Suturing wounds with tension

Normally with suturing a square knot is used. Two throws on the needle driver in one direction, one throw the opposite and the final throw the same way as the initial direction. In wounds with tension, instead of doing a second throw the opposite direction of the first, add one more throw in the same direction so the suture will stay in place and not loosen. You can then proceed with the second and third throw as would normally be done to complete the square knot. —Dr. Shane Silver, Winnipeg-based dermatologist

Hyaluronic acid filler for earring wearers

Women who are fond of big earrings know that if you have an earring that is too heavy, you can get a disk that you put on the back that supports the weight of the earring. In a similar way, you can use hyaluronic acid filler to act as an internal disk. It is very easy to do. You can also use [filler] for the creases in the ear, too. You lose volume there just like anywhere else. —Dr. Julia Carroll, dermatologist at Toronto’s Compass Dermatology

Light and shadow assessment for soft tissue augmentation

When assessing the face of patient for soft tissue augmentation, it is a good idea to look for light and shadow. For example, if you look at someone youthful, you will see that they have very little shadow on their face. As we age, however, the skin starts to become more wrinkled, we start to lose volume, and then all of a sudden you start to see areas of highlights and lowlights, as well as shadows and good reflection. So by looking at those shadows in particular and correcting those particular areas you can make a huge difference with small amounts of product, and make someone look the best that they can be while still looking like themselves. —Dr. Vince Bertucci, Woodbridge, Ont. dermatologist and president of the Canadian Dermatology Association

Vascular lesions at birth

Vascular lesions present right at birth are rarely simple hemangiomas. Most hemangiomas. . . show a little telangietic erythema, and over the ensuing several weeks they will start to blossom. But those that are present right at birth should make you think of things other than your gardenvariety infantile hemangioma. —Dr. Albert C. Yan, chief of the Section of Pediatric Dermatology at the Children's Hospital of Philadelphi.

Have you (or your colleagues) determined a Best Practice in aesthetic medicine that might deserve wider attention among your peers? Or have you picked up a takeaway message from a conference that you’d like to disseminate further? By all means, here’s the opportunity to share your knowledge and expertise. Forward your pearl to Volume 5 Number 1


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Atelier Beauty of the idealized human form, depicted through artistic expression through the ages

ALLEGORY OF PAINTING oil on canvas by Charles-Alphonse Dufresnoy (1611-1668) Courtesy Dijon (France) Fine Arts Museum


The Chronicle of Cosmetic Medicine + Surgery

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The Chronicle of Cosmetic Medicine + Surgery June 2015  

June 2015; 5(1) Features Cosmetic Medicine 2015 Clinical Forecast, microneedling for skin rejuvenation, documenting informed consent on risk...

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