PRIME Nov/Dec 2023 by IM-Aesthetics

ICAD 2023

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Allurion Profile

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Lasers And Lights To Treat Scars

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Industry News And Events

November/December 2023 ❙ Volume 13 ❙ Issue 6

Nov/Dec 2023 Volume 13 Issue 6

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INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE

A NUTRACEUTICAL APPROACH TO

skin vitality TREATING TRAUMATIC SCARS

THE UKRAINIAN EXPERIENCE

THE HALLMARKS OF AGEING

AND HOW TO ADDRESS THEM

prime-journal.com

A MESOTHERAPY SOLUTION

TO TREAT PIGMENT AND MELASMA

THE CHINESE AESTHETIC MARKET

FULL OF PROMISE

EXPERTISE EVIDENCE

EXCELLENCE ENGAGEMENT

27-28-29 MARCH 2024 MONTE-CARLO, MONACO GRIMALDI FORUM

Under the High Patronage of H.S.H. Prince Albert II of Monaco

Under the scientiﬁc supervision of the Aesthetic Multispecialty Society (AMS)

WWW.AMWC-CONFERENCE.COM

| EDITORIAL

FEEL TRULY PRIVILEGED TO BE ATTENDING THE 17TH EDITION OF ICAD Bangkok, Asia’s most established aesthetic dermatology congress, from November 23–25. Designed in collaboration with the Dermatological Society of Thailand (DST), this prestigious event will gather leading aesthetics and anti-ageing professionals from Asia and across the globe to discuss the latest products, technologies, services and procedural trends. To mark the occasion, we have a special preview on page 12 featuring interviews with members of ICAD’s scientific committee on the reasons for the event’s continued success and what makes the Thai aesthetic market so unique. Also in this issue, Dr Andre Berger explores the power of nutraceuticals as a formidable weapon in the battle against ageing skin. In an age where wellness and aesthetic medicine increasingly intertwine, understanding the role of nutraceuticals is vital in achieving youthful, glowing skin. Dr Berger delves into the science behind these compounds and their place in the physician’s toolkit. You can read the full article on page 40. Next, we have Dr Michael Sagner taking a look at the hallmarks of ageing. Beyond treating the external signs of ageing, Dr Sagner emphasises the importance of tackling the underlying causes of ageing. While life expectancy continues to increase globally, health at older ages is declining, and lifestyle-related diseases have become the leading cause of premature death and disability around the world. Despite advances in scientific understanding of the biological processes of ageing, effective interventions to address the hallmarks of ageing still revolve largely around lifestyle changes. New bio-pharmaceutical interventions promise to prevent ageing-related diseases and improve healthspan. This article uncovers the secrets to ensuring not only youthful looks but also a healthier, more fulfilling lifespan for patients. On page 54, Doctors Vladlena Averina and Olena Grisha provide a moving account of how aesthetic dermatology is being employed to rehabilitate individuals with post-war injuries in Ukraine. Their experiences underscore the powerful role that medical aesthetics plays in healing and restoring lives. AMWC China 2023 took place on October 20–22 and further cemented China as a market with huge potential. Aesthetic medicine in China is on the precipice of remarkable growth, and our writer, Rosalind Hill, speaks to three leading doctors about its evolution and the challenges that lie ahead. Read the full article on 22.

Understanding the role of nutraceuticals is vital in achieving youthful, glowing skin. Affiliated partners:

Balraj Juttla Editor, PRIME balraj.juttla@informa.com

Delicious

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Cover image Stock.Adobe.com Retouching Linda Duong

All Eyes On Dubai ICAD 2023 Lasers And Lights To Treat Scars Industry News And Events

Nov/Dec 2023 Volume 13 Issue 6

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International Journal of Aesthetic and Anti-Ageing Medicine Facebook MySpace A NUTRACEUTICAL Informa Australia, Level 4/24 York St, APPROACH TO Sydney, NSW, 2000, Australia skin vitality ISSN 2159-8908 (print) ISSN 2159-8916 (online) INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE

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Join PRIME’s editorial team for the latest updates in aesthetic and anti-ageing Editor Balraj Juttla balraj.juttla@informa.com Delicious medicine, Flickr debates, and Art Director David ‘Spike’ McCormack Slash Dot Mixx Skype interaction with your peers Digital Marketing Manager Slim Hakimi slim.hakimi@informa.com and colleagues, conference Production & Ads Department balraj.juttla@informa.com information and special Please send your manuscripts and press releases to: balraj.juttla@informa.com Facebook offers MySpace All submitted manuscripts are evaluated on the basis of scientific quality, originality, appropriateness, Follow contribution to the field and style. Suitable manuscripts Reddit are subject to peer-review. Manuscripts and us FriendFeed YouTube accompanying files should be prepared in accordance with our Author Guidelines, which are available @PrimeJournal via www.prime-journal.com. TREATING TRAUMATIC SCARS

THE UKRAINIAN EXPERIENCE

THE HALLMARKS OF AGEING

AND HOW TO ADDRESS THEM

A MESOTHERAPY SOLUTION

TO TREAT PIGMENT AND MELASMA

THE CHINESE AESTHETIC MARKET

FULL OF PROMISE

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B R E A KTH RO U G H I N T I S S U E [ R E ] G EN E R AT I O N F OR FAC E & B O DY

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CLEARED* PATENTED TECHNOLOGY ADVANCED TEMPERATURE CONTROL

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*In the United States is indicated for treatments based on the emission of electromagnetic waves that lead to a rise of internal temperature of tissues involved in the treatment for electrocoagulation and hemostasis. It can be used on adult patients only.

F O R

M E D I C A L

U S E

O N L Y

November/December 2023

| CONTENTS

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p38 p28

Merz Aesthetics receives FDA approval for new filler under-eye indication Research highlights the potential immune system impact of fillers

A combination of laser and light to treat scars Diala Haykal, MD, describes how she combines a non-ablative fractional 1550 nm laser with Selective Waveband Technology (SWT®) intense pulsed light from the Nordlys™ multi-application platform to treat scars

EVENT PREVIEW

AESTHETIC FEATURES

NEWS

9 10

ICAD 2023: a captivating journey through aesthetics

INDUSTRY INSIDER

18 22

A closer look inside Allurion’s mission to end obesity Wendy Lewis delves into how the company plans to use the Allurion Program, Virtual Care Suite, and artificial intelligence to succeed CUTERA® celebrates legacy milestone 25 years of excellence and clinical innovation in global medical aesthetics Full of eastern promise: aesthetic medicine in China It is an exciting time for the Chinese aesthetic medicine market. Poised for significant growth this decade, Rosalind Hill spoke to three leading doctors about its evolution and the challenges that remain All eyes on Dubai Another boom in aesthetics in the region sees an upturn in clinic openings and visiting clinicians from all over the world. Mona Mirza, CEO and Founder of Dubai-based aesthetic clinic Biolite, takes a closer look What aesthetic doctors are excited about right now Wendy Lewis interviews 6 top doctors to find out CASE REPORT

Luminescens® treating pigmentation and melasma with a professional mesotherapy solution Jo Coletta describes the results she experienced using a new depigmentation and brightening programme

A nutraceutical approach to skin vitality Andre Berger, MD, reviews the place of nutraceuticals in the physician’s armoury to tackle signs of skin ageing The hallmarks of ageing and how to address them in anti-ageing clinical practice Michael Sagner, MD, highlights the need to go beyond treating the external signs of ageing and address the underlying hallmarks of ageing to better ensure a healthy lifespan for patients Treatment of traumatic scars: The Ukrainian experience Vladlena Averina, MD, and Olena Grisha, MD, explain how aesthetic dermatology is helping in the rehabilitation of post-war injuries PRIME PROMOTIONS

58 Secret 1540 nm erbium glass laser treatment for hair regrowth in androgenetic alopecia 60 Proposal of solutions for mild inflammatory skin and recovery of skin damage after laser treatment 64 ATTIVA® S.I.H. Technology: a thriving Italian journey including FDA certification achievement and United States market entry EVENTS

round-up of the major industry events happening A around the world over the next 12 months

prime-journal.com | November/December 2023

NEWS |

news

A round-up of news stories in the aesthetic and anti-ageing medicine industry

MERZ AESTHETICS RECEIVES FDA APPROVAL FOR NEW FILLER UNDER-EYE INDICATION LATEST APPROVAL EXPANDS BELOTERO BALANCE® (+) FILLER TREATMENT AREAS

erz Aesthetics, the world’s largest dedicated medical aesthetics business, announced the US Food and Drug Administration (FDA) have approved Belotero Balance® (+) for volume augmentation for the improvement of the infraorbital hollow (IOH) in adults over the age of 21, further expanding the usage and capability of Belotero Balance® (+), and addressing consumer under-eye concerns. ‘We’re so excited to be able to offer this new Belotero Balance® (+) indication to healthcare professionals and consumers and are thrilled with the promising results that we’ve seen to date through our studies,’ said Patrick Urban, President, North America, Merz Aesthetics. ‘At Merz Aesthetics, we hold ourselves to the standard of always continuing to innovate and offer the best possible treatments for our customers to bring to their patients. This innovation is an impressive addition to our dermal filler portfolio here in the US, and one we’re very proud of.’ This approval stems from positive pivotal study results demonstrating the efficacy and

safety of Belotero Balance® (+) for the treatment of infraorbital hollows in June of 2023. This pivotal study enrolled 150 adults with moderate to severe infraorbital hollows. Subjects were randomised to a Belotero Balance (+) treatment group or a delayed treatment/control group. At Week 8 (the primary endpoint), the estimated average responder rate for the treatment group was 80.6%, while the estimated average responder rate in the control/delayed-treatment group

was 1.9%. The difference between the estimated response rates was 78.7%, showing superiority of Belotero Balance (+) treatment over control. Response was defined as ≥ 1-point improvement in both infraorbital hollows compared to baseline at Week 8 on the Merz Infraorbital Hollow Assessment Scale (MIHAS)— a 5-grade, scientifically validated scale. Additionally, at Week 8, 98.9% of subjects in the treatment group showed improvement on the Global Aesthetics Improvement Scale as determined by the treating investigator. ‘This latest indication for Belotero Balance® (+) is an exciting step in our US brand portfolio, allowing us to provide our HCP partners with a way to help their patients correct under-eye volume loss,’ said Dr. Samantha Kerr, Chief Scientific Officer, Merz Aesthetics. Overall, Belotero Balance (+) was well tolerated in the study, and the safety profile was consistent with previously reported studies, with the most common treatmentrelated adverse event being injection-site swelling (6.3% of subjects).

CROWN LABORATORIES LAUNCH PANOXYL® ACNE CARE PARTNERSHIP Crown Laboratories announced its newest PanOxyl® retail partnership with Ulta Beauty, the nation’s largest beauty retailer. The assortment will include 8 existing SKUs within its award-winning acne care portfolio. This launch will offer Ulta Beauty guests a new way to discover the PanOxyl brand and drive additional brand awareness through the retailer’s 1,350+ store locations across the US and online.

The PanOxyl assortment will include the brand’s two hero SKUs: Acne Foaming Wash 10% Benzoyl Peroxide (BPO) and Acne Creamy Wash 4% BPO. Additionally, customers will be able to purchase the new Acne Treatment Bar 10% BPO, Clarifying Exfoliant 2% Salicylic Acid, Adapalene Gel USP 0.1%, Oil Control Moisturizer SPF 30, and Balancing Repair Moisturizer. The PanOxyl assortment at Ulta Beauty will

November/December 2023 | prime-journal.com

maintain the brand’s accessibility, priced between $8 and $14 per unit, while boasting efficacious results. ‘Over the last few years, we’ve seen a growing market desire for a convenient way to engage with PanOxyl — a demand we can attribute to viral celebrity mentions and influencer testimonials on social media, that speak to the efficacy of the portfolio,’ says Steve Gallopo,

General Manager and Executive Vice President of Therapeutics at Crown Laboratories. ‘Expanding access to our products is always rewarding and we’re excited to finally provide our consumers access to PanOxyl at what is essentially the Millennial and Gen-Z beauty lovers’ playground.’ PanOxyl is committed to empowering Ulta Beauty guests through experience-based education.

IT’S THE ONE

SWT : The only way to IPL ®

Selective Waveband Technology (SWT®) delivers precise narrowband IPL.¹︐² With 50% less fluence required than broadband IPL, this improves comfort, keeps downtime low, and enables use of multiple technologies in a single session – all without compromising patients' safety and comfort, as well as results.¹︐²︐³︐⁴ The Nordlys system is a multi-application platform with in-demand treatments across 24 indications, including pigmentation, vascularity, skin resurfacing, scars and hair removal.¹

Four timeless technologies: SWT® IPL, high-ROI Frax 1550™ and Frax 1940™, and Nd:YAG 1064 nm¹ Grows with your practice – add handpieces to extend treatment options¹ Compact and quiet, with software modes ranging from guided to expert¹ Treats a wide range of skin tones¹

For more information, contact your local Candela sales professional or visit candelamedical.com. 1. Nordlys User Manual, 2021. 2. Candela, data on file, 2022. 3. Bjerring P, et al. Lasers Surg Med. 2004;34(2):120126. 4. Schallen KP, Murphy M. Treatment of photodamaged skin with a combined dual-filter intense pulsed light and fractional 1550-nm laser system. Lasers Surg Med Suppl. 2020;52(S32). 5. Nordlys and Frax Pro with Frax 1940 , CE mark. 6. The Aesthetic Society. Aesthetic Plastic Surgery National Databank Statistics 2019. Available from https://www.surgery.org/sites/default/files/Aesthetic-Society_Stats2019Book_FINAL.pdf. Accessed Jan 25, 2022. © 2023 Candela Corporation. This material contains registered and unregistered trademarks, trade names, service marks and brand names of Candela Corporation and its affiliates. All other trademarks are the property of their respective owners. All rights reserved. PU02255EN, Rev. A

candelamedical.com

NEWS |

RESEARCH HIGHLIGHTS POTENTIAL NEW PSORIASIS IMMUNE SYSTEM IMPACT OF FILLERS DRUG AWARDED EXPERTS CAUTION THAT FILLERS MAY CAUSE AN IMMUNE REACTION

yaluronic acid — the key has more medical ramifications is unknown at this compound in most fillers — has stage. However, this does highlight the importance been found to block lymphatic of using a medically trained clinician for injectable channels, which help the body fillers.’ drain fluid and are a key part of Earlier this year, a study of BAAPS Facelift the immune system that helps to fight disease. surgeons showed a trend in women enquiring Research is now being planned to see if the and having facelifts at a younger age, which treatment affects the risk of diseases including could be linked to the rise in concerns about cancer. Fillers have also been linked to cysts, using fillers. lumps, swelling and facial pain. A US research team unveiled the findings The study found during the Annual Scientific conference of the 70% of surgeons had observed a trend of British Association of Aesthetic Plastic Surgeons younger patients under 50 enquiring about in London which brings together the best facelifts. surgeons from around the world to speak about 65% of surgeons observed that patients advancements in facial surgery and body interested in facelifts are more circumspect about contouring. using facial fillers. Dr Spero Theodorou, one of the conference 80% of surgeons noticed an increase in speakers and director of the leading intra-operative anatomical distortion due to the bodySCULPT plastic surgery practice in New use of fillers in facelift patients. York, spoke out about the study that will be Commenting on the findings of the study, published later this year in the international President Marc Pacifico said ‘Our surgeons have plastic surgery literature. seen filler lasting longer than ‘Under-eye filler is one of Many have noted that expected, well over a year in the biggest problems. You many cases. Many have noted anatomical structures are that anatomical structures are see women everywhere with swollen eyes. It’s taken certainly more tethered and certainly more tethered and us 20 years but we’ve scarred when fillers have scarred when fillers have proved it, I don’t gain been used and previously been used and previously anything from doing this. I have seen an increase in have seen an increase in intraoperative and will be a pariah. You have young women having intraoperative and preoperative anatomical fillers in their faces. It’s preoperative anatomical distortion due to the overuse never going to go away. It’s of fillers.’ distortion due to the Currently, the UK does not very hard to remove and it overuse of fillers. blocks lymphatics in your tightly regulate who can inject face. This is a very fillers and what they can use, important system. Not all with government officials now patients will have swelling, but developing strategies to evidence suggests all will have regulate the industry. some degree of lymphatic ‘This research will blockage.’ Said Dr help us recognise Theodorou. some of the previously Don’t panic unappreciated BAAPS president Marc biological Pacifico said: ‘People don’t impacts of these need to panic and have products. Even if fillers dissolved as an it’s only a small emergency. This is percentage who preliminary research but it are affected, the gives us a scientific numbers will be explanation for side-effects we quite high,’ said are seeing with fillers. Whether it Pacifico.

November/December 2023 | prime-journal.com

FDA APPROVAL

UCB, a global biopharmaceutical company, announced that the US Food and Drug Administration (FDA) has approved BIMZELX® (bimekizumabbkzx) for the treatment of moderate-tosevere plaque psoriasis in adults who are candidates for systemic therapy or phototherapy. BIMZELX is the first and only approved psoriasis treatment designed to selectively inhibit two key cytokines driving inflammatory processes — interleukin 17A (IL-17A) and interleukin 17F (IL-17F). The approval of BIMZELX is supported by data from three Phase 3, multicentre, randomised, placebo and/or active comparatorcontrolled trials, which evaluated the efficacy and safety of BIMZELX in 1,480 adults with moderate-to-severe plaque psoriasis. ‘Today’s FDA approval for BIMZELX is an exciting milestone that reflects our commitment to continuously improving the standard of care in plaque psoriasis and to raising expectations of what treatment can deliver. We know that completely clear skin is valued by people with psoriasis and, in our Phase 3 trials, at week 16, 85-91% of patients treated with BIMZELX achieved clear or almost clear skin, with 59-68% achieving the goal of complete clearance,’ said Emmanuel Caeymaex, Executive Vice President, Immunology Solutions and Head of US, UCB. ‘With BIMZELX now approved for psoriasis, we will move forward rapidly to submit applications for additional indications in the US.’ The FDA recommended dosage of BIMZELX for psoriasis patients is 320 mg (given as two subcutaneous injections of 160 mg each) at Weeks 0, 4, 8, 12, and 16, then every 8 weeks thereafter. For patients weighing ≥120 kg, a dose of 320 mg every 4 weeks after week 16 may be considered. BIMZELX may be administered by a healthcare professional, or a patient may self-inject after proper training. BIMZELX is available as an autoinjector and a pre-filled syringe. BIMZELX will be available in the U.S. in approximately one month.

MEETING PREVIEW |

ICAD 2023 A CAPTIVATING

JOURNEY THROUGH AESTHETICS As one of the fastest-growing aesthetic markets in the world, Thailand is perhaps the perfect home for the International Congress of Aesthetic Dermatology. PRIME speaks to some of its scientific committee members to learn more

OR ALMOST TWO decades, Bangkok has been host to the annual International Congress of Aesthetic Dermatology (ICAD) — an event which hosts a global faculty of industry leaders and experts in partnership with the Dermatological Society of Thailand (DST). As the largest international event in the region, it has firmly placed the

Thai aesthetic industry on the map and showcased the expertise of the professionals on the Indochinese peninsula. ‘ICAD has put Thailand on the map for leadership in aesthetics,’ said Dr Rataporn Ungpakorn, a Bangkok-based dermatologist and the International Affairs executive member for the DST. ‘I can say on behalf of neighbouring Asian dermatologists that DST and ICAD make

November/December 2023 | prime-journal.com

it more accessible, convenient and costeffective to spend a weekend away from busy practices.’ ‘ICAD is the biggest aesthetic conference in Thailand and has had a number of benefits for the region and a positive impact on the practice of aesthetic dermatology,’ agreed Dr Rungsima Wanitphakeedecha, a board-certified dermatologist based in Bangkok. ‘ICAD provides a platform for

| MEETING PREVIEW local and international experts in aesthetic dermatology to share their knowledge, insights, and research findings. We offer a range of educational sessions, workshops, and hands-on training opportunities. This can enhance the skills and expertise of practitioners, leading to improved patient care and outcomes.’

A transformative learning experience Indeed, through its partnership with IMAesthetics, organiser of AMWC Monaco, the DST and ICAD’s scientific directors have been able to attract a large pool of speakers to design a cutting-edge programme, in addition to the panel provided by the national dermatological societies in Asia. This year’s event, taking place across 23–25 November 2023, will be no different, as the scientific faculty look to take attendees on a journey through aesthetics, encompassing a precongress laser exploration and unleashing injectable techniques, before embarking on a transformative learning experience that will equip the audience with the knowledge, skills and confidence to provide exceptional facial treatments across all age groups. ‘New techniques, new materials, and continuous state-of-the-art education are what characterise ICAD,’ said Dr Dario Bertossi, a facial plastic surgeon from Italy, who also serves as ICAD’s International Scientific Director. ‘Attending ICAD has benefitted my practice in many ways; it has evolved my approach to patients through connecting with new generations of experts with the chance to exchange and learn more about skin quality treatments from Asian countries where this approach is much more developed than in European countries.’

The Thai aesthetic market The aesthetic market in Thailand has undergone a significant transformation in recent years — much like its Indian and Chinese counterparts. Buoyed by a young population with money to spend on looking and feeling good, it is anticipated that the market’s CAGR will grow 9.7% in the years to 2030, primarily driven by the increasing disposable income of the population, the growing awareness of aesthetic enhancement options, and advancements in medical technology. The advances in aesthetic treatments, in

particular, have led to a rising demand for minimally invasive and non-invasive procedures. While 10 years ago, patients would opt for more ‘obvious’ treatments, now the approach — much like those in the West and elsewhere in the SouthAsian region — is more subtle, skilful and no less impactful. ‘The Thai aesthetic and anti-ageing market has evolved significantly over the years, driven by various factors including changing consumer preferences, advancements in technology, economic growth, and globalisation,’ said Dr Wanitphakeedecha. ‘Patient preferences and treatment trends can vary, but there are common themes that align with the desire for non-invasive procedures and quick recovery. These trends often reflect a broader shift in the aesthetic industry towards more convenient and less disruptive treatment. In general, botulinum toxin and filler injection, laser

‘Patient preferences and treatment trends can vary, but there are common themes that align with the desire for non-invasive procedures and quick recovery. These trends often reflect a broader shift in the aesthetic industry towards more convenient and less disruptive treatment. treatment, and thread lifting are still the main treatments I offer in my practice. But in the last few years, there has also been a greater focus on skin quality, so using skin boosters to improve skin quality and give that all-important glow.’ ‘The Thai aesthetic market has grown exponentially, and particularly where skin quality treatments are concerned — you could say it’s a market leader,’ agreed Dr Bertossi. ‘The combined approach shows better results in the field of medical aesthetics to improve the ageing process.’ Unsurprisingly, social media has had a significant impact on the growth of medical aesthetics in Thailand. Platforms such as Instagram and TikTok are being used to promote aesthetic treatments and to share before-and-after photos and videos. Social media is also being used to educate people about the different types of aesthetic treatments available and to dispel myths and misconceptions.

A place for growth and development The location and beauty of Thailand itself also make the country a prime destination for medical tourism— not only are treatments affordable, but they are high quality and well-regulated, too. The Thai FDA also ensures that the treatment options provided are rigorously tested and proven to be safe and effective. But this by no means restricts the growth of the market and, in many ways, provides greater opportunities for the doctors practising within. ‘Doctors in the Thai aesthetic market, including dermatologists, plastic surgeons, and other medical professionals, have various opportunities for career growth and development,’ said Dr Wanitphakeedecha. ‘The market is dynamic and continues to evolve, offering several avenues for doctors to excel. Even though there are a wide range of opportunities for doctors, success often depends on staying informed and educated about industry trends, providing excellent patient care, and continually seeking ways to improve and grow within the field. The ability to adapt to changing patient preferences and technological advancements will be key to success in the aesthetic market.’ Dr Ungpakorn agrees that ICAD is perfectly placed to support the growth in expertise and professionalism of aesthetic practitioners the world over. ‘Thailand is renowned as a tourism haven with great food, smiling people and world-class medical services,’ he said. ‘An explosion of aesthetic demands are being seen in Asia, as well as in Thailand. As a matter of fact, to be able to organise ICAD for over a decade proves that Thailand has a strong foundation for aesthetic practice and the right location for medical conventions such as this.’ Additionally, with Informa’s acquisition of the American Academy of Anti-Ageing Medicine (A4M) conference, Dr Ungpakorn reveals that ICAD will embrace anti-ageing sessions into future scientific programmes to reach its potential to become an even more significant event.

prime-journal.com | November/December 2023

COMPANY PROFILE | ALLURION |

A CLOSER LOOK INSIDE ALLURION’S MISSION TO

END OBESITY

Wendy Lewis delves into how the company plans to use the Allurion Program, Virtual Care Suite, and artificial intelligence to succeed

2023 trend: weight loss is the fastest growing category in medical aesthetics.

HE UNITED STATES AND OTHER REGIONS OF THE WORLD ARE IN the throes of an obesity epidemic. Close to two billion adults are currently overweight, and 650 million of them are considered obese, according to the World Health Organization1. Losing weight and keeping it off are not easy feats. Bariatric or metabolic surgery, including gastric sleeve surgery and Roux-en-Y gastric bypass, can help people shed significant amounts of excess weight, but just 1% of the eligible population opts to undergo surgical treatment for obesity largely due to associated risks and downtime. Injectable weight loss medications, including glucagon-like peptide-1 receptor agonists (GLP-1s) such as semaglutide and tirzepatide, are also highly effective options, but not everyone is on board with their potential side effects. Minimally invasive fat-melting or freezing devices also have limited efficacy for people who are significantly overweight or obese. This is why there is so much excitement and enthusiasm about the Allurion Program, a weight-loss platform that combines the Allurion Gastric Balloon, the world’s first and only swallowable, procedureless gastric balloon for weight loss, with the Allurion Virtual Care Suite. The Suite includes the Allurion Mobile App for consumers, Allurion Insights for healthcare providers featuring the Iris artificial intelligence (AI) coaching Platform, and the Allurion Connected Scale and Health Tracker devices. The balloon, which suppresses appetite for around four months, plus the additional support Allurion provides, sets users up for weight loss success. The Allurion Gastric Balloon is an investigative device in the United States, but it is approved in Europe, Brazil, Mexico, Canada, Australia, and India

November/December 2023 | prime-journal.com

WENDY LEWIS is Founder/ President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy since 1997, author of 13 books, and frequent presenter on the international stage. Her first textbook, Aesthetic Clinic Marketing in the Digital Age (CRC Press) will debut a second edition in 2023. email: wl@wendylewisco.com

Figure 1 Allurion Virtual Care Suite. The Suite includes the Allurion Mobile App for consumers, Allurion Insights for healthcare providers featuring the Iris artificial intelligence (AI) coaching Platform, and the Allurion Connected Scale and Health Tracker devices

| ALLURION | COMPANY PROFILE to date. The Allurion team takes great pride in bringing the brand to join the New York Stock Exchange in the Summer of 2023. So far, more than 130,000 people in 80-plus countries have lost over 2.8 million lbs. The company’s unparalleled growth has been further fueled by a paradigm shift in where these procedures are safely performed, the increased awareness of medical weight loss due to GLP-1s, and the addition of an AI component to further drive evidence-based patient results.

Allurion vs other weight loss balloons Weight loss balloons are big business. The intragastric or weight loss balloon market size was valued at $18.36 Billion in 2022 and is projected to reach $42.58 Billion by 2030, growing at a Compound Annual Growth Rate of 11.16% from 2023 to 2030, according to a report from Verified Market Research2. However, not all weight loss balloons are created equal. Some other weight loss balloons don’t always provide consistent results, says Chardon. With Allurion, patients lose 10–20% of their body weight in just 16 weeks — consistently. Unlike other balloons, the Allurion gastric balloon is folded into a small capsule that is connected to a thin catheter and once swallowed, it is then inflated with 550 mL of liquid through the catheter to create a feeling of fullness and help control hunger. The balloon is indicated for people with a body mass index greater than 27. It takes 15 minutes to place the gastric balloon, and there is no surgery, no endoscopy and no anesthesia required for placement or removal. Allurion patients swallow a capsule containing the deflated balloon with a catheter. Once the balloon is confirmed to be in the stomach via x-ray, it is filled with a sterile saline solution through the catheter. A second x-ray takes place to ensure the Allurion Balloon is filled correctly. Potential side effects include a couple of days of nausea, but that’s it. Thus, this model offers some significant So far, more advantages over other than 130,000 balloon systems because the procedure is easier to patients in 80incorporate into aesthetic plus countries practices. have lost over 2.8 Patients are reported to lose an average of 15% of million lbs. their weight after four months, which is comparable to what may be achieved after one year on semaglutide. After approximately 16 weeks, the balloon deflates and passes naturally, and the company’s studies show that 96% of weight loss from the Allurion Balloon can be sustained at 12 months. The overarching goal is to establish long-term behavioral changes and keep weight off or continue to lose weight if necessary. If patients still want to lose more weight, a second balloon can be placed after completing the first program. Jen Pain is an Allurion patient and senior director of upstream Marketing at Allurion. She had her balloon placed in February 2023. ‘Throughout the four months

SHANTANU GAUR, Chief Executive Officer, Allurion

BENOIT CHARDON, Chief Commercial Officer, Allurion

residency of the balloon, I lost 18% of my body weight and since then have not only maintained that weight loss but using the principles from the Allurion Program have lost an additional 2% of body weight,’ she says. The non-invasive nature of Allurion, in comparison to other balloons, was definitely an important factor for me. ‘I would never have considered anything that required anesthesia, so either another balloon that requires endoscopy and anesthesia or an even more invasive bariatric surgery seemed too severe for me,’ she says. ‘I also was very clear on the potential side effects for Allurion, and from the science, knew that this was significantly less compared with other balloons.’

Figure 2 Female patient (A) before (102 kg) and (B) 16 weeks after balloon placement (83 kg)

prime-journal.com | November/December 2023

COMPANY PROFILE | ALLURION |

The Botox® of weight loss Leading medical aesthetic networks have adopted the Allurion Program for more than 3 years now with a solid track record of success.

In the beginning, Allurion balloons were largely placed by bariatric surgeons, but now, aesthetic centers are increasingly embracing the technology and offering it to their patients. ‘Allurion is poised to become the “Botox” of weight loss,’ says Benoit Chardon, Allurion’s Chief Commercial Officer. After transforming the cosmetics company FILORGA into a global skincare success story, developing Restylane’s global footprint, and getting Coolsculpting to a $2.5 Billion acquisition by Allergan, Benoit decided to join Allurion to make it its next success story. ‘Aesthetic clinics want to get away from the typical clinic model and get into wellness

November/December 2023 | prime-journal.com

and less superficial treatments, and Allurion offers a new safe solution,’ he says. Many aesthetic clinics are seeing the value of adding Allurion as they see weight loss drugs as outside of their comfort zone. According to Chardon, 90% of Allurion patients are first-time aesthetic patients, and 78% of patients have tried everything to lose weight. ‘The quest for a healthy weight is a priority, and weight loss is the entry point to a new holistic approach to the body, which those involved in aesthetic medicine must now offer. This holistic approach includes weight loss, body contouring, toning, and firming,’ Chardon says. Allurion is set to power the fastest-growing category in aesthetics: body contouring, he says. ‘The Allurion Program has the potential to revolutionize the way we treat weight loss,’ says Nantapat Supapannachart, MD, from Apex Medical Center in Bangkok, Thailand. ‘Its minimally invasive nature, effectiveness, and patient-friendly approach have the potential to reach a broader audience and make a significant impact on the global obesity epidemic.’ Tracy Cohen Sayag is the President of Groupe Clinique des Champs-Élysées, aesthetic medicine and medical wellness in France. ‘Patients are increasingly demanding the solutions we offer in this field, and the Allurion Program is one of our most emblematic treatments.’ Shawn Seit, MD, the Founder and Medical Director of Rejuuv Medi Spa, a medical spa with three locations in Toronto, Ontario, Canada Toronto, is also on board with this program. ‘I chose to introduce The Allurion Program to my clinics because of its potential to deliver truly remarkable results to my patients.’ Calling the Allurion Program ‘a ground-breaking weight

| ALLURION | COMPANY PROFILE loss and weight management treatment,’ Dr. Seit says that it provides a less invasive alternative to traditional surgical procedures. ‘It can be highly effective in achieving weight loss and improving overall health.’ Dr Cristian Gomez Pareja of Clínica Novum in Colombia successfully implemented the Allurion Program’s swallowable gastric balloon treatment. ‘This treatment, which is minimally invasive and highly effective, has transformed lives by offering real results in the fight against overweight and obesity,’ Pareja says. ‘Our approach is based on solid scientific support and protocols guided directly by the manufacturer, thus ensuring the quality and effectiveness of the treatment we provide.’ And so far, so good. ‘The effective results obtained through this treatment have not only benefited our patients but have also catapulted Clínica Novum as a leader in the American continent and, in some parts of the world, as a reference in the treatment of overweight and obese people.’ Patients are also offered treatment for any unwanted cosmetic effects that can arise with rapid and massive weight loss, says Dr Gomez Pareja. ‘This is our exclusive non-surgical body rehabilitation therapy.’ A key ingredient to Allurion’s success is how much they invest in the training of doctors and their staff. Chardon explains. ‘With its 300 employees around the world, Allurion invests 5% (versus a market standard of 2%) of its income for the professional training of doctors and their teams to achieve a quality and homogeneous experience between our clinics, placing the satisfaction of our patients at the heart of our strategy,’ he says.

AI in action to enhance patient care Artificial intelligence is changing how we do just about everything today — and losing weight and keeping it off is no exception. ‘Artificial intelligence will shape the next decades of healthcare, and Allurion is doing pioneering work in this field,’ says Chardon. In 2022, the company invested in a software for partner clinics that correlates weight loss data and patient profiles: Success Predictor. The proprietary machinelearning algorithm predicts outcomes as early as 20 days from the start of the Allurion Program, enabling doctors to focus on the right patient at the right time through early identification of patients needing additional support. This year, AI was extended to the patient app with ‘Coach Iris’. Allurion’s Coach Iris is a new generative AI-powered weight-loss coach designed to enhance outcomes within the Program and maximize a clinic’s efficiency. Coach Iris offers always-on support, education, and motivation on a broad range of health and weight-loss topics, including tailored meal plans, recipes, exercise routines, stress management

The Allurion weight loss program is to the body what Botox is to the face. – Benoit Chardon, Chief Commercial Officer and Shantanu Gaur, Chief Executive Officer

techniques, and motivational insights. Coach Iris also reaches out to patients to keep them actively engaged in their weight loss program. ‘As a premium first, results-orientated business that has the patient at the center of everything we do, we are excited about the opportunity to add Coach Iris to our suite of post-procedure programs and support,’ says Tommy Veverka, CEO of Transform Healthcare Holdings in the UK. ‘Making the weight loss journey less complex, easier, with an ever-increasing likelihood of a desired result is at the heart of what we do.’ He says Coach Iris will gel perfectly with this philosophy. ‘It will be a perfect “always on” solution for advice and support for our customers and patients,’ he says. To learn more about adding Allurion to your practice, visit: https://www. allurion.com/

References 1. World Health Organization. Obesity and overweight. WHO, 9 June 2021. Available at: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (last accessed 5 November 2023) 2. Verified Market Research. Global Intragastric Balloon Market Size By Product (Single Balloon, Dual Balloon), By Filling Material (Saline-Filled, Gas-Filled), By End-Use (Hospitals, Ambulatory Surgical Centers), By Geographic Scope And Forecast. Sep 2023. Available at: 3. https://www.verifiedmarketresearch.com/product/intragastric-balloonmarket/#:~:text=Intragastric%20Balloon%20Market%20size%20 was,non%2Dincisions%20and%20without%20stitches (last accessed 5 November 2023)

prime-journal.com | November/December 2023

COMPANY PROFILE | CUTERA |

® CUTERA

CELEBRATES

LEGACY MILESTONE

25 years of excellence and clinical innovation in global medical aesthetics

S AN INDUSTRY LEADER AND INNOVATOR OF AESTHETIC AND dermatologic solutions, the Cutera team is bringing new energy to aesthetics as they celebrate their 25-year anniversary. Founded in 1998 by a team of Silicon Valley-based engineers in Brisbane, California, Cutera, Inc. has established a long history of developing transformative technologies that have shaped the aesthetic landscape. Since its inception, Cutera has pioneered multiple novel platforms for practitioners and their patients globally, with more on the horizon as they usher in a new era of Cutera. ‘We take pride in our legacy of innovation and engineering excellence,’ said Taylor Harris, who recently stepped into the role of Chief Executive Officer after a long career in the medical technology industry. ‘Cutera’s “New Energy” concept is driven by our foundation of ingenuity with a focus on transformative patient outcomes through the power of people and partnership.’ Cutera continues to drive new advancements with the power of research and development. ‘The technologies that our engineers develop are at the forefront of our energy-based solutions,’ says Michael Karavitis, Executive Vice President and Chief Technology Officer of Cutera, Inc. ‘What sets us apart is our ability to not focus on the past, but rather look forward into new and breakthrough opportunities in aesthetic dermatology,’ he says. ‘Our goal is to delight our customers with novel and first-to-market applications so they can offer state-of-the-art treatments to their patients.’ Their customer-centric philosophy gets high marks from practitioners of all specialties. According to Richi Mandavia, MBBS, BSc, MSc, PhD, MRCS (ENT), Managing Director of Drs Tatiana + Rishi Advanced Aesthetics in London, ‘Our experience with the Cutera team stands out from the industry. Their technology is second to none, and the level of

We are consistently impressed by Cutera’s unique approach to addressing challenging conditions. So much research goes into designing and building great products to help practices deliver great results safely and effectively. – Ashish C. Bhatia, MD, FAAD

November/December 2023 | prime-journal.com

| CUTERA | COMPANY PROFILE With truFlex, we can focus on their goals for strengthening and toning, firming the abdominal area, and addressing the buttocks and thighs as well. – Michael Somenek, MD

personalised service we can count on is a cut above many other device companies.’

Focused on life-changing innovations With a strong track record of first-to-market discoveries, Cutera made history in 2022 with AviClear, the first 1726 nm laser FDA-cleared for the long-term treatment of mild, moderate, and severe inflammatory acne vulgaris. By specifically targeting the sebaceous gland, 92% of

prime-journal.com | November/December 2023

COMPANY PROFILE | CUTERA |

Taylor Harris, CEO, Cutera, Inc

Michael Karavitis, Executive Vice President, and Chief Technology Officer, Cutera, Inc

patients treated with AviClear saw at least half their acne resolved 12 months after their final treatment session1. ‘We believe AviClear offers a new paradigm shift in acne care. With acne being one of the most common skin conditions in the world, AviClear offers a new alternative for patients seeking a durable solution,’ says Steve Kreider, Senior Vice President of Global Marketing at Cutera Inc. According to Dermatologist David J. Goldberg, MD, JD, Director of Cosmetic Dermatology and Clinical Research at Schweiger Dermatology Group in New York City, ‘AviClear is a revolutionary, safe, and effective long-lasting option for the treatment of acne without the side effects that we see from many oral medications. It has transformed the way we manage even the most challenging acne patients.’ AviClear offers a modern alternative to oral and topical treatments and the side effects that often follow these traditional methods. According to Ashish C. Bhatia, MD, FAAD, founder and Co-Director of Dermatologic, Laser & Cosmetic Surgery at Oak Dermatology with three offices in Illinois, ‘We are consistently impressed by Cutera’s unique approach to addressing challenging conditions. So much research goes into designing and building great products to help practices deliver great results safely and effectively. We have been impressed by the results our AviClear patients are seeing. This extraordinary technology offers us a new tool to help positively change our patient’s lives.’

Body sculpting ingenuity We take pride in our legacy of innovation and engineering excellence. – Taylor Harris, CEO

From face to body, Cutera has also proven to be a leader in non-invasive body sculpting solutions with their multi-award-winning truBody® portfolio of products. In 2012, truSculpt® became the first radiofrequencybased device on the market to receive FDA clearance for fat reduction via lipolysis. Later, in 2017, the technology evolved to be the fastest fat-reduction technology on the

November/December 2023 | prime-journal.com

market. Following suit in 2020, truFlex™ muscle sculpting boasted the fastest muscle sculpting technology with 15-minute treatment options. The truBody brand was fully introduced in 2022 with the pairing of the truSculpt and truFlex technologies to address both fat and muscle, giving practitioners a 360-degree approach to body contouring and customisation with Cutera’s ‘Trim and Tone’ protocol. The innovative technology offers a personalised and complete solution that delivers effective results from these indemand treatments. According to facial plastic surgeon Dr. Michael Somenek of Somenek + Pittman in Washington DC and New York City, ‘We have been impressed with Cutera’s truBody pairing. The versatile treatment areas, results, and customisation encourage them to come back to treat additional areas. Having both devices allows us to address

| CUTERA | COMPANY PROFILE AviClear is a both muscle and fat, allowing for a robust offering. truSculpt features revolutionary, safe, more monopolar RF to target the and effective long- subcutaneous fat layer and achieve lasting option for the long-lasting fat reduction for patients. treatment of acne With truFlex, we can focus on their goals for strengthening and toning, without the side firming the abdominal area, and effects that we see addressing the buttocks and thighs as from many oral well.’ medications. A bright future – David J. Goldberg, MD, JD

Cutera has a lot to look forward to with an experienced international

leadership team. ‘We have a significant opportunity ahead of us as we continue to expand our presence as a leader within the aesthetic and dermatology space. Our global partners and customers are excited for the success of AviClear in North America and are thrilled to welcome the launch of this revolutionary technology in their local market next year.’ According to Brent Hauser, President of International. Cutera’s rich history stems from their commitment to expanding and refining their portfolio of awardwinning solutions while meeting their customers’ modern business challenges. ‘We are looking forward to the next 25 years as we build upon the value that we bring to practices and their patients globally,’ concludes Harris. Learn more about Cutera’s portfolio of products at www.cutera.com

Steve Kreider, Senior Vice President of Global Marketing, Cutera, Inc

Brent Hauser, President of International, Cutera, Inc

A GROWING MARKET According to The Aesthetic Society, 400,180 non-surgical body contouring treatments were performed in the U.S. in 2022, which represents the 4th most popular non-surgical treatment, just behind neurotoxins, dermal fillers, and skin treatments2

References 1.

Results may vary

Data on file

2. The Aesthetic Society. Aesthetic Plastic Surgery National Databank Statistics 2022. Available from: https://cdn.theaestheticsociety.org/ media/statistics/2022TheAestheticSocietyStatistics.pdf% (last accessed November 2, 2023)

prime-journal.com | November/December 2023

INDUSTRY INSIDER | THE CHINESE AESTHETIC MARKET |

FULL OF EASTERN PROMISE

AESTHETIC MEDICINE IN CHINA

It is an exciting time for the Chinese aesthetic medicine market. Poised for significant growth this decade, Rosalind Hill spoke to three leading doctors about its evolution and the challenges that remain 22

November/December 2023 | prime-journal.com

| THE CHINESE AESTHETIC MARKET | INDUSTRY INSIDER

CROSS THE LAST DECADE, THE to become more standardised in the future,’ said Chinese medical aesthetic market has Professor Yilin. grown steadily and, despite the ‘In order to promote a standardised and healthy temporary impact of COVID, is development of the industry, in recent years, the state expected to expand steadily to 20301. has stepped up supervision and promulgated a series of In fact, the predicted growth of policies and regulations involving product research and aesthetic medicine in China far outstrips global industry development, production, sales, promotion, and services growth according to Deloitte’s report ‘China: Medical within the medical aesthetics industry,’ agreed Dr Hang Aesthetic Industry Outlook 2022’: across 2017–2021 the Wang, Chief Physician and Director of the Department of global aesthetic market CAGR was 3% versus China’s Medical Aesthetics, West China Hospital of Stomatology, 17.55%, with predictions across 2021–2030 of a global Sichuan University. ‘In the first half of 2023, a total of 13 CAGR of 10.5% against 14.2% for China. Unsurprisingly, policies and regulations were announced, targeted at there is a lot of excitement about the region’s growth and rectifying the irregularities in the industry, and promoting potential; however, that does not mean a more sustainable and healthy the industry is not without its challenges. of the medical aesthetics The future of China’s development Such challenges would be familiar to industry.’ medical aesthetics industry is seasoned aesthetic professionals the One such example of these new policies world over, spanning from regulation to a very promising, despite the designed to improve practices and shortage of qualified practitioners. As current market lagging behind outcomes in the Chinese medical aesthetic medicine expands in the region, aesthetic industry is the ‘Guiding Opinions such hurdles seem to be rapidly Europe and the United States. on Further Strengthening the Supervision overcome, leaving an exciting prospect – Prof. Yilin Cao of the Medical Aesthetics Industry’ policy, for growth and investment. launched in May 2023 and providing one ‘The future of China’s medical aesthetics industry is of the region’s most detailed policies to date, with clear very promising, despite the current market lagging provisions on access management, supervision during behind Europe and the United States,’ said Professor Cao and after treatment, supervision of related fields and Yilin, Director of Shanghai Institute of Plastic and industries, and comprehensive requirements around the Reconstructive Surgery and President of First BCC Plastic compliance of practicing institutions. Surgery Hospital. ‘The recent decline of China’s economy, ‘China’s medical aesthetics industry and systems are especially since the pandemic, has hit the medical gradually moving towards more standardisation, with aesthetics industry to some extent, but in the long run, I greater transparency of information, thus, boosting the think the medical aesthetics industry has bright safety of Chinese consumers,’ said Dr Wang. ‘In the long prospects. After all, with China’s large population, it will run, grey areas such as “black medical aesthetics”, “black continue to play a significant role in the international injection” and “violation of regulations and counterfeiting” market. And with the economy on a steady development within the industry will definitely be abolished. Leading path, I can foresee the medical aesthetics market in China medical and aesthetics companies with comprehensive growing much bigger. So, I am still very optimistic about licenses, strong research and development, and mature the future.’ and compliant products are expected to benefit from the rigorous industry supervision. With the cooperation of The development of standards is key various national departments, medical aesthetics to growth product companies, medical aesthetics service institutes According to figures from Statista2, the market is now and consumers, China’s medical aesthetics industry valued at 217.9 billion yuan (2021). This is expected to chain will be more regulated and ready to promote the almost double to 400 billion yuan by 2025, and it seems sustainable expansion of the market.’ there is no stopping its growth as a market heavily influenced by the trends of the South Korean K-beauty Broadening horizons scene and, like other countries in the region, a young It certainly is an exciting time for the Chinese aesthetic population heavily influenced by social media and with market— clear growth projections and clear governance money to spend on both looking good and feeling good are important prospects for investment and provide as a result. But despite that, the Chinese aesthetic market reassurance to key players looking to enter the market. has faced challenges with regard to its regulation and ‘At present, products in China’s medical aesthetics standards, facing criticism of poor and low-quality market are mainly imported brands, as well as several service back in 2019. However, regulators have been local brands,’ said Dr Wang. As you’d expect, some of the quick to act, with more stringent standards coming into more well-known and well-respected brands, like force, which is a positive for such a burgeoning industry Allergan, Galderma, Merz and Cynosure, have a presence ROSALIND HILL is a freelance with huge potential. in the market alongside local brands such as SinoBiom, journalist and content ‘The supervision of China’s medical aesthetics industry strategist. She was the launch Jinbo and Botanee. But where more mature markets is now getting more stringent, and various departments editor for PRIME Journal in such as the UK and Europe have a proliferation of dermal 2011. are unified when it comes to continuous rectification and fillers and toxins, in China only 30 brands of hyaluronic curbing of irregularities. This market is definitely on track contact missrosalindh@gmail.com acid and four toxins are registered for use. To safely

prime-journal.com | November/December 2023

INDUSTRY INSIDER | THE CHINESE AESTHETIC MARKET |

enter the market, brands are required to prove their treatments, the latter of which are proving particularly quality through local clinical trials and R&D. popular among Chinese men1. ‘The administrative access of medical ‘Consumer awareness of anti-ageing has aesthetic drugs, materials, and equipment increased considerably, and firming and antito NMPA is very strict, and the cycle is ageing treatments surpassed whitening long, which presents a number of and brightening to become the most challenges for those practicing,’ popular services,’ said Dr Wang. ‘With continued Dr Wang. ‘There are the popularity of “light” medical higher thresholds, resulting in aesthetics services, and the fact fewer products that can enter that treatment-seekers are paying clinical practice; some more attention to anti-ageing, technologies that have been more invasive medical aesthetics popularised internationally are services that were popular just a difficult to implement here in few years ago are gradually being China.’ replaced by wrinkle removal, However, things may be apple skin and dark circle starting to change, particularly removal, and other non-surgical as Chinese doctors themselves facial rejuvenation projects.’ look to broaden their knowledge Professor Yilin has seen similar and expertise. trends in his own clinic. ‘Non-surgical, ‘The aesthetics sector in China, minimally-invasive treatments have and the industry as a whole, has seen certainly gained popularity over surgical rapid developments following the treatments in terms of number of cases. country’s opening up and reforms. And I think a big factor impacting this is the Especially in recent years, there has been a downtime and potential trauma caused by more significant transformation in terms of invasive treatments. Taking our institution as an technological advancements and evolving example, surgery used to account for around 70% of our philosophies,’ said Dr Weidong entire income. But now that trend Tian, Professor and Director of The aesthetics sector in China, and has reversed, with non-surgical the Trauma and Plastic Surgery making up 70% and the industry as a whole, has seen rapid treatments Department at West China surgical treatments just 30%. This is developments following the country’s the current domestic trend, and Stomatology Hospital, Sichuan University. ‘Chinese medical opening up and reforms. Especially in people’s perception of aesthetics has aesthetics encompass many recent years, there has been a significant definitely changed drastically.’ aspects. One primary focus is in terms of technological Changing perceptions industry regulation, which transformation requires continuous refinement, advancements and evolving philosophies. At the core of China’s growth in and the quality and skills of – Dr Weidong Tian aesthetics medicine is the changing practitioners in the medical perceptions of aesthetics among the aesthetics field need ongoing patient population. Not only are improvement. It’s essential to keep up with new aesthetic treatments more socially acceptable (in fact, it technologies and align with global trends.’ is the male population driving the greatest growth in Those key global trends are focused on anti-ageing botulinum toxin treatments) but Generation Z (the and regenerative medicine, according to Dr Tian. generation of people born in the late 1990s and early ‘Technologies like stem cell exosomes, among others, 2000s)— influenced by social media and K-beauty have made significant progress in the anti-ageing field, trends — have money to spend and a greater desire to and regenerative medical aesthetics has become a focal look and feel good. Even Millennials, now entering their point of attention, and the future of medical aesthetics late 30s and early 40s, are keen to pause the signs of will undoubtedly revolve around tissue regeneration ageing. This provides a huge — as yet untapped — potential 1. Deloitte Consulting, Allergan and organismal anti-ageing as a perennial theme.’ market for aesthetic physicians starting to build their Aesthetics. China Medical Aesthetic Perhaps unsurprisingly, though, it’s non-invasive practices in the region. And a huge, untapped market for Industry Outlook 2022. China: 18 August, 2022. Available at: https:// aesthetic procedures that have driven most of the brands too — if they can meet the new, high standards www2.deloitte.com/cn/en/pages/ strategy-operations/articles/ market’s growth and that are most popular among coming into play. As Dr Wang told PRIME, ‘China has a dtt-china-medical-aesthetic-industrypatients right now and pursued by all age groups, but large base of beauty aspirants, and there is a rapidly outlook-2022.html 2. Statista. Market size of the with the largest consumer group being those aged 26–30 growing pool of doctors in private hospitals who have aesthetic medical and surgical industry in China from 2017 to 2021, years. According to Deloitte’s report, 83% of treatments rich experience in clinical treatment. The future is bright.’ with forecasts until 2025 (in billion carried out in 2021 were minimally invasive. These types yuan). November 2022. Available at: https://www.statista.com/ of treatments are more acceptable to consumers because statistics/1089021/china-medicalaesthetics-industry-market-size/ they are ‘quick’ and have limited downtime. Of these, 64% sought filler treatments while 69% sought toxin

References

November/December 2023 | prime-journal.com

R E D U C E FAT. TONE MUSCLE. Average fat reduction per treatment area1

Up to increase in muscle mass2

Model. Not actual patient.

BEFORE

AFTER

1 truSculpt treatment and 4 truFlex treatments

BEFORE

AFTER

1 truSculpt treatment and 4 truFlex treatments

PHOTOS COURTESY OF JEFFREY FROMOWITZ, MD

PHOTOS COURTESY OF TAHL HUMES, DO

RESULTS MAY VARY

Take your patients beyond their best LEARN MORE AT YOURTRUBODY.COM

TRUSCULPT/TRUFLEX: Please review the operator’s manual and treatment guidelines for the contraindications, precautions, warnings, side effects and possible adverse events associated with the truSculpt/truFlex treatment. Results and experience may vary. REFERENCES: 1. Somenek MT, Ronan SJ, Pittman TA. Lasers Surg Med. 2021;53(3):337-343. 2. Ronan SJ. A Novel Bio©2023 Cutera, Inc. All rights reserved. AP003907 rA (12/22)

INDUSTRY INSIDER | AESTHETICS IN DUBAI |

ALL EYES ON

DUBAI

Another boom in aesthetics in the region sees an upturn in clinic openings and visiting clinicians from all over the world. Mona Mirza, CEO and Founder of Dubai-based aesthetic clinic Biolite, takes a closer look

MONA MIRZA is CEO and Founder of Biolite, Dubai.

T IS NO COINCIDENCE THAT DUBAI IS currently the word on everyone’s lips in the aesthetic industry. UK clinicians en masse seem to be turning their attention to the region with the notion of streets paved with gold, the promise of treasures untold and the benefit of zero personal tax. Sounds ideal, right? We are seeing more and more cosmetic aesthetic clinics opening in the region, the most popular of all the Emirates potentially due to its modern practices, melting pot of cultures and the bubble of wealth that the combination of expats and locals provide. With over 16 years at the forefront of Dubai aesthetics, keeping a bird’s eye view of the Biolite brand and its offering is important to ensure we retain our poll position, especially with the increasing global interest. We are fortunate to have strong patient loyalty, great repeat custom, a supportive press and influencer

November/December 2023 | prime-journal.com

network and a complex of best-in-class practitioners spanning an array of disciplines. Biolite has become a name synonymous with world-class health and aesthetic solutions, giving us a lead on the competition. As its founder, I make it my purpose to continually research to find the latest and best treatments, products, devices and protocols, always scouting for only the best experts and staff. Without this complete recipe, I don’t believe we would have been afforded the accolades, success and longevity that we have had to date and my recognition for service to business from Sheikh Mohammed bin Rashid Al Maktoum. Currently, there are 236 licensed plastic surgeons and 386 licensed dermatologists in Dubai. There are 277 facilities offering plastic surgery and dermatology services, according to the Dubai Health Authority (DHA), and these numbers continue to grow. Established clinics and practitioners in the region are

| AESTHETICS IN DUBAI | INDUSTRY INSIDER ID else you are only eligible for a tourist sim. With VAT set to rise from 5% to 8% next year, the VAT benefits will only be around for so long, rising steadily in recent years. However, the benefit of no personal tax is surely enough to make you shift mountains to move your practice.

bending over backwards to stay relevant in this everchanging market. Add to this the wave of UK-based practitioners visiting the region with regularity, investing their time and expertise into the market, and its population of patients well-versed in all things aesthetic. Visiting clinics seem to be very a la mode, and the race is on to secure the best in the business. Once licensing and regulatory requirements are complete, Dubai is your oyster, but this process can be drawn out, and delays are very common. There are a variety of motivations to move to Dubai: lifestyle, family benefits, tax benefits, weather — if you like it hot — and being a part of a rapidly growing industry and a futurefocused society. It works perfectly for some. I’ve heard it said that restaurants and nightclubs have a half-life of just a few years in Dubai until the newest, latest launch comes along to eclipse them. The same can be said of clinics, although the approach isn’t the same. With a responsibility to provide the latest, safest and most effective treatments to its patients, new isn’t always best, and there is a good deal of education to do around this. Combining treatments and knowing what an individual actually needs inside and out through dialogue and diagnosis is arguably where the market is pointing and makes up the founding principle of Biolite, offering a new category we call ‘healthness’. As a city run on its principles, patient safety and employee rights are of the utmost importance, and the red tape clinics and clinicians need to deal with goes towards creating maintained quality of service and patient confidence.

Where to start?

Keep in line and stay informed Regulation and legislation change with regularity and swiftly. Ignorance is no excuse for not keeping within the lines of the law and any failure to do so is met seriously with fines being handed out to businesses and individuals liberally. Clinics and their practitioners undergo inspections, and all licenses require annual renewals. Whatever your specialism, the DHA (Dubai Health Authority) needs to grant a license. Dubai plays host to some exciting expos, bringing the world of aesthetics together. Dubai Derma is one such event, and Beauty World Middle East attracts some cosmetic aesthetic exhibitors. This is a market everyone wants to launch into, so we are spoilt for choice when it comes to new devices and products. The trick is to filter out the best from the rest. I have strong PR support from my team at Mantelpiece PR, which operates in the UK and UAE specialising in this industry specifically, and the sharing of information from both markets provides great insight. I also spend time visiting relevant expos all over the world looking for inspiration, taking in everything the industry has to offer

The final word

Established clinics and practitioners in the region are bending over backwards to stay relevant in this ever-changing market.

It is time-consuming to become fully licensed to practice in Dubai and is largely dependent on your qualifications and specialism. Don’t ask how long the process takes, as this is very individualised and requires annual renewals. There are strict guidelines, for example, about who can inject in Dubai, unlike the UK, and exams that need passing before you can even begin. Some dedicated consultancy firms can manage the process of obtaining your license, and if you want to open your company in the UAE, they can help obtain an Emirates ID and Company Registration as well. In fact, to have a UAE mobile phone contract, you need to have an Emirates

In summary, there are really exciting opportunities in the region for top practitioners, but only the best need apply. It is a very unforgiving market, as are its patients who demand the last word in luxury. Practitioners are only as good as their most recent patient testimonial or latest before and after images, plus success is heavily reliant on word of mouth and a steady stream of names: influencers, celebrities, stars of stage and screen, royalty and the like. Legislation and regulation are not to be taken lightly, and failure to comply with all the laws and practices is taken very seriously, and fines are hefty.

prime-journal.com | November/December 2023

INDUSTRY INSIDER | NEW PRODUCTS |

WHAT

AESTHETIC DOCTORS ARE EXCITED ABOUT RIGHT NOW U Wendy Lewis interviews 6 top doctors to find out NDOUBTEDLY, DURING 2023, WE SAW A LOT OF captivating launches across the key medical aesthetic categories, from novel pairings of widely used technology to new applications of topical agents, dermal fillers, ingestibles, and medically advanced skincare. We reached out to six aesthetic doctors from the US to get the scoop on the newest go-to treatments they have added to their practices.

WENDY LEWIS is Founder/ President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy since 1997, author of 13 books, Editor in Chief of beautyinthebag.com, and frequent presenter on the international stage. Her first textbook, Aesthetic Clinic Marketing in the Digital Age (CRC Press) will debut a second edition in 2023. email: wl@wendylewisco.com

Barry DiBernardo, MD, FACS Plastic Surgeon New Jersey Plastic Surgery, Montclair, NJ, USA GETHAIRMD™ My team at New Jersey Plastic Surgery has been excited of late because our hair growth business is expanding with the addition of the GetHairMD programme. Their suite of noninvasive solutions fills the void between over-the-counter solutions and more invasive solutions, such as hair grafting. From shampoos, conditioners, serums, nutraceuticals, in-office clinical hair growth laser, the unique Follicular Infusion System, and the best-in-industry laser cap, we know our patients are covered. GetHairMD partners with aesthetic practices, and they provide exclusive territories, so I don’t have to worry about competitors offering the same thing in my backyard! Their exclusive training is top-notch, and they invest tens of thousands of dollars of marketing back into my practice.

November/December 2023 | prime-journal.com

| NEW PRODUCTS | INDUSTRY INSIDER Richard Jin, MD, PhD, RJ Clinical Institute Internal Medicine Temecula & Mission Viejo, CA, USA

More and more female patients are enrolling in this programme due to the multi-modality approach that focuses purely on medically proven methods. 50% of men and roughly 45% of women suffer from some variation of hair loss, and for the first time in our practice, we have an easy, bundled programme to address hair loss from so many angles under one brand. I also love the unique Follicular Infusion System that painlessly drives a clinically proven serum directly to where it needs to be, straight into the root of the follicle. Even if you have the best topical agent, if it doesn’t get to the right place, you will not see the results. Best of all, it is a quick, needleless, nodowntime procedure for patients. All-in-all, my investment to join the GetHairMD network was a great decision that is sending new patients to our practice through their marketing efforts, deploying a delegable package of clinically proven non-invasive solutions, and within my own protected territory.

Troy Pittman, MD, FACS Plastic Surgeon, Somenek + Pittman, Washington DC and New York City, NY, USA SECRET™ PRO, CUTERA® One of the things that I’m excited about are the results we are getting for post-surgical incision treatments (tummy tucks, breast reductions, etc.) with the Secret Pro— combination CO2 laser and RF microneedling from Cutera®. Using these two modalities simultaneously at around 4 weeks post‑op results in faster wound healing and better overall surgical scars. We use the CO2 platform to help reduce post-inflammatory hyperpigmentation and sort of ‘blur’ the wound edges to make the incision less noticeable. This is combined, in the same treatment session, with RF microneedling to help with overall scar remodelling, which ultimately results in a softer, flatter incision. One of the novel things I like about this treatment, in addition to combining modalities that were previously used separately, is the timing. We have found that early intervention allows us to treat the incision at the end of the proliferation phase (super boosting collagen production) before the remodelling phase begins. We are using it for all of our tummy tuck and breast patients to reduce the appearance of visible incisions when needed. It is also an effective treatment for improving skin texture and mild sagging around the jowls and neck, as well as to improve the appearance of fine lines and creases.

SMARTLUX MINI AND VIVISCAL

We are using it for all of our tummy tuck and breast patients to reduce the appearance of visible incisions when needed. Troy Pittman, MD Secret Pro, Cutera

We have recently incorporated the SmartLux Mini into our practice. This novel and compact phototherapy device uses three wavelengths: blue (415–425 nm) for treating acne, infrared (820–830 nm) for relieving muscle pain and promoting circulation, and a combination of red (630–640 nm) and infrared (820– 830 nm) for dermatological treatment of periorbital wrinkles. Our clinic combines red-light therapy with PRP hair treatments and blue/UV treatment in combination with our RF microneedling facial treatments. Viviscal™ is a dietary supplement designed to enhance hair growth and improve hair health by providing a blend of nutrients and marine-derived proteins to nourish hair follicles and promote thicker, fuller hair. Our clinic combines the Viviscal supplements with redlight therapy and PRP hair treatments. It is user-friendly and delivers notable outcomes for hair growth and health improvement. The straightforward regimen and scientifically formulated blend of nutrients and proteins make it easy to incorporate into our patients’ daily routines. Many patients have reported positive results in terms of thicker, healthier hair, reinforcing its efficacy in addressing hair-related concerns.

The straightforward regimen and scientifically formulated blend of nutrients and proteins make it easy to incorporate into our patients’ daily routines. Richard Jin MD, PhD SmartLux Mini and Viviscal

prime-journal.com | November/December 2023

INDUSTRY INSIDER | NEW PRODUCTS |

Faryal Farooqi, MD, CEO and Founder, Anushka Concierge Medicine & Wellness, West Palm Beach, FL, USA RF MICRONEEDLING WITH EXOSOMES We have seen great results pairing Morpheus8 with Benev Exosomes. We use Morpheus8 primarily to offer 20-minute RF microneedling, 24 needles for the face at a 1–4 mm depth and 40 needles for the body for up to 8 mm deep. We are using the burst technology so patients receive simultaneous energy delivered at multiple depths in one pulse. Its safety and effectiveness on all skin types and the results we can achieve have made it a very popular treatment in our practice. We recently started pairing Morpheus8 with Benev Exosomes, and it has been the holy grail for minimal downtime for aesthetic procedures. When used in combination with the exosome serum, our patients can leave the facility looking radiant with little to no downtime. The Benev Exosome Regenerative Complex is in a class of its own. This biotech breakthrough serum harnesses the power of stem cell-derived lyophilised exosomes; it uses potent growth factors, peptides, minerals, vitamins, and amino acids to optimise the regenerative capacity for skin of any age. With Morpheus8 we can lay down the framework, and the application of the exosomes also helps to prevent the development of post-inflammatory hyperpigmentation (PIH) when treating darker skin tones. As the exosome is absorbed into the skin, it allows just the right amount of

We have seen great results pairing Morpheus8 with Benev Exosomes. We are using the burst technology so patients receive simultaneous energy delivered at multiple depths in one pulse. Its safety and effectiveness on all skin types and the results we can achieve have made it a very popular treatment in our practice. Faryal Farooqi, MD Morpheus8 with Benev Exosomes

November/December 2023 | prime-journal.com

inflammatory response to take place in the skin, boosting collagen and elastin production by 200% and more. Patients look radiant right after their treatment, which makes them more inclined to return for their recommended series of three spaced one month apart. Since the semaglutide rage took the US by storm, rapid weight loss has driven body treatments for arms (for laxity and creepiness), legs (for cellulite), buttocks (for stretch marks and texture) and abdomen for skin tightening. With Morpheus8, we can penetrate deeper layers of the skin (8mm), which stimulates the skin to reorganize itself and reverse the clock. The benefits of exosomes are to soothe the skin and help to alleviate the itchiness patients develop on the treated areas as they heal from within.

Michael Gold, MD Dermatologist, Gold Skincare Center, Nashville, TN, USA OPULUS BEAUTY LABS OPULUS Beauty Labs is a very innovative skincare range created by one of the original co-founders of Clarisonic. The patented technology has two broad components: the handheld Activator and the novel new chemistry. They have created a smart cosmetic jar. The user opens the lid to place a capsule inside (called Opoule), then closes the lid, pushes a button, and 100 seconds later, they have a warmed skincare product ready to be applied to their skin. The chemistry innovation is quite unique. Each capsule has two layers, an outer shell and a core, so the entire capsule becomes the product. The experience for patients is as if they are compounding their own topical skincare. The OPULUS team has taken care to decrease packaging by doing away with bottles because the proprietary manufacturing process stabilises actives in the outer shell, which protects the other beneficial ingredients. The entire capsule is made of cosmetic ingredients, so there is no plastic waste, which appeals to Millennials and GenZ and those who seek out clean beauty brands that are environmentally friendly. Another unique feature is their patented Retinol+ Ramp Up Regimen over a 4-week period. The patient can follow the order of capsules in the box to gently increase their exposure to retinol. This offers a good regimen for first-time retinoid users or those who complain about having sensitive skin. What my staff likes about the OPULUS line is the luxury brand concept with an innovative approach to topical agents in single-dose products, from moisturisers to

| NEW PRODUCTS | INDUSTRY INSIDER The entire capsule is made of cosmetic ingredients, so there is no plastic waste, which appeals to Millennials and GenZ and those who seek out clean beauty brands that are environmentally friendly.

rosacea and acne keloidalis nuchae to melasma. With the burgeoning cosmetic needs of the skin of colour populations, having a platform like Aerolase’s Neoderm in my practice has been transformative. When I compare Aerolase to other devices in the market, I notice that many predominantly cater to fairskinned patients. However, with Neo Derm’s unique energy delivery, I’m empowered to address a multitude of concerns related to water, pigment, and redness, making it possible to treat a diverse range of conditions across various skin tones. From a financial vantage point, Aerolase devices have been a game-changer for my practice. Not carrying additional consumable costs or other fee-splitting has been economically advantageous. I can afford to offer treatments like acne at reasonable rates to my patients. This not only benefits them but also ensures a steady revenue stream for my practice.

Michael Gold, MD OPULUS Beauty Labs

prescriptions. It is easy for patients to use, and they will see results. OPULUS offers us a fresh and innovative approach to medical skincare products.

Karan Lal, MD Dermatologist, Affiliated Dermatology, Phoenix, AZ, USA NEODERM, AEROLASE In my experience with energybased procedures in dermatology, I’ve come to appreciate their immense potential. Incorporating Aerolase and its devices, like NeoDerm, into my practice has revolutionised my approach to dermatological treatments. I frequently encounter issues like postinflammatory hyperpigmentation, melasma, and acne, which span both medical and cosmetic realms. NeoDerm is particularly invaluable in addressing these conditions, especially for darker skin types. Its laser energy delivery is designed in such a way that it circumvents the risk of thermal damage. I’ve observed Aerolase making a significant mark in the field of dermatology. Their devices are tailored to accommodate a wide spectrum of patients, especially those with skin of colour. The versatility of their devices allows me to treat diverse conditions, from vascular

Incorporating Aerolase and its devices, like NeoDerm, into my practice has revolutionised my approach to dermatological treatments. Karan Lal, MD, NeoDerm, Aerolase

prime-journal.com | November/December 2023

CASE STUDY | PIGMENTATION |

LUMINESCENS®

TREATING PIGMENTATION AND MELASMA

WITH A PROFESSIONAL MESOTHERAPY SOLUTION Jo Coletta describes the results she experienced using a new depigmentation and brightening programme ABSTRACT With pigmentation disorders being such a commom complaint in the UK, I am always looking for new innovative treatments options. I have found positive results with treating pigmentation using LUMINESCENS®, a depigmentation and brightening treatment programme. This treatment is suitable for hyperpigmentation, post-inflammatory hyperpigmentation, melasma, sun damage and freckles, acne scars, and birthmarks and is safe and effective for darker skin tones.

JO COLETTA is a Clinic Owner/Aesthetician/ Advanced Skin Therapist; Jo Coletta Skin, London, UK email jo@jocolettaskin.com website www.jocolettaskin.com social media @jocolettaskin

KEYWORDS LUMINESCENS, depigmenting, skin brightening

IGMENTATION DISORDERS AFFECT MANY PEOPLE. THE MAIN causes of these disorders are sun damage, inflammation, irritation of the skin, and hormonal changes. Treatments that have proven successful and effective in treating pigmentation1 and melasma2 include laser3, skin peels4, microneedling, and skincare products5. However, these treatment methods can often lead to some downtime. Any form of pigmentation6 changes and conditions can affect an individual’s selfconfidence7, and usually the individual will not know the causes and what treatments are available to help.

Mechanism of action LUMINESCENS® kit consists of two 4 ml vials of professional mesotherapy8 solution and one home cream. Both products contain four active complexes that aim to reduce current pigmentation and prevent the formation of any new pigmentation: ■ Melanogenic enzyme blockers, targeting some specific proteins such as tyrosinase ■ Melanin formation and transport blockers, such as copper chelators and MC1R inhibitors ■ Keratolytics, promoting the removal of existing melanin ■ Antioxidants and dermo-normalisers that inhibit free radicals, preventing the cascade of melanin synthesis.

November/December 2023 | prime-journal.com

| PIGMENTATION | CASE STUDY

Objective

treatments, and the use of the LUMINESCENS® home cream daily, my client showed a significant improvement in depigmentation and overall brightening of her skin. This is clearly visible from her baseline pigmentation OBSERV520x skin analysis photo on the left to the photo taken 28 days later on the right (Figure 1). To maintain the results, my client is continuing to use the LUMINESCENS® home cream as part of her skincare routine and will return for further in-clinic LUMINESCENS® mesotherapy treatments to see if we can improve the results even further.

LUMINESCENS® is a protocol with brightening and depigmenting activity specifically designed to treat the face and body. The activity is carried out by specific active ingredients, assisted by a superficial peeling action that promotes epidermal renewal and favours the delivery to deeper derma layers.

Case report My client is a 42-year-old female who has suffered from severe pigmentation changes to her skin for many years. She has previously tried many other treatments and skincare products but was never satisfied with the results. After a full consultation, she agreed to try LUMINESCENS®, where the results would be observed and recorded. The first procedure was the in-clinic mesotherapy treatment using 2 ml of LUMINESCENS® solution, needling it into the skin at a depth of 0.25 mm with the microneedling device. The total treatment time was approximately 45 minutes. Two weeks after the first treatment and using the LUMINESCENS® home cream daily, my client returned to the clinic, where we noticed an improvement in the appearance of the melasma that she had on both cheeks. Her skin also appeared a lot brighter. We followed the recommended protocol and performed the second treatment using the remaining 2 ml of the LUMINESCENS® solution from the original vial, needling it into the skin with the microneedling device at a depth of 0.25 mm. After 28 days, the recommended two in-clinic

After skin preparation, we performed the first LUMINESCENS® mesotherapy application using the microneedling device at a 0.25 mm depth into the skin and finished with an application of the LUMINESCENS® treatment home cream.

Materials and method ■ Day 1 (Clinic protocol): After cleansing the area, we took a series of pictures of my client’s skin using the OBSERV520x Skin Analysis. The daylight and pigmentation mode pictures were used for her baseline and progress images. After skin preparation, we performed the first LUMINESCENS® mesotherapy application using the microneedling device at a 0.25 mm depth into the skin and finished with an application of the LUMINESCENS® treatment home cream. My client was then given the cream to continue to use daily at home. The client was told not to cleanse her skin until the following morning. ■ Day 2–7 (Home protocol): After cleansing, my client applied the LUMINESCENS® home cream twice a day thereafter, both morning and evening. SPF was applied after the home cream during the daytime. ■ Day 8–13 (Home protocol): After cleansing, the client applied the LUMINESCENS® home cream once a day in the evenings, massaging it until it was completely

prime-journal.com | November/December 2023

CASE STUDY | PIGMENTATION |

absorbed. SPF was applied during the daytime. ■ Day 14 (Clinic protocol): Second LUMINESCENS® mesotherapy application in-clinic using the microneedling device at a depth of 0.25mm followed by an application of the LUMINESCENS® treatment home cream. The client was told again not to cleanse her skin until the following morning. ■ Day 15–28 (Home protocol): After cleansing, my client continued to apply the LUMINESCENS® home cream once a day, in the evenings. My client was massaging it in until it was completely absorbed. SPF was applied during the daytime. ■ Day 28: The client returned to the clinic for a review, where we took more pictures of her skin to compare the results using the OBSERV520x skin analysis using the pigmentation and daylight mode. Throughout the 28-day protocol, no other treatments were performed in-clinic, and no further brand of active ingredient skincare was used in her home protocol. Only a gentle cleanser both morning and night and a factor 50 SPF.

Conclusion

Figure 1 (A) Before and (B) 28 days after treatment. Photos in daylight and pigmentation modes.

As a result of observing the in-clinic treatments and the home protocol with LUMINESCENS®, we can visibly see from the OBSERV520x skin analysis before and after pictures my client’s melasma has lightened, and there is an overall brightening of her skin. She reported that unlike other methods she has previously tried, she did not experience any discomfort, sensitivity or peeling during the LUMINESCENS® treatment plan and that it has had no negative impact on her daily life or social diary. I will continue to monitor my client’s progress and future results with further treatments. Declaration of interest None Figures 1–2 © Jo Coletta

References

Figure 2 (A) Before and (B) 28 days after treatment. Photos in daylight and pigmentation modes.

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1. Lee AY. Skin Pigmentation Abnormalities and Their Possible Relationship with Skin Aging. Int J Mol Sci. 2021 Apr 2; 22(7):3727. doi: 10.3390/ ijms22073727.PMID: 33918445 2. Artzi O, Horovitz T, Bar-Ilan E, et al. The pathogenesis of melasma and implications for treatment. J Cosmet Dermatol. 2021 Nov; 20(11): 3432-3445. doi: 10.1111/jocd.14382. Epub 2021 Aug 19.PMID: 34411403 3. Lee YS, Lee YJ, Lee JM, Han TY, Lee JH, Choi JE. The Low-Fluence Q-Switched Nd:YAG Laser Treatment for Melasma: A Systematic Review. Medicina (Kaunas). 2022 Jul 14; 58(7):936. doi: 10.3390/ medicina58070936.PMID: 35888655 4. Conforti C, Zalaudek I, Vezzoni R, et al. Chemical peeling for acne and melasma: current knowledge and innovations. G Ital Dermatol Venereol. 2020 Jun; 155(3):280-285. doi: 10.23736/ S0392-0488.19.06425-3. Epub 2019 Dec 4.PMID: 31804050 5. Austin E, Nguyen JK, Jagdeo J.

Topical Treatments for Melasma: A Systematic Review of Randomized Controlled Trials. J Drugs Dermatol. 2019 Nov 1;18(11): S1545961619P1156X. PMID: 31741361 6. Plensdorf S, Livieratos M, Dada N. Pigmentation Disorders: Diagnosis and Management. Am Fam Physician. 2017 Dec 15; 96(12): 797-804.PMID: 29431372 7. Kagha K, Fabi S, Goldman MP. Melasma’s Impact on Quality of Life. J Drugs Dermatol. 2020 Feb 1;19(2):184-187. doi: 10.36849/ JDD.2020.4663.PMID: 32129968 8. Khalili M, Amiri R, Iranmanesh B, Zartab H, Aflatoonian M. Safety and efficacy of mesotherapy in the treatment of melasma: A review article. J Cosmet Dermatol. 2022 Jan; 21(1): 118-129. doi: 10.1111/jocd.14644. Epub 2021 Nov 30.PMID: 34846788

CASE STUDY | SCAR TREATMENT |

A COMBINATION OF LASER AND LIGHT TO

TREAT SCARS

Diala Haykal, MD, describes how she combines a non-ablative fractional 1550 nm laser with Selective Waveband Technology (SWT®) intense pulsed light from the Nordlys™ multi-application platform to treat scars

DIALA HAYKAL, MD, Centre Laser Palaiseau, Palaiseau, France

KEYWORDS Non-Ablative Fractional 1550 nm Laser, IPL, Nordlys

CARS ARE THE NORMAL RESULT OF THE CUTANEOUS WOUND healing process that leads to fibrosis and an altered skin morphology1. Scars can have significant cosmetic, physical, and psychological impacts on patients, prompting many to seek treatment1,2. Scars on the head and neck may be particularly physically disfiguring and associated with profound psychosocial implications3. Various non-invasive light-based therapies, such as laser and intense pulsed light (IPL), may induce scar remodelling and reduce its appearance. Non-ablative fractional lasers are commonly used for skin resurfacing, as well as a wide range of scar types, including acne scars, surgical scars, and traumatic scars4. The non-ablative laser device emits microscopic laser beams into the tissue, creating tiny areas of coagulated tissue surrounded by intact tissue. This controlled damage triggers the body’s natural healing response, as well as stimulating collagen production and tissue regeneration5. As the tissue heals, it is replaced with new, healthier tissue, resulting in improved skin texture. Treatment is regarded as gentle and associated with a relatively low risk of complications and social downtime. IPL is another light-based modality that may improve scars. IPL utilises a spectrum of light wavelengths to target specific skin concerns, including hyperpigmented scars and reddened or vascular scars. IPL works by delivering short bursts of high-intensity light onto the scarred tissue. The light energy is absorbed by the pigmented or vascular components of the scar, such as melanin or blood vessels. This selective absorption helps break down excessive pigmentation or reduce the discolouration associated with scars, leading to a more even skin tone6. The Nordlys™ multi-application platform by Candela® (Marlborough, MA, USA) is a multimodality system offering a range of Selective Waveband Technology (SWT®) narrowband

November/October 2023 | prime-journal.com

| SCAR TREATMENT | CASE STUDY

IPL applicators with wavelength ranges of 400–720 nm, 530–750 nm, 555–950 nm and 600–950 nm, as well as nonablative fractional 1550 nm and 1940 nm laser applicators and a Nd:YAG (1064 nm) applicator to address a variety of skin conditions*. The 1940 nm applicator produces controlled superficial depths of focal damage, while the 1550 nm applicator causes thermal coagulation deeper in the dermis. The SWT applicators incorporate unique dualfilter technology and sub-millisecond pulses to target vascularity and epidermal pigment7.

A new treatment modality was recently introduced to address photoaged skin by combining 1550 nm laser resurfacing with the SWT IPL treatment8. In our clinic, we use the 1550 nm laser to resurface scar tissue combined with the 530–750 nm (PR 530) SWT applicator.

Case Study A 24-year-old female patient presented with a visible scar on her upper left eyebrow. The scar resulted from a recent accident when she fell and hit her eyebrow area on a

To optimally address vascularity (redness) and overall skin texture, the subject underwent two sessions of combined SWT treatment (PR 530 applicator) and 1550 nm laser treatment, spaced 6 weeks apart to allow adequate time for skin healing and rejuvenation. prime-journal.com | November/October 2023

CASE STUDY | SCAR TREATMENT |

containing retinoids or exfoliating agents for several days prior to treatment. To ensure patient comfort during the laser procedure, a topical numbing cream (EMLA) was applied to the treatment area approximately 30 minutes before the session commenced. Following each treatment, the patient applied a gentle, fragrance-free moisturiser to keep the treated area hydrated and protected. She was advised to avoid excessive sun exposure, use sunscreen daily, and refrain from picking or scratching the treated area. The patient experienced mild redness and swelling for a few days following each treatment session. After treatment, the patient experienced remarkable results (Figure 1B), and she expressed immense satisfaction and gained a newfound sense of happiness and confidence in her appearance.

Conclusion Figure 1 A 24-year-old woman, before (A) and after 2 sessions (B) with SWT treatment with the PR 530 IPL applicator combined with 1550 nm laser resurfacing. Photos Courtesy of Diala Haykal, MD. Centre Laser Palaiseau. All photos are unretouched. Individual results may vary.

sharp object. Despite trying various topical creams and ointments, the scar had not improved over time. The subject was concerned about the scar’s appearance, which affected her self-esteem and daily activities. The 2 cm scar was slightly deep, with a pinkish hue, and was surrounded by normal skin with no signs of active infection (Figure 1A). To optimally address vascularity (redness) and overall skin texture, the subject underwent two sessions of combined SWT treatment (PR 530 applicator) and 1550 nm laser treatment, spaced 6 weeks apart to allow adequate time for skin healing and rejuvenation. The selected SWT applicator and treatment parameters were based on skin type, texture, and colour. At each treatment session, a single pass was administered with the PR 530

In our experience, combining PR 530 SWT treatment to target the vascular component of scar redness and 1550 nm laser treatment to resurface the scar tissue is highly effective in improving the appearance of the skin tissue. This combination treatment approach offers a comprehensive solution for scar management, addressing both the discolouration and texture of the scar tissue. It is important to manage patient expectations, as complete scar removal may not be possible, although significant improvement in scar appearance and texture can be achieved. Individual results may vary depending on factors such as scar type, scar severity, and patient response to treatment. The timing of treatment initiation after injury may also be of importance to treatment outcome8. The number of sessions required depends on the scar’s response and the desired outcome. Declaration of interest None Figure 1 © Diala Haykal * Frax 1550 for Nordlys and Frax Pro, CE mark

In our experience, combining PR 530 SWT treatment to target the vascular component of scar redness and 1550 nm laser treatment to resurface the scar tissue is highly effective in improving the appearance of the skin tissue. applicator with 7J/cm2 fluence and 2.5-ms pulse duration and three passes with the 1550 nm laser with 6-mm scan width, 30 mJ energy, 20% coverage, 2.7-ms pulse duration and 730 µm penetration depth. Prior to the treatment sessions, the patient was advised to avoid sun exposure and use a broad-spectrum sunscreen with a high SPF to protect the skin. She was also instructed to discontinue any topical products

References 1. Babilas P, Schreml S, Szeimies RM, Landthaler M. Intense pulsed light (IPL): A review. Lasers Surg Med. 2010;42(2):93–104. 2. Xiao A, Ettefagh L. Laser Revision of Scars. 2022 Oct 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 30969508. 3. Seago M, Shumaker PR, Spring LK, et al. Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus

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Recommendations. Lasers Surg Med. 2020 Feb;52(2):96-116. doi: 10.1002/ lsm.23201. Epub 2019 Dec 9. PMID: 31820478. 4. Tidwell WJ, Green C, Jensen D, Ross EV. Clinical evaluation and in-vivo analysis of the performance of a fractional infrared 1550 nm laser system for skin rejuvenation. J Cosmet Laser Ther. 2018 Oct;20(6):360-363. doi: 10.1080 /14764172.2018.1 511915. Epub 2018 Aug 24. PMID: 30142304.

5. Cartier H, Patarin M, Prost ALP. (2020). Use of Intense Pulsed Light in the Treatment of Scars. In: Fodor L, Ullmann Y. (eds) Aesthetic Applications of Intense Pulsed Light. Springer, Cham. https://doi. org/10.1007/978-3-030-228293_15 6. Bjerring P, Christiansen K, Troilius A, Dierickx C. Facial photo rejuvenation using two different intense pulsed light (IPL) wavelength bands. Lasers Surg Med 2004;34:120-6. 7. Schallen KP, Murphy M.

Treatment of photodamaged skin with a combined dual-filter intense pulsed light and fractional 1550-nm laser system. Laser Surg Med. 2020 June;52(S32):S20. 8. Karmisholt KE, Haerskjold A, Karlsmark T, Waibel J, Paasch U, Haedersdal M. Early laser intervention to reduce scar formation–a systematic review. Journal of the European Academy of Dermatology and Venereology. 2018 Jul;32(7):1099-110.

IT’S THE ONE

SWT : The only way to IPL ®

candelamedical.com

AESTHETIC FEATURE | NUTRACEUTICALS |

A NUTRACEUTICAL APPROACH TO

SKIN VITALITY Andre Berger, MD, reviews the place of nutraceuticals in the physician’s armoury to tackle signs of skin ageing

ANDRE BERGER, MD, is a Cosmetic Surgeon and Founder of Rejuvalife Vitality Institute, Beverly Hills, CA, USA email: aberger@rejuvalife.md

COVER STORY KEYWORDS Nutraceuticals, Extracellular Matrix, ECM, skin ageing

ABSTRACT In this article, we embark on a journey to explore the intriguing intersection of aesthetic dermatology and the extracellular matrix (ECM). The understanding of the ECM in the field of aesthetic dermatology has undergone a remarkable transformation, shifting from a mere structural component to a pivotal element that profoundly influences skin health and vitality. Looking towards the future, the potential of the ECM extends far beyond specialty domains, impacting various facets of health and wellness. To fully harness this potential, we must overcome existing barriers and rethink our conceptual frameworks. This includes delving deeper into the mechanisms governing ECM interactions. By gaining valuable insights into how the ECM functions and malfunctions, we can develop a more comprehensive understanding of various disease states and skin conditions.

HE PURSUIT OF YOUTHFUL, healthy‑looking skin has long been a subject of interest and research. In recent years, there has been a growing recognition of the role that nutrition plays in maintaining skin health and preventing the signs of ageing. The objective of this review article is to provide a comprehensive analysis of the nutraceutical approach to skin ageing. By synthesising the existing scientific literature using PubMed, Embase, and Cochrane Library databases, this review aims to delve into the mechanisms, evidence, and potential benefits of nutraceuticals in combating skin ageing. It will explore the diverse range of nutraceuticals utilised in skin care, such as vitamins, minerals, botanical extracts, and other bioactive compounds, and shed light on their specific roles and applications. Furthermore, this review will examine the interactions between nutraceuticals and the extracellular matrix (ECM), the crucial structural component of the skin, as well as explore the potential synergies between nutraceuticals and conventional skincare interventions. Firstly, it is essential to establish a clear understanding of nutraceuticals and their derivation. Nutraceuticals can be defined as food or food components that provide medical or health benefits beyond basic nutrition. Derived from the

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Moreover, this knowledge opens up new avenues for improving treatment strategies, enabling the creation of more effective and personalised approaches to address specific skincare concerns. One particularly promising avenue is the tailored utilisation of nutraceuticals. These compounds hold the potential to enhance skin vitality by targeting the ECM and its associated processes. This underscores the critical importance of understanding the ECM in the realm of aesthetic dermatology. So, why is understanding the ECM so vital? It offers a multitude of benefits, ranging from supporting skin health and mitigating the signs of ageing to addressing a wide array of dermatological issues. In summary, this presentation serves as a call to realise the untapped potential of the ECM in aesthetic dermatology. By comprehending its pivotal role, we can elevate our approach to skincare and wellness, offering tailored solutions that not only promote skin vitality but also enhance overall well-being.

combination of ‘nutrition’ and ‘pharmaceutical,’ the term emphasises the dual nature of these substances, offering both nourishment and potential therapeutic properties. These unique characteristic sets nutraceuticals apart from traditional skincare products and highlights their potential for holistic skin health promotion. The significance of nutraceuticals in skin care and their potential to address skin ageing cannot be overstated. Skin ageing is a multifaceted process influenced by intrinsic factors such as genetics and extrinsic factors such as environmental exposure and lifestyle choices. The accumulation of chronological and environmental damage leads to visible signs of ageing, including wrinkles, sagging, and uneven skin tone. While conventional topical treatments and invasive procedures have long dominated the field of anti-ageing interventions, the recognition of nutrition as a crucial factor in skin health has opened new avenues for preventive and therapeutic approaches.

Definition of skin quality and its importance in maintaining healthy skin Skin quality refers to the overall condition and characteristics of the skin that contribute to its health, appearance, and functionality. It encompasses various attributes that reflect the skin’s hydration, elasticity,

| NUTRACEUTICALS | AESTHETIC FEATURE Nutraceuticals can be defined as food or food components that provide medical or health benefits beyond basic nutrition. Derived from the combination of ‘nutrition’ and ‘pharmaceutical,’ the term emphasises the dual nature of these substances, offering both nourishment and potential therapeutic properties.

prime-journal.com | November/December 2023

AESTHETIC FEATURE | NUTRACEUTICALS | Skin quality attributes

Figure 1 Skin quality attributes

Topographical Visible

Is this what you are documenting? A baseline to demonstrate the benefit of treatment.

Mechanical

Table 1 Skin quality attributes and their definitions ATTRIBUTE

DEFINITION

Uneven pigmentation Redness Dullness/Sallowness Radiance Oiliness/shine Dryness Roughness Fine Lines Coarse Lines Pores Crepiness Hydration Laxity Elasticity/pliability Firmness Thickness

Variations in melanin Erythema or visible heamoglobin Absence of glow; yellowish or grey undertones Ability of skin to ‘glow’ or reflect light Excess sebum on the skin surface Lack of moisture / dehydration Uneven, not level texture Light wrinkles Deep wrinkles Surface landmark of pilosebaceous unit Fine ‘cigarette paper’ wrinkling of skin Water content / moisture Loose skin Ability to recoil after manipulation Relative ability to be stretched Density of the epidermis and dermis

Is this what you are documenting? A baseline to demonstrate the benefit of treatment.

firmness, texture, and overall appearance. Achieving and maintaining optimal skin quality is of paramount importance for individuals seeking to maintain healthy, youthful-looking skin. Healthy skin quality is crucial for several reasons. Firstly, the skin acts as a protective barrier against environmental aggressors, pathogens, and harmful ultraviolet (UV) radiation. A well-maintained skin barrier is essential in preventing water loss, maintaining proper hydration levels, and shielding the underlying tissues from damage. Secondly, skin quality influences the skin’s ability to heal wounds and resist infections. Optimal skin quality facilitates the regeneration of skin cells, ensuring efficient tissue repair and minimising the risk of complications. Finally, skin quality plays a vital role in aesthetic aspects, as it greatly contributes to the overall appearance, texture, and youthfulness of the skin.

Defining attributes of skin quality Several attributes contribute to skin quality, each playing a crucial role in maintaining healthy and vibrant skin (Figure 1, Table 1).

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■ Visible attributes: Redness, dullness, sallowness, radiance, shine, uneven pigmentation ■ Topographical attributes: Roughness, fine lines, course lines, dryness, pores ■ Mechanical attributes: Crepiness, laxity, hydration, elasticity, pliability, firmness, thickness. Hydration: Adequate hydration is essential for maintaining skin health and function. Well-hydrated skin appears plump, smooth, and supple. Proper hydration levels promote optimal skin barrier function, preventing excessive water loss and protecting against external irritants. Conversely, dehydrated skin can become dry, dull, and prone to irritation and premature ageing. Elasticity: Skin elasticity refers to its ability to stretch and return to its original shape. Elastic skin is resilient and exhibits a firm and smooth texture. Loss of elasticity is a common sign of skin ageing, resulting in sagging, fine lines, and wrinkles. Maintaining skin elasticity is crucial for maintaining a youthful appearance and minimizing the visible signs of ageing. Firmness: Skin firmness refers to the tautness and tightness of the skin. Firm skin appears lifted and toned, while loss of firmness can lead to sagging and a loss of facial contours. Collagen and elastin fibres in the skin provide structural support and contribute to skin firmness. Maintaining firmness is essential for a youthful and rejuvenated appearance. Texture: Skin texture refers to the smoothness, evenness, and uniformity of the skin’s surface. Healthy skin has a smooth texture, while uneven texture can manifest as roughness, uneven pigmentation, or blemishes. An improved skin texture contributes to a more radiant and youthful appearance. Overall appearance: The overall appearance of the skin encompasses its brightness, clarity, and uniformity of colour. Healthy skin appears luminous and radiant, while skin with poor overall appearance may appear dull, sallow, or uneven in tone. Achieving a balanced and even skin tone is an essential aspect of skin quality.

Types of nutraceuticals used in skin care The integration of nutraceuticals into skincare regimens has gained considerable attention due to their potential to promote skin health and combat the signs of ageing. Nutraceuticals encompass a wide range of bioactive compounds derived from natural sources, including vitamins, minerals, botanical extracts, and other phytochemicals. These substances offer a holistic approach to skincare by providing essential nutrients and exerting various beneficial effects on the skin.

Overview of key nutraceuticals used in skin care Vitamins

Vitamins play a crucial role in skin health and are commonly utilised as nutraceuticals in skincare formulations. In general, higher levels of water-soluble vitamins are harmless, with the excess excreted in urine.

| NUTRACEUTICALS | AESTHETIC FEATURE Fat-soluble vitamins can accumulate in the liver; hence, excess consumption should be avoided. ■ Fat-soluble vitamins » Vitamin A: protects against UV damage and slows signs of ageing, encourages the production of new skin cells, strengthens the skin barrier, and promotes cellular turnover and collagen synthesis, thus improving skin texture and reducing the appearance of wrinkles » Vitamin D: maintains general skin health, supports wound healing and tissue repair, and protects against photo-ageing and cancer » Vitamin E: possesses antioxidant properties and aids in skin hydration and barrier function » Vitamin K. ■ Water Soluble Vitamins » Biotin (Vitamin B7): little evidence » Folate (Folic Acid, Vitamin B9): skin appearance and texture — new skin cells and collagen formation » Vitamin B6: dry Skin, dermatitis, eczema — removes chemical toxins » Vitamin B12: DNA synthesis and fat and protein metabolism » Vitamin C: acts as a potent antioxidant, protecting the skin from oxidative stress and supporting collagen production. Vitamins play a vital role in maintaining skin health and are commonly used in nutraceutical formulations targeting skin ageing. Vitamin C (ascorbic acid) is a potent antioxidant that not only protects the skin against oxidative stress but also promotes collagen synthesis, leading to improved skin firmness and the reduced appearance of wrinkles. Vitamin E (tocopherol) is another powerful antioxidant that helps protect the skin from environmental damage and supports skin hydration. Vitamin A derivatives, such as retinol and retinyl palmitate, have been extensively studied for their ability to stimulate collagen production, enhance skin cell turnover, and improve overall skin texture and tone.

Minerals Certain minerals also play a crucial role in skin health and are utilised in nutraceutical approaches to combat skin ageing. Zinc is known for its anti-inflammatory properties and is involved in collagen synthesis. Its deficiency can impair wound healing and contribute to skin conditions such as acne. Selenium, another essential mineral, possesses antioxidant properties and helps protect the skin from UV-induced damage. Copper is involved in the synthesis of elastin and collagen, promoting skin elasticity and firmness. ■ Calcium: promotes new skin cell growth, helps retain skin moisture, and helps prevent skin cancer ■ Copper: contributes to collagen production and helps maintain the skin’s elasticity ■ Magnesium: improves skin texture and appearance, relieves atopic dermatitis-associated dryness, and helps underlying causes of acne ■ Selenium: acts as an antioxidant and supports the skin’s defence against UV-induced damage ■ Zinc: plays a vital role in wound healing and sebum

regulation, making it valuable in addressing acne-prone skin ■ Silicon: helps improve skin health and elasticity as well as helps improve hair and nail health.

Botanicals

Vitamin A: protects against UV damage and slows signs of ageing, encourages the production of new skin cells, strengthens the skin barrier, and promotes cellular turnover and collagen synthesis, thus improving skin texture and reducing the appearance of wrinkles.

Botanical extracts are another important category of nutraceuticals used in skin care: ■ Antioxidants » Astaxanthin (‘king of antioxidants’) » Lutein and zeaxanthin » Lycopene » Quercetin » Resveratrol » Coenzyme Q10 » Curcumin » Capsaicin » Alfa Lipoic Acid » N-Acetylcysteine. ■ Essential fatty acids (non-dry, non-flakey skin) ■ Hyaluronic acid (‘Beauty from within’) ■ Collagen peptides (hydrolyzed collagen — essential amino acids, such as glycine, hydroxyproline, proline) ■ Mushrooms: modulate inflammation, neutralise free radicals, increase blood flow to the skin, down-regulate histamine-mediated allergic responses ■ Ceramides: barrier function ■ Probiotics: balance skin microbiome ■ Nitric oxide supplements: promote vasodilation. ■ Glutathione: poor oral absorption ■ NAD+: cellular repair. These extracts harness the power of plants, offering a plethora of bioactive compounds that possess diverse properties beneficial for the skin. Botanical extracts have long been used in traditional medicine and are increasingly recognised for their potential in skin care. Green tea extract, rich in polyphenols, has shown antioxidant and antiinflammatory effects, protecting the skin from damage and reducing signs of ageing. Grape seed extract contains proanthocyanins, which have been found to enhance collagen synthesis and improve skin elasticity. Aloe vera extract is known for its soothing and moisturising properties, promoting skin hydration and reducing inflammation. These are just a few examples of the numerous botanicals used in nutraceutical formulations for skin ageing.

Other ingredients In addition to vitamins, minerals, and botanicals, other ingredients such as collagen peptides, hyaluronic acid, coenzyme Q10, and omega-3 fatty acids are commonly included in nutraceutical products for skin ageing. Collagen peptides, derived from hydrolyzed collagen, can improve skin hydration, elasticity, and overall skin texture. Hyaluronic acid is a natural component of the skin that helps retain moisture and enhance skin plumpness. Coenzyme Q10 is an antioxidant that supports cellular energy production and protects against oxidative damage. Omega-3 fatty acids, typically derived from fish oil, possess anti-inflammatory properties and contribute to skin barrier function.

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Mechanisms of action of nutraceuticals in improving skin health and preventing skin ageing

Overview of the extracellular matrix and its role in maintaining skin structure and function

Nutraceuticals exert their effects on skin health through various mechanisms of action. One key mechanism is their antioxidant activity. Many nutraceuticals are rich in antioxidants, which scavenge free radicals and protect the skin from oxidative stress. By reducing oxidative damage, nutraceuticals can help prevent premature ageing, including the formation of wrinkles and age spots. Another mechanism involves the modulation of inflammation. Chronic inflammation contributes to skin ageing by impairing collagen synthesis and promoting the breakdown of the extracellular matrix. Nutraceuticals with anti-inflammatory properties, such as omega-3 fatty acids and curcumin, can help mitigate inflammation and maintain skin health. Nutraceuticals also support collagen synthesis and maintenance. Collagen is a crucial protein in the extracellular matrix, providing structural support and elasticity to the skin. Nutraceuticals like collagen peptides, resveratrol, and certain plant extracts can stimulate collagen production, improving skin firmness and reducing the appearance of fine lines and wrinkles. Furthermore, nutraceuticals may influence gene expression and cellular signalling pathways involved in skin ageing. For instance, certain polyphenols found in botanical extracts can modulate gene expression related to collagen synthesis and antioxidant defence, thereby promoting youthful skin.

The ECM is a complex network of proteins and other molecules that provide structural support and regulate cellular behaviour within tissues. In the context of skin, the ECM is a critical component that plays a vital role in maintaining its structure, integrity, and function. Composed primarily of collagen, elastin, proteoglycans, and glycoproteins, the ECM provides mechanical strength, elasticity, and hydration to the skin. Collagen, the most abundant protein in the ECM, forms a fibrillar network that gives the skin its structural integrity and tensile strength. Elastin, on the other hand, confers elasticity and allows the skin to recoil after stretching or deformation. Proteoglycans, such as hyaluronic acid, contribute to the hydration and lubrication of the skin, while glycoproteins, including fibronectin and laminin, mediate cell-matrix interactions and regulate various cellular processes. The ECM also serves as a reservoir for growth factors, cytokines, and other bioactive molecules that regulate cell signalling, tissue repair, and remodelling. It acts as a dynamic microenvironment that influences cellular behaviour, including cell migration, proliferation, differentiation, and synthesis of ECM components.

Scientific evidence supporting the effectiveness of nutraceuticals in skincare The effectiveness of nutraceuticals in improving skin health and preventing skin ageing is supported by a growing body of scientific evidence. Numerous in vitro and in vivo studies have demonstrated the beneficial effects of specific nutraceuticals on various aspects of skin ageing, including wrinkle reduction, increased collagen production, and improved skin hydration. Clinical trials have also provided evidence of the efficacy of nutraceuticals in skincare. For instance, studies have shown that oral supplementation with collagen peptides can enhance skin elasticity and reduce the appearance of wrinkles. Similarly, the topical application of vitamin C has been shown to improve skin tone and texture. Moreover, advancements in bioavailability and delivery systems have improved the efficacy of nutraceuticals in reaching the target layers of the skin. Nanoencapsulation and liposomal technologies, for instance, enable better absorption and penetration of nutraceuticals, maximising their potential benefits.

Overview of the key constituents of the extracellular matrix Collagen is a crucial protein in the extracellular matrix, providing structural support and elasticity to the skin.

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The ECM is a complex network composed of various constituents that collectively contribute to the structural integrity and function of the skin. Understanding the key components of the ECM is essential for comprehending their interactions and their impact on skin ageing (Figure 2). Collagen is the predominant protein in the ECM and provides structural support and tensile strength to the skin. It forms fibrils and networks that contribute to the skin’s elasticity and firmness. Elastin, another important ECM component, imparts elasticity and resilience to the skin, allowing it to stretch and recoil. Glycosaminoglycans (GAGs) and proteoglycans are polysaccharide-rich molecules found within the ECM. GAGs, such as hyaluronic acid, chondroitin sulfate, and dermatan sulfate, attract water molecules and contribute to the hydration and viscosity of the skin. Proteoglycans, which consist of a core protein with attached GAG chains, support the ECM structure and play a role in cell-matrix interactions.

Importance of the ECM as a therapeutic target in skin ageing During the ageing process, the ECM undergoes significant alterations, leading to structural changes and functional decline in the skin. These changes include decreased collagen and elastin synthesis, increased collagen degradation, accumulation of abnormal cross-links, and decreased hydration. As a result, the skin becomes less firm, loses elasticity, and develops wrinkles, fine lines, and sagging. Targeting the ECM as a therapeutic approach to skin

| NUTRACEUTICALS | AESTHETIC FEATURE ageing has gained considerable attention. By modulating ECM components and their interactions, it is possible to promote ECM remodelling, restore skin structure, and improve its overall function. Nutraceutical interventions have emerged as promising strategies to support ECM health and counteract the signs of skin ageing.

Potential effects of nutraceutical interventions on ECM health and function Nutraceuticals have been extensively studied for their potential effects on ECM health and function. Various ingredients found in nutraceuticals have shown the ability to stimulate collagen synthesis, enhance elastin production, inhibit collagen degradation enzymes, and promote ECM remodelling. For instance, certain vitamins, such as vitamin C and vitamin E, are involved in collagen synthesis and have antioxidant properties that protect the ECM from oxidative damage. Polyphenols, found in botanical extracts like green tea, grape seed, and pomegranate, exhibit anti-inflammatory and antioxidant effects, supporting ECM integrity and preventing collagen degradation. Additionally, dietary supplements containing collagen peptides, hyaluronic acid, and other ECM components have gained popularity in skin health and anti-ageing regimens. These nutraceuticals provide the necessary building blocks for ECM synthesis and support hydration, elasticity, and firmness. Furthermore, nutraceuticals rich in antioxidants, such as astaxanthin and resveratrol, can scavenge free radicals, reduce oxidative stress, and prevent ECM damage. Omega-3 fatty acids, commonly found in fish oil, have antiinflammatory properties that can attenuate inflammationinduced ECM degradation. Although further research is needed to fully elucidate the mechanisms and efficacy of nutraceutical interventions on the ECM, emerging evidence suggests their potential to modulate ECM health and function, ultimately promoting skin rejuvenation and combating skin ageing. ECM plays a crucial role in maintaining skin structure and function. Targeting the ECM as a therapeutic approach to skin ageing holds great promise. Nutraceutical interventions have demonstrated potential in promoting ECM remodelling, supporting collagen synthesis, inhibiting degradation enzymes, and improving overall skin health. Further studies are necessary to validate the effectiveness and optimal use of nutraceuticals for targeting the ECM in the context of skin ageing.

Interactions between ECM components and their impact on skin elasticity, firmness, and resilience The interactions between ECM components are crucial for maintaining the integrity and functional properties of the skin. Collagen and elastin interact to provide the skin with its elasticity, allowing it to stretch and recoil without losing its shape. Collagen fibrils provide the structural framework, while elastin fibres allow the skin to regain its original

Figure 2 ECM constituents

Epithelial cells Specifically, the ECM is comprised of an interlocking mesh of glycosaminoglycans and fibrous proteins.

NON-CELLULAR COMPOUNDS • Heparan sulfate • Hyaluronic acid • Chondroitin sulfate • Collagen • Keratan sulfate • Fibronectin • Laminin • Elastin CELLULAR COMPOUNDS • Fibroblasts • Chondrocytes • Osteoblasts • Stem cells

Macrophage

Basal lamina Fibroblasts

Elastic fibres

Capillary

Mast cell GAGs Collagen fibres

position after deformation. The cross-linking between collagen molecules, mediated by enzymes such as lysyl oxidase, contributes to the stability and strength of the ECM. GAGs and proteoglycans play important roles in the hydration and viscoelastic properties of the skin. GAGs attract and retain water molecules, maintaining skin Understanding hydration and plumpness. The hydration of the ECM is the key components vital for maintaining the turgidity and resilience of the skin. Proteoglycans, with their negatively charged GAG of the ECM is chains, create a hydrated gel-like environment that essential for supports cell-matrix interactions, modulates signalling pathways, and facilitates nutrient transport. comprehending Moreover, interactions between ECM components their interactions and cells are essential for maintaining tissue and their impact on homeostasis and regulating cellular behaviour. Cell skin ageing. surface receptors, such as integrins, mediate the attachment of cells to ECM components, enabling cellular signalling and communication. These interactions are vital for cell migration, proliferation, differentiation, and ECM synthesis. Disruptions in the interactions within the ECM can lead to the loss of skin elasticity, firmness, and resilience observed during skin ageing. Degradation of collagen and elastin fibres, alterations in the composition and organization of GAGs and proteoglycans, and changes in cross-linking mechanisms can compromise the structural integrity and functional properties of the ECM. The constituents of the ECM, including collagen, elastin, GAGs, and proteoglycans, interact with one another to maintain skin elasticity, firmness, and resilience. Disruptions in these interactions contribute to the signs of skin ageing. Understanding the complex interplay between ECM components is crucial for

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developing nutraceutical approaches that target the ECM to promote healthy skin ageing.

ECM proteins from damage. They scavenge free radicals, reduce MMP activity, and promote collagen synthesis, thereby preserving the integrity of the ECM. Other nutraceuticals, such as omega-3 fatty acids, have been shown to modulate inflammatory responses and inhibit the production of inflammatory mediators. By reducing inflammation, these compounds can mitigate ECM degradation and promote a healthier ECM environment. Additionally, nutraceuticals rich in amino acids, such as proline and lysine, provide essential building blocks for collagen synthesis. They support the production of new collagen fibres and help maintain the structural integrity of the ECM. The use of nutraceuticals in topical formulations and oral supplements has shown promising results in restoring ECM health and improving skin ageing outcomes. However, further research is necessary to optimise their formulation, dosing, and delivery methods for maximum efficacy. An unhealthy ECM is a hallmark of skin ageing and is influenced by intrinsic and extrinsic factors. Nutraceuticals offer a potential solution to restore ECM health and function by counteracting oxidative stress, inflammation, and collagen degradation. Incorporating nutraceuticals into skincare formulations and dietary interventions may represent a promising approach for promoting a healthy ECM and combating skin ageing.

Factors contributing to an unhealthy ECM The ECM undergoes various changes during the ageing process and in response to external factors, leading to an unhealthy ECM. Several factors contribute to these alterations, including intrinsic ageing, chronic exposure to UV radiation, oxidative stress, inflammation, hormonal changes, and lifestyle factors. Intrinsic ageing is a natural process characterised by the gradual decline in cellular functions and ECM remodelling. It leads to a decrease in the production of ECM components, such as collagen and elastin, and a reduction in their quality. As a result, the ECM becomes less organised and less supportive, leading to a loss of skin elasticity, firmness, and resilience. Chronic exposure to UV radiation is a major extrinsic factor that accelerates ECM degradation. UV radiation stimulates the production of matrix metalloproteinases (MMPs), enzymes responsible for degrading collagen and elastin fibres. The excessive activity of MMPs leads to the breakdown of ECM components and impairs the structural integrity of the skin. UV radiation also promotes the generation of reactive oxygen species (ROS), inducing oxidative stress and further damaging the ECM. Oxidative stress, which occurs when there is an imbalance between the production of ROS and the body’s antioxidant defences, can directly affect the ECM. ROS can modify ECM proteins, cross-linking them abnormally and impairing their function. Additionally, oxidative stress can activate signalling pathways that contribute to ECM degradation and impair the synthesis of ECM components.

Consequences of an unhealthy ECM for skin ageing An unhealthy ECM has significant consequences for skin ageing. The loss of collagen and elastin fibres results in a decrease in skin elasticity and firmness, leading to the formation of wrinkles, fine lines, and sagging skin. The compromised structural integrity of the ECM also impairs the skin’s ability to retain moisture, leading to dryness and an uneven texture. Moreover, an unhealthy ECM disrupts the normal cellmatrix interactions necessary for maintaining tissue homeostasis. It affects the communication between cells and the ECM, leading to alterations in cell behaviour, impaired tissue repair processes, and delayed wound healing. The compromised ECM also creates a favourable environment for the development of chronic inflammatory conditions, further contributing to skin ageing.

Green tea extract, rich in polyphenols, has been shown to enhance collagen synthesis and inhibit MMP activity, thus preserving the ECM structure.

Potential of nutraceuticals to restore ECM health and function Various nutraceuticals have demonstrated beneficial effects on ECM components. For instance, certain antioxidants, such as vitamins C and E, polyphenols, and carotenoids, can help mitigate oxidative stress and protect

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Influence of essential nutrients on ECM synthesis, remodelling, and repair Vitamins, such as vitamin C, vitamin E, and vitamin A, have been extensively studied for their role in ECM health. Vitamin C is a vital cofactor for collagen synthesis, promoting the formation of stable collagen fibres. It also acts as an antioxidant, protecting the ECM from oxidative damage. Vitamin E, another potent antioxidant, helps maintain the integrity of ECM proteins by preventing lipid peroxidation. Vitamin A supports ECM remodelling by regulating the synthesis and degradation of collagen and other ECM components. Minerals, including zinc, copper, and selenium, are essential for ECM synthesis and stability. Zinc is a cofactor for enzymes involved in collagen synthesis and crosslinking, while copper is crucial for the maturation of collagen molecules. Selenium contributes to the antioxidant defence system, protecting the ECM from oxidative stress-induced damage. Botanicals, such as green tea extract, grape seed extract, and aloe vera, contain bioactive compounds that can influence ECM health. Green tea extract, rich in polyphenols, has been shown to enhance collagen synthesis and inhibit MMP activity, thus preserving the ECM structure. Grape seed extract exhibits antioxidant properties and promotes collagen synthesis, contributing to ECM integrity. Aloe vera contains polysaccharides and other

| NUTRACEUTICALS | AESTHETIC FEATURE bioactive compounds that stimulate collagen production and enhance ECM repair processes.

collectively contribute to the loss of overall skin quality. The visible signs of skin ageing, including wrinkles, sagging, uneven texture, and a dull complexion, are closely associated with the structural and functional changes occurring within the ECM.

The role of nutrition in supporting ECM integrity and function Nutrition plays a vital role in supporting ECM integrity and function. Adequate intake of essential nutrients ensures the availability of substrates and cofactors necessary for ECM synthesis, maintenance, and repair processes. These nutrients contribute to the formation of robust collagen and elastin fibres, provide antioxidant protection against ECM damage, and support the overall structure and function of the ECM. Furthermore, nutrition influences the balance between ECM synthesis and degradation. An imbalance in this process can lead to ECM abnormalities and contribute to skin ageing. Proper nutrition helps maintain this balance by promoting collagen synthesis and inhibiting excessive ECM degradation through the regulation of MMP activity.

Potential of nutraceuticals to counteract ECM ageing Nutraceuticals offer promising potential to counteract ECM ageing and mitigate the visible signs of skin ageing. Many nutraceuticals possess antioxidant properties that can combat oxidative stress and protect the ECM components from damage. They can scavenge free radicals, reduce inflammation, and enhance the skin’s natural defence mechanisms against oxidative stress. Furthermore, nutraceuticals may modulate enzymatic activities involved in ECM remodelling. Some nutraceuticals exhibit inhibitory effects on MMPs, helping to maintain a balanced turnover of ECM proteins and prevent excessive degradation. Certain nutraceuticals also possess anti-glycation properties, preventing the formation of AGEs and reducing the cross-linking of proteins within the ECM. By inhibiting glycation, these nutraceuticals may help preserve the flexibility and functionality of the ECM. Scientific research has shown promising evidence supporting the effectiveness of various nutraceuticals in targeting ECM ageing. However, further studies are needed to elucidate the specific mechanisms of action, optimal dosages, and long-term effects of nutraceutical interventions on ECM health and function.

Common drug-induced nutrient depletions that may affect ECM health Certain medications can induce nutrient depletions, which may have implications for ECM health. For example, longterm use of corticosteroids can deplete vitamin C levels, impairing collagen synthesis and ECM integrity. Nonsteroidal anti-inflammatory drugs (NSAIDs), commonly used for pain management, can inhibit collagen synthesis and disrupt ECM homeostasis by interfering with prostaglandin production. Additionally, medications that affect nutrient absorption, such as proton pump inhibitors (PPIs) used for gastric acid suppression, can lead to deficiencies in minerals like magnesium and calcium. These minerals play a vital role in ECM structure and function, and their depletion can negatively impact ECM health. Awareness of drug-induced nutrient depletions is crucial in the context of ECM health and skin ageing. Healthcare professionals should consider potential nutrient deficiencies and provide appropriate guidance or supplementation to mitigate any adverse effects on the ECM.

Impact of ECM ageing on skin appearance and function The ageing-related changes in the ECM have a profound impact on skin appearance and function. As the ECM undergoes structural alterations, the skin loses its elasticity, firmness, and resilience. Fine lines and wrinkles become more prominent, and the skin may appear thinner and more fragile. The diminished ECM integrity also affects the skin’s ability to retain moisture. With age, the ECM loses its capacity to hold water, resulting in reduced skin hydration and a dry, rough texture. Furthermore, the altered ECM composition and organization can impair the skin’s barrier function, making it more susceptible to environmental damage and water loss. The ECM ageing mechanisms discussed above

Definition and components of the matrisome

Nutraceuticals offer promising potential to counteract ECM ageing and mitigate the visible signs of skin ageing. Many nutraceuticals possess antioxidant properties that can combat oxidative stress and protect the ECM components from damage.

The matrisome refers to the complex mixture of proteins and other macromolecules that constitute the extracellular matrix (ECM). It encompasses a diverse array of components, including structural proteins, glycoproteins, proteoglycans, and matricellular proteins. These constituents work in harmony to provide structural support, regulate cellular behaviour, and maintain ECM homeostasis. The matrisome can be broadly classified into two categories: core matrisome and matrisome-associated proteins. The core matrisome consists of essential ECM proteins, such as collagen, elastin, and glycosaminoglycans (GAGs). These proteins form the structural backbone of the ECM and contribute to its mechanical properties, including elasticity and tensile strength. Matrisome-associated proteins, on the other hand, play regulatory roles and mediate various cellular processes within the ECM.

Role of the matrisome in maintaining ECM homeostasis and skin health The matrisome plays a crucial role in maintaining ECM homeostasis, which is essential for healthy skin. It provides the structural framework that supports the epidermis and dermis, ensuring their proper organization and function. The components of the matrisome interact with cells, signalling molecules, and other ECM components to

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orchestrate a dynamic microenvironment that influences cellular behaviour, tissue remodelling, and repair processes. One of the key functions of the matrisome is to regulate cell behaviour, including cell adhesion, migration, and proliferation. By providing adhesive sites and binding partners, the matrisome influences cell attachment and movement within the ECM. It also acts as a reservoir for growth factors, cytokines, and other signalling molecules, modulating their bioavailability and spatial distribution, thereby influencing cell function and tissue repair processes. Additionally, the matrisome contributes to the hydration and moisture retention properties of the skin. GAGs, such as hyaluronic acid, within the matrisome can bind and retain water molecules, maintaining optimal skin hydration and contributing to its plumpness and smoothness.

Potential modulation of the matrisome by nutraceuticals in skin ageing Nutraceutical interventions hold potential in modulating the matrisome and promoting ECM health in skin ageing. Various nutraceuticals have been identified to influence the synthesis, remodelling, and turnover of ECM components, thus impacting matrisome. The modulation of the microsome by nutraceuticals represents a promising avenue for addressing skin ageing. However, further research is needed to elucidate the specific mechanisms of action, optimal combinations of nutraceuticals, and their long-term effects on the matrisome and skin health.

Combination therapies and their potential synergistic effects on ECM health Combination therapies involving the simultaneous use of multiple nutraceuticals have gained interest in the field of skin ageing. These approaches aim to capitalise on the potential synergistic effects of different compounds to address multiple aspects of extracellular alterations in a comprehensive manner. For example, a combination of nutraceuticals that stimulate collagen synthesis, inhibit MMP activity, and enhance GAG synthesis can provide a holistic approach to rejuvenating the ECM. By simultaneously addressing different aspects of ECM health, these combination therapies have the potential to deliver more significant improvements in skin quality and appearance compared to single-agent interventions. Furthermore, combining nutraceuticals with other established anti-ageing modalities, such as topical retinoids or cosmetic procedures like laser therapy or microneedling, may yield synergistic effects. These combination therapies can work in concert to target both the extracellular and cellular components of skin ageing, optimising the overall outcomes.

However, it is important to note that the efficacy and safety of combination therapies should be carefully evaluated through rigorous research and clinical trials. Understanding the potential interactions, dosage considerations, and individual variations in response to combination treatments will be crucial in maximizing their benefits and minimising any adverse effects.

Common drug-induced nutrient depletions

Nutraceutical interventions hold potential in modulating the matrisome and promoting ECM health in skin ageing. Various nutraceuticals have been identified to influence the synthesis, remodelling, and turnover of ECM components, thus impacting matrisome.

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In the pursuit of managing various health conditions, individuals often rely on prescription medications. While these medications can be beneficial, it is important to consider their potential impact on nutrient status, as certain drugs can deplete essential nutrients that are relevant to skin health. Here, we discuss some commonly prescribed drugs and their potential effects on nutrient levels.

Antacids and Proton Pump Inhibitors (PPIs) Antacids and PPIs are frequently prescribed for the treatment of acid reflux and peptic ulcers. However, longterm use of these medications can interfere with the absorption of several key nutrients. PPIs, for example, can reduce the absorption of vitamin B12, which is essential for DNA synthesis and cell division. Vitamin B12 deficiency has been associated with skin manifestations such as hyperpigmentation and dermatitis.

Oral contraceptives Oral contraceptives are widely used for birth control and the management of hormonal imbalances. However, they can deplete certain nutrients, including B vitamins such as folate, vitamin B6, and vitamin B12. These vitamins are essential for skin health, as they play a role in DNA synthesis, collagen formation, and skin cell turnover. Deficiencies in these vitamins may contribute to skin problems such as dryness, dullness, and impaired wound healing.

Statins Statins are commonly prescribed for the management of high cholesterol levels. While these medications are effective in reducing cardiovascular risk, they may interfere with the production of coenzyme Q10 (CoQ10) in the body. CoQ10 is an antioxidant that plays a crucial role in cellular energy production and skin protection against oxidative damage. Depletion of CoQ10 may impact skin health and accelerate the ageing process.

Diuretics Diuretics are frequently prescribed for conditions such as hypertension and oedema. These medications increase urine production, leading to the loss of water and electrolytes, including potassium and magnesium.

| NUTRACEUTICALS | AESTHETIC FEATURE Potassium is essential for maintaining proper skin hydration and regulating fluid balance, while magnesium is involved in collagen synthesis and maintaining skin elasticity. Depletion of these electrolytes may compromise skin health and contribute to dryness and loss of elasticity.

Corticosteroids Corticosteroids are potent anti-inflammatory drugs used to manage various skin conditions, including eczema and psoriasis. However, long-term use of corticosteroids can lead to nutrient deficiencies, particularly vitamin D and calcium. Vitamin D plays a crucial role in skin health, as it regulates immune function, promotes wound healing, and supports skin barrier integrity. Calcium is important for maintaining skin structure and strength. Deficiencies in these nutrients may negatively impact skin health and contribute to impaired healing and compromised skin function. It is important for healthcare professionals and individuals using these medications to be aware of the potential nutrient depletions they may cause. Regular monitoring of nutrient levels and appropriate supplementation, if necessary, can help mitigate the effects of drug-induced nutrient depletions on skin health. Additionally, incorporating nutrient-rich foods and a balanced diet can also contribute to maintaining optimal nutrient status for healthy skin.

Conclusion The nutraceutical approach to skin vitality offers a promising avenue for maintaining skin health and combating the signs of ageing. Nutraceuticals, including vitamins, minerals, botanicals, and other ingredients, have shown potential in improving skin appearance and addressing extracellular alterations associated with ageing. Through various mechanisms of action, nutraceuticals can support the synthesis, remodelling, and repair of the ECM, which plays a crucial role in maintaining skin structure and function. They can help restore ECM health, promoting skin elasticity, firmness, and resilience. Additionally, nutraceutical interventions have been shown to counteract the detrimental effects of ageing, UV

Key points The understanding of the extracellular matrix (ECM) in aesthetic dermatology has evolved significantly, recognising its role as a pivotal element influencing skin health and vitality. The ECM’s potential extends beyond aesthetics, impacting various aspects of health and wellness, necessitating a reevaluation of existing concepts and mechanisms governing ECM interactions. Insights into ECM functions and dysfunctions provide a comprehensive understanding of various disease states and skin conditions, paving the way for more effective and personalised skincare treatments. Tailored use of nutraceuticals targeting the ECM and associated processes offers promising avenues for enhancing skin vitality and addressing specific skincare concerns.

radiation, oxidative stress, and other factors on the ECM. The matrisome, comprising collagen, elastin, glycosaminoglycans, and proteoglycans, is a key component of the ECM. Nutraceuticals have the potential to modulate the matrisome, contributing to ECM homeostasis and skin health. Moreover, the influence of essential nutrients on ECM synthesis, remodelling, and repair cannot be overstated. Nutritional support plays a crucial role in maintaining ECM integrity and function, as well as supporting overall skin health. However, it is important to consider the potential impact of commonly prescribed medications on nutrient status, as drug-induced nutrient depletions can affect ECM health and skin appearance. Scientific evidence supports the efficacy of nutraceuticals in improving skin appearance and combating skin ageing. Studies have demonstrated their ability to enhance hydration, elasticity, firmness, texture, and overall skin quality. Moreover, combination therapies involving multiple nutraceuticals and their synergistic effects have shown promising results in promoting ECM health and mitigating skin ageing. The growing trend of using nutraceuticals in skin care highlights the increasing interest in natural and holistic approaches to promote skin health and combat the signs of ageing. However, further research is needed to elucidate the optimal formulations, dosages, and treatment regimens for different nutraceuticals, as well as their long-term effects on skin ageing. Future research should continue to explore the mechanisms of action, optimal formulations, and clinical efficacy of nutraceuticals, paving the way for evidence-based recommendations in the field of skin care and ageing. Declaration of interest None Figures 1 & 2 Courtesy of Andre Berger reproduced by PRIME Journal

References 1. Jenkins G. Molecular mechanisms of skin ageing. Mech Ageing Dev. 2002 Jul;123(7):801-10. 2. Varani J, et al. Vitamin A antagonizes decreased cell growth and elevated collagen-degrading matrix metalloproteinases and stimulates collagen accumulation in naturally aged human skin. J Invest Dermatol. 2000 Nov;115(5):882-8. 3. Pullar JM, et al. The Roles of Vitamin C in Skin Health. Nutrients. 2017 Aug 12;9(8):866. 4. Kim HH, et al. Modulation of collagen metabolism by the topical application of dehydroepiandrosterone to human skin. J Invest Dermatol. 2004 Mar;122(3):701-7. 5. Pullar JM, et al. The Roles of Copper and Vitamin C in Skin Health. Nutrients. 2017 Aug 28;9(8):866. 6. Costa A, et al. The Dark Side of the Human Skin: A Journey Through Sun-induced DNA Damage. Pigment Cell Melanoma Res. 2015 Sep;28(5):569-90. 7. Park K. Role of Micronutrients in Skin Health and Function. Biomol Ther (Seoul).

2015 Sep;23(3):207-17. 8. Schagen SK, et al. Discovering the link between nutrition and skin ageing. Dermatoendocrinol. 2012 Jul 1;4(3):298-307. 9. Binic I, et al. Skin ageing: natural weapons and strategies. Evid Based Complement Alternat Med. 2013;2013:827248. 10. Meyer AL, et al. Polyphenols and Aging: Focus on Inflammation. Inflammation, Aging, and Oxidative Stress. Springer, Cham, 2016. 335-352. 11. Farage MA, Miller KW, Elsner P, Maibach HI. Characteristics of the Aging Skin. Adv Wound Care (New Rochelle). 2013 Jul;2(5): 5-10. 12. Del Bino S, et al. Ultraviolet radiation and the skin: Photobiology and sunscreen photoprotection. J Am Acad Dermatol. 2011 Dec; 64(6): 892-905. 13. Gupta M, et al. Diet and Skin Aging-From the Perspective of Food Nutrition. J Cosmet Dermatol. 2020 Dec;19(12): 3087-3098.

14. Pullar JM, et al. The Roles of Vitamin C in Skin Health. Nutrients. 2017 Aug 12; 9(8): 866. 15. Afaq F, et al. Polyphenols: Skin Photoprotection and Inhibition of Photocarcinogenesis. Mini Rev Med Chem. 2011 Dec; 11(14): 1200-1215. 16. Schagen SK, et al. Discovering the link between nutrition and skin ageing. Dermatoendocrinol. 2012 Jul; 4(3): 298-307. 17. Asserin J, et al. The effect of oral collagen peptide supplementation on skin moisture and the dermal collagen network: evidence from an ex vivo model and randomized, placebo-controlled clinical trials. J Cosmet Dermatol. 2015 Dec; 14(4): 291-301. 18. Rhie G, et al. Aging- and photoaging-dependent changes of enzymic and nonenzymic antioxidants in the epidermis and dermis of human skin in vivo. J Invest Dermatol. 2001 Jul; 117(1): 1212-1217. 19. Heinrich U, et al. Green tea polyphenols provide photoprotection,

increase microcirculation, and modulate skin properties of women. J Nutr. 2011 Jun; 141(6): 1202-1208. 20. Pilkington SM, et al. Intake of Water and Other Fluids and Their Relationship with Skin Hydration in Healthy Women: A Systematic Review. Nutrients. 2019 Jan 7; 11(1): 70. 21. Moghimipour E, et al. The Effect of Astaxanthin on the Skin Elasticity of Postmenopausal Women. J Med Food. 2017 Jun; 20(6): 588-594. 22. De Spirt S, et al. An oral supplement enriched with fish oil, resveratrol, lycopene, and vitamins C and E increases skin elasticity in women. Nutr Res. 2018 Jun; 54: 1-10. 23. Heinrich U, et al. Green tea polyphenols provide photoprotection, increase microcirculation, and modulate skin properties of women. J Nutr. 2011 Jun; 141(6): 1202-1208. 24. Saric S, et al. Skin Ageing: Natural Weapons and Strategies. Evid Based Complement Alternat Med. 2013; 2013: 827248.

25. Darvin ME, et al. Influence of Nutrition on Skin Aging and Aesthetic Dermatology. Dermatology. 2014; 226(4): 256-268. 26. Wijnhoven SWP, et al. The Potential Benefits and Limitations of Strawberries in a Functional Food for Human Health. Front Nutr. 2019; 6: 1. 27. Tundis R, et al. Functional Ingredients from the Sea for Nutraceutical Products. Mar Drugs. 2016 Oct; 14(10): 1-13. 28. Rodrigues LMG, et al. The role of natural antioxidants in the prevention of UV-induced skin damage. Int J Mol Sci. 2016 Jun; 17(6): 1-15. 29. Park JH, et al. The effect of niacinamide on reducing cutaneous pigmentation and suppression of melanosome transfer. Br J Dermatol. 2011 Oct; 165(4): 1023-1030. 30. Ganceviciene R, et al. Skin anti-ageing strategies. Dermatoendocrinol. 2012 Jul; 4(3): 308-319.

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AESTHETIC FEATURE | ANTI-AGEING |

THE HALLMARKS OF AGEING AND HOW TO ADDRESS THEM IN ANTI-AGEING CLINICAL PRACTICE

Michael Sagner, MD, highlights the need to go beyond treating the external signs of ageing and address the underlying hallmarks of ageing to better ensure a healthy lifespan for patients ABSTRACT The world is in the midst of a severe health crisis. Despite increases in life expectancy globally, health at older age is declining and chronic noncommunicable diseases (i.e., lifestyle-related diseases) have become the leading cause of premature death and disability in almost all countries on the planet. This is due to a change in lifestyles and longer lifespans, which exposes the human body to more stressors across the lifespan and increases the prevalence of ageing-related chronic diseases. Despite advances in scientific understanding of the biological processes of ageing, effective interventions to address the hallmarks of ageing still revolve largely around lifestyle changes. New bio-pharmaceutical interventions promise to prevent ageing-related diseases and improve healthspan.

GEING IS NOT A DISEASE. ALL living organisms undergo ageing processes and ultimately die. Most biological processes associated with ageing begin at the very moment of conception and ultimately lead to the death of cells and the organism. Disease, however, is not necessarily an outcome of ageing. Unfortunately, due to changes in lifestyles (nutrition, less physical activity, psychological stress and social factors), most people will enter their last decades in life with one or multiple chronic conditions such as hypertension, insulin resistance, sarcopenia, lipidemia and others, which ultimately lead to diseases such as type-2diabetes, cancer, stroke and myocardial infarction and neurodegenerative diseases which have become the leading causes of death globally. The increase in life expectancy that was observed over the last 100 years is mainly due to improvements in hygiene and a reduction in infant mortality rather than due to other scientific discoveries or breakthroughs in the field of ageing research. With longer lives (lifespan), we unfortunately also experience an increase in ageing-related chronic diseases. The goal must, therefore, be to maintain good health for as long

as possible across the course of one’s life (healthspan). Ageing is driven by hallmarks fulfilling the following three premises: ■ Their age-associated manifestation, as observed in ageing humans over decades ■ The acceleration of ageing by experimentally accentuating them, such as skin and UV exposure ■ The opportunity to decelerate, stop, or reverse ageing by therapeutic interventions on them, such as established and experimental drugs like metformin or rapamycin. These processes interact and are not independent of each other in a complex biological system.

MICHAEL SAGNER, MD, Ageing Research at King’s College, Faculty of Life Sciences and Medicine; European Society of Preventive Medicine, Sarena Clinic London, UK email: sagner@esprevmed.org

Hallmarks of ageing New ‘ageing clocks’ allow us to determine the disparity between biological and chronological age, which can reflect the efficacy of age-accelerating or decelerating interventions. Standardised physiological measurements (e.g., respirometry to measure basal and maximal energy expenditure), functional tests (e.g., at the sensory, psychomotor, and cognitive levels), and ever more sophisticated ‘omics’ technologies (e.g., genomics, epigenomics, transcriptomics, proteomics, and metabolomics), often applied at the single-cell level,

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KEYWORDS Biostimulation, connective tissue, extracellular matrix

| ANTI-AGEING | AESTHETIC FEATURE With longer lives (lifespan), we unfortunately also experience an increase in ageing-related chronic diseases. The goal must, therefore, be to maintain good health for as long as possible across the course of one’s life.

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AESTHETIC FEATURE | ANTI-AGEING |

are instrumental for evaluating the spatiotemporal patterns of health degradation and the (in)efficacy of anti-ageing strategies. All currently described 12 hallmarks of ageing are strongly related to each other; they include: ■ Genomic instability ■ Epigenetic alterations ■ Loss of proteostasis ■ Disabled macroautophagy ■ Deregulated nutrientsensing ■ Mitochondrial dysfunction ■ Cellular senescence ■ Stem cell exhaustion ■ Altered intercellular communication ■ Chronic inflammation ■ Dysbiosis and Gut Microbiota Changes.

Interventions addressing nutrition, regular physical activity, sleep, stress, and psychosocial factors have been shown to prevent ageing-related diseases and improve health biomarkers such as inflammation.

Clinical interventions to address ageing Addressing the hallmarks of ageing and pathomechanisms is mainly achieved through lifestyle interventions, which are currently shown to have the strongest impact on health outcomes. For example, interventions addressing nutrition, regular physical activity, sleep, stress, and psychosocial factors have been shown to prevent ageing-related diseases and improve health biomarkers such as inflammation. Inflammation increases during ageing (‘inflammaging’) with systemic manifestations, as well as with pathological local phenotypes including arteriosclerosis, neuroinflammation, osteoarthritis and others. New pharmaceutical and biological interventions are being tested to address either singular or multiple hallmarks of ageing. Promising results have been seen with compounds such as metformin, rapamycin, NMN, aspirin, small molecules, immunotherapy, and others. Although many of these interventions are still far from reaching the bedside, it is conceivable that they will significantly improve the way we treat and prevent agerelated diseases in the following decades. An example is the popular idea of increasing telomere length with the hypothesis that it increases cell longevity. Unfortunately, the complexity of telomeres should discourage us from pursuing them as a therapeutic, as

depressed patients show an increase in telomere length, and cancer cells show an increase in telomerase. In a personal conversation, Elizabeth Blackburn, who won the Nobel Prize for her work on telomeres, discouraged any clinical interventions for telomere length at this point. Ageing is associated with reduced tissue renewal at a steady state, as well as with impaired tissue repair upon injury, with each organ having its own strategy for renewal and repair. Regenerating ‘old’ tissue is a goal of regenerative medicine interventions, which are currently being explored in research settings.

Conclusions Key points Ageing is not a disease but an inevitable condition of life Healthy ageing should be a priority and is possible with new interventions Preventing chronic diseases should be at the core of any anti-ageing programme Lifestyle optimisation are effective to support any aesthetic or plastic surgery intervention and can improve outcomes significantly Aesthetic practicioners should do include preventive medicine for every patient

In clinical practice, healthy ageing across the patient’s lifespan should be a priority for all clinicians and specialities. Focusing solely on external appearance or aesthetics without addressing the hallmarks of ageing is a common shortcoming of medical practitioners in the field. Practitioners who see patients for aesthetic treatments or plastic surgery should perform a basic health check: blood pressure, heart rate, waist-to-hip ratio, and, if possible, a lipid and glucose panel to assess the health status which will impact any aesthetic or anti-ageing intervention. The key therapeutic with the strongest evidence to address the hallmarks of ageing and the main causes of premature death and illness, cancer, type 2 diabetes and cardiovascular diseases is lifestyle (nutrition, exercise, smoking cessation and psychosocial interventions). Treatments to address aesthetics should be added as a layer on top of the fundamental ‘anti-ageing’ medicine principles. Declaration of interest None

References 1. Carlos López-Otín. Cell . 2023 Jan 19;186(2):243-278. doi: 10.1016/j.cell.2022.11.001. Epub 2023 Jan 3. Hallmarks of aging: An expanding universe 2. Tomas Schmauck-Medina. Aging (Albany NY) . 2022 Aug 29;14(16):6829-6839. doi: 10.18632/aging.204248. Epub 2022 Aug 29. New hallmarks of ageing: a 2022 Copenhagen ageing

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meeting summary 3. Carlos López-Otín. Cell . 2013 Jun 6;153(6):1194-217. doi: 10.1016/j.cell.2013.05.039. The hallmarks of aging 4. Luana Toniolo. Histol Histopathol . 2023 Jun;38(6):597-605. doi: 10.14670/HH-18-576. Epub 2022 Dec 16. Experimental models for ageing research

12-13 J U LY 2024

BUSINESS DESIGN CENTRE, LONDON, UNITED KINGDOM

Under the scientific super vision of the Aesthetic Multispecialt y Societ y (AMS)

WWW.FACECONFERENCE.COM

AESTHETIC FEATURE | SCAR TREATMENT |

November/December 2023 | prime-journal.com

| SCAR TREATMENT | AESTHETIC FEATURE

TREATMENT OF TRAUMATIC SCARS THE UKRAINIAN EXPERIENCE

Vladlena Averina, MD, and Olena Grisha, MD, explain how aesthetic dermatology is helping in the rehabilitation of post-war injuries ABSTRACT Scarring is a huge burden on world healthcare, and the global scar treatment market is projected to represent as much as $34.9 billion by the year 2023. Scarring can lead to many adverse side effects (beyond the aesthetic), such as reduced mobility, compromised function in organs such as the liver or kidney, development of functional disabilities, anxiety, depression, or even the serious consequence of suicide. In this article, the authors talk about their clinical experience treating scars and traumatic skin lesions caused by the ongoing conflict in Ukraine.

As the number of patients increased, Dr Averina organised the charity project ZAGRAVA, which provides dermatological rehabilitation for those injured during the war. We had the opportunity to share our experience during the AMWC Monaco 2023 session on scars.

Traumatic scars

Traumatic scars are the results of wound healing after tissue injury. Scars are caused by the dysregulation of N THIS ARTICLE, WE WOULD LIKE TO TALK proliferation and apoptosis of fibroblasts, an imbalance about our clinical experience in adjusting between the synthesis and degradation of collagen in the aesthetic and dermatological protocols for the extracellular matrix, and the abnormal structure of the treatment of severe burns and scars after epithelium. shelling. The prevalence of hypertrophic scars, the most Ukraine is known in the medical anti-ageing common type of traumatic scar, is reported to be as high community as a developed and growing market for as 70% after burn injuries. Wound healing is influenced aesthetic treatments. by a number of environmental and genetic factors. Since the full-scale Russian invasion, we, and our We should take into consideration the critical colleagues in aesthetic dermatology, characteristics of scars, which include: have been providing specific The first military ■ Pigmentation medical care in post-emergency female patient in our ■ Erythema cases when patients need correction ■ Texture clinic was sent to us in ■ Thickness of scars and traumatic skin lesions May 2022 by an ■ Pliability. due to wounds, burns, and shrapnel injuries. All such treatments we Patient evaluation should be ophthalmologist provide for free. approximately 2 to 3 months after injury colleague from the or final reconstructive surgery. The first military female patient in hospital after she had our clinic was sent to us in May 2022 To know when we should start our by an ophthalmologist colleague two operations on her treatment and create an appropriate from the hospital after she had two eyes to remove plastic protocol, we should first understand the operations on her eyes to remove stages of wound healing: fragments after a car ■ Stage 1: Swelling (hemostasis, plastic fragments after a car explosion. explosion. inflammation). Blood vessels at the

VLADLENA AVERINA, MD, is a dermatovenerologist, Head of Averina clinic, Founder of charity organization ZAGRAVA; OLENA GRISHA, MD, Dermatologist, Averina clinic, Kyiv, Ukraine email: dr.averina1998@gmail.com

KEYWORDS Scars, Traumatic scars, burns, IPL, Lasers

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AESTHETIC FEATURE | SCAR TREATMENT |

Figure 1 Summary of lasers, intense pulsed light (IPL), radiofrequency and ultrasound for traumatic scars Devices

Mechanism

Clinical outcome

Pulsed dye laser, potassium titanyl phosphate laser, and intense pulsed light

Target hemoglobin and decrease blood supply; increase expression of CTGF

Improve scar colour, texture, and pliability

Factional lasers

Fractional photothermolysis and collagen remodeling

Improve in appearance and contracture relieve pain and pruritus and facilitate drug delivery

Radiofrequency devices

Create micro-plasma sparks and induce thermolysis

Effective for both hypertrophic and atrophic scars and facilitate drug delivery

Ultrasound

Acoustic pressure and ‘hammering’ effect

Adjuvant therapy for traumatic scar

Treatment for traumatic tattoo (A) Before and (B) after treatment

site of the cut start to form clots to prevent the loss of too much blood. White blood cells move into the wound, working as infection-control agents that fight bacteria. This phase can last up to six days after surgery; symptoms are redness and swelling. ■ Stage 2: Rebuilding (proliferation). This stage lasts about four days to a month after surgery. A scar will start to form on the cut. The edges will come together with some thickening of the skin or new red bumps inside the wound. Sharp, shooting pains are normal and signal you are getting sensations back in the nerves. ■ Stage 3: Remodeling -(maturation). The wound has filled, and a new surface has formed. This stage lasts between six months and two years. The scar goes from thick, raised and red to flat and thin. The general management of traumatic scars includes multicomponent methods: ■ Surgical

Key points It is important to understand the stages of wound healing Treating traumatic scars requires a combination of modalities Lasers are the mainstay for scar treatment and it would be difficult to reach the high level of results without them

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■ Non-surgical interventions (pressure therapy, silicone, corticosteroid, radiotherapy) ■ Laser, intense pulsed light (IPL), PDT, radiofrequency, ultrasound ■ Injectables (PDRN, PRP, BoNT-A, enzymes, exosomes, HA with amino acids, succinate). Multiple treatments are usually needed. Scar treatment is a long process and can take between 6 months to 2–3 years. A very important fact is that effective early wound care is important to minimise scar formation. Modern scar treatment is quite difficult without lasers and other machines. Laser scar revision utilises photothermal energy to target intra- and extra-cellular structures within scar tissue to stimulate the remodelling of dermal collagen and elastin. Ablative laser resurfacing, with CO2 or Er:YAG lasers, has been shown to be effective for traumatic and surgical scars, especially when resurfaced within 6 to 10 weeks after trauma or surgery or even immediately after surgery.

For traumatic scar with tissue deficit on the arm after a shrapnel injury, we begin with fractional laser three times at 3-week intervals, followed by PRP in and around the scar for four sessions with 2–3 weeks intervals. Fractional ablative laser resurfacing has emerged as a popular treatment modality for atrophic and surgical scars. In fractional ablative resurfacing, columns of thermal damage (microscopic thermal treatment zones) are separated by surrounding untreated skin, resulting in rapid re-epithelialisation and reduced downtime as only a fraction of skin is altered. In our practice, we use modern protocols with instrumental, injectable and topical treatment for scars and can even combine them with surgical excision and reconstruction of tissue. For traumatic tattoos, we use the following protocol after topical or infiltrating anaesthesia (Figure 1). ■ uncovering skin with the ablative Er:YAG laser 2940 nm for the deep pieces ■ Mechanical removal with 18G needle and forceps ■ Radiofrequency removal with the help of rough tissue for superficial pieces ■ PRP therapy every month for two sessions (3–4 procedures) ■ One session of polydeoxyribonucleotide (PDRN) in 3–4 weeks (3–4 procedures) ■ Topical cream with polynucleotides. It is almost impossible to remove everything at once: hundreds of small fragments of black plastic, each one had to be processed and removed separately. For mixed scars with embedded small pieces of glass (Figure 2), the protocol was as follows: ■ PDRN once per 2–3 weeks

| SCAR TREATMENT | AESTHETIC FEATURE ■ Fractional laser once per month ■ Botulinum toxin in dilution 1:2 in and around the scar for two sessions with a 3 months interval between sessions ■ IPL once ■ Silicone plaster for 2 months ■ Topical cream with polynucleotides. We were able to remove some glass pieces during treatment; however, some pieces were too small and deep, making it impossible to take them out. This created a problem for recovery. For traumatic scars with tissue deficit on the arm after a shrapnel injury, we begin with fractional laser three times at 3-week intervals, followed by PRP in and around the scar for four sessions with 2–3 weeks intervals. Next comes enzyme injections (collagenase, lyase) two times at 1-month intervals. The patient’s ability to extend their hand was much improved during the treatment. Cicatricial changes require treatments every 2–4 weeks, with either a laser or polynucleotide injections. At the beginning of treatment, we draw up the entire protocol, and if a patient is unable to travel to our clinic, we ask colleagues from another clinic in the ZAGRAVA charity project in different cities to work according to this protocol. In any case, the patient can use our protocol to complete the treatment at any convenient clinic.

Conclusion We are very grateful to other Dermatological Societies for participating in our charity programme to restore the health of patients affected by the war and also for sharing their knowledge with our doctors. For now, ZAGRAVA provides training for more than 200 Ukrainian doctors in Europe and Asia. Unfortunately, we have a growing number of these patients in our country, and we must be ready to help professionally. Declaration of interest None

Figure 2 Treatment for mixed scars and embedded glass. (A) Before and (B) fractional laser treatment, (C) botulinum toxin treatment, (D) after treatment protocol

Fractional ablative laser resurfacing has emerged as a popular treatment modality for atrophic and surgical scars. In fractional ablative resurfacing, columns of thermal damage (microscopic thermal treatment zones) are separated by surrounding untreated skin, resulting in rapid re-epithelialisation and reduced downtime as only a fraction of skin is altered.

References 1. Research and Markets. Global Scar Treatment Market 2013-2018 & 2023 Rise In Online Retailing Of Scar Treatment Products. Available at: https://www.prnewswire.com/ news-releases/global-scar-treatmentmarket-2013-2018–2023—rise-in-onlineretailing-of-scar-treatmentproducts-300698219.html 2. Jagdeo J, Shumaker PR. Traumatic scarring JAMA Dermatol. 2017;153(3):364. doi:10.1001/ jamadermatol.2016.5232 3. Bayat A, McGrouther DA. Skin scarring. BMJ. 2003 Jan 11; 326(7380): 88–92.doi: 10.1136/bmj.3 26.7380.88 4. Xiujun Fu, Jiying Dong, Shen Wang,

Min Yan, Min Yao. Advances in the treatment of traumatic scars with laser, intense pulsed light, radiofrequency, and ultrasound. Burns & Trauma, Volume 7, 2019, s41038-018-01410, Available at: https://doi.org/10.1186/ s41038-018-0141-0 5. Tanzi EL,Alster TS, Laser treatment of scars. Skin therapy letter. 2004 Jan; [PubMed PMID: 14716440] 6. Khatri KA,Mahoney DL,McCartney MJ, Laser scar revision: A review. Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology. 2011 Apr; [PubMed PMID: 21401378]

Figure 3 Treatment for traumatic scar with tissue deficit following a shrapnel injury. (A) Before and (B) after treatment protocol

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PROMOTION

SECRET 1540 NM ERBIUM GLASS LASER TREATMENT FOR HAIR REGROWTH IN ANDROGENETIC ALOPECIA Singapore-based Sin Yong, MBBS, discusses the mode of action and clinical results he experienced using the Secret 1540 nm non-ablative fractional erbium glass laser for hair regrowth

SIN YONG, MBBS, MRCS (Edinburgh), MSc Practical Dermatology (UK), MSc Aesthetic Medicine (UK), Laser Surgery and Aesthetic Doctor, White Clinic, Singapore

ECRET DUO IS AN FDA‑approved system with unique capabilities of microneedle radiofrequency and a 1540 nm erbium-glass laser, which allows for combination approaches. This case study focuses on evaluating the efficacy and safety of the non-ablative fractional erbium glass laser alone in hair regrowth.

Treatment A male with Fitzpatrick skin type IV (age 64) with a history of androgenetic alopecia and no other forms of medication or therapy. He underwent two sessions of the 1540 nm nonablative erbium glass laser at 4-week intervals. Pre-treatment photographs were taken, while post-treatment photographs were taken 4 weeks after the last treatment session. The treatment protocol was based on personal experience with erbium glass lasers and tissue reactions and titrated to affect for each patient. Prior to treatment, the areas affected by androgenetic alopecia were assessed and the treatment boundary planned 1 cm beyond visible areas of reduced hair loss. Topical anaesthesia was applied to the treatment area for 20 minutes before commencement. Treatment was conducted with the help of an assistant to separate the hair with two combs to expose the scalp underneath. I-motion was selected with 10.8 mJ using the 300 µm lens under CW mode, where a total of 3 complete passes were performed in the first session. Gradual titration of increased energy was performed for the second session based on the patient’s ability to

Figure 1 (A) view of the vertex before any treatments commenced, and (B) taken at the 3 month mark, 1 month after the second session of treatment.

tolerate the pain. For the first session, two passes of 300µm lens, 8.4 mJ energy with a distance 0.6 mm random. An additional pass of 10.8 mJ with distance 0.6 mm I-motion was used thereafter to areas that are more affected by hair loss. For the second session, two passes of 300 µm lens, 9.6 mJ energy with distance 0.6 mm random. An additional pass of 10.8 mJ with distance 0.6 mm I-motion was used thereafter to areas that are more affected by hair loss. Mild erythema was noted as the end point. The patient felt some light prickly sensation but it resolved after a few hours. Post-treatment recommendations included the avoidance of direct exposure to sunlight or sun tanning for two weeks. Patient had no restrictions in normal activity. Patient was followed up 1 month after the last treatment. No side effects were experienced (Figure 1).

laser has demonstrated improvements in hair density of about 10% after two sessions. Based on the initial findings, further improvement can be achieved with increased sessions. The effects from 1540 nm laser micro trauma is similar to microneedling and aims to stimulate angiogenesis as a postulated pathway to improving androgenetic alopecia. It is likely that the 1540 nm laser aids in upregulation of key proteins involved in hair synthesis, though standardisation of the treatment protocol, such as irradiance time and irradiance level has to be set for each respective device to deliver the optimum irradiance for hair stimulation. Lasers and light therapy can definitely play a role in the treatment armamentarium for patients with androgenetic alopecia, especially in patients who are averse to side effects of conventional oral finasteride and topical minoxidi.

Conclusion

For more information, visit eng.ilooda.com

The non-ablative fractional 1540 nm

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PROMOTION

PROPOSAL OF SOLUTIONS FOR MILD INFLAMMATORY SKIN AND RECOVERY OF SKIN DAMAGE AFTER LASER TREATMENT Jongmin Park, MD, discusses the uses for cosmetic skinboosters with exosomes in clinical practice

JONGMIN PARK, MD, is a Board certified Dermatologist, Director of ZELL dermatology and cosmetic laser centre, Seoul, Korea

ECENTLY, IN THE Republic of Korea, interest in natural and gradual skin improvement has grown in the antiageing field, and various types of skinboosters have become very popular. How to improve their skin condition is a huge concern for many people, and the procedures to improve skin condition are being advanced and diversified. These include superficial injection of soft hyaluronic acid gel into the skin, use of polynucleotides (PN) type injections, injection of polymer stimulating agents such as poly-L-lactic acid (PLLA) and poly-D, L-lactic acid (PDLLA), and recently using cosmetic skinboosters with exosomes.

Introducing plant exosomes Exosomes are a type of nano-sized (30–200 nm) extracellular vehicles that are produced within cells and released into the extracellular environment. They are informationtransporting materials that are secreted to transfer information between approximately 200 known types of cells in the human body1. Essentially, exosomes play a role in transporting biological substances such as proteins, fats, metabolites, and nucleic acids to recipient cells. Proteins transported by exosomes include integrins, MHC molecules, and cytoskeleton

proteins2. Proteins or RNA expressed in specific cells can transfer to other cells through exosomes. Exosomes have various functions, including cell proliferation, inflammation control, anticancer, antioxidant, immune control, tissue regeneration, and intestinal symbiotic bacteria control. In particular, plant exosomes have recently attracted great attention in biomedical medicine. In general, plant-derived exosomes are characterised by lower immunogenicity, no cytotoxicity, natural anti-inflammatory activity, and high biocompatibility3,4 compared to animal-derived exosomes. Various studies are continuing to better understand the interrelationship, and although progress remains to be made, according to a series of recent studies, plant-derived exosomes are known to have a high level of biological activity and are effective in wound healing and skin regeneration5.

Uses for plant exosome skinboosters The effects of skinboosters containing exosomes are generally known as anti-ageing, anti-

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inflammatory, and wound healing. Two areas in clinical practice skinboosters can be of use are improving the skin quality of chronic inflammatory skin, and second, increasing the effectiveness and reducing side-effects after laser treatment. First, when applied to patients with seborrheic skin or mild acne related to sebaceous glands and folliculitis, exosome alleviated inflammation, reduced skin trouble, and improved redness in the long term. For patients with highly inflamed cystic acne-prone skin or seborrheic dermatitis, professional treatment such as drug treatment is necessary. The case in Figure 1 is a beforeand-after comparative photo after the EXO’LUTION™ was applied three times at two-week intervals. It can be seen that the sebum level, an indicator of oil-moisture balance, has clearly improved compared to before the treatment. Patients with seborrheic skin who are at high risk of inflammation and have mild skin trouble can experience anti-inflammatory effects and oil-moisture balance in the short term through the active ingredients and plant exosomes in EXO’LUTION™.

“Two areas in clinical practice skinboosters can be of use are improving the skin quality of chronic inflammatory skin, and second, increasing the effectiveness and reducing side-effects after laser treatment.”

Figure 1 Comparison images after three treatments with EXO’LUTION™ in December 2022. (A) BeforeThe effect of sebum and moisture control is confirmed. Data on file, JETEMA.

possibility of temporary skin problems caused by high-output thermal energy, which often leaves temporary or long-lasting pigmentation. To reduce this possibility of skin problems, including pigmentation, it is highly recommended to apply a skinbooster as a preventive measure. Accordingly, I am actively applying the skinbooster EXO’LUTION™ in the finishing step of all laser treatments performed at my clinic. Many patients demand bright, clean, and elastic skin without blemishes, so at my clinic, treatments such as the 1927 nm Thulium laser, microneedle RF, and Pico laser are used frequently. In particular, the Thulium laser with a wavelength of 1927 nm is a fractional laser specialised for pigment alleviation and is popular because it can be expected to reduce pore sizes and improve skin texture along with improving pigmentation and skin tone. However, at times, pigmentation or existing freckles may worsen. Treatment with EXO’LUTION™ skinbooster after laser treatment

can add to the inflammation relief effect and pigmentation improvement effect to the original advantages of laser, so applying EXO’LUTION™ skinbooster contributes to increasing the satisfaction level of patients. Skin dryness after laser treatment can be prevented and alleviated with the moisturising effect of a skinbooster. You can create differentiation of treatment at your clinic by using cosmetic skinboosters rather than pharmaceuticals as an in-hospital

Sebum and Moisture Control 60

No.of sebum

In Figure 2, Exosome-only skinbooster ASCE+ (ExoCoBio, Republic of Korea) was applied to the skin on the patient’s right side, and EXO’LUTION™ (JETEMA, Republic of Korea) was applied to the skin on the patient’s left side. Visual observation confirmed that both skin problems did not worsen, and inflammation was improved. As a result of confirmation through patient consultation, it was stated that the effect was shown on both sides, with no difference in the results between the right and left sides. He was particularly satisfied with the increased moisture level of the skin and the alleviation of skin trouble. In conclusion, in the case of seborrheic skin or acne skin types that are accompanied by long-term inflammation, I think that improvement in these symptoms can be expected when exosomes are applied alone or used in combination with a sebum (blackhead) extraction procedure. In addition, in the case of vasodilator-mediated flushing, a vascular laser is necessary and effective. However, in the case of red and sensitive inflammatory flushing that appears secondary to chronic inflammatory skin, the response of the laser is significantly poor. In this case, the application of a skinbooster containing exosomes with an anti-inflammatory effect could be a good alternative. The second application of exosomes is as a routine prescription after laser treatment, which can cause inflammation. Laser treatment is generally a procedure that causes thermal damage and then regenerates the damaged tissue. There is a

1st

2nd

30 20 10 0

Before

3rd

prime-journal.com | November/December 2023

PROMOTION

PROPOSAL OF SOLUTIONS FOR MILD INFLAMMATORY SKIN AND RECOVERY OF SKIN DAMAGE AFTER LASER TREATMENT

(continued)

ASCE+

EXO'LUTION

Figure 2 Split face study (Right side of patient ASCE+, ExoCoBio, Republic of Korea / Left side of the patient EXO’LUTION™, JETEMA, Republic of Korea). (A) Before. (B) After four weeks. Apr. 2023. Data on file, JETEMA.

Table 1 Ingredients of EXO’LUTION™ VIAL 1: 61 INGREDIENTS

VIAL 2: 5 TYPES OF PLANT EXOSOME

25 types of amino acids

Cica exosome

9 types of minerals

Red ginseng exosome

15 types of vitamins

Salvia exosome

Glutathione

Edelweiss exosome

2 types of co-enzymes

Heartleaf exosome

3 types of nucleic acids Different molecule size of HA

protocol. Skinbooster is recommended not only because it is effective in improving skin conditions but also because it has the advantage of differentiating the treatment protocol.

Conclusions EXO’LUTION™ Vial 1 consists of a total of 61 effective ingredients, including amino acids, minerals, vitamins, glutathione, co-enzymes, and hyaluronic acid. Since most people’s skin is basically tired and damaged

from external stimulation, these active ingredients help by adjusting the skin balance. EXO’LUTION™ is essentially a multivitamin for the skin. EXO’LUTION™ Vial 2 is composed of 5 types of plant exosomes, so it can be expected to have anti-inflammatory effects, making it suitable for preventing minor skin trouble and reducing the inflammation that can occur after laser treatment. Recommended areas of application: ■ When trying to improve the symptoms of patients with mild

November/December 2023 | prime-journal.com

seborrheic skin ■ When trying to prevent temporary damage, pigmentation, and dryness caused by a laser treatment. Depending on the patient’s condition and desired outcome, a variety of products and treatments may need to be selected. Since patients want to improve their skin safely, painlessly, and comfortably but also do not want to suffer any side effects after the procedure, the use of skinboosters to meet both of these requirements is an inevitable choice at modern cosmetic skin care centres. For more information, contact global@jetema.com

Further Reading 1. Pegtel DM, Exosomes, Annual Review of Biochemistry, 2019, 88, 487-514 2. Kalluri R. The biology, function, and biomedical applications of exosomes, Science, 2020, 367, eaau6977 3. Shkryl Y, et al. Plant exosomal vesicles: perspective information nanocarriers in biomedicine. Applied Sciences, 2022, 12.16: 8262.

4. Karamanidou T, Tsouknidas A. Plant-Derived Extracellular Vesicles as Therapeutic Nano carriers. Int. J. Mol. Sci. 2021: 23, 191. 5. Orefice NS, et al. Purposing plant-derived exosomes-like nanovesicles for drug delivery: patents and literature review. Expert Opinion on Therapeutic Patents, 2023, 33. 2: 89-100

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PROMOTION

ATTIVA® S.I.H. TECHNOLOGY: A THRIVING ITALIAN JOURNEY INCLUDING FDA CERTIFICATION ACHIEVEMENT AND UNITED STATES MARKET ENTRY Tema Medicina explains how ATTIVA’s subdermal induced heat technology is reshaping regenerative medicine

OR YEARS, THE MEDICALaesthetic field had been searching for fresh opportunities in the realm of regenerative medicine. A full eight years have transpired since this groundbreaking technology, known as ATTIVA Subdermal Induced Heat Technology, made its debut in the world of Aesthetic Medicine, both in Italy and across the globe. ATTIVA, a radiofrequency innovation, was meticulously crafted to offer three distinct modes of operation: ■ Endodermic: This mode involves specialized cannulas containing a thermal sensor. ■ Exodermal: Equipped with patented ceramic handpieces that function in a capacitive mode. ■ Vaginal: Featuring unique endo- and exo-vaginal handpieces, ensuring the patient’s privacy is fully respected and independence from the operator. Since its initial introduction, ATTIVA has garnered substantial interest within

Below: Prof. Giorgio Maullu (right) and Dr. Jack Zamora (left) at the Clinic of Dr Zamora in Denver, CO, USA

the Italian medical community. It was heralded as an efficient and secure technology that did not necessitate an extensive learning curve to deliver results. Notably, its endodermic mode promised surgical-like outcomes without the associated postoperative side effects or complications. Over the course of its first three years, every conceivable condition and technical enhancement was explored to make it progressively more effective and user-friendly. Similarly, in the global market, which is continuously evolving, ATTIVA’s treatments consistently stood out for their enduring benefits to patients and their ease of use, all while ensuring the safety of the operator. Affirming these characteristics, in February 2023, ATTIVA achieved the coveted FDA certification in the United States. This certification marked its entry into the U.S. market, leading to a remarkable surge in the number of treatments administered. The triumph of this accomplishment primarily stems from two fundamental aspects that set ATTIVA apart: safety and efficacy.

Safety and efficacy ATTIVA is an endodermal radiofrequency and its use in this mode involves special cannulas. The safety aspect is twofold, both for the patient and for the operator. This is due to the fact that there is precise control of the temperature of the cannula inserted in the subcutaneous tissue which is obtained via a sensor housed inside the cannula (thermocouple) and at the same instant monitoring of the skin surface by means of a special thermal camera that projects onto the machine monitor not only a numerical value but also the chromatic

November/December 2023 | prime-journal.com

heat diffusion achieved. In this way, whichever temperature the operator uses, it is controlled both in terms of depth and on the surface, eliminating any possibility of burns or adverse reactions. The same control conditions exist for the exodermic and vaginal modes. With CRISMENC, the Center for Research and Development in Aesthetic Medicine at the University of Sassari (Italy), led by Professor Alessio Pirino and Professor Giorgio Maullu, and the Center of the University of Verona (Italy), led by Professor Andrea Sbarbati, the structural and biochemical changes obtained in tissues after undergoing endodermic treatment were evaluated in volunteers subjected to in vivo biopsies.

Advanced temperature control to achieve the best regenerative stimulation The first clinical results were encouraging; in fact, the treated tissues appeared brighter and firmer, ptosis was greatly reduced and, most importantly, they lasted for many months, even more than 18. The photos presented show the remarkable result of skin retraction and improvement in appearance, confirmed by the histological results in which the increase in papillary ridges, increase in connective thickness and the absence of lamellar spaces in the loose connective tissue at six months after treatment, compared to the pre-treatment time, is determined. Further investigations on the subject have shown that the optimal temperature for stem cell stimulation is 46/48 degrees. This has revolutionised the use of ATTIVA: anaesthesia is not necessary for tissue regeneration treatments! Therefore, evident from the in-depth study of the connective tissue,

“I love Attiva because it works. I can finally treat those hard to treat areas because of the advanced technology and size of cannulas available. Attiva is performed in the office and delivers immediate results. It is definitely a game changer in our clinic.” — Dr Jack Zamora

Figure 1 Skin analysis (A) before treatment (B) 3 months after, and (C) 6 months after treatment. Note the skin retraction and improvement in appearance, confirmed by the histological results in which the increase in papillary ridges, increase in connective thickness and the absence of lamellar spaces in the loose connective tissue at six months after treatment, compared to the pre-treatment tissue

Figure 2 (A) Before and (B) after treatment

Figure 3 (A) Before and (B) after treatment

Figure 4 (A) Before and (B) after treatment

the stimulation of the direct and indirect piezo-electric effect that the treatment induces, as well as the heat, contributes to the regenerative stimulation of all tissues, including the involvement of the district immune system. The possibility of having a specific but controllable temperature for each use has expanded the boundaries for the uses of the technology. In fact, it ranges from treating axillary hyperhidrosis permanently with just a few sessions to treating double chins or critical areas, such as the inner thighs and arms, with long-lasting results. This diversity of treatments is always linked to the common denominator: safety and efficacy. ATTIVA’s success can be attributed to its remarkable efficiency in treating the intricate connective tissue structure. The controlled application of heat, which permeates all tissue planes, coupled with the mechanical impact of the cannula used during the procedure, engages with the microvacuolar structures within the extracellular matrix, ultimately triggering biophysical and regenerative responses. This naturally potent effect has enthralled the American medical-aesthetic community, which had long been in search of fresh opportunities within the field of regenerative medicine. The unparalleled results achieved with ATTIVA have sparked global interest in S.I.H Technology, as this treatment knows no seasonal or climate-related limitations. Find out more at: www.attivarf.com

prime-journal.com | November/December 2023

EVENTS CALENDAR |

events

Industry events in 2023/24 for the aesthetic and anti-ageing market

NORTH AMERICA

REST OF WORLD

16–18 MAY 2024

1–3 DECEMBER 2023

18–19 NOVEMBER 2023

VISAGE 2023

EADV Symposium

Beauty Through Science

AMWC Japan

Monte Carlo, Monaco

St Julian’s, Malta

www.visagecourse.com

eadv.org/symposium

17–19 NOVEMBER 2023

30 MAY – 1 JUNE 2024

AMWC Americas

ICAD 2023

SCARS 2023

Beauty Through Science 2024

Miami, FL

Bangkok, Thailand

Berlin, Germany

Stockholm, Sweden

www.amwcamericas.com

www.icad-conference.com

www.scars-meeting.com/

www.btsstockholm.com

EUROPE 17–18 NOVEMBER 2023

15–16 MARCH 2024

13–16 JUNE 2024

ACE 2024

5-CC World Congress 2024

London, UK

Lisbon, Portugal

www.aestheticsconference.com/

www.5-cc.com

27–29 MARCH 2024

12–13 JULY 2024

AMWC 2024

FACE 2024

Monte Carlo, Monaco

London, UK

www.euromedicom.com

www.faceconference.com

66 November/December 2023 | prime-journal.com

New York, NY

Kyoto, Japan

www.bts-newyork.com/nyc

www.amwc-japan.com/en

22–24 FEBRUARY 2024

23–25 NOVEMBER 2023

30 MAY – 1 JUNE 2024

24–26 MAY 2024

Vegas Cosmetic Surgery

AMWC ASIA TDAC

Las Vegas, NV

Taipei, Taiwan

www.vegascosmeticsurgery.com

www.amwc-asia.com

EXPERTISE EVIDENCE

EXCELLENCE ENGAGEMENT

27-28-29 MARCH 2024 MONTE-CARLO, MONACO GRIMALDI FORUM

Under the High Patronage of H.S.H. Prince Albert II of Monaco

Under the scientiﬁc supervision of the Aesthetic Multispecialty Society (AMS)

WWW.AMWC-CONFERENCE.COM

❚

All Eyes On Dubai ICAD 2023 Lasers And Lights To Treat Scars Industry News And Events

November/December 2023 ❙ Volume 13 ❙ Issue 6

Nov/Dec 2023 Volume 13 Issue 6

❙

INTERNATIONAL JOURNAL OF AESTHETIC AND ANTI-AGEING MEDICINE

A NUTRACEUTICAL APPROACH TO

skin vitality TREATING TRAUMATIC SCARS

THE UKRAINIAN EXPERIENCE

THE HALLMARKS OF AGEING

AND HOW TO ADDRESS THEM

prime-journal.com

A MESOTHERAPY SOLUTION

TO TREAT PIGMENT AND MELASMA

THE CHINESE AESTHETIC MARKET

FULL OF PROMISE