New Advancements in Aesthetic Medicine · Cryolipolysis Many of us have stubborn fat despite diet and exercise. Cryolipolysis uses controlled cooling to target and kill only these

New Advancements in Aesthetic Medicine

Dr Michael Ng

MBBS, Dip Internal Medicine, Dip Cardiology, Dip Practical Dermatology, LCP

Medical Aesthetic Certification (MAC) Program

Dynamic development in this Industry

More new minimal invasive and non invasive techniques and technologies developed to give a better aesthetic result-hence less complications, better results with less pain

Presented in conferences and clinical studies.

Introduction


HA fillers with lignocaine

HA for Hydration

HA with Succinate

HA with Aminoacids and Antioxidants

Fractional devices: lasers, RF

Cryolipolysis

Minimally invasive liposculpture

Hair implants

Thread lifting and rejuvenation

PRP

Stem Cells

Topics to discuss


MAIN PROBLEM with FILLERS

PAIN: topical anaes, nerve blocks, local anaes inj

PURPOSE

to alleviate pain and discomfort during injection of HA Fillers.

PRODUCT

premixed lignocaine to HA fillers

HA fillers mixed with lignocaine 0.3%

HA Fillers with Lignocaine


CONCEPT

With additional lignocaine in the HA fillers it will alleviate the pain during administration.

The “pain” will only go off after the injection.

Reduce time in clinic waiting for LA to work



STUDIES AND PAPERS

Several studies show that there are no changes in longevity of HA fillers and its efficacy.

In fact some studies even observed that the addition of lignocaine appeared to decrease erythema, bruising, and swelling, which may be due to the antihistamine properties of low dose lignocaine (inhibit histamine release from mast cells)



Principle: Improve the health of the skin

Part of skin: Dermis

Plain HA not HA crosslinked fillers

Route of administration: Injection

Size of HA: 3000nm

Intercellular space: 15-50nm

?Role of nano HA in topical application: proinflammatoryand fibrotic problems; promote metastases

HA for Hydration


PURPOSE

Succinate acted as energy generating agent and also as anti oxidant.

PRODUCT

A non-crosslinked HA mixed with Succinate

HA with Succinate


CONCEPT

Succinate conversion to Fumarate will reduce FAD to FADH2 , 2 electron will be transferred to ETC for conversion of ADP to ATP thus will generate more energy to produce collagen in Fibroblast cell.

Because succinate is a good electron Donor, it also have anti oxidant properties.

HA with Succinate


HA with Succinate

HA with Succinate

HA with Succinate

PURPOSE To administer all essential amino acid as precursor for

collagen production

Combination with anti oxidant

PRODUCT 8 Amino acids : Glycine, Lysine, Threonine, Proline +

Isoleucine, Leucine, Valine, Arginine

Anti-oxydants : Glutathion, N-acetyl-L-cysteine, Alphalipoicacid

2 Minerals : Zinc and copper

Vitamin B6

Non crosslinked HA

HA with amino acids and antioxidants


What is Fractional Photothermolysis? Emission of laser light in a fractional manner via

microbeams < 300 microns diameter to cause microscopic zones of injury (microthermal zones, MTZ) extending from epidermis down into dermis with surrounding areas of healthy tissue; 2004 by Manstein et al

The damaged areas are rapidly repaired from the healthy surrounding tissue

Columns of injury act as conduits for the transepidermalelimination of melanin, melanocytes, damgedkeratinocytes and dermal debris

Dermal-epidermal signallingdermal remodelling with new collagen formation

Target chromophobe = water

Fractional lasers


Ablative: Epidermis and Dermis

Nonablative: Dermis

Ablative Vs Nonablative






Nonablative: Er:YAG eg Fraxel; Er-glass eg Lux, Palomar, Mosaic Lutronic

Ablative: CO2 eg Lumenis, SmartXide DOT, Edge One, Fraxel; Er:YAG eg Pixel, Sciton, Fraxel

Types of FP lasers


Safety Vs Efficacy

AblativeFractional Ablative

Fractional Non- Ablative

Non-AblativeLow

High

Low HighSAFETY

Efficacy


The system consists of a Fractional RF Microneedle™ array that assists in reinvigorating the skin and can aid with things like face lifts, acne, acne scarring and large pores through variable intensity treatment on differing skin depths.

Fractional RF


Fractional RF


The fractional RF microneedling™ technology is an innovative design that uniquely treats the target area through rapid penetration of specially designed insulated micro-needles without causing extensive damage to the epidermis.

Fractional RF


Through the action of the microneedles, a tiny column is created that facilitates healing and brings about a growth factor that develops the mechanism of natural recovery with the effect being similar to that of peeling, but with minimal impact on the epidermis.

Fractional RF


Each needle in the array is insulated at the tip, with only 0.3mm exposed at the apex where the RF emits. The system differs from laser therapy in that the electrical energy is transposed into thermal energy and where the RF energy exits the end of the needle, it transfers from its point circle to the adjoining areas causing denaturalisation and coagulation.

Fractional RF


Fractional RF


A high-tensioned RF pulse is emitted onto the target area inside the skin.

The fractional RF causes thermolysis directly to this area and selectively degenerates the collagen fibres between the superficial dermis and muscle band, resulting in the fibres immediately dwindling and thus promoting the construction of new collagen through a stimulus of the fibroblasts.

Fractional RF


As the needles are insulated apart from their tips, the micro holes that are created are not exposed to thermal damage during the RF emission which in turn minimises the side effects of pigmentation and spares any damage to the epidermis.

In addition to improving the scarring associated with acne lesions. The system is sufficiently optimised to deliver enough thermal energy to denature cells and kill acne bacteria and reduce sebaceous glands activity.

Fractional RF


Noninvasive method of destroying fat cells by controlled cooling to around 4deg C resulting in localised reduction in fat deposits.

First noticed in children eating popsicles

Not for weight reduction but useful for body sculpting or recontouring

Reduction in 20% fat

Cryolipolysis


Other methods of fat reduction were more invasive: laser, U/S, RF

Above freezing temp: fat more susceptible to cold

Panniculitis and apoptosis - fat reduction over a few months

Role of vacuum in device increase surface area treated and increase blood flow to enhance inflammatory response

Branded Devices: Coolsculpting, Lipoglaze, 3DLipo, Claatu, Zerona

Cryolipolysis


Cryolipolysis

Many of us have stubborn fat despite diet and exercise.

Cryolipolysisuses controlled cooling to target and kill only these fat cells.

In the weeks to follow, your body naturally processes the fat and eliminates dead cells.

Results are long term because treated fat cells are gone for good.


Method to remove unwanted fats by means of a minimally invasive procedure.

Only local tumescent anaesthesia with sedation

Limited to small area and normally less than 500ml of fats aspirated.

Use of 1mm microcannula

60-90 mins

Liposuction alone

Larger incision if laser, U/S or RF assisted liposuction

Minimally Invasive Liposculpture


A minimally invasive hair restoration implant technique, using synthetic biocompatible polyamide strands that allow the coverage of thinned or bald scalp areas and deliver an immediate aesthetic result

Biofibre from Italy; Nido corp from Japan

Implant 2500 or Medicap high density 1000

20-30 days to stabilise. 10% loss per yr

CE approved but NOT FDA approved

Hair Implant


Hair Implant


Hair Implant


Concerns with artificial hair implants recurrent infections

rejection and periodic loss of fibers needing frequent replacement

frequent allergic reactions leading to severe contact dermatitis, irritant effects

fears about possible carcinogenicity

cicatricial alopecia

granulomatous hypersensitivity

cyst formation

Hair Implant


Platelet rich plasma is a concentration of human platelets in a small volume of plasma measured as 1,000,000 platelets per mm3 or 2-6 times the native concentration of whole blood at a pH of 6.5 - 6.7 (whole blood pH = 7.0 - 7.2)

First clinically used in 1987 autologously at the end of Cardiothoracic Surgery to reduce bleeding complications and need for allogenic blood products.

PRP


PRP


Growth factors are polypeptide signal proteins that are released from local tissues or blood components and are instrumental in modulating cellular functions -including cell proliferation, cell differentiation, tissue regeneration and wound healing.

Each growth factor (cytokine) binds specific cell surface receptors, which in turn modulate the activities of second messengers.

PRP


PDGF (Platlet Derived Growth factor)

Chemoattractive to Mesenchymal Stem Cells and endothelial cells. Differentiation for fibroblasts and osteoblasts. Up regulate effects of other growth factors on cells such as Macrophages.

TGF-ß (Transforming Growth Factor beta)

Promote cell mitosis and differentiation for connective tissue and bone. Acts on Mesenchymal Stem Cells, preosteoblastsand fibroblasts. Inhibits osteoclast formation

PRP


IGF (Insulin-like Growth Factor) Regulate cell growth and development, especially in

nerve cells, as well as cellular DNA synthesis. Mitogenetic to osteoblast lineage cells and stimulators of bone formation from existing osteoblasts.

VEGF (Vascular Endothelial Growth factor) Stimulate angiogenesis, cemo-attractive for osteoblasts

EGF (Endothelial Growth Factor) Induce epithelial development and promote

angiogenesis

PRP


The 5 Major Steps In The Platelet Activation Process

1. Formation of tri-dimensionalmesh (fibrin strand)or matrix…

2. Release of growth factors

by the thrombocytes and leukocytes….

3. Chemo-attraction or migration ofmacrophages and stem cells…

4. Stem Cells proliferation &mitosis…

5. Stem cells differentiation…

PRP helps regenerate aged and damaged skin and hypodermal tissues.

Wrinkles & volumes correction

PRPBIO

STIMULATION

Architectural skin reconstruction/ reorganization

DERM0-COSMETICS PEELS FILLERS

(Hyal-Acid)

Renewal of the corneal layer

Germinative layer Stimulation

Dermis Stimulation

Hyperpigmentation removal

USES

Orthopaedics/Sports Medicine

Surgery

Dermatology/Aesthetics/Plastic surgery

Dental

New uses

PRP


Orthopaedic uses: Trigger finger

Chronic myofascial pain (CMP)

OA knees

Tennis and Golf elbow

Frozen shoulder

Carpal tunnel syndrome (CTS)

Cervical spondylosis

Lumbar spondylosis

Plantar fasciitis

PRP


Surgical uses:

Anal fistula closure

Anal abscess closure

Postsurgical wound closure

Dental uses:

Receding gums lines

Implants

Maxillofacial surgery

PRP


Dermatological/Aesthetic uses: Nonhealing ulcers as a gel Burns Acne scarring Open pores Fillers Skin rejuvenation Pigmentation Skin tightening Fat grafting procedures Tissue augmentation Hair restoration Lip rejuvenation With threads G spot & A spot rejuvenation

PRP


1. Skin rejuvenation, fine lines and wrinkles, scars injection (intradermis)

mesotherapy (intradermis)

topical plasma & Dermaroller (micro-needling) intradermis

Post fractional CO2 with cryoiontophoresis

With threads

2. Volumetric ‘filling large volume injection of A-PRP intradermis and hypodermis

of the tear troughs, eyelids, naso-labial folds, marionette lines, peri-oral areas, cheeks, forehead, glabella, neck & back of hands.

PRP mixed with fillers such as hyaluronic acid and calciumhydroxyl- appatite (Radiesse) = ‘bio-active’

PRP in aesthetics


PRP


Platelet

Thromboplastin

Growth Factor

Thrombin

Plasma

Prothrombin

Fibrinogen

albuminetc

Fibrin rich Plasma(FRP)

Plasma Gel

Meso plasma

37℃, Ca2+

Platelet rich Placenta (PRP)

Tissue healing

Dermal Injection

wound healinganti-inflammationVEGF activating

Mask, dressing

Volume PRPBio Filler

•moisture•whiteningMesotherapy

Prosys PRP System

Platelet rich Plasma (PRP)

Material: Polydioxanone (PDO) is a polymer of the monomer p-dioxanone.

Absorbable suture: completely absorbed in 6 months by hydrolysis and excreted in the urine

Previously commonly used in cardiac surgery

Thread lifting


Effect of PDO threads:

Minimally Invasive, non-surgical

Persistent effect as it absorbs over 6 months

Regenerative effect via EGF, FGF, IGF, TGF, VEGF

Cog design prevents skin dimpling along thread line

Multidirectional Cog distributes force evenly and allow better lifting with 360 deg anchoring

Cannula reduces risk of damage to tissues and vessels

Thread Lifting


Types of PDO threads: Monofilament: usu. short, simple and straight for

rejuvenation Spring: coiled like a spring: midface and eye area Bidirectional Cogged: long anchoring Multidirectional Cogged via cannula: call pull midface and

lower jaw Spiral Multidirectional Cogged via cannula: can pull midface

and lower jaw Combination Multidirectional and Unidirectional Cogged via

cannula: esp for nose

Thread lifting


Thread Lifting


Spring ThreadFor midface 28G needle

Threads in eye area


Threads for nose


Stem cells divide to either replenish themselves or become more specialised cells

Regarded as a source of repair cells

Animal or Human origin

Embryonic or Nonembryonic “Adult” stem cells

Work started on culturing mouse embryonic stem cells 30 yrs ago

By 1998 , human embryonic stem cell cultured from IVF embryo donation

Stem Cells


By 2006 Induced pluripotent stem cells (iPSC) were made by “reprogramming”

REGENERATIVE MEDICINE

Properties of Stem Cells:

Self-replicating for long periods

Unspecialized cells

Can become Specialized (Differentiation)

Stem Cells


Control of cell proliferation and differentiation

Internal signals: genes

External signals: adjacent cell interaction, chemicals secreted by neighbouring cells, microenvironment

Stem Cells


Embryonic Stem Cells:

From preimplanted IVF donation

Subculturing (replating) in culture medium

Growth without differentiation for 6+ months = Pluripotent

Embryonic Stem Cell Lines are stored Frozen

Transcription factors : Oct 4, Nanog

Stem Cells


Medical Aesthetic Certification (MAC) ProgramDirected differentiation of mouse embryonic stem cells. (© 2008 Terese Winslow)

Adult Stem Cells:

Undiff cells among diff cells in organs of body eg brain, heart, fat, skin,teeth, GIT, liver, gonads etc

BMT 60-70 yrs ago

More difficult to culture adult stem cells in large quantities

Stem Cells



Hematopoietic and stromal stem cell differentiation (© 2008 Terese Winslow)

Haemopoietic Stem Cells: B lymphocytes, T lymphocytes, natural killer cells, neutrophils, basophils, eosinophils, monocytes, and macrophages.

Mesnchymal Stem Cells bone marrow (bone marrow stromal stem cells, skeletal stem cells) bone cells (osteoblasts and osteocytes) cartilage cells (chondrocytes) fat cells (adipocytes) stromal cells that support blood formation

Neuronal Stem Cells Neurons Astrocytes Oligodendrocytes.

Epithelial stem cells of GIT absorptive cells, goblet cells, Paneth cells, and enteroendocrine cells.

Skin stem cells occur in the basal layer of the epidermis and at the base of hair follicles. The epidermal stem cells give rise to keratinocytes, which migrate to the surface of the skin and form a

protective layer. The follicular stem cells can give rise to both the hair follicle and to the epidermis

Stem Cells


Skeletal muscle Adipose tissue Umbilical cord Synovium Circulatory system Dental pulp Amniotic fluid Foetal blood Liver Bone marrow Lung

Sources of MSCs


Avoid Allo recognition No allergy

Improves immune ftn

Secretes Cytokines and Growth Factors

Has immunomodulatory ftn on MSCs

Most adult stem cells are lineage restricted but still are

multipotent

Function of MSCs


Transdifferentiation: adult stem cell of one lineage changed to a cell of a different type of another lineage

Stem Cells


Adult or Embryonic:

Embyronic easier to culture

Less likely to reject autologous adult stem cells

iPSCs are reprogrammed adult stem cells

Danger of cancer risk with embryonic cells

Stem Cells


Neuronal: stroke, traumatic brain injury, learning defects, Alzheimer’s, Parkinsons, spinal cord injury, blindness, deafness, ALS, musculodystrophy, Autism, ED

Aesthetics and Skin: baldness, skin rejuvenation, nonhealingulcers, wounds, fat transfer

Systemic diseases: DM, A-I diseases eg psoriasis, JRA, SLE, IBD

Musc. Skel.: OA, RA,

Cardiac: MI, CCF, Cardiomyopathy

Liver: fatty liver, HBV, HCV

Cancer

BMT

Uses of Stem Cells


THE END


Documents

New Advancements in Aesthetic Medicine · Cryolipolysis Many of us have stubborn fat despite diet and exercise. Cryolipolysis uses controlled cooling to target and kill only these