,VVXH - aaamed.org

Offi cial Journal of the American Academy of Aesthetic Medicine

Defi ning The Ideal Female Body: A West African Perspective

Practical Approach To Safe, Smooth and Effective Micro-cannulaTreatment: Micro-cannula Use for Fillers In Aesthetic Medicine

PDO Threads for Skin Tightening and

Lifting: A Checkered Past But Promising Future

Up-to-date Combined Therapy of Stable Vitiligo.

Personal Experience

Maximizing Donor Harvesting In Hair

Transplantation

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American Journal of


Advancing the Art and Science of Aesthetic Medicine Medicine

Issue 02

Treatment of Dermatosis

Papulosis Nigra in Skin Types IV,

V and VI

Revolutionary Approaches to Light and Laser Rejuvenation

Male Enhancement Surgery

Botox: The Here and Now

Fat Grafting with Platelet Rich Plasma

American Journal of


MedicineAdvancing the Art and Science of Aesthetic Medicine

Ketogenic Diets in the Treatment of Obesity

Basics of Medical Malpractice Insurance - “Terms that every physician should know”

A Logical Approach inTreatment ofAging Asian Face

Key Ethical Issues in Aesthetic Medicine

Anti-Aging Prevention

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02 AJAM Issue 02 - 2012

American Journal ofOffi cial Journal of the American Academy of Aesthetic Medicine

Advancing the Art and Science of Aesthetic Medicine Medicine

46

EDITORIAL BOARDEditor-in-Chief

Dr Michel Delune

Contributors Dr. Renier Van Aardt Dr. Desmer Destang

Dr. Lewis M. Feder Dr. Kian Karimi Dr. Opkala Maluski Dr. François Michel

Dr. Ali Modarressi Dr. Patrick Treacy Dr. Vladimir Tsepkolenko Dr. Akaki Tsilosani

CREATIVESenior Graphic Designer

Elmer Gono

CIRCULATION & PRODUCTIONCirculation & Production Manager

Jess Foong

MARKETING & COMMUNICATIONSCongress Manager/ Managing Editor

Fernanda [email protected]

Business/Courses ManagerEllen Dahlin

[email protected]

ADVERTISING SALESBusiness Manager/Exhibitor and Ad Sales

Shermaine C. [email protected]

INTERNATIONAL OFFICEInternational Managing Director

Janice [email protected]

Business Development DirectorJessica Mok

SCIENTIFIC COMMITTEEChairman

Dr Michael Stevens

MembersDr. John S. Kim

Dr. David P. MelamedDr. Omnia M. Samra-Latif Estafan

Dr. Alejandro Espaillat

INTERNATIONAL CIRCULATION BY

Contents

Practical approach to safe, smooth and effective micro-

cannula treatment: Micro-cannula use for fi llers in

Aesthetic Medicine

3 From the Editor-in-Chief

4 Assessment of the Wellbeing Effect of Photobiomodulation

10 Radiofrequency, PRP and Microneedling – A Novel Triple Combination Therapy for Aesthetic Rejuvenation

14 Chemodermabrasion

18 Why Body-Contouring Procedures After Massive Weight Loss has to be Reimbursed

by Health Insurances

24 Combining therapies for optimal outcomes in treating the aging face and introduction to the DUBLiN Facelift

32 Up-to-date combined therapy of stable vitiligo. Personal experience

36 PDO Threads for Skin Tightening and Lifting: A Checkered Past but Promising Future

40 Defi ning The Ideal Female Body: A West African Perspective

46 Practical approach to safe, smooth and effective micro-cannula treatment: Micro-cannula use for fi llers in Aesthetic Medicine

50 Maximizing Donor Harvesting In Hair Transplantation

50

Statements of fact and opinion in the American Journal of Aesthetic Medicine (AJAM) are those of the respective authors and contributors as specifi ed and not necessarily those of the editors or publisher. AJAM does not make any representation express or implied in respect of the accuracy of the material in this publication. AJAM does not necessarily endorse or agree with the opinions and statements made in the publication or its related websites.

AJAM, the editors,employees and publisher cannot be held liable for any legal responsibility or liability for any errors or omissions that may be made. The information provided in this publication is for reference only. The ultimate

responsibility for the interpretation of the information in the publication lies with the medical practitioner or reader. The content in this publication cannot be

reproduced, whether in part or in whole, without the permission of the publisher.All rights reserved.

Medical Training Pte Ltd

2012 AJAM 3Offi cial Journal of the American Academy of Aesthetic Medicine

From the Editor--in--ChiefDear Colleagues,

The popularity of aesthetic procedures has exploded and shows no sign of leveling off. Statistics gathered by the American Society of Plastic Surgeons (ASPS) note that non-surgical aesthetic procedures performed in the U.S. in 2017 rose by 186% since 2000, reaching an annual 15.7 million procedures last year.

While the number of procedures performed may be growing annually, not all medical aesthetic practices will thrive. To stay at the forefront of both patient satisfaction and business success, clinics must anticipate consumer demand and constantly evaluate their mix of services with an eye to results, client response, and fi nancial factors. This is where being abreast of the most recent aesthetic trends comes into play.

Just as marketing strategies, patient care, and budgeting are imperative to your medical aesthetics clinic’s success, ongoing aesthetics education should be an essential part of your regular business operations. In fact, overlooking continuing education could be the kiss of death for your business.

Certainly, education can offer personal and professional benefi ts, but it can also strengthen a clinic’s branding and marketing strategies. Building a brand around a team that’s always learning allows your clinic to draw in patients who are willing to invest in better services for optimal results. For clinics building a brand that circles around staff, sharing events from training days or new accomplishments by staff, such as the receipt of a new certifi cation or passing the fi nal exam of an advanced course, to social media accounts can attract prospective patients online. Likewise, ongoing training may afford new marketing opportunities in areas you may have otherwise overlooked, including new digital technologies that support your business’s online presence.

Ongoing education is also a useful way to get to know other industry professionals who may be leading the way in designing new technologies or techniques that are offering even better results. Investing in a course or conference where you can attend seminars is a worthwhile use of your money to gain direct access to these industry leaders. Take the opportunity to learn from them and don’t shy away from networking. You’ve paid to gain access so get the most for your hard-earned dollars by asking questions, seeking out additional tips or techniques, and getting to know these medical aesthetic industry power players. Be sure to maintain your connections following these events, too. You never know where their career might take them or where yours may take you!

In the end, ensure you’re always staying in the know regarding upcoming opportunities. Keep abreast of the latest educational events at the American Academy of Aesthetic Medicine including our 15th AAAM Congress. For those searching for ongoing clinical education opportunities, contact us today to discover more about our courses and what we offer to our partners and members.Please visit our website at www.aaamed.org for more details.

We at the AAAM continue to revolutionize the aesthetic medicine arena and look forward to continuous support in achieving our goals.

Dr Michel DeluneEditor-in-Chief, AJAMPresident Emeritus, AAAM

3 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine


Assessment of the Wellbeing

by François Michel, MD

AbstractLight-emitting diode (LED) photobiomodulation is known for its anti-infl ammatory and restorative effects. It is obvious in photographs and in patients' behaviors that the procedure, while being performed on the skin of the face for aesthetic issues, has an effect of the patients' wellbeing. The "wellbeing effect" has been described in only 1 pilot study, but it has been corroborated by studies of the brain in the laboratory. Considering the lack of a convenient questionnaire to assess the wellbeing effect of photobiomodulation for use in daily medical practice, the author created an analogical questionnaire with the purpose of having a convenient tool for the assessment of quality of life following photobiomodulation treatments on the face, as well as to gauge the patients' feelings regarding overall aesthetic improvement. The questionnaire was the starting point for the creation of a software application.

BackgroundLight-emitting diode (LED) devices emit non-thermal light that elicits a biological effect; the effect depends on the color or wavelength of the light emitted. Red has anti-infl ammatory effects, and it increases collagen generation. Infrared does the same while penetrating deeper into the skin. Blue acts more superfi cially, with a certain capacity for disinfection.Historically, infrared lamps were used a century ago in Asia, on approximately 30 million people, with a restorative and anti-infl ammatory effect. The fi rst patent was submitted in Japan in 1964 for wound healing purposes.1

In France, Dubertret et al (1998) demonstrated, in vitro, the prophylactic effect of light from infrared lamps on the deoxyribonucleic acid of fi broblasts subsequently injured by ultraviolet light.2 In 2004, they showed that mitochondria were involved in the process.3 This pathway was also found to be


AJAM 2018 5Offi cial Journal of the American Academy of Aesthetic Medicine

involved in vivo in a study by Barolet et al (2008), showing the photopreventive effect of using LEDs.4-6 Since LEDs are semiconductors, they can also be easily modulated to emit in a pulsing manner.

Former light sources used in low-level laser therapy (LLLT) were essentially small, spot-sized lasers like the heliumneon laser at 632 nm (red). These tended to target small areas and, as such, were more suited to the laboratory as opposed to clinical settings. LED photobiomodulation was designed based on what was learned from LLLT studies.

Overall, photobiomodulation triggers an upregulation of cellular metabolism and a downregulation of oxidative stress. In addition, collagen production is increased for enhanced wound healing.5-7

Despite its long history and association with improvements, LED photobiomodulation remains controversial as a treatment. In effect, the technique does not heat up the skin and has no tissue end point. This is unlike the considerations made by laser proponents (thermal laser users), where technical specifi cations such as wavelength, exposure time, power used, and fl uence (which is diffi cult to calculate) can be different from one laser to the next. In addition, when using a laser, increasing the fl uence in an attempt to enhance treatment outcomes might have the opposite effect.

Despite criticism of the use of LED photobiomodulation, its positive effects are being observed. Physicians are equipping themselves with these devices for treatments related to aesthetics enhancement,

Parameter Wavelength 1 Wavelength 2 Wavelength 3

Output intensity 19 mW/cm2 6.2 mW/cm2 10 mW/cm2

Energy output(Maximum per LED)

1644 mW/cm2 533 mW/cm2 888 mW/cm2

Output wavelength 625 ± 4 nm 590 ± 5 nm 850 nmNote: Sessions interval of 2 months; 4.35 J/cm2, 2 minutes, 99 HzLED = light-emitting diode.

rheumatology, and vascular pathology; essentially any fi eld where a restorative and anti-infl ammatory effect is desired.

Medical Observations of the AuthorThe author used LED photobiomodulation as a mild aesthetic treatment for moderate erythema, heliodermia, superfi cial wrinkles, and atrophic scars (see Table 1). As the sessions were carried out, the author observed a progressive improvement in the facial expressions of patients (see Figures 1 and 2). For those exposed to the light emitted by LED photobiomodulation, a positive side effect was apparent – the wellbeing effect.

Table 1Parameters of 3 Wavelengths

Figure 1Facial Expressions of Patient 1

Figure 2Facial Expressions of Patient 2



The numerous positive effects of LED photobiomodulation on the skin include an anti-infl ammatory effect (less red) and reduction of whitening, which may be due to less fi brosis, in some hypovascularized skin. The positive psychological effects include alleviation of depression as well as a reduction in anxiety and nervousness. Photographs of patients also show changes in facial expressions following LED photobiomodulation sessions. It remains to be seen if any scientifi c evidence exists to support the wellbeing effect.

Published Medical StudiesThe psychological effects of LEDs have been studied. One pilot study was conducted on 10 patients, and the authors found a reduction in depression and anxiety following exposure to LED light at 810 nm at 250 mW applied for 4 minutes (60 J).8 These results were attributed to an improvement in blood fl ow to the frontal lobes of the brain. A literature review revealed that infl ammation aggravates psychological problems, and this may be countered by light from LED photobiomodulation, which has an anti-infl ammatory effect.9-12

In another study, LEDs were implanted in the scalp of 2 patients, one of whom suffered from cranial trauma, to evaluate its effects.13 Improvements were observed in attention span, memory, and higher brain functions, and a net reduction in post-traumatic stress was noted; however, these necessitated maintenance treatments.

A protective effect of LEDs was observed in an experimental Parkinson's model.8 A study that followed found that LLLT provides an interesting therapeutic approach to control the progression of Alzheimer's

disease.18 Another study suggests that LLLT may increase neurogenesis,19 and 1 review suggests that LLLT may have wider applications to neurodegenerative and psychiatric disorders.15 Other studies also demonstrated a restorative effect of LLLT on mice brains.21, 22

A study compared the effects of pulsed or continuous wavelengths of light and found that a 810 nm laser pulsed at 10 Hz was the most effective.15 The same authors evaluated the effects at different wavelengths and found that mice with moderate-to-severe traumatic brain injury (TBI) treated with 665 and 810 nm laser, but not with 730 or 980 nm laser, had signifi cant improvements in Neurological Severity Score. Another study by the same authors evaluated the effect of repetition regimen on the use of transcranial LLLT to treat stroke and TBI. Mice with severe TBI treated with 1 laser treatment had signifi cant improvements, and there were greater improvements with 3 laser treatments.17

Another study showed that the percentage of surviving mice was highest (63%) in the group that received transcranial laser therapy in the pulsed wave mode at 100 Hz.22

It is interesting to note that without prior intention, the parameters of this current study were quite similar to those of the above studies, both in terms of the wavelengths used and the frequency of sessions, which are typically similar to those used in dermatological and aesthetic treatments. The fl uences and pulse frequencies, however, are different from most LLLT studies.

A study showed that LEDs act via the cytochrome p53 pathway, like sunlight. This brings to light the notion that it is likely the same underlying mechanism that is responsible for the wellbeing effect.24

The authors of another study discovered a gene involved in sun addiction. Seventy-nine sun-addicted and 213 non-sun-addicted subjects were studied, and the PTCHD2 gene was found to be statistically signifi cantly involved in the pathology.25 It can be concluded that the effect of LED photobiomodulation will vary depending on the patient's genetic background.

Physicians are equipping themselves with these devices... [in] essentially


Highlighting the Wellbeing Effect of LED TreatmentsThe scale established by Endicott is a valid one, but in the realm of aesthetic treatments, it is too intrusive as it delves into the sexuality of test subjects, their fi nancial situation, and their ability to ambulate without feeling dizzy or falling. In short, it is more than confusing for patients. An excerpt from the quality of life scale in Dermatology is also dramatic:

As for the Skindex®, we have the same distortion between the questions and the reason for the aesthetic care, usually not a severe problem and such a questionnaire is badly perceived by our patients in a daily practice.

The Analogical ScaleThe analogical scale (see Figures 3A and 3B) was designed by the author to be a convenient tool for use as part of a study as well as a physician's daily practice; to be as useful as "before" and "after" treatment pictures. It gives an idea of the quality of life of patients and also helps to detect distortions of self-image (dysmorphophobia) and of the self-perception of mood.

The opinion of others involved with the patient is asked. In the case of an improvement of mood, positive feedback is expected from the patient's entourage. In the case of a deterioration of mood or an addiction to aesthetic treatments, the opposite is expected. The main point is that the percentage of change, according to the physicians and patients, are not all zero.

The preliminary results at 2 months after the fi rst session are shown in Table 2; 10 patients were studied. The answers to "Why are you here?" ("mainly for an aesthetic treatment" [+12.5%] versus "mainly to improve your spirits" [+40%]) mainly show that the motivation for having treatment shifts from a desire for aesthetic improvement to reasons of wellbeing experienced. It has been shown by other studies that satisfaction is higher for patients than for their physicians or aesthetic teams.

The ApplicationThe idea is to get answers regularly to improve the relevance of the results. The respondents' states of mind can change depending on many factors, and repetition of questions improves the reliability of the results. For instance, patients can receive the questionnaire monthly on their smart phones or tablets and the increase or decrease in results will appear as statistics. The aesthetic team may answer during appointments.

Patient AppearancePatient Aesthetic Appearance

Patient Mood

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10

Patient QuestionnaireWhy are you here?Mainly for an aesthetic treatment?

The people around youDisapprove-------------Ignore------------------------------Approve

At now, your outward appearanceDissatisfi ed--------------------------------------------Very Satisfi ed

Your MoodPoor------------------------------------------------------------Excellent

Mainly to improve your spirits?

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10

Questionnaire to be completed by the patient during his appointment with the practitioner and also from their computer, tablet, according to a frequency established by the practitioner.

This questionnaire is completed by the medical team during his appointment with the practitioner.

The assessment is compared with that given by the patient.

Figure 3AThe Analogical Scale (Patient Questionnaire)

Figure 3BThe Analogical Scale (Treatment Team Impression)


François Michel, MD, is a dermatologist from France. His practice involves several systems: medical dermatology,

approach via a medical spa that combines medicine and wellbeing with a preventive goal.

Patient Questionnaire

Why are you here?

Mainly for an aesthetic treatment +12.5%

Mainly to improve your spirits +40%

The people around you... How do they feel about you having this treatment?

Your outward appearance is better +10

Your mood is better +12%

Opinion of the aesthetic team

Aesthetic outcome of the patient +5%

Patient mood +6%

References

1 Offi cial Gazette of the United States Patent Offi ce.2 Menezes S, Coulomb B, Lebreton C, et al. Non-coherent near infrared

radiation protects normal human dermal fi broblasts from solar ultraviolet toxicity. J Invest Dermatol. 1998;111(4):629–33.

3 Frank S, Oliver L, Lebreton-De Coster C, et al. Infrared radiation affects the mitochondrial pathway of apoptosis in human fi broblasts. J Invest Dermatol. 2004;123(5):823–31.

4 Frank S, Menezes S, Lebreton-De Coster C, et al. Infrared radiation induces the p53 signaling pathway: role in infrared prevention of ultraviolet B toxicity. Exp Dermatol. 2006;15(2):130–7.

5 Yaou Zhang, Shipeng Song, Chi-Chun Fong, et al. cDNA microarray analysis of gene expression profi les in human fi broblast cells irradiated with red light. Journal of Investigative Dermatology. 2003;120:849–57.

6 Barolet D. Light-emitting diodes (LEDs) in dermatology. Photodynamic therapy light source. Semin Cutan Med Surg. 2008;27:227–38.

7 Barolet D, Roberge C, Auger F, et al. Regulation of skin collagen metabolism in vitro using a pulsed 660 nm LED light source: Clinical correlation with a single-blinded study. J Invest Dermatol. 2009;129(12):2751–9.

8 Schiffer F, Johnston AL, Ravichandran C, et al. Psychological benefi ts 2 and 4 weeks after a single treatment with near infrared light to the forehead: a pilot study of 10 patients with major depression and anxiety. Behav Brain Funct. 2009;5:46.

9 Zakharyan R, Boyajyan A. Infl ammatory cytokine network in schizophrenia. World J Biol Psychiatry. 2014;15(3):174–87.

10 Song X, Fan X, Song X, et al. Elevated levels of adiponectin and other cytokines in drug naïve, fi rst episode schizophrenia patients with normal weight. L Schizophr Res. 2013;150(1):269–73.

11 Le-Niculescu H, Levey DF, Ayalew M, et al. Discovery and validation of blood biomarkers for suicidality. Mol Psychiatry. 2013;18(12):1249–64.

12 Al-Asmari A, Khan M. Infl ammation and schizophrenia: Alterations in cytokine levels and perturbation in antioxidative defense systems. Hum Exp Toxicol. 2014;33(2):115–22.

13 Naeser MA, Saltmarche A, Krengel MH, et al. Cognitive improved function after transcranial, lightemitting diode treatments in chronic, traumatic brain injury: two box carryforwards. Laser Photomed Surg. 2011;29(5):351–8.

14 Cartmel B, Dewan A, Ferrucci LM, et al. Novell obstructs identifi ed in year exome-wide association study of tanning dependence. Exp Dermatol. Oct;23(10):757–9.

15 Xuan W, Vatansever F, Huang L, et al. Transcranial low-level laser therapy improves neurological performance in traumatic brain injury in mice: effect of treatment repetition regimen. PLoS One. 2013;8(1):e53454.

16 Zhang Q, Zhou C, Hamblin MR, et al. Low-level laser therapy effectively prevents secondary brain injury induced by immediate early in reply embarrassment X-1 defi ciency. J Cereb Blood Flow Metab. 2014;34(8):1391–401.

17 Oron A, Oron U, Streeter J, et al. Near infrared transcranial laser therapy applied at various modes to mice following traumatic brain injury signifi cantly reduces long-term neurological defi cits. J Neurotrauma. 2012;29(2):401–7.

18 Xuan W, Vatansever F, Huang L, et al. Transcranial low-level laser therapy enhances learning, memory, and neuroprogenitor. J Biomed Opt. 2014;19(10):108003.

19 Moro C, Massri NE, Torres NR, et al. Photobiomodulation inside the brain: has Novell method of applying near-infrared light intracranially and its impact on dopaminergic concealment survival in MPTP-treated mice. J Neurosurg. 2014;120(3):670–83.

20 Ando T, Xuan W, Xu T, et al. Comparison of therapeutic effects between pulsed and continuous wave 810-nm wavelength laser irradiation for traumatic brain injury in mice. PLoS One. 2011;6(10):e26212.

21 Wu Q, Xuan W, Ando T, et al. Low-level laser therapy for closed-head traumatic brain injury in mice: effect of different wavelengths. Lasers Surg Med. 2012;44(3):218–26.

22 Xuan W, Agrawal T, Huang L, et al. Low-level laser therapy for traumatic brain injury in mice increases brain derived neurotrophic Factor (BDNF) and synaptogenesis. J Biophotonics. 2014;9999(9999).

23 Oren M, Bartek J. The sunny side of P53. Cell. 2007;128(5):826–8.

ConclusionThe wellbeing effect of LED photobiomodulation is evident in practice but remains diffi cult to prove despite the scientifi c basis established in the literature. It is only the beginning for such a LED photobiomodulation application. It will be necessary to conduct further clinical studies to fi ne tune the parameters of fl uence, wavelength, pulsing mode, and the length and frequency of treatment sessions. These will allow us to better identify the expectations and reactions of patients as a result of this treatment modality. This is an opportunity to reconsider aesthetic treatments in terms of their effect on quality of life, while keeping ethical considerations in mind.

The author thanks Professor Barolet.Table 2 Results of the Patient Questionnaire

21 AMA PRA Category 1 CreditsTM

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– A Novel Triple Combination Therapy for

Radiofrequency, PRP and Microneedling

Aesthetic Rejuvenationby Dr. Desmer Destang

A triple combination of microneedling, radiofrequency,

and PRP presents a novel option capable of producing

aesthetic improvements in patients of all skin colors.

2018 AJAM 11Offi cial Journal of the American Academy of Aesthetic MedicineOffi cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 11Offi cial Journal of the American Academy of Aesthetic MedicineOffi cial Journal of the American Academy of Aesthetic Medicine

IntroductionAs the quest for beauty and youth continues, physicians are seeking new and innovative ways to satisfy their patients' desires. Radiofrequency (RF), Platelet Rich Plasma (PRP) and microneedling are not new technologies, but when used in a sensible combination therapy protocol, superior results, and enhanced patient satisfaction can be achieved.

PRP technology has been widely utilized since the mid 1990s in sports medicine for its regenerative properties. PRP is autologous blood which has been specially prepared and centrifuged. The resulting separation contains a small fraction (approximately 4%) of cells rich in platelets and growth factors. This minute fraction, however, can be as high as ten times more concentrated in healing factors than unprepared plasma. PRP also contains factors for angiogenesis and reduction of infl ammation.

Radiofrequency in aesthetic medicine uses the body as a conducting electrical circuit. On application of RF energy to the body, resistance is encountered at various skin layers, and by the energy fl ow will cause heat to be produced at the sites of maximum resistance. This heat effectively stimulates fi broblasts, without adverse stimulation of melanocytes.

Microneedling is an effective procedure that harmonizes the function of all cells involved in aesthetic rejuvenation – the fi broblasts, melanocytes, and the keratinocytes. Microfi ne needles penetrate the dermis at depths of up to 3mm to produce their effects.

Supportive treatments used in the protocol including mandelic acid and other acid peels, microdermabrasion, and subcision surgery will also be mentioned.

A Novel Combination Therapy ProtocolBy combining these 3 rejuvenation modalities, physicians can expect amplifi ed results compared to monotherapy. The aims of aesthetic rejuvenation on a histologic level are as follows:

collagen, elastin and glycosaminoglycans (GAGs).

TreatmentPrimary Cells

ModulatedBiological Effects Clinical Effects

Conditions that can be Improved

Radiofrequency

PRP

Microneedling

melanin production.

production of normal skin cells.

increase clearance of damaged cells.

sebaceous glands.

bacterial (P. Acnes) population is also necessary.

By achieving these, the clinician can expect to improve skin laxity, elasticity, mild to moderate wrinkles, skin discolorations,

and stretch marks. This combination was chosen since each treatment has a low impact on melanocytes, which can be labile and unpredictable in skin of color.

Microneedling is an effective procedure that harmonizes the function of all cells involved in

aesthetic rejuvenation –

and the keratinocytes.

Treatment of Wrinkles, Skin Laxity, Stretch MarksThe improvement of wrinkles, skin laxity and striae distensae is possible with this triple combined therapy. Other supportive therapies such as chemical peels, carboxytherapy, microdermabrasion and prescription topicals such as Retin A are also recommended. Patient expectation should be managed, especially with older stretch marks, which can be diffi cult to improve.

AlopeciaPrimary cells

targetedRecommended Protocol

6 week stimulation therapy

Supportive treatments:

Acne & Acne ScarsPrimary cells

targetedRecommended

Protocol

P. acnes

P. acnes


Supportive treatments

Subcision surgery

Mandelic acid peels

Treatment of Alopecia

microneedling, PRP and radiofrequency can be achieved. Microscopic studies have confi rmed that improvement in blood supply and numbers of follicular bulge cells. Adjunctive treatments such as corticosteroid injections and Minoxidil should also be included in the treatment plan.

Treatment of Acne and Acne ScarsAcne and acne scars are among the primary dermatological treatments where the triple combination therapy is applied. Acne patients also benefi t immensely from mandelic acid peels, either alone or in combination with other acids, microdermabrasion, and prescription topicals. Patients with acne scars may also be treated with subcision surgery, which can be further enhanced with concurrent PRP injections.

Stretch marks

Primary cells targeted

Recommended Protocol


Supportive treatments:

Maintenance therapy


Acknowledgement Special thanks to Dr. Michel Delune and Dr. Zein Obagi for their exceptional and innovative insights into Aesthetic Dermatology.

References

Cutis. 2013 Jan;91(1):39–46

Rev Dermatol. 2011;6(2):139–143

Medscape. Mar 06, 2012

Clin Dermatol. 2007 Sep–Oct;25(5):487–91

Am Jour Aesth Medicine 2013 Issue 4; 26–29

Dermatol Surg.

J Cosmet Dermatol.

The Art of Skin Health.

An Bras Dermatol.

J Am Acad Dermatol.

Arch Dermatol Res. 2015

J Clin Aesthet Dermatol. 2015 Jul;8(7):36–42

Indian J Dermatol. 2015 May–Jun;60(3):260–3

Acta Derm Venereol. 2016 Jan 20;96(1):87–91

J Cutan Aesthet Surg. 2014 Jan;7(1):63–4

J Cosmet Dermatol.

J Dermatolog Treat.

Asian J Transfus Sci.

microdermabrasion in the treatment of striae distensae: clinical and J Cosmet Dermatol.

Dermatol Ther.


The protocol used for acne and acne scars will also work to

include skin lighteners e.g. hydroquinone and arbutin may also be indicated.

Success in aesthetic dermatology treatments relies primarily on regulating and optimizing the function of a group of cells within both the dermis, and the epidermis. Treatment modalities used in combination effect superior results to monotherapies. A triple combination of microneedling, radiofrequency, and PRP presents a novel option capable of producing aesthetic improvements in patients of all skin colors.

From best clinical results, the primary and most important common treatment denominator is microneedling, with depths of at least 2mm that penetrate into the dermis. PRP and RF should be considered as treatment enhancers that improve healing, reduce infl ammation, and augment neocollagenesis. This often translates into better results, patient satisfaction, and patient retention.

With the world's population becoming increasingly more varied, respect for the labile and unpredictable nature of melanocytes is very important. Therefore, knowledge of these procedures capable of improving the skin's condition and skin health, without initiating or aggravating pigmentary changes is valuable.

Remember that the above are guidelines only, and the physician should be suffi ciently knowledgeable to determine how to modify treatment plans to accommodate for natural individual variation and response.

DERMABRASION OF THE face is a long and well-established treatment for acne scarring, actinic damage, keratoses, severe, pigmentary disorders, and a host of other skin imperfections, including rhinophyma (caused by rosacea), tattoos, and fi ne lines and wrinkles around the mouth. First developed by Curtin and later improved upon by Orentreich, who used the wire brush, dermabrasion employs the use of varying sizes of diamond fraise and speeds varying up to 25,000 RPM. The dermabrasion process wounds the skin, which is later replaced by new tissue. This procedure is normally done under local anesthesia, regional block, or on occasion, general anesthesia. Spot dermabrasion is normally frowned upon as it may cause pigmentation problems in the healing phase.

Dermabrasion is usually not recommended for individuals who have taken isotretinoin within the last 6 to 12 months, recently had facial surgery, keloid formation, or herpes infection. Some common temporary side effects include scarring, redness, swelling, acne fl are-ups, hyperpigmentation, and increased sensitivity to sunlight.

Chemical peel is a technique used to exfoliate the skin, enabling new, smooth skin to resurface. Chemical peel uses different chemical solutions of varying strengths according to the patient's skin type and what clinical improvement is to be achieved. The three types of chemical peels are superfi cial, medium, and deep peels. I have been performing facial dermabrasion in conjunction with chemical peel, which I call "chemodermabrasion", on the face and other areas, for more than 20 years, using the diamond fraise.

Chemodermabrasion


by Lewis M. Feder, MD

2018 AJAM 15Offi cial Journal of the American Academy of Aesthetic MedicineOffi cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 15Offi cial Journal of the American Academy of Aesthetic MedicineOffi cial Journal of the American Academy of Aesthetic Medicine

In the 1990s, I began to use chemical peels of varying concentrations in conjunction with facial dermabrasion. I have found that the use of trichloroacetic acid in varying concentrations, applied before and after facial dermabrasion, enhanced the result of dermabrasion or chemical peeling alone.

I fi rst presented these fi ndings at the American Academy of Cosmetic Surgery's annual meeting in New Orleans in 1994. Many physicians were astounded by the before and after photographs, and the excellent results. Pre-treatment with varying products, such as glycolic acids, retinoids, and other rejuvenating skin products is essential, and is used at least 2 weeks prior to surgery. Sun avoidance is also essential both before surgery, and for six months after. Prior to the procedure, a prescription of acyclovir should be given to prevent infection of herpes simplex virus.

MethodologyThe entire procedure takes approximately one hour to perform. After photographs are taken, the patient is taken to the operating room, and anesthesia normally employed includes Propofol IV, Demerol and Versed IM, and tumescent anesthesia to the full face using a blunt spinal needle to achieve a hard surface. Waiting at least 10 minutes is important for the tumescent anesthesia to cause vasoconstriction and a hard surface on which to operate. Occasionally, I employ the use of Frigiderm, to further harden the skin surface before beginning the dermabrasion, I carefully soak sterile gauze in trichloroacetic acid, typically in the range of 20%. I apply the gauze to the entire face at that time.

Using a wider diamond fraise, I normally begin on the forehead and proceed inferiorly with the dermabrator set between 20,000–25,000 RPM. Smaller diamond fraises are used for the periorbital areas and nasal areas. The use of eye shields is necessary to prevent damage to the eye globes. Proceeding further down, I insert my fi ngers into the patients mouth to enable me to do the perioral area, including the cupid's bow. It is essential to complete the full dermabrasion to extend below the mandibular rim to ensure pigmentary harmony. After the full dermabrasion procedure is performed, lidocaine and epinephrine mixed with sterile water, using sterile gauze, is applied on the entire face for 2 minutes. This will cause further vasoconstriction and clear the facial fi eld in preparation for the subsequent chemical peel.

Once again, sterile gauze is immersed in the trichloroacetic acid solution that was used at the beginning of the surgery. A small bolus of Versed IV may be employed before the application of the acid peel, to a denuded face, as this is usually more painful. After the acid has been applied on the patient's face for 1–2 minutes, the lidocaine, epinephrine gauze soaks are again applied for another 1–2 minutes.

Bacitracin 1% ointment is then applied to the entire face, followed by sterile Vigilon dressing. Kling dressing is then applied to the entire face causing further hemostasis and creating a mummifi ed appearance. 20 to 40 mg. of prednisone is injected IM. Ice packs are also applied to the face at this time. The patient is brought to the recovery area with head slightly raised for one hour.

With chemodermabrasion, the physician has more control, less downtime, a more cost effective procedure, and often with a better outcome, than by the use of the laser alone.

Case 1

Case 2

Pre-op 3 Days Post-op

Pre-op 3 Days Post-op

Dressings are removed the following day using sterile water to help remove the crust and other debris. Saturating the dressing with water allows easier removal of the surgical dressing. At that time, hydrogen peroxide is applied to allow a thin crust to form and being careful not to remove the crust entirely.

The patient is to apply bacitracin ointment for the next 5 days, avoiding all sun exposure, using the peroxide and water for cleansing. After the fi rst 5 days, discontinue the bacitracin and begin the use of 0.1% triamcinolone and apply BID for fi ve days.

In my experience of over 500 chemodermabrasions, my results have been far better than either procedure used alone. Initially, one would propose dermabrasion is 50–80% however, the results invariably show even greater improvement.

Most healing occurs within 2–3 weeks, while complete healing is within 3–6 months. The patient's skin tone continually improves from dusky pink to lighter pink, and eventually resumes to normal skin tone.

Summary The procedure, which I term chemodermabrasion, is a far more effective procedure than dermabrasion or chemical peel alone. In fact, the results appear to be signifi cantly better than the use of many lasers, including the ablative CO2 laser. With chemodermabrasion, the physician has more control, less downtime, a more cost effective procedure, and often with a better outcome, than by the use of the laser alone. This procedure can be used in patients of all skin types. The surgeon is able to contour the face, apply more or less pressure when necessary, and in general, get a far more artistic, tailored result than by using many of the newer and highly expensive laser procedures. This procedure should not be undertaken by the novice. One must have great experience in using a dermabrasion machine, near vital areas, in conjunction with chemical peeling. Chemodermabrasion should certainly be a consideration, in the surgeon's armamentarium, when considering facial rejuvenation and resurfacing. Although, this is an older procedure, and not as glamourous as some of the newer laser technologies, the results are excellent in trained hands with proper patient selection.

Case 3

Case 4

Case 5

Case 6

Chemodermabrasion should certainly be a consideration, in the surgeon's armamentarium, when considering facial rejuvenation and resurfacing.

Pre-op

Pre-op

Pre-op

Pre-op

3 Days Post-op

2 Weeks Post-op

2 Weeks Post-op

4 Weeks Post-op

5 Days Post-op


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AbstractBariatric surgery reduces dramatically overweight and comorbidities, and improves health related quality of life (HRQoL) of morbid obese patients. However up to 50% of patients will regain weight several years after bariatric surgery, loosing partially the benefi ts previously obtained. Furthermore after massive weight loss, most patients suffer from skin excess that can be addressed by body-contouring procedures. But in absence of scientifi c studies demonstrating their benefi ts, these are unfortunately rarely reimbursed by health insurances. In this present study we aim to investigate if body contouring, could improve HRQoL and improve long term weight control after bariatric surgery.

MethodsIn a prospective study, 102 matched control patients who had Roux-en-Y Gastric bypass bariatric surgery (RYGBP) for morbid obesity without body contouring, were compared to 98 patients who had body-contouring after RYGBP. HRQoL was measured by Moorhead-Ardelt score and long term weight was assessed until 8 years post-bariatric surgery.

ResultsMean weight was similar in both groups before RYGBP (125.1kg +/– 20, BMI 46) and up to 2 years post-RYGBP (80.4kg +/– 17, BMI 29), when plastic surgery were usually performed in body-contouring group.HRQoL was improved signifi cantly more (specifi cally for self-esteem and physical activity items) in group of patients how underwent body-contouring after RYGBP in comparison to that with RYGBP alone (98% of patients vs. 85%). In control group, after a massive weight loss, patients regain an average of 1.94 kg/year, which is signifi cantly more than patients who had body-contouring surgery (0.6 kg/year, p<0.01).

ConclusionOur study demonstrated that body-contouring is an effective procedure which has an impact on long term weight control after RYGBP, probably related to an improved HRQoL. This weight stability could also contribute to maintain comorbidities' improvement. These results confi rm the important role of plastic surgery in the global treatment of morbid obesity, and its necessity to be covered by health insurances.

Why Body-Contouring Procedures After Massive Weight Loss has to be Reimbursed by Health Insurances

by Modarressi Ali, MD


IntroductionMost medical treatments associating diet, physical exercise, eating behavior modifi cations or drugs are ineffective in most cases for patients presenting a BMI more than 40kg/m21. With a positive risk-benefi t balance, bariatric surgery (from Greek baros, weight; and iatrikos, being a part of the medicine) has become the treatment of choice of morbid obesity2. Among surgical options, Roux-en-Y gastric bypass (RYGBP) is presently considered the gold standard2-5,6,7 for morbid obesity with more than 100,000 operations each year in the USA alone8. Indeed, the procedure results in the best weight loss and comorbidity improvement9,1,10 and 30–40% mortality decrease11,12; it offers the lowest complication rate in both the short and long-term. Moreover, RYGBP also improves HRQoL13-16.

However, even though RYGBP offers a fast, massive weight loss within the fi rst 18 months after surgery, 50% of patients unfortunately regain some of the lost weight, with a mean weight regain of 5–10% within the fi rst 18 to 36 months after surgery and 10–15% over the course of the next ten years17. This weight regain can be associated with a recurrence of comorbidities, such as hypertension, diabetes, and hyperuricemia17,18. DiGiorgi et al. showed that within the fi rst 6 months after RYGBP, 64% of diabetic patients presented with a complete resolution of their type II diabetes. Yet, beyond 3 years after RYGBP, 26% of them experienced a recurrence of the disease; and among patients with initial improvement without complete resolution of diabetes, 20% worsened over time18,19.

Furthermore, more than two thirds of patients who have undergone bariatric surgery consider the resulting excess skin to be a negative consequence of surgery20. This excess skin present problems for the patients in their daily life and provokes important psychosocial disturbances21 that could compromise the benefi cial effects of the weight loss.

This dissatisfaction motivates 74 to 85% of patients to seek body-contouring (BC) procedures. But only 21% undergo at least one such procedure22,23, because in most cases, BC is not covered by health insurance. More than 80% of patients do not undergo this procedure because they cannot afford it (54.7%) or need to establish a payment plan (28.5%). It has been demonstrated that in USA people who make more than $50,000 annually have 4.2 times more BC than people who make less than $20,000 annually. Finally, only 12 to 21% of patients will undergo BC after massive surgical weight loss23. In many cases, insurance companies do not consider excess skin to be a disease, and BC is not viewed as a cost-effective treatment. Until now, no research had investigated whether patients who have undergone bariatric and plastic surgery experience a better long-term result in term of weight and quality of life, or not.

With the explosion in the number of plastic surgery interventions after massive weight loss, it seems necessary to estimate its cost-effectiveness. Its relative costs have to be compared with its psychological, social and long term results. These data are crucial to convince health insurances to reimburse body-contouring costs after a massive weight loss. Therefore in two distinguish studies we assessed: 1) the impact of body contouring on weight loss and stability24, and 2) the contribution of body contouring on health related quality of life (HRQoL).25

Material and MethodsWe compared 98 consecutive patients (89.8% females, mean age 42.6 [34–55 years]) who had BC procedures after RYGBP (Group A) to 102 matched patients (81.4% females, mean age 38.6 [31–48 years]) who had only RYGBP (Group B). These patients without BC had not undergone BC because health insurance did not cover the cost. All had been submitted to RYGBP for morbid obesity (BMI >40) at least 18 months before plastic surgery with stable body weight during the last 6 months.

To assess the weight change, patients were followed-up, and data (e.g., weight, metabolic measures, complications) were collected during the follow-up appointments at 1 month, 3 months, 6 months, 9 months, 12 months, and 18 months after surgery and then each year after RYGB.

HRQoL was assessed at each time-point by using the Moorehead-Ardelt26 questionnaire, which is the HRQoL part of the "Bariatric Analysis and Reporting Outcome System" (BAROS). This questionnaire evaluates 5 domains of HRQoL: self-esteem, physical activity, social life, work ability and sexual activity.

Surgical ProcedureBariatric surgeryAfter a multidisciplinary consilium, a fully standardized RYGBP (i.e., gastric pouch of < 30ml, alimentary loop of 150 cm, bilio-pancreatic loop of 50 cm) was performed on morbidly obese patients (i.e., BMI > 40 kg/m2) by general surgeons in our surgical department. These surgeries were performed via laparotomy until 2001 and laparoscopy thereafter.

Plastic surgeryGroup A patients received the following procedures: 97% abdominoplasty (with 47% incisional hernia repair), 32% mammoplasty (i.e., 51% mastopexy alone, 33% breast reduction, and 16% breast augmentation with or without breast lift), 19% cruroplasty, and 14% brachioplasty. Moreover, 45% of patients underwent combined procedures through one or several operations.



Results1. RYGBP induces fast massive weight loss in the fi rst 18 months (Figure 1)Pre-RYGBP, patients presented with a mean BMI of 46 kg/m2 (range 41 to 48 kg/m2) and a mean weight of 125 kg (range 109 to 140 kg). RYGBP alone resulted in initial massive mean weight loss of 45.2kg. Then the patients reached a

plateau around 12 to 18 months after surgery, thereby allowing them to obtain a minimal mean weight of 78.3 kg (range 65 to 92 kg), a mean EBWL of 68.4% (range 58.2 to 80.7%), and a mean BMI of 29.9 (range 26 to 34 kg/m2) (p<0.001). During this period, 88.32% of the patients achieved >50 % EBWL (i.e., 87.67% in group A and 88.52% in group B, p>0.05). Similar kinetics of weight loss were observed in both groups with non-signifi cant differences between groups A and B up to 2 years post-RYGBP (p>0.05), which is the mean time point when BC was achieved.

2. Secondary weight regain after RYGBP is prevented by BC surgery (Figure 1)In group A, BC was performed within 2 years on average after RYGBP. At the time just before BC in group A and at the matched time in group B, the weight lost, BMI, and EBWL were similar for groups A and B. (Table 1)Beyond the second year after RYGBP, patients without BC (group B) started to regain signifi cant weight. The weight differences between groups gradually became more signifi cant over time. The yearly weight and BMI increase was signifi cantly more important in group B than in group A (i.e., +1.78 kg/year versus +0.51 kg/year (p=0.001) of weight regain and +0.60 kg/m2/year versus +0.16 kg/m2/year (p=0.006) of BMI increase, respectively). The EBWL decrease was also signifi cantly higher in group B as compared to group A (i.e., p<0.001 for –2.91%/year versus -0.86%/year, respectively).

Six years post-RYGBP, the mean weight regain was 3.6% (range 0 to 6.34%)

in group A and 10.8% (range 7.4 to 20%) in group B (p < 0.001). This resulted in a higher fi nal weight in group B as compared to that of group A (i.e., 101.2 kg versus 82.5 kg, respectively, p=0.01). The mean BMI increased signifi cantly more in group B than in group A (i.e., 3.2% [range 0 to 21%] versus 16% [range 8.7 to 22%], respectively, p <0.001) to achieve a BMI of 37.2 and 30.6 kg/m2, respectively.

Figure 1Comparison of weight, BMI and EBWL between group A and matched group B, The line = mixed linear regression model adjusted to age and gender 2–7 years after RYGBP.

Bypass and BC (N=98)

Bypass only (N=102) p

Age (years), mean (SD), IQR

Women, N (%)

Pre-RYGBPBMI (kg/m2), mean (SD), IQRWeight (kg), mean (SD), IQR

2 years post-RYGBPBMI (kg/m2), mean (SD), IQRWeight (kg), mean (SD), IQR

EBW (%), mean (SD), IQREBWL (%), mean (SD), IQR

42.6 (11.1), (34–55)

88 (89.8%)

46.0 (5.1), (42–48)124.6 (17.5), (110–137)

29.9 (5.1), (26–34)79.7 (15.9), (68–90)

113.0 (23.5), (94–126)68.4 (16.3), (58.2–80.7)

38.6 (10.1), (31–48)

91 (89.1%)

46.1 (7.7), (41–48)125.3 (24), (109–140)

30.3 (6.6), (27–34)81.1 (19.8), (70–93)

112.5 (36.7), (89–126)67.2 (17.7), (56.8–79.2)

NS

NS

NSNS

NSNSNSNS

Table 1Demographic and data comparison between group A and matched group B: no signifi cant difference between these two groups during the period pre-gastric-bypass (RYGBP) to 2 years post-RYGBP when body-contouring (BC) was proposed to patients in group A. SD: standard deviation, IQR: interquartile range, NS: non-signifi cant, p>0.05. BMI: body mass index, EBW: excess of body weight


DiscussionBody image dissatisfaction, low self-esteem, and reduced HRQoL motivate many behaviors among obese people, including participation in diet programs and cosmetic surgery27. For patients seeking bariatric surgery, HRQoL is very important, too. In 66% of cases, psychosocial impairment is the main motivation for their desire to have bariatric surgery; in contrast, only 10% of patients indicate a medically motivated desire for bariatric surgery28. Unfortunately because of excess skin that appears after the quick, massive surgical weight loss, patients' HRQoL remains impaired after bariatric surgery.

We suggest that weight stabilization after plastic surgery could be improved based on HRQoL improvement. This improvement may encourage patients to maintain a stable weight over the years. Moreover, Kalarchian et al. concluded that any interventions that improved the psychosocial functioning of a patient would also strengthen the weight loss maintenance29. Likewise, we hypothesize that BC, which improves HRQoL14,30,31, could also help patients to maintain previously obtained weight loss after RYGBP.

We believe that BC contributes to achieving the main goal for patients seeking bariatric surgery, i.e., a better quality of life. However, HRQoL improvement could also be explained by better weight control after BC. We have demonstrated that HRQoL improvement after RYGBP is directly related to EBWL; i.e., 97.8% of patients who had achieved more than 75% EBWL estimated their quality of life improved; but among those who had achieved less than 25% EBWL only 50% felt their quality of life improved32.

Figure 2Data demonstrates HRQoL of patients without body-contouring (BEFORE group) (n=102) compared to those with body-contouring (AFTER group) (n=98)Total score is estimated as "much better" (scores +2.25 to +3), "better" (+0.75 to +2), "same" (+0.5 to –0.5), "worse" (–0.75 to –2 points) and "much worse" (–2.25 to –3).Majority of patient estimates their HRQoL improved in comparison to their pre-gastric bypass HRQoL. Body-contouring improves signifi cantly further the HRQoL total score and its different domains.

3. Body-contouring improves health-related quality of life (Figure 2)The quality of life was evaluated as "better" by 65% of patients and "much better" by 22% after RYGBP alone (Group A1 and B). This improvement was essentially important for self-esteem (89%) and physical activity (88%). Social life and work ability were improved in 63% and 61% of patients, respectively. Only 38% of patients evaluated their sexual activity as improved.

After plastic surgery, in comparison to the scores achieved after RYGBP alone, the total score were signifi cantly improved in all domains of HRQoL. In group B, 98% of patients estimated their quality of life improved after BC ("much better" 58%, "better" 40%) in comparison to 85% (Group B) without BC ("much better" 22% and "better" 63%) with a mean total score of 1.95 vs. 1.5 (p<0.001).

This improvement was signifi cant after BC in all domains of HRQoL comparing group B to A: self-esteem (98% vs. 89%, mean score 0.85 vs. 0.71, p<0.001), social life (87% vs. 62%, mean score 0.3 vs. 0.2, p<0.001), work ability (76% vs. 66%, mean score 0.24 vs. 0.19, p<0.001), physical activity (92% vs. 88%, mean score 0.38 vs 0.32, p<0.05) and sexual activity (65% vs. 43%, mean score 0.18 vs 0.07, p<0.001).

More than two thirds of patients who have undergone bariatric surgery consider the resulting excess skin to be a negative consequence of surgery. This excess skin present problems for the patients in their daily life and provokes important psychosocial disturbances that could compromise the

weight loss.

2018 AJAM 21

Previous researches have clearly demonstrated that RYGBP per se appears to be a cost-effective intervention for moderately to severely obese people as compared to non-surgical approaches33. The surgical treatment decreases 45% of direct costs (e.g., the number of consultations, medical treatments, and hospitalizations) and also indirect costs (e.g., unemployment rate and sick leave) for morbidly obese patients who undergo bariatric surgery as compared to the morbidly obese who do not have weight loss surgery34. The decrease in these costs is mainly related to a decrease in comorbidities, which is directly linked to weight loss. Previous research has demonstrated that even small weight changes (i.e., as little as 5%) can dramatically change comorbidities35. The weight stability and the prevention of weight regain offered by BC, as demonstrated in this study, may contribute to the possible prevention of a secondary worsening of comorbidities. BC procedures after bariatric surgery could be thus considered part of a cost-effective treatment plan for obesity. Therefore, more studies focused on comorbidity improvement and cost-effectiveness of plastic surgery is needed.

Having demonstrated the advantages of BC after massive surgical weight loss on weight control and HRQoL, we suggest that BC should then be encouraged by bariatric surgeons. As concluded by Warner et al., patients seeking bariatric surgery are insuffi ciently informed of possibilities offered by plastic surgery after gastric bypass; indeed, only 7% of bariatric surgeons always refer their patients to a plastic surgeon, and only 33% refer patients occasionally36. Plastic surgeons should be included in the multidisciplinary team for bariatric surgery before RYGPB to inform patients about the likely development of excess skin following this surgery and to discuss all the

possibilities offered by plastic surgery thereafter. However, no excessive promises about the results should be made, and insurances conditions and restrictions should also be evoked.

BC should not be considered as an aesthetic treatment, but as a reconstructive surgery for sequels of massive weight loss. A perfect silhouette will never be achieved; therefore patients have to be informed about aesthetical outcomes, including unavoidable scars left by BC.

It has been demonstrated that 74–85% of patient desire a BC after RYGBP22,23. But as in most cases the BC it is not covered by health insurances, majority of patients don't achieve this procedure because they can't afford it (54.7%) or need a payment plan (28.5%)23. In our study only 32% of patients underwent a BC procedure after RYGBP.

ConclusionWith the increasing number of bariatric surgeries occurring today, the number of candidates for plastic surgery will certainly increase as well. However, in the absence of cost-effectiveness studies, insurance companies do not currently cover the costs of these operations as long as the excess skin does not achieve "a value of somatic or psychic disease." For the fi rst time, our study demonstrates that BC signifi cantly improves body weight control and prevents weight regain after RYGBP. This could suggest that BC after massive surgical weight loss may improve comorbidities that can relapse over the long-term period after RYGBP alone. These improvements offered by BC are probably associated with a decrease in direct and indirect costs for morbidly obese patients, which is thus an important argument in favor of this kind of treatment

Plastic surgeons should be included in the multidisciplinary team for bariatric surgery before RYGPB to inform patients about the likely development of excess skin following this surgery and to discuss all the possibilities offered by plastic surgery thereafter.



Ali Modarressi, MD is Privat Docent and the "chief of clinic" of Plastic, Reconstructive and Plastic Surgery department of University hospital of Geneva in Switzerland. During his 10 years training in Switzerland, Dr Modarressi acquired important experience in all areas of plastic surgery including cosmetic, reconstructive surgery and microsurgery. He is

Reconstructive Surgery (FMH) and fellow of the European Board of Plastic Surgeons (EBOPRAS). Major emphasis was placed on tissue regeneration with stem cells (fat grafting and platelet rich plasma) and wound healing, where he did an extensive research. Thanks to his basic science and clinical experience he trained many physicians since several years in

and coverage by health insurance. If we consider morbid obesity as a real disease, global care should be accepted. Since plastic surgery after massive weight loss is mandatory for HRQoL improvement and weight loss maintenance in many patients, BC must be considered as a reconstructive surgery for those who have achieved massive weight loss. Indeed, the treatment of the morbid obesity should not be considered achieved as long as the plastic surgery is not fi nished. We hope that our results will be used as an argument in favour of BC and its coverage by health insurances.

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21 Knol, J.A., Management of the problem patient after bariatric surgery. Gastroenterol Clin North Am, 1994. 23(2): p.345–69.

22 Kitzinger, H.B., et al., The Prevalence of Body Contouring Surgery After Gastric Bypass Surgery. Obes Surg, 2011.

23 Gusenoff, J.A., et al., Temporal and demographic factors infl uencing the desire for plastic surgery after gastric bypass surgery. Plast Reconstr Surg, 2008. 121(6): p.2120–6.

24 Balague, N., et al., Plastic surgery improves long-term weight control after bariatric surgery. Plast Reconstr Surg, 2013. 132(4): p.826–33.

25 Modarressi, A., et al., Plastic surgery after gastric bypass improves long-term quality of life. Obes Surg, 2013. 23(1): p.24–30.

26 Oria, H.E. and M.K. Moorehead, Bariatric analysis and reporting outcome system (BAROS). Obes Surg, 1998. 8(5): p.487–99.

27 Sarwer, D.B. and A.N. Fabricatore, Psychiatric considerations of the massive weight loss patient. Clin Plast Surg, 2008. 35(1):

p.1–10.28 Peace, K., et al., Psychobiological effects of gastric restriction

surgery for morbid obesity. N Z Med J, 1989. 102(862): p.76–8.29 Kalarchian, M.A., et al., Psychiatric disorders among bariatric

surgery candidates: relationship to obesity and functional health status. Am J Psychiatry, 2007. 164(2): p.328–34; quiz 374.

30 Adami, G.F., et al., Body image in obese patients before and after stable weight reduction following bariatric surgery. J Psychosom Res, 1999. 46(3): p.275–81.

31 Sarwer, D.B., et al., Psychological considerations of the bariatric surgery patient undergoing body contouring surgery. Plast Reconstr Surg, 2008. 121(6): p.423e–434e.

32 Modarressi, A., et al., Plastic Surgery After Gastric Bypass Improves Long-Term Quality of Life. Obes Surg, 2012.

33 Picot, J., et al., The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess, 2009. 13(41):

p.1–190, 215–357, iii–iv.34 Christou, N.V., et al., Surgery decreases long-term mortality,

morbidity, and health care use in morbidly obese patients. Ann Surg, 2004. 240(3): p.416–23; discussion 423–4.

35 Goldstein, D.J., Benefi cial health effects of modest weight loss. Int J Obes Relat Metab Disord, 1992. 16(6): p.397–415.

36 Warner, J.P., et al., National bariatric surgery and massive weight loss body contouring survey. Plast Reconstr Surg, 2009. 124(3):

p.926–33.


The DUBLiN Lift To establish the clinical effectiveness of combining fi ve treatments in the rejuvenation of the aging face in an effort to increase aesthetic effect, patient safety and reduce laser downtime.

AbstractThe face is the area for which most patients seek cosmetic rejuvenation as the convex lines of a youthful appearance tend to fl atten and droop as one grows older. The younger face is characterized by a balance captured in the classic shape of the inverted triangle. The reversal of this "triangle of beauty" as aging proceeds is considered generally less aesthetically appealing.1 At present, a variety of differing dermatologic and volumising treatments are available for facial rejuvenation. These include chemical peels, dermal fi llers, IPL and RF lasers, plasma rich platelets, micro-needling, microdermabrasion, botulinum injections and laser resurfacing. Each has their own relative benefits as well as their own risks.2-3 In recent years, facial rejuvenation has been revolutionized with the development of CO2 fractionalised laser skin resurfacing (FLSR). This procedure has benefi ts of faster recovery time, more precise control of ablation depth and reduced risk of post procedural problems. However, there have been cases of hypopigmentation, hypertrophic scars and skin mottling most often seen on the face, neck and chest when the laser parameters are used more aggressively.4 The technique does not also attend to chronological aging problems such as volume defi cits resulting from the loss and repositioning of facial fat61. This paper looks at the possibility of combining fi ve established therapies in an attempt to address these defi cits.

The facial rejuvenating therapies included microneedling, low dose Ultralase laser, (PRP) plasma rich protein growth factors, Omnilux 633 light and neurotoxins. The technique is called the DUBLiN facelift as an acronym of the procedures involved. D Dermaroller U Ultralase Laser B Blood growth factors Li Light (near red 633) N Neurotoxin.

The author compared this method to FLRS in terms of reduction of photo ageing and overall aesthetic effect. Neurotoxin was used in both studies.

ObjectiveThe face and more especially the eyes, is very important in contact between humans, as these areas provide a window to the rest of society regarding a patient's level of health, tiredness, emotional status as well as interest in others.4 Many doctors consider the periorbital area face is the most important area of rejuvenation as eye-to-eye communication occurs in approximately 80% of all human interactions.5 Both areas present a barometer of a patient's chronologic and environmental age and mastering the proper evaluation and execution of their aesthetic rejuvenation is critical to all cosmetic doctors. More recently, patients are seeking effective facial rejuvenation procedures with less downtime and low risks.6 This behavioural change in attitude has been prompted by a realisation of both doctors and patients that the much hyped non-ablative methods were often subject to extravagant claims in terms of effi cacy.2–4 For many years CO2 laser resurfacing was considered the 'gold standard' in treating photodamaged facial skin.5-10 Cutaneous laser resurfacing with fractionalised (CO2) laser

for Optimal Outcomes

in Treating the Aging FaceIntroduction to the

Combining Therapies

DUBLiN Faceliftand

by Dr. Patrick Treacy


involves the vaporisation of the entire epidermis as well as a variable thickness of the dermis. Many physicians stated that the ultrapulsed CO2 laser was the most effective method of laser resurfacing.11–12 Photodamaged skin occurs after years of exposure to harmful ultraviolet light and is demonstrated clinically as a gradual deterioration of cutaneous structure and function. This results in the epidermis and upper papillary dermis having a roughened surface texture as well as laxity, telangiectasias, wrinkles and variable degrees of skin pigmentation.16–17

Although, ultrapulsed CO2 resurfacing lasers were considered the best treatment option, they had many post-procedural problems18-19, including prolonged postoperative recovery, pigmentary changes and a high incidence of acne fl ares, herpes simplex virus (HSV) infection.21-22 Many patients complained of oedema, burning, and erythema that sometimes lasted for many months.24-25 The implied risks and long downtime made many patients reluctant to accept

this method.26-27 More recently, fractionalised resurfacing lasers (FLSR) have addressed many of these earlier problems with benefi ts of faster recovery time, more precise control of ablation depth, and reduced risk of post procedural problems.7 These lasers are extremely versatile, in that they can be used for the treatment of facial rhytides, acne scars, surgical scars, melasma and photodamaged skin and many have reached the market at the same time.29 With the advent of FLSR the number of completely ablative resurfacing cases has declined for most practitioners. However, care should be taken when treating sensitive areas such as the eyelids, upper neck, and especially the lower neck and chest by using lower energy and density and scarring has been noted in these areas.30 Scarring after fractional CO2 laser therapy is considered mainly due to overly aggressive treatments, lack of technical fi nesse. Physicians have also recorded postoperative infections leading to scarring although it is generally felt that these may be prevented by careful taking of history, vigilant postoperative monitoring and/or prophylactic antibiotics.47-48


In terms of facial rejuvenation, CO2 Laser light at 10600 wavelength results in vaporisation with thermal denaturation of type I collagen, collagen shrinkage and later collagen deposition. However, in very deep rhytides, acne scarring and severe elastotic changes from sun damage, the fractional CO2 requires multiple treatments to achieve the same results as the older lasers.50 Several studies have evaluated using different laser combinations in the same session in order to improve collagen deposition, with a wider zone of fibroplasia.5-8, 50 Because of the inherent risks of FLSR and its inability to deal with some evidence of chronological aging, it was advocated to here establish the clinical effectiveness of using a multiprocedural approach to volumisation and collagen regeneration. The author used microneedling with low energy laser and platelet rich plasma (PRP) to address these issues.

It is recognised that the most important rejuvenation process for photoaged skin is the collagen remodelling process, and dermal fi broblasts are known to have the most important function.49 Rejuvenation of skin injury caused by UV light is a complex process that organically involves cytokines interacting with several growth factors and control proteins.50 The procedures evaluated included platelet rich plasma (PRP), microneedling (MN), Omnilux 633nm near-red light with neurotoxins as an adjunct to low level FLRS. Cells in the epidermis and dermis can be targeted by (MN) and near-red light (633nm) resulting in fi broblast stimulation. Omnilux reviveTM (633nm) therapy stimulates fi broblast activity, leading to faster and more effi cient collagen synthesis and ECM proteins. It also increases cell vitality by increasing the production of cellular ATP and stimulates the contractile phase of the remodelling process producing better lineated collagen.53-56 Collagen induction therapy (CIT) is an aesthetic medical procedure that involves repeatedly puncturing the skin with tiny, sterile needles. Typically, this is done with a specialized device called a microneedling device.

Controlled studies have suggested that the application of autogenous PRP can enhance wound healing in both animals and humans.49 Five major growth factors such as TGF, insulin-like growth factor (IGF), PDGF, EGF and VEGF are known to be related to the wound-healing processes.50 These growth factors are released from platelets and the production of collagen of fi broblasts is stimulated by IGF, EGF, interleukin-1 (IL-1) and tumour necrosis factor (TNF)-.43-44 In vivo studies report TGF- to be the most stimulative growth factor. PRP may be used for dermal augmentation and Sclafani observed aesthetic improvements of the nasolabial fold in less than 2 weeks and the results lasted for up to 3 months. 49-50

Research Design and MethodsThis multicentre randomised study included 44 patients of skin type 1 and 2 aged between 39–68 years presenting with photoageing of skin, thirty seven of whom were women and seven were men. The subjects presented with the typical hall marks of chronological and photoageing such as expression lines, rhytides, wrinkles, eyelid skin laxity, dermatochalasis, lowered brows, lateral hooding and prominent fat pads. All patients were subjected to a programme of skin tightening and neocollogenesis by one of two methods, conventional FLSR or the DUBLIN Lift. Fifteen patients underwent Lumenis ActiveFx with settings (Energy) 125 mJ (Rate) 19w CPG 3/5/4. Twenty nine patients received the DUBLIN Lift, a three phase combination of established treatments with microneedling, platelet growth hormones, near-red 633nm light and low energy ultralase fractional CO2 laser skin tightening. All patients received Dysport® in three areas one week prior to the other treatments as an adjunct to the laser resurfacing.

The DUBLiN Lift was introduced as three phases over a period of three weeks. Phase I included Dysport® at dilution 3.5:1 in three areas, glabellar, frontalis and periorbital. Phase 2 introduced intense fi broblast stimulation and modifi cation through microneedling, PRP growth factor induction and near-red phototherapy. Phase 3 included low–level (CO2)

Ultrapulse laser with settings (Energy) 100 mJ (Rate) 14w CPG 3/5/2 and adjunct near-red 633nm phototherapy. The study evaluated post procedural aesthetic results at two weeks, four weeks and twelve weeks. The length of downtime, patient discomfort and adverse side effects were noted for each phase.

Dublin LIFT 633 LightDublin LIFT PRP


Clinical assessment of patients in each grouping was made at 2 weeks, I month and 3 months postoperatively in the presence of two aesthetic staff. The degree of improvement in photoageing was based on the degree of re-epithelialization rate, reduction of rhytides, reduction of tactile roughness and loss of hyperpigmentation and telangiectasias. The prolongation and severity of erythema as well as the presence of negative side effects (such as herpes) were also recorded.

The effi cacy of treatment was evaluated using a variation of the fi ve-point scale (Fig 1) originally suggested by Dover et al.36 Investigators and patients evaluated effi cacy using palpability assessments and change from baseline score at 0, 6 and 12 weeks. A total global score was recorded in each patient based on the addition of points obtained from six photodamage variables. The degree of perceived improvement in overall aesthetic effect refl ecting chronological age was assessed separately by patients and physicians using the Wrinkle Severity Rating Scale and the Global Aesthetic Improvement Scale. The WSRS is recognised as a valid and reliable instrument for quantitative assessment of facial skin folds, with good inter- and intra-observer consistency.60 Wrinkle severity is measured by using a wrinkle severity rating scale with 1 being absent and 5 being extreme. By allowing objective grading of data, these proved useful clinical tools for assessing the effectiveness of facial volumisation with PRP and MN-633.

Interventions: Lumenis ActiveFx CO2 laser. Traylife Protein Rich Plasma, Omnilux 633 diode light. Dermaroller® and Dysport®. All participants received selective regional anaesthesia blocks with 2% Lignocaine plus adrenaline, topical combination anaesthetic of 23% lignocaine and prophylactic Valtrex 500 mg twice daily for eight days. Valium 5-10mgs mgs stat was

given as a pre-med to some patients. A post procedural advice sheet and Neurofen or Codeine with Paracetemol as required.

Histology: Skin biopsies were obtained from fi ve of the patients' intraoperatively before Phase 2 treatment and at 3 months postoperatively performed to determine the amount of epidermal damage, subsequent infl ammation, and new collagen synthesis. The extent of neocollogenesis was compared with data on fi le for patients who had skin biopsies for laser resurfacing and neurotoxin alone in 2007. Each 1 cm × 1 cm piece of skin was fi xed with 10% formalin neutral buffered solution. After treatment with polyester wax, the skin samples were sliced into 6-μm thicknesses. The sliced sections were treated with haematoxylin and eosin (H&E) and Masson's trichrome staining solutions. Through tissue evaluations, the thickness of the dermal layer and presence of collagen fi bres were observed. The thickness of the dermal layer was calculated by measuring at fi ve different sites from each section, and the mean value of the thickness of the dermal layer for each group was used for the comparison.

Results Over 3 months, 29 subjects (Group 2) were selected to compare the effect of low energy FLRS (fractionalised laser resurfacing) with adjunctive treatments to conventional ablative laser resurfacing. These patients received a three phase combination of established treatments with neurotoxin, microneedling, platelet growth hormones, near-red

Dublin LIFT NW Eye

G2 EK Dublin LIFT Eye

Before After

Parameter 0 1 2 3 4

Global Score Area ofRoughness X0

Area ofRoughness X1

Area ofRoughness X2

Area ofRoughness X3

Area ofRoughness X4

Fine lines None Rare Several Moderate Many

PigmentaryProblems

None Patchy Moderate Heavy Marked

TouchProblems

Even Rare Mild Moderate Severe

Facial Veins None Rare Several Moderate Severe

Coarse lines None Rare Several Moderate Many

Complexion Pink Pale Grey SuggestionYellow Grey

DistinctYellow Grey

Table 1Patient treatment (positive) scoring chart

Before

After


633nm light and low energy ultralase fractional CO2 laser skin tightening over a three weekly period. Phase I included the administration of Dysport® neurotoxin in the upper face. Phase 2 introduced fi broblast stimulation from microneedling and PRP growth factor induction with near-red phototherapy and Phase 3 included low–level (CO2) Ultrapulse laser with adjunct near-red 633nm phototherapy. Results were compared to 15 patients (Group 1) who received FLSR at the level of settings (Energy) 125 mJ (Rate) 19w CPG 3/5/4 and whose data was already on fi le. Patients in both groups were administered received Dysport® neurotoxin one week prior to treatment to complement and preserve the aesthetic effect. The study evaluated post procedural aesthetic results at baseline, six weeks and twelve weeks by means of a scoring system based on Dover's photoageing scale as well as using the Wrinkle Severity Rating Scale and the Global Aesthetic Improvement Scale.

Histological results were obtained from both groups showing the depth of laser penetration and consequential formation of new collagen. All skin biopsies showed thermal coagulation of epidermis and superfi cial dermis in a depth ranging from 85 to 113 microns. The zone of residual thermal (coagulative) damage was less in the Group 2 patients where less laser energy was used. The best neocollogenesis results at 3 months were evident in Group 1 where one patient (Image E) had evidence of effect at 700 microns. This was refl ected in the patient's skin, which continued to improve over the period. Because the variance in energy of the CO2 laser in Group 1 and Group 2 it was expected that the documented depth of histological ablation and thermal effects would vary between them. Responses of aesthetic effect were evaluated at 6, and 12 week after baseline.

The two methods appeared to produce different clinical improvement of lesions and rhytides. The GAIS global score for photoageing for the DUBLiN lift improved from 13.2 to 10.2 at Day 30. This compared to 13.8 at baseline to 9.6 at Day 30 for conventional FLRS alone. The score for fi ne lines was the most signifi cant reduction dropping form 3.6 at baseline to 1.4 at Day 30. The score for reduction of coarse

wrinkles (3.2 at baseline to 2.2 at 6 weeks) was more diffi cult to interpret in this heterogeneous age grouping with older patients requiring the conventional ActiveFx settings rather than the 'softer' ones. According to investigator-based Wrinkle Severity Rating Scale and Global Aesthetic Improvement Scale assessments at 3 months after baseline, DUBLIN Lift was superior in 62.0 percent and 55.2 percent of patients, respectively, whereas FLSR was superior in 33.3 percent and 34.4 percent of patients. (p < 0.0004). "Optimal cosmetic result" was achieved in a higher percentage of patients in Group 2 than Group 1.

Investigator-based and patient-based ratings using both WSRS and GAIS indicated that the DUBLIN Lift was more effective than conventional ablative laser resurfacing in creating cosmetic correction in the lower face. This resulted from the volumising effect of adding PRP to the larger folds in this area. At 3 months post-treatment, a higher proportion of patients showed a > or = 1-grade improvement in Wrinkle Severity Rating Scale with DUBLIN Lift than with FLSR. The author suspects the PRP may have a longer aesthetic effect when used in association with NM and 633 light than has been previously noted.48-49 However the results were almost reversed whenever periorbital rejuvenation was assessed alone with almost every patient (93%) favouring conventional FLSR. Investigator-based Global Aesthetic Improvement Scale assessment of this region at 3 months after baseline indicated that FLSR was superior in 93.0 percent of patients, whereas

DUBLIN Lift was superior in 6.8 percent of patients (p = 0.0025).

Re-epithelialization occurred in all laser treated areas by both groups by day 7 and this appeared to be clinically similar for both procedures. Mean duration of erythema was 6.9 days after resurfacing (range, 4–10 days) in Group 1 and 4.2 days in Group2 (range, 3–7 days). This appeared to be in keeping with previous studies.14 All patients reported having no crusting effect remaining on their face after 6 days. Residual erythema remained in one patient in Group 1 for a period of 14 days but this was minimal. Postoperative erythema was most intense in the areas treated by with the ActiveFx at the energy level above 125Mj.

Dublin LIFT Injecting PRP

G2 EK Dublin LIFT

After

Before


Parameter 0 1 2 3 4

ErythemaSeverity

None Rare Several Moderate Severe

InfectiveOutbreak(Herpes/Acne)

None Rare Several Moderate Severe

Crusting None Rare Several Moderate Severe

Pain ofProcedure

None Mild Tolerable Moderate Severe

Improvement None Minimal Fair Good Excellent

5 ExtremeExtreme (extremely deep and long folds, detrimental to facial appearance). ...

4 SevereSevere: very long and deep folds; prominent facial features; less than 2 mm visible

3 ModerateModerate: moderately deep folds; clear facial feature visible at normal appearance but not when stretched

2 MildMild: Shallow but visible fold with a slight indentation; minor facial feature

1 AbsentAbsent: no visible nasolabial fold; continuous skin injectable implant alone

Degree Description

1 Exceptional improvement

Excellent corrective result at week 12. No further treatment required

2 Very improved patient

Marked improvement of the appearance, but not completely optimal.

3 Improved patient

Improvement of the appearance bettercompared with the initial condition. Touch-up is advised.

4 Unaltered patient

The appearance substantially remains the same compared with the original condition.

5 Worsened patient

The appearance has worsened compared withthe original condition.

Table 2Patient treatment (negative) scoring chart Table 3

WSRS Patient scoring chart

Table 4Global Aesthetic Improvement Scale (GAIS)

The mean pain sensation (Table 2) felt during the DUBLiN Lift was 2.2 compared to conventional FLRS treatment at 3.4. We noted most patients did not really feel pain with the ActiveFx until the proceduralists crosses 100mj. No patient experienced any adverse reaction to laser skin resurfacing except one case of herpetic infection in each group. (Group 1 was 6.6% and Group 2 was 3.4%). Both treatments were well tolerated. Clumping of platelets occurred in 10% of patients treated with PRP and the author felt that this was due to the concentration of solution used. In fact, anecdotal evidence suggests that most cosmetic physicians are using PPP (platelet poor plasma) in most areas of the face rather than the higher concentrations used by orthopaedic surgeons. Mean patient age in Group 1 was 49.24 years (range, 37–71 years) and Group 2 was 54.86 (range, 41–76 years).

Conclusions Facial aging is a consequence of many interacting intrinsic and extrinsic factors. The most important of these include sun exposure, or photoageing and the intrinsic changes associated with chronological aging. Over a period the muscles of facial expression produce dynamic and static facial lines and folds. The author presents a novel method of facial rejuvenation that examines the possibility of the clinical effectiveness of combining fi ve treatments in the rejuvenation of the ageing face in an effort to increase aesthetic effect, patient safety, and reduce laser downtime. He concludes that although fractionalised CO2 laser resurfacing is recognised as the gold standard procedure for tissue that has lost its elasticity

Dublin LIFT Herpes Simple

Pain of Procedure: None; Mild; Tolerable; Moderate; Severe

This paper looks at the possibility

in an attempt to get a synergistic

Before After


References

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it has adverse risks and does not adequately address the problems associated with chronological aging. He addresses the requirement to apply adjunct methods such as plasma rich platelets to address nasolabial or marionette lines and volume defi cits resulting from the loss and repositioning of facial fat. The author also establishes the benefi t of using other facial rejuvenating therapies including microneedling, PRP growth factors, 633 nm light to limit the depth of laser penetration and decrease the risk of scarring and permanent pigmentary alteration. The novel technique is called the DUBLiN facelift as an acronym of the procedures involved: Dermaroller, UltraPulse laser, Blood growth factors, Light (near-red 633 nm), and Neurotoxin.

The author has done this research independently and receives no fi nancial benefi t from the companies who provided the materials for the study.

Dr. Patrick Treacy is Chairman of the Irish Association of Cosmetic Doctors and Irish Regional Representative of the British Association of Cosmetic Medicine. He is a Fellow of the Royal Society of Medicine and the Royal Society of Arts. (London). Dr. Treacy also serves as Chairman of the Ailesbury Humanitarian Foundation, and Honorary Ambassador to the Michael Jackson Legacy Foundation, and

and dermatology journals. Dr. Treacy has pioneered facial endoprosthesis techniques for HIV facial lipodystrophy and radiosurgery thermocoagulation.


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43 A.P. Sclafani Applications of platelet-rich fibrin matrix in facial plastic surgery. Facial Plast Surg., 25 (2009 Nov), pp. 270–276.44 Sadick NS. A study to determine the efficacy of a novel handheld light-emitting diode device in the treatment of photoaged skin. Journal of Cosmetic

Dermatology. 2008; 7: 263–267.45 Baez F and Reilly LR. The use of light-emitting diode therapy in the treatment of photoaged skin. Journal of Cosmetic Dermatology. 2007; 6: 189–194.46 Lee SY, et al. A prospective, randomized, placebo-controlled, double-blinded, and split-face clinical study on LED phototherapy for skin rejuvenation:

Clinical, profilometric, histologic, ultrastructural, and biochemical evaluations and comparison of three different treatment settings. Journal of Photochemistry and Photobiology B. 2007; 88: 51–67.

47 Bhat J, Birch J, Whitehurst C and Lanigan SW. A Single-Blinded Randomized Controlled Study to Determine the Efficacy of Omnilux Revive Facial Treatment in Skin Rejuvenation. Lasers in Medical Science. 2005; 20: 6–10.

48 Russell BA, Kellett N and Reilly LR. A study to determine the efficacy of combination LED light therapy (830 nm and 633 nm) in facial skin rejuvenation. Journal of Cosmetic and Laser Therapy. 2005; 7: 196–200.

49 Kim JW. Clinical trial of Non thermal 633nm Omnilux LED array for renewal of Photoaging: Clinical Surface Profilometric Results. Journal of the Korean society for Laser Medicine and Surgery. 2005;9: 69–76.

50 Fabbrocini G, De Vita V, Pastore F, et al. (April 2012). "Collagen induction therapy for the treatment of upper lip wrinkles". J Dermatolog Treat 23 (2): 144–52.

51 Majid I (January 2009). Microneedling therapy in athrophic facial scars: an objective assessment. J Cutan Aesthet Surg 2 (1): 26–30. 52 Doddaballapur S (July 2009). Microneedling with dermaroller J Cutan Aesthet Surg 2 (2): 110.53 Day DJ, Littler CM, Swift RW, Gottlieb S. The wrinkle severity rating scale: a validation study Am J Clin Dermatol. 2004;5(1):49–52. Department of

Dermatology, New York University Medical Center, New York, New York 10021, USA.54 Rohrich RJ, Pessa JE: The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007, 119:2219–

2227.

by Vladimir Tsepkolenko

Up-to-date combined therapy of stable vitiligo

Personal experience


TopicalityTraditionally dyschromias are of particular importance in modern dermatology and esthetic medicine. Vitiligo is a frequently acquired disorder of skin pigmentation characterized by distinctly outlined de-pigmented areas, its aetiopathogenesis still not fully understood. Histologically we can observe either absence or abrupt decrease of melanin content in melanocytes within vitiligo focuses. Its high rate of occurrences among many ethnic groups and regions, considerable infl uence of patients’ psychological status as well as the absence of reliable treatment methods dictates the current need to look for new ways of vitiligo treatment. Standard vitiligo therapy (external, NB UVB and PUVA) is safe however requires long-lasting treatment course, taking as a rule from 1,5 to 2 years. Among its considerable disadvantages should be noticed the fact that only half of patients achieve 75% of repigmentation and even more in case of long term, consistent therapy1.

Recently we have been observing widely practiced combination of standard and surgical methods of vitiligo treatment. Dermatosurgical techniques such as methods of tissue therapy (epidermal blister grafting, follicular grafting) and cell therapy (non-cultured cell suspensions of melanocytes and keratinocytes) widely used to treat stable forms of vitiligo, resistant to standard therapy2,3.

Purposes and objectivesLong-lasting standard type therapy, unstable results and a big number of complications after combinations of regular and surgical techniques determined the need to look for the new methods of stable vitiligo treatment. New possibilities have in this area have become available with cell technologies implementation4.

Considering advantages and disadvantages of existing methods of skin repigmentation as well as the possibility to apply cultured melanocytes and keratinocytes, we developed a complex approaches of persistent vitiligo types treatment.

Materials and methods The study of the presented algorithm effi ciency included 27 volunteers from 9 to 63 y.o. Among them were 9 males and 18 females.

Prior to the complex treatment, all the volunteers signed informed consent of participation in the study and use of achieved results for scientifi c purposes.

Quality control of the administered cell suspensions was monitored by means of ductal cytofl uorometry using specifi c melanocytes antibodies.

Study methodsClinical effi ciency of the suggested algorithm was evaluated:

All patients were divided into 4 groups depending the skin phototype and performed therapy.

The 1st group consisted of patients of Fitzpatrick I and II skin phototype, they were treated according to the treatment protocol developed by us. 2nd group patients with III and IV skin phototype was also treated according our treatment protocol. 3rd group (control) of patients with I and II skin phototype was treated by standard vitiligo treatment (narrow-band UVB 311 nm, external treatment). 4th group, consisting of patients with III and IV skin phototype were also treated by standard vitiligo treatment.

Our algorithm of complex technique of stable vitiligo treatment consists of 3 stages. At the fi rst stage we have pigmentation induction at the donor site of healthy skin (NB UVB 311 nm) in esthetically insignifi cant or naturally hyperpigmented areas

of plasma enriched platelets (PRP) into the vitiligo areas to create high concentration of growth factors including Epidermal Growth Factor (EGF).

Considering advantages and disadvantages of existing methods of skin repigmentation as well as the possibility to apply cultured melanocytes and keratinocytes, we developed a complex approaches of persistent vitiligo types treatment.


0-10 10-20 20-30 30-40

Age

35%

65%

Men - 35% Women - 65%

Gender

34 AJAM 2018

At the 2nd stage, 3–5 weeks later, were performed intradermal administration of cell suspension diluted in PRP solution with concentration of 1mln melanocytic- keratinocyte suspension for 1 cm² depigmented skin area. 2–3 days later we began the local photo therapy course NB UVB 311 nm, 3 times a week.

3rd stage assumes repeated administration of cell suspension but not earlier than in 2 months’ time, in case the percentage of reconstructed pigmentation is less than 50%.

Results and discussionThe fi rst group comprises of 11 persons (7 females, 4 males), 2nd group – 16 (11 females and 5 males). Control group made 17 individuals (8 females, 9 males) and 21 persons (13 females and 8 males) formed 3rd and 4th group.

Protocol Control

1 group 2 group 3 group 4 group

11 pers. 16 pers. 17pers. 21 pers.

7f. 4m. 11f. 5m. 8f. 9m. 13f. 8m.

Patient L., 26 y.o., Diagnosis: Stable vitiligo, (12 years) focal type, treated by transplantation of cultured melanocytic – keratinocyte suspension according to the protocol, 1 session

Patient L., 28 y.o., Diagnosis: Stable vitiligo (7 years) generalized pain, BeforeAfter treatment: treated by transplantation of cultured melanocytic – keratinocyte suspension according to the protocol, 2 sessions

Among the fi rst groups, that were treated according to the protocol, we achieved excellent repigmantation (75–100%) in 15 patients (56%), good repigmentation (50–75%) in 10 patients (37%) and unsatisfactory result was observed in 2 cases (7%). Besides, in the fi rst group, excellent result was achieved in 6 cases and 9 in the second. Good repigmentation was observed in 4 persons from the 1st group and 6 from the second, unsatisfactory repigmentation was

recorded for 1 person in the fi rst and second group each. It is important to note that repeated administration was required for 6 patients from the 2nd group with excellent result. The treatment period in 1st and 2nd group lasted 10–14 weeks.

Among the 3rd and 4th control groups, undergone standard treatment without cell technologies, excellent results (75–100%) were achieved in 7 patients of the 3rd group and 9 patients of the 4th group. Good rate of pigmentation reconstruction (50–75%) was observed in 8 patients of the 3rd group and 9 patients from the 4th group. Unsatisfactory pigmentation (less than 50%) was observed in 2

To achieve optimal results in treating the stable form of vitiligo we suggest complex algorithm based on autologous melanocytes and keratinocytes administration. The method is about donor site preparation (induction of pigmentation or the use of naturally hyperpigmented areas), preparation of the recipient vitiligo site (intradermal platelet rich plasma injections to create high concentration of growth factors) along with intradermal administration of melanocytic- keratinocyte suspension, diluted in PRP solution, into depigmented skin sites with the following local NB UVB 311nm phototherapy.


GroupNumber

of patients

Excellent repigmentation

(75 – 100%)

Good repigmentation

(50 – 75%)

Unsatisfactory repigmentation(less than 50%)

Absolute number of patients

%Absolute

number of patients

%Absolute

number of patients

%

1 11 6 55 4 36 1 9

2 16 9 56 6 38 1 6

Executive director of the Ukrainian Institute of Plastic Surgery and Cosmetology “Virtus”. Honored Doctor of Ukraine. M.D. Professor of the Sub-faculty of dermatovenerology and cosmetology of the M. Horky Dontesk National Medical University. Head of the Department of regenerative technologies of the Research Institute of rehabilitation and spa medicine of the Ministry of Health of Ukraine. Author

monographs: “Plastic aesthetic surgery. Modern perspectives”

co-author of the doctors’ manual in 2 volumes “Plastic surgery course” (2010).Member of the editorial board of professional

Anti-aging and Dermatologist. President of the Ukrainian Association of Aesthetic Medicine. One of the founders of the International Society of Plastic Surgeons and Oncologists. Honored Member of the Spanish Society of Aesthetic Medicine. Guest Associate Professor at the postgraduate course “ANDI Roma” (Italy). Presidium member of the International Association of Aesthetic Medicine (UIME).


patients from the 3rd group and 3 from 4th group. The treatment period in the 3rd and 4th groups lasted from 4 to 8 months.

It is important to note that in the 1st and 2nd groups we observed considerable reduction of the length of treatment comparing to the control groups and increased percentage of patients with excellent results. Approximately 40 percent of the 3nd group cases (with III and IV Fitzpatrick phototype) required repeated administration of cells, what should be considered when composing programs for this category of patients. Presumably, it is necessary to use higher dosages of cell for these patients.

Conclusions Widely used standard methods of vitiligo treatment are often too much time consuming and do not deliver guaranteed results.

To achieve optimal results in treating the stable form of vitiligo we suggest complex algorithm based on autologous melanocytes and keratinocytes administration. The method is about donor site preparation (induction of pigmentation or the use of naturally hyperpigmented areas), preparation of the recipient vitiligo site (intradermal platelet rich plasma

along with intradermal administration of melanocytic- keratinocyte suspension, diluted in PRP solution, into depigmented skin sites with the following local NB UVB 311nm phototherapy.

References

1 Njoo MD, Spuls PI, Bos JD et al. Nonsurgical repigmentation therapies in vitiligo. Meta-analysis of the literature. Arch Dermatol 1998; 134:1532–40.

2 Rusfi anti M., MD, Wirohadidjodjo Y Widodo, MD. Dermatosurgical techniques for repigmentation of vitiligo. International Journal of Dermatology 2006; 45: 411–417.

3 Falabella R, Barona MI. Update on skin repigmentation therapies in vitiligo. Pigment Cell Melanoma Res 2008; 22: 42–65.

4 Tsepkolenko V.A. Karpenko E.S. Literature review. Skin repigmentation using cell technologies. Newsletter of esthetic medicine 2014; V.14, No. 3-4: 90–104.

5 Ai-Young Lee. Role of Keratinocytes in the Development of Vitiligo. Ann Dermatol 2012. V. 24, No. 2: 115–125.

The method has demonstrated its high effi ciency, safety (as compared to surgery), shorter treatment course, possibility to treat larger vitiligo areas by means of small donor site, way of long term storage of cell material in cryobank for future use.

The method we present, offers excellent results in treating stable vitiligo after single application.

The following perspective research stage is focused on determining optimal doses of individualized cell product for getting guaranteed result5.

GroupNumber

of patients

Excellent repigmentation

(75–100%)

Good repigmentation

(50–75%)

Unsatisfactory repigmentation(less than 50%)

Absolute number of patients

%Absolute

number of patients

%Absolute

number of patients

%

3 17 7 41 8 47 2 12

4 21 9 43 9 43 3 14

by Kian Karimi

PDO Threads for Skin Tightening and Lifting:

A Checkered Past but Promising Future


THE AGING FACE is characterized by myriad of factors including skin wrinkling, soft tissue descent, bony resorption, and fat atrophy. These consequences of aging have ever increasing options for correction in a surgical and non-surgical fashion. Although surgical techniques are highly effective for correction of these issues, non-surgical or "minimally invasive" modalities have grown wildly popular in the United States and have seen continuous growth in demand over the last severalyears.1

Although advances in radiofrequency, microneedling, ultrasound, and heat technologies have been exciting and effective for different indications, there continues to be an unmet need in minimally invasive aesthetics for an actual lift of the skin and soft tissues in different areas, particularly the face.

Utilizing threads to perform lifting procedures has been around for over three decades.2 Dr. Sulamanidze is credited as being one of the fi rst to propose threads for lifting facial tissues with APTOS threads in 1998. Initially these threads were also permanent suture material but since then have been switched to dissolvable ones.

The experience with "thread lifting" in the United States has been poor –the Contour Threadlift system (Surgical Specialties Corp, Reading, Pennsylvania) was approved by the US Food and Drug Administration (FDA) in 2005. These threads were composed of polypropylene, a permanent suture material, and was utilized to perform thousands of "thread lifting" procedures through the country either as a standalone procedure or in conjunction with other procedures. These threads were purported to "replace" face and necklifting and to last for several years. The threads were wrought with complications, high rates of dissatisfaction, and were diffi cult to remove when there was a problem, sometimes necessitating the patient have a surgical procedure to extract them. Multiple studies also looked at the results and complication rates of these threads and dissuaded against their use3,4. The Contour Threadlift system was eventually removed from the market and left both patients and aesthetic physicians with a poor impression of the procedure. Multiple studies also looked at the results and complication rates of these threads and dissuaded against their use3,4. The Contour Threadlift system was eventually removed from the market and left both patients and aesthetic physicians with a poor impression of the procedure.

Recently, a subcutaneous and knotless technique with polydiaxanone (PDO) has been described as a material for offi ce based skin tightening and neocollagenesis and for lifting of the soft tissues of the skin and body5. This method, popular in many Asian and European countries, has not previously been utilized or described in the United States. The PDO

threads form a V-shape and are deployed in a hypodermic needle ranging from 18 gauge to 31 gauge and can be smooth, have a twist, or have uni or bidirectional "barbs," reminiscent of other barbed sutures. The threads are inserted in the superfi cial subcutaneous plane and when the needle is withdrawn the thread remains deployed under the skin.

Utilizing threads to perform lifting procedures has been around for over three decades.2 Dr. Sulamanidze is

propose threads for lifting facial tissues with APTOS threads in 1998. Initially these threads were also permanent suture material but since then have been switched to dissolvable ones.

Offi cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 37

For the smooth and twist fi bers, there is no "catching" of the dermis but simply placement of a dissolvable suture material that then undergoes breakdown over a period of 4–6 months, depending on the thickness of the thread and the relative metabolism of the patient's skin. The smooth fi bers are typically placed in a crosshatching pattern to create a "mesh" of threads which will result in improvement of the skin quality and texture over time. This procedure is generally repeated after 4–6 weeks for improved results and to sustain results achieved from previous treatments. The twist fi bers are generally placed in areas that would benefi t from a slight amount of volume such as medial to the nasolabial folds, the marionette lines, or in the vermillion borders of the upper and lower lips. A recent


study describes impressive histological response in guinea pigs after placement of these smooth threads – at one, three, and seven months after placement of the thread a 20, 7, and 2 times concentration of type 1 collagen and TGF-B1 was measured, respectively.6 This proves that that the increase in collagen and improvement of the dermal septal network persists beyond the lifetime of the thread.

The barbed threads are utilized to create a lift by approaching the area of sagging from distal to proximal and withdrawing the hypodermic needle or cannula after it has traveled in a precise superfi cial subcutaneous plane. As the needle or cannula is removed, gentle massage in the direction of the desired lift is performed to achieve the result. Although there is no fi xation of the sutures to deeper tissues as is the case with other thread lifts of the past and present, there is a net resultant effect by the redrapage of the tissues over the barbed sutures. Typically multiple barbed sutures are utilized for one area in favorable vectors to create a natural result.7

Results and patient satisfaction with PDO threads has been tremendous in our experience thus far, especially when combined with injectable fi llers for volume defi cit and neuromodulators for hyperdynamic rhytids. Our most popular treatment is lifting of the lower third of the face with barbed PDO threads to help smoothen out the jowls and the corners of the mouth where there is often that "fl ap" of skin that is diffi cult

Changes in expression of collagen Type I (A) and TGF-ß1(B) after thread lift, showing mean levels compared to nontreated section. Assessment of molecular changes indicated statistically signifi cant increases in collagen Type I and TGF-B1 at 1 month after implantation (p<.05). The increase was maintained until the end of the study at 7 months (p<.05). TGF-ß1, transforming growth factor beta 1.

Histologic evaluation of capsule formation. Fibrous capsule (black arrow) around the inserted thread is well noted in a 1-month specimen (A). Fibrous sheath is still noted in a 3-month specimen (B). Inserted thread is degraded and the surrounding capsule is replaced by connective tissue (C and F) (A–C; hematoxylin and eosin x40, F; Masson trichrome x40). Strong tissue reaction with infl ammatory cell aggregation is more prominent in a 1-month sample (D). Giant cell and granulomatous reaction are observed in a 7-month specimen (D and E; hematoxylin and eosin x200).

Dr. Kian Karimi, MD is a facial plastic & reconstructive surgery specialist in Los Angeles, CA and has been practicing for 13 years. He graduated from Indiana University School of Medicine - M.D. in 2005 and specializes in facial plastic & reconstructive surgery and ear, nose, and throat.


References

1 American Society for Aesthetic Plastic Surgery (ASAPS) Website: http://www.surgery.org/media/news-releases/statistics-surveys-

and-trends2 Paul MD. Barbed sutures in aesthetic plastic surgery: evolution of

thought and process. Aesthet Surg J 2013;33:17S–31S.3 Abraham RF et al. Thread-lift for facial rejuvenation. Arch Facial

Plast Surg. ;Vol 11 (No. 3), May/June 2009;178–183.4 Rachel JD et al. Incidence of complications and early recurrence

in 29 patients after facial rejuvenation with barbed suture lifting. Dermatol Surg 2010;36:348– 354 .

5 Suh DH et al. Outcomes of polydiaxanone knotless thread lifting for facial rejuvenation. Dermatol Surg 2015;41:720–725.

6 Kim J et al. Investigation on the Cutaneous Change Induced by Face-Lifting Monodirectional Barbed Polydioxanone Thread. Dermatol Surg 2017;43:74–80.

7 Karimi K. Technique for nonsurgical lifting using polydioxanone threads. JAMA Facial Plast Surg. 2018 Aug 9

Before and immediately after barbed PDO threads to lift the lower third and Restylane Lyft mixed with platelet rich fi brin (PRF) injected to the midface and tear troughs.

Before (left) and 1 month after (right) placement of 18 gauge Barb-4 PDO threads for the midface and lower third and injection of Revanesse Versa™ to the tear troughs.

to treat with other modalities. There is defi nitely a learning curve for proper placement of the threads to minimize irregularity and asymmetries, especially with animation.

Results and patient satisfaction with PDO threads has been tremendous in our experience thus far, especially when combined with injectable fi llers for volume defi cit and neuromodulators for hyperdynamic rhytids. Our most populartreatment is lifting of the lower third of the face with barbed PDO threads to help smoothen out the jowls and the corners of the mouth where there is often that "fl ap" of skin that is diffi cult to treat with other modalities. There is defi nitely a learning curve for proper placement of the threads to minimize irregularity and asymmetries, especially with animation.

Complications are manageable and minor. Puckering / dimpling is the most frequent complication to occur with placement of the threads although this is mostly preventable and typically self resolves in 1–2 weeks. Irregularity, symmetry, and visibility of the threads are potential complications seen primarily with the barbed sutures. These issues are generally managed conservatively with massage, placement of fi ller to smooth out the tissues around the threads, or radiofrequency treatments to allow faster metabolism of the dissolvable thread. Injection, migration, and extrusion are extremely rare but have been reported. Placement of PDO threads in the correct plane avoids injuries to deeper structures and post procedure pain and discomfort. Fortunately, there are no devastating potential complications such as skin tissue necrosis and blindness.

by Dr. Opkala Maluski

IntroductionThe desire for aesthetic procedures in the developed world has rapidly been on the rise over the last two decades. The public acceptance of aesthetic procedures, buttressed by beauty ideals which are extensively promoted by the media and beauty product companies, has fuelled this need.

In the developed world, what is termed ideal has changed over time. From the slender frame, symmetrical face and narrow shoulders of Ancient Egypt exemplifi ed by Queen Cleopatra, beauty ideals have changed many times to the slim well defi ned bodies with full breasts and thigh gaps as seen in Kate Moss1, 2, 3.

The variation in the perception of beauty in the traditional African society can be appreciated when comparing the fair, slender, straight nosed beauties of Northern Africa with the chocolate coloured, well-endowed belles of Southern Africa2.In the traditional West African society, the ideal body image was predominantly infl uenced by cultural values. With the advent of colonialism and thus the penetrance of western culture into the West African sub-region, the ideal body image as seen by the traditional West African gradually underwent a change. This became evident as shown in the increased desire for lighter skin and slimmer bodies as exemplifi ed in beauty pageants that are showcased frequently in West Africa.

Currently, with the gradual paradigm shift that is taking place in the West African society and probably Africa, the ideal body image is moving away from Western aesthetic ideals to ethnic specifi c beauty. Even in Western countries, changes are taken place due to the increasing multicultural nature of the population. This shows that ethnocentric variability in aesthetic ideals is now being recognized in order to satisfy the increased need for aesthetic procedures by ethnic patients whilst preserving their racial identity2.



This pilot study attempts to construct an ideal image of the modern West African lady through a snapshot of people's perspectives, and thus extrapolate on its signifi cance to the aesthetic medicine practice in West Africa.

The studyAim: To construct the ideal female West African body image.

Objectives:

ideal body for a West African female.

out an aesthetic procedure.

Methods:The study was conducted in Nigeria and Ghana over a period of three months. A random sampling approach was used. All respondents were females. A total of 75 questionnaires were administered during a short interview. The data was analysed using Microsoft Excel.

ResultsThe minimum age of the respondents was 20, and the maximum age was 42. The highest number of respondents fell within the 29 to 30 age bracket. There was an almost equal number of respondents who were single (49.3%) or married (48%), and the rest of the respondents lived with their partners. Most of the respondents were in the medical fi eld (49.3%), followed by 19.2% who were in the Social and Arts sector, and then 16.4% who worked in the fi nancial sector. 73.7% of the respondents were Nigerian, followed by Ghanaian (22.4%), Gambian (2.6%), and Guinea-Bissau (1.3%). 28.8% of the respondents fell into the $501 – 1000 income range per month, followed by those in the $1001 – 2000 income range (26.0%). 24.7% of the respondents fell into the $0 – 500 income range, and the least number of respondents (20.5%) fell into the >$2000 range.

Figure 1.Ideal Facial Colour. Most of the respondents (67.1%) chose brown as their ideal facial colour as compared to 27.4% who chose a lighter skin colour.

Figure 2.Ideal Nose Type. 86.2% of the respondents preferred a straight nose as the ideal type of nose, as compared to 9.2% that chose a fl at nose.

Figure 3.Ideal Lip Type. 87.8% of the respondents noted that they considered full lips as ideal, as compared to 12.2% that preferred slimmer lips.

Figure 5.Ideal Abdomen. Most of the respondents (90.67%) chose a fl at abdomen as the ideal abdomen as compared to a plump abdomen (9.33%).

Figure 4.Ideal Breast Size. 36.7% of the respondents chose the ideal breast size as the C and D cup sizes equally, followed by 22.4% who chose the B cup, with the lowest numbers going to the A and F cups (1.3% each). Light skinned

Brown

Black

Flat

Other

Straight

Slim

Full

Plump

Flat

A

B

C

D

F


DiscussionAesthetic procedures are progressively becoming a global phenomenon. Beauty and youth are becoming signifi cant determinants of economic security, and thus cosmetic surgery is now seen as the solution to appearing well groomed, confi dent, and viable in the workplace4. The quest for aesthetic procedures has moved from that which was only available to the wealthy and Caucasian, to that which is being provided increasingly to those from an ethnic background. This is due to the increase in disposable income, the popularization of cosmetic surgery and its relative affordability, and its growing acceptance as a normal beauty routine5,6.

In 2013, a total of 15.1 million cosmetic surgery procedures were done in the United States of America, with 31% of these

Figure 6.Ideal Body Figure. 76% of the respondents chose the hourglass fi gure as the ideal as compared to the other categories.

Figure 7.Ideal Buttock Shape. 56.3% of respondents chose the round buttock shape as compared to the heart shaped buttock shape (42.3%).

Figure 8.Ideal Leg Shape. Most respondents (86.1%) chose slender legs as the ideal leg shape.

Figure 9. 54% of the respondents said that they were willing to spend 25% of their earnings over 3 months on achieving their ideal body image, followed by 14% who were willing to spend 50% of their earnings over 3 months. Only 8.6% were willing to spend a 100% of their total earnings.

Heart

Round

Square

Thin

Slender

Muscular

Fat

25%

10%

50%

none

75%

3%

100%

20%

How much of earnings over 3 months will you be willing to spend?

Income level ($)

How much of earnings over 3 months will you be willing to spend?

0 – 500 501 – 1000 1001 – 2000 >2000

25% 24.3% 20% 50% 50%

50% 37.8% 20% 0% 0%

75% 24.3% 50% 50% 16.7%

100% 13.5% 10% 0% 33.3%

100% 100% 100% 100%

Table 1shows a further breakdown of income levels when compared to desired expenditure.

Straight

V Shaped

A Shaped

Hourglass


being done on ethnic minorities like Hispanics, African – Americans 7. One can thus see the rising demand by the ethnic minorities from 17% of the total cosmetic surgeries done in 2005 to 31% as it is now6. It is estimated that the number of cosmetic procedures performed on African-Americans has increased by 56% from 2005 to 20138.

To cater for this, the cosmetic surgery industry is adapting to ethnic specifi c needs, since different ethnic groups favour different procedures. In 2013, the most popular cosmetic surgery for African-Americans was abdominoplasty, followed by liposuction, then breast augmentation and fi nally blepharoplasty7. This is in contrast to those preferred by the Caucasians of which the most popular was blepharoplasty, amongst others7. This underscores the importance of addressing the ethnic specifi c needs of people who want to enhance their bodies without losing their ethnic identity9.Many studies have been done on the cosmetic needs of people in the developed societies, and the body characteristics that are preferred by those who seek cosmetic procedures. These can be seen by the differences in the types of cosmetic surgeries which are performed within the different ethnic groups.

What about the West African female?Although there have been a few studies on the ideal body image of the West African female10, there is no information on their specifi c aesthetic preferences. There is also a paucity of available data on cosmetic surgeries done within the sub-region from which one can solicit such information. With the current shift towards preservation of ethnic beauty, the question arises – what are the body characteristics that the modern day West African female would consider as ideal?Over 70% of the respondents were Nigerian, which is not surprising, since Nigeria is the most populous country in

Africa 11. Most of the respondents who could spend 25% of a three month income (75.3%) fell within the $500 to >$2000 per month income range, which corresponds to the earnings of those within the middle class12,13. This is important because the rapid growth of the middle class in the African society over the last few years connotes an increased purchasing power and disposable income, which can enable access to aesthetic procedures, something which was previously the forte of the upper class2.

From this pilot study, one can attempt to construct the ideal body image of the average modern West African middle class female. The complexion would be brown in colour, with a straight nose, full lips, an ample bosom with breast sizes falling within the C and D cup size, a fl at abdomen, an hour glass fi gure, a bottom shape that falls between the heart shape and the round shape, and slender legs.

This construct is very interesting, and a few points can be gathered from this. Over 70% of the respondents chose either brown (67%) or black (5.5%) as their ideal facial colour. This can be interpreted as signs of a paradigm shift away from western aesthetic ideals of being fair/light skinned which have permeated the traditional West African interpretation of beauty, to an ethnocentric beauty ideal – the chocolate complexion. When considering the desire for a straighter nose by the respondents (86.2%), one may also deduce that the overall aim may not be to have a "white" nose on a black face, but to make the nose to look more aesthetically pleasing in proportion to the facial structure6.

Although this study is a brief snapshot of the West African perspective on ethnic body preferences, it has big implications for the aesthetic practitioner in this investment rich, rapidly modernizing sub region of Africa. Whilst keeping the preservation of ethnic identity and safe practice in mind, the aesthetic practitioner who takes the plunge will have an idea of the aesthetic demands of clients.


The construct also suggests a fusion between the traditional connotation of beauty – full lips, big bust, and a well-developed backside, with a modern western themed look – straight nose, fl at abdomen, hourglass fi gure, and slender legs. This may well represent the modern African lady who satisfi es the traditional West African viewpoint of beauty, and yet can be considered as beautiful from a western point of view. The fi nancial commitment towards achieving an aesthetic ideal is obvious from Figure 9 which shows that more than 50% preferred to spend 25% of their income over 3 months for that. Table 1 shows a further breakdown of the income levels and preferred expenditure for aesthetic procedures. Further calculation revealed that about 75% of all the respondents that chose to spend 25% of their 3 monthly income fell within the $501 to >$2000 income level. In terms of actual cash-in-hand, this ranges from a minimum of $375 to over $1,500. When compared to the current prices of aesthetic procedures in the United States of America, this suggests that the modern middle class West African lady can afford to have some minor aesthetic procedures done, and even save up for major aesthetic procedures if so desired14,15.

Although this study is a brief snapshot of the West African perspective on ethnic body preferences, it has big implications for the aesthetic practitioner in this investment rich, rapidly modernizing sub region of Africa. Whilst keeping the preservation of ethnic identity and safe practice in mind, the aesthetic practitioner who takes the plunge will have an idea of the aesthetic demands of clients. As time goes on and client satisfaction with services rendered increases, one can develop a huge client base that encompasses the countries within this sub region, with obvious fi nancial benefi ts.

ConclusionThe ideal image of the modern western female has been researched in great detail, and those ideals are being promoted by the media, the cosmetic and the fashion industry. The pursuit of ethnocentric beauty in recent times have led to the question – what are the ethnic body preferences of the modern West African female? This study attempts to paint a picture of the ideal body of the modern middle class West African female. Although it is a pilot study, it has implications for the aesthetic practitioner who wishes to provide such services to the West African sub region.

References

1 Women's Ideal Body types Throughout History. Buzzfeed documentary on Youtube.

2 Okpala AM, Ampomah O. Aesthetic Medicine in West Africa: A trend giving rise to a need. American Journal of Aesthetic Medicine 2013; 4:56–60.

3 Ruud, Maddie. Western Standards of Beauty: An illustrated Timeline. Article in Women's Body Image, Hubpages; 2012.

4 Honigman R, Castle D. Aging and cosmetic enhancement. Clinical Interventions in Aging 2006; 1(2): 115–119.5 Pots of promise. The Economist 28/01/2015. E-pub.6 Cosmetic Surgery Is Moving Toward Multi-ethnic Beauty Ideals.

The Culture of Beauty, 2010. http://ic.galegroup.com/ic/ovic/ViewpointsDetailsPage/ViewpointsDetailsWindow?zid=caf062fc06b7a4fd45a29c03adbcc65e&action=2&catId=&documentId.

7 American Society of Plastic Surgery Statistics Report 2013.8 O'Connor, Maureen. Is Race Plastic? My Trip into the Plastic

Surgery Minefi eld. The Cut. July 27, 2014.9 Wimalawansa S, McKnight A, Bullocks J. Socioeconomic Impact of

Ethnic Cosmetic Surgery: Trends and Potential Financial Impact the African American, Asian American, Latin American, and Middle Eastern Communities Have on Cosmetic Surgery. Semin Plast Surg 2009; 23:159–162.

10 Duda, R. B., Jumah, N. A., Hill, A. G., Seffah, J., & Biritwum, R. Assessment of the ideal body image of women in Accra, Ghana. Trop Doct 2007; 37(4): 241–244.

doi: 10.1258/004947507782332883.11 Wikipedia. https://en.wikipedia.org/wiki/Nigeria.12 The worlds fastest growing middle class. www.uhy.com. Accessed 15/02/2015.13 Ncube, Mthuli. The Making of the Middle Class in Africa. Future

Development (http://blogs.worldbank.org/futuredevelopment) Accessed 15/02/2015.

14 Cost of Plastic Surgery in the United States. www.infoplasticsurgery.com.15 US plastic surgery statistics: chins, buttocks and breasts up, ears down. www.theguardian.com. Thursday 19 April 2012.

The pursuit of ethnocentric beauty in recent times have led to the question – what are the ethnic body preferences of the modern West African female? This study attempts to paint a picture of the ideal body of the modern middle class West African female. Although it is a pilot study, it has implications for the aesthetic

practitioner who wishes to provide such services to the West African sub region.


to slice cleanly through whatever soft tissue it fi nds in its path, and—most relevant to fi ller injection—that includes blood vessels.

Having a blunt rounded tip allows a micro-cannula to dissect through tissue rather than cut indiscriminately. Provided that the clinician is gentle enough, has developed a good technique, and has respect for and good knowledge of the local anatomy, bruising is not only incredibly rare, but patient comfort is remarkable. Let me stress that there is a learning curve. At my fi rst few attempts at using micro-cannulas, I did not like them. It was not a familiar feeling to me, it appeared crude in its execution, and it seemed more painful than simply gliding a small needle at pinpoint precision to where I wanted to deposit the fi ller.

Being persistent and willing to learn from others helped me master cannula use, grasp the full concept, and wrap my mind around some basic principles and approaches. Embracing cannula use has transformed my fi ller practice over the past three years. Three guiding principles aided in my quest to master cannula use: as little pain as possible, as little bruising as possible, and a most natural result. All three of these can be attained at a higher level than the traditional needle approach to treatment.

The fi rst step to a beautiful fi ller result is proper planning. The need for an artistic eye and a good concept of facial aesthetics and beauty, as well as a very good understanding of facial anatomy, is of paramount importance. Assuming that this is the case, the approach that I prefer when treating a full face is treating the superior aspects of the face—such as forehead, brow and temples — fi rst, working my way inferiorly to the mid-face, and ending with the jawline. I've always been a stickler for precision, a trait I think I picked up as a youngster watching my engineer father for hours as he assembled and built intricate electronic components. Being very methodical and precise is helpful when using cannulas as well.

OH, HOW TIMES have changed! I recall how in 2001, when I had the desire to offer fi ller treatment in my practice, I had received a starter kit by mail from the one and only company to distribute an HA fi ller in Canada. Using the instruction booklet, my wife was the obvious choice for my fi rst patient, treating Nasolabial lines and lips. No anesthetic, multiple punctures, trial and error. Oh what fun!

Let's move forward about 15 years and take a look at how the fi ller treatment landscape has changed. The focus today is on full-face correction, multiple areas, as painless as possible, little or no bruising, and no downtime. In an effort to increase comfort, I employed nerve blocks for lip treatments for the fi rst few years. In my own experience as well as considering the experience shared by colleagues at various meetings and conferences over the years, the approach to fi ller treatments has evolved to become increasingly refi ned and precise.

Somehow our European colleagues seem to have a head start on many cosmetic medical approaches compared to North America, notably so when it comes to micro-cannula use for fi ller treatments. We're quickly catching up though, and through innovation on both sides of the pond, our patients are privileged to better and better experiences and results. Having a large practice with a large injectable proportion has enabled me to adapt and innovate my approach to fi ller injections and create an organized approach that should be of benefi t for other clinicians.

Cannula use in medicine and surgery is nothing new. A hollow tube with a blunt tip and side port near the tip is old news. What is new, however, is cannulas that are as small as 30 gauge, fl exible, and between one and two inches in length. The Dermasculpt micro-cannula was one of the fi rst to be FDA approved in January 2012, followed by Magic needle, Softfi l, TSK and Sculpt-face. The fi rst thing that comes to mind when taking a micro-cannula in hand is safety. The needles included with your average fi ller syringe have a very sharp point with a bevel that has a surgically sharp cutting edge. It is designed

Practical approach to safe, smooth

by Renier Van Aardt


Using an eyeliner pencil or something similar, with the patient in an upright position and with good lighting, mark areas of volume defi ciency in all the planned treatment areas. Visually plan and mark the most appropriate entry points, avoiding blood vessels and entering in anatomical "safe zones"—away from important structures. Entry points zones that I typically identify may be at the lateral brow, just medial to the temporal fusion line, zygomatic arch or in the region of the cheek mound, distal aspect of the naso-labial line, and mid-jowl. For lips, I use a 30 gauge cannula and enter just medial to the lateral commissure, an entry point for each the upper and lower lip. Once satisfi ed with the entire treatment plan, it's good practice to ensure that the patient is comfortable and that the patient's head is resting securely. Treatment may be done in a semi-reclined position; however, assessment should always be done in an upright position.

Take extra care when a cannula entry point is created. A needle of the same diameter as the cannula can be used, as skin is elastic and a larger trocar increases pain and the risk of a bruise; however, it is of critical importance to note the exact point of entry, angle of the needle, and the direction in which the entry tract is made. Having an assistant to remove the trocar needle just prior to entering with the cannula can be very helpful in this instance. In my experience, there is no need to roll, "jiggle," or "fl ick" the needle - these maneuvers just increase the risk of vascular injury. One precise entry to the correct sub-dermal plane and exit is all that's required if the simple rules of angle, direction, and noting the exact point of entry are adhered to. Holding the syringe with cannula like a dart aids in being precise and seamlessly advancing the cannula into the desired tissue plane.

For patient comfort, pre-application of topical anesthetic or simply cooling the entry point with ice, or briefl y with cryotherapy, is advised. Distraction techniques such as having a nurse massage the patient’s shoulder, placing small vibratory device on the skin next to the entry point, or pinching the skin are good habits to adopt and all reasonable ways to keep your patients comfortable, loyal, and happy.

To advance the cannula to the distal treatment zone once entered, hold the syringe like a pool cue and roll it while gently moving back and forth in order to dissect through. When required to place fi ller in the sub dermal plane, it helps to stretch the skin with the opposing hand. When required to place fi ller deep, pinching up the skin with the opposing hand assists with entering and advancing at the appropriate depth. Whenever fi rm resistance is encountered, pull back, slightly change direction, and try again. Never apply strong

One precise entry to the correct sub-dermal plane

and exit is all that’s required if the simple rules of angle,

direction, and noting the exact point of entry are adhered

to. Holding the syringe with cannula like a dart aids in

being precise and seamlessly advancing the cannula into the

desired tissue plane.

Dr. Renier Van Aardt has a broad base of clinical experience and expertise to draw on. He’s been offering dermatological laser treatments to patients since 2000. He is also among the top 25 injectors of more than 1,000 Allergan accounts in Canada. Dr. van Aardt graduated from the University of Stellenbosch in Cape Town, South Africa in 1991, with

Family Medicine.

force in order to avoid unwanted tissue injury. Alternating with a pinch and stretch maneuver with the opposing hand can assist in fi nding a smooth dissection trajectory. Consider your knowledge of anatomy in order to respect important structures such as vessels, nerves, and muscles and treat accordingly to avoid injury.

Next, it's a matter of placing, layering, and fi lling per plan. You can pull back on the plunger to rule out intra-vascular injection in important vascular areas. It helps to start injecting distally and retro trace to reduce the risk of intra vascular injection. Use appropriately cross-linked fi ller products according to the depth of placement and areas being treated and matched to the desired outcome. Unless the goal is to correct pre-existing asymmetries, attempt to treat as symmetrically as possible — hence the importance of marking the skin prior to treatment. The ability to place the fi ller in a very smooth and even manner as opposed to using short needles is one of the fi rst advantages that I noticed early on. Another advantage is how large an area can be treated trough a singe entry point, minimizing telltale signs and reducing pain and bruising at the same time.

As one becomes more adept and comfortable with cannula use, fi ner nuances can be appreciated, and treatments can evolve to become more three-dimensional. Depending on the angle of the syringe, the tip of the cannula will move in the opposite direction. It's counter-intuitive and opposite of how a stiff, short needle behaves. In this respect, one can learn how to "drive" the syringe and cannula to layer fi ller in a particular pattern as well as fan the product when wider deposition is required. Treatments become more and more creative and faster as this skill develops.

It is necessary to mention some important aspects applicable to micro cannula use. It is advisable to prepare the skin widely with a good surgical antiseptic such as chlorhexidine and alcohol or iodine. Wear sterile gloves, and if multiple areas are being treated in one setting, drape the patient with sterile towels. Because micro-cannulas are long and fl exible, they

are more likely to touch the skin and gloves, and if not sterile, there is an increased risk of infection. A cannula holder is handy if the same cannula will be used on more than one syringe. Alternatively, the assisting nurse can re-sheath the cannula and reapply it to the next syringe.

Always assess the patient in an upright position and if any further correction is required, do so at this time. The last step should be to gently assess, sculpt, and lightly massage all the treated areas with the use of ultrasound gel or a pleasant smelling Aloe Vera gel, making sure that there are no visible bumps in treated areas. Avoid overly aggressive massage or pressure to reduce bruising or risk of reducing desired results. Patients should avoid the use of makeup for a few hours and be instructed to sleep with their head somewhat elevated and not place pressure on the treated areas for 72 hours. Although I do not wish for my patients to manipulate the fi llers, should they in the rare instance see a small bump or irregularity in any of the treatment areas, I do allow them to gently massage those with the tip of their fi nger to smooth it out, as it's easier to do earlier rather than days or weeks later.

How have cannulas impacted my fi ller practice? Well, word of mouth referrals are notably up. The word is spreading around town that I'm the doc to see. Why? Well, in the words of Dr Arthur Swift: "If you bruise them you lose them and if you pain them, you don't retain them." Patients also love the very soft, subtle and natural correction that is somehow now more consistent than in my pre-cannula days. Not to mention, "happy wife, happy life!" We certainly have come a long, long way since those early days, and if anyone can attest to that, my wife surely can.

It is advisable to prepare the skin widely with a good surgical antiseptic such as chlorhexidine and alcohol or iodine. Wear sterile gloves, and if multiple areas are being treated in one setting, drape the patient with sterile towels. Because micro-cannulas are long and

sterile, there is an increased risk of infection.


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Maximizing Donor Harvesting

inHair Transplantationby A.Tsilosani MD, PhD

NOWADAYS, FOLLICULAR UNIT Transplantation (FUT) is the leading method of hair restoration surgery. Despite the fact that Follicular Unit extraction (FUE) day by day is getting more popular, there is no doubt that FUT allows to harvest and implant higher number of FU’s in single session. In case of high level baldness (Norwood IV-VII classes) patient may need transplantation of a big number of follicular units (3500–10000). If there is a possibility of transplanting the required number of grafts during one session, patient would only benefi t from this: 1. He gains time - the optimal cosmetic result of the hair

transplant surgery obtained earlier, because it occurs 1 year after the fi rst session, instead of 1 year after the last session.

2. Patient undergoes all the inconveniences related to operation only once.

3. Patient saves money, as long as for one gigasession he fairly hopes for a discount and one gigasession would cost

him less than two average sessions.4. Patient gets a better fi nal donor scar (even the donor strip

is wide the fi nal result is better than after 2 or 3 incisions in the same place).

5. In many cases, grafts from the fi rst session grow better than after subsequent sessions5, maybe because of less scaring leading to better growth, or because of some other reasons, but it still remains the fact that growth is much better on the virgin head, just as on the virgin soil.

But many hair transplant surgeons consider that performing gigasessions may cause many diffi culties. They can be grouped as:

compromise the vascularity of the recipient area and lead to grafts survivability decrease.

body time and the risk of grafts dehydration. The patient and the staff get tired and that may affect the quality of work.

and bad scalp laxity. Wide strip excision in such patients causes an unacceptable scar formation.

Offi cial Journal of the American Academy of Aesthetic Medicine50 AJAM 2018

2018 AJAM 51

Usually gigasessions are performed in cases of high level baldness – Norwood classes IV, V, VI, VII, when recipient area excels 100cm² and transplanting more than 3500 FUs would result in average density of less than 50FU/cm2. Recent research has proved that small (less than 1mm) and sharp instruments used for recipient sites creation, do not alter blood supply and do not decrease grafts survivability even when the density of implantation is more or equal to 70 FUs4;7. That means that the density of 35–50 FUs per 1cm2 can be considered as absolutely safe.

Regarding the second problem: gigasessions are possible to be performed only at the clinics with big team of professionals. In such case for gigasession (up to 5000 grafts transplantation) 6 hours is quite enough. Mostly important is to correctly organize the team work. Gigasessions start with tumescent anesthesia, which decreases bleeding and stays for a long time. In this process for which 30mins are enough only one surgeon and one nurse are involved. Later the same team (1 surgeon and 1 nurse) cuts out a big donor strip, which takes less than one hour including trichophytic closure of the wound. Then, the same team prepares recipient sites, which takes no longer than 1.5 hours. Thus, for all (starting from fi rst steps of local anesthesia and creation of last recipient site) 3 hours are needed. At the same time, second team (1 surgical assistant for slivering and 5–6 cutters) prepares the needed number of grafts using stereomicroscopes. In case of highly experienced cutters each cutter prepares 300–400 (depending on the donor material) high-quality grafts in one hour. So 2.5–3 hours needed to get 5000 grafts.

Afterwards, the coming step is implanting grafts in pre-created recipient sites. 3 implanters fi ll in the sites and 1–2 assistants keep recipient area clean and dry. Highly experienced surgical assistant’s speed of implanting is 10–15 recipient sites per minute (depending on bleeding and popping). If the team of implanters consist of 3 assistants for 5000 grafts implantation 2.5–3 hours are absolutely enough.

Thus, HT surgery of 5000 grafts takes less than 6 hours (including several 5–10 minutes break for the patient) which seems to be tireless, neither for patient nor for the staff.

We consider that the only obstacle for performing gigasession could be a poor donor supply of the concrete patient – low donor density and laxity of the scalp.

In a case of high follicular density of the donor site (more than

cm² size for receiving 5000 FUs. Usually strip length is limited to 30–35cm, so the average strip width should be 2.0cm. This means that strip width in the centre has to be extended up to 3cm. It is possible to get a strip of this width only in case

of very good scalp laxity. It’s quite rare, especially in Asian and African patients, who’s hair density usually are not high and in average varies from 50–75 FUs (120 hairs) per 1cm2 2, 3. If we attempt to increase the number of transplanted grafts it will lead us to the tight wound closure, which may increase the risk of wide donor scars formation.

For maximizing donor harvesting, scalp exercises are recommended before surgery. According to J. Wong scalp exercise improves scalp laxity and it may increase the chance of harvesting additional number of grafts, up to 1500 FUs9. But, often this is not enough and therefore needs additional time before surgery.

Other option is using Hyaluronidase injection before surgery, which signifi cantly increases scalp laxity but its action is temporary and gives false impression of scalp looseness. After ending the action of Hyaluronidase the scalp tightness increases, goes back to previous condition and brings us to ischemia. We have often passed through such complications as donor area necrosis and shock loss in donor area. (fi gure 1, 2).

In order to reduce the strip width without decreasing the number of grafts transplanted during one operation, we decided to combine strip method (FUSS) with FU extraction (FUE). For example, for obtaining 5000 FUs for transplantation we initially perform FUE of about 1500 FUs from the zones above and below the

from which we get appr. 3500 FUs.

Figure 2.Shock loss in donor area

Figure 1. Donor area necroses


Offi cial Journal of the American Academy of Aesthetic Medicine52 AJAM 2018

Figure 3–4.Scalp tension forces measurement after strip excision.

Figure 5–6.Donor area after combination of FUT and FUE

Figure 7–8. Donor scars after combination FUT and FUE

Figure 9–10.The result of 5122 graft transplant with combo of FUT and FUE on huge post burn scar of the scalp.

Our study measuring the scalp tension power using 2 dynamometers

during the process of closing the donor wound, revealed that if at least 30% of grafts are obtained through FUE and the rest are generated from a strip, the tension force decreases twice during wound closure8.

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References

1 Hwang S.T. Hair Transplantation East Asian Males. In W. Unger and R. Shapiro ed. Hair Transplantation, Fifth Edition. Informa, pages: 428–430

2 Imagawa K. Knowing the Difference in Restoring the Asia Look. In D. Pathomvanich and K.Imagava ed. Hair Restoration Surgery in Asians. Springer 2010. Page 15–20

3 Kim J.C. Asian Hair: A Korean Study. In D. Pathomvanich and K. Imagava ed. Hair Restoration Surgery in Asians. Springer 2010.

Page 21–224 Nakatsui Th., Wong J., Croot D. Survival of Density Packed Follicular

Unit Grafts Using the Lateral Slit Technique. Dermatologic Surgery. 2008; #8, p. 1016–1022

5 Seager D.J. The "One-Pass Hair Transplant" – a Six Year Perspective. Hair Transplantation Forum Int. 2002; 12(5): 1–6

6 Tsilosani A.,Gugava M., Tamazashvili T. One layer donor closure versus two-layer donor closure in large hair transplant sessions – a biomechanical approach. Georgian Medical News. #7–8,2004; pages:18–22.

7 Tsilosani A. One hundred follicular units transplanted into 1cm² can achieve a survival rate greater than 90%. Hair Transplantation Forum Int.2009, Vol 19, #1, page 1–7.

8 Tsilosani A. Expanding graft numbers combining strip and FUE in the same session: effect on linear wound closure forces. Hair Transplantation Forum Int. 2010, Vol20, #4, page 122–124.

9 Wong J. Preoperative Care for Super Mega-Sessions. In D.Pathomvanich and K.Imagava ed. Hair Restoration Surgery in Asians. Springer 2010. Page 81–82

This technique was fi rst tested in 2006 and soon we have found the obvious potential of such synthesis. This method gives us an opportunity to harvest the necessary quantity of grafts, and also substantially decreases compression on the edges of the donor wound while closing.

Combining the techniques of FUE and strip excision is rather simple. First, the desired strip outline is marked. The strip width in this case seldom exceeds 1.5cm (with the length range from 25–30cm). From 500 to 2000 grafts is harvested using FUE method above and below the strip edges following by a strip excision, which generates from 2500 to 3500 grafts as a result of preparation depending on the follicular density. As a result, from 3000 to 5000 FUs are obtained for the transplantation. Additionally, our practice showed that this combination signifi cantly decreases scalp tension forces when closing the donor wound.

Our study measuring the scalp tension power using 2 dynamometers (fi gure 3, 4) during the process of closing the donor wound, revealed that if at least 30% of grafts are obtained through FUE and the rest are generated from a strip, the tension force decreases twice during wound closure8. Using this combination almost in every patients donor wounds were closed accurately for further formation of cosmetically acceptable scars (fi gure 5, 6, 7, 8). The fi gure 9,10 demonstrates the result of 5122 graft transplant with combo of FUT and FUE on huge post burn scar of the scalp in patient with poor donor density and laxity.

The combination of strip surgery and FUE increases the duration and the cost of the operation; nevertheless, we believe this is the optimal option for maximizing donor supply in patients with poor donor laxity and density.

Akaki Tsilosani MD, PhDClinic Founder and DirectorHair Transplantation Clinic “TALIZI”Tbilisi, [email protected]

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Practice Opportunities Looking to join an aesthetic medicine practice, or hiring a practitioner? In future issues of the AAAM journal, we will have a Practice Opportunities classifi ed ads section where medical practices or doctors can post their needs – whether to join or expand a practice or to hire new doctors. Posting is free for AAAM members.

Medical Negligence & Settlement Stressed by negligence law suits in aesthetic medicine? AAAM invites contributions on actual experiences with negligence law suits and how they ended up. Members can learn from such contributions.

Submission of ManuscriptsThe American Journal of Aesthetic Medicine welcomes submission of articles presenting research, fi nding or observations related to aesthetic medicine and cosmetic medicine.

General InstructionsArticles will be considered if they have not been previously published and are not under review elsewhere.

Instructions for Original and Review ArticlesWhile the American Journal of Aesthetic Medicine primarily seeks publication of original clinical and research articles that describe a variety of research designs and methods, we also welcome review articles and other articles concerning business and economic aspects of aesthetic medicine.

Authorship GuidelinesThe author should have made a substantial, direct, intellectual contribution to the manuscript, since authorship is a way of taking responsibility for, and receiving credit for, intellectual work.

Organization of Manuscript and Writing Style

Manuscript Title The title should list the author(s), including organizational or institutional affi liation and title or position. Manuscript titles should not exceed fi fteen (15) words.

References References should be numbered in the order in which they appear in the text, and they should be listed at the end of the article in the order in which they are cited. Additional references should be added in a separate list. Authors are responsible for the completeness and accuracy of references.

Tables Each table should be printed on a separate page that includes a title, and a clear explanation of all abbreviations and components of measure used in the table. The title should provide an understanding of the table without the need to refer to the text for explanation. All letters, numbers, and symbols must be clear and large enough to be read when reduced for publication.

Tables should be numbered in the order in which they appear in the text, and they should be listed at the end of the article in the order in which they appear in the manuscript. For each table, this list should include table number, title, and the page number where the table is located.

Figures Each fi gure should be printed on a separate page that includes a brief title for the fi gure. The title should provide an understanding of the fi gure, without the need to refer to the

text for explanation. All letters, numbers, and symbols must be clear and large enough to be read when reduced for publication. Illustrations and photographs should be clear and in focus, on a plain contrasting background. The author must provide written permission from any person who appear in photographs.

Figures should be numbered in the order in which they appear in the text, and they should be listed at the end of the article in the order in which they appear in the manuscript. For each fi gure, this list should include fi gure number, title, and the page number where the fi gure is located.

Confl ict of Interest Disclosure Form

All authors must complete, sign, and send a confl ict of interest disclosure form to AJAM.

The American Journal of Aesthetic Medicine requires all authors to complete a confl ict of interest disclosure form, since confl icts of interest can directly or indirectly affect the reported outcome of any intellectual accomplishment. Potential confl icts of interest may occur when authors are affi liated with a company or institution that could profi t from a particular outcome of a study.

Publication Agreement

All authors must complete, sign and send a publication agreement form to AJAM. The publication agreement indicates that the author grants and transfers exclusively to the American Journal of Aesthetic Medicine all rights, including but not limited to copyright, during the full term of copyright granted in the United States of America and elsewhere. Articles should be submitted to: [email protected].

Guidelines for AJAM Authors

AMERICAN ACADEMY OF AESTHETIC MEDICINE

Hands-On Based Learning Courses 2019 International Venues

REGISTRATION & MORE DETAILS:

Asia, Australia, Europe: MS JESSICA MOKCBB Medical Training Pte Ltd (Singapore)Tel: +65 3157 5933asiaaesthetic@ezyhealth.comwww.asiaaestheticmedicine.comwww.europeaestheticmedicine.com

Middle East & India: MS SUNITA MEHTAInternational Business Consult (Dubai)Tel: +97 14 3370 [email protected]/aaam

South Africa: MS LAURA HARTMANAMCSA Events OrganizersTel: +27 12 567 [email protected]

USA:MS ELLEN DAHLINAmerican Academy of Aesthetic MedicineTel: +1 310 944 [email protected]

*course calendar is subject to changes by AAAM. Information correct at time of printing. Please check websites for updates.

ASIA PACIFIC AND AUSTRALIALevel 1 Certifi cate Course in Aesthetic MedicineBangkok 22 – 24 Feb

Melbourne 23 – 25 Mar

Kuala Lumpur 5 – 7 Apr

Bangkok 14 – 16 Jun

Yangon 6 – 8 Jul

Kuala Lumpur 2 – 4 Aug

Sydney 24 – 26 Aug

Bangkok 1 – 3 Nov

Sydney 23 – 25 Nov

Level 2 Diploma Course in Aesthetic MedicineBangkok 21 – 25 Feb

Melbourne 22 – 26 Mar

Kuala Lumpur 4 – 8 Apr

Kuala Lumpur 1 – 5 Aug

Sydney 22 – 26 Nov

Bangkok 31 Oct – 4 Nov

Level 3 Board Certifi cation Exam in Aesthetic MedicineBangkok 24 Feb

Sydney 24 Nov

Masters Course in PRP and Stem Cells TherapyKuala Lumpur 9 – 10 Apr

EUROPELevel 1 Certifi cate Course in Aesthetic MedicineAmsterdam 9 – 11 Feb

London 11 – 13 May

Amsterdam 27 – 29 Jul

Budapest 14 – 16 Sep

London 19 – 21 Oct

Level 2 Diploma Course in Aesthetic MedicineAmsterdam 26 – 30 Jul

London 18 – 22 Oct

Level 3 Board Certifi cation Exam in Aesthetic MedicineLondon 12 May

SOUTH AFRICALevel 1 Certifi cate Course in Aesthetic MedicinePretoria 6 – 8 Mar

Pretoria 11 – 13 Sep

Level 2 Diploma Course in Aesthetic MedicinePretoria 4 – 8 Mar

Pretoria 9 – 13 Sep

Level 3 Board Certifi cation Exam in Aesthetic MedicinePretoria 6 Mar

Pretoria 11 Sep

MIDDLE EAST, EGYPT AND INDIALevel 1 Certifi cate Course in Aesthetic MedicineCairo 7 – 9 Mar

Dubai 14 – 16 Mar

India 26 – 28 Apr

Dubai 4 – 6 Jul

Cairo 17 – 19 Jul

Cairo 19 – 21 Sep

India 8 – 10 Nov

Dubai 12 – 14 Dec

Grow the Aesthetic Medical Facet of your Practice with AAAM - the Global Leader in Aesthetic Medicine Training

Level 2 Diploma Course in Aesthetic MedicineDubai 12 – 16 Mar

Dubai 2 – 6 Jul

Cairo 17 – 21 Jul

Cairo 19 – 23 Sep

India 6 – 10 Nov

Dubai 10 – 14 Dec

Level 3 Board Certifi cation Exam in Aesthetic MedicineDubai 14 – 15 Mar

Dubai 4 – 5 Jul

Dubai 12 – 13 Dec

Masters Course on Cadaver Anatomy for Facial AestheticsCairo 5 – 6 Mar

Cairo 17 – 18 Sep

Masters Course in Cosmetic GynecologyDubai 17 – 18 Mar

Dubai 8 – 9 Jul

Cairo 24 – 25 Sep

Dubai 17-18 Dec

Masters Course in Face ThreadliftingDubai 19 – 20 Mar

Masters Course in Botolinum Toxin and FillersDubai 7 Jul

Masters Course in Hair TransplantDubai 10 – 12 Jul

Masters Course in Advanced Body AestheticsDubai 15 – 16 Dec

Masters Course in Fat Grafting (basic) + Fat Remodeling and MesotherapyDubai 19 – 20 Dec

USA

Level 1 Certifi cate Course in Aesthetic MedicineLas Vegas, NV 11 – 13 Jan

Miami, FL 8 – 10 Mar

Dallas, TX 17 – 19 May

Philadelphia, PA 7 – 9 Jun

Cerritos, CA 2 – 4 Aug

Miami, FL 13 – 15 Sep

Newark, NJ 11 – 13 Oct

Long Beach, CA 6 – 8 Nov

Las Vegas, NV 6 – 8 Dec

Level 2 Diploma Course in Aesthetic MedicineDallas, TX 15 – 19 May

Long Beach, CA 4 – 8 Nov

Level 3 Board Certifi cation Exam in Aesthetic MedicineDallas, TX 19 May

Long Beach, CA 8 Nov

16th Annual AAAM CongressLong Beach, CA 8 – 10 Nov

Masters Course in LiposuctionCerritos, CA 5 – 7 Aug

A M E R I C A N A C A D E M YO F AESTHETIC MEDICINE

January 11–13, 2019Level 1 Certifi cate Course in Aesthetic MedicineLas Vegas, NV

March 8–10, 2019 Level 1 Certifi cate Course in Aesthetic MedicineMiami, FL

May 15–19, 2019Level 2 Diploma Course in Aesthetic MedicineDallas, TX

May 17–19, 2019Level 1 Certifi cate Course in Aesthetic MedicineDallas, TX

May 19, 2019Level 3 Board Certifi cation Exam in Aesthetic MedicineDallas, TX

June 7–9, 2019Level 1 Certifi cate Course in Aesthetic MedicinePhiladelphia, PA

August 2–4, 2019Level 1 Certifi cate Course in Aesthetic MedicineCerritos, CA

August 5–7, 2019Masters Course in LiposuctionCerritos, CA

September 13–15, 2019Level 1 Certifi cate Course in Aesthetic MedicineMiami, FL

October 11–13, 2019Level 1 Certifi cate Course in Aesthetic MedicineNewark, NJ Dates and locations are subject to change. Please refer to website or contact us for updates.

Contact: Ellen Dahlin Phone: +1-310-944-1790 Email: [email protected] www.aaamed.org

November 4–8, 2019Level 2 Diploma Course in Aesthetic MedicineLong Beach, CA

November 6–8, 2019Level 1 Certifi cate Course in Aesthetic MedicineLong Beach, CA

November 8, 2019Level 3 Board Certifi cation Exam in Aesthetic MedicineLong Beach, CA

November 8–10, 201916h Annual AAAM CongressLong Beach, CA

December 6–8, 2019Level 1 Certifi cate Course in Aesthetic MedicineLas Vegas, NV

AAAM Course and Board Certifi cation Calendar2019

LEVEL 1 (Open to full-fl edged, licensed medical doctors only) Introduction to Aesthetic Medicine: Botulinum Toxin A, Dermal Fillers, Lasers, IPLs, and Skin Rejuvenation and Chemical Peelings21 AMA PRA Category 1 CreditsTM Physician earns Certifi cate in Aesthetic Medicine

LEVEL 2 (Require completion of Level 1 Certifi cate Course)Advanced Aesthetic Medicine: Advanced Botox and Dermal Filler Techniques, Cosmetic Dermatology, Phlebology and Pain Management, Sclerotherapy, and Marketing and Business Management (Completion of Level 1 required)35 AMA PRA Category 1 CreditsTM

Physician earns a Diploma in Aesthetic Medicine

LEVEL 3 (Completion of Level 1 and 2 required, plus six months study period and clinical practice)Board Certifi cation Exam:Written and Oral Examination Successful graduates receive a Diploma and may refer to themselves as “AAAM Board Certifi ed in Aesthetic Medicine”

MASTERS COURSES (Registration subject to AAAM approval)

Documents

,VVXH - aaamed.org