Micro- Cannula Use for Fillers in Aesthetic Medicine PDO Threads for Skin Tightening and Lifting: a Checkered Past but Promising Future

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Deﬁ ning The Ideal Female Body: A West African Perspective

Practical Approach To Safe, Smooth and Effective Micro-cannula Treatment: 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

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine Join AAAM as a Member Today! Your membership is your business. And your future.

You play a vital role in advancing the Aesthetic Medicine specialty, for your patients and the medical community. Join AAAM now and become an active member of this growing specialty.

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Live Patient Workshops AMERICAN ACADEMY OF AESTHETIC MEDICINE (AAAM) Certifi cate Course in Aesthetic Medicine %/,3,80*(4*(+,3?5-,9:/,:0* ,+0*04, 09 3-Day Course | Level 1 dedicated to advancing the art and science of aesthetic medicine. INTRODUCTION TO AESTHETIC AAAM promotes and teaches the clinical science of aesthetic MEDICINE INCLUDING: 3,+0*04, :9-(*;2:?+8(=4-853(65525-/0./2?,>6,80,4*,+ Member US$2,400 Non Member US$2,600 68(*:0:054,89:8(04+5*:58954:/,*2040*(29*0,4*,(4+/(4+954 Skin Conditioning and Chemical Peelings :,*/407;,9(4+685*,+;8,904(,9:/,:0*3,+0*04,(4+;6+(:04. B$104*54+0:05404.685.8(39(4+*2(990A*(:054 8,.;2(82?544,=2,(+04.5803685<,+3,+0*(2(,9:/,:0*:,*/407;,9 B/,30*(26,,204.(.,4:9(4+9,2,*:054 B"8,<,4:054(4+3(4(.,3,4:5-*53620*(:0549 09:/,,>*2;90<,&$3,3),85-:/,4:,84(:054(2&40545- Neurotoxins and Dermal Fillers ,9:/,:0* ,+0*04,& =/0*/8,*5.40@,9 *5;89,904 B4+0*(:0549(4+*549,4: :/,&40:,+$:(:,990(;9:8(20(;856,4+0($5;:/-80*( B"(:0,4:9,2,*:054 B (4(.,3,4:5-53620*(:0549 (4+:/, 0++2,(9: !;8=582+=0+,-(*;2:?(8,,>6,8:904:/,08 Lasers, IPL and other New Tools in 8,96,*:0<,A,2+9 Aesthetic Medicine B(9,89(4+:/,086/?90*9 AAAM COURSES B(9,891048,9;8-(*04. %8(0404.099:8;*:;8,+04:/8,,6(8:9()(90*2,<,2*,8:0A*(:,*5;89, B5+?*54:5;804.3,+0*(2+,<0*,9 (4(+<(4*,+2,<,2+06253(*5;89,(4+(=80::,4(4+58(2 Certifi cate in Aesthetic Medicine awarded upon successful course completion. ,>(304(:054:5(::(04 )5(8+*,8:0A*(:054 485223,4:8,7;08,9 Live Patient 6/?90*0(49:5/(<,<(20+20*,4*,9:568(*:09,3,+0*04, !<,8 Workshops 6/?90*0(49/(<,(::,4+,+ :8(0404.*5;89,9(4+*54.8,99,904 Diploma Course in Aesthetic Medicine 5-Day Course | Level 2 :/,&$(4+=582+=0+, !4(<,8(.,904*, 953,+5*:589 (completion of AAAM Level 1 required) 68(*:0904.(,9:/,:0*3,+0*04,(::(04)5(8+*,8:0A*(:054=0:/ ADVANCED AESTHETIC Member US$3,900 ,(*/?,(8 MEDICINE INCLUDING: Non Member US$4,100 +<(4*,+5:;204;3%5>04 and Dermal Fillers AAAM CONGRESSES 593,:0*,83(:525.? AAAM hosts annual congresses on advancements in aesthetic "/2,)525.?(4+"(04 (4(.,3,4: 3,+0*04,)?=,22145=496,(1,89(4+,>6,8:904:/,A,2+(85;4+ "2(:,2,:#0*/"2(93("#" :/,=582+ 4-583(:05454 9 :/ 54.8,99C (81,:04.(4+;904,99$:8(:,.0,9 5<,3),8 0454.,(*/=022),(<(02()2,9554(: -58?5;8,9:/,:0*9"8(*:0*, Diploma in Aesthetic Medicine awarded upon www.aaaamed.org. successful course completion. LLEVEVEELLL AAAM MEMBERSHIP '0:/:/5;9(4+95-3,3),89-853(*8599:/,.25),5<,8 Board Certifi cation Exam in Aesthetic Medicine 1-Day Examination | Level 3 (completion of AAAM Level 1 & 2 :8(0404.*5;89,9(4+*54.8,99,9:(104.62(*,04*0:0,954 required and six months following completion of Level 2) ,<,8?*54:04,4: 09:/,-58,359:685<0+,85-7;(20:? INCLUDES A TWO-HOUR Member US$3,300 ,9:/,:0* ,+0*(2,+;*(:05404:/,=582+ ,3),89 MULTIPLE CHOICE WRITTEN Non Member US$3,500 04*2;+,6/?90*0(49-853<(805;996,*0(2:0,9,9:/,:0* ,+0*04, EXAMINATION ,83(:525.?(302? ,4,8(2"8(*:0*, "2(9:0* #,*549:8;*:0<, Those passing the written examination move on to $;8.,8?$;8.,8?4:,84(2 ,+0*04,(4+3(4?5:/,89 504;9%5+(?4:,84(2 ,+0*04,(4+3(4?5:/,89 504;9%5+(? anan ooralral eexaminationxamination Upon passing both written and oral examinations, graduates receive a Board Certifi cate in Aesthetic Medicine and may refer to him/herself as a “AAAM Board Certifi ed in www.aaamed.org Aesthetic Medicine”. Offi cial Journal of the American Academy of Aesthetic Medicine American Journal of

EDITORIAL BOARD Editor-in-Chief Advancing the Art and Science of Aesthetic Medicine Medicine 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 * Contents Dr. Vladimir Tsepkolenko * Dr. Akaki Tsilosani

CREATIVE Senior Graphic Designer Elmer Gono

CIRCULATION & PRODUCTION Circulation & Production Manager Jess Foong

MARKETING & COMMUNICATIONS Congress Manager/ Managing Editor 46 Fernanda Winslett [email protected] Practical approach to safe, smooth and effective micro- Business/Courses Manager Ellen Dahlin cannula treatment: Micro- [email protected] cannula use for ﬁ llers in Aesthetic Medicine ADVERTISING SALES Business Manager/Exhibitor and Ad Sales Shermaine C. Sleeter 3 From the Editor-in-Chief [email protected]

INTERNATIONAL OFFICE 4 Assessment of the Wellbeing International Managing Director Effect of Photobiomodulation Janice Yeo [email protected]

10 Radiofrequency, PRP and Business Development Director Microneedling – A Novel Triple Jessica Mok Combination Therapy for Aesthetic SCIENTIFIC COMMITTEE Rejuvenation Chairman Dr Michael Stevens

14 Chemodermabrasion Members Dr. John S. Kim 18 Why Body-Contouring Dr. David P. Melamed 50 Dr. Omnia M. Samra-Latif Estafan Procedures After Massive Dr. Alejandro Espaillat Weight Loss has to be Reimbursed by Health Insurances Statements of fact and opinion in the American Journal of Aesthetic Medicine 40 Defi ning The Ideal Female (AJAM) are those of the respective authors and contributors as specifi ed and Combining therapies for optimal Body: A West African not necessarily those of the editors or publisher. AJAM does not make any 24 representation express or implied in respect of the accuracy of the material outcomes in treating the aging face Perspective in this publication. AJAM does not necessarily endorse or agree with the opinions and statements made in the publication or its related websites. and introduction to the DUBLiN 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. Facelift 46 Practical approach to safe, The information provided in this publication is for reference only. The ultimate responsibility for the interpretation of the information in the publication lies with smooth and effective micro- the medical practitioner or reader. The content in this publication cannot be cannula treatment: Micro- reproduced, whether in part or in whole, without the permission of the publisher. 32 Up-to-date combined therapy of All rights reserved. stable vitiligo. Personal experience cannula use for fi llers in Aesthetic Medicine INTERNATIONAL CIRCULATION BY 36 PDO Threads for Skin Tightening and Lifting: A Checkered Past but 50 Maximizing Donor Harvesting

Medical Training Pte Ltd 02 AJAM IssuePromising 02 - 2012 Future In Hair Transplantation From the Editor--in--Chief

Dear 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 Delune Editor-in-Chief, AJAM President Emeritus, AAAM

3 AJAMOfﬁ 2018 cial Journal of the American Academy of Aesthetic Medicine Ofﬁ cial Journal of the American Academy of 2012Aesthetic AJAM Medicine 3 Assessment of the Wellbeing ,ăLJ[VM7OV[VIPVTVK\SH[PVU by François Michel, MD

Abstract Background Light-emitting diode (LED) photobiomodulation is known for Light-emitting diode (LED) devices emit non-thermal light that its anti-infl ammatory and restorative effects. It is obvious in elicits a biological effect; the effect depends on the color or photographs and in patients' behaviors that the procedure, wavelength of the light emitted. Red has anti-infl ammatory while being performed on the skin of the face for aesthetic effects, and it increases collagen generation. Infrared does the issues, has an effect of the patients' wellbeing. The "wellbeing same while penetrating deeper into the skin. Blue acts more effect" has been described in only 1 pilot study, but it has superfi cially, with a certain capacity for disinfection. been corroborated by studies of the brain in the laboratory. Historically, infrared lamps were used a century ago in Asia, Considering the lack of a convenient questionnaire to on approximately 30 million people, with a restorative and assess the wellbeing effect of photobiomodulation for use anti-infl ammatory effect. The fi rst patent was submitted in in daily medical practice, the author created an analogical Japan in 1964 for wound healing purposes.1 questionnaire with the purpose of having a convenient tool for the assessment of quality of life following photobiomodulation In France, Dubertret et al (1998) demonstrated, in vitro, treatments on the face, as well as to gauge the patients' the prophylactic effect of light from infrared lamps on the feelings regarding overall aesthetic improvement. The deoxyribonucleic acid of fi broblasts subsequently injured by questionnaire was the starting point for the creation of a ultraviolet light.2 In 2004, they showed that mitochondria were software application. involved in the process.3 This pathway was also found to be

4 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine Parameter Wavelength 1 Wavelength 2 Wavelength 3 Output intensity 19 mW/cm2 6.2 mW/cm2 10 mW/cm2 Energy output 1644 mW/cm2 533 mW/cm2 888 mW/cm2 (Maximum per LED) Note: Sessions interval of 2 months; 4.35 J/cm2, 2 minutes, 99 Hz Output wavelength 625 ± 4 nm 590 ± 5 nm 850 nm LED = light-emitting diode. Table 1 Parameters of 3 Wavelengths involved in vivo in a study by Barolet et al (2008), showing rheumatology, and vascular pathology; essentially any fi eld the photopreventive effect of using LEDs.4-6 Since LEDs are where a restorative and anti-infl ammatory effect is desired. semiconductors, they can also be easily modulated to emit in a pulsing manner. Medical Observations of the Author The author used LED photobiomodulation as a mild aesthetic Former light sources used in low-level laser therapy (LLLT) were treatment for moderate erythema, heliodermia, superfi cial essentially small, spot-sized lasers like the heliumneon laser wrinkles, and atrophic scars (see Table 1). As the sessions were at 632 nm (red). These tended to target small areas and, as carried out, the author observed a progressive improvement in such, were more suited to the laboratory as opposed to clinical the facial expressions of patients (see Figures 1 and 2). For settings. LED photobiomodulation was designed based on what those exposed to the light emitted by LED photobiomodulation, a was learned from LLLT studies. positive side effect was apparent – the wellbeing effect.

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 Figure 1 effect, the technique does not Facial Expressions of Patient 1 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 Figure 2 related to aesthetics enhancement, Facial Expressions of Patient 2

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine AJAM 2018 5 Physicians are equipping themselves with these devices... [in] essentially HU`ÄLSK^OLYLHYLZ[VYH[P]LHUK HU[PPUÅHTTH[VY`LMMLJ[PZKLZPYLK

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 The numerous positive effects of LED photobiomodulation (TBI) treated with 665 and 810 nm laser, but not with on the skin include an anti-infl ammatory effect (less red) 730 or 980 nm laser, had signifi cant improvements in and reduction of whitening, which may be due to less Neurological Severity Score. Another study by the same fi brosis, in some hypovascularized skin. The positive authors evaluated the effect of repetition regimen on the psychological effects include alleviation of depression use of transcranial LLLT to treat stroke and TBI. Mice with as well as a reduction in anxiety and nervousness. severe TBI treated with 1 laser treatment had signifi cant Photographs of patients also show changes in facial improvements, and there were greater improvements with expressions following LED photobiomodulation sessions. 3 laser treatments.17 It remains to be seen if any scientifi c evidence exists to support the wellbeing effect. Another study showed that the percentage of surviving mice was highest (63%) in the group that received Published Medical Studies transcranial laser therapy in the pulsed wave mode at The psychological effects of LEDs have been studied. 100 Hz.22 One pilot study was conducted on 10 patients, and the authors found a reduction in depression and anxiety It is interesting to note that without prior intention, the following exposure to LED light at 810 nm at 250 mW parameters of this current study were quite similar to those applied for 4 minutes (60 J).8 These results were attributed of the above studies, both in terms of the wavelengths to an improvement in blood fl ow to the frontal lobes of used and the frequency of sessions, which are typically the brain. A literature review revealed that infl ammation similar to those used in dermatological and aesthetic aggravates psychological problems, and this may be treatments. The fl uences and pulse frequencies, however, countered by light from LED photobiomodulation, which are different from most LLLT studies. has an anti-infl ammatory effect.9-12 A study showed that LEDs act via the cytochrome p53 In another study, LEDs were implanted in the scalp of pathway, like sunlight. This brings to light the notion that it 2 patients, one of whom suffered from cranial trauma, is likely the same underlying mechanism that is responsible to evaluate its effects.13 Improvements were observed in for the wellbeing effect.24 attention span, memory, and higher brain functions, and a net reduction in post-traumatic stress was noted; however, The authors of another study discovered a gene involved these necessitated maintenance treatments. in sun addiction. Seventy-nine sun-addicted and 213 non- sun-addicted subjects were studied, and the PTCHD2 A protective effect of LEDs was observed in an gene was found to be statistically signifi cantly involved in experimental Parkinson's model.8 A study that followed the pathology.25 It can be concluded that the effect of LED found that LLLT provides an interesting therapeutic photobiomodulation will vary depending on the patient's approach to control the progression of Alzheimer's genetic background.

6 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine Highlighting the Wellbeing Effect of LED Treatments Patient Questionnaire The scale established by Endicott is a valid one, but in the Why are you here? realm of aesthetic treatments, it is too intrusive as it delves into Mainly for an aesthetic treatment? the sexuality of test subjects, their ﬁ nancial situation, and their 1|2|3|4|5|6|7|8|9|10 ability to ambulate without feeling dizzy or falling. In short, it is more than confusing for patients. An excerpt from the quality Mainly to improve your spirits? of life scale in Dermatology is also dramatic: 1|2|3|4|5|6|7|8|9|10 As for the Skindex®, we have the same distortion between the questions and the reason for the aesthetic care, usually The people around you not a severe problem and such a questionnaire is badly Disapprove------Ignore------Approve perceived by our patients in a daily practice. 1|2|3|4|5|6|7|8|9|10

The Analogical Scale At now, your outward appearance The analogical scale (see Figures 3A and 3B) was Dissatisﬁ ed------Very Satisﬁ ed designed by the author to be a convenient tool for 1|2|3|4|5|6|7|8|9|10 use as part of a study as well as a physician's daily practice; to be as useful as "before" and "after" treatment Your Mood pictures. It gives an idea of the quality of life of patients Poor------Excellent and also helps to detect distortions of self-image 1|2|3|4|5|6|7|8|9|10 (dysmorphophobia) and of the self-perception of mood. Questionnaire to be completed by the patient The opinion of others involved with the patient is asked. In during his appointment with the practitioner and the case of an improvement of mood, positive feedback also from their computer, tablet, according to a is expected from the patient's entourage. In the case of a frequency established by the practitioner. 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 Figure 3A all zero. The Analogical Scale (Patient Questionnaire)

The preliminary results at 2 months after the ﬁ rst session are shown in Table 2; 10 patients were studied. The answers Patient Appearance to "Why are you here?" ("mainly for an aesthetic treatment" Patient Aesthetic Appearance [+12.5%] versus "mainly to improve your spirits" [+40%]) 1|2|3|4|5|6|7|8|9|10 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 Patient Mood satisfaction is higher for patients than for their physicians or 1|2|3|4|5|6|7|8|9|10 aesthetic teams. This questionnaire is completed by the medical The Application team during his appointment with the practitioner. The idea is to get answers regularly to improve the relevance of the results. The respondents' states of mind can change The assessment is compared with that given by the depending on many factors, and repetition of questions patient. 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 Figure 3B statistics. The aesthetic team may answer during appointments. The Analogical Scale (Treatment Team Impression)

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Offi cial Journal of the American Academy of Aesthetic Medicine AJAM 2018 7 Patient Questionnaire Conclusion Why are you here? The wellbeing effect of LED photobiomodulation is evident in practice but remains diffi cult to prove despite the scientifi c Mainly for an aesthetic treatment +12.5% basis established in the literature. It is only the beginning Mainly to improve your spirits +40% for such a LED photobiomodulation application. It will be The people around you... necessary to conduct further clinical studies to fi ne tune the How do they feel about you having this treatment? parameters of fl uence, wavelength, pulsing mode, and the Your outward appearance is better +10 length and frequency of treatment sessions. These will allow Your mood is better +12% us to better identify the expectations and reactions of patients Opinion of the aesthetic team as a result of this treatment modality. This is an opportunity Aesthetic outcome of the patient +5% to reconsider aesthetic treatments in terms of their effect on Patient mood +6% quality of life, while keeping ethical considerations in mind.

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

François Michel, MD, is a dermatologist from France. His practice involves several systems: medical dermatology, HLZ[OL[PJKLYTH[VSVN`^P[OSHZLYZHUKÄSSLYZHUKHOVSPZ[PJ approach via a medical spa that combines medicine and wellbeing with a preventive goal.

References 13 Naeser MA, Saltmarche A, Krengel MH, et al. Cognitive improved 1 Offi cial Gazette of the United States Patent Offi ce. function after transcranial, lightemitting diode treatments in chronic, traumatic brain injury: two box carryforwards. Laser Photomed Surg. 2 Menezes S, Coulomb B, Lebreton C, et al. Non-coherent near infrared 2011;29(5):351–8. radiation protects normal human dermal fi broblasts from solar 14 ultraviolet toxicity. J Invest Dermatol. 1998;111(4):629–33. Cartmel B, Dewan A, Ferrucci LM, et al. Novell obstructs identifi ed in year exome-wide association study of tanning dependence. Exp 3 Frank S, Oliver L, Lebreton-De Coster C, et al. Infrared radiation affects Dermatol. Oct;23(10):757–9. the mitochondrial pathway of apoptosis in human fi broblasts. J Invest 15 Dermatol. 2004;123(5):823–31. Xuan W, Vatansever F, Huang L, et al. Transcranial low-level laser therapy improves neurological performance in traumatic brain 4 Frank S, Menezes S, Lebreton-De Coster C, et al. Infrared radiation injury in mice: effect of treatment repetition regimen. PLoS One. induces the p53 signaling pathway: role in infrared prevention of 2013;8(1):e53454. ultraviolet B toxicity. Exp Dermatol. 2006;15(2):130–7. 16 Zhang Q, Zhou C, Hamblin MR, et al. Low-level laser therapy 5 Yaou Zhang, Shipeng Song, Chi-Chun Fong, et al. cDNA microarray effectively prevents secondary brain injury induced by immediate early analysis of gene expression profi les in human fi broblast cells irradiated in reply embarrassment X-1 defi ciency. J Cereb Blood Flow Metab. with red light. Journal of Investigative Dermatology. 2003;120:849– 2014;34(8):1391–401. 57. 17 Oron A, Oron U, Streeter J, et al. Near infrared transcranial laser 6 Barolet D. Light-emitting diodes (LEDs) in dermatology. Photodynamic therapy applied at various modes to mice following traumatic therapy light source. Semin Cutan Med Surg. 2008;27:227–38. brain injury signifi cantly reduces long-term neurological defi cits. J Neurotrauma. 2012;29(2):401–7. 7 Barolet D, Roberge C, Auger F, et al. Regulation of skin collagen metabolism in vitro using a pulsed 660 nm LED light source: 18 Xuan W, Vatansever F, Huang L, et al. Transcranial low-level laser Clinical correlation with a single-blinded study. J Invest Dermatol. therapy enhances learning, memory, and neuroprogenitor. J Biomed 2009;129(12):2751–9. Opt. 2014;19(10):108003. 8 Schiffer F, Johnston AL, Ravichandran C, et al. Psychological benefi ts 19 Moro C, Massri NE, Torres NR, et al. Photobiomodulation inside the 2 and 4 weeks after a single treatment with near infrared light to brain: has Novell method of applying near-infrared light intracranially the forehead: a pilot study of 10 patients with major depression and and its impact on dopaminergic concealment survival in MPTP-treated anxiety. Behav Brain Funct. 2009;5:46. mice. J Neurosurg. 2014;120(3):670–83. 9 Zakharyan R, Boyajyan A. Infl ammatory cytokine network in 20 Ando T, Xuan W, Xu T, et al. Comparison of therapeutic effects schizophrenia. World J Biol Psychiatry. 2014;15(3):174–87. between pulsed and continuous wave 810-nm wavelength laser irradiation for traumatic brain injury in mice. PLoS One. 10 Song X, Fan X, Song X, et al. Elevated levels of adiponectin and other 2011;6(10):e26212. cytokines in drug naïve, fi rst episode schizophrenia patients with normal weight. L Schizophr Res. 2013;150(1):269–73. 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 11 Le-Niculescu H, Levey DF, Ayalew M, et al. Discovery and validation of Surg Med. 2012;44(3):218–26. blood biomarkers for suicidality. Mol Psychiatry. 2013;18(12):1249– 64. 22 Xuan W, Agrawal T, Huang L, et al. Low-level laser therapy for traumatic brain injury in mice increases brain derived neurotrophic 12 Al-Asmari A, Khan M. Infl ammation and schizophrenia: Alterations in Factor (BDNF) and synaptogenesis. J Biophotonics. 2014;9999(9999). cytokine levels and perturbation in antioxidative defense systems. Hum Exp Toxicol. 2014;33(2):115–22. 23 Oren M, Bartek J. The sunny side of P53. Cell. 2007;128(5):826–8.

8 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 21 AMA PRA Category 1 CreditsTM AAAM MASTERS COURSE IN LIPOSUCTION TECHNIQUES DECEMBER 10-12, 2018 | Cerritos Medical Center | Cerritos, California !(*#$!"*% "#!# * !#* !"!#)#$ $!" #

FACULTY John Kim, MD, FAAFP, (USA) Attendance Laser Surgeon & Cosmetic/Aesthetic Physician is Limited to Senior AAAM Faculty 10 physicians!

ABOUT THE COURSE This three-day course provides physicians with minimal aesthetic surgery experience with the scientifi c background and surgical demonstrations needed to perform Tumescent in Offi ce Power Assisted Lipolysis (TOPAL) liposuction. Tumescent liposuction uses local anesthesia for safety, minimal discomfort, virtually no surgical blood loss and optimal cosmetic results. It includes one day of scientifi c lecture, and two days of surgical demonstrations.

REGISTRATION FEE AAAM MEMBER FEE: US$5,500 NON MEMBER FEE: US$5,700

LEARNING OBJECTIVES & OUTCOMES 5 +'-" - "'#*. ,( 5 ('.- -#/ )-# '-(',.%--#(' 5+-# ,.+!#%&+$#'!,.,#'!+ % /'-'-(&2 5,- +-" .& , '-' ,-" ,#- "'#*. 5 % --" .%-#&- '-+2,#- , 5 + (+&-" )+( .+ , %2' 6# '-%2 5 +'+ )+(.#% + ,.%-, 5#'('6 ' ' ,,+2 (+('.-#'!-" )+( .+ regardless of patient size 5 . () +-#/ -#& '(&)%#-#(',

LIVE SURGICAL DEMONSTRATIONS AND HANDS-ON 5#)(,.-#('( -" ' $ 5#)(,.-#('( -" + ,- 5#)(,.-#('( -" +&, 5#)(,.-#('( -" (& ' 5#)(,.-#('( -" -"#!",

Open to licensed physicians, regardless of specialty, who are interested in the science of Aesthetic Medicine, and in expanding their practice in that area.

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Space is Limited! Register today at: www.aaamed.org "" ,#!" !$% #%' A triple combination of microneedling, radiofrequency, and PRP presents a novel option capable of producing aesthetic improvements in patients of all skin colors.

Radiofrequency, PRP and Microneedling – A Novel Triple Combination Therapy for Aesthetic Rejuvenation by Dr. Desmer Destang

10 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine Introduction ;+3*.!#1(0%+*+")!(*+ 50!/"+.!2!* +*0.+((! As the quest for beauty and youth continues, physicians are melanin production. seeking new and innovative ways to satisfy their patients' ;* .!/! (!.* !+"/1." !'!.0%*+ 50!/ desires. Radiofrequency (RF), Platelet Rich Plasma (PRP) and ;0%)1(0%+*+"/()!).*!!,%0$!(%( !((/"+.%* .!/! microneedling are not new technologies, but when used in a production of normal skin cells. sensible combination therapy protocol, superior results, and ;* .!/!*#%+#!*!/%/0+% $!(%*#/1,,(5*10.%0%+** enhanced patient satisfaction can be achieved. increase clearance of damaged cells. ;! .!/!/!1),.+ 1 0%+** 0%2%05+" PRP technology has been widely utilized since the mid 1990s sebaceous glands. in sports medicine for its regenerative properties. PRP is ;+. *!,0%!*0/.! 1 0%+*+"0$!.+,%+*% *!/ autologous blood which has been specially prepared and bacterial (P. Acnes) population is also necessary. centrifuged. The resulting separation contains a small fraction (approximately 4%) of cells rich in platelets and growth By achieving these, the clinician can expect to improve skin factors. This minute fraction, however, can be as high as ten laxity, elasticity, mild to moderate wrinkles, skin discolorations, times more concentrated in healing factors than unprepared ,+/0%*9))0+.5$5,!.,%#)!*00%+* *! *!/ ./ plasma. PRP also contains factors for angiogenesis and and stretch marks. This combination was chosen since each reduction of infl ammation. treatment has a low impact on melanocytes, which can be labile and unpredictable in skin of color. Radiofrequency in aesthetic medicine Primary Cells Conditions that Treatment Biological Effects Clinical Effects uses the body as a Modulated can be Improved conducting electrical Radiofrequency : & ., )/0/ : (&+0&$%0"+&+$ : &$%0".7.*"./(&+ : (&+)4&05+!0,+" circuit. On application : ", ,))$"+"/&/ : +%+ "! : 0."0 %*.(/ of RF energy to the 0."0*"+0."/1)0/ : &)!*,!".0".%50&!/ body, resistance is PRP : & ., )/0/ : ")".0"! : ")".0"!%")&+$ : (&+)4&05+!0,+" : /) "))/ %")&+$ : +%+ "! : +"/ ./ encountered at various : -&)).&"/ : ", ,))$"+"/&/ 0."0*"+0."/1)0/ : 0."0 %*.(/ skin layers, and by the : +$&,$"+"/&/ : &)!*,!".0".%50&!/ energy fl ow will cause : ),-" & heat to be produced at Microneedling : & ., )/0/ : ", ,))$"+"/&/ : "!1 "! +" : +" the sites of maximum : ".0&+, 50"/ : +$&,$"+"/&/ : *-.,2"!/(&+0,+" : +"/ ./ : /) "))/ : /) ")) /(&+0"401." : ),-" & resistance. This heat : ")+, 50"/ /0&*1)0&,+ : 0&*1)0"!%&. : 0."0 %*.(/ effectively stimulates : -&)).&"/ : ,//& )"!,3+ $.,30% : fi broblasts, without : " ",1/$)+!/ ."$1)0&,+,# : +"2"+/(&+0,+" *")+&++! : &)5/(&+ adverse stimulation /" 1*-.,!1 0&,+ : .$"-,."/ of melanocytes. : &)!*,!".0".%50&!/ : (&+)4&05+!0,+" 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 Microneedling is an effective surgery will also be mentioned. procedure that harmonizes the A Novel Combination Therapy Protocol function of all cells involved in By combining these 3 rejuvenation modalities, physicians can expect ampliﬁ ed results compared to monotherapy. The aims aesthetic rejuvenation – of aesthetic rejuvenation on a histologic level are as follows: [OLÄIYVISHZ[ZTLSHUVJ`[LZ ;0%)1(0%+*+"8.+(/0/"+.%* .!/! ,.+ 1 0%+*+"*+.)( collagen, elastin and glycosaminoglycans (GAGs). and the keratinocytes.

OffiOffi cial Journal of the American Academy of Aesthetic MedicineMedicine 2018 AJAM 11 Treatment of Wrinkles, Skin Laxity, Stretch Marks The 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.

&" ' Primary cells Recommended " ,(- targeted Protocol Stretch marks &*/,#0."0*"+0 : & ., )/0/9#,. 6 week stimulation Treatment of Acne and Acne Scars : 0&20&,+,# +", ,))$"+"/&/ therapy Acne and acne scars are among the primary dermatological 7 ., )/0/3&0% ")/0&+ / . +", ,))$"+"/&/ -.,!1 0&,+ & .,+""!)"3&0% treatments where the triple combination therapy is applied. : +$&,$"+"/&/ -.,!1 0&,+,# Acne patients also beneﬁ t immensely from mandelic acid : 4#,)&0&,+ /+! / .+!")& peels, either alone or in combination with other acids, ,#/1.# " %5)1.,+& &! &! -"") (".0&+, 50"/ / . microdermabrasion, and prescription topicals. Patients with : 0&*1)0&,+,# 1--,.0&2" & .,+""!)"3&0% acne scars may also be treated with subcision surgery, which /) "))/ 0."0*"+03&0% can be further enhanced with concurrent PRP injections. %"*& )-"")/+! / .+!")& *& .,!".* ./&,+ &! -"") %/0"+/"4#,)&0&,+ ,#(".0&+, 50"/ Supportive treatments: Primary cells Recommended Acne & Acne Scars #,.&*-.,2"!/(&+ : & .,!".* ./&,+ targeted Protocol 0"401." . ,450%".-5 &*/,#0."0*"+0 : ".0&+, 50"/ 6 week stimulation Maintenance therapy : "!1 0&,+&+ : ")+, 50"/ therapy / "!#"(. +")"/&,+/ -0&"+0/3&0% / . & .,!".* ./&,+ : "!1 " & .,+""!)"3&0% ,.*+!")& &!-"") &+8**0&,+ : " ",1/$)+!/ / *&-!#"('. : 2"+/(&+0,+" : P. acnes 0".& / .+!")& & .,+""!)"3&0% +!0"401." : & ., )/0/ &!-"") : " ."/",&) -0&"+0/3&0% / . / #'!)( '. -.,!1 0&,+ +"/ ./ & .,+""!)"3&0% "0&+ / / : " ."/"P. acnes 0".&) / .+!")& ),! &!-"") Treatment of Alopecia : ", ,))$"+"/&/ Supportive treatments %..!#.+30$1/%*#0$!)1(0%)+ (0$!.,%!/+" / . microneedling, PRP and radiofrequency can be achieved. & .,!".* ./&,+ Microscopic studies have conﬁ rmed that improvement in 1 &/&,+/1.$".5 3&0%,.3&0%,10 blood supply and numbers of follicular bulge cells. Adjunctive #,. +"/ ./ treatments such as corticosteroid injections and Minoxidil Subcision &+0"++ "0%".-5 should also be included in the treatment plan. surgery + " : + "*,+0%9 ,* &+"!3&0% & .,!".* ./&,+ Primary cells #,.&*-.,2&+$ ,.*+!")& &!-"") Alopecia Recommended Protocol targeted +"/ ./%&/ : 2".5 *,+0%/9 -., "!1." + " & .,+""!)"3&0% &*/,#0."0*"+0 : ,))& 1). "))/ 6 week stimulation !,+"*,+0%)51+0&) +! : 0&*1)0&,+,# : -&)).&"/ therapy 2&/& )"&*-.,2"*"+0 : ,/*" "10& )/ #,))& 1). "))/ / -#&+ '. &/+,0"! 9"0&+ / : "!1 " & .,+""!)"3&0% / "+6,5) &+8**0&,+ Mandelic acid peels -".,4&!" : +$&,$"+"/&/ ."&+2)1 )"0, Supportive treatments: 0%"*+$"*"+0 : ,.0& ,/0".,&!&+'" 0&,+/ ,#-0&"+0/3&0%)) : &+,4&!&) $.!"/,# +"%"5 : ,,.."/-,+!"./9."#". .")/,0%"/#"/0 #,.%&.0.+/-)+0 #,./(&+,# ,),.

12 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine &=0,?809?:1#,9/'90A09%649?:90 The protocol used for acne and acne scars will also work to References +*0.+(* !2!*+100$!/'%*0+*!+,% (#!*0/0$0 I =@020=!%,/4.6!%!0B2090=,?4:9=,/4:1=0<@09.D?0.39:7:2D include skin lighteners e.g. hydroquinone and arbutin may also Cutis. 2013 Jan;91(1):39–46 be indicated. I 4.3,07:7/&309.=0,>492'>0:1!:9,-7,?4A0$,/4:1=0<@09.D49 ?30$05@A09,?4:9:1?30%649C;0=?Rev Dermatol. 2011;6(2):139–143 I ,@=40,=.7,D 7,9 ,?,=,>>: ,@=09+0418,9 4>.@>>4:9 #7,?070?$4.3#7,>8,#=:.0/@=0 ,D8;=:A0,.4,7;;0,=,9.0 Success in aesthetic dermatology treatments relies primarily Medscape. Mar 06, 2012 on regulating and optimizing the function of a group of cells I 7>?0=&% @;?:9$!:9,-7,?4A0.@?,90:@>=08:/07492@>492 within both the dermis, and the epidermis. Treatment modalities =,/4:1=0<@09.D/0A4.0>Clin Dermatol. 2007 Sep–Oct;25(5):487–91 used in combination effect superior results to monotherapies. I 0>?,92 0/4.,7 4.=:900/74921:=?301=4.,980=4.,9#,?409? A triple combination of microneedling, radiofrequency, and Am Jour Aesth Medicine 2013 Issue 4; 26–29 PRP presents a novel option capable of producing aesthetic I ,.3,104=:&>.:-,= ,7/:9,/:0>?,=4&:=70?," :8;,=4>:9:1!:9,-7,?4A0=,.?4:9,7=-4@8 ,>0= 98 improvements in patients of all skin colors. ,9/ 4.=:900/74921:=?30&=0,?809?:1?=:;34..90%.,=> $,9/:84E0/7494.,7&=4,7Dermatol Surg. 0- H From best clinical results, the primary and most important I >41 ,9:/4,%%4923:8-490/,@?:7:2:@>;7,?070?=4.3 ;7,>8,B4?384.=:900/7492A0=>0>84.=:900/7492B4?3/4>?4770/B,?0=49 common treatment denominator is microneedling, with depths ?30?=0,?809?:1,?=:;34.,.90>.,=>,.:9.@==09?>;74?1,.0>?@/D of at least 2mm that penetrate into the dermis. PRP and RF J Cosmet Dermatol. ,9/:4 5:./ should be considered as treatment enhancers that improve I "-,24+"The Art of Skin Health.$#=0>>%! healing, reduce infl ammation, and augment neocollagenesis. This often translates into better results, patient satisfaction, and I 48,/0 4.=:900/7492491,.4,7=0.,7.4?=,9?807,>8,=0;:=?:1, patient retention. >0=40>:1 .,>0>An Bras Dermatol. 0. H I :3097-@7@6! 4.=:900/749249>649:1.:7:==0A40B:1@>0> ,9/01F.,.DJ Am Acad Dermatol. 0- H With the world's population becoming increasingly more I 49%#,=6%**::9*%@3:8;,=4>:9:11=,.?4:9,7 varied, respect for the labile and unpredictable nature of 84.=:900/7492=,/4:1=0<@09.D,9/-4;:7,==,/4:1=0<@09.D:9 melanocytes is very important. Therefore, knowledge of these ,.90,9/,.90>.,=,9/49A0>?42,?4:9:180.3,94>8.:8;,=,?4A0 =,9/:84E0/.:9?=:770/.7494.,7?=4,7Arch Dermatol Res. 2015 procedures capable of improving the skin's condition and skin 0. H health, without initiating or aggravating pigmentary changes I 7:8D,?4 ,=,6,? B,/% 0/3,?)7,6,3,9D,=,2 is valuable. 4.=:900/7492&30=,;D1:=?=:;34..90%.,=>9"-50.?4A0 A,7@,?4:9J Clin Aesthet Dermatol. 2015 Jul;8(7):36–42 Remember that the above are guidelines only, and the I 3@=,?$ ,?3,;,?4%$0>;:9>0?: 4.=:900/7492&=0,?809?49 09 B4?39/=:2090?4.7:;0.4,)3:,470/?:$0>;:9/?::9A09?4:9,7 physician should be suffi ciently knowledgeable to determine &30=,;DIndian J Dermatol. 2015 May–Jun;60(3):260–3 how to modify treatment plans to accommodate for natural I 49%#,=6%**::9*B:9%@3=,.?4:9,7 4.=:900/7492 individual variation and response. $,/4:1=0<@09.D&=0,?809?1:=.90=07,?0/#:>?49G,88,?:=D =D?308,Acta Derm Venereol. 2016 Jan 20;96(1):87–91 I 3,9/=,>306,=*0;@=4( D>:=0(7:;0.4,,=0,?,>@..0>>1@7 :@?.:80B4?384.=:900/7492,9/?=4,8.49:7:90,.0?:94/0J Cutan +Y+LZ[HUNPZ<:IVHYKJLY[PÄLKHUKHJJVTWSPZOLKPU Aesthet Surg. 2014 Jan;7(1):63–4 HLZ[OL[PJTLKPJPULZPUJL :OLOHZILLUPUJSPUPJHS I >41 ,9:/4,%%4923:8-490/,@?:7:2:@>;7,?070?=4.3 WYHJ[PJLMVYV]LY`LHYZ:OLOHZZ[\KPLK^P[OZVTLVM ;7,>8,B4?384.=:900/7492A0=>0>84.=:900/7492B4?3/4>?4770/B,?0=49 [OLTVZ[YLZWLJ[LKHUKWYLZ[PNPV\ZUHTLZPU+LYTH[VSVN` ?30?=0,?809?:1,?=:;34.,.90>.,=>,.:9.@==09?>;74?1,.0>?@/D PUJS\KPUN+YALPU6IHNP:OLPZL_[LUZP]LS`[YHPULKPU J Cosmet Dermatol. ,9/:4 5:./ [OLHK]HUJLK(LZ[OL[PJ\ZLVM)V[V_KLYTHSÄSSLYZ797 I D9.3 ,>34=%;;74.,?4:9>:1;7,?070?=4.3;7,>8,49 [YLH[TLU[ZTLKPJHSTPJYVULLKSPUNJOLTPJHSWLLSZZRPU /0=8,?:7:2D.=4?4.,7,;;=,4>,7:1?3074?0=,?@=0J Dermatolog Treat. HUHS`ZPZTPJYVKLYTHIYHZPVUHUKTLKPJHSSHZLYZ/LYZWLJPHS ".? H PU[LYLZ[PZPUHLZ[OL[PJJVUKP[PVUZVMZRPUVMJVSVYTLKPJHS TPJYVULLKSPUNHUKTHUKLSPJHJPKWLLSZ:OLHSZVZLY]LZHZ I %4923,7#2,=B,7%3:?#%%,D,7%1F.,.D:1;7,?070?=4.3 HULK\JH[VYHUKPZOPNOS`PU]VS]LKPUJSPUPJHSYLZLHYJO/LY ;7,>8,49?=0,?809?:1,9/=:2094.,7:;0.4,Asian J Transfus Sci. WLYMLJ[PVUPZ[UH[\YLHUKWHZZPVUMVYKLSP]LYPUNYLZ\S[ZMVYOLY @7H0. H WH[PLU[ZOHZHSZVSLKOLY[V^VYR^P[OZVTLVM[OLILZ[-+( I -=,348+7&,?,BD$7%,8:92D 74:8;,=4>:9 SHIZPU[OL<:([VJYLH[LHUKMVYT\SH[LJ\Z[VTWYVK\J[Z -0?B009?3001F.,.D,9/>,10?D:1;7,?070?=4.3;7,>8,A> THKL[VZ\P[OLYWH[PLU[ZHUK[OLPYZRPUJHYLJVYYLJ[P]LULLKZ microdermabrasion in the treatment of striae distensae: clinical and 34>?:;,?3:7:24.,7>?@/D J Cosmet Dermatol. 0. H I M,E 0D@0A,>?7:9>:,>?=: ,7A: $M:>@.0?, "=4A0 94?@,,L9#090F?>:1;7,>8,=4.3492=:B?31,.?:=>#$ Acknowledgement 49>649;3:?:/,8,20.7494.,7=0>;:9>0,9/34>?:7:24.,7,>>0>>809? Dermatol Ther. @7H@2 H Special thanks to Dr. Michel Delune and Dr. Zein Obagi for their exceptional and innovative insights into Aesthetic Dermatology.

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 13 Chemodermabrasion by Lewis M. Feder, MD

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.

14 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine 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. Pre-op 3 Days Post-op Case 1 Once again, sterile gauze is immersed in the trichloroacetic acid solution that was used at the beginning of the surgery. In the 1990s, I began to use chemical peels of varying A small bolus of Versed IV may be employed before the concentrations in conjunction with facial dermabrasion. application of the acid peel, to a denuded face, as this is I have found that the use of trichloroacetic acid in usually more painful. After the acid has been applied on the varying concentrations, applied before and after facial patient's face for 1–2 minutes, the lidocaine, epinephrine dermabrasion, enhanced the result of dermabrasion or gauze soaks are again applied for another 1–2 minutes. chemical peeling alone. Bacitracin 1% ointment is then applied to the entire face, I fi rst presented these fi ndings at the American Academy of followed by sterile Vigilon dressing. Kling dressing is Cosmetic Surgery's annual meeting in New Orleans in 1994. then applied to the entire face causing further hemostasis Many physicians were astounded by the before and after and creating a mummifi ed appearance. 20 to 40 mg. photographs, and the excellent results. Pre-treatment with of prednisone is injected IM. Ice packs are also applied varying products, such as glycolic acids, retinoids, and other to the face at this time. The patient is brought to the rejuvenating skin products is essential, and is used at least 2 recovery area with head slightly raised for one hour. 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 With chemodermabrasion, the physician of herpes simplex virus. has more control, less downtime, a more cost effective procedure, and often Methodology with a better outcome, than by the use The entire procedure takes approximately one hour to perform. of the laser alone. 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 Pre-op 3 Days Post-op the range of 20%. I apply the gauze to the entire face at that time. Case 2

OffiOffi cial Journal of the American Academy of Aesthetic MedicineMedicine 20182018 AJAM 15 Chemodermabrasion should certainly Dressings are removed the following day using sterile water to help remove the crust and other debris. Saturating the dressing be a consideration, in the surgeon's with water allows easier removal of the surgical dressing. At armamentarium, when considering facial that time, hydrogen peroxide is applied to allow a thin crust to rejuvenation and resurfacing. 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 Pre-op 3 Days Post-op 5 Days Post-op results invariably show even greater improvement. Case 3 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

Pre-op 2 Weeks Post-op than the use of many lasers, including the ablative CO2 laser. Case 4 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 Pre-op 2 Weeks Post-op be a consideration, in the surgeon's armamentarium, when Case 5 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.

3L^PZ4-LKLY4+PZH)VHYK*LY[PÄLK+LYTH[VSVNPZ[HUK *VZTL[PJ:\YNLVU^P[OVMÄJLZVU5L^@VYRZ-PM[O(]LU\L /LOHZTVYL[OHU`LHYZVML_WLYPLUJLPUHSSHZWLJ[ZVM JVZTL[PJKLYTH[VSVN`HUKHLZ[OL[PJZ\YNLY`+Y-LKLYPZHSZV HUH[[LUKPUNWO`ZPJPHUH[)L[O0ZYHLS4LKPJHS*LU[LYPU5L^ @VYR*P[`0UHKKP[PVUOLPZH^LSSRUV^UH\[OVYMVYZL]LYHS ZJPLU[PÄJW\ISPJH[PVUZHUPU[LYUH[PVUHSSLJ[\YLYHUKHMYLX\LU[ Pre-op 4 Weeks Post-op N\LZ[ZWLHRLYVUTHU`;=HUKYHKPV[HSRZOV^Z^VYSK^PKL ;OPZWHWLY^HZWYLZLU[LKPU5V]LTILYH[[OL(((4Z Case 6 [O>VYSK*VUNYLZZPU4PHTP-SVYPKH

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Abstract Bariatric 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.

Methods In 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.

Results Mean 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).

Conclusion Our 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.

18 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine Introduction With the explosion in the number of plastic surgery Most medical treatments associating diet, physical exercise, interventions after massive weight loss, it seems necessary eating behavior modifi cations or drugs are ineffective in most to estimate its cost-effectiveness. Its relative costs have to cases for patients presenting a BMI more than 40kg/m21. With be compared with its psychological, social and long term a positive risk-benefi t balance, bariatric surgery (from Greek results. These data are crucial to convince health insurances baros, weight; and iatrikos, being a part of the medicine) has to reimburse body-contouring costs after a massive weight become the treatment of choice of morbid obesity2. Among loss. Therefore in two distinguish studies we assessed: 1) the surgical options, Roux-en-Y gastric bypass (RYGBP) is presently impact of body contouring on weight loss and stability24, considered the gold standard2-5,6,7 for morbid obesity with more and 2) the contribution of body contouring on health related than 100,000 operations each year in the USA alone8. Indeed, quality of life (HRQoL).25 the procedure results in the best weight loss and comorbidity improvement9,1,10 and 30–40% mortality decrease11,12 ; it offers Material and Methods the lowest complication rate in both the short and long-term. We compared 98 consecutive patients (89.8% females, Moreover, RYGBP also improves HRQoL13-16. mean age 42.6 [34–55 years]) who had BC procedures after RYGBP (Group A) to 102 matched patients (81.4% However, even though RYGBP offers a fast, massive weight females, mean age 38.6 [31–48 years]) who had only loss within the fi rst 18 months after surgery, 50% of patients RYGBP (Group B). These patients without BC had not unfortunately regain some of the lost weight, with a mean undergone BC because health insurance did not cover the weight regain of 5–10% within the fi rst 18 to 36 months after cost. All had been submitted to RYGBP for morbid obesity surgery and 10–15% over the course of the next ten years17. (BMI >40) at least 18 months before plastic surgery with This weight regain can be associated with a recurrence stable body weight during the last 6 months. of comorbidities, such as hypertension, diabetes, and hyperuricemia17,18. DiGiorgi et al. showed that within the fi rst 6 To assess the weight change, patients were followed-up, and months after RYGBP, 64% of diabetic patients presented with data (e.g., weight, metabolic measures, complications) were a complete resolution of their type II diabetes. Yet, beyond 3 collected during the follow-up appointments at 1 month, 3 years after RYGBP, 26% of them experienced a recurrence months, 6 months, 9 months, 12 months, and 18 months after of the disease; and among patients with initial improvement surgery and then each year after RYGB. without complete resolution of diabetes, 20% worsened over time18,19. HRQoL was assessed at each time-point by using the Moorehead-Ardelt26 questionnaire, which is the HRQoL part Furthermore, more than two thirds of patients who have of the "Bariatric Analysis and Reporting Outcome System" undergone bariatric surgery consider the resulting excess skin (BAROS). This questionnaire evaluates 5 domains of HRQoL: to be a negative consequence of surgery20. This excess skin self-esteem, physical activity, social life, work ability and present problems for the patients in their daily life and provokes sexual activity. important psychosocial disturbances21 that could compromise the benefi cial effects of the weight loss. Surgical Procedure Bariatric surgery This dissatisfaction motivates 74 to 85% of patients to seek After a multidisciplinary consilium, a fully standardized body-contouring (BC) procedures. But only 21% undergo at RYGBP (i.e., gastric pouch of < 30ml, alimentary loop of least one such procedure22,23, because in most cases, BC is 150 cm, bilio-pancreatic loop of 50 cm) was performed on not covered by health insurance. More than 80% of patients morbidly obese patients (i.e., BMI > 40 kg/m2) by general do not undergo this procedure because they cannot afford it surgeons in our surgical department. These surgeries were (54.7%) or need to establish a payment plan (28.5%). It has performed via laparotomy until 2001 and laparoscopy been demonstrated that in USA people who make more than thereafter. $50,000 annually have 4.2 times more BC than people who make less than $20,000 annually. Finally, only 12 to 21% of Plastic surgery patients will undergo BC after massive surgical weight loss23. Group A patients received the following procedures: 97% In many cases, insurance companies do not consider excess abdominoplasty (with 47% incisional hernia repair), 32% skin to be a disease, and BC is not viewed as a cost-effective mammoplasty (i.e., 51% mastopexy alone, 33% breast treatment. Until now, no research had investigated whether reduction, and 16% breast augmentation with or without patients who have undergone bariatric and plastic surgery breast lift), 19% cruroplasty, and 14% brachioplasty. experience a better long-term result in term of weight and Moreover, 45% of patients underwent combined procedures quality of life, or not. through one or several operations.

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 19 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) Figure 1 Comparison of weight, BMI and EBWL between group A and matched group B, The line In group A, BC was performed within = mixed linear regression model adjusted to age and gender 2–7 years after RYGBP. 2 years on average after RYGBP. At the time just before BC in group A and at the matched time in group B, Bypass and BC Bypass only p (N=98) (N=102) the weight lost, BMI, and EBWL were similar for groups A and B. (Table 1) Age (years), mean (SD), IQR 42.6 (11.1), (34 55) 38.6 (10.1), (31 48) NS – – Beyond the second year after RYGBP, Women, N (%) 88 (89.8%) 91 (89.1%) NS patients without BC (group B) started to regain signifi cant weight. The weight Pre-RYGBP BMI (kg/m2), mean (SD), IQR 46.0 (5.1), (42–48) 46.1 (7.7), (41–48) NS differences between groups gradually Weight (kg), mean (SD), IQR 124.6 (17.5), (110–137) 125.3 (24), (109–140) NS became more signifi cant over time. The yearly weight and BMI increase was 2 years post-RYGBP BMI (kg/m2), mean (SD), IQR 29.9 (5.1), (26–34) 30.3 (6.6), (27–34) NS signifi cantly more important in group Weight (kg), mean (SD), IQR 79.7 (15.9), (68–90) 81.1 (19.8), (70–93) NS B than in group A (i.e., +1.78 kg/year EBW (%), mean (SD), IQR 113.0 (23.5), (94–126) 112.5 (36.7), (89–126) NS versus +0.51 kg/year (p=0.001) of EBWL (%), mean (SD), IQR 68.4 (16.3), (58.2 80.7) 67.2 (17.7), (56.8 79.2) NS – – weight regain and +0.60 kg/m2/year versus +0.16 kg/m2/year (p=0.006) Table 1 of BMI increase, respectively). The Demographic and data comparison between group A and matched group B: no EBWL decrease was also signifi cantly signifi cant difference between these two groups during the period pre-gastric-bypass higher in group B as compared to (RYGBP) to 2 years post-RYGBP when body-contouring (BC) was proposed to patients in group A (i.e., p<0.001 for –2.91%/ group A. SD: standard deviation, IQR: interquartile range, NS: non-signifi cant, p>0.05. year versus -0.86%/year, respectively). BMI: body mass index, EBW: excess of body weight 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 Results < 0.001). This resulted in a higher fi nal weight in group 1. RYGBP induces fast massive weight loss in the fi rst 18 B as compared to that of group A (i.e., 101.2 kg versus months (Figure 1) 82.5 kg, respectively, p=0.01). The mean BMI increased Pre-RYGBP, patients presented with a mean BMI of 46 kg/ signifi cantly more in group B than in group A (i.e., 3.2% m2 (range 41 to 48 kg/m2) and a mean weight of 125 kg [range 0 to 21%] versus 16% [range 8.7 to 22%], (range 109 to 140 kg). RYGBP alone resulted in initial massive respectively, p <0.001) to achieve a BMI of 37.2 and mean weight loss of 45.2kg. Then the patients reached a 30.6 kg/m2, respectively.

20 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine Discussion Body image dissatisfaction, low self-esteem, and reduced

HRQoL motivate many behaviors among obese people,

including participation in diet programs and cosmetic 27 surgery . 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 28 motivated desire for bariatric surgery . Unfortunately $IWHU $IWHU $IWHU $IWHU $IWHU $IWHU

%HIRUH %HIRUH %HIRUH %HIRUH %HIRUH %HIRUH because of excess skin that appears after the quick, massive 7RWDO 6HOIHVWHHP 3K\VLFDODFWLYLW\ 6RFLDO/LIH :RUNDELOLW\ 6H[XDODFLWYLW\ surgical weight loss, patients' HRQoL remains impaired after bariatric surgery. 0XFKEHWWHU %HWWHU 6DPH :RUVH 0XFKZRUVH

We suggest that weight stabilization after plastic surgery could Figure 2 be improved based on HRQoL improvement. This improvement Data demonstrates HRQoL of patients without body-contouring may encourage patients to maintain a stable weight over (BEFORE group) (n=102) compared to those with body-contouring the years. Moreover, Kalarchian et al. concluded that any (AFTER group) (n=98) interventions that improved the psychosocial functioning of a Total score is estimated as "much better" (scores +2.25 to +3), patient would also strengthen the weight loss maintenance29. "better" (+0.75 to +2), "same" (+0.5 to –0.5), "worse" Likewise, we hypothesize that BC, which improves (–0.75 to –2 points) and "much worse" (–2.25 to –3). HRQoL14,30,31, could also help patients to maintain previously Majority of patient estimates their HRQoL improved in obtained weight loss after RYGBP. comparison to their pre-gastric bypass HRQoL. Body-contouring improves signifi cantly further the HRQoL total score and its We believe that BC contributes to achieving the main goal different domains. 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% 3. Body-contouring improves health-related quality of life EBWL estimated their quality of life improved; but among those (Figure 2) who had achieved less than 25% EBWL only 50% felt their The quality of life was evaluated as "better" by 65% of patients quality of life improved32. 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 More than two thirds 38% of patients evaluated their sexual activity as improved. of patients who have undergone bariatric After plastic surgery, in comparison to the scores achieved surgery consider after RYGBP alone, the total score were signifi cantly improved the resulting excess in all domains of HRQoL. In group B, 98% of patients skin to be a negative estimated their quality of life improved after BC ("much better" 58%, "better" 40%) in comparison to 85% (Group B) without consequence of BC ("much better" 22% and "better" 63%) with a mean total surgery. This excess score of 1.95 vs. 1.5 (p<0.001). skin present problems for the patients in their This improvement was signifi cant after BC in all domains of daily life and provokes HRQoL comparing group B to A: self-esteem (98% vs. 89%, important psychosocial 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. disturbances that 66%, mean score 0.24 vs. 0.19, p<0.001), physical activity could compromise the (92% vs. 88%, mean score 0.38 vs 0.32, p<0.05) and sexual ILULÄJPHSLMMLJ[ZVM[OL activity (65% vs. 43%, mean score 0.18 vs 0.07, p<0.001). weight loss.

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 21 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.

Previous researches have clearly demonstrated that RYGBP possibilities offered by plastic surgery thereafter. However, per se appears to be a cost-effective intervention for no excessive promises about the results should be made, and moderately to severely obese people as compared to non- insurances conditions and restrictions should also be evoked. surgical approaches33. The surgical treatment decreases 45% of direct costs (e.g., the number of consultations, medical BC should not be considered as an aesthetic treatment, but treatments, and hospitalizations) and also indirect costs (e.g., as a reconstructive surgery for sequels of massive weight loss. unemployment rate and sick leave) for morbidly obese patients A perfect silhouette will never be achieved; therefore patients who undergo bariatric surgery as compared to the morbidly have to be informed about aesthetical outcomes, including obese who do not have weight loss surgery34. The decrease unavoidable scars left by BC. in these costs is mainly related to a decrease in comorbidities, which is directly linked to weight loss. Previous research has It has been demonstrated that 74–85% of patient desire a BC demonstrated that even small weight changes (i.e., as little after RYGBP22,23. But as in most cases the BC it is not covered as 5%) can dramatically change comorbidities35. The weight by health insurances, majority of patients don't achieve this stability and the prevention of weight regain offered by BC, procedure because they can't afford it (54.7%) or need a as demonstrated in this study, may contribute to the possible payment plan (28.5%)23. In our study only 32% of patients prevention of a secondary worsening of comorbidities. BC underwent a BC procedure after RYGBP. procedures after bariatric surgery could be thus considered part of a cost-effective treatment plan for obesity. Therefore, Conclusion more studies focused on comorbidity improvement and cost- With the increasing number of bariatric surgeries occurring effectiveness of plastic surgery is needed. today, the number of candidates for plastic surgery will certainly increase as well. However, in the absence of cost- Having demonstrated the advantages of BC after massive effectiveness studies, insurance companies do not currently surgical weight loss on weight control and HRQoL, we suggest cover the costs of these operations as long as the excess skin that BC should then be encouraged by bariatric surgeons. As does not achieve "a value of somatic or psychic disease." concluded by Warner et al., patients seeking bariatric surgery For the fi rst time, our study demonstrates that BC signifi cantly are insuffi ciently informed of possibilities offered by plastic improves body weight control and prevents weight regain surgery after gastric bypass; indeed, only 7% of bariatric after RYGBP. This could suggest that BC after massive surgical surgeons always refer their patients to a plastic surgeon, and weight loss may improve comorbidities that can relapse over only 33% refer patients occasionally36. Plastic surgeons should the long-term period after RYGBP alone. These improvements be included in the multidisciplinary team for bariatric surgery offered by BC are probably associated with a decrease in before RYGPB to inform patients about the likely development direct and indirect costs for morbidly obese patients, which is of excess skin following this surgery and to discuss all the thus an important argument in favor of this kind of treatment

22 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine and coverage by health insurance. If we consider morbid Ali Modarressi, MD is Privat Docent and the "chief of clinic" obesity as a real disease, global care should be accepted. of Plastic, Reconstructive and Plastic Surgery department of University hospital of Geneva in Switzerland. During his Since plastic surgery after massive weight loss is mandatory 10 years training in Switzerland, Dr Modarressi acquired for HRQoL improvement and weight loss maintenance in many important experience in all areas of plastic surgery including patients, BC must be considered as a reconstructive surgery cosmetic, reconstructive surgery and microsurgery. He is IVHYKJLY[PÄLK^P[O:^PZZKPWSVTHVM7SHZ[PJ(LZ[OL[PJ for those who have achieved massive weight loss. Indeed, Reconstructive Surgery (FMH) and fellow of the European the treatment of the morbid obesity should not be considered Board of Plastic Surgeons (EBOPRAS). Major emphasis was achieved as long as the plastic surgery is not ﬁ nished. We placed on tissue regeneration with stem cells (fat grafting and platelet rich plasma) and wound healing, where he did an hope that our results will be used as an argument in favour of extensive research. Thanks to his basic science and clinical BC and its coverage by health insurances. experience he trained many physicians since several years in KPMMLYLU[ÄLSKVMHLZ[OL[PJTLKPJPULHUKZ\YNLY`

References 19 DiGiorgi, M., et al., Re-emergence of diabetes after gastric bypass

1 in patients with mid- to long-term follow-up. Surg Obes Relat Dis, Buchwald, H., et al., Bariatric surgery: a systematic review and meta- 2010. 6(3): p.249–53. analysis. Jama, 2004. 292(14): p.1724–37. 20 2 Kinzl, J.F., et al., Psychosocial consequences of weight loss Maggard, M.A., et al., Meta-analysis: surgical treatment of obesity. Ann following gastric banding for morbid obesity. Obes Surg, 2003. Intern Med, 2005. 142(7): p.547–59. 13(1): p.105–10. 3 Dymek, M.P., et al., Quality of life after gastric bypass surgery: a cross- 21 Knol, J.A., Management of the problem patient after bariatric sectional study. Obes Res, 2002. 10(11): p.1135–42. surgery. Gastroenterol Clin North Am, 1994. 23(2): p.345–69. 4 van Gemert, W.G., et al., Psychological functioning of morbidly obese 22 Kitzinger, H.B., et al., The Prevalence of Body Contouring Surgery patients after surgical treatment. Int J Obes Relat Metab Disord, 1998. After Gastric Bypass Surgery. Obes Surg, 2011. 22(5): p.393–8. 23 5 Gusenoff, J.A., et al., Temporal and demographic factors Hell, E., et al., Evaluation of health status and quality of life after inﬂ uencing the desire for plastic surgery after gastric bypass bariatric surgery: comparison of standard Roux-en-Y gastric bypass, surgery. Plast Reconstr Surg, 2008. 121(6): p.2120–6. vertical banded gastroplasty and laparoscopic adjustable silicone gastric banding. Obes Surg, 2000. 10(3): p.214–9. 24 Balague, N., et al., Plastic surgery improves long-term weight

6 control after bariatric surgery. Plast Reconstr Surg, 2013. 132(4): Livingston, E.H., Procedure incidence and in-hospital complication rates of p.826–33. bariatric surgery in the United States. Am J Surg, 2004. 188(2): p.105–10. 25 Modarressi, A., et al., Plastic surgery after gastric bypass improves long-term quality of life. Obes Surg, 2013. 23(1): p.24–30. 7 Tice, J.A., et al., Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med, 2008. 26 Oria, H.E. and M.K. Moorehead, Bariatric analysis and reporting 121(10): p.885–93. outcome system (BAROS). Obes Surg, 1998. 8(5): p.487–99. 8 Encinosa, W.E., et al., Use and costs of bariatric surgery and prescription 27 Sarwer, D.B. and A.N. Fabricatore, Psychiatric considerations of weight-loss medications. Health Aff (Millwood), 2005. 24(4): the massive weight loss patient. Clin Plast Surg, 2008. 35(1): p.1039–46. p.1–10. 9 Schauer, P.R., et al., Effect of laparoscopic Roux-en Y gastric bypass on 28 Peace, K., et al., Psychobiological effects of gastric restriction type 2 diabetes mellitus. Ann Surg, 2003. 238(4): p.467–84; discussion surgery for morbid obesity. N Z Med J, 1989. 102(862): p.76–8. 84–5. 29 Kalarchian, M.A., et al., Psychiatric disorders among bariatric 10 Lee, W.J., et al., Effects of obesity surgery on the metabolic syndrome. surgery candidates: relationship to obesity and functional health Arch Surg, 2004. 139(10): p.1088–92. status. Am J Psychiatry, 2007. 164(2): p.328–34; quiz 374. 11 Adams, T.D., et al., Long-term mortality after gastric bypass surgery. 30 Adami, G.F., et al., Body image in obese patients before and after N Engl J Med, 2007. 357(8): p.753–61. stable weight reduction following bariatric surgery. J Psychosom Res, 1999. 46(3): p.275–81. 12 Sjostrom, L., et al., Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med, 2007. 357(8): p.741–52. 31 Sarwer, D.B., et al., Psychological considerations of the bariatric

13 surgery patient undergoing body contouring surgery. Plast Reconstr Sarwer, D.B., T.A. Wadden, and A.N. Fabricatore, Psychosocial and Surg, 2008. 121(6): p.423e–434e. behavioral aspects of bariatric surgery. Obes Res, 2005. 13(4): p.639–48. 32 Modarressi, A., et al., Plastic Surgery After Gastric Bypass Improves Long-Term Quality of Life. Obes Surg, 2012. 14 Song, A.Y., et al., Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring), 2006. 14(9): 33 Picot, J., et al., The clinical effectiveness and cost-effectiveness of p.1626–36. bariatric (weight loss) surgery for obesity: a systematic review and

15 economic evaluation. Health Technol Assess, 2009. 13(41): Menderes, A., et al., Dermalipectomy for body contouring after bariatric p.1–190, 215–357, iii–iv. surgery in Aegean region of Turkey. Obes Surg, 2003. 13(4): p.637–41. 34 Christou, N.V., et al., Surgery decreases long-term mortality,

16 morbidity, and health care use in morbidly obese patients. Ann Cintra, W., Jr., et al., Quality of life after abdominoplasty in women after Surg, 2004. 240(3): p.416–23; discussion 423–4. bariatric surgery. Obes Surg, 2008. 18(6): p.728–32. 35 17 Goldstein, D.J., Beneﬁ cial health effects of modest weight loss. Int J Sjostrom, L., et al., Lifestyle, diabetes, and cardiovascular risk factors Obes Relat Metab Disord, 1992. 16(6): p.397–415. 10 years after bariatric surgery. N Engl J Med, 2004. 351(26): p.2683–93. 36 Warner, J.P., et al., National bariatric surgery and massive weight

18 loss body contouring survey. Plast Reconstr Surg, 2009. 124(3): Berrington de Gonzalez, A., et al., Body-mass index and mortality among p.926–33. 1.46 million white adults. N Engl J Med, 2010. 363(23): p.2211–9.

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 23 Combining Therapies for Optimal Outcomes in Treating the Aging Face and Introduction to the

DUBLiN Facelift by Dr. Patrick Treacy

The DUBLiN Lift The facial rejuvenating therapies included microneedling, To establish the clinical effectiveness of combining fi ve low dose Ultralase laser, (PRP) plasma rich protein growth treatments in the rejuvenation of the aging face in an effort factors, Omnilux 633 light and neurotoxins. The technique is to increase aesthetic effect, patient safety and reduce laser called the DUBLiN facelift as an acronym of the procedures downtime. involved. D Dermaroller U Ultralase Laser B Blood growth factors Li Light (near red 633) N Neurotoxin. Abstract The face is the area for which most patients seek cosmetic The author compared this method to FLRS in terms of rejuvenation as the convex lines of a youthful appearance tend reduction of photo ageing and overall aesthetic effect. to fl atten and droop as one grows older. The younger face is Neurotoxin was used in both studies. characterized by a balance captured in the classic shape of the inverted triangle. The reversal of this "triangle of beauty" Objective as aging proceeds is considered generally less aesthetically The face and more especially the eyes, is very important in appealing.1 At present, a variety of differing dermatologic and contact between humans, as these areas provide a window volumising treatments are available for facial rejuvenation. to the rest of society regarding a patient's level of health, These include chemical peels, dermal fi llers, IPL and RF lasers, tiredness, emotional status as well as interest in others.4 plasma rich platelets, micro-needling, microdermabrasion, Many doctors consider the periorbital area face is the most botulinum injections and laser resurfacing. Each has their important area of rejuvenation as eye-to-eye communication own relative benefits as well as their own risks.2-3 In recent occurs in approximately 80% of all human interactions.5 years, facial rejuvenation has been revolutionized with the Both areas present a barometer of a patient's chronologic development of CO2 fractionalised laser skin resurfacing and environmental age and mastering the proper evaluation (FLSR). This procedure has benefi ts of faster recovery time, and execution of their aesthetic rejuvenation is critical to more precise control of ablation depth and reduced risk of all cosmetic doctors. More recently, patients are seeking post procedural problems. However, there have been cases effective facial rejuvenation procedures with less downtime of hypopigmentation, hypertrophic scars and skin mottling and low risks.6 This behavioural change in attitude has been most often seen on the face, neck and chest when the laser prompted by a realisation of both doctors and patients parameters are used more aggressively.4 The technique that the much hyped non-ablative methods were often does not also attend to chronological aging problems such subject to extravagant claims in terms of effi cacy.2–4 For as volume defi cits resulting from the loss and repositioning of many years CO2 laser resurfacing was considered the facial fat61. This paper looks at the possibility of combining fi ve 'gold standard' in treating photodamaged facial skin.5-10 established therapies in an attempt to address these defi cits. Cutaneous laser resurfacing with fractionalised (CO2) laser

24 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine involves the vaporisation of the entire epidermis as well as a this method.26-27 More recently, fractionalised resurfacing variable thickness of the dermis. Many physicians stated that lasers (FLSR) have addressed many of these earlier problems the ultrapulsed CO2 laser was the most effective method of with benefi ts of faster recovery time, more precise control laser resurfacing.11–12 Photodamaged skin occurs after years of ablation depth, and reduced risk of post procedural of exposure to harmful ultraviolet light and is demonstrated problems.7 These lasers are extremely versatile, in that they clinically as a gradual deterioration of cutaneous structure can be used for the treatment of facial rhytides, acne scars, and function. This results in the epidermis and upper papillary surgical scars, melasma and photodamaged skin and many dermis having a roughened surface texture as well as have reached the market at the same time.29 With the advent laxity, telangiectasias, wrinkles and variable degrees of skin of FLSR the number of completely ablative resurfacing cases pigmentation.16–17 has declined for most practitioners. However, care should be taken when treating sensitive areas such as the eyelids, Although, ultrapulsed CO2 resurfacing lasers were considered upper neck, and especially the lower neck and chest by using the best treatment option, they had many post-procedural lower energy and density and scarring has been noted in problems18-19, including prolonged postoperative recovery, these areas.30 Scarring after fractional CO2 laser therapy is pigmentary changes and a high incidence of acne fl ares, considered mainly due to overly aggressive treatments, lack of herpes simplex virus (HSV) infection.21-22 Many patients technical fi nesse. Physicians have also recorded postoperative complained of oedema, burning, and erythema that infections leading to scarring although it is generally felt that sometimes lasted for many months.24-25 The implied risks these may be prevented by careful taking of history, vigilant and long downtime made many patients reluctant to accept postoperative monitoring and/or prophylactic antibiotics.47-48

Offi cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 25 In terms of facial rejuvenation, CO2 Laser light at 10600 Controlled studies have suggested that the application of wavelength results in vaporisation with thermal denaturation autogenous PRP can enhance wound healing in both animals of type I collagen, collagen shrinkage and later collagen and humans.49 Five major growth factors such as TGF, insulin- deposition. However, in very deep rhytides, acne scarring like growth factor (IGF), PDGF, EGF and VEGF are known to and severe elastotic changes from sun damage, the fractional be related to the wound-healing processes.50 These growth CO2 requires multiple treatments to achieve the same factors are released from platelets and the production of results as the older lasers.50 Several studies have evaluated collagen of fi broblasts is stimulated by IGF, EGF, interleukin-1 using different laser combinations in the same session in (IL-1) and tumour necrosis factor (TNF)-.43-44 In vivo studies order to improve collagen deposition, with a wider zone of report TGF- to be the most stimulative growth factor. PRP may fibroplasia.5-8, 50 Because of the inherent risks of FLSR and its be used for dermal augmentation and Sclafani observed inability to deal with some evidence of chronological aging, aesthetic improvements of the nasolabial fold in less than 2 it was advocated to here establish the clinical effectiveness weeks and the results lasted for up to 3 months. 49-50 of using a multiprocedural approach to volumisation and collagen regeneration. The author used microneedling with Research Design and Methods low energy laser and platelet rich plasma (PRP) to address This multicentre randomised study included 44 patients of skin these issues. type 1 and 2 aged between 39–68 years presenting with photoageing of skin, thirty seven of whom were women and It is recognised that the most important rejuvenation process seven were men. The subjects presented with the typical hall for photoaged skin is the collagen remodelling process, and marks of chronological and photoageing such as expression dermal fi broblasts are known to have the most important lines, rhytides, wrinkles, eyelid skin laxity, dermatochalasis, function.49 Rejuvenation of skin injury caused by UV light lowered brows, lateral hooding and prominent fat pads. All is a complex process that organically involves cytokines patients were subjected to a programme of skin tightening interacting with several growth factors and control proteins.50 and neocollogenesis by one of two methods, conventional The procedures evaluated included platelet rich plasma FLSR or the DUBLIN Lift. Fifteen patients underwent Lumenis (PRP), microneedling (MN), Omnilux 633nm near-red light ActiveFx with settings (Energy) 125 mJ (Rate) 19w CPG with neurotoxins as an adjunct to low level FLRS. Cells in the 3/5/4. Twenty nine patients received the DUBLIN Lift, a epidermis and dermis can be targeted by (MN) and near- three phase combination of established treatments with red light (633nm) resulting in fi broblast stimulation. Omnilux microneedling, platelet growth hormones, near-red 633nm reviveTM (633nm) therapy stimulates fi broblast activity, light and low energy ultralase fractional CO2 laser skin leading to faster and more effi cient collagen synthesis and tightening. All patients received Dysport® in three areas one ECM proteins. It also increases cell vitality by increasing week prior to the other treatments as an adjunct to the laser the production of cellular ATP and stimulates the contractile resurfacing. phase of the remodelling process producing better lineated collagen.53-56 Collagen induction therapy (CIT) is an aesthetic The DUBLiN Lift was introduced as three phases over a medical procedure that involves repeatedly puncturing the period of three weeks. Phase I included Dysport® at dilution skin with tiny, sterile needles. Typically, this is done with a 3.5:1 in three areas, glabellar, frontalis and periorbital. Phase specialized device called a microneedling device. 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 PRP Dublin LIFT 633 Light

26 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine given as a pre-med to some patients. A post procedural advice Before After 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 Dublin LIFT NW Eye was compared with data on fi le for patients who had skin biopsies for laser resurfacing and neurotoxin alone in 2007. Clinical assessment of patients in each grouping was made Each 1 cm × 1 cm piece of skin was fi xed with 10% formalin at 2 weeks, I month and 3 months postoperatively in the neutral buffered solution. After treatment with polyester wax, presence of two aesthetic staff. The degree of improvement in the skin samples were sliced into 6-μm thicknesses. The sliced photoageing was based on the degree of re-epithelialization sections were treated with haematoxylin and eosin (H&E) rate, reduction of rhytides, reduction of tactile roughness and Masson's trichrome staining solutions. Through tissue and loss of hyperpigmentation and telangiectasias. The evaluations, the thickness of the dermal layer and presence prolongation and severity of erythema as well as the presence of collagen fi bres were observed. The thickness of the dermal of negative side effects (such as herpes) were also recorded. layer was calculated by measuring at fi ve different sites from each section, and the mean value of the thickness of The effi cacy of treatment was evaluated using a variation the dermal layer for each of the fi ve-point scale (Fig 1) originally suggested by Dover group was used for the Before et al.36 Investigators and patients evaluated effi cacy using comparison. palpability assessments and change from baseline score at 0, 6 and 12 weeks. A total global score was recorded Results in each patient based on the addition of points obtained Over 3 months, 29 subjects from six photodamage variables. The degree of perceived (Group 2) were selected to improvement in overall aesthetic effect refl ecting chronological compare the effect of low age was assessed separately by patients and physicians using energy FLRS (fractionalised the Wrinkle Severity Rating Scale and the Global Aesthetic laser resurfacing) with After Improvement Scale. The WSRS is recognised as a valid adjunctive treatments to and reliable instrument for quantitative assessment of facial conventional ablative laser skin folds, with good inter- and intra-observer consistency.60 resurfacing. These patients Wrinkle severity is measured by using a wrinkle severity rating received a three phase scale with 1 being absent and 5 being extreme. By allowing combination of established objective grading of data, these proved useful clinical tools for treatments with neurotoxin, assessing the effectiveness of facial volumisation with PRP and microneedling, platelet MN-633. growth hormones, near-red G2 EK Dublin LIFT Eye

Interventions: Lumenis Parameter 0 1 2 3 4 ActiveFx CO2 laser. Global Score Area of Area of Area of Area of Area of Traylife Protein Rich Plasma, Roughness X0 Roughness X1 Roughness X2 Roughness X3 Roughness X4 Omnilux 633 diode Fine lines None Rare Several Moderate Many light. Dermaroller® and ® Pigmentary None Patchy Moderate Heavy Marked Dysport . All participants Problems received selective regional Touch Even Rare Mild Moderate Severe anaesthesia blocks with 2% Problems Lignocaine plus adrenaline, Facial Veins None Rare Several Moderate Severe topical combination anaesthetic of 23% Coarse lines None Rare Several Moderate Many lignocaine and prophylactic Complexion Pink Pale Grey Suggestion Distinct Valtrex 500 mg twice daily Yellow Grey Yellow Grey for eight days. Valium Table 1 5-10mgs mgs stat was Patient treatment (positive) scoring chart

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 27 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 Dublin LIFT 34.4 percent of patients. (p < 0.0004). "Optimal cosmetic Injecting PRP result" was achieved in a higher percentage of patients in Group 2 than Group 1.

633nm light and low energy ultralase fractional CO2 laser Investigator-based and patient-based ratings using both skin tightening over a three weekly period. Phase I included WSRS and GAIS indicated that the DUBLIN Lift was more the administration of Dysport® neurotoxin in the upper face. effective than conventional ablative laser resurfacing in Phase 2 introduced fi broblast stimulation from microneedling creating cosmetic correction in the lower face. This resulted and PRP growth factor induction with near-red phototherapy from the volumising effect of adding PRP to the larger folds and Phase 3 included low–level (CO2) Ultrapulse laser in this area. At 3 months post-treatment, a higher proportion with adjunct near-red 633nm phototherapy. Results were of patients showed a > or = 1-grade improvement in Wrinkle compared to 15 patients (Group 1) who received FLSR at Severity Rating Scale with DUBLIN Lift than with FLSR. The the level of settings (Energy) 125 mJ (Rate) 19w CPG 3/5/4 author suspects the PRP may have a longer aesthetic effect and whose data was already on fi le. Patients in both groups when used in association with NM and 633 light than has were administered received Dysport® neurotoxin one week been previously noted.48-49 However the results were almost prior to treatment to complement and preserve the aesthetic reversed whenever periorbital rejuvenation was assessed effect. The study evaluated post procedural aesthetic results at alone with almost every patient (93%) favouring conventional baseline, six weeks and twelve weeks by means of a scoring FLSR. Investigator-based Global Aesthetic Improvement Scale system based on Dover's photoageing scale as well as using assessment of this region at 3 months after baseline indicated the Wrinkle Severity Rating Scale and the Global Aesthetic that FLSR was superior in 93.0 percent of patients, whereas Improvement Scale. DUBLIN Lift was superior in 6.8 percent of patients (p = Histological results were obtained from both groups showing Before 0.0025). the depth of laser penetration and consequential formation of new collagen. All skin biopsies showed thermal coagulation Re-epithelialization occurred of epidermis and superfi cial dermis in a depth ranging from in all laser treated areas by 85 to 113 microns. The zone of residual thermal (coagulative) both groups by day 7 and this damage was less in the Group 2 patients where less laser appeared to be clinically similar energy was used. The best neocollogenesis results at 3 months for both procedures. Mean were evident in Group 1 where one patient (Image E) had duration of erythema was 6.9 evidence of effect at 700 microns. This was refl ected in the days after resurfacing (range, patient's skin, which continued to improve over the period. 4–10 days) in Group 1 and 4.2 Because the variance in energy of the CO2 laser in Group 1 days in Group2 (range, 3–7 and Group 2 it was expected that the documented depth of After days). This appeared to be in histological ablation and thermal effects would vary between keeping with previous studies.14 them. Responses of aesthetic effect were evaluated at 6, and All patients reported having 12 week after baseline. no crusting effect remaining on their face after 6 days. Residual The two methods appeared to produce different clinical erythema remained in one improvement of lesions and rhytides. The GAIS global score patient in Group 1 for a period for photoageing for the DUBLiN lift improved from 13.2 to of 14 days but this was minimal. 10.2 at Day 30. This compared to 13.8 at baseline to 9.6 Postoperative erythema was at Day 30 for conventional FLRS alone. The score for fi ne most intense in the areas treated lines was the most signifi cant reduction dropping form 3.6 at by with the ActiveFx at the baseline to 1.4 at Day 30. The score for reduction of coarse G2 EK Dublin LIFT energy level above 125Mj.

28 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine Parameter 0 1 2 3 4 Extreme (extremely deep and long folds, 5 Extreme detrimental to facial appearance). ... Erythema None Rare Several Moderate Severe Severity Severe: very long and deep folds; 4 Severe prominent facial features; less than 2 mm Infective visible Outbreak None Rare Several Moderate Severe (Herpes/Acne) Moderate: moderately deep folds; clear 3 Moderate facial feature visible at normal appearance Crusting None Rare Several Moderate Severe but not when stretched Pain of Mild: Shallow but visible fold with a slight None Mild Tolerable Moderate Severe 2 Mild Procedure indentation; minor facial feature Improvement None Minimal Fair Good Excellent Absent: no visible nasolabial fold; 1 Absent continuous skin injectable implant alone Table 2 Patient treatment (negative) scoring chart Table 3 WSRS Patient scoring chart

The mean pain Degree Description sensation (Table 1 Exceptional Excellent corrective result at week 12. 2) felt during the improvement No further treatment required DUBLiN Lift was 2 Very improved Marked improvement of the appearance, but 2.2 compared patient not completely optimal. to conventional 3 Improved Improvement of the appearance better FLRS treatment at patient compared with the initial condition. Touch-up 3.4. We noted is advised. most patients did 4 Unaltered The appearance substantially remains the not really feel patient same compared with the original condition. pain with the Dublin LIFT Herpes Simple 5 Worsened The appearance has worsened compared with ActiveFx until the patient the original condition. proceduralists crosses 100mj. No patient experienced any Pain of Procedure: None; Mild; Tolerable; Moderate; Severe adverse reaction to laser skin resurfacing except one case of herpetic infection in each group. (Group 1 was 6.6% and Table 4 Group 2 was 3.4%). Both treatments were well tolerated. Global Aesthetic Improvement Scale (GAIS) 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 Before After 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 This paper looks at the possibility facial lines and folds. The author presents a novel method of facial rejuvenation that examines the possibility of the clinical VMJVTIPUPUNÄ]LLZ[HISPZOLK effectiveness of combining ﬁ ve treatments in the rejuvenation of the ageing face in an effort to increase aesthetic effect, [OLYHWPLZPUMHJPHSYLQ\]LUH[PVU patient safety, and reduce laser downtime. He concludes that in an attempt to get a synergistic although fractionalised CO2 laser resurfacing is recognised as the gold standard procedure for tissue that has lost its elasticity ILULÄJPHSLMMLJ[

Offi cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 29 it has adverse risks and does not adequately address the Dr. Patrick Treacy is Chairman of the Irish Association of Cosmetic Doctors and Irish Regional Representative of the problems associated with chronological aging. He addresses British Association of Cosmetic Medicine. He is a Fellow the requirement to apply adjunct methods such as plasma rich of the Royal Society of Medicine and the Royal Society platelets to address nasolabial or marionette lines and volume of Arts. (London). Dr. Treacy also serves as Chairman of the Ailesbury Humanitarian Foundation, and Honorary defi cits resulting from the loss and repositioning of facial fat. Ambassador to the Michael Jackson Legacy Foundation, and The author also establishes the benefi t of using other facial OLZLY]LZVU[OLLKP[VYPHSIVHYKZVMÄ]LPU[LYUH[PVUHSHLZ[OL[PJ rejuvenating therapies including microneedling, PRP growth and dermatology journals. Dr. Treacy has pioneered facial endoprosthesis techniques for HIV facial lipodystrophy and factors, 633 nm light to limit the depth of laser penetration radiosurgery thermocoagulation. 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, The author has done this research independently and receives no UltraPulse laser, Blood growth factors, Light (near-red 633 fi nancial benefi t from the companies who provided the materials for nm), and Neurotoxin. the study.

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Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 31 Up-to-date combined therapy of stable vitiligo Personal experience by Vladimir Tsepkolenko

32 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine Topicality Traditionally dyschromias are of particular importance in Considering advantages and modern dermatology and esthetic medicine. Vitiligo is a disadvantages of existing methods frequently acquired disorder of skin pigmentation characterized by distinctly outlined de-pigmented areas, its of skin repigmentation as well as aetiopathogenesis still not fully understood. Histologically we the possibility to apply cultured can observe either absence or abrupt decrease of melanin content in melanocytes within vitiligo focuses. Its high rate of melanocytes and keratinocytes, occurrences among many ethnic groups and regions, we developed a complex considerable infl uence of patients’ psychological status as well as the absence of reliable treatment methods dictates the approaches of persistent vitiligo current need to look for new ways of vitiligo treatment. types 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 Prior to the complex treatment, all the volunteers signed patients achieve 75% of repigmentation and even more in informed consent of participation in the study and use of case of long term, consistent therapy1. achieved results for scientifi c purposes.

Recently we have been observing widely practiced Quality control of the administered cell suspensions was combination of standard and surgical methods of vitiligo monitored by means of ductal cytofl uorometry using specifi c treatment. Dermatosurgical techniques such as methods of melanocytes antibodies. tissue therapy (epidermal blister grafting, follicular grafting) and cell therapy (non-cultured cell suspensions of melanocytes Study methods and keratinocytes) widely used to treat stable forms of vitiligo, Clinical effi ciency of the suggested algorithm was evaluated: 2,3 resistant to standard therapy . F>1;=)44A*A,-:5)<747/1;< F=;16/7*2-+<1>-5-<07,;7.,1/1<)4,-:5)<7;+78A)6,,1/1<)4 Purposes and objectives 807<715)/16/ Long-lasting standard type therapy, unstable results and a big F;=*2-+<1>-4A*A8)<1-6<015;-4.7:0-:;-4. number of complications after combinations of regular and surgical techniques determined the need to look for the new All patients were divided into 4 groups depending the skin methods of stable vitiligo treatment. New possibilities have in phototype and performed therapy. this area have become available with cell technologies implementation4. The 1st group consisted of patients of Fitzpatrick I and II skin phototype, they were treated according to the treatment Considering advantages and disadvantages of existing protocol developed by us. 2nd group patients with III and IV methods of skin repigmentation as well as the possibility to skin phototype was also treated according our treatment apply cultured melanocytes and keratinocytes, we developed protocol. 3rd group (control) of patients with I and II skin a complex approaches of persistent vitiligo types treatment. phototype was treated by standard vitiligo treatment (narrow- band UVB 311 nm, external treatment). 4th group, consisting Materials and methods of patients with III and IV skin phototype were also treated by The study of the presented algorithm effi ciency included 27 standard vitiligo treatment. volunteers from 9 to 63 y.o. Among them were 9 males and 18 females. Our algorithm of complex technique of stable vitiligo treatment consists of 3 stages. At the fi rst stage we have pigmentation Age Gender induction at the donor site of healthy skin (NB UVB 311 nm) in esthetically insignifi cant or naturally hyperpigmented areas 35% 4)*1)5)27:);3168=6+0*178;A)6,<0-6<:)6;.-:1<7>-:<7 65% *17<-+061+)44)*7:)<7:A)4;78-:.7:516/16<:),-:5)4162-+<176; of plasma enriched platelets (PRP) into the vitiligo areas to create high concentration of growth factors including 0-10 10-20 20-30 30-40 Men - 35% Women - 65% Epidermal Growth Factor (EGF).

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 33 Patient L., 26 y.o., Diagnosis: Stable vitiligo, (12 years) focal type, Patient L., 28 y.o., Diagnosis: Stable vitiligo (7 years) generalized treated by transplantation of cultured melanocytic – keratinocyte pain, Before suspension according to the protocol, 1 session After treatment: treated by transplantation of cultured melanocytic – keratinocyte suspension according to the protocol, 2 sessions

At the 2nd stage, 3–5 weeks later, were performed To achieve optimal results in intradermal administration of cell suspension diluted in PRP treating the stable form of vitiligo solution with concentration of 1mln melanocytic- keratinocyte suspension for 1 cm² depigmented skin area. 2–3 days later we suggest complex algorithm we began the local photo therapy course NB UVB 311 nm, based on autologous melanocytes 3 times a week. and keratinocytes administration. 3rd stage assumes repeated administration of cell suspension The method is about donor but not earlier than in 2 months’ time, in case the percentage site preparation (induction of of reconstructed pigmentation is less than 50%. pigmentation or the use of naturally Results and discussion hyperpigmented areas), preparation of The ﬁ rst group comprises of 11 persons (7 females, 4 males), 2nd group – 16 (11 females and 5 males). Control group the recipient vitiligo site (intradermal made 17 individuals (8 females, 9 males) and 21 persons platelet rich plasma injections to (13 females and 8 males) formed 3rd and 4th group. create high concentration of growth factors) along with intradermal Protocol Control 1 group 2 group 3 group 4 group administration of melanocytic- 11 pers. 16 pers. 17pers. 21 pers. keratinocyte suspension, diluted in 7f. 4m. 11f. 5m. 8f. 9m. 13f. 8m. PRP solution, into depigmented skin

Among the fi rst groups, that were treated according to the sites with the following local NB UVB protocol, we achieved excellent repigmantation (75–100%) in 311nm phototherapy. 15 patients (56%), good repigmentation (50–75%) in 10 patients (37%) and unsatisfactory result was observed in 2 recorded for 1 person in the fi rst and second group each. It is cases (7%). Besides, in the fi rst group, excellent result was important to note that repeated administration was required achieved in 6 cases and 9 in the second. Good for 6 patients from the 2nd group with excellent result. The repigmentation was observed in 4 persons from the 1st group treatment period in 1st and 2nd group lasted 10–14 weeks. and 6 from the second, unsatisfactory repigmentation was Among the 3rd and 4th control groups, Number Excellent Good Unsatisfactory undergone standard treatment without cell Group of repigmentation repigmentation repigmentation technologies, excellent results (75–100%) were patients (75 – 100%) (50 – 75%) (less than 50%) achieved in 7 patients of the 3rd group and 9 Absolute Absolute Absolute patients of the 4th group. Good rate of number of % number of % number of % patients patients patients pigmentation reconstruction (50–75%) was observed in 8 patients of the 3rd group and 9 1 11 6 55 4 36 1 9 patients from the 4th group. Unsatisfactory 2 16 9 56 6 38 1 6 pigmentation (less than 50%) was observed in 2

34 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine Number Excellent Good Unsatisfactory The method has demonstrated its high Group of repigmentation repigmentation repigmentation effi ciency, safety (as compared to patients (75–100%) (50–75%) (less than 50%) surgery), shorter treatment course, Absolute Absolute Absolute possibility to treat larger vitiligo areas by number of % number of % number of % patients patients patients means of small donor site, way of long term storage of cell material in cryobank 3 17 7 41 8 47 2 12 for future use. 4 21 9 43 9 43 3 14 The method we present, offers excellent patients from the 3rd group and 3 from 4th group. The results in treating stable vitiligo after single application. treatment period in the 3rd and 4th groups lasted from 4 to 8 months. The following perspective research stage is focused on determining optimal doses of individualized cell product It is important to note that in the 1st and 2nd groups we for getting guaranteed result5. 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) References required repeated administration of cells, what should be 1 Njoo MD, Spuls PI, Bos JD et al. Nonsurgical repigmentation considered when composing programs for this category of therapies in vitiligo. Meta-analysis of the literature. Arch Dermatol patients. Presumably, it is necessary to use higher dosages of 1998; 134:1532–40. cell for these patients. 2 Rusfi anti M., MD, Wirohadidjodjo Y Widodo, MD. Dermatosurgical techniques for repigmentation of vitiligo. International Journal of Dermatology 2006; 45: 411–417. Conclusions 3 Falabella R, Barona MI. Update on skin repigmentation therapies in Widely used standard methods of vitiligo treatment are vitiligo. Pigment Cell Melanoma Res 2008; 22: 42–65. often too much time consuming and do not deliver 4 Tsepkolenko V.A. Karpenko E.S. Literature review. Skin guaranteed results. 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. To achieve optimal results in treating the stable form of vitiligo Ann Dermatol 2012. V. 24, No. 2: 115–125. 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 162-+<176;<7+:-)<-01/0+76+-6<:)<1767./:7?<0.)+<7:; along with intradermal administration of melanocytic- keratinocyte suspension, diluted in PRP solution, into depigmented skin sites with the following local NB UVB 311nm phototherapy. 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 VMV]LYZJPLU[PÄJZ[\KPLZPUUV]H[PVUZPUTLKPJHSÄLSK monographs: “Plastic aesthetic surgery. Modern perspectives” ¸3HZLY[LJOUVSVNPLZPUHLZ[OL[PJTLKPJPUL¹ co-author of the doctors’ manual in 2 volumes “Plastic surgery course” (2010).Member of the editorial board of professional ZJPLU[PÄJTHNHaPULZ/LYHSKVMHLZ[OL[PJTLKPJPUL4LKP_ 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).

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 35 PDO Threads for Skin Tightening and Lifting: A Checkered Past but Promising Future

by Kian Karimi

36 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine THE AGING FACE is characterized by myriad of factors Utilizing threads to perform lifting including skin wrinkling, soft tissue descent, bony resorption, and fat atrophy. These consequences of aging have ever procedures has been around for over increasing options for correction in a surgical and non-surgical three decades.2 Dr. Sulamanidze is fashion. Although surgical techniques are highly effective for correction of these issues, non-surgical or "minimally invasive" JYLKP[LKHZILPUNVULVM[OLÄYZ[[V modalities have grown wildly popular in the United States and propose threads for lifting facial tissues have seen continuous growth in demand over the last several years.1 with APTOS threads in 1998. Initially these threads were also permanent Although advances in radiofrequency, microneedling, ultrasound, and heat technologies have been exciting and suture material but since then have effective for different indications, there continues to be an been switched to dissolvable ones. unmet need in minimally invasive aesthetics for an actual lift of the skin and soft tissues in different areas, particularly the face. threads form a V-shape and are deployed in a hypodermic Utilizing threads to perform lifting procedures has been needle ranging from 18 gauge to 31 gauge and can be 2 around for over three decades. Dr. Sulamanidze is credited smooth, have a twist, or have uni or bidirectional "barbs," as being one of the fi rst to propose threads for lifting facial reminiscent of other barbed sutures. The threads are inserted in tissues with APTOS threads in 1998. Initially these threads the superfi cial subcutaneous plane and when the needle is were also permanent suture material but since then have been withdrawn the thread remains deployed under the skin. 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 For the smooth and twist fi bers, there is no "catching" of the the results and complication rates of these threads and dermis but simply placement of a dissolvable suture material 3,4 dissuaded against their use . The Contour Threadlift system that then undergoes breakdown over a period of 4–6 months, was eventually removed from the market and left both patients depending on the thickness of the thread and the relative and aesthetic physicians with a poor impression of the metabolism of the patient's skin. The smooth fi bers are typically procedure. placed in a crosshatching pattern to create a "mesh" of threads which will result in improvement of the skin quality and Recently, a subcutaneous and knotless technique with texture over time. This procedure is generally repeated after polydiaxanone (PDO) has been described as a material for 4–6 weeks for improved results and to sustain results achieved offi ce based skin tightening and neocollagenesis and for lifting from previous treatments. The twist fi bers are generally placed of the soft tissues of the skin and body5. This method, popular in areas that would benefi t from a slight amount of volume in many Asian and European countries, has not previously such as medial to the nasolabial folds, the marionette lines, or been utilized or described in the United States. The PDO in the vermillion borders of the upper and lower lips. A recent

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

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 Changes in expression of collagen Type I (A) and TGF-ß1(B) after thread lift, showing mean levels compared to nontreated other thread lifts of the past and present, there is a net resultant section. Assessment of molecular changes indicated statistically effect by the redrapage of the tissues over the barbed sutures. signifi cant increases in collagen Type I and TGF-B1 at 1 month Typically multiple barbed sutures are utilized for one area in 7 after implantation (p<.05). The increase was maintained until the favorable vectors to create a natural result.

end of the study at 7 months (p<.05). TGF-ß1, transforming growth factor beta 1. 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

38 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 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 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 to treat with other modalities. There is defi nitely a learning Before (left) and 1 month after (right) placement of 18 gauge curve for proper placement of the threads to minimize Barb-4 PDO threads for the midface and lower third and injection irregularity and asymmetries, especially with animation. of Revanesse Versa™ to the tear troughs. 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.

References 1 American Society for Aesthetic Plastic Surgery (ASAPS) Website: http://www.surgery.org/media/news-releases/statistics-surveys- and-trends 2 Paul MD. Barbed sutures in aesthetic plastic surgery: evolution of Before and immediately after barbed PDO threads to lift the thought and process. Aesthet Surg J 2013;33:17S–31S. lower third and Restylane Lyft mixed with platelet rich ﬁ brin (PRF) 3 Abraham RF et al. Thread-lift for facial rejuvenation. Arch Facial injected to the midface and tear troughs. 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 Dr. Kian Karimi, MD is a facial plastic & reconstructive surgery Face-Lifting Monodirectional Barbed Polydioxanone Thread. specialist in Los Angeles, CA and has been practicing for Dermatol Surg 2017;43:74–80. 13 years. He graduated from Indiana University School of 7 Karimi K. Technique for nonsurgical lifting using polydioxanone Medicine - M.D. in 2005 and specializes in facial plastic & threads. JAMA Facial Plast Surg. 2018 Aug 9 reconstructive surgery and ear, nose, and throat.

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 39 +LÄUPUN;OL0KLHS -LTHSL)VK`!(>LZ[ (MYPJHU7LYZWLJ[P]L by Dr. Opkala Maluski

Introduction The 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.

40 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine This pilot study attempts to construct an ideal image of the Flat modern West African lady through a snapshot of people's perspectives, and thus extrapolate on its signiﬁ cance to the Other aesthetic medicine practice in West Africa. Straight

The study Figure 2. Ideal Nose Type. 86.2% Aim: To construct the ideal female West African body image. of the respondents preferred a straight nose Objectives: as the ideal type of nose, H'8*<<.<<=1.9.;,.9=2878/=1.<*695.989>5*=28787=1. as compared to 9.2% that ideal body for a West African female. chose a ﬂ at nose. H'8-.=.;627.=1.2;E7*7,2*5,8662=6.7==8@*;-<,*;;B270 out an aesthetic procedure.

Slim Methods: The study was conducted in Nigeria and Ghana over a period Full of three months. A random sampling approach was used. All Figure 3. respondents were females. A total of 75 questionnaires were Ideal Lip Type. 87.8% of administered during a short interview. The data was analysed the respondents noted using Microsoft Excel. that they considered full lips as ideal, as compared Results to 12.2% that preferred The minimum age of the respondents was 20, and the slimmer lips. 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 A (48%), and the rest of the respondents lived with their partners. B Most of the respondents were in the medical ﬁ eld (49.3%), followed by 19.2% who were in the Social and Arts sector, C and then 16.4% who worked in the ﬁ nancial sector. 73.7% D of the respondents were Nigerian, followed by Ghanaian F (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 Figure 4. (20.5%) fell into the >$2000 range. 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

Light skinned cups (1.3% each).

Brown

Black Plump Flat

Figure 5. Ideal Abdomen. Most of the respondents (90.67%) Figure 1. chose a ﬂ at abdomen as Ideal Facial Colour. Most of the respondents (67.1%) chose the ideal abdomen as brown as their ideal facial colour as compared to 27.4% compared to a plump who chose a lighter skin colour. abdomen (9.33%).

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 41 How much of earnings over 3 months will you be willing to spend? Straight

V Shaped 25%

A Shaped 50%

Hourglass 75% 100%

10%

none

20% Figure 6. Ideal Body Figure. 76% of the respondents chose the hourglass ﬁ gure as the ideal as compared to the other categories. 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 Heart earnings over 3 months. Only 8.6% were willing to spend a 100%

Round of their total earnings.

Square

Income level ($) How much of earnings 0 – 500 501 – 1000 1001 – 2000 >2000 over 3 months will you be willing to spend? 25% 24.3% 20% 50% 50% 50% 37.8% 20% 0% 0% Figure 7. 75% 24.3% 50% 50% 16.7% Ideal Buttock Shape. 56.3% of respondents chose the round 100% 13.5% 10% 0% 33.3% buttock shape as compared to the heart shaped buttock shape 100% 100% 100% 100% (42.3%). Table 1 shows a further breakdown of income levels when compared to desired expenditure.

Thin Discussion Slender Aesthetic procedures are progressively becoming a global phenomenon. Beauty and youth are becoming signiﬁ cant Muscular determinants of economic security, and thus cosmetic surgery Fat 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 Figure 8. income, the popularization of cosmetic surgery and its relative Ideal Leg Shape. Most respondents (86.1%) chose slender legs affordability, and its growing acceptance as a normal beauty as the ideal leg shape. 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

42 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine being done on ethnic minorities like Hispanics, African – Africa 11. Most of the respondents who could spend 25% Americans 7. One can thus see the rising demand by the of a three month income (75.3%) fell within the $500 to ethnic minorities from 17% of the total cosmetic surgeries >$2000 per month income range, which corresponds to done in 2005 to 31% as it is now6. It is estimated that the the earnings of those within the middle class12,13. This is number of cosmetic procedures performed on African- important because the rapid growth of the middle class in the Americans has increased by 56% from 2005 to 20138. African society over the last few years connotes an increased purchasing power and disposable income, which can To cater for this, the cosmetic surgery industry is adapting enable access to aesthetic procedures, something which was to ethnic specifi c needs, since different ethnic groups favour previously the forte of the upper class2. different procedures. In 2013, the most popular cosmetic surgery for African-Americans was abdominoplasty, From this pilot study, one can attempt to construct the ideal followed by liposuction, then breast augmentation and fi nally body image of the average modern West African middle blepharoplasty7. This is in contrast to those preferred by the class female. The complexion would be brown in colour, with Caucasians of which the most popular was blepharoplasty, a straight nose, full lips, an ample bosom with breast sizes amongst others7. This underscores the importance of falling within the C and D cup size, a fl at abdomen, an hour addressing the ethnic specifi c needs of people who want to glass fi gure, a bottom shape that falls between the heart enhance their bodies without losing their ethnic identity9. shape and the round shape, and slender legs. Many studies have been done on the cosmetic needs of people in the developed societies, and the body This construct is very interesting, and a few points can be characteristics that are preferred by those who seek cosmetic gathered from this. Over 70% of the respondents chose procedures. These can be seen by the differences in the either brown (67%) or black (5.5%) as their ideal facial types of cosmetic surgeries which are performed within the colour. This can be interpreted as signs of a paradigm different ethnic groups. shift away from western aesthetic ideals of being fair/light skinned which have permeated the traditional West African What about the West African female? interpretation of beauty, to an ethnocentric beauty ideal – the Although there have been a few studies on the ideal body chocolate complexion. When considering the desire for a image of the West African female10, there is no information straighter nose by the respondents (86.2%), one may also on their specifi c aesthetic preferences. There is also a paucity deduce that the overall aim may not be to have a "white" of available data on cosmetic surgeries done within the nose on a black face, but to make the nose to look more sub-region from which one can solicit such information. With aesthetically pleasing in proportion to the facial structure6. 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

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.

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 43 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.

The construct also suggests a fusion between the traditional

connotation of beauty – full lips, big bust, and a well- References developed backside, with a modern western themed look – 1 Women's Ideal Body types Throughout History. Buzzfeed straight nose, fl at abdomen, hourglass fi gure, and slender legs. documentary on Youtube. This may well represent the modern African lady who satisfi es 2 Okpala AM, Ampomah O. Aesthetic Medicine in West Africa: A the traditional West African viewpoint of beauty, and yet can trend giving rise to a need. American Journal of Aesthetic Medicine 2013; 4:56–60. be considered as beautiful from a western point of view. 3 Ruud, Maddie. Western Standards of Beauty: An illustrated The fi nancial commitment towards achieving an aesthetic ideal Timeline. Article in Women's Body Image, Hubpages; 2012. is obvious from Figure 9 which shows that more than 50% 4 Honigman R, Castle D. Aging and cosmetic enhancement. preferred to spend 25% of their income over 3 months for Clinical Interventions in Aging 2006; 1(2): 115–119. that. Table 1 shows a further breakdown of the income levels 5 Pots of promise. The Economist 28/01/2015. E-pub. and preferred expenditure for aesthetic procedures. Further 6 Cosmetic Surgery Is Moving Toward Multi-ethnic Beauty Ideals. calculation revealed that about 75% of all the respondents The Culture of Beauty, 2010. http://ic.galegroup.com/ic/ovic/ that chose to spend 25% of their 3 monthly income fell within ViewpointsDetailsPage/ViewpointsDetailsWindow?zid=caf062fc0 6b7a4fd45a29c03adbcc65e&action=2&catId=&documentId. the $501 to >$2000 income level. In terms of actual cash-in- 7 American Society of Plastic Surgery Statistics Report 2013. hand, this ranges from a minimum of $375 to over $1,500. 8 O'Connor, Maureen. Is Race Plastic? My Trip into the Plastic When compared to the current prices of aesthetic procedures Surgery Minefi eld. The Cut. July 27, 2014. in the United States of America, this suggests that the modern 9 Wimalawansa S, McKnight A, Bullocks J. Socioeconomic Impact of middle class West African lady can afford to have some Ethnic Cosmetic Surgery: Trends and Potential Financial Impact the minor aesthetic procedures done, and even save up for major African American, Asian American, Latin American, and Middle 14,15 Eastern Communities Have on Cosmetic Surgery. Semin Plast Surg aesthetic procedures if so desired . 2009; 23:159–162. 10 Duda, R. B., Jumah, N. A., Hill, A. G., Seffah, J., & Biritwum, R. Although this study is a brief snapshot of the West African Assessment of the ideal body image of women in Accra, Ghana. Trop Doct 2007; 37(4): 241–244. perspective on ethnic body preferences, it has big implications doi: 10.1258/004947507782332883. for the aesthetic practitioner in this investment rich, rapidly 11 Wikipedia. https://en.wikipedia.org/wiki/Nigeria. modernizing sub region of Africa. Whilst keeping the 12 The worlds fastest growing middle class. www.uhy.com. preservation of ethnic identity and safe practice in mind, the Accessed 15/02/2015. aesthetic practitioner who takes the plunge will have an idea 13 Ncube, Mthuli. The Making of the Middle Class in Africa. Future of the aesthetic demands of clients. As time goes on and client Development (http://blogs.worldbank.org/futuredevelopment) satisfaction with services rendered increases, one can develop Accessed 15/02/2015. a huge client base that encompasses the countries within this 14 Cost of Plastic Surgery in the United States. www.infoplasticsurgery.com. sub region, with obvious fi nancial benefi ts. 15 US plastic surgery statistics: chins, buttocks and breasts up, ears down. www.theguardian.com. Thursday 19 April 2012. Conclusion The 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.

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

Practical approach to safe, smooth HUKLăLJ[P]LTPJYVJHUU\SH [YLH[TLU[!4PJYVJHUU\SH\ZLMVY

ÄSSLYZPU(LZ[OL[PJ4LKPJPUL by Renier Van Aardt

OH, HOW TIMES have changed! I recall how in 2001, when to slice cleanly through whatever soft tissue it fi nds in its path, I had the desire to offer fi ller treatment in my practice, I had and—most relevant to fi ller injection—that includes blood received a starter kit by mail from the one and only company vessels. to distribute an HA fi ller in Canada. Using the instruction booklet, my wife was the obvious choice for my fi rst patient, Having a blunt rounded tip allows a micro-cannula to dissect treating Nasolabial lines and lips. No anesthetic, multiple through tissue rather than cut indiscriminately. Provided punctures, trial and error. Oh what fun! that the clinician is gentle enough, has developed a good technique, and has respect for and good knowledge of Let's move forward about 15 years and take a look at how the local anatomy, bruising is not only incredibly rare, but the fi ller treatment landscape has changed. The focus today is patient comfort is remarkable. Let me stress that there is on full-face correction, multiple areas, as painless as possible, a learning curve. At my fi rst few attempts at using micro- little or no bruising, and no downtime. In an effort to increase cannulas, I did not like them. It was not a familiar feeling comfort, I employed nerve blocks for lip treatments for the to me, it appeared crude in its execution, and it seemed fi rst few years. In my own experience as well as considering more painful than simply gliding a small needle at pinpoint the experience shared by colleagues at various meetings and precision to where I wanted to deposit the fi ller. conferences over the years, the approach to fi ller treatments has evolved to become increasingly refi ned and precise. Being persistent and willing to learn from others helped me master cannula use, grasp the full concept, and wrap Somehow our European colleagues seem to have a head my mind around some basic principles and approaches. start on many cosmetic medical approaches compared to Embracing cannula use has transformed my fi ller practice North America, notably so when it comes to micro-cannula over the past three years. Three guiding principles aided in use for fi ller treatments. We're quickly catching up though, my quest to master cannula use: as little pain as possible, as and through innovation on both sides of the pond, our patients little bruising as possible, and a most natural result. All three are privileged to better and better experiences and results. of these can be attained at a higher level than the traditional Having a large practice with a large injectable proportion needle approach to treatment. has enabled me to adapt and innovate my approach to fi ller injections and create an organized approach that should be The fi rst step to a beautiful fi ller result is proper planning. of benefi t for other clinicians. The need for an artistic eye and a good concept of facial aesthetics and beauty, as well as a very good understanding Cannula use in medicine and surgery is nothing new. A hollow of facial anatomy, is of paramount importance. Assuming tube with a blunt tip and side port near the tip is old news. that this is the case, the approach that I prefer when treating What is new, however, is cannulas that are as small as 30 a full face is treating the superior aspects of the face—such gauge, fl exible, and between one and two inches in length. as forehead, brow and temples — fi rst, working my way The Dermasculpt micro-cannula was one of the fi rst to be FDA inferiorly to the mid-face, and ending with the jawline. I've approved in January 2012, followed by Magic needle, Softfi l, always been a stickler for precision, a trait I think I picked up TSK and Sculpt-face. The fi rst thing that comes to mind when as a youngster watching my engineer father for hours as he taking a micro-cannula in hand is safety. The needles included assembled and built intricate electronic components. Being with your average fi ller syringe have a very sharp point with very methodical and precise is helpful when using cannulas a bevel that has a surgically sharp cutting edge. It is designed as well.

46 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 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.

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 Using an eyeliner pencil or something similar, with the patient or simply cooling the entry point with ice, or briefl y with in an upright position and with good lighting, mark areas of cryotherapy, is advised. Distraction techniques such as having volume defi ciency in all the planned treatment areas. Visually a nurse massage the patient’s shoulder, placing small vibratory plan and mark the most appropriate entry points, avoiding device on the skin next to the entry point, or pinching the skin blood vessels and entering in anatomical "safe zones"—away are good habits to adopt and all reasonable ways to keep from important structures. Entry points zones that I typically your patients comfortable, loyal, and happy. identify may be at the lateral brow, just medial to the temporal fusion line, zygomatic arch or in the region of the cheek To advance the cannula to the distal treatment zone once mound, distal aspect of the naso-labial line, and mid-jowl. For entered, hold the syringe like a pool cue and roll it while lips, I use a 30 gauge cannula and enter just medial to the gently moving back and forth in order to dissect through. lateral commissure, an entry point for each the upper and When required to place fi ller in the sub dermal plane, it helps lower lip. Once satisfi ed with the entire treatment plan, it's to stretch the skin with the opposing hand. When required good practice to ensure that the patient is comfortable and to place fi ller deep, pinching up the skin with the opposing that the patient's head is resting securely. Treatment may be hand assists with entering and advancing at the appropriate done in a semi-reclined position; however, assessment should depth. Whenever fi rm resistance is encountered, pull back, always be done in an upright position. slightly change direction, and try again. Never apply strong

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 47 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 ÅL_PISL[OL`HYLTVYLSPRLS`[V[V\JO[OLZRPUHUKNSV]LZHUKPMUV[ sterile, there is an increased risk of infection.

force in order to avoid unwanted tissue injury. Alternating with are more likely to touch the skin and gloves, and if not sterile, a pinch and stretch maneuver with the opposing hand can there is an increased risk of infection. A cannula holder is assist in fi nding a smooth dissection trajectory. Consider your handy if the same cannula will be used on more than one knowledge of anatomy in order to respect important structures syringe. Alternatively, the assisting nurse can re-sheath the such as vessels, nerves, and muscles and treat accordingly to cannula and reapply it to the next syringe. avoid injury. Always assess the patient in an upright position and if any Next, it's a matter of placing, layering, and fi lling per plan. further correction is required, do so at this time. The last step You can pull back on the plunger to rule out intra-vascular should be to gently assess, sculpt, and lightly massage all injection in important vascular areas. It helps to start injecting the treated areas with the use of ultrasound gel or a pleasant distally and retro trace to reduce the risk of intra vascular smelling Aloe Vera gel, making sure that there are no visible injection. Use appropriately cross-linked fi ller products bumps in treated areas. Avoid overly aggressive massage or according to the depth of placement and areas being pressure to reduce bruising or risk of reducing desired results. treated and matched to the desired outcome. Unless the Patients should avoid the use of makeup for a few hours and goal is to correct pre-existing asymmetries, attempt to treat as be instructed to sleep with their head somewhat elevated symmetrically as possible — hence the importance of marking and not place pressure on the treated areas for 72 hours. the skin prior to treatment. The ability to place the fi ller in a Although I do not wish for my patients to manipulate the very smooth and even manner as opposed to using short fi llers, should they in the rare instance see a small bump or needles is one of the fi rst advantages that I noticed early irregularity in any of the treatment areas, I do allow them to on. Another advantage is how large an area can be treated gently massage those with the tip of their fi nger to smooth it trough a singe entry point, minimizing telltale signs and out, as it's easier to do earlier rather than days or weeks later. reducing pain and bruising at the same time. How have cannulas impacted my fi ller practice? Well, word As one becomes more adept and comfortable with cannula of mouth referrals are notably up. The word is spreading use, fi ner nuances can be appreciated, and treatments can around town that I'm the doc to see. Why? Well, in the words evolve to become more three-dimensional. Depending on the of Dr Arthur Swift: "If you bruise them you lose them and if angle of the syringe, the tip of the cannula will move in the you pain them, you don't retain them." Patients also love the opposite direction. It's counter-intuitive and opposite of how a very soft, subtle and natural correction that is somehow now stiff, short needle behaves. In this respect, one can learn how more consistent than in my pre-cannula days. Not to mention, to "drive" the syringe and cannula to layer fi ller in a particular "happy wife, happy life!" We certainly have come a long, pattern as well as fan the product when wider deposition is long way since those early days, and if anyone can attest to required. Treatments become more and more creative and that, my wife surely can. faster as this skill develops.

It is necessary to mention some important aspects applicable Dr. Renier Van Aardt has a broad base of clinical experience and expertise to draw on. He’s been offering dermatological to micro cannula use. It is advisable to prepare the skin widely laser treatments to patients since 2000. He is also among with a good surgical antiseptic such as chlorhexidine and the top 25 injectors of more than 1,000 Allergan accounts alcohol or iodine. Wear sterile gloves, and if multiple areas in Canada. Dr. van Aardt graduated from the University of Stellenbosch in Cape Town, South Africa in 1991, with are being treated in one setting, drape the patient with sterile KLNYLLZPU4LKPJPULHUK:\YNLY`HUKPZIVHYKJLY[PÄLKPU towels. Because micro-cannulas are long and ﬂ exible, they Family Medicine.

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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: G#6+-/7/8>90+,318?7,/<901<+0>=-69=/>9/+-29>2/<7+C compromise the vascularity of the recipient area and lead to grafts survivability decrease. G 981.?<+>39890131+=/==398F 29?<=38-90 body time and the risk of grafts dehydration. The patient and the staff get tired and that may affect the quality of work. G#99<.989<=?::6C90-98-/:+>3/8>F69A.989<./8=3>C and bad scalp laxity. Wide strip excision in such patients causes an unacceptable scar formation.

50 AJAM 2018 Offi cial Journal of the American Academy of Aesthetic Medicine Usually gigasessions are performed in cases of high level of very good scalp laxity. It’s quite rare, especially in Asian baldness – Norwood classes IV, V, VI, VII, when recipient and African patients, who’s hair density usually are not high area excels 100cm² and transplanting more than 3500 and in average varies from 50–75 FUs (120 hairs) per 1cm2 FUs would result in average density of less than 50FU/cm2. 2, 3. If we attempt to increase the number of transplanted Recent research has proved that small (less than 1mm) and grafts it will lead us to the tight wound closure, which may sharp instruments used for recipient sites creation, do not increase the risk of wide donor scars formation. alter blood supply and do not decrease grafts survivability even when the density of implantation is more or equal to 70 For maximizing donor harvesting, scalp exercises are FUs4;7. That means that the density of 35–50 FUs per 1cm2 recommended before surgery. According to J. Wong scalp can be considered as absolutely safe. exercise improves scalp laxity and it may increase the chance of harvesting additional number of grafts, up to 1500 FUs9. Regarding the second problem: gigasessions are possible But, often this is not enough and therefore needs additional to be performed only at the clinics with big team of time before surgery. professionals. In such case for gigasession (up to 5000 grafts transplantation) 6 hours is quite enough. Mostly important is Other option is using Hyaluronidase injection before surgery, to correctly organize the team work. Gigasessions start with which signifi cantly increases scalp laxity but its action is tumescent anesthesia, which decreases bleeding and stays for temporary and gives false impression of scalp looseness. a long time. In this process for which 30mins are enough only After ending the action of Hyaluronidase the scalp tightness one surgeon and one nurse are involved. Later the same team increases, goes back to previous condition and brings us to (1 surgeon and 1 nurse) cuts out a big donor strip, which ischemia. We have often passed through such complications takes less than one hour including trichophytic closure of the as donor area necrosis and shock loss in donor area. wound. Then, the same team prepares recipient sites, which (fi gure 1, 2). takes no longer than 1.5 hours. Thus, for all (starting from fi rst steps of local anesthesia and creation of last recipient In order to reduce the strip site) 3 hours are needed. At the same time, second team (1 width without decreasing surgical assistant for slivering and 5–6 cutters) prepares the the number of grafts needed number of grafts using stereomicroscopes. In case of transplanted during one highly experienced cutters each cutter prepares 300–400 operation, we decided (depending on the donor material) high-quality grafts in one to combine strip method hour. So 2.5–3 hours needed to get 5000 grafts. (FUSS) with FU extraction (FUE). For example, for Afterwards, the coming step is implanting grafts in pre-created obtaining 5000 FUs for recipient sites. 3 implanters fi ll in the sites and 1–2 assistants transplantation we initially keep recipient area clean and dry. Highly experienced perform FUE of about surgical assistant’s speed of implanting is 10–15 recipient Figure 1. 1500 FUs from the zones sites per minute (depending on bleeding and popping). If Donor area necroses above and below the the team of implanters consist of 3 assistants for 5000 grafts =><3:+8.>2/8>2//B-3=39890 F -7A3.>2=><3:3=7+./ implantation 2.5–3 hours are absolutely enough. from which we get appr. 3500 FUs.

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 '=:/<-7HA/8//.>92+<@/=>+=><3:89>6/==>2+8 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 Figure 2. Shock loss in donor area

Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 2018 AJAM 51 Figure 3–4. Scalp tension forces measurement after strip excision.

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

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

Our study measuring the scalp tension power using 2 dynamometers ÄN\YL 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 Figure 7–8. 8 Donor scars after combination FUT and FUE during wound closure .

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antiagingcenter.it | webpromoitalia.com | youtube.com/promoitaliavideo | @valeriogram | facebook.com/webpromoitalia | #promoitalia 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 References grafts, and also substantially decreases compression on the 1 Hwang S.T. Hair Transplantation East Asian Males. In W. Unger and R. Shapiro ed. Hair Transplantation, Fifth Edition. Informa, pages: edges of the donor wound while closing. 428–430 2 Imagawa K. Knowing the Difference in Restoring the Asia Look. In D. Combining the techniques of FUE and strip excision is rather Pathomvanich and K.Imagava ed. Hair Restoration Surgery in Asians. Springer 2010. Page 15–20 simple. First, the desired strip outline is marked. The strip width 3 Kim J.C. Asian Hair: A Korean Study. In D. Pathomvanich and K. in this case seldom exceeds 1.5cm (with the length range Imagava ed. Hair Restoration Surgery in Asians. Springer 2010. from 25–30cm). From 500 to 2000 grafts is harvested using Page 21–22 FUE method above and below the strip edges following by 4 Nakatsui Th., Wong J., Croot D. Survival of Density Packed Follicular a strip excision, which generates from 2500 to 3500 grafts Unit Grafts Using the Lateral Slit Technique. Dermatologic Surgery. 2008; #8, p. 1016–1022 as a result of preparation depending on the follicular density. 5 Seager D.J. The "One-Pass Hair Transplant" – a Six Year Perspective. As a result, from 3000 to 5000 FUs are obtained for the Hair Transplantation Forum Int. 2002; 12(5): 1–6 transplantation. Additionally, our practice showed that this 6 Tsilosani A.,Gugava M., Tamazashvili T. One layer donor closure combination signifi cantly decreases scalp tension forces when versus two-layer donor closure in large hair transplant sessions – a closing the donor wound. biomechanical approach. Georgian Medical News. #7–8,2004; pages:18–22. 7 Tsilosani A. One hundred follicular units transplanted into 1cm² can Our study measuring the scalp tension power using 2 achieve a survival rate greater than 90%. Hair Transplantation Forum dynamometers (fi gure 3, 4) during the process of closing Int.2009, Vol 19, #1, page 1–7. the donor wound, revealed that if at least 30% of grafts are 8 Tsilosani A. Expanding graft numbers combining strip and FUE in the same session: effect on linear wound closure forces. Hair obtained through FUE and the rest are generated from a strip, Transplantation Forum Int. 2010, Vol20, #4, page 122–124. the tension force decreases twice during wound closure8. 9 Wong J. Preoperative Care for Super Mega-Sessions. In Using this combination almost in every patients donor wounds D.Pathomvanich and K.Imagava ed. Hair Restoration Surgery in were closed accurately for further formation of cosmetically Asians. Springer 2010. Page 81–82 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, PhD Clinic Founder and Director Hair Transplantation Clinic “TALIZI” Tbilisi, Georgia [email protected]

54 AJAM 2018 Ofﬁ cial Journal of the American Academy of Aesthetic Medicine 12 AMA PRA Category 1 CreditsTM

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Dr. Marcello Suarez-Bigetti completed his training as a general surgeon. Specializing in cosmetic phlebology, conducted 25 clinical trials on the germany developed sclerosant agent Polidocanol. Dr Suarez is recognized as an authority in the sub specialty of phleboloy, has pioneered the exploration of new therapies for the treatment and prevention of vein-related disorders. Dr. Suarez has been involved in physician training programs for 16 years including many topics in cosmetic dermatology and dermatological surgery. Dr. Suarez sits on several Scientiﬁ c Advisory Boards. Dr Suarez has developed original surgical procedures in cosmetic surgery, developed a technique for auto-grafting and autologous adipocyte transplantation, developed a proprietary technique for follow up CO2 laser resurfacing techniques, conducted animal and human clinical trials on wound healing and laser tissue interaction. He has published numerous articles in a variety of Dermatological Surgery Magazines.

FOR MORE INFORMATION, CONTACT: # * $ &( ,)'&%)&()!"'$ &( ,+++$ &( &% ( )) , 12 AMA PRA Category 1 CreditsTM

CERTIFICATION PROGRAM NOVEMBER 10, 2018 | SATURDAY

MEDICAL ASSISTANT, MEDICAL AESTHETICIAN CERTIFICATION PROGRAM HOW TO DO A CONVERSION AND TURN YOUR BUSINESS INTO GOLD!

Mrs Manon Pilon Join a panel of experts hosted by Manon Pilon! SPA / MED SPA consultant, INTRODUCTION OF ALL THE PARTICIPANTS recognized educator, medical spa owner MEDICAL ASSISTANT, MEDICAL AESTHETICIAN CERTIFICATION PROGRAM and operator, medical FROM THE PHONE CALL TO THE SALES OF A PACKAGES: aesthetician, international How to do a Conversion AND Turn your business into GOLD! director of education and ,%%%&!&&!!!%&&!$' %"'!$%!"&(% R&D director for Derme & ," +"'$$" !&$&"!""! !"!&!& CO, and author, Canada , '%!%%! $&!'&"!"$%&&!#$"%%"! % , ")&"%%%& %&& "&"$$" &" , ")&""!($&#"! &"% , %#"!%' &&"!&""!($%"! , "!%' &&"!&""!($%"!"#% ,!&$& !&"!($%"! ,+%!*#&&"!% ,"$#" "+! +%%! #&"!#$(!&"!

SKIN PHYSIOLOGY AND EASY AESTHETIC VOCABULARY TO IMPRESS. How to communicate and convert your patient in the consultation and overview of the following skin conditions. Including ,!"&%! , '&!"'% '% %"($()!!& #& ,"% ,!"% , !&&"! , ' & MD EXPECTATIONS FROM A MEDICAL ASSISTANT/NURSE ,$#$&"!"&#&!& ,$#$&"!"& &$ "$ # ,$#$&"!"&& "$ &*! $%!&"!% ,"%&#$"'$!%&$'&"!%

NETWORKING WORKSHOP $& %!$""#&!&%! %%%&!&$" ")&""!($&&$& !&#%!&"% % ")&"% ! "%#% Scenario will be demonstrated!

495USD PER DAY or 2 day package for 395USD PER DAY

To register now call AAAM at +1-619-578-3460 or visit www.aaamed.org for more information TM

FOR Expect THOSE WHO the Best

IMPORTANT SAFETY INFORMATION What are the risks? NATURAL & LONG LASTING RESULTS Bleeding and Bruising: Bleeding is usually minimal and resolves within a few minutes. ® Revanesse Versa™ is optimized for remarkable results. It is possible to have a bleeding episode from Our formula features highly refined, spherical particles ƥĺĚĿŠŏĚČƥĿūŠūĲƥĺĚŕūČîŕîŠĚƙƥĺĚƙĿîūƑǶŕŕĚƑ that provide optimal smoothness, volume and long-lasting that requires treatment, but it is unusual. results. Bruising in the area is also an expected reaction and can take up to a week to resolve. Swelling: Swelling is also expected and LESS SWELLING may take several days to a week to resolve. It is unusual but medical treatment may be In a recent study another popular (HA) dermal filler was necessary if swelling is slow to resolve. Pain: shown to produce swelling 24% more often than VersaTM. Some discomfort is expected with injections but usually lasts less than a day. Injection site swelling (47.2% [77/163] with Revanesse® For additional risks, please talk to your VersaTM, 71.2% [116/163] with Comparator) healthcare provider. For product and safety information, please visit: RevanesseUSA.com

Revanesse® VersaTM is indicated for injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds, See what sets us apart: RevanesseUSA.com such as nasolabial folds, in adults 22 years of age or more. Guidelines for AJAM Authors

Organization of Manuscript and text for explanation. All letters, numbers, and Writing Style symbols must be clear and large enough to be read when reduced for publication. Illustrations Manuscript Title and photographs should be clear and in focus, The title should list the author(s), including on a plain contrasting background. The author organizational or institutional affi liation and must provide written permission from any title or position. Manuscript titles should not person who appear in photographs. exceed fi fteen (15) words. Figures should be numbered in the order in References which they appear in the text, and they should Submission of Manuscripts References should be numbered in the be listed at the end of the article in the order order in which they appear in the text, in which they appear in the manuscript. For The American Journal of Aesthetic and they should be listed at the end of the each fi gure, this list should include fi gure Medicine welcomes submission of article in the order in which they are cited. number, title, and the page number where the articles presenting research, fi nding Additional references should be added in a fi gure is located. or observations related to aesthetic separate list. Authors are responsible for the medicine and cosmetic medicine. completeness and accuracy of references. Confl ict of Interest Disclosure Form

General Instructions Tables All authors must complete, sign, and send a Articles will be considered if they have Each table should be printed on a separate confl ict of interest disclosure form to AJAM. not been previously published and are page that includes a title, and a clear The American Journal of Aesthetic Medicine not under review elsewhere. explanation of all abbreviations and components of measure used in the table. requires all authors to complete a confl ict of interest disclosure form, since confl icts of interest Instructions for Original and The title should provide an understanding can directly or indirectly affect the reported Review Articles of the table without the need to refer to the text for explanation. All letters, numbers, and outcome of any intellectual accomplishment. While the American Journal of Aesthetic Potential confl icts of interest may occur when Medicine primarily seeks publication of symbols must be clear and large enough to be read when reduced for publication. authors are affi liated with a company or original clinical and research articles institution that could profi t from a particular that describe a variety of research outcome of a study. designs and methods, we also welcome Tables should be numbered in the order in which they appear in the text, and they review articles and other articles should be listed at the end of the article Publication Agreement concerning business and economic in the order in which they appear in the aspects of aesthetic medicine. All authors must complete, sign and send a manuscript. For each table, this list should publication agreement form to AJAM. The include table number, title, and the page publication agreement indicates that the author Authorship Guidelines number where the table is located. grants and transfers exclusively to the American The author should have made Journal of Aesthetic Medicine all rights, a substantial, direct, intellectual Figures including but not limited to copyright, during contribution to the manuscript, Each fi gure should be printed on a separate the full term of copyright granted in the United since authorship is a way of taking page that includes a brief title for the fi gure. States of America and elsewhere. responsibility for, and receiving credit The title should provide an understanding Articles should be submitted to: for, intellectual work. of the fi gure, without the need to refer to the [email protected].

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. AMERICAN ACADEMY OF AESTHETIC MEDICINE Grow the Aesthetic Medical Facet of your Practice with AAAM - the Global Leader in Aesthetic Medicine Training

ASIA PACIFIC AND AUSTRALIA Level 2 Diploma Course in Aesthetic Medicine Dubai 12 – 16 Mar Level 1 Certiﬁ cate Course in Aesthetic Medicine Dubai 2 – 6 Jul Bangkok 22 – 24 Feb Cairo 17 – 21 Jul Melbourne 23 – 25 Mar Cairo 19 – 23 Sep Kuala Lumpur 5 – 7 Apr India 6 – 10 Nov Bangkok 14 – 16 Jun Dubai 10 – 14 Dec Yangon 6 – 8 Jul Kuala Lumpur 2 – 4 Aug Level 3 Board Certiﬁ cation Exam in Aesthetic Medicine Sydney 24 – 26 Aug Dubai 14 – 15 Mar Bangkok 1 – 3 Nov Dubai 4 – 5 Jul Sydney 23 – 25 Nov Dubai 12 – 13 Dec

Level 2 Diploma Course in Aesthetic Medicine Masters Course on Cadaver Anatomy for Bangkok 21 – 25 Feb Facial Aesthetics Melbourne 22 – 26 Mar Cairo 5 – 6 Mar Kuala Lumpur 4 – 8 Apr Cairo 17 – 18 Sep Hands-On Kuala Lumpur 1 – 5 Aug Sydney 22 – 26 Nov Bangkok 31 Oct – 4 Nov Masters Course in Cosmetic Gynecology Based Dubai 17 – 18 Mar Dubai 8 – 9 Jul Level 3 Board Certiﬁ cation Exam in Aesthetic Medicine Cairo 24 – 25 Sep Bangkok 24 Feb Dubai 17-18 Dec Learning Sydney 24 Nov

Masters Course in Face Threadlifting Masters Course in PRP and Stem Cells Therapy Courses Dubai 19 – 20 Mar Kuala Lumpur 9 – 10 Apr

Masters Course in Botolinum Toxin and Fillers 2019 EUROPE Dubai 7 Jul Level 1 Certifi cate Course in Aesthetic Medicine Amsterdam 9 – 11 Feb Masters Course in Hair Transplant International London 11 – 13 May Dubai 10 – 12 Jul Amsterdam 27 – 29 Jul Venues Budapest 14 – 16 Sep London 19 – 21 Oct Masters Course in Advanced Body Aesthetics Dubai 15 – 16 Dec Level 2 Diploma Course in Aesthetic Medicine Amsterdam 26 – 30 Jul Masters Course in Fat Grafting (basic) + REGISTRATION & MORE DETAILS: London 18 – 22 Oct Fat Remodeling and Mesotherapy Asia, Australia, Europe: Dubai 19 – 20 Dec MS JESSICA MOK Level 3 Board Certifi cation Exam in Aesthetic Medicine CBB Medical Training Pte Ltd London 12 May USA (Singapore) Level 1 Certifi cate Course in Aesthetic Medicine Tel: +65 3157 5933 SOUTH AFRICA Las Vegas, NV 11 – 13 Jan [email protected] Level 1 Certifi cate Course in Aesthetic Medicine Miami, FL 8 – 10 Mar www.asiaaestheticmedicine.com Pretoria 6 – 8 Mar Dallas, TX 17 – 19 May www.europeaestheticmedicine.com Pretoria 11 – 13 Sep Philadelphia, PA 7 – 9 Jun Cerritos, CA 2 – 4 Aug Miami, FL 13 – 15 Sep Middle East & India: Level 2 Diploma Course in Aesthetic Medicine MS SUNITA MEHTA Newark, NJ 11 – 13 Oct Pretoria 4 – 8 Mar Long Beach, CA 6 – 8 Nov International Business Consult (Dubai) Pretoria 9 – 13 Sep Las Vegas, NV 6 – 8 Dec Tel: +97 14 3370 400 [email protected] Level 3 Board Certifi cation Exam in Aesthetic Medicine Level 2 Diploma Course in Aesthetic Medicine www.ibcme.com/aaam Pretoria 6 Mar Dallas, TX 15 – 19 May Pretoria 11 Sep Long Beach, CA 4 – 8 Nov South Africa: MS LAURA HARTMAN MIDDLE EAST, EGYPT AND INDIA Level 3 Board Certifi cation Exam in Aesthetic Medicine AMCSA Events Organizers Level 1 Certifi cate Course in Aesthetic Medicine Dallas, TX 19 May Tel: +27 12 567 1513 Cairo 7 – 9 Mar Long Beach, CA 8 Nov [email protected] Dubai 14 – 16 Mar www.aesmedsa.co.za India 26 – 28 Apr 16th Annual AAAM Congress Dubai 4 – 6 Jul Long Beach, CA 8 – 10 Nov Cairo 17 – 19 Jul USA: Cairo 19 – 21 Sep MS ELLEN DAHLIN India 8 – 10 Nov Masters Course in Liposuction American Academy of Aesthetic Dubai 12 – 14 Dec Cerritos, CA 5 – 7 Aug Medicine Tel: +1 310 944 1790 *course calendar is subject to changes by AAAM. Information correct at time of printing. [email protected] Please check websites for updates. www.aaamed.org AMERICAN ACADEMY OF AESTHETIC MEDICINE %' !" ' # ! !' !' !&!"" !

AAAM Course and Board Certiﬁ cation Calendar2019

January 11–13, 2019 November 4–8, 2019 Level 1 Certifi cate Course in Level 2 Diploma Course in Aesthetic Medicine Aesthetic Medicine Las Vegas, NV Long Beach, CA March 8–10, 2019 November 6–8, 2019 Level 1 Certifi cate Course in Level 1 Certifi cate Course in Aesthetic Medicine Aesthetic Medicine Miami, FL Long Beach, CA May 15–19, 2019 November 8, 2019 Level 2 Diploma Course in Level 3 Board Certifi cation Aesthetic Medicine Exam in Aesthetic Medicine Dallas, TX Long Beach, CA

May 17–19, 2019 November 8–10, 2019 Level 1 Certifi cate Course in 16h Annual AAAM Congress Aesthetic Medicine Long Beach, CA Dallas, TX December 6–8, 2019 May 19, 2019 Level 1 Certifi cate Course Level 3 Board Certifi cation in Aesthetic Medicine Exam in Aesthetic Medicine Las Vegas, NV Dallas, TX June 7–9, 2019 LEVEL 1 (Open to full-fl edged, licensed medical doctors only) Level 1 Certifi cate Course in Introduction to Aesthetic Medicine: Botulinum Toxin A, Dermal Fillers, Aesthetic Medicine Lasers, IPLs, and Skin Rejuvenation and Chemical Peelings Philadelphia, PA 21 AMA PRA Category 1 CreditsTM Physician earns Certifi cate in Aesthetic Medicine August 2–4, 2019 Level 1 Certifi cate Course in LEVEL 2 (Require completion of Level 1 Certifi cate Course) Aesthetic Medicine Advanced Aesthetic Medicine: Advanced Botox and Dermal Filler Cerritos, CA Techniques, Cosmetic Dermatology, Phlebology and Pain Management, Sclerotherapy, and Marketing and Business Management (Completion of August 5–7, 2019 Level 1 required) Masters Course in 35 AMA PRA Category 1 CreditsTM Liposuction Physician earns a Diploma in Aesthetic Medicine Cerritos, CA LEVEL 3 (Completion of Level 1 and 2 required, plus six months study period and September 13–15, 2019 clinical practice) Level 1 Certifi cate Course in Board Certifi cation Exam: Aesthetic Medicine Written and Oral Examination Successful graduates receive a Diploma and may Miami, FL refer to themselves as “AAAM Board Certifi ed in Aesthetic Medicine” October 11–13, 2019 Level 1 Certifi cate Course in MASTERS COURSES (Registration subject to AAAM approval) Aesthetic Medicine Newark, 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 $"