WRINKLE TREATMENT UPDATE- THE PERFECT CHEMICAL BROW LIFT

WRINKLE TREATMENT UPDATE- THE PERFECT CHEMICAL BROW LIFT, IMCAS 2013

Few things get me more excited than the tips on perfecting the chemical brow lift I came back from Paris with. 

This is because anti wrinkle injections are the most popular of all the cosmetic medicine treatments done at Skin Temple, and around the world in 2012.

The global economic downturn since 2008 has left many cosmetic and plastic surgeons bemoaning their reduced revenue, but in the world of non surgical skin treatments business is doing ok, with many people opting for non surgical options such as anti-wrinkle injections, dermal fillers and laser skin treatments.

Anti-wrinkle injecting might look easy enough to most people, and on face-value (pardon the pun) it's certainly not a technically difficult procedure, but there are some real pitfalls for both novice and experienced injectors. 

Take a look at any celebrity filled magazine and you'll be sure to find an example of someone who looks good, but slightly odd, and chances are they are having a cosmetic treatment that could be done better by a very experienced injector.

For example, take a look at Kylie Minogue's right eyebrow, Nicole Kidman's frown and forehead areas, and Kim Kardashian's cheeks.  All of these features look slightly odd to me..not particularly unattractive, but distinctly in the odd basket.  

Nicole Kidman's eyebrows are nicely lifted in the outer parts (the standard chemical brow lift) but significantly lowered in the inner parts by the standard frown treatment technique she appears to be a fan of.   

 This can sometimes make her look a little odd, and will cause sagging of the inner upper eyelid skin as she ages.  Her forehead is remarkably immobile for a woman of 45years old, and again, such complete lack of expression reduces her ability to communicate with her audience and exacerbates the low position of her eyebrows.

A better aesthetic treatment would specifically address the problem of medial brow ptosis and lift both ends of brows equally.  This is the technique that was discussed at IMCAS Paris 2013, and since my return I've been trying it out on a number of patients prone to this problem, with excellent results!

Not everyone needs or suits this technique, but for those that do, or have put off having anti-wrinkle treatments for fear of looking slightly odd, it's fantastic news. 

HAND REJUVENATION- IMCAS review

HAND REJUVENATION

Long regarded as the area that gives a woman's true age away, hands are now in the spotlight as the area to pay particular attention to, now that safe and effective treatment options have become available.

Hands show the ageing process in numerous ways, from thinning of the skin, loss of subcutaneous fat volume, to loss of elasticity, precancerous changes and surface pigmentation.  The nails are another area of much neglect, and complete hand rejuvenation must also address this area.

In Paris there was much discussion on the best way to rejuvenate the hands, with some famous examples of celebrities who have forgotten this area:

Sarah Jessica Parker

Madonna

Home based hand care remains the cornerstone of patient satisfaction, and is essential to address before longterm success can be achieved with clinic treatments.  All consultations at Skin Temple address the use of home care on the skin, and we also offer preventative care for avoiding skin cancers on high risk areas such as the backs of the hands and face.

As far as clinic based procedures are concerned, the options include:

• Laser or Light based treatments for surface pigmentation  and collagen stimulation

• Topical cryotherapy or immune modulator creams for precancerous actinic keratoses

• Fillers and Collagen stimulators for volume loss

At Skin Temple we commonly use our alexandrite based Gentlelase to remove isolated areas of pigmentation on the backs of the hands, or our IPL for more widespread pigmentation problems.  These treatments work incredibly well, but take about two weeks to recover from, and the patient must be very careful to wear sunscreen (and preferably also gloves when driving!) in order to prevent a reaccumulation of pigmentation.

I'm not a big fan of cryotherapy though, having seen many cases of permanent hypopigmentation from this procedure used in general practices and dermatologist offices over the years.  In my opinion, it is much safer and more cosmetically appealing to use an immune modulator such as Aldara or a topical chemotherapy product such as Efudix to treat sunspots (actinic keratoses) or early squamous cell or basal cell carcinomas.  Sometimes these will need to be excised and surgically repaired, which we also do in the clinic.

 

The two most popular options are gel based dermal fillers or collagen stimulators.

Gel based fillers must be soft enough to disperse evenly under the skin, so those with strong lifting capacity (known as G' prime rating *see below for further explanation) are inappropriate in this area.  Even dispersion prevents lumpiness and allows for fewer insertion points and smaller cannulas.  Low G' prime gel based fillers will last up to 12 months, but may only last 6 months in some patients.

Collagen stimulators are currently my favourite method of hand rejuvenation, as some work quickly but with reliable medium term longevity.  Again, some products, when diluted 50:50, have a lower G prime allowing for easy distribution in the upper dermis.  

So please, if you're looking after your facial appearance, don't forget your hands too!

*To quote Dr Leslie Baumann, cosmetic dermatologist in the USA:

"The stiffness or G′ (pronounced G prime) of a product is one of the most important considerations. G′ is a measurement of gel hardness. It is obtained when a gel is placed on a plate. A second plate is placed over the gel and a lateral force is applied. The measurement of resistance to deformation is known as the elastic modulus or the G′. Together with the cohesivity of the product, G′ values could be used to determine the appropriate placement of an XX dermal filler. For example more robust products (higher G′ values and higher cohesivities) such as XXXXXXXX^™ XXXXX XXXX and XXXXXXX^®, should be used in deeper lines, such as nasolabial folds and marionette lines, as well as to lift the lateral brow, to correct the nasal bridge, to give the ear lobe youthful volume, to evert the nipples, and to raise the nasal tip. More fluid products such as XXXXXXX^™ XXXXX and XXXXXXXXX^® are more suited to be used over large areas such as the cheekbones and cheeks. Low G′ products such as XXXXXXXX^® and XXXXXXXX XXXX^® are necessary in areas that require a softer agent, such as the body of the lip or the tear trough. As new products reach the market, knowing the G′ will help practitioners match fillers with indications."

Please note that several of the products mentioned by Dr Baumann are not available in Australia (XXXXXXXX XXXX, XXXXXXXX)  whilst other products with much higher G' available in Australia (XXXX**) are not yet available in the USA, nor are some of the lighter G' products commonly used in Australia (XXXXXXXX XXXX**, XXXXXXXX XXXXX**, XXXXXXXX**, XXXXXXXX XXXXXX**, XXXXXXXX XXX XXXXXXX**).

**Apologies to those confused by the products referred to above.  For legal reasons, under Australian law, the TGA has directed all medical practitioners to refrain from using the names of S4 products "unless authorised or required to be made under the Act." Therefore all S4 product names have been censored in this post and replaced with generic Xs.  If a member of the public were to write this blog, it would not be a problem though! Government censorship of educational material on the internet and harassment of cosmetic practitioners is a very real occurrence in Australia today.

Anti-wrinkle injections: American XXXXX VERSUS French XXXXXXX...which is better?

XXXXX** VERSUS XXXXXXX**....THE JURY GIVES THEIR VERDICT

IMCAS 2013, Paris

Numerous studies from both the USA and Europe were completed and posted in a number of peer-reviewed scientific journals in 2012, looking at data comparing the use and effects of American Xxxxx and French Xxxxxxx.  Some studies also included the German toxin, Xxxxxx, soon to hit Australian shores in early 2014.

The remarkable and most notable outcomes of these papers was the consistency of the findings.

As a result, we can now reliably state that:

• Xxxxxxx has a faster rate of onset than Xxxxx

• Xxxxxxx and Xxxxx have near identical maximal effects.

• The conversion for Xxxxxxx and Xxxxx units is generally 2.5:1, but in some areas of the face may be closer to 2:1.

• Xxxxxxx has a longer duration of effect compared to Xxxxx, by several weeks in most published studies

• Xxxxxx is identical to Xxxxx in terms of dosage units, onset, peak effect and duration.

Diffusion continues to be discussed, with most published articles commenting on the importance of toxin concentration when measuring and especially comparing diffusion.

Overall, I'm predicting that Allergan, makers of Xxxxx, will be under significant pressure to lower the cost of Xxxxx vials in Australia by the end of the year.

Otherwise, they risk losing very significant market share as the scare campaign against Xxxxxxx backfires when people realise what advantage it has over Xxxxx in terms of value for money.

The main caveat for consumers in the toxin turf war, is to find an injector experienced in BOTH Xxxxx and Xxxxxxx.  Only unbiased injectors are capable of giving unbiased opinions, in my opinion!

Sadly, there was also data presented that looked at the prevalence of counterfeit product being sold online.  Truly horrifying to see what is actually in some of this stuff!

It's difficult for consumers to know if they are being injected with legitimate product. 

One tip worth remembering though is that these products can ONLY be sold to REGISTERED MEDICAL PRACTITIONERS. So that nurse who's offering half-price "Xxxxx" injections from her own home, or the local hair salon, is definitely not operating a legitimate business.  The product may well have been purchased online, and she/he most certainly won't be covered by any insurance (medical negligence or public liability) in the event of any adverse complication if the product is later found to be contaminated.

You know what they say, don't you?  If it sounds too good to be true, it probably IS too good to be true!  

**Apologies to those confused by the changes made to the brand names in this post.  For legal reasons, I am unable to use the exact names of the anti-wrinkle injections used in Australia.  That is because I am a medical practitioner.  If I was a beauty therapist, or any other unregistered health practitioner of any kind, or in fact just a regular member of the public, I would be able to mention all of those by name.  No wonder it is increasingly difficult for the public to get accurate and unbiased information on cosmetic treatments in Australia!  Censorship of public health information is rampant in Australia when it comes to cosmetic medicine.

IMCAS 2013 Paris

Winter in Paris?  Yes, please!!

It's been quite a few years since I had the pleasure of a voyage to Paris (that's what happens when you're 'grounded' with a young child!) so it was a real thrill to be back in the City of Love (with my number one Love Child in tow!) for this year's IMCAS conference..the 15th year.  And gosh, how it has grown in size since my last visit!

I also attended a full day masterclass on facial anatomy, courtesy of Ipsen Pharmaceuticals who make the French brand of anti-wrinkle injectable.

Followed by a live demonstration of a cadaver facial dissection by one of Paris' best plastic surgeons,  it was a great reminder of basic facial anatomy, and the importance of landmarks to avoid rare but nasty complications from cosmetic injecting.  

The venue was an absolute knock-out too.. in classic Parisian chi-chi style!

It was also lovely to see some other Australian injectors over there, as well as some Galderma reps.

As usual, the views of Paris were breathtakingly gorgeous for anyone who values aesthetic beauty..whether in architecture, fashion, homewares or faces!

View from my apartment!

The original Mona Lisa!

The walk home!

Our last night in Paris..the view from the very top of the Eiffel Tower!

IMCAS this year addressed a number of topics of growing concern, which will be the focus of some of the Skin Temple blog posts for the next few months.

These include:

• the issue of trust in cosmetic practice..thanks to the PIP breast implant fiasco in France (and the death of one woman in Hong Kong from an unproven 'cosmetic' procedure gone horribly wrong) in 2012

• hand rejuvenation

• neck rejuvenation
• periorbital laser resurfacing
• laser hair removal updates
• facial volumetry ( a topic of MASSIVE interest with the American dermatologists attending the conference)
• mens skincare
• mens rejuvenation techniques
• advanced muscle relaxant injecting
• ultrasound tightening
• lipolysis- new treatment options
• treating skin of colour
• laser tattoo removal advances

It was wonderful to see how much American aesthetics is evolving..from the brash and over filled look of the nineties, to something that is starting to resemble our approach to beauty in Australia.

Unlike Australia, many of the fillers currently used extensively in Europe and Australia for many years still remain unavailable in the USA..which really explains why they seem to be so obsessed with the relatively new (to them) area of facial volumetry!

I love the humour of this Mona Lisa image though, and there is an Australian version out there in cyberspace but I've not managed to track it down yet!  Needless to say that she's a brunette with much smaller breasts, lips and well defined eyebrows though!  I'm sure that if we could see her full smile, we'd also find teeth that are much more natural looking in colour and shape than those seen so often in the USA too!  When individual features are too perfect looking, it screams "fake" a mile away!

Especially when someone over 50years of age has perfectly pure white, porcelain veneers..

Cultural differences are very real, and also extend to the Asian communities, where almost 100% of muscle relaxant patients will have their masseters treated for jawline reshaping.

With my enroute stopover in Hong Kong I managed to sneak in a visit to Madame Tussaud's ..and spotted the dummies of Angelina Jolie and Brad Pitt...both of whom have jawlines that would be taboo in Chinese culture...though he would probably be accepted more readily than his wife!  Wax dummies really are quite freakishly life like..the skin luminosity that most celebs have these days is replicated beautifully on the manniquins.  I think that explains my aversion to Nicole Kidman's too frozen forehead..it really looks very waxy at times, and I think her wax dummy would probably look freakishly real..like Angelina's and Madonna's also.

So, with all that in mind, it is my pleasure to keep anti-wrinkle injections looking natural wherever possible..after all, we use our eyebrows to communicate non-verbally, and this is a critical factor in interpersonal relationships, not just from an aesthetic point of view.

Sometimes, the best way to evaluate an aesthetic outcome is to view the patient 's static AND residual dynamic expression, rather than try to completely obliterate it!  My opinion only!

Men's Skincare..an increasing trend!

I love looking after problem skin!

Lately I've noticed that an increasing number of men are attending our medispa for medical advice related to their skin concerns.

Here's an example of a young man who attended for advice on his acne problems:

Above is the baseline image.

Below is the follow up image, just 4 weeks later!

Happy patient, happy doctor!


Here's another example of a young man who wanted to his cheeks filled, but was advised to fill his jawline at the same time (to prevent looking too feminine!):

Image above is client before filler injected to cheeks and jawline.
Image below is same client 2 weeks after treatment.

Men are definitely catching up with the non-surgical trends sweeping the world..and is it any wonder? Just like women, they also want to look their best.  But there are definitely some pit falls for anyone who thinks that men should be injected in the same way as women..they really do have specific needs to retain a masculine appearance in general!

Not every red facial rash is Rosacea!

The other day I met a man who came in requesting treatment of his "rosacea" with laser...he'd already been to a well known laser clinic and been diagnosed with the rosacea by the nurse/laser therapist.

Here's his baseline pic:

He was therefore quite surprised to hear that I completely disagreed with the 'diagnosis'..and that the treatment for his condition isn't with laser rejuvenation, but that it would actually respond to topical antifungal preparations.

So, what's the problem?

This is actually a quite severe case of seborrhoeic dermatitis..one of the most common skin and scalp complaints around.

Seborrhoeic dermatitis typically causes a scaly scalp..also known as common dandruff.  But if left untreated for years, as in this case, it will spread onto other areas..usually the eyebrows, central face and sometimes into the outer ear canals.

This patient actually had seborrhoeic dermatitis so badly that it had extended throughout his entire beard area too.

How do I know that this is seborrhoeic dermatitis rather than rosacea?

Well, the two conditions really don't look alike...

Seborrhoeic dermatitis causes a scaly rash, rosacea doesn't.  The rash of rosacea is typically pustular and telangectactic, without any involvement of the scalp for example.

Because this patient has such a chronic case of seborrhoeic dermatitis, the chronic inflammation has caused moderately severe redness of the central face, which dramatically improved following treatment only with antifungal cream and shampoo..within just 3 weeks!  Here's the 'after' pic (though I haven't quite finished with him yet!):

Funnily enough, he had only applied the antifungal cream to the cheeks, missing the upper lip scaly areas, so is going to apply to those areas before he returns next!  To help resolve the residual redness on the cheeks a little quicker, I also performed one session of laser rejuvenation (Medicare rebatable too..another win for the patient!) onto those areas that are now clear of fungus at the follow up session.
Needless to say, he is a very happy patient!  Will update this post once I have the updated image from the next review visit.

Lessons from this experience:
If you have a skin complaint, have your rash properly diagnosed by a trained MEDICAL doctor.  Nurses and laser therapists are NOT MEDICALLY QUALIFIED to diagnose, even though they may have been trained to administer treatments!
Laser treatment can be expensive..and a waste of time and money if it is done inappropriately.
We all (unless you're 'lucky' enough to be a 3rd gen family trust baby!) work hard for our income..but having a conflict of interest and performing unnecessary treatments doesn't do your clients or your business reputation any favours!