The role of PPE or Personal Protective Equipment has taken a drastic change in recent times.What was once used solely in workplaces with a certain degree of safety hazards is now an undeniable necessity in ensuring our health and protection.

Personal Protective Equipment acts as a barrier between the skin and harmful contaminants or impact hazards from the environment. In this current age, it is what stands between the unprecedented transmission of the highly infectious COVID-19 and our safety.

With the virus being transmitted through direct and indirect contact, mere physical proximity amongst each other can pose as a serious threat.  While we slowly work to resume necessary social activities, we must take necessary precautions to mitigate the harms.  Everyone in the workplace should wear PPE and understand what it is for.

What is PPE?

Personal Protective Equipment is an apparatus or accessory worn over the body to protect against injury, contamination, impact, and exposure to microbes, biological secretions, splatters, chemicals, and other safety hazards.

There are different types of PPE, and each one is specifically made to protect against a particular type of safety hazard. With COVID-19, the mode of transmission is through physical contact—so the protective equipment recommended by WHO is one that acts as a barrier against the skin, face, and respiratory system.

Types of PPE for COVID-19

Face and Eye Protection

These PPE equipment protect the eyes and face from any possible infection, exposure or immediate impact from biological spatters, viral contaminants, and harmful microbes.

Face Shields cover the entire facial area including the eyes, nose, and mouth with a clear polycarbonate lens that offers unrestricted visibility. Face Shields may be repeatedly used as long as the proper disinfection process is undertaken after every use.

Medical Goggles fully enclose the entire area around the eyes to protect against becoming contaminated or infiltrated with biological spatters, infectious microbes, and impact hazards. Medical Goggles may be repeatedly used as long as the proper disinfection process is undertaken after every use.

Respiratory Protection

This apparel prevents pathogenic microorganisms, infectious contaminants, toxic gases, or any other particulate matter that may cause irritation and infection from entering the lungs through the nose and mouth.

N95 Masks have four layers of protection to effectively filter 95% of all air particulates from entering the respiratory system. N95 Masks have passed the US Regulatory standards for respiratory protection against viruses, microbes, and all toxic inhalants. N95 Masks should be worn for a maximum of eight hours only and should be replaced as often as necessary.

KN95 Masks are tight-fitting respirator masks that cover the mouth and nose against all air contaminants including pollution, pollen, dust, smoke, germs, bacteria, ash, and other nasal allergic triggers. KN95 masks pass health regulatory standards around the world. KN95 Masks should be worn for a maximum of eight hours only and should be replaced as often as necessary.

Surgical Masks prevent biological spatters, pathogenic microorganisms, and viral contaminants from getting expelled by the wearer towards the environment. Masks should be discarded and replaced as soon as they become contaminated.

Skin and Body Protection

This PPE covers the skin so that no liquid spatters, toxic chemicals, viral microbes, and biological secretions can come into contact with the body.

Medical Coveralls enclose the entire body including the head, arms, torso, and legs with a non-woven fabric that effectively repels moisture, fluids, and liquid matter. Disposable Emergency Medical Coveralls should be used for a maximum of eight hours only.

Medical Gloves provide secure, enclosed protection for the hands against contamination and exposure to liquid spatters, biological secretions, viral microbes, and other hazardous particles. Gloves should be used for a maximum of 8 hours only and discarded after every use that involves some degree of exposure to contaminants.

All PPE clothing must be sterile, CE-marked/FDA-Approved and recommended by the World Health Organization.

How To Wear PPE?

The proper donning and disposal of PPE is key to ensure that the PPE performs for optimum protection.

An important reminder in wearing PPE is that one garment must not interfere with another. The entire set of apparel worn by an individual must be comfortable enough for movement but also for utmost functionality with no leakages.

Here are the following steps to wear full PPE properly:

1.  Identify and gather the proper PPE set. Always ensure it is the correct size for the person who will be wearing it.

2. Wash hands thoroughly for thirty seconds.

3. Put on the Medical Coveralls.

4. Wear the mask (KN95 or N95 or Surgical Mask) while ensuring that the nosepiece is fitted to the nose. Place the loops around the ears. Both nose and mouth should be covered. Secure the top tie on the crown of the head and the bottom tie on the base of the neck

5. Put on either the Face Shields or Goggles. Use the most appropriate face protection that does not interfere with the seal of the mask.

6. Put on the gloves.

How To Remove PPE Gear?      

PPE gear must be removed properly or else contamination and exposure to infectious contaminants are very likely, invalidating the usage of PPE in the first place.

Here are the following steps in removing the PPE in proper order:

1.  Remove gloves properly, making sure the hands do not come into contact with the external side of the glove that has been exposed to the environment.

2. Remove the coveralls carefully in the utmost avoidance of contact to the side exposed to the environment. Assistance from another person may be required.

3. Wash hands thoroughly for 20 seconds and more, or use hand sanitizer.

4. Remove the Face Shield or Goggles by grabbing the strap or snapping the lock. Pull it upwards and away from the head.

5. Remove the mask by tugging at the loops over the ears and throw it in the proper trash bin immediately. Do not touch the front of the mask.

6. Wash hands thoroughly for 20 seconds.

Conclusion

With the number of Covid-19 cases rising, it is a necessary precaution to maintain social distancing, adhere to quarantine, and to wear PPE when in contact with another individual. PPE is very integral to our safety and survival as well as others around us.

Understanding what Personal Protective Equipment is, what it does, and how to wear and dispose of it properly is how we can ensure not only our health and safety but everyone around us. It is also important to remember to use PPE when performing treatment of patients with products such as Sculptra.

Filler Complications

Introduction

The increased popularity of dermal fillers in enhancing facial aesthetics is due to their minimally invasive nature, short recovery time, and excellent outcomes. While collagen fillers dominated the market for over 20 years since their approval by the Food and Drug Administration (FDA) in 1981, it was the emergence of hyaluronic acid (HA) fillers that paved the way for new filler brands and technologies.

As with any medical procedure, a multitude of complications can occur after filler injection. The supposed reversibility of HA-based fillers adds their popularity; however, increased use of these fillers also puts less common but significant side effects in the spotlight. Injecting physicians must be aware of the adverse effects associated with dermal fillers because some of these complications can be devastating and irreversible. Additionally, some complications occur more frequently with specific filler materials or products; thus, the injector must know the properties of each filler at their disposal.

Patient Evaluation

As many complications are due to problems with injection technique, it is important to train extensively and gain experience, preferably with a reversible filler, in order to minimize potential problems. However, side effects are also related to the inherent properties of the filler or unappreciated patient factors.¹ Patients presenting with complications after a filler injection should be questioned about previous medical procedures, filler-related issues, number of injections and treated areas.² Immunosuppressed patients must be counseled for higher risk of infection. In patients with immunologic diseases, it is recommended to consult the rheumatologist or dermatologist before performing additional procedures.

If a patient is not satisfied with previous filler outcomes, the physician should not re-administer the same product. It is best to suggest an alternative filler material or treatment modality, or not treat at all.  In attempting to remedy a complication, the patient should be informed that the elective treatment might require multiple sessions. It is also important to inform the patient that such interventions may result to permanent scarring.

Pre-Procedure Considerations

The best way to treat complications is to prevent them from occurring. Providing excellent predictable outcomes and avoiding unsatisfactory results begins before the actual injection process. While there is no filler product available without concomitant side effects, the physician can minimize complications by choosing the appropriate filler type and injection technique. Not all hyaluronic acid fillers have the same properties and indications. Each filler differs in cohesiveness, molecular size, and cross-linking technologies. In patients who have been treated multiple times, a detailed facial surgery and filler history should be obtained to guide the decision to inject, the placement of the product, and the type of filler to use.

The patients’ expectations should be managed. Completing a proper initial evaluation prior to injection is essential. The priority of the treatment is to satisfy the patient, thus before and after photographs should be taken. During the initial assessment, identify asymmetries and discuss each skin concern to facilitate a clear and honest discussion towards achieving the patient’s desired outcome. It is also essential to discuss the financial commitment involved in pursuing the treatment plan, including the number of syringes needed and if subsequent sessions will be necessary to reach the patient’s intended goal.

Skin Testing

The reactivity profile of the chosen filler should be reviewed prior to injection. Any filling material from foreign sources can theoretically trigger immune reactions to a variable degree, from redness to anaphylaxis. Products that are highly reactive, such as those containing bovine collagen, require skin testing prior to injection.³ Anaphylaxis is extremely rare but the Food and Drug Administration (FDA) still requires allergy testing for these products. The most popular filler material, hyaluronic acid, has a low rate of hypersensitivity, ranging from 0.6% to 0.8% regardless if the formula is bacterial or viral in origin.⁴ Hypersensitivity reactions to bovine collagen may be local or systemic while reported reactions to hyaluronic acid were often immediate, localized, and typically resolved within three weeks.⁵

The use of collagen fillers has declined due to the development of new fillers with better safety profiles. New products containing hyaluronic acid and calcium hydroxyapatite have been found to be superior to collagen with a very small chance of local reactions. Popular bovine collagen and human collagen products are no longer being manufactured; the only product available with 80% purified bovine collagen, which requires skin testing, has polymethylmethacrylate as the main ingredient (Artefill).

Filler Selection

Product-related complications are influenced by the physiochemical properties of the filler and the patient’s response to the product.⁶ Currently, available fillers may be classified as temporary or permanent. Temporary fillers are biodegradable and are absorbed or metabolized by the body. The duration of effects of these fillers vary and is dependent on the type and amount of filler injected, treatment location, and injection technique utilized.⁷ Temporary fillers cleared by the FDA include hyaluronic acid, collagen, calcium hydroxylapatite (CaHA), and poly-l-lactic acid (PLLA). The only FDA-approved permanent filler contains biocompatible, non-biodegradable polymethylmethacrylate (PMMA) beads intended to reduce wrinkles around the mouth, and recently, for the treatment of acne scars.

Inappropriate Placement and Its Manifestations

It is imperative to understand the underlying body, soft tissue structures and vascular anatomy when injecting facial fillers. Accurate and safe placement of filler products depends not only on these factors but also on thorough understanding of the patient’s history and the product’s properties. Inappropriate placement of fillers, such as superficial injection, can lead to a range of complications. Injecting too superficially is a common error and may result in inflammatory nodule formation, visible product, a bluish hue under the skin, and hypertrophic scarring.^8,9 While these reactions can be somewhat prevented by the use of correct injection technique, they can, however, cause anxiety and dissatisfaction for patients.

Simple lumps and bumps associated with superficial placement can be alleviated by massaging the area, as well as through aspiration or incision and drainage.¹⁰ If the reaction is due to an hyaluronic acid product, hyaluronidase can help treat this problem. Polymethylmethacrylate plus collagen is a permanent filler that, less forgiving, can be associated with another set of complications such as long-lasting itching and redness. If the product in question contains calcium hydroxyapatite (Radiesse), superficial injection is associated with white nodule formation. This is often managed by puncturing and expressing the nodules using a No 11 blade or needle.¹¹ The same technique is used if the injecting physician overfills a particular area. Massaging the area to disperse the product is an adequate solution in some cases; however, one can puncture the skin and express excess filler if the overfill persists.

Injection Site Reactions

Despite best practices, including allergic testing and proper product selection, reactions can still occur. Local injection site reactions are the most common side effect associated with filler injection since it requires skin piercing and introduction of a foreign substance. Other foreign materials other than the filler, such as residual makeup incompletely removed from the patient’s skin, could cause a reaction; therefore, makeup in the injection area must be removed prior to application. The most commonly observed reactions are redness, swelling, bruising, tenderness or pain, and itchiness. These reactions are often mild to moderate and could last for a few days to a week.

Edema and ecchymosis are often due to injection technique, speed of injection, and filler choice. Regardless of the product injected, swelling and bruising are usually localized, mild, and self-limiting. Comparing the package inserts of some popular fillers: Juvederm Ultra (HA) has an 86% reported incidence of swelling and 59% incidence of bruising; Injections from Sculptra (PLLA) has 4-7% incidence of swelling and 6-38% incidence of bruising; and the use of Radiesse treatment (CaHA) has a reported 69.2% incidence of swelling and 63.2% incidence of bruising.^12,13,14 Dr. John Quinn suggests using the smallest needle possible and microcannula for danger areas to reduce the risk of swelling and bruising. This is particularly important when augmenting the lip as the labial artery runs deep in the body of the lips, thus the border between wet and dry area is more likely to bruise.

Early Onset Complications

One of the most devastating complications of soft tissue augmentation with injectables is intravascular injection, which can lead to potential tissue necrosis, scarring, and even blindness. The best treatment for vascular compromise begins with sufficient prevention. Thorough knowledge of facial anatomy and awareness of danger zones reduces the risk, but actual vascular structures possess considerable variation. Early recognition of the warning signs is highly important as the injecting physician must be ready to administer appropriate treatment immediately. Hyaluronidase and other supplemental treatments, such as a warm compress, nitro paste, and sildenafil, must be immediately available.

The glabella, nasolabial fold, and nose are the most common danger zones, as these areas have rich anastomoses with the internal carotid artery.¹⁵ Nose reshaping with facial fillers has become a common procedure in the past few years. Because of the increasing incidence of nasal tip necrosis due to the compression of facial blood vessels in the area, this procedure should be performed by specialists rather than newly trained practitioners. Post-injection blindness is not a commonly reported side effect with dermal filler, but knowing proper management and prevention is paramount. Pain and pallor are common signs of arterial compromise. Embolization and compression of the glabellar arteries can occur due to the small amount of space between the skin and periosteum in this area.⁸ In the event of a vascular compromise, treatment includes massage, hyaluronidase, heat, and topical GTN.

Delayed Onset Complications

Delayed onset nodule formation and granulomatous reactions have been reported with several filler products. Biofilms may play a role in the presentation of delayed onset erythematous nodules (“angry red bumps”). These bumps are different from ordinary nodules (collections of injected fillers) and are regarded as possible foreign body reactions, hypersensitivity reactions, infections, or sterile abscesses. To help minimize the risk of infection, clean preparation of the skin using chlorhexidine is recommended prior to filler injection. A granuloma is an immune response to an implanted foreign material and develops via an accumulation of immune-related cells, such as lymphocytes, in an attempt to eliminate the foreign body.¹⁶

In contrast to granuloma, the key signs of infection are erythema, warmth, and tenderness. The usual cause of late onset infection is less common bacteria like mycobacteria.¹⁷ Successful treatment requires appropriate antibiotic therapy as well as aggressive debridement of all infected skin and subcutaneous tissue. Dr. Quinn prescribes clarithromycin 500 mg twice a day for four weeks, while other physicians advise the use of ciprofloxacin 750 mg bd for a month.

Implanted fillers can migrate up to several years after injection. Semi-permanent and permanent fillers are most likely to migrate, but infection or delayed granuloma can also trigger migration. If the injected product is HA-based, hyaluronidase is the preferred treatment, but surgical removal may be necessary for other filler materials.

Conclusion

An efficient way to enhance facial aesthetics with minimal downtime, dermal fillers are the gold standard for soft-tissue augmentation. While adverse events are rare, cautious injection and public education regarding the potentially catastrophic consequences of unregulated filler injection are essential. It is the responsibility of the physician to consider the individual characteristics of each patients and the properties of available fillers when selecting a treatment. The physician’s readiness to handle various adverse events, and careful following of treatment consensus in the occurrence of a nodule, granuloma, or vascular compromise, ensures optimal management.

References

1.  Leonhardt, J.M., Lawrence, N., & Narins, R.S. Angioedema acute hypersensitivity reaction to injectable hyaluronic acid, Dermatol Surg, 31, 5.

2.Jin Moon, H., & Sook Yi J. (2016). Management of Facial Filler InjectionComplications in Aesthetic Plastic Surgery of the East Asian Face, Thieme, p. 406

3. Bailey, S., Cohen, J., & Kenkel, J. (2011). Etiology, Prevention, and Treatment of Dermal Filler Complications, Aesthetic Surgery Journal, 31, 1.

4. Andre, P. (2004). Evaluation of the safety of a non-animal stabilized hyaluronic acid (NASHA—Q-Medical, Sweden) in European countries: a retrospective study from 1997 to 2001, J Eur Acad Dermatol Venereol, 18, 4.

5. Friedman, P.M., Mafong, E.A., Kauvar, A.N., & Geronemus, R.G. (2002). Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation. Dermatol Surg, 28, 6.

6. Gravier, M., Bass, L., Lorence, P., et al. (2018). Differentiating non-permanent injectable fillers: Prevention and treatment of filler complications, Aesthetic Surgery Journal, 38, 1.

7. Luebberding, S., & Alexiades-Armenakas, M. (2013). Critical appraisal of the safety of dermal fillers: a primer for clinicians, Curr Derm Rep

8. Narins, R.S.M., Jewell, M.M., Rubin, M.M., Cohen, J.M., & Strobos, J.M. (2006). Clinical conference: management of rare events following dermal fillers-focal necrosis and angry red bumps, Dermatol Surg, 32.

9. Zielke, H., Wölber, L., Wiest, L., Rzany, B. (2008). Risk profiles of different injectable fillers: results from the injectable filler safety study (IFS Study), Dermatol Surg, 35, 1.

10. Brody, H.J. (2005). Use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyaluronic acid misplacement, Dermatol Surg, 34, 1.

11. Berlin, A., Cohen, J.L., & Goldberg, D.J. (2006). Calcium hydroxylapatite for facial rejuvenation, Semin Cutan Med Surg, 25.

12. Juvederm package insert. [Available from: http://www3.juvederm.com/professionals/pdf/juvederm_dfu.pdf ]. Accessed April 1, 2019.

13. Sculptra package insert. [Available from: http://products.sanofi -aventis.us/sculptra/sculptra.html ]. Accessed April 1, 2019.

14. Radiesse Injectable Implant Instructions For Use. [Available from: http://www.accessdata.fda.gov/cdrh_docs/pdf5/P050037c.pdf ]. Accessed April 1, 2019.

15. Brennan, C. (2014). Avoiding the “danger zones” when injecting dermal fillers and volume enhancers, Plast Surg Nurs, 34, 3.

16. Sidwell, R.U., Dhillon, A.P., Butler, P.E., & Rustin, M.H. (2004). Localized granulomatous reaction to a semi-permanent hyaluronic acid and acrylic hydrogel cosmetic filler, Clin Exp Dermatol, 29.

17. Hirsch, R.J., Narurkar, V., & Carruthers, J. (2006). Management of injected hyaluronic acid induced Tyndall effects, Lasers SurgMed, 33, 3.

18. Plaus, W.J., & Hermann, G. (1991). The surgical management of superficial infections caused by atypical mycobacteria, Surgery, 110.

For centuries, the ideal male body has been depicted as an athletic, lean, and muscular figure; this is seen in many historic art pieces, such as Greek sculptures. Today, many actors are considered body icons and are sprawled across the front pages of magazines globally. Research has found that the ideal male body shape is characterized by lean and well-defined muscle mass, and it is often a body type that many women prefer as well. This body type is considered a physical manifestation of traits such as discipline, dominance, resilience, attractiveness, and sexual experience.It is possible to achieve this ideal physique by committing to regular exercise and a healthy diet, but some men do not have the time or inclination to spend hours at the gym. Physique also changes as men age, and it is difficult to get rid of the fat that may appear. Additionally, each man has his own goal of how his body should look, and the so-called ideal body is not necessarily everyone’s preference. As such, different approaches must be used as part of consultation and treatment when considering the option of body contouring procedures for men.

Consultation – Inquiries and Suitability

Not everyone is suitable for a body contouring procedure. Lifestyle should be discussed before any procedure occurs; diet, alcohol consumption, and exercise should be rated on a scale by patients. If men have negative lifestyles, their lymphatic systems will be unable to process the fat cells as they are being broken down, which means treatment will be ineffective. If a patient’s lifestyle is addressed and optimized during the treatment and follow up, results can be more noticeable. A healthy lifestyle is simply required to maintain the results; sometimes patients are advised to come back after they have improved their lifestyles.

The fat that requires treatment is also important. Body contouring targets subcutaneous fat, but many men usually present visceral fat that is stored around important organs and can only be targeted with diet and exercise. Patients should address this first and then come back to be assessed for treatment of any remaining subcutaneous fat.

Finally, the predominant reason many men do not go through with a body contouring procedure is price. This is especially common if they are unaware of how much the procedure(s) cost. It is important to discuss prices over the phone with patients and outline costs on clinic websites before patients come in for consultation.

Treatment

The most common area of concern for men is the abdomen. In this area, men want to reduce fat and tone muscles. The second area is the flanks (also known as the “muffin top”), which is an area that is almost impossible to get rid of with exercise. The third area is a chest with gynaecomastia. Men’s chests can also droop, but they can be perked up relatively easily because men have less breast tissue. Outlined below are some common treatments used for contouring the male body.

1. Cryolipolysis

During cryolipolysis, a high-pressure suction handpiece is used to target areas of the body that are then cooled to negative temperatures. The cold induces fat cell apoptosis, and the dead fat cells are eliminated from the body through lymphatic drainage. This procedure is especially useful for fat pockets that are hard to get rid of. The applicator is a good option for men, as it is a two-plate style applicator that usually covers the entire abdominal area. Thus, the fat doesn’t have to be squeezed into a suction handpiece.

Usually, it takes up to four to twelve weeks for the body to expel the dead fat cells. During this time, patients may notice tenderness and swelling. This form of treatment may be uncomfortable, as the area goes numb during the procedure, which can take up to 50 minutes. Numbing of the area for up to three weeks and cold burns are possible side effects. A possible complication is paradoxical adipose hyperplasia, which means that after cryolipolysis, there is an area of fat remaining that makes it look like weight was gained.

 

2. Laser-assisted lipolysis

Instead of freezing fat tissue, this option involves heating it using laser energy to permanently destroy fat cells in adipose tissue. The treatment takes 25 minutes and aims to destroy around 24% of treated fat in problematic areas, such as the abdomen and flanks. Results can be seen as early as six weeks, but optimal results tend to be visible at 12 weeks. Additionally, two to three treatment sessions are required to see results.

There is a risk of thermal injury and nerve damage, but the risk is low if practitioners of this treatment modality follow protocols carefully. Abdominal scarring should be considered a contraindication, as this can be a painful treatment.

3. Radiofrequency (RF)

RF offers body contouring through heating and melting away fat cells. Some devices can use RF energy alone or are combined with methods like suction. The fat layer is heated to 45°Celsius, and the RF energy induces apoptosis in fat cells while sparing the surrounding cells. Volume reduction follows three to eight weeks after the treatment. Venus Freeze is one example of a device that uses RF energy; it heats the tissue using a combination of multi-polar RF and pulsed electromagnetic fields.

Ultimately, patients should have eight to ten treatments once a week. Contraindications include metal implants in the treatment area, the presence of cancer, and a history of cancer. Although RF devices are programmed to prevent overheating the skin’s surface, burns may still occur. Older devices can also have uneven depths of RF penetration, which can result in uneven fat breakdown.

4. High-intensity focused electromagnetic technology

High-intensity focused electromagnetic technology builds muscle and burns fat. For example, Emsculpt is a high-intensity focused electromagnetic device that, in a non-invasive manner, induces supramaximal contractions that are not achievable through exercise or voluntary contraction. The muscle tissue responds and remodels its inner structure. This results in muscle building and the burning of fat. Patients achieve a flatter appearance and improve their core strength and posture; they can even reduce back pain. Four treatments are required, and it is a great option for people with a baseline level of fitness and muscle tone who want to be more defined. It is not a painful procedure.

Aside from mild soreness, no side effects or adverse reactions have been reported, though it is advised patients do not have metal in or near the treatment area. Practitioners should adhere to the treatment protocol.

5. VASER liposuction

VASER liposuction is a more invasive form of treatment, and it is for patients who are already in good physical condition and are looking to contour their body. This is an FDA-approved technology and involves injecting a tumescent liquid into the area being treated. Then, high-frequency ultrasound vibration is used to break fat cells apart using probes inserted into the fat tissue.

A gentle suction procedure is used to remove the emulsified fat and shape the body. Treatment is time-dependent, with the procedure time based on surface area and the site(s) treated. Patients are able to go home two to three hours after the treatment. Patients should plan for a week-long recovery, as the treatment is quite invasive.  Compression garments are required for aftercare in addition to several lymphatic drainage sessions that should be done through gentle massage. Some side effects include pain, infection, and risks from the anesthesia. Additionally, probes can burn the skin if applied incorrectly. If lymphatic drainage is not performed, seroma may occur, which is the accumulation of inflammatory fluids. After gynaecomastia, there may be some asymmetry and nipple sensitivity as well.

Considerations

Through body sculpting, there is a risk of feminization of the male patient’s figure. It is important for physicians to keep the male body type, which is usually in the shape of an inverted triangle. A masculine figure should not be compromised and demasculinized unless the patient has specifically requested this. Additionally, choosing an appropriate device for the clinic is also challenging, especially if a budget must be adhered to. It is important to consider the development of the device and whether the supplier will provide ongoing training for it. Branding is important and should be considered. Additionally, the device and the literature about it should focus on males. A clinical, safe, and effective environment should be maintained. Patients should be comforted and counseled in what their procedure will feel like, as well as what other products could be used, such as Radiesse, for example.

Sculptra is an injectable that contains poly-L-lactic acid as one of its main ingredients. It is often packaged into a vial as a dry powder that must be reconstituted. Poly-L-lactic acid is a cosmetic filler material that, when injected into the tissues, stimulates collagen production by being targeted by the immune system as foreign bodies. This is the mechanism behind its augmentation function. This article will focus on the technical aspects of using Sculptra for facial rejuvenation.

Preparation

Reconstitute Sculptra at least two to seven days before treatment with 6ml of bacteriostatic water. On the day of the injection, add 3ml of lidocaine with epinephrine to make a solution of 9ml in the vial; this reduces the need to introduce a local anesthetic injection before the treatment. Do not shake the vial when attempting to mix the solution; instead, just gently roll the vial, make sure no bubbles are formed. Use a 21-gauge needle to draw the solution from the vial and use a 25-gauge needle to inject. Follow strict aseptic standards to minimize the risk of infection. Clean the treatment area thoroughly prior to injecting. Although the injection depth will vary depending on the area being treated, most practitioners advocate a subdermal injection.

Equipment and technique

Either needles or cannula can be used for Sculptra. One distinct advantage with cannula is that practitioners are able to employ the fanning technique with these devices to cover substantial areas under the skin. To inject large areas with needles would be to introduce more trauma by repeatedly puncturing the skin. As such, using a cannula ultimately results in less risk for bruising. One downside is that if you are inexperienced with the cannula, it may be harder to operate than needles. Nonetheless, needles are still a viable option due to their cost-effectiveness and ease-of-use. An example a needle suited for injecting Sculptra is the 0.5” Terumo 26-gauge needles. You may also consider other brands that have 1.5” 25-gauge needle measurements. You may use longer needles, as with cannula, with the fanning technique in the subdermal layer. A slip-lock syringe may provide a better grip on the needle hub than many Luer lock syringes. If you feel excessive resistive force during extrusion of the filler materials, do not force it. Ensure that you perform aspiration prior to any injection, and make sure that the needle stays in place. This is also important, as the aliquots required for Sculptra to function are relatively larger than other cosmetic fillers. Pay attention to the sensation of blocked needles, as it commonly occurs. Remain still and gentle throughout the injection process to minimize trauma. Finally, after injection, message the area so that the filler material is spread more evenly.

Treatment areas

A crucial point regarding Sculptra is that is should never be used on areas where there are bony prominences with minimal fat covering, such as the forehead and nose. Other areas of concern are the lip vermilion and the modiolus. Cosmetic fillers should be performed from the top-down, as the requirements for the lower parts of an area changes as the treatment goes on.

Temple

The temporal hollows require 1 to 3ml of product on each side that are directed into the periosteal level. Make sure to not inject any product into the superficial temporal artery or any of the branches or veins.

Zygomatic arch

Using the 1.5” needle, inject Sculptra deep into the superior surface of the arch, and perform the retrograde injection technique. 2ml of filler material should be used, as it can provide the necessary amount of volumization to lift the lower portion of the face.

Mid-cheek

The cheeks need about 2 to 3ml of cosmetic filler material per cheek. Aim the needle over the malar region and inject the Sculptra deep into the periosteum. Utilize the fanning technique here to deposit it into the malar fat pad and cheek fat tissues from a single puncture location.

Often, the area most commonly needing volumization is the area over the infra-orbital foramen. Be respectful of the neurovascular bundle that exists here, though, as it is deep and has a fibrous covering. Use one finger to push up fat from a lower position to create a buffer and ensure that the needle does not reach the periosteum. If you are anxious about damaging the bundle, aim a slightly lateral. Place boluses of up to 1.5ml from the medial to the lateral of the mid-cheek without removing the needle completely. Only change the direction of your needle once you have withdrawn almost all of it.

Alar triangle

Position your needle at a 45-degree angle 5mm medial to the alar triangle. Pull the nose forwards to shift the angular artery away from the injection site.

Parotid and buccal areas

Treating this area can help to lessen the prominence of the masseter and can improve the appearance of the jawline and jowls. In cases where there is masseter hypertrophy, use a 1.5-inch needle, as treating this condition will require a deeper insertion. Do not inject below the parotid fascia and avoid the superficial temporal artery that is in close proximity. Perform the fanning and retrograde injection technique. Use approximately 2ml of filler material in this area.

Marionette and chin

Start treating this area with an injection at the inferior part of the chin along the mandibular rami. This area usually demands a few bolus placements. The mental crease can also be treated, but this area should be treated with a deep injection done with the retrograde injection technique.

Skin texture improvement

The techniques elaborated above can also be used for any region of the skin, particularly regions that are thin and have had UV-induced changes and/or atrophic acne scars.

Aftercare

Post-treatment care is an important step of treatment with Sculptra. Not only will you need to massage the injected areas, but the patient must also do it at home. The recommended duration of such massages is two five-minute massages a day for a period of one week. Many patients tend to massage too little than too much. Convey the importance of massaging and encourage it, so as to help your patients achieve optimal results.

Reference

1.  Niamtu J. Injectable Fillers: Lip Augmentation, Lip Reduction, and Lip Lift. (ed). Cosmetic Facial Surgery, 2nd ed: Elsevier; 2018. pp. 569-638.

When talking about chemical peeling, it is important to recognize that these peels actually induce controlled chemical damage onto the skin. By using what is usually an acidic solution, chemical peels remove the epidermis and dermis, so that they can undergo regeneration from nearby adnexal structures, which ultimately results in the improvement of skin color, texture, and other concerns. Depending on the strength of the solution, the level of dermal collagen affected will either be superficial, medium, or deep. This article will focus on the peeling agents available and how they are capable of restoring epidermal structures. The indications of the different solutions will also be elaborated.

Popularity of skin peels

The Plastic Surgery Statistics Report in 2017 that was prepared by the American Society of Plastic Surgeons showed that there were close to 1.4 million individuals who opted for chemical peeling, which is a significant increase over the 1.15 million individuals that opted for such treatments in 2000. This increase of approximately 20% shows an obvious growing demand for chemical peeling. Along with pop media often advertising the benefits of such treatment, this growth stresses a growing need for practitioners to be more comfortable and confident with chemical peels and chemical rejuvenation procedures requested by patients.

Purpose of skin peels

The main indications for chemical peeling are the following conditions: scars, pre-neoplastic or neoplastic epidermal lesions (e.g. actinic keratosis, lentigines), acne, pigmentary problems, demarcation lines caused by other procedures, and UV-induced skin damage. Amongst these reasons for chemical peeling, UV-induced skin damage remains the most common reason for patients seeking out chemical peels. As previously mentioned, the depth of penetration of the chemical peel depends on the solution. Superficial peels are used for epidermal peeling; medium peels are used for the papillary dermis; and deep peels are used for the reticular dermis. Overall, with the advent of more modern aesthetic devices and aesthetic techniques that are more efficient, such as injectable dermal fillers and the versatile use of botulinum toxin, chemical peeling has lost some of its luster as it has become more of an adjuvant therapy following these treatment methods.

Combinations

Since different chemical peeling agents have different mechanisms of action, many practitioners prefer to combine several peeling agents to compound their effects.

Frequently used hydroxyl acid combination therapies are: Skin Tech’s Easy Phytic Peels, where glycolic, lactic, phytic and mandelic acid are used; Skin Tech’s Easy Droxy Versicolor, where glycolic, lactic, salicylic, citric, and kojic acid are used; ZO’s 3Step Stimulation Peel, where glycolic, salicylic, and lactic acid are used; Agera Skin Peels, which uses salicylic acid, 1-ascorbic acid, and lactic acid; and NeoStrata’s Skin Peel Renewal Solution, which uses glycolic acid and mandelic or citric acid.

Superficial peels

The superficial chemical peels are ideally used on patients with acne, discoloration and sun spots, surface scars, and fine lines. Patients need to adhere to pre- and post-treatment protocols that are vital in optimizing the aesthetic outcome. As the patient adjusts to the peeling agent, the frequency and degree of exposure can be increased as deemed appropriate. Superficial peels tend to only induce transient side effects that do not need active intervention. Light peeling agents often contain ingredients such as glycolic acid, TCA, Jessner solution, salicylic acid, and solid CO2 slush.

Alpha-hydroxy acids

The hydroxyl acid group is separated into alpha-hydroxy acids (AHA) and beta-hydroxy acids (BHA). AHAs are commonly found in foods and have been used in skin rejuvenation programs for more than four decades. 25 Usually, AHA chemical peels are formulated to correspond to the level of injury intended. Factors such as pH, concentration of free acid, volume in contact with the skin, and duration of that contact are all vital in deciding the depth of injury. For example, low concentrations of AHA are known to cause lower cohesion in corneocytes at the stratum corneum and granulosum, while higher concentrations can cause epidermolysis. Many consumers see AHAs as a benevolent compound, as they associate them with fruit acids.

One of the most frequently used AHAs is glycolic acid, which can reach concentrations of up to 70%. Glycolic acid chemical peels are used in a weekly or biweekly fashion to treat acne, mild evidence of photoaging, and melasma. It is vital that you take note of this peel’s time of contact with the skin, as it should be neutralized with either water or 5% sodium bicarbonate before four minutes have transpired. Glycolic acid peels, and AHA chemical peels more generally, are peeling agents that are time-dependent; exercise caution during the procedure involving such agents to make sure that they are not applied for an excessive or insufficient amount of time.

AHA chemical peels work by inducing chemical damage to the desmosomal attachments between the corneocytes, which reduces the latter’s cohesion. Studies have also shown that they can also improve skin appearance by increasing dermal thickness, increasing the glycosaminoglycan concentration in the skin, increasing collagen density, and enhancing elastic fibers. Glycolic acid peels that are present in the market include Dermaceutic, Skin Tech, Murad, and NeoStrata, among others. Lactic acid is another hydroxyl acid that is used because of its intrinsic hydrating nature. In practice, it is converted to lactate, which acts as the active component when the lactic acid chemical peel comes into contact with the skin. It is also considered less potent than glycolic acid.

Resorcinol

Derived from the chemical compound phenol, resorcinol has been in use for more than a century. Its mechanism of action involves affecting the hydrogen bonds in keratin, which results in pigmentation correction. It is not usually used alone; instead, it is typically used in peels that contain other chemical agents such as Jessner solution. Complications that can arise from the use of peels containing resorcinol range from thyroid disorders and myxedema to cardiac rhythm disorders. With this in mind, allergy skin testing is compulsory prior to resorcinol use.

Retinoic acid

Topical retinoids are a derived from vitamin A and are used in many over-the-counter topical medications. Stronger formulations would usually require prescriptions. Currently, there are three main formulations of topical retinoids on the market: retinol, retinal, and retinoic acid. They are highly efficacious when used to treat UV-induced damages and acne. Retinoic acid chemical peels can also have a synergistic effect with other peeling agents, such as salicylic and glycolic acid. Tretinoin is also frequently used a pre-procedure priming agent.

Jessner solution

Jessner solution is a combination of a variety of keratolytic components that has been in use for the past 100 years for the treatment of inflammatory and comedonal acne vulgaris and hyperkeratotic skin disorders. Amongst chem exfoliating agents, chemical peels with Jessner solution has one of the most intense keratolytic actions, as it starts by decreasing corneocyte cohesion in the stratum corneum layer, which later progresses to inter- and intracellular edema at the upper epidermis layer as Jessner solution is applied over a longer period of time. The endpoint at which to terminate the peel is erythema with either blotchy frosting or uniform frosting. It is important to note that chemical peels with Jessner solution are made of 14% salicylic acid, and this can be absorbed systemically, which, when absorbed in excess, can lead to salicylism. Although the risk for salicylism is low, there is still an inherent possibility of it occurring if the treatment process was done on a large area. Extra care must be taken to avoid this. Early manifestations of salicylism include tinnitus, dizziness, and headaches. Although these symptoms can resolve on their own, salicylism can be fatal later on as salicylic acid levels build up. Increase water intake to resolve the symptoms more quickly. Other active components of chemical peels with Jessner solution are 14% resorcinol and 14% lactic acid.

Beta-hydroxy acids

Salicylic acid is perhaps the most widely used beta-hydroxy acid. It is a component that makes up Jessner solution. Later on, Albert Kligman developed a 30% salicylic acid peel that provided several additional benefits compared to glycolic acid peels. Salicylic acid peels can provide a more uniform application, as their translucency allows the practitioner to judge its formation of white precipitates, meaning areas that were missed can be easily spotted. The white precipitation is different from the frosting seen in other peeling agents; it is known as pseudo-frost since it occurs due to the deposition of salicylic acid after its hydroethanolic vehicle has evaporated. It is also not time-dependent and does not need any neutralization process. In addition, the anesthetic property of salicylic acid helps to provide some patient comfort during and after the procedure. It also has additional action on patients suffering from acne, as it has both keratolytic and comedolytic effects. The appearance of comedones and papules can be significantly reduced in one month of treatment. Multiple studies performed have also noted increased improvement in patients whose acne was treated with salicylic acid compared to those whose acne was treated with AHA. Examples of manufacturers salicylic acid peels are Epionce, Mene & Moy, NeoStrata, ZO, Priori and Jan Marini.

Medium peels

Peels that cause damage through to the level of the upper reticular dermis are regarded as medium peels. These peels produce epidermal necrosis, papillary dermal edema, and homogenization in the first few days. After treatment, wound healing in the form of increased collagen production and the expansion of the papillary dermis occurs within three months. As a result, improvements can be noted on fine lines and pigmentation. Indications for medium peels are Glogau group II patients and patients with epidermal lesions, pigmentary dyschromia, and mild acne scars.

For a substantial amount of time, 40% to 50% TCA was considered the standard medium-depth peeling agent, as it worked well against fine wrinkles, actinic damage, and pre-neoplastic skin lesions. However, the high risk of side effects stopped such peels from gaining more traction amongst consumers. For example, scarring and pigmentary changes were common with patients who used a TCA solution that was 50% or higher, and these effects were often resilient to correction. Nowadays, medium peel agents are typically ones that are 35% TCA with either Jessner solution, 70% glycolic acid, or solid CO2. The most popular variant is the Jessner-35% TCA peel combination since it is able to treat a wider range of patients, is easier to use, and has a good safety profile. Studies have shown that these three combination peels are as effective as 50% TCA but have a better safety profile. Moreover, the level of penetration in combination peels is also better than 50% TCA peels, which may partly explain how these combination peels are safer than peels that solely have a high concentration of TCA. Combination peels are able to freshen sallow, atrophic skin and reduce fine wrinkles with little no risk of any pigmentary side effects. Collagen remodeling also occurs over a three to four-month period during which continued improvements will be apparent in respect to skin texture and wrinkles. Like superficial peels, the Jessner-35% TCA peel should be used with hydroquinone, a topical retinoid, and broad-spectrum sunscreens. Examples of TCA peels in the market currently are Skin Tech’s Only Touch peels, Easy TCA peels, and Unideep peels. Combination peels can also be bought directly from manufacturers; such manufacturers include Glo Therapeutics and Triplex.

Deep peels

Deep peels, even more so than superficial or medium peels, are a double-edged sword. It inflicts a greater amount of skin damage all the way to the level of the mid-reticular dermis. Traditionally in deep peels, TCA in concentrations over 50% or phenol-containing solutions are used, but the risk for side effects for TCA-based solutions are too great to recommend. Therefore, phenol solutions are currently more popular in the market. Phenol has been in use for the past two centuries in its original purpose as a disinfectant and later on as an anesthetic agent. Initially, there was much resistance to using phenol in skin peels, but studies that demonstrated the mechanism of action of phenol helped lead to the eventual acceptance of the substance in chemical peels. With the use of phenol peels, the phenol dissolves within the epidermal layer within 36 hours, which affects melanin production. With deep peels, the elastotic layer is destroyed, and new collagen fibers appear in the Grenz zone. The length of time for recovery can be a deterrent for many patients because as long as six weeks is needed for regeneration. The area will appear red for weeks and even months. Inform and reassure patients undergoing treatment with phenol peels that the formation of new blood vessels is the cause of such long-term redness. Compared to medium and superficial peels, phenol peels need only one treatment session for long term effects. Skin Tech’s Lip and Eyelid peels are an example of phenol peels.

Deep Peel Combinations

An optimal treatment regimen usually consists of combining a few treatment modalities such as mesotherapy, injectable dermal fillers, botulinum toxin, microdermabrasion, and/or microneedling. Commonly used deep peels consist of phenol and a combination of other different peeling agents. Such peels include the Perfect peel, which consists of glutathione, kojic acid, TCA, retinoic acid, salicylic acid, and phenol; VI Aesthetics’ VI Peel, which has salicylic acid, retinoic acid, TCA, and phenol; and Skin Tech’s Easy Phen Light, which has TCA and phenol.

Conclusion

The field of chemical peels, and aesthetic medications in general, is constantly changing and advancing, and these developments require that you adopt a life-long learning attitude. It is also critical that you have an effective discussion regarding the results of treatment with your patients. You must understand their needs in the first place before commencing treatment, as this can help you deliver ideal outcomes for your patients.

References

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2. Coleman C, Could YOU face peeling off a layer of skin to look younger? Brutal way to beautify is making a comeback, The Mail on Sunday (2014) http://www.dailymail.co.uk/health/article-2619510/Could-YOU-face-peeling-layer-skin-look-younger-Brutal-way-beautify-making-comeback.html#ixzz3tqeEawvr

3. Deprez P, Text Book of Chemical Peels, CRC Press (2007) pp.185-206.

4. Berardesca E, Distante F & Vignoli GP, et al., ‘Alpha hydroxyacids modulate stratum corneum barrier function,’ Br J Dermatol,137(1997) pp.934-8.

5. Van Scott EJ, Yu RJ, ‘Actions of alpha hydroxy acids on skin compartments,’ J Geriat Dermatol 3(1995), pp.19-24.

6. Bauman L & Saghari S, ‘Chemical peels,’ Cosmetic Dermatology: Principles and Practice, 2(New York: 2009).

7. Ditre CM, Griffin TD & Murphy GF ‘Effects of alpha-hydroxy acids on photoaged skin: a pilot clinical histologuic and ultrastructural study,’ J Am Acad Dermatol 34(1996), pp.187-95.

8. Okano Y, Abe Y & Masaki H, et al., ‘Biological effects of glycolic acid on dermal matrix metabolism mediated by dermal fibroblasts and epidermal keratinocytes,’ Exp Dermatol 12(2003), pp.57-63.

9. Bowes L, ‘The science of hydroxy acids: mechanisms of action, types and cosmetic applications’ Journal of Aesthetic Nursing, 2(2013), pp.77-81.

10. Wehr R, Krochmal L, Bagatell F & Ragsdale W, ‘Controlled two centre study of lactate 12% lotion and a petrolatum based cream in patients with xerosis,’ J Am Acad Dermatol, 37(1986), pp.205-9.

11. Davies M, Marks R, ‘Studies on the effect of salicylic acid on normal skin,’ Br J Dermatol 95(1976), pp.187-92.

12. Brody HJ, Monheit GD, Resnik SS, Alt TH, ‘A history of chemical peeling,’ Dermatol Surg, 26(2000), pp.405-9.

13. Rook A, Wilkinson DS, Ebling FJG, ‘Textbook of Dermatology,’ Blackwell Scientific, (Oxford: 1972).

14. CDCP, ‘National Institute for Occupational Safety and Health,’ Resorcinol, (2011), http://tinyurl.com/nnj4qv2

15. Fromage G, ‘Topical retinoids: exploring the mechanisms of action and medical aesthetic applications,’ Journal of Aesthetic Nursing, 2 (2013): pp.68-75.

16. Cucé LC, Bertino MC, Scattone L, Birkenhauer MC, ‘Tretinoin peeling,’ Dermatol Surg, 27(2001), pp.12-4.

17. Safoury OS, Zaki NM, El Nabarawy EA & Farag EA, ‘A study comparing chemical peeling using modified jessner’s solution and 15% trichloroacetic acid versus 15% trichloroacetic acid in the treatment of melisma,’ Indian Journal of Dermatology 54(2009), pp.41-45.

18. Monheit GD, ‘The Jessner’s + TCA peel: a medium-depth chemical peel,’ J Dermatol Surg Oncol, 15(1989), pp.945-50.

19. Ayres S, ;Superficial chemosurgery in treating ageing skin.’ Arch Dermatol 85(1962) pp.385-93.

20. McCollough EG, Longsdon PR, ‘Roenigk H, Roenigk R Dermatologic Surgery: principles and practice,’ Chemical Peeling with Phenol, (Marcel Dekker, New York, 1989), pp.997-1016

21. Roenigk RK & Roenigk HH, ‘Dermatologic Surgery,’ Principle and Practice, (UK: Marcel Decked Ltd 2edn 1996), pp.1147-60.

22. Landau M, ‘Advances in deep chemical peels,’ Dermatol Nurs 17(2005), pp.438-41.

23. Landau M, ‘Deep chemical peels (phenol),’ Colour Atlas of Chemical Peels, (Berlin: 2edn 2012).

24. Petes W, ‘The Chemical Peel,’ Ann Plast Surg, 26(1991) pp.564-71.

25. Green a & Sabherwal Y, Antiaging Benefit Ingredients: AHAs, PHAs, and Bionic Acids (Elevier 2016).

26. Grimes, Pearl E, ‘Jessner’s Solution,’ Color Atlas of Chemical Peels, (Springer Berlin Heidelberg 2012), pp.57-62.

27. Bensimon R, ‘Croton Oil Peels,’ Aesthetic Surgery Journal, 26(2008) http://www.coupureseminars.com/media/docs/CrotonOilPeelsAestheticJournal.pdf

28. AMERICAN SOCIETY OF PLASTIC SURGEONS. 2017 Plastic Surgery Statistics Report. https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf (accessed 1 August 2018).

29. Monheit GD, Chastain MA. Chemical and Mechanical Skin Resurfacing.

The demand for body contouring treatments is at an all-time high: the IMCAS projects that the value of the body contouring and energy devices segment of the global aesthetic medical and surgical market is set to reach 2.3 billion euros in 2018, a substantial increase from its valuation of 1.5 billion euros in 2013. This can be attributed to the constant innovation and development in the industry that has resulted in the recent emergence of treatment modalities that cater to reshaping the body and reducing or eliminating areas of fat that are resistant to diet or exercise.

Traditionally, patients only had the option of excising fat through body contouring surgical procedures, such as brachioplasty, abdominoplasty, or the like in order to achieve their aesthetic goals. However, the available options have expanded considerably since, thereby allowing patients to seek alternative treatments that may be far more suitable for them in terms of price and safety. This article will discuss some of the more recent treatment options available when it comes to contouring the body, how to select patients seeking these treatments, the expected results of each treatment, and its individual side effect profile.

Patients seeking body contouring

Typically, patients looking for body contouring treatments can be roughly grouped into two categories based on the level of expectation of treatment outcomes. The first group generally is more well-informed about the types of treatment, may have tried some of these treatments previously, and have a clear vision of what they would like out of the treatment. These patients are usually more realistic about treatment outcomes. The second group is somewhat less well-informed, so they have more unrealistic expectations on the results they would get from treatment. Furthermore, patients in the second group are less committed to diet and exercise plans and are less likely to complete their treatment courses. This makes managing them more challenging.

Common concerns patients have with their bodies include excess fat, cellulite, or pockets of stubborn fat that do not go away with diet and exercise. As with any aesthetic treatment, body dysmorphic disorder (BDD) is something that should be considered when assessing potential patients. It is especially pertinent in light of the fact that body-contouring treatments are probably the most demanded cosmetic treatment by patients with BDD.

Patient assessment/selection

In order to properly assess and determine a patient’s suitability for treatment with products similar to Belotero, it is important to obtain a complete medical history that includes a patient’s exercise and dietary background in order to identify any problematic lifestyle habits that may need addressing. At this point, it is also worthwhile to conduct an in-depth assessment of the patient’s reasons and expectations for treatment. Usually, patients with unrealistic expectations of the potential treatment outcome can end up unsatisfied or disappointed with the results; therefore, it is important that the pre-treatment information provided to patients is detailed, comprehensive, clear, and realistic. This includes emphasizing the need for repeat treatments and the delayed onset of the final result, as is the case for most non-invasive treatments.

Documentation in the form of pre-treatment photography and volume measurement is important for this process, as results can be easier to discern when comparing before and after pictures. It is also necessary at this stage to rule out any patients with BDD symptoms. To do this, a validated screening questionnaire—such as the Body Dysmorphia Disorder Questionnaire (BDDQ), which has a 94% accuracy rate for identifying this disorder—is particularly useful. Generally, it is better to avoid treating patients with conditions that predispose them to unrealistic expectations, as patients who have such expectations will invariably be unsatisfied with treatment results, and this can lead to patient complaints.

Methods of body contouring

In the past 20 years, there has been advances in the aesthetic medical device sector that have led to the emergence of new body contouring treatments. Many of these treatments include a thermal injury component that acts to selectively induce adipocyte apoptosis, which is programmed cell death. However, newer therapies focus on strategies that are able to selectively target fat cells without the potential side effects associated with heating or cooling tissues for prolonged periods. These will be briefly outlined in the following sections.

Cryolipolysis

Also known as fat freezing, cryolipolysis works because fat cells are triggered to undergo apoptosis when exposed to low temperatures. This trait is selective, as other cells apart from adipocytes are not as susceptible to cooling. Once apoptosis is induced, an inflammatory response occurs, and the dead fat cells are removed by phagocytes. After the inflammatory response has subsided, the end result usually seen is a reduction in volume and the restructuring of the subcutaneous tissue.

Medical devices that stimulate cryolipolysis typically combine freezing with skin surface protection and a vacuum mechanism. This treatment is suitable for all skin types. Side effects are minimal, with post-treatment paraesthesia, bruising, and erythema expected side effects. Pain after treatment is common and can be managed with pain-relieving medications. They often subside on their own with time. Repeat treatments are necessary, with optimal effects conferred after four to six months.

Radiofrequency

Radiofrequency (RF) has been a stalwart modality for a variety of purposes over the past decades. RF treatments use the conversion of radiofrequency waves to heat in order to apply deep tissue and skin heating to induce vasodilation and inflammatory changes so as to bring about dermal thickening and reorganization and the thickening of deeper connective tissue(s). In adipose tissue specifically, heating the adipocyte layer to a temperature of 43°C–45°C stimulates selective apoptosis in fat cells, resulting in volume reduction 3–8 weeks post-RF treatment. Often, multiple sessions are required to achieve the desired results. Short-lived effects of this treatment, which includes erythema, are common and anticipated.

Despite built-in safety mechanisms, such as temperature sensors to prevent overheating of the skin, complications like burns may still occur due to the operator-dependent nature of the instrument. Furthermore, older monopolar RF devices do not evenly penetrate the skin, potentially resulting in the inconsistency of fat breakdown and subsequent irregularities of the surface contour. In this regard, bipolar or multipolar RF handpieces afford better predictability in the penetration depth of RF waves, therefor resulting in more even results. This treatment is associated with short-lived effects, such as erythema.

Low level laser therapy

A minimally invasive body contouring technique that was developed fairly recently, low-level laser therapy uses infrared or near-infrared light exposure to modulate body composition by direct and indirect methods. These methods include inciting changes in the adipocyte metabolism and by changing the levels of leptin, a hormone involved in appetite regulation. The US FDA has approved the use of lasers that use light wavelengths in the range of 532nm–635nm for the purposes of body contouring. Again, this modality requires multiple sessions to obtain optimal effects and has a low-risk side effect profile.

High intensity focused ultrasound

A recent addition to the stable of body contouring therapies, high intensity focus ultrasound was traditionally used in medical aesthetics to tighten and lift the superficial muscular aponeurotic system (SMAS) layer of the face. This technique causes coagulative necrosis (tissue death) of the subcutaneous layer, allowing for new skin growth that is tightened and has less volume. This effect usually take place around 12 weeks after treatment. This technique requires multiple treatment sessions, is suitable for all skin types, and has minimal side effects.

Deoxycholic acid

There has been notable unregulated use of injectable treatments for the reduction of submental fat (double chin) for some time, with a deoxycholic acid preparation for such a treatment only given CE approval in 2012. Deoxycholic acid works to lyse, or dissolve, fat cells when injected in areas containing adipose tissue. After which, a mild inflammatory response in conjunction with phagocytosis will occur and will lead to the permanent reduction of the fullness of treated areas. Its mode of action seems to be selective towards lipid-rich tissue only; hence, the risk of damage to the surrounding tissue(s) appears to be minimal. Furthermore, this treatment does not increase plasma lipid levels. In Europe, a phase III clinical trial examining the treatment of submental fat with a deoxycholic acid preparation called ATX-101 saw promising results, with volume reduction in the submental area, no increase in skin laxity, and minimal reported adverse events. For this treatment, repeat sessions spread over a few weeks are usually necessary for optimal results.

Conclusion

The body contouring sector in the aesthetic medicine market is growing rapidly, with new devices and novel technological platforms being commercialized every year. Careful patient selection is crucial when it comes to body contouring treatments in order to best manage expectations. Determining the best instrumentation for one’s clinical practice will depend on cost, available space, staffing levels, and patient demographics.

References

1.  Statista, Value of global aesthetic medical and surgical market from 2012 to 2018, by segment (in billion euros). Data sourced from IMCAS. https://www.statista.com/statistics/319161/global-aesthetic-medical-and-surgery-market-value-by-segment/

2.  de Brito MJA, Prevalence of body dysmorphic disorder symptoms and body weight concerns in patients seeking abdominoplasty, J Aesthet Surg, (2016) Mar 4;36(3):324-32.

3.  Brohede S, Wingren G, Wijma B Wijma K Validation of the Body Dysmorphic Disorder Questionnaire in a community sample of Swedish women, Psychiatry Res, (2013) Dec 15;210(2):647-52.

4.  Krueger N, Mai SV, Luebberding S, Sadick NS, Cryolipolysis for noninvasive body contouring: clinical efficacy and patient satisfaction Clin Cosmet Investig Dermatol. (2014); 7: 201-205.

5.  Ortiz AE, Avram MM, Noninvasive Body Contouring: Cryolipolysis and Ultrasound Semin Cutan Med Surg (2015) 34(3) 129-33

6.  Avram M.M., and Harry R.S, ‘Cryolipolysis for subcutaneous fat layer reduction’, Lasers in Surgery and Medicine, 41 (10) (2009), p.p. 703-08

7.  Jack DR, Radiofrequency: an important tool in the aesthetic practitioner’s repertoire, Aesthetics journal January (2016).

8.  Royo de la torre J, Moreno-Moraga J, Muñoz E, Cornejo Navarro P Multisource, Phase-controlled Radiofrequency for Treatment of Skin Laxity: Correlation Between Clinical and In-vivo Confocal Microscopy Results and Real-Time Thermal Changes, J Clin Aesthet Dermatol, (2011) Jan; 4(1): 28-35.

9.  Tonks S, ‘Body Contouring and LLLT.’ Aesthetics journal, August (2016).

10.  Shalom A, Wiser I, Brawer S, Azhari H. Safety and tolerability of a focused ultrasound device for treatment of adipose tissue in subjects undergoing abdominoplasty: a placebo-control pilot study. Dermatol Surg, (2013);39(5):744-751.

11.  Rauso R, Salti G, A CE-Marked Drug Used for Localized Adiposity Reduction: A 4-year Experience Aesthet Surg J (2015) 35(7) 850-7

12.  Thuangtong R, Bentow JJ, Knopp K. Tissue-selective effects of injected deoxycholate. Dermatol Surg. (2010);36:899-908.

13.  B Rzany, T Griffiths, P Walker, S Lippert, J McDiarmid, and B Havlickova Reduction of unwanted submental fat with ATX-101 (deoxycholic acid), an adipocytolytic injectable treatment: results from a phase III, randomized, placebo-controlled study Br J Dermatol, (2014) Feb; 170(2): 445-453.

History of lip aesthetics

Lips aesthetics change through the years, with various features and forms favoured by different cultures during different eras for reasons related to cultural beliefs, courtship and social status, and beauty and aesthetic ideals. For example, a study conducted that examined Caucasian fashion models in the late 20th century showed fuller and more anteriorly positioned lips are considered more attractive. Additionally, a study examining changes in the profile of the male model from 1930 for 65 years found significant changes in the appearance of the ideal lip, including an enhanced lip protrusion, increased lip curl and an increase in vermilion display. The desire to achieve this aesthetic ideal, coupled with the increasingly accessible treatments available, have led to a dramatic rise of lip augmentation procedures. In fact, lip augmentation is one the most popular types of aesthetic procedures in demand since the advent of modern dermal fillers.

 The “ideal” lip

While the standards that constitute the ideal lip varies by culture and era (for instance, Western culture tends to favour plump and well-defined lips, there are certain common features that should be considered, including fullness and volume, correct proportion between upper and lower lips, and a well-defined vermilion border.

In addition to the above, the lips should also be aesthetically harmonious and in proportion with the rest of the face. Sexual dimorphism must also be considered—men have larger mouth widths, total lip height, lip volumes and philtrum widths than women. As mentioned previously, the aesthetic industry has experienced advances in technology that has resulted in a boom in the number of temporary, semi-permanent and permanent implants and fillers. However, with the increase in available treatments, practitioners should also be expected to be up-to-date with the current knowledge of lip anatomy, terminology, assessment and aesthetics in order to fully utilize these products and techniques successfully.

Lip anatomy

The lips cover the entrance to the oral cavity, and serve to influence mastication and phonation, as well as affect facial expression to facilitate nonverbal language. The upper lip extends from the base of the nose superiorly to the free edge of the vermilion border interiorly and to the nasolabial folds laterally. Hallmarks of the upper lip include the philtrum (a vertical groove in the middle area of the upper lip) and its pillars. The upper lip takes the shape of a “flattened M” in this area, commonly referred to as “Cupid’s Bow”. The vermilion is the red portion of the lip and consists of a “dry” and “wet” section. It is demarcated from the surrounding skin by the vermillion border, a rim of paler skin. The upper and lower lips join together at the oral commissures which form the corners of the mouth.

Assessing lips

The patient should be examined in their natural sitting position, in order to assess the lips in an upright manner. The lips should also be examined while they are relaxed and when they are in motion. This is to assess the natural position of the lips, as well as symmetry of muscle movement, and to check for action and hyperactivity of muscle groups. All of these aspects will be discussed further in the following sections. Lip position will be affected by changes in the positioning of the teeth and alveolar, both of which tends to increase in retrusion relative to the chin and bony facial plane with age. However, it is important to keep in mind that the lips should only be one element in what makes a smile attractive. Some of the other factors that determine the lower face and smile aesthetic include skeletal components, like the position of the jawbone relative to the maxilla; soft tissue factors such as the prominence of the chin and nose, as well as lip and soft tissue morphology; and factors related to the dentitions, gingivae and alveolar bone, such as crown length and width, incisor crown angulation, the incisal plane, the midline, gingival margin, open gingival embrasure, and gingiva-to-lip distance.

Clinical evaluation

Lip assessment is best performed methodically for optimal treatment outcomes. An example of a systematic lip evaluation includes assessing the following parameters:

•  Lip height: The characteristics that should be measured in order to assess lip height include the upper and lower lips, lower lip/chin height, ratio of upper lip to lower lip/chin height, interlabial gap (the gaps between the lips at rest), and the upper and lower lip vermilion height.

•  Lip thickness: An important consideration when assessing the lips as it is directly affects lips prominence and is influenced by ethnic background. Thinner lips are more capable of following the teeth and jaw movements, which makes any loss of movement or other aesthetic effects more apparent.

•  Lip contour: The contour should be assess in both front and side views to evaluate the curvature, curl and inclination of the lip. The lips curl is affected by the position and strength of dentoskeletal support of the lips. One such instance is the occurrence of a flat upper lip due to maxillary dentoalveolar retrusion.

•  Lip posture: The posture of the lip should be evaluated when the lips are at rest (relaxed with normal muscle tone), in a natural head position in repose. Also assess lip seal (ability of the lips to close) at this point. In certain cases, lip seal is not achieved when the lips are at rest, due to particular characteristics of the lip posture, and adaptive postures are used instead. In these cases, the patient is undergoing continuous contraction of circumoral musculature.

•  Lip inclination: As mentioned before, support of the lips is dentoalveolar. Thus, the structure of the underlying bone and teeth will greatly influence how the lips will look. This is particularly pertinent when it comes to lip inclination, where protrusion or retrusion of the upper and lower incisors will change the inclination of the lips accordingly. For instance, impingement of the upper incisor teeth onto the lower teeth can result in eversion of the lower lip.

•  Lip prominence: From the side, assess the prominence of the lips in relation to the prominence of the nose and chin. Lip prominence will vary according to skeletal factors, soft tissue factors such as lip thickness, or dentoalveolar factors such as position of the incisor teeth.

•  Lip activity and function: Lip activity is assessed in terms of hyper- (high activity or overactivity) or hypo- (underactive, or low muscle toned, lips) tonic lips. Hypotonic lips appear flaccid and may be overstretched to attain lip seal. This feature is typical in individuals with an increased lower-face height. Hypertonic lips, on the other hand, may retrocline the lower incisor teeth (in the case of a hypertonic lower lip), or result in a gummy smile (due to a highly toned upper lip levator muscle).

Conclusion

The importance of the practitioner’s knowledge and understanding of the aging lip and perioral region cannot be overstated when it comes to the aesthetic treatment of lips. The patient should also be made fully aware of the considerations that go into treating the lips. In doing so, successful and satisfactory treatment results can be achieved.