Highlights from the International Scientific Meeting on Cosmetic Dermatology
The perceptions of beauty differ around the world, ranging from the “long neck” Pa Dong tribe along the borders of Thailand and Burma, the blue tattoos among the Maori, “lotus feet” during olden day China, to the “thin” culture in the US. For years, women from around the world have struggled to fit into the Western standard of beauty, as witnessed by the popularity of double eyelid (blepharoplasty) surgeries and whitening creams for fairer skin.
The opportunities in Asia’s aesthetics market have skyrocketed as Asians become wealthier and more concerned with their looks. By the year 2021, the global medical tourism market, which is a key driver of the aesthetics medical market, is predicted to surpass $48 billion, with the Asian market valued at $17 billion. Korea, Taiwan, and Thailand were among the top medical tourism countries for cosmetic procedures in 2017.1
According to the International Association for Physicians in Aesthetic Medicine (IAPAM), by the end of 2018, the number of nonsurgical aesthetic procedures performed increased by 461% since 1997. The use of botulinum toxin has gone up by 600%, a 205% increase was observed in soft tissue filler use, and laser skin resurfacing is now 198% more popular. Ten percent of patients were men, leading to a 106% increase in the number of men that opted for aesthetic procedures in the last 20 years.2
Treatment trends in Asia are also evolving. While the majority of Asian facial aesthetics patients are female, the proportion of males seeking treatment has increased from 12% in 2005–2009 to 19% in 2010–2014. The proportion of younger Asian patients (aged 18–40 years) who present with aesthetic concerns has increased slightly from 44% to 48% in the same time frame. This could be due to an increased sense of self identity and pride, and younger patients having more economic power, aspiration, and social independence.3
Even though aesthetic standards have changed over the years due to the influence of Western culture, Asian women still want to preserve their ethnic identities by refining their Asian features rather than totally Westernizing their appearance. Compared with Caucasian women, East Asian women prefer a small, delicate, and less robust face, lower position of double eyelid, more obtuse nasofrontal angle, rounder nose tip, smaller tip projection, and slightly more retruded mandibular profile.4
In fact, cosmetic surgery of ethnic features plays an important role in understanding female identity in the Asian context.5 Plastic surgeons have begun to develop techniques to preserve ethnic characteristics and retain the Asian identity. Together with a thorough knowledge of changes that occur in ageing, plastic surgeons are now able to choose the best protocol for rejuvenating the ageing face by combining a variety of face lift operations, thread-lift injection of fat or fillers, botulinum toxin, lasers, and mesotherapy to get optimum results.6
The combination of techniques in aesthetic intervention is discussed in detail in various consensus around the world. These include consensus by the Asian Facial Aesthetics Expert Consensus Group,7 Global Aesthetics Consensus Group,8 Carruthers et al,9 and Chao et al.10 These groups agreed that the structural and anatomical features specific to the Asian face as well as differences from Western populations in facial ageing necessitate unique aesthetic treatment strategies.
Some of the treatment strategies that are currently available include thread lift for facial rejuvenation such as Happy LiftTM (Revitalizing) threads, hyaluronic acid (HA) dermal fillers such as SkinfillTM plus, microneedling, and platelet rich plasma. Happy LiftTM (Revitalizing) is effective in mid-face lifting and rejuvenation of the superior cervical region of the face and neck.11 SkinfillTM plus is useful in treatment of defects related to ageing such as wrinkles, loss of volume, and treatment of wrinkles around the lips.12
The future looks promising with the potential of stem cell use in skin repair, and a product formulated using the stem cells from the umbilical cord lining of the New Zealand red deer has recently been launched. Other new trends to gear up for in 2019 are cosmetic dermatology for men (particularly specific chemical peels for their skin type), 4D digital facial mapping, a longer lasting botulinum toxin, ultrasonic liposculpture, no-peel peels, as well as the Dermapen.
Happy LiftTM (Revitalizing) threads are a range of absorbable, monofilament, suspension-barbed threads of synthetic origin (poly-L-lactic acid and caprolactone). This type of barbed suture is a good alternative to more invasive procedures where facial tissue repositioning is required. Happy LiftTM (Revitalizing) threads allow an immediate and long-term facial reshaping, a natural outcome, and a biostimulatory action on collagen production.11
Different techniques are suggested for the use of Happy LiftTM (Revitalizing) threads to provide safe, effective reshaping of the frames and curves of the face. The key strategies that need to be taken into account to achieve these outcomes are:
• Correct analysis of patient’s needs and features
• Accurate assessment of patient’s anatomy and ageing
• Accurate treatment plan
• Sterile and clean procedure
• Patient follow-up and proper postoperative instructions to reduce complications
Before the deployment of the threads it is necessary to identify the safety lines of the treatment area, the entry and exit points of the guiding needle, and the path of the threads along the reshaping lines.
Happy LiftTM (Revitalizing) threads are convergent and bidirectional.11 The effect of the threads after insertion helps with the accumulation of soft tissue towards the central part of the thread (Figure 1).
Happy LiftTM (Revitalizing) double needle threads come in 12 or 23 cm length with straight needle at the ends. Happy LiftTM (Revitalizing) free floating threads are 12 or 23 cm in length and are indicated in the repositioning of the malar/submalar area. It is important to remember that the insertion layer for the threads has to be subcutaneous (supra-superficial musculoaponeurotic system [SMAS] plane), not only for the threads to work on the tissues,11 but also to avoid pain and bleeding due to insertion that is too deep, as well as to avoid visibility of the thread due to insertion that is too superficial (Figure 2).
The various techniques for the Happy LiftTM (Revitalizing) double needle threads are:
• Jawline Reshaping (JR) Technique – to reshape the frame of the jawline, providing a non-invasive thread lifting of the lower face.
• Malar Reshaping (MR) Technique – to reshape facial frame, lifting in an upper and more lateral position the superficial fat compartment of malar and cheekbone area.
• Lateral Reshaping (LR) Technique – to reshape facial frame, lifting in an upper and more lateral position the superficial fat compartment of the cheek. This technique is more indicated in Caucasian patients.
• Oval Reshaping (OR) V Vertical Technique – to reshape facial frame, making face more oval and lifting the mid- and lower-face superficial cheek fat compartment.
• Oval Reshaping (OR) H Technique – to vertically reshape the facial frame, providing non-invasive thread lifting.
The Happy LiftTM (Revitalizing) free floating thread techniques are the STR-2 and STR-3 techniques.
• STR-2 Technique – Once the target area to reshape has been identified, the reshaping lines are determined. Once the areas of the face are anaesthetized and disinfected, the cannula needle is inserted along the course of R1 through IN1 and OUT1. The thread is inserted into the needle and placed in an adequate position (ie, the central part of the target area [TA]). The medial side of the thread is kept blocked between two fingers. The cannula needle is then removed. The same steps are repeated for R2. The surgeon will then relocate the volume by pulling the extremities of the threads and lifting the malar soft tissues. The course of the thread will then be massaged in order to open the barbs and allow its positioning. The thread should then be cut close to the skin. The area is massaged, and sterile strips are applied. Figure 3 illustrates an example of how the threads are measured to be cut in correspondence to the skin.
• STR-3 Technique – The steps for this technique are similar to STR-2, except with an additional reshaping line (R3, from IN3 to OUT3).
It is important to note that the treatment plan has to be adapted to the individual patient’s anatomy, face morphology, and needs. Before the procedure, the asymmetry, thickness, and quality of the subcutaneous tissue should be taken into account to avoid complications. Most side effects and complications associated with thread lift procedures can be reduced and prevented with the appropriate knowledge of anatomy, proper patient analysis, sterile procedure, correct insertion, and proper postoperative instructions.11
In conclusion, the minimally invasive face lifting by Happy LiftTM (Revitalizing) threads is a relatively safe procedure. The few fundamental techniques should be followed and once mastered, it is a simple, fast, and effective procedure. Patient satisfaction is also good due to the short duration of the procedure and evident but natural outcomes.
A 33-year-old female with a chubby face requested for recontouring of the face. After undergoing the OR-H procedure with Happy LiftTM (Revitalizing) double needle, there was improvement in her facial contour by 9 months. Her face appeared slimmer even though her body mass index had not changed.
A 32-year-old male patient requesting for facial recontouring was recommended to undergo Happy LiftTM (Revitalizing) double needle JR technique, coupled with SkinfillTM plus dermal filler 2 mL. The result was satisfactory, with improved facial contouring after 7 days. In conclusion, the combination treatment of Happy LiftTM (Revitalizing) double needle with SkinfillTM plus dermal filler should be considered for suitable patients to increase patient satisfaction.
A 35-year-old female in need of facial recontouring underwent combination technique of Happy LiftTM (Revitalizing) double needle JR technique and SkinfillTM plus dermal filler 2 mL. After 7 days, the facial contour was much improved. Patient satisfaction was also reported.
A 37-year-old female presented with displacement of middle cheek and nasolabial fat compartment. In addition, she also requested to treat her double chin and superior jowl area. She was treated with Happy LiftTM (Revitalizing) double needle JR and MR techniques, using double needle 12 cm, 2.0 USP calibre, bidirectional threads. Six months later there was good improvement in all the areas treated.
A 50-year-old female requested for treatment in the nasolabial fold. She was treated with Happy LiftTM (Revitalizing) double needle using the MR technique. Three months later, she showed improvement in the area treated.
An introduction to stem cells
Stem cells are precursor cells that are able to differentiate into different cell lineages. The three main groups include haematopoietic stem cells, epithelial stem cells, and mesenchymal stem cells.13 The umbilical cord is an attractive source of stem cells; both mesenchymal and epithelial stem cells can be isolated from the umbilical cord lining membrane. These have been known to regenerate mesenchymal tissue such as bone, cartilage, and cardiac and striated muscle, as well as epithelial tissue such as skin, cornea, and liver.14
The number of cord lining epithelial cells and mesenchymal cells that can be explanted is enormous; each square centimetre of umbilical cord amniotic membrane normally yields 20 million epithelial cells and 20 million mesenchymal cells. An average cord of 330 cm2 yields 6 billion epithelial cells and 6 billion mesenchymal cells at the first growth generation (passage 1).14 Growth of the cells up to 30 generations has been achieved, yielding thus 6 billion30 cells of each type.
Stem cells in cosmeceutical practice
The serum of CL-MSC conditioned media works well in the restoration of skin fullness in the glabellar crease area, reduction of cheek pigment, and restoration of nasojugal fullness.
In in vitro tests, aged keratinocytes and fibroblasts were cultured in different concentrations of CL-MSC conditioned media to assess cell growth and proliferation at different time intervals. The skin cells responded significantly to CL-MSC conditioned media exposure with increased epidermal proliferation and cell turnover compared with control (Figure 4). CL-MSC conditioned media exposure also resulted in accelerated rapid closure of a pipette tip scratch wound, as well as increased epidermal thickness and dermal fullness.15
Compared with human foreskin fibroblast conditioned media, the CL-MSC also showed more accelerated healing of dermal fibroblasts after wound infliction (pipette tip scratch). In addition, the CL-MSC conditioned media increased the expression of glycosaminoglycan and extracellular matrix proteins (Figures 5 and 6).16
Due to the encouraging results, the CL-MSC conditioned media was then applied for cosmeceutical purposes. In a few clinical observations in Asian and Caucasian patients after laser treatment, the CL-MSC conditioned media showed good results, which included:
• Reduction of post-laser inflammation
• Rapid resolution of erythema
• Rapid resolution of swelling
• Increased patient comfort
• Decreased patient downtime
• Optimization of laser results
In conclusion, the CL-MSC conditioned media shows great potential in wound healing as well as in skin rejuvenation.
Role of antioxidants in dermatitis:
A new treatment strategy
Free radical production in the cell is inevitable. In normal conditions, there is an equilibrium between free radical and reactive oxygen species (ROS) formation and endogenous antioxidant defence mechanisms. However, when this balance is disturbed, it can produce oxidative stress, which leads to cellular damage.17
Patients suffering from atopic dermatitis (AD) have been shown to be more prone to damage caused by ROS or oxidants compared with normal healthy individuals. There is an increase in oxidants such as malondialdehyde (a stable end product of fatty acid peroxidation) and a decrease of enzymatic and non-enzymatic antioxidants in AD patients. These are important contributing factors in the pathogenesis of AD.17
To better treat and prevent AD, there has to be a better understanding of its pathogenesis. There is an interplay of factors, including barrier dysfunction, immunological response, and environmental factors.18 Defects in skin barrier include filaggrin deficiency, ceramide reduction, and over-desquamation. Immunological factors include the key roles of T cells, dendritic cells, innate lymphoid cells, mast cells, and eosinophils. Examples of environmental factors are smoking, climate, and the role of skin microbiota such as Staphylococcus aureus.18
In addition, there is now evidence that oxidative stress also plays a role in the development and maintenance of AD. Oxidative stress can directly cause damage to cell membranes, DNA, and organelles, resulting in skin barrier defects. It also enhances dermal inflammation and enables infection by microbial pathogens.19
Since oxidative stress has been found to be involved in skin diseases such as dermatitis, it is postulated that antioxidative strategies can serve as effective and easy methods for improving these conditions.20
New skin care options are now available for the management of dermatitis and one of them is prescription emollient devices, also known as prescription barrier repair creams. This is a new class of moisturizing agents that target specific defects in skin barrier function. They contain anti-inflammatory agents and antioxidants, among other ingredients.
Products that incorporate antioxidants have the ability to improve the permeability barrier by stimulating epidermal differentiation, lipid production, antimicrobial defence, and antioxidation capacity.21
For instance, studies on the effects of the antioxidant furfuryl palmitate have shown that these products can represent a valid aid in the treatment of a range of skin disorders, such as atopic and seborrheic dermatitis. Products containing antioxidants can constitute a valuable alternative to topical corticosteroids in mild-medium severity skin disorders, especially when there is a need to avoid a pharmacologic agent, such as in paediatric patients, intolerant subjects, or atopic patients. Moreover, these antioxidants can also act in synergy with other topical or systemic treatments, as well as pharmacologic agents, to promote faster recovery of the normal skin condition, reducing inflammation and restoring the skin barrier.22
RelizemaTM is one of the new generation emollients that is enriched with antioxidants. The antioxidant active substances in RelizemaTM are superoxidodismutase, beta glycyrrethinic acid, and the new patented molecule furfuryl palmitate. The action of the antioxidants is supplemented by the presence of skin barrier repairing agents such as phytosphingosine and phytosterols. The formulation provides double action effects to the skin: anti-inflammatory effect as well as skin barrier repair (protection).
The RelizemaTM range of products include creams, lotions, bath oil, cleansers, intimate sprays, and baby care. These products are beneficial in AD, diaper dermatitis, dermatitis of the intimate parts, and dry and sensitive skin.
Besides dermatitis, there are also new treatment options for the management of hyperpigmentation.
New treatment options for hyperpigmentation
Common causes of facial hyperpigmentation include melasma, sun and age-related hyperpigmentation (eg, freckles, lentigines), post-inflammatory (eg, acne), post-procedural, and hori naevus.23,24 While treatments such as creams, chemical peels, intense pulsed light, and lasers may work for hyperpigmentation, not all are effective for treating melasma.
Established topical treatments for melasma include hydroquinone, tretinoin, and azelaic acid.25 However, treatments such as hydroquinone may have side effects; hence there is a need for alternative agents. So far, other topical therapies may contain retinol, arbutin, kojic acid, licorice extract, oleosin, vitamin C, niacinamide, soybean extract, and N-acetyl glucosamine.
An effective cosmeceutical product usually contains multiple active agents and its efficacy is not tested based on a single agent alone. In fact, positive clinical outcome is likely due to synergistic action of multiple agents.
A new range of depigmentation formulations has undergone preliminary clinical study on 100 melasma patients.26 The RELIFE Pigment SolutionTM Program includes a day cream, night cream, and a cleanser that prepares the skin for the treatment products (Table 1).
Results from the study showed that there was a gradual reduction in the modified Melasma Area and Severity Index (mMASI) score measured at three different time points, namely, baseline, 45 days, and 90 days. The reduction was found to be highly statistically significant (p<0.001) (Figure 7).26
Furthermore, there was lightening effect on the three kinds of melasma: epidermal, dermal, and mixed.
After 90 days of treatment, almost half of the patients showed a marked or very strong improvement, as seen in the investigator global assessment (IGA) indexes. These results were statistically significant compared with the assessment at 45 days (p<0.00001) (Figure 8).26
In addition, physicians assessed that in almost 80% of patients, the degree of tolerability was very high (Figure 9).26
In conclusion, the preliminary clinical study results showed that the RELIFE Pigment SolutionTM Program is an effective formulation for the management of hyperpigmentation and melasma.