The Chronicle of Cosmetic Medicine & Surgery Spring 2014

CosMed_Spring2014_05-28-14_cosmetic_dermatology_summer-2013_07-19-13.qxd 5/28/2014 10:29 AM Page 1

DYSPORT ® · D I S C O V E R ·

DYSPORT ®

D I S C O V E R

Onset of effect was reported as soon as 24 hours, with a median time of 3 days to onset of treatment response1

*

†

Signi� cant treatment success‡ – as assessed by both investigators and patients, respectively – was reported at Day 30 through Day 120 vs. placebo1§

With demonstrated FAST-ACTING and LONG-LASTING results

NEW botulinum toxin – Now available in Canada

Dysport (botulinum toxin type A) is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines in adult patients <65 years of age.1

SERIOUS WARNINGS AND PRECAUTIONS:1

The term “Unit” upon which dosing is based is a speci� c measurement of toxin activity that is unique to Ipsen’s formulation of botulinum toxin type A. Therefore, the units used to describe Dysport activity are different from those used to describe that of other botulinum toxin preparations and the units representing Dysport activity are not interchangeable with other products. Dysport should only be administered by physicians with the appropriate quali� cations and experience in the treatment and the use of required equipment. Follow the recommended dosage and frequency of administration for Dysport.

Dysport is contraindicated in patients:1 who are hypersensitive to botulinum toxin type A or to any ingredient in the formulation or component of the container;

with infection at the proposed injection sites; and

known to be allergic to cow’s milk protein. (Note that, as lactose intolerance is a gastrointestinal condition, the symptoms of lactose intolerance are not expected to be seen after injections of drugs containing lactose.)

In clinical studies, the most frequently reported adverse events (≥3%) were nasopharyngitis (6%), headache (5%), injection site pain (3%), upper respiratory tract infection (3%), and sinusitis (3%).1

* The � rst diary day (Days 1–7) that a patient responded “yes” to the question “Since being injected, have you noticed any effect on the appearance of your glabellar lines?”.

† A score of none (0) or mild (1) using the investigator’s assessment at maximum frown at Day 14 (Visit 2) OR a score of no wrinkles (0) or mild wrinkles (1) using the patient self-assessment at maximum frown at Day 14.

‡ Success was de� ned as post-treatment glabellar line severity of none or mild (from moderate or severe) on Day 30 at maximum frown (1+ grade improvement).1

§ Results of a 6-month, single-dose, double-blind, multicentre, randomized, placebo-controlled study (n=158) in which 105 previously untreated patients received 50 units (U) of Dysport administered in 5 aliquots of 10 U/0.05 mL, and 53 previously untreated patients received placebo.1

1 PrDysport™ Product Monograph. Medicis Aesthetics Canada Ltd. June 11, 2012.2 Ipsen Global Regulatory Group. World-wide Marketing Authorization for PSUR(s). January 2011. Data on � le, Medicis

Pharmaceutical Corporation.3 Aesthetic BoNT-A competitive analysis in top 6 European countries. 2011. Data on � le. Medicis Pharmaceutical Corporation.

The Dysport trademark is used under license. All other trademarks are the property of their respective owners. Unless otherwise indicated, all trademarks are property of the Valeant family of companies.

With demonstrated

24hrs

DSPCA 14-013

Dysport

Dysport

Dysport

Dysport

Available in 57 countries – leading the market in both the United Kingdom and Poland2,3

Why wait? Learn more at ValeantCanada.ca today


From the editors Dr. Michael J. Weinberg on whether cosmetic surgery is best undertakenafter learning reconstructive surgery ..............................................................................................4

Thinking like a businessman? Dr. Eric Swanson argues for a return to a tradi-tional model: ‘Treat patients well and they will beat a path to your door’ ........................................6

Cosmetic Update: On the leading edge of research, discoveries and new clinical findings in aesthetic medicine. Complications for obese reduction-mammaplasty patients, &c. 10

Cosmetic Medicine 2014: Growing experience has taught Canadian clinicians whotreat patients with fillers that adhering to the principle of ‘less is more’ is a good approach ..........12

Bimatoprost effective for growing eyelashes Dr. Jean Carruthersexplains the aesthetic effect of a medicine developed as glaucoma therapy ..................................19

Managing patient expectations and outcomes Tools such as FACE-Qcan be useful measuring instruments of patient satisfaction in facial surgery ................................20

Age perception An objective study finds cosmetic procedures reduce an average of 3.1years from patients’ appearance................................................................................................21

Pregnant or post-partum women: Dr. Mary Maloney says a checklist is essen-tial for dermatologic or cosmetic procedures on this cohort ........................................................23

Body contouring Increased demand follows ‘explosive’ growth of bariatric surgery proce-dures, according to Dr. Jonathan Toy ....................................................................................25

Treating the Cosmetic Patient ‘Taking herbal supplements?’ That’s the questionphysicians sometimes forget to ask ............................................................................................26

Published four times annually by the proprietor, Chronicle Infor mation Resources Ltd., from offices at 555 Burnhamthorpe Rd., Suite 306, Tor onto, Ont. M9C 2Y3Canada. Tele phone: 416.916.2476; Fax 416.352.6199.E-mail: health@chroni cle.orgContents © Chronicle Information Resources Ltd, 2014,except where noted. All rights reserved worldwide. ThePublisher prohibits reproduction in any form, including print,broadcast, and electronic, without written permission. Printed in Canada.Subscriptions: $59.95 per year in Canada, $79.95 per yearin all other countries, in Canadian or US funds. Single copies:$7.95 per issue. Subscriptions and single copies are subjectto 13% HST.Canada Post Canadian Publications Mail Sales ProductAgreement Number 40016917. Please forward all correspon-dence on circulation matters to: Circulation Manager, DentalChronicle, 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont.M9C 2Y3 Canada.E-mail: [email protected] ISSN 1927-4955 Cover image: © Luba V Nel | Dreamstime Photos

Since 1995, Ideas in the Service of Medicine. Publishers of: The Chronicle of Skin & Allergy, The Chronicle of Neurology & Psychiatry,The Chronicle of Healthcare Marketing, Best Practices Chronicle, healthminute.tv, and Linacre’s Books

EditorsSheetal Sapra, Oakville, Ont.

Nowell Solish, Toronto

Guest EditorMichael J. Weinberg, Toronto

National Editorial Board

Sheldon V. Pollack, Toronto (Chairman)

Scott Barr, Sudbury, Ont.

Arie Benchetrit, Montreal

Vince Bertucci, Woodbridge, Ont.

Yves Hébert, Montreal

Frances Jang, Vancouver

Julie Khanna, Oakville, Ont.Mark Lupin, VancouverMathew Mosher, Vancouver

W. Stuart Maddin, Vancouver

William McGillivray, VancouverKent Remington, Calgary

Jason K. Rivers, Vancouver

Arthur Swift, Montreal

Jean-François Tremblay, Montreal

Fred Weksberg, Toronto

Industry AdvisorsAnn Kaplan, iFinance, Toronto

Roxane Chabot, RBC Consultants,Montreal/Miami

Publisher Mitchell Shannon

Editorial DirectorR. Allan RyanSenior Associate EditorLynn Bradshaw

Assistant EditorsJohn Evans

Emily Innes

Sales & Marketing Sandi Leckie, RNProduction & CirculationCathy Dusome

ComptrollerRose Arcierowww.chronicle.cawww.twitter.com/[email protected]

DYSPORT ® · D I S C O V E R ·

Onset of effect was reported as soon as 24 hours, with a median time of 3 days to onset of treatment response1

*

†

Signi� cant treatment success‡ – as assessed by both investigators and patients, respectively – was reported at Day 30 through Day 120 vs. placebo1§

With demonstrated FAST-ACTING and LONG-LASTING results

NEW botulinum toxin – Now available in Canada

Dysport (botulinum toxin type A) is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines in adult patients <65 years of age.1

SERIOUS WARNINGS AND PRECAUTIONS:1

The term “Unit” upon which dosing is based is a speci� c measurement of toxin activity that is unique to Ipsen’s formulation of botulinum toxin type A. Therefore, the units used to describe Dysport activity are different from those used to describe that of other botulinum toxin preparations and the units representing Dysport activity are not interchangeable with other products. Dysport should only be administered by physicians with the appropriate quali� cations and experience in the treatment and the use of required equipment. Follow the recommended dosage and frequency of administration for Dysport.

Dysport is contraindicated in patients:1 who are hypersensitive to botulinum toxin type A or to any ingredient in the formulation or component of the container;

with infection at the proposed injection sites; and

known to be allergic to cow’s milk protein. (Note that, as lactose intolerance is a gastrointestinal condition, the symptoms of lactose intolerance are not expected to be seen after injections of drugs containing lactose.)

In clinical studies, the most frequently reported adverse events (≥3%) were nasopharyngitis (6%), headache (5%), injection site pain (3%), upper respiratory tract infection (3%), and sinusitis (3%).1

* The � rst diary day (Days 1–7) that a patient responded “yes” to the question “Since being injected, have you noticed any effect on the appearance of your glabellar lines?”.

† A score of none (0) or mild (1) using the investigator’s assessment at maximum frown at Day 14 (Visit 2) OR a score of no wrinkles (0) or mild wrinkles (1) using the patient self-assessment at maximum frown at Day 14.

‡ Success was de� ned as post-treatment glabellar line severity of none or mild (from moderate or severe) on Day 30 at maximum frown (1+ grade improvement).1

§ Results of a 6-month, single-dose, double-blind, multicentre, randomized, placebo-controlled study (n=158) in which 105 previously untreated patients received 50 units (U) of Dysport administered in 5 aliquots of 10 U/0.05 mL, and 53 previously untreated patients received placebo.1

1 PrDysport™ Product Monograph. Medicis Aesthetics Canada Ltd. June 11, 2012.2 Ipsen Global Regulatory Group. World-wide Marketing Authorization for PSUR(s). January 2011. Data on � le, Medicis

Pharmaceutical Corporation.3 Aesthetic BoNT-A competitive analysis in top 6 European countries. 2011. Data on � le. Medicis Pharmaceutical Corporation.

The Dysport trademark is used under license. All other trademarks are the property of their respective owners. Unless otherwise indicated, all trademarks are property of the Valeant family of companies.

24hrs

DSPCA 14-013

Dysport

Dysport

Dysport

Dysport

Available in 57 countries – leading the market in both the United Kingdom and Poland2,3

Why wait? Learn more at ValeantCanada.ca today


4 The Chronicle of Cosmetic Medicine + Surgery

It is a privilege to write the guest editorial forthis issue. The ChronICle of CosmeTIC

medICIne + surgery is a new initiative whichfills a niche in the cosmetic medicine and sur-gery market. showcasing all the excellentwork done by Canadian medical and surgicalspecialists in the field, The ChronICle servesto foster collaboration between the medicaland surgical members and among those of uswith varying areas of expertise within eachdiscipline.

highlights in this issue include the sur-vey by Dr. Jugpal Arneja on plastic sur-gery practices in Canada which revealed that amajority of plastic surgeons have significantreconstructive practices at the start of theircareers, and that this is maintained well intotheir more senior years (see page 27). further,the study found that the transition to a cosmet-ic practice may be happening earlier in theunited states than in Canada, leading theauthors to theorize that this may be due topoor reimbursement for reconstructive work inthe u.s.

Achieving a balance between reconstruc-tive surgery or medical dermatology and cos-metic practice is a significant issue for derma-tologists and plastic surgeons. universalhealth care is a pillar on which social andcommunity support rests in this great countrywe live in. Consequently, I was glad to seethat a significant percentage of plastic sur-geons in Canada continue to maintain some

aspect of reconstructive practice. In my view,the transition to cosmetic surgical practice islikely best undertaken after some experiencein reconstructive surgery, and some experi-ence in understanding patients and theirexpectations.

unfortunately, in the new medical envi-ronment, in which many new graduates willstruggle to find hospital jobs, we may find anincreasing number of residents going directlyinto cosmetic medicine. I am not convincedthat this is the best path, both for surgeons,and for patients. my hope is that physicianswill continue to maintain some balance, inthe interests of promoting excellence in ourfield, ensuring patients receive our full sup-port, and also in the hope that future surgeonswill have the benefit of the rich and variedcareer that those that came before them haveenjoyed.

I found the report on Dr. PeterAdamson’s discussion of facial rejuvenationand attractiveness very interesting. I commenddr. Adamson on his diligent surgical studywhich showed a range of longevity in rejuve-nation results from three to seven years.Previously the general teaching has been—andthe public has come to expect—a five to 10year span. I have never thought that 10 yearswas typically achievable, nor necessarilysomething desirable to strive for, as I agreewith dr. Adamson that people prefer a morenatural look.

Commentaryand opinion oncurrent topics of interest in aesthetic medicine

Cosmetic surgery: best undertaken after learning reconstructiven Dr. Michael J. Weinberg, TO R O N TO

P L A S T I C S U R G E O N

Your feedback, please: The editors of The Chronicle of Cosmetic Medicine + Surgeryinvite your comments concerning the articles in this publication, on issues of current interestin the practice of aesthetic medicine, and on matters at large. Write us at:[email protected]


Volume 4 Number 1 5

Over-correction in the interests of offer-ing a more long-lasting result can push usinto the realm of the very unnatural or “done”look that the public increasingly finds unat-tractive and fears. However, while modest,natural looking correction may be desirable,it behooves us to carefully manage the expec-tations of our patients. The attractivenessfinding was surprising. I am not sure that Iagree with his explanation and I think thatthis warrants further investigation as patientsreally do want to look more attractive afterour treatments. It would be great to see thisstudy repeated after non-surgical proceduresor injectible face lifts.

The article on commercialization in plas-tic surgery brings up some important points.The piece focuses mostly on the restrictionsplaced on surgeons by big corporations in theU.S., however, some of the principlesaddressed can be applied to our Canadianpractices. We are fortunate in Canada not tohave the challenges of dealing with HMOs,but tight hospital budgets and rising expensesfor private facilities exert their own uniquepressures.

Out of the grip of greedTemptations are significant to work from theproduct backwards, rather than starting withthe patient. Evidence of questionable respons-es to the pressures we face can be seen inincreasingly aggressive marketing practices,early adoption of unproven techniques inorder to be the “first and most fashionable,”and unproven claims of efficacy for newproducts, just to name a few. My dad oncetold me that I would stay out of the grip ofgreed if I went to work everyday and didn't

think about how much money I was makingor needed to make. These words from a sea-soned surgeon are indeed wise, especially inthese challenging and highly competitive fis-cal times.

Finally, I thoroughly enjoyed the pieceon looking forward to 2014. Kudos to Dr.Vince Bertucci, whose insights I havealways appreciated. It’s always good tohave newer and better tools for our trade.Just as we have been fortunate in the surgi-cal sphere to see a huge range of breastimplants become available, expanding theoptions and improving the outcomes for ourbreast augmentation patients, so too we nowsee the same great expanse in the filler mar-ket.

I agree that Volbella and Voluma are twosafe, versatile new products that offer advan-tages to previous fillers. The ideal durationfor a product has not been established, andwe are still haunted by the complications ofprevious permanent fillers.

I think that the non-invasive body con-touring market is a huge potential market, butthe fat cell is proving to be a tough adversary.Hence, the current early generation machinesare not yielding results that are consistentenough for wide adoption, and will requiresignificant improvement if we are to attainthe levels of patient satisfaction all of us aimfor.

I hope that you too will enjoy the highlyinformative, current and diverse articles in thisedition of THE CHRONICLE, as I have. We wel-come comments.

Dr. Weinberg is Division Lead PlasticSurgery, Trillium Health Partners, and MedicalDirector, Toronto Plastic Surgery Clinic

Cosmetic surgery: best undertaken after learning reconstructiven Dr. Michael J. Weinberg, TO R O N TO

P L A S T I C S U R G E O N

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ADDICTIVE

CosMed_Spring2014_05-28-14_cosmetic_dermatology_summer-2013_07-19-13.qxd 5/30/2014 1:00 PM Page 5

n Dr. Eric Swanson, a plastic surgeon practic-ing in leawood, Kan., was born in Toronto andcompleted medical school and a residency in plas-tic surgery at the university of Toronto followedby a fellowship in cosmetic surgery at scarboroughgeneral hospital. dr. swanson moved to Kansas in1989 to begin practice and opened the swansonCenter for Cosmetic & laser surgery and leawoodsurgery Centre 10 years later. his practice’s web-site states, “dr. swanson believes that knowledgeis the remedy for patient apprehension about cos-metic surgery and that the marketplace is often toofocused on selling commercial products to be areliable source.”

dr. swanson recently explored the topic ofcommercialization of plastic surgery and its ethicalimplications of a corporate model in medicine in anarticle published in the sept. 2013 issue of The

Aesthetic Surgery Journal (33(7):1065-1068). TheChronICle’s Emily Innes spoke with dr. swansonabout his observations on the changing practices inplastic surgery. How do you define “corporate medicine”andwhat does it have to do with plastic surgery? Corporate medicine applies corporate businessstrategies to what has traditionally been a doctor-patient service relationship. It views plastic surgeryas a commercial product as opposed to a medicalservice. It limits the surgeon’s options. It may insiston a specific treatment or procedure—you don’thave the freedom to recommend another treatmentthat might be better suited for your patient.

let’s say the corporate strategy is to performall surgery in the office under local anesthesia, butthe patient is scared of needles. That is not going towork very well for that individual. or, perhaps thecorporation promotes laser liposuction, but thepatient would be better treated with a tummy tuck.Applying the corporate model, the product comesfirst. The traditional pattern is inverted. rather thanstarting with the patient’s concern—the way it’sbeen done in medicine for over a century—you arestarting with ‘have I got a treatment for you’.Why would some surgeons want to work withinthis corporate model, and what do they haveto gain? It is economic. They are thinking, especially whenthe economy is tight, ‘I wouldn’t mind [gaining]more patients and having more business’ and ‘thecorporation can take care of my expenses and mymalpractice insurance. All I need to do is performthis procedure. This approach might appeal to ayoung surgeon who is just starting practice and thephone is not ringing or an older surgeon who isslowing down and wants to transition into some-thing that is a little easier to manage without theheadaches of running an office.

But, in my view you are really sacrificing alot. you are giving up your freedom in what treat-

On the leadingedge of research,discoveries andnew clinical findings in aesthetic medicine

The trouble with thinking‘corporate medicine’


A plastic surgeon argues for a return to a traditional model: ‘Treat patients well and they will beat a path to your door’


BASELINE WEEK 16

Representative photographs of hair regrowth response for 1 subject at baseline and at week 16. May not be representative of results in all patients.1

Demonstrated efficacy at week 16:(Secondary endpoint)

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and untreated hypertension; baldness not due to hereditary factors; patients with any scalp abnormality (including psoriasis and sunburn); shaved scalp or whose scalp’s skin is broken, inflamed, irritated, infected, or severely sunburned; use of occlusive dressings or other topical therapeutic medications for treating disorders of the skin of the scalp; certain prescription and non-prescription medications,

treatments (e.g. cancer chemotherapy) or diseases (e.g. iron deficiency, thyroid disorders or secondary syphilis), as well as severe nutritional problems and poor grooming habits, may also cause temporary hair loss which should not be treated with PrROGAINE® FOAM 5%.

- Relevant warnings and precautions: for external scalp use only; hands should be washed thoroughly after use; avoid spray inhalation; ethanol (alcohol) in PrROGAINE® FOAM 5% will cause burning and irritation of the eyes; Butylated hydroxytoluene may cause local skin reactions or irritation to the eyes or mucous membranes; Cetyl alcohol and stearyl alcohol may cause local skin reaction; changes in hair colour and/or texture; if shedding persists for more than 2 weeks, use should be discontinued and users should consult their doctor; should not be used with no family history of hair loss, sudden and/or patchy hair loss or unknown reason for

hair loss; patients with known cardiovascular disease or cardiac arrhythmia should contact a physician before using PrROGAINE® FOAM 5%; risk of systemic side effects such as salt and water retention, hypertension, tachycardia, angina, and edema; monitor for signs of systemic effects of minoxidil such as hypotension, chest pain, rapid heartbeat, faintness or dizziness, sudden unexplained weight gain, swollen hands or feet, persistent redness or irritation of the scalp; use should be discontinued in the event of systemic effects and/or severe dermatologic reactions

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CosMed Page 7_8.qxp_Layout 1 2014-06-05 12:39 PM Page 1


ments you recommend and you are giving upcontrol. Now the non-physician executives aremaking decisions that affect the care. Doctorswho are signing up are willing to performthose procedures at highly discounted rates.The economics are not very favourable unlessyou operate quickly and spend less time withyour patients.WWhhaatt aarree tthhee uunneetthhiiccaall ddeecciissiioonnss tthhaatt ssuurr--ggeeoonnss ccaann mmaakkee wwhheenn wwoorrkkiinngg aatt aa ccoorrppoo--rraattee pprraaccttiiccee?? It becomes a problem when you outsource yourmarketing. Corporations will make a lot ofpromises. They will often display very impres-sive before and after pictures and claims ofmaking you look younger by 10 to 20 years arenot unusual. In other words, they will makeexaggerated promises that are commonplace inthe business world.

But plastic surgery is different from sell-ing widgets. You are working with people whoare vulnerable and place trust in you. Peopleare very insecure about their body shape andlooking older.

Plastic surgeons must remember that theyare doctors first. They took an oath. What isbest for the patient comes before any commer-cial interest. IInn yyoouurr aarrttiiccllee,, yyoouu mmeennttiioonn tthhaatt tthheerree ccaannbbee rreedduucceedd ccoossttss ffoorr ppaattiieennttss iiff tthheeyy ggoo ttoo aaccoorrppoorraattee mmooddeell pprraaccttiiccee.. WWhhyy sshhoouulldd tthheeyyaavvooiidd ttaakkiinngg tthhee ddeeaall?? None of us is immune to the appeal of gettingsomething for less. The patient needs to knowthat with discounted prices come reduced serv-ices. There are no free lunches. I tell patients itis a mistake to pay too much for plastic sur-gery, but it is a bigger mistake to pay too little.

Patients may be giving up the attendanceof an anesthetist, they may be giving up having[the procedure] done in a proper surgery centrerather than an office in a strip mall, and theymay be compromising the quality of theirresult by enlisting less experienced and lessreputable plastic surgeons. There is no bargainif you have to undergo a second corrective pro-cedure by another surgeon. I see that all time.

About six years ago ‘Lipodisolve’ was allthe rage. Billboards showed buff models andclaimed that simple injections could dissolvefat away. Patients were asked to make depositsof a few thousand dollars for a course of injec-tions. After learning that it did not work theway they expected, patients eventually came tosee me and other plastic surgeons for liposuc-

tion, which would have been the better optionfor them in the first place.

I think the most important thing is safety,then quality, and then maybe you could look atprice. But, you can’t compromise, safety andquality, not when it comes to your health.

DDoo yyoouu tthhiinnkk tthheerree sshhoouulldd bbee mmoorree ggoovveerrnn--mmeenntt rreegguullaattiioonnss oonn aaddvveerrttiissiinngg oorr ppllaassttiiccssuurrggeerryy pprraaccttiicceess?? No, I’m not convinced extensive regulations arethe answer. I am a believer in the marketplace.If the procedure or product deserves to surviveit will, and if the results don’t match the hype,it won’t. Eventually the word is going to get outand no amount of advertising can overcome badword-of-mouth, especially in the internet age.

WWhhaatt iiff aa ppaattiieenntt ccaammee iinnttoo yyoouurr ooffffiiccee hhaavv--iinngg hheeaarrdd aabboouutt aa ““LLiiffee aalltteerriinnggpprroodduucctt..””WWhhaatt wwoouulldd yyoouu tteellll tthheemm??First of all, few of us believe such claims any-more. I caution patients that before and afterphotos may not represent their surgeon’s workand there is often fine print. It is best to insiston viewing your surgeon’s work, not corporateexamples that may not indicate who did it andexactly what was done.

I recommend the ‘rule of 10’. If you see10 examples of results that you would person-ally accept, all performed by the surgeon youhave chosen, that is a pretty good startingpoint. Second and third opinions are a goodidea, if only to strengthen your confidence inyour decision. Of course, referrals from otherpatients are invaluable.

WWhhaatt iiss tthhee mmeessssaaggee tthhaatt yyoouu wwaanntt ttoo ggeettaaccrroossss ttoo ppllaassttiicc ssuurrggeeoonnss aabboouutt ccoommmmeerr--cciiaalliizzaattiioonn iinn tthhee ffiieelldd?? Medicine is no place for ‘buyer beware’, andthat includes plastic surgery. Be careful ofclaims of superiority, such as ‘we have the bestdoctors’ or ‘we have the best treatments’ or ‘werarely have any complications’. Plastic sur-geons who sign up must realize they areresponsible for claims made on their corporatewebsite.

My advice to plastic surgeons who areconsidering enlisting with one of these prod-uct-driven corporations? Don’t sell yourselfshort. Maybe you are not busy now, but youwill be if you stay true to your ideals. It is oldfashioned advice: treat patients well and even-tually they will beat a path to your door. Underpromise and over deliver.

�Cosmetic Update

Indication and clinical use:PrROGAINE® FOAM 5% (5% minoxidil topical foam) is indicated for the treatment of male androgenetic alopecia on the top of the scalp (vertex).

demonstrated in clinical trials


Contraindications:

PrROGAINE® FOAM 5%

Relevant warnings and precautions:

PrROGAINE®

PrROGAINE® FOAM 5%

dermatologic reactions

For more information:

PrROGAINE® FOAM 5%

ReferencesJ Am Acad Dermatol

PrROGAINE®

FOAM(MINOXIDIL FOAM 5% W/W)

Johnson & Johnson Inc.All rights reserved.

C

M

Y

CM

MY

CY

CMY

K

Indication and clinical use:PrROGAINE® FOAM 5% (5% minoxidil topical foam) is indicated for the treatment of male androgenetic alopecia on the top of the scalp (vertex).



Contraindications:

PrROGAINE® FOAM 5%

Relevant warnings and precautions:

PrROGAINE®

PrROGAINE® FOAM 5%

dermatologic reactions

For more information:

PrROGAINE® FOAM 5%

ReferencesJ Am Acad Dermatol

PrROGAINE®

FOAM(MINOXIDIL FOAM 5% W/W)

Johnson & Johnson Inc.All rights reserved.

2014-02-27 8:47 AM

CosMed Page 7_8.qxp_Layout 1 2014-06-05 12:39 PM Page 2

HIDDEN BEHIND THE HIGH QUALITY CARE OF EAU THERMALE AVÈNE… STERILE COSMETICS INVENTED BY PIERRE FABRE LABORATORIES

P I E R R E FA B R E L A B O R AT O R I E S I N N OVAT I O N

AVA I L A B L E I N D R U G S T O R E S


n While reduction mammaplasty is a generallysafe procedure when conducted on obese women, itdoes carry an increased risk of surgical site compli-cations which need to be discussed with obesepatients before surgery, according to research pub-lished online in Aesthetic Surgery Journal (nov. 8,2013).

The authors conducted a retrospectiveanalysis of 2492 reduction mammaplasties in theu.s. national surgical Quality ImprovementProgram database, performed between 2006 and2010. They collected data on BmI, as well addemographic and comorbidity data, and medicaland surgical complication, reoperation, and mor-tality data through 30 days post-surgery. of thesampled patients, 55% had BmI>30 (consideredobese by Who standards).While the overall surgicalcomplication rate was 4.0%, itrose from 2.4% in patientswith BmI<25 to 7.1% whereBmI>45 (p=0.006). There wasalso an adjusted odds ratio(or) of 2.97 for BmI>45 vs BmI<25. superficialsurgical site infections were found in 2.9% ofpatients, making it the most common surgicalcomplication (2.1% where BmI<25, rising to5.1% in BmI>45, p=0.03). The medical compli-cation rate was 0.6%, the reoperation rate was2.1%, and there were no deaths. A BmI=>39 wasshown to have a significantly higher rate of com-plications –or=2.38 –by maximal point analysis.

—Read more at http://ow.ly/wSX5h

JAMA: Reluctance toperform endoscopicforehead-midface liftunfoundedn researchers found that the endoscopic forehead-midface lift is reliable for addressing midface

descent, with no objectively identified significantdifferences in lateral canthus position before orafter surgery, according to research published inJAMA Facial Plastic Surgery (sept./oct. 2013;15(5):352-357).

The authors note thatmany surgeons are reluctant tocarry out this lift due to fearsof change in the shape andappearance of the eyelid. Toevaluate any change, they con-ducted a retrospective reviewof consecutive patients undergoing endoscopicforehead-midface-lift and lower blepharoplasty forcosmetic midface rejuvenation in a private facialplastic surgery practice. Photometric data wasobtained from 40 such patients before and aftersurgery, and the photos were analyzed for hori-zontal width, vertical height, palpebral fissurewidth, or angle between medial and lateral canthi.right and left eyes were independently evaluated,with a 2-tailed paired t test with a confidenceinterval <= 0.05 used to analyze the results. nostatistically significant change was seen in hori-zontal width (right p=0.25, left p=0.07), verticalheight (right p=0.99, left p=0.72), palpebral fis-

sure width (right p=0.28, left p=o.48), and angleof the lateral canthus (right p=0.99, left p=0.30)before and after surgery.

—Read more at http://ow.ly/wSYEC

New anti-aging Tx?Grape seed extractand soy phospholipidsdelivered transbuccallyn Transbuccal formulations of nutraceutical-gradecosmetics may be able to induce signal transduc-tion pathways in the facial hypdermis, inducinganti-aging effects through all skin compartmentsincluding the dermal and epidermal layers,researchers report in International Journal ofCosmetic Science (dec. 2013; 35(6):562-567).

Investigators formulated a combination ofgrape seed extract and soy phospholipids and stan-dardized it for elastase activity and free radicalinhibition. This was then used to contact the hypo-dermal layer of human skin biopsies and the 3T3-l1 preadipocytes –the latter using a transbuccaldelivery vehicle. PCr arrays and histochemistrywere then used to quantify the effects. Application

nCosmetic Update


More surgical site complications for obese patients during reduction mammaplasty procedures

Sealants equivalent in head-to-head studyn When compared head-to-head in facelift surgery, the fibrin sealants Tissucol and Quixil were nearlyidentical in terms of patient safety and quality of result, though Tissucol demonstrated both hemostaticand ‘gluing’effects while Quixil was primarily effective at securing hemostasis,according to research published in Clinical, Cosmetic and investigationalDermatology (nov. 2013; 2013(6):273-280).

some 20 patients were enrolled in a prospective left/right study, with the twosealants being used at the same time in each patient, one sealant on each side of theface. rates of hematoma and seroma, degree of induration, edema, ecchymosis,pain levels, and patient satisfaction were then compared. The results between thetwo fibrin glues were nearly equivalent, with one exception. one patient experienced a significant(40ml) hematoma on the side treated with Quixil, which bleeding the authors suggest was due to a sud-den rise in blood pressure during the immediate postoperative period.

—Read more at http://ow.ly/wSXsm


of the standardized material to the hypodermallayer of the biopsies triggeredmodulation of gene expressoinin the upper layers of the skin,and a clear morphologicalimprovement at the dermal andepidermal levels. When appliedto the 3T3-l1 preadipocytesusing a mucoadhesive, intraoral film, these cells’-modulated gene expression was consistent with dif-ferentiation and detoxification effects.

—Read more at http://ow.ly/wSXbu

Revised analgesia regimen reduces opioid consumption following rhinoplastyn Adding a single dose of pregabalin and dexam-ethasone to multimodal analgesia in rhinoplastysurgery provided efficient analgesia and reducedopioid consumption, according to a paper publishedin Aesthetic Plastic Surgery (dec. 2013;37(6):1100-1106).

researchers randomly assigned 60 patientsinto three groups. group C were given a combina-tion of two placebos, group P was given pregabalin

and a placebo, and group Pd was given both prega-balin and dexamethasone. dosages of the activedrugs were 300mg of pregabalin orally one hourbefore surgery, and 8mg of dexamethasone intra-venously during induction. Post-operatively, painwas managed using patient-controlled intravenousanalgesia, consisting of a 20mg bolus dose of tra-madol with a 45 minute lockout time. researchersthen assessed the numeric rating scale (nrs), sideeffects, and consumption of tramadol, pethidine,

and ondasetron. median nrsscores immediately after sur-gery, and one and six hourspost-surgery were significantly(p<0.001) higher in group Cthan group Pd. The 24-hourconsumption of tramadol and

pethidine was also significantly lower in bothgroup P and Pd compared to group C (p<0.01 forboth). group P’ total tramadol consumption was54.5% less than group C’, and group Pd’ was81.9% less (p<0.001 for both). group C also had ahigher incidence of nausea in the two-hour and 24-hour periods post-surgery than either other group(p<0.05). groups P and Pd had a significantlyhigher frequency of blurred vision than C in the 24hour post-op period (p<0.05 for both).

—Read more at http://ow.ly/wSXk6

Volume 4 Number 1 11

New HA gel well tolerated, effective: studyn VyC-20l, a new 20mg/ml hyaluronic acid (hA) gel, appears to be both safe and effective for treat-ing age-related midface volume deficit (mVd), with correction lasting as long astwo years, according to the results of a study published in Dermatologic Surgery(nov. 2013; 39(11):1602-1612).

researchers enrolled 235 subjects with mVd –aged 35 to 65 –into a multicen-tre, single-blind, controlled study. A group of 47 other individuals made up a no-treatment control group. Improvement of one or more points on the validated six-point mid-face Volume deficit scale (mfVds) at six months –rated live by twoblinded independent evaluators –was considered response. Primary endpoint required a 70% or greatertreatment group response, as well as a significant (p<0.001) difference between treatment and controlresponse rates. After treatment, 85% of the treatment had improved one or more points on the mfVdsat month six, and a statistically significant difference (p<0.001) was seen in response rate between thetreatment and control arms. The filler was tolerated well, with no unanticipated adverse effects. Almosthalf the treated subjects maintained their correction for 24 months.

—Read more at http://ow.ly/wSXKu


n by Louise GagnonO F T H E C H R O N I C L E

looking ahead to 2014, physicians can anticipatenumerous developments in cosmetic medicine.

for example, physicians providing aestheticcare to patients will have more dermal fillers avail-able to them as manufacturers fine-tune variables inthe composition of dermal fillers.

factors such as hyaluronic acid (hA) concen-tration, lift capacity, and cohesivity affect the clini-cal performance of a dermal filler, according to Dr.Vince Bertucci, a dermatologist and medicaldirector of Bertucci medspa in Woodbridge, ont.and vice-president of the Canadian dermatologyAssociation.

“By tweaking each of these factors, manufac-turers are able to give us products with unique charac-teristics with different indications,” said dr. Bertucci.

he cited Juvederm Volbella, an injectable gelwhich has lower hA concentration at 15 mg/ml, asa lip filler that produces a smooth and natural result.The Vycross technology features efficiently cross-linked short-chain and long-chain hA, resulting inlonger duration of effect and excellent tissue integra-tion (Clinical, Cosmetic, and InvestigativeDermatology 2012; 5:167–172).

“Because of the Vycross technology, the dura-tion of Volbella is about nine to 12 months,” dr.Bertucci said. “With previous lip fillers, we wouldbe lucky if we got three to six months duration.”

dr. Bertucci said he and other clinicians havefound that Volbella can be used outside of the perioralarea in an off-label manner. he re port ed that he has

used it successfully for sites like the teartrough.

“Those of us that use it for the lipsrecognize that its low hA concentrationmakes it well-suited for the tear trough,”explained dr. Bertucci. “Its low hA con-centration means that there is minimaledema after treatment – the excellent tis-sue integration and spreadability of theproduct reduces the risk of Tyndall effect.”

Juvederm Voluma has greater hAconcentration, cohesivity, and lift capac-ity, making it ideal for cheek and chinaugmentation, for example. Allergan’snewest product, Volift with lidocaine,which is available in europe but not yetin Canada, also uses the Vycross tech-nology and has characteristics betweenthose of Voluma and Volbella. It is tar-geted at facial contouring and treatingdepressed skin areas like the nasolabialfolds, said dr. Bertucci.Dr. Andrei Metelitsa, medical co-

director of the Institute for skin Advancementin Calgary and clinical assistant professor atthe university of Calgary, agreed the Vycrosstechnology makes Volbella a dermal filler thatis not bulky, is less hydrophilic, and producesless swelling.

“It helps you obtain a natural result,”said dr. metelitsa.

Fillers for specific applicationsDr. Jennifer Upitis, president of theCanadian Association of Aestheticmedicine, said dermal fillers areincreasingly becoming niche productsin the aesthetic world rather than beingmanufactured to be general fillers. Thedrive to accelerate recovery for patientsand reduce complications is motivatingthis differentiation across dermalfillers, added dr. upitis

“Prod ucts are being tweaked sothere are fewer side effects,” said dr.upitis, noting cross-linking is a hugecomponent that determines the impactof a dermal filler. “Volbella gives greatresults, and there is less downtime.”Dr. Rao Dr. UpitisDr. BertucciDr. Metelitsa


Growing experience has taughtCanadian clinicians who treatpatients with fillers that adher-ing to the principle of ‘less ismore’ is a good approach

cosmeticmedicine

2014©

Timothy Large | D

reamstim

e Photos


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nCosmetic Medicine Update 2014

Adjuncts are entering the marketplace toincrease the recovery time after treatment withfillers, lasers, and surgery. oxygenetix, developedby Biophora, is a foundation make-up that aims to“heal and conceal” and is designed to be worn afterprocedures like chemical peels. It contains ceravitae,an oxygen complex purported to promote collagencell production in wounded skin.

“This is camouflage make-up that can beapplied after aggressive laser treatment or even afterfillers have been injected,” said dr. upitis. “If peopledon’t want downtime, they have options like these.”

sunscreens are necessary to prevent photo-aging of the skin and skin cancers, and future sun-screens will likely contain revised labelling to indi-cate they offer not only sufficient uVB protection,but sufficient uVA protection as well, she explained.

“They have traditionally been tested in the lab[for their protection against] uVB and not uVA,”said dr. upitis. “That is starting to change. We wantto have products that offer broad-spectrum uVA anduVB protection for our patients.”

Treatments for body contouringPatients are seeking aesthetic enhancement to thebody, and are curious about technologies that aim totighten silhouettes, said Dr. Jaggi Rao, a dermatol-ogist and founder and medical director of the Albertalaser & dermatology Centre in edmonton, and amember of the board of directors of the CanadianAssociation of Aesthetic medicine. While body con-touring technologies will not produce outcomes com-parable to liposuction, they provide improvementsthat are subtle for patients, said dr. rao.

“There is no device that is a substitute for lipo-suction, but if patients want some degree of bodycontouring, then [these technologies] work well,”said dr. rao. “The trend is to use non-invasiveapproaches. There are a few devices that operateunder different principles, but they aim to achievethe same thing.”

dr. rao cites radiofrequency (rf) devicessuch as reaction from Viora Inc., ultrasound tech-nologies like ultrashape V3, trusculpt from Cutera,and technologies that employ cryolipolysis likeCoolsculpting, by Zeltiq. “you get some improve-ments [with these technologies], but you have tokeep up and maintain treatment,” said dr. rao.

There are no head-to-head studies to demon-

strate if any of the body contouring technologiesare superior, said dr. rao. “The evidence is expe-riential,” he noted.

for the time being, the points of differentiationare not efficacy measurements but rather endpointssuch as procedural discomfort or degree of down-time. Cost is also another consideration, said dr. rao.

“If the procedure is painful, we can makepatients more comfortable with the use of analgesicsand different types of sedation,” said dr. rao, notinganecdotal feedback from patients is that the Venusfreeze, a rf treatment, can cause physical discomfort.

one innovation in body contouring is a newprotocol to optimize the use of the liposonixsystem, which delivers high-intensity ultrasoundenergy, said dr. Bertucci.

The technology aims to reduce fat around thewaist, and manufacturers now promote using morepasses and less fluence in terms of the operation ofthe technology, said dr. Bertucci.

“With more passes and less fluence, itbecomes a more comfortable procedure and is muchbetter tolerated by patients,” he said.

At-home devices on increaseeven if patients are not seeking body contouringtreatments, they are considering at-home technolo-gies for delivering cosmetic rejuvenation, contendsdr. metelitsa. Indeed, it would be a prudent step forclinicians to familiarize themselves with at-homedevices that are becoming greater in number andmore popular with patients, he says.

“my prediction is that physicians will have tobecome more familiar with oTC [over-the-counter]devices,” said dr. metelitsa. “They can be adjunc-tive therapies to in-office treatment.”

There are at-home devices such as the PaloViaskin renewing laser, the first at-home laser approvedby the u.s. food and drug Administration designedto treat wrinkles around the eyes or crow’s feet.

An injectable that recently completed clinicaltrials is ATX-101, a proprietary formulation ofdeoxycholic acid, a bile salt that naturally occurs inthe body, which is aimed at reducing submental fat,explained dr. Bertucci.

“Phase 3 clinical trials have shown that theATX-101 is safe and effective in reducing submen-tal fat accumulation,” said dr. Bertucci, noting thetherapy has been studied in separate clinical trials in

europe and in north America. “ATX-101, which isnot yet commercially available, will provide analternative for patients who wish to contour the neckwithout undergoing surgery.”

“localized adverse events such as injectionsite swelling and bruising were noted in the clinicaltrials,” he said

Another compound under study is rT001, atopical gel to treat lateral canthal lines that hasshown efficacy and safety in several Phase 2b clini-cal studies. “It has tremendous potential in terms ofreaching patients who are needle-phobic,” noted dr.metelitsa.

Consolidation seems to be taking hold in theaesthetic industry, with industry aiming to broadentheir product offering to physicians who specializein aesthetic medicine, observed dr. Bertucci.

“Companies are becoming more integratedwith comprehensive product offerings, so as to pro-vide a complete set of solutions to physicians,” saiddr. Bertucci. “each vendor is aiming to have in itsportfolio a neuromodulator, dermal fillers, and askin care line at a minimum. As with many otherindustries, bundling and one-stop shopping seems tobe the order of the day.”

While many injectors in Canada use a 1 ccreconstitution per 100 units of Xeomin or Botox, or1.2 cc for dysport, they may find larger volumes ofreconstitution – such as between 2 and 3 cc – bettersuited for some sites, such as the lateral canthallines, said dr. Bertucci. While maintaining the sameabsolute dose, larger volumes allow for greaterproduct diffusion and a smoother, less harsh effect insome areas, he says.

Cannulas are gaining in popularity for fillerinjections, but it’s imperative that injectors do notassume there is no risk to using cannulas, said dr.Bertucci.

“The beauty of cannulas is that fewer needle-stick entry points are required, so there is less poten-tial for bruising,” he said. “Importantly, there is alsopotentially less risk of ischemia and necrosisthrough intravascular injection. however, care mustbe taken to not be overly aggressive, as cannulationof vessels may occur even using a 27-gauge or 30-gauge cannulas. While cannulas may reduce risk,they should not be considered risk-free.Additionally, there is a learning curve with cannulasand injection time may be increased.”


n by Emily InnesO F T H E C H R O N I C L E

Patients using bimatoprost ophthalmicsolution 0.03% once daily have reportedthe positive outcome of growing moreprominent eyelashes, according to a report inAesthetic Surgery Journal (Aug. 2013;33(6):789-798).

during the multicentre, double-masked,randomized, vehicle-controlled study, 278patients received either bimatoprost or vehicleand completed four questionnaires. The

researchers investi-gated the patient’ssatisfaction regardinglash fullness and length and their overall satisfaction.The questionnaires also addressed the impact of thechanged lashes on the patient’s confidence, attractive-ness, professionalism, and daily routine.

After 16 weeks the patients using bimatoprostreported greater improvements from baseline on allareas of satisfaction, the authors stated.

Dr. Jean Carruthers, a clinical professor inthe department of ophthalmology at The university ofBritish Columbia in Vancouver and one of the study’sauthors, said bimatoprost was initially being used as a

glaucoma medication when it was observed that patient’s eyelashes were growing. This phenomenon was being reported as an adverse effect because males

thought it was undesirable, said dr. Carruthers. “The researchers were saying, ‘no, this is just great, this is what we want’,”

she said. “There is a little bit of serendipity in this.” After the observation was made, dr. Carruthers and her colleagues studied

how patients responded to the product. “hypotrichosis of the eyelashes may negatively influence an individual’s

self-perception and appearance,” stated the authors. “Assessing the impact oftreatment from a patient’s perspective may be particularly relevant in trials [suchas this one, which looked at] aesthetic agents.”

Eyelash growth successdr. Carruthers said she was surprised bimatoprost was successful at producinggrowth in eyelashes because most products have proven ineffective in the past.

“People have tried to grow eyelashes with all kinds of things and hair withall kinds of things,” she said.

dr. Carruthers said she thinks minoxidil does not work nearly as well asbimatoprost, which also works on the scalp, eyebrows, and other locations of thebody. she and her colleagues are currently testing the effectiveness of bimato-prost for eyebrow growth.

she said bimatoprost is a better alternative to previous methods such as sur-

gery, which involves the surgeon taking hairsfrom the scalp or pubic regions and dissectingthem into single hair follicles then inserting theminto the eyelash margin. A problem with thismethod is that the hair still thinks it is growingfrom the scalp and doesn’t stop growing like eye-lashes do. The hair needs to be continually

trimmed. she said other previous methods includedgluing fake eyelashes onto the lids, gluing extensionsonto the natural lashes, and using mascara.

dr. Carruthers said a side effect of the bimato-prost was some participants reacted strongly to theproduct and the lashes grew larger than desired to thepoint where they had to be trimmed.

“The other thing is there is a trick to using it andthat is that eyelashes grow in phases. They go through

a dormant phase and then they wake up and they start growing again,” said dr.Carruthers. “If you use the [bimatoprost] everyday for three or four months, whatyou will start to see is that all your eyelashes start to fall out because you havelined up all the hair follicles in your lash margins to be on the same schedule.”

dr. Carruthers said to avoid this adverse effect she recommends patientsstart using it only two or three times a week after about six weeks.

she said the medication cannot be used for patients with alopecia areatabecause there is no cure for the autoimmune disease yet, which would need to betreated first before bimatoprost could work.

“I think another approach is going to be needed to treat those [patients] andI think that’s where the cosmetic [approach] is really helpful,” she said.“Tattooing on eyebrows and gluing on eyelashes are helpful to those people.”

The studies findings have positive implications for an aging populationbecause the authors showed a dramatic decrease in eyelash length, thickness, andcolour brightness.

The length for healthy adults between the ages of 22 and 29 years were anaverage of 7.89 mm compared to 6.39 mm for those between the ages of 60 and65. The thicknesses for the same age groups were 1.62 mm versus 1.17 mm.

Eyelash growth improves self-esteemdr. Carruthers said the medication is still in early days, but it has been popularamong her patients, who have given the product positive responses.

“People just absolutely love it,” she said. “It is extraordinary that it took solong to come.” her patients tell her “‘I love that stuff, I need more’.”

dr. Carruthers said it is particularly enjoyed by athletes whose mascaramight run because they are sweating or getting into a pool.

“It does amazing things for [the user’s] self-esteem,” said dr. Carruthers.“you focus on something when you don’t have it and it bothers you, but when itis there, it is absolutely great.”

Non-proprietary and brand names of therapies:bimatoprost ophthalmic solution 0.03% (latisse, Allergan); minoxidil (rogaine,Johnson & Johnson)

For more information visit: http://ow.ly/soKSH

Bimatoprost effective for growing


eyelashes



A tool for measuring patientsatisfaction in facial surgeryn by John EvansO F T H E C H R O N I C L E

following the success of the BreAsT-Q outcome measuring instrument,researchers are developing a new set of scales called fACe-Q for collectingpatient-reported outcomes of facial aesthetic procedures, many of which havealready been validated.

“BreAsT-Q started with the research question ‘What kinds of operationsgive the highest patient satisfaction in breast surgery?’” says Dr. AndreaPusic, a Canadian plastic surgeon specializing in reconstruction after cancer,now working at the memorial sloan-Kettering Cancer Center in new york, andone of the researchers developing fACe-Q.

“our team coalesced around workon the BreAsT-Q. In terms of movingto the fACe-Q, the thing that really wasthe compelling reason to do the workwas that in cosmetic surgery, doctorshave such an array of different treat-ments and different products that we canoffer to our, and a lot of differentsources of evidence for what might bebest for which patient. Comparing onetreatment to the next is to some extentanecdotal.”

dr. Pusic noted that the availableresearch data is very clinician-driven, inthat it is essentially the clinician’sappraisal of the results and procedure.“our team perspective was that it wouldalso be very useful and valuable tounderstand how patients felt about theimpact of different treatments and cos-metic facial procedures. That’s reallythe driving force—to be able to under-stand how patients feel about the impactof facial cosmetic treatments, and to beable to use that information to one, helpclinicians perhaps to better know whattreatments work best in what situations,but also help patients make better deci-sions about what they might want to get

done, because they would be able to better understand the expected outcomes,and the impact of treatment. Also for them to be better able to understand whatbenefits they may or may not derive from a particular treatment.”

This new patient-reported outcome instrument contains a number of sub-scales that look at satisfaction with facial appearance, health-related quality oflife, recovery, early life impact, and adverse events. As well the scales can be bro-ken up by specific areas of treatment—ears, nose, forehead, cheeks, and otherareas.

There are other tools that can be used to measure facial outcomes, says Dr.Anne Klassen, an associate professor at mcmaster university in hamilton,who also worked on the development of the BreAsT-Q and fACe-Q. “There iswhat’s called the dereford Appearance scale that a lot of research has incorpo-rated,” she says. “But it is more generic. It tries to do everything for everyone, soit is not really specific to any particular patient’s concerns.

“The way I think our scales are different than anything that is out there isthat we do a lot of qualitative work first. We did interviews with 50 facial aes-thetic patients who were having all sorts of different types of treatments done.Then we used that qualitative data—tape recordings of these interviews—andused the words of the patients to come up with what the most important issuesare for them.”

“In developing the fACe-Q, we envisioned it could ultimately be used forresearch,” says dr. Pusic. “you could do a research study of, say, a new techniqueto do a face lift. But you could use the fACe-Q and have patients, before andafter treatment, complete these different scales and measure the change in theirperceptions of outcome. We also envisioned that in research it could be used in aclass compare across different treatments. so maybe you have a new way to doa facelift, but you want to compare that to a previous way.”

Managing patient expectations and outcomes

Dr. Klassen

Dr. Pusic


some of the fACe-Q scales are still under testing, dr. Klassen says,because with the wide range of scales included it can take time to collect datafrom an appropriate sample of patients. While many of the scales will be of usein research, including those that record patient-reported outcomes and quality oflife, dr. Klassen says others will be of immediate benefit to practicing clinicians.

“We also have screening scales,” says dr. Klassen. “We have an expecta-tions scale, for instance, which can be used in clinical practice to find out if some-one has realistic expectations of the outcome. If someone has filled this out in clin-ical practice and their expectations were on the unrealistic side, or they are expect-ing their whole life to be transformed by having something done, then the surgeoncould spend more time with them and educate them on what would be a more real-istic outcome.” for screening, there are also scales of psychological distress.

‘Could be they don’t like your office staff’The fACe-Q instrument also has scales for measuring patients’ perceptions ofthe non-treatment aspects of their experience—process of care, says dr. Klassen.There are scales for patient satisfaction with information, satisfaction with theclinician, and satisfaction with the office staff. “Those can be used for qualityimprovement,” she says. “so if you really wanted to know, you might have, as asurgeon, excellent outcomes, but [patients] really don’t like you. They don’t likeyour manner. or it might be that they have a need for more information—theydon’t have their information needs satisfied. or it could be that they love you andthey have good outcomes, but they really don’t like your office staff. so we’vegot that grouping of scales as well.”

Quality benchmarking will also be facilitated by fACe-Q, says dr. Pusic.“one of the things in aesthetics is understanding the quality of your outcomescompared to your peers. so the hope would be ultimately that with the fACe-Qoutcome, surgeons will be able to respond to patients who walk in and say show

Managing patient expectations and outcomes

facial rejuvenation surgery —including face,brow, eye, and neck lifts—does objectively andquantitatively make patients look younger byan average of about three years, according toa study published in the journal Jama FacialPlastic Surgery (Nov/Dec. 2013; 15(6):405-410).

Researchers showed preoperative andpostoperative photographs of 49 rejuvenationsurgery patients from a private plastic surgerypractice in Toronto to 50 blinded raters todetermine if patients are achieving their pri-mary objectives for undergoing aesthetic plasticsurgery, which are usually to look more youth-ful and more attractive.

The mean overall “years saved” followingthe surgery, determined from the true ageminus the guessed aged, was 3.1 years (rangefrom -4 years to 9.4 years). The authors statedthere was a small but statistically insignificant

increase in attractiveness scores (p>0.54). “The study did show what we expected, it

did not show huge changes, but that isbecause the study was very rigorous and so wedidn’t show huge changes in age reduction,”said Dr. Peter A. Adamson, president of theFace the Future™ Foundation and otolaryngol-ogist-head and neck surgeon at his practiceAdamson MD Associates Cosmetic FacialSurgery Clinic. “The thing about attractivenesswas a bit of surprise finding. We thought if theylooked younger, they should also look moreattractive... And so we were trying to decide,why is this?”

Darwin’s theory of evolutionDr. Adamson, the study’s senior investigator,said the thinking behind having a more youth-ful look being equated with beauty comes fromDarwin’s theory of evolution, which is that a

more youthful person represents greater fertili-ty, which is attractive because humans arehardwired to look for someone with goodreproductive capabilities.

Dr. Adamson theorizes that many of thepatients were rated in the average range ofattractiveness because most people think mostof us fall within the general norm, and alsobecause humans possibly have a “built in for-giveness factor for age.”

“If you looked at an infant and theylooked like an 80 year old you are going to berepulsed … Yet, if you see your 80-year-oldgrandmother, who has sun damage and wrin-kles and a little saggy skin, often someone willsay ‘she is still a beautiful woman’ because youknow she is 80,” he explained.

“This might account for the reason, eventhough people do look better with aestheticsurgery, that we don’t expect any more attrac-

An objective study finds procedures reduce 3.1 years from age perception

© Johanna G

oodyear | Dream

stime Photos



me your fACe-Q data, or tell me your fACe-Qscores for your patients. And when something isbeing done really well, [fACe-Q scores] would betangible evidence of superior outcome.”

dr. Pusic says the need to measure patient sat-isfaction with factors beyond the treatment itself,and how critical those perceptions were to overallpatient satisfaction with outcome, began to emergeeven during the development of the earlierBreAsT-Q scale, and were only reinforced by theinterviews with facial aesthetic treatment patientsconducted for fACe-Q’s development.

“We did a study of BreAsT-Q data, and actu-ally the strongest predictors of patient satisfaction ofoutcome was things like satisfaction with officestaff, and the strongest one was satisfaction withinformation,” she says. “so it is critical that sur-

geons be alert to how well patients are beinginformed about procedures, and the fACe-Q canhelp them understand how to do that better.”

The use of patient-reported outcome measuresis entering wider use worldwide, says dr. Klassen.she notes the BreAsT-Q is being used in commer-cial clinical trials, as well as in a u.K. audit of morethan 8,000 breast reconstruction procedures, andother patient-reported outcome scale surveys areadministered before and after most medical proce-dures in that country, she says.

As part of the success of BreAsT-Q, it hasbeen translated into, and linguistically verified in,about 13 languages, says dr. Pusic, which makesinternational information sharing and collaborationeasier. Already, fACe-Q—though it has only beenofficially released in roughly the last six months—has

been translated and verified in three languages, withtwo more translations in progress, she says.

“for clinicians, [fACe-Q] is a very excitingnew tool that will allow us to understand and meas-ure things that previously we felt were kind of intan-gible,” says dr. Pusic. “And I think that by havingthat information we are going to be able to make bet-ter surgical decisions, we are going to be able to dif-ferentiate what’s new from what’s new and actuallybetter in cosmetic surgery. I think we are going to beable to tailor our treatments better. I think we’re justgoing to be able to make better, data-driven, evi-dence-based decisions.”

“from a patient’s perspective it’s going toallow patients to be better informed about expectedoutcomes,” dr. Pusic says. “The question I get askedmost often by patients when they’re trying to makea decision is what do your other patients tell youabout how they felt after they had this done? so Ithink now we’re actually going to be able to conveythat in a very real fashion, and not just trying toguess what my other patients have been thinking.

“so I think it is going to help patients be bet-ter informed, and better informed patients makebetter decisions, and I think better informedpatients are ultimately happy with whatever theydo decide.”

dr. Klassen says the team is also developing asimilar instrument for body contouring calledBody-Q. “you can use it for bariatric patients, rightthrough to body contouring, including cosmetic—soliposuction, and abdominoplasty, but also massiveweight loss patients. That [instrument] is just aboutto be field tested. I’m actually just testing rightnow—we’ve got the database set up and we are test-ing. Then we are going to start collecting data frompatients. But we have got our scales all developed.”The field tests of Body-Q are being supported bythe Canadian Institutes of health research.

much of the funding for these scales has comefrom the Plastic surgery foundation, a research-funding arm of the American society of Plasticsurgeons, says dr. Pusic. “They appreciated thisissue right from the get-go, and they’ve been a driv-ing force in terms or being behind us and tremen-dously supportive of this work,” she says. “so Ithink it speaks well of that national society that theysaid ‘here is the unmet need in plastic surgery. howdo we address that with our research funding?’”

tiveness from them,” he said. “We have already given you the benefit of the doubt that you lookyounger, and that’s all you are going to get, because we expect you to look better.”

Dr. Adamson said his previous study had resulted in showing a difference of seven years(Archives of Plastic Surgery Jul.-Aug. 2012; 14(4):258-262). He said he thinks the numbers werelower in this study because a high number of forehead lift patients were included.

“We know that forehead lifting alone doesn’t make you look that much younger,” said Dr.Adamson. “Because if you look at a lot of people today,you’ll see models who are 22 with very low brows and theyare still considered very youthful. And, so we have changedour concepts about the forehead and whether brow liftingactually makes people look younger.”

Dr. Adamson said he is not worried people will inter-pret the study to mean that they will not become moreattractive from aesthetic surgery. “If [aesthetic surgery] wassomething that was generally bad, fewer and fewer peoplewould be having it done, not more and more,” he said.“There are lots of studies out there showing that there ishigh satisfaction rate—we have published one ourselves—and the people who have had this work done have theirquality of life improved …which is the bottom line”(Archives of Facial Plastic Surgery 2008; 10(2):79-83).

Drastic changes are not the goalThree years is probably a reasonable result, because generally patients are not looking for dras-tic changes, according to Dr. Adamson. “They are not looking for huge decreases in age… Butthey do want to look healthy, refreshed, happy, engaged with life for their years.

“I think it is very easily rationalized that yes, we may not have as many years, as shown inthis study, in reduction of age as we would think we would have, but that’s OK because they arestill getting what they like,” said Dr. Adamson. —Emily Innes

For more information visit: http://ow.ly/soLw1

Age perception—continued from page 21


nn Patient expectations

Dr. Adamson


n by Emily InnesO F T H E C H R O N I C L E

dermatologic and cosmetic procedures are sometimesunavoidable during pregnancy and the post-partumperiod, in which case surgeons need to selective aboutthe timing of the surgery, the positioningof the patient, cautious about the use ofantibiotics and anesthesia, and carefullymonitor the patient’s blood sugar levels,according to a study published inDermatologic Therapies (Jul-Aug. 2013;26(4):321-330).

The study’s authors noted that theone time where surgeons have to beconcerned about more than one patientundergoing the procedure at the sametime is during pregnancy.

Dr. Mary Maloney, a facultymember in the division of dermatologyat the university of massachusettsmedical school in Worchester and a co-author of the study, said she would notnormally recommend dermatology orcosmetic surgeries during pregnancy orpost-partum because healing is moredifficult during that time, but there are

some instances where a procedure is required. for example, dr. maloney said malignant

tumours need to be treated when they are recognizedand, sometimes, benign tumors such as pyogenicgranulomas that are bothersome need to be treatedimmediately as well.

“It really depends on what needsto be done. I think most women wouldnot have a straight up cosmetic proce-dure—a face lift, dermabrasion, aninjection of Botox, or Juvéderm—prob-ably for multiple reasons. Their obste-trician is not going to be happy aboutBotox or any form of protein fillers andwill discourage that kind of work beingdone,” she said. “But, certainly anincreasing tumour, a mole that changes,or a true skin cancer would actuallyrequire surgery during pregnancy.”

Avoid surgery in first trimesterdr. maloney said the time to try to avoidsurgery is during the first trimesterbecause the risk of birth defects is at itshighest. she acknowledged that this issometimes complicated because womendo not always know they are pregnant in

the early stages and the need for surgery may be urgent. “most of the [surgeries we perform] would be

safe in the first trimester, but… we want to be extracareful and avoid things that can be delayed if theycan, but if they can’t, we can take care of them very

Checklist essential fordermatologic or cosmetic proceduresperformed on

pregnant or

post-partum

harinaivotezar |Creative C

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Cosmetic MDs play important role in treating acneA Vancouver-based dermatologist said acne is a concern for many women beyond adolescence and should betaken seriously and treated professionally by cosmetic practitioners.

Dr. Shannon Humphrey, the director of Continuing Medical Education in the Department of Dermatologyand Skin Science at the University of British Columbia and director of the Acne and Rosacea Subspecialty Clinic,shed light on the complexity of acne treatments and highlighted the importance of directing patients to thedevelopment of a good skin care regimen. She was speaking at Cosmetic Update, held in Vancouver in April.

“[Acne] has a profound impact on quality of life and, using validated measures, it has been shown thatacne has the same impact on quality of life as chronic debilitating diseases like diabetes, asthma, and epilep-sy,” said Dr. Humphrey.

She said 50% of women in their twenties, 25% of women in their thirties, and 10% of women in their for-ties complain of having problems with acne.

Dr. Humphrey said treating acne is a smart business practice because it can build a therapeutic alliance thatmay also include cosmetic treatments. “Nothing will bond the patient to you like curing their acne,” she said.

When assessing a patient with acne Dr. Humphrey determines the patient’s type of acne, kind of lesions,skin type, demographics, and history with acne. She said it is also important to ask patients about their prefer-ences in treatments, their values, their biases, and their understanding of treatment options.

When it comes to treating mixed papular and pustular diseases, Dr. Humphrey recommends fixed-dosecombination topical therapies.

“Each topical has a different mechanism of action. They don’t work for the same type of lesion,” she said.“Retinoids tend to work best for comedones, antibiotics are both anti-inflammatory and they address P. acnes


women



nPregnant or post-partum women

safely,” she said. “The later in pregnancy you can do[the surgery], the better you feel about it.”

Reduce anesthesia, avoid antibioticsAn important consideration when performing sur-gery on a woman who is pregnant is to reduce thelocal anesthesia—especially a topical agent—anduse a safe prepping agent such as chlorhexidine glu-conate solution 4.0% w/v, and try to avoid antibi-otics during recovery, said dr. maloney.

If an antiobiotic is required, she recommendsavoiding tetracycline, minocycline, and doxycyclinebecause they can deposit in the teeth or bones of the fetus.

“you have your selection narrowed for youand you try very hard not to have a need to use someof the stronger antibiotics,” she said.

dr. maloney said the physical positioning ofpatients who are pregnant, especially in their secondor third trimester, is important during surgery, andthey should be placed on their sides. This prevents

the fetus from pushing down on the vena cava, whichcan impede circulation and could make the patientfeel faint or cause blood clots. she also recommendsplacing a pillow between the patient’s legs.

These patients should be on a mechanical operat-ing table because if they are feeling faint from hypoten-sion they need to placed in the tredelenburg positionquickly to regain equilibrium, said dr. maloney.

The patient may get hypoglycemic attacksbecause of difficulty regulating blood sugar. for thisreason, dr. maloney, said it is good to check if thepatient has eaten before surgery, to have snacks onhand, and to make sure they are also well hydrated.

some concerns for women in the post-partumperiod are a continued imbalance of hormones dur-ing the first three months, which means the patientwill still be at risk for hyperpigmentation and thick-ened scars, said dr. maloney.

she said the clinician also needs to consider ifthe patient is breast feeding, in which case they haveto still be selective about which anesthesia andantibiotics to select.

“Things do open up a little bit more after preg-nancy,” said dr. maloney. “But, you still need tostay away from antibiotics that would transfer to theteeth. however, you can prescribe any antibiotic thatwould be safe for a newborn.”

dr. maloney said she believes clinicians havea fairly good understanding of the findings present-ed in the study, but they tend to forget good practicesbecause it is not that common to perform surgery ona pregnant or post-partum woman. In her practice,the staff work together to remind everyone how faralong the women is in her pregnancy.

Create checklist “It is probably not a bad idea to have a least a mentalchecklist, if not a real check list, for the nursing staff,for the assisting staff, so that they remember to getpeople up slowly, make sure they are on a mechani-cal table, and so on,” said dr. maloney. “have somekind of office protocol to help everybody do thingsthe way you really intend to do them.”

dr. maloney said there are procedures shewould not perform on pregnant patients, includingface lifts, cosmetic laser, Botox, or fillers. If apatient came to me for those things, or others, Iwould refuse," she said.

For more information visit: http://ow.ly/soIG9

(Propionibacterium)… and finally benzoyl peroxide does a little bit of everything.” Dr. Humphrey said there are currently new fixed-dosed combination topical products in the

development phase, but some are already on the market. The newest product is clindamycin 1.2%/tretinoin 0.025% topical gel in a crystalline formula-

tion, which Dr. Humphrey said acts as an extended release, which makes potential side effectsmore tolerable for patients who don’t normally respond well to topical acne treatments.

She noted another effective new therapy is adapalene and benzoyl peroxide topical gel 0.1%/2.5%.Dr. Humphrey said dapsone 5% is a topical treatment that works well on inflammatory

lesions, but is less effective for comedonal acne. For that type of acne she advises to use comedeextractors in addition to treating with a topical retinoid, because physical extraction will significant-ly decrease the length of time to see improvement.

Dr. Humphrey said to limit the duration of antibiotic therapy in acne, adding an expertguideline is 12 weeks as the upper limit of time for antibiotic treatment. She noted that physiciansshould avoid the concurrent prescription of oral and topical antibiotics. If one type of antibiotic hasbeen successful in the past for a patient, then it should be prescribed again. In topical antibiotics,those that contain benzyol peroxide products are recommended, she said.

Dr. Humphrey said because of antibiotic resistance some patients might not respond well tothis method of treatment.

Laser and energy-based treatments are not considered first line therapies by expert guide-lines or by Dr. Humphrey.

She said systemic treatments such as hormonal treatments and isotretinoin should only beused in medical spas if the practitioner has the proper skill set, conducts a full medical history, andhas conducted pre-treatment counseling with the patient.

According to Dr. Humphrey, patients with post-adolescent acne androgens can be targetedwith both a fixed-dose combination topical treatment and an oral contraceptive pill or potassium-sparing diuretics.

The diuretic dose should be 50 to 200 mg and once the acne has responded the dose canbe reduced and used for several years at the lowest dose of 25 mg.

Dr. Humphrey describes isotretinoin as the “gold standard”, but the patients should receiveextensive counselling to understand the risks, the time commitment of six months including month-ly blood tests, and the requirement not to drink alcohol.

She said though the label suggests it is only for severe recalcitrant nodular acne, it is oftenalso used for physical and psychological scarring, and for treatment resistant cases.

She stressed the importance of informing patients about selecting a good cleanser and mois-turizer such as a gentle cleanser and non-comedogenic emollient.

“It’s a really easy second step, and patients feel like you’re really taking care of them from aholistic dermatologic or cosmetic perspective,” she said. —Emily Innes

Non-proprietary and brand names of therapies: clindamycin 1.2%/tretinoin 0.025% topical gel(Biacna, Valeant); adapalene and benzoyl peroxide topical gel 0.1%/2.5% (Tactuo, Galderma);dapsone 5% (Aczone, Valeant); isotretinoin (Accutane, Roche; Epuris, Cipher).

Cosmetic MDs and acne—continued from page 23


What are the trends in body contouring?for massive weight loss body contouring, its popu-larity has been gradually increasing, really since theearly 2000s when people started performing morebariatric surgical procedures, both in the u.s. and inCanada. After weight loss, people have concernsabout extra skin in multiple different regions of theirbody. That usually requires some type of correction.

As far as the number of people looking for sur-gery it depends on the region, and of course itdepends if your region has bariatric surgical pro-grams. In edmonton we have patients that comefrom all over Alberta. There is not a program likeours anywhere else in Alberta, so patients comefrom Calgary, the northwest Territories, and we’veseen some saskatchewan and some B.C. patients,even. so there is quite a bit of demand.

regarding development of plastic surgery afterweight loss, most people have noticed a significanttrend in increasing numbers of the procedures. Ifyou actually look at the numbers of bariatric surgi-cal procedures in Canada and in the world, inCanada the number of publicly-funded bariatricsurgical procedures—even in the last 10 years—as

gone up about 12-fold. so that’s significant. And agood portion of those patients end up wanting somekind of cosmetic procedure afterwards.

If you look at the number of top plastic surgeryprocedures, according to the American society ofPlastic surgeons, weight loss body contouring pro-cedures have exploded in terms of percentages.looking at the statistics from 2007, lower body liftprocedures or circumferential skin excisional proce-dures are estimated to have increased about 4,000per cent from 2000 to 2007, according to theAmerican society of Plastic surgeons. so quite a bitof increasing demand, and it is only growing asmore patients have bariatric surgery. some peoplealso lose weight without bariatric surgery, of course.so that’s where the demand is coming from. Are non-surgical approaches viable for bodycontouring in patients who have experienceda massive weight loss?A lot of the time, if you’e looking at a massiveweight loss patient they have an excessive amountof extra skin. really, the only solution is a surgicalsolution in terms of cutting out the extra skin andsome of the extra fat. so any of those interventions,

such as thermolysis or any superficial types of skintightening are generally are not adequate forpatients who have lost that much weight.What should other surgical practitioners keepin mind regarding this sort of body contouring?The massive weight loss patient is a much morecomplicated patient than the average person whocomes in for other types of cosmetic surgery. Thereare challenges, including significant amounts ofextra skin and poor skin quality, as well as differ-ences in terms of how the skin and soft tissues willreact to having surgery. There can be instances ofpost-operative skin relaxation. If you do breast sur-gery, the breast implants or breast-lifting proce-dures are less reliable. The complication rates aregenerally higher, especially wound healing compli-cation rates, depending on the patient. And thecomplication risks of everything else is generallyhigher in massive weight loss patients.

Then there are also safety issues that you haveto be aware of for minimizing those risks. Propernutritional assessment, proper dVT or Pe prophy-laxis, being cautious of thromboembolism. And you


Body contouring

The Chronicle’s John Evans speaks with Dr.Jonathan Toy, a plastic surgeon practicing inEdmonton who works with the Weight Wiseprogram, a multi-disciplinary program thatincludes bariatric surgeons, general surgeons

who do mostly laparoscopic bariatric sur-gery, as well as dieticians, psychiatrists, andnutritionists. He presented on the topic ofbody contouring in massive weight losspatients at the 2013 Annual Meeting at theCanadian Society of Plastic Surgeons Dr. Toy

please turn to page 26—


nTreating the Cosmetic Patient

The use of unregulated herbal supplementsis common among cosmetic surgerypatients, according to a single-centre study.many of these supplements contain ingredi-ents that may cause problems with clotting,blood pressure, or may cause dry eyes, rais-ing the risk of complications during andafter surgery, says Dr. Bahman Guy -uron, a plastic surgeon from Cleveland,ohio and the senior author of the study.

Published in Plastic and Reconstruct -ive Surgery (July 2013; 132(1):78-82), thestudy retrospectively looked at 200 patientswho underwent facial cosmetic surgery at asingle centre. “It was my observation thatthere were a lot of patients on herbal med-ications, and I didn’t know the in cid -ence,”says dr. guyuron, who also per-formed the surgeries. “We wanted to lookinto the scientific evidence, rather than justobservation.”

he found that nearly half—49%—ofhis patients were taking supplements of some form. While that number didinclude patients who were only taking vitamin and mineral supplements (25% ofpatients reported being in this category), the remainder were taking either somecombination of vitamin and mineral supplements along with animal- and plant-based supplements (22% of patients), or animal- and plant-based supplementsalone (2.5% of patients). further, 35 patients (17.5%) were taking something thathad been linked to increased bleeding risk, including bilberry, bromelain, fish oil,

flaxseed oil, garlic, methylsulfonyl-methane (msm), selenium and vitamin e.

The diversity of supplements beingtaken in the sample patients was also large.They reported taking 53 different types ofsupplements, an average of 2.8 per patient.one patient wasusing 28 differ-ent supplements,according to thestudy.

B e c a u s esupplements arenot regulated bythe u.s. fdA,there’ no way topredict withcon fid ence how they will interact, saysdr. guyuron, or even the degree of risk ofhematoma or intraoperative bleedingfrom those agents known to increasethose risks.

“most of the time, the doses are not calculated that well. most of the studies[on relative risk of bleeding] are based on a variety of similar products. so there isno way of having one hundred per cent accuracy about the risk. But I would saythat those herbal medications that cause bleeding are going to result in hematomasor intraoperative bleeding which frustrates the surgeon and cause the surgery totake longer than usual,” he says. “essentially, every patient who takes herbal med-ication and continues through the date of surgery is going to have an element of

that. how much, I can’t tell you.”

Problems with side effectsThe list of commonly used herbal sup-plements with surgically problematicside effects is long, according to dr.guyuron: ephedra, ginkgo, ginseng,kava, st. John’s wort, valerian, feverfew,ginger and more. But even consideringthat list, side effects or drug interactionsjust aren’t predictable, he says.

“frankly, we know some thingsabout the herbal medications, but we don’tknow everything about them,”he says.“They may have some side effects that wedon’t even know about, because theseherbal medications have not been scruti-nized the way that most other medicationsthat are fdA approved are scrutinized. sowe don’t know what else they can do.”


always have to be aware of any structural abnormalities that could be found in conjunction, that may appear during surgerysuch as hernias that are hidden, or other structural anomalies like that.

These patients are also much more complicated in terms of their psychiatric component. There is a significant psychi-atric component that can be involved with people who have lost a lot of weight. so that’ something that everyone has to beaware of, because it obviously complicates their consent as well as their post-operative care and post-operative course. sowe have to be cognizant of the fact that psychiatric co-morbidities may occur in the massive weight loss patient as well.

Is a psychiatric professional part of your multi-disciplinary team in Edmonton?generally yes. That’s part of the Weight Wise program in edmonton. There is psychiatric and psychological support forpeople throughout the process of weight loss from the start, and post-weight loss as well.

So then, what’s coming down the pipe in the near future regarding this type of body contour-ing? What improvements in technologies or techniques are being researched?As far as the massive weight loss plastic surgery, it has only really taken off in the last decade or so. There are alwaysimprovements in surgical techniques—to improve the longevity of techniques, to improve the ease of techniques, toimprove the results, to make the surgery more efficient. If you are operating on multiple different parts of people’ bodies,you have to be cognizant of the amount of time they are spending under anesthesia, so new techniques are always comingabout to im prove that. other than just simple straightforward excisional surgeries, some of the newer techniques in ourfield are attempts to use fat grafting for certain problems, and different types of procedures to improve the longevity ofthe surgeries themselves.

Body contouring—continued from page 25

please turn to page 28—

‘Taking herbal supplements?’

forget to ask


More plastic surgeons in Canada establish a primari-ly reconstructive practice than cosmetic practices,unlike in the United States where reconstructive sur-gery is on the decline, according a study publishedin the Canadian Journal of Plastic Surgery (Autumn2012; 20(3)163-168).

Researchers observed a transition away fromreconstructive surgery in the United States, possiblybecause of a decrease in reimbursements from insur-ance providers, rising malpractice and overheadcosts, a reduction in the number of residency train-ing programs, and increasing competition from non-plastic surgeons, and wanted to investigate if a sim-ilar trend was occurring in Canada.

The researchers sent a survey to 352 plastic sur-geons whose email addresses are registered with eitherthe Canadian Society of Plastic Surgeons and/or theCanadian Society for Aesthetic Plastic Surgery todetermine the type of practice the surgeons operated.A total of 120 surveys were returned, of which 75% ofrespondents indicated they had a practice that was pri-marily reconstructive and 25% had a primarily cos-metic practice. This compares with a 50% rate for bothgroups in the U.S.

“It seems that reconstructive plastic surgery isin good stead in Canada,” said Dr. JugpalArneja, with the division of plastic surgery at theBritish Columbia Children’s Hospital andUniversity of British Columbia. “Was I surprised?No, because I trained in Canada, so I understand theCanadian health care system, but what surprised meis the trend in the U.S., where plastic surgeons arenot being compensated as well as we are for recon-structive surgery and reimbursements are goingdown; some argue that the specialty of reconstruc-tive plastic surgery is on a downward trend due tofewer trained specialists in plastic surgery that arechoosing the reconstructive route.”

Dr. Arneja said the length of schooling requiredfor both reconstructive and cosmetic surgeons wasabout the same; however, the study’s authors notedthose who went into reconstructive surgery tended tohave a higher level of debt following residency (aver-age of $28,500 for reconstructive surgeons and$17,200 for cosmetic surgeons).

“Our results suggest that Canadian plastic sur-geons with greater educational debt following residen-cy are more likely to enter a reconstructive practice.Reconstructive plastic surgery may be viewed as amore secure option given the compensation models in

Canada and volume of work,” stated the authors. Another factor the authors surmised may be an

influential factor in determining the type of practiceis the surgeon’s length of career. The study resultsshowed that reconstructive surgeons transitioned tocosmetic practice later in their career. They alsonoted that this change does not happen abruptlybecause 71% of respondents had a mixed practice.

“We summarized that [cosmetic surgeons] are alittle bit older, so they have been doing reconstruc-tive surgery for a while, so maybe they were tired ofworking in a hospital setting and the bureaucracy,”said Dr. Arneja. “[As a cosmetic surgeon] you areyour own boss with a little bit more flexibility andmore decision-making capabilities when you haveyour own little office as and surgical suite asopposed to working in a hospital consisting of manymore moving parts.”

However, the authors stated there was no statis-tical difference in the number of hours worked perweek, vacation time taken per year, proportion ofsurgeons who haveuniversity appoint-ments or who workwith residents. Supply anddemand mis-matchDr. Arneja said eventhough the per cent ofplastic surgeons ishigh in Canada com-pared to aesthetic sur-geons, there is still a“supply and demandmismatch” for recon-structive surgery.

“If you look atmost reconstructiveplastic surgeons’ wait-lists, the time to firstsee a surgeon and sub-sequently the waitlistfor surgery, those met-rics are, if not months,sometimes years forsome surgeons, whileon the aesthetic side Iwould be surprised ifsurgeons have months

and months of waitlists,” said Dr. Arneja.In 2010, for every one plastic surgeon there was

approximately 70,726 Canadians compared to onesurgeon for every 39,466 Americans, according tothe study.

Dr. Arneja personally hypothesizes that recon-structive surgery is more appealing to Canadianplastic surgeons because the compensation modelsare acceptable and the field provides a greater varia-tion in work.

“In cosmetic surgery you do a limited numberof operations and for people who enjoy workingmany different anatomical areas, they may do morethan 100 or more different operations. I think if youwere a cosmetic surgeon you might knock that downto 20 to 30 operations,” said Dr. Arneja.

“ I enjoy the variety [of reconstructive surgery],so for me personally, I would say that the diversity isappealing and if you told me I was just a burn sur-geon or a breast implant surgeon and the only opera-tion I could do was burn surgery or augmentationmammoplasty, I would probably go crazy.”

—Emily InnesFor more information visit: http://ow.ly/soLw1

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CANADIAN LASER AESTHETIC SURGERY SOCIETY dr. guyuron insists his own patients stop using the supplements at minimumtwo weeks before the date of surgery.

Patients are likely to under report or not report herbal supplement use fora number of reasons, says dr. guyuron. In the case of a retrospective study suchas this one, patients may simply not remember what they were taking a year ago,he says. for patients currently taking supplements, “They may have two reasonsnot to share with you. one is that they don’t see the importance of potential com-plications, or they may not know about them,” he says. “The other is they mayhave some concerns that, since we are physicians, and mainly prescribe medica-tions that are evidence-based, they may think that we would think less highly ofthem if we know they are on herbal medications.”

These facts just emphasize the need for patient education, says dr. guyuron.“By educating them as to the reason why we are asking the question and howimportant it is for us to know what they are on, patients can be informed. Whenthey are informed, they may be more likely to share the information with us thanotherwise. so I think that when we educate the patients as to the reasons why weare asking these questions, we have been able to elicit more responses.”

supplement use varied significantly by age and gender, according to thestudy. herbal supplements were used more by women (89.8% of users werefemale), and non-herbal were more frequently used by men (77.5% of users weremale) (p<0.04). The choice to use herbal medications was also correlated withage (herbal, average age 51.4 years, non-herbal, average age 38.5 years,p<0.001). —John Evans

Herbal supplements—continued from page 26

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Invited Guest Speakers Dr. Doris Hexsel: Cellulite Update

Full Face Injections of botulinum toxinsDr. Mark Dupere: Surgical and Non-Surgical Approach to the Male FaceDr. T. Zmijowskyj: CMPA - Risk Mitigation Strategies in the Digital AgeCorey Dubeau, Atmos Marketing: Social Medial Marketing


llI am big fan of fibrin glue. I have been using since we used to get the european glue back in the’90s, and I think they do several things in a surgical patient. not used so much as a glue, butthey function as a sealant and allow a lot of the lymphatics to be controlled in the immediate

post-op period. you apply pressure for three minutes and you use the spray glue. They improve hemosta-sis, they decrease the postoperative swelling and bruising, and have helped me avoid braces or dressingsin most of my patients. That's helpful because they are swelling less, have less edema and more of patientcomfort.

—Dr. Renalto Saltz, Director of Saltz Plastic Surgery in Utah, and a guest speaker at the 2013 CLASS meeting in November

llPIh (Post-inflammatory hyperpigmentation) is one of the common concerns when decidingwhich patients are at greatest risk when having laser procedures. I find that looking at mypatients’ hands is the best predictor of risk. grading their palmar creases according to degree of

brown colouration, helps me maximize safety and minimize PIh by determining treatment spacing andsettings.

—Dr. Mark Lupin, Clinical Instructor on Faculty with the Department of Dermatology and Skin Science,University of British Columbia, and Director of the Cosmedica clinic in Victoria, B.C.

llAftercare Access: for patients who have procedures done at the office, it can be a nice policy tooffer your patients your email (some colleagues have mentioned the benefits of providingpatients with their cell phone number) to contact you if they have any questions or concerns.

Patients are quite pleased, and less likely to report problems with the procedure.

—Dr. Benjamin Barankin,Medical Director at the Toronto Dermatology Centre, Toronto

Here: Take mymobile number,please

Colouration onhands predicts risk for laser procedures

Fibrin glue meansless swelling, morepatient comfort

Pearls

Have you (or your colleagues) determined a Best Practice in aesthetic medicine that might deserve wider attention among your peers? Or have you picked upa takeaway message from a conference that you’d like to disseminate further? By all means, here’s the opportunity to share your knowledge and expertise.Forward your pearl to [email protected]



AtelierBeauty of the idealized human form, depicted through artistic expression through the ages

MEDICAL ASTROLOGYJoannes de Ketham, c. 15th cent.Fasciculo de medicina, folio b2 recto.

Courtesy U.S. National Library of Medicine



sun spots brown spots uneven skin tone

pregnancy mask freckles

day and night anti-spot lightening creams

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reduces the appearance of

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anti-rednesssoothing care

reduces the appearance of facial redness

with 2% Niacinamide and 4% Quassia extract*

soothes and hydrates

* Reference: Ferrari A, Diehl C. Evaluation of the efficacy and tolerance of a topical gel with 4% Quassia extract in the treatment of rosacea. J Clin Pharmacol 2012 Jan; 52 (1): 84-8.

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The Chronicle of Cosmetic Medicine & Surgery Spring 2014