In Depth | March 2014 Plastic Surgery Practice
By Wendy Lewis
As Audrey Hepburn said in the movie Sabrina, released in 1954, “Paris is always a good idea.” This is especially true when you are eager to stay on top of the trends in aesthetic medicine and surgery.
And International Master Course on Aging Skin (IMCAS) Paris 2014 was not a disappointment. “For the 16th IMCAS Congress, we welcomed over 4,500 delegates representing 80 countries, with more than 300 international speakers,” said IMCAS Course Director Benjamin Ascher, MD, chairman and head of the Clinique of Aesthetic Surgery IENA in Paris.
The theme of IMCAS Paris 2014 was “Feed Your Science Craving.” The group convened at Le Palais de Congres to hunt for the next big thing, and 166 exhibitors generated enough excitement to keep them engaged rather than shopping the winter sales.
“The congress continues to grow in attendance and scope of content, and remains the premier ‘go-to’ event for new clinical research and product launches,” said Rockville, MD-based dermatologist Hema Sundaram, MD, who serves on the IMCAS Paris 2014 Scientific Committee.
The worldwide market for medical aesthetics was valued at €460M, or $625M US, in 2013, which represented a 7.3% increase over 2012. This included the key four sectors: body contouring and energy devices, fillers, toxins, and cosmeceuticals. By 2018, the market total is estimated to rise to €670M, or $910M US.
Although the US has experienced the most consistent growth at 7% annually, Latin America (9%) and Asia (12%) are passing us by and Asia Pacific shows the strongest growth trend. The top 10 countries for medical aesthetics are, in descending order, the US, Brazil, China, Japan, Mexico, Italy, South Korea, India, France, and Germany.
The IMCAS Industry Tribune panel also noted a sustained resiliency of the medical aesthetics sector. A race for technology was seen with the acquisition of medical equipment as a vehicle to better penetrate doctors’ clinics, add value to the brand, and pave the way to deliver upgrades. An overriding goal of the major players in the aesthetics market (such as Allergan, Valeant, Galderma, and Merz) appears to be to emerge as a fully vertically integrated brand, as demonstrated by recent acquisitions. For example, Valeant has recently acquired a host of companies, including Solta Holdings Inc, Medicis Pharmaceutical Corp, and Obagi Medical Products Inc.
QUOI DE NEUF
This being Europe with far more lax regulation for medical devices to gain a CE Mark, there were several new items of note. Innovations and medical devices to improve the predictability of the lipofilling process created a lot of excitement at the conference. Guy Magalon, MD, a plastic surgeon from Marseille, France, presented his experience with fat grafting utilizing the new Puregraft® 50 System, which just received FDA clearance in the US. Unlike centrifuge techniques, Puregraft maintains the integrity of fat tissue structures through the use of gravity and a proprietary filtration technique. “We are able to obtain a healthier, more viable graft more rapidly,” he said.
Clinical researcher Serge Mordon, PhD, of the French National Institute of Health and Medical Research in Lille, France, provided an overview of new techniques for scar reduction, concluding that the initiation of laser treatment within the first few weeks after injury may prevent adverse scar proliferation. The LASH® (Laser Assisted Skin Healing) Treatment from Ekkyo was originally an 800-nm diode laser that has been upgraded to 1,210 nm to avoid complications with melanin, so that skin types I-VI can be treated safely.
He also described ReCell® (Avita Medical) Spray-On Skin™ as a stand-alone autologous cell harvesting, processing, and delivery technology that uses the patient’s own cells to accelerate wound healing and minimize scar formation. “ReCell® is a cell culture product that allows for the
immediate processing of small split-thickness skin biopsy to produce a complete population of cells, including keratinocytes, melanocytes, Langerhans cells, and fibroblasts,” he explained. ReCell® is under clinical investigation and is not approved for marketing in the US at this time.
Several twists on injection systems were also attracting attention. RollerJet® was demonstrated by Milanese plastic surgeon Daniel Cassuto, MD. This device is a multi-needle syringe intended for transdermal delivery of filling substances. The device creates micro channels below the dermal epidermal junction to infuse material of the physician’s choice.
Juvaplus, Geneva, Switzerland, displayed its Juvapen™ cordless powered injection system that consists of three speeds of injection, flow modes and drop modes, and is compatible with most syringe types.
LE VIEILLISSEMENT DU VISAGE
Great controversy erupted concerning the way faces age and how aesthetic physicians evaluate facial aging to determine the best treatment protocol.
“Great anatomists and iconic plastic surgeons … have challenged the traditional assumptions about facial aging and came up with results that leave us with a challenge of our own: to make sense of some of our past rejuvenation techniques,” said Parisienne Maxillofacial Surgeon Nelly Gauthier, MD, who received the IMCAS Award this year for the best program. “But most importantly, those discoveries about facial aging open the path to future directions to improve our rejuvenating treatments and fulfill this acute, ever-growing consumer need to keep looking young for longer.”
She continued: “My aim with this program was to detail those discoveries and confront them with the actual treatments. Are we performing real rejuvenation or real transformation of faces? It seems we often do the latter. Knowledge is power, and I wanted to give the audience a little bit of both.”
Plastic Surgeon Val Lambros, MD, of Newport Beach, Calif, began the definitive longitudinal study of aging in 2005. His research incorporates repeated observations of faces over long periods, often several decades. “We understand facial aging by the things that we do to try to correct it. Our perception of aging is evolutionary and hard-wired in the brain,” he said.
Lambros asked the crowd, “What makes people look older?” “There are many sufficient conditions to consider, including old skin, deep creases, and the ratio of eyes and mouth,” he answered. “Weight has profound effects on aging. Fat people age differently because they have less wrinkles and more deep creases,” he concluded. “Deflation can mimic descent. The face is not a digital structure; it is analog. It has curves, and curves have meanings and can tell you things. Even tiny physical changes can make huge perceptual changes.”
Lambros pointed out that certain components of the aging process are almost universal, such as the fact that the upper lip thins and stretches and the lid cheek junction remains stable. “Just because you can pick it up doesn’t mean that it fell down. Just because it didn’t fall down doesn’t mean that you shouldn’t pick it up,” he said. “Easy conclusions are learned quickly, but the longer term is needed to be able to prove what happens with the formation of jowls and the flow of tissues in the cheek. It is frustrating and demanding research that will take decades to complete.”
Philippe Kestemont, MD, a facial plastic surgeon in Nice, France, presented his anatomical approach to facial filling. “There are two points of balance in the face: the eyebrow and the labial corner,” he said. He explained his injection technique using SoftFil® cannulae for enhanced precision.
The surgical tracks focused on facial and body techniques, with special attention given to rhinoplasty.
New York facial plastic surgeon Minas Constantinides, MD, presented a technique dubbed, “The Lateral Crus Canting Suture.” “This technique enhances the aesthetics of the alae and tip while at the same time opening the internal nasal valves,” he said. “It specifically elevates the inferior border of the lateral crus of the tip cartilage, stabilizing the nostril edge without the need of additional cartilage grafting. At the same time, it elevates the inferior border of the upper lateral cartilage, which opens the internal nasal valve.”
A new ultrasonic rhinosculpture technique was presented for the first time by Parisian plastic surgeon Olivier Gerbault, MD, an IMCAS course coordinator. Gerbault has been working on this project and designing the specialized instruments for more than a year. “This method involves a set of instruments designed to trim and reshape the nasal bones with a piezoelectric motion of the inserts,” he said. “It allows a very accurate control of the fracture lines, without any irradiated fractures.”
Moreover, the soft tissues are spared, without any risk of injuring the skin or the mucosa, Gerbault explained. “The nasal bones can easily be trimmed and also reshaped with rasps and burrs. This breakthrough technology simplifies rhinoplasty, while decreasing postoperative bruising for patients.”
The whole category of injection devices and innovative instruments has exploded in Europe, and in the past few years it has made its way to the US. Europe is swimming in fillers of all shapes and sizes, including discounted products flooding the market from Asia.
Hassan Galadari, MD, a dermatologist from Dubai, presented the results of a split-face clinical comparing a novel filler, Ellansé (polycaprolactone) S to a leading hyaluronic acid gel (Perlane). “I have been using Ellansé since 2009 and have not had any permanent complications and no granuloma,” he said.
It is a microsphere-based product that is essentially composed of the same material as Monocryl and made into an injectable gel. The filler comes in four different types. The Ellansé dermal filler family includes
S, M, L, and E. “Ellansé E lasts for about
4 years and is ideal for HIV patients. The
S and M last from 1 to 2 years, respectively, and are what I use most often.”
Herve Raspaldo, MD, a facial plastic surgeon from Cannes, France, presented data on Juvéderm® Volift® with Lidocaine for facial sculpting using Vycross hyaluronic acid gel (Allergan). “Vycross is as good and as advanced as Voluma, but it is softer and more forgiving,” he said.
He also presented the results of a scientific study comparing Volbella with Restylane in the lips. “We found that there was a better outcome and less adverse events with Volbella, which is softer, malleable, and gives more natural and predictable lips.”
Parisian plastic surgeon Pierre Nicolau, MD, presented some severe complications from permanent filler injections using polyacrylamide gels. Specifically, vascular problems represented 16% of complications, or four cases per 10,000 injections, and full necrosis occurred in four cases per 100,000 injections. “The most common risk comes from direct injection within an artery. The risk factor for vascular problem is using a too thin needle, too much volume, and too much pressure,” he said.
Dermatologist Philip Levy, MD, from Geneva, Switzerland, best known for his coveted Nefertiti Lift technique, introduced a novel facial injection concept. “I advanced an original Hyaluronic acid gel lip rejuvenation injection technique combining both a precise four-point sequence to lift the corner of the mouth associated with an original central lower lip natural plumping.”
Florida dermatologist Susan Weinkle, MD, spoke on periorbital rejuvenation using multiple modalities. “Periorbital chemical peeling is often overlooked as an adjunct to treatment of this area with neuromodulators and soft-tissue augmentation.”
The tear trough is challenging, she said. “Even when the Hyaluronic acid is placed in the deep plane, you can over time begin to see a tyndall effect due to weakness of the obicularis oculi muscle. Therefore, using superficial placement with a 32g needle and a Hyaluronic acid that does not appear to cause tyndall is an excellent alternative.”
Another new filler from Korea and LG Life Sciences is Yvoire®, called a Reliable HA material, that utilizes a technology to stabilize high-concentration, high-molecular-weight cross-linked Hyaluronic acid. There are two variations: Classic and Volume.
Fat grafting is also experiencing a resurgence. “Thanks to the advent of volumizing fillers, the patient awareness of facial atrophy is driving the quest for a longer-lasting, more economical full face filler,” said New York dermatologist Lisa Donofio, MD.
Fat freezing and melting, breast augmentation with fat and implants, and vaginal rejuvenation were among the main themes presented during body sessions.
“The use of lasers for vaginal rejuvenation is one of the groundbreaking developments which can have a huge impact on patients’ quality of life,” said British plastic surgeon Christopher Inglefield, MD, who chaired a session on Vulvovaginal Rejuvenation. Bernard Mole, MD, a Parisian plastic surgeon, presented about a unique filler. “Vivacy Desirial® is specifically developed for vaginal injections,” he said. “Desirial, which is a cross-linked Hyaluronic acid gel that is injected into the dermis of the labium, works to maintain elasticity and proper functioning of female genital tissue, which can become thin and dry.” Desirial® Plus is also used for remodeling the labia majora. Vivacy is unique in that it contains mannitol, a natural antioxidant, incorporated into a monophasic gel.
Inglefield also presented a new type of breast implants, B-Lite Breast Implants, that are currently under clinical investigation. “This represents the most significant development in breast implants for 30 years,” he said. “B-Lite is two-thirds the weight of standard implants, thereby reducing the long-term consequences of implant tissue interaction.”
Syneron Medical presented a comprehensive Body Shaping Symposium featuring the new VelaShape® III and UltraShape® systems. According to Boca Raton plastic surgeon Jason Pozner, MD, “Syneron’s new VelaShape III is a hotter device. The radiofrequency (RF) energy has more power, so it works better and heats up tissue in much less time, providing more consistent results with less discomfort.”
LA TECHNOLOGIE MÉDICALE
There was a big emphasis on new equipment and medical devices, many of which demonstrated added versatility, smaller size, and increased ease of use.
New Jersey dermatologist David Goldberg, MD, presented a synopsis of RF monopolar deep volume heating, bipolar superficial heating, and unipolar that heats like a microwave oven. “Unipolar devices, such as Alma VShape™, have been used to treat cellulite and skin tightening. New RF devices can also melt fat cells from BTL Aesthetics Vanquish™ and InMode
Venus Concept introduced its new Venus Legacy workstation, featuring LiftFx™ and SculptFx™. “With Venus Legacy, there is a wonderful opportunity to delve into body contouring,” said Nashville dermatologist Michael Gold, MD. “The 4D technology platform combines multipolar RF, pulsed electromagnetic fields, and adjustable pulsed suction with real-time thermal feedback.”
The next generation to be introduced in the near future will be Venus Viva™, a portable unit offering fractional RF. “The Venus Viva is a new-generation fractional radiofrequency technology that can be used on all skin types for skin tightening, acne scarring, and pore shrinkage,” added New York dermatologist and PSP editorial advisory board member Neil Sadick, MD.
Dermatologist Mukta Sachdev, MBBS, MD, from Bengaluru Area, India, gave several presentations on potential complications in darker skins and how to avoid them. She introduced “grid fractional technology,” a newer technology used for nonablative rejuvenation for darker skin types. She emphasized patient selection, avoiding complications, and managing postinflammation hyperpigmentation as the best ways to ensure best physician and patient outcomes.
Dermatologist Raechel Eckel, MD, from Ireland conducted a workshop on treating healthy skin, sponsored by ZO® Skin Health. “According to Dr Zein Obagi’s classification, unhealthy skin is discolored, rough, diseased, dry, sensitive, and loose,” she said. “Deciding as a physician on whether I need topical agents or peels as well depends on where the pigmentation is. If the pigment has gone deeper into the dermis, it will require a peeling agent. Hydroquinone is only safe to use for a period of 5 months. After that, we cannot continue to treat pigmentation with hydroquinone.” Eckel added that lasers should never be a first-line treatment for pigmentation.
German dermatologist Welf Prager, MD, presented the results of a clinical trial combing cosmeceuticals and lasers. “Combination of different treatments lead to improved results through synergistic effects, and starting patients on a cosmeceutical program pre-, peri-, and postprocedural is very much appreciated by the patients,” he said.
The study combined nonablative fractional Laser (Emerge 1410 nm Diode Laser, Palomar) with CEFerulic® (SkinCeuticals) directly applied after laser treatment. “Due to perforation of the skin, the uptake of the products is significantly increased,” he said. “We concluded in our study that the use of antioxidants in CEFerulic® is safe in this setting and improves the outcome of the procedure. Due to reduction of oxidative stress, the downtime was reduced, and the outcome for reduction of wrinkles and dyschromia was enhanced.”
Finally, IMCAS 2014 marked the second edition of the Humanitarian Awards. La Jolla Plastic Surgery’s Steven Cohen, MD, presented three special awards dedicated to the memory of the late Thomas Rees, MD. The winners were German Plastic Surgeon Andre Borsche, French anesthesiologist Jean-Michel Ekherian, and Italian dermatologist Professor Torrelli Lotti for their outstanding medical contributions and humanitarian efforts.
For more info, visit www.IMCAS.com.
Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, ?www.wendylewisco.com, founder/editor in chief of beautyinthebag.com, and a contributing editor to Plastic Surgery Practice. She can be reached at [email protected].
Original citation for this article: Lewis, W. The Last Time I Saw Paris: Live from International Master Course on Aging Skin Paris 2014, Plastic Surgery Practice. 2014; March: 22-25.