Number #26 summary

Vascular treatments and erythematous scars
Which patients with prominent thread veins, portwine stains, angiomata and red scars post-surgery are likely to benefit from laser and intense pulsed light? Dr Peter Crouch gives his verdict

The two relatively discriminating targets for vascular treatments are haemoglobin and water. There are various factors that apply when crafting the treatment to match the patient’s needs.
First is the type of lesion. A correct diagnosis is essential for appropriate clinical management and for medico-legal documentation. Some lesions will require biopsy to confirm diagnosis.
Second is the depth of the lesion (or diameter of blood vessels), which is important for venous lakes/portwine stain and for thread veins. Third is the lesion’s location—bony prominences or thin skin such as shins and ankles or near the eye present challenges.
     Optical attributes of the lesion are another consideration. The choice of wavelength will depend on the photothermal attributes of the target Fitzpatrick skin type of the patient.
The skin type should always be considered, as melanin can be targeted by 532nm KTP, 585nm pulse dye and intense pulsed light treatment beams. You must be careful not to damage the melanin present when using any of these treatments. Uncomplicated non-facial haemangiomas
can usually be best left alone to resolve naturally—most do. Some patients request reduction and may have unrealisitic expectations so sensitive counselling may be required.

Pigmentation disorders
Unwanted dark spots account for about one in five visits to the dermatologist, says Dr Leslie Baumann

Hyperpigmentation is the general term for conditions that cause some patches of skin to be darker than others. It can be stubborn and induce stress. With a little insight into the biology of skin—and the increasingly effective lightening products on the market—almost anyone can see significant improvement in their complexion’s evenness.
     First things first: how is skin colour produced? The short answer is that melanin—its amount, quality, and distribution—creates human skin colour. The slightly longer answer is that melanin is produced within melanosomes, organelles located in the cytoplasm of melanocytes (skin cells in the basal layer of your epidermis). The number of melanocytes in human skin is the same in people of all races. In darker-skinned individuals, though, the melanosomes are larger and contain more melanin.
     Once melanin is produced, melanosomes migrate to the melanocytes’ dendrite tips, where they come into contact with keratinocytes, skin cells closer to the surface of the epidermis. The final stage of the pigmentation process, however, wherein melanin is transferred from the melanocytes to keratinocytes, is still poorly understood. Of course, that’s how pigmentation happens undisturbed by external influences. Doctors call the result constitutive skin colour (CSC), a person’s genetically influenced skin colour without the impact of UV light or environmental factors.

Local anaesthesia and facial aesthetics
Dr Brian Franks discusses the use of local anaesthesia for administering dermal fillers

As with all facial aesthetic procedures, optimum client comfort is essential. This is obtained through the administration of local anaesthesia (LA) when dermal fillers are applied to the lips.
However, the administration of LA is just as important for client comfort as the result of LA itself. It is not about just “thrusting” the LA needle into the gum tissue. It is the technique of administering painless injections which will enhance your clinical reputation.
     Also, in this as yet unregulated industry of facial aesthetics, have you ever thought about the consequence of not having proof of adequate training should a client suffer any adverse effect due to the administration of LA? Would your insurance company pay up in the event of a claim? And if a civil action were taken, would the judge look favourably on you if you had no proof of formally recognised training in the provision of LA?
     The two most common sites for LA administration recommended for lip anaesthesia are the infra-orbital for the upper lip and mental block for lower lip. These are best administered intra-orally. They can be administered extra-orally through the skin but, unless you are very skilled at this technique, my belief is that the intra-oral route is less likely to give rise to complications.

Whitening and veneers
Dental smile lifts are the simplest way of taking years off appearance without going under
the scalpel, writes Dr Nik Sisodia

There has never been a better time for those who wish to improve their smile to seek help from a cosmetic dentist. In many cases, simple changes are all that are required and can transform people’s lives.
     Many who have undergone such treatments report much more confidence in social situations, better progress in their working lives and generally feel better about themselves. This is not at all surprising as research both in the UK and USA has shown that dental appearance affects how others perceive our intellectual ability, honesty, social standing, socio-economic background, psychologic adjustment and a whole host of other personal characteristics.
     Having a nice smile also elevates social attractiveness. Studies carried out over 20 years ago established that nicer, more even smiles were perceived as friendlier, of a higher social class, and had greater intelligence, all things that prospective partners are likely to find attractive and desirable.

Facial wasting treatments
Dr Sean Cummings discusses the aesthetic products he uses and his methods for treating facial-wasting, resulting from HIV and anti-retroviral drugs

Facial wasting will affect up to approximately 40 per cent of people with HIV who are taking modern anti-retroviral drugs (ARVs). Facial wasting results from fat-loss in the underlying skin and from loss of other tissue volume, such as muscle. The consequences are profound with deterioration in social interaction, withdrawal from work, reduced potential at work and in developing major, life-enhancing relationships.
     The great paradox is that ARVs are life-saving, reducing mortality and morbidity from previously lethal complications of HIV disease. At the same time they cause massive body distortion, resulting in stigmatising and clearly recognisable features of HIV disease. The consequence for many is now a perverse avoidance of diagnosis, so as to avoid the development of a major wasting syndrome that will identify those individuals as being HIV positive.
     Facial wasting has proved difficult to reverse. There are particular culprits within the range of ARVs, and these are being withdrawn from first-line treatment where possible. Disturbingly however, perhaps due to cost, approximately 30 per cent of people treated in the UK are still being treated with these drugs.

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