Issue #21 summary - GO BACK TO ARCHIVE

Nipping PCOS in the bud
Nancy was 32 years old and was referred because of a thyroid nodule which, on fine needle aspiration, was found to be benign. Taking a careful history, Nancy complained of severe fatigue, steady weight gain (despite being careful), acne before her periods, unpredictable periods, and extreme mood swings. On investigation, she was found to have polycystic ovarian syndrome (PCOS).
   I started her on a low glycemic index (GI) diet and regular exercise, and prescribed metformin. Her initial weight was 165 pounds and she was quite frumpy in appearance and dress. Within 14 months, she weighed 130 pounds, developed a curvy figure and reported boundless energy She was promoted at work, which was likely due to greater self-esteem.
   The accurate diagnosis of PCOS, combined with lifestyle changes and an insulin-sensitising drug, transformed Nancy’s entire physique.
   PCOS affects a staggering number of women. One-quarter to one-third of women of reproductive age suffer from PCOS, most of whom have severe insulin resistance. Both are a major health hazard for women of all ages.
   PCOS, in particular, is a risk factor for diabetes, heart disease, fatty liver, uterine cancer, serious sleep disorders, depression, miscarriages, multiple pregnancies and preeclampsia. Fortunately, PCOS is manageable. A programme that includes medications that sensitise the body to insulin, as well as lifestyle changes that address metabolic basis of of PCOS, can be remarkably effective. One of the key elements of this programme is following a low GI. Low GI eating emphasises foods containing carbohydrates that break down slowly, thus releasing sugar into the bloodstream slowly, keeping the blood sugar more stable.

Saline versus silicone
In Europe, silicone-filled implants are by far the most popular type. Their saline counterpart accounts for a minority share of the market. By contrast, the opposite is true in the US, because the availability of silicone implants was restricted in the early 1990s owing to the belief the substance may be carcinogenic and cause or contribute to tissue diseases.
   At present, silicone gel-filled breast implants are available for select cases: women seeking breast reconstruction or revision of an existing breast implant, women who have had breast cancer surgery, a severe injury to the breast, a birth defect that affects the breast, or a medical condition causing a severe breast abnormality.
   Silicone, however, appears destined for a comeback in the US, primarily because years of internal investigations have not proven silicone to affect a patient’s health. Improvements to the implant—chiefly, the replacement of liquid with gel—have also been a contributing factor.
   Europe has also been active in researching the safety of silicone implants. Studies have repeatedly shown there to be no link between the implant and cancer or autoimmune diseases.
In the US, two major medical device companies—Inamed, a division of Allergan, and Mentor Corporation­—manufacture silicone gel-filled breast implants. Both have been conducting long-term clinical trials in answer to the FDA’s call to prove that silicone gel-filled implants are affirmatively safe and effective.
   Inamed is conducting several clinical trials on silicone-filled breast implants. One is a study of Inamed’s Style 410 cohesive silicone gel-filled breast implants. Over 10 years, 940 patients will be monitored. Inamed has made several silicone-filled breast implant products available to patients meeting eligibility criteria. Data is to be collected through five years of patient follow-up.

Complementary modalities
Laser medicine has played a central role in the development of invasive and non-invasive aspects of cosmetic science over the past 20 years. The recent addition of radio frequency, infra-red technology and fractional resurfacing for tissue tightening and contouring has enabled a multi-modality use of light and sound frequencies for facial rejuvenation.
   As a high-tech society, we accept cosmetic procedures as a norm rather than surrendering to growing old gracefully. Lasers have cut a niche in cosmetic surgery and non-surgical facial rejuvenation as the demand for these procedures is at an all-time high.
   In our clinics, we have 23 individual laser frequencies that we use in our daily practice.Newer technologies seem to be appearing often, and whether we acquire them or not, we all need to keep abreast of advancements and modern developments.
   There is a certain core knowledge that laser physicians must possess to be able to practise safely, and the emerging knowledge is what is considered topical or “hot”. The quality of the final results of laser treatment depends on technical expertise, good judgement and, to some extent, luck.
   The treatment of photo-ageing and natural ageing of skin has changed significantly over the past three to four years. Light-based therapy, non-ablative lasers, ablative lasers and radio-frequency have gained popularity. The three most exciting developments in the field of cutaneous laser medicine are Fraxel, Thermage and Portrait.
   The use of ablative lasers has reached a peak, and the higher potential of side-effects has levelled to a reasonable degree. Fractional resurfacing combines the tissue-
tightening properties of ablative lasers with the improvement of skin texture and pigmentation of non-ablative lasers.

High performance lasers
Founded in 1964, only four years after the invention of the first operable laser, Fotona has been involved with lasers since their very conception. Fotona first began producing lasers for use in defense and communications and subsequently moved into industry and medicine.
   Fotona produces most of the components in their laser systems in-house. This, along with stringent testing for all products, means it can ensure its laser systems are of the highest quality, reliability and durability and in compliance with all applicable international standards.
Regardless of their application, all of Fotona’s systems are subjected to strict temperature and vibration tests in line with the most stringent military standards. Alongside its unique in-house manufacturing and testing capabilities, Fotona has longstanding partnerships with several leading universities, clinics and medical research institutes worldwide. These relationships enable the company to pioneer new technologies and applications.
   Fotona was one of the first companies to move into the medical laser market. The technology and know-how from its work in defense and communications, combined with its exceptional production and R&D capabilities, have seen medical lasers become Fotona’s main business. The company produces a comprehensive range of laser systems meeting the demands of medical professionals, dental practitioners, and increasingly the spa and beauty segments. The product range serves all the aesthetic market segments, from entry-level systems to versatile combination laser systems that are able to provide an enormous range of applications.

Medical laser eyewear
Standards in the European Union make great demands on laser safety eyewear. Laser protection glasses need to ensure that for the specified laser light both the attenuation factor is high enough and that no, or only a small and safe part of the light, can reach the human eye.
The second part of the standard is the most difficult to achieve because, for a direct incident laser beam, the laser safety eyewear needs to keep protection for a minimum of 10 seconds or 100 pulses.
   Classification starts from class 1 (safe for the human eye) and ends with class 4 (even scattered light is dangerous). The limit for class 1 lasers is equal to the MPE (maximum permissible exposure) value for the unprotected eye without the risk of any damage.
   For laser protection glasses a rough estimation is that, behind the glasses, these class 1 values should not be exceeded even in the case of a direct laser hit.
   When choosing protective eyewear, it is essential also to take adequate care when selecting frames. Frames’ material can be much more readily damaged and even penetrated by the laser than the filter itself. It is common practice to give additional protection to the frames by adding metal inserts, making them suitable for higher power lasers.
   Lightweight plastic glasses, which are more convenient to wear, do usually have lower protection due to the requirement to protect for at least 10 seconds. It can be challenging to find the best compromise.

Attacking thread veins
The TC3000 treats fine thread veins, telangiectasia, psoriasis and rosacea, resulting in the immediate and lasting disappearance of the vessels on legs, face and other body parts, says its manufacturer, F Care Systems.
   The TC3000 can treat small vessels that cannot be treated with micro-sclerotherapy. It can also treat vessels on areas such as ankles and face where micro-sclerotherapy cannot be used.
Unlike a laser, the TC3000 has no side-effects such as de-pigmentation and scarring, and is not painful. Also, a well-done treatment with the TC3000 will work on all skintypes.
   A treatment takes 10–15 minutes, during which 40–70cm of veins can be treated. The patient may resume everyday activity immediately.
   The TC3000 technique, says F Care, has some major advantages: instant, long-lasting results—the vein disappears immediately; fast; can be used on all areas, including ankles, knees and face; no bandages are needed; relatively painless; all skin phototypes; all seasons; and easy to use
   What is equally important is the lack of side-effects. There is no depigmentation, allergic reactions, burns, necrosis and inflammation, says F Care. The thermocoagulator uses a high frequency energy pulse. This pulse produces a thermal lesion, resulting in the instant disappearance of the vessel.

Adjusting the volume
I have performed “refreshing” techniques for 10 years, offering patients an alternative to the classical facelift for facial rejuvenation. I have also treated faces that have been over-stretched by the traditional facelift techniques.
   Refreshing does not give the same results as rhytidoplasty: it is a more gentle, facial recontouring procedure and complements other facial techniques.
   My technique of superficial syringe liposculpture uses the finest cannulas to recontour the jaw line and inject fat into the naso-labial, malar and glabellar regions. This postpones the first facelift or complements older patients’ facelifts.
   My concept of facial rejuvenation has altered. I was never happy performing facelifts on young patients aged 35–45, because I was reluctant to put an extensive and permanent scar on “borderline age” cases. I felt there was another approach to stretching the skin to accomplish the “younger look”.
   Before liposuction, little could be done. The ‘so-called’ mini-lift of the temporal or cervical regions still has the stigma of rhytidoplasty.
   Blepharoplasty solves the problems of excess skin, muscle and fat within the orbital region. It is a wonderful procedure, made quicker and safer with a CO2 laser, giving a three–four day recovery time. It solves the eyelid problems thoroughly and leaves inconspicuous scars.
Using the trans-conjunctival incision, I avoid the lower eyelids’ skin incision. After removal of the fat, skin retracts in 90% of patients.
   The fine wrinkles that do not disappear with the procedure can be treated with the light alphahydroxic peels, especially with 70% glycolic acid, or even with a CO2 laser peel. I rarely revise excess skin after the second post-operative month.

Posterior necklifts
The ageing skin and the skin folds of the neck, especially below the Adam's apple, cannot be elevated by means of a facelift. But I have used a technique where the submental and submandibular areas are liposuctioned.
   Through a postauricular incision close to the hairline, the whole neck is undermined up to the fossa jugularis, and the skin of the neck is lifted and sutured to the mastoid and occipital bone to apply a proper traction. To avoid facelift and to correct an ageing neck this technique is modified in younger patients, which helps avoid facelift operations at an early age. This method elevates the submental region and corrects the results after neck liposuction.
   The advantages of this technique are fewer injuries, invisible scars behind the ears, short recovery time and low cost. A submental liposuction of the back of the neck and a facelift alone will not be able to eliminate the skin folds and the skin damage at the lower half of the anterior neck. This angle differs between 105-120 degrees and makes a young appearance of the neck possible.
   The hypertrophied submandibular gland, or a ptosis of the platysma muscle which hangs down, causes a bad result when using liposuction alone. Up to now, surgeons have been performing a facelift, or operating on the neck, by removing a part of the gland or by making a special platysmal suture- both resulting in terrible scarring.
   The advantage of the method I use is that it avoids the problem of an undesirable scar in front of and behind the ears. Nor is there the risk of hair loss because of incisions in the scalp.
A 5-6cm incision behind the ears is needed for the fixation of the skin and fascia coli to the periost of the mastoid and occipital bone. Excision of the skin in this method is neccessary to give an extra pull to the skin of the lower neck.

Bioidentical hormones and natural menopause
The average age of menopause is 52 years, but declining hormones start peri-menopause at least 10 years before. A common concern in clinical practice is the end of the fertile years. The onset of menopause often coincides with the “empty nest” syndrome, when children leave home and parents start to become elderly, or sometimes when the whole of a woman’s stable life changes because of divorce or a new partner. There is also a decline in sexual drive and sexuality; the onset of menopause is sometimes related to a decline in testosterone and, therefore, sexual drive.
   The factors that affect menopausal age are genetic, geographical, nutritional, smoking, reproductive history and oral contraception. A loss of confidence can occur because of poor body image due to changes in skin condition, hair, which may be thinning or loss of hair and increase in body weight. In combination with hot flushes, a women may feel embarrassed as well as debilitated, and this can lead to considerable anxiety.
   Common symptoms in menopause will often include hot flushes, night sweats, abnormal skin sensation, not wanting to be touched and irritation by clothing. This can be due to low oestrogen levels.
   Other common symptoms are irritability, mood swings, hyper-anxiety, loss of memory and concentration. Headaches may be related to menopausal hot flushes. Insomnia—often connected to increased sweating at night—can lead to extreme irritability and tiredness. At the same time, some women complain of low energy and stamina.
   The changing pH in the vagina, attributable to loss of oestrogen, can be a cause of discharge and irritation, as well as stress incontinence. A reduction in intensity of orgasm and considerable sexual dissatisfaction is of common concern.

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