Aesthetics November 2016 by Aesthetics & CCR

! m ok co st bo s. La to ard ce aw an cs ch eti h st ae

VOLUME 3/ISSUE 12 - NOVEMBER 2016

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Biofilms CPD Dr Souphiyeh Samizadeh details the formation and treatment of the bacteria-based infection following dermal filler injections

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Special Feature: Acne Scarring

Smile Enhancement

Networking Sucessfully

Practitioners discuss how they effectively treat acne scarring using laser devices

Dr Rupert Critchley shares his techinques for improving a smile using botulinum toxin

Dr Kieren Bong advises how to build valuable relationships through networking

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CONTOUR & DEFINE

Contents • November 2016 06 News

The latest product and industry news

13 Conference Report: BCAM

Aesthetics reports on the highlights of the BCAM Conference

14 Allergan Report

Aesthetics visits Allergan Pharmaceuticals in Ireland to learn more about the Botox manufacturing process

16 News Special: Treating Adverse Events

Aesthetics investigates treatment complication costs to the NHS

Special Feature Acne Scarring Page 21

19 Conference Preview: ACE 2017

A look at the Premium Clinical Agenda

CLINICAL PRACTICE 21 Special Feature: Acne Scarring

Practitioners discuss how they treat acne scars using laser devices

26 CPD: Biofilms

Dr Souphiyeh Samizadeh examines the formation and treatment of biofilms

31 Smile Enhancement

Dr Rupert Critchley details techniques for improving a smile using botulinum toxin

34 Treating Permanent Dermal Filler Complications

Mr Niall Kirkpatrick and Mr Pericles Foroglou discuss permanent filler complications and explain how they are removed

39 Hair Transplantation

Mr Asim Shahmalak details the recent developments in hair transplantation

43 Advertorial: SkinCeuticals

Introducing Phyto Corrective Masque to the SkinCeuticals Correct Range

44 Periocular Complications

Mr Daniel Ezra advises how to avoid and manage complications associated with treatment around the eyes

48 Advertorial: Radara

Radara – restoring skin health and radiance with microchannelling

49 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 51 Providing Competent and Valuable Consultations

Nurse prescriber Elizabeth Rimmer discusses educating in consultations

54 The Elevator Speech

Dr Harry Singh explains how to effectively market your services in 30 seconds

57 How to Network Successfully

Dr Kieren Bong shares his tips on how to network effectively

63 Balancing Home and Work Life

Global business executive Reece Tomlinson discusses the importance of a work-life balance

67 In Profile: Jane Laferla

Independent nurse prescriber Jane Laferla details her career in aesthetics

69 The Last Word

Intravenous therapy business owner Sarah Lomas argues why the treatment should be aligned to the aesthetic market

Networking Successful Networking Page 57

Clinical Contributors Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in aesthetic medicine. She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic and presents at both national and international conferences. Dr Rupert Critchley is the lead clinician and director of Viva Skin Clinics. After qualifying as a medical doctor in 2009, he has completed an array of courses in advanced non-surgical aesthetics; attained MRCS part A and is also a fully qualified GP. Mr Niall Kirkpatrick is a consultant craniofacial plastic surgeon at the Chelsea and Westminster Hospital NHS Foundation Trust in London. He gets many referrals by clinicians to both the Craniofacial Unit and his private practice to remove permanent fillers. Mr Pericles Foroglou is a consultant plastic surgeon and associate professor of plastic and reconstructive surgery at the Aristotle University of Thessaloniki. He has a special interest in craniofacial and aesthetic surgery. Mr Daniel Ezra is a consultant oculoplastic surgeon in Moorfields Eye Hospital in central London, where he is also the research lead and training director for oculoplastic surgery. He runs a private practice on Harley Street and Moorfields. Mr Asim Shahmalak is a hair transplant surgeon and studied at the University of Karachi, Pakistan. He founded Crown Clinic in Manchester and also has consulting rooms in Harley Street. He has been a hair loss expert on the Channel 4 show Embarrassing Bodies.

NEXT MONTH • IN FOCUS: The Evolution of Aesthetics • Treating Obesity with Botulinum Toxin • Overview on Treating the Neck • Going Self-employed

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Editor’s letter It’s November already and we are quickly heading towards Christmas – but before the seasonal festivities, the social event of the aesthetics calendar is fast approaching – the Aesthetics Awards! So get your outfits Amanda Cameron ready for December 3. We still have a few Editor tickets available – buy them now and make the Awards your Christmas celebration. The judging is well underway and we are pleased to say that we have had a record number of votes this year – we are very excited to find out who the winners are at the Awards ceremony. The busy conference season has now come to an end for this year; you will find our conference report on the British College of Aesthetic Medicine’s event on p.13. The next big UK conference will be the Aesthetics Conference and Exhibition (ACE) 2017 on March 31 and April 1, and I am delighted to say that we have many of the speakers in place already. I believe we are still the only conference to have a completely independent Premium Clinical Agenda (p.19), without sponsored sessions, ensuring the views and experiences presented are balanced. The fact we have had so

many registrations already is an indication that a number of you may value this as well. In this month’s journal we have a focus on lasers. I don’t think I have ever before seen so many laser companies vying for your business. With the large number of lasers on the market, we have decided to investigate what types should be used to treat a common skin concern, acne scarring, in our Special Feature on p.21. With the huge psychological impact of acne and acne scarring, it is important for practitioners to know the options available for treatment. Among other insightful features, our CPD article this month is on biofilms. Written by Dr Souphiyeh Samizadeh, the article discusses how they occur and how they should be treated – turn to p.26 to learn more. We also look at the potential risks involved with permanent filler use and methods of removal on p.34, techniques involved for correcting a ‘gummy smile’ on p.31 and the latest developments in hair transplant procedures on p.39. We have so many articles to educate and inform you as usual so enjoy our November issue and make sure you have booked your table for the Awards by visiting www.aestheticsawards.com. It promises to yet again be a night to remember!

Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Mr Dalvi Humzah is a consultant plastic, reconstructive and

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic surgeon in the NHS for 15 years, and is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally. Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015. dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies. qualifications in medicine and dentistry. Based in Knightsbridge, London she practices a variety of aesthetic treatments. Dr Tonks has appeared on several television programmes and regularly speaks at industry conferences on the subject of aesthetic medicine and skin health.

years experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers. and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide. 12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook. for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

PUBLISHED BY EDITORIAL Chris Edmonds • Managing Director T: 0203 096 1228 | M: 07867 974 121 chris@aestheticsjournal.com Suzy Allinson • Brand Director T: 0207 148 1292 | M: 07500 007 013 suzy@aestheticsjournal.com Amanda Cameron • Editor T: 0207 148 1292 | M: 07810 758 401 mandy@aestheticsjournal.com Chloé Gronow • Deputy Editor & Communications Manager T: 0207 148 1292 | M: 07788 712 615 chloe@aestheticsjournal.com Kat Wales • Journalist T: 0207 148 1292 | M: 07741 312 463 kat@aestheticsjournal.com Shannon Kilgariff • Journalist T: 0207 148 1292 | M: 07584 428 630 shannon@aestheticsjournal.com

ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com CUSTOMER SUPPORT Sammy Carlin • Customer Support Executive T: 0203 096 1228 | support@aestheticsjournal.com EVENTS Kirsty Shanks • Events Manager T: 0203 096 1228 | kirsty@synaptiqgroup.com DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | peter@aestheticsjournal.com Chiara Mariani • Designer T: 0203 096 1228 | chiara@aestheticsjournal.com

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Patient safety

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #NewTreatment Dr Tapan Patel @drtapanp Performing the first #cellfina treatment in the UK for cellulite. Another first for @PHIclinic

#Clinic Dr Jane Leonard @_drjane So excited to be back with the team #GraceBelgravia for my #aesthetic #clinic tomorrow #botox #cometic #doctor #Conference ERME clinic @ERMEclinic @UlianaGout #BCAM @Churchhouseconf Dr Ruth Harker and Dr Uliana Gout at the British College of Aesthetic Medicine Conference #Injections Dr Kathryn @RealYouClinic A reality star doing aesthetic fillers and injections! Unbelievable! #BAAPS2016 Marc Pacifico @MarcPacifico Fantastic talk by @perfecteyesltd @BAAPSMedia #BAAPS2016 on nonsurgical treatment of the lower lids #plasticsurgery #Training DHAesthetic Training @mdhtraining Packed audience for @mdhtraining @pdsurgery @Anna32Baker Anatomy Accurate Injections #livedemo #Dermatology Dr Anjali Mahto @DrAnjaliMahto Lovely morning discussing #skin and #skincare @BSFcharity birthday press #breakfast @RCPLondon #dermatology #dermatologist

RCS publishes patient safety information The Royal College of Surgeons has released new information for patients who are considering cosmetic surgery. The patient resource was requested by the Department of Health following the Keogh Review in 2013 and offers advice on how to choose the right surgeon, and explains the risks of undergoing surgery and complications to consider. It also includes questions to ask a surgeon before consenting to an operation, a checklist and animation films to further patients’ understanding. “The cosmetic surgery industry is booming, but due to the aggressive marketing and ruthless sales tactics of some unscrupulous companies, it can be very difficult for patients to find independent, trustworthy information which gives them a clear idea of what an operation would entail,” said vice president of the RCS, Mr Stephen Cannon. He added, “The vast majority of cosmetic surgery is carried out in the private sector and many people do not realise that the law currently allows any qualified doctor – surgeon or otherwise – to perform cosmetic surgery, without undertaking additional training or qualifications.” In the coming months the RCS will also publish a register of ‘certified surgeons’ to allow patients to look for a surgeon who has provided evidence to the RCS that they have the appropriate training, experience and insurance to practice in the UK. Hair removal

Naturastudios launches new hair removal system A new device providing users with five laser hair removal treatment modes in a single system has been launched by Naturastudios. The Forma Magma Lite Touch system is a 808 nm diode laser that aims to generate safe and effective treatment programmes based on an individual’s skin type by providing exact skin measurement readings and incorporating cooling technology. Dr Simon Zokaie, medical director of Linia Skin Clinic who uses the laser said, “The Magma offers a wide range of treatment protocols with the ability to tailor each individual treatment for all skin types. The chilled tip and melanin metre for setting the parameters make the Magma very safe and easy to use. For laser hair removal, treatments that required eight to 12 sessions now only require three to eight sessions to see the same results.”

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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PDO threads

Elionce biodegradable PDO thread range released Polydioxanone (PDO) thread range, Elionce, has been released in the UK. Elionce biodegradable PDO threads aim to create a natural, younger-looking face. There are seven PDO threads in the range that offer bespoke cannulas to help reduce facial trauma. According to the company, the products also have a two-year shelf life, are CE certified and can produce results that last up to 18 months. Dr Ash Dutta of Aesthetic Beauty Centre said, “Elionce PDO threads are the threads of the future with their optimised range and their premium quality. Their unique moulded shape allows for greater lifting and a longer lasting effect.” Awards

Photo booth sponsor announced for the Aesthetics Awards Aesthetic distributor Church Pharmacy will sponsor a photo booth at the Aesthetics Awards on December 3. Guests of the ceremony, which will take place at the Park Plaza Westminster Bridge Hotel, will be able to enjoy taking photographs of themselves using the photo booth, using different props and celebrating with fellow colleagues. Guests will then be able to take the instantly-printed photographs home with them. “Our friends working in aesthetics definitely aren’t shy!” said Zain Bhojani, co-director of Church Pharmacy. He added, “We thought that instead of just having a bunch photos that are forgotten amongst the thousands that sit in our photo apps, this would be a fun opportunity for guests to take something home with them to remember a great evening with friends.” Skincare

Skinmed launches TEBISKIN Cera-Boost products Dermatological distribution company Skinmed has launched two new skincare products aimed at boosting ceramide in the skin. The TEBISKIN Cera-Boost Face and the Cera-Boost Body aim to act as a multi-level emollient, providing nutrients and hydration, and contain nine ceramides which aim to build a dense lipid structure to boost the epidermis. Skinmed claims the product is ideal for sufferers of eczema, psoriasis, acne, dry skin and hyper-reactive skin as these patients are more likely to have ceramide issues. “Ceramides play an important part in controlling cellular and skin water loss,” said Peter Roberts, founder of Skinmed. “Water loss leads to dehydration and dehydration impairs cellular function, can hasten cell death and lead to a lower resistance to energy damage, such as from the sun,” he added.

THE BUSINESS DESIGN CENTRE / LONDON / 31 MAR & 1 APR 2017

COUNTDOWN TO ACE 2017 PREMIUM CLINICAL AGENDA The independent Premium Clinical Agenda is split into four sessions, offering you the opportunity to only book what is most relevant to your aesthetic practice. Choose to book your place at The Ageing Female Face, The Male Face, The Young Female Face and/or The Beginner’s Guide to Facial Assessment, where you will hear from the UK’s leading practitioners on vital anatomical considerations to be aware of, how to create bespoke treatment plans, and the latest techniques and technologies available to enhance facial treatments. In addition, speakers will each perform a live demonstration of a treatment, allowing you to see their recommended techniques in action and the excellent results that they produce. SPEAKER INSIGHT Aesthetic nurse prescriber Sharon Bennett will present The Young Female Face at the Premium Clinical Agenda along with Dr Raj Acquilla. She says, “Dr Acquilla and I will analyse photographs of a young female patient’s face, discuss the wide variety of treatment options available, outline the most appropriate options for the individual patient, and perform a live demonstration of a treatment before taking questions from the audience. This unique structure will be used across the other Premium Clinical Agenda sessions; offering delegates an exceptional level of education and insight from expert practitioners.” WHAT DELEGATES SAY “ACE has so much in store for anyone interested in developing their aesthetic practices and techniques, and is the best place to come to learn about new and upcoming treatments and technologies.” AESTHETIC DOCTOR, EDINBURGH

“I would encourage nurses to come to ACE because it’s very unique in that we have all the specialities, all the professions coming together and we can learn from each other in delivering similar outcomes.” AESTHETIC NURSE, LONDON HEADLINE SPONSOR

www.aestheticsconference.com

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses

BACN MEMBER SURVEY

BACN membership is growing rapidly at the rate of about 20 new members a month, which means the BACN has to keep pace with its members’ needs. Our latest survey shows a very high satisfaction rate, with 98% of members willing to recommend the BACN to friends and 94% feeling they are well informed, having very high awareness of the Chair (86%) and the CEO (77%). Key services that have been welcomed are the Practitioner Finder on our website, SMS messaging about key developments, the BACN Facebook page and the regional structure of meetings. Use of the website is high, as is readership of the newsletter. All of these communication routes can be offered to potential sponsors, with more than 80% of our members happy to receive special offers via emails from the BACN.

NUFFIELD BIOETHICS FORUM The BACN CEO Paul Burgess gave feedback to the Nuffield Forum on the latest issues facing the cosmetic industry. Burgess highlighted the developments that were taking place with regard to regulation and the newly proposed Joint Council for Cosmetic Practitioners (JCCP). Other key issues raised were age of consent and aesthetic procedures, the inspection of non-surgical cosmetic clinics by the CQC and the use of advertising in the sector.

DATES FOR YOUR DIARY The BACN launches its Autumn/Winter round of regional meetings. These are great local events carrying CPD points and an excellent way to meet other nurses working in the aesthetics sector. New members and prospective members are very welcome: 11th Nov: Wales and South West Meeting, Bristol 14th Nov: London, East Anglia & South East Group Meeting, London 21st Nov: South Coast Group Meeting, Southampton 25th Nov: North West Group Meeting, Manchester 28th Nov: Ireland Group Meeting, Dublin 2nd Dec: Central Group Meeting, Birmingham 5th Dec: Scotland Group Meeting, Edinburgh

MEET A MEMBER Paul Burgess is the CEO of the BACN. He joined the association in 2013 and, along with other members on the board, has led the BACN Transformation Plan. As CEO, Burgess has to balance his activities to ensure that he understands all BACN members’ requirements, members are kept informed about the association and use its services effectively, and ensure that the BACN is a ‘voice’ for the industry and a champion of patient safety.

This column is written and supported by the BACN

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Conference

Schuco announced as headline sponsor for ACE 2017 Schuco International has been confirmed as the headline sponsor for the Aesthetics Conference and Exhibition (ACE) 2017 taking place on March 31 and April 1 in London. “Schuco has chosen to sponsor ACE because it is the leading aesthetics conference on the calendar providing practitioners an excellent opportunity to continue their professional learning,” said Chris Littlejohn, commercial director at Schuco International. He added, “We are excited to showcase our existing range whilst using ACE to launch new products never seen before in the UK.” New sponsors have also been announced for the ACE 2017 Masterclass and Expert Clinic sessions. Lumenis UK and Teoxane Laboratories are confirmed to sponsor a Masterclass session and Church Pharmacy, Alumier MD, Cynosure and Mesoestetic will each be sponsoring an Expert Clinic session. Registration for ACE 2017 is now open and delegates are encouraged to take advantage of the special 10% Early Booking Discount for the Premium Clinical Agenda, which is available until December 31. For more information, or to register for the event, visit, www.aestheticsconference.com. Skincare

Universkin launches Fullbody skincare line Skincare company Universkin has introduced a new line aimed at treating the body. Universkin Fullbody aims to improve the appearance of a variety of conditions such as stretch marks, cellulite, loose skin on the arms and legs, sun damage, eczema, psoriasis, age spots and wrinkles. Similar to the Universkin products for the face, Fullbody allows practitioners to create up to 1,159 bespoke formulas in 57 concentrations, choosing from 19 active ingredients that include caffeine, vitamin A, vitamin C, vitamin B3, Urea, L-carnitine, organic silica and alphahydroxy acids. To build a bespoke formula for the patient, practitioners must conduct a skin diagnosis to select the relevant active ingredients. According to the company, the preparation time of the formula is less than a minute. Universkin Fullbody is available in the UK through aesthetic distributor Schuco International. Vaginal rejuvenation

Novus Medical to distribute Juliet laser Medical aesthetic company Novus Medical has become the UK distributor of a minimally invasive device aimed at treating women’s intimate health concerns. Novus claims the Juliet laser by Asclepion can be used to treat vaginal atrophy, stress urinary incontinence, irritation, poor vaginal lubrication, vaginal dryness and dyspareunia. The non-surgical procedure takes minutes and can be performed without need for anaesthesia. The laser treatment works by targeting the sub-mucosa, which is said to be ‘elastic, rich in collagen and can be stimulated without damaging surrounding tissue’. Director of Novus Medical, Jim Westwood, said, “The unique technology behind the Juliet makes it one of the most complete laser devices on the market for the comprehensive care of female intimate diseases.”

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Training

Harley Academy becomes CPD accredited The British College of Aesthetic Medicine (BCAM) has endorsed the Harley Academy’s level 7 aesthetic course with continued professional development (CPD) accreditation. The accreditation ensures that the Harley Academy has met BCAM’s guidelines, including ‘The event should be appropriate for trained (career grade) doctors, clinical content must follow all appropriate patient consent and confidentiality policies and the principles outlined in the GMC’s Good Medical Practice guidelines, and the teachers/facilitators should have relevant expertise, knowledge and skills to deliver the education programme within the specific subject/s identified’. Paul Charlson, president of BCAM said, “We are delighted that level 7 training, as outlined in the recent Health Education England report, is being adopted by training organisations. BCAM supports any educational organisation that delivers to this standard. BCAM are therefore delighted that Harley Academy is leading the way.” Founding director of Harley Academy, Dr Tristan Mehta said, “We are very proud that BCAM has recognised that our course represents this new era in aesthetics. We also expect that this higher standard of education will propagate throughout practitioners, and other course providers, and ultimately lead to a new standard of patient care.” Skincare

Nimue Skin Technology launches new products

Vital Statistics One in 12 adults in the UK has eczema (National Eczema Society, 2016)

The average adult loses around 10 cups of water every day through breathing, sweating, urinating and eliminating waste (Mayo Clinic, 2016)

Research by e-learning organisation Learnnovators suggests that online learning will increase by 23% on average in 2017 (Learnnovators, 2014)

In the UK, the average amount of sick days employees take per year is 6.9 days (CIPD, 2015)

Research from Mintel forecasts the men’s haircare market to grow 11% over the next four years to reach £94 million by 2020 (Mintel, 2016)

Skincare company Nimue Skin Technology has launched a new skin resurfacing treatment and acid neutraliser. The skin resurfacing treatment, Nimue-SRC, is available in three skin classifications – Environmentally Damaged, Hyperpigmented and Problematic – that all aim to resurface the skin and stimulate epidermal growth through the removal of damaged layers of the stratum corneum, while reducing downtime, inflammation and offering faster skin barrier repair. The treatment system is formulated with a specific combination and concentration of acids, and the company recommends using the new Neutraliser Plus post treatment to slow down the skin’s pH normalisation, while replacing bio lipids to increase repair of the skin. In addition to neutralising the activity of the acids in the Nimue-SRC, the Neutraliser Plus aims to simultaneously deliver barrier repair, as well as anti-inflammatory, antioxidant and antiageing benefits to the skin. Key active ingredients in the Neutraliser Plus include isostearyl isostearate and ferulic acid.

In a survey of 500 US women (aged 18-34) 72% have purchased a makeup product because it included a free gift with purchase (Lab42, 2013)

As of 2015, 75% of men in the US are overweight or obese (National Institute of Diabetes and Digestive Kidney Diseases, 2015)

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Events diary 23rd - 25th November 2016 British Association of Plastic Reconstructive and Aesthetic Surgeons Winter Scientific Meeting 2016, London www.bapras.org.uk

3rd December 2016 Aesthetics Awards, London www.aestheticsawards.com

26th - 29th January 2017 IMCAS Annual World Congress 2017, Paris www.imcas.com

3rd – 7th March 2017 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

31st March - 1st April 2017 Aesthetics Conference and Exhibition, London www.aestheticsconference.com

6th -8th April 2017 15th Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc2017.org

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Awards

Cosmedic Pharmacy to sponsor Best Clinic Scotland at the Aesthetics Awards Cosmedic Pharmacy will sponsor a category at the Aesthetics Awards 2016 on December 3. The Cosmedic Pharmacy Award for Best Clinic Scotland will recognise a clinic that has has demonstrated excellent practice and a commitment to customer service, patient care, safety and positive patient feedback. Iain Ashby, superintendent pharmacist at Cosmedic Pharmacy, said it chose to sponsor the Awards as a celebration of their company’s growth over the past 12 months, to say thank you to their customers and to help share the industry celebration. He said, “We are thrilled to be a sponsor of the Aesthetics Awards – all of our directors share a common Scottish heritage and so sponsoring this award was always going to have a strong appeal to us.” Ashby continued, “To be associated with some of the names of other sponsors after such a short time in business is extremely pleasing and is a great encouragement to further grow and expand the product range Cosmedic Pharmacy is able to offer practitioners via our industry partnerships.” You can view the full list of finalists and book tickets for the Aesthetics Awards at, www.aestheticsawards.com

Insurance

Enhance Insurance introduces service for BCAM members Enhance Insurance has created a special medical indemnity insurance policy that is exclusive to members of the BCAM. According to Enhance Insurance, the product has been designed to ensure that the best value is obtained for all BCAM members, with premiums and policy excesses that reflect the expertise and experience of BCAM practitioners. The service includes the standard cover, plus access to additional benefits including exclusive rates for pre and post procedural support, 50% reduction for first year licence fee for iConsult Clinic Management Platform, discounted insurance premiums and access to the BCAM risk management portal and telephone advice line. “This scheme enables lower premiums, defensibility as a group and additional benefits,” said BCAM president Dr Paul Charlson. “Insurance within our industry can at times be frustrating and does not always cover what practitioners need, leaving them potentially vulnerable. I am delighted to be able to work with Enhance Insurance Services.”

Tattoo removal

Lynton Lasers launches new picosecond laser Lynton Lasers has introduced a new version of its picosecond laser, the PICO SERIES for tattoo removal. The company claims the PICO SERIES is the world’s first platform to incorporate a ruby 694 nm laser wavelength, which aims to clear all treatable tattoo colours, including green and blue pigments that are harder to treat. As well as picosecond technology, the device also includes nanosecond Q-switched pulses at 1064 nm, 532 nm and 694 nm and has a peak power of 1.8GW and a pulse duration of 375ps. The PICO SERIES also comes with the new FraxTip lens, which is an attachment that allows highly concentrated energy to be generated by the laser to induce trauma on the epidermis, which aims to increase collagen and elastin production while preventing any significant thermal damage to surrounding tissue. “A number of our laser physicists have worked for many years with picosecond lasers both at Lynton and at the University of Manchester,” said Dr Jonathon Exley, managing director at Lynton Lasers. He added, “While we believe them to be highly effective, picosecond lasers currently lack the well-evidenced safety profile of traditional gold-standard nanosecond lasers. However, next generation picosecond lasers, such as our new PICO SERIES, overcome these challenges by combining both picosecond and nanosecond technology across three wavelengths, allowing the effective and safe removal of all treatable tattoo colours on all skin types.”

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Aesthetics

Regulation

HIS compliant clinic space available to Scottish practitioners Aesthetic nurse prescribers Frances Turner Traill and Michelle McLean have opened their clinics to practitioners wanting to perform aesthetic treatments in a faculty that complies with the regulations outlined by Healthcare Improvement Scotland (HIS). From April 1 next year, HIS will begin regulating independent clinics in Scotland and according to these regulations, practitioners must treat in a HIS regulated premises. Turner Traill and McLean say they have decided to allow practitioners to practice in their facilities to help those who may work in the NHS and only work in aesthetics part time, those who do not want to open a new clinic or those who may be currently renovating their clinics to comply with the new regulations. “Frances and I are offering space to smaller practitioners within our clinics who may be thinking of giving up their aesthetic practice due to the new regulations coming in,” said McLean, who added, “As part of the British Association of Cosmetic Nurses we feel we should be helping and supporting smaller practitioners to maintain their practice and client base rather than throwing it all away as they feel they have no option.” As well as a registered practice, practitioners have the opportunity to access a prescribing service for non-prescribing nurses, delivery of products from Aesthetic Pharmacy, a pay-as-you-go service, facilities that are open late for six days a week, private reception and waiting area for patients and further education and in-house training. Practitioners also have the choice between three available sites in Glasgow, South Lanarkshire and Inverness. Dermal filler

Belle launches Biorivolumetria in the UK Biorivolumetria dermal fillers by Regenyal Laboratories have been introduced to the UK by distributor Belle. The filler range aims to provide a biocompatible and bioabsorbable product that recreates lost volume, addresses skin blemishes caused by ageing, regenerates and restructures the skin, and produces naturallooking results. According to Belle, the chemical structure of the product allows for the isolation of three molecular weights of hyaluronic acid (HA) rather than two, often found in other HA fillers. The company claims that the HA is cross-linked with 1,4-butanediol diglycidyl ether (BDDE) at an amount that is 30% lower than the majority of other similar products to provide a ‘safer product with fewer side effects’. Ben Sharples, managing director of Belle, said, “Regenyal Biorivolumetria has proven extremely popular throughout Europe since its launch in 2009 and we are excited to finally be able to offer its benefits to clients in the UK.” For practitioners wanting to learn more, there will be a Biorivolumetria training event in London on November 26.

60 Seconds with… Miss Sherina Balaratnam, Surgeon & Aesthetic Practitioner What is your background? I am a surgeon with a background in NHS plastic surgical training where my areas of interest included skin cancer, reconstruction and burns. I now specialise in non-surgical aesthetic treatments. What is the ethos behind S-Thetics? To deliver safe, effective and clinically-proven treatments to our patients that benefit their health and help them achieve their aesthetic goals. What products and services does S-Thetics offer? We specialise in the latest scientifically-based skin and medical aesthetic treatments and offer a broad range of treatments within our menu – from advanced skincare products and facial treatments, to cosmetic injectables and non-surgical skin rejuvenation using medical grade technology. Why did you recently introduce SculpSure to the clinic? My patients were increasingly asking me for an option to help contour and reduce fat in problem areas such as their tummy and flanks. After researching the many devices and technologies in our industry, I identified SculpSure as the best option for my practice. Not only for the efficacy and safety profile, but also the pedigree of Cynosure and their heritage in laser liposuction. SculpSure represents an evolution of this technology to a purely non-invasive format. What benefits have you seen from introducing SculpSure? As well as broadening our treatment portfolio, SculpSure helps us to provide patients with a longer-term treatment plan. For instance, patients may wish to focus on their body contouring goals initially, but have medium and long-term objectives around their skin health. Our initial results with SculpSure are encouraging and we are looking forward to our patients benefitting from this innovative technology. What have you planned for the future? We have just launched S-Thetics at Bristol Plastic Surgery. This is a partnership between S-Thetics, Mr Nigel Mercer and Mr Antonio Orlando, two of the region’s leading plastic surgeons. This column is written and supported by

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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News in Brief Survey suggests half of people suffer from a skin condition The British Skin Foundation (BSF) has released a new survey suggesting that more than half of people have suffered from or continue to suffer from a skin disease. The results from 364 respondents indicated that seven in ten people have visible scars or visible skin conditions; with 72% of this group saying it affects their confidence. Institute Hyalual introduces new sales director Institute Hyalual has welcomed a new UK sales director. Claire Williams has had six years of experience in the industry through previous employment with Bausch and Lomb, and GSK. “I’m really excited by my new role at Institute Hyalual,” Williams, said adding, “They have some very interesting products and I am looking forward building on the hard work the team have already put in.” 35% of women intend to purchase all-natural beauty products According to a US survey, a third of women want to purchase more all-natural beauty products than they currently do. The study also indicated that 55% of women check the ingredient labels on beauty products prior to purchase and women between 18-34 showed the most interest in going green, with 73% indicating it is important to them to choose all-natural beauty products when making a purchase. The poll was conducted online in the US by Harris Poll on behalf of eco beauty brand Kari Gran and included responses from 1,126 women aged 18 and older. Teoxane names Hillview Cosmetic Clinic as Outstanding The Hillview Cosmetic Clinic in Clough has won an award recognising excellence in business practice from Teoxane UK. The clinic was recognised for its ‘bespoke approach to aesthetics, going above and beyond during consultation and formulating tailored programmes unique to each clients’ concerns’. “It is a wonderful feeling to have won the Teoxane Outstanding Clinic Award, as it means I’ve been recognised for my commitment in aesthetic practice,” said clinic owner and independent nurse prescriber Pauline McIlrath, adding, “It’s a great accolade for myself as a sole practitioner and I am so proud to have received the award.”

Aesthetics Journal

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Laser

Dr Victor Sagoo launches first ExSys EPL Excimer Lamp for vitiligo treatment in UK Aesthetic practitioner, Dr Victor Sagoo has introduced the ExSys 308 Excimer Lamp to his West Midlands clinic to treat patients suffering from a number of skin conditions including vitiligo. The device is a 308 nm Excimer Pulsed Light (EPL) system that aims to allow practitioners to use high doses of UVB light necessary for fast, effective treatments, while minimising the risk of exposure to healthy skin. As well as vitiligo, the device can also treat psoriasis, alopecia areata, resistant dermatitis, acne and other inflammatory skin conditions. According to Dr Sagoo, he is the first in the UK to offer this treatment to patients. He said, “Through my training in Germany I was very impressed by the results of the high power Excimer lamp with minimal downtime and side effects and how much of an improvement in the qualities of life this device was achieving over a course of treatments. The Excimer device is very well established in Europe and the Middle East where vitiligo is very common — I am very excited about the ExSys 308 Excimer device and can see it becoming an integral part of my medical cosmetic practice.” Suncare

Study indicates SPF use can reverse signs of photodamage Research released in the Dermatologic Surgery journal has suggested that consistent sunscreen application can improve the existing signs of photodamaged skin. Researchers studied 32 women between the ages of 40 and 55 years with Fitzpatrick skin types 1 to 3 and mild to moderate photodamage who applied a broad-spectrum photo-stable sunscreen with SPF 30 to their face each morning for 52 weeks. After the year, evaluations of the women indicated there was significant improvement of 40-52% on the skin’s surface and pigmentation, including texture, clarity, mottled, and discrete pigmentation. Researchers noted that all women had improved texture and clarity.

On the Scene

Sculpsure Demonstration, London On October 6th, Cynosure hosted an evening drinks reception at the Hilton Olympia London, to speak about and demonstrate body contouring device SculpSure. Around 30 attendees gathered at the London hotel to watch aesthetic surgeon Mr Benji Dhillon demonstrate the device. Mr Dhillion spoke to the audience about SculpSure and how the FDAcleared laser treatment works in contouring the body, claiming the 1060 nm laser can efficiently treat areas of troublesome fat in just 25 minutes. After the demonstration, attendees were encouraged to ask questions and engage in discussion. Doug Neuhofer, marketing assistant at Cynosure said, “The event was a great success! Attendees learnt about SculpSure and had the opportunity to ask Dr Benji Dhillon lots of questions.”

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Aesthetics Journal

On the Scene

Aesthetics On the Scene

S-Thetics medical aesthetic clinic launch, Bristol On September 29 guests were welcomed to Bristol Plastic Surgery for the second S-Thetics medical aesthetic clinic launch. The event began with an introduction to the S-Thetics concept and its approach to skin health, as well as the new portfolio of treatments that are now available. Guests were then presented with live demonstrations of some of the treatments, including the skin analysis system VISIA and the EndyMed 3DEEP radiofrequency device for skin tightening and an overview of iS Clinical skincare treatments. Medical director of S-Thetics, Miss Sherina Balaratnam said, “We have been delighted at the response to our new treatment portfolio, many of which are available exclusively to patients in Bristol and the South West for the first time.” She added, “My career in Bristol started more than 10 years ago during my NHS training in plastic surgery at Frenchay hospital. I’m proud to work alongside two of the region’s leading plastic surgeons to provide a comprehensive range of treatments for the face and body,”.

British College of Aesthetic Medicine Conference, London Aesthetics reports on the highlights of the annual aesthetic conference of the British College of Aesthetic Medicine Aesthetic practitioners from across the UK gathered at the prestigious Church House Conference Centre in Westminster for the annual British College of Aesthetic Medicine (BCAM) conference on Saturday September 24. Two programmes ran side-by-side throughout the day, showcasing the latest clinical and business topics and providing delegates with insightful live demonstrations. Dr Beatriz Molina, vice president of BCAM and conference director, welcomed guests in the building’s Assembly Hall for the main lecture programme. Speaking first was Dr Sangita Singh, who outlined different types of patients and gave advice on how to recognise ‘the red flag patient’, summarising her talk with, “if in doubt, just say no to treatment.” Other highlights of the morning session included Mr Rajiv Grover’s presentation, which emphasised the importance of having an aesthetic eye to ensure facial balance, which then led to an interactive panel discussion that included insights from Mr Grover, Dr Uliana Gout, Dr Ravi Jain, Dr Amanda Wong-Powell, Dr Xavier Goodarzian and Dr

EF MEDISPA 10 year anniversary, London

Invited guests gathered at EF MEDISPA on Kensington Church Street in London to celebrate the clinic’s 10-year anniversary on September 22. EF MEDISPA founder Esther Fieldgrass welcomed guests and thanked her staff and suppliers for their work and support and unveiled the newly refurbished Kensington clinic, which opened in 2006, and was the first of five clinics. After the event, Fieldgrass said, “We had a great turnout, and people I hadn’t seen for 40 years or more came in their droves to see me, the team and our new look. My hope is that this clinic paves the way for a new kind of space that’s dedicated to inside-out health, wellbeing and beauty.” She continued, “The main highlight of the last 10 years has been seeing my business grow from the first clinic in Kensington, to the opening of Chelsea in 2009, St John’s Wood in 2011 and Canary Wharf 2015, and of course our flagship franchise clinic in Bristol.”

Molina. The panel discussed treatments around the eye, including the use of fillers, botulinum toxin and threads, and their talks were complemented by live demonstrations, including a Plexr treatment performed by Dr David Jack. After a hot lunch, Dr Tahera Bhojani-Lynch discussed treating the male face, asking audience members how many treat men in their clinics of which half of the delegates raised their hands. Dr BhojaniLynch went on to suggest that practitioners should not necessarily be trying to make men look younger, but rather more masculine, ‘it’s not that they don’t want treatment, it’s that the don’t know what they want,’ she stated. Meanwhile, in the business and clinical innovations sessions, sponsored demonstrations and business talks were presented on a range of topics including skin peels, insurance and choosing skincare. Gary Conroy, co-founder of private label cosmeceutical company 5 Squirrels, examined how to increase patient referrals and patient loyalty, and Dr Philip Dobson provided the latest legal medical advice for practitioners. The last topic of the day on the clinical agenda saw Dr Lucy Glancey and Dr Wong-Powell detailing developments in vaginal rejuvenation. A closing statement by Dr Wong-Powell was well received with applause from the audience. She said, ‘We need to think as a group about the ethics of this procedure, who should be doing these treatments and if we are doing right by our patients.’ Throughout the day delegates were also able to network with distributors and suppliers in the exhibition. BCAM president Dr Paul Charlson said of the conference, “It’s been great; it’s the one time you get all BCAM members together to discuss aesthetics – it’s been a really good networking event.”

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Production at Allergan, Westport Aesthetics visits Allergan Pharmaceuticals in Ireland to learn more about the Botox manufacturing process At first, the small town of Westport in Ireland seems perhaps an unusual place for global pharmaceutical company Allergan to house its only Botox manufacturing site. Set over more than 500,000ft2 on a 30-acre campus, the factory stands out amongst the rolling hills and cosy independent shops, cafés and restaurants of Westport. Yet Paul Coffey, the vice president and manager director of the site, explains that Allergan is a welcome and respected business amongst the local community. He says, “Members of the community are very appreciative of having a large pharmaceutical company like Allergan based here, but Allergan doesn’t take that for granted and always treats the community with a lot of respect.” For example, Coffey explains, 100% of waste created at the site is recycled, maintaining high environmental standards in the area. The factory was established in Westport in 1977, when the son of Allergan’s founder Gavin S. Herbert, Gavin Herbert Jr, was looking to expand the company into Europe. With its rich history and vibrant tourist presence, he fell in love with Westport and decided to set up base. Originally, the site started off as a small facility for contact lens cleaning solutions, however it continued to grow year on year, until it become the centre it now is, employing 1,100 staff and manufacturing the global supply of Botox. Although there are 13 international Allergan manufacturing sites, Westport is the only place where Botox is produced, exporting to 70 countries worldwide. Coffey explains this is because Allergan consolidates all of its manufacturing into ‘centres of excellence’ to ensure the highest standards of quality are maintained. Coffey claims that this is achieved through the educated workforce, of whom 80% have a university qualification, the low staff turnover rate (average service is 12 years) and continued investment in advanced manufacturing technology. The first Botox facility at Westport was built in 1990, before its first commercial release from the site in 1994. Coffey says, “We thought it was going to be a small operation, but we were just a little bit wrong! In 1998 we started to recognise that Botox was going to be bigger than expected so doubled the site’s Botox manufacturing capacity. In 2005, we doubled capacity again.” He adds, “As we’ve seen with Botox, it’s grown very rapidly so we’re constantly thinking ahead and making sure we’re keeping up with demand.” The Westport site is responsible for the drug product formulation, sterilisation, labelling and packaging, testing and release, as well as the storing and distribution of Botox. As the product is aseptically manufactured, a grade A classification room is used to maintain its sterility. This consists of a large rectangular box within the room where the product is filled, which is only accessible through glove ports to ensure there is no possible contamination. While air in an operating theatre is changed an average of 25 times an hour,1 the air in the sterile room is changed 200 times an hour to ensure it is clean, explains Coffey. He adds, “On a monthly basis we take approximately 16,000 microbial samples to verify there’s no bacteria in any part of the room.” The operator working within the sterile room has to go through extensive training in all aspects of their work, in particular how to put on their sterile suit. Coffey explains that they must wear surgical scrubs and then put on the sterile suit without touching the outside to avoid any contamination. He notes that they will fail their training if there are

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more than two bacteria present on their suit at the end of the process. A significant breakthrough for Allergan came in 2008, when technology capable of performing cellular culture was installed at the Westport site. Coffey explains that Allergan had spent 10 years and $60 million creating a non-animal assay for testing the potency of Botox. “This is now the assay that is used for all the product releases for the US and European markets, and most of the other markets around the world.” During packaging, Allergan uses both semi-covert and covert methods to identify counterfeit Botox products. While the covert tests cannot be revealed to the public, semi-covert operations include the use of a unique UV matrix on every box and on top of each vial, and a tamper-evident label that will change colour if anyone attempts to remove it using heat. In addition, photographs of each vial are taken at each stage of the packaging process; meaning that if any part of the process has been missed, the vial will be ejected from the production route for staff to investigate and solve any problems. The storage and distribution of Botox is critical says Coffey. The packaged Botox is stored at -10 degrees for eight days prior to shipping. A data logger is included in every single shipment to Allergan’s thirdparty logistics providers, which tracks the appropriate temperature, suitable to different regions, throughout its journey. The Westport team then receives a printout to verify it has been stored correctly, before it is sent to final customers in dry ice conditions. If the appropriate temperatures haven’t been met during distribution then the products are recalled. With extensive tests and controls at every step of the manufacturing process, the aim is to give Allergan customers a consistent and reliable vial of Botox at every use. Coffey says, “We monitor all feedback from our customers and if an issue comes back we’ll review the batch manufacture and trend issues over time so we can see if there’s anything specific that we need to investigate.” Looking ahead, the Westport site is looking forward to celebrating its 40th birthday next year and continuing to expand its production sites to accommodate the continued growth of Botox for both its cosmetic and therapeutic use across the globe. REFERENCES 1. H Humphreys et al., ‘Guidelines on the facilities required for minor surgical procedures and minimal access interventions’, Journal of Hospital Infection, p.105. <https://www.his.org.uk/ files/8813/7389/0782/Guidelines_on_the_facilities_required_ for_minor_surgical_procedures_and_minimal_access_ interventions.pdf>

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Correcting Aesthetic Complications – whose responsibility is it? Aesthetics investigates the cost of private aesthetic treatment complications on the National Health Service and asks, ‘why aren’t more adverse events being treated by the private sector?’ On September 3 this year, The Times reported that three clinical commissioning groups in Manchester had spent almost £2 million over the past five years on surgery required as a result of complications from botulinum toxin injections. Although, some aesthetic professionals believe this number is likely to also include dermal fillers. The article stated campaigners were warning that the figures suggested a national bill of as much as £1 million a year.1 With the NHS already under huge financial pressure,2 should it be responsible for correcting sub-standard treatments caused by private aesthetic practitioners? The facts and figures “It’s impossible to give a definitive answer on how much the NHS spends correcting aesthetic complications because no reliable data or statistics exist at the moment,” says Emma Davies, aesthetic nurse prescriber and vice chairperson of the aesthetics complications group SaveFace. “The reason we have no data is because there is no governance, therefore we lose data. Consequently, all the information we have at the moment is very anecdotal,” she adds. The lack of data on the costs incurred by the NHS in dealing with complications caused by cosmetic treatments in the private sector was highlighted in the 2013 Keogh Review. The report argues the need for available data, ‘in order to drive the required improvements in clinical practice, patient education, innovation and research’.2 However, the report did reveal figures submitted by surgeons at the Chelsea and Westminster Hospital in London, which showed that over a 15-month period, 12 patients presented to its A&E department needing treatment for complications from surgical cosmetic procedures. This resulted in 34 outpatient visits and 66 inpatient nights, costing a total of £43,000. The hospital also specifically highlighted costs for dealing with one individual’s dermal filler complication, which resulted in a five-night hospital stay and a reported cost to the NHS of £4,028.3

Consultant plastic surgeon Mr Niall Kirkpatrick published an article with fellow surgeons in the British Medical Journal in 2013 that looked at the resource implications for NHS hospitals when treating facial filler complications.4 He says, “The cost of treating patients with infections from dermal fillers is about £2,000 a time. The costs of reconstructive surgery as a result of aesthetic complications are poorly calculated in the NHS but are likely to run to many thousands of pounds per treatment.” Dr Tatiana Lapa, GP and aesthetic practitioner, agrees the lack of data is concerning, “Knowledge is power but at the moment we are saying there is ‘some sort’ of cost to the NHS, but we’re not entirely sure what that cost is. I believe if we actually have raw data, showing this is how much it is costing the NHS, then it does provide scope for change,” she says. Where does the responsibility lie? Davies says, “For the patient, it is important that the practitioner delivering the treatments is managing the risks to prevent these things happening, so if a complication does occur, they are capable and competent to manage that complication. If that practitioner isn’t competent, the patient should be referred, but I don’t think they should be referred to the NHS unless they require emergency care and I don’t think the NHS should foot the bill.” Dr Lapa agrees, “A lot of people are shirking responsibility saying ‘I haven’t been trained in how deal with this, therefore, go see someone else’ and I don’t think that’s right. If you are able to perform a treatment, I think it is reasonable to expect you are able to deal with any common and serious complications of that treatment.” She explains, “If, in certain cases, the practitioner is not able to treat the adverse event, it should then be their responsibility to refer the patient to someone that is able to. It shouldn’t fall to the NHS.” Dr Lapa also notes that many healthcare professionals within the NHS are not equipped to deal with aesthetic complications. “Many may have no idea how to dissolve

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filler, so if you show up to A&E, there is likely to be no hyaluronidase in the department. Therefore, it’s not always possible for the NHS to pick up the pieces,” she says. Going forward Although there are several bodies and organisations through which complications can be reported, such as the Medicines and Healthcare products Regulatory Agency through the Yellow Card Scheme. and the General Medical Council, Davies believes there needs to be a single portal for reporting. “In order to submit and quantify data, we need to have an organised format. I think bodies such as SaveFace, the Joint Council for Cosmetic Practitioners and Treatments You Can Trust should all be joining forces and working with the regulators to ensure this,” she explains. Mr Kirkpatrick says there needs to be improvement in regulation in order to address the issue, “The NHS would not have to cover these costs if the aesthetic industry was appropriately regulated by the government, with practitioners only being allowed to practice if covered by medical indemnity, as doctors must be, so that patients have recourse to compensation if there are complications. This compensation could cover the costs of the necessary treatment.” Dr Lapa believes the UK specialty could benefit by setting up a national insurance scheme. She explains, “One of the solutions brought up in the Keogh Review was to have a national insurance scheme like the one set up in Denmark. The National Patient Insurance Scheme is a public and private partnership funded by insurance companies and regional state boards. Then, if patients have treatments that go wrong, they can access it and it’s there as a safety net.”2 Mr Kirkpatrik concludes, “I believe that patients should have access to emergency treatment if needed for complications such as acute infections. However, I do not think that the NHS should cover the extensive treatment costs of reconstructive surgery necessary to correct the complications. The government is planning to legislate soon but I fear that it will be too little, too late.” REFERENCES 1. Michael Savage, Up to £1m a year spent fixing bad Botox, The Times, (2016), <http://www.thetimes.co.uk/article/up-to-1m-a-yearspent-fixing-bad-botox-q8qm9tdwb> 2. My Health London, Today’s NHS – our current challenges, (2016), <https://www.myhealth.london.nhs.uk/help/nhs-today> 3. ,DoH, Review of the Regulation of Cosmetic Interventions, Department of Health, (2013) <https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/192028/Review_ of_the_Regulation_of_Cosmetic_Interventions.pdf> 4. Nadine Hachach-Haram, Marco Gregori, Niall Kirkpatrick, Richard Young, Jonathan Collier, Complications of facial fillers: resource implications for NHS hospitals, BMJ, (2013) <http:// casereports.bmj.com/content/2013/bcr-2012-007141.abstract>

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Enhance your skills at the Premium Clinical Agenda Find out more about the independent Premium Clinical Agenda at ACE 2017 which comprises four expert sessions on facial assessment and treatment, presented by the UK’s leading medical aesthetic practitioners The Aesthetics Conference and Exhibition (ACE) will once again bring together top aesthetic professionals to deliver the latest in clinical education and business practice. Taking place on March 31 and April 1 next year, the event will be one of the first opportunities for delegates to discover the latest treatments, techniques and industry developments set to advance the aesthetic specialty even further in 2017. By registering for free, delegates will have access to the valuable educational sessions through the Expert Clinic, Masterclasses and Business Track, as well as the 2,500m2 Exhibition Floor, which will be home to more than 80 diverse stands, featuring exhibitors’ latest products and devices. For a superior learning experience delegates can book their place at the Premium Clinical Agenda. Designed to offer delegates the greatest flexibility, this agenda features four separate sessions that each focus on facial ageing in different patient types. Delegates can book to attend one or more sessions, depending on their specific interests and experience. Friday Morning: The Ageing Female Face Consultant plastic and aesthetic surgeon Mr Dalvi Humzah, aesthetic practitioner Dr Beatriz Molina and aesthetic nurse prescriber Anna Baker will lead this interactive session on treating an ageing female face. The practitioners will be presented with images of a middle-aged female face showing the typical signs of ageing. Each practitioner will then have 20 minutes to analyse the patient’s face, detailing their assessment to the audience and discussing the full treatment protocol that they would recommend. Delegates will be encouraged to join the discussion and offer their thoughts on suitable treatments, before live demonstrations are performed. The speakers will then each demonstrate one treatment from their suggested protocol, outlining effective rejuvenation techniques as well as pre- and post-procedure care. Baker said, “I’m looking forward to taking part in this unique approach to presenting; it will be interesting to discuss the treatment recommendations from the perspectives of three different professions, as well as share our techniques for successful rejuvenation.” Friday Afternoon: The Male Face With many clinics reporting an increase in men requesting facial rejuvenation treatments, the Premium Clinical Agenda will offer a session dedicated to teaching practitioners how to effectively assess and treat male patients. Aesthetic practitioner Dr Kate Goldie and consultant dermatologist Dr Maria Gonzalez will present this engaging session and, as in the other modules, the speakers will each analyse images of a male face before outlining their recommended treatment

methods. Alongside their assessments, they will outline how to address the various anatomical considerations in men compared to women and detail how to alter injectable and other treatments so they have a desired effect, such as on the deeper static lines often found on a male face. The speakers will also provide valuable advice on how to tailor a consultation to communicate effectively with a male patient and create bespoke aftercare plans to suit a male lifestyle. They will then perform a live demonstration of a recommended treatment on the male patient, discussing best practice techniques and safe administration.

Saturday Morning: Beginner’s Guide to Facial Assessment This module is dedicated to providing the most valuable practical advice to medical professionals who are new to the aesthetics specialty. Dental surgeon and aesthetic practitioner Dr Souphiyeh Samizadeh and aesthetic nurse prescriber Lorna Bowes, who both have extensive experience in training beginners, will get back to basics in this interactive, dedicated session. Dr Samizadeh will assess images and treat an ageing female face, while Bowes will do the same for a young female face. They will also perform a live demonstration on their patients, outlining anatomical considerations to be aware of, as well as pre- and posttreatment care. Attendees to this session will learn the wide range of aesthetic treatment options that are available, discovering how they can tailor them to individual patients and safely administer them in practice. The speakers will also provide advice on recognising when a patient may require more advanced procedures and how to appropriately refer to a suitably experienced practitioner. Saturday Afternoon: The Young Female Face The final session on the Premium Clinical Agenda will feature presentations from international speaker Dr Raj Acquilla and chair of the BACN, nurse prescriber, Sharon Bennett. The session will focus on the treatment of a young female face, showing the first signs of ageing. Each practitioner will spend 20 minutes assessing the patient’s aesthetic concerns, before performing a live demonstration of one of their recommended treatments. They will also discuss how to appropriately vary treatments between women who are experiencing different stages of facial ageing and tailor them to individual concerns. As with the other three sessions, pre- and post-procedure care will be discussed, along with advice on how to safely and successfully limit and manage complications. Dr Acquilla said, “Understanding how to treat women at different stages of the ageing process is vital to aesthetic practice. Sharon and I will provide you with the latest advanced technique advice to enhance your rejuvenation and beautification skills.” Reserve your place – book now! Tickets are already selling fast for these exclusive Premium Clinical Agenda sessions, so delegates are encouraged to book as soon as possible. Discounts are available to those who book multiple sessions, in addition to a 10% Early Booking Discount available until December 31. Visit www.aestheticsconference.com to find out more and book now. HEADLINE SPONSOR

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Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Treating Acne Scars with Lasers Practitioners discuss patient concerns surrounding acne scarring and how they treat the indication using laser devices Patients of all ages can suffer from the burden of acne vulgaris. Approximately 85% of people between the ages of 12 and 24 experience at least minor acne.1,2 However, even when the acne finally subsides, for many patients, this is not the end of their concern. Patients can be left with permanent atrophic and/or hypertrophic scars lasting into adulthood. These scars, much like the acne itself, can cause deep psychological distress, making the scarring just as important to treat as the acne.2 According to practitioners interviewed for this article, there are many approaches to treating scarring caused by acne, including chemical peels, microdermabrasion, microneedling, dermal fillers, and devices such as radiofrequency and laser.2 With the advancement of laser technology, this article will discuss the use of fractional ablative and fractional non-ablative lasers for the treatment of acne scarring. Acne scars “Acne scarring is due to prolonged inflammation of the skin caused by acne, but it does not appear to be linked directly to severity,”2,3 explains consultant dermatologist Dr Maria Gonzalez. She adds that patients with severe acne who have been treated appropriately without delay and with drugs such as oral isotretinoin to clear the acne, may not necessarily result in scarring,2 but also notes that, “There does seem to be a genetic link between those who scar and those who do not scar and it’s not always predictable – some people just genetically respond to inflammation in a way that produces scarring.”4 Consultant dermatologist Dr Firas Al-Niaimi adds, “A strong family history, nodulocystic and severe acne, those who have been left untreated and those who have been manually squeezing their spots are at risk of developing acne scarring.”2,3,5 Specialist dermatology nurse and independent prescriber Isabel Keloid Rolling Boxcar Ice Pick Lavers says she doesn’t believe acne scarring is gender specific. She says, “It affects both sexes and even though I often hear people say that men’s backs get worse scarring, I’ve seen many girls Figure 1: Type of scars that can be caused by acne2,4,8 who have had acne and been

left with severe scarring affecting their backs.” Aesthetic surgeon Mr Benji Dhillon says that darker skin types can have a higher risk of poor aesthetic outcomes following acne, due to the risk of post inflammatory hyperpigmentation (PIH), which they are more susceptible to.2,6 He also explains that acne scars are predominately found on the cheeks, the temples, the forehead, sometimes along the jawline and on the back.2 “If they have bad facial acne they may have some on their back, but it’s not often the first thing that patients get treated – they like to get their face treated first,” he acknowledges. Typically, there are three types of acne scars: ice pick (more deep than wide), boxcar (wider than deep with distinct edges) and rolling (can be smoothed out if stretched) atrophic scars.2,5 In some cases (particularly on the chest and shoulders) hypertrophic or keloid scars can result from acne and these are generally treated with other options than the atrophic acne scars. (Figure 1).2,5 Mr Dhillon explains, “Ice pick scars are traditionally very difficult to treat given their physical characteristics. Boxcar scars and rolling scars, although not easy to treat, are slightly more amenable to some of the treatment options such as lasers.” Why choose lasers for acne scarring? In order to improve the appearance of an acne scar, the aim of laser treatment is to stimulate the skin to produce collagen through creating a wound in the epidermis. Aesthetic practitioner Dr Andrew Weber explains, “Fractional lasers produce micro thermal zones of coagulated tissue, allowing for resurfacing, collagen stimulation (of a non-scar type) as well as skin tightening due to the heat produced.”9 Dr Al-Niaimi believes that lasers are a good option due to the added control you get over other treatment methods. “The advancement in laser technology allows us to create a form of controlled injury into the skin to the depth that is required. For example, if you have shallow scars then we can control that depth of injury into the skin at a shallow level and, in the case of deep scars, we can create a controlled injury at a deeper level,” he explains. Mr Dhillon agrees, “I personally like using lasers because I am able to tailor treatments to the type of scarring and to the type of patient in terms of their expectations and downtime. One of the

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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NotNot for use in the U.S.U.S. market. © 2013. All rights reserved. eTwo, Sublative andand CO CO RE RE are are trademarks of Syneron Medical, Ltd.Ltd. Syneron andand the the Syneron logo, Candela andand the the Candela logologo are are registered trademarks. PB81281EN for use in the market. © 2013. All rights reserved. eTwo, Sublative trademarks of Syneron Medical, Syneron Syneron logo, Candela Candela registered trademarks. PB81281EN Not for use in the U.S. market. © 2013. All rights reserved. eTwo, Sublative and CO22RE2are trademarks of Syneron Medical, Ltd. Syneron and the Syneron logo, Candela and the Candela logo are registered trademarks. PB81281EN

Post 3 Sublative Treatments

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Post 3 CO2RE Treatments

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concerns you always have with any form of treatment where you are making an injury to try and improve skin is PIH. I know that if I am using a laser device, although I can never rule out PIH, I will have a degree of control over the settings I use.” The two main forms of laser devices for acne scarring is fractional ablative and fractional non-ablative, explains Mr Dhillon, who says that, “Fractional ablative lasers target various layers of the skin whilst also creating an epidermal injury.” He continues, “For non-ablative you are also targeting various layers of the skin but without an injury to the epidermis.”9 The consultation Practitioners interviewed agreed that a comprehensive consultation is needed, including an assessment of the types of scars, skin characteristics, including skin type and thickness, and treatment history. Lavers adds, “If they’ve been on oral isotretinoin they must wait a number of months before we can consider treatments because the skin is still fragile.” Practitioners also note that the psychological impacts of the condition must be considered alongside the patient’s expectations and treatment downtime. Mr Dhillon says, “The most challenging part of the acne scarring treatment process is actually dealing with the patient’s expectations – they require a degree of counselling – scarring is not just physical but is also a psychological issue. As a practitioner, you have to really probe into how this affects them.” He advises to look out for ‘red flags’ and make sure the patient understands the level of results that will be achieved, emphasising that, “We should never promise an outcome.” Dr Gonzalez says that when determining the appropriate treatment, it is vital to understand the patient’s lifestyle and expectations in the consultation, especially for the more aggressive treatments with long downtime such as the ablative lasers. “I always show my patients pictures of other patients post-procedure to demonstrate what they will look like before they commit to their treatment – that’s how they decide if that’s something they can tolerate or not,” she says. Lavers adds, “Once the patient is scarred it is so difficult to reverse, often impossible, but one aims to improve the appearance of the scar to a point that the patient feels much better about their appearance. I often say to people ‘I can’t magic your scars away but I can hopefully make them look a lot better’.”

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Radiofrequency Unlike laser, radiofrequency produces an electrical current as opposed to light that is passed through the dermis to produce small thermal wounds, which stimulates dermal remodelling to produce new collagen.8 Lavers and Dr Gonzalez believe this method is also worth considering for treatment of acne scars. Lavers explains, “I like radiofrequency because the downtime is quite minimal. The main damage that occurs is in the dermis, which is pretty much untouched, where the remodelling of the collagen in the skin takes place and not on the skin’s surface.” Lavers says the energy levels of radiofrequency devices can be adapted to cater for different patients and their scar severity, “If you have patients with skin of colour, you have to be more careful because any trauma you cause can equally trigger PIH, so if you have darker skin types you tend to stay at the lower energy levels, but when treating patients with Caucasian skin one is able to use higher energy levels, which are required for more severe acne.” Typically, she says her patients usually require three to four treatments, and the optimal results are seen around three months after the final treatment. She explains that, post-treatment, patients may see redness and a bit of fine scaling but that this can be covered with makeup. Dr Gonzalez explains that the ideal patient to treat with radiofrequency would be, “Anybody with scarring, including ice pick scarring, once they are aware that they can expect about 25-30% improvement. I often use radiofrequency in patients whom are not suitable to start on aggressive treatments such as a CO2 laser. A notable group would be patients with pigmented skin, of whom post treatment hyperpigmentation is very likely when ablative treatments are used. The incidence of post treatment pigmentation is less likely with radiofrequency if appropriately carried out.”

Fractional ablative “Out of all the acne scarring treatments, deep peels and fractional ablative lasers probably give the best results,” says Dr Gonzalez. Ablative lasers generate beams of light that are absorbed by the skin as energy, which is delivered through a range of wavelengths. The two fractional ablative lasers most commonly used for acne scarring are CO2 and erbium yttrium aluminum garnet (Er:YAG) lasers.7 The CO2 device emits light in the infrared range at a wavelength of 10,600 nanometres,7 Mr Dhillon explains, noting that it aims to act on the superficial layers of the skin, “It works by using water as a chromophore, which sits in the skin so you can generate an injury in the deeper layers to stimulate collagen and try and improve scarring from within.” Dr Al-Niaimi notes that the CO2 is ideal for more impact and tightening, but says that it is a more aggressive treatment with a longer downtime. He explains, “There will be ablation but there will also be some residual heat around the ablative area

“A strong family history, nodulocystic and severe acne, those who have been left untreated and those who have been manually squeezing their spots are at risk of developing acne scarring” Dr Firas Al-Niaimi, consultant dermatologist

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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which we could call the coagulation zone, but because of this there is going to be a longer downtime.” He says practitioners must be careful with skin of colour and thin skin, saying, “For thinner skin you have to be more careful and will need to use lower settings. For thicker skin you can use a higher setting and be more aggressive if the scars are deep.” Dr Gonzalez notes that CO2 lasers are her preference for ablation because, “The Erbium doesn’t penetrate as deeply into the skin as the CO2 laser so if you want a better result you should use a CO2 laser. However, some practitioners have perfected the use of erbium lasers in acne scarring by using multiple passes, which increase the penetration of this laser. For fractional ablative lasers treatments every three to four months are recommended and patients should expect to have at least three treatments in a year in order to see results.” In addition, she notes, that the downtime can be from seven to nine days. Conversely, Dr Weber says, “We do not use a CO2 laser because of the downtime.” For ablation, he would instead use a fractional Er:YAG 2940 nm laser, “The treatment is not optimal but the downtime is minimised. Today’s patients require minimal downtime and although with the 2940 nm there is some swelling and redness, it is easily covered by makeup. Most self-conscious acne scarring sufferers are young and have full time jobs so are unable to tolerate downtime.” Fractional non-ablative Dr Al-Niaimi points out, “It’s not just the fractional ablative to consider, I also use a lot of fractional non-ablative for acne scarring.” He says that the results of non-ablative systems are somewhat inferior to the fractional ablative but do have some benefits, “They usually require more treatments compared to the fractional ablative but they are associated with less downtime and less risk of PIH – they are for mild to moderate acne scarring and the results can be very acceptable.” Dr Al-Niaimi notes the common wavelengths for the fractional nonablative that can be used for acne scarring are 1540 nm, 1550 nm and 1565 nm. He says his choice of using a fractional non-ablative device will be based on the patient’s preference, severity of the acne scarring and if they want a reduced downtime. He says patients will usually require from three to five treatments, with two to three days of downtime, “I generally explain that the results are gradual and that they may require lots of treatments, depending on the severity of the scars,” he says. Mr Dhillon also uses non-ablative devices in his clinic based on the patient’s preference and would consider a non-ablative device if the patient can’t afford the downtime associated with ablative lasers. He says, “I always counsel them and say that they will require more sessions than you would an ablative device, but saying that, we are actually starting to use less of the fractional non-ablative devices and more of the fractional ablation.” Lasers in combination “Lasers are one option for acne scar treatments, not the sole option,” Dr Al-Niaimi explains, saying he will often use combination treatments for optimum results. Choice of combination treatments, he says, “Depends on the type of acne scarring and sometimes the size – I often combine lasers, excision and subcision for some of the deep rolling scars, and I might combine that with some fillers after the laser treatments for some of the atrophic areas where there is tissue loss.” Mr Dhillon has some experience using dermal fillers for resistant ice pick scars, but says, “Personally I don’t like using fillers for acne scars because they are a short lived improvement – fillers break down – so it comes back to the patient’s expectations of treatment.”

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“Out of all the acne scarring treatments, deep peels and fractional ablative lasers probably give the best results” Dr Maria Gonzalez, consultant dermatologist

Dr Gonzalez says she will consider a number of treatments with laser for acne scarring, “What you are trying to do is stimulate collagen in the dermis – you can use lasers to achieve this, you can use peels, microneedling, or radiofrequency. It is also useful to combine any or all of these treatments. If combining treatments care is required in the timing of different treatments in order to minimise the risk of complications.” Mr Dhillon also emphasises the importance of skincare, “It’s probably just as important as the device-based treatment. I’d get the patient to start making sure that they are consistently using sun protection every day before and after treatment.” He would also introduce a vitamin C serum, explaining, “It has been suggested to prolong and improve the benefits of treatment and prevent the break down of collagen.”8 Dr Al-Niaimi adds, “If you use vitamin C after fractional ablative lasers you get quicker healing, less downtime and you also stimulate more fibroblasts.”8 Conclusion When determining acne scar treatment, it is important for practitioners to take note of the type of acne scar and the downtime associated with the treatment. For practitioners considering treating acne scars with laser devices, Mr Dhillon advises, “I think the most important thing is not to be afraid to say no to patients, and also understand their desires and wishes rather than just focusing on their physical needs when it comes to acne scarring.” Dr Al-Niaimi concludes, “It is very important to have photographs before the treatment to monitor the results. Be very confident and familiar with your machine and constantly remind yourself of other technologies and treatments. Lastly, it’s really important to understand that acne patients have been thinking about this for a long time and this is a really important thing for them – showing some compassion can go a long way.” REFERENCES 1. Bhate K, Williams HC, ‘Epidemiology of acne vulgaris’, Br J Dermatol, 168(2013), pp. 474-85 <https:// www.ncbi.nlm.nih.gov/pubmed/23210645> 2. Gabriella Fabbrocini, M.C Annunziata, V D’Arco, V De Vita, G Lodi, M.C. Mauriello, F Pastore, & G Monfrecola, ‘Acne Scars: Pathogenesis, Classification and Treatment’, Dermatol Res Pract, (2010), <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958495/> 3. Layton AM1, Henderson CA, Cunliffe WJ, ‘A clinical evaluation of acne scarring and its incidence’, Clin Exp Dermatol, 19(1994), pp.303-8 <https://www.ncbi.nlm.nih.gov/pubmed/7955470> 4. MT Hession, & EM Graber, ‘Atrophic Acne Scarring: A Review of Treatment Options,’ J Clin Aesthet Dermatol, 8(2015) pp.50–58. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295858/> 5. WP Werschler, RS Herdener, VE Ross, E Zimmerman, ‘Treating Acne Scars: What’s New? Consensus from the Experts’, J Clin Aesthet Dermatol, 8(2015), <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4570086/> 6. EC Davis, & VD Callender, ‘A Review of Acne in Ethnic Skin: Pathogenesis, Clinical Manifestations, and Management Strategies’, J Clin Aesthet Dermatol, 3(2010) pp.24–38. <https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2921746/> 7. Michael McLeod; Lauren Meshkov; Keyvan Nouri, ‘Lasers in the Treatment of Acne Scars’, Expert Review of Dermatology, 6(2011), pp.45-60, <http://www.medscape.com/viewarticle/737145_5> 8. Al-Niaimi F, Waibel JS, Mi QS, Ozog D, et al.,’Laser-assisted delivery of vitamin C, vitamin E, and ferulic acid formula serum decreases fractional laser postoperative recovery by increased beta fibroblast growth factor expression’, Lasers Surg Med, 48(2016), pp.238-44. <https://www.ncbi.nlm.nih.gov/ pubmed/26612341> 9. UA Patil & LD Dhami, ‘Overview of lasers’, Indian J Plast Surg, 42(2008) pp.101–113 <https://www.ncbi. nlm.nih.gov/pmc/articles/PMC2825126/>

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hybridisation demonstrates bacteria in the majority of biopsies which were culture negative.1,2 As such, the recognition and understanding of biofilms as a potential cause of such adverse reactions has significant relevance for their management. Tests including polymerase chain reaction (PCR) of bacterial protein and fluorescence in situ hybridisation can aid diagnosis.11

Definition

Biofilms Dr Souphiyeh Samizadeh details the formation and treatment of the bacteria-based infections following dermal filler injections Although the concept of a biofilm is well established in other fields such as dentistry and chronic infections,1-3 it is a relatively new concept in medical aesthetics and dermatology. The role of biofilms in adverse reactions post injection of dermal fillers is attracting increasing attention. Reported adverse reactions include nodules, abscesses, delayed reactions, vascular compromise and infection.4-9 Although rare, these may occur, in particular with long-acting dermal fillers, partially or completely non-resorbable polymers,4,10 and may persist for months causing anxiety for the patient and the practitioner.1 Due to the culture results being negative and a lack of successful identification of the causative bacteria, adverse events were in the past thought to be allergic or foreign body reactions.6 However, some of these reactions are now believed to be caused by the formation or as a consequence of biofilms. Recent studies have indicated that fluorescence in situ

A biofilm is an aggregate of microorganisms (bacteria, protozoa, fungi, algae, yeast and other microorganisms) that are physically joined together. They produce an extracellular matrix containing many different types of extracellular polymeric substances such as polysaccharides, proteins and DNA.1,3 These surface-associated microbial communities can form in all environments and irreversibly adhere (so cannot be removed by gentle mechanical agitation) to living and non-living surfaces.4 Biofilms play an important and positive role in the ecosystem, for example they contribute substantially to energy flow and nutrient cycling,12 however they can have negative effects in medical settings, where biofilm-related infections can occur.5 Biofilms are usually formed on solid surfaces that are exposed to or submerged in water. In the human body, many chronic infections involve surfaces such as implants, tissue fillers, orthopaedic implants, artificial heart valves, contact lenses, catheters, and teeth.3,5 Examples of tissue-related biofilms include chronic sinusitis, kidney stones and osteomyelitis.5 Such aggregate of bacteria (whether it is device-related or tissuerelated) becomes tolerant to the host defences, can withstand very high doses of antibiotics and can often fail to be identified using culture.2,5 Therefore, treatment is difficult with a high risk of reoccurrence. In addition, planktonic bacteria from the biofilm can spread into the surrounding tissues or bloodstream.5 Biofilm antibiotic tolerance and antibiotic resistance are two different matters and are not to be confused. Biofilms indicate increased tolerance to antibiotics. The following factors are thought to result in a multilayer defence, allowing the biofilm to become resistant to antibiotics:13 • Poor penetration of antibiotics • Nutrient limitation and slow growth • Adaptive stress responses Bacteria within a biofilm becomes susceptible to antibiotics when the biofilm is disrupted.3

Process of biofilm formation Primary Bacterial Species

Secondary Bacterial Species

Matrix

Microcolony

Attachment Figure 1: Biofilm formation process

Growth

Maturation

Detachment

The formation of a biofilm has four stages; attachment of bacteria to the solid or tissue surface, formation of a microcolony, maturation of the biofilm and dispersion.6 Free-floating bacteria can adhere to the living or nonliving surfaces and become sessile. Their formation is usually rapid and microcolonies can be detected as soon as eight to ten hours after infection. Extracellular polymeric substances are produced and act as a glue and scaffolding to hold the biofilm together.1,5,15 The biofilm growth increases the resistance of the bacteria to antimicrobials and makes the organisms less exposed to the immune system.7 Biofilms are usually dormant (low-grade infection), however, depending on the external triggering factors, they can become active. Disturbances in a biofilm’s local environment, for example, trauma, further injection, hematogenic infection or iatrogenic manipulation or manipulation,16 can result

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The recognition and understanding of biofilms as a potential cause of such adverse reactions has significant relevance for their management

in manifestations such as local low-grade infection, abscess, local lumps, foreign body granuloma, nodule or systemic infection.8 It must to be noted that biofilm antibiotic tolerance should not be confused with antibiotic resistance because, although bacteria within a biofilm tend to survive antibiotic treatment, they become susceptible to the treatment when the biofilm is disrupted.

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authors, however, this is a much debated topic and not evidence based.5,15,18 In a study carried out by Alhede et al., using mice, they reported that tissue gel fillers used in their study provided a perfect habitat to sustain biofilm growth, and even low numbers of contaminating bacteria resulted in formation of biofilms. The research additionally suggested that administration of antibiotics prophylactically resulted in prevention of bacterial growth in all their cases.5 Smaller gauge needles are recommended to limit access for bacteria, as well as minimise trauma.4 A reduction in the amount of implanted dermal fillers is also recommended, as discussed below.

Increased risks Long-term treatment with dermal fillers has been associated with an increased risk of biofilm formation. The dormant biofilm may become activated on repeated treatment. Other factors thought to contribute in biofilm development include:8 • Surface area of product: the larger the surface area, the more surface available for bacteria adherence and colonisation.8,19 • Longevity of product: a study carried out by Alhede et al. on bacterial biofilm formation and treatment in soft tissue fillers reported that sustainability of induced infections appear to depend on longevity of the gel.5,18 • Inadequate sterile technique: in the study by Alhede et al., the route of bacterial infection was suggested to be during injection of the filler. The researchers reported that as little as 40 single bacteria was sufficient to cause an infection.5

Prevention strategies Patient history A comprehensive medical history should reveal any information on bleeding disorders, immunocompromised states, previous infections or any infection around the area of treatment. In addition, it should determine if the patient has had any previous tissue fillers or implants. Infections in the area or adjacent to the site of treatment can exacerbate and cause complication. The infecting organisms can therefore populate the area of filler implantation.9 It is recommended that any infections such as sinusitis, periodontal disease, ear, nose, or throat infections, or dental abscesses should be treated prior to placement of dermal fillers.9,17 Therefore, to prevent occurrence of adverse effects, it is paramount to be mindful of patient-, product-, and technique-related factors.9 Hygiene The first step in prevention is taking care of hygiene to prevent microbial contamination, therefore prevention of adherence of microorganisms to the surface and biofilm formation. Similar to other practises in medicine, a standardised procedure for device implantation and handling is recommended. For example, the insertion of medical devices must be performed by sufficientlytrained healthcare professionals and maximum sterile barrier precautions (sterile gloves, cap, mask, sterile gown, and a sterile full-body drape) should be used.5 As dermal fillers are implantable devices, aseptic technique is recommended.4 Skin disinfection and the method and choice of disinfectant solution are of key importance. Alcohol-based antiseptics (alcohol-based chlorhexidine, alcohol-based povidone-iodine) are the most efficient solutions.5 The use of topical antibiotic agents and prophylactic antimicrobial therapy has been suggested by a few

The authors of the Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers argue that hyaluronic acid fillers have a low incidence of biofilm formation.11 In the panel’s opinion, incidences of biofilm formation vary by filler used. It was also suggested that dermal fillers that are made up of resorbable substances would result in a low incidence of longlasting or late complication,11 however there may be an increased risk if the product is placed where there is a permanent filler.9 Further research is required for more definitive evidence.

Biofilms form when bacteria adhere on the surface of the temporary or permanent implants and aggregate into communities

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Biofilms are usually formed on solid surfaces that are exposed to or submerged in water Diagnosis Diagnosis of adverse reactions requires careful patient history. Biopsy of the site helps with definitive diagnosis of the reaction. Two key factors for diagnosis are appropriate cultures and sufficient incubation time.20 Tests such as pyrosequencing (method of DNA sequencing) and polymerase chain reaction (DNA replication using a small amounts of starting material), in addition to the conventional culture methods, can be used to identify the bacterial components of biofilm.5 Accurate identification of the offending organisms can minimise the potential for development of resistant pathogens and optimise chances of successful treatment.

Treatment options In most cases, removal of the colonised device, and/or surgical excision of the involved/infected tissue may be the only effective option to eradicate a biofilm-related infection.5 The non-invasive options including antibiotics, steroids, and 5-fluorouracil are only effective prior to development of a biofilm.11,21 Antibiotics and drainage could suppress an active infection, however complete resolution is rare (if not impossible) without removal of the implant and its associated biofilm. Invasive surgical procedures are sometimes inevitable. However, the non-surgical options such as hyaluronidase and lasers could be considered prior to surgical removal, which may result in scarring. Cassuto et al. used lithium triborate 532 nm and 808 nm diode lasers to treat granulomatous or cystic lesions. They reported that the treatments were completely or partially effective. The mechanism of action is through melting the tissue, filler material, and inflammatory cells into a necrotic debris. These then can immediately be removed through the drilled holes. In addition, the researchers suggested that the heat from the laser beam which is 65-70°C is likely to kill the bacteria in the biofilm community and melt the microparticles.11 An in vitro study carried out by Pecharki et al. reported that hyaluronidase promotes Streptococcus intermedius detachment and effectively breaks down bacterial biofilms.22 The significance of this when using hyaluronidase in medical aesthetics needs to be established. An acute infection needs to be taken care of prior to removal/dissolving of the dermal filler.

Summary The increase in demand and popularity of injectable dermal fillers for aesthetic enhancement has increased the incidence of complications.4,23 Improper or inadequate disinfection of the skin, poor injection technique, presence of potential pathogens, (e.g. the patients’ own microflora such as Propionibacterium acnes, Staphylococcus epidermidis, and mycobacteria), injection in

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presence of previous permanent implants and reduced immunity increase the risk of bacterial infections. Biofilms form when bacteria adhere on the surface of the temporary or permanent implants and aggregate into communities that are physically joined together and become resistant to antimicrobial therapies and the immune system. Diagnosis and developing effective treatment of the biofilm is crucial in aesthetic practice. Even when experienced clinicians inject dermal fillers, they can cause various inadvertent reactions, ranging from minor and self-limited responses to severe complications. As such, there is an essential need for prompt diagnosis, treatment and close follow-up. The aesthetic clinician should not only have an in-depth understanding of the potential complications caused by injectable fillers, but also be able to diagnose, know when to mediate and also be confident in recognising and managing possible adverse sequelae. Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in aesthetic medicine. She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic. She has presented at both national and international conferences, and is actively involved with research into aesthetic medicine. REFERENCES 1. Donlan RM., ‘Biofilms: Microbial Life on Surfaces’, Emerging Infectious Diseases, 8(9) (2002), pp.881-90. 2. Uppuluri P, Chaturvedi AK, Srinivasan A, Banerjee M, Ramasubramaniam AK, Köhler JR, et al., ‘Dispersion as an Important Step in the Candida albicans Biofilm Developmental Cycle’, PLoS Pathogens, 6(3) (2010) e1000828. 3. Salta M, Wharton JA, Blache Y, Stokes KR, Briand JF., ‘Marine biofilms on artificial surfaces: structure and dynamics’, Environmental microbiology, 15(11) (2013), pp.2879-93. 4. Christensen L., ‘Normal and pathologic tissue reactions to soft tissue gel fillers’, Dermatologic Surgery, 33(s2) (2007), S168-S75. 5. Alhede M, Er Ö, Eickhardt S, Kragh K, Alhede M, Christensen LD, et al., ‘Bacterial biofilm formation and treatment in soft tissue fillers’, Pathogens and Disease, 70(3) (2014), pp.339-46. 6. Abduljabbar MH, Basendwh MA., ‘Complications of hyaluronic acid fillers and their managements’, Journal of Dermatology & Dermatologic Surgery, 20 (2016) (2), pp.100-6. 7. Definition of ‘symmetry’ – English Dictionary: Available from: <http://dictionary.cambridge.org/us/ dictionary/english/symmetry> 8. Signorini M, Liew S, Sundaram H, De Boulle KL, Goodman GJ, Monheit G, et al., ‘Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidence- and Opinion-Based Review and Consensus Recommendations’, Plastic and reconstructive surgery, 137(6) (2016), 961e-71e. 9. De Boulle K, Heydenrych I., ‘Patient factors influencing dermal filler complications: prevention, assessment, and treatment’, Clinical, cosmetic and investigational dermatology, 8 (2015), p.205. 10. Wolfram D, Tzankov A, Piza-Katzer H., ‘Surgery for foreign body reactions due to injectable fillers’, Dermatology, 213(4) (2006), pp.300-4. 11. Cassuto D, Marangoni O, De Santis G, Christensen L., ‘Advanced laser techniques for fillerinduced complications’, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al]. 35 Suppl 2 (2009), pp.1689-95. 12. Battin TJ, Kaplan LA, Denis Newbold J, Hansen CME., ‘Contributions of microbial biofilms to ecosystem processes in stream mesocosms’, Nature, 426(6965) (2003), pp.439-42. 13. Stewart PS., ‘Mechanisms of antibiotic resistance in bacterial biofilms’, International Journal of Medical Microbiology, 292(2) (2002), pp.107-13. 14. Andersson DI., ‘Persistence of antibiotic resistant bacteria’, Current opinion in microbiology, 6(5) (2003), pp.452-6. 15. Sadashivaiah AB, Mysore V., ‘Biofilms: Their Role in Dermal Fillers’, Journal of Cutaneous and Aesthetic Surgery, 3(1) (2010), pp.20-2. 16. DumitraŞCu DI, Georgescu AV., ‘The management of biofilm formation after hyaluronic acid gel filler injections: a review’, Clujul Medical, 86(3) (2013), pp.192-5. 17. Narins RS, COLEMAN WP, Glogau RG., ‘Recommendations and treatment options for nodules and other filler complications’, Dermatologic Surgery, 35(s2) (2009), pp.1667-71. 18. Bjarnsholt T, Tolker-Nielsen T, Givskov M, Janssen M, Christensen LH., ‘Detection of bacteria by fluorescence in situ hybridization in culture-negative soft tissue filler lesions’, Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al]., 35 Suppl 2 (2009), pp.1620-4. 19. Rohrich RJ, Monheit G, Nguyen AT, Brown SA, Fagien S., ‘Soft-tissue filler complications: the important role of biofilms’, Plastic and reconstructive surgery, 125(4) (2010), pp.1250-6. 20. Beer K, Avelar R., ‘Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations’, Dermatologic Surgery, 40(11) (2014), pp.1175-9. 21. CONEJO MIR JS, Sanz Guirado S, ÁNgel MuÑOz M., ‘Adverse Granulomatous Reaction to Artecoll Treated by Intralesional 5‐Fluorouracil and Triamcinolone Injections’, Dermatologic surgery, 32(8) (2006), pp.1079-82. 22. Pecharki D, Petersen F, Scheie AA., ‘Role of hyaluronidase in Streptococcus intermedius biofilm. Microbiology’, 154(3) (2008), pp.932-8. 23. Zielke H, Wölber L, Wiest L, Rzany B., ‘Risk profiles of different injectable fillers: results from the Injectable Filler Safety Study (IFS Study)’, Dermatologic surgery, 34(3) (2008), pp.326-35.

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Bocouture® (incobotulinumtoxinA) 50 units Prescribing Information M-BOC-UK-0007 Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults below 65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: Intramuscular injection, the recommended total dose range is 10 to 20 units, a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50 units/1.25mL). Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with aging or photodamage). In this case, patients may not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia

and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia). Frequency of adverse reactions by indication is defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Upper Facial Lines: Very common: Headache. Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma. For a full list of adverse reactions, please consult the SmPC. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation: July 2016. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. 1. Bocouture® 50U Summary of Product Characteristics (SPC). April 2016. Available from: https:/www.medicines.org.uk/emc/ medicine/23251 2. Carruthers A et al. Multicentre, Randomized, Phase III Study of a Single Dose of IncobotulinumtoxinA, Free from Complexing proteins, in the Treatment of Glabellar Frown Lines. Dermatol Surg. 2013:1-8 3. Prager W, et al. Comparison of Two Botulinum Toxin Type A Preparations for Treating Crow’s Feet: a Split-Face, DoubleBlind, Proof-of-Concept Study. Dermatol Surg. 2010 Dec; 36 Suppl 4:2155-60 4. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 5. BOC-DOF-012 Bocouture® Convenient to Use, August 2015 BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0025 Date of Preparation August 2016

PURIFIED1• EFFECTIVE2, 3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins

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allowing people to build rapport, trust and instill confidence.5 In essence, every human understands the meaning of a smile and the underlying associated emotions, thus making smiling an integral part of human interaction and behaviour. It is for this reason that an individual’s smile is so important, and why an aesthetically pleasing smile, including the teeth and lips, is so highly sought after in the aesthetics arena.

Smile science and aesthetics

Smile Enhancement Dr Rupert Critchley shares his techniques for improving a smile using botulinum toxin Smile verb or noun Form one’s features into a pleased, kind, or amused expression, typically with the corners of the mouth turned up and the front teeth exposed.

Psychology of the smile A smile is universally acknowledged as one of our most powerful human attributes. Whether a social smile at six weeks old, or a smile at successes later in adult life, evidence of the importance of a smile has been well documented by evolutionary, cross-cultural and social psychological research for many decades. Alongside the union of biological evolution and foundation of the Darwinian Theory, Charles Darwin was lesser-known for making important contributions to early experimental psychology of the smile. Studies published in Expression concluded that the smile is truly universal, unlike other physical actions such as body language or verbal communication, which differs from one culture to another.3 Other less-ethical experiments were carried out by French anatomist Guillaume Duchenne, who studied emotional expression by stimulating various facial muscles with electrical currents. The term ‘Duchenne Smile’ refers to what characterises a ‘true smile’ and is suggested as a predictor of marital happiness, personal wellbeing and even longevity.4 In contrast, a ‘false smile’ can be an indicator of negative emotional states such as grievance and misery. More recently, scientists have discovered a total of 14 different smile types ranging from broad and symmetrical to narrow and lopsided.5 Smiles are impactful in more than one way: internally, by helping build self-confidence and overall well-being, having a ‘self-medicating’ effect, i.e. the hormonal and physiological consequences of a smile that make us feel good and want to smile more, and externally, by

Generally speaking, we recognise a smile as a behavioural expression indicating pleasure and happiness. Once the senses are aroused, neurotransmitters are released in the left anterior temporal region or limbic system in the brain. As a result, motor pathways are activated.6 Two key muscles – the zygomatic major and the orbicularis oculi – are roused into action. The entire event that results in a smile being formed is short, typically lasting from two-thirds of a second to four seconds. In this time, the zygomatic major pulls the lips upward and the orbicularis oculi squeezes the outside corners of the eyes into the shape of a crow’s foot.3 It is widely accepted that the known aesthetic characteristics of an attractive, or ‘perfect’ smile is one which is symmetrical, wide, displaying white, straight teeth which follow the lip line and gingival visibility of between 1-3mm. Although dental assessment still plays an important role in the beautification of the smile, the development of advanced injection techniques using botulinum toxin type-A for correcting common smile imperfections is becoming increasingly popular in the aesthetics field and is an important skill for clinicians.

Injection techniques for smile improvement using botulinum toxin The common causes of an ‘imperfect’ or un-aesthetically pleasing smile which can be safely treated with non-surgical injectables include: the ‘gummy smile’, smile asymmetry due to an overpowering unilateral depressor anguli oris (DAO) and downslanting lip edge corners, and ‘long and sad’ face at rest due to a bilateral overpowering DAO. Please note as per best practice, only a suitably trained clinician should carry out these advanced procedures. A thorough history and appropriate consent should be taken, target areas of injection marked, and before and after images obtained. The safest approach to treatment is to avoid over paralysation of the muscle by injecting smaller quantities of botulinum toxin, with a review and top up if required at the two-week point. The ‘gummy smile’ A ‘gummy smile’ is a term used to describe the excessive display of gingival tissue in the maxilla when a person smiles. This common complaint can impact someone psychologically by affecting their selfesteem and confidence. Until recently, corrective procedures involving invasive orthognathic surgery or orthodontic appliances were the most common treatment options for patients suffering from a gummy smile.7 Now, however, the scalpel is increasingly being laid to rest and non-surgical techniques using botulinum toxin are often favoured. This treatment is less costly, less painful and requires less patient downtime, whilst achieving the same standard of results. Techniques of this treatment vary but ultimately the aim is to target and weaken only those muscles around the mouth that are causing the excess retraction of the lip upon smiling. Typically, there are four injection points that can be used to depress the lip at different locations (Figure 1).

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

@aestheticsgroup Figure 1

• Injection points 1 and 4: 1cm directly lateral from the most superior point of nasolabial sulcus (levator anguli oris) dropping the lateral aspects of the lip. • Injection points 2 and 3: a vertical line is drawn between the nose and the lip border – injection point is two-thirds above the lip on the ridge of the philtrum (orbicularis oris) dropping the middle one-third of the lip downwards. Smile asymmetry due to unilateral overpowered depressor anguli oris Botulinum toxin injections can be used to correct smile symmetry as a result of a unilateral overpowered DAO. Patients are rarely aware of potential correction using botulinum toxin and a thorough history should be obtained to ensure there is no underlying neurological pathology. Figure 2

• Injection points: 1-1.5cm below the angle of the mouth (deep into the DAO) several injections can be made on either side running down towards the mandible.

Treatment results Treatment results vary from patient to patient but providing the practitioner has appropriate anatomical understanding and training, patients are generally very satisfied with results (Figure 4). The results last four to six months depending on administration. Before

Aesthetics aestheticsjournal.com

The clinician must have appropriate training in advanced non-surgical injectables and be mindful of facial anatomy, avoiding the key vessels in the perioral area, in particular, the superior and inferior labial arteries, the facial artery/angular branch. Toxin quantity depends on the choice of product. Under no circumstances do you want to impact the general movement and function of the facial muscles, which could affect the patient’s ability to smile altogether, or could cause difficulties with speech, chewing and/or drinking. Over-administration can result in drooping or ptosis of the lip below the gingival margin causing obstruction of visible teeth on full smile. In addition, it is of utmost importance that the clinician manages patient expectations prior to treatment, as well as discusses the immediate effects such as temporary redness, swelling and potential bruising. Spreading of the treatment to the muscle nearby can easily be prevented by avoiding rubbing or massaging the treated areas for approximately four hours post treatment.8

Conclusion • Injection points: 1-1.5cm below the angle of the mouth – unilateral injection in the DAO (arrow on Figure 2 marks the direction of pull of stronger DAO).

Downturned lip corners due to bilateral overpowered depressor anguli oris This common complaint mostly occurs due to the imbalance between lip elevator and stronger DAO function (Figure 3). The dentition and orthodontic status of the patient may also play a role in development of this pathology. Figure 3

Aesthetics Journal

After

Figure 4: Gummy smile before and after administration of botulinum toxin

Potential side effects and management The risk of complications depends on both the clinician’s competence and experience, as well as the post-procedure advice given. Generally, the risk of complications can be minimised by cautious measures of product, anatomical awareness and injection technique. The depth of administration should be intramuscular with the needle perpendicular to the skin surface and bevel facing upwards.

The smile plays a key role in the expression of happiness, confidence and social interaction on many psychosocial levels. The aesthetics of a person’s smile not only alters their physical appearance but is also proven to impact their psychological and emotional wellbeing. Someone who feels that they suffer from a ‘gummy smile’, where more than 3mm of gingival tissue is displayed when they smile, may try to hide this by not smiling fully, or not smiling at all. This can make them feel uneasy and unable to connect as well with others in social environments, as well as potentially impacting how they are perceived by others. It’s therefore understandable why people seek treatment for this condition. The use of botulinum toxin type-A injections to relax key muscles around the mouth can greatly improve smile aesthetics by incapacitating the muscle’s ability to elevate above the gingival tissue to the same extent as before. In comparison to other treatments, botulinum toxin injections are a quick and minimally-invasive alternative with less chance of complications, available at a lower cost and requiring less patient downtime than many surgical alternatives. Dr Rupert Critchley is the lead clinician and director of Viva Skin Clinics. After qualifying as a medical doctor in 2009, he has completed an array of courses in advanced non-surgical aesthetics; attained MRCS part A and is also a fully qualified GP. REFERENCES 1. Oxford Dictionaries, ‘Smile’ (Oxford Dictionaries, 2016) < http://www.oxforddictionaries.com/us/ definition/american_english/smile> 2. Encyclopedia Britannica, ‘Emotional Development in infants’ (Encyclopedia Britannica, 2016) <https:// www.britannica.com/topic/social-smiling> 3. Eric Jaffe, The Psychological Study of Smiling (Psychological Science, 2010) <http://www. psychologicalscience.org/index.php/publications/observer/2010/december-10/the-psychologicalstudy-of-smiling.html>. 4. Paul Ekman, The Duchenne Smile: Emotional Expression and Brain Physiology (Journal of Personality and Social Psychology 1990) <https://www.paulekman.com/wp-content/uploads/2013/07/TheDuchenne-Smile-Emotional-Expression-And-Brain-Physiolog.pdf> 5. Adrian Furnham Ph.D., The Suprising Psychology of Smiling (Psychology Today, 2014) <https://www. psychologytoday.com/blog/sideways-view/201410/the-surprising-psychology-smiling>. 6. Ronald E Riggio Ph.D., There’s Magic In Your Smile: How Smiling Affects Your Brain (Psychology Today, June 25, 2012) <https://www.psychologytoday.com/blog/cutting-edge-leadership/201206/ there-s-magic-in-your-smile> 7. Angelillo JC, The surgical correction of vertical maxillary excess (long face syndrome). (NCBI, January, 1982) <http://www.ncbi.nlm.nih.gov/pubmed/7073194> 8. Sudeeptha Dinker, A Anitha, Abhinay Sorake, Kishore Kumar, Management of gummy smile with Botulinum Toxin Type-A: A case report (NCBI 2014) <http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3959148/>

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Issues with permanent fillers

Treating Permanent Dermal Filler Complications Mr Niall Kirkpatrick and Mr Pericles Foroglou discuss the complications that can arise from permanent filler injections and explain how they are removed Patient demand for aesthetic procedures, which appear simple and relatively cheap compared to surgical interventions, has significantly increased. Following this trend, there has been a remarkable rise in the use of soft tissue or dermal fillers over the last decade or so, used predominantly for volumetric augmentation of facial features or wrinkle levelling. Patients are also seeking longer lasting or indeed ‘permanent’ results requiring fewer injections to achieve their desired aesthetic goals. Manufacturers

have tried to meet this demand with the introduction of longer-lasting or permanent filler materials. However, some practitioners, and certainly many patients, do not understand the risks associated with these types of fillers. We believe it is essential for any aesthetic practitioner to know the complications that can arise from the treatment, how the complications must be dealt with and what they need to advise their patients when it comes to permanent or long-term dermal filler injections.

All filler materials have risks associated with their use and their rapid expansion in the cosmetic industry is unavoidably associated with what we have noticed as a rising number of complications related to both the products and their forms of administration. Whilst some complications may be tempered by the use of filler materials that will resorb relatively quickly within around six months, the use of fillers that are permanent or long lasting, which can last up to two to four years, inevitably leads to complications that patients may have to live with over a long period of time. As well as this, infection rates of up to 19% have been reported following the use of one particular permanent filler,2 and complication rates for all types of fillers are as high as 27%.3 There seems to be significant public ignorance about dermal fillers and their properties, and generally, from our experience, patients do not understand the difference between permanent and temporary fillers. Temporary fillers are made from materials that the body is capable of breaking down and resorbing – many are related to natural molecules found in the body. Permanent fillers are made from materials that the body cannot resorb and therefore tends to try and ward off as foreign bodies. We have noticed an increased demand for longer lasting fillers. This growth is what could be prompting companies to increasingly cross-link the resorbable filler molecules to delay resorption. The longer the resorption period the more ‘permanent’ the filler becomes, and as a consequence, the greater the risk of complications such as chronic infections and biofilm formation.2,3,4,10

Dermal filler regulations

Complications of dermal fillers

In the US, the Food and Drug Administration treats dermal fillers similarly to pharmaceuticals and their use is regulated dependent on appropriate and controlled clinical studies that evaluate the safe and effective use of fillers in specified areas.13 Consequently, few dermal fillers are approved for use in the US.1 In contrast, in the UK and EU, injectable filler manufacture and use is largely unregulated and are categorised as medical devices in the UK and EU. As such, they do not have to undergo the same rigorous clinical safety trials of pharmaceuticals before their use. Although published guidelines and recommendations are available, such as the General Medical Council’s guidance14 and the Royal College of Surgeons’ standards,15 there is to date no legislation that regulates the administration of fillers in the UK. There are currently more than 160 dermal fillers available on the UK and EU market12 – many of which have not undergone rigorous clinical safety trials. This failure to classify them as drugs is therefore a major problem.

‘Normal’ transient and predictable complications of all dermal filler injections, both permanent and temporary include: post-injection pain, redness, ecchymosis, swelling, hyaluronic acid (HA) hydroscopic effect (for non-permanent fillers only), mild nodularity and palpability and transient visibility.4,10 Immediate complications can include under or over-correction, implant visibility, placement of the filler in the wrong tissue plane, infection, vascular compromise4 and blindness from retinal artery occlusion.7,8,9 Many complications are sequelae that should

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Permanent fillers are often difficult to remove and cause permanent damage to structures, and chronic infections can lead to significant and permanent scarring not occur after treatment and some may be avoidable with proper technique, appropriate anatomical knowledge and material selection. Whilst most of these complications can be mitigated to an extent if resorbable temporary fillers have been used, particularly when hyaluronidase can be administered for HA fillers, these complications can be permanent if permanent fillers are injected. Detailed below are some examples of complications that can arise from all dermal fillers, however these complications may be more problematic with permanent fillers as surgical intervention for removal may be necessary because they cannot be absorbed by the body. Acute infections: usually due to skin commensals, but later infections are often due to atypical organisms and mycobacterium. Reactivation of herpes virus may be experienced. Infections should be treated empirically with macrolides or tetracycline, pending culture and sensitivity. Infections, whether they are acute or chronic, remain a lifetime risk for all patients injected with permanent fillers, as there is no method of ensuring complete removal of all material.3,4,10 Direct arterial embolisation: can lead to tissue necrosis, especially in the glabellar supratrochlear arterial branches, the labial artery, the nasal dorsal artery and the angular vessels along the line of the nasolabial folds. Direct arterial embolisation leads to immediate skin blanching and pain. Compromise of the venous circulation: can be seen from compression due to large filler quantities, and this causes a persistent dull aching, swelling and a

patchy violaceous discolouration of the skin. This is most commonly seen in the region of the angular vessels along the line of the nasolabial fold. A lack of anatomical knowledge in non-professional injectors will inevitably lead to a higher risk of these complications.3,4,10 Vascular compromise: commonly seen in the glabellar area, particularly in relation to a glutaraldehyde cross-linked bovine collagen filler that has since been restricted.4,3,10 It can however, occur with any filler and can be minimised with the use of small gauge needles (30-32G) and injecting with a needle withdrawal technique, where you inject as you withdraw the needle. Immediate treatment of vascular compromise is to stop injection, attempt aspiration, vigorous massage to distribute the filler widely, the use of warm compresses, and 2% nitroglycerin paste to increase local vasodilatation, and the use of hyaluronidase for HA fillers.4 Chronic pain: we are increasingly witnessing patients with chronic pain in the distribution of the infraorbital and zygomaticofacial nerve territories from injections in the region of the tear trough, a common site for injection. Whilst at present the exact mechanism for such pain is not understood, the use of permanent rather than temporary fillers may be more difficult to resolve. Early onset complications: include noninflammatory nodules, and are usually localised accumulations of filler, especially seen with bovine or human collagen or HA derivatives. Treatment of these is generally conservative with gentle massage and, if persistent, the use of hyaluronidase. Stab incisions into the nodules can be

considered. Whilst over-augmentation with HA fillers can be reduced with the use of hyaluronidase, this is not a possible treatment for patients treated with permanent filler nodules. Early inflammatory nodules: are red, painful and tender. These should be treated as infections and empirically treated with macrolides or tetracycline, pending culture and sensitivity. Fluctuance or impending skin erosion requires incision and drainage. Antibiotic treatment should be continued for at least four to six weeks. If inflammation continues, the judicious use of intralesional corticosteroids can be considered. Delayed onset complications: include persistent erythema and telangiectasia and may require treatment with 532 nm or 1064 nm lasers. Other delayed onset complications include inflammatory nodules, granulomas and sterile abscesses. These represent a heightened peri-implant cellular activity. Treatment should commence with macrolides or tetracycline antibiotics for four to six weeks. If there is no response within one to two weeks, intralesional corticosteroids can be considered. If there is no further improvement, tissue biopsy for culture may be required and guided antibiotic treatment accordingly. Granulomas: all dermal fillers can produce late granulomas and abscesses. We have seen granulomas occurring in patients with both permanent and temporary fillers even up to ten years post injection. Biofilms: a quiescent infection by bacteria, probably introduced at the time of initial injection and a particular problem for patients with permanent fillers. They result in the formation of a structured community of microorganisms adherent to an inert surface and encapsulated by a protective self-developed polymer matrix such as polysaccharides, protecting them from phagocytosis.11 These organisms are able to maintain integrity against the host immune system by reduced metabolism and growth rates. The use of antibiotics often leads to resistance.

Removing permanent fillers When these complications occur, surgical removal of the permanent filler may be required to resolve the issues associated

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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After

contrast medium is injected into the patient at the time of the scan to enhance visualisation of certain tissues – will help determine the anatomical site and whether the filler is sufficiently encapsulated to be able to be removed by open or surgical needle and stab incision expression. Other procedures include Figure 1: Left image shows extensive scarring of right cheek from approaches to the midchronic infection secondary to permanent filler injection. Right image face via the lower eyelid, shows post treatment with excision of affected tissue, interpolation of a rhytidectomy approaches superficial temporal fascia flap and secondary fat grafting. to the lateral cheek with it. However complete removal of all element, and bicoronal approaches to the filler particles is not possible and whilst upper third of the face, as well as open reducing the ‘filler load’ may reduce the rhinoplasty approaches. risk of recurrent biofilm infection, there Intraoperatively, the use of an experienced is also the risk of introducing infective radiologist in ultrasonography will help organisms at surgery, which should be guide needles and incisions into the filler considered. Permanent fillers are frequently targets (Figures 2 & 3). It is important if described by manufacturers as producing considering open approaches at the same discrete collections with capsule formation time that the ultrasound-guidance removal and therefore easy to remove in the is performed first, as open approaches future, if unwanted. This has not been our introduce air into the tissues, making experience in patients with complications the ultrasound impossible to interpret. of their permanent fillers, where the fillers Ultrasound is particularly useful following are often found not to be encapsulated needle and stab incision expression, to and indeed be distributed widely, having demonstrate a complete as possible filler migrated in the tissues. Permanent fillers removal. are often difficult to remove and can cause permanent damage to structures, and Conclusion chronic infections can lead to significant Avoiding complications from the use of and permanent scarring (Figure 1).3,4,10 permanent dermal fillers requires thorough training in medical and anatomical Removing permanent fillers from the knowledge as well as aesthetic common complex anatomical regions of the face sense. However, the use of permanent can be a difficult procedure, and requires fillers may lead to permanent complications. extensive knowledge of the craniofacial Surgical costs for removal of fillers are region. In managing the complications of very high compared to the initial costs of permanent fillers, preoperative radiological injection. Most patients appear unaware MR imaging with contrast – where a that they would have to meet the costs of

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medical treatment to correct complications themselves. We suspect that complications are significantly higher than those often quoted.   Mr Niall Kirkpatrick is a consultant craniofacial plastic surgeon at the Chelsea and Westminster Hospital NHS Foundation Trust in London where he is also a core member of the North West London specialist multidisciplinary team for the management of skin cancers and a member of the multidisciplinary team for Vascular Anomalies. He gets many referrals by clinicians to both the Craniofacial Unit and his private practice to remove permanent fillers. Mr Pericles Foroglou is a consultant plastic surgeon and associate professor of plastic and reconstructive surgery at the Aristotle University of Thessaloniki. Mr Foroglou is dedicated to providing and promoting excellence in aesthetic plastic and reconstructive surgery teaching and safe practice. He has 20 years of experience as a specialist working in London and Greece and has a special interest in craniofacial and aesthetic surgery. REFERENCES 1. Lim LM, Dang JM, et al. ‘Dermal Filler Devices Executive Summary,’ FDA, (2018) <http://www.fda.gov/ohrms/dockets/ ac/08/briefing/2008-4391b1-01%20-%20fda%20executive%20 summary%20dermal%20fillers.pdf> 2. Nadarajah JT, Collins M, Raboud J, Su D, et al., ‘Infectious Complications of Bio-Alcamid Filler Used for HIV-related Facial Lipoatrophy’, Clin Infect Dis (2012); 55(11): pp.1568-74. 3. Salati SA & Al Aithan B, ‘Complications of Dermal Fillers – An Experience from Middle East’, Journal of Pakistan Association of Dermatologists, (2012); pp.22:12-18 4. Sclafani AP & Fagien S, ‘Treatment of Injectable Soft Tissue Filler Complications’, Dermatol Surg (2009); 35: pp.1672-1680. 5. Lloyd’s Register Quality Assurance, (2016), <www.lrqa.co.uk/ medical-devices/regulation> 6. Medicines and Healthcare products Regulatory Agency and Department of Health, ‘Medical devices regulation and safety’, 2015, <https://www.gov.uk/.../medicines-medical-devices.../ medical-devices-regulation-safety> 7. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and ischemic oculomotor nerve palsy after vascular embolization of injectable calcium hydroxylapatite filler. Ophthal Plast Reconstr Surg 2010;26:289e91. 8. Kim YJ, Choi KS, ‘Bilateral blindness after filler injection’, Plast Reconstr Surg, 131(2013). 9. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S, ‘Blindness following cosmetic injections of the face’, Plast Reconstr Surg, 129(2012). 10. Bray D, Hopkins C, & Roberts DN, ‘A review of dermal fillers in facial plastic surgery Current Opinion in Otolaryngology & Head and Neck Surgery’, 18(2010),pp.295–302. 11. Wu H, Moser C, Wang H, Høiby N & Song Z, ‘Strategies for combating bacterial biofilm infections International Journal of Oral Science’, 7(2014) pp.1–7. 12. Medicines & Healthcare products Regulatory Agency (2016), <https://www.gov.uk/government/organisations/medicines-andhealthcare-products-regulatory-agency> 13. FDA, ‘Soft Tissue Fillers Approved by the Center for Devices and Radiological Health,’ FDA, 2015, <http://www. fda.gov/MedicalDevices/ProductsandMedicalProcedures/ CosmeticDevices/WrinkleFillers/ucm227749.htm> 14. GMC, ‘Guidance for all doctors who offer cosmetic interventions’, General Medical Council, (2016), <http://www. gmc-uk.org/guidance/news_consultation/27171.asp> 15. RCS, ‘Professional Standards for Cosmetic Practice’, Royal College of Surgeons, <https://www.rcseng.ac.uk/publications/ docs/professional-standards-for-cosmetic-surgery>

Figure 2: Ultrasound guidance to direct stab expression of filler material also allows confirmation of filler removal post expression

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Reference: 1. Hamzavi I et al. J Am Acad Dermatol 2007; 57(1): 54-59. Vaniqa 11.5% Cream eflornithine Prescribing Information. (Please consult the Summary of Product Characteristics (SmPC) before prescribing). Active Ingredient: eflornithine 11.5% (as hydrochloride monohydrate). Indication: Treatment of facial hirsutism in women. Dosage and Administration: Should be applied to the affected area twice daily, at least eight hours apart. Application should be limited to the face and under the chin. Maximal applied doses used safely in clinical trials were up to 30 grams per month. Improvement in the condition may be noticed within eight weeks and continued treatment may result in further improvement and is necessary to maintain beneficial effects. Discontinue if no beneficial effects are noticed within four months of commencing therapy. Patients may need to continue to use hair removal methods (e.g. shaving or plucking) in conjunction with Vaniqa. Application of Vaniqa should be no sooner than 5 minutes after use of other hair removal method, as increased stinging or burning may occur. A thin layer of the cream should be applied to clean and dry affected areas. The cream should be rubbed in thoroughly. The medicinal product should be applied such that no visual residual product remains on the treated areas after rub-in. Hands should be washed after applying this medicinal product. For maximal efficacy, the treated area should not be cleansed within four hours of application. Cosmetics (including sunscreens) can be applied over the treated areas, but no sooner than five minutes after application. The condition should improve within eight weeks of starting treatment.

Paediatric populations: The safety and efficacy of Vaniqa in children 0-18 years has not been established. Hepatic/renal impairment: caution should be used when prescribing Vaniqa. Consult SmPC for further information. Contraindications, Warnings, etc: Contraindications: Hypersensitivity to eflornithine or to any of the excipients. Warnings & Precautions: Excessive hair growth can result from serious underlying disorders (e.g. polycystic ovary syndrome, androgen secreting neoplasm) or certain active substances (e.g. cyclosporin, glucocorticoids, minoxidil, phenobarbitone, phenytoin, combined oestrogen-androgen hormone replacement therapy). These factors should be considered in the overall medical treatment of patients who might be prescribed Vaniqa. For cutaneous use only. Contact with eyes or mucous membranes (e.g. nose or mouth) should be avoided. Transient stinging may occur if applied to abraded or broken skin. If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. If irritation continues, treatment should be discontinued and the physician consulted. Contains cetostearyl alcohol and stearyl alcohol which may cause local skin reactions (e.g. contact dermatitis) as well as methyl parahydroxybenzoate and propylparahydroxy-benzoate which may cause allergic reactions (possibly delayed). Interactions: No interaction studies have been performed. Pregnancy and lactation: Women should not use Vaniqa whilst pregnant or breastfeeding. Ability to drive and use machines: Vaniqa has no or negligible effects on

UKEFL3585b Date of preparation: August 2016.

the ability to drive and use machines. Adverse Effects: These are ranked under heading of frequency using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Very common: acne. Common: pseudofolliculitis barbae, alopecia, stinging skin, burning skin, dry skin, pruritus, erythema, tingling skin, irritated skin, rash, folliculitis. Uncommon: bleeding skin, furunculosis. Rare: rosacea, skin neoplasm, skin cysts, vesiculobullous rash. Consult SmPC in relation to other adverse effects. Legal Category: POM. Marketing Authorisation Number(s): EU/1/01/173/003. NHS Cost: (excluding VAT). Tube containing 60g – £56.87. Marketing Authorisation Holder: Almirall, S.A. Ronda General Mitre, 151 08022 Barcelona, Spain. Further information is available from: Almirall Limited, 1 The Square, Stockley Park, Uxbridge, Middlesex, UB11 1TD, UK. Tel: (0) 207 160 2500. Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk. Date of Revision: 10/2015. Item code: UKEFL3336

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Almirall Ltd.

For more information please go to: www.medicines.org.uk/emc/medicine/21243

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doll’s hair, with several hairs sprouting together in unsightly individual clumps. However, techniques for replanting donor hair have improved. Thanks to the technique slowly evolving over time as surgeons became more experienced at performing the operations and shared their knowledge, leading to a much more natural blend with existing natural hair.

Recent Developments in Hair Transplantation Mr Asim Shahmalak details developments in hair transplantation and new techniques for follicular unit extraction A brief history of hair transplantation Modern hair transplant techniques were first developed in Japan in the 1930s1 where surgeons used grafts to help restore eyebrow and eyelashes as well as the scalp hair of burns victims. It did not become a treatment for male pattern baldness until the 1950s when dermatologist Dr Norman Orentreich planted the first grafts in balding areas.2 Techniques progressed from there and follicular unit transplantation (FUT), or strip harvesting as it can be known, became the first popular method of hair transplantation. FUT is where a strip of hair is surgically removed from the back or side of the scalp and follicular unit grafts (one to four hairs) are extracted and replanted in the balding area by the surgeon, using very small micro blades or fine needles. However, the main drawback with this method is that a scar is left in the donor area, which is visible if the patient likes to wear his or her hair short.3 Early FUT procedures in the 1980s had mixed success.4 Patients could be left with plug-like

FUE Case Study One – Patient A 35-year-old Patient A has had three FUE procedures at the Crown Clinic over the last four years. On each occasion he had around 1,200 grafts (2,200 individual hairs) moved from the back and side to the front of his scalp where his hair is still receding, particularly at the temples. Patient A began losing his hair in his early 20s. He chose the FUE method to limit scarring to the back and sides of his scalp where he often wears his hear short. Hair loss is a continual process and Patient A could have slowed down his natural hair loss by taking a clinically-proven drug to keep the amount of hair he had, such as finasteride.10 This would not have helped Patient A to grow any new hair, but it could have significantly halted the onset of his male pattern baldness. Around 3% of patients taking Propecia (finasteride)11 suffer side effects such as a reduced libido and Patient A declined to take this drug.

Before

FUE and its development over the last ten years A different hair transplantation method, follicular unit extraction (FUE), was first developed as a technique in the 1990s by Australian physician Dr Ray Wood and his sister Dr Angela Campbell.5 They felt that cutting out a big patch of skin to harvest the donor hair was unnecessarily traumatic so developed a new technique where the follicular units were taken one-by-one, directly from the donor area, with fine needles. Early FUE techniques were fairly unsophisticated and there was noticeable scarring from punch grafts used to the remove the donor hair, which ranged in diameter from 1.5mm to 2mm. However, more recently, these punches have become much smaller – between 0.6mm and 1mm in diameter, due to improved equipment – meaning that the scarring is almost indiscernible to the naked eye.6 Modern day FUE treatments involve removing individual follicular unit grafts, containing one to four hairs, under local anaesthetic using tiny punches. The grafts are replanted in the donor area using a fine needle, typically over the course of one day. Most surgeons are able to transplant up to 4,000 grafts in a single day, though operations commonly involve between 1,500 and 3,000 grafts. FUE is much more time-consuming than FUT and

After

Figure 1: Images before and after second treatment

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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After

Before and after imagery: all patients have had their Ultherapy® treatment line counts tailored to their individual needs by their practitioner. These line counts may differ from those recommended in the Instructions For Use.

*stimulates new collagen and elastin which can reverse the signs of ageing References: 1. Sasaki GH & Tevez A. JCDSA. 2012; 2: 108-116 2. Ulthera System Instructions for Use, 1001393IFU Rev H 3. Lee HS, et al. Dermatol Surg. 2011;1-8 4. Data on File: ULT-DOF-008 – Ultherapy Mechanism of Action White Paper 5. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202 6. ULT-DOF-003 Ultherapy Treatment Duration. Merz - July 2015 7. Alam M, et al. J Am Acad Dermatol. 2010;62:262-269 8. http://www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed May 2016 9. CE Certificate 3808396CE01, DEKRA April 2012 Adverse incidents must be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents must also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143

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FUE Case Study Two – Patient B 40-year-old Patient B had 2,000 hair grafts taken from the back and side of the scalp and transplanted into his balding crown through FUE at the Crown Clinic in January 2016. It was Patient B’s second hair transplant in the last five years, due to continual hair loss, after he started losing his hair when he was just 18. Patient B had previously worn wigs and toupees worth £500 to cover his baldness.

Aesthetics Journal

Before

Aesthetics

During treatment

After

Figure 2: Images show before, during and after FUE treatment

Complications

In the first two weeks after a transplant, nearly all the transplanted hair falls out due to the trauma of being moved to a new location on the scalp

therefore it is more expensive – costing approximately 50% more per procedure. Over the last five years I believe FUT has been superseded as the most popular method for treating baldness in men and women by FUE. Several high profile celebrities who have had hair transplants using the FUE method – most notably the England football captain Wayne Rooney, who is thought by hair loss specialists to have had FUE7 and model Calum Best8 – could be associated with a rise in patients seeking FUE treatment. This shift in the preferences of my patients has been apparent in my clinic. Five years ago, 80% of my patients opted for FUT and 20% for FUE; now, it is the complete opposite with 80% opting for FUE. The main advantage over strip harvesting is that the scarring with FUE is minimal. Due to the smaller punch holes developed over the last five years, the scarring is barely visible two weeks after the operation. For the first few days, a patient has red pin-pricks in the areas of the scalp used for harvesting but these fade. All incisions and cuts leave a scar, but an FUE scar is barely visible to the naked eye because each FUE scar shrinks to less than 0.5mm.9 I have also noticed a surge in men wanting to wear their hair short around the back and sides of the scalp – and this style favours FUE over FUT.

As with any surgery, there can occasionally be complications such as an infection, which can usually be remedied with antibiotics. Also, there is a chance that the new follicles become ingrown hairs, leading to cysts. These ingrown hairs need to be removed and the cysts burst. With all hair transplant procedures there is a transection rate – recording the number of grafts that fail to take hold in the donor area. Transection rates for FUT and FUE vary between clinics. A low transection rate is a good sign of quality because it reflects the expertise of the surgeon in placing the grafts. The gold standard for the FUE transection rate is 5%.9

Side effects and post-operative care The patient will need a week to recover from the transplant. It is recommended that they sleep slightly upright with several pillows for the first few days after a procedure so they do not damage the hairs. The patient should wear a buttoned-up shirt for a week or so afterwards, because removing a T-shirt or jumper after a procedure can displace the transplanted hair. In the first two weeks after a transplant, nearly all the transplanted hair falls out due to the trauma of being moved to a new location on the scalp. This is known as ‘shock loss’ and is only temporary.12 Between eight and 12 weeks later, the new hair will begin to grow from the transplanted follicles. The new growth will progress over the next six to nine months but it can be a year before a hair transplant can be shown off to its full effect.

New techniques in hair transplantation over the last five years Robotic hair restoration Robotic hair restoration machines to assist with the extraction of follicles in FUE have been developed in the last seven years. Hair is selectively harvested with robotic precision with the aim of preserving the natural look of the donor area. The machine locates and extracts follicular units according to specifications programmed by the physician. A robotic system,13 introduced in 2011, is appropriate for brown-haired and black-haired men. Those with fairer hair may need to dye it first in order for the robot to best visualise the hair follicles.14 The effectiveness of these robotic transplants is yet to be confirmed. Early studies into the effectiveness of robotic surgery suggest that transection rates tend to be higher than manual procedures. Robotic transection rates

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Stimulating hair growth Platelet rich plasma (PRP) PRP therapy17 for hair loss is a treatment that involves extracting a patient’s own blood, processing it in a centrifuge to separate the enriched cells (PRP) and then injecting these cells back into the scalp. PRP contains proteins that stimulate natural hair growth.17 The treatment can be combined with hair transplant surgery or clinically proven hair loss medication such as finasteride and Minoxidil.18 In a recent study published in Dermatologic Surgery,19 physicians in South Korea published data supporting the clinical application of PRP in hair restoration.

were as high as between 6-15%.15 While the robot removes much of the highly repetitive work in extracting the grafts, there are significant disadvantages compared to more manual methods – particularly the size of the punches being larger, leading to more scarring. The machines are expensive and this impacts on patient costs. Scalp micropigmentation (SMP) or hair tattooing SMP16 is a relatively new non-invasive technique for disguising baldness developed in the last ten years. SMP involves having your scalp tattooed with tiny dots that resemble the appearance of stubble or a short ‘crew’ cut. There is no scarring and it can also be used to hide transplant scars or conceal small areas where hair is thinning to make it appear denser. It is a good option for men who suffer from alopecia universalis (complete hair loss), and have no natural donor hair for a hair transplant. SMP does not penetrate the skin as deeply as normal tattooing and the colour can be matched to your previous hair colour and skin tone. The main drawback is that the tattoos fade and need to be replenished after approximately 18 months.

A look into the future A hair transplant is a skilful distribution of available hair. However, no new hair is produced. But what if surgeons could solve the problem of the limited number of donor hair follicles? Researchers are currently trialling new alternative treatments: New stem cell techniques involve retaining part of the donor hair follicle and supporting its regeneration – producing two follicles from one and doubling the extent of the donor hair. The main drawbacks so far have been related to the quality of both of the resulting hair grafts.10

Robotic hair restoration machines to assist with the extraction of follicles in FUE have been developed in the last seven years

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Hair cloning involves healthy follicle cells that are extracted from areas of the scalp where there is no baldness. These cells are multiplied (cloned) by various culturing methods and the newly produced cells are then injected back in the balding areas of the scalp where they would produce new hair. However, the method is still in the research phase and no hair transplant clinics are currently using it to my knowledge.11

Conclusion I believe FUE will continue to dominate for years to come, though there will always be a place for FUT, as FUE is not suitable for some patients. New stem cell techniques and hair cloning are still in their infancy and are unlikely to impact significantly on patients in the next five years. In the longer-term, though, they could both assist surgeons and provide new solutions for patients suffering from hair loss. Mr Asim Shahmalak is a hair transplant surgeon who gained his medical degree from the University of Karachi, Pakistan, in 1988. He founded Crown Clinic in Manchester nine years ago and also has consulting rooms in Harley Street. He has been a hair loss expert on the Channel 4 show Embarrassing Bodies. REFERENCES 1. Paul J McAndrews, History, American Hair Loss Association, (2016) <http://www.americanhairloss.org/ 1. surgical_hair_restoration/history.asp> 2. Jenny Shaprio and Nina Otberg, Hair restoration surgery, Hair Loss and Restoration, Second Edition, p.179 CRC Press; U.S (2015) 3. Orentreich N, Autografts in alopecias and other selected dermatological conditions, Annals of the New York Academy of Sciences 83:463-479, (1959) 4. http://www.hairdoc.com/hair-loss-answers/chapter-11-history-of-surgical-hair-restoration/ 5. FUE Hair Transplant, Historical Development of Hair Transplant Surgery, (2016) <http://www.fuehairtransplant.com/haartransplantation/informationen/geschichtliche-entwicklung.html> 6. Hair transplant network, Hair Transplant Evolution, (2016) <http://www.hairtransplantnetwork.com/ Hair-Loss-Treatments/hair-transplant-history.asp> 7. Total Hair Loss Solutions, Wayne Rooney – Hair Transplant (2016) <http://www.totalhairlosssolutions. com/wayne-rooney-hair-tranplants-hair-loss-clinic-in-leeds/> 8. Deni Kirkova, ‘No man wants to be bald’: Calum Best reveals ‘life changing’ results forking out £6,000 on his THIRD hair transplantation (and says he wont rule out a forth) Mail Online, (2015), <http://www.dailymail.co.uk/femail/article-2910384/No-man-wants-bald-Calum-Best-reveals-lifechanging-results-forking-6-000-hair-transplant-says-won-t-rule-fourth.html> 9. The Balding Blog, What Doctors Don’t Want You To Know About FUE, (2006) <https://baldingblog. com/2006/11/17/what-doctors-dont-want-you-to-know-about-fue/> 10. Hair Loss Talk, Propecia long term results, (2016) <https://www.hairlosstalk.com/treatments/ propecia/5-year-trial-results/> 11. Drugs.com, Propecia side effects, (2016) <https://www.drugs.com/sfx/propecia-side-effects.html> 12. New York Hair Loss, How to Reduce Hair Shedding after a Hair Transplant, (2014) <http://nyhairloss. com/shedding-hair-transplant/> 13. The Balding Blog, Less than 3% transection rate from FUE, what about the Artas Robot and other doctors? (2014) <https://baldingblog.com/2014/08/27/less-than-3-transection-rate-from-fue-whatabout-the-artas-robot-and-other-doctors/> 14. Miguel Canales, Does the Robot work with Dark, Blonde, Grey, Curly, White or Ethnic Hair? (2016) <http://siliconvalleyhairinstitute.com/robot/> 15. Robotics in Follicular Unit Extraction, Bernstein Medical Center for Hair Restoration, (2016) <http:// www.bernsteinmedical.com/robotic-hair-transplant/fue-overview/> 16. Men’sHealth, Scalp Pigmentation Explained, Grooming, (2011), <http://www.menshealth.co.uk/style/ grooming/scalp-pigmentation-baldness> 17. Zheng Jun Li et al., Autologous Platelet-Rich Plasma: A Potential Therapeutic Too for Promoting Hair Growth, Dermatologic Surgery, (2010) <http://www.orangecountyhairrestoration.org/webdocuments/ Autologous-PRP-%20J-Derm-Articled.pdf> 18. American Hair Loss Association, Two Clinically Proven Treatments for Men’s Hair Loss, (2016) <http:// blog.americanhairloss.org/hair-loss/mens-hair-loss-treatment/> 19. Hirotaro Fukuoka et al., The Latest Advance in Hair Regeneration Therapy Using Proteins Secreted by Adipose-Derived Stem Cells, The American Journal of Cosmetic Surgery, (2012) <http://www. orangecountyhairrestoration.org/webdocuments/ADSC-hair-restoration.pdf> 20. Dody Gasparik, The Future of Hair Restoration, WorldwideHealth, (2016) <https://www. worldwidehealth.com/health-article-The-Future-of-Hair-Restoration.html> 21. Bernstein Medical, What is hair cloning? Hair Cloning? (2016) <http://www.bernsteinmedical.com/ hair-cloning/>

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

PREPROCEDURE

POSTPROCEDURE

reduction in

POSTPRODUCT DISCOMFORT APPLICATION

POSTPRODUCT immediately RINSE OFF

MEAN TOLERANCE SCORE

Treated Untreated

1.5

* Statistically significant improvement vs post-procedure baseline and untreated facial half p < 0.01 * Statistically significant improvement vs post-procedure baseline p < 0.01

1 0.5 0 PREPROCEDURE

POSTPROCEDURE

POSTPRODUCT APPLICATION

POST-FRACTIONAL PROCEDURE

post use

POSTPRODUCT RINSE OFF

Protocol: A dermatologist-controlled split-face clinical study on 30 female subjects ages 18-65. Phyto Corrective Masque was applied to one randomized facial half following full-face 1550 nm non-ablative fractional laser procedure. After 15 minutes the full face was rinsed with water and patted dry.

-47%

improvement vs post-procedure baseline p < 0.01

MEAN TOLERANCE SCORE

-47%

-2.8°C

MEAN CLINICAL GRADING SCORE

-20%

-2.8°C

.9°

-20%

At SkinCeuticals, we are passionate about Phyto Corrective Masque Technology reduction in visual REDNESS post use working hand-in-hand with aesthetics Temporary skin reactivity from sun exposure, 10 professionals to develop innovative environmental aggressors, facial extractions cosmeceuticals based on science, which or certain aesthetic procedures can lead to 8 TESTED EFFECTIVE POST-PROCEDURE truly meet the challenges faced in-clinic. redness, discomfort, blotchiness, dehydration POST-FRACTIONAL LASER STUDY 6 Treated When considering a more advanced and a loss of natural radiance. PCM has Untreated 4 aesthetic treatment, many patients put been specifically formulated as the ideal * Statistically significant up barriers due to fears about downtime, soothing and replenishing option for clinic 2 improvement vs post-procedure baseline and untreated facial erythema, oedema and swelling. These and home use. Clinical tests showed that reduction in visual REDNESS post use half p < 0.01 0 concerns not only include immediate after a 15-minute application, PCM delivers PREPOSTPOST10 PROCEDURE PROCEDURE PRODUCT post-procedure discomfort, but also a 20% average reduction in post-procedure RINSE OFF effective8 ongoing home maintenance. redness, as well as a 47% average reduction SkinCeuticals are therefore proud to in discomfort.1 The mask also immediately 6 Treated unveil Phyto Corrective Masque – the reduces skin surface temperature and Untreated 4 latest addition to the ‘Correct’ portfolio, restores hydration, thus minimising downtime * Statistically results. significant which has and maximising 2 been specifically formulated to improvement vs post-procedure reduction in DISCOMFORT post use baseline and untreated facial address temporary skin reactivity and immediately postThe high potency pure botanical extracts half p < 0.01 0 procedure discomfort. Phyto Corrective deliver a soothing, healing effect with double PREPOSTPOST2 Treated PROCEDURE Masque (PCM) offers a PROCEDURE new option toPRODUCT meet the concentration versus the existing Phyto Untreated RINSE OFF 1.5 the challenge of post-procedure downtime, Corrective Serum. The calming dipeptide * Statistically significant and has data from four different clinical ingredient helps modulate perceptions of improvement vs post-procedure 1 baseline and untreated facial tests outlining the safety and efficacy for unpleasant temperature, roughness and half p < 0.01 0.5 * Statistically immediate post-procedure use.1 irritation – reducing thesignificant sensation of tingling

A Versatile Treatment Approach Phyto Corrective Masque takes cosmeceutical post-procedure care to the next level, but can also be an effective homecare solution for ongoing recovery of compromised skin and maintenance of results. For post-treatment use, it delivers intense hydration and a soothing sensation to minimise skin reactivity following nonTHER M AL IM AGI NG OF FACI A L ablative aesthetic procedures, extractions, IPL, peels and PDT. Safety for use was average reduction in skin tested following Fraxel laser treatment, and use of Phyto Corrective Masque in combination with other non-ablative treatments is at the HCP’s discretion. Phyto Corrective Masque can also be used as part of an ongoing comprehensive T HER MAL home IMAGING OF skincare regime, over and above temporary daily use to enhance post-procedure average reducti recovery. The mask can be applied as a leave-on, rinse-off or overnight treatment, depending on the skincare needs. Everyday causes of skin reactivity, heat and redness such as exercise, hot baths and POST-FRACTIONAL PROCEDURE sun exposure can be effectively relieved by the cooling, calming formulation.

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Expert Opinion: POST-FRACTIONAL PROCEDUREH “I have used Phyto Corrective Masque to reduce downtime following fractional laser and peel treatments and was pleased to see that patients experienced a positive cooling and calming effect”, said Dr Askari Townshend, Medical Director of ASKINOLOGY. “These patients have also been using REFERENCES the mask as part of an ongoing home maintenance regime and I look forward to seeing 1. SkinCeuticals Data on File. Dermatologist-controlled split-face clinical study on 30 female subjects aged 18-65. PCM applied how Athis product hassplit-face benefitted their daily Protocol: dermatologist-controlled clinical study on 30 femaleroutine.” subjects ages 18-65. Phyto Corrective Masque was applied to one randomized facial half Protocol: A dermatologist-controlled split-face clinical to one randomised facial half, following full face 1550nm nonfollowing full-face 1550 nm non-ablative fractional laser procedure. After 15 minutes the full face was rinsed with water and patted dry.

Aesthetics | November 2016

following full-face 1550 nm non-ablative fractional las

ablative fractional laser procedure.

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Periocular Complications Mr Daniel Ezra advises how to successfully avoid and manage complications associated with treatment around the eyes Recent years have seen an explosion in the number and range of aesthetic facial treatments. Whilst there is good safety data to support most of these treatment modalities, very few have had any form of safety evaluation with regard to potential periocular complications and their management. Management of complications in medical aesthetics is a major unmet educational need for practitioners and most recognised training programmes rarely address the best way to deal with complications. This is especially true of the eyes, around which many cosmetic interventions are targeted, but often with very little knowledge of recognising potential complications and how to manage them. Whilst there are numerous potential problems that can arise from different treatments, this article will summarise the relevant aspects of the common treatments with a focus on some simple take-home messages.

Botulinum toxin therapy The periocular areas are the most common sites for botulinum toxin therapy, with the corrugator muscles and orbital orbicularis oculi muscles targeted to soften the glabellar lines and crowâ&#x20AC;&#x2122;s feet respectively. Some of the most common side effects of toxin injections into this area are ptosis (droopy eyelid) and double vision. This occurs because of diffusion of the toxin to the extraocular muscles, which are the muscles deep within the eye socket that are attached to the eye and mostly control movement. Anatomically, the contents of the orbit are separated from the anterior eyelid tissues and protected by a tough connective tissue layer called the orbital septum. The orbital septum forms a diaphragm across the eye socket taking origin from all of the bony rim and inserting into the canthal tendons and tarsal plates of the eyelids. The orbital septum is pierced by the levator palpebrae superioris, which is the muscle responsible for most of the upper

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eyelid opening. The inferior part of the muscle and its aponeurosis lie anterior to the protective septum, making it susceptible to toxin seepage, which can result in ptosis.1 Ptosis Risk factors for the development of ptosis include anatomical considerations related to the injection site, dose and dilution. The needle should never approach the insertions of the orbital septum and beginners should always point the needle away from the eye. Care should also be taken by more advanced practitioners who may be treating more delicate areas such as the pretarsal orbicularis in order to treat small degrees of ptosis or the lower lid pretarsal roll. Injections within the orbital aperture should always be directed subcutaneously to protect deeper structures, and patients should also be monitored for symptoms of dry eye, which results from impaired eyelid closure. Injections at higher doses have some advantages, such as longevity of effect and also more profound muscle weakening, which may be desirable for some patients. However, higher doses injected close to the orbital septum carry a higher risk of ptosis. If higher doses are required, the risk can be minimised by reducing the volume of drug injected for a given dose. Ptotis can occur in up to 5% of patients,2 and it can usually be treated effectively with apraclonidine eye drops. These a-adrenergic agonists stimulate the contraction of the Mullerâ&#x20AC;&#x2122;s muscle, which raises the eyelid and is sympathetically innervated for fight-or-flight response.1 However, care should be taken to avoid using this medication for long periods of time as it is known to cause significant skin irritation in the form of chronic or acute allergic dermatitis, pupillomotor changes, watering, discomfort, dry mouth and altered taste.3 Apraclonidine is not a treatment for other forms of ptosis and should never be used in this way. Diplopia Double vision after toxin therapy is much less common and is almost always due to the administration of higher doses of toxin too close to or beyond the orbital septum.4 If you are finding that patients regularly have problems with diplopia, you should revisit your training and technique. Diplopia is one of the most debilitating ophthalmic symptoms and can severely limit work and other activities of daily living. Temporary supportive measures for patients with transient post-treatment diplopia are possible in the form of prisms and, sometimes, occlusive contact lenses, so patients with this complication should be referred to an ophthalmologist for further treatment.

Before

Filler therapy

After

Figure 1: Typical result of lower lid tear trough HA injections to rejuvenate the lower lid hollows

Figure 2: Persistent lower lid filler injection resistant to oral antibiotics

Hyaluronic acid (HA) fillers have now become the treatment of choice for non-surgical soft tissue augmentation. These are generally safe treatments with minimal immunogenicity, long lasting duration and excellent patient satisfaction (Figure 1). However, they are associated with quite significant complications, especially if the filler is applied incorrectly. HA filler complications are the most common problems I tend to see in my revision practice, often presenting with a variety of issues. Although the range of complications that arise is similar to those encountered in other anatomical locations, the

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thin and delicate tissues around the eyes make complications more common in the periocular areas.

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Essential kit • Eye wash station • Normal saline • Access to apraclonidine, antibiotics, steroid injections • Hyaluronidase • Warm compresses • Cold compresses

• Emergency ophthalmic referral details • Cannulas • Universal pH paper • Sterile gloves • Chlorhexidine or povidone Iodine

requires specialist treatment consisting of combinations of antibiotics, steroids, surgical drainage and hyaluronidase therapy.8

Figure 3: Fundus images showing a branch retinal artery occlusion. The images demonstrate the difference between healthy retina (superior half) and the typical pale and oedematous retina, observed in arterial occlusions, in the inferior half of the images.

Swelling Swelling is the most common problem and is associated with all fillers, and this is especially true of the tear trough area. Swelling is due to the hydrophilic nature of the gels and also the inherent disruption of normal vascular and lymphatic dynamics.5 The risk of persistent swelling can be minimised in a variety of ways. Firstly, careful thought must be applied in considering the type of filler material to be used around the eyes. There is a range to choose from, and the choice of filler should match the location being injected. If you are using the same filler for all parts of the face, you are likely to be doing something wrong. Highly cross-linked HA gels are excellent for larger volume and deeper fills such as the nasolabial folds or lateral cheeks. However, these are more prone to swelling and should be avoided around the eyes in favour of less cross-linked preparations or blends.3 In addition, remember that when treating the tear troughs, small volumes are key. If you are used to treating areas where large injection volumes are used, you will find the volume requirements around the tear trough very different, as often 0.2-0.3ml is more than sufficient for each tear trough deformity. Infection Foreign body reactions and infections can present several months or even years after the initial injections (Figure 2). Granuloma and foreign body reactions are one of the most common complications and it is important to differentiate these from lumps and bumps caused by excessive injection or poor technique. Granulomas are discrete nodules characterised by specific inflammatory responses. They are often red, tender and well defined. These reactions had previously been thought to be sterile, but are now understood to be infective in origin.6 Infective processes are thought to be due to either inoculation at the time of injection or biofilm formation around the gel.7 Infections are very difficult to treat because the organism can sequester within the filler6,7 with poor vascular penetration leading to common recurrence after antibiotic use. Preventing organism inoculation at the time of injection is a critical precaution when administering fillers. It is therefore essential to ensure that procedures are conducted under aseptic conditions. This means using sterile gloves and conducting skin prep with either chlorhexidine or povidone iodine. Established infection

Vascular occlusion Vascular occlusions are the most serious complications associated with HA filler use. Filler injections in the tear trough area induce significant perfusion changes with engorgement of the veins evident immediately after the injections, most likely resulting from changes to the delicate relationship between drainage of the lymphatics and venous pressure.9 There have been many reports of blindness or loss of vision resulting from periocular HA injection use.10 This phenomenon is due to vascular occlusion of the central retinal artery caused by passage of filler through the external carotid arterial system into the internal carotid tree (Figure 3). This is most likely to occur through the numerous external/internal carotid artery terminal branch anastomoses around the orbit, many of which are branches of the ophthalmic artery, which perfuse the eyelids and periocular tissues. Vision loss is sudden and often associated with ptosis, ophthalmoplegia and pain.11 Other forms of vascular occlusion can cause local areas of necrosis which tend to occur around medial structures of the face, particularly in the distribution of the supraorbital or labial endarteries. This leads to necrosis of the skin in these distributions, which is sometimes mistaken for infection. The characteristic signs of vascular skin occlusion are sudden blanching and discolouration of the skin associated with pain and paraesthesia.12 The injecting should stop immediately and warm compresses should be applied to promote vasodilatation. I would recommend applying hyaluronidase, at a dose of approximately 300u in total over the area and repeated daily if necessary. Higher doses of hylauronidase should be avoided as this can induce very significant adverse soft tissues changes as outlined below. Patients

The characteristic signs of vascular skin occlusion are sudden blanching and discolouration of the skin associated with pain and paraesthesia

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Chemical injuries

Figure 4: Skin discolouration, hollowing and gaunt appearance following hyaluronidase injections to the tear trough

should also be treated with oral antibiotics. In the event of symptoms of vision loss, patients should be sent as an emergency to their local accident and emergency department or eye department. Acute management is highly specialised and would include decreasing intraocular pressure with either intravenous acetazolamide or direct anterior chamber puncture and decompression, although the prognosis for visual recovery is very poor.13 Vascular complications must be avoided and by ensuring that the injection technique is appropriate, these risks can be minimised. This critically means that it is essential to ensure that the injector has a thorough understanding of the anatomy of the area to be injected with an emphasis on vascular branches and their variations and to be aware of the key danger areas. Low pressure injecting with gentle pressure on the syringe plunger is also essential to avoid intravascular injection. Wider bore needles or cannulas are also helpful and can reduce hydrostatic pressure of the filler during the injection phase. The risk can be further minimised by aspirating the syringe to exclude intravascular positioning. Using cold compresses prior to injection may be helpful by encouraging vasoconstriction.14 Management Therapy with hyaluronidase is an essential technique for managing the complications of filler injections. Hyaluronidase is a powerful enzyme used for a variety of medical purposes to break down natural connective tissues. Whilst deeper injections to other areas of the face are often more forgiving, the thinness of the tear trough areas allows for much less tolerance of adverse results from hyaluronidase use. Higher doses can lead to damage of native extracellular matrix glycosaminoclycans, leaving a gaunt appearance with poor skin texture (Figure 4). Patients are increasingly presenting with hyaluronidase-related damage, which is often untreatable. Hyaluronidase therapy to the periocular area can have devastating results and should only be provided by experienced practitioners with caution. The view that fillers are a ‘natural substance’ and can be simply dissolved without complications is outdated. Given that we are now understanding more about how fillers interact with the body we need to move away from the simplistic view of fillers as an easily reversible therapy and any periocular hyaluronidase therapy must be delivered with extreme caution.

The sheer range of aesthetic techniques means that many different types of chemicals and drugs are often used in close proximity to the eyes. Eyelash tinting, acid peels and retinoid therapies can all cause chemical injuries and corneal damage. Although caution should be undertaken when using chemicals around the eyes, inadvertent inoculation of the ocular surface can be a common presenting scenario to the ophthalmologist. Acid injuries are less severe than alkali injuries, but can cause quite significant corneal epithelial damage and denudement. Corneal protection is predominantly a form of barrier immunity and any compromise of the epithelium can lead to infections and pain. In the event of ocular inoculation, an eyebath should be available on the premises for immediate washing, or running a sterile saline bag gently onto the eye with the patient leaned over the sink. Rapid washing is essential and the pH of the tear film should be measured to ensure a neutral pH is achieved and this can be confirmed with universal indicator paper. Patients should then be referred to the local accident and emergency department if they remain in pain as they will often require a bandage contact lens and antibiotic therapy, as well as close review.15

Conclusion Optimal complication management for aesthetic treatments is a major unmet training need, and this is particularly true for periocular complications. If safe and effective treatments are to be provided for patients, a basic understanding of the relevant anatomy and physiology underlying these treatments is required to allow them to choose the correct product and administer it in a safe fashion. Mr Daniel Ezra is a consultant oculoplastic surgeon at Moorfields Eye Hospital in central London, where he is also the research lead and training director for oculoplastic surgery. He runs a busy private practice based at Harley Street and at Moorfields focusing on periocular and facial aesthetics. Mr Ezra has a special interest in revision surgery after blepharoplasty and managing filler complications, which account for a large proportion of his practice. REFERENCES 1. Ezra DG, Beaconsfield M, Collin R., ‘Surgical anatomy of the upper eyelid: old controversies, new concepts’, Ex Rev Op, 4(1) (2009), pp.47-57. 2. Scheinfeld N., ‘The use of apraclonidine eyedrops to treat ptosis after the administration of botulinum toxin to the upper face’, Dermatol Online J,11(1) (2005), pp.9. 3. Yuksel, NE; Karabas, L; Altintas, O; et al., ‘A comparison of the short-term hypotensive effects and side effects of unilateral brimonidine and apraclonidine in patients with elevated intraocular pressure’, Opthalmologica, 216 1 (2002), pp.45-49. 4. Wollina, U; Konrad, H., ‘Managing adverse events associated with botulinum toxin type A - A focus on cosmetic procedures’, American Journal of Clincial Dermatology, 6 3 (2005), pp.141-150. 5. Sundaram H, Cassuto D., ‘Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications’, Plastic and Reconstructive Surgery, 132 (4 Suppl 2) (2013) 5S–21S. 6. Beer K, Avelar R., ‘Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations’, Dermatol Surg,40 (11) (2014), pp.1175-1179. 7. Wagner, Ryan D.; Fakhro, Abdulla; Cox, Joshua A.; et al., ‘Etiology, Prevention, and Management of Infectious Complications of Dermal Fillers’, Seminars in Plastic Surgery, 30 2 (2016), pp.83-85. 8. Rzany B, DeLorenzi C., ‘Understanding, avoiding, and managing severe filler complications’, Plast Reconstr Surg, 136 (5, Suppl) (2015), pp.196S-203S. 9. Pimentel de Miranda A, Nassiri N, Goldberg RA., ‘Engorgement of the Angular and Temporal Veins Following Periorbital Hyaluronic Acid Gel Injection’, Ophthalmic Plastic and Reconstructive Surgery, 32(2) (2016), pp.123-6. 10. Beleznay, Katie; Carruthers, Jean D. A.; Humphrey, Shannon; et al., ‘Avoiding and Treating Blindness From Fillers: A Review of the World Literature’, Dermatologic Surgery, 41 10 (2015), pp. 1097-1117. 11. Hwang CJ., ‘Periorbital Injectables: Understanding and Avoiding Complications’, J Cutan Aesthet Surg, Medknow Publications, 9(2) (2016), pp.73-9. 12. Signorini, Massimo; Liew, Steven; Sundaram, Hema; et al., ‘Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidence- and Opinion-Based Review and Consensus Recommendations’, Plastic and Reconstructive Surgery, 137 6. 13. Beatty S, Au Eong KG., ‘Acute occlusion of the retinal arteries: current concepts and recent advances in diagnosis and management’, J Accid Emerg Med, 2000 17 (5), pp.324-9. 14. Signorini M, Liew S, Sundaram H, De Boulle KL, Goodman GJ, Monheit G, et al., ‘Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidenceand Opinion-Based Review and Consensus Recommendations’, Plastic and Reconstructive Surgery, 137(6) (2016), 961e–71e. 15. Duffy B., ‘Managing chemical eye injuries’, Emerg Nurse, 16(1) (2008), pp.25-9.

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Radara restores the peri-orbital area in three ways: • Repair: Radara’s unique micro-channelling patch technology encourages new collagen production and allows deeper penetration of the HA serum1 • Rejuvenate: Results can be noticed from two weeks, and at four weeks wrinkles are reduced on average by 35%, with skin feeling noticeably smoother and firmer1 • Replenish: Skin quality is boosted by restored elasticity, hydration and support, with a radiant, refreshed and luminous appearance

Radara integrates seamlessly into your patient’s normal skincare regime, taking just five minutes to apply each night for a period of four weeks. Thanks to the quick, easy and painless application, Radara is the ideal choice for all your aesthetic patients – from those using cosmeceutical skincare, peels and lasers, to those having cosmetic injectables. So when patients come in looking for the ideal skincare solution to get them through the party season, Radara offers the perfect option to deliver great results and complement your ongoing aesthetic treatment programme. One Month Supply (x56 patches, x1 HA serum pump) – Trade price £99, Consumer RRP £240, from Wigmore Medical. For further information please contact: info@radara.co.uk / www.radara.co.uk / @radaraUK This is where Radara comes in: it is a true step-change in skin rejuvenation and offers the perfect skin health booster and maintenance treatment for every aesthetic patient. Specifically tailored for the periorbital area, Radara is an innovative, targeted and painless approach to skin revitalisation using a new micro-channelling technology. This at-home treatment consists of a one-month regimen of microchannelling patches and a high purity, specially formulated hyaluronic acid serum, which delivers an average 35% reduction in lines and wrinkles in just four weeks.1 48

REFERENCES 1. 8-week trial, independently assessed by clinical dermatologists. Data on File, Innoture Medical Technology Ltd.

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A summary of the latest clinical studies Title: The comparison between intradermal injection of abobotulinumtoxinA and normal saline for face-lifting: a split-face randomized controlled trial Authors: Wanitphakdeedecha R, Ungaksornpairote C, Kaewkes A et al. Published: Journal of Cosmetic Dermatology, September 2016 Keywords: BTA, NSS, face-lifting Abstract: The objective was to determine the face-lifting effect of abobotulinumtoxinA (ABO) intradermal injection and NSS. Twenty-two subjects with symmetrical faces on both facial expression and expressionless were randomly injected with ABO at 1:7 cc dilution (500 unit or one vial in 7 cc of NSS) on one side and NSS on the other side using intradermal injection technique. Standardised photographic documentation was obtained at baseline, and at two weeks after treatment. The face-lifting effect was graded by two blinded dermatologists using photographic comparison and rated by the patients. Face-lifting effect was demonstrated in 40.9% and 4.5% of patients with ABO and NSS, respectively. There was a statistically significant difference in face-lifting effect when comparing between ABO and NSS (P = 0.021). The face-lifting was reported in 50.0% of patients receiving ABO injection. The patients with oval-face shape tended to respond better with ABO (P = 0.046). The odds of facelifting effect for patients aged younger than 32 was higher than patients aged older than 32 with the odds ratio of 7.9 and 95% confidence interval of 1.1-56.1. Facial asymmetry was found in 22.7% of subjects. Patients with oval-face shape and aged younger than 32 tended to respond better. Therefore, patient selection should be emphasised to improve efficacy of this technique. Title: Evaluation of the in vivo effects of various laser, light, or ultrasound modalities on human skin treated with a collagen and polymethylmethacrylate microsphere dermal filler product Authors: Wu DC, Karnik J, Margarella T, Nguyen VL, Calame A et al Published: Lasers in Surgery and Medicine, September 2016 Keywords: Radiofrequency, skin tightening, upper arms Abstract: Bellafill is a soft tissue dermal filler composed of non-resorbable polymethylmethacrylate (PMMA) microspheres, suspended in a water-based carrier gel composed of 3.5% bovine collagen. It has been approved by the FDA for the correction of nasolabial folds and atrophic facial acne scars. This prospective, in vivo clinical study evaluated the safety and histopathological effects of a number of different laser, light, and ultrasound treatment modalities on PMMA-collagen filler previously injected into human tissue. Following a negative reaction to the bovine collagen skin test, the abdomen of one subject was divided into a grid with 32 treatment sections. Seventeen treatment areas received subdermal injections of PMMA-collagen product (0.1-0.2â&#x20AC;&#x2030;cc in each area). The subject was assessed for adverse events at each post-treatment office visit. Eighty days post-injection, 30 treatment sections were treated with laser, light, or ultrasound therapy (16 of the 17 PMMA-collagen treated areas, with two of those areas receiving a combination of therapies, and an additional 14 areas receiving laser therapy alone). One PMMA-collagen treated area was not exposed to any energy devices, and one remaining treatment area received no treatment of any kind, representing an internal control. Sixty days following energy device treatment, the tissue was excised in

a planned mini-abdominoplasty procedure and sent for histological examination. The subject experienced no adverse events during the study. No histological changes in PMMA microspheres were observed in any treatment area. An expected lymphohistiocytic response was identified in all areas where PMMA microspheres were present. Laser, light, and ultrasound treatments can safely be administered following a PMMA-collagen injection. Title: Comparing the Efficacy of Monopolar Radiofrequency and Glycolic Acid Peels in Facial Rejuvenation of Ageing Skin Using Histopathology and Ultrabiomicroscopic Sonography (UBM) Authors: Wakade DV, Nayak CS, Bhatt KD Published: Journal Acta Medica, September 2016 Keywords: Monopolar RF, glycolic acid, UBM Abstract: The objective is to compare the benefits of monopolar radiofrequency and glycolic acid peels in facial rejuvenation with regards to histopathology and Ultrabiomicroscopic sonography (UBM). In this study, forty patients with mild to moderate photoageing received four treatments with three weeks intervals of monopolar RF on one side of the face and glycolic acid peels in increasing concentrations (NeostrataR) on the other side. Pre and post treatment, 2mm biopsies were taken from both preauricular areas, and Ultrasonography using a 35 MHz probe was done from outer canthus of the eye and nasolabial folds from both sides of the face. A blinded assessment was done to measure the increase in the grenz zone and dermal thickness. In 35/40 patients there was a significant increase in the grenz zone on histopathology and decrease in subepidermal low-echogenic band (SLEB) on UBM of the nasolabial folds on both sides of the face (p < 0.05). Radiofrequency and chemical peels showed equal efficacy in the treatment of facial rejuvenation. Title: Dermatography (Medical Tattooing) for Scars and Skin Grafts in Head and Neck Patients to Improve Appearance and Quality of Life Authors: Drost BH, van de Langenberg R, Manusama OR et al. Published: JAMA Facial Plastic Surgery, September 2016 Keywords: Medical tattooing, dermatology, colour Abstract: The study analysed the effect of dermatography on the subjective perception of the appearance of scars and skin grafts and the quality of life in head and neck patients. A case series of 56 patients undergoing dermatography took place. Participants were invited to respond to two questionnaires measuring their scar or graft appearance and their quality of life before and after dermatography as an adjuvant treatment for benign or malignant head and neck tumors. The mean improvement in scar or skin graft perception on the visual analog scale of the modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty before and after dermatography was 4 points. On the modified Patient Scar Assessment Questionnaire, uniform improvement of approximately 1 point across 9 questions was observed. The answers to all patient satisfaction and quality-of-life questions on both questionnaires improved significantly after dermatography. Dermatography is an effectual adjuvant procedure to improve the subjective perception of scar and skin graft appearance and the quality of life in head and neck patients.

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Providing Competent and Valuable Consultations Independent nurse prescriber Elizabeth Rimmer discusses how to educate your patients in a consultation to ensure they can provide informed consent Aesthetic educational events, inevitably and appropriately, see a majority of the focus placed on the acquisition of practical clinical skills and techniques. Effective consultation and its process, however, is something that is not often discussed in detail, but is an essential part of a successful practice in any setting. Do you know what the factors are that facilitate an effective consultation? How do you know when you have achieved that? Do you consciously work on improving the way you communicate with patients and colleagues? If not, why not?

Using an educational-style approach Before starting a consultation, we need to decide the ‘level of understanding’ that we need to establish. Due to the ever-present threat of litigation, we need our patients to develop and demonstrate competence of the treatments and the risks that surround them. Many of our patients, especially those seeking treatments for the first time, can be said to have a lack of knowledge and understanding regarding aesthetic

treatments and their appropriate indications. This is hardly surprising when consumer media seems to pay so little attention to detail when reporting on aesthetic treatments. It is commonplace to see completely different terms or treatments used interchangeably in the consumer media, such as ‘botulinum toxin’ being injected into the lips when the journalist actually means dermal filler. In the context of education, a paper by Neighbour1 suggests that it may be possible for a ‘trainee’ to identify their own learning outcomes and therefore develop their own curriculum. This philosophy is one that can be replicated within the consultation in an aesthetic clinic. If we consider our patient to be the trainee, we need firstly to facilitate the identification of their outcomes (what they want to achieve) and then, with the help of the practitioner, develop the curriculum i.e. the treatment plan. Practitioners can choose to use a teaching framework for consultation to implement an individualised strategy of assessment, identification of objectives, and negotiate a plan of action and evaluation.2

Basic outline of a consultation Brief outline of events and personal introduction

Explain the schedule of events of the consultation. Introduce yourself and highlight your clinical experience.

Medical questionnaire

Carry out a thorough medical questionnaire.

Assessment

Discuss the reason for attendance. Use open questions such as ‘tell me what brings you here today?’

Address the concerns

Provide succinct information and explanations of treatment options and try to offer information where you have identified knowledge gaps.

Negotiation of plan

Negotiate a plan of action with the patient that will address the issues highlighted in the consultation that is acceptable to both parties.

Evaluation

After the treatment, ask the patient to evaluate the treatment as well as the consultation process.

Outline and introduction The length of a consultation will vary between practitioners and patients, but on average will last around forty-five minutes. Consultations, or ‘teaching sessions’ usually start with outlining the ‘format’ for the session, which can put the patient at ease by familiarising them with the process that they are about to experience. Also introduce yourself and highlight your clinical experience to help to facilitate the patient’s trust. Medical questionnaire The medical questionnaire can be given to the patient to complete or can be carried out as a joint exercise. Working through the questionnaire together may elicit more useful information and help build a picture of your patient and their lifestyle. As well as previous medical conditions, previous aesthetic treatments should be included in as much detail as possible. Making an assessment It is time to assess the patient’s goals or requests. Foley asserts that if an instructor is talking more than the learner, it may suggest that low-level learning is occurring.1 Whilst educating in this particular setting will entail a reasonable amount of information giving, allowing the patient to talk without interruption is a solid starting place to understanding the patient’s concerns and perspective and making the correct assessment. This process can be guided by open-ended questions such as, ‘tell me what brings you here today?’ Rather than ‘I see you are booked in for botulinum toxin?’ Reflective listening is another useful skill worth developing. Relay the information you have heard back to the patient. This will not only demonstrate that you are fully engaged with them but will also provide the option for either confirmation from the patient or clarification on any misunderstandings. The use of tools such as a hand held mirror or pictures can assist in visualisation and confirmation that accurate understanding has taken place. In addition, summarising what the patient says using phrases such as, ‘I am hearing that your main concern is the area around your eyes and that people often comment that you look tired, am I right?’ can confirm their concerns. The assessment should contribute a significant portion of the consultation (more than 50%). Getting this right will put the rest of the consultation in a positive starting position for both practitioner and patient.3

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Demonstrating attributes such as emotional intelligence is an essential component of the patient/practitioner relationship

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Evaluation Asking your patient for feedback at a later date should not only focus on the treatments received but the content and experience of the consultation. Working on clinical skills is imperative and the importance of the constant pursuit of improving consultation skills can be enhanced by specific feedback. Demonstrating attributes such as emotional intelligence is an essential component of the patient/practitioner relationship and cannot be fully taught or measured but can be worked on.8

Summary Identification of objectives Once the concerns have been established, it is possible to identify the treatment objectives. How do we address the patient’s concerns? This part of the consultation will require more informationgiving and is where the ‘teaching session’ will primarily take place. As the practitioner, you should provide succinct information and explanations of treatment options and offer information where you have identified knowledge gaps. To help the patient understand, you can choose to make some brief notes, draw diagrams or offer them the opportunity to do so, always provide leaflets and directions to helpful web resources. It is imperative to use non-medical terms, which, despite being a cliché, is still common practice for many medical professionals. Research has also indicated that cultural differences between doctors and their patients inhibit effective communication for a number of reasons.4 Schouten et al, summarised these under five key headings; differences in health and illness models, differences in cultural values, differences in preferences for doctor-patient relationships, racism/ perceptual biases and language barriers.4 In the field of aesthetics it could also be added that cultural differences impact on perceptions of facial and body attractiveness. The impact of these differences is certainly made easier if the practitioner is working in areas that regularly engage with specific ethnic and cultural groups allowing for familiarisation with cultural norms for body image and the intricacies of communication. Likewise this may prove more difficult for practitioners whose exposure to a variety of ethnic and cultural backgrounds is limited to the occasional consultation. Whilst having an objective-based outcome,

a skilled practitioner must have the ability to be flexible within a treatment process in order to respond to the unplanned situations arising from a clinical context.5 During the consultation there needs to be acknowledgement that things do not always go to plan – if this is understood by the patient then their experience can be improved in these potentially stressful events. At the end of this stage the practitioner should be confident that the patient understands and has developed competence of the options available, the contraindications, side effects and risks. Negotiating and implementing the plan If adequate assessment and identification of goals has taken place successfully and your patient has understanding of the treatments and risks, the negotiation of a treatment plan should follow easily. An effective consultation will also highlight those who could be described as ‘vulnerable’ and therefore unable to provide consent.6 This may be someone who has a poorly managed mental health problem or even someone who is simply experiencing a period of difficulty, which may be impacting on perceived benefits of undergoing a treatment. This point is important and the desire to please the patient or the desire for income must never override this. If any of these concerns are demonstrated during a consultation, then this must be tactfully and respectfully dealt with.7 These difficult scenarios may be managed by using phrases such as, ‘my feeling is that this treatment would benefit you more if we waited until you are feeling a bit better. I would really like to talk it through again in a few months. What do you think?’ It may be that the patient requires signposting to another service and so having a good knowledge of local services will facilitate your ability to do this.

So for those who consider their communication skills to be already excellent, consider the proposed question, could you do better? The answer is indeed, we could all do better. Getting the consultation right will inevitably improve the overall experience of your patient9 and will therefore increase the likelihood of ongoing retention. As practitioners, we also have a role and responsibility to educate our patients in order to ensure that the correct treatment is chosen and that informed consent has taken place. Elizabeth Rimmer is an independent nurse prescriber. She opened her holistic health and skin clinic, London Professional Aesthetics, in central London in 2014. Rimmer is also an active member of the British Association of Cosmetic Nurses and The British Dermatological Nursing Group. REFERENCES 1. Neighbour R, The Inner Apprentice: An awareness- centred approach to vocational training for general practice, London: Petroc Press, (1988). 2. Palomba CA, Banta TW, Assessment essentials: Planning, implementing, and improving assessment in higher education (1999). 3. Stott N, Davies R, The exceptional potential in each primary care consultation, The Royal Journal of the College of General Practitioners, (1979). 4. Schouten BC, Meeuwesen L, ‘Cultural differences in medical communication: A review of the literature,’ Patient Education and Counselling, 64(2006), pp.21-34. 5. Paton B, ‘Knowing within: Practice wisdom of nurse educators’, Journal of Nursing Education, 46(2007), pp.488-495. 6. Maksud DP, Cogwell Anderson R, ‘Psychological Dimensions of Aesthetic Surgery: Essentials for Nurses,’ American Society of Plastic Surgical Nurses, 15(1995) pp.134-190. 7. Paul S, Applebaum M, ‘Assessment of patients’ competence to consent to treatment,’ The New England Journal of Medicine, 357(2007) pp.1834-1840. 8. Weng HC, Chen HC, Chen HJ, Lu K, Hung SY, ‘Doctor’s emotional relationship and the patient-doctor relationship’, Medical Education, 42(2008), pp.703-711. 9. Thom DH, Campbell B, ‘Patient-physician trust: an exploratory study’, Journal of Family Practice, (2016).

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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The Elevator Speech Dr Harry Singh outlines how to effectively market your services in 30 seconds to persuade potential patients to book a consultation Just imagine you are about to enter a lift on the ground floor. Another person joins you, so there are now two of you in the lift. You are going to Floor 13 and the other person is going to Floor 16. It will take you roughly 30 seconds to reach your floor. The other person turns to you and asks, “What do you do?” What would your answer be? Don’t forget this could be a potential customer and first impressions count. According to an article published in Psychological Science citing five experiments by the authors, it takes a tenth of a second to form an impression of a stranger from their face, and longer exposures don’t always significantly alter those impressions. 1,2 I play out this elevator scenario on a regular basis during my lectures and more than 90% of the audience will reply with something along the lines of, ‘I’m a dentist’, ‘I’m a doctor’, ‘I’m a nurse’ or ‘I do botulinum toxin injections’. The problem with these answers is that you are stating that you are the profession you belong to or the product that you offer. As soon as you say you are your product or profession, the person will have pre-conceived ideas of these. In many cases, this can be a positive, but can also be a negative considering the bad press about certain facial aesthetic procedures that are often portrayed in the media, such as celebrities and the public who have experienced a bad service or result. They may think of dentists as scary and expensive. They may have thoughts that botulinum toxin is painful or unnatural. However, there must be a better way. And, in my opinion, there is. When replying to the original question of ‘What do you do?’, instead of answering it with your profession or the products you work with, talk about the value you offer. It is this that will engage and ultimately encourage customers to buy from you. Let’s now look at how we can convey the value we offer in 30 seconds or less – hence the phrase ‘the elevator speech’, which can be used in situations where you are hoping to promote your services. The elevator speech consists of five parts:

should make our first statement very general and not directly personal to them. My opening line would be something like, “You know how some people are concerned about fine lines and wrinkles…” Note how I have used ‘how some people’, thus not necessarily directing the statement to them. However it broadens the appeal of my offering, because now they will start thinking about their friends and family, who may be concerned with fine lines and wrinkles, as well as themselves.

2. Why is the problem a problem? I often find that many people seem to need a lot of motivation before taking action. Generally speaking, psychically we are inclined to be pleasure seekers and pain avoiders.3 This means that we will either take action to gain something enjoyable or we will take action to avoid, or get away from something that may be uncomfortable or painful.3 We will have one dominate over the other and most of us will be a mixture of both. Pain is almost always a stronger motivator for action, we will take more action to get away from pain than to seek pleasure.3 For example, in my personal life, I take a leisurely approach to my weight and fitness; some days are good and some days are bad. I know how fit I would like to be, but find it hard to be motivated to continually take action. But, if my wife tells me that if I don’t get fit, she will leave me, do you think I will be much more motivated to take action? I see ‘pain’ as the catalyst of action and ‘pleasure’ as the continuation of action. Therefore we want the person in the elevator to consider the consequences of taking no action. My statement would continue to say, “You know how some people are concerned about fine lines and wrinkles, which means that they appear older than they really are?” Because people don’t necessarily want to look younger, rather, they just want to look good for their age, this statement should resonate with the person I am talking.

3. Your unique solution 1. What is the problem? Generally, we only seek a solution or buy something if we have a problem that needs solving. If you look back at any purchasing decision, you will find that purchasing that particular item solved a problem you once had. For example, if you join a gym it’s normally solving your goal to get fitter or lose weight. If you order a take away, it’s solving the problem of hunger and convenience. Therefore, the first thing we say should relate to a problem that the potential customer may be facing or thinking about. We obviously don’t want to embarrass that potential customer by suggesting that, for example, they don’t look good or may need some botulinum toxin. Instead, we

Now that we have addressed what the problem is and the consequences of taking no action, we should consider the solution. The biggest mistake you can make is to sell too early and in too much detail. The action we want that potential customer to make is to call us for a consultation. We are not selling the whole treatment plan on the first visit – build trust first, solve a minor problem/concern for them, before jumping into a full face treatment plan. We therefore want to make our solution very generic to overcome anticipated objections. If we can overcome objections before the person starts thinking about them, there is likely to be a much higher conversion rate.

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

BOOK YOUR FREE DEMONSTRATION What objections could come up concerning, for example, botulinum toxin? It could be the fact it’s a toxin, which may raise concerns with safety, seeing unnatural or frozen results. As such, we should address this in our next statement, perhaps by saying, “I offer gentle, natural and safe results.” You can see that the statement is very non-specific, because, as stated before, we are not selling the details, but the opportunity for them to come and see us for a consultation.

THE LEADING LIGHT

4. Why choose you? Next, we want to look at what makes you stand out from the competition. This could be your profession, experience, location, specific qualifications or skills or equipment. “I have been doing this since 2002,” would be a good statement to make next. You could also say, “I’m medically qualified and open on weekends.” Also, you could reference that you offer a unique treatment that no one else offers in your local area. You are looking for your USP – unique selling proposition.

5. A call to action Lastly, but most importantly, we want the person to take action easily. We also want to broaden our network and encourage them to pass the message to family and friends. To end, I would say, “If you know anyone who might be interested, here is my card.” You can now see the ‘elevator speech’ put together below. This should take no longer than 30 seconds to say.

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When to use the elevator speech This technique is very useful to convey the value of what you offer as a practitioner. I use the elevator speech verbally, when I am at networking business events where I am looking to promote my services. I use the same format on my website and any marketing material I want to distribute. However, there is a time and a place and I don’t use it when in social situations and functions where I am not looking to sell. In these situations we are not looking to drum up business and a couple of words explaining your profession will suffice. Dr Harry Singh has been carrying out facial aesthetics since 2002. Alongside dental and aesthetic work he has a strong interest and experience in marketing. He has published numerous articles on the clinical and nonclinical aspects of facial aesthetics and spoken at dental and facial aesthetics conferences on these topics. REFERENCES 1. Wargo, E, ‘How many seconds to a first impression?’ Association for Psychological Science, (2006) <http://www.psychologicalscience.org/index.php/publications/observer/2006/july-06/howmany-seconds-to-a-first-impression.html> 2. Willis J & Todorov A, First Impressions: Making Up Your Mind After a 100-Ms Exposure to a Face Psychological Science, 17(2006), pp. 592-598 <http://pss.sagepub.com/content/17/7/592.abstract> 3. Higgins TE, ‘Beyond Pleasure and Pain’, American Psychologist, 52(1997) <http://www.columbia. edu/cu/psychology/higgins/papers/higgins%201997%20regulatory%20focus.pdf>

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doctor, for instance, may wish to network with plastic surgeons and vice-versa, as each can refer patients to the other. The same can be said of pharmaceutical representatives, staffing agencies and professionals such as marketers, web developers and graphic designers. Any professional that can help you, your career and/or your business grow are professionals that you should be seeking out to network with – especially if the relationship would be mutually beneficial. While all of that is true, how do you go about networking successfully? There are two approaches to this: digital and ‘real world’.

How to Network Successfully Dr Kieren Bong shares his tips on effective professional networking Networking is an important part of career advancement, and for some it may be the quickest path to success – particularly as a healthcare professional in the private sector. Knowing how to network successfully can be crucial if you wish to move up your particular ladder. When thinking of progressing to a role with more responsibility, networking with the ‘right’ people can make the world of difference. This also applies if the goal is to move between the NHS and private sector. Whatever your actual career goals, networking can be seen as being one of the most important things that you can ever do for your career.1 It isn’t just about switching roles either, or landing a new job. Successful networking, with a view to advancing one’s career, can

lead to invaluable resources, information and ‘insider’ knowledge that can in turn lead to taking that next step up. When it comes to moving up the ladder in your career, your employer will want that transition to be as smooth as possible – seamless, even. Networking with like-minded professionals can help you get there. When networking, it is also important to note that the people you should be meeting don’t always have to be those in the same profession as you. If you are a nurse who just started venturing into aesthetic medicine, for example, meeting other more experienced and professionally advanced nurses can help – but don’t limit yourself. In regards to business development, you need to be thinking in terms of complementary professions. A cosmetic

Any professional that can help you, your career and/or your business grow are professionals that you should be seeking out to network with

Real world networking like a professional Networking connections in the healthcare industry are often found by attending conferences, or by joining professional associations. Turning up to conferences, business cards at hand, is a good start but it won’t get you where you need to be – you also have to actually network, but how to do it properly and effectively? Be easily identifiable. By leaving your lanyard or name tag/badge on, you make yourself more visible to other attendees even when away from the conference venue itself. If you nip across the street, or even a little further into town, for a bite to eat, chances are that other attendees will have had the same idea. This is a great way to strike up conversation with other professionals, away from the conference itself, and make a new contact. Even at the venue, being identifiable can present opportunities – imagine giving an elevator pitch, in an actual elevator?! Get to key speakers, before they speak. This is a tactic that may require a little finesse, but can pay dividends. If one of the featured speakers may be a valuable contact, why wait until after they have spoken? Chances are, they will be very popular after their presentation and you will end up waiting in a queue. What are the odds of them remembering you as anything other than another attendee? Pretty slim. Single out who you want to connect with and get to them before they get on stage. Take this opportunity to wish them luck, and, ensuring you have researched them prior to the conference, compliment them on something they have achieved. After they have spoken, and you see them again later in the day, congratulate them on their presentation or talk and continue the

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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conversation. If there was something that you found particularly pertinent then bring that up and provide your own insight. This serves three purposes: one, it shows that you were listening. Two, it shows that it resonated with you enough to motivate you to expand on it with your own input, and three – it massages the ego, just a little bit, and who doesn’t respond to that? Be sociable. The vast majority of conferences are held in venues where there is a nearby bar or café, usually just a few rooms away. By basing yourself in this area for a portion of the day, you open up a lot of opportunities for meeting attendees as they head for refreshments. If you are in a bar, stick to soft drinks, of course, especially if it is early in the day – the last thing you want to do is create the wrong impression. Sitting at the bar or in a café may seem like the lazy approach, but you just might be surprised. This can be

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opportunity but you are not sure you can do it, say yes – then learn how to do it later!”2 What do you have to offer? When attending conferences, the key thing to remember is that it is a two-way street. Don’t think just in terms of what others can do for you, but think also about what you can do for them. Have a very clear understanding of what you do in your field, why you chose that profession and what makes you special or different from anyone else. If you are in a position to offer something, be able to articulate it without being too ‘on the nose’. Subtlety is key here; you want to be a provider not a seller. The very best salesmen will provide the result, not sell the product that gets the person there. People don’t necessarily care about the ‘how’ – they are buying the effect. How many people care about how an aspirin works? Not many. They just want to know it works. Be a provider, not a seller.

Don’t think just in terms of what others can do for you, but think also about what you can do for them

particularly helpful if there is a TV nearby that you are ‘watching’. If there is a topical show on, news item, sporting event etc., that is usually enough to get a conversation started without being obvious. As a quick example, I happened to be waiting for lunch at a bar restaurant across the road from Grimaldi Forum in MonteCarlo, where the AMWC congress is held annually. I got talking to a representative of a South Korean company that manufactures laser machines. We were talking about something that had happened outside the bar earlier in the day but the conversation inevitably turned to ‘so, what do you do?’. Even though this wasn’t a ‘networking event’, the end result was the same. Always try to be open to opportunities and learn to say ‘yes’; as Richard Branson once said, “If somebody offers you an amazing

Follow ups. Finally, follow up on referrals that you are given and do so quickly – the longer you leave doing something, the more likely you are to not do it. Also, it is always better to act when your name is still fresh in people’s minds. Emails are very much the preferred way of doing this, for a few reasons: • It’s non-disruptive. Nobody’s day was ever disturbed because they received an email. • You can make it personal. Like a letter, a well-written (and personalised, not generic) email can speak volumes – chiefly, that you care enough to actually write. • You can be more specific. An email can contain much more information (although you shouldn’t saturate it) than a phone call ever could without becoming tedious.

You can clearly and articulately order your thoughts and read over to make sure it’s making the best impression without worrying about making small talk. If you have been given a referral’s personal email address by a third party (this happens quite a lot), go out of your way to find the person’s professional email address and use that instead; these small courtesies can go a long way to creating a great first impression with your new contact. In the event that you get a reply, you can suggest meeting for an informal chat over lunch or coffee to expand on what you can offer one another. If contact details have been shared, it’s safe to assume that there is an interest there. Additionally, if you come across something your new contact may find interesting (or even go out of your way to ‘come across something’) share a link with a brief description, explaining why you thought they might find it interesting. The only rule here, really, is to keep it relevant and as potentially useful as you can; perhaps it’s a news article relating to a treatment both of you offer, or perhaps it’s another networking event?

Successful digital networking Digital networking is a completely different process to the real world experience, but the potential rewards far outstrip those offered by more ‘traditional’ networking methods. That being said, the digital networking route can be a little trickier to navigate and get right – especially when there are so many outlets (social media for example) to choose from. Many people, for instance have turned to LinkedIN to build a professional network but that may not be the best approach these days as outlined in an article on TechCrunch, which suggests that there is more than one problem with the services. Apart from the fact that LinkedIN share value dropped by more than half in just one month, 2 its value as a business resource appears to be diminishing, which may mean businesses find fewer reasons to be ‘active’ there. As a result, regular LinkedIN users may ultimately find little reason to be there, or, at least, in the spirit in which the site was launched. In my opinion there are far more effective channels out there, and professionals are likely already using them, albeit perhaps for personal rather than professional reasons. Facebook, despite its recent run of bad

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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Social networks are an excellent place to meet new contacts and grow your network, just remember to keep it professional and be consistent with it

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shows others just how knowledgeable you are in your field and how valuable your opinion really is. You should do this on your public posts also, not just within groups and communities, so that people outside of your groups can find you too – this casts your net much further afield. Social networks are an excellent place to meet new contacts and grow your network, just remember to keep it professional and be consistent with it. You can still have fun with social channels, just be aware of who may be able to see your posts.

Take your first steps

press, with regards to political bias, social experiments, restricting user post reach, and deliberately restricting business post reach to ‘encourage’ paid posts,3,4 it is still an excellent networking tool, as is Google Plus. Google’s offering deserves an article all of its own to properly explain the massive networking opportunities that are available, however I have outlined a few basic points below. There have been claims that Google Plus is a ‘ghost town’, with little or no active users.5,6 The ironic thing about these statements is that these people are not active on the site themselves, with no posts, no followers and no profile details beyond their own names. In short, it’s akin to reviewing a car when all you have is a photograph of it. Google Plus is a community builder, literally. Where Facebook connects you to people you already know, Plus encourages networking with like-minded people that you haven’t discovered yet – the very essence of professional networking. Google Plus Communities allow people with shared interests to find each other and share ideas, talk and generally get to know and learn from one another. When it comes to genuine link building and networking, in my opinion, it’s hard to beat Google Plus. Ultimately, whichever channel or service that you decide to make use of, the basics for successful digital networking are pretty much universal. Flesh out your profile. Whatever social channel you use, there is going to be a profile. Make sure that you fill out all of the relevant areas properly, and treat it as a part of your CV. Do you want other professionals to know that your proudest moment was

chugging five pints of lager in a row, or that you have published journal articles? Get a high quality headshot. Your profile picture is often the first thing people will notice, so a blurry photo of you at a birthday party just isn’t going to scream ‘connect with me’. A high quality headshot speaks volumes as to the potential professionalism of the person behind it. Join relevant communities and groups. Channels such as Facebook and Google Plus have specialist groups and communities. Joining the groups most relevant to you and your career ambitions is one of the fastest ways to create new contacts in that field. Interacting and generating content The biggest mistake many people make when joining communities is to post and run. That is to say, they simply share an article or something about themselves and then walk away. This is not how you build a relationship in the real world, and it will not float online either. Interaction is crucial to successful networking, and the digital frontier is no different. Comment on other people’s posts, and reply to comments that others leave on yours. When sharing external content, preface it with your own introduction – don’t just post a link without saying anything. People are much more likely to take an interest in what you post, if they see that you are interested beyond simply sharing for the sake of it. The idea is to generate conversation, and the best way to do this is by providing your own insight. Expanding on the above point, generating your own content is also a great idea and

Networking should be fun, and if it ever feels like more of a chore than a joy then there is a good chance you are approaching it wrong and that in itself can damage your chances of making meaningful connections. Go into the whole thing with a positive attitude, a bit of a spring in your step and confidence in your abilities. Whatever your area of expertise, follow the above advice and you will be networking like a pro in no time at all. Dr Kieren Bong trained in both medicine and surgery. He is a university lecturer in Cosmetic Dermatology, as well as an international trainer, speaker and key opinion leader for Teosyal. Dr Bong has been featured in numerous publications and magazines. REFERENCES 1. Importance of Networking (US: Strategic Business Network, 2011) <http://www.strategicbusinessnetwork.com/about/ importance> 2. Richard Branson, My top 10 quotes on opportunity (US: Virgin. com, 2016) <https://www.virgin.com/richard-branson/my-top-10quotes-on-opportunity> 3. Damian Kimmelman, LinkedIn Problems Run Deeper than Valuation (US: TechCrunch, 2016) <https://techcrunch. com/2016/02/23/linkedin-problems-run-deeper-than-valuation/> 4. Erik Devaney, Why don’t my Facebook fans see my posts? The decline of organic Facebook reach (US: Hubspot, 2016) <http:// blog.hubspot.com/marketing/facebook-declining-organic-reach #sm.00002ycnkyc85d6f11w7iazc0j3r6> 5. John Brandon, Is Facebook as left-leaning as everyone suspects? (US: Fox News, 2016) <http://www.foxnews.com/ tech/2016/09/26/is-facebook-as-left-leaning-as-everyonesuspects.html> 6. Seth Fiegerman, Inside the failure of Google+, a very expensive attempt to unseat Facebook (UK: Mashable UK, 2015) <http://mashable.com/2015/08/02/google-plushistory/#UH6VsWSulPqI> 7. John Brandon, Why Google is finally putting Google+ out of its misery (US: Inc.com, 2015) <http://www.inc.com/john-brandon/ the-long-painful-road-to-finally-end-the-google-misery.html>

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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challenges associated with running a business.5 Therefore, how do we as leaders, managers and business owners bridge this gap and reduce the dissatisfaction that so many employees face as a result of this perceived lack of balance in their lives?

Work-life integration The solution may be to look at the problem differently. Rather than suggesting that work and life are on opposing plains and are mutually exclusive of one another, ‘work-life integration’ suggests that the key to achieving balance is to integrate the two via the blending of what they do professionally and personally.6 But, some may ask, how can work-life integration be much more effective at actually achieving balance? Primarily, work-life integration allows employees the ability to integrate what they value into their daily lives. Whether it be exercising or spending more time with their families, almost everyone has aspects of their life upon which they place great importance and would otherwise grow dissatisfied if they were not able to perform as Global business executive Reece Tomlinson result of their work commitments. When an discusses the importance of a work-life balance and aemployee can blend work and leisure, it creates how to implement these values in your practice higher levels of satisfaction and overall happiness at the workplace. This can equate to fitting in According to the Oxford Dictionary, the term ‘work-life balance’ is gym sessions during the work day, taking breaks to meet a friend defined as ‘the division of one’s time and focus between working for lunch or attend important family events, leaving early to have and family or leisure activities’.1 Achieving balance, based on this dinner with the family and working in the evening to make up for the empirical separation of work versus family and leisure activities time lost during the day. Regardless of how this blend is achieved, has been a topic that has been widely discussed and pursued. the concept is significantly more fluid than the traditional concept Unfortunately, achieving equilibrium through this notion of work-life of work-life balance and is one that allows employees to feel more balance is both misleading and the term itself is arguably largely satisfied with both the professional and personal elements of antiquated. At best, the term presents an ideal that few can actually their lives.6 As a clinic owner or manager, providing an atmosphere achieve and, at worst, it creates an invisible paradigm that states that conducive to work-life integration can be simple to implement and the one’s work-life must come at the expense of one’s personal-life and benefits will far exceed the costs. A 2014 study by Gallop indicated vice versa. Traditionally, work-life balance has attempted to provide that companies with high levels of employee engagement are 22% a defined time to which an employee works, which conveniently more profitable and experience 65% lower employee turnover.5 happens to permit an employee with enough non-working hours In economic times like these, where finding suitable employees is remaining to have a ‘life’ and, as a result, achieve supposed ‘balance’. nothing short of a challenge, this is a statistic that clinic owners and The problem with this notion is that the busy world we all live in does managers need to take note of. not always allow for this. Whether it’s the rampant use of technology to provide easy access to emails after hours or long commutes to and The four concepts from the workplace; a myriad of factors contribute to the undeniable I’ve led and managed companies that promote work-life integration reality that, for many, real work-life balance can be difficult to achieve. and others that indivertibly promoted the opposite. However, from Data collected by Investec Private Banking in 2015 indicated that 25% these experiences, I’ve concluded that there are four simple but of professionals, including those working in healthcare, are unhappy effective concepts that can be relatively easily implemented in order with their work-life balance.2 Another 2015 study by the Organisation to provide an atmosphere more conducive to work-life integration. for Economic Cooperation and Development reported that one in every eight employees across the 35 countries works 50 hours or 1. Be flexible about working outside of the office more each week on a routine basis.3 When analysing the statistics, it Providing flexibility as to when and where the employee chooses is clear that a large number of employees are dissatisfied with their to work can be powerful because it can change the dynamic of the work-life balance. employee-employer relationship to one that becomes both more For many, such as aesthetic clinic owners and managers, achieving performance-focused and simultaneously mutually beneficial. For work-life balance is simply not feasible. This inability to achieve example, providing flexibility could mean the difference between work-life balance, in the traditional sense of the word, is due largely an employee having dinner with their children and completing the to high levels of work demands, irregular work hours, patient remainder of their work at home after they put the children to bed, demands, training and education obligations as well as the myriad of versus regularly missing such an important daily event, which may

Creating Balance Through Work-life Integration

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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eventually lead to resentment and dissatisfaction at work. Not only are these factors important to employees, they are equally as important to the clinic owner and managers themselves. All factors being considered equal, the long-term impact of providing flexibility can be a dramatic increase in job satisfaction. In order to achieve this flexibility, it is important to provide the tools that allow flexible and remote work to be performed. New technologies and computer platforms ranging from communication, data management, and enterprise resource planning (ERP) systems are available and are designed to incorporate remote work programmes. These technologies may not be as expensive as you think, but of course, must be budgeted for. The focus should be on employee results, regardless of where the employees complete the work, as long as it is feasible. One of the challenges with providing flexibility is the concept of whether or not it can get abused by employees. The answer is yes it can, however, the easiest way to manage this is to make the employee’s performance the sole measuring tool for whether or not they are doing their job. If the objectives are communicated and measured, an employee will not be able to take advantage of such flexibility and appropriate corrective action by the clinic owner or manager can be taken. Providing flexible working conditions requires trust on behalf of the clinic owner or manager that employees will do their jobs and not abuse the system, those who do should be disciplined appropriately, reprimanded or ‘let go’, as abuse of such flexibility will typically be associated with a lack of performance, which in today’s clinic, cannot be tolerated. Providing flexibility may not be feasible for all positions, but when it is, it is simple to implement, can be cost-effective and goes a long way for improving balance. 2. Promote healthy activities in the workplace This one is as simple as it sounds. I’m not suggesting you implement mandatory fitness sessions, but it can be as straightforward as providing the opportunity to join healthy activities such as in-office yoga, walking clubs, and lunchtime sports. Regardless of one’s propensity for physical fitness, exercise can increase employee happiness and wellbeing. A study completed by the Department of Exercise Science at the University of Georgia determined that even small amounts of physical activity increased brain activity and reduced stress hormones.7 At the company I run, we provide in-office yoga, juice days – where we bring in freshly squeezed fruit and vegetable juices, and a myriad of office events to help break-up the day and get people moving. It’s amazing what simply getting active, even for short periods of time, can do for how you feel during the day. Moreover, it is a great recruitment tool as it is attractive to potential employees, is relatively cheap and our internal studies tell us that this is deeply valued. 3. Encourage employees to take flexible personal time and vacations This one may seem quite contradictory to the way the average workplace is structured, however, providing employees with time to take care of personal items without having to take it as part of their annual leave is critical to improving balance. When I hear of employers refusing to provide personal time to their employees for no apparent reason for things like doctor appointments, having a lunch with a relative who is in town for a short period of time or attending major personal milestone events; it simply astounds me. Refusing to grant time for such activities can create resentment, resentment fuels negative performance, and, from experience,

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increases employee turnover. Whether it’s managed through a formal programme or kept informal, providing your employees with the ability to leave in order to take care of personal items or just to simply get out of the office is something that can be profoundly important. However, as I mentioned in concept 1, such flexibility should be provided solely on the premise that employee performance does not become negatively impacted. In the context of an aesthetic clinic, ensuring successful customer experiences is paramount and therefore not all positions may fit the flexible working model. When it comes to vacations, we take it a step further and offer our employees the ability to take the time they need or want. Of course, once they have used their paid leave, extra days will be unpaid. Keep in mind that with such initiatives it must be made very clear that performance cannot suffer and the day-to-day duties must be completed without issue. Of course, the opportunity for abuse of such a programme is there, however, if you hire employees you trust, this should not be an issue. 4. Have some fun Assuming one works 40 hours per week, approximately 35% of our waking hours are at work. Add the demands of life into the mix and it’s easy to see why it’s important to have some fun at work. Spending 35% of your time at a place that is dry, perhaps boring, and generally not fun, leads to a stale environment that your employees may eventually dread coming into. If we all have to work, which most of us do, why not make it fun? Throw in office games, social activities, birthday parties and celebrate wins as a team. Tie in quarterly incentives and have parties when the objectives are met. You can still incorporate the need to focus on results while having fun, in fact, I would suggest that the entire concept of providing such activities should be based around achieving major milestones. Not only does having fun improve the general office atmosphere, it also builds employee rapport and, in my experience, can build the effectiveness of teams.

Summary In closing, it is becoming recognised that what is good for employees, is good for their employers. Not only will the above four concepts have a major impact on your employee’s sense of balance, they can also help to significantly improve the corporate culture, improve company performance and help attract top talent. Reece Tomlinson is the global CEO of Intraline Medical Aesthetics Ltd. He holds an MBA, is a chartered professional accountant and has completed extensive executive education. His areas of expertise include: executive leadership, strategy development and execution, international business management, negotiations, product commercialisation, business development, sales management, corporate finance and M&A. REFERENCES 1. Oxford Dictionary, ‘Work life balance’ (2016) <http://www.oxforddictionaries.com/definition/english/ work-life-balance> 2. Antonia Molloy, A quarter of UK professionals are unhappy with their work-life balance, survey finds, (2015) <http://www.independent.co.uk/news/business/news/a-quarter-of-uk-professionalsare-unhappy-with-their-work-life-balance-survey-finds-10071994.htmlOECD> 3. (2015), How’s Life? 2015: Measuring Well-Being, OECD Publishing, Paris, <http://dx.doi.org/10.1787/ how_life-2015-en> 4. Josh O Kane, ‘Canada’s Work-Life Balance More Off Kilter Than Ever’, The Globe and Mail, Oct. 25, 2012. 5. Boris Groysberg and Robin Abrahams, Manager Your work, Manager Your Life, Harvard Business Review, March 2014 6. Dan Schawbel, Forbes.com, Work Life Integration: The New Norm, Jan. 21, 2014 <http://www. forbes.com/sites/danschawbel/2014/01/21/work-life-integration-the-new-norm/#58759cb62184> 7. Department of Exercise Science, University of Geogia, Effects of Acute Bouts of Exercise on Cognition, March. 2003.

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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“We all started at the beginning and the newcomers are the future – let’s give them all the support and advice we can” Independent nurse prescriber Jane Laferla recalls how she went from setting up a nursing home business to becoming an aesthetic nurse prescriber “Growing up in Cardiff, I really didn’t know what I wanted to do when I left school, but I did know I wanted a professional career and to be successful in whatever I did,” says aesthetic nurse prescriber Jane Laferla. She felt the first ‘buzz’ of success and achievement when, at 15 years old, she became the Welsh champion in trampolining, going on to represent Great Britain in the European Championships the following year. In 1978, at 18 years old, Laferla read an advert in a local paper, advertising a career in nursing, specifically in caring for patients with mental health concerns and learning disabilities. “I still wasn’t totally set on being a nurse,” Laferla explains, adding, “But the opportunity to develop a career encouraged me to apply.” Three months later, she began training to become a nurse with South Glamorgan Health Authority. “I qualified as a registered nurse in 1983, and over the next couple of years I worked in various clinical and managerial positions,” she says. Laferla moved into the private sector in 1993 and worked as an area clinical manager for a number of assessment and treatment units for adults with challenging behaviour. Then, in 1999, Laferla decided to start her own business, she explains, “I was working on setting up my own care home during the day and working long shifts at night to pay the bills.” Finally,, the work paid off and Positive Lifestyles Ltd was established, opening its first care home in late 2000, employing 10 staff. “Over the next six years Positive Lifestyles Ltd developed into a main care provider in the South Wales region,” says Laferla. “Whilst being one of the most stressful times in my career, it was also one of the most exciting and fulfilling times, especially when in 2005 we won a Welsh Business Award for customer care and an award recognising us as one of the fastest growing businesses in Wales.” By 2006, Laferla felt she had taken the company as far as she could, with nine registered care homes, employing more then 150 staff. Laferla says, “The business was sold in 2007. The sale afforded me financial stability, but I was already thinking about my next career or business move.” By this time, Laferla was 44 years old and having regular botulinum toxin injections. She was very happy with her results and became intrigued with medical cosmetics, saying, “I started to do some research and in 2006 I undertook my first botulinum toxin and dermal filler training.” She recalls, “At the time, there was very limited support around, no one seemed prepared to offer advice, support or mentorship; you were seen as competition. I was out there on my own, which was an isolating and daunting feeling.” Laferla participated in training at every opportunity and started attending aesthetic conferences and advanced masterclass training, led by experienced practitioners such as Mr Adrian Richards, Dr Mauricio De Maio, Dr Kate Goldie and Dr Arthur Swift. Then in 2011, a sales representative from Merz Pharma told her about a group of nurses who had formed the British Association of Cosmetic Nurses (BACN). “I soon became aware that there were many nurses in a similar situation to me. Becoming

a member of the BACN and attending the regional group meetings and conferences was a real turning point in my aesthetics career. I no longer felt alone or isolated, but a part of the supported network. Here, I met like-minded colleagues and developed wonderful friendships.” In 2012 the General Medical Council prohibited remote prescribing in aesthetics – presenting another challenge for Laferla. Wondering whether to continue in aesthetics or not, she shared her concerns with her BACN colleagues and was encouraged by the then chair of the BACN Emma Davies, to undertake the V300 Independent Nurse Prescribing. “I remember thinking ‘I’m nearing 50 years old, do I still have what it takes to go back to university and undertake more academic work?’ But with Emma’s encouragement I did it and in 2013 I qualified as an independent nurse prescriber at the University of West England. I felt more elation passing this exam than I did with the sale of my business,” she recalls. Eventually, after spending a few years working for national clinic chains, in 2008 Laferla decided to establish her own private practice, La Ferla Medical Cosmetics, in Cardiff. When asked by the BACN to become the lead nurse for Wales and the South West in 2012 she willingly accepted. “I wanted to give something back. As BACN members we have a wealth of knowledge and expertise that we will continue to share, and we will support existing and new nurses entering aesthetics,” she says. “My membership has been instrumental in improving my standards, competence and expertise in the aesthetic field, resulting in a successful practice with thousands of happy patients.”

What treatment do you enjoy giving the most? A non-surgical facelift using dermal fillers. I love the wow factor! What technological tool best complements your work as a practitioner? Medical needling, as you can use it to treat a range of indications. I’ve treated patients with cleft lip scarring following surgery – it’s life-changing for some. Do you have an industry ‘pet hate’? I don’t like it when people are condescending to practitioners who are new to the industry. We all started at the beginning and the newcomers are the future – let’s give them all the support and advice we can. What aspects of aesthetics do you enjoy the most? I love the art of injecting and seeing the changes I can make to my patients and their self-esteem, but mostly I love training and education. I learn something everyday; you can never stop learning, especially in aesthetics.

Reproduced from Aesthetics | Volume 3/Issue 12 - November 2016

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