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Defensive Strategies CPD

Dr Godfrey Town and Dr Ross Martin discuss defending against patient claims

Special Feature: Treating the Stomach Practitioners explore using energy-based devices for treatment

Managing Oily Skin

Dr Chandi Rajani outlines her strategy for treating oily skin with botulinum toxin

Understanding Paid Searches

Steve Mulvaney details maximising your patient reach through paid advertising



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Contents • October 2018 08 News The latest product and industry news 20 News Special: Animal Products and Patient Perceptions Aesthetics looks at patient perceptions towards animal testing in

injectable products

22 Judging the Aesthetics Awards Find out more about the process for judging the 2018 Awards

CLINICAL PRACTICE 25 Special Feature: Treating the Stomach Practitioners advise on using energy-based devices to treat the

Special Feature Treating the Stomach Page 25

abdominal area

31 CPD: Implementing Efficient Defensive Strategies Dr Godfrey Town and Dr Ross Martin discuss defending yourself against

patient claims related to lasers

38 Advertorial: SkinCeuticals

Expert focus on the SkinCeuticals antioxidant portfolio

40 Treating Rhinophyma

Dr Daron Seukeran explains the skin condition and his treatment approach using CO2 laser

42 Advertorial: Viveve® A look at the radiofrequency device designed for treating vaginal laxity and

improving sexual function

45 Injecting the Infraorbital Area

Dr Tom van Eijk provides his protocol for treating infraorbital hollowness

49 Managing Oily Skin Using Toxin Dr Chandni Rajani explores using botulinum toxin for the treatment of oily skin 54 Nutraceutical Supplementation Dr Beata Cybulska discusses the use of nutraceuticals for increasing

collagen and hyaluronic acid production

IN PRACTICE 60 Understanding Paid Searches Digital marketer Steve Mulvaney explains how patients find your clinic through online searching

64 Obtaining Support in Aesthetics Nurse prescriber Kay Greveson explores the value of support for those

starting out in the specialty

66 Utilising Online Content Marketing Clinic owners and marketing professionals discuss how to create the most

relevant online content to attract patients

71 In Profile: Dr Sherif Wakil Dr Sherif Wakil reflects on his journey into aesthetics and his love for

energy-based devices

72 The Last Word Professor Marcos Sforza argues the importance of using scientifically-

Clinical Contributors Dr Godfrey Town is an RPA2000 certified laser protection adviser and holds a PhD in light-based therapy from the University of Wales, Swansea and has an Expert Witness Certificate from Cardiff University Law School. He is also a registered clinical technologist. Dr Ross Martin has worked in the cosmetic industry as a practitioner, adviser and expert witness for the last 24 years. He is a recognised laser expert medical practitioner, working with lasers since 1993. He is also a qualified mediator. Dr Daron Seukeran is a consultant dermatologist at the James Cook University Hospital in Middlesbrough and is the group medical director of sk:n clinics in the UK. He undertakes general dermatology and dermatological surgery, however his main interest is laser surgery.

59 Abstracts A round-up and summary of useful clinical papers

In Practice Using Paid Searches Page 60

supported products

Dr Tom van Eijk worked in plastic surgery for three years, before beginning to concentrate on non-surgical aesthetic treatments with injectables in 2003. Following this, he began training his peers on how to inject botulinum toxin and hyaluronic acid fillers in 2004. Dr Chandni Rajani specialises in general practice and aesthetic medicine. She graduated from King’s College London with a distinction in medicine and a prize-winning First Class Honours Degree in Physiology (maternal and foetal health). Dr Beata Cybulska is a board-registered dermatovenereologist in Poland and an aesthetic practitioner in the UK. She graduated from the International Foundation of Anti-ageing and Aesthetic Medicine in Warsaw and the Queen Mary University in London.

ACE 2019

Registration Open aestheticsconference.com

NEXT MONTH • IN FOCUS: Hair • Developments in hair removal • Identifying and classifying hair loss

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Editor’s letter What happens in October? Well, to start with, it is Breast Cancer Awareness month so all us girls (and chaps) need to be breast aware and doing all those important checks that can easily be forgotten – do it today! Amanda Cameron October 7 appears to be a busy day; National Editor Smile Day – always a good one – Jeans for Genes Day and National Poetry Day; so get your jeans on, recite a poem and smile! It is a Friday after all. It’s also a good opportunity to market some of your lip and perioral treatments – responsibly of course! More importantly, however, is what’s happening in the Aesthetics calendar! October is the final month you have to vote for winners in certain categories of the Aesthetics Awards and judges complete all of their scoring. If you would like to know more about the judging process, take a look at the article on p.22. There are still some tables available for the ceremony, but not many, so if you would like to make the Aesthetics Awards your Christmas

celebration please book now. October is also the month we launch the Aesthetics Conference and Exhibition 2019! You can visit aestheticsconference.com to register for free today, as well as book your spot on up to four Elite Training Experiences. Turn to our news story on p.11 to find out more! Energy-based treatments are always in the news and the myriad of machines out there continues to grow. This month we take a look at treatment options for the stomach on p.25, in which we interview some high profile practitioners for their thoughts, tips and expertise. In addition, our CPD by Dr Godfrey Town and Dr Ross Martin on p.31 focuses on the regulation of the energy market and gives some important advice on mitigating risk when using these machines – keeping both practitioners and patients safe. As always, send your suggestions for new articles and thoughts on this issue to editorial@aestheticsjournal.com – we look forward to hearing from you!

Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined the 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 aesthetic surgeon with over 20 years’ experience. He is an international presenter, as well as the medical director and lead tutor of Medicos Rx. Mr Humzah also runs the multi-award winning Dalvi Humzah Aesthetic Training courses. He is a founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow.

Dr Raj Acquilla is a cosmetic dermatologist with more than 12 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.

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. She is a registered university mentor in cosmetic medicine and currently a second year student on the Northumbria University Masters course in non-surgical cosmetic interventions. Bennett has been developing her practice in aesthetics for 25 years.

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

Mr Adrian Richards is a plastic and cosmetic surgeon with 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.

Dr Maria Gonzalez has worked in the field of dermatology 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.

Dr Sarah Tonks is a cosmetic doctor, holding dual 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.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multiaward winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts. Dr Williams is also author of Amazon-No-1 Bestseller ‘Future Proof Your Skin’.

Dr Christopher Rowland Payne is a consultant 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.

Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University. Dr Samizadeh frequently presents at international conferences and is passionate about raising industry standards.



Chris Edmonds • Chairman T: 0203 096 1228 chris@aestheticsjournal.com Suzy Allinson • Brand Director T: 0207 148 1292 | M: 07500 007 013 suzy@aestheticsjournal.com ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com CUSTOMER SUPPORT Olivia Cole • Sales Support Executive T: 0203 096 1228 | support@aestheticsjournal.com Chloe Carville • Sales Support Executive T: 0203 096 1228 support@aestheticsjournal.com EVENTS Kirsty Shanks • Events Manager T: 0203 096 1228 | kirsty@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 Shannon Kilgariff • Senior Journalist T: 0207 148 1292 shannon@aestheticsjournal.com Megan Close • Journalist T: 0207 148 1292 megan@aestheticsjournal.com Jenny Frame • Journalist T: 0207 148 1292 jenny@aestheticsjournal.com DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | peter@aestheticsjournal.com Chiara Mariani • Designer T: 0203 096 1228 | chiara@aestheticsjournal.com

ABC accredited publication

@aestheticsgroup Aesthetics Journal Aesthetics @aestheticsjournaluk


Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Olivia Cole, support@aestheticsjournal.com © Copyright 2018 Aesthetics. All rights reserved. Aesthetics Journal is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed

by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


Events diary 4th – 5th October 2018 British Association of Aesthetic Plastic Surgeons Annual International Conference, London www.baaps.org.uk

12th – 14th October 2018 International Association for Aesthetic Gynaecology and Sexual Wellbeing, London www.iaagsw.com

8th – 9th November 2018 British Association of Cosmetic Nurses Autumn Aesthetic Conference, Birmingham www.bacn.org.uk

Aesthetics Journal

Aesthetics aestheticsjournal.com

Body contouring

BTL Aesthetics launches the EMsculpt Aesthetic device manufacturer BTL Aesthetics has released its latest non-invasive body sculpting device, the EMsculpt. According to BTL Aesthetics, the device targets both muscle and fat, which aims to bring a new technology to the aesthetic specialty. The manufacturer claims the EMsculpt relies on high intensity focused electromagnetic field (HIFEM) energy to induce muscle contractions and kill fat cells. BTL Aesthetics states that the device has been cleared by the FDA for the improvement of abdominal tone and strengthening of the abdominal muscles. The HIFEM technology aims to penetrate the skin to impact fat, as well as muscle tissues. Once penetrated, the energy induces supramaximal muscle contractions that are accompanied by a rapid metabolic reaction in fat cells to strengthen and build muscle and breakdown fat. Aesthetic practitioner Dr Rosh Ravindran was one of four practitioners in the UK who were specifically chosen to support the launch as KOLs for the device. He said, “The current approach to body shaping and contouring is through fat cell death, either through freezing or other energy-based modalities. The EMsculpt is the first device of its kind that addresses not only fat loss but abdominal contouring through muscle tone.” Appointment

1st December 2018 The Aesthetics Awards, London www.aestheticsawards.com

1 –2

March 2019

1 & st2 M A Rnd CH 2019 / LONDON

The Aesthetics Conference and Exhibition, London www.aestheticsconference.com

MAG appoints Dr Beatriz Molina as medical director Aesthetic product supplier Medical Aesthetic Group (MAG) has announced that aesthetic practitioner and owner of Medikas clinic, Dr Beatriz Molina, will join the company as its medical director. According to MAG, Dr Molina, will be responsible for leading medical standards compliance, ensuring products and treatments meet all clinical requirements and advising on potential new products to be introduced to the group. Dr Molina will also lead MAG’s training team. Managing director of MAG, David Gower, said, “We are delighted to welcome a leading doctor with an impeccable reputation to lead our medical compliance and communication to our customers."


W WW. AEST H ET ICSCON F ER E NC E .CO M Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018




Aesthetics Journal


Industry update

Aesthetics Awards

Russell Kane to host the Aesthetics Awards 2018 British comedian Russell Kane has been confirmed as the official host for the Aesthetics Awards 2018 that takes place on Saturday December 1 at the Park Plaza Westminster Bridge Hotel, London. Kane, who is best known for his stand-up performances, won the Edinburgh Comedy Award in 2010 and the Melbourne Comedy Festival’s Barry Award in 2011. Finalists for the Aesthetics Awards are recognised across a range of categories that reward practitioners, clinics, companies and organisations who deliver clinical excellence, outstanding customer service and endorse best practice in the aesthetics specialty. HA-Derma has recently been confirmed as a new category sponsor for The Profhilo Award for Best Clinic Scotland. Voting is open in 12 categories until October 31, so readers are encouraged to cast their votes now for who they believe should win this year. As last year’s Aesthetics Awards ceremony was a sell-out success, attendees are encouraged to book now via www.aestheticsawards.com

Committee members’ confirmed for JCCP Practitioner Register The Joint Council for Cosmetic Practitioners (JCCP) has announced the names of the members on its Practitioner Register Committee. The primary purpose of the JCCP Practitioner Register Committee is to oversee the development, management, maintenance and implementation of the JCCP Practitioner Register and associated Fitness to Practice (FTP) procedures. The list of named Practitioner Register Committee members include JCCP members and members of the sector’s wider stakeholder community. Among the members are: chair of the JCCP Practitioner Register Committee, Professor Mary Lovegrove, nurse prescriber Andrew Rankin, solicitor and JCCP legal advisor Ben Lambert, independent education and training consultant Diane Hey, CEO of Hamilton Fraser Cosmetic Insurance Eddie Hooker, JCCP technical advisor Tim Frome, aesthetic practitioners Dr Roshan Ravindran and Dr Uliana Gout, aesthetic dentist Dr Jalpesh Patel and aesthetic pharmacist prescriber Nazia Hussain. The JCCP has also published its FTP procedures and Code of Practice. According to the JCCP, the FTP was modelled on those developed by the professional statutory regulatory bodies and aims to assist in the effective delivery of patient safety and public protection. Expansion

John Bannon Pharmacy launches in the UK Irish medical aesthetic supplier, John Bannon Ltd, has now expanded into the UK market as John Bannon Pharmacy. The company, now with offices in the Midlands, will be offering a range of aesthetic products to registered practitioners. This launch is in partnership with marketing consultant Iain Ashby. Geoff Duffy, product specialist at John Bannon Ltd said, “John Bannon Ltd in Ireland has been looking to expand into the UK market and when the opportunity to work with Iain Ashby presented itself, the timing was perfect.” John Bannon Pharmacy has also recently partnered with Schuco Aesthetics to supply Princess Dermal Fillers, Princess PDO Threads and the Plasma device, distributed in the UK by Schuco Aesthetics. According to Schuco Aesthetics, by purchasing through John Bannon Pharmacy, aesthetic practitioners can feel reassured that they are receiving genuine products within a tightly controlled supply chain.

IS N OW O P E N 2019


Aesthetics Journal


Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Aesthetics Journal

Aesthetics aestheticsjournal.com


Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Patients Dr Greg Williams @DrGregWilliams Is #SnapchatDysmorphia and #SelfieAwareness driving an increase in #HairTransplantSurgery in young men? This is why it is so important for hair transplant surgeons to say no when requested surgery is not appropriate #PatientsNotClients #Memories Miss Sherina Balaratnam @MissBalaratnam #Throwback to some memorable times with my colleagues and here’s to many more! #Dermatology Dr Stefanie Williams @DrStefanieW #DermTip: I strictly advice against using laser or IPL on melasma as there is a high risk of rebound #Melasma #Dermatology #Launch Dr Dev Patel @DrDevPatel1 What an immense honour it has been to speak at the official UK launch of AlumierMD’s exciting skincare product! #Skincare #Pigmentation #AntiAgeingSkincare #Research Dr Firas Al-Niaimi @DrFirasAlNiaimi_ Proud to have just presented my research work to a large international audience at the annual conference of the European Academy of Dermatology and Venereology in Paris #Science #Dermatologist #Education Dr Uliana Gout @UlianaGout Hello from Barcelona! Great to lecture on peels, fillers and management. Great atmosphere at the 5CC Congress. #Conference #Barcelona #Education

ABC Lasers launches new protocol UK laser and light-based device distributor ABC Lasers has introduced a new protocol for the Alma Laser Accent Prime device. Designed for body contouring and skin tightening, the Alma Accent Accentuate treatment protocol involves using the UltraSpeed applicator for 20 minutes, followed by 40 minutes using the Accentuate applicator. According to ABC Lasers, UltraSpeed uses a new type of ultrasound technology delivered with an extra-large applicator plate for high speed fat reduction. This applicator features a plate type sonotrode, which emits simultaneously longitudinal and transverse ultrasonic waves through concentric profiles. The energy is distributed homogenously throughout the treatment area, which aims to disrupt fat cells. Following the use of UltraSpeed, the Accentuate applicator aims to complement the treatment by delivering radiofrequency energy into defined areas, heating tissues at varying depths, and causing a thermal effect within the skin. The company states that this contours and shapes the treated area by tightening the skin after the fat cells have already been disrupted by UltraSpeed. Aesthetic practitioner Dr Tijon Esho commented, “Facial and body contouring is a key growth area in aesthetics and the Alma Accent represents currently one of the best innovations in the market in this area. Combining ultrasound with radiofrequency technology, I have observed amazing results for treating both fat and skin laxity – and it’s fast. It’s a welcome addition to my clinics.” Training

River Aesthetics Academy launches Aesthetic clinic River Aesthetics has launched an education centre, River Aesthetics Academy, which will offer clinical, theory and practical training at its flagship training facility at Canford Cliffs in Dorset. According to Dr Victoria Manning and Dr Charlotte Woodward, who run the clinic and specialise in thread lifting and vaginal rejuvenation treatments, River Aesthetics Academy will also offer delegates ongoing support through advanced training and postcourse mentorship. The first course will take place on November 9 and focus on delivering training on the V Soft PDO Thread Lift, which uses absorbable medical grade threads and aims to rejuvenate and regenerate the skin. This course is tailored to advanced aesthetic doctors, dentists and nurses. The second course will take place on November 16 and provide training for delegates on using Desirial, a treatment that aims to restore hydration, elasticity, tone and sensitivity of the vulvo-vaginal area. According to River Aesthetics, the course is suitable only for doctors and nurses who have been in the aesthetic field for more than 12 months, have gynaecological experience and thorough knowledge of gynaecological anatomy related to injectables.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



Aesthetics Journal


ACE 2019

ACE 2019 registration now open Delegates can now register for the Aesthetics Conference and Exhibition (ACE) 2019, which is set to take place on March 1 and 2 at the Business Design Centre in London. Delegates who attend will have the opportunity to discover the latest treatment and product innovation in 2019, while networking with fellow aesthetic medicine professionals. Attendees will receive a plethora of educational opportunities through ACE’s clinical and business programme, with more than 40 CPD points available to collect over the two days. The Elite Training Experience has also been confirmed for a second year in a row. The trainers at ACE 2019 will be Medics Direct Training, Dalvi Humzah Aesthetic Training and Aesthetic Training Academy. An additional, expert trainer is to be announced next month. In the Elite Training Experiences, world renowned aesthetic practitioners and mentors will provide delegates with a taster of their own established training courses. For more information or to book your place at ACE 2019, visit www.aestheticsconference.com Business development

Allergan to acquire aesthetic company Bonti Global pharmaceutical company Allergan has announced that it will acquire US-based biotechnology company Bonti. Bonti focuses on the development and commercialisation of neurotoxin programmes. Following the completion of the acquisition, Allergan will obtain global rights to two of Bonti’s botulinum neurotoxins; serotype E (BoNT/E) EB-001A (aesthetic) and EB-001T (therapeutic). A statement released by Allergan explained that this BoNT/E is alleged to be characterised by a rapid onset of action within 24 hours, with a two to four week duration of effect. "The acquisition of Bonti is a strategic investment for the future of our medical aesthetics business and has the potential to enhance our best-in-class medical aesthetics pipeline," said Brent Saunders, chairman and CEO of Allergan. "With the medical aesthetics market expanding, a fast-acting neurotoxin with a two to four-week duration will be an attractive option for consumers, particularly those who are considering a medical aesthetics treatment for the first time," he added. Allergan will acquire Bonti for $195 million as well as potential additional commercial milestone payments, which are subject to certain adjustments and other customary closing conditions. Skincare

AlumierMD releases new Essentials Kit Skincare developer AlumierMD has introduced a new take-home kit that aims to help patients maintain in-clinic treatment results at home. The Essential Kit packs are tailor-made to specific skin concerns to address patients’ individual skincare needs. They include a cleanser, a hydrating serum and a SPF. The normal/dry skin kit includes the full-size HydraBoost Cleanser, Ultimate Boost Serum and Sheer Hydration Untinted SPF, as well as extras including AlumierMD’s Vitamin Rich Sample and HydraDew Sample. The normal/oily kit includes the full-size Purifying Gel Cleanser, Ultimate Boost Serum and Clear Shield products, while the Vitamin Rich Sample and HydraLight Sample are also available as extras.

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

AESTHETICS AWARDS The BACN (working with Hamilton Fraser Cosmetic Insurance) is extremely proud to be a finalist for the PHI Clinic Award for Professional Initiative of the Year, specifically for our GDPR Campaign and Roadshow that was delivered to all nurse members. It’s a fantastic achievement for us to be finalists, and working with Hamilton Fraser ensured we had resources and expertise for what was a real issue for members at the beginning of 2018. We are looking forward to the awards evening and celebrating excellence within aesthetics.

BACN CONFERENCE There are just a few BACN Workshops and Masterclass tickets remaining for our Autumn Aesthetic Conference. With a varied agenda of workshops, our Masterclass will be delivered by Dr Wolfgang Redka-Swoboda, consultant and scientific director for Teoxane Germany. Two main topics will be covered: The Secret of Projection and Extension, and The RedkaGaladari Point, a Safe and Effective Access for a Full-Face Treatment with HA Fillers. On our main conference day on November 9, our agenda will focus on ‘The Science, The Art, The Ethics – Understanding Today’s Aesthetic Nursing Practice’. Nurses will be leading sessions delivered by BACN sponsors and there will be a number of issues discussed, including blindness and visual disturbance following dermal fillers, safeguarding in modern aesthetic practice, and ANP prescribing. Full agendas for both days can be found on the BACN website.

CALLING ALL BACN MEMBERS We are sharing more and more content across our social media pages to show everyone what our BACN members are up to, and we would love to see what you’re doing too. You can send images/videos from your clinic, photos from days out/events, insights into aesthetics and behind the scenes shots of a ‘day in the life’ of a BACN member. If you would like to get involved, tag @BACNurses in your posts and email us content that can be shared. We want to showcase the knowledge and experience our BACN members have. Get in touch if you want to get involved! This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018

@aestheticsgroup Energy

Syneron Candela acquires Ellipse IPL and laser platforms Aesthetic device company Syneron Candela has acquired Ellipse, a Danish medical device company that manufactures and markets intense pulsed light (IPL) and laser-based platforms. Ellipse’s key products include Nordlys, a multi-application, multi-technology IPL and Nd:YAG device for vascular and pigmented lesions, and hair removal; as well as an IPL-only system which is used for skin rejuvenation, facial veins and hair removal. Geoffrey Crouse, chief executive officer of Syneron Candela said of the announcement, “The acquisition of Ellipse allows Syneron Candela to strengthen its footprint in the multi-application space and provide our customers with a comprehensive portfolio.” He continued, “Ellipse platforms will provide aesthetic practices with a fully scalable multi-application, multitechnology device. We look forward to Ellipse strengthening our portfolio as we continue to deliver our brand promise of science, results, trust to our physicians and patients worldwide.”

Aesthetics Journal

Vital Statistics Data collected from 32 studies around the world, comprising 26.5 million patients, found that 5.46% of people are affected by rosacea (National Rosacea Society, 2018)

Surgical procedures accounted for 77% of the total cosmetic expenditures in the US in 2017 and non-surgical procedures accounted for 23% (ASAPS, 2017)

In a recent survey of 480 British men, 25% said they spend between £11 and £20 on male grooming products each month


Naturastudios releases CryoPen Aesthetic equipment supplier Naturastudios has released a new cryotherapy device, the CryoPen. The device is designed to target skin imperfections such as skin tags, pigmentation and milia, amongst others. The company states that the CryoPen emits nitrous oxide under high pressure, which destroys the tissue by freezing the intercellular fluid, forming ice shards and crystals that rupture the cell’s membrane, destroying the cells. This then cuts off the blood supply during the freezing process, according to the company. Emma Mackintosh, marketing manager at Naturastudios stated, “The CryoPen has revolutionised the removal of skin lesions, by providing a convenient and compact device for practitioners. The CryoPen completes our range of skin perfecting devices and systems, helping to offer patients a wide range of treatment options.” The device is distributed exclusively in the UK by Naturastudios. Carboxytherapy

Fusion GT introduces Carbomix Aesthetic distributor Fusion GT has introduced the Carbomix device that combines carboxytherapy and hyperbaric oxygen therapy. According to Fusion GT, its carboxytherapy device can be used to treat cellulite, wrinkles and scars, while hyperbaric oxygen therapy can address indications such as facial skin ageing and hyperpigmentation. The company explains that Carbomix has a specialised software that allows for feedback control with digital sensors for temperature control and filters for CO2 and oxygen distribution. Fusion GT adds that the device results in no downtime after procedures and is pain-free due to patented valves that control the amount and temperature of the gas administered.

Aesthetics aestheticsjournal.com

(Statista, 2018)

The average age of people with acne in the US has increased over the last decade from 20.5 years to 26.5 years old (MDacne, 2018)

According to social media scheduling website MassPlanner, infographics create three times higher engagement on social media, including likes and shares, over any other type content (Intrepy, 2018)

In the US, 118,523 chemical peel procedures took place in 2017 (ASAPS, 2017)

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018

See us at

Stand E24



Gary Wilson, Commercial Manager of MedivaPharma Aesthetics Pharmacy Tell us about MedivaPharma... MedivaPharma is a medical aesthetics pharmacy committed to supporting healthcare professionals (HCPs) by providing an ethical and responsible service that enhances patient safety and responsible clinical practice. The pharmacy has recently received outstanding support for our efforts to implement a GPhC-regulated prescription dispensing process, designed to protect genuine HCPs and patient rights. We’re heading in the right direction. What can you do for your customers? We work with over 2,000+ HCPs and we’re welcoming new customers to our pharmacy every week. We want to work with people that share our values and principles; from this we gain the best client relationships that have contributed to our pharmacy growth as well as the growth and success enjoyed by our clients. • Supply of quality, genuine and licensed aesthetic products • Bespoke business support for our regular customers • Market-leading deals on a range of medical aesthetic products • Exceptional customer service • Supporting licensed HCPs in aesthetics What does the future hold? MedivaPharma has grown substantially year on year, exceeding expectations, and yet there is so much more for us to do. We proudly work with thousands of healthcare professionals and we have developed a set of principles designed to support trained, licensed medical professionals that value patient safety above all else. Since the implementation of our pharmacy prescription process, justifying the need for greater regulation and responsible pharmacy practises, MedivaPharma has received a record number of new customers who have signed up to the pharmacy. Our plan is to reach out and explore opportunities with UK partners, training providers and education outlets to develop our range of pharmacy services. Our customer base is growing rapidly so we’re looking at new exciting opportunities going forward. This column is written and supported by

Aesthetics Journal

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Lumenis announces new training partnership Aesthetic device company Lumenis has partnered with education provider The Wynyard Aesthetics Academy LLP. Set up by a group of industry professionals, The Wynyard Aesthetics Academy LLP is a specialist development, education and training provider for the beauty and aesthetics specialty. Lumenis explained that the partnership enables them to deliver not only manufacturer training at the point of installation, but also professional development and education to its customers at Level 4, 5 and 6 in line with the Health Education England (HEE) guidelines. Helen Gordon, manager of The Wynyard Aesthetics Academy LLP said, “The partnership with Lumenis puts the Academy at the forefront of professional development and education across the laser industry.” Keven Williams, chief technical officer at The Wynyard Aesthetics Academy LLP added that he was ‘delighted to be working with one of the leading providers of laser equipment worldwide’. Qualification

MATA introduces new injectable qualifications The Medical and Aesthetic Training Academy (MATA) has launched two new postgraduate level qualifications on injectables named the ‘Certificate in Clinical Aesthetic Injectable Therapies’ and the ‘Diploma in Clinical Aesthetic Injectable Therapies’. According to MATA, they provide a vocational programme of study in clinical aesthetic injectables designed to meet individual needs with an emphasis on clinical skills development, in-depth knowledge and understanding. The Certificate in Clinical Aesthetic Injectables is tailored toward those entering the aesthetic specialty. The Diploma in Clinical Aesthetic Injectables is designed for existing and experienced aesthetic practitioners who wish to develop and extend their knowledge and clinical practice. The programmes combine theoretical content and clinical practice and, according to MATA, encompass the latest Joint Council of Cosmetic Practitioners educational competencies and the Cosmetic Practice Standards Authority standards. MATA notes that the programmes are rated Level 7 on the Ofqual regulated qualifications framework. Skincare

Fillerina launches neck and cleavage at-home treatment Fillerina, a needleless topical gel filler, has introduced the Fillerina Neck and Cleavage treatment. The 14-day at-home treatment is marketed as an alternative for non-injectable treatments or for patients who wish to boost or maintain treatment results. The Fillerina Neck and Cleavage treatment aims to hydrate and rejuvenate the delicate skin in these areas. According to Fillerina, the product is formulated with eight types of hyaluronic acid with a low molecular weight and three molecules of collagen. The brand claims the ingredients work together to aid with the smoothing of wrinkles, plumping lines, binding large quantities of water and helping to level out the cutaneous skin layer by penetrating the surface and middle layers of the skin. The UK distributor for Fillerina is Metro Health & Beauty.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018

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Venus Concept introduces practice enhancement programme

Schuco Aesthetics moves premises

Manufacturer of non-invasive aesthetic devices Venus Concept has introduced its practice enhancement programme to its customers in the UK and Ireland. According to the company, the team of practice enhancement managers (PEM) works alongside customers on all aspects of their business to ensure they have the tools and resources needed to grow and succeed. The role of a Venus Concept PEM is to provide ongoing support to their customers, at no extra cost, and aid with areas such as marketing, social media training, planning open-house events, business planning, facilitating clinical training and device testing and troubleshooting. Caroline Gemmell, PEM at Venus Concept said, “Through talking to customers, we quickly establish exactly what aspects of their business they need support with and supply them with the tools and resources they need to take their business to the next level.”

UK aesthetic distributor Schuco Aesthetics has relocated its premises from Watford to Leavesden Park. According to Schuco Aesthetics, moving represents a fresh chapter for the company as it continues to develop, grow and focus on the needs of its customers. The distributor states that the aim of moving was to implement ‘schuco at home’, a space designed to create a relaxed and comfortable space to work in and one that would allow teams to freely interact and collaborate with each other. The ‘schuco at home’ premises features a new academy training facility, which is a fully functioning clinical space where product demonstrations and training for customers can take place. An additional factor in moving was Schuco’s partnership with DPD, its new logistics provider. The company claims the new partnership will allow it to be more responsive to customers’ needs to ensure they have the products they need at the time that they need them. Marketing manager for Schuco Aesthetics, Edward Fox, said, “We are delighted to join a vibrant and growing community at our new home in Leavesden Park. We have created an exciting space for our team, customers and partners to come together to work, engage and collaborate in and look forward to welcome them into our home.”

Employee announcement


InMode Aesthetic Solutions expands team Medical device manufacturer InMode Aesthetic Solutions has appointed two new employees. Paul Talbot will be the new UK aesthetics sales manager. Talbot previously worked at Lumenis, where he developed a strategic growth initiative. He said, “I hope to replicate my previous successes by driving initiatives and implementing strategies to increase sales and take the InMode’s operation to the next level.” “I quickly realised that InMode is a progressive, fast growing medical technology company whose technological advancements are setting it apart from other manufacturers. What also impressed me is the fact that InMode is owned by the management, and therefore in control of its own destiny, investing profits back into the company,” Talbot added. Also joining the team is Kate Harris, who will take on the new role of area sales manager in the South East and Midlands. Harris has 18 years’ experience in the beauty and aesthetics industry and has said she is ‘delighted to join such an innovative team and further progress her career.’

Nimue Skin Technology releases new Superfluids Skincare company Nimue Skin Technology has announced the launch of its Professional Superfluids. There will be five products in the range including the Retinol Superfluid, for patients whose primary concern is ageing; the Vitamin C Superfluid, for those with hyperpigmented and dull skin; the Prebiotic Superfluid, which targets problematic and acne-prone skin; Transdermal Nicotinamide Adrenaline Dinucleotide (NAD) Superfluid, for patients who are concerned with sagging as well as dull skin; and the Cyanoacrylate Superfluid, used for the treatment of sensed and inflamed skin. The Superfluids are used to customise an aesthetic clinic's existing professional treatments and provide an example of a patient presenting in clinic with problematic, acne-prone skin but with an usual dryness due to the change in seasons. The customised Superfluids would treat the overall concern as well as addressing any temporary dryness, Nimue claims. Victoria Sargeson, Nimue brand manager for distributor Sweet Squared said, “These innovative products allow Nimue skin therapists to be completely in control of the treatment and address the patient’s primary skin concerns, as well as any temporary concerns at the time of the appointment. Skin professionals can use up to two Superfluids in any one treatment, these simply mix with the existing treatment.” The Superfluids will be available from November 2018 and will be distributed in the UK and Ireland by Sweet Squared.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Aesthetics Journal


Alma Lasers launches PICO CLEAR Alma Lasers, laser and light-based device distributor, has launched the PICO CLEAR technology for dermatology treatments. According to the company, PICO CLEAR technology aims to treat a wide range of dermatological concerns, including tattoo removal, acne scars and wrinkles. It works to deliver short picosecond pulses of energy into the skin tissue to target the relevant pigment or skin concern. Alma Lasers claims that the PICO CLEAR is able to remove tattoos and treat pigmentation in fewer treatments than traditional lasers due to its shorter pulse duration. Acne

Study highlights new vaccine for acne prevention A study published by the Journal of Investigative Dermatology has revealed promising results for a new vaccine that could prevent acne vulgaris. The study suggests that propionibacterium acnes, an opportunistic skin bacterium, have been linked to the cause of acne vulgaris. It details that a vaccine could block this bacteria by producing an inflammation-triggering toxin called christie-atkins-munch-petersen. Lead researcher, Dr Chun-Ming Huang stated, “Once validated by a large-scale clinical trial, the potential impact of our findings is huge for the hundreds of millions of individuals suffering from acne.” The study has only been held on mice and skin cells at present, and the next stage is for it to be tested in a large-scale clinical trial on humans. HIFU

Skyncare launches MediLIFT Aesthetic technology provider Skyncare has released a new high intensity focused ultrasound (HIFU) device called the MediLIFT. The device aims to stimulate the natural production of collagen to lift and tighten loose skin on the face and body. According to the company, the technology works by bypassing the epidermis to target underlying structural tissues of the deep dermis and the superficial muscular-aponeurotic system (SMAS), where the focal point temperatures of 60-65°c stimulates the production of new viscoelastic collagen and elastin. A spokesperson from Skyncare said, "Skyncare are excited to launch the newest addition to our product range the HIFU MediLIFT. With a sleek design, multi-line technology and touchscreen interface, HIFU has never been more affordable, easier to operate or faster to deliver!” Partnership

sk:n acquires Cellite clinic Medical skincare clinic group sk:n has opened a new clinic on Charles Street in Cardiff. sk:n has acquired Cellite clinic, which was opened by Dr Harryono Judodihardjo and his wife in 1998 and won The Cosmedic Pharmacy Award for Best Clinic Midlands and Wales in 2017 and Best Clinic Wales in 2016 at the prestigious Aesthetics Awards. Dr Judodihardjo said, “We are all very excited to join such an established, leading medical clinic group, and I believe that our joint expertise will bring a new dimension to what we can offer here on Charles Street. The award-winning quality of our service and treatments will by no means be compromised, but can only improve and grow as we embark on this new journey with sk:n.”

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News in Brief Superdrug injectable services raises industry concerns The Royal College of Surgeons (RCS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) have expressed concerns that health and beauty retailer Superdrug is now offering in-store injectable treatments. Superdrug recently partnered with global pharmaceutical company Allergan to offer injectable treatments. In response to this, the RCS and BAPRAS have co-authored a formal letter to Mr Peter Mcnab, the CEO of AS Watson, the owner of Superdrug, explaining that they believe that offering injectables on the high-street will encourage ‘impulse buys’ of botulinum toxin. At the time of publication, there has been no response to these concerns. DERMAFILL to be manufactured to stricter standards Medical supply company Breit Aesthetics has announced that the hyaluronic acid (HA) product DERMAFILL will now be manufactured to stricter standards in Sweden. According to Breit Aesthetics, the product’s technology has been improved to provide consistent safety and up to 40% improvement in durability. The company also states that the DERMAFILL syringes have been redesigned for improved application and will now be available in 1ml packs. Black Skin Directory introduces e-pop-up shop The online resource for patients with skin of colour, Black Skin Directory, is set to open its pigmentation e-pop-up shop on October 1. According to Black Skin Directory, the shop will offer three clinically-proven products, which have been selected as they aim to address pigmentation. The company claims this is one of the most common skincare concerns reported by women of colour following the summer months. The products included are the NeoStrata Enlighten Illuminating Serum, the Nuhanciam Anti Dark Spot Power Factor 4 and the SkinBetter Science Even Tone Cream. FTG releases the NANO NT Aesthetic manufacturer and product supplier Finishing Touches Group (FTG) has launched a new needle, the NANO NT. The NANO NT is specially designed for micropigmentation treatments to create precise, thin hair strokes on areas such as the brows. The NANO NT is a 0.25mm needle that features a tubular design at the top of the cartridge. FTG states that this is to ensure high precision needle guidance, great stability and better pigment flow for every skin type. FTG are the exclusive UK distributors for the NANO NT needle.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018

On the Scene

River Aesthetics at Grace Belgravia launch, London Aesthetic practitioners Dr Charlotte Manning and Dr Victoria Woodward launched their third River Aesthetics clinic on September 13 in London. The new clinic is the latest service to be offered at the women-only health, wellbeing, lifestyle and medical club Grace Belgravia. Patients, colleagues, aesthetic suppliers and other guests were welcomed by Kate Percival, CEO and co-founder of Grace Belgravia. Percival said, “We are very excited to be partnering with River Aesthetics at Grace Belgravia, as they embody our ethos of female wellness." Dr Woodward and Dr Manning spoke about their ethos, stating that their results should never be recognised as a treatment, but an enhancement of an individual’s own aesthetic. Their treatment focuses include vaginal rejuvenation, bi-identical hormone replacement therapy and PDO and PLLA threads and collagen stimulating fillers. After the event, Dr Manning said, “Tonight was amazing, it’s an incredible collaboration between River Aesthetics and Grace Belgravia and it was great to share what we do with guests. It’s an exciting time for River Aesthetics.” On the Scene

AlumierMD EverActive C&E launch, London On September 12 aesthetic practitioners joined skincare developer AlumierMD at the IceTank venue in London to celebrate the launch of the EverActive C&E serum. Guests enjoyed a networking reception, before sitting down to a presentation from lead UK key opinion leader, Dr Dev Patel, and product and education specialist at AlumierMD, Victoria Hiscock. Dr Patel explained that the EverActive C&E is a high strength vitamin C (15%) and E serum, which aims to reduce the appearance of fine lines and wrinkles, revitalise skin and neutralise free radicals caused by UV damage. The product contains L-ascorbic acid (LAA), tocopherol acetate and the peptide Matrixyl Synthe'6 and is packaged into a delivery system that separates the active serum and vitamin C crystals until the patient is ready to start using the product. According to Hiscock, the packaging ensures the patient receives at least 15% vitamin C that it is not affected by oxidisation over the course of the month. Dr Patel concluded by stating, “This product is a very nice all-rounder, it’s going to help you prevent complications and get the results that you are looking for. You are really giving comprehensive protection to your patient.” The event in London was the first of three to celebrate the new launch, with the other two taking place in Manchester on September 13 with aesthetic nurse prescriber Sarah Louise, and Dublin on September 14 with aesthetic practitioner Dr Eithne Brenner.

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NatraSan Skin+ Half Page Vertical Aesthetics Journal October 2018


Animal Products and Patient Perceptions

Aesthetics Journal

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suspect that is why they cannot switch entirely form living test subjects (whether animal or human).”11 Ipsen stated in a press release, "This major milestone is the result of Ipsen’s commitment to animal welfare and extensive investments in the research and development of an in vitro Cell-Based Assay that could achieve a level of precision comparable to the mouse-based LD50 assay. The CBA is meant to replace the mouse-based LD50 assay and will lead to a drastic reduction of animal-based testing."1,2 Although the general treatment of animals does attract significant press coverage and lobbying from animal activist groups, how animal conscious are aesthetic patients and do they really care about how their products are made?

Is animal welfare on patients’ radar?

“In all the years I have been practising, I have never had a patient ask me about animal testing. We certainly get people asking whether our products contain animal-based ingredients,* particularly if a filler contains Following the news that global collagen, but nobody has ever asked me about animal biopharmaceutical group Ipsen has testing,” Dr Bhojani-Lynch says. Aesthetic nurse prescriber Lou Sommereux agrees that implemented a new cell-based test for these kinds of questions are not common in her clinic toxin products, Aesthetics looks at patient either; however, she believes that there is a naivety among the public when it comes to medicines and animal testing, perceptions towards animal testing so this is unlikely to be an indication that they are not Botulinum toxin manufacturer Ipsen recently announced that it animal conscious. She explains, “Maybe one of the reasons that I don’t had implemented the use of a cell-based test for products sold in get asked about it very much is because it’s widely known that animal the EU.1,2 The in vitro Cell-Based Assay (CBA) test aims to replace the testing for cosmetics is banned, and so people probably assume that controversial LD50 (lethal dose) poisoning test, which is defined as no aesthetic products are tested on animals. I don’t think people are ‘the dose of a test substance that is lethal for 50% of the animals in a really aware that medicines have to go through animal testing and I dose group’.3 think it’s something that perhaps they should be made more aware of.” The announcement was applauded by animal activist groups such Barney Reed, senior scientific manager at the RSPCA agrees that as Cruelty Free International and the European Coalition to End there is a lack of public knowledge when it comes to animal testing Animal Experiments (ECEAE). Dr Katy Taylor, director of science at for botulinum toxin. He recently stated on Twitter, “Most people having the ECEAE, stated, “We are delighted that Ipsen has successfully these injections are probably unaware of the animal suffering the gained the approval of a non-animal alternative in Europe. This will testing of these types of products can cause. They would no doubt be put an end to the cruel killing of hundreds of thousands of mice for horrified to find out that their desire for a wrinkle-free face may lead to the testing of their botulinum toxin products.”4 Since 2013 there has lab animals experiencing suffering.”12,13 been a complete EU ban on the manufacture, import and marketing Dr Bhojani-Lynch notes, “As medical professionals we have always of cosmetics developed through animal testing.5 However, toxin accepted that if you prescribe any medicine there would have been products are subject to testing because they are classified as a some animal testing. We may not like it, but we have to accept it. medicine by the Medicines and Healthcare products Regulatory Animal testing is unfortunately what is required and, as we are seeing, Agency and each new batch is considered a new product, therefore there is a lot of legislation to minimise it.” they require rigorous potency, quality and safety testing before Sommereux says that the types of patients who will be particularly being released to the market.6,7 interested in what their products contain are vegans and vegetarians. Ipsen’s testing methods for Azzalure/Dysport now aligns with those According to the Vegan Society, veganism is a lifestyle choice that used for Allergan’s Botox/Vistabel and Merz’s Bocouture/Xeomin, is on the rise.14 Recent reports suggest more than 3.5 million British 8,9 which implemented cell-based testing in 2011 and 2015 respectively. people now identify as such, compared to 540,000 in 2016.14,15 However, it’s important to note that the companies have not stated that She says, “I think that people are more aware of how we impact the the tests will completely eradicate animal testing for toxin products; planet overall, through considerations for things like plastic use, animal according to Allergan, such a test can reduce the use of animal-based welfare and other environmental reasons, so they are changing their testing by up to 95%.10 lifestyle to reflect their values.” Cosmetic doctor and ophthalmologist Dr Tahera Bhojani-Lynch, who Although, she notes, “In my experience, I have found that these types has been working with injectables since 1995, notes, “I think the of patients are in the minority. If someone is conscious of animal difficulty with biological assays is that they are not a substitute for welfare, however, it’s my responsibility to sit down and talk them animal testing; they are an alternative. What that means is that they through the products I use. Maybe it will mean that they don’t have tell us different things. For that reason, the results of biological assays treatment and that’s absolutely fine; we need to respect people’s have to be validated as being meaningful in living creatures, and I values and their opinions.”

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Transparency is key Although Sommereux does not directly ask patients about specific lifestyle choices such as diet when performing facial rejuvenation treatments, she does advocate making them aware of how products are made if they mention they are vegan, vegetarian or concerned with animal welfare. She says it’s vital that practitioners have thorough knowledge on the ingredients of the products they use, as well as how they have been tested, explaining, “If a patient has made it clear to you that their lifestyle is geared around using non-animal based or tested products and you are not divulging where the products you use on them come from, then I personally think that’s terrible.” Sommereux suggests that it could be a good idea to mention animal testing or even ingredients that contain animal derivatives in consent forms, which would make it easier to initiate discussion and patients can then carefully consider the products they undergo treatment with. She concludes, “I think it’s very important for practitioners to be honest and have morality and sensitivity to our patients’ needs in all situations.” REFERENCES 1. Ipsen, IPSEN’S CELL-BASED ASSAY RECEIVES APPROVALS IN THE E.U. AND SWITZERLAND FOR ITS BOTULINUM TOXIN, August, 2018.<https://www.ipsen.com/websites/IPSENCOM-PROD/wp-content/uploads/2018/08/28165732/00-IAW-ONLINE-POSITION-STATEMENT_ Ipsens-CBA-implementation-2018-08-27.pdf> 2. Ipsen, IPSEN’S CELL-BASED ASSAY RECEIVES APPROVALS IN THE E.U. AND SWITZERLAND FOR ITS BOTULINUM TOXIN, July, 2018. <https://www.ipsen.com/websites/IPSENCOM-PROD/ wp-content/uploads/2018/07/26170420/00-IAW-ONLINE-POSITION-STATEMENT_Ipsen-received-approvals-in-EU-and-CH-FINAL-2018-07-04.pdf> 3. ScienceDirect, Median lethal dose. <https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/median-lethal-dose> 4. European Coalition to End Animal Experiments (ECEAE) Press release, ‘EU animal protection organisations welcome Ipsen move to replace cruel animal botox tests’, 31st August 2018. Data on file. 5. EU Commission, Ban on Animal Testing, 2018. <http://ec.europa.eu/growth/sectors/cosmetics/ animal-testing_en> 6. MHRA, Animal use in medicines and medical devices regulation, 2018. <https://www.gov. uk/government/publications/animal-use-in-medicines-and-medical-devices-regulation/animal-use-in-medicines-and-medical-devices-regulation> 7. A Rust, et al., A Cell Line for Detection of Botulinum Neurotoxin Type B, Pharmacol, 2017. <https:// www.frontiersin.org/articles/10.3389/fphar.2017.00796/full> 8. Allergan, ​Corporate Statement on Animal Testing, <https://www.allergan.com/responsibility/ animal-testing.aspx> 9. Merz, Alternative Test Method for Botulinum Neurotoxin Now Approved in Europe, 2015, <https://www.merz.com/blog/news/alternative-test-method-for-botulinum-neurotoxin-now-approved-in-europe/> 10. Allergan, Annual Report, 2011. <https://www.allergan.com/miscellaneous-pages/allergan-pdf-files/2011annualreport> 11. Ashton, R, et al., State of the Art on Alternative Methods to Animal Testing from an Industrial Point of View: Ready for Regulation?, Workshop Reports, 2014. 12. Twitter, RSPCA Lab Animals, 2018. <https://twitter.com/RSPCA_LabAnimal/status/1029657688395919360> 13. Y Lowe, Superdrug face backlash against Botox treatment from animal rights groups, The Telegraph, 2018. <https://www.telegraph.co.uk/news/2018/08/18/superdrug-face-backlash-against-botox-treatment-animal-rights/> 14. Compare the market, Cars Against Humanity, 2018 <https://cdn.comparethemarket.com/market/ global/pr-content/cars-v-cattle/cars-vs-cattle--infographics--all_v105.pdf> 15. The Vegan Society, Find out how many vegans are in Great Britain, 2016. <https://www.vegansociety.com/whats-new/news/find-out-how-many-vegans-are-great-britain> 16. PETA, Animal-Derived Ingredients List. <https://www.peta.org/living/food/animal-ingredients-list/>

* Global animal rights organisation PETA has an ingredients list which can be used to determine what ingredients may be animal derived.16


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Does each judge review all the categories? No! Judges usually assess between one and two categories each. One reason for this is they simply wouldn’t have time – with 26 categories and hundreds of entries, it would be a very busy few months for them! The main reason, however, is to avoid any conflicts of interest. Every judge must sign a declaration form before access to the entries is given. On this declaration, they must detail any categories they, or a colleague, has entered or plan to enter, any relevant financial disclosures and any reasons they would not be able to judge a particular category objectively. They must also sign to confirm that they will:

Judging the Aesthetics Awards Find out more about the role of the prestigious Aesthetics Awards judges On October 31, voting and judging for the Aesthetics Awards will come to a close. Scores will then be carefully collated before the 2018 Winners, along with Commended and Highly Commended finalists, will be revealed at the glamorous ceremony in the Park Plaza Westminster Bridge ballroom on December 1. More than 850 guests who work across the specialty are expected to attend for an evening filled with excitement, entertainment and, of course, celebration! But before all that, the 63 judges supporting the Aesthetics Awards have an extremely difficult job in carefully considering numerous entries in their assigned categories. So how does it work? And how is a fair process guaranteed?

• Endeavour to score fairly based on the merit of each entry • Treat any information contained within the entries sent in a confidential manner • Not share the details of the categories they are judging or scores awarded with any external parties • Not use the information contained within any entries judged for their own commercial or personal purposes Before assigning categories, the Aesthetics team spends time researching the judge and judges are instructed to notify the team immediately if any further conflicts of interest arise after signing their declaration.

How do judges score entries? Entries are scored on a special portal on the Aesthetics Awards website. Judges are provided with access to a page dedicated to their assigned categories, which they can log into, save scores and come back to it later, if necessary. The easy-to-use system means judges are able to really concentrate on the content of the entries. The entry is presented in the exact format it is submitted by the entrants and, of course, if entrants have provided supporting evidence, judges can view images and download any documents provided. For each question, scores are given out of 10 and judges can make further comments at the bottom of each entry.

Aesthetics answers the most commonly asked questions…

Who are the Aesthetics Awards judges? There are 63 Aesthetics Awards judges in total, who are mainly medical practitioners working within aesthetics. As the Aesthetics Awards is a ceremony for professionals, judged by those who are experts in their field, it’s important that doctors, dentists, nurses and surgeons all take part in the judging. Other judges comprise company specialists, including business consultant, author and marketing specialist Wendy Lewis, the CEO of Hamilton Fraser Cosmetic Insurance Eddie Hooker, and PR consultant Julia Kendrick. Kendrick, who has been on the panel for three years, said, “For me, the Aesthetics Awards really is the pinnacle of industry awards because the application and judging process is so thorough and really tailored to each entry. In such a closely-knit industry where many of us have worked together, the judges’ declarations and vetting to ensure impartiality is really important. I have always been given appropriate categories for judging and I believe the rigour of the whole process means everyone can feel justifiably confident and proud of being named a Finalist, Commended, Highly Commended or Winner!”

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



Judges are advised that, although background knowledge of an entrant may inform judgement to a certain extent, they should base their decisions primarily on the entry that has been submitted. Aesthetics specifically asks them to consider the entry holistically and score based on sound evidence, along with a demonstration of commitment to clinical excellence, rather than choosing the most well-known or biggest brand, company or individual.

What happens next for finalists? Once all of the judges have submitted their scores, the Aesthetics team will gather results and very carefully total the numbers. If a category also has a voted-for element, then the number of votes will be measured alongside the judges scores in a 30-70 ratio, respectively. This all gets checked thoroughly by the team to ensure there are no mistakes, anomalies or outliers before the Winner trophies are engraved, certificates printed and those successful are announced on the night! If you haven’t booked your ticket yet, do so fast! Visit aestheticsawards.com to purchase individual tickets or tables of 12. See you on December 1!

Aesthetics Journal


Voting Voting is open for 12 categories. As the Aesthetics Awards is an awards ceremony for aesthetic professionals, judged by aesthetic professionals, with the aim of justly rewarding best practice and the highest standards within the specialty, it wouldn’t make sense for the general public or patients to take part in voting. Therefore, the 12 voteable categories are all those which aesthetic professionals will have had experience of and be able to fairly assess who they think should win! So, if you’ve worked with or been influenced by any of the finalists in the voted-for categories listed on the website, then support them by submitting your vote before October 31! > > > > > > > > > > > >

Skin Product/Range of the Year Injectable Product of the Year Energy Treatment of the Year Best Clinic Support Partner Best UK subsidiary of a Global Manufacturer Best Manufacturer in the UK The Healthxchange Award for Sales Representative of the Year The IAPCAM Award for Distributor of the Year Wholesaler of the Year The PHI Clinic Award for Professional Initiative of the Year The Sinclair Pharma Award for Best Independent Training Provider The Dalvi Humzah Aesthetic Training Award for Best Supplier Training Provider

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Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018 PRX-T Half Page Horizontal Aesthetics Journal October 2018

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Cellfina® is delighted to be a Finalist for the ‘Barry Knapp Award for Product Innovation of the Year, 2018’, at the UK’s leading Aesthetics Awards ceremony.

Visit www.cellfina.co.uk or www.cellfina.ie Contact 020 8236 3516 Email customerservices@merz.com The Cellfina® System is CE-marked with the intended use for long-term reduction of cellulite, maintained at three years, by precise release of targeted structural tissue (fibrous septae). The most common side effects were soreness, tenderness and bruising. The Cellfina® System is only available through a licensed aesthetic practitioner. For full product and safety information, refer to the Instructions for Use. Reference: 1. Kaminer, M.S., et al., A Multicenter Pivotal Study to Evaluate Tissue Stabilized-Guided Subcision Using the Cellfina Device for the Treatment of Cellulite With 3-Year Follow-up. Dermatol Surg, 2017(0): p. 1–9

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. © 2018 Merz Aesthetics. All trademarks are the property of their respective owners.

M-CEL-UKI-0283 Date of Preparation September 2018



Aesthetics Journal


for all kinds of patients, even those who are athletic can benefit, as they still sometimes have the occasional pocket of fat in the lower abdominal area.” Another benefit of non-surgical treatment is the ability to improve the tone and texture of the stomach, which surgeon and founder of S-Thetics Miss Sherina Balaratnam says is a major concern for patients. As such she stresses the importance of identifying the patient’s main concern – considering skin tone, texture, shape and laxity – before choosing a suitable treatment approach that will address them successfully.

Choosing technologies

Treating the Stomach Practitioners discuss key considerations when using energy-based devices to treat the abdominal area In recent years, it is safe to say that energy-led treatments, including laser, radiofrequency, ultrasound or cryolipolysis, have significantly increased and therefore influenced treatment offerings in a practitioner’s clinic. We know that the global medical aesthetic devices market is developing and is expected to reach an estimated value of $11.20 billion by 2021.1 “I hate my flabby belly” is a statement likely to be heard on a day-to-day basis by many aesthetic practitioners specialising in body contouring treatments and a quick Google Trends search shows that ‘how to lose belly fat fast’ was in the top 10 most frequently asked questions on the search engine last year.2 So, in an evolving specialty, how do you decide which energy-based device you should be introducing into your practice for abdominal treatments? What type of patients are most suitable for the treatment? And is there ever a one-size fits-all approach for this area? Aesthetics speaks to four practitioners for their recommendations.

Aims of energy-based stomach treatments The aims of non-surgical treatment to the stomach is firstly to remove fat, and secondly to tighten the skin. Aesthetic practitioners Dr Rita Rakus, founder of the Dr Rita Rakus Clinic, and Dr Martyn King, founder of the Cosmedic Skin Clinic, agree that those offering treatments must be realistic with the quality of results they can expect to achieve non-surgically. For example, they say that if the patient has an overhanging ‘apron’ of skin and tissue, they would be more suitable for an abdominoplasty as opposed to any non-surgical treatments. Dr Rakus explains, “We have to analyse how much fat and loose skin there is; sometimes energy-based devices aren’t suitable for the type of treatment needed and we need to be honest with the patient if we don’t think they will get the results they want.” She adds, “These devices are particularly good at sculpting the abdominal area and working to target those really stubborn areas of fat that patients just can’t shift, like on the midriff.” Aesthetic practitioner Dr Rekha Tailor, founder of Health & Aesthetics, echoes this and states that she often has patients with fairly athletic body-types seeking treatment as they just can’t ‘budge the bulge’. She says, “These treatments are useful

With so many technologies available, how do you know what to choose? Dr Tailor suggests that practitioners start off by offering two types of energy-based treatment, one that breaks down fat cells and one that tightens the skin, as these are the two most common issues that patients present with. “I use two devices in my practice, the Accent Prime, that combines ultrasound and radiofrequency for skin tightening, and CoolSculpting, a cryolipolysis device,” she adds. Dr King, who uses the ultrasound cavitation, cryolipolysis and radiofrequency 3D-lipo device, as well as cryolipolysis device, Cristal, highlights that many devices incorporate more than one treatment, “If you look at cryolipolysis, there is evidence that it will remove around 20% of the fat but it will also cause some skin tightening. Treatments such as simultaneous cavitation and radiofrequency will cause some skin tightening as well as fat reduction. So, for those looking to introduce just one device, there are many out there that incorporate more than one technology.”3 Miss Balaratnam echoes this, “One of the devices I use, SculpSure, delivers fat reduction but at the same time we see an improvement in skin tightening due to the secondary benefit of some of the heat within the dermal layer.” She also uses radiofrequency device, EndyMed for skin tightening benefits. “I think the most important thing is to look for a device that is FDA-approved, has a high safety profile and is supported by peer-reviewed clinical data. Multiplatform technologies can be a big advantage as you can treat multiple indications using the same technology.” Dr Rakus adds, “I have eight energy-based devices that treat the stomach, all of which are good for treating a variety of areas. I don’t believe that there is one machine that can tackle absolutely everything, so I like having the options.” She continues, “For example, if a patient comes to me with a stubborn roll of lower abdominal fat that won’t respond readily to diet or exercise, I will offer a treatment using the Cristal ICE device that uses cryolipolysis, whereas if a patient presents with loose skin but no fat issue, I would introduce ULTRACel which uses high intensity focused ultrasound and radiofrequency.” Dr Rakus notes that it is also worth ‘keeping your ear to the ground’ and keeping up to date on the latest product launches at UK conferences and overseas, as well as watching what has been trending on social media. She acknowledges, “One of my patients actually saw that CoolSculpting had launched in America and then told me about it when she came in for a treatment! Patients are now very savvy – with the internet, social media and celebrity endorsement it’s not uncommon for patients to know about the latest technology before we do.” As technologies are continuously evolving in the aesthetics arena, Miss Balaratnam and Dr Rakus both agree that it is important for practitioners to stay updated and be open to trying new advancements to improve their results. For example, they have both started using a new device that uses high intensity focused electromagnetic waves to help simultaneously build muscle and

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


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Aesthetics Journal

burn fat, called EMsculpt. “With EMsculpt, the high intensity focused electromagnetic (HIFEM) technology penetrates through the skin and fat to target the muscle and cause supramaximal contraction. So far, all patients that I have treated at the clinic have reported how toned, tight and firm they feel in both the buttock and abdominal areas, and have noticed an increase in their body confidence,” explains Miss Balaratnam.

Suitable patients First of all, it is wise to find out why your patients are requesting treatment to the stomach area, Dr Rakus notes, “People often want these treatments from a fashion perspective. They want to be able to fit into their wedding dress or look great on the beach in a bikini.” Miss Balaratnam adds, “People want to show off their stomachs; we live in a culture now where women don’t want to resign themselves to losing their femininity, especially after having children. Body contouring treatments can help to give these women back their confidence.” All practitioners agree that it is important to make patients aware that the results won’t be instant, a factor that Dr Tailor has found to be a common misconception, “My main concern is that patients want a quick result, but they need to be aware that treatment is going to take around three to six months. If they are planning on going on holiday for example, they need to plan ahead.” When considering suitability for non-surgical stomach treatments, Dr Tailor adds, “The ideal patient should be within two or three stone of their ideal weight and have stubborn fat pockets. They should also be mentally stable with no signs of body dysmorphic disorder. But, it’s important to note that this isn’t a weight loss treatment, it’s a body sculpting treatment. If the patient overeats and doesn’t exercise, then the results will not be maintained.” As per all treatments, practitioners should also seek a full medical history from patients. Miss Balaratnam finds it particularly useful when treating mothers, to get information on their pregnancy and childbirth. “Ask about the weight of their babies, the number of pregnancies and whether this was via natural delivery or caesarean section. This will give an idea of the degree of loss of skin elasticity, the presence of hernias as well as divarication of the rectus abdominis muscle so that you can determine which of the technologies is best suited to the patient,” she says. Miss Balaratnam also suggests assessing lifestyle choices, including alcohol consumption. She says, “I will advise patients to preferably give up alcohol all together. This clears the lymphatic system which is essential during the process of fat metabolism where the brokendown fat is naturally eliminated via the body. If our lymphatic system is congested, this will not happen as readily. A congested system just won’t give you the result. Simple.”4 Dr Rekha Tailor adds, “As with all procedures, you must always offer a cooling-off period for patients to go away and think about it. As well as being good practice, set out by the General Medical Council, a cooling-off period allows patients time to consider the advantages, disadvantages and costs. It’s important that the patients have no regrets later on, which could potentially lead to complaints.” In regards to maintaining patient results, Miss Balaratnam suggests asking the patient to provide a percentage figure of the level of improvement they are expecting to see “By doing this, it gives you an idea of what they feel they should achieve with a non-surgical technology.”

Treatment approach Once a suitable patient has been selected and the main areas of concern have been identified, the next step is to perform the


Copycat and counterfeit machines Copycat machines, commonly known for copying the technology of others, and counterfeit machines, which are designed to deceive the purchaser by copying the branding of an original machine, are a key concern for Dr Tailor. She explains that practitioners should be wary of machines that have not been subject to efficacious clinical trials, “I think the big issue the industry faces is the selling and marketing of machines that come into the UK market from the Far East, for example. Often, they have not undergone relevant trials regarding safety and efficacy. In the US, there are stringent FDA regulations which must be complied with before any machine is launched, however this is not the case in the UK. There have been anecdotal cases with counterfeit CoolSculpting machines for example, where they have been known to cause third degree burns for not effectively monitoring skin temperature.” Dr King also recognises that this is a problem and says that patients often fall for the cheaper deals and wonder why the treatment doesn’t work so well, “Good treatments cost money and a lot of people are price driven. If they see a cheaper machine on the market, they will usually go for that even though they may not be as safe or effective.” However, Dr Rakus says that copycat machines aren’t always a bad thing, providing they aren’t an exact copy and haven’t breached copyright regulations, as well as having proof of safety and efficacy, such as participation in multiple clinical trials with suitable parameters. She says, "Take your mobile phone as an example and see what has happened to it in three years – it has probably updated significantly. It’s the same with energybased machines and sometimes independent companies are quicker at making these updates than some of the bigger, well-known companies. I’ve got nothing against them and I am always keeping my eye out for the latest ones, provided that it is technically superior and safe.”

treatment. Dr King explains that as the stomach has a bigger surface area, it can be easier to treat than other areas. He explains, “I think it is generally easier to treat the stomach because of the underlying structure; you have the skin, the subcutaneous fat then your muscle layer – it’s all in one place. But you have to be very artistic with the way that you perform the treatment. You are sculpting a body and that is a form of art.” Dr Tailor adds, “The good thing about energy-based devices is that they work. The bad thing is also that they work. If you do a bad job, it’s going to show.” According to all practitioners interviewed, a successful approach is to ‘treatment blend’ as there is no one-size-fits all approach when treating the stomach. Miss Balaratnam explains, “We are not here to sell treatments, we are here to deliver great results. The chances are that whatever your Figure 1: Patient before and six weeks after treatment. Patient had a combination of six cryolipolysis and patient’s concerns six cavitation treatments with vacuum rolling for are, it requires a multi- lymphatic drainage. Photos courtesy of Dr Martyn factorial approach. King and the Cosmedic Clinic.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Aesthetics Journal

Aesthetics aestheticsjournal.com

post procedure. “I often finish my radiofrequency and cavitation treatments with lymphatic massage and have a qualified therapist on site who specialises in that area. Lymphatic massage encourages the drainage of the fat that has been liquefied,” Dr King says.5 Miss Balaratnam adds that in her experience dry body brushing following a procedure can also help to break down fatty tissue and improve vascular blood circulation, “I think that self-massage is key as it breaks down fatty tissue and puts it into the lymphatic circulation.” Once Figure 2: 52-year-old patient before and 12 weeks after using two sessions of SculpSure to the abdomen and flanks. Photos courtesy of Miss Sherina Balaratnam and S-Thetics. the patient has undergone treatment, Dr Rakus also believes in offering them The patients won’t be aware of this; they just pinch their belly and professional nutritional advice to help with their diet, “I’m not going to say ‘what are you going to do about it?’.” She continues, “As a wellhave a patient spend a significant amount of money on a treatment educated practitioner, you know that there is probably going to be with me and then just send them away. There’s no point if they skin laxity and the patient is going to want to remove some fat, this is come back to you in six months in tears saying that the treatment why it is so important to introduce treatment blending. For example, didn’t work, probably because you didn’t advise them on the right I have just treated a patient who has had four children. I have aftercare. I believe that 50% of my work is performing the treatment, performed two treatments of SculpSure followed by six treatments the rest is looking after my patient’s health. To help with this I have of Endymed radiofrequency. After six weeks the results are looking weight loss programmes and nutritionists available on site.” Miss extremely positive; I am encouraging her to wait for the whole three Balaratnam expands on this point by emphasising the importance months’ before comparing before and after photographs so we can of follow-up consultations to analyse how the patient is reacting to see two things; the fat loss as well as the collagen contraction.” treatment, stating, “If you don’t have your reviews at set times then Dr Rakus suggests that practitioners look at the bigger picture, it’s hard to then track the patient’s progress. We book patients in for “You have to make the patient look good. You can’t just say, ‘Well their complimentary follow up right at the start of when they agree there is a section here in the middle, let’s just freeze that’, then upon a treatment plan because it’s important that the patient sees the you’d have flanks sticking out or a lots of cellulite under the ribs. I result. As practitioners, we can learn from these results and educate would always advise treating the flanks, even if the patient is only ourselves further.” concerned with the lower abdomen, because once you have treated that area, they will only notice the untreated flanks.” Dr King, who A look to the future also runs the Aesthetics Complications Expert (ACE) Group, notes All practitioners interviewed agree that the body contouring it is very important to consider complications as although, in his market is set to continue to grow significantly and treatments to experience when the correct machine is used in the correct hands the stomach require planning, strong knowledge of the concern complications are uncommon, they can happen. He advises, “You presented and a specific treatment programme, which will nearly should not be performing more than one cavitation or cryolipolysis always be multi-factorial. With advancements developing in the treatment a week per patient as you are causing the fat cells to leak industry and the rise in patient awareness, Dr King states, “Over and are releasing fatty acids into the body. Although there is no time, technology, safety and results get better and the complication clear evidence, common sense dictates that increasing fatty acids rate goes down. As the technology changes, the treatments within the circulation by too great a level could risk harm to the become more affordable and so the market gets more competitive; cardiovascular system.” He adds, “Cavitation and radiofrequency these are well-established treatments and ones that are only going generate heat and there is the potential to cause burns, there to become more popular in time.” Miss Balaratnam concludes, have also been cases where patients have ended up with a frost “The best part is being able to showcase results. These treatments burn following cryolipolysis. I would advise checking in with a consist of very exciting technologies, so we will do whatever works complications group should you have any queries on this.” best in order to show them off!”

Results and post procedure Dr King explains that looking to the scales isn’t always the best way to monitor treatment results. He says, “I always do patients’ biometrics, we use the Tanita scales, so we not only measure weight, we measure circumference, body fat, water and composition.” He continues, “It can be disheartening for patients to look at scales alone, as it is common for patients to see an increase in muscle mass when exercising, so naturally the weight won’t be coming down. When looking at the biometrics as a whole, however, you may notice that their fat concentration has come down, so you can see progress.” To optimise results, he also strongly advises lymphatic massage

REFERENCES 1. CNBC, Press releases, Global Medical Aesthetic Devices Market worth USD 11.20 Billion by 2021: By Product, Application, Industry Size, Share and growth, 2016 <https://www.cnbc.com/2016/10/18/ globe-newswire-global-medical-aesthetic-devices-market-worth-usd-1120-billion-by-2021-by-productapplication-industry-size-share-and.html> 2. Google Trends, Year in Search 2017 <https://trends.google.com/trends/yis/2017/GLOBAL/> 3. Plastic and Reconstructive Surgery, Cryolipolysis for Fat Reduction and Body Contouring: Safety and Efficacy of Current Treatment Paradigms, 2015 < https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4444424/> 4. Annual review of immunology, The lymphatic system: integral roles of immunity < https://www.ncbi. nlm.nih.gov/pmc/articles/PMC5551392> 5. Journal of the European Academy of Dermatology and Venereology, Effects of mechanical massage, manual lymphatic drainage and connective tissue manipulation techniques on fat mass in women with cellulite, 2010 <https://www.ncbi.nlm.nih.gov/pubmed/19627407>

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018

IN PATIENT SATISFACTION When given a choice, most patients prefer BOTOX®1,2

1. Banegas RA, et al. Aesthet Surg J. 2013;33:1039–1045. 2. De Boulle KD. J Cosmet Laser Ther. 2008;10:87–92. BOTOX® is indicated for the temporary improvement in the appearance of the following facial lines, when the severity of these lines has an important psychological impact in adult patients: moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines), moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile, moderate to severe crow’s feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously. Prescribing Information can be found overleaf. UK/0187/2018d Date of preparation: September 2018

Produced and funded by


BOTOX® (botulinum toxin type A) Glabellar and Crow’s Feet Lines Abbreviated Prescribing Information Presentation: Botulinum toxin type A (from clostridium botulinum), 50 or 100 or 200 Allergan Units/vial. Indications: Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines); moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile; moderate to severe crow’s feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously in adults, when the severity of these lines has an important psychological impact for the patient. Dosage and Administration: See Summary of Product Characteristics for full information. Do not inject into blood vessels. Botulinum toxin units are not interchangeable from one product to another. Not recommended for patients <18 years. The recommended injection volume per muscle site is 0.1 ml (4 Units). Glabellar Lines: Five injection sites: 2 in each corrugator muscle and 1 in the procerus muscle: total dose 20 Units. Crow’s Feet Lines: Six injection sites: 3 in each lateral orbicularis oculi muscle: total dose 24 Units. In the event of treatment failure or diminished effect following repeat injections alternative treatment methods should be employed. Contraindications: Known hypersensitivity to any constituent. Infection at proposed injection site(s). Warnings/Precautions: Use not recommended in women who are pregnant, breast-feeding and/or women of childbearing potential not using contraception. The recommended dosages and frequencies of administration of BOTOX should not be exceeded due to the potential for overdose, exaggerated muscle weakness, distant spread of toxin and the formation of neutralising antibodies. Initial dosing in treatment naïve patients should begin with the lowest recommended dose for the specific indication. Prescribers and patients should be aware that side effects can occur despite previous injections being well tolerated. Caution should be exercised on the occasion of each administration. There are reports of side effects related to spread of toxin distant from injection site, sometimes resulting in death. BOTOX should only be used with extreme caution and under close supervision in patients with subclinical or clinical evidence of defective neuromuscular transmission and in patients with underlying neurological disorders. Caution in patients with underlying neurological disorder and history of dysphagia and aspiration. Patients should seek medical help if swallowing, speech or respiratory disorders arise. Previously sedentary patients should resume activities gradually. Relevant anatomy and changes due to prior surgical procedures must be understood prior to administration and injection into vulnerable anatomic structures must be avoided. Pneumothorax associated with injection procedure has been reported. Caution is warranted when injecting in proximity to the lung, particularly the apices or other vulnerable structures. Serious adverse events including fatal outcomes have been reported in patients who had received off-label injections directly into salivary glands, the oro-lingualpharyngeal region, oesophagus and stomach. If serious and/or immediate hypersensitivity reactions occur (in rare cases), injection of toxin should be discontinued and appropriate medical therapy, such as epinephrine, immediately instituted. Procedure related injury could occur. Caution in the presence of inflammation at injection site(s), ptosis or when excessive weakness/atrophy is present in target muscle. Reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. New onset or recurrent seizure occurred rarely in predisposed patients, however relationship to botulinum toxin has not been established. Clinical fluctuations may occur during repeated use. Too frequent or excessive dosing can lead to antibody formation and treatment resistance. It is mandatory that BOTOX is used for one single patient treatment only during a single session. May cause asthenia, muscle weakness, somnolence, dizziness and visual disturbance which could affect driving and operation of machinery. Interactions: Theoretically, the effect may be potentiated by aminoglycoside antibiotics or other drugs that interfere with neuromuscular transmission. Adverse Effects: See Summary of Product Characteristics for full information on side effects. Based on controlled clinical trial data, the proportion of patients treated for glabellar lines that would be expected to experience an adverse reaction after treatment is 23% (placebo 19%). In pivotal

controlled clinical trials for crow’s feet lines, such events were reported in 8% (24 Units for crow’s feet lines alone) and 6% (44 Units: 24 Units for crow’s feet lines administered simultaneously with 20 Units for glabellar lines) of patients compared to 5% for placebo. Adverse reactions may be related to treatment, injection technique or both. In general, adverse reactions occur within the first few days following injection and are transient, but rarely persist for several months or longer. Local muscle weakness represents the expected pharmacological action. Localised pain, tenderness and/or bruising may be associated with the injection. Fever and flu syndrome have been reported. Frequency By Indication: Defined as follows: Common (≥1/100 to <1/10), Uncommon (≥1/1,000 to <1/100). Glabellar Lines (20 Units): Infections and infestations. Uncommon: Infection. Psychiatric disorders. Uncommon: Anxiety. Nervous system disorders. Common: Headache. Uncommon: Paraesthesia, dizziness. Eye disorders. Common: Eyelid ptosis. Uncommon: Blepharitis, eye pain, visual disturbance. Gastrointestinal disorders. Uncommon: Nausea, oral dryness. Skin and subcutaneous tissue disorders. Common: Erythema. Uncommon: Skin tightness, oedema (face, eyelid, periorbital), photosensitivity reaction, pruritus, dry skin. Musculoskeletal and connective tissue disorders. Common: Localised muscle weakness. Uncommon: Muscle twitching. General disorders and administration site conditions. Common: Face pain. Uncommon: Flu syndrome, asthenia, fever. Crow’s Feet Lines (24 Units): Eye disorders. Common: Eyelid oedema. General disorders and administration site conditions. Common: Injection site haemorrhage*, injection site haematoma*. Uncommon: Injection site pain*, injection site paraesthesia (*procedure-related adverse reactions). Crow’s Feet Lines and Glabellar Lines (44 Units): General disorders and administration site conditions. Common: Injection site haematoma*. Uncommon: Injection site haemorrhage, injection site pain* (*procedure-related adverse reactions). The following adverse events have been reported since the drug has been marketed for glabellar lines, crow’s feet lines and other indications: Cardiac disorders: Arrhythmia, myocardial infarction. Ear and labyrinth disorders: Hypoacusis, tinnitus, vertigo. Eye disorders: Angle-closure glaucoma (for treatment of blepharospasm), strabismus, blurred vision, visual disturbance, lagopthalmos. Gastrointestinal disorders: Abdominal pain, diarrhoea, constipation, dry mouth, dysphagia, nausea, vomiting. General disorders and administration site conditions: Denervation atrophy, malaise, pyrexia. Immune system disorders: Anaphylaxis, angioedema, serum sickness, urticaria. Metabolism and nutrition disorders: Anorexia. Muscoskeletal and connective tissue disorders: Muscle atrophy, myalgia. Nervous system disorders: Bronchial plexopathy, dysphonia, dysarthria, facial paresis, hypoaesthesia, muscle weakness, myasthenia gravis, peripheral neuropathy, paraesthesia, radiculopathy, seizures, syncope, facial palsy. Respiratory, thoracic and mediastinal disorders: Aspiration pneumonia (some with fatal outcome), dyspnea, respiratory depression, respiratory failure. Skin and subcutaneous tissue disorders: Alopecia, dermatitis psoriasiform, erythema multiforme, hyperhidrosis, madarosis, pruritus, rash. NHS Price: 50 Units: £77.50, 100 Units: £138.20, 200 Units £276.40. Marketing Authorization Number: 50 Units: 426/0118, 100 Units: 426/0074, 200 Units 426/0119. Marketing Authorization Holder: Allergan Ltd, Marlow International, The Parkway, Marlow, Bucks, SL7 1YL, UK. Legal Category: POM. Date of preparation: June 2015. Further information is available from: Allergan Limited, Marlow International, The Parkway, Marlow, Bucks SL7 1YL

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

UK/0187/2018d Date of preparation: September 2018

Produced and funded by

1 oint



Aesthetics Journal


Implementing Efficient Defensive Strategies Expert witnesses Dr Godfrey Town and Dr Ross Martin consider options for defending yourself against patient claims related to lasers and other energy-based devices The practice of defensive medicine is not a new concept to the medical profession. The incidence of complaints that turn into allegations of negligence is certainly on the increase,1,2 and many aesthetic practitioners may not be aware of how vulnerable they can be to such allegations. There is undoubtedly a need for help and advice on how to stay protected against the commonest occurrences. This article will explain how aesthetic practitioners using lasers and other energy-based devices can ensure they can mitigate their chances of a claim being held against them, as well as defend themselves should they be faced with a claim.

Risks of energy-based devices Fortunately, in the use of lasers and other intense light sources (ILS) in aesthetic procedures, serious injury is a rare occurrence. In the US, the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) data on complications confirms only eight reports of eye injury with ILS and laser amongst 1,257 medical device reports between 1991-2013.7 Although it is extremely rare to get an ocular complication, injury to the skin is much more common and must be considered by all practitioners.8-11

Developing defensive strategies for energy-based devices

Legal responsibility All aesthetic professionals have a ‘duty of care’, which is a legal obligation not to cause a patient injury while in their care.3 To mount a legal case successfully against a clinic, a breach of duty, often referred to as negligence, must be suggested by the circumstances surrounding the patient’s concern. Contrary to popular perception, the legal test of negligence is actually quite hard to achieve, as a direct act or culpable omission by the defendant has to be demonstrated. This must result in injury to the claimant as a reasonably foreseeable consequence of the act or omission of the defendant. Sometimes insurers will resolve cases by simple negotiation or as a result of mediation on what are called ‘settlement terms’ rather than by a court, so as to limit their exposure to costs.4 The lawyers managing these cases will have some knowledge of the techniques that are being used in clinics, but beyond that they rely on the opinion of experts to decide whether to pursue a case. Insurance companies and defence organisations also employ experts for the same reasons. Ultimately, of course, it is for a court to decide where negligence may or may not lie, but one must remember that few of these cases ever get anywhere near a court.

Professional responsibility

Evidence of minimum prior educational requirements Many new laser and other EBD devices can be operated by the medically-trained healthcare professional or delegated under supervision to ‘physician extenders’ who have been suitably trained.12 In November 2015, Health Education England (HEE) published a recommended qualification framework for delivery of cosmetic procedures, providing the indicative content and knowledge elements of training and education for practitioners. The recommended framework is now owned by the newly formed Joint Council for Cosmetic Practitioners (JCCP) and has been adopted and amended. However, the JCCP recognises that its two registers are voluntary and therefore not a legal requirement.13,14 The manufacturer or supplier of devices is only responsible for providing the user with basic training in the safe use of the device. In our experience of the aesthetic sector, this rarely includes specific application coaching or preceptorship training. Increasingly, IPL devices are being operated by personnel from differing professional backgrounds. This makes it very difficult to generalise about the type and quality of training that might be considered adequate. In addition, the professional background and training of operators required by the various regulatory and licensing agencies varies from country to country within the UK.15-18 In our

Additionally, healthcare professionals are also answerable to their licensing bodies regarding the way they carry out their professional duties. Where the conduct of a medical professional is governed by a complex set of rules laid down by regulatory bodies such as the General Medical The effect of claims on the practitioner Council (GMC), it is possible for complaints to reach An area often neglected in discussions on this subject is the effect that this the attention of these organisations in addition to civil whole process has on the practitioner. Litigation and all the unpleasantness of litigation. There are several areas of practice where the process, including the language used by lawyers and the vast amounts of risks will occur in an aesthetic setting, but this article paperwork to be dealt with, can increase levels of stress. Data confirms that will focus on those associated with energy-based practitioners have taken their own life whilst awaiting these proceedings.5,6 devices.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


opinion, a suitable apprenticeship model with both learned theory and a qualified mentor to ensure that workplace skills are developed is the ideal. This will allow for variations in regional rules and provide reassurance to the public that the operator was properly trained. As a general rule, compliance with whichever regulation or licensing requirement is in place in a particular jurisdiction will confer a level of protection for the operator, should a complaint arise. The opposite is that if guidance is available and is ignored, the point will be seized upon by any expert asked to look at the complaint. Seeking patients’ consent It is a general legal and ethical principal that valid consent must be obtained before commencing any physical examination, treatment or personal care for a patient.19 This principle reflects the right of patients to determine what happens to their own bodies and is a fundamental part of good practice. A healthcare professional (or other healthcare staff) who does not respect this principle may be liable both to legal action by the patient and to action by their professional body.20 While there is usually no statute setting out the general principles of consent, case law (common law) in England has established that touching a patient without valid consent may constitute the civil or criminal offence of battery.21 Furthermore, if healthcare professionals (or other healthcare staff) fail to obtain proper consent and the patient subsequently suffers harm as a result of treatment, this may be a factor in a complaint against the healthcare professional involved. Failing to respect this principle may expose a health professional to both legal action and disciplinary action by their professional body. Failure to warn a patient of a risk of injury, however small the probability of the risk occurring, denies the patient the chance to make a fully informed decision. It is therefore necessary for healthcare practitioners to give information about all significant possible adverse outcomes and make a record of the information given.22,23 In the absence of specific guidance for non-medical aesthetic practitioners, this approach should be adopted as best practice. The legal case of Montgomery in England24 has been seized upon enthusiastically as ‘the most important medical negligence case in the last 30 years’ by lawyers looking for new business. In our experience, before this case, it was considered acceptable in the UK only to warn a patient about side effects of treatment that were reasonably common. New case law puts the onus on the practitioner to warn of all side effects that the particular patient might be expected to be made aware of. According to the GMC, patients attending a consultation must be provided with written information (e.g. patient education brochure) about the proposed procedure or treatment and the patient must be given a verbal explanation of the procedure by a practitioner who is familiar with the treatment, its possible complications and side effects, and any available alternatives. They must have adequate opportunity to read, review and understand the consent form and other material, and have time to reflect on the nature and purpose of the treatment, before reaching a voluntary and informed decision before proceeding with a proposed intervention.25 A good technique, and one which we have used, is to leave the room while a patient considers the form in front of them. In our experience, all too often complainants claim that the practitioner sat over the patient watching them sign the form and were given no opportunity to reflect or ask questions. For consent to be valid, the GMC states that it must be taken, preferably by someone who is competent to perform the procedure, and given voluntarily by an appropriately informed person who has

Aesthetics Journal

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Case law puts the onus on the practitioner to warn of all side effects that the particular patient might be expected to be made aware of

the capacity to consent to the intervention in question (normally this will be the patient or someone with parental responsibility for a patient under the age of 18). Acquiescence where the person does not know what the intervention entails is not ‘consent’.26 Different jurisdictional requirements may apply in regards to consent from ‘young people’ e.g. aged 16 or 17, but where they are presumed to be capable of consenting to their own medical treatment, consent will only be valid if it is given voluntarily by an appropriately informed young person, capable of consenting to the particular intervention.27 Consent must be given voluntarily and freely, without pressure or undue influence being exerted on the person either to accept or refuse treatment. Such pressure can come from partners or family members, as well as commercial pressure from other clinics/ practitioners. Practitioners should be alert to this possibility and where appropriate should arrange to see the person on their own to establish that the decision is truly their own.28 Some people may wish to know very little about the treatment that is being proposed. If information is offered and declined, it should be recorded in the notes.29 Where prospective patients have language difficulties, patients will be asked to bring a trusted relative or friend to translate and ensure that the consent form is fully understood before signing. However, if the staff member giving information is not confident about the adequacy of the translation, treatment should be declined.29 The validity of consent does not depend on the form in which it is given. Written consent merely serves as evidence of consent. Although completion of a consent form is, in most cases, not a legal requirement,21,30 the use of such forms is generally accepted as good practice where an intervention is undertaken. In addition to the actual consent form, the operator may wish to consider making hand or type-written records of the consenting process to support contemporaneously what is stated in the consent form.31 Alternatively, or additionally, the use of check-boxes next to the most salient points, to be initialled by the patient, also makes a very clear statement to somebody looking for evidence of consent that it has actually been obtained and is recommended. The use of such defensive techniques has become even more important in England with the introduction of new Montgomery case law.32 The practitioner has a ‘duty of candour’ to be honest and open with patients both when explaining a proposed course of treatment, during the procedure and

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



Aesthetics Journal

Top tips 1. Appropriately select patients. Obsessive complaints or unrealistic expectations should certainly ‘ring alarm bells’. Full-blown body dysmorphic disorder is well described.42 You do not have to treat these patients – use a polite excuse like ‘this treatment is not really suitable for you’. 2. Be careful what you say to those around you whilst performing procedures. The patient may remember and misinterpret statements that you have made. 3. Decline to comment on the care provided by other practitioners until you are in full possession of the facts and circumstances. 4. Use mediation techniques. If you do find yourself in the position of having a discussion with your patient regarding an untoward incident, it is always best to firstly try techniques that a mediator might use. Determine what the complainer’s ideas of what has gone wrong are, why they are upset, correct any misconceptions as far as possible and seek what they are trying to gain from the process.

in the event of an untoward incident. This includes communicating clearly with patients and treating them with respect and dignity. Any misrepresentation of these elements will invalidate consent.33 The completion of the consent form is only part of the consent process and should only be carried out in the context of an informed discussion with the person giving consent, with more detailed explanation given where necessary. The practitioner providing the treatment is responsible for ensuring that the person has given valid consent before treatment begins. The law does not set any timescale for the validity of consent to an intervention so it remains valid indefinitely as long as it would appear to be reasonable that it is still valid i.e. until completion of the treatment or unless consent is withdrawn by the person.34 Clinical governance and oversight/supervision The degree of medical supervision required for a laser or other EBD intervention will vary according to jurisdiction. In certain regional areas of England, namely the London boroughs, Nottingham and some Essex boroughs, a licensing scheme exists for establishments that provide ‘special treatments’, which includes laser and ILS interventions and where the degree of clinical governance is specified.26 In Scotland, Wales and Northern Ireland this is regulated by Healthcare Improvement Scotland (HIS), Health Inspectorate Wales (HIW) and the Regulation and Quality Improvement Authority (RQIA), respectively. However, the abiding principle to reduce the risk of a complaint, is that there must be an appropriate degree of medical oversight. In particular, a current written treatment protocol should be followed that has been issued by an expert in the procedure using the laser or other EBD and that the protocol’s authorship and credentials be identified clearly and be subject to evidence of periodic review.16-18 Specific predesigned stationery, adapted to a particular procedure taking place, is often useful in ensuring that the correct parameters for light-based treatments are being recorded as used. For instance, in a typical case of tattoo removal, we would expect to see recorded as a minimum: the wavelengths of laser used, the spot size/energy output (or fluence), pulse duration and the number of pulses or repetition rate of the laser. In the event of an adverse incident, anything less than this would, in our opinion, not allow an investigating expert to make a judgement based solely on the notes about whether the


operator had fully understood the principal underlying the use of the machine with which he, or she, was treating the patient. In the UK, a number of organisations, including BAAPS, BAPRAS, BCAM, BAD and the BACN publish ethical guidelines which their members are obliged to follow. Specific treatment-related guidelines published by specialist bodies in the international peer-reviewed press may also serve as a ‘benchmark’ for best clinical practice.35,36 When advertising your services, you must follow advertising regulations or codes in your particular jurisdiction. In particular you must be certain that the information that you publish is factually correct and can be checked, and that it does not exploit patients’ vulnerability or lack of medical knowledge. Additionally, claims should not be made for the superiority of one practitioner over another.37,38

Good practice To help keep patients safe, follow guidance on establishing and participating in systems and processes that support quality assurance and service improvement.39 In particular: • Comply with any statutory reporting duties in place • Contribute to national programmes to monitor quality and outcomes, including those of any relevant laser or other EBD registries • Routinely monitor patient outcomes, and audit your practice, reporting at least annual data • Report product safety concerns to the relevant national regulator You should share insights and information about outcomes with colleagues who offer similar interventions, to improve outcomes and patient safety. You must tell patients how to report complications and adverse reactions.39

Resolving disagreements Generally, patients become annoyed when they perceive that they are not being listened to or feel that they are being ‘fobbed-off’. A degree of openness involving a discussion about the patient’s own ideas about what has gone wrong, together with their long-term worries and what they consider can be done to redress the balance, is a good course of action. It is important, however, that medical indemnity providers are kept in the loop before this process starts. Procedures would normally be conducted in-house at the initial stage or possibly, in large organisations, by someone designated to this role. Unless this preliminary procedure fails, and again with the permission of the insurer, a form of alternative dispute resolution could be considered. The UK judiciary is keen to reduce the burgeoning number of claims and is looking increasingly towards alternative dispute resolution such as mediation to fill the gap. This is already happening in higher courts.40,41 Laser and ILS practitioners should also be aware that under the Equality Act 2010, several every day situations encountered routinely in the clinic such as, but not limited to, HIV/AIDS and pregnancy have ‘protected’ status. In the event of disinclination or refusal to treat a person with any of these conditions could imply a breach of the Act and expose the clinic, its staff and professional consultants to liability claims.42

Conclusion The incidence of complaints that turn into allegations of negligence is increasing and practitioners are often unaware of their vulnerability to potential litigation. Compliance with regional regulation and licensing provisions will confer a level of protection for the operator, should a complaint arise. Valid patient consent and the practitioner’s duty

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018

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to be honest and open with patients is vital, as any demonstrated misrepresentation may invalidate consent and expose the practitioner to the risk of prosecution for battery. In the event of a personal injury claim, alternative dispute resolution is encouraged.

Reflection questions 1. Which of the following is a useful approach with patients? a. Use of mediation techniques when discussing an untoward incident with a patient b. Commenting on the care provided by other practitioners c. Treating patients with unrealistic expectations d. Chat casually to those around you while performing procedures 2. Which of the following is NOT an absolute requirement of informed consent? a. Taken by someone competent to perform the procedure b. Given voluntarily and freely by an informed person c. Honesty when explaining a proposed course of treatment d. Written consent 3. Which of the following is NOT ‘Best Practice’ guidance? a. Routinely monitor patient outcomes b. Focus patient information only on the procedure you offer c. Report product safety concerns to the national regulator d. Share information with those who offer similar procedures Dr Godfrey Town PhD is an RPA2000 certified laser protection adviser and holds a PhD in light-based therapy from the University of Wales, Swansea and has an Expert Witness Certificate from Cardiff University Law School. He is a registered clinical technologist and has published more than 25 peer-reviewed scientific and clinical papers. He sits on several international laser and light safety standards committees. Dr Ross Martin MB, ChB has worked widely in the cosmetic industry as a practitioner, adviser and expert witness for the last 24 years. He has a special interest in medical and surgical aesthetics and is a recognised laser expert medical practitioner, working with lasers since 1993. He is a qualified mediator. He has owned clinics in Nottingham, Hull and Sheffield and has worked in laser clinics across the country. REFERENCES 1. NHS Annual Report and Accounts 2018 <https://resolution.nhs.uk/annual-report-and-accounts-201617/> 2. Jalian HR, Jalian CA, Avram MM. Common causes of injury and legal action in laser surgery. JAMA Dermatol. 2013; 149(2):188-193. 3. Ferrari F. Donoghue v Stevenson’s 60th Anniversary Annual Survey of International & Comparative Law 1994; 1:1: Article 4. <https://digitalcommons.law.ggu.edu/cgi/viewcontent. cgi?referer=&httpsredir=1&article=1003&context=annlsurvey> 4. ACAS Settlement Agreements: A Guide. 2013; <http://www.acas.org.uk/media/pdf/o/a/Settlement_ agreements_(the_Acas_Guide)JULY2013.pdf> 5. Horsfall S. Doctors who commit suicide while under GMC fitness to practice investigation. December 2014:< https://www.gmc-uk.org/Internal_review_into_suicide_in_FTP_processes.pdf_59088696.pdf> 6. Davis J. 13 doctors died while GMC ‘failed to act’ on suicides risk, review finds. 2015 <http://www. pulsetoday.co.uk/your-practice/regulation/13-doctors-died-while-gmc-failed-to-act-on-suicides-riskreview-finds/20030569.article > 7. Tremaine AM, Avram MM. FDA MAUDE Data on Complications With Lasers, Light Sources, and EnergyBased Devices. Lasers Surg Med. 2015; 47:133-140. 8. Nanni CA, Alster TS. Complications of cutaneous laser surgery. A review. Dermatol Surg. 1998; 24:20919. 9. Greve B. Raulin C. Professional errors caused by lasers and intense pulsed light technology in dermatology and aesthetic medicine: preventive strategies and case studies. Dermatol Surg. 2002; 28(2):156-61. 10. Willey A, Anderson RR, Azpiazu JL et al. Complications of Laser Dermatologic Surgery. Lasers Surg Med. 2006; 38:1-15.

Aesthetics 11. Haedersdal M. Cutaneous side effects from laser treatment of the skin: skin cancer, scars, wounds, pigmentary changes, and purpura – use of pulsed dye laser, copper vapour laser and argon laser. Acta Derm Venereol 1999; 78(suppl 207):1-32. 12. American Society for Laser Medicine and Surgery. Procedural skill and technique proficiency for laser medicine and surgery in dermatology: November 2, 2005. 13. HEE, PART ONE: Qualification requirements for delivery of cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, 2015. <https://www.hee.nhs.uk/sites/default/files/documents/ HEE%20Cosmetic%20publication%20part%20one%20update%20v1%20final%20version.pdf> 14. HEE, PART TWO: Report on implementation of qualification requirements for cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, 2015. <https://www.hee.nhs.uk/sites/ default/files/documents/HEE%20Cosmetic%20publication%20part%20two%20update%20v1%20 final%20version_0.pdf> 15. Legislation.gov.uk, London Local Authorities Act 1991. <http://www.legislation.gov.uk/ukla/1991/13/ contents/enacted> 16. HIS, The regulation of independent healthcare in Scotland, 2011. <http://www. healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/independent_ healthcare.aspx> 17. Healthcare Inspectorate Wales, About us, 2017. <http://hiw.org.uk/about/?lang=en 18. The regulation and Quality Improvement Authority, RQIA Provider Guidance 2016-17. <https://rqia.org.uk/ RQIA/files/de/de9ca079-adc5-4efb-a82d-cdd2fba88aab.pdf> 19. General Medical Council, Consent Guidance: Part 1: Principles. 2018; <https://www.gmc-uk.org/guidance/ ethical_guidance/consent_guidance_part1_principles.asp> 20. Chan SW, Tulloch E, Cooper ES, et al. Montgomery and informed consent: Where are we now? BMJ 2017; 357:2224. <https://doi.org/10.1136/bmj.j2224> 21. Department of Health. Reference guide to consent for examination or treatment. Crown copyright; Second edition; July 2009 <https://assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/138296/dh_103653__1_.pdf> 22. General Medical Council, Consent guidance: Contents. <https://www.gmc-uk.org/guidance/ethical_ guidance/consent_guidance_contents.asp> 23. Chester v Afshar [2004] UKHL 41. <https://publications.parliament.uk/pa/ld200304/ldjudgmt/jd041014/ cheste-1.htm> 24. Lee A. ‘Bolam’ to ‘Montgomery’ is result of evolutionary change of medical practice towards ‘patientcentred care’ Postgrad Med J. 2017;93: 46-50. 25. General Medical Council, Consent guidance: Responsibility for seeking patient consent. <https://www. gmc-uk.org/guidance/ethical_guidance/consent_guidance_responsibility_for_seeking_a_patients_ consent.asp> 26. General Medical Council, Consent Guidance: Guidance involving children and young people. <https:// www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_involving_children_and_young_ people.asp> 27. General Medical Council, Consent Guidance: Obstacles of sharing information. <https://www.gmc-uk. org/guidance/ethical_guidance/consent_guidance_obstacles_of_sharing_information.asp 28. General Medical Council, Consent Guidance: Expressions of consent.: <https://www.gmc-uk.org/ guidance/ethical_guidance/consent_guidance_expressions_of_consent.asp> 29. General Medical Council, Working with doctors Working for patients. Communicating information about your services. 2018; <https://www.gmc-uk.org/guidance/ethical_guidance/28721.asp> 30. Laurie G, Postan E. Rhetoric or reality: What is the legal status of the consent form in health-related research? Medical Law Review 2013; 21:3:371-414. 31. General Medical Council, Consent Guidance: Expressions of consent.: https://www.gmc-uk.org/ guidance/ethical_guidance/consent_guidance_expressions_of_consent.asp 32. The Supreme Court (2015) Judgment: Montgomery (Respondent) v Lanarkshire Health Board (Respondent) (Scotland), paragraphs 86-91. <https://www.supremecourt.uk/cases/docs/uksc-2013-0136judgment.pdf> 33. GMC/NMC Openness and honesty when things go wrong: the professional duty of candour. < https:// www.gmc-uk.org/DoC_guidance_englsih.pdf_61618688.pdf> 34. Diamond B. What is the law on patient consent? Nursing Times. 2008 Feb <ttps://www.nursingtimes.net/ what-is-the-law-on-patient-consent/754082.article> 35. Drosner M, Adatto M. Photo-epilation: guidelines for care from the European Society for Laser Dermatology. J Cosmet Laser Ther. 2005; 7:33-8. 36. Adamic M, Troilius A, Adatto M, Drosner M, Dahmane R. Vascular lasers and IPLS: guidelines for care from the European Society for LaserDermatology (ESLD). J Cosmet Laser Ther. 2007; 9(2):113-24. 37. General Medical Council, Working with doctors Working for patients. Rules about advertising cosmetic procedures. 2018; <https://www.gmc-uk.org/guidance/ethical_guidance/29191.asp> 38. General Medical Council, Working with doctors Working for patients. Communicating information about your services. 2018; <https://www.gmc-uk.org/guidance/ethical_guidance/28721.asp> 39. General Medical Council, Working with doctors Working for patients. 2018; <https://www.gmc-uk.org/ guidance/good_medical_practice/contents.asp> 40. The Society of Mediators: CMC proposes automatic referral to mediation. 26th November 2017; <http:// www.218strand.com/story/2017/11/26/cmc-proposes-automatic-referral-to-mediation/19/> 41. Civil Justice Council: A response by the Association of Personal Injury Lawyers. December 2017; <https://www.apil.org.uk/files/pdf/ConsultationDocuments/3503.pdf> 42. Castle DJ, Phillips KA, Dufresne Jr RG. Body dysmorphic disorder and cosmetic dermatology: more than skin deep. J Cosmet Dermatol. 2004; 3:2:99-103 Equality Act 2010,. <http://www.legislation.gov.uk/ ukpga/2010/15/pdfs/ukpga_20100015_en.pdf>

Answers 1. Use of mediation techniques when discussing an untoward incident with a patient 2. Written consent 3. Focus patient information only on the procedure you offer


Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Tina, Stylist/Makeup Artist, Age 51

Belle, Hair Stylist, Age 51


After 3 Months

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After 3 Months

After 6 Months


After 3 Months

After 6 Months


After 3 Months

After 6 Months

All treatments were carried out by The Cosmetic Skin Clinic. Disclaimer: Please be aware that results and beneďŹ ts may vary from patient to patient taking into consideration factors such as age, lifestyle and medical history.

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Expert Focus on the SkinCeuticals Antioxidant Portfolio At SkinCeuticals, global scientific director Hina Choudhary is responsible for ensuring scientific integrity across all phases of product development, including clinical testing and scientific communication. We welcome the opportunity to ask her a few key questions… What sets the SkinCeuticals Antioxidant Range apart from other antioxidants?

What can patients expect from using a topical antioxidant?

The backbone of SkinCeuticals science is the development of potent antioxidant topical skincare, based on the pioneering work of Dr Sheldon Pinnell. As the founding father of topical antioxidants, he was the first to patent a stable form of Vitamin C, proven through peer-reviewed research, to effectively penetrate skin, delivering eight times the skin’s natural antioxidant protection. Since then, we have set the industry standard, thanks to further breakthroughs made by our R&D team, in stabilising active ingredients and formulating synergistic combinations of antioxidants to provide superior protection and stability. Our commitment to efficacy testing is unparalleled – we assess this against three criteria: does the final formulation penetrate into the skin, does it have a quantifiable action in skin and does that action translate to end benefits for the patient. As a scientist, I feel proud to work for a brand that dedicates such high levels of time and resource to ongoing research into identifying the causes of skin damage and validating the capacity of our antioxidant formulas, in order to provide efficient prevention and protection against environmental aggressors.

Clinical studies prove that the SkinCeuticals Antioxidant Range successfully reduces signs of premature ageing by neutralising UV, IR-A and pollution-induced free radicals whilst supporting the skin’s natural repair. Following the recommended daily regimen in applying a SkinCeuticals Antioxidant every morning will deliver visible improvements to the skin’s firmness and skin tone, as well as a reduction in the appearance of lines and wrinkles. Vitamin C also has a brightening effect on skin and we often find that patients comment on improved skin radiance after only two or three daily applications of C E Ferulic or Phloretin CF. We know that integrating cosmeceutical skincare with inclinic treatments also improves and sustains treatment results. Moreover, C E Ferulic is proven to help in healing following laser skin rejuvenation.

Why is research into Atmospheric Skin Ageing of such significance? ‘Atmospheric Skin Ageing’ is a term that SkinCeuticals introduced to bring awareness to the fact that multiple environmental aggressors can contribute towards the complex process of skin ageing. At SkinCeuticals we believe in finding ways to prevent future damage to the skin. We were the first cosmeceutical range to test our antioxidant formulas for skin protection against infrared radiation after proving their efficacy against UVA/UVB. We were also the first brand to quantify the effects of ozone pollution on skin and to prove that our antioxidants help to reduce the damage it does to human skin. Today, with more than 90% of the world’s urban population estimated to be living with pollutant levels in excess of WHO standard limits, being able to provide antioxidant serums that help to counteract the negative impact of ozone pollution on skin is of huge significance. This year we have embarked on an extensive, multiyear research initiative to investigate the capacity of our antioxidants to provide protection against visible light by preventing free radical assault and replenishing antioxidants in skin. For the first phase of this study, we have collaborated with a globally recognised scientific institution to determine a quantifiable measure for visible light effects on skin. Phase II will quantify the added protection SkinCeuticals Antioxidants provide to the skin. These results are due in 2019. 38

How does C E Ferulic help promote recovery when used post-laser procedures? We understand that during a laser resurfacing treatment, the epidermal barrier of the skin is disrupted and the skin’s natural level of Vitamin C is depleted rapidly. C E Ferulic, with its high concentration of pure Vitamin C, has been specifically formulated to increase the levels of Vitamin C in the skin effectively and reduce the level of inflammation. We have also conducted multiple studies on C E Ferulic to prove that when it is used as an immediate post-treatment intervention, following a fractional ablative laser treatment, patients experience reduced swelling, redness and overall downtime, enabling them to get back to daily life more quickly.1 With laser treatments ever on the rise, I believe that this use of C E Ferulic will certainly continue to be popular. REFERENCES 1. Lasers Surg Med. 2015. Published online. DOI 10.1002/lsm.22448

Contact For more information about SkinCeuticals advanced skincare: Email: contact@skinceuticals.co.uk Twitter: @SkinCeuticalsUK Instagram: skinceuticals_uki

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Treating Rhinophyma Dr Daron Seukeran discusses this rare skin condition and describes his treatment approach using CO2 laser The name rhinophyma comes from rhino (nose) and phyma (growth). It is a disfiguring, rare disease that is characterised by a progressive hypertrophy of the soft tissues of the nose that displays with increased volume, mainly in the lower half.1 The diagnosis of rhinophyma is easy to ascertain based on the clinical features of the disease. In advanced cases, medical management is believed to be inferior to the results seen with surgical treatment.1 Rhinophyma is often associated with the end stage in the development of rosacea, accompanied by hypertrophy of the sebaceous glands, which causes an enlargement of the nose. However, its exact cause is unknown. Rhinophyma is an uncommon condition that often results in both functional and cosmetic impairment. A study from Estonia stated that the 1% of all patients with rosacea may get a rhinophyma,2 while other studies have suggested that around 10-15% of the population present with rosacea.3,4 Interestingly, rhinophyma is more commonly found in men than women, but unfortunately we don’t know the reasoning behind this. A large variety of surgical and non-surgical treatments have been published in the literature to treat it.5 Although rhinophyma is not a common dermatological concern that patients will present with in an aesthetic clinic, it is

important for aesthetic practitioners, who are assessing patients’ skin regularly, to understand the disease and know how to identify it in order to recommend or to refer for treatment. It is also important to know that patients may present with accompanying rosacea, where there is redness and flushing of the face.

Aetiology As mentioned, the exact cause of rhinophyma is unknown; it is believed to be multifactorial in origin with a principal aetiology of unregulated superficial vasodilation. The extravasation leads to chronic oedema of the dermal interstitium with a sequela of local inflammation, fibrosis, and dermal and sebaceous gland hyperplasia.6 Over time, this leads to the characteristic bright red to purplish telangiectasias and irregular, lobulated thickening of the skin of the nose.6

Psychological impact Historically, rhinophyma was mistakenly considered to be linked with alcohol consumption. This is because substances such as alcohol and caffeine can cause local vasodilation.6 This alleged association with alcohol has caused much social stigma and loss of self-esteem in patients suffering from the disease. There are several nicknames for the condition, with the most common being ‘whiskey nose’ and ‘rum nose’.5 Dermatology conditions like this can also

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have a psychological impact on other people’s perceptions of an individual. It is interesting to note that according to a 2017 study by Croley et al., which looked at the dermatologic features of classic movie villains, six (60%) of the all-time top 10 American film villains have dermatologic findings. These include cosmetically significant alopecia (30%), periorbital hyperpigmentation (30%), deep rhytides on the face (20%), multiple facial scars (20%), verruca vulgaris on the face (20%), and rhinophyma (10%). The authors also found that the top 10 villains have a higher incidence of significant dermatologic findings than the top 10 heroes (60% vs 0%; P = .03).7

Diagnosis The diagnosis of rhinophyma is usually clinical and is identified by an increasing bulbous deformity of the nose. The surface of the nose can be pitted and often has telangiectasias. The thicker and more sebaceous nasal tip and alae are preferentially enlarged in most patients, but involvement can spread to the thinner nasal dorsum and sidewalls to a lesser degree. As the nose enlarges, the aesthetic subunits of the nose merge and become less defined. While the underlying frameworks of the skin are usually unaffected, it is possible for patients to also suffer from secondary nasal airway obstruction at the external nasal valves.2 Rhinophyma can occasionally be complicated by unnoticed cutaneous malignancies such as basal cell carcinomas, squamous cell carcinomas, or lymphomas, so a practitioner should be aware of this before considering treatment.2

Treatment There are multiple treatment modalities available to practitioners in the treatment of rhinophyma. However, there are no randomised, prospective, control studies for any treatment, which makes it difficult to recommend a single treatment over another. Nonetheless, practitioners should recognise that there is an increased risk of scarring and hypopigmentation which can occur on or near the nasal ala. As well as this, a patient’s risks may increase if their tissue destruction extends to the papillary dermis or if their pilosebaceous units are ablated.8 The initial consultation should include counselling about the treatment, ensuring that the patient has realistic outcome expectations and is aware of potential complications. I recommend that the patient is given an

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Aesthetics Journal


are concerns about post-inflammatory hypopigmentation. However, ensuring one stays within the appropriate limits of ablating, there is a low risk of these complications.13


Figure 1: A 56-year-old male patient presenting with rhinophyma before and 16 weeks after treatment using a CO2 laser from one treatment session.

adequate opportunity to seek information and ask questions, and this can be reinforced with written information. Detailed consent forms need to be completed by the patient and they should include information on the technique used, possible post-operative course expected and post-operative complications. Pre-operative photography should be carried out in all cases.9 Treatment of rhinophyma must have a surgical approach. These are divided into: 1. Full-thickness excision followed by splitthickness skin graft (includes the epidermis and part of the dermis). 2. Full-thickness excision followed by fullthickness skin graft (includes the epidermis and the entire thickness of the dermis). 3. Decortication or partial excision. Decortication techniques include dermaplaning, dermabrasion, cryosurgery, electrosurgery, laser surgery and sharp blade excision.1 Laser surgery Although there are several options available for treatment, my preferred option is the carbon dioxide (CO2) laser. This is because it has a low risk of complications and I have found that it has higher patient satisfaction compared to other approaches.5,10 The CO2 laser has become the common laser of choice in the treatment of rhinophyma because sharp margins and good haemostasis can be achieved with improved wound healing, compared with scalpel excision.5 In 2016, 24 rhinophyma patients were treated with a 10,600 nm CO2 pulsed laser. They had a six-month, post-treatment follow-up. In the follow-up, researchers identified that CO2 laser warrants a careful nasal surface ablation, allowing the remodelling of the hypertrophic areas, with

an excellent cosmetic result, a very short healing time, and virtually no side effects.11 Positive results were also described by Corrandino et al. in 2013. They used a CO2 laser in 14 elderly male patients, using a personal approach, known as the ‘downward steps’ technique. With this technique, the authors removed the pathological hypertrophic tissue using a progressive reduction of the laser power during the treatment. In a single laser session, patients showed good results from both a morphological and aesthetic point of view, according to authors.12 In other research, Madan et al. reported on 124 cases between 1996-2008 where exuberant sebaceous tissue was ablated using the Sharplan 40C CO2 laser under local anaesthesia. They used varied techniques according to the severity of rhinophyma; the laser was used in a continuous mode to debulk the larger rhinophymas, and in a resurfacing mode or continuous mode to reshape the nasal contours. After three months, results were classified as good to excellent in 118 patients and poor in six patients.13 In my clinical experience, I have found that a single treatment with a CO2 laser is usually enough to produce the desired result, but occasionally with large rhinophymas a subsequent treatment may be required. The impact is quite significant due to immediate reduction in the bulbous deformity, and there is marked improvement in the psychological distress caused by this condition.

Rhinophyma is an uncommon condition without any known causes. Treatment using CO2 laser combines the advantages of haemostasis and the gradual precise reduction of the nasal tissues layer by layer. It produces excellent results with a low risk of complications when used appropriately. Patients should be properly consulted and informed that the procedure is costintensive and time-consuming. Dr Daron Seukeran is a consultant dermatologist at the James Cook University Hospital in Middlesbrough and is the group medical director of sk:n clinics in the UK. He undertakes general dermatology and dermatological surgery, however his main interest is laser surgery. REFERENCES 1. Hakima EM, Zahra MF. Rhinophyma. Pan Afr Med J. 2017 Mar 3;26:122. 2. Christopher Griffiths, et al., Rook’s Textbook of Dermatology, 4 Volume Set, 9th Edition, 2016. P.11,91 3. McAleer MA, Fitzpatrick P, Powell FC. The prevalence and pathogenesis of rosacea. Poster presentation, British Association of Dermatologists annual meeting, Liverpool, July 1-4, 2008. 4. Berg M, Liden S. An epidemiological study of rosacea. Acta Dermato-Venereologica. 1989;69:419-423. 5. Wolter, Scholz T, Liebau J. Giant Rhinophyma: A Rare Case of Total Nasal Obstruction and Restitutio Ad Integrum. Aesthetic Plast Surg. 2017 Aug;41(4):905-909. Epub 2017 Mar 24. 6. Laun J, Gopman J, Elston JB, Harrington MA. Rhinophyma. Eplasty. 2015 May 1;15 7. Croley JA, Reese V, Wagner RF Jr. Dermatologic Features of Classic Movie Villains: The Face of Evil.JAMA Dermatol. 2017 Jun 1;153(6):559-564.  8. Fink C, Lackey J, Grande DJ. Rhinophyma: A Treatment Review. Dermatol Surg. 2018 Feb;44(2):275-282.  9. Krupashankar DS1; IADVL Dermatosurgery Task Force. Standard guidelines of care: CO2 laser for removal of benign skin lesions and resurfacing.Indian J Dermatol Venereol Leprol. 2008 Jan;74 Suppl:S61-7.  10. Rapid treatment of rhinophyma with powered microdebrider. Case Rep Otolaryngol. 2013;2013:621639. doi: Faris C, Manjaly JG, Ismail-Koch H, Caldera S. 10.1155/2013/621639. Epub 2013 Feb 21. 11. Bassi A, Campolmi P, Dindelli M, Bruscino N, Conti R, Cannarozzo G, Pimpinelli N. Laser surgery in rhinophyma. G Ital Dermatol Venereol. 2016 Feb;151(1):9-16. Epub 2014 Sep 18. 12. Corradino B, Di Lorenzo S, Moschella F. ‘Downward steps technique’ with CO2 ultrapulsed laser for the treatment of rhinophyma: our protocol. Acta Chir Plast. 2013;55(1):16-8. 13. Madan V1, Ferguson JE, August PJ. Carbon dioxide lasers treatment of rhinophyma: a review of 124 patients.

Laser complications The key complications of CO2 laser surgery are that there is a risk of both hypertrophic and atrophic scarring. Postoperative infection is also a risk, and there

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018

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Aesthetics Journal

Injecting the Infraorbital Area Dr Tom van Eijk provides his protocol for the treatment of infraorbital hollowness by injecting hyaluronic acid Looking tired is one of the complaints that I find drives patients towards clinics in search of aesthetic correction.1 In the last decade, non-surgical solutions to reduce the â&#x20AC;&#x2DC;tired lookâ&#x20AC;&#x2122; have increased in popularity due to the limited intensity2 and cost of the treatment in comparison to surgical interventions. Since the skin in the infraorbital area is very thin, anything that distorts this structure is visible. One night of not sleeping or even five minutes of crying can have a striking effect under the eyes. Some people show their age and tiredness more than others, leading to concerned remarks by peers regarding their wellbeing, thus influencing them to seek aesthetic treatment. One of the most popular non-surgical treatments is the injection of hyaluronic acid (HA) in the lower eyelid region to reduce the depth of the tear trough, in order to freshen up the patientâ&#x20AC;&#x2122;s appearance. Unfortunately, I have found that most of the less than optimal results are seen in this particular area. This has been noted through observing the vast number of unhappy patients seeking advice on websites1 or requiring a second opinion consultation. Treating this delicate area can be very tricky as the thin skin can be unforgiving and incapable of hiding overcorrection or misplacement of HA filler. As such, I have developed a protocol named the Palma Technique for treating infraorbital hollowness using HA filler, which aims to address both the skin and the tissue underneath.

A complex and high-risk area The lower eyelid area, known as the infraorbital region, is one of the more complex areas of the face as far as anatomy goes. Delicate structures that are highly susceptible to visible signs of


ageing, due to their mechanical vulnerability, are layered here; fat pads, septa, muscles, vessels and various other skin qualities all contribute towards looking healthy and well rested. When we are younger and these factors are all in good condition, the infraorbital region looks like one continuous plane. However, as we age this is no longer the case and the area can begin to look uneven in volume and skin tone. Surplus skin, intraorbital fat and changes in the quality of tissue can all reveal an individual's age and the condition of their physical and emotional wellbeing. This area should only be treated by advanced practitioners with thorough knowledge of the infraorbital anatomy and several years of practice in injectables, as arteries run here that are connected with those responsible for blood flow to the optic nerve. Cases of blindness after injecting hyaluronic acid causing occlusion of the ophthalmic artery have been reported, although the incidence of these complications is higher when the injections are placed in the nasal bridge or glabella region.2,3 Due to the loose connective tissue of the lower eyelid, bruising can be a real problem for the patient, as makeup can sometimes not fully conceal these haematomas. It is therefore important to explain and prepare patients for this during the consultation.

Using a cannula The risks of bruising and intravascular injection associated with using needles explain the popularity of the use of cannulas for this particular injection. The blunt tip of a cannula means that you are less susceptible to piercing a vessel and provides a safer way to inject the filler substance subdermally. Although the initial opening in the skin needs to be created with a sharp tool, and in most cases a slightly bigger needle, the cannula can travel underneath the skin without causing as much damage as a needle would.

Using a needle One of the main features of HA is the fact that it can fill and provide volume. Another aspect of the same material is that, when placed superficially in the dermis, it will strengthen the skin and will stimulate the fibroblasts to produce more collagen.4 Due to the bluntness of the cannula, injecting into the dermis, and therefore strengthening or thickening this layer, is impossible. In my opinion, strengthening of the infraorbital dermis is essential when injecting volume into this area and can at least compensate for the changes that come with ageing. For example, the thinning skin of the lower eyelid that reveals the underlying anatomical structures. Using a needle enables the injector to separately correct the missing volume and the lack of dermal strength,5 which in most patients are combined in an infraorbital filler indication. This becomes particularly apparent when the majority of suboptimal results are being observed, a suborbital hollowness is overcorrected and replaced by a protuberance. When a protuberance is placed superficially it can appear to be blue, which is known as the Tyndall effect.1 In some cases, the subdermal placement of filler interferes with the natural flow of lymph fluid, leading to an excess of swelling of the lower eyelid.2

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


The Palma Technique When assessing the patient, the strength and thickness of the skin reveals itself when the skin is squeezed between the index finger and Figure 1: Assessment of infraorbital area thumb. The lack of volume cannot be accurately assessed by observation alone. Palpating the region will assess the hollowness and yield a more precise indication of where and how much volume correction will be needed. Figure 1 is an example of a formal assessment that I have made on a patient. I have indicated that there is lack of skin strength, shown in purple, both the plane (secondary dermal weakness, due to ageing) and the superimposed linear (tertiary dermal weakness, due to wear and tear), combined with a lack of volume in the green sections. The level of the dermal attachment of the zygomatic cutaneous ligament is indicated in yellow. I advise to start treatment with the correction of dermal strength by injecting minute quantities of filler into the mid-dermis, starting lateral

Palpating the region will assess the hollowness and yield a more precise indication of where and how much volume correction will be needed from the lower eyelid, with the end point being the thicker skin of the cheek, at the level of the zygomatic cutaneous ligament. On average the skin lateral to the cheek is thinner and thins even more with ageing, therefore thickening this skin first will counteract that. Separate from the correction of dermal strength, but in the same session using the same syringe, volume correction of reduced lower eyelid fat can be achieved by filling the previously palpation-assessed hollowness. This can be done with the same needle, after aspiration and appreciation of the tissue in which the needle tip is placed, by gently moving the tip from side to side, to minimise the chance of injecting in a vessel. It only takes a minor movement to feel the consistency of the tissue. One can also use a cannula for deeper volumisation. Surplus skin is quite common in this area, as well as the bulging of the intraorbital fat pads which lie in the orbit to cushion the eye. Both of these indications cannot and should not be corrected with filler, as no filler has the capacity to reduce the surface of dermal or fat tissue. This means that we cannot treat some of the factors contributing to the ‘hollow’ or ‘tired’ look by using dermal HA fillers. We also should not try to overcompensate for these factors by adding more volume than would correct the actual volume deficit.

Aesthetics Journal

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Treatment regime The effect of strengthening by intradermal injecting is limited, especially the first time, particularly in thin skin like this. If one treatment of intradermal injections does not raise the strength of the dermis enough to lead to an optimal result, waiting for collagen stimulation is advised.4 Injecting more filler the first time will not further increase the dermal strength, therefore patience is key with this procedure. Once the collagen level has increased, which will take a few months, a second dose can be administered in order to further strengthen the skin. In some cases where the lateral skin is very weak in comparison to the cheek, a third treatment is advised. I find that this is common in patients who are over 40 years old. Once the optimal result is obtained, typically after two or three sessions, I advise my patients to have the area examined every one to two years. This is so both further ageing and the decay of the results of the treatment can be assessed and addressed in a new treatment. Dosage As the thin dermis reveals any evidence of overcorrection, the appropriate dosage of the filler injected superficially is key during this treatment. Therefore, I believe that less is more. While injecting, I advise practitioners to monitor how the skin behaves differently, particularly concentrating on its tendency to fold, when it is being squeezed, rather than the depth of the hollowness. I would recommend focusing on strengthening the skin by continuously monitoring and squeezing the skin after each injection. Don't be surprised that it might take only 0.1ml of product to strengthen each lower eyelid. I would recommend choosing a 1ml syringe and use 0.2ml for the dermal strengthening, leaving 0.8ml for both infraorbital areas to correct the subdermal volume. Before


The volumisation of the subdermal areas that require correcting will After immediately be visible as the shape of the area will have a less sunken appearance. Bruising and swelling can Figure 2: Patient before treatment and six months later, occur as a result of after their third treatment. the treatment so the correction of volume is best assessed after approximately two weeks. In my experience, this is also when the improved strength of the dermis will contribute toward the overall aesthetic outcome of the treatment. Upon following the Palma Technique, the added volume will be covered by thicker skin and thus the evenness of the suborbital plane will be better corrected than it would have been if treated by merely adding subdermal volume. As the stimulation of the skin’s own collagen is a process that will take several months, patients will notice a gradual improvement in the aesthetic result over time (Figure 2). I have found that the diminishing transparency of thin suborbital skin due to new collagen also contributes to the aesthetic improvement of the infraorbital area. Further correction of volume can be planned as soon as two weeks after the first intervention. To benefit from the collagen stimulation, a second treatment of dermal strengthening is advised for at least two months after the initial session.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



Aesthetics Journal

Risks Since the dense dermis does not allow the dermal filler to spread as it would in subdermal loose connective tissue,8 a high number of superficial injections are needed to manually distribute the material in the skin. This will heighten the chances of bruising, especially during the first session, when the skin is at its weakest. Hitting anything vital such as an artery is unlikely with injections as shallow as these. However, it is essential that practitioners performing this treatment have a thorough understanding of depths of injection and anatomy in order to differentiate between adding volume and adding strength.

Conclusion In my opinion lower eyelid hollowness, which results in a ‘tired look’ is, in most cases, defined by the lack of volume and a lack of dermal strength. It is also defined by a surplus of dermal tissue and sometimes the bulging of intraorbital fat pads. It is important to note that a surplus of skin and bulging fat pads cannot be corrected with HA. Volume compensation with subdermal filler can only partly correct this hollow look. Dermal strengthening is essential in further correcting the anatomical changes that come with ageing and I believe that using a needle is the only way to place HA into the dermis to provide dermal strength.

Aesthetics Dr Tom van Eijk worked in plastic surgery for three years, before deciding to solely concentration on non-surgical injectable treatments in 2003. He then began training his peers on how to inject botulinum toxin and hyaluronic acid fillers in 2004. Dr van Eijk has since developed a number of protocols including the Fern Pattern Technique, Lip Tenting Technique and Palma Technique for the lower eyelid region. REFERENCES 1. Cosmetic Treatments & Surgeries. Realself. 2018. <https://www.realself.com/reviews> 2. Funt David, Pavicic Tatjana ‘Dermal fillers in aesthetics: an overview of adverse events and treatment approaches’. Clin Cosmet Investig Dermatol. 2013; 6: 295–316. 3. Schelke LW, Fick M, van Rijn LJ, Decates T, Velthuis PJ, Niessen F. ‘Unilateral blindness following a non-surgical rhinoplasty with filler’. Ned Tijdschr Geneeskd. 2017;16 4. Quan Taihao, Wang Frank (2012) ‘Enhancing Structural Support of the Dermal Microenvironment Activates Fibroblasts, Endothelial Cells, and Keratinocytes in Aged Human Skin In Vivo’. Journal of Investigative Dermatology, advance online publication, 25 October 2012; doi:10.1038/jid.2012.364 5. Van Eijk Tom, Braun Martin (2007). ‘A Novel Method to Inject Hyaluronic Acid: The Fern Pattern Technique’. Journal of Drugs in Dermatology. 6 (8): 805-8. 6. Glogau RG, Kane MA ‘Effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid gel dermal fillers’. Dermatol Surg. 2008;34(Suppl 1):S105– S109. 7. Viana GA, Osaki MH ‘Treatment of the tear trough deformity with hyaluronic acid’. Aesthet Surg J. 2011 Feb;31(2):225-31 8. Sunderam H, Cassuto D. ‘Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications.’ Plast Reconstr Surg. 2013 Oct;132

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Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



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Managing Oily Skin Using Toxin Dr Chandni Rajani explores the use of botulinum toxin for the treatment of oily skin The desire for flawless skin is apparent to all working in the aesthetics and skincare profession and, in my experience working in an aesthetic practice, oily skin and subsequently large pores is one of the most common dermatological complaints made. A novel therapeutic option for targeting oily skin involves intradermal injection of botulinum toxin; studies have demonstrated this to be effective and safe, with minimal systemic or local side effects.1,2,5,7 This article aims to explore the evidence base for the efficacy in using botulinum toxin for treating oily skin and its mechanism of action, alongside its safety profile.

Causes of oily skin Sebum provides a physiological function, which is to lubricate the stratum corneum. It is composed of various fatty acids, wax esters, triglycerides, cholesterol and squalene. This aids in acting as a water-proof barrier in protecting the skin against friction, enabling the transport of antioxidants into the skin, aiding wound healing and possessing anti-microbial activity.4 However, when produced in excess, sebum can predispose to acne vulgaris (acne).2 Although a common complaint amongst those with acne, oily skin and Pores large pores can also affect those without this condition, expanding the breadth of people affected. Epidermis The primary complaint tends Sebaceous gland to be of skin which appears ‘greasy’, worsening throughout Derma Sweat gland the day. Sebum production varies between individuals. Several Hair follicle Hypodermis factors put one at risk of excess sebum production from the Adipocytes Muscle sebaceous glands. For example, hormonal pathology such as Figure 1: The components that make up human skin. The androgen-secreting tumours, sebaceous glands are situated in the mid-dermis and produce congenital adrenal hyperplasia, sebum via intentional self-destruction of the sebocyte, which forms the main cellular unit. peri-ovulation, gender (men

may have excess sebum production due to increased testosterone levels), as well as warm and humid climates can all affect sebum production.1 Sebaceous glands are holocrine glands in the mid-dermis; they produce sebum via intentional self-destruction of the sebocyte which forms the main cellular unit.3 They are usually associated with a hair follicle and an outlet, together forming the pilosebaceous complex.3 They are found across the whole body in varying densities. Unsurprisingly, acne-prone areas such as the face, upper chest, back and scalp elicit the highest density and, in contrast, there is a relative absence across the soles of the feet and palmar areas.4 The distribution of sebaceous glands, and consequently increased sebum production, can lead to oily skin, particularly in the ‘T-zone’ of the face, where the density of sebaceous glands is as high as 300-900/ cm2.5 Sebum activity is partly hormonally driven, under androgenic influence.3 In the neonatal period, sebaceous gland activity is high, and then gradually reduces until increasing drastically around puberty.1,4 Although the total number of sebaceous glands remains fixed throughout life,3 they increase in size at adolescence, producing more sebum.6 Sebum production declines in the peri-menopause, or in the sixties or seventies for males.1

Treatment using botulinum toxin The majority of treatments for oily skin and large pores are either topical or systemic therapies. Topical therapeutic agents include retinoids (both natural and synthetic derivatives), with systemic treatments involving medications such as the oral contraceptive pill, spironolactone, isotretinoin, as well as laser and photodynamic therapy.1 Isotretinoin is thought to be the most effective therapy for treating oily skin. It is also known as 13-cis retinoic acid and acts to reduce the secretion of sebum from the pilosebaceous unit as well as leading to a reduction in size of the sebaceous glands.1 However, due to its side effect profile, many patients find its use difficult to tolerate.2 For example, patients tend to complain of troubling xerostomia, alongside dry eyes and xerotic skin which, in severe cases, can lead to superimposed skin infections.1 Research has shown intradermal botulinum toxin to be an encouraging treatment option.7 Botulinum toxin, a potent neurotoxin, is derived from the bacterium Clostridium

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Using a sebumeter A sebumeter is a device used to provide an objective assessment and quantify sebum production from different regions of the face and body. It works by employing a photometry method, allowing detection of sebum collected onto an opaque strip and thereafter determines its translucency. The amount of lipid present is thought to correlate to the light transmission through the opaque strip. The strip is placed on an area of skin for 30 seconds at a constant pressure before being lifted again. The level of translucency is thereafter translated into a numerical value, such that different regions can be objectively compared with regards to sebum levels.2,5 sebumeters are mainly used in dermatological research and for testing efficacy of cosmetic products; however, some aesthetic clinics do use them for a more objective assessment of sebum production in the face and scalp. A sebumeter could therefore be a useful tool when objective assessment of oily skin is required. There may be a role for increasing use in aesthetic clinics following suitable training, enabling patient satisfaction to be gauged alongside a more objective skin assessment.

botulinum. There are seven subtypes identified (A-G) with botulinum toxin A and B being more widely used in the commercial setting.8 Botulinum toxin blocks transmission of the neurotransmitter acetylcholine into the synaptic cleft, preventing it from binding to the post-synaptic membrane and enabling subsequent muscle relaxation; this aids in reducing the appearance of fine lines and wrinkles. Specifically, it cleaves to proteins, which assist in fusion of the acetylcholinecontaining vesicles to the presynaptic membrane, disabling the neurotransmitter release.1 Although the exact mechanism by which intradermal botulinum toxin can reduce sebum release has not been made entirely clear, it is likely that the acetylcholine receptors within sebocytes are primary targets.8 Sebocytes within sebaceous glands also express acetylcholine receptors, and these play an integral role in sebum production and sebocyte maturation.1 The greatest density of acetylcholine receptors lie at the infundibulum of the pilosebaceous unit.2 Research In this section, I will explore all the studies published to date, to my knowledge, which have aimed to elucidate a role for the use of botulinum toxin in the treatment of oily skin. Note that the studies discussed are taken from what is freely available, and so may include information obtained from abstracts only. In an early retrospective study conducted by Shah in 2008 involving 20 patients, botulinum toxin type A was injected intradermally into sebum-prone areas of the skin on the face (the â&#x20AC;&#x2DC;T-zoneâ&#x20AC;&#x2122;). At one month, 17 of the 20 patients noticed a significant reduction in facial pore size and sebum production, with photographic evaluation supporting this and no reported complications. Of note, this study was retrospective and lacked an objective measure of sebum control.2,7 More recent evidence has further supported this treatment approach. In 2013 Li et al, conducted an in vitro study which demonstrated that sebocytes express a nicotinic acetylcholine receptor Îą7, with a dose-dependent increase of acetylcholine on

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lipid synthesis. They further recruited 20 volunteers into a splitface study (double-blind, placebo-controlled), finding a marked reduction in sebum production on the botulinum toxin treated side of the face.9 It is possible that botulinum toxin reduces sebaceous gland activity via blockade of acetylcholine receptors concentrated in the pilosebaceous unit.1,2 Rose and Goldberg further investigated this in 2013 by conducting a prospective study to elucidate the efficacy of intradermal botulinum toxin injections in treating excess sebum production from the forehead. They recruited 20 female and 10 male participants (two were lost to follow up). They utilised abobotulinumtoxinA (Dysport) and injected three to five units intradermally at ten points positioned horizontally across the upper third of the forehead, using a 30 gauge needle. This cohort was subsequently followed up at one, four, eight and 12 weeks. Photographs were taken and sebumeter readings were recorded, providing a more objective assessment. The results showed a significant reduction in sebum production in all participants across all follow-up visits (p<0.001). Sebumeter readings demonstrated a 75% reduction in sebum produced at week one, 80% reduction at week four, 73% at week eight and 59% at week 12. Assessment of the photographs demonstrated an improvement in pore size and all patients reported satisfaction with results achieved.2 Min et al more recently supported this evidence in 2015 with a prospective randomised, double-blinded study to investigate sebum control using intramuscular injections of botulinum toxin A into the frontalis muscle. There were 42 female participants recruited. They were allocated to two groups; one group received two unit intramuscular injections at each point (total of 10 units) and the other group received four unit intramuscular injections into these areas (total of 20 units). Botulinum toxin A (Botox) was injected intramuscularly across five horizontal set points on the foreheads of all the subjects. Both groups were analysed at two, four, eight and 16 weeks, with photographs being taken at these points and sebumeter readings recorded. Results demonstrated a significant reduction in sebum production within 0.5cm of each of the five sites injected with intramuscular botulinum toxin. The increase in dose did not appear to make a difference with regards to sebum regulation, thus this effect was not found to be dose-dependent. They did find there was an increase in sebum levels at a more peripheral radius of 2.5cm at two, four and eight weeks in these participants. The authors noted that the toxin may diffuse into the dermal layer following an intramuscular injection into the frontalis, inhibiting acetylcholine signalling within the pilosebaceous unit. Direct intradermal injections may therefore be more effective in treating oily skin than intramuscular injections.5

Results demonstrated a significant reduction in sebum production within 0.5cm of each of the five sites injected

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Technique When treating patients using botulinum toxin, the aim is to target the pilosebaceous unit, which sits intradermally. If the product is placed too superficially, it is unlikely to yield a significant effect in reduced sebum levels. It has been suggested by some studies that injecting at an angle of 75 degrees may aid in ensuring intradermal placement, thus avoiding inadvertent muscle paralysis.10 This is particularly pertinent in treating the perioral region and the cheek region, where paralysis of skeletal muscle is undesirable and can lead to loss of function. Some studies have also mentioned correct placement of botulinum toxin can be confirmed by extrusion of the product is from surrounding pores. This was used as an end point in Rose and Goldberg’s study.2



Complications The studies mentioned in this article do not report any major complications. However, in Rose and Goldberg’s study, two subjects reported reduced frontalis muscle tone at two months.2 Therefore, although a low-risk treatment, optimum injection technique is crucial in both effectiveness and in minimising inadvertent intramuscular placement.10

Summary Excess sebum production and the appearance of ‘greasy’ skin is a common complaint with consequences such as acne vulgaris, as well as having a psychological impact on patients. Intradermal injection of botulinum toxin to target sebaceous glands is a treatment option which deserves consideration in selected patients, with research thus far being encouraging. This method could prevent patients from undergoing systemic therapy where the side effects are greater, putting forward a lower risk alternative. The studies mentioned highlight patient satisfaction, but also statistically significant results from more objective assessments. Further research that explores its effectiveness, dose and placement would help to consolidate the current evidence-base.1,2 Dr Chandni Rajani specialises in general practice and aesthetic medicine. She graduated from King’s College London with a distinction in medicine and a prize-winning First Class Honours Degree in Physiology (maternal and foetal health). Her experience in general practice alongside aesthetic medicine has generated an interest in researching novel therapeutics for dermatological pathology. REFERENCES 1. Endly DC, Miller RA, ‘Oily skin: A review of Treatment Options’, Journal of Clinical Aesthetic Dermatology, 10 (2017), 49-55 2. Rose AE, Goldberg DJ, ‘Safety and efficacy of intradermal injection of botulinum toxin for the treatment of oily skin’, Dermatologic Surgery, 39 (2013), 443-448 3. Hoover E, Krishnamurthy K, ‘Physiology, Sebaceous glands’, Treaure Island (FL), StatPearls Publishing (Internet), 2018 4. Smith KR, Thiboutot DM, ‘Thematic review series: Skin Lipids, Sebaceous gland lipids: friend or foe?’, Journal of Lipid Research, 49 (2008), 271-281 5. Min P, Xi W, Grassetti L, Trisliana Perdanasari A, Torresetti M, Feng S, Su W, Pu Z, Zhang Y, Han S, Zhang YX, Di Benedetto G, Lazzeri D, ‘Sebum Production Alteration after Botulinum Toxin Type A Injections for the Treatment of Forehead Rhytides: A Prospective Randomized Double-Blind Dose-Comparative Clinical Investigation’, Aesthetic Surgery Journal, 35 (2015), 600-610 6. Niemann C, Horsley V, ‘Development and homeostasis of the sebaceous gland’, Seminars in Cell and Developmental Biology, 23 (2012), 928-936 7. Shah AR, ‘Use of intradermal botulinum toxin to reduce sebum production and facial pore size’, Journal of Drugs in Dermatology, 7 (2008), 847-850 8. Kim YS, Hong ES, Kim HS, ‘Botulinum toxin the field of Dermatology: novel indications’ Toxins, 9 (2017), 403 9. Li ZJ, Park SB, Sohn KC, Lee Y, Seo YJ, Kim CD, Kim YS, Lee JH, Im M, ‘Regulation of lipid production by acetylcholine signalling in human sebaceous glands’, Journal of Dermatological Science, 72 (2013), 116-122 10. Campanati A, Martina E, Giuliodori K, Consales V, Bobyr I, Offidani A, ‘Botulinum Toxin Off-Label Use in Dermatology: A Review’, Skin Appendage Disorders, 3 (2017), 39-56

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a normal pathway of protein synthesis and needs vitamin C and essential minerals such as zinc, manganese and copper as cofactors necessary for the functions of enzymes and transcription factors.8 Humans lose on an average 1.5-2% of collagen from the age of 20.9 The total dermal thickness decreases at about the same rate in men and women.10 This is accelerated during menopause when the synthesis of collagen drops to 30%.11 Many antiageing treatments focus on stimulation of collagen synthesis and improvement of quality and function of treated tissues. Oral supplementation with nutraceuticals containing hydrolysed collagen peptides, hyaluronic acid and vitamins with antioxidant properties has become popular, with many new products being launched every year. The efficacy of oral supplementation has been questioned amid concerns about their absorption in the gut and distribution of the constituents of such supplements.

Collagen peptides

Nutraceutical Supplementation Dr Beata Cybulska explores the use of nutraceuticals for increasing collagen and hyaluronic acid production Ageing is a complex process caused by genetic, hormonal and environmental factors, affecting all the cells and organs of the human body.1-4 Most of the signs of ageing in connective tissues are associated with dysregulation of the collagen matrix, rise in inflammatory markers and reduced blood flow. It is produced by fibroblasts alongside elastin and keratin fibres, which provide integrity and firmness to the tissues. Degradation of the collagen matrix with age impacts on the activity of fibroblasts, resulting in fewer collagen fibres being produced, diminished hydration and supply of oxygen and nutrients, resulting in impaired immune responses. Ultraviolet irradiation induced matrix metalloproteinases in the epidermis and dermis result in degradation of collagen and are regarded as primary mediators of connective tissue ageing.5 Skin, being the largest and most visible connective tissue organ, shows signs of ageing before they become noticeable elsewhere in the body. This article will explain how nutraceutical supplementation can directly stimulate fibroblast production and collagen synthesis, as well as increase natural levels of hyaluronic acid within the dermis and other connective tissue organs in the body. It will examine bioavailability of specific nutrients necessary for collagen production and their effectiveness in promoting collagen type I, II and III in the skin and cartilage supported by preclinical and clinical studies.

Collagen structure Collagen consists of three amino acids: hydroxyproline, glycine and proline, which are wound together into triple helix structure composed of alpha chains.6,7 Collagen is synthetised following

Collagen peptides are natural, bioactive ingredients consisting of a mixture of hydroxyproline, glycine, proline and arginine, which are produced by enzymatic hydrolysis of collagen. These are either of marine, bovine or porcine origin.12 Several preclinical and clinical studies have shown that hydrolysed collagen peptides were absorbed through the gut into the bloodstream and then delivered to joints and skin where they improved tissues’ quality.13-26 Oral supplementation with collagen peptides in women increased the collagen density in the dermis by 9%.27 The choice between marine versus bovine or porcine hydrolysed collagen peptides is usually made for dietary, religious or cultural reasons.28-30 Marine origin hydrolysed collagen peptides are a popular byproduct of the fishing industry and are rich in collagen type I which is the most common type of collagen found in skin, tendons, blood vessels, organs and bone.6 Fish is generally regarded as healthy and ‘clean’ by the public, yet it is one of the top 10 most common allergens.31 It often comes from free water and may not be health certified. One of the pioneers in the production of marine hydrolysed collagen peptides is from a company called Nippi in North America.32 Nippi extracts collagen peptides from fish scales and skin through a complex and controlled natural hydrolysis process producing eco-friendly fish collagen peptides from farmed and wild-caught fish. Another example of collagen peptides is Peptan which comes in three forms; bovine collagen peptides, porcine collagen peptides and fish collagen peptides.33 Bovine hydrolysed collagen peptides (gelatin) are less popular. The reason for this may be issues around the possibility of transmission of infection to humans and negative publicity surrounding ‘mad cow disease’. What makes bovine collagen different is the presence of collagen type I, II and III. The fact that cartilage is made of collagen type II suggests that bovine origin hydrolysed collagen peptides may be particularly useful as an oral supplement to activate collagen synthesis in cartilage and have protective effects on joints.34,35 They are also beneficial to the skin as suggested by a significant increase in collagen type I and IV and fibroblasts, as well as a reduction of metalloproteinases 2 (MMP2), which are responsible for collagen degradation and skin ageing.36 Other studies demonstrated a significant increase in skin hydration and collagen density with reduction in collagen fragmentation and statistically significant higher content of procollagen type I (65%) and elastin (18%) in the dermis of volunteers who ingested bovine collagen peptides compared to the placebo after eight weeks of oral intake.37,38 Interim clinical data showcased a 12-week clinical skin absorption

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



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Co-factors A co-factor is a chemical compound which is required for a biological reaction. Co-factors are ‘synergistic ingredients’ that play an important role in healthy collagen synthesis and repair. Although enzymatically hydrolysed collagen peptides and hyaluronic acid are key nutrients for stimulation of collagen synthesis and skin hydration, other nutrients play a role in maximising their effects. • Vitamin C (L ascorbic acid) is an antioxidant involved in fighting against reactive oxygen species and oxidative stress.56 It is also an important co-factor for lysyl hydroxylase and prolyl hydroxylase; two enzymes needed for collagen biosynthesis.8 • Grape seed extract is a natural antioxidant composed of flavonoids and polyphenols such as proanthocyanidins that bond with collagen in the connective tissues, promoting their repair and preventing collagen degradation.57,58 • Green tea extracts rich in catechins (active polyphenols) prevent increase in collagen crosslinking and formation of glycation end products, which plays a role in protection against ultraviolet radiation, resulting in an improvement of skin quality.59 • Alpha lipoic acid is a water and fat-soluble antioxidant capable of regenerating other antioxidants, such as Vitamins C and E. It has anti-inflammatory effect on the skin and the body in general assisting with repair processes.60 Taken orally, alpha lipoic acid helps to prevent cellular damage of fibroblasts via its antioxidant properties, slowing down the ageing process.61 • Copper is essential for healthy collagen and elastin production. The synthesis of mature elastin and collagen are controlled by the availability of copper. Oral supplementation with copper increases lysyl oxidase which is involved in collagen cross-linking.62-64 • Manganese is required for the activation of prolidase, an enzyme involved in the synthesis of amino acid proline.65 It is therefore essential for the synthesis of collagen in human fibroblasts and wound repair. • Zinc is vital to the functioning of more than 300 hormones and enzymes.66 One of the most important of these is copper/zinc superoxide dismutase, an antioxidant enzyme associated with longevity and protection against oxidative stress.67 Oxidative stress is a major contributor to skin ageing, therefore zinc is a vital antiageing component.68

Oral supplementation with collagen peptides in women increased collagen density in the dermis by 9%

study demonstrated by blood serum levels at baseline and two hours post ingestion as well as skin biopsies at baseline and 12 weeks post ingestion that hydrolysed bovine collagen peptides, hyaluronic acid and L ascorbic acid among other co-factors necessary for collagen biosynthesis were effectively absorbed and resulted in increased levels of collagen and hyaluronic acid in the skin and a visible improvement in wrinkles (75%) and skin hydration (100%).39 Bioavailability of oral supplements is characterised by their absorption in the gut and metabolic interactions in the body. The bioavailability of hydrolysed collagen peptides is influenced by the size of their particles. Conventional collagen’s molecular weight MW is 30-90 kDa.6,7 Absorption studies demonstrated that collagen peptides with low MW have been absorbed in the gut and appeared in the blood and tissues.19 An example of bovine hydrolysed collagen peptides is a generic, patented formula called Arthred, which is found in a number of formulations. It is pharma grade pure collagen derived from the hide of German cattle produced by Gelita AG.40 Arthred contains a therapeutic dosage of over 10,000mg and has short-chain peptides of low mean MW of approximately 3 kDa (mean chain length of 25-30 amino acids) available in stable, soluble powder form which can be mixed with water or other beverages.40 It is deemed as ‘predigested’ and is already in the form needed for straight absorption through the small intestine, therefore the stomach does not need to break it down. Due to its source the amino-acid composition of Arthred resembles that of collagen in articular cartilage, which is characterised by a high proportion of hydroxyproline and hydroxylysine. Arthred is confirmed as being generally recognised as safe (GRAS) by the Food and Drug Administration (FDA) and safe for human consumption by the Scientific Committee on Food of the European Union.41,42

Hyaluronic acid Hyaluronic acid (HA) is a glycosaminoglycan, which is present in the extracellular matrix in the connective, epithelial and neuronal tissues. It plays a role in cell proliferation, migration and cell surface receptor interactions.43 HA stimulates fibroblast proliferation within the collagen matrix and indirectly improves collagen production in the connective tissues. It also regulates water balance and maintains cell structure.44,45 The average 70kg person has roughly 15g of HA in the body, one third of which is degraded and synthesised every day.46 About 50% of the body’s supply of HA is found in the skin where it is involved in tissue repair. The quantity of HA in the skin gradually decreases due to ageing.47 Orallyadministered HA has been shown to be absorbed and improve skin hydration and smoothness.48-53 It is not confirmed whether the anti-wrinkle effect of oral HA is different depending on its molecular weight or amount of intake.54,55

Conclusion There are numerous preclinical and clinical studies demonstrating a positive impact of oral supplementation with hydrolysed collagen peptides and HA on quality and function of connective tissue organs, including skin and joints, amongst others. Oral supplementation with collagen peptides should be considered as an adjunct

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018

Nutraceutical Skin Drink Repair • Rejuvenate • Replenish

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to other aesthetic modalities to enhance their efficacy. It is important when choosing a supplement to consider its origin, molecular weight of the particles and therapeutic dosages, as well as a mix of compounds including co-factors necessary for collagen synthesis, to assure its highest bioavailability and efficacy in tissue repair and regeneration. Disclosure: Dr Beata Cybulska is a key opinion leader for Boley Nutraceuticals which develops a nutraceutical collagen supplement. Dr Beata Cybulska is a board-registered dermatovenereologist in Poland and an aesthetic practitioner in the UK. She graduated from the International Foundation of Anti-ageing and Aesthetic Medicine in Warsaw and the Queen Mary University in London, which awarded her Master of Science degree in aesthetic medicine. She has presented at aesthetic conferences including the FACE, AMWEC Visage, ESCAD and IAGSSW and has written articles for numerous publications. REFERENCES 1. Kligman LH. Photoaging. Manifestations, prevention, and treatment. Dermatol Clin 1986;4:517-28. 2. Guercio-Haur C, Macfarlane DF, Deleo VA. Photodamage, photoaging and photoprotection of the skin. Am Fam Physician 1994;50:327-32, 334 3. Naylor EC, Watson RE, Sherratt MJ. Molecular aspects of skin ageing. Maturitas 2011;69:249-56 4. Baumann L. Skin ageing and its treatment. J Pathol 2007;211:241-51 5. Fisher GJ, Wang ZQ, Datta SC, Varani J, Kang S, Voorhees JJ. Pathophysiology of premature skin aging induced by ultraviolet light. N Engl J Med. 1997 Nov 13;337(20):1419-28. 6. Fratzl, P. Collagen: Structure and Mechanics. New York: Springer, 2008. ISBN 0-387-73905-X. 7. Ricard-Blum S. The collagen family. Cold Spring Harb Perspect Biol 2011;3:a004978 8. Pinnel SR, Murad S, Darr D. Induction of collagen synthesis by ascorbic acid. A possible mechanism. Arch Dermatol. 1987 Dec;123(12):1684-6. 9. Shuster S, Black MM, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol 1975; 93: 639–43. 10. Branchet MC, Boisnic S, Frances C, Roberrt AM. Skin Thickness Changes in Normal Aging. Gerentology. 1990;36(1):28-35 11. Castelo-Branco C, Duran M, González-Merlo J. Skin collagen changes related to age and hormone replacement therapy. Maturitas. Oct, 1992;15(2):113-9. 12. Bensaid. A, Tomé D, L’Heureux-Bourdon D, Even P et al. A high-protein diet enhances satiety without conditioned taste aversion in the rat. Physiology and Behavior 2003; 78. 311–320. 13. Fernandez JL, Perez OM. Effects of gelatine hydrolysates in the prevention of athletic injuries. Archivos de Medicina del Deporte. 1998;15:277-82 14. Oesser, S and J Seifert. Stimulation of type II collagen biosynthesis and secretion in bovine chondrocytes cultured with degraded collagen. Cell Tissue Res. 2003;311: 393-9 15. Proksch E, Segger D, Degwert J, Schunck M et al. Oral supplementation of specific collagen peptides has beneficial effects on human skin physiology: a double-blind, placebo-controlled study. Skin Pharmacol Physiol. 2014; 27(1):47-55. 16. Clark KL, W Sebastianelli, KR Flechsenhar, DF Aukermann, FMeza, RL Millard, JR Deitch, PS Sherbondy, and A Albert. 2008. 24-week study on the use of collagen hydrolysate as a dietary supplement in athletes with activity-related joint pain. Curr Med Res Opin. 24:1485-96 17. Shigemura Y, Kubomura D, Sato Y et al. Dose-dependent changes in the levels of free and peptide forms of hydroxyproline in human plasma after collagen hydrolysate ingestion. Food Chem 2014; 159: 328–32; 18. Kawaguchi T, Nanbu PN, Kurokawa M. Distribution of prolylhydroxyproline and its metabolites after oral administration in rats. Biol Pharm Bull 2012; 35: 422-7; 19. Watanabe-Kamiyama M, Shimizu M, Kamiyama S et al. Absorption and effectiveness of orally administered low molecular weight collagen hydrolysate in rats. J Agric Food Chem 2010; 58: 835-41 20. Oba C, Ohara H, Morifuji M et al. Collagen hydrolysate intake improves the loss of epidermal barrier function and skin elasticity induced by UVB irradiation in hairless mice. Photodermatol Photoimmunol Photomed 2013; 29: 204-11 21. Ohara H, Ichikawa S, Matsumoto H et al. Collagen-derived dipeptide, proline-hydroxyproline, stimulates cell proliferation and hyaluronic acid synthesis in cultured human dermal fibroblasts. J Dermatol 2010; 37: 330-8. 22. Shimizu J, Asami N, Kataoka A et al. Oral collagen-derived dipeptides, prolyl-hydroxyproline and hydroxyprolyl-glycine, ameliorate skin barrier dysfunction and alter gene expression profiles in the skin. Biochem Biophys Res Commun 2015; 456: 626–30. 23. Tanaka M, Koyama Y, Nomura Y. Effects of collagen peptide ingestion on uv-b-induced skin damage. Biosci Biotechnol Biochem 2009; 73: 930-2 24. Sumida E, Hirota A, Kuwaba K, Kusubata M, Koyama Y, Araya T, et al. The effect of oral ingestion of collagen peptide on skin hydration and biochemical data of blood. J Nutr Food. 2004;7:45–52 25. Liang J, Pei X, Zhang Z et al. The protective effects of long-term oral administration of marine collagen hydrolysate from chum salmon on collagen matrix homeostasis in the chronological aged skin of sprague-dawley male rats. J Food Sci 2010; 75: H230–8 26. Zague V, de Freitas V, da Costa Rosa M et al. Collagen hydrolysate intake increases skin collagen expression and suppresses matrix metalloproteinase 2 activity. J Med Food 2011; 14: 618–24; Skin Pharmacol Physiol. 2014;27(1):47-55 27. Asserin J, Lati E, Shioya T, Prawitt J. The effect of oral collagen peptide supplementation on skin moisture and the dermal collagen network: evidence from an ex vivo model and randomized, placebo-controlled clinical trials. J Cosmet Dermatol. 2015 Dec;14(4):291-301. 28. Natural Health Products Ingredients Database: Hydrolyzed Collagen. Government of Canada, Health Canada, Health Products and Food Branch, Natural Health Products Directorate. 12 June 2013 29. Francis FJ ed. Gelatin. Encyclopedia of Food Science and Technology (2nd ed.). John Wiley & Sons. 2000; pp. 1183–1188 30. Ward AG, Courts A. The Science and Technology of Gelatin. New York: Academic Press. 1977 ISBN 0-12-735050-0.

Aesthetics 31. Kuehn A, Swoboda I, Arumugam K, Hilger Ch, Hentges F. Fish Allergens at a Glance: Variable Allergenicity of Parvalbumins, the Major Fish Allergens. Front Immunol. 2014; 5: 179 32. Nippi marine collagen peptides available from http://nippicollagen.com/about-nippi/) 33. Peptan<https://www.peptan.com/about-peptan/product-range/> 34. Bello, AE and S Oesser. 2006. Collagen hydrolysate for the treatment of osteoarthritis and other joint disorders: a review of the literature. Cur Med Res Opin. 22:2221-32 35. Oesser S, Adam M, Babel W, Seifert J. Oral administration of 14C labelled gelatine hydrolysate leads to an accumulation of radioactivity in cartilage of mice (C57/BL). J of Nutr. 1999;129 (10): 1891–1895 36. Zague V, De Freitas V, Da Costa Rosa M, Alvares de Castro G et al. Collagen Hydrolysate Intake Increases Skin Collagen Expression and Suppresses Matrix Metalloproteinase 2 Activity. J Med Food 2011; 14 (6):618–624 37. Proksch E, Segger D, Degwert J, Schunck M, Zague V, Oesser. Oral supplementation of specific collagen peptides has beneficial effects on human skin physiology: a double-blind, placebocontrolled study. Skin Pharmacol Physiol. 2014;27(1):47-55 38. Asserin J, Elian Lati, Shioya, Prawitt BE & J. The effect of oral collagen peptide supplementation on skin moisture and the dermal collagen network: evidence from an ex vivo model and randomized, placebo-controlled clinical trials. J of Cosmet Dermatol. 2015; 14:291-301 39. Briden ME, Nutraceuticals: The fountain of Youth? Presented at the FACE 2015 in London 40. Arthred available at https://www.allergyresearchgroup.com/arthred-powder 41. U.S. Department of Health and Human Services, FDA. Agency Response Letter: GRAS Notice No. GRN 000021, July 29, 1999.http://www.cfsan.fda.gov/~rdb/opa-g021.html 42. Opinion of the Scientific Panel on Biological Hazards of the European Food Safety Authority on the “Quantitative assessment of the human BSE risk posed by gelatine with respect to residual BSE risk”, The EFSA Journal, 312, (1-28) 43. Fraser JR, Laurent TC, Laurent UB (1997). “Hyaluronan: its nature, distribution, functions and turnover”. J. Intern. Med. 242 (1): 27–33). It was isolated and identified from the vitreous humor in a cow’s eyes by Meyer et al. in 1934 (Meyer K, Palmer JW: The polysaccharide of the vitreous humor. J Biol Chem. 1943, 107: 629-634 44. Stern R, Maibach HI: Hyaluronan in skin: aspects of aging and its pharmacologic modulation. Clin Dermatol. 2008, 26: 106-122) 45. Stern R. Hyaluronan catabolism: a new metabolic pathway. Eur. J. Cell Biol. 2004;83(7):317–25) 46. Laurent TC, Fraser JR. Hyaluronan. FASEB J. 1992;6(7):2397–2404). 47. Longas MO, Russell CS, He XY. Evidence for structural changes in dermatan sulfate and hyaluronic acid with aging. Carbohydr Res. 1987;159(1):127–136 48. Kajimoto O, Odanaka W, Sakamoto W, Yoshida K, Takahashi T: Clinical effect of hyaluronic acid diet for Dry skin - objective evaluation with microscopic skin surface analyzer-. J New Rem & Clin. 2001, 50 (5): 548-560 49. Sato T, Yoshida T, Kanemitsu T, Yoshida K, Hasegawa M, Urushibata O: Clinical effects of hyaluronic acid diet for moisture content of dry skin. Aesth Dermatol. 2007, 17: 33-39 50. Yoshida T, Kanemitsu T, Narabe O, Tobita M: Improvement of dry skin by a food containing hyaluronic acids derived from microbial fermentation. J New Rem & Clin. 2009, 589 (8): 143-155-erashita 51. Cyphert JM, Trempus CS, Garantziotis S. Size matters: molecular weight specificity of hyaluronan effects in cell biology. Int J Cell Biol. 2015;2015:563818 52. Hisada N, Satsu H, Mori A, et al. Low-molecular-weight hyaluronan permeates through human intestinal Caco-2 cell monolayers via the paracellular pathway. Biosci Biotechnol Biochem. 2008;72(4):1111–1114 53. Kawada C, Yoshida T, Yoshida H, Matsuoka R et al. Ingested hyaluronan moisturizes dry skin. Nutr J. 2014; 13: 70 54. Terashita T, Shirasaka N, Kusuda M, Wakayama S. Chemical composition of low-molecular weight hyaluronic acid from (chicken) and maintaining the moisture effect of skin by a clinical test. Memoirs of the Faculty of Agri of Kinki University. 2011;44:1–8. (in Japanese) 55. Balogh L, Polyak A, Domokos M, Kiraly R et al. Absorption, uptake and tissue affinity of high molecular weight hyaluronan after oral administration in rats and dogs. J. of Agricul & Food Chem. 2008; Vol 56(22): 10582-10593 56. Murad McArdle F, Rhodes LE, Parslew R, Jack CI, Friedmann PS, Jackson MJ. UVR-induced oxidative stress in human skin in vivo: effects of oral vitamin C supplementation. Free Radic. Biol. Med. 2002;33:1355-1362) 57. Shi J, Yu J, Pohorly JE, Kakuda Y. Polyphenolics in grape seeds-biochemistry and functionality. J Med Food. December 2003;6(4):291-9 58. Nassiri-Asl M, Hosseinzadeh H. Review of the pharmacological effects of Vitis Vinifera (grape) and its bioactive compounds. Phytother. Res. PTR. 2009;23:1197–1204 59. Heinrich U, Moore CE, De Spirt S, Tronnier H, Stahl W. Green tea polyphenols provide photoprotection, increase microcirculation, and modulate skin properties of women. J Nutr. June 2011;141(6):1202-8 60. British Journal of Dermatology, October 2003, pages 841–849; and Clin. & Experi. Dermatol. October 2001:pages 578–582 61. Annals of the New York Academy of Sciences. April 2002, pages 133–166 62. Harris ED, Rayton JK, Balthrop JE, DiSilvestro RA, Garcia-de-Quevedo M. Copper and the synthesis of elastin and collagen. Ciba Found Symp. 1980;79:163-82 63. Rayton, J. & Harris, E. (1979) Induction of lysyl oxidase with copper. J. Biol. Chem. 254, 621-626 64. Harris, E. (1976) Copper-induced activation of aortic lysyl oxidase in vivo. Proc. Nati. Acad. Sci. USA 73, 371-374 65. Muszynska A, Palka J, Gorodkiewicz E. The mechanism of daunorubicin-induced inhibition of prolidase activity in human skin fibroblasts and its implication to impaired collagen biosynthesis. Exp Toxicol Pathol. 2000;52(2):149-155 66. Prasad AS. Zinc: the biology and therapeutics of an ion. Ann Intern Med. 1996 Jul 15;125(2):142-4. 67. Landis GN, Tower J. Superoxide dismutase evolution and life span regulation. Mech Ageing Dev. 2005 Mar;126(3):365-79 68. Kohen R. Skin antioxidants: their role in aging and in oxidative stress–new approaches for their evaluation. Biomed Pharmacother. 1999 May;53(4):181-92

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Aesthetics Journal


A summary of the latest clinical studies Title: Hyaluronic Acid (HA)-Based Hydrogels for Full-Thickness Wound Repairing and Skin Regeneration Authors: Hong L, Shen M, Fang J et al. Published: Journal of Materials Science: Materials in Medicine, September 2018 Key words: Hyaluronic acid, wound healing, regeneration Abstract: In this work, two kinds of hyaluronic acid (HA)-based hydrogels were fabricated: one is made from physical freezing-thawing of HA solution (HA1), and the other is from chemical cross-linking of HA and polysaccharide (HA2). They were applied to repair fullthickness skin defects with New Zealand rabbits as the test animals, using powder HA and cotton dress as the references. The wound starts to heal after wounds were disinfected with iodine followed by coating with HA2, HA1, HA and cotton dress (the control), respectively. They were recorded as 4 treatments (groups), HA2, HA1, HA and the control. The healing progress was followed and tested in the duration of 56 days and the biological repairing mechanism was explored. From the wound area alteration, white blood cell (WBC) measurements and H&E staining, HA2 was the most promising treatment in promoting the wound healing with least serious scar formation. Immunochemistry analyses and real-time PCR tests of the bio-factors involved in the wound healing, vascular endothelial growth factor (VEGF), alpha-smooth muscle actin (α-SMA) and transforming growth factor beta-1 (TGF-β1), exhibited that HA2 enhanced VEGF and α-SMA secretion but reduced TGF-β1 expression at early stage, which alleviated the wound inflammation, improved the skin regeneration and relieved the scar formation. Title: The Role of Nutrition in Inflammatory Pilosebaceous Disorders: Implication of the Skin-Gut Axis Authors: Maarouf M, Platto JF, Shi VY Published: Australasian Journal of Dermatology, September 2018 Key words: Acne, pilosebaceous, inflammation, nutrition, diet Abstract: Nutrition plays a critical role in the manifestation and management of inflammatory pilosebaceous disorders. There is rich potential for insight into the impact of dietary effects on the pathophysiology of inflammatory pilosebaceous disorders including acne vulgaris, hidradenitis suppurativa, rosacea, and the closely related seborrhoeic dermatitis. Acne vulgaris and hidradenitis suppurativa are thought to have similar diet-modulating pathogenic pathways. Western diet influences Acne vulgaris and hidradenitis suppurativa by increasing insulin and modulating FOX01/mTOR, resulting in over-expression of cytokeratins, hyperproliferation of keratinocytes, and hypercornification of the follicular wall. Key receptors in rosacea are alternatively activated by UV radiation, hot beverages, spicy foods, vanilla, cinnamon, caffeine, alcohol, cold temperatures, and niacin- and formalin-containing foods, to increase oedema and flushing, resulting in erythema, telangiectasia, and warmth, characteristic features of the condition. Seborrhoeic dermatitis, while not a follicular disorder, is closely related, and can be modulated by dietary influences, such as biotin and probiotics. This overview summarizes the role that nutrition plays on these disorders, and identifies dietary modifications as potential adjunctive therapies.

Title: New Insight Regarding the Zygomaticus Minor as Related to Cosmetic Facial Injections Authors: Hur MS, Youn KH, Kim HJ Published: Clinical Anatomy, September 2018 Key words: Botulinum toxin, facial rejuvenation, zygomaticus Abstract: The present study aimed to determine the arrangement and terminal attachments of the zygomaticus minor muscle (Zmi) fibers connecting the orbital and mouth regions. The Zmi was examined in 32 specimens of embalmed Korean adult cadavers. The Zmi was present in all 32 specimens (100%). In 31 of the specimens (96.9%), the Zmi that inserted into the upper lip was formed by muscle fibers that arose from the zygomatic bone and muscle fibers that extended from the orbicularis oculi muscle (OOc). After the Zmi fibers blended with the inferior margin of the OOc, these fibers constituted the inferior and medial margins of the OOc. These fibers were then attached to the medial palpebral ligament, the maxilla, the levator labii superioris alaeque nasi muscle, and the depressor supercilii muscle. In 30 of 32 specimens (93.8%), muscle fibers that extended from the OOc constituted the lateral margin of the Zmi, usually descending to the level between the nasal ala and the vermilion border of the upper lip and inserting into the upper lip. The obtained data will be helpful for understanding their connected movements and in kinematics and electromyographic analyses, therapies involving injections of BoNT (botulinum toxin) type A, and various types of facial surgery. Title: Genito Pelvic Vaginal Laxity: Classification, Etiology, Symptomatology and Treatment Considerations Authors: Newman R, Campbell P, Gooneratne M et al. Published: Springer Current Sexual Health Reports, September 2018 Key words: Vaginal laxity, laser, radiofrequency Abstract: Genitopelvic laxity remains a heterogenous medical condition that is treated by a variety of health care professionals. There remains much confusion regarding definitions of esthetic and functional pelvic laxity as well as which therapeutic intervention may be best suited to treat this condition. There are currently no commonly accepted vernacular, definitions, medical etiology, and predisposing risk factors to this medical and esthetic condition. There is no accepted standardization for assessment and treatment paradigms. The published literature on non-invasive office-based technological interventions for both laser and radiofrequency devices includes primarily prospective descriptive studies, and randomized sham-controlled research is sparse. We provide a comprehensive review of the condition and propose new terminology so that clinicians worldwide may be using the same terms to discuss the same condition. A proposed comprehensive treatment paradigm is presented that outlines conservative to more aggressive interventions for this condition. Common terminology, nosology, and a better understanding of the mechanism of action of each therapeutic device are warranted. An awareness of the medical etiology of genitopelvic laxity, coupled with a better familiarity of disease impact, will allow better treatment paradigms to be developed and implemented. There is a need for high-quality sham-controlled longitudinal studies as it pertains to new emerging technologies such as laser and radiofrequency.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Aesthetics Journal

Understanding Paid Searches Digital marketer Steve Mulvaney explains how to gain new patients via search engine advertising We are all familiar with typing in the white box in the centre of a search-engine home screen such as Google, Bing or Yahoo. Often we are seeking information, products and services or just answers to simple questions that make us go ‘hmmm?’. As a user, while searching online, we may not always be aware that search engines are a tool driven by intent and the top four results generated are often companies that have paid to be there. As a clinic business owner or marketing manager, you need to know whether potential patients are actively looking online for services you provide. It’s important to understand your patients’ intent through their online search queries to maximise your opportunity to win new patients. Understanding your patients’ intent is particularly important if you’re running paid ads. In this article, I will explain what search intent is, the basic types of search intent and how to ensure your digital marketing efforts are focused on delivering highly targeted, high value traffic to your website. Technically speaking, search intent can differ slightly between organic – results that are based on relevance – and paid results; our focus here is primarily on paid ads.

Why use paid search ads? The beauty of paid advertising is that it levels out the playing field between those with huge budgets and those with more modest budgets. This is because serving ads in the top positions is largely based on the quality and relevance of an account’s keywords and not just based on the highest bid. This means that it’s possible to appear at the top of the results page having paid less for clicks than your competitors.1 As a private aesthetic practice, you’ll no doubt be focused on generating patient leads each month to ensure a steady flow of new enquiries and bookings for procedures. For many potential patients, their journey to finding you is likely to start with an internet search, most probably using Google as it has around an 85% share of search in the UK.2

Carrying out a search on your own services will show you just how competitive those search result positions really are. If you’re not visible at the top of the search page, then your competitors are likely to be getting those potential patients and leads that could otherwise be yours.

What is search intent? Search intent is the way we look at a search query to try and establish what the searcher is looking for. Broadly speaking, intent can be categorised in the following ways:3 • To know something: usually the answer to a specific question, such as ‘what is’, ‘how do’, ‘where are’. These are also known as ‘informational’ searches. An example would be when a patient searches ‘what are hyaluronic acid dermal fillers?’. • To go somewhere: typically includes searches about a specific website or business without entering the full URL or brand name with the intent of finding that particular website or webpage. Also known as ‘navigational’ searches, an example could be if someone searched ‘Aesthetics journal’ with the intent of going to the Aesthetics journal website. • To do something: searches which include keywords such as ‘buy’, ‘quote’ or ‘book’ alongside ‘online’, and including specific product-related searches. These are referred to as ‘transactional’ searches. An example would be when a patient searches ‘book lip filler treatment’. • Commercial investigation: this is used when someone is searching for product comparisons, price comparisons and

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product/service reviews. An example would be when a patient searches ‘laser hair removal cost comparison’. To strive toward getting the very best results from your paid ad platform using these search intent types, you should consider your service offering as a funnel. The transaction searches, the ones which will get you profit, are at the bottom of the funnel i.e. they’re likely to be the final step before a searcher, or patient, becomes an enquiry. Being at the bottom of your funnel, this searcher will have the highest value to your practice. The potential downside to this is that they’ll also have the lowest volume – there will always be more people browsing items in a shop than those who actually end up making a purchase. It’s worth remembering that in the online world, your patient will see you long before you see them. For this reason, it can be a good idea to appear in some searches in the commercial investigation stage too. As we’ve already touched on, these kinds of searchers are actively looking for a solution to their particular issue; but, they’ve not yet made their final decision as to who they wish to purchase from. You may also wish to consider your options for searchers who fall under the ‘go somewhere’ and ‘know something’ categories. For ‘go somewhere’ you may find that searches on your URL place you high on organic search, and you certainly stand a greater chance of this if you’ve also invested in SEO. Also, if your brand name is a direct match to your URL, running a paid search campaign focused on your brand name should also serve your website at the top of the search results. Whether or not you wish to appear for ‘know something’ type searches can be down to personal preference and/or budgetary constraints. This is because, typically speaking, they don’t contribute directly to a booking or enquiry but can influence a searcher’s decision to make that booking. For example, if I run an acne treatment clinic I may have blog posts or a frequently

What do paid ads look like? The top four positions on a search engine’s results page will often be ads. This depends on whether or not a business wants to show ads for a keyword used in a search query. On Google, these ads will always be identified by a little green box with the word ‘ad’ written inside it (shown in Figure 1). There can be a maximum of four ads at the top of the search page and a maximum of three ads at the bottom of the page, giving a total of seven ads on the search results page if all are purchased.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



asked questions section on my website where I can answer informational type questions. I may find that answering these questions leads some searchers to read other pieces of content on my site and may therefore influence that person to enquire about, or book, my services. The flipside of this is that the same searcher may well click on my ad, consume my content, then look elsewhere online for another practice that can satisfy their needs. Not only will I have lost a potential patient, but my ad budget has been depleted too. Typical patient journey Let’s consider a typical journey from the perspective of a patient. An individual may firstly have a requirement or desire for a particular treatment, such as ‘anti-wrinkle injections’. They will then decide to search for solutions online. They may firstly do this when they are on the go via their mobile device and they will visit several relevant websites along the way, engaging more with some than with others. A couple of days later, they may continue their search – perhaps on a desktop computer during a lunch break at work. They could recall some of the websites they visited earlier and engage with those sites again. Their search query may differ slightly – for example ‘anti-wrinkle procedures’ – and they’re presented with a mix of ads they’ve seen previously, along with some new ads, followed by the organic listings that will appear below these. Finally, on the weekend they have the opportunity to search again, maybe this time in front of the TV using their tablet device. They are likely to have a more refined search query that’s closer to one showing purchase intent, such as ‘anti-wrinkle procedures Edinburgh’. If this point is the first time you’ve served an ad to this person, there’s a chance you’ll be clicked on and this person could become a patient. But, other practices that might also have ads previously at other stages may also appear in this search, which could draw the searcher to them and away from you, as they’ve already had some level of engagement from the prospective patient.

Figure 2: Google ad from searching ‘acne treatment cost’.

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Budget So, how is it possible to appear above the competition and pay less than them per click? This is because the major search engines want to deliver the most relevant results possible to their searchers. If the path between the initial search query and the page that the searcher lands on when they click your Figure 1: Real search result on Google using the search term ‘acne treatment’. Note that Google search results are influenced by an individual’s location and previous search ads is highly relevant, history, so people in different parts of the country will get slightly different results. then you can appear above a less relevant result and pay less per click. The actual cost would be something like the search ‘what you’ll pay per click is usually determined is acne?’. by the competitiveness of the keywords in On a Google search, we’d most likely see your account. Therefore, it’s not unusual to a Google Answer Box at the top of the find that keywords showing transactional or results page giving us a useful description commercial investigation intent can be the of the condition. We will generally also see most expensive in your account.4,5 These are organic links to informational articles about more competitive because they’re bringing in acne. new business for you and your competitors. The big giveaway around this kind of search The takeaway message here is to ensure is that there are no ads being served. So, your paid ad account is first and foremost we can reasonably deduct from this that structured to serve ads for search queries although these search results are helpful to that show transactional (purchase) intent, the searcher, they show no real intent that so I would recommend putting the majority could lead to an enquiry or booking. of your budget in this area. As well as Taking a step even further back, if you transactional intent, you should also consider simply have the keyword ‘acne’ in your paid the value in having a smaller budget allocated ads account, then you’ll likely receive clicks to ads for some searches which show where no intent has been expressed or can commercial investigation intent. be deduced. This is a quick way to exhaust Deciding upon your ad budget can be your budget. However, the search ‘What is a confusing task as there are seemingly acne?’ shows a little more intent in that the endless variables in your decision-making searcher is clearly asking a question. What process. Generally speaking, having a we don’t get is any sense of why they’re much smaller budget (if any) for searches asking the question or even where they’re that show informational intent will also be situated geographically, which may be an advantageous. However, it depends on how important detail. We can perhaps see an much you would like to spend, and I would additional layer of search intent with the recommend first placing your budget in the search ‘acne treatment’. transactional and commercial investigation Here we can expect to see Google intent categories first. Shopping results at the top of the results page showing something like Figure 1. We Example of a patient search see the first results because companies Let’s again consider the example of a selling off-the-shelf products will very often private practice offering acne treatments. use the word ‘treatment’ in their product A search that shows little purchase intent descriptions within Google Shopping.

Figure 3: Google ad from searching ‘private acne treatment Liverpool’.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



Aesthetics Journal


Buying search terms

Competitor tip

In simple terms, you are free to choose any words (for your keywords) that are in common use. There are restrictions on offensive words, adult content and counterfeit goods etc, as well as restrictions on copyrights and trademarks. You should also consider the restrictions on healthcare and medicines, all of which are covered in Google’s Advertising Policies.6 Consider how you could use relevant keywords that a searcher might use when looking for services you provide. I would almost always advise against using a single keyword in your account as you can’t see any purchase intent.

You may, on occasion, see a competitor showing ads when searching for your clinic or even your name. While this may seem ethically questionable, it is allowed. I therefore believe you should certainly monitor this and occasionally run some searches on your own brand terms. But, don’t do this too often as if you Google yourself too much then your analytics results won’t be reflective of what’s actually occurred, so you’ll skew your account performance figures with your own searches. If you do find that a competitor is using your brand name for their paid ads, then I would recommend that the first response should be a polite letter asking them to stop – getting into a bidding war on each other’s brand names on Google Ads ultimately benefits nobody. You should also strongly consider running brand campaigns on your own brand; this would involve a campaign in your account to show ads using your brand name as a keyword. In many ways, I find that this is the best response to this particular situation. More often than not, branded campaigns have a cheaper cost per click, due to the fact that they’re simply less competitive than other keywords. Finally, if you appear top organically and top of a paid-for branded search you can dominate the search results page!

There are three ways to tell search engines to show ads: • Exact match keyword: only shows an ad if the searcher typed in the keywords exactly as they appear. • Phrase match keyword: shows ad if all three words appeared in the same order as the search engine keyword, but the searcher may have also used additional words either side of the keywords. • Broad match modified: would be triggered if all three of the keywords are contained within a search, they can also be included in any order and with any other words used in the search. The key point here is to create your list of keywords by thinking of them as collections of more than one word that forms a search query that your target audience are likely to use if they’re looking for a service you provide. Bear in mind that phrase matched and broad matched modified keywords can quickly exhaust your budget without necessarily delivering the right quality of traffic to your website. Also, understand that your competitors can and likely will be bidding on the same keywords as you. So, do a test search on your service and another on your service plus your location and see how many ads there are in the top positions.7-9

Underneath the Google Shopping results there will typically be some standard text ads offering similar solutions which are product and not service led. Let us now consider a search that shows commercial investigation intent, such as ‘acne treatment cost’. Here we could reasonably and safely assume that this searcher is aware that they want acne treatment, they’ve decided to look at having this done and are now looking for cost information (see search results in Figure 2, which comes up with an ad for a clinic). Finally, the results for a search on ‘private acne treatment Liverpool’ is shown in Figure 3. For your private aesthetic practice this is a great search query because the searcher gives us three clear pieces of information indicating purchase intent: • We know they’re looking for acne treatment • They’re self-funded or insured and/or there’s a time critical factor evidenced by using the keyword ‘private’ • They’ve specified a geography in which they’d prefer to receive the procedure – ‘Liverpool’ You can be much more confident that showing your ads for this query could

generate a click to your website, which, in turn, could lead to the searcher making a booking with you and giving you a return on your ad spend investment.

Conclusion Committing budget to your digital marketing campaigns, particularly paid ads, can be very costly and frustrating when not done properly. Equally, when correctly structured, your paid search engine ad campaigns can be a fantastic source of patient leads each and every month. If you don’t yet have a paid ad account, it’s almost certainly something that is worthwhile investigating as a way of driving patient leads. Having a greater understanding of the searcher’s intent based on their search query can really help you to define which keywords you should have in your account. Visualising a sales funnel and structuring your account around search intent is the best way to ensure the highest return on your ad spend.

Steve Mulvaney is the founder of Red Effect Digital, an agency created in 2011 that specifically focuses on paid search, paid social, remarketing and call tracking for clients in the healthcare and e-commerce sectors. REFERENCES 1. Google Ads Help – Definition of Quality Score - <https:// support.google.com/google-ads/answer/140351> 2. Statistica, Market share of search engines held by Google in the United Kingdom (UK) from May 2015 to January 2018. <https://www.statista.com/statistics/279797/market-share-heldby-google-in-the-united-kingdom-uk/> 3. Yoast, What is search intent? 2018. <https://yoast.com/searchintent/> 4. 39 Celsius Web Marketing Consulting, ‘How Much Should I Spend On Google Adwords (PPC)?, 2016. <https://www.39celsius. com/how-much-should-i-spend-on-google-adwords-ppc/> 5. Brad Smith, ‘How Much Does Google AdWords Cost? Here’s How To Create Your Budget, AdEspresso, 2017. https:// adespresso.com/blog/how-much-does-google-adwords-cost/ 6. Google Advertising Policies, 2018. <https://support.google.com/ adspolicy/topic/1626336> 7. Google Ads help, Basic tips for building a keyword list, 2018. <https://support.google.com/google-ads/answer/2453981> 8. Google Ads help, About keywords, 2018. <https://support. google.com/google-ads/answer/1704371> 9. Nielpatel, How to Set up a Google Search Network Campaign (The Right Way), 2018. <https://neilpatel.com/blog/how-to-set-upa-google-search-network-campaign-the-right-way/>

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Aesthetics Journal

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to a Facebook online forum or invites to the associationâ&#x20AC;&#x2122;s meetings and annual conferences, for example. This gives you the chance to meet like-minded professionals and make the first steps to building a peer support group.

Obtaining Support in Aesthetics Aesthetic nurse prescriber Kay Greveson on the value of support for those starting out in the specialty Working as an aesthetic practitioner can sometimes make you feel isolated as you may often find yourself working independently. When you are starting out in your career, the idea of feeling supported can help you to gain confidence, build professional relationships and even help you to land new opportunities. To many, the idea of finding time to network or undertake shadowing opportunities, in addition to the myriad of other demands in running an aesthetic practice, can be overwhelming; particularly compared to the NHS where working as a team and shadowing opportunities are more common. With that being said, I have found itâ&#x20AC;&#x2122;s these efforts that can be vital in helping you to build a community that you can trust, in which you feel supported. It goes without saying that building relationships and connecting with peers is essential in aesthetics. This article will explore how the novice practitioner can flourish when it comes to improving their networking skills and gaining support to give them the confidence that they deserve.

How networking can offer support Networking is a vital skill that essentially helps you to meet new people and build professional relationships. It is something that we do daily, without even realising. Whether thatâ&#x20AC;&#x2122;s attending events or meetings, discussing difficult cases with colleagues or just talking with other practitioners about what you have going on in your clinic, networking is everywhere. In aesthetics, networking skills enable you to meet people with similar interests and share information. It also allows you to keep up-to-date with current trends and developments in your profession.2 Developing a network of friends and colleagues can give you the energy and motivation to build your profile and open new doors, as well as discuss concerns and ask for advice.3 However, it is a skill that may not come naturally to some people. If you are shy or insecure then the thought of introducing yourself to others may feel daunting. Although it may seem foreign at first, you can start building networks by asking colleagues to introduce you to their friends, arranging informal visits to your clinic or by shadowing colleagues, joining professional forums or attending conferences. Below I explore some of the best places to kickstart your networking and obtain valuable support from your aesthetic peers. Aesthetic groups and associations Associations such as the British Association of Cosmetic Nurses (BACN), Private Independent Aesthetic Practices Association (PIAPA), British College of Aesthetic Medicine (BCAM), British Dental Association (BDA), the British Association of Aesthetic Plastic Surgeons (BAAPS), the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), the Aesthetics Complications Expert (ACE) Group, amongst others, offer numerous educational opportunities, as well as opportunities for networking and ultimately gaining support. Depending on which association you sign up to, for which there is usually a fee, you may be entitled to have access

Conferences Unlike online support, which is discussed below, meeting people at conferences allows for face-to-face interactions, opportunities to bounce ideas off others, make lasting friendships and supportive relationships. They generally include interactive debates, live demonstrations and are often CPD verified, which is essential for revalidation and further development. There are lots of great conferences across the UK, like the Aesthetics Conference and Exhibition for example. Not only are there exclusive talks and training sessions at such events, but exhibition floors allow you to walk around the industry stands and get talking to the sales representatives or company directors present about products and new technologies; conversation will then naturally develop. It may also be a perfect opportunity to find a clinic support partner, like a PR agency or an insurance firm for example. Companies like this will ultimately help to work alongside your clinic to offer advice in certain areas that you may not be able to. Online forums Online peer support is available in many forms, such as the BACN or ACE online Facebook pages,4 which facilitate sharing of knowledge and experience, offering advice and support to practitioners of all levels. There are also free forums that you can join and although the free ones may be useful, I believe that by paying into an association provides more regulated, professional connections and support in the long run. If you are part of an online forum and there is a conference or training event coming up, you could start by posting on the group to ask if others are planning to attend and maybe plan a place or time to meet. Perhaps start by asking if anyone is going to the same session as you or if a group of you want to get together over lunch. This may feel easier than starting conversations in person at the event.

Training opportunities I would advise fellow practitioners to make the most of any training and education events that come your way and use them to build confidence, further your knowledge and network with fellow students. As well as

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Aesthetics Journal


Social Media Social media is a great way to network and share your thoughts. For example, by asking questions or starting polls on Twitter or tagging other practitioners on relevant posts on Instagram can help you to keep your knowledge and skills up to date, start conversations, share ideas and debate on the latest trends with peers in aesthetics. All professionals participating in social media content should familiarise themselves with the Nursing and Midwifery Council (NMC) and General Medical Council (GMC) code of conduct regarding social media use to ensure they do not compromise patient confidentiality and act professionally to avoid jeopardising their reputation.5 Example: I’ve just attended a fantastic training event with @InsertAestheticTrainer! What I want to know, is how many of you trained on cadavers? Would you recommend it?

of course serving the purpose of improving your clinical skills, here you can get tips from other students about how they run their practice and what new treatments they offer. You will find that many practitioners are open to sharing ideas and advice in these scenarios and will be just as relieved as you are to have an opportunity to share common issues and challenges. As well as training providers or topic-specific events that are listed on training pages such as on the Aesthetics website, it may also be worth contacting your local sales representatives to find out when their next training dates are.

Clinical supervision Formal clinical supervision involves two professionals (the mentor and mentee) sharing clinical, organisational, developmental and emotional experiences in a secure and confidential environment.10 Unlike an appraisal, I believe that clinical supervision offers more of a reflective experience, is non-judgemental and can often lead to improved clinical care, as well as being recommended by the Quality Care Commission.11 Including clinical supervision in your aesthetic practice could not only improve your confidence but also give you an increased depth of knowledge, identify

training needs and reduce emotional stress through sharing experiences and reflecting on difficult cases. It is also something that should be done to show competence and reflection in practice as part of your revalidation.13,14 A clinical supervisor should be someone who you feel comfortable sharing information with and who is working in a similar role. If you are new to aesthetics and do not have anyone you feel you can approach for clinical supervision, try some of the tips I have given above. I believe that it is also worth noting that your clinical supervision should be in line with that set out by the Cosmetic Practice Standards Authority (CPSA)15 supervision matrix. Local mentoring and shadowing could be very beneficial to offering you support within your career, especially in the early days. When I started out in the specialty, I was lucky enough to have a close friend who was experienced in aesthetics to guide me through my first 12 months. They offered valuable clinical support and that allimportant reassurance if I was worried about the results of a treatment I had performed or if a patient called with concerns. This, along with attendance at local regional groups, boosted my confidence in the early years. When looking for a local mentor, I recommend approaching a few

Secure messaging groups Secure messaging applications such as Facebook messenger and WhatsApp are also being increasingly used to develop communities of like-minded people who can share information or troubleshoot situations. Often these are developed as a result of industry-led training days and other events, as a means of delegates communicating with each other and the medical key opinion leader/ course trainer. If you attend a local training day, ask if such a group exists or you could even be the one to instigate the formation of a messaging group. I would suggest that you approach the people you have met from your course as well as the tutors or trainers to see if they would be open to this. Tutors would be the obvious first choice due to their experience on a given subject but in contrast, their availability may also be more limited. There is no harm in asking if a group exists or could be created.

different practitioners/clinics and don’t be discouraged by any initial knock-backs.

Conclusion I believe that throughout your whole career it is important to have a strong support network around you, particularly when you are just starting out. I think it is important to find the time to network and identify what sort of networking opportunities work best for you as this is where you will meet likeminded people. That paired with training opportunities, clinical supervision and being part of an organised community will set you on track for feeling supported and confident in your line of work. The burden of balancing family, work and social life can seem overwhelming, but undergoing examples such as the above, can reap positive rewards. I would urge anyone starting out in this specialty to make the first steps today and link together with your local aesthetic community. Kay Greveson is an aesthetic nurse prescriber and owner of Regent Park Aesthetics. She is an award-winning nurse with 14 years’ experience, splitting her time between working in the NHS and running her own established aesthetic business. REFERENCES 1. Henderson, A. How can aesthetic practitioners benefit from building relationships with peers? Journal of aesthetic nursing, Vol 7, 6, (2017), 342. 2. Royal College of Nursing. Professional development: networking. <https://www.rcn.org.uk/professional-development/ your-career/networking Last accessed 13/8/18> 3. Underdown, P. The power of networking in aesthetics: how to build your professional profile. Journal of Aesthetic Nursing. Vol 6, 3, (2017), 154 4. Aesthetics Complication Expert Group <http://acegroup.online/> 5. Nursing and Midwifery Council. Guidance on using social media responsibly, (2017) <https://www.nmc.org.uk/standards/ guidance/social-media-guidance/> 6. General Medical Council Guidance on use of social media <https://www.gmc-uk.org/ethical-guidance/ethical-guidancefor-doctors/doctors-use-of-social-media/doctors-use-of-socialmedia> 7. British Association of Cosmetic Nurses, Membership benefits, 2018 <https://www.bacn.org.uk/become-a-member/ membership-benefits/> 8. Private Independent Aesthetic Practices Association, Member benefits <https://piapa.co.uk/benefits> 9. British College of Aesthetic Medicine, <https://bcam.ac.uk/> 10. Lewis W. The importance of keeping up with emerging technologies and trends. Journal of Aesthetic Nursing, 2016, (5), 2, 98-99 11. Oladayo B, Stonehouse, D. Clinical supervision: an important part of every nurse’s practice. British Journal of Nursing.2017, vol 26,6, 331-334. 12. Quality Care Commission. Supporting information and guidance: Supporting effective clinical supervision <https://www.cqc.org. uk/sites/default/files/documents/20130625_800734_v1_00_ supporting_information-effective_clinical_supervision_for_ publication.pdf> 13. General Medical Council. Guidance for doctors who offer cosmetic interventions, 2016 <https://www.gmc-uk.org/ethicalguidance/ethical-guidance-for-doctors> 14. Nursing and Midwifery Council. Revalidation: What you need to do <http://revalidation.nmc.org.uk/what-you-need-to-do> 15. Cosmetic Practise Standards Authority, Supervision Matrix <http://www.cosmeticstandards.org.uk/supervision-matrix.html>

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Aesthetics Journal

Utilising Online Content Marketing Aesthetics sits down with clinic owners and marketing professionals to find out how to create and promote the most relevant online content to attract patients Right now, ‘content marketing’ seems to be the frequently used buzzword when it comes to growing your brand online. The Content Marketing Institute, a resource for information on content marketing, defines it as a ‘strategic marketing approach’ concentrated on generating ‘valuable content to attract and retain a clearly defined audience’.1 The premise of content marketing is not to directly advertise your services; instead its aim is to offer patients useful content that answers their questions and shares your expertise to encourage ‘profitable consumer action’.1 However, why should you choose this approach over traditional digital advertising? This article will look at why blogs and video content are two of the most valuable forms of online content marketing to your existing and potential aesthetic patients and how you can get this material across in the most successful way.

Starting with a strategy An online content strategy is defined as the piece of a marketing plan that details how a brand will develop and manage both written and visual media forms.2 In his blog post entitled ‘How to Develop a Content Strategy’, founder of business lead generation platform, Justin McGill, recommends considering the following for developing a successful content marketing strategy:2 • What questions will your content answer for your audience? • How unique will your content be? • What formats will you focus on? Senior digital marketing consultant, Gina Hutchings, believes that what digitally active users want is useful information that applies to them. She states, “The best content comes in the form of trustworthy and authoritative pieces that are relatable to your audience; things like case studies and solutions to issues.” Hutchings adds, “Practitioners should be prepared to offer their audience something for free before they invest in your services.” Consultant plastic surgeon and clinic owner Mr Taimur Shoaib believes aesthetic businesses will benefit from creating an online content strategy that is patient centred. The professionals interviewed note that at the heart of an online content strategy should be the aim of answering questions that patients may have; for example, queries on the recovery time or potential risks associated with specific treatments. It is also beneficial for both your business and patients that this is done in a unique and shareable way. Mr Shoaib explains, “The patients that we’re trying to engage with in aesthetics generally want to know about themselves; for example, why would you do this treatment for me and why am I turning to this page for information? If patients are interested then they’ll click to find more information on how you can help.”

Gauging audience requirements Interviewees all note that producing content that is appropriate for your target audience is vital for driving your business’s growth. However, getting to know what specific material your potential patients are looking for can seem like a daunting task. Hutchings suggests that deciphering what form of content and subject matter is of most interest to your audience can start with a simple poll or survey that can be shared online and in clinic; for example, asking what types of treatment they’re interested in learning more about. Additionally, she notes that, at times, interactions such as focus groups can lead to the most fruitful results. Hutchings advises, “Choose a cross-section of people you think would make

Aesthetics aestheticsjournal.com

your desired clientele. For example, you may want to expand your male market, so invite 10 men who could be potential patients to attend a focus group. You can then ask them about what online content they would find interesting and why they would click and follow your clinic.” Similarly, aesthetic practitioner and clinic owner Dr Qian Xu believes that connecting with your target audience in person can be extremely beneficial when gauging audience requirements. She states, “I’m targeting professional women. By going to business networking events to meet potential patients in person, I can find out what their concerns are and they will tell me what advice they look for, which will identify what content I should be posting.” Hutchings also advises that linking current events that are relatable to patients into your blog posts can improve their shareability. She states, “You should showcase procedures and results, describing how they’ve been achieved and offer treatment information in the form of downloads to develop your brand’s authority and add value for your patients. Always include useful content to your readers; a blog should be seen as a source of information. In the same sense that people use Google or look on news apps, your blog can be utilised as a voice of authority in the sector by readers.”

Producing your content It is useful to consider the subjects your blog will cover and how best they can be conveyed. The professionals advise using blog posts and video hosted on your website as the main format for your online content, which can then be distributed and shared through your social media and email channels. They recommend breaking down your longer posts into more digestible chunks that can be read quickly and easily, or sharing short video snippets, with hyperlinks to your website to read or view the content in full. The aim of this is to generate more visits to your website and entice potential patients to visit other pages, building trust in your levels of professionalism through your content and brand, before eventually converting to paying patients. Blogs Written blogs can be utilised in a variety of ways and may prove to be better suited to your aesthetic business compared to video. For example, communicating complex or longer-form descriptions, examples of case studies, explanations of the latest

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



Aesthetics Journal


Methods of brainstorming unique content ideas Professionals interviewed for this article recommend techniques such as: • Conducting and distributing a survey to patients via email • Asking patients to complete a form while in your clinic’s waiting room, detailing what information and topics they would find interesting • Creating and reacting to Google alerts for news on key terms in aesthetics such as ‘dermal fillers’ • Looking at what is trending on social media platforms such as Twitter • Examining what subjects respected blogs/websites in your specialty are covering • Taking note of interesting conversations you have with patients and co-workers • Reading recent, respected journals on medical aesthetics • Attending industry events, conferences and exhibitions

Many companies, practitioners and clinics also utilise features such as Instagram stories to provide a ‘behind the scenes’ insight of treatment overviews and dayto-day practises. “There’s nothing wrong with creating social media stories on your phone because that feels very genuine and as if you’re catching the moment,” says Bracey-Wright. However, she notes that, “If you’re putting a video on your website or embedding it into your newsletter then it has to be produced and edited properly.”

Service speaks louder than words controversial stories hitting the consumer press or your analysis of a new beauty trend may be more useful to your audience in a well-written format with relevant headings as opposed to in a video.3 Hutchings notes that a blog can be used as a great platform for encouraging interaction with readers. Content marketing agency, CopyPress describes blogs as advantageous for providing detailed and accurate information as references can be easily listed in written form. This means that material for further reading is readily available to your audience if they require it and hyperlinks to other content on your blog or website can be embedded.3 When looking to upload educational material that is specific to a certain specialty within aesthetics, director of EBWPR, Emma BraceyWright believes utilising the professionals working in your clinic is key. She notes, “Have the right specialists supporting your online editorial so that it’s legitimate. For example, if you’re writing content on your website about suncare, if you have a dermatologist in your clinic then have them write it or include

Regulations for content The Committee of Advertising Practice (CAP) provides rules that businesses in the aesthetic specialty must adhere to when marketing products and services; the Advertising Standards Authority (ASA) ensures that this guidance is followed. With regard to both surgical and non-surgical cosmetic procedures, the CAP Code states that marketing communications must ‘be prepared with a sense of responsibility to consumers and to society’ and must not ‘mislead consumers by exaggerating the capability or performance of a product’.5

quotes from them. Also make sure everything is well researched and backed up with studies to reference.” This approach could also apply to creating relevant and credible video content. Video In addition to using a blog as an extension of your business’s website, content strategy consultant, Jodi Harris states that, “Videos are among the most versatile of tactics content marketers can leverage.” She recommends considering the following in order to create successful online video content:4 • The content can work in both long and short formats. For example, the content should be relevant in both a short Snapchat story and in a longer video on YouTube. • It should be useful as a standalone piece or as a segment within a series of conversations. • Ensure the video can thrive across a multitude of platforms. It should work while embedded on your website, in an email, through apps or on third-party sites such as YouTube. Bracey-Wright explains that video content can prove useful when creating online content to market your treatments and services. She notes that people are naturally curious and potential patients enjoy looking at what’s happening in clinic. “To give people information on what to expect in a treatment, I think an in-depth video that shows the treatment process is the best thing to do. Obviously, if you are filming a particular treatment that is not going to be the nicest to look at, then I suggest editing the footage in a certain way to make sure that it wouldn’t put people off, but at the same time, you must make the portrayal genuine," BraceyWright states.

Consistently uploading content online is advantageous for remaining relevant, however quality over quantity is key for producing the best online content for an aesthetic business, according to interviewees. Considering the needs of your target audience is crucial to remain relevant, as is ensuring that potential patients leave your online platform with their questions answered. Addressing why your services can help patients in a unique way should remain at the forefront of your content marketing strategy. Dr Xu finalises her thoughts on producing successful online content by stating, “I see content marketing as the exterior packaging. What you have in terms of how good you are at your job is the product inside the packaging that patients want. You need to have a good level of quality content as a starting point, following that, providing excellent service will speak louder than words.” REFERENCES 1. Content Marketing Institute. What Is Content Marketing? <https:// contentmarketinginstitute.com/what-is-content-marketing/> 2. McGill, J. How to Develop a Content Strategy: A Start-to-Finish Guide. 2018. <https://blog.hubspot.com/marketing/contentmarketing-plan> 3. CopyPress. Blogging Vs. Vlogging: Which is Better for You?. Aug 2017. https://www.copypress.com/blog/blogging-vs-vloggingbetter/ 4. Harris, J. 10 Tips (and a Ton of Tricks) to Maximize Your Video Content Investment. Content Marketing Institute. Oct 2017. < https://contentmarketinginstitute.com/2017/10/video-contentinvestment/> 5. ASA. Cosmetic interventions Advertising Guidance (non-broadcast and broadcast). <https://www.asa.org.uk/ asset/06D92630-75DE-4DDC-81F365D94E7BA21C/>

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



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“If you can’t handle the complication, don’t do the treatment” Dr Sherif Wakil reflects on his journey into aesthetics, his love for energy-based devices and why he feels a responsibility to constantly achieve more He is a cosmetic and sexual aesthetic doctor, international trainer and founder of SW Clinic, Royale Academy of Aesthetic Medicine and the International Association of Aesthetics Gynaecology and Sexual Wellbeing (IAAGSW), so what is it Dr Sherif Wakil loves most about the aesthetics specialty and how has he got to where he is today? It was through his love of art and fine detail that he became interested in aesthetics. Dr Wakil said, “I fell in love with aesthetics straight away. When I first graduated in medicine, from Cairo University in Egypt, I worked as a resident in A&E for a short period of time and was fascinated by very fine detail, like scarring to the face for example. I wanted to learn how to make everything perfect. I love to paint and sculpt in my spare time and I think this reflects in my work today; you have to have a very artistic eye when working in aesthetics.” Dr Wakil trained in both gynaecology and plastic surgery before moving to the UK and explains that there wasn’t much scope for either fields when he moved in 2001. As a result of this, Dr Wakil trained and worked at the Royal London Hospital as a spinal surgeon, something which he notes gave him an exceptional amount of experience and confidence. “Over the eight years whilst I worked here, I was dealing with severely injured patients who required a lot of delicate, precise work. I learned so much but I knew I always wanted to go into aesthetics. All of my weekends and evenings were spent at training courses and workshops in this area and I would also work at clinics, performing filler and toxin treatments, trying to learn as much as I could,” he notes. It was the development in the industry that allowed Dr Wakil to introduce gynaecology and andrology into the aesthetics arena, something that had not been seen before in Europe. Dr Wakil had heard about the aesthetic gynaecology market coming to the fore in the US in 2010, thus deciding to go stateside and undertake extensive training in this area. His experience in America led him to meeting Dr Charles

Runels, the inventor of the O-Shot and the P-Shot, which are sexual rejuvenation treatments using platelet rich plasma (PRP). Dr Wakil reflects on working alongside Dr Runels, “When I heard about the merging of aesthetics and gynaecology, I knew this was the magic combination I had been searching for. I learned a lot from my training in the States and from that I was the first to launch the O-Shot and P-Shot treatments into Europe in 2014.” Following this launch, Dr Wakil also introduced his own trademarked protocol, The O Concept™, a variety of tailored treatments for both men and women with sexual dysfunction; something that Dr Wakil has said has created attention across the globe. “The treatment can encompass a number of different modalities such as PRP, lasers, radiofrequency or injectables with specific sequence and dose parameters. I ask them to fill out a questionnaire, and do a thorough consultation explaining all options, from that will decide what is most suited to their needs.” Following this, Dr Wakil also notes the development of energy-based devices, which he believes help him do the job he does today, “Energybased devices have improved dramatically in terms of quality, results and ease of use. As far as aesthetic gynaecology is concerned, I could not do what I do without them. In a lot of cases we can achieve almost surgical results with non-surgical treatments. It’s fantastic yet I do believe there is always more research to be done to use the devices to reach optimal results.” He continues, “When I first started doing sexual aesthetic treatments, a lot of my peers didn’t understand it. I would say, ‘I am working to help restore people’s confidence’. I am working with patients who have no sexual relationship with their partner and their whole mental wellbeing is off because of this sexual dysfunction. By performing a treatment that is designed for them, you are helping them to perform better in many aspects of their lives. My patients often tell me that I have helped to restart their lives and that, to me, is priceless.” He also advises those starting out in the specialty to make sure they are highly trained

in complications. He explains, “Practitioners should only start a career in aesthetics if they are really passionate about helping people and have an artistic eye. If you can’t handle the complication, don’t do the treatment and don’t take on anything that is beyond what you are not trained to do. A lot of my colleagues are offering complication training and I would advise every practitioner to enrol in these types of courses.” Dr Wakil explains that although he is proud of what he has achieved so far, he is always striving for more. This month he is running his second world congress and exhibition at the Royal Society of Medicine, IAAGSW, and as well as that wants to continue his international training, in which has trained more than 800 doctors. Dr Wakil concludes, “I am hungry for new knowledge and education; I feel very responsible for making changes in the industry and I want to leave a legacy behind.” Is there anything you would have done differently? I came up with a quote that I always say to myself, ‘In my 40s I am trying to resuscitate every single minute I killed in my teens’. I wish I could tell my younger self to learn something new every day! What technological tool best compliments you as a practitioner? The human body! Regenerative and functional medicine using PRP, stem cells and fat cells from your body to be part of your treatment is fascinating. What’s the main piece of advice you would give practitioners? Training. I also never speak negatively about people because I think it will always come back round to you. I always try to spread the positive karma. What’s the best piece of career advice you have ever been given? Winners concentrate on winning and losers concentrate on winners. I don’t give attention to anything that is happening outside of my goals and don’t get involved in the politics of aesthetics unless it is related to regulation, which impacts everyone.

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018


Aesthetics Journal

The Last Word Professor Marcos Sforza argues the importance of using scientifically-supported products across the aesthetics specialty Decades ago, medical aesthetic treatments were limited to surgical procedures and of course only conducted by surgicallytrained practitioners. However, today, the non-surgical field is of great importance for both plastic surgeons and other aesthetic practitioners, including doctors, dentists and nurses, as well as those trained in skin treatments such as chemical peels and energy-based modalities. Aesthetic treatments encompass an enormous range of procedures, from relatively minor interventions such as chemical peels, injectables and dermal fillers, to major surgery. However, I believe the rapid growth and diversification of the sector is compounding the difficulties of quality control. I am referring to the huge number and various types of aesthetic products now available on the market, from both reputable distributors to online sellers. I believe it is important that today’s practitioners prioritise, and have a comprehensive understanding of, science-backed aesthetic products from peels to fillers. According to research,1 many chemicals in personal care products have not been tested for safety and different ingredients may also accumulate and interact in potentially harmful ways. Chemical exposure has been linked to rising rates in breast cancer, asthma, autism, reproductive system problems, and other health issues.2 Complaints of adverse health events

related to cosmetic and personal care products more than doubled from 2015 to 2016, according to a study in JAMA Internal Medicine.3 This study states that unless we modernise and expand the collection of data about aesthetic and cosmetic procedures, industry professionals will be unable to measure or manage cosmetic results. This is because there will not be the necessary information available for professionals to check whether certain reactions to products like anti-wrinkle injections for example, are common or potentially harmful. Without a wide collection of data, we won’t have a clear idea of the necessary safety regulations, which need to be implemented in advance. Recognising the gold standard Some of these issues are partly down to the fact that practising in private medicine removes many of the checks and balances found within the National Health Service, which protect patients from experimentation and exploitation.

Aesthetics aestheticsjournal.com

However, I believe all medical and aesthetically trained professionals should be able to balance company profits with an ethical requirement to do what is best, and scientifically proven, for their patients. According to a recent study, the general gold standard for scientific testing should be randomised, double-blinded and conducted in a controlled environment. There should be human clinical trials against placebo or an approved prescription product, carried out by an unbiased third-party research group, using the final finished formulation.4 Phrases such as ‘clinically proven’, ‘dermatologically tested’, or ‘salon quality’ are just a few terms I find commonly used by companies and their marketing teams to convey the impression their products are evidence-based and, thus, effective. Some businesses also choose not to use higher doses of active ingredients in products, as they can cause side effects such as redness and skin irritation, which is not going to help sales. This is considered acceptable, so long as a product does not contain a pharmacologically-active substance or make medical claims, as it then becomes classed as a medicine.5 Therefore, a fine balancing act is created between producing a product that contains enough active ingredient, but not too much, and marketing it to convince customers it works, without catching the attention of stricter regulation. But if a product is not made to its full effectiveness, ultimately, it’s the loyal patients who are duped into procedures or treatments, which will only achieve minimal results. As well as this, various manufacturers may refer to studies on individual ingredients, but you should not assume the activity of these ingredients will be maintained when these are mixed with multiple others. For example, titanium dioxide (a naturally occurring mineral often used as a pigment or thickener) is considered to be safe when put into a viscous mixture, such as in sun cream or toothpaste. Yet in powder form, such as in mineral makeup powders, it can cause cancer when inhaled, according to the

Industry professionals should prioritise more scientifically-supported research across the aesthetics specialty

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



Aesthetics Journal


I believe all medical and aesthetically trained professionals should be able to balance company profits with an ethical requirement to do what is best for their patients International Agency for Research on Cancer (part of the World Health Organization).6 Even if there is some science behind an ingredient, manufacturers aren’t required to prove the ingredient works in that product’s specific formulation or concentration. It is also important to consider who conducted the studies on aesthetic treatments. Some companies may claim their studies are sponsored by a third party, when they are conducted in their own in-house laboratories. This may reduce the chance of the data being truly objective. The need for trial and error? The counter-argument here often focuses on the premise aesthetic treatments are ‘innocent until proven guilty’. The skincare landscape, for example, is vast and more people are trying to navigate it. For ingredients that do have evidence behind them, there are often unknowns that remain. The proposed study parameters stated earlier are also very expensive for companies to produce, which is potentially another reason why a company may not issue them. If they had to, it would be likely only big pharmaceutical companies would be the ones releasing products, thus creating a monopoly, which also wouldn’t be ideal. Confronted with the countless product choices and ambiguous information about the efficacy of different products, aesthetic professionals should continue to educate themselves and each other about what works. I believe this is only going to happen if there is some degree of experimentation involved. It’s not like shooting in the dark, of course, but there’s never going to be a ‘one-size-fits-all’ offering to suit everyone who comes in for treatments. A study may prove a product to be generally safe, but products cannot be tested on absolutely everyone, so there might still be an individual who reacts negatively to it. People have different skin types and body shapes; some are more irritated by certain ingredients and people heal in different ways too.

Future solutions I think industry professionals can and should prioritise and promote more scientificallysupported research across the aesthetics specialty and there are several ways they can do this. Firstly, clinics should encourage their staff to regularly attend scientific meetings, seminars and conferences organised by the relevant industry bodies, associations and reputable providers, so they remain informed on all the latest innovations and issues occurring across the specialty. More meetings, discussions and correspondence between stakeholders from all groups – professionals and companies – would be beneficial so guidelines focus more on what data supports certain products, which, consequently, could help integrate both surgical and non-surgical interventions. I think these guidelines should put in place a set standard for how many trials have taken place for a product, how many recipients it’s been tested on and whether these fit with the gold standard for product trials. This means professionals will only be using products with the most extensive research behind them. Of course, this could one day be a legislative framework that manufacturers and distributors must follow, although due to the current non-regulation of the aesthetics specialty this could be a long wait. In my opinion however, the specialty is starting to move more in this direction. I think this is because more people are talking about the importance of science-backed products in conferences and in clinics, so more research is starting to take place. Potential changes could include regulations that require vigorous tests on certain ingredients, which should be implemented by the relevant bodies such as the Office for Product Safety and Standards; a government body that was created in January 2018 to enhance protection for consumers and the environment.7 This would help practitioners ensure they

have the right skills to recognise whether the products they are looking to use are safe, the providers of such products are responsible and the public get accurate information and support if things go wrong with a certain product. It would also be useful to implement legislation where more products are tested outside their own research and development teams. I am not saying researchers knowingly twist information about the efficacy of treatments, but there is the possibility internal testing can create conflicts of interest, which impacts how research is presented and interpreted. Conclusion Only by providing more transparency around product claims, enhancing training and defining set guidelines for both surgical and non-surgical procedures, will science become a bigger priority in aesthetic practices across the country. Not only this, but if new legislation is enforced, it could help regulating bodies learn more about the long-term health effects of aesthetic and cosmetic products. Professor Marcos Sforza is an aesthetic surgeon who is currently the scientific director at MyAesthetics Ltd and operates for MyBreast cosmetic surgery in London. He was trained by plastic surgeon Ivo Pitanguy in Brazil. On moving to England, he has completed more than 5,000 procedures. He is also a published author of more than 30 papers, book chapters and articles on burn care, trauma, reconstruction, stem cell medicine and aesthetic surgery. REFERENCES 1. Harvard T.H. Chan. 2014. Harmful, untested chemicals rife in personal care products. <https://www.hsph.harvard.edu/news/ features/harmful-chemicals-in-personal-care-products/> 2. Harvard T.H. Chan. 2014. Harmful, untested chemicals rife in personal care products. <https://www.hsph.harvard.edu/news/ features/harmful-chemicals-in-personal-care-products/> 3. Kwa, Michael, BA, Welty, Leah, Phd, Xu, Shuai, MD, MSc ‘Adverse Events Reported to the US Food and Drug Administrations for Cosmetics and Personal Care Products’, JAMA Intern Med., Volume 177, No. 8, (August 2017) p. 1069 – 1228 4. Sullivan, Gail M., MD, MPH, Getting Off the “Gold Standard”: Randomized Controlled Trials and Education Research, Journal of Graduate Medical Education, Volume 3, No. 3, (September 2011) p. 285-289 5. Chemistry World. 2012. Here comes the science bit. <https:// www.chemistryworld.com/feature/the-science-of-skincare/5494. article.> 6. Scientific American. 2009. Saving Face: How Safe Are Cosmetics and Body Care Products? <https://www. scientificamerican.com/article/how-safe-are-cosmetics/.> 7. Office for Product Safety and Standards (UK: GOV.UK, 2018) < https://www.gov.uk/government/organisations/office-forproduct-safety-and-standards/about>

Reproduced from Aesthetics | Volume 5/Issue 11 - October 2018



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Rosmetics info@rosmetics.co.uk rosmetics.co.uk 0345 5050601

Lumenis UK Ltd Contact: Hannah Nugwela hannah.nugawela@lumenis.com Tel: 0208 736 4110 www.lumenis.com/Aesthetic

Schuco International (London) Limited 01923 234 600 sales@schuco.co.uk www.schuco.co.uk

e Eden Aesthetics Contact: Tania Smith +44 01245 227 752 info@edenaesthetics.com www.edenaesthetics.com www.epionce.co.uk

macom® Contact: James Haldane macom® - compression garments & shapewear +44 (0)20 7351 0488 info@macom-medical.com www.macom-medical.com


SkinCeuticals www.skinceuticals.co.uk contact@skinceuticals.co.uk

Med-fx Contact: Lorraine McLoughlin +44 01376 532800 sales@medfx.co.uk www.medfx.co.uk

e-MASTR info@e-mastr.com www.e-mastr.com

Enhance Insurance Contact: Sharon Allen sharon.allen@enhanceinsurance.co.uk 0800 980 776 www.enhanceinsurance.co.uk

Medira Ltd +44 (0) 800 292 2014 info@medira.co.uk www.medira.co.uk

Fusion GT 0207 481 1656 info@fusiongt.co.uk www.fusiongt.co.uk

Church Pharmacy 01509 357 300 info@churchpharmacy.co.uk www.churchpharmacy.co.uk

Medical Aesthetic Group Contact: Jenny Claridge +44 02380 676733 info@magroup.co.uk www.magroup.co.uk

Flawless Pen enquiries@flawlessdistribution.co.uk www.flawlesspen.com Contact 07841 389234 Service: Microneedling, Training, Support


MedivaPharma 01908 617328 info@medivapharma.co.uk www.medivapharma.co.uk Service: Facial Aesthetic Supplies

Galderma (UK) Aesthetic & Corrective 01923 208950 Email: info.uk@galderma.co.uk https://aesthetics.galderma.co.uk


HA-Derma IBSA Italia’s aesthetic portfolio UK and Ireland. Contact: Iveta Vinklerova 0208 455 48 96 info@ha-derma.co.uk www.ha-derma.co.uk Services: Distributor of IBSA’s Profhilo, Aliaxin, Viscoderm, Skinko

WELLNESS TRADING LTD – Mesoestetic UK Contact: Adam Birtwistle +44 01625 529 540 contact@mesoestetic.co.uk www.mesoestetic.co.uk Services: Cosmeceutical Skincare Treatment Solutions, Cosmelan, Antiagaing, Depigmentation, Anti Acne, Dermamelan

Aesthetics | October 2018


Surface Imaging Solutions Limited Medical imaging software and Photography Systems Nicolas Miedzianowski-Sinclair 07774802409 nms@surfaceimaging.co.uk www.surfaceimaging.co.uk

Syneron Candela UK Contact: Head Office 0845 5210698 info@syneron-candela.co.uk www.syneron-candela.co.uk Services: Syneron Candela are global brand leaders in the development of innovative devices, used by medical and aesthetic professionals.



01159 140640 enquiry@cosmeticdigital.co.uk www.cosmeticdigital.co.uk

John Bannon Pharmacy enquiries@johnbannonpharmacy.co.uk www.johnbannonpharmacy.co.uk Contact: 01827 338115


Beamwave Technologies 0208 191 7117 hello@beamwave.co.uk www.beamwave.co.uk

Cosmetic Digital Aesthetics and Medical Cosmetics Digital Marketing and Web design


Digital Aesthetics team@digitalaesthetics.co.uk digitalaesthetics.co.uk 0203 397 3736 Creative and Marketing Agency

blowmedia Creative and Digital Design agency Contact name: Tracey Prior tracey@blowmedia.co.uk 01628 509630 www.blowmedia.co.uk

Consentz Medical Practice Software Contact: Tai Gantois 01932 481 081 contact@consentz.com www.consentz.com

Skin Diagnostic Equipment ian@observ.uk.com www.observ.uk.com 07773 778 493



Boston Medical Group Limited Distributor of Revanesse info@boston-medical-group.co.uk www.boston-medical-group.co.uk 0207 727 1110



DermaLUX Contact: Louise Taylor +44 0845 689 1789 louise@dermaluxled.com www.dermaluxled.com Service: Manufacturer of LED Phototherapy Systems

AestheticSource Ltd Contact: Sharon Morris 01234 313130 www.aestheticsource.com sharon@aestheticsource.com

Natura Studios 0333 358 3904 info@naturastudios.co.uk www.naturastudios.co.uk



5 Squirrels Own Brand Skincare www.5squirrels.com info@5squirrels.com


List your company details here for £750+VAT for 12 issues For more information contact Aesthetics – 0203 096 1228 hollie@aestheticsjournal.com

t TOR Generics LTD Contact: Sharon Wilson 01923 836700 www.tor-generics.com/

TEOXANE UK 01793 784459 info@teoxane.co.uk www.teoxane.co.uk

Thermavien Contact: Isobelle Panton isobelle@thermavein.com 07879 262622 www.thermavein.com


Read her lips

90% of patients thought the results with Restylane Kysse looked natural 24 weeks after treatment.1 Date of preparation: November 2017 RES17-11-0695f

Reference: 1.Data on file. AMWC Monaco Poster, 2015

Profile for Aesthetics

October 2018  


October 2018