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Facing the future Leading experts share their thoughts on the year ahead in aesthetics

Tech talk How to choose the best fat reduction technologies for your clinic Anatomy of the forehead - CPD Mr Dalvi Humzah and Anna Baker on the frontalis muscle. CPD accredited article

Weight loss Dr Martyn King discusses the value of combining cavitation with a diet and exercise plan

Rules of engagement Bernadette John on the potential pitfalls of social media for business

Prescribing Information can be found on the inside front cover Date of preparation November 2013 1132/BOC/NOV/2013/LD

Practitioners & their patients feel the difference... “The favourable safety profile has lead to high patient satisfaction and subsequent recommendations from one patient to another, increasing our practice1”

Not palpable2 ®

No Tyndall Effect1 ®

Comfortable on injection2 ®

Best Customer Service Voted in 2011, 2012, & 2013

1. Kuhne, U et al. Five-year retrospective review of safety, injected volumes, and longevity of the hyaluronic acid Belotero Basic for facial treatments in 317 patients. J Drugs Dermatol. 2012 Sep; 11(9):1032-5 2. Data on File: BEL-DOF2_001 Belotero Juvederm Study MRZ 90028_4007

Injectable Product of the Year 2013

Tel: +44(0) 333 200 4140 Fax: +44(0) 208 236 3526 Email:

Date of preparation: November 2013 1132/BOC/NOV/2013/LD

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common(≥1/100,<1/10);uncommon(≥1/1000,<1/100);rare(≥1/10,000,<1/1000);veryrare(<1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis,

eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. GeneraldisordersandadministrationsiteconditionsUncommon:injectionsitereactions(bruising,pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: FEB 2012. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to or on +44 (0) 333 200 4143. 1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. Date of preparation: November 2013 1132/BOC/NOV/2013/LD


Contents • January 2014 INSIDER 05 THE WORD Emma Davies on the benefits of association membership 06 NEWS The latest product and industry news

CLINICAL PRACTICE Forehead Anatomy Page 22

12 ON THE SCENE Out and about in the industry this month 14 NEWS SPECIAL: FACING FORWARD Industry experts share their predictions for 2014

CLINICAL PRACTICE 17 SPECIAL FOCUS: FAT REDUCTION Choosing the right technology for your clinic 22 CPD CLINICAL ARTICLE Dalvi Humzah on the anatomy of the forehead 27 CLINICAL FOCUS Dr Martyn King discusses combining cavitation with a diet and exercise plan 30 TECHNIQUES Dr Mike Comins highlights the importance of good hygiene with injectables 33 CLINICAL STUDY We summarise the results of a multicentre study on non-invasive cryolipolysis 36 SPOTLIGHT ON Mr Alex Karidis explains the practical benefits of the new VelaShape III 39 TREATMENT FOCUS Dr Mervyn Patterson on the relationship between chronic inflammation and skin ageing 42 ABSTRACTS The latest clinical studies

IN PRACTICE 45 THE DANGERS OF SOCIAL MEDIA Bernadette John on what to avoid when communicating your business online 48 HIRING AND FIRING Specialist lawyer Vanessa Di Cuffa on recruitment regulation 50 PITCHING TO THE PRESS Publicist Tingy Simoes gives an insider’s guide on selling your story 52 THE PROFESSIONAL NO Wendy Lewis on the fine art of screening patients 54 IN PROFILE We speak to Lee Garrett about his unusual journey into the industry 56 THE LAST WORD Natalie Blakely shares her views on the Voluntary Register

Subscribe to Aesthetics Subscribe to Aesthetics, the UK’s only free of charge journal for Medical Aesthetic Professionals. Visit or call 01268 754 897.

IN PRACTICE Voluntary Register Page 56

This month’s contributors Emma Davies is chair of the BACN and has been an aesthetic nurse since 1998. She is also one of the founders of The British Association of Sclerotherapists. Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon based at Plastic and Dermatological Surgery. He is key opinion leader for many aesthetic companies. Dr Martyn King is owner and director of Cosmedic Skin Clinic and medical director of Cosmedic Pharmacy. He is chair of the Managing Aesthetics Complications Expert Group. Dr Mike Comins is president and fellow of BCAM. He is part of the cosmetic interventions group and is an accredited trainer for advanced Vaser liposuction. Mr Alex Karidis is a plastic surgeon with over 25 years of experience. He has run his own practice at St John’s Wood for 17 years. Dr Mervyn Patterson is an experienced aesthetic doctor specialising in injectable anti-ageing treatments. He is co-owner at Woodford Medical. Dr Natalie Blakely is a renowned cosmetic doctor and medical director of the Light Touch Clinic in Surrey, who also created patient record system Consentz for the iPad.


• IN FOCUS: Smile and lower face • Interdisciplinary aesthetic dentistry • Psychological impact of aesthetic treatments • Keogh Review latest

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Editors’ letter

The word

Welcome to a new year and a new issue of Aesthetics. Our clinical focus this month is non-surgical body contouring, helping you to think about key Leah Hardy considerations when choosing a fat Editor reduction system for your clinic. This month, talk has centred around the desire throughout the industry to improve standards. It has become clear that the regulation that we’d all hoped for post-Keogh is not going to happen. Contributors Dr Natalie Blakely, (p56) Emma Davies of the BACN (p54) and aesthetic nurse Lee Garrett have all suggested that it is time for the profession to come together to establish minimum standards, and insist on better training and improved ethics. As the leading industry journal for aesthetic medicine, we endeavour to play our part in this, through the introduction of CPD articles, the provision of guidance on law and ethics surrounding consent and the use of digital photography (p 45). Finally, in our special supplement read all about last month’s Aesthetics Awards, which recognised the industry’s best. We wish you all a successful 2014, and many happy patients.

The British Association of Cosmetic Nurses was formed in 2010 and our role has proved even more vital than we originally anticipated. Within months of our formation, professional bodies banned remote prescribing for cosmetic indications, leaving nonprescribing nurses in a state of confusion. We were able to give Emma Davies unambiguous advice, build relationships with universities, and Chair, BACN support members adjusting to the change. We participated in the consultation process of The Keogh review, representing the views of nurses from a credible evidence base informed by our membership survey. Had the BACN not had a membership of 600, we would not have been invited to the table and nurses may not have been represented. Concurrently, The British Standards Institute was working with European committees to produce a European Standard for cosmetic services. Again, we participated and successfully ensured that nurses with the prescribing qualification are recognised as qualified to practice independently. Had the BACN not existed, nurses would certainly have been excluded from the document. The Department of Health has charged Health Education England with setting a standard for education. BACN have been invited to join an expert committee and will go prepared with our Competency Framework and a draft framework for education. Now, more than ever, those in aesthetic practice must appreciate the importance of bodies such as BACN and BCAM, who need the support and engagement of members in order to ensure that the future landscape of aesthetics is one we can feel safe and proud to be part of. The higher the membership; the greater the influence we have. Visit for more information.

Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s advisory board to help steer the direction of educational, clinical and business content. Dr Mike Comins is President and Fellow of the British College

Amanda Cameron is a sales and marketing professional,

of Aesthetic Medicine. He is part of the cosmetic interventions working group, and is on the faculty for the European College of Aesthetic Medicine. Dr Comins is also an accredited trainer for advanced Vaser liposuction, having performed over 3000 Vaser liposuction treatments.

and was one of the first nurse injector trainers in the UK for dermal fillers. With over 20 years experience in the industry in both the UK and Europe, Amanda has extensive knowledge of medical aesthetics and business development.

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is an aesthetic doctor and previous

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.

maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, who fell in love with the results possible through minimally invasive methods. Now based at Beyond Medispa in Harvey Nichols, she practises cosmetic injectables and hormonal based therapies.

Sharon Bennett is currently Vice Chair of the British

Dr Nick Lowe is president of the BCDG and a Consultant

Association of Cosmetic Nurses (BACN) and also the UK lead on the BSI committee for aesthetic non-surgical medical standard. Sharon has been developing her practice in aesthetics for 25 years and has recently taken up a board position with the UK Academy of Aesthetic Practitioners (UKAAP).

Dermatologist with over 30 years of experience and practices in London and California. Dr Lowe is Clinical Professor of Dermatology at the UCLA School of Medicine in Los Angeles, as well as director of a clinical research company specialising in skin ageing.

PUBLISHED BY EDITORIAL Chris Edmonds • Managing Director T: 01268 754 897 | M: 07867 974 121 Leah Hardy • Editor T: 01268 754 897 | M: 07880 812 582 Suzy Allinson • Associate Publisher T: 01268 754 897 | M: 07500 007 013 Sarah Dawood • Journalist T: 01268 754 897 | M: 07788 712 615 Betsan Jones • Journalist T: 01268 754 897 |

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Insider News

Letters “I read about the introduction of 4T medical 32G FMS Fine Micro Syringe in the November issue of Aesthetics and subsequently purchased them for use in my clinic. They have proved to be very successful, with my Botox patients reporting much greater comfort during treatment. These small innovations can make a big difference to patients. Thank you Aesthetics for bringing these new needles to my attention.” Lee Garrett, Director of FreedomhealthSKIN

“I always used to enjoy my Cosmetic News monthly read and knew there was a change in the air, but I had forgotten about that when I received the journal in the post. I was intrigued with the sealed Cosmetic News cover and peeled this to reveal the new Aesthetics cover. I thought this was so clever, and alone as I was in the clinic I burst out laughing with childish joy. Ingenious! What a great way to launch the magazine, and being so near to Christmas it really felt like opening a present.” Lou Sommereux, Specialist Cosmetic Nurse

Talk Aesthetics

Industry experts rally against Government’s inaction “Best practice and patient safety must come first,” is the message from three industry experts rallying for a mandatory register for those administrating cosmetic injectables. Helena Collier, clinic director and aesthetic nurse at Skintalks, aesthetic nurse Lorna Bowes and Editor of the Journal of Aesthetic Nursing Natasha Devan have spoken out against the Government’s “immoral position” in prioritising economic growth over the safety of cosmetic patients. Their comments follow Sir Bruce Keogh’s recommendations for cosmetic intervention regulation, and the Government’s apparent subsequent decision to hold back on regulating the industry. Collier said, “It is utterly appalling that, for a second time, the supreme decision-making committee of our country has chosen to turn its back on protecting the British public from serious harm.”

Biothecare Estétika reveal UK franchise opportunities Biothecare Estétika has announced UK franchise opportunities for business professionals looking to specialise in non-invasive aesthetic therapies. The European aesthetic franchise has over 170 existing treatment centres spanning 15 countries. Biothecare Estétika’s therapies include electro-stimulation to define body contours, skin peels to revive and rejuvenate the skin, and photo acne to purify and clarify troublesome skin. All treatments are carried out by formally trained professionals, and franchise packages are delivered with full training and on-going technical and medical support. Biothecare Estétika have been practicing their mantra of safe, effective and medically approved treatments in the UK for the past three years.

Sterimedix launch fully compatible cannulas

#relaunch Good Surgeon Guide / @goodsurgeon @aestheticsgroup love the new look. Especially enjoyed the insider news special report. Congratulations! #labialreduction Dr Monah / @Doctor_Monah @aestheticsgroup just think that too many women feeling pressurised about such procedures which are often unnecessary.... Raising money for #changingface at the #aestheticsawards James Partridge / @JRJPartridge @aestheticsgroup What a brilliant evening it must have been! I can assure you we will use £2,278 very carefully indeed... If you want to be featured in next month’s letters section, email us at or follow us on Twitter @aestheticsgroup and include#talkaesthetics in your comments. 6

Sterimedix has launched aesthetic cannulas that are fully compatible with all types of filler syringes from all manufacturers. The updated range uses a pre-hole needle one size larger to facilitate smooth cannula insertion. Sterimedix Silkann cannulas, the only UK manufactured cannulas available on the market, range from 18g to 30g with varying lengths, and are compatible with all manufacturers including Juvéderm. Designed specifically for the injection of dermal fillers, the Silkann range incorporates safety features that include a screw thread polycarbonate hub, reducing the risk of cannula detachment during use, and markers to signal the orientation of the port during injection.

Aesthetics | January 2014

Insider News

EF MEDISPA introduce Neckline Define EF MEDISPA have introduced the new Neckline Define peel to their range of treatments. The medical spa, which previously won Best Clinic Chain at the 2011 Aesthetics Awards, now offer the newly-launched peel at their range of spas in Kensington, Chelsea and St John’s Wood. The peel works to redefine ageing skin as well as to protect younger skin, making it suitable for patients of various ages. A combination of creams and a hand held roller device, the treatment contains Pyruvic Acid, Lactic Acid and Acetyl glucosamine which increase the levels of hyaluronic acid in the skin to offer a firming and plumping effect. Patients experience minimal downtime and redness due to the way the treatment works beneath the surface layers of the skin, and this is maintained with a personalised home package.

Report reveals urbanites’ attitudes towards procedures An international survey by a global media company has provided insight into young working professionals’ attitudes towards medical aesthetics. Global media company Metro International S.A. has conducted its largest study to date on the attitudes of urbanites living in Hong Kong, Moscow, London, New York and Sao Paolo. The results, incorporating data from social media, show that 10% of Metropolitan women think it’s OK for men to get Botox and 29% of the people asked think someone in their group of friends or family needs plastic surgery, whilst 52% of Metropolitan women believe it’s OK for men to have hair-transplantation procedures. The Metropolitan Report is the third of its kind, and describes its target as the “upwardly mobile urbanite”. Additional data was collected from social media conversations as monitored by Whispr Group for a period of three months.

Free exhibition entry for ACE Entry to The Aesthetics Exhibition, as part of the Aesthetics Conference and Exhibition 2014, will be free of charge. As the UK’s largest exhibition of premium aesthetic manufacturers and distributors, The Aesthetics Exhibition will be open to all industry professionals looking to find out about the best products and services currently on the market. The Aesthetics Conference and Exhibition, now in its fifth year running (formerly CN EXPO), is expected to have over 2,000 visitors in March next year. Attendees will have the opportunity to participate in 25 free workshops and meet with over 80 exhibitors. The workshops, a combination of clinical and business, will range from mastering the latest techniques to expanding a client base. The largest UK event to focus solely on aesthetic medicine, the conference and exhibition together offer approved professional development lectures, workshops and masterclasses, as well as business seminars and customer service workshops. To find out more about ACE and to book your place, visit the website at or call 01268 754 897.

News in Brief Sharon Bennett elected member of CEN Deputy Chair of BACN and member of Aesthetics editorial advisory board Sharon Bennett has been elected as UK Expert on the European (Cen) standard in non-surgical medical aesthetics. “I will be leading on editing the new non-surgical, cosmetic, medical standard for Europe and liaising with our European colleagues at CEN,” said Bennett. New Skin Health for Life concept HydraFacial now offer monthly facials on a direct debit basis, promoting the concept of ‘Skin Health for Life’. The concept, aimed at improving the long-term quality of the skin, is backed by a host of leading industry experts including Mr Alex Karidis. MEDfx partner with ACE We are delighted that Med-fx will be the consumables and registration partner for the Aesthetics Conference and Exhibition (ACE) in March 2014. Med-fx Limited is part of one of the UK’s largest specialist medical products distribution groups. 3D-Aesthetics launch Duo cryolypolisis device 3D-Aesthetics have launched a new Duo cryolypolisis device that treats two areas in one session. 3D-lipomed uses a combination of technologies to target fat removal, including cavitation ultrasound and radio frequency for tightening. Interest in pixel laser resurfacing decreases According to statistics from clinic comparison site, enquiries for pixel laser resurfacing has dropped by 59% in the past 12 months. Based on enquiries in the last quarter of 2013, has estimated that enquiries for Platelet rich plasma (PRP) filler will enjoy the biggest rise in interest in 2014, at 807%. New book on appearance anxiety A new clinical manual has been published providing a CBT-based approach to appearance anxiety. CBT for Appearance Anxiety: Psychosocial Interventions for Anxiety due to Visible Difference is published by Wiley-Blackwell and looks at individuals distressed about a visual difference, such as a disfigurement from birth. Addendum The authors of the study ‘Physical Properties of Hyaluronic Acid Fillers,’ which was cited in our December issue, were omitted. They are: A.Ö. Bingöl, PhD and A. Dogan, PhD; Research & Development, Adoderm.

Aesthetics | January 2014


Insider News

Vivacy introduce labial injection with live workshop

PIP’s Jean-Claude Mas jailed for fraud

Vivacy and Medical Aesthetic Group introduced their Hyaluronic Acid treatment at a workshop in London’s Courthouse Clinic in December. Desirial, which is an injection of a crosslinked Hyaluronic Acid gel into the dermis of the labium, works to maintain elasticity and proper functioning of female genital tissue, which can become thin and dry. Leading French gynaecologist-obstetrician Dr Berrini carried out practical demonstrations on three models, illustrating proper technique and addressing the treatment’s reconstructive values in improving the thickness and quality of the skin and the support tissues. Dr Kathryn Taylor Barnes, an attendee at the workshop, said, “Desirial treatments are usually performed once or twice per year depending on symptoms. It can be used just for the appearance of the area, or can be used to enhance the strength and integrity of the vulval tissues.” Desirial is formulated from a combination of hyaluronic acid with mannitol making the product a natural antioxidant. Desirial will be launched officially at IMCAS at the end of January.

A court in Marseille found PIP’s Jean-Claude Mas guilty of fraud on Tuesday 10 December. The head of Poly Implant Prothèse was sentenced to four years in prison and ordered to pay a fine of €75,000 (£45, 638). The 74-year-old was found guilty of fraud after using industrial-grade silicone, and not medical-grade silicone, in thousands of defective breast implants sold all over the world. Mas has been permanently banned from working in medical services. Lesser sentences were given to four other former PIP executives.

Dr Nick Lowe joins Aesthetics editorial board Dr Nick Lowe is the newest member of the Aesthetics journal Editorial Advisory Board. Joining a team of industry experts, renowned consultant dermatologist Dr Nick Lowe contributes over 30 years of experience in the industry to the group who help to steer and guide the direction of the journal. Dr Lowe was also recently elected as President of the British Cosmetic Dermatology Group (BCDG), which is part of the British Association of Dermatologists (BAD). In his new position, Professor Lowe plans to run weekend training courses in safe and ethical skin rejuvenation for dermatologists. Of the appointment he said, “My plans are to increase the visibility of British Association of Dermatology as the best-known professional group for skin ageing, skin cancer, laser therapy, and all diseases of the skin, hair and nails.”

Vinoderm launches skincare priorities range in the UK Swiss premium brand Vinoderm will introduce their specialised skincare to the UK in early 2014. The skincare range consists of five clusters of products targeted at individual skincare priorities. The clusters are individually grouped as Protection, Anti-Ageing, Whitening, Essential and Cleansing, and individually address issues such as elasticity, pigmentation and premature ageing. Each product combines grapeseed antioxidant as the unifying ingredient, with an additional active substance that works to differentiate the effect of each range. The Vinoderm products derive from Viniferol, an ingredient extracted from grape seeds and known for its antioxidant properties. This extract combines water-soluble procyanidins and oilsoluble tocopherols, which together work against oxidative stress, slowing down the ageing process. The line will be available to sell at medical aesthetic clinics after the new year.

93% of patients say they would have Radiesse® again1... 86% feel more attractive2

80% feel more confident2

95% would recommend Radiesse2

RAD070/0813/LD Date of Preparation: August 2013

1. Moers-Carpi M et al, Physican and Patient Satisfaction After Use of Calcium Hydroxylapatite for Cheek Augmentation. Dermatol Surg 2012, 38: 1217-1222. 2. Tzikas T. A 52 month Summary of Results Using Calcium Hydroxylapatite for Facial Soft Tissue Augmentation. Dermatol Surg 2008, 34, (Supp 1): s9-s15

no wonder you Best Customer Service Winners in 2011, 2012, & 2013

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Industry News


Dr Andrew Vallance-Owen joins ACE Question Time panel The former Medical Director of Bupa is to join the ACE Question Time panel in March. Dr Andrew Vallance-Owen, who is a member of Sir Bruce Keogh’s Cosmetic Interventions Review team, will join the panel as part of the Aesthetics Conference and Exhibition (ACE). Chaired by former BBC News and ITN broadcaster Peter Sissons, the evening will take place on Saturday March 8 at The Business Design Centre. The panel will be comprised of medical aesthetic experts who will share their opinions on the latest topics influencing the industry today. Other panel members include Apprentice winner Dr Leah Totton, Fellow of the British College of Aesthetic Medicine (BCAM) Dr Mike Comins, founder of the Cosmetic Skin Clinic Dr Tracy Mansford, and vice chair of the British Assosication of Cosmetic Nurses (BACN), Sharon Bennett. We are delighted to announce that the evening will be sponsored by 3D-lipolite, a new three-dimensional weight loss program combining treatment with diet and exercise. The event has limited availability and front row seats are offered on a first come first served basis. Tickets are £39. To avoid disappointment, book your place online today at or call 01268 754 897.

SkinBase announce Pay As You Go system SkinBase have announced the launch of their latest IPL machines with patented Pay As You Go technology. The IPL PAYG allows operators to obtain the machines for a small refundable security deposit, instead paying a fixed fee based on the type of treatment performed. Each time a treatment is carried out the IPL machine communicates with headquarters and the operator pays 30% of the treatment price. An affordable option for clinic owners, the SkinBase IPL works to offer permanent hair reduction, photo rejuvenation, and acne and vascular lesion treatments. The SkinBase IPL features the largest applicator head on the market at 13.02cm.

Ann Clwyd chairs panel at The Westminster Briefing A panel of industry and policy experts came together on 26 November to discuss changes that may be implemented to the industry following the Keogh Review. The Review, led by Sir Bruce Keogh, was set up following the recent PIP scandal and called for major regulatory change in the cosmetic surgery industry. 43 delegates attended the briefing. The panel was chaired by Ann Clwyd MP and included Tim Baxter, the lead for the Implementation team at the Department of Health, Sally Taber, who spoke about the Independent Sector Complaints Adjudication Service, and Dr Andrew Vallance-Owen, a member of the Review team. Delegate Helena Wilday, clinic co-ordinator at The Cosmetic Clinic, said, “I think the report will be brilliant for patient welfare. Clinics that are completely transparent will come out the stronger ones.” Sally Taber said that the control of practitioners would be the most prominent change as a result of the review, as long as regulators take that on board. Health Minister Dr Dan Poulter MP is leading the government’s response to the review, hoped to be due by the end of December.

of men in the USA underwent Botox injections in 2012 The American Society for Aesthetic Plastic Surgery

all online traffic to Medical Aesthetic clinics is via a mobile device


2,000 13%


who undergo non-surgical treatments such as dermal fillers and chemical peels revealed that

have previously received treatments from untrained friends and acquaintances Transform Cosmetic Surgery survey

treatment for those between the

age of 35-50


is botulinum toxin ASAPS Cosmetic Surgery National Data Bank Statistics


= of Metropolitan women think

it’s OK for men to get Botox Metro International S.A


people surveyed have non-surgical treatments to look “a little fresher”

of 1,500

Transform Cosmetic Surgery Group



11 to 30 year olds

are affected by


Acne Academy


Aesthetics | January 2014

clinics in the UK surveyed said Thursday was the busiest day of their week


Insider News

BACN update Competency Framework

Events diary 30th January - 2nd February 2014 International Master Course on Ageing Skin - IMCAS Annual Meeting 2014, Paris

The British Association of Cosmetic Nurses (BACN) has released revised competencies intended as a guide of practice for their members. The document provides an update to the existing Competency Framework and aims to raise quality in practice by stressing the need to establish and maintain appropriate standards of education, training and practice. It is accredited by the RCN and is intended for use by individuals, to map their learning and level of practice through self-assessment, and for trainers and educators to structure their courses. It is also for mentors and appraisers to use as a tool for planning and setting goals, and for employers to identify skills and implement staff supervision. Emma Davies, chair of the BACN, said, “In the light of recommendations made in The Keogh Report this document should prove extremely useful for those charged with developing a framework for education and training fit for purpose. “The field of aesthetic medicine must become a safe and respectable specialism and professional bodies can make that happen, with or without the impetus of government.” BACN will be engaging with Health Education England and will also present their Framework for Education in Aesthetics, building on the Competency Framework. “We look forward to collaborating with all the relevant disciplines, who we are optimistic will come together working towards the goals we all share,” said Davies. The association will also revise and update their Competency framework again next year.

8th - 9th March 2014 Aesthetics Conference and Exhibition ACE 2014, London 3rd - 5th April 2014 Anti-Ageing Medicine World Congress AMWC 2014, Monaco 20th - 22nd June 2014 Facial Aesthetic Conference and Exhibition - FACE 2014, London 20th September 2014 British College of Aesthetic Medicine BCAM Conference 2014

FemiLift hosts first international workshop

25th - 26th September 2014 The British Association of Aesthetic Plastic Surgeons - BAAPS Meeting 2014, London 3rd October 2014 British Association of Cosmetic Nurses BACN Meeting 2014, London

Energy-saving light could cause skin damage A recent study by the British Journal of Dermatology concluded that some energy-saving light could damage photosensitive skin. The study revealed that some compact fluorescent lamps (CFLs) emit UVA rays that pose a risk to sun-sensitive skin, causing skin damage and redness. The scientists behind the study found that, “UVR from CFLs can aggravate the skin of photosensitive and healthy individuals when situated in close proximity.” Renowned consultant dermatologist Dr Nick Lowe commented on the survey’s results, highlighting the importance of wearing a daily SPF 15 UVA protective day cream to avoid damage and ageing. Dr Lowe’s previous research has shown that very small amounts of UVA could lead to skin damage and accelerated skin ageing.


The First International FemiLift Workshop took place at London Bridge Plastic Surgery last month, and was attended by over 40 doctors, gynaecologists and surgeons from China, Europe and all over the UK. Mr Chris Inglefield, chief surgeon at London Bridge Plastic Surgery, presented an introductory lecturer to laser non-invasive treatment methods for vaginal rejuvenation and stress urinary incontinence. Yair Leopald, vice president of Alma Lasers Surgical then gave a presentation on CO2 laser principles, which was followed by three live procedures carried out by Mr Inglefield. Each took less than 10 minutes to perform. Alma Surgical FemiLift is a non-invasive method of vaginal tightening that offers an alternative to surgery. It aims to help women with stress urinary incontinence and unfulfilling sex lives, and therefore aims to improve self-confidence and relationships. It is a concentrated, thermal heating system for the vaginal tissue’s inner layers, inducing collagen and elastin contraction and regeneration to make the vaginal canal smaller. The treatment remodels vaginal tissue, providing structural changes in the vagina and urethra, over a series of up to five treatments, two to four weeks apart, and is undertaken by a gynaecologist. Femilift can only be performed by a gynaecologist or a plastic surgeon with experience of female genital plastic surgery.

Contribute Are you interested in submitting an article, study or letter to Aesthetics.? We are interested in helping you share your knowledge and expertise. Contact the editor

Aesthetics | January 2014

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Insider On the scene

Karen Betts Gift of Confidence event, Vanilla, London

IAAFA Annual Conference 2013, The Royal College of Physicians, London

Leading permanent cosmetic make-up artist Karen Betts hosted an event offering exclusive confidence boosting treatments for people with medical conditions. The ‘Gift of Confidence’ evening took place on 25 November and offered permanent makeup, facials, skin therapy, nouveau lashes and HD brows. The treatments aim to help cancer patients, those with facial disfigurement, mastectomy, hair loss, burns, scars, cleft lips and more. “We’re changing perceptions of permanent make up, giving real insight into the positive impact it has on people’s self esteem,” said Karen Betts, managing director of Nouveau Beauty Group. “Losing the eyebrows and lashes can be traumatic. I needed to do an event like this for the industry, to show people that this work is out there.” The treatment sessions were complemented by inspirational stories from a host of Karen’s clients. Diane Ayre, who has previously undergone chemotherapy, said, “Whilst doctors heal the body, getting the eyebrows back helps fuse physical and emotional healing. Medical tattooing can start the process of restoring you as a person.”

The annual conference held by The International Academy of Advanced Facial Aesthetics (IAAFA) featured a selection of lectures from medical professionals, business managers and manufacturers. The lectures showcased treatment demonstrations, new products and business advice, including topics such as skin hydration, treating the perioral region and harnessing social media. The two-day event was host to 27 speakers, was attended by 180 delegates, and took place on 29 and 30 November. Bob Khanna, president and founder of the IAAFA, said, “Our aim is to give doctors and dentists a broad understanding of medical aesthetics, and of the latest advances in surgical and non-surgical work. The conference will enable practitioners to provide the best for their patients and arm them with the very best information to transfer optimum treatment outcomes.”

The Aesthetics Awards, Grange Tower Bridge Hotel, London

National Aesthetic Nursing Conference, London

The winners of the Aesthetics Awards were announced at a glamorous ceremony held in London on 7 December. Over 500 medical aesthetic professionals attended the event, which was sponsored by Syneron Candela and Uma Jeunesse. 140 candidates reached the final, and winners were decided based on votes from journal readers, a specially selected judging panel and feedback from mystery shoppers. Winner of the Rising Star award, Dr Johanna Ward, (seen here with Dr Leah Totton), said “Winning an award was a great honour and very humbling. The Aesthetic Awards are a wonderful opportunity to celebrate the outstanding achievements of individuals and innovators in our industry.” For the full story, see our Awards Supplement.

The Journal of Aesthetic Nursing (JAN) held their second National Aesthetic Nursing Conference on December 13. The day conference saw a host of speakers address issues, including laser skin resurfacing, facial anatomy and the future of aesthetic nursing. Marea Brennan Thorns, awarded Aesthetic Nurse of the Year 2013 by the British Journal of Nursing, delivered the keynote address on the vision of aesthetic nursing by 2020. Natasha Devan, editor of JAN, stressed the importance of the conference as a supportive network. “It’s for aesthetic nurses to feel part of a community, especially those who work in isolation,” she said. “The government doesn’t necessarily support this industry, so it’s important for us to come together for support.”

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Insider News Special Report

At the beginning of a new year, we asked the members of our editorial advisory board what they predict will be the most important developments and key trends in aesthetic medicine in 2014

Facing the future Sharon Bennett

Dr Mike Comins

“I hope 2014 will see the government push forward recommendations from the Keogh Report, particularly with regard to education and training of medical aesthetic professionals. As I write, Health Education England is consulting with representative organisations (BACN, BCAM, BAD etc.), but await a government formal decision on the next stage. Recently, the European Standards Organisation (CEN) approved a new work item: the Non-Surgical Medical Aesthetic Services standard. I am pleased to be leading the British Standards Institute UK committee on this document in 2014, and liaising with our European Colleagues. Once the standard is complete I hope that eventually it will be regarded as the minimum requirement to practice here in the UK.”

Mr Adrian Richards

Dr Sarah Tonks

“One innovation in particular that I’m interested in for 2014 is a US-based topical botulinum toxin type A topical gel from Revance Therapeutics, for those who are looking for the muscle-relaxing effects of Botox, without the use of needles. It’s likely to be approved in the US and we wait to see when it will be available here, as it’s supposed to be very effective for treating the thin skin of the under-eye area. Another is a new lipolytic injection using deoxycholate, for dissolving localised areas of fat, such as double chins. While fat dissolving injections are already available, this is the first involved in a full-scale drug trial, so the findings, due mid 2014, should be very interesting. I’m hoping the government response to the Keogh report will have positive implications. As more aesthetic practitioners enter the industry, and demand for treatments grows, I believe it’s absolutely crucial to establish a proper regulatory framework to make treatments safer for all.”

Dr Nick Lowe

“We are all striving to satisfy our patients’ desires and improve the way they feel about themselves. For me, female genital rejuvenation is the ultimate expression of this; demonstrating that aesthetic medicine is not all about that which is publically visible. Desirial from Stylage is an example of a brand new dermal filler containing mannitol, specifically designed for the rejuvenation of the intimate region. Currently a doctor-led treatment; it can be used to improve loss of volume in the outer labia and mons. Other nonsurgical options for cosmetic gynaecology that I predict will become more popular include the use of platelet rich plasma (PRP) and the use of resorbable sutures to narrow the opening. My final top picks for 2014 include the increasing penetration of PRP into mainstream aesthetics, and an increased interest in mesotherapy for skin rejuvenation.”

Amanda Cameron

“There is a very interesting new gel, Mirvaso, developed for the facial erythema of rosacea. It is based on the eye drops ingredient brimonidine tartrate and looks as though it will be a great help to those suffering from persistently red faces. It has been approved in the US and expected here in early 2014. There are also vascular lasers from Cynosure with a new wavelength so we can treat pigment such as birthmarks without the horrendous bruising that used to be common. I’m looking forward to the arrival of the topical botulinum toxin gel from Revance, which may be useful for sweating and oily skin as well as fine lines. Finally the fat dissolving injectable with deoxycholate could be incredibly useful in a wide range of uses, including as an adjunct to CoolSculpting.” 14

“I see a lot of changes happening in 2014. Both in respect of regulation, and what we are going to be able to achieve for patients cosmetically. In terms of regulation, I look forward to working with the Department of Health in trying to implement any changes that improve patient safety. I am currently looking at one or two new treatments for body sculpting, in particular a new technique targeting the buttock area. I’m also very excited about revamped thread lifts such as Silhouette Soft. By combining thread lifts with tissue stimulating filler such as Sculptra we can finally tackle the jowls and the neck non-surgically, in a way we could never before. This will make a dramatic difference to the way I approach my non-surgical facial aesthetics.”

“No new launch or trend in 2014 will overshadow the fact that the industry is seeing a substantial and growing shift toward non-invasive treatments. However, as technology progresses, sadly, the regulation in our industry is in reverse. It looks as if we alone will have to improve standards as we cannot rely on government to lead the way. We need all professional bodies to unite and reach agreement on how best to deliver safe treatments, for our future security and prosperity. Knowledge is power! The onus will be on providers to inform and educate and those who offer full and comprehensive consultation together with outstanding professional customer service, and the appropriately trained and qualified practitioners, will shine.”

Aesthetics | January 2014


BOOK YOUR FREE PLACE TODAY Success of a clinic depends on a variety of factors, from offering a comprehensive treatment portfolio to executing effective marketing strategies. The Aesthetics Conference and Exhibition is the largest professional event in the UK to focus on all aspects of medical aesthetics practice and has been specifically designed to help you maximise your clinic’s potential.


By registering free you will have access to the most comprehensive programme of: • 100 premium suppliers • 25 expert-led workshops • 2 days of educational masterclasses Don’t miss out. To book your free place today visit: or call 01268 754 897

e: t: +44 1782 579 060

Clinical Practice Special Focus With non-invasive body contouring treatments booming, leading experts reveal what you should consider and clinicians explain how they found their perfect system

How to pick the right body contouring treatment for your clinic In aesthetic medicine, fat has long been seen as ‘liquid gold’ because of the way demand for body contouring, fat reduction and anti-cellulite treatments can add value to a practice. Certainly they have never been in greater demand. According to a survey conducted by BAAPS, surgical body-shaping procedures such as liposuction and tummy tucks were down 14% in 2012, which Rajiv Grover, consultant plastic surgeon and President of BAAPS, says may well be due to the increasingly effective nature of non-surgical treatments. He goes so far as to say that non-invasive methods “will be the future of fat removal”. So should you join the gold rush? Non-surgical alternatives to liposuction offer many advantages to both patient and clinician. These include faster treatment times, fewer complications, less need for aftercare, no pain and no need for anaesthesia, all of which reduce costs to the clinic and increase the numbers of patients seeking treatment. But in a fast moving market, practitioners must think carefully before making an investment in capital equipment to ensure it is the best fit for their clinic, meets their patients’ needs, and offers a good business model. There is no doubt that your investment could vary wildly depending on the system you choose. Some of the unbranded devices that come from outside the EU start at £8,000 or even less. Basic low level laser devices cost from around £10,000, while other devices using ultrasound and cryolipolysis cost from around £65,000 to over £100,000 and have expensive consumables on top. However, these are backed by big companies and therefore can also offer fantastic marketing materials and clinical research. To help guide your decision-making, we asked business experts and leading clinicians what their best advice would be for newcomers to the market. Practitioners also explained how and why they made their decision to purchase a particular body contouring system, fat loss or skin tightening system. Mary-Kay Sheehy, clinical director of aesthetic consultancy business Suite7, has a wide experience in sales, marketing, business development and training in medical aesthetics. She explains that key issues medical practitioners should consider when choosing a system include your patient demographics, clinic size, staff and budget, including the cost of consumables. “You need to look at your patient population, to determine how old and affluent they are, and how committed to treatments they are,” she says. “For example, if you have a youngish, working population they normally don’t have time to commit to three to four treatments a week and would ideally want a one-off treatment.” Aesthetics | January 2014

COST OF SALES Wendy Lewis, president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy explains why clinic size should be a key consideration. “Space can be an issue, especially in urban clinics. You need to calculate how long the treatment takes to perform and who will be performing it. Clearly the most profitable procedures are delegatable to non-medical staff. Systems that take up a room for hours at a time may make it harder to see good ROI.” She argues that when calculating profit margins, clinicians must factor in all costs, including the “Capital cost of the device, consumables, the time the treatment takes to perform, as well as staff involvement pre- and post-treatment.” Tim Stevens, practice support specialist at Coolsculpting, agrees that it is important to know your costs before you invest saying “Companies that are upfront about their consumable costs, and build them into the business plans they present to potential customers, have an active interest in the ongoing training, marketing and success of their clients.” 17

Clinical Practice Special Focus

5 crucial things to remember when purchasing a system 1 Do your research before you even consider trying a system. 2 Don’t fall for all the before/after marketing photos. 3 Don’t fall for cheaper, unproven devices from unknown manufacturers, 4 Ask for evidence and any clinical trials. 5 Always speak directly to other clinics who have the device. BRAND CONSIDERATION Finally, Lewis highlights the importance of not only choosing for your clinic and patient demographic, but also picking a reputable brand. “As a practitioner you should not consider flogging a technology that does not have appropriate clinical data and a CE mark,” she says. “US FDA clearance is also a big selling point for consumers today.” Although she explains that it can cost between $10million and $75million to obtain, and can take five or more years. Mary Kay Sheehy agrees, adding “FDA approval would be ideal but it is a long process and sometimes it costs too much for companies to get it.” However, Lewis warns, “Cheap no name devices with zero consumer awareness or clinical data to support their claims are not the way to go. Consumers today are savvy and go online to find out what the best devices are and who has them.” Dr Raj Acquilla, cosmetic dermatologist at the Dr Raj Acquilla Clinic, says that although investing in more well-known fat loss technologies can be expensive, prices have come down. “Anything good used to cost between £80,000-£100,000,” he says. “Now you can get a really high quality device for £30,000 or £40,000. They’re not far beyond the reach of an introductory to intermediate budget.”

MARKETING Lewis details the structure you should put in place surrounding your investment, saying “For every new treatment you offer, you should have a marketing plan, pricing strategy and necessary assets in terms of materials, brochures, posters, before and after photos and web pages in order to launch it properly and make the most of your investment.” Dr Claire Oliver, owner and clinical director at Air Aesthetics Clinic agrees marketing is vital: “Be mindful that large investments in technologies require a commitment to marketing to ensure targeted payback of system is achieved.” Dr Ravi Jain, medical director and founder at Riverbanks Clinic, says market research is an easy way to both determine what your patients want and to begin marketing to them. “Simply send your client database an email telling them that you are thinking of investing in systems a or b, and asking them if they would be interested in this. If they are, you know they are potential patients; they are already intrigued, you won’t need to do too much marketing and you can make a profit quite quickly.” 18

DEVELOPMENT AND TRAINING When buying a system Sheehy suggests opting for one that offers continuing training. “It is only after many treatments have been performed that manufacturers learn how to make their protocols even better. With many of the non-invasive body contouring devices the techniques are vital to getting the right results, and a one-off training session is normally not enough.”

RESEARCH Effectiveness and safety must be prime concerns for any clinician wanting happy patients. Dr Nick Lowe, renowned consultant dermatologist at The Cranley Clinic, says, “Before making a decision about any technology, always ask about the research.” He opted for cryolipolysis system CoolSculpting by Zeltiq, “Because of the reputation of the scientists at Harvard MIT who developed it. I went for it because of the volume of peer reviewed research that was conducted into its safety and efficacy,” he says. Dr Tracy Mountford, founder and medical director of the Cosmetic Skin Clinic, also opted for CoolSculpting primarily on its scientific merit, but also because it met her other core requirements. “I spent a long time looking for an alternative to liposuction, because I wanted to stay pure to my business model which is to offer purely non-surgical treatments. My patients were asking my advice about treatments that were already out there so I knew there was growing demand, but to meet their needs, anything I offered had to be safe, proven, painless and have no downtime.” Similarly, cosmetic dermatologist Dr Raj Acquilla, who uses radiofrequency device Exilis from BTL in his clinic, agrees that evidence is crucial. “You have to go on the evidence,” he says. “I didn’t consider any system unless it already had FDA clearance, and it had several exhaustive critical papers behind it with good medical research.”

SPEED, CONVENIENCE AND COMFORT Patients today lead increasingly busy lives and want faster, oneoff treatments with no downtime. Dr Ravi Jain uses ultrasound system MedContour and cryoliposis system CoolTech in his clinic. He says he was impressed by the technology of cryolipolysis, and chose CoolTech primarily because he believes the results can be more aesthetically pleasing than with other cryolipolysis systems, but also because of the speed of treatment. “Because the system includes two headpieces, you could treat two areas in one hour,” he says. “So the treatments were quicker, and it was much more cost-effective with a faster return on investment.” To meet the growing demand of patients for faster, one-off treatments, Dr Tracy Mountford, who has created a dedicated CoolSculpting suite at her clinic, has recently invested in a second CoolSculpting device in order to offer patients ‘DualSculpting’ in which two areas are treated at the same time, halving treatment time and increasing the number of patients who can be treated in a day. Dr Jain explains why investment in a machine that works well for your clinic and patients is so important, “MedContour has an inexpensive initial outlay, and isn’t very practitioner dependent so new therapists could still get good results from it. However, patients had to come every week: many wouldn’t travel long distances, so we lost a lot of enquiries and only had local patients.” Dr Acquilla adds that if a system does involve diet, exercise or multiple treatments then, “The shorter the duration

Aesthetics | January 2014

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Clinical Practice Special Focus

between treatment intervals the better, because the patient’s compliance levels are greater then.” Dr Carolyn Berry, clinical director at Firvale Clinic who uses CoolSculpting, says “Fat is big business, but my patients don’t want to take time off work to recover. They also want minimal pain.” Dr Lowe says he rejected certain ultrasound treatments because although effective, they were, “Horrendously painful”, which might discourage patients from a return visit.

WHEN ONE IS NOT ENOUGH When considering adding body contouring to your clinic, you may wish to consider how it complements your existing treatment offer. Both Dr Tracy Mountford and Dr Lowe say CoolSculpting works well with their existing Thermage radio frequency skin tightening systems from Solta Medical to tighten any small areas of loose skin. Dr Sach Mohan, founder at Revere Clinic, invested in radiofrequency body contouring product EndyMed by AesthetiCare, which he uses in combination with CoolSculpting. “I chose EndyMed because of the way it harnesses radio frequency technology and has multiple radio frequency generators, which repel against each other, driving radio frequency deeper and helping us achieve uniform tissue-heating, which is the clinical endpoint,” he says. “EndyMed and CoolSculpting complement each other well because after eight out of ten CoolSculpting treatments, patients will have some loose skin,” he continues. “You can lose one and half litres of fat from the

treatment, so we can use EndyMed to get very good skin tightening afterwards.” Mohan also says versatility was important to him. “Endymed has multiple modalities and indications,” he says, “Including a facial handpiece and a fractionated resurfacing handpiece (FSR) which is able to both resurface and tighten the skin. This enables us to treat stretchmarks often seen in conjunction with the subcutaneous elastosis.” If your core business is in facial aesthetics, it could be useful to choose a system which can treat the body and face. Dr Acquilla says, “I use the same modalities with Exilis for chin and jawline reshaping as for lower limb rejuvenation. I need to select a device that has the accuracy and flexibility to deliver energy to those very sensitive anatomical areas, and Exilis has a body piece and a handpiece.”

TRY BEFORE YOU BUY For those who are considering a particular system but are still uncertain, Dr Ravi Jain suggests taking your time to really consider the various options. “Attend meetings,” he says, “Speak to people who have systems, and attend workshops where machines are demoed, where you can also speak to other practitioners.” Donnamarie McBride, director at LoveLite Ltd. also suggests that practitioners do their research. “Research is the key,” she says. “Speak to other people who have the machine, even if they’re in a different country. It’s also important to try the machine out yourself.” Speaking to other practitioners who have the system that

you know rather than going through the sales representative or company is key as they may pick practitioners who may not give you an accurate picture. It may be beneficial, therefore, to talk to clinics outside your area, including in Europe or ones based in the US. Wendy Lewis agrees that you should trial a machine before buying. “Try a device on a few of your own patients or staff before you buy, to be sure it is a good fit for your clinic,” she says. Esther Fieldgrass, founder of EF Medispa, who uses Accent Radiofrequency by Alma Lasers in combination with Multisculpt, a combination of radiofrequency, infra-red and mechanical massage, says, “I attend conferences where I try the equipment myself; I need to know that what I’m offering my clients I would have myself, and that it’s going to work.” Dr Acquilla trials potential systems on willing patients: “I wouldn’t make a commitment unless you know whether it’ll work in your practice. I’d suggest a two to three month loan period from the manufacturer before buying. You may need to pay a deposit, but that is a worthwhile investment.” Dr Jain states, “Every practice should be in body contouring because that’s the biggest growth area in aesthetics.” As our experts have demonstrated, by researching your options thoroughly and considering key factors such as your demographic, clinic size, budget and treatment menu you can find a system that works for you, your business and, most importantly, your patients.

Why buying cheap could cost you It is a risk to choose to buy from unknown manufacturers, particularly if bought online from outside the EU. In a worst-case scenario, these can injure patients. This may damage your reputation if patients complain or sue, and may even ruin your career. “There are plenty of rebadged Chinese and Korean exports online that put a lot of money into marketing to make them look legitimate, but they have no good regulatory standards. They fall apart, have no warranty and no feedback mechanism.” Dr Ravi Jain “I am concerned that with some copycat cryolipolysis devices there is a real risk of causing ischaemic freezing ulcers.” Dr Nick Lowe “You have no guarantee of knowing what you are buying: it could just be a fancy computer on the outside, but the insides are useless. You have no guarantee that it will do what it says, of who will fix it if it breaks and how much that will cost. It could cost you a lot more in the long-run.” Mary-Kay Sheehy


Aesthetics | January 2014

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Clinical Practice CPD Clinical Article

one point

Frontalis Anatomy:

Key considerations for aesthetic practice ABSTRACT Understanding key anatomical concepts of the face is important in order to be able to treat a patient effectively in any aesthetic treatment. With a robust anatomical knowledge of the occipito-frontalis muscle, the clinician can appreciate how each patient’s anatomy may vary and how the clinician’s choice of injection placement with botulinum toxin A reflects this. Recent detailed anatomical studies of this area provide further clarification regarding static, dynamic and functional anatomy. Through critical analysis of this data, it is possible to tailor treatments on an individual basis.

KEY WORDS; Frontalis, Midline dehiscence, Botulinum toxin A, Anatomy.

INTRODUCTION In this article the anatomy of the frontalis muscle will be revisited and reviewed. We will examine how this awareness will enable the effective placement of Botulinum toxin A. It is widely accepted that botulinum toxin achieves a desired softening of established horizontal rhytides and offers near eradication of rhytides that are largely dynamic in nature.1 in this article we aim to provide an accurate overview of the muscle, related vessels, arteries and nerve supply to ensure a safe and effective treatment outcome and cosmetic result.

ANATOMY The frontalis (more accurately termed the Occipito-frontalis) is a quadrilateral, flat and exceptionally thin muscle, with no bony attachment.2 It forms part of a group of elevator muscles, which elevate the brow. The musculoaponeurotic group consists of the frontalis, the galea aponeurotica and the occipitalis. The medial fibres of frontalis closely interweave with muscle fibres of the brow depressors at the level of the glabellar and interdigitate with the procerus, the corrugator supercilli, depressor supercilli, and orbicularis oculi.3 Hence there is no bony insertion; below the dermal insertion there is a potential space. If this area is inadvertently injected with botulinum toxin it may result in spread of the toxin down to the orbital septum, resulting in ptosis. The frontalis fibres extend posteriorly over the forehead to fuse with the galea aponeurotica in the occipital area. Here, the occipital bellies arise by tendinous fibres from the lateral two thirds of the highest nuchal line of the occipital bone and the mastoid part of the temporal bone. Its lateral most fibres are intertwined and blended with orbicularis oculi over the external angular process of the frontal bone, onto which it inserts.4 The galea aponeurotica is a continuous musculo membranous sheet, which extends from the external occipital protuberance and supreme nuchal lines to the brow. The aponeurosis is continuous laterally with the temporal fascia: principally membranous, it contains the occipitofrontalis muscle. This muscle represents the third layer in the scalp equivalent to the SMAS layer in the face.5 Rohrich and Pessa6 described findings from their study of thirty hemifacial cadaveric dissections, which demonstrate the subcutaneous fat of the face partitioned discretely as opposed to a confluent mass. The authors describe the subcutaneous forehead fat to be divided into 3 segments with borders identified through the use of Methylene blue dye in the following arrangement. They are described in the following ‘compartments’:

Figure 1 Mr Dalvi Humzah is a consultant plastic reconstructive and aesthetic surgeon based at Plastic & Dermatological Surgery, West Midlands. Mr Humzah is a KOL for a number of companies in the Aesthetic field.

Anna Baker is an Independent

nurse prescriber and cosmetic nurse practitioner at The Nuffield Health Hospital Cheltenham and practices specialist dermatology PDT clinics.


Figure 2

Aesthetics | January 2014

Central compartment: A midline region with an inferior border at the nasal dorsum. The authors suggest the lateral border is a dense facial plane, referred to as a central temporal septum with the supra-trochlear vessels running along this area. Middle forehead compartment: Situated on either side of the central fat and located medially to the superior temporal septum, bordered inferiorly by the orbicularis retaining ligament of the superior orbit. Lateral temporal cheek fat: Spans the forehead to the cervical region with superior and inferior temporal septa representing the superior boundaries.

Clinical Practice CPD Clinical Article Mendelson describes how the face may be viewed and treated as five distinct layers7, the principles of which hold relevance in relation to the use of toxin in treating the frontalis: Layer 1: Skin Layer 2: Superficial fascia, also referred to as the subcutaneous layer. Layer 3: Superficial muscular aponeurotic system, commonly referred to as the SMAS. This can be seen on dissection as a strong fibrous sheet which covers the whole face and holds the muscles in place. Layer 4: Loose areola, also referred to as the gliding plane Layer 5: Deep fascia, which is a thin layer of connective tissue.

Figure 3 This concept of the face having five distinct layers is noteworthy for the injector as the first three layers (skin, superficial fascia and SMAS) move cohesively as one over the loose areolar layer, which is comprised of loose connective tissue and provides a gliding plane, which is crucial for facial expression. The lateral temporal septum also separates the deep temporal compartment with the temporalis muscle from the medial forehead compartment containing the frontalis muscle. The most lateral part of the eyebrow does not have any frontalis fibres attached to it; the lateral fibres of orbicularis oculi act as ‘brow depressor’ and relaxation of these fibres with botulinum toxin injection will allow the lateral brow to ‘lift’.

ARTERIAL SUPPLY The face and scalp are highly vascularised and supplied by five arteries which stem from the internal and external carotid artery; supratrochlear, supraorbital, superficial temporal, posterior auricular and occipital.8 The majority of the skin and subcutaneous tissue of the face is supplied by branches of the external carotid artery. The ophthalmic artery moves anteriorly through the optic canal to enter the orbit, dividing into the

supraorbital and supratrochlear branches which exit through their respective foramen, along the superior orbital rim.9 The supratrochlear branch emerges in the area of the corrugators and moves superiorly with branches extending in its path. Within the corrugator complex, the artery is vulnerable to injury from needle puncture through Figure 4 injection of toxin and the clinician is advised to exercise caution here due to its superficial path. The supraorbital branch exits the orbit in the midline of the superior orbital rim and travels deeper in subcutaneous tissue, to the frontalis. The supraorbital and supratrochlear arteries run with corresponding nerves, the suproaorbital artery is the larger of the two and anastomoses with the superficial temporal artery to connect the internal and external carotid systems. This is a key anatomical consideration for the injector when placing any product in this area due to the potential risk of serious vascular complications. The external carotid runs along the lateral aspect of the neck, dividing into two branches, below the dermis, anteroinferior to the tragus of the ear. One is the superficial temporal artery, a terminal branch of the external carotid that lies superiorly in front of the ear and crosses the zygomatic arch, branching widely into the skin that overlies the temporalis fascia in the subFigure 5 cutaneous tissue (Level 2). The skin crease anterior to the ear marks the surface for the superficial temporal artery. The middle temporal artery pierces the fascia, supplies temporalis and anastomoses with the deep temporal branches of the maxillary artery. The second branch of the terminus of the external carotid is the internal maxillary artery, which runs deeply. Numerous anastomoses and interconnections occur between the arteries in the upper face, which the injector must be aware of when placing product in this area.

VENOUS DRAINAGE Facial veins have a remarkably similar distribution pattern to that of the arteries and venous drainage of the face generally follows the arterial pattern, with flow in the opposite direction. The supraorbital and supratrochlear veins run with the corresponding arteries and nerves.10 The supraorbital vein begins in the forehead where it interweaves with the superficial temporal vein and passes inferiorly then superficially to the frontalis muscle and meets with the supratrochlear vein medially across the orbit to form the angular vein. The superficial temporal vein drains the forehead and scalp.11

NERVE SUPPLY The Cranial nerve V11 (the facial nerve), which activates muscles of facial expression, emerges from the skull through the stylomastoid foramen and produces the posterior auricular nerve, which passes upwards behind the ear to supply the auricularis posterior and the occipital belly of occipital frontalis.12 The nerve then approaches the posteriomedial surface of the parotid gland. Just before entering, or when inside the branches of the gland divide allowing the cervicofacial and temporofacial branches to develop. Within the substance of the gland each divides and rejoins and divides again to finally emerge from the gland in 5 main branches: Aesthetics | January 2014


Clinical Practice CPD Clinical Article

temporal, zygomatic, buccal, mandibular and cervical. The temporal branches emerge from the upper border of the gland, underneath the SMAS and masseteric fascia; it then crosses the zygomatic arch to pass in a deep supraperiostial level. It transitions subcutaneously to innervate the frontalis and presents as fine branches within the subcutaneous layer (Level 2). The trigeminal nerve (cranial nerve V) provides sensory innervation of the face through its three branches: the ophthalmic nerve, the maxillary nerve and the mandibular nerve.13 Figure 6 The ophthalmic and maxillary nerves serve most relevance to this anatomical discussion. The ophthalmic nerve is the superior point of division for the trigeminal nerve and divides into three branches: the lacrimal, the frontal, and the nasociliary branches. The lacrimal nerve supplies the lacrimal gland, the upper eyelid, the conjunctiva and the lateral angle of the eye. The frontal nerve subdivides again into two branches: supratrochlear and supraorbital, with the supratrochlear nerve supplying the medial angle of the eye, the upper eyelid and part of the glabellar. The supraorbital nerve emerges from the superior orbital segment through the supraorbital foramen, supplying the lateral canthus, the upper eyelid, and the temporal and frontoparietal regions of the head. The maxillary nerve is a further division of the trigeminal nerve; it gives off an orbital branch, then divides again to supply the lateral part of the upper eyelid, and a temporomaxillary branch, supplying the anterior temporal region. It continues from below the orbital margin, through the infraorbital foramen as a large branch, leading to the infraorbital nerve, which supplies the lower eyelid, the nose laterally, upper lip and the cheek.14

FRONTALIS MIDLINE DEHISCENCE CONSIDERATIONS Superiorly to the nasion the frontalis fibres continue for a varied distance before an aponeurosis develops in the space between the two bilateral muscle segments. The point of divergence of the two muscles is regarded as the point of dehiscence or midline attenuation point.15 Many taught methods of injection placement with toxin advocate a midline injection point. However, a recent study by Spiegel et al in 2009 sought to define the anatomy of the frontalis muscle and accurately capture the height and dimensions of the midline dehiscence.16 The authors demonstrated in male cadavers a considerable variation in their medial frontalis muscle border, presenting as either a ‘W’ shape or a stair-step shape. Female cadavers 24 demonstrated less irregularity with a smoother border and muscle fibres higher in midline, and were noted to have a higher relative dehiscence with less lateral spread. In three out of the nine female cadavers, a continuous muscle showed with no point of dehiscence and active muscle evident high on the forehead, demonstrated to 6cm above the orbital rims. Further findings from Figure 7 the data reported the frontalis muscle with a 3.5cm midline dehiscence in men and 3.7cm in women. The angles that the left and right muscles formed with the midline were also found to be more acute in female cadavers, which is important as this indicates that it may be necessary to place botulinum toxin more laterally in males to avoid placing product in areas containing no muscle tissue. The findings from this study signify the importance of identifying the midline attenuation point in selecting either a surgical or pharmaceutical treatment to improve the appearance of forehead rhytides, and enforce the importance of identifying the anatomical differences between male and female subjects in relation to this highly variable muscle. Results from the study should enable the clinician to conserve product usage by decreasing the likelihood of injecting toxin into areas of the forehead without muscle tissue.

CONCLUSION It has been our aim in this paper to provide insight around the anatomical characteristics of the frontalis muscle. The variability of individual frontalis anatomy and importance of understanding and treating accordingly has been discussed together with key findings from recent frontalis anatomical research, to equip the practitioner with accurate insight in treating the frontalis muscle for cosmetic rejuvenation. It is vital to understand anatomy to ensure a safe and appropriate treatment and to enhance the cosmetic result. The content of this paper has been compiled to concisely support clinicians in gaining a clearer understanding of the characteristics of the frontalis muscle, by drawing upon current research to encourage critical thinking and an evolving practice.

REFERENCES 1. Carruthers A, Carruthers J, Cohen J (2003) A prospective, double-blind, randomized, parallelgroup, dose-ranging study of botulinum toxin type A in female subjects with horizontal forehead rhytides. Dermatol Surg 29:461–467 2. Ascher B (ed) (2009) Injection Treatments in Cosmetic Surgery. 2nd Edition. Informa Books, London 3, 10. Benedetto AV (2011) Botulinum Toxins In Aesthetic Practice. 2nd Edition. Informa Books, London 4, 15, 16. Spiegel JH, Goerig RC, Lufler RS, Hoagland TM (2009) Frontalis midline dehiscence: An Anatomical Study and discussion of clinical relevance. Journal of Plastic, Reconstructive & Aesthetic Surgery. 62: (950-954) 5, 7. Mendelson B (2013) In Your Face. Hardie Grant Books, Melbourne 6. Rohrich JR & Pessa JE (2007) The fat compartments of the face: Anatomy & clinical implications for cosmetic surgery. Plastic Reconstructive Surgery. 119: 2219-2217 8, 12. Moore KL, Dalley AF (1999) Clinically Oriented Anatomy. 4th Edition. Lippincott Williams & Wilkins, Philadelphia: PA 9. Sinnatamby CS (2006) Lasts Anatomy Regional & Applied. 11th Edition. Churchill Livingstone Elsevier, London 11. Sinnatamby CS (2006) Lasts Anatomy Regional & Applied. 11th Edition. Churchill Livingstone Elsevier, London 13. Lowe NJ, Shah A, Lowe PL, Patnaik R (2010) Dosing, efficacy, and safety plus the use of computerized photography for botulinum toxins type A for upper facial lines. J Cosmet Laser Ther 12:106–111 14. Benedetto AV(ed) (2006) Botulinum Toxin In Clinical Dermatology. Taylor and Francis, Oxford


Images copyright of 2006 Lippincott Williams & Wilkins. A Wolters Kluwer Company. All rights reserved.

Aesthetics | January 2014

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Clinical Practice Clinical Focus

Combining cavitation with diet and exercise Dr Martyn King discusses the benefits of the 3D-Lipolite medical program In England, 61.3% of adults are overweight or obese, putting them at higher risk of getting type 2 diabetes, heart disease and certain cancers. Excess weight can also make it difficult for people to find and keep employment, and can affect self-esteem and mental health. Health problems associated with being overweight cost the NHS more than five billion pounds every year. Weight loss is a thriving industry, with global equipment sales for body contouring devices surpassing billion dollars last year in the UK. Technology has rapidly advanced, but to achieve a significant weight loss, the answer lies not only in technology and procedures, but also with a focus on diet and exercise. Our body strives to balance blood sugar levels in a narrow therapeutic range by a



variety of hormones, yet often our diet is fighting against this process. If blood sugar levels go too high, this leads to arterial damage and conversion to fat. If levels go too low, this leads to low mood, tiredness and poor concentration. The key to an optimum diet is through balancing blood glucose levels by eating the right amount of food at the right times. Calories are important in weight loss, but restricting calorific intake too much is detrimental as it can lead to reduced muscle mass and strength, reduced bone mineral density and increased fracture risk. Exercise has to be appropriate and tailored on an individual basis. Excessive exercise for someone who is overweight

or not used to exercise is likely to result in strain on the cardiovascular system. Non-surgical technologies available for treating fat and cellulite include cryolipolysis, cavitation, radiofrequency, light treatments and vacuum rolling. Cryolipolysis is based on the principle that fat cells are destroyed by low temperatures, whereas the dermis and epidermis are somewhat resilient. Fat cells are targeted by thermal conduction through the skin and frozen to at least -5째C, where they are destroyed and removed by the body over a few weeks. Cavitation is the application of low frequency ultrasound, which produces a strong wave of pressure that specifically targets the membranes of fat cells. The cell membranes vibrate and disintegrate, leading to the death of the adipocyte. Radiofrequency energy can be targeted to the sub-dermal fatty layer where it is converted into heat and leads to cell destruction. It also targets collagen fibres causing contraction. A clinical study was carried out to investigate the effectiveness of combining technology, prescription diet, physical exercise and biometric monitoring to achieve optimum weight loss. The study was conducted at Cosmedic Skin Clinic by myself, Dr Martyn King, and Sharon King RN NIP. Ten patients were recruited into the study after a medical assessment. Initial recordings were taken, including blood investigations, biometric measurements (Tanita Segmental Body Composition Scales), Health and Wellbeing scores (The Warwick-Edinburgh Mental WellBeing Scale), urine testing, blood pressure and photography. Each patient had a unique treatment plan based on their targets, Basal Metabolic Rate (BMR) and exercise capabilities. The diet program, created with the aid of a nutritionist, centred on eating 25% starchy carbohydrate, 25% protein, 45% greens and 5% dressing for main meals. The diet consisted of a milkshake at 7am, a snack at 10am, a soup sachet at 1pm, a milkshake at 4pm and a meal at 7pm. If required, a further snack was allowed at 10pm. The soups and milkshakes contained a special formulation developed specifically for the study to encourage weight loss and provide essential vitamins and nutrients. The essence of the diet was to maintain a healthy, balanced blood glucose level throughout the day without peaks or troughs. Patients were advised to try and have something to eat or drink every three hours. A combination of technologies was used to target specific body areas. The majority of treatment consisted of cavitation, although cryolipolysis and radiofrequency were also used where it was deemed beneficial. During the program the average number of treatments received by each patient was 17.1. Exercise was agreed using the F.I.T.T. principle (Frequency, Intensity, Time and Type) and concentrated on After Before different domains (aerobic Aesthetics | January 2014


Clinical Practice Clinical Focus

exercise, resistance training, functionality, mobility and flexibility). Physical activity was assessed using the Borg scale, which subjectively gauges perceived exertion, and ranges from six (no exertion at all) to 20 (maximum exertion). Exercise ranged from getting out of a chair without using the arms, to intense gym sessions with a personal trainer. Patients attended on a weekly basis for their treatment, with medical assessments carried out monthly. At the end of the four-month period final measurements were taken. The average starting weight of the patients on the study was 104.2kg and the average weight loss obtained was 12.6kg (range 7.7-24.3kg), which equates to an average percentage loss of 12.5% (range 9.0-21.2%). The average reduction in waist circumference was 13.8cm (range 7.0-26.5cm) and hip circumference 11.5cm (range 6.5-22.5cm). Blood pressure measurements improved on average by 13.4mmHg systolic (range -2-34mmHg) and 7.8mmHg diastolic (range -2-27mmHg). Total cholesterol

levels showed an average 1.1mmol/L point reduction although HbA1c only showed a 0.07% change. Health and wellbeing scores demonstrated a 15.6% improvement from baseline. A main benefit of the combined treatment was the ability to contour the body. Exercise and diet can produce weight loss but patients are often left with sagging skin, or they may have not lost weight from the desired area. This can be targeted using non-surgical technology. The program, now available to clinics, comes with specific training on the diet and exercise regime required to ensure weight loss occurs effectively and safely. Clinics and patients receive webbased or printed booklets explaining diet allowance, suggested snacks, recipes and exercise programmes. Due to the success of the program, patients were offered to continue the trial for a further two months and then participation in a maintenance phase. This consisted of continuation on the prescribed diet with supplements, and continuing with the exercise program

but without weekly treatments. They will continue to be monitored by the clinician on a monthly basis. Most diets fail to maintain weight loss long-term, but we hope that the maintenance phase will enable our patients to do just this. Dr Martyn King is owner and director of Cosmedic Skin Clinic and medical director of Cosmedic Pharmacy. He is chair of the Managing Aesthetics Complications Expert Group, and member of the British College of Aesthetic Medicine. Alongside his wife Sharon King, Dr King ensures that Cosmedic Skin Clinicâ&#x20AC;&#x2122;s training academy provides independent training in all aspects of aesthetic medicine. Financial disclosures: Dr Martyn King has a commercial interest in the 3D lipolite medical weight loss program, which combines technology, diet and exercise and is the basis of the clinical study outlined in this article.

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Clinical Practice Techniques

Keeping it clean Dr Mike Comins explains the vital importance of hygiene in your practice Despite the glossy veneer of our industry, as healthcare professionals it is vital that we never lose sight of the fact that we are offering a medical service. In light of the Keogh report there has been a focus on the serious complications that can occur with injectables. These include skin necrosis, blindness and long-term granulomas. Certainly we should take these complications seriously, but we mustn’t also overlook the basics of our medical training, such as microbiology. More specifically in terms of injectables, blood-borne viruses such as HIV, Hepatitis B and Hepatitis C. Over the years I have heard tales of people sharing syringes of fillers, believing it’s okay for friends to share; putting insulin needles back in a Botox vial; storing partially-used filler vials for another patient and so on. I’m sure many doctors and nurses have countless other examples and similar horror stories. This is not acceptable, and it serves to highlight the importance of self-regulation for our industry, and the ability to regulate those carrying out these kinds of treatments. I can’t overemphasise enough the need for stringent adherence to the Centre for

Disease Control and Prevention, Infection Control and Safe Injection Practices. Whilst the public have become increasingly aware of HIV, healthcare professionals also need to remain focused on Hepatitis C and B (HCV and HBV). Unlike the HIV virus, which is very unlikely to survive outside the body for more then a few seconds, Hep B and C can. Hep C can survive for up to four days outside of the body, whilst Hep B can survive for at least seven days. Some clinicians believe by attaching a clean needle to a partially used syringe of filler or vial of botulinum toxin, they have protected their patients from viral contamination. However the risks do not stop with the needle. The smallest amount of negative pressure in the syringe can cause microscopic amounts of blood to travel up the needle and into the syringe. Even a swab of gauze used to mop a patients face post botox and discarded onto a counter may leave behind a potential reservoir of viruses that can then contaminate other gauzes or needles and transfer the virus from patient to patient. “WHO estimate 300 million people in the world are infected with the Hepatitis B virus, of which the vast majority would be

asymptomatic and may not know they are carriers and infectious,” says Graham Foster, Professor of Hepatology at Queen Mary University of London. “The average carrier may have many thousand viral particles per ml of blood and it is not unusual for someone in the Hepatitis B “e” antigen positive (HBeAg) phase to have millions of virions per ml. A small drop of blood would be enough to infect many thousands of people.” According to Public Health England, the number of people living with HCV related Cirrhosis and/or Hepatocellular Carcinoma in the UK has risen by over 1000% in the last 20 years. Charles Core, Chief Executive of the Hepatitis C Trust explains that IV drug use is not the primary issue. “Of the 185 million people living with HCV worldwide ten million got it through IV drug use and almost all the rest through unsafe healthcare.” These facts are alarming. We need to ensure our industry is not going to be a part of this growing global problem. When we do hear of these unsafe practice stories we have a duty as healthcare professionals to flag them up to the relevant authorities. “The idea of sharing a vial of cosmetic filler between patients is, quite frankly, terrifying,” says Professor Foster. “It’s imperative that anyone using injectables fully understands the risks of blood-borne infections, and vigilantly adheres to infection control protocols.” Cosmetic injectable treatments should only be performed by professionals with proper microbiology training. We also have a duty of care to use products from reputable manufacturers and ensure that we keep up to date with changes in microbiology. Emma Davies, Chair of the British Association of Cosmetic Nurses concludes, “Nurses in the NHS undertake mandatory training in infection control, with updates as per local protocols. Those in Independent Practice must be mindful that such training remains mandatory outside the NHS, and must not be neglected as part of necessary CPD.”

CENTRE FOR DISEASE CONTROL – INFECTION CONTROL AND SAFE INJECTION PRACTICE INJECTION SAFETY To ensure injection safety, healthcare workers should: • Use a sterile, single-use, disposable needle and syringe for each injection, and discard them intact in an appropriate sharps container after use. • Use single-dose medication vials, prefilled syringes, and ampules when possible. • Avoid administering medications from single-dose vials to multiple patients or combining leftover contents for later use. • Restrict multiple-dose vials (if used) to a centralised medication area or use only for a single patient. Never re-enter a vial with a needle or syringe used on one patient if that vial will be used to withdraw medication for another patient. Store vials in accordance with the manufacturer’s recommendations and discard if sterility is compromised. • Avoid using bags or bottles of intravenous solution as a common source of supply for multiple patients. • Use aseptic technique to avoid contamination of sterile injection equipment and medications. 30

Aesthetics | January 2014

Clinical Practice Techniques

HAND HYGIENE AND GLOVES To ensure hand hygiene and proper use of gloves, healthcare workers should: • Wash their hands with soap and water, or use an alcohol-based hand rub before preparing and administering an injection; before and after donning gloves for obtaining blood samples; after inadvertent blood contamination; and between treating patients. • Wear gloves for procedures that might involve contact with blood, and change gloves and wash hands between patients.

WORK ENVIRONMENT In maintaining a safe and sanitary work environment, healthcare workers should: • Dispose of used syringes and needles at the point of use in a sharps container that is punctureresistant and leak- proof, and that can be sealed before completely full. • Maintain physical separation between clean and contaminated equipment and supplies. • Prepare medications in areas physically separated from those with potential blood contamination. • Use barriers to protect surfaces from blood contamination when blood samples are obtained. • Clean and disinfect blood-contaminated equipment and surfaces in accordance with recommended guidelines.

PATIENT CARE EQUIPMENT When dealing with patient care equipment, healthcare workers should: • Handle equipment that might be contaminated with blood in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to themselves, other patients, and surfaces. • Evaluate equipment and devices for potential cross-contamination of blood. They should also establish procedures for the safe handling of such equipment during and after use, including cleaning and disinfecting or sterilising as indicated.

FURTHER READING course/page2070.html Dr Mike Comins is President and Fellow of the British College of Aesthetic Medicine. He is part of the cosmetic interventions working group, and is on the faculty for the European College of Aesthetic Medicine. Dr Comins is also an accredited trainer for advanced Vaser liposuction, having performed over 3000 Vaser liposuction treatments.


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Clinical Practice Clinical Study

Safety, tolerance, and patient satisfaction with Non-invasive Cryolipolysis We summarise the results of a multicentre study to investigate the clinical outcomes of non-invasive cryolipolysis (CoolSculpting ZELTIQ Aesthetics) in European subjects.

OVERVIEW Cryolipolysis, a new technique for non-invasive fat removal, was investigated for safety, tolerance, and
patient satisfaction. A retrospective study was performed at clinical sites in Belgium and France. Safety was assessed according to reports of side effects. Tolerance was evaluated according to pain scores and patient perception of treatment duration. Clinical outcomes were assessed according to patient surveys, caliper measurements, and assessment of photographs. Five hundred and eighteen patients were treated (73% female, 27% male; mean age 42.7). A variety of treatment areas were studied in an effort to assess safety and efficacy. There were 891 total areas treated, comprising the flanks (love handles) (59%), abdomen (28%), back (12%), inner thighs and knees (1%), and buttocks (1%). The majority of sites were treated once (86.5%), although some areas were treated two (13%) or three (0.5%) times.

SAFETY AND TOLERABILITY: RESULTS Side effects from the cryolipolysis treatment were minor. Erythema was reported in 100% of cases. The skin aspect immediately after treatment was observed to be clay-like (52%), as illustrated in Figure 1, or stiff (48%), as shown in Figure 2. Additional side effects observed immediately after treatment included rare vasovagal reaction (2.1%) after anterior abdominal area treatment and varying levels of pain. In 96% of patients, the pain was reported as minimal to tolerable. Severe pain was reported in 4% of patients, occurring only during the initial five minutes of cryolipolysis, with no interruption of treatment required. Tolerability

Fig. 1

of the cryolipolysis treatment was assessed by querying patients on their perception of treatment duration. The procedure was well tolerated, with 77% feeling the time was ‘about right,’ 11% feeling the procedure was shorter, and 1% feeling the treatment was much shorter than the actual treatment time. Only 11% of respondents felt the procedure was too long. Of the total patient population, 92% (n = 479) were assessed for short-term side effects one month after treatment, but 8% (n = 39) could not be located for assessment. In those assessed, there were few short-term side effects noted; 9.8% of patients reported bruising in the treatment area, which was determined to be caused by the vacuum handpiece. Transient changes in sensitivity were reported in a small number of patients. Decreased sensitivity in the treatment area was reported in 0.4% (n=2) of patients, and both cases resolved spontaneously in one to five weeks. Transient increased sensitivity in the treatment area was reported in a larger percentage of patients-2.5% (n=12) within the first few days after treatment. One case of increased sensitivity was reported after treatment of the flanks and the remaining 11 cases after treatment of the abdomen. All cases of increased sensitivity spontaneously resolved in three weeks or less. Recommended treatment was ibuprofen (400 mg twice daily) until resolution. 12 patients (2.5%) also reported nodular or diffuse infiltration in the treatment area within a few days after treatment. Erythema and pain accompanied infiltration, which lasted eight to 25 days. Recommended treatment was ibuprofen (400mg twice daily) or acetaminophen (2-4g once daily). All cases resolved spontaneously, with complete regression. Anecdotal evidence suggests that these patients experienced greater efficacy than those who did not experience infiltration. It is hypothesised that a more pronounced inflammatory response triggered a more pronounced response to treatment. (Figure 3 demonstrates a case of nodular infiltration, with the pretreatment

Fig. 2

Fig. 3

photograph and a three-month follow-up photograph showing a region of red, indurated, sensitive plaque in the treatment area.) In summary, short-term side effects included bruising, transient changes in sensitivity, and nodular or diffuse infiltration at the treatment site. All reported shortterm side effects resolved spontaneously. There were no reports of persistent erythema, blistering, or skin necrosis. There were no cases of dyschromia. There were no long-term side effects. No adverse events were reported.

Aesthetics | January 2014


Clinical Practice Clinical Study

RESULTS: EFFECTIVENESS Efficacy assessment was a secondary endpoint for this study and was gauged using three metrics: patient-reported satisfaction scores, caliper measurement of fat layer reduction, and investigator assessment from standardised preand post-treatment photographs. Treatment efficacy was evaluated by consultation three months after the procedure at the Belgian clinical centre, which treated 75 of the 518 patients in this study; 66% of these patients (n=49) were evaluated at three months, and 34% (n=26) could not be located. The French clinical centre, which treated 443 of the 518 patients in the study, also evaluated treatment efficacy in telephone follow-up; 44% of these patients (n=194) were evaluated more than 3 months after treatment, and 56% (n=249) could not be located. The results reported here represent the combination of patients from both sites (n=243). Patients were asked whether they were extremely satisfied, satisfied, neutral, or disappointed in their results. 73% reported being extremely satisfied or satisfied. 82% said they would recommend the procedure to a friend. 14% said they were unsure, and 5% said no. Treatment efficacy was assessed according to caliper measurements before treatment and at the three-month follow-up consultation (n=49). Patients were instructed not to change diet or exercise habits in order to maintain stable weight during the study. Attention was given to proper patient selection; only non-obese, fit patients with localised fat deposits were included. Weight was measured before treatment and at the follow-up visit. Mean weight was 65.9 ± 11.3 kg before treatment and 66.0 ± 11.7 kg at the follow-up visit - a statistically insignificant change. Caliper measurements were taken at the treatment site and a control site. When comparing the treated site with the control site, 94% of subjects showed a reduction in fat thickness. On average, the subjects had a 23% reduction in fat thickness at the treated site. In contrast, the control site showed a statistically insignificant change in fat thickness, with mean caliper measurements of 3.18 ± 1.02 cm before treatment and 3.14 ± 1.02 cm at follow-up. Finally, the investigator performed an efficacy assessment by grading pre- and three-month post-treatment photographs (n=49). Based on the investigator’s analysis, 73% of the subjects displayed reduction of fat thickness in the treated area. The most effective treatments seemed to occur in the abdomen and flank sites - 85.5% of subjects showed improvement in these two treatment sites. In comparison, there seemed to be little to no visual indication of treatment response in the thigh, knee, and buttock areas.

CONCLUSIONS The investigators also found that careful patient selection, proper anatomic site selection, and adequate number of treatment cycles are critical for achieving successful patient outcome. The most effective treatment was noted in the abdomen and flank sites. The investigators observed limited treatment response with fibrous bulges in areas such as the thighs, knees, and buttocks.

REFERENCES 1. Avram MM, Harry RS. Cryolipolysis for subcutaneous fat layer reduction. Lasers Surg Med 2009;41:703–8. 2. Rotman H. Cold panniculitis in children. Arch Dermatol 1966;94:720–1. 3. Duncan WC, Freeman RG, Heaton CL. Cold panniculitis. Arch Dermatol 1966;94:722–4. 4. Beachman BE, Cooper PH, Buchanan CS, Weary PE. Equestrian cold panniculitis in women. Arch Dermatol 1980;116:1025–7. 5. Manstein D, Laubach H, Watanabe K, Farinelli W, et al. Selective cryolysis: a novel method of non-invasive fat removal. Lasers Surg Med 2009;40:595–604. 6. Dover J, Burns J, Coleman S, Fitzpatrick R, et al. A prospective 34

Further research should be performed to optimise treatment time, number of cycles, and perhaps hand-piece shapes to improve cryolipolysis efficacy in fibrous bulges, which are typically difficult to treat. Additional fundamental research should be performed to establish the mechanism of action by which cryolipolysis damages adipocytes. It is not known why adipocytes are more sensitive to cold than other cell types and how adipocyte apoptosis occurs and leads to inflammatory infiltration at the treatment site. Authors: Christine C. Dierickx, Md, Jean-Michel Mazer, Md, Mila Sand, Md, Sylvie Koenig, Md, and Valerie Arigon, Md.

clinical study of non-invasive cryolipolysis for subcutaneous fat layer reduction-interim report of available subject data. Lasers Surg Med 2009;S21:45. 7. Coleman SR, Sachdeva K, Egbert BM, Preciado J, et al. Clinical efficacy of non-invasive cryolipolysis and its effects on peripheral nerves. Aesthetic Plast Surg 2009;33:482–8. 8. Nelson AA, Wasserman D, Avram MM. Cryolipolysis for reduction of excess adipose tissue. Semin Cutan Med Surg 2009;28:244–9. 9. Alster TS, Tanzi EL. Complications in laser and light surgery. In: Goldberg DB, editor. Laser skin surgery. vol 2. Philadelphia: Elsevier; 2005. pp. 103–17.

Aesthetics | January 2014

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Clinical Practice Spotlight On

VelaShape III: Understanding tissue interaction with RF for faster results in body contouring Alex Karidis discusses the benefits of the newest addition to the VelaShape family of devices. The basic premise of all non-invasive body contouring devices is to modify the adipocyte. The final aim is to either temporarily or permanently reduce the size and/or number of adipocytes, which in turn will result in a measurable reduction of fat and a circumferential reduction of the treated area. Targeted heating of the skin and fat using applied Radio Frequency (RF) energy has already demonstrated circumferential reduction and skin tightening. The mechanism of action is through an increased rate of fat metabolism resulting in accelerated lipid turnover ultimately leading to fat cell shrinkage and reduced volume. In addition, heating of the skin facilitates fibroblast activity, resulting in increased dermal collagen and ground substance, leading to a tightening of the skin and connective tissue. Despite significant results in the past, some inconsistencies were encountered with the previous generation of VelaShape devices. In order to understand these inconsistencies it is crucial to understand the key elements and parameters that have to take place within the tissues in order to reliably initiate the aforementioned cascade of events. These ideally need to be: • To reach an end point temperature of between 43-45°C • To create more heat below the skin surface and within the adipose tissues and sustain this heat in the tissue longer. • Control and maintain end point temperature over time. By achieving these goals, fewer treatment cycles and treatment times can also be achieved. One of the key observations gleaned from the previous generation of VelaShape products has been the significance of the impedance of the tissue. Impedance is the measure of resistance (measured in ohms) to the effects of any electrical current and this has been found to vary significantly in the different types of tissue. In very thin and muscular abdomens without much adipose tissue, this can be 100 ohms, whilst in a patient with a larger BMI this can be of the order of 400-500 ohms. This variation in tissue impedance in individual patients, as well as within the same patients, and the lack of adaption of the delivered RF energy in previous generation RF energy systems has been one of the reasons for the inconsistencies of results in the past. The VelaShape III possesses Intelligent

Delta Delta Temperature Temperature (oc)(oc)

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Delta Temperature (oc) Vela II Delta Temperature (oc) Vela III

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0 0

1 1

2 2

3 3

4 5 4 5 Time (minutes) Time (minutes)

6 6

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8 8

9 9

Aesthetics | January 2014

Bipolar RF in a closed loop fashion, giving the device the ability to measure the skin impedance ever 1ms and adjust RF power and energy levels accordingly to uniformly and accurately heat the tissue consistently regardless of the skin impedance of the patient. This has the advantage of delivering more consistent and reproducible results and reduces the risk of discomfort. The other key concept that has driven the development of the VelaShape III is the ‘Thermal dose’ concept. This states that the higher the temperature achieved in any given adipose tissue, the shorter the treatment time required. Increasing the tissue temperature from 42.5°C - 45°C can reduce the time the tissue needs to be in this elevated temperature by a factor of approximately eight. The new VelaShape III possesses 150 watts, which is approximately two and a half times more than the VelaShape II. This increased power plus the new impedance control assures the same energy gets delivered into the tissue regardless of the tissue impedance. It is now possible, depending on the area needing treatment, to achieve the desired result with only one treatment. In summary therefore, whilst the end results for patients are very similar compared to previous generation multi-treatment VelaShape devices, for busy patients who cannot commit to up to six treatments, the alternative of a single treatment of 45 - 90 minutes is available. However, if patients prefer more frequent but shorter treatments, this can also be offered. Alex Karidis, has over 25 years of experience in plastic surgery and has run his own practice in St John’s Wood, London for 17 years. Mr Karidis has now expanded his non-surgical offering outside of London with the opening of the first Karidis Medispa in Beauty Bazaar, Harvey Nichols in Liverpool.

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This is not intended for the U.S. market. Š2013. All rights reserved. Syneron and the Syneron logo are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. Candela is a registered trademark of the Candela Corporation. UltraSculpt and UltraShape are registered trademarks of UltraShape. PB82801EN

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EME/021/1013 Date of prep: October 2013

References 1. Rzany B et al, Dermatol Surg 2012;38: 1153â&#x20AC;&#x201C;1161 2. Cartier et al, J Drugs Dermatol. 2012; 11 (1)(Supp): s17-s26 (*Results taken from a mean value across all treatments performed in study) 3. Farhi D et al, J Drugs Dermatol 2013; 12: E88-E93

Clinical Practice Treatment Focus

Managing skin ageing As more patients are presenting with chronic inflammatory skin diseases, Dr Mervyn Patterson says it’s time to rethink aggressive skincare regimes. An increasingly important aspect of skincare regimes, designed to prevent and reverse the visible signs of skin ageing, is the use of products with active ingredients focused on reducing unwanted chronic inflammation. The driving force behind this pivotal shift is that inflammation has now been implicated as a cause of many diseases, including cancer and visible skin ageing. The two significant triggers for inflammation are disruption of the external skin barrier and UV light exposure. It is now apparent that optimising the health of the external skin barrier structure and function to a high as possible level minimises the penetration of ultraviolet radiation and other damaging molecules. These are absolute requirements for the treatment and prevention of skin ageing and other skin conditions.

GROWING AWARENESS Denham Harmon has been credited as the first person to postulate the theory of free radical theory of ageing with his documentation of cellular destruction by reactive species over fifty years ago. Kligman and Laker described microscopic evidence that inflammation played a role in visible skin ageing two decades ago(2). Andrew Weil, a prominent proponent of the anti-inflammatory diet has published his own recommendations for a healthy diet and supplementation. He believes that “without question, diet influences inflammation.” Weil and others point to the surprising link between inflammation and serious disease including heart attacks, Alzheimer’s disease, stroke, multiple sclerosis, rheumatic fever, rheumatoid arthritis, type 1 diabetes mellitus, systemic lupus erythematosus and scleroderma, colon, prostate and skin cancer. They propose that a single inflammation reducing remedy would effectively treat and prevent these conditions. Similar strategies are now proposed for treatment of ageing cells in the skin.

A RISING TIDE OF INFLAMMATORY PROVOKED DISEASE. The incidence of chronic inflammatory skin disease is significantly increasing in all age groups. Current estimates put the incidence of childhood dermatitis as high as 30% of the population. Occupational contact dermatitis is one of the leading causes of lost days at work with estimates putting the incidence as high as 9%(6). In the last decade the scientific community has started to recognise the link between inflammation and malignancy. The western world is facing an epidemic of skin cancers. 50% of people over sixty-five years old are suffering from a solar keratosis. Since the mid-1970s in the UK, malignant melanoma incidence rates have increased more rapidly than any of the current ten most common cancers. The incidence of Non-melanoma skin cancers NMSC is also increasing inexorably. In 2010, there were 99,549 cases of NMSC registered in the UK although due to recording practices this is likely to be a substantial underestimate. (7) This Aesthetics | January 2014

is despite public education and the introduction in the 1980’s of sunscreens with a sun protection factor of fifteen or higher and the use of agents broadening the protection to UVA exposure. During this time however there has been a dramatic rise in the use of exfoliating agents using alpha hydroxyl acids (AHAs), retinoids and microdermabrasion. It has been shown that even mild barrier disruption and sub erythematous doses of ultraviolet light each induce microscopic inflammation and tissue destruction. Chronic, repeated disruption of the external skin barrier due to any cause has been shown to activate chronic inflammation. (8,9) On the other hand acute inflammation created by procedures such as microdermabrasion and certain peels does not appear to induce skin damage resulting in worsening of visible skin ageing. Chronic inflammation produced by AHAs and retinoids would appear to be produced by barrier disruption. In 2002 the Food and Drugs Administration (FDA) due to concerns over increased photosensitivity and pre-malignant change in cells developed a warning for AHAs with a concentration over ten percent and pH less than three. Since the AHAs are not photosensitisers unlike retinoids the photoreactivity must be due to barrier destruction. (8,10) While short term use of retinoids in animal studies suggests a reduction of visible premalignant and cancerous growths Halliday reported increased skin cancers with prolonged use. (11)

TRADITIONAL MEDICINE AND ANTI-INFLAMMATORIES Potent anti-inflammatory products such as steroids and methotrexate have been very important tools in the physicians fight against conditions such as psoriasis, dermatitis, some skin cancers and a range of internal inflammatory diseases and cancers. Topical application of Diclofenac, a non-steroidal anti-inflammatory drug, received FDA approval to treat pre-malignant solar keratosis. Similarly Indo39

Clinical Practice Treatment Focus

methacin, applied topically appears to improve visible skin ageing in animal models. (12) This successful use of medicine for treating a wide range of conditions supports the observations linking inflammation to diseases and cancer. Systemic lupus erythematosus, dermatomyositis and scleroderma are systemic diseases with characteristic skin damage. Characteristic epidermal changes and irregular pigmentation of the skin is present in these diseases and also visible skin ageing.

THE COMPLEMENTARY ARGUMENT The last two decades has seen the public’s use of alternative and complementary medicine rapidly increase. Of the top ten selling herbs, half of them have documented anti-inflammatory and/or antioxidant mechanisms of action in humans or animal studies. More than one hundred herbs are being marketed in topical non-prescription skin care products. Many of these have proven anti-inflammatory and/or antioxidant activity suggesting they may be beneficial in treating and preventing inflammatory diseases and skin ageing. Care should be taken to not simply assume that all have proven benefit in humans. Of eight thousand documented antioxidant ingredients, only fourteen have been incorporated into topical formulations that were documented in human clinical trials to improve parameters of visible skin ageing. (13,14,15) Botanical extracts rich in alpha hydroxy acids (AHAs) such as apple, retinoids including retinol (vitamin A) as in carrot, certain ascorbic acids (vitamin C) such as citrus, soy milk and total soy, arbutin (16), date palm fruit as a solitary agent (17), green tea when applied topically plus taken orally (18), colloidal oatmeal (19) and oat (20), and proprietary formulations of date kernel, meadowfoam and flax (15); pycnogenol (3) and parthenolide free extract (PFE) of feverfew (21) all have evidence in clinical trials to support their use in the treatment of ageing skin. The use of herbs as oral supplements is ever increasing in popularity with many containing multiple antioxidant and or anti-inflammatory ingredients. Three of these are supported by clinical studies suggesting efficacy in improving skin ageing. 15

UNDERSTANDING MECHANISMS The skin is our first line of defence against a range of potential external irritants. These environmental insults trigger the formation of destructive reactive oxygen species otherwise known as free radicals. Smoking, pollution, a huge range of chemicals contained in both prescription and over the counter cosmetic products, preservatives, allergens, medical and cosmetic procedures including excessive exfoliation, UV and X radiation. 8,10 As soon as the skin senses disruption of the external skin barrier, the transmitter Tumour Necrosis Factor Alpha (TNFα) is released along with Interleukins 1 (IL-1) and 8 (IL-8) and other markers that ramp up inflammation as part of the acute repair cascade to respond to a damaged skin barrier. 22,23 Metalloproteinase enzymes (MMPs) are enzymes that are part of the skin’s response to inflammation and function to remodel much in the same way as osteoblasts reabsorb unwanted bone matrix. They are synthesised rapidly in several skin cells including fibroblasts, keratinocytes and masts cells. MMPs degrade damaged extra cellular matrix, collagen and elastin to allow the skin to respond to injury. Whilst this activity is beneficial in some repair situations, chronic elevation of MMP levels leads ultimately to collagen reduction and loss of skin thickness and elasticity. Collagenase (MMP-1), stromelysin (MMP-3) and gelatinase (MMP-9) are the most important. These enzymes also play important roles in premalignant and malignant deterioration of skin cells. 24


The evidence to hand suggests that reversing and preventing chronic inflammation is the ideal approach to treating skin ageing, skin diseases and skin cancers. Ideally a skincare regime should contain topical products that optimise the health of the external skin barrier and dampen chronic inflammation. A diet rich in anti-inflammatory and antioxidant foods combined with oral supplementation may also improve outcomes. Allowing the skin to return to its normal function and structure will help reverse some of the existing signs of visible skin ageing and minimise future deterioration. Skincare professionals treating the skin should consider the impact of their interventions in terms of how much barrier disruption Factors that effect barrier disruption and the complex cascade of inflammatory pathways and chronic inflammation will be that are triggered. produced. To reduce side effects, Inflammatory Pathways hasten recovery and maximise outHumidity; UV & X Radiation; Elderly; Neonates; Increased Stress; Skin Type 1; Hormonal Imbalance; Increased Bacteria comes from a procedure it is ideal to BARRIER DISRUPTION OTHER INFLAMMATORY PATHWAYS prepare the skin with skincare products that optimise the external barrier Cytokines + Bacteria TNFαß and reduce chronic inflammation. Nuclear <5.5 Acid pH Toll Histamine IL-1a,b,IRA Growth Receptors Receptors Factors Maintenance skin care regimes to PPAR & LXR treat and prevent skin ageing should + Inflammation + Inflammation TGFß IL-6 improve the quality of the skin by MAP repairing the barrier and controlling Circulating Arachidonic saccharides Acid Kinases chronic inflammation. Cyclo-oxygenase Lypoxygenase + Immunity + IL-8 Glycation UV ERK JNK ROS Alpha hydroxy acids and retinols in Prostaglandins CJUN CFOS + Inflammation high concentrations can have a neg+ Inflammation AP-1 ative effect on skin barrier function. Care should be taken with skincare NFKß + MMPs Gene Activation (Matrix metalloproteinases) ingredients that induce significant + Microscar + Inflammation + macrophages + Dysplasia persistent redness or peeling and + lymphocytes + leukocytes increased sun sensitivity. Clinicians + mast cells fine lines Skin Disease Actinic wrinkles Skin Sensitivity Keratoses need to be mindful that ingredients furrows Skin Cancer + Chemokines in skincare can have negative and (Adhesion molecules, defensins, selectins) positive effects on skin health. agd



Aesthetics | January 2014

Clinical Practice Treatment Focus REFERENCES 1. Lavker R, Kligman A. Chronic Heliodermatitis: A morphological evaluation of chronic actinic dermal damage with emphasis on the role of mast cells, J Invest Dermatology 1988; 90:325-330. 6. Lerbaek A, Kyvik KO, Ravin H et al Incidence of hand eczema in a population-based twin cohort: genetic and environmental risk factors. Br J Dermatol 2007;157:552-7. 7. Data provided by the Office for National Statistics June 2012 8. Elias P, et al. The link between barrier function and inflammation. Arch Derm 2001; 137:8:60-62. 9. Baumann L, Eichenfield L, Taylor S. Advancing the Science of Naturals. Cosmetic Dermatology 2005; 18:24: suppl 4:2-7. 10. Duell E, Fisher G, Kang S, et al. Pathophysiology of premature skin aging 11. Halliday GM, et al. J Invest Dermatol 2000; 114(5):923-7. 12. Bissette D, Chatterjee R, Hannon D, et al. Photoprotective effect of topical anti-inflammatory against ultraviolet radiation-induced chronic skin damage in hairless mouse. Photodermatol Photoimmunol Photomed 1990; 7:153-158. 13. LaGow B Chief Ed. PDR for Herbal Medicines 3rd Ed. Thomson PDR Montvale, NJ. 2004; 254, 320, 328, 604, 747. 14. Jellin JM, Gregory P, Bate F, et al. Pharmacistâ&#x20AC;&#x2122;s Letter/Prescriberâ&#x20AC;&#x2122;s Letter. Natural Medicines Comprehensive Database, 3rd Ed. Stockton, CA. Therapeutic Research Facility. 2000; 91, 92, 130, 131, 147-149, 361, 525-528, 849, 972-974. 15. Thornfeldt CR, Herbs in Cosmeceuticals: Are They Safe and Effective? Chapter 19 in: Draelos Z, Thaman L, eds. Cosmetic Formulation of Skin Care Products. Taylor & Francis Group, New York, NY 2006; 30:309-351. 16. Draelos ZD, Thaman, LA, eds. Cosmetic Formulations of Skin Care Products. Taylor and Francis. New York, London. 2006; 208. 17. Bauza E, et al. Date palm kernel extract exhibits antiaging properties and significantly reduces skin wrinkles. Int J Tissue React. 2002; 21:131-136. 18. Chiu AE, et al. Treatment of rosacea with herbal ingredients. Dermatol Surg 2005; 31:855-860.

19. Baumann L. Oatmeal Cosmeceutical Critique, Skin and Allergy News 2004 (Nov); 38. 20. Baumann L. Cosmeceutical Critique Compendium: Supplement to Skin and Allergy News 2006; 3-23. 21. Martin K, Southall M, Lyte P, et al. Parthenolide-free fever few: an extract with effective anti-irritant activity in vitro. Poster 1039 presented at: American Academy of Dermatology 63rd Annual meeting: 2/18-22/05. New Orleans LA. 22. Nickoloff B, Naidu Y. Perturbation of epidermal barrier function correlates with initiation of cytokine cascade in human skin. J Am Acad Dermatology 1994; 30:535-546. 23. Elias P, et al. Barrier function regulates DNA synthesis. Sem Dermatol 1992; 11:176-182. 24. Pilcher B, Sudbeck B, Dumin J, et al. Collagenase-1 and collagen in epidermal repair. Arch Dermatol Res 1998; 290: Suppl 37-46.

ABOUT THE AUTHOR: As a co-owner of Woodford Medical, Dr Mervyn Patterson is a highly experienced aesthetic doctor providing a wide range of non-surgical treatments. Financial disclosures: Medical Director Eden Aesthetics Distributors of Epionce / Agera skincare, and Colorescience mineral makeup. Dermagenesis Microdermabrasion and Dermafrac microneedling @drmervpatterson

To discover what sets Epionce apart contact Episciences Europe LLP on 01245 227788

Clinical Practice Abstracts

A summary of the latest clinical studies Title: Cellulite and Focused Extra Corporeal Shockwave Therapy for Non-Invasive Body Contouring: A Randomised Trial Authors: Knobloch K, Joest B, Kr채mer R, Vogt PM Published: Dermatol Ther (Heidelb). 2013 Dec 3 Keywords: Focused extra corporeal shockwave therapy, cellulite, gluteal strength training, non-invasive body contouring Abstract: Focused extracorporeal shockwave therapy (ESWT) has been demonstrated to improve wound healing and skin regeneration such as in burn wounds and scars. The authors hypothesised that the combination of focused ESWT and a daily gluteal muscle strength program is superior to SHAM-ESWT and gluteal muscle strength training in moderate to severe cellulite. This was a single-centre, double-blinded, randomised-controlled trial. Eligible patients were females aged 18-65 years with cellulite. The primary outcome parameter was the photo-numeric Cellulite Severity Scale (CSS) determined by two blinded, independent assessors. The intervention group (group A) received six sessions of focused ESWT (2,000 impulses, 0.35 mJ/mm2, every one-two weeks) at both gluteal and thigh regions plus specific gluteal strength exercise training. The control group (group B) received six sessions of SHAM-ESWT plus specific gluteal strength exercise training. The combination of noninvasive, focused ESWT (0.35 mJ/mm2, 2,000 impulses, six sessions) in combination with gluteal strength training was superior to gluteal strength training and SHAM-ESWT in moderate to severe cellulite in terms of the CSS in a 3-month perspective. Title: Filler placement and the fat compartments Authors: Fitzgerald R, Rubin AG Published: Dermatol Clin. 2014 Jan Keywords: Facial adipose tissue, facial fat compartmentalization, fat compartments, filler placement Abstract: Understanding the anatomy and distribution of facial fat and the alterations that occur during the aging process is essential to effectively and precisely achieve facial rejuvenation. Over the past several years, through cadaveric dissections and computed tomographic studies, much has been discovered concerning the adipose tissue of the face and how it influences the dynamic process of aging. Site-specific augmentation with fillers can now be used to refine facial shape and topography in a more predictable and precise fashion. The purpose of this article is to provide an introduction to facial fat compartmentalization along with clinical examples to illustrate how the knowledge of underlying anatomy influences sitespecific augmentation. Title: Laser Therapy for Prevention and Treatment of Pathologic Excessive Scars Authors: Jin, Rui M.D.; Huang, Xiaolu M.D.; Li, Hua M.D., Ph.D.; Yuan, Yuwen M.D., Ph.D.; Li, Bin M.D.; Cheng, Chen M.D.; Li, Qingfeng M.D., Ph.D. Published: Plastic & Reconstructive Surgery. 2013 Dec Keywords: hypertrophic scars, keloids, scars, laser therapy Abstract: The management of hypertrophic scars and keloids remains a therapeutic challenge. Treatment regimens are currently based on clinical experience rather than substantiated evidence. A 42

meta-analysis was conducted to evaluate the effectiveness of various laser therapies. The pooled response rate, pooled standardised mean difference of Vancouver Scar Scale scores, scar height, erythema, and pliability were reported. Twenty-eight well-designed clinical trials with 919 patients were included in the meta-analysis. The overall response rate for laser therapy was 71% for scar prevention, 68% for hypertrophic scar treatment, and 72% for keloid treatment. The 585/595-nm pulsed-dye laser and 532-nm laser subgroups yielded the best responses among all laser systems. This study presents the first meta-analysis to confirm the efficacy and safety of laser therapy in hypertrophic scar management. Title: A promising split-lesion technique for rapid tattoo removal using a novel sequential approach of a single sitting of pulsed CO2 followed by Q-switched Nd: YAG laser (1064 nm) Authors: Sardana K, Garg VK, Bansal S, Goel K Published: J Cosmet Dermatol. 2013 Dec Keywords: laser, tattoo, tattoo removal Abstract: Laser tattoo removal conventionally uses Q-switched

(QS) lasers, but they require multiple sittings, and the end results depend largely on the type of tattoo treated. In pigmented skin, due to the competing epidermal pigment results, laser results in tattoo are slow and inadequate. The objective of this trial was to evaluate the efficacy of a combined use of ultrapulse CO2 and QS Nd:YAG (1064 nm) laser in the treatment of tattoos in Indian skin. A splitlesion trial was carried out in five patients, with the left side of tattoos receiving the QS Nd:YAG (1064 nm) and the right side, a sequential combination of Up CO2 and QS Nd: YAG at six weeks interval with a maximum of six sittings. The trial found that a combination of an Up CO2 laser with QS Nd: YAG laser is a promising tool for rapid and effective removal of blue-black/blue amateur tattoo in pigmented skin.

Title: Honey in dermatology and skin care: a review Authors: Burlando B, Cornara L. Published: J Cosmet Dermatol. 2013 Dec Keywords: acacia honey, antimicrobial action, cosmetic and dermatological formulations, phytocompounds, skin cells, skin disease and aging Abstract: Historical records of honey skin uses date back to the earliest civilisations, showing that honey has been frequently used as a binder or vehicle, but also for its therapeutic virtues. Antimicrobial properties are pivotal in dermatological applications, owing to enzymatic H2 O2 release or the presence of active components, like methylglyoxal in manuka, while medical-grade honey is also available. Honey is particularly suitable as a dressing for wounds and burns and has also been included in treatments against pityriasis, tinea, seborrhea, dandruff, diaper dermatitis, psoriasis, hemorrhoids, and anal fissure. Mechanisms of action on skin cells are deeply conditioned by the botanical sources and include antioxidant activity, the induction of cytokines and matrix metalloproteinase expression, as well as epithelial-mesenchymal transition in wounded epidermis. Future achievements, throwing light on honey chemistry and pharmacological traits, will open the way to new therapeutic approaches and add considerable market value to the product.

Aesthetics | January 2014

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In Practice Social Media

The dangers of social media Being careless on social media could cost you your career, warns Bernadette John. Today, almost all medical aesthetic practitioners either engage, or are planning to engage via social media. Yet errors of judgment when using digital applications and social media could see your practice sued for millions of pounds, loss of your insurance or you being hauled up in front of disciplinary hearings by your professional body, all of which could lead to the end of your career. Any practice gleaning its inspiration for online engagement and brand promotion directly from the internet or indeed from many self-styled ‘social media gurus’ or trainers, many of whom are surprisingly ignorant of ethics and even the guidelines issued by professional bodies, could find themselves in deep water. The cornerstone of any social media training or strategy for aesthetic clinical practice must be familiarity with the guidelines of the appropriate governing professional body, ensuring patient dignity and respect for patient privacy. The Nursing and Midwifery Council (NMC), the General Medical Council (GMC) and the General Dental Council (GDC) have all published guidelines on the use of social media for their disciplines in 2013.

If you are considering the use of patient photos to create a gallery of your work, be clear about how you will achieve fully informed consent in advance

Digital photography and recording – a potential minefield Many online articles advocate the use of commercial, photo-sharing platforms such as Instagram, Pinterest, Flickr and even Facebook to host galleries of ‘before and after’ photos of their patients’ wrinkles or even children’s orthodontics. They do this with no mention of the importance of patient consent, and no acknowledgement of the potential issues around confidentiality or the ability of metadata (information embedded in digital photos, including device identifiers, location data, date and time) to break patient confidentiality. With digital photographs, obscuring the eyes with a black bar is simply not enough. The same applies to audio and visual recordings. The GMC reminds us that it is important to remember that “when deciding whether a recording is anonymous, doctors should bear in mind that apparently insignificant details may still be capable of identifying the patient. Extreme care should be taken about the anonymity of such recordings before using or publishing them without consent in journals or other learning materials.” “When using social media, you must maintain and protect patient information by not publishing any information which could identify them on social media without their explicit consent.” (GDC 2013) Certainly, informed consent cannot be achieved when a patient is already anaesthetised, or in a chair with a dental dam in situ, as has happened in one case I know of. If you are considering the use of patient photos to create a gallery of your work, be clear about how you will achieve fully informed consent in advance, without placing pressure on patients. Current GMC guidance states that before you take a photograph or other recording “you should explain the purpose of the recording and how it will be used, how long the recording will be kept and how it will be stored, and that patients may withhold consent or withdraw consent during or immediately after the recording and this will not affect the quality of the care their receive or their relationship with those providing care.” Also be clear about removing EXIF data from any electronic photos taken (there are Apps such as the NoIMGData App that can do this) and be sure that you are familiar with the current discipline-specific clinical guidelines on photography, for example, the GMC paper ‘Making and using visual and audio recordings of patients’ published in 2011. Doctors need to bear in mind that when used for clinical purposes such recordings form part of the patient’s medical record and the same standards of confidentiality, and the same requirements for consent to disclosure, apply. How the images are taken is also important. Images taken on mobile phones Aesthetics | January 2014


In Practice Social Media

and devices are almost impossible to safeguard. Many NHS clinical areas do not allow photographs to be taken with mobile phones, to ensure confidentiality and safeguard dignity, so familiarise yourself with this policy in your place of practice, and reflect on the security of any images you take. In a recent case in front of the GMC, a cosmetic surgeon, Dr Erik Scholten, took a photograph of a woman’s ‘unusual’ genitals on his iPhone without her permission with the intention of using the picture for teaching purposes. The patient was on the operating table, anaesthetised and about to have her PIP breast implants removed. He is now bankrupt and has been suspended from the profession. Currently in the U.S., Catherine Manzione is suing Dr. Grigoriy Mashkevich for $18 million as she was “greatly distressed and humiliated” to find a number of pre- and post-rhinoplasty photographs of herself on the doctor’s website, asserting, “This is not a doctor releasing photographs: this is a doctor releasing medical records.” If little or no explanation of the intended destination or potential reach of photographs is given, coupled with an absence of signed consent documents, a clinician taking photos on their digital camera, mobile phone or tablet device is putting themselves at risk of legal action. Patients may consent assuming that photos are destined for their notes folder or for teaching. If your PR or social media consultant is advocating the use of patient photos to create a gallery of your work, ask them to establish how you will achieve fully informed consent, and further, to demonstrate how to strip metadata from electronic photos. Also ask them to explain their understanding of the current clinical guidelines. Aside from the issue of images and recordings potentially being uploaded to the cloud and shared across your various devices from phones to tablets and laptops, use of common apps such as Facebook and Twitter can also be highly problematic. Your own patients could put other patients’ confidentiality at risk. I have seen cases where patients have been tweeting and even taking photographs in the waiting room. If you have well-known patients seeking cosmetic treatments this is a particular risk, as these images are highly desirable to the media. I suggest that clinical practices display notices to say something along the lines of “We prize patient confidentiality so we would like to suggest that it is best when using social media, not to mention your fellow patients and we do not allow patients to take photographs on the premises.” Of course, you should never post any information, dialogue or comments about individual patients online that could break confidentiality or bring you or your profession into disrepute. 46

It is now very common for patients to investigate their doctors online so consider the impact your personal posts and images could make. Regular status updates on Facebook, about how you get no sleep at all since the birth of your baby, could cause patients to wonder about the quality of your work or whether you are rested enough to have made the appropriate diagnosis or to have carried out a procedure. Images of you having a night out, drinking at home or even images that reveal your affiliation with a specific political party or organisation could cost you a patient. Even if you haven’t personally posted the images, you could suffer a detriment if you have been tagged in other people’s photographs. More seriously, casual jokes on social media that, for example, you don’t know how you passed your final exams as you spent your five years at university drunk, or a photograph of your partying the night before a procedure could be used to create an unprofessional characterisation of you. This might subsequently cause your insurer to accept liability and pay out without going to court if a patient ever sues as they suffer an adverse event. The consequences may sound extreme but this could render you unemployable, without your ever being sanctioned by your professional body. If a patient contacts you via social media, you should be sure to maintain professional boundaries, and remind them that you cannot mix your personal and professional life. It is generally not a good idea to make or accept links with patients on personal social media. In short, do not assume you can have a separate private life on social media. The GMC regulates the doctor as a person, not just as a clinician. A fitness to practice hearing could arise from social media activity even if the doctor only posts during their own time. Anonymity is all very well, but the GMC states that doctors who identify themselves as such on social media must not be anonymous. So if you do use social media, guard your privacy and that of your family well. Ultimately, it is virtually impossible to maintain anonymity on social media, so assume that everything you say there has your signature on it. Bernadette John is the Digital Professionalism Lead at Kings College London, well versed in the detail of social media platforms and the guidelines published by the governing bodies of various professional groups. She has 24 years experience in various professional roles from Midwife to Year Lead at a Medical School. She is in demand to consult and lecture internationally and provides pragmatic support, accessible advice, crisis management and training for employers, employees and students.

LINKS TO THE ONLINE GUIDANCE: GMC (2011). Making and using visual and audio recordings of patients . patients_2011.pdf GDC (2013). Guidance on using social media. Standards/Documents/Guidance%20on%20using%20social%20media%20%28Sept%20 2013%29.pdf GMC (2013). Doctors use of social media. social_media.pdf_51448306.pdf GMC (2013). Notes on Doctors Use of Social Media - php?note_id=549553408401395 NMC (2012). Social Networking Sites. Advice-by-topic/A/Advice/Social-networking-sites/ Two press stories

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In Practice Legal

What laws should you know about when recruiting staff? Specialist lawyer Vanessa Di Cuffa explains.

Hiring and Firing Combining being a clinician and a small business owner can be very daunting, particularly when it comes to hiring, and even worse, firing, staff. Many new businesses will not have a HR specialist on board, and you may wish to advertise and recruit directly, without using an agency. If that’s the case, you need to be mindful of the plethora of discrimination laws that exist. Keep the advert simple. Words like ‘young’, ‘energetic’ and ‘flexible’ can cause issues. Don’t specify a sex, unless it really is a requirement of the job. Simply outline the role and ask for interested candidates to apply by sending in CVs or filling in an application form.

that an employee signs and returns the contract and make sure it is dated. Most new employees will be subject to a probationary period and this should be outlined in any contract. The normal period is six months with the ability to extend if necessary. During this probationary period you can impose a shorter notice period and usual internal processes may not apply. An employee has to have two years of continuous service before a claim for unfair dismissal can be brought (in most cases). That said, anyone who has protection under discrimination legislation may be protected before they even start. There are actually nine protected characteristics: sex, gender reassignment, being married or in a civil partnership, being pregnant or on maternity leave, race, disability, sexual orientation, religion or belief and age. After two years you need a fair reason to dismiss an employee. There are currently five legal criteria: redundancy, conduct, capability, some other substantial reason or illegality. Most problems you have with an employee will fall under the first three, but again, take advice to identify the right one and how to handle it. Whatever the reason, there will be a process that you need to follow before you can action a dismissal. That said, the law has recently introduced the ability to enter into discussions that are ‘off the record’ with an employee, and would culminate in the employee exiting the business under a specific legal agreement.

Be cautious in an interview. Have set topics and make sure you ask all the candidates about the same topics, though you don’t necessarily have to ask the same questions. Do not discuss age or childcare plans or arrangements. Don’t ask about health or other personal matters. Only discuss the role and the attributes the candidate has. Make sure you check that an employee is eligible to work in this country. That applies to all candidates you interview without exception. There is a checklist of the documents you need to ask for on the UK Border Agency website and also guidance about the necessary checks to conduct. Failure to carry these out can result in large fines for your small business, and claims of discrimination from aggrieved employees.

Failure to identify the right way to handle your employee can result in claims being made against you and large financial penalties being imposed. Employees do have to pay to bring such claims, which is a deterrent but claims are still being made and defending them is time consuming, draining and costly. There are no winners in litigation. Doing things properly and taking the right advice at the right time can reduce the risk of this. Sound and practical commercial legal advice will provide you with a solution that helps you run your business and thrive.

Once you find your successful candidate, send them a formal written job offer. The letter can be very brief and include a proposed contract or alternatively your offer letter can be more detailed and constitute a simple contract. Contracts do not have to be lengthy and complicated, but it is advisable that the more senior and valuable the employee is, the more detailed the contract is. Seek advice from an employment lawyer on what would be appropriate. If you simply want to send an offer letter, then you have two months from the day an employee starts working before you have to issue a full contract with the key legal terms required. Make sure that any offer is conditional upon receipt of references, preferably written; but be mindful that references are simply statements of fact these days and rarely provide much useful information about the individual. Always ensure

Vanessa Di Cuffa is a Partner specialising in Employment law and HR at law firm Shakespeares: Vanessa advises on all aspects of employment law and HR across sectors including medical, ranging from small SMEs to large corporate organisations. She is commercially focused, providing you with real solutions.


Aesthetics | January 2014

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In Practice PR

How to pitch a story to the press

Don’t annoy the journalist: once you have ascertained your publication, your contact, and your story has been pitched, sit back for a couple of days. Feel free to chase up, but leave a day or two after pitching. And don’t whine about rival experts; this is a sure-fire way of ensuring they don’t use you again!

Stay focused – don’t give up: if they don’t hear from you after a while, they will not beat a path to your door. Having said that, journalists are busy people and newsrooms can get quite frantic. Respect their schedules.

Exclusives: you needn’t be a brain surgeon to

From finding the right person to avoiding being annoying, publicist Tingy A. Simoes offers an insider’s guide. You’ve hopefully pinpointed something newsworthy to say, and a particular group of people who should know about it. So, how to approach a journalist? It’s rather unlikely that you as clinicians will find yourselves making the first call to pitch a story directly to a reporter. This will be the job of your PR (if you have one), or perhaps your marketing person or even your practice manager. Taking note of the tips below will give you invaluable tools and an understanding of the process.

How to find contact details for the media: look on the web, browse the newsstands. There are plenty of free websites where you can look up media contact details, and many newspapers and outlets will actually list their editorial teams. In magazines, you can always flick through the pages to the masthead, which will list the editorial staff.

How to ascertain the best person to speak with: feel free to contact the general switchboard and ask, “Who covers health?” or, “Who would be the best person to talk to about a local clinic’s charity fundraising?” etc. The issue is that, sometimes, there is often more than one contact who can be appropriate. Just because ‘Health’ doesn’t want to cover it, ‘Features’ or ‘News’ might, so it can be a bit of a guessing game and certainly involves a lot of trial and error. This is why experienced publicists, particularly publicists who are known for one particular sector, such as cosmetic surgery, are invaluable. They will know that sometimes the ‘Business’, ‘Home Affairs’ or ‘Culture & Society’ reporter will be covering news from this arena.

Do your research: in PR, as in life, flattery will almost always help. If you have time before an interview or before approaching a journalist for the first time, look up what else they have covered in the past. You will seem much more clued up if you say, “I enjoyed the piece you did last month on teeth whitening/swine flu/ bunions.” They will be pleasantly surprised.

Put yourself in the journalist’s shoes…what would they want to know? Offer interviews and photos. A tip: do NOT send big attachments unsolicited. They will only clog up their inbox and annoy them. Leading us to… 50

Aesthetics | January 2014

figure this one out. It basically means you offer it to one person first. Offering journalists a story can be a complex balance game, and most journalists will turn their nose up at a press release that’s been carpetbombed to 900 contacts. To individually contact each prospect, and wait until they run it past their editors, then get back to you with feedback (which could well be a ‘maybe’) can be extremely time-consuming. However, it invariably yields the best results. A newspaper or TV programme that has a head start over anyone else, will be perceived as ‘clued-up’ and therefore earn your gratitude. Never pit two journalists against each other for the same story. This will enrage them and is a sure-fire way of ensuring they will never, ever write up any of your stories! Getting a ‘hit’, i.e. securing coverage, can be quite a serendipitous process. You may ring an editor today and they can categorically say that there is absolutely no interest in covering cosmetic surgery or aesthetic treatments at all. Next week this may change, and they probably won’t backtrack and call you, but simply use whoever is contacting them at the time. Also, outlets that historically haven’t proven friendly to cosmetic surgery may undergo a change in direction and decide that, after all, it is something that they’re interested in. This happens a lot when there’s a new editor or producer in charge. It’s a fluid environment and things are constantly changing: space for a story can suddenly open up last minute, which is why good publicists are always on the move. It is rarely a nine to five job! Adapted from ‘How to Cut it in the Media: A PR Manual for Plastic Surgeons and Professionals in Cosmetic Medicine by Tingy A. Simoes’, available in e-book and print format via Amazon and reputable e-tailers. Tingy Simoes has over 15 years experience in healthcare PR and is owner/managing director of Wavelength Marketing Communications

LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE)

Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection Date of preparation: March 2013

site(s) or when the targeted muscle shows excessive weakness or atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

(twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013

Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to Galderma (UK) Ltd.


In Practice Patient Relations


Right time, right advice Wendy Lewis on the delicate art of patient screening and how to turn patients away There is an art to communicating with cosmetic patients that is quite different from how a GP may speak to a patient with stomach pains. The great divide between aesthetic treatments and standard medical care is that the former is usually purely a want, and the latter is about a need. No one really needs to smooth out his or her wrinkles or plump up their lips. Rather it is something one wants to have done. That is a huge difference. A cosmetic patient who does not respond to you or just doesn’t really like your personal style may not be a good fit for your clinic. In that case, the patient may actually be doing you a big favour by choosing another doctor. Ultimately, how comfortable prospective cosmetic patients feel with you and your clinic staff determines their decision of whether to stick with you or go to someone else. Therefore, if the relationship doesn’t start out on a solid footing, it usually will not improve. In many cases, it is harder to say no than to say yes.

THE CONSULTATION PROCESS The consultation is a vital aspect of a successful outcome in medical aesthetics. The key purpose of a cosmetic consultation is developing a rapport and educating the patient on the procedures that may be appropriate to suit their needs. Setting realistic expectations for your patients is also a critical factor. What you want to do to the patient is less important than what the patient wants you to do to them. At the end of the day, it is his or her face or lips in question and they have to be happy with the outcome. It is the practitioner’s responsibility to present a wide spectrum of potential procedures, both the ones being recommended as well as the alternatives: you should cover risks, potential complications, and alternative treatments, as well as a realistic estimate of recovery time. It also helps to be sensitive to the patient’s budgetary concerns by having a clinic staff member review fees. For example, if the patient is anticipating that a filler will cost £300, but you use two syringes costing twice that amount, the overall impression the patient may be left with is that she was either misled or overcharged. Working with your patients to arrive at a sensible solution takes extra time and effort, but the pay off is immense in patient satisfaction and loyalty. 52

Aesthetics | January 2014

Regrettably, practitioners don’t always know enough about a patient from an initial visit to decide whether they want to move ahead with treatment. The staff member who assumes the pivotal role of patient screening can help to identify potentially challenging patients. Every member of the clinic staff should be adept at interfacing with patients, including the practitioner. Aesthetic medicine is a service business, and strong interpersonal skills are paramount to success. The impression you should leave with patients is “We’re here if you need us”, rather than having patients feel that they are being sold too many procedures, or procedures they did not come in for. Good communication and listening skills are essential. If you listen carefully, you should be able to pick up why the patient came to your clinic and what his or her priorities are. Inquire about what research has been done already to establish a starting point, and what, if any, aesthetic treatments the patient has already had. Patients who bash previous doctors or complain about treatments they have had should also raise concerns, as this is indicative of a pattern of behaviour. Their distrust for doctors and dissatisfaction may run deep, and you could be walking into a negative situation. The mission of the cosmetic consultation is two-fold; it allows the patient to interview the practitioner, and it is the primary opportunity for the practitioner and the staff to screen the patient. Any clinic that boasts about operating on a 100% closing ratio is missing the point. Your goal should never be to treat every patient who walks into your clinic, for a long list of reasons that should be obvious. In the first place, not every patient can afford to have the treatment they want. Some will be unsuitable due to their health and medical history, while others may need something entirely different to what you can offer, i.e. excisional skin surgery instead of energy based skin tightening. Still others may not be good candidates for psychological reasons such as body dysmorphia, and OCD. Your closing ratio is the number of patients you close (i.e., sign up for a treatment) compared to the number of patients you see. For example, if you consulted with 10 patients in a week and four of them had a treatment as a result, your closing ratio would be 40 percent. In a medical aesthetics clinic, the consultation is more about relationship building than it is about making a pure clinical diagnosis and arriving at a treatment protocol. It is not always feasible to shorten the clinic visit when it comes to dealing with cosmetic patients, because the direct contact and follow-up factors into developing long-lasting patient relationships. It is generally accepted practice to have a clinic manager or patient coordinator pre-screen new patients; however, the ‘real’ consultation is always between the practitioner, who will be doing the actual procedure, and the patient.

JUST SAY NO Ideally, the best time to end a doctor-patient relationship is before it technically begins. Therefore, when a patient steps foot into the clinic and the practitioner decides that he or she is not a good candidate for the treatments you offer, or will not be happy with what you can provide, the optimum chance to cut the cord is right there on the spot. If instead, you suggest that the patient thinks it over, or comes back for another visit, you are in essence prolonging the inevitable. This carries some risk that the patient may be lulled into thinking that you are willing to treat them. When there comes a time that they ask to schedule a procedure in your clinic, and you decline or your staff has to try to dissuade them, she or he will most likely be angry with you. In this climate, patients who feel misled or poorly treated by a practitioner have many outlets to share their dissatisfaction. The most obvious of these are and other ratings and reviews sites. Consider another scenario; a patient you have treated previously returns and requests a procedure that you as the practitioner feels she is unsuited for. Instead of leading her on, honesty is the best approach. But in all cases, refrain from using language that can be construed as insulting, offensive or derogatory. For example, a practitioner who tries to say to a woman that she needs to lose some weight before he will do a body contouring procedure on her should proceed with caution. Under no circumstances would this be considered good news by the patient. Statements like “Lose a few stone, and come back to see me,” or “Non-invasive fat melting won’t do anything for you,” will not be well received. You can turn it around so that you come off as a caring physician who has only the patient’s best interests in mind, by saying, “I don’t think you will get a good result from this device, and I want you to be happy,” or “This device works best as a part of a programme of diet and exercise, so let’s come up with a plan that meets your long term goals.” While no woman wants to hear this, when positioned in this manner, it may be well accepted without creating an awkward situation or animosity between the clinic and the patient. Lastly, discharging a patient from care can have medicolegal ramifications. If you are eager to get rid of a patient whom you have treated and is driving you and your clinic staff mad so you wish never to see them again, you may be well advised to seek legal advice. In this case, depending on the circumstances, a formal discharge may need to be in writing with proof of delivery and a referral to another practitioner for follow-up care. It is important to bear in mind that good documentation in the patient’s medical chart is necessary in all of these instances to protect the practitioner in the long-term.

Wendy Lewis is President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, the author of 11 books on anti-ageing and cosmetic surgery, and Founder/Editor in Chief of She is an international presenter and lecturer and has written over 500 articles for medical journals and consumer publications.

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In Practice In Profile

“Now I can care for my patients the way I always wanted” Lee Garrett on his unconventional route to the top

Lee Garrett is an aesthetic nurse with a successful Harley Street clinic and a host of high profile patients. He reveals his unusual route into the industry. There aren’t many aesthetic medical practitioners who also have the skills to fix a roof. But Lee Garrett is the first to agree that he had an unconventional career path into the industry. His first job, at the age of 18, was as a roofer but by the age of 24, Garrett was looking for a new path. “I was coming out as gay” he explains, “and I wanted a career where I could fit in as a gay man. I had wanted to be a nurse for a while, but the wages were so low I went into hairdressing instead.” This led to a 14-year career in hair and beauty, during which Garrett developed his aesthetic eye, people and management skills. He also met his partner, Dr Séan Cummings, a doctor then working in the NHS, but keen to set up a private practice aimed at the gay community. In 2003 the Freedomhealth clinic was born and Garrett sold his salon to become the clinic manager. Many of Freedomhealth’s early clients were men with HIV who suffered from facial lipodystrophy, which is treated with filler injections. This meant Dr Cummings attended dermal filler training courses, and Garrett often went with him, sometimes acting as a model for students and to learn more about the profession. He introduced skin treatments to the clinic, and then in 2004 completed a six-month NVQ course at St George’s Hospital in London to become a qualified Health Care Assistant. After further training and mentoring Garrett introduced lasers for hair removal to his clinic, but he was still ambitious and wanted to perform injectable treatments. So at the age of 37, Garrett decided to take a nursing degree, whilst continuing to work at Freedomhealth one or two days a week. On qualifying in March 2008, Lee found a post as a full-time critical care nurse at a large London hospital but the experience left him deeply disillusioned. “I would have stayed if the NHS was a better place to work, but within six months I was back at Freedomhealth.” Garrett soon found himself fully booked, but two years ago, again returned to 54

education to gain an independent nurse prescriber qualification. “I realised there would be a move to only allowing nurse prescribers to inject Botox, and that the change was likely to come in very quickly,” he explains. However, he says, “Even now some courses are worryingly poor quality and focus too narrowly on prescribing Botox. I think it is very important that aesthetic nurse training is rigorous. It is vital we can treat any complications, so we need to be confident prescribing pain relief, Aciclovir, hyaluronidase and antibiotics. My course at South Bank University, where I obtained my nursing degree, was aimed at NHS nurses. Now as the head of Freedomhealth SKIN division I can care for all my patients the way I always wanted to.” The clinic was unusual in marketing itself directly at men, successfully advertising in magazines such as Attitude before a word of mouth recommendation led to journalist Amanda Platell seeking treatment, which she subsequently

There is not enough emphasis on training to treat men wrote about positively in the national press. This had an instant and dramatic effect on the numbers of inquiries and drove more female patients to the clinic. However, Garrett’s clinic still has a large number of male clients, and Garrett feels strongly that the industry does not yet understand the potential of this growing market. “There is not enough emphasis on training to treat men,” he says. “It’s very rare to see a male model on training courses, yet male facial anatomy is quite different to women’s. Even the packaging for dermal fillers tends to be in feminine pinks and purples. That has to change as increasing numbers of men seek aesthetic treatments.” Garrett is well placed to spearhead a change and his skills have been noticed within the industry. He sat on the Steering Committee for the Aesthetic Nurses Forum, is a UK moderator for Sciton Laser Technology and is involved in Educational Road shows for Q-Med and Allergan. Garrett also teaches other medical professionals to use Allergan’s new vicross range, Voluma, Volift and Vobella. And for the future he hopes to teach, mentor and help raise standards. “My aim for the industry is that we all work together to insist on minimum standards; rather than surgeons, doctors and nurses continually turning against each other on who should be doing what. When we fight the Government sees us as weak. Together we can be strong and take this industry forward as one of excellence and trust.”

Aesthetics | January 2014


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In Practice The Last Word

Incomplete registers are never very successful. Of course, none of this is the fault of the people behind the various organisations given the job of recruiting members. The fault lies squarely with lack of government action, and the reluctance of politicians to make registers compulsory and give them any useful powers.

The Last Word Why it’s time to self-regulate our industry The politicians’ failure could be our industry’s opportunity, says Dr Natalie Blakely Like so many of us in the aesthetics industry, I saw the publication of the Keogh Report as a great opportunity for reform. The industry is currently almost completely unregulated, and while that remains the case, the NHS will pay for mistakes made. I hoped for a register of implantable devices, including fillers, regulation of fillers, plus the first compulsory register of aesthetic practitioners in the UK. I fully support a register for those doing injectables, and for it to be open only to people who are medically trained: surgeons, doctors, dentists and nurses. I’d have also liked to see re-regulation of lasers, with a register of practitioners with a BTEC in lasers as a minimum qualification. Both the public and practitioners supported change, at the time of writing, it seems clear we’ve missed the boat, and little seems likely to be done. Indeed, even before the government response to the Keogh Report was released we learned that the idea of a compulsory register had been abandoned when yet another voluntary register was proposed instead. So what’s wrong with a voluntary register? Firstly, with voluntary registers, there is a recognised financial benefit or gain to those who set them up, so I, and many other practitioners, regard them with scepticism. Secondly, I’m already registered with the General Medical Council and the Care Quality Commission, which are very rigorous, perform inspections, and have the power to revoke my licence. A voluntary register with no power to inspect or strike off, which cannot place any sanctions on my clinic or myself, simply does not have the same credibility. Why would I pay to join a register with lower standards? It simply doesn’t make sense. And of course, dodgy practitioners with something to hide would never risk being inspected, so the very people who would be weeded out by a compulsory register will simply duck out of a purely voluntary system. Now, some say that the benefit of a voluntary register for good doctors and nurses is that the public will prefer the reassurance of using a clinic or practitioner whose name appears on it. This would of course be a great advantage. But for whatever reason, we know that the public remained mostly blissfully unaware of previous registers. Take up has been low, and there’s little reason to suggest any new version would be different.

So what can we do now? I believe the missed opportunities of the government could be the industry’s opportunity to act. We’ve learned we can’t rely on politicians, so now it’s our turn, as individuals, to decide that we should only ever employ best practice. And not just as individuals. I believe it is now time for the industry bodies to come together for the safety of the public to create some kind of internal regulation. The British College of Aesthetic Medicine(BCAM), The British Association of Cosmetic Nurses (BACN), and The British Association of Aesthetic Plastic Surgeons (BAAPS) should get together to define a reasonable entry level for practitioners to show they are competent in Botox and fillers. They should also define a minimum standard for training courses. At the moment, almost anyone can set up a training course, and they are often useless. Certainly, there was no way I could have safely injected anyone after a half-day course, and even longer courses are often not rigorous enough. Other areas where I am convinced we should have new internal standards are in consenting patients. I developed my own digital consenting system, Consentz, because I believe that when we are consenting patients it is an opportunity to explain treatment choices properly, and to document that conversation. I’d like to see practitioners routinely taking lot numbers of all the products they use, so if there is a recall, or a problem as with PIP implants, it makes calling back patients much easier. Consentz includes a facility for recording this data, which could be part of an implantable devices register, if we ever get such a thing. But all this takes leadership. I hope that our industry can unify to provide it. This failure by government could be our opportunity to improve practice and ethics in the whole medical aesthetics community. I would be happy to discuss improving standards within the industry with interested individuals or organisations, via Dr Natalie Blakely is an award winning Cosmetic Doctor and the Medical Director of the Light Touch Clinic in Surrey. Dr Natalie is known for her expertise in administering injectable treatments. In addition to running her clinic Dr Natalie has created Consentz, a patient management system for the iPad.

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Presentation: 1 gram of cream contains 70mg lidocaine & 70mg tetracaine.Indications: For use in adults to produce local dermal anaesthesia on intact skin prior to dermatological procedures. Dosage and Administration: For procedures such as pulsed-dye laser therapy, Pliaglis should be applied at a thickness of 1mm for 30 minutes. For procedures such as laser-assisted tattoo removal, Pliaglis should be applied at a thickness of 1mm for 60 minutes. After the required time, the peel must be removed from the skin prior to the procedure. The maximum application area should not exceed 400 cm2. For facial procedures, Pliaglis should be applied by healthcare professionals only. Pliaglis should be applied with a flat surfaced tool, never with fingers. Pliaglis is for single patient use. Contraindications: Hypersensitivity to lidocaine, tetracaine, other anaesthetics of the amide or ester type, to para-aminobenzoic acid or any of the other excipients. Should not be used on mucous membranes or on broken or irritated skin.

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reference: 1. Juvéderm VOLIFT with Lidocaine DFU, 2013. Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK | May 2013 UK/0658/2013

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