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VOLUME 3/ISSUE 5 - APRIL 2016

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SEE US AT STAND 57

Mid-face Rejuvenation CPD AestheticsJournalCover_April2016_FINAL.indd 1

Mr Dalvi Humzah and Anna Baker detail the anatomical features of the mid-face

Special Feature: A Combined Effort Practitioners discuss the use and benefits of combination treatments

21/03/2016 08:33:57

Microfocused Ultrasound

Customer Journey

Dr Galyna Selezneva explains how to treat skin laxity using ultrasound

Paul Jackson shares advice on the key stages of a patient’s online journey


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Contents • April 2016 06 News The latest product and industry news 14 News Special: The Growth of the Global Cosmeceutical Market Aesthetics reports on the rise of cosmeceuticals and investigates the source of the worldwide growth 16 Aesthetics Conference and Exhibition 2016 A final preview of ACE 2016 18 Sign in to the new Aesthetics website A look at the new digital platform for aesthetic professionals

CLINICAL PRACTICE 21 Special Feature: A Combined Effort Practitioners discuss combination treatments used for facial rejuvenation 27 CPD: Mid-face Rejuvenation Mr Dalvi Humzah and Anna Baker detail the anatomical features of the mid-face and how to successfully rejuvenate the area 31 The Effects of Pollution on the Skin Dr Jane Leonard shares advice on managing skin damage caused by environmental factors 34 Triple Boost HydraBright Dr Maryam Zamani details the ageing process and shares her newly developed combination technique for periorbital and facial rejuvenation 39 PDO Threadlifting Dr Irfan Mian outlines how to achieve successful aesthetic results using PDO threads 45 Microneedling Combined with Stem Cells Aesthetic nurse prescriber Natali Kelly examines the use of microneedling in combination with stem cells for acne scar treatments 49 Treating Migraines Dr Chris Blatchley shares his approach to managing migraines with botulinum toxin 53 Microfocused Ultrasound Dr Galyna Selezneva explains how to use microfocused ultrasound to treat skin laxity 57 Abstracts A round-up and summary of useful clinical papers 58 Advertorial: Sesderma Sesderma presents a combined treatment based on ferulic acid and vitamin C

IN PRACTICE 58 Introducing IVNT to Your Clinic Dr Samantha Gammell and Dr Jacques Otto share advice on expanding a clinic’s treatment portfolio with intravenous nutritional therapy 61 The Online Customer Journey Paul Jackson advises practitioners on recognising the key stages of a patient’s digital journey 65 The Eight ‘Cs’ of Aesthetic Practice: A Practitioner’s Guide Dr Niroshan Sivathasan recommends how to make the most of your aesthetic practice 67 In Profile: Mr Dalvi Humzah Mr Dalvi Humzah reflects on his journey into medical aesthetics and shares his passion for anatomy teaching 69 The Last Word Mr Sultan Hassan argues the benefits of offering patients remote consultations and advises on how this can be done safely

Subscribe Free to Aesthetics Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228

Special Feature Combination Treatments Page 21

Clinical Contributors Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and medical director of AMP Clinic in Oxfordshire. He also runs the award-winning Facial Anatomy Teaching course and the Aesthetic Clinical Training Course. Anna Baker is a dermatology and cosmetic nurse practitioner. She works alongside Mr Dalvi Humzah as the coordinator and assistant tutor for Facial Anatomy Teaching. Baker has a postgraduate certificate in applied clinical anatomy, specialising in head and neck anatomy. Dr Jane Leonard is a GP and cosmetic doctor. She specialises in skin conditions, antiageing medicine and bio-identical hormones. Dr Leonard achieved a first class honours degree in Anatomical Sciences, specialising in head and neck. Dr Maryam Zamani is a board certified ophthalmologist with experience in ocuplastic surgery and dermatology. She obtained her medical doctorate from George Washington University School of Medicine, US. Dr Irfan Mian is medical director of the Chinbrook Medical Cosmetic Centre in London. He has practised medicine for more than 30 years and was a clinical lecturer at King’s and Guy’s Hospital NHS Trust. Natali Kelly is an aesthetic nurse prescriber, based in Knightsbridge, London. She has eight years of experience combining her surgical background with non-surgical facial aesthetics and cosmetic dermatology. Kelly is passionate about skin rejuvenation. Dr Chris Blatchley has been working in aesthetics since 2007 and has studied migraine treatments since 2009. He has presented on using botulinum toxin to treat migraines to specialist neurologists at the Oxford Headache Symposium. Dr Galyna Selezneva is an aesthetic medical doctor currently practising at the Dr Rita Rakus clinic in London. She is a specialist in non-invasive procedures, including non-surgical face and body treatments.

Last chance to register for the Aesthetics Conference and Exhibition 2016 15-16 April www.aestheticsconference.com NEXT MONTH • IN FOCUS: Injectables • Medium and Deep Chemical Peels • Non-surgical Breast Lifts • The Benefits of Entering Awards


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Editor’s letter Well, this is it – the Aesthetics Conference and Exhibition (ACE) issue has arrived! If you’re reading this before ACE and have still not registered, then I urge you do so quickly. Last year we had so much positive feedback, with Amanda Cameron delegates claiming it was the best UK conference Editor and a ‘must go to’ event; don’t miss out on the extensive learning opportunities we have available and guarantee your place now. If you are reading this at ACE, welcome! We hope you’re having a fantastic time and leave the conference equipped with greater knowledge than you arrived with. One of the key anatomical areas we will be addressing at the premium ACE Conference is treating the mid-face, with Mr Dalvi Humzah, Dr Simon Ravichandran and Frances Turner Traill presenting. We are delighted that Mr Humzah, along with Anna Baker, has written this month’s CPD article (p.27) on the same topic, allowing delegates to get ahead of the game before the presentation. Their in-depth feature focuses not only on how to treat the mid-face, but also provides a detailed anatomical description of the area and advises on how to avoid potential complications.

In addition, two more of our ACE speakers have written superb articles for this month’s journal. Read about Dr Maryam Zamani’s new combination technique for treating periorbital ageing on p.34, before attending her Conference session on ‘Enhancing the Eye’ on Friday. Delegates can also discover how botulinum toxin can be used to treat migraines in Dr Chris Blatchley’s article on p.49 and at his Business Track presentation, also on Friday. We’re also delighted to announce that this month, we have launched the new Aesthetics website (p.18). The new site offers an interactive platform for users to engage with fellow aesthetic professionals and discover all the latest industry news. I urge you all to visit www.aestheticsjournal.com and join as a member. If you see any members of the Aesthetics team at ACE 2016, please do come and say hello! It is always a pleasure to meet our readers and discuss the latest happenings within our diverse specialty. This year we’ll be at stand 44, where you can come to share your experiences of ACE, discuss article ideas and Meet the Experts. Don’t forget to share pictures and engage with us on social media using the #ACE2016 and tag us @aestheticsgroup on Twitter, @aestheticsjournalUK on Instagram and Aesthetics on Facebook.

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic surgeon in the NHS for 15 years, and is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally.

years experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers.

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015.

and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.

12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook.

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

qualifications in medicine and dentistry. Based in Knightsbridge, London she practices a variety of aesthetic treatments. Dr Tonks has appeared on several television programmes and regularly speaks at industry conferences on the subject of aesthetic medicine and skin health.

for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

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Recommendations

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Statistics Barbara Jemec @bjemec #IWD2016 statistics for UK female consultants in surgical specialties. 17.3% in #plasticsurgery

#Wisdom Dr Vishal Madan @Manchesterderm Sometimes no treatment is the best treatment but it takes a great doctor to give it and a perfect patient to take it. #comeswithexperience #BACN Frances T Traill @FTTraill Great meeting today in #London with @BACNurses #Bacnrocks #Education S-Thetics @MissBalaratnam #MDCodes Visionary Day with Allergan #UK #LCA #faculty #facialaesthetics #dermalfillers #beautification #synergy

Global Aesthetics Consensus Group reviews botulinum toxin type A A new evidence-based review published in Plastic and Reconstructive Surgery has led to refinements in treatment planning and implementation using botulinum toxin. A multidisciplinary group of plastic surgeons and dermatologists, including Professor Hema Sundaram and Dr Massimo Signorini, convened the Global Aesthetics Consensus Group to develop updated consensus recommendations with a worldwide perspective for the use of botulinum toxin and hyaluronic acid dermal fillers. The group, using an interrogative, diagnostic approach, concluded that the use of botulinum toxin has evolved from the upper face to also encompass the lower face, neck and mid-face. They found that injection dosage and placement are based on analysis of target muscles in the context of adjacent ones and associated soft and hard tissues, and that the indication for selection of botulinum toxin as a primary intervention is when excessive muscular contraction is the primary aetiology of the facial disharmony to be addressed. The recommendations of the group are said to demonstrate a paradigm shift toward neuromodulation rather than paralysis, including lower dosing of the upper face, more frequent combination treatment with hyaluronic acid fillers, and intracutaneous injection where indicated to limit depth and degree of action. The Global Aesthetics Consensus Group advocates an aetiology-driven, patient-tailored approach, to enable achievement of optimal efficacy and safety in patient populations that are rapidly diversifying with respect to ethnicity, gender, and age. Meeting

Aesthetics: Interventional Cosmetics inaugural board meeting

#InternationalMeeting Nigel Mercer @NigelMercer Representing @BAPRASvoice at the Korean Society meeting in Seoul this weekend. Looking forward to seeing our Korean Colleagues again!! #Journal BelleDerma Aesthetic @PatriotSister Love having a new #Aesthetics #journal to read #content

Aesthetic practitioners gathered at the Royal Society of Medicine to formalise a board structure and educational strategy for future gatherings of the Aesthetics: Interventional Cosmetics Meetings. Dr Christopher Rowland-Payne was elected as the group’s president and other elected board members included Mr Jonathan Britto, Dr Patrick Treacy, Dr Beatriz Molina, Mr Ash Mosahebi, Dr Harryono Judodihardjo, Mr Paul Banwell and Dr Uliana Gout. The next Aesthetics: Interventional Cosmetics Meeting will take place on 22 September 2016.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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Lips

Lip Volume added to the Fillerina product portfolio A new lip-plumping product has been added to the Fillerina portfolio. According to Medical Aesthetic Supplies, the UK distributor of Fillerina, the molecular blend used in Fillerina Lip Volume aims to specifically target the delicate and thin skin of the lips. The key ingredients include 1,000Da of hyaluronic acid, which aims to penetrate the deep layers of the skin’s tissues covering the lips in order to promote lip volume; 50,000Da of hydrolysed hyaluronic acid, which aims to penetrate the middle and deep layers of the tissues covering the lips to promote lip firmness and volume; and sodium hyaluronate crosspolymer, which aims to offer a continual release of hyaluronic acid on the skin’s surface to help keep tissues plumped up. Fillerina Lip Volume is available in two doses to suit the user’s individual preferences, with Dosage 2 containing a higher concentration of active ingredients than Dosage 1. The product uses a rollerball applicator, making it possible for the user to apply the product several times a day. Dr Elisabeth Dancey said, “The new Fillerina Lip Volume fits well into my practice. Many people prefer to achieve natural-looking full lips without an intervention and without the risk of the lips looking too big. Fillerina Lip Volume allows them to achieve volume, quality and freshness over a period of time with a simple homeuse lip treatment.” Fillerina, which won the award for Product Innovation of the Year at the Aesthetics Awards 2015, is a topical gel filler that aims to plump the skin without the use of needles. Acne

Allergan receives FDA approval for ACZONE Global pharmaceutical company Allergan has received approval from the Food and Drug Administration (FDA) for a topical acne treatment. ACZONE Gel (dapsone) 7.5% aims to treat both inflammatory and non-inflammatory acne through daily use in patients 12 years of age or older. “For the ACZONE Gel, 7.5% pivotal trials, we studied 4,340 acne patients, demonstrating efficacy and tolerability,” said David Nicholson, executive vice president and president of global R&D brands at Allergan. “The new FDA product approval also offers just once-daily dosing and a new pump delivery system. As part of Allergan’s commitment to the medical dermatology space, we have truly raised the bar for ourselves in efforts to offer an effective acne product to address physician and patient needs.” Safety and efficacy were assessed in clinical trials during two identically designed, randomised, multi-centered, double-blind, vehicle-controlled 12-week studies. A total of 4,340 acne patients were randomised to receive either ACZONE Gel, 7.5% or a vehicle. The majority of patients (99%) had moderate acne, with a baseline score of three on the Global Acne Assessment Score (GAAS). At week 12, inflammatory lesions were reduced by 15.8 lesions (54.6%) vs 13.9 lesions with the vehicle (48.1%), and non-inflammatory lesions were reduced by 20.7 lesions (45.1%) vs 18.0 lesions with vehicle (39.4%). Out of the 2,161 patients who used the ACZONE Gel, 7.5%, 1.1% experienced mild application-site dryness vs 1.0% with the vehicle and 0.9% experienced pruritus vs 0.5% with the vehicle. ACZONE Gel, 7.5% will be available nationwide in May 2016.

Countdown to ACE 2016 Latest programme updates Miss Sherina Balaratnam will present her strategic and multidisciplinary approach to facial rejuvenation, which aims to enhance patient results and increase patient satisfaction. Julia Kendrick will present two sessions; one that outlines how PR can help grow business and increase sales, and a second in which she will share her practical guide for becoming your own spokesperson while increasing your media profile.

Insight Dermatologist and international speaker Dr Maria Gonzalez says: “ACE is always a great learning experience as it allows delegates to listen to top practitioners presenting on the latest case studies and demonstrating the latest techniques, as well as exchange ideas with other professionals. I encourage my colleagues from all over the UK to attend; they won’t be disappointed and will have the opportunity to bring essential tips and professional advice on best practice to their clinics, not only from a clinical point of view but also in terms of business support and new supplier contacts. I’m very pleased to be part of the ACE faculty of speakers; I will be presenting on skin pigmentation as part of the Conference session dedicated to the mid-face, together with esteemed colleagues of mine such as Mr Dalvi Humzah, Dr Simon Ravichandran and Frances Turner Traill.”

What delegates say “ACE is always a very enjoyable experience. Excellent classes!” Aesthetic nurse, Norfolk

“All sessions I attend are very informative, very interactive and there is always so much going on. A very good experience.” GP, Cornwall

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Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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Radiofrequency

New products launching at ACE 2016 A host of aesthetic companies will be presenting recently launched products at the Aesthetics Conference and Exhibition (ACE) on April 15 and 16. The 2500m2 Exhibition Floor will host more than 80 stands from top aesthetic medical suppliers, many of which will be showcasing new products. Aesthetic manufacturer 3D-lipo will launch the latest addition to its laser device range, the 3D-shockwave, designed to stimulate skin tightening, reduce cellulite and improve stretch marks. Vida Aesthetics, will showcase several new products: a new combination of peptides called Eye Complex Poli Revitalizing (ECPR), a rejuvenating complex indicated to improve the appearance of bags, dark circles and fine lines in the periorbital region. In addition, Mesoserums, a new cosmetic range, Hair Poli-Revitalising Complex (HCPR), Fenol TCA easy peel and TMX Bio-Revitilizers will also be introduced at ACE. Aesthetic distributor, HA-Derma, will launch Aliaxin dermal fillers, and present the products in a Masterclass on Friday April 15, led by Professor Daniel Cassuto, Professor Hema Sundaram and Dr Irfan Mian. Also launching at ACE is SculpSure, a body-sculpting device, which aims to destroy fat cells, from laser and

Naturastudios launches PhysioSKIN Aesthetic equipment supplier Naturastudios has released a new treatment aimed at treating spider and thread veins. The company has partnered with vascular surgeon and vein specialist Dr Brian Newman to develop PhysioSKIN, which aims to safely and effectively treat all minor damages from blood vessels, including telangiectasias, spider veins, cherry angiomas, milia, soft fibroma, also known as molluscum pendulum, skin tags and rosacea. The treatment is said to utilise the principle of ‘thermoesclerosis’ – a fast radiofrequency, which sends a pulse from the tip of a filament for precision and accuracy. This technology aims to treat superficial skin imperfections and minimise their appearance or eliminate them completely. The frequency used is controlled in short cycles, unlike other frequencies, where the pattern of heat can be up to three times higher, which the company says may cause irritation and damage of the skin. According to Naturastudios, PhysioSKIN uses less energy than other devices of its type. Study

light-based aesthetic treatment manufacturer, Cynosure. TSK Laboratory is launching the INViSIBLE NEEDLE, which is 33% thinner than a 30G needle used for insulin syringes and 14% thinner than the TSK 33G needle. The needle aims to provide patients with a painless experience and, according to TSK, is ideal for botulinum toxin injections. Eden Aesthetics Distribution is launching a new Growth Factor Rejuvenation Complex (GF-R), which is a serum that is used for its DermaFrac machine; a device that combines microneedling and deep tissue serum infusion. Aesthetic marketing company, Bioaesthetics, will be showcasing two new product lines at ACE. New radiofrequency device AGNES and ALPS Post-Surgical Gel products, used to accelerate healing and reduce redness and inflammation, will be demonstrated on the Exhibition Floor. UK distributor, Globe AMT will present its new laser hair removal device, DEKA Motus AX Alexandrite laser, and pharmaceutical company Sesderma will also launch a new range at ACE. Laser distributor, Cutera Medical will present its new tattoo removal laser, Enlighten, and aesthetic manufacturer, Intraline, will showcase its new filler for men. Pabau, a practice management application that is used to manage business needs such as schedules, treatment notes, invoicing, payments and marketing, will launch its iPad and mobile app version, Pabau Go. To access the Exhibition, practitioners can register free, which will also allow access to CPD clinical and business agendas over the two days. ACE 2016 will take place at the Business Design Centre in London on April 15 and 16. For more information and to register, visit www.aestheticsconference.com

Research indicates collagen peptides improve cellulite Collagen protein supplier GELITA has conducted a double-blind placebo-controlled study that indicates a specific collagen peptide can improve the appearance of moderate cellulite. The study, published in the Journal of Medicinal Food, involved 105 women between the ages of 24-50 who received a daily dose of 2.5g of VERISOL collagen peptides or a placebo. At the end of the six-month study period, a mean cellulite score reduction of approximately 9% was determined in subjects with a normal BMI, compared to the placebo group. The improvement was also recorded in participants with a BMI greater than 25, although the beneficial effect was less pronounced (4% reduction). ‘Skin waviness’ reduced by 8% on average and was observed via a skin surface profile measurement after six months of treatment. This was even more pronounced in the normal BMI study group, with a decrease in thigh skin waviness of 11.1%. Moreover, dermal density was said to show ‘significant improvement’ compared with the placebo group. “Even though a variety of cellulite therapies such as massage, weight loss and topical agents are available, scientific evidence to support the effectiveness of these treatments is scarce,” said Dr Stephan Hausmanns, vice president of Boston University’s Health and Nutrition department. He continued, “Dietary supplementation with specific collagen peptides takes a different approach: by aiming to restore the normal structure of the dermal and subcutaneous tissue, it fights the cause of the condition rather than the symptoms. We are very pleased with the outcome of the study because it clearly outlines the potential of our bioactive collagen peptides to improve the skin morphology of cellulite-affected areas.”

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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Training

Dr Souphiyeh Samizadeh to hold complication management course Dental surgeon and medical aesthetic practitioner Dr Souphiyeh Samizadeh has launched a new training course that aims to teach practitioners how to successfully manage botulinum toxin and dermal filler complications. The one-day course, Botulinum Toxin A and Dermal Filler Complications: Prevention, Recognition and Treatment, will consist of a morning of theoretical learning and an afternoon of practical training. Delegates can also opt to attend a one-to-one day with Dr Samizadeh, should they wish to gain more experience and increase their confidence in managing complications. Dr Samizadeh said, “With a lack of comprehensive training and support in the industry, it is imperative for the healthcare professionals who practice aesthetic medicine to be familiar with the potential complications and their management. We will also have a study club and a support group where we can share our experiences and learn from each other.” The course will take place in central London at the end of April.

Aesthetics

Vital Statistics The number of cosmetic operations that took place last year grew by 13% since 2014 (The British Association of Aesthetic Plastic Surgeons, 2016)

In a survey of 2,006 respondents, almost 40% aged 25-44 said they would have an aesthetic treatment if their partner wanted them to (Intraline Medical Aesthetics survey)

Cellulite

BTL Aesthetics releases two new products Aesthetic device manufacturer BTL Aesthetics has added two new products to its treatment portfolio. According to BTL, the BTL X-Wave (Cellutone) utilises targeted vibrations to improve aesthetic results. Used as a standalone treatment or in combination with the BTL Vanquish ME, the device helps increase blood supply, resulting in better lymphatic drainage and improved elimination of fat cells. Dr Annie Chiu said, “My practice has been using BTL Cellutone in conjunction with BTL Vanquish ME for treatment of both the abdomen and thighs. The combination therapy has helped improve skin texture and tightening, as well as delivering faster circumferential reduction, so much so that I am seeing results as early as three sessions, compared to what I used to see weeks after four treatments.” In addition, BTL has launched the BTL Exilite, an IPL device that aims to help treat vascular and pigmented lesions, permanent hair reduction, and acne. According to BTL, the device can also be used alongside radiofrequency to influence targeted tightening and skin resurfacing. Dr Jeffrey Hunt said, “I have found the new BTL Exilite to be an easy transition from our other pulsed light systems. Treatments are fast, well tolerated and effective.”

Only 8% of women have not removed hair in the UK in the past 12 months (Mintel Men’s and Women’s Shaving and Hair Removal UK 2014 report)

More than 80% of adult acne occurs in women (NHS Acne Causes 2014)

57% of marketers use video as a marketing tool (2015 Social Media Marketing Industry Report by Social Media Examiner)

Light Therapy

Dr Prempeh champions BIOPTRON Light Therapy A consultant at Forth Valley Hospital is championing BIOPTRON after seeing ‘phenomenal results’. Dr Prempeh is said to have successfully used the BIOPTRON Light Therapy device on a patient suffering from a pressure sore wound. The sore had remained static for a year before the BIOPTRON light treatment, but is said to have shown improvement two months after. “The patient, his relatives and the nursing staff were amazed at the phenomenal results achieved with just over two months of light therapy.” said Dr Prempeh.

A study of 200 Chinese women suggests urban pollution could age women’s skin 10% faster than those who live in the countryside (Olay study, 2014, funded by Procter & Gamble)

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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Events diary 4th – 6th April 2016 British Society for Investigative Dermatology Annual Meeting 2016, Dundee www.bad.org.uk

15th – 16th April 2016 Aesthetics Conference & Exhibition, London www.aestheticsconference.com

28th April 2016 British Association of Sclerotherapists 2016 Annual Meeting, Basingstoke www.bassclerotherapy.com

11th – 15th May 2016 Face Eyes Nose Conference, Coventry www.faceeyesnose.co.uk

29th June – 1th July 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting 2016, Bristol www.bapras.org.uk

5th – 7th July 2016 British Association of Dermatologists Annual Meeting, Birmingham

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Peels

AestheticSource and Innomed Training launch Peels Progression Programme Aesthetic distributor AestheticSource and training company Innomed have launched a new training programme, designed to enable practitioners to develop their peeling skills using well-established peeling brands. The Peels Progression Programme offers a three-stage course; beginning with superficial glycolic peels, before moving to medium depth TCA peels and finally deep phenol peels. Lorna Bowes, aesthetic prescriber and director of AestheticSource, said, “We can offer a peeling option to suit every practitioner, from beginners to seasoned professionals, with our unique portfolio of peeling brands – Exuviance, NeoStrata and SkinTech – and our structured training programme.” According to AestheticSource, the aim of the programme is to provide practitioners with career progression opportunities and support at every stage of the learning process. By partnering with Innomed, training will be delivered by trainers who run their own well-established clinics, so practitioners can learn from colleagues with real experience in using the three levels of peels. Dr Xavier Goodarzian, Innomed Training lead trainer and clinic owner, said, “We are delighted to partner with AestheticSource to provide what we believe to be a first for the industry. Innomed Training has more than 10 years’ experience in delivering award-winning, skills-based training. Combining this with AestheticSource’s comprehensive portfolio of peeling products, we now offer a peel for every practitioner, at every level, with great after-course support too.” Radiofrequency

www.bad.org.uk

17th September 2016 British Association of Cosmetic Nurses Annual Conference and Exhibition, Birmingham www.bacn.org.uk Meeting

PIAPA to hold seminar in Manchester The Private Independent Aesthetic Practices Association (PIAPA) will hold a meeting in Manchester on April 26. ‘Step Ahead in Aesthetics’ will provide attendees with a day of talks that aim to educate and enhance skills. Pam Underdown will speak about how to run a successful business; Dr Tahera Bhojani will look at dermal filler complications, how to avoid them and what to do if they happen; Emma Senior and Linda Mather will update delegates on the Northumbria University Aesthetics Syllabus; Gilly Dickons will speak about how to handle adverse reactions and Dr Kate Goldie will conclude the day with a talk about the different ways of treating the face throughout the 1940s, 1950s and 1960s. The meeting will take place at the Best Western Cresta Court Hotel, Altrincham.

Viora and AZTEC Services launch radiofrequency device Aesthetic distribution company AZTEC Services and medical aesthetic provider Viora have launched the V10 and V-FORM radiofrequency device and handpiece. The V10 is a multi-radiofrequency technology platform, which aims to treat all areas of patients for body contouring, cellulite reduction, skin tightening, resurfacing and rejuvenation. The V-FORM is a new handpiece that is compatible with the V10, and aims to deliver multi-core for contouring and cellulite reduction treatments. “In today’s economic reality, practitioners need to find the most costeffective solution for their clinics, while facing fierce competition,” said Anthony Zacharek of AZTEC Services, UK distributor for Viora. He continued, “V10 gives our customers an edge by being the only platform in the market that treats the complete body, from head to toe. The V10 platform’s inherent flexibility and cost-effectiveness for radiofrequency applications, paired with V-FORM’s breakthrough in treatment speed, safety and results, makes this combination an exciting entry in the world of medical aesthetics.” Industry

Gerovital launches in the UK International skincare brand Gerovital has launched in the UK through distributor, Romade Ltd. Developed by gerontologist professor Ana Aslan 50 years ago, the products aim to offer solutions to overcome different skin problems for people of all ages and skin types through professional, dermato-cosmetic and homecare products. Romade Ltd will also start offering training courses to practitioners interested in the Gerovital range of products, to be held at the E-cliniq Beauty and Aesthetic Clinic, London.

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Awards

Entry for the Aesthetics Awards 2016 opens May 1 Practitioners, clinics, manufacturers and distributors can once again prepare for the premier Awards ceremony in the UK when entry for the Aesthetics Awards 2016 opens on May 1. The Aesthetics Awards bring together the best in medical aesthetics to celebrate the achievements of the last year. Awards will be presented to those who have worked hard to represent the highest standards in clinical excellence, product innovation and practice achievement. With 23 categories to enter, which will be detailed in an Awards Special in next month’s issue of the journal, there are opportunities for everyone working within the aesthetic specialty to be celebrated. New sponsors have also been announced this month, including; The Schuco International Award for Special Achievement, The Sterimedix Award for Injectable Product of the Year and The Wigmore Medical Award for Best Clinic North. Director of marketing and business development at Wigmore Medical, Raffi Eghiayan, said, “Wigmore Medical are happy to be involved with the Aesthetic Awards 2016. It is an event that is so highly regarded in the aesthetic industry.” Training

Level 7 aesthetic training course launches in Northumbria Northumbria University is to provide practitioners with further education to ensure they meet the educational standards set by the recent Health Education England (HEE) reports. The course, PG Cert/ PG Dip/Masters: Professional nonsurgical aesthetic practice, aims to further educate existing and aspiring aesthetic practitioners, who already hold professional registration as doctors, nurses or dentists, by providing them with level 7 training in aesthetic practice. According to the course leaders, practitioners will learn to analyse and improve their own professional decision-making and practice to ensure the safe assessment of patients. They will be taught how to make ethical and balanced judgements regarding the appropriate use of non-surgical/aesthetic interventions, and effectively communicate their rationale when the intervention is not in the patient’s best interests. The programme will be a level 7 linked award with exit points at postgraduate certificate (PG Cert), postgraduate diploma (PG Dip), and Masters level. PG Cert level aims to prepare practitioners to develop the clinical knowledge and competencies required to provide non-surgical cosmetic treatments, underpinned by sound professional decision making; PG Dip level aims to build on the certificate level by enabling practitioners to understand and critique the evidence-base for aesthetic practice, set-up and run independent aesthetic practices, which provide safe, ethical, person-centred care, and enable them to facilitate practice-based learning and assessment of other practitioners; Masters level aims to further add to the evidence-base for non-surgical cosmetic/ aesthetic procedures. “The development of this programme is a timely response to the increasing focus on aesthetic practice following the recent Keogh review to improve patient safety for non-surgical cosmetic procedures,” said senior lecturer at Northumbria University, Emma Senior. “Patient safety is at the heart of this programme.” Minimum entry requirements for postgraduate certificate will be evidence of successful level 6 study within the last five years, plus 120 credits or equivalent at level 5, as well as professional registration as a nurse, doctor or dentist with two years’ experience.

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Eddie Hooker, CEO and founder of Hamilton Fraser Cosmetic Insurance How did Hamilton Fraser Cosmetic Insurance begin? In 1996 I had just started an insurance brokerage firm when we received an enquiry from a nurse looking for indemnity for injectable treatments. An underwriter agreed to a policy despite it being an unknown risk and Hamilton Fraser Cosmetic Insurance was born. This was the first policy of its kind for the industry in the UK. This year we are celebrating our 20th anniversary and as the industry has evolved with new products on the market we have continuously adapted by adding new treatments to our policy. We have become the market leading insurance provider for medical malpractice in the aesthetic sector, known for our expertise, educating practitioners on best business practice and raising industry standards. Where do you see Hamilton Fraser Cosmetic Insurance in the future? As well as continued growth in indemnity for temporary procedures, in the last few years we have insured a lot more invasive procedures, and are finding that many more doctors and plastic surgeons are turning to us to help protect their businesses. We are also witnessing a trend towards clinic and surgery insurance which covers equipment loss and damage that would otherwise come at a high cost to recover. The Consumer Rights Act 2015 has changed the industry landscape again. All traders are now required to signpost their consumers to a government authorised consumer redress scheme. Hamilton Fraser is at the forefront of these developments and in the summer of this year we will be launching the Cosmetic Redress Scheme, designed to resolve complaints made by consumers against traders in the aesthetic sector. What else in on the horizon for Hamilton Fraser Cosmetic Insurance? Over the coming months we will be speaking at major industry events including ACE, FACE and CCR. My presentation at ACE on the 15th of April at 10:40am will highlight some of the claims we have received over the years, patient selection and how to avoid a claim to protect your business. Our Cosmetic team will also be attending a wide variety of industry events so please do come and talk to us when you see us. This column is written and supported by

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Devices

Cambridge Stratum releases new aesthetic devices Aesthetic equipment provider Cambridge Stratum has released a portfolio of new clinical appliances into the UK market. The company, which launched in October 2015 at the British Association of Cosmetic Nurses (BACN) conference, has eight new treatments available that aim to address skin and antiageing concerns. The Stratum 8 modular multi-functional platform aims to be more cost-effective by providing access to a wide range of laser, intense pulsed light (IPL) and radiofrequency-based treatments. The different functions aim to treat a variety of skin concerns including, acne, skin rejuvenation, rosacea, hair removal, body contouring, tattoo removal and skin tightening. The Skin Analyser aims to measure moisture, elasticity, sebum level, pore number and size, melanin, acne bacteria and more, and also comes with a tablet computer and has a x30 magnification lens. Also available in the range are the Aluna Diode Laser Range for hair reduction; HydroMedi Pro, developed in partnership with SkinMed, for skin maintenance; DermaDeep LED light therapy with a choice of three or four wavelengths, for a wide range of indications; the HI-FU device which aims to contour the body and create new collagen; and the FDA-approved Stratum 2 IPL system, which aims to be an enhanced version of an already-established IPL device. Cambridge Stratum say that their aim is to ‘supply world class products at more affordable prices with no loss of product quality or support’. The company hopes to aid aesthetic clinics to obtain a faster return on investment, enhance their reputation and increase their profits. Skincare

Adare Aesthetics launches REFORM skincare Medical aesthetic distribution company Adare Aesthetics has launched a new brand of cosmeceuticals. The REFORM skincare range includes eight products, the Everyday Moisturiser, Hyal Vitamin C+E Serum, Hyaluronic Acid Serum, Phyto Botanical Gel, Retinol 1% Crème, Advanced Formula Sunscreen SPF 30, Vitamin B5 Gel and the Vitamin C 20% Serum. The distributor claims the products are ‘cross-functional’, and cover a broad spectrum of skin issues. “We are really excited to see REFORM Skincare now available for sale,” said managing director of Adare Aesthetics, Ivan Lawlor. “Our philosophy is simple; use SPF and vitamin C every day for overall skin protection and use another product suitable for issues such as pigmentation (phyto-botanical gel or retinol) or damaged skin (vitamin B5).” He continued, “We believe it will be a great success based on its quality and efficacy.” Investigation

Investigation claims banned nurses staging ‘Botox parties’ An investigation by the BBC has suggested two disqualified nurses have been staging injectable parties in homes and beauty salons. The BBC claims that both men were once registered nurses but were ordered to stop practising in 2012 and 2015, respectively, making it illegal for them to prescribe medicine. One of the men is claimed to have never had a prescribing qualification in the first instance. An undercover reporter for the British broadcaster filmed one of the men at an injectable party, where he is said to have injected three women with botulinum toxin and is claimed to have offered the reporter ‘as much Botox as required’. Mr Rajiv Grover, former president of the BAAPS, told the Independent, “If they are struck off, they are breaking the law if the prescribe it. If they are not a suitably qualified medical professional, it’s a criminal office.”

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News in Brief Combination treatment device launches Advanced Beauty Solutions and the Academy of Advanced Aesthetics will launch the Infinity Pro, a new combination treatment device at the ACE 2016. The device combines three technologies: cryo-cavitation, cryo-pads and acoustic wave therapy. Infinity Pro is sold as a package, with four days of accredited training, including diploma and CPD points, to ensure optimal treatment outcomes. Training provider launches in Liverpool Training provider Facethetics has launched in south Liverpool to provide comprehensive training for professionals looking to advance their skillset. Headed by managing director of Woodlands Beauty Clinic, Alison Stananought, Facethetics will offer a selection of one and two day courses covering a variety of aesthetic, antiageing and skin treatments. New cosmetic surgery provider opens in London A new cosmetic surgery provider aimed at women aged 35-50 has opened in Fitzroy Square, London. Fitzroy Surgery, launched by chairman of Make Yourself Amazing (MYA), John Ryan, aims to offer treatments to enhance patients’ natural looks and create the best version of themselves. Fitzroy currently has a further eight clinics operating in the UK, including Manchester, Birmingham, Cardiff and Bristol. Aesthetic consumer magazine launches Totally Aesthetic Publishing and One Media have launched a new magazine aimed at aesthetic consumers. TOTALLY AESTHETIC Magazine is a treatment, product and wellness-focused publication that aims to offer an alternative to the ‘botched body’ television shows. Instead, it aims to provide educational information on the range of treatments and practitioners available in the UK. The first issue will be shared online and in print in June. The magazine will be available in salons, spas, clinics, gyms, hotels, Waitrose and Sainsbury’s.

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Training

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Acne

New aesthetic surgical training website launches A new website focusing on aesthetic plastic surgery training and education that offers videos, livestream events and webinars by leading plastic and aesthetic surgeons has been launched. TheWebinarSurgeon.com aims to educate all surgeons, trainees, nurses, and doctors about surgical skills, techniques and tips of surgical and non-surgical aesthetic procedures. The site was founded by Mark Slocombe of CreationVideo.com and Peter Cranstone of Eurosurgical Ltd, who said the site aims to address the shortage of aesthetic plastic surgery training and education worldwide. TheWebinarSurgeon.com will feature specialist instructional surgical training videos on a variety of aesthetic and cosmetic plastic surgery topics, livestreamed training events to a global audience, expert surgical presentation webinars by experienced plastic and aesthetic surgeons, and filmed and livestreamed content from seminars, congresses and meetings. The website works with experienced plastic surgeons and practitioners such as UK doctors, Professor James Frame and Mr Paul Levick, US practitioner Dr Greg Mueller and Brazillian practitioner, Dr Marcelo Olivan.  Professor Frame said he is excited to be working on this project to help improve education and training in the field. “We realise that the future for training more than one or two at a time, is to use the power and reach of the internet, to develop important training messages for a much wider, international audience,” he said.  

Study indicates use of 0.3% A/BPO gel improves severe acne According to a new study, a combination of adapalene 0.3% and benzoyl peroxide 2.5% gel (A/BPO) has indicated to be superior to a vehicle for the treatment of severe acne. The data, presented at the 2016 American Academy of Dermatology (AAD) annual meeting, was collected from 252 patients during a randomised, double-blind controlled study. Tanghetti et al conducted the study and compared A/BPO to a vehicle in patients with severe acne. Patients received once-daily treatment for 12 weeks. The co-primary success points were the percentage of patients rated ‘clear’ or ‘almost clear’ and a change in inflammatory (IN) and noninflammatory (NIN) lesion counts also from baseline to week 12. There was said to be a treatment success rate difference of 20.1%. At week 12, 0.3% A/BPO was claimed to be superior to the vehicle in percent change in IN (–74.4% vs. –33%) and NIN lesion counts (–72.1% vs. –30.8%). In addition, 0.3% A/BPO was considered ‘safe and well-tolerated among study patients’. Tanghetti et al said, “The availability of this new treatment option should allow clinicians to better customise severe inflammatory acne management.” Reputation

Practitioners offered the chance to increase their profile Delegates are invited to meet the Aesthetics journal team at ACE and learn more about how they can see their name in print. Delegates of all aesthetic backgrounds are encouraged to consider becoming an Aesthetics contributor and increase their profile by submitting case studies, business, clinical, or opinion piece articles. Attendees can also share their industry news and events, such as new products or training courses, and be featured in the journal’s News or On The Scene pages. The Aesthetics stand will be situated at stand 44 in the main exhibition hall at ACE, where delegates can obtain a free copy of the journal and talk to journalists about the exciting opportunities available. The Aesthetics journal editor, Amanda Cameron, is keen to meet delegates and discuss ideas for contribution. She said, “This is a great opportunity for any individual working within the aesthetic industry to share their ideas and thoughts about our journal content with our wonderful team. I highly recommend delegates approach us with their suggestions, whether they are an experienced writer or hoping to start, we would love to hear from them and discuss our opportunities further.” Aesthetics business development manager Hollie Dunwell will also be present over the two days to discuss advertising opportunities and upcoming events.

On the Scene

Sesderma UK launch, London Clinical skincare and aesthetics company Sesderma hosted industry professionals and aesthetic practitioners at the W Hotel, London, on February 25 for its official UK launch. The Spanish company showcased its extensive portfolio of antiageing products, whilst attendees enjoyed champagne and canapés. The evening was host by Safety in Beauty campaign founder Antonia Mariconda, who introduced a short film that explained how the nanotechnology incorporated in the Sesderma products allows for deeper penetration of the ingredients in the skin. Founder of Sesderma, Dr Gabriel Serrano, then took to the podium and presented attendees with a slideshow presentation that gave a background to his life and work and how he came to set up the company more than 25 years ago.

Dr Serrano said, “Sesderma is delighted to launch in the British aesthetics industry. We fully respect the committed stance that our British medical aesthetic colleagues embrace when selecting clinically proven skincare products, and our clients will find Sesderma an exciting new addition to their extensive portfolio.” Sesderma’s UK sales manager, Joanna Briggs, concluded the speeches, telling the audience of her excitement of launching the brand in the UK, “Sesderma has taken a new scope, expanding its presence in the top international markets. For us, the United Kingdom represents a unique opportunity to offer high quality tailor-made treatments for the end consumers.” The Sesderma range includes skincare and medicalgrade products and is now available in the UK.

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The growth of the global cosmeceutical market

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So what is causing cosmeceuticals to grow in popularity so significantly?

New and improved Bowes suggests that the introduction of new ingredients, added to existing core ingredients to further improve cosmeceuticals, has had an influence on their growth. She said, “We have second and now third generation hydroxy acids that improve on the results that you get with the first generation alpha hydroxy acids. We now have ingredients that are multi-tasking; so instead of just resurfacing skin and creating neocollagenesis, you get skin barrier support, matrix metalloproteinase inhibition (MMP), antioxidant properties, antiglycation properties – all from one single ingredient.” Dr Schulte believes changes in EU regulation have also had an impact on the quality and quantity of ingredients in the products over recent years. He said, “There are now regulations which mean you have to be clearer on the statements you make.5 For example, if ingredient ‘A’ is proven to be effective when used at a concentration of 50% during laboratory testing, then when you put ingredient ‘A’ in your product and claim it is effective, it must be at the same concentration. In the old days you could find products on the market containing, let’s say, just 5% of ingredient ‘A’ but also claimed to be 100% effective, which in fact it was not, but more or less nobody was questioning this. So now things are getting better for the consumer.” Dr Malik adds, “The formulations are always changing and evolving and the way in which we can utilise the active ingredients is getting better and better, which makes them easier to use. You also get less irritation and less downtime with products now, such as ones that contain newer formulations of vitamin A. So this is also making them more popular.”

The definition “First of all, we need to establish what is and what isn’t a cosmeceutical,” said independent nurse prescriber Lorna Bowes. She explained, “There is absolutely no legal requirement that a product must meet to be branded a ‘cosmeceutical’. Could some of the growth be because there are just more brands using this term? Maybe. I think there needs to be more clarity in the market of what constitutes a cosmeceutical.” According to the Oxford Dictionary the term cosmeceutical can be defined as ‘a cosmetic that has or is claimed to have medicinal properties’,2 but the word itself is not officially recognised by the FDA3 or the Medicines and Healthcare product Regulatory Agency (MHRA).4 This means that any company can use the term to describe its products, regardless of the ingredients or their effects.

Complementary treatments Practitioners are also more frequently recommending that patients use cosmeceuticals in conjunction with injectable and energy-based treatments to enhance their results. “Cosmeceuticals are definitely an adjunct to aesthetic treatments,” said Dr Malik. “Cosmeceuticals prepare the skin and often you can get better results with your energybased devices. The two go hand-in-hand and once you have done the treatments, whether you have had injectables or a laser treatment, cosmeceuticals will protect your investment.” Dr Schulte agrees, “If you have deep frown lines, you need botulinum toxin; if you have deep nasolabial folds, you need fillers; but with all these procedures you never change the quality of the skin and this is so important. I see it this way; if you look at a house, cosmeceutical products are the roof and the injectable treatments are the cellar.”

Results driven Cosmeceuticals aim to be more effective than basic cosmetic products such as moisturisers, makeup and hair products. They claim to contain active ingredients that are known to be beneficial and Bowes describes them as products that have ‘genuine, medical peer-reviewed published data’. Cosmetic doctor and general practitioner Dr Rabia Malik has seen a change in her patients’ wants and needs over the past few years, “Consumers are looking for results and there is a real consumer demand for products with active ingredients that actually deliver. I think people are fed up with products that make lots of claims and then don’t work. They want products that can be supported by science or with data, they want cosmeceuticals.” Founder of QMS Medicosmetics skincare brand Dr Erich Schulte agrees, “People are willing to spend a lot of money on skincare but they want to see results. The ‘promises’ are not enough anymore with the big brands and consumers demanding more, knowing more and wanting something that scientifically works.”

Continued growth? Bowes believes the cosmeceutical market share will keep growing, “There is an increasing awareness of skincare that truly delivers, such as cosmeceuticals, and consumers are going to start to demand it more and more.” Dr Malik adds, “I think we will see a lot more nanotechnology and newer delivery systems. There is still a lot of work going on in getting a higher percentage of actives in to the skin. I also think we will see improved raw materials and so we will get better quality products, and, as a result, the cosmeceutical market is likely to become even bigger in the future.”

With new research predicting the global cosmeceutical market will reach $61 billion US dollars by 2020, Aesthetics investigates what could be driving the market and fuelling growth New research by business consulting firm RNCOS has indicated that the cosmeceutical market share will continue to ‘incessantly increase’, and is estimated to reaching a staggering 61 billion US dollars by 2020.1 The increase in popularity of cosmeceutical products has been noticeable to many, with this years’ International Master Course on Aging Skin (IMCAS) conference dedicating a whole day to the products, and it’s scientific director, plastic surgeon Dr Benjamin Ascher, predicting the sector is set to ‘explode in popularity’ over the coming years.

REFERENCES 1. Report Buyer, Global Cosmeceutical Market Outlook 2020, RNCOS (2015) <https://www.reportbuyer. com/product/1103487/global-cosmeceuticals-market-outlook-2020.html> 2. Oxford Dictionaries, cosmeceutical, English, (2016) <http://www.oxforddictionaries.com/definition/ english/cosmeceutical> 3. FDA, ‘Cosmeceutical’, U.S Food and Drug Administration, (2014) <http://www.fda.gov/Cosmetics/ Labeling/Claims/ucm127064.htm> 4. Cosmetic Business, Tell-tale signs, Home, (2008) <http://www.cosmeticsbusiness.com/technical/ article_page/Tell-tale_signs/48716> 5. EUR, Regulation (EU) No 1223/2009, Access to European Union Law (2016) <http://eur-lex.europa.eu/ legal-content/en/ALL/?uri=CELEX%3A32009R1223>

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Business Track agenda will provide delegates with vital business and industry knowledge. Speakers experienced in aesthetic business development will share advice on how to enhance your brand, marketing and clinic operations. Delegates are urged to bring their colleagues and front of house staff to the Business Track, to make the most of the information shared within the sessions.

A Last Look at ACE 2016 With more than 2,000 practitioners expected to attend this month’s Aesthetics Conference and Exhibition in London, we detail why this is an event not to be missed Exceptional feedback, leading speakers, and access to free clinical and business content, combined with a comprehensive Conference agenda, has attracted thousands of delegates for the Aesthetics Conference and Exhibition (ACE), taking place on April 15 and 16 at the Business Design Centre in Islington, London. With just two weeks left before the event, ensure that you don’t miss out on the chance to discover new products and innovations, expand your clinical knowledge and enhance your business skills, while gaining CPD points, at the leading aesthetics conference and exhibition in the UK. Aesthetics journal editor and ACE 2016 organiser, Amanda Cameron, said, “ACE offers fantastic learning opportunities for every practitioner who is interested in expanding, growing or making the move into medical aesthetics. It is the perfect place to embrace educational training to increase your clinical and business skills, as well as network with industry professionals.”

Free clinical content Register for free to explore the wide range of clinical content ACE has to offer at the Expert Clinics, Masterclasses and Treatments on Trial sessions. Two dedicated areas in the Exhibition Hall will be devoted to the Expert Clinics, giving delegates the opportunity to learn from respected aesthetic professionals. Sponsored sessions will be presented by knowledgeable practitioners representing Rosmetics, Naturastudios, AestheticSource, AesthetiCare, 3D-lipo, Fusion GT, BTL Aesthetics, Healthxchange, Syneron Candela,

Medico Beauty, SkinCeuticals and Lynton Lasers. Non-sponsored sessions include talks on lip argumentation, laser treatments, lower face treatments and surgical and non-surgical hair treatments, amongst many others. Masterclasses will deliver a highly focused learning experience from knowledgeable practitioners and key opinion leaders on how to increase patient results using expert techniques and advanced product knowledge. The sessions will be sponsored by Galderma, HA-Derma, Neauvia and Zeltiq, and will cover a variety of topics; including periorbital rejuvenation with HA fillers and PDO facial thread lifting. New to ACE this year, the Treatments on Trial sessions on Saturday April 16 will allow delegates to join engaging debates and discussions on the latest products and devices available on the market. Supported by BTL Aesthetics, Lumenis, Church Pharmacy together with BeamWave and Syneron Candela, the agenda will focus on body contouring and weight loss. It is vital for practitioners to be aware of the latest developments in their industry, and these sessions will provide that opportunity, as well as the chance to directly compare the products offered by these manufacturers. Company representatives will also answer questions, allowing delegates to discover the best options for their practice and their patients.

Free business content

Exhibition Visit the ACE 2016 Exhibition to network and meet aesthetic industry professionals in 2500m2 of exhibition space, which will showcase leading distributors, manufacturers, products, and innovations in aesthetics. Delegates can watch live demonstrations and discover new product launches from some of the most renowned aesthetic companies.

Networking Event After a busy day of learning, delegates can relax and socialise with a complementary glass of prosecco at the Networking Event on Friday April 15 from 5:30pm. Sponsored by 3D-lipo Ltd, this will provide delegates with the opportunity to liaise with colleagues and business partners and meet leading industry figures.

Conference Delegates can book either a 1 or 2-day Conference Pass, which will grant access to sessions from the UK’s leading aesthetics practitioners. Renowned speakers including Mr Dalvi Humzah, Dr Raj Acquilla, Dr Tapan Patel and Sharon Bennett will engage in expert panel discussions and explore the anatomy, treatment and complication management of key anatomical areas, including the eye, forehead, temple, brow, mid-face, lower face, neck, breast, décolletage, vagina, buttock and thigh. Speakers will utilise multiple screens for optimum learning, incorporating live treatment demonstrations, anatomy dissection exploration and audience participation and interactive voting. Don’t miss your chance to learn, register today at www.aestheticsconference.com HEADLINE SPONSOR

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Having clinical knowledge is just one part of running a successful aesthetic practice. Sponsored by Church Pharmacy, the free

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features. The popular In Profile feature, which each month explores a prominent practitioner’s journey into aesthetics will run alongside a video interview, with exclusive added content and advice for viewers to enjoy. All ACE and Aesthetics Awards news and highlights can be read and watched via the new website, again featuring interviews with renowned aesthetic practitioners and professionals sharing their opinions, experience and advice for building a patient base and establishing a prosperous aesthetic clinic.

Sign in to the new Aesthetics website We explore the new highly interactive, educational and user-friendly digital platform for aesthetic professionals With enhanced usability, brand new interactive features, effective optimised search and a refreshed appearance, the new Aesthetics website is now live. The new-look site will be the go-to resource for all things aesthetics, from the latest industry news, features and CPD-accredited education, to job opportunities, training courses, and a comprehensive supplier directory. By simply joining as a member or logging-in to an existing Aesthetics account, users can create and update their own profile and gain access to articles and events, join and engage in community discussions, watch interviews with renowned aesthetic practitioners, and promote their products and services to other aesthetic professionals. Search functions With the prominent search bar on the home page, which utilises a tagging structure unique to the industry, users can explore the many features and tools that the new Aesthetics website offers. For example, typing in key words such as ‘dermal fillers’ generates relevant content from all parts of the website, including of course features and news, but also supplier listings, training courses, community discussions, CPD articles, and sessions due to take place at the Aesthetics Conference and Exhibition (ACE) all tagged with or related to the search term. The website has been optimised for mobile use, allowing quick access to all of the valuable content via a smartphone or tablet for use ‘on-the-go’. News and Features Industry news is displayed in an eye-catching carousel at the top of the Aesthetics website, allowing easy viewing of the latest announcements, launches and developments. Conference reports and event summaries also feature on the carousel, ensuring that professionals are up-to-date with everything happening within the industry. Readers of the journal can now view all of their favourite clinical and business features online, including the monthly Special Feature and Last Word articles, with links to the author’s contributor profile to read more of their educational and useful content published in Aesthetics, as well as special online

CPD Continued learning and professional development is fundamental to safe and successful aesthetic practice. As such, the new website will feature CPD-accredited education in the form of articles and videos, with learning objectives tested via multiplechoice questions. Upon correct completion of the questions, users will receive a downloadable CPD certificate, which they can use to self-certify their learning. Members can also add external events to a Training Record in order to keep a list of all the CPD and other training that they have undertaken, for personal reference, CV purposes or for easy recall when revalidating. Community Engaging with fellow aesthetic practitioners is of huge value in an industry that is as ever changing as aesthetics. Having a platform to debate regulation concerns, discuss treatment options, seek advice on complication management and discover best practice techniques is becoming increasingly important; and so the Aesthetics

The new-look site will be the go-to resource for all things aesthetics, from the latest industry news, features and CPDaccredited education, to job opportunities, training courses, and a comprehensive supplier directory

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website now offers a Community Forum which users can visit to communicate with other like-minded professionals. Users can start a discussion of their choice, add images, and add relevant tags to their post to help other users find these and get involved. This highly interactive feature will raise awareness and educate users in safe aesthetic practice in the UK. Marketplace Whether users are looking to advertise or seek a new job or new piece of equipment, the Aesthetics website can meet all marketplace needs. Members can visit the Jobs section to find all the latest listings in the industry, including adverts for both businesses and medical professionals. The Classifieds page is home to new and used aesthetic equipment, from body shaping devices to visual imaging systems. If you would like to add a listing to the marketplace, this can be done so at no charge for a limited time. Directory The Aesthetics website is the ideal place to promote a brand to an engaged professional audience. Companies can add a description and contact details to the Directory page to allow users to find out about the products and services they offer. In addition, the specialised tagging system used by Aesthetics enables listings to appear whenever a user types in key words associated with a company. A standard directory

V Soft Lift is a PDO thread system inserted into the subdermal tissue for temporary support of the face and body. It is a less invasive treatment than surgical methods, offers better results than laser treatments and can be used in place or in conjunction with dermal fillers and Botulinum toxin treatments Polydioxanone (PDO) has been used for more than 20 years in orthopaedics, surgery, plastic surgery and ophthalmology.

Before

listing is currently free to add for all members and Premium options are available for those seeking additional exposure. The Aesthetics website also offers prime opportunities to increase brand awareness in the form of targeted banner advertising using the specialised tagging system to surface adverts alongside related content, ensuring that members are always provided with information that is relevant to their interests. Visit www.aestheticsjournal.com to set up your Aesthetics profile and start benefitting from the exclusive, educational content and services available today. For editorial opportunities email editorial@aestheticsjournal.com For advertising opportunities email support@aestheticsjournal.com

PDO threads have a high safety profile, complete absorption and minimal tissue reaction. The PDO thread generates tensing fibrosis in the surrounding tissue. When inserted correctly in the subcutaneous tissue, the risk of scarring is absent. V Soft Lift is not comparable with other types of thread lifting. The threads are thinner, shorter and inserted with an ultra-thin wall high quality needle.

PDO THREAD TREATMENT SYSTEM

After

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A Combined Effort There are multiple treatments at practitioners’ disposal for treating facial skin, with outcomes commonly optimised when two or more are used in combination. Allie Anderson discusses various combination treatments and how they work There are many factors that contribute to ageing of the face. Whether it’s loss of volume, lines and wrinkles, sagging, heavy jowls, or a declining skin condition, the numerous signs of ageing often have different causes. As such, when treating the ageing face, seldom does one treatment or procedure address all aesthetic concerns. Most would agree that whichever part of the face – or indeed, whatever aesthetic concern – one is addressing, the optimum line of defence is to combine a number of treatments to achieve the best results. According to practitioners interviewed for this article, when deciding which combination(s) to use to treat a particular patient, the most important element is to interpret the patient’s concerns and determine the underlying problem. “What a patient sees is the end result of various factors, and it’s our job to ascertain what those factors are and to treat them accordingly,” comments Dr Elisabeth Dancey from the Bijoux Medi-Spa. “For example, a patient might say, ‘I look tired’. The reason is that their face has lost some volume, they’ve lost the support of the tissues, they’ve lost the roundness, and they’ve lost the way the light reflects on their face – and as a consequence they look tired. So the treatment would therefore be to replace that volume with fillers for example. Or patients may say, ‘I’ve got a saggy jaw line’, and that’s the end result of many things, including volume loss and skin laxity. So my choice of treatments would take that into consideration.” Only skin deep For Dr Martyn King, owner and director of Cosmedic Skin Clinic, combination facial treatments would typically be aimed at targeting each of three different depths: deep, medium and superficial. “As a doctor, I tend to deal more with issues beneath the skin – these are often the more invasive procedures that go quite deep, to tackle problems like volume loss and sagging,” he explains. “So my first treatment will often be PDO (polydioxanone) thread lifts or deep, collagen-stimulating fillers.” To address medium-depth problems, Dr King says, one might also use threads, with the addition of platelet-rich plasma (PRP), while superficially, treatments like

microdermabrasion or skin peels would be aimed at rejuvenating the skin. Dr King reports that a common patient group visiting his clinic, is the 40-plus female with some visible signs of ageing, such as volume loss, descent of the facial tissue, sagging jowls, fine lines and loss of elastin and collagen. A typical combination of treatments, he says, would be to use thread lifts to combat the sagging issues, together with deep dermal fillers for the concerns related to loss of volume. The degree of severity of each concern would guide the order in which treatments are applied, and the techniques used. “If there isn’t much volume loss, then I will do the lifts first and look at adding some volume afterwards,” Dr King comments. “If, however, the patient’s face is quite flat and thin, then I’ll often use dermal fillers super-periosteally, usually on the cheeks, a little on the zygomatic arch and sometimes, submalar. The patient might still need a bit of lifting, but having added some volume to the face, it makes the lifting easier.” Dr Nestor Demosthenous, founder of Dr Nestor’s Medical Cosmetic Centre, also uses this combination for similar patient cohorts. “I find that the two complement each other well. For patients over 40 years of age, fillers help to re-volumise and contour the malar area and help to turn down and elongate the chin, allowing a softening of jowls,” he explains. “Threads then achieve a better, natural lift in a revolumised ageing face, which aim to transpose sagging skin to a higher, more youthful position, without the need of over filling. The two in combination help us to achieve a more natural result, without the need to over volumise, and still effectively soften nasolabial folds and lift sagging jowls. Given the bio-stimulation in achieving collagen production from both products, it is an obvious choice to combine the two treatments.” Age before beauty One way of splitting combinations of treatments is by age group. Dr JJ Masani, founder and director of the Mayfair Practice, often determines which combination of treatments to use on a patient by their age, broadly differentiating three main age ranges: 25 to 35, 35 to 55, and 55 upwards. While this is not an exact science – and there will commonly be some crossover – the types of aesthetic concerns people present with are largely consistent according to the age group. For example, Dr Masani says, patients aged 25 to 35 often have residual problems with acne, rosacea and early signs of declining skin texture, such as enlarged pores. “The first and most important thing is to see what the patient’s skin looks like and its quality,” he explains. “For instance, if the person has acne, then I will put all my efforts into getting rid of the acne.” This would entail low-dose Roaccutane – which contains high levels of vitamin A – along with another topical treatment containing tretinoin (a form of retinoic acid) and the antibiotic clindamycin. For treating rosacea, which Dr Masani reports is a common complaint among his patients in the 25 to 35 age group, he would use

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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10mg of Roaccutane twice a week, combined with a different type of antibiotic called metrosa, which is applied to the face in gel form. Dr Masani suggests that Roaccutane can also be an effective treatment for patients in this age group who don’t have acne or rosacea, but who have oily skin, caused by excess sebum. “There are two enemies for the skin: sunlight and the sebaceous gland,” Dr Masani comments. “The sebum that comes from the sebaceous gland sits on the skin and produces chronic inflammation, which can also be treated with the low-dose Roaccutane to reduce the production of sebum and give the skin a glow.” For patients aged 25 to 35, botulinum toxin can be used in combination with Roaccutane in order to improve skin texture. “Botulinum toxin is not just for the sake of chasing lines; it also has lifting capacity, making it an effective option for younger patients who would benefit from a slight lift of the brow and cheeks, and reduction in pore size,” he adds. Dr Dancey also treats patients under the age of 35 with botulinum toxin, similarly to, “restore the correct position of their eyebrows and to calm down over-activity of the muscles that are moving the face too much.” Filling the gaps A suitable treatment to combine with botulinum toxin is dermal fillers, of which Dr Masani uses three types in patients aged between 35 and 55, depending on how they present. The first are fillers containing hyaluronic acid, which has been shown to be effective particularly at treating ageing associated with the lower half of the face from the nasolabial folds to the vertical lip lines, marionette lines and thinning of the lip.1 The second is polylactic acid, a synthetic, biodegradable peptide polymer that was originally used to treat facial lipoatrophy caused by drug therapy in HIV patients2 and is effective in facial rejuvenation by stimulating fibroblasts and thereby producing new collagen,2 generating a gradual increase in volume. The third is calcium hydroxylapatite, a substance found naturally in human bones that is often used to fill nasolabial folds, marionette lines and frown lines, and to enhance fullness of the cheeks.3 Research has found that when used in combination with and (at least one week) after botulinum toxin, the effects of calcium hydroxylapatite can be improved, particularly for glabellar and marionette lines.4 Women in the 35 to 55 age group, Dr Masani explains, begin to suffer more marked volume loss, so an additional treatment can be included in regimen in the way of the PDO threads. “This gives a beautiful pull and tension to lax skin, improving the jaw line, the nasolabial folds and the quality of the skin,” he says.

Aesthetics

The key consideration with combining any two or more together is knowledge of the underlying anatomy, and an appreciation of the complications that could arise

using a machine with a handpiece attached.5 In this context, plasma is a highly energised gas, often referred to as ‘the fourth state of matter’. It is produced in the machine’s handpiece by a combination of nitrogen and ultra-high frequency RF waves, and emitted in millisecond pulses. The longer the pulse, the more energy is delivered to the skin. As the plasma energy is delivered to the skin with the movement of the handpiece over the area being treated, it is rapidly transferred into heat energy, which in turn penetrates the superficial and deep dermis. This controlled application of heat energy replaces damaged collagen and encourages new collagen production.5 This technique is often used on the eye region in order to combat hooding of the upper eyelids and to improve laxity of the lower lids. “It tightens the skin in the area to which it’s applied, and is great to use for people with smokers’ lines and the deeper lines around the eyes that you so often see in patients of that age,” Dr Masani says.

The light touch At clinicbe, a significant number of patients present with what founder and director Dr Barbara Kubicka describes as “difficult skin”, which includes complaints like rosacea, redness, sun damage, mild For the 55 and over age group, Dr Masani uses any number of the acne, and sensitive, acne-prone skin. All of these concerns would combinations discussed thus far. He is also exploring the possibility be addressed with a combination of intense-pulsed light (IPL) and of using a procedure that converts nitrogen gas into plasma energy chemical peels, both of which can be adjusted according to the exact problem and its severity. “For example, for treating redness in the Before left side After left side Before right side After right side cheeks we use a certain setting of the IPL machine and a different peel than if we are treating the T-zone, when we can use slightly different settings of the machine and different chemical peels,” she explains. This blend of treatments elicits good results because they each target a different aspect of the conditions for which they are applied, Dr Kubicka adds. “To take rosacea as Figure 1: Before and two months after one treatment for acne scarring with dermal-needling followed by ultrasound an example, it has two components: with hyaluronic acid and vitamin C. Images courtesy of Dr JJ Masani.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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gently manipulated using a series of precise movements.” Adding in a monopolar system of radiofrequency energy delivers heat to the tissue, which stimulates subdermal collagen production to tighten the skin and reduce the appearance of mild to moderate facial skin laxity, fine lines and wrinkles.11 “Simply, these treatments combined give the best results in the shortest time span,” Turner Traill comments. “Although the appointment Figure 2: Before and after treatment with IPL, 20% glycolic acid peel. Images courtesy of Dr Barbara time can be lengthy we find the combination Kubicka. of different treatments at one time suits one is the redness of the skin, and the second is congestion and many. But, as with every treatment in medical aesthetics it’s about oiliness,” she says. “The IPL is very effective at treating the redness managing expectations.” She recommends that practitioners aspect, but not the congestion. If we use a glycolic peel, for example, approach combination treatments by concentrating on the main area that might be too much for the skin to tolerate if the skin is very of concern and the supporting structures around that. “For instance sensitive, and a very gentle peel is not going to achieve much, or if the eye area is the main concern, look at the surrounding anatomy help with the redness.” Therefore, the variety of chemical peels such as lactic, mandelic or different strengths of glycolic, can be used effectively to complement the benefits of IPL.6 Dr Kubicka reports that the two treatments are often performed during the same session, with the IPL applied first so as not to overexpose the skin and cause irritation – this may occur with the application of the peel,7 which, by nature, is a more abrasive treatment. IPL entails the emission of lights of different wavelengths, which target specific types of cells where they are transformed into heat energy. Side effects include pain, soreness, peeling, swelling, bruising and occasionally, blistering,10 so it follows that skin treated with IPL can be sensitive immediately post-treatment, so adding a chemical peel on top must be done with caution, says Dr Kubicka. “We obviously run the risk of overstimulating the skin, so the skill lies in choosing the appropriate combinations of light wavelength settings and type of peel, because it’s very much about selecting the right product for the patient.” Before

After

Figure 3: Before and after treatment with IPL, 30% lactic acid peel, mandelic acid peel, 20% glycolic acid peel. Images courtesy of Dr Barbara Kubicka.

A current trend At the Frances Turner Traill Skin Clinic, practitioners typically offer radiofrequency and microcurrent treatments, sometimes in conjunction with injectables. “Combination treatments would consist of a microdermabrasion or a very light superficial peel to exfoliate the skin in preparation,” says clinical director and nurse prescriber Frances Turner Traill. “Secondly we use the micro-current therapy, concentrating on the main areas of concern to lift and tone the muscle, and we then use the radiofrequency to tighten the skin over the muscle.” The micro-current therapy, she explains, delivers tiny electrical impulses to the muscles in the area being treated to give a ‘facial toning’ or ‘non-surgical facelift’ effect. “During each one-hour treatment session all 32 facial muscles are

The variety of chemical peels such as lactic, mandelic or different strengths of glycolic, can be used effectively to complement the benefits of IPL

and what is lacking,” Turner Traill says. “Sometimes patients can see an immediate result but we always caution that this is a slow burn. You wouldn’t expect a six pack after one intense gym session with a personal trainer, these combination treatments are the same.” Holistic approach As with any aesthetic treatment or procedure applied individually, the key consideration with combining any two or more together is knowledge of the underlying anatomy, and an appreciation of the complications that could arise. Practitioners interviewed highlighted that when considering combination treatments for any patient, professionals must look at is how well they will harmonise. Dr Dancey’s advice is simple: “You have to think about the treatments and whether they are complementary. If there is any doubt that they are, do them individually.” REFERENCES 1. Gold MH, ‘Use of hyaluronic acid fillers for the treatment of the aging face’, Clin Interv Aging, 2(3) (2007), pp.369-376. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2685277/> 2. Bowler PJ, ‘Impact on facial rejuvenation with dermatological preparations’, Clin Interv Aging, 4 (2009), pp.81-89. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2685229/> 3. American Society of Plastic Surgeons, Dermal Fillers: Calcium Hydroxylapatite (Texas: Plasticsurgery. org) <http://www.plasticsurgery.org/cosmetic-procedures/dermal-fillers-calcium-hydroxylapatite.html> 4. Jacovella PF, ‘Use of calcium hydroxylapatite (Radiesse®) for facial augmentation’, Clin Interv Aging, 3(1) (2008), pp.161-174. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2544361/> 5. Energist Medical Group, NeoGen Plasma System overview (Swansea: Energistgroup.com) <http:// www.energistgroup.com/products/product-details.asp?Auto_ID=120> 6. Effron C, Briden ME, Green BA, ‘Enhancing cosmetic outcomes by combining superficial glycolic acid (alpha-hydroxy acid) peels with nonablative lasers, intense pulsed light, and trichloroacetic acid peels’, Cutis, (2007), pp.794-8. <http://www.ncbi.nlm.nih.gov/pubmed/17455887> 7. Anitha B, ‘Prevention of Complications in Chemical Peeling’, J Cutan Aesthet Surg, 3(3) (2010), pp.186188. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047741/> 8. Ngan V, Intense pulsed light therapy (Hamilton NZ, DermNetNZ.org, 2005) <http://www.dermnetnz. org/procedures/ipl.html> 9. Abraham MT, Mashkevich G, ‘Monopolar radiofrequency skin tightening’, Facial Plast Surg Clin North Am, 15(2) (2007), pp.169-77. <http://www.ncbi.nlm.nih.gov/pubmed/17544932>

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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Mid-face Rejuvenation Mr Dalvi Humzah and Anna Baker detail the anatomical features of the mid-face and how to successfully rejuvenate the area Abstract With age, the mid-face changes due to a combination of remodelling of the maxilla and pyriform aperture, volumetric and positional changes of the superficial and deep mid-facial fat pads, and changes in skin tone and texture. It is widely accepted that these changes significantly influence many of the visual changes in the lower face. These may be effectively treated with a variety of injectable techniques to rejuvenate the mid-face. The current literature concerning the pertinent anatomy for mid-facial rejuvenation is therefore discussed within this article. Introduction In recent years, the way we analyse and plan the non-surgical approach to the mid-face has changed dramatically. The focus has shifted away from treating visible lines/folds as they present, and is now centred on treating the age-related changes at the root cause. The restoration of a dynamic and harmonious volume distribution is a key factor in non-surgical rejuvenation of the mid-face. There is a growing body of literature demonstrating the multifactorial nature of facial ageing. These indicate that facial analysis and subsequent rejuvenation should initially address such anatomical changes. An understanding of the anatomical changes associated with ageing is required to formulate effective strategies to rejuvenate the ageing mid-face. Key words Mid-face, dermal filler, anatomy, injection techniques Boney changes The most significant age-related change that the face undergoes concerns the underlying skeletal structure. It has been demonstrated that the facial skeleton in males and females undergo predictable patterns of bone resorption in defined anatomical regions. Shaw et al1 undertook a comprehensive study comprising 120 subjects using computed tomography to analyse these changes. The maxillary angle (measured from the superior to inferior maxilla, at the articulation of the inferior maxillary wing and alveolar wing), decreased significantly with age for both male and female subjects. The maxilla has also been shown to recede more medially and inferiorly.2 While the pyriform angle showed no significant change with increasing age, the pyriform aperture area increased significantly in ageing males and females.3 These changes are pivotal in the context of the ageing face as they represent a decreasing and weakening foundation on which the soft tissue structures reside. It has also been proposed that the mid-cheek is more susceptible to ageing, in view of the natural posterior incline of the mid-cheek skeleton from the relative prominence of the infra-orbital rim.4 Some individuals may also possess a congenitally weak or inadequate skeletal structure, which may be the primary

cause of premature ageing.3 It is important for the practitioner to understand these changes as these have implications on the impact of subsequent soft tissue descent,3 and how that may be corrected with dermal filler. Deep fat compartments Morphological changes of the facial fat compartments result in the loss of smooth contours and shadowing that is evident in the ageing mid-face. Gierloff et al4 consolidated findings from Rohrich and Pessa,5 in which they describe data from computed tomographic scans of 12 unembalmed specimens. The deep medial cheek (DMC) fat compartment is noted to have a medial and lateral component. The medial component is triangular in shape and was noted to be present in six specimens in this small cohort study. It was located beneath the nasolabial compartment and extended medially. The medial component of the DMC fat does not lie immediately on the periosteum of the maxilla. In some individuals, the lateral part of the DMC fat may demonstrate a lateral extension, located beneath the superficial medial cheek fat and the lateral boundary in the buccal fat pad. Gierloff et al6 also found the sub-orbicularis oculi fat (SOOF) to have a medial and lateral component in the majority of analysed specimens. The medial component lies approximately 3mm inferior to the lower orbital rim, immediately above the periosteum of the maxilla. The inferior portion overlaps the lateral part of the DMC fat, and the medial part of the SOOF is covered by the nasolabial and medial cheek fat. The lateral component of the SOOF is located underneath the lateral orbital compartment and the middle cheek fat. It lies above the prominence of the zygoma but does not reach the superior aspect of the zygomatic arch. It lies parallel to the medial

Figure 1: Arrows indicate the areas of the facial skeleton susceptible to resorption with ageing. The size of the arrow correlates with the amount of resorption. Image adapted from Wong & Mendleson.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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of this compartment and the lower border of the zygomaticus major muscle is adherent to this compartment.7 The maxilla and a compartment lateral to the philtrum build the medial border, and, Sub-orbicularis oculi fat (lateral part) in some specimens, the nasolabial fat was noted Sub-orbicularis oculi fat to overlap the medial cheek fat inferiorly. (medial part) Rohrich and Pessa7 identified three cheek fat compartments; the medial, middle and lateral Deep medial cheek fat (medial part) temporal cheek fat. Medial cheek fat was Deep medial cheek fat (lateral part) consistently noted lateral to the nasolabial fold, bordered superiorly by the orbicularis retaining Buccal extension of the buccal fat ligament and the lateral orbital compartment. Ristowâ&#x20AC;&#x2122;s space Jowl fat lies inferior to this fat compartment. Middle cheek fat was located superficially in its Figure 2: Image shows the mid-portion, anterior and superficial to the parotid subcutaneous and deep fat gland. The zygomatic ligament was located as a compartments. Adapted from point of adherence where these compartments Gierloff. meet.7 The lateral temporal-cheek compartment is the most lateral compartment of cheek fat. This lies immediately superficial to the parotid gland and superficial musculoaponeurotic system part of the SOOF and inferiorly to the buccal fat pad. The SOOF (SMAS) and was consistently found to connect the temporal fat to holds significance in the context of treating the mid-face with dermal the cervical subcutaneous fat.7 fillers and practitioners are advised to avoid inadvertent placement The study findings demonstrate volume loss of the superior part of product in this plane. Doing so may precipitate the onset of malar of the nasolabial and medial cheek fat, which will consequently oedema, in part due to injury to the lymphatics within the SOOF, worsen the appearance of the tear trough deformity, the nasojugal which can be challenging to correct, may not resolve with time and fold, and the palpebromalar groove. The volume increase of may result in an unsightly aesthetic outcome.6 the inferior part of the nasolabial fat will lead to a pronounced The authors conclude from this study that the pivotal findings nasolabial fold and a pronounced superior jowl.7 in relation to the mid-face confirm an inferior migration of fat compartments, which can accentuate the nasojugal fold and Facial retaining ligaments nasolabial fold. An elevation and reduction of the nasolabial fold can The zygomatic ligament is one of the major ligaments supporting be achieved by augmentation of the medial part of the DMC fat. the facial soft tissues but develops only minimal laxity between its origin and connection to the SMAS.5 This is in contrast to Subcutaneous fat compartments other ligaments, such as the masseteric ligaments below the oral Rohrich and Pessa7 indicate that the subcutaneous layer of the commissure, which generally weaken and stretch with age.10 face has two components: the subcutaneous fat, which provides volume, and the fibrous retinacular cutis, that binds the dermis Rejuvenation techniques to the underlying superficial musculoaponeurotic system. They During aesthetic treatment, validated facial assessment scales are established the subcutaneous facial fat to be partitioned into useful tools for the practitioner and patient to use to establish a discreet compartments using methylene blue dye. It is known that mutual agreement on a desired outcome, as well as managing there is a general weakening of the retinacula cutis structure in the expectations from treatment. Validated facial assessment subcutaneous tissue.5 gages such as the Merz Scales can be very useful.11 Once the The study confirmed that the nasolabial fat compartment is bound hair is fastened away from the face and the skin cleansed with laterally by the medial cheek fat and the sub-orbicularis oculi fat. a chlorhexidine-based solution, the practitioner is advised to The orbicularis retaining ligament represents the superior border topographically identify key mid-facial anatomical landmarks. The infraorbital rim is marked and the foramen may be located 3-5mm inferior to the orbital rim, aligned to the medial limbus.12 The inferior and superior borders of the zygomatic arch are delineated as well as marking an ala-tragal line. This is to guide the practitioner in terms of the safe depth of product placement; a supraperiosteal approach cephalic to the line and a subdermal approach caudal to the line.13 Augmenting the lateral aspect of the face provides a natural enhancement.14 A safe deep plane to place product using a cannula approach is the pre-zygomatic space.12 The roof of the space is formed by skin, subcutaneous fat and orbicularis oculi and this plane is deep to the

It has been demonstrated that the facial skeleton in males and females undergo predictable patterns of bone resorption in defined anatomical regions

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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SOOF, which is of key importance in terms of minimising the risk of complications. Product inadvertently placed into the SOOF may precipitate malar oedema. With this in mind, a cannula approach, supraperiosteally, will ensure that product remains in a safe plane.8 Vectors may be placed using a cannula approach, commencing at the zygomatic arch, supraperiosteally, to provide structural support to restore lateral definition along the zygoma. If the soft tissue descent extends to the medial cheek, further vectors may be placed within the subdermal plane. The advantage of using a biostimulatory product, such as calcium hydroxylapatite, allows a tightening effect in the soft tissues, due to the neocollagenic effect of the calcium microspheres.14 Suitable products would require a good lifting capacity, such as volumising hyaluronic acid dermal fillers. An advantage of a cannula approach in the mid-face means there may be less chance of compromising significant anatomical structures, such as the transverse facial artery and branches of the facial nerve, which reside at a deeper plane at this anatomical region, and are deep to the SMAS.12 A number of techniques are described to restore a youthful eminence to the anterior mid-face. Augmentation of the DMC fat compartment is increasingly acknowledged to be an effective approach to enhance anterior facial projection.15 The aim of correction involves an approach to place a viscous dermal filler at the superolateral portion of the maxilla, requiring minimal product volume to effectively improve the appearance of the nasolabial fold, nasojugal groove, as well as lifting the nasolabial. The volume of required product may vary depending upon the type of product used. In addition, this deep approach will also provide structural support to the maxilla and soft tissues, without compromising any anatomical structures, by using a cannula or needle approach. A subtle correction is advised, as over-treatment may result in an unnatural and disproportionate anterior fullness. This technique may be further complimented by effacing nasolabial shadowing at the pyriform aperture, using a perpendicular approach with a bolus at the alar. This will add structure to the boney changes at the pyriform and support the soft tissues, without compromise to the alar/sill artery, which resides superficially, in the subcutaneous plane.16 Lee et al17 consolidated earlier studies analysing the depth and anatomical location of the facial artery. The location in the nasolabial region has been inconsistently described.18 The findings from Lee et al17 indicate that the location may be superior, inferior and along the nasolabial fold, which is a key consideration for practitioners involved in augmenting this region. Placing product intradermally along the nasolabial fold will not compromise the artery. An injectable technique designed to place the product intradermally is the blanching technique,19 for use with cohesive polydensified hyaluronic acid. We recommend a 30g needle, placed almost parallel to the skin at an angle of approximately 10-12 degrees is used. Multiple punctures are placed closely together, creating small beads and multiple punctures are repeated until the wrinkle has been effaced. It is important to note that the blanching technique is only suitable for cohesive polydensified matrix hyaluronic acid due to the unique tissue integration properties.18

to evolve to shape our understanding of the ageing face and practitioners are advised to remain abreast of new findings.

Conclusion A detailed and meticulous analysis of the face is imperative to ensure that the treatment plans achieve a balanced and harmonious result. The practitioner requires an advanced anatomical understanding to appreciate the multifactorial age-related structural changes to the facial skeleton. Anatomical literature will continue

Further Reading • Lam S.L., Glasgold R., Glasgold M, ‘Analysis of Facial Aesthetics As Applied to Injectables’, Plastic and Reconstructive Surgery, 136(5s) (2015), 11s-21s. • Loghem J.V, Yutskovskaya Y.A, Werschler P, ‘Calcium Hydroxylapatite Over a Decade of Clinical Experience’, The Journal of Clinical and Aesthetic Dermatology 8(1) (2015), pp.38-49. • Rokhsar C.K, Lee S, Fitzpatrick R.E, ‘Review of photorejuvenation: devices, cosmeceuticals, or both?’, Dermatol Surg, 31:11 (2005), pp.66-78.

Anna Baker is a dermatology and cosmetic nurse practitioner. She works alongside Mr Dalvi Humzah and is the coordinator and assistant tutor for Facial Anatomy Teaching. Baker has a postgraduate certificate in applied clinical anatomy, specialising in head and neck anatomy. Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and medical director of AMP Clinic in Oxfordshire. He also runs the award-winning Facial Anatomy Teaching course and the Aesthetic Clinical Training Course. Mr Humzah worked as a consultant plastic surgeon in the NHS for 10 years and teaches nationally and internationally.

Anna Baker will be on the ‘Forehead, Temple and Brow’ panel, Mr Dalvi Humzah will be on the ‘What to do with the Mid-face’, ‘Enhancing the Eye’, ‘Perioral Area and Lips’ and ‘Lower Facial Contouring: Chin and Submental Region’ panels at the Aesthetics Conference and Exhibition 2016. To find out more, visit www.aestheticsconference.com/programme REFERENCES 1. Shaw R.B, Katzel E.B, Koltz P.F, Yaremchuk M.J, Girotto J.A, Kahn D.M, Langstein H.N, ‘Aging of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies’, Plastic and Reconstructive Surgery, 127(1) (2011), pp.374-383. 2. Pessa J.E, Zadoo V.P, Mutimer K.L, ‘Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging’, Plastic and Reconstructive Surgery, 102(1) (1998), pp.205-212. 3. Shaw R.B. Jr, Kahn D.M, ‘Aging of the midface bony elements: a three-dimensional computed tomographic study’, Plastic and Reconstructive Surgery, 119 (2), (2007), pp.675-681. 4. Rohrich R.J, Pessa J.E, ‘The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments’, Plastic and Reconstructive Surgery, 121(5) (2008), pp.1804-1809. 5. Wong C.H, Mendelson B, ‘Newer Understanding of Specific Anatomic Targets in the Aging Face as Applied to Injectables: Aging Changes in the Craniofacial Skeleton and Facial Ligaments’, Plastic and Reconstructive Surgery, 135(5s), (2015), 44s-48s. 6. Gierloff M, Stöhring C, Gassling T.B.V, Açil Y, Wiltfang J, ‘Aging Changes of the Midfacial Fat Compartments: A Computed Tomographic’, Study Plastic Reconstructive Surgery, 129(1) (2012), pp.263-273. 7. Rohrich R.J, Pessa J.E, ‘The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery’, Plastic and Reconstructive Surgery, 119(7), (2007), pp.2219-2227. 8. Pessa, J and Garza, J, ‘The Malar Septum: The anatomic basis for Malar Mounds and Malar Edema’, Aesthetic Surgery Journal, 11:17 (1997). 9. Lambros V, ‘Models of facial aging and implications for treatment’, Clin Plast Surg, 35 (2008), pp.319-327. 10. Furnas D.W., ‘The retaining ligaments of the cheek’, Plastic and Reconstructive Surgery, (1) (1989), pp.11-6. 11. Geister T.L, Bleßmann-Gurk B, Rzany B, Harrington L, Görtelmezer R, Pooth R, ‘Validated Assessment Scale for Platysmal Bands’, Dermatol Surg, 39 (2013), pp.1217-1225. 12. Surek C.C, Beut J, Stephens R, Jelks G., Lamb J, ‘Pertinent Anatomy and Analysis for Midface Volumizing Procedures’, Plastic and Reconstructive Surgery, 135(5) (2015), 818e-829e. 13. Tzikas T.L, ‘A 52-month summary of results using calcium hydroxylapatite for facial soft tissue augmentation’, Dermatol Surg, 34(1) (2008), S9-S15. 14. Sadick N, Katz B.E, Roy D, ‘A multicenter, 47 month study of safety and efficacy of calcium hydroxylapatite for soft tissue augmentation of nasolabial folds and other areas of the face’, Dermatol Surg, 33(2007), S122-S127. 15. Cotofana S, Schenck T.L, Trevidic P, Sykes J, Massry G.G, Liew S, Graivier M, Dayan S, Maio M.D.M, Fitzgerald R, Andrews J.T, Remington B.K, ‘Midface: Clinical Anatomy and Regional Approaches with Injectable Fillers’, Plastic and Reconstructive Surgery, 136(5s) (2015), 219s-234s. 16. Shim K.S, Hu K.S, Kwak H.H, Youn K.H, Koh K.S, Fontaine C, Kim H.J, ‘An Anatomical Study of the Insertion of the Zygomaticus Major Muscle in Humans Focused on the Muscle Arrangement at the Corner of the Mouth’, Plastic and Reconstructive Surgery, 121(2) (2008), pp.466-473. 17. Lee J.G., Yang H.M., Choi Y.J., Favero V., Kim Y.S., Hu K.S., Kim H.J., ‘Facial Arterial Depth and Relationship with the Facial Musculature Layer’, Plastic and Reconstructive Surgery 135(2), (2015), pp.437-444. 18. Park T.H., Seo W.W., Kim J.K Chang C.H., ‘Clinical experience with hyaluronic acid-filler complications’, Journal of Plastic, Reconstructive and Aesthetic Surgery, 64 (2011), pp.892-896. 19. Micheels P, Sarazin D, Besse S, Sundaram H, Flynn T.C, ‘A Blanching Technique for Intradrmal Injection of the Hyalruonic Acid Belotero’, Plastic and Reconstructive Surgery, 132(4S-2)(2013), 59S-68S.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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from a lipid membrane to the DNA in a cell’s nucleus, in an attempt to steal the last electron needed to stabilise themselves. This process causes intracellular chaos. The damage causes inflammation, led by cytokine generation, which not only affects the cell itself, it over-spills into surrounding structures, causing collateral damage of the tissue.3 Activation of matrix metalloproteinases UV exposure also activates destructive intracellular enzymes, known as matrix metalloproteinases (MMPs). This group of enzymes includes collagenase, which cause the breakdown of collagen and elastin. In a different context, the activation of MMPs is essential for the remodelling of connective tissue and wound healing. However, when UV radiation and toxic pollutants artificially trigger this process, it causes premature collagen breakdown, which leads to accelerated ageing of skin cells, and ultimately the visible signs of ageing, in particular, wrinkle formation and volume loss.4

The Effects of Pollution on the Skin Dr Jane Leonard discusses how environmental factors such as UV radiation and pollution can affect the skin and details how to recognise related skin conditions in patients The primary purpose of the skin is protection; it provides a physical barrier against radiation, toxic chemicals, and water exposure to protect the internal organs. In carrying out this function, the skin encounters inevitable harm which leads to the signs of skin ageing that we are familiar with: wrinkles, fine lines, altered pigmentation, loss of volume and skin tone. We know that both internal and external factors lead to skin ageing; internal factors include smoking and excess alcohol, and external factors include sun exposure through UV radiation and environmental pollution. I have come across many different theories of how exposure to pollution can lead to skin ageing. The most widely accepted is the theory of free radicals and oxidative stress. This states that the accumulation of free radical damage and oxidative stress creates a cascade of intracellular damage, which impairs cellular processes that allow skin cells to divide in order to grow and repair themselves.1,2 Oxidative stress and free radical theory It is commonly accepted that UV radiation and photoageing cause the majority of visible signs of ageing. When UV radiation comes into contact with the skin surface it initiates the production of free radicals and the formation of reactive oxidative species (ROS).3 Examples of these are oxygen ions, free radicals and peroxides. ROS are highly reactive, unstable molecules due to the presence of their unpaired electron. They will attach themselves to anything

Chemical pollutants UV radiation is not the only environmental factor that causes skin ageing. A landmark study in the Journal of Investigative Dermatology compared women living in urban and rural environments over 24 years and found that those living in the urban area that had been exposed to increased pollution had more dark spots and wrinkling.5 Microscopic particles are released into the atmosphere every second from fires, power plants, construction sites and motor vehicles. These tiny chemical particles create an invisible but toxic film on the surface of the skin.6 The microscopic size of the particles allows them to easily penetrate the skin pores, making their way through the deeper layers of the skin to eventually target the skin cell nucleus. They create a cascade of intracellular damage. This process is driven by the activation of free radicals leading to oxidative stress and the activation of MMP, both described above.5 It also triggers a phenomenon known as replicative senescence; this is a process of cellular ageing, where the cell can no longer replicate. This is a natural process but it can be triggered prematurely by the effects of UV radiation and environmental toxins. The hallmark of this process is the shortening of telomeres at the ends of DNA strands, which help ensure chromosomal stability. Skin cells are some of the most rapidly dividing cells in the body; when DNA is damaged, it is susceptible to replicative senescence, which means they are no longer able to divide, multiply and repair themselves.5 The additive effect of these processes leads to intracellular and collateral inflammation and dehydration of skin cells and surrounding structures. This causes collagen breakdown and damages the lipid layer of the skin, thus impairing its barrier function, which manifests itself in the loss of elasticity, firmness and volume.7 Ozone effects The ozone also has an impact on skin ageing and can trigger exacerbations of pre-existing skin conditions.8 The ozone exists in the stratosphere and troposphere and is also found in low concentrations at ground level as a by-product of human activities, which release chemical pollutants into the atmosphere, such as smog. The effects of the ozone are amplified by the presence of other environmental factors such as UV radiation and other toxic pollutants.8 Studies suggest that the ozone, like other chemical pollutants, first

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targets the stratum corneum and start to penetrate down to the dermis. Their path of destruction is driven by oxidative stress, the formation of free radicals and MMP activation.8 The presence of the ozone induces epidermal damage to the skin through collagen breakdown and impairing the lipid membrane of skin cells to inhibit their barrier function. In addition, the ozone also inhibits the protecting effects of antioxidants, making harmful damage inevitable and irreversible once the process has started. The inflammatory aspect of ozone damage has been associated with a flare-up in skin conditions including; urticaria, eczema, contact dermatitis, and other nonspecific eruptions.9,10,11

with inflammatory changes in the skin, and the flare up in existing or new skin conditions such as acne and dermatitis.

Skin conditions triggered by pollution In addition to premature ageing, what ailments can pollution trigger in the skin?

Examination Carry out a full facial assessment, paying attention to patterns of wrinkle formation and volume loss, and ask yourself: are they localised or global? Are they associated with hyper/ hypopigmentation? How is the skin texture? Does this pattern extend into the neck? Is the extent of the ageing consistent with the age of the patient? It is also useful to examine the patient’s hands too, rather than just focusing on the face, as hands and face are often the main areas suffering repeated exposure to the effects of the environmental pollutants.

Chloracne Acne and the effects of acne are something that most practitioners are familiar with. On rare occasions, environmental pollution can result in an acne variant called chloracne, also known as halogen acne. Chloracne results from environmental exposure to certain halogenated aromatic hydrocarbons. The skin’s manifestations of acne indicate systemic poisoning by these compounds.12 Von Bettman first observed chloracne in 1897, followed by Herxheimer in 1899.12 Today, chloracnegens are thought to include polychlorinated compounds, such as herbicides. Chloracne is caused by direct contact of the toxins with the skin, however some cases have been documented which involve ingestion or inhalation of toxins too.13 Although chloracne tends to slowly resolve upon cessation of exposure to chloracnegenic compounds, the duration of chloracne correlates with the severity of the disease.13 Like other causes of acne, chloracne can be challenging to treat. The most effective documented treatment is topical treatment with retinoids.14 Irritant contact dermatitis The direct effect of toxic chemicals on the skin surface can lead to an eczematous eruption. Commonly this condition is caused by cosmetic products or a change in washing powder, for example, but it can also be triggered by toxins and solvent in the atmosphere.15 Chemical depigmentation Exposure to environmental chemicals can also have a destructive effect on epidermal melanocytes, which can cause hyper or hypopigmentation of the skin known as chemical depigmentation, which resembles vitiligo. The most common causative agents are derivatives of hydroquinone and related compounds.16 Occupational leukoderma is commonly observed, where chemicals have a depigmenting effect on the skin, which is typical in workers who have skin contact with them. This condition tends to have a hypopigmenting effect on the skin called chemical leukoderma, which unfortunately has no specific treatment.16 Recognising the signs The signs of accelerated skin ageing caused by pollution are similar to those we are all aware of. When caused by environmental exposure to UV, in combination with toxic chemicals, the skin signs tend to show changes in skin texture and pigmentation, rather than the formation of lines, wrinkles and volume loss alone. The signs of skin ageing, secondary to UV radiation and environmental pollutants, are also often associated

History When assessing patients it’s key to talk thorough their history, in particular occupational history, their sun exposure and exposure to chemicals or toxins. In patients with pre-existing skin conditions such as eczema, acne or dermatitis, ask about triggering and relieving factors, to see if a pattern emerges in association with environmental changes, i.e. do symptoms only flare up at work? Are they seasonal? Are they triggered by the use of particular cosmetic products?

Management Antioxidants Antioxidants prevent against free radical damage and oxidative stress through stabilising the free radicals by donating one of their own electrons to neutralise them and ending the ‘electron stealing’ reaction. This ends the path of destruction in the skin cell nucleus, which can lead to inflammation and collagen damage.17 Antioxidants can be applied to the skin directly, in the form of creams or serums, or can be obtained from dietary sources. Vitamin E is the most abundant fat-soluble vitamin in the body and defends against oxidation and lipid peroxidation.18 Vitamin C is a water-soluble antioxidant, which acts primarily in cellular fluid. It also helps to return vitamin E to its natural form. Topical preparations need to be able to penetrate the outmost barriers of the skin’s surface in order to reach the cell nucleus to have the desired effect.19 The dietary effects of antioxidants are controversial; as little as 1% of antioxidants taken orally reaches the surface skin where they are needed to carry out their protective role.19 That said, a diet rich in antioxidants should always be encouraged as their benefits are not exclusive to skin; research shows antioxidants have other health benefits, in particular protecting against cardiovascular disease and cancer.20  Cleanse Thoroughly cleansing the skin surface to remove the invisible film of toxic pollutants gathered over the day is the first step in protection. Cleansing and exfoliating with products containing alpha hydroxy acids (AHA) like glycolic acid, are excellent as they to help to chemically exfoliate the skin and encourage new skin cells to the skin surface. Protect Sunscreen is fundamental to protecting the skin from harmful UV rays. It provides a physical barrier to prevent UV radiation coming into contact with the skin, which creates the harmful free radical cascade. SPF 50 is recommended for complete protection. It should be used separately as the final part of the skincare regime, and not combined

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with moisturisers and foundations, as they are less effective. High factor sunscreen is especially important when using products containing AHAs as they increase the photosensitivity of the skin. Summary UV radiation, ozone and chemical pollutants can all cause premature skin ageing by the activation of free radicals and matrix metalloproteinases, and oxidative stress. This leads to intracellular inflammation and the breakdown of collagen and elastin. Damage can be minimised by effective cleansing, application of antioxidants and, most importantly, application of sunscreen. Dr Jane Leonard is a GP and cosmetic doctor. She specialises in skin conditions, antiageing medicine and bio-identical hormones. Dr Leonard achieved a first class honours degree in Anatomical Sciences, specialising in head and neck. She has also spent time in dermatology research and has had her worked published in Australia.

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REFERENCES 1. Khalid Rahman, Studies on free radicals, anti-oxidants, and co-factors. Clinical Interv Aging (2007) Jun; 2(2)219236, pp.219- 223, <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684512/> 2. Alfredo Gragnani, Sarita Mac cornick, Veronica Chominski, et al, Review of major theories of skin ageing, Advances in Aging research, (2014), 3, 265-284, p.266 3. Ruta Ganceviciene, Aikaterini l.Liakou, Athanasios Theodoridis et al, Skin anti-ageing Strategies, Dermatoendocrinol, (2012) Jul 1; 4(3): 308-319, pp.308-312 <http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3583892/> 4. Taihao Quan, Zhaoping Qin, Wei Xia, Yuan Shao et al, Matrix-degrading Metalloproteinases in Photoaging, J Investig Dermatol Symp Proc, (2009) Aug; 14 (1): 20-24 <http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2909639/> 5. Zoe Diana Draelos, Aging in a Polluted world, Journal of Cosmetic Dermatology, Vol 13 (2) p.85 6. Fiona Embleton, How pollution means city living is making your skin age faster – and the skincare that can help, High 50 Beauty, (2014) <http://www.high50.com/beauty/how-pollution-is-making-your-skin-age-faster> 7. Du, Anderson, A, Lortie, M, Parsons, R and Bodnar, A, Oxidative damage and Cellular Defense Mechanisms in Sea Urchin Models of Ageing, Free Radical Biology Medicine, 63, 254-263, p.256 8. Weber, S. U, Thiele, J. J, Cross, C. E, and Packer, L, Vitamin C, uric acid, and glutathione gradients in murine stratum corneum and their susceptibility to ozone exposure, J. Invest. Dermatol, (1999) 113, 1128–1132 9. Xu, F, Yan, S, Wu, M, Li, F, Xu, X, Song, W, et al, Ambient ozone pollution as a risk factor for skin disorders, Br. J. Dermatol. (2011) 165, 224–225 10. Madronich, S, Wagner, M, and Groth, P, Influence of tropospheric ozone control on exposure to ultraviolet radiation at the surface, Environ. Sci. Technol. (2011). 45, 6919–6923. 10.1021 11. Burke, K. E, and Wei, H, Synergistic damage by UVA radiation and pollutants. Toxicol. Ind. Health. (2009) 25, 219–224 12. Qiang Ju, Kuochia Yang, Christos C.Zouboulis, Johannes Ring, Wenchieh Chen, Chloracne: From clinic to research, Dermatologica Sinica (2012) Vol 30 (1) 2-6 13. Tindall JP, Chloracne and chloracnegens, J Am Acad Dermatol 1985; 13: 539-58, p.542 14. Qiang Ju, Christos C Zouboulis, Longging Xia, Environmental pollution and acne: Chloracne. Dermatoendocrinol, (2009) May-Jun; 1 (3): 125-128 <http://www.dermnetnz.org/acne/chloracne.html> 15. JSC English, RS Dawe, J Ferguson, Environmental effects and skin disease, Oxford Journal Medicine & Health, British Medical Bulletin, Vol 68 (1) 129-142 16. Wattanakrai P, Miyamoto L, Taylor JS, Occupational pigmentary disorders. In: Kanerva L, Elsner P, Wahlberg JE, Maibach HI (eds) Handbook of Occupational Dermatology. Berlin: Springer, 2000; 280–94 17. R. Kohen, Skin antioxididants: Their role in aging and in Oxidative stress – New approaches for their evaluation, Biomedicine & Pharmacotherapy, Vol 53 (4). 181-192 p.181 18. Packer L. Valacchi G, Antioxidants and the Response of Skin to Oxidative Stress: Vitamin E as key indicator, Skin Pharmacol Appl Skin Physiol 2002; 1 5: 2 82-290 19. Charlene DeHaven, Skin Aging, its prevention and treatment, Innovative Skincare, <http://innovativeskincare. com/docs/ClinicalPaper_Skin%20Aging.pdf> 20. Sarita Bajaj, Afreen Khan, Antioxidants and diabetes, Indian J Endocrinol Metab, (2012) Dec; 16 (Suppl 2) S267-271

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a more aesthetically pleasing result, because it helps elevate overlying soft tissue.6 Obtaining a smooth aesthetic outcome is a challenge and is most feared for its complications.1 Knowing the facial anatomy, selecting the proper product and good delivery technique of hyaluronic acid fillers is essential in preventing visual and palpable lumps or nodules.

Triple Boost HydraBright for Periorbital and Facial Rejuvenation Dr Maryam Zamani details the facial ageing process and shares her new technique for rejuvenation

Mesotherapy Mesotherapy is a minimally invasive technique used to rejuvenate the skin using a series of transdermal microinjections of a cocktail of various pharmaceuticals, vitamins and other bioactive substances.10 Originating in Europe with a strong following, mesotherapy is thought to increase the synthesis of fibroblasts and enhance the synthesis of collagen, elastin and hyaluronic acid to firm, brighten, and hydrate the skin.11 The injury created by the microneedling also helps stimulate the bodyâ&#x20AC;&#x2122;s own healing response, aiding the stimulation of collagen and elastin formation. PRP Platelet-rich plasma, known as PRP in medical aesthetics, is a relatively new modality. PRP is a highly concentrated autologous solution of plasma prepared from the patients own centrifuged blood.12 PRP is a minimally invasive treatment used to improve moderate lines, wrinkles and improve skin texture, volume and tone. It has been well documented for its use in wound healing and now for cosmetic uses.12,13 Platelets contain multiple growth factors in the form of alpha granules and dense granules.12 Alpha granules contain multiple growth factors including platelet-derived growth factors, transforming growth factors, epithelial growth factors, and vascular endothelial growth factors.14,15 Together these growth factors help cell proliferation, differentiation, angiogenesis and chemotaxis.12 Mehryan et al illustrated significant improvement in colour homogeneity in the infraorbital dark circles,16 while other similar studies showed improvement in infraorbital wrinkles and skin tone.17 PRP can help improve skin tone, texture and colour.

Ageing is a multifactorial process caused by the accumulation of both intrinsic and extrinsic factors. Gravity, skeletal remodelling, subcutaneous fat distribution changes and loss, and skin changes, all contribute to the ageing face.1 Extrinsic factors include environmental insult such as photodamage caused by UV exposure, and lifestyle factors including; smoking, stress, diet, and drug abuse.2,3,4 Loss of collagen, leading to the atrophy of the dermis, degeneration of elastin fibers and loss of hydration account for intrinsic skin ageing.4 Clinical signs of ageing skin include rhytides, lentigines, telangiectasia, loss of elasticity, uneven skin tone and volume loss.5 The sequence of ageing starts with loss of skin elasticity resulting in rhytides, volume loss, and downward descent of the skin and fat pads.6 The resorption of the infraorbital fat pads distorts the ogee curve, making the under eye appear aged.1,7,8 In the upper face, this progresses to create a longer eyelid to cheek junction, lengthening the lower eyelid and influencing the formation of a tear trough with a V-shaped deformity along the maxilla and zygoma.6 This cumulative process creates a more tired appearance of the face and eyes. The primary goal of periorbital rejuvenation is to restore a balanced distribution of facial fullness while addressing the overlying skin.1 Repair of ageing skin epidermis and dermis can be pharmacologically enhanced by topical application agents such as mesotherapy.9 Hyaluronic acid can also be used to help restore facial harmony by replacing the volume depletion that occurs with ageing.

Side effects and contraindications Short-term effects of mesotherapy, PRP and hyaluronic acid fillers include discomfort, redness, swelling, and ecchymosis. With hyaluronic acid fillers, excess injection of the filler can lead to increased swelling, the tyndall effect or visible irregularities.18 It is important to note that a slight under correction is always recommended to achieve the best aesthetic result. Periorbital rejuvenation with hyaluronic acid has the potential for significant complication of intravascular injection causing visual compromise, blindness or skin necrosis.19 Periorbital rejuvenation requires a deep understanding of facial anatomy. With an injection, there is always the risk of intra-vascular injection, nerve trauma, and skin infections. This treatment is contraindicated in any patient with a dermatological disease affecting the face, platelet dysfunction, pregnancy or lactation or who someone is currently undergoing anticoagulation therapy, chemotherapy or steroid therapy.20

Hyaluronic acid Hyaluronic acid dermal fillers help augment soft tissue imbalances. The importance and value of injections of hyaluronic acid into the periorbital and midface areas is well documented.6 Dermal fillers have evolved to help not only restore volume and enhance facial contouring, but also to hydrate the skin. Hyaluronic acid placed into the periorbital area should be placed on the periosteum to create

Triple Boost HydraBright eye rejuvenation Facial ageing is the interplay of multiple concomitant factors and therefore requires multiple different treatment modalities to help improve this common aesthetic concern. I have created a new Triple Boost HydraBright eye rejuvenation treatment that uses a combination of hyaluronic acid, PRP and mesotherapy to create a brighter, voluminous and rejuvenated lower eyelid.

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Technique Careful patient evaluation and selection is critical to any aesthetic treatments used, but particularly invaluable when treating the periorbital area. Upward gaze helps accentuate periorbital volume loss, allowing improved visualisation of tear trough deformity. A complete medical history is required to make sure that the snapshot of the patient is consistent and unchanging. Patients should not be susceptible to cheek oedema with waxing and waning of the lower eyelid swelling. The patients I have treated have all presented with tired eyes, hollowing of the eyes and sagging of the overlying skin. Pre-treatment photos are taken and informed consent is signed. Hyaluronic acid: The patient’s face is anaesthetised for 15 minutes with 4% lidocaine. I begin this treatment by taking the 20ml of the patient’s own blood and centrifuging it at 2,500rpm for eight minutes. While the blood is prepared, I cleanse the face thoroughly with chlorhexidine and begin by injecting with hyaluronic acid. I prefer using Volift in the Juvéderm range of products as the hyaluronic acid to inject the lower eyelid and cheek in this treatment. Juvéderm Volift uses the Vycross technology allowing more effective crosslinking, so a lower concentration of hyaluronic acid can be used to create a smoother overall appearance with improved duration. The first injection is placed lateral to the infraorbital nerve, entering perpendicular as a bolus of 0.05ml to 0.15ml of Volift placed just superficial to the periosteum. The second injection of hyaluronic acid is placed in the lateral orbital rim just below the lateral canthus, again as a bolus of 0.05ml to 0.1ml just anterior to the periosteum. The third injection is placed medial, again perpendicular to the skin, and a bolus of 0.05ml of hyaluronic acid is injected superficial to the periosteum. The hyaluronic acid is then moulded gently with digital massage to create a smooth lid-cheek junction. Prior to any placement of hyaluronic acid, aspiration is done to help avoid vascular embolisation. All bleeding points are treated with immediate pressure to help prevent ecchymosis. PRP: Once the filler process is complete, the centrifuged blood is prepared. The platelet poor plasma is separated from the platelet rich plasma. The PRP is then activated with calcium citrate. This is then injected as microinjections both deeply and superficially into the skin and some of the remaining PRP is used to gently massage the periorbital area. If there is excess PRP, this may be used on the remainder of the face. Mesotherapy: Following the application of PRP, a series of microinjections (1-2ml) are administered as intradermal nappage into the periorbital area, and papules containing active ingredients including hyaluronic acid, vitamin C, Dimethylaminoethanol (DMAE) and silicone are injected to help boost collagen synthesis, hydrate the skin, restore skin firmness and improve skin tone.21

Aesthetics

Figures 1-4: Illustrate patients pre-treatment and two weeks post Triple Boost HydraBright eye rejuvenation treatment.

Conclusion Patient selection, comprehensive knowledge of the facial anatomy and an aesthetic understanding of a refreshed periorbital area are critical in creating a rejuvenated result. Successful treatment of the periorbital area with this combination treatment provides a repeatable and aesthetically refreshed look for the patients. There are currently no clinical studies showing the synergist combination of these combined treatments, and such an undertaking would be beneficial for medical aesthetics. However, this combination treatment illustrated diminished appearance of tear trough defects while brightening and tightening the periorbital skin in treated patients. I found that this non-surgical correction of the periorbital area is effective to treat volume deletion and to strengthen the periorbital skin with high patient satisfaction. Dr Maryam Zamani is a board certified ophthalmologist with experience in ocuplastic surgery and dermatology. She obtained her medical doctorate from George Washington University School of Medicine, US, and has worked at Cardiff University in facial aesthetics.

Dr Maryam Zamani will discuss the potential pitfalls and complications of treating the periorbital area in the Enhancing the Eye session at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/programme to find out more. REFERENCES 1. Shetty. R., ‘Under eye infraorbital injection technique: the best value in facial rejuvenation’, Jour of Cosmetic Derm, 13, 1 (2014), pp. 79-84. 2. Farage MA, Miller KW, Berardesca E, Maibach HI, ‘Clinical implications of aging skin: cutaneous disorders in the elderly’, Am J Clin Dermatol, 10(2) (2009), pp.73-86. 3. Yaar M, Gilchrest BA., ‘Photoageing: Mechanism, prevention and therapy’, Br J Dermatology, 157 (5) (2007), pp.874-87. 4. Uitto J.,The Role of elastin and collagen in cutaneous aging: instrinsic aging versus photoexposure’, J Drugs Dermatol, 7 (2008), s 12-6. 5. Glogau RG., ‘Aesthetic and anatomic analysis of aging skin’, Semin Cutan Med Surg, 15 (3) (1996), pp.134-8. 6. Funt DK., ‘Avoiding malar edema during midface/cheek augmentation with dermal fillers’, J Clin Dermatology, 4(12) (2011), pp.32-36. 7. Coleman SR, Grover R., ‘The anatomy of the aging face: volume loss and changes in 3-dimensional topography’, Aesthetic Surg J, 26 (2006), S4-9. 8. Besins, T., ‘The “R.A.R.E” technique (reverse and repositioning effect): the renaissance of the aging face and neck’, Aesthteic Plast Surg, 28 (2004), pp.127-42. 9. Klingman LH., ‘Photoageing. Manifestations, prevention and treatment’, Clin Geriatr Med, 5(1) (1989), pp.235-51. 10. Moetaz El-Domyati, MD, Tarek S. El-Ammawi, , MD, Osama Moawad et al, MD, Hasan El-Fakahany, MD, Walid Medhat, MD, Mỹ G. Mahoney, PhD, and Jouni Uitto, MD, PhD., ‘Efficacy of mesotherapy in facial rejuvenation: a histological and immunohistochemical evaluation’, Int J Dermatol, 51(8) (2012), pp.913-919. 11. Iorizzo M, De Padova MP, Tosti A., ‘Biorejuvenation: theory and practice’, Clinic Dermatol, 26(2) (2008), pp.177-81. 12. Leo, MS. Kumar AS, Kirit R. Konathan R. Sivamani RK., ‘Systematic review of the use of platlet-rich plasma in aesthetic dermatology’, Journ of Cosm Derm, 14, pp.315-323. 13. Shin MK, Lee JH, Lee SJ et al., ‘Platelet-rich plasma combined with fractional laser therapy for skin rejuvenation’, Dermatol Surg, 38 (2012), pp.623-30. 14. Lubkowska A, Dolegowska B., Banfi F., ‘Growth factor content in PRP and their applicability in medicine’, J Biol Regul Homeost Agents, 26 (2012), 3s-22S. 15. Marx RE., ‘Platelet-rich plasma: evidence to support its use’, J Oral Maxillofac Surg, 62 (2004), pp.489-96. 16. Mehryan P, Zarab H, Rajabi A et al., ‘Assessment of efficacy of platlet-rich plasa (PRP) on infraorbital dark circles and crows’ feet wrinkles’, J Cosmet Dermatol, 13 (2014), pp.72-8. 17. Kang BK, Shin MK, Lee JH et al., ‘Effects of platlet-rich plasma on wrinkles and skin tone in Asian lower eyelid skin: preliminary results from a prospective, randomized, split-face trial’, Eur J Dermatol, 24 (2014), pp.100-1. 18. Juhasz ML, Marmur ES., ‘Temporal fossa defects: techniques for injecting hyaluronic acid filler and complications after hyaluronic acid filler injection’, J Cosmet Dermatol, 14(3) (2005), pp.254-9. 19. Eckart H., ‘Managing Complications of Filler: Rare and not-so-rare’, J Cutan Aesthet Surg, 8 (2015), pp.198-210. 20. Everts, PAM, Knape JTA, Weibrich G, Schonberger, JPAM, Hoffman J, Overdevest EP, Box HAM, Zundert AV., ‘Platlet-Rich Plasma and Platelet Gel: A Review’, J Extra Corpor Technol, 38 (2006), pp.174-87. 21. Priknhnenko, S., ‘Polycomponent mesotherapy formulations for the treatment of skin aging and improvement of skin quality’, Clin Cosmet Investig Dermatol, 8 (2015), pp.151-157.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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PDO Threadlifting Dr Irfan Mian examines the rise of PDO threadlifts and discusses the best techniques to achieve successful results In recent years there has been a substantial growth in the availability and provision of non-surgical medical aesthetic treatments. In 2014 for example, Americans spent more than $12 billion on surgical and non-surgical procedures for the second year in a row.1 In aesthetics, botulinum toxin and dermal filler treatments remain the mainstay of this growth.2 There is now a huge variety of dermal fillers available for the practitioner to choose from that are at a low cost, easy to administer and are widely available.3 New types of treatments such as threadlifts have also become very popular, and have shown to be effective, safe and can be performed with minimal downtime.4 Popularity of threadlifts Threadlifts have been used to achieve a ‘mini-face’ or ‘body’ lift for many years.5 Materials that have been commonly used for threads include gold, poly-llactic acid, caprolactone, poly-propylene and polydioxanone (PDO) to name a few. Throughout their use, threads have achieved a high degree of patient satisfaction.6 PDO has been used in surgical procedures as an absorbable suture for many years, for example, they have been part of cataract surgical procedures since the 1980s.7 In the past few years, PDO has been used to make the threads for face and body to achieve lifting in these areas. PDO is used extensively in South Korea, where many of the threads are manufactured.

Patient selection and communication The technique for thread insertion is relatively straightforward, provided suitably trained and experienced practitioners carry it out. It is important, prior to any treatment, that certain criteria are assessed to determine the patient’s suitability for PDO threads. Firstly, the patient’s medical history has to be checked. Auto-immune diseases, hepatitis B and C, HIV infection, pregnancy and breastfeeding, anti-caogulation therapy, existing infection and history of keloid formation are all contraindications for treatment.8 Care should be taken with patients who appear to be suffering from body dysmorphia. These patients sometimes demand results, which a non-surgical procedure like PDO threads cannot achieve. In my practice, I politely refuse to treat them as I know that it may be impossible to satisfy their requests. PDO threadlifting can give good results in the late 30s to 60s age group where a ‘finger’ test is positive, however it is not suitable for everyone. The test is positive if a finger can be used to get a satisfactory face or neck lift with a little finger skin elevation. The

elevation, in my method, should need the finger to move 1-3cm only. In very lax skin or in very obese patients, a much greater finger elevation is needed – the finger may need to be elevated three or more centimetres. If the finger test is considered negative, then the patient would not be a suitable candidate for a PDO threadlift. It is also of critical importance that the limitations of what can be achieved are fully explained to the patient prior to the procedure. Pre-operative and post-operative photographs are essential not only to show what has been achieved, but also to point out any asymmetry that may be present. I had a recent case where one of my patients complained that I was the cause of a wrinkle line on her cheek, which extended from her cheek to the lower border of the mandible. She thought that a PDO maxillary threadlift had caused this line on her face. I was able to show her the pre-operative photographs and the complaint was amicably resolved with her offering me many apologies, as she had not registered the facial line previously. In fact, she subsequently went on to recommend me to two of her friends for whom I also did PDO threadlifts. The aesthetic concerns of the patient should be carefully noted and recorded and this must be followed by a thorough clinical examination. The examination should include noting the texture of the skin, and the degree of skin laxity as previously mentioned. Signs of skin infection including herpes type 1 should be looked for, as well as inflammation of the skin and mucous membranes of the mouth and eyes, as well as the presence of ulcers.9 The various facial vectors should be determined and the number and type of the threads used should be ascertained. The amount, type and points of local anaesthesia would also be determined and recorded at this stage. Techniques It is well established that PDO threads, correctly inserted in the tissues, result in a mechanical lift, which is maintained by the formation of collagen.10 In many cases, the

The aesthetic concerns of the patient should be carefully noted and recorded and this must be followed by a thorough clinical examination

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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Figure 1: Advantages of the MASH technique

1) Easy to learn and to achieve the correct tissue plane for thread insertion

2) Safe method if a blunt cannula is used 3) Eliminates the need for regional, local or block anaesthesia except at the ‘entry point’

4) Less facial tissue distortion and bruising resulting in reduced ‘downtime’

5) As facial muscles are not anaesthetised the patient can see results post treatment immediately without having to wait for the anaesthetic to dissipate 6) Can be used to place adjunctive products use of monofilament, spiral or cog threads are all that is needed to achieve a satisfactory result. In the case of a mid-face and mandibular jowl lift, various techniques have been used. The 5-point thread facelift, which I believe gives excellent results, has been developed and described by Dr Jacques Otto.4,14 The 5-point, 8-point or even the 10-point thread facelift have also been used for a mid-face and mandibular jowl lift, but do not suit every case. The number of points that are used should not be necessarily fixed at 5-point, 8-point or 10-point, however. Instead, aesthetic practitioners should do a case-by-case assessment to determine the number of points of elevation. In cases of facial asymmetry these points may differ in position and number on each side of the face and neck. Combination treatments In other cases a more holistic approach is needed and PDO threads can be used with botulinum toxins, dermal fillers, lasers and radiofrequency. The development of new hybrid hyaluronic acid (HA) tissue modulators using patented heat technology, are well suited as adjunctive treatments to PDO threads because the unique high and low hyaluronic particles have been shown to be neocollagenic.16 This property would appear to be synergistic with PDO thread

Figure 2: Patient A before and after PDO threadlifting

neocollagenesis. Hybrid HA modulators also have an effect of smoothing the superficial skin due to the presence of low molecular HA chains. 16 This is a desired effect when using PDO threads, as skin folds can occur. This type of HA filler can be placed in the correct tissue plane by using the Bio Aesthetic Point (BAP) technique. In clinical practice, the HA fillers and botulinum toxins are placed after the PDO threads are in situ. The use of dermal fillers and PDO threads together is not new, but I believe that the use of hybrid HA complexes is a new development and give better overall results. In my patients, post-operative skin folds have been reduced and the skin has appeared fresher and better hydrated even after one day. Care must be taken with thermogenic combination treatments such as laser, as PDO threads may denature with heat. These types of treatments should therefore be done before PDO threads are inserted. Depth for insertion The correct tissue plane for the insertion of PDO threads is the subcutaneous tissue for barbed threads (superficial musculoaponeurotic system or SMAS layer).12,13,14 If the threads are placed too superficially in the dermal plane then they could be felt and may even be visible in the skin. In this plane, they will not achieve

the correct degree of lifting of the tissues or stimulate collagen production. If the PDO threads are placed too deeply, there is a greater risk of damage to the facial artery and vein, the facial nerve and other anatomical structures. Aesthetic practitioners should familiarise themselves with a detailed knowledge of the anatomy of the face and neck. In particular they should take note of Manson’s point, which identifies the facial artery with 100% accuracy within 3mm, in both cadaveric and living human subjects.18 How to find the correct depth Finding the correct plane can be a challenge, so I have developed my own technique to ensure PDO threads are correctly placed (Figure 1). The MASH technique (Mian’s Alternative Snooker Hold) is an easy method to reach the subcutaneous plane when placing threads and allows for immediate and on-demand local anaesthesia. After appropriate sterilisation and skin cleaning, the PDO thread is inserted into a 2ml syringe, which has been prefilled with local anaesthetic without vaso-constrictor. A ‘no touch’ technique is employed. An entry point is made and the syringe and PDO thread cannula combination is slowly inserted into the opening, ensuring that the syringe is touching the skin. This will achieve the correct 10-15 degree angulation, which will ensure the blunt thread cannula is in the correct plane (SMAS). Care should be taken to ensure the cannula does not touch the skin. This will not only result in a superficial thread placement, but may also give rise to tissue inflammation as a result of contamination of the cannula by the skin. The cannula is slowly advanced to its endpoint. During advancement, the index finger of the free hand should be able to ‘feel’ the end of the cannula. The combination of syringe attached to the thread cannula should be treated like a snooker cue. At any time during the insertion, the attached syringe can deliver a little local anaesthetic where it is needed. Only 0.01ml to 0.02ml is usually required and this technique reduces the need for large amounts of skin and nerve block anaesthesia of the face. The local anaesthetic syringe can be exchanged for a HA filler syringe and the HA filler placed using the retrograde, bolus or fanning technique, with the same cannula that was used to insert the PDO thread. Other materials such as skin boosters can be delivered in a similar way. At any point during the procedure,

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Aesthetics Dr Irfan Mian is a medical and dental practitioner and is medical director of the Chinbrook Medical Cosmetic Centre in London, as well as a trainer for Vida Aesthetics Ltd. He has 30 years’ experience and was a clinical lecturer at King’s and Guy’s Hospitals NHS Trust. Dr Mian has been interested in medical aesthetics since 2003 and invented and pioneered the MASH technique, which is a registered, copyright protected technique. Dr Irfan Mian will present the IBSA/HADerma Masterclass, ‘Overcoming Dermafiller Challenges. Delivering Excellent Results Safely’ at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/ programme to find out more.

Figure 3: Patient B before and after PDO threadlifting

the patient can signal if they are in pain or discomfort. The cannula advance must be immediately stopped and a small amount of local anaesthesia should be injected while everything is held stable. After a few moments the snooker hold on the syringecannula combination can be resumed and the cannula slowly advanced to the endpoint. As the syringe-cannula combination is turned two or three times to achieve ‘tissue grab’, the free hand is used to ‘massage’ the cannula of the tissues leaving the PDO thread in place. The technique is repeated as required for the placement other threads. When performed correctly, the MASH technique has several advantages and benefits (Figures 2 & 3). Following thread placement, the cog threads are held by artery forceps and twisted 10 to 15 times prior to cutting them close to the skin, thereby allowing them to retract into the tissues. The entry point should be sealed with a dressing. Side effects Side effects of treatment can include swelling, bruising, infection (usually due to poor technique), and thread migration. Postoperative skin folds may also occur.7 Most of these side effects are transient and resolve over several days. In my experience, infection in patients who have treatment abroad and then return home is fast becoming an issue. Mycobacterial infection following facial thread lift placement has also been reported. This can be difficult to treat as antibiotic resistance can occur.17 Threads can also move away from the site of insertion but this is more common with uni-directional or bi-directional threads. In my experience, the newer 3D multidirection cog threads do not migrate. Small mono and spiral threads may protrude

from the skin and have to be cut back. This is usually due to poor technique, but can also occur spontaneously some days after insertion. More serious complications include facial nerve damage, which may result in facial paralysis and blood vessel damage, especially when needle threads are used.11 Length of results In regard to the length of the results, long-term studies are not available for the simple reason that PDO threads have not been used in medical aesthetics for a long time. However, short-term clinical studies have shown that the results of the PDO threadlifts were maintained, on the whole, for six months with a little loss of facial elasticity.5 In my experience of carrying out approximately 120 threadlifts, the average patient satisfaction time is approximately 12 months. I have found that my average patient satisfaction time was very short when I first started in 2013, where it was six months or less in some cases. However, now with more experience, better threads and improved thread-lift planning and techniques, results usually last 12, or sometimes up to 18 months. Conclusion PDO threads are a safe and effective way to achieve tissue lifting in the face and body. They should be placed in the correct tissue plane and the MASH technique can achieve this. A holistic approach to patient management is also proposed, to ensure the patient receives optimal results. A tissue HA modulator can also give a better overall result when combined with PDO threads. This technique can also be employed for other treatments, such as the placement of fillers, platelet rich plasma or other products.

REFERENCES 1. The American Society for Aesthetic Plastic Surgery Reports Americans Spent More Than 12 Billion in 2014; Procedures for Men Up 43% Over Five Year Period, American Society for Aesthetic Plastic Surgery, (2015), <http://www.surgery.org/ media/news-releases/the-american-society-for-aestheticplastic-surgery-reports-americans-spent-more-than-12-billionin-2014--pro> 2. ISAPS ‘Global Statistics on Cosmetic Procedures,’International Society of Aesthetic Plastic Surgery, (2015), <http://www.isaps. org/Media/Default/global-statistics/July%202015%20ISAPS%20 Global%20Statistics%20Release%20-%20Final.pdf> 3. Bray, Dominic; Hopkins, Claire; Roberts, David N A review of dermal fillers in plastic surgery Current opinion in Otolaryngology & Head & Neck Surgery August 2010-Vol 18-issue 4-p295-302. 4. Suh, D.H, Jang, H.W, Lee, S.J. & Lee, W.S, ‘Outcomes of polydioxanone knotless thread lifting for facial rejuvenation,’ Dermatological Surgery 6(2015). 5. Llorca, V, MD & Soyano, S, ‘Lifting effect with polydioxannone absorbable threads without anchors on face and neck,’ Unidad Antiaging Hospital de Levante Benidorm (2006). 6. Shimizu, Y & Terase, K ‘Thread Lift with absorbale monofilament threads,’ Journal of Japan: Society of Aesthetic and Plastic Surgery, 1(2013). 7. PDS (Polydioxanone suture) A new Synthetic Absorbable Suture in Cataract Surgery. A Preliminary study. Bartholomew R.S. Dept of Opthalmology,University of Edinburgh,Scotland,UK Opthalmalogica 1981;183:8181-85 DOI :10.1159/000309144 8. Shimizu, Y & Terase, K, ‘Thread lift with absorbable monofilament thread,’ Journal of Japan Society of Aesthetic Plastic Surgery, 35(2013), <http://www.mesothread.com/filebox/[JSAPS]Dr.%20 Yuki%20Shimizu_LFL.pdf > 9. Valeska SS, Pereira, Raiza NC, et al, ‘Herpes simplex virus type 1 is the main cause of genital herpes in women of Natal, Brazil,’ European Journal of Obstetrics & Gynecology and Reproductive Biology (2012) < http://www.sciencedirect.com/science/article/pii/ S0301211511006609> 10. Langevin H et al, ‘Subcutaneous Tissiue Fibroblast Cytoskeletal Remodeling Induced by Acupuncture: Evidence for a Mechanotransduction-Based Mechanism,’ Journal of Cell Physiology (2006) pp.767-764. 11. Pawar, SS, Meyers, AD, et al, ‘Complications of facelift surgery,’ (2014) <http://emedicine.medscape.com/article/843613-overview> 12. Mitz V, Peyronie M, ‘The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area,’ Plastic Reconstructive Surgery, (1996) <http://www.ncbi.nlm.nih.gov/pubmed/935283> 13. Jacono, A, Narayan, S, ‘Extended SMAS Facelift’ (2014) <Andreq Jacono, Deepak Marayan Extended SMAS Facelif > 14. Padin, VL, ‘Experience in the Use of Barbed Threads and NonBarbed Serdev Sutures in Face and Body Lift – Comparison and Combination,’ Miniinvasive Face and Body Lifts - Closed Suture Lifts or Barbed Thread Lifts (2013), <http://www.intechopen.com/ books/miniinvasive-face-and-body-lifts-closed-suture-lifts-orbarbed-thread-lifts/experience-in-the-use-of-barbed-threadsand-non-barbed-serdev-sutures-in-face-and-body-lift-comparis> 15. Otto, J, ‘PDO Threads for skin rejuvenation and facial tissue antiptosis,’ Body Language (2015). 16. D’Agostino et al, ‘Invitro analysis of the effects of wound healing of high and low molecular weight chains of hyaluron and their hybrid complexes,’ BMC Cell Biology (2015). 17. Yau, B, Lang, C, Sawhney, R, ‘Mycobacterium Abscess PostThread Facial Rejuvenation Procedure,’ ePlasty 15(2015). 18. Calva D, Chopra KK, Sosin M, De La Cruz C, Bojovic B, Rodriguez ED, Manson PN, Christy MR, ‘Manson’s Point’ A facial landmark to identify the facial artery. Journ Plast Reconstr Aesthet Surg 68(9) (2015), pp.1221.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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Microneedling Combined with Stem Cells Natali Kelly discusses how to rejuvenate the skin and treat acne scarring using a microneedling device in combination with stem cells The skin is the body’s largest and fastest growing organ and the advancements in the aesthetic industry have given rise to consumer demand for skin rejuvenation treatments. Treatment for acne remains a common request, as the prevalent skin condition is said to affect between 70-96% of individuals.1 Although acne scars can be largely preventable, once the scarring occurs, a patient’s quality of life can be greatly impacted. In my clinic we are seeing an increase in patients seeking treatment to improve scarring and their wellbeing. In this article, I shall be discussing how using a microneedling device along with a plant stem cell serum can help to rejuvenate skin and improve the appearance of acne scars. Microneedling and stem cells The advantages of microneedling were first observed by Dr Andre Camirand in the 1990s, who experimented by treating post-surgical scars with a tattoo gun; this was further developed by Dr Des Fernandes who introduced skin needling using a roller in 1996.3 Microneedling can be used to treat a number of skin complaints, including pigmentation, wrinkles, acne, scarring and stretch marks, and is also known as ‘collagen induction therapy’ for skin rejuvenation.4 It is a minimally invasive treatment that causes controlled micro-injuries to the skin to stimulate new collagen and elastin in the reticular dermis. This natural wound-healing process involves activation of neutrophils and the release of cytokines and growth factors that stimulate fibroblast proliferation, re-epithelialisation and collagen remodelling.5 In my opinion the popularity of automated needling devices reduces the risks of trauma and scarring often caused by handheld devices and human error. Vertical needle insertions can reduce pain and create hundreds of micro

channels, enhancing the delivery of topical serums. Microneedles have been used in transdermal and dermal drug delivery for more than a decade.6 Stem cells contain growth factors that may help to heal wounds, repair damaged tissues, regenerate aged skin, and reinvigorate growth of skin, hair, nails, and mucous membranes.7 There are various types of stem cells, including human stem cell-conditioned medium, and plant stem cells. However it is worth noting that only patented plant cell activators are scientifically proven to stimulate dermal cells.13 This combined treatment is an emerging antiageing treatment and recent studies suggest that, statistically, there is significant improvement in hydration, melanin, skin texture, dermal thickness and collagen, compared to microneedling alone.8,9 Microneedling using plant stem cells can be used to treat the face, neck, décolletage and, in particular, the areas of the face that are difficult to treat; such as the periorbital and perioral regions. I often see patients who have had treatment elsewhere and have been over-treated with dermal fillers. With this treatment, however, there are reduced risks and, in my opinion, natural and elegant results can be achieved. Treatment In terms of patient selection, the treatment is suitable for most skin colours and types and doesn’t carry the risks of burns and downtime associated with chemical peels and lasers.3 It is unsuitable for active acne, as bacteria can be spread, hence exacerbating the condition. From the ‘organic patients’ who are not ready for injectables but want more results than

Recent studies suggest that, statistically, there is significant improvement in hydration, melanin, skin texture, dermal thickness and collagen, compared to microneedling alone

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hours until any redness subsides. Depending on the patient’s budget, aftercare can consist of topical stem cells or vitamin C and E and a good SPF; which has beneficial hydrating, antioxidant properties and can reduce the risks of post-inflammatory hyperpigmentation.10 Respectively, vitamin A and hydroquinone may be prescribed pre and post treatment, depending on the severity of pigmentation and scarring.12 I recommend three treatments at an Figure 1: 58-year-old woman having her first microneedling and stem cell treatment for sun damage, signs interval of four to six weeks apart for of ageing and skin rejuvenation. Images show the microneedling treatment and cold hyaluronic facemask. skin rejuvenation. For acne scarring, facials and skincare, to your regular injectable patients who realise depending on severity, I would recommend a minimum of five the limitations of botulinum toxin and dermal fillers – this treatment treatments, with maintenance treatments every three to six months, is suitable for a wide range of patients. A topical local anaesthetic depending on the patient’s needs. should be applied to the skin for comfort and left on for up to 30 minutes depending on needle depth. Needle depth is decided Conclusion depending on the severity of the scarring and skin rejuvenation Microneedling alone is a successful treatment for skin rejuvenation, required. Skin should also be thoroughly disinfected with isopropyl however, used in combination with stem cells, it can accelerate the alcohol prior to needling. I prefer to use an electronic microneedling natural wound-healing response, providing more stimulation of growth pen; this allows me to personalise my treatment specifically when factors with a faster healing response and reduced downtime. This, in treating different parts of the face, as well as different skin types turn, maximises patient outcomes and overall satisfaction. In terms of and concerns. A thin layer of stem cell serum is applied to the business, it proves to be a cost-effective treatment and it can also be patient’s skin by hand and delivered into the dermis with circular a means of excellent patient retention, in the education of maintaining movements. I usually start at the forehead, moving downwards. healthy skin and promoting combination treatments. Patient education Once erythema and pinpoint bleeding are achieved, I apply more is key, and you should see your pro-active patients returning to clinic in stem cells to the treated area and repeat the process on each between their usual injectable visits. As with most treatments that filter side of the face. I adjust the needle length when treating areas of from medicine to aesthetics, growth factors in wound healing is well concern. The treatment takes one hour. I then go on to treat the established. I do believe, however, that we need more controlled trials neck and décolletage if the patient has requested treatment in in skin rejuvenation to ultimately prove efficacy.11 these areas. Post treatment, a cold hyaluronic acid facemask will be Natali Kelly is an aesthetic nurse practitioner based applied to hydrate and soothe the inflammation. Additionally, I have in Knightsbridge, London. She has eight years of heard anecdotally that patients can have LED light therapy to further experience combining her surgical background, with non-surgical facial aesthetics and cosmetic activate the stem cells and reduce erythema; this was mentioned in dermatology. She is passionate about skin rejuvenation a talk by Dr Kwon Han Jin at a recent conference. and gained her prescribing qualification at King’s College, London.

Patients can expect to see a clinical improvement in collagen synthesis, photoaged skin, texture, tone and firmness The treatment is usually well tolerated and offers a fast recovery. However, mild to moderate erythema is expected and mild swelling around the periorbital region can present itself; this may last a few days. The skin can feel tight and dry for a few days after the treatment, due to re-epithelialisation as the skin orchestrates itself to re-establish barrier function and integrity.5 Patients can expect to see a clinical improvement in collagen synthesis, photoaged skin, texture, tone and firmness. Bear in mind that results are variable in patients with scarring and a good consultation is key in managing a patient’s expectations. For aftercare, patients should reduce their use of active skincare, such as retinol and exfoliants for 24-48

REFERENCES 1. Leyden JJ, (1997), Therapy for acne vulgaris, New England Journal of Medicine 336, 1156-1162 2. Pistor, M, (1979) Un defi therapeutiche: la mesotherapie. 3rd ed. Paris pp. 1-50 3. Lewis W, (2014), Is microneedling really the next big thing? Plastic Surgery Practice, <http://www. plasticsurgerypractice.com/2014/06/microneedling-really-next-big-thing/#sthash.rfmApvgR.dpuf> 4. Majid I, (2009) Microneedling therapy in atrophic facial scars: An objective assessment, J Cutan Aesthet Surg, 2 26–30 5. Hantash BM, Zhao LM, Knowles JA, Lorenz HP, (2008) Adult and fetal wound healing, Front Biosci, 13 51–61 6. McAllister DV, Wang PM, Davis SP, et al, (2003) Microfabricated needles for transdermal delivery of macromolecules and nanoparticles: Fabrication methods and transport studies, Proceedings of the National Academy of Sciences of the United States of America, 100(24):13755-13760 7. Dahl, MV, (2012)‘Stem cells and the skin’, Journal of Cosmetic Dermatology. 11 4:297-306. 8. Seo, KY. Kim, DH. Lee SE. Yoon MS. Lee HJ, (2013) Skin rejuvenation by microneedle fractional radiofrequency and a human stem cell conditioned medium in Asian skin: a randomized controlled investigator blinded split-face study, Journal of Cosmetic and Laser Therapy. 15 (1):25-33 9. Seo KY1, Yoon MS, Kim DH, Lee HJ, (2012) Skin rejuvenation by microneedle fractional radiofrequency treatment in Asian skin; clinical and histological analysis, Lasers Surg Med. 44. (8):631-6 10. Chawla S. Split face comparative study of microneedling with PRP versus microneedling with vitamin C in treating atrophic post acne scars. J Cutan Aesthet Surg ;7:209-12. <http://www. jcasonline.com/text.asp?2014/7/4/209/150742> 11. Lee HJ, Lee EG, Kang S, Sung J-H, Chung H-M, Kim DH, (2014) Efficacy of Microneedling Plus Human Stem Cell Conditioned Medium for Skin Rejuvenation: A Randomized, Controlled, Blinded Split-Face Study, Annals of Dermatology. 26 (5):584-591 12. Davis, Erica C, and Valerie D, Callender, Postinflammatory Hyperpigmentation: A Review of the Epidemiology, Clinical Features, and Treatment Options in Skin of Color, The Journal of clinical and aesthetic dermatology 3.7 (2010): pp.20–31 13. Dr Philip Levy, (2016) Powerful ingredients, <http://drlevyswitzerland.com/index.php?option=com_ content&view=article&id=7&Itemid=105&lang=en>

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neck, and approximately one in 20 patients will report no benefit. This article will not cover the science behind how BoTN-A works; however references for further reading are included at the end of the article and readers are welcome to get in touch for more information.

Treating Migraines Dr Chris Blatchley details the current treatment protocols for migraines and shares his approach to successful treatment with botulinum toxin Migraines are very common, with more than 10% of women and 5% of men suffering from them worldwide.¹ It is now established that botulinum toxin (BoTN-A) can be a very effective treatment, and it is well worth learning the injection protocol, which is not greatly different to standard aesthetic injection techniques. In my experience, many aesthetic practitioners report having patients who find their intermittent, or episodic, migraines (as well as their headaches between attacks) disappear following BoTN-A treatments. Indeed, they are reminded that it’s time for another treatment when their headaches begin to return. Some sufferers have far more disabling migraines that aren’t adequately controlled by aesthetic doses. If the migraines become more frequent, they Figure 1

Figure 2

Glabella injections

10U

Forehead injections

4U

2U

are described as chronic rather than episodic. The two groups are a continuum of the same ‘migraine mechanism’3 and there is no exact division between the two.1,3 As an aesthetic practitioner, it is not difficult to improve your injection protocols to help with these more severe migraines. If you do, you will have thankful, loyal patients who will likely refer your services and stay with you for life. In this article I will give an overview of migraines and their standard drug treatment. These will normally be managed by the patient’s GP, but it is useful to know to further your knowledge on migraine management. I will then explain simply how you can improve your BoTN-A injection protocol. I find that at least 90% of patients will be very pleased with the results, though a few will require more extensive injections into the Figure 3 Combined injections

1U

Figure 1: For glabellar injections, point needle medially at 30 degrees to skin into body of corrugator. Figure 2: For the forehead the lateral 1U injections are optional for cosmetic appearance. The top row of 2U points are optional, depending on the height of the brow and frontalis activity.

Migraines vs. headaches The distinction between headaches and migraines is also not clear-cut, as they are both caused by the same migraine mechanism.3 However migraineurs will often describe their headaches as different to their migraines. Marked autonomic symptoms of photophobia, a need for quiet, and nausea and vomiting may be more disabling than the headache, and can often make them lose a couple of days a month. BoTN-A tends to reduce the frequency and intensity of the migraines, in particular the feeling that there is another migraine on its way. The headaches themselves will usually become less severe, which is of course pleasing to the patient. Generally, migraine treatment is seen as the specialist preserve of neurologists. Although there appears to be a certain complex mystique to the classification system of headaches, the basics relating to migraines, as described in the British Association for the Study of Headache (BASH) guidelines, are not difficult to understand. You should be able to help the patient understand their condition more, and not just administer the botulinum toxin. Confirming the migraine diagnosis Migraineurs will usually have a long history of headaches, and will have seen their GPs, and perhaps neurologists, so that the diagnosis is not in doubt. The hallmark of a migraine is a gradual onset of headache with associated autonomic symptoms of nausea and vomiting, avoidance of bright lights and strong sounds. Some will experience an aura of distorted vision or paraesthesia just before the migraine properly starts.1 Some patients will have been investigated with MRI scans, though this is not needed as the diagnosis is generally made from the patient’s history. If a patient reports a recent onset of headaches then this needs to be investigated to exclude other causes. However these patients are unlikely to present to you, and if in doubt then refer the patient to their GP. Traditional teatment options The clinical aim is to control the symptoms of migraines and, secondly, reduce the frequency of future migraine attacks with as

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little treatment as necessary. Unfortunately you cannot ‘cure’ the predisposition to migraines. BoTN-A is interesting because it is helping the understanding of how and why migraines start, and can be enormously effective. However it is not easily available on the NHS, and expense may be one reason why the NICE guidelines restrict its use.2 Other treatment strategies, described in the BASH guidelines and listed below, should not be forgotten.1 Lifestyle: patients can reduce their frequency and severity of attacks by adopting a healthy lifestyle – any consultation should include this advice. Eating breakfast immediately upon getting up, e.g. cereal/muesli, regular sleep, and avoiding alcohol are often very effective.1 Non-drug treatments: osteopathy is often tried, sometimes with good success. Following numerous conversations with neurologists, my opinion is that it works in a similar way to steroid injections in the neck (greater occipital nerve block) by reducing the inflammation around the bony attachment of the muscles in the base of the skull. Please read the BoTN-A section for more information. Pain relief during the attack: NSAIDS such as ibuprofen are the mainstay of analgesia.1 Some patients report that they can abort attacks if taken early enough. Ensure that no over-the-counter medications containing codeine are being taken, or, at the most, only very occasionally. It is well recognised that if taken for more than 8-10 days a month, they can induce a medication-overuse headache, which presents as a chronic headache very similar to chronic migraine. It is very difficult to tell the difference and may be a reason why BoTN-A fails, but the opiates MUST be withdrawn.1 There is no clinical evidence that ‘cold turkey’ withdrawal is more effective than gradual withdrawal, which can take over a month. BoTN-A may help with this. Nausea and vomiting: the autonomic effects of migraines produce gut statis, and domperidone is the antiemetic of choice for nausea and vomiting because it increases peristalsis to help ensure that it does not lie in the stomach unabsorbed. As such, it is very important for the patient to take the domperidone as early as possible before the gut statis take hold.1 Stopping the attack: triptans are the modern mainstay to stop a migraine. They cause constriction of the blood vessels and help reduce the pain produced by the dilation phase of the meningeal vessels and

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engorgement of the meninges. They should not be taken during the aura phase of the migraine, as this phase is caused by spasm of the vessels and so the effect of the triptan is wasted. It is a common mistake to take it too early and the triptan should be taken as the aura phase is resolving, just before or as the headache starts.3 Triptans should not be taken for more than 10-12 days a month, as they can also cause medication-overuse headache.1 Fortunately the withdrawal process from triptans is shorter than opiates. Preventatives: Beta blockers, amitriptyline, anti-epileptics and other neuro-active drugs are used to suppress the underlying migraine process. However they are often associated with a lot of side effects, particularly tiredness, so they can be of limited use.1 BoTN-A for migraines Although it is not completely clear how BoTN-A works to help migraines, it can be very effective in preventing attacks if administered correctly. The latest theories are that it works by blocking free nerve endings in the fascia/muscle attachments, thus reducing the excitation of the trigeminocervical tract in the brain stem.4 This is where the afferent fibres of the ophthalmic branch of the trigeminal nerve, from around the eye, and the greater occipital nerve, from the neck, overlap. This area acts as a relay station, sending signals to higher centres in the mid-brain where the migraine starts. Other precipitating factors include changes in estrogen level during the monthly cycle, bright or flashing lights, loud sounds, strong smells and starvation, each of which work separately and directly on the higher centres.5 It is unlikely that BoTN-A works purely by muscle relaxation, though this may help by reducing the free pain nerve ending stimulation in the associated fascial attachments. The value of BoTN-A is that it is not associated with the side effects of the usual preventative drugs, mentioned previously. Amending your injection protocol for migraine treatments Neurologists, especially in the UK, generally use the PREEMPT Protocol created by Allergan to treat migraines with botulinum toxin. In my opinion this protocol, which is now five years old, can be improved upon because it does not inject the corrugators effectively. This helps explain the general neurological view that BoTN-A is only

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effective against chronic and not episodic migraines. My experience is that if the corrugators are injected with 60U Botox/ Xeomin (3x the normal aesthetic dose) and 15-25U to the forehead, then, in the vast majority of cases, injections in the neck are unnecessary. This significantly keeps the costs down, because the PREMPT Protocol uses far more BoTN-A by including injections in the neck and temples. There is no reason why one cannot start by just injecting the glabella/forehead and add injections to the neck/temples later if necessary. Injection technique Of the three main forms of toxin, I use Xeomin/Bocouture 100U diluted with 2.5ml bacteriostatic saline, giving 20U per 0.5ml insulin syringe. You will need just under 100U to inject the glabella/forehead. The dosages will be the same for Botox/Vistabel. I have not used Dysport/Azzalure, but you would need to adjust the dose in the normal way. 1U Botox/Xeomin = 2.5U Dysport. When injecting, hold the syringe at approximately 20 degrees to the skin, pointing medially towards the procerus, so that the tip of the needle is in the belly of the corrugator. Do not introduce the needle down vertically, since hitting the bone will blunt the needle and increases the chance of lid ptosis by puncturing extensions to the orbital septum. Dr Chris Blatchley has been working in aesthetics since 2007 and studying migraine treatments since 2009. He has presented on using botulinum toxin to treat migraines to specialist neurologists at the Oxford Headache Symposium. Dr Blatchley runs Capital Aesthetics in London, where he offers a range of non-surgical treatments.

Dr Chris Blatchley will present ‘Treating Migraines with Botox Can Grow Your Patient Database’ at the Aesthetics Conference and Exhibition Business Track. Visit www.aestheticsconference.com/ programme to find out more. REFERENCES 1. British Association for the Study of Headache, Guidelines (UK, BASH, 2010) < http://www.bash.org.uk/guidelines/ > 2. National Insititute for Health and Care Excellent, Migraine (UK, NICE, 2015) <http://cks.nice.org.uk/migraine#!scenario> 3. Lane R, Davies P, ‘Migraine’, Taylor & Francis Group, UK (2006). 4. Matak I, Lackovic Z, ‘Botulinum Toxin A, Brain and Pain’, Prog Neurobiol,(2014). 5. Goadsby P, ‘The trigeminocervical complex and migraine: current concepts and synthesis’, Curr Pain Headache Rep, (2003).

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Microfocused Ultrasound Dr Galyna Selezneva details how she uses microfocused ultrasound with visualisation to treat skin laxity in patients Microfocused ultrasound waves (MFU) aim to stimulate the body’s natural healing and cell regeneration process, which in turn boosts collagen and influences an uplifted effect. This happens without disturbing the skin’s surface, and a non-invasive MFU device can be used to lift, tone and tighten facial and neck skin, as well as improve the appearance of the décolleté.1 Although there are different MFU systems to choose from, the one that I prefer to use, which has been recognised in clinical trials to be safe and effective, is Ultherapy.2 This device combines MFU with high-resolution ultrasound imaging (MFU-V), which allows the practitioner to identify the individual layers of the skin, anatomical features such as blood vessels and bones, and landmarks such as cysts, in order to focus treatment to a patient’s individual concerns. I feel I can bring a unique perspective to this technique, both as a practitioner and former patient who has benefited from it. The clinic I am based at has considerable experience in the aesthetic use of focused energy devices and of radiofrequency for skin tightening. As the latest generation of devices has embraced ultrasound, our clinic has moved seamlessly into this field. It is beneficial to ensure that you offer the latest and safest devices at your clinic, as we do, and have been properly trained by a skilled practitioner. I have been trained by my clinic lead, Dr Rita Rakus, and have been taught both US and European protocols. Treatment principles There are two types of ultrasound used in medicine: high-intensity focused ultrasound (HIFU), which is used mainly for medical applications, and MFU, which uses lower levels of energy (0.4-1.2 J/mm2 at a frequency of 4-10 MHz) to treat superficial layers of the skin.3 An MFU beam can pass harmlessly through the skin to target subcutaneous tissue at a focal point.4 This ultrasound energy causes cellular friction, raising the heat in the targeted area.5 This heat in turn acts on the fibroblasts that synthesise collagen. The device I use precisely heats the tissue containing fibroblasts to 60-70°C, the point at which collagen fibrils break apart and contract in small (less than 1mm3 thermal coagulation points (TCPs) to a depth of up to 5mm, while sparing adjacent tissues.6,7,8,9 Denaturing collagen fibres impairs their function and the body responds through natural wound healing by creating new collagen (neocollagenesis).10 Two phases of tightening occur; an initial posttreatment phase takes place immediately due to the contraction and denaturation of collagen at the TCPs;11 a second stage of lifting then occurs as the body initiates an inflammatory response, stimulating the synthesis of new collagen with improved viscoelastic properties.12 Macrophages engulf and break down ‘injured’ tissue and attract fibroblasts to promote repair.5,7,13 The procedure The procedure begins with a medical assessment in which the practitioner agrees a treatment plan with the patient. The practitioner needs to identify target areas and decide how to apply the treatment and how much energy to use, according to the characteristics of each patient. Target areas are identified by lax skin that results in weakness of the jawline or ‘jowls’, nasolabial folds, or heavy eyelids, and the consequent need for a brow lift. The number of passes of the handheld ultrasound applicator that will be required in a targeted area will be based on the recommended device protocols and clinical experience. These areas will be photographed for before and after comparisons. A coupling gel is then applied to the skin and the

practitioner deploys the applicator in a treatment lasting one hour. While only one session is usually necessary, practitioners follow their own protocols and our clinic uses its discretion to determine whether another is required. An experienced practitioner can use MFU to contour the face by tightening the jawline, enhancing the cheekbones or lifting the eyebrows. The treatment has also been used at our clinic to achieve facial symmetry in patients who have suffered a stroke or paralysis. Ultrasound can be combined with other forms of treatment such as injectables, radiofrequency and lasers, to achieve optimal results. Although most patients can undergo this process, a small group of people may be unsuitable, such as those who are pregnant and breastfeeding, or those who have an auto-immune condition, skin cancer, active cancer, certain collagen vascular disorders, open wounds, uncontrolled diabetes or are recovering from chemotherapy.14,15 Age, skin type, alcohol intake or certain serious illnesses do not tend to affect the level of clinical improvement.16 Patient experience During treatment patients report sensations that can be uncomfortable, some patients describe a ‘pricking’ sensation, as if little hot needles are pricking them. This is most likely because the deep focal points undergo a temperature elevation to 64°C.17 US practitioners tend to manage pain through multiple medications, including benzodiazepines to reduce anxiety. The use of benzodiazepines to treat pain in patients is not uncommon in the US,18 although there has been longstanding debate regarding whether benzodiazepines possess analgesic properties, and at least one literature review reveals insufficient evidence to support the contention that they have meaningful analgesic properties in most clinical circumstances.19 At my clinic, we follow protocols that aim to enable patients to feel more comfortable; prior to the treatment I provide a step-by-step in depth explanation of what will Before

After

Figure 1: 60-year-old woman before and 180 days after one treatment with the Ultherapy device Before

After

Figure 2: 61-year-old woman before and 90 days after one treatment with the Ultherapy device

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happen in which I share my own personal experiences of it; and during treatment I employ what I call ‘talkanaesthesia’ – a distraction technique using conversation if a patient appears anxious – as well as oral painkillers that take into account recommended protocols and depend on a patient’s individual medical history, if necessary. For up to an hour or so following treatment a small proportion of patients may experience redness, swelling, tingling or tenderness to the touch in treated areas, but these side effects are mild and temporary. 3,20 When complications arise, they are invariably practitioner-dependent rather than treatmentdependent, and I believe if a practitioner manages this process well, the patient will not experience problems or require downtime. While there is some tightening of the skin immediately after treatment, the wound-healing response stimulates tissue remodelling over 90-180 days.21 The results are most visible after about three months, and beneficial effects are durable and generally reported to last between six and 18 months.22 Research and safety Pre-clinical studies demonstrate the ability of MFU to reach the subcutaneous fat, facial superficial musculoaponeurotic system (SMAS), the fan-shaped area where the facial muscles connect with the dermis, to cause tissue contraction.5,6,9 It has been indicated in a study by Alam et al that the Ulthera device can tighten the brow by treating the full face and neck.3 One study, by Oni et al, indicated overall improvement in skin laxity in 63.6% of evaluated patients when using the device on the lower face/neck and at day 90, 65.6% of patients had perceived improvement in the skin laxity.23 In another study, by Fabi et al, which evaluated the safety and efficiency of MFU-V for treating the face and neck for skin laxity 180 days after treatment, it was suggested that 77.7% of women treated achieved noticeable improvement.16 The Food and Drug Administration cleared the Ulthera MFU-V device in 2009 for eyebrow lift following full-face treatment; in 2012 it gained approval for lifting the tissue beneath the chin and neck; and in 2014 for treating the chest to improve the décolleté.24 A number of studies, of which some are mentioned in this article, have indicated that the use of focused ultrasound is safe and effective for tightening and lifting skin in the neck, but also in other anatomical regions such as the upper arms, thighs, and knees.25 An evaluation of MFU-V for the treatment of décolletage laxity and rhytids has suggested this is also safe.26,27 While discomfort is commonly reported, one study suggested that this pain was not significantly different to that endured during other forms of skin-tightening.3,19, 28 Conclusion To gain valuable tips and guidance I have recently spent a week at one of the leading MFU clinics based in the US and have learnt that, as both a practitioner and a patient, the treatment can be enhanced in several ways. I would recommend fellow practitioners also take part in continued training to develop their knowledge and understanding of MFU treatments. My experience has taught me that, first, the practitioner should manage the patient’s expectations with candour – someone who requires a more invasive approach, such as a facelift, should be advised accordingly. Secondly, during treatment, a practitioner should observe a patient’s body language to respond to signs of tension. Finally, it is important for the practitioner to maintain an ongoing relationship with the patient following treatment in order to reassure them, as the results will take time to manifest and side effects may occur. In my opinion, MFU is an effective and safe non-invasive form of treatment to lift and tighten skin, which gives patients a fresher, natural look with minimal discomfort and no downtime. Please note

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that, as with all aesthetic procedures, its effectiveness depends on the skill and technique of the practitioner, which should be continually developed and improved upon through comprehensive training. Dr Galyna Selezneva is an aesthetic medical doctor currently practising at the Dr Rita Rakus clinic in London. She is a specialist in non-invasive procedures for face and body, using the latest technology including energy devices and laser treatments. Dr Selezneva specialises in the fat-freezing CoolSculpting treatment.

Dr Galyna Selezneva will present a BTL Aesthetics Expert Clinic at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/programme to find out more. REFERENCES 1. MacGregor, J & Tanzi, E, (2013) Microfocused Ultrasound for Skin Tightening, Unionderm, <https:// www.unionderm.com/documents/SCMS_Vol_32_No_1_Microfocused_Ultrasound.pdf> 2. Fabi S.G, (2015a) Noninvasive skin tightening: focus on new ultrasound techniques, Clinical, Cosmetic and Investigational Dermatology, 8 pp. 47–52 3. Alam M, White L.E, Martin, N et al, (2010) Ultrasound tightening of facial and neck skin: a rater-blinded prospective cohort study, Journal of the American Academy of Dermatology, 62 pp. 262–69 4. Dubinsky T.J, Cuevas C, Dighe M.K, Kolokythas O, Hwang J.H, (2008), High-intensity focused ultrasound: current potential and oncologic applications, AJR. American Journal of Roentgenology, 190 pp. 191–99 5. White W.M, Makin I.R, Barthe P.G, Slayton M.H, Gliklich R.E, (2007), Selective creation of thermal injury zones in the superficial musculoaponeurotic system using intense ultrasound therapy: a new target for noninvasive facial rejuvenation, Archives of Facial Plastic Surgery, 9 (1) pp. 22-29. 6. Laubach H.J, Makin I.R, Barthe P.G, Slayton M.H, Manstein D, (2008), Intense focused ultrasound: evaluation of a new treatment modality for precise microcoagulation within the skin, Dermatologic Surgery, 34, pp. 727–34 7. White et al (2007) Clinical pilot study of intense ultrasound therapy to deep dermal facial skin and subcutaneous tissues, Archives of Facial Plastic Surgery, 9 pp. 88–95 8. Bozec L, Odlyha M, (2011) Thermal denaturation studies of collagen by microthermal analysis and atomic force microscopy, Biophysical Journal, 101 (1) pp. 228–36 9. White W.M, Makin I.R, Slayton M.H, Barthe P.G, Gliklich R, (2008), Selective transcutaneous delivery of energy to porcine soft tissues using Intense Ultrasound (IUS), Lasers in Surgery and Medicine, 40 (2) pp. 67–75 10. Ferraro G.A, De Francesco F, Nicoletti G, Rossano F, D’Andrea F, (2008), Histologic effects of external ultrasound-assisted lipectomy on adipose tissue, Aesthetic Plastic Surgery, 32 pp. 111–15 11. Ulthera, Ultherapy: Mechanism of Action (MOA), White Paper, n/d, Mesa, AZ: Ulthera Inc, <www. ultherapy.com/uploads/document/professional/MOA%20Whitepaper%20-%201002845B.pdf> 12. Christiansen D.L, Huang E.K, Silver F.H, (2000) Assembly of type I collagen: fusion of fibril subunits and the influence of fibril diameter on mechanical properties, Matrix Biology, 19 pp. 409–20 13. Mosser D.M, Edwards J.P, (2008), Exploring the full spectrum of macrophage activation, Nature Reviews Immunology, 8 (12) pp. 958–69 14. Rosenberg C.S, (1990), Wound healing in the patient with diabetes mellitus, Nursing Clinics of North America, 25 (1) pp. 247–61 15. Greenhalgh D.G, (2003), Wound healing and diabetes mellitus, Clinics in Plastic Surgery, 30 (1) pp. 37–45 16. Fabi S.G, Goldman M.P, (2014), Retrospective evaluation of micro-focused ultrasound for lifting and tightening the face and neck, Dermatologic Surgery, 40 (5) pp. 569–75 17. Dahan, S & Pusel, B, (2014) Microfocused ultrasound, Facial Rejuvenation: Lasers, lights and energy based devices, John Libbey; Paris 18. Tennant F, (2014) Benzodiazepines in Pain Practice: necessary but troubling, Editor’s Memo, PPM Practical Pain Management, <http://www.practicalpainmanagement.com/treatments/pharmacological/ non-opioids/benzodiazepines-pain-practice-necessary-troubling> 19. Reddy S, Pat, R.B, (1994) The benzodiazepines as adjuvant analgesics, Journal of Pain and Symptom Management, 9 (8), pp. 510–14 20. Lee et al (2012) Suh D.H, A intense-focused ultrasound tightening for the treatment of infraorbital laxity, Journal of Cosmetic and Laser Therapy, 14 pp. 290–95 21. Ulthera Inc, (2016) How does ultherapy work? Lasers in Surgery and Medicine, 37 (5), pp. 343–49 <http://uk.ultherapy.com/Physicians/Science-Of-How-Ultrasound-Skin-Lift-Works [accessed February 2016]. See also Meshkinpour A, Ghasri P, Pope K, et al (2005) Treatment of hypertrophic scars and keloids with a radiofrequency device: a study of collagen effects> 22. Fabi S.G, (2015); Fabi S.G, (2015b) Micro-focused ultrasound skin tightening, PRIME: International Journal of Aesthetic and Anti-ageing Medicine, May 14, <https://www.prime-journal.com/microfocused-ultrasound-skin-tightening> 23. Oni G, Hoxworth R, Teotia S, Brown S, Kenkel J.M, (2014), Evaluation of a microfocused ultrasound system for improving skin laxity and tightening in the lower face, Aesthetic Surgery Journal, 34 (7) pp. 1099–110 24. Dayan S.H, Fabi S.G, Goldman M.P, Kilmer S.L, Gold M.H, Prospective, multi-center, pivotal trial evaluating the safety and effectiveness of micro-focused ultrasound with visualization (MFU-V) for improvement in lines and wrinkles of the décolletage, Plastic and Reconstructive Surgery, 134 (4, s1) (2014), pp. 123–24 25. Alster T.S, Tanzi E.L, (2012) Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound, Dermatologic Surgery, 38 pp. 754–59 26. Fabi S.G, Massaki A, Eimpunth S, Pogoda J, Goldman M.P, (2013), Evaluation of microfocused ultrasound with visualization for lifting, tightening, and wrinkle reduction of the décolletage, Journal of the American Academy of Dermatology, 69 pp. 965–71 27. Fabi S, Bolton J, Goldman M.P, Guiha I, (2012), The Fabi-Bolton chest wrinkle scale: a pilot validation study’, Journal of Cosmetic Dermatology 11 (3) pp. 229–34 28. Kakar R, Ibrahim O, Disphanurat W, et al, (2014), Pain in naïve and non-naïve subjects undergoing nonablative skin tightening dermatologic procedures: a nested randomized control trial, Dermatologic Surgery, 40 (4) pp. 398–404

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


VISIT THE MERZ AESTHETICS

LIVE DEMONSTRATION ZONE

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YOU

Friday 15th April

Saturday 16th April

Moderator: Dr Kate Goldie

Moderator: Mr Dalvi Humzah

10.30am - 11.00am Dr Kate Goldie The Next Steps in your Practice: Building Confidence

10.30am - 12.00pm Dr Kate Goldie Multi-layering technique using the Belotero® range for full face rejuvenation

MA/244/MAR/2016/LD Date of preparation March 2016.

11.00am - 12.00pm Helena Collier, RGN NIP Tear Trough Technique 1.45pm - 2.45pm

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3.15pm - 4.00pm

Dr Tracy Mountford How I use Ultherapy® in my Practice:Techniques and Outcomes

Moderator: Dr Emma Ravichandran 1.30pm - 2.30pm

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Dr Emma Ravichandran Lips and the Perioral Complex

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A summary of the latest clinical studies Title: A Multicenter Study for Cellulite Treatment Using a 1440-nm Nd:YAG Wavelength Laser with Side-Firing Fiber Authors: DiBernardo BE, Sasaki GH, Katz BE, Hunstad JP, Petti C, Burns AJ Published: Aesthetic Surgery Journal, March 2016 Keywords: cellulite, laser, side-firing fiber, subdermal Abstract: Fifty-seven patients underwent a 3-step cellulite treatment with a 1440-nm Nd:YAG laser with a side-firing fiber and temperature-sensing cannula. Efficacy was measured by the blinded evaluators to distinguish baseline photos from those taken at 12 months posttreatment, with results on a 5-point, 2-category ordinal photonumeric scale when comparing baseline photos to 12 months posttreatment. Subject and physician satisfaction was assessed based on completion of a satisfaction survey. Twelve month data were analyzed and compared to 6 month data. Evaluators chose baseline photographs 97% on average from 6 (-1, +2) months and 91% from the 12 (-3, +2) months posttreatment photographs. At 6 (-1, +2) months, the average improvement score was 1.7 for dimples and 1.1 for contour irregularities. At 12 (-3, +2) months, the average improvement score was 1.4 for dimples and 1.0 for contour irregularities. The average satisfaction score for the physician was 5.6 and the patient was 5.3 on a 6-point scale. A single, 3-step, minimally invasive laser treatment using a 1440-nm Nd:YAG laser, side-firing fiber, and temperature-sensing cannula to treat the underlying structure of cellulite proved to be safe and maintained effectiveness at least 1 year post treatment. Title: Comparative Evaluation of Efficacy and Tolerability of Glycolic Acid, Salicylic Mandelic Acid, and Phytic Acid Combination Peels in Melasma Authors: Sarkar R, Garg V, Bansal S, Sethi S, Gupta C Published: Dermatologic Surgery, February 2016 Keywords: melasma, pigmentation, chemical peels, skincare Abstract: Melasma is acquired symmetric hypermelanosis characterized by light-to-deep brown pigmentation over cheeks, forehead, upper lip, and nose. To compare the therapeutic efficacy and tolerability of glycolic acid (35%) versus salicylic-mandelic (SM) acid (20% salicylic/10% mandelic acid) versus phytic combination peels in Indian patients with melasma. Ninety patients diagnosed with melasma were randomly assigned into 3 groups of 30 patients each. Group A received glycolic acid (GA35%) peel, Group B received SM acid, and Group C received phytic combination peels. Each group was primed with 4% hydroquinone and 0.05% tretinoin cream for 4 weeks before treatment. Chemical peeling was done after every 14 days in all groups until 12 weeks. Clinical evaluation using melasma area and severity index (MASI) score and photography was recorded at every visit and follow-up was done until 20 weeks. There was a decrease in MASI score in all 3 groups but it was statistically significantly lower in Group A than Group C (p = .00), and it was also statistically significantly lower in Group B than Group C (p = .00) but there was no statistically significant difference between Groups A and B (p = .876). It is concluded that GA (35%) and SM acid peels are both equally efficacious and a safe treatment modality for melasma in Indian skin,

and are more effective than phytic acid peels. Salicylic-mandelic peels are better tolerated and more suitable for Indian skin. Title: Tracking and Increasing Viability of Topically Injected Fibroblasts Suspended in Hyaluronic Acid Filler Authors: You HJ, Namgoong S, Rhee SM, Han SK Published: Journal of Craniofacial Surgery, February 2016 Keywords: injectables, hyaluronic acid, fibroblasts, bioimplants Abstract: A new injectable tissue-engineered soft tissue consisting of a mixture of hyaluronic acid (HA) filler and cultured human fibroblasts have been developed by the authors. The purpose of this study was to track the injected fibroblasts and to determine the effect of adding prostaglandin E1 (PGE1) or vitamin C on the viability of fibroblasts. Human fibroblasts labeled with fluorescence dye were suspended in HA filler and injected into 4 sites on the back of nude mice. The injected bioimplants consisted of one of the 4 followings: HA filler without cells (HA group), fibroblasts suspended in HA filler (HA + FB group), PGE1-supplemented fibroblasts in HA filler (HA + FB + PGE1 group), and vitamin C-supplemented fibroblasts in HA filler (HA + FB + VC group). At 4 weeks after injection, locations and intensities of the fluorescence signals were evaluated using a live imaging system. The fluorescence signals of the fibroblast-containing groups were visible only at the injected sites without dispersing to other sites. The HA +FB + PGE1 group showed a significantly higher fluorescence signal than the HA + FB and the HA + FB +VC groups (P < 0.05, each). There was no statistical difference between the HA + FB and HA + FB +VC groups (P = 0.69). The results of the current study collectively suggest that injected fibroblasts suspended in HA filler stay at the injected place without moving to other sites. Title: New Patient-Oriented Tools for Assessing Atrophic Acne Scarring Authors: Layton A, Dréno B, Finlay AY, Thiboutot D, Kang S, Lozada VT, Bourdès V, Bettoli V, Petit L, Tan J. Published: Dermatology and Therapy, February 2016 Keywords: acne, scarring, atrophic acne scar Abstract: Many patients with acne have clinically relevant scarring for which they seek treatment, implying that there is an impact on their lives. Currently there are no validated tools to assess the burden of atrophic acne scarring from the patient’s perspective or to assess treatment benefit. Two patient-reported outcome measures, the selfassessment of clinical acne-related scars (SCARS) and the facial acne scar quality of life (FASQoL) tools, both specific to facial atrophic acne scarring, were developed according to Food and Drug Administration guidance methodology. Patient interviews were conducted first to elicit patient-important concepts about scarring, then to validate patients’ understanding of wording in the tools. Concept elicitation interviews were conducted with 30 subjects and cognitive interviews with 20 subjects. With acne scarring, important concepts for patients included size, surface area affected, counts, and depth. The SCARS and FASQoL tools were shown to address relevant concepts that were easily understood by patients. Two patient-reported measures, SCARS and FASQoL, have been developed to help clinicians assess the severity and impact of acne scars. Responsivity of these instruments to treatment will require further evaluation.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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which aim to help boost one’s immunity,4,5 aid athletic performance,6 for re-energising,7-12 to assist with diet and detox, as an anti-oxidant booster,4 promotion of hair growth, and to lighten or whiten skin.13 In spite of this classification of IV nutrition products as supplements in the UK, there are thousands of publications in the PubMed.gov archives in support of IVNT for various medical conditions, which is why IVNT clinics are huge business in the US. The global market for parenteral nutrition is forecast to reach US $8.7 billion by 2020, driven by the growing popularity of home health nutrition therapy.14 According to the report by Global Industry Analysts, “The United States represents the largest market worldwide, led by aging population, increase in the number of chronic diseases such as cancer, AIDS and gastrointestinal disorders.”14

Introducing IVNT to your clinic Dr Jacques Otto and Dr Samantha Gammell discuss the rise in intravenous nutritional therapy’s popularity and detail how you can incorporate this safely into your clinic Growth of IVNT in the UK In the 1960s, Dr John Myers, a physician from Baltimore, pioneered the use of intravenous (IV) vitamins and minerals as part of the overall treatment of various medical conditions such as acute asthma attacks, migraines, fatigue (including chronic fatigue syndrome), fibromyalgia, acute muscle spasm, upper respiratory tract infections, chronic sinusitis, seasonal allergic rhinitis, cardiovascular disease, and other disorders.1 However, the acceptance and popularity of intravenous nutritional therapy (IVNT) in North America, South America, the Middle East and the Far East is owed to Dr Alan R Gaby, who took over the care of the late Dr Myers’s patients in 1984 and continued to treat various medical conditions using his modified Myers’ Cocktail.1 Since this time, more recent advances in IVNT include the addition of amino acids to the modified Myers’ Cocktail. IVNT had been practically nonexistent in the UK until 2014. However, a change was illustrated in the summer of 2015, when aesthetic doctors, independent nurse prescribers and non-prescribing nurses participated in a survey. Surprisingly, 48% of respondents were providers of IVNT, and the results indicated that, “The most widely used brand by respondents was IntraVita, followed by Myers’ Cocktail, Reviv and VitaminDrip.”2 This shows the increase in popularity and availability of IVNT in the UK. Regulation At the beginning of 2015, the Medicines and Healthcare Products Regulatory Agency (MHRA) classified intravenous nutrition products as supplements and not medicines.3 As such, in the UK, medical claims cannot be made by practitioners or on their clinics’ websites. Instead, IVNT is largely offered to promote general health and wellbeing using different cocktails of vitamins, minerals and amino acids

Demand In the UK, demand for IVNT is increasing. For example, in the past year, our company, IntraVita, has reported an unprecedented increase in demand for the training and supply of IVNT products. In 2015, we trained more than 100 practitioners and it is estimated that this number will rise to more than 300 practitioners by the end of 2016. We believe that as many as 500 practitioners will be providing IVNT in their UK clinics by the end of 2017.15 Considerations If you choose to incorporate IVNT in your clinic, it is important to consider the following important factors when choosing a trainer and supplier of INVT products.

1. Products should be manufactured in an EU Good

2. 3.

4. 5. 6. 7. 8.

Manufacturing Practice (GMP) manufacturing facility. US Food and Drug Administration approved products are not legal in the EU, unless the MHRA has approved a manufacturer’s license. According to the MHRA, ‘To make, assemble or import human medicines, you need a manufacturer licence, issued by the MHRA. To qualify for a manufacturer licence you need to show MHRA that you comply with EU GMP and pass regular GMP inspections of your site.’16 Products should be preservative free to minimise the risk of allergic reactions.17 Ensure that your product supplier has Supplier’s Product Liability Insurance in place. Cosmetic or aesthetic insurance companies do not necessarily cover product liability. Post-training support by suppliers. Practitioner’s insurance cover that includes IVNT is available. Reliable IVNT product suppliers that carry large stock inventories to ensure timeous product delivery. Calculated safe osmolarities for each IVNT protocol or ‘cocktail’ to avoid potential complications. Proper training should be available from a qualified medical practitioner.

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It is also important to note that the ideal clinical setting for the provision of an IVNT service is similar to most aesthetic clinics, with a properly trained and insured practitioner who has valid basic life support and anaphylaxis training. Training A general misconception among practitioners is that vitamins, minerals and amino acids are basic nutrients and they therefore do not require in-depth training. As with all treatments, however, the safety comes from understanding and avoiding the risks and potential side effects. IVNT training should include:

1. The mechanism of action of each nutrient: minerals, vitamins and amino acids.

2. The safety of IVNT, including the management of potential adverse events.

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Packages We recommend that IVNT should be promoted as a package of six treatments: the first few treatments done weekly and then fortnightly to achieve maximum results. Maintenance treatments are normally 8-12 weeks but typically the patient will know or feel when they need a top-up treatment. One-off treatments are not advisable because in some cases it may take two-to-three treatments to reverse deficiencies. Conclusion It is without a doubt that IVNT popularity has increased in the UK, and, as mentioned earlier, we predict that clinics offering this treatment will increase to 500 by the end of 2017. If you do choose to incorporate this treatment, it is imperative that you choose an appropriate trainer and supplier, and fully understand the different products and risks associated with administering these.

3. How to consult and consent patients, and how to document the treatment.

4. How to correctly calculate the osmolarity of each ‘cocktail’. 5. How to correctly prepare each ‘cocktail’ of vitamins, minerals and amino acids.

6. The practical aspects of IVNT, including setting up drips and calculating drip rates.

7. The training company should provide IVNT protocols for practitioners to use in their clinics.

8. Literature references. How to market to patients Patients are often surprisingly well informed about IVNT and many patients are already seeking out clinics that offer treatments. For those less informed, information on your website, blog and an introductory email to your patient base is a simple and effective marketing tool. Social media marketing using Facebook and Twitter is also essential and can dramatically increase your patient footfall. An open evening introducing IVNT is also recommended so a group of select patients can be informed about IVNT in a short period of time and be offered an introductory discount.

We recommend that IVNT should be promoted as a package of six treatments: the first few treatments done weekly and then fortnightly to achieve maximum results

In next month’s issue of Aesthetics, we will explore the important clinical factors you need to consider when introducing IVNT to your practice. Dr Jacques Otto is a cosmetic doctor with a master’s in medical pharmacology, philosophy in medical law and family doctor practice degree. His main interests are researching new antiageing products, cosmetic products, and cosmetic non-invasive medical device development. He is also a polydioxanone (PDO) thread trainer and is the co-founder of IntraVita Ltd. Dr Samantha Gammell is the founder and medical director of The Hadleigh Clinic and The Aesthetic MediSpa, and the former president of the British College of Aesthetic Medicine. She has a medical degree and a first class honours degree in molecular medicine. Dr Gammell trains with the leading IVNT doctors in the US and provides IVNT to her own patients.

Disclosure: In 2014, Dr Samantha Gammell and Dr Jacques Otto, together with aesthetic distributor Mr Vernon Otto, founded IntraVita Ltd. They now teach and train other medical practitioners in IVNT use. REFERENCES 1. Gaby Alan R, ‘Intravenous Nutrient Therapy “The Myers’ Cocktail”, Alternative Medical Review, 7 (2002), pp.389-403. 2. Jackson Lorna, Intravenous Vitamin Infusions Fad or Fabulous? (2015). 3. MHRA Letter to IntraVita Ltd. (28 August 2015) Data on file – all queries welcome. 4. Blanchard J, Tozer TN, Rowland M., ‘Pharma-cokinetic perspectives on megadoses of ascorbic acid’, Am J Clin Nutr 66 (1997), pp.1165-1171. 5. Harakeh S, Jariwalla RJ, Pauling L., ‘Suppression of human immunodeficiency virus replication by ascorbate in chronically and acutely infected cells’, Proc Natl Acad Sci USA, 87 (1990), pp.72457249. 6. Newhouse IJ, Finstad EW., ‘The effects of magnesium supplementation on exercise performance’, Clin J Sport Med, 10 (2000), pp.195-200. 7. Rosenbaum EE, Portis S, Soskin S., ‘The relief of muscular weakness by pyridoxine hydro- chloride’, J Lab Clin Med 27 (1941), pp.763-770. 8. Cox IM, Campbell MJ, Dowson D., ‘Red blood cell magnesium and chronic fatigue syndrome’, Lancet 337 (1991), pp.757-760. 9. Howard JM, Davies S, Hunnisett A., ‘Magnesium and chronic fatigue syndrome’, Lancet, 340 (1992), p.426. 10. Clague JE, Edwards RH, Jackson MJ., ‘Intravenous magnesium loading in chronic fatigue syndrome’, Lancet, 340 (1992), pp.124-125. 11. Ellis FR, Nasser S., ‘A pilot study of vitamin B12 in the treatment of tiredness’, Br J Nutr, 30 (1973), pp.277-283. 12. Lapp CW, Cheney PR., ‘The rationale for using high-dose cobalamin (vitamin B12)’, CFIDS Chronicle Physicians’ Forum, (1993), pp.19-20. 
 13. Shimada Y, Tai H, Tanaka A, Ikezawa-Suzuki I, Takagi K, Yoshida Y, Yoshie H., ‘Effects of ascorbic acid on gingival melanin pigmentation in vitro and in vivo’, J Periodontol, 80 (2009), pp.317-23. 14. Global Industry Analysts, Inc. Parenteral Nutrition Market Trends (US, Global Industry Analysts, 2015) <http://www.strategyr.com/Parenteral_Nutrition_Market_Report.asp> 15. Data on file via IntraVita Ltd – all queries welcome. 16. MHRA, Overview, manufacturer’s Licence (UK, MHRA, 2016) <https://www.gov.guidance/apply-formanufacturer-or-wholesaler-of-medcines-licences> 17. Medscape, Benzyl alcohol allergy: Importance of Patch Testing with Personal Products (2016) <ttp:// www.medscape.com/viewarticle/521354_3>

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The Online Customer Journey Digital marketing manager Paul Jackson advises on how to ensure you aren’t missing the key stages of your patients’ digital journey One of the most effective ways to build your online marketing plan and outperform your competitors is to map your customers’ journey while they are online. Online marketing has become an important and widely used part of the marketing mix for aesthetic brands, clinics and practitioners, however it needs to be functioning from all touch points to be successful. For your patients, their journey starts with the realisation of a problem or a need for your services. This could be an individual decision, through recommendation, an advertisement or a number of other triggers. This is where your online marketing needs to begin. The customer journey must be considered beyond the point of which a patient uses your services; it should be helpful to potential patients at each step of their decisionmaking process. The online customer journey comprises five main steps, which should be considered to increase the chances of convincing patients to choose your clinic. These steps include information gathering and research, comparison and evaluation of alternative clinics, enquiry and purchase, review and evaluation and post-procedure patient behaviour. Information gathering and research Naturally, researching what types of procedures are available, in which clinic and with which practitioner is the first action a potential patient takes online. This is particularly important in the aesthetics and cosmetics industries, as your target audience is likely to carry out extensive research due to the nature, cost and range of procedures available. Search engines are the starting point for many people, perhaps searching very broadly for services that will solve their problem or meet their needs. It is therefore important that your clinic and name are visible and prominent in the search engines so that you’re in a position to capture a potential patient’s interest and gain awareness of your name or clinic from an early stage. To do this, search engine optimisation of your website will help you appear more prominently in the organic search engine results, and search engine advertising will boost your visibility, putting your adverts in front of potential patients at the exact time that they are looking for a solution that you offer. It is not enough just to be visible at this stage however; you need to back it up with website content that will satisfy a potential patient’s research needs. Does your website provide all the information that a potential patient will need to feel informed

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about a treatment or procedure? This could include costs, duration, downtime, side effects, longevity, case studies and more. Detailed website content, FAQ pages, downloadable guides and informative videos can provide this information effectively online. Beyond this, you can also ensure that your website visitors are able to ask questions they can’t find answers to, such as through enquiry forms and contact numbers, or even through adding a live chat function on your website, which can be added to your site easily and for a low cost through one of the many providers online or through a website plugin. If using live chat, remember to ensure that your staff are quick to respond to messages, that the feature is turned off when staff aren’t available to respond, and that training is given on how to respond to people and what should and should not be said and done. As always, it is critical that you are not considered to be offering medical advice online. Comparison and evaluation of alternatives Once the patient has gathered the information they need to proceed, it is time for them to make a decision on which clinic or practitioner to opt for. While your website may have provided valuable treatment information, potential patients are now weighing up your prices, your location, your experience and expertise, your credibility and trustworthiness, and the experiences they have had during the research stage. There are a number of things you can do to put yourself in the prime position, which include, clearly displaying evidence of accreditations and awards, reviews and testimonials, case studies, press coverage, profiles of key team members, and information on your pricing and location. Particularly in the aesthetics and cosmetics industry, even the slightest doubt or concern can be enough to deter a potential patient when it comes to procedures on the body. Not having this information available prominently on your website may not only limit your chances, it may actually detur patients from choosing your clinic all together.

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Enquiry and purchase With the patient having now obtained the information they need to be able to confidently compare the options available, they will now make a decision and proceed. It is here that the purchase, booking or enquiry process itself comes in to play. How easy is it to make a booking on your website? How quickly do you respond to enquiries? How flexible are your cancellation or booking change policies? All of these factors will be in the mind of the potential patient and will be crucial to ensuring that they stay with you along this stage of the journey. Having done the hard work to gain the patient’s awareness, capture their attention, provide them with information, and be preferable to competitors, it would be a terrible

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As everybody has a voice online to air their thoughts and experiences, online reputation management is an increasingly crucial activity shame to lose them at this stage due to a poor booking or enquiry process, but it can easily happen. Just like stage two, ease and simplicity are important, as is filling the patient with confidence. If you require that patients make an enquiry, let them know what happens afterwards, how long it will take you to respond, and what they can expect. Then keep to those timeframes and remember that being the quickest to respond will aid your success in gaining that patient; as long as the reply is still of a high quality of course. If a booking is required, only ask people to submit the information you really need, as many booking forms can be found asking for everything from fax numbers to middle names and multiple phone numbers — providing this information is tedious and time consuming for the patient and the more effort they have to make, the less likely they will continue with your service. Also make your booking and cancellation policies clear so patients know where they stand if they do need to make a change to their booking – it helps limit the perceived risk in the transaction. Review and Evaluation Now that you have secured the booking, it is time for your service, procedures and staff to live up to expectations and, where possible, exceed them. Having made the decision to be your patient, the person will naturally review their decision. Are they glad they chose you? Was the outcome what they wanted? Some businesses promise so much in attracting somebody to be a patient that they oversell their clinic, team and offering to a level that can’t be reached by the reality. Whether it is simply being transparent and realistic about any discomfort or downtime associated with a treatment, or displaying representative photos of your premises on your website, it is beneficial in the longterm to portray your business in the most genuine way possible. Focusing on patient satisfaction is an approach that is critical in the aesthetics industry, and this is particularly important when considering what your patients do after they have undergone a treatment or procedure with you.

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Post-procedure behaviour When a patient leaves your clinic it is easy to be grateful for their business and to move on to the next one. However, it is at this time that the patient could be of most value to you, and you can facilitate a wide range of beneficial outcomes. If the patient was satisfied with their treatment or procedure, they may at least be open to returning to you as a patient again in

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future. They may talk to their friends about you, they may be willing to write a review of your clinic or provide a testimonial, and they may connect with you, be an advocate for you, and recommend others to you on social media. On the other hand, if the person was not a satisfied patient, they may well still do all of these activities but paint you in a negative light. If this does occur it is important to spot the negative comments as soon as possible, to respond diplomatically and to take the conversation offline so that it is not carried out in the public eye online. As everybody has a voice online to air their thoughts and experiences, online reputation management is an increasingly crucial activity. Just a few positive or negative reviews could potentially earn or cost you large amounts of business. The postprocedure behaviour of your existing patients can directly and significantly influence the ‘comparison of alternatives’ stage of the customer journey for future potential patients. Some effective techniques for leveraging post-procedure behaviour include contacting your patients by email shortly after to ask if they would leave a review for you or if they’d be interested in following you on social media, for example. Where possible, use mainstream third-party review platforms such as Feefo, Trust Pilot or Google Reviews and then embed these reviews on your website as this will give your reviews maximum visibility. Always aim to make the process as simple as possible for the patient to help ensure that they will be willing to write such feedback for you, such as including links and step-by-step instructions. A good marketing tool Understanding your customers’ online journey can be an extremely effective way to improve your marketing and boost your business online. After mapping this out for your patients and your business, go through the five steps of the online customer journey process yourself. Try identifying where there are gaps in your marketing, where you might have issues in obtaining relevant information, or where you could do more to ensure the patient moves easily to the next stage of the journey with you. Closing these gaps could hold the secret to the growth of your online bookings or enquiries. By being visible and reaching your target audience when they recognise a need for your services, you are positioned to provide your potential patients with the initial background information that they need to understand more about your procedures and treatments. A strong presence in this stage puts you in a position to be compared against your competition and to be in the running for their business. If you’re one of the clinics being evaluated, then you can have the chance to gain that patient’s business, to provide them a service and then leverage their postprocedure behaviour. This could simply be a review or testimonial or even a recommendation to a friend, which could grow to influence future prospective patients and develop a long-term and highly valuable patient. Paul Jackson is the digital marketing manager at BeSeen Marketing in Buckinghamshire and specialises in social media and online marketing for the aesthetics, beauty, cosmetics and fashion industries. He works with many brands, clinics and practices to grow their businesses and achieve success through effective online marketing. Jackson is also a prominent speaker and can be seen at industry conferences across the country.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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The Eight ‘Cs’ of Aesthetic Practice: A Practitioner’s Guide Dr Niroshan Sivathasan advises how to get the most out of your practice The five ‘Cs’ of diamonds are well known: carat weight, clarity, colour, cut, and certification. When assessing and grading a diamond, these properties are fundamental. Like diamonds, I believe there are several ‘Cs’ to aesthetic practice, and if we fulfil each of these ‘Cs’, we can create a successful business that our patients will love. Just as the astute diamond patron assesses the skill of the artisan, the reputation of the institution, and the qualities of the transaction using a series of ‘Cs’, the discerning aesthetic patient is also aware of the need for careful evaluation. So what should aesthetic practitioners consider in order to put their services at the top of the pile?

The ‘Eight Cs’ of cosmetics Everyone should understand that both medicine and nursing are arts based on science, and that no intervention may be guaranteed to produce the desired result without a potential side effect and/or complication. Indeed, this is where the skill of the practitioner and the features of a clinic, including its cleanliness and calibre of its staff, really kick-in to counteract or mitigate an adverse situation. Clinician Arguably, the clinician is the most important variable for people seeking elective services. A point worth considering is: do I, as a practitioner, make the patient feel confident with my demeanour and advice? Trust is intangible, yet pivotal to successful treatment, and many people are able to tell when somebody is talking beyond their limits of knowledge or capability. Clinic The clinic should be fit for purpose and appropriately equipped. Would you be impressed if you were to enter your practice? And does it compare well with the offices of your local competitors? The appearance and decoration is one thing, but does your clinic have provisions for emergency care and access, as required?   Certification Certification of the practitioner (level of training and the direct relevance of any attained skills) and clinic (recent accreditation) should serve to reassure the end-user. Also consider, is your training formally accredited, and, if so, does it attract any discounts from your indemnity-provider? Consultation This includes a transparent discussion in simple language and forms the basis of consent. Contrary to widespread belief, consent does not always have to be written and can just be verbal. However, there are instances where written consent is absolutely necessary. For more information see the Department of Health document: Reference guide to consent for examination or treatment.1 The consultation should also allow for adequate time for patients to thoroughly consider their

Aesthetics

options. This shall also allow you to refuse treating some patients and dodge likely disasters. Of course, some practices are run like fast food joints, but I believe that patients are best served when the clock is secondary to the care and consideration afforded during the consultation, which shall, in return, reduce the risk of medicolegalcomeback. If your business employs a model of ‘very low price with high turnover’ or ‘pile ‘em high, and see ‘em quickly’, then periodically consider if you have engaged in the optimal strategy. Competition Competition has greater bearing in the absence of word-of-mouth referrals and ‘genuine’ testimonials, and this is particularly true for surgical endeavours.  Be aware that some potential patients serially ‘window shop’ and that a clinician’s time has inherent value, so do not devalue your brand or your services, which has involved a varying degree of personal sacrifice, by offering free consultations with no qualifiers. Impress upon all patients that miracles cannot be promised and do not jump on the bandwagon of unsafe practice just to remain competitive. Cooling-off A cooling-off period is not necessary for all procedures. For instance, I believe it is okay to administer soft tissue fillers during the same sitting, but procedures such as breast augmentation need some time for reflection. Of course patients must take responsibility for their wellinformed choices, but you must stay abreast of regulatory changes pertaining to this matter. Care Care in the post-treatment period includes the provision for contacting the clinic easily, reviewing plans as needed, and the ability to deal with complications successfully.  Change As I conclude, this final ‘C’ must always be kept in mind – change. Think about what the patient wants to change, and why. Does the patient have realistic expectations, does their wish fall within their budget, and are you able to honestly deliver within the individual’s constraints? The internet is teeming with inaccuracies, laymen masquerading as experts and expressing conjecture as fact, so do not be bullied into agreeing to do things that you are not certain of or have reservations about.

Summary Cosmetic standards and regulations vary significantly around the world, and navigating the potential pitfalls is critical for all stakeholders. We talk about pearls and stars, but perhaps analogising with diamonds is the easiest way to remember the key concepts. If in doubt, err on the side of caution and remember that individuals are exactly that: one size does ‘not’ fit all, and people should be considered in a bespoke fashion. Dr (Mr) Niroshan Sivathasan is a Sydney-based cosmetic surgeon and trainer for pharmaceutical companies. He completed his bachelor’s and medical degrees, as well as postgraduate qualifications in surgery and aesthetic medicine in London, prior to undertaking a higher fellowship in cosmetic surgery in Australia. REFERENCES 1. Gov UK, (2009) Department of Health, Reference guide to consent for examination or treatment, second edition, <https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/138296/dh_103653__1_.pdf>

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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“Always chase the experience and not the final goal” Mr Dalvi Humzah recalls his excitement upon joining the aesthetics specialty and details how he has grown his practice over the years “I always knew I wanted to be surgeon,” explains consultant plastic surgeon Mr Dalvi Humzah, “but it took me a little bit of time to work out what kind of surgeon I wanted to be.” Mr Humzah originally aspired to become a liver transplant surgeon but changed his mind during his training. “I spent a whole year working with the transplant team and at the end I had to make a career choice; it was either liver transplants or plastic surgery, and I chose the latter. I realised transplants weren’t for me, but I think plastics had always been there ‘bubbling away’ at the surface.” After completing his medical degree at King’s College London in 1995, Mr Humzah went to Edinburgh to begin his registrar training, subsequently working his way up through the ranks before completing his Fellowship of the Royal College of Surgeons (FRCS) and becoming a consultant in 1997. As a consultant plastic surgeon, Mr Humzah started to take more of an interest in aesthetics, “To be a good plastic surgeon you have to be good at not only reconstruction, but the aesthetics,” he explained. “You can’t reconstruct somebody and say ‘right, I’ve done the reconstruction and the repair, but it doesn’t look good’, so I realised you’ve got to have an aesthetic eye in whatever you do.” Back in the mid-to-late 90s, injectable treatments in aesthetics were just starting to appear, and Mr Humzah remembers it as an ‘exciting time’, “You could open a journal and there would be so many new things just about toxin, and our knowledge was changing on an almost week-by-week basis.” Mr Humzah recalls, “We’ve gone from having just one dermal filler and one toxin to hundreds of them. Now, there are all these new energy-based devices that I wouldn’t have even dreamt of in 1997. If someone had told me then that we could freeze tissue and get rid of fat I would’ve been incredibly sceptical.” After ten years in the NHS as a consultant, Mr Humzah decided to focus solely on his private work and left the NHS, albeit with a ‘heavy heart’. He explains, “I enjoyed the NHS; there are some very positive things about it. We had great comradery, but I felt I needed more control and to go in my own direction.” In 1998 Mr Humzah set up his own practice, “I wasn’t motivated by having a huge practice, for me, it was to be able to spend time doing what I enjoyed, such as teaching.” As a fully-qualifed consultant, Mr Humzah spends a lot of time teaching and running training courses. His Facial Anatomy Teaching course recently won Training Initiative of the Year at the Aesthetics Awards 2015, for the second year running. “Teaching is something I really enjoy. I love looking at and exploring the anatomy, and having my own practice means I can do more teaching, which I hope is something that continues.” He explains, “Anatomy knowledge has changed tremendously and what we knew even five years ago is not necessarily accurate now. That’s why I think meetings such as the Aesthetics Conference and Exhibition (ACE) are so great – where I am on the steering committee. We have a real mixture of talks on different skills and specialisms.” Mr Humzah has accomplished many achievements, but there are a couple he is particularly proud of, “Obviously training to consultant level is, I believe, your biggest achievement,” he said. “But once I established my aesthetic practice, I wanted to ensure it kept moving and evolving. I am very lucky to have people such as aesthetic nurse prescriber Anna Baker around me; together, we have really grown the non-surgical practice within the Nuffield Hospital in Cheltenham.” When asked if he has an ethos or motto he follows, Mr Humzah modestly answers, “Keep it simple, get the basic foundations and keep running smoothly. Oh, and be nice!”

What treatment do you enjoy giving the most? I like a lot of the facial treatments that I do, whether it be surgical or non-surgical. I do find the face extremely interesting. What technological tool best compliments you as a practitioner? I have a lovely 3D camera that I’ve been using for several years now and I think it really helps my practice. I can show patients their face in 3D and really analyse it; using it as a stepping-stone as to how we are going to treat them appropriately. What’s the best piece of career advice you’ve ever been given? Always chase the experience and not the final goal, or money. Get experience in as many areas as possible before you move on. Do you have an industry pet hate? I like to see it as a ‘specialty’ rather than an ‘industry’. I don’t like how we can’t develop ourselves as a major specialism; we should be a specialism of aesthetics. What aspects of the industry do you enjoy the most? I enjoy a lot of the conferences. I think some of these multidisciplinary conferences are fabulous and that’s why I put myself forward to get involved. They’re a great way of not only teaching people but also an excellent place to network and meet other colleagues. We get doctors, nurses, dentists, and more, all there learning together and it’s great.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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The Last Word Mr Sultan Hassan argues how remote consultations in cosmetic surgery can enhance a practice and improve patient satisfaction The use of remote consultations in aesthetic practice is a relatively novel tool that has advantages as well as disadvantages. Some practitioners may be wary of adopting this technology, but I believe by having the relative safeguards in place, there is a role for this type of consultation in developing our growing practice. Since 2011, my practice has used remote consultations, whereby patients can be consulted via video call, instead of the traditional face-to-face visit in a practitioner’s office. As we are now seeing increasing numbers of patients seeking our services from across the UK and the world, having video consultations allows us to expand our patient base to help patients who may not have the time or resources to come into our clinic. It should be noted that although these are useful initial meetings between a practitioner and a remote patient, there needs to be a subsequent qualifying face-to-face meeting before any planned intervention. We do not advocate remote prescribing and fully support the current increased regulations to stop this poor practice in the industry. Approximately 10% of initial consultations at my practice now take place remotely using Skype and, occasionally, FaceTime. Skype allows me as a surgeon to share my screen with the patient and present diagrams and photographs, as well as surgically-important pointers, to help explain to the patient the reasons why a particular procedure may be preferable. We believe two-way video conferencing to be essential as this allows both the practitioner and patient to observe each other, use important visual cues to illustrate points and essentially have an almost normal conversation. Remote inspectionbased examination of the patient’s area of concern has been used successfully for procedures as diverse as breast augmentation, arm-lift, liposuction and non-surgical treatments. The benefits of remote consultations In today’s busy society, initial remote consultations can be far more convenient than face-to-face consultations and still provide most of the benefits. A patient and indeed their practitioner can be in their own home surrounded by their family or by other members of their team respectively. In my opinion, one of the main advantages of remote consultations is the convenience to both patient and practitioner with the ease of evening video calls and other out-of-hours appointments. Another clear advantage of this technology I have found is that some patients find it easier to speak about their concerns without being in the same room as the practitioner. Being able to discuss this whilst in the comfort of their home is often easier for the patient.

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Points to consider Video calls are said to be relatively secure, however, there may be a question mark around just how secure they are. I advise both parties have up-to-date antivirus and malware protection that help avoid security breaches. It is also essential to have a good, stable wifi signal and not rely on 4G, as a poor signal can result in poor or delayed audio and poor quality video that can affect the quality of the consultation. Under these circumstances it may be necessary to reschedule until a better quality call is available. Alternatively, high-resolution static photographs can also be shared via screen share features, whereby programmes allow either party to share their screen with the other and observe their cursor, focusing attention on important aspects, just like a face-to-face consultation. Even though out-of-hours consultations are great for many patients, it can be detrimental to the consultant’s family life. To reduce the impact, at my surgery we offer just one weekday evening per week between 7-9pm for these types of consultations and an alternate Saturday morning. There is an important issue around chaperonage that should now be catered for to protect both parties during a remote consultation. Ultimately, in this age of increasing litigation and allegation, it is important to protect both parties from any doubt by having a chaperone present, albeit invited as an additional party to the remote meeting if not physically present at the practitioner’s location. At my practice we now also occasionally use remote consultations to help support patients in the post-operative recovery period; this can be essentially similar to a triage review. Emphasising massage method is easy to do over video or explaining correct positioning of a pressure garment, but practitioners must still be aware of when a patient needs to be directed to local medical services if there is clinical concern; if you are concerned about the possibility of any serious health risks or when the patient has expressed any concerns during the perioperative period. We always emphasise that remote consultations simply add a convenient assessment tool to our pre-cosmetic surgery evaluation pathway and is not a replacement of face-to-face consultations that must be completed before any intervention can proceed. All our patients are also advised that should any important issues come to light during subsequent face-to-face consultation, that were not apparent previously which may impact the surgery, then any planned surgery may need to be rescheduled to allow further consideration. Conclusion As part of our remote consultation process, our patients complete a medical questionnaire and we’ve received excellent feedback and satisfaction scores from these. We do, however, stress to patients who wish to have a video call as an initial consultation that they must have a subsequent face-to-face meeting if they intend to then proceed with a procedure. I believe remote consultations are here to stay, however patients should be asked to give informed consent for this type of consultation and it should be made clear that this forms part of a general consultation process to help assess and prepare them for a procedure. With appropriate precautions and security measures, remote consultations are an exciting development in aesthetic practice. Mr Sultan Hassan of Elite Surgical is experienced in reconstructive, breast, body contouring and cosmetic surgery. Mr Hassan performs up to 500 cosmetic surgery procedures year and has more than 14 years’ experience in plastic surgery. He regularly appears on Channel 4’s Embarrassing Bodies.

Reproduced from Aesthetics | Volume 3/Issue 5 - April 2016


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Date of Preparation: October 2015

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Combination Treatments