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When reveal beauty, we’re you by your side. we’re by your side.

VOLUME 7/ISSUE 5 - APRIL 2020

When you reveal beauty, we’re by your side. When you reveal beauty, we’re by your side.

Cromaoffers offersaawide widerange range state-of-the-art products Croma ofof state-of-the-art products in minimally invasive aesthetic medicine. This allows in minimally invasive aesthetic medicine. This allows youyou to to combine techniques for personally tailored treatment combine techniques for personally tailored treatment andideal idealresults. results.Learn Learn more about Croma’s products and more about Croma’s products andservices servicesat atcroma.at croma.at and HAFiller Filler| Threads | Threads | PRP | ACA & SVF | Skincare HA | PRP | ACA & SVF | Skincare

Croma offers a wide range of state-of-the-art products in minimally invasive aesthetic medicine. This allows you to combine techniques for personally tailored treatment and ideal results. Learn more about Croma’s products and services at croma.at

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Tear Trough Anatomy CPD HA Filler | Threads | PRP | ACA & SVF | Skincare

Three practitioners explore the anatomy for treating the tear trough croma_inserat_210x297_NL_ada_1811_gch.indd 1

Special Feature: Treating Vaginal Laxity

Exploring the treatment of vaginal laxity with radiofrequency

Croma offers a wide range of state-of-the-art products

Cellulite and Microwave Technology

Dr Paolo Bonan shares a successful case 11.12.18 study13:45 of cellulite treatment

11.12.18 11.12.18 13:45 13:45

Patient Retention

Alan Adams discusses the opportunities following a sale


Contents • April 2020 06 News The latest product and industry news 14 Conferences

Highlights from the ACE Group conference and a preview of IMCAS Asia

16 Managing a Clinic during the COVID-19 Pandemic

Aesthetic professionals share advice on sustaining your business

18 Advertorial: Elevating Training Standards A report on the Merz Innovation Partner Workshop in March 21 Special Feature: Treating Vaginal Laxity with RF

Three practitioners discuss the causes and treatment of vaginal laxity

Special Feature: Radiofrequency and Vaginal Laxity Page 21

CLINICAL PRACTICE 26 CPD: Understanding Tear Trough Anatomy Aesthetic practitioners detail the anatomy of the tear trough 31 Introducing Muscle Stimulating Technology Aesthetics explores the different devices currently on the market 35 Treating Cellulite with Microwave Technology Dr Paolo Bonan shares a case study of cellulite treatment 40 Advertorial: SkinCeuticals Antioxidants

An antioxidant is the cornerstone of any topical skincare regimen

42 Using Isotretinoin Beyond Acne

Dr Firas Al-Niaimi details the conditions that can be treated with isotretinoin

44 Case Study: Rejuvenating the Periorbita

Nurse Anna Kremerov describes a successful under-eye treatment

47 Treating the Body with Low Level Lasers

Robert Sullivan explores the use of non-thermal low level lasers for the body

50 Understanding Filler Complications for Rhinoplasty

Mr Dario Rochira explains why dermal fillers can be contraindicated for closed preservation rhinoplasty

52 Advertorial: Rejuvenating Lip Structure

Dr Kate Goldie shares her new lip augmentation technique

54 Advertorial: Treating Cellulite with EMTONE

Simultaneous energy delivery – a proven solution for cellulite

55 Abstracts

A roundup and summary of useful clinical papers

57 Utilising Meditation in Aesthetics

Dr Amiee Vyas shares the benefits of meditation

60 Getting Patients to Love Your Clinic

Business coach and author Alan S. Adams discusses the importance of maximising opportunities to retain patients after a sale

63 Incorporating BHRT into Practice

Dr David Eccleston advises on incorporating BHRT into aesthetics

66 Advertorial: Restylane Lyps is Back by Popular Demand Sharon Bennett explains how to create natural-looking lips for millennials 67 In The Life Of: Dr Galyna Selezneva Getting to know a practitioner renowned for her body sculpting treatments 68 The Last Word

Clinical Contributors Dr Eleanor Reid is an aesthetic practitioner and dental surgeon, graduating from Newcastle University. Dr Reid has a background in maxillofacial surgery and dentistry and is lead trainer in Newcastle-upon-Tyne for Acquisition Aesthetics. Miss Lara Watson is dual qualified in medicine and dentistry and works as a surgical trainee in oral and maxillofacial surgery. Dr Watson is a faculty member for Galderma and is also a co-founding director of Acquisition Aesthetics. Miss Priyanka Chadha works as a plastic surgery registrar in London and is co-director of Acquisition Aesthetics training academy. Sha has higher degrees in surgical education and training. Dr Chadha is a faculty member for Galderma. Dr Paolo Bonan is the head of dermatology and in charge of the laser cutaneous cosmetic and plastic surgery unit, Villa Denatello Clinic, Florence, Italy. He is also a professor in Laser Surgery at the University of Rome.

IN PRACTICE

In Practice Meditation in Aesthetics Page 57

Khatra Paterson highlights issues around using celebrity images for marketing

NEXT MONTH

Dr Firas Al-Niaimi is a consultant dermatologist, Mohs and laser surgeon. He is a group medical director at sk:n clinics and is a senior research fellow in the dermatology and laser department at Aalborg University, Denmark. Anna Kremerov is an advanced nurse practitioner and a registered prescriber. She has a master of science in advanced clinical practice, as well as Level 7 in injectables for aesthetic medicine. Robert Sullivan is a progressive podiatrist and surgeon, a fellow of the open college of podiatry and a member of the college of podiatry. He has worked for many years in the fields of non-thermal laser medicine. Mr Dario Rochira is a plastic surgeon practising on Harley Street with more than 15 years’ experience in cosmetic surgery. He trained at the Catholic University in Rome and is a member of BAPRAS and ISAPS.

IN FOCUS: MEN • Treating the Male Perioral Area • Toxin for Men

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Editor’s letter Well, what crazy and uncertain times we’re living in at the moment. As a result of the spread of COVID-19, at the time of writing, the Prime Minister has just announced a nationwide lockdown, meaning only key workers are permitted to leave their houses Chloé Gronow for work and all others should work from Editor & Content home. For many of you reading this, working Manager from home is simply not an option. As a result, @chloe_aestheticseditor aesthetic clinics across the country have had to close their doors for the foreseeable future. By the time this journal reaches you, the situation is likely to have evolved again. There’s no sugar-coating it, it’s likely that we will all face challenges in keeping our businesses running over the next months and you may find that staying positive is difficult. But remember, as aesthetics practitioners, you are part of a hugely supportive community. In the past week, we have seen numerous manufacturers, suppliers and service providers offering their support and business advice to clinic owners, while practitioners are rejoining

the NHS to support the stretched workforce as best they can, as well as sharing their hygiene tips and knowledge of protecting yourself and others from risk of infection across social media. We detail some of their best advice in our News Special on p.16. And if you’re feeling stressed, have you considered meditation? Dr Amiee Vyas explores the benefits of meditating for both you and your patients on p.57. Here at Aesthetics, we encourage you to use time out of clinic to focus on your continued professional development. As well as our excellent CPD article in this month’s issue on the anatomy of the tear trough, you can read all our past CPD articles on our website. For every one you read you will be issued a certificate that can be used for your professional revalidation. You can also join a webinar about the new peeling product, AlphaRet Professional Peel System, from AestheticSource on April 28. This will be hosted on our website from 6pm and cover everything you need to know about using the peel and how it can benefit your patients! Sending love and best wishes from all the Aesthetics team – stay strong, share your experiences so we can all learn from one another, and we’ll hopefully see you in person soon!

Clinical Advisory Board

Leading figures from the medical aesthetic community have joined the Aesthetics Advisory Board to help steer the direction of our educational, clinical and business content

WE WANT TO HEAR FROM YOU!

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with more than 20 years’ experience and is director of P&D Surgery. He is an international presenter, as well as the medical director and lead tutor of the multi-award-winning Dalvi Humzah Aesthetic Training courses. Mr Humzah is founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow. Do you have any techniques to share, case studies to showcase or knowledge to impart?

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic nonsurgical medical standards. She is a registered university mentor in cosmetic medicine and has completed the Northumbria University Master’s course in non-surgical cosmetic interventions.

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

Mr Adrian Richards is a plastic and cosmetic surgeon with 18 years’ experience. He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

Dr Raj Acquilla is a cosmetic dermatologist with more than 12 years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer for botulinum toxin and dermal fillers.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multi-award winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts.

Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She has recently completed her Master’s in Aesthetic Medicine, for which she is also a course mentor. Partridge is a founding board member of the British Association of Cosmetic Nurses and has represented the association for Health Improvement Scotland.

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 AntiAgeing Experts. Dr Patel is passionate about standards in aesthetic medicine.

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

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Webinar

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#Tweakment @drarielhaus Thank you @drritarakus_ and @alicehartdavis for inviting the @drarielhaus team to be a part of the #TweakmentsClinic at St John’s Hyde Park last night – it was a fantastic event and opportunity to meet fellow practitioners and educate patients on the different treatment options we provide. #Training @dr_marcus_mehta Fantastic day at our London facial aesthetics training school meeting and presenting to a panel of journalists, influencers and editors! We presented all about injectables and 2020 trends to look out for! #aesthetics #Safety @marcpacifico @thebaaps council meeting in beautiful #cheltenham. Privileged to be surrounded by hard-working colleagues of integrity who all give up their time to contribute to the specialty #patientsafety & #patienteducation #Speakers @sinclair_uk What a great day at our North Regional Meeting in Manchester hosted by @joannesinclairpharma Thank you to all of our speakers @drsaleenazimri @dr_mj_smileworks @dr.raj.thethi @patriciagoodwin4950 for your fantastic presentations and demonstrations today! #Webinar @leewalker_academy Thank you for everybody who tuned in for todays impromptu webinar. Few behind the scenes shots with @drcetto. Huge thanks to @teoxanelabuk for hard work and pulling it together in less than 24 hours!!! #teoxanelaboratories #teoxaneapproach

AestheticSource to hold AlphaRet peeling webinar Award-winning product distributor AestheticSource will share an online masterclass on the new Skinbetter Science AlphaRet Professional Peel System and sunbetter Tone Smart SPF 50 on April 28. Hosted on the Aesthetics journal website from 6pm, the interactive session will be led by nurse prescriber Anna Baker and Dr Amiee Vyas, who will introduce the technology and detail the commercial benefits of the products. The pair will also showcase a video of the treatment in action, describing how it should be used and the results that can be achieved. According to AestheticSource, the innovative new peel combines the power of the AlphaRet technology with a proprietary triple acid blend formula, which is designed to treat a broad range of patients and skin types. The company adds that the Tone Smart SPF 50 is a 100% mineral-active sun protection in a tone-adapting compact that provides a hint of colour upon application. Vikki Baker, marketing manager at AestheticSource, said, “We are delighted to be able to share two of the latest Skinbetter Science brand innovations in a remote learning experience, led by Dr Amiee Vyas and Anna Baker. AestheticSource is committed to supporting businesses and continuing education via alternative solutions in the current climate.” Dr Amiee Vyas commented, “I’m very excited to be presenting on the webinar launch of the AlphaRet Professional Peel System and Sunbetter. I think these peels have the potential to change the way we approach patient treatment plans in practice and that the session covering technologies, clinical approaches and profitability is going to be very useful for attendees.” Details on how to join this webinar will be shared via email and social media in the next couple of weeks. Please note the agenda is subject to change or be postponed as a result of the COVID-19 pandemic. LED

Battery-powered Celluma devices released Light emitting diode (LED) device manufacturer BioPhotas has introduced the Celluma iSeries to the Celluma portfolio of light therapy devices. The series offers battery-powered options of the company’s most popular models, the Celluma PRO and the Celluma LITE. BioPhotas will also be offering to upgrade any previously sold Celluma devices with the battery-powered option, allowing current owners to get the latest technology features. President and CEO of BioPhotas, Patrick Johnson said, “We are excited to introduce the Celluma iSeries, the first battery-powered LED ‘panel’ device that is FDA-cleared and medically CE-marked for treating a variety of skin, muscle and joint conditions. Now the convenience and efficacy of the Celluma series is enhanced so it can be used anywhere and anytime. Advances in battery technology have also allowed us to provide multiple Celluma treatment cycles without impeding versatility or portability.”

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Awards

Aesthetics Awards shortlisted for prestigious industry awards ceremony The Aesthetics Awards ceremony has been shortlisted as a finalist in the Best Awards Event by a Publisher category at the Awards Awards. The Awards Awards is an event that celebrates the very best of the awards industry and is dedicated to recognising those who normally work behind the scenes. The category for Best Awards Event by a Publisher is judged on innovation, success and creativity of the event, plus evidence of optimal leverage of the link between the publication and the awards brand. Chloé Gronow, editor and content manager at Aesthetics Media, part of Easyfairs, the company behind the Aesthetics Awards and Aesthetics journal, said, “This is the perfect way to commend the collaboration between our awards ceremony and the journal, which are both valued by so many in the medical aesthetics specialty. We work hard to interlink the two, alongside our conferences and exhibitions ACE and CCR, to offer the aesthetic community everything they need to learn, network and celebrate their successes in this ever-changing specialty.” She continued, “Entering the Awards is also a chance for us to reflect on our own work and aspire to make the Aesthetics Awards even better year on year. We already have some exciting plans for the 2020 ceremony in December, so look out for them in our May issue when entry opens!” Practitioners, companies and products can all enter the Aesthetics Awards from May 1. The ceremony will take place in London in December.

Vital Statistics

321 million new people joined social media in 2019, which made a total of 3.8 billion social media users at the start of 2020, an increase of 9% (Hootsuite, 2020)

By 2021, it is estimated that more than half of companies will use LinkedIn for marketing (emarketer.com, 2020)

It is estimated that CBD skincare could account for around 10% of global skincare sales within the next 5-10 years (Prohibition Partners, 2020)

Aftercare

New disinfectant available through Healthxchange Aesthetic supplier Healthxchange Pharmacy is now the exclusive UK distributor for aftercare treatments Thoclor GF1 and GF2, manufactured by biotechnology company Thoclor Labs. Thorclor explains that the GF1 is an in-clinic aftercare treatment designed to support the skin’s healing process, prevent infection, control inflammation, reduce the risk of scarring and shorten recovery time. The company states that it can be used for treatments that compromise the outermost layer of the skin, including microneedling, dermaplaning, peels, fillers, laser, waxing and permanent makeup. The Thoclor GF2 Skin Rejuvenation is an additional treatment that patients can take home and add to their skincare routine. It is specifically designed to combat inflammageing. Dr John Curran, chairman of Healthxchange Group, commented, “Most cosmetic medical procedures carry a risk of infection and often prolonged inflammation. Thoclor, a novel hypochlorous acid-based system, has the dual quality of effectively eradicating pathogens on the skin, protecting against post-procedure infection and has powerful anti-inflammatory effects; quickly reducing redness.”

32% of people said that they have aesthetic procedures to feel more confident and 24% said it was to look more attractive (The Private Clinic, 2020)

Over the last four years, the global male aesthetics market size has maintained an annual growth of 5.45% (Statista, 2020)

64% of consumers said they look for products with recyclable packaging (SOIL association, 2020)

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Skin

AestheticSource becomes new Oxygenetix distributor Aesthetic distributor AestheticSource is now the exclusive UK supplier of US skincare and foundation brand Oxygenetix. Oxygenetix is a post-procedural foundation, designed for use after a variety of skin treatments, such as laser hair removal, chemical peels, facial surgery and acne treatments. The foundation contains an oxygen-enriched formula that aims to increase the body’s cell production of collagen and elastin which, the company claims, provides a quicker healing process. Lorna McDonnell Bowes, co-founder and CEO of AestheticSource, commented, “We are thrilled to be introducing Oxygenetix to our portfolio of brands. We’re looking forward to growing the brand’s clinic base and providing the strong support it deserves to expand in the aesthetic arena, working with existing and new customers as we further develop this excellent brand.”

Study indicates rise in allergies to natural skincare ingredient A study published in the British Journal of Dermatology has indicated that allergies to propolis, an ingredient found in many natural skin products, has more than doubled since 2007. Propolis is a mixture that honeybees produce by mixing saliva, beeswax and plant exudates, and it can be found in a range of cosmetics such as shampoos, conditioners, lipsticks, lip balms, lotions and toothpastes. The analysis of 125,436 people took place between 2007 and 2018 across Germany, Austria and Switzerland, and gathered data using patch tests. Between 2010 and 2018, the study found an increase of 68% in positive allergy testing to propolis. Professor Wolfgang Uter, lead author of the study, said, “The increase in allergy to propolis that we have observed certainly warrants targeted investigation of what is driving sensitisation. At present, we do not know the full extent of its availability and how widely it is used. If the allergy trend continues, we will need to consider a reassessment of risk, and probably risk management such as a limit on the concentration of propolis allowed in products that are left on the skin.” Nina Goad, head of communications for The British Association of Dermatologists, commented, “Currently, propolis is not routinely included in patch testing in the UK, so the level of allergies here cannot be fully established. However, if trends in its use in the UK show an increase, a similar situation would be expected in our allergy clinics. While there may be benefits to natural skincare products, it shouldn’t be assumed that they are safer for the skin than their non-natural counterparts. If somebody experiences a skin reaction, a natural skin product shouldn’t be ruled out as the culprit.”

Industry

Business

Miss Sherina Balaratnam becomes global ambassador for iS Clinical

Skincare company iS Clinical has announced that surgeon, aesthetic practitioner and medical director of S-Thetics clinic, Miss Sherina Balaratnam is its first global brand ambassador. Miss Balaratnam commented, “I am hugely honoured that I am the first doctor globally, outside the US, to be invited to act as a brand ambassador for iS Clinical, at the personal invitation of the company founders. I have worked with cosmeceutical skincare for more than 10 years, with iS Clinical for more than four years, and have seen literally hundreds of our patients benefit from sometimes life-changing improvements in skin quality. I am immensely proud to be representing a company and products of such unwavering commitment to quality, purpose and ethics and look forward to exciting plans moving forward.”

Healthxchange introduces new patient postal service

Aesthetic supplier Healthxchange Pharmacy has launched its Direct to Patient Service, which allows customers to send skincare and other topicals direct to a patient address rather than to a clinic. The company states that this is to reduce patients’ needs to meet in person whilst they are all social distancing, allowing them to continue with their skincare routine as well as helping clinics continue to offer services. Dr John Curran, chairman of the Healthxchange Group, commented, “At this time, it’s important to think of ways to do business remotely. Our new Direct to Patient Service will help our clients be proactive, keeping sales and revenue without having to pay for inventory or lose business elsewhere.”

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Skincare

Complications

5 Squirrels releases new skin cleanser Private label cosmeceutical supplier 5 Squirrels has introduced a new skin cleanser, Clear, to the Your Signature Range of own-brand products. The company explains that the cleanser contains three key active ingredients: 10% glycolic acid, 3% salicylic acid and 2% lactic acid. The glycolic acid aims to dissolve the bonds of thickened dead skin cells, causing exfoliation of the upper surface to reveal newer hydrated heathy skin. Salicylic acid has anti-inflammatory properties, which work as a keratolytic by exfoliating the skin deep within the follicles. Lactic acid is specifically selected due to its ability to exfoliate the skin, lighten dark spots, and improve cell turnover, according to 5 Squirrels. Gary Conroy, co-founder of 5 Squirrels Ltd, said, “Over the past year our loyal clients challenged us to formulate a high strength product for oily skin. Yet again we have risen to the challenge. Clear has been tested in many clinics, producing fantastic results. Many of these clinics now have a waiting list to purchase this product so we’re delighted to be bringing it to market!” Radiofrequency

InMode launches new device Medical device manufacturer InMode has released Evolve, a non-invasive hands-free workstation designed to remodel skin, treat adipose tissue, and tone muscles using radiofrequency and electromagnetic pulses. The company explains that the device is founded on a threedimensional approach to tissue remodelling, deploying three proprietary technologies – Tite, Trim and Tone – allowing for customised treatment for a variety of body types. Shakil Lakhani, president of InMode North America, commented, “Our ability and success in bringing innovative solutions to the market are derived directly from listening carefully to our customers. The demand for an all-inclusive body solution in the non-invasive space is long overdue. We are proud to be the first company to offer the full range of treatments from non-invasive to minimally invasive in this segment. This exciting new technology is the latest addition to the InMode portfolio; as we continue to innovate, this ecosystem will only become more robust.” Eyes

Medik8 releases new eye balm UK skincare manufacturer Medik8 has launched a periorbital hydrating product called Illuminating Eye Balm. The formulation includes cucumber extract that aims to cool the area, red algae extract to regulate osmotic pressure under the eyes and reduce puffiness, and hydrating actives glycerine and hyaluronic acid, which draw moisture from the lowers layers of the skin, according to Medik8. The company states that Illuminating Eye Balm gives both immediate and long-term brightening of the under-eye area.

Survey highlights lack of hyaluronidase awareness A survey conducted by aesthetic practitioners Dr Mohamed Hani and Dr Philippe Hamida-Pisal has indicated that there is a lack of standardisation for the training and practical use of hyaluronidase in aesthetic practice. 100 UK-based practitioners, from different backgrounds and levels of experience, answered questions about the use of hyaluronidase to correct problems related to dermal fillers. Although all practitioners confirmed that they believe hyaluronidase is essential for anyone practising dermal fillers, less than 60% of those surveyed had received formal training on how to administer the injectable. As well as this, 90% of those surveyed said that this should be an essential part of dermal filler training activities. Dr Hani commented, “Current literature has confirmed the essential role of hyaluronidase in aesthetic practice to correct and treat a number of acute and non-acute complications that could arise from dermal filler. Of note, the evidence supporting the above remains empirical and somewhat inconsistent. That may in turn lead to inconsistency in the theoretical knowledge, practical training agendas and clinical usage of hyaluronidase among aesthetic practitioners.” Sun protection

New tinted SPF launches Skincare company Institut Esthederm has introduced the Photo Reverse tinted high protection cream to its suncare range. The company explains that the cream is especially formulated to offer UV protection for hyperpigmented skin, while also giving it a tint of colour. According to the company, its global cellular protection technology helps to prevent cellular damage and gradually brightens the skin. The formula also contains yellow and orange pigments which aim to protect skin against blue light. Dermatologist Dr Ariel Haus commented, “Photo Reverse specifically targets hyperpigmentation with brightening peptides and powerful antioxidants. This can help protect against oxidative stress by neutralising free radicals, which are all around us in UV light, visible light, stress and pollution.”

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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

BACN PRIDE

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Menopausal skincare

Mesoestetic launches two intradermal solutions

There is no question that this is an extremely difficult time. Many are closing their businesses and offering their skills back to the NHS. The BACN is applauding those who have taken the decision to work temporarily in the NHS; helping out, giving valuable expertise to the public and helping to ease the burden that has been placed on NHS staff.

RENEWALS AND EVENTS While the BACN could not be prouder of how members have reacted in this unprecedented situation, we operate our renewals period during April and May. Unfortunately the BACN simply cannot exist without the financial commitment from members in each membership year. The BACN is looking at all possible ways to continue, whilst also understanding issues members are having with finances at this time and have contacted members to discuss in more detail. As members will be aware, the BACN was due to begin the Spring/ Summer regional meetings in the coming months. The BACN is assessing the viability of hosting all events four weeks out and will be notifying members of cancellations at this point, if not before. The BACN hopes that some of the later dates will still be able to go ahead, however this promise cannot be made at this moment in time.

Pharmaceutical company mesoestetic has introduced two new products for intradermal injection to its mesohyal range, mesohyal REDENX and mesohyal ARGIBENONE. mesohyal REDENX is aimed at treating gravitational wrinkles whilst enhancing skin density and firmness. The company explains that it combines a tripeptide and a tetrapeptide to activate the synthesis proteins of the extracellular matrix, improving the redensification biological mechanisms impaired by the reduction of oestrogens and other factors of ageing. mesohyal ARGIBENONE is an antioxidant solution aimed at reducing dynamic expression lines and photo-induced damage by combining a biomimetic hexapeptide and idebenone with hyaluronic acid. This acts on the formation process of expression lines and on the key cell pathways that are altered during the ageing process, the company claims. Adam Birtwistle, managing director of mesoestetic UK, said, “Our two new ampoules, mesohyal REDENX and mesohyal ARGIBENONE represent a new generation of biological active ingredients formulated with biomimetic peptides; expect the high quality and results associated with products from mesoestetic combined with care and innovation. These two products alone offer the complete antiageing solution, with particular reference to the often-neglected needs of menopausal skin.” Body contouring

VIRTUAL SUPPORT The BACN has been working tirelessly with its regional leaders, strategic partners, sponsors and BACN Board to deliver members valuable resources and information during this time. The BACN is currently working with partners to provide resources and for these to include pre-recorded demonstrations, educational presentations, business advice and much more from industry-leading voices. These will be followed by Q&A sessions with the speakers who were booked to attend. In addition, the BACN is also planning to provide a peer-to-peer support session during the online meetings whereby members can ask questions to the group and their regional leaders. Please contact Tara Glover at tglover@bacn.org.uk to talk through the steps needed to take part. This column is written and supported by the BACN

New cryotherapy machine launches US aesthetic equipment brand Zemits has launched in the UK, introducing its CoolRestore cryotherapy device to the market. The device has two treatments modes: cryo mode and smart mode. According to Zemits, the cryo treatment mode uses cold therapy as low as -18°C, and can be performed in one target area for anywhere between 15-30 minutes. The company explains that this allows for the skin to cool to a temperature that enables fat elimination and skin firming. The smart treatment mode has a preset protocol that changes between hot and cold therapy, alternating between two minutes of each. Referred to as shock thermal therapy, the company states that this boosts the effectiveness of eliminating adipocytes. CoolRestore also has a handpiece that is able to measure the current temperature of the skin, and indicate that on the device’s screen. Zemits explains that this allows the operator to always be aware of the patient’s current temperature.

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Skincare

Skinbetter Science releases two new products Skincare company Skinbetter Science has introduced two new products to its portfolio, the AlphaRet Professional Peel System and the sunbetter tone smart SPF 50. The AlphaRet Professional Peel System, formulated with lactic, glycolic and salicylic acid, comes in two strengths – 30 and 50 – which the company explains is to benefit a broad range of patients and skin types. Skinbetter Science states that strength 30 is designed for patients with mildly photo-damaged skin, including those with early signs of ageing and blemishes, whereas strength 50 is aimed at patients with moderate photodamage, fine lines and wrinkles, hyperpigmentation, blemishes, uneven skin tone and dullness. The sunbetter tone smart SPF 50 is a mineral-active sun protection product in a toneadapting compact, that also tints the skin. It contains active ingredients, zinc oxide and titanium dioxide. Skinbetter Science explains that this is ideal for patients post treatment, or those with sensitive skin, because it provides protection from UVA and UVB rays, blue light and infrared radiation. Skinbetter Science is distributed in the UK exclusively by AestheticSource. A webinar on the two products will be hosted on the Aesthetics website on April 28 from 6pm. On the Scene

Thames Skin Clinic opening, Twickenham

On March 6, Thames Skin Clinic opened its doors to journalists and practitioners for its spring launch event. Over the course of the day there were educational talks about a variety of topics, including growth factors, facial redness, how to achieve healthy skin, how wrinkle treatments work and the art of achieving natural looking results. There were also live demonstrations showcasing treatments offered in the clinic, such as a Plasma Shower facial and a ZO Stimulator Peel. Clinic owner and aesthetic practitioner Dr Anna Hemming, said, “It’s been a 12-year journey for me to open this clinic, and along the way I’ve learnt what’s important – making sure the licenses are correct and that the environment is safe for patients. We offer a full range of antiageing and skin treatments, as well as injectables. I have my own bespoke protocols under the Thames name, so we really do look after individual’s skin and we want to take them on a journey.”

News in Brief BABTAC criticises non-medic influencer injectors The British Association of Beauty Therapy and Cosmetology (BABTAC) has released a statement expressing concerns with the rise of non-medically trained influencers administering injectables. To highlight the importance of medical training, BABTAC has released a photo of a medical emergency kit to encourage patients to question whether their practitioner is in possession of this kit, as well as the risks associated with going to an untrained injector. BABTAC has also suggested a number of other questions that patients should ask when considering injectable treatments. ABC lasers expands business UK laser and light-based device distributor ABC Lasers is expanding its national sales team, with the promotion of Adam Bashier to national sales director as well as hiring two new business development mangers, Marianne Evangeli and Albert Best. Bashier, previously a business development manager for the company, said of his new position, “It’s been an exciting seven years working for ABC Lasers. I am proud to head up such a dedicated team for such a strong and well respected brand in the laser sector.” Scottish Government to collect evidence for complications As part of its current Consultation on the Regulation of Non-Surgical Cosmetic Procedures in Scotland, the Scottish Government is collecting information on a UK-wide basis in an attempt to gather evidence on harm caused by non-surgical cosmetic procedures. The Government states that they need information to inform their next steps, because it is proving difficult to obtain reliable evidence to support the reported increase in complications. Submissions to the questionnaire must be submitted by April 17. iS Clinical launches travel-sized balm Skincare company iS Clinical has launched a travel-sized version of the Sheald Recovery Balm. The company states that the new size means patients can take their aftercare treatment while they’re travelling, making sure they can regularly apply and ensure optimum post-treatment results. The company recommends that the balm is used post procedure to prevent scabbing and itching, minimise scars and help wound healing. It can also be used as a daily moisturiser for dry and irritated skin. Harpar Grace International is the exclusive UK distributor of iS Clinical.

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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On the Scene

Skin of Colour Workshop, London On March 12, Black Skin Directory (BSD) hosted a Skin of Colour Workshop at the Harley Academy, London. The purpose of the event was to educate skin health professionals on the needs of skin of colour patients, and how best to treat their concerns. Throughout the day there were talks from various speakers including; oral and maxillofacial surgeon Ms Natasha Berridge, aesthetician Andy Millward, aesthetic practitioner Dr Ifeoma Ejikeme and consultant dermatologist Dr Sandeep Cliff. Dija Ayodele, CEO of BSD, said, “It was great to see so many professionals in the room On the Scene

dedicated to furthering their knowledge in skin of colour concerns. The workshop was a complete sell out and a huge success. The speakers kept the delegated engaged

all day with interesting content, from understanding how melanocyte activity is different to why skin whitening and bleaching is still prevalent in some communities. The Q&A sessions delivered practical nuggets that the delegates could take back to their clinics to provide a higher level of service to the skin of colour patients which no doubt will have a positive effect on their bottom lines too! We were grateful to have the support of AestheticSource who supported the delegates learning with goody bags containing Cyspera and Clinisept+.”

On the Scene

UCL Aesthetics MS Launch, London On March 12, leading aesthetic surgeons and practitioners came together for the launch of the Master of Surgery course in Aesthetic Surgery and Minimally Invasive Aesthetics. Based at University College London (UCL), the Master’s degree will launch in September 2021. The programme aims to provide clinicians with a rigorous education in clinical skills, contemporary best practice and evidencebased principles in aesthetics. Programme leader Professor Ash Mosahebi welcomed attendees to the launch, before giving a keynote address on trends and opportunities within the medical aesthetic profession. Dr Eqram Rahman shared an overview of the course, while other talks discussed advanced aesthetics in breast and torso treatments, advanced aesthetics in the head and neck module, an introduction to advanced aesthetic practice for minimally-invasive treatments and the impact of postgraduate programmes in aesthetics. Following the event, Dr Rahman commented, “The launch was wonderful; the diversity of discussions was outstanding and the sessions were engaging and insightful. There was a lot of stimulating discussion around evidencebased practice which, to my knowledge, the only such initiative to promote, practice and excel the patient safety and care in the field of aesthetic medicine by a higher education institute in the UK.”

Mentorship Workshop, Harley Street Following the postponement of ACE 2020 last month, Aesthetics Clinical Advisory Board member Dr Tapan Patel offered to hold a free workshop for a small group of practitioners who had travelled to London for the event. Taking place at Dr Patel’s PHI Clinic in Harley Street on March 13, the session gave practitioners new to aesthetics the opportunity to ask questions and discuss best practice within the specialty. As a key opinion leader and award-winning clinic owner with more than 20 years’ experience, Dr Patel was able to share valuable insight on patient retention and product selection, as well as advising on complication prevention and management. One of the first questions asked was, how do you get more patients? Dr Patel recommended practitioners aim to hold clinics at least once a week and dedicate as much time to patients as possible. “Even if you haven’t got many patients, still book an hour with them,” he said, adding, “Ask lots of questions and really take your time to assess their concerns. It’s all excellent learning opportunities for you, and patients will value your time. Give great service and go the extra mile.” The delegates noted that one of the main challenges they face when it comes to patient retention was competition, particularly from non-medics practising in their locality. Dr Patel reminded the practitioners that their unique selling point is that they are medical professionals, often with years of clinical experience, so they should really emphasise that in their marketing. He also urged practitioners not to offer financial incentives for treatments, as doing so would be a breach of Advertising Standards Authority guidelines and professional codes of conduct. “As an alternative, consider offering added value to your patients’ treatments with a facial or glycolic acid peel,” he suggested, emphasising, “Never compromise your ethics and remember that your best advocate is your patient – it’s much more expensive to recruit a new patient than it is to look after your existing.” The next question asked was how do you choose treatments and products for your clinic? Having trialled numerous injectable brands and energy-based devices, Dr Patel advised delegates to always analyse the studies behind the products, look at their track record and the expert panel using them. He noted, “Don’t choose something just because it’s cheaper – I always ask myself, ‘Would I use this on my mum?’ and if the answer is no, then I wouldn’t use it on my patients.”

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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ACE Group conference

members Dr King, Dr Cormac Convery, Dr Lee Walker, nurse prescribers Emma Davies and Sharon King, and prescribing pharmacist Gillian Murray presented on A report from the Aesthetic Complications and discussed the latest in complication prevention and management. Dr Convery explored the causes Expert Group annual conference and treatments of delayed onset nodules, while tips The importance of face-to-face diagnosis, early intervention for dealing with an aesthetic emergency were covered by aesthetic and the use of an evidence-based approach were highlighted nurse Linda Mather, who discussed the ACE Group’s emergency throughout the Aesthetics Complication Expert (ACE) Group hotline, which is open to all members. Murray, Dr Convery and Dr conference on March 11. Co-founder and chair of the ACE Group King all discussed the causes, diagnosis and treatment approaches Dr Martyn King opened the day, welcoming 400 delegates to the for vascular occlusions, highlighting the need for fast intervention and Birmingham Repertory Theatre for the first conference of its size. support from colleagues when necessary. Aesthetic practitioner Dr He brought attention to the Group’s newly published complications Lee Walker presented several talks on anatomy; one included his top book and thanked AestheticSource for suppling Clinisept+, as well considerations for treating the lips, where he highlighted the need for as Hamilton Fraser Cosmetic Insurance and Acre Pharmacy for practitioners to inject superficially for safer injections and to avoid the their presence at the event. Throughout the day, ACE Group board philtral column. Dr King also shared dozens of images from the ACE Group Facebook forum, educating delegates about the differences between a vascular occlusion and a bruise, and Murray, Dr Convery and Dr King all discussed the causes, diagnosis and treatment approaches for vascular occlusions. The speakers then came together at the end to answer audience questions in a panel discussion. Dr King said he was extremely proud following the event, commenting, “The feedback has been amazing. I would like to personally thank all board members who have worked tirelessly, giving up their own time, to make the conference a huge success. Some delegates have even commented that it is the best conference they have ever attended.” Following the success of the day, Dr King confirmed that the ACE Group is planning to run another conference in 2021, with the date yet to be released.

IMCAS ASIA 2020 Preview

A first look at the Asian edition of the International Master Course on Ageing Science

IMCAS is traveling to Bangkok, Thailand from October 15-17 in collaboration with The International Thaicosderm Congress of Aesthetic Medicine (ITCAM) of the Thai Society of Cosmetic Dermatology and Surgery (THAICOSDERM) to host the 14th edition of IMCAS Asia.

The event was conceived to create a meeting ground for medical professionals in dermatology, plastic surgery and related fields. The scientific programme offers more than 160 sessions featuring the latest research and techniques with a systematic look at specificities of Asian morphologies, so that attendees may provide the best care to patients of all ethnicities. 15 key themes, including injectables, lasers and energybased devices, clinical dermatology, genital treatments, regenerative medicine, face and body surgery, form the foundation to underpin attendees’ progress. Leading the list of dynamic courses is the Anatomy on Cadaver Workshop, a unique series of sessions that combine live broadcasts of cadaver dissections and live patient demonstrations of non-surgical procedures to help attendees avoid danger zones. For those seeking more action, the 70 exhibiting companies and their proposed activities such as live demonstrations and symposia give delegates the chance to explore the latest innovations and products, and gauge their effectiveness. Register before August 15 on www.imcas.com to benefit from early bird rates! This report is written and supported by IMCAS

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Managing a Clinic during the COVID-19 Pandemic Aesthetics speaks to professionals for their advice on running a business during these challenging times At the time of writing, the UK Government has imposed a nationwide lockdown in order to reduce the transmission of coronavirus (COVID-19).1 The World Health Organization (WHO) has labelled the spread of the virus a ‘global pandemic’,2 with thousands across the world infected and hundreds of deaths in the UK.3 As a

Closing the clinic Aesthetic practitioner Dr Vincent Wong chose to close his clinic on March 18. He said, “London has the highest number of COVID-19 cases in the UK and, naturally, a lot of patients are worried about their own health. When the Government suggested everyone to stay home as much as possible, many patients had already rescheduled or cancelled their appointments. From a personal point of view, I have to be extra careful with exposure to others because of my lung surgery two years ago.” Dr Wong has suspended all cancellation policies. Aesthetician and founder of Black Skin Directory, Dija Ayodele, had only recently opened her new clinic, West Room Aesthetics. She made the decision to close on March 20. She said, “I think even with all the measures we had put in place, it was right to close, even in the absence of a direct diktat from the government at the time. The health of all our clients is paramount and there is no safe way to maintain a two metre boundary so closure was naturally the next step. That said, all our clients have been super understanding and supportive, with a rush of last minute skincare orders! I’ve been really touched (to tears!) with the emails I’ve received, which just goes to show how far client goodwill is for businesses who do the right thing. I am confident that when this crisis is over, the relationship will be stronger than ever.” Virtual consultations Many practitioners will be considering communicating with patients via video messaging for the foreseeable future,

result of this tragic outbreak, not only are people’s lives at risk, but their livelihoods too. And while some businesses can function on a work-from-home basis, many, such as aesthetic clinics, cannot. So, what can you do to keep your business going and spirits up?! Aesthetics talks to a range of professionals for their words of advice.

offering consultations and skincare advice. For those who aren’t as technologically savvy, it can be quite daunting. As such, Dr Wong advises: • Be prepared by ensuring you have a good internet connection, good quality sound and lighting to aid the communication and the ability to take notes – have patience as the process will take longer than anticipated (from both physician and patient) • It is important to assess patients’ needs, but we must explain the limitations of video consultation at the start • Use positive body language by sitting up straight, using open hand gestures and having a smiling face to build up effective rapport and engagement in the virtual platform • Recognise that this may be a brand new experience for some, so make sure your patient is in a comfortable setting (and confidential safe space) with good lighting • If possible, conduct the video consultation on a laptop/computer so that the patient can send photos to your phone during the consultation. This will also allow you to annotate photos to send back to the patient to ensure that key messages are delivered Encouraging patient safety Advising patients on staying safe is, of course, imperative during these uncertain times. Dr Wong notes that as well as recommending use of hand sanitisers and disposable gloves, he is

suggesting patients take vitamin C and zinc supplements to help boost immune systems. “The pandemic outbreak can also cause a lot of anxiety, so I’m advising my patients to meditate too,” he adds. So how do you maintain interest in your services over the next few weeks? Dr Wong says, “I guess the key is to empathise – many of our patients will be facing salary cuts or loss of earnings, so they may have limited funds to invest in treatments. During this period, it is important to keep up the level of engagement and educate them on good medical grade skincare so that they can still maintain skin quality without spending too much. When we enter the ‘recovery’ phase, it would be a good time to offer discounts or subscription services to encourage patients to have treatments.” Moving forward, Dr Wong emphasises that practitioners need to stay updated with the science around COVID-19. “As medical professionals, patients may look to us for advice and reassurance,” he says. Business continuity With reduced patient time, Ayodele recommends that practitioners look at what else they can offer. She asks, “Can you post products? Can you film content that you can retail on your website?” All are strategies that aim to retain patient engagement and maintain sales, she says. Ayodele also suggests thinking of your future plans. “Get out the flip-chart and start working on ideas and business continuity plans; plan for 12 and 18 months’

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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time so when this is over you can hit the ground running. Keep your notebook handy so you can jot down thoughts and ideas,” she explains. It could also be a time to assess your

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current business focus. Ayodele notes, “It’s a great time to look at your current processes and see whether you actually need some of them. You may be able to fine tune the business and actually

become more agile and responsive.” Ayodele adds, “Try not to worry; we’re all, to some degree, in the same boat and where possible, let’s all band together and help each other out.”

As a result of the pandemic, the Aesthetics Conference and Exhibition (ACE) 2020, planned for last month, has been postponed. In the meantime, speakers from the Business Track agenda share their advice on keeping your clinic running Alan Adams, The Top Clinic Coach “This isn’t about business as usual. This is about something much more important than that; it’s about relationships, staying in touch with the people that are most important to you and recognising that right now they are not focused on aesthetics. What they’re looking for is reassurance, kindness and connection. By offering that, you’re focusing on relationship and not business, which means you’re going to have a win in the mid to long term. Make everyone feel that we are all in this together and will get through it. I’d recommend doing an individual video message to your top 50 customers. It may take a while, but it will make your patients feel valued. As soon as things are a bit clearer around what’s happening, you can send a more generic message with an offer for when they return. And just to put all this into context, our grandparents and great grandparents faced a situation where the Government was telling them that they were going to war; we’re being told to stay at home.”

how to stay well when health is threatened. Finally, contact other practitioners in your area and offer support – I recently reached out to a long-standing competitor and we are good pals now! Networking is a highly valuable tool; you never know where it can lead and we can always learn valuable lessons from each other.”

Alex Bugg, Web MarketingClinic “Use your extra time to focus on health and family first, but if you need a task to focus on, then why not use it for auditing and updating your website, writing educational content for your blog, and gathering reviews from patients for Google? All of this will benefit your search engine optimisation. The blogs or other content you write will also be useful for filling up your social media pages, when you want to keep them active.”

Julia Kendrick, Kendrick PR “In times of crisis, regular and balanced communication is critical. Ensure you have regular posts on your website, blog and social media to clarify your business status (closed, online consults, free advice etc) and to also encourage the health and welfare of your patients and their families – help direct people to the proper sources of information, and combat negativity and panic with a considered and sensitive tone. Be mindful of the balance between a commercial approach and looking opportunistic – any moneyoff offers or frivolous marketing strategies could be deemed in poor taste and result in a backlash. In difficult times your brand has the opportunity to truly showcase your values and what you stand for. Look for ways to showcase your support for patients and the broader community – whether that’s providing supplies for local charities, or perhaps some of your staff are switching back to support the NHS in this time of need.”

Emma Coleman, nurse prescriber “I think staying focused on our core brand USP will help us through these trying times; going back to what we wanted to achieve in our clinic from day one will help us decide how to manage this unprecedented situation. Maintain quality communication with your patients through as many avenues as possible – newsletters, social platforms, etc – and impart helpful tips and advice on

Adam Hampson, Cosmetic Digital “One thing is certain – your patients and the public in general will be online more than ever before. From health advice and news, to buying online and looking at services for when we return to normal. Amongst the uncertainty in business is also opportunity. Consider campaigns that are not lead generation but drive data collection or build brand awareness. For those with smaller budgets there is less competition. At some point we will return to normal, so use the time to get jobs done on your website and marketing you haven’t had the time for, but need to do.”

Danny Large, DSL Consulting “Everybody is scared at the moment, but try and put a plan together for what you can do in the current situation. If you have more time on your hands, write down all the little jobs that you have wanted to do around the clinic and start putting a plan together on when and how to do them. In regards to marketing, why not look at segregating your database into specific treatments so in the future you can send targeted marketing messages to your patients. Be better prepared and organised because just as night follows day, this virus will not last forever.” Sally Taber, JCCP “It is no longer enough for any practitioner to rest on their professional laurels. There is always more to learn. As you languish in isolation, use the opportunity to advance your professional standing by taking all available opportunities for continuing professional development. Top of your ‘to do’ list should be a gap analysis of your qualifications to see what you might be missing or need a refresher of. You can check yourself against the Standards set by the Cosmetic Practice Standards Authority (CPSA), for example. You can do this easily by registering yourself with the Joint Council for Cosmetic Practitioners. Enlarge your skill-sets and broaden your horizons. Let your patients see that you are the best when we all return to normal life.” REFERENCES 1. COVID-19: guidance on social distance and for vulnerable people (UK: GOV.UK, 2020) <https://www.gov.uk/government/ publications/covid-19-guidance-on-social-distancing-and-forvulnerable-people> 2. Coronavirus disease (COVID-19) outbreak (WHO, 2020) <https:// www.who.int/emergencies/diseases/novel-coronavirus-2019> 3. Number of coronavirus (COVID-19) cases and risks in the UK (UK: GOV.UK, 2020) <https://www.gov.uk/guidance/coronaviruscovid-19-information-for-the-public>

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


Advertorial Merz

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Merz Institute of Advanced Aesthetics â&#x20AC;&#x201C; Elevating Training Standards A report on the Merz Innovation Partner Workshop on March 5 and 6 The Merz Institute of Advanced Aesthetics (MIAA) is the training and education brand representing the full Merz portfolio. It is an expert-led educational brand devoted to advancing knowledge and providing UK Healthcare Practitioners with academic and practical skills to successfully compete in the area of aesthetics. Merz Aesthetics understands the value of supporting healthcare professionals (HCPs) with expert-led education and guidance on Merz brands. This requires a team of established trainers committed to raising industry standards by sharing knowledge and expertise with likeminded peers. Merz is proud to invest in the skills of the growing group of trainers, known as the Merz Innovation Partner (MIP) team, in order to fulfil our mission of putting medicine back into aesthetics. The Merz Innovation Partner workshop held in Glasgow on March 5 and 6 was hosted by the Merz Innovation Board (Dr Kate Goldie, Dr Emma Ravichandran, Dr Simon Ravichandran, Dr Julia

Sevi, nurse prescriber Helena Collier and consultant plastic and aesthetic surgeon Mr Dalvi Humzah). As recognised experts in the field of aesthetic medicine and Merz brands, this team delivered a comprehensive agenda to advance the breadth and depth of knowledge of the MIPs. The focus was to enhance skills in teaching key scientific messages relevant to making sound clinical decisions when using Merz brands. Also in attendance was special guest, Professor Sebastian Cotofana. Professor Cotofana is an internationally recognised anatomist and an Associate Professor of Anatomy at the Mayo Clinic College of Medicine and Science in Rochester, Minnesota. Professor Cotofana delivered several highly relevant and impactful applied anatomy lectures over the course of the two days to support the clinical knowledge of the MIP team. Our investment in highly-educated specialists to share knowledge and expertise will reflect on the overall quality of the training programme delivered by the Merz Institute of Advanced Aesthetics.

Merz Innovation Board and Partners

From left to right: Dr Kim Booysen, Dr Paula Mann, Sarah Holness, Dr Simon Ravichandran, Annie Cartwright, Dr Emma Ravichandran, Helena Collier, Freya Carlsen, Anna Gunning, Dr John Tanqueray, Julie Redmond, Dr Julia Sevi, Mr Dalvi Humzah, Emma Chan, Dr Orla Grimes, Aine Larkin.

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Aesthetics | April 2020


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Aesthetics

Day one: BELOTERO®

Day two: Radiesse®+ and Ultherapy®

Following a welcome and introductions from the Merz Aesthetics team, the trainers planned exciting new updates to upcoming Masterclasses. Attendees also attended a pharmacovigilance training to ensure they adhere to industry compliance best-practices when delivering the Masterclasses. The education on Merz products began with preparation for BELOTERO® Masterclasses, shared by Dr Emma Ravichandran and Dr Simon Ravichandran. The pair used their expert knowledge to upskill MIPs on how to deliver these scientific presentations and ensure that key messages on how to use the hyaluronic acid range of dermal fillers are clear and understood by Masterclass attendees. In the afternoon, special guest Professor Cotofana gave an in-depth presentation on anatomy, showing unique studies, videos and cadaver images to contribute to the MIPs’ understanding of in-depth facial anatomy. In his talk, different injection depths, planes and layers were outlined, before the trainers were divided into three groups and discussions on injection techniques, depths, product choice and quantity for optimal results took place.

The second day of the Merz Innovation Partner Workshop consisted of a Radiesse®+ Masterclass Refresh, led by Mr Humzah. He discussed the technology behind the calcium hydroxylapatatite dermal filler, its safety profile and the scientific studies supporting its efficacy. Live demonstrations of using Radiesse®+ in the lower face were performed, with considerations for facial assessment and injection technique discussed. As a pre-cursor to the Ultherapy® session, Professor Cotofana led an engaging discussion on the anatomical facts of skin laxity. Dr Julia Sevi then took over the education with an introduction to Ultherapy®. She then outlined how the micro-focused ultrasound with visualisation can stimulate the production of new collagen and elastin1 deep within the skin, gradually lifting and sculpting2 it from the inside out with minimal downtime.3

Q&A with Professor Cotofana

Merz Innovation Partners said… “The whole Merz Innovation Partner Workshop had a strong and consistent emphasis on medical practice and the supporting scientific evidence behind our clinical practice and product choices.” Annie Cartwright, MIP

“I love the fact that I am still learning new and exciting information, which not only benefits my own practice, but ensures that as a Merz Innovation Partner I possess the latest knowledge to pass on to our delegates at our masterclass events.” Freya Carlsen, MIP

“Delighted to attend the Merz Institute Workshop in Glasgow, the highlight for me was anatomy and physiology with Professor Cotofana. The presentation, slides, and sharing of information far exceeded my expectations. I was literally on the edge of my seat!” Sarah Holness, MIP

Advertorial Merz

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What drives your passion for anatomy? I feel that anatomy can provide us with a lot of valuable answers if we ask the right questions. Anatomy is much more than origin and insertion of muscles or the major torture subject for medical students. Anatomy can be very modern and up-to-date. Do you think anatomy plays a key role in education? Yes, absolutely. Anatomy is one of the most important pillars that carries healthcare-related education. It provides the learner with in depth understanding of the human body and can explain concepts of pathophysiology and treatments. Anatomy should not be seen as an one-time educational component. With increasing knowledge different questions will be asked, to which anatomy can answer them. This advertorial was written and supplied by Merz.

M-MIAA-UKI-0046 March 2020. Adverse events should be reported. Reporting forms and information for the United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for the Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

Aesthetics | April 2020

REFERENCES 1. Ulthera System Instructions for Use, 1001393 IFU 2. Fabi SG and Goldman MP. Dermatol Surg. 2014;40;570 3. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202

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and it’s more about how the woman feels.” Dr Nataly Atalla, a senior consultant gynaecologist specialising in fertility, reproductive medicine and menopause, adds, “Vaginal laxity is when the vagina becomes loose, has no tone, hangs below and becomes wider, so the normal feel that women are used to becomes very different. It’s commonly associated with other symptoms related to failed pelvic floor support like vaginal prolapse and urinary control problems such as frequency, urgency or stress incontinence/leaks.” Much like other areas such as the face, with age brings collagen and elastin loss to the vaginal canal, says Dr Lakhani, which will contribute towards laxity. However, she says that childbirth and the menopause significantly accelerate this. Dr Atalla emphasises, “Childbirth is the first related cause of vaginal laxity. Following childbirth, women commonly suffer from muscle weakness, pelvic floor muscle tone loss and looseness which, if not recovered, can cause weak pelvic floor support. It can also influence organs around and supported by the vagina to hang down loose or sink. These organs include the uterus, bladder or bowels, causing a different effect on their feeling inside and down below. It can also impact these organ’s functions, such as bladder or bowel function and, essentially, sexual sensitivity, function and satisfaction.” The second main trigger for vaginal laxity occurs with age from around the mid 30s onwards, adds Dr Atalla. Aesthetics interviews three practitioners who “This is a crucial factor far underestimated and falsely to only happen at or after menopause, while explore the causes of vaginal laxity and their assumed in fact all female ageing is more relevant to hormones. tips for treatment using radiofrequency Hormones start changing as women start to enter the pre or perimenopause stages. Women exhibit changes Designer vagina. It has a ring to it, doesn’t it? It is a term that in both ovarian hormone levels and balance changes, which includes has been frequently used by the media to describe the cosmetic oestrogen, progesterone and testosterone.” surgical intervention of the female genitalia and, more recently, She adds, “So, even women who have never had children will find the non-surgical rejuvenation alternatives such as dermal fillers, that their vagina will begin to feel different, with tone, moisture, and platelet-rich plasma, chemical peels, and energy-based devices. sensitivity changes and it will become devitalised over time. This is However, contrary to popular belief, practitioners treating this related to loss of elastin and collagen, with loss of sensitivity, normal area say patients very rarely present to clinic with requests of texture and blood flow in the vagina and its underlying tissues.” a ‘designer vagina’ and their concerns usually run deeper than improving just the appearance. Dr Atalla adds that patients may present with a perceived enlargement Aesthetic practitioner Dr Shirin Lakhani has worked in women’s or hypertrophy of the labia, with surrounding vulva and labial skin, and health, as a GP, and holds a Diplomate of the Royal College of tissues may become atrophic and wrinkled. This can change not only Obstetricians and Gynaecologists. She says that when it comes to the feel but the appearance of the vulva and labial area. the intimate area, the main reason women present is to address She says, “Exactly what happens to your face also happens down issues with their functionality. “I would say that for 99% of my below – dryness, skin wrinkling and loosening – so practitioners need patients the motivations to seek help are to improve discomfort, to educate patients that this is all part of hormone changes and ageing sexual function, incontinence and the overall feeling they have and discuss how we can improve it.” down there, rather than their aesthetic appearance,” Dr Lakhani Symptoms can directly impact quality of life, such as mental health and explains. For many patients, these issues stem from vaginal laxity, relationships and it is an underreported condition, practitioners note.1 which according to practitioners interviewed, can be successfully managed using radiofrequency (RF) technology – a familiar tool to Tips for consulting patients many aesthetic practitioners. All practitioners interviewed agree that these are sensitive patients and there needs to be a large focus on education. In the consultation, Understanding vaginal laxity as with other treatments, practitioners also need to include a patient Aesthetic practitioner and former surgeon Miss Mayoni Gooneratne history, evaluation of the symptoms and examination to make a correct has a PhD in the neurology and control of the bowel and pelvic floor, diagnosis and treatment plan. and specialises in feminine health. She defines laxity as a symptomAccording to practitioners, a consultation of around 45 minutes is led problem that women describe when their vagina feels looser than normal, and Dr Lakhani highlights that patients should have the option normal. She states, “Vaginal laxity is not a physiological measurement to come back if needed. Miss Gooneratne adds, “For this area, the

Treating Vaginal Laxity with Radiofrequency

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consultation absolutely must focus on the patient’s gynaecological and sexual history to ensure that they are having true symptoms that are going to be treatable in your hands. If you find in the consultation that they fall outside your remit, or that they would benefit more from other approaches, then you must refer to a specialist.” First and foremost, making patients feel comfortable to talk about their issues is key. “In the consultation you need to reassure women that they are not alone, because every single person that comes in thinks that they are the only one who is suffering – so it’s important to educate,” Dr Lakhani comments, adding, “Practitioners also need to be very comfortable in discussing every aspect of a patient’s sexual behaviour, such as the symptoms they are having, how often they are having sex, or if they have ever even had an orgasm. Practitioners need to be direct, but sensitive, and you can’t be embarrassed yourself, otherwise you are never going to make your patients feel at ease.” In the consultation, Dr Atalla will always look at a patient’s lifestyle factors and how to make improvements to this before any treatment. “I will assess women from A-Z and this includes diet changes, fitness and exercise, essential menopause vitamin supplements, weight control, and hormone therapy. I will always address lifestyle and hormone issues first because this will give me maximum success when I do the non-invasive procedures for rejuvenation.” If practitioners do not currently provide hormone services, Dr Atalla suggests to work alongside a gynaecology reproductive specialist. Miss Gooneratne uses a scoring system called the Female Sexual Function Index (FSFI) that allows her to quantify the problems a patient has, how it affects them and then how this may be improved by treatment. “I get patients to do this before, then one month and three months after treatment. It allows me to monitor results and help manage patient expectations, as non-surgical treatments are never going to be able to completely resolve their problems, but with proper patient selection we can make a good improvement,” she says. When assessing patients, Dr Lakhani will rate vaginal laxity as mild, moderate or severe and discuss with them how she can make improvements. She will also delve into the patient’s motivations for coming to clinic. “You need to sensitively find out if there is any pressure from someone else to have treatment – such as a male partner. Practitioners need to highlight that treatment isn’t likely going to be an option to fix a relationship. I don’t treat anyone who comes in for their male partner,” she explains. A physical assessment of their intimate health is also really important Miss Gooneratne says. “You need to ensure they don’t have prolapse and are without infections or diseases by doing a proper examination. They also need to have a recent smear that’s negative,” she explains, adding, “In the consultation, I will explain to them the treatment approaches in a very practical level – they know they will be lying in a certain position and I show them a demo tip so they know what to expect.” Miss Gooneratne will always give them a cooling-off period of about two weeks. Before

“Even if you don’t treat patients externally, with RF you will get some degree of cosmetic improvement as the tightening pulls everything back up" Dr Shirin Lakhani

excellent effectiveness and results with less downtime, they are less expensive and I believe there are lower risks of complications like burns, scarring or any deformations. I think that the risks of complications are reduced with RF owing to automatic temperature controlled therapy. I am glad I have not seen complications in any of my patients.” Dr Lakhani, says, “In my hands, RF is a great treatment option for vaginal laxity and is very popular amongst practitioners. RF at a temperature of around 43 degrees achieves the required depth of penetration needed for sufficient tightening via elastogenesis and collagenesis.” Dr Lakhani adds, “We don’t have the same heat receptors in the vaginal canal so this temperature is bearable and patients will feel something similar to a warm massage.” Miss Gooneratne highlights that she is confident in the safety profile of RF because it has been used in other areas of the body for many years. She states, “When done well and effectively it can result in really nice results, with a high safety profile, and without mass downtime as you are not ablating the skin. It’s easy to deliver and it’s comfortable for patients.” Another positive about RF is that it can also be used to address cosmetic concerns, practitioners suggest. Miss Gooneratne says, “I am happy to do this given the safety profile and the evidence I have seen with RF – it really helps to tighten the tissue and with the device I use you can see an instant result. The treatment is a bit longer, by around 15 minutes.” Dr Lakhani adds, “Even if you don’t treat patients externally, with RF you will get some degree of cosmetic improvement as the tightening pulls everything back up. The labia majora will tend to close a little and have a shrinking effect.” After

Treatment using radiofrequency To improve vaginal laxity and its associated symptoms, practitioners state that the overall aim of treatment is to induce new collagen and stimulate remodelling of vaginal tissue to have a tightening effect on the vaginal canal.1,2 Studies suggest that other energy-based devices such as CO2 laser and Er:YAG laser can have positive rejuvenating effects,2,3,4 however all practitioners interviewed prefer to use RF to treat this condition. Dr Atalla explains, “I use RF over lasers as I find that I get

Figure 1: Patient presenting before and after one treatment using the Votiva FormaV device for 15-20 minutes. The first treatment was vaginal, then the external and labia minora were treated for 10 minutes. Images courtesy of Inmode UK.

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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of around 30 minutes about two to four weeks apart and results last for around two years onwards, provided patients continue with their positive lifestyle factors, vitamins, pelvic exercises and optimised hormone therapy levels – these are crucial. If patients are also concerned with their outside vulval and labial appearance I will treat the vulva skin directly using the partner Fractora handpiece to Votiva after the first or second session, depending on the severity of the area. My patients love this treatment.” Figure 2: Patient before and after three treatments using Ultra Femme 360 device. Patient had internal and external treatment. Images courtesy of Dr Shirin Lakhani. Miss Gooneratne advises others to look for a device that has good long-term data showcasing treatment efficacy. Choosing a RF device She says, “Viveve did an interesting sham study that found that after There are many different devices available, each with a different three months, the treated group and the sham group had really similar treatment protocol. When choosing a device, Miss Gooneratne results in FSFI improvement, but the laxity score in the sham group considered the number of treatments, deciding that for practicality begun to drop down to being dysfunctional again after three months.5 she didn’t want patients to come in several times for an effective This highlights the importance of long-term data; practitioners should treatment. “You also need a comfortable device with safe delivery and also be mindful of how patients potentially have a large psychological a good cooling system. The business and commercial aspect also bias and may think the results are better than they actually are as they plays a part; it had to be cost-effective for both myself and patients,” want this treatment to work so badly – this is why I always get them in she says. Miss Gooneratne uses the Viveve monopolar RF device. for a review after three months.” She states, “From a practical standpoint, this device has a two-pence head size, the tip is directed exactly where you want it and so you A passion for women’s health know exactly where you are firing the energy. You treat in quadrants All practitioners advise against entering the world of intimate women’s in a clock face formation and you treat each quadrant five times. You health unless you have a real passion and invested interest for helping don’t need to move in and out of the vaginal canal and the handpiece change the lives of those affected by vaginal laxity and other intimate flashes blue when you make contact with the tissue, which helps me concerns. Miss Gooneratne says, “I am keen to encourage my fellow deliver a controlled treatment.” Viveve is a one-off treatment, says practitioners to have a background and interest in women’s health Miss Gooneratne, and results last for around 12 months. She adds, and gynaecology. It’s not for someone who just wants to make a quick “It should be noted that we are treating the single muscular tube, dollar.” Dr Lakhani also believes that only practitioners with experience not the pelvic floor, so I always encourage patients to continue their in women’s sexual health should be both consulting and performing pelvic floor exercises for maximum results.” Comfort is a priority for these treatments. “I have had several cases where I have had to Miss Gooneratne, as the treatment will last around 45 minutes. “I make refer on and I am concerned that those without a gynaecological sure they have pillows for support and that they have a phone or background will not be able to see the red flags.” something to do as patients will get bored very quickly otherwise.” Dr Lakhani adds, “Treating these patients is seriously the most Dr Lakhani chooses to use the Ultra Femme 360 device. “I looked at rewarding thing I do. Before implementing this into your practice the other devices on the market and assessed the treatment efficacy, you need to know that it’s changing someone’s life and it can even procedure and consumables costs – the detachable probe that is be emotionally draining as a practitioner. If you are not interested in inserted is single use and this needs to be considered as the cost of women or talking to them about their most intimate concerns then this impacts patient costs,” she says, adding that a big selling point for don’t offer this treatment.” her was the shorter treatment time. “I feel that as a patient having a Reflecting back to the ‘designer vagina’ terminology, Dr Lakhani says, treatment in the intimate area, you want it to be as quick as possible. “I am glad to see that more and more headlines are shifting their focus One of the big draw factors for me was its circumferential tip – it treats from the designer vagina angle; anyway, technically speaking, it’s not all around the vaginal canal at the same time. From my perspective, a designer vagina it’s a designer vulva, but it doesn’t really have the this takes out practitioner error and it shortens the treatment time same ring to it!” to around eight minutes.” Dr Lakhani says that patients need one REFERENCES treatment each week over a three-week period and results last 1. Krychman, M et al. “Effect of Single-Session, Cryogen-Cooled Monopolar Radiofrequency Therapy on Sexual Function in Women with Vaginal Laxity: The VIVEVE I Trial.” Journal of women’s health around nine months. “I tend to bring my patients back at six months (2002) vol. 27,3 (2018): 297-304. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865245/#Bhttps:// before it gets to that so that we are constantly building on what we www.ncbi.nlm.nih.gov/pmc/articles/PMC5865245/#B5> 2. Karcher, C et al., Vaginal rejuvenation using energy-based devices, Int J Womens Dermatol., have already achieved,” she says. 2016;2(3):85–88. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5418869/> Safety, cost-effectiveness and patient satisfaction are also a priority 3. Mitsuyuki, M, Treating Vaginal Laxity Using Nonablative Er:YAG Laser: A Retrospective Case Series of Patients From 2.5 Years of Clinical Practice, Sexual Medicine, February 2020. <https://www. for Dr Atalla, who chooses to use the Votiva FormaV device. “When I sciencedirect.com/science/article/pii/S2050116120300015> was looking for a non-surgical treatment solution I wanted something 4. Sejal A, Vaginal rejuvenation: From scalpel to wands, Int J Womens Dermatol. 2019;5(2):79–84. Published 2019 Mar 7. that would not be painful, didn’t have a long treatment time, had 5. Allan, B et al., Treatment Of The Vaginal Introitus To Evaluate Effectiveness: Results From A a short downtime and good efficacy. It also needed to be readily Randomized, Placebo-Controlled Study, IUGA 2016 Annual Meeting, Capetown, South Africa. <https:// www.berger-klinik-frankfurt.de/vaginalstraffung.html?file=files/top_medizin/Leaflet_Study-Results_ available and be provided in my comfortable outpatient clinic settings. Geneveve-by-Viveve_EN.pdf> As a woman myself at this stage of my life, I also needed to question whether I would have the treatment myself. For me the Votiva FormaV was the best option.” She adds, “Improvements are immediately noted after the first session, but for longevity I will do three sessions Before

After

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Understanding Tear Trough Anatomy

2020

Dr Eleanor Reid, Miss Lara Watson and Miss Priyanka Chadha explore the anatomy of the tear trough for successful injectable treatments The tear trough deformity is characterised by a sunken appearance of the eye and a resultant dark shadow cast in the lower eyelid region. It is not exclusively a result of facial ageing and a mild tear trough may be seen in younger patients. It is the deepening of the trough and changes to the surrounding soft tissue architecture that occur with age, which leads to the characteristic features of the tear trough deformity.1 Patients who request correction of the tear trough deformity often present complaining of dark circles, a fatigued appearance, or aged or an un-aesthetically pleasing groove around the eye. Traditional techniques to address this cosmetic issue previously relied on chemical peels or surgical excision of skin, muscle and fat.2 More recently the need to restore volume to the orbit as part of an overall rejuvenation strategy has been appreciated, with treatment of the tear trough with hyaluronic acid (HA) dermal fillers gaining huge popularity. It is widely recognised that diagnosis and management of complications that arise from medical aesthetic treatments are an unmet training need.3 This is particularly true with regards to treatment of the tear trough region, where there is very little safety data supporting treatment modalities regarding potential periocular complications and their management.3 Although the range of potential complications that arise are similar to other areas in the face, the delicate nature of the eyes means that complications from treatment arise more commonly in this region.4 Understanding soft tissue and vascular anatomy is essential to rejuvenation of the undereye area.

Definitions and nomenclature The term ‘tear trough’ applies to the medial one-third of the periorbital hollow that extends obliquely from the medial canthus to the mid-pupillary line, forming a sulcus. The sulcus involves the thin, loose skin of the eyelid where it originates at the lower eyelid inner canthus and extends down to the thicker skin of the cheek.5 This indentation where the thin eyelid skin above meets the thicker nasal and medial cheek skin below defines the tear trough

0

1

2

0

Palpebral line

1

Tear trough

2

Palpebromalar groove

3

Mediojugal fold

3

Figure 1: Presentations of the periorbital area7

deformity. This boundary also delineates the line along which fascia is anchored to the underlying periosteum.1,6 Lateral to this point, the depression is referred to as the ‘palpebromalar groove’ or ‘lid cheek junction’.7 In patients who present with both a deep tear trough deformity and also a deep lid cheek junction, these two landmarks form an indentation that is nearly continuous and is visible several millimeters beneath the infraorbital rim.6 Medially and inferiorly the junction is referred to as the ‘mediojugal fold’ or the ‘mid-cheek groove’ (Figure 1).7 The pretarsal thin skin within the tear trough is different in texture, colour and quality in comparison to the adjacent thicker skin of the nasal and cheek skin.1 In comparison to the adjacent thicker nasal and cheek skin which is abundant with subcutaneous fat, the pretarsal skin is notably thinner, with little or no subcutaneous fat, and some individuals suffer from the presence of distinct melanocytic pigmentation.1,5

Factors that contribute to tear trough deformity Pigmentation, fat pat herniation and rhytidosis all contribute to the formation of the tear trough. The appearance of ‘dark circles’ in some patients presenting for tear trough correction may be emphasised by distinct melanocytic hyperpigmentation.1 Globally, patients with darker skin types are more notably affected than those with lighter skin types.5 Due to its transitory nature there is little data regarding the exact prevalence of periorbital hyperpigmentation; however, one Indian study by Sheth et al. suggested that it was most prevalent in the age group of 16-25 year olds.8 Although hyperpigmentation occurs in both sexes it is reportedly more prevalent in females.5 Hyperpigmentation arises from damage or overstimulation of the cells that contain melanin, resulting in an overproduction of the pigment.9 The underlying congenital or acquired aetiology behind this cell damage may be multifactorial, with no one aetiological factor predominating.5,7 Causes may include excessive ultraviolet light exposure, nevi, hormonal changes, melanoma or dermal melanocytosis.10 However, clinicians should also be aware that the presence of hyperpigmentation may be an indication of an underlying nutritional deficiency, skin disorders, systemic disease or sleep disturbance.5 Although dyspigmentation does not contribute to the depth of the tear trough, it can create the illusion of depth and therefore exaggerate the appearance of a tear trough deformity.2 Prominent venous pooling or thin skin can create a purple discolouration to the skin, accentuating periorbital darkening.1,7 Patients seeking treatment of the tear trough should be adequately assessed with regards to the presence of pigmentation. For these patients, the limitations of treatment with dermal filler alone should constitute a key aspect of the consultation process and other or additional treatment modalities may be indicated (Figure 2 & 3).8

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the anterior lacrimal crest to the medial limbus. There is scant subcutaneous tissue between the skin and the muscle in this area.1 The levator labii superioris originates from the medial orbital rim just below the muscle attachment of the orbital portion of the orbicularis oculi muscle.1 The gap between these two muscles was previously believed Figure 2: Patient displaying with perioribital Figure 3: Patient displaying with notable fat to explain the tear trough.16 However, a 2009 hyperpigmentation. pad prolapse in the tear trough region. cadaveric study by Haddock et al. has shown it The development of the tear trough deformity is often associated to be located inferomedial to the deformity, indicating that it does not with the orbital fat herniation superiorly into the lower lid fat contribute to the surface anatomy.6 As the trough progresses laterally, 1 compartments, accentuating the concavity of the trough. Low lid it falls inferiorly with a maximum distance to the orbital rim in the central fat herniation distracts from the deficiency in the trough, forming an portion.1 Lateral to the corneoscleral limbus the orbicularis oculi muscle independent problem. Orbital fat prolapse may be identified by the attaches to bone by the orbicularis retaining ligaments in the region of characteristic shape of the orbital fat compartments that can often be the lid cheek junction.1,7 The orbicularis retaining ligament attaches to visualised through the skin, with a cigar shape formed by the central the underlying zygoma caudal to the arcus marginalis at the orbital rim, fat compartment.11 Patients presenting with notable fat pad prolapse as opposed to directly to the infraorbital rim.6 may be a contraindication for treatment with dermal fillers alone. In The fibres of the ligament continue superficially, separating the these patients, surgical correction with lower blepharoplasty may be preseptal and orbital portions of the orbicularis oculi muscle. The indicated (Figure 4).12 length of the fibres of the retaining ligaments increase to a maximum In addition to fat pad prolapse, the occurrence of rhytidosis of the centrally at the arcuate expansion of the orbital septum, decreasing lower eyelid skin may create the impression of a more severe tear in length laterally until becoming almost negligible, merging with trough deformity.2 The skin in the periocular region is some of the the lateral orbital thickening in the region of the lateral canthus.1,7 13 thinnest found in the body. Unlike all other facial areas, there is The presence of a ligamentous attachment in the lid cheek junction minimal or no subcutaneous fat combined with a dynamic structure defines a differential deep plane to the tear trough.6 The retaining 4,10 due to an intimate relationship with the orbicularis muscle. With ligaments form a v-shaped deformity that correlates to the lid cheek age, connective elements such as collagen and elastin degenerate, junction (Figure 5).7 14 compromising the tone and laxity of the skin. Such degeneration It is theorised by authors that with age the tear trough deformity accentuates the appearance of the tear trough, whereby the becomes exacerbated due to soft tissue atrophy and the attenuation underlying depression is unveiled by the thin pretarsal skin.7 of the orbital septum, allowing orbital fat to herniate through the lax It is important to note that ageing of the periorbital region does not palpebral orbicularis.7 The tear trough is a dynamic region; given that occur in isolation. Volume loss of the mid-face is attributed to a loss there is a fixed attachment of the orbicularis oculi muscle to the orbital of anterior projection of the maxilla, and the decent and atrophy of rim and subsequent contraction of this muscle, volume loss is visible the malar fat pads contribute to the deepening of the tear trough earlier and more dramatically than in other facial areas.1 15 deformity with increasing age.

Anatomy With regards to anatomy, the infraorbital region is one of the most complex areas of the face. To understand the ageing process and safe treatment of the tear trough deformity it is important to consider the relevant muscles, ligaments, fat pads and vasculature in the tear trough and periorbital region. Muscles and ligaments Cadaveric dissections confirm two distinct planes that contribute to the tear trough and lid cheek junctions; the subcutaneous plane and the deep plane.6 In the subcutaneous plane, there is no distinction or separation between the tear trough anatomy and that of the adjacent lid cheek junction.6 Superficially, the tear trough is found to correlate with the junction of the preseptal portion and orbital portion of the orbicularis oculi muscle.6 Anatomically, the tear trough is at the orbital rim in its most medial portion, with the location of the indentation running along the fibres of the orbicularis oculi muscle.1 In this position, the orbicularis Figure 4: The v-shaped deformity muscle has a direct attachment to that correlates to the lid cheek junction the inferior orbital rim, running from

Due to the hydrophilic nature of HA fillers, it’s reported that ‘under treatment’ is imperative and the temptation to create a ‘perfect’ result during treatment should be avoided

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Orbital group

Ocular group

Lacrimal artery

Long ciliary artery

Supraorbital artery

Short ciliary artery

Anterior and posterior ethmoidal artery

Anterior ciliary artery

Internal palpebral artery

Central retinal artery

Frontal artery (terminal branch)

Muscular artery

Nasal artery (terminal branch) Figure 5: The branches of the ophthalmic artery20,21

Fat compartments The eyes are surrounded by fat contained within deep and superficial fat compartments that are encased in fibrous sheaths containing small blood vessels.17 Loss of facial fat begins in the mid 20s and it is theorised that deep fat compartments show more significant signs of atrophy as they are adjacent to the bone and therefore less biologically active.18 The eye is suspended in the orbit by orbital fat which provides glide planes for motions of the eyelid and the globe.17 In the upper eyelid, there are two fat pads: the nasal and central (preaponeurotic). In the lower eyelid, there are three fat compartments: nasal, central and lateral.17 The nasal and central fat pads are separated by the inferior oblique muscle which elevates and extorts the eye.14 The orbital fat pads are held in place over the orbit by the orbital septum. As the orbital septum becomes weak with age, these infraorbital fat pads can herniate against the lower eyelid.17 Deep to the orbicularis muscle overlying the periosteum of the malar eminence is the suborbicularis fat pads (SOOF). Gradual gravitational descent of the SOOF plays an essential role in descent of mid-facial soft tissues and subsequently the periorbital region.18 Vasculature The vascular anatomy of the orbit and ocular vascular anatomy is highly complex. Following the pioneering work of anatomist Franz Meyer in 1887,19 the vascular anatomy of the orbit and ocular region has been extensively documented in the literature for over a century. Most accounts refer to Meyerâ&#x20AC;&#x2122;s original work, based on 20 specimens, describing the so-called â&#x20AC;&#x2DC;normal patternâ&#x20AC;&#x2122; of the vasculature.20 However, a series of detailed systematic studies on a large number of specimens by ophthalmologist Sohan Hayreh in 1962 demonstrated that the orbital vasculature presents with a high degree of individual variation.20 The ophthalmic artery (OA) is the primary source of blood supply to the orbit; it is the first branch of the internal carotid artery

Superficial temporal artery and vein

Lacrimal artery and marginal arcade

Angular artery and vein Supratrochlear and supraorbital vessels

Figure 6: Vascular anastomoses surrounding and supplying the orbit

after it arises from the cavernous sinus entering the orbital cavity through the optic foramen (Figure 5).20,21 However, studies report multiple other variants in the origin of the OA with the most common variant, noted in 3% of individuals, being that the OA arises from the middle meningeal branch of the external carotid artery entering the orbit via the superior orbital fissure.22-24

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The branches of the OA listed in Figure 5 can be divided into those that supply the orbit and surrounding parts, and those that supply the surrounding ocular region, supplying the orbital muscles and the bulb of the eye.20,21 Only a minor extent of orbital blood supply is derived from the external carotid artery via its infraorbital branches and orbital branch of the middle meningeal artery.22 Reduced or no perfusion of the ciliary blood supply to the optic nerve head via occlusion of the long and short posterior and anterior ciliary arteries can lead to signs and symptoms of anterior ischaemic optic neuropathy (AION), including loss of vision.25 As demonstrated in Figure 6 there is a vast network of vascular anastomoses surrounding and supplying the orbit. Anastomoses between branches of the ICA, particularly the terminal supraorbital and supratrochlear branches of the ophthalmic artery and the ECA, namely the terminal angular artery branch of the facial artery, are well documented in the literature.26 Similarly, the superficial temporal arteries have been demonstrated to anastomose with the orbit.26 With

The pretarsal thin skin within the tear trough is different in texture, colour and quality in comparison to the adjacent thicker skin of the nasal and cheek skin

this in mind, occlusion of any of these contributing arteries has the potential to cause potential vision change.27 The mechanism of visual compromise is understood to involve the incorrect deposition of hyaluronic acid filler into an ECA branch artery, which anastomoses with one of the key ICA vessels supplying the eye. For example, a bolus of filler could track retrograde through the angular artery to then travel anterograde through the ophthalmic artery resulting in visual loss.3,4 It is important to note that blindness from facial injections is extremely rare.28 A meta-analysis review of world literature reported that before 2015, there were only 98 cases of vision change after aesthetic facial injection reported globally.26 It should be noted that this data refers only to those cases of blindness following HA filler injection that have been reported and does not account for any unreported incidents. Injections in the nasal region are the most common area for fillerrelated visual loss due to the location of the dorsal nasal artery branch of the ophthalmic artery.27 Although risk of blindness can occur with injection of dermal fillers into any anatomical region of the face, the glabella, nasolabial and forehead/temple region are also deemed to be high risk areas.27 Despite the uncommon incidence of this complication, due to the

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potentially devastating outcome of this adverse event, the risk of visual loss should be discussed during the process of informed consent with the patient before facial injections with dermal filler. Lymphatics The lymphatic vessels in the periocular region are divided into pretarsal and post-tarsal. Lymphatic drainage of the pretarsal orbicularis oculi muscle and eyelid skin are provided by the pretarsal vessels. The deep plexus post-tarsal vessels provide lymphatic drainage of the conjunctiva, lacrimal glands and tarsal plates. The palpebral lymphatic vessels drain in to two main sites; laterally and medially. The lateral lymphatic drainage group drain in to the deep and superficial parotid nodes providing drainage for the deeps vessels of the lacrimal glands of the conjunctiva and lateral aspects of both eyelids. The medial portion of the upper and lower eyelid and lacrimal sac drain into the submandibular nodes.29

Practical application In aesthetic medicine, the use of HA fillers dominates the market. These products are favoured for: immediate and natural results, non-immunological and highly biocompatible status, long lasting but non-permanent results, reversibility via enzymatic digestion and incremental administration.30,31 As mentioned, due to the dynamic nature of the area, scant subcutaneous fat and thin skin, the tear trough is a technically challenging area to rejuvenate.4 Appropriate technique, product selection and placement can help to avoid some complications.32 Low viscosity, low elasticity products are favoured in this area for their soft flowing qualities and a homogenous pattern of tissue integrations.33 Highly cross-linked HA fillers are excellent for deep placement and restoring deeper lines and volume loss, however such products are prone to interfering with lymphatic drainage and may induce swelling. They are therefore inappropriate for use in the tear trough region.3 Due to the hydrophilic nature of HA fillers, it’s reported that ‘under treatment’ is imperative and temptation to create a ‘perfect’ result during treatment should be avoided.2 Practitioners should respect to the product’s ability to attract water in the weeks following treatment should be made to avoid the treatment area being overcorrected.2 Safe needle and cannula techniques can both be applied to treat the tear trough deformity. The consideration that microcannulas, particularly those with a narrower calibre, have the potential to act like needles and penetrate vessels, should be made.4,3 It is imperative the product is placed on to the periosteal level when using needle techniques and in the suborbicularis plane when implementing the use of a cannula to avoid the Tyndall effect or an irregular contour.4

Treat with care The tear tough is a technically challenging area to rejuvenate and should only be performed by appropriately qualified and trained medical professionals. Understanding the soft tissue and vascular anatomy of the tear trough region and potential variation is essential to achieving safe rejuvenation of the under-eye area. A holistic approach should be taken to treatment with assessment of the mid-face and surrounding structures. Thorough patient assessment with regards to skin texture, pigmentation and presence of fat pad herniation is essential to achieving satisfactory aesthetic outcome.

Dr Eleanor Reid is an aesthetic practitioner and dental surgeon graduating from Newcastle University. Dr Reid has a background in maxillofacial surgery, hospital and practice-based dentistry and is lead trainer in Newcastle-upon-Tyne for Acquisition Aesthetics, as well as being the director of Paragon Aesthetics. Qual: BDS Miss Lara Watson is dual-qualified in medicine and dentistry and works as a surgical trainee in oral and maxillofacial surgery. Miss Watson is a faculty member for Galderma and is also a co-founding director of Acquisition Aesthetics. Qual: BM, BMedSci, BSc, MRCS(Eng), BDS(Hons) Miss Priyanka Chadha currently works as a plastic surgery registrar in London and is co-director of Acquisition Aesthetics training academy. Her academic CV comprises national and international prizes and presentations, as well as higher degrees in surgical education and training. Miss Chadha is a faculty member for Galderma. Qual: MBBS(Lond), BSc(Hons), DPMSA(Lond), MRCS(Eng), MSc(Lond) REFERENCES 1. Hirmand H. Anatomy and non-surgical correction of the tear trough deformity. Last Reconstr surgery 125 699 2010 2. Sharad J. Dermal fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques and their Outcomes. J Cutan Aesthet Surg 2012 Oct-Dec 5(4) 229-238. 3. Ezra D. Perioccular complications. Aesthetics Journal Nov 2016. 4. Hwang CJ. Periorbital Injectables: Understanding and avoiding complications. Journal of Cutaneous and Aesthetic Surgery 2016 Vol 9 (2) 5. Roberts WE. Periorbital hyperpigmentation: Review of Etiology, Medical Evaluation and Aesthetic Treatment. Journal of drugs and dermatology. April 2015 Vol 13 472. 6. Haddock N, Saadeh P, Boutros S, Thorne C. The tear trough and lid/cheek junction: Anatomy and Implications for Surgical Correction. Plastic Reconstr Sure. 2009;123(4): 1332-1340 7. Ross K, Strutman, MD, Mark A, Codney, MD. Tear trough deformity: Review of Anatomy and Treatment Options. Aesthetic Surgery Journal 32 (4) 2012 426-440. 8. Sheth p, Shah H, J Dave Periorbital Hyperpigmentation: A Study of its Prevalence, Common Causative Factors and its Association with Personal Habits and Other Disorders. Indian J Dermatol. 2014 Mar-Apr; 59(2): 151–157. 9. Chandra M, Levitt J, Pensabene C. Hydroquinone Therapy for Post-inflammatory Hyperpigmentation Secondary to Acne: Not Just Prescribable by Dermatologists. Acta Dermato-venerologica. 92 (3):232-5. 10. Vrcek I, Ozgur O, Nakra T. Infraorbital Dark Circles: A Review of the Pathogenesis, Evaluation and Treatment. J Cuban Surg 2016 9 (2) 65-72. 11. Goldberg RA, McCann JD, Fiaschetti D, Ben Simon GJ. What auses eyebags? Analysis of 114 consecutive patients. Plast Recontr Surg 2005;115 (5) 1395-1402 12. Murri M, Hamill E, Hauck M, Marx D. An Update on Lower Lid Blepharoplasty Semin Plast Surg. 2017 Feb; 31(1): 46–50. 13. Bucay VW, Day D. Adjunctive skincare of the brow and periorbital region. Chin plastic Sure. 2013; 40:225-236 14. Ramos-e Silva M, Boza JC, Cestar TF. Effects of age (neonates and elderly) on skin barrier function. Clinics in dermatology. (3) 2012 274-276. 15. Mendelson B, Wong CH. Changes in the Facial Skeleton with Aging: Implications and Clinical Applications in Facial Rejuvenation. Aesthet Plast Surg (2012) 36:753 16. Flowers RS. Tear trough implants for correction of tear tough deformity. Chin Plast Surg 1993;20 (2)403-415. 17. Woodward J. Review of Periorbital and Upper face: Pertinent Anatomy, Ageing, Injection Techniques, Prevention and Management of Complications of Facial Fillers. Journal of Drugs in Dermatology Vol 15 Issue 12 2016 1524-1531 18. Wan D, Amirlak B, Rohrich R, Kathryne D. The Clinical Importance of the Fat Compartments in Midfacial Aging. Last Reconstr Surg 2014. 19. Meyer F. Zur anatomie der Orbitalarteien. Morphol Jahr 1887; 12 414-458. 20. Hayreh SS. Orbit Vascular Anatomy eye (Lond). 2006 Oct. 20(10):1130-44.[Medline]. 21. (https://emedicine.medscape.com/article/1189696-overview) Oct 20, 2017Author: Hon-Vu Q Duong, MD; Chief Editor: Thomas R Gest, PhD 22. Hayreh SS, Dass R. The opthalmic artery I. Origin and intra-cranial and intra-canalicular course. Br J Opthalmol 1962; 46 65-68 23. Hayreh SS, Dass R. The opthalmic artery II. Intraorbital course Br J Opthalmol 1962; 46 165-185. 24. Hayreh SS, Dass R. The opthalmic artery III. Vranches Br J Opthalmol 1962; 46 212-247. 25. Hayreh, SS. Posterior Ciliary Artery Circulation in Health and Disease The Weisenfeld Lecture. Investigative Ophthalmology & Visual ScienceMarch 2004, Vol.45, 749-757. doi:10.1167/iovs.03-0469 26. Belezany K, Carruthers JDA, Humphrey S, Jones DJ,. Avoiding and treating blindness from fillers: a review of world literature. Dermatologic Surg. 2015; 41: 1097-1117 27. Hawkes E. Considering Dermal Filler Blindness. Aesthetics Journal Nov 2019. 28. Walker, Lee, and Martyn King. “This month’s guideline: Visual Loss Secondary to Cosmetic Filler Injection.”The Journal of clinical and aesthetic dermatology vol. 11,5 (2018): E53-E55. 29. Palermo E C. Anatomy of the periorbital region. Sure Cosmet Dermatol 2013;4 (3) 245-56. 30. Rheological properties of several hyaluronic acid-based gels: Acomparitive study. Jounral of Drugs and Dermatology 2018 (17) 948 31. King, M, Convery C, Davies. ACE guidelines: The use of Hyaluronidase in Aesthetic Practice. 32. Goldberg RA, Fiaschetti D. Filling the periorbital hollows with hyaluronic acid gel: Initial experience with 244 injections. Ophthal Plast Reconstr Surg. 2006;22:335–41. 33. Sundaram H, Cassuto D. Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications. Plast Reconstr Surg. 2013;132(4 Suppl 2):5S–21S.

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Introducing Muscle Stimulating Technology With the recent rise of muscle stimulating technology available on the market, Aesthetics explores the different devices currently available Strict diets and intense exercise regimes are no longer the only way for individuals to achieve a toned and sculpted body – contouring of the body is now a booming industry. According to the American Society for Dermatologic Surgery (ASDS) annual member survey, its popularity is continuously growing amongst the public, having risen 43% from 2017 and quadrupling since 2012.1 Results of the survey indicated that for every one liposuction, there were more than 10 non-invasive body-sculpting treatments performed in the US. In a separate survey conducted by the ASDS, body sculpting was also ranked as the most common treatment that consumers were considering for three years running.2 Most clinics will be familiar with devices that aim to heat or cool fat tissue to achieve contouring results, but there is now new technology available that aims to simultaneously increase muscle mass and reduce fat. The technology in these devices aims to replicate the results of strength training workouts, with the application of such being shown to bypass the central and peripheral nervous system, directly stimulating motor neurons and allowing for full muscle contractions.3 This causes muscle hypertrophy, which works through three main processes; mechanical tension, metabolic stress, and muscle damage. Mechanical tension refers to the disruption of muscle structures. This results in metabolic stress causing muscle damage, which then leads to hypertrophic responses where the tissue is forced to adapt to the stress and develop the muscle.5 While electrical muscle stimulators (EMS) have previously been available for home purchase, these were designed to be attached and used as part of a daily workout to make already active muscles train harder. When having an in-clinic treatment, patients are not required to partake in any activity in order to achieve visible results. Manufacturers all state that there is no downtime required following treatment, with patients being able to immediately return to their normal routines. Here, we take a look at the devices that are currently available in the UK.

EMsculpt by BTL Aesthetics Before

After

Patient pictured four weeks after her fourth treatment of EMsculpt

What is EMsculpt? EMsculpt is cleared by the US Food and Drug Administration (FDA) to strengthen, firm and tone the abdomen, buttocks and thighs, using an electromagnetic field to simultaneously build muscle and cause fat cell disruption.6,7 High intensity focused electromagnetic (HIFEM) technology penetrates through the skin aiming to impact fat, as well as muscle tissues. Once penetrated, the energy intends to induce supramaximal muscle contractions that are accompanied by a rapid metabolic reaction in fat cells. A study of 22

patients, each treated with four 30-minute sessions, were evaluated through an MRI scan after two months. Results indicated that abdominal fat thickness was reduced on average by 18.6% and abdominal muscle mass increased by 15.4%.6 The treatment takes 30 minutes and research indicates the devices replicates 20,000 crunches per session.7 The manufacturer recommends four treatments within a two-week period, spaced two or three days apart for optimum results. What are the benefits? A company-sponsored study of 33 EMsculpt patients found there was an average of 19% reduction in subcutaneous abdominal fat one month after treatment and a 23% reduction three months post treatment.7 Positive results are usually reported two to four weeks after the last session and continue to improve for several weeks following the treatment. What practitioners say: Dr Tracy Mountford said, “EMsculpt not only improves patients’ physiques aesthetically, but can also improve core and gluteal strength. By strengthening the gluteal muscle, we can help to strengthen and stabilise the hip area, whilst also improving back pain in pre-disposed individuals by strengthening the core. Not only can we deliver patients a treatment that offers an aesthetic improvement, but one that can also improve their physical health, strength and wellbeing.”

StimSure by Cynosure Before

After

Before and after the patient had a total of six StimSure treatments, two per week.

What is StimSure? StimSure provides an electromagnetic field that can engage the entire target muscle group. A prolonged contraction, made by a series of individual twitch contractions back to back, aims to create a ‘maximal tetanic contraction’ that results in more efficient growth of muscle fibres. Cynosure claims that StimSure is simple to operate, with a secure fixing belt. The device delivers up to 24,000 muscle contractions in 20 to 30 minutes and to acheive best results, Cynosure recommend six to eight treatments, twice a week.16 The applicators have one of the longest lifespans in the market, guaranteed for 10,000 treatments as they are oil cooled. What are the benefits? StimSure can be used to strengthen and tighten the abdominal, gluteal and thigh muscles, as well as to treat posture by correcting and strengthening core and back muscles. It can also be used to treat issues such as diastasis recti.8 What do practitioners say? Dr Joney de Souza said, “We begin our patients’ transformation with SculpSure for fat reduction, interspersed with StimSure sessions to deliver improved muscle tone and posture, before smoothing and tightening the skin using TempSure. So far, patient feedback on this methodology has been outstanding!”

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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TESLAFormer by Iskra Medical Before

What is the TESLAFormer? TESLAFormer uses functional magnetic stimulation (FMS) technology, which is based on the principle of electromagnetic induction. A functional magnetic field is generated by a pulse of current created through a wire inside the device, and the magnetic field After inside the body causes an electric current which triggers stimulation of moto neurons. This results in contraction of the muscle.9 The TESLAFormer is reported to produce 50,000 contractions per every 30-minute session.10 Patient before and after four treatments of What are the benefits? FMS has been TESLAFormer. Sessions shown to increase muscle mass after were carried out four multiple treatments on the same target times over two weeks. location, and can be used for muscle strengthening, toning and sculpting of the body on areas of glutes, abs, hamstring and thighs, calves, arms, back and pelvic floor. The FMS technology has also been reported to help stimulate pelvic floor muscles for urge and stress urinary incontinence, faecal incontinence, milder forms of drooping uterus, and bladder and erectile dysfunction.11,12 Results are visible four weeks following the last session, and continue to improve for up eight weeks following the procedure.10 What do practitioners say? Dr Vincent Wong commented, “TESLAFormer is a great device that utilises functional magnetic stimulation to sculpt the body. The device bypasses the central nervous system to create supramaximal contractions that are impossible to achieve with normal exercise routines. Patients find the treatment very effective with no pain and no downtime. Most of my patients see and feel a big change after one to two sessions.”

TruSculpt Flex by Cutera Medical Ltd Before

After

Before and after the patient’s eighth session, which were carried out twice a week.

What is the TruSculpt Flex? The technology uses multi-directional stimulation (MDS) which is bio-electrical muscle stimulation instead of electromagnetic stimulation.13 MDS offers three different treatment modes: prep, tone and sculpt. Prep creates a twisting motion to warm up and stretch the muscles and slowly builds a tolerance to the muscle contractions. The tone mode contracts, holds and relaxes the muscle from strength and endurance, and the sculpt mode causes fast, deep, sequential contractions of the muscles to build mass and increase metabolic rate. According to Cutera, the TruSulpt Flex technology can replicate 54,000 crunches in 45 minutes. Preliminary data collected by the company on treatments with the truSculpt Flex showed an average of 30% increase in muscle mass. The survey of 28 patients also highlighted that pain was minimal, with patients having only experienced pain on average of 2.27 out of 10 during the procedure.14 What are the benefits? TruSculpt Flex aims to improve abdominal tone,

strengthen the abdominal muscles, and develop a firmer abdomen. The device is also used for strengthening, toning and firming of the buttocks and thighs. What do practitioners say? Dr Tapan Patel commented, “With the TruSculpt Flex, we have the ability to tailor the treatment dependent on the individual’s fitness levels and we are also able to target specific muscles directly, instead of just treating a large area. An average 30% muscle hypertrophy is something that will resonate with our patients.”

3D-PowerSculpt from 3D-Lipo Before

After

What is 3D-Powersculpt? This device engages the muscle through the 3D-Powersculpt handpieces. Electromagnetic fields are used to contract and stimulate muscle energy production. Featuring seven different waveforms for varied desired results, the technology keeps the Patient before and after fourth treatment of muscles tense and contracted PowerSculpt repeatedly throughout the treatment, forcing the muscle tissue to adapt, resulting in muscle building and fat burning, according to the company. The machine can be used as a stand-alone treatment or alongside other 3D-Lipo body treatments. According to the company, one 30-minute treatment is equivalent to completing 20,000 crunches or squats and no exercise is required during the treatment course.15 What are the benefits? Areas that can be treated are the arms, upper abdomen, lower abdomen, buttock, legs and inner thigh. Studies on this device are still pending publication.

Combine with diet and exercise While all companies state that the muscle-stimulating devices do provide patients with visible results, they highlight the importance of a balanced diet and exercise regime. It’s recommended that practitioners communicate this with patients in order to maintain their physique and to optimise results. REFERENCES 1. ASDS, 2019, <https://www.asds.net/skin-experts/news-room/press-releases/asds-membersperformed-more-than-125-million-treatments-in-2018> 2. ASDS, 2019, https://www.asds.net/Portals/0/PDF/consumer-survey-2019-infographic.pdf 3. Schoenfeld Brad, 2010, The mechanisms of Muscle Hypertrophy and their application to resistance training, Journal of strength and conditioning research 4. Duncan D, non-invasive Induction of Muscle Fiber Hypertrophy and Hyperplasia: Effects of HighIntensity Focused Electromagnetic Field Evaluated in an In-Vivo Porcine Model: A Pilot Study, Aesthetic surgery journal 5. Howe L, Et al, 2017, muscle hypertrophy: a narrative review of training principles for increasing muscle mass, strength and conditioning journal 6. Kinny B, Lozanova P, 2018, High Intensity Focused Electromagnetic Therapy Evaluated by Magnetic Resonance Imaging: Safety and Efficacy Study of a Dual Tissue Effect Based Non-Invasive Abdominal Body Shaping 7. Close M, 2018, https://aestheticsjournal.com/feature/spotlight-on-emsculpt 8. Worcester Business Journal, 2019’ <https://www.wbjournal.com/article/hologic-subsidiary-releasesmuscle-contraction-machine> 9. Radakovic T, Radakovic N, 2015, the effectiveness of the functional magnetic stimulation therapy in treating sciatica syndrome 10. Iskra Medical, Body Forming with FMS brochure 11. But I, Et al, 2005, Functional magnetic stimulation for mixed urinary incontinence, Journal of Urology 12. Shafik A, 2000, Magnetic stimulation of the cavernous nerve for the treatmentof erectile dysfunction in humans 13. Kravatis M, Kothare A, 2019, TruSculpt Flex: Technology and Differentiation in the Market, information available upon request 14. Ronan S, 2019, A Novel Bio-electric Current Srimulation Device for Improvement of Muscle Tone: The Trusculpt Flex 15. 3D-Powerscult trade sheet, 3D-Lipo, 2020, information available upon request 16. Data on file (obtained from KendrickPR and Cynosure)

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Case Study: Treating Cellulite with Microwave Technology

worsens, fat and water become wholly enclosed in a prison of always hardened septa, which is composed of fibrous connective tissue.7,8 Studies have shown that compared to radiofrequency, which ranges from a frequency of 30kHz to 1GHz, microwaves at a frequency of 2.45GHz result in more absorption in the fat than they do in the uppermost layers of skin.9,10 The skin allows the passage Dr Paolo Bonan shares a case study of cellulite of energy with high frequencies (from treatment and explains how microwave technology MHz to GHz), but it does not allow works to achieve successful results it when the frequency of the same energy gets lower (from KHz to MHz). When we think of microwaves, the first thought which will come This is due to the different dielectric properties of fat and skin; in the to mind is of microwave ovens. These emit microwaves via a free microwave range, skin shows low permittivity (meaning that it absorbs emission antenna, and the generated electromagnetic field is of little energy) and high conductivity (so microwaves can easily pass ‘radiative type’ (free air emission), where the light is free to bounce through the skin), whereas fat has lower conductivity, meaning that back and forth over the metallic walls. If the microwaves encounter the energy will stop in the fatty layers, and higher permittivity, so it any water molecules on their journey, such as those found in food, can store a large amount of energy. The result of this is that energy then the molecules will attempt to align with the electromagnetic can be effectively deposited within the fat cells, as opposed to the field. It is this molecular motion which creates heat, and the resultant cutaneous tissue, without causing excessive heating in the dermis.11 1 warming of our dinner. This allows for the microwaves to provoke oscillation and vibration Less commonly known is that microwave technology is also effects in the fat molecules, creating heating within the fatty tissue employed in many branches of medicine, including oncology, urology (Figure 1). This heat creates an imbalance inside the adipocyte, and dermatology.2 Within the field of aesthetics, perhaps the most leading to the fat content changing its chemical structure, and causing well-known application for microwaves is in the treatment of axillary the cell to increase its metabolism and to expel small droplets of fat. hyperhidrosis.3 Microwaves have been shown to be effective for the This process is known as ‘blebbing’, and can be seen in Figure 2.11 selective heating of the interface between the skin and underlying To deliver this microwave energy to tissue safely, the emission of the fat in the underarm area, resulting in damage of the sweat glands, radiation must be highly controlled. Unlike the ‘free-air’ emission of and a reduction in excess sweating.4,5 The ability of microwaves to a microwave oven, these microwaves are delivered via a handpiece penetrate to deeper layers of the subcutaneous tissue6 has naturally with a central emitting electrode and are then ‘recalled back’ by led to research being conducted to the application of the technology the peripheral circular return electrode. In this way, the penetration for body contouring and the targeting of unwanted fat, cellulite and depth of the microwaves can be closely defined to avoid heating in skin laxity. Its use for these applications, more specifically cellulite, will the muscle.12 be discussed in this paper. As a result, 80% of the emitted energy can be delivered to the fat, whilst 20% is retained within the skin. The integrated cooling tip of the How microwave handpiece counteracts some of this superficial heating, so that only technology targets approximately 6% of the energy is retained within the skin.12 cellulite At this point, the adipocyte cell membrane is still intact, but as the The hypodermis consists of cellular stress increases, the blebbing increases to such a degree small ‘recesses’ or ‘lobules’ that the cell membrane will rupture. This is clearly demonstrated which are separated by in Figure 3, which shows the broken cell membranes following bands of fibrous tissue treatment with a microwave device.11 called septa. In men, these The fat that has been excreted from the adipocytes, alongside the Figure 1: The distribution of microwave bands tend to run in-line broken fat cells, are then eliminated through the lymphatic system in energy through the tissue13 with the skin, but in women, a process known as macrophage these bands are perpendicular to the skin. Cellulite results from lipolysis. The trafficking of fatty both a build-up of fat in the adipose tissue (the hypodermic fat cells) acids into and out of adipocytes and water retention around them in the dermis and hypodermis. If is a physiological mechanism adipocytes increase their volume, as happens with weight gain, and if regulated by a complex series water accumulates in these recesses, then the walls are compressed, of proteins and enzymes and damaging the microcirculation and the natural form of the cell. is under control by a variety of Because these walls are attached to the dermis in the anchor points hormonal and metabolic factors.14 they pull at the skin’s surface, whilst fat cells push towards the dermis. In a 2019 study with 19 healthy Figure 2: Optical microscopy In other words, when the adipocytes get bigger or the oedema patients, Bonan et al. showed showing a stressed fat cell, six increases, the ‘envelopes’ containing them change shape and pull on hours after microwave exposure that microwaves could act directly from the Onda microwave device, their anchor points on the skin. The result is a skin surface that takes on the adipocyte tissue, sparing demonstrating evident blebbing on a bumpy ‘orange-peel’ appearance. Over time, as the condition all around the perimeter11 the dermoepidermal layers,

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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A

promoting heating of the adipocyte cell, and consequently leading to macrophage-mediated adipocytes lysis.15 Specifically related to cellulite, the energy of the technology is absorbed by the fibrous connective B branches, which causes the solubilisation of the collagen with consequent debridement of the tight non-elastic weft that strangles the lobules. The solubilisation of collagen, in addition to producing the loss of the pitted appearance of Figure 3: Histological images of the skin, also makes it possible to tissue with human abdominal reactivate the fibroblasts which are fat (magnification x 20). (A): Control. (B) Sample of stimulated to produce new, more patient immediately after elastic collagen. The heat produced treatment. Image (B) clearly shows adipocytes with by the microwave technology broken membrane and initial causes an immediate collagen hyperaemia with dilation of the fibre, shrinking in the dermis with blood vessels. Image courtesy of Prof. R. Perrotta, M.D. and M.s. a consequent tightening. The final Tarico, M.D., Catania – Italy.11 effect is the improvement of skin laxity and the visible result in the disappearance of the orange-peel cellulite effect.11,13 In my clinic, I use the Onda device with Coolwaves microwave technology, which at the time of publication is the first and only device available that uses this technology. It is very versatile, with a deep handpiece that holds a circumference of 35cm² and the shallow handpiece which is 25cm². The shallow handpiece was utilised in the treatment of the following case study to induce the shrinkage of fibrous connective branches causing the solubilisation of the collagen.

Patient concerns A 45-year-old woman presented to clinic with unwanted cellulite on the super-lateral area of the thigh. I conducted a thorough lifestyle and medical check to discover any illnesses, risk factors and possible causes of concern which could be responsible for the onset of cellulite problems such as obesity, alcohol, smoking, hormonal imbalances or metabolic condition.7 The patient was in good health with no medical history to note. She consumed alcohol in moderation, kept well hydrated and enjoyed exercise, but had difficulty targeting this area to reduce unwanted cellulite. There were no open wounds/lesions within the intended treatment area and no history connected to contraindications such as medication, allergies or possible pregnancy. A physical assessment followed to identify the areas to be treated and to evaluate the scale of the cellulite. The Nurnberger-Muller scale helpfully charts four distinct levels of cellulite

affliction (Figure 4). This patient’s cellulite was at grade 3 on the scale, with visible depressions on standing and lying down, without having to pinch the skin.16 We discussed the treatment options available to address her concerns, which included liposuction or various massage treatments. We outlined that the method we would utilise to treat her concerns would be microwave technology because excellent results can be seen within as little as one treatment, it is tolerated very well, it is very safe and I thought she would be an excellent candidate. It’s important to understand a patient’s goals and ensure that as a practitioner you set realistic expectations when discussing treatment approaches. The individual should understand how many treatments are needed, at what intervals, and what can be done to improve results. It’s important to highlight that results can vary from patient to patient. I explained to her that mild side effects could occur, including itching, numbness, warmth, tenderness, redness, swelling, burns, bruising and blisters on the treated area. These possible adverse reactions are usually transient and are resolved a few days after treatment. Possible adverse effects on the treated area include skin and fat tissue necrosis, skin contour irregularities and asymmetry. This may occur after improper use of the system, such as excessive energy levels or incorrect fat tissue evaluation.17

The heat produced by the microwave technology causes an immediate collagen fibre, shrinking in the dermis with a consequent tightening Pre-treatment Given the high degree of absorption of microwaves by water,18 it is recommended to suspend the use of body creams in the area at least one week before the treatment. This is to avoid greater absorption of the microwaves in the superficial layers of the skin and, therefore increasing the penetration within the adipose tissue.13 The patient should drink two litres of water a day to facilitate the drainage of interstitial fluids. It is recommended to start this the day before the treatment and continue after the treatment.13 Standardised pre-and post-treatment photographic documentation of area treated should always be carried out at a variety of angles. This helps to monitor the effectiveness of the treatment.

Figure 4: The Nurnberger-Muller scale16 Grade 3

Dimpling while both standing and lying down

Grade 2

Dimpling is visible when standing, but not when lying down

Grade 1

Dimpling when pressure is applied

Grade 0

No dimpling when pressure is applied

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Before

@aestheticsjournaluk

After

Figure 5: Patient before and after three cellulite treatments using Onda Coolwave technology

Aesthetics

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parameters of 140W/90.000J per 15x15cm square (one placed on the trochanter and one on the inner thigh) per session. The whole treatment was over in around 25 minutes. Once treatment was completed, the patient returned to their normal daily routine and activities without downtime. Good hydration and a healthy diet and exercise regimen where recommended to the patient. Typically, two to four treatments are advised at four-week intervals to maximise clinical outcome with full visible results expected by 12 weeks’ post treatment.17 Some patients achieve their desired outcome in a single treatment, however this patient required three (Figure 5).

Treatment process

Following treatment

Before starting the treatment, the area must be cleansed of any impurities that could interact with the microwaves or obstruct the handpieces. The patient was advised to have any dense hair in the area removed before treatment, to improve the coupling between the handpiece and the skin.13 Identification of the boundaries of the cellulite were made and the treatment area was divided into sub-areas of 15x15cm. With the patient lying on the bed face down, a thin film of paraffin oil (pharmaceutical grade) is spread over the entire treatment area for proper contact of the handpiece with the skin for better coupling and greater fluidity of the movements. During the treatment the patient could feel slight heating effects in the tissue, which they described as a hot deep tissue massage, without undue discomfort. Treatment parameter data, such as the stage of cellulite, handpiece utilised, power, dose, cooling and number of sessions must always be recorded in the patient’s notes. For this patient, we utilised treatment

I advocate that patients undergo lymphatic drainage massages after each session, as well as at the end of the cycle of treatments, to further assist in the removal of waste and toxins from bodily tissues, which was carried out for this patient. The results show an excellent improvement in visible dimpling, and a reduction on the cellulite score from three to two. The patient was extremely satisfied with the outcomes.

Summary Microwave technology makes it possible to treat all three common concerns of body shaping: cellulite, fat loss and skin laxity. This case study is an example of the possibilities for cellulite using this approach. It is a comfortable procedure, with few side effects, which is safe and comfortable for patients. Dr Paolo Bonan is the head of dermatology and in charge of the Laser Cutaneous Cosmetic and Plastic Surgery Unit, Villa Donatello Clinic, Florence, Italy. He is also a professor in Laser Surgery at the University of Rome ‘Guglielmo Marconi’ and the University of Siena. Qual: MD

A study showed that microwaves could act directly on the adipocyte tissue, sparing the dermoepidermal layers, promoting heating of the adipocyte cell, and consequently leading to macrophage-mediated adipocytes lysis

REFERENCES 1. Microwave Technology, Science Direct, Microwave-Assisted Sample Preparation for Trace Element Analysis, 2014. <https://www.sciencedirect.com/topics/materials-science/microwave-technology> 2. A. Rosen; M.A. Stuchly; A. Vander Vorst, Applications of RF/microwaves in medicine, IEEE Transactions on Microwave Theory and Techniques (Volume: 50, Issue: 3, Mar 2002) 3. Long-term efficacy and quality of life assessment for treatment of axillary hyperhidrosis with a microwave device, M Lupin, HCH Hong, KF O’Shaughnessy - Dermatologic Surgery, 2014 4. C Jacob Treatment of hyperhidrosis with microwave technology, - Semin Cutan Med Surg, 32, 2, 8, 2013 5. H Chih Ho Hong, M Lupin Kathryn F. O’Shaughnessy Clinical evaluation of a microwave device for treating axillary hyperhidrosis - Dermatologic Surgery, 38, 5 2012 6. F. Sterzer, Microwave medical devices, IEEE Microwave Magazine ( Volume: 3 , Issue: 1 , Mar 2002 ) 7. ABR Rossi, AL Vergnanini Cellulite: a review, - Journal of the European Academy of Dermatolgy and Venereology 14, 4, 2000 8. Matthew Avram, Cellulite: a review of its physiology and treatment, J. Cosmetic and Laser Therapy, 6, 4, 2004 9. Lihong V. Wang, Xuemei Zhao, Haitao Sun, and Geng Ku, Microwave-induced acoustic imaging of biological tissues, Review of Scientific Instruments 70, 3744 (1999) 10. J-S Hwang, T-H Woo, S-B Park and C-Y Cheon. Microwave Hyperthermic Lipolysis using External RF Antenna. Journal of Electrical Engineering & Technology. 2012; Vol 7, No. 5, pp. 759-64. 11. Deka White Paper “How the New Onda System Works: The Coolwaves Effect” <https://www.lynton. co.uk/images/products/ONDA/Onda_DekaWP_July2018.eng.rev1.1.pdf> 12. Onda Clinical User Manual, DEKA 13. Onda Frequently Asked Questions Deka May 2019. <file:///Users/shannon.kilgariff/Downloads/ FAQ%20ONDA_ENG%20rev%201.6%20(1).pdf> 14. R Foster, M-C Ziskin & Q, Balzano. Thermal response of human skin to microwave energy: A critical review. Health Physics. 2016. 111, pp. 528-541 15. B-R Thompson, S Lobo, D-A Bernlohr. Fatty Acid flux in adipocytes; the ins and outs of fat cell lipid trafficking. Mol Cell Endocrinol. 2010, 318(1-2), pp. 24-33. 16. Daniel P Friedmann, et al., Cellulite: a review with a focus on subcision, Clinical, Cosmetic and Investigational Dermatology, Doe Press, 2017. 17. P Bonan, L Marini, T Lotti. Microwaves in body sculpting: A prospective study. Dermatol Ther. 2019, 32: e12782. 18. Water and Microwaves, 2019, <http://www1.lsbu.ac.uk/water/microwave_water.html>

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Advertorial SkinCeuticals

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SkinCeuticals Advanced Topical Antioxidants Discover the benefits of SkinCeuticals antioxidant formulations and new testing against atmospheric aggressors An antioxidant is the cornerstone of any topical skincare regimen to improve skin health and quality. With over 30 years of research, four generations of antioxidant breakthroughs and more than 20 peer-reviewed studies, SkinCeuticals provides advanced, clinically proven, synergistic formulations of potent Vitamin C.

Setting the standard in efficacy Only the SkinCeuticals Vitamin C antioxidants meet the strict Duke University formulation parameters essential to deliver enhanced absorption and proven efficacy:1 • Pure l-ascorbic acid: topically delivered l-ascorbic acid has been shown to increase vitamin C levels in skin • High concentrations of pure l-ascorbic acid: 10-20% concentration provides meaningful levels of vitamin C in skin • Formulated at an acidic pH below 3.5 for optimal delivery in skin Before

Ultimate protection and visible benefits C E Ferulic, Phloretin CF and Phloretin CF gel provide 8x the skin’s natural environmental protection.1 Daily use of C E Ferulic or Phloretin CF is strongly recommended because these have been proven to neutralise free radical damage from environmental aggressors such as UV, infrared radiation-A and Ozone (O3) pollution. Importantly, these products also offer visible, proven benefits on key anti-ageing markers, delivering high patient satisfaction.

New testing: C E Ferulic & the effects of atmospheric aggressors Traditionally, the effects of atmospheric aggressors on the skin have been tested individually. In a first for SkinCeuticals, a new study exposed skin explants to varying combinations of ultraviolet light (UV),2 Ozone (O3) and diesel engine exhaust (DEE) that our skin would experience in a typical, urban environment. By combining the top three atmospheric aggressors, SkinCeuticals has created a clinical environment that mirrors the conditions our skin goes through every day in an urban environment. Topical treatment with C E Ferulic was shown to effectively prevent oxidative damage, inflammation, and skin protein damage induced by combined aggressor exposure.

“Today, with more than 90% of the world’s urban population estimated to be living with pollutant levels in excess of WHO standard limits, being able to provide antioxidant serums that help to counteract the negative impact of ozone pollution on skin is of huge significance” Renowned Harley Street dermatologist Dr Ariel Haus

40

Aesthetics | April 2020

After

Before and after C E FERULIC showing reduction in coarse wrinkles, improved skin firmness, and a brightened complexion. Protocol: 16-week clinical study conducted on 50 Caucasian male and female subjects ages 40–60 years old (USA, 2013).


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When When skin skin When waswas exposed skin exposed wasto exposed to thethe to the combination combination combination of of UVUV ++ ozone ofozone UV + + ozone + diesel diesel engine engine diesel exhaust, engine exhaust, Cexhaust, ECFerulic E Ferulic C E Ferulic helped helped preserve helped preserve filaggrin preserve filaggrin proteins filaggrin proteinsproteins

Protocol: Protocol: Six-day Protocol: Six-day study study Six-day on skin on skin study explants explants on skin fromfrom explants 3 different 3 different from donors 3 donors different withwith 4donors days 4 days ofwith exposure of 4exposure days to of aexposure tocombination a combination to a combination of aggressors: of aggressors: of0.25 aggressors: 0.25 ppmppm ozone 0.25 ozone for ppm 2 forhours, ozone 2 hours, diesel for diesel 2 hours, engine engine diesel exhaust exhaust engine for 30 for exhaust 30 minutes, minutes, for and 30 and minutes, and 2 2 2 for 18 for2J/cm 18 seconds. seconds. for 18 C Eseconds. CFerulic E Ferulic was C was Eapplied Ferulic applied to was skin toapplied skin explants explants to skin prior prior explants to exposure. to exposure. prior to Product exposure. Product waswas left Product left on skin on was skin for left24-hours. foron24-hours. skin for Skin 24-hours. Skin explants explants Skin were were explants exposed exposed were to the to exposed the different different to combinations the combinations different combinations of aggressors of aggressors of aggressors UV UV 2J/cm 2J/cm UV every every day,day, over every over theday, the 4-day 4-day over period. the period. 4-day SkinSkin explant period. explant samples Skinsamples explant were were samples collected collected were after collected after 1 day 1 day ofafter aggressor of aggressor 1 day of exposure aggressor exposure andexposure and analyzed analyzed and by immunofluorescence analyzed by immunofluorescence by immunofluorescence staining. staining. staining. REFERENCES

1. Pinnell, S.R., et al (2005). Ferulic Acid Stabilizes a Solution of Vitamin C and E and Doubles its Photoprotection of Skin. J Invest Dermatol 125:826-832. 2. Protocol: Six-day study on skin explants from 3 different donors with 4 days of exposure to a combination of aggressors: 0.25 ppm ozone for 2 hours, diesel engine exhaust for 30 minutes, and UV 2J/cm2 for 18 seconds. C E Ferulic was applied to skin explants prior to exposure. Product was left on skin for 24-hours. Skin explants were exposed to the different combinations of aggressors every day, over the 4-day period. Skin explant samples were collected after 1 day of aggressor exposure and analyzed by immunofluorescence staining.

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Using Isotretinoin Beyond Acne Dr Firas Al-Niaimi explores the various conditions that can be treated with isotretinoin Isotretinoin, also known as 13-cis retinoic acid, is a synthetic drug widely known for its treatment of acne.1 The mechanism of action results from isotretinoin-induced expression of apoptotic protein necrosis factor, and a recent review suggests that apoptosis is the culprit for the multitude of well-known side effects of isotretinoin.2 Cell proliferation is regulated by the activation of specific receptors; the nuclear retinoic acid receptors which isotretinoin binds to and activates. Furthermore, it is said to decrease polyamine synthesis and keratinisation, which contributes to its anti-inflammatory and anti-prolific properties.3 The UK licence for isotretinoin was first established in 2001 with strict pregnancy prevention criteria and regular monitoring of blood tests, namely liver function tests and lipids.4 Whilst widely used in acne, there are a number of other dermatological conditions which respond to isotretinoin which will be discussed in this article.

four months. Overall, the isotretinoin group demonstrated higher absolute and relative reductions in the number of lesions (at least 90%), as well as Skindex scores, in comparison to the placebo arm. In addition, quality of life scores, as well as clinical outcomes, were better in the isotretinoin group.11 Low dose isotretinoin with doses between 10-20mg a day were successfully used in papulopustular rosacea patients in another study, with a clearance of 90% in 52 patients.12 Gollnick et al. carried out a study reviewing the use of various doses of isotretinoin (from 0.1-0.5mg/kg) in conjunction with either doxycycline or placebo and found that 0.3mg/kg of isotretinoin had the most effective outcome in the treatment of rosacea.13 In total, five studies have shown the efficacy of isotretinoin in rosacea.11-15 Caution is required in ocular rosacea due to the drying effects on the lacrimal system, which can contribute to further drying of the eyes.

Scarring alopecia Hidradenitis suppurativa Hidradenitis suppurativa (HS) is an inflammatory relapsing condition that typically affects folds in the body, such as the axillae and inguinal folds, resulting in sinus tract formations and scarring. In some cases, it can be associated with severe forms of acne. A retrospective review has been carried out assessing the use of isotretinoin for the treatment of the disease.5 Isotretinoin has successfully been used in the management of HS and, in particular, in mild to moderate cases with or without associated acne.6 The effects are likely to be antiinflammatory, in addition to anti-proliferative. Its use, however, has somewhat been eclipsed given the availability of anti-TNF drugs as a successful treatment in moderate to severe cases.

Sebaceous gland pathology Isotretinoin is known to exert its effect on the sebaceous gland activity through certain receptors (RAR) leading to sebocyte apoptosis and reduced sebum production.7 These effects lead to the common clinical side effects of observed dry skin.7 Beyond acne, isotretinoin has been used successfully in a number of sebaceous gland-related pathology such as seborrhea, seborrhoeic dermatitis and sebaceous gland hyperplasia.7 A randomised comparative trial comparing alternate daily use of 10mg isotretinoin versus topical anti-seborrhoeic treatment in moderate to severe seborrhoea and seborrhoeic dermatitis, among 45 patients over six months, demonstrated a significantly greater reduction in scalp sebum secretion in the isotretinoin arm after three months.8 Isotretinoin has also shown to be beneficial in sebaceous hyperplasia and sebaceous adenoma, cyclosporine-induced sebaceous hyperplasia in renal transplant and diffuse familial sebaceous hyperplasia.9,10

Rosacea Isotretinoin has been increasingly used in the management of rosacea as a second or third line treatment with good degree of success and evidence. In general, the doses tend to be lower (0.3-0.5mg/kg) compared to the doses used in acne. Sbidian et al. carried out a randomised-controlled trial among 156 patients with difficult to treat papulopustular rosacea, comparing 0.25mg/kg of body weight a day isotretinoin use versus placebo, with review at

Isotretinoin has been used â&#x20AC;&#x201C; uncommonly â&#x20AC;&#x201C; in scarring alopecia cases in the literature. A retrospective study of 28 patients with folliculitis decalvans reviewed which treatment modalities had the best outcome using either clindamycin and rifampicin, clarithromycin, dapsone or isotretinoin. The authors found that isotretinoin treatment was the most successful, with 90% of patients remaining in remission two yearsâ&#x20AC;&#x2122; post treatment cessation.16 A recent case study demonstrated an excellent outcome of isotretinoin at a dose of 0.3mg/kg/day in an 18-year-old male with dissecting cellulitis recalcitrant to multiple antibiotics, clotrimazole and betamethasone. At the four month follow-up there was near complete remission.17 In this case, the authors postulated that isotretinoin reduced the overzealous immune response and thus normalised the skin and follicular apparatus through the anti-inflammatory and antiproliferative effects of isotretinoin.

Photoageing Topical retinoic acid is widely used and known as an effective agent in the management of photodamage and photoageing. Oral isotretinoin has been used in the management of photoageing, albeit with mixed results in comparison to topical applications of the drug. Two studies have demonstrated that 20mg of isotretinoin daily does not improve outcome,18,19 whereas one case series demonstrated a statistically significant increase in collagen fibres post treatment with either 10 or 20mg isotretinoin three times per week for three months, with overall skin improvement as a result.20

Viral warts Isotretinoin has also been demonstrated to have a good clinical outcome in the treatment of warts. Al-Hamamy et al. demonstrated that 73.07% of warts treated for two months with 0.5mg/kg/day of oral isotretinoin resolved, with 78.94% of the cohort found to have no recurrence at four months.21 Another case study using isotretinoin in conjunction with interferon had complete clearance at three months and no recurrence at one year.22 Of note, from my knowledge, topical retinoic acid has been widely used as an adjunct to treat viral warts and prophylactically to reduce recurrence.

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Non-melanoma skin cancer prophylaxis Immunosuppressed patients, organ transplant recipients as an example, are at higher risk of developing skin cancers, particularly non-melanoma skin cancers, with squamous cell carcinoma being most common. Retinoids exert a chemoprotective effect, partly due to their anti-proliferative effects. Acitretin has higher evidence of chemoprevention in comparison to isotretinoin in organ transplant recipients, whereas isotretinoin is preferred in xeroderma pigmentosum and nevoid basal cell carcinoma.23 Further studies in this field are required. In a single reported case there was a 70% reduction in the size of a squamous cell carcinoma treated with isotretinoin.24

Miscellaneous Other conditions for which isotretinoin has been used or are suggested to be of benefit include: Vohwinkel syndrome with ichthyosis,25 lichen amyloidosis,26 lymphangioma circumscriptum,27 erythema dyschromicum,28 chronic granulomatous disease,29 erythrokeratodermia variablilis,30 atrophoderma vermiculatum,31 synovitis/acne/hyperostosis/osteitis syndrome (SAPHO syndrome),32 prurigo pigmentosa,33 follicular mucinosis,34 granuloma annulare,35 steatocystoma multiplex.36 Case studies have also been published which show evidence for benefit of isotretinoin in lichen planus,37 psoriasis,38 pityriasis rubra pilaris,39 cutaneous lupus40 and eruptive histiocytoma.41 The likely mechanism of action involves anti-inflammatory, anti-angiogenic, immunomodulatory, sebosuppressive, and anti-neoplastic effects.

Side effects and dosage Common side effects reported with isotretinoin include anaemia, arthralgia, dry skin, dry mucosae and importantly (but rarely) depression. The link between isotretinoin and suicide has not been definitely proven, although, it is likely that in some predisposed individuals and those with a history of psychiatric illness or severe depression, isotretinoin may best be withheld.42

Conclusion Isotretinoin is a drug widely used by dermatologists in the management of acne. Increasingly, the drug is used in various dermatological disorders beyond acne as detailed in this article. Its mechanism of action is a combination of anti-proliferative, anti-inflammatory as well as sebo-regulatory influences, hence the drying effect observed in the skin with its use. Correct dosing and monitoring is required and it is anticipated that further studies in this field will take place given the rising popularity of its use beyond acne. Dr Firas Al-Niaimi is a consultant dermatologist, Mohs and laser surgeon. He is a group medical director at sk:n clinics and also works on Harley Street in London. Dr Al-Niaimi has written for more than 160 publications and his own book for preparation for dermatology specialist examination, in addition to 10 book chapters. He is also a senior research fellow in the dermatology and laser department at Aalborg University, Denmark, and is involved in clinical and translational research in the field of lasers. Qual: MD, MSc, MRCP, EBDV REFERENCES 1. Bauer LB, Ornelas JN, Elston DM, Alikhan A. Isotretinoin: controversies, facts and recommendations. Expert Rev Clin Pharmacol. 2016;9(11):1435-1442. 2. Melnik BC. Apoptosis May Explain the Pharmacological Mode of Action and Adverse Effects of Isotretinoin, Including Teratogenicity. Acta Derm Venereol. 2017 Feb 8;97(2):173–81. 3. Khalil S, Bardawil T, Stephan C, et al. Retinoids: a journey from the molecular structures and mechanisms of action to clinical uses in dermatology and adverse effects. J Dermatol. Treat 2017;28(8):684-696. 4. Layton AM, Dreno B, Gollnick HPM, Zouboulis CC. A review of the European Directive for prescribing

systemic isotretinoin for acne vulgaris. J Eur Acad Dermatol Venereol JEADV. 2006 Aug;20(7):773–6. 5. Boer J. Are there indications for isotretinoin treatment of hidradenitis suppurativa? Dermatology. 2017;233:111–112. 6. Patel N, McKenzie SA, Harview CL, et al. Isotretinoin in the treatment hidradenitis suppurativa: a retrospective study. J Dermatolog Treat. 2019 Sep 26:1-3. doi: 10.1080/09546634.2019.1670779. [Epub ahead of print] 7. Zouboulis CC. Isotretinoin revisited: pluripotent effects on human sebaceous gland cells. J Invest Dermatol. 2006;126(10):2154-6. 8. de Souza Leão Kamamoto C, Sanudo A, Hassun KM, Bagatin E. Low-dose oral isotretinoin for moderate to severe seborrhea and seborrheic dermatitis: a randomized comparative trial. Int J Dermatol. 2017;56(1):80–5. 9. Gupta V, Mridha AR, Sharma VK. Sebaceous hyperplasia and sebaceous adenomas presenting as leonine facies and improving with oral isotretinoin. Clin Exp Dermatol. 2016;41:923–924. 10. Jung HY, Kim M, Cho BK, et al. A case of cyclosporineinduced sebaceous hyperplasia in a renal transplant patient successfully treated with isotretinoin. Ann Dermatol. 2016;28:271–272 11. Sbidian E, Vicaut É, Chidiack H, Anselin E, Cribier B, Dréno B, et al. A Randomized-Controlled Trial of Oral Low-Dose Isotretinoin for Difficult-To-Treat Papulopustular Rosacea. J Invest Dermatol. 2016;136(6):1124–9. 12. Rademaker M. Very low-dose isotretinoin in mild to moderate papulopustular rosacea; retrospective review of 52 patients. Australas J Dermatol. 2018;59:26–30. 13. Gollnick H, Blume-Peytavi U, Szabo EL, et al. Systemic isotretinoin in the treatment of rosacea – doxycycline- and placebo-controlled, randomized clinical study. J Dtsch Dermatol Ges J Ger Soc Dermatol. 2010;8:505–515. 14. Uslu M, Şavk E, Karaman G, Şendur N. Rosacea treatment with intermediate-dose isotretinoin: followup with erythema and sebum measurements. Acta Derm Venereol. 2012 Jan;92(1):73–7. 15. Rallis E, Korfitis C. Isotretinoin for the treatment of granulomatous rosacea: case report and review of the literature. J Cutan Med Surg. 2012;16(6):438–41. 16. Tietze JK, Heppt MV, von Preußen A, Wolf U, Ruzicka T, Wolff H, et al. Oral isotretinoin as the most effective treatment in folliculitis decalvans: a retrospective comparison of different treatment regimens in 28 patients. J Eur Acad Dermatol Venereol. 2015;29(9):1816–21.. 17. Marquis K, Christensen L-C, Rajpara A. Dissecting cellulitis of the scalp with excellent response to isotretinoin. Pediatr Dermatol. 2017;34:e210–e211. 18. Bagatin E, Parada MOB, Miot HA, et al. A randomized and controlled trial about the use of oral isotretinoin for photoaging. Int J Dermatol. 2010;49(2):207–14. 19. Bagatin E, Guadanhim LRS, Enokihara MMSS, Sanudo A, Talarico S, Miot HA, et al. Low-dose oral isotretinoin versus topical retinoic acid for photoaging: a randomized, comparative study. Int J Dermatol. 2014;53(1):114–22 20. Rabello-Fonseca RM, Azulay DR, Luiz RR, et al. Oral isotretinoin in photoaging: clinical and histopathological evidence of efficacy of an off-label indication. J Eur Acad Dermatol Venereol. 2009;23(2):115–23. 21. Al-Hamamy HR, Salman HA, Abdulsattar NA. Treatment of plane warts with a low-dose oral isotretinoin. ISRN Dermatol. 2012;2012:163929. 22. Yildirim M, Inaloz HS, Baysal V, Kesici D, Candir O. A case of condyloma acuminatum treated successfully with low-dose isotretinoin and interferon. Int J Clin Pract. 2004 ;58(9):889–91. 23. Bettoli V, Zauli S, Virgili A. Retinoids in the chemoprevention of non-melanoma skin cancers: why, when and how. J Dermatolog Treat. 2013;24(3):235-7. 24. Skroza N, Proietti I, Tolino E, et al. Isotretinoin for the treatment of squamous cell carcinoma arising on an epidermoid cyst. Dermatol Ther. 2014;27:94–96. 25. Nico MMS, Fernandes JD. Low-dose isotretinoin prevents digital amputation in loricrin keratoderma (Vohwinkel syndrome with ichthyosis). J Dtsch Dermatol Ges J Ger Soc Dermatol. 2017;15:665–667. 26. Atacan D, Ergin C, C¸elik G, et al. Oral isotretinoin: a new treatment alternative for generalized lichen amyloidosis. Australas J Dermatol. 2016;57:246–247. 27. Ayhan E. Lymphangioma circumscriptum: good clinical response to isotretinoin therapy. Pediatr Dermatol. 2016;33: e208–e209. 28. Wang F, Zhao Y-K, Wang Z, et al. Erythema dyschromicum perstans response to isotretinoin. JAMA Dermatol. 2016;152:841–842. 29. Spillane AP, Hivnor CM. Isotretinoin use in a case of chronic granulomatous disease. Pediatr Dermatol. 2009;26:756–758. 30. Singh N, Thappa DM. Erythrokeratoderma variabilis responding to low-dose isotretinoin. Pediatr Dermatol. 2010;27: 111–113. 31. Apalla Z, Karakatsanis G, Papageorgiou M, et al. A case of atrophoderma vermiculatum responding to systemic isotretinoin. J Dermatol Case Rep. 2009;3:62–63. 32. Galadari H, Bishop AG, Venna SS, et al. Synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome treated with a combination of isotretinoin and pamidronate. J Am Acad Dermatol. 2009;61:123–125. 33. Akoglu G, Boztepe G, Karaduman A. Prurigo pigmentosa successfully treated with low-dose isotretinoin. Dermatology. 2006;213:331–333. 34. Arca E, Kose O, Tas € ¸tan HB, et al. Follicular mucinosis responding to isotretinoin treatment. J Dermatolog Treat. 2004;15:391–395. 35. Young HS, Coulson IH. Granuloma annulare following waxing induced pseudofolliculitis-resolution with isotretinoin. Clin Exp Dermatol. 2000;25:274–276. 36. Apaydin R, Bilen N, Bayramgurler D, et al. Steatocystoma multiplex suppurativum: oral isotretinoin treatment combined with cryotherapy. Australas J Dermatol. 2000; 41:98–100. 37. Muthu SK, Narang T, Saikia UN, et al. Low-dose oral isotretinoin therapy in lichen planus pigmentosus: an open-label non-randomized prospective pilot study. Int J Dermatol. 2016;55:1048–1054. 38. Al-Shobaili H, Al-Khenaizan S. Childhood generalized pustular psoriasis: successful treatment with isotretinoin. Pediatr Dermatol. 2007;24:563–564. 39. Dicken CH. Treatment of classic pityriasis rubra pilaris. J Am Acad Dermatol. 1994;31:997–9. 40. D’Erme AM, Milanesi N, Difonzo EM, et al. Treatment of refractory subacute cutaneous lupus erythematosus with oral isotretinoin: a valid therapeutic option. Dermatol Ther. 2012;25(3):281-2. 41. Kwinter J, DeKoven J. Generalized eruptive histiocytoma treated with isotretinoin. J Cutan Med Surg. 2009;13(3):146-50. 42. Ludot M, Mouchabac S, Ferreri F. Inter-relationships between isotretinoin treatment and psychiatric disorders: Depression, bipolar disorder, anxiety, psychosis and suicide risks. World J Psychiatry. 2015;5(2):222-7.

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Accordingly, my strategy in treating this patient was to replace the facial volume, as well as to improve dermal thickness and elasticity in this area. By replacing the volume in the mid-cheek deep fat compartments, it’s possible to create adequate support to the tear trough area with an indirect approach and, based on my experience filling this area, improves infraorbital hollows indirectly.

Treatment options

Case Study: Rejuvenating the Periorbita Nurse prescriber Anna Kremerov describes successful treatment of the under-eye area using a non-direct approach Assessment A 52-year-old female patient presented to my clinic with concerns of dark under-eye circles and acute skin laxity in the infraorbital area, following years of yo-yo dieting, lack of sleep and stress. She asked for a tear trough correction to achieve the desired outcome. She was otherwise healthy, with a history of light smoking. When I assessed her full face, I could see she has a good lateral cheek projection. However, she was quite clearly hollow in the anterior cheek, and this had exacerbated her under-eye appearance. In addition, her overall tired look was enhanced by facial laxity and formation of superficial rhytids in the infraorbital region. Following assessment, I concluded that a single treatment with a direct approach to treating her tear trough area could fail to meet the patient’s desired aesthetic outcome, and a different approach was needed to achieve the long-lasting periorbital and facial rejuvenation, along with

natural-looking results. It’s imperative to understand that the cause of tear trough deformity is multifactorial, and isolated treatment may not be sufficient to achieve a good aesthetic outcome.1 The main components of the tear trough are the periorbital hollow itself, superior fat bulge, a distinct change of skin colour and skin thickness in the eyelid-cheek junction.2

Different approaches, along with their advantages and disadvantages were discussed in detail with the patient. A twoweek cooling-off period was implemented before agreeing to go ahead. It was important that she could think carefully about each of her options, weighing the benefits of each against the possible risks and side effects. Options presented included collagenstimulating filler, hyaluronic acid-based fillers, botulinum toxin injections, skin boosters and mesotherapy, skin resurfacing procedures such as IPL treatment and laser skin resurfacing. All of them are excellent treatments; however, when I asked the patient about her eye area, she mentioned that she gets swelling of the region in the morning. Added to the poor elastic recoil, this made me reluctant to treat her tear trough area directly with HA filler, as per my original plan. While the patient knew very little about collagen depletion, she was keen to learn more about how a collagen-stimulating filler could help. Unlike HA, PCL particles cannot be dissolved so I explained this thoroughly to her, paying special attention to the product specification. She was then happy to proceed with the recommended course of treatment. She was informed of the possible risks prior to the procedure, and an individual treatment plan was defined prior to the procedure. My product of choice was Ellansé M. This is because it works not only by volumising and correcting superficial rhytids but also

It’s imperative to understand that the cause of tear trough deformity is multifactorial and isolated treatment may not be sufficient to achieve a good aesthetic outcome

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the same cannula entry point, treatment was extended to the zygomatic malar region on the periosteal plane to provide a soft contour to the lateral cheek area, with 0.5ml administered on each side. The submalar region was treated from the same entry point in the subcutaneous plane using a retrograde linear threading and Patient before and immediately after treatment to the infraorbital area with indirect approach using Ellansé M. fanning technique, with 0.05-0.1ml per by stimulating the body’s own collagen thread. A total of 0.4ml was used on each for a long-lasting, natural result.3,4 Ellansé side. More superficial placement of the is a collagen biostimulator composed of a product in the subdermal plane with the totally bioresorbable polycaprolactone (PCL) same size cannula was used to achieve microspheres in a carboxymethylcellulose biostimulation, in order to increase collagen carrier gel.4 It offers immediately visible production within the dermis and address results, and it’s complete bioresorbability subdermal volume loss.3 This technique make this product suitable for patients was utilised over the mid-face region, with seeking long-lasting and stable results.4 0.6ml used on each side. In this case, I used a single entry injection Treatment point to achieve desirable volume The patient was treated in a sitting replacement, with a total on 4ml injected; position. Makeup was removed prior 2ml on each side. to the procedure, and the area was My preferred technique is a single-point carefully disinfected with Clinisept+ Prep entry using a cannula, which allows me to & Procedure. The orbital rim was palpated achieve a whole mid-face revolumisation. and marked. The infraorbital foramen was I believe using a cannula is a safer and identified and marked prior to injection, as more comfortable technique for the patient, this is a no-go area to avoid severe nerve which could also decrease the risk of and artery compression and embolism. potential side effects such as bruising, On examination, there was a noticeable vascular compromise, bleeding and volume deficit in the anterior part of her ecchymosis.6,7 With any technique, I always cheek, so I made the decision to target this use my non-injecting hand to palpate the area to volumise and improve the patient’s skin and avoid overcorrection. It is also infraorbital hollows indirectly. We agreed important to inject the product slowly with to treat the anterior part of her cheek and small boluses and to watch the tissue as check what degree of improvement we can you inject to see how much filling has been get in the infraorbital region with an indirect created.8 approach. The procedure was performed The possible side effects observed with the with protective gloves. To facilitate a more PCL-based filler are identical to the comfortable procedure, I mixed 0.2ml of HA-based fillers and can be associated with lidocaine 2% with each 1ml syringe of the a risk of short and long-term complications product, as it can be safely performed such as oedema, bruising, vascular without altering the physical properties of compromise, nodules and granuloma the product.5 The depth of injection always formation.8 It’s imperative to discuss depends on the facial area treated and the post-procedural care with the patient and result I am trying to achieve. In the malar to highlight the importance of the aftercare area, a combination of retrograde injections in the prevention of some adverse events. and small boluses performed in the deep Following treatment, patients are advised to supraperiosteal plane, with 0.05-0.1ml per avoid makeup, exposure to heat or extreme line/bolus using a 25 gauge cannula. In cold, keep their face clean, avoid alcohol this case, I used 0.5ml on each side. From and physical activity for the next 24 hours.8,9 Before

After

Results At the three-month review, the patient remained extremely happy with the results. By replacing the volume in the mid-cheek deep fat compartments, I have managed to create an adequate support to the tear trough area with an indirect approach and improve infraorbital hollows indirectly. Thanks to the unique product properties, further collagen biostimulation will help to improve facial laxity by stimulating the body’s own collagen for a long-lasting, natural result. Anna Kremerov is an advanced nurse practitioner and a registered prescriber. She has a Master of Science in Advanced Clinical Practice as well as Level 7 in Injectables for Aesthetic Medicine. Kremerov is a founder and clinical director of Anna Medical Aesthetics based in Swindon, Wiltshire. Qual: ANP, NIP, MSc in Advanced Clinical Practice REFERENCES 1. Michael A.C.Kane,’ Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid’, Aesthetic Plastic Surgery, 29(2005) <https://link.springer.com/article/10.1007/ s00266-005-0071-7> 2. Jaishree Sharad, ‘Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes’, Journal of Cutaneous and Aesthetic Surgery, 5,4 (2012): 229-238 3. Kim JS. Changes in Dermal Thickness in Biopsy Study of Histologic Findings After a Single Injection of PolycaprolactoneBased Filler into the Dermis. Aesthet Surg J. 2019 Nov 13;39(12):NP484-NP494. doi: 10.1093/asj/sjz050. PMID: 30778526; PMCID: PMC6891800. 4. de Melo, Francisco et al. ‘Recommendations for volume augmentation and rejuvenation of the face and hands with the new generation polycaprolactone-based collagen stimulator (Ellansé®).’ Clinical, Cosmetic and Investigational Dermatology, 10(2017), pp. 431-440. 5. de Melo, Francisco, and Joanna Marijnissen-Hofsté. ‘Investigation of physical properties of a polycaprolactone dermal filler when mixed with lidocaine and lidocaine/ epinephrine.’ Dermatology and Therapy, vol. 2,1 (2012): 13. doi:10.1007/s13555-012-0013-7 6. Jani A J van Loghem, Dalvi Humzah and Martina Kerscher, ‘Cannula Versus Sharp Needle for Placement of Soft Tissue Fillers: An Observational Cadaver Study’, Aesthetic Surgery Journal, 38 (2016). 7. James Fulton, Caroline Capertone, Susane Weinkle and Luc Dewandre , ‘Filler injections with the blunt-tip microcannula’, Journal of Drugs in Dermatology, 11(9) <https://jddonline.com/ articles/dermatology/S1545961612P1098X> 8. Lawrence S.Bass,’Injectable filler techniques for facial rejuvenation, volumisation, and Augmentation’, Facial Plastic Surgery Clinics of North America, 23(4), 2015, pp.479-488

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(Ref-1) dependent activator protein-1 (AP-1) (a heterodimer of c-Fos and c-Jun), nuclear factor kappa B (NF-ÎşB), p53 activating transcription factor/cAMP-response elementbinding protein (ATF/CREB) and hypoxiainducible factor (HIF)-1.6 As a result of these changes, an increase is seen in cell proliferation and migration, and modulation in Robert Sullivan explores the positive effect that levels of transcription factor.2-5 non-thermal low level lasers can have on the body the These transcription factors then cause through fat cell management protein synthesis that triggers further effects; cytokines, growth factors, inflammatory Non-thermal low-level laser therapy (NTLLLT) has been in clinical mediators, and increased tissue oxygenation.2,3 Again, specific use since the late 1960s,1 and for many years its method of action wavelengths also results in the release of the pro-inflammatory was not fully understood or appreciated. NTLLLT covers a broad cytokine TNF-a from the cells.8 This leads to increased infiltration of medical spectrum which can be used to the benefit of our patients the tissues by leukocytes. NTLLLT also enhances the proliferation, and the expansion of our clinical practice. NTLLLT is also known maturation, and motility of fibroblasts, and increases the production simply as low-level laser, however the term NTLLLT will be used in of basic fibroblast growth factor.9,10 According to Chung et al., this article as not all low-level lasers are non-thermal and some are lymphocytes become activated and proliferate more rapidly and misleadingly labelled as so. Patients are not just looking for ways to epithelial cells become more motile, which allow wound sites aesthetically modify their appearance, but many are also looking for to close more quickly, plus the ability of macrophages to act as ways of restoring, re-energising and revitalising their cells. Current phagocytes is also enhanced under the application of NTLLLT.6 research, as presented in this article, suggests that beauty is no longer skin deep. This short article review demonstrates, in science, that Clinical studies NTLLLT possibly has the ability to restore, rejuvenate, revitalise, and A large number of animal model and clinical studies have re-energise the body, as well as being used for fat cell management. demonstrated highly beneficial NTLLLT effects on a variety of diseases and injuries, and it has been widely used in both chronic How NTLLLT works and acute conditions. NTLLLT may enhance neovascularisation, The biochemical mechanism underlying the therapeutic results of promote angiogenesis and increase collagen synthesis to NTLLLT has a wide range of effects at the molecular, cellular, and promote healing of acute and chronic wounds.11,12 NTLLLT provided tissue levels. There is strong evidence to suggest that within the acceleration of cutaneous wound healing with a biphasic dose cell, NTLLLT acts on the mitochondria via cytochrome-c (COX) to response favouring lower doses.13 It can also stimulate healing of increase adenosine triphosphate (ATP) production. This up-regulates deeper structures such as nerves, tendons, cartilage, bones, and mitochondrial respiration and is the energetic component that even internal organs,14-18 as well as reduce pain, inflammation and 2-5 produces an energy cascade and electron transport. swelling caused by injuries, degenerative diseases or autoimmune Immune cells, in particular, appear to be strongly affected diseases.19-21 There is an exponential increase in the numbers of by NTLLLT. Mast cells play a crucial role in the movement mitochondrial DNA, somatic stem cells and transcription factor as a of leukocytes and are of large importance in inflammation. result of the laser application, all of which decline in age.6,22-24 Specific wavelengths of light can trigger mast cell degranulation, modulation of reactive oxygen species (ROS) and free nitric Body contouring and fat cell management oxide (NO), and the induction of transcription factors. Numerous More recently NTLLLT is being used in body contouring and fat cell transcription factors are regulated by changes in cellular redox management because there is no damage to the fat cell.7 Because state. As described by Chung et al., among them are redox factor-1 fat cells are part of our endocrine system, the release of fat as

Treating the Body with Low Level Lasers

Case study

Before

The patient depicted in Figure 1 undertook a standard plan of nine treatments over 10 weeks (she was asked to maintain her current exercise and nutritional regiment), using a 532 nm non-thermal low-level green laser. It is important to say that this is a true laser, which is one that is collimated, monochromatic and unidirectional. It delivers a 532 nm linear rotating beam through six heads, four of which are moveable to achieve maximum area coverage. The laser was applied 11-15cm

After

Figure 1: A 47-year-old patient before and after eight sessions of NTLLLT treatment

from the skin surface. The heads were distributed to cover the stomach area and thighs, and after 20 minutes the

patient is turned over and the heads repositioned in order to continue the treatment; this is a 40-minute protocol. This was carried out the same way for each session and measurements were taken before and after each session with results filed. The picture shows the condition of the patient at the inception of the treatment. As can be seen, there was well dispersed cellulite deposits, large amounts of fat to the stomach, lateral flanks and mid torso. The after image shows improved skin tone, reduction in cellulite and fat.

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free fatty acid has no adverse effect on our blood chemistry or triglyceride levels.25,27 Caruso-Davis et al. conducted a study to examine the clinical effectiveness by which 635-680 nm NTLLLT acts as a non-invasive body contouring intervention method. Results of 40 participants showed a statistically significant cumulative girth loss of 2.15cm after eight 30-minute treatments over four weeks. As a secondary objective, in vitro assays were conducted to determine cell lysis, glycerol and triglyceride release. Three separate experiments were performed to evaluate whether fat loss was induced by irradiation with NTLLLT due to:7 1. Laser activation of the complement cascade 2. Laser-induced adipocyte death 3. Laser-induced increased triglyceride release or lipolysis from adipocytes Obtained from subcutaneous fat during abdominal surgery, human adipose-derived stem cells were plated and differentiated to form adipocytes.28 In the first experiment, results showed that serum complement does lyse fat cells in both irradiated and non-irradiated adipocytes. Consequently, it was determined that NTLLLT does not activate the complement cascade to induce fat loss from adipocytes.7 In the second experiment, researchers found that irradiation with NTLLLT does not kill adipocytes in both irradiated and non-irradiated groups.7 The adipocytes maintained intact metabolic functions and the number of viable cells, as measured by the propidium iodide assay, remained the same. Through a dye injected into both groups, calcein levels were lower in the laser-treated group, suggesting reduction of cell-trapped calcein due to leakage. Finally, results of the last experiment showed that irradiation with NTLLLT increased triglyceride release, but not lipolysis from adipocytes.21 The findings from these three in vitro experiments are consistent with the theory that NTLLLT create pores in adipocytes, and fat leaks into the interstitial space without inducing cell lysis, while further confirming the ability of the laser to influence fat loss.7 NTLLLT has also shown to provide further clinical benefit to patients, including a reduction in both cholesterol and leptin levels.1 According to Coll et al., an adipocyte-derived hormone called leptin influences appetite, energy expenditure, and neuroendocrine function.29 In a two week trial (n=22), Maloney et al. demonstrated a 50% reduction, 29.49 to 14.60 points (P < 0001), in leptin levels after six total treatments of NTLLLT.1

Summary As a scientist and clinician, I frequently hear patients reporting feelings of more energy, improved health, less pain and better sleep patterns as a result of an increase in cellular activity and function, with better internal body communication. Based on the scientific evidence presented in this article, it is plausible to conclude that NTLLLT improves cellular function and, as supported by the presented evidence, produces within the body, the ability to restore, re-energise and rejuvenate. As we age and lose energy and cellular function, we have within us the chemicals and biological agents for life, health and beauty. NTLLLT may be the way to empower our bodies for a better healthier life.

Robert Sullivan is a progressive podiatrist and surgeon, a Fellow of the Open College of Podiatry, and a Member of the College of Podiatry. He has worked for many years in the fields of non-thermal laser medicine, with experience including advanced education and support in body sculpting, fat loss and obesity management. Qual: DPMed., BSc.(Hons) Pod., MSc. Surg (Edin)., DSc. (IRL)., M.Inst,ChP., FCFhCSc., FIChPA., FSSChP. REFERENCES 1. Maloney R, Shanks S, Jenney E. The reduction in cholesterol and tri-glyceride serum levels following low-level laser irradiation: A non-controlled, non-randomized pilot study.Laser Surg Med. 2009;21S:66. 2. Karu TI. Primary and secondary mechanisms of action of visible to near-IR radiation on cells. J Photochemical Photobiol B. 1999; 49:1–17. [PubMed: 10365442] 3. Chen AC-H, Arany PR, Huang Y-Y, Tomkinson EM, Saleem T, Yull FE, Blackwell TS, Hamblin MR. Low level laser therapy activates NF-κB via generation of reactive oxygen species in mouse embryonic fibroblasts. Proc SPIE. 2009; 7165:71650–71659. 4. Karu TI, Kolyakov SF. Exact action spectra for cellular responses relevant to phototherapy. Photomed Laser Surg. 2005; 23:355–361. [PubMed: 16144476] 5. el Sayed OS, Dyson M. Effect of laser pulse repetition rate and pulse duration on mast cell number and degranulation. Lasers Surg Med. 1996; 19:433–437. [PubMed: 8983003] 6. Chung, H., Dai, T., Sharma, S.K. et al. The Nuts and Bolts of Low-level Laser (Light) Therapy. Ann Biomed Eng 40, 516–533 (2012). https://doi.org/10.1007/s10439-011-0454-7 7. Caruso-Davis MK, Guillot TS, Podichetty VK, et al. Efficacy of low-levellaser therapy for body contouring and spot fat reduction.Obes Surg.2011;21:722-729. 8. Walsh LJ, Trinchieri G, Waldorf HA, Whitaker D, Murphy GF. Human dermal mast cells contain and release tumor necrosis factor-alpha which induces endothelial leukocyte adhesion molecule-1. Proc Natl Acad Sci USA. 1991; 88:4220–4224. [PubMed: 1709737] 9. Hawkins D, Abrahamse H. Biological effects of helium-neon laser irradiation on normal and wounded human skin fibroblasts. Photomed Laser Surg. 2005; 23:251–259. [PubMed: 15954811] 10. Medrado AR, Pugliese LS, Reis SR, Andrade ZA. Influence of low level laser therapy on wound healing and its biological action upon myofibroblasts. Lasers Surg Med. 2003; 32:239–244. [PubMed: 12605432] 11. Hopkins JT, McLoda TA, Seegmiller JG, and David Baxter G. 2004. Low-level laser therapy facilitates superficial wound healing in humans: a triple-blind, sham-controlled study. J Athl Train 39:223-229. 12. Yu W, Naim JO, and Lanzafame RJ. 1994. The effect of laser irradiation on the release of bFGF from 3T3 fibroblasts. Photochem Photobiol 59:167-70. 13. Corazza AV, Jorge J, Kurachi C, and Bagnato VS. 2007. Photobiomodulation on the angiogenesis of skin wounds in rats using different light sources. Photomed Laser Surg 25:102-6. 14. Robecchi MG. 2004. Low-power laser biostimulation enhances nerve repair after end- to-side neurorrhaphy: a double-blind randomized study in the rat median nerve model. Lasers Med Sci 19:57-65. 15. Fillipin LI, Mauriz JL, Vedovelli K, Moreira AJ, Zettler CG, Lech O, Marroni NP, and Gonzalez- Gallego J. 2005. Low-level laser therapy (LLLT) prevents oxidative stress and reduces fibrosis in rat traumatized Achilles tendon. Lasers Surg Med 37:293-300. 16. Morrone G, Guzzardella GA, Torricelli P, Rocca M, Tigani D, Brodano GB, Fini M, and Giardino R. 2000. Osteochondral lesion repair of the knee in the rabbit after low-power diode Ga-Al-As laser biostimulation: an experimental study. Artif Cells Blood Substit Immobil Biotechnol 28:321-36. 17. Weber JB, Pinheiro AL, de Oliveira MG, Oliveira FA, and Ramalho LM. 2006. Laser therapy improves healing of bone defects submitted to autologous bone graft. Photomed Laser Surg 24:38-44 18. Shao XH, Yang YP, Dai J, Wu JF, and Bo AH. 2005. Effects of He-Ne laser irradiation on chronic atrophic gastritis in rats. World J Gastroenterol 11:3958-61. 19. Bjordal JM, Johnson MI, Lopes-Martins RA, Bogen B, Chow R, and Ljunggren AE. 2007. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta- analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord 8:51. 20. Bjordal JM, Lopes-Martins RA, and Iversen VV. 2006b. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peri- tendinous prostaglandin E2 concentrations. Br J Sports Med 40:76-80; discussion 76-80. 21. Carati CJ, Anderson SN, Gannon BJ, and Piller NB. 2003. Treatment of postmastectomy lymphedema with low-level laser therapy: a double blind, placebo-controlled trial. Cancer 98:1114-22. 22. Farfara, Dorit & Tuby, Hana & Trudler, Dorit & Doron-Mandel, Ella & Maltz, Lidya & Vassar, Robert & Frenkel, Dan & Oron, Uri. (2014). Low-Level Laser Therapy Ameliorates Disease Progression in a Mouse Model of Alzheimer’s Disease. Journal of molecular neuroscience: MN. 55. 10.1007/s12031014-0354-z. 23. Sun N, Youle RJ, Finkel T. The Mitochondrial Basis of Aging. Mol Cell. 2016 Mar 3;61(5):654-666. doi: 10.1016/j.molcel.2016.01.028. PMID: 26942670; PMCID: PMC4779179. 24. Ciccarone, F., Di Leo, L., Lazzarino, G. et al. Aconitase 2 inhibits the proliferation of MCF-7 cells promoting mitochondrial oxidative metabolism and ROS/FoxO1-mediated autophagic response. Br J Cancer 122, 182–193 (2020). https://doi.org/10.1038/s41416-019-0641-0 25. Neira R, Arroyave J, Ramirez H, et al. Fat liquefaction: Effect of low-level laser energy on adipose tissue.Plast Reconstr Surg. 2002;110:912-922.26. 26. Karu TI, Afanasyeva NI. Cytochrome c oxidase as primary photoaccep-tor for cultured cells in visible and near IR regions.Dokl Akad Nauk(Mosc). 1995;342:693-695 27. Coelho M, Oliveira T, Fernandes R. Biochemistry of adipose tissue: an endocrine organ. Arch Med Sci. 2013;9(2):191–200. doi:10.5114/aoms.2013.33181 28. Tsuji W, Rubin JP, Marra KG. Adipose-derived stem cells: Implications in tissue regeneration. World J Stem Cells. 2014;6(3):312–321. doi:10.4252/wjsc.v6.i3.312 29. Coll AP, Farooqi IS, O’Rahilly S. The hormonal control of food intake. Cell. 2007;129(2):251–262. doi:10.1016/j.cell.2007.04.001

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Understanding Filler Implications for Rhinoplasty Plastic surgeon Mr Dario Rochira explains why dermal fillers can be contraindicated for closed preservation rhinoplasty and how practitioners can work together to ensure best patient outcomes Dermal fillers are widely used for non-surgical nose reshaping. Often, patients will present to clinic for this treatment because they are not ready for surgical interventions, are not suitable candidates for surgery, or, commonly, because they are interested in surgery, but want to try something more temporary first to see how they might feel about a more permanent solution. There are many complications that can arise with non-surgical nose reshaping using filler, which include, but are not limited to, skin necrosis and blindness.1,2 However, dermal fillers can also be responsible for a different complication if they are injected up to a year before the patient undergoes rhinoplasty. This is particularly so if the closed preservation rhinoplasty technique is used, which is what I focus this article on.3 I will explain why dermal fillers are contraindicated for closed preservation rhinoplasty, and how non-surgical aesthetic practitioners can work together with surgeons to ensure maximum patient care and successful outcomes.

Understanding closed preservation rhinoplasty Closed preservation rhinoplasty is a newer form of surgical rhinoplasty that preserves the structural and functional integrity of the tissues within the nose, including the cartilages, muscles, ligaments and bones. This technique preserves the nasal dorsum (bridge), unlike traditional rhinoplasty, which involves excision and removal of the dorsal bones and cartilage, as well as reconstructive technique. The reason why many patients opt for this is because the procedure is less invasive, less aggressive, has reduced bruising and swelling and results in less recovery time with more predictable results than traditional rhinoplasty. It also has a lower rate of revision Bone surgery.3,4,5 The basis and rationale of Key-stone area (mobile joint) this technique comes from Cartilage recent anatomical findings that relate the nasal anatomy to nasal aesthetics and surgical techniques.3,5 The most important and revolutionary finding is that the key-stone Figure 1: The key-stone area is the junction between the bony vault area (the junction between and the cartilaginous vault of the nasal bones and cartilages on dorsum (yellow circle).4 Image courtesy of Mr Dario Rochira. the dorsum) is a semi-mobile

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chondrosseous joint, which can be converted from convex to straight by resecting its underlying cartilaginous support (Figure 1).3,5 I have found that the endonasal approach (without any skin incision) is the best method, as the tip can also be reshaped from the inside leading to a less traumatic and less invasive operation, resulting in more controlled and predictable results.4,5 A further study conducted by Cakir et al. has demonstrated that a closed approach to the subperichondrial and subperiosteal dissection is associated with less swelling and bruising, preserving sensitivity and resulting in faster recovery.6

Why dermal fillers are contraindicated It is my experience that hyaluronic acid fillers injected into the nose last considerably longer than when they are injected in other areas of the face.7 Most practitioners inject the filler to the radix area (just below the glabella) in a deep plane, which is the layer just above the periosteum (sub-SMAS layer). This is important because when closed preservation rhinoplasty is performed, the dissection at the radix is carried out in the subperiosteal plane. As a result, any filler previously injected into this area may not be inspected or possible to remove. While it is relatively easy for a surgeon to remove any filler from the tip area as it is closer to the incision (Figure 2), it is a big Figure 2: Surgical removal of HAchallenge, if not impossible, to based filler injected into the tip 13 months before surgery. remove any filler from the radix area, particularly in a closed approach. The open approach (skin incision and elevation) may offer better visibility of the radix, however the removal of the filler is still a big challenge due to the thin skin of this area, resulting in potential skin irregularities or skin necrosis when removing the filler. This can create a poor aesthetic result following surgery. The patient may have a straight dorsum immediately after surgery, but over time, the previously injected filler will be absorbed, creating a residual hump or very deep and low radix (Figure 3).

Practitioners should be asking patients if their intention is to undergo surgery at a later date

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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B

responsibility to educate the patient that closed preservation rhinoplasty Straight-look should be no less than one year after dorsum the filler is injected, or one month Filler after the filler has been dissolved with Dorsal hump hyaluronidase. In the ideal scenario, non-surgical aesthetic practitioners should also make the patient’s records available to the treating surgeon. The records should include detailed treatment notes C D Dorsal hump on the type of filler used, injection plane and technique, amount of filler Filler Filler injected and treated areas, date and absorbed signature, as well as before and after images. The surgeon can then make a full, accurate assessment of the native nasal anatomy of the patient and plan the surgical steps accordingly. It should be noted that, in my experience, it is very common for Figure 3: Patient presents with a dorsal hump and asks for a non-surgical nose-reshaping to make the patients not to even remember the dorsum straight-looking (A). Filler is injected to the radix (B). Closed preservation rhinoplasty is performed name of their previous practitioners; without dissolving the filler previously injected and not seen during surgery (C). Hump ‘recurrence’ after perhaps the procedure was performed the filler is absorbed over time (D).4 Images courtesy of Mr Dario Rochira. abroad, they simply don’t want to give Therefore, if this type of operation is scheduled within a year details or don’t want me to contact the practitioner. I have also (or the patient has indicated that they are interested in surgical previously written to the practitioners, but without answer. A good interventions), the injection of filler to the radix should be avoided.8 relationship and communication between the surgeon and the Alternatively, the filler should be dissolved using hyaluronidase aesthetic practitioner is always encouraged. one month before the surgery. It is most surgeons’ opinion that A further recommendation is that more studies are still needed to this hyaluronidase procedure should be carried out by the treating establish guidelines on the best time frame between filler injections aesthetic practitioner as they know what and where the filler was and rhinoplasty, especially given the wide range of different fillers injected, which should produce the best outcome for the patient. currently on the market.

Recommendations As mentioned, patients often present to non-surgical aesthetic professionals to address shape concerns with their nose as a trial before surgical interventions. With this in mind, I believe that practitioners should be asking patients if their intention is to undergo surgery at a later date. Practitioners then have a

If this type of operation is scheduled within a year or the patient has indicated that they are interested in surgical interventions, the injection of filler to the radix should be avoided

Mr Dario Rochira is a plastic surgeon, practising on Harley Street, with more than 15 years’ experience in cosmetic surgery. He trained at the Catholic University of Rome and is a member of the BAPRAS and ISAPS. Mr Rochira’s main interest is rhinoplasty and he was the first specialist in plastic surgery to offer preservation rhinoplasty, which is a type of rhinoseptoplasty, into his practice in the UK. Qual: MD REFERENCES 1. Kim DW, Yoon ES, Ji YH, Park SH, Lee BI and Dhong ES, “Vascular complications of hyaluronic acid filler and the role of hyluronidase in management, Journal of Plastic and Reconstructive Aesthetic Surgery, Vol 64 (2011), 1590-1595. 2. McKeown DJ, “The risk of blindness following non-surgical Rhinoplasty”, Jo urnal of Plastic and Reconstructive Aesthetic Surgery, Vol 66, (2013), e238. 3. Rollin K Daniel, “The Preservation Rhinoplasty: a new Rhinoplasty Revolution”, Aesthetic Surgery Journal, Vol 38 (2018), 228-229. 4. Baris Cakir, Yves Saban, Rollind Daniel, Peter Palhazi, Preservation Rhinoplasty (Istanbul, 2018). 5. Yves Saban, Rollin K Daniel, Roberto Polselli, Maria Trapasso and Peter Palhazi, “Dorsal Preservation: The push down technique reassesed”, Aesthetic Surgery Journal, Vol 38 (2018), 117-131. 6. Baris Cakir, Ali Riza Oreroglu, Teoman Dogan and Mithat Akan, “A Complete Subperichondrial Dissecation Technique for Rhinopasty with management of the nasal ligaments”, Aesthetic Surgery Journal, Vol 35 (2012), 564-574. 7. Per Hedén, Nasal Reshaping with Hyaluronic Acid: An Alternative or Complement to Surgery, Plastic and Reconstructive Surgery Global Open, 2016. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5142491/> 8. Johnson ON and Kontis TC, “Nonsurgical Rhinoplasty”, Facial Plastic Surgery, Vol 32 (2016), 500-6.

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


Advertorial Merz

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Rejuvenating Lip Structure with BELOTERO® Dr Kate Goldie shares her newest lip augmentation technique for ageing patients specifically designed to utilise the BELOTERO® Lips range for natural-looking results Lips are usually the first area practitioners learn to treat, but are often the hardest to master. Many lip augmentation techniques involve deep injections into the body of the lip, however this might not be the best approach for older patients, according to aesthetic practitioner Dr Kate Goldie. She, along with the Merz Innovation Board has pioneered a new method to augmenting ageing lips, which focuses on repositioning, recreating and restoring lip architecture rather than volumising for natural results.

How did your lip augmentation come about? Recent research using MRI scans suggest that the lip doesn’t lose volume with age, but rather changes position from a ‘J’ shape into more of an ‘I’ shape.1 This occurs from the superior labial zone to the mucosa of the lip, where it meets the vermillion border, which is held by the orbicularis oris. This knowledge is key because if you simply inflate the lip and take a volumising approach for older patients, treatment can make the patient look worse. So, instead we want to restore and reposition the lip, and recreate this ‘J’ shape.1 To achieve this, I developed a superficial threading technique that utilises the BELOTERO® Lips Contour and BELOTERO® Lips Shape products for a specific outcome, which is beautiful natural results to ageing lips.

How does the technique work? The technique involves the insertion of micro droplets of product in very specific placements, superficially above the major vessels of the lip, which we know are usually 3mm beneath the surface.2 The technique can be performed with either a needle or cannula, however I prefer to use a needle when treating the lips of older patients. With a needle, the number of injection points will vary per patient, and each pass will be less than 0.025ml. Importantly, the practitioner must hold and mould the area rather than massage for around 30 seconds. In my experience, the benefits of this technique are added safety, because you are not near the vessels, greater precision, less pain, and more natural results.

What products do you use for this technique? The technique has been specifically created to utilise BELOTERO® Lips Contour and BELOTERO® Lips Shape. These products offer a 52

complementary approach to lip enhancement. BELOTERO® Lips Contour is used to restore the vermillion border,3 and the special thing about this product is that it is highly cohesive, is smooth but strong, has low viscosity and low elasticity, and it is very integrative, which all mean that product is less likely migrate out of the lip. Research using ultrasonography images has shown that the cohesive nature of BELOTERO® Lips Contour allows for seamless integration into the tissue after just 30 days.4,5 By injecting tiny amounts of product, it should not migrate and should integrate into the skin reducing the risk of lumps or the Tyndall effect. BELOTERO® Lips Shape is then used for augmentation and enhancement of the upper and lower body of the lip.3 The results are natural movement and integration, long-lasting effect, good compatibility and tolerability, and high patient satisfaction.5

“This technique was developed to utilise the BELOTERO® Lips Contour and Shape products for a specific outcome, which is beautiful natural results to ageing lips” Dr Kate Goldie

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Advertorial Merz

Why do you choose the BELOTERO® range? I have been using BELOTERO® products for the last 10 years and have always achieved great results with my patients. BELOTERO® Lips Shape and BELOTERO® Lips Contour are HA dermal fillers with patented Cohesive Polydensified Matrix® or CPM® technology for seamless integration into the skin.5,6 They are ideal to add or restore volume to thin lips and to sculpt and define lip contours to full lips for natural-looking results. As practitioners in the UK and Ireland, we have a huge number of HAs available to us, BELOTERO® is the only cohesive polydensified matrix product on the market.7 Research has also shown that the BELOTERO® range is least likely to cause any immunological reaction,7 and I certainly have not ever experienced this with any of my patients, which is another reason why I choose these products.

“The results from using BELOTERO® Lips Shape and Contour in this way are natural movement and integration, long-lasting effect, good compatibility and tolerability, and high patient satisfaction”

A BELOTERO® Tweakment case study with Alice Hart-Davis Dr Goldie’s technique using BELOTERO® Lips Contour and Shape was recently featured as ‘Tweak of the Week’ by beauty journalist and author of The Tweakments Guide, Alice Hart-Davis.8 Dr Goldie sought to improve Alice’s structure, architecture and hydration. First, she treated the vermillion boarder using small superficial injections of BELOTERO® Lips Contour to enhance its definition, and to improve the symmetry of the cupid’s bow. A total of 0.3ml of BELOTERO® Lips Contour was used. This was followed by BELOTERO® Lips Shape, which was injected in a similar manner into the body of the lip to provide the scaffolding to restore the lip to its original form. A total of 0.6ml was injected into the body of the lip using BELOTERO® Lips Shape. After one month, the products will integrate with Alice’s own tissues and provide a natural result. Alice Hart-Davis said after the treatment, “I have seen Dr Goldie do this new technique on stage at international conferences so I was very excited to try it for myself and see the results in my own lips. The shape I have now is the shape I’m always trying to draw on with lipstick, and it’s how they used to look quite a while ago. I never thought of lip treatments in terms of building architecture of the lip – this technique is a very specific way of rejuvenating lip structure and I think the results are fantastic.” Before

After

Dr Kate Goldie

What’s your top tips for successful lip treatments? Know that every hyaluronic acid product is different and you need to use their individual characteristics to their best advantage to get a specific outcome. When using BELOTERO® Lips Shape and BELOTERO® Contour, use these products to specifically reposition, recreate and give architecture to the lip by using less product per pass, superficially, to achieve beautiful natural results. Remember, it’s the last final touches that you do that really make for a successful treatment.

This advertorial was written and supplied by

Beauty journalist and author Alice Hart-Davis before and two weeks after treatment

REFERENCES 1. Iblher et al; Changes in the aging upper lip - a photomorphometric and MRI-based study - Journal of Plastic, Reconstructive & Aesthetic Surgery, 2008, 61:1170-1176 2. Distribution pattern of S and I Labial arteries REF-0651 3. Instructions for Use (IFU) Belotero+ Lips Contour & Instructions for Use (IFU) Belotero+ Lips Shape. 4. Tran C. et al; In vivo bio-integration of three hyaluronic acid fillers in human skin: a histological study – Dermatology, 2014, 228:47-54. 5. Micheels P et al; Two Crosslinking Technologies for Superficial Reticular Dermis Injection: A Comparative Ultrasound and Histologic study; J Clin Aestheti Dermatol 2017; 10(1) 29-36. 6. Micheels P et al; Effect of Different Crosslinking Technologies on Hyaluronic Behaviour. J Drugs Dermatol 2016; 15 (5): 600-606. 7. Prasetyo AD et al. Clin Cosmet Investig Dermatol. 2016 Sep 8;9:257-80. 8. Hart-Davis A, 2019, The Tweakments Guide, www.thetweakmentsguide.com

M-BEL-UKI-0772 Date of Preparation March 2020 Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/ about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

Aesthetics | April 2020

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Advertorial BTL

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Sometimes 1+1 does not equal 2 Simultaneous energy delivery – a proven solution for Cellulite EMTONE is an all new device for the global aesthetics market to treat all five causes of cellulite – something that has not been achieved before. EMTONE from BTL combines radiofrequency (RF) and targeted pressure energy, two proven and effective technologies that can treat all cellulite conditions, and it is not limited by body mass index or skin type.

The condition Cellulite is the name for the dimpled, lumpy appearance of skin that mainly develops in the hips, thighs or buttocks. There are many factors that predispose us to have cellulite appear on our bodies. To find an effective treatment for cellulite we must understand what is happening anatomically to give the dimpled appearance we know as cellulite. In females, there is a very superficial layer of fat just under the skin, as this fat increases it bulges out giving the lumpy appearance. This is exacerbated as our skin thins with age and the resistance to the underlying fat bulging is reduced. In addition, the strands in the dermal layers become more fibrous and twisted, pulling down to increase the dimpling effect in the skin. As fat accumulates in the interlobal space there is an increase in pressure and a decrease in the ability of the lymphatic systems to drain away lymph fluid; this static fluid adds to the swelling in the area. This congestion decreases healthy blood circulation in the affected area and good circulation is a prerequisite for neocollagenesis. The basic anatomical causes of cellulite are: 1. Enlarged hypodermis fat chambers apply pressure outwards between interlobular spaces 2. Collagen fibres remain rigid pulling inwards against outward pressure (dimple) 3. Loss of skin elasticity decreases resistance to internal outward pressure 4. Metabolic waste accumulation in the interstitial spaces 5. Poor blood flow There are underlying causes which are part of our genetic make-up that lead to the formation of cellulite. However, these genetic causes lead to actual structural changes in our skin, and it is these structural changes that can be rectified to reduce the appearance of cellulite. Recent studies have shown that the anatomical structures that create the appearance of cellulite are not simply down to excess fat. To understand our cellulite better we need to understand the structures in our dermis that lead to the appearance of cellulite. The cause of cellulite is a combination of factors, not just one in isolation. Studies have shown that as cellulite develops through the various stages of severity there are molecular and structural changes in the hypodermis, which are triggered by several factors.

Method of action EMTONE is a safe and effective alternative to invasive procedures currently available such as liposuction and subcision. EMTONE treatment modalities are proven over many years for different applications such as skin tightening on the face and body contouring, supported by multiple peer reviewed clinical studies for these treatment modalities. The BTL EMTONE now combines both RF and targeted pressure energy to directly treat the anatomical causes of cellulite. 54

Before

After

After 4th treatment, courtesy of Marc Salzman, M.D Before

After

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Causes and solutions • Fat pockets in the interlobal spaces dermal layers: EMTONE heats these fat cells to 40-43 degrees (not painful). The fat cells at these elevated temperatures are shown to reduce in volume. • Poor skin condition: EMTONE and targeted pressure energy manipulation are both proven to increase the levels of collagen and elastin in the dermal layers. • Poor lymphatic drainage: EMTONE and targeted pressure energy manipulation effectively give a deep lymphatic drainage massage, increasing lymphatic flow and drainage. Manual lymphatic drainage (MLD) – a light massage by a trained masseur is a technique that aids the elimination of lymphatic fluids and needs to be administered at least twice a week. However, this technique will only give a temporary improvement to just one of the causes to the appearance of cellulite. BTL EMTONE completes this lymphatic massage during the application in EMTONE. • Poor blood circulation: EMTONE and targeted pressure energy manipulation effectively give a deep massage increasing blood flow. A healthy microcirculation in the affected area will encourage healthy growth of new collagen proteins. The treated area will flush, resolving usually within one hour.

The treatment The EMTONE treatment takes around 30 minutes depending on how many areas are to be treated. An application cream is applied and then the handpiece is massaged over the area. Patients will feel a comfortable tolerable heat and the targeted pressure energy will push against their skin at a rate of 10 times a second. Four to six treatment sessions are required at weekly intervals. Patients may see an immediate improvement because static lymph and excess fluid in the area has been massaged away. The full effect of the EMTONE RF and targeted pressure energy will take a full 12 weeks. This is the body’s natural response time to produce new collagen proteins as part of the body’s natural reparative process. This advertorial was written and supplied by

www.btlaesthetics.com/uk Six weeks after 4th treatment, courtesy of BTL Aesthetics

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A summary of the latest clinical studies Title: The Nonsurgical Rhinoplasty: A Reterospective Review of 5,000 Treatments Authors: Harb A, Brewster CT Published: Plastic Reconstructive Surgery, March 2020 Keywords: Rhinoplasty, dermal fillers, nose, NSR Abstract: Nonsurgical rhinoplasty with injectable dermal fillers has become an increasingly popular alternative to surgical procedures, in view of its relative low cost, convenience and rapid recovery, and low risk profile. The safety and efficacy of nonsurgical rhinoplasty remains a relatively contentious and ambiguous matter, given that there are few large-scale series reporting results or complications. This study reports the experience of a single clinician performing nonsurgical rhinoplasty in the largest cohort to date. Nonsurgical rhinoplasty was performed in 5,000 patients. The commonest indication was dorsal hump (44 percent). Swelling and erythema were self-limiting side effects encountered in approximately half of patients. Infection was seen in two patients, and localized skin necrosis was observed in three patients. Nonsurgical rhinoplasty is a safe procedure with positive aesthetic results when performed by an experienced clinician. Knowledge of nasal anatomy, comprehensive training, and use of appropriate materials are key in ensuring safety and results Title: Radio-frequency Based Devices for Female Genitourinary Indications: Position Statements from the European Society of Sexual Medicine Authors: Romero-Otero J, Et al Published: Journal of Sexual Medicine, March 2020 Keywords: Genitourinary Indications; Radiofrequency Abstract: Radiofrequency (RF)-based treatment has been introduced as an aesthetic alternative treatment for various medical indications without the scientific backup of a satisfactory body of evidence. Furthermore, the United States Food and Drug Administration issued a warning regarding the safety of energy-based technologies for indications such as vaginal â&#x20AC;&#x153;rejuvenation,â&#x20AC;? cosmetic vaginal treatment, vaginal conditions related to menopause, and symptoms of urinary incontinence and sexual function on July 30, 2018. The aim was To perform a thorough review of the existing literature regarding RF-based vaginal devices for the treatment of female genitourinary indications and summarize the evidence available in a few short statements. A thorough review of the literature regarding RF treatments for gynecological indications was performed based on several databases. Studies that included at least 15 patients were eligible for analysis. Although a high level of heterogeneity of studies poses a serious challenge, the committee reached a decision on several statements related to the use of RF-based devices for genitourinary indications. Further randomized controlled trials with proper methodology and design are required to establish both benefits and possible harm these treatments may have in both short and long term for all the different indications studied.

Title: Vascular Compromise After Soft Tissue Facial Fillers: Case Report and Review of Current Treatment Protocols Authors: Halepas S, Et al Published: Journal of Oral Maxillofacial Surgery, March 2020 Key Words: Filler, augmentation, vascular compromise Abstract: The use of facial fillers for soft tissue augmentation is becoming a mainstream treatment modality for patients. Owing to the relative ease of administration, as well as the lucrative nature of such procedures, the number of providers offering facial fillers has been expanding. Although many adverse effects of facial fillers are minor and localized to the site of injection, 1 potential serious, albeit uncommon, adverse effect of facial filler treatment is avascular necrosis. In this article, we review soft tissue filler complications and describe the case of a 52-year-old female patient in whom vascular compromise developed after facial filler administration. In addition to reviewing complications and best practices for treatment management, we discuss anatomic considerations, present an overview of the most common filler materials, describe histologic changes with dermal fillers, and discuss litigation consequences with the use of these minimally invasive procedures. Although facial filler treatment is regarded as a minimally invasive and extremely safe procedure, it is not without complications. Avascular necrosis after soft tissue augmentation with facial fillers is exceedingly rare, with only a few cases reported in the literature, but practitioners who offer this procedure need to be well versed in treatment protocols. Title: Nonablative Fractional Laser Therapy for Treatment of Actinic Keratosis with Three Months Follow Up Authors: Nourmohammad Pour P, Et al Published: Journal of Cosmetic Dermatology, March 2020 Keywords: Actinic keratosis, nonablative, laser, skin Abstract: Actinic keratosis (AK) is a common skin disorder that is treated with different treatment modalities. The aim of this study was to assess the therapeutic effect of a 1540-nm nonablative fractional laser on the AK. Ten patients with 31 AK were included in the study according to the inclusion and exclusion criteria. Treatment with nonablative fractional laser (1540 nm) 3 times at 4 weeks intervals in a noncontact mode was applied. Clinical severity was assessed at each session and 3 months after the last session. It is pertinent to mention that the patients were also involved in the assessment of improvement. The results of present study showed that in comparison to the baseline, 3-session AK therapy with nonablative fractional laser significantly not only improved the AK severity by 79%, but also reduced the AK counts (from 31 to 17). On the other hand, the patients consented to the therapeutic effect. According to the obtained results and available studies, it seems that therapy with a 1540-nm nonablative fractional laser could be considered as a safe and effective alternative therapeutic option for the treatment of AK.

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


Aesthetics Media is delighted to support Facing the World as our chosen charity for 2020. Every donation made will get a social media shout-out on the Aesthetics Media Instagram, Twitter and Facebook accounts. Thank you in advance for your support of this worthy cause.

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Utilising Meditation in Aesthetics Dr Amiee Vyas explores how practising yoga and meditation can benefit aesthetic patients and your own personal wellbeing In the world of aesthetic medicine, where our services focus on outward beauty, people often forget about the mind. With its origins more than 5,000 years old in Indian philosophy, yoga is an ancient practice for the unification of body and mind, combining physical postures, rhythmic breathing and meditation.1,2 Meditation is one of the modalities used in Ayurveda, the comprehensive natural healthcare system originating from the Vedic times of India, which is now commonly used as complementary healthcare in the western world.3 According to recent research by Bupa Global, meditation is the UK’s favourite form of wellbeing therapy, with over a quarter of adults (26%) using it to improve their mental wellbeing in the past five years.4 Meditation is also the most popular complementary health approach used in the US, with a report from the 2017 National Health Interview Survey finding that American adults’ use of meditation tripled from 2012-2017.2,5 In recent years, the World Health Organization (WHO) has recognised traditional and complementary medicine as an important and often underestimated part of healthcare, and that the demand for its services is increasing.6 I come from a family of healthcare professionals and, interestingly, many of these individuals are also teachers of meditation and yoga. It’s therefore unsurprising that I have known these techniques since childhood and I have seen first-hand the positive impact of incorporating daily meditation practices into your life, not only for personal wellbeing, but also with regards to how we can impact the lives of our patients and enrich their journeys with us in clinic.

Stress reduction is one of the most common reasons to take up meditation. A 2013 study by Rosenkranz et al. showed meditation can also reduce post-stress inflammatory response.16 Physical and mental stress causes release of cortisol to provide the energy and substrate required to cope with stress-provoking stimuli as part of the body’s fight-or-flight response, and, in turn, an inflammatory response.17 Ongoing production of cortisol, if the stress signal is not switched off, can have detrimental effects on our physical and mental health causing issues from anxiety and depression, to heart disease.18 Meditation is often described as a skill as it improves with practice and takes consistency to get comfortable.19 As with any skill, practice gets you so far, but the guidance of someone who can teach you makes all the difference.19 Two of the notable techniques widely practised today are mindfulness and Vedic meditation. Mindfulness is a good starting point; it reflects the basic and fundamental human capacity to attend to relevant aspects of experience in a non-judgemental and non-reactive way, which in turn cultivates clear thinking, equanimity, compassion and openheartedness.20 Put simply, it is the ability to be present and fully engaged in whatever we’re doing in the moment.19 It is a steppingstone into deeper forms of meditation like Vedic meditation, which connect you to your deep inner self or consciousness.3 In the same way we encourage our patients to only seek aesthetic treatment and advice from qualified medical professionals, the same can be said for meditation teachers. I personally believe it is important to seek guidance from those who are qualified, experienced and have expertise in the field. I recommend that you encourage patients to do the same, or you can even partner with a suitable teacher through your clinic as an added service.

Applying meditation to aesthetics What are the benefits? The benefits of yoga on the body as a physical exercise is well established and there is now a growing body of evidence to support a positive effect on brain structure and function, particularly with regards to the mediation strand of the practice.7-10 There are many welldocumented health benefits of meditation. These include deep relaxation through stimulating increased alpha and theta wave activity in the brain for stress reduction, improved mood including reduced anxiety, reduced depression and aggression, reduction in both physical and psychological pain, improved memory and increased efficiency and focus.3,11-15 One study involving 50 meditators and 10 controls looked at the effect of meditation on the executive attention network, finding meditators were faster on all tasks.14 Furthermore, physiological benefits include reduced blood pressure and heart rate, reduced lactate, symptomatic relief for pre-menstrual syndrome and menopausal symptoms, as well as others.3,12

As the aesthetic medicine industry moves towards wellness, with many patients seeking our services as part of their personal self-care, stress management is inevitably filtering into our work in clinics. Self-care is understood as peoples’ ability to care for themselves physically, emotionally and spiritually.21 Nurse prescriber and clinic owner Julie Scott recently stated in an interview with Aesthetics that emotional and physical wellness go hand in hand. If you are not

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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Tips for meditation One concept called Sri Sri’s Pancha Kosha meditation is simple and easy enough for you or your patients to practice anytime. I like this meditation because even if the mind wanders, you can always come back to where you last remember and pick it back up. To do this, sit comfortably and relax with your eyes closed and take yourself through these five steps, breathing in and letting go after each one. 1. Become aware of all the sounds in your environment. 2. Become aware of the whole body, from the soles of your feet to the top of your head. Giving each part of your body individual attention and honouring it without judgement. 3. Become aware of your thoughts. There’s no need to engage the thoughts, but just watch them as they pass by, don’t resist or hold on to any thought (thoughts in general are not an obstacle to meditation). 4. Become aware of your emotions, whether pleasant or unpleasant. Again, don’t resist any feeling or emotion, but just observe them however they are. 5. Recognise the stillness and peace at the core of your being, beyond the outer layers (sounds, body, thoughts, emotions) of existence.

emotionally and psychologically well, then you cannot be physically well and what we are doing then may become redundant.22 With the rise of pressure from social media to look perfect, individuals are speaking to themselves more negatively than ever before. Frequent selfie viewing on social media has been shown to have a negative association with self-esteem and decreased life satisfaction.23 Meditation programmes can result in reductions of multiple negative dimensions of psychological stress, as well as improve emotional resilience and a provide a greater sense of self-love by bringing about a restructuring of priorities and values, while reorienting the mind towards what is truly meaningful in life.24,25 Other

or minimal flaws in appearance. It affects 0.7-2.4% of the general population, with a large percentage of those attempting to receive aesthetic treatments, meaning many cases are first picked up in our clinics.27 Accelerated skin ageing has been linked with poor sleep, which can result in increased signs of intrinsic ageing, as well as a worse perception of personal physical attractiveness.28 Meditation has been found to successfully improve sleep quality, helping individuals to both fall asleep faster and for longer than non-meditators.29 A pilot study on Sudarshan Kriya and Pranayama, which combines physical yoga, meditation and breathwork, furthermore showed an improved antioxidant status both at the

Meditation is often described as a skill as it improves with practice and takes consistency to get comfortable forms address interpersonal relationships, nurturing pro-social qualities of kindness and compassion25 including towards one’s self.26 I feel this is particularly important to consider when patients aim to drastically change their appearance, leaning towards body dysmorphic disorder (BDD). BDD is a disorder of self-perception, characterised by an obsession with perfection, with an impairing preoccupation with non-existent

enzyme activity and ribonucleic acid (RNA) level in practitioners due to changes in expression of the relevant genes, which may translate into better response to environmental stress.30,31

In the workplace As professionals in this industry, meditation is valuable on another level. Through its ability to nurture pro-social qualities it enables us

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to authentically connect with others and may improve our rapport with patients.25 Research shows that a Mind-Body (MB) skills course including meditation and mindfulness can strengthen the capacity for self-care and self-awareness, which are increasingly recognised as important competencies for future physicians and nurses.20,32 They form a cornerstone for patient-centred care in which a mutual, humanistic partnership between patient and healthcare provider is established.32-34 Self-awareness enables individuals to reflect on their own attitudes and emotions and can lead to an increased understanding of the influence of their own attitudes and behaviour on the patient.32,35 Increasing self-awareness can thus generate healthcare professionals with conscious control to deeply attune to the patient when providing care or to step back if necessary.32,34 This is important because practitioner-patient relationship in aesthetics is guided by the patient’s desires, but relies on us as the practitioners to sign post when continued treatment may be damaging to their appearance and/or mental health in line with the GMC’s good medical practice principle to do no harm.36 Furthermore, MB programmes have been shown to have the potential to develop empathy.32 In practice, improved empathic capacities in patient care are related to improved satisfaction, better compliance to treatment, improved clinical outcomes and fewer medical errors.32,35 This increases patient trust in us as their treatment providers and will make for long-lasting patient relationships.

Summary Incorporating meditation into our clinics can benefit both practitioners and enhance the patient experience. Choosing how to incorporate this depends on the patients we see and their individual needs and, as with other interventions, seeing the benefits of meditation varies with patient motivation. Especially in medical clinics, incorporating meditation must align with our other evidence-based treatments and be implemented under proper guidance from experts in the field. Current literature shows promising evidence of the benefits of meditation as a complementary therapy, but further studies including large randomised trials and longitudinal studies on practitioners will reveal scope for the future.

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


Dr Amiee Vyas is the founder of Doctor Amiee Facial Aesthetics & Skin, Mayfair. She specialises in natural enhancements that aim to deliver positive change focussing on skin health and wellness. Dr Vyas is accredited by Save Face, a trainer in injectables for Acquisition Aesthetics and a trainer and KOL in cosmetic dermatology for AestheticSource. Qual: MBBS BSc

TOUCH THE FUTURE OF CELLULITE REDUCTION

REFERENCES 1. Balaji PA, Varne SR, Ali SS, Physiological effects of yogic practices and transcendental meditation in health and disease. N Am J Med Sci. 2012 Oct; 4(10):442-8. 2. Gothe NP, Khan I et. al. Yoga effects on Brain Health: A systematic Review of Current Literature. Brain Plast. 2019 26;5(1):105-122 3. Sharma H, Meditation: Process and effects.Ayu. 2015 36(3):233-237 4. Bupa, Meditation is Brits’ most popular wellbeing therapy, 2019 <https://www.bupa.com/ newsroom/news/meditation-brits-favourite-wellbeing-therapy> 5. Yoga for Health, 2016 <https://nccih.nih.gov/health/meditation/overview.htm> 6. WHO Traditional Medicine Strategy 2014-2023, <https://www.who.int/medicines/publications/ traditional/trm_strategy14_23/en/> 7. Wiese C, Keil D et.al. Effects of Yoga Asana Practice Approach on Types of Benefits Experienced. Int J Yoga. 2019;12(3):218-225 8. Ross A, Friedmann E, et.al. National survey of yoga practitioners: mental and physical health benefits. Complement Ther Med 2013; (4):313-23 9. Field T. Yoga clinical research review. Complement Ther Clin Pract. 2011 Feb; 17(1):1-8. 10. Field T, Yoga Research Review. Complement Ther Clin Pract, 2016;24,145-61 11. Lagopoulos J et.al. Increased theta and alpha EEG activity during nondirective meditation. J Altern Complement Med 2009.1187-1192. 12. Arias AJ et.al. Systematic review of the efficacy of meditation techniques as treatments for medical illness.J Altern Complement Med. 2006 Oct; 12(8):817-32. 13. Horowitz S. Health benefits of meditation. Altern Complement Ther. 2010;16:223–8 14. Chan D, Woollacott M. Effects of level of meditation experience on attentional focus: is the efficiency of executive or orientation networks improved? J Altern Complement Med. 2007 Jul-Aug; 13(6):651-7. 15. Deepeshwar S et.al. Hemodynamic responses on prefrontal cortex related to meditation and attentional task. Front Syst Neurosci. 2014; 8():252. 16. Rosenkranz MA, Davidson RJ et.al. A comparison of mindfulness-based stress reduction and active control in modulation of neurogenic inflammation. Brain, Behaviour and Immunity 2013; (27):174-184. 17. Jankord R, Herman JP. Limbic regulation of hypothalamo-pituitary-adrenocortical function during acute and chronic stress. Ann N Y Acad Sci. 2008 Dec; 1148():64-73. 18. Hannibal KE, Bishop MD. Chronic Stress, Cortisol Dysfunction and Pain: A Psychoneuroendcrine Rationale for Stress Management in Pain Rehabilitation. Phys Ther 2014 94(12) 1816-1825 19. Headspace, What is meditation? 2020 <https://www.headspace.com/meditation-101/what-ismeditation> 20. Fortney L, Taylor M. Meditation in Medical Practice: A Review of the Evidence and Practice. Prim Care. 2010 37(1)81-90 21. Wilkinson A. & Whitehead L. Evolution of the concept of self-care and implications for nurses: A literature review. Int J Nurs Stud, 2009: 46(8):1143–1147. 22. Close M. Incorporating Wellness into Your Clinic. Aesthetics Journal January 2020 23. Wang R,Yang F and Haigh MM. Let me take a selfie: Exploring the psychological effects of posting and viewing selfies and groupies on social media. Telematics and Informatics. 2016 34(4) 274-283 24. Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and wellbeing: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(3):357–368. 25. Dahl CJ, Lutz A & Davidson RJ. Reconstructing and deconstructing the self: Cognitive mechanisms in meditation practice. Trends Cogn Sci. 2015 Sep; 19 (9): 515-523 26. Galente J et. al. Effect of kindness-based meditation on health and well-being: A systematic review and meta-analysis. J Consult Clin Psychol. 2014; 82(6) 1101-14 27. Vashi NA, Obsession with perfection: Body dysmorphia. Clin Dermatol. 2016 34(6):788-791 28. Oyetakin-White P et. al. Does poor sleep quality affect skin ageing? Clinical and Experimental Dermatology. 2014;(40)1 29. Martires J and Zeidler M. The Values of Mindfulness Meditation in the Treatment of Insomnia. Curr Opin Pulm Med, 2015;21 (6), 547-52 30. Sharma H. et. al. Gene Expression Profiling in Practitioners of Sudarshan Kriya. J Psychosom Res. 2008. 64(2)213-8 31. Beri K. Breathing to younger skin: ‘reversing the molecular mechanism of skin aging with yoga.’ Future Science OA. 2016 Jun;2(2):FSO122 32. Van Vliet M et. al. A Mind- Body Skills Course Amoung Nursing and Medical Students: A Pathway for an Improved Perception of Self and the Surrounding World. Glob Qual Nurs Res. 2018: 5 33. International Council of Nurses. (2012). The ICN code of ethics for nurses. <https://www.icn.ch/ sites/default/files/inlinefiles/2012_ICN_Codeofethicsfornurses_%20eng.pdf> 34. Quinn J. F. (2014). The integrated nurse: Wholeness, self-discovery, and selfcare. In Kreitzer M. J., Koithan M. S., editors. (Eds.), Integrative nursing (pp. 17–32). New York: Oxford University Press 35. Epstein RM & Hundert EM. Defining and assessing professional competence. JAMA 2002 9;287(2):226-35 36. GMC, Good medical practice, 2019. <https://www.gmc-uk.org/ethical-guidance/ethical-guidancefor-doctors/good-medical-practice>

VISIBLE REDUCTION IN CELLULITE1

ALL SKIN & BODY TYPES

NON-INVASIVE & NO ANESTHESIA

EMTONE.COM SALES@BTLNET.COM

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you to tailor your message to their personal requirements. You need to make sure you have permission to use the email address in compliance with GDPR (if it’s for marketing purposes) and you need to make sure that they can opt-in or opt-out at anytime. You can also ask if you can have their permission to send them something via email and/or hard copy as an added-value tool, such as a guide you’ve prepared about your treatments.

What tactics can you use post-sale?

Getting Patients to Love Your Clinic Business coach and author Alan S. Adams discusses the importance of maximising opportunities to retain patients after a sale has been completed When it comes to completing a sale, many clinic owners wrongly assume that it’s simply just a waiting game until the patient needs, and wants, to return for more treatments. However, they’re missing a huge trick here because it’s a part of the overarching selling journey which provides ample opportunity for clinic owners to encourage customers to return more often, and therefore spend more. We’re of course ethical people in this business, so I’m talking about growing potential customer spend in appropriate areas such as facials, skincare treatments and other non-invasive services, rather than encouraging additional spend on services they don’t need like invasive or injectable treatments. Note that I will use the term ‘customer’ throughout this article as I am discussing the commercial aspects of patient management, rather than their clinical journey.

What is a customer journey? The customer journey concept is one of three areas of sales that I cover to help clinics sell more, and sell more often. The Sale Warmup and The Sale are the other two areas, but The After Sale is the biggest because there really is no limit to what someone can do to help customers feel the most valued and recognised. It also provides a huge variety of tools to completely transform the customer journey from one that is basic and ticking itself along (or not at all in many cases), to

one that absolutely considers every potential opportunity to nurture customers. The customer journey is exactly what it says on the tin. It’s everything that a customer can experience from the very first time they come into contact with your clinic, to the very last point in their buying journey and beyond. Within this journey, there are several touchpoints – the opportunities that you, as a clinic owner, have to contact your customers; existing or potential. For those that actually invest the time in understanding their own customer journey, there still may only be a few obvious times in which the customer is contactable – when they enquire, when they attend an appointment, and when they pay and leave. However, there are so many more to this than you would initially expect. For example, when someone calls with an enquiry, you need to be capturing all you can about that would-be customer – including their name, where or how they found you, what they’re looking for, and their contact details such as phone number and email address. This will allow

So, once you’ve been able to plan your own customers’ journey, considering every possible instance that your potential and existing customers are in contact with you and the clinic, it’s time to think about what happens once a sale has taken place. How exactly can you influence how often a customer comes back to you once they have bought, and ensure that they spend more than they have in the past? There are essentially two keys ways in which you can improve your spend and your frequency of visits from customers: data and communication. Data is the quality of information and knowledge you have about existing and potential customers, while communication is the methods and tools you have available to market smartly to them. If you have both of these in place, you’re in a great position to start boosting your customer journey and post-sale opportunities. I will now discuss two of the most valuable tools that clinic owners can adopt using the data you have, alongside strong communication. VIP memberships Once a sale has taken place, you’re in the unique position to offer something else – something that has a high perceived value for customers, will help generate increased brand loyalty, and help you to reduce cashflow worries. The launch of a VIP membership ‘club’ is a tactic I’ve talked about before and something so many clinics can start offering straight away. It involves the launch of a club, especially reserved for your top patients – the big spenders, and the ones who you rely

There really is no limit to what someone can do to help customers feel the most valued and recognised

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on as customers. You can build your club however you like; it may be that you include some products, a mix of treatments each month, and exclusive offers such as discounts on additional services or being the first to try the latest revolutions in aesthetics. Again, you can price it exactly how you see fit, but just make sure that it is carefully considered. You want the Golidlocks effect here; if it’s too low you’ll lose the credibility of it being VIP and exclusive, and if it’s too high you risk out-pricing even your biggest patients. You need to keep this club to a certain number so that you retain that level of ‘exclusivity’, and you also need to passionately communicate exactly just how special you’ll make your members feel. It’s all about the perceived value of your treatments and services. However you choose to launch your own club, you’re looking at an immediate cash influx at the start of each month. For example, if you have 20 members each paying £100 a month to be a Platinum Member (or whatever you wish to call them), you’re immediately generating £2,000 in income. What difference could that make to your business and your life? A well-devised membership programme is a must, especially in the aesthetics industry when there really is no guaranteed number of patients coming through the door each month. According to Forbes, Amazon Prime members spend 150% more than they did prior to becoming Amazon Prime members because of all the benefits they get, and it just makes it so easy for them.1 In addition to introducing a membership programme, you should also be thinking about the payment options you offer. For example, do you require payment upfront, or are you able to offer a monthly instalment programme? Ideally, you want the treatments to be paid for in one go, but for cashflow purposes this monthly drip-feeding of funds can be much more useful to you as a business. Packages Think about how often people use your services, and look at what you can do to increase this number. The work you have already done will help you understand why your patients come to you in the first place, so use that knowledge to encourage them to come back more often. Talk to your own team about communicating with patients about the additional services and products you have within your clinic. This could be through additional add-ons, or as part of a package – bundling your services

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and offering them to patients as a package can be an effective way of increasing their spend with you. It’s all about perception, so give some thought to how you want to position each of the packages too. For example, the highest package you offer might be £5,000, the middle £2,500, and the cheapest £1,000. What you include within these packages is again up to you, but studies have shown that people are much more likely to pick the middle option (Centre Stage effect).2 In this example, the anchor point is £5,000 as the highest package communicated first, so the £2,500 will naturally seem quite reasonable in comparison. If, on the other hand, you were to communicate it the other way round — starting with £1,000, then £2,500, and £5,000, the anchor point becomes £1,000 and anything above that seems steep. This is called the ‘Contrast Theory’ by Dr Robert Cialdini and I’d highly recommend doing further research if you think it could be useful to your clinic’s pricing structure.3

Nurturing your patients As mentioned earlier, you also need to consider what you can do to make your patients feel special and valued in other ways. It may only be a small thing, but asking them when their birthday is can be a great first step to expanding your customer journey touchpoints. You can use information like this to offer them a discount or a free product to accompany a treatment they book. It doesn’t have to just be for their birthdays though – they only come around once a year so you’ll also want to link into national holidays like Mother’s Day, Valentine’s Day and Christmas. You can also be really clever about how you time these offers, so if you know that revenues will be down in January, why not put on a special offer for treatments booked in December which can be used (and paid for) in January? Whether you use email or social media as your preferred way of communicating with your existing and potential customers, you should be offering regular incentives to get people coming through the door more often. The chances are that some will want to take advantage of a special offer and get themselves booked back in sooner than they would’ve done without an incentive or prompt from you. With the help of well-delivered PR, pay per click advertising, and advertising tactics, you can also continue to keep new leads coming through and using the above methods to turn

them into patients and then raving fans who are loyal to you. Your expertise, knowledge and skills might be the best in the business, but until you share that with potential patients, they won’t necessarily know that they should come to you rather than another clinic down the road. So do think about all the tactics you have at your disposal, and carefully plan when they may be most effective for you and your business. As long as you’re working on the growth of your business often and with consistency (rather than being so busy in your business doing the doing), you will experience a positive impact on your overall sales and marketing strategies.

Reap the rewards While these are only two of the tactics that I cover within The After Sale (and there are many, many more) I believe that they will perhaps be two of the biggest helps when it comes to getting patients to want to come back to you more frequently. As a clinic owner, you’ve got the skills and technical know-how to deliver truly amazing results, but at the end of the day, you are running a business – and this is naturally not an area many study when they go to launch their aesthetics brand. Running a business, as I know first-hand from my own experience, can be very stressful and the onus is most usually placed on the owner. Whether it’s worry about finances and cashflow, or feeling like the business isn’t growing as fast as you hoped, there is light at the end of the tunnel and with just a few simple strategies like these, you can soon start to reap the rewards that business owners dream of when they first start the journey to running their own clinic. Alan S. Adams is an awardwinning business coach and bestselling author. He is also a member of the Chartered Management Institute and the Professional Speaking Association. He has been recognised by Enterprise Nation as one of the Top 50 Advisors in the UK and the publication of his third book, The Beautiful Business: Secrets to Sculpting Your Ultimate Clinic, sees him focus very specifically on the medical, cosmetic and aesthetic clinic sector. REFERENCES 1. Here’s how much Amazon Prime customers spend per year (US: Forbes, 2017) <https://fortune.com/2017/10/18/amazon-prime-customer-spending/> 2. Rodway, Schepman & Lambert (2012). Preferring the One in the Middle: Further Evidence for the Centre stage Effect. 3. Cialdini R, The Psychology of Persuasion <https://www.amazon. com/gp/product/006124189X/ref=as_li_qf_sp_asin_il_ tl?ie=UTF8&camp=1789&creative=9325&creativeASIN=006124189X&linkCode=as2&tag=theoneque-20>

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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practice that is recognised and guided by the medical, nursing and pharmaceutical professional bodies.7 cBHRT allows different medicines to be combined in a formula that is unique to the patient’s individual prescription. The same approved hormones used in licensed rBHRT are combined in a UK pharmacy registered with and regulated by the General Pharmaceutical Council (GPhC).8 The resulting hormone combination is a namedpatient, prescription-specific, qualityassured extemporaneous medicine which can no longer be termed as ‘licensed’ as the ingredients have been combined.

Incorporating BHRT into Practice Dr David Eccleston provides his tips for successfully incorporating customised bio-identical hormone replacement therapy into an aesthetic practice Bio-identical hormone replacement therapy (BHRT) is a field that is fast gaining worldwide traction within the medical and aesthetic industry. According to market research company IMARC Group, the global BHRT market is projected to reach US $6.3 billion by 2024.1 Patients are educating themselves on the options available to them and seeking this treatment from private hormone specialists. However, it has become a natural fit for medical practitioners within aesthetics to offer this service as their existing patient base is generally already interested in ageing treatments and within the appropriate age group, making them the ideal target market. In my experience, BHRT has demonstrated a great way for aesthetic clinics to add more value to existing patients, as well as attracting new patients with this service offering.

About BHRT Bio-identical or ‘body identical’ hormones have been around since the early 1930s2 and are an important option for women in balancing their hormones. Bio-identical hormones are produced from the chemical diosgenin, which is extracted from plant sources such as Mexican wild yam and soy, and manufactured into micronised

form.3 Many prescribers do not realise that synthetic hormones have a different arrangement of carbon, oxygen and hydrogen atoms compared to naturallyoccurring hormones in the body; therefore, hormone replacement therapy (HRT) does not behave in the same way as the hormones made by our body. Conversely, BHRT has the same chemical and molecular structure as the hormones produced in the body. As a result, they fit our hormone receptor sites wholly and their effects can be more consistent with the normal biochemistry of the body.4,5 cBHRT vs. rBHRT There are two types of BHRT: registered bio-identical hormone replacement therapy (rBHRT) and customised bio-identical hormone replacement therapy (cBHRT). Customisation (or the compounding) of hormones offers personalised solutions for treating hormone imbalances and follows a prescription that is based on the individual patient’s diagnosis, symptoms and blood hormone levels that are measured at specific time points.6 cBHRT is classed as ‘off-licence’ prescribing (also known as ‘unlicensed’), which is common across many healthcare sectors. Prescribing unlicensed medicines is a regulated

With more demand for a personalised treatment approach, cBHRT made in a regulated compounding pharmacy is becoming more commonly prescribed to patients. The benefit of this personalised approach is that the patient is less likely to experience side effects,5 as they are given the lowest required dose needed to manage their symptoms. It also offers them the opportunity to access a wider range of routes of intake compared to rBHRT, which are typically taken via capsule form for progesterone and gel/patch form for oestrogen, so patients can choose their preferred method. Combining different hormones into a cream, for example, can simplify a regimen and therefore encourage compliance. Personalised treatments also allow the patient a much longer consultation than available on the NHS, meaning that they have time to fully discuss their symptoms and a fully comprehensive medical assessment can be conducted.

My experience with cBHRT From personal experience as an aesthetic practitioner, and with a strong medical background, including in obstetrics and gynaecology, I could not ignore this treatment. Whilst working both in aesthetics and general practice, I was seeing an increased demand for cBHRT, which led me to seek training. I worked with my team to ensure we were set up to do this to the highest standard and we soon had regular patients. We have now expanded to train our in-house practice nurse to support this popular service and I personally support and oversee every case with her. The most frequent line I hear from patients after the start of treatment is, “I have got my life back” and, for me, professionally, this

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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has been the most rewarding part of the work I do. Having built cBHRT successfully into our practice, I want to share the learnings and the key things to consider before incorporating it into your own practice, which requires careful consideration.

Typical patients I certainly advise that practitioners treat less complex cases to begin with, such as straightforward, menopausal women with no family history of cancer. The majority of patients seeking treatment in my practice are between 40-60 years of age. In my experience, around 80% of the typical patients seeking treatment are either premenstrual, perimenopause, menopause, andropause or suffering with adult acne. I’ve found that perimenopause (the years leading up to menopause) can be the most challenging time for women, as their own hormones are fluctuating wildly, and these patients are most regular in my practice.

Considerations for introducing BHRT into practice There are many things you as a practitioner need to consider before you can add this treatment to your offering, which are discussed below. Clinical background The only legal requirement to be trained to offer these treatments is that you need to be a UK registered prescribing practitioner so that you can prescribe to a UK pharmacy. I believe that prescribing practitioners without experience in women’s health should work with another specialist practitioner with experience in this area, as well as seeking additional training in women’s health, before commencing any BHRT training. In the UK, this can be done through the British Menopause Society or specialist training academies. Many doctors who graduated post 2000s, around the time of the Women’s Health

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I would discourage any practitioner who is simply looking to seek financial rewards from offering this treatment Initiative (WHI) study which showed an increase in coronary events, stroke, breast cancer and venous blood clots in women taking combined HRT, did not get formal training in menopause management and it is important to understand the essentials before learning how to prescribe hormones.10

Information and Quality Authority in the Republic of Ireland) before you consider offering this service to check if registration is required, as this is individual to each clinic. You will also need to check whether your current insurance provider will cover you for prescribing cBHRT.

Passion for women’s health I think it is extremely important that practitioners have a passion for women’s wellbeing. Most of the practitioners in my network have built hormone treatments into their practice because of how rewarding it is. When done properly, you can make a huge difference to your patient’s quality of life. To be able to help when I hear the usual complaints of menopause symptoms and other hormone imbalances is incredibly rewarding. Therefore, I would discourage any practitioner who is simply looking to seek financial rewards from offering this treatment.

Training in cBHRT Training is a mandatory requirement for cBHRT to know how to diagnose and treat the typical conditions such as premenstrual syndrome, perimenopause, adult acne and andropause. In considering a training provider, I recommend choosing an accredited course that provides ongoing educational and clinical resources. I found it useful to choose a provider that offers a network of like-minded peers and access to regular accredited education such as webinars to discuss clinical case studies. My team and I have personally trained with the Marion Gluck Training Academy, and we have found it to be very supportive; however, there are several other options available to practitioners.

Regulation and compliance As BHRT requires the diagnosing and treatment of a medical condition, it is generally a requirement to be registered with the Care Quality Commission (CQC), if you are not already.11 I recommend that you contact the CQC (or the regional equivalent: Health Inspectorate Wales, Healthcare Improvement Scotland and Regulation and Quality Improvement Authority in Northern Ireland, Health

Benefits to introducing cBHRT to practice Overall, offering this treatment therapy to our new and existing patients has provided: • Added value to our clinic: a competitive advantage in meeting the demands of our patients • New revenue channel: offering additional services to existing patients, and attracting new patients • New patients: attractive to new patients, with a high number driven from referral from current patients who have experienced the treatment • Increased patient retention: long patient lifetime and ongoing servicing of patients’ treatment

Investment One of the biggest advantages of building cBHRT into your practice is that there is minimal financial outlay involved, unlike many aesthetic treatment pathways which involve the investment of expensive equipment. If you already have a consulting room and basic medical equipment (including scales and a sphygmomanometer), then it means your route to market is quicker. Obviously, there will be training costs, with the average cost being around £2,000. Blood testing You may already take blood tests in your aesthetic or medical clinic if you are also offering nutritional/functional medicine services. In this case, the set up you have will be very similar. Blood tests are generally

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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cBHRT controversies It should be noted that there are controversies surrounding cBHRT and, as such, it is not endorsed by the British Menopause Society (BMS) or the Royal College of Obstetricians and Gynaecologists (RCOG).9 The bodies have released a consensus statement highlighting their concerns, which states, amongst other items, that, ‘cBHRT products are not recommended by the BMS as they are not evidence based for effectiveness and safety and because rBHRT options are available’.9

taken periodically to assess your patients’ current hormone levels. If you cannot take blood in your clinic, you will need to source a local laboratory that offers this service or partner with a phlebotomist. Most practitioners take blood during the consultation and then send it to the laboratory for analysis – often the laboratories offer a daily courier service. I find this is the easiest for the patient. Some training providers also partner with a blood-testing laboratory and have pre-arranged preferential pricing for cBHRT graduates, which can be useful to consider when choosing a provider. Pelvic ultrasound scans and other tests Another important aspect of hormone treatment is pelvic ultrasound scanning, which is important to ensure the endometrial lining is not thickened prior to and during treatment.12 To provide these scans, you will need to partner with a trusted diagnostics company (radiologist) to refer patients to. As part of the cBHRT consultation it will also be important to know that the patient has had an up-to-date smear test, mammogram and DEXA scan, if applicable. These tests are available on the NHS or may need private referral. Compounding pharmacy partner A key element of building cBHRT into your practice is choosing a pharmacy that will supply the hormonal treatments you will be prescribing. Personalised cBHRT is made to dose requirement in a compounding pharmacy. Your pharmacy will become your partner in treating your patients, so you will want to do your due diligence in deciding who to use. As a bare minimum, they must be regulated by the General Pharmaceutical Council.8 We work closely with a compounding pharmacy called Specialist Pharmacy. Marketing You will need to consider how you reach your audience for the introduction of this treatment. For most aesthetic practitioners, they already have an existing patient base

which they should utilise. The demographic coming in already for aesthetic treatments are often the same who are starting to experience menopausal symptoms. For our practice, marketing involved updating our existing communication platforms, such as our website and newsletters, to include this service. Word of mouth is also an extremely successful marketing channel for many cBHRT clinics. Most of the new patients I see have come thanks to a recommendation from a friend who has rid herself of hot flushes, is sleeping better or is finally able to enjoy sexual intercourse again. This means you need to focus your efforts on providing an outstanding service – something you will already be doing for your other services. As with all references to product claims, it is important to ensure that you are compliant with the guidelines set out by the Advertising Standards Agency (ASA), so it would be prudent to read these before marketing your services.13,14,15

Best practice

REFERENCES 1. Market Watch, Hormone Replacement Therpay Market: Global Trends, Share, Size, Growth, Opportunity and Forecast 2019-2024. <https://www.marketwatch.com/press-release/ hormone-replacement-therapy-market-research-reportmarket-share-size-trends-forecast-and-analysis-of-keyplayers-2024-2019-09-03> 2. Cirigliano,M (2007). “Bioidentical hormone therapy: a review of the evidence” (PDF). Journal of Women’s Health. 16 (5): 600-31. 3. Harvard Health Publications, what are bioidentical hormones? Harvard Medical School, (2015) <https://www.health.harvard. edu/womens-health/what-are-bioidentical-hormones> 4. Steven F Hotze & Kelly Griffin, Hormones, Health and Happiness: A Natural Medical Formula for Rediscovering Youth with Bioidentical Hormones (Second edition), (2013). 5. Moskowitz, D. A comprehensive review of the safety and efficacy of bioidentical hormones for the management of menopause and related health risks. Alternative Medicine Review. 2006 Sep;11(3):208-23. 6. Ruiz, A.D., Daniels, K.R., Barner, J.C. et al. Effectiveness of Compounded Bioidentical Hormone Replacement Therapy: An Observational Cohort Study. BMC Women’s Health 11, 27 (2011). <https://doi.org/10.1186/1472-6874-11-27> 7. Gov.uk, Off-label or unlicensed use of medicines: prescribers’ responsibilities (UK: Gov, 2020) <https://www.gov.uk/ drug-safety-update/off-label-or-unlicensed-use-of-medicinesprescribers-responsibilities> 8. About Us, Specialist Pharmacy (UK: Specialist Pharmacy, 2020) <https://specialist-pharmacy.com> 9. British Menopause Society, Bioidentical HRT, 2019. <https:// thebms.org.uk/publications/consensus-statements/ bioidentical-hrt/> 10. Chester R, Kling J, Manson J (2018) “What the Women’s Health Initiative has taught us about menopausal hormone therapy”. Clin Cardiol 41(2):247-252. 11. CQC, Scope of Registration: Independent Medical Practitioners Working in Private Practice. <https://www.cqc. org.uk/sites/default/files/20150428_scope_of_registration_ independent_medical_practitioners_working_in_private_ practice.pdf> 12. General Pharmaceutical Council. <https://www. pharmacyregulation.org/> 13. ASA, Health: Bio-identoical Hormone Replacement Therapy, 2017. <https://www.asa.org.uk/advice-online/health-bioidentical-hormone-replacement-therapy.html#anchor%204> 14. ASA, Sector Compliance - Bio-identical Hormone Replacement Therapy, 2017. <https://www.asa.org.uk/news/sectorcompliance-bio-identical-hormone-replacement-therapy.html> 15. ASA Ruling on Stratford Dermatherapy Clinic, 2017. <https://www.asa.org.uk/rulings/stratford-dermatherapyclinic-a16-350785.html>

As mentioned, it is part of our clinical judgement to determine whether or not a patient is outside of scope, so in these cases it is always recommended to refer to a specialist. I believe in providing cBHRT services properly, and, in doing so, we have established a successful practice with lots of excellent patient outcomes. Integrating cBHRT into our service offering has been a natural fit, and many patients want to experience the other treatments we offer. Practitioners must ensure they have the relevant background training and choose a reputable cBHRT training provider that will support them and their team throughout their journey. Dr David Eccleston qualified in 1987, training further in dermatology, ENT, ophthalmology, obstetrics and gynaecology, before entering general practice. He founded The Oakley Partnership Private Medical Practice in 2014. Dr Eccleston is also the clinical director of Medizen cosmetic dermatology clinic in Birmingham. Qual: MB, ChB, MBCAM

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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TM by popular demand! back ylane Lyps is Restylane Lyps is back by TM

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In The Life of Dr Galyna Selezneva This month, Aesthetics met up with a practitioner renowned for her body sculpting treatments and experienced an insight into her daily life How I spend my morning…

How I unwind after work…

I like to keep my morning routine simple and easy, so that I can stay relaxed. I wake up after pressing the snooze button about fourteen times; I never ever wake up to my alarm! Eventually, when I do manage to get up, the first thing I do is go and find my dog – a pomsky. My husband and I like to shower the dog with lots of love and kisses in the morning. Then I stretch, I dry brush, I shower and I drink water. Hydration is key to a healthy life and body, so I make sure that I drink at least half a litre, but it has to be lukewarm because that way it hits the gut better. I skip all the complicated morning routines when it comes to skincare – I like to keep it basic and just focus on exfoliation and hydration.

I don’t say this in a cheesy way, but when you love what you do, you don’t work a day in your life. Every single one of my patients has my number, and they all message or email me. So, I don’t know if I ever completely unwind as there’s always a part of me switched on, but I wouldn’t have it any other way. I wouldn’t want my doctor, if I needed them at 10pm for some reason, to not be able to reply to me. In my spare time, I watch a lot of TV; a lot of Netflix. I used to be a psychiatrist, I love anything to do with psychopaths, serial killers and paranoia, so I watch documentaries and series in that genre. That’s my guilty pleasure. I also collect comic books and graphic novels – I’m a massive sci-fi fan and I could watch a lot of Star Wars.

A typical working day for me involves…

The most defining day in my career was…

I usually start at 8:30am and finish at 8:30pm. In regards to how many patients I would see within that time, I couldn’t tell you. I have what I like to call ‘clinical flexibility’ – I don’t know if that exists as a term, but it means I could see between four and 20 patients a day. That’s because I mostly work with devices. If patients want a treatment such as CoolSculpting, they will need three to six treatments in different areas, which I would often do over several sessions. But, if they are only in London for a day, they might want to get them all done within those 24 hours. I won’t do treatments back to back with one patient, but I will do two separate treatments with a break in the middle – normally after the first procedure I send them off to Harrods for a few hours. So, if that was the case, I’d see hardly any patients that day. On the other hand, some of my treatments only last for 15 minutes and then I’m able to see many more people. I also used to work two or three weekends a month, but I didn’t mind that because I enjoyed it. I try to work a bit less now though, only one Saturday a month. At the end of each working day, I have my half-hour drive home and that’s

How I got into aesthetics… My career properly began one day when I was getting a treatment at Dr Rakus’ clinic. I was so in awe of her and what she did that I asked her if she would mentor me and let me shadow her. Luckily she agreed, and I’ve been working in her clinic ever since!

My most popular treatment… I’ve been nicknamed ‘the body’ because my main focus is on body contouring, although I do face treatments too. I was the first UK practitioner to have studied at the CoolSculpting university in California, and that’s still the technology I use the most – although we have lots of different machines at the clinic. when I talk to my mother. I tell her everything that’s happened in my day and we’ll plan the day ahead. My mother is a big part of my life, I’m such a mummy’s girl.

When I first started in aesthetics, I went on a trip to LA to train with plastic surgeon Dr Grant Stevens, who was considered the number one in the world for body sculpting. While I was there, Dr Raj Kanodia had also agreed to train me and let me watch his procedures and consultations. So I would spend the mornings with Dr Stevens and then the afternoons shadowing Dr Raj Kanodia, with a lunch break in between, somewhere nice in Beverley Hills. One evening, Dr Kanodia took me out to show me around LA, and we went to the restaurant Nobu in Malibu, and sat on the sea line. As I was sat there, eating sushi, I could feel the wind in my face and the sea salt on my lips and I thought, ‘damn, my life is great’. I couldn’t believe that I was in LA being trained by the best people in the business. I was so humbled. That was a very beautiful and defining moment for me. Of course, I also have to say that every day I work with Dr Rita Rakus at her clinic in Knightsbridge defines my career. She inspires me every single day and I really have to thank her for everything she’s done for me.

Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020


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The Last Word Nurse prescriber Khatra Paterson highlights issues around using celebrity images for clinic marketing Over the last decade, social media has become an integral part of people’s lives, which has not only allowed businesses to reach a wider audience through social media marketing, but it has also given us more access into the daily lives of celebrities. Following celebrities on social media can increase the emotional connection with them, leading the public to feel as though they are a part of the celebrities’ lives and being influenced by their activities. Sharing celebrity images can help clinics to increase visibility and engagement on social media, as they present a recognisable face to followers. When done ethically and correctly, this can help followers understand how a celebrity has enhanced their features using aesthetic treatments. However, I am noticing several issues when it comes to using celebrities in marketing, which I detail in this article and explain what I believe can be done to ensure we are doing the best by our patients.

Problems with sharing celebrity images on social media Celebrity patients who are happy to share their treatments on social media can help clinics gain the trust of followers. Patients are able to see what results can be achieved when clinics caption the picture with a breakdown of the treatment the celebrity has had, along with the benefits of having them, thus educating our audience. I treat a number of celebrities; some of who choose to keep their treatments confidential. I respect their wishes, but have seen other clinics guessing the treatments my celebrity patient has had done, of which they have been totally wrong. In my opinion this cannot only cause distress for the celebrity, but it also completely misleads future patients, making it more difficult to meet their expectations. Unless a celebrity has publicly spoken about or confirmed the treatments they have had, I believe we should avoid sharing images that imply what you think they may have had done for risk of being wrong. I see many clinics that share pictures of a celebrity aged 18 and then aged 28, implying or assuming that they have had filler in their cheeks and jawline to improve definition. However, the reality may be that the celebrity

has simply lost her puppy fat. Weight loss, makeup and good lighting can help create a noticeable difference, meaning their change in appearance may not be down to cosmetic interventions at all. As an example, images of The Duchess of Cambridge and discussion around the treatments she has had are rife among clinics, which has garnered press attention.1 Often, the photographs don’t even offer a direct comparison; they have been taken years apart and show The Duchess with and without makeup. In my opinion, using them in this way is wrong. Certainly, the demand and popularity of aesthetic treatments, particularly amongst millennials, has been increased by social media images such as those from the Kardashian-Jenner family – the use of their images are extremely common. However, when similar results cannot be achieved with the so-called ‘Kylie Package’ of 5mls of filler to contour the cheeks, sharpen the jawline and extend the chin, we are misleading the consumer. The General Medical Council (GMC) guidelines state that you must not mislead the public on the results you are likely to achieve and you must not falsely claim or imply that certain results are guaranteed from an intervention.2 As practitioners, we cannot make individuals look or resemble anyone else but the best version of themselves. Two advertisements promoting the ‘Kylie Jenner package’ were recently banned by the Advertising Standards Authority (ASA) for this reason.3,4

So, what’s the solution? Generally, practitioners need to become familiar with the Committee of Advertising Practice’s guidelines for their marketing.5,6 When it comes to celebrities and influencers, I encourage my fellow aesthetic practitioners to only use them to educate the public on safe and ethical treatments by having honesty and integrity with everything you do. This means crediting the clinic who has treated them (if it isn’t you) and making sure you are clearly advising your audience of the true treatments that have been carried out. Don’t ever assume or use an image to your own advantage at the detriment to others. Remember that your role is to protect

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your patients by advising them of the best treatment, if any, for them. The public is becoming more aware of the role of celebrities and their influence, so if you are wanting to use images of celebrities, then I advise to not only ensure you have a true understanding of treatments, if any, to achieve the results shown but to consider copyright rules before sharing another’s images.7 Also, if it’s your own work then you can add your logo to the image before sharing online so that people know that it’s yours. If a celebrity talks publicly about how good or flawless their skin is looking, then you can comment on this and explain how you can help your patients with the services you offer. Alternatively, you could use an image of a celebrity with glowing skin and let your followers know how they could also achieve better skin health rather than guessing or implying you know what the celebrity has had done. Whenever you share anything online, remember once it is posted it can be screenshot and shared. Getting it wrong can create repercussions not only for your reputation, but also for your potential future relationships with celebrities. The Nursing and Midwifery Council (NMC) encourages us to protect our professionalism with this advice: ‘If you are unsure whether something you post online could compromise your professionalism or your reputation, you should think about what the information means for you in practice and how it affects your responsibility to keep to the Code’.8 Khatra Paterson is an aesthetic nurse prescriber. She has worked in the aesthetic industry for 10 years and has been full time after leaving the NHS in 2014. Paterson is the owner and director of KP Aesthetics, as well as a member of the BACN and ACE Group. REFERENCES 1. Gray, S, Kate Middleton: Royal fury with plastic surgery company - how does she look much fresher?, Express, November 9, 2019. <https://www.express.co.uk/life-style/life/1202264/kate-middletonnews-plastic-surgery-latest-pictures> 2. ASA Ruling on Faces By AKJ Aesthetics Ltd, 25 September 2019. <https://www.asa.org.uk/rulings/faces-by-akj-aestheticsltd-A19-565851.html> 3. GMC, Maintaining trust <https://www.gmc-uk.org/ethical-guidance/ ethical-guidance-for-doctors/cosmetic-interventions/maintainingtrust> 4. ASA Ruling on Queen of Aesthetics, 25 September 2019. <https:// www.asa.org.uk/rulings/queen-of-aesthetics-A19-565844.html> 5. CAP, An Influencer’s Guide to making clear that ads are ads. <https://www.asa.org.uk/uploads/assets/uploaded/3af39c72-76e14a59-b2b47e81a034cd1d.pdf> 6. CAP Advertising Guidance, 2020. <https://www.asa.org.uk/adviceand-resources/resource-library/advertising-guidance.html> 7. Fiona Clark, How to Avoid Breaching Publishing Laws, Aesthetics journal, April 2018. <https://aestheticsjournal.com/feature/how-toavoid-breaching-publishing-laws> 8. NMC, Read Social media guidance online. <https://www.nmc.org. uk/standards/guidance/social-media-guidance/read-social-mediaguidance-online/>

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Your Aesthetic Network You may not have been able to meet them at ACE last month, but you can read all about the noteworthy suppliers, manufacturers and service providers in the specialty right here! duction Fat Re

3D LIPO Launched in 2012, aesthetic device manufacturer 3D-lipo Ltd supply advanced, non-surgical systems to the aesthetics market. They specialise in multi-technology devices targeting fat loss, cellulite reduction, skin tightening, facial indications, vaginal rejuvenation, laser hair removal and tattoo removal. 3D-lipo is currently available in over 800 clinics in the UK. 3d-lipo.co.uk

ng

Skin Tighteni

Cellulite

A Powerful Three Dimensional Alternative to Liposuction

No other system offers this advanced combination of technologies designed to target fat removal, cellulite and skin tightening without the need to exercise

4T MEDICAL LTD supplies carefully selected cosmeceutical and medical aesthetic products that meet the highest manufacturing standards. The company, which is located near Cambridge, has built a solid reputation for providing competitively priced products and outstanding customer service. Training is available for all products. 4tmedical.com

Why choose 3D-lipo? Cavitation

• A complete approach to the problem • Prescriptive • Multi-functional • Inch loss • Contouring • Cellulite • Face and Body skin tightening • Highly profitable • No exercise required

Complete start up and support package available from under £400 per month

Cavitation is a natural phenomenon based on low frequency ultrasound. The Ultrasound produces a strong wave of pressure to fat cell membranes. A fat cell membrane cannot withstand this pressure and therefore disintegrates into a liquid state. The result is natural, permanent fat loss.

Cryolipolysis Using the unique combination of electro and cryo therapy 20-40% of the fat cells in the treated area die in a natural way and dissolve over the course of several months.

Radio Frequency Skin Tightening Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable depths of penetration.

ABC LASERS, leaders in aesthetic/medical equipment and surgical systems, are sole distributors for Alma Lasers. ABC’s technological innovations, clinical expertise and in-depth understanding of practitioners’ needs led to the development of the multi-technology Harmony PRO platform, Soprano PLATINUM – the genuine pain-free hair removal laser – and Accent Prime Platform. abclasers.co.uk

3D Dermology Combines pulsed variable vacuum and skin rolling for the effective treatment of cellulite.

What the experts say... ‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients.

Before

After

3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

For further information or a demonstration call: 01788 550 440

www.3d-lipo.com www.3d-skintech.com

AESTHETICA SOLUTIONS For independent aesthetic practitioners looking to place low volume orders for branded toxins and fillers, Aesthetica Solutions can promise competitive prices. We take a very traditional and ethical approach to our customer service, and are dedicated to providing an unrivalled, quality user experience. We strive to develop a personal and friendly working relationship with each and every client. aestheticasolutions.co.uk AESTHETICARE works in partnership with clinics and practitioners to help them deliver outstanding, natural results for their patients in skin rejuvenation and problem skin resolution. With a system of advanced skin devices, treatments and medigrade skincare, AesthetiCare enables you to take your patients on a journey to better looking skin using the very best, clinically proven products. aestheticare.co.uk AESTHETICSOURCE provides world renowned clinically proven brands promoting Skin FitnessTM focusing on NeoStrata®, SkinTech®, RRS®, Exuviance® & XXtralash, with more to come. Our passion is for great customer service; supported by bespoke marketing materials, strong PR, thorough training and friendly, helpful knowledgeable staff. We are here to support your business. aestheticsource.com

TM

ALLERGAN is a global pharmaceutical company that develops and manufactures branded pharmaceuticals, primarily focused on four key therapeutic areas: medical aesthetics, eye care, central nervous system and gastroenterology. Its medical aesthetics portfolio includes the Juvéderm range of facial fillers, botulinum toxin A and CoolSculpting for body contouring. allergan.co.uk ALLIANCE PHARMACEUTICALS LTD, together with KELO-COTE®, is delighted to support ACE 2020. The KELO-COTE® patented range of products includes a gel, spray and UV gel, which are used for the treatment and prevention of keloid and hypertrophic scars. alliancepharmaceuticals.com

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ANTEAGE MD® is a division of Cellese led by scientists, researchers and physicians, with a focus on skincare treatments. Their products deliver the natural biosignals needed for healing and rejuvenation, used in antiageing skin treatments, microneedling, hair regrowth, vaginal rejuvenation and skin brightening. anteage.com ARCHIDEMIA are suppliers of professional medical scientific books and resources. We have an extensive range of books and can guarantee almost any title that you are looking for. Specialist areas include, aesthetic medicine, plastic surgery, dermatology and dentistry. archidemia.com AZTEC SERVICES is UK distributor for Novoxel and Viora. Our product range offers customers the very best systems for their clinics, including microdermabrasion, laser, IPL, RF, multi-technology systems, and the new, amazing Tixel skin rejuvenation system from Novoxel. We provide fast, efficient support and back-up, which is a hugely important aspect of running a successful clinic. aztecservices.uk.com BRITISH ASSOCIATION OF COSMETIC NURSES The BACN is the largest professional association for nurses carrying out cosmetic treatments in the UK. It operates under a strict Code of Conduct to provide services and support to all of its members and to promote and support patient safety in the area of non-surgical aesthetic treatments. bacn.org.uk BRITISH COLLEGE OF AESTHETIC MEDICINE (BCAM) exists to advance safe and ethical aesthetic medicine to the benefit of medical practitioners and members of the public. We represent aesthetic medical practitioners in a unified manner, maintain standards and practice ethics in aesthetic medicine. bcam.ac.uk BLOW MEDIA are a Creative Design and Digital Agency specialising in the Aesthetics and Surgical sectors. With more than 15 years heritage working with the most prominent and successful industry brands, Blow Media are the leading digital agency in this arena. Our mantra is ‘The Relentless Pursuit of Brilliance’ - from branding to website design & build, we have the in house skills and expertise to bring your vision to reality. blowmedia.co.uk BLUE STREAM ACADEMY LTD is a leading provider of eLearning resources for healthcare professionals in the UK. The company supports over 150,000 trainees with 95+ CPD accredited eLearning modules, a management of information system, and a fully integrated HR system. The modules are developed alongside subject matter experts, and existing content is regularly reviewed and updated. bluestreamacademy.com BTL AESTHETICS is a leader in the aesthetics industry with cutting edge technology supported by a comprehensive library of peer-reviewed publications. It is a market leader in skin tightening and body contouring applications and in line with industry trends leading the way in feminine health. The BTL Exilis Ultrafemme 360 radiofrequency system is targeted for vaginal health and the BTL Emsella for high frequency focused electromagnetic applications for pelvic floor rehabilitation. btlaesthetics.com/uk CAMBRIDGE STRATUM is a distributor of world-class aesthetic and medical equipment. Our goal at Cambridge Stratum is to provide tried and trusted products, at more affordable prices, without loss of product quality or support. We ensure all equipment is fully approved and undergoes long-term evaluation and testing (in our award-winning associated Cambridge clinic), before it is released for sale. cambridgestratum.com CELLUMA LIGHT THERAPY, the award-winning Celluma is a 3-in-1 LED device FDA-cleared to treat acne, wrinkles and pain. Can be used clinically as a powerful stand-alone modality or as a treatment add-on. Celluma is CE-certified for dermal wound healing and is ideal for use following ablative procedures including microneedling, microdermabrasion, microcurrent, and LASER. Celluma is hands-free, stand-free, affordable, portable, and ideally suited for spas, medi-spas, luxury spas and medical practices, alike. biophotas.com CHURCH PHARMACY specialises in medical aesthetics, supplying the largest range of botulinum toxins and dermal fillers and is renowned in the aesthetics industry for it award-winning customer service. It’s at the heart of everything we do from supporting our customers with product information, streamlining the sales process, tracking parcels to their door and a great aftercare service. churchpharmacy.co.uk COSMETIC DIGITAL with more than 13 years’ experience in the aesthetic and medical cosmetic sector, Cosmetic Digital is the UK’s number one digital marketing agency. Our services include branding, web design, Google SEO, organic and paid digital marketing, and social media. Our specialist UK team helps clients, large and small, to grow their businesses. We are the go-to agency for creativity, technical expertise and knowledge of your industry. cosmeticdigital.co.uk

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COSMETIC INSURE is a specialist provider of insurance products and services specifically designed for the aesthetics industry, using a panel of insurers to ensure flexibility. Whether an individual practitioner, national clinic chain or product supplier, our experienced team can offer free advice on all your insurance requirements. cosmeticinsure.com CROMA: Croma-Pharma is a pharmaceutical company based in Austria with 12 international offices. As a leading European manufacturer of hyaluronic acid, the company specialises in minimally invasive aesthetic medicine. They market HA fillers, PDO lifting threads, a Platelet Rich Plasma system and a personalised skincare technology. at.croma.at/home-en CRYOPEN medical device company dedicated to the research and development of innovative, technologically advanced medical products and applications. It distributes cryosurgery instruments to permanently remove benign skin lesions that are no longer treatable as a standard NHS procedure. CryoPen will equip aesthetic practitioners with the full package including the medically certified CryoPen, marketing and accredited training. naturastudios.co.uk CUTERA MEDICAL LTD; since 1998, Cutera has provided worldwide leading laser and light-based medical aesthetic systems. Our devices offer a wide range of medical aesthetic applications for the face and body, delivering class-leading results, faster and safer. The UK direct team can offer the perfect solution for patient satisfaction and practice growth. cutera.com/ CYNOSURE INC leads the world in aesthetic laser technologies and research, creating innovative, safe and efficacious procedures for the treatments that patients want most. Its technologies include hair removal, treatment of vascular and pigmented lesions, skin revitalisation, tattoo removal, body contouring, and the reduction in the appearance of cellulite. cynosureuk.com/ DELEO, created in 2010 and based at Saint-Raphaël in the South of France, is specialised in the conception, production and commercialisation of innovative aesthetic medical devices. Deleo is the European leader of cryolipolysis and High Power LED devices. DELEO is present in more than 35 countries. deleo-medical.com DERMALUX: Multi-award winning Dermalux is the trusted brand for professional LED Phototherapy. Five-time winner of Best Treatment and Best UK Manufacturer 2018 at the Aesthetics Awards, we manufacture the Dermalux systems in the UK for assured quality, clinical efficacy and compliance. As a medical device manufacturer, our investment in R&D and proprietary, cutting edge LED technology has secured Dermalux is a superior device with outstanding results. dermaluxled.com E-CLINIC is a comprehensive and easy to use in-clinic management software system for clinics and practitioners, with the power and flexibility to deal with complex workflows and bespoke requirements. It’s used by some of the biggest cosmetic surgery groups and hundreds of aesthetic practitioners across Britain and in Europe, all of whom rely on the software for the smooth running of their businesses. e-clinic.co.uk EDEN AESTHETICS specialises in high quality, scientifically researched aesthetic equipment and skincare products which we distribute across the UK and Ireland. All our products are subject to full ongoing research and have been tested and endorsed by leading medical practitioners in the UK and Europe to ensure customer satisfaction. As part of our commitment to our customers we offer extensive ongoing training, marketing support and a comprehensive national PR campaign. edenaesthetics.com/n ELÉNZIA: As a family fronted brand house, skincare distributor Elénzia provides technical solutions aiming to improve customers health, beauty and wellbeing with scientifically proven products. The company is the exclusive distributor of the Endor Technologies aesthetics range, clinically proven to improve radiofrequency treatments by 18 times and laser treatments by 32%. elenzia.com ENDOSPHERES: Prooduced by Italian manufacturer Fenix Group, Endosphéres Therapy is a non-invasive lymphatic drainage procedure aimed at stimulating the body’s natural mechanisms to break down, remove and re-shape fat and adipose tissues. It also stimulates elastin and collagen production to rejuvenate skin. It can be used in aesthetic centres, medi-spas and beauty centres. endospheres.com

Enhance Insurance

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Advice

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Support

ENHANCE INSURANCE is a London-based independent insurance and risk management broker. They have more than 45 years of experience providing insurance services for medical professionals, NHS Trusts, private clinics, medical technology companies, multinational pharmaceuticals and life science organisations, to develop an insurance proposition specifically designed for the medical and aesthetics sector. enhanceinsurance.co.uk ERCHONIA LASERS: Cosmetic and medical laser manufacturer Erchonia Corporation has been working in the industry for the last 22 years, conducting research and development with leading physicians. The company advances the science of low level lasers, used to treat foot fungus and the appearance of cellulite, reduce body fat, eliminate pain, accelerate healing and treat acne. erchonia.com

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FACE FOR BUSINESS: Pulse, a call handling service run by Face for Business, provides a specialist service to the aesthetic, health and wellbeing sector, designed to help practitioners secure appointments and enable them to manage business without interruption. The personal assistants will answer calls in your company name, pass on messages, agree diary bookings and take payments. ffb.co.uk GALDERMA UK & IRELAND LIMITED: Galderma is a global pharmaceutical company specialising in the research, development and marketing of corrective and aesthetic solutions to meet the dermatological needs of people throughout their lifetime, while serving healthcare professionals and also focused exclusively on meeting the needs of dermatology patients. Visit our stand for more information. galderma.co.uk GERARD’S COSMETIC CULTURE: Cosmetic brand Gerard’s was founded in the Franciacorta region of Italy in 1970. It utilises elements that are eco-friendly in order to create modular and functional products, specifically formulated to deliver immediate and long term results. Gerard’s distributes products to over 35 countries worldwide, but they are made exclusively in Italy. cosmetic-culture.co.uk GLOWDAY: Launching this year, Glowday is a new booking platform for non-surgical aesthetic treatments. Its aim is to give practitioners a place to showcase reviews and build their reputation, while ensuring clients have all the information they need to book treatments with medically qualified professionals. glowday.com HA-DERMA is the exclusive UK distributor of IBSA Italia’s aesthetic products. IBSA’s core products include the award-winning Profhilo, Viscoderm and Aliaxin and are based on Hydrolift Action, an approach aimed at counteracting the physiological reduction of HA in the skin, restoring hydration, elasticity and even skin tone. ha-derma.co.uk HAMILTON FRASER COSMETIC INSURANCE has been providing insurance to the medical malpractice industry since 1996. Alongside medical malpractice, we offer insurance for clinic and surgery, directors and officers, and cyber liability. Not only do we offer competitive premiums, we also believe in providing expert customer service, to ensure that you and your business have the right protection. hamiltonfraser.co.uk/cosmetic-insurance HANSBIOMED EUROPE LTD: Originating from South Korea, MINT PDO is a safe and effective thread used to pull soft tissues of sagging skin to a desired position. The bi-directional and helically positioned barbs provide instant face lifting results with minimal pain and scarring. Used in 14 other countries worldwide, it is certified FDA and CE. hansbiomed.com/eng HARLEY ACADEMY: Established in 2015, Harley Academy created the UK’s first fully-regulated Level 7 qualification in Injectables for Aesthetic Medicine, and are an Allergan-appointed training provider. Led by Dr Tristan Mehta, the academy spans across four UK training hubs in London, Birmingham, Liverpool and Manchester, with a community of 1,000 medical professionals. harleyacademy.com

Group

HEALTHXCHANGE is the market leading distributor of aesthetics supplies. They offer reputable brands including Allergan Botox®, Juvederm Vycross® range, Obagi Medical Products, ULTRAcel, LIPOcel, ENVY Facial, AQUALYX and Dr LEVY. Committed to digital technologies, their e-pharmacy makes 24/7 ordering easy and efficient, while their latest project, Clever Clinic, a bespoke dermatology app, is set to revolutionise patient management in aesthetics. healthxchange.com HYDRAFACIAL is an aesthetic facial treatment, manufactured in the US by aesthetic technology manufacturer the HydraFacial Company. The device is non-invasive and multi-modality, able to treat skin of any age, type or tone. It utilises a patented roller-flex technology and combines an exfoliation service with a daily application of a take-home serum, providing instantly visible results. hydrafacial.co.uk INBODY UK are the global leaders in body composition analysis, providing accurate and reliable measurements to patients and professionals all over the world. InBody UK currently supplies all corners of the UK healthcare and wellbeing market, along with the rapidly growing aesthetic and medical weight loss sector. The company produces tangible body composition results of fat loss and muscle development, which is crucial to the patient undergoing medical weight loss treatment. uk.inbody.com INITIAL MEDICAL specialises in healthcare waste management, providing a complete collection, disposal and recycling service for hazardous and non-hazardous waste produced by aesthetic practices within the UK. The company offers products and services including sharps and needle disposal, waste segregation, soft clinical waste and infection control products.initial.co.uk INSPIRE TO OUTSTAND specialises in CQC compliance and registration support for new providers, including clinics and practices from healthcare. They offer support and guidance through the process, which includes the provision of governance documentation to preparing the clinic to be inspection ready. Other services offered include guidance for clinics who are currently registered with the CQC and preparing for rating inspections. inspiretooutstand.co.uk

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INMODE is a medical device company that develops a broad range of products for minimally - invasive cosmetic surgery based on patented proprietary RFAL (Radiofrequency Assisted LipoTightening) technology. InMode UK aesthetic devices creates a whole new category of minimally - invasive body recontouring and firming procedures offering reliable and effective applications for physicians, and safety and comfort for patients. inmodemd.co.uk

PHARMACY

JOHN BANNON PHARMACY are proud to act as distributors for some of the world’s leading aesthetic manufacturers. Our professionalism and unrivalled customer service guarantees that as your pharmacy partner we will strive to offer good value pricing, great training opportunities, easy ordering methods, and opportunities to work with our strategic partners. Covering the whole of the UK and Ireland, our experienced staff are always keen and ready to help. johnbannonpharmacy.co.uk JOURNAL OF AESTHETIC NURSING (JAN) is the only peer-reviewed clinical and professional journal for aesthetic nurses. Published 10 times a year, JAN was created to continually support aesthetic nurses in advancing their clinical practice. Articles include clinical overviews and case studies, with a strong focus on non-surgical cosmetic medicine. magonlinelibrary.com/journal/jan LUMINERA is a research and development company, and manufacturer of injectable medical devices in the field of aesthetic medicine. The company’s portfolio includes hyaluronic acid based dermal fillers (Hydryalix and Hydryal), calcium hydroxyapatite based dermal filler (Crystalys) and the composite matrix dermal filler composed of calcium hydroxyapatite and hyaluronic acid (HArmonyCa). luminera.com LG CHEM, YVOIRE® Korean based chemical company LG Chem launched the first Korean hyaluronic acid filler, YVOIRE® Classic, in the Korean aesthetic market. YVOIRE® is listed in the US FDA and approved by European Directorate for the Quality of Medicines & Healthcare. The specialist YVOIRE® products available in the UK are all Class III Medical Device CE marked. global.lgyvoire.com/brand.jsp LYNTON LASERS: UK laser manufacturer, Lynton Lasers Ltd has been providing equipment to private clinics and the NHS for the last 25 years. Winners of the Aesthetics Awards ‘Best Manufacturer in the UK’ award, the company offers an up-to-date range of equipment and product development and demonstrate excellent customer service and support for practitioners using their products. lynton.co.uk MERZ is a global, family-owned aesthetics and neurotoxin company, that has a mission is to bring innovative products to the market so that people all over the world can live better, feel better, and look better. It has a modern approach to aesthetic medicine, with a unique and well-balanced product portfolio that is designed to deliver personalised and natural looking outcomes. merzpharma.co.uk

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NEEDLE CONCEPT, based in Biarritz, France, specialise in designing injection technology, including the first micro-cannula called Magic Needle and the Meso and PRP meso-injector U225. The U225 is a high precision device that can make painless injections into any area of the body. Hand made production and high quality spare parts allow the needles to be reliable tools for large medical applications. needleconcept.lacom.info NEXTMOTION: Based in France, Nextmotion is a company that develops and markets innovative products for doctors in aesthetic medicine, cosmetic surgery and dermatology. The Nextmotion app offers standardization of before and after documentation in motion, digitization of the medical office and 3D capture and simulation tools. nextmotion.net MEDICAL AESTHETIC GROUP (MAG) is one of the UK’s leading aesthetic suppliers and seeks out the most innovative products and systems available, including Oxygenetix, DCL, PRX-T33, MELINE, V Soft Lift, Innoaesthetics, Mene & Moy, MELINE and Innoaesthetics. Dr Beatriz Molina now leads MAG’s medical standards compliance, ensuring products and treatments meet all clinical requirements, strengthening its commitment to bring only the very best medical aesthetic products to the profession. magroup.co.uk MEDICAL-UP Medical-Up is a medical device and services distribution company specialising in weight-loss solutions and aesthetic treatments. Our goal is to create new opportunities for clinics from a portfolio of established and new, innovative products. medical-up.co.uk MEDIRA is home to the market leading Cellenis PRP and PRF. I’ts unique in quality, simple to use and affordable, using the latest generation three gel separation technology. Available in 11ml and 22ml blood draw tubes, a higher platelet concentration is easily achieved. Visit our stand where all of your questions can be answered. medira.co.uk MONEYPENNY is a telephone answering and live chat provider dedicated to the healthcare sector, handling 15 million calls and chats annually on behalf of its clients. Established in 2000, the company focuses on helping businesses with customer service by providing them with a Moneypenny receptionist, who will address new patient enquiries. moneypenny.com/uk

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Aesthetics

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NOVO NORDISK is a global healthcare company that manufactures and markets pharmaceutical products and services. Its focus is on helping people with obesity, haemophilia, growth disorders and other serious chronic diseases. Headquartered in Denmark, Novo Nordisk employs approximately 41,600 people in 80 countries and markets its products in more than 170 countries. novonordisk.co.uk OBSERV SKIN ANALYSIS: Many skin conditions originate from the deeper skin layers and are difficult to diagnose with the human eye. The Observ Skin Analysis System exposes those conditions by using a patented skin fluorescence and polarised light technology. Using this technology, you can instantly reveal skin conditions, create awareness and propose treatments. observ.uk.com OPATRA brings together the latest technological leaps and scientific innovations to create potent skincare solutions and dynamic tools that are redefining the beauty industry. As a leading device manufacturer and wholesaler, Opatra recognises that our remarkable success is a reflection of your happiness with our easy-to-use instruments that help to produce healthy, youthful, and glowing skin. opatra.com PABAU is a complete practice management application used by hundreds of healthcare practitioners in the UK. Manage schedules, treatment notes, invoices, payments, marketing and lots more. It works great for all sizes, from large teams, solo practitioners and anything in between. pabau.com SINCLAIR PHARMA has a portfolio of differentiated, complementary aesthetics technologies with a focus on collagen stimulation. Our products are experiencing significant growth as we target clinical demand for effective, high quality, longer duration, natural looking and minimally invasive treatments. sinclairpharma.com SKINADE, BOTTLED SCIENCE is the team behind Skinade – better skin from within®, an innovative skincare drink that works from the inside out. Recommended by top skin professionals, its unique liquid formulation promotes smoother, younger and more hydrated skin by targeting the skin’s natural production of collagen, hyaluronic acid and elastin. Launched in March 2013, it now has more than 1100 stockists nationwide. skinade.com SKINCEUTICALS: Born from decades of research, SkinCeuticals’ high potency formulas are proven to be absorbed optimally into the skin. Our mission is to improve skin health. Dedicated to this purpose, we make one simple promise – to provide advanced skincare backed by science. Originating in the US, we provide skincare solutions recommended by dermatologists, plastic surgeons, medispas and other skincare professionals worldwide to both correct and prevent the signs of ageing. skinceuticals.co.uk SKINGLO: Nutrivitality lead the way in supplements with their invention of NutriProtect Technology, which uses liposomes to protect vitamins and nutrients on their way to your bloodstream. This allows for up to eight times more absorption than other supplements on the market. Products that use this technology include collagen drink ‘SkinGlo.’ skinglocollagen.com SPRINGPHARM is a dynamic pharmacy with an innovative approach to the aesthetics industry and a leading exponent of medicine management in the UK. Our emphasis is to bring a flexible and strategic approach to the industry that will benefit patients, prescribers and practitioners alike. Springpharm continues to challenge the industry as a strong advocate of regulation and evidence-based practice. springpharm.co.uk TEAL WASH, since 1959, product manufacturer Teal Patents Ltd have specialised in developing mobile and portable hot water sinks and basins for medical, salon, treatment and therapy businesses in the UK. The Teal range of mobile sinks includes the Stop n’Wash, Hygienius and Hygienius ProWash and the KiddiSynk. Currently Teal produces over 12,000 units per annum for every type of application. tealwash.com TELETA is an MHRA accredited pharmaceutical wholesaler, a GHPC registered pharmacy and official distributor for Love Cosmedical aesthetic products in the UK & Ireland. Our business is built on the foundations of integrity, equality, collaboration and respect, aiming to provide first class customer service. teleta.co.uk TEOXANE UK is a subsidiary of parent company Teoxane Laboratories. Teoxane Laboratories was established in Geneva in 2003 and is specialised in the design and manufacturing of hyaluronic acid-based dermal fillers. As a result of its uncompromising commitment to innovation, quality and patient satisfaction, Teoxane is now among the top three hyaluronic acid-based dermal filler manufacturers in the world, with products in more than 80 countries. teoxane.com

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Aesthetics

aestheticsjournal.com 3 1 J U LY & 1 A U G U S T 2 0 2 0 / L O N D O N

THE NATIONAL MEDICAL WEIGHT LOSS PROGRAMME the management of obesity is increasingly being added to the service menus of medically led aesthetic clinics. However, with the use of newer evidence-based prescription medicines alongside misunderstanding concerning regulations, there is a lack of training providers who can guide clinics through setting up a safe and compliant service. The National Medical Weight Loss Programme was founded in 2018 and provides training written and delivered by an expert adviser for NICE. elements.org.uk THERMAVEIN is the leader in red vein treatments and a global company based in the UK. ThermaVein’s thermocoagulation uses a safe effective micro-current to destroy vessel walls. Results are instant and permanent, offering a solution for red veins known as telangiectasia. It is used worldwide by healthcare professionals and is CE 93/42 compliant, FDA listed and ANVISA registered. thermavein.com TINKABLE AESTHETIC CLINIC operating for more than 14 years, the Tinkable license was formulated to provide a continuity of high quality, honest and medically professional aesthetic treatments throughout the UK. As a Tinkabe licensee, practitioners can have direct contact with clinical leads and the resource of a team of industry experts and medical product specialists. Tinkable want medical professionals to stand out from the competition, and represent quality throughout the industry. tinkablelicense.co.uk TOTALLY DERMA® is an advanced, scientifically researched, high potency formulated nutraceutical anti-ageing COLLAGEN DRINK supplement with proven 95% bioavailability. It works SYSTEMICALLY, from the inside, to stimulate the body’s optimum production of collagen, elastin and hyaluronic acid, addressing both the aesthetic signs of ageing and underlying physiological processes. It is formulated/manufactured for distribution to worldwide practitioner-led medical aesthetic clinics, dermatologists, plastic surgeons, dental surgeries, medispas, and professional salons. totallyderma.com TSK LABORATORY EUROPE B.V. manufactures premium quality needles and cannulas in Japan for the global aesthetic market. TSK is a market leader in a wide range of specialty needles for filler, mesotherapy and botulinum toxin injections. Popular TSK products are the STERiGLIDE™ cannula (50% better gliding), THE INViSIBLE NEEDLE™ (thinnest toxin needle available) and the LOW DEAD SPACE needles (saving up to 0,08ml of product per needle). tsklab.com VENUS CONCEPT is a company driven to create progressive technology and products. We create a partnership with our customers, based on innovative products supported by unparalleled marketing and customer service support, allowing business owners to confidently enhance their clinic’s offerings with a safe, painless and profitable treatment solutions. venusconcept.com/en-gl LABORATOIRES VIVACY is a French manufacturer specialising in the development, production and distribution of injectable hyaluronic acid-based medical devices for aesthetic and anti-ageing medicine. The company has also created new technologies for use in gynaecology, ophthalmology and rheumatology, and exports to more than 80 countries around the world. vivacylab.com/en WEB MARKETING CLINIC is a family-run digital agency, which specialises in medical and medical aesthetics marketing. The agency builds websites and delivers marketing campaigns for medical professionals, clinics, distributors and aesthetic brands. The team’s creatives, developers and strategists help generate leads and increase the profile of your business. webmarketingclinic.com

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Q-MEDICAL TECHNOLOGIES Founded in 2004, Q-Medical Technologies is an award-winning UK-based medical distributor for the aesthetics industry and the NHS. Its products are sourced globally, including; AccuVein Vein Finders, Ellman radiofrequency devices and the NovaClinical aesthetic treatment range. qmedical.co.uk WIGMORE MEDICAL is an established aesthetic distribution company in the UK, with more than 35 years of industry experience. Wigmore Medical provides for all your aesthetic needs, from filler to toxin, consumables to laser equipment, topical anaesthetics to advanced skin care. Wigmore Medical is the sole distributor for a large range of brands including the award-winning ZO Skin Health. Wigmore Medical hold bespoke training courses in every skill associated within aesthetics. wigmoremedical.com WISEPRESS, a specialist book retailer, has been supplying books and journals to medical professionals for over 32 years. It exists both as an online medical bookshop and a medical conference bookshop, exhibiting at over 200 exhibitions each year. Books can be purchased at the stand or posted to you, with the site delivering worldwide. wisepress.com

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TIME FOR YOUR PRACTICE TO FLEX ITS MUSCLES. Pump up your practice with truSculpt®flex, a muscle sculpting device that offers personalised treatments based on patient fitness level, shape and goals.

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Treat 8 areas simultaneously

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REDEFINING MUSCLE SCULPTING

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Designed and manufactured in the San Francisco Bay Area, USA, our world-leading portfolio of laser & energybased aesthetic devices provide professionals with the innovation, quality, and performance required to provide unrivalled clinical results for their patients.

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