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S : IC 19 ! ET 0 Y H 2 A T DS OD ES R T A A K W O A O B

VOLUME 6/ISSUE 9 - AUGUST 2019

YOUR BEAUTY HAS A FUTURE

Disinfection for the Skin CPD Dr Souphiyeh Samizadeh advises on disinfection prior to injectables

Special Feature: Filler Properties Practitioners discuss the impact of various filler properties in younger patients

Treating a Gummy Smile Dr Mark Hughes explores injectable approaches for gummy smiles

Introducing Treatment Pricing

Clinic owner Kerri Lewis advises on successful pricing strategies


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The ONLY event to unite the surgical and non-surgical communities to raise industry standards Learn the latest in facial rejuvenation, patient safety, injectables and more from world-class speakers. Earn up to 80 CPD points during 2 days of unmissable live demonstrations and brand takeovers, across 7 conference streams:

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· Getting started in Aesthetics · Clinic and Practice Management · Aesthetics Masterclasses

NEW for 2019!

· Non-Surgical Conference · Live Demonstrations

· SCULPT IT with Juvéderm Volux exclusive takeover

· What’s New and True in Cosmetic Dermatology by the British Cosmetic Dermatology Group

· Vivacy Symposium hosted by Dr Nimrod Friedman · Live Laser Hack with tattoo removal, veins and acne treatments · Surgical and non-surgical Aesthetic Gynaecology · CCR Press Ambassador Francesca White

Co-located with

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Contents • August 2019 06 News The latest product and industry news 14 On the Scene Out and about in aesthetics 15 Teoxane Academy Visit, Geneva Aesthetics tours the new Teoxane Academy and the laboratory behind the

Teosyal dermal fillers in Switzerland

18 News Special: Protecting Clinical Titles A report on the recent regulation developments in the Netherlands

Special Feature: Filler Properties Page 21

CLINICAL PRACTICE 21 Special Feature: Choosing Filler for Younger Patients Practitioners discuss how different filler properties impact facial

rejuvenation results in younger patients

26 CPD: Skin Disinfection for Injectables Dr Souphiyeh Samizadeh advises on disinfection of the skin before

injectable treatment

31 Nasal Assessment Technique Mr Ayad Harb shares his approach to assessing the nose prior to non-

surgical rhinoplasty procedures

35 Treating a Gummy Smile Dr Mark Hughes details toxin and dermal filler procedures for gummy smiles 38 An Introduction to Mesotherapy Dr Lorendana Nigro presents mesotherapy formulations to improve the

quality of the skin

43 Offering Microcurrent Therapy Aesthetic nurse Laura Rosser highlights the benefits of a microcurrent facial

In Practice: Getting Started with PR Page 59

for skin rejuvenation

47 Using BDD Assessment Tools Dr Raj Arora outlines body dysmorphic disorder screening approaches 53 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 55 Enhancing the Patient Journey Mr Alex Karidis and chief operations officer Deborah Vine share their

Clinical Contributors Dr Souphiyeh Samizadeh is a dental surgeon and clinical director of Revivify London clinic. She is the founder of the Great British Academy of Aesthetic Medicine, and an honorary clinical teacher at King’s College London. Mr Ayad Harb is a consultant plastic and aesthetic surgeon, operating in private clinics in London and Bicester, Oxfordshire. His practice is focused on cosmetic surgery, facial aesthetics and body contouring. Dr Mark Hughes is an accredited member of the British Academy of Cosmetic Dentistry, a 15 year full member of the American Academy of Cosmetic Dentistry and co-founder and Dental Director of Define Clinic in Beaconsfield – Whole Face Aesthetics. Dr Loredana Nigro graduated from WITS Medical School in Johannesburg in 2003. She is a senior aesthetic clinician at Riverbanks Clinic in Harpenden and a KOL and clinical consultant for mesoestetic UK.

59 Getting Started with PR Communications consultant Julia Kendrick explores considerations for

Laura Rosser is an aesthetic nurse and founder of Belle Derma Aesthetics in South Wales. Rosser has nine years’ experience as a registered nurse, four years in aesthetics and five years in the permanent makeup industry.

63 Introducing Treatment Pricing Clinic owner Kerri Lewis discusses strategies for treatment pricing

Dr Raj Arora is an aesthetic practitioner and an NHS GP based in Surrey. She is the founder of The Facebible Clinic and is opening her second clinic in 2020. Dr Arora has a BSC in Medical Education.

experience of using a clinic mobile app

investing in public relation services

67 In Profile: Professor Syed Haq Professor Syed Haq shares his career highlights while exploring the link

between disease and ageing

68 The Last Word

Dr Dev Patel explores whether its more appropriate to use the term ‘patient’ rather than ‘client’ in a clinical setting

NEXT MONTH

• IN FOCUS: Team • Retaining Millennials in your Reception Team • Asking for a Pay Rise • Employee Lifecycle

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Editor’s letter Injectable procedures using botulinum toxin and dermal fillers are at the core of most aesthetic clinics. With many new products and techniques being introduced each year, deciding which to adopt can be challenging. At Aesthetics our aim is to make the process Chloé Gronow a little easier, so we hope you find this reading Editor & Content Manager material useful, particularly for this issue that’s all about injectables! So to begin, do you understand which filler properties work best for each area of the face? Four respected practitioners share their insight and product recommendations for contouring purposes in younger patients on p.21. If you’re looking to introduce a new injectable treatment to patients, then Mr Ayad Harb’s article on p.31 could be a good starting point. He shares how he assesses the nose prior to a non-surgical rhinoplasty. While it is imperative that practitioners have the appropriate training from a reputable provider prior to administering this procedure, according to Mr Harb it is one that is hugely valued by aesthetic patients.

To gain a CPD point this month, have a read of Dr Souphiyeh Samizadeh’s article on skin disinfection prior to injectable procedures on p.26. As with all our CPD articles, you can also read this on our website and receive a certificate of confirmation for your CPD submission. Don’t miss Dr Mark Hughes’ fascinating piece on treating a gummy smile with toxin and fillers on p.35, which has some great before and after photographs, as well as Dr Loredana Nigro’s useful introduction to mesotherapy formulations for skin rejuvenation on p.38. But, what if a patient doesn’t feel that they are ready for injectable procedures? Aesthetic nurse Laura Rosser highlights how microcurrent therapy can be a beneficial introduction in her useful overview on p.43. Finally, many thanks to everyone who donated to the Aesthetics team’s 10K run on July 21. We had extremely generous donations from readers, contributors and advertisers and are delighted to say, at the time of writing, we have raised £1,264 for our chosen charity for 2019, the British Red Cross. Although we are all shattered this week (deadline week fell just after the run!), we are really proud of what we’ve achieved and can’t thank everyone enough for their support!

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. Mr Dalvi Humzah, Clinical Lead

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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EDITORIAL Chloé Gronow • Editor & Content Manager T: 0203 196 4350 | M: 07788 712 615 chloe@aestheticsjournal.com Shannon Kilgariff • Deputy Editor T: 0203 196 4351 M: 07557 359 257 shannon@aestheticsjournal.com Megan Close • Journalist T: 0203 196 4363 M: 07557 359 257 megan@aestheticsjournal.com MARKETING Aleiya Lonsdale • Head of Marketing T: 0203 196 4375 | aleiya.lonsdale@easyfairs.com Annabelle Arch • Marketing Manager T: 020 3196 4427 | annabelle.arch@easyfairs.com DESIGN Peter Johnson • Senior Designer T: 0203 196 4359 | peter@aestheticsjournal.com

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Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Chloe Carville, contact@aestheticsjournal.com

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© Copyright 2019 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184 ABC accredited publication DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


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Conference

Talk #Aesthetics Follow us on Twitter @aestheticsgroup and Instagram @aestheticsjournaluk

#Award Miss Sherina Balaratnam @MissBalaratnam So proud to receive this World Stars #Award. Thank you @ISCLINICAL for a very special time here in #BeverlyHills and a huge thank you from team S-Thetics for this recognition #USA #ScalpMicropigmentation Dr Greg Williams @Drgregwilliams Ready, steady, go!! Starting hand on #ScalpMicropigmentation training for doctors on prosthetic skin @FarjoHair with #FinishingTouchesGroup

CCR appoints press ambassador Medical aesthetic conference CCR has appointed Tatler’s health and beauty editor, Francesca White as its official press ambassador. Easyfairs, the owner of CCR and Aesthetics Media, has explained that this partnership aims to add a new dimension to the show and to open up the world of aesthetics to the consumer market. White will be interviewing exhibitors and key opinion leaders during the event, which is taking place on October 10 and 11 at Olympia London, as well as reporting on the latest news within the specialty. White commented, “I am delighted to be this year’s CCR press ambassador and be part of such an important event in the aesthetics industry. I am always on the lookout for the latest news in aesthetic medicine, the new techniques being introduced by the top practitioners, and the upcoming trends and regulations to be aware of.” To register for CCR, visit www.ccr-expo.com. Audit

Aesthetics journal renews ABC accreditation ! CS TI EN HE DS OP ST AR W AE AW NO Y TR EN

VOLUME 6/ISSUE 6 - MAY 2019

H

VOLUME 6/ISSUE 8 - JULY 2019

! CS Y TI TR TH HE EN ON ST DS M AE AR XT NE AW S EN OP

VOLUME 6/ISSUE 5 - APRIL 2019

ST AR AE AWO K BO

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IC ET D S W ! O N

#10K Aesthetics Media @aestheticsjournaluk We did it! Team Aesthetics smashed the @virginsport Asics 10K today and raised more than £1,000 for the amazing @britishredcross. Thank you so much to everyone who donated and cheered us on!

BUILD MUSCLE & BURN FAT NO SURGERY – NO DOWNTIME

#WEM2019 Blair Stevens @blairsinclairpharma I had a great time in Seoul for the Sinclair 2019 World Expert Meeting – thanks to all the speakers for making it a great conference @sinclair_college #Dermatology Dr Vishal Madan @Manchesterderm @BritDermEvents British Association of Dermatologists Annual meeting this morning, delighted to share my experience on setting up a #dermatology clinic. @everything_skin

EMSCULPT is the only procedure to help both women and men burn fat, while toning the underlying muscle.

18183 UK VOLUX Aesthetics Journal Cover Advert JUN 2019.indd 1

Complications of Toxin CPD

Mr Stagnell and Ms Berridge outline botulinum toxin concerns

Special Feature: Chemical Peel Complications

Practitioners advise on adverse events following chemical peels

Re-treating Dissolved Filler

Dr Saleena Zimri discusses HA treatment considerations after previous dissolution

18/06/2019 17:18

Using the Yellow Card Scheme Feza Haque and Mitul Jadeja explore the importance of Yellow Card reporting

Anatomy of the Nose CPD

Mr Deniz Kanliada presents an anatomical overview of the nose for injectable treatment

Special Feature: Treating Midfacial Fat Loss

Practitioners explore injection techniques for fat loss in the mid-face

Botulinum Toxin Update

Mr Dalvi Humzah outlines developments in toxin products across the globe

Utilising Email Marketing Lists

PIH in Darker Skin CPD

Marketer Sam Hunt details using targeted Dr Abirami Pararajasingam and email lists to boost Dr Sandeep Cliff explore treatment for PIH your business

Special Feature: Post-Procedure Makeup

Practitioners discuss using makeup following aesthetic treatment

Male Toxin Treatments

Mrs Aggie Zatonska details techniques for toxin injections in male patients

Successful Media Interviews

Julia Kendrick shares her top 10 media training tips

The Aesthetics journal has received approval from the leading industry-owned auditor for media products and services, ABC, for the fourth year. Each year, the Aesthetics journal is audited by ABC to ensure that it adheres to its strict standards and requirements in record keeping, data reporting, circulation, membership, and distribution, among other considerations. The ABC Stamp of Trust logo stands for quality and trust in media so that both readers and advertisers can be confident to be associated with the brand. According to Aesthetics journal editor, Chloé Gronow, the ABC audit is an important kite mark to obtain to reiterate the high-quality standard and transparency that the journal strives for. She said, “We are delighted to receive ABC accreditation for the fourth year, demonstrating that the journal is a trusted resource that thousands of medical aesthetic professionals choose to read each month. This accreditation also emphasises that we are transparent with our circulation figures, which we hope will continue to instil trust in us amongst both our loyal and future advertisers.”

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Acquisition

AbbVie to buy Allergan for $63 billion American biopharmaceutical company AbbVie will buy global pharmaceutical company Allergan in a $63 billion cash and stock deal. It is reported that Allergan shareholders will receive 0.8660% of AbbVie shares and $120.30 in cash for each share that they hold. A statement released by AbbVie said the new acquisition will provide scale and profitability to the company’s growth platform and will create substantial value for shareholders of both companies. It is reported that although the two companies’ portfolios do not overlap, the synergies will come from the distribution leverage, research and development departments, and portfolio diversification. Brent Saunders, chairman and CEO at Allergan commented, “Our combined company will have the opportunity to make even bigger contributions to global health than either can alone and will create substantial value for shareholders of both companies.” Richard Gonzalez, chairman and chief executive officer at AbbVie, added, “This is a transformational transaction for both companies and achieves unique and complementary strategic objectives. The combination of AbbVie and Allergan increases our ability to continue to deliver on our mission to patients and shareholders. With our enhanced growth platform to fuel industry-leading growth, this strategy allows us to diversify AbbVie’s business while sustaining our focus on innovative science and the advancement of our industry-leading pipeline well into the future.” The deal is expected to close in early 2020 and is subject to regulatory and Allergan’s shareholder approvals. Skincare

Skinbetter Science releases new peel pads Skincare brand Skinbetter Science has introduced the AlphaRet Exfoliating Peel Pads to its portfolio. The at-home peel pads are designed to improve skin smoothness and clarity, while also reducing lines and wrinkles. The formula contains glycolic, lactic and salicylic acid, as well as Skinbetter Science’s AlphaRet technology, which is a patented ingredient that combines a retinoid and lactic acid. According to a small study of five participants who underwent treatment three times a week, 100% experienced noticeable results after three weeks. They reported healthier, brighter, smoother and more radiant looking skin. Skinbetter Science is distributed in the UK exclusively by AestheticSource. Lorna McDonnell-Bowes, director of AestheticSource said, “The new AlphaRet Exfoliating Peel Pads work in synergy with the innovative AlphaRet Cream for addressing multiple skin concerns such as tone, texture and fine lines. The proprietary combination of AlphaRet and a triple-acid complex provides a customised at-home skincare exfoliation regimen and the single-use pads are ideal for travelling, and are now a permanent addition to my own suitcase.”

Vital Statistics 34% of eczema smartphone apps contain information which is inconsistent with international guidelines (British Association of Dermatologists, 2019)

A UK survey indicated that 81% of internet users in the UK bought a product or service online, with 45% now feeling comfortable purchasing via mobile devices (We are Social, 2019)

96% of small businesses in the UK employ fewer than 10 people (Merchant Savvy, 2018)

More than a third of UK adults have felt anxious because of concerns about their body image (Mental Health Foundation, 2019)

In the US, there were 7,437,378 botulinum toxin treatments performed last year, a 3% rise from 2017 (ASAPS, 2019)

A survey conducted in the UK demonstrated that 84% of patients didn’t know what products were used during their treatment or how they were sourced (SaveFace, 2019)

Luxury skincare accounted for 71% of new products entering the beauty industry in the UK last year, compared to 54% 10 years ago (Mintel, 2019)

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Events Diary 20th September International Association for Prevention of Complications in Aesthetic Medicine Symposium www.iapcam.co.uk 21st September British College of Aesthetic Medicine Conference www.bcam.ac.uk 10th-11th October CCR & BAAPS Annual International Conference www.easyfairs.com/ccr-expo-2019 www.baaps.org.uk 7 -8 November th

th

British Association of Cosmetic Nurses Conference www.bacn.org.uk

7th December The Aesthetics Awards 2019 www.aestheticsawards.com

Dermal filler

VIVACY updates distribution partners

French manufacturer VIVACY, which launched a UK subsidiary last year and opened offices in London this March, has announced that the company has updated its distribution partners. VIVACY products will now be available through Wigmore Medical, Church Pharmacy and the company directly. Camille Nadal, country director of VIVACY said, “Wigmore Medical and Church Pharmacy have been displaying a set of core values that we believe are key to obtaining the best results and service for our clients. We are delighted to be working with them.”

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Awards

Finalists for the Aesthetics Awards announced next month The most prestigious event of the year is taking place on December 7 at the Park Plaza Westminster Bridge Hotel; the Aesthetics Awards. Finalists will be announced in the September issue of the Aesthetics journal and published online on September 2. There are still tickets available for this unmissable event, which can be bought individually or as tables of 10. New sponsors have also been announced; HA-Derma is supporting The Profhilo Award for Best Clinic South England and Church Pharmacy is the sponsor for the The DigitRx Award for Product Innovation of the Year. To find out more and to book your tickets visit aestheticsawards.com or email contact@aestheticsjournal.com. Presentation

DHAT to deliver presentation skills course Dalvi Humzah Aesthetic Training (DHAT) is launching a course specifically focused on presentation skills with the first taking place on December 6. The one-day course will aim to ensure that all delegates are able to control nerves, structure an effective presentation, formulate memorable slides for presenting, deal with difficult questions, stimulate and manage interaction, plus so much more. The course is designed for eight to 12 delegates working within all areas of aesthetics, including clinic or team managers, trainers, sales representatives and medical professionals. It will be led by DHAT lead tutor and director Mr Dalvi Humzah, dermatology and cosmetic nurse prescriber Anna Baker and clinical educators Lisa HadfieldLaw and Hayley Allan. Those who secure a place on the course will be expected to prepare beforehand and present short presentations to the group. Delegates will also be required to give and receive feedback during the day. Voluntary register

JCCP receives annual renewal from PSA The Joint Council for Cosmetic Practitioners (JCCP) has received accreditation from the Professional Standards Authority (PSA) for a second year. The PSA annual review reported on JCCP activity, including the work of the stakeholder council, raising public awareness of the risks involved in non-surgical treatments, the introduction of the new Fast Track Assessment process and the continuing development and implementation of standards in the sector. As well as this, the JCCP has also announced that it has signed a memorandum of understanding (MOU) with the British Beauty Council (BBC). The BBC is a not-for-profit, inclusive organisation that works to engage politicians and business leaders in the value of British beauty to the national economy. The JCCP has explained that the organisations will be working together to promote public protection and consumer safety in the aesthetics specialty to encourage positive engagement. Professor David Sines, executive chair of the JCCP, commented, “The beauty sector in the UK plays a huge part in the non-surgical aesthetic sector. The JCCP recognises this role, which is underpinned by approved standards and qualifications. The JCCP has clearly defined within its standards framework those areas where it believes the beauty sector can legitimately practice and those areas where it considers the risks are too high and procedures should only be undertaken by medically qualified professionals. By working together with the best interest of patients as the number one priority this partnership will be to the benefit of all.”

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Acquisition

Skin Group International acquires Sally Durant Training Aesthetic training consultancy, Sally Durant Training, has been acquired by Skin Group Training, under the brand of Skin Group International. The acquisition is designed to ensure that all current students who were enrolled onto the existing Sally Durant courses are able to complete them, following the recent news that the training provider had gone into administration. It has been confirmed by Skin Group Training that founder Sally Durant will continue to work with the business as a consultant. Durant commented, “The acquisition by Skin Group will allow Sally Durant Training to trade forward under new ownership and enable all students to complete their courses. Skin Group International is passionately committed to delivering training at the highest standards, which is a perfect match for my own ethos.”

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

BACN AUTUMN EVENTS The next round of BACN regional meetings are now available to book on our website, which has newly launched. The events booking system is now smoother and quicker, and you will find all our upcoming regional meetings and agendas in a clear and simple format. The website also has a new feature whereby members can book Basic Life Support (BLS) training onto the end of their event – keeping all bookings in one easyto-access place. BLS does have limited spaces some so book early to avoid disappointment.

2020 EVENTS

Skincare

Medik8 releases eight new Skin Kits Global skincare company Medik8 has launched new skincare kits under the CSA and Discovery ranges. The four new entrylevel Discovery Kits are designed for all skin types and are called; SKIN AGEING, BLEMISH, PORE REFINING and REDNESS. They target each of these skin concerns and contain a selection of some of the company’s bestselling products. Medik8 has also curated four CSA Philosophy Kits which combine products from its vitamin C, sunscreen and vitamin A lines, hence the name CSA, in a variety of strengths. The CSA Philosophy Kit is designed for those embarking on their skincare journey, the Advanced Edition is the step-up for those already familiar with medium strength serum and the Elite Edition features the highest strength serums, the company explains. As well as this, the company has also introduced the CSA Philosophy Kit Eye Edition. Industry

Galderma confirms Med-fx as sole-preferred distributor Pharmaceutical company Galderma (UK) Limited and aesthetic and skincare product supplier Med-fx Ltd will launch new, enhanced packages of customercentric support services for healthcare professionals who purchase products marketed under the Azzalure and Restylane brands in the UK and Ireland from September 8. The deal to make Med-fx Galderma’s sole-preferred distributor for its aesthetic portfolio was confirmed on June 20 when the companies signed the contract. Galderma has also confirmed that distribution agreements with Church Pharmacy and Wigmore Medical have ended, but both businesses can continue to sell through stock purchased from Galderma prior to September 8 and they both can order further products under Galderma’s standard terms and conditions of sale in the future. Toby Cooper, medical solutions business unit head, Galderma UK and Ireland said, “We want to reassure customers that current and future supply of our brands is still available. Product is readily available from usual stockists, but Med-fx is on standby to assist any customers seeking an alternative supplier.”

The BACN has revised the event strategy for 2020. There will be two trial pilot events in Leeds and Manchester with a slightly different format than usual. If successful, this format will then be rolled out across the country. The purpose of this change is to help new practitioners feel more comfortable in attending and to ensure advanced practitioners who are taking precious time out of clinic can attend sessions relevant to them. The events will be segmented into two parts, as follows: 1. AM: Newer practitioners to aesthetic nursing (0-2 years’ experience) are invited to join for the morning sessions from 9.30 to 12pm, which will focus on introducing new members to the group and the BACN as a whole. This session will also include sponsored talks and presentations from industry professionals. Lunch: From 12pm both new practitioners from the morning session and advanced practitioners arriving for the afternoon session will come together for a networking lunch, which will be followed by a peer-to-peer review and roundtable discussion to promote sharing of knowledge between diversely experienced members. 2. PM: The afternoon session will be aimed at more advanced practitioners (2+ years’ experience) with a focus on an injectableled demonstration from industry leaders and peer-to-peer learning – members are invited to present case studies of their work for group discussion. This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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BCAM announces conference speakers

The British College of Aesthetic Medicine (BCAM) has confirmed the speakers for its 2019 annual conference on Saturday September 21 in London. The conference will have two agendas, a business and clinical, and is open to both BCAM members and non-members who are aesthetic doctors or dentists. Confirmed speakers at the event include aesthetic practitioners Dr Kate Goldie, Dr Raj Acquilla, Dr Tapan Patel, Dr Beatriz Molina, Dr Lucy Glancey, Dr Simon Zokaie, and Dr Rupert Critchley, as well as consultant dermatologist Dr Sandeep Cliff, reconstructive oculoplastic surgeon Mrs Sabrina Shah-Desai, ophthalmologist Dr Tahera BhojaniLynch, TV presenter Dr Hilary Jones, laser and light adviser Dr Elizabeth Raymond-Brown and journalist Alice Hart-Davis. Following the educational sessions delegates can enjoy drinks and canapés to network and discuss the day’s learnings. The event will take place at the Church House Conference Centre in Westminster.

Tinkable Aesthetic Clinic launches business opportunity Clinic group Tinkable Aesthetic Clinic has introduced a new business opportunity that is similar to a franchise scheme for aesthetic medical professionals called the Tinkable License. The opportunity is formulated to allow practitioners to gain what they call a ‘Tinkable Aesthetic Clinic License’, which allows practitioners to practice under the brand’s name. According to the clinic, the license provides a structure for independent medical practitioners to operate their business as part of a qualityassured network. The practitioner is given clinical, marketing and business resources, which allows them to focus on the patient whilst their business develops and grows, according to Tinkable Aesthetic Clinic. To be eligible, practitioners must be a medical prescriber, or there must be a medical prescriber in the structure of the business to carry out a face-to-face consultation for all prescription medicines. They must also go through a five-step application and approval process. It is a requirement for practitioners to become Save Face accredited within six months of approval. Training

Harley Academy appointed as an Allergan-approved trainer Aesthetic training provider Harley Academy has been recognised as an approved training provider by global pharmaceutical company Allergan. The announcement comes as a result of the newly-launched support website, Allergan Spark. Dr Tristan Mehta, founder and CEO of Harley Academy, said, “At Harley Academy we want to offer the best education to the next generation of aesthetics professionals, so I am delighted that we have partnered with Allergan to develop innovative training programmes using the market’s leading products.” Dan Conacher, director of the Allergan Medical Institute and Digital, added, “We are very proud to work closely with Harley Academy who we believe are real innovators in this area and will allow us to support more practitioners as they look to work in this exciting industry.” Harley Academy has also launched its latest course, the 1:1 Juvéderm Volux training, which encompasses the recently-launched dermal filler specifically for the chin and jawline.

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Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Training

Digital

BACN updates website The British Association of Cosmetic Nurses (BACN) has launched a new website that is designed to offer a smoother user experience along with added benefits and more resources for its members to access via the portal. For example, the association has developed resources with insurance provider Hamilton Fraser such as fact sheets, information videos and news updates, as well as a jobs board and branded marketing content. There is also a new e-portfolio section for members where they can upload any documents relevant to them to use for revalidation purposes. As well as this there is also a practitioner finder that has been updated for the public to use to source reputable nurses within their area. “Our new website really showcases our professional position in the specialty, and ensures we stay up-to-date with the ever-changing environment our members find themselves in,” said Gareth Lewis, BACN membership and marketing manager. “We have worked with partners to offer more services than ever before, along with upgrading and tailoring our existing benefits,” he added. To coincide with the new launch, the BACN has also opened booking for the Autumn Aesthetic Conference 2019 taking place once more at Edgbaston Stadium in Birmingham on November 7-8.

AestheticSource Symposium agenda released Aesthetic distributor AestheticSource has announced the agenda and speakers for its Symposium taking place on September 6. The full-day event will focus specifically on the diagnosis, treatment and maintenance of pigmentation and skin health. It will educate delegates by sharing supporting data and case studies, as well as showcasing the AestheticSource portfolio. Speakers confirmed include consultant dermatologist Dr Jinah Yoo, dermatologist Dr Mukta Sachdev, aesthetic nurse prescriber Anna Baker, aesthetic practitioners Dr Mayoni Gooneratne, Dr Xavier Goodarzian and Dr Aimee Vyas, aesthetician Dija Ayodele and ophthalmologist Dr Daksha Patel. Topics that will be covered include treating skin of colour, combination therapies, chemical peels and ongoing treatment and home care, amongst others. The day will conclude with a drinks reception, a barbeque and summer games. Collagen

Proto-col portfolio expands British skincare company Proto-col has announced a new sub-brand designed specifically for salons, spas and skincare clinics called Proto-col Clinical. The brand will see the launch of higher strength collagen drinks and vegan superfood supplements, which, according to the company, aim to enable practitioners to deliver new treatments, as well as support business growth through extended sales opportunities. As well as this, Proto-col will be launching the Collagen and Hyaluronic Acid Capsules in September. The capsules use 2,500mg of Verisol bioactive collagen peptide and 50mg of hyaluronic acid. Proto-col explains that the product is designed to reduce the appearance of lines and wrinkles, improve skin’s elasticity and promote cell proliferation in fibroblasts.

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Patrick Johnson, CEO of Celluma What should practitioners consider when selecting a LED device? First and foremost, ISO certification does not denote approved indications for use. Many LED devices have no medical credentials or clinical studies demonstrating their efficacy. As a medical professional, we believe that you should be using devices that have been certified for medical use, so this should be at the forefront of your mind when choosing a LED device. Tell us about Celluma’s credentials? The Celluma is FDA-cleared for nine separate indications, six in the area of musculoskeletal pain management and three in skin. Over five years, we collected clinical data on Celluma’s performance and submitted it to the FDA in support of our cleared indications. BioPhotas then obtained its ISO 13485-2016 certification as a medical device manufacturer and the Celluma was CE marked as a Class 11a medical device for all FDA-cleared indications, with the exception of wrinkle treatment, which is not a medical condition according to the EU medical device authorities. Celluma is the only LED device medically CE marked for dermal wound healing. How are FDA clearances relevant in the UK? Historically, the review process of the US FDA and the EU medical device authorities have differed around the element of clinical data. In the US, the FDA typically requires that a device manufacturer provide clinical data on the efficacious performance of their devices – we certainly did. We also used this clinical data and our FDA clearances to support our medical CE mark applications. Whereas in the EU, devices can be approved with the support of general clinical literature. The reason FDA clearance is relevant to the UK is that with the new Medical Devices Regulation coming into force in May 2020, review standards are taking a similar approach advocated by the FDA, and EU device manufacturers will have to provide devicespecific clinical data to support their marketing claims. Celluma has already done this. This column is written and supported by

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Feminine health

Marion Gluck Training Academy launches new course Aesthetic training provider Marion Gluck Training Academy has launched an online course titled Foundation in Women’s Health. The course aims to educate practitioners looking for essential knowledge in the basics of current hormone management for women. It covers basic female anatomy and physiology of key female reproductive organs, hormones, key physiological events, main female steroid hormones, current treatment guidelines and recommendations for menopause and how menopause may be diagnosed and managed, as well as hormonal treatment options. According to Marion Gluck Training Academy, the course is CPD accredited and serves as both a standalone course for all practitioners, or as a as preliminary course for prescribing practitioners who wish to continue training onto course Level 1 (Introduction to BHRT) and 2 (Developing your BHRT Knowledge) to develop competence and confidence in diagnosing and treating patients. Training

Cosmetic Courses launches Volux training Aesthetic training provider Cosmetic Courses is now offering medical professionals training in the safe and effective use of Juvéderm Volux. The one-day course covers techniques to reshape, contour and rejuvenate the lower facial third using needle and cannula, as well as anatomy of the area. According to Cosmetic Courses, the training has been designed in-line with Allergan’s approach to the chin and jawline for Volux use and will also introduce the MD Codes for the chin and jawline. The course will be run by Cosmetic Courses’ Midlands clinical lead, dentist and aesthetic practitioner Dr Olha Vorodyukhina and clinical lead and aesthetic nurse prescriber, Mel Recchia. Mr Adrian Richards, clinical director of Cosmetic Courses and consultant plastic and reconstructive surgeon said, “We are excited to be training in Juvéderm’s latest product, Volux, and more so to have created a course focusing solely on the lower third of the face, which is becoming increasingly popular within the industry.” Delegates must be confident, advanced injectors who are using both needle and cannula to administer dermal fillers, according to Cosmetic Courses. Laser

Novus Medical releases Cool Laser Medical aesthetic company Novus Medical has launched a new device, the Cool Laser. It is a fractional erbium laser designed for skin resurfacing, removing or minimising scars, treating pigmentation spots such as birthmarks and melasma, as well as addressing stretch marks and wrinkles, the company explains. The Cool Laser also features cryogenic technology to deliver air of up to -35°C to the skin, which allows for a quicker healing time, reduces inflammation, downtime and increases the activation of collagen production, Novus Medical claims.

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Body contouring

CoolSculpting’s CoolTone device receives FDA clearance The latest addition to the Allergan body contouring portfolio of products, the CoolSculpting CoolTone, has received FDA clearance for improvement of abdominal tone, strengthening of the abdominal muscles, and development for a firmer abdomen. The CoolTone device uses magnetic muscle stimulation (MMS) technology to penetrate into the muscle layers and induce involuntary muscle contractions, which the body responds to by strengthening its muscle fibres, resulting in improved muscle conditioning, according to Allergan. CoolTone is also indicated for strengthening, toning and firming of buttocks and thighs. Allergan is now taking orders for the CoolTone device and the first units will ship early in the fourth quarter of this year. The UK release date is yet to be confirmed. LED

Celluma introduces training in the UK Light emitting diode (LED) device manufacturer Celluma is now offering a one-day Level 4 accredited LED training certification at the Wynyard Aesthetics Academy. The course is open to both Celluma and non-Celluma owners and has been written in accordance with the UK National Qualification Credit Framework, carrying 60 learning points. Denise Ryan, vice president of brand management at Celluma said, “As an evidence-based company, science and research has always been very important to us. Being able to now provide high-quality education on the science and clinical applications of Celluma light therapy is the natural evolution of the support we provide to our new and potential Celluma practitioners.” Energy

Cambridge Stratum upgrades Stratum 8 device The Stratum 8 device by medical equipment supplier Cambridge Stratum now includes a pico-second laser for tattoo and pigmented lesion removal. The Stratum 8 is a multifunction platform machine that includes a 980ps pulse duration 1064/532 nm laser, capable of delivering 400mJ (single pulse) and 800mJ (dual pulse) at up to 10HZ, for tattoo and pigmented lesion removal, according to Cambridge Stratum. This upgraded Stratum 8 also features other treatment heads, which include Er:Yag, Er:Glass, long pulse Nd:Yag, intense pulse light/enhanced pulse light, bipolar radiofrequency and mono-polar radiofrequency. John Culbert, CEO of Cambridge Stratum, said, “Our aim is to provide customers with the best aesthetic equipment at affordable prices. The inclusion of a picosecond laser for tattoo removal in this platform machine means that for many clinics it will cover all their needs for some considerable time. Adding further heads really is ‘plug and play’ and the space/cost savings are considerable.”

News in Brief BAS confirms 2020 conference dates The annual Sclerotherapy Conference hosted by the British Association of Sclerotherapists (BAS) will take place on Tuesday May 19 next year at the Dorney Lake Conference Centre near Windsor. Phlebologists, vascular surgeons and nurses, aesthetics practitioners and dermatologists who are interested in treating veins will meet to learn, share best practice and advance their knowledge and skills. The conference is CPD certified and certificates are recognised by the GMC and NMC for appraisal and revalidation, according to the BAS. Image Skincare UK launches online Clinical skincare company Image Skincare will now be selling its products directly to customers on its UK website after previously only being available through purchase in clinics. The decision to sell the brand online comes as a result of customer demand for more accessibility and convenience, but also to combat the issue of third-party unauthorised sites selling the products, the company explains. Graham Clarke, UK sales director said, “We remain committed to our professional partners and stand firm on the value that true skin health encompasses not only products but services and treatments from our professional partners. You cannot buy service or treatment on any website, there is no website that can do what our professional partners do.” IAPCAM becomes CPD accredited The International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) conference will feature CPDaccredited content this year for the first time. The conference will take place on Friday September 20 at the Church House Conference Centre in London. Nimue Skin Technology releases Summer Travel Kit Skincare company Nimue Skin Technology has launched a retail kit containing the Sun-C Environmental Shield SPF50 in both a 50ml and a 20ml size. The product protects the skin from free radicals and offers protection against key causes of premature ageing including UVA, UVB, infrared and high energy visible light smart phones and computer screens, Nimue Skin Technology claims. According to the company, the Sun-C Environmental Shield SPF50 is also the first professional skincare product to feature the molecule cyanoacrylate. This molecule prevents the accumulation of pollution particles in the epidermis and replenishes skin with antioxidants, the company explains.

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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On the Scene

Out and about in the specialty

Academic Aesthetics Mastermind Group, London

Skinbetter Science press launch, London

On July 1, the third Academic Aesthetics Mastermind Group (AAMG) meeting was hosted by co-owners of Trikwan Aesthetics clinic Dr Zoya Diwan and Dr Sanjay Trikha in London. The first lecture, presented by Dr Diwan, was focused on anatomy and more specifically the jawline. She then presented a case study for discussion before moving onto a jawline filler paper review presented by one of the AAMG members, aesthetic practitioner Dr Chris Rennie. Following two successful events, Dr Diwan was also able to share data gathered from the two previous proposed studies (on chin augmentation and tear trough fillers), with the aim to publish this in a peer-reviewed journal later this year. Dentist and aesthetic practitioner Dr Sepideh Etemad-Shahidi commented, “I have attended all three events so far and they have been excellent! It’s amazing having doctors, dentists, GPs, plastic surgeons and other disciplines all coming together to discuss particular cases. I have personally presented the critical appraisal on tear troughs and chin filler articles and found it a great experience.”

HA-Derma Event, Italy

Aesthetic distributor AestheticSource held an exclusive event at the Brasserie of Light in Selfridges, to launch the Skinbetter Science range to the UK consumer press on July 4. Vikki Baker, marketing manager at AestheticSource, and Nikki Jones, training and key account manager, welcomed guests to the event, who enjoyed cocktail refreshments and canapés. Aesthetic practitioner Dr Sophie Shotter, aesthetic practitioner and surgeon Mr Benji Dhillon and reconstructive oculoplastic surgeon Mrs Sabrina Shah-Desai then each presented their experiences using the products, highlighting the importance of skin health and choosing skincare which is backed up with science. Mr Dhillon said, “Tonight was really fun night talking about something different in the skincare world and it was great to speak to the consumer press who have a very unique perspective on skincare. I believe Skinbetter Science is something different that has come into the UK market as it helps deliver really simple skincare solutions with results.”

Achieving Aesthetic Excellence, London

On July 4 and 5, UK and Ireland distributor of IBSA Italia, HA-Derma invited a group of UK and Ireland based practitioners to visit pharmaceutical company Altergon’s factory, where the company’s products are developed. The two-day agenda enabled guests to meet the scientist behind IBSA’s HA technology, Professor Chiara Schiraldi, and attend her presentation, on the formulation and discovery of the company’s NAHYCO technology and its implementation in hyaluronic acid injectable Profhilo. They were also able to gain insight on the methods behind the Viscoderm Hydrobooster and Aliaxin dermal filler range, with a preview of a new product set to launch later this year. Delegates also had a tour of the factory, where they could see first-hand how the raw hyaluronic acid material is manufactured. Sales and marketing manager for HA-Derma, Iveta Vinklerova, said, “We were delighted to have the opportunity to invite a dedicated group of practitioners from the UK and Ireland who are large users of Profhilo and the IBSA portfolio. This event has been a huge success.”

On June 22, 150 aesthetic practitioners were invited to join key opinion leaders and the Healthxchange team at the Royal College of Physicians for the company’s third Achieving Aesthetic Excellence event. Dermatologist Dr Serena Mraz, who kicked off the agenda, expressed the importance of general health on preventing skin ageing as well understanding multiple approaches to skin rejuvenation, sharing her own case studies throughout. She later discussed treating melasma and pigmentation, and showcased a live demonstration of the Obagi Blue Peel. Roger Vernon, director of national accounts, training and education at Obgai Medical, drew upon the main business and aesthetic trends in the US compared to the UK. As well as this, Vernon highlighted the importance of marketing yourself correctly on social media. Later in the day, business consultant Marcus Haycock outlined the importance of brand building and how to activate, convert and retain patients. The final talk was led by aesthetic practitioner Dr Raj Acquilla, who performed a live demonstration of full-face rejuvenation with a specific focus on the jawline where he used Allergan’s latest launch, Volux. Steve Joyce, marketing and technology director of Healthxchange said, “We were delighted to welcome so many Healthxchange clients to our third event. We enjoy facilitating events like this so we can bring the very best international speakers and give access to preferred partners who assist us in bringing the very best products to our clients.”

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Teoxane Academy Visit, Geneva Aesthetics tours the new Teoxane Academy and the laboratory behind the Teosyal dermal fillers in Switzerland

Aesthetics was invited to Geneva alongside aesthetic practitioners from the UK to visit the headquarters of global hyaluronic acid-based dermal filler and cosmeceutical brand Teoxane Laboratories. Housed at the laboratory is the new Teoxane Academy, an on-site learning facility for aesthetic practitioners. The facility features a beautiful lobby, conference room, patient area, and separate treatment room where live demonstrations can be broadcast or viewed through a window from the conference room. Mr Patrick Trevidic, a plastic, reconstructive and aesthetic surgeon based in Paris, is a presenter at the Teoxane Academy. He discussed treatment planning, patient assessment, anatomy in different facial zones and provided live treatment demonstrations. He said, “I think that Teoxane has a great approach to medical education. The Academy is a great new platform to share the latest clinical knowledge, education and practice to visiting practitioners in order to promote more reliable and successful injections.” Aesthetics also met with François Bourdon, R&D director at Teoxane, who explained the company’s manufacturing process, “We have the advantage of having constant interaction between the different departments on site, which are medical, clinical, research and development, regulatory, quality and manufacturing. Using advanced technology with Teoxane-specific know-how, and the

highest quality raw material, Teoxane is able to produce dermal fillers with a wide range of mechanical properties to better adapt to different indications.” Through a tour of the laboratory, Aesthetics experienced first-hand how much precision, effort and thought goes into the whole manufacturing process. The development of

Bourdon stated that Teoxane RHA gels are created to adapt easily to dynamic facial movements. He added, “Even with a lower degree of modification, the RHA gels display equivalent or longer-lasting effect than conventional products, in spite of being three to four times less crosslinked. This was proven with the clinical studies conducted for FDA registration.” Aesthetic practitioner and dentist Dr MJ Rowland-Warmann, said she had a great experience at the Academy and loved seeing the product production first-hand. She commented, “I thought the experience was really informative; the tour of the laboratory was excellent. It was really interesting to see the ins and outs of how the products are made and how they are safety tested, as well as how Teoxane achieves quality assurance. I have also learnt a lot of injection tips and tricks and things that I will be able to take back to my practice; it’s been really good.” Aesthetic practitioner Dr Roy Saleh, who also visited the Academy, added, “I have been injecting for a long time and it is fantastic to

Teosyal RHA, for example, took more than seven years from the first formulations’ testing in the laboratory to the approval. Bourdon said, “Teoxane uses a specific process for crosslinking hyaluronic acid (HA), based on a patented technology. The latest products developed by Teoxane (Teosyal Resilient Hyaluronic Acid – RHA) benefit from an advanced optimisation of the crosslinking conditions, allowing Teoxane to significantly decrease the crosslinking degree of the HA; in other terms, the crosslinked HA for RHA products is less modified and therefore closer to the natural HA that is already present in the skin. These results can be achieved thanks to a better preservation of the long chains of HA during the crosslinking reaction.”

see how the products are made and to see the care that’s been put into making them. It was great to see someone as expert as Dr Trevidic at the Teoxane Academy, talking about what he can achieve with the products. The way that the treatments were done and the care and attention that was shown to the patients was really fantastic.”

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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profession, Dr Plinsinga assures. She explains that those already working in aesthetics must have done so for five years, treated at least 600 patients per year, worked a minimum of 16 hours per week and achieved at least 40 CPD points per year. Once they have proved this, they can then apply for inspection by which a doctor (who holds the KNMG title and is recognised as a KNMG certified inspector) and an inspection officer will assess the practitioner’s competencies. As soon as the practitioner is approved and registered, they are able to refer to themselves as a cosmetic doctor KNMG. The NVCG explains that it also only applies to doctors, as nurses and dentists are not able to practice aesthetics in the Netherlands.

Protecting Clinical Titles Aesthetics asks why the Netherlands has introduced a protected title for its aesthetic doctors and explores what this means going forward Professional titles are a controversial topic within aesthetics; many are often misunderstood by patients and some are even misused by practitioners. It can be infuriating for some practitioners who have worked incredibly hard to obtain a particular title to see it attached to a less-experienced colleague, as well as being dangerous to patients who seek treatment from practitioners who do not have the relevant experience associated with the title they are using. With the aim to eradicate these possible concerns, the Dutch Society of Aesthetic Medicine (NVCG), announced last month that it will be introducing a protected title for practitioners who demonstrate a certain level of competency.1 The title, cosmetic doctor KNMG, is granted by the Royal Dutch Medical Association (KNMG), recognised by the Dutch Government. The title may only be used if the doctor is registered on the Register of Medical Specialties (RGS).2 Although this is not a legal requirement, it is recommend by the NVCG to help instil best practice within the industry. Aesthetics explores how this change came about, asks what the thoughts are from the industry and whether it is something that UK professionals can learn from.

Understanding the change The process was initiated by the NVCG with the support of the Ministry of Health, Welfare and Sport1 aiming to professionalise the industry, explains Dr Sindy Plinsinga, board member of the NVCG and head of training framework, Foundation for Cosmetic Medicine Training (SOCG), who was one of the leading forces in reaching this goal. She says, “Much like the rest of the world, regulation in aesthetics has always been a significant issue in the Netherlands. Within the NVCG we decided around seven years ago to take the professionalisation of the aesthetic medicine industry a step further. We felt that granting a protected title to those who demonstrate a certain level of competency would help to achieve that.” She continues, “We also found that patients were becoming more and more aware of the risks and many were contacting the NVCG to find reputable practitioners. The announcement of this protected title is certainly a step in the right direction for safeguarding the sector and I believe it will ultimately help patients choose trustworthy doctors.” So how do doctors obtain this title? Dr Plinsinga explains that a doctor can enrol onto the full-time two-year university and residency course implemented and developed by the SOCG and NVCG straight out of medical school.3 Once completed they will be certified and registered. However, there will be a transitional period until June 2022 for those who are already practising the

What happens to those who don’t comply? Dr Plinsinga explains that it is currently prohibited in the Netherlands to falsely carry a protected title.4 Although currently no official consequence has been put in place for the practitioners who falsely use the title ‘cosmetic doctor KNMG’, the NVCG has stated that if such practitioners are using the title incorrectly, not only is it misleading to the public but it is also against Dutch law.4 “We are asking all practitioners to inform their patients fairly at all times and if this means communicating that they are not on this register, they should do so. We will be monitoring this over the next few months, however in the worst-case scenario, we may need to proceed with legal action. We don’t want patients exposed to doctors who are unlawfully using the title when they do not have the right to do so,” explains Dr Plinsinga.

Industry thoughts The announcement appears to have divided opinions within the industry. Aesthetic practitioner Dr Tom Van Eijk, who trained in the Netherlands but practises all over the world, including the UK, says, “The NVCG worked hard to get this profile, but in my opinion the title represents only a small portion of the doctors that perform aesthetic procedures in the Netherlands. The potential danger of getting this title is that people who register for it hint or claim to be superior doctors to the ones who have not. Instead of a guide for patients to choose the right doctor for the safest treatment and best aesthetic outcome, this profile might be misused merely as a marketing tool.” Greg White, CEO of the British College of Aesthetic Medicine (BCAM), which has voiced its support for the title, understands why some practitioners may

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


“The announcement of this protected title is certainly a step in the right direction for safeguarding the sector and I believe it will ultimately help patients choose trustworthy doctors”

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REFERENCES 1. NVCG, Cosmetic doctor KNMG from July 1, 2019 protected title NVCG, July 2019 <https://nvcg.nl/ cosmetisch-arts-knmg-vanaf-1-juli-2019-beschermde-titel-nvcg/> 2. KNMG, What is a register? <https://www.knmg.nl/opleiding-herregistratie-carriere/rgs/registers.htm> 3. NVCG, Profile training in cosmetic medicine <https://nvcg.nl/profielopleiding-cosmetischegeneeskunde/> 4. Swinkels J, Reregistration of medical specialists in the Netherlands, October 1999 < https://www.ncbi. nlm.nih.gov/pmc/articles/PMC1116965/> FURTHER READING • KNMG, The Royal Dutch Medical Association, About < https://www.knmg.nl/contact/about-knmg.htm#> • Business.gov.nl, Registration of medical specialists, <https://business.gov.nl/regulation/registrationmedical-specialists/>

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All interviewed agree that the patient should always be at the fore. Dr Eijk comments, “Unfortunately, we tend to drift away from the content of our job in favour of making rules, focusing on paperwork, protocols and registration processes. Of course, I agree that setting standards is a good thing but we need to ask ourselves, ‘Where does it leave the patient?’. We must ensure that our focus is on them at all times.” For the UK specifically, White adds, “The Dutch are a brilliant example and the fact that they have provided such a clear learning point for us is really welcomed. The faster we can follow in their footsteps in the UK, the better.” Dr Plinsinga concludes, “It’s been a long process, but I believe that we have given our practitioners a sense of relief that they will finally be recognised for their hard work and acquired specialised knowledge. As well as this, it will also encourage other specialties to work together in a more trusted, reputable manner; for example, if a surgeon needs to refer a patient to a cosmetic doctor and vice versa. I think the rest of the world can take this as an example and I’m incredibly proud of what we have achieved so far.”

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think this; however, believes that as far as the patient is concerned, it can only be considered a positive. “There may be some vested interests, however if you count this as a patient safety argument, then it’s very difficult to dispute against it. Patient safety must come first and I would like to see something similar implemented in the UK,” he shares. White also believes that whilst a protected title is something to be proud of, he’d like aesthetics recognised as its own specialty in both the UK and abroad. “I think to achieve suitable standards, aesthetics really does need to be recognised as its own medical specialty, just as cardiology or gynaecology is, for example. We are currently in talks with the General Medical Council and a number of other stakeholders to gain recognition for aesthetics as a whole,” he explains.

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The secret to full facial rejuvenation Dr Kuldeep Minocha, Aesthetic Practitioner

“ My go-to product would always be Restylane Lyft™ ” DR KULDEEP MINOCHA

Do you have any tips for practitioners looking to treat the whole face? Each time you see a patient, look at them with fresh eyes. Take the time to look at how the light is hitting the face and where the shadows are.

Which dermal fillers do you prefer? I only ever use the Restylane® range. I’ve used Restylane® in over 30,000 treatments over twelve years. My reputation depends on using products I know and trust. There are eight fillers in the range and each one varies slightly in consistency, particle size and lift capacity. I like having a broad artistic palette to choose from and it means I can tailor the treatment for each patient.

What do you look for when assessing the face? •

Skin quality – assess skin hydration, sun damage, fine lines and wrinkles

Facial shape and balance – is there too much weight in the lower third and can we recreate the heart-shaped or oval-shaped face?

Proportions and contours – look at the frontal view, the profile view and the three-quarter view and assess the relationships between each subunit of the face

Facial symmetry – are the features balanced and how do they change when animated?

Emotion – does the face look sad, angry or tired and which areas are contributing to these emotions?

A patient treated with Restylane Lyft™, Restylane Refyne™, Restylane Volyme™ and Restylane Defyne™

BEFORE RES19-03-0144 DoP: March 2019

AFTER

What products do you use for If I’m looking to fill a large area I use Restylane Volyme™, say for the temple or the sub-malar area. If I’m injecting more superficially I’d go for Restylane Refyne™ which has a smaller particle size and integrates nicely into the skin. Where I want definition and projection on the cheeks, nose, jaw or chin, I use Restylane Lyft™. If I’m reconstructing or restoring the lips I’ll use Restylane™, but if I’m looking to volumise, beautify and enhance the lip I’d use Restylane Kysse™ which is softer and integrates well.

If you could only choose one product what would you choose? That’s easy. My go-to product would always be Restylane Lyft™. The high G-prime, precision and lift means you can get a impressive result with only the reabsorption of the bone and the descent of the fat pads that happens to all of us as we age. more and more people want the biggest bang for their buck. With Restylane Lyft™ you get that.

About Dr Minocha Dr Kuldeep Minocha qualified as a GP in 1996. After working for the NHS as GP principal in Essex for a number of years, he commenced training and practice in facial aesthetics in 2006. Dr Minocha founded Minocha Health, his aesthetic practice, the same year, before concluding his NHS commitments in 2011 to take up a full-time career in aesthetics. Dr Minocha is a global brand ambassador and key opinion leader for Galderma.


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Understanding biomimetics

Choosing Filler for Younger Patients Practitioners share their preferred dermal filler product choices for contouring and augmenting different anatomical facial regions in younger patients Contouring has been a popular makeup technique for several years now.1 With the aim to define, enhance and sculpt the structure of the face, the technique allows individuals, especially popular with young females, to get the perfect snap for their Instagram account. The makeup technique, which involves highlighting and shadowing certain areas to accentuate places that naturally catch the light with concealer or highlighter, peaked in popularity in 2016.1 Although consumer magazines are predicting the trend will die down and become more focused on a natural look,2-4 practitioners suggest that many patients are turning to non-surgical treatments to make their illusion a reality. Aesthetic practitioner Dr Charlotte Woodward explains, “Patient requests for a natural contour are definitely growing and are most popular with younger patients. This is likely associated with the current selfie culture. I also find that patients are requesting a much stronger jawline, chin and other angular features like in the mid-face, something which wouldn’t have been requested previously. People are now becoming more aware that this look can be enhanced with non-surgical treatments.” When these patients present to clinic, one thing that is particularly important, Dr Woodward says, is to take a full-face

approach to assessment and treatment. “It’s especially important in younger patients because they don’t usually need rejuvenation; they just want a bit more definition or volume. Quite often, young patients want one area tweaked, but practitioners need to recognise when this may make their face out of proportion, so other areas can be augmented to keep that natural balance,” she explains. To achieve successful facial contouring results, product selection is key, practitioners note, and will vary quite significantly. Aesthetics speaks to practitioners Dr Raul Cetto, Dr Beatriz Molina, Dr Sophie Shotter and Dr Woodward about what products they choose to enhance, contour and augment anatomical areas that are commonly requested by younger patients.

“When treating all patients, it’s very important for practitioners to know the rheological properties of each dermal filler they use extremely well. Depending on what you want to achieve you will use different fillers for the different areas across the face, you can’t just have one single syringe and use it in all areas,” explains Dr Molina. Dr Cetto says that this is why dermal fillers are produced to act and behave differently to each other when they are injected. He reiterates, “It’s incredibly important to have different fillers with different properties in your portfolio because every single tissue layer has different biophysical properties. You need to choose a product that will be able to mimic the properties in the layer you are injecting – it’s called biomimetics, where the filler mimics the tissues that it is restoring or replacing.”5 Generally speaking, Dr Cetto says there are five tissue layers that practitioners must consider when choosing their filler (Figure 1).6,7 As an example of how the layers can differ, Dr Cetto says, “The superficial fat layer has type 1 fat, which consists of large adipocytes that are very strong but very malleable and respond well to movement, whereas the deep fat layer, which is attached to the bone, has much smaller adipocytes and provides projection of the overlying tissues and is not subject to movement.8-10 Even though both layers are fat, they have different biomechanical properties so your filler needs to be able to mimic them for natural outcomes and your product will almost certainly need to differ.” Dr Shotter adds, “Without understanding that you need to choose different fillers with different properties according to the area and the depth you are treating, you shouldn’t be going anywhere near a needle, in my opinion. The other crucial factors for selecting products are the patient’s skin type, texture, facial properties, gender, and skin thickness. So, it’s very important to understand how your filler is going to behave in different patients.”

“I find that patients are requesting a much stronger jawline, chin and other angular features like in the mid-face” Dr Charlotte Woodward

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Epidermis

Skin

Dermis

Superficial fat pads

Muscle

Deep fat

Bone

Figure 1: The typical layers of the facial tissues

Dr Cetto notes that for younger patients, practitioners will likely focus on the superficial planes to enhance what is already there, rather than replacing what has been lost in the deep layers. However, he says, that this isn’t essential, and treatment approaches will vary according to individual patients.

Choosing your products Upper face To contour a forehead that is displaying a lack of convexity, Dr Cetto will use a product that has good strength that can project the overlying tissues. He explains, “It also needs to have some form of malleability and stretch because it’s a tight compartment. I like to place my product with a cannula deep onto the bone and I prefer Teosyal RHA 4. I love the whole Teosyal range because it is designed to behave very similarly and naturally to the tissues.” Dr Shotter’s approach involves using the Juvéderm range. She says, “Because the forehead doesn’t have a lot of tissue, to enhance and contour for younger patients I usually choose Volbella or Volift to achieve gentle projection and shaping rather than using anything too stiff.” Dr Molina adds, “When I am treating the forehead, I like to use a product that is soft and gentle but also malleable that will not be too think or lumpy and give a nice contour. I would usually choose Aliaxin SR to achieve this. I’d inject the product superficially using a 25 gauge TSK cannula,” she says. Dr Molina will use the same filler for the temple and will inject in a fanning technique; she thinks a cannula method is more cost effective as it prevents

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product wastage compared to using needle in this area. She adds, “If you want to treat using the well-known technique by Dr Arthur Swift for the temple11 then you would use a product with higher G prime. I would either choose Aliaxin EV or Restylane Volyme and inject with a needle deep onto bone.” According to Dr Cetto, there is yet to be consensus from anatomists about how many skin layers there are in the temples, which makes this area tricky in terms of filler placement. “To make the best use of my product in this large area, I will adopt a layered approach using a cannula in layers that are deemed as ‘safe’. I will do my first injection just below the temporal fusion line and behind the lateral orbital rim down to the periosteum using products which will create good projection – like Ultra Deep or RHA 4 – and I will finish by treating the superficial subcutaneous fat, just below the skin,” he says. When Dr Woodward augments the temples, she will choose a strong and firm product. “I like to use either Ultra Deep, Perfectha Subskin, or Ellansé with a needle down to bone to create volume. Whenever there are skin texture issues, I like to use Ellansé where it’s not contraindicated (lips, tear troughs and glabella), as this can improve texture, as well as shape, and augment the area. It’s important to note that this product is not a hyaluronic acid (HA), so it can’t be dissolved, but it can be much longer lasting so this can be very attractive to patients,” she explains. Dr Shotter will use a high G prime product for contouring the temple, which is stiff and provides lift. “I tend to work with a needle in this area, deeply, and try to give a nice lift at the tail of the eyebrow, so I need a product with higher lifting capacity. For this, I will choose Voluma; sometimes I may use a softer product with a cannula in a superficial plane if I need a bit more refinement,” she explains. Mid-face The mid-face is an area that usually requires several different fillers, according to the practitioners interviewed, depending on the patient and areas for placement. Dr Cetto

reminds practitioners that products that are suitable for deep injections will not be suitable for superficial injections or areas with little overlying tissue. “Injecting a deep volumising product with a high G prime into the superficial fat is how you cause that chipmunk cheek because it won’t integrate or move with the tissues,” he emphasises. Dr Cetto likes to use a layered approach when contouring the mid-face. “It’s a much more efficient way of utilising product. I use a deep volumiser, Ultra Deep, and then a superficial volumiser to enhance and contour – RHA 4. Conversely, for older patients, you likely want to focus more on the deep fat pads, which start atrophying,” Dr Cetto says. Dr Molina agrees, adding that for sculpting and contouring, good tissue integration is important. She says, “When I am treating a younger patient who is not showing signs of ageing in their deep layers, I am usually treating the subcutaneous level with a cannula to give me a good artistic shaping of the cheeks and cheekbone with Aliaxin EV because I find I get lovely contours with a natural result – I have also previously used Restylane Refyne for this. If the patient needs a bit of volume and some pillars for support, then I will inject deep with a needle using a high G prime product such as Aliaxin SV, and then I’ll put a lower G prime product over the top for a contouring effect using a cannula.” Aliaxin SV is a new product that is launching in the UK in October, which Dr Molina finds is good for contouring faces, cheekbones, jawlines and chins. “This is because it has good lifting capacities but maintains the softness of the rest of the range,” she explains. If the patient has a flat mid-face, Dr Woodward will inject Perfecta Subskin, Ultra Deep or Ellansé with a needle, deep down to the bone, in the malar groove and the alar triangle. “It’s important to always under-treat when using Ellansé because unlike hyaluronic acid you only get 85% of the results immediately after treatment but will increase over three months,” she notes. She says she will also consider overlaying RHA 4 superficially on top of the deeper injections if

“When treating all patients, it’s very important for practitioners to know the rheological properties of each dermal filler they use extremely well” Dr Beatriz Molina

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Before

After

Figure 2: Before and after cheekbone with Aliaxin SV. Patient treated with 1ml per side.

required. Dr Shotter says that deep injections can look nice on the right young patient. “I find that Voluma, which has a relatively high G prime gives a nice shape to the cheekbone when injected deep. This can make someone look contoured without makeup, which is what many patients are looking for at the moment. To treat the superficial fat pads, I will use Volift,” Dr Shotter explains. Nose The nose is a common concern for many young patients and, in makeup contouring, it’s possible to add highlights and shadows to alter its appearance.12 When contouring with dermal filler, firstly, Dr Shotter and Dr Cetto note that there is no dermal filler product that is licensed to be used on the nose, so all products are injected off-label. “This means that any practitioner must check with their insurance provider to see if they are covered for doing off-label treatments,” Dr Cetto advises, adding, “As the foundations of the nose are solid tissues, I like to use a product that mimics those characteristics, and for me that is the volumiser Ultra Deep as I can inject small amounts to get a great lift. For a large defect, I will use a short cannula, but for small alterations I will use a needle.” Dr Molina only ever uses cannula in the nose because she feels that it is safer to avoid vascular compromise. Dr Molina treats a lot of noses, and her product of choice can vary according to the patient. “If I want pure projection, like on an Asian nose for instance because they usually have thicker skin and are flatter compared to Caucasians, I will need a product with a high G prime and good lifting capacity. I will usually choose NASHA technology that won’t integrate and will project – Lyft is my filler of choice here, but never for thin skin as it will be visible,” Dr Molina explains, adding, “If I also want some shaping and integration, I will choose Aliaxin EV. Then, for very mild interventions I will choose Aliaxin FL; I have also used Refyne to achieve this.”

Lower face Dr Molina says, “I am seeing an obvious trend of patients coming in and actively seeking jawline contouring and augmentation. I will choose my product according to how much lift I deem is necessary for the patient. For example, for a very nice, angled jawline that is very divined I will choose Aliaxin SV. For something softer, especially in females, I will choose Aliaxin EV as you will not need as much projection.” For the jawline and chin, Dr Woodward says she uses a firm product to augment. She will either use Ellansé, Perfecta Subskin or Ultra Deep in the deep layer, then overlay using RHA 4. “It’s deceiving how much product you will need in a chin and jawline to give you a very sharp contour, so make sure patients are aware of this,” she advises. Dr Shotter also likes a filler that won’t move to create a defined appearance. “When you are augmenting the jaw, I look for a product that is very stiff as you will usually be injecting onto the bone to create sharp definition. I am really liking Volux for this because it’s high G prime gives a superior sculpt and really holds its shape in this area,” she says.

Learn what products work best for you Dr Molina highlights that when contouring it’s important to choose products that will achieve natural results, and place these in the correct plane. “I think for the younger patients, it’s the soft fillers that create the most natural contours because it allows the face to move with the patient when they animate,” she says. All practitioners agree that no matter the patient’s age or facial area you are treating, you must always consider your patient’s unique facial features and requirements, area of injection, and depth before you choose your product. “I think looking at the biomimetics – the biomechanical characteristics of the tissues – is a good starting point when you are choosing your fillers,” says Dr Cetto. “Think about what

product and treatment approach will suit your patient; it’s not a one size fits all, and this sometimes gets forgotten, especially by junior injectors,” adds Dr Woodward, emphasising, “I have several different filler brands, which have different properties and I think you need to pick what’s right for the patient. I like to give patients a choice, for example some want a reversible HA, but others want a long-lasting product.” Dr Molina reiterates, “Know your product inside-out and challenge yourself to learn about various brands; try a range of products so that you can pick and choose what works best for you. If you only have one filler, or even one brand, you might not be getting the optimum results for you and your injection style, so understand what your style of injecting is, the anatomy, and your patients and, if necessary, get more training to push your boundaries.” REFERENCES 1. Google Trends, Contouring, 2004-2019. <https://trends.google. com/trends/explore?date=all&q=contouring> 2. Bridget March, 13 big beauty trends for 2019, Bazar, 2019. <https://www.harpersbazaar.com/uk/beauty/skincare/ a25568595/beauty-trends-2019/> 3. HudaBeauty, RIP To These Beauty Trends In 2019, 2019. <https:// hudabeauty.com/rip-to-these-beauty-trends-in-2019/> 4. Brooke Shunatona, How to Contour and Highlight for Your Face Shape, Cosmopolitan, 2019. <https://www.cosmopolitan.com/ style-beauty/beauty/how-to/a43730/face-shape-contour-map/> 5. Aligned Biomimetic Scaffolds as a New Tendency in Tissue Engineering, Curr Stem Cell Res Ther. 2016;11(1):3-18. <https:// www.ncbi.nlm.nih.gov/pubmed/25697498> 6. Rakesh Khazanchi et al, Anatomy of Ageing Face, Indian Journal of Plastic Surgery, Vol. 40, No. 2, July-December, 2007, pp. 223-229. 7. Rebecca Fitzgerald, et al., Update on Facial Aging, Aesthetic Surgery Journal 30(Suppl 1) 11S-24S. 8. Schenck, TL, et al. The Functional Anatomy of the Superficial Fat Compartments of the Face: A Detailed Imaging Study, Plast Reconstr Surg. 2018 Jun;141(6):1351-1359.  9. Sims, AM, et al. Elastic and viscoelastic properties of porcine subdermal fat using MRI and inverse FEA, Biomechanics and Modeling in Mechanobiology, 2010, Volume 9, Issue 6, pp 703–711. 10. Sebastian Cotofana et al, The Functional Anatomy of the Deep Facial Fat Compartments: A Detailed Imaging-Based Investigation, Plastic & Reconstructive Surgery 143(1):53-63, 2019.  11. Dr Arthur Swift, The Aesthetic BluePrint, Injectors Anatomy of the Temporal Fossa, 2017, YouTube. <https://www.youtube.com/ watch?v=prEGKIVOJ68> 12. HudaBeauty, Nose Contouring Tricks For Every Type Of Nose!, 2019. <https://hudabeauty.com/nose-contouring-tricks-foreveryone-for-every-type-of-nose/>

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Skin Disinfection for Injectables Dr Souphiyeh Samizadeh advises on disinfection of the skin prior to injectable treatment We are all well-aware of the risk of complications following injectable procedures such as dermal fillers and botulinum toxin. Skin disinfection is an important step towards preventing complications, such as infection, from occurring, and failing to employ adequate practice can put your patients at risk. This article will explore the importance of skin disinfection before injectable procedures, examining what is available and considerations for their use.

Why disinfect? Cutaneous microbiota (bacterial skin flora) play a role in both cutaneous health and disease, with some microorganisms having the potential to become pathogens.1 The diverse milieu of present microorganisms support the growth of commensal bacteria which, in turn, directly and indirectly protect the host from pathogenic bacteria. Resident organisms are mainly gram-positive, and include Staphylococcus, Micrococcus, and Corynebacterium sp., Staphylococcus aureus and Streptococcus pyogenes. Gramnegative organisms are not usually found or flourish on normal skin due to its dry environment. When skin’s normal environment and defence mechanisms are changed or breached (e.g. become moist/ occlusive), both commensal and pathogenic bacteria can grow.2 Thus, percutaneous procedures such as injection of botulinum toxin A and dermal fillers necessitates correct and optimal antimicrobial skin preparation. Dermal filler Injection of foreign materials such as dermal fillers are, indeed, placement of an implant that will remain in place for some time. As such, these are associated with a risk of infection.3 Risk of adverse events and infection have been reported to be associated

Figure 1: 360-degree spherical panorama view inside biofilm of antibiotic resistant bacteria. A biofilm is an aggregate of microorganisms (bacteria, protozoa, fungi, algae, yeast and other microorganisms) that are physically joined together.16

with skin bacteria including Staphylococcus epidermidis and Propionibacterium acne,4 stiffer gels and longer-lasting filler materials,5,6 injection technique and certain locations.7,8,9 Only a few microorganisms, stated above, are reported to be sufficient to contaminate the medical device during insertion/ placement via mucous membrane or skin.10,11 This can result in bacterial colonisation of the implanted hydrogels which, in time, builds resistance to antimicrobial actions with the onset of symptoms varying shortly or years post implantation.12-14 One study reported that in several dermal fillers, including polyacrylamide, hyaluronic acid and hydroxyapatite gels, pathogens such as Pseudomonas aeruginosa, Staphylococcus epidermidis, and Propionibacterium acnes form strong biofilms (Figure 1).15,16 Other authors have reported bacterial colonisation over the semi-permanent fillers used in their study and no bacterial growth or chemoattractant properties over permanent acrylic compounds.17 In regards to skin preparation and dermal fillers, Wang et al. used two in vitro models to explore this. They simulated and examined skin preparation and injection of dermal filler using pig skin (alcohol, chlorhexidine and povidone-iodine wipes reported similar efficacy) and silicone materials (to study transfer of viable bacteria). They used dermal filler simulant (a clear liquid with similar elastic properties). Increased bacteria transfer was reported with needle diameter (30 gauge, 25 gauge, 18 gauge), decreased transfer with increased injection depth from 1-3mm, similar transfer via serial puncture and linear threading techniques, and increased with fanning technique. They explained the ‘in vitro’ nature of their study was a limitation. Greater disinfection time, ‘multiple wipe steps’, and choice of correct technique were recommended to improve efficacy of skin preparation.18 De Boulle and Heydenrych report the following as related to major dermal filler complications:19 • Inappropriate patient selection • Sterility • Product placement • Volume • Injection technique The above contributing factors are also supported by ‘Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations’ published in 2018.20 Botulinum toxin In 2003, Hutin et al. published a paper, which was a bulletin of the World Health Organization, titled ‘Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections’. They recommended washing visibly soiled or dirty skin, however, reported that swabbing clean skin prior to injections is not necessary. When disinfecting the skin, they advised that single-use swabs should be

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used to maintain product-specific recommended contact time to ensure optimal antibacterial activity.21 It should be noted that the advice was not specific to any particular medication/preparation and was only restricted to ‘infection control’. Studies have reported that local infections and complications (e.g. abscesses, sepsis) can be caused by intramuscular injections.22-24 A case report of mycobacterial (non-tuberculous mycobacteriosis) infection secondary to injection of botulinum toxin A was published in 2015, but the authors could not find the source of the contamination.25 To my knowledge, no other major cases of infection have been reported post injection of botulinum toxin. However, avoidance of injection close to areas of infection, adjacent to acne or inflamed skin is advised26 and use of optimal disinfection protocol is still important and recommended.

Prevention Contamination during injection/placement is the first step to the pathogenesis process, so prevention is key. In this regard, two important steps are to be considered; skin preparation prior to injectables and the injection technique.18 Skin preparation Patient preparation prior to skin disinfection should not be overlooked. Patients should firstly have their hair in a hairband or surgical cap and their hands washed and alcohol gelled in case they do attempt to touch treatment areas during or after the procedure. It is advisable for the patients to attend clinic without makeup. If they present wearing makeup, it should be removed, as well as skincare products, including sunscreen.27 It is best to clean the target area and the vicinity, as contaminants can interfere with the activity of the antiseptics, for example, reduce alcohol’s antimicrobial action.28 To prevent possible contamination and infection, accurate and optimal skin disinfection is obligatory. Antiseptic agents There are various types of antiseptic agents that can be considered for injectable procedures. Alcohol Variations: • Isopropyl alcohol 70% • Isopropyl alcohol (70%) plus povidone-iodine • Isopropyl alcohol (70%) plus chlorhexidine gluconate (2%) Alcohol is a fast-acting, broad-spectrum antimicrobial antiseptic. It induces antimicrobial activity against the following by causing protein and DNA damage:29-32 • Gram-positive and gram-negative bacteria • Multidrug-resistant pathogens including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) • Mycobacterium tuberculosis • Fungi Its action is rapid (< 30 seconds) but does not have a persistent and cumulative activity. The persistent effect of the disinfectant used is important as it suppresses the regrowth of the remaining and residual skin flora. Alcohol-based solutions, including chlorhexidine and alcohol or povidone-iodine and alcohol, have greater antimicrobial activity in comparison to alcohol alone and, upon application, there is an immediate reduction of the microbial count, with sustained efficacy for a period of time.33

Oral disinfection and injection Implantation of dermal fillers via oral mucosa and multiple injection sites are to be avoided.55 A chlorhexidine gluconatebased mouthwash can be used, and is recommended, prior to lip and perioral injections to decrease oral bacterial flora and therefore reduce the risk of contamination.19,56 Chlorhexidine gluconate has excellent bactericidal activity and substantivity (oral retentiveness). The 0.2% and 0.12% rinses have similar efficacy when used at correct doses and the time of the rinse should be 30-60 seconds.57 Non-chlorhexidine based mouthwashes may not have the same antimicrobial efficacy or longevity of the action.58 Sodium hypochlorite-based mouthwashes (diluted to low percentages such as 0.05%-0.25%) are broad-spectrum antimicrobial agents.44,59 Oral rinse with such mouthwashes is recommended19 and are particularly important when intraoral and extra-oral massage is employed by the practitioner.

Povidone-iodine Variations: Povidone-iodine (combination of molecular iodine + polyvinylpyrrolidone) Povidone-iodine has a broad spectrum antimicrobial activity, with proven efficacy and action against resistant microorganisms (e.g. methicillin-resistant Staphylococcus aureus).34 It takes three to five minutes for optimal effect. It has been reported that combination of ethyl or isopropyl alcohol and povidone-iodine are rapid acting, broad spectrum and more persistent than either of the agents used alone.35 Practitioners should consider contraindications before use. Chlorhexidine Variations: Chlorhexidine gluconate Chlorhexidine gluconate (0.5-1%) based products (in alcohol) has broad spectrum activity, excellent efficacy and persistent action (48 hours).33A combination of the fast and immediate action of alcohol and persistent activity of chlorhexidine or iodine is optimal.36,37,38 Caution is advised when using chlorhexidine. It should be kept away from the eyes and ears (ototoxic) and practitioners should check for allergy prior to application.32,39 Sodium hypochlorite Sodium hypochlorite is an effective antiseptic agent. Its introduction for hand hygiene in the 19th century by Hungarian physician Dr Ignaz Semmelweis resulted in a steep reduction in morbidity and mortality.40 It is used effectively and safely in large scale industrial environments and at home. It is a strong bactericidal (gram-positive and gramnegative bacteria), sporocidal and fungicidal. Alvarez et al. examined the antiseptic action between 10% povidone-iodine and 10% sodium hypochlorite and reported no difference.41 In another study, the antiseptic activity of 10% sodium hypochlorite was examined versus 2% chlorhexidine gluconate in 70% isopropyl alcohol in 30 healthy volunteers. They reported equal efficacy, but only for procedures that do not require a long-acting agent. The same study reported the same efficacy for procedures that do not require a long-lasting action for chlorhexidine gluconate in isopropyl alcohol, sodium hypochlorite, and povidone-iodine.42 Topical use of sodium hypochlorite is reported to have a long safety record, and is not a mutagen, carcinogen or teratogen, however it is associated with redness and sensitivity.43,44,51 There is toxicity associated with sodium

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Summary Skin disinfection is recommended prior to injectables. This is of particular importance when injections are short/long term implants, as the product remains for a period of time. Alcohol, chlorhexidine gluconate in isopropyl alcohol, sodium hypochlorite, povidone-iodine, and hypochlorous acid are all effective antiseptic agents. However, their mode of action, antimicrobial coverage, onset and longevity of effect varies. By taking these variables into consideration, the optimal agent can be chosen for various medical aesthetic procedures. The antiseptic of choice should be fast-acting, broad-spectrum and for more invasive procedures, suppress regrowth of microorganisms during and for a time after the procedure.

Figure 2: Example of a disposable sterile pack. Pack should contain: 1x pair of examination gloves, 1x sterile sheet (water repellent/absorbent – patient), 1x white waste disposal polythene bag, 1x paper dressing towel (2 ply), 5x non-woven swabs (4 ply), 1x reduced static apron, 1x wound measure guide (10cm in length), 1x sterile sheet (water repellent/absorbent – outer use).

hypochlorite use; uses beyond topical use (inhalation, injection, ingestion, deposition into tissue/blood stream) can result in ‘significant morbidity and even mortality’, according to one study.45 Hypochlorous acid Hypochlorous acid also has a long history and wide applications ranging from hospital environment cleaning to wound care with reported ‘powerful microbicidal, antibiofilm, and wound-healing potency’.46-48 It is generated from sodium hypochlorite and hydrogen peroxide, although manufacturers claim that very little to no sodium hypochlorite is detected in the final solution49,50 because of its association with redness and sensitivity.51 Hypochlorous acid is non-cytotoxic, has a wide range of activity (bactericidal, fungicidal, virucidal, sporicidal), reported to be pH-neutral to both the skin and wound cells, and has antibiofilm activity.48,52,53 These properties make stable hypochlorous acid solution effective and optimal in medical aesthetic settings and for pre- and posttreatment application. Severing et al. studied the safety and efficacy profiles of different commercial sodium hypochlorite/ hypochlorous acid solutions, and concluded that efficacy and biocompatibility depends on their ‘specific formulation and physicochemical properties’.54

Injection practices For administration of dermal fillers, use of disposable sterile packs per patient is recommended (Figure 2). Sterile packs are inexpensive, easy to obtain and convenient to use. Sterile gloves can be used, but are not essential.14 Despite using sterile packs, needles and cannulae should not be placed on the working surface without their sheath or cover, touched with gloves or gauze. The dermal filler gels are sterile, however, I understand that the majority of the syringes in the market are not. The practitioners should ensure needle or cannulae are not contaminated during the procedure. To avoid risk of biofilm formation, injection through nasal or oral mucosa is not recommended.6,60 Correct application protocol for a chosen antiseptic should be employed. It is beyond the scope of this article to discuss clinical setting, clinician professional presentation, clinical attire and personal protective equipment (PPE) and such similar topics. However, these topics are also important, and all healthcare professionals should have training on this or seek it if they do not.

Dr Souphiyeh Samizadeh is a dental surgeon and clinical director of Revivify London clinic. She is the founder of the Great British Academy of Aesthetic Medicine, is an honorary clinical teacher at King’s College London and Queen Mary University of London and is the visiting associate professor for Shanghai Jiao Tong University. Dr Samizadeh has multiple published papers in peer reviewed journals and frequently presents at national and international conferences. She trains aesthetic doctors, dermatologists and surgeons worldwide.

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REFERENCES 1. Cogen A, Nizet V, Gallo R. Skin microbiota: a source of disease or defence? British Journal of Dermatology. 2008;158(3):442-55. 2. Chiller K, Selkin BA, Murakawa GJ, editors. Skin microflora and bacterial infections of the skin. Journal of Investigative Dermatology Symposium Proceedings; 2001: Elsevier. 3. Kim JH, Ahn DK, Jeong HS, Suh IS. Treatment algorithm of complications after filler injection: based on wound healing process. J Korean Med Sci. 2014;29 Suppl 3(Suppl 3):S176-S82. 4. Christensen L, Breiting V, Bjarnsholt T, Eickhardt S, Høgdall E, Janssen M, et al. Bacterial infection as a likely cause of adverse reactions to polyacrylamide hydrogel fillers in cosmetic surgery. Clinical infectious diseases. 2013;56(10):1438-44. 5. Wang Y, Guan A, Isayeva I, Vorvolakos K, Das S, Li Z, et al. Interactions of Staphylococcus aureus with ultrasoft hydrogel biomaterials. Biomaterials. 2016;95:74-85. 6. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clinical, cosmetic and investigational dermatology. 2013;6:295. 7. Gladstone HB, Cohen JL, editors. Adverse effects when injecting facial fillers. Seminars in cutaneous medicine and surgery; 2007: WB Saunders. 8. El-Khalawany M, Fawzy S, Saied A, Al Said M, Amer A, Eassa B. Dermal filler complications: a clinicopathologic study with a spectrum of histologic reaction patterns. Annals of diagnostic pathology. 2015;19(1):10-5. 9. Glogau RG, Kane MA. Effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid gel dermal fillers. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al]. 2008;34 Suppl 1:S105-9. 10. von Eiff C, Jansen B, Kohnen W, Becker K. Infections associated with medical devices. Drugs. 2005;65(2):179-214. 11. Britt MR, Garibaldi RA, Wilfert JN, Smith CB. In vitro activity of tobramycin and gentamicin. Antimicrobial agents and chemotherapy. 1972;2(3):236-41. 12. Christensen LH. Host tissue interaction, fate, and risks of degradable and nondegradable gel fillers. Dermatologic Surgery. 2009;35:1612-9. 13. Rohrich RJ, Monheit G, Nguyen AT, Brown SA, Fagien S. Soft-tissue filler complications: the important role of biofilms. Plastic and reconstructive surgery. 2010;125(4):1250-6. 14. DeLorenzi C. Complications of injectable fillers, part I. Aesthetic surgery journal. 2013;33(4):561-75. 15. Alhede M, Er Ö, Eickhardt S, Kragh K, Alhede M, Christensen LD, et al. Bacterial biofilm formation and treatment in soft tissue fillers. Pathogens and disease. 2014;70(3):339-46. 16. Samazadeh, S, ‘Biofilms’, Aesthetics, 2016. <https://aestheticsjournal.com/cpd/module/biofilms> 17. Alijotas-Reig J, Miró-Mur F, Planells-Romeu I, Garcia-Aranda N, Garcia-Gimenez V, Vilardell-Tarrés M. Are Bacterial Growth and/or Chemotaxis Increased by Filler Injections? Implications for the Pathogenesis and Treatment of Filler-Related Granulomas. Dermatology. 2010;221(4):356-64. 18. Wang Y, Leng V, Patel V, Phillips KS. Injections through skin colonized with Staphylococcus aureus biofilm introduce contamination despite standard antimicrobial preparation procedures. Scientific reports. 2017;7:45070. 19. De Boulle K, Heydenrych I. Patient factors influencing dermal filler complications: prevention, assessment, and treatment. Clinical, cosmetic and investigational dermatology. 2015;8:205-14. 20. Urdiales-Gálvez F, Delgado NE, Figueiredo V, Lajo-Plaza JV, Mira M, Moreno A, et al. Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations. Aesthetic plastic surgery. 2018;42(2):498-510. 21. Yvan Hutin et al., Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections, Bulletin of the World Health Organization : the International Journal of Public Health 2003 ; 81(‎7)‎: 491-500 22. Gautschi OP, Zellweger R. Methicillin-resistant Staphylococcus aureus abscess after intramuscular

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


steroid injection. New England Journal of Medicine. 2006;355(7):713-. 23. Rossi L, Conen D. Intramuscular injections--an outdated form of administration? 6 cases of Staphylococcus aureus sepsis following intramuscular injections. Schweizerische medizinische Wochenschrift. 1995;125(31-32):1477-82. 24. Velissaris D, Matzaroglou C, Kalogeropoulou C, Karamouzos V, Filos K, Karanikolas M. Sepsis requiring intensive care following intramuscular injections: two case reports. Cases J. 2009;2:7365. 25. Saeb-Lima M, Solis-Arreola G-V, Fernandez-Flores A. Mycobacterial infection after cosmetic procedure with botulinum toxin a. J Clin Diagn Res. 2015;9(4):WD01-WD2. 26. Vartanian AJ, Dayan SH. Complications of botulinum toxin A use in facial rejuvenation. Facial Plastic Surgery Clinics. 2005;13(1):1-10. 27. Kilgariff, S, Special Feature: Makeup Post Procedure, Aesthetics, May 2019. 28. Larson E, Bobo L. Effective hand degerming in the presence of blood. J Emerg Med. 1992;10(1):7-11. 29. Kampf G, Jarosch R, Ruden H. Limited effectiveness of chlorhexidine based hand disinfectants against methicillin-resistant Staphylococcus aureus (MRSA). J Hosp Infect. 1998;38(4):297-303. 30. Sakuragi T, Yanagisawa K, Dan K. Bactericidal activity of skin disinfectants on methicillin-resistant Staphylococcus aureus. Anesth Analg. 1995;81(3):555-8. 31. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the hicpac/shea/apic/idsa hand hygiene task force. American Journal of Infection Control. 2002;30(8):S1-S46. 32. Tintner R, Jankovic J. Botulinum toxin type A in the management of oromandibular dystonia and bruxism. Scientific and therapeutic aspects of botulinum toxin Philadelphia: Lippincott Williams & Wilkins. 2002:343-50. 33. Hemani ML, Lepor H. Skin preparation for the prevention of surgical site infection: which agent is best? Rev Urol. 2009;11(4):190-5. 34. Durani P, Leaper D. Povidone-iodine: use in hand disinfection, skin preparation and antiseptic irrigation. International wound journal. 2008;5(3):376-87. 35. Art G. Combination povidone-iodine and alcohol formulations more effective, more convenient versus formulations containing either iodine or alcohol alone: a review of the literature. Journal of infusion nursing : the official publication of the Infusion Nurses Society. 2005;28(5):314-20. 36. Anderson DJ, Podgorny K, Berrios-Torres SI, Bratzler DW, Dellinger EP, Greene L, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology. 2014;35(S2):S66-S88. 37. Barnett J. Surgical skin antisepsis preparation intervention guidelines. Leadership. 2013;21:0.4. 38. Maiwald M, Chan ES-Y. Pitfalls in evidence assessment: the case of chlorhexidine and alcohol in skin antisepsis. Journal of Antimicrobial Chemotherapy. 2014;69(8):2017-21. 39. Phillips N. Berry & Kohn’s Operating Room Technique. 11 ed: Mosby; 2007. 1040 p. 40. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/ Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports. 2002;51(Rr-16):1-45, quiz CE1-4. 41. Alvarez JA, Macias JH, Macias AE, Rodríguez E, Muñoz JM, Mosqueda JL, et al. Povidone-iodine against sodium hypochlorite as skin antiseptics in volunteers. American journal of infection control. 2010;38(10):822-5. 42. Macias JH, Arreguin V, Munoz JM, Alvarez JA, Mosqueda JL, Macias AE. Chlorhexidine is a better antiseptic than povidone iodine and sodium hypochlorite because of its substantive effect. American journal of infection control. 2013;41(7):634-7. 43. Bruch MK. Toxicity and safety of topical sodium hypochlorite. Contributions to nephrology. 2007;154:24-38. 44. De Nardo R, Chiappe V, Gomez M, Romanelli H, Slots J. Effects of 0.05% sodium hypochlorite oral rinse on supragingival biofilm and gingival inflammation. Int Dent J. 2012;62(4):208-12. 45. Peck B, Workeneh B, Kadikoy H, Patel SJ, Abdellatif A. Spectrum of sodium hypochlorite toxicity in man-also a concern for nephrologists. NDT plus. 2011;4(4):231-5. 46. Dimmit D. Hypochlorous acid for definitive terminal cleaning of the hospital environment. 2015. 47. Rasmussen ED, Williams JF, editors. Stabilized hypochlorous acid disinfection for highly vulnerable populations: Brio HOCL™ wound disinfection and area decontamination. 2017 IEEE Global Humanitarian Technology Conference (GHTC); 2017: IEEE. 48. Serhan Sakarya M, Necati Gunay M, Meltem Karakulak M, Barcin Ozturk M, Bulent Ertugrul M. Hypochlorous Acid: an ideal wound care agent with powerful microbicidal, antibiofilm, and wound healing potency. Wounds. 2014;26:342-50. 49. NatraSan, 2019. <https://www.natrasanskin.co.uk/> 50. Clinisept+, 2019. <https://www.cliniseptplus.com/clinisept-faqs/#1551698694459-1c9e2a0a-7bdf> 51. Lennetech, Disinfectants Sodium hypochlorite. <https://www.lenntech.com/processes/disinfection/ chemical/disinfectants-sodium-hypochlorite.htm> 52. Otero A, Valentin R. Absence of Infection in Orthopedic Surgical Wounds Irrigated With Hypochlorous Acid. Ostomy Wound Manage. 2016;62(11). 53. Bowes L. Could a technology from the past change skin disinfection for the future? 2017. 54. Severing AL, Rembe JD, Koester V, Stuermer EK. Safety and efficacy profiles of different commercial sodium hypochlorite/hypochlorous acid solutions (NaClO/HClO): antimicrobial efficacy, cytotoxic impact and physicochemical parameters in vitro. The Journal of antimicrobial chemotherapy. 2019;74(2):365-72. 55. Dumitraşcu DI, Georgescu AV. The management of biofilm formation after hyaluronic acid gel filler injections: a review. Clujul Med. 2013;86(3):192-5. 56. Hermesch CB, Hilton TJ, Biesbrock AR, Baker RA, Cain-Hamlin J, McClanahan SF, et al. Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: efficacy and risk factor analysis. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 1998;85(4):381-7. 57. Balagopal S, Arjunkumar R. Chlorhexidine: The gold standard antiplaque agent. Journal of Pharmaceutical sciences and Research. 2013;5(12):270. 58. Haerian-Ardakani A, Rezaei M, Talebi-Ardakani M, Keshavarz Valian N, Amid R, Meimandi M, et al. Comparison of Antimicrobial Effects of Three Different Mouthwashes. Iran J Public Health. 2015;44(7):997-1003. 59. Rich SK, Slots J. Sodium hypochlorite (dilute chlorine bleach) oral rinse in patient self-care. The Journal of the Western Society of Periodontology/Periodontal abstracts. 2015;63(4):99-104. 60. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J. 2011;31(1):110-21.

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OWN YOUR BEAUTY Let your patients show their emotions with confidence

Susanne, actual BeloteroÂŽ patient, 46

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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 at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. M-BEL-UKI-0256 Date of Preparation November 2017

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Nasal Assessment Technique

Facial assessment

For a successful NSR outcome, there should be a perfect harmony between the nose and the surrounding facial structures. Therefore, the first step in achieving a proper congruity between the nose and the rest of the face is familiarity with the entire face. The analysis of the face should take place in an organised manner by dividing it into three segments – upper, mid, and Mr Ayad Harb shares his preferred lower zones – and reviewing each zone on front and profile assessment technique, the ‘squidge’ factor, views. It is vital to remember that in the context of nonsurgical augmentation, manipulation of one structure may when treating the nose with dermal filler exaggerate the other disharmony in another. For example, When assessing a patient for non-surgical rhinoplasty (NSR), one in a patient with a relatively large nose and small chin, augmentation has to be mindful of the anatomical layers that make up the nose of the nose, albeit into a more aesthetically pleasing shape, may and take into account several factors. These include overall facial exaggerate the discrepancy and imbalance in the lower face and chin. balance, the particular cosmetic imperfections in the nose, skin quality, In the upper face, one should observe the length and width of the patient psychology and one vital factor, which is difficult to quantify and forehead and the position and arch of the eyebrows. In the mid-face, can only be assessed by laying an experienced hand on the patient’s the standard intercanthal distance is approximately 31-33mm. In the nose – what I describe to my patients, as the ‘squidge’ factor. lower face, ideally the length of the nose should match the distance In this article, I will explain what the ‘squidge’ factor is and explore from the stomion to below the chin.5 Vertical alignment of the chin, lip why I believe it to be a suitable tool for patient education and nasal and nose is examined carefully. assessment. Though not scientific terminology, it is easily understood by all and clearly conveys the main limitations of treatment to the Skin quality patient. Counselling using clear and unambiguous language, ensuring Skin thickness varies between patients and within different locations patient understanding, realistic expectations and informed consent, in the same nose.6 Patients who have either thick or thin skin may are vital in NSR treatment. Note that I believe NSR is a treatment that present to be a challenge in NSR. Patients with thick, oily skin often should be performed by experienced practitioners only. present difficulty in achieving acute definition due to the relative firmness of the thick dermis. On the other hand, thin skin introduces Anatomical layers in the nose a higher risk of vascular injury and there are difficulties in hiding and There are four distinct layers that occupy the area between the skin moulding a highly cohesive gel implant.6 This information should and the underlying osseocartilaginous frame; the superficial areolar/ be noted and discussed with the patient. One of my fundamental fatty layer, the fibromuscular layer, the deep areolar/fatty layer, and principles in NSR procedures is to minimise the amount of product the perichondrium/ligamentous layer, shown in Figure 1.1 Immediately used, in order to avoid dispersion and expansion of the product and under the skin, there are superficial fatty layers containing vertical subsequent widening of the nose or loss of the fine architecture and fibers and septi running from the skin to the underlying SMAS. This contour. It follows, therefore, that using a highly cohesive product that layer is significantly thicker in the radix area and becomes extremely will produce more ‘lift’ per unit volume and that can withstand the thin in the mid-vault region, while thickening in the supratip area.1 The weight of the overlying tissues, will mean that less volume is required SMAS of the nose is the continuation of the SMAS of the upper half and a superior result can be achieved. of the face. The third layer of the nose is the deep fatty layer that separates the fibromuscular layer from the underlying nasal frame. The Examination of the nose major superficial blood vessels and motor nerves run within this layer. One should adopt a systematic approach to nose assessment, A distinct feature of the deep fat layer is that it does not have focusing on the three essential points of the nose – the radix, fibrous septa, so injection into this layer is relatively easy and the dorsum and tip and examine their actual versus ideal shapes. Each resulting volume is smooth. However, the presence of major blood of the three points should be viewed from the front, side and above. vessels makes this a high-risk area. The fourth soft tissue layer is the I find that assessing the patient from above reveals even the most periosteum and perichondrium.2-4 Injection of filler is always aiming to subtle deviations and discrepancies, shown in Figure 2. I examine be on this layer. size, width, symmetry, deviation and projection, with a light source pointed up from the feet of the Procerus patient, to exaggerate any natural shadows and deficiencies. Upper lateral cartilage On the profile view, the first zone Fibromuscular to assess is the radix, which should Nasalis and SMAS be 6mm deep for a female and 4mm deep for a male. The deepest Skin portion of the radix is approximately LLSAN at the level of the upper eyelash Superficial fat margin.5 The dorsal hump is Deep fat assessed regarding its size and Depressor septis location. The nasal length is then Lower lateral cartilage Figure 2: Example of assessing a patient from above assessed, which should equal Figure 1: The anatomical layers of the nose

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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the distance from the stomion to the submental. There should be a well-defined supratip break for females, and less so in males.5 The columellar-labial angles should be around 94-97° for a male and 97-100° for a female. The columellar should protrude about 3-4mm caudal to the alar rim, as long as the alar rim is deemed to be in an optimal position.5 The ‘squidge’ factor While it might be easy to imagine what a nose side profile might look like with certain injection strategies, it is vital to be able to advise the patient accurately and present them with realistic expectations and maintain a safety margin in all treatments. One of the most important factors that will determine the limitations, success or risks of a NSR is how flexible and ‘squidgy’ the tissues are. This is particularly true at the tip of the nose, where the size, stiffness and projection of the lower lateral cartilage, as well as the tightness and thickness of the overlying skin can have a major impact on the injector’s ability to affect any change in the shape and definition of the tip. I often ask the patients themselves to feel their nose or that of their accompanying partner or family member, comparing the ‘squidginess’ of the skin at the tip versus the radix. This enables the patient to realise the differences between individual noses as well as the different areas within the same nose, and hence the variability in the possible corrections and longevity of the results. An injector who has performed many NSRs will develop an ability to judge how much of a correction can be expected, based on palpation and pinching of the skin. This is certainly a skill that I have developed over the years and it has helped me to become more realistic and accurate when counselling my patients about their expected results. When assessing the tip of the nose, I perform a pinch test with the most distal parts of my index finger and thumb tips, and not the pulp area, shown in Figure 3. This generally allows me to raise a pinch of skin away from the underlying cartilage, even in the most challenging cases, to be able to assess the potential space between the two layers, where I could inject the dermal filler. Attempting to do the same using the pulps of the fingers generally raises the whole tip, including skin and cartilage and would not provide an accurate assessment. In my experience, when considering NSR, the ideal nose should be adequately flexible, with around 2mm of skin pinch and a strong cartilaginous base provided by the lower lateral cartilages. This allows the practitioner to palpate the correct injection plane and create a space into which the filler is then easily injected. The overlying skin accommodates the new volume without tension, and the cartilaginous base withstands the additional weight and is able to provide the necessary support. These factors combine to produce a beautifully defined and well-projected tip. Typically, slim Caucasian and Asian noses exhibit this quality, making them ideal patients for non-surgical treatment. Heavy, sebaceous skin in men usually exhibits a tighter pinch test. Similarly, thick skin, particularly in patients of Afro-Caribbean or East Asian descent (where the tip contains a thicker subcutaneous fat layer) is usually less flexible, has a weaker cartilage and a tighter pinch test, which is more difficult to discern skin from underlying cartilage.7 Post-surgical patients can have a very Figure 3: An example of the ‘squidge’ factor tight skin pinch test, to the extent that

sometimes there is absolutely no pinch possible, due to tight scarring from surgery and disruption of the natural anatomical planes. These patients should be approached with caution or avoided altogether if any concern lingers in the practitioner’s mind. A tip that is overly tight, with very little or no skin-pinch or one where the cartilage is rigid, tenting the skin tautly and offering no flexibility, is a poor candidate for non-surgical correction and the risks of vascular compromise from intravascular injection or excessive pressure, are expected to be high.8 This is mainly due to the fact that the anatomical planes can become less well defined, making injection into the correct deep plane, more difficult and less predictable. On the other hand, a tip which is excessively soft and flexible, whereby the entire tip feels as if it is ‘empty’, with palpable skin laxity and very weak cartilage support, is also a poor candidate for non-surgical correction. The problems arise from a skin envelope, which is lacking any structure or native volume and a thin and weak cartilaginous foundation. The skin laxity can lead the injector into a false supposition that re-inflation of the entire tip with filler is an imperative. However, this will commonly lead to a bulbous and overfilled tip that lacks any definition or projection. It is my belief that high volume injections raise the risk of vascular compromise, and these should be avoided at all times, particularly in the tip. Furthermore, the already feeble cartilaginous support will not stand up against the weight of additional filler gel and is likely to buckle, further compounding the existing problems of lack of definition and tip projection. The solution in this scenario is to target the caudal tip of midline septum with a small bolus of filler gel to improve tip projection. The most important point in this scenario is to temper the patient’s expectations, advising them that a slight lift is possible, however, a pointed, defined and raised tip is likely to be impossible and a high-risk target.

Conclusion In order to achieve any enhancement at a given point, in particular the tip, adequate laxity of the skin is required. This can be assessed by a pinch test using the index finger and thumb tips. In cases of tightness of the skin envelope, where no skin pinch is possible, then the correct plane of injection is likely to prove challenging to access, exposing the injector to increased risks of incorrect placement, vascular injury or injection under higher pressure. In these circumstances, treatment should be avoided, and the patient should be counselled about the likely risks. Where the skin is felt to be very squidgy, similar risks may exist. Mr Ayad Harb is a consultant plastic and aesthetic surgeon, operating in private clinics in London and Bicester, Oxfordshire. His practice is focused on cosmetic surgery, facial aesthetics and body contouring. Mr Harb specialises in non-surgical rhinoplasty and complex nose correction after surgery. Mr Harb is an international trainer in medical aesthetics and plastic surgery, as well as a consultant and international KOL for Teoxane. REFERENCES 1. Ozturk C, Larson J et al., The SMAS and Fat Compartments of the Nose: An Anatomical Study, Aesthetic Plastic Surgery, 2013. 2. Oneal RM, Izenberg PH, Schlesinger J, Surgical anatomy of the nose, Aesthetic Plastic Surgery Rhinoplasty, 1993 3. Firmin F, Discussion: the superficial musculoaponeurotic system of the nose, Plastic and Reconstructive Surgery, 1988. 4. Letourneau A, Daniel RK, Superficial musculoaponeurotic system of the nose, Plastic and Reconstructive Surgery, 1988. 5. Guyuron B, Precision rhinoplasty Part I: The role of life-size photographs and soft tissue cephalometric analysis, Plastic and Reconstructive Surgery, 1988. 6. Lessard M, Daniel RK, Surgical anatomy of septorhinoplasty, Archives of Otolaryngology, 1985 7. Chopra K, Calva D, Sosin M, A Comprehensive Examination of Topographic Thickness of Skin in the Human Face, Aesthetic Surgery Journal, 2015, Vol 35(8) 1007–1013 8. Tansatit T, Moon H J, Rungsawang C, Safe Planes for Injection Rhinoplasty: A Histological Analysis of Midline Longitudinal Sections of the Asian Nose, Aesthetic Plastic Surgery, 2016

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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where American psychologists analysed nearly 50 years of data, from more than 100 studies, each of which tried to determine whether facial expressions can affect people’s moods.2 The studies, which included more than 11,000 people worldwide, concluded that smiling does make people feel happier, while scowling makes them feel angrier, and frowning makes them feel sadder.2 This raises the most important question: Q. When do we treat a gummy smile? A. When it bothers the patient

Treating a Gummy Smile

Diagnosis

A gummy smile is a highly subjective diagnosis that shows tremendous variability over medical, dental and non-dental populations. When patients Dr Mark Hughes details the causes and diagnosis of a identify gingival (gum) display as an gummy smile and explores suitable treatment options area of concern, a treating practitioner has to be able to determine the A gummy smile can influence great distress and a lack of aetiology prior to investigating treatment options. However, some confidence in many people. Treatment options traditionally come patients do not express concern about their gum display or a desire from the worlds of both dentistry and maxillofacial surgery but to treat it, despite it being pointed out. The gum level is the gingiva aesthetic procedures now offer a non-surgical approach.1 It is to lip relationship. A study conducted by Dr Vincent Kokich Jr, asked important, however, to know how to diagnose the source of the a group of 300 people that included lay people (those who are not problem and to recognise when a multi, or interdisciplinary approach medically qualified) orthodontists and dentists what they thought, is required for best outcomes. I work with closely with my clinic’s when presented with varying examples and severity of gum display. co-owner, aesthetic practitioner Mr Benji Dhillon, so we can offer a It was reported that lay people were unable to detect asymmetry comprehensive assessment and treatment plan for all our patients. until it was at 3mm, or a lateral incisor narrowing until 4mm.3 Orthodontists rated their threshold at 2mm, the strictest requirement What is a gummy smile? in the study group. Surprisingly, open gum embrasure became It is generally accepted by dentists that gum display in a full detectable by dentists at 3mm whereas gum to lip distance was spontaneous smile of less than or equal to 2mm is aesthetically 4mm, the most lenient of the study group.3 This study demonstrates 1 pleasing. For patients who have more than this, it can be that almost everyone agreed that 2mm or less of gum tissue distressing and responsible for an actual or perceived lack showing was the level where most thought the smile looked normal. of confidence, as a display of more than 2mm of gum dispels Most started noticing the gum tissue at 3-4mm and thought that too aesthetic ideals. They will often adopt a more reserved or much gum tissue was showing anything more than 4mm.3 ‘practised’ smile to attempt to hide it. I have found that it can Some research suggests that around 14% of women and 7% of men be a source of ridicule or bullying from a very young age. In my have excessive gingival exposure (more than 2mm) when smiling.4 experience, sufferers can often appear less ‘happy’ or less ‘fun’ However, it is most likely higher than we think, primarily due to the than others due to the development of a subconscious routine of ability of the patient to learn how to ‘hide’ the situation. preventing their most spontaneous smile to occur. As a cosmetic dentist, it also worth explaining to my non-dental colleagues reading this article, that a gummy smile, is not Psychological impact necessarily unattractive, especially if the patient’s smile and While it is often generally believed that smiling can make us feel teeth are aesthetically pleasing. In other words, a gummy smile is better, the theory has never been proven in the academic literature. generally a far greater source of distress to patients, if their teeth However, a recent study was published in the Psychological Bulletin, are discoloured, crowed and out of proportion, shown in Figure 1. So, in my experience, often by simply correcting the smile first, the Before After gummy smile becomes far less important.

Causes

Figure 1: Example of correction of poor dental aesthetics rather than the gummy smile. This case could have been further improved with botulinum toxin injections.

In my experience, gummy smiles occur for a variety of reasons but most commonly it is due to a short upper lip, excessive gum tissue or small teeth, all of which are genetic. Before treatment, it’s necessary to understand exactly what causes a gummy smile. There are at least seven different causes, and if you don’t diagnose the cause correctly, you’re going to pick the wrong treatment for your patients.

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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*

1,

Juvéderm® VOLUX can restore and create facial volume 1,† in the chin and jaw area for 18–24 months.3,4,‡ Model treated with JUVÉDERM®. Results may vary. * Juvéderm® VOLUX contains lidocaine.1 The addition of lidocaine does not alter the physical properties of JUVÉDERM® products.5 † No available controlled clinical data on the effectiveness and tolerance of Juvéderm® VOLUX injection into anatomic regions other than the chin and jawline.1 ‡ Based on comparative preclinical testing and results from repeat treatment data, added to Juvéderm® VOLUX clinical study showing duration beyond 18 months after initial treatment or initial + top-up treatment in the chin and jaw, and based on clinical results for Juvéderm® VOLUMA with lidocaine showing 24 month duration in the mid-face establishes Juvéderm® VOLUX as having an in situ duration of 18–24 months.4 1. Juvéderm® VOLUX DFU. 72778JR10. Revision 2018-07-26. 2. Allergan. Data on File. INT/0663/2018. Juvéderm® VOLUX final clinical evaluation report. Oct 2018. 3. Allergan. Data on File. INT/0654/2018. Juvéderm® VOLUX final clinical study report & clinical evaluation report – efficacy and duration data. Oct 2018. 4. Allergan. Data on File. INT/0074/2019. Juvéderm® VOLUX final clinical evaluation report, July 2018. Jan 2019. 5. Raspaldo H et al. J Cosmet Dermatol. 2010;9:11–15. ©2019 Allergan. All rights reserved. Material developed and produced by Allergan. UK/0203/2019 Date of preparation: April 2019

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


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Presented concern

Concern explained

Possible treatment methods

Short upper lip

If a patient has an extremely short upper lip it’s not going to cover gingiva and their upper teeth

• •

Hypermobile lip

The lip moves too much

Botulinum toxin treatments

Vertical maxillary excess

Short lower jaw and an overgrowth of the upper jaw

Orthognathic surgery

Overgrowth of the upper teeth

Anterior over eruption, an excess overbite

• • • •

Orthodontics Cosmetic dentistry Periodontal surgery Combinations of the above

Tooth wear and subsequent overgrowth of the teeth downwards

Compensatory eruption

• • • •

Orthodontics Cosmetic dentistry Periodontal surgery Combinations of the above

Fillers Lip repositioning surgery

could create an unnatural look, or worse, and from experience, prevent the patient from being able to actually smile. It’s also important to note that the improvement with injectables is temporary and must be repeated every three to six months. It is important to make the patient aware that the procedure is not ‘permanent’ and requires maintenance injections over time.

Conclusion

Often patients present with a combination of aetiological factors and a multi• Orthodontics disciplinary approach will provide the very • Cosmetic dentistry Altered active eruption The teeth don’t make it out of bone best results. • Periodontal surgery • Combinations of the above It is important to be able to know when to refer for advice from an experienced Altered passive The gingiva doesn’t recede in a normal fashion, Periodontal surgery eruption as the person matures cosmetic dentist and vice versa. I work very closely with an aesthetic practitioner Table 1: Concerns and treatment methods available for gummy smile indications based on my experience in my clinic, which I believe allows us Treatment options to offer our patients the most comprehensive assessment and So, how else can a gummy smile be treated? The ideal target is the most effective treatment combinations. Treatment planning to get somewhere under 3mm for patients who desire to change for a gummy smile is one such area where we can combine our their smiles. As mentioned in Table 1, there are some indications expertise. Correct diagnosis in these cases is essential and this will where only dental treatment or surgery will be suitable however, determine what treatment is most suitable, however generally for for the purpose of this article, I will be focusing on non-surgical patients with only upper lip hypermobility, injectable treatments can techniques involving botulinum toxin and dermal fillers. These are be a suitable option. often popular choices because they have little to no downtime Dr Mark Hughes is an accredited member of the British associated with them. The price is also more appealing than Academy of Cosmetic Dentistry and 15-year full member surgery as generally botulinum toxin costs around £350 for this of the American Academy of Cosmetic Dentistry. He is the co-founder and dental director of Define Clinic procedure in the UK, whereas a gum lift procedure and dental in Beaconsfield, which offers cosmetic and restorative veneers can cost up to £15,000. dentistry, as well as aesthetic treatments. Studies suggest that botulinum toxin, when injected into the REFERENCES elevator muscles of the upper lip can be an effective method.5 1. Izraelewicz-Djebali K, Gummy Smile: orthodontic or surgical treatment?, Journal of Dentofacial A botulinum toxin treatment works by injecting the product into Anomalies and Orthodontics, 2015 <https://www.jdao-journal.org/articles/odfen/pdf/2015/01/ odfen2015181p102.pdf> the upper lip elevator muscles as it paralyses them and inhibits 2. Coles NA, Larsen JT, Lench HC, A meta-analysis of the facial feedback literature: Effects of facial contraction of the upper lip when smiling to prevent the gummy feedback on emotional experience are small and variable, Psychological Bulletin, 2019 1. Kokich VO Jr, Kiyak HA, Shapiro PA, Comparing the perception of dentists and laypeople to altered smile, shown in Figure 2.5 In my experience, placement in the alar dental esthetics, J Esthet Dent, 1999 fossa is most common – it usually determines the surface anatomy 2. Livada R, Shiloah J, Correcting Excess Gingival Display, Decisions in Dentistry, 2016 <https:// decisionsindentistry.com/article/correcting-excess-gingival-display/> of levator labii superioris alaeque nasi muscle (LLSAN). I would 3. Suber J et al., OnabotulinumtoxinA for the treatment of a gummy smile, ResearchGate, 2014 <https:// recommend that two to three units of botulinum toxin is used per www.researchgate.net/publication/261187831_OnabotulinumtoxinA_for_the_Treatment_of_a_ Gummy_Smile> injection site. Thin lips, which would fall under the short upper lip category in our table can also contribute to the problem. They can FURTHER READING • Levine RA, McGuire M, The diagnosis and treatment of the gummy smile, Compendium Contin be treated by using dermal filler to increase the volume and thus Educ Dent, 1997 the position of the lower border of the upper lip, which helps to • Fowler P, Orthodontics and orthognathic surgery in the combined treatment of an excessively “gummy smile”, N. Z. Dent, 1999 hide the excess gum display. • Lee EA, Aesthetic crown lengthening: classification, biologic rationale, and treatment planning However, botulinum toxins and fillers only work if the problem is in considerations. Pract Proced Aesthet Dent, 2004 • Robbins JW, Differential diagnosis and treatment of excess gingival display, Practical periodontics the lips, not the bone. As such, care has to be taken in diagnosis and aesthetic dentistry, 1999 and one has to be careful not to over inject the muscles, or they • Chu SJ, Karabin S, Mistry S. Short tooth syndrome: diagnosis, etiology, and treatment management. Before

After

• •

Journal of the California Dental Association, 2004 Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New approach to the gummy smile, Plastic and Reconstructive Surgery 1999 Bolas-Colvee B, Tarazona B, Paredes-Gallardo V, Arias-De Luxan S, Relationship between perception of smile esthetics and orthodontic treatment in Spanish patients, PLOS ONE, 2018

Figure 2: A hypermobile lip treated with botulinum toxin injections. Photos courtesy of Dr Peter McQuillan, Harley Street Dental Studio.

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The extracellular matrix To understand mesotherapy, it’s useful to consider skin structure, specifically the extracellular matrix (ECM) – the three-dimensional network of macromolecules. These include elastin, collagen and other glycoproteins in the inter-cellular space that support skin structure and therefore appearance. Significant drivers of ageing skin include:8,9 • Loss of collagen and elastin in the matrix – causing volume loss and laxity • Downregulation of the collagen I/III ratio – reducing smoothness of natural repair • Oxidative damage and degradation of the matrix itself • Hyper- or irregular pigmentation

Ingredients

Mesotherapy for Skin Quality Dr Loredana Nigro introduces the various mesotherapy options to address skin quality and ageing Mesotherapy was developed in 1952 by Dr Michel Pistor who described it succinctly as, ‘A little volume, a few times and in the right place’.1 Today, it is a well-established treatment in which liquid or gel compounds are injected intradermally at various depths, at multiple injection sites, to trigger or support aesthetically corrective processes in the skin, through a combination of physical stimulation, pharmacological effect, and appropriate microdosing.1 Although there are many indications – such as cellulite, stretch marks and alopecia – this article will focus on the core ingredients supporting skin rejuvenation. Various injection techniques and devices are used, from manual injection and nappage, to sophisticated devices, which deliver grid dosage of the required substrates, but they are outside the remit of this article.1-3 Mesotherapy is often used synergistically with other protocols, including topical application regimes, intra-dermal treatments such as carboxytherapy (which improves microcirculation and detoxification), or with energy-based treatments such as highfrequency ultrasound.1,4,5

Safe-use guidelines The indications for mesotherapy are broad and usually specific to the combination of injection technique and substrates. Combinations are formulated according to the use, case and experience of the practitioner,1 and one of the main uses of mesotherapy is to improve skin condition and firmness. Inappropriate use of mesotherapy substrates has led to controversy; for example, the injection of phosphatidylcholine for lipolysis has been associated with unpredictable and extreme post-treatment inflammation, and was banned in Brazil in 2002.6 Safe and effective mesotherapy treatments combine professional administration by an aesthetic practitioner with an appropriate selection of injectable components or ingredients.6 In my practice, a useful rule of thumb is that mesotherapy products should bear the CE marking, which certifies that they comply with the relevant EU directive on medical devices.7

Maintaining a competent ECM is crucial to optimising the appearance of the ageing skin. The principal of mesotherapy is to introduce appropriate and effective combinations of compounds into the skin based on their demonstrated pharmacological, metabolic or physical effects on skin ageing. Hyaluronic acid Ubiquitous in aesthetics, hyaluronic acid, or HA, is a glycosaminoglycan which is a key component of the ECM. It has an important role in skin hydration, healing and structure, as well as the structural functions of other tissues.10 In young adults, approximately 50% of the body’s HA content is found in the skin, but this diminishes rapidly to zero during skin senescence, leading to subcutaneous volume loss and skin ageing.11-13 Studies associate HA with scar-free healing, and increased synthetic ratio of collagen I/III, improving skin quality.14 HA naturally degrades rapidly, and therefore regular intradermal administration supports improved structural rejuvenation.11 In addition to its intrinsic effects, HA is useful as a base delivery substrate for other pharmacologically active mesotherapy ingredients because of its mucoadhesive, biodegradable and non-toxic nature.15 One three-month study looked at the efficacy of a non-cross-linked HA filler delivered by mesotherapy (via serial puncture 2-2.5mm depth) to 55 women with cutaneous ageing signs. One cheek was injected with the HA and the other with saline physiological solution. A trained panel blindly scored skin complexion radiance from standardised and calibrated photographs. They found that non-reticulated HAbased mesotherapy significantly and sustainably improves skin elasticity and complexion radiance.10 Organic silicon Silicon is the third most commonly occurring trace element in humans and is critical in synthesis of collagen and elastin, as well as the cross

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Ingredient

Formulation

Lines/wrinkles

Firming

Dull/dehydrated

Hyaluronic acid

Gel solution with HA. Typically low molecular weight and non-crosslinked.

Organic silicon

Typically monomethylsilanetriol and maltodextrinstabilised orthosilicic acid in a HA base (<20Mmol)

Highly polymerised DNA

Fragmented sodium deoxyribonucleotide, other nucleosides/nucleotides

DMAE

DMAE in HA base – 0.1-0.5%

Vitamins

Multiple vitamins in appropriate concentrations: A,B,C,E,K, coenzymes

Acne scaring

Pigmentation

Table 1: Mesotherapy ingredient indication matrix for skin rejuvenation and quality. Information amended from table provided by mesoestetic.

polymerisation of collagen – a reasonable proxy for its ‘firming’ effect. In addition, silicon is metabolised by the thymus in humans, which suffers significant age-related atrophy. This is likely the cause for the steep decline of silicon levels in the body as we age.16 While elemental silicon has very low bioavailability, organic silicon compounds such as monomethylsilanetriol and maltodextrin stabilised orthosilicic acid are readily absorbed,17 and in oral administration studies, have led to significant improvements in hair, skin and nail quality.17,18 The local injection of organic silicon has been shown to upregulate hyaluronan synthase 2 and proline hydroxylase, improving fibroblast resilience, local HA synthesis, maintenance of HA levels, and mitigate stem cell senescence.19,20 Synergistic use of injectable organic silicon, along with HA, maximises bioavailability of local components for collagen synthesis, polymerisation (tightening), and improvement of collagen I/III ratios.16,17,19 Highly polymerised DNA A relatively new ingredient in mesotherapy is highly polymerised fragments of DNA (HPDNA).21 HPDNA and, more generally, nucleosides and nucleotides, improve wound healing, mitigate inflammation, and upregulate metabolism in the fibroblasts, which produce collagen.21 HPDNA supports the formation and synthesis of collagen type I proteins in vivo, in preference to collagen III, which leads to a denser ECM typical of younger skin. Controlled trials have demonstrated a marked improvement in in vivo skin would healing22,23 and collagen I synthesis under the application

Figure 1: Effects of treatment for pigmentation and skin firmness with vitamin C, DMAE, HA, organic silicon. Images courtesy of mesoestetic.

Mesotherapy practitioners will usually choose ingredients that best suit the indication and will formulate combination treatments for individual patients to address their bespoke skin concerns

of HPDNA, without adverse outcomes. In my opinion, this suggests potential efficacy in combination with the direct tissue action of mesotherapy and synergistic kinetic or energy-based treatments for rejuvenation, but more studies would be useful.21 Dimethylaminoethanol Dimethylaminoethanol (DMAE) has broad clinical indications, and increased rigidity of the cervicofacial region was noted with oral administration for unrelated conditions in the 1970s.16 Studies have shown significant mitigation of periorbital fine wrinkles, forehead lines and lip fullness with application of topical 3% gel.24,25 Although, potential cytotoxicity concerns have been raised relating to the high 3% concentrations required to topically penetrate the epidermis.16,23 Non-toxic 0.1-0.2% micro-doses of DMAE can be delivered intradermally via mesotherapy, and have been shown to reduce the epidermal and dermal thinning associated with ageing, and to completely mitigate the age-related upregulation of collagen III relative to collagen I.26,27 DMAE has also been shown through in vivo trials to improve dermis thickness and water content of the stratum corneum.26,28

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Vitamins Vitamins are critical for normal rejuvenation, and many older patients have vitamin deficiencies.29 Micro-dosing of various vitamins and coenzymes through mesotherapy can demonstrably improve skin quality, particularly:30 • Vitamin C: a powerful antioxidant that directly ameliorates hyperpigmentation, reduces wrinkles and firms the skin. It has been shown to increase the number of fibroblasts, increasing collagen synthesis and the collagen I/III ratio.31 • Vitamin A: upregulates regeneration of melanocytes and the stratum corneum, has an antioxidant effect, and regulates skin glands and oiliness. • Vitamin E: physiologically supports skin repair. • B-vitamins and coenzymes: support optimal metabolism and physiological development of the skin and ECM.

Treatments and outcomes Mesotherapy practitioners will usually choose ingredients that best suit the indication and will formulate combination treatments for individual patients to address their bespoke skin concerns. An indication grid of common mesotherapy ingredients is explained in Table 1. There are some ingredients that are not listed, however these are the main ones for rejuvenating skin.

Summary Mesotherapy has a broad treatment range. Clinical practitioners can develop their own specific treatment protocols based upon research, experience and recommendations from providers and industry bodies. In my own experience, mesotherapy for skin quality is a demonstrably effective treatment. The periodic intra-dermal introduction of hyaluronic acid, along with pharmacologically active compounds and vitamins, provides a direct approach to rebuild and maintain the ECM – boosting collagen growth and volumisation, normalising pigmentation, and maximising the patient’s critical collagen I/III ratio. Although there is some research, it is limited and more studies would be beneficial in this area. Dr Loredana Nigro graduated from WITS Medical School in Johannesburg in 2003. She worked in internal medicine in South Africa’s public health sector until 2009, and decided in 2010 to move into aesthetic and antiageing medicine in private practice. She is currently a senior aesthetic clinician at Riverbanks Clinic in Harpenden and works with patients of all ages and skin types. Dr Nigro is also a KOL and clinical consultant for mesoestetic UK.

REFERENCES 1. Konda D, Mesotherapy: What is new? Indian J Dermatol Venereol Leprol. 2013 Jan-Feb;79(1):127-34. 2. Mesotherapy Worldwide, Physician - Protocol Corner. <http://www.mesotherapyworldwide.com/ Mesotherapy_Protocols_Corner.htm> 3. Sivagnanam G, Mesotherapy the French Connection, Journal of Pharmacology and Pharmacotherapeutics, January-June 2010, Vol 1, Issue 1. 4. Mesoestetic Mesotherapy Guide, data on file with Dr Loredana Nigro. 5. Aurora Tedeschi, et al., Mesotherapy with an Intradermal Hyaluronic Acid Formulation for Skin Rejuvenation: An Intrapatient, Placebo-Controlled, Long-Term Trial Using High-Frequency Ultrasound, Aesthetic Plastic Surgery February 2015, Volume 39, Issue 1, pp 129–133. 6. Kamalpour et al., Injection Adipolysis: Mechanisms, Agents, and Future Directions. The Journal of Clinical and Aesthetic Dermatology [01 Dec 2016, 9(12):44-50] 7. COUNCIL DIRECTIVE 93/42/EEC, 1993. <https://eur-lex.europa.eu/legal-content/EN/TXT/ PDF/?uri=CELEX:31993L0042&from=EN> 8. Journal of Tissue Engineering, et al., The extracellular matrix: Structure, composition, agerelated differences, tools for analysis and applications for tissue engineering’, Journal of Tissue Engineering, 2014 Dec 20;5:2041731414557112. 9. Human skin pigmentation: melanocytes modulate skin color in response to stress Gertrude-E. Costin,1 and Vincent J. Hearing† talks about pigment 10. Martine Baspeyras, et al., Clinical and biometrological efficacy of a hyaluronic acid-based mesotherapy product: a randomised controlled study, Arch Dermatol Res. 2013; 305(8): 673–682. 11. Papakonstantinou, E., Roth, M., & Karakiulakis, G. (2012). Hyaluronic acid: A key molecule in skin aging. Dermato-Endocrinology, 4(3), 253–258. doi:10.4161/derm.21923 12. Tzellos TG, Klagas I, Vahtsevanos K, Triaridis S, Printza A, Kyrgidis A, et al. Extrinsic ageing in the human skin is associated with alterations in the expression of hyaluronic acid and its metabolizing enzymes. Exp Dermatol 2009; 18:1028-35; PMID:19601984; http:// dx.doi.org/10.1111/j.16000625.2009.00889.x 13. Noble PW. Hyaluronan and its catabolic products in tissue injury and repair. Matrix Biol 2002; 21:25-9; PMID:11827789. 14. M.A.Croce et al., Hyaluronan affects protein and collagen synthesis by in vitro human skin fibroblasts, Tissue and Cell, Volume 33, Issue 4, August 2001, Pages 326-331. 15. Gangliang Huang & Hualiang Huang (2018) Application of hyaluronic acid as carriers in drug delivery, Drug Delivery, 25:1, 766-772, DOI: 10.1080/10717544.2018.1450910 16. JJ, Hampson GN. Orthosilicic acid stimulates collagen type 1 synthesis and osteoblastic differentiation in human osteoblast-like cells in vitro. Bone. 2003 Feb;32(2):127-35 17. Anderson Oliveira Ferreira et al., Anti-Aging Effects of Monomethylsilanetriol and MaltodextrinStabilized Orthosilicic Acid on Nails, Skin and Hair, Cosmetics 2018, 5, 41. 18. doi: 10.1186/1743-7075-10-2. 19. Fabiano Svolacchia, et al., Organic Silicium In Aesthetic Medicine: A Review Of Letterature And Meta-Analysis, December 2017/ 20. Margherita Maiol et al., REAC technology and hyaluron synthase 2, an interesting network to slow down stem cell senescence, Scientific Reports volume 6, Article number: 28682 (2016). 21. Tao Jiang, et al., Structurally Ordered Nanowire Formation from Co-Assembly of DNA Origami and Collagen-Mimetic Peptides, J. Am. Chem. Soc, 2017. 22. Uhoda, N. Faska, C. Robert, G. Cauwenbergh, and G. E. Piérard, “Split face study on the cutaneous tensile effect of 2-dimethylaminoethanol (deanol) gel,” Skin Research and Technology, vol. 8, no. 3, pp. 164–167, 2002. 23. B.Sommerfeld, Randomised, placebo-controlled, double-blind, split-face study on the clinical efficacy of Tricutan on skin firmness, Phytomedicine, Volume 14, Issue 11, 5 November 2007, Pages 711-715. 24. Fabiano Svolacchia, The PDRN (polydeoxyribonucleotide) In Cosmetic Medicine, Biological Introduction, Literature And Meta-Analysis, 2018. 25. Alfredo Gragnani, et al., Dimethylaminoethanol Affects the Viability of Human Cultured Fibroblasts, Aesthetic Plastic Surgery 31(6):711-8, January 2008. 26. Su Liu et al., Effects of Dimethylaminoethanol and Compound Amino Acid on D-Galactose Induced Skin Aging Model of Rat, The Scientific World Journal, Volume 2014. 27. Tadini, K.A et al., In vivo skin effects of a dimethylaminoethanol (DMAE) based formulation, An International Journal of Pharmaceutical Sciences, Volume 64, Number 12, 1 December 2009, pp. 818-822(5). 28. Johnson KA, et al., Vitamin nutrition in older adults, Clinics in Geriatric Medicine [01 Nov 2002, 18(4):773-799. 29. Prikhnenko S, Dalens M, Polycomponent mesotherapy formulations for the treatment of skin aging and improvement of skin quality, 7 April 2015 Volume 2015:8 Pages 151—157. 30. Nermin M. Yussif et al., Evaluation of the Anti-Inflammatory Effect of Locally Delivered Vitamin C in the Treatment of Persistent Gingival Inflammation: Clinical and Histopathological Study, Journal of Nutrition and Metabolism, 2016.

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Offering Microcurrent Therapy Aesthetic nurse Laura Rosser discusses the benefits of a microcurrent facial for skin rejuvenation Microcurrent therapy, also known as electrotherapy or the microcurrent facial, is a treatment modality that is often overlooked by healthcare professionals as it is most commonly associated with the beauty industry. However, this article will explore how it can be used as a successful stand-alone treatment for patients who are apprehensive about undergoing more invasive procedures, and also how it can be utilised as an additional treatment for rejuvenating the skin.

History of microcurrent therapy Electrotherapy dates back to the ancient Egyptians. Existing medical papyri (ancient Egyptian texts) refer to the use of the ‘Nar’ fish – the Egyptian catfish – which was reportedly used to conduct electricity through the body to eliminate disease and cure common ailments including migraines, headaches and gout.1 This method of treatment captured the imaginations of many Greek and Latin writers, including Plato and Aristotle.1 One piece of work by the army surgeon of Emperor Nero insisted on an application of two to three live catfish to the head of the patient to cure migraines and headaches.2 As a treatment for gout, the sufferer was assisted to stand on a wet shoreline and receive electrotherapy, which would cause the entire foot to go numb, working its way up the tibia as far as the knee.2 In 1830, Italian physicist Dr Carlo Matteucci discovered that injured tissue in the human body discharged its own electricity3 and by the 1840s, Dr Matteucci shed light on the electrical properties of animal tissues. In fact, Dr Matteucci was the first to detect an electrical current in the heart4 and scientists have since expanded on this work to explore the benefits of electrotherapy in healthcare.3 The

outcomes of one study published in 2003 on the treatment of leg ulcers with a microcurrent device showed the mean reduction of the wound surface of the ulcer was reduced by 95% after just eight weeks of treatment.5 It is widely believed that Dr Thomas Wing, a fifth generation Chinese physician who was treating patients for Bell’s palsy and facial pain in the 1970s, noticed that the faces of his subjects appeared smoother and they looked younger in appearance following their treatments.6 Evidence for the efficacy of physical therapies for the treatment of Bell’s palsy is lacking and a Cochrane systematic review of the efficacy of physical therapies concluded that there was no significant benefit in this treatment area;7 however, the ongoing findings relating to improvement in skin tone and appearance have continued. For example, a 2003 study conducted by Dr Emil Chi, the director of the department of pathology and chairman of the department of histopathology at the University of Washington Medical School, determined that when subjects’ skin tissue was treated with microcurrent technology, there was a 45% increase in the number of elastin fibres in the dermis and a 10% increase in collagen thickness in the connective tissues. The study also showed a 35% increase in blood circulation to treated areas and increased lymphatic drainage,8 all of which are the desired outcomes from a traditional microcurrent therapy facial.

What is microcurrent therapy and how does it work? The body has a continual flow of electrical impulses that transmit signals through tissues, via electrons, chemicals and electromagnetic bonds.9 Microcurrent technology offers a safe and effective way of reprogramming muscle fibres to lift and tone the muscles of the face and body. It has a long history of use in both the beauty industry and the field of physiotherapy with its harmlessness confirmed10 with use of transcutaneous electrical nerve stimulation (TENS) being widely used for musculoskeletal pain.11 One recent study suggested safety and efficacy of using microcurrent to the soles of the children’s feet to stimulate growth in short-stature individuals.12 Microcurrent lifts and tones the muscles by stimulating the Golgi tendon organ, which is present in every muscle in the body. It is a proprioceptor, which is adjacent to the myotendinous junction.13 Together with the muscle spindle fibres, the Golgi tendon organ is responsible for muscle tone.11 The microcurrents are delivered through a specific device with two handpieces, or wands; one that is positive and one negative. Different

Microcurrent technology offers a safe and effective way of reprogramming muscle fibres to lift and tone the muscles of the face and body

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settings can be used to achieve different outcomes. Lower frequency settings of around 0.8Hz allow for the microcurrent to penetrate more deeply through the skin and into the dermis to reach the muscle fibre and stimulate the lymph nodes. This can also provide a lymphatic drainage action, which reduces puffiness in areas where excess interstitial fluids can accumulate, such as the mid and lower face, under eyes and jawline. Microcurrent has also been shown to be effective in reducing swelling through lymphatic drainage following rhinoplasty surgery in a study conducted in 2016.14 The higher frequency settings (up to 600Hz) enable the current to act superficially to stimulate the epidermis, thus improving the condition and texture of the skin by contracting the muscle fibres and stimulating the circulatory skin to give an additional rejuvenating effect to the skin.15 When microcurrent is applied to the skin it also stimulates healing by restoring the natural flow of electrical impulse, blood flow and stimulates collagen and elastin production, as previously discussed. One study of 30 women under 45 years of age showed a marked reduction in facial lines and wrinkles, reduced acne scarring and reduction of scars from injury in participants treated with microcurrent technology, in addition to reducing active acnes.16 An additional benefit of microcurrent technology in the aesthetics field is the application of electroporation. This is an electrical technique that involves the application of high-voltage electrical impulses for very short durations to enhance the skinâ&#x20AC;&#x2122;s permeability. It does this by creating transient pores in the stratum corneum, therefore increasing permeability and the percutaneous absorption of drugs,17 or more commonly used in aesthetics, active topical ingredients to provide a rejuvenating effect on the skin. A conductive gel is used to transmit the electrical current through and over the skinâ&#x20AC;&#x2122;s surface, which can also be infused with beneficial ingredients. At my clinic, I use a mild alpha hydroxy acid (AHA) peel to speed up the cell renewal process, followed by a microcurrent gel with a blend of aloe vera, marine collagen and royal jelly. I find that this combination has an instant brightening and hydrating effect on the skin. A 2014 study has shown that a skincare regime involving AHAs and vitamins significantly improves the appearance of the skin, including wrinkles and skin texture, as well as elasticity, without significant adverse effects.18 A study explored the effects of aloe vera application with and without microcurrent therapy on the healing of surgically-induced wounds in rats. It indicated that the group treated with microcurrent plus aloe vera presented an earlier onset of the proliferative phase compared to the control group and animals treated with aloe vera gel alone. In both groups the number of fibroblasts and newly-formed vessels were much greater than the control group, indicating that both treatments are effective in their own right.19

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Case studies Before

After

Figure 1: 50-year-old patient before and after six microcurrent therapy sessions

Before

Case study 1 A 50-year-old patient desired overall facial rejuvenation, expressing particular dissatisfaction with the eye area and laxity of skin tissue in the upper eyelid. The patient underwent a course of six sessions, spaced seven to 10 days apart, to the full face with some extra time spent around the eye; approximately six to seven minutes per eye.

Case study 2 This 59-year-old patient expressed a desire for a more lifted facial appearance in the cheek area. Six sessions of microcurrent facial treatments were performed seven to 10 days apart. Results show a marked reduction in the nasolabial folds, as well as lifting and firming of the mid-face and rejuvenation and plumping to the perioral area.

After

Figure 2: 59-year-old patient before and after six microcurrent therapy sessions

Case study 3 This 60-year-old patient expressed a desire for overall skin rejuvenation, lifting and toning. A marked improvement could be seen after just one session of microcurrent using a lifting and toning action using two probes to physically lift and tighten the muscle, whilst adding an electrical impulse. A smoothing action was used with the probes to aid lymphatic drainage alongside a feathering technique. This technique involves passing smalltipped electrodes over the skin at a high frequency to stimulate circulation to the epidermis, which provides an electroporation effect when used in conjunction with topical products or a facemask. Smoothing of the forehead lines can be seen, in addition to overall improvement in hydration of the skin and reduction of hyperpigmentation. This patient went on to have a course of six treatments. Before

After

Before

After

Figure 3: 60-year-old patient before and immediately after one treatment of microcurrent therapy

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Clinical practice As an aesthetic nurse who offers a wide range of non-surgical treatments, including skin treatments and more invasive injectable procedures, I find that there are a group of patients, and even potential patients, who are not yet ready to explore more invasive options such as toxin or dermal fillers. They are often people who fear the long-term outcomes of these treatments due to common misconceptions or they may even have needle phobia. It is beneficial to my practice that whilst educating this patient group in the efficacy of these treatments, I am also able to offer a safe, noninvasive, yet effective treatment that helps to gain my patient’s trust. Another benefit in addition to patient satisfaction is patient comfort. The majority of patients report that microcurrent therapy is very relaxing and state that they can see immediate results. Many also report that they can continue to feel an ongoing tightening experience of the skin up to three to four days after treatment. As with any treatment, some maintenance is required and I often compare the treatment to a gym workout for the face. Results can be seen after one session; however, I find that best results are seen with a regular treatment regime of around seven days apart for a course of between six to seven sessions. Some patients will come back every few weeks for a maintenance session, some will opt to have another course of treatment in a few months’ time. As with attending the gym, the more time you invest, the greater the results you will see. Some will occasionally go on to have injectable treatments, but will continue to have microcurrent facials as a way to improve their skin tone, reduce fine lines and puffiness, and to complement the results of injectables. Additional benefits I have discovered whilst incorporating this treatment into my aesthetic practice can be to improve facial asymmetry caused by muscle weakness. I have found that it can also reverse the effects of toxin treatment when a complication such as ptosis or brow heaviness has occurred as I find that microcurrent therapy can re-educate the muscle and give movement back.

Contraindications and side effects As with most treatments, pregnancy is contraindicated. Other contraindications include:20 • Epilepsy • Cancer • Photosensitive migraines • Patients with pacemaker • Extreme acne or rosacea • Metal plates or implants in the face • Botulinum toxin or dermal fillers in the two weeks prior to treatment Microcurrent facials have very few side effects and I have not experienced any from my own patients. It is reported that some patients have experienced drowsiness and mild nausea following treatment. Hydration is recommended after treatment, and any negative symptoms usually pass within 12-24 hours.21

Microcurrent therapy can be offered as a non-invasive alternative to injectables to reduce the appearance of facial lines and wrinkles. It can also be used to treat mild acne, acne scarring and improve wound healing and has a deeply hydrating effect on the skin when topical products are incorporated into the treatment. In addition, microcurrent therapy provides lymphatic drainage by reducing interstitial fluid that causes puffiness and acts as a transmitter to aid product absorption through electroporation of medications or facial products. Laura Rosser is an aesthetic nurse and founder of Belle Derma Aesthetics in South Wales, a Save Face and Acne and Rosacea Association-accredited clinic and treatment provider. Rosser has nine years’ experience as a registered nurse, four years in aesthetics and five years in the permanent makeup industry. REFERENCES 1. Park Roz, ‘Ancient Egyptian Headaches: Ichthyo- or electrotherapy?’, Pharmacy & Medicine in Ancient Egypt. Proceedings of the conferences held in Cairo (2007) & Manchester (2008) ed. by J.Cockitt & A.R. David B.A.R. Archeopress, Oxford (2010). 127-131, p.1,2 2. Park Roz, ‘Catfish Remedy for Gout in Ancient Egypt’ (Read at History of Ancient Medicine conference, Reading University. 2006), p.9 3. Bull. B.R ‘The electrophysiological work of Carlo MatteuccI’ (1996) Brain Research Bulletin Volume 40, Issue 2, ;40(2). p.69-91 <https://www.sciencedirect.com/science/article/abs/ pii/0361923096000366?via%3Dihub> 4. Rogers Kara ‘Defibrillation- Health’ (2009) Britannica Enclopedia, p.1. <https://www.britannica.com/ science/defibrillation#ref1118183> 5. Wirsing PG et al., ‘Wireless microcurrent stimulation- an innovative electrical stimulation method for the treatment of patients with leg and diabetic foot ulcers’, International Wound Journal, 12 (2015) 693-698, p.1. 6. ‘The history of frequency-specific microcurrent’ Anaesthesia Key, (2016) <https://aneskey.com/thehistory-of-frequency-specific-microcurrent/> 7. Teixeira L.J, Soares B.G, Vieira V.P, Prado G.F. ‘Physical Therapy for Bell’s palsy (idiopathic facial palsy)’ Cochrane Database Systemic Review, 2008;3:CD006283. 8. Madigan-Fleck Erin, ‘The Physiological Effects of Microcurrent’, p.5 <https://www.dermascope.com/ treatments/the-physiological-effects-of-microcurrent> 9. Madigan-Fleck Erin, ‘The Physiological Effects of Microcurrent’, p.3. https://www.dermascope.com/ treatments/the-physiological-effects-of-microcurrent 10. Fatimeh Saniee et al., ‘Consider of Microcurrent’s effect to variation of Facial Wrinkle trend, Randomized Clinical Trial study’, Journal of Life Science, 9, 2012, p.1186. 11. Yvonne Coldra et al. ‘ACPWH guidance on the safe use of Transcutaneous Electrical Nerve Stimulation (TENS) for musculosketal pain during pregnancy’ (2007) < https://www.oaa-anaes.ac.uk/ assets/_managed/editor/File/PDF/info_for_mothers/TENS%20Statement%20JUNE%2007%20 ACPWH%20Final.pdf> [accessed 16 July 2019] 12. Arum Jung et al., ‘Efficacy and safety of microcurrent stimulation of acupoints on the sole of the foot of children with short stature in 25th percentile of height by age: A randomized controlled trial’, European Journal of Integrative Medicine (2016) Volume 8, Issue 2, p.122-127. <https://www. sciencedirect.com/science/article/abs/pii/S1876382015300330> 13. Enrico Marani and Egbert A.J.F Lakke ‘Peripheral Nervous System Topics’ The Human Nervous System (Third edition, 2012). <https://www.sciencedirect.com/topics/neuroscience/golgi-tendonorgan> 14. Aleksanyan TA et al. ‘Treatment with the use of microcurrent lymphatic drainage physiotherapy during the postoperative period following rhinoplastic surgery’ Vestn Otorinolaringol. 2016; 81(5), p.50-53. <https://www.ncbi.nlm.nih.gov/pubmed/27876738> 15. Madigan-Fleck Erin, ‘The Physiological Effects of Microcurrent’, p.3 <https://www.dermascope.com/ treatments/the-physiological-effects-of-microcurrent> 16. Fatimeh Saniee et al., ‘Consider of Microcurrent’s effect to variation of Facial Wrinkle trend, Randomized Clinical Trial study’, Journal of Life Science, 9, 2012, p.1184-1189. 17. Longsheng Hu and others ‘Ionophoretic Transdermal Drug Delivery’ Handbook of Non invasive Drug Delivery Systems (2010). https://www.sciencedirect.com/topics/neuroscience/electroporation 18. Diana Tran et al. ‘An antiaging skin care system containing alpha hydroxy acids and vitamins improves the biomechanical parameters of facial skin’ (2014) Clinical Cosmetic and Investigatory Dermatology. 2015; 8, p.9–17. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4277239/> 19. Fernanda Aparecida Sampaio Mendonca et al., ‘Effects of the application of Aloe vera and microcurrent on the healing of wounds surgically induced in Wistar rats’, ACTA Cirurgica Brasileira, vol.24 no.2 Sao Paulo (Mar/April 2009) <http://www.scielo.br/scielo.php?script=sci_ arttext&pid=S0102-86502009000200013> 20. Silhouette International ‘Non-Surgical Microcurrent Facial Lifting- Dermalift Microface Intense with Jaw sculpt, User Manual’ Silhouette International, Silhouette House (p. 6) <https:www. silhouettebeauty.com> 21. Author unknown (2018) ‘Microcurrent Facelift’ The Derm review <https://thedermreview.com/ microcurrent-facelift/>

Conclusion Microcurrent therapy is a safe and effective rejuvenating treatment with a long history of research. It can be used in addition to more advanced aesthetic treatments or as a stand-alone treatment to offer re-contouring of the facial muscles, deep skin hydration and collagen synthesis.

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Using BDD Assessment Tools Dr Raj Arora outlines the current tools available for carrying out a suitable screening for Body Dysmorphic Disorder prior to a proposed aesthetic procedure Body dysmorphic disorder (BDD) is a condition whereby patients suffer from a disabling preoccupation with perceived flaws or defects in their appearance.1 These perceived flaws/ defects are often unnoticeable to others but are a huge focus to the patient. Individuals with BDD frequently seek cosmetic treatments to correct perceived defects and reduce the extreme dissatisfaction with their physical appearance. I also think it’s important to note here that the prevalence of BDD in a cosmetic surgery setting is significantly higher (5-15%) than in the general population (1-3%).2 This was also highlighted in recent news that high-street retailer Superdrug, which now offers injectable treatments, would need to introduce BDD questionnaires as a priority due to the volume of the general population having access to them.3 One survey carried out in the US found that 84% of plastic surgeons had unknowingly carried out a cosmetic procedure on a patient with BDD.4 As an aesthetic practitioner and GP, I take a keen interest in mental health; especially that surrounding body image. Guidelines provided by the National Institute for Health and Care Excellence (NICE) state the importance of screening to diagnose BDD and it is crucial to be able to identify those individuals who are struggling with, or are at risk, of BDD5 to ensure we are not overlooking a mental health condition requiring treatment. This also allows us, as responsible practitioners, to offer the help that patients may need. It is also important to ensure that we protect ourselves (by screening for BDD) from those patients that may have unrealistic expectations from a planned procedure. If we are treating patients with an ethical stance then we should show interest in their mental wellbeing and consider if we will achieve a desired outcome or whether the issue deeper. During my day-to-day practice, I have found that there are many different screening tools available to assess for this disorder and it is not always clear which tool is ‘best’ to use. In this article, I will analyse some, but not all, of the tools available to assess and screen for BDD and share, in my opinion, which I believe to be most effective.

Understanding BDD BDD is an under-diagnosed and often underreported condition. Research published in Plastic Surgery Nursing found that it often occurs during the adolescent years.6 According to the NICE guidelines, it is estimated that approximately 0.5-0.7% of the UK population has BDD.5 NICE reported a tendency of equal proportions of men and women across all age groups. The causes of BDD are often embedded in psychological and physiological factors.6 They can include, but are not limited to: • Abuse or bullying • Low self-esteem • Perfectionism • Depression/anxiety We can also look at the symptoms of BDD to understand what is required in an assessment tool to ensure we are correctly screening individuals. If we broadly group symptoms then there are two categories: common obsessive concerns about appearance and common compulsive behaviours.7 Obsessive concerns can include intrusive negative thoughts about body image; a particular feature or multiple features. Common compulsive behaviours may include repetitively checking mirrors, seeking constant reassurance from others, constantly comparing appearance to others, or even seeking cosmetic enhancements.8 BDD criteria looks at the categories of preoccupation (constant thoughts regarding the ‘perceived flaw’), impairment of global functioning (not being able to carry out normal daily

activities, social avoidance, impact on work life/school life), and subjective distress (intensity of emotions experienced by an individual in response to their ‘perceived flaw’ in those with possible BDD).9,10 From a litigation perspective; detection of BDD is vital to ensure optimal patient outcomes and to reduce patient dissatisfaction post procedure. Having a pre-procedure checklist, which includes an assessment for BDD, can provide practitioners with some legal protection but can also ensure that we are practising ethically and in the best interests of our patients. Should we feel that a patient exhibits symptoms of a mental health disorder then referral and further management is needed.11 There has been a transition in the way that BDD is viewed with regards to its relationship with aesthetic procedures. Previously, BDD was viewed as an absolute contraindication to aesthetic procedures. However, more recent research shows that decision-making based on BDD severity and individual global functioning (as mentioned above) of a patient may be more appropriate.9

BDD tools

There are a number of tools in place, created by a number of associations and researchers, that are designed to screen for BDD. Each has its advantages and disadvantages in my opinion, however whichever tool you use in your clinical environment it is important to understand exactly how the patient’s flaw is affecting their day to day life. The tools which provide a detailed insight allow us to assess the patient better by looking at different facets of their life and heeding the impact that the flaw may have. Also, some questionnaires look at the patient’s own insight into their possible BDD symptoms. This is helpful to understand whether the patient has any awareness of a possible mental health condition related to their perception of their own appearance. There are a number of tools available, however, for the purpose of this article, I have chosen both quick answer questionnaires and others that are more detailed. This way we can see how they differ and whether they could potentially be used together. Appearance Anxiety Inventory The Appearance Anxiety Inventory (AAI) is a 10 question self-report scale that measures the cognitive and behavioural aspects of body image anxiety and BDD. It can be used for both diagnosis and assessing severity.12 The AAI was developed by Veale

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et al.12 to assess cognitive processes and behaviour characteristics of BDD. It was originally used to assess the progress of patients throughout therapy for BDD. The AAI uses a five-point Likert scale to answer the 10 questions. The range of scores is from 0-40. The recommended cut-off score is 19, at and above this level is thought to be indicative of BDD. The 10 questions are as follows: 1. I compare aspects of my appearance to others 2. I check my appearance (e.g. in mirrors, by touching with my fingers, or by taking photos of myself) 3. I avoid situations or people because of my appearance 4. I brood about past events or reasons to explain why I look the way I do 5. I think about how to camouflage or alter my appearance 6. I am focused on how I feel I look, rather than on my surroundings 7. I avoid reflective surfaces, photos or videos of myself5 8. I discuss my appearance with others or question them about it 9. I try to camouflage or alter aspects of my appearance 10. I try to prevent people from seeing aspects of my appearance within particular situations (e.g. by changing my posture, avoiding bright lights) I feel that the above tool is helpful in that it does cover a broad range of questions with relation to symptoms of BDD. It looks at both obsessive concerns and compulsive behaviours. In terms of severity, it is difficult to assess from this scale as it does not quantify frequency of behaviours. As an overall screening tool this could be useful; however, I believe that other tools could be better at capturing detail.

Working closely with mental health professionals is, in my opinion, very important Cosmetic Procedures Screening-Questionnaire The Cosmetic Procedures Screening-Questionnaire (COPS) looks at perceived defects or flaws. The scale describes these perceived flaws as ‘features’.13 The questionnaire was also developed by Veale et al.13 and the idea was to create a questionnaire that would be brief, easy to access and would be able to pick up potential dissatisfaction post procedure or a deterioration in BDD symptoms. During the assessment the patient fills out a self-report where they outline up to five top features which cause concern. The initial part of the questionnaire is qualitative; therefore patients get an opportunity to document their feelings in their own words. There is then opportunity for a pie chart to be filled out with percentage attribution of concern with regards to the aforementioned ‘features’. The pie chart is useful as it allows us to understand from the patient’s perspective exactly how much this ‘feature’ is affecting them and the importance that they are placing on that particular feature, compared with a second or third feature. The next step screening questionnaire then uses nine questions to explore these features further. Each question has a scale of 1-8. A score of 40 or

more is highly suggestive of BDD.13 The COPS questionnaire provides a lot of detail and insight into the symptoms of the patient. The questions are structured in a way that they look at both frequencies of obsessive behaviours, as well as the effect of their symptoms on their relationships and social interactions. I feel that this tool gives good amount of detail and can be useful for the patient to visualise the concerns in the pie chart, but it can be lengthy compared to others to follow through in a busy clinic. It may be helpful to get the questionnaire filled in prior to the first appointment with a patient. Body Dysmorphic Disorder Questionnaire The Body Dysmorphic Disorder Questionnaire (BDDQ) asks four questions based on concerns for appearance, frequency of concern and how this concern with appearance may have affected different domains of the patient’s life such as social, school/work and any avoidance of activities.14 The likelihood of BDD is then based on the answers to these particular questions and a note is made by the practitioners of which answers of ‘yes’ indicate a likely BDD diagnosis. The first two questions are: • “Are you worried about how you look?” • “Do you think about your appearance problems a lot? And do you wish you could think about them less?” The patient must answer positively to at least one of these to continue with the questionnaire. Following this, a positive answer to at least one part of the third question (below), assessing distress and global impairment caused by the preoccupation, is further required for a likely BDD diagnosis. • “How much time do you spend thinking about your defect(s) per day on average?” has the response alternatives a) less than 1 hour per day, b) 1-3 hours per day and c) >3 hours per day Thinking about the appearance flaw ‘at least an hour per day’ is a) time-criterion when diagnosing BDD according to the Structured Clinical Interview for DSM-IV.8 The DSM-IV are the codes used in the diagnostic and statistical manual of mental disorders.15 It is published by the American psychiatric association and covers mental health disorders for both children and adults. BDD criteria is fulfilled with positive answers to the first three questions of the BDDQ in combination with answer b) or c) on the fourth question. The fourth question, “Is your main concern with your appearance that you are not thin enough or that you might become fat?” is used to exclude people primarily concerned about their weight and body image appearance. This helps to not over diagnose BDD when an eating disorder might be a potentially more accurate diagnosis. I believe that this is a fair tool for the diagnosis of BDD as it does enquire about compulsive behaviour as well as obsessive concerns with regards to one’s appearance. However, the fourth question directly addresses body concerns over a specific perceived flaw. Perceived flaws can be seen to be an issue if they are causing pre-occupational thoughts, social avoidance or mental health concerns in line with BDD. Compared with some of the other BDD questionnaires and screening tools I feel that this particular scale may be slightly vague. However, the BDDQ does work as a self-reporting questionnaire and a study carried out by Phillip et al. has shown it has high sensitivity (100%) and specificity (89%) for BDD diagnosing in psychiatry and cosmetic medicine.16

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Body Dysmorphic Disorder Modification of the Y-BOCS (BDD-YBOCS) This is a modified version of the Yale-Brown obsessive disorder scale.10 It looks specifically at BDD and covers both insight and avoidance. This is an 11-item questionnaire with an individualised four-point answering scale for each question. Scale scores range from 0-48 and the cut off is 20 for a BDD diagnosis.10 The questions are aimed at 12 specific areas, these include the following: • • • • • • • • • • • •

Time occupied by thoughts of defect Interference in daily life due to thoughts related to defect Distress with regards to thoughts about defect Resistance against thoughts of body defect Degree of control over thoughts of body defect Time spent in activities related to body defect Interference due to activities related to body defect Distress associated with activities related to body defect Resistance against compulsions Degree of control over compulsive behaviour Insight Avoidance10

The BDD-YBOCS questionnaire is only practitioner administered, as there has been no reliability or validity demonstrated in using it as a self-reporting measure as of yet. The first 10 items on the questionnaire assess excessive preoccupation, obsessions and compulsive behaviours associated with dissatisfaction with physical appearance. The first three items (time, interference and distress) are based on the BDD diagnostic criteria as mentioned earlier. These are, in turn, related to both excessive preoccupation and compulsive behaviours. As seen above, the last two questions assess insight and avoidance. I believe that this tool works well as it looks at different aspects of a patient’s life that could be affected by the flaw that they are concerned about. BDD is a condition which affects social, professional and day-to-day activities, so it is helpful to have a questionnaire which focuses on the frequency of these compulsive behaviours. It also looks at severity of dissatisfaction which is also an important factor in assessing BDD.10 The BDD-YBOCS goes into great detail looking at both obsessive concerns and compulsive behaviours. The rating scale also allows us to rate severity and this can be very helpful when considering possible treatments for BDD.

Considerations It is, of course, important to consider exactly how we may use the above BDD tools. The first two mentioned, the AAI and the COPS questionnaire, can be filled out by the patient. The last two are practitioner led and therefore must be filled out in clinic with the presence of the practitioner and of course this will be more time consuming, especially as both the BDDQ and BDD-YBOCS scale are quite detailed. I believe that it may be an idea to combine use of these BDD questionnaires. The AAI and COPS could be used as a screening tool whereby the patient fills them out prior to clinic appointment. Based on the score from these questionnaires the clinician can then decide whether a more in-depth BDD assessment tool is required and can fill out the BDDQ or BDD-YBOCS. The COPS questionnaire is longer than the AAI and does provide more information on insight and possibly severity of symptoms so, in my opinion, this would be a good initial screening tool. This could then be combined with BDDYBOCS to get a more detailed idea of the patient’s symptoms and

level of dissatisfaction with their appearance. We must also appreciate that there could be limitations to solely letting patients fill out their questionnaires as if they have limited insight into their possible BDD symptoms they may underscore on the initial screening tool. Therefore, I think to some extent there should always be at least a brief psychological assessment as part of the aesthetic consultation. Practitioners could, in theory, adapt or create their own BDD tools, but these must be validated and trialled/tested in further research by practitioners themselves to check both sensitivity and specificity to be used as a valued tool in assessing BDD. Working closely with mental health professionals is, in my opinion, very important. This could mean that you are able to refer a patient back to their GP or refer onto a colleague who specialises in BDD or Obsessive Compulsive Disorder (OCD). Building such relationships can be beneficial not just for referral purposes, but also for gaining and sharing knowledge with mental health colleagues. Not all of the mentioned tools cover all aspects, however those that do, such as BDD-YPOCS and COPS, can be fairly time consuming as they require a higher number of detailed questions to be answered.

Conclusion Validated assessment tools like those mentioned in this article are valuable for the pre-procedure assessment process. The important aspects of BDD that need to be evaluated via such assessment tools include compulsive behaviours, impairment of global functioning, avoidance of social situations and also insight into their condition. Although there are many tools available to assess BDD, there is still room for further research to be carried out in perhaps finding a more succinct assessment tool. Dr Raj Arora is an aesthetic practitioner and an NHS GP based in Surrey. She is the founder of The Facebible Clinic based in Heathrow and is opening her second clinic in 2020. Dr Arora has a BSC in Medical Education and takes a keen interest in mental health and wellness, alongside her passion for aesthetics and medicine. REFERENCES 1. Body Dysmorphic Disorder (BDD), Anxiety and depression association of America <https://adaa.org/ understanding-anxiety/related-illnesses/other-related-conditions/body-dysmorphic-disorder-bdd> 2. Clarke et al., The routine psychological screening of cosmetic surgery patients, Aesthetics journal, February 2016 3. Aestheticsjournal.com, Superdrug;s injectable service to provide tougher checks for BDD, January 2019 <https://aestheticsjournal.com/news/superdrug-s-injectable-service-to-provide-tougherchecks-for-bdd> 4. Joseph AW, Ishii L et al., Prevalence of body dysmorphic disorder and surgeon diagnostic accuracy in facial plastic and oculoplastic surgery clinics. JAMA Facial Plast Surg, 2016;19:269–274 5. NICE, Overview | Obsessive-Compulsive Disorder and Body Dysmorphic Disorder: Treatment | Guidance, November 2005 <www.nice.org.uk/Guidance/CG31> 6. Anderson RC, Body dysmorphic disorder: Recognition and treatment. Plast Surg Nurs. 2003;23:125–128 7. Mind, the Mental Health Charity - Help for Mental Health Problems, Body Dysmorphic Disorder (BDD), November 2018, <www.mind.org.uk/information-support/types-of-mental-health-problems/ body-dysmorphic-disorder-bdd/#.XQvptS3Myu4> 8. Vahia V, Diagnostic and statistical manual of mental disorders 5th edition, American Psychiatric Association, 2013 9. Brito MJ, Almeida Arruda Felix G, et al., Body dysmorphic disorder should not be considered an exclusion criterion for cosmetic surgery, J Plast Reconstr Aesthet Surg, 2015 10. Goodman et al., The Yale-Brown Obsessive Compulsive Scale, Archives of General Psychiatry, 1989 11. Sweis I.E., Spitz J., Barry D.R., Jr., Cohen M, A review of body dysmorphic disorder in aesthetic surgery patients and the legal implications, Aesthetic Plast Surg, 2017 12. Veale, D., Eshkevari, E., Kanakam, N., Ellison, N., Costa, A., & Werner, T, The Appearance Anxiety Inventory: Validation of a Process Measure in the Treatment of Body Dysmorphic Disorder. Behavioural and Cognitive Psychotherapy, 2014 13. Veale D, COPS 9 item screening questionnaire, 2013, < https://www.academia.edu/29517737/ COPS_9_item_screening_questionnaire> 14. Phillips K.A, Instruments for assessing BDD: the BDDQ: a self-report screening instrument for BDD (appendix B), The broken mirror: understanding and treating body dysmorphic disorder, 2005 15. DSM-IV-TR, DSM library < https://dsm.psychiatryonline.org/doi/abs/10.1176/appi. books.9780890420249.dsm-iv-tr> 16. Phillips K et al., A retrospective follow up study of body dysmorphic disorder, Comprehensive Psychiatry, 2005 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1613798/>

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A summary of the latest clinical studies Title: Relationship between forehead motion and the shape of forehead lines-A 3D skin displacement vector analysis Authors: Frank K et al. Published: Journal of Cosmetic Dermatology, July 2019 Keywords: 3D Scanning, Facial anatomy, Frontalis Muscle Abstract: Neuromodulator injections of the forehead are often performed using standardized protocols. This study was designed to identify the individual skin motion pattern of the forehead and to relate this pattern to the underlying frontalis muscle morphology to offer guidance for neuromodulator placement. 37 healthy volunteers (29 Caucasians, six African Americans, two Asians) with a mean age of 39.84 ± 14.4 years [range: 22-73] were enrolled. 3D images of the forehead were analyzed using a Vectra H1 camera system computing skin displacement vectors between the noncontracted and the maximally contracted forehead of the volunteers. Relationships between the shape of the horizontal forehead lines (straight vs wavy) and the forehead motion pattern were calculated. Independent of age or gender, a greater forehead motion angle was associated with the presence of wavy forehead lines 21.34°± 5.9 with P < 0.001, whereas straight forehead lines were associated with a smaller forehead motion angle 6.68°± 2.9 P < 0.001. Females had more frequently straight horizontal forehead lines versus males: 68.4% vs 44.4% (P = 0.037). Young volunteers (<39.8 years) did not differ in their mean forehead motion angle when compared to older volunteers (>39.8 years): 13.70°± 9.0 vs 12.39°± 8.0 with P = 0.530. Injections of neuromodulators in the forehead can be individualized by respecting the shape of the horizontal forehead lines. Wavy lines require injection points that are located more laterally, whereas straight lines require more centrally located injection points. Title: Validated Assessment Scales for Skin Laxity on the Posterior Thighs, Buttocks, Anterior Thighs, and Knees in Female Patients Authors: Kaminer MS et al. Published: Dermatologic Surgery, June 2019 Keywords: Skin laxity, Assessment scales, Skin tightening Abstract: Two photonumeric grading scales were created and validated for skin laxity in female patients: Skin Laxity-Posterior Thighs/Buttocks, and Anterior Thighs/Knees. Fifteen aesthetic experts rated photographs of 50 women in 2 validation sessions. Responses were analyzed to assess inter-rater and intra-rater reliability. Overall inter-rater reliability according to intraclass correlation efficient (ICC) 2.1 and weighted kappa was at least “substantial” for both scales in both sessions, and “almost perfect” (≥0.81) for the Anterior Thighs and Knees scale in session 2. Intrarater reliability was “almost perfect” for both scales (ICC 2.1) and “substantial” to “almost perfect” by weighted kappa. A correlation between the skin laxity scales and body mass index, age, weight, sun exposure, and cellulite severity was observed. The skin laxity photonumeric grading scales are valid and reliable instruments for assessing laxity on the posterior thighs and buttocks, and anterior thighs and knees. The scales will be of value for standardizing clinical evaluations and quantifying outcome measurements in research and clinical practice.

Title: Influence of needle size and injection angle on the distribution pattern of facial soft tissue fillers Authors: Pavicic et al. Published: Journal of Cosmetic Dermatology, July 2019 Keywords: Needles, Facial injection, Anatomy Abstract: Soft tissue filler injections are performed using either sharp-tip needles or blunt-tip cannulas. Product can change planes in an uncontrolled manner during needle injections, potentially leading to unintentional intra-arterial placement. There is a paucity of data on the influence of injection angle on the dispersion patterns of soft tissue fillers. A total of 126 injection procedures were conducted in seven Caucasian body donors (four males, three females) with a mean age of 75.29 ± 4.95 years and a mean body mass index of 23.53 ± 3.96 kg/m2 . Injection procedures were performed in various facial regions (forehead, scalp, zygomatic arch, mandibular angle), utilizing different needle sizes (25G, 27G, 30G) and different angles (90°, 45°, 10°). Layer-by-layer dissections were performed to verify the location of the injected product. Dissections were facilitated by the colored material. Utilizing a 30G needle (compared to a 25G needle) reduces the superficial spread with OR 0.70 (95% CI, 0.48-0.99) and P = 0.049, whereas injecting at 90° (vs 10° with the bevel down) increases the odds for superficial spread with OR 10.0 (95% CI, 7.11-14.09) and P < 0.001. Precision during soft tissue filler injections, defined as the product remaining in the plane of intended implantation, can be enhanced by changing the needle size and the injection angle. Utilizing a 30G needle and injecting at a 10° angle with bevel facing down reduces the uncontrolled product distribution into superficial fascial layers. Title: Experiences of barbed polydioxanone (pdo) cog thread for facial rejuvenation and our technique to prevent thread migration Authors: Unal M et al. Published: Journal of Dermatological Treatment, July 2019 Keywords: PDO, Threading, Rejuvenation Abstract: One of the most common nonsurgical options for facial rejuvenation is lifting using threads. Application of PDO threads is generally secure and effective procedure, but complications on the involved regions can occur. In this study, we shared our experiences of efficacy and safety of PDO thread lifting for facial rejuvenation and presented our technique to prevent the migration of threads. Thirty-eight patients who underwent PDO cog treatment for facial rejuvenation were evaluated. Via 23G/90mm sharp needle, bidirectional barbed PDO cog thread was inserted into subcutaneous tissue. The outcomes of procedure were assessed by Global Aesthetic Improvement Scale-GAIS and patient satisfaction. Thirty-eight patients included in this study. Mean age of participants was 39.6 ± 7.5 years. The GAIS score showed satisfactory results (very much improved: 78.9%; much improved: 18.4%; improved: 2.6%). According to patient satisfaction, all patients were satisfied with the clinical outcomes of procedure (excellent: 76.3%; very good: 21.0%; good: 2.6%). No patient reported “fair” or “poor” result. Our results revealed barbed PDO cog thread is highly effective in facial rejuvenation. Also, tying the PDO threads in same entry point to each other seems to be an effective technique to prevent thread migration.

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


TISSUE REMODELLING IMPROVEMENT OF SKIN QUALITY

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absorbed all the necessary intelligence, but sometimes this process isn’t enough. Perhaps the patient immediately disregards the written information, reads it then forgets, or maybe it’s written in a way that is too hard for them to digest. As a result, the patient may not enjoy a comfortable or informed recovery as they otherwise could.

How an app can improve patient experience

Enhancing the Patient Journey Mr Alex Karidis and clinic chief operations officer Deborah Vine share their experience using a clinic mobile app to help enhance the patient experience and boost business Technology and healthcare go hand in hand so it’s no surprise that the cosmetic surgery and aesthetic clinics have entered the mobile app market. Apple introduced third-party web applications in 2007 and the first plastic surgery app was launched just two years later.1 According to communications company Ofcom, smartphone ownership reached 78% in 2018, and it is more prevalent in 16-24-year-olds where 95% own a smartphone.2,3 So, this market is likely to continue to grow as a younger, more appsavvy generation matures. There are valid concerns that many of these applications are trivialising cosmetic procedures, making a game out of what should instead be a serious matter, such as those that allow users to digitally enhance their looks. However, when used ethically and appropriately, this technology can enhance the patient-clinic relationship, as well as allow for opportunities for repeat business and referrals.

Issues with patient communication A good surgeon, doctor, dentist, or nurse in medical aesthetics will ensure that their patients are fully informed and educated at every stage of their journey. It is not only a part of our duty as medical professionals but, as we know, this also makes for a better

all-round experience for both the patient and practitioner. Yet, we are also well-aware that the consultation process, the run-up to the day of operation/medical aesthetic procedure and the immediate recovery period, can be an overwhelming time for patients, particularly in terms of the amount of information they have to process. In fact, we believe that one of the big stumbling blocks to a successful outcome that fulfils patient expectations is a breakdown in communication. This is not necessarily the fault of the patient or the practitioner, but can be driven by the amount of necessary medical information that needs to be conveyed in limited time settings. As a clinic, we can produce written information for patients, and we can offer them repeat consultations to ensure that they have

In order to resolve this potential issue, we explored the concept of creating a clinic mobile app to improve patient experience and education. When we launched at the beginning of 2017 it had huge benefits to not only our patients, but our staff and business as a whole. There are several apps that aesthetic clinics use to enhance their patient experience. Many of these include features that act to complement a clinic’s website and have functions that enable patients to see a practice’s treatment menu, book appointments, view offers and see and add reviews, for example. However, most do not present patients with information on how they might feel at certain times in their treatment journey. So, we decided to take our app one step further. We designed it to have the ability to guide the patient through every stage of their treatment journey and provide that information in easily digestible chunks. This way, when all the information is explained in the consultation, they receive it again at a later date, when they need to know it. We initially focused the app on our most popular procedures – breast augmentation, eyelid surgery, surgical facelift, rhinoplasty and male breast reduction – with the intention of expanding it in the future to cover more procedures, including non-surgical procedures such as botulinum toxin and dermal fillers. In pure marketing terms, the app works as a micro website, providing much of the same content as our main website, but delivering

Friends and family can also download the app and receive the same information, so they are fully involved in the patient journey

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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As a result of our app, patient reassurance is increased as the app has given us a more direct, personal way to communicate to patients, taking it out of the clinical setting and into the hands of the patient it a unique and targeted way. It also supports brand awareness as we have worked hard to ensure the look, feel and message of the app is in line with our clinic branding and positioning. We established a clear timeline of each treatment and set up push notifications to alert the patient of relevant information sensitive to their procedure and date of surgery. They will receive notifications, outlining when to stop smoking or begin pre-op fasting for example, or advice on what they should be eating when they return home to support their recovery. They also receive alerts explaining what is and is not normal as part of their recovery so that they can recognise if there are any recovery issues or complications. We also let them know when to expect a phone call from our nurse – both pre- and post-op – and every member of our team has been involved with the development of the app to ensure patients have an extra helping hand. Our nurses and support staff were an invaluable resource when it came to devising practical advice; for example, a checklist of what to pack for your day of surgery is sent two days before the operation and, post-surgery, we focus on mood-boosting emotional support, right when they need it. As well as providing the basic information on the actual procedure, we wanted to take a holistic approach to enhance patient support. We therefore also provide motivational recovery support, nutritional and wellbeing tips from nutrition specialsts, life coaches and psychologists, and provide real patient experiences, so they feel much more prepared, both mentally and physically. Friends and family can also download the app and receive the same information, so they are fully involved in the patient journey. We find this is particularly important in the recovery period when they are providing

aftercare support. As a result of our app, patient reassurance is increased as the app has given us a more direct, personal way to communicate to patients, taking it out of the clinical setting and into the hands of the patient. Patients often comment on their increased peace of mind throughout the process. The value to the patient is clear, but we also feel that the app has been of great benefit to the clinic and our team. It helps to manage patient expectations and keep them informed, which we feel contributes to a more optimal finished result and greater patient satisfaction, which is always our chief concern. Another benefit to the app is that it allows us to include questionnaires, which we can use to improve our service. The app also allows patients the opportunity to anonymously register how they are feeling, so we are able to collect data to enhance their experience.

Considerations We worked very closely with a development team to ensure we offered the most valuable app as possible, with up-to-date information. We wanted the app to be free for our patients and simple to download, and this was a huge consideration for us when we selected our developer. The app was not inexpensive to have developed, as it was the first of its kind in our industry in the UK and we somewhat needed to start from scratch. However, developing an app doesn’t come without considerations. Providing this service for patients was not a quick fix. Producing the content and making sure it was useful and worked effectively for our patients was a huge time commitment, involving input from all members of our clinic team and support staff. We also produced video content, as

feedback we have received suggests that patients often find information conveyed by video easier to digest. Another consideration is data – we ensure that the app is entirely anonymous and it does not carry any identifiable patient data, so there is no risk of a GDPR breach. This also means it provides a safe space to share and interact. The hard work doesn’t end when the app is launched, as we have to constantly update information and make sure it’s correct and not misleading in any way. A patient journey app must be valuable and useful for patients or it’s not worth doing in our opinion, so unless you’re able to devote a lot of time to the development process, it might be worth exploring other methods of supporting your patients first.

Summary The digital health revolution is transforming how patients access and interact with healthcare and although we don’t believe that technology should ever replace the human touch, it can certainly enhance the support we provide our patients. Done well, a patient journey app can not only benefit your patients but also profit your practice. Patients can, of course, choose not to use the app, but for those who wish to have the information at their fingertips when they are feeling that they need support, it is a strong tool to help provide a safe, caring, responsive, effective and well led approach to treatment. Mr Alex Karidis is a cosmetic surgeon and founded the Karidis Clinic in London in 1997. He completed his medical degree at Aristotle University of Thessaloniki, Greece, then trained in the NHS before developing his specialism with accreditations from The British Association of Aesthetic Plastic Surgeons, the Royal College of Physicians and Surgeons of Glasgow and the Hellenic Board of Plastic Surgeons. Deborah Vine is the chief operations officer at the Karidis Clinic in London and Mr Alex Karidis’ business partner. She has a wealth of business growth and development experience within the wellness and aesthetic specialty. REFERENCES 1. Adrienne D. Workman, et al., ‘A Plastic Surgeon’s Guide to Applying Smartphone Technology in Patient Care’, Aesthetic Surgery Journal, Volume 33, Issue 2, February 2013, Pages 275–280. <https://academic.oup.com/asj/ article/33/2/275/277273> 2. Statista, UK: smartphone ownership by age from 2012-2018, 2016. <https://www.statista.com/statistics/271851/smartphoneowners-in-the-united-kingdom-uk-by-age/> 3. Ofcom, A decade of digital dependency, 2018. <https://www. ofcom.org.uk/about-ofcom/latest/features-and-news/decade-ofdigital-dependency>

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Getting Started with a PR

• What is your timeframe for PR activities to take place and see results? • Are there key milestones to consider e.g. a clinic expansion, brand launch or new staff?

PR and communications consultant Julia Kendrick explores considerations for investing in PR services

The question of budget

The question of when to invest in ‘proper PR’ – i.e. help from a specialist consultant or agency – is one that many clinics agonise over. Some believe they get on just fine without any PR support at all, while others do their PR in-house – with varying degrees of success and satisfaction. For many clinics, they simply cannot afford the additional outgoings on top of overheads. On the flipside, I can’t count the number of times I’ve been approached by prospective clients saying, “We just want some PR” but this is the sum total of their thinking thus far; no brief, no timeline, no budget. This renders the next steps of a PR consultant somewhat difficult. There is no one-size fits all answer as to when is the right time for PR support in your business, but this article outlines the key considerations so that if and when you make the leap, you have the best chance of securing a successful supplier partnership.

Before you get started Before searching for PR support, there are two key elements to consider: 1. Your PR objectives: the tangible outcomes you wish to see from PR 2. Your anticipated monthly budget I frequently receive requests from clinics for ‘some PR support’ but there is no upfront clarification on what this constitutes, what outcomes they want and how they define ‘success’. This is always a warning signal for me as a PR, and if upon further questioning we still can’t get a clear picture of a clinic’s goals, timeframe or budget, I usually have to politely decline the business. This is because, from experience, I know it results in mismatched expectations and ultimately, poor deliverables. Without clarity on the objectives for a PR or marketing campaign, you have no way to determine the success or return on investment (ROI) – so this is a mandatory step for both parties before undertaking any activity.

You CAN do it yourself There are plenty of PR and marketing elements that you can deliver without specialist support and it is certainly possible that you as a clinic or practitioner can do your own PR – to a degree. For example, with training you can create your own marketing materials, run local launch events, build relationships with press and influencers from the ground up, and manage your own social media channels – posting regularly, building engagement and generating a compelling brand reputation. However, there is a huge caveat; doing your own PR and marketing requires time and expertise. If you can dedicate the time to train yourself up and put the right marketing tools in place to deliver the PR activities, whilst still running your aesthetic business, then you can minimise your need for hiring an inhouse marketing manager, or an external PR service. However, for most busy practitioners this is a tall order. The critical factor of whether you should invest in PR support is not money, it is time. Your time is valuable and should be spent on the activities that bring in the most revenue possible.

Key objectives to consider before contacting a PR By providing clear direction to the potential PR supplier, you can also ensure that they have the right capabilities to support your business. Key objectives to consider are: • What does PR success look like to you? Do you want brand profiling (i.e. focusing on your overarching business/clinic) or individual profiling (focusing on just you)? • Are you aiming for more print/online press coverage, or to focus more on influencer partnerships (spreading your name via word of mouth/social media versus journalist)? • What about events or strategic partnerships? • Where do you want to be seen (local or national titles, which publications)? • What do you want to be known for? • What are your overarching business objectives? ☑☑ Business growth? By what percentage? By when? ☑☑ Increased sales, new patient sign-ups, patient retention? What are the metrics?

Don’t simply ask, “How much will it cost?” as the standard response is usually, “How much do you want to spend?”. It is critical to have a clear idea of your available budget to give the PR supplier a ball-park to work with. Whether you can afford a few hundred or a few thousand pounds per month – consider what this cost equates to. If you brought in one new toxin or filler patient per month, would you have covered the outlay? And what are the chances that your PR activity would only attract one extra patient? The likelihood is you would be bringing in many more, so the value of that PR spend becomes tangible in terms of revenue and reputation. There is no accurate rule of thumb for revenue percentage to spend on marketing (no matter what Google tells you) as this is highly dependent on your industry and net profit margin after expenses. If you give vague guidance on budget, the supplier will likely come back with services either way above or way below your desired level – wasting time for both parties. Whatever you can afford, be clear about this up front, as this facilitates a realistic response. If there is a mismatch on desired services versus available spend, the PR supplier can at least come back with a compromise, which will better fit your desired budget.

Finding a PR supplier There are several ways to find a good PR supplier; peer recommendations are a great place to start, so do ask your colleagues and connections. Ensure you get a clear picture of the work conducted, the results achieved and what the working relationship was like. Bear in mind, the PR supplier may not work with you if they are currently representing one of your peers (i.e. they are conflicted out, which means their contract prohibits them working for a similar business in the same region). Other options include public relations guilds or professional bodies such as the Chartered Institute of PR, the Public Relations Communications Association and the Healthcare Communications Association. Many of these have individual or agency directories, listing accredited suppliers based on industry sectors. PRs must pay to be members of these bodies and must adhere to their codes of conduct1,2 – so you

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


Your patients with obesity have the will. You can offer them the way.

If you would like to request a visit from a representative please contact us on SaxendaUK@novonordisk.com For all product related enquires please contact us via our online information request form at www.novonordisk.co.uk

Indication: Saxenda® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of ≥ 30 kg/m² (obesity) or ≥ 27 kg/m² to < 30 kg/ m² (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea. Treatment with Saxenda® should be discontinued after 12 weeks on the 3.0 mg/day dose if patients have not lost at least 5% of their initial body weight.

Prescribing Information

Please refer to the Saxenda® summary of product characteristics for full information. Saxenda® Liraglutide injection 3 mg. Saxenda® 6 mg/mL solution for injection in a pre-filled pen. One pre-filled pen contains 18mg liraglutide in 3mL. Indication: Saxenda® is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of ≥ 30 kg/m² (obesity) or ≥ 27 kg/m² to < 30 kg/m² (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea. Posology and administration: Saxenda® is for once daily subcutaneous use only. Saxenda® is administered once daily at any time, independent of meals. It should be injected in the abdomen, thigh or upper arm. It must not be administered intravenously or intramuscularly. The injection site and timing can be changed without dose adjustment. However, it is preferable that Saxenda® is injected around the same time of the day. Recommended starting dose is 0.6 mg once daily. Dose should be increased to 3.0 mg once daily in increments of 0.6 mg with at least one week intervals to improve gastrointestinal (GI) tolerability. If escalation to the next dose step is not tolerated for two consecutive weeks, consider discontinuing treatment. Treatment with Saxenda® should be discontinued after 12 weeks on the 3.0 mg/day dose if patients have not lost at least 5% of their initial body weight. Daily doses higher than 3.0 mg are not recommended. Saxenda® should not be used in combination with another GLP-1 receptor agonist. When initiating treatment, consider reducing the dose of concomitantly administered insulin or insulin secretagogues (such as sulfonylureas) to reduce risk of hypoglycaemia. Blood glucose selfmonitoring is necessary to adjust the dose of insulin or insulin-secretagogues. No dose adjustment is required based on age but therapeutic experience in patients ≥75 years is limited and not recommended. No dose adjustment required for patients with mild or moderate renal impairment (creatinine clearance ≥30 mL/min) or mild or moderate hepatic impairment but it should be used with caution. Saxenda® is not recommended for use in patients with severe renal impairment (creatinine clearance <30 mL/min), including end-stage renal disease, or severe hepatic impairment or children and adolescents below 18 years. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Special warnings and precautions for use: Saxenda® must not be used as a substitute for insulin in patients with diabetes mellitus nor should it be mixed with other injectables (e.g. insulins). Diabetic ketoacidosis has been reported after rapid discontinuation or dose reduction of insulin. There is no clinical experience in patients with congestive heart failure New York Heart Association (NYHA) class IV and therefore Saxenda® is not recommended for use in these patients. Due to limited experience, Saxenda® is not recommended in patients: aged ≥75 years, treated with other products for weight management, with obesity secondary to endocrinological or eating disorders or to treatment with medicinal products that may cause weight gain, with severe renal impairment, with severe hepatic impairment. As Saxenda® for weight management was not investigated in subjects with mild or moderate hepatic impairment; it should be used with caution in these patients. Use of

Saxenda® is not recommended in patients with inflammatory bowel disease and diabetic gastroparesis since it is associated with transient GI adverse reactions including nausea, diarrhoea and vomiting. Acute pancreatitis has been observed with the use of GLP-1 Saxenda® prescribing information – March 2019 version 5 receptor agonists, patients should be informed of the characteristic symptoms. If pancreatitis is suspected, Saxenda® should be discontinued; if acute pancreatitis is confirmed, Saxenda® should not be restarted. In weight management clinical trials, a higher rate of cholelithiasis and cholecystitis was observed in patients on Saxenda® than those on placebo, therefore patients should be informed of characteristic symptoms. Thyroid adverse events such as goitre have been reported in particular in patients with pre-existing thyroid disease. Saxenda® should be used with caution in patients with thyroid disease. An increased risk in heart rate was observed in clinical trials. Heart rate should be monitored at regular intervals and patients informed of the symptoms of increased heart rate. For patients who experience a clinically relevant sustained increase in resting heart rate, treatment with Saxenda® should be discontinued. There is a risk of dehydration in relation to GI side effects associated with GLP-1 receptor agonists. Signs and symptoms of dehydration, including renal impairment and acute renal failure have been reported. Precautions should be taken to avoid fluid depletion. Patients with type 2 diabetes mellitus receiving Saxenda® in combination with a sulfonylurea may have an increased risk of hypoglycaemia. The addition of Saxenda® in patients treated with insulin has not been evaluated. Fertility, pregnancy and lactation: Saxenda® should not be used during pregnancy. If a patient wishes to become pregnant, or pregnancy occurs, treatment with Saxenda® should be discontinued. It is not known whether Saxenda® is excreted in human milk. Because of lack of experience, it should not be used during breast-feeding. Apart from a slight decrease in the number of live implants, animal studies did not indicate harmful effects with respect to fertility. Undesirable effects: Very common (≥1/10); nausea, vomiting, diarrhoea, constipation. Common (≥1/100 to <1/10); hypoglycaemia, insomnia, dizziness, dysgeusia, dry mouth, dyspepsia, gastritis, gastro-oesophageal reflux disease, abdominal pain upper, flatulence, eructation, abdominal distension, cholelithiasis, injection site reactions, asthenia, fatigue, increased lipase, increased amylase. Uncommon (≥1/1,000 to <1/100); dehydration, tachycardia, pancreatitis, cholecystitis, urticaria, malaise. Rare (≥1/10,000 to <1/1,000); anaphylactic reaction, acute renal failure, renal impairment. The Summary of Product Characteristics should be consulted for a full list of side effects. MA numbers and Basic NHS Price: 5 x 3 ml pre-filled pens EU/1/15/992/003, £196.20. Legal category: POM. Full prescribing information can be obtained from: Novo Nordisk Limited, 3 City Place, Beehive Ring Road, Gatwick, West Sussex, RH6 0PA. Marketing Authorisation Holder: Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Denmark. Date last revised: March 2019

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Novo Nordisk Limited (Telephone Novo Nordisk Customer Care Centre 0845 6005055). Calls may be monitored for training purposes.

Saxenda® is a trademark owned by Novo Nordisk A/S.

UK19SX00009 | April 2019


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Telephone interviews and ‘chemistry’ meetings The following checklist gives a guide as to some key questions to ask during these initial calls to determine which candidates would be suitable for your next stage of assessment. • What services do they offer? It may be traditional PR and press relations, or a more digital/social media approach, or a mixture of both. • What’s their expertise in this area? ☑☑ Which similar companies or brands have they worked on? Do they currently represent any other aesthetic professionals or clinics? Can they share a credentials deck or portfolio of their work and expertise? • What’s their working style like? ☑☑ Some take a hands-on approach with lots of updates and emails, others will only contact you at key points. Make sure you’re clear about how you like to work • How do they track, measure and report? ☑☑ Status reporting – weekly, monthly or quarterly? ☑☑ Regular face-to-face or telephone updates? • Who’s on your team? ☑☑ You may have initial discussions with the director, but they are unlikely to be your day-to-day contact, so find out their team structure and your likely main contact • Fees and ROI? ☑☑ How much will they charge? What will this include? And critically, how do they measure success and show their value to your business? This will be a close working relationship, so this is primarily about whether you get on well. You may feel sufficiently confident after the initial phone call to move forwards. If not, a meeting to determine if you have ‘chemistry’ is a great opportunity to understand the PR agency’s main selling points, how they work and how they can best support you.

get an unofficial ‘quality’ check if a supplier is associated with one of these bodies. Bear in mind, medical aesthetics is a specialist area and it can require both pharmaceutical-level communication capabilities as well as a consumer beauty approach. Most agencies focus on either one or the other (large agencies may have different divisions under one roof). Few have direct experience in this specific sector, so you will need to take this into account within your selection and briefing process, checking whether they have the relevant experience, if they have worked in the industry or with similar companies to yours and if they have the right relationships.

It’s all in the brief Once you’ve identified some potential PR suppliers, reach out via phone or email to assess whether you would be a mutual fit. This will determine whether your business fits well in their portfolio and expertise, and whether their approach, values and style of working aligns with your own. If this isn’t aligned early on, it can be difficult to achieve an effective working relationship and lead to difficulties in getting your desired PR outcomes. The key point here is to give a top-line mini brief about your

business, outline your broad objectives and anticipated budget. I always appreciate it when a client gives a brief overview of their business, even if it’s just a few lines in the email, because it helps assess the challenges they may be facing and how to best support their needs (or in fact, if there is somebody better suited that the PR can connect them with). Your mini brief should clearly outline your PR objectives, expectations and challenges, alongside clear timelines, the budget available and expected deliverables. The more specific and clear the brief, the easier the fit will be to identify which PR suppliers meet your requirements. As a next step, request a call back to discuss your needs in more detail and if you feel it is necessary (or if the PR proactively requests one), provide a more extensive written brief.

Getting value from your PR As noted throughout, the key to a successful relationship with your PR is clarity and accountability from the outset. If both sides are clear on what is going to be achieved, how, by when and at what budget, then you have the best possible chance of a fruitful and successful experience. Bear in mind that PR takes time to deliver results, create traction and

build profile. Success is also not just limited to media coverage – it could be about increased opportunities to profile yourself, building a position of authority, improving relationships with press, influencers and brands, not to mention successful issues management. With digital activities, tracking is amplified to give a clear idea of ROI through increased website hits, newsletter opens, social channel growth, post sharing etc. All of these elements should be managed in a way which frees up your precious time to do what you do best, and drive that revenue. If in doubt, you can always start with a trial – I advise a minimum of three months. This is because this is the minimum amount of time you need to allow to see some of the PR outputs, even in the ‘short lead’ press i.e. online, daily and weekly titles. Remember, monthly titles like the top women’s press (Vogue, Harper’s, Tatler etc) work at least three months ahead, so even if something is secured quickly, you won’t see it in print for a significant period of time.

Conclusion Outsourcing PR and marketing is an important business decision which should ultimately free up more of your valuable time to deliver primary revenuegenerating activities. To maximise success, identify potential suppliers through peer recommendations or professional bodies and approach them with a clear brief that outlines your needs, expectations and budget. Assess candidates via telephone discussions and chemistry meetings to find your best possible match. Keep your channels of communication open to learn, assess and adapt your approach for best possible results. Julia Kendrick is an awardwinning PR, communications and business strategy consultant with more than 15 years’ experience. She owns Kendrick PR, which offers both trade and consumer PR for the beauty, wellbeing and aesthetic medicine industries. Kendrick also created the E.L.I.T.E. Reputation Programme – the industry’s first online PR and marketing training developed specifically for medical aesthetic practitioners. REFERENCES 1. Chartered Institute of PR, Code of Conduct. <https://www.cipr. co.uk/content/members/public-relations-register-overview/ciprcode-conduct> 2. Public Relations & Communications Association Code of Conduct. <https://www.prca.org.uk/about-us/pr-standards/ professional-charter-and-codes-conduct>

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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How much do you want to be paid?

Introducing Treatment Pricing Clinic owner Kerri Lewis discusses the key factors to consider when setting the prices of your services to ensure your business is profitable When setting up your own business there are so many challenges to overcome that it’s easy to overlook important considerations. One is working out if the prices you’ve set for your services are actually making you money, or if you are working at a loss each time you perform a procedure. It may sound obvious, but it’s an alarmingly easy mistake to make and one that could negatively impact your business if you don’t give it due attention. This article will discuss the common challenges and key considerations practitioners have when setting prices for their services. The points covered will be most helpful to those in the early beginnings of starting their own business.

lifestyle improvement. If I’m right, then you shouldn’t be content with taking what money happens to be left in the pot at the end of each month. Strategic advisor and business coach Dan Kennedy states that this behaviour is the number one reason why entrepreneurs end up broke. He says, ‘If you don’t know what your time is worth, you can’t expect the world to know it either’.1 If your ultimate goal is to sell your business later down the line, then you need to ensure that you are earning a healthy and consistent profit. This is because when it comes to selling, the value of a business is usually based on its profit and the consistency of that profit over a period of time.2 If this isn’t a goal for you, and you simply want to live comfortably then you should still follow the same profitable practices so that you can take a good wage and reinvest in your business.

Establish personal goals I’m guessing that one of the reasons you decided to work for yourself was for a

COSTS

Before you start to set your prices, you must work out your break-even figure for each of your services. One of the many factors influencing your break-even point, of which I will delve into later, is wages. How much are you paying yourself? Once you’ve worked out your price, you’ll be able to use it when setting profitable prices for your services. Working out your base earning target (BET)3 is quite simple as a business owner; just ask yourself, ‘How much do I want to earn?’. Once you’ve done this, you can work out your hourly wage. For example, to set your annual salary (I will use £100,000 for ease here) divide this by the number of working days – we will use 233, which is calculated by taking 28 days’ holiday away from the 261 working days in 2019. Divide that figure by the number of daily working hours; in this example, I’m presuming eight. So, £53.65 is your hourly wage. In regard to staff wages, this can be largely guided by the industry norms; you can start by looking at the typical wage for each role locally to you. You may consider tweaking the ‘going rate’ depending on the level of experience and knowledge the individual candidate brings to your business. You may find that setting wages for staff who are actively bringing in money to the business is easier, such as a therapist; however, it can be more challenging understanding the worth of supportive roles such as receptionists. Discussing supportive roles, Stever Robbins from Entrepreneur.com states, “Their value isn’t so much in the money they make, but in the money they save. So, ask yourself, what it would cost not to have them on board, and use the answer to justify their salary.”4 Now that you know how much you, and your staff, are worth per hour, not only will you be able to make better financial decisions as you’ll be able to see if certain tasks are worth your time, you will also be able to consider delegating to an additional staff member or outsource help. DISCOUNT

PROFIT

Treatment name

Sales price

Product costs

Consumable costs

Prescriber costs

Aesthetician costs

VAT

Overheads to administer treatment

Overheads for follow up

Cost of top up/adjustments

Typical discount given (if any)

Gross profit

Your take home pay

Actual gross profit

Gross profit margin

e.g. Toxin three areas

The normal treatment price to the customer

For the quantity of toxin you need available for this treatment

To administer the treatment

If applicable

Only if required for support

If applicable

You need to know your ‘breakeven’ point to calculate this

You need to know your ‘breakeven’ point to calculate this

What it typically costs to administer a top up or adjustment

e.g £50 off for friends and family

Sales price minus all costs and discounts given

£ for YOU

£ for YOUR BUSINESS

The % of the sales price that is actual gross profit

Table 1: An example of a profitability spreadsheet, supplied by Aesthetic Business Transformations10

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Conclusion Avoid discounting The impact of slashing your prices goes beyond your profit; your brand image will also very likely take the brunt of your pricing choices. In my opinion, I think that discounting can weaken your brand and I believe it is much more beneficial for your business to be associated with quality treatments, which are set at a fair price. In fact, business author Mark McNeilly stated in an article, “Over several years, continued discounting erodes margins significantly which in turn erodes shareholder value.”8 Additionally, I would think carefully about using third-party discount platforms or websites to spread brand awareness and to build a patient base. For example, e-commerce marketplace Groupon requires that the business discounts its services or products offered by at least 50%, and sometimes up to 90%. Then, when a customer purchases a deal, Groupon takes half of the revenue.9 At a quick glance, what could this look like for your business? If you usually price a glycolic peel, for example, at £100 (for the sake of easy maths) and you were required to discount it by 50% you’d be offering that peel at £50 per treatment; you would only receive £25 of that total. Now imagine that you had to discount by 90%, you’d be offering the treatment at £10 and would only take away £5. Table 1 also allows you to factor in any discounts that you are considering so that you can see the impact it will have on your profit margin.

Get to grips with your costs Business publication Forbes sited ‘poor accounting’ as the number one reason small businesses lose money.5 I cannot emphasise enough how vital it is to be in control of your finances. If you’re guilty of burying your head in the sand and simply focusing on the day-to-day treatment of your patients I can confidently say, you will not be alone. A good way to start understanding how the prices you set impacts your bottom line is a profitability spreadsheet (Table 1); it allows you to see how much of the price you set is eaten up by your costs. If you do not fully consider all your expenses, including the cost of running your building for the duration of each treatment, your wage, VAT (where applicable), how much marketing spend is required to get each patient through your door, and so on, you may offer services at a loss. Once you’ve calculated all of those costs, you’ll be able to see what your profit margin is for each treatment and, if needed, adjust accordingly. Working out your profit margin is fundamental to master as a business owner and there are many ways to do this. One approach I like to use is the ‘third:third:third’. This means that 1/3 of the price you set needs to cover overheads for the duration of the service, a 1/3 should cover cost the of the treatment and then 1/3 is profit – or 33%.6 This is a very basic guideline to use as a starting point, but you may feel that you can justify setting a higher price to get a larger profit on some treatments to align

yourself with local competition, as well as factoring in your skills and experience into the price.6 If you discover you’re running at a loss after completing your profitability spreadsheet, you’ll now have the power to change it. You could choose to either increase your price, package the service in question with another service to add value to the patient, or discontinue the service altogether. I recommend to consider the first two options initially, especially if you have invested in additional training and equipment.

Market research An initial concern for me when starting up in business was the risk of setting prices too high and out-pricing potential patients. Setting prices too low was also a concern because our profit would suffer and could impact the growth of the business. If you’ve not already done so, you should research your market, by simply viewing their prices online to see what others are charging for similar services. This will give you an indication of how much potential patients are willing to pay in your location, for example one area of botulinum toxin in Leeds seems to vary between £120 and £195, whereas in Portsmouth the price generally falls between £145 and £200.7 I would advise caution when price matching a competitor as there are a number of factors to take into consideration. For example, you may have higher overheads than them, more experienced staff or a different target audience, so the reality may be that you lose money if you are chasing the sale.

Understanding your business finances are key to setting profitable prices in your business. If the services that you offer are not generating a profit, you may need to consider discontinuing them altogether or adjusting the price. Steady profit built over a period of time, whilst building your brand reputation, can be a useful method to ensure that patients don’t notice or are not bothered by huge price increases. As a business owner, the responsibility is yours to make sure the business is successful and the bottom line is, if you’re not making a profit your business will struggle to survive. If you find that you’re struggling with the commercial side of your clinic, seeking the help of a professional business coach for specific guidance on your finances, as well as other aspects of your running a profitable practice could be a worthwhile investment. Kerri Lewis opened her clinic, The Skin to Love Clinic, in St. Albans in 2013. She won the SME Young Business Person of The Year award in 2017 and the Business Woman of the Year award in 2018. Last year The Skin to Love Clinic was also recognised as a finalist at the Aesthetics Awards for Best Clinic South England. REFERENCES 1. Kennedy, D. No B.S. Time Management for Entrepreneurs: The Ultimate No Holds Barred Kick Butt Take No Prisoners Guide to Time Productivity and Sanity. 3rd Edition. Entrepreneur Press , 2017 2. Digital Exits, 8 Steps to Sell Your Business (in 2019). https:// digitalexits.com/sell-your-business/ 3. Davis S, 7 time management lessons from The World’s Highest-Paid Copywriter, June 2019 <https://www.samuelthomasdavies.com/dan-kennedy-time-management/> 4. Entrepreneur Europe, How to Set Salaries <https://www.entrepreneur.com/article/159438 > 5. Olenski S, To discount or not to discount? That is the questions, Forbes, January 2017 <https://www.forbes.com/sites/steveolenski/2017/01/16/to-discount-or-not-to-discount-that-is-thequestion/#9ec26ac4314d> 6. Canadian Contractor, The rule of one third: are you making a minimum of 33 per cent gross margin?, December 2014 <https://www.canadiancontractor.ca/canadian-contractor/therule-of-one-third-are-you-making-a-minimum-of-33-per-centgross-margin/12136/> 7. Date on file 8. Fast Company, Price promotions may be killing your brand: here’s what you can do about it, April 2013 <https://www. fastcompany.com/3006315/price-promotions-may-be-killingyour-brand-heres-what-you-can-do-about-it> 9. Wolfe L, How Groupon Works and How It Impacts Small Businesses, The Balance Small Business, September 2018 <https:// www.thebalancesmb.com/how-using-groupon-can-hurt-yourbusiness-3867065> 10. Aesthetic Business Transformations <https://www.aesthetic-bt. com/>

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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“I’m always trying to push myself to achieve better outcomes” Professor Syed Haq shares his career highlights while exploring the link between disease and ageing As a young man of Indian origin, Professor Syed Haq’s family believed that he had only one of two possible careers; engineering or medicine. “We have a long family history of medicine within the family, and in the old days it was a very typical pathway in Indian households because it was, and still is, seen as an established, respectable and sustainable career. I think it’s because you’re helping people, and the Indian community are very much centralised on family and helping one another,” he explains. So, Professor Haq chose the medical route and completed his degree at United Medical and Dental Schools of Guy’s and St. Thomas’ Hospitals, London, in 1993. He worked and trained at various hospitals in London (Hammersmith and Brompton), before completing a PhD in cardiology at Massachusetts General Hospital and becoming a Fellow at Harvard Medical School in 1999. “While studying I researched and wrote numerous papers on molecular biology, cellular signalling, cardiology and also undertook cutaneous biology research. This is where my interest in ageing really started because I noticed a real link between disease, inflammation and ageing,” Professor Haq explains. While living in the US, Professor Haq won numerous prizes for his work, including being named Young Investigator of the Year in New England and being runner up in the Lewis N Katz prize for cardiology by the American Heart Association (AHA). “When I was in the US I also earned the title ‘Professor’ by Tufts University, which was granted due to my achievement with the AHA,” he adds. In 2005 Professor Haq moved back to the UK and opened a private practice in Harley Street called The London Preventative Medical Centre, now Invictus Humanus. He reminisces, “At the time, my clinic was based on troubleshooting diagnoses for patients, so I was treating those who were undiagnosed or felt weren’t being treated appropriately, which meant I saw a wide range of immunological disease.” From this, Professor Haq became involved in overseeing phase II clinical trials for diseases such as systemic multiple sclerosis and secondary progressive

multiple sclerosis. “I have since implemented studies in Alzheimer’s disease using a particular drug platform and soon we will have scope to do large phase II clinical trials examining efficacy, which is very exciting.” Professor Haq’s aesthetics journey started in 2006 when he was approached by a sales representative for the Radiesse dermal filler range. He found the concept very interesting and thought he was positioned perfectly for the aesthetic specialty as he had a unique outlook on the ageing process. He explains, “Through my Alzheimer’s work, I gained a real in-depth knowledge and understanding of how the brain is prematurely ageing or deteriorating. This translates to every part of your body, including the skin, bones, fat and tissues associated with your appearance, so I was well suited to naturally understand the aesthetics field and decided to get more actively involved. I think to become a good aesthetic practitioner you truly need to understand ageing and think of the skin from a molecular level, instead of just what you see on the surface.” Professor Haq progressed to consulting for the company, and developed some of the first clinical training in the UK for its use. He has since worked with many filler and toxin companies, including Merz, Teoxane and Galderma, and is currently on Galderma’s advisory board for botulinum toxin. Today, about 50% of Professor Haq’s practice is aesthetics, while the other 50% is focused on disease research, management and prevention. “I do find there is a lot of overlap between my two sides of practice; for example, someone could come in requesting toxin for migraines, but when you do a complete examination you can identify

that the patient’s migraines are actually associated with premenstrual syndrome or other pathologies. Instead of offering toxin treatment, you can more appropriately address their underlying hormone issues instead. It’s important not to look at your patients from one perspective and to assess their whole general wellbeing,” he explains. Professor Haq was also a past committee member for the University of Central Lancashire MSc in Non-Surgical Facial Aesthetics course, and was one of the early practitioners to oversee its the implementation. “One of the problems with the aesthetic industry, I think, is the quality of teaching and education, so I was delighted to be a part of this course to help deliver higher standards,” he explains. When asked about his top tips for successful dermal filler injections, Professor Haq advises, “For new injectors, always start off with a hyaluronic acid filler, and one that is less viscous with a lower G prime because it’s more forgiving. When choosing a filler, really understand the origins of that filler and its rheology. I only choose fillers that have a large amount of robust clinical evidence to back up their efficacy and safety profile – so multiple double-blind placebo-controlled clinical trials are essential.” When asked about his work ethos, Professor Haq shares, “I have always had the view to strive in giving something back, and that’s why I am involved in developing medication for devastating diseases. I believe in striving to push myself to achieve better outcomes.” He concludes, “My mother wants me to use my medical skills and aesthetic skills to make a bigger difference, and that’s what I am trying to achieve.”

What’s your industry pet hate? I don’t appreciate practitioners who want to be a ‘Jack of all Trades’, but the master of none. What is your biggest achievement? Simply being a father, and then a doctor, because that’s what my parents sacrificed a lot to achieve. Maybe my biggest achievement is yet to come... I hope so! What’s exciting you at the moment? The forthcoming short-acting toxins entering the market as I think they may have very interesting uses outside of ageing treatments, such as in wound healing and scar repair.

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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The Last Word Dr Dev Patel argues why it’s more appropriate to use the term ‘patient’ rather than ‘client’ in aesthetics I have considered the ‘patient’ vs. ‘client’ debate on many occasions. I am sure most would agree that the aesthetic environment we work in is somewhat unique. For the medics amongst us, this is far removed from working within the NHS and seeing non-paying ‘patients’ presenting with more established symptoms of physical and mental illness. If you say ‘client’ for an antiageing case, do you still use ‘client’ for an acne case seeking chemical peels? After all, acne is an established skin condition.

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these two labels communicate differing levels of care and personal involvement in the relationship.2 The Latin routes of these terms (Table 2) should also be considered, but it is the third column that is most relevant: what the possible connotations are and what does each term ‘say’ to the end-user? Additionally, I think it is just as important to consider what the use of each term implies to the practitioner; I have never had a single patient – and I will now use that term as I usually would – question my use of this label; not one. Even in mainstream medicine, we have evolved from the paternalistic relationship model, which focuses on the doctor’s agenda rather than the patient’s. In fact, one of the four biomedical ethical pillars is based on respecting patient autonomy; a principle I have been tested on in many medical exams over the years.3 In an aesthetic setting, I would even argue that when aesthetic practitioners were purely doing what patients asked of us, the patient did not often end up looking their best. We have almost moved in the opposite direction to mainstream medicine’s model of communication; now, the patient asks for lip fillers and I may have to tell them they need their chin treated instead. Practitioners have had to claim back some autonomy, to ensure we give the patient what they need and not what they want.

Definitions Let us first examine the respective definitions of ‘client’ and ‘patient’ as given by the English Oxford dictionary:1 Client: a person who uses the services or advice of a professional person or organisation. I can certainly see how this fits with what goes on in my own clinic – I am a professional person – a doctor in my case – providing services to people. Patient: a person who is receiving medical treatment, especially in a hospital or a person who receives treatment from a particular doctor, dentist etc. Clearly, this also fits with what I do and my occupation is specifically stated within the definition. If both definitions work on the surface, we need to consider the modern connotations of these terms. As our ‘customers’ come first (yet another term we could arguably use), let us first consider the connotations of each label. Assistant professor at Northwestern University Prosthetics-Orthotics Center John Brinkmann wrote an article on this very topic, examining the differences between ‘client’ and ‘patient’. In Table 1, Brinkmann gives an opinion on how Term

Focus

Defining question

Patient

Care – the practitioner is responsible for providing care

What care do you need?

Client

Expertise and service – the client is hiring a professional to do something for him or her

What are you paying me to do?

Most importantly, it reinforces to my patient that the treatment they have is a medical treatment, which brings established risks with it

Table 1: Brinkmann’s opinion on how the terms ‘patient’ and ‘client’ communicate differing levels of care2

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


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Term

Origin

Definition

Possible connotations

Patient

From the Latin word patiens; originally meant one who suffers; to undergo suffering or to bear

A person receiving or registered to receive medical treatment; synonyms: sick person

Can be construed as stigmatising as its usage may enhance perceived disability and impairment; connotations of passivity and deference; can be interpreted as paternalistic, evidence of inherent power inequities, and a reflection of the dominant biomedical approaches

Client

Latin root meaning dependent; Latin cliens meaning follower, retainer

One that is under the protection of another; one who engages the professional advice or services of another

Carries connotations of an agency relationship, whereby one individual purchases professional services from another; specifically selected to avoid a connotation of being sick or ill; linked to financial renumeration

Table 2: The origins of the terms ‘patient’ and ‘client’. Table adapted from Brinkmann2

Whether my patient brings a disease of the body or mind or not, they are seeking advice and usually treatment for their skin’s health and wellbeing, and, in turn, their mental wellbeing Why do practitioners use ‘client’?

Why I only use ‘patient’

One repeated argument in support of using ‘client’ has been that use of the word ‘patient’ implies a lack of autonomy on behalf of the customer.3 Another common argument for ‘client’ is that our customers are not – in general – ill. I think this is a fair point; in fact, we are unlikely to treat someone with a chemical peel or dermal fillers for example, if they are acutely unwell. However, I believe it is short-sighted to consider this point alone. Whether my patient brings a disease of the body or mind or not, they are seeking advice and usually treatment for their skin’s health and wellbeing, and, in turn, their mental wellbeing. For me to consider their concern, even if it is just a frown line, I must call upon my cumulative clinical experience to establish rapport, glean a thorough history of their concern and their general health. I must then examine their skin and the issue at hand, before discussing treatment options and deciding on a mutually agreed management plan. When the time comes, I will need to obtain informed consent for whichever treatment is due to be performed. I will then administer the treatment, keeping in mind practices established in mainstream medicine (e.g. infection control).

So, what is it I am highlighting here? The fact that by using the word ‘patient’ I am reinforcing in my own mind the responsibilities of the role I have in this patient-practitioner relationship and the standards and ethical principles on which it is based. I also wish to remind the patient of this. They are walking into a confidential environment where they may offload their grievance at their frown lines as well as any ‘mental baggage’ that comes along with it. This may, in turn, influence the course of our consultation and ultimate treatment plan. It reminds them that giving me a thorough medical history is important and cannot be quickly skipped over, as one does when visiting a spa for a massage. Most importantly, it reinforces to my patient that the treatment they have is a medical treatment, which brings established risks with it; for example in the case of dermal fillers, potentially rare but catastrophic complications such as blindness can occur, which certainly needs medical attention. I should add that the same applies to my team of aesthetic therapists; they are told from day one the significance and importance of using the term ‘patient’. They are also seeing patients presenting with medical concerns such as pigmentation and acne and need to make

the same careful assessment, before utilising corrective treatments such as laser or chemical peels. We have all encountered cases of substandard practice in aesthetics with little or no consultation and almost everything else that follows being equally as shocking. In these cases, I am sure it is a ‘client’ walking through the door and the relationship is very much transactional (no offence intended towards any respected colleagues who favour ‘client’; it is a matter of personal choice). At the other end of the spectrum, I work in a CQCregistered clinic and whether I am faced with a rash or a person wanting lip enhancement, I am a doctor throughout, utilising my clinical experience to diagnose and ultimately ease the suffering of a rash or improve the self-esteem of my patient. Either way, not one aspect of my principles of practice from clinical to ethical, can be dismissed. The care, trust, level of intimacy and responsibility within the medical practitionerpatient relationship is unique and calling my patients ‘patients’ reinforces this subconscious message to all involved. Dr Dev Patel is founder and medical director of the multiaward winning Perfect Skin Solutions. He has previously served as both a Naval doctor and NHS general practitioner. He is a UK and global KOL and speaker at various international aesthetic events and recently led the first communication workshop for Merz UK. REFERENCES 1. English Oxford Dictionary – online version 2019 <https:// www.oed.com/> 2. Brinkmann, J. 2018 (Apr). Patient, Client or Customer: What should we call the people we work with? The O&P Edge. <https://opedge.com/Articles/ViewArticle/2018-04-01/ patient-client-or-customer-what-should-we-call-the-peoplewe-work-with> 3. Beauchamp and Childress; Principles Biomedical Ethics, OUP, 5th edition 2001.

Reproduced from Aesthetics | Volume 6/Issue 9 - August 2019


Comes Highly Recommended â&#x20AC;&#x153;3D-lipo has revolutionised the cosmetic industry. Efficacious and affordable, patients and doctors alike love this treatment - it is a win-win situationâ&#x20AC;? Paul Banwell FRCS (Plast), Director The Banwell Clinic


THE NEXT WEBINAR FOR HEALTHCARE PROFESSIONALS HOSTED BY AESTHETICS JOURNAL IN ASSOCIATION WITH GALDERMA WILL BE

‘ABOBOTULINUM TOXIN A IN ACTION: KEY PRINCIPLES & TREATMENT FOR LATERAL CANTHAL LINES’ IT WILL BE HELD ON MONDAY OCTOBER 14 AT 7PM. How do I guarantee my place on ‘Abobotulinum toxin A in Action: Key Principles & Treatment for Lateral Canthal Lines’ Webinar’? 1. Registration will be open in the coming weeks! Join the Aesthetics website for free and tick ‘Get communications from Aesthetics with up-to-date news, features and events’ in your profile to be notified when registration is live! 2. Once registration is live you will be prompted to use your DocCheck* password to confirm that you are a Doctor, Nurse or Dentist and able to access this webinar (if you registered for the last Aesthetics webinar, your DocCheck account will be valid) 3. Tick the box to confirm that you would like to sign up for the webinar. You’ll then receive reminder emails for the event closer to the time to ensure you don’t miss out! *What if I don’t have a DocCheck login?

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Azzalure Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 125 Speywood units of reconstituted solution (powder for solution for injection) Indications: Temporary improvement in appearance of moderate to severe: • Glabellar lines seen at maximum frown, and/or • lateral canthal lines (crow’s feet lines) seen at maximum smile in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Azzalure should only be administered by physicians with appropriate qualifications and expertise in this treatment and having the required equipment. Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed using a sterile suitable gauge needle. Glabellar lines: recommended dose is 50 Speywood units divided equally into 5 injection sites, 10 Speywood units to be administered intramuscularly, at right angles to the skin; 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. Lateral canthal lines: recommended dose per side is 30 Speywood units divided into 3 injection sites; 10 Speywood units to be administered intramuscularly into each injection point, injected lateral (20 - 30° angle) to the skin and very superficial. All injection points should be at the external part of the orbicularis oculi muscle and sufficiently far from the orbital rim (approximately 1 - 2 cm); (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. The efficacy and safety of repeat injections of Azzalure has been evaluated in Glabellar lines up to 24 months and up to 8 repeat treatment cycles and for Lateral Canthal lines up to 12 months and up to 5 repeat treatment cycles. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis. Special warnings and precautions for use: Care should be taken to ensure that Azzalure is not injected into a blood vessel. Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. There is a potential risk of localised muscle weakness or visual disturbances linked with the use of this medicinal product which may temporarily impair the

ability to drive or operate machinery. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy, Lactation & Fertility: Not to be used during pregnancy or lactation. There are no clinical data from the use of Azzalure on fertility. There is no evidence of direct effect of Azzalure on fertility in animal studies. Side Effects: Most frequently occurring related reactions are headache and injection site reactions for glabellar lines and; headache, injection site reactions and eyelid oedema for lateral canthal lines. Generally treatment/injection technique related reactions occur within first week following injection and are transient. Undesirable effects may be related to the active substance, the injection procedure, or a combination of both. For glabellar lines: Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and haematoma). Common (≥ 1/100 to < 1/10): Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites, predominantly describes brow paresis), Asthenopia, Eyelid ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual impairment, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity, Eye movement disorder. Rare (≥ 1/10,000 to < 1/1,000): Urticaria. For lateral canthal lines: Common (≥ 1/100 to < 1/10): Headache, Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites), Eyelid ptosis, Eyelid oedema and Injection site disorders (e.g. haematoma, pruritus and oedema). Uncommon (≥ 1/1,000 to <1/100): Dry eye. Adverse reactions resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1613/001/001 (IRE) Legal Category: POM Further Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: September 2018 Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Galderma (UK) Ltd. Date of Preparation: July 2019 Job code: AZZ19-017-0067

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Aesthetics August 2019  

Injectables

Aesthetics August 2019  

Injectables