Aesthetics December 2019 by Aesthetics & CCR

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VOLUME 7/ISSUE 1 - DECEMBER 2019

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Squamous Cell Carcinoma CPD

Dr Libin Mathew and Dr Sandeep Cliff explore SCC presentation and treatment

Special Feature: Exploring Harley Street The history and future for aesthetic clinics on Harley Street

Stem Cells in Regenerative Medicine

Mr Ivor Lim introduces the use of stem cells in regenerative medicine

18/06/2019 17:18

Understanding Clinical Negligence

Dr Bib Vhadra outlines elements involved in a negligence claim

Contents • December 2019 06 News The latest product and industry news 13 On the Scene Out and about in aesthetics 15 Merz Expert Summit, Munich A report on the global gathering of Merz practitioners in Germany 16 News Special: BACN Code of Conduct Update Aesthetics reports on the BACN’s move to restrict the training and

prescribing of beauty therapists

Special Feature: Exploring the Evolution of Harley Street Page 21

18 ACE 2020 A look at the unmissable clinical education on March 13-14 21 Special Feature: Exploring the Evolution of Harley Street The history of Harley Street and the future for this well-known postcode

CLINICAL PRACTICE 26 CPD: Understanding Squamous Cell Carcinoma Dr Libin Mathew and Dr Sandeep Cliff discuss the presentation and

treatment of squamous cell carcinoma

31 Updates to Breast Augmentation Mr Adrian Richards provides an overview of the latest trends and

developments in breast implant surgery

36 Advertorial: Treating the Jaw with Restylane Successful jawline treatment with aesthetic practitioner Dr Heather Muir 39 Case Study: Treating PIH Aesthetic practitioner Vanita Rattan treats PIH following a mite infestation

in a patient with skin of colour

43 Stem Cells in Regenerative Medicine Mr Ivor Lim introduces the use of stem cells in regenerative medicine 47 Treating Acne with Topicals Dr Aileen McPhillips discusses acne management with cosmeceuticals 52 Advertorial: NEW CUSTOM D•O•S•E from SkinCeuticals The personalised skincare experience designed for your patients’ skin 55 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 57 Understanding Clinical Negligence Dr Bib Vhadra outlines the main elements involved in a negligence claim and

discusses the case law involved

61 Staying Professional on Instant Messenger Dr Stevie Potter discusses how to keep communications across social media

instant messaging applications professional

65 Utilising Brand Photography Photographer Hannah McClune explores how to get started in personal

brand photography

69 In Profile: Dr Patrick Treacy Dr Patrick Treacy shares his adventures throughout his medical and aesthetic

career and reminisces on the growth of the specialty

70 The Last Word Mr Ayad Harb discusses why he believes the term ‘aesthetic ideal’ is

In Practice: Understanding Clinical Negligence Page 57

outdated and why practitioners should adopt a personalised approach

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Clinical Contributors Dr Libin Mathew completed his Bachelor of Medicine, Bachelor of Surgery at King’s College London, as well as a Bachelor of Science in Pharmacology (Hons). He is a core medical trainee at East Surrey Hospital. Dr Sandeep Cliff is a consultant dermatologist and has a particular interest in skin cancer and inflammatory dermatosis. He has been principal investigator for over six clinical research trials and is a clinical sub-dean at Brighton and Sussex Medical School. Mr Ivor Lim is double certified in both plastic surgery and hand surgery from the Academy of Medicine, Singapore, as well as from the Intercollegiate Specialty Boards in the UK with FRCS (Plastic Surgery) qualifications. Mr Adrian Richards is a plastic and cosmetic surgeon with more than 15 years’ experience in both the NHS and private clinics. He is a member of BAAPS, is clinical director of Cosmetic Courses and practises at The Private Clinic. Vanita Rattan has completed a medical degree and a degree in physiology and pharmacology from University College London Medical School. She has treated more than 25,000 cases of hyperpigmentation. Dr Aileen McPhillips is a graduate of Queen’s University, Belfast and currently works as a GP and aesthetic practitioner. She is a member of the Royal College of General Practitioners and completed a Level 7 certificate in Injectables for Aesthetic Medicine.

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Editor’s letter What’s your biggest achievement in 2019? It can be easy to dwell on the challenges faced throughout the year, so I encourage everyone to take a step back to reflect on the positives and celebrate our successes. While some may bemoan that we still have a Chloé Gronow way to go with regulation, there are so many Editor & Content companies and practitioners working hard to Manager uphold standards and promote patient safety across the UK, which we all should be championing. Last month we broke the news that BACN members voted to update their Code of Conduct in relation to training beauty therapists (covered in detail on p.16). This garnered a hugely positive response on social media, with more than 50 shares on Facebook and reaching almost 10,000 people. It was fantastic to watch the comments rolling in, with the majority praising the BACN for this positive step forward. At the time of writing, we are gearing up for the Aesthetics Awards on December 7 – a perfect time to come together and applaud everyone’s achievements. If you’re reading this in the first week of

December there may still be some tickets remaining, so please do get in touch if you’d like to join! In our final issue of the year, we talk about evolution. Where have we come from and where are we going? On p.21 we chat to practitioners about the development and future of Harley Street; will the prestige associated with the area ever change and can it be replicated elsewhere? We’d love to know what our readers outside of London think – drop me a message to share your thoughts! It’s always beneficial for non-surgical practitioners to be aware of developments in the cosmetic surgery world, so Mr Adrian Richards provides an update on breast surgery techniques and trends on p.31. Mr Ivor Lim gives an insightful overview of the future of stem cells in regenerative medicine on p.43, while Mr Ayad Harb shares his views on why practitioners should be changing their approach to creating an ‘aesthetic ideal’ in his Last Word piece on p.70. I also urge you all to read our In Profile with Dr Patrick Treacy this month. With a career spanning more than 30 years, travels across the globe and tales of treating Michael Jackson, it really is a fascinating read on the evolution of the specialty and the notable part Dr Treacy has played.

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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Dermatology

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

#BACN Melanie Recchia @alchemyskinclinicbucks I know I’m short but this guy is tall! @nik_kane I really enjoyed presenting at the BACN conference! #BeBACN #BreastAwareness Francesca White @francesca_white Last night’s @the_beauty_ triangle talk, ‘Breasts Today’ brought together the most empowering female panel, who taught us everything from basic breast checks to surgical interventions and beyond. An enormous thank you to @lucydoctormummy, @drjacquelinelewis and #fionakeane for an incredible evening. And I couldn’t do any of it without our wonderful coordinator @alyona_perelygina #BreastChecks #Surgery #NonSurgical #Teaching Dr Firas Al Niaimi @drfirasalniaimi_ A short but wonderful visit to Hong Kong. Sadly it’s time to leave but managed to combine some lecturing, workshop and sightseeing. Off to my next destination: Vietnam! #Travel #LaserGuy #Education Dr Raj Acquilla @RajAcquilla Seriously hot #LIVE show in #Sydney today with my main man Dr Arthur Swift @DrASwift @Allergan #Conference Sharon Bennett @sharonbennettskin What a fabulous and professional BACN conference. The coming together of amazing experts sharing their skills and knowledge, evidence led guidance and anatomy focus! #BACN #Learning #BestPractice

Galderma launches new rosacea campaign A campaign aiming to empower and equip rosacea patients to discuss the true burden of their disease with a dermatologist has launched. Face Up To Rosacea is headed by global pharmaceutical company Galderma and features a website that acts as a resource for rosacea support. The website guides patients through a series of questions relating to their individual signs and symptoms, how their rosacea makes them feel and what treatments they have used in the past, before creating a personalised appointment guide for the user to take to their next consultation. According to research by Galderma in 2018, comprising 710 patients across six countries, approximately 82% of patients felt their rosacea was not under control, and one in five people made substantial adjustments to their daily life because of their rosacea. Dr Kamel Chaouche, head of global medical affairs, prescription, at Galderma said, “Galderma is committed to advancing rosacea patient care. By listening to the views of rosacea sufferers and healthcare professionals (HCPs) from around the world we identified an opportunity to support the patient-HCP dialogue in a really tangible way. The new patient appointment guide has the potential to truly revolutionise future rosacea appointments, leading to better outcomes.” Acquisition

Enhance Insurance acquired by Tasker Insurance Group Medical aesthetics insurance provider Enhance Insurance has been acquired by speciality insurance broking group, Tasker Insurance.The Enhance team, headed up by Martin Swann and led by Sharon Allen, will form part of the specialist retail broking division within Tasker Insurance Brokers but will continue to trade under the Enhance brand. Speaking of the acquisition, CEO of Tasker Insurance Robert Organ said, “Since its launch in 2016 Enhance has become an established market brand in aesthetics and the Enhance team have become the trusted risk and insurance advisors for a large number of the medical aesthetic community.” He continued, “We are delighted to welcome Martin and his team to Taskers, both he and Sharon are well respected within the marketplace and they will be a real asset to our business. We look forward to supporting them in continuing to develop the Enhance brand, products and team.” Martin Swann, managing director of Enhance Insurance and founder of the Enhance brand commented, “I am personally very excited to be joining Tasker Insurance. It is a dynamic and fast-moving business with a real focus on its clients and their respective industries. The move to Taskers will not only enable us develop the Enhance service offering and team but also bring to market some exciting products that we have had in the pipeline for some time.” He added, “All I can say for now is to watch this space as there will be some exciting news to share with you over the coming months.”

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Devices

StimSure launches in EU Laser manufacturer Cynosure, a division of Hologic, has launched a non-invasive electromagnetic device StimSure in Europe and the Middle East. The company explains that by contracting and stimulating muscles, the device can build, tone, strengthen and tighten the abdomen, glutes and thighs, delivering up to 24,000 muscle contractions in 20 to 30 minutes. According to Cynosure, a prolonged contraction, made by a series of individual twitch contractions back to back, creates a maximal tetanic contraction that results in more efficient growth of muscle fibres. The company states that StimSure uses 1.0 tesla per applicator and has the function to create personalised programmes, so practitioners can tailor treatments for their individual patient. For optimum results, a total of six to eight treatments are recommended, performing two per week. Industry

Merz Group restructures Global pharmaceutical company Merz will divide into three independently operating businesses: Merz Aesthetics, Therapeutics and Consumer Care. The company explains that under the new structure, which will start operating on January 1, all functions and aspects of the global Merz Aesthetics business will be solely focused on serving the needs of customers. Merz explains that its Therapeutics branch will generate a long-term, sustainable pipeline centred on movement disorders and Merz Consumer Care will focus on new growth opportunities to expand its success in new areas and strengthen its agile, customeroriented culture as a fast-moving consumer goods business. In addition, Bob Rhatigan has been appointed as global CEO of Merz Aesthetics, having previously served as CEO of Merz Americas. “We are pleased to make this change from a position of strength as an organisation and in support of our long-term sustainability strategy. This positions Merz Aesthetics as the world’s only global fully-focused, medical aesthetics business, committed first and foremost to customers,” said Philip Burchard, CEO of Merz Group.

Vital Statistics 50% of worldwide consumers look to celebrities most often to help deﬁne beauty (Allergan 360 Report, 2019)

Daily active Instagram story users increased from 150 million in January 2017 to 500 million in January 2019 (Statista, 2019)

Global prevalence of indoor tanning in adolescents for 2013-2018 was 6.5%, which was 70% lower than the 22% prevalence for 2007-2012 (British Journal of Dermatology, 2019)

The average internet user now spends more than 6 hours and 42 minutes online each day (Hootsuite Digital Report, 2019)

The US saw a 61% increase in sales in beauty-positioned supplements in the past year (Euromonitor International, 2019)

Digital

Instagram removes likes for UK users Social media platform Instagram will be hiding the number of likes on some posts in the UK as part of a global trial that aims to remove pressures on users. The company explained in a Tweet that whilst they had positive feedback from early testing in Australia, Brazil, Canada, Ireland, Italy, Japan and New Zealand, they are continuing the test to learn more from the global community. Psychodermatologist Dr Alia Ahmed, said, “This is a step in the right direction to protect vulnerable users of social media. The number of people with appearance-related concerns is increasing, especially in the younger age group. Largely unfiltered access to unrealistic images via social media has a role to play in this. I strongly encourage social media platforms to next concentrate their efforts on removing false information and advertising, as well as push transparency on images or videos displayed by users.”

Melasma is most common in women, particularly those pregnant, where 50% may be aﬀected (British Association of Dermatologists, 2018)

A survey of 596 Chinese aesthetic practitioners indicated that 90.5% believed that being beautiful would improve their daily life

(Dr Souphiyeh Samizadeh, Aesthetic Plastic Surgery, 2018)

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Events Diary 4th-6th December British Association of Plastic Reconstructve and Aesthetic Surgeons Winter Scientific Meeting www.bapras.org.uk 30th January - 1st February 2020 IMCAS World Congress www.imcas.com/en 5th-7th May 2020 British Medical Laser Association Conference www.bmla.co.uk

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Packaging

Croma Pharma reveals new packaging for Arthrex ACP Pharmaceutical company Croma Pharma has introduced its own branded packaging design for the personalised cell therapy device Arthrex ACP double syringe system. The company explains that the update aims to assist in portfolio alignment and harmonise its aesthetic products. The new design integrates to the existing appearance of the Croma product range. The Arthrex ACP double syringe system for aesthetic applications is exclusively distributed in nine European countries by Croma Pharma. Supplement

7th December

The Aesthetics Awards 2019 www.aestheticsawards.com

13 & 14 MARCH 2020 / LONDON

13th-14th March

The Aesthetics Conference and Exhibition www.aestheticsconference.com Skincare

Nimue launches microneedling device

Totally Derma now available in daily sachets Nutraceutical collagen drink company Totally Derma has announced that the product can now be bought in 12g daily serving sachets. According to the company, the drink aims to deliver visible improvements in skin, hair and nails, as well as joint pain and gynaecological menopausal dryness. It contains more than 10,000mg of hydrolysed powdered collagen (bovine source) per daily serving, as well as a high therapeutic dosage (210mg) of hyaluronic acid, vitamin C, green tea extract, grapeseed extract, copper, zinc, manganese and alpha lipoic acid. Anita Eyles, director of Totally Derma said, “We are delighted to now offer daily serving sachets for our existing and new clinic partners. By giving customers a chance to sample or purchase Totally Derma sachets, whilst educating them on the products’ extensive skin and body health benefits, it will provide clinics with a turnkey sales solution and added revenue stream, as well as increase awareness for the Totally Derma brand.” The company has confirmed that a number of sachets will be supplied free with every minimum order quantity purchase of 12 tubs. In addition, clinics will be able to purchase individual sachets for retail sales. ACE

Skincare company Nimue Skin Technology has launched microneedling treatments that aim to refine skin texture and reduce signs of ageing with minimal downtime and disruption of lifestyle. The Nimue cylindrical roller device is studded with 192 sterile, fine, stainless steel needles, 1mm in length and 0.2mm in diameter, with the top of the needle tapered to a point of 0.07mm. The company explains that this shape is specifically designed to make the treatment less painful for the patients, whilst maintaining the collagen induction process. The device can be combined with Nimue’s transdermal solution TDS and Super Fluids for optimal treatment results.

New business sessions confirmed for ACE 2020 A number of renowned business professionals will share their expertise at the ACE 2020 Business Track on March 13-14. On Friday 13, marketing professional Alex Bugg will speak on dominating Google search results in your area, before PR consultant Julia Kendrick recommends ways to enhance your profile, and marketing specialist Danny Bermant shares advice on how to secure appointments through your digital strategy. Saturday March 14 will see an engaging talk on ‘The After Sale’ from business coach Alan Adams, who will provide delegates with practical tips on ensuring repeat custom from your patients. Readers can register for ACE now by visiting aestheticsconference.com and entering code 10001.

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Treatment

HydraFacial Elite launches Aesthetic technology manufacturer HydraFacial has launched the HydraFacial Elite with refined features. The HydraFacial is a non-invasive, six-step treatment that aims to provide non-invasive skin resurfacing and temporary pore opening through cleansing, exfoliating, and extracting impurities evenly, whilst simultaneously delivering patented serums to the skin. The HydraFacial Elite has an updated design and new interface. The company explains that both blue and red LED light can be used simultaneously or separately and will charge more rapidly for a longer standby mode. The HydraFacial Elite also includes mechanical lymphatic drainage and a simplified tip installation and removal for ease of use. The HydraFacial Perk eye and lip treatment is accessed with just a switch from HydraFacial Elite. HydraFacial director Martyn Roe said, “HydraFacial was the first brand to pioneer hydradermabrasion technology and disrupted the industry when it launched in the UK eight years ago. HydraFacial Elite is the next step in our commitment to continually innovate and showcase the best practice in aesthetic clinics and patient results. We’re delighted at the reception to its UK launch.” Topicals

Medicalia skincare released

US-based skincare brand Medicalia is now available to practitioners in the UK and Ireland from product distributor Pevonia. There are nine product collections to the Medicalia brand: Medi-Renew, MediSoothe, Medi-Heal Face, Medi-Repair, Medi-Clear, Medi-Refine, Medi-Heal Body, Medi-Protect and the Professional Medi-Peels. All of which are dermatologist-tested, hypoallergenic, noncomedogenic and non-irritant, while products designed for the eye are also ophthalmologist tested. According to Medicalia, stockists will also receive product and treatment training, promotional materials, and PR and marketing support, along with ongoing specialists technical support. Hair restoration

Theradome introduces latest helmet device Medical device company Theradome Inc has added the EVO LH40 laser helmet device to its portfolio of hair restoration products. The company explains that the device contains 40 nanometre proprietary lasers which aim to flood coherent light across the scalp to ensure that affected areas are treated simultaneously. According to Theradome, the laser light penetrates the scalp at 3-5mm to stimulate the base of the hair follicles and promote hair regrowth. The Theradome EVO LH40 is cordless, portable, suitable for at-home use and features a one-touch button function, accompanied by a user-friendly guided voice command function.

Dr Kim Booysen, aesthetic practitioner Why did you choose to work in aesthetic medicine? I fell in love with aesthetics because it allows me to still practice medicine but without the pressures I experienced in emergency medicine, something I have heard other practitioners mention. Aesthetics allows me to treat the side effects of ageing and skin conditions, diagnosing the cause of these symptoms, planning and executing a treatment and dealing with any complications and adapting the treatment as the patient journey progresses. So for me, the clinical aspect is still there, but with the added advantages of happy patients who I have time to get to know and build long-standing, trustworthy relationships with. The science of aesthetic products is also fascinating and with new treatments emerging daily, the science just keeps getting better. What does it mean to be a Merz Innovation Partner? Having worked with Merz as a Field Clinical Specialist, I was honoured to be asked to become involved in their new training initiative. The Merz Innovation Partners (MIPs) are all experienced and successful practitioners with a passion for education. Merz provided intensive product education with industry experts and the MIPs are now sharing this in-depth knowledge at various masterclasses. The MIP programme is a wonderful opportunity to share knowledge and work with some inspiring people. What matters to you when it comes to education? Understanding the science behind aesthetic products is key. I believe that aesthetic practitioners should understand their product’s composition and how they behave in the body. We learn the active ingredients and interactions of other prescription medications and we should aim for the same standard in aesthetics. Hearing innovators such as Dr Jurgen Frevert speak so passionately about the science behind the products, keeps me motivated to fully understand the products I choose for patients, allowing me to offer more effective treatments. M-MA-UKI-0653 D.O.P November 2019 This column is written and supported by

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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

BACN AUTUMN AESTHETIC CONFERENCE Thanks to everybody who attended the BACN Autumn Aesthetic Conference on November 7 and 8 in Birmingham. The conference was the BACN’s biggest yet, with the largest number of delegates and a fantastic exhibition area on the Friday. Highlights included Mr Charles East’s talk on rhinoplasty in 2019, along with Veronica Donnelly’s jampacked discussion about all things VAT. At the conference, Sharon Bennett, BACN Chair, introduced the new campaign ‘I AM A BACN NURSE’ which the BACN will be launching in the coming months and throughout 2020, equipping members with tools to shout from the rooftops about their BACN membership and highlight the professionalism and duty of care to patients that BACN members exhibit throughout their day-today practice. The BACN also passed the motion that regulated healthcare professionals should not train or prescribe for beauty therapists/lay people in injectable cosmetic treatment such as dermal fillers and botulinum toxins, and this will now be reflected in the BACN Code of Conduct. More information on the location and dates for 2020 events will be provided to members soon.

AESTHETICS AWARDS The BACN will be attending the Aesthetics Awards 2019 to celebrate the achievements of the many nurses and their clinics that are nominated in the many categories, along with cheering on the best in aesthetics. Good luck especially to all the BACN nurses nominated in The SpringPharm Award for Aesthetic Nurse Practitioner of the Year – Melanie Recchia, Jackie Partridge, Elizabeth Rimmer, Adrian Baker, Rachel Goddard, Susan Young and Aine Larkin.

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Appointment

BAS announces new board appointments The British Association of Sclerotherapists (BAS) has welcomed vascular surgeon Mr Haroun Gajraj and consultant vascular surgeon Mr Zola Mzimba to its management board. BAS president Mr Philip Coleridge Smith commented, “Haroun and Zola will bring Mr Haroun Gajraj Mr Zola Mzimba zest and great enthusiasm to the organisation, having been keen supporters of the BAS for many years. They share our aims of raising standards and promoting best practice and education in foam sclerotherapy and microsclerotherapy. Haroun brings a passionate desire to foster safety and the highest standards of care, and Zola is an active member of the Irish Vascular Groups and will play a key part in representing their views, as well as promoting the BAS to vascular and aesthetic medicine practitioners in both Northern Ireland and the Republic of Ireland.” Clinical trial

Study suggests skin exposure to UV light alters gut bacteria A study led by Professor Bruce Vallance of the University of British Columbia and published in Frontiers in Microbiology has suggested that skin exposure to narrow band ultraviolet light (UVB) alters the gut microbiome in humans. The analysis suggests that vitamin D mediates the change, which authors believe could help explain the protective effect of UVB light in inflammatory diseases such as multiple sclerosis (MS) and inflammatory bowel disease (IBD). Healthy female volunteers (n=21) were given three one-minute sessions of fullbody UVB exposure in a single week. Stool samples were taken before and after treatment for analysis of gut bacteria, as well as blood samples for vitamin D levels. The results showed that skin UVB exposure significantly increased gut microbial diversity, but only in subjects who were not taking vitamin D supplements during the study (n=12). The largest effect was an increase in the relative abundance of lachnospiraceae bacteria after the UVB light exposures. According to authors, the results also showed some agreement with studies using UVB on mice, such as an increase in firmicutes and decrease in bacteroidetes in the gut following exposure. Gifting

Each year, the BACN holds an Annual General Meeting. BACN members have all been provided notice of this meeting by email – BACN Accounts and information relative to the meeting can be found in the BACN Member’s Area. The AGM will be held at Park Plaza Westminster Bridge, 200 Westminster Bridge Rd, Lambeth, London SE1 7UT on December 7 at midday. Please contact Tara Glover, BACN Events Manager at tglover@bacn. org.uk for more information. This column is written and supported by the BACN

Aesthetic companies launch Christmas giftsets This year has seen a rise in the release of new festive giftsets from some of the leading companies in the field. Aesthetic distributor AestheticSource has launched four skincare sets and sample size baubles from Skinbetter Science, two Exuviance crackers for the face and body, a NeoStrata Skin Active Deluxe Sample Kit and a PEEL2GLOW cracker. As well as this, skincare manufacturer Medik8 has introduced the Midnight Beauty Christmas Collection, featuring three limited edition kits, inspired by classic fairy tales, containing products suited for a night-time regime. Skincare company iS Clinical has also introduced branded Fire & Ice gift vouchers. There are additional offerings from nutritional supplement company, Advanced Nutrition Programme, nutraceutical company Proto-col, skincare companies Image Skincare and Nimue Skin Technology.

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Training

Acquisition Aesthetics launches new course 13 & 14 MARCH 2020 / LONDON

Training provider Acquisition Aesthetics will hold a tear trough masterclass in Newcastle and London on February 1 and March 14, respectively. The one-day CPD-certified masterclass will be led by aesthetic practitioner Dr Elle Reid, with a focus on the detailed surgical anatomy of the tear trough. The company states that delegates will learn to master the Acquisition Aesthetics Signature Technique for tear trough correction, which uses both a combination of needle and cannula, under the supervision of the trainers to ensure confidence in treatment planning and delivering bespoke treatments. The practical training will be performed on live models in small, focused learning groups, with a maximum of three delegates per trainer.

WH AT DO YOU WA NT TO L E A R N A BOU T IN 20 20 ?

Environmental

4T Medical becomes carbon neutral Aesthetic product supplier 4T Medical has become a carbon neutral organisation, achieved by offsetting its current emissions and partnering with Carbon Footprint Ltd to plant trees in local schools. As a next step in its longterm commitment to sustainability, 4T Medical has set itself the goal of becoming carbon negative by 2021. The company explains that it has put in place several initiatives which include reducing its impact through energy efficiency, transportation and travel efficiency, as well as compensating for unavoidable CO2 emissions with carbon offsets. Julien Tordjmann, managing director of 4T Medical, said, “Having a net zero carbon footprint is a major milestone for 4T Medical. As the climate crisis escalates, I am very proud that we are taking responsibility for the carbon emissions resulting from our operations. We have a number of other schemes planned to minimise our impact on the environment and we very much hope others in our industry will follow suit.” Regulation

NMC celebrates 100 years of nursing regulation The Nursing and Midwifery Council (NMC) is celebrating a century of pride and awareness about the vital role nurses, working across all health and care settings, play in the UK. On December 23, 1919, the Nurses Registration Act was passed in the House of Commons after 32 years campaigning by Ethel Gordon Fenwick, former matron of St Bartholomew’s Hospital in London. She believed in establishing a compulsory register of nurses to standardise training, improve patient safety, and advance the profession. The NMC celebrations involved a competition to design a commemorative pin badge, a new film, an interactive timeline and a celebratory event. Andrea Sutcliffe, chief executive and registrar at the NMC, said, “A century on from the introduction of nurse registration, I’m sure Ethel Gordon Fenwick would be proud of her legacy and the fantastic contribution nurses make every day in our communities. It’s a great privilege and responsibility for the NMC to regulate such an important and trusted profession. We want to use our anniversary to reflect on all that has been achieved since 1919 and show how nurses have made and continue to make a difference for people using services and their families.”

BUSINESS TRACK The Business Track is back for ACE and this year you and your team have the opportunity to learn from 19 different sessions, each worth half a CPD point over the two days. Content covered will include boosting your profile, enhancing your local search engine results, securing appointments and patient retention, meaning whether you’re a practitioner, business owner or clinic employee, there is something for everyone! CLINICAL AGENDA More than 30 renowned aesthetic KOLs will present the latest innovations in product development and treatment approaches from leading aesthetic suppliers in the UK. Sessions have limited spaces available and some have access restrictions depending on your profession, so ensure you check the agenda in advance of attending!

WHAT DELEGATES SAY “Being able to receive the latest specialty information in all areas of the profession from regulations to patient retention was fantastic!” AESTHETIC DOCTOR, LONDON

2019 was exceptional – I can’t wait to attend ACE 2020! AESTHETIC NURSE, SCOTLAND

VISIT aestheticsconference.com Use registration key 10001 HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Education

Cutera to host first UK laser training event Laser and light-based medical provider Cutera Medical Ltd is set to host its first UK version of the company’s laser training workshop, the Cutera University Clinical Forum (CUCF) on February 17 2020. The event will take place at the Park Plaza in Westminster and will consist of a range of talks and open panel discussions which will focus on all the latest clinical trends and developments, combined with live product demonstrations which will review some of Cutera’s newest product launches. The event will be led by a number practitioners including aesthetic practitioners Dr Tapan Patel, Dr Victoria Manning, Dr Julia Sevi, Dr Sach Mohan, dermatologist Dr Asif Hussein and facialist Nicola Russell. Cutera country manager Tim Taylor said, “I am delighted to bring such a significant event to the UK market, with an unbelievably strong panel of expert speakers. We have ensured CUCF London is the perfect event for any aesthetic professional considering introducing laser or advanced technology into their business, providing delegates with unrivalled knowledge and expertise with the opportunity to see a range of our devices in action and network with fellow professionals.” On the Scene

TAMC 2019, Dubrovnik Around 400 delegates travelled to the beautiful Croatian city of Dubrovnik for The Aesthetic Medicine Congress (TAMC) on October 11-13. Held in association with the British College of Aesthetic Medicine (BCAM), the aim of the event was to stimulate ideas, educate, share expertise, initiate discussions and extend networking opportunities for medical aesthetic practitioners around the globe. There were almost 50 speakers in attendance from the UK, Sweden, The Netherlands, Greece, Croatia, the US, Switzerland, Ireland, France, Bulgaria, the UAE, Belgium, among other countries. Among the topics discussed were jawline contouring: the new buzz for millennials, bichectomy – buccal fat pad removal, how to become an international aesthetic brand, correcting the lid cheek junction without surgery, the effect of music on healing and rejuvenating the body, important advances in dermal filler and botulinum toxin techniques in the last five years, shaping of the body and face with devices, amongst many other topics. In addition to the lectures, during the three days of the first evenings, a cocktail party was held, followed by a gala evening with a performance by Croatian music band Cubismo. On the last night the delegates enjoyed a concert by Austrian pianist Joe Meixner. The congress also featured 40 exhibitors and companies such as Galderma, Teoxane, Allergan, Merz, Hydrafacial, mesoestetic, and many others.

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News in Brief Harpar Grace updates website UK aesthetic product distributor Harpar Grace has added a new training schedule and booking system to its website. The company explains the platform provides flexibility and choice for both workshop and virtual-based learning offered by its clients, including iS Clinical, Déesse and Totally Derma. Director Alana Marie Chalmers commented, “We recognise that our practices range from busy multisites to bespoke sessional clinics, hence have launched a training programme and platform enabling users to self-select and book directly onto courses to support their business.” Fraxin launches VMA Fat Loss Manufacturing company Fraxin has added a second product to its portfolio, Fraxin VMA Fat Loss. The treatment aims to reduce subcutaneous adipose tissue and is suitable for use in the chin, breast, stomach, hips, buttocks, back, arms and thighs, according to the company. Comprising red-purple sea algae extracts, the product is administered via derma pen, derma roller, derma stamp, microneedle and microchannel. A representative of the manufacturing team at Fraxin LLC stated, “Fraxin VMA is designed to deliver equal or better results than the currently available deoxycholate products on the market, all without the requirement for painful injections, and at a fraction of the cost.” Pigmentation sunglasses launch Sunglasses that aim to protect individuals who are prone to hyperpigmentation have been launched by aesthetic practitioner Vanita Rattan. The ‘Dr V’ sunglasses aim to give those who suffer from genetic or hormonal melasma, or who are prone to hyperpigmentation on the cheekbones, protection from sun damage to stop existing damage from getting worse. The sunglasses feature UV filters and are larger than conventional sunglasses, measuring 6.5cm in height for maximum skin protection. Final sponsor confirmed for the Aesthetics Awards Aesthetic device company Candela has been confirmed as the sponsor for the Best Clinic Group, UK & Ireland (3 clinics or more) category in the 2019 Aesthetics Awards, taking place on the 7th of this month. Finalists in the category are Clinetix, The Consultant Clinic, The Laser and Skin Clinic and Tinkable Aesthetic Clinic.

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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On the Scene

Out and about in the specialty

Luminera UK Workshop, London On November 17 injectable company Luminera hosted its first UK workshop at Elite Academy on Harley Street. The hands-on event focused on teaching aesthetic practitioners how to use skin booster Hydryal 4%. Speakers included aesthetic practitioner and Luminera key opinion leader Dr Gurnam Virdi, aesthetic practitioner Dr Lilyana Marks and head of Luminera UK, Eliran Perez. Following the event, Perez said, “We were thrilled to have the first ever Luminera UK workshop taking place on the prestigious Harley Street. Since the company was established, all of our endeavours have been dedicated to highlighting the uniqueness and advantages that our products pose. One of them is without any doubt our Hydryal 4% skin booster. We were very happy with the vast demand and interest that the product created at this workshop and think it is important to host events such as this so practitioners can understand the main advantages and the unique injection methods. We are planning several workshops in London, Manchester and Glasgow.”

VIVACY Masterclass, London French injectable manufacturer Laboratoires VIVACY held a Masterclass for around 40 practitioners in London on October 29 at the Hallam Conference Centre. Titled 4D ELEMENTS CONCEPT for Safe & Natural Beautification, the event aimed to educate aesthetic practitioners on the STYLAGE hyaluronic acid dermal filler range and best uses in practice. The day included talks from scientific director of Vivacy, Denis Couchourel, who explained the rheology of the STYLAGE products, and how they are best used in different areas. Plastic surgeon Miss Mimi Ehrenreich from Israel presented on patient communication, highlighting the need for practitioners to build a positive relationship. She also discussed the artistic side of aesthetics and how to look at a patient’s shape, shadow, proportion, symmetry and skin texture for beautiful, natural results. Finally, Miss Ehrenreich explored the importance of facial movement when performing aesthetic treatments, highlighting the need to choose the right products in specific areas. There was also a combined talk by Couchourel and Miss Ehrenreich on complications, explaining how to prevent and manage them, should they occur. The presentations were followed by two live demonstrations, showcasing cheek enhancement and nasolabial fold correction, as well as a tear trough treatment through mid-face volumisation.

BACN Autumn Aesthetic Conference, Birmingham Aesthetics reports on the British Association of Cosmetic Nurses’ annual event for members Nurses from across the UK met at Edgbaston Stadium in Birmingham on November 7-8 for two days of lectures and demonstrations from the very best in aesthetic nursing. The first day consisted of a Professional Sessions Symposium, which began with an engaging presentation from general surgeon and aesthetic practitioner Miss Mayoni Gooneratne, who spoke on increasing patient retention through combination treatments. She advised nurses on how to see gaps in their offering, encourage staff to develop specialisms in order to offer new treatment approaches and recommended incorporating skincare into the cost of treatments. This was followed by chartered tax advisor, Veronica Donnelly’s VAT update. She acknowledged that there was fear and confusion in the sector when it comes to understanding the rules surrounding tax and VAT owed by aesthetic practitioners, so noted that HMRC is not entitled to see your records on demand, informing practitioners on what they have to produce and how to do so in a controlled environment. She also advised delegates to think carefully about the risks in their

business and how to set up a company that protects their personal assets. The afternoon saw informative talks from nurse prescriber Sharon Gilshenan, who spoke on using Aliaxin for facial volume restoration, which was followed by an engaging discussion on using botulinum toxin to treat migraines, led by Dr Tariq Sumrein. Aesthetic practitioner Dr Beatriz Molina then spoke on preventing and managing complications, before nurse prescriber Lou Sommereux shared her experiences of treating and, in some cases, refusing treatment of patients suffering from body dysmorphic disorder. She reminded delegates of the importance of ‘saying no’ and when to refer to mental health colleagues. On day two, a traditional conference and exhibition took place, with the Aesthetics Media team in attendance, promoting the Aesthetics Awards, which got everyone excited for the celebrations on December 7. Delegates heard from aesthetic practitioner Dr Lee Walker, nurse prescriber Anna Baker, nurse prescriber Mel Recchia, consultant plastic surgeon Mr Charles East, Dr Lara Watson and Dr Priyanka Chadha. The conference concluded with a vote on the BACN’s motion to update its code of conduct in relation to the training of beauty therapists, which garnered a unanimous response to do so from members, discussed in more detail on p.16. Chair of the BACN, Sharon Bennett, said, “The conference was absolutely packed and our most successful yet. There was a whole array of different topics that are all really relevant. It’s been a fabulous meeting, with both new members and old members. Everyone has taken home such a lot from the learned, experienced presenters.”

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Merz Expert Summit, Munich Aesthetics reports on the global gathering of Merz aesthetic practitioners in Germany Focused on ‘The Life Changing Power of Aesthetic Medicine’, the Merz Expert Summit on November 16 brought together more than 450 leading providers of the Merz portfolio, from across the globe, for a day of innovation and education. Philip Burchard, CEO of Merz Group, opened proceedings with an overview of the company restructure, covered on p.7, emphasising that this change was made to strengthen focus for aesthetic customers and drive sustainable growth. He then welcomed the newly-appointed CEO of Merz Aesthetics, Bob Rhatigan, who said, “The restructure will offer better responsiveness, agility and access to all people in the Merz organisation, at all levels. Globally, everyone in Merz Aesthetics will be focused on serving practitioners.” UK-based practitioner Dr Kate Goldie opened the Summit, describing the event as the ‘hottest ticket in town’ in which a visionary programme would be presented. She went on to lead a fascinating discussion of how practitioners need to recognise ‘facial perception drift’ in which she presented evidence of how easily our perceptions can be altered as we become more familiar with the way something looks. Both patients and practitioners can become ‘visually drunk’ she said; the more used to looking at something unusual we get, the more normal it becomes. Dr Goldie advised practitioners to be aware of their

own perception drift and teach patients of the concept, warning that without doing so aesthetic results will become more and more unnatural. Aesthetic practitioner Dr Steven Dayan also gave an insightful presentation on the importance of recognising biases. He emphasised the fact that ‘beauty’ is a proven mathematical concept, relating back to PHI, yet ‘attractiveness’ is a conscious, biased interpretation. He claimed that 50% of how beautiful/attractive we find a person is based on a subconscious bias of what we know is ‘beautiful’, while the other 50% is a conscious choice of what an individual person finds ‘attractive’. Dr Dayan stressed how attractiveness is different for everyone, even amongst aesthetic professionals – citing research that indicates the differing views of plastic surgeons and dermatologists. To demonstrate his point, Dr Dayan asked the audience to vote for the features of noses, lips, chins and buttocks they deemed ‘most attractive’ which, as expected, produced a variety of results. To conclude he emphasised how practitioners need to recognise their own biases and expand their reference range. “Step into someone else’s space to see things differently,” he said, “You have to have an open mind and look at other perspectives.” The agenda also featured an innovative talk on the impact of botulinum toxin on

emotional wellbeing. Dr Fiona Gupta, assistant professor of neurology at Mount Sinai Hospital, reminded delegates that while many people dismiss aesthetic treatment as not being ‘healthcare’, the World Health Organization’s definition of health is, ‘A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’. She emphasised that aesthetic practitioners can have a huge impact on patients’ psychosocial wellbeing and presented evidence that indicates as such. The day continued with live demonstrations and interactive presentations from Merz’s renowned global faculty, who advised on the best practice use of the full Merz portfolio of products; Belotero, Bocouture, Radiesse, Ultherapy and Cellfina. Following the presentations, Aesthetics sat down with Dr Terri L. Phillips, vice president and head of global medical affairs at Merz, to find out more about the company’s portfolio and development. “We have a unique portfolio of products that offers a comprehensive package to practitioners and can be optimised across patient demographics,” she said. In her role, Dr Phillips oversees the research and development of new products, getting them through the approval process and ensuring clinicians understand how to use them safely. She notes that Merz values the expertise of the practitioners using its products and aim to learn from their experiences. “It’s very common for practitioners to use products in a different way to how we recommend, so our job is to take all that new information and bring it back into the company as intelligence and decide whether we should pursue that way of use,” she said. One product’s development that Merz will be focusing on in particular in 2020 is Radiesse, noted Dr Phillips, explaining, “There’s nothing like Radiesse in the market and we plan to do more to collaborate with clinicians and educate them on its uses going forward.” Dr Phillips concluded by emphasising the role of Merz Aesthetic Consultants, or MACs, who are experienced Merz trainers that offer oneto-one support to product users. She said, “Sometimes practitioners will have questions above and beyond what is on the instructions for use or has been covered in their initial training so, on request, MACs will visit them in their clinic and train them on advanced techniques, ensuring they use products in the safest possible way.”

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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consider and plan their treatment, and we may decide not to treat, or we may refer. A qualified nurse is furnished with competency in multiple clinical skillsets, judgement, critical thinking and evaluation’.

Considerations for nurses The association asked its members to remember the principles of the Nursing and Midwifery Council (NMC) Code, which emphasises that nurses should act within patients’ best interest and be able to demonstrate competency for all they do, as well as the competency of those they delegate to. According to the NMC, delegation is defined as the transfer, to a competent individual, of the authority to perform a specific task in a specified situation.1 As such, the BACN stated, ‘One could postulate that those training someone else in healthcare is akin to delegating a task, and that those training others therefore must be responsible in Aesthetics reports on the British Association of ensuring that the training meets the NMC Cosmetic Nurses’ move to restrict the training delegation requirements. The same applies of beauty therapists to prescribing for others and the delegation of the administration of medicines’. The Following a motion at the British Association of Cosmetic Nurses BACN also reiterated the NMC’s statement on remote prescribing, (BACN) conference on November 7 and 8, members unanimously which reads, ‘All prescribers must take individual responsibility for agreed to update its Code of Conduct to state that regulated their prescribing decisions and should recognise that there are healthcare professionals should not train or prescribe for beauty certain areas of practice where remote prescribing is unlikely to therapists or ‘lay people’ in the use of injectable treatments such as be suitable, for example when prescribing medicines likely to be dermal fillers and botulinum toxin. subject to misuse or abuse, or injectable cosmetic treatments’. The motion has also been supported by the British College of The association went on the emphasise that the training of a beauty Aesthetic Medicine (BCAM) and the Aesthetics Clinical Advisory therapist/lay person who has: no medical qualification, no clinical Board. When Aesthetics exclusively shared the news on social media knowledge or acumen, no pathway or requirement to demonstrate last month, the posts reached almost 10,000 people, garnering huge competency, is not required to evidence or show accountability, support amongst the medical aesthetic community. cannot consult or consent adequately as the clinical knowledge is absent, cannot prescribe and therefore manage complications, Why now? is not part of a multi-disciplinary team and is not answerable or The BACN acknowledged that there has been a rise in complications accountable for their actions, must surely conflict with the Code as a result of beauty therapists offering aesthetic treatments, which where maintaining patient safety is a priority. The statement has meant the public is exposed to an inability to be cared for medically by this group. In its statement, the BACN noted, ‘The public are often subject to ghosting, blocking and intimidation should they complain, and the medical professionals are increasingly required to pick up and help, often out of good will’. The association continued, ‘Whilst the task of injecting a botulinum toxin or a dermal filler (implant) at its most basic level can be taught relatively easily, much wider knowledge and clinical acumen are required. The tick-box consultation method in medicine does not work if the answers to the questions are not NMC Code clearly understood and acted upon. Our own patients may present with a medical condition or medications and our clinical judgement, scrutiny and reasoning will come into play when we

BACN Code of Conduct Update

‘Nurses should act within patients’ best interest and be able to demonstrate competency for all they do, as well as the competency of those they delegate to’

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

concluded, ‘We have no doubt that the practice of teaching the unregulated beauty sector or lay people to administer injectable treatments is contrary to the NMC Code of Conduct’.

Moving forward Following the successful motion, BACN Chair Sharon Bennett commented, “We are overwhelmed; we had a 100% unanimous vote on this and we know that the British College of Aesthetic Medicine is in support of us. It’s a step forward in demonstrating that we are professionals and these treatments should be in the hands of professionals, not lay people. We hope the public will recognise that this is the pathway to go down when considering aesthetic treatments.”

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The British College of Aesthetic Medicine said... Paul Charlson, president of the BCAM, agreed with the points made by the BACN. He emphasised, “The lack of statutory regulation to protect the public means that the industry must continue to support voluntary Dr Paul Charlson regulation and maintain good standards. BCAM conducted a member’s survey recently and, as a result, arrived at the decision that it does not support nonclinicians practising to Level 7 in line with JCCP current guidance. BCAM therefore does not support its members training or prescribing to non-clinicians attempting to practice independently at Level 7.” These measures, BCAM hopes, will help discourage the practice. He continued, “We feel this stand point protects the public from the higher level of risk posed by non-clinicians. This is in line with the BACN’s recent motion. It is regrettable that despite considerable effort we still do not have statutory legislation which will improve public safety. We will continue to lobby for a law change.”

The Aesthetics Clinical Advisory Board said... The Aesthetics Clinical Advisory Board, of which BACN Chair Sharon Bennett is a member, Mr Dalvi Dr Stefanie also agrees with the Jackie Partridge Humzah Williams BACN’s motion. Clinical Lead, consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah, said, “This is a very good move that I personally support. It’s excellent to see both the BACN and BCAM reminding members of the key principles of our governing bodies, ensuring patient safety always comes first. This should be supported by all our colleagues.” Nurse prescriber Jackie Partridge noted, “I think this stance is long overdue and I certainly welcome this as best practice,” while dermatologist Dr Stefanie Williams added, “I fully agree that non-healthcare professionals must not inject fillers or botulinum toxin, so I am pleased that BACN and BCAM are ‘outlawing’ training non-healthcare professionals in these procedures.” REFERENCES 1. NMC, Standards for prescribers (UK: NMC, 2019) <https://www.nmc.org.uk/standards/ standards-for-post-registration/standards-for-prescribers/useful-information-for-prescribers/>

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Unmissable Clinical Education at ACE 2020 Make the most of the high quality, free education available at the renowned Aesthetics Conference and Exhibition in London This year at the Aesthetics Conference and Exhibition (ACE), you can see live demonstrations, discover new products and treatments, increase your CPD points and hear from more than 50 of the most highly respected speakers, under one roof. This year, for the first time, all content is free to attend over both days of the event. This is your perfect opportunity to attend live demonstrations and also learn the latest on aesthetic injectables, regenerative therapies, lasers, skincare, chemical peels, aesthetic devices and more! Register now for your free pass and make your way to London on March 13-14 to take advantage of these exclusive not-to-be-missed clinical opportunities.

Understanding injectable innovations With the number of injectable procedures, increasing year on year, clinical sessions at ACE will have an even larger focus on treatment

â&#x20AC;&#x153;I definitely recommend coming to ACE, you can learn a lot, the session I attended was fantastic, it was so informative, they discussed all the different products in the range and it was great to see the demonstrations. Really, really brilliantâ&#x20AC;?

success, avoiding vascular complications, techniques for both needles and cannulas and promoting patient safety. You can learn from live patient demonstrations from leading aesthetic practitioners, understanding new ways to enhance your patientsâ&#x20AC;&#x2122; natural beauty and overall satisfaction.

Purchasing your next medical device Owning the right aesthetic device is important to you and your business. However, knowing what equipment to buy can be confusing for many aesthetic practitioners. This is why the device sessions and stands at ACE are the place to be if you are thinking of investing for the first time, looking for something new or wanting to upgrade your current technologies. Knowledgeable practitioners will discuss the latest innovations and developments in technology, providing you and your team with the certainty you need to invest and the knowledge to maximise patient results.

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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“Good practical sessions performed by excellent practitioners and good visual screening of practice” Boost your knowledge on skincare science

SESSIONS ON THE CLINICAL AGENDAS ARE SPONSORED BY:

Every year, more and more people are investing in their facial skincare, but many patients still aren’t knowledgeable about the appropriate ingredients they personally need, or how to protect their skin with the correct SPF. The skincare sessions at ACE will explore the latest ingredients and products available on the market, that you can use to improve patient knowledge, maximise patient satisfaction and retention, whilst increasing your understanding of the products effectively, and how to best sell them to your patients.

Join us on March 13 and 14

“The session I attended was fantastic, it was so informative, they discussed all the different products in the range, and it was great to see the demonstrations by two of the doctors. Really, really brilliant”

This is just a snippet of all the content you can learn about with your free ACE 2020 pass. As well as our clinical agendas sponsored by Galderma, Teoxane, Allergan, HA-Derma, SkinCeuticals, Church Pharmacy and more, you will also gain crucial advice for running your practice from 19 free business sessions. Not only that, but you will meet representatives from more than 80 aesthetic companies, who will show you their newest and most innovative products, as well provide you with free samples and exclusive ACE 2020 show offers*. The amount of exclusive educational content available, as well as the precious networking opportunities, makes ACE 2020 an event you cannot miss.

FIND OUT MORE A N D REG I S TER F OR F REE www.aestheticsconference.com use code 1 0001 *Please note that access to some of the clinical sessions are restricted to certain professionals so check the session information beforehand

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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A cosmetic introduction

Exploring the Evolution of Harley Street Aesthetics delves into the history of Harley Street and investigates the future for this well-known medical postcode Harley Street. The area that needs no explanation. It’s recognised globally as a hub for medicine and has housed some of the most influential doctors, nurses, dentists and surgeons since its humble beginnings. Even if you are not practising aesthetics in London, as a medical professional you will be very familiar with this street as a centre for cosmetic interventions. With the approach of a new decade, Aesthetics explores the evolution of the specialty and asks practitioners whether the prestige associated with the Marylebone postcode will ever change.

The history The grid of streets around what is now Harley Street was known as The Estate. This was owned by the Duke of Newcastle, John Holles, who passed it onto his daughter Henrietta Cavendish Holles, who married Edward Harley. In 1713, they decided to develop the streets for residential purposes and titled it Harley Street.1 However, by 1860, around 20 doctors had taken to Harley Street for private practice thanks to the central location, quality housing and accessibility to most of the biggest train stations and hospitals in the city. By 1914 this had risen to 200, and when the National Health Service was formed in 1948 there were 1,500 doctors.1 The street began to be known as a centre of medical excellence, which was solidified when the Medical Society of London opened nearby in 1873 and the Royal Society of Medicine in 1912.2 Amongst the most famous names of all time were British surgeon and polymath Sir Henry Thompson, who specialised in urology, Dr Edward Bach who specialised in vaccines and bacteriology, as well as developing the Bach Flower Remedies, and the founder of modern nursing, Florence Nightingale. To date, it is reported that there are now more than 3,000 medical professionals working on the street.1 Today, most of Harley Street is owned by The Howard de Walden Estate. They are the freehold owner of most of the buildings in the 92 acres of Marylebone, which extends from Marylebone High Street to Portland Place and from Wigmore Street to Marylebone Road.3

Plastic surgery has had a presence on Harley Street since very early on, particularly in relation to trying to restore the appearances of the young men that fought in the two World Wars.4 However, non-surgical aesthetics really came into play towards the end of the 19th century through the introduction of bovine collagen fillers in 1981, then botulinum toxin for cosmetic use in 2002.5,6 Consultant plastic surgeon Mr Basim Matti has been practising on Harley Street since 1985. He reminisces, “I’ve seen The Estate change so much over the years. I remember when surgeons wouldn’t admit that they were doing cosmetic surgery as it was seen by colleagues as ‘dirty work’. Fast forward a number of years and many realised that there was a lot of lucrative work to be done and, in fact, it was the future of medicine. With the introduction of collagen injections, many realised that both non-surgical and surgical procedures worked very well together. I’ve also seen lots of practitioners go from working in both the NHS and private practices to simply working privately, which has been particularly interesting.” Aesthetic practitioner Dr Rikin Parekh, who has a clinic and training centre on Harley Street, adds, “Even over the last eight years that I have been working in the area it has definitely evolved. The market is now saturated, and anyone can say they work on Harley Street or are ‘Harley Street trained’, which I think is a bit of a shame because I fear it could lose its prestige. However, I still believe there really is no place like it in the world.”

How important is it for aesthetic practitioners to be in the area? For Dr Parekh, being on Harley Street was a strategic business decision and there is nowhere else he would rather practise. He shares, “I initially started working in a clinic on Upper Wimpole Street, the road

All practitioners agree that the main challenge with working in this well-respected location is the costs associated with it

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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version 1.0 – July 2019

1. Sito G, et al. Aesthet Surg J. 2019. doi: 10.1093/asj/sjz026. 2. Micheels P et al. J Drugs Dermatol 2017;16(2):154–61.

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parallel, and knew that when I launched my own clinic I had to be in that area to sustain a successful business for my patients and training delegates. I believe this is due to the great location and reputation associated with the street. I also knew that my target patient base was primarily Russian at the time and I recognised that Harley Street was an area which was suitable to them. I said to myself, ‘If we are going to be anywhere, it has to be Harley’.” Aesthetic practitioner Dr Tapan Patel, who opened his clinic’s doors on Harley Street in 2014, after spending 10 years practising in Golders Green, North West London, comments, “There’s no denying that it’s a great area in terms of footfall, location and reputation. But what I find particularly good is that there is lots of support from some of the biggest pharmacies, colleagues and both NHS and private hospitals – something which I think lots of other areas could learn from.” Mr Matti agrees this is one of the main advantages of the location. Consultant plastic surgeon Mr Ali Juma, who practises primarily in Liverpool, opines that the prestige is all about branding which is recognised across the whole country. He says, “When there are some of the best medically trained doctors in the world in one street, you’re going to create kudos, respect, reputation and branding; effectively making Harley Street a brand.” This is echoed by aesthetic practitioner Dr Sophie Shotter, who has a clinic in Kent but practises in a Harley Street clinic twice a week. She says the decision to do so was more about the digitalisation of industry and ensuring that her name is associated with the area. “In my opinion, Harley Street doesn’t mean anything to practitioners anymore, it’s much more for the consumer. Patients put this search term into Google as they think they will find the best of the best at this location, so having that association is useful for my Kent business. One of my first

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ever reviews stated ‘a little piece of Harley Street in Kent’ and having that term linked with my practice has been very beneficial,” she explains, adding, “Additionally, in terms of starting to deal with press and boosting your profile, I find many aren’t interested unless you are practising there.” Mr Matti loves the patient base that the reputation of the street brings. He shares, “I see such a wide variety of international patients due to its reputation, many of whom want privacy and out-of-hours appointments. This is completely achievable on Harley Street and the service is very discreet.” For Dr Shotter, having a presence on Harley Street allows her to broaden her skills as a practitioner as she sees a variety of patients looking for different aesthetic ideals. “In my Kent practice, the vast majority of my patients are Caucasian. However, because of the international patient base on Harley Street, I see a far wider variety of skin conditions, ethnicities and treatment requests. This is a challenge which I particularly enjoy, and I love being able to help such a variety of people.” For Mr Juma, while he believes Harley Street is one of the most respected locations for medicine and cosmetic interventions in the world, it isn’t the ‘be all and end all’ for the

For Dr Shotter, having a presence on Harley Street allows her to broaden her skills as a practitioner as she sees a variety of patients looking for different aesthetic ideals

growing aesthetics industry. He says, “It’s important not to forget about the Harley Street equivalents in the rest of the country – like Rodney Street in Liverpool or St John Street in Manchester, for example. Whilst you don’t need to practice on such streets to be successful, we must remember that often patients go for what they know. Even if you have a great brand but it is in a location no one has ever heard of, they may not go to you. It’s all about association. I can see many the opportunity of mini Harley Streets popping up all over the country as the demand for aesthetics is at an all-time high.” With that being said, Dr Patel recognises that whilst the Harley Street name, and others like it, does have perks, there are equally successful clinics all over the country. He says, “I am seeing so many practitioners running beautiful clinics in more remote locations and it’s just a completely different setup to what Harley Street can offer. By not being in London, you will get more space, more real estate, you pay less overheads and the parking is easier.” He questions, “Who’s to say that opening just outside of the North Circular wouldn’t be equally advantageous?”

What are the main challenges of working on Harley Street? There has been much criticism about the rise of aesthetic clinics opening on Harley Street, something which The Independent labelled in 1994 as ‘home to the best and the worst’.7 The publication also reported that some of the doctors from other specialties felt that cosmetic surgery practitioners were ‘cashing in on their good name’.8 Mr Matti recognises the slight change in the street’s reputation. “The quality of Harley Street as a name has become diluted; patients really can’t be sure if you are going to be seeing the best as you once were. It used to be all word of mouth

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but, today, with the rise of social media, it’s just a numbers game of followers and reviews.” With this in mind, Dr Parekh also states that the stricter vetting process may deter unexperienced and inappropriately trained practitioners from Harley Street. He says, “We know that anyone can rent a room, but I think it is harder to rent a room on Harley Street. Don’t get me wrong, some do get through and we have seen the horror stories in the press, but practitioners have to go through quality checks in terms of registration criteria

“It’s not the hub of aesthetics in the UK, it’s the hub of medicine, and we as aesthetic practitioners should respect that” Dr Rikin Parekh

which they may not need to for other areas.” He continues, “I also rent rooms to practitioners and carry out my own set of insurance and qualification checks on them. This can be a beneficial process; having reputable people ensuring no laypeople get through the door is a duty and one that we must take seriously to protect the prestige of the street.”

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All practitioners agree that the main challenge with working in this well-respected location is the costs associated with it. Dr Patel comments, “Rents are getting very prohibitive. We have recently had a rent review and it is extremely high, so you need to make sure that being on Harley Street is going to be worth your while. I often wonder how many new practitioners would do it. I expect we are at saturation point and I certainly don’t see more clinics opening any time soon.” With so many clinics in one area, competition could be a potential challenge, but not for Dr Patel. He shares, “A few years ago, I did some work in Taiwan and there was one road with 400 aesthetic clinics on it. In South Korea, there are thousands in one square mile. Similarly on Harley Street – but not quite on this scale – there is another clinic in my building. There are three or four in the building next to me and 10 more in the next building along. So, in three buildings there are 16 clinics. However, I’ve never viewed the competition in this area as a bad thing.” Mr Juma adds, “From what I have found, if you want to compete, you have to do so at the highest of levels. By doing so you ensure patients’ safety and best outcomes, which are both paramount.” He advises, “In my experience, if you really want to be more competitive without a higher budget, think about peripheral practices. By this, I’m not necessarily referring to outside of London if this is where you are based, but more suburbia. You can then be more competitive on price yet offer the best for your population of patients in your locality.”

are going to continue to practice there, you have to offer the best level of service to the patients, however, this will come at a price. Harley Street is in the majority for those who have the right budget. By the law of averages, the larger establishments are likely to continue getting stronger, however, in the case of the smaller providers they may find it challenging to continue to exist in this area and may choose to move peripherally.” For Mr Matti, he says that Harley Street will always remain as the centre of excellence, primarily due to its iconic history, but he recognises that it’s not enough just to have a practice on the street anymore. “Unfortunately, we are in a time where not everyone is excellent that is practising here and that saddens me. In a time where regulation is lacking, you have to support your Harley Street practice with a number of different platforms, like social media, consumer media and linking yourself with key organisations and associations. If you keep yourself very private, as it once used to be, it doesn’t work anymore.” Dr Shotter agrees that she cannot see Harley Street losing its prestige, but believes that many more practitioners will be using shared structures to practice in as opposed to owning the whole building, primarily due to cost and ease. Dr Parekh concludes, “I really like that there are lots of medical disciplines on the street, it’s not the hub of aesthetics in the UK, it’s the hub of medicine, and we as aesthetic practitioners should respect that. Harley Street will always be Harley Street and I don’t think that will ever change.” REFERENCES 1. Harleystreet.com, History of Harley Street <https://www. harleystreet.com/why-harley-street/history/> 2. Harleytherapy.co.uk, Harley Street Revealed – a history of prestige, January 2014 <https://www.harleytherapy.co.uk/ counselling/harley-street-history.htm> 3. The Howard de Walden Estate, About the Estate <https://www. hdwe.co.uk/about-the-estate.aspx.> 4. Finney C, Cosmetic Changes, Marylebone Journal <https:// www.marylebonejournal.com/articles/cosmetic-surgery-harleystreet-medical-area> 5. Kontis TC, Rivkin A, The history of injectable facial fillers, JAMA Facial Plastic Surgery, May 2009 6. Franca K et al., The history of botulinum toxin: from poison to beauty, Wiener Medizinische Wochensschrift, March 2017 <https://www.researchgate.net/publication/315137024_The_ history_of_Botulinum_toxin_from_poison_to_beauty> 7. Oxford E, Harley Street: a suitable case for lament, The Independent, 1994 <https://www.independent.co.uk/ news/uk/home-news/harley-street-a-suitable-case-forlament-1433039.html> 8. Elkins R, What is going on in Harley Street?, The Independent, September 2006 <https://www.independent.co.uk/life-style/ health-and-families/health-news/what-is-going-on-in-harleystreet-5539962.html>

The future of Harley Street Both Mr Juma and Dr Parekh expect the street to become more elitist in the coming years. Mr Juma explains, “I think that if you

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Understanding Squamous Cell Carcinoma Dr Libin Mathew and Dr Sandeep Cliff explore the causes, diagnosis and treatment of squamous cell carcinoma As skin cancer rates continue to climb and are expected to do so for the foreseeable future,1 it is important that aesthetic practitioners are able to recognise them promptly and advise the patient to seek specialist care. Aesthetic practitioners are uniquely placed to help their patients as they work with a patient regularly over a period of time and, as such, are able to monitor their skin and may be the first to note any suspicious changes. Additionally, practitioners are in a position of influence as patients often request advice on skincare, allowing the opportunity for practitioners to stress the importance of sun protection. Squamous cell carcinoma (SCC) is a form of non-melanoma skin cancer (NMSC) and the second most common form of skin cancer.2 It typically presents confined to a single area that can be managed with localised treatment options, but it is associated with tumour progression causing local tissue destruction or metastases. Metastases rates for SCC vary from 2-5%.2 The disease can therefore be associated with significant morbidity and mortality. As such, early treatment is indicated to prevent the rapid progression of the tumour. This article will review how to recognise SCCs and the treatment options available.

Clinical findings SCCs typically develop in areas that are frequently exposed to the sun of fair-skinned individuals, especially in those who are prone to sunburn (Fitzpatrick types I-III).3 The incidence rates are thus unsurprisingly higher in parts of the world with comparatively higher ultraviolet radiation levels.3 The head and neck are the most frequently affected areas followed by the upper/lower extremities, limbs and trunk, relating to the areas most frequently exposed to the sun.4 In individuals with darker skin (Fitzpatrick types IV-VI), the increased melanin provides enhanced protection against the damage from cumulative sun exposure. As such, the rates of SCCs are significantly lower in this population group and tend to develop in non-sun exposed areas which are affected by chronic wounds or inflammation.5 SCC development is closely associated with the presence of actinic keratoses (AKs) in fair-skinned individuals (Figure 1).6 AKs are erythematous and scaly macules or plaques formed by the proliferation of dysplastic keratinocytes.6 As with SCCs they are found in areas of high sun exposure where cumulative ultraviolet (UV) damage results in their development over time. Individuals with a large number of AKs are at increased risk of both melanomas and NMSCs.7 AKs are considered precancerous and one of the initial stages in the sequence of development of SCCs. It is known that a small proportion of AKs will develop into SCCs but the exact rate of transformation is not clear. Figure 1: Actinic keratosis

Previous studies quote varying figures, with a 2000 systematic review of the literature finding rates of 0.025-16% per lesion/per year,8 whereas a 2013 systematic review quoted progression rates from 0-0.075% per lesion/per year.9 The large variability between studies is possibly due to the different definition of AKs that the studies may use. It is generally accepted that the exact rate is difficult to identify as there is a lack of reliable monitoring of AKs over time.7 Nonetheless, the presence of AKs is an indication of an area of skin with actinic damage that warrants treatment (discussed below), which can be managed by the patient’s GP. Bowen’s disease Otherwise known as SCC in situ (cancerous cells that have not breached the outer layer of skin), Bowen’s disease is closely related in appearance to AKs. The lesions are typically well defined, erythematous patches Figure 2: Bowen’s disease or plaques with overlying scale (Figure 2). They arise in sun exposed areas and grow slowly over years. These lesions are generally asymptomatic, but have the potential to become invasive SCCs (3-5%) over time (Figure 3 & 4). They respond well to treatments such as topical creams, cryotherapy and photodynamic therapy.10 Invasive SCC There are three grades within which these cancers are categorised: 1. Well differentiated 2. Moderately differentiated 3. Poorly differentiated Poorly differentiated SCCs have a poorer prognosis than well differentiated tumours, with higher rates of local recurrence and metastases.11 Well differentiated SCCs are generally firm nodules or papules with hyperkeratosis, whilst poorly differentiated tumours are softer, granulomatous papules or nodules. The latter is more likely to be ulcerated or haemorrhagic.12 Invasive SCCs can cause symptoms such as bleeding or pain. Tumours with perineural invasion can produce neurological symptoms such as numbness or burning. Perineural invasion is associated with a poorer prognosis.13 Once an SCC has developed, the usual natural history is that of local invasion followed by more distant spread (lymphatic, blood or perineural) which eventually proves fatal.13 Keratoacanthoma These lesions are clinically similar in appearance to SCCs and are considered by some to be a variant. They are more common in sun-exposed sites but they are not cancerous. They generally grow quickly appearing as firm, dome-shaped lesions with a central area of hyperkeratosis. They can, in some instances, self-resolve.14

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Figure 3 & 4: Examples of SCCs

Diagnosis Once there is clinical suspicion of a SCC, the next step is to obtain histological evidence of the cancer through a biopsy. The histology provides information regarding the differentiation of the tumour as well as assessing for perineural invasion and tumour depth, allowing for staging of the cancer. Various biopsy techniques can be used including shave, punch and excision, provided they are deep enough i.e. to the mid-reticular dermis.15

Epidemiology Incidence rates for cutaneous SCCs are rising across many countries with largely European heritage.16,17 The difficulty with reporting accurate incidence rates on just SCCs is that many studies combine basal cell carcinomas (BCC) with SCCs and other NMSCs.18,19 One study in the UK reported European age-standardised incidence rates (EASR) for SCCs of 77 per 100,000 person years with a mean annual increase of 5% for both BCCs and SCCs over a two-year period.20 SCCs have a higher incidence amongst men compared to women and increases with age in both gender groups. In the UK, between 2013 and 2015 there was a reported EASR of 111 in men compared to 42 per 100,000 person years in women.20 The difference between the genders has been attributed to comparatively increased lifetime cumulative sun exposure in men compared to women.21 A study in Ireland found there to be more than a 10-fold increased incidence rate over the age of 80 compared to 50-64 in both men and women.17 Although SCCs are rare under the age of 45 years, there has been an alarming increasing incidence rate amongst younger individuals.17,22 The incidence rate of SCCs is also seen to be influenced by geographic variability with a higher incidence closer to the equator. For example, the age-adjusted incidence in Finland is four and six per 100,000 for men and women, respectively.23 Comparatively, in Queensland Australia the rates are approximately 1,035 and 472 per 100,000 for men and women, respectively.24

Risk factors The most important risk factor in lighter-skinned individuals is cumulative sun exposure.25 Both UVA and UVB wavelengths have been implicated, with UVB being the principle factor. UV radiation is absorbed by DNA and can cause damage, which if not repaired can result in neoplastic transformation.25 One of the most common mutations is in the p53 tumour suppressor gene, which has been associated with UVB radiation.26,27 Individuals with occupations with high UV exposure are at significant risk of developing SCCs. One study found an almost two-fold increased risk amongst those with high occupational sun exposure.28 It is also important to consider UVA exposure, for instance in PUVA (psoralen and ultraviolet A) use in psoriasis patients. One study following patients over a 30year period found those that had more than 350 treatments had a greatly increased (approximately 35-fold) incidence of SCC.29 Tanning beds have become an important and increasingly relevant

risk factor as they principally emit UVA radiation. These beds can cause skin damage when used repeatedly over time, increasing the risk of NMSCs especially when used under the age of 25.30 Another important risk factor in the development of SCCs is chronic immunosuppression, for instance post organ transplantation or secondary to HIV, lymphoma/leukaemia and chronic glucocorticoid use. The rates amongst those who have received organ transplants has been reported to be 65 to 250 times higher than that of the general population.31 Immunosuppressed individuals are at particular risk of multiple lesions. In heart transplant patients who have had a post-transplant NMSC, 60-70% will develop a further SCC in the following five years.32 Glucocorticoids are used in a number of inflammatory conditions and can be used for a lengthy period of time, but they have been reported to increase the risk of SCC by two-fold in some studies.33,34 The risk of developing a SCC increases with both prolonged and an increased level of immunosuppression.35,36 The effects of immunosuppression are further compounded by UV exposure, with those who are immunosuppressed and living in sunnier climates at higher risk of developing a SCC. It is thought that immunosuppressive agents can amplify the damaging effects of UV radiation on DNA and also impair the ability to eliminate precancerous cells.37 Chronic inflammation has also been recognised as a risk factor for SCC, for example with scars, ulcers or even chronic inflammatory skin conditions. Marjolinâ&#x20AC;&#x2122;s ulcers are a rare type of SCC that develop within chronic wounds or scars.38 The time of transformation into a malignant lesion can vary widely from the point of initial trauma. There are a few congenital conditions that confer an increased risk of SCCs and this includes xeroderma pigmentosum (XP), a rare condition where the ability to repair DNA damage caused by UV radiation is diminished.39 Individuals with XP are extremely sensitive to sun exposure and can develop skin cancers from childhood, with the incidence being approximately 2,000 times that of the general population under the age of 20.39 Other rare inherited conditions associated with an increased risk of SCCs include epidermolysis bullosa,40 albinism41 and Fanconiâ&#x20AC;&#x2122;s anaemia, amongst others. Individuals with these conditions have to be particularly vigilant with sun care and monitor their skin regularly from a very young age. Other environmental risk factors associated with the development of SCCs include exposure to arsenic42 and ionising radiation.43 Smoking has had some conflicting studies in the past that were unable to firmly establish it as a risk factor,44,45 however more recent studies have suggested a statistically significant increased risk of developing SCCs in smokers.46,47 Infection with human papillomavirus has also been suggested as a potential risk factor, but it appears more relevant in individuals who are genetically predisposed to developing SCCs and a clear association has yet to be established.48

Primary prevention The most important piece of advice that applies for SCCs, other NMSCs and melanomas is the importance of protecting oneself from the sun. This comprises the use of sun protection factor (SPF) (a UVA rating of 4 or 5 stars and SPF 30 as recommended by the British Association of Dermatologists),49 protective clothing and sun avoidance (during the middle part of the day) to reduce the risk of SCCs. There are numerous studies that support the regular use of sunscreen for reducing the number of both AKs and SCCs.50,51 A

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randomised control trial in Australia with 1,484 participants found a 40% reduction in incidence of SCCs with regular sunscreen use (SPF 16) as opposed to inconsistent use.52 This advice also translates to immunocompromised individuals who are inherently at a higher risk of developing SCCs where regular use of sunscreen is significantly more protective than discretionary use.53 Alongside counselling individuals regarding sun safety, it is important that practitioners provide advice on sunbeds which are a significant source of artificial UV radiation. There are several countries that have released legislation restricting the use of sunbeds, whilst Brazil and Australia have banned their use.54

Curettage and cautery Curettage and cautery (C&C) is a quick procedure that may be better tolerated than surgical excision. This is reserved for low-risk lesions which are well-defined and relatively small. It involves curetting away the tumour (using both visual and ‘feel’ of the abnormal tissue) before cauterising the base with a rim of surrounding skin. This is repeated two to three times to leave a scab. The cosmetic result is generally favourable but can be inferior to surgical excision in cosmetically sensitive areas. Whilst this may be sufficient treatment for well-differentiated SCCs, the other types of SCCs will require further excision of the C&C scar.15

Management

Photodynamic therapy Photodynamic therapy is not recommended in the treatment of SCCs as there is a high risk of recurrence.59 However, it can be used as the treatment of Bowen’s disease or AKs with good initial and long-term clearance.60 A photosensitising agent is applied to the lesion and then exposed to phototherapy or daylight to trigger oxidisation in the abnormal cells. Side effects include erythema at the site and a burning sensation, but these resolve without any long-term complications.

Once the diagnosis of a SCC has been established, lesions are categorised into either low-risk or high-risk lesions based on the histology. High-risk lesions include those that are poorly differentiated, demonstrate perineural, lymphatic or vascular invasion, thickness >4mm and lesions on the ear or lip amongst other clinical/histological criteria for risk stratification.55 The overall prognosis for patients with a primary SCC is very good, with a five-year survival rate greater than 90%.62 The primary concern with SCCs, especially the high-risk lesions, is of spread either locally or distant metastasis. The most common site of spread is to the local or regional lymph nodes, followed by more distant sites such as lung, liver, brain and bone. The overall rate of metastasis is low at less than 5% but the five-year survival rate is significantly worse at 25-40%.63 Patients who have had a primary SCC are at increased risk of a second skin cancer within the following five years. Over this time frame, the risk of another NMSC is approximately 50%, whilst the risk of another SCC is approximately 30%.64 As such, patients who have had a SCC are kept under regular follow-up for skin surveillance and examination of lymph nodes for a period of two to five years. The length of follow-up varies with the grade of the lesion, with longer follow up periods for high-risk lesions. Patients are also educated regarding sun safety, carrying out self-skin examinations and regularly examining their lymph nodes. If concerned with any new lesions, they are encouraged to contact their general practitioner or local dermatology team for an urgent assessment. Surgery The recommended first-line treatment for most SCCs is surgical excision with a pre-determined margin. This is carried out usually in the outpatient setting under local anaesthesia. The margin of excision around the lesion to achieve histological clearance in over 95% of cases varies from 4mm for low-risk lesions to 6mm for high risk lesions.56 The tissue sample is reviewed histologically to assess clearance of the SCC from the margins, and if incompletely excised, will require further surgery or radiotherapy in patients whom this is contraindicated. Mohs micrographic surgery in the UK is more commonly used in the treatment of BCCs but is used for SCCs that are small, poorly defined or in areas where tissue preservation is necessary (where excision with margins will significantly damage cosmetically or functionally sensitive areas such as around the nose, eyelid and ear).57 Radiotherapy Radiotherapy is typically not a monotherapy of choice but it can be used in certain patients e.g. elderly patients who are not candidates for surgery or those that refuse surgery. It is more often used as adjuvant treatment with surgery for some high-risk SCCs to reduce the risk of local recurrence.58

Cryotherapy Cryotherapy involves multiple cycles (usually two to three) of targeted freezing with liquid nitrogen and thawing to destroy the abnormal cells. It does not allow for histological confirmation of treatment margins. It is rarely used in the treatment of SCCs except where other treatments may not be possible e.g. patient with poor general health. Cryotherapy is used more commonly in treating Bowen’s disease and AKs where it can be sufficient to completely clear the lesion.61 Side effects include erythema, pain and oozing that can take weeks to resolve. The ulcerated area can heal with residual hypopigmentation. Topical treatments Topical treatments are not recommended for the treatment of SCCs.15 It is, however, commonly used in treating Bowen’s disease and AKs.6,10 Agents used include topical fluorouracil and imiquimod. The treatment courses can vary but patients need to be forewarned regarding the inflammatory reaction that occurs. This includes stinging/burning, erythema and, rarely, erosions. Treatment courses can be repeated if required for any residual disease or recurrence.

Conclusion Aesthetic practitioners are suitably placed to assist patients in diagnosing SCCs and ensuring they are promptly treated through suitable referral. Practitioners should always encourage their patients to apply sunscreen to help them prevent the development of SCCs. Dr Libin Mathew completed his Bachelor of Medicine, Bachelor of Surgery at King’s College London, as well as a Bachelor of Science in Pharmacology (Hons). He is a core medical trainee at East Surrey Hospital. He is an aspiring dermatologist with an interest in inflammatory dermatoses, skin cancer and surgery. Dr Sandeep Cliff is a consultant dermatologist at a university hospital and has a particular interest in skin cancer and inflammatory dermatosis. He has lectured and demonstrated extensively throughout the world on various non-invasive techniques for facial rejuvenation, including lasers, dermal fillers and toxins. He has been principal investigator for over six clinical research trials and is a clinical sub-dean at Brighton and Sussex Medical School.

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REFERENCES 1. Goon PKC, Greenberg DC, Igali L and Levell NJ, Predicted cases of U.K. skin squamous cell carcinoma and basal cell carcinoma in 2020 and 2025: horizon planning for National Health Service dermatology and dermatopathology. Br J Dermatol, 176 (2017), 1351-1353. 2. Brougham ND, Dennett ER, Cameron R and Tan ST, The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors, J Surg Oncol. 106(7) (2012), 811-5. 3. Lomas A, Leonardi‐Bee J, and Bath‐Hextall F, A systematic review of worldwide incidence of nonmelanoma skin cancer, Br J Dermatol, 166 (2012), 1069-1080. 4. English DR, Armstrong BK, Kricker A, Winter MG, Heenan PJ and Randell PL, Demographic characteristics, pigmentary and cutaneous risk factors for squamous cell carcinoma of the skin: a case-control study, Int J Cancer, 76(5) (1998), 628. 5. Gloster HM and Neal K, Skin cancer in skin of color, J Am Acad Dermatol, 55(5) (2006), 741–760. 6. Siegel J, Korgavkar K. and Weinstock M, Current perspective on actinic keratosis: a review, Br J Dermatol, 177 (2017), 350-358. 7. Green AC, Epidemiology of actinic keratoses, Curr Prob Dermatol, 46 (2015), 1–7. 8. Glogau RG, The risk of progression to invasive disease, J Am Acad Dermatol, 42 (1 Pt 2) (2000), 23-4. 9. Werner R, Sammain A, Erdmann R, Hartmann V, Stockfleth, E and Nast, A, The natural history of actinic keratosis: a systematic review, Br J Dermatol, 169 (2013), 502–18. 10. Bath-Hextall FJ, Matin RN, Wilkinson D and Leonardi-Bee J, Interventions for cutaneous Bowen’s disease, Cochrane Database Syst Rev, 2013(6) (2013), CD007281. 11. Jennings L and Schmults CD, Management of high-risk cutaneous squamous cell carcinoma, The Journal of clinical and aesthetic dermatology, 3(4) (2010), 39-48. 12. Lallas A, Pyne J, Kyrgidis A, Andreani S, Argenziano G, Cavaller A, Giacomel J, Longo C, Malvestiti A, Moscarella E, Piana S, Specchio F, Hofmann-Wellenhof R and Zalaudek I, The Clinical and dermoscopic features of invasive cutaneous squamous cell carcinoma depend on the histopathological grade of differentiation, Br J Dermatol, 172 (5) (2015), 1308-1315. 13. Farasat S, Yu SS, Neel VA, Nehal KS, Lardaro T, Mihm MC, Byrd DR, Balch CM, Califano JA, Chuang AY, Sharfman WH, Shah JP, Nghiem P, Otley CC, Tufaro AP, Johnson TM, Sober AJ and Liégeois NJ, A new American Joint Committee on Cancer staging system for cutaneous squamous cell carcinoma: creation and rationale for inclusion of tumor (T) characteristics, J Am Acad Dermatol, 64(6) (2011), 1051-9. 14. Schwartz RA, Keratoacanthoma: a clinico-pathologic enigma, Dermatol Surg, 30(2) (2004) 326–333. 15. Kim JYS, Kozlow JH, Mittal B, Moyer J, Olenecki T, Rodgers P, Guidelines of care for the management of cutaneous squamous cell carcinoma, JAAD, 78 (3) (2018), 560-578. 16. Robsahm TE, Helsing P and Veierod MB, Cutaneous squamous cell carcinoma in Norway 1963–2011: increasing incidence and stable mortality, Cancer Med, 4 (2015), 472–80. 17. Deady S, Sharp L and Comber H, Increasing skin cancer incidence in young, affluent, urban populations: a challenge for prevention, Br J Dermatol, 171 (2014), 324–31. 18. Miller DL and Weinstock MA, Nonmelanoma skin cancer in the United States: incidence, JAAD, 30 (5 Pt 1) (1994), 774-8. 19. Rogers HW, Weinstock MA, Harris AR, Hinckley MR, Feldman SR, Fleischer AB, Coldiron BM, Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol, 146(3) (2010), 283-7. 20. Venables ZC, Nijsten T, Wong KF, Autier P, Broggio J, Deas A, Harwood CA, Hollestein LM, Langan SM, Morgan E, Proby CM, Rashbass J and Leigh IM, Epidemiology of basal and cutaneous squamous cell carcinoma in the U.K. 2013-15: a cohort study, Br J Dermatol, 181(3) (2019), 474-482. 21. Xiang F, Lucas R, Hales S, Neale R, Incidence of Nonmelanoma Skin Cancer in Relation to Ambient UV Radiation in White Populations, 1978-2012: Empirical Relationships, JAMA Dermatol, 150 (10) (2014), 1063–1071. 22. Christenson LJ, Borrowman TA, Vachon CM, Tollefson MM, Otley CC, Weaver AL and Roenigk RK, Incidence of Basal Cell and Squamous Cell Carcinomas in a Population Younger Than 40 Years, JAMA, 294(6) (2005),681–690. 23. Hannuksela-Svahn A, Pukkala E and Karvonen J, Basal cell skin carcinoma and other nonmelanoma skin cancers in Finland from 1956 through 1995, Arch Dermatol, 135(7) (1999), 781. 24. Green A, Battistutta D, Hart V, Leslie D and Weedon D, Skin cancer in a subtropical Australian population: incidence and lack of association with occupation. The Nambour Study Group, Am J Epidemiol. 144(11) (1996) 1034. 25. Ramos J, Villa J, Ruiz A, Armstrong R and Matta J, UV dose determines key characteristics of nonmelanoma skin cancer, Cancer Epidemiol Biomark Prev. 13 (2004), 2006–2011 26. Brash DE, UV signature mutations, Photochem Photobiol, 91 (2015), 15–26. 27. Tsai KY and Tsao H, The genetics of skin cancer, Am J Med Genet C Semin Med Genet, 131C(1) (2004), 82-92. 28. Schmitt J, Haufe E, Trautmann F, Schulze H, Elsner P, Drexler H, Bauer A, Letzel S, John S, Fartasch M, Brüning T, Seidler A, Dugas‐Breit S, Gina M, Weistenhöfer W, Bachmann K, Bruhn I, Lang B, Bonness S, Allam J, Grobe W, Stange T, Westerhausen S, Knuschke P, Wittlich M and Diepgen T, Is ultraviolet exposure acquired at work the most important risk factor for cutaneous squamous cell carcinoma? Results of the population‐based case–control study FB‐181, Br J Dermatol, 178 (2018), 462-472. 29. Stern RS, The risk of squamous cell and basal cell cancer associated with psoralen and ultraviolet A therapy: A 30-year prospective study, JAAD, 66(4) (2012), 553 – 562. 30. Wehner MR, Shive ML, Chren MM, Han J, Qureshi AA and Linos E, Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis, BMJ, 345 (2012),e5909 31. Euvrard S, Kanitakis J and Claudy A, Skin cancers after organ transplantation, N Engl J Med, 348 (2003), 1681–91. 32. Brewer JD, Colegio OR, Phillips PK, Roenigk RK, Jacobs MA, Van de Beek D, Dierkhising RA, Kremers WK, McGregor CG and Otley CC, Incidence of and risk factors for skin cancer after heart transplant, Arch Dermatol. 145(12) (2009),1391-6. 33. Karagas MR, Cushing GL Jr, Greenberg ER, Mott LA, Spencer SK and Nierenberg DW, Nonmelanoma skin cancers and glucocorticoid therapy, Br J Cancer, 85(5) (2001),683-6. 34. Sørensen HT, Mellemkjær L, Nielsen GL, Baron JA, Olsen JH and Karagas MR, Skin Cancers and Non-Hodgkin Lymphoma Among Users of Systemic Glucocorticoids: A Population-Based Cohort Study, JNCI: Journal of the National Cancer Institute, 96(9) (2004), 709–711. 35. Fortina AB, Piaserico S, Caforio AL, Abeni D, Alaibac M, Angelini A, Iliceto S and Peserico A, Immunosuppressive Level and Other Risk Factors for Basal Cell Carcinoma and Squamous Cell Carcinoma in Heart Transplant Recipients, Arch Dermatol, 140 (9) (2004), 1079–1085. 36. Ramsay HM, Reece SM, Fryer AA, Smith AG and Harden PN, Seven-year prospective study of nonmelanoma skin cancer incidence in U.K. renal transplant recipients, Transplantation, 84(3) (2007), 437. 37. Berg D and Otley CC, Skin cancer in organ transplant recipients: Epidemiology, pathogenesis, and management, J Am Acad Dermatol, 47(1) (2002), 1.

38. Pekarek B, Buck S and Osher L, A Comprehensive Review on Marjolin’s Ulcers: Diagnosis and Treatment, J Am Col Certif Wound Spec, 3(3) (2011), 60. 39. Kraemer KH, Lee M, Andrews AD and Lambert WC, The Role of Sunlight and DNA Repair in Melanoma and Nonmelanoma Skin Cancer: The Xeroderma Pigmentosum Paradigm, Arch Dermatol, 130 (8) (1994), 1018–1021. 40. Fine JD, Johnson LB, Weiner M, Li KP and Suchindran C, Epidermolysis bullosa and the risk of lifethreatening cancers: the National EB Registry experience, 1986-2006, JAAD, 60(2) (2009), 203. 41. Kromberg JG, Castle D, Zwane EM and Jenkins T, Albinism and skin cancer in Southern Africa, Clin Genet, 36(1) (1989), 43. 42. Kennedy C, Bajdik CD, Willemze R and Bouwes Bavinck JN, Chemical exposures other than arsenic are probably not important risk factors for squamous cell carcinoma, basal cell carcinoma and malignant melanoma of the skin, Br J Dermatol, 152 (2005), 194–7. 43. Lichter MD, Karagas MR, Mott LA, Spencer SK, Stukel TA and Greenberg ER, Therapeutic ionizing radiation and the incidence of basal cell carcinoma and squamous cell carcinoma. The New Hampshire Skin Cancer Study Group, Arch Dermatol, 136 (2000), 1007–11. 44. De Hertog SA, Wensveen CA, Bastiaens MT, Kielich CJ, Berkhout MJ, Westendrop RG, Vermeer BJ, Bouwes Bavinck JN and Leiden Skin Cancer Study, Relation between smoking and skin cancer, J Clin Oncol, 19(1) (2001), 231. 45. Odenbro A, Bellocco R, Boffetta P, Lindelöf B and Adami J, Tobacco smoking, snuff dipping and the risk of cutaneous squamous cell carcinoma: a nationwide cohort study in Sweden, Br J Cancer, 92 (7) (2005), 1326. 46. Leonardi-Bee J, Ellison T and Bath-Hextall F, Smoking and the risk of nonmelanoma skin cancer: systematic review and meta-analysis, Arch Dermatol, 148(8) (2012), 939. 47. Pirie K, Beral V, Heath AK, Green J, Reeves GK, Peto R, McBride P, Olsen CM and Green AC, Heterogeneous relationships of squamous and basal cell carcinomas of the skin with smoking: the UK Million Women Study and meta-analysis of prospective studies, Br J Cancer, 119(1) (2018), 114. 48. Akgül B, Lemme W, García-Escudero R, Storey A and Pfister HJ, UV-B irradiation stimulates the promoter activity of the high-risk, cutaneous human papillomavirus 5 and 8 in primary keratinocytes, Arch Virol, 150(1) (2005), 145-151. 49. British Association of Dermatologists. BAD sunscreen fact sheet, 2013. http://www.bad.org.uk/skincancer/sunscreen-fact-sheet#what-is-spf [accessed 13th October 2019] 50. Thompson SC, Jolley D and Marks R, Reduction of solar keratoses by regular sunscreen use, N Engl J Med, 329 (16) (1993), 1147–1151. 51. Green A, Williams G, Neale R, Hart V, Leslie D, Parsons P, Marks GC, Gaffney P, Battistutta D, Frost C, Lang C and Russell A. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet. 354(9180) (1999), 723. 52. van der Pols JC, Williams GM, Pandeya N, Logan V and Green AC, Prolonged prevention of squamous cell carcinoma of the skin by regular sunscreen use, Cancer Epidemiol Biomarkers Prev, 15 (2006), 2546–8. 53. Ulrich C, Jürgensen JS, Degen A, Hackethal M, Ulrich M, Patel MJ, Eberle J, Terhorst D, Sterry W and Stockfleth E, Prevention of non-melanoma skin cancer in organ transplant patients by regular use of a sunscreen: a 24 months, prospective, case-control study, Br J Dermatol, 161 Suppl 3 (2009), 78. 54. Sinclair CA, Makin JK, Tang A, Brozek I and Rock V, The role of public health advocacy in achieving an outright ban on commercial tanning beds in Australia, Am J Public Health, 104 (2014), e7–9. 55. Slater D and Barrett P, Dataset for the Histological Reporting of Primary Invasive Cutaneous Squamous Cell Carcinoma and Regional Lymph Nodes. London: The Royal College of Pathologists, 2019. https://www.rcpath.org/uploads/assets/9c1d8f71-5d3b-4508-8e6200f11e1f4a39/dataset-forhistopathological-reporting-of-primary-invasive-cutaneous-squamous-cell-carcinoma-and-regionallymph-nodes.pdf [accessed 11th September 2019] 56. Newlands C, Currie R, Memon A, Whitaker S and Woolford T, Non-melanoma skin cancer: United Kingdom National Multidisciplinary Guidelines, J Laryngol Otol, 130(S2) (2016), S125–S132. 57. Motley R. and Arron S, Mohs micrographic surgery for cutaneous squamous cell carcinoma, Br J Dermatol, 181(2019), 233-234. 58. Veness MJ, Porceddu S, Palme CE and Morgan GJ, Cutaneous head and neck squamous cell carcinoma metastatic to parotid and cervical lymph nodes, Head Neck, 29(7) (2007), 621. 59. Morton CA, Szeimies RM, Sidoroff A and Braathen LR, European guidelines for topical photodynamic therapy part 1: treatment delivery and current indications - actinic keratoses, Bowen’s disease, basal cell carcinoma, J Eur Acad Dermatol Venereol, 27(5) (2013), 536. 60. Truchuelo M, Fernández-Guarino M, Fleta B, Alcántara J and Jaén P, Effectiveness of photodynamic therapy in Bowen’s disease: an observational and descriptive study in 51 lesions, J Eur Acad Dermatol Venereol, 26(7) (2012), 868-74. 61. Mackenzie-Wood A, Kossard S, de Launey J, Wilkinson B and Owens ML, Imiquimod 5% cream in the treatment of Bowen’s disease, J Am Acad Dermatol, 44(3) (2001), 462. 62. Hollestein LM and de Vries E, Nijsten T. Trends of cutaneous squamous cell carcinoma in the Netherlands: increased incidence rates, but stable relative survival and mortality 1989-2008. Eur J Cancer 2012;48(13):2046-53. 63. Rowe DE, Carroll RJ and Day CL Jr. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. Implications for treatment modality selection, J Am Acad Dermatol, 26(6) (1992), 976-90. 64. Marcil I and Stern RS, Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: a critical review of the literature and meta-analysis. Arch Dermatol. 136(12) (2000), 1524.

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seek smaller busts. According to the latest statistics from The British Association of Aesthetic Plastic Surgeons (BAAPS), breast implant procedures are dropping (Figure 1).1 However, itâ&#x20AC;&#x2122;s important to note that BAAPS members represent a minority of surgeons performing these procedures in the UK and we do not have accurate data on how many breast implant procedures are performed or how many women currently have implants in the UK.

Recent controversies Concerns regarding BIA-ALCL and BII have been widely reported in the media over the last couple of years.4 Itâ&#x20AC;&#x2122;s helpful for non-surgical aesthetic practitioners to know what these are and the latest information available to enable them to properly reassure and educate their patients. It should be noted that although the media has been picking up on the potential issues behind BIA-ALCL and BII recently, there has been no change in the scientific evidence available to spark this awareness.4

Updates to Breast Augmentation Consultant plastic surgeon Mr Adrian Richards provides an overview of the latest trends and developments in breast implant surgery Breast augmentation remains to be the most popular surgical cosmetic treatment in the UK.1 While non-surgical practitioners will not be offering this procedure, they may get asked questions by patients about the options available and surgeons they would recommend. It is therefore important that clinicians can give up-to-date and useful information to help patients on their journey. This article aims to give aesthetic practitioners a basic understanding of common breast concerns, and the latest trends and techniques in the specialty, so they can advise patients on the best way forward.

asymmetry, shape issues and inverted nipples. In my practice, removal of breast implants is becoming more popular partly due to the increased demographic of women with implants and partly due to concerns regarding breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII). In my experience, patients in the UK generally seek more moderate, natural-sized breasts, while patients in countries such as the US, South America and Brazil tend to seek larger implants, and the French usually

Anaplastic large cell lymphoma BIA-ALCL is a very rare form of cancer that occurs in the breast lining, not the breast tissue.4,5 It is still very uncommon and itâ&#x20AC;&#x2122;s unclear how prevalent the link between BIA-ALCL and implants actually is. According to the BAAPS, current research suggests the risk in the UK is approximately 1 in 24,000 breast implants sold.4 Studies are ongoing and we are unable to give a definitive risk to patients, but it would seem that the condition is much less common with smooth or nanotextured implants.4-7 With any foreign device, the body forms a capsule or lining around it. In some cases,

12.5k Augmentation

Current trends

Reduction

10k Number of procedures

There are many conditions that women can present with when it comes to the breasts. These may include inverted nipples, breast asymmetry, breast hypertrophy, breast ptosis, tuberous breasts and post-implant concerns.2 In 2016, lingerie brand Triumph surveyed more than 6,000 women from the UK, Germany, France, Italy, Denmark and Poland between the ages of 20-50. It found that women are often concerned with the perkiness of their breasts (40%), size (34%), shape (32%) and cleavage (29%). It also noted that a total of one in three women in the UK and France were unsatisfied with their busts.3 I am currently finding that most patients are presenting with concerns regarding

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0 2009

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2013

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2015

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Figure 1: The number of cosmetic breast surgeries recorded by members of the BAAPS since inception of its annual report.1

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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the lining can get inflamed and cause a T-cell lymphoma, which develops fluid and an internal scar around breast implants. BIA-ALCL most commonly presents as swelling and a change in breast size, which occurs rapidly over several days or weeks. Although BIA-ALCL can occur any time after implantation, it has been reported that the mean time for presentation is approximately 10 years after implant placement.7,8 The medical community is becoming more aware of a link between BIA-ALCL and Figure 2: Before and after breast auto-augmentation using MIRAR technique. Breast implants were breast implants that have a textured surface. removed and breast auto augmentation performed in 2018. Images courtesy of The Private Clinic. Textured implants have been previously used due to their association with a reduced or lower risk of the questions about whether the symptoms may be caused by other capsular contracture rate, which is when the capsule around the reasons. There is limited data on BII’s prevalence and it is difficult implant hardens, causing the tissue to become firm, tight and cause to link breast implants with the perceived associated symptoms as pain.9,10,11 there are no definitive tests. There has since been a move to use smoother implants to reduce That said, in May 2019, the US Food and Drug Administration (FDA) the risk of BIA-ALCL. Surgeons worldwide are no longer using acknowledged the potential connection between breast implants the textured implants associated with BIA-ALCL following their and illness, announcing steps to improve the information available to withdrawal from sale and a voluntary recall from the manufacturer women which sparked the increased media awareness this year.14 12 in July 2019. This may explain why they have been featured so According to the FDA, it has been reported that removal of the heavily in the media this year. It’s important to note that there breast implants without replacement may reverse symptoms of BII have been no recommendations for removal of these implants in some cases.5 Of course, much more research is needed and any in asymptomatic patients and monitoring and surveillance is concerns should be reported to the patient’s surgeon. recommended.4,12 This is unlike the PIP scandal, where implants had been fraudulently manufactured with unapproved silicone gel, Technique updates causing the NHS to offer removal or replacements.13 Practitioners who hear their patients complaining or enquiring of Breast auto-augmentation symptoms associated with BIA-ALCL (persistent swelling, presence Like most other treatments, there has been an evolution in breast of a mass or pain)5 should advise them to consult their surgeon. For surgery techniques over the years. One notable change is the use of the majority of patients diagnosed with BIA-ALCL, their treatment a patient’s own breast tissue for remodeling the breast after removal would involve removal of the implant and surrounding capsule. of breast implants. Most surgeons would recommend to remove and Those who have been diagnosed with BIA-ALCL at a more replace implants after around 15 years, but some suggest that for advanced stage may require chemotherapy, radiotherapy, and patients with normal breasts, a policy of monitory and surveillance lymph node dissection.7 can be undertaken for those reluctant to undergo surgery.15,2 Typically, implants usually need removing or updating due to the changes in the Breast implant illness tissue and the body surrounding the implants.2 BII is a relatively new concern that has been gaining momentum With age, and situations like pregnancy, the breasts will generally in the last year or so, particularly via social media. Some patients obtain more tissue. These factors influence gravity, skin laxity and with breast implants feel they have generalised symptoms that stretch, which will likely make the bust much heavier. Some patients are directly connected to their silicone implants, such as hair loss, then choose to seek replacement or removal of implants that they feel tiredness and fatigue, headaches, chills, photosensitivity, brain fog, no longer suits their lifestyle.2 4,5 pains, rash, sleep disturbance and joint pain. While implants can be replaced, a newer and really interesting There is debate amongst the medical community about whether procedure that myself and other surgeons are performing is breast BII is a true medical condition that actually exists, and there are auto-augmentation. The breast auto-augmentation technique that I have developed is called the Mastopexy Implant Removal and Reconstruction (MIRAR) technique. The procedure removes the implant and uses the patient’s own natural breast tissue to reshape and enhance the bust shape. Results are achieved by relocating the patient’s own breast tissue into the upper portion of the breast to give the desired lifting and shaping effect, without the need for an implant. I’m finding that the procedure is producing some lovely, natural results (Figure 2).

It has been reported that removal of the breast implants without replacement may reverse symptoms of BII

LED light therapy LED light therapy is emerging to treat capsular contractures,16 which can form around any kind of implant.10 We are currently running a preliminary trial on 10 patients using the Celluma device and seeing

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Key findings from BCIR report The second report by the BCIR was released in October and includes data from July 2018 to June 2019:21 • 340 submitting organisations from England are currently registered to enter data in the registry • 15,235 patients have been recorded as having at least one operation in the last year • There were about 15,570 operations undertaken between July 2018 and June 2019 at 130 NHS and 163 independent sector provider sites • Mentor Medical Systems was the most popular manufacturer of breast implants (16,150 devices implanted), followed secondly by Motiva (2,635) and thirdly by Nagor (2,525) • 15 people had breast implant operations during which anaplastic large cell lymphoma (ALCL) was found. The registry cannot identify whether these cases of ALCL are instances of breast implant associated anaplastic large cell lymphoma (BIA-ALCL)

some encouraging results. The idea behind the treatment is that it reduces inflammation, which is what is causing the capsule, and so the capsule softens.17 For our study, we have developed a new capsule scoring system, which is helping us determine their severity more accurately. The Baker system is the traditional scoring system used by surgeons, in which capsular contraction severity is classed into four groups; Group 1 being the mildest and Group 4 being the most severe.10 Our new FAP scoring system is divided into three classes, scored between 1 and 5. These include firmness, appearance and pain, giving a top overall score of 15. We feel that the system allows us to monitor the capsule effect and severity a lot easier and more accurately to determine if our treatments are having an improvement.

Future developments As mentioned, breast implant data in the UK is unfortunately lacking. We do not have accurate records of who has had them or a total number of patients who do. After discussion with colleagues, our current estimates are that 30-40,000 breast implants are performed in the UK per year and the procedure has been performed for more than 30 years. Consequently, it is likely that more than one million UK women may have undergone a breast augmentation procedure. From 1995 to 2005 there was a voluntary register where surgeons could input their data. However, this was abandoned due to a high proportion of women not consenting to their details being recorded and not all surgeons were participating and entering their patients’ data, so the statistics were never accurate.18 Following recommendations from the Keogh review, a Government register was launched in 2018, called the Breast and Cosmetic Implant Registry (BCIR).18-21 From January 2019, patient consent is no longer required to record data to this register and submission of records to the BCIR is mandatory for NHS-funded patients, while being requested for privately-funded patients being treated in any provider in England and Scotland. Ireland and Wales are not currently a part of this register.19,20 Although not all private surgeons enter their data into this system, I believe the register is a great step for the future of breast implant surgery in the UK. It will hopefully help to identify issues and allow patients to be traced and notified in the event of a product recall or other safety concerns relating to a specific type of implant, which can help safeguard patients.

Another positive is that an annual report is released by the BCIR that includes vital data and statistics that I believe will help further the identification of trends and complications relating to specific implants (see Key findings from BCIR report section).21

Summary Breast surgery is frequently discussed in the media and it’s important for non-surgical practitioners to have a basic understanding of their patients’ potential concerns. To ensure you are providing a full comprehensive service to your patients, should they show concerns regarding their breast implants, encourage them to visit their surgeon. As well as this, seek connections and professional relationships with local surgeons you can trust to refer your patients who are thinking about undergoing a surgical breast procedure. Mr Adrian Richards is a plastic and cosmetic surgeon with more than 15 years’ experience in plastic surgery in both the NHS and private clinics. He is a member of the British Association of Aesthetic Plastic Surgeons (BAAPS). He is also clinical director of multi award-winning training provider Cosmetic Courses and practises at The Private Clinic. REFERENCES 1. BAAPS, Cosmetic surgery stats: number of surgeries remains stable amid calls for greater regulation of quick fix solutions, May 2019, <https://baaps.org.uk/media/press_releases/1708/cosmetic_surgery_ stats_number_of_surgeries_remains_stable_amid_calls_for_greater_regulation_of_quick_fix_ solutions> 2. Adrian Richards & Hywel Dafydd, Key Notes on Plastic Surgery 2nd Edition, 2002. 3. WOMEN’S CONFIDENCE IS ‘BUST’, Triumph, 2016. <http://www.multivu.com/players/uk/7765651womens-confidence-is-bust/> 4. BAAPS, A statement by The British Association of Aesthetic Plastic Surgeons (BAAPS) on Channel 4 Dispatches programme and concern over the safety of breast implant, June 2019. <https://baaps. org.uk/media/press_releases/1726/a_statement_by_the_british_association_of_aesthetic_plastic_ surgeons_baaps_on_channel_4_dispatches_programme_and_concern_over_the_safety_of_ breast_implants> 5. US FDA, Questions and Answers about Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), October 2019, <https://www.fda.gov/medical-devices/breast-implants/questions-andanswers-about-breast-implant-associated-anaplastic-large-cell-lymphoma-bia-alcl> 6. US FDA, Medical Device Reports of Breast Implant-Associated Anaplastic Large Cell Lymphoma, July 2019. <https://www.fda.gov/medical-devices/breast-implants/medical-device-reports-breast-implantassociated-anaplastic-large-cell-lymphoma> 7. Leberfinger AN, et al., Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Systematic Review, JAMA Surg. 2017 Dec 1;152(12):1161-1168. <https://www.ncbi.nlm.nih.gov/pubmed/29049466> 8. Brittany Z. Dashevsky et al., Breast implant associated anaplastic large cell lymphoma: Clinical and imaging findings at a large US cancer center, 2018, <https://onlinelibrary.wiley.com/doi/full/10.1111/ tbj.13161> 9. US FDA, Risks and Complications of Breast Implants, October 2019, <https://www.fda.gov/medicaldevices/breast-implants/risks-and-complications-breast-implants> 10. Hannah Headon et al., Capsular Contracture after Breast Augmentation: An Update for Clinical Practice, Arch Plast Surg. 2015 Sep; 42(5): 532–543. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4579163/> 11. Malata CM et al., Textured or smooth implants for breast augmentation? Three year follow-up of a prospective randomised controlled trial, Br J Plast Surg. 1997 Feb;50(2):99-105. <https://www.ncbi.nlm. nih.gov/pubmed/9135425> 12. Allergan Voluntarily Recalls Biocell® Textured Breast Implants And Tissue Expanders, July 2019, <https://www.allergan.com/News/Details/2019/07/Allergan%20Voluntarily%20Recalls%20 BIOCELL%20Textured%20Breast%20Implants%20and%20Tissue%20Expanders> 13. NHS, PIP breast implants, 2019. <https://www.nhs.uk/conditions/pip-implants/> 14. Statement from FDA Principal Deputy Commissioner Amy Abernethy, M.D., Ph.D., and Jeff Shuren, M.D., J.D., director of the FDA’s Center for Devices and Radiological Health on FDA’s new efforts to protect women’s health and help to ensure the safety of breast implants, May 2019. <https://www. fda.gov/news-events/press-announcements/statement-fda-principal-deputy-commissioner-amyabernethy-md-phd-and-jeff-shuren-md-jd-director-fdas> 15. Goodman CM et al., The life span of silicone gel breast implants and a comparison of mammography, ultrasonography, and magnetic resonance imaging in detecting implant rupture: a meta-analysis, Ann Plast Surg. 1998 Dec;41(6):577-85. 16. Dr Jacob Haiavy, How I Do It - Postoperative care following aesthetic breast surgery – treatment of capsular contracture with Celluma low level light therapy, PMFA Journal, 2019. https://www. thepmfajournal.com/education/how-i-do-it/post/how-i-do-it-postoperative-care-following-aestheticbreast-surgery-treatment-of-capsular-contracture-with-celluma-low-level-light-therapy 17. Jacob Haiavy, Postoperative care following aesthetic breast surgery – treatment of capsular contracture with Celluma low level light therapy, The PMFA Journal, 2019. 18. Sir Bruce Keogh, Review of the Regulation of Cosmetic Interventions, Department of Health, 2013 <https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/ file/192028/Review_of_the_Regulation_of_Cosmetic_Interventions.pdf> 19. NHS, Breast and Cosmetic Implant Registry, 2019. <https://digital.nhs.uk/data-and-information/clinicalaudits-and-registries/breast-and-cosmetic-implant-registry#overview-of-the-registry> 20. ABS, Breast Implant Registry, 2019, <https://associationofbreastsurgery.org.uk/clinical/breast-implantregistry/> 21. Breast and Cosmetic Implant Registry, July 2018 to June 2019 Data Summary (England, management information), 17 October 2019. <https://files.digital.nhs.uk/62/8C3560/BCIR_Report_2019.pdf>

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ve been treating Susan for about eight years. She came Consultation o see meI’ve because she was concerned about the loss of been treating Susan for about eight years. She came to see efinition me in her jawline. because she was concerned about the loss of definition in her jawline.

Product choice

decided Product to use a choice combination of products - Restylane yft™ andI Restylane Defyne™. Restylane Lyft™ has a Lyft™ and decided to use a combination of products – Restylane igh G prime which meant I could use a small amount of meant I Restylane Defyne™. Restylane Lyft™ has a high G prime which roduct injected in a bolus to lift the tissue quickly and could use a small amount of product injected in a bolus to lift the tissue rovide structure. good tissue so Iquality was so I was quickly andSusan providehad structure. Susan hadquality good tissue ot concerned about seeing the product under the skin. not concerned about seeing the product under the skin. Restylane estylaneLyft™ Lyft™ is favourite my favourite for the posterior is my productproduct for the posterior area of the mandible, rea of the mandible, while in the pre-jowl sulcus I used while in the pre-jowl sulcus I used Restylane Defyne™. It still has a good estylaneGDefyne™. still has a so good G quite prime andbut is it is a bit more prime and It is crosslinked will be robust, rosslinked so willand beintegrates quite robust, but is a bit more cohesive well into theittissues, which is important in an ohesive and integrates well into the tissues, which is animated area. mportant in an animated area. Before

BEFORE

Technique

After

AFTER

1 I injected a 0.5ml bolus deeply down to the bone using Technique

a needle on each side of the mandible at a 90° angle a 0.5mldirectly bolusdown deeply boneAspirate 1 I injected inserting anddown feelingto for the the bone. using a needle on each side of the mandible at a before injecting. 90° angle inserting directly down and feeling for 2 I then used a 25 gauge cannula for the two injections the bone. which Aspirate before injecting. were at least 1cm in front of the anterior border of the

a 25 gauge 2 I then used masseter muscle.cannula I created afor linethe withtwo the cannula along injectionsthe which wereand atthen least 1cmupinfrom front the point in mandible came theof anterior anterior border of the masseter muscle. I created the mental region. Rotate gently, if needed, to introduce the a line withcannula the cannula slowly. along the mandible and then came up from anterior in the mental 3 I then used athe cannula along point the border of the mandible, region. Rotate gently, if Restylane needed, Defyne™ to introduce the motion injecting 0.5ml of in a fanning cannula slowly. upwards on each side of the pre-jowl sulcus. I started posteriorly first,along with deep linearly threading a cannula theinjections, border then of the 3 I then used with a fanning technique. mandible, injecting 0.5ml of Restylane Defyne™ 4 To address patient’s on ‘orange peel’ dimpling in a fanning motionthe upwards each side of theon her chin which was particularly noticeable when smiled or pre-jowl sulcus. I started posteriorly first, withshe deep talked, I added more Restylane Defyne™ between injections, then linearly threading with a fanning the skin technique.and the mentalis muscle with a similar fanning technique.

Top tips Top tips Palpate the masseter muscle and inject 1cm

⊲⊲ anteriorly Palpate the masseter muscle to andthis injectpoint 1cm anteriorly or or posteriorly to avoid posteriorly this point to avoid the facial artery or vein. the facial to artery or vein.

⊲⊲ It’s best to mark up the patient when he or she is sitting

It’s best to mark up the patient when he or she upright. is sitting ⊲⊲ Use a hair upright. net and tie hair back as it can easily fall into the treatment area. Use a hair net and tie hair back as it can easily ⊲⊲ fall Make sure thattreatment the introducer needle for the cannula isn’t into the area. inserted too deeply into the tissue to decrease the risk of Make sure that major the introducer needle for the bruising or hitting vessels. cannula isn’t inserted too deeply into the tissue ⊲⊲ Avoid injecting the jowl itself to help create a smooth to decrease the risk of bruising or hitting major contour along the jawline. vessels. Avoid injecting the jowl itself to help create a smooth contour along the jawline.

“I really like Restylane Lyft™, it has incredible lifting capacity. Restylane Defyne™ integrates well into the I really like Restylane Lyft™, it tissues, which is important has incredible lifting capacity. in an animated area.” Restylane DefyneTM integrates well into the tissues, which is important in an animated area.” Dr Heather Muir

HEATHER MUIR About Dr Heather Muir BDS (Gla) MSc (UClan) Heather qualified from Glasgow Dental School in 1998 and has worked in general practice ever since. Heather has a Master’s in Facial Aesthetics from University of Central Lancashire. She has over 16 years’ experience in facial aesthetic treatment and About Dr Heather Muir BDS has been teaching these skills to doctors, dentists and nurses (Gla) MSc (UClan) since 2006. Heather is part of the Galderma Faculty.

Heather qualified from Glasgow Dental School in 1998 and has worked in general practice ever since. Heather has a Masters in Facial Aesthetics from University of Central Lancashire. DOP November 2019 She has over 16 years’ experience in RES19-06-0324c facial aesthetic 4 To address the patient’s ‘orange peel’ dimpling on treatment and has been teaching these skills to her chin which was particularly noticeable when doctors, dentists and nurses since 2006. Heather is she36 smiled or talked, I added more Restylane Aesthetics | December 2019 part of the Galderma Faculty. Defyne™ between the skin and the mentalis muscle

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Case Study: Treating PIH Aesthetic practitioner Vanita Rattan details how she treated post-inflammatory hyperpigmentation following a mite infestation in a patient with skin of colour Commonly, aesthetic practitioners may see post-inflammatory hyperpigmentation (PIH) present as a complication following aesthetic treatments like laser or chemical peels, or maybe from skin conditions like acne. However, it can occur from a variety of other circumstances. Asian and African skin pigments very quickly and extra care must be taken with these skin types to prevent making the pigmentation worse.1 This article describes the management of a scabies infestation of an African British lady, who was successfully treated at The Hyperpigmentation Clinic. At our clinic, as far as I am aware, we formulate and manufacture the only professional-grade hyperpigmentation treatment specifically created for skin of colour. It is a stable mask with 40% (extremely high) active ingredients intended for repeated treatment. Over the last five years, I have treated more than 25,000 cases of hyperpigmentation with a 95% success rate, seeing a 60-100% reduction, and 5% failure rate noting no reduction in hyperpigmentation.

how we would treat it. We did a patch test, signed the consent form and discussed the potential complications that treatment could have. According to our clinic data, there is a one in 1,000 chance of inflammation, irritation or a rash following our treatment approach. Although we use one method, as part of good medical practice, other treatments are also outlined and discussed with the patient in their consultation. This patient chose to utilise our pigmentation treatment plan.

How did mites cause PIH? When mites burrow into the skin and lay eggs, it causes severe itching. Histamine release then takes place during the inflammation period of the infestation, where her melanocytes were stimulated.1 These cells then begin to increase the rate of melanin production in the cell, which then passes into the melanosomes and up into the surrounding keratinocytes.2 These keratinocytes will then slowly make their way to the surface and 28 days later hyperpigmentation can be seen. As this lady is of African

History A 54-year-old African British lady presented to clinic with PIH of the upper and lower left arm. She has also suffered with elbow hyperpigmentation since her 20s. The patient had received the PIH from an infestation of mites (scabies). She caught the mites one day when she was returning to the UK from France when a refugee grabbed hold of her arm. She didn’t notice anything at the time, but after about three to four weeks she started experiencing severe itching on her upper left arm. This excruciating itching spread down her arm. She visited her GP who prescribed Permethrin 5% cream to kill the mites and the eggs, along with antihistamine pills and hydrocortisone cream for the itching. The patient visited me when the scabies had cleared a few weeks after finishing her treatment, as she was very anxious about the pigmentation left behind. She felt that she was unable to wear short sleeve tops, go swimming or feel comfortable with her partner. At the initial consultation, we took the patient’s, explained what had happened to her skin and

Background of ingredients Kojic Dipalmitate: stable form of powerful tyrosinase inhibitor to reduce melanin synthesis.6 Phytic acid chelates copper: copper is essential part of the enzyme tyrosinase which makes melanin. It is also a gentle exfoliant.7 Dioic acid (octadecenedioic acid): similar to azelaic acid, but is 18 carbon atoms long instead of nine carbon atoms. It binds to PPAR-gamma receptors on nuclear membrane of melanocytes to reduce tyrosinase mRNA production and reduce melanin synthesis.8,9 Lactic acid: suppresses melanin formation by directly inhibiting tyrosinase activity, an effect independent of their acidic nature. Lactic acid therefore works on pigmentary lesions not only by accelerating the turnover of the epidermis but also by directly inhibiting melanin formation in melanocytes.10 Retinaldehyde: has been shown to improve pigmentation by one step conversion to retinoic acid followed by increasing epidermal cell turnover – called epidermopoiesis. It also decreases melanosomal transfer of melanin. The retinaldehyde changes the stratum corneum to affect the permeability barrier to facilitate the penetration of depigmenting agents in the epidermis.11 Niacinamide: inhibits melanosome transfer in the melanocyte/keratinocyte model. In one clinical study, niacinamide has shown to significantly decrease hyperpigmentation and increase skin lightness compared with vehicle alone after four weeks of use.12

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descent, her melanocytes are larger than in Caucasian skin and are far easier to stimulate.3 This means when a patient has skin of colour we must ensure we do everything we can to prevent inflammation of any treatment.4

Treatment of PIH For the creation of the mask, we use 40% tyrosinase inhibitors including alpha arbutin, beta arbutin, niacinamide, magnesium ascorbyl phosphat, octadecenedioic acid, salicylic acid, retinaldehyde, liquorice extract, ferulic acid and phytic acid.5 This is an extremely difficult compound mask to create as there is a very high concentration of acids in a fat base. With Asian and African skin, the melanocytes are large and easily triggered, while the hyperpigmentation is also often very dark and resistant. This means your treatment must be very effective, using appropriate percentage of ingredients, but also must not burn the skin due to the use of high percentages, which is a tough balance to achieve. I therefore believe that treatment should only be attempted by experienced practitioners. Once the mask was applied to the patient’s arm in clinic, it was left on for five hours. The arm was wrapped with water resistance clear wrap to provide occlusion and warmth, which is the best environment for the treatment. The patient went home with the mask on as it does not need to be neutralised and she washed it off in the shower five hours later. We provided the patient with aftercare creams that aim to prevent inflammation, continue to calm the melanocytes and increase cell turnover to heighten the rate of the results. These aftercare creams have the same ingredients as the initial mask, but with differing percentages which are lower than the in-clinic mask.

Results The patient started to see results 12 weeks after the second session, which, in my experience, is to be expected. At this point, she saw approximately 40% reduction as measured by our colorimeter and her visual assessment. At 12 weeks following the third session, she saw a 70% reduction (Figure 1) and after the fourth session saw an 85% total reduction. At this point, there are diminishing returns with this treatment so we did not recommend further sessions. In the future, the Before

After

Figure 1: 54-year-old patient presenting with PIH before treatment and 12 weeks after the third treatment session, which was nine months after the initial consultation.

When mites burrow into the skin and lay eggs, it causes severe itching. Histamine release then takes place during the inflammation period of the infestation, when her melanocytes were stimulated patient will need to vigilantly apply SPF 50 as, in my experience, once melanocytes have been triggered in one area, they are more sensitive to UV and being triggered again.

Conclusion Asian and African skin can hyperpigment extremely quickly. When treating these skin types, care must be taken to avoid any inflammation of the area as you can cause more hyperpigmentation than you started off with.2 Should hyperpigmentation occur, it’s important that patients are managed appropriately, that there are no inflammatory mediators triggering melanocytes and that results are maintained through regular use of SPF. Vanita Rattan completed a medical degree and a degree in physiology and pharmacology at the University College London Medical School in 2008, however does not currently practice as a doctor. She has treated more than 25,000 cases of hyperpigmentation and has clinics in Mayfair, Birmingham, Manchester and Glasgow. Rattan is currently launching anti-melasma sunglasses that aim to improve patients’ zygomatic melasma treatment success. REFERENCES 1. Erica C. Davis, MDa and Valerie D. Callender, et al., Postinflammatory Hyperpigmentation: A Review of the Epidemiology, Clinical Features, and Treatment Options in Skin of Color, J Clin Aesthet Dermatol. 2010 Jul; 3(7): 20–31. 2. Jean-Paul Ortonne, Donald L. Bissett, Latest Insights into Skin Hyperpigmentation, Journal of Investigative Dermatology Symposium Proceedings, Volume 13, Issue 1, April 2008, Pages 10-14. 3. A. Bernard Ackerman, Almut Böer, Bruce Bennin, Geoffrey J. Gottlieb, Histologic Diagnosis Of Inflammatory Skin Diseases, An Algorithmic Method Based on Pattern Analysis, Third Edition. 4. Tania Ferreira Cestari, Lia Pinheiro Dantas, and Juliana Catucci Boza, Acquired hyperpigmentations, An Bras Dermatol. 2014 Jan-Feb; 89(1): 11–25. 5. Yayli S, Treatment of Hyperpigmentation in Darker Skins. Dermatology and Dermatologic Diseases, pigmentary disorders, 2015, 2:158. 6. Ahmad Firdaus B. Lajis, Muhajir Hamid, and Arbakariya B. Ariff, Depigmenting Effect of Kojic Acid Esters in Hyperpigmented B16F1 Melanoma Cells, J Biomed Biotechnol. 2012; 2012: 952452. 7. Graf E, Empson KL, Eaton JW, Phytic acid. A natural antioxidant, J Biol Chem. 1987 Aug 25;262(24):11647-50. 8. Tirado-Sanchez A,Santamaria-Roman A,Ponce-Olivera RM, Efficacy of Dioc (Octadecene-dioic acid) compared with Hydroquinone in the treatment of Melasma.Int J Dermatol.2009Aug;48(8):893-5. 9. J M Gillbro, M J Olsson, The Melanogenesis & mechanisms of skin lightening agents, existing & new approaches, Inter Jour of Cosmetic Science, Volume 33,issue 3 June,pages 210-221. 10. A,Ohashi A,Sato H,Ochiai Y,Ichihashi M,Funasaka Y, The Inhibitory effect of Lactic acid on melanin synthesis in Melanoma cells, Exo Dermatol.2003;12Suppl2:43-50.Usuki Division of Dermatology, Dept of Clinical and Molecular Medicine,Kobe University Graduate School of Medicine, Kobe, Japan. 11. Ortonne, JP, Retinoid therapy of Pigmentary disorders. Dermatologic Therapy, 2006, 19:280-288. 12. Hakozaki,T.,Minwalla,L.,et al., The effect of Niacinamide on reducing cutaneous pigmentation and suppression of Melanosome transfer. British Journal of Dermatology, 2002, 147:20-31.

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Stem Cells in Regenerative Medicine Consultant plastic surgeon Mr Ivor Lim introduces the use of stem cells in regenerative medicine It is an urban myth that household dust comprises 80% of shed human skin.1 But why is human skin even shed at all? This is one example of many continuous regenerative processes that take place in the body at any one time, occurring at a background level that is barely discernible, in spite of the skin being the largest organ of the human body.1 For the epidermis of the skin, new cells are generated to replace the 30-40,000 surface cells shed every minute which form, with secreted oils, the first line of defence from direct environmental injury and insult.2 Similar regeneration is found in the intestinal mucosal epithelial lining, with a cellular turnover as short as four days, making it the most rapid renewing tissue in the human body. Regular tissue turnover and routine shedding of cells is a key element in maintaining the epithelium in optimal health. In fact, this basic premise that cells become diseased, get injured or just grow old and need replacement by the generation of new cells is the common thread that links any living cell, tissue or organ. It is this basic understanding of human regeneration that provides the background for regenerative medicine, the branch of medical translational research that develops methods to regrow, repair or replace damaged or diseased cells, organs or tissues to restore or establish normal function.1

Growing of cells in the laboratory is an established technique, and it is even possible to grow different cells together in three dimensions on a collagen scaffold to mimic ‘simpler’ structures like skin

Stem cells The ability to form regenerated cells and tissues from the patient’s own tissue or cells is the ideal scenario, solving the problem of tissue or organ rejection, as well as addressing the shortage of organs available for donation. Growing of cells in the laboratory is an established technique, and it is even possible to grow different cells together in three dimensions on a collagen scaffold (what we call a three-dimensional organotypic culture) to mimic ‘simpler’ structures like skin.3 I stress here that ‘simpler’ is in inverted commas as the skin is not a simple structure at all. However, our ‘ideal scenario’ isn’t always feasible. In spite of the increased understanding of the molecular biology of cells and the rapid development of tissue-engineering techniques to grow tissues and organs in-situ, we can only manage broad brushstrokes in the laboratory; nature’s fine detail we unfortunately cannot (yet) fully replicate. The finite number of cells that can be harvested and the age of the cells at the time of harvest are also variables that cannot be controlled. This is where stem cells come into play, as they have a unique ability to differentiate into all the cell types of the human body. Fusion of the sperm and egg in the process of fertilisation generates the first diploid cell, a stem cell, which is able to differentiate into all the various cell types that make up the human body. Subsequently, stem cells persist throughout the life of the organism, generating new cells to replace old, worn or shed cells.4 Research started in earnest in the 1980s with animal stem cells, segueing to human studies in the 1990s. By 1998, the human embryonic stem cell lines had been derived,6 with characterisation of bone marrow mesenchymal stem cells hot at its heels in 1999.7 In regenerative medicine, mesenchymal stem cells (MSC) are probably the best-known stem cell type being used, and there are currently 976 trials around the world recorded using these cells to treat myriad conditions ranging from spinal cord injury to skin diseases to depression.8 MSC have been harvested from bone marrow, adipose tissue and most recently from the outer lining membrane of the umbilical cord, which has been found to be the highest yielding source of MSC with significant purity of 99% compared to other stem cell sources.9 These cord-lining MSC have been grown to good manufacturing practice standards for use in a current US Food and Drug Administration (FDA) trial to heal chronic diabetic foot ulcers.10

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Transplantation of cells Conceptually, the transplantation of cells to replace those missing from trauma, tumour or degeneration seems straightforward enough, but the reality is more complicated. Transplanted cells need to ‘take’ and survive in the new strata into which they have been inserted, and certainly not all transplanted cells will survive in their new environment. Having survived, it is also speculative as to how they may differentiate into the correct cells required in the said area. For example, stem cell to chondrocyte differentiation in an osteoarthritic joint. What is certain in cells that have survived is that they start secreting protein cytokines and growth factors specific to their cellular type via secretory vesicles and membrane-bound exosomes. For stem cells, these cytokines and growth factors are directed towards repair and regeneration, largely by influencing new vessel formation in the area (angiogenesis), as well as cell division (mitogenesis) and extracellular matrix regeneration.11 When cells are grown in culture media in dishes in the laboratory, the cytokines and growth factors described above are secreted into the culture media, and the culture media thus becomes ‘conditioned’. This conditioned media can be collected by aspiration, leaving the cells behind to usefully condition new added media.

MSC have been harvested from bone marrow, adipose tissue and most recently from the outer lining membrane of the umbilical cord Stem cells and skin The stratum basale of the epidermis holds caches of stem cells (interfollicular stem cell cells as opposed to hair follicular stem cells) that generate new epidermal cells to transit through the histologically recognised stages of stratum spinosum, stratum granulosum, stratum lucidum and finally the stratum corneum where the cells lose their nuclei and are eventually shed.12 As skin ages, proliferation rates drop in the epidermis, and epidermal cell turnover time begins to lengthen. Dermal thickness also decreases with age, with a decline in the production of glycosaminoglycans as hyaluronic acid. The end result of this progressive structural and functional deterioration increases susceptibility to eczema, contact and allergic dermatitis, seborrheic keratosis and various neoplasms as basal and squamous cell carcinoma.13,14 It is important to note here that stem cells cannot be put into cosmetic products for varying reasons. As mentioned previously, such stem cells are cultured in a media where they secrete thousands of proteins. The cells are then removed and you are left with stem cell conditioned media. When keratinocytes from aged skin are grown in stem cell conditioned media from any source, increased proliferation and growth of the keratinocytes is seen. Likewise, a pipette tip scrape wound of skin dermal cells (fibroblasts) has been found to close faster when exposed to stem cell conditioned media.9 Three-dimensional organotypic skin cultures have also been shown to increase in thickness when grown in stem cell conditioned media.9 All of these observations strongly suggest that the stem cell conditioned media has regenerative effects on skin cells which can

potentially reverse the effects of skin cell ageing described above, and it can usefully be incorporated into a cosmeceutical product to improve the appearance of aged skin.

What can we expect going forward? With the exceptional advancements in the regenerative medicine specialty over the last decade, I look forward to what we can expect in the future and there are currently a number of areas where I believe we can see the use of regenerative medicine excel. It is generally accepted that there is endless potential applications in the treatment of diabetes,15 corneal regeneration,16 haemophilia,17 ischaemic hearts18 and many more. More specific to aesthetics, in male pattern baldness for example, it appears that hair follicle stem cells are present but may lack specific hair follicle progenitor cells.19 Application of stem cell conditioned media with its potent mix of protein cytokines and growth factors may be able to restore the function of these quiescent follicles to enhance hair growth and some preliminary trials have already demonstrated efficacy in such a situation.20 I believe there is also huge potential growth for other delivery methods for facial rejuvenation. Disclosure: Mr Lim is a founding director of Singaporean biotechnology company CellResearch Corporation which focuses on umbilical cord lining stem cell research and development. Mr Ivor Lim is a founding director of Singaporean biotechnology company CellResearch Corporation. He is double certified in both plastic surgery and hand surgery from the Academy of Medicine, Singapore, as well as from the Intercollegiate Specialty Boards in the UK with FRCS (Plastic Surgery) qualifications. He continues to conduct stem cell research. REFERENCES 1. Quora, Did you know that dust is largely composed of human skin? <https://www.quora.com/Didyou-know-that-dust-is-largely-composed-of-human-skin> 2. Eva Bianconi, Allison Piovesan, Federica Facchin, et al. An estimation of the number of cells in the human body, Annals of Human Biology, 40:6, 463-471, 2013 3. Oh JW, Hsi T-C, Guerrero-Juarez CF, et al. Organotypic skin culture. J Invest Dermatol 133(11),: e14, 2013 4. Zakrzewski W, Dobrzynski M, Szymonowicz M. Stem cells: past, present, future. Stem Cell Res Ther 10:68, 2019 5. Mason C, Dunnill P. A brief definition of regenerative medicine”. Regenerative Medicine. 3 (1): 1–5, 2008 6. Thomson JA, Itskovitz-Eldor J, Shapiro SS et al. . Embryonic stem cell lines derived from human blastocysts”. Science. 282 (5391): 1145–7, 1998 7. Pittenger MF, Mackay AM, Beck SC, et al. Multilineage Potential of Adult Human Mesenchymal Stem Cells Science 02 Apr 1999: Vol. 284, Issue 5411, pp. 143-147 8. ClinicalTrials.gov <www.clinicaltrials.gov> 9. Lim IJ and Phan TT. Epithelial and mesenchymal stem cells from the umbilical cord lining membrane. Cell Transplant. 23(4-5): 497-503, 2014 10. ClinicalTrial.gov, <https://clinicaltrials.gov/ct2/ results?cond=&term=corlicyte&cntry=&state=&city=&dist= > 11. Yu B, Zhang XM, Li XR. Exosomes derived from mesenchymal stem cells. Int J Mol. Sci. 15, 41424157, 2014 12. Grove GL, Kligman AM. Age-associated changes in human epidermal cell renewal. J Gerontol 1983: 38(2):137-42 13. Glogau RG. Systemic evaluation of the aging face. In: Bolognia JL, editor; Jorizzo JL, editor; Rapini RP, editor. Dermatology. Edinburgh: Mosby; 2003. pp. 2357–2360 14. Farage MA, Miller KW, Berardesca E, Maibach HI Clinical implications of aging skin: cutaneous disorders in the elderly. Am J Clin Dermatol. 10(2):73-86, 2009 15. Zhou Y, Shu UG, Lin G, Yan TL, et al., Characterization of Human Umbilical Cord Lining-Derived Epithelial Cells and Transplantation Potential. Cell Transplantation. 2011 16. Reza H, Ng BY, Gimeno F, Phan TT, et al. Umbilical Cord Lining Stem Cells as a Novel and Promising Source for Ocular Surface Regeneration. Stem Cell Reviews and Reports. 2015 17. Sivalingam J, Krishnan S, Ng WH, Phan TT, et al. Biosafety Assessment of Site-directed Trangene Integration in Human Umbilical Cord-Lining Cells. Molecular Therapy. 2010 18. Martinez E, Vu DT, Wang J, et al., Grafts Enriched with Subamnion-Cord-Lining Mesenchymal Stem Cell Angiogenic Spheroids Induce Post-Ischemic Myocardial Revascularization and Preserve Cardiac Function in Failing Rat Hearts, Stem Cells and Development. 2013 19. Garza LA, Yang C-C, Zhao T et al. Bald scalp in men with androgenetic alopecia retains hair follicle stem cells but lacks CD200-rich and CD34-positive hair follicle progenitor cells. J Clin Invest 121(2):613-622, 2011 20. Fukuoka H, Narita K, Suga H. Hair Regeneration Therapy: Application of Adipose-Derived Stem Cells. Current Stem Cell Research & Therapy. 2017; 12(7): 531–534

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Treating Acne with Topicals Dr Aileen McPhillips discusses the management of acne vulgaris with cosmeceutical topical treatments and presents two case studies Acne is an inflammatory skin condition that most commonly occurs during puberty or teenage years.1 However, this is not always the case. In fact, acne is the eighth most common skin disease worldwide1 and therefore it is something we see, as medical professionals, frequently in practice. Many adults continue to have acne well into their 30s and beyond. It is not uncommon for acne to develop for the first time in adulthood. Research has suggested that acne persists into the 20s and 30s in around 64% and 43% of individuals, respectively, however a much lower percentage will seek professional treatment.2 I find that this is because people ‘learn to live with it’ or wait for the condition to self-resolve. This article will look at how an effective skincare regimen with medical-grade products can provide a satisfactory long-term outcome for patients with mild-moderate acne. First of all, it is important to note that acne can have long-term consequences. The longer the acne is present, the more likely scarring or an impact on psychological wellbeing can occur. Research has shown that the presence of acne can negatively affect quality of life, self-esteem and mood, along with increasing anxiety, depression and suicidal ideation amongst patients of all age groups.3-6 Therefore, early recognition and treatment is key.

Acne treatments Acne is a common inflammatory skin condition affecting the pilosebaceous units of the skin.7 It consists of open comedones (blackheads), closed comedones (whiteheads) and inflammatory lesions, such as nodules, pustules and papules.7 The four pathological factors involved in the development of acne are; increased sebum production, irregular follicular desquamation, propionibacterium acnes proliferation and inflammation of the area.8 In my experience, a successful treatment for acne will generally aim to reduce oil production, speed up skin

cell turnover, fight bacterial infection and/or reduce inflammation – which helps prevent scarring.8 The goal of acne treatments is to control and treat existing lesions, prevent permanent scarring, limit the duration of the disorder and minimise morbidity.8 Patients are often initially treated with topical agents, such as benzoyl peroxide, retinoids or antibiotics. Depending on response and/or severity they may be treated with systemic treatments, such as oral antibiotics, hormonal treatments (contraceptive pill) or isotretinoin.9-11 I have prescribed many of these treatment options whilst working in general practice – with variable outcomes. However, I often felt management options within primary care were lacking. Topical treatments available on the NHS, although effective in some patients, generally do not contain the added ingredients that cosmeceuticals have for additional skin benefits and soothing effects, therefore are often more difficult for patients to tolerate, due to skin irritation. I have found that this can lead to lack of treatment compliance.12

Why topicals? Within my aesthetic practice there are many treatment options available to patients, including the use of cosmeceutical topical treatments. I have found that patients often decline systemic treatment due to potential adverse effects, discussed in more detail below. It is my experience that many patients are reluctant to take antibiotics long term given the potential side effects, such as gut disturbance and the increasing concern regarding antibiotic resistance. Another systemic treatment option is isotretinoin which has many potential significant side effects.10 Although not common, serious side effects include mental health disturbance, raised intracranial pressure, inflammatory bowel disease and hepatitis.10 As the medicine is teratogenic, patients must not become pregnant whilst taking it and it is advised that they should use two forms of contraception during treatment.11 With all of this in mind, it is

understandable that many patients do not want to opt for this treatment approach. Once I have discussed all of the above with my patients, I then consider what topical treatments would be most beneficial to them. The main ingredients in such treatments that have been shown to be of benefit include salicylic acid, benzoyl peroxide, sulphur, alpha-hydroxy acids and retinoids.12,13 I will discuss these in more detail below. Salicylic acid Salicylic acid has keratolytic and comedolytic properties along with being mildly antiinflammatory. Salicylic acid produces desquamation of hyperkeratotic epithelium by dissolving the intercellular cement.14 It works as an exfoliant and prevents comedonal acne by slowing follicular shedding of cells and therefore prevents clogging of follicles.15 It also decreases secretion of sebum,6 which is an added benefit in patients with acne. A number of studies have shown the benefit of using salicylic acid in the management of acne. One study demonstrated that twice daily use of 2% salicylic acid impregnated pads showed significant benefit over placebo at four, eight and 12 weeks where total lesion counts were assessed.16 A further review of three placebo-controlled studies concluded that the use of salicylic acid pads reduced the number of primary lesions and therefore the number and severity of all lesions associated with acne.17 A doubleblind, placebo-controlled trial looked at the use of 2% salicylic acid cleanser in the treatment of acne.18 Thirty patients with mild-moderate acne were reviewed over an eight week period. Expert grading of lesions was performed at regular intervals through the study period. Results showed that the cleanser was well tolerated and provided significant reduction in acne lesion counts throughout the entire study interval. Benzoyl peroxide The mode of action of benzoyl peroxide in acne is three-fold; reduction of sebum, comedolysis and inhibition of p.acnes.19 Its lipophilic properties permit penetration of the pilosebaceous duct and its efficacy is largely related to superficial inflammatory lesions.9 Benzoyl peroxide has been used as an effective treatment for many years. A systemic review of randomised vehiclecontrolled trials for determining the efficacy of benzoyl peroxide topical therapy reviewed 12 trials with 2,818 patients receiving benzoyl peroxide and 2,004 receiving vehicle treatment. Results showed that the average

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percentage reduction in total number of acne lesions was significantly more for the treatment group versus the vehicle group â&#x20AC;&#x201C; 44.3% versus 27.8% reduction and 41.5% versus 27% reduction in non-inflamed lesions.20 Another study compared benzoyl peroxide to topical erythromycin and found that although both preparations showed similar reduction of inflamed lesions, the benzoyl peroxide also significantly reduced the number of non-inflamed lesions.21 Benzoyl peroxide formulations may contain a range of particle sizes. Benzoyl peroxide is often micronised, which ensures a consistent particle size. It has been suggested that micronised benzoyl peroxide particles that are smaller than the follicular orifice (approximately 10Âľm) penetrate the pilosebaceous unit more effectively.22 A smaller particle size may increase anti-acne efficacy by enhancing bioavailability and intra-follicular penetration of the benzoyl peroxide.22 Sulphur Sulphur is used to treat various skin conditions due to its anti-inflammatory and antibacterial properties. It inhibits bacterial dihydropteroate synthase within the skin. This prevents the conversion of p-aminobenzoic acid to folic acid, which causes a bacteriostatic effect on the growth of several gram-negative and gram-positive organisms, including p.acnes.23 It is also reported to have a keratolytic effect, along with absorbing excess sebum. The keratolytic action is due to the formation of hydrogen sulphide through a reaction that depends upon direct interaction between sulphur particles and keratinocytes.24 The combined antibacterial action and drying properties have been shown to reduce the number of inflammatory lesions and comodones.23 A study was carried out looking at the effect of a topical sodium sulfacetamide/sulphur lotion on patients with mild-moderate acne. Results showed a 78% reduction of total acne lesion count and 83% reduction of inflammatory acne lesions over a 12-week period, with all participants reporting significant clinical improvement by the end of the study period.25 Alpha-hydroxy acids Alpha-hydroxy acids (AHAs), in particular glycolic acid, are a class of chemical compounds frequently used in dermatology.26 AHAs induce desquamation and keratolysis, meaning they have been shown to be of benefit in acne patients.26 Depending on the pH of the finished products, they also exhibit comedolytic

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Case studies

Before

After

Shown in Figure 1 is a 38-year-old patient who presented with persistent moderate acne. She had tried various over-the-counter preparations (such as cleansers) with no improvement. No specific triggers were noted. She declined oral medication due to potential adverse effects. The patient was generally well otherwise and not taking Figure 1: Patient before and 12 weeks after following her topical treatment plan any medication. During a face-to-face consultation, moderate acne was noted with comedones and widespread pustules. We discussed options and developed a cosmeceutical programme, consisting of products from the ZO Skin Health range which include key ingredients such as salicylic acid, vitamins C, A, and E, retinoids and sulphur, to follow. I reviewed the patient at six and 12 weeks, with ongoing improvement noted at each review. The patient is satisfied with the improvement in her skin. She continues to use the recommended skincare regimen with ongoing benefit. Before After Figure 2 shows a 45-year-old lady who presented with adult-onset moderate-severe facial acne. She had tried over-the-counter preparations and been prescribed topical medications by her GP, such as combined antibiotics and retinoid preparations, with no/minimal benefit. The patient had attempted to stop the long-term oral antibiotics she was put on several times, but on each attempt there was a significant Figure 2: Patient before and 12 weeks after following her topical treatment plan flare of acne. The patient visited a dermatologist but declined isotretinoin due to potential side effects. During a faceto-face consultation, moderate acne was noted with scarring with comedones and occasional pustules and she was generally well otherwise. We discussed skincare options for initial management and developed a cosmeceutical programme to follow, which as before was from the ZO Skin Health range. We also discussed longer term management of scarring. I reviewed the patient at six and 12 weeks with ongoing improvement noted at each review. The patient is no longer taking antibiotics (she reduced the dose upon commencing the skincare programme and stopped after two weeks). She continues to use the skincare regimen with ongoing benefit and has now commenced microneedling to address the scarring. Note that topical retinoid treatment should be stopped 24 hours prior to microneedling.

as well as antimicrobial properties.26 A randomised double-blind placebo-controlled trial was carried out to look at the effect of 10% glycolic acid oil-in-water emulsion as monotherapy in mild acne. The results showed the acne improved significantly after 45 days and continued to improve up to the 90-day study period.27 Baldo et al. reviewed the tolerability and efficacy of a cream with a mix of AHAs in 248 patients with mild-moderate acne in a multicenter, nonrandomised, open study in 2010.28 Results confirmed high tolerability (scoring good to excellent) and efficacy (high in 64.2%) of the AHA-based cream.

Retinoids Recent evidence-based guidelines from the American Academy of Dermatology and the European S3 guidelines from the European Dermatology Forum have agreed that retinoids have an essential role in the management of acne.29,30 Retinoids function by slowing the desquamation process, therefore decreasing the number of comedones and microcomedones; they are the most effective comedolytic agent in use and are also anti-inflammatory.31 Evidence has shown that topical retinoids are effective in reducing the number of comedones and inflammatory lesions by

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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around 40 to 70%.32 Efficacy may improve with higher concentrations of product, however these preparations may be more difficult to tolerate due to risk of irritation.32 A randomised controlled trial was carried out to compare the retinoid adalapene 0.3% against adapalene 0.1% and gel vehicle only. Within the trial, 653 patients were randomly allocated to each treatment and observed over 12 weeks. A consistent, dosedependent effect was demonstrated for all efficacy measures, showing that adapalene gel was more effective than placebo and efficacy further improves with higher potency.33 A systemic review was carried out to evaluate the efficacy, safety and tolerability of topical retinoids in the treatment of acne vulgaris.34 During this, 54 clinical trials were included and reviewed. It was concluded that retinoids are safe and efficacious for the treatment of acne vulgaris, however should be used in combination with benzoyl peroxide to optimise results in patients.

In my practice Based on what I have discussed in this article, I ensure that I include the mentioned ingredients in my clinical practice and look for skincare that incorporates this. Following a thorough history and skin examination, I establish the patient concerns and expectations. Skincare options and regimens are discussed, along with the timeframe required and long-term plan. I have found that best results are achieved when the patient uses several products in combination on a regular basis. The combination aims to address the mechanisms of pathogenesis as discussed previously; reduce oil production, speed up skin cell turnover, fight bacterial infection and/or reduce inflammation. Review appointments are arranged to allow the patient and practitioner to assess progress. I feel this aids treatment compliance and allows for alteration of management as required.

Limitations Although topical treatments are generally well tolerated, some topical treatments may cause local skin irritation, especially at higher doses.34 This may limit patient compliance. Acne treatments with the active ingredients mentioned previously are often not recommended for use in pregnancy, due to absence of safety data and lack of evidencebase.35 Length of time required for effective treatment may also be a limiting factor. Most topical preparations require at least six to eight weeks before an improvement is seen and at least six to eight months for

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significant benefit.36 I arrange regular review appointments with each patient as this allows time to discuss how the treatment plan is going along with reviewing photographs. Patients are generally more motivated when they can see changes and improvement. Treatment with topical agents may be more difficult if acne lesions cover a larger body area (for example, face and back) and so systemic treatment may be more appropriate. As well as this, cost of cosmeceutical products is also a consideration in long-term treatment. To manage this, I always form a long-term plan and discuss cost at initial consultation so patients are aware from the beginning. Topical treatments are not suitable to treat severe acne, which may include cysts or nodules. Assessment and management by a dermatologist is advised.

Conclusion Acne is an extremely common condition affecting a wide age range of patients. It can have severe and long-term consequences, therefore early and effective treatment is important in the management of this patient group. An effective topical treatment regimen, with medical-grade ingredients can provide successful and long-term treatment with minimal negative impact on the patient. Dr Aileen McPhillips is a medical graduate of Queen’s University, Belfast and currently works as a GP and aesthetic practitioner, running her own clinic ‘Aesthetics by Dr Aileen’ based in Aughnacloy, Co. Tyrone. She is a member of the Royal College of General Practitioners and completed a Level 7 certificate in Injectables for Aesthetic Medicine. Dr McPhillips enjoys all aspects of aesthetic practice, although has a keen interest in maintaining skin health and skin rejuvenation. REFERENCES 1. Tan JK, Bhate K, A global perspective on the epidemiology of Acne, The British Journal of Dermatology, July 2015 2. Rocha MA, Bagatin E, Adult-onset Acne: Prevalence, Impact, and Management Challenges, Clinical, Cosmetic and Investigational Dermatology, 2018 3. Bhate K, Williams HC, Epidemiology of Acne Vulgaris, British Journal of Dermatology 2013 4. Hanna S, Sharma J, Klotz J, Acne Vulgaris: more than skin deep, Dermatology Online Journal, Aug 2003 5. Gallitan SM, Berson DS, How Acne Bumps Cause the Blues: The Influence of Ace Vulgaris on Self-Esteem, International Jornal of Womens Dermatology, Dec 2017 6. Gallitan SM, Berson DS, How Acne Bumps Cause the Blues: The Influence of Ace Vulgaris on Self-Esteem, International Jornal of Womens Dermatology, Dec 2017 7. Mayo Clinic, Acne Symptoms & Causes <www.mayoclinic.org/ diseases-conditions/acne/symptoms-causes> 8. Strauss JS et al., Guidelines of care for Acne vulgaris management, Journal of American Academy of Dermatology, 2007 9. Savage LJ, Layton AM, Treating Acne Vulgaris: Systemic, Local and Combination Therapy, Expert Review of Clinical Pharmacology 2010 10. Dréno B, Thiboutot D, Gollnick H, et al. Global alliance to improve outcomes in acne: large-scale worldwide observational study of adherence with acne therapy, International Journal of

Dermatology, 2010 11. EMC, Roaccutane 20mh soft capsules <www.medicines.org.uk/ emc/product/6470/smpc> 12. Mayo Clinic, Acne Diagnosis & Treatment <https://www. mayoclinic.org/diseases-conditions/acne/diagnosis-treatment/ drc-20368048> 13. Fox L, Csongradi C, Aucamp M, duPlessis J, Gerber M. ‘Treatment Modalities for Acne’. Molecules 2016; 21:1063. 14. Furman BL, Salicylic Acid, Reference Module in Biomedical Science, 2018 15. Arif T, Salicylic Acid as a Peeling Agent: a comprehensive review, Clinical, Cosmetic and Investigational Dermatology, August 2015 16. Eady EA et al., The Benefit of 2% Salicyclic Acid lotion in acne – a placebo-controlled study, Journal of Dermatological Treatment, 1996 17. Weisman S, Zander E, Treatment of Acne Vulgaris with Salicylic acid pads, Clinical Therapeutics, 1992 18. Woodruff J, A double-blind, placebo-controlled evaluation of a 2% Salicylic Acid Cleanser for Improvement of Acne Vulgaris, Journal of the American Academy of Dermatology, April 2013 19. Cotterill JA, Benzoyl Peroxide, Acta Dermato-Venereologica, 1980 20. Lamel SA et al., Evaluating Clinical Trial Design: Systematic Review of Randomised Vehicle-Controlled Trials for Determining Efficacy of Benzoyl Peroxide Topicaal Therapy for Acne Archives of Dermatological Research, Nov 2015 21. Burke B, Eady EA, Cunliffe WJ, Benzoyl Peroxide versus topical Erythromycin in the Treatment of Acne Vulgaris, British Journal of Dermatology, Feb 1983 22. Bikowski J, A Review of the Safety and Efficacy of Benzoyl Peroxide (5.3%) Emoillient Foam in the Management of Truncal Acne Vulgaris, Journal of Clinical and Aesthetic Dermatology Nov 2010 23. Wolf K, Silapunt S, The Use of Sodium Sulfacetamide in Dermatology, Cutis, August 2015 24. Lin. AN, Reimer RJ, Carter DM, Sulfur Revisited, Journal of the American Academy of Dermatology, March 1988 25. Breneman DL, Ariano MC, Successful Treatment of Acne Vulgaris in Women with a new Topical Sodium Sulfacetamide/ Sulfur Lotion, International Journal of Dermatology, 1993 26. Babilas P, Knie U, Abels C, Cosmetcis and Dermatologic Use of Alpha Hydroxy Acids, Journal der Deutschen Dermatologischen Gesellschaft, July 2012 27. Abels C, Kaszuba A, Michalak I, Werdier D, Knie U, Kaszuba A, A 10% Glycolic Acid containing oil-in-water Emulsion Improves Mild Acne: a randomised double-blind placebo-controlled trial, Journal of Cosmetic Dermatology, Sep 2011 28. Baldo A, Bezzola P et al., Efficacy of an Alpha-Hydroxy Acid (AHA)-based Cream, even in Monotherapy, in Patients with Mild-Moderate Acne, Giomala Italiano di Dermatologia e Venereologia, June 2010 29. American Academy of Dermatology Association, Acne Clinical Guideline <www.aad.org/guidelines/acne> 30. Nast, A, Dreno B, Bettoli V, Bukvic Mokos Z, Degitz K, Dressler C, Finlay AY, Haedersdal, M, Lambert et al., European Evidencebased (S3) Guideline for the Treatment of Acne – update 2016, Journal of the European Academy of Dermatology and Venereology 31. Russell JJ, Topical Therapy for Acne, American Family Physician, Jan 2000 32. Costa CS, Bagatin E, Evidence on Acne Therapy, Sao Paula Medical Journal 2013 33. Thiboutot D et al., Adapalene Gel 0.3% for the treatment of Acne Vulgaris: a multicentre, randomised double-blind, controlled, phase III trial, Journal of the American Academy of Dermatology, Feb 2006 34. Kollo SS, Pecone D, Pona A, Cline A, Feldman SR, Topical Retinoids in Acne Vulgaris, American Journal of Clinical Dermatology, June 2019 35. Pugashetti R, Shinkai K, Treatment of Acne Vulgaris in Pregnant Patients, Dermatologic Therapy July-Aug 2013 36. Kraft J, Freiman A, Management of acne, Canadian Medical Association Journal, April 2019 <https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3080563/>

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

Advertorial SkinCeuticals

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NEW CUSTOM D•O•S•E from SkinCeuticals The unique personalised skincare experience designed for your patients’ skin SkinCeuticals Custom D•O•S•E technology is an innovative skin correction programme. It enables skincare professionals to create a tailor-made serum, formulated in clinic, matched to each individual patient’s skin needs. Combining active ingredients, usually only produced in a factory setting, it allows skincare professionals to produce a single, personalised serum on the spot that can address multiple skin concerns such as fine lines, discolouration and loss of elasticity to improve skin health and quality. Custom D.O.S.E was created to meet growing demands from consumers for personalised skincare regimens and allows skincare professional to offer a unique service which encourages high patient loyalty and satisfaction. “Our customers are consistently concerned with skin ageing and discolouration, among various skin conditions that require a personalised approach to address them,” said Leslie Harris, Global General Manager of SkinCeuticals. “The D•O•S•E technology empowers skincare professionals to co-create personalised formulas that address patients’ unique skincare needs in minutes. We’ve created a better ecosystem for them to offer enhanced experiences for their patients using technology to address specific skin concerns.”

formulated there and then in clinic. The skincare expert recommends a treatment plan that contains the corrective D•O•S•E serum and a corresponding regimen which can be adjusted over time based on the patient’s progress, seasonal changes and planned aesthetic procedures.

Proven ingredients During the development of the technology over 250 skin types were analysed when selecting the active ingredients to include in D•O•S•E, creating dozens of unique ingredient combinations. Each ingredient contained in the D•O•S•E formula is proven effective on different skin types and tones. Custom D•O•S•E starts with a simple hydro base or a light milky emulsion base, with additional active ingredients then added according to the Custom D•O•S•E diagnostics and based on the skincare professional’s expert recommendations. Custom

How does CUSTOM D.O.S.E work in-clinic? Patients discuss their skin concerns with their skincare professional and undergo a diagnostic test to assess their skin’s specific biological and environmental characters that make their skin concerns unique. The data is transferred to the Custom D•O•S•E machine and serum is

“The D•O•S•E technology empowers skincare professionals to co-create personalised formulas that address patients’ unique skincare needs in minutes” Leslie Harris, Global General Manager, SkinCeuticals

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Advertorial SkinCeuticals

The Technology More than 85,000 lines of code process data from a tablet led professional skin assessment. 1,227 unique mechanical parts dispense and mix serum. 1,200 rotations per minute yield industrial quality compounded formulas. 500 subjects clinically tested for product safety, efficacy and perception. More than 250 combinations of skin traits considered when selecting key ingredients .

“The service has greatly enhanced our clinic’s offering for patients, who love that they can have a bespoke serum created in minutes” Mr Matt James, MB, ChB, FRCS ( eng ), FRCS (plastics), BAAPS BSSH Co Founder of Cavendish Clinics

TESTED IN PRACTICE D•O•S•E currently has 12 highly concentrated ingredients chosen for their efficacy in treatment of discolouration and related signs of ageing to promote exfoliation, skin brightening and skin firmness.

SKIN EXFOLIATION

• • • •

Glycolic Acid: helps facilitate the skin’s natural exfoliation and minimises the build-up of dead skin cells to improve the skin tone and texture Lactic Acid: a good humectant which helps exfoliate dry, dull surface cells to reveal more youthful skin Phytic Acid: a multifunctional acid that is capable of trapping and sequestering metal ions and plays a role in supressing lipid peroxidation Hepes: a gentle exfoliant that helps to refine skin texture and promote even skin tone

SKIN BRIGHTENING

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Liquorice Root Extract: promotes even skin tone and minimises the appearance of discolouration Mulberry Extract: helps minimise the appearance of discolouration and promotes a fresh-looking complexion SymWhite: helps brighten the skin to prevent the appearance of discolouration by suppressing excess melanin production

SKIN FIRMNESS

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ProXylane: supports skin’s matrix and improves skin firmness Retinol 0.1%-0.3%-0.5%: helps improve the appearance of ageing skin, by evening out skin tone, promoting cell turnover and reducing fine lines and wrinkles

SkinCeuticals Custom D.O.S.E has been rigorously tested in clinic by leading skincare experts in London. Dr. Stefanie Williams, Dermatologist & Medical Director at Eudelo who were the first clinic in the U.K. to launch CUSTOM D.O.S.E says “I love the SkinCeuticals DOSE system, as it allows us to tailor and customise Eudelo patients’ serums to their individual needs. Plus - the design looks amazing!”. The service has since launched in selected clinics across the U.K. including Cavendish Clinic in Kensington, Mr Matt James Plastic Surgeon and Co-Founder of Cavendish Clinics says “We are thrilled to have launched SkinCeuticals Custom D.O.S.E. at Cavendish Clinic. The service has greatly enhanced our clinic’s offering for patients, who love that they can have a bespoke serum created in minutes which is tailored to their skin needs, we can evolve the formula as their skin needs change over time. Our patients love it and it has greatly enhanced our clinic’s offering.” Dr Martyn King of Cosmedic Skin Clinic, in Staffordshire says “Cosmedic Skin Clinic is thrilled to be one of the first clinics in the country to launch SkinCeuticals Custom D.O.S.E. Following a skin analysis and consultation with one of our skincare experts, we are able to recommend, formulate and deliver the perfect product for our patient’s needs. Combining the science, clinical research, highly potent active ingredients and the very best quality that we have come to love and expect from SkinCeuticals, we are able to produce bespoke serums to deal with a wide range of skin concerns including sun-damage, pigmentation, lines and wrinkles, ageing, acne, inflammation, pores and uneven skin tone and texture. The SkinCeuticals Custom D.O.S.E. machine is a work of art and patients love to see their own formula being produced in front of their eyes and individually labelled and packaged for them. The feedback has been amazing and our patients love that we are not just selling a product, we are providing a unique, tailored treatment in a bottle.” For more information on Custom D•O•S•E contact us at Email: contact@skinceuticals.co.uk Twitter: @SkinCeuticalsUK Instagram: @skinceuticals_uki

Aesthetics | December 2019

THE WORLDâ&#x20AC;&#x2122;S MOST

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A summary of the latest clinical studies Title: Inadvertent Intra-Arterial Injection of Deoxycholic Acid: A Case Report and Proposed Protocol for Treatment Authors: Lindgren AL, Welsh KM Published: Journal of Cosmetic Dermatology, November 2019 Keywords: Deoxycholic acid, Vascular Occlusion, Injectables Abstract: Deoxycholic acid (ATX-101) is a secondary bile acid that was approved as an injectable drug for the reduction of submental fat. Necrosis, an uncommon but serious adverse event, can occur due to inadvertent superficial injection or intra-arterial injection of the acid. The management of the intra-arterial injection of deoxycholic acid has not been well characterized. Here, we discuss methods to decrease the risk of such injections and draw on existing protocols for the inadvertent intra-arterial injection of sclerotherapy solutions and dermal fillers to propose a safe, practical approach to treatment. A case report is presented of a 42-year-old woman who received a deoxycholic acid injection for the correction of submental fullness, which was complicated by the inadvertent intra-arterial injection of the acid. The adaptation of published treatment protocols for the inadvertent injection of sclerosing solutions and dermal fillers allowed for a good outcome in this patient. The inadvertent intra-arterial injection of deoxycholic acid is a rare event. The risk of such injections can be reduced with attention to injection technique and can be managed successfully following the adaptation of protocols in the literature for similar events from vascular compromise due to dermal fillers and sclerosing solutions. Title: An Open-Label, Intra-Individual Study to Evaluate a Regimen of Three Cosmetic Products Combined with Medical Treatment of Rosacea: Cutaneous Tolerability and Effect on Hydration Authors: Santoro F, Lachmann N Published: Dermatology and Therapy, October 2019 Keywords: Rosacea, Skincare, Hydration Abstract: Although rosacea management includes general skincare, previous studies have not evaluated comprehensive skincare regimens as adjuvants to other treatments.The primary objective of this open-label, intra-individual study of subjects with rosacea was to evaluate the cutaneous tolerability of a regimen consisting of Cetaphil PRO Redness Control Day Moisturizing Cream (once daily in the morning), Cetaphil PRO Redness Control Night Repair Cream (once daily in the evening) and Cetaphil PRO Redness Control Facial Wash (foam once in the morning and once in the evening). Secondary objectives were to evaluate the effect on transepidermal water loss (TEWL) and cutaneous hydration and to determine the subjects’ evaluation of efficacy, tolerability and future use. A dermatologist examined subjects and measured TEWL and cutaneous hydration on day (D) 0, D7 and D21, when subjects ranked symptoms. Subjects completed a questionnaire on D21. The per-protocol population consisted of 42 subjects receiving treatment for rosacea. Eleven subjects developed adverse events, none of which were considered to be related to the skincare products. Five subjects showed signs or symptoms that were potentially associated with the skincare products that might

suggest poor cutaneous tolerability; these were generally mild. TEWL decreased significantly by a mean of 17% on D7 and a mean of 28% on D21 compared with baseline (both P < 0.001). Skin hydration increased significantly by a mean of 5% on D7 (P = 0.008) and a mean of 10% on D21 (P < 0.001) compared with baseline. Subjects reported that the regimen was pleasant (98%) and effective (95%) and that it offered various benefits; 90% of subjects reported that they would like to continue to use the regimen and would buy the products. The skincare regimen improved skin hydration and skin barrier function in subjects receiving medical treatment for rosacea and was well tolerated. Title: Botulinum Toxin Type A Injection-related Suppurative Granuloma: A Case Report Authors: Thanasarnaksorn W et al. Published: Journal of Cosmetic Laser Therapy, 2019 Keywords: Botulinum toxin, Granuloma, Complication Abstract: Botulinum toxin type A (BoNTA) injection has become increasingly popular for esthetic minimally invasive procedures worldwide, owing to its efficacy and safety. Serious and longterm complications are rare. Here, we report a case of painless skin-colored cutaneous nodules on the face that developed a few days after BoNTA injection. The histopathology revealed a suppurative granuloma which yielded negative results for all organisms on histochemical staining and tissue culture. While waiting for the results of polymerase chain reaction (PCR), we started administration of systemic broad-spectrum antibiotics that were effective against atypical mycobacteria, since suppurative granuloma is usually related to mycobacterial infection, and a negative result of histochemical staining is common among these organisms. The nodules were flattened down after antibiotics started 6 weeks. All lesions were clear without any scar after 6 months of treatment. Title: The Facial Fat Compartments Revisited: Clinical Relevance to Subcutaneous Dissection and Facial Deflation in Face Lifting Authors: Stuzin JM et al. Published: Plastic Reconstructive Surgery, November 2019 Keywords: Fat Compartments, Facial Rejuvenation, Technique Abstract: The facial fat compartments were described over a decade ago, but their clinical relevance to both deflation and techniques in facialrejuvenation is underappreciated. Although much of the literature following their description has focused on further anatomical elucidation of compartment anatomy, clinical relevance has focused on volumetric compartment augmentation. From the authors perspective, understanding compartmentalization of facial fat provides an anatomical roadmap of the facial subcutaneous plane and a patient-specific guide for the degree of skin flap dissection in facial rejuvenation. The compartmentalization of facial fat also explains the regional development of cheek deflation in aging. An individualized treatment plan to restore facial shape can be achieved with deep compartment volume augmentation and repositioning of superficial facial fat using the superficial musculoaponeurotic system.

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Understanding Clinical Negligence Lawyer Dr Bib Vhadra outlines the three main elements involved in a negligence claim and discusses the case law involved in them One of the most common legal challenges that any clinician faces is an action in clinical negligence; this is no different for an aesthetic practitioner and the same basic legal rules and principles would apply. However, it is often misunderstood what a claim in clinical negligence involves and what a patient (or claimant) would need to prove in order to succeed in a claim of clinical negligence.

The law of negligence The law of negligence has developed incrementally over time through legal precedents established by the courts and is a subset of a body of civil law known as tort.1,2 The law of tort involves the infringement of a legal right or a legal duty and governs what occurs when one party sues another party for an infringement of that right or duty. The party bringing the case (or the ‘claim’) is known as the ‘claimant’ and the party against whom the case is brought is known as the ‘defendant’.1 In simple terms, negligence can be defined as a breach by a defendant of a legal duty of care owed to a claimant that results in actionable damage or loss to the claimant unintended by the defendant. An analysis of this definition indicates that there are three main elements involved in a claim for negligence:1 1. Duty of care 2. Breach of duty 3. Causation

These elements would also apply to a clinical negligence claim against an aesthetic practitioner and, as in all negligence claims, the burden falls on the claimant to prove all these elements, to a standard known as ‘the balance of probabilities’.2 This means that the claimant is required to prove to a court that it is more likely than not that the elements of negligence are satisfied. Or in other words, that there is a greater than 50% probability that these elements are satisfied. Duty of care The first element in a negligence claim involves proving that the defendant owed the claimant a duty of care. A duty of care can be defined as a legal obligation, which is imposed on a party, requiring adherence to a standard of reasonable care in situations that could foreseeably harm others.3 The principles of the imposition of a duty of care have had a protracted evolution in the courts. A milestone in the development of duty of care came with the well documented House of Lords’ decision in Donoghue v Stevenson in 1932.4 Although, up until that point, there existed contractual obligations regarding the performance of a contract with reasonable care and skill, there was no real test for a duty of care to individuals that may not be party to a contract. The decision in Donoghue v Stevenson determined the principles upon which the law of negligence is based. The facts

of the case involved the claimant (Mrs Donoghue) suffering gastroenteritis and shock as a result of drinking ginger beer that was contaminated with the remains of a decomposing snail.4 The claimant was unable to bring an action against the manufacturer or the vendor in contract law since she was not a party to any contract, as she had not bought the offending bottle of beer herself (it was bought for her by a friend).4 The difficult issue that the House of Lords were required to decide was whether the defendant (in this case the manufacturer of the ginger beer) owed any duty of care to the end user and, more generally, in what cases or circumstances a party would owe a duty of care to another party.4 The House of Lords held by a majority of 3:2 that the claimant’s case disclosed a cause of action. The court held that a manufacturer does owe a duty of care to an end user. More importantly, the Lords also established the ‘neighbour principle’ in order to determine whether a defendant would owe a duty of care in any novel situation that would arise and require determination before a court.4 This test, outlined by Lord Atkin in his judgement, indicates that there must be a close relationship or proximity between defendant and claimant; this is not proximity in the physical interpretation of the word, but in the sense that the other party is in mind when undertaking a particular act. This neighbour test was the test adopted by the courts in determining whether any given novel situation gives rise to a legal duty of care. The test for establishing a duty of care in novel situations was further developed in the House of Lords’ decision in Caparo Industries PLC v Dickman in 1990.5 The facts of Caparo involved an action against the defendant accountants (Dickman) by the claimant shareholders, alleging that the defendants owed the claimants a duty of care in producing an audit report, required by statute.5 The claimants had bought shares in a company, as part of a takeover, relying on the audit report produced by the defendant. However, it was later found that the company profits were misrepresented in the audit report, causing the claimant loss.5 The House of Lords reversed the decision of the Court of Appeal and held that no duty of care had arisen in relation to existing or future shareholders; in doing so, the House of Lords established a tripartite test for determining whether a duty of care is owed in a novel situation, re-defining the neighbour principle in Donoghue v Stevenson.4 The three questions that needed to be considered as

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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part of the three-part test in the determination of duty of care were: 1. Whether there is reasonable foresight of harm to the claimant 2. If there is sufficient proximity of relationship between the claimant and the defendant 3. Whether it is fair, just and reasonable to impose a duty In terms of a clinical negligence claim, it is more than often established that a clinician owes a patient a duty of care and is rarely in dispute between parties. This established duty of care extends to a number of clinical situations, and may include, amongst others: 1. Correctly assessing a patient’s condition, considering any symptoms and patient’s views and conducting an appropriate examination and tests 2. Working within the limits of personal competence 3. Disclosing any material risks involved with any recommended treatment 4. Advising of any reasonable alternative or variant treatments 5. Keeping professional knowledge and skills up to date 6. Maintaining accurate, clear and legible records 7. Consulting and taking advice from colleagues and specialists where needed 8. Referring a patient to another practitioner, when in the patient’s best interests6 However, there may be situations which the courts may not have encountered before, especially in a rapidly expanding field such as aesthetic medicine; in these cases, known as novel duty situations,7 the tests outlined above would be used by the courts to determine whether a clinician owes a duty of care to a patient for that given situation. Breach of duty Once it is established that a duty of care exists, the second stage in a negligence claim is to consider whether the defendant breached that duty of care. In determining this, the claimant is required to prove that the defendant failed to reach a standard required by law to fulfil that duty.8 In general, a two-stage test is employed to determine whether a claimant has breached their duty of care: 1. The courts would assess what standard of care the defendant should have exercised (a question of law)

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2. Whether the defendant fell below the standard of care that they should have exercised (a question of fact) In assessing the standard of care, in a normal negligence case where the defendant may not be a clinician (or what is known as a skilled defendant), the test derives from the case Blyth v Birmingham Waterworks9 where it was stated, ‘Negligence is the omission to do what the reasonable man would do, or do something that the prudent or reasonable man would not do’. Hence it can be seen that the general standard of care that a defendant must meet in order to discharge their duty of care is that of the ‘reasonable man’ or rather, the ‘reasonable person’. In the case Glasgow Corp v Muir,10 Lord MacMillan clarified that the reasonable person test is objective and impersonal. Furthermore, it is not a question of the defendant doing their utmost or achieving the highest standard of care in discharging their duty, but simply to come up to the standard of the reasonable person. However, the situation is slightly different when considering a skilled defendant such as a clinician. The test for the standard of care for a skilled defendant comes from the 1957 case Bolam v Friern Hospital Management Committee.11 The facts of this case involve the claimant (Mr Bolam) agreeing to electroconvulsive therapy as a voluntary patient at a hospital run by the defendant (Friern Hospital Management Committee). However, Mr Bolam was not given any muscle relaxant and not restrained during the procedure; unfortunately during the procedure Mr Bolam flailed around violently, suffering serious injuries including a fracture of the acetabulum.11 Mr Bolam sued the defendant hospital management committee on the basis that they were negligent in not administering muscle relaxants, not restraining him and not advising him of the risks involved. The problem that the court faced in determining breach of duty in Bolam was the standard that the skilled defendant should have exercised in treating the claimant. The court, in this case, modified the normal ‘reasonable person’ test and ruled, ‘A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a reasonable body of medical men skilled in that particular art. A doctor is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion which takes a contrary view’.11 This test, known as the Bolam test, essentially stipulates that for a claimant to prove that

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a clinician breached their duty of care, they would need to prove that the clinician acted in a way which was not supported by a reasonable body of medical opinion.4 In practice, this would be achieved through the use of expert evidence and the defendants would seek to offer expert evidence to prove that they were acting in accordance with a reasonable body of medical opinion. The Bolam test has received criticism because it can be perceived that the claimant is disadvantaged; whereas a claimant would be required to prove that there is no responsible body of medical opinion that would have approved of the defendant’s actions, a defendant merely needs to find an acknowledged expert to agree that their actions were within the range of acceptable practice. Furthermore, similar to the reasonable person test, the question in the Bolam test is not whether the defendant’s actions were ideal practice, but whether they were above a minimum level of practice. A number of cases have sought to clarify the Bolam test, one of the most important being Bolitho v City and Hackney Health Authority.12 In this case, the House of Lords held that the courts are not bound to exonerate a clinician just because he brings evidence from a body of medical experts that approve the approach taken, but that, if it is the case that the medical opinion is not capable of withstanding logical analysis, then the court is entitled to hold that body of medical opinion as unreasonable.12 It is important to note, that breach of duty regarding the disclosure of risk is now not governed by the Bolam test since the decision in Montgomery v Lanarkshire, which ruled that clinicians had a duty of care to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment.13 Causation The third stage in a negligence claim would be to consider causation. Once it had been established that the defendant owed the claimant a duty of care, and that the defendant had breached that duty of care, then the claimant would be required to prove, on the balance of probabilities, that the breach of duty actually caused the damage or loss that the claimant suffered, and that it was not too remote.14 The general test for causation is known as the ‘but for’ test and stems from the decision in the case Barnett v Chelsea and Kensington Hospital Management Committee.15 The facts of this case involve three night watch-men attending the defendant hospital at 8am

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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complaining of nausea after drinking tea earlier at 5am. The casualty officer on duty refused to see the patients, advising a nurse over the phone to tell the patients that they should go home and see their own doctors. It transpired later that the night watchmen had sustained arsenic poisoning and one of them, Mr Barnett, died later in the day. Mr Barnett’s widow brought a claim against the defendant hospital for negligence.15 However, the courts dismissed the claim and found that the defendants were not negligent. Although the defendants were negligent to the extent that they had breached their duty of care, through the casualty doctor failing to attend to Mr Barnett, expert evidence was admitted that even if the patient was seen, admitted and treated, he would have died in any event.15 Therefore it was found that although the defendants had breached their duty of care to the claimant, this had not caused his death, hence the claim failed on causation. The ‘but for’ test for causation, can simply be summarised as, ‘But for the defendant’s breach of duty, on the balance of probabilities, would the harm claimed for have been sustained by the claimant?’16 If the claimant would not have sustained the harm claimed for, but for the defendant’s breach of duty, on the balance of probabilities, then causation would be satisfied on this level. However, if the claimant would have sustained that harm, in any event, despite the defendant’s breach of duty, then causation would fail, as was the case in Barnett v Chelsea and Kensington.15 An important issue when considering causation is the concept of remoteness. The harm suffered or caused by the defendant’s breach of duty must not be too remote in order for it to be recoverable in a claim for negligence. The test for remoteness was established by the case known as The Wagon Mound.17 In simple terms, the case established that in order for the damage to be recoverable it must have been reasonably foreseeable at the point of breach of duty. Remoteness in relation to causation has been further developed through subsequent case law, to include (for example) rules that will allow recovery of damages even if the exact injury was not foreseeable but the type of injury was foreseeable18 and also rules that extend liability, even if the full extent of harm was not foreseeable.19

Recommendations for best practice There are a number of steps that the aesthetic practitioner can take to reduce their

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risks and exposure to a clinical negligence claim. These steps would generally need an examination of their individual clinical practice and the potential breaches of their duty of care and how these can be avoided or at least minimised. For example, these steps could include but shouldn’t be limited to: • Conducting a thorough examination paying special attention to presenting complaints and concerns, so that all treatment options can be offered and a full disclosure of material risks involved with each treatment option • Managing expectations and not overselling treatments • Taking a full medical history, including a history of previous aesthetic treatments and any adverse reactions • Obtaining written informed consent, disclosing all material risks. In this context the test of materiality is whether, in the circumstances, of the particular case: ⊲⊲ a reasonable person in the patient’s position would be likely to attach significance to the risk ⊲⊲ or the practitioner is or should reasonably be aware that the particular patient would be likely to attach significance to it • Maintaining accurate, legible contemporaneous records documenting all discussions and communications with patients, treatments, dosages and equipment settings • Taking pre- and post-operative photographs and storing these safely • Practicing within the scope of one’s competence, ensuring adequate training and experience is gained in treatments offered and the management of any potential complications • Referring a patient when in their best interests to do so • Using products and carrying out treatments only within their specified guidelines • Encouraging patient to follow postoperative guidelines, providing these in writing and documenting the same • Maintaining confidentiality at all times. If there is a requirement to divulge details of a patient’s treatment (e.g. in the event of an adverse reaction), to obtain the patient’s written consent first If problems do arise, the reasons for patients to embark on litigation against a clinician are numerous and often multifactorial; the first port of call for any aesthetic practitioner

would be their indemnity insurance provider. Although there may be any number of defenses available for any particular clinical negligence claim, all stakeholders would agree that, similar to the age-old adage ‘prevention is better than cure’, minimising and avoiding the risk of adverse events and associated litigation is always preferential.

Conclusion The rules pertaining to clinical negligence are both complex and constantly evolving, especially in a rapidly advancing field such as aesthetic medicine. It is of paramount importance to all aesthetic practitioners to be aware of the basic legal rules that govern a clinical negligence claim and to maintain a practice that is risk-averse. Dr Bib Vhadra completed his initial undergraduate training at King’s College Hospital School of Medicine and Dentistry and has more than 20 years experience in providing cosmetic treatments. He is the clinical director at First Aesthetics in Guildford, Surrey and is passionate about patient safety, medical law and the ethical provision of aesthetic treatments. Dr Vhadra also holds a law degree and has undertaken training as a barrister, being called to the bar in 2014. REFERENCES 1. Jones MA, Dugdale AM, Simpson M, Clerk and Lindsell on Torts, 22ND edition, Chapter 8, Sweet and Maxwell Ltd, 2017 2. Kestemont L, Handbook on Legal Methodology: From Objective to Method, Intersentia publishers, 2018 3. Jones MA, Dugdale AM, Simpson M, Clerk and Lindsell on Torts, 22ND edition, Chapter 8, Sweet and Maxwell Ltd, 2017 4. E-lawresources.co.uk, Donoghue v Stevenson, 1932 <http:// www.e-lawresources.co.uk/Donoghue-v-Stevenson.php> 5. E-lawresources.co.uk, Caparo Industries v Dickman, 1990 <http://e-lawresources.co.uk/cases/Caparo-Industries-vDickman.php> 6. Powers M, Barton A, Jacson B, Powers and Harris Clinical Negligence, 5th edition, 2015 7. Jones MA, Dugdale AM, Simpson M, Clerk and Lindsell on Torts, 22ND edition, Chapter 8, Sweet and Maxwell Ltd, 2017 8. Jones MA, Dugdale AM, Simpson M, Clerk and Lindsell on Torts, 22ND edition, Chapter 8, Sweet and Maxwell Ltd, 2017 9. Casebriefs.com, Blyth v Birmingham Waterworks <https:// www.casebriefs.com/blog/law/torts/torts-keyed-to-prosser/ negligence/blyth-v-birmingham-waterworks-co/> 10. Webstroke.co.uk, Glasgow Corp v Muir, 1943 <https:// webstroke.co.uk/law/cases/glasgow-corp-v-muir-1943> 11. E-lawresources.co.uk, Bolam v Friern Hospital Management Committee, 1957 <http://www.e-lawresources.co.uk/Bolam-v-Friern-Hospital-Management-Committee.php> 12. E-lawresources.co.uk, Bolitho v City & Hackney Health Authority, 1997 <http://www.e-lawresources.co.uk/Bolitho-vCity--and--Hackney-Health-Authority.php> 13. https://www.supremecourt.uk/cases/docs/uksc-2013-0136judgment.pdf 14. Jones MA, Dugdale AM, Simpson M, Clerk and Lindsell on Torts, 22ND edition, Chapter 8, Sweet and Maxwell Ltd, 2017 15. E-lawresources.co.uk, Barnett v Chelsea and Kensington Hospital, 1969 <http://www.e-lawresources.co.uk/Barnett-vChelsea--and--Kensington-Hospital.php> 16. Jones MA, Dugdale AM, Simpson M, Clerk and Lindsell on Torts, 22ND edition, Chapter 2, Sweet and Maxwell Ltd, 2017 17. https://www.lawteacher.net/cases/overseas-tankship-v-mortsdock.php 18. E-lawresources.co.uk, Hughes v Lord Advocate, 1963 <http:// www.e-lawresources.co.uk/Hughes-v-Lord-Advocate.php> 19. Lawteacher.net, Defence in an accident claim, February 2018 <https://www.lawteacher.net/free-law-essays/contract-law/ defence-in-an-accident-claim-contract-law-essay.php>

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to avoid breaching patient confidentiality and expected professional standards.8 This means making sure that we do not post negative statements on our social media profiles about patients, even if anonymised, to avoid bringing the profession into disrepute. The standards set by all professional bodies make particular reference to the sharing of information and anonymising data.6,7 The JCCP has also recently published its own guidelines on the use of social media, which combine the results from the various medical bodies; practitioners should familiarise themselves with this guidance as well as their own individual specialty guidance. 9

Conversational tone

Staying Professional on Instant Messenger Dr Stevie Potter discusses how to keep communications across social media instant messaging applications professional There are currently more than three billion social media users across the world, the majority of whom access their platforms on a mobile device. Usage has increased by 10% since 2018,1 so it is therefore easy to see why businesses turn to social media as their first point of call for advertising and communication. Additionally, the return on investment can be considerable.2 Platforms such as Facebook and Instagram also come with their own direct message functions, to make patient-practitioner communication easy and accessible at any time of day. Snapchat, Instagram, Facebook and Whatsapp are attractive as a free method of communication, where people can make contact easily and instantly, as well as being able to share files and pictures in one place.3 Not only do social media platforms provide an enticing deal to aesthetic businesses, but patientsâ&#x20AC;&#x2122; perspectives in the 21st century mean that medical practitioners having online visibility also appear more credible, trusted sources than those without a presence on social media.4 These platforms have their place in business and can enhance the provision of healthcare,5 which could therefore extend to aesthetic medicine but, in using such platforms, we must be mindful of the need to maintain our professional standards and communicate

appropriately. In this article, I explore whether direct messaging systems come with implications for the patient-clinician relationship and discuss how we can ensure that we remain available and professional to our patients, without allowing invasion of our private lives, which is something that I think we are all too guilty of.

Current guidelines The General Medical Council (GMC) identifies benefits in the use of social media (e.g. spreading of helpful preventive care advice) but also reminds doctors that it can be difficult to maintain professionalism in online communications, despite their duty to do so.6 The Nursing and Midwifery Council (NMC) has a similar stance on maintaining boundaries with patients and also recognises that online communication can make this complicated. 7 The General Dental Council (GDC) gives some further explanation of the problems that may be faced in using social media and how they are relevant to the councilâ&#x20AC;&#x2122;s standards for professionals; the expected behaviour of a dentist is not altered just because the format for communication is not a traditional one.8 The GDC points out that anything published on social media can become instantly public, so may carry a need for stricter adherence to guidelines

In my experience, the use of language across instant messaging applications and social media in general is far more throwaway and informal than that used in the faceto-face consultations, phone conversations and emails that I use on a daily basis. People often use colloquial language, abbreviations and emojis, regardless of their relationship with the recipient. Patients have no particular standards to abide by and no frameworks for guidance in communication with clinicians, so it is our job to set the example in our conversations on social media. If we consider the need to remain professional when dealing with instant messaging, we should be steering the conversational tone toward a manner we would find acceptable within our own clinic. We should also remember that the emphasis and attitude with which words are delivered can be lost in written communications, and so we need to think about how our messages can be interpreted when we are communicating with patients on social media. For example, when dealing with questions about post-operative symptoms, we should ensure we remain sympathetic and not dismissive, with the best course of action always being to reassure and invite patients for a face-to-face appointment if the issue is more severe. While I recognise that it is important to make patients feel at ease and provide an approachable, personal bedside manner, we should treat all forms of written communication as a reflection of our profession and act with the expected demeanour to avoid us blurring the professional/personal boundaries.

Sensitive information Aesthetics professionals in particular must accept responsibility for any material that they upload onto social media and consider

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Summary Taking a step back When using social media for our practice, we should not only be mindful of the benefits and risks to our patients, but also to our own lives. In a society where business pages are rated by their responsiveness to instant messaging and replies are judged in average minutes taken to respond,12 it is no wonder that clinicians feel compelled to answer messages at any time of day, in any circumstance. We are all entitled to a private life and we are responsible for ensuring we separate our private and professional relationships, which extends to the hours and environments we answer our communications in. We are constantly reminded to ensure we have down time from our digital devices to avoid being overwhelmed;13 with mobile devices being such a key part of our personal and professional lives now, this can often be difficult. Using functions such as ‘away’ on Facebook messenger to ensure we have timetabled down time can be helpful, while still providing an emergency contact detail can help us rest easy that patients are not being left out in the cold in an urgent situation. It is also important to ensure patients are given a definitive time scale for your planned response, so include the hours during which you will respond in your automated reply. Organisations that can answer urgent phone calls while clinic owners are out of the office or otherwise engaged can also give patients a reassuring alternative channel for communication outside of social media platforms.

posts as permanent additions to the public sphere, due to the difficulties in erasing media from the internet.9 This means that we should also consider the implications of sending pictures such as before and after photos to patients, even in private messenger formats, as there is potential for breaches in privacy if our business media accounts are accessed from our personal mobile devices.14 Transparency in the profession is important and patients should be allowed access to their records, including photographs, but it is worthwhile taking a brief moment to ensure they are aware of the limitations in security involved with instant messenger functions. Patients can then decide whether they would prefer to receive their data via more secure channels such as email servers or certain time-limited document sharing services e.g. expiry times on Dropbox links. Patients should be discouraged from discussing their private information (such as in depth treatment details and medical history) in detail online and this should be extended to their use of instant messaging, as the risk of dissemination of this material through intention or accident is high.10 Encouraging patients to avoid discussing such topics online may also help avoid the situation of complaints arising in this sphere. This does not mean placing a gagging order on all our patients, but simply discussing with them at their first consultation how you find it best to communicate and a brief explanation of why it is more appropriate to discuss more detailed issues in person or over the phone or even video call.

Negative feedback Medical professionals have clear guidance on how they are expected to react to feedback and complaints in their sector6,11 and this guidance can be carried into the field of aesthetics. Professionals are advised that they must have a clear, written complaints procedure, which is visible to patients.11 When patients are using social media, it is likely they are not accessing this procedure and so they may not be able to process their feedback through the correct channels. Likewise, when we receive negative feedback outside of our usual professional context, often we are less likely to treat this in the same way we would in a faceto-face or written format. This can lead to complaints not being dealt with in the correct way and escalating unnecessarily. Similarly, with the availability of social media on mobile devices, patients may find themselves more readily raising concerns about minor issues using these channels, as they are less confrontational and much more flippant. We also run the risk of having complaints and responses disseminated into the public sphere. When we do find ourselves thrown negative feedback on social media platforms, it is therefore sensible to guide our patients down a more formal route, rather than engaging in a conflict which may not be so reasoned in its approach. Inviting patients in for a chat in person about their concerns may be considered more professional and caring than a response on social media.

While social media presents benefits to growing our aesthetics businesses, offering open preventive advice and information, along with an easy communication channel for current and potential patients, we should be mindful of the pitfalls of informal, instant messaging. We are responsible for maintaining an appropriately professional relationship to ensure we do not encroach on our own private lives or bring our specialty into disrepute. We also need to be aware of the risks of breaching patient confidentiality on social media and act responsibly with regard to the sharing of patient information and photography. Scheduling away time for applications on our mobile devices and using automated message functions with details of emergency contacts, can help us get the most from our social media platforms without blurring the lines of professional relationships. Dr Stevie Potter is a dentist, graduating from Newcastle University in 2013. She started working in aesthetics in 2015 and is now aiming to complete her combined aesthetic medicine training with Harley Academy in spring 2020. Dr Potter runs her own aesthetics clinic, The Wonder Clinic from her dental surgery in Axminster. REFERENCES 1. S Kemp, Digital trends 2019: Every single stat you need to know about the internet, 2019 <https://thenextweb.com/ contributors/2019/01/30/digital-trends-2019-every-single-stat-youneed-to-know-about-the-internet/> 2. D. J. Gould, S. Nazarian, “Social Media Return on Investment: How Much is it Worth to My Practice?,” Aesthetic Surgery Journal, vol. 38, no. 5, pp. 565-574, 2018 3. E. Madudova, J. Fabus, “A Study of Consumer Behaviour of Active Usage of Instant Messaging Applications,” International Journal of Economics, Business and Management Research, vol. 1, no. 5, pp. 350-357, 2017 4. C. L. Ventola, “Social Media and Health Care Professionals: Benefits, Risks, and Best Practices,” Pharmacy and Therapeutics, vol. 39, no. 7, pp. 491-499, 2014 5. C. Hawn, “Take Two Aspirin And Tweet Me In The Morning: How Twitter, Facebook, And Other Social Media Are Reshaping Health Care,” Health Affairs, vol. 28, no. 2, pp. 361-368, 2009. 6. General Medical Council, “Ethical Guidance for Doctors,” 2013 7. Nursing & Midwifery Council, “Social Media Guidance,” January 2019 8. General Dental Council, “Guidance on Using Social Media,” 28 June 2019 9. D. Sines, “JCCP Policies and Procedures,” 20 August 2019 <https://www.jccp.org.uk/AboutUs/jccp-policies-and-procedures> 10. W. Lewis, “The symbiotic relationship between aesthetic medicine and social media,” 2016. <https://aestheticsjournal. com/cpd/module/the-symbiotic-relationship-between-aestheticmedicine-and-social-media> 11. General Dental Council, “Standards for the Dental Team,” 30 September 2013 12. Facebook, “How are my response rate and response time defined for my Page?,” 2019. 13. K. Bong, “Avoiding Burnout,” Aesthetics journal, 2016 <https:// aestheticsjournal.com/feature/avoiding-burnout> 14. B. L. Filkins and J. Y. Kim, “Privacy and security in the era of digital health: what should translational researchers know and do about it?” American Journal of Translational Research, vol. 8, no.3, pp. 1560-1580, 2016

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Utilising Brand Photography Photographer Hannah McClune explores the importance of personal brand photography and provides tips on how to get started Photography is a crucial step in building a strong brand in our digital world. If you want patients to take you seriously, then imagery that makes you appear polished and professional is a must. Imagine your ideal patient landing on your website or social media account. If there are no photos, your credibility is limited at best. This article will discuss how personal brand photography can be used to gain new patients and help strengthen your brand values. I will also be sharing some tips on how to do this well, and some key considerations.

What is personal brand photography? There is a common misconception that a personal brand photograph is the same as commercial, corporate, headshot or product photography. However, there is one major difference and that is personality. Personal brand photography involves warm, authentic, real and genuine imagery to show the personality of you and your

brand. Often when you imagine photographs at work for your marketing it is easy to feel restricted to the patient before/after type images, or images of your products or still shots of your clinic. These certainly do have their place; however, personal brand photography is a fresh new take on photographing your business with a personal element. In fact, Instagram posts that feature faces receive 38% more likes compared to those that do not.1,2 It provides a ‘real’ approach that is able to get who you are across to your customers through your images. If they set the right tone and have a professional look, you’ll find your patients can respond really well to more personal imagery. It has even been shown that 78% of consumers trust brands that produce custom content, compared to generic content.3 Personal brand images usually include more of a lifestyle approach, which makes your brand relatable; people love to see what you do and how you are an expert in your

Figure 1: Examples of personal brand photography images. Dr Pamela Benito in yoga gear with the Aesthetics journal, Dr Mayoni Gooneratne in a café, Dr Fiona McCarthy in a café, PR consultant Julia Kendrick reading the Aesthetics journal. Images taken by Hannah McClune.

field. Having photographs that present who you truly are gives an authentic voice to your brand. If your social media and website has poorly taken images it will represent you in an equally poor way. If polished and professional is how you want to be seen, then that is how your pictures must appear to be too. Aesthetic practitioner Dr Pamela Benito says, “In the field of aesthetic medicine, which has grown tremendously over the recent years and where social media has become such an influential tool, we need to understand how important photography is. In my experience, I have realised how important it is for my patients to see not just before and after pictures, but also photos of myself and my lifestyle which seems to have many more likes!” PR consultant Julia Kendrick also recognises the value, having had several brand shoots herself. She says, “Professional brand photography is an essential tool which can really support and amplify the PR and marketing efforts of a business. It allows you to instantly communicate your brand and create an impression among target audiences, giving an immediate overview to your style, values, calibre of services and more!”

Types of relevant images There is always a place for headshots in personal brand shoots; they are something that is a regular request as a business need. However, instead of standing in front of a white or plain backdrop, the setting should be one that fits your brand. That may be a natural, green, clean style with out-of-focus lush tropical plants behind you. Or it may be a polished, high-end vibe. For example, Dr Fiona McCarthy at a gorgeous café in Figure 1. Another example is Dr Amiee Vyas, where her shoot plan included yoga and meditation as this fits with the dream patients she identified. Yet, they don’t often get to see outside of the clinic. When I first chat to aesthetic practitioners we discuss ideas for images that would be relevant to them. The goal of the images is to support your marketing messages. Having a shoot split into three story telling sections works well: 1. Pictures of you working. From consultations to fake procedures 2. Styled content. This could be of products you love, on-brand colour styling pieces, magazines, journals. These should be pieces to tell a story and add interest to an Instagram feed

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Steps to get the most from personal brand photography 1. List what is important to you and for your business 2. Define these with clear brand values 3. Review if those brand values fit with the messages you share in your photographs 4. If yes, high five yourself, well done! It’s not an easy achievement 5. If no, consider who your ‘dream patient’ is 6. Take a variety of images to appeal to that dream patient to show your brand values and reflect your personality too

3. Personality building. These images are the ones that add more ‘you’ to the feed. If you love flowers, shoot at a florist. If you encourage healthy eating, include pictures of you making smoothies. If you like being outside, shoot on a walk. The list goes on! As well as considering the setting, how you pose in the image and where you look is another important factor. Your photographs have the power to ‘break the fourth wall’ between you and your audience.5 That boundary can be crossed with engagement by eye contact. Don’t be afraid to gaze directly into the camera lens; the result can be a stronger connection with your audience.

unique to you. Once you have a clear outline of your top brand values you need to be able to show them clearly. Each image you share must showcase these. For example, if a value is ‘informed’ a few ways you can demonstrate this is with pictures of:

Tips on planning your brand shoot

Consider your dream patient This is all about exploring who you want the images to appeal to. Take some time to really understand and identify your patients. Truly think about the type you’d like to book more of. Picture them in your head and scribble down in as much detail your answers to the following questions:

The types of images taken on your personal brand shoot should be carefully planned out with the goal to appeal to the people you want to attract. If you, your staff or someone you know has skills in photography, then you can take advantage of this, however, if you don’t, perhaps consider in seeking help from a professional photographer. No matter how you do it, one of the very first steps before you get photographs taken is completing a detailed brief. There are two questions that are particularly important for you to consider: what are your brand values and who is your dream patient? What are your brand values? To grow your business, you need to make it simple for your dream patient to be able to see what you stand for, your brand values. Do you know yours? If not, grab a mug of coffee and curl up on the sofa with this article, a pen and notepad. Let your mind wander to answer what it is that is important to you. What has meaning that you want to reflect in your business? Think deeply here; it is easy to choose wonderful, but vague words. For example, honest, friendly, reliable… they sound lovely, but they are not going to get you noticed. Instead, drill down further into what specifically makes those top line terms

• You and a patient talking at a consultation • Close ups of completing health check forms • Explaining the different products they could use • Looking in mirrors together to point out what is possible

• • • • • • • • • • • • • • • • • • •

What is their age bracket? Where do they live? What is their job? What do they earn? How do they spend their free time? Do they have children? Do they have pets? Do they like to travel? What type of holidays do they have? Where do they go out at the weekend? Where do they shop? Where do they go out to eat? Which magazines do they read? What do they read? Which blogs do they read? Which newspapers do they read? What podcasts do the listen to? What social media do they use? What time do they go online? Where do they go to get beauty ideas? Why is it they may want a treatment? Have they had any aesthetic work before? Why would they be nervous about a procedure? Why would they be excited about a treatment?

• What advice might they need? • Where are they going to get referrals? Don’t stop here. Keep writing about your patients and add as many more notes as possible on who they are. Having this list of answers is the first step in all marketing you do. You can understand exactly who it is you are trying to reach with your photographs. By identifying your dream patient, you’ll be able to understand what kinds of imagery will attract the patients you want and, equally as important, turn off the ones you do not want to be working with. It is great to be able to plan your photo shoot with this ‘dream patient’ in mind, which can support content based around the issues you’ve identified patients may have and the advice they may need. Be an expert to their specific needs and someone they can relate to and trust.

Summary People buy from people they know, like and trust.6 It’s the same across all industries and the aesthetics specialty even more so due to the patient wanting to feel reassured before a procedure in what can be a nervous time for them. Building that rapport with patients before they meet you is possible through your photography, so consider the steps detailed in this article to bring out the best in you and your services through imagery. Hannah McClune previously worked in marketing, before becoming a photographer in 2011 and is the owner of Visible by Hannah. Her role involved commissioning photo shoots from the concept and briefing to using the resulting images in global campaigns. She has a BA (hons) in Marketing and a post-graduate diploma from the Chartered Institute of Marketing and Market Research Society certificates. McClune has a holistic approach to how images fit into a business’s wider marketing needs. REFERENCES 1. Omnicore, Instagram by the numbers, 2019 <https://www. omnicoreagency.com/instagram-statistics/> 2. Medium.com, 16 visual content marketing statistics that will wake you up, 2018 <https://medium.com/marketing-andentrepreneurship/16-visual-content-marketing-statistics-that-willwake-you-up-59c4c0b80465> 3. G2, 90 marketing statistics you need to know in 2019, 2019 <https://learn.g2.com/marketing-statistics> 4. Thermopylae Sciences + Technology, Human Process Visual data Better, September 2014 <http://www.t-sciences.com/news/ humans-process-visual-data-better> 5. Alwaysactingup.com, Breaking the 4th wall, <https:// alwaysactingup.wordpress.com/what-is-the-4th-wall/> 6. Burg B, All things being equal, Burg.com <https://burg. com/2010/04/all-things-being-equal/>

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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“There is no doubt that the further study of stem cells and growth factors will change this field” Dr Patrick Treacy shares his adventures throughout his medical and aesthetic career and reminisces on the growth of the specialty “I was captured by Saddam Hussein’s army while working as a doctor in Iraq, delivered a baby at sea while I was a ship doctor off the coast of Mexico, had to have a piece cut out of my leg to debride a HIV needlestick, and experienced conflict first-hand while growing up in Northern Ireland,” tells Dr Patrick Treacy, and the stories go on… It’s hard to believe that someone can fit all these adventures, and more, into one lifetime, while also having an established career in aesthetics. Dr Treacy even became Michael Jackson’s practitioner in 2006, but that is a story best told in his memoir, Behind the Mask, which he published in 2015. “I never speak publicly about my patients, but in Michael’s case, I made an exception because I want to defend him from his detractors and show his human side, a person who always cared deeply about others,” he writes. Dr Treacy’s story began in a small village in rural County Fermanagh, Garrison. He was extremely bright as a child, winning national awards for science and biochemistry, which pre-empted him to study molecular biology at Queen’s University in Northern Ireland. However, he strived to be a doctor, so transferred to medicine at the Royal College of Surgeons in Dublin, graduating in 1986. “I knew medicine was my forte and I really wanted to continue and study plastic surgery but getting into it was quite difficult at the time in Ireland and I also aspired to travel,” Dr Treacy explains. He went on to work as a doctor in countries like Iraq, South Africa, California and New Zealand. While he was in Australia, the use of botulinum toxin was just beginning and was something that interested him, so he completed formal toxin training in Brisbane in 1997. Dermal fillers and the IPL laser were also gaining popularity during this time; Dr Treacy says, “These new modalities really interested me and I was really attracted to helping people with cosmetic injuries and concerns so, when I decided to come back to Dublin in 1998, I opened Ailesbury Clinic. At the time, there were no other clinics in Ireland doing these kinds of treatments, and there were just a few aesthetic clinics in the UK.” The business developed into two successful clinics, which Dr Treacy still runs to this day. He also started separate hair transplant clinics in Serbia, Moscow, Holland, Dubai and Saudi Arabia that franchised to another 20 clinics in India, which he later sold. One of the most memorable experiences in the early days came in 2001; he says, “People were suffering from HIV and, as a consequence, they were getting facial lipodystrophy. I came up with a technique to treat these patients which existed until the new antiviral drugs came forward in 2007.” Dr Treacy has won over 20 medical and innovation awards from across the globe, and is currently a finalist in several others, which

is something he is extremely proud of. However, when thinking about his achievements, he says, “I think one of my biggest has to be establishing the hyaluronic acid protocols for hyaluronidase in 2005 – moving the concept of dosing from the tens to the hundreds, I think, has been pivotal. Also, being asked to speak at international conferences for my research throughout my career in topics such as treating complications, neurological effects of botulinum and accelerating wound repair has been a real highlight.” Although Dr Treacy has been extremely successful in his own right, his top tip for success involves others. He explains, “There are an awful lot of egos in this industry, so I would advise people to stay level-headed, get above the corporate aspect of aesthetic medicine, and always follow a good physician for mentorship. I also believe that practitioners should always keep their colleagues as good friends because you never know when you may need them!” When looking to the future of the industry, Dr Treacy believes new developments in diagnostic technology will change the way practitioners approach their treatments. He adds, “There is also no doubt that the further study of stem cells and growth factors will change aesthetics and allow us to regenerate tissue in a way that we haven’t been able to yet. I think it could even be used to reverse blindness in vascular occlusion cases one day, which would be crucial in this field.” Looking to Dr Treacy’s own future, he says he will continue to strive towards further developments in the field, adding to his list of over one hundred scientific articles. He is also expecting to release a new book next year, which is sure to be filled with more fascinating adventures.

What is your pet hate?

I’m seeing a lot of people learning medicine via social media and advising others when they don’t have the knowledge to consult on the matter, which I don’t agree with.

Any tips for dealing with celebrity patients?

Treat them the same as any other patients, but you do need to be more available. Don’t ever be manipulated by them and don’t give them what they want if it goes against your medical judgement.

What motivates you?

I love giving something back. I do a lot of humanitarian work in countries like Africa and Haiti and I have an incredible level of respect for people who do this. I believe the way out of poverty is education, not money, and if you have a skill you can use it to help others.

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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The Last Word Mr Ayad Harb discusses why he believes the term ‘aesthetic ideals’ is outdated Human faces exhibit infinite variability and perceived physical beauty and are individual, variable, subjective and a mysterious phenomenon. Society has long sought to understand the concept of beauty – to contain it, control it and replicate it. As a cohort of aesthetic practitioners and surgeons, we have developed our own set of aesthetic ideals, extracted partly from evidence-based science but mostly from tabloids, reality television and social media trends. These aesthetic ideals aim to predict facial features which would be judged as beautiful and to try and recreate them through the medium of scalpels, toxins and injectables.

What are aesthetic ideals? The most fundamental aesthetic ideals described are those of facial proportions and symmetry. Concepts of horizontal thirds and vertical fifths, described by Leonardo Da Vinci1 have been adopted into contemporary aesthetic teaching to assess and redesign the distribution of facial features and volume, with the aim of creating harmonious, well balanced and ultimately more beautiful faces. Countless theories have been proposed, by those who all used their anatomical analysis and aesthetic genius to describe ‘ideal’ ratios, lines and planes that contribute to our perception of beauty.2-8 We have even sought to appropriate the golden ratio, Phi, into our system of facial assessment and treatment.9 This mysterious number, denoted by the symbol Φ (phi), an irrational number of the order of 1.618, is ubiquitous in nature and seems to continuously appear when measuring aesthetically pleasing objects, animate or inanimate. Marquardt even created a mathematical model10 – a mask – which could be superimposed onto any face and ‘prove’ that they were, in fact, ugly. The scientists, anatomists and artists of the past, present and undoubtedly, future, who give us these beautiful theories, have all had at their heart, the noble endeavour of making sense of what it is to be beautiful and to wrap it up in a simple formula or procedure. Little did they know, I suspect, that their years of hard work, laborious experiments and facial analysis, would be usurped by a cynical aesthetic industry, trivialised, monetised and sold to the impressionable and insecure.

The flaws in aesthetic ideals There are, of course, shortcomings in many of these rules, including Da Vinci’s ‘five-eyes wide’ theory,1 which we must be aware of in the context of our clinical practice. The first is that they were generally based on, and therefore can only reliably apply to, young, white, female faces. Any deviation in age, gender or ethnicity, makes these ‘ideals’ in my opinion, inaccurate, inappropriate and practically useless. The second, is that many of these rules are based on observations of averages. Take 100 beautiful faces and measure the average lip ratio, nose size, eye shape or cheek projection and that number becomes the ‘ideal’ for a beautiful face. In actual fact, the number is an average and, when applied to a patient’s face, it will probably produce an averagely beautiful result, which is not necessarily a bad thing. That was precisely

what happened with Marquardt’s Phi mask.10 It was technically perfect, based on the divine ratio. And yet, multiple studies have failed to show any correlation between a mathematically beautiful face and perceived facial attractiveness.11

An individual approach Our patient population is incredibly diverse in age, ethnicity, lifestyle and personal preference. Each patient will have their own ideal – I would be uncomfortable and, not-to-mention, wrong, to try and dictate to a patient how her lips should ideally be or try to ‘mansplain’ the concept of cheek contour and ideal facial proportion. Each patient will have their own set of facial characteristics and quirks that make them individual and unique, and any treatment must be sympathetic to these features. Attempting to dogmatically apply a template, or rule learned from a textbook is, in my opinion, a crude and inappropriate strategy which will, at best, produce average results. Furthermore, a colour-by-numbers approach to facial aesthetic treatments could lead to facial disharmony, disproportion and potential clinical risks. Ultimately, there is no mask, ratio, code or line that will fit all faces and there is no short-cut to producing a beautiful result from an aesthetic treatment. There is no ideal. I believe that nothing will replace the traditional skills of listening to your patients’ concerns in order to give them their own ideal result. There is no substitute for careful observation, a trained aesthetic eye and an experienced hand. Ultimately, our perception of facial beauty is a subjective measure and we must therefore trust our own subjective judgement, aesthetic eye or gut-feeling when delivering aesthetic treatments, as much or more than any objective measure or prescribed ratio. There will always remain an element of mysteriousness to beauty, which science has not or perhaps cannot quantify. That, for me, is the beautiful thing about beauty. Mr Ayad Harb is a consultant plastic and aesthetic surgeon, operating in private clinics in London and Bicester, Oxfordshire. Mr Harb specialises in non-surgical rhinoplasty and complex nose correction after surgery. He is an international trainer in medical aesthetics and plastic surgery, as well as a consultant and international KOL for Teoxane. REFERENCES 1. Farkas LG, Hreczko TA, Kolar JC, et al. Vertical and horizontal proportions of the face in young-adult North-American Caucasians: revision of neoclassical canons. Plast Reconstr Surg. 1985;75:328-338 2. Hinderer UT, de Rio Legarreta J. Aesthetic surgery of the malar region. In: Regnault P, Daniel R, eds. Aesthetic Plastic Surgery. Boaston, Little Brown, 1984 3. Peck H, Peck S. A concept of facial esthetics. Angle Orthod. 1970;40(4):284–318 4. Ricketts RM. Esthetics, environment, and the law of lip relation. Am J Orthod. 1968;54(4):272–89 5. Burstone CJ. Charles J. Burston, DDS, MS. Part 1 facial esthetics. Interview by Ravindra Nanda. J Clin Orthod 2007;41:79-87 6. Powell N, Humphreys B. Proportions of the aesthetic face. New York: Thieme-Stratton; 1984. 7. Holdaway R. A soft tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. Am J Orthod. 1984;85(4):279–93 8. Anic-Milosevic A, Mestrovic S, Prlic A, Slaj M. Proportions in the upper lip–lower lip–chin area of the lower face as determined by photogrammetric method. J Craniomaxillofac Surg. 2010;38(2):90–5 9. Prokopakis EP, Vlastos IM, . The golden ratio in facial symmetry. Rhinology. 2013 Mar;51(1):18-21. doi: 10.4193/Rhino12.111 10. Marquardt SR. Dr Stephen Marquardt and the golden decagon of human facial beauty. Interview with Dr Gottlieb. J Clin Orthod. 2002;36(6):317–8. 11. Holland E. Marquardt’s phi mask: pitfalls of relying on fashion models and the golden ratio to describe a beautiful face. Aesthet Plast Surg. 2008;32(2):200–8

Reproduced from Aesthetics | Volume 7/Issue 1 - December 2019

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Aesthetics December 2019

Articles inside

Staying Professional on Instant Messenger

Utilising Brand Photography

In Profile: Dr Patrick Treacy

The Last Word

Understanding Clinical Negligence

Treating Acne with Topicals

Updates to Breast Augmentation

Abstracts

Stem Cells in Regenerative Medicine

Advertorial: Treating the Jaw with Restylane

Case Study: Treating PIH

Advertorial: NEW CUSTOM D•O•S•E from SkinCeuticals

CPD: Understanding Squamous Cell Carcinoma