Aesthetics December 2017

g s in t! is in n m ra u ’t T sco on ite i D El ce d % 10 en e ri th xpe E

VOLUME 5/ISSUE 1 - DECEMBER 2017

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Laser and Light Regulations CPD

Dr Elizabeth Raymond Brown and Dr Godfrey Town explain laser and light regulations

Special Feature: Overview of Microneedling

Practitioners explore different microneedling techniques

Treating NSR Complications Dr Beatriz Molina details her new technique for treating vascular compromise

Transitioning into Aesthetics

Dr Kalpna Pindolia discusses transitioning from the NHS to aesthetics

OWN YOUR BEAUTY Let your patients show their emotions with confidence

Susanne, actual BeloteroÂŽ patient, 46

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Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur.

Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

M-BEL-UKI-0256 Date of Preparation November 2017

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Contents • December 2017 06 News

The latest product and industry news

16 Conference Reports

Highlights from the sk:n, and International Association of Aesthetic Gynaecology and Sexual Wellbeing conferences

18 News Special: Data Breaches

Aesthetics investigates data security risks in clinic

Special Feature Evolution of Microneedling Page 25

20 ACE Preview: Business Track

A look at the free content available at the ACE 2018 Business Track

22 Advertorial: Meet the Trainer with Kelly Saynor

Learn about the Theory of Skin training courses available from Medica Forte

CLINICAL PRACTICE 25 Special Feature: Evolution of Microneedling

Practitioners explore different microneedling techniques

In Practice Social Media Stories Page 67

30 CPD: Laser and Light Interventions

Dr Elizabeth Raymond Brown and Dr Godfrey Town highlight different standards and regulations for laser and light interventions

36 Different Approaches to Treating the Periorbita

Dr Nikola Milojevic discusses treatment options for the ageing eye

42 Permanent Makeup Removal

Specialist Lorena Öberg explains her method for removing makeup tattoos

45 Non-surgical Chemical Blepharoplasty

Dr Jane Ranneva advises on treating the eye area with chemical peels

49 Case Study: Non-surgical Rhinoplasty Complication

Dr Beatriz Molina discusses her new treatment method for vascular compromise on the nose

53 Micromastia and Breast Asymmetry

Mr Hagen Schumacher details treatment methods for micromastia

56 Advertorial: Harpar Grace International

Harpar Grace International introduces the Déesse Pro Edition mask A round-up and summary of useful clinical papers

IN PRACTICE 58 Transitioning into Aesthetics

Dr Kalpna Pindolia discusses her transition into aesthetics from the NHS

60 Creating Surveys

Sales director Ben Savigar-Jones explains how to create patient surveys

64 Writing a CV

Recruitment specialist Victoria Vilas advises on writing a compelling CV

67 Social Media Stories

Digital marketing CEO Natasha Courtenay-Smith describes how to use social media stories to market your clinic

71 In Profile: Miss Jonquille Chantrey

Miss Jonquille Chantrey shares her love of research, teaching and travelling the world

73 The Last Word

Dr Maryam Zamani questions the use of permanent fillers in aesthetics

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Dr Godfrey Town is a RPA2000 certified laser protection adviser and holds a PhD in light-based therapy at the University of Wales. He is a registered clinical technologist and has published more than 25 peer reviewed scientific and clinical papers.

Dr Elizabeth Raymond Brown holds a PhD and has teaching and assessing qualifications from Loughborough University. She is a RPA2000 certified laser/light protection adviser and a regular contributor to conferences, workshops and training events.

Dr Nikola Milojevic is the owner of Milo Clinic in Harley Street. He has more than 14 years’ experience in aesthetics and has performed over 40,000 dermal filler and botulinum toxin procedures, as well as 6,000 tear trough treatments.

Lorena Öberg has been a permanent makeup artist and tattoo removal technician for eight years. She has her own brand of permanent makeup machines, DiamaDerm, as well her own skincare range. She is based on Harley Street in London and Surrey.

Dr Jane Ranneva is a dermatologist and specialist in rehabilitative, reconstructive and aesthetic medicine.

She is an experienced trainer for chemical peeling, international trainer for dermal filler injections, and certified trainer for botulinum toxin injections.

57 Abstracts

Clinical Contributors

Dr Beatriz Molina is medical director and owner of Medikas. Dr Molina is a key opinion leader for Galderma UK and an international speaker. She is the founder of the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM).

Mr Hagen Schumacher is clinical lead of the Department of Plastic Surgery in Hinchingbrooke Hospital and is also based at MyAesthetics Group.

His specialist interests are head and neck, breast reconstruction and aesthetic surgery.

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Editor’s letter Excitement is at an all-time high as THE event of the year takes place on December 2. For those reading this before the Aesthetics Awards 2017, you can expect it to be bigger and better than ever before – we sold out so soon before the event that we added even more tables than Amanda Cameron planned. Best of luck to all Finalists! If you are Editor reading this after the Awards, then congratulations to everyone for all your achievements this year. You can catch up on the highlights in the Aesthetics Awards supplement, which will be published alongside our next issue.

As we are approaching the end of 2017, this month in the journal, we examine the evolution of aesthetics, and my, have we evolved! I joined the specialty when we only had one filler and a handful of lasers and chemical peels. Now, I can’t even count the number of different tools we have available to us. Some key articles to highlight this month include the Special Feature, where we speak to six practitioners about the rise of microneedling treatments (p.25), our CPD article, which

outlines the latest regulations for laser and light interventions (p.30) and following a data breach at a London clinic this month, our News Special discusses how technology has changed the way we store patient information (p.18). Also in the journal, we have an article by Dr Nikola Milojevic on different treatments for the periorbital region (p.36), and continuing the discussion on p.45, Dr Jane Ranneva details how to rejuvenate the area using chemical peels. In our In Practice section, Dr Kalpna Pindolia discusses how she overcame the challenges of moving into aesthetics from the NHS (p.58) and Victoria Vilas explains how to write a good CV (p.64).

Soon, it will be all over for another year and we will have the Aesthetics Conference and Exhibition (ACE) 2018 to look forward to, for which free registration is now open. We have launched a whole new training concept that will be taking place alongside ACE – the Elite Training Experience. This gives you a taste of some of the best training available in the specialty. Book your session with either Dalvi Humzah Aesthetic Training, Academy 102, Medics Direct Training or the RA Academy before December 31 for a 10% discount.

Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined the Aesthetics journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with over 20 years’ experience. He is an international presenter, as well as the medical director and lead tutor of Medicos Rx. Mr Humzah also runs the multi-award winning Dalvi Humzah Aesthetic Training courses. He is a founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow.

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 in the cosmetic use of botulinum toxin and dermal fillers.

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. She is a registered university mentor in cosmetic medicine and currently a second year student on the Northumbria University Masters course in non-surgical cosmetic interventions.

Bennett has been developing her practice in aesthetics for 25 years.

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 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

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

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

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

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multiaward 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. Dr Williams is also author of Amazon-No-1 Bestseller ‘Future Proof Your Skin’.

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.

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. Dr Samizadeh frequently presents at international conferences and is passionate about raising industry standards.

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Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Webinar Dr Bawa Aesthetics @drbawaaesthetic Great webinar by @Allergan on anatomy of the face and facial aesthetics! #alwayslearning #learninglunch #knowyourstuff #Dermatology Dr Anjali Mahto @DrAnjaliMahto Day of education ahead @BritishCosmDerm today with @BavDerm @Manchesterderm @CedarsDerm #dermatology #skin #Radio RiverMedical @RiverMedical1 Busy recording our new radio ad down in 4FM!

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Industry

Schuco International partners with Med-fx Aesthetic distributor Schuco International has confirmed aesthetic supplier Med-fx as its exclusive distribution partner for the Princess dermal filler product range. According to the company, Princess dermal fillers can now only be purchased in the UK directly from Schuco or Med-fx. Schuco states that aesthetic practitioners purchasing through them or Med-fx can be reassured that they are receiving genuine products within a tightly controlled supply chain, where storage, transportation and stock rotation are guaranteed to be in line with manufacturer recommendations. Commercial director at Schuco International, Chris Littlejohn, said, “We know that product safety and a secure supply chain is critical to the success of our customers, to ensure the safety of their patients. This partnership means we can now provide even more safety, support and reassurance for aesthetic clinics and practitioners, as direct purchases will be guaranteed under the strictest quality-controlled supply chain.” David Tweedale, head of Med-fx added, “We are excited to be working with Schuco in this exclusive partnership. At Med-fx, we pride ourselves on providing the highest quality products within our portfolio, so the addition of the Princess dermal filler range to our offering is a great fit.”

Fat

SculpSure receives CE mark for submental area #Training Laser & Skin Clinic @LaserandSkin_ Very informative day @MerzAesthetics on Advanced Injectable Techniques with renowned Dr Prager @Ravichand1Simon and Dr Emma Ravichandran #PRP Dr Daniel Sister @DrDanielSister It’s a good job I’m not afraid of the cold, heading to Kazakhstan tomorrow to train medics in #PRP #draculaprp #draculatherapy. Brrrr! #Conference Medikas @Medikas1 Great day so far, 160 cosmetic doctors from all over Spain #filler #aesthetics #AMEM

Body contouring laser device SculpSure has received Conformité Européene (CE) certification for treatments on the submental area. The device, which is already certified to treat the abdomen, waistline, back, and inner and outer thighs, can now place the CE mark on procedures aimed at treating a double chin. Practitioners are required to purchase a laser attachment to allow the treatment applicators to fit onto the submental area. SculpSure is developed by laser manufacturer Cynosure, which was recently acquired by Hologic. Kevin Thornal, divisional president of Cynosure at Hologic said, “The receipt of the CE mark to treat the double chin is an important growth milestone for SculpSure. The laser’s proven effectiveness rate, coupled with the fact that SculpSure is certified to treat patients with a wider body mass index range, will provide healthcare professionals with a distinct treatment advantage, that can drive demand and widen their patient communities.”

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Conference

First UK practitioners invited to speak at TSLMS Meeting Aesthetic practitioners Dr Tapan Patel and Dr Benji Dhillon have become the first in the UK to be invited to present at the Tennessee Society for Laser Medicine and Surgery (TSLMS) Annual Meeting in the US. The meeting is organised by Dr Brian Biesman and Dr Michael Gold and focuses on lasers and energy-based devices, injectables for cosmetic concerns, skincare, practice management and medical dermatology. According to Dr Patel and Dr Dhillon, the invitation is a great opportunity to share some of their their techniques and UK developments with an international audience.

Dr Dhillon said, “The TSLMS Meeting is a very focused congress with exceptionally high-quality content, delivered by various thought leaders in their respective fields. We are particularly attracted to the fact that it is a ‘personal’ meeting, allowing delegates to meet with speakers individually rather than just learn from a distance. It is a great opportunity to share some of our techniques and evidence with a US audience and learn from many high-quality speakers at these meetings.”

The TSLMS Annual Meeting takes place on May 9-12 next year at the Music City Convention Center in Nashville, Tennessee.

Skincare

AlumierMD releases Alumience A.G.E serum Skincare developer AlumierMD has introduced a new serum that aims to assist the skin in fighting against environmental aggressors such as urban air pollution. Alumience A.G.E contains a blend of antioxidants, specialised peptides, anti-glycation ingredients and a biomimetic pollution shield, including alteromonas ferment extract, carnosine silymarin, vitamin E, acetyl tyrosine, proline, arginine and vitamin C. According to the company, these ingredients aim to provide daily protection from dry skin and reduce the visible signs of ageing that may be caused by free radicals, pollution and advanced glycation end products. Samantha Summerfield, marketing and events manager at AlumierMD, said, “It is key that people who live in major urban centres are defended against daily aggressors that will accelerate the ageing process of the skin. This formula is based on proven science and clinical research to provide both our professionals and their patients with tangible results.”

Aesthetics

Vital Statistics

There were 775,000 microdermabrasion procedures reported in the US in 2016 (The American Society of Plastic Surgeons, 2017)

According to IMCAS, Europe’s cosmetic market is growing at a rate of 6% a year across all segments (IMCAS, 2016)

In a survey of 200 US plastic surgeons, 64% said they learn about procedures from online videos, with the most popular being rhinoplasty and injectables (Emory University, 2016)

A study of 83,000 women, which took place over 14 years, suggested that five or more glasses of wine a week raises the risk of rosacea by 49% (Brown University, Rhode Island, 2017)

In a survey of 1,096 people aged 15-30, 767 of whom were female, 52% said they would only post a selfie which had a filter over it (Flawless, 2017)

According to hair growth company Keranique, almost 40% of women over the age of 18 experience some form of hair thinning (Keranique, 2016)

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Events diary 2nd December 2017 The Aesthetics Awards 2017, London www.aestheticsawards.com

1st – 3rd February 2018 IMCAS Annual World Congress 2018, Paris www.imcas.com

1st – 5th March 2018 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

4th – 7th April 2018 Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc2018.org

27th – 28th April 2018 The Aesthetics Conference and Exhibition 2018, London www.aestheticsconference.com

Eyelash

XXtralash launches new PolyGF Serum Eyelash enhancing brand XXtralash has developed a new formula, which the company claims can increase lash length by 25%.

The XXtralash PolyGF Serum aims to stimulate hair follicles on the eyelid, enabling them to grow and become longer and thicker. It also aims to nourish the lashes, maintaining their healthy condition.

Among the key ingredients are non-human growth factors: keratinocyte growth factor, basic fibroblast factor, insulin-like growth factor 2 and vascular endothelial growth factor; which aim to stimulate cells to split, to produce proteins needed for eyelash growth. Also included in the formula is hydrolysed soy protein, antioxidant boosters magnesium ascorbyl phosphate and vitamin c, adenosine, Salvia officinalis (sage) oil, myristoyl pentapeptide 17 and myristoyl hexapeptide 16.

The product can be applied in a thin layer twice per day after cleansing and drying the eye area and, according to the company, initial results may be seen within two weeks. XXtralash is exclusively distributed in the UK by AestheticSource.

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Plasma

Fusion GT introduces Felc nano to the UK Aesthetic distributor Fusion GT has launched a new plasma device to the UK. According to the company, the Felc nano is the first plasma device to combine cathodic and anodic plasma for excess skin sublimation, providing less downtime and swelling compared to other plasma technologies. It is said, by the company, to work by generating nano plasma between the needle’s tip and the patient’s skin, aiming to sublimate the superficial layer of skin, to cause a shrinking and shortening of the excess skin tissue. The device was developed by Professor Giorgio Fippi, who has 30 years’ experience and research in the electro-surgery field. He said, “Felc nano plasma is the most advanced plasma technology I have created to date. My precious creation, Plexr, has been a great platform for launching plasma technology within the aesthetics market, but I am pleased to let the UK know that I have finally created a plasma device that really minimises patient healing time.”

Tiziana Giovanelli, director at Fusion GT, added, “I am so pleased to be able to launch Felc nano to the UK aesthetics market. Plexr has been a game changer for many practitioners over the past five years, however I am finally happy to provide practitioners with the latest, most advanced plasma device which will truly improve the results for practitioners and patients.”

Aftercare

Dermastir adds face mask to range Skincare company Dermastir has added the Post-Op Bio-Cellular Retexturizing Face Mask to its range of products. According to Alta Care Laboratoires, the French creators of Dermastir, the product utilises biotechnology to create a skin tissue-like material from the fermentation of microorganisms. It claims that the mask is hydrophilic, diminishes transepidermal water loss (TEWL) and inhibits enzymes that break down hyaluronic acid, collagen and elastin in the skin.

The mask aims to hydrate the skin and decrease redness and bruising caused by aesthetic treatments such as injectable procedures, chemical peels, and laser procedures. Managing pharmacist of Alta Care Laboratoires, Ivan Pullicino, said, “Taking care of the patient post procedure is becoming very important for aesthetic practitioners worldwide, to give more value to the service they are offering.

Dermastir Post-Op Bio-Cellular Retexturizing Face Mask is a great product that helps to decrease the temperature of the skin post procedure, and the transdermal hydration helps dermal fillers last longer. The quality of the biocellular fibres and the hyaluronic peptide serum is so high that it forms a matrix that is very similar to skin tissue, giving it very high adhesive transdermal properties.”

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Conference

New sessions added to ACE 2018 programme

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Ross Walker, Commercial Director of Clinical Health Technologies, Clinisept+

The exciting clinical programme for the Aesthetics Conference and Exhibition (ACE) 2018 is quickly filling up, with new sponsors announced for a range of sessions within the free Expert Clinic and Masterclass agendas. The Expert Clinic agenda takes place on the 2500m2 Exhibition Floor and will feature top experts in the speciality discussing their latest products, while the Masterclasses will provide delegates with interactive talks from leading product suppliers and manufacturers and their KOLs. Among the new Expert Clinic sponsors are aesthetic clinic and distributor Rosmetics and aesthetic manufacturer Teoxane UK. Jordan Sheals, brand manager of Teoxane UK, said, “Teoxane are delighted to be holding three different Expert Clinic sessions at ACE 2018. At the event, delegates will see Dr Lee Walker, Dr Kieren Bong and Dr Wolfgang Redka-Swoboda explore the most innovative tools and techniques in hyaluronic acid to deliver the best results, in the safest way.”

Meanwhile, distributor AestheticSource has announced it will hold a Masterclass.

Lorna Bowes, director of AestheticSource, said, “AestheticSources’ Masterclass is extremely exciting as we will be launching the new Skin Tech Peel, Easy Phen Very Light. This exciting innovation allows easy application, consistent results as well as the significant patient benefit of a one-off medium depth peel. If you are using peels in your current practice and are looking for something new, that gives a slightly deeper peel without heavy downtime but with easy application, then do not miss this Masterclass.” Also newly announced is the ACE 2018 registration sponsor, which will be UK distributor Healthxchange. Marketing director of Healthxchange Group, Steve Joyce, said, “We are delighted to sponsor ACE and are also very excited to be exhibiting. Healthxchange Group is passionate about education; we feel that ACE is focused in supporting the work of medical aesthetic professionals and we want to encourage the sharing of knowledge in the field.” ACE 2018 is taking place on April 27-28 at The Business Design Centre in Islington, London. For more information, or to register for free, visit www.aestheticsconference.com.

Industry

EF Medispa offers franchise opportunity Aesthetic clinic chain EF Medispa is offering individuals the opportunity to open an EF Medispa clinic of their own through franchising. The group currently has four clinics in London: Kensington, Chelsea, St John’s Wood, Canary Wharf, with a fifth in Richmond set to soon open. EF Medispa also has clinics located in Bristol and Birmingham. According to the clinic, franchisees will benefit from EF Medispa’s business systems, marketing, treatment protocols and training. Franchised businesses will be located in high street locations or affluent suburbs. The company states that total investment required for the franchise is around £650,000, plus other operational costs, depending on the size of the property and amount of renovation required.

What is Clinisept+?

Clinisept+ is a skin disinfectant that contains a unique, high purity and stabilised hypochlorous skin cleansing technology that delivers a unique combination of greater protection against infection before, during and after aesthetic procedures. Clinisept+ has perfected a version of hypochlorous that fully retains its multi-pathogen efficacy with a two-year shelf life. It is completely fungicidal, bacetericidal and sporidical.

Why has it caused such a stir in aesthetics?

Clinisept+ is the first significant development in skin disinfection chemistries in more than 30 years. It delivers better levels of protection against infection than traditional skin disinfectants such as chlorhexidine and alcohol, and yet it is much more compatible with the skin. In fact, it is the first skin disinfectant that can be used before, during and after a procedure without causing sensitisation or irritation. This means that, as well as being used in the clinic, patients can continue to use Clinisept+ after a treatment to maintain very high levels of skin hygiene – it’s ideal for skin recovery.

What are practitioners reporting?

The UK’s most respected aesthetic practitioners have reported reductions in erythema and oedema as a result of using Clinisept+ in comparison to traditional skin disinfectants. In addition, they also report a significantly increased speed of skin recovery following a treatment.

Feedback such as, “Wounds are healing more quickly than with previous post-op regimes, with less redness and a cleaner wound,” is commonly recieved from both our Key Opinion Leader Panel and other practitioners.

Is Clinisept+ suitable for different circumstances?

Clinisept+ is very suited to use in the wider medical environment; the benefits it brings are too significant to restrict it to aesthetics alone and we are already discussing a range of other medical applications. We are working on a rapid roll-out schedule, so will be launching some new additions to the Clinisept+ range in the new year and also expanding distribution into other countries. Watch this space!

This column is written and supported by

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Dermatology

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

SkinMed introduces new rosacea treatment

BACN STRATEGY 2017-2020 The BACN has just finished its 2014-2017 strategy cycle and has worked on the new strategy for the next three years. We will be developing and agreeing a clear set of values that meet the changing environment of aesthetics, along with improving, developing, and growing high quality support services and programmes that provide value for BACN members. Additionally, we will be developing and enhancing the reputation and importance of the BACN as the voice of aesthetic nurses, and providing education, training, and CPD functions.

BACN CONFERENCE 2018 The BACN has reviewed venues and locations for the 2018 Autumn Aesthetic Conference and is proud to announce that we will be at Edgbaston International Cricket Ground in Birmingham on Thursday November 8 and Friday November 9, 2018. We will be expanding our conference to a two-day event after the success in 2017, with a full day of workshop and masterclasses followed by a day of speakers, demonstrations and an exhibition. BACN members will receive further information regarding the annual conference in early 2018.

BACN REGIONAL MEETINGS We have just gone through our autumn/winter regional meetings throughout the UK with demonstrations and educational talks from a range of BACN partners. The meetings were well attended by newer members and those who are very experienced, allowing for networking and crucial peer-to-peer review. All meetings come with CPD accreditation that members can record online in the members area. Tara Glover, BACN events manager, will be working with partners and regional leaders for the meetings in 2018.

AESTHETICS AWARDS 2017 The BACN is proud to announce that all eight finalists in the ‘Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year’ are members of the BACN. Congratulations to all nominated and to the winner! We are also proud to be finalists in the ‘PHI Clinic Award for Professional Initiative of the Year’ for the BACN Nurse Revalidation Programme.

MEET A MEMBER SPECIAL This month we want to say thank you to every nurse that has joined our association. Working with our members and meeting nurses throughout the UK at our events is the highlight of our roles at HQ. We’d like to wish our members a Merry Christmas and Happy New Year!

This column is written and supported by the BACN

Dermatological company SkinMed has introduced TripleLock on Rosacea to its treatment portfolio. According to the company, TripleLock on Rosacea utilises new patented, medically licenced Synchrorose products, which incorporate a transient receptor potential vanilloid (TRPV1) receptor blocker, resulting in reduced, internally stimulated, reddening events. The company states that these receptors are hyperreactive in rosacea sufferers. The treatment protocol is further enhanced

by Tebiskin Cera-Boost Face cream, which targets epidermal resistance, as well as Tebiskin Post Laser Care (PLC) rescue cream, which aims to restrict acute reddening situations. Additionally, follow-on treatment Tebiskin Reticap, which contains encapsulated retinol, vitamin C and acetyl glucosamine, aims to provide skin stability for long-term relief. According to the company, the protocol targets symptoms and underlying causes of rosacea, while increasing tolerance to internal and external triggers. Head trainer at SkinMed, Peter Roberts, said, “Following extended research and outstanding results, we’re proud to launch this advanced protocol to enhance the already outstanding results achieved with Synchrorose alone. Now we have further raised the bar on what’s possible using new TripleLock on Rosacea.”

Microneedling

mesoestetic launches microneedling pen Skincare manufacturer mesoestetic has launched its new microneedling pen, the m.pen pro. According to the company, the pen is a cordless device that allows technicians to work at five different speeds at six scaled depths. mesoestetic states that the device has been specially designed to use with its C-prof and X-prof solution ranges, which include liquid-based solutions for depigmentation, photoageing and facial tightening, among others.

Adam Birtwistle, managing director of distributor Wellness Trading, said, “The m.pen pro is the perfect addition to the mesoestetic product portfolio; built to be light, cordless and easy to use whilst being fully adjustable to suit both aesthetic and medical practitioners. We are delighted to be able to offer this to our clients, with protocols developed by leading aesthetic physicians from the home of mesoestetic in Barcelona.”

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Vaginal rejuvenation

New intimate health platform released in UK Aesthetic device company Invasix has launched a new platform aimed at improving feminine health concerns.

The Votiva comprises two handpieces, FormaV and FractoraV, which provide internal and external treatment. The FormaV is said be a non-invasive deep muscle tightening technology that uses uniform radiofrequency. It is applied to the vaginal canal and aims to address pelvic floor tightening, areas of labial hypertrophy and vaginal laxity. The company claims patients will experience results immediately, with continued improvement over the following weeks. The FractoraV uses customised fractional radiofrequency energy that aims to improve superficial skin tone problems and tightening of the skin. Invasix states the full depth heating can improve elastin and collagen remodelling.

Neil Wolfenden, managing director at Invasix said, “We are thrilled to announce the launch of Votiva to our portfolio of industry leading technology. The Votiva platform allows practitioners to treat both internally and externally with just one device. User feedback has been extremely positive and we are looking forward to introducing the treatment to clinics across the UK.” Nurses

BACN Conference to be extended The British Association of Cosmetic Nurses (BACN) Autumn Aesthetic Conference 2018 will take place over two days in Birmingham on November 8 and 9 next year. According to organisers, this year’s event was so popular that they decided delegates should have access to the main exhibition hall over two days, while having the opportunity to attend workshops and masterclasses on day one, and hearing from speakers and demonstrators on the second day. The conference will also take place at a new venue, moving from the International Convention Centre to Edgbaston Cricket Ground/Stadium. With the new venue and dates, the BACN hopes to attract even more delegates, striving to reach 400 members in attendance, an increase of 100 from this year. Gareth Lewis, membership and marketing manager for the BACN, said, “The BACN Autumn Aesthetic Conference is a chance to network with a wide range of peers working throughout the country, alongside attending specialist workshops and visiting exhibitors tailored to delegates’ needs. By attending, nurses can expect a wide range of exhibitors, speakers, and networking opportunities, together with learning vital skills to enable them to lead and demonstrate utmost professionalism within aesthetics.”

Promotion

MAG offers monthly Oxygenetix giveaway UK aesthetic product supplier Medical Aesthetic Group (MAG) has launched a new monthly promotion to give aesthetic clinics the chance to win £350 worth of Oxygenetix products and be featured as ‘Clinic of the Month’ across its social media channels. To enter, clinics must capture their best in-clinic post-treatment transformations using Oxygenetix Foundation and email them to info@emmabw.com using the subject line ‘Oxygenetix Transformation’ by the 20th of each month. Winners will be selected on the first of every month and the promotion ends in February.

News in Brief Schuco International celebrates 60 years in business Aesthetic distributor Schuco International is celebrating 60 years in the medical market. To thank both existing and new customers, throughout the next 12 months, the company will be holding a series of product promotions and special offers. Paul Huttrer, chief executive at Schuco International, said, “We are immensely proud of Schuco’s achievements over the last 60 years – we will continue to expand the support, expertise and training we offer our customers.”

MedivaPharma partners with HADerma UK pharmaceutical supplier MedivaPharma has gone into partnership with UK distributor HA-Derma. According to MedivaPharma, the partnership will allow the pharmacy to continue to fulfil customer demands with new products, education and training opportunities. HA-Derma’s sales and marketing manager, Iveta Vinklerova, said, “We are pleased to extend our list of approved pharmacies stocking both Aliaxin and Profhilo, which is due to the growing demand we currently have.”

Enhance Insurance welcomes Leanne Benson Enhance Insurance has hired Leanne Benson as its new claims handler and team administrator. Enhance business development executive, Sharon Allen, said, “In the short time that Leanne has been with us she has demonstrated her commitment to customer service and eagerness to continue to develop her knowledge of the industry and products.

We are very pleased to have her on board.”

Wendy Lewis releases new marketing book A new book entitled, ‘Aesthetic Clinic Marketing in the Digital Age’ written by US aesthetic business consultant Wendy Lewis is being launched this month.

According to Lewis, the book will offer insights on transferring from print to digital marketing, building a clinic website, newsletters and blogs, among other features. Lewis said, “It is my sincere hope that this book offers aesthetic practitioners some words of wisdom and guidance to look at how they can run their clinic in a fresh new way so that they can grow.”

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Industry

BAAPS issue statement for cosmetic surgery insurance petition The British Association of Aesthetic Plastic Surgeons (BAAPS) has issued a statement supporting a petition to make it illegal for practitioners to offer cosmetic surgery without appropriate insurance. The statement, from consultant plastic surgeon and former BAAPS president, Mr Douglas McGeorge, states, “BAAPS cautions that whilst the General Medical Council requires surgeons to have indemnity insurance (also known as negligence or malpractice insurance) by law, the amount of cover insurance policies provide is not specified, and so it is currently possible for surgeons to take out inadequate levels of insurance. Such policies may only pay out in extreme cases (to be determined by the insurance providers), or may only pay a limited, often insignificant amount.” A patient who received substandard cosmetic surgery started the petition, and states that she wants the UK Government to tighten insurance laws to stop rogue practitioners performing procedures. Mr McGeorge added in his statement, “This is one of many regulatory loopholes that allows unscrupulous providers to cut corners and commodify medical procedures.

The Association has been urging the government to address this for well over a decade.” The petition needs 10,000 signatures for the government to respond and 100,000 signatures will allow the petition to be considered for debate in parliament. It will run until April 25. The full statement can be viewed on the BAAPS website.

27 & 28 APR 2018 / LONDON

INTRODUCING THE ELITE TRAINING EXPERIENCE AT ACE 2018 IN THE AGENDA The Elite Training Experience, taking place alongside the Aesthetics Conference and Exhibition (ACE) 2018 on April 27 and 28, offers the unique opportunity to taste four training sessions with world renowned aesthetic training providers. Featured in the agenda is the award-winning Dalvi Humzah Aesthetic Training, led by consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah and his faculty, where presentations will include how to use cannulas to address specific facial and skin concerns; RA Academy, led by renowned aesthetic practitioner Dr Raj Acquilla, will provide a total-face approach to treatment and will discuss male vs. female aesthetic ideals; established aesthetic practitioner Dr Tapan Patel will deliver an aesthetics masterclass where delegates can learn how to improve on their injection techniques with Academy 102; and aesthetic practitioner Dr Kate Goldie will advise on periorbital rejuvenation, lipshaping techniques and combining treatments, with her distinguished academy Medics Direct Training.

SPEAKER INSIGHT

Data protection

Report suggests many clinics are unaware of GDPR A new report is claiming that aesthetic clinics are unaware of the implications of new data protection rules due to come into force on May 25 next year.

The report was put together by law firm Irwin Mitchell and practice management software company Consentz and features a survey conducted by YouGov. According to the survey of 136 organisations operating in the medical and health sector, only half (51%) of senior decision-makers in the sector are currently aware of the new General Data Protection Regulation (GDPR). The survey also found that 38% of organisations are unaware of the new fines and 14% admitted they would need to make significant job cuts if they received the maximum fine. Also highlighted in the survey results was that just 37% are certain that they would be able to detect a data breach, and only 29% are confident they would notify the relevant stakeholders within the required timescale of three days. Michael Geary, CEO and co-founder of Consentz said, “I haven’t been asked about GDPR once yet by users or businesses which are interested in using Consentz. Awareness is low and this is worrying when you consider all the changes to how clinics will have to manage their data. I think it will be next year until conversations about GDPR compliance become common.”

Stuart Padgham, partner and data protection specialist at Irwin Mitchell, added, “These results are concerning because with next May’s deadline fast-approaching and with so much at stake, our study reveals there’s a very real possibility that a large number of organisations operating in the medical and health sector will not be compliant in time.”

Dr Raj Acquilla says, “The Elite Training Experience is a valuable and unique opportunity for delegates to have a taste of four of the top training providers available in medical aesthetics. I strongly encourage healthcare professionals to book a session at the Elite Training Experience as those who do will get an exclusive 10% discount on a future training with their chosen provider.”

FREE CONTENT AT ACE 2018 Delegates who book the Elite Training Experience will also access free CPD-verified content at ACE 2018, including 17 Expert Clinic sessions, 12 Masterclasses and 18 Business Track sessions, as well as the 2500m2 Exhibition Hall.

WHAT DELEGATES SAY “As an advanced practitioner, I attend ACE to continually progress my learning, and I would advise any injector, no matter how experienced, to do the same.”

AESTHETIC DOCTOR, LONDON

ACE HEADLINE SPONSOR

www.aestheticsconference.com

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Book launch

Business expansion

Dr Stefanie Williams’ new book becomes Amazon bestseller Board certified dermatologist and Aesthetics journal editorial board member Dr Stefanie Williams has launched her second book, Look Great, Not Done! The Art & Science Of Ageing Well: How Aesthetic Treatments Can Work For You, which has become an Amazon bestseller. Aimed at patients, Dr Williams describes her personal aesthetic journey, combining the discoveries she has made with the in-depth knowledge and understanding from more than ten years as a dermatologist.

She provides readers with a step-bystep guide of how they can have radiant, healthy and beautiful skin that reflects their youthful outlook and boosts their confidence. “I want to enable men and women to benefit from the positive help aesthetic treatments can offer without that fear of looking ‘done’,” says Dr Williams, adding, “Which is perfectly possible, due to an exciting paradigm shift that’s happening in aesthetic medicine right now.

These are truly exciting times!

Vikki Baker joins AestheticSource UK distributor AestheticSource has employed Vikki Baker as its new marketing manager. Baker began her career in aesthetics in 2009 while working in training and events for Q-Med UK Ltd. From 2011 she worked with Galderma, before moving to become the marketing manager for AestheticSource. Baker also worked as marketing manager for Cosmex Clinic Cambridge.

Director of AestheticSource, Lorna Bowes, said, “Vikki brings a wealth of knowledge and experience to AestheticSource. We are expanding fast and having Vikki as part of our team will allow us to offer even more marketing support to our customers. Her enthusiastic approach means she fits perfectly in to the AestheticSource family and we are all delighted to welcome her.”

IMCAS World Congress 2018

Aesthetics presents a preview of the International Master Course on Aging Science 2018 Celebrating its 20th anniversary in 2018, the IMCAS World Congress will take place from February 1-3 at the Palais des Congrès in Paris. With an expected 8,000 attendees from 90 different countries, and 600 international expert speakers, IMCAS World Congress 2018 will feature 160 scientific sessions, with more than 270 learning hours. The scientific programme is divided into various learning tracks, covering 15 different themes, including the fillers and botulinum toxins track, laser, and body shaping track, clinical dermatology track, practice management track, and face and body surgery tracks.

According to IMCAS, the Anatomy on Cadaver workshop on the first day of the congress is the ‘must attend’ event. This one-day module combines a live cadaver dissection, broadcast from the ‘Fer à Moulin’ Surgery School of Paris, with patient demonstrations in parallel. This year will be focused on threads, vulvovaginal rejuvenation as well as, injectable and fat injections, and will aim to offer attendees an insight on the most thorough approach in the use of different techniques and how to plan for anatomy when performing these treatments.

The event will also feature three Regional Masterclasses that explore different aesthetic ideals – the China Masterclass, Middle East and North African Masterclass and Eastern European Masterclass. Each masterclass is organised in collaboration with scientific societies from the region, and welcomes speakers from the region and around the globe. The sessions aim to delve into the specificities of the regions and cultures to give attendees the knowledge to produce the best results for their patients.

New to IMCAS in 2018 is the Aesthetic Innovation Forum, which aims to give entrepreneurs the opportunity to showcase their innovations to a room of investors. IMCAS claims that entrepreneurs will have the chance to exchange and gain knowledge from those already successful, and investors will have the opportunity to discover new innovations to potentially invest in. One innovation will be crowned the ‘IMCAS Innovation of the Year’ at the first IMCAS Shark Tank.

In addition, more than 250 leading companies will be showcasing their innovations in the exhibition hall, where attendees can discover the latest products and treatments.

A networking cocktail event will take place on the Friday, while a Gala Dinner will be held on the final night of the congress, which, according to IMCAS, will offer delegates the opportunity to reunite with familiar colleagues and friends, and network with new ones.

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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On the Scene

Out and about in the aesthetic specialty

Teoxane Expert Day, Cheshire

Aesthetic company Teoxane UK invited 250 practitioners to attend the fourth Teoxane Expert Day at The Mere Golf Resort & Spa in Cheshire on November 10. The Expert Day began with a welcome brunch and speech by Dr Paul Charlson, followed by a packed itinerary of scientific and anatomical lectures and live demonstrations, covering areas including the tear trough, lip anatomy, sculpting of the male face and contouring of the mid-face. Speaking at the event and demonstrating Teoxane’s range of fillers using the Teosyal Pen, were Dr Kieren Bong, Dr Wolfgang Redka-Swoboda, and Dr Lee Walker.

At the end of the day there was the Teoxane Tournament, which involved the day’s speakers competing for a prize by analysing live patient cases.

This was followed by a jazz party that went into the evening. Jordan Sheals, brand manager at Teoxane UK said, “The feedback we have collected so far has re-enforced success of our key objective: to provide medical education at the highest standard. It’s inspiring to see a room of 250 practitioners with the passion for medical education, for science, innovation and delivering excellence in facial aesthetics.”

PRP Industry Showcase and Train the Trainer, London Aesthetic professionals were invited to Posh Aesthetic Beauty & Laser Clinic in East Croydon on November 6 to take part in a train the trainer evening and to learn more about PRP Lab kits. The event was planned by the UK branch of PRP Lab, MedAesthetics, in conjunction with aesthetic supplier Med-fx, which will soon be distributing PRP Lab kits, as well as Facethetics Training in Liverpool, who are about to incorporate PRP Lab kits in their platelet rich plasma (PRP) and platelet rich fibrin (PRF) training. Guests were presented with a scientific explanation of the benefits of PRP and its applications, as well as the use of the ‘subdermal matrix volumising’ technique using PRF to achieve a filler effect, which was followed by a practical demonstration of the two treatments. Attending the event was medical director for PRP Lab, Dr Maria Toncheva; director of MedAesthetics Ltd, George Brankov; director of Facethetics Training – representing PRP Lab in the UK, Alison Stananought; nurse trainer for Facethetics Training, Christine Blackburn; and account director for Med-fx, Kelly Tobin.

Brankov said of the event, “The event was a great success. All attendees went away with new knowledge that can be offered to their respective clients. The event proved that PRP Lab and MedAesthetics are at the forefront of PRP treatment field.”

IPAR 4th International Annual Meeting, Barcelona On November 3, Skin Tech Pharma Group collaborated with educational group, the International Plastic Aesthetic Residence (IPAR), to organise a scientific programme. Attendees gathered at the Port Aventura Convention Centre in Barcelona to share their clinical experiences and scientific developments to extend their knowledge, and have the chance to develop new skills in skin peeling and rejuvenation. The sessions covered the latest clinical studies and trends in injectables, mesotherapy, biorevitalisation, and combined injections using fillers and Skin Tech’s RRS. There were 17 speakers at the event, including Dr Philippe Deprez, Dr Jane Ranneva and Dr Lali Hanani. New products were also launched at the event, including the Easy Phen Very Light and the HAPPY intim, which will both be available in the UK in early 2018. Lorna Bowes, the director of UK Skin Tech distributor AestheticSource, said, “Skin Tech Pharma Group’s joint venture with educational group IPAR went from strength to strength. It was a fascinating conference with exciting launches in the UK for Spring 2018.”

Obagi Ambassador Network days, London & Manchester Global specialty pharmaceutical company Obagi Medical held an ambassador network event on October 25 in London and October 26 in Manchester.

The events, held at Chandos House in London and Healthxchange Academy Manchester, brought together a group of Obagi representatives from clinics across the UK. The days were designed to showcase commercial success and recognise the highest levels of clinical excellence in medical skincare. Guests were provided with a full day agenda, which included presentations on pigmentation and deviant skin types, acne and chemical peels, combination treatments, managing stimulation and suppression of melanocytes and managing complications.

In the afternoon, delegates also heard ambassador complication studies, before awards were given out to ambassadors, recognising their excellence in categories such as Best Patient Result, Best Use of Marketing and Most Improved Clinic Sales. Guest speaker, Dr Sam Van Eeden said, “It was my honour to share the excellence of knowledge we all need to deliver safe and effective treatments to the trusting public and patients.”

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Conference Reports

Aesthetics reports on the highlights of the latest conferences in the specialty

sk:n Medical Convention 2017, Birmingham Almost 200 medical professionals were welcomed at the Vox Conference Centre, Birmingham, for the annual Medical Convention sponsored by aesthetic clinic group sk:n, on Friday November 10. Delegates had access to an interesting and diverse conference agenda, as well an exhibition area. The agenda began with a welcome speech from the chairman of sk:n medical standards committee Dr Daron Seukeran, followed by the first presentation of the day on the Seven Steps to Patient Consultation

by Allergan business consultant Dan Hopkins. Hopkins explained how the patient consultation can be broken down into a structured process and how, during this time, practitioners can show their true value.

Next, aesthetic nurse Dee Hadley provided an in-depth description of the Allergan MD Codes, showing some impressive before and after images of a patient she had treated using fillers in different facial areas. Dr Maria Vitale-Villarejo from Spain then spoke for skincare distributor AesthetiCare, providing a review of data for Fernblock, a nutraceutical aimed at protecting against harmful solar radiation. This was followed by Dr Johanna Ward, who explained the growing concern over vitamin D deficiency in the UK. The focus then turned to skin conditions, with aesthetic nurse Shannon Lister giving a presentation on behalf of Healthxchange on the use of hydroquinone for skin pigmentation.

Lister acknowledged that the ingredient has been regarded as

safe and effective by the Food and Drug Administration for more than 40 years and discussed some of the myths surrounding it, such as its involvement in triggering cancers.

Next, dermatology nurse Julie Van Onselen spoke for Almirall on female facial hirsutism and Vaniqa. She highlighted the issues women with unwanted facial hair often deal with, including depression and avoiding social situations due to the condition, and explained how using Vaniqa can help treat patients.

Delegates were treated to a delicious hot and cold buffet before being invited back in the auditorium for the second half of the agenda. Opening the afternoon programme was Dr Sam Dhatt, CEO of aesthetic skincare company DermaQuest, who gave a talk on the advancements in skincare. He provided an interesting comparison between the use of human stem cells and plant stem cells in skincare. Dr Seukeran then spoke on daylight photo dynamic therapy (PDT) on behalf of Galderma, before the cofounder of the sk:n medical standards committee Dr Sean Lanigan gave an update on the treatment of vascular conditions including rosacea, for global aesthetic device company Syneron Candela.

The day concluded with an update on acne scarring treatments

by Dr Asif Hussein of sk:n clinics, and a panel discussion on how to avoid complaints and litigation, which included head of medical standards at sk:n Lisa Mason, lawyer at Bevan Brittan Ltd Adrian Dagnall and Treatments You Can Trust founder Sally Taber.

IAAGSW Conference 2017

Around 250 aesthetic practitioners, gynaecologists and surgeons gathered in London for the first ever International Association of Aesthetic Gynaecology and Sexual Wellbeing (IAAGSW) Conference at the Royal Society of Medicine in London on October 27-29.

Among the female sexual rejuvenation topics on the first day, was anatomy by Mr Paul Banwell; injectable hyaluronic acid for genital rejuvenation by Dr Nicolas Berreni and the use of devices for improving the aesthetic appearance and function of the

vagina by Dr Gustavo Leibaschoff.

The second day kicked off with the female and male sexual rejuvenation agenda.

This agenda discussed the role of PRP in male sexual enhancement with Dr Sherif Wakil and the use of botulinum toxin in treating erectile dysfunction by Dr Hussein Ghanem. Within the regenerative agenda were presentations on current and future regenerative medicine in the treatment of pelvic floor disorders with Dr Ernesto Delgado, and nano grafting application in male and female genital rejuvenation by

Dr Leibaschoff. This was followed by the bioidentical hormone agenda, covering the use of hormones in sexual rejuvenation

by Dr Fouad Ghaly and understanding comprehensive nutrition in sexual energy by Dr Beata Cybulska.

Following the conference on October 29, 80 delegates stayed for a third day of learning, at a hands-on masterclass in bioidentical hormones by Dr Fouad Ghaly and Dr Theodore Achacoso.

“The congress and exhibition was excellent and went extremely well,” said chair of the conference and founder of the IAAGSW, Dr Sherif Wakil, adding, “Everybody, from the delegates to the speakers, were over the moon with the professionalism of the event and I was really overwhelmed with the fantastic delegate feedback; people said they had never before seen some of these treatments at another congress.”

According to Dr Wakil, preparation has already begun for next year’s congress, which he is planning to hold in London in October 2018.

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Shockingly, a survey by cyber security company Intel Security, revealed that out of 19,000 people surveyed across 144 countries, 97% cannot identify a sophisticated phishing email.4 Drive-by downloads, on the other hand, are typically carried out by exploiting browser vulnerabilities where security is lacking, and downloading a programme onto the users’ device, which the attacker can then control remotely.5

How Safe is Your Patient Data?

Aesthetics investigates data security risks and questions what practitioners can do to prevent cyber attacks from happening in their clinic On October 17, London Bridge Plastic Surgery faced a data breach in its clinic after it was attacked by hackers who stole confidential patient data. According to the clinic, adequate data security software was installed prior to the breach and appropriate measures were immediately taken to block the attack.

Although it is unclear what provoked the cyber attack at London Bridge Plastic Surgery, a spokesperson for the clinic said, “Regrettably, following investigations by our IT experts and the police, we believe that our security was breached and that data has been stolen. We are still working to establish exactly what data has been compromised.”1 They added, “We are horrified that they have targeted our patients.

The group behind the attack are highly sophisticated and wellknown to international law enforcement agencies, having targeted large US medical providers and corporations over the past year.

We are profoundly sorry for any distress this data breach may cause our patients.”1 With the threat of cyber attacks increasing in the UK by 55% year-onyear across all businesses,2 Aesthetics investigates how and why this is happening and asks what measures can be taken to reduce the chances of a data breach occurring.

How do data breaches happen?

“Phishing and drive-by downloads are the most common ways of getting malicious software on your system and would be the most likely causes of a data breach in an aesthetic clinic,” according to medical malpractice and risk specialist, and divisional director of Enhance Insurance, Martin Swann; but, he notes that this may not necessarily have been the case for the attack at London Bridge Plastic Surgery. Phishing is the fraudulent practice of sending emails, telephone calls or text messages by someone posing as a legitimate institution, to lure individuals into providing sensitive data, which is then used to access important accounts.3

Practitioner responsibilities So can practitioners do anything to protect themselves and reduce the risk of data breaches occurring? Swann says, “Ensuring data is encrypted is one of the things you can do. Data encryption translates data into another form, or code, so that only people with access to a decryption key or password can access it.”6 Aesthetic nurse prescriber Frances Turner Traill, who runs a busy clinic and has been close to a security threat herself, stresses, “It’s so important to keep patient information secure, we always ensure all of our data is encrypted in our clinic to minimise the chances of a data breach occurring.”

She adds, “Every patient who comes into our clinic has a password protected number which identifies them on our system, we never refer to them electronically by their name when inputting their information.

Doing this means that if there were a data breach, patient details would still be confidential.” Swann says that it is highly important that every business takes the necessary steps to mitigate the chances of a breach to their network, for example, having adequate network security, installing updates or software patches (which can add a new feature or fix a bug), and running penetration tests.

The subject of data security sits very close to home for Turner Traill, after she experienced a security threat, when her clinic got broken into. Although patient data wasn’t stolen, Turner Traill says, “It made me understand how vulnerable we are and how much information we put out there, which is very worrying.” She adds, “I realised that, if someone wants to break in, either physically or electronically, there’s not much you can do to stop them, but you can make it harder for them.”

Swann states that in the unfortunate circumstance a data breach does occur, practitioners can maintain patient confidence with their speed of response, communication with the public and patients through a reputable PR agency or representative, and dealing with the breach in a quick and efficient manner. According to a recent survey by YouGov and customer management software company Consentz, of 136 organisations operating in the medical and health sector, just 37% are certain that they would be able to detect a data breach,7 which highlights the importance of data security training in-clinic.

Swann says, “Practitioners should ensure their staff are trained and that cyber awareness is part of their clinic.” Turner Traill agrees, “We provide staff training and have policies in place on data protection and

Out of 19,000 people surveyed across 144 countries, 97% cannot identify a sophisticated phishing email

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confidentiality. Data protection should be part of your clinic’s plan. Just as you would do health and safety checks, the same process should be in place for data security.”

Going forward The new General Data Protection Regulations (GDPR)8 are due to come into force in May 2018, where all European businesses must legally report if they have received a data breach to the UK Information Commissioner’s Office (ICO). Under the new GDPR, the maximum fine for simply failing to alert the necessary regulatory authority of a data breach within 72 hours could be €10 million (around £8.5 million) or 2% of a company’s global revenue; whichever is greater.9 With this in mind, data security is even more vital and is something that all practitioners

“Having a clear process of what to do in the event of a breach and having a breach response plan is something that every practice and clinic should have” Martin Swann, divisional director of Enhance Insurance

Aesthetics

should be thinking about, according to Swann.

“Having a clear process of what to do in the event of a breach and having a breach response plan is something that every practice and clinic should have,” says Swann, adding, “The important thing with a breach response plan is to know if you suffer a breach, who you need to call, who your emergency breach response team is, who will investigate the breach and collate the data, and – from May – who you need to tell.” Turner Traill says, “Practitioners don’t know enough about data security, which is why we need professional advice and help – we need to have specialists who can deal with these things.”

She concludes, “We can’t wait for a data breach to happen, we need staff to be trained and be vigilant.”

REFERENCES 1. London Bridge Plastic Surgery. ‘Data Security Breach – Patient Statement’ (Oct 2017) <https://www. lbps.co.uk/data-security-breach-statement/?> 2. Meredith, S. ‘UK fraud hits record high after increase in cyber attacks’ (CNBC, Jan 2017) <https://www. cnbc.com/2017/01/24/uk-fraud-hits-record-high-after-increase-in-cyber-attacks.html> 3. Phishing. ‘What is Phishing?’ <http://www.phishing.org/what-is-phishing> 4. Paganini, P. ‘New Intel Security study shows that 97% of people can’t identify phishing emails’ (Security Affairs, May 2015) <http://securityaffairs.co/wordpress/36922/cyber-crime/study-phishingemails-response.html> 5. Bullguard. ‘What is a drive-by download?’ <https://www.bullguard.com/bullguard-security-center/ internet-security/internet-threats/what-is-a-drive-by-download.aspx> 6. Lord, N. ‘What is data encryption?’ (Digital Guardian, July 2017) <https://digitalguardian.com/blog/whatdata-encryption> 7. Shirt, D. ‘Survey reveals low levels of awareness of GDPR amongst marketing firms’ (Irwin Mitchell, May 2017) <https://www.irwinmitchell.com/newsandmedia/2017/may/survey-reveals-low-levels-ofawareness-of-gdpr-amongst-marketing-firms-jq-83094> 8. Swann, M. ‘Getting ready for GDPR’ (Aesthetics Journal, July 2017) https://aestheticsjournal.com/ feature/getting-ready-for-gdpr 9. Official Journal of the European Union, REGULATION (EU) 2016/679 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 27 April 2016, <http://eur-lex.europa.eu/legal-content/EN/ TXT/PDF/?uri=CELEX:32016R0679&from=EN>

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to design your website to attract more new enquiries; while creative digital and design professionals Tracey Prior and Scott Baker will be running a session on how to increase the overall success of your website by making it more user-friendly, increasing your clinic’s revenue.

Build Upon Your Commercial Skills From marketing and clinic development advice to the latest advances in risk management and industry regulations, find out how you can make the most of the high-quality content at the FREE Business Track at ACE 2018 While you may be extremely skilled in delivering cosmetic treatments, managing a clinic reception or understanding patient needs, how does your business knowledge weigh up? You could be the best injector, have outstanding dermatology knowledge or have a lot of loyal patients, but unless you have exceptional business skills, then you won’t have the power to grow to your full potential.

At the Business Track, taking place on April 27-28 at the Aesthetics Conference and Exhibition (ACE) 2018, you will gain crucial non-clinical skills from industry experts that will help take your business to the next level.

Whether you’re new to the specialty, or would like to hear the latest tips and advice, you will advance your skills in the areas of branding and marketing, clinic development, patient experience, as well as gain knowledge in

regulations and risk mitigation.

With 18 free 30-minute sessions to look forward to, there is something for everyone.

All professionals within medical aesthetics can attend, including practitioners, clinic managers, marketing teams, brand directors and clinic staff – your whole team can benefit from this CPD-verified agenda!

Branding and marketing We all know the importance of effective branding and marketing in acquiring patients and driving sales. See business strategy and communications consultant Julia Kendrick reveal how to build and maintain an effective PR and marketing approach to help drive new revenue and growth. Marketing consultant Adam Hampson will share his top tips for digital marketing, Google ranking and how

Martin Swann, divisional director Enhance Insurance ACE Business Track Sponsor “The ACE 2018 Business Track is a great forum for practitioners, clinic managers, and others within aesthetics to obtain some valuable information outside of their technical clinical skills to improve the running of their business. We are excited to be presenting two of our own sessions at the Business Track to give delegates the latest information on how they can mitigate the numerous risks within their clinic and to ensure that they understand the latest data protection regulations. The members of our team are also really looking forward to attending to see what new things we as a business can learn from the 18 different sessions. See you at the Business Track!”

Clinic development Are you looking to build and develop your clinic in the next 12 months? Find out how to grow your clinic from scratch with nurse practitioner Jacqueline Naeini, and learn the latest business and product tips from Dr Rita Rakus, who has more than 20 years’ experience and regularly treats celebrity patients. Determine what your key performance indicators are to set goals and measure your practice’s performance with senior business developer at Allergan, Marcus Haycock; and with new regulations on training approaching, learn how you can choose the right training course to ensure your money is well invested for both you and your staff with cosmetic and dermatology nurse Anna Baker.

If you are thinking of expanding your clinic you will need to devise an effective strategy; branding professional Gary Conroy will explain the best ways to do this, while also explaining how to construct an exit strategy to make your asset attractive to potential investors or acquirers.

Patient experience Improving your patients’ experience is the highest priority for any practitioner. Explore how to offer patients payment plans and finance options to gain new or retain existing patients with Rebecca McDermott, and gather tips for building a prosperous business in aesthetics from successful clinic and training course director Mr Adrian Richards.

If you want to learn how to deliver high patient satisfaction in your clinic, nurse and skincare distributor Lorna Bowes will show you how to select the right treatments that will benefit your particular patient base, while producing positive profits.

Regulation and risk mitigation The do’s and don’ts in terms of regulation, law and risk management is imperative for all aesthetic professionals to bear in mind.

Business Track sponsor, Enhance Insurance, is organising two sessions, which will feature a talk from divisional director Martin Swann and a presentation from integrative psychotherapist Norman Wright, who will discuss concerns with the

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

Insider News mental wellbeing of patients in aesthetics. In this presentation, you will also hear from a medical negligence defense lawyer, who will discuss some of the difficulties that you may face when defending yourself against a claim. With laws and regulations surrounding clinic record keeping and VAT so complex, obtain clear guidance on how to efficiently and legally keep records for medical patients from Veronica Donnelly, while certificated laser protection adviser Dr Elizabeth Raymond Brown will provide you with an update on the latest laser regulations.

As there is much confusion surrounding training standards, and with the new Joint Council for Cosmetic Practitioners (JCCP) launching just before ACE, Dr Tristan Mehta will provide an overview of the standards, compare the register to governmental regulation and give practitioners a clear understanding of what’s expected of them and on how to get on the register.

Finally, insurance broker Naomi Di-Scala will examine high risk treatments and deliver an analysis of the year’s claims trends, providing tips on how you can prevent similar claims.

Also available at ACE By registering free for ACE 2018, you not only have access to the Business Track, but you can also visit the Masterclasses, Expert Clinic and the 2,500m2 Exhibition Floor. Taking place at ACE for the first time is the Elite Training Experience, which comprises four training sessions run by Dalvi Humzah Aesthetic Training, Academy 102, RA Academy and Medics Direct Training. Each session costs just £175.50+VAT if booked before December 31!

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Advertorial Meet the Trainer

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Meet the Trainer Aesthetic nurse Kelly Saynor is the founder of Medica Forte, which provides the Theory of Skin training courses. She talks training opportunities in aesthetic treatments and business skills Tell us about the Theory of Skin. How did you establish the training?

Medica Forte launched the Theory of Skin school in August this year, which is a bespoke, state-of-the-art training suite in Cheshire. Myself and my business partner Justin Saynor decided to open the Theory of Skin as we wanted to consolidate all of the training we provide under one roof, which allows practitioners access to a range of courses, both business and cosmetic focused. In line with HEE guidelines, we wanted to offer practitioners courses that will help them feel like they can assert themselves in front of patients, run their own businesses, train staff, and much more.

What are the main training opportunities available at the Theory of Skin?

We offer a range of business courses, and these include: Having a Powerful Impact: created for everyone who wants to develop their presentation and conference speaking skills, teaching practitioners how to get their message across in an interesting and engaging manner.

Build Trust with Confidence and Competence: aimed at those who struggle to take money confidently without discounting, stand their ground when a patient’s goals are unrealistic and shy away when conversations in the workplace become difficult.

Train the Trainer: designed to teach aesthetic trainers to remain engaged when training small and large groups, how to use certain tools and techniques to maximise the success of a training session, and answer questions in a calm and clear manner.

Inspiring your Team: where practitioners learn how to become an effective and inspirational medical team leader, become aware of their responsibilities as a manager, effectively plan an aesthetic business strategy and communicate with their medical team.

Controlling your Time: with so many practitioners working between NHS and aesthetic practices, the most valuable resource is time, therefore this course is focused on how practitioners can gain control of their time and make more use of it, so that they have the 22

Aesthetics | December 2017

Aesthetics

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Tell us about your experience.

How did you become an aesthetic trainer?

I trained as a nurse at the University of Manchester, specialising in Kelly Saynor paediatrics, and then later moved into cosmetic surgery in 2004, after becoming disillusioned with the NHS. I was fascinated by how aesthetic and cosmetic techniques helped patients improve their appearance without dramatically changing the way they looked. I spent four years in Manchester working for the Harley Medical Group, then worked for various other companies before opening my practice Renew Medical Aesthetics in 2008. I realised, after doing training for other companies and having positive feedback, that training was something I knew I enjoyed and wanted to do more of. So, I decided to develop my own training courses to utilise my knowledge.

Together we saw a real gap in the market Who else supports your training?

Jane Seward BA (Hons), CIPD CTP runs the business courses and is a qualified associate trainer who has Jane Seward more than 17 years’ experience, both nationally and internationally.

She has operated as part of a training team within huge organisations such as Ikea, to train their staff, and has spent six years working as a CIPD accredited trainer in the Middle East. She was an ex-patient of mine – that’s how we met, so we had already built a relationship where we trusted one another. Together we saw a real gap in the market for these types of courses.

Jane has delivered more than 30 courses covering key skill areas and has been working as a freelance trainer with several training providers, who specialise in key competence areas such as communication, leadership, time management and customer services.

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Aesthetics

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Advertorial Meet the Trainer

K E Y STATS 20 years’ clinical experience 14 years in medical aesthetics 3-4 courses per month 10 delegates or less per class

potential to achieve more in their job and aesthetics career.

We also offer cosmetic training, which includes The Perfect Peel, as well as two cosmetic courses, Understanding Chemical Peels; which is focused on different chemical peel types and depths, and Microsclerotherpy; where practitioners learn to treat different types of varicosities.

Who would benefit the most from attending your training sessions?

All aesthetic practitioners, as well as clinic managers would benefit from these courses. When it comes to personal qualities, we don’t get taught how to make a memorable presentation or how to stand out in front of our peers. Most practitioners also multi-task by running a clinic and caring for their children and are not ‘business people’, so don’t know how to effectively manage their time. We offer courses to help in all of these areas.

What are the measurable outcomes for trainees and how are they assessed?

All of our courses are CPD accredited and trainees will get a certificate that allows them to successfully deliver the course that they are being

TES T IM O NIA L S “I can’t express how much I have enjoyed today. Loved every minute and I feel I have learnt a vast amount.

Thank you so much for everything, it was fab!”

Amy Smith, nurse prescriber

“I often leave courses feeling alone and flat. Your energy is amazing and I really hope to build The Perfect Peel brand within my clinic and do good work.”

Rachel Morris Healy, aesthetic nurse

“Your training inspired me to read further into dermatology and then tell my client list about what I had learned... after a 12-hour day, that’s saying something. Thank you so much.”

Dr Kathryn Taylor-Barnes

trained in. The courses are all insured by cosmetic insurance company Hamilton Fraser and we are one of their recognised training centres.

For the cosmetic courses, delegates have hands-on training and I watch them perform the treatment. Once I have seen them do two or three treatments, I assess whether they are competent.

What support do you offer once a delegate’s training has been completed?

Once delegates have attended any of the business-focused courses, they should feel happy and confident to go off and utilise their new knowledge and skills. For the cosmetic courses, I am always keen to make sure that all of my delegates know they can contact me at any time to answer any of their questions. I always offer them my contact details in case they need any additional support.

UPCOMING TRAINING DATES • Controlling your time • Jan 10, Feb 14, Mar 21 • Build Trust with Confidence & Competence Jan 17, Feb 21, Mar 28 • Having a Powerful Impact Jan 24, Feb 28 • Train The Trainer (3 day course) Jan 29-31 & Mar 5-7 • Inspiring Your Team Feb 7 & Mar 14 • The Perfect Peel Webinar Training Feb 15, Mar 15 • Understanding Chemical Peels Mar 13 • The Perfect Peel Training Mar 27 For more information on training, please contact us: E info@medicaforte.com T 0330 111 8574

For a comprehensive range of facial aesthetics training, look out for the new Med-fx training portal – launched in November at medfx.co.uk Aesthetics | December 2017

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An Overview of Microneedling Practitioners discuss the various microneedling options and important considerations to be aware of when delivering this procedure The concept of administering controlled injury to the skin to induce collagen production is one that all aesthetic practitioners will be familiar with. When causing the right form of injury, the dermis reacts to the trauma by repairing itself, generating new collagen and elastin; resulting in a rejuvenated appearance.1 The treatment is widely known as microneedling, collagen induction therapy and percutaneous collagen induction, and it is routinely performed in clinics across the globe. But how did it originate? And how has it developed since then?

History • 1995: Orentreich and Orentreich coin the term ‘subcision’ and publish a study on treating scars through wound healing2 • 1996: Dr Des Fernandes shares his first work on skin needling of lines above the lips3 • 1997: Dr Andre Camirand et al. publish two years’ worth of research on using tattoo guns without ink to treat post-surgical scars4 • 1999: Dr Des Fernandes presents clinical studies on using needling for skin rejuvenation5 In 1995 dermatologists Dr Norman Orentreich and Dr David Orentreich described a newly-coined term ‘subcision’ as a minor surgical procedure for treating depressed scars and wrinkles. They inserted a tri-beveled hypodermic needle through a puncture in the skin’s surface and manoeuvered its sharp edges under the defect to make subcuticular cuts or ‘subcisions’. The researchers found that the depression was lifted by the releasing action of the procedure, as well as from the connective tissue that forms through normal wound healing.2 In 1997, Montreal-based plastic surgeon Dr Andre Camirand et al. published their research on using tattoo guns without ink to treat post-surgical scars. After a couple of Before

After

Figure 1: Before and after two SkinPen treatments. Images courtesy of Christina Clarke, Bellus Medical and BioActive Aesthetics.

Before

Aesthetics

years of research, they found that hardened scars were softened, making them more mobile, stretchable and less evident, while achromic (no colour except black, white or shade of grey) scars began to re-pigment. In their study, Dr Camirand and his team also cite similar cases they learnt of, which were described in 1992 and 1993, where the appearance of scars was improved simply through needle punctures. Around the same time as Dr Camirand’s research, plastic surgeon and founder of Environ skincare, Dr Des Fernandes extended the needling concept to include overall skin rejuvenation.

His first work on the subject covered skin needling on lines just above the lips presented at the International Society of Aesthetic Plastic Surgery (ISAPS) congress in Taipei in 1996.3,5 In an article reflecting on his innovation, he explained that like Dr Camirand, he started by using a tattoo artist’s device with a flat array of four needles (a stamp) that could penetrate 1-2mm into the skin. He soon found, however, that intensive needling led to downtime of up to 10 days. As such, he said, “I reasoned that if one could use a roller with 3mm needles, one could needle deeper and probably faster and because there would be fewer holes, the skin would return to a normal appearance sooner.

Intensive treatments this way looked almost the same as using a tattoo gun, but the healing time was reduced to five to seven days.”6 In 1999, Dr Fernandes said he had a sufficient number of clinical results to present to delegates in a presentation to the ISAPS conference in San Francisco, which he felt was well received by delegates and significantly influenced the development of microneedling.6 Various microneedling devices have since been created, with different modes of action and unique selling points.

Aesthetics speaks to six practitioners to learn more about their microneedling experiences and important considerations to be aware of for this type of procedure.

Indications and treatment Microneedling can be used for broad indications, says surgeon and aesthetic practitioner Miss Jonquille Chantrey. “I use it to improve skin texture and even skin tone, as well as to thicken the skin and improve the strength of the dermis. I’ll offer microneedling to patients who’ve got sagging skin and to those that have increased pore size.

It may not necessarily reduce the pore size but, in my experience, it does help to improve the skin’s support around the pores, which can sometimes help with their appearance,” she says, adding that microneedling can also be used to improve the appearance of sun damage, burns, scarring and where skin grafts meet normal skin.

For all the practitioners interviewed, microneedling is one of the most straightforward treatments they offer. Dermatologist Dr Harryono Judodihardjo explains, “Microneedling is an option if After

Figure 2: Before and after two INTRAcel treatments. Images courtsey of SmartMed and Healthxchange Pharmacy.

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. Instructions for Use (IFU) RadiesseÂŽ 3. Schachter D, et al. Calcium Hydroxylapatite With Integral Lidocaine Provides Improved Pain Control for the Correction of Nasolabial Folds. Journal of Drugs in Dermatology. August 2016; Volume 15. Issue 8. 1005-1011 4. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ deviceapprovalsandclearances/pmaapprovals/ucm439066.htm

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Before

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After

Figure 3: Before and after three INTRAcel treatments. Images courtesy of Smartmed and Healtxchange Pharmacy.

someone cannot afford downtime or is on a tight budget.”

That is not to say, though, that it doesn’t offer noteworthy results.

Consultant oculoplastic surgeon and aesthetic practitioner Dr Maryam Zamani notes, “It’s very well received. Patients like it because it’s something they understand – creating an injury to generate new collagen – they feel like they’re doing something good for their skin without being artificial. Microneedling can have excellent results.” Board-certified dermatologist Dr Stefanie Williams adds, “It’s a very natural treatment because we are just using the skin’s own regenerative potential. There is also the potential to customise microneedling by adding solutions or serums to needle in, such as growth factor solutions or platelet rich plasma (PRP), which is my favourite, or a skin lightening solution – it’s very customisable.”

Skin preparation “The majority of my patients go on a skin protocol before any type of skin intervention. A couple of weeks of preparation just to get the skin in better function usually gets good results,” says Miss Chantrey.

Dr Williams agrees, noting that she puts her patients on a regime that consists of an antioxidant and SPF in the morning and vitamin A in the evening. “If patients have darker skin types, I start them on an anti-pigment serum as well, four weeks prior to microneedling to avoid post-inflammatory hyperpigmentation,” she states. Aesthetic practitioner Dr Rita Rakus offers her patients a skin analysis to determine the depths of lines and pores prior to microneedling. She says that the skin prep regime she recommends will vary depending on the patients’ concerns and budgets, noting, “If patients choose not to undergo a skincare regime prior to treatment, I will treat them as long as they haven’t done anything beforehand that could make their skin sensitive, such as too much sun exposure.”

As with any aesthetic treatment, infection control Before prior to a procedure is paramount. Dermatologist Dr Harryono Judodihardjo explains that he starts by removing all makeup, cleansing the skin with antibacterial skin preparations and wiping the skin dry before applying a topical anaesthetic cream.

Aesthetics

microneedling cylinder-shape ‘drums’ come with various needle lengths ranging from 0.5-3mm. Some rollers can also be used at home by the patient for basic skin rejuvenation, however Dr Judodihardjo advises patients to use a shorter needle length. He explains, “For selftreatment the 0.5mm needle length is recommended as, at this length, the treatment is not painful. I tell patients that this home treatment can be done daily or at least three times per week. Each device can be used up to 100 times.” For facial tightening, Dr Judodihardjo says he uses needle lengths ranging from 1-1.5mm, with treatments repeated monthly, three to five times. To treat scars, however, he advises that longer needles are needed; ranging from 1.5-3mm and repeated every six weeks, five times. “For facial tightening and scar treatments using longer needles for deeper skin penetrations, it is more appropriate that they are performed in a safe and hygienic clinical setting,” he advises.

Pens Dermatologist Dr Simon Zokaie is an avid user of the Dermapen 3. He explains that he moved from using a roller as he felt the pen allowed him to treat different skin conditions in one treatment.

“With the rollers you have certain depths that are set, so often you need several different rollers to treat various parts of the skin for different concerns. In my experience, switching rollers to treat different depths can be difficult, whereas the pen allows flexibility to change my needle depth throughout the treatment with the simple press of a button,” he explains, adding, “The pen also has a speedometer, which helps the practitioner vary the speed on different parts of the skin with one tip.”

The Dermapen 3 consists of 12 needle cartridges, which are sterilised in single-use packages, to reduce the risk of cross contamination. It is plugged in to use and creates 1,300 microchannels per second and practitioners can purchase various different pens that have different mechanisms of action.7,8 Dr Zamani also prefers to use a pen. She uses the SkinPen, which consists of 14 straight needles that work at 7,000 revolutions per minute at depth settings from 0-2.5mm.9 “It’s wireless and works for six hours after charging,” she says, noting that, for her, this greatly improves ease of use and reduces the risk of the wire becoming contaminated with patients’ blood. The device has a sealed cartridge that aims to prevent fluid intake and also comes with a disposable sleeve, which again aims to keep the pen hygienic.9 After two treatments

After three treatments

Devices There are numerous microneedling brands on the market, making it impossible to cover all in one article, however the technology now generally consists of rollers, pens and those that are used in combination with energy-based treatments, as covered below.

Rollers Dr Judodihardjo uses the Genuine Dermaroller for his microneedling treatments. He explains that the

Figure 4: Before and after three treatments with the Dermapen. Images courtesy of Dermapenworld and Naturastudios.

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Energy-based combinations Dr Rakus and Miss Chantrey both combine their microneedling treatments with radiofrequency, using INTRAcel, with Miss Chantrey using the INTRAcel FRM handpiece as an add-on to ULTRAcel, which is another skin rejuvenation device that can be combined with INTRAcel. Dr Rakus explains that the INTRAcel works by using insulated microneedles with bipolar radiofrequency energy, which aim to destroy the damaged tissue in the dermis.10 This, she explains, gives rise to new collagen. “Because the needles are insulated, it stops the epidermis being burnt,” she says, adding, “The device also has different powers and depths, so you can adjust the treatment depending on if you want to treat superficial lines, skin rejuvenation, acne scars, skin quality or increase elasticity. It targets the problem at a deeper level in a profound way, without cause unnecessary damage anywhere else,” she explains. For Dr Rakus, she says she will often give patients a free INTRAcel treatment to demonstrate its benefits.

“After the treatment they say, ‘wow I can really see results’ – we need to break them out of their comfort zone.” Following that she usually offers a course of three treatments, one month apart.

Post treatment “I ask patients not to have a sauna or go swimming, not to put on makeup and avoid direct sun exposure on the same day as a microneedling treatment,” says Dr Zokaie, adding, “I also advise them not to use any harsh soaps or exfoliants on the treated area for a day, just in case they irritate the skin.” Similarly to the pretreatment skincare protocol, depending on the concern, Dr Zokaie recommends a number of skincare protocols. Most commonly for antiageing, he recommends patients use retinol products at night, deep cleansers, moisturisers with HA serums for hydration and antioxidants to help protect the skin, along with a sunscreen. He adds, “I also give them a cooling facial mask to take home with them. It’s not essential but it is nice to use for 20 mins to an hour as it relaxes and hydrates the skin following the microneedling.”

Dr Chantrey agrees with Dr Zokaie’s advice, explaining, “I’m really strict about infection control so tell my patients no makeup for the rest of the day. I also tell them not to wash their face – leave it completely for about 24 hours. I advise that after 24 hours, patients can start using mineral makeup and clean makeup brushes. I then put them back onto their existing skincare routine. Once their skin barrier has improved after a few days I start to introduce the retinol again – this is probably between day three and five.”

Dr Judodihardjo says, “Immediately after the treatment the skin is porous and will momentarily allow some percutaneous drug penetration. We tend to apply ascorbic acid [vitamin C] immediately after the treatment. The skin needs to be moisturised over the next seven days and patients need to be advised to avoid UV exposure for at least three months after microneedling.”

Contraindications, side effects and complications Miss Chantrey explains that the only time she wouldn’t use microneedling is if the skin has keloid scarring, active infection, active acne, or a dark and unstable skin type. If a practitioner were to use a roller over an area of active infection, it could spread and cause more concerns such as hyperpigmentation and scarring, she advises.

General side effects of microneedling include bleeding, slight bruising, redness, dryness and skin flakiness. More serious issues include hyper- and hypo-pigmentary changes, and infection, which is why recognising a patient’s Fitzpatrick skin type and putting them on an anti-pigment serum prior to treatment is so important, emphasises Dr

Aesthetics

Williams. As discussed previously, maintaining strict hygiene control will considerably reduce the risk of infection, adds Miss Chantrey.

The possibility of cross contamination has significantly influenced Dr Williams’ choice of product. While she prefers to use a pen over needle rollers, she will only use one per patient; rather than having one pen with interchangeable needle heads. She explains, “The patient may have a course of six treatments and we re-use that pen for all six, with fresh sterile needles of course, but it’s one pen per patient because of the potential for backflow into the handpiece.”

Of course, Dr Williams says that she appreciates many practitioners may not want to change pens for every patient or simply cannot afford to so. As such, she emphasises that it is vital that they are not only changing the needle but are thoroughly spraying the hole where the needle goes in the handpiece with alcohol spray to minimise the risk of contamination.

Dr Williams also points out the risk of needlestick injury to the practitioner administering the treatment when using a traditional needle roller. She found that that there is a higher risk for the practitioner to sting themselves when using a roller, which also carries a risk of cross contamination. “Two of my practitioners had a needlestick injury in clinic with a needle roller,” she says, continuing, “With the pen, the needles go in at 90 degrees, so there is a much lower risk of injury to the practitioner, as well as risks of micro-tearing the patient’s skin, when coming in from a 45 degree angle. We’ve never had a needlestick injury since we’ve used pens.”

For practitioners using energy-based devices, there is also the risk of burns to consider. “Practitioners have to be really well trained on their device so they really understand how they behave,” says Miss Chantrey, advising, “It’s important to be very careful with microneedling technically – I’ve seen patients over the years who’ve sustained iatrogenic injuries which have resulted in scarring after devices have been dragged across the skin.”

Conclusion Before offering any microneedling treatment, Dr Rakus advises, “Make sure you are properly trained and know the protocol.

With experience, you can get much better results as you won’t be nervous and under-treat the patient. But of course, don’t take risks. Don’t transgress the rules and break protocol to experiment, especially early on. If you want to, discuss this with the trainers and colleagues to agree best practice beforehand.”

She concludes, “Remember that there’s no point being the best person at microneedling if your patients aren’t also taking care of their skin. It’s vital to spend plenty of time emphasising the importance of skincare to patients and giving them treatments that really work.”

REFERENCES 1. Alster TS, Graham PM, ‘Microneedling: A Review and Practical Guide’, Dermatol Surg, (2017).

2. Orentreich DS, Orentreich N, ‘Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles’, Dermatol Surg. (1995) 21(6), pp.543-9.

3. Dr Des Fernandes, ‘Skin needling for treating wrinkled upper lips and difficult scars – an alternative to laser resrufacing’ <https://emaniocreativecom.ipage.com/files/product-information/white-papers/ needling/Skin-needling-for-treating-lips-and-scars.pdf> 4. Camirand A, Doucet J., ‘Needle dermabrasion’, Aesth Plast Surg (1997) 21(1), pp.48-51.

5. Dr Des Fernandes, The Evolution of Microneedling (NZ: Spa & Beauty, 2015) <https://www. spabeauty.co.nz/Beauty+Articles/x_post/the-evolution-of-skin-needling-00260.html> 6. Healios Wound Solutions, Collagen Induction Therapy (US: Healios Wound Solutions, 2017) <http:// www.healioswoundsolutions.com/collagen-induction-therapy/> 7. Dermapen World, Dermapen 3: The Latest Micro Needling Device (US: Dermapen World, 2014) <https://www.youtube.com/watch?v=TFsIKqswqGs> 8. Naturastudios, DERMAPEN (UK: Naturastudios, 2017) <https://www.naturastudios.co.uk/dermapen_ home.php> 9. SkinPen, SkinPen Precision offers Next Generation Micro-Needling Technology (US: SkinPen, 2017) <http://www.skinpenuk.com> 10. Healthxchange Pharmacy, INTRAcel Treatment (UK: Healthxchange Pharmacy, 2017) <https://www. healthxchange.com/treatments/intracel>

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Laser and Light Intervention Standards Dr Elizabeth Raymond Brown and clinical technologist Dr Godfrey Town present the different standards and regulations in the UK for laser and light interventions Lasers and intense light sources (ILS) – which include intense pulsed light (IPL) and light emitting diode (LED) technologies – are suitable for a range of interventions, from invasive surgical procedures, such as laser lipolysis and ablative skin rejuvenation, to non-invasive therapies, such as hair reduction, tattoo removal and non-ablative skin rejuvenation. Lasers and ILS are subject to standards and regulatory controls because of the unique potential hazard they pose to tissues of the eye and skin, including the risk of blindness and skin burns.1,2 In the European Union (EU), including the UK, devices based upon optical energy have been used for both medical and cosmetic applications. The Care Quality Commission (CQC) defines the scope of medical or surgical procedures as treatments provided by a healthcare professional, which are related to disease, disorder or injury.3 This is reflected in the European Medical Device Regulation (MDR),4 which comprises requirements that relate to the safety and performance of medical devices. This article describes the different standards and regulations for medical and cosmetic devices in the UK and explains what aesthetic practitioners need to know with regard to purchasing and training.

EU regulation of device manufacturing Any medical device placed on the EU market must comply with relevant legislation. Manufacturers' products which meet 'harmonised standards' have a presumption of conformity to the MDR (previously the Medical Device Directive or MDD). These products must have a Conformité Européenne (CE) mark applied. To ensure a device meets the MDR’s requirements, a device manufacturer may nominate an organisation called a Test House or Notified Body which has been recognised by an EU Member Government. This Notified Body may be a private sector organisation or a government agency, and serves as an independent testing service. It will undertake equipment tests against the relevant European Standards, called European Norms (EN), and scrutinise user guides, labelling equipment features and functions.5 For example, a key standard for medical lasers is EN 60601-2-22:2013 ‘Medical electrical equipment: Particular requirements for basic safety and essential performance of surgical, cosmetic, therapeutic and diagnostic laser equipment’.6 Under the previous MDD, EN 606012-22:2013 was harmonised with the Directive, meaning that if a laser is deemed to have passed the tests against the requirements of EN 60601-2-22:2013, then by presumption of conformity, the equipment will also satisfy the relevant sections of the new MDR. EU standards and Brexit The UK’s membership of the International Standards Organisation (ISO)7 and International Electrotechnical Commission (IEC),8 will be unaffected by the UK leaving the EU.9 The British Standards Institute

KEY abbreviations: • British Medical Laser Association (BMLA) – society for medical lasers in the UK. • British Standards Institute (BSI) – the UK National Standards Body, holds the UK membership of CENELEC, CEN, ETSI. • European Committee for Electrotechnical Standardization (CENELEC) – is responsible for standardisation in the electrotechnical engineering field.

• European Committee for Standardization (CEN) – one of three EU organisations (with CENELEC and ETSI) who are responsible for developing and defining voluntary standards at European level.

• European Medical Device Regulation (MDR) – previously the Medical Device Directive or MDD. This comprises requirements that relate to the safety and performance of medical devices.

• International Electrotechnical Commission (IEC) – prepares and publishes international standards for all electrical, electronic and related technologies.

• International Standards Organisation (ISO) – independent, non-governmental international organization with a membership of 162 national standards bodies.

(BSI),10 as the UK National Standards Body, will continue its work developing and publishing British Standards and there will be no change in this activity. At a European level, the BSI holds the UK membership of the three European standardisation organisations: the European Committee for Electrotechnical Standardization (CENELEC),11 the European Committee for Standardization (CEN),12 and the European Telecommunications Standards Institute (ETSI).13 CENELEC and CEN are private organisations outside of the EU, responsible for coordinating the work of 34 countries in producing and circulating European EN Standards. Post-Brexit, the BSI’s membership will continue as normal in making and publishing standards and it is the organisation’s ambition for the UK to continue to participate in the development of European Standards through full membership of CENELEC and CEN. Since CENELEC and CEN are independent from political authorities, BSI’s aspirations are unaffected by Prime Minister Theresa May’s announcement on January 17 2017 that the UK will leave the Single Market.9,14 New EU regulations New regulations were formally published in May 2017 and will replace the current Directive (93/42/EEC) as well as the Active

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Implantable Medical Device Directive (90/385/EEC).4 The new Medical Device Regulation (MDR), which applies fully from May 2020, will bring more scrutiny of technical documentation and address concerns regarding the assessment of product safety and performance by placing stricter requirements on clinical evaluation and post-market surveillance. It also requires better traceability of devices through the supply chain.

Therefore, irrespective of whether a medical intervention is intended or not, all devices emitting infrared, visible or ultraviolet radiation, including coherent and non-coherent sources, intended for use on humans, will fall under the new MDR.4 One of the key objectives of the new MDR will be ‘To give patients, consumers and healthcare professionals confidence in the devices they might use every day’.15 An important consequence of the new MDR will be the obligation that professional cosmetic and consumer lasers and ILS devices that are not currently sold as medical devices will be reclassified.

This means they will be required, amongst other obligations, to meet the conditions of quality assurance in production, clinical evidence of efficacy and safety, post-marketing surveillance and remedial action planning.4

Aesthetics

China Export mark Unfortunately, it has been alleged that a fraudulent and fake ‘China Export’ mark exists with a striking similarity to the official Conformité Européenne China Export European CE marking (Figure 1). There is Figure 1: Comparison of the official CE mark and alleged ‘China Export’ mark.26 The differences can be actually no official observed in the scaling of the marks and the spatial China Export mark. difference between the C and the E. Some people may get confused with this as it implies that the product meets relevant Directives – this was raised in the European Parliament in 2008.25 Consequently, many of the lower cost devices, that are regularly purchased online from countries in Eastern Asia/China and are typically used in beauty clinics rather than the medical sector, might not comply with any of the required standards for safe use. The CE mark may be no smaller than 5mm high and its proportions must follow the graduated drawing in Figure 1. If a Notified Body has been involved in the conformity assessment procedure, its four-digit identification number must also be displayed.26

UK regulation of device manufacturing The Medicines and Healthcare products Regulatory Agency (MHRA)16 is responsible for the regulation of therapeutic products in the UK. Particular interventions are deemed to be a CQC ‘regulated activity’ when undertaken by registered healthcare professionals (HCPs), which are provided under The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.17 For laser and ILS devices sold as non-medical, professional cosmetic treatment devices, it is the role of the Chartered Trading Standards Institute (CTSI), which is supported by Public Health England (PHE), an executive agency of the DoH,18 to enforce the standards. The CTSI is a professional association which represents trading standards professionals working in local authorities, business and consumer sectors. However, lack of a national trade or professional body to monitor the cosmetic device industry means that public complaints against clinics or practitioners rarely result in successful enforcement or prosecution.

CE marking For medical and non-medical laser and light devices to be sold legally in both the UK and EU, they must be legitimately CE-marked.19 Equipment bearing the CE symbol should indicate conformity with the relevant European Directive(s) such as the MDD.20 CE-marked medical devices which meet the MDD also carry a four-digit reference number from which the Notified Body, member state and Directive can be traced.21 It is assumed by many practitioners who use laser and light devices that CE-marked equipment is compliant with the MDD, and the majority of devices are. However, some equipment, particularly if directly imported by individuals and not through a recognised supplier, can bypass testing requirements and carry only the Supplier Declaration of Conformity (SDoC) from the country of manufacture.

A Declaration of Conformity states the name and address of the

organisation responsible for the product, lists the EU Directives and standards it meets and is dated and signed by the organisation placing the product on the EU market. This means that the device may not necessarily carry a legitimate CE mark for the intended purpose of the device.

Although not harmonised with the MDD, these SDoCs should ideally meet BS EN ISO/IEC 17050-1:201022 quality assurance and EU electrical safety standards, but for privately imported equipment, there is no monitoring or guarantee of conformity. In these instances, the obligation to ensure that the devices meet relevant EU Directives and standards is the responsibility of the individuals purchasing the device directly. In the eyes of the law, they are the importer and they are legally responsible for the safety of the product in its use on consumers.23,24 It is widely accepted amongst informed practitioners that there is little to stop the sale (usually via the internet), of incorrectly or falsely CE-marked devices, which may lack adequate EU electrical safety compliance and medical device safety compliance. Most worryingly, such devices are readily available to purchase by those who may not be appropriately trained to operate such devices. Typically, such buyers often practise without professional body regulation, guidance or standards.

Regulations of device use in the UK We have explained the standards and regulations relating to laser and light device manufacturing, but it is important to also consider factors controlling the actual use of such devices.

Up until October 2010, both HCP and non-HCP treatment providers using lasers and ILS devices in England were regulated by the CQC in facilities providing either treatment of disease, disorder or injury, non-surgical cosmetic interventions, or both.27 The Care Standards Act 2000 included standards for various providers. These standards covered ‘Prescribed Techniques and Prescribed Technologies’ or ‘P’ standards for laser and ILS therapies. The ‘P’ standards provided the basis for the IHAS Essential Standards, which were updated in 2015/16 and relaunched by the British Medical Laser Association

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(BMLA) in October 2016.28 They reflect essential arrangements for safety and quality, as well as providing a useful template for facility audit by both clinic management and enforcement/regulatory bodies.

In 2010, the UK Government deregulated the cosmetic sector in England with the repeal of the Care Standards Act 2000.29 This has allowed anyone in England to purchase laser and ILS devices legally and deliver treatments with little or no training. There are also few restrictions on working from appropriate premises or enforcement of holding suitable insurance.

As a result of devolved UK government powers to Wales and Northern Ireland, while the repeal of the Care Standards Act 2000 took place in England, the provisions of the ‘P’ standards still apply in these areas. They are enforced by the Health Inspectorate Wales (HIW)30 and the Regulation and Quality Improvement Authority (RQIA)31 in Northern Ireland.

In certain regional areas of England, namely the London boroughs,32 Birmingham,33 Nottingham34 and some Essex boroughs,35 a licensing scheme exists for establishments that provide ‘special treatments’, which include; massage, electrolysis, laser and ILS therapies. In London, this licensing scheme is delivered under provisions of the London Local Authorities Act 1991.32 The ‘P’ standards that apply in Northern Ireland and Wales and the ‘Special Treatment Licence’ provisions of some UK boroughs, are very similar in content.30,36 Regulation in Scotland On April 1, 2011, Healthcare Improvement Scotland (HIS)37 took over the regulation of independent healthcare services in Scotland from the CQC. The current National Care Standards (NCS) of the Scottish Government for laser and light interventions were designed to improve and maintain the quality of delivered services, as required by the Regulation of Care (Scotland) Act 2001.38 The key legislation is the Public Services Reform (Scotland) Act 201039 and the Scottish Statutory Instrument (SSI) relating to HIS (Requirements as to Independent Health Care Services) Regulations 2011.40 Until recently, HIS only regulated independent hospitals, voluntary hospices and private psychiatric hospitals. However, since April 1, 2016, HIS formally registers independent clinics in Scotland where services are provided by medical practitioners, registered nurses, midwives, dental practitioners and dental care professionals. It became an offence to operate an unregistered independent clinic in Scotland from April 1, 2017.41 The HIS regulations clearly state that a provider must have appropriate systems, processes and procedures for all aspects of care and treatment carried out by the independent healthcare service, including the use of Class 3B or Class 4 lasers and ILS equipment.37 Moreover, the National Care Standards for Independent Specialist Clinics,42 which only exists in Scotland, requires clinics to, ‘Take account of all relevant legislation and current good practice guidelines’, citing the MHRA guidance. Thus, the expectation is that independent clinics in Scotland using laser and light devices, must have access to the services of a certified laser protection adviser and work to a set of Local Rules detailing safety procedures as specified by the MHRA.1 Training Whilst there are standards and guidance documents relating to the use of laser and light devices, standards for the training of practitioners is less widely available.1,2,6,43 Training currently available for laser and light devices has variable

Aesthetics

content, duration and quality. This may be due to the wide variation in equipment pricing in a highly competitive marketplace and a variety of distributors and outlets. Reputable distributors will provide online or face-to-face training, typically ranging from one to three days in duration and will offer users certification. Although there are many legitimate and useful manufacturer training courses, there are some that are not competence based, nor formally assessed, therefore the quality of such training is variable and difficult to align with academic standards such as those proposed by Health Education England (HEE), which is discussed below.

The standard BS EN 16844:2017 ‘Aesthetic medicine services – Nonsurgical medical procedures’44 was developed concurrently to the surgical standard (BS EN 16372:2014 ‘Aesthetic surgery services’) by the CEN/TC 403 technical committee.45 It was approved by national committees in January 2017 and was published on July 31.

This British Standard provides recommendations for procedures for clinical treatment, including the ethical framework and general principles according to which clinical services are provided by all aesthetic practitioners. These recommendations apply before, during and after the procedure.

Outside London and some provincial councils with unitary powers to control certain cosmetic interventions through Special Treatments licensing, this non-surgical medical procedure standard provides an authoritative benchmark guide for local authorities in England seeking to ensure compliance under general safety legislation.

The use of laser and ILS in the UK is firmly established in both the private and public sectors, hospital departments, private aesthetic clinics and beauty salons. As we have seen, their use has been underpinned by British and international standards and guidance documents since the 1980s with the MHRA Guidance publication1 and standards such as BS EN 60825-8:2006.2 The current MHRA Guidance document1 contains the ‘Core of Knowledge’ syllabus (Appendix C), which in the UK, remains a fundamental component of laser and light-related education and training in both the private and public sectors.

Voluntary educational guidance Guidelines are general rules, codes of conduct or statements that determine a course of action. Although not binding or legally enforceable, when issued by a professional authoritative body such as the BMLA or the European Society for Lasers and Energy Based Devices (ESLD), they may carry weight in litigation cases where they provide a ‘benchmark’ in establishing whether the actions of a professional could be deemed to be competent or not e.g. the Bolam test.46 In November 2015, HEE published a recommended qualification framework for delivery of cosmetic procedures in two parts.47,48 This publication provided the indicative content and knowledge elements of training and education for practitioners delivering a range of non-surgical interventions. The recommended framework developed by HEE has been adopted and is now owned by the newly formed Joint Council for Cosmetic Practitioners (JCCP). The JCCP remit is to develop and implement credible training frameworks and competencies, supported by registers of practitioners and training providers that are open to public scrutiny, by 2018.49 However, the JCCP recognises that the registers will be voluntary for non-surgical cosmetic interventions and will therefore not be a legal requirement.45 This UK sector is currently well served by a significant number of credible, robust, academic programmes of study, ranging from Quality and Credits Framework (QCF) Level 3 to Level 7 in all laser and light

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modalities listed in the HEE documents, namely: hair reduction, skin rejuvenation, tattoo removal, treatment of vascular and pigmented lesions, non-ablative and ablative therapies. The core HEE principles should be included within the programme specifications of credible training providers which include: patient assessment, informed consent, information governance and record keeping, ensuring that practitioners have a clear understanding of the requirement to operate from safe premises, infection control, treatment room safety and adverse incident reporting.

Conclusion Variations in UK regional Government policy have led to significant disparities in licensing and enforcement of controls over the use of lasers and ILS devices in the UK. The distinction between ‘medical’ and ‘cosmetic’ causes issues when assessing which agency is responsible for the enforcement of equipment standards. Equipment compliance standards are too easily avoided, mistaken or overlooked through internet purchase and weak enforcement, plus Chinese export marketing methods can create insecurity about the legitimacy of the CE marking on some devices.

Recently published surgical and non-surgical standards provide guidance for procedures for clinical treatment and should be used as reference documents for good practice in areas of England where no regulatory controls exist.

Learners in the UK have access to a range of robust accredited courses and qualifications with competencies that accurately assess the clinical knowledge and skills recommended within the HEE publications. Given the number of credible programmes that exist, it is beholden upon practitioners to continue their professional and personal development in this growing specialism to deliver high standards of treatment and patient care.

Dr Godfrey Town is an RPA2000 certified laser protection adviser and holds a PhD in light-based therapy at the University of Wales, Swansea and has an Expert Witness Certificate from Cardiff University Law School.

He is a registered clinical technologist and has published more than 25 peer reviewed scientific and clinical papers. He sits on several international laser and light safety standards committees.

Dr Elizabeth Raymond Brown holds a PhD and has teaching and assessing qualifications from Loughborough University. She is an RPA2000 certified laser/light protection adviser, has published papers and journal articles and developed nationally recognised qualifications in laser therapies. She is a regular contributor to conferences, workshops and training events in the medical cosmetic laser sector.

REFERENCES: 1. Medicines and Healthcare products Regulatory Agency. Lasers, intense light source systems and LEDs – guidance for safe use in medical, surgical, dental and aesthetic practices. MHRA; 2015.

2. British Standards Institution. BS EN 60825-1:2014. Safety of laser products. classification and requirements. London: British Standards Institution; 2014.

3. CQC, Treatment of disease, disorder or injury, 2013. <https://www.cqc.org.uk/sites/default/files/ documents/ra_5_treatment_of_disease_disorder_or_injury.pdf> 4. Regulation (EU) 2017/745 of the European Parliament and of the Council of 5 April 2017 on medical devices, amending Directive 2001/83/EC, Regulation (EC) No 178/2002 and Regulation (EC) No 1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC, Article 2: Definitions (1) <http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32017R0745> 5. EU Commission, Notified Bodies, 2017. <http://ec.europa.eu/growth/single-market/goods/buildingblocks/notified-bodies/> 6. British Standards Institution. BS EN 60601-2022:2013. Medical electrical equipment. Particular requirements for basic safety and essential performance of surgical, cosmetic, therapeutic and diagnostic laser equipment. London: British Standards Institution; 2013.

7. ISO, About ISO, 2017, <https://www.iso.org/about-us.html> 8. IEC, About IEC, 2017, <http://www.iec.ch/about/> 9. BSI, Standards policy on the UK leaving the EU 2017 <https://www.bsigroup.com/en-GB/about-bsi/ uk-national-standards-body/EUReferendum/> 10. BSI, About BSI, 2017, <https://www.bsigroup.com/en-GB/about-bsi/>

Aesthetics GENLEC, Who we are, 2017. <https://www.cenelec.eu/aboutcenelec/whoweare/index.html> CEN, Who we are, 2017. <https://www.cen.eu/about/Pages/default.aspx> ETSI, About ETSI, 2017. <http://www.etsi.org/about> BBC, Brexit: UK to leave single market, says Theresa May, <http://www.bbc.co.uk/news/ukpolitics-38641208> 15. USE REF 4 & IRQA, Medical Device Regulation, (MDR), 2017, <http://www.lrqa.co.uk/standards-andschemes/mdd/new-medical-device-regulation/> 16. The Health and Social Care Act 2008 (Regulated Activities) Regulations SI 2014 No. 000. s 3.1.

17. The Health and Social Care Act 2008 (Regulated Activities) Regulations SI 2014 No. 000. s 3.1.

SCHEDULE 1: Regulated Activities 4.

18. Public Health England, 2017. <https://www.gov.uk/government/organisations/public-health-england> 19. Gov.co.uk, Guidance CE Marking, 2012. <https://www.gov.uk/guidance/ce-marking> 20. BSI, CE marking approval for medical devices in Europe, 2017, <https://www.bsigroup.com/en-GB/ medical-devices/our-services/ce-marking/> 21. Health and Safety Executive, Notified Bodies, <http://www.hse.gov.uk/work-equipment-machinery/ notified-bodies.htm> 22. British Standards Institution. BS EN ISO/IEC 17050-1:2010. Conformity assessment. Supplier’s declaration of conformity. General requirements. London: British Standards Institution; 2010.

23. EU Commission, Buying goods online coming from a non-European Union country, Taxation and customs union, 2017, <https://ec.europa.eu/taxation_customs/individuals/buying-goods-servicesonline-personal-use/buying-goods/buying-goods-online-coming-from-a-noneu-union-country_en> 24. Gov.uk, Guidance, Product liability and safety law, 2012 <https://www.gov.uk/guidance/productliability-and-safety-law> 25. CE Marking Association, CE Marking and the Chinese Export logo, <http://www. cemarkingassociation.co.uk/ce-marking-and-the-chinese-export-logo/> 26. EU Commission, Manufacturers, 2017, <http://ec.europa.eu/growth/single-market/ce-marking/ manufacturers_en> 27. Explanatory Memorandum to The Health And Social Care Act 2008 (Consequential Amendments No 2) Order 2010, 2010. <http://www.legislation.gov.uk/uksi/2010/813/pdfs/uksiem_20100813_ en.pdf> 28. British Medical Laser Association, Essential Standards Regarding Class 3B and Class 4 Lasers and Intense Light Sources in Non-surgical Applications, 2017 <http://www.bmla.co.uk/wp-content/ uploads/BMLA%20Essential%20Standards%20May%202017.pdf> 29. Local Government Association. Deregulation of Class 3B and 4 Lasers – Briefing for Regulatory Officers in England. London:2010.

30. Healthcare Inspectorate Wales, Welcome to Healthcare Inspectorate Wales, 2017. <http://hiw.org. uk/?skip=1&lang=en> 31. Indirect government services, Regulation and Quality Improvement Authority (RQIA) <https://www. nidirect.gov.uk/contacts/contacts-az/regulation-and-quality-improvement-authority-rqia> 32. Legislation.gov.uk, London Local Authorities Act 1991. <http://www.legislation.gov.uk/ukla/1991/13/ contents/enacted> 33. Birmingham City Council Act 1991 Special Treatments Licence <https://www.birmingham.gov. uk/info/20083/general_licensing_applications/290/apply_for_a_massage_or_other_special_ treatment_licence> 34. Nottinghamshire County Council Act 1985 (Part IV 10.) Licensing of Premises for Massage and/or Special Treatments April 2010. <http://www.rushcliffe.gov.uk/media/rushcliffe/media/documents/pdf/ businessandlicensing/licensing/Sunbed_Conditions.pdf> 35. The Essex Act 1987 <https://www.legislation.gov.uk/ukla/1987/20/contents/enacted> 36. The Regulation and Quality Improvement Authority, RQIA Provider Guidance 2016-17. <https://rqia. org.uk/RQIA/files/de/de9ca079-adc5-4efb-a82d-cdd2fba88aab.pdf> 37. Healthcare Improvement Scotland, 2017. <http://www.healthcareimprovementscotland.org> 38. Legislation.gov.uk, Regulation of Care (Scotland) Act 2001, <http://www.legislation.gov.uk/ asp/2001/8/contents> 39. Legislation.gov.uk, Public Services Reform (Scotland) Act 2010. <https://www.legislation.gov.uk/ asp/2010/8/contents> 40. HIS, The regulation of independent healthcare in Scotland, 2011. <http://www. healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/independent_ healthcare.aspx> 41. Kilgariff, S, HIS Registration Launch, Aesthetics, 2017 <https://aestheticsjournal.com/feature/hisregistration-launch> 42. Scottish Executive. National Care Standards: Independent Specialist Clinics. Edinburgh. 2014.

Standard 2(3). p. 18.

43. British Standards Institution. BS EN 60601-2-57: 2011 Medical electrical equipment - Part 2-57: Particular requirements for the basic safety and essential performance of non-laser light source equipment intended for therapeutic, diagnostic, monitoring and cosmetic / aesthetic use. London: British Standards Institution; 2011.

44. British Standards Institution. BS EN 16844:2017 Aesthetic medicine services – Non-surgical medical procedures. London: British Standards Institution; 2017.

45. British Standards Institution. BS EN 16372:2014 Aesthetic surgery services. London: British Standards Institution; 2014.

46. Jones, WJ, Law & Ethics: The healthcare professional and the Bolam test, British Dental Journal, 2000. <http://www.nature.com/bdj/journal/v188/n5/full/4800441a.html?foxtrotcallback=true> 47. HEE, PART ONE: Qualification requirements for delivery of cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, 2015. <https://www.hee.nhs.uk/sites/default/ files/documents/HEE%20Cosmetic%20publication%20part%20one%20update%20v1%20final%20 version.pdf> 48. HEE, PART TWO: Report on implementation of qualification requirements for cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, 2015. <https://www.hee.nhs.uk/ sites/default/files/documents/HEE%20Cosmetic%20publication%20part%20two%20update%20 v1%20final%20version_0.pdf> 49. Joint Council for Cosmetic Practitioners, 2017 <http://www.jccp.org.uk/> 11.

12.

13.

14.

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or dark circle appearance is due to mid-cheek malar fat pad atrophy and the subsequent parting between the lower eye bag fat pad and the malar fat pad, which slides lower with gravity. The decreased elasticity of the overlying ageing skin also Dr Nikola Milojevic explains how dermal fillers, contributes to this hollow, as botulinum toxin and plasma can be used to address well as skeletal ageing.7,8 In the upper eyelid, the skin increasingly the signs of ageing in the upper and lower eye sags and droops due to a loss History and overview of elasticity in individuals with a genetic predisposition or due to The history of eyelid procedures dates back to 25 A.D. when Aulus extrinsic factors.9 Cornelius Celsus, a Roman philosopher, described the excision of excess skin of the upper eyelid.1 Coming forward to the 1970s, Dr Indications and patient presentation Bob Flowers from Hawaii introduced the supratarsal fixation for the Upper and lower eyelid ageing is a problem for many patients upper eyelid crease,2 which is where a low eyelid is re-established – according to the British Association of Aesthetic Plastic by fixating a fold higher up; a procedure very popular among Asian Surgeons (BAAPS), blepharoplasty was the second most common patients to this day. Dr Flowers was a close friend and colleague of surgical procedure in 2016 in the UK, with the first being breast my late father Professor Bosko Milojevic, and they worked on this augmentation.10 Patients usually present with the complaint that procedure together, hence my fascination with the periorbital area they look tired, despite the fact that they often feel full of energy from a very early age.3 and lead healthy lives.

More pertinent to this article was the accidental discovery of botulinum toxin for wrinkles. In 1987, a Canadian ophthalmologist, Common presentations in my clinic for eye concerns include: Dr Jean Carruthers was treating blepharospasm in her patients with botulinum toxin, and, to her surprise, noticed a side effect of wrinkle • Younger patients, aged 20 to 30 years of age, who present with reduction around the eyes.4 an inherited tear trough indentation under the eye, giving them a Then, in 2007, ophthalmologist and oculoplastic surgeon Dr tired look at an early age; these patients look older for their age Raman Malhotra first described the non-surgical ‘eye bag’ removal because of it. Often these patients also have dark circles. procedure using hyaluronic acid (HA) dermal fillers, and my practice • A later onset tear trough under the eye, most commonly in has been enriched by this procedure ever since. With these patients in their mid 30s, due mainly to malar fat pad atrophy. This new advances, we are able to apply a more holistic approach to indentation often extends onto the upper cheek. treatment and, increasingly, we’re able to perform procedures • Augmented eye bags, caused by the growing size of the effectively, with fewer risks and downtime than surgical procedures. infraorbital fat pad, which bulges and does not slide down, due to the presence of a ligament. There may also be excess skin below Anatomy and physiology the eye and into the lateral canthal line area, as well as rhytides The anatomy and physiology of the ageing upper face is well below and around the eyes.11 5 known and documented. In the lower eye area, there is often • ‘Lowered’ upper eyelids, due to excess skin and lack of elasticity, tear trough depression due to a genetic predisposition associated which often results in a presentation of a reduced field of vision, with the tear trough ligament.6 In most cases, however, the hollow providing an indication for which patients can usually have a surgical blepharoplasty on the NHS.

Different Approaches to Treating the Periorbita

Before

Treatments Below, I will detail some of the common treatments I perform in my clinic related to the above concerns.

After

Figure 1: A 64-year-old female before and four weeks after one treatment of fractionated plasma on the upper eyelids.

Tear trough with dermal fillers This is a complex procedure, only to be performed by those with extensive experience in the administration of dermal fillers and a thorough knowledge of facial anatomy. The choice of material is key, and more permanent options, such as permanent fillers, which patients may seek, are simply contraindicated here due to the longterm risk of side effects.12 In my opinion, the only option for treatment of the tear trough is a cross-linked HA dermal filler, as it is reversible using hyaluronidase, which gives patients and practitioners reassurance. Also, the cross-linking ensures that the results last,13,14 and with the right choice of filler, from my experience, these results can last as long as 12-24 months. In some cases, I have even seen results last longer than 24 months.

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Before

After

Figure 2: A 38-year-old female before and after treatment for eye bags, wrinkles and dark circles. Patient had 2ml of hyaluronic acid in the tear trough, 1ml in the cheeks, and botulinum toxin in the glabella and around the eyes. Note the upper eyelid is now more visible and eye bags have diminished.

It is important that the thickness of the filler has been chosen correctly; practitioners must note that they are unlikely to use the same type of filler for different patients. In patients with shallow dark circles and thin skin, a filler with a low G-prime, designed for rejuvenation may be used. However, in patients with larger eye bags and significant volume loss, it is more appropriate to use a filler with a high G-prime and volumise the upper cheek to help fill the tear troughs.15 On average, I use 1ml filler per eye.

x = 2.5 - 5.0 units

o = 1.25 units

Figure 3: Botulinum toxin injection points for periorbital rejuvenation

I prefer to use a needle as I feel that it offers a much more precise way to achieve good results without side effects, as opposed to the cannula. As long as practitioners know the anatomy of the area, they can avoid side effects such as bruising and vascular compromise. Sometimes bruising is an unavoidable side effect, although if managed properly, it should not adversely impact the lifestyle of the patient. It is important to inject deep and, in most cases, just above the periosteum. I use many different techniques including the bolus technique, linear threading, and the pyramid technique, where I deposit a small amount of filler with a low G-prime closer to the surface.16 I use all of these techniques in most of my patients to achieve the best results, as, in my opinion, they work in synergy for results which are the most natural, with the least side effects. Of course, depending on the depth of the tear trough, or whether the skin under the eye is thin or thick, some of the techniques may or may not be necessary. With as many as 30 injections around each eye, I build the dermal filler to correct the depression and to literally hide the eye bag in what I call a ‘patchwork technique’, which is not possible with a cannula.

In my opinion, the only option for treatment of the tear trough is a crosslinked HA dermal filler, as it is reversible using hyaluronidase, which gives patients and practitioners reassurance A massage of the treated area is very important, and the patient should be advised of strict aftercare instructions to avoid side effects such as redness, bruising and oedema, which tend to last for up to a week.17 Patients should avoid exercise and alcohol for 24 hours, and should apply ice and arnica gel to the treated area. Long-term swelling, unevenness and lumps can occur, however, they are rare.

In my experience, these issues are either resolved by a vibrating massage or hyaluronidase. The massage should be very strong and pressured in nature, with a vibrating motion of the fingers necessary, to literally break down any clumping or areas of persistent oedema.

Patient education and management of expectations before the procedure is important, and will go a long way to improving outcomes and patient satisfaction. Recorded complications include allergies, infections, vascular compromise and even blindness,18 however these are rare and extensive knowledge and experience in offering this treatment will help to avoid such concerns.

Botulinum toxin for periorbital wrinkles As the skin surrounding the eyes loses elasticity, wrinkles around and under the eyes become more permanent. These are wrinkles of expression, and the main muscle that causes these wrinkles is the orbicularis oculi.

When treating patients with dermal fillers for tear troughs, I often also advise toxin treatment of the orbicularis oculi for two reasons. Firstly, because the combination treatment on the lower eye area with dermal fillers has a better cumulative effect, and secondly, for those with lowered upper eyelids, this treatment may raise the eyebrows and open the eyes up.

The usual dose of botulinum toxin around the eyes is 2.5-5 units per injection at three superficial injection points and, for wrinkles under the eye, it is possible to inject a lower dose of 1.25-2.5 units, up to the mid-pupillary line.

Fractionated plasma for excess skin Plasma is a Greek word which means ‘anything formed’,18 and it is one of the four fundamental states of matter; the others being solid, liquid and gas. Plasma can be described as a cloud of protons, neutrons and electrons, where all the electrons have come ‘loose’ from their respective molecules and atoms, giving the plasma the ability to act as a whole, rather than as a group of atoms. Plasma is more like a gas than any of the other states of matter due to the atoms not being in constant contact with each other.

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

@aestheticsgroup Before

After

Figure 4: A 35-year-old male before and two weeks after treatment for eye bags. Patient had 2ml of hyaluronic acid filler.

Aesthetic fractionated plasma devices19 use a special generator to produce a micro current. The electrical discharge generated is used to treat indications through the applicator, which is composed of a plastic handpiece and a medical stainless-steel electrode. The electrical discharge causes a temperature rise in a targeted part of the skin in a very selective way, with high energy density.20 This causes sublimation spots of the superficial corneocytes, without affecting the basal cell layer, creating a lifting effect.20 Plasma devices can be used to remove the excess skin on the upper eyelid. In many cases, only one treatment is needed, but sometimes a second treatment is necessary after four to six weeks, to remove all excess skin. They can also be used for rejuvenating the whole face, as well as removing moles, xanthelasma (yellow cholesterol deposits in the skin around the eyes) and even scars.21 I believe the fractionated devices achieve better results and less side effects when compared to their predecessors, which were not fractionated.22 From speaking to colleagues and peers, and from my own experience with non-fractional devices, damage to the surrounding tissue side effects were much more common. I believe this is due to the continuous beam of energy used, compared to the pulsating beam of the fractionated devices. The fractionated devices also do not go as deep, and evaporate the excess skin superficially.

Topical anaesthesia is applied to the upper eyelid and crow’s feet wrinkles 45 minutes before the procedure. You should draw the area to be treated first and then treat from the top to the bottom, as well as alternate spots from the right to the left side to make it more comfortable for the patient. Also, you use a ‘spray movement’, moving the hand, operating the device up and down on the area being treated, in a repetitive motion. Each spot will sublimate the tissues, creating a retraction. Thus, causing sublimation spots of the superficial corneocytes without affecting the basal cell layer (sublimation, without ablative effects on the skin).

It is recommended by the product manufacturer of the device I use, that during each treatment you should not sublimate more than one third of the surface treated,28 to avoid side effects. During the session, ask your patient to open and close their eyes, to allow maximum precision in the zone which is being treated. Only one pass over the same spot is also recommended. The treatment usually takes between 10-15 minutes, patients report minimal pain, and significant skin retraction is seen immediately after the treatment.23 Some patients may experience a light oedema and swelling in the treated area which will disappear in a few days. They will also have some mild crusting of the skin, lasting between seven and 15 days. After the procedure, I instruct patients to wash their face with a mild cleanser, apply gauzes soaked in a normal saline twice a day for three days, and apply sterile petrolatum several times a day until healing is complete. Treatment with topical antibiotic ointment for six to nine days is also necessary, as well as steroid cream. Avoiding sun exposure for seven to eight weeks is advised.

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Conclusion The aesthetic specialty is continually finding new solutions for facial rejuvenation, and with the introduction of new fractionated plasma devices, we can have a complete approach to the rejuvenation of the eye area. Until recently, we were able to treat most eye bag and tear trough problems using dermal filler techniques and botulinum toxin to reduce the wrinkles under and around the eyes. Now, we also have a new approach to effectively treating excess drooping of the upper eyelid skin using plasma. The plasma devices can significantly lift the upper eyelid tissue, with minimal downtime and without the risks of a surgical procedure. Most importantly, these results are permanent, but just like the surgical alternative, blepharoplasty, nothing is precisely 100% permanent, as the skin continues to age, and it may be necessary to repeat this procedure down the line.

Dr Nikola Milojevic is the owner of Milo clinic in Harley street. He has more than 14 years’ experience in aesthetic medicine and with over 40,000 performed dermal filler and botulinum toxin procedures and 6,000 tear trough procedures, he is regarded a key opinion leader in this field.

REFERENCES 1. Pastorek Norman, Bustillo Andres, Blepharoplasty- Masters book, <https://www.drbustillo.com/ news-media/blepharoplasty-masters-book> 2. Kaizen, L.B. The history of cosmetic blepharoplasty. Adv Ophthal & Reconstruct Surg 1986;5:89-96 3. Milojevic N, (Milo Clinic website- About us – 2005) <https://www.miloclinic.com/about.aspx> 4. Milojevic N, (Milo Clinic website, Dr Milo Blogs - 18, July, 2008) , <https://www.miloclinic.com/ aesthetic-medicine-past-present-and-future> 5. Khazanchi R, Aggarwal A, Johar M. Anatomy of aging face. Indian J Plast Surg [serial online] 2007 [cited 2017 Nov 6] 6. Wong CH, Hsieh MK, Mendelson B. The tear trough ligament: anatomical basis for the tear trough deformity. Plast Reconstr Surg. 2012 Jun;129(6):1392-402 7. Paskhover B, Durand D, Kamen E, Gordon NA. Patterns of Change in Facial Skeletal Aging, JAMA Facial Plast Surg. 2017 Sep 1;19(5):413-417 8. Yang N, Qiu W, Wang Z, Su X, Jia H, Shi H. Anatomical study of the tear trough area, Zhonghua Zheng Xing Wai Ke Za Zhi. 2014 Jan;30(1):50-3. Abstract 9. Damasceno RW, Avgitidou G, Belfort R Jr, Dantas PE, Holbach LM, Heindl LM. Eyelid Aging: pathophysiology and clinical management. Arq Bras Oftalmol. 2015 Sep-Oct;78(5):328-31 10. BAAPS annual audit results 2017, web page, https://baaps.org.uk/media/press_releases/29/ the_bust_boom_busts 11. Damasceno RW, Avgitidou G, Belfort R Jr, Dantas PE, Holbach LM, Heindl LM. Eyelid Aging: pathophysiology and clinical management. Arq Bras Oftalmol. 2015 Sep-Oct;78(5):328-31 12. Milojevic B, Complications after silicone injection therapy in aesthetic plastic surgery, Aesthetic Plastic Surgery December 1982, Volume 6, Issue 4, pp 203–206 13. MacReady Nora, Dermal Fillers: Focus on Hyaluronic acid, Medscape dermatology, 2008 14. Hyaluronic Acid: Does Size Matter? [Panel discussion]. Program and abstracts of the American Society for Aesthetic Plastic Surgery (ASAPS) 2008 Annual Meeting; May 1-6, 2008; San Diego, California.

15. ascali M, Quarato D, Pagnoni M, Carinci F, Tear Trough Deformity: Study of Filling Procedures for its Correction, J Craniofac Surg. 2017 Sep 12 16. Jiang J, Wang X, Chen R, Xia X, Sun S, Hu K, Tear Trough deformity: different types of anatomy and treatment options, Postepy Dermatol Alergol. 2016 Aug;33(4):303-8 17. Morley Ana, Malhotra Raman, Use of Hyaluronic Acid Filler for Tear-Trough Rejuvenation as an Alternative to Lower Eyelid Surgery , Ophthalmic Plastic & Reconstructive Surgery: March/April 2011 - Volume 27 - Issue 2 - pp 69-73 18. Myung Y1, Yim S, Jeong JH, Kim BK, Heo CY, Baek RM, Pak CS, The Classification and Prognosis of Periocular Complications Related to Blindness following Cosmetic Filler Injection, Plast Reconstr Surg. 2017 Jul;140(1):61-64 19. Propulsion, How does solar electric propulsion (ion propulsion) work? <http://www.qrg. northwestern.edu/projects/vss/docs/propulsion/2-what-is-plasma.html> 20. Al Shaimaa E, Case reports on the potential of Fractionated Plasma on dermatological and medical aesthetic treatments, Case Reports 2017 Plasmage, Alexandria University, Plasmage Workshop, IMCAS 2017 21. Bogle MA, Arndt KA, Dover JS. Evaluation of plasma skin regeneration technology in low-energy full-facial rejuvenation. Arch Dermatol 2007.

22. Rossi E, Franetani F, Trakatelli M, Ciardo S, Pellacani G. Clinical and Confocal Microscopy Study of Plasma Exeresis for Nonsurgical Blepharoplasty of the upper eyelid: A Pilot Study . Dermatol Surg. 2017 Sep 19 23. Official Protocol Blepharoplasma - Brera Medical Technologies, Plasmage

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Permanent Makeup Removal Tattoo and permanent makeup removal specialist Lorena Öberg describes her method for removing permanent makeup tattoos Ever since I started performing permanent makeup tattoo treatments, I have noticed its growth in popularity.1,2 Google Trends exemplifies this growth, where interest in the term ‘eyebrow tattoo’ has steadily increased over the past five years.3 However, in my experience, coinciding with this growth is the number of patients requiring removal.

Traditionally, patients have requested removal because they feel the makeup no longer suits their more mature look. However, I am increasingly seeing people who have received bad permanent makeup treatment and have been disfigured by untrained technicians.

Currently, Level 5 training is recommended

by Health Education England (HEE) for tattoo removal using lasers,4 although an individual does not need any qualifications to perform the actual permanent makeup treatment.

However, permanent makeup is a difficult skill to learn, so even if one has training, it does not mean that they can do the treatment well.

For medical aesthetic clinics currently performing tattoo removal, or if they are interested in doing so, they should also consider incorporating permanent makeup removal.

Removing pigment from skin There are three ways to reduce or ‘lighten’ pigment molecules from the skin: topical, nonlaser solutions applied with a tattoo gun, and laser. All three of these methods have a place in your practice and can be considered for different circumstances, as discussed below.

1. Topical There are many lotions that are being sold as ‘tattoo removal creams’, but I have not come across any clinical studies showing their effectiveness without combining laser.

I have personally found them ineffective because they cannot penetrate into the dermis to reach the tattoo ink.5-7 One guinea pig model study demonstrated a reduction in tattoo pigment using imiquimod and tretinoin after 28 days, however application started

six hours after tattooing, which is not very reflective of real-life scenarios.8 There is also data that suggests that the use of imiquimod with laser is more effective than laser alone.9 Prior to laser treatments, I have found that there are alternative topical methods that can help to assist with the removal of pigment.

If a permanent makeup tattoo is under six months old, I use a simple technique of applying fine sea salt to the area and gently exfoliating twice-per-day for two months, which draws out the ink. I have found this can cut the number of required laser treatments in half, but it’s only effective with new tattoos as after around six months the ink settles.

2. Non-laser solutions These procedures are performed by a trained permanent makeup artist and there are many variations of this same treatment.

Removal can be achieved by opening the skin – in a way much like the original procedure – using a tattoo or a permanent makeup machine. A bonding agent is then applied to the open skin, which then draws the ink to the skin’s surface.7 Bonding agents can be anything from salt or glycolic acid, to any number of branded products readily available to permanent makeup and tattoo artists.10,11 In my experience, one session will be equivalent to two months of topical exfoliation. I have found that this method is popular with artists who do not have access to lasers and it is especially useful when removing the skin-coloured pigment due to its large molecular size, which is discussed below. However, the limitation of this approach is that, generally, the rate of scarring is far higher than a laser as it causes damage to the epidermis.

3. Lasers Lasers are widely accepted as the most common treatment for removing pigment from the skin, so, like regular tattoos, they are widely used to remove permanent makeup.

I do not recommend treating a tattoo that

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has been done in under six months.12 This is because there is a higher ink concentration, which will mean that the patient will require more laser sessions and the laser itself will react more violently, even on lower power settings, as it is more attracted to the ink molecules.13 This translates into a more aggressive treatment, therefore increasing the chances of scarring. Permanent makeup pigments are different in composition to tattoo inks as they are made from different ingredients.14 It’s therefore important to understand how makeup inks will react under the laser. The two main things to consider when removing permanent makeup pigments is whether the pigment contains titanium dioxide (the colour white) and the molecule size.

Titanium dioxide Titanium dioxide in the form of ‘white’ is used in most pigments for those with a lighter Fitzpatrick skin type as those with darker skin require a tattoo with darker pigment, hence unlikely to contain titanium. It is also used in most lip pigments because it gives the tattoo a brighter base to sit on, making the colour stand out more.

Titanium is a metal that has been rusted into a white powder. When the laser hits this oxidised metal, a chemical reaction occurs that turns the titanium to its original state, which is a dark grey colour.15 This is why practitioners were previously told by laser manufacturers that they could not laser permanent makeup pigments as it turns black.15 Although this does occur, practitioners should have no problems removing it with further treatments – ranging from two to eight – and they should make their patients aware that this may happen. However, this is not recommended for the lip area as patients may find having black or grey lips distressing if this contrasts with their skin colour. For this area, I instead try to remove most of the pigment molecules with the non-laser method and then clean up residual particles that may linger in the deeper layers of the skin with a laser.

Molecule sizes and colour Molecule size for micropigmentation pigments can vary from one to 20 microns.

These measurements mostly take into consideration the agglomerates of smaller molecules that happen in pigments and inks.

The molecule size will also vary from organic to inorganic or synthetic organic pigments.

All pigment components come in powder form, they are then mixed with agents such as

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Eyeliner removal

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Before

I currently perform around five eyeliner removal procedures a week and I only use laser because the non-laser bonding agents and salt exfoliation is too harsh for this area. Removing eyeliner has its own After set of challenges and I currently only know a handful of practitioners competent in this procedure. The skin around the periorbital area is extremely sensitive so we need to be very careful. You must protect the cornea using the correct sized corneal protective shields that need to be inserted under the Figure1: Before and after permanent makeup eyeliner removal using one eyelid. The laser must be used on the lowest session of laser. possible setting, with the least amount of power output, using the largest spot size possible. These levels will vary from laser to laser, but most users know their machine intimately by the time they attempt this delicate procedure. Treatments should also be spaced by a minimum of eight weeks, allowing for the epidermis to complete its full shedding cycle and so the lymphatic system has more time to dispose of the molecules, leading to fewer treatments.20

Before

have found that when dealing with larger sized molecules, these cannot be targeted effectively with picosecond technology and therefore I believe that a nanosecond laser is far more effective when dealing with permanent makeup.18,19 Up to 10 treatments for the face and 12 for the body may be required when using lasers to break the titanium molecules up enough. In my experience, when treating skin-coloured pigment, you can get more superior results by using two to three non-laser solution sessions in combination with a laser protocol.

After one treatment

After three treatments

Figure 2: Images show patient before treatment, after one laser treatment and after three laser treatments on the brow.

glycerin. Most molecules used in permanent makeup, such as titanium molecules, are big; unlike carbon black molecules more commonly used in black body tattoo ink. This is especially the case with skin coloured pigments that are designed to cover up mistakes, which are deliberately manufactured to have titanium molecules that are large enough to be used as a cover up.16 Types of lasers suitable for makeup removal When using lasers, the molecule size they target at their optimum level and the wavelengths need to be considered.

In my experience, when used correctly, a Q-switched Nd:YAG is the most effective and is a gentle removal method. Research has shown that picosecond lasers can be more effective than nanosecond lasers for black ink tattoo removal.17 However, I

Removal complications Scarring is a risk of the non-laser approach, as well as any laser procedure, including any form of tattoo removal. It is therefore important to remove the pigment safely using the fewest laser sessions possible to limit trauma to the skin.21 Allergy can also be an issue, as this can occur when attempting removal even if they have never shown previous signs of a problem. Test patching is crucial, but practitioners must bear in mind that test patching does not guarantee that an allergy is detected. An allergy may still manifest when more of the allergen is put through the body’s lymphatic system.22

Summary Permanent makeup removal can be an incredibly rewarding treatment and when done correctly, it has a very low complication rate. There are still a relatively low number of laser technologies available

that have ventured into this treatment and therefore there is room for future developments in this area.

Lorena Öberg has been a permanent makeup artist and tattoo removal technician for eight years. She has her own brand of permanent makeup machines, DiamaDerm, as well her own skincare range, Lorena Öberg Skincare. She is based on Harley Street in London and Surrey, and lectures all over the world on tattoo and permanent makeup removal.

REFERENCES 1. Kimmel, Carolyn, More women choosing permanent makeup, The Patroit-News, 2012. <http://www.pennlive.com/ bodyandmind/index.ssf/2012/05/more_women_choosing_ permanent.html> 2. Fitzpatrick RE, Goldman MP, Dierickx C, Laser ablation of facial cosmetic tattoos. Aesthetic Plast Surg. 1994 Winter;18(1):91-8. <https://www.ncbi.nlm.nih.gov/pubmed/8122584> 3. Google Trends, Eyebrow Tattoo, 2017. <https://trends. google.co.uk/trends/explore?date=2012-01-01%20 2017-11-09&q=Eyebrow%20Tattoo> 4. HEE, Part One: Qualification requirements for delivery of cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, 2015.

5. Real Self, Tattoo Removal Cream. <https://www.realself.com/ question/best-tattoo-removal-cream> 6. Mayo Clinic, Does tattoo removal cream really work? Answers from Dr Lawrence E. Gibson, 2015. <https://www.mayoclinic. org/healthy-lifestyle/adult-health/expert-answers/tattooremoval-cream/faq-20058090> 7. Smith, A, Tattoo Removal Creams and Non-Laser Tattoo Removal, 2015. <http://info.astanzalaser.com/blog/tattooremoval-creams-and-non-laser-tattoo-removal> 8. Solis RR, Diven DG, Colome-Grimmer MI, Snyder N 4th, Wagner RF,Experimental nonsurgical tattoo removal in a guinea pig model with topical imiquimod and tretinoin.

Dermatol Surg. 2002 Jan;28(1):83-6; discussion 86-7. <https:// www.ncbi.nlm.nih.gov/pubmed/11998793> 9. Ricotti CA1, Colaco SM, Shamma HN, Trevino J, Palmer G, Heaphy MR Jr. Laser-assisted tattoo removal with topical 5% imiquimod cream. Dermatol Surg. 2007 Sep;33(9):1082-91. <https://www.ncbi.nlm.nih.gov/pubmed/17760599> 10. PhiRemoval, Tattoo Removal Kits, <http://phiremoval.com/ tattoo-removal-kits/> 11. Material Safety Data Sheet, Consea and Rejuvi Laboratory USA, 2017. <http://www.e-raze.com/data.shtml> 12. Phys org, How tattoos ‘move’ with age, University College London, 2011. <https://phys.org/news/2011-04-math-tattoo-age. html> 13. Perpetual Permanent Makeup, Permanent Makeup Pigments Vs Tattoo ink, <http://www.perpetualpermanentmakeup.com/ permanent-makeup-pigments-vs-tattoo-ink> 14. Jesitus, John, Tattoo removal is a booming business, Dermatology Times, 2015. <http://dermatologytimes. modernmedicine.com/dermatology-times/news/rethinking-ink> 15. Linda H. Dixon, Information about pigments we use in P.C. everyday, Kolorsource. <http://kolorsource.com/index. php?option=com_content&view=article&id=8&Itemid=46> 16. E. Victor Ross, USN; George Naseef, MD; Charles Lin, PhD; et al, Comparison of Responses of Tattoos to Picosecond and Nanosecond Q-Switched Neodymium:YAG Lasers, Arch Dermatol. 1998;134(2):167-171 17. Chemisty World, Ink Chemistry, 2003. <https://www. chemistryworld.com/news/ink-chemistry/3002158.article> 18. Mitsubishi Chemical, Three Main Properties of Carbon Black, 2006. <http://www.carbonblack.jp/en/cb/tokusei.html> 19. Tattoo removal: Lasers outshine other methods, American Academy of Dermatology Association, 2017. <https://www.aad. org/public/diseases/cosmetic-treatments/tattoo-removal> 20. Premier Pigments, Pigment Migration, <http://www. premierpigments.com/pigment_migration.html> 21. Niti Khunger, Anupama Molpariya, and Arjun Khunger.

Complications of Tattoos and Tattoo Removal: Stop and Think Before you ink. J Cutan Aesthet Surg. 2015 Jan-Mar; 8(1): 30–36.<https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4411590/> 22. Dr Mercola, Tattoos Last, and So Does the Pain for 1 in 10, 2015. <https://articles.mercola.com/sites/articles/archive/2015/06/10/ allergic-reaction-tattoo.aspx>

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Non-surgical ‘Chemical Blepharoplasty’ Dr Jane Ranneva explains how to treat the sensitive eye area using chemical peels Ageing of the periorbital area is a common concern amongst many patients.

Rejuvenation of the upper and/or lower eyelids using chemical peels is a relatively simple and quick rejuvenation procedure.

It is commonly referred to as ‘chemical blepharoplasty’, despite the fact that it is non-surgical. The results are inadequate for treating fat pads, but are excellent in all resurfacing indications. However, the practitioner must be experienced in performing deep chemical peels on other areas of the face, and peels of this depth should not be performed by novice or inexperienced practitioners.

Patient and product selection In practice, I have found that applying chemical peels to the eyelids can treat wrinkles and fine lines, dyschromia, keratoses and sagging eyelids successfully. However, the results of a ‘chemical blepharoplasty’ may be inadequate if there is a large amount of excess skin on the lower eyelid. In these cases, surgical blepharoplasty is indicated.

When peeling the eye area, practitioners need to consider a type of peel that is safe and will create a lifting effect. I have found that alpha hydroxy acid (AHA) and trichloroacetic acid (TCA) peels are ineffective for nonsurgical ‘chemical blepharoplasty’ because they are unable to reach the reticular dermis and modify it.1 I therefore choose to use a phenol peel, and if treating in limited areas using small quantities, there is a very low Before

Day 1

risk of danger related to its toxicity.1-7 There are many different levels of phenol formulations, but for optimum effectiveness and patient safety, I use a phenol oil formula because it has a good depth of penetration in the thin eyelid skin. Before treatment, practitioners should be aware of the complications (explained below) and contraindications for phenol, some of which include active herpes, keloid history, history of radiotherapy, surgical intervention in the same area and the recent use of retinoids.7,8

Pre-chemical peel treatments Prior to the ‘chemical blepharoplasty’, to avoid any reactional hyperpigmentation, the patient should apply a bleaching cream containing tyrosinase inhibitors and antioxidants twice a day for two to three weeks.

Practitioners should consider botulinum toxin injections in the musculus orbicularis oculi one to eight days before the application of the peeling solution as it keeps the muscles paralysed during the skin regeneration phase and, in my experience, allows a better and longer lasting result. If the patient has a history of herpes, prevention is necessary for four days before and up to four days after the peel (valacyclovir 500mg twice a day).

Immediately before the chemical peel treatment (30 minutes), give the patient an analgesic. The skin should always be degreased and disinfected; you can use a mixture of 50% alcohol and 50% acetone before application. Place one drop of Day 3

petroleum jelly-based ophthalmic ointment in the eyes immediately before starting the procedure and once finished to prevent postpeel ocular irritation. The practitioner should perform nerve blocks if the patient displays any pain or if they do not tolerate pain well.

In the absence of nerve blocks, applying a chemical peel may trigger a strong burning sensation for approximately 15 seconds, after which the skin will become numb for about 15 minutes. After 15 minutes, the patient will experience a gradual, unpleasant, warm, pulsatile inflammatory sensation. This can last until the middle of the first night due to the effects of the sympathetic nervous system.1

Treatment protocol Practitioners should consider their applicator choice; I find that a single cotton bud is ideal for the eye area as it is light, precise and simple. An assistant should be present throughout the whole procedure to clear any tears as soon as they appear to prevent any diluted phenol from dripping onto the face or going up into the conjunctivae by capillarity. This will avoid eye injuries in the form of corneal damage.

It is extremely important that a fresh cotton pad is used for each tear. Using a 1cm3 syringe, 0.2cm3 of the peel solution should be drawn up from the bottle, and the cotton bud soaked by ‘injecting’ 0.10-0.14cm3 of the solution directly onto it. After disinfecting the area and carefully degreasing, the peel solution should be applied carefully onto one of the lower lids with the cotton bud. The tarsus of the upper eyelid is not usually treated because it can induce severe oedema,9,10 which is very uncomfortable for the patient and will not significantly improve results. Distinct frosting – when the skin turns white during a peel – usually occurs immediately and marks the end of the phenol application. To treat the second eyelid, three drops of product should be ‘injected’ onto the end of the same cotton bud and applied to the eyelid. The same quantity of solution and the same procedure is needed to treat the upper eyelids. Following the ‘chemical

Day 6

Figure 1: Patient before and after non-surgical ‘chemical blepharoplasty’. Images courtesy of Skin Tech.

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blepharoplasty’, an evening-out peel is necessary to prevent demarcation lines.

To do this, a milder peel can be applied, such as a superficial-medium depth peel based on TCA. It should be applied on the rest of the face when the periorbital application has finished and before any dressing is applied.1 The practitioner can apply a thick coat of an anti-inflammatory, anti-erythema, antioxidant rich, post-peel mask immediately before applying bismuth subgallate powder. The powder will stick perfectly on the post-peel mask and form a protective barrier. It will stay on the skin for six to eight days by forming a crust-like protection. This is an excellent antiseptic, preventing scarring as it allows for skin regeneration under the powder.11,12

Following treatment The patient should not sleep with the treated skin pressing against any surface, including a pillow, the night after the treatment as the treated area might stick to the surface and result in infection, scarring, prolonged erythema or other complications.13-15 Practitioners should arrange to see the patient on the first, third and sixth day following the peel to monitor their progress and ensure that there is no infection. ln the case of infection, prescribe the patient antibiotics (usually orally). On the third day, apply sterile, white petroleum jelly on the edge of the treated areas. On the sixth day, apply it on the entire treated area as this will help unstick the bismuth subgallate. The patient can then wear makeup beginning on the eighth day, so long as the skin has fully recovered.

Complications and side effects Eyelid oedema Severe eyelid oedema, which usually lasts seven days at the most, will appear immediately after the solution has been applied. It usually peaks on the morning of the first and second day and goes down during the day, when the patient is no longer lying down. It spreads to the upper cheek on the second day, the lower cheek on the third day, the lower jaw on the fourth day and, on the fifth day, it is barely noticeable. It is not uncommon for the patient to be unable to open his or her eyelids on the morning of the first day. If the oedema lasts longer than seven days, it is not normal.7,16 This is not very common, and if it does happen, the practitioner should proceed with thorough medical history and if there is infection, which can be the cause of the oedema, medical follow-up is necessary.

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Erythema Erythema will develop just a few minutes after the peel has been applied and will peak during the first few weeks. The erythema takes longer to fade on lighter, more transparent skin, and is easily covered up with makeup. The bismuth subgallate powder comes away from the skin automatically due to the petroleum jelly, which prevents transepidermal water loss (TEWL) evaporation.16,17 Delayed healing The increased depth of action of the phenol sometimes translates into a persistent moist scab in the inside corner of the upper eyelid, where the phenol has macerated more intensely. Applying an antibiotic cream or ointment remedies the problem, and it should resolve before the fifteenth day. There are no sequelae from this slow healing. If the scab persists for more than two weeks, the practitioner should closely monitor the patient.1,7 Risk of pigmentation disorders The practitioner must be prepared for any reactional hyperpigmentation, even though it is generally accepted that phenol has more of a depigmenting, than a hyper-pigmenting, effect. If the skin that is being treated is a very melanin-reactive phototype such as Fitzpatrick IV or above, or has been identified in the consultation as the potential to have a severe inflammatory reaction, the melanocytes should be sedated with tyrosinase inhibitors and antioxidants before and after the peel.18 This needs to be used on the areas being treated and the surrounding areas.

Bleaching cream should be applied as soon as possible after the peel. The skin can usually tolerate the cream up to the tenth day after the peel. Inhibition of melanocytes should be continued for a minimum of six weeks.17 If the peel is being performed on a skin Fitzpatrick I-III, and if the patient follows advice to keep out of the sun and use sun protection, there should be no postinflammatory hyperpigmentation. However, there is an increased risk of prolonged erythema on lighter skin types. Patients should completely avoid the sun and use effective sun protection (SPF 50+) for up to three to six months, followed by gradual exposure to UV light thereafter.1,7 Demarcation line As mentioned, there is a risk of a demarcation line on the skin that has severe dyschromia or sun damage, wrinkles, freckles, keratoses

or lentigines, as the skin treated will look rejuvenated and stand out clearly from the surrounding damaged skin. It is especially important to combine the peel with a superficial-medium TCA-based peel to minimise the demarcation line if the skin phototype has been properly selected.1,7

Summary I have found that ‘chemical blepharoplasty’ using an adapted phenol oil formula for this sensitive area is a good alternative to surgical blepharoplasty when there is not an excess amount of skin. It is easy to apply and patients usually recover within several days. Practitioners must ensure they are experienced in chemical peeling before attempting this procedure.

Disclosure: Dr Jane Ranneva is a medical advisor for Skin Tech Pharma Group.

Dr Jane Ranneva is a dermatologist and specialist in rehabilitative, reconstructive and aesthetic medicine. She is an experienced trainer of chemical peeling, international trainer of dermal filler and botulinum toxin injections.

REFERENCES 1. Philippe Deprez, ‘Phenol: Chemical blepharoplasty and cheiloplasty’, Textbook of Chemical Peels: Superficial, Medium, and Deep Peels in Cosmetic Practice, CRC Press, 2(2017), pp.

308-315.

2. Bruce RM, Santodonato J and Neal MW (1987), ‘Summary review of the health effects association with phenol.’ Toxicol. Ind. Health 3, 535-568.

3. Kania CJ (1981) ‘A scientific note on: phenol.’ J. Am. Med. Technologists 43, 20 4. Corning DM and Hayes MJ (1970) ‘The dermal toxicity of phenol: an investigation of the most effective first-aid measures.’ Brit. J. Ind. Med. 27, 155-159 5. Flickinger CW (1976) ‘The benzenediols: catechol, resorcinol and hydroquinone – review of the industrial toxicology and current industrial exposure limits.’ Amer. Ind. Hyg. Assoc. J. 37, 596-609 6. Gross BG. (1984) ‘Cardiac arrhythmias during phenol face peeling’.

Plast Reconstr Surg. 1984 Apr;73(4):590-4.

7. European Union Risk Assessment Report, CAS: 108-95-2.

EINECS: 203-632-7, ‘phenol’ V64, Institute for Health and Consumer Protection. 2006. <https://echa.europa.eu/ documents/10162/1ca68f98-878f-4ef6-914a-9f21e9ad2234> 8. Niti Khunger (2014), Step by Step Chemical Peels, 2ed. Jaypee Brothers Medical Publishers (P) Ltd, 162-163.

9. Skin Tech Instructions for Use. Reference available from upon request from Skin Tech Pharma Group: www. skintechpharmagroup.com.

10. Hugh M. Gloster, Complications in Cutaneous Surgery, Springer, 2008, 190.

11. Skin Tech Protocols, available upon request from Skin Tech Pharma Group <http://www.skintech.info/professionals/index.php> 12. James J. T. Chen, Black J. B. Chen, Topical pharmaceutical compositions for healing wounds, 2001. <https://www.google. com/patents/US6232341> 13. Litton D and Trinidad G (1981) Complications of chemical face peeling as evaluated by a questionnaire. Plastic and Reconstructive Surgery (Baltimore) 67, pp.738-744.

14. Truppman ES, Ellenby JD (1979) ‘Major electrocardiographic changes during chemical face peeling. Plast Reconstr Surg 63: pp44-48.

15. June K Robinson et al. Surgery of the Skin, Elsevier, 3ed. (2015) pp.405-406.

16. Marwali Harahap (1993), Complications of Dermatologic Surgery: Prevention and Treatment, Springer-Verlag, 70 17. Skin Tech Pharma Group, ‘Chemical Peel Blepharoplasty’, <http:// www.peeldeep.com/professional-area/outstanding-technology/ chemical-blepharoplasty/> 18. Rashmi Sarkar, Chemical Peels for Melasma in Dark-Skinned Patients, Journal of Cutaneous and Aesthtetic Surgery, 2012 Oct-Dec; 5(4): 247-253

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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mandible, anterior to the masseter. It penetrates the masseteric fascia and rises upwards toward the eye. The facial artery lies deep to the zygomaticus and risorius muscles, but superficial to the buccinator and levator anguli oris. At the level of the mouth, the facial artery sends two labial arteries, inferior and superior, into the lips where they pass below the orbicularis oris. The continuation of the facial artery near the medial canthus beside the nose is the angular artery.4 In the nasal area, the biggest concern in terms of complications is vascular compromise and anatomical structure damage. If a patient has had a surgical rhinoplasty procedure and wants to slightly add to this result with dermal filler, due to the added changes of anatomical variations, they are at a higher risk of compromising the vascular supply.5

NSR complication case study

Case Study: Treating a NSR Complication Dr Beatriz Molina discusses her unique way of managing a vascular complication following a non-surgical rhinoplasty treatment The majority of non-surgical techniques using hyaluronic acid (HA) dermal fillers, to rejuvenate and/or address facial disharmonies deliver safe, effective, and reproducible aesthetic results. HA dermal fillers allow for the correction of rhytids, folds, and volume deficits in response to age-related changes or disease, and they can also be used for minor corrections following surgical procedures such as rhinoplasty.1 Although the safety profile of HA fillers is favourable, adverse reactions can occur. Most of these are noted to be mild and transient – serious adverse events are rare.

Early adverse reactions to HA fillers include vascular infarction and compromise, inflammatory reactions, injection-related events and inappropriate placement of filler material. Among late reactions are nodules, granulomas, and skin discoloration.2 Most adverse events can be avoided; a detailed understanding of facial anatomy, suitable patient and product selection, and appropriate aseptic technique can reduce the chances of them occurring. Should an adverse reaction occur, practitioners must be prepared with the knowledge and tools available for effective treatment.6

Non-surgical rhinoplasty procedures ‘Non-surgical rhinoplasty’ (NSR) is a treatment that commonly uses HA dermal filler to shape the nose. Although it is a relatively fast procedure, generally taking around 15-20 minutes, only highly experienced practitioners should attempt this treatment, as the nose is an extremely high-risk area due to the rich vascular blood supply.3 For successful treatment, injectors must know the location of the relevant arteries. The facial artery comes from the external carotid and circles around the inferior and anterior borders of the

A 40-year-old female patient, who I had successfully treated three times before, came to me for another NSR treatment. Prior to my treatments, she had undergone a surgical rhinoplasty, but still had a small defect post-surgery that she wanted to correct.

Surgical rhinoplasty patients are particularly difficult to treat as their vascular supply may be compromised, so practitioners must be extremely careful when treating with fillers.7 On July 19, 2017, I performed the NSR treatment using a 25G cannula and a HA dermal filler. A small amount of lidocaine was firstly injected into the tip of the nose, then a 23G needle was used to facilitate an entry point for the cannula; it’s important to note that only the tip off the needle was inserted. I injected 0.1ml of HA into the tip of the nose, then I injected 0.1ml into the right side. During the procedure, I noticed that there was a small area of blanching (a white discolouration) where I was injecting, on the right alar part of her nose. After injecting hundreds of noses in my 12 years’ experience, this was the first time that I had seen this. Immediately, I stopped injecting, massaged the area vigorously and applied heat with warm compresses. After 30-40 seconds, there was an established blood flow of the skin and the colour went back to normal. Throughout this, the patient did not report any pain or discomfort. I decided to stop the procedure and informed the patient of what had just happened. The choice was to observe the patient, or to use hyaluronidase.

On occasion of a complication such as this, some studies suggest that practitioners should immediately use hyaluronidase and massage the area, using warm compressions if appropriate.4,11 They also state that hyaluronidase should be injected immediately and used daily in liberal doses where signs and symptoms are present such as erythema, pain on injection or in the days following. They note that you should treat wherever the vasculature appears compromised, not only at the site of injection. I explained the situation to the patient and discussed options with her; in particular, the use of the hyaluronidase. I was debating whether or not to inject hyaluronidase in this circumstance, as the patient was not experiencing any pain and the skin seemed to have a normal colouration and good blood flow.

We agreed that we would have a follow-up appointment in 24 hours, unless there were any changes or concerns before then. She was fully aware that she could contact me if she had any worries and I gave her my personal mobile number. I advised her to contact me if she started to experience any discomfort or pain, or if any redness appeared on the skin and I also showed her photos of what skin may look like when compromised.

The following day, the patient was not reporting any pain or skin changes. However, on the morning of July 21, which was two days’ post treatment, the patient woke up and noticed some skin

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way to administer the hyaluronidase that would not require injecting and, therefore, not cause additional pain to the patient or risk further damaging the blood supply to the nose. I decided to use a device I have in my clinic called the Plasma Shower, part of the Plasma BT platform, which is an atmospheric pressure plasma technology. I had previously been using it in my clinic to deliver serums transdermally into the skin Figure 1: Patient presenting Figure 2: Immediately after without having to inject them. I had not used Figure 3: Immediately after with discolouration and first treatment using Plasma Plasma Shower with SSR it with hyaluronidase before, but I thought pustulation on the right Shower and 1,200 units of HA and Dermalux for 30 that I could target the HA by transdermally side of the nose, two days hyaluronidase transdermally. minutes. following NSR treatment delivering the hyaluronidase. The Plasma using HA dermal filler.

Shower also has reported healing effects,13,14 which I thought would be an added benefit.

July 26 July 28 Three months after I started by using the Plasma Shower on the nose for three minutes. Then I topically applied 0.2ml of hyaluronidase onto the nose. For intravascular infarction, recommendations are of a minimum of 200300 units of hyaluronidase (spread over the entire area of impending necrosis), repeated daily for a minimum of two days, until signs of permanent necrosis or reestablished Figure 4: Immediately after Figure 5: Immediately after Figure 6: Patient three blood flow appears. Doses of up to 1,500 second treatment of Plasma third treatment of Plasma months after treatment. units are suggested if needed, because the Shower with SSR HA and Shower with SSR HA and consequence of inadequate dosing is tissue Dermalux for 30 minutes.

Dermalux for 30 minutes. necrosis. They also state that the patient should be reassessed every 24 hours.4 discolouration on the nose, which she said was also painful. She Other guidelines suggest a minimum of 500-600 units.6 I therefore contacted the clinic and I asked her to come in to see me straight considered these guidelines for using hyaluronidase topically. away. When I assessed the patient, there was a livedo reticularis-like Consequently, I applied 600 units of hyaluronidase topically onto the appearance (blotchy white and red skin) on the whole nose as well nose (1,500 vial diluted in 10ml of sodium chloride). I noticed that there as a pustulation on the right side, which was the area where the was improvement, but it was too slow, so it was necessary for the blanching occurred (Figure 1). As soon as I saw this, I realised that solution to be in a higher concentration to increase its effectiveness. I there was a vascular compromise and I knew I had to dissolve the decided to dilute 1,500 units of hyaluronidase in 1ml of sodium chloride filler using hyaluronidase. As the patient’s skin was very tender and and applied another 600 units. In total, 1,200 units of hyaluronidase sore, she was reluctant to be injected again. I was also concerned was given transdermally. To my great relief, the patient felt the pain about injecting hyaluronidase, as it would add more pressure to the was subsiding, and we could see the skin’s colour was improving area, which could exacerbate the patient’s pain and possibly make dramatically (Figure 2). Once the patient was comfortable, and there the complication worse. At this point, I tried to think of an alternative was no pain on palpation, I stopped treatment and agreed to see her again the following day to review the results. When she came back on July 22, the patient was feeling better than the previous day, but there was still some mild tenderness on the tip of the nose. I decided to repeat the procedure, until the patient had no further pain. I delivered a further 750 units of hyaluronidase transdermally.

We agreed to have a chat the next morning to discuss the possibility of further hyaluronidase treatment. When I called her on Sunday morning July 23, the patient said she felt that there was a vast improvement, she had no pain at all and did not wish to be seen that day. We agreed to wait until Monday for further review. On Monday July 24, the patient came back to my clinic. There was no pain and her skin colour seemed much better, but I decided to try and help the skin to heal and recover further by hydrating and stimulating repair. I used the Plasma Shower device again, to deliver a HA product, to hydrate the cells and speed up recovery. I chose to use SSR HA Injectable because I had been using this in my clinic to help skin recovery after deep chemical peels. Then we proceeded to lie the patient under a LED phototherapy device (Dermalux) for 30 minutes to assist with the July 21 Before

July 21 After

July 24

I was concerned about injecting hyaluronidase, as it would add more pressure to the area, which could exacerbate the patient’s pain and possibly make the complication worse

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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redness (Figure 4). We repeated the same treatment on Wednesday July 26 (Figure 5)3 and on Friday July 28 to further help heal and hydrate the skin4 (Figure 6).5

Discussion It is important that practitioners have the ability to recognise complications and make the correct clinical judgements for successful treatment. While the patient was obviously concerned about the complication occurring, she had been coming to me for treatment for years and trusted my clinical judgement. I ensured that I was available to her at all times while we were dealing with this complication, and after she had the first treatment she was very happy with the outcome. We have since not re-injected the nose, but she has been to see me for other treatments. I would never consider re-injecting the area for a minimum of three to four months, ideally six. There is no evidence or articles to support this statement; however I feel as though it is common sense to tread carefully when treating patients who have had known complications. For other practitioners who are experiencing similar complications where they feel like an injection of hyaluronidase might cause further pain, discomfort and irritation, I believe that delivering hyaluronidase transdermally is a useful solution. I believe this kind of complication approach is extremely interesting and would benefit from further study. I am therefore currently undergoing a retrospective study to look into this further, after which I am hoping to devise a protocol for its use.

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Aesthetics Dr Beatriz Molina is medical director and owner of Medikas clinics. Dr Molina is a KOL for Galderma UK and is also an international speaker and a country mentor leader for Galderma Global. She is the founder of the IAPCAM and a finalist for the The SkinCeuticals Award for Medical Aesthetic Practitioner of the Year at the Aesthetics Awards 2017.

REFERENCES 1. Alam M, Dover JS. Management of complications and sequelae with temporary injectable fillers. Plast Reconstr Surg. 2007;120(Suppl):98S–105S. 2. Signorini M et al., Plast. Reconstr Surg. 137: 961e, 2016 3. Narins RS, Jewell M, Rubin M, Cohen J, Strobos J. Clinical conference: Management of rare events following dermal fillers. Focal necrosis and angry red bumps. Dermatol Surg. 2006;32:426–434.

4. Ozturk CN, Li Y, Tung R, Parker L, Piliang MP, Zins JE. Complications following injection of soft-tissue fillers. Aesthet Surg J. 2013;33:862–877.

5. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: Protocol for prevention and treatment after use of dermal fillers. Dermatol Surg. 2006;32:276–281.

6. Ozturk CN, Li Y, Tung R, et al. Aesthet Surg J. 2013;33(6):862-877. 2. DeLorenzi C. Aesthet Surg J. 2014;34(4):584-600. 3. Glaich AS, Cohen JL, Goldberg LH. Dermatol Surg. 2006;32(2):276-281.

7. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications.

Aesthet Surg J. 2011;31:110–121.

8. Sclafani AP,Fagien S. Treatment of injectable soft tissue filler complications. Dermatol Surg.

2009;35(Suppl 2):1672–1680.

9. Funt D, Pavicic T. Dermal fillers in aesthetics: An overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;6:295–316.

10. De Boulle K. Management of complications after implantation of fillers. J Cosmet Dermatol.

2004;3:2–15.

11. DeLorenzi C. Transarterial degradation of hyaluronic acid filler by hyaluronidase. Dermatol Surg.

2014;40:832–841.

12. Cohen JL, Biesman BS, Dayan SH, et al. Treatment of hyal- uronic acid filler-induced impending necrosis with hyaluronidase: Consensus recommendations. Aesthet Surg J. 2015;35:844–849.

13. Insook Ahn, Evaluation on suitability to use on acne prone skin with ‘Plasma Shower®’and ‘25 Days’, Korea Institute for Skin and Clinical Sciences, 2015.

14. Insook Ahn, Evaluation of epidermis thickness improvement using ‘Plasma Shower®’ and ‘Voveo Premium Essence’, Seoulin Medicare Co. Ltd., Korea Institute for Skin and Clinical Sciences, 2016.

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Aesthetics

An Overview of Micromastia and Breast Asymmetry Cosmetic and plastic surgeon Mr Hagen Schumacher discusses the conditions of micromastia and breast asymmetry, and how they can be treated most effectively What is micromastia?

More than half the female population has asymmetrical breast development during teenage years,1 and according to a study by the Mayo Clinic, nearly seven out of 10 adult women feel their left and right breasts are not similar in appearance.2 Disparity in breast size is actually quite normal, with a 15-20% difference between breasts considered average.3 However, sometimes instances occur when asymmetry becomes highly developed or the breasts remain extremely small postpuberty. The medical term for the latter is micromastia, which is the post-pubertal underdevelopment of a woman's breast tissue. This is also sometimes referred to as breast hypoplasia.4 Women suffering with this condition fundamentally have two nipples on a flat chest rather than developed mammary glands.

There are two types of micromastia: bilateral and unilateral. Bilateral is when there is no breast tissue on either side of the chest.

Unilateral is when there is breast tissue on one side and none, or a significantly smaller amount of tissue, on the other side.

Women often have asymmetrical breasts as a result of micromastia.

For example, in a study of 111 patients with micromastia, over 95% exhibited breast asymmetry.5 While these conditions are not uncommon, they can have an enormous impact on a woman's selfesteem and confidence.

What causes micromastia and breast asymmetry?

Some of the causes of micromastia can be related to congenital defects presented at birth, such as abnormalities in the pectoral muscles. They may be evident when a child is born, for example; in the case of Poland syndrome,6 where part of the chest wall muscle is missing, or they may only become apparent in adolescence, for example; mammary hypoplasia or hyperplasia, or breast asymmetries.

Lifestyle factors in later life can sometimes enhance asymmetry of underdeveloped breasts. During pregnancy and breastfeeding, the size and shape of the breasts can change.7 As breast tissue swells with milk, and then shrinks again once breastfeeding has ended, the contours of the bust line may change.

When it comes to breastfeeding, it doesn’t matter how much a woman tries to feed the baby evenly from both breasts, the child may sometimes prefer one over the other. Ultimately, one of the breasts may stretch and appear uneven as time passes. It is also possible for one breast to return to its pre-pregnancy size while the other stays larger, droops, or flattens more. Some patients may even end up with one breast permanently a full cup size smaller or larger than the other. 8

Body alignment can play a role in breast asymmetry. The fat deposits and muscles in the body tend to become more evenly distributed when the body is in perfect alignment. The truth, however, is that during a person’s life, sleeping positions, injuries, stress, and posture, will cause body alignment to change and this over-development of the muscles causes fat tissue in the breasts to appear uneven. Breast deformities can also be acquired as a result of trauma, burns, tumours, infection or endocrine dysfunction.

Treatment of serious cases

The best procedures to remedy severe micromastia usually involve surgery. One of the options available is breast augmentation with implants.

Breast implant surgery can address the problems of both bilateral and unilateral micromastia. For bilateral micromastia, both the implants will be the same size. For unilateral micromastia, implants will be used to help the breasts appear as similar in size as possible. ‘Gummy bear’ high-strength cohesive silicone gel implants, or regular silicone gel implants, create the most natural looking results in women with very little breast tissue, as these implants have a decreased chance of rippling.9 However, if significant asymmetry has occurred as well, a combination of breast reduction, breast uplift and nipple repositioning might also be necessary. Depending on each case, it might mean making the smaller breast bigger, the bigger breast smaller and correcting nipple position and size. There is a tendency for patients to request the smaller breast to be larger, but often the better symmetry is achieved in reducing the larger breast to the smaller breast. Removing excess tissue from the larger breast creates a more natural and long-term result without the need for a surgical implant. Most breast procedures such as this are day cases and may require an overnight stay in hospital after the procedure.

Issues to consider General issues with breast surgery can involve scarring, possible interference with breastfeeding and sometimes, a risk to the nipple itself in terms of its blood supply. When it comes to obvious asymmetry, there’s a need to thoroughly check a patient’s breasts prior to surgery. This is because some research suggests breast asymmetry may be a sign of an increased risk of breast cancer.10 In order to detect any signs of cancer it would be advisable for the patient to have either an ultrasound or mammogram pre-operation.

The purpose of this would be to detect any significant disorder of the breast(s) prior to surgery, so the problem can be resolved beforehand.

The incidences of new breast cancer cases are increasing at a yearly rate.11 It is essential to detect an early cancer so cosmetic procedures do not distort and diminish the opportunity for cure, or limit the usefulness of lumpectomy in cancer treatment. If the patient is between 18 to 40 years’ old, I would recommend they get an ultrasound prior to surgery, whereas if the patient is post 40, a mammogram is highly advised. This is because a patient under 40 is considered low risk and younger patients also have denser breast tissue, making a mammogram difficult to read.12 With micromastia, there is often a debate as to when, and if, surgical intervention is appropriate for younger patients. However, research has demonstrated significant breast asymmetry can cause adolescent girls and young women to score lower on measurements of mental health, than those with a greater degree of breast evenness.13 Doctors at Boston Children's Hospital assessed 59 girls

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between the ages of 12 and 21 whose breasts differed by at least one cup size.14 When compared to a control group of girls without breast asymmetry, the patients were found to have lower self-esteem and worse emotional wellbeing than their even-breasted counterparts.

One of the study's authors, Dr Brian Labow, suggested early intervention, such as consultation, support and surgery if necessary, can help reduce the mental health effects of these conditions.

However, surgery would probably not be advised if a patient is still going through puberty, as breast asymmetry can even itself out as the body continues to develop.15 There are occasionally cases of self-perceived micromastia, which involves a discrepancy between a person's body image and their internalised images of appropriate or desirable breast size and shape. Patients who demonstrate an obsession with very minor issues could be suffering from mental health conditions such as body dysmorphia disorder (BDD).

Whilst procedures are designed to meet what patients think to be desirable and may, in some cases, alleviate psychological suffering,16 those with more serious mental health conditions may actually worsen, rather than improve, their illness following surgery.

At MyAesthetics, the clinic I am based at, we believe the more scrupulous, face-to-face time we have with the individual, the better.

We always offer and encourage patients to have two consultations, prior to surgery with no maximum visits. Whilst many individuals don’t always need or want a second consultation, this does mean they can take as much time as they need to decide whether or not surgery is for them and we have unlimited opportunities to assess their psychological welfare.

If still unsure about a patient’s psychological wellbeing after followup consultations, I believe all potential patients should be referred to a psychiatrist for further evaluation. Psychologists report specialist cognitive behavioural therapy (CBT) is most effective for those with BDD.17 CBT is said to work because it focuses on the experience of patients when they are alone, rather than in social situations, and the patient is encouraged to focus on all the characteristics of his or her self to develop a more helpful or flexible view.18

Non-surgical alternatives If breasts are very underdeveloped or there is a highly obvious asymmetry, it is unlikely this can be corrected without surgery.

However, for smaller differences, there are non-surgical treatments that may help. One treatment option that can provide a more natural result is a fat transfer augmentation.19 Instead of putting an implant in the smaller breast, it can be augmented using the patient’s own body fat. This procedure is beneficial as breasts are kept naturallooking and as similar to each other as possible. Some practitioners use PRP for rejuvenation purposes in the breasts and claim they can restore some fullness and sensitivity to them. There is also evidence of benefits to using PRP in conjunction with fat transfer, as it is said to help with resorption.20 Some energy devices are also used which aim to strengthen, lift and tone the pectoral muscle by emitting microcurrents which causes involuntary contraction. However, practitioners often have to repeat this procedure around 12 to 15 times to achieve best results.21 Occasionally, patients ask for fillers to be put into the smaller breast and, although this would be possible, fillers are only designed for small amounts of volume. If used to augment the breast the results would not only be temporary, but also extremely expensive, as treatment would need to be repeated regularly.22 Therefore, I would personally advise against this method.

Aesthetics

Conclusion Any procedure that can make someone feel better about how they present themselves to the world is worth considering. Part of that consideration, however, includes the risk/benefit ratio of the procedure and whether non-surgical options would also be a good alternative.

If practitioners who are conducting surgical interventions all provide effective screening, have sufficient psychological education and offer unlimited consultations and extensive face-to-face time, it means patients receive the appropriate support and treatment they need.

Mr Hagen Schumacher is clinical lead of the Department of Plastic Surgery in Hinchingbrooke Hospital and is also based at MyAesthetics Group, parent company to MyBreast clinic in Cambridgeshire.

He is chair of the skin cancer multidiscipline team, lead appraiser and deputy chair of the Medial Advisory Committee in the same trust. His specialist interests are head and neck, breast reconstruction and aesthetic surgery in these regions.

REFERENCES 1. Urban Agenda, The Impact of Breast Size on Female Self-Esteem: (USA, Urban Agenda, 2015)<https://www.urbanagenda.org/body-confidence/the-impact-of-breast-size-on-female-selfesteem/> 2. Mansi Kohli, Women’s Health: Understanding Breast Asymmetry Disorder, (2011) http://www. indiatimes.com/health/healthyliving/women’s-health-understanding-breast-asymmetrydisorder-238538.html 3. Kirtly Parker Jones, Dr., My Breasts Are Different Sizes – Am I Normal?: (USA, The Scope University of Utah Health Sciences Radio, 2014) <https://healthcare.utah.edu/the-scope/shows.php?shows=0_ aup26c6j> 4. Winocour, Sebastian, MD, MSc and Lemaine, Valerie, MD, MPH, FRCSC, ‘Hypoplastic Breast Anomalies in the Female Adolescent Breast’, Seminars in Plastic Surgery, Volume 27 – Issue 1 (February 2013) p. 42–48 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706053/> 5. Yeslev, M, Braun, SA and Maxwell, GP, ‘Asymmetry of Inframammary Folds in Patients Undergoing Augmentation Mammaplasty’, Aesthetic Surgery Journal, Volume 36 – Issue 2 (February 2016) p.15066 <https://www.ncbi.nlm.nih.gov/pubmed/26353799> 6. Winocour, Sebastian, MD, MSc and Lemaine, Valerie, MD, MPH, FRCSC, ‘Hypoplastic Breast Anomalies in the Female Adolescent Breast’, Seminars in Plastic Surgery, Volume 27 – Issue 1 (February 2013) p. 42–48 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706053/> 7. WebMD, Breastfeeding Overview (USA, WebMD Medical Reference, 2015) <https://www.webmd. com/parenting/baby/nursing-basics#5> 8. WebMD Breast problems after breastfeeding (USA, WebMD Medical Reference, 2015) <https://www. webmd.com/parenting/baby/after-nursing#1> 9. Stevens, Grant Dr., Hirsch, Elliot, MD, Tenenbaum, Marissa, MD and Acevedo, Maria, ‘A Prospective Study of 708 Form-Stable Silicone Gel Breast Implants’, Aesthetic Surgery Journal, Volume 30 – Issue 5 (September 2010) p. 693-701 < https://academic.oup.com/asj/article/30/5/693/255411/AProspective-Study-of-708-Form-Stable-Silicone> 10. Boyles, Salynn, Breast Asymmetry Points to Cancer Risk: (USA, WebMD Medical Reference, 2006) <http://www.webmd.com/breast-cancer/news/20060320/breast-asymmetry-points-to-cancer-risk> 11. Cancer Research, Breast cancer incidence (invasive) statistics: (UK, Cancer Research UK, 2014) <http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/ breast-cancer/incidence-invasive#heading-Two> 12. Cancer Research, Breast Screening: (UK, Cancer Research UK, 2014) < http://www. cancerresearchuk.org/about-cancer/breast-cancer/screening/breast-screening> 13. American Society of Plastic Surgeons, Study Shows Mental Health Impact of Breast Size Differences in Teens: (USA, American Society of Plastic Surgeons website, 2014) <https://www.plasticsurgery.org/ news/press-releases/study-shows-mental-health-impact-of-breast-size-differences-in-teens> 14. Nuzzi, Laura C. B.A.; Cerrato, Felecia E. M.P.H.; Webb, Michelle L. P.A.-C.; Faulkner, Heather R. M.D., M.P.H.; Walsh, Erika M. M.D.; DiVasta, Amy D. M.D., M.M.Sc.; Greene, Arin K. M.D., M.M.Sc.; Labow, Brian I. M.D., ‘Psychological Impact of Breast Asymmetry on Adolescents: A Prospective Cohort Study’, Plastic & Reconstructive Surgery: December 2014 - Volume 134 - Issue 6, p. 1116–1123 <http://journals.lww.com/plasreconsurg/Abstract/2014/12000/Psychological_Impact_of_Breast_ Asymmetry_on.3.aspx> 15. Nethersole, Shari, M.D, Expert Advice: Asymmetric Breast Development, (US, familyeducation) < https://www.familyeducation.com/life/physical-changes/asymmetric-breast-development> 16. Poole, Nigel, Consent to Cosmetic Surgery, (UK, Consulting Room, 2012) <https://www. consultingroom.com/Blog/308/consent-to-cosmetic-surgery- > 17. Body Dysmorphic Disorder Foundation, Cognitive Behaviour Therapy, (UK, Body Dysmorphic Foundation website, 2017) <http://bddfoundation.org/helping-you/getting-help-in-the-uk/#cognitivebehaviour-therapy> 18. Veale, D, ‘Cognitive-behavioural therapy for body dysmorphic disorder’, Advances in Psychiatric Treatment, 7(2001), pp. 125–132 <http://veale.co.uk/PDf/CBT%20for%20BDD.pdf> 19. Fa-Cheng, Li, MD, PhD; Chen, Bing, MD and Cheng, Lin, MD, ‘Breast Augmentation with Autologous Fat Injection’, Annals of Plastic Surgery, Volume 73 – Issue 1 (September 2014) p.37-42 <https://www. ncbi.nlm.nih.gov/pmc/articles/PMC4219534/> 20. Rong Jin, Lu Zhang, and Yu-Guang Zhang, Does platelet-rich plasma enhance the survival of grafted fat? An update review, (2013) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3631549/> 21. The Non Surgical Group, Non Surgical Breast Uplift, (2017) <http://www.thenonsurgicalgroup. co.uk/309-2> 22. Ishii, Hidenori, MD and Sakata, Kazuaki, MD, ‘Complications and Management of Breast Enhancement using Hyaluronic Acid’, Plastic Surgery, Volume 22 – Issue 3 (Autumn 2014) p.171-74 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173863/>

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Aesthetics | December 2017

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Aesthetics

A summary of the latest clinical studies Title: Efficacy of IncobotulinumtoxinA for the Treatment of Glabellar Frown Lines in Male Subjects: Post-Hoc Analyses from Randomized, Double-Blind Pivotal Studies.

Authors: Jones, DH, Kerscher M, et al.

Published: Dermatologic Surgery, November 2017 Keywords: Botulinum toxin, IncobotulinumtoxinA, male face, wrinkles Abstract: Males are increasingly seeking minimally invasive cosmetic procedures such as botulinum toxin injection. However, few studies have specifically examined the efficacy of such procedures among men. The objective was to assess the efficacy of incobotulinumtoxinA for treating glabellar frown lines (GFLs) in men. Three incobotulinumtoxinA studies were included in post hoc analyses of responder rates: 2 pivotal Phase 3 US registration studies for GFLs (n = 55 males in a pooled analysis) and a European pivotal Phase 3 study for upper facial lines (UFLs; n = 21 males). In the pooled analysis of Phase 3 GFL studies, 55.9% of males and 81.4% of females were responders on the Facial Wrinkle Scale (FWS) at 30 days. Similarly, 54.5% and 88.0% of males and females, respectively, treated for GFLs in the upper facial line study were responders on the Merz Aesthetics Scales (MAS) at 30 days. Lower proportions of male responders on the Facial Wrinkle Scale /Merz Aesthetics Scales were consistent with results from onabotulinumtoxinA and abobotulinumtoxinA GFL studies. Compared with females, males demonstrate lower response rates on wrinkle severity scales in studies on all 3 available botulinum toxins. Variations in treatment response are potentially associated with key male anatomic differences (e.g., muscle mass). Results emphasize the need for customized treatment plans.

Title: Psychological Stress and Psoriasis. A Systematic Review and Meta-analysis Authors: Snast I, Reiter O, et al.

Published: The British Journal of Dermatology, November 2017 Keywords: Psoriasis, skin condition, stress Abstract: Psychological stress has long been linked with psoriasis exacerbation/onset. However, it is unclear if they are associated. A comprehensive search of Pubmed, PsycINFO, Cochrane library, and clinicaltrials.gov databases was performed.

Studies investigating the association between preceding psychological stress and psoriasis exacerbation/onset were classified as cross-sectional, case-control or cohort. Surveys evaluating beliefs regarding stress-reactivity were analysed separately. Suitable studies were meta-analysed. Thirty-nine studies were included evaluating 32,537 patients: 19 surveys, 7 cross-sectional, 12 case-controls and 1 cohort. Based on surveys and cross-sectional studies, 46% of patients believed their disease was stress-reactive and 54% recalled preceding stressful events.

Case-control studies evaluating stressful events rates prior to psoriasis exacerbation (N=6) or onset (N=6) varied in time lag to recollection (≤9 month to ≥ 5 years). Pooling 5 studies evaluating stressful events preceding psoriasis onset yielded an OR of 3.4 (95%CI, 1.8-6.4, I2 =87%), however the only study evaluating documented stress disorder diagnosis reported similar rates (OR

1.2, 95%CI, 0.8-1.8) between patients and controls. The association between preceding stress and psoriasis exacerbation/onset is based primarily on retrospective studies with many limitations.

No convincing evidence exists that preceding stress is strongly associated with psoriasis exacerbation/onset.

Title: Treating Multiple Body Parts for Skin Laxity and Fat Deposits using a Novel Focused Radiofrequency Device with an Ultrasound Component: Safety and Efficacy Study Authors: Chilukuri S, Denjean D, et al.

Published: Journal of Cosmetic Dermatology, November 2017 Keywords: Body contouring, radiofrequency, skin laxity, ultrasound Abstract: Growing demand for noninvasive skin tightening and reduction in fat results in an increasing pressure for devices with good clinical efficacy, consistency of results, and high patient comfort. The objective was to validate clinical efficacy and versatility of a novel device, which combines radiofrequency (RF) and ultrasound for treating skin laxity and fat deposits. We treated 34 subjects with facial skin laxity and/or abundant body or arm fat deposits. Subjects were divided based on their indications.

Ten subjects received treatments to the face, 7 subjects to arms, 8 subjects to thighs, and 9 subjects on abdomen. All patients received 4 treatments on a weekly basis. Photographs of patients were assessed by blinded evaluators to recognize the baseline images from the 3-month follow-up images. Patient comfort and satisfaction were evaluated using a 5-point Likert scale questionnaire. Any adverse events were recorded. Patient images were correctly recognized in >90% of cases in all study groups. Patient questionnaires showed overall satisfaction with the therapy course and results. On a scale of 1 to 5, the patients agreed (4.1) that they are satisfied with the results that the treatment is comfortable (4.1) and that they are satisfied with the treatment time (4.1). No adverse events were reported.

Title: Neck Rejuvenation using a Multimodal Approach in Asians Authors: Doh EJ, Kim J, et al.

Published: The Journal of Dermatological Treatment, November 2017 Keywords: Asian skin, dermal filler, hyaluronic acid, neck rejuvenation Abstract: A multimodal approach is essential for neck rejuvenation because many factors contribute to the aging of the neck. We evaluated the effect of combined therapy using microfocused ultrasound with visualization (MFU-V), neuromodulator injection, and filler injection for neck rejuvenation.

Subjects were sequentially treated with three kinds of interventions in a single session, as follows: (A) MFU-V or calcium hydroxyapatite injection for restoring skin laxity; (B) hyaluronic acid filler injection for horizontal neck lines; and (C) neuromodulator injection for platysmal bands. All ten patients showed clinical improvement of neck aging after combined treatment. Patients with a more aged neck at baseline were more likely to show greater improvement after treatment. In conclusion, neck rejuvenation using multimodal approach is effective in Asians.

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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to reducing wrinkles. Because of this, I found myself questioning whether working in aesthetics was less noble then mainstream medicine. I wondered ‘Is the work with the sick, any less valuable than the work we do with the well?’ Now, I have come to strongly believe the work we do in aesthetic medicine is much more meaningful as a medical professional than is sometimes perceived by others. The impact you can have on a patient in this context, through improving concerns and boosting their self-esteem, can be profound and rewarding. Also, you meet so many inspiring aesthetic Dr Kalpna Pindolia offers a personal practitioners, just like you do in conventional medicine.

Medical aesthetics is being moulded by our community perspective on transitioning from working with pioneering developments that continue to build our in the National Health Service to medical evidence base. Technology is evolving with innovative products and devices coming onto the market, just like aesthetics with traditional medicine. The sense of responsibility With the plethora of skills possessed by medical professionals, within the work we do is also central to the future of the discipline. aesthetic medicine has become an increasingly viable option to Likewise, there are a variety of difficult and interesting concerns from diversify in or even to choose as an entirely alternative career patients who come from diverse socioeconomic backgrounds, culture pathway. With a relatively young history and continuous growth, and life experience. As practitioners in this growing field, we are in a there is no denying that medical aesthetics is a discipline that is unique position to empower perceptions of beauty. professionally engaging as an avenue to practise the science, as All in all, I have discovered there is certainly no need to compare well as the art of medicine. what you find rewarding as a medical professional in this specialty After working in emergency medicine for seven years, like many of my compared to the NHS, as long as you are passionate about it. The fellow colleagues, my priorities had changed. I spent a further three opportunities to make a difference in medical aesthetics are there for years working as a cruise ship doctor to reflect on my career so far the taking, should you seek them. and make future plans. Returning to emergency medicine as a locum after this was a challenge that reiterated my current thoughts of how 2. Working as a sole practitioner in a new capacity this particular specialty fitted poorly into my lifestyle. I started looking One thing I didn’t realise before I first got into aesthetics, is into alternative options, which involved making a list of aspects of my how much I would miss the team atmosphere of the NHS. The current role I liked and those I disliked. Then I went on to consider camaraderie, technical support and teamwork of the emergency roles that I thought may achieve the balance I needed, using a department was special. As well as working alone much more career coach for support. I did a foundation and advanced course, as than I was used to, I also felt like I was back to being a junior all part of exploring many potential options. Needing some short-term of a sudden. Compared to my middle grade role in the NHS and financial balance, I then went to work for the Centre of Health and senior doctor role onboard ships, I did not have the same level of Disability Assessments (CHDA). During this time, I was establishing experience in aesthetics. an aesthetic patient-base part-time and then studied for a Level My solution to these challenges was, and still is, to build 7 qualification in non-surgical aesthetics. This was certainly an professional relationships and train as much as I possibly can. Apart intense time with a lot of juggling involved. After 15 months at the from investing in formal training, there are regular industry events in CHDA, the advantages of a career in medical aesthetics, such as a the UK, and further afield. There are yearly conferences in the UK better work-life balance, whilst maintaining an income, had become where you can learn from live talks and demonstrations, as well as undeniable. I then focused on this new and developing passion network with industry colleagues. Company representatives can full-time. also assist you with information about materials and provision of The journey from being an NHS professional to an independent training. Additionally, knowing your limits and pacing your progress practitioner has not necessarily been smooth, or easy. The reduces the feeling of being overwhelmed with the multiple transition from the illness to wellness industry is unique, with potential services and revenue streams available. completely new types of patients and a different skillset needed.

I have had the tremendous benefit of learning from nurses, dentists As well as this, booming consumer demand does not necessarily and doctors as trainers and mentors. From knowledge, technical equate to success for the individual practitioner. So, in this article, I know-how and business tips, these professionals have been shall explore some of the personal challenges I have encountered instrumental to my progress so far. from moving into aesthetics from the NHS so far, and divulge how I Networking within the field, as well as in the business realm, is have overcome these. vital to progress. Struggling with networking is normal for those who are more introverted by nature, but the more you do, the 1. Retaining my professional identity as a doctor more comfortable it becomes. Apart from reducing isolation levels, Moving into aesthetics was perceived with indifference by some of my it reveals valuable sources for support in managing difficulties, NHS colleagues and friends. They appeared to challenge my identity and identifying colleagues to refer to for advanced treatments or as a ‘proper’ doctor. This initially also gave me doubts over my identity management of complications. Emotionally-supportive people will as a doctor. When I made the move, family and colleagues would motivate and perpetuate your progression. They can also support often ask about how the euphoria of life-saving work compares your financial worth with inspiration and business networking.

Five Challenges of Transitioning into Aesthetics

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Joining associations such as the British College of Aesthetic Medicine (BCAM) and the British Association of Cosmetic Nurses (BACN) can also broaden your education and industry network.

Social media groups on Facebook can provide peer-to-peer support. Journals are also a great way to expand your knowledge base, as well as to get to know industry colleagues and their areas of interest, which may be aligned with yours. There is certainly a special supportive atmosphere embracing aesthetic medicine where we are all continually learning, no matter what your experience level is in the industry.

3. Criticism of work In the era of social media, and with somewhat small industry circles, I found that your work is scrutinised more by colleagues and potential patients in the privately paid health industry, compared to the relatively closed area of NHS work. Perception of the quality of your work can vary, as does the definition of beauty for an individual. There is always that worry about how your work will be perceived, especially in a specialty where the definition of good outcomes is open to interpretation.

Patients rate and recommend your services on a number of different platforms, like social media, which you might not be used to. Good ratings provide social proof of a patient’s confidence in an aesthetic practitioner. A quality consultation process, investing time to discuss realistic expectations and potential risks, is well worth it in this respect. Negative responses are best dealt with calmly and with professionalism to limit any further damage to your reputation.

As I have grown in experience, I have accepted that the anxiety this can cause is actually an advantage, because it ultimately demonstrates that you care. From feedback, whether positive or negative, comes the chance to develop and grow as a professional as well as personally.

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subject the well patient to medical and psychological risk, weighing up the decision to treat does become less daunting over time.

5. Entering the world of business and marketing As medical professionals, we have a multitude of talents including anatomical knowledge, communication skills and clinical abilities.

However, marketing, business operations, advertising and financial administration are not usually within our expertise, coming from the NHS. This new venture can be intimidating and it is the nature of the aesthetics specialty that, often, when you are starting out, you need to think about these business factors while trying to develop your fundamental aesthetic skills. It is important to become familiar with business topics such as marketing, finance and law. But, we are not all marketers, financiers or lawyers. It is OK if you realise that some areas are not within your remit. Using your strengths is important, so determine what these are and learn to recognise when delegation would be more efficient and cost effective. Most of my business awareness has been from a combined approach of attending formal courses and conferences that run business workshops and also from discussions with various providers, for instance, business coaches.

Social media is a way of picking up tips as well as more formal discussions with companies, such as digital marketeers, PR agencies and bloggers. It is also often worth identifying your niche early to differentiate yourself from others. This process involves recognising an area within the discipline representing your passion. Defining a space that competition has not isolated as profitable, is a method of generating and improving the viability of your business. You do not always get it right initially, but testing the waters usually reveals what works for you. I have found that, overall, if your attitude is driven by passion for your work rather than financial gain, it helps you to see past the intimidation of competitors and overwhelming business administration. There are potential patients out there, so remember that it takes time to build your base to grow your business.

4. Managing expectations There is no doubt that celebrity culture and the internet have popularised the aesthetics specialty, and with this is the spread of misinformation and unrealistic expectations. The world of private medicine is about practitioner reputation and patient satisfaction for a paid service. To manage the patient’s expectations, allowing plenty of time for the consultation leads to better outcomes and helps the patient’s understanding of your medical decisions. I can spend up to an hour with a patient at the first consultation. As well as this, using your communication and empathy skills empowers the patient so that you can both come to the most appropriate shared decision.

Informed consent is a concept most medical professionals are generally experienced with, so using this builds the foundations of balanced patient choice.

Aesthetic medicine is ethically challenging and you need to take into account psychosocial and ethical parameters. Patients seek assistance on their perception of their appearance. Awareness of conditions such as body dysmorphia is crucial and an essential component of continuing professional development. Knowing when not to treat and the process of declining treatment can be extremely difficult, but is also central to delivering responsible treatments.

Robust reinforcement of the positives allows for acceptance of more negative statements, such as ultimate refusal of treatment.

If the patient is approached with confidence and considered with empathy, these discussions get more comfortable over time.

Maintaining rapport is of great importance should the patient require onward referral too. If we remember that non-surgical procedures

Conclusion In the context of booming consumer demand and better working hours compared to numerous NHS positions, many medical practitioners are drawn to the field of aesthetics. With the various challenges to conquer, there come equal opportunities to grow.

Medical professionals tend to be resilient and adaptive in nature so this change is entirely possible.

New practitioners should have an understanding that medical aesthetics is not an easy option or an instant destination, so careful planning, patience and determination facilitates the journey. Driving forward from a place of passion and networking for professional development, perpetuates confidence along the way. Approaching tasks mindfully and constructively gets you through most hurdles and is effectively a source of growth. After all, the aim in all medical professions is the same for everyone – providing a high calibre and professional service. Aesthetic medicine has afforded me the balance I desire with work as well as life outside of work. In conclusion, the transition from the NHS to aesthetics may be unique in its demands, but it is also a life-changing opportunity.

Dr Kalpna Pindolia is an experienced emergency medicine and maritime medicine doctor. She has now dedicated her career to the medical aesthetic specialty full-time, working in a central London clinic, as well as recently starting her own practice. Dr Pindolia is also a trainer for Harley Academy.

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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your data only adds to this and it becomes the most up-to-date information available, offering you an advantage in the field.

Choosing a survey topic

Utilising Surveys for Marketing Sales director and marketing manager Ben Savigar-Jones discusses how you can create a patient survey to improve your marketing Anyone who is vaguely familiar with marketing techniques will be aware of the importance of having interesting content that is relevant to your patients. Useful and relevant content can help with your website’s search engine optimisation (SEO) and social media following, allow you to build authority within your industry and aid brand recognition.1 Surveys are a great way to generate compelling content relatively quickly.

Depending on the type of questions you ask, you can use the answers you collect to produce original, unique and interesting data that can be used to create content for your marketing. They may also act as a tool to help you get to know your patients better, so that you can improve your services. This article will explore the benefits of collecting your own clinic data through surveys of your patients and discuss how it can be used for the purpose of marketing and PR coverage. It will also provide advice on how to effectively conduct a survey and will explain how to best utilise this data.

Why collect your own data?

In my experience, feedback-style surveys are generally the most common types of surveys utilised by clinics. They can allow you to gain insight into various areas of your practice, allowing you to improve your services such as the ease of booking, customer service at reception, or the quality

of patient care.

However, surveys that explore patients’ general attitudes and opinions on aesthetic procedures can also be beneficial, as you will be able to use the statistics gathered to promote your clinic and services in your marketing efforts. For example, if 90% of your patients surveyed said that forehead lines were the aesthetic concern that bothered them the most, you could angle your marketing to demonstrate that you offer treatments specifically for this, which would likely appeal to members of the public with a similar demographic to your current patients.

Additionally, there are businesses, agencies and publications everywhere that are looking for new stories to cover. By sending a detailed press release to the right sources (discussed in more detail below), your interesting, original research can create newsworthy statistics that will generate valuable content for publications, while disseminating your own brand or products.

If your survey is featured in a publication and attributed to your clinic, this can create great PR coverage for you as readers will identify your clinic as one that is attuned to its patients’ needs and requests.

One of the best things about surveys is that the data you gain is 100% original and owned by you. Nobody else will have the same data, even if similar questions have been surveyed before. If you do choose a topic that has been researched before, then

The best way to choose a topic is to consider something that is specifically relevant to your business and patients, such as your treatment offering. Another great place to start is current news topics or subjects that are already in the general public’s mind; for example, if the media is currently talking about weight loss and obesity, then it might be useful to discover what your patients’ perceptions towards these topics are. A staple topic in the medical and aesthetic sector is public awareness – can you ask questions in your survey to gauge public understanding, or lack thereof?

A great tool for searching recent content around a particular area is Buzzsumo,10 which is a website that will show recent, popular content on almost any topic. For example, if you search for ‘lip filler’, Buzzsumo will provide you with a long list of popular stories and content that talks about lip filler. You can use the free version to get a taste of what is out there. Keep in mind that if you are going to use survey platforms that you promote over social media and your social media pages are ‘public’, it can be harder to control who responds to your survey, even if it is directed towards your patients. As such, you may want to think of a topic that can also be put to the general public, which will still give you relevant information. Some examples could be: ‘If you could change one thing about your body what would it be?’ or ‘What one factor puts you off visiting a medical aesthetic practitioner the most?’

Question format Best practice is to keep the questions incredibly clear and as short as possible.

Avoid technical language and instead use simple vocabulary that everyone can understand. I recommend avoiding asking too many open-ended questions8 – I have found that multiple choice is better as it’s quicker for patients to respond to and allows you to create statistics and percentages easily. However, certain open-ended questions, added to the end of a multiplechoice question, could be useful, as the patient can give you more specific feedback, explaining why they have answered a question a certain way.

Below are two examples of questions that you might consider including, as well as an explanation of why the data could be useful.

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Considerations • Amount of people you want to survey: you want to get as many responses as possible but, in my experience, for data to be newsworthy and receive a lot of press coverage, you really need to be looking at a minimum of 500 people. However, smaller surveys of 100-200 people can still produce valuable information but results in smaller coverage.

• Cost: some survey platforms are free, while others are paid for. Among other benefits, paying for a platform can give you the option to ask more questions and allow you to change the styling of the survey.

• Number of questions you want to ask: the amount of questions you ask depends on the topic you are investigating. Best practice is to keep a survey to a maximum of 10 questions so respondents do not to lose interest.3 • Demographic breakdowns: it is useful to ask those surveyed for information on their age, gender, profession and location so you can tailor your data to these. For example, data demonstrating that women care more about crow’s feet while men care more about forehead lines can be very useful to include.

Which of the following aesthetic concerns are you most worried about on the face?

Making the question specific to the face allows you to ask an additional question for the body, hence gathering more data.

Provide multiple-choice answers of the most common areas patients are concerned with and wait for the responses to see which generates the most results. If the majority of respondents care most about forehead wrinkles, as suggested earlier, you can focus your marketing efforts on procedures to specifically help with this problem.

Which of these aesthetic procedures do you consider the safest?

The data gathered from this kind of question can offer insight into public perception of certain types of procedures. For example, you may discover that people perceive botulinum toxin to have a bad reputation when it comes to safety. If you can pair this with evidence of the safety of the procedure, then you have produced a story that is interesting to fellow practitioners and the public alike.

Choosing a platform When conducting a survey of your patients, you can either produce it via hard copy or electronically. Paper surveys may be convenient to give to patients while they are waiting in your clinic for treatments, right after they have received their treatment, or you can choose to post it to them.

Alternatively, you can use electronic surveys, and encourage your patients to fill this out online. To do this, you might want to consider installing an in-clinic tablet so that patients can offer feedback straight away. The benefit of electronic surveys is that you do not need to delegate a staff member to input all the completed surveys, hence gathering the

data can be much quicker.2 It is important to note that if you conduct a paper survey in-clinic or email an electronic one directly to your patients, then you can actively convince patients to fill it in and you may be more in control of who completes the survey, rather than if you promote an electronic survey via social media, as discussed above. There may be costs associated with each option;7 however, surveys can be very affordable to conduct. Online digital surveys can be free, while the paid-for services start from around £50 for approximately 100 to 200 guaranteed responses, and you can pay extra to get more. Paper survey costs, on the other hand, depend mainly on printing and postage, which can vary.2 The most wellknown and one of the most popular survey platforms is SurveyMonkey – it is used by three million people worldwide every day.4,5 The free package offers 10 questions, 100 respondents from your database and some customisation of the look of the survey such as altering the colour to match your brand and including your logo. There are other very similar platforms available that have comparable offerings when choosing a free package, such as Typeform, Client Heartbeat and Zoho Survey.6

Encouraging survey completion The major challenge is getting patients to fill your survey in. There is no magic trick to get people to share information with you or spend time taking part in your survey, however, in my experience, offering incentives is by far the best way to engage people. Think of an incentive that will appeal to your target market. Vouchers for places they shop, and hampers or discounts on your non-injectable services are all good ideas. You can either offer a small incentive to every respondent

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(although this can get expensive) or use ‘a chance to win’ format. When sending your electronic survey via email, creating an eyecatching subject line, limiting the amount of text and including an easy-to-see link to the survey will all help in ensuring that your respondents complete it. If you use language such as, ‘Only takes 2 minutes!’ it may help to boost responses. Make sure to test the time it takes before though; you may end up with incomplete responses if it actually takes longer to complete. If you are happy to get responses from people who are not your patients, you should also share it on social media and encourage your followers to share your survey to their networks to increase your reach. The other way you can encourage survey completion is by ensuring your staff are pushing it; get your receptionist to mention it when your patients go to book their next appointment and encourage them to explain to patients how useful it is to improve the products and services you offer. In theory, you can run your survey for as long as you like; however, I suggest having a target number of responses in mind and run your survey until you have the desired result; about a month is a good amount of time.

Utilising your data Once your surveys have been completed, collate your data and make a list of the most striking statistics. If you can’t see anything that might be of interest straight away, look into demographic data or compare your findings to data from clinics based in different areas to see if there is any variation.

You can also compare it to older data to see if there are any interesting comparisons between past opinions and what people think now. It is a good idea to run a similar survey in a year’s time to compare differences in results.

Once you have the story you want to tell, write it up into a short press release.9 There are a few rules of thumb when writing press releases to send to the media. Make sure you highlight the most interesting findings from your survey straight away and do not be tempted to put ‘filler’ content in that an editor has to trawl through to find what is interesting. Once the press release is written, compile a list of publications relevant to your clinic. You may well know of some already, but use a search engine to discover more. Simply type in ‘aesthetic news’, ‘cosmetic/aesthetic publications’ or ‘cosmetic/aesthetic magazines’ and similar variations, to help you find more. You can either write the press release yourself, or

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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choose to employ an agency to do this for you. Either way, make sure it is accompanied by information on your aesthetic offering, explaining how your services support the trends seen in the survey.

Ensure you highlight that you have conducted the survey yourself and remember to tell publications to accredit the research to you. Be on the lookout of those that do not, so that you can approach them and ask them to do so. Be well-versed in your survey findings so you are prepared to provide commentary on the results, should you be asked. If you have the time, create other content such as blog posts and infographics (pictures with short statistics and information) that discuss the findings of your research. A white paper which informs patients of your findings and your thoughts on them that can also be useful.11 You can also share your findings on social media and put together a marketing email to inform your patents of the facts that might interest them.

Irrelevant data Be aware that, as time goes on, the data that you collect will become increasingly out of date. How long you use your data for will depend on the nature of the question asked and how likely the results are to change over time. For example, if you ask a question about what treatments your patients are most interested in, they might have a different response in 12 months’ time. In my experience, as general rule, results start to become less newsworthy after approximately six months. If the data is a year old, it could be worth running the survey again, not least because you can compare changes over the year.

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Conclusion Surveys can be a useful tool for both your marketing and to monitor your clinic’s progress. Choose your questions carefully, ensure you use a platform where you will garner enough respondents, as well as the right respondents, to produce a story that generates substantial coverage that will ultimately improve your practice.

Ben Savigar-Jones is the UK and Ireland sales director at Cynosure and Sculpsure UK, having previously worked as sales and marketing manager for Cynosure since January 2011. Savigar-Jones is a highly experienced marketing professional and has worked in the aesthetic specialty for more than a decade.

REFERENCES 1. Jayson DeMers, ‘Why Content Marketing is the Best Long-Term Marketing Strategy’, 2016. <https:// www.inc.com/jayson-demers/why-content-marketing-is-the-best-long-term-marketing-strategy.html> 2. Susan E Wyse, ‘Which is more effective: paper-based surveys or online surveys?, 2012. <https://www. snapsurveys.com/blog/which-is-more-effective-paper-based-surveys-or-online-surveys/> 3. Benchmark, ‘how many questions should a good survey have?, 2017. <https://www.benchmarkemail. com/help-FAQ/answer/how-many-questions-should-a-good-survey-have benchmark> 4. SurveyMonkey, ‘About Us’, 2017. <https://www.surveymonkey.co.uk/mp/aboutus/> 5. SurveyMonkey, ‘The easiest DIY market research solution that works around your schedule’, 2017. <https://www.surveymonkey.com/mp/audience> 6. Megan Marrs, ‘7 Best Survey Tools; Create Awesome Surveys For Free!,’ WordStream, 2017. <http:// www.wordstream.com/blog/ws/2014/11/10/best-online-survey-tools> 7. Google Surveys, Overview of Pricing, 2017. <https://support.google.com/360suite/surveys/ answer/2447244?hl=en> 8. SurveyMonkey, ‘Writing Good Survey Questions’, 2017. <https://www.surveymonkey.co.uk/mp/writingsurvey-questions/> 9. The Guardian, ‘How to write an effective press release’, 2015. <https://www.theguardian.com/smallbusiness-network/2014/jul/14/how-to-write-press-release> 10. Buzzsumo, 2017. <http://buzzsumo.com/> 11. David Jones, ‘Creating Magnetic Marketing Content With Surveys’, Survey Gizmo, 2017. <https://www. surveygizmo.com/survey-blog/content-marketing-surveys/>

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Writing a CV Recruitment specialist Victoria Vilas details the important considerations to make when writing a CV Let's face it, drafting your curriculum vitae (CV) isn't the most thrilling way to spend your spare time, but the effort is worth it in the long run. If you take the time to get the details right, highlight your strengths and skills, and concisely summarise your capabilities as a practitioner and an employee, then you could secure a job at a leading aesthetic clinic.

You may know that you are a skilled practitioner and a loyal, hardworking employee, but in order to get any further in the recruitment process you first need to convey that to a hiring manager via a document alone. If you make a good impression with your CV and covering letter, then you'll get the chance to demonstrate more of your capabilities at an interview. If you submit a poor application, you could miss out on a great employment opportunity.

As a medical professional, you are likely to have a lot to say about your training and experience, with a number of facts and figures to list, but you still need to create a CV that is concise, clear, and compelling.

basic, logical rules that every CV should follow. Your CV should be as concise as possible. I advise to make a list of all the key facts (your experience, personal statement, personal interests) and figures (qualifications, training dates), that your CV should include before you put it all together in a document. This will give you an idea of how much space you can dedicate to each section. A full medical CV, for example for the NHS, could consist of three to eight pages, or more if you are at a consultant level. However, a CV specifically angled towards the aesthetics industry can often be edited down to just three or four, depending on experience, keeping the content relevant to the specialism. A CV should be typed in 10/11/12 font size, in a basic font such as Arial or Calibri. Some medical professionals will need more space to detail their training and experience, but you still need to be strict when editing. Hiring managers may have hundreds of applications to read, so if you submit a 10-page CV, they may skim through and miss key details.

Covering letters

Contact details Your CV should be headed with your name and your contact details. This may seem like an obvious point, but it's worth checking that you have included your latest mobile number and email address, as an application will be a complete waste of time if an employer can't get in touch with you. Include an address, even if it's only the name of the town you live in. Employers won't need your full home address until they draw up contracts, but they will want to know if you live within reasonable commuting distance, and if you are likely to be able to commence employment on the date they need their new employee.

If you are in the process of relocating, say so, either in your cover letter or personal statement, especially if it would explain why your current address is in Edinburgh, but you're applying for a job in London.

A job application shouldn't just consist of a brief email stating the job you are applying for, with your CV file attached. When you apply, your covering letter is the first thing a hiring manager will see, and it's a great opportunity to set a positive tone to your application.

A good covering letter should complement your CV. It shouldn't duplicate the information in your CV, it should tell an employer what your CV does not, and should be specific to the given role. Your CV is there to provide all the necessary information on your employment and training, but it doesn't state outright why you are attracted to this particular vacancy. Let the hiring manager know why you want the job, what you can bring to the company and why you'd be a good fit. Your letter doesn't need to be too lengthy, Iâ&#x20AC;&#x2122;d recommend 200 words or less, see it as an introduction to your CV.

CV writing basics There is no definitive CV template that applies to all workers, but there are some

Personal statement When writing the introductory paragraph on your CV, make sure it is a 'personal'

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statement and not just a generic list of your supposed qualities. Use your introductory statement to give a brief personal profile, including what you excel at and have a passion for, and what your career goals are. Do bear in mind what an employer will be looking for, though. For example, if you state that your goal is to become a full-time aesthetic practitioner running your own clinic, then an employer looking for a loyal, long-term employee may have concerns.

Itâ&#x20AC;&#x2122;s important to remember not to duplicate what can be read further into your CV. Make the personal statement as short (100 words or so), positive and punchy as possible, while remaining relevant to the job you're applying for. It is also wise to revisit what you've written in your personal statement every time you apply for a job, in case earlier drafts are angled towards a vacancy with slightly different requirements.

Professional experience Make your lists of jobs and training courses in reverse chronological order.

The most comprehensive descriptions and vital information should be reserved for more recent employment and training, as employers will look for experience that is recent enough to still be relevant. Usually training, for an experienced practitioner, will fit on one side of A4. You only need to list the date, course title and course provider.

An overview of the course content isnâ&#x20AC;&#x2122;t required as the title usually speaks for itself and, if it's a recognised course, further details can be looked up if necessary.If you are an experienced medical practitioner, your job application should make clear the amount of experience you have in medical aesthetics specifically. Your extensive training and NHS experience may demonstrate your medical prowess, but an aesthetic clinic owner will need to know how much practical experience of aesthetic procedures you have. If you have experience, give as much information as possible. For example, if you are trained in a number of advanced dermal filler techniques, state what they are, and which injectable products you used. If you are a GP who also practises aesthetic medicine, give an idea of how regularly you see patients, and what range of procedures you perform. When writing about your professional experience, try to think about each job not just in terms of what you were employed to do, but what you did to be a successful and valuable employee. Break things down into

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'duties' and 'achievements', and state the responsibilities you had, providing details on what you did well. Perhaps you were promoted or given extra responsibilities.

Maybe you were presented with an award or given a bonus, or perhaps you got consistently good feedback from your patients. Don't be afraid to promote yourself, as an employer won't just be looking to see if you're qualified to do the job at hand, they'll be looking for signs of talent and passion, too.

Personal interests Let's put it this way, no hiring manager is going to flick through a CV and discard it because they couldn't find out what novels you like to read or whether you have any pets. However, adding a section on your personal interests may give your CV a bit of character. Remember to keep it brief, and choose hobbies which highlight aspects of your personality that would be beneficial for the job you’re applying for.

Playing sports, for example, can indicate that you work well in a team and enjoy challenges.

Social hobbies, like mentoring others, may suggest you communicate well with people.

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Other considerations

Conclusion

If you are a medical professional who practises both in aesthetic medicine and in another medical role, be it in private or public healthcare, it makes sense to create two versions of your CV. Your medical aesthetic CV can then foreground the experience relevant to your aesthetic work, and your full medical CV doesn't have to be edited down to lose the focus on your other specialties.

If you had a year out to go travelling, or you were on maternity leave, then add a brief line to say so. It'll be better than a hiring manager thinking you did nothing for a year, or made a mistake with dates. If you changed career and retrained as a nurse for example, don't be afraid to touch on what you did before your medical training. You don't have to go into great detail, but it will be better than leaving a long, unexplained gap between leaving school and starting your nursing career. If you previously worked in a commercial environment, it could show that you have skills gained from outside of the public healthcare sector that could be advantageous for a private sector job.

When drafting your job application, always remember to consider what an employer will see as important and impressive, as anything other than that is likely to be superfluous. Don't be afraid to promote yourself and make the most of your skills and attributes, but make it relevant. Take the time to get the details right and avoid careless mistakes; think about asking a friend to proof-read your CV for you, as their fresh eyes may be able to spot confusing sentences or typos that you have overlooked. Make the effort to write a rolespecific covering letter, and try to make the best first impression you can.

Victoria Vilas is the operations and marketing manager at ARC Aesthetic Professionals, a recruitment consultancy specialising in the aesthetic medicine and cosmetic surgery sector.

Since 2008, the team have aimed to help numerous organisations within the industry grow their businesses by hiring aesthetic professionals in the UK.

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month,5 while Snapchat, in comparison, has 301 million active users per month.6 While Facebook is the latest social network to add the story feature, recent articles3 suggest that Facebook Stories is under-performing – although there are no reported usage figures.

Perhaps because of this, Instagram users now have the option to cross-share their Instagram stories to Facebook instead, as Facebook owns Instagram.4 Due to Snapchat and Instagram being the most widely used, this article will mainly focus on these platforms.

How do you use stories?

Social Media Stories Digital marketing CEO Natasha Courtenay-Smith explains how to effectively use social media stories in your clinic’s marketing strategy From status updates and image posts, to videos and now stories, social media is ever-changing and for many, it can often feel overwhelming. Available on smartphones and tablets, stories are one of the newest media formats at our disposal across multiple platforms including Snapchat, Instagram and Facebook. A regularly updated social media page is crucial for marketing any clinic, and implementing stories as part of your social media strategy can improve your engagement, content, and visibility.

While it may seem daunting to tackle this new media plan, it is actually very simple and straightforward. So, let’s look further into stories and find out how they work, and what advantages they might bring to your clinic.

What is a story?

A ‘story’ in social media terms is a collection of images and/or short videos that are linked together and broadcasted as they happen in real-time. Stories are shown in a continuous reel and, once uploaded, automatically delete after 24 hours.1 It might all sound a bit bizarre and perhaps slightly pointless when you think that the content you produce vanishes for good after 24 hours. However, between Snapchat and Instagram – which are the two biggest platforms for this kind of sharing – more than 400 million people view stories each day, so it is worth producing content that reaches these individuals.1

Why are they popular?

It is generally thought that the reason why stories are so popular is because they are

incredibly quick and easy for followers to take in.2 Followers can navigate through each story, on both Instagram and Snapchat, by tapping on the image or video, which plays back the content in the order it was posted.

Stories are temporary, and users can add features such as filters, text, and doodles directly onto the image. The content is always short and snappy and videos can be no longer than 15 seconds in length.

Stories allow users to share in-the-moment updates and document their daily life. For Instagram, using stories prevents clogging up the user’s main news feed or profile.

Therefore, I believe this can be a very powerful tool, as people tend to take great care on the consistency of their brand. They often carefully curate their feed and profile and may not want to disorganise it with everyday comings and goings.

In my opinion, the separation between posts and stories on Instagram works brilliantly; not only can your dedicated patients, clients, and followers stay up-to-date on whatever is going on at your clinic, they won’t feel overwhelmed or annoyed by any overposting. Plus, in my experience, there are now many people who prefer the stories sections of platforms such as Instagram as the content is quicker to consume.

What platforms use stories?

There are three main social media platforms that have the story feature: Snapchat, Instagram, and Facebook. Instagram is the largest photo sharing site in the world, with more than 800 million active users each

Regardless of which platform you are using, stories are relatively easy to work.

Snapchat stories Snapchat stories appear on the story feed, which can be accessed by swiping from right to left until a screen labelled ‘Stories’ appears.

On this page, users can broadcast their own story by clicking the ‘My Story’ box, or watch stories from the people they follow under ‘Recent Updates’. To post a story, simply take a photo or video by tapping the shutter button on the camera within the app. You can also add text, draw on the photo, or add stickers.

Popular features on Snapchat include ‘Geofilters’, a sticker that appears based on a user’s location, which may be useful for practitioners holding an event or a product launch at their clinic. You can also pay a social media agency to custom make an ‘Ondemand Geofilter’ for your business, or, if you have the technical skills, you can create one for free yourself. On-demand Geofilters for businesses can use branding, business marks, business names, business logos, or other promotional content for a business or brand.

They cannot, however, use photographs of people, URLs, phone numbers, emails, drug-related content, or content that you don’t own or have the authorisation to use.7 Another popular option is ‘Lenses’, which are fun facial filters that pop-up on the screen.

These filters let you add lenses such as flower crowns, puppy ears and voice changers to your images and videos. Although you probably won’t want to use these filters too often in order to remain professional, they can be used on staff members for example, to show a fun side to your clinic, if you feel this is appropriate. You can also upload images and videos from your camera roll, however videos will be automatically cropped to fit the 10-second format, so it’s worth editing the video beforehand. To view a user’s story, simply tap on their name. Users posting a story have the option to save the image or video to

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‘Memories’, a cloud-like storage device built into Snapchat that stores all the content you want to save. Doing this allows you to keep a record of your published content, allowing you to access it at a future date.

Instagram stories Instagram stories are found on the main homepage at the top left of the feed where you will see a small camera icon. Press this and your camera is activated. You can also access your stories by swiping left on Instagram. Like Snapchat, you can add text, stickers, and draw on the image.

You can also access ‘selfie filters’, which let you add features such as virtual koala ears, a butterfly crown or smooth skin and makeup, among others, as well as your location and customised hashtag stickers.

You should absolutely not use filters to enhance and/or alter results on patients however, as that would be highly misleading to the public. According to the Advertising Standards Authority (ASA), advertising claims, including visual claims, should not mislead by exaggerating the effect the product is capable of achieving. Marketers should ensure they retain appropriate material to be able to demonstrate whether any re-touching has been carried out, in the event of an investigation.8 Instagram stories also offer the option to tag someone, much like the platform allows you to tag a user in a photo caption when posting on your feed. You may want to target certain patients and tag them in a story, although it’s important to use this with discretion so your followers don’t feel like you’re ‘spamming’ them. You can also add clickable hashtags and interactive polls. One of the most popular options on Instagram is Boomerangs, which are short one-to-three second picture bursts that endlessly loop back and forth. You may wish to use this feature to promote a new product in your clinic. Additionally, you have the option to upload content from your camera roll to your Instagram story. To do this, you need to tap on the camera icon in the upper left of your screen to add a story, then swipe up and an image-picker will appear. You can then choose your image and edit it as you wish.

When a story has been uploaded, a pink and orange circle will appear around the user’s profile picture. To view it, simply tap on the picture. You can view exactly how many people, and who viewed your story by clicking on it, which is a great way to monitor the content’s reach. To make your story more popular, use location hashtags, such as ‘London’ or ‘Harley Street’ or a result

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like ‘YouthfulSkin’. This enables viewers to discover your clinic’s stories when typing in these hashtags. It’s important to remember that if your profile is set to ‘public’, then Instagram stories appear publicly on your profile, and can be discovered by anybody. If your profile is on ‘private’, only your authorised followers can view your stories.

What are the benefits of stories?

There are many reasons why stories can benefit aesthetic clinics.

Visibility Stories help you avoid the algorithms – Instagram updated their feed to a popularitybased algorithm last year, meaning that the platform decides what type of content an Instagram user should see based on their interests, relationships and timeliness of posts.9 When using stories, you can still be visible to viewers, as they will always appear at the top of the screen. This will help you and your brand remain in your followers’ minds, even if your main profile photo content isn’t at the top on their feed.

Personality Offering a behind-the-scenes look at your clinic can draw in potential patients. In my opinion, this works better in story-form than on a regular profile page/news feed, because stories tend to feel more personal.

Capturing photos and videos of daily life at the clinic, as well as showing off the personalities of the doctors and clinic staff, will make patients feel as if they know you and will help build a rapport.

Promotion Offering giveaways and exclusive offers for people who view your stories will increase engagement as well as purchase intent.

For example, you could record a video of a facial and say ‘If you’ve seen this video, you can get 10% off your next facial. Contact us to book’. It is important to bear in mind, however, the recent General Medical Council (GMC) guidance report, which encourages cosmetic interventions to always be given their due gravitas and, by extension, has banned marketing gimmicks, such as offering medical treatments as prizes.10 Therefore, I recommend to only use offers for treatments considered non-medical. Stories can also redirect users to your website. For Instagram, verified accounts with more than 10,000 followers get the option to add links directly to their stories;11 however, by ensuring you have a link on your biography, you

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can alternatively type ‘link in bio’ onto the content to redirect viewers – this can still work effectively. Snapchat has also recently introduced the link option, which, unlike Instagram, is available for all users, and is accessed by clicking on the little paper clip icon when taking a Snapchat photo or video.

This is great for promoting your website as well as any blog posts, testimonials, or linking to a specific treatment option.

Immediacy Social media stories are an excellent platform for any live event. If your clinic is hosting an event or if you are attending a seminar or giving a talk, posting it as a story will allow you to broadcast what is going on, without having to continually upload pictures and videos to your profile or feed. If you follow a very particular posting strategy on Instagram and Facebook, something like an event or a talk can really throw off the balance of a carefully curated feed. However, posting it as a story can let viewers see the event unfold live, without having to navigate through multiple photos and videos.

Choosing a platform to use Now you know a bit more about the different platforms, it’s time to decide which platform(s) to use. If you don’t have Snapchat but already have a following on Instagram, I believe that using Instagram stories may be a better fit for you to begin with. Even if you’re new to Instagram, from my experience, it’s easier to build an audience and following in comparison to Snapchat. There is no generic search feature to find users on Snapchat, so any potential followers must have your exact username to follow you and discover your stories, whereas on Instagram they can find you by using hashtags, or even your location.

Snapchat does give users better control over their privacy as you are able to choose exactly who can view your content. To do this, from the camera tab, you can tap the little ghost icon at the top, then tap the gear icon in the top right to access your settings. Scroll down to the ‘Who Can...’ section to:12 • Allow everyone, just your friends or a custom group of users to be able to view your stories (by tapping ‘View My Story’) • Select whether you want to allow everyone or just your friends to be able to contact you (by tapping ‘Contact Me’) This makes Snapchat more of an intimate social platform, and viewers may find it more personable in comparison to Instagram stories.

If you already use both platforms in your clinic, upload stories to both and test the

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Important considerations

As an aesthetic practitioner, there are some considerations that need to be made when using social media stories, as well as social media in general. It’s a legal requirement to ensure you have patient consent if you are going to publish pictures and videos of them receiving treatments or procedures, or before and after images.13 The GMC’s guidance states important points to consider when marketing, including the need for content to be accurate, responsible and not misleading. It states, ‘Market your services responsibly, without making unjustifiable claims about interventions, trivialising the risks involved, or using promotional tactics that might encourage people to make illconsidered decisions’.14 Practitioners should also be conscious not to post anything private and confidential, such as medical records and patient details.15

engagement between the two. If the two platforms work, then you don’t have to choose – use both.

Conclusion Social media stories are a great way for your clinic or brand to build awareness and engage with your audience, alongside your regular social content. They give you the chance to connect with your followers in a fun and unique way without overcrowding your own profiles or carefully crafted feeds. They cost nothing, and can act as anything from a behind-the-scenes video to an advertisement.

Aesthetics Natasha Courtenay-Smith is the co-founder of Bolt Digital, which specialises in drive profit and sustainable business growth to clients. She is a European influencer on integrated digital marketing, social media, PR, as well as branding and positioning. Courtenay-Smith has also advised the UK government on strategies to help business owners cope with the pace of innovation in the digital age.

REFERENCES 1. Gotter, A. ‘3 Ways to Use Instagram Stories Ads for Business’ (Social Media Examiner, May 2017) <https://www.socialmediaexaminer.com/3-ways-to-use-instagram-stories-ads-for-business/> 2. Spall, V. ‘Snapchatm Instagram and Facebook Stories – How can Brands Capitalise?’ (Browser Media, April 2017) <http://www.browsermedia.co.uk/2017/04/04/snapchat-instagram-facebook-storiespopular/> 3. Statista, ‘Number of monthly active Instagram Users from January 2013 to September 2017’ <https:// www.statista.com/statistics/253577/number-of-monthly-active-instagram-users/> 4. Statista, ‘Estimated number of monthly active Snapchat users from 2013 to 2016’ <https://www.statista. com/statistics/626835/number-of-monthly-active-snapchat-users> 5. Sulleyman, A. (The Independent, Oct 2017) <http://www.independent.co.uk/life-style/gadgets-andtech/news/facebook-stories-app-filters-masks-editing-post-instagram-pages-a7998321.html> 6. King, R. ‘The Popularity of Instagram Stories Presents a Dire Challenge for Snapchat’ (Fortune, Aug 2017) <http://fortune.com/2017/08/02/instagram-stories-snap/> 7. Hines, K. ‘How to create a Snapchat Geofilter for Your Event’ (Social Media Examiner, Feb 2016) https://www.socialmediaexaminer.com/how-to-create-a-snapchat-geofilter-for-your-event/ 8. ASA, ‘Before and after photos’ (2014) <https://www.asa.org.uk/advice-online/before-and-after-photos. html> 9. Lodi, H. ‘Is Instagram’s popularity declining with new algorithm?’ (The National, July 2017) < https:// www.thenational.ae/lifestyle/fashion/is-instagram-s-popularity-declining-with-new-algorithm-1.613834> 10. GMC, Guidance for Doctors Who Offer Cosmetic Procedures, General Medical Council, <http:// www. gmc-uk.org/guidance/ethical_guidance/28687.asp> 11. Instagram, ‘ How do I add a link to my story?’ < https://help.instagram.com/691455604353423> 12. Moreau, E. ‘Instagram Stories vs. Snapchat Stories: What’s the Difference?’ (Lifewire, August 2017) <https://www.lifewire.com/instagram-stories-vs-snapchat-stories-whats-the-difference-4069910> 13. Good Medical Guidance (The General Medical Council) http://www.gmc-uk.org/guidance 14. Kendrick, J. ‘Maintaining Compliant Marketing in Aesthetics’ (Aesthetics Journal, Feb 2017) <https:// aestheticsjournal.com/cpd/module/maintaining-compliant-marketing-in-aesthetics> 15. GMC. ‘Good practice in handling patient information’ (General Medical Council, 2017) (https://www. gmc-uk.org/guidance/ethical_guidance/30579.asp

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AVAILABLE IN 4 PACK SIZES

Bocouture® (Botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information:M-BOCUK-0067. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the Xseverity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride.

Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1ml (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis.

Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photodamage). In this case, patients

may not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding.

Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia).

Hypersensitivity reactions have been reported with Botulinum neurotoxin products. Upper Facial Lines: very common: Headache.

Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90, 100 U twin pack £459.80. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany.

Date of Preparation: February 2017. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

1. Bocouture® 50 units Summary of Product Characteristics (SmPC).

March 2016. Available from: https://www.medicines.org.uk/emc/ medicine/23251.

2. Bocouture® 100 units Summary of Product Characteristics (SmPC).

September 2016. Available from: https://www.medicines.org.uk/ emc/medicine/32426 3. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomized, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0085 Date of Preparation October 2017

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“I’ve never believed in racing to the top; I want longevity” Miss Jonquille Chantrey explains how she was headhunted into aesthetics and shares her love of research, teaching and travelling the world Academic record University of Nottingham: Bachelor of Medical Sciences (BMedSci), research degree in Psychiatry 1999 & Bachelor of Medicine Bachelor Surgery (BMBS) 2001 University of Nottingham and Manchester: surgical training (MRCS) 2004 "I have always been interested in the philosophy, psychology and art surrounding the subject of beauty, and aesthetic practice has given me the opportunity to indulge this interest on a daily basis," says aesthetic surgeon Miss Jonquille Chantrey.

Since coming into the aesthetics specialty 14 years ago, Miss Chantrey has seen it evolve and grow. It was a career path she took during her plastic surgery training, after being headhunted for a clinic in the south of France, whilst presenting at a burns conference, "Someone came up to me, who ended up being quite a prolific individual in aesthetic medical education, and asked if I had considered working in aesthetics." She continues, "Up until this point, I had never considered solely focusing on an aesthetic career – my interests were head and neck reconstruction and burns management.” Miss Chantrey engaged in personal study and attended a spectrum of aesthetic courses.

But the transition from surgical trainee to independent aesthetic practitioner proved tough and required some juggling, as at this time, Miss Chantrey was the clinical director of SurgiCare, an on-call NHS surgeon, European

What treatment do you enjoy doing the most?

Challenging facial cases. For example, I have a patient who was involved in an aeroplane crash, she had multiple burns and it affected her whole existence. Now, after a series of non-surgical treatments, she can face the world again.

Vaser Liposuction trainer and a member of the Allergan teaching faculty. In 2009, Miss Chantrey became northern clinical director of clinic group The Private Clinic, before launching her own aesthetic clinic in Alderley Edge, Cheshire, in 2011 – Expert Aesthetics.

“I opened Expert Aesthetics because I wanted to take more ownership over what I was doing,” she explains, “I never wanted a glorified factory line of patients coming through the door.” However, only months after opening, Miss Chantrey had a three-month waiting list. Over the last eight years, Miss Chantrey has gradually built her presence abroad, lecturing at aesthetic conferences around the world. She says, “I’ve built my international profile slowly, I’ve never believed in racing to the top; I want longevity. It is amazing to travel the world, and I have learnt a lot through doing that, but it is a very difficult balance, as I have such a busy practice.”

When asked how she balances her time between all of her commitments, she answers simply, “With great difficulty! I tend to need diversity by nature, so I have to be careful with how much I take on-board.” Despite her busy schedule, Miss Chantrey shows no signs of slowing down, “Next year I will be focusing on three areas; firstly, I will support the doctors in my clinic to make sure they reach their potential, secondly, I am commencing a business expansion programme to meet the demands on my clinic, and thirdly, I will look to roll out a training academy with a rapidly emerging surgeon, who is going to give a fresh perspective on facial aesthetics. I can't say too much more on this at present.”

How do you think social media has affected the industry?

I’m a teacher, so I believe in sharing knowledge and also patient education. However, codes of conduct are lacking on social media and what you post one day has been duplicated by someone else the next.

Clinical Trials Alongside her clinical practice, her ambitions to conduct high-quality clinical research and travel began when Miss Chantrey became a plastic surgeon for a skin and anti-scarring biotech company. Miss Chantrey explains, “The opportunity to collaborate on international clinical trials has strengthened my clinical perspective.

I like to scrutinise literature when the latest products and technologies become available.” She adds, “The opportunity to be integral in designing studies, and applying ethical guidelines provides a breadth of skills that help in pushing the aesthetic boundaries.”

In her role as a principal investigator and medical advisor to Phase II and III studies, Miss Chantrey travelled to burns units in the US, Russia and throughout Europe, researching drugs to improve traumatic burns and surgical scarring. She continues to work on selected clinical trials that she believes are relevant to drive the specialty forward. She says, “Five years ago, I was on the concept advisory board for Juvéderm Volite and have been responsible for developing data and protocols, and injecting the study subjects. I launched it in the UK, AMWC Monaco, Switzerland and led the Train the Trainer programmes in Singapore, Malaysia, Australia and New Zealand.”

What has been your biggest achievement so far?

Staying true to who I am is an achievement in these competitive environments which can be harsh, to say the least. My integral values haven’t changed and to me, that really matters.

Do you have any words of advice for new practitioners?

Training is everything; find a good academy. Source a good mentor who will help and support you for a number of years. I have mentored many over the years and will continue to do so.

Reproduced from Aesthetics | Volume 5/Issue 1 - December 2017

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Aesthetics

The Last Word

erythema, oedema, and unresponsive to antihistamines, which can occur days or weeks after initial treatment.1

Dr Maryam Zamani debates the use of permanent fillers in aesthetics

Treating complications The main issue associated with using non-biodegradable dermal fillers is that if one of the above complications occur, then they are often far more difficult to treat.4 To address many of the above complications for HA fillers, immediate dissolution with hyaluronidase can be achieved. Patients may require further treatment using steroids, antibiotics or lasers, depending on the complication.9 Homogenous fillers, like HA, rarely induce granulomas,4 but if such adverse events happen with HA, they can potentially be resolved with hyaluronidase treatment with or without other adjunct treatments such as steroids or antibiotics.

Malar oedema, caused by dermal fillers injected into the periorbital area, can be long-lasting and difficult to treat for all types of fillers due to lymphatic compromise coupled with thin overlying tissue. Vascular compromise, following dermal filler injection, is an immediate, major complication that necessitates swift and aggressive treatment to minimise potential serious irreversible complications.8 With non-biodegradable dermal fillers, such complications are more difficult to treat as they cannot be dissolved using hyaluronidase. Instead, they often require extrusion, excision or surgical drainage, which may all result in permanent suboptimal, unsatisfactory aesthetic outcomes. In especially high-risk areas like the periorbital region, the use of non-biodegradable fillers means complications are even more difficult to treat.

With limited to no recovery time and lower costs compared to surgical procedures, dermal fillers have revolutionised non-surgical aesthetic enhancements. However, all dermal fillers have the potential to cause complications and as the number of procedures performed increases, the number of complications will inevitably follow. While most complications are related to the technique of the practitioner, some are associated with the material itself.1 Broadly speaking, there are two types of fillers: temporary biodegradable and permanent non-biodegradable dermal fillers. For optimal outcomes, all injectors should have a detailed anatomical understanding, excellent injection techniques and a detailed knowledge of the characteristics of fillers available.

In this article, I will argue why I do not ever consider the use of permanent non-biodegradable dermal fillers due to the increased difficulty in managing complications, which can impact patient safety.

Biodegradable vs non-biodegradable It’s hard to determine exactly how many dermal fillers are on the market, but just from researching different markets online, I estimate that there are more than 200 dermal fillers available worldwide.1 Biodegradable fillers are absorbed by the body, and therefore their effects are relatively short-lived. The most common form of biodegradable filler used is hyaluronic acid (HA), which lasts six to 18 months.1 There are biodegradable fillers that have a longer duration effect of up to two years; calcium hydroxylapatite is the most common.1 Permanent non-biodegradable fillers are most commonly made of polymethylmethacrylate (PMMA).2,3 Obviously, biodegradable fillers biodegrade, which can lead to repeated injections over time. This could be perceived as costlier than a permanent filler, deterring some patients. However, although the option may seem appealing, permanent substances do not adjust to the natural skin and bone changes that occur over time from the ageing process. This can therefore disturb the balance of a patient’s face in the long-term.

Filler complications All fillers are associated with potential short and long-term complications, and the treatment of these depends on what type of product has been used. Most adverse reactions result from technical faults such as wrong indication, placement site and infection, and are not specific to a particular filler.4 However, non-biodegradable fillers can have clinically prevalent complications that are more pronounced and persist for longer.5 After any dermal filler treatment, the following complications are possible: swelling, erythema, ecchymosis, lumps, nodules, filler clumping, filler dislocation,6,7 overcorrection, neovascularisation, hyperpigmentation, dyspigmentation, infection, biofilms, abscesses, granulomas, malar oedema and vascular compromise.8 Vascular compromise can cause other complications such as visual loss or tissue necrosis.8 Antibody mediated oedema (angioedema) is a complication where patients may develop a hypersensitivity to the type of dermal filler used because of a Type I hypersensitivity reaction. Chronic or delayed oedema can be characterised by

Summary The key to successful treatment is to know the facial anatomy, filler characteristics, proper technique and have a conservative approach to avoid pitfalls and complications. However, complications will still happen. Although there is the argument that permanent fillers can have a reduced long-term cost and it may be more convenient for the patient, I personally do not believe that there is a role for permanent non-biodegradable fillers in my practice. As removal of permanent non-biodegradable dermal fillers must be achieved surgically, I also believe that those without surgical training must be especially wary of this type of filler placement. Any adverse reaction can be catastrophic for the patient, as well as the treating practitioner, and complications can be long standing.

Dr Maryam Zamani is a board-certified ophthalmologist and ocuplastic surgeon with experience in clinical dermatology. She obtained her medical doctorate from George Washington University School of Medicine, US, and has worked at Cardiff University in facial aesthetics.

REFERENCES 1. David Funt & Tatjana Pavicic, Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013; 6: 295–316.

2. Mercer, Nigel, ‘Dermal fillers are medical devices in the UK’, BMJ, 2009; 339. <https://doi.org/10.1136/bmj.b2923> 3. Hilinski JM, Cohen SR. Soft tissue augmentation with ArteFill. Facial Plast Surg. 2009;25(2):114–119.

4. Eckart Haneke. Managing Complications of Fillers: Rare and Not-So-Rare. J Cutan Aesthet Surg. 2015 Oct-Dec; 8(4): 198–210.

5. Kirkpatrick N., Foroglou P. Treating Permanent Dermal Filler Complications Aesthetics, 17 NOV, 2016. <https://aestheticsjournal.com/feature/treating-permanent-dermal-filler-complications> 6. Lemperle G, Rullan PP, Gauthier-Hazan N. Avoiding and treating dermal filler complications. Plast Reconstr Surg. 2006;118:92s–107s 7. Joo Hyun Kim, Duk Kyun Ahn, Hii Sun Jeong, & In Suck Suh. Treatment Algorithm of Complications after Filler Injection: Based on Wound Healing Process. J Korean Med Sci. 2014 Nov; 29(Suppl 3): S176–S182.

8. Grunebaum LD, Bogdan Allemann I, Dayan S, Mandy S, Baumann L. The risk of alar necrosis associated with dermal filler injection. Dermatol Surg. 2009;35(Suppl 2):1635–1640.

9. Cassuto D, Marangoni O, De Santis G, Christensen L. Advanced laser techniques for filler-induced complications. Dermatol Surg. 2009;35(Suppl 2):1689–1695.

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PROVEN DERMAL HYDRATION 1 AND PATIENT SATISFACTION FOR UP TO 9 MONTHS WITH JUST ONE TREATMENT.2,3,‡,†,§,¥ Utilising patented VYCROSS® technology,4 JUVÉDERM® VOLITE™ is injected intradermally 5 and can be used for areas such as the face, neck and décolletage and hands.6 When your patients glow on the outside, they feel great inside.7 References: 1. Allergan Data on File INT/0654/2016(1). JUVÉDERM® VOLITE™ Clinical Study (V12-001), 9 months topline - hydration results. Feb 2017. 2. Allergan Data on File INT/0297/2017. JUVÉDERM® VOLITE™ Clinical Study (V12-001), 9 months topline summary. Apr 2017. 3. Allergan Data on File INT/0655/2016(1). JUVÉDERM® VOLITE™ Clinical Study (V12-001), 9 months topline - patient satisfaction results.

Feb 2017. 4. Lebreton P, 2004. Réticulation de polysaccharides de faible et forte masse moléculaire; préparation d’hydrogels monophasiques injectables; polysaccharides et hydrogels obtenus.

Publication number: WO 2004/092222 A2. 5. JUVÉDERM® VOLITE™ DFU. 73140JR10, Revision 2016-02-19. 6. Allergan Data on File INT/0078/2017. JUVÉDERM® VOLITE™: Treatment Target Area - face, neck, decollete & hands. Feb 2017. 7. Allergan Data on File INT/0448/2016(1). Skin Quality Market Research Insights. Jul 2016. 8. Allergan Data on File INT/0773/2016. JUVÉDERM® VOLITE™ Names. Oct 2016. 9. Goodman GJ et al. Plast Reconstr Surg. 2015;136:139S-48S. Footnotes: † After a single treatment, which included initial (n=131) and top-up administered at day 30 (n=31).1,2,3 ‡ Cheek skin hydration (secondary end point), improved significantly from baseline at Months 1, 4, 6 and 9.1,2 § Patient satisfaction was measured using the FACE-Q Satisfaction with Skin questionnaire and subject responses regarding treatment recommendation to a friend.3 ¥ Study conducted using JUVÉDERM® VOLITE™ B without lidocaine.8 Added lidocaine enhances patient comfort during injections and has no substantive effect on the rheological properties of HA products.9 Please refer to the JUVÉDERM® VOLITE™ Directions For Use for further information.5

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