UR NG ! % YO INI E K 10 O RA NC VE BO E T IE A IT ER S EL XP 1 TO E 3 EC D
BY
VOLUME 6/ISSUE 1 - DECEMBER 2018
MORE THAN
45 MILLION SYRINGES MANUFACTURED
HA DERMAL FILLERS
FOR THE CREATORS OF BEAUTY, FROM THE EXPERTS IN HYALURONIC ACID
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Managing Patient Pain CPD
SCHO11506 Aesthetics Journal Front Cover_192x185mm_v4.indd 1
Dr Lee Walker outlines the evidence on managing pain during aesthetic procedures
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Special Feature: Preventative Ageing
Practitioners discuss treatment approaches in younger patients
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Acne Scarring and PRP
Dr Duncan Brennand shares his technique for managing acne scars with PRP
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Clinic Share 20/11/2018 Schemes
15:38
Dr Malcolm Willis details how he incentivises staff with shares in his business
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Contents • December 2018 06 News The latest product and industry news 14 On the Scene
Out and about in aesthetics
16 Conference Reports A look at the British Association of Cosmetic Nurses’ annual conference in
Birmingham and The Aesthetic Medicine Congress in Croatia
19 News Special: Reflection on 2018
The Aesthetics Editorial Board discuss their year in the specialty
22 ACE Preview: Building Your Business
Special Feature Preventative Ageing Page 25
Valuable advice on improving business acumen at the Aesthetics Conference and Exhibition 2019
25 Aesthetics Statistics The results of the Aesthetics readers’ survey
CLINICAL PRACTICE 25 Special Feature: Preventative Ageing
Practitioners outline their consultation techniques and treatment methods to slow the signs of ageing in younger patients
32 CPD: Pain Management
Dr Lee Walker details strategies for managing pain to improve patient comfort during aesthetic procedures
In Practice Clinic Share Schemes Page 61
36 Skin Through the Seasons
Dr Shirin Lakhani provides an introduction to how the skin adjusts throughout the year
41 Eye Rejuvenation Using Pulse-Triggered Laser
Aesthetic nurse Jane Lewis presents a case study of a non-surgical eye rejuvenation
44 Advertorial: IntraVita A look at the development of intravenous nutrition therapy 47 Understanding Retinol Tolerance
Dr Justine Kluk outlines the use of retinol and how to overcome poor patient tolerability
53 Acne Scarring and PRP
Dr Duncan Brennand explores the use of platelet-rich plasma and microneedling for the treatment of acne scars
59 Abstracts
61 Using Share Schemes
Dr Malcolm Willis shares advice on offering share schemes to increase staff retention
64 Considerations for Setting Up Your Own Business
Dr Qian Xu discusses the pros and cons of working for yourself
67 Utilising Your Reception Team Dr Rekha Tailor discusses how to make the most of clinic reception teams
to aid overall business success
70 In Profile: Miss Priyanka Chadha and Miss Lara Watson Aesthetic practitioners Miss Priyanka Chadha and Miss Lara Watson share their
journey to establishing a training academy and their passions for safety
72 The Last Word
Mr Fulvio Urso-Baiarda argues why he believes there is a need for more data on aesthetic procedures
NEXT MONTH • IN FOCUS: Dermatology • Photosensitising Drugs • Acne & Pregnancy • Aesthetics Awards 2018 Winners Supplement
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Dr Lee Walker is an aesthetic dental surgeon and clinical lead at multi-award winning BCity clinics, Liverpool. He is an official Teoxane country expert and international speaker, regularly sharing knowledge through masterclasses across the UK, Europe and Asia. Jane Lewis started her nursing career in 1981 and moved into the private sector in 1986, gaining extensive experience in plastic surgery and dermatology; most notably Lewis was the development director for a large chain of aesthetic clinics for fifteen years. Dr Shirin Lakhani has a background in medicine, having trained in the NHS and various hospital sub-specialities, including anaesthetics, where she developed her skills in injection techniques. Dr Lakhani is now the medical director of Elite Aesthetics in Kent. Dr Justine Kluk is a consultant dermatologist and spokesperson for the British Association of Dermatologists. Her clinic is located at 25 Harley Street and her main clinical interests are acne, acne scarring and rosacea. Her NHS base is St George’s Hospital, London.
A round-up and summary of useful clinical papers
IN PRACTICE
Clinical Contributors
Dr Duncan Brennand was a consultant interventional radiologist at University College London Hospital in 2006. Now he is a practitioner of minimallyinvasive, image-guided percutaneous interventions and is the founder of L’Atelier Aesthetics in London.
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Editor’s letter Oh what a night!! Glorious company, great entertainment and a superb venue! We hope everyone has recovered from the Aesthetics Awards celebrations. The event was quite spectacular; I was so impressed when I arrived and saw the set, even bigger and Amanda Cameron better than last year! Editor Many congratulations to all the Winners, Highly Commended and Commended finalists, not to mention all those shortlisted. You are all winners in our eyes, so use the PR opportunities to the max and shout about your successes to your patients and clients. As always, our January issue will come with an Aesthetics Awards supplement, filled with reports of the evening and all the fabulous pictures of everyone looking so glamorous, so stay tuned for that! For all you ardent Aesthetics readers, can you believe it’s been five years since our first issue came out?! This month is our Evolution Special so we look at what’s changed since then and pay particular attention to the developments this year. In November, we sat down with five of our Editorial Board members
and got their feedback on the changes in 2018, as well as learning about their hopes for 2019. Turn to p.19 to check it out! We also look at preventative ageing on p.25, examining the reported benefits, suitable treatments and patient selection. As they say, prevention is better than cure… if only all these options had been around when I was young! Getting acclimatised to retinols by Dr Justine Kluk on p.47 is another fascinating read, as is clinic share schemes by Dr Malcolm Willis on p.61, who details how he retains and motivates his staff through share rewards. If you are an employer, we’d love to know how you keep staff engaged, just as we would love to hear from employees on company benefits you value or would like to see more of. Let us know by tweeting @aestheticsgroup or emailing editorial@aestheticsjournal.com. Don’t forget, ACE 2019 is just around the corner on March 1 and 2, and you only have until the end of the month to make the most of the early booking discount for the Elite Training Experience. Save 10% on every session you book before December 31. Now it’s time to take a break, recover from the awards ceremony and have a read of some very interesting articles with your feet up!
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.
Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She is currently undertaking her Masters in Aesthetic Medicine, for which she is also a course mentor. Partridge is a founding board member of the British Association of Cosmetic Nurses and has represented the association for Health Improvement Scotland.
Dr 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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Competency
Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Nurses Cheryl Barton @CherylITBarton #BACN Conference just goes from strength to strength here in @edgbaston #Birmingham! If you are an #Aesthetic nurse @BACNNurses is an organisation that provides you with excellent educational support. #EditorialBoard Megan Close @MegCloseJourno Thank you to some of our wonderful editorial board members who were able to attend our editorial dinner to discuss all things 2019!! @sharonbennettuk @DrStefanieW @mdhtraining @SurgeonAdrian @dermalclinic Exciting things are definitely coming... #aestheticsjournal #Reconstructivesurgery Mark Henley @MrMarkHenley Excellent advert from @BAPRASvoice highlighting the dangers of #fireworks on #bonfirenight. The number of patients attending A&E because of firework injuries has more than doubled since 2009-10 with some requiring #reconstructivesurgery #fireworksafety #MentalHealth Chris R Macdonald @CRMaesthetics Great to see this ASA ruling towards the regulation of cosmetic surgery advertising. Cosmetic Surgery can significantly improve patient’s lives but the decision must not be trivialized and vulnerable groups must be protected @BAAPSMedia @mentalhealth #plasticsurgery #LoveIsland #TAMCongress Dr Galyna Selezneva @dr_galyna Had so much fun presenting Non Invasive Body Contouring Trends at @tamcongress in #Dubrovnik! Thank you @drnickmilojevic and his lovely and super professional team! #50thpublication Olivier Brandford @olivierbrandford Delighted to have my 50th scientific publication in #pubmed including 5 so far this year #plasticsurgery #systematicreview #nationaloutcomes #BREASTQ #socialmedia #patientreportedoutcomes #Fundraising Dr Anjali Mahto @DrAnjaliMahto Thank you @BSFcharity for a lovely evening and so proud of what this awesome twosome @Ocean_ Brothers have achieved #skincancer #dermatology
BACN to introduce new framework for members The British Association of Cosmetic Nurses (BACN) has confirmed that the organisation will be implementing a new Specialist Nurse Competences Project.The project will be overseen by the newly formed Education and Training Committee led by aesthetic nurse prescribers Anna Baker and Mel Recchia, both of whom are BACN Board members. The organisation explains that the aim of this is ‘to establish a clear education, training and competency-based framework for establishment of levels of the Specialist Aesthetic Nurse in the UK’. The framework will be divided into five categories based on the member’s experience; novice, advanced beginner, competent, proficient and expert. It will aim to advise and agree on eligibility, levels of support, criteria for support, supported activities and management. Paul Burgess, CEO of the BACN explains that the next steps are to prepare and agree on a draft competency framework, discuss with the Nursing and Midwifery Council and implement this into the aesthetic nursing specialty, all of which will start in January 2019. Sharon Bennett, BACN chair said, “For many years the BACN has been promoting the idea of the ‘Specialist Aesthetic Nurse’. We made a great start with the publication of the ‘Competency Framework for Nurses’ some years ago. Now, we need to update this and relate it to all the new frameworks of standards that are now in place. We have received overwhelming support for this from our members.” Approval
Galderma receives new FDA approval for Restylane The US Food and Drug Administration (FDA) has approved hyaluronic acid (HA) dermal filler Restylane Lyft for cheek augmentation and the correction of age-related mid-face contour deficiencies via small blunt tip cannula in patients over the age of 21. According to international pharmaceutical company Galderma, Restylane Lyft for the mid-face is the only HA filler on the market that is FDA-approved for use via cannula. The approval is the third indication for Restylane Lyft, which is also approved for the nasolabial folds and the back of hands. “The FDA approval of Restylane Lyft for mid-face via cannula marks the seventh FDA approval in aesthetics for Galderma in the past four years,” said Alisa Lask, general manager and vice president of the US aesthetic business at Galderma. She added, “We have increased our investment in research and development this year in order to help grow the aesthetic market. Our goal is to continue to offer new solutions and delivery systems to our customers to help drive new patients into aesthetic clinics.” In the EU, Restylane Lyft is indicated for deep dermal implantation to enhance facial harmony by providing shape and contour, and is indicated for the cheek, chin and jawline for patients over the age of 21.
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Industry
JCCP appoints new trustees The Joint Council for Cosmetic Practitioners (JCCP) has appointed two new trustees to help oversee the running of the organisation and ensure it meets its charitable objectives. The first new trustee is marketing specialist Andrew Masheter who has more than 30 years’ experience in the not-for-profit and public sectors, specialising in strategy, marketing, communications, commercial development and PR. Masheter has joined the JCCP to advise on its marketing and PR strategies and initiatives. Victor Ktorakis is the second trustee to join, who has 14 years’ experience as an environmental health officer (EHO) and is currently a senior EHO for the London borough of Enfield, with lead responsibility for special treatment licensing. He joins as a non-voting trustee to advise the JCCP on how the rules, regulations and practises of EHOs can be upgraded and supported when looking at the licensing of premises where aesthetic treatments are taking place. According to the JCCP, this is a complex and developing area which it is looking at to enhance patient safety and protections. Professor David Sines, chair of the JCCP, said, “It is my great pleasure to welcome Andrew and Victor to the JCCP Board of Trustees. As the JCCP develops it needs to recruit people with specialist knowledge and experience to its Board of Trustees. Both Andrew and Victor fulfil that role and I look forward to working with them.”
E L I T E
Elite Training
T R A I N I N G E X P E R I E N C E
2019
Early booking discount ends this 4 ELITE TRA I N I N G P R OVI D E R S month for Elite Training O NE UNIQ UExperience E EXPERIENCE The exclusive 10% early booking discount for the Elite Training Experience, taking place at the Aesthetics Conference and Exhibition (ACE) 2019, expires at the end of December. Delegates who attend one or more of the three-hour CPD-accredited sessions hosted by Aesthetic Training Academy, with Dr Simon Ravichandran and Dr Emma Ravichandran, Dr Bob Khanna Training Institute, with Professor Bob Khanna, Dalvi Humzah Aesthetic Training, with key speakers Mr Dalvi Humzah and nurse prescriber Anna Baker, or Medics Direct Training, with Dr Kate Goldie, will be able to learn about anatomy, injection techniques, watch live demonstrations and much more. Each session is priced at £195 +VAT with an exclusive 10% early booking discount valid until the end of this month. The Elite Training Experience sessions cater for all levels of experience, however access is restricted to certain medical professions. More information on who can attend each session can be found on the website. Practitioners are encouraged to visit www.aestheticsconference.com and book before December 31 to make the most of this discount. Acne
Epionce launches new skincare duo Skincare company Epionce has launched two new products, aimed to work in tandem to treat acne-prone skin on the face and body. According to the company, the Purifying Wash incorporates botanicals with salicylic acid that is designed to help clear acne blemishes without over-drying the skin, whilst the Purifying Spot Gel is clinically proven to clear blemishes by 84.8%. The duo is recommended for daily use on adult skin, including very dry and sensitive skin. Epionce products are supplied by aesthetic distributor and training provider Eden Aesthetics.
Events diary 31st Jan – 2nd Feb 2019 IMCAS Annual World Congress 2019, Paris www.imcas.com
4th-6th April 2019 Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc.2019conference.org
14th May 2019 British Association of Sclerotherapists Annual Conference, Windsor www.bassclerotherapy.com
1 & 2 MARCH 2019 / LONDON
1st – 2nd March 2019
The Aesthetics Conference and Exhibition, London www.aestheticsconference.com
Statistics
Cosmetic surgery procedures rise Last month the International Society of Aesthetic Plastic Surgery (ISAPS) released its annual global aesthetic survey, which was sent to 35,000 plastic surgeons on its database and analysed by an independent research firm. The results indicated a 5% increase in surgical cosmetic procedures within the past year. The survey stated that breast augmentation continued to be the world’s most popular cosmetic procedure with 1,677,320 being performed across the world in the last 12 months, followed closely by liposuction and eyelid surgery. In regards to the non-surgical market, injectable procedures, particularly botulinum toxin ranked at number one with 5,033,069 procedures, a 1% increase over the year. Dr Renato Saltz, president of ISAPS commented, “It’s great to see the 2017 results released to see the continued growth in plastic surgery and cosmetic procedures in many different countries around the world. The USA remains in lead position followed by Brazil.”
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses
BACN CONFERENCE Thanks to all our delegates and exhibitors who made the Autumn Aesthetic Conference the biggest and best one yet. A fantastic two days filled with educational workshops, demonstrations, and networking opportunities Both days were sold out, demonstrating the growth in demand each year. After great feedback regarding the venue which was new for this year, the BACN Autumn Aesthetic Conference 2019 will be held once more at Edgbaston Stadium on 7th and 8th November 2019.
BURSARY PROGRAMME A new Bursary Award Programme for BACN nurses, supported and funded by Church Pharmacy, will launch in January. This programme will offer financial support to BACN members wishing to undertake a broad range of education, CPD and specialist training. More information regarding this will be sent out to members in the new year, and details will be provided on our website/social media platforms.
ANNUAL GENERAL MEETING
Galderma launches ‘Your Little Winter Helper’ campaign Pharmaceutical company Galderma has launched a new dermal filler winter marketing campaign to support its customers in promoting their business in the run-up to the festive period. The ‘Your Little Winter Helper’ campaign includes branded visuals, video GIFs and messaging that highlights the versatility of dermal fillers and skinboosters. According to Galderma, customers will be provided with vibrant, easy-to-use materials that have been designed with patients in mind and can be used on Facebook, Instagram and Twitter, as well as on a clinic’s website and in clinic. Katie Bennett, Restylane brand manager UK and Ireland at Galderma, said of the launch, “Following on from the success of Galderma’s Valentine’s and Summer campaigns, we wanted to make sure that our customers are equipped with the tools they need to promote their business during the all-important run-up to Christmas. The materials for this winter skin campaign have been specially created to help our customers boost their profile on social media channels, via open days and in clinic.” Aesthetic reconstructive oculoplastic surgeon, Mrs Sabrina Shah-Desai, director of Perfect Eyes UK, added, “What’s great about the Galderma campaign is that it includes images which will appeal to both men and women, so I can select the right image and channel for each target audience.” Survey
Aesthetics journal releases readership survey results 19 N 20 IO ! E RAT EN AC IST OP
Aesthetics Media Ltd has received promising results from its recent survey, THE SECRET where readers were asked IS OUT for summer! to give their feedback on the valuable clinical content and business advice that the Aesthetics journal provides. Out of all participants in the survey, 33% stated they have been working in the medical aesthetics specialty for more than 10 years, with 16% for five to 10 years, 10% for three to five years and 27% for one to three years. The results found that 87% of Aesthetics journal readers recommend articles that they read each month to peers and colleagues in the specialty and 76% of respondents enjoy reading the journal for one to two hours. Additionally, 56% of respondents read articles published that catch their individual interest, while 39% noted that they read absolutely everything provided in each monthly issue of the journal. The feedback gathered also showed that 95% of readers use Aesthetics as a trusted resource for information on new products, equipment and services in aesthetics. Upon viewing advertisements in Aesthetics in the last 12 months, 95% of readers said they have taken action to discuss the advertised services, contact advertisers or purchase the products advertised. Lastly, out of Aesthetics’ digital subscribers, 66% stated that they find the weekly e-newsletter helpful to extremely helpful in keeping up-to-date with the latest news and information in aesthetics. For a full, visual breakdown of the statics gathered from Aesthetics’ survey, turn to p.25. Subscription to the Aesthetics journal is free for UK residents and just £100 per annum for those outside the UK. Visit www.aestheticsjournal.com for more information. G W RE NO
VOLUME 5/ISSUE 11 - OCTOBER 2018
tic he st ae
K O ! .com BO OWwards N sa
VOLUME 5/ISSUE 10 - SEPTEMBER 2018
VOLUME 5/ISSUE 9 - AUGUST 2018
ALI N FI
2019
Aesthetics aestheticsjournal.com
Marketing
s tic 18 E! he 20 D st s INSI Ae ard S ST Aw
Each year the BACN holds an AGM to confirm the management committee for the following year, and to note approval of accounts. This year, the meeting will be held in London at the Bevan Brittan office, 2 Fleet Place, London EC4M 7RF on December 10 at 2pm. More information can be found via the members’ area of the BACN website and a digital webinar will be made available for remote access.
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RES18-02-0113r Date of preparation: July 2018
FINALIST 2018
We have the secret.
Science Behind Ageing CPD Dr Fiona McCarthy details the biological influences on ageing
The BACN is developing its strategic partnerships with companies for next year, working on new programmes, and provisions for holding events in the new year. The focus will be around developing aesthetic nursing as a specialism. To do this the BACN has now established an Education and Training Committee, which is charged with developing a new ‘Competency Framework’ for nurses and categories/levels of aesthetic nursing. This new Committee starts its activities in January 2019 and will build upon the BACN Competency Framework 2015, as well as the many new standards and frameworks that have emerged. This column is written and supported by the BACN
Special Feature: A Holistic Approach Communicating a multi-treatment approach to patients
Defensive Designing a Logo Strategies CPD
Treating Nasolabial Folds
Mr Dalvi Humzah presents his protocol for using filler for the nasolabial folds
Clare Mansfield covers
key considerations Dr Godfrey Town and Dr Ross Martin for an aesthetic clinic discuss defending against patient claims logo design
Special Feature: Treating the Stomach Practitioners explore using energy-based devices for treatment
Managing Oily Skin
Understanding
Paid Searches Using HA Fillers CPD: Part Two
Dr Chandi Rajani Steve Mulvaney details outlines her strategy maximising your for treating oily skin patient reach through Dr Souphiyeh Samizadeh explores the different with botulinum toxin paid advertising technologies of dermal fillers
Special Feature: Mid-facial Thread Lifting Practitioners explain their best tips for a successful mid-face lift
Jawline Sculpting Using Filler
Dr David Ong presents his technique for shaping the jawline
The Unhappy Patient
Dr Qian Xu details how new practitioners can avoid unhappy patients
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Qualification
ISO standards to be offered for aesthetic sector For the first time an International Organization for Standardization (ISO) standard, which is an internationally recognised standard that ensures products and services are safe and reliable, will be used for professional certification within the aesthetics sector. Two schemes will be available and delivered through independent international certification body IQ Verify (IQV); the IQV learning provider scheme (in accordance with ISO17065:2012) and personnel certification scheme in Skin Rejuvenation (in accordance with ISO17024:2012). These two schemes will be accredited by the United Kingdom Accreditation Service (UKAS), which is an accredited body that certifies IQV. According to a representative from IQV, this development is a major step towards further increasing the professional standards in the aesthetics industry, and illustrates a commitment to the continued improvement for patient safety. Aesthetic training provider Harley Academy is undergoing the first audit in early October, allowing it to offer IQV’s 17024:2012 personnel certification scheme for skin rejuvenation. This is to be the pilot for all aesthetic schemes for which UKAS will be assessing compliance, according to IQV. The company‘s director and general manager Mark Salt stated, “This is an exciting development in the aesthetics industry, which not only offers international recognition but also ensures the continued raising of the bar in terms of knowledge and competence of practitioners.” Distribution
Med-fx supplies iS Clinical Fire & Ice The iS Clinical Fire & Ice professional peel system will now be available through aesthetic supplier Med-fx. Distributed in the UK by Harpar Grace, iS Clinical Fire & Ice is a clinical treatment that acts like a mild peel, combining glycolic acid with retinol, aiming to resurface the skin, treat problematic skin, reduce fine lines and encourage cellular renewal. Commenting on the new partnership, founder and director of Harpar Grace, Alana Chalmers said, “We are delighted to expand the Med-fx iS Clinical offering with this iconic professional peel system as it continues to remain in demand in the UK.” Devices
Spectra Vein launches Aesthetic equipment provider Cambridge Stratum has launched a new laser that aims to treat vascular lesions, thread veins, spider veins and rosacea. The Spectra Vein is a 980 nm diode laser, which, the company claims, has a 30w output, adjustable pulse widths from 5-400ms, plus continues wave mode, and a repetition rate of up to 50Hz. John Culbert, CEO of Cambridge Stratum, said, “The Spectra Vein is the second machine in our Spectra range of compact, high performance, affordable machines that both outperform existing platform machines and provide additional flexibility. The use of solid state technology also provides a step improvement in reliability. and the machine comes with our market leading three-year warranty.”
1 & 2 MARCH 2019 / LONDON WWW.AESTHETICSCONFERENCE.COM
COUNTDOWN TO ACE 2019 BUSINESS TRACK
Sales techniques, marketing, PR, consent, HR, regulation, data protection, advertising, patient retention, ROI, VAT, building a team… what do you want to learn about in 2019? The Business Track at the Aesthetics Conference and Exhibition has it all! With 19 sessions, each worth half a CPD point, taking place across the two days, there is something for everyone to learn – whether you’re a business owner or clinic employee! SPEAKER INSIGHT Alan Adams, an award-winning business coach, will deliver an in-depth talk on the five essential ways to grow your clinic at the Business Track. He says, “Your clinic’s metrics are key to tracking and assessing the progress of your business. Knowing how to improve your clinic’s metrics can lead to a potential increase in your company’s turnover and overall growth. I will offer best practice advice and answer all your burning questions to ensure you increase turnover in 2019!” WHAT DELEGATES SAY “I really enjoyed the Business Track talks that I attended, they were really interesting, especially for a new start-up business” Aesthetic doctor, Portsmouth “The quality of talks was high and practical” Aesthetic nurse, Newcastle THE BUSINESS TRACK IS SPONSORED BY
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Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Vital Statistics Nearly 56% of women have mistakenly thought someone was older than they were because of the way their hands looked (Nestlé Skin Health, 2018)
In the UK, 37% of adults have considered having a non-surgical procedure, with 22% having considered a surgical procedure (Realself, 2018)
According to the British Association of Dermatologists, diet and lifestyle could increase the risk of developing psoriasis by 30% (BAD, 2018)
In a UK survey, 30% of respondents said that they would preferably choose a natural/organic product when buying lip care (Statista, 2018)
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Rosacea
Study highlights association between rosacea and coffee A study published in JAMA Dermatology has indicated that increased caffeine intake from coffee is inversely associated with the risk of rosacea in women. The cohort study included 82,737 female participants in the Nurses’ Health Study II, which was established in 1989, with followup conducted biennially between 1991 and 2005. All analysis took place between June 2017 and June 2018. There were 4,945 cases of rosacea reported and authors found a significant inverse association between risk of rosacea and increased caffeine intake, particularly that from coffee. This association was not found for caffeine intake from other food sources such as tea, soda, and chocolate. Clinic
The Harper Clinic opens GP and women’s health doctor Dr Shahzadi Harper has opened a female holistic wellbeing centre on Harley Street in London.The clinic will address female hormonal needs and a range of symptoms including concerns with premenstrual syndrome, perimenopause, menopause and libido. Dr Harper said, “I opened the clinic because I felt women weren’t getting the all-round integrated care that they should have. I’m also a great believer in preventative medicine and I think for a woman at this transitional point in her life, it’s a good time to address medical needs and prevent illnesses in the future.” Among the treatments on offer is the FemiLift, a minimally-invasive treatment for postmenopausal vaginal dryness using a Pixel CO2 laser from ABC lasers. She added, “I think the FemiLift is a perfect addition to my treatment portfolio as there are limited options for women with stress incontinence.” Gifting
Of almost 1,000 consumers polled, 92% said they would stop purchasing from a company after three or fewer poor customer service experiences (Gladly, 2018)
When asked what events would influence the reason behind considering cosmetic treatments, the most popular answer, with 23%, was that people wanted to appear youthful at work or when starting a new job (Realself, 2018)
Obagi Medical Christmas gifting launches This year, aesthetic supplier Healthxchange Pharmacy has launched festive gifts including Christmas Crackers and Christmas Baubles. Three are three Obagi Christmas Crackers: the Velvet Cracker, containing Obagi Hydrate Moisturiser and Retinol 0.5%; the Glow Cracker, containing Hydrate Moisturiser and Professional-C Serum 15%; and the Radiant Cracker, containing Hydrate Moisturiser, Retinol 0.5% and ELASTIderm Eye Complete Complex Serum. The crackers are also available empty for clinics to add their own choice of products. The Christmas Baubles are large, clear baubles suitable for holding a variety of products and come with Obagi-branded tissue paper. Steve Joyce, marketing and technology director at Healthxchange Pharmacy, said, “After the incredible success of the Obagi Christmas Crackers last year, we decided to broaden our Christmas offering and we hope that our clinics and stockists really enjoy the new products.”
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Patient experience
Transform Group creates pledge to patients Clinic operator Transform Group has launched ‘The Patient Charter’, pledging to provide the highest quality of care to patients before, during and after their procedure. The Patient Charter has been created by Transform Group, which operates clinic chains Transform and The Hospital Group, outlining the clinical and internal governance, as well as patient engagement measures, that both organisations have in place to ensure patients receive the highest quality continuity of care throughout their cosmetic interventions or weight loss journey. According to Transform Group, The Patient Charter reflects the company’s belief that every patient should start their clinical journey with confidence in their cosmetic intervention or weight loss surgery provider. CEO of Transform and The Hospital Group, Tony Veverka, said, “With a significant amount of misinformation out there in the public domain, we have found that many patients can feel uncertain about what they should expect from their procedure, surgeon, provider, and aftercare. We believe that providers have a responsibility to address this uncertainty, ensuring that they are earning a patient’s trust from the outset, and being held accountable to delivering the highest standards of care, every step of the way.” Recruitment
HA-Derma expands team The exclusive UK and Ireland distributor of IBSA Italia, HADerma, has recruited a new member to its sales team. Debra Derosa has been appointed as account manager for the North West and Scotland and has more than 10 years’ experience in the aesthetic and medical industries. HA-Derma has confirmed that her key responsibilities will be supporting existing clients, alongside building relationships with potential new clients in the North West and Scotland. “IBSA is a progressive, fast growing company whose technological advancements are setting it apart from other manufacturers. It is a really exciting time to be joining their UK and Ireland distributor, HA-Derma, and I can’t wait to get started,” said Derosa. Iveta Vinklerova, director of HA-Derma, added, “Debra is a fantastic and valued addition to the team. We are very pleased to have her on board.” Publication
Antiageing book released Dr Duncan Carmichael, who has had 25 years’ experience working as a medical doctor and regularly lectures and speaks at conferences on aesthetics and antiageing medicine, has authored a new book; Younger for Longer. According to Dr Carmichael, the book provides patients with a comprehensive understanding of what optimal health is, how to get it and ‘how you can slow down the ageing process and stay healthy for life’. Topics throughout the book include nutrition, toxins, men and women’s health and an understanding of why our skin, brain and liver age. Dr Carmichael said, “My inspiration for writing this book came from my passion in antiageing medicine. More often than not, finding good health is not always about detoxing or taking supplements but more about looking at our lifestyle as a whole. For example, our hormone levels vary throughout our life, but if they are supported correctly they can keep us youthful and vital into our final years. This book aims to provide readers with tips on how they can stay healthy for life and in turn, look younger for longer.”
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Universkin’s chief technology officer, Dr Thierry Ellena, PhD Why did you create SkinXs? Thanks to Universkin’s unique approach to personalised skincare, hundreds of practitioners around the world are already helping patients to get their skin glowing again. Skin Xs is the second major step in our vision for better skincare. We first gave practitioners the best products to treat their patients and now aim to give them the best tools to enhance patients’ follow-up, loyalty, recruitment and experience. That is how SkinXs was born. What is SkinXs and how does it work? SkinXs is a digital platform that serves as a virtual assistant. It starts with a 10 minute online dermatological questionnaire, which was created in collaboration with medical experts. Through the proprietary diagnostic and formulation algorithms of SkinXs, the practitioner is then able to select the most suitable active ingredients for each individual patient based on the specific needs of their skin. What are the benefits of introducing SkinXs? First, it’s time-saving. Your patients share their skin information before their consultation and, based on the data, the algorithm provides an accurate skin diagnostic and the most suited personalised formula, meaning you have more time to focus on patient service. Second is outreach. The digital phenomenon breaks down the notions of time and space. Thus, you can give thorough consultations with several patients at the same time and from various places. SkinXs works on all types of devices and each practitioner has their own unique link to the questionnaire that they can share on multiple online platforms (social media, newsletter, consultation reminders, etc.) to drive audience engagement and loyalty. In addition, patients’ data belongs to the practitioners and the system is 100% compliant with the latest regulations on data privacy. How do I get SkinXs? If you’re already a Universkin client, contact our UK partner Schuco Aesthetics to activate your account. You will receive the kick-off packaging with all the information you need to ensure a smooth implementation. If you are new customer, contact Schuco Aesthetics to get started. This column is written and supported by
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Premises
Pabau expands head office Clinical customer relationship management (CRM) company Pabau has launched a new 600 square feet headquarters. The new office is in Skopje, Macedonia, and features an indoor garden and unique boardroom, as well as an onsite fish and chip shop. It has the capacity to house up to 200 new staff members and, according to the company, the business plans to take on 80 new employees in the next 12 months. According to CEO William Brandham, the move reflects the brand’s commitment to its current employees, whilst helping to facilitate the attraction and retention of up and coming world-class talent. Brandham said, “This marks a key moment in the company’s history. Pabau will continue to dedicate itself to creating a truly paperless system. Not only will it create further jobs for the UK, it also ensures the company remains at the top of its game, delivering high-quality, market-leading products to its global customer base, time and time again. It will provide our staff with the most inspirational working environment, whilst opening our doors to welcome the brightest talent.” Medication
New pharmacy launches A pharmacy that is ‘dedicated to private prescribers’ called Galenic Laboratories, trading as Roseway Labs, has launched into the aesthetic sector. The company supplies licensed, unlicensed and compounded medications, as well as vitamins, minerals, supplements and diagnostic testing kits. The unlicensed medicines may include items that are approved in other countries but haven’t been licensed by the NHS, for example, natural desiccated thyroid drugs. Elizabeth Philp, CEO, said, “Roseway Labs is the doctor’s dispensary. Many frustrated prescribers want to offer effective, personalised medicines that just aren’t available in the UK or are available at an inflated price; with Roseway Labs they now can.” According to Roseway Labs, prescribers may either send prescriptions through their e-prescribing system or email copies with a follow up of the original in the post. Although based in London, the company delivers to all locations across the UK and can post internationally, however there may be restrictions on import due to local customs. Philp concludes, “We are regularly adding products to our range, as we learn what is important to our customers, who typically work in the fields of dermatology, aesthetics, hair loss and bio-identical hormones.” Topicals
Murad introduces new products Skincare company Murad has added two new products to its portfolio; the Multi-Vitamin Infusion Oil and the Outsmart Blemish Clarifying Treatment. The Multi-Vitamin Infusion Oil, Murad’s first ever facial oil, is designed to target lines, wrinkles, dullness and dryness, rough texture and uneven skin tone, the company claims. It includes six vitamins, from A to F. The second product, the Outsmart Blemish Clarifying Treatment features Murad’s patented Penta-Acid technology which includes salicylic acid, hydroxydecanoic, sebacic acid, lysophosphatidic acid and glycolic acid to target existing breakouts and help keep skin clear of acne-causing bacteria, oiliness and blackheads while minimising dryness and irritation.
Aesthetics aestheticsjournal.com
News in Brief Sclerotherapy conference date confirmed for 2019 The British Association of Sclerotherapists (BAS) has confirmed that its annual conference for 2019 will take place on May 14 at Dorney Lake Conference Centre, near Windsor. The conference aims to give all sclerotherapy practitioners useful information that they can take away and implement in their own practices, whatever their role or level of experience. Discounts are available for members of the BAS, the British Association of Cosmetic Nurses (BACN) and the Aesthetic Complications Expert (ACE) Group. The meeting will be CPD certified and certificates will be issued. Obagi Challenge returns Healthxchange Pharmacy, the UK distributor of Obagi Medical, has announced that the Obagi Challenge will return for its second year. According to the company, the challenge encourages clinics and practitioners who have successfully treated their patients using Obagi products to share their results for the chance to win a £300 spa voucher. The winning patient will receive a £1,000 holiday voucher and two runners-up will be presented with an Obagi gift pack. The challenge is open until December 31. ANSES calls for ban on sunbeds in France The French Agency for Food Safety, Environment and Labor (ANSES) has urged its government to ban tanning beds following an increase of cancer in young people from exposure to artificial ultraviolet rays. France, much like the UK, has previously restricted the use of tanning beds to over18s only. The ban comes following reports that 43% of melanoma cases among young people are directly connected to tanning beds. The French government so far has only tightened restrictions, but not made any move towards implementing a total ban. Institute Hyalual recruits new team member Aesthetic product developer Institute Hyalual has appointed Danielle Dale as the account manager for the north of England. Dale has three years’ experience in account management and has said that she is ‘very excited to join the industry’. The company has stated that Dale will be responsible for managing existing accounts, new business development, sales and marketing and general support of clients. Her main focus will be on Rederm, the WOW facial and a range of peels that will launch soon.
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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On the Scene
Out and about in the specialty
SkinCeuticals Master Physician Business Seminar, London Cosmeceutical company SkinCeuticals held its first Master Physician Business Seminar on October 24, aiming to ‘help delegates improve and hone their business skills to increase client acquisitions and develop their clinics’. The seminar was held in London and focused on business and practice management advice, with recommendations on how to fine tune best service to different patient types to maintain and expand a strong customer base. Throughout the day presentations were given on retail innovations, practical aspects of digital marketing, ways to build customer relationships and social media. The seminar concluded with an Action Plan Workshop, which encouraged delegates to develop strategic actions and goals from the day. Antonia Parsons, medical affairs and content manager at SkinCeuticals UK said, “The day was a huge success and the feedback has been excellent. It was great to see the delegates absorbed and motivated by new ideas. We plan to hold more business seminars in the future!”
HA-Derma Masterclass, London On November 10 aesthetic distributor HA-Derma hosted a Masterclass led by Dr Gabriel Siquier Dameto at the Royal Society of Medicine in London. The masterclass was designed for selected advanced practitioners with previous clinical experience in both the Aliaxin dermal filler range and Profhilo. To start the session, Iveta Vinklerova, director of HA-Derma, gave delegates a full insight into pharmaceutical company IBSA Italia’s heritage, discussing the manufacturing process of hyaluronic acid raw material and their product portfolio. UK and Irish national sales manager Frank Ward then introduced the new patented Hydrolift technology and IBSA’s Guide to Product Selection scale, giving practitioners what she described as a universal and meaningful tool to select each product based on rheological characteristics for optimal treatment outcomes. Dr Dameto then presented on dynamic and static facial areas supported by a live demonstration, with steps to creating the perfect lip and neck rejuvenation techniques. There was also a live demonstration using advanced combination techniques for the periorbital forehead and temple areas. All topics featured HA-Derma’s products including Aliaxin SR, EV, FL or GP, Profhilo or the recently launched Viscoderm Hydrobooster.
Aesthetic Exchange with Cynosure UK, London On November 3 laser developer and manufacturer Cynosure UK launched Aesthetic Exchange; a new concept for a learning and development platform in the form of exclusive events and online resource. The launch was hosted by aesthetic laser surgeon Dr Dianne Quibell at the ME Hotel in London and was the first of the series of events. Delegates from more than 40 clinical practices enjoyed a full day of educational sessions, panel discussions, presentations, live demonstrations and peer-to-peer networking. According to Cynosure UK, the Aesthetic Exchange will deliver ongoing educational sessions and opportunities for practitioners, helping to get clinics started with hair removal and facial rejuvenation technologies, before expanding into picosecond technology and tattoo removal, as well as exploring the growth potential of body contouring and skin tightening. Ben Savigar-Jones, UK and Ireland sales director at Cynosure said, “The event was a huge success – we had great feedback from our delegates who were blown away by the knowledge and expertise of our speakers, and the focused education on all the key treatment areas from Cynosure. We are looking forward to hosting a series of additional Aesthetic Exchange events to help our customers grow and expand their businesses!”
Business of Hair Seminar, Birmingham On November 10, business advisory company DSL Consulting held the Business of Hair Seminar at the National Exhibition Centre (NEC) in Birmingham. The agenda for the day was developed for hair restoration professionals, including those from the British Association of Hair Restoration Surgery and the Institute of Trichologists to offer business advice. The event started with a welcome talk from Danny Large, director of DSL Consulting Ltd, and was followed by advice on building a website from Mark Bugg, director at Web Marketing Clinic. Throughout the day delegates saw talks from Naomi Di Scala, aesthetic insurance and claims manager from Hamilton Fraser Cosmetic Insurance on covering your practice and GDPR, Pabau’s William Brandham on customer relationship management, as well as talks on social media from founder of aesthetic business consultancy Delivering Demand, Jemma Edwards. A delegate said of the event, “As a new clinic manager, the event was extremely beneficial for me and gave me an insight into the treatments available and allowed me to connect with successful people within the business. Networking with friendly and welcoming individuals made the event enjoyable and I would love to attend something similar in the near future.”
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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BACN Autumn Aesthetic Conference 2018, Birmingham
Bob Khanna on his approach to assessing and treating a patient’s profile. Nurse prescriber Fiona Wondergem then presented on safeguarding considerations in aesthetic practice, followed by considerations for professionalism and competency in aesthetics by nurse Aesthetics reports on the highlights from prescribers Anna Baker and Jane Laferla. After lunch, the British Association of Cosmetic Nurses Bennett launched the new BACN bursary programme, sponsored by Church Pharmacy. The bursary scheme Autumn Conference will start in January 2019 and will offer financial support Around 300 aesthetic nurses met at Birmingham’s cricket ground, to BACN members wishing to undertake education, CPD and Edgbaston Stadium, on November 8-9 for the British Association specialist training. Galderma UK held a sponsored session on facial of Cosmetic Nurses (BACN) Workshop and Masterclass Day assessment, presented by oculoplastic surgeon Mrs Sabrina Shahand annual Autumn Aesthetic Conference. The workshop day Desai and nurse prescriber Jackie Partridge, who performed a live on November 8 included a talk on delivery systems in skincare by demonstration. This was followed by a session on complications Victoria Hiscock, product and education specialist from skincare by nurse prescribers Linda Mather and Sharon King, who said that developer AlumierMD, and aesthetic practitioner Dr Gabriel Siquier analysis of data from the Aesthetic Complications Expert (ACE) Dameto performed a live demonstration of Aliaxin in the temples Group indicates 53% of total complications between 2016-2018 were and mid-face. Cosmetic doctor and ophthalmologist Dr Tahera associated with lip augmentation. Representatives from the MHRA Bhojani-Lynch demonstrated a mid-face and tear trough correction then discussed adverse event reporting and Allergan held a session using Teosyal dermal fillers and also explored how to prevent the presented by consultant plastic, reconstructive and aesthetic surgeon ‘chipmunk cheek’. The day also included business workshops, Mr Christopher Inglefield on treating skin using Juvéderm Volite. featuring an update to education and training by BACN CEO Paul Frances Turner Traill, who has just stepped down as a BACN advisory Burgess, nurse prescriber Jodie Grove spoke on introducing your board member, said of the conference, “It was the best conference, own skincare to your clinic, director of Cosmetic Digital Adam exhibition, and educational learning experience the BACN has ever Hampson discussed Google tips and Hamilton Fraser claims organised. It was very open, discussing topics like complications, manager Naomi Di Scala explored cyber risks. competencies, and how we manage our practices.” The Autumn Aesthetic Conference on November 9 began with a Speaking about the event as a whole, Burgess said, “It’s been an welcome from Burgess and BACN chair, nurse prescriber Sharon amazing show, the workshop day was fully sold out and the reaction Bennett, who discussed the importance of becoming a specialist to the presentations has been great. It’s been a big success!” nurse in aesthetics. Following this was aesthetic practitioner Professor The next BACN conference will take place on November 7-8.
TAMC, Dubrovnik Aesthetics reports on The Aesthetic Medicine Congress (TAMC) in association with the British College of Aesthetic Medicine The historic, sunny city of Dubrovnik, Croatia, hosted the first ever TAMC conference on October 19-21 in association with the British College of Aesthetic Medicine (BCAM). Organised by aesthetic practitioner and TAMC president Dr Nikola Milojević, the congress attracted 250 delegates and more than 20 speakers from across the world. The programme began with a presentation and live demonstration
from UK aesthetic practitioner Dr Tapan Patel, who presented his advanced techniques for his full-face approach. Several other live demonstrations focused on the full-face over the three days, including Greek practitioner Dr Dimitrios Sykianakis, who combined needles and cannulas, and Irish aesthetic practitioner Dr Patrick Treacy, who also demonstrated his approach. Other sessions which were particularly popular included the rise of aesthetic gynaecology by UK aesthetic practitioner Dr Sherif Wakil, skin quality and tightening by Croatian dermatologist Dr Željana Bolanča and UK practitioner Dr Peter Prendergast, and non-invasive body contouring technology by UK aesthetic practitioner Dr Galyna Selezneva. BCAM director and
appraisal clinical lead, Dr Paul Myers, also presented on the BCAM appraisals system and the British model of medical licences. There were also two sponsored lectures from pharmaceutical companies Galderma and Allergan. Turkish dermatologist Dr Omur Tekeli spoke about the importance of personalising the mid-face to restore, enhance, lift and define with Galderma’s OBT/NASHA range, and dermatologist Dr Samo Gorenšek from Slovenia spoke on using Vycross technology for improving skin quality. The conference also had an exhibition with around 15 aesthetic companies. Dr Milojević said of the event, “We had great fun at the congress and had some fabulous speakers. I really wanted it to be something that delegates and speakers would really remember. So, as well as the congress we had a wonderful cocktail party and a big gala dinner. We have already started gathering speakers for next year and I am hoping to get some big names from the US. I also look forward to increasing our involvement with BCAM. People have told me it was the best congress they had ever been to, so I am very pleased with how it went.” The next congress is to take place on October 11-13 next year.
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Reflection on 2018 Aesthetics Editorial Board members look back at their year in the speciality and discuss their aspirations for 2019 Five years have passed since Aesthetics first went to print and a lot has changed in that time. In 2013 we reported on the launch of new injectable products, skincare and devices promising to enhance patients’ results with little to no downtime and great profitability for practitioners. Some have stood the test of time, while others haven’t been so successful. Also hot on the agenda was regulation; in our first issue we published an article entitled ‘Stopping the ‘Botox’ Cowboys’, which covered the law surrounding prescribing and administering botulinum toxin. Unfortunately, articles like this would not be out of date today.1 But what has changed? In the last year, we’ve seen plenty more products and treatments come to market, as well as regulation development with the implementation of the Joint Council of Cosmetic Practitioners (JCCP) and Healthcare Improvement Scotland (HIS). So, what are the leading practitioners in the specialty most excited about? And how do they see aesthetics evolving in 2019? We spoke to five of the Aesthetics Editorial Board members to find out…
Sharon Bennett, aesthetic nurse prescriber I think bioidentical hormone replacement therapy (BHRT) is a growth area, although having the bloods taken to assess patients’ hormone levels can be costly, which may be holding some people back. Some practitioners have questioned whether BHRT fits in aesthetic practice, but I do believe it does. Aesthetic practice should be holistic and we should address the signs of ageing that occur in perimenopausal women, so why would we not provide our patients with a treatment that can help them through this process and have a positive impact on their skin, energy and wellbeing? Many patients I see are on hormone replacement therapy (HRT) anyway, so BHRT could offer an alternative that doesn’t have the negative effects associated with HRT.7 Lately I’ve seen more and more patients seeking treatment in their 70s, who’ve never had treatment before and I wonder, why now? What has changed to make them come in? It may be the visibility and the acceptance of cosmetic treatments available
Dr Stefanie Williams, boardcertified dermatologist After introducing plasma therapy to my clinic earlier this year, I think it is definitely here to stay – we get great results on the upper eyelids. In my opinion, apart from a surgical blepharoplasty, there isn’t really an equivalent for the upper eyelids. For patients who don’t want surgery and just have mild skin laxity in this area, it works really well, especially in combination with Ultherapy to lift the brows. Patients will get significant swelling following plasma treatment though, so I often prescribe a three-day course of oral steroids to prevent this. I do have concerns with the plasma removal of lesions, especially by non-dermatologists. Personally, I would never remove pigmented lesions without a histology; unless it’s clearly a skin tag. In terms of acne treatment, there has been an interesting meta study looking at isotretinoin and depression. This study did not confirm a link, which is my clinical experience too, with lower daily doses. There is now good data on the effectiveness of lower daily does of oral isotretinoin, which is what we tend to use today. One review, for example, examined the use of isotretinoin in low doses and unconventional regimens in different types of acne. According to the authors, “Although high doses of isotretinoin are recognised as a standard treatment, a number of clinical studies indicate that in most patients with a moderate form of acne, lower dosage of the drug is sufficient to achieve improvement and, what is most important, is safer because of significantly fewer side effects.”6
them, or just the need to do something for themselves. Generally speaking, they’re not seeking huge changes, they’re wanting some improvement but with realistic expectations. Older patients are often far easier to treat than younger patients, as they are generally happy with a lesser improvement, compared to the younger generation who scrutinise their looks far more. Many older patients don’t even like to see themselves in their photographs taken during consultation. We’ve also seen an increase in transgender patients, looking to feminise or masculinise their facial features or reduce hair growth. From a British Association of Cosmetic Nurses perspective, of which I am chair, something we advocate to our members, regardless of the types of patients they see, is the importance of a thorough consultation and managing expectations. It can be daunting to treat a patient from a demographic you’re unfamiliar with, but if you take the time and care to really get to know what they want from a treatment, and advise them accordingly during the consultation, then one should see satisfied, returning patients.
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Mr Dalvi Humzah, consultant plastic reconstructive and aesthetic surgeon Next year I think the biggest change we may see in the injectables market is the introduction of new botulinum toxins. Daewoong Pharmaceutical Co. is set to release Nabota via its global sales partner Evolus Inc to the US and European markets in the first half of 2019. The toxin is currently under approval review with the Food and Drug Administration (FDA), as well as the European Medicines Agency (EMA).2,3 Korean manufacturer Medytox is also expected to release another two products. The company formed a licensing partnership with Allergan in 2013, selling the development and
Jackie Partridge, aesthetic nurse prescriber The biggest change for me this year has been becoming registered through HIS. In April, HIS confirmed that aesthetic nurses who own HIS-regulated clinics can now legally stock prescription-only medicines, which has been really well received.8 Registrations and inspections are now being rolled out and I had my first inspection recently – I will get the results in a few weeks. I sit on the HIS board representing the BACN and there are lots of developments in the pipeline. It’s important to acknowledge the criticism around the fact that HIS is only ‘regulating the regulated’. In other words, it regulates medical professionals who are, of course, already regulated by their medical bodies, such as the Nursing and Midwifery Council and General Medical Council. It doesn’t regulate non-medics, which means that Scotland is still rife with beauty therapists and other non-medics offering injectable procedures. The other point to bear in mind is that HIS only investigates the environment in which you are providing a registered service; it doesn’t look at whether you’re a good injector or not. But, regulation has to start somewhere and so far I think HIS has made a positive impact on aesthetics in Scotland and is hopefully leading the way forward.
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commercial rights of Innotox, an injectable botulinum toxin. In May this year, Allergan confirmed it would begin Phase III clinical trials of the drug. Medytox is also expected to receive approval to market Neurotox, another toxin product, in China.4,5 I’m really interested to see how these new products will influence the market if they get approval. They will add competition and we may see a shift in prices. As an independent training provider, it’s important that I offer training on a range of different toxins, as well as fillers, to ensure my delegates are exposed to the various products on the market and will be able to adapt their techniques and approach to treatments should more become available. This is certainly something that I will be implementing in 2019.
Mr Adrian Richards, consultant plastic and reconstructive surgeon After selling my clinic last year and training many delegates completely new to aesthetics, the lack of business knowledge is something that has really stood out to me in 2018. At the end of the day, we’re medical professionals, not business people, so understanding the commercial aspects of running a clinic doesn’t always come easy. I would advise anyone entering aesthetics to also think of their exit strategy – you should always have an end goal in mind and then make a plan of how to get there. As well as working way past the age you want, not having a plan means it can be difficult to hand over the reins to someone your patients will be unfamiliar with, making your clinic difficult to sell. For those managing clinics and staff, I’d recommend ensuring you establish a clear contractual agreement of their terms of practice from the outset. As aesthetics becomes even more popular, with more patients seeking treatment and more medical professionals entering the specialty, many new practitioners will want to gain experience in a clinic setting, before potentially establishing a competitor clinic nearby or offering treatments on the side, at a cut price. Not only could this have a negative impact on your patient numbers, but it could also mean that staff you employ are less motivated to work well for you. However, if you set clear boundaries with your employees, you should hopefully avoid this concern, maintain motivated staff and increase patient numbers with the additional skilful hands you now have.
Moving forward There were certain aspects of 2018 that really got the Board Members talking. In particular was the apparent lack of reporting complications. Mr Humzah reflected on a presentation he gave in which he asked how many of the audience had experienced a complication, to which many raised their hands, compared to how many had reported it to the manufacturer or the Medicines and Healthcare product Regulatory Agency (MHRA), to which there was a significant lack of raised hands. All the practitioners emphasised the importance of doing so and the ease of completing the Yellow Card reporting through the MHRA. “I recently reported a complication via the MHRA website,” said Mr Humzah, explaining, “It was so straightforward – you just filled in a form, ticked whether you wanted to remain anonymous or not and submitted. It took hardly any time at all! I then had an email confirming that the relevant authorities had been notified. It’s vital that we build data on the number of adverse events that take place so we can identify any trends and issues with particular products or devices. It’s so simple to fill out a Yellow Card, so there’s no reason not to.” Another concern for the Board Members was the increasing use of cameras and phones to film and take photographs of presentations and live demonstrations at conferences. Despite speakers and conference representatives clearly stating that this is against the rules, the members have found that delegates still flout the rules. Another concern for the Board Members was the increasing use of cameras and phones to film and take photographs of presentations and live demonstrations at conferences.
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
Despite speakers and conference representatives clearly stating that this is against the rules, delegates still flout the rules. This, says Bennett, is disrespectful to the speakers and conference organisers, as well as being a serious breach of data protection. She notes, “Patients will usually consent to their photos being shown for educational purposes, and speakers may have used copyrighted material in their presentation that is only allowed to be used by them. The probability that any photos taken of patients during a presentation and being shared and used is a reality and in breach of GDPR.” Partridge adds, “The worst is filming or taking pictures of cadaver training, even when it’s not live and just used on slides – it’s so disrespectful. Although, I do acknowledge that in some practitioners’ defence, they are using them for their own self-reflective learning.” Before getting cameras out in future, the Board Members agree that delegates should assume it is not allowed and always ask the speaker or company representative first. In terms of regulation, the Board Members agreed that progress has been made in 2018 with the launch of the JCCP. Although not all members have joined, they were supportive of the move to exclude beauty therapists from joining at Level 7 for injectable procedures. Mr Richards said that his training company, Cosmetic Courses, is on the board and he is feeling really positive about it. “The difficulty is that they can’t stop therapists injecting, but they are making it more difficult to be recognised,” he said. Looking forward, the Aesthetics Board Members agree that 2019 will be another exciting year for the specialty, with more product innovations and steps forward in regulation high on the horizon. Despite all coming from different professional backgrounds, they emphasise the value of sharing knowledge and working together in order to offer the highest level of care and safety to the increasing number of patients being seen in this ever evolving field of medicine. REFERENCES 1. Aesthetics, ‘Stopping the ‘Botox’ Cowboys’, (UK: Aesthetics, 2013) <https://issuu.com/ aestheticsjournal/docs/aesthetics_december_2013> 2. Choi Moon-lee, ‘Daewoong Pharmaceutical Strengthens Partnership with Evolus’ (Korea: Business Korea, 2018) <http://www.businesskorea.co.kr/news/articleView.html?idxno=25504> 3. Flora Southey, ‘Evolus boasts early resubmission of FDA-rejected Botox alternative’ (US: BioPharma, 2018) < https://www.biopharma-reporter.com/Article/2018/08/10/Evolus-boasts-early-resubmission-ofFDA-rejected-Botox-alternative> 4. Grace Chung, ‘Best Under a Billion 2018: A Spotlight On Botox Manufacturer Medytox’ (Asia: Forbes, 2018) <https://www.forbes.com/sites/gracechung/2018/07/25/best-under-a-billion-2018-a-spotlighton-botox-manufacturer-medytox/#7d414c9f4a3d> 5. Sohn Ji-young, ‘Allergan to start phase 3 trials of Medytox’s liquid BTX in Q4’ (Korea: Korea Herald, 2018) <http://www.koreaherald.com/view.php?ud=20180523000882> 6. The Marion Gluck Clinic, ‘Bioidentical hormone replacement therapy’, (UK: The Marion Gluck Clinic, 2018) <http://www.mariongluckclinic.com/our-services/bio-identical-hormone-replacement-therapy> 7. Torzecka et al., ‘The use of isotretinoin in low does and unconventional treatment regimens in different types of acne: a literature review’, Postepy Dermatol Alergol, (2017) pp.1-5. <https://www. ncbi.nlm.nih.gov/pmc/articles/PMC5329102/> 8. Aesthetics, Scottish nurses to stock POMs (UK: Aesthetics, 2018) <https://aestheticsjournal.com/ news/scottish-nurses-to-stock-poms>
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Building Your Business Establishing a private practice and standing out from the crowd is tough – how can you do it successfully? Aesthetics asks key questions to skilled business professionals and ACE 2019 speakers to hear their expert advice… How can I boost my turnover in 2019?
How can I get press coverage for my clinic?
ALAN ADAMS, BUSINESS COACH AND AUTHOR If you want to boost your turnover in 2019 the most important thing you can do is not just have a business plan, but one that’s solid, long-term and effective. Many clinics don’t have one at all or, if they do, it’s floating around in their heads, which is the worst place it can be. The most critical aspect within this plan is your sales and marketing strategy, and getting this absolutely nailed will be the difference between targeted, strategic growth (and increase in profits), or a bottom-line that’s plateaued.
JULIA KENDRICK, PR CONSULTANT You must position and package your services in a compelling manner: it’s got to peak a journalists’ interest. Why are you different? Is your treatment new, bespoke – a first, biggest, best, most powerful etc? Ensure the story appeals to their readership – if their readers will care, so will they!
LEARN MORE! Effective PR Friday March 1: 3:30pm ACE 2019
LEARN MORE! The Five Essential Ways To Grow Your Clinic Friday March 1: 10:10am ACE 2019
What key things should I know about tax and VAT in 2019? VERONICA DONNELLY, VAT AND TAX CONSULTANT It’s important to be aware that VAT is a growing concern in the sector. Her Majesty’s Revenue and Customs (HMRC) is increasingly using task teams to target aesthetic businesses and more businesses are now being reviewed. In 2019, practitioners need to understand VAT rules and the records you should keep to deal with an HMRC inspection, including Making Tax Digital records and reporting.
LEARN MORE! Tax and VAT Saturday March 2: 2pm ACE 2019
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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How do I set achievable KPIs? DR HARRY SINGH, MARKETER AND AESTHETIC PRACTITIONER In my experience, there are five essential key performance indicators (KPIs) you need to monitor every month: 1. Number of enquiries per month 2. % enquiries converted to visits 3. % visits converted to treatments 4. % treated patients that are retained 5. % treated patients that refer others Then you should follow a three-step process to set achievable KPIs. I recommend considering: 1. Where you are 2. Where you want to go 3. How you’re going to get there When you do this for the first time, you will have raw data at the end of the first month. Then, you should consider how much improvement we want to make to each of the five KPIs. I would suggest aiming for a 5% increase to each in a three month period. The reason for this is that 5% doesn’t sound like a hard target and three months is a short period of time to really get focused on this new goal. So, how are you going to get there? Well, that’s for another day!
LEARN MORE! Setting Key Performance Indicators Friday March 1: 2pm ACE 2019
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What should I know about regulation in 2019? PROFESSOR DAVID SINES, CHAIR OF THE JCCP The aesthetic sector is rapidly embracing the principles and standards that are required to provide safe, responsive and effective procedural practice for patients and members of the public. In 2019, the JCCP will continue to campaign for the statutory regulation of the profession. The Government is becoming increasingly aware of the need to introduce greater measures to protect the public, including LEARN MORE! the need to revisit the regulatory policy landscape Regulation during 2019. The JCCP will continue to encourage all Update practitioners to join the voluntary register and to adopt Friday March 1: the published Cosmetic Practice Standards Authority and 11:30am JCCP educational competencies and practice standards, ACE 2019 as evidence of their proficiency and commitment to practise safely.
What should I know about employing and retaining staff? DR VICTORIA MANNING, AESTHETIC PRACTITIONER AND CLINIC OWNER LEARN Building your clinic team is one of the hardest MORE! things for practitioners to do. As owners and Ideal Clinic Team clinical directors, we have the passion for Saturday success and drive for our business, but your staff may not March 2: have the same enthusiasm. Remember that your front-of12:30pm house team are the first and last people your patients will ACE 2019 see; so it is so important to get right. The three things my business partner, Dr Charlotte Woodward, and I consider when employing and managing staff are: • Staff members’ personalities fit with the business image • Everyone’s ideas and opinions are considered so there is mutual respect • All the team members have the clinic ethos in mind with respect, vision and passion held by all. We want our team to feel proud that they are part of River Aesthetics. Build your team slowly and grow together as a team!
How can digital marketing enhance my practice? ADAM HAMPSON, DIGITAL MARKETING CONSULTANT Digital marketing aims to build your clinic into an industry competitor through climbing search engine ranks, brand awareness, and outreach to new clients through clever communications. A great digital marketing strategy drives fresh enquires and clients to your website and through your doors.
LEARN MORE! Digital Marketing & Websites Saturday March 2: 2:40pm ACE 2019
Want to learn more? Hear all of these experts speak and put your questions to them at the ACE 2019 Business Track! Register today for your FREE pass! www.aestheticsconference.com THE BUSINESS TRACK IS SPONSORED BY
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Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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A step-by-step approach However, when thinking about preventing or delaying the ageing process, it’s best to approach it from the inside out, according to board-certified dermatologist Dr Stefanie Williams. “Preventative ageing involves doing little things, starting with lifestyle adjustments and good skincare to slow down the skin’s ageing process before you even begin to see visible changes like lines, wrinkles and loss of elasticity,” she says. At her clinic, Dr Williams promotes a ‘step-wise’ system of preventative ageing, the cornerstone of which is adopting a healthy lifestyle: a nutritious, balanced diet, regular exercise, refraining from smoking or drinking too much alcohol, and daily use of a broad-spectrum, high-SPF sunscreen. “These are things that one should do at any age, alongside a good skincare regime, which forms the next step up,” she says. For Dr Williams, cosmeceutical skincare is essential, and this should Amid a growing trend for youngsters seeking comprise two key ingredients. “You should include a high-grade antioxidant serum – which could treatment, journalist Allie Anderson explores be a 10-15% vitamin C – in the morning straight some of the issues surrounding preventative after cleansing, and sun protection of between SPF 30 and 50. This is an extremely preventative ageing and asks: how young is too young? regime for any age,” she says. The second crucial As the adage goes, prevention is better than cure. Ageing is ingredient, she adds, is vitamin A for patients approaching their inevitable, but if one can delay it both on the inside and on the late 20s – sometimes earlier if they have sun-damaged skin. She outside, then for many it’s an option worth serious consideration. explains, “We add this in the evening, either in the form of retinol Having the odd nip and tuck to push back the hands of time was or retinaldehyde, or – in certain cases – it might be a prescriptiononce the domain of people in their 40s and older. But with increasing strength tretinoin.” pressure on young Millennials to look flawless – thanks, in part, to the Following the introduction of a topical vitamin A, the next step in Dr popularity of social media – requests for aesthetic treatments from Williams’s system is a medical-grade, results-driven facial. “This could those in their early 20s are on the rise. incorporate a mild chemical peel or transmicrodermobrasion, to In the US, the number of botulinum toxin procedures performed on help skin to regenerate itself and prevent ageing,” she says, adding, 20 to 29 year olds has increased some 28% since 2010, while it’s “The final step up would be to introduce minimally invasive, in-clinic reported that enquiries for anti-wrinkle procedures from patients aged treatments like platelet-rich plasma, medical needling, non-ablative 18 to 25 have swelled by more than 50% year on year. laser treatments and carboxytherapy – all of which are regenerative Some argue that offering treatments like injectables to patients so treatments that are great to slow down the ageing process.” young potentially raises ethical questions: quite simply, most people in their early 20s don’t need it. Step 5: minimally-invasive But, according to aesthetic nurse prescriber Melanie Recchia, if there clinic treatments is a clinical sign that the patient would benefit from a treatment, then it’s acceptable. “Some people in their 20s have a very strong frown Step 4: medical-grade facial line, for example,” she says, explaining, “A little bit of botulinum toxin there will help stop those lines from developing into deep wrinkles.” Step 3: add vitamin A to skincare regime Cosmetic dentist and aesthetic practitioner Dr Rikin Parekh explains that injectables can have a preventative mode of action. Step 2: cosmeceutical skincare, including antioxidant vitamin C “As we age, our muscle activity changes, so our muscles get stronger in some areas and weaker in other areas. We can treat these areas with botulinum toxin to limit the activity of these Step 1: lifestyle and SPF muscles, so the lines and wrinkles don’t become as prominent as they might otherwise do,” he comments. Figure 1: Step-up preventative ageing system, like the one As such, he tends to offer botulinum toxin as a preventative promoted by Dr Williams. treatment to patients who are exhibiting “very early signs of ageing” – typically from the age of around 25. “It’s then that we begin to see Youth comes from within volume changes in the face, when production of collagen and elastin At Dr Martin Kinsella’s Re-Enhance Clinic, the team offers a different is reducing, so I would consider a very light-touch treatment,” Dr option for preventative ageing, known as bioidentical hormone Parekh explains. replacement therapy. Similar to conventional HRT – common among
Preventative Ageing in Aesthetics
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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women in their 40s and 50s to minimise undesirable symptoms of menopause – bioidentical hormone treatment uses synthetic compounds that are identical in chemical structure to naturally occurring human hormones.3 “This alternative form of HRT is customised and tailored to the individual patient,” Dr Kinsella says, explaining, “We take a blood test and examine the levels of all the major hormones. That helps us to determine which hormone levels are low or out of balance, and we can restore those individual hormones back to their optimum range.” Dr Kinsella says that female patients often come to him seeking a solution for all manner of age-related physical problems like hot flushes, night sweats, ‘brain fog’, heavy or irregular periods, irritability and lethargy. Alongside those, women will often experience weight gain, reduced muscle tone and loss of libido. But, as well as leading to physical symptoms, hormonal imbalances tend to become evident in facial aesthetics. “Most of the signs of ageing we treat in the specialty are down to changes in the skin, and a great deal of that is due to changes in oestrogen,” Dr Kinsella comments, explaining, “Women age rapidly from the age of 50 onwards and start to look markedly older, and that’s because they’ve lost the oestrogen in the skin. The skin oestrogen has a huge effect on the dermal thickness, on hydration and on pigmentation, so rebalancing oestrogen is absolutely fundamental.” This is equally
“The longer you wait for wrinkles to take hold, the harder it’s going to be to manage them” Professor Bob Khanna
true, he adds, for younger patients in their 30s and 40s who wish to prevent the visible signs of ageing on their skin. As such, bioidentical hormone therapy can be used as a preventative ageing treatment, as well as a corrective one. Dr Kinsella explains that the treatment regime involves giving patients a combination of hormones based on the results of the initial blood test. The hormones are given individually so the dosage of each can be tailored to the patient’s specific hormone levels; that way, patients get exactly what they need in the dose they need. He says, “As the treatment progresses, we monitor how the patient is responding, and we can adjust the doses of the hormones accordingly. We might need to tweak the dose of progesterone, while maintaining the dose of oestrogen, for example.” Typically, the hormones will be given as a capsule, in the form of transdermal gel or cream, or sometimes by injection, depending on the patient’s requirements. The hormones that can be tested and given therapeutically are:1 • Testosterone • Oestrogen • Progesterone • HGH (human growth hormone) • Thyroid • Cortisol • DHEA (dehydroepiandrosterone)
• Melatonin • Vitamin D Treatment rounds last three months, but notwithstanding any side effects or adverse reactions – of which, Dr Kinsella has not experienced – a patient would stay on the required combination long term, as determined by six- and 12-monthly blood tests. It is worth being aware, however, that although anecdotal evidence is positive, the NHS notes that there isn’t any good evidence to support the fact that bioidentical hormones are safer than HRT or exactly how effective they are.4
Never too young…? According to cosmetic and reconstructive dental surgeon Professor Bob Khanna, there is a noticeable rise in under-25s seeking preventative ageing treatments, particularly among young women visiting his clinic with their mothers. “Quite often I have a patient I’ve been treating for a while and I’ve built a relationship with, and they come in with their daughters,” he says. “They might ask me what they should be doing to prevent visible ageing, and I’ll tell them to start with a good skincare regime.” Professor Khanna would confidently offer prophylactic botulinum toxin to patients as young as 20. “If they show early signs that they will develop hypertrophy in certain areas – such as the masseter and glabellar muscles – then I would be totally at ease using careful, small amounts of toxin to help regulate that muscle activity,” he says. As a preventative measure, botulinum toxin would be performed every four to six months – less frequently than when it’s used correctively (every three months). Other minimally-invasive treatments such as PRP and hyaluronic acid skin boosters can be given to aid neocollagenesis once every 12 weeks, Professor Khanna adds. However, some argue that when very young patients request aesthetic procedures, practitioners have a duty to recognise potential insecurities that run deep. “If young people already have insecurities about themselves and how they look, and you treat them, you’re effectively agreeing that they need the treatment and feeding those insecurities,” says Recchia. Evidence suggests that the popularity of photo-editing apps is fuelling the rise in youngsters seeking to change how they look, because they give a distorted view of beauty. Such is the growth in demand to look more like one’s filtered images that the phenomenon even has its own name – ‘Snapchat dysmorphia’.5 According to a recent Journal of the American Medical Association (JAMA) Facial Plastic Surgery study, there has been an upsurge in requests for preventative ageing in order to emulate the ‘flawless’ image projected by photo filters.6 In the UK, the most vulnerable cohort are those aged 18 to 24: the most prolific users of Snapchat.7
Keeping check on reality If a patient presents with no strong visible signs of ageing, suggests Recchia, the better option is to encourage them to consider all their options. “I would urge them to look at other treatments than injectables, such as quality skincare,” she says, adding, “As well as not being necessary, when you start having injectables it can be very difficult to stop” – which of course can have financial as well as psychological implications. “It’s important that, as practitioners, we educate our patients so they understand how the skin works and how it ages, so they can learn what to do about it early on,” emphasises Recchia. Professor Khanna, on the other hand, says early clinical intervention is important. “The longer you wait for wrinkles to take a hold, the harder
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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it’s going to become to manage them,” he comments. Whatever age one regards as old enough to embark on preventative ageing, the key is to maintain a realistic idea of what’s achievable – and that applies to patients and practitioners alike. “If you see something often enough, it starts to become normal in your perception,” says Dr Parekh. “I feel like in the aesthetics specialty too many people are over-treating, and some practitioners lose sight of what ‘normal’ is, and what is aesthetically pleasing.” And younger patients could be particularly vulnerable to this, since they may be more influenced by unrealistic and unattainable ideas of beauty perpetuated by celebrity culture and media. Experience and in-depth knowledge of the anatomy and physiology of the face helps to preclude this, comments Dr Parekh, adding that practitioners also have a duty to turn patients away if treatment is either unnecessary or inappropriate.
Future-proofing the skin The practitioners agree that they have a role in promoting the importance of preventative skincare – most crucially sun protection – to all patients, especially those at the younger end of the spectrum who might not even have considered anti-ageing treatments. According to Dr Williams, pointing out the health benefits of using sun protection can be a starting point for conversation. “Unfortunately, we still see a lot of young people sunbathing and using indoor tanning, and that – as we know – is not only a significant cause of ageing, but also increases the risk of skin cancer,” she says. “That can make a good entry for discussion about the benefits of sun protection; if you don’t want to talk about it in the context of ageing, you can talk about it in terms of protecting the skin and reducing the risk of skin cancer and other chronic damage.” Here, a thorough consultation is essential, allowing practitioners to assess what approach is most likely to strike a chord with each patient. It can also enable them to pick up on a patient’s nuances – like the way they talk and express themselves – which, in turn, can indicate how and when they are likely to begin showing visible signs of ageing, according to Professor Khanna. He says, “When you observe someone in conversation, in dynamic action, you can tell a lot about that person. People tend to wear their personalities on their face.” Thus, he explains, a person who is often stressed or angry is likely to frown a lot, which will be apparent on their face and in the pattern of lines and wrinkles that are developing. The reverse is also true, whereby a more happy-go-lucky person will typically have fewer static lines. Practitioners agree that the results of a corrective procedure are often immediate and objectively measurable. A patient in their 50s who has extensive toxin and fillers will notice a reduction in lines and wrinkles, and increase in volume, straight away. The same often can’t be said of younger patients undergoing preventative ageing, because they have fewer visible ageing signs to begin with. Professor Khanna says high-quality clinical photography at the start of a preventative ageing regime and at regular intervals thereafter can shed some light. “In terms of preventative ageing, this allows you to monitor changes in a patient’s appearance over time,” he says. “I take photographs of all my patients, so I can look back to when they started and compare to when they finish, and follow the progress of every single patient at every step of the way.”
Making a decision Regardless of what we do to our faces in the pursuit of eternal youth, there’s no doubt that making healthy lifestyle choices can help. For
Practitioners agree they have a role in promoting the importance of preventative skincare example, there is some evidence that a diet rich in fresh fish, fruit and vegetables might help prevent damage that causes premature skin ageing, and conversely, a diet high in refined carbohydrates can speed up the ageing process.8 And for that, it’s never too early. When it comes to taking things further, however, there is a worrying pattern emerging, with aesthetic procedures becoming increasingly more accessible to an ever-younger cohort. Responding to news of Superdrug launching botulinum toxin and dermal fillers in some of its stores, the British Association of Aesthetic Plastic Surgeons (BAAPS) said the availability of high-street injectables signalled a ‘reckless disregard for safety and responsibility to patients’. Even though Superdrug’s treatments are only being offered to over25s, the fact they are available at all in a retail environment that attracts teenage customers arguably runs the risk of normalising aesthetic procedures among that group. In a statement, consultant plastic surgeon and BAAPS council member, Mary O’Brien, said, “Many young and vulnerable people who associate certain high-street stores with ‘beauty products’ may be misled by unscrupulous marketing into believing that botulinum toxin injections are risk-free and just another ‘beauty product’, rather than a medical intervention.”9 As far as Dr Parekh is concerned, the specialty is duty-bound to make patients aware of the gravity of aesthetic procedures, and effective training plays a part. “Most practitioners are aware of what is ethically right and wrong,” he concludes, “And, as a training provider, it’s my position to set standards and give moral guidance to my delegates. The main emphasis, essentially, is on treating only where there is a real need. If there isn’t, we can usually assume it’s a skin concern that can be addressed with a simple skincare regime.” REFERENCES 1. Valenti, L and Atkins, C. Preventative Botox in Your 20s is Real – But it Could Be Aging You. (Vogue, August 2018) <www.vogue.com/article/preventative-botox-injections-twenty-somethings-expertguide-wrinkles-fine-lines-eyes-lips-forehead> 2. Kremer, D. How young is too young for Botox? (Harley Street Aesthetics, April 2016) <www. harleystreetaesthetics.com/blog/dr-kremers-blog/2016/04/22/how-young-is-too-young-for-botox> 3. Re-Enhance, Bio-Identical Hormone Replacement Therapy in Women (Re-Enhance Medical and Dental Clinic) <www.re-enhance.com/see-all-treatments/hormones-and-health/bio-identical-hormonereplacement-therapy-in-women/> 4. NHS Choices, Alternatives: Hormone Replacement Therapy (HRT) (UK: NHS, 2018) https://www.nhs. uk/conditions/hormone-replacement-therapy-hrt/alternatives/ 5. Tweedy, J, Cosmetic doctor reveals alarming rise in cases of ‘Snapchat dysmorphia’ as Generation Z becomes obsessed with looking like their ‘perfect’ filtered photos (Mail Online, August 2018) <www. dailymail.co.uk/femail/article-6082589/Cosmetic-doctor-reveals-alarming-rise-Snapchat-dysmorphia. html> 6. Rajanala, S et al, Selfies—Living in the Era of Filtered Photographs, JAMA Facial Plast Surg. 2018;20(6):443-444 <www.jamanetwork.com/journals/jamafacialplasticsurgery/articleabstract/2688763> 7. Statista, Share of Snapchat users in the United Kingdom (UK) in January 2018, by age group (Statista, 2018) <www.statista.com/statistics/611255/snapchat-users-in-the-united-kingdom-uk-by-age-group/> 8. American Academy of Dermatology, What causes our skin to age? (AAD, 2018) <www.aad.org/public/ skin-hair-nails/anti-aging-skin-care/causes-of-aging-skin> 9. British Association of Aesthetic Plastic Surgeons, BAAPS Statement on high street Botox injections (BAAPS, August 2918) <www.baaps.org.uk/media/press_releases/1617/baaps_statement_on_high_ street_botox_injections>
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Pain Management in Aesthetics Dr Lee Walker outlines the possible strategies for managing patient pain for aesthetic procedures Patient comfort during non-surgical treatment is of paramount importance. Pain control during procedures can lead to increased rates of acceptance and the likelihood of undergoing further treatments without the fear and anxiety associated with injections. There are a plethora of techniques using pharmacologic and nonpharmacologic methods to ensure patient comfort when providing non-surgical rejuvenation treatments. The selection of technique is based around the experience, skill and knowledge of the clinician. This article will focus on the science and common strategies available to today’s aesthetic practitioner.
Pain Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Nociception (pain) involves the ‘sensory detection of a noxious event or potentially harmful environmental stimulus’.1 Skin pain receptors (cutaneous nociceptors) activate two different types of nerve fibres: 1. A fibres: these are fast, myelinated fibres carrying impulses for sharp sensations 2. C fibres: slow, non-myelinated fibres carrying impulses for dull pain A certain number of nociceptors are needed in a confined area of skin to elicit pain. Local and topical anaesthetics work by blocking free nerve endings, thus, preventing pain transmission. This is accomplished by blocking voltage-gated sodium channels.2
Topical anaesthetics
Topical anaesthesia has diverse applicability in alleviating pain, anxiety and discomfort caused by needle insertion and local anaesthetic injection prior to anaesthesia during non-surgical procedures.3 This article will discuss the three most commonly available topical anaesthetics: 2.5% lidocaine/2.5% prilocaine cream (EMLA), 4% tetracaine gel (Ametop) and 4% liposomal lidocaine gel (LMX4).
Mechanism of action All topical anaesthetics possess the same mechanism of action once they are inside the dermis. The anaesthetic binds the voltagegated sodium channel of the free nerve endings and blocks sodium influx. The blockade of sodium influx inhibits nerve cell depolarisation and prevents propagation of nerve cell impulses along the nerve (Figure 1). Nerve fibres are categorised into three major anatomic classes: myelinated somatic nerve fibres (A fibres), myelinated preganglionic autonomic fibres (B fibres) – not activated by skin pain receptors, and non-myelinated (C fibres). Topical anaesthetics firstly block the conduction of myelinated autonomic B fibres, regulating the vascular smooth muscle. They then block the non-myelinated (slow, dull pain) C fibres and then, finally, the myelinated (fast, sharp pain) A fibres, which regulate pain and temperature.1 The efficacy of the topical anaesthetic depends on its ability to penetrate the stratum corneum. Once through this superficial skin layer, it affects the nerve endings situated within the dermis. Factors affecting penetration of topical anaesthetics:4 • Thickness of stratum corneum • Acidity of the tissue – pKa (acid dissociation constant) • Application time • Concentration of active ingredients • Type of delivery system, such as laser assisted (Erbium Yag or CO2 laser to increase cutaneous bioavailability of topical anaesthetic), iontophoresis (transdermal drug delivery using a voltage gradient on the skin), or manual • Combination anaesthetics (such as a prilocaine and lidocaine mix) or single methods to increase penetration of topical anaesthetics • Exfoliation of the skin to reduce the thickness of stratum corneum (superficial peels or microdermabrasion) • Degreasing of the skin (using alcohol) • Occlusive dressing (such as Micropore and Tegaderm)
Extracellular Side
Depolarised ++
++
Na+
--
Closed
Na+ --
++
++
TA
Open
Closed
--
--
Cytoplasmic Side Na+ = Sodium Ion TA = Topical Anaesthetic
++
Na+
++
--
A 2017 Cochrane systematic review5 of topical anaesthetics for dermal lacerations reported no serious complications among any participants treated with cocaine-based (TAC is the only solution containing tetracaine 0.5%, adrenaline 0.05%, cocaine 11.8%) or cocaine-free topical anaesthetics. One mild, self-limiting skin reaction did occur in one case after application of the cocaine-based topical anaesthetic. Nevertheless, clinicians should exhibit caution and apply topical formulations only as directed, while avoiding mucous membrane contact and following appropriate dosing regimens.5
-Membrane Depolarisation Inhibited
Figure 1: Mechanism of action of topical anaesthetics. Image adapted from Sabanko et al.1
Common types of anaesthetics EMLA Eutectic Mixture of Local Anaesthetics (EMLA) consists of two amide group local anaesthetics:
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2.5% lidocaine and 2.5% Topical anaesthetic prilocaine. In 1992 it was cost comparison the first commercially Cost-analysis of the three available topical anaesthetic topical anaesthetics using the that provided effective British National Formulary (BNF) analgesia. Analgesia is reveals variation between these achieved after 60 minutes three agents. Ametop is the of application of EMLA, most expensive, followed by with an initial blanching LMX4 and then EMLA, which is effect due to peripheral the most cost effective.6 vasoconstriction, followed by redness due to vasodilatation. It lasts for up to 60 minutes.6 Depth of anaesthesia depends on the contact time with EMLA. Anaesthetic effect has been shown to reach a maximal depth of 3mm when applied for 60 minutes, and 5mm when applied for 120 minutes.4 One study indicated that skin cooling and EMLA applications significantly decrease the pain associated with periocular botulinum toxin injections. However, when choosing between the two, patients in this study had a slight preference for EMLA cream over skin cooling.7 Even with the vasoconstrictive effect, EMLA has been shown to produce safe and effective results in pulsed dye laser treatments and to reduce laser-induced pain stimuli in Q-switched Nd:YAG laser.8 For laser treatments, Arendt-Nielsen et al. recommend that EMLA should be applied for one hour under occlusion prior to the procedure.9 An additional consideration for aesthetic practitioners is that EMLA applied under an occlusive dressing has been found to influence skin tissue thickness, which was concluded in one study of 20 volunteers.10 Ametop Ametop is 4% tetracaine in a lecithin-gel base. It is a long-acting ester anaesthetic and has been shown to provide effective analgesia within 30-45 minutes of application lasting for four to six hours.11 Transient local erythema is the most commonly reported adverse reaction.11 Topical anaesthetics with a PABA ester-type structure Ametop has been reported to cause most anaesthesia-related allergic reactions compared to other topical anaesthetics.4 Practitioners should therefore consider the possibility of increased allergic risk if using it on patients. LMX4 LMX4 is another widely used topical anaesthetic, containing 4% lidocaine in a liposomal delivery system. Liposomes facilitate the penetration of encapsulated lidocaine to the dermis (using their lipid bilayered structure to easily penetrate through the hydrophobic stratum corneum) and prevents its degradation, thus providing a sustained release.6 LMX4 commonly takes 30 minutes to effectively
work, and its recommended application is 60 minutes.6 One study indicated that LMX4 was patients’ anaesthetic agent of choice due to the rapid-acting and sustained effect of LMX4 as compared to EMLA and Ametop.8 Interestingly, one study that applied anaesthetics for 30 and 60 minutes on the intact upper lip skin of 15 volunteers suggested that LMX4 and Ametop appeared to be faster acting than EMLA.12
Local anaesthesia An essential skill for aesthetic practitioners to attain is the ability to provide safe and effective local anaesthesia (LA). Clinicians must understand the chemistry of the LA used, the anatomy involved, available techniques, devices and proper deposition of the local anaesthetics while performing infiltrations and regional nerve blocks. LA use falls into two groups: esters (benzocaine, procaine) and amides (lidocaine, articaine, bupivacaine, prilocaine, mepivacaine). A tip to remember amides and esters: amides have two ‘i’s’ and esters have one ‘i’ – for example, lidocaine has two ‘i’s in its name, while Tetracaine has one. It is commonly known that amides are used more frequently compared to esters, as amides produce a more rapid and profound anaesthetic effect.13 Esters are no longer produced in injectable form as they have an increased risk of allergic reactions.13 Table 1 shows the clinical characteristics important in selecting LA. The use of vasoconstrictors with LA within aesthetic medicine is a contentious issue. In my experience, the vasoconstrictive effect of anaesthetics containing adrenaline maybe beneficial in minimising the risk of vascular accident by reducing the size of the vessels at the injection site. However, the use of adrenaline causes ‘blanching’ of the tissue and thus, a vascular occlusion maybe missed as a result. LA containing no adrenaline has the benefit of avoiding the ‘blanching’ phenomenon, but may increase the risk of intravascular injection by dilating the vessels in the injection area. LA and its ability to obtain profound anaesthesia may also mask pain associated with intravascular injection, so the clinician must stay vigilant and use adjunctive techniques to minimise the likelihood of this serious complication. There are various techniques available to the aesthetic practitioner when anaesthetising the tissue with LA. These include:14 • Regional block anaesthesia • Infiltration anaesthesia • Tumescent anaesthesia
Regional anaesthesia (regional block) Regional anaesthesia refers to the injection of local anaesthesia near a cluster or plexus of nerves to render a certain area numb. Effective analgesia can be achieved in a target area without the need for multiple infiltration injections. The added benefit of regional anaesthesia is that there is no major Maximum tissue distortion. Commonly used regional blocks in epinephrine dose aesthetic medicine include infraorbital block and mental block. Other regional blocks which can be used include 3mg/kg the supraorbital, supratrochlear and zygomaticofacial 5mg/kg nerve blocks.14
Onset
Duration
Maximum dose
5-10 mins
200 mins
2.5mg/kg
Lidocaine
<2 mins
30-60 mins
3mg/kg
Articaine
2-3 min
180-360 min
7mg/kg
Mepivacaine
3-5 min
45-90 min
5-6mg/kg
5mg/kg
5 min
30-90 min
5mg/kg
7mg/kg
5-15 min
200 min +
3mg/kg
3mg/kg
10-20 min
40 min
7mg/kg
N/A
Agent Bupivacaine
Prilocaine Ropivacaine Procaine
Table 1: The clinical and characteristics of local anaesthetics20
7mg/kg
Infraorbital block The target of infraorbital block (Figure 2) is the second sensory branch of the of the trigeminal nerve (V2). The infraorbital nerve can be accessed via the intraoral or extraoral route. The upper lip can be anaesthetised using this technique, but must be supplemented with infiltration
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Infraorbital foramen
Figure 2: Position of infraorbital nerve and area of anaesthesia
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anaesthesia was described for use in liposuction and is a procedure that employs the usage of infiltration into the subcutis with lidocaine (0.05-0.1%) combined with sodium bicarbonate (generally 10 mEq/L) and epinephrine (generally 0.65-1 mg/L). A maximum dose of lidocaine 35mg/kg has been established, recommended and stated in the literature, although doses of 55 mg/kg have been reported to be safe.17 The addition or substitution with anaesthetics such as prilocaine or bupivacaine is not currently supported.2 Epinephrine is part of the tumescent formula as it lowers maximum lidocaine levels and delays absorption, confers haemostasis, and can sustain the effects of anaesthesia. Sodium bicarbonate is added to neutralise the acidic lidocaine.17 Strategies to reduce pain of injections with LA
Mental foramen
Figure 3: Position of mental nerve and area of anaesthesia
over the midline due to the presence of the nasopalatine nerve which supplies the central incisor area. This technique can also be used for the mid-cheek, side of the nose and the lower eyelid.14 Mental block The target of mental block (Figure 3) is the third sensory branch of the trigeminal nerve (V3). Once again, the nerve can be accessed via the intraoral and extraoral routes. The lower lip and chin can be anaesthetised with this technique without the need for a midline infiltration injection.14 Infiltration anaesthesia This type of anaesthesia is commonly used in aesthetic medicine, dentistry and dermatology. The technique involves serial puncture with deposits of local anaesthesia (0.2ml per deposit) intradermally or into the subcutaneous tissue. I believe that infiltration anaesthesia is an easier skill to acquire but its disadvantage is that there are increased injections and distortion of the tissue architecture. Figure 4 shows a typical pattern of infiltration anaesthesia for upper and lower lip augmentation.15 Tumescent anaesthesia Tumescent anaesthesia can be used when treating large areas of the face. It can be particularly useful when using fully ablative or deep fractional laser treatments. Traditionally, tumescent
Figure 4: Typical infiltration injections for upper and lower lip augmentation.16
Warm the anaesthetic prior to use Warming can be achieved from an anaesthetic warming device, by keeping at room temperature instead of a refrigerator, or even by warming between one’s hands. There are two popular postulated mechanisms of action for warming injection solution. The first is that cold temperatures stimulate more nociceptor fibres. The second is that as the temperature increases, local anaesthetic molecules diffuse faster across cell membranes, producing a quicker time of onset.2 Use the smallest gauge needle possible and change often Using separate needles for drawing up and injecting significantly reduced pain intensity of needle insertion, according to one study.2 This is because a sharper needle reduces the force required to puncture the skin, activating fewer nerve fibres. This reduces temporal stimulation of afferent nociceptor fibres and thus minimises pain.2 Insert the needle perpendicular to the skin By getting the needle perpendicular to the skin so that it penetrates the skin at 90 degrees (instead of 45 degrees), the needle passes through fewer pain fibres (Figure 5). A level II evidence study of 65 subjects receiving two injections standardised to rate, volume, temperature and pH found a statistically significant difference in pain reduction with 90 degree versus 45 degree needle insertions.2 Inject LA subdermally rather than intradermally Injecting subdermally is less painful than injecting intradermally. The nerves are knocked out at their source at the trunk and branch level, rather than in the leaves of the neural tree.2 Inject very slowly It is reported that pain is greater with rapid injections.2 The pain of infiltration is from activated skin nociceptors responding to rapid distention and stretching of the tissue. Slowing injection rates facilitates ‘accommodation’ of nerve endings and provides time for the anaesthetic to diffuse and block the nerve transduction of the stimulated fibres.2
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Other pharmacological methods to reduce pain of injection Preserved bacteriostatic saline Benzyl alcohol, a preservative in bacteriostatic saline can help reduce pain on injection with botulinum toxin. It is an ester unrelated to PABA, making it a viable substitute for those allergic to LA. The effect of benzyl alcohol lasts between two to three minutes. It is less painful on injection than bacteriostatic saline mixed with other anaesthetics.17 Vapocoolants For a large variety of procedures, vapocoolants (non-pharmaceutical topical anaesthetics) are effective at anaesthetising an area to give fast and affordable pain management. The most commonly used coolant is ethyl chloride. A recent study of 30 patients by Zeiderman et al.18 indicated that vapocoolant spray at the time of cosmetic facial injections leads to a 59% decrease in perceived pain score with neurotoxin injections and 64% decrease in perceived pain score with filler injections.17
Non-pharmacological strategies in managing injection pain Ice Ice is a quick-acting, non-invasive method of non-pharmacological topical anaesthesia that may provide vasoconstriction. It has been suggested that a temperature of 10°C may be ideal for anaesthetic effect.17 A 10-second ice contact time results in cooling to 11.4°C to 18.0°C up to five seconds post contact. Ice wrapped in aluminium foil has been found to be similar to that of ice wrapped in latex for contact times less than 20 seconds, but it is more effective at cooling at times longer than 20 seconds.17 The skin must be disinfected after every application of ice prior to injection.17 Vibration Vibration is achieved via a hand-held electronic device. The device acts on the large A fibres which sense vibration and blocks pain signals to the skin. Vibration competitively inhibits A-delta (fast) and C nerve fibres (slow), that work on pain transduction. In 2011 Sharma et al.19 reported that patients had less injection pain on the vibrationtreated half of the face as compared to the control side when administering botulinum toxin injections. Overall, 86% of patients
One study indicated that LMX4 was patients’ anaesthetic agent of choice due to the rapid-acting and sustained effect
preferred to receive vibration with their next botulinum toxin treatment. Five of 50 patients experienced transient side effects perceived to be associated with vibration, including tingling teeth, increased bruising, and headaches.17 Distraction Tactile distraction in the area of needle insertion can also be used to reduce pain. Fast myelinated fibres can effectively ‘close the pain gate’ if a new stimulus such as pressure or touch is perceived near the pain source. Other forms of stimulation, such as pinching, stretching, pressing, or tapping near needle insertion sites have also be described to reduce perceived pain.2
Conclusion Pain management in aesthetic medicine is critical to a positive patient experience. Patients should be informed of the types of anaesthesia available prior to treatment. Providing pain-free treatment will ensure patients return for subsequent treatments and can reduce anxiety associated with injection. Dr Lee Walker is an aesthetic dental surgeon and clinical lead at multi-award winning BCity clinics in Liverpool with more than 16 years’ experience in the field of medical aesthetics. He is the founder and lead speaker for the Northern Aesthetic Practitioner Group, is a member on the expert panel for the Aesthetic Complications Expert Group (ACE) and is a Teoxane country expert and international speaker. REFERENCES 1. Sobanko JF, Miller CJ, Alster TS. Topical anesthetics for dermatologic procedures: a review. Dermatol Surg 2012;38:709–21 2. Strazar A, Leynes P, Lalonde D. Minimizing the Pain of Local Anesthesia Injection. Plast Reconstr. Surg. 132: 675, 2013. 3. You P, Yuan R. Design and evaluation of lidocaine- and prilocaine-coloaded nanoparticulate drug delivery systems for topical anesthetic analgesic therapy: a comparison between solid lipid nanoparticles and nanostructured lipid carriers. Drug Design, Development and Therapy 2017:11 2743–2752 4. Kumar M, Chawla R, Goyal M. Topical anesthesia. Journal of Anaesthesiology, Clinical Pharmacology. 2015;31(4):450-456. 5. Tayeb BO, Eidelman A, Eidelman CL, McNicol ED, Carr DB. Topical anaesthetics for pain control during repair of dermal laceration. Cochrane Database of Systematic Reviews 2017, Issue 2. 6. Chiang Y, Al-Niami F. Comparative Efficacy and Patient Preference of Topical Anaesthetics in Dermatological Laser Treatments and Skin Microneedling. J Cutan Aesthet Surg. 2015 Jul-Sep; 8(3): 143–146 7. Elibol O, Ozkan B, Hekimhan PK, Cağlar Y. Efficacy of skin cooling and EMLA cream application for pain relief of periocular botulinum toxin injection. Ophthalmic Plast Reconstr Surg. 2007 Mar-Apr;23(2):130-3. 8. Friedman PM, Mafong EA, Friedman ES, Geronemus RG. Topical anesthetics update: EMLA and beyond Dermatol Surg. 2001 Dec; 27(12):1019-26. 9. Arendt-Nielsen L, Bjerring P. Laser-induced pain for evaluation of local analgesia: a comparison of topical application (EMLA) and local injection (lidocaine). Anesth Analg. 1988 Feb; 67(2):115-23. 10. Tahir A, Webb JB, Allen G, Nancarrow JD.The effect of local anaesthetic cream (EMLA) applied with an occlusive dressing on skin thickness. Does it matter? J Plast Reconstr Aesthet Surg. 2006;59(4):404-8 11. Chiang Y, Al-Niami F. Comparative Efficacy and Patient Preference of Topical Anaesthetics in Dermatological Laser Treatments and Skin Microneedling. J Cutan Aesthet Surg. 2015 Jul-Sep; 8(3): 143–146 12. Fraczek M, Demidas A. Acta Assesssment of the efficacy of topical anesthetics using the tactile spatial resolution method. Acta Dermatovenerol Croat. 2012;20:7–13 13. Jung R, Local anesthetics and advances in their administration – an overview. JPCCR 2017;11(1):94–101 14. Chrystelle Sola, Christophe Dadure, Olivier Choquet, and Xavier Capdevila, Nerve Blocks of the Face, NYSORA, Based on Hadzic’s Textbook of RAPM 2nd Ed 2017<https://www.nysora.com/nerve-blocksface> 15. Dhepe V. ‘Local Anesthesia for Cosmetic Procedures’, Niteen Dermatosurgery Taskforce, IADVL, SkinCity, Post Graduate Institute of Dermatology and Lasers, Solapur, Maharashtra India, <http://cdn. intechopen.com/pdfs/33810/InTech-Local_anesthesia_for_cosmetic_procedures.pdf> 16. Pocket Dentistry, Anesthesia Considerations for Cosmetic Facial Surgery, 2015. <https://pocketdentistry. com/4-anesthesia-considerations-for-cosmetic-facial-surgery/> 17. Park K, Sharon V. A Review of Local Anesthetics: Minimizing Risk and Side Effects in Cutaneous Surgery. Dermatol Surg 2017;43:173–187 18. Zeiderman MR, Kelishadi SS, Tutela JP, et al. Vapocoolant Anesthesia for Cosmetic Facial Rejuvenation Injections: A Randomized, Prospective, Split-Face Trial. Eplasty. 2018;18:e6. 19. Sharma P1, Czyz CN, Wulc AE. Investigating the efficacy of vibration anesthesia to reduce pain from cosmetic botulinum toxin injections. Aesthet Surg J. 2011 Nov;31(8):966-71. 20. Benko K: Clinical Characteristics of Local Anaesthetics – Fixing Faces Painlessly: Facial Anaesthesia in Emergency Medicine’, in: EB Medicine, Vol. 11, No. 12,Dec 2009
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Skin Through the Seasons Dr Shirin Lakhani provides an introduction to how the skin adjusts with the seasons and ways to prepare patients for treatments The skin is the largest organ of the body and provides us with overall protection from the environment. It is becoming widely accepted by both practitioners and patients that our environment influences our skin, and therefore a change in our environment, such as a change in season, require us to adjust our skincare routines to maintain skin health. Additionally, as most aesthetic practitioners will be aware, many skin diseases, such as eczema, psoriasis, acne, rosacea and melasma, show seasonal variability, so it is important to factor in the changes in the weather when planning skin treatments in clinic.
Understanding structure and function of skin The skin is composed of two main layers: the epidermis, and the dermis. The epidermis, the uppermost layer, is made of closely packed epithelial cells.1 The dermis is made up of connective tissue and contains blood vessels, hair follicles and sweat glands. Beneath the dermis lies the subcutaneous layer, also known as the hypodermis, which is composed mainly of loose connective tissue and adipose tissue.1 The epidermis forms a barrier to the world; keeping out water, bacteria, toxins, ultraviolet light and allergens. The keratinocytes are the major cell type in the epidermis and, at the uppermost layer, form the stratum corneum. The epidermis also contains melanocytes, which synthesise melanin in response to ultraviolet radiation (UVR) as well as hormonal and inflammatory stimulation.1 The dermis is a thick layer of fibrous and elastic tissue (made mostly of collagen, with a small but important component of elastin) that gives the skin its flexibility and strength. The dermis contains nerve endings, sweat glands and sebaceous glands, hair follicles, and blood vessels. It is divided into the papillary dermis and the reticular dermis.1
Skin changes with seasons A recent study published in the British Journal of Dermatology (BJD) indicates that the barrier function of skin alters between summer and winter. The study highlighted changes that occur in the skin at a cellular level through assessing 80 subjectsâ&#x20AC;&#x2122; cheek and hand skin in both summer and winter, whilst additionally analysing the natural moisturising factors (NMF) and skin texture. The study suggested that there were seasonal effects on NMF in the hands and cheeks as well as an increase in the breakdown of filaggrin, a protein which maintains the barrier function, and also changes in the texture of corneocytes.3 It is well-known that sebum production increases in the hotter summer months, and pigmentary changes are also more prevalent during the summer.4 As well as this, transepidermal water loss Epidermal Layers Stratum corneum (horny cell layer) Epidermis
Dermis
Stratum lucidum Stratum granulosum (granular cell layer) Stratum spinousum (squamous cell layer)
Hypodermis
Figure 1: Structure of the human skin and the outermost layer, the epidermis
Stratum basal (basal cell layer)
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(TEWL) is significantly lower in the summer, resulting in increased hydration levels, and many of the lipids present in the stratum corneum are higher in the summer than the winter.5-7 So, what is it about the seasons that causes such variations in the way our skin behaves and what can we do to minimise the damage?
Warm weather We all know the harmful effects of UV radiation from the sun on our skin, but there is also the benefit of vitamin D production. Vitamin D is synthesised in our bodies from cholesterol when the skin is directly exposed to UVB radiation.8 In the UK, there is not enough UVB radiation in the winter months for our bodies to be able to synthesise this essential pro-hormone, but there is during the spring and summer from March to September. However, in order to do this, the NHS recommends exposing uncovered skin (with no SPF) to sunlight for short periods of time between 11am and 3pm.9 In my experience, most people can safely expose their limbs to sunlight during these hours for periods of 20-30 minutes; however, as an antiageing practitioner, I would recommend protecting the face with SPF at all times. The relationship between skin and Vitamin D is not limited to its synthesis. Vitamin D plays a vital role in the function of skin, being involved in cell differentiation and proliferation, cutaneous immune function and sebaceous gland and hair follicle function. Additionally, Vitamin D deficiency has been linked with a plethora of skin disease such as psoriasis, acne and skin cancers.8,10 Pigmentary changes are exacerbated in hot sunny weather,11 and patients undergoing procedures such as chemical peels, laser or plasma treatments, are more at risk of post-inflammatory hyperpigmentation (PIH). Melasma also worsens during the summer months, as both UVR and heat stimulate melanocytes and it is important to make patients aware of this.12 I advise patients with melasma to avoid direct sunlight, and to wear a high factor SPF. Where practical, it is best for them to avoid being out during the hottest part of the day. Despite their best efforts though, the majority of patients will have some deterioration in their melasma in the hotter months. A high temperature can make oil glands secrete more sebum, which mixes with sweat and leaves skin uncomfortable with a shiny appearance.6,7 If a patient has acne, it may get worse as a result of the increase in sebum production. Extreme heat and humidity can increase fungal infections such as impetigo
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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and athlete’s foot.13,14 Rosacea also tends to be exacerbated, due to UV radiation being an important trigger.12 Another factor to bear in mind is that certain medications increase photosensitivity15 and there is usually an increase of patients presenting with skin rashes during the warmer months as a result of their medications. Skin conditions that show improvement in the summer months include eczema and psoriasis. Acne can either be worse, due to an increase in sebum production, or it can also improve as there is less dead skin to clog up pores.5,7,16
conditioned skin is less likely to experience complications. Therefore, as the cooler autumn months approach, you can start to prepare your patient’s skin for more-aggressive procedures like peels, lasers and plasma by using a regime of retinol and pigment inhibitors. It is also important not to forget the effects of the sun on the skin in winter. I always tell my patients, if you can see without the lights on, you need SPF, even when indoors.
Summary Treatment in warmer months In the summer, I tend to avoid aggressive regimes for patients who have not used strong retinol products before, unless they are extremely committed and are going to be compliant with staying out of the sun and fastidiously using SPF. I regularly advise a good oil control cleanser, as this removes the excess sebum produced, a lightweight serum packed with antioxidants that mop up free radicals produced by exposure to UV radiation and a good quality SPF, which is essential for all patients. For oily, acne-prone patients who may suffer more in the warmer months, I also recommend an exfoliator (my favourite one combines physical and chemical exfoliation) and a salicylic acid product. This may already be present in the cleanser or exfoliator, but often I add additional products to further break down excess sebum. In terms of procedures, unless you have a committed patient who understands the risks, it is best to avoid anything that makes the skin prone to PIH. This includes aggressive peels, plasma device treatment and laser treatments. A popular peel during the warmer months is a mandelic acid peel, which is a less aggressive alpha hydroxy acid peel, giving the benefits of chemical exfoliation without the associated downtime or complications.17 In my experience, it is particularly beneficial in rosacea sufferers, as it is less irritating than other alphahydroxy acids, and also has antimicrobial properties.
Cooler months As previously discussed, humidity can affect the texture of the skin and impact on skin disorders like eczema, but it is worth noting that humidity fluctuates according to the season. In the winter, rapidly changing temperatures, from heated indoor to cold outdoor environments can affect the capillaries, causing them to rapidly expand and contract, leading to redness and telangiectasia, and prolonged exposure to wet weather can strip the skin’s barrier function.18 Cold air increases TEWL and harsh winds strip the skin of its natural lipids, which are essential for maintaining skin barrier function.18 Add to this the effects of central heating and rapidly changing temperatures when coming inside from outside, and it’s no wonder skin becomes dry. Patients with normal skin can experience dryness in the winter months, but for those who suffer with dry skin conditions anyway, the winter months can be difficult. Treatment in cooler months The cooler months are the time to step up skin hydration and use products which upregulate the skin’s natural moisture production, whilst supporting the epidermis and repairing barrier function. Products containing ceramides and hyaluronic acid are great for boosting hydration, while products containing ingredients such as colloidal oatmeal can aid compromised, dry, irritated, itchy skin.19,20 Winter is a great time to reverse some of the damage caused during the summer too. Lower temperatures and less intense UV radiation reduce the risk of complications from procedures so this is the time for more aggressive approaches. Remember that preparation for these procedures is paramount; it is well recognised that properly-
Temperature, humidity and UV radiation all change with the seasons. As our largest and outermost organ, the skin is affected by these changes. However, with an understanding of the physiology of skin, we can prepare for the variability in weather and minimise skin disease that may worsen depending on the season. It is essential not to wait for the signs of disease to occur before beginning treatment, and I would say that preparation for the summer and winter should ideally occur in spring and autumn, respectively. Dr Shirin Lakhani has a background in medicine having trained in the NHS and various hospital sub-specialities, including anaesthetics where she developed her skills in injection techniques. Dr Lakhani then went on to complete her training in general practice. She is now the medical director of Elite Aesthetics in Kent and is passionate about skin. REFERENCES 1. Obagi Z. The Art of Skin Health Restoration and Rejuvenaton. 2nd Edition 2. Mitotic activity of keratinocytes in regeneration and tissue homestasis - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/Structure-of-the-human-skin-A-Thesubcutaneous-layer-the-dermis-and-the-epidermis_fig1_286092505 3. K.A. Engebretsen et al, Changes in filaggrin degradation products and corneocyte surface texture by season, British Journal of Dermatology (2018). 4. Jablonski N and Chaplin G, Royal Society of Publishing, Human skin pigmentation, migration and disease susceptibility, 2012 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3267121/> 5. Wei KS, Stella C, Wehmeyer KR, Christman J, Altemeier A, Spruell R, Wimalasena RL, Fadayel GM, Reilman RA, Motlagh S, Stoffolano PJ, Benzing K, Wickett RR. Effects of season stratum corneum barrier function and skin biomarkers. J Cosmet Sci. 2016 May-Jun;67(3):185-203. 6. De Paepe K, Houben E, Adam R, Hachem J, -P, Roseeuw D, Rogiers V, Seasonal Effects on the Nasolabial Skin Condition. Skin Pharmacol Physiol 2009;22:8-14 7. Youn, Sang Woong & Im Na, Jung & Young Choi, Sun & Huh, Chang-Hun & Chan Park, Kyoung. (2005). Regional and seasonal variations in facial sebum secretions: A proposal for the definition of combination skin type. Skin research and technology: official journal of International Society for Bioengineering and the Skin (ISBS) [and] International Society for Digital Imaging of Skin (ISDIS) [and] International Society for Skin Imaging (ISSI). 11. 189-95. 10.1111/j.1600-0846.2005.00119.x. 8. Dermato-Endocrinolgy, Sunlight and Vitamin D, 2013 <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3897598/> 9. NHS, How to vitamin D from sunlight, 2018 <https://www.nhs.uk/live-well/healthy-body/how-to-getvitamin-d-from-sunlight/> 10. Zafra J, Aesthetics journal, The impact of sun on skin, 2018 <https://aestheticsjournal.com/feature/ the-impact-of-sun-on-skin> 11. Meyer K, Pappas A et al, Journal of Drugs in Dermatology, Evaluation of Seasonal Changes in Facial Skin With and Without Acne, 2015 <https://www.ncbi.nlm.nih.gov/pubmed/26091385> 12. Barbara M. Rainer, Sewon Kang & Anna L. Chien, Dermato-Endocrinology, Rosacea: Epidemiology, pathogenesis, and treatment, 2017 13. Hay RJ, Moore MK. Mycology, in Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook of Dermatology, 7th edition, Oxford, UK, Blackwell Science Ltd 2004: 31.23. 14. Jha AK1, Gurung D, Nepal Medical College journal, 2006 Dec;8(4):266-8, Seasonal variation of skin diseases in Nepal: a hospital based annual study of out-patient visits. 15. Medscape, Drug-Induced Sensitivity, 2018 <https://emedicine.medscape.com/article/1049648overview> 16. Pascoe, Vanessa Lindsay et al, Journal of the American Academy of Dermatology , Volume 73 , Issue 3 , 523 – 525, Seasonal variation of acne and psoriasis: A 3-year study using the Physician Global Assessment severity scale 17. Handel, A. C., Miot, L. D. B., & Miot, H. A. (2014). Melasma: a clinical and epidemiological review . Anais Brasileiros de Dermatologia, 89(5), 771–782. 18. Mostafa WZ, Hegazy RA, Journal of Advanced Research, Vitamin D and the skin: Focus on a complex relationship: A review., 2015;6(6):793-804 19. Jartarkar SR, Gangadhar B, Mallikarjun M, Manjunath P, Clin Dermatol Rev, A randomized, single-blind, active controlled study to compare the efficacy of salicylic acid and mandelic acid chemical peel in the treatment of mild to moderately severe acne vulgaris, 2017;1:15-8 20. Del Rosso J, Zeichner J et al, Journal of Clinical and Aesthetic Dermatology, 2016, Understanding the Epidermal Barrier in Healthy and Compromised Skin: Clinically Relevant Information for the Dermatology Practitioner <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5608132/>
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Case Study Consultation A 69-year-old female patient presented with concerns about the overall look and feel of her facial skin, with a particular concern about the wrinkles and laxity of the skin around her eyes. She was happy to explore injectable and laser options, however, she could not afford much downtime as she had a birthday party approximately four weeks after the initial consultation and wanted to see some treatment results by this time. The patient is in good health, does not smoke and was not on any medication. She presented with a flattening of her cheeks with a festoon at the cheek and eye junction. The patient disclosed that she experiences puffiness and often redness around the eye, as well as all over uneven tone and dullness of her facial skin. She had fine lines and wrinkles around the eyes, cheeks and lower face. Her forehead did not present as a problem as she had previously had botulinum toxin in this area, however she had noticed some flaccid skin on the upper bridge of her nose. We discussed her concerns and possible treatment Registered nurse and clinic owner Jane Lewis options in detail, as well as what she could realistically expect to achieve in a short time frame. The patient was explores non-surgical treatment options for reasonable and understood that with her short-term eye rejuvenation and presents a case study restrictions we would not treat all concerns before the showcasing the results event. Therefore we devised a six-month treatment plan for her to consider, which included the Fraxel Dual laser3 Eye rejuvenation is something that is frequently asked about by and Thermage1 monopolar radiofrequency skin tightening (which our patients, whether its reducing dark circles or fine lines and would also address the concern on the upper bridge of her nose) and wrinkles, the ageing eye is a common concern for many people; dermal filler cheek augmentation.5 both men and women. The eyes are often an area that can show Together we decided that with her requirement of no downtime signs of ageing as the skin is typically thinner, more delicate and and the initial short time frame before her event, we would start her susceptible to structural changes around it, such as flattening of the treatment plan with an intense course of four treatments using the mid-face fat pad, which can have an impact on its appearance. Byonik pulse-triggered laser, with a further four treatments undertaken There are many modalities which we can use to improve various weekly thereafter and monthly maintenance treatments throughout aspects of skin ageing, such as monopolar radiofrequency to tighten her six-month plan. I wanted the patient to undergo the first four lax skin,1 fillers2 or topicals for tear trough correction and 1550 treatments as close together as possible within a two week time nm wavelength fractional laser for the improvement of fine lines frame, with the intention of quickly achieving some results prior to her and wrinkles. With treatments such as these, patients often have event, before hopefully seeing further improvement following another concerns regarding downtime and there may also be a delay in some treatments if they present with poor quality skin. Many of our patients want subtle improvements and wish to â&#x20AC;&#x2DC;age gracefullyâ&#x20AC;&#x2122; but convenience is a huge factor for many of them and I have found that they do not want to be inconvenienced by obvious downtime following treatment. Sometimes when patients agree to go ahead with these treatments, we find that their skin is not ready for laser. By this I mean, their skin could be lacking in hydration and moisture and/or a barrier impairment, possibly with visible dryness and inflammation. Due to these factors, we must postpone treatment whilst they use a personalised at-home skincare regime (recommended by us) to improve the quality of their skin and, thus, improve their treatment results, while reducing the potential of side effects and the length of downtime. In the case study I present below, I use a pulse-triggered laser called the Byonik, which combines two wavelengths of 658 nm and 806 nm.4 I discuss how to create improvement in the quality of the skin with laser rejuvenation, while also discussing the reasons why I have chosen this particular treatment.
Case Study: Eye Rejuvenation Using Pulse-Triggered Laser
I believe that many people would benefit from the treatment, however, as with all treatments it is important to manage patient expectations
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Before
Before
After
After
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Immediately after the second round of laser the Byonik HA-Gel Max, which has a concentration of 39% HA and contains the antioxidants, was applied to her skin; this was immediately followed by the final five minutes of laser light, totalling three sessions in one treatment. Manufacturers guidelines were followed post-laser exposure as to which Byonik products were used.
The second treatment was performed four days later and the same protocols were followed as in the first treatment, however extra time was also spent on the glabella; approximately an additional 30 seconds of laser exposure. The third treatment was performed five days later, and the protocol Figure 1: A 69-year old female patient before and 11 days after her initial treatment. This photo was taken immediately after her fourth treatment. Results are expected to continue to improve. and areas of focus were the same as the second treatment, however the patient was stepped up four treatments. We decided we would treat the entire face but would to the HA-Gel Superior in the second round of gel application; the HAfocus primarily on the eye area and glabella to begin with. Gel Superior contains 51% HA and the same antioxidants as the Max I decided that we would treat the patient approximately twice a week gel. Her fourth treatment was a repeat of the third treatment in both during the initial course. With the combination of near-infrared light, the areas focused on and the gels used were the same. After each red light, transmembrane diffusion reflection and the nanoscience treatment the patient was reminded to hydrate by drinking a minimum technology of the Byonik device, we can impregnate the treated of two litres of water throughout the day. We also recommend using a cells of the patient with antioxidants transported by dehydrated good barrier cream or moisturiser to prevent as much water loss from hyaluronic acid.6-12 This then causes a bio-lifting of the skin, lengthens the skin as possible, after deeply hydrating it during the treatment. the telomere of the skin cell (a compound structure at the end of a chromosome) thus delaying the ageing of the cells, reducing Results inflammation, detoxifying the tissue, and improving the tone and The most notable results after the treatment were that the patient’s hydration of her skin without downtime for the patient.13-20 skin tone had become more uniform, there was improvement in the The aim of this course was to quickly improve the quality and depth of her periorbital wrinkles and there was a tightening of the hydration of her skin, for both the purpose of her event and to get her skin on the upper lids. The skin that had become loose over the skin laser-ready prior to her planned treatments, whilst improving her bridge of her nose had retracted away from the inner canthus of the wrinkles and skin laxity. eyes, and the patient commented that this area had improved and become less ‘heavy’. The procedure The full face treatment takes approximately 50 minutes, during which Considerations we perform two cleanses and a light enzyme exfoliation prior to the I believe that many people would benefit from the treatment, laser being used, in order to ensure the skin is thoroughly cleansed however, as with all treatments it is important to manage patient of debris and dead skin cells. As the patient is a skin type II on the expectations. First of all, it is important to match the patient to the Fitzpatrick scale we used the laser light for five minutes per round, recommended number of treatments during their consultation. As as recommended by the manufacturer. During those five minutes a guideline, from my experience, I’d say that around the first two more time was spent on the eye area during each round of laser, treatments the average patient will experience an improvement approximately a minute per eye. in fine lines, softer feeling skin and skin hydration; post three to Following the first round of laser exposure, the Byonik HA-Gel Plus, five treatments, they should see an improvement in moderate which has a 29% concentration of HA, was applied to the skin; this wrinkles and skin is further hydrated, with the HA beginning to be was followed by the second session of laser lasting five minutes. retained in the skin; post six to eight treatments there should be an improvement in moderate wrinkles, skin will have more volume and is firmer, tone is more even and skin is deeply hydrated with water being retained. Discussing this with patients highlights the importance of patients committing to a course of treatment to achieve ultimate results, rather than expecting too much from a single treatment. For the treatment, I would avoid treating those with epilepsy and photodermatitis due to the patient being subjected to laser light; as well as any cancer and tumours as we are increasing the activity of the lymphatic system.21 Pregnant patients would also be excluded. Limited use would occur if a patient has ingested substances such as photosensitising drugs that leads to light sensitivity, hyperthyroidism or those with a cardiac pacemaker.
Many of our patients want subtle improvements and wish to ‘age gracefully’ but convenience is a huge factor for many of them
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
Conclusion Eye rejuvenation is a treatment request that many practitioners will receive and with the use of multiple modalities that are available, I believe it is possible to get the desired results with minimum downtime. The case presented in this article showcases that the use of the pulse-triggered laser protocol is an effective treatment for natural-looking eye rejuvenation and can be used alongside other treatment modalities to significantly improve signs of ageing, skin health and quality. Jane Lewis is the founder of multi-award-winning The Skin to Love Clinic in St. Albans, Hertfordshire. Lewis started her nursing career in 1979 and was the development director for a large national chain of cosmetic clinics for fifteen years, as well as the director of clinical training for an international medical device company, training medical professionals globally. REFERENCES 1. Sukal SA1, Geronemus RG. Thermage: the nonablative radiofrequency for rejuvenation. Laser and Skin Surgery Centre of New York. New York, USA. 2008. 2. Berguiga M, Galatoire O. Tear trough rejuvenation: A safety evaluation of the treatment by a semi-cross-linked hyaluronic acid filler. Department of Oculoplastic Surgery, Fondation Rothschild , Paris. 2017 3. Narurkar VA, Alster TS, Bernstein EF, Lin TJ, Loncaric A. Safety and Efficacy of a 1550nm/1927nm Dual Wavelength Laser for the Treatment of Photodamaged Skin. Journal of Drugs in Dermatology. 2018 ;17(1):41-46. 4. Byonik Science <https://www.byonik.net/en/byonik-treatment/byonik-science/> 5. Eun Jung Ko, Hyuk Kim, Won-Seok Park & Beom Joon Kim. Correction of midface volume deficiency using hyaluronic acid filler and intradermal radiofrequency. Journal of Cosmetic and Laser Therapy, 17:1, 46-48. 2015 6. Fujiwara TK, et al. Confined diffusion of transmembrane proteins and lipids induced by the same actin meshwork lining the plasma membrane. Mol Biol Cell. 2016 7. Moreira H, Slezak A, Oszminanski J, Gasiorowski K. Antioxidant and cancer chemopreventive activities of Cistus and Pomegranate polyphenols. Acta poloniae pharmaceutica. Poland. 2017. 8. Shin S, Lee JA, Son D, Park D, Jung E. Anti-Skin-Ageing Activity of a Standardized Extract from Panax ginseng Leaves in Vitro and In Human Volunteer. Biospectrum Life Science Institute. Korea. 2018 9. Yang, JH. Topical application of fucoidan improves atopic dermatitis symptoms in NC/Nga mice. Catholic University of Daegu. Republic of Korea. 2012. 10. Hyun YJ, Piao MJ, Ko MH, Lee NH, Kand HK, Yoo ES, Koh YS, Hyun JW. Photoprotective effect of Undaria crenata against ultraviolet B-induced damage to keratinocytes. Jeju National Universty. Republic of Korea. 2013. 11. Kim MJ, Kim, DS, Yoon HS, Lee WJ, Lee NH, Hyun CG. Melanogenesis inhibitory activity of Korean Undaria pinnatifida in mouse B16 melanoma cells. Interdisciplinary Toxicology. 2014 Jun;7(2):89-92 12. Katsube T, Yamasaki Y, Iwamoto M, Oka S. Hyaluronaidase-Inhibiting Polysaccharide Isolated and Purified from Hot Water Extract of Sporophyll of Undaria pinnatifida. Food Sci. Technol. Res., 9 (1) 25-29, 2003. 13. Wickens JM, Alsaab HO, Kesharwani P, et al. Recent advances in hyaluronic acid-decorated nanocarriers for targeted cancer therapy. Drug Discov Today. 2016 14. Mezghani Sana, Hammami Amira, Amri Mohamed. Low-level laser therapy: effects on human face aged skin and cell viability of hela cells exposed to uv radiation. Laboratory of Functional Neurophysiology and Pathology, University Tunis Ela Mana, Tunisia. 2015 15. Andrei P. Sommer, Dan Zhu, Adam R. Mester & Horst-Dieter Forsterling . Pulsed Laser Light Forces Cancer Cells to Absorb Anticancer Drugs-The Role of Water in Nanomedicine, Artificial Cells, Blood Substitutes, and Biotechnology. University of Ulm, Germany. 2011 16. Barolet D, Christiaens F, Hamblin MR. Infrared and skin: friend or foe. J Photochem Photobiol B. 2016 17. da Rosa AS, dos Santos AF, da Silva MM, Gonsalves Facco G, Martins Perreira D, Araruna Alves A.C, Cesar Pinto Leal Junior E, Camillo de Carvalho PdT. Effects of Low Level Laser Therapy at Wavelengths of 660 and 808nm in Experimental Model of Oesteoarthritis. Photochemistry and Photobiology, USA. 2011. 18. Kujawa, Jolanta & Zavodnik, Ilyai & Lapshina, Alena & Labieniec-Watala, Magdalena & Bryszewska, Maria. Cell Survival, DNA, and Protein Damage in B14 Cells under Low-Intensity Near-Infrared (810 nm) Laser Irradiation. Photomedicine and laser surgery. 2005 19. Kim MJ, Kim, DS, Yoon HS, Lee WJ, Lee NH, Hyun CG. Melanogenesis inhibitory activity of Korean Undaria pinnatifida in mouse B16 melanoma cells. Interdisciplinary Toxicology. 2014 Jun;7(2):89-92 20. Katsube T, Yamasaki Y, Iwamoto M, Oka S. Hyaluronaidase-Inhibiting Polysaccharide Isolated and Purified from Hot Water Extract of Sporophyll of Undaria pinnatifida. Food Sci. Technol. Res., 9 (1) 25-29, 2003. 21. Data on file obtained by The Skin To Love Clinic.
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The Evolution of IVNT in the UK Dr Jacques Otto, the head trainer at IntraVita, details the company’s development and standards for the training and use of intravenous nutrient therapy I was introduced to Intravenous Nutrient Therapy (IVNT) in 2009 in the Far East where I noticed the positive health and wellbeing effects of intravenous nutrients. Teaming up with Vernon Otto, in 2009 we started to manufacture intravenous nutrients (vitamins, amino acids and minerals) under European Good Manufacturing Practice (EU GMP), before establishing IntraVita.
obligations of those who administer these products IntraVita only supplies clinicians trained and certified (for insurance purposes) by IntraVita, including doctors, dentists, nurses, pharmacists and paramedics. Since 2014 IntraVita has trained more than 1,000 practitioners from the UK and abroad and, for the period 2014 to 2018, has supplied over 60,000 intravenous nutrient formulations to hundreds of clinics.
Classification and use The United Kingdom Medicines and Healthcare Regulatory Agency has advised that there are a number of vitamins and minerals available for intravenous administration in the UK which are labelled as medicinal products and have marketing authorisations. These are for specific medical purposes and often solely by virtue of their mode of administration, default to being prescription-only medicines (POMs). Where products are not intended to used for a medical purpose and make no medical claims then the MHRA has advised that these may fall outside the definition of a medicine. In such cases, the MHRA advice is that for clinics to ensure that those who administer the products are appropriately qualified. Provided no medicinal claims are made, EU GMP is adhered to and the products are only used for promotion of health and wellbeing. IntraVita’s products also fall outside the remit of the Care Quality Commission (CQC) for the same reason. The only POMs used in IntraVita’s formulations include 0.9% sodium chloride, sterile water for injection, calcium gluconate and magnesium sulfate. IntraVita’s formulations exclude any MAMs for off-license indications and it is company policy that Intravenous Drug Therapy (IVDT) for offlicense indications has no place in IVNT. Intravenous nutrition is excluded from clinical education curricula in most countries around the world. Multinational pharmaceutical companies are mostly disinterested in IVNT because a nutrient can’t be patented and therefore it can easily be copied. In the light of the MHRA’s advice in regard to professional 44
Formulations The formulations are preservative free, don’t contain traces of animals, so are vegan friendly, and are also free of geneticallymodified organisms, hexane and sugar. No serious side effects or complications have been reported during this period, compared to pharmaceutically-manufactured products that contain preservatives to increase product shelf life. This can lead to allergic reactions and, rarely, anaphylaxis. To improve safety and efficacy, over the past three years, our research and development has focused on developing multi-nutrient formulations and, more recently, we introduced ready-mixed multi-nutrient formulations in glass bottles. These formulations enhance ease of infusion preparation, save time, minimise user error and, most importantly, reduce the risk of infusion contamination with microbes.
Insurance and training IntraVita’s products have product liability insurance in the UK and practitioners that have completed our face-to-face or online training can obtain insurance from Cosmetic Insure, Hiscox, Lonsdale and Hamilton Fraser. In the UK, practitioners registered with the General Medical Council (GMC), must undergo appropriate training and have valid insurance in order to practice IVNT. Practitioners that do not use EU GMP intravenous nutrients are urged to contact their insurance company to verify if their insurance is valid and products sourced from jurisdictions outside the EU, for example, the US (FDA approved), India, South Africa Aesthetics | December 2018
and Canada are advised to check with the MHRA that their products are not regarded as medical products. Efficient training of practitioners has been one of IntraVita’s main priorities because IVNT is not taught at medical schools as part of clinical training. Therefore, IntraVita has been very selective in choosing training academy partners. Cosmetic Courses has been our sole partner for the past year and a half, with training being delivered by myself. Since 2014, the UK IVNT market has evolved rapidly with practitioners offering concierge services to clients in their homes, offices and hotel rooms. Another development includes intravenous infusion services offered to people at festivals where intravenous drugs, e.g. paracetamol and others, are administered. IntraVita disapproves of and distances itself from these new developments and the team draw a clear distinction between IVDT and IVNT. Finally, but most importantly, we are vehemently opposed to beauty therapists administering IVNT. This is because they are not accountable to a regulatory body such as the GMC, General Dental Council, Nursing and Midwifery Council, General Pharmaceutical Council or Health and Care Professions Council, and lack clinical training and experience. Thus, it is our opinion that it is not in the best interest of the public to seek IVNT infusions from beauty therapists. In our opinion, insurance companies that insure beauty therapists demonstrate a lack of insight and disregard of public interest and safety.
Dr Jacques Otto is the head clinical trainer at IntraVita and has postgraduate Master’s degrees in pharmacology, general practice and medical law. He was a pharmaceutical physician and scientific affairs manager of Abbott Laboratories in South Africa from 1990 to 1993.
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My Experience Medical director and founder of The IV Clinic and Ghosh Medical Group Dr Arun Ghosh shares his experiences of using and training in the use of IVNT I have been performing Intravenous Nutritional Therapy (IVNT) exclusively for more than three years and, during this time, I have seen the growth of the industry throughout the UK. Though we are behind our American counterparts, much can be learnt from their practices and their pitfalls. Our clinic has seen an increase in all demographics for this type of therapy; from the fitness and beauty industry to those worried about their health and nutrition. Personally I have trained on many of the different courses on offer, both here in the UK and abroad. Currently for practitioners, the standards of training differs hugely between companies and organisations. Companies also differ in their goals for IVNT benefits and client base. Clinical standards and guidelines are not the same throughout the different companies and their claims are often not based on any recognised controlled trials. This has led to much criticism in the way IVNT is being offered, from high street shops and home/hotel visits to expensive health clinics, and has contributed to patient complacency and concern regarding the use of IVNT.
AIMS is the first attempt in the UK to set standards of training and support for practitioners Standards of care There are always risks associated with any procedure and I have personally seen reactions and side effects from poor formulas and clinical guidelines, which in hindsight could easily have been avoided if the standards of training were higher and follow-up care was easy to access. The IV Clinic, as a result, tries to be at the forefront of setting these standards in terms of advertising and clinical administration. The IV Clinic has now grown into several clinics in the UK and abroad, and I have taken onboard clinicians across a variety of areas from acute care, oncology and community IV backgrounds. Included in my team are medical, pharmaceutical and nursing directors to create medical standards on par with NHS hospital and CQC levels of care. Currently there is no reason for other clinics to follow suit, but having a level set as high as this means I can reassure all of my clients and staff that their wellbeing is at the forefront of The IV Clinicâ&#x20AC;&#x2122;s ethos.
Tailoring treatment The IV Clinic team has now been well established and gathering feedback from our clinics has been our first aim in tailoring our IVNT menu for maximum benefit. All our practitioners have a good understanding of drip ingredients, osmolarity and infusion rates for safety, so are able to tailor IV drips for individual clientâ&#x20AC;&#x2122;s needs, rather than follow set menus. The IV Clinic has blood pathology levels, which are standard for all clients, as they are in many clinics in the US. We feel they are a vital part of the process in order to demonstrate if and when IVNT is indicated, beneficial, and not harmful. The learning has not stopped for me; I continue to train on courses around the world to bring together global data and constantly look to improve our IVNT menu. Looking forward We are now aiming to hold trials to provide clear data comparing IVNT with placebo, alternative treatments and how much quicker goals are achieved when IVNT is introduced, whether they be nutritional, beauty or athletic. On a more long-term scale, we also aim to train those who want to bring their IVNT standards up to our level and advance their IVNT training to achieve results safely and gather data from our own collective trials. Personally, I think that IVNT is very much in its infancy and we will see a huge amount of change in the coming years, for which I hope to be well prepared. If we are willing to learn from the experience of the aesthetics specialty we can correct many issues quickly at this infant stage, prior to it becoming over run and mismanaged by rogue practises. Thus, laying to rest many of the misconceptions that we see printed and, more importantly, reassure the public over the safety of IVNT. The Association of Intravenous Micro-nutritional Supplementation (AIMS) is the first attempt in the UK to set standards of training and support for practitioners. It offers a chance for companies to try to pull together and set clear standards across the board. Self regulation is the first step in raising the level of IVNT and public reassurance, so I would urge all practitioners looking to offer IVNT to sign up to AIMs.
Aesthetics | December 2018
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The Association of Intravenous Micronutrient Supplementation Director of AIMS Vernon Otto details what member can expect from this association Development The Association of Intravenous Micronutrient Supplementation (AIMS) was founded in July 2017 with the aim of raising standards of practitioner education and training, and to inform and educate the public on IVNT. To date, AIMS has 300+ members and is hoping to have more than 600 by December 2019. IVNT has been around for over 30 years in the US, Far East and in some parts of Europe, yet it is fairly new to the UK, especially in the aesthetics specialty. Within aesthetics, two disciplines of nutrient supplementation have emerged; Intravenous Nutrient Therapy (IVNT) and Intravenous Drug Therapy (IVDT). There is a clear distinction between the two and AIMS will ensure that the public and practitioners are aware of the difference. Policy IVNT uses intravenous nutritional therapy products for supplementation focusing on vitamins, amino acids and minerals; it does not treat medical conditions nor make medical claims. IVNT, therefore, does not currently fall within the remit of the CQC. IVDT, however, incorporates market authorised prescription-only medicines, such as anti-sickness, painkiller and antiinflammatory medications. This therefore does come under MRHA and CQC regulations. AIMS is not in agreement with medicines being used off licence or without correct clinical indication. Our first aim is therefore
to address this type of practice and produce guidelines for practitioners who wish to do this, so they are safe and comply with all regulated guidance. AIMS is of the view that the infusions should only be administered by doctors, dentists, nurses, pharmacists and paramedics, as the route of administration is intravenous and only suitably-trained medical personal are capable of conducting this after a thorough medical history. We also believe that these are the capable professionals of treating complications such as anaphylaxis. AIMS is strongly opposed to beauticians and nonmedically trained personnel administering drips in the UK for these reasons. Guidance AIMS will be producing guidelines to support UK IVNT practitioners and encourage all practitioners to follow suit. Particular concerns and issues will be addressed through clinical trials and peer feedback and support; building a pool of knowledge that can be passed on to colleagues to minimise the risk of complications and provide safe protocols for their patients. AIMS will also offer an advice support service for practitioners that need it. Over the coming months, AIMS will be working closely with insurance companies in the UK and publishing particular guidelines on who can be insured, what products are covered by medical malpractice insurance (usually EU sourced/
What does the MHRA say? The United Kingdom Medicines and Healthcare product Regulatory Agency (UK MHRA) has advised that there are a number of vitamins and minerals available for intravenous administration in the UK which are labelled as medicinal products and have marketing authorisations. These are for specific medical purposes and often solely by virtue of their mode of administration, default to being prescription-only medicines (POMs). Where products are not intended to be used for a medical purpose and make no medical claims then the MHRA has advised that these may fall outside the definition of a medicine. In such cases, the MHRA advice is that for clinics to ensure that those who administer the products are appropriately qualified. The MHRA has provided advice in respect of the classification of medicinal products in this article.
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Aesthetics | December 2018
Getting Insured Medical malpractice broker Jacquie Ford outlines how Cosmetic Insure can support IVNT practitioners Cosmetic Insure is one of the leading brokers for medical malpractice insurance in the UK. It is IntraVita Internationalâ&#x20AC;&#x2122;s broker of choice when it comes to insuring practitioners to administer IVNT in the UK. Cosmetic Insure can arrange insurance for doctors, dentists, nurses, paramedics and pharmacists to administer IVNT treatments in their own clinics or off-site as a concierge service. Only products sourced in the European Union will be covered by medical malpractice insurance policies. To date Cosmetic Insure has had no claims concerning IVNT in the UK, however this does not mean that the treatment is complication or risk free. It merely gives an indication.
manufactured) and what is not covered. AIMS will also be speaking to the CQC and MHRA for any particular concerns they wish to address and guidelines they would like practitioners to follow. In order to protect patients and preserve the procedure in the UK for the foreseeable future, AIMS is encouraging practitioners to join today and follow its guidelines on IVNT administration.
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Understanding Retinol Tolerance
of topical vitamin A derivatives on the skin ageing process. It enhances epidermal cell turnover, thereby reducing contact time between keratinocytes and melanocytes, promoting a rapid loss of pigment through epidermopoiesis.1 Since the initial observations by Kligman and Willis, these findings have subsequently been reproduced in numerous clinical studies and underpin the recommendation by dermatologists and other medical aesthetic professionals for individuals seeking smoother, firmer and more evenly pigmented skin to include a topical vitamin A derivative in their daily skincare regime.7,8 Continuous use is required for optimum results, and most of the aforementioned benefits are not clinically apparent before three months of regular use.1 The exception is improved skin smoothness, which can be detected as soon as one month after commencing application.1 Long-term treatment is required to maintain results once achieved and, notwithstanding withdrawal of treatment for women who are pregnant or breastfeeding due to the teratogenic effects of retinoids, there are no limits to the duration of treatment.1
Patient tolerability
Unfortunately, despite itâ&#x20AC;&#x2122;s clear efficacy as an antiageing treatment, the introduction of tretinoin predictably leads Dr Justine Kluk discusses the use of retinol to the development of retinoid dermatitis, a syndrome in skincare and explores how to overcome characterised by redness, flaking and sensitivity, that poor patient tolerability limits tolerability and provides a barrier to long-term compliance.9 Retinoid dermatitis occurs in almost Vitamin A and its derivatives have been a popular addition all cases, although one study suggests that the percentage for to topical skincare products for many years and, second only tretinoin can reach up to 95% of patients.10 to sunscreen, are recognised as the gold standard for the Retinol, a precursor of endogenous retinoic acid, has also been prevention and treatment of skin ageing.1 Natural retinoids, recognised as an effective antiageing treatment after it was such as tretinoin (retinoic acid) and synthetic retinoids, such reported to induce similar cellular and molecular changes to as tazarotene and adapalene, are prescribed medications, retinoic acid, but with fewer adverse effects.9,11 There are limited whereas retinol, retinaldehyde and retinyl esters are skincare/ studies that have directly compared outcomes for retinol and cosmeceutical agents contained in many over-the-counter retinoic acid head to head, however it has generally been assumed antiageing preparations. They exert their action by binding to that retinol is less effective due to the additional step required to specific nuclear receptors and modulating the expression of genes convert it to the active form. Indeed, recent research indicates that involved in cellular differentiation and proliferation, normalising cell whilst similar clinical benefits may be detected, these are likely to keratinisation.1 Medical aesthetic practitioners should consider introducing a topical retinoid into the patient skincare regime, where rejuvenation and maintaining a youthful skin appearance are the primary goals of treatment. Side effects and tolerability are the main barriers to continued use, but these can be overcome by appropriate patient selection and proper instruction on application.
Benefits of topical retinoids Kligman and Willis were the first to introduce the concept of using topical retinoids on photodamaged skin for rejuvenation in 1975.2 The benefits they observed included reduced wrinkles and surface roughness, and an improvement in mottled pigmentation.2 Histologically, decreased corneocyte adhesion, epidermal hyperplasia and increased collagen and elastin synthesis were observed.2,3 Later, around the 1980s,4 topical retinoids were also shown to play an important role in blocking collagenase activity, thus preventing collagen degradation as a separate effect.5,6 Tretinoin is the subject of most papers demonstrating the benefits
If their skin is said to be reactive, then it may be best to begin treatment with applications every other night, gradually working up to daily use
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be of a smaller magnitude for retinol. Nonetheless, the improved side effect profile and tolerability of retinol may offset this to some degree, making it an attractive over-the-counter alternative.9,11 When considering the addition of a topical vitamin A derivative to the patient skincare regime, there are several considerations the practitioner needs to make. Patients have a wide range of skin types, ages and races and, for best results, treatment must always be individualised. To improve acceptance and long-term compliance, detailed instruction in the use and anticipated side effects of treatment are invaluable. Retinoid dermatitis usually appears within the first week or two of application and, depending on skin type, settles to near normal within a month of regular use.8 Whilst somewhat uncomfortable, mild scaling and stinging can be seen as advantageous if the practitioner explains that these are signs of adequate dosing. Application frequency can be calibrated against this response and many patients can titrate treatment themselves eventually by adjusting the dose and frequency of application, after initial instruction by their practitioner. The following tips, adapted from Kligman’s original guidelines for the use of topical tretinoin (Retin-A), can help facilitate this process.8
Tips for compliance Start with a lower strength If the patient in question is naive to topical retinoid treatment, always start with a lower strength product and aim to build the potency gradually over time. A comfortable starting point for most is 0.3% retinol.8 Provide cleansing instructions Cleansing should take place in the morning for comfort and in the evening for removal of makeup. Water should be warm and clean fingertips are the ideal applicator. Before application of the retinol, the skin should be cleansed with a mild facewash and dabbed dry gently with a soft towel or cloth. My preference is for a simple cream or gel-based cleanser. Moisturiser should be applied every morning after washing the face. Apply retinoids at night Retinoids are recognised photosensitisers, and patients should be advised to apply their retinol treatment at night as the final act of the day. A pea-sized amount of the retinol product should be applied to the central forehead and spread evenly over the face with clean fingers. Transient stinging or burning may be observed and is a good indicator that a sufficient quantity has been applied. Ideally, nothing further is applied to the skin thereafter as dilution with other creams, such as moisturisers, can reduce efficacy.8 Provide moisturising instructions Offering a suitable moisturiser for daytime use can reduce symptoms, such as peeling. Whilst greasier or heavier moisturisers tend to be most effective at combatting peeling, many patients prefer lighter preparations as they are more cosmetically acceptable. This is also relevant if the patient has a history of acne, where occlusive formulations may induce a flare. If the frequency of retinol application is reduced during the initial stages of introduction to aid tolerance, or later during the maintenance phase, moisturiser should still be applied daily even on days when retinol is not used.8 Although I do not routinely recommend applying moisturiser after retinol application at night, it is not uncommon for patients to request an evening moisturiser as well. In this scenario, they are best advised to wait a
Risk of retinoid side effects Kligman and colleagues identified patients in the following groups to be at greatest risk of side effects:8 Fair skinned, freckled, blue eyed, Celtic individuals who sunburn easily and tan poorly 1. People who have sensitive skin that stings strongly after use of perfumes, sunscreens or astringents 2. Flusher-burners; people whose faces turn red and feel hot after embarrassment or alcoholic drinks 3. Middle-aged individuals who generally have been heavy users of cosmetics, cleansers and toiletries – they frequently complain of dry skin 4. People with prior skin disorders, such as eczema, rosacea and seborrheic dermatitis8 In contrast, those with lowest sensitivity tend to be older individuals with advanced photodamage and darker skin types with larger pores and oilier skin.
minimum of 15-30 minutes after retinol application before moisturising to allow sufficient time for absorption.8 Adjust frequency of application Another helpful strategy when introducing retinol is to gradually taper the application frequency. This is particularly pertinent if the patient has sensitive skin. To determine this, ask the patient directly how their skin reacts to other skincare products such as cleansers, toners, moisturisers or sunscreens. If their skin is said to be reactive, then it may be best to begin treatment with applications every other night, gradually working up to daily use. Examples of reactive skin include redness, flushing, burning or itching.8 A different technique known as ‘short contact therapy’, is also sometimes used to improve compliance in this group. It involves rinsing the product off 30 minutes post application. Efficacy of tretinoin short contact therapy seems to be superimposable to that of tretinoin applied in the standard way; however, reports of irritation are far fewer.10 Consider area of application Treatment is principally aimed at improving the appearance of the face, however photodamaged skin on the hands and forearms can also be treated in the same way. Special attention should be given to particular body sites where the risk of irritation tends to be higher. The eyes and lips themselves should be avoided; however, it is possible to apply the treatment right up to the margins, particularly if reduction of crow’s feet or perioral rhytids is an intended goal of therapy. For those who are prone to ocular irritation and sensitivity, a dedicated eye contour product may be preferred. Many brands will do specific products for the eye area, which may contain less fragrance, fewer preservatives, a lower strength of retinol or even a retinyl ester e.g. retinyl palmitate instead, as these are better tolerated in delicate areas. Treatment of the delicate, thin-skinned neck and décolleté also requires caution. It is advisable to apply the treatment very thinly to this area and even less frequently in the beginning, for example, every third night initially, and then every other night as tolerance develops.8 Educate patient of possible effects of retinol Individual responses to the introduction of retinol therapy vary greatly. Some patients report little or no adverse effects, whilst others have
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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The eyes and lips themselves should be avoided, however it is possible to apply the treatment right up to the margins, particularly if reduction of crow’s feet or perioral rhytids is an intended goal of therapy a more stormy path. To start with, the skin may feel tight and dry with some stinging. Irritation commonly takes the form of mild redness along with dryness and fine scaling that may last a month or more. Those who experience excessive irritation or discomfort in the first few weeks may reduce application to alternate nights or even every third night depending on the severity of their symptoms (e.g. redness, dryness, scaling). As tolerance increases, daily application can eventually be resumed in most cases. To maintain confidence in their practitioner, patients should be told what to expect from the outset and reassured that these side effects are anticipated, rather than a sign of something sinister, such as allergy. Without this, many give up on treatment before their skin has had a chance to accommodate.8 Escalate doses with caution Dose escalation should be handled with similar caution. As soon as tolerated without ongoing redness, dryness or flaking, patients can try doubling the dose of their retinol by applying a pea-sized amount to each temple and spreading evenly over the face. After some months, around three to six in my experience, the dose can be increased again by moving up to a higher strength retinol, such as 1.0%, or indeed a prescription retinoid if appropriate. Patients must be warned that by applying higher strength retinol, any previous irritation encountered is likely to recur temporarily and can be offset by the use of a richer moisturiser, such as a heavier cream or balm rather than a lighter weight fluid or lotion, the following morning. 8
these patients back to zero by eliminating all soaps and active skincare ingredients from their daily routines before initiation, giving instructions on suitably gentle alternatives. Patients should also be counselled specifically about avoiding irritants, such as toners, scrubs and peels. The stratum corneum is thinned during early retinol therapy, thus sunscreen is mandatory to protect the skin from further photodamage. This should ideally be an SPF of 30 or higher.8 Educate patients on result timings Patients should be advised that evidence of clinical benefit can take three or more months to be appreciated and that for best longterm outcomes, maintenance must be kept up indefinitely. After eight months to one year of therapy, when maximum benefit ought already to have been obtained, daily therapy can be reduced to a maintenance schedule of two to three applications per week.8
Conclusion Over the counter retinoids, such as retinol, can improve skin smoothness, reduce wrinkles and regulate pigmentation, albeit at a smaller magnitude than tretinoin, the benchmark topical retinoid treatment. Retinoid dermatitis, manifesting with redness, dryness and flaking, should be anticipated soon after initiation, but resolves with continued use. Careful explanation of anticipated side effects and precise instruction on product choice and application predict better tolerability and patient compliance with long-term treatment. Dr Justine Kluk is a consultant dermatologist and spokesperson for the British Association of Dermatologists. Her private dermatology clinic is located at 25 Harley Street and her main clinical interests are acne, acne scarring and rosacea. Dr Kluk’s NHS base is St George’s Hospital, London. REFERENCES 1. Serri R, Iorizzo M. Cosmeceuticals: focus on topical retinoids in photoaging. Clinics in Dermatology 2008;26(6):633-5. 2. Kligman AM, Willis I. A new formula for depigmenting human skin. Arch Dermatol 1975; 111:40-8. 3. Griffiths C, Russman AN, Majmudar G et al. Restoration of collagen formation in photodamaged human skin by tretinoin (retinoic acid). New Engl J Med 1993;329:530-5. 4. Bauer EA, Seltzer JL, Eisen AZ. Inhibition of collagen degradative enzymes by retinoic acid in vitro. J Am Acad Dermatol 1982;6:603-607 5. Fisher GJ, Reddy AP, Datta SC et al. All-trans retinoic acid induces cellular retinol-binding protein in human skin in vivo. J Investig Dermatol 1995;105:80-6. 6. Fisher GJ, Datta SC, Talwar HS et al. Molecular basis of sun-induced premature skin ageing and retinoid antagonism. Nature 1996;379:335-9. 7. Kligman AM, Grove GL, Hirose R et al. Topical tretinoin for photoaged skin. J Am Acad Dermatol 1986;15:838-59. 8. Kligman AM. Guidelines for the use of topical tretinoin (Retin-A) for photoaged skin. J Am Acad Dermatol 1989;21:650-4. 9. Kong R, Cui Y, Fisher GJ et al. A comparative study of the effects of retinol and retinoic acid on histological, molecular, and clinical properties of human skin. Journal of Cosmetic Dermatology 2016;15(1):49-57. 10. Stefano Veraldi, Mauro Barbareschi, Susanna Benardon & Rossana Schianchi. Short contact therapy of acne with tretinoin. Journal of Dermatological Treatment 2013; 24(5):374-376 11. Kang S, Duell EA, Fisher GJ et al. Application of retinol to human skin in vivo induces epidermal hyperplasia and cellular retinoid binding proteins characteristic of retinoic acid but without measurable retinoic acid levels of irritation. J Invest Dermatol 1995;105:549-56.
Use retinol in combination Retinol should never be used alone. It must always be paired with sunscreen and moisturiser. In my clinical experience, optimal concordance with topical retinoid therapy occurs when the patient is given clear guidance about which products to use alongside their treatment. Some patients will already be using a number of other skincare products, and many complain of sensitive skin, failing to realise that this is the direct result of inappropriate product selection and combination. For the avoidance of doubt, it is often helpful to bring
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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a technique that has been successfully used to treat atrophic scarring from acne and other aetiologies (e.g. chicken pox),7-11 and combining this process with platelet-rich plasma (PRP) is an promising recent development. A small prospective observer blinded study was recently performed by Yadav et al., which compared microneedling alone with microneedling with PRP. Results showed both a qualitative and quantitative advantage in those receiving PRP, but this did not achieve statistical significance. However, patient satisfaction in the two groups was higher for those receiving PRP and this parameter was statistically significant.12 The remainder of this article will set out the rationale for combining PRP with microneedling and how it can be applied in clinical practice.
Types of acne scarring There are three broad categories of acne scarring: 1. Atrophic 2. Hypertrophic 3. Keloidal
Treating Acne Scarring Dr Duncan Brennand explores the use of platelet-rich plasma and microneedling for the treatment of acne scars Across the globe acne is an enormously common problem; the Global Burden of Disease Project estimates that it affects 9.4% of the world’s population, making it the eighth most prevalent disease worldwide.1 Onset is most frequent in the post-pubescent period, but adult onset and continuity of the disease into adulthood can occur and it is becoming more frequently recognised.2 Acne is a chronic inflammatory disease of the skin’s specialised sebaceous follicles, which are found predominantly on the face and trunk. Hormone-mediated increased sebum production, obstruction of the follicle by desquamation of the follicular epithelium and colonisation of the sebum by the bacteria propionibacterium acnes result in microcomedo formation, and these can progress to become comedones and inflammatory skin lesions.3,4 One of the recognised consequences of acne is persistent scarring. This affects up to 20% of teenagers4 and facial scarring is present to some degree in 95% of acne sufferers, with similar incidence in both sexes.5 When acne is severe and/or when successful treatment is delayed, it can result in significant, disfiguring scarring.4,5 Although frequently dismissed by both the medical community and general population, this scarring can be very detrimental to the emotional and psychosocial wellbeing of those affected, leading to anxiety, depression and even suicidal feelings.6 Unfortunately, given its prevalence and both physical/psychological sequelae, no single effective treatment is available to combat acne scarring.7,8 Many different strategies, including topical steroids, laser resurfacing and surgical excision, are in use by dermatologists, plastic surgeons and others across the aesthetic medicine community to address it.7,8 Percutaneous non-ablative collagen stimulation by microneedling is
Atrophic scars, where there is a net loss of collagen, make up the bulk (up to 90%) of facial acne scars. Hypertrophic and keloidal scars are found predominantly on the torso particularly the shoulders and back. Atrophic scars can be further subdivided into the following groups:12 1. Ice-pick scars: deep ‘v-shaped’ narrow scars, which can reach the subcutaneous layer. Make up 60-70% of acne scars. 2. Box car scars: sharp-edged wider ‘u-shaped’ scars commonly 0.1-0.5mm deep. Make up 20-30% of acne scars. 3. Rolling scars: tethered undulating scars usually greater than 4mm wide. Make up 15-25% of acne scars.
It should be noted, however, that differentiating between atrophic scar types can be difficult, and patients often present with scars of differing types that co-exist.13 The reason it is important to determine the category of scar is that, in practice, it is atrophic scars that are the target for microneedling/PRP. In my experience, as well as the published literature,7,13,16,19,20 it is shallow box car scars and milder forms of rolling scars that respond particularly well to this treatment modality. However, in my experience, all scar types should show some improvement.
How does microneedling work and why add PRP? Microneedling is a well-established and frequently performed aesthetic technique. It is a form of percutaneous, non-ablative collagen induction therapy. Thousands of microchannels are created using either a dermaroller or electronic microneedling device. These channels reach down to the papillary dermis, but effectively spare the Types of Acne Scars
Ice pick
Rolling
Box car
Scar edges Fascia Figure 1: The three types of atrophic acne scars. Image adapted from Fabbrocini et al. 2010. 14
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epidermis and stratum corneum, thus preserving barrier function.13,14 Both the injury response, with growth factor and cytokine release, and changes in epidermal/dermal electrical potential have been postulated as mechanisms for the fibroblast migration/activation that has been shown to occur after microneedling. 16,18-20 The in vivo effects of this fibroblast stimulation include collagen deposition and neoangiogenesis, which can continue for up to one year. With successive treatments, collagen deposition in areas of atrophic scarring can result in tissue remodelling and smoothing of the skin.17,18 PRP is plasma that contains an increased concentration of platelets. For optimal clinical use this should be in excess of 1x106 platelets/ µL, which represents an enrichment of 300-700%.16 PRP is produced by the fractionation of whole blood using a centrifuge. Multiple commercially-produced kits are available to assist/standardise production, but reproducible non-proprietary techniques are also described in the literature.16 PRP contains a high concentration of platelet growth factors, which are released when the platelets in the PRP are activated. In aesthetic procedures, this occurs when the PRP interacts with collagen after it is administered and routine exogenous activation (e.g. with calcium chloride or thrombin) is not needed. Key growth factors that are released include platelet-derived growth factor (PDGF), transforming growth factor (TGF) and insulin-like growth factor, as these all promote collagen synthesis and fibroblast activation.16,18-20 Given that, as described above, microneedling relies upon the tissue healing mechanism for its effects and that key growth factors involved in that process are released by PRP as it is activated, it would be reasonable to hypothesise that microneedling and PRP could act synergistically. Although there is a lack of robust clinical trial data, several small studies have shown that microneedling is more effective at treating acne scarring when used in combination with PRP than when used alone.7,16,18-20 and that has certainly been my anecdotal experience. As an example, Asif et al. took a sample group of 50 patients with acne scarring and performed a concurrent split face study comparing microneedling/intradermal PRP injections with microneedling/intradermal injections of distilled water; the right half of the face being treated with the former technique and the left with the latter. In this very small study there was a greater improvement in the qualitative and quantitative scores (using Goodman’s scoring system for acne scarring) on the side treated with miconeedling/PRP. An ‘excellent’ degree of qualitative improvement was seen in 20 PRP-treated cases compared with five cases of microneedling/distilled water and a quantitative improvement of 62.2% (PRP) vs. 48.5% (distilled water).16
Technique and tips for success As with many procedures one of the key determinants of a successful outcome is initial patient selection. It should be remembered that microneedling/PRP is only one technique at our disposal and is not suitable for everyone. Each patient for whom this combination technique is being considered should be carefully assessed clinically and meticulously photographed. I advise patients that they should expect multiple treatments, usually at least three separated by one month and that we do not anticipate immediate results as, in my experience, it can take up to four weeks for any improvement to become apparent. Keeping each patient on board and compliant with the proposed treatment plan is vital to success. As a stand-alone technique, I have achieved my best results in patients with box car scars and rolling scars that demonstrate only minimal tethering, this is in keeping with the published literature.12,13 I now
Before
After three sessions
Figure 2: Patient before and three sessions after microneedling with PRP, 1.5mm needle length, electronic derma stamp used. There were four weeks in-between each treatment.
consider this to be my first-line approach in those situations. However, it is a technique that can be easily combined with other strategies, such as subscision of more severely tethered rolling scars and trichloroacetic (TCA) application to ice-pick scars. One of the really appealing characteristics of this treatment is that it uses autologous blood rather than an exogenous product that might be deemed ‘unnatural’ by the patient. However, patients are often perturbed by the fear of venesection and by the thought of seeing their own blood. They also might be concerned about the effects that ‘blood loss’ might have if they pursue this treatment. Do not underestimate these anxieties and overcome them with careful explanation; a warm, calm, comfortable environment and a confident demeanour, remembering that venesection is an important skill and that practice makes perfect. When I first started to offer PRP-based therapies at my clinic, we tried out several of the commercially available kits and found them all pretty user-friendly and effective. However, we did find them to be expensive, although competition does appear to be driving kit prices down. As a result, when the size of my practice increased, we chose to go down a non-proprietary route and now use our own in-house, closed system, double spin technique modified from that described by Amable et al.,21 using ACD (acid citrate dextrose) anticoagulated vacutainer tubes for blood collection and a non-refrigerated centrifuge.
It should be remembered that microneedling/PRP is only one technique at our disposal and is not suitable for everyone
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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As per the Amable et al. technique we incorporate a soft spin of 300xg for five minutes to deplete the sample of red cells/leukocytes and a hard spin of 700xg for 17 minutes to produce a platelet pellet that can be resuspended in a minimal volume of supernatant. I audit my platelet yields regularly and have found this to be a reproducible technique, with platelet yields in excess of 1.5x106 platelets/µL. Typically, we acquire 24ml (three 8ml tubes) of venous blood from an antecubital fossa vein using a 22G butterfly and vacutainer system. From this we harvest 3ml of product. Topical anaesthetic (9.6% lidocaine) is applied in a thick layer over the face and left for 30mins; then, using a mesotherapy gun and nappage technique (multiple serial superficial injections of a small quantity of PRP), we distribute 2ml of PRP intradermally, treating the whole face, but concentrating on any specific areas of scarring. After this, we mix 1ml of PRP with noncrosslinked hyaluronic acid, which thickens it, rendering it more usable, and use this as a serum during microneedling. Both dermarollers and electronic microneedling devices can be used for this treatment. I use an electronic device as it is available in clinic, but I am not aware of any studies demonstrating statistically significant superiority of one device over another in this setting. This is a very well-tolerated technique with minimal downtime. With adequate topical anaesthesia, periprocedural discomfort can be successfully minimised. Some post-procedural erythema and oedema is expected, and in my experience this can persist for several days. Contraindications to this treatment include active acne, anticoagulation and bleeding disorders, active herpes labialis infection and a tendency to keloidal scarring.9
Conclusion Atrophic acne scarring is a common and frequently challenging medical problem that often has significant psychosocial consequences for those affected. Treatment must be tailored to the individual and is likely to involve multiple different strategies. In my clinic, we now include microneedling combined with PRP as a first-line therapy because it is a well-tolerated, relatively inexpensive, highly reproducible technique with few side effects and it can be easily combined with other treatment modalities. Most importantly, in my anecdotal experience, it can significantly improve the severity of acne scars, particularly those with a box car or rolling morphology, resulting in reduced patient distress and an improved quality of life. In future, it is my hope that a multicentre, large-scale double blind controlled trial could be performed to provide a stronger evidence base for this exciting new treatment.
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Dr Duncan Brennand was appointed as Consultant Interventional Radiologist at University College London Hospital in 2006 and is now an internationallyrecognised practitioner of minimally-invasive, imageguided percutaneous interventions. He is the founder and co-owner of L’Atelier Aesthetics in Harley St London, a clinic dedicated to facial aesthetics and vein treatments. REFERENCES 1. J.K.L. Tan K. Bhate, ‘A global perspective on the epidemiology of acne’ British Journal of Dermatology vol 172 (2015) issue S1 p3-12 2. Andrea L. et al, ‘Guidelines of care for the management of acne vulgaris’ Journal of the American Academy of Dermatology Volume 74 (May 2016), Issue 5 Pages 945-973.e33 3. James J. Leyden, M.D., ‘Therapy for Acne Vulgaris’ New England Journal of Medicine Vol 336 (1997) p1156-116 4. Prof Hywel C Williams et al, ‘Acne vulgaris’ The Lancet Vol 379 (2012), Issue 9813 p361-372 5. A.M. Layton C.A. Henderson W.J. Cunliffe ‘A clinical evaluation of acne scarring and its incidence’ Clinical and experimental dermatology Volume19 (1994), Issue4 p303-308 6. Shannon Hanna, BSC, Jasdeep Sharma, MD1, Jennifer Klotz, MD2 ‘Acne vulgaris: More than skin deep’ Dermatology Online Journal 9(3): 8 2003 7. G Kravvas, F Al-Niaimi, ‘A systematic review of treatments for acne scarring part 1, Scars, Burns and Healing Vol 3 (2017) p1-17 8. G Kravvas, F Al-Naimi, ‘A systematic review of treatments for acne scarring part 2 Scars, Burns and Healing Scars, Burns and Healing vol 4 p1-14 9. S Patil, SK Patil, ‘Dermaroller: simple and effective acne scar treatment’ International Journal of Research in Dermatology, vol 2 (2016) issue 3 p43-46 10. A Garg, SS Chaudhary ‘Efficacy of dermaroller on morphology of acne scars: analytical and prospective study’ International Journal of Research in Dermatology, vol 3(2017) issue 3 p399-402 11. Ramut et al, ‘Microneedliing: Where do we stand now? A systematic review of the literature, Journal of Plastic , Reconstructive and Aesthetic Surgery Vol 71(2018) p1-14 12. Yadav et al, ‘A comparative study of efficacy of micro-needling alone versus micro-needling with autologous platelet rich plasma in facial atrophic acne scars’ International Multispeciality Journal of Health Vol 3(2017) Issue 8 p268-274 13. CI Jacob, JS Dover, MS Kaminer ‘Acne scarring: a classification system and review of treatment options’ Journal of the American Academy of Dermatology Vol 45 (2001) Issue 1 p109-117 14. Fabbrocini et al, “Acne scars pathogenesis, classification and treatment” Dermatol Res Pract 2010; 2010: 893080 15. Yaseen et al, ‘Combination of platelet rich plasma and microneedling in the management of atrophic acne scars’ International Journal of Research in Dermatology Vol 3 (2007) issue 3 p346-350 16. Asif et al, “Combined autologous platelet rich pplasma with microneedling verses microneedling withdistilled water in the treatment of atrophic acne scars: a concurrent split face study” J Cosmet Dermatol 2016 Issue 15 p434-443 17. Varani et al, “Decreased collagen productionin chronologically aged skin:roles of age dependent alteration in fibroblast function and defective mechanical stimulation” The American Journal of Pathology Vol 168 (2006) Issue 6 p1861-1868 18. Liebl et al “Skin cell proliferation stimulation by microneedles” Journal of the American College of Clinical Wound Specialists Vol 4(2012) Issue 1 p 2-6 19. Ranjan et al, ‘A study of the efficacy of Skin Needling and Platelet Rich Plasma in the treatment of Acne Scars’ Nepal Journal of Dermatology, Venereology and Leprology, Vol 15 (2017) issue 1 p17-23 20. Chawla S, ‘Split Face Comparative Study of Microneedling with PRP Versus Microneedling with Vitamin C in Treating Atrophic Post Acne Scars’ Journal of Cutaneous and Aesthetic Surgery Vol 7 (2014) issue 4 p209-212. 21. Amable et al, ‘Platelet-rich plasma preparation for regenerative medicine: optimization and quantification of cytokines and growth factors’ Stemcell Research and Therapy Vol 4 (2013) issue 3
REGIST ER N OW 2019
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Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
IN THE LEADER1 NOW indicated for forehead lines - treat 3 key areas of the face simultaneously: crow’s feet, glabellar and now forehead lines2
1. Allergan. Data on file. INT/0827/2017 September 2017. 2. Allergan. BOTOX® Summary of Product Characteristics. October 2018. BOTOX® is indicated for the temporary improvement in the appearance of: • moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines) and/or • moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile and/or • moderate to severe forehead lines at maximum eyebrow elevation when the severity of the facial lines has an important psychological impact in adult patients. Prescribing Information can be found overleaf. UK/0187/2018f Date of preparation: November 2018
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TM
BOTOX (botulinum toxin type A) Glabellar, Forehead and Crow’s Feet Lines Abbreviated Prescribing Information Presentation: Botulinum toxin type A (from clostridium botulinum), 50 or 100 or 200 Allergan Units/vial. Indications: Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines) and /or ; moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile and/or; moderate to severe forehead lines at maximum eyebrow elevation when the severity of the facial lines has an important psychological impact in adult patients.. Dosage and Administration: See Summary of Product Characteristics for full information. Do not inject into blood vessels. Botulinum toxin units are not interchangeable from one product to another. Not recommended for patients <18 years. The recommended injection volume per muscle site is 0.1 ml (4 Units). Glabellar Lines: Five injection sites: 2 in each corrugator muscle and 1 in the procerus muscle: total dose 20 Units. Crow’s Feet Lines: Six injection sites: 3 in each lateral orbicularis oculi muscle: total dose 24 Units. Forehead Lines: Five injection sites: Each in the frontalis muscle: total dose 20 Units. In the event of treatment failure or diminished effect following repeat injections alternative treatment methods should be employed. Contraindications: Known hypersensitivity to any constituent. Infection at proposed injection site(s). Warnings/Precautions: Use not recommended in women who are pregnant, breast-feeding and/or women of childbearing potential not using contraception. The recommended dosages and frequencies of administration of BOTOX should not be exceeded due to the potential for overdose, exaggerated muscle weakness, distant spread of toxin and the formation of neutralising antibodies. Initial dosing in treatment naïve patients should begin with the lowest recommended dose for the specific indication. Prescribers and patients should be aware that side effects can occur despite previous injections being well tolerated. Caution should be exercised on the occasion of each administration. There are reports of side effects related to spread of toxin distant from injection site, sometimes resulting in death. BOTOX should only be used with extreme caution and under close supervision in patients with subclinical or clinical evidence of defective neuromuscular transmission and in patients with underlying neurological disorders. Caution in patients with underlying neurological disorder and history of dysphagia and aspiration. Patients should seek medical help if swallowing, speech or respiratory disorders arise. Previously sedentary patients should resume activities gradually. Relevant anatomy and changes due to prior surgical procedures must be understood prior to administration and injection into vulnerable anatomic structures must be avoided. Pneumothorax associated with injection procedure has been reported. Caution is warranted when injecting in proximity to the lung, particularly the apices or other vulnerable structures. Serious adverse events including fatal outcomes have been reported in patients who had received off-label injections directly into salivary glands, the oro-lingual-pharyngeal region, oesophagus and stomach. If serious and/or immediate hypersensitivity reactions occur (in rare cases), injection of toxin should be discontinued and appropriate medical therapy, such as epinephrine, immediately instituted. Procedure related injury could occur. Caution in the presence of inflammation at injection site(s), ptosis or when excessive weakness/atrophy is present in target muscle. Reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. New onset or recurrent seizure occurred rarely in predisposed patients, however relationship to botulinum toxin has not been established. Clinical fluctuations may occur during repeated use. Too frequent or excessive dosing can lead to antibody formation and treatment resistance. It is mandatory that BOTOX is used for one single patient treatment only during a single session. May cause asthenia, muscle weakness, somnolence, dizziness and visual disturbance which could affect driving and operation of machinery. Interactions: Theoretically, the effect may be potentiated by aminoglycoside antibiotics or other drugs that interfere with neuromuscular transmission. Adverse Effects: See Summary of Product Characteristics for full information on side effects. Based on controlled clinical trial data, the proportion of patients treated for glabellar lines that would be expected to experience an adverse reaction after treatment is 23% (placebo 19%). In pivotal controlled clinical trials for crow’s feet lines, such events were reported in 8% (24 Units for crow’s feet lines alone) and 6% (44 Units: 24 Units for crow’s feet lines administered simultaneously with 20 Units for glabellar lines) of patients compared to 5% for placebo. In clinical trials for forehead lines, adverse events considered
to be related to Botox were reported in 14.3% of patients treated with 64 Units (20 Units to the frontalis with 20 Units to the glabellar complex and 24 Units to the lateral canthal lines area) compared to 8.9% of patients that received placebo. Adverse reactions may be related to treatment, injection technique or both. In general, adverse reactions occur within the first few days following injection and are transient, but rarely persist for several months or longer. Local muscle weakness represents the expected pharmacological action. Localised pain, tenderness and/or bruising may be associated with the injection. Fever and flu syndrome have been reported. Frequency By Indication: Defined as follows: Common (≥1/100 to <1/10), Uncommon (≥1/1,000 to <1/100). The following represent adverse reactions that have been reported following injection of Botox for Glabellar Lines, Crow’s Feet Lines with or without Glabella Lines, Forehead Lines and Glabellar Lines with or without Crow’s Feet Lines. Infections and infestations. Uncommon: Infection. Psychiatric disorders. Uncommon: Anxiety. Nervous system disorders. Common: Headache. Uncommon: Paraesthesia, dizziness. Eye disorders. Common: Eyelid ptosis. Uncommon: Blepharitis, eye pain, visual disturbance and Eyelid oedema Gastrointestinal disorders. Uncommon: Nausea, oral dryness. Skin and subcutaneous tissue disorders. Common: Erythema. Uncommon: Skin tightness, oedema (face, periorbital), photosensitivity reaction, pruritus, dry skin, Brow Ptosis. Musculoskeletal and connective tissue disorders. Common: Localised muscle weakness. Uncommon: Muscle twitching. General disorders and administration site conditions. Common: Face pain, injection site bruising*, Injection site hematoma* Uncommon: Flu syndrome, asthenia, fever, Injection site haemorrhage*, Injection site pain* Injection site paraesthesia (* procedure- related adverse reaction) Crow’s Feet Lines (24 Units): Eye disorders. Common: Eyelid oedema General disorders and administration site conditions. Common: Injection site haemorrhage*, injection site haematoma*. Uncommon: Injection site pain*, injection site paraesthesia (*procedure-related adverse reactions). Crow’s Feet Lines and Glabellar Lines (44 Units): General disorders and administration site conditions. Common: Injection site haematoma*. Uncommon: Injection site haemorrhage, injection site pain*(*procedure-related adverse reactions). The following adverse events have been reported since the drug has been marketed regardless of indication: Cardiac disorders: Arrhythmia, myocardial infarction. Ear and labyrinth disorders: Hypoacusis, tinnitus, vertigo. Eye disorders: Angle-closure glaucoma (for treatment of blepharospasm), eyelid ptosis, strabismus, blurred vision visual disturbance and lagopthalmos. Gastrointestinal disorders: Abdominal pain, diarrhoea, constipation, dry mouth, dysphagia, nausea, vomiting. General disorders and administration site conditions: Denervation atrophy, malaise, pyrexia. Immune system disorders: Anaphylaxis, angioedema, serum sickness, urticaria. Metabolism and nutrition disorders: Anorexia. Muscoskeletal and connective tissue disorders: Muscle atrophy, myalgia. Nervous system disorders: Brachial plexopathy, dysphonia, dysarthria, facial paresis, hypoaesthesia, muscle weakness, myasthenia gravis, peripheral neuropathy, paraesthesia, radiculopathy, seizures, syncope, facial palsy. Respiratory, thoracic and mediastinal disorders: Aspiration pneumonia (some with fatal outcome), dyspnea, respiratory depression, respiratory failure. Skin and subcutaneous tissue disorders: Alopecia, brow ptosis, dermatitis psoriasiform, erythema multiforme, hyperhidrosis, madarosis, pruritus, rash. NHS Price: 50 Units: £77.50, 100 Units: £138.20, 200 Units £276.40. Marketing Authorization Number: 50 Units: 426/0118, 100 Units: 426/0074, 200 Units 426/0119. Marketing Authorization Holder: Allergan Ltd, Marlow International, The Parkway, Marlow, Bucks, SL7 1YL, UK. Legal Category: POM. Date of preparation: October 2018. Further information is available from: Allergan Limited, Marlow International, The Parkway, Marlow, Bucks SL7 1YL
Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.
UK/0187/2018f Date of preparation: November 2018
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A summary of the latest clinical studies Title: Hyaluronic acid, a promising skin rejuvenating biomedicine: A review of recent updates and pre-clinical and clinical investigations on cosmetic and nutricosmetic effects Authors: Bukhari SNA, Roswandi NL, Waqas M, et al. Published: International Journal of Biological Macromolecules, December 2018 Keywords: Antiaging, nasolabial folds, dermal filler, face rejuvenation, hyaluronic acid, nutricosmetic Abstract: Owing to its remarkable biomedical and tissue regeneration potential, hyaluronic acid (HA) has been numerously employed as one of the imperative components of the cosmetic and nutricosmetic products. The present review aims to summarize and critically appraise recent developments and clinical investigations on cosmetic and nutricosmetic efficacy of HA for skin rejuvenation. A thorough analysis of the literature revealed that HA based formulations (i.e., gels, creams, intra-dermal filler injections, dermal fillers, facial fillers, autologous fat gels, lotion, serum, and implants, etc.) exhibit remarkable anti-wrinkle, anti-nasolabial fold, anti-aging, space-filling, and face rejuvenating properties. This has been achieved via soft tissue augmentation, improved skin hydration, collagen and elastin stimulation, and face volume restoration. HA, alone or in combination with lidocaine and other co-agents, showed promising efficacy in skin tightness and elasticity, face rejuvenation, improving aesthetic scores, reducing the wrinkle scars, longevity, and tear trough rejuvenation. Our critical analysis evidenced that application/administration of HA exhibits outstanding nutricosmetic efficacy and thus is warranted to be used as a prime component of cosmetic products. Title: Fractional microneedling radiofrequency treatment for axillary osmidrosis: A minimally invasive procedure Authors: Lin L, Huo R, Bi J et al. Published: Journal of Cosmetic Dermatology, December 2018 Keywords: axillary osmidrosis; fractional microneedling radiofrequency; minimally invasive; subcutaneous surgery Abstract: Axillary osmidrosis is a distressing condition that can reduce quality of life and lead to personal and social problems. We sought to assess retrospectively the efficacy and safety of fractional microneedling radiofrequency (FMR) treatment for axillary osmidrosis compared with subcutaneous surgery in a Chinese population. In total, 48 and 42 patients receiving FMR treatment and subcutaneous surgery, respectively, were recruited. The treatments were assessed in terms of efficacy, complications, and malodor recurrence. Patient satisfaction and the Dermatology Life Quality Index (DLQI) were also evaluated. In total, 93.75% of patients in the FMR group and all patients in the surgery group showed good-to-excellent improvement in osmidrosis (P > 0.05). The patients’ satisfaction in the FMR group was significantly higher than that in the surgery group at 1 month after treatment, but there were no differences between the two groups at the 3rd and 6th months (P > 0.05). The DLQI score was significantly decreased after both treatments. Two patients in the surgery group experienced hemorrhage complications, and no patients in the FMR group showed severe adverse effects. There was no significant difference in the malodor recurrence rate between the groups. Fractional
microneedling radiofrequency treatment offers a safe and effective method for treating axillary osmidrosis with minimal recovery time and no strict postoperative immobilization. Title: Laser treatment for facial acne scars: A review Authors: Sadick NS, Cardona A Published: Journal of Cosmetic & Laser Therapy, November 2018 Keywords: Psoriasis, self-esteem, anxiety Abstract: Acne scarring is a widely prevalent condition that can have a negative impact on a patient’s quality of life and is often worsened by aging. The aim of this review is to evaluate the different laser modalities that have been used in peer-reviewed clinical studies for treatment of atrophic acne scars, and summarize current clinical approaches. A Medline search spanning from 1990 to 2016 was performed on acne scarring. Search terms included “atrophic acne scars,” “ablative’’, “nonablative,” “fractional,” “nonfractional,” “neodymium,” “alexandrite,” “pulsed dye” lasers, and results are summarized. Various types of lasers have been evaluated for the treatment of atrophic acne scars. While they are efficacious overall, they differ in terms of side effects and clinical outcomes, depending on patients’ skin and acne scar type. A new emerging trend is to combine lasers with other energy-based devices and/or topicals. Evaluation of the literature examining acne scar treatment with lasers, revealed that clinical outcomes are dependent on various patient factors, including atrophic acne scar subtype, patient skin type, treatment modality, and side-effect profile. Title: Influencing Factors of Social Anxiety Disorder and Body Dysmorphic Disorder in a Nonclinical Brazilian Population Authors: Tatiana Soler P, Novaes J, Miguel Fernandes H Published: Psychological Reports, November 2018 Keywords: Exercise; beauty, body dysmorphic disorder, obsessivecompulsive disorder, social phobia Abstract: The aims of this study were twofold: (i) to investigate the prevalence of social anxiety disorder and body dysmorphic disorder in a nonclinical, Brazilian population and (ii) to examine the effects of selected factors such as sociodemographic characteristics (sex, age, marital status, workload, education, and income), body mass index, current diet, physical activity, and use of aesthetic treatment. A total of 428 adults (279 women and 149 men) aged 18 to 60 years (M = 31.51, SD = 10.73) participated in the study. Social anxiety disorder was measured using a Brazilian version of the Social Phobia Inventory. Body dysmorphic disorder by using a body dysmorphic symptoms scale validated for the Brazilian population. The main results showed that 28.7% of the sample reported symptoms of social anxiety disorder. Body dysmorphic disorder was more prevalent among women, individuals who had sought aesthetic treatment and individuals who were physically inactive. Moreover, lower levels of social anxiety disorder were observed in physically active individuals who had sought aesthetic treatment compared with physically inactive individuals who had sought aesthetic treatment. Social anxiety disorder was negatively correlated with age, daily workload, and income, while body dysmorphic disorder was positively associated with body mass index and negatively with income.
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
Congratulations to all the winners and
Congratulations Congratulations to all thetowinners all the winners and finalists and finalists at the at 2018 Aesthetic Awards 2018 Aesthetic 2018 Aesthetic AwardsAwards
John Bannon — serving aesthetic practitioners UK1985, andwith si John Bannon —John serving Bannon aesthetic — serving practitioners aesthetic throughout practitioners the UK throughout and Ireland thethroughout since UK and 1985, Ireland in the partnership since inIreland partnershi
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This course will provide an introduction to, and understanding of, topics relating to the development of obesity, the consequences, and health risks resulting from this condition. It will also help to develop preventative strategies and solutions for Aesthetic Practitioners looking to work in weight management. This course can be used as an adjunct to further education on medication prescribing in obesity for products such as Saxenda®. The course lessons address a range of topics: • The Obesity Crisis (The five factors of obesity, Globesity, How we define obesity)
OBESITY: MANAGEMENT
• Causes (The human being, Diet, Lifestyle, Environment, The patient and the health professional, Chronic stress and obesity)
FOR AESTHETIC PRACTITIONERS
Obesity is an increasing problem in the UK. With the NHS continuing to disband services, patients are looking to other service providers to help. Aesthetic Practitioners providing weight management services can help people with obesity transform their lives. REGISTER YOUR INTEREST TODAY: ccheducation.co.uk/aesthetic
£199
• Consequences (Obesity and adverse health consequences, How obesity affects your life, Stigma and discrimination) • Solutions (Physical activity and sleep, Culture and society, Communicating change, Acting on change, Energy balance) • Duration: 8-10 hours • Method of learning: Online • Mode of learning: Podcasts, videos, online learning units • Accreditation: 10 CPD hours; endorsed by the Association for Study of Obesity • Availability: 24/7 on tablet, laptop, smart phone or PC
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d finalists at the
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I find that in aesthetics, retention is a challenge because an employer can only afford to pay the employee a salary if their clinic’s expenses are covered, which is always substantially less than that person practising from their own home or on an hourly room rental. Money is the motivator!
The concept of employee ownership
ince 1985, in partnership with ip with
Using Share Schemes Dr Malcolm Willis provides advice on offering share schemes to increase staff retention There is a well-known aphorism that illustrates the future of those who do not notice a changing world. Charles Handy, visiting Professor at the London School of Economics, describes a frog being placed in cold water that is slowly heated. As the water heats, the frog adapts its body temperature until boiling point, which causes it to be boiled alive. The premise is that the frog does not perceive any danger until it is too late and it is cooked to death!1 Similarly, the world of business, and indeed the aesthetics specialty, is changing. Those of us with aesthetic businesses need to understand that we are potentially seeing the end of the employee society – a product of the industrial age with rigid hierarchies and, in some cases, a job for life.2 The skilled workers who generate our income are increasingly able to make work adapt to their needs, rather than the other way around.3 For example, the majority of employees in aesthetic clinics are women with families and other social responsibilities with a need for flexibility around their busy life schedule. An aesthetic practitioner may want to work in the evening after her partner has got home to look after the children, or during the day between school runs. By allowing her to book her own patients she retains control of her schedule and is more likely to be happy. In the current work environment, retention of talented, salaried staff can be a challenge for clinic owners. Loyalty to your company can fall to the back of the queue when the option of self-employment or other opportunities in clinics elsewhere can bring rewards. Is there a different way of doing things to avoid this disruption? Yes; several in fact. In this article, I will explain what has worked exceptionally well for my clinic, which has for the first time been shortlisted in the prestigious Aesthetics Awards in the iS Clinical Award for Best Clinic South England category.4 Please note that I am not a financial advisor, but am simply sharing my experiences and approach to enhancing staff retention.
Why staff retention is a challenge Hierarchies are not for everyone.5 Often, individuals dislike working in organisations where there’s always a manager to tell them how to do their job. I think this could partly be why so many clinicians are surging into aesthetics from the NHS. As human beings, increasingly we want to work independently or in a holacracy,6 where authority and decision-making are distributed throughout a holarchy of teams that are self-organised, such as the type espoused by business author Jacob Morgan in The Future of Work. He believes that the five trends shaping the future of work are new behaviours, new technologies, mobility and new beliefs due to millennial attitudes and globalisation.7
Employee ownership companies contribute £30 billion to the UK economy every year and the sector is growing at 10% per annum.8 Everyone has heard of The John Lewis model of employee ownership, which is the largest employee-owned company in the UK. According to John Lewis, this partnership model enables ‘partners’ to share their views about the business and use their voice as ‘co-owners’ to encourage a co-ownership culture.9 Employee-owned businesses are either completely or significantly owned by their employee. According to the Employee Ownership Association, the economic contribution of employee ownership in the UK is significant, delivering 4% of UK GDP annually, and this is growing.10 There are three different forms of employee ownership: 1. Direct: employees become registered individual shareholders of a majority of the shares in their company using one or more tax advantaged share plans 2. Indirect: shares are held collectively on behalf of employees, commonly through an ‘employee trust’ 3. Combined direct and indirect: a combination of individual and collective share ownership8 Some of the benefits of shared ownership schemes include impact on staff motivation, having a positive effect on their productivity, innovation, engagement, commitment to company success, as well as feeling more fulfilled and less stressed. Employee-owned businesses are also often good at recruiting and retaining committed staff.8 A company does, however, need to make a profit before it is able to pay any bonus. The brutal fact that many of us know is that new businesses usually run at a loss for the first few years – especially when premises, equipment and all overheads are thrown in. Therefore, the simple truth is that it will take you longer to make a profit if you ‘give away’ a percentage of your earnings.
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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advancement we have sponsored (e.g. filler and • Share Incentive Plans toxin treatments, fractional • Save As You Earn (SAYE) ablative laser treatments etc.). Receptionists are • Company Share Option Plans exempt, although they do • Enterprise Management Incentives (EMIs) 13 get commission on products • Employee shareholder sold at the front desk. We are particularly pleased On the other hand, in an aesthetic setting, to be able to offer our wealth-generating I have found that if you introduce an employees, who have been with us longer employee ownership scheme, you don’t than two years, capital shares in the business. tend to lose your high earning, skilled, key We only offer this to employees who have staff because they have been poached been with us for more than two years as by the competition down the road. This is they have demonstrated commitment to our because you are rewarding employees business. These shares are valued annually. with a guaranteed share of what they earn. The nominal issue at first valuation is £1 per Our experience is that the individuals who share, but this increases year on year. At work with us are entrepreneurial and highly present, 10% of the company is ring-fenced motivated by the concept of reward for their for employee ownership. If the shares are efforts. On another note, when the company given to the employee, they will be taxed is sold, the rewards of implementing a share at 30% capital gains on redemption.11 If the scheme can be considerable. For example, employee leaves before a sale, the shares a purchaser of the company who continues are bought back at original issue price. There the scheme is likely to retain all the key staff. are a number of tax and employee share schemes available.12 We chose to implement Employee ownership in aesthetic an employee enterprise management practice incentive (EMI) scheme. EMI is a tax In aesthetics, a huge proportion of our staff advantageous HM Revenue and Customs tends to be women, who are often mature, (HMRC) scheme that is designed to reward well-educated with minds of their own, have and encourage employee involvement with families and aspirations. In my experience, a view to more productive and satisfying our staff want to be enthused, empowered, working relationships. What an individual entrusted, involved and persuaded – they company does is determined by advice want to be rewarded. Interestingly, when from one’s accountants and lawyers. With morale is high, and staff feel valued, this scheme, employees must do 75% of their notion of profit extends beyond the their total working time or work 25 hours’ financial bottom line to include professional, per week in the clinic to be eligible. The psychological, emotional and social profit. art of successful business is knowing how I find that the saying ‘what’s good for you is and when to write down investment, capital good for me!’ is a valuable approach for the and other costs against tax. The value of a successful running of an aesthetic practice. company is calculated according to a formula As a business owner, I believe that if I’m known as EBITDA (earnings before interest, going to be successful, then let’s give staff tax, depreciation and amortisation)13 which is the chance of sharing in the spoils. a proxy for a company’s operating profitability. The aim is to issue initial shares when the How the share scheme works in my clinic company is technically loss-making. Since starting The Doctors Laser Clinic in When putting an EMI scheme together, you 2010, we have used a ‘direct’ employee need apply to HMRC with a submission ownership share scheme – as far as I know, of your accounts as they need to register our clinic is the only medical aesthetic clinic in the UK doing this. We decided to have a 20% current account share scheme for all fee-earning staff doing practical procedures (for VATable items this effectively rises to 25%). We have since changed this and implemented a 50% share (after deducting material costs) with some of the high level, skilled work in recognition of the experience and qualifications of the practitioners whose
Types of tax and employee share schemes
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the value of the company at the time of initial share issue.14 If done at an opportune moment, such as when you are still making losses, the shares have only nominal value. This scheme has benefits for your business in terms of corporation tax. If an employee leaves your business, the shares are remitted at issue price. The incentive for employees is to stay long enough to contribute to the growing value of the enterprise and in due course draw dividends. When cashed in at a future date, any capital gain on these shares is only taxed at 10%.12,13 This approach used along with others outlined below, has allowed for our practice to really grow. We started off with one treatment room, five doctors, one nurse, one hair removal laser and toxin treatments in 2010. The practice now includes three doctors, four nurses and three laser technicians at Level 5 BTEC, who practise in seven treatment rooms with about 20 treatment modalities. How we built success As well as implementing share schemes, we had a few additional tactics that helped our clinic succeed. Like many other new businesses, our company made significant losses over the first few years as investment was written down against profit. There eventually came a sweet point when we could look over the horizon and see ourselves coming into profit. In the clinic’s early days, our staff had zero hours’ contracts. This meant they would only come into the clinic when they had patients to see. They were able to book their own patients remotely using our clinic software management system Pabau;15 other systems are also available. This approach allowed us to save time and money as we were not paying for staff to be there when they were not making money. For the first four years, we subcontracted our telephone service to an external company, which took caller’s details and immediately emailed the enquiry onto our personal digital assistants. The service we chose to use was Virtual Office,15 although there are other similar services
The saying ‘what’s good for you is good for me!’ is a valuable approach for the successful running of an aesthetic practice
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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available. This helped save costs because we didn’t need a formal reception set up and we only paid 40p per call handled. The enquiries that were sent were distributed to the staff equally and I personally asked each member in rotation whether they wanted the work or not – they did! We ensured that all our staff were cross-skilled so that they can cover in the event of illness, holiday or absence. In my experience, the principle is that in this business, if you are good then you get return custom; if you’re very good you get recommendation, and so it builds. Our clinic works that for every £100 gross earnings that is earned by the business, £20 goes to the practitioner. This has helped our staff understand the importance of cross-selling and motivates them to achieve sales. Using this strategy was slow at first but over eight years we have built a substantial clientele.
Share schemes can work in aesthetics I believe that, generally speaking, if you are going to be successful in aesthetics you need to be kind, honest, truthful, charge a
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reasonable fee, do a good job and put it right at no expense to the patient if it goes wrong. With your staff, I think that you need to show that you care, value them, enthuse them, educate them, empower them and share your profits with them. In the short term, you may be poorer financially, but in the long term you will reap rich rewards. You will enjoy the benefits of being part of a functional, dynamic community that is a million light years away from the dystopian, dysfunctional world of the bureaucratic hierarchies! Dr Malcolm Willis spent 30 years as a family GP in Norfolk, having served in the Army as doctor in The Falkland’s War and Northern Ireland. He spent 10 years as an Honorary Senior Lecturer in Medicine at Norwich Medical School teaching medical students dermatology, cardiology and respiratory medicine. According to Dr Willis, he should be retired but loves the vitality and professionalism of his co-workers too much to give up.
REFERENCES 1. Maxim Jean-Louis, The Future of Work in a Changing World, Aurora. <http://aurora.icaap.org/index.php/aurora/article/ view/52/65> 2. The Employee Society Peter F. Drucker American Journal of Sociology Vol. 58, No. 4 (Jan., 1953), pp. 358-363 3. Charles Handy – Beyond Certainty 1995 and The Empty Raincoat 1994 4. The Aesthetics Awards finalists, the iS Clinical Award for Best Clinic South England, 2018. <https://aestheticsawards.com/ voting/category/12> 5. The Influence of Social Hierarchy on Primate Health – Sapolski - Science 29 Apr 2005 6. Arthur Koestler’s 1967 book The Ghost in the Machine 7. Jacob Morgan, 12 Skills You MUST Build To Succeed In The Future Of Work. <https://thefutureorganization.com/ 8. Employee Ownership Association, Employee Ownership Impact Report, <http://employeeownership.co.uk/wp-content/ uploads/The-Impact-Report.pdf> 9. John Lewis Model of employee ownership. <https://www. johnlewispartnership.co.uk/work/employee-ownership.html> 10. Employee Ownership Association, What is Employee Ownership? <http://employeeownership.co.uk/what-isemployee-ownership/> 11. Holly Bedford, HMT Corporate Finance, Share Buybacks – Income Tax or Capital Gain? http://www.hmtllp.com/sharebuybacks-income-tax-or-capital-gain/ 12. Gov.uk, Tax and Employee Share Schemes <https://www.gov. uk/tax-employee-share-schemes> 13. Investopia, EBITDA - Earnings Before Interest, Taxes, Depreciation and Amortization, 2018. <https://www. investopedia.com/terms/e/ebitda.asp> 14. Gov.uk, Tax and Employee Share Schemes, Enterprise Management Incentives (EMIs) <https://www.gov.uk/ tax-employee-share-schemes/enterprise-managementincentives-emis> 15. Pabau Clinic Management Software Features <https://www. pabau.com/> 16. Virtual Head Office – The Pay As You Go Head Office <https:// virtualheadoffice.co.uk/>
COME AND MEET US AT STAND 6 WINNER 2018
For more information: T: 01753 595183/07853 932645 www.skinpenuk.com Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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frustrating when starting out. Working in an existing clinic would be very different. You are working for someone else and will be paid a set amount of money for doing a set amount of work each month. Commonly, a clinic will pay you by the hour and there may be commission-based opportunities. If you want a regular pay cheque, then I would say that working in an established clinic is for you.
The clinic location and ownership of patients
Considerations for Setting Up Your Own Business Dr Qian Xu outlines the pros and cons of working for yourself versus working for an established clinic Moving from the comforts of the hospital environment to the world of aesthetics can be a big shock to the system for most healthcare professionals. Many new practitioners may prefer to look for a familiar environment and seek a job in a wellestablished aesthetics clinic, whilst some who are able to make a financial investment may prefer to set up their own clinic. Like a lot of other aesthetic practitioners, I have chosen the latter. This is because I have always wanted to build something for myself to have the freedom to decide when to work and how much to work; I didn’t just want to go from one job into another job. It has been a tough six years, but it has also been hugely rewarding. This article is aimed at those starting out in their career as I will discuss the pros and cons of working for yourself, as opposed to working for a business that is already well-established within the aesthetics specialty.
Working hours A lot of healthcare professionals are drawn to aesthetics because of the thought of a better work-life balance. If you can earn more while working less hours, with no night shifts, then it’s a no-brainer. By setting up your own business you will be in charge of your own patients, you will have absolute control over when you want to work and
how much you want to work. You don’t have to book patients in the evenings or weekends if you don’t want to. If you work in a clinic, you will have less choice over your working hours and workload. Many clinics do open in the evenings and weekends, as those are the most popular times for people to attend. So, it’s highly likely that you will be required to work some of those shifts for the clinic. Having said that, working for yourself is not exactly nine to five either. Seeing the patients is the easy part. It is all the businessrelated activities that will actually take up most of your time. If you are aware of this when you first start and build your business in a smart way, you can ensure that your clinic will grow without it taking up more and more of your time.
Income stability If you work independently, you get to decide your own prices. Whilst some may think ‘Great – I can charge four times the cost of the product!’ you mustn’t forget that as you are running your own business, you also need to pay for other things such as rent, insurance, utility bills, advertising and training. Because of this, it can be very normal for a practitioner to not be making any profit at all in the first year, or even the second year of business, which can become
If you apply for a clinic job, the clinic location is obviously fixed. Some more well-known chains have clinics in different locations that you may be able to work from and these clinics are already stocked with everything you need; so you can just turn up to work and do your job. The patients you see will belong to the clinic. Your contract is likely to prevent you from taking those patients with you when you leave, and it may also specify that you can’t work for another clinic or for yourself within a certain radius of the clinic. This wouldn’t be an issue if you set up on your own. If you have multiple locations, you can give your patients the choice of where to see you. There are a number of factors you will need to consider when looking for your own clinic space including requirements of the premises which would need to be explored separately.1,2
Marketing How to market your services appropriately and effectively is the thing that every practitioner struggles with; we are clinicians after all, not marketers. This is why sometimes working in a clinic can be more appealing, so you can focus on what you do best, and someone with marketing experience is appointed for that line of work. Indeed, larger clinics often have a whole marketing team dedicated to this with a much larger marketing budget than you. So how can you, an individual practitioner, compete with them? As an independent practitioner, if you try to tackle marketing in the same way as the big clinic chains, you may lose a lot of money very quickly. This is because no one knows about you or your brand. Your reputation and brand identity can take a long time to build. If someone likes you and wants what you offer, then they will buy and refer their friends. I’d recommend that networking and ‘getting yourself out there’ is the best way to market yourself. I have found that hosting and attending networking events is
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
usually very successful as patients like to meet you in person rather than just through Instagram, for example.
Peer support There is no denying that working alone can be extremely lonely and sometimes access to supervision and mentoring is still very limited. While it is possible now to have clinical mentoring as part of the Level 7 qualification, the quality of continuous support is extremely variable. For non-prescribers, finding a prescriber to support your work can also be a huge challenge, unless you already know a prescriber. Most people think that they would be better supported if they work in a clinic and one of the positive things about working in a clinic is that it can feel less lonely having other practitioners to work alongside, and be part of a team, who can cross-cover for each other in case of emergencies or holidays. Usually, when having your own business (where you are the only employee), no one can cover for you, so you could get called at any time to deal with a problem. This is the risk that you must be prepared to take to do this kind of work. In reality, complications are extremely rare and patients are usually happy to work around your holidays. So, this has never been an issue for me. Having said that, I do believe that every practitioner should have an experienced aesthetic practitioner they can call for help and advice, regardless of your experience and qualifications. Knowing you have the support of your peers can only be a benefit.
Summary There are a number of considerations you must take into account when starting out and deciding if you want to work for yourself or as part of a larger, perhaps more established brand. In a speciality where it is very common to work for yourself, I would say that although it can be daunting at the beginning, having the autonomy to decide who you want to treat, when you want to see them and how much you want to charge for your time is worth the time, money and effort that you put in. Being an independent practitioner doesn’t mean you have to be all alone. Networking is a great way of making new friends, inside and outside of the aesthetics sector. Don’t just post in Facebook forums, try to meet people in person. Dr Qian Xu is the founder and medical director of Skin Aesthetics. She has a background in surgery and emergency medicine, before she began specialising in aesthetic medicine in 2012. Dr Xu was a lead trainer and mentor at Harley Academy, and since leaving in May 2018, she has set up the Aesthetics 360 Business Training Academy. FURTHER READING 1. Care Quality Commission, ‘The fundamental standards’, (UK: CQC, 2018) <https://www.cqc.org. uk/what-we-do/how-we-do-our-job/fundamental-standards> 2. Joint Council of Cosmetic Practitioners, ‘JCCP Premise Standards’, (UK: JCCP, 2018) <https:// www.jccp.org.uk/ckfinder/userfiles/files/JCCP_Premises_Standards_Terms_of_Reference. pdf&ie=UTF-8&oe=UTF-8>
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explained in more detail below. This is because we want them to be able to answer as many questions fielded to them as possible by patients. One day they might be asked about what Food and Drug Administration approval is, other days they might be asked about what fillers the clinic uses; they need to know about every aspect of the business. It is the receptionist’s responsibility to maintain the high standards that the owner or medical director has set out, and to reflect and represent the brand in the best way possible. Below are some points that I really focus on when it comes to my reception team.
Utilising Your Reception Team Dr Rekha Tailor discusses how to make the most of your clinic’s reception team and how its members can help provide overall business success At my clinic, we pride ourselves on our customer service and that goes far beyond education, training and the treatment itself. I want to strive to provide an exclusive, clinic experience from the beginning right through to end and this often starts with the first point of contact a patient has; our reception team. The importance of reception teams can be overlooked and, in some cases, many business owners divide this role between therapists. However, I believe your reception team is as vital as any other role. Your reception team members are usually the first and last faces that are seen by a patient and they can therefore be seen as the face of your brand and leave that allimportant last impression.
The face of your brand Firstly, I think you need to ask yourself what it is you want to get out of your reception team and recognise that a receptionist’s responsibility has changed over the years. Typically, they would answer phones and greet patients, but now much more is expected of them. This may be due to the expansion of digital marketing and social media where people have access to so much more information, so when a potential patient calls a business, they are generally well informed and are looking for accurate
information immediately. I always say that members of a reception team have to be all things to all people; by this I mean a comforting voice to concerned patients or an information service for potential patients, in addition to their roles as vital administration staff. My receptionists answer enquiries on emails as well as social media, while manning the phones, and also welcoming patients, making coffees and supporting the entire clinic team. Part of what makes the team so valuable is them being able to help and guide all patients before their initial consultation. To achieve all of these things, from day one I ensure that any new members of my reception team begin extensive training,
Appearance In my clinic, I provide receptionists with a black suit and on-brand colour blouse so they fit into their surroundings and look professional when a patient walks in. They all wear name badges in order to create a more personal approach and reassure patients so that they know who they are talking to. From well-kept hair and nails, to polished shoes, we always ask our team to be well presented. I believe it is important to distinguish the reception team from the aestheticians (particularly as many reception staff are not trained in performing treatments) so I personally made the choice to have my reception team wearing suits rather than clinical scrubs. Not only should receptionists take pride in themselves, but they should also take pride in the clinic surroundings too. As well as first impressions, I find that it’s often the smaller details that impress patients the most. A tidy and luxurious environment are all things that won’t go unnoticed and will set you apart from other clinics. I always ask that my reception team members offer patients a luxury magazine, a hot or cold drink, provides the free Wi-Fi password, and remember to play branded videos on our flat screen televisions.
It’s the receptionist’s responsibility to maintain the high standards that the owner or medical director has set out and represent the brand in the best way
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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Communication is key Mystery shopping Something that I find has been really vital to training our staff is by enrolling in a mystery shopping scheme. With this, a ‘patient’ will call and ask certain questions proceeding to book an appointment. They report back to us on things like how quickly the phone was answered, whether the reception team introduced themselves, whether they offered information needed and how the call experience was in general. When they arrive in the clinic, we want to know whether they were offered a tea or coffee and how they were made to feel. Was there anything else that set us apart from others? By doing this it means that we have a subjective opinion on the experience of the clinic and service from beginning to end. Costs can vary depending on the type of service that you require, I would say that it is normal to pay up to £1,000 for a telephone mystery shop.
Etiquette Etiquette and good manners are key for any reception staff, including the language and tone of voice used. For example, I ask that all of my receptionists answer the phone within three rings, take the caller’s name and use it during the call. They must also introduce their name so the caller knows who they are talking to. I also ask that they wait until the patient hangs up before they do and that they follow up the call with an email, providing them with all the relevant information that they may need. Upon booking, we also send our patients a map and image of the clinic, with details on where to park and how to find us;
Training I always train my reception team members on the products that we sell and allow them to experience all of the treatments so that they can describe first-hand what to expect to patients. This can range from asking team members to undertake online courses about complaints and telephone manners, sitting in with our aestheticians who specialise in a particular treatment or taking them to events such as the Aesthetics Conference and Exhibition, where they can attend business talks and meet with suppliers. Of course, if the patients are looking for much more
I always train my reception team members on the products that we sell and allow them to experience all of the treatments so they can describe first-hand what to expect to patients this helps to make the process extremely easy for them and provides instant access to any information or education they may want prior to any consultation or booking. I believe that it is the clinic owner’s responsibility to ensure the receptionists have whatever they need to do their job well. For example, in my clinic I have pre-written email templates for all treatment types with plenty of information and educational attachments. We also openly show a clear complaints protocol on a sign on the desk in reception, which includes all information on the Care Quality Commission and feedback from CQC inspectors.1
in-depth information, such as how much filler would be suitable for their lips, the receptionists are aware to advise them to come in and meet with the appropriatelytrained practitioner. Our receptionists are always supported and given access to the aestheticians, clinic manager, other medical staff or myself throughout the day if they are ever in need of extra information. The team is also trained on how to use our clinic management software to ensure that the correct procedures and process are followed and are as smooth as possible.
Many clinics are open six days a week and often there will be an overlap in staff. Because of this, I think communication is key to maintaining a successful business. It is essential that employees are aware of all that has happened in their absence on a day-to-day basis. Therefore, I advise that my team utilise a handover sheet. This is for all details to go on so that for the upcoming days, weeks or even months the team has a full list of issues, notes or things to remember so that nothing slips through; these are also stored in one place to ensure nothing is lost. For example, this can include things such as noting we are down to our final batch of folders for the next stationery order, to notes on changes to the customer relationship management (CRM) system. We are also very conscious of data security and password protect our internal server and lock all cabinets and filing systems daily. In addition to this daily handover, we have a weekly meeting where we can discuss marketing plans, opportunities, news, events and training. It is a useful time for all staff to explain their highs and lows of the week, tell everyone what they have learnt or exchange information from the week’s learnings.
Conclusion A receptionist in a luxury clinic is extremely important to the success of your business. Having genuine concern and empathy for patients is always a requirement within the team. A kind, listening ear is needed as patients can sometimes be nervous about a treatment. Our reception team is the first port of call for these patients for reassurance and information, hence why I believe it is fundamental in investing time and training in your team members to ensure the overall success of your business. Dr Rekha Tailor is the founder and medical director of health + aesthetics. She has been a qualified medical practitioner for more 26 years and an aesthetic practitioner for more than 10. Previous to this she was a fully accredited GP, after training at the University of Manchester.She is a full member of the British College of Aesthetic Medicine (BCAM). REFERENCES 1. Care Quality Commission <https://www.cqc.org.uk/>
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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“We hope to improve communication and collaboration between the surgical and non-surgical aesthetic specialties” Miss Priyanka Chadha and Miss Lara Watson discuss their passion for patient safety, explain why they believe cosmetic surgery and non-surgical aesthetics correlate, and explore their joint venture of promoting excellence in aesthetics training A colleague and mutual friend once told surgeons Miss Priyanka (Priya) Chadha and Miss Lara Watson that they would never see eye-to-eye because of their competitive nature. However, much to this individual’s disbelief, when they met on their first day of foundation training in 2012 it was like ‘Love at first sight’, laughs Miss Watson. She explains, “I can remember the very moment I met Priya and can even recall what she was wearing! We clicked straight away as we found we had a lot in common, like our aspiration to pursue surgical careers.” Since then, the pair have remained firm friends as well as becoming business partners. Although they are relatively new to the non-surgical aesthetic sector, they have achieved a lot in both their surgical and academic careers so far. Their combined accomplishments include eight degrees, over 50 academic prizes and countless national and international presentations. As junior doctors, they both secured full membership to the Royal College of Surgeons early on in their training and have since founded a successful aesthetics training academy, which received a commendation for the Enhance Insurance Award for Best Independent Training Provider in 2017. It’s safe to say that education is more than simply a requirement for the pair, who clearly demonstrate a
passion for academia and further education. Miss Chadha jokes, “We’re both geeky academics at heart.” So, where did their passions come from? For Miss Chadha, it all started at Imperial College London, where she studied medicine. “I have two older siblings who are also both surgeons,” she says, explaining, “I decided to do plastic surgery within the first year of entering medical school, simply because it fitted with me and my personality perfectly.” She graduated in 2012 with a distinction in both Medicine and Surgery. After scoring in the top 1% of the country for Core Surgical Training, Miss Chadha proceeded to secure a registrar number with a number one ranking. Miss Chadha also completed a Diploma in Philosophy and Ethics of Healthcare in 2015, which she says has allowed her to better understand the legalities surrounding consent, something that she has found can be challenging for many practitioners. “I think it’s one of the most poorly understood areas within both medicine and aesthetics. Understanding the legalities and ethics around consent is really important – my background in medical ethics and law makes me appreciate that,” she explains. Miss Chadha also completed her Master’s in Teaching and Surgical Education from
“We have found that people want to be empowered by an in-depth understanding of anatomy and grasp concepts around this really well” Miss Priyanka Chadha
Imperial College London, as well as gaining a Diploma in the Ethics and Philosophy of Healthcare. Miss Watson graduated from medical school in 2012, by which time she had also achieved a Bachelor of Sciences in Advanced Anatomy and a Bachelor of Medical Sciences in research. After discovering she had, “A real draw to surgery of the head and neck” during her foundation training, Miss Watson returned to studying in pursuit of a career in oral and maxillofacial surgery. She has since been awarded a Bachelor of Dental Surgery with Honours from King’s College London. Miss Watson describes how she always had an interest in art, which she considers closely related to aspects of surgical practice. “I have a real love of art and enjoy dabbling in figurative sculpture. I actually considered studying the History of Art at BSc level before deciding that anatomy would be a safer choice!” She notes, adding, “I feel that an understanding of artistic principles can really help the training surgeon, especially those working on the head and neck.” Miss Watson is now pursuing higher training in her chosen specialty of oral and maxillofacial (OMFS) surgery, having secured the only OMFSthemed core surgical rotation in London, at King’s College Hospital. A few years following their own aesthetic training, the pair were inspired by a sense of duty to respond to a seeming gap in the industry and decided to establish their own training academy. “The conception of our training academy came following a complication that I had, which made me notice that there was really limited support out there when it came to complications,” said Miss Chadha. She adds, “I consulted Lara for assistance and we had a really long discussion about the general inadequacy of support for complications in aesthetics and
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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that there was a gap that needed to be filled. We decided to bring a multidisciplinary group of practitioners together who could fill this gap; doctors, surgeons and dentists. We have a lot of support and guidance ourselves from senior colleagues too.” In 2016, the pair launched Acquisition Aesthetics, aiming to assist doctors, dentists and nurses in furthering their clinical education to become more confident in their skills to help promote patient safety and practitioner support. Their team consists of more than 15 trainers, each specialising in different areas, including dermatology, dentistry, plastic and maxillofacial surgery, regenerative medicine, and more. “We have found that people want to be empowered by an in-depth understanding of anatomy and grasp concepts around this really well,” Miss Chadha notes, explaining, “At the end of the day that is what leads to safe practice, and I feel like our delegates leave feeling confident that they can deliver safe treatments. They also leave feeling
Aesthetics aestheticsjournal.com
feel confident with. We also get comfort from knowing that they are going to deliver beautiful results to their patients in a way that is going to support public safety.” While many practitioners choose to say goodbye to the NHS to pursue private aesthetic practice, Miss Chadha and Miss Watson continue to dedicate the majority of their time to the health service. As well as their academy, the pair have an unwavering commitment to the NHS, although they say that coordinating their commitments can be a challenge. However, Miss Chadha says, “Between the two of us we manage to balance our training commitments on top of our NHS commitments. That said, we are also extremely lucky to have a fantastic group of people who support us at our training academy, from administrative staff to trainers and advisory consultants.” For those looking to succeed in aesthetics, Miss Chadha and Miss Watson agree it’s important to never underestimate the depth and significance of learning. Miss Watson
“One of our mottos is ‘knowledge is power’, so never stop learning and never stop asking questions” Miss Lara Watson
supported, which is one of the principles of our academy and something we have carried through right from the beginning.” Miss Watson adds, “One of our aims is to improve the communication and collaboration between the surgical and the non-surgical aesthetic specialties. We believe that better communication between these two modalities could pave the way towards safer practice in the non-surgical sector and perhaps enhanced cosmetic results in the surgical sector. Through our academy we try to incorporate what we have learnt from the surgical side in order to provide a special insight to our training delegates, which includes a strong anatomical focus. We also utilise training methods we have experienced ourselves in surgery to create cutting-edge teaching programmes in aesthetic medicine.” Miss Watson notes that her and Miss Chadha get a real ‘buzz’ from training, “We love that feeling at the end of a course when we know we have trained an empowered group of people who feel ready to start out in the industry with a set of skills that they
says, “One of our mottos is ‘knowledge is power’, so never stop learning and never stop asking questions. Try not to isolate yourself, join forums and discussion groups, share your ideas and concerns and seek help with difficult cases.” She adds, “Get yourself out there. There are so many courses, conferences and opportunities for further learning available to today’s practitioners. It’s a really exciting time for the aesthetics sector.” While the pair have an extensive education portfolio, they practise what they preach and are continuing to train and learn. When asked about their five-year plan, Miss Watson says, “I will be continuing to train in maxillofacial surgery and hope that Acquisition Aesthetics continues to grow in the way that it has. Looking towards the future, we would love to see the nonsurgical aesthetics field more aligned with the surgical field, including enhanced regulation. We very much hope we can be part of that change.” Miss Chadha echoes this vision, adding,
How does it feel to be an Aesthetics Awards finalist for the second year running? LW: Fantastic! We’re thrilled that our fantastic team’s hard-work has been acknowledged. PC: It’s especially wonderful to be recognised for a second year running. What’s your best advice for success? LW: If you maintain your integrity throughout whatever conflict you come across or criticism you might face, you can’t go too far wrong. PC: A consultant plastic surgeon once advised me to keep my head down, and carry on. Keep ploughing through and have continued determination. What do you enjoy training delegates in the most? LW: The aesthetic consultation, including facial examination. For me this is when the science of anatomy and the art of aesthetics synergise. It’s the key to achieving great results. PC: Definitely the consent process – understanding the legalities and ethics around consent is a really eye-opening lecture for all our delegates and it changes their approach as they go through the training day. You can see their mind-set evolve. What are you most looking forward to in the future? PC: We have exciting prospects for 2019, including expansion to a number of new cities with the academy and new roles within Galderma, which we are proud to announce, as two of their educational faculty members. LW: We’re also developing the technology and digital side of the academy hugely, which is certainly taking up the majority of our time. It’s all really exciting and we’re working with some pretty impressive (and really clever) people to do it.
“Collaboration is key and when heads are put together, what can be achieved is pretty impressive. Collaboration between surgical and non-surgical aesthetics will contribute to safety and clinical progression in the industry. I also believe supporting peers and new practitioners entering aesthetics would be a really nice thing to see more of.”
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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The Last Word Mr Fulvio Urso-Baiarda argues that the lack of data in the specialism is damaging patient safety and explains why he believes more data is needed to protect both practitioners and patients The non-surgical cosmetic industry is booming, as patients are frequently turning to non-invasive solutions that result in less recovery time. The current market is worth an estimated £3.6 billion, with treatments such as botulinum toxin and dermal fillers accounting for 90% of the market share.1 And where there is demand, there is supply, which, in the UK, is largely unregulated. It’s my view that this lack of regulation is risking a situation where the credibility of the sector will suffer irrevocable damage if we do not change the way we do things. But, to change the lack of regulation, I believe we need evidence to evaluate patient outcomes and ensure we put in place the most effective care. The paucity of available statistical evidence and facts is hindering our ability to safeguard patient safety and this needs to change. As clinical practitioners in the aesthetics field we should be at the forefront in adopting a recognised, centralised, system of data collection.
What can be measured can be improved The Nuffield Council on Bioethics’ 2017 report titled ‘Cosmetic Procedures: ethical issues’ highlighted the urgent need for better data on the use of procedures, as well as the need for more research to improve the evidence base if improvements in the practice of the specialism are to progress.2 Similarly, the GMC recognises
the importance of sharing information and states in its guidelines for doctors who offer cosmetic interventions that ‘you should share insights and information about outcomes with other people who offer similar interventions to improve outcomes and patient safety’.3 However, currently in the UK, small sample data or commercially driven data are the primary benchmarks available to practitioners. Many industry associations such as the British Association of Aesthetic Plastic Surgeons (BAAPS) are active in collecting data from their members, although this is only from practitioners who have voluntarily become members. As well as this, data collected from all parties, including associations, insurance providers, manufacturers etc. are not pooled to one centralised place. Even if this were to occur, pooling data from multiple sources can cause double reporting (the same incident reaching a central source via two different routes independently). I also believe that, anecdotally, there is tremendous underreporting of scenarios such as complications, which I think is impacting patient safety. Practitioners may/ should be aware of reporting drug/device problems to the Medicines and Healthcare products Regulatory Agency (MHRA), but they may feel defensive to report technicallydependent problems. Insurers will only record situations resulting in an insurance
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claim, and legal firms will only have data from those resulting in litigation. These could be the tip of the iceberg, because even relatively serious events can result in neither, especially in the non-surgical world. A rich data set will allow us to understand the variables in the treatment outcomes. For instance, if complications are arising due to a specific product or poor hygiene standards. Currently, no one really knows the extent of the adverse event incidents caused by medical aesthetic treatments such as dermal fillers and botulinum toxin and the public is under the misconception that non-surgical means non-medical. Compiling data on adverse effects will help reinforce that treatments should only be carried out by medically-trained professionals, equipped to intervene should things go wrong. If this data is collated in a centralised place, it can be analysed and will provide clear indications for industry improvements. Finding any patterns and correctly interpreting the results is an important step towards creating a better and safer system for practitioners to work within.
What needs to be done? Although some industry improvements have been made in the five years post the Keogh review,5 much more work still needs to be done regarding data collection and regulation. What is needed is not just ‘some’ data, but ‘enough’ data to establish who is having the treatments in the industry (age, gender, race etc.), exactly who is providing them (the background of the practitioner – are they medically trained?), where they are taking place, together with product types, dosages and resulting complications. Capturing data will help the sector become more open and transparent, providing the evidence to prove what works and what doesn’t. It will also help remove non-evidenced based decision making. For example, if the data reveals more complications occur when administered in non-clinical settings, then it will help strengthen the argument for legislative change. I believe all practitioners should be active in reporting their clinic data. Although I think this reporting should continue to be submitted to a professional’s regulatory bodies and associations, I do think there also needs to be a common place to submit this data. I believe the Joint Council for Cosmetic Practitioners (JCCP) offers a unique opportunity to help to move this issue forward because there are all different
Reproduced from Aesthetics | Volume 6/Issue 1 - December 2018
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types of practitioners and training providers that are eligible to join and therefore will represent a wide variety of individuals. For those reluctant to self-report adverse events, I think it’s important to view this process in a positive light. We all want to raise standards across the sector and data will help us achieve this. In the absence of a formal reporting process, I think practitioners need to report what has gone wrong to the JCCP register. This would allow tracking and calculations to be made on the rate of incidents on a nationwide scale and would mean we could evaluate what treatments are associated with poor outcomes and help minimise risk.
Pushing for legislative change As Professor David Sines, chair of the JCCP, has stated, “Nothing less than statutory regulation will protect the public.”4 I agree with this statement and as clinicians, I believe we need to drive forward this debate for legislative change. Data helps make the case for mandatory regulation by highlighting the standard of medical training required to perform treatments adequately and the importance of clinical settings to protect patient safety. Statutory registration would require all registrants to report adverse incidents to the regulator, which would enable a rich data bank to be built in one place, that could be shared with agencies such as the MHRA, with the aim of reviewing practice standards and the provision of safe practice guidelines and products. Currently, stakeholders like the General Medical Council, the Cosmetic Practice Standards Authority (CPSA) and the JCCP are working together to drive forward the legislative debate and push for regulation. We can help
protect patients and increase data collection by supporting these frameworks, so we can build our specialty based on facts, and not intuitive guesswork. Data collection is the starting point for making much-needed improvements to the aesthetics specialty, enabling us to change the landscape and shape our profession. If we don’t have sufficient facts and figures, we will never be able to measure effectiveness of treatment or the capability of practitioners and push for regulation. Mr Fulvio Urso-Baiarda is a consultant plastic, reconstructive and aesthetic surgeon working in private practice. He has been awarded numerous prizes for his work. Mr Urso-Baiarda is also author of the aesthetic textbook Evidence-Based Cosmetic Surgery. He is an advocate of improving and regulating the safety standards within the industry and has worked with both the Cosmetic Practice Standards Authority (CPSA) and the Joint Council for Cosmetic Practitioners (JCCP) to help raise awareness amongst colleagues and the public. REFERENCES 1. BBC, Botox and fillers: Are these ‘tweakments’ all they’re cracked up to be?, 2017. <https://www. bbc.co.uk/bbcthree/article/075551b0-d866-45db-ab6a-149ce182d741> 2. The Nuffield Council on Bioethics’, Cosmetic procedures: ethical issues, 2017. <http:// nuffieldbioethics.org/project/cosmetic-procedures> 3. GMC, Guidance for doctors who offer cosmetic interventions, 2016. <https://www.gmc-uk. org/-/media/documents/Guidance_for_doctors_who_offer_cosmetic_interventions_210316. pdf_65254111.pdf> 4. Kilgariff, S, News Special: The Launch of the Joint Council, 2018. <https://aestheticsjournal.com/ feature/news-special-jccp-to-update-hee-framework>
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