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

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

VOLUME 7/ISSUE 3 - FEBRUARY 2020

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

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

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

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Treating the Neck CPD

HA Filler | Threads | PRP | ACA & SVF | Skincare

Dr Souphiyeh Samizadeh explores neck rejuvenation with injectable treatments croma_inserat_210x297_NL_ada_1811_gch.indd 1

Special Feature: Tackling Skin Conditions Dermatologists share successful patient case studies

11.12.18 11.12.18 13:45 13:45

Ageing and Pigmentation

Dr Amiee Vyas treats a patient with pigmentation and 11.12.18 ageing with skincare

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

Referring for Hair Concerns

13:45

Dr Ingrid Wilson advises on best referral options for patients with hair loss


Contents • February 2020 06 News The latest product and industry news 14 Regulators Tighten Toxin Advertising Rules

New technology will monitor social media advertisments

17 Case Study: A Warning to Toxin Providers

Dr John Curran and Hayley Jordan review a recent medical legal case

18 Influencer Injectors

The industry responds to the rise of non-medic ‘influencer injectors’

20 Develop Your Business Skills at ACE 2020

Special Feature: Treating Dermatology Conditions Page 23

Learn from industry business experts on March 13 and 14

CLINICAL PRACTICE 22 Advertorial: Sterimedix Innovations in Cannulas The only UK manufacturer of aesthetic cannulas leads the way in innovation 23 Special Feature: Treating Dermatology Conditions

Dermatologists discuss treatment approaches in five case studies

31 CPD: Treating the Neck with Injectables

Dr Souphiyeh Samizadeh explores neck treatment using toxin

35 Case Study: Angiomas & Pigmentation Physicist and bioengineer Mike Murphy presents a masking technique for

anigomas and lesions

41 Case Study: Ageing and Pigmentation Dr Amiee Vyas presents a case study with topical skincare 45 Considerations for Cheeks Dr Tino Solomon explores the attractiveness of cheeks and considerations

for augmentation

49 Advertorial: Croma-pharma: Made in Austria Becoming a global player with minimally invasive aesthetic medicine 51 Treating Acne and Scarring Aesthetic nurse prescriber Amanda Wilson shares an introductory overview 55 Understanding Moisturisers Dr Benjamin Chun-Man Lee explains how and why moisturisers benefit skin 60 Advertorial: The Next Evolution of Body Contouring State of the art muscle toning using the innovative StimSure device 61 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 62 Utilising Radio Marketing Clinic manager Kerri Lewis uncovers the usefulness of radio marketing 65 Capitalising Patient Imagery Mr Benji Dhillon presents key considerations for creating patient imagery 69 Referring for Hair Concerns Dr Ingrid Wilson explores the referral options for patients with hair loss

In Practice: Utilising Radio Marketing Page 62

Clinical Contributors Dr Souphiyeh Samizadeh is a dental surgeon and clinical director of Revivify London clinic. She is the founder of the Great British Academy of Aesthetic Medicine, as well as an honorary clinical teacher at King’s College London and Queen Mary University. Mike Murphy is a physicist and bioengineer with 34 years’ experience in medical lasers. He is currently the general secretary of the Association of Laser Safety Professionals, is a Certificated Laser Protection adviser. Dr Amiee Vyas is the founder of Doctor Amiee Facial Aesthetics & Skin, with a focus on skin health and wellness. She is a KOL in cosmetic dermatology for AestheticSource, and is accredited by Save Face. Dr Tino Solomon practises at the DrMediSpa clinic. A graduate of UCL medical school, he initially underwent speciality training in general and laparoscopic surgery before making the move to primary care. Amanda Wilson is a nurse prescriber with a special interest in dermatological diseases. She treats a high number of acne patients and is one of the lead trainers at Healthxchange Pharmacy, where she runs training and management courses. Dr Benjamin Chun-Man Lee is a speciality doctor in dermatology (SAS), specialising in skin allergies. He is an Honorary Teaching Fellow at University of Surrey, and a former clinical tutor for PGDip and MSc in Clinical Dermatology with the University of South Wales.

73 In The Life of Dr Anjali Mahto An insight into the daily life of a consultant dermatologist passionate about

education and bridging the gap between dermatology and aesthetics

74 The Last Word Dr Ruth Harker argues why she believes dermatology training is essential in

aesthetic practice

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Editor’s letter February. The excitement of Christmas and New Year is a distant memory and nicer weather still feels like a long way off. Luckily, you’ve still got the Aesthetics journal to brighten your month! We’ve packed this issue full of great content, Chloé Gronow particularly focused on skin. We all know Editor & Content that ensuring patients have a regular and Manager appropriate skincare routine is an essential part @chloe_aestheticseditor of aesthetic enhancement, so we’ve gathered leading dermatologists and aesthetic practitioners to share their advice on some key skincare and dermatology topics. You can read five dermatology-focused case studies on acne, scarring, psoriasis, folliculitis and pilonidal sinus on p.23, followed by an overview of a new technique to treat angiomas using IPL by laser professional Mike Murphy on p.35. Successful treatment of pigmentation using skincare alone is then detailed by Dr Amiee Vyas on p.41, while nurse prescriber Amanda Wilson shares an introduction to acne and acne scarring treatments on p.51 and Dr Benjamin Chunman Lee delves into the

science behind moisturusers on p.55. Not forgetting, in this month’s Last Word on p.74, Dr Ruth Harker argues for mandatory dermatology training for all aesthetic practitioners – we’d love to know what you think, so send me your feedback. I’m also really excited to introduce a new feature for 2020 called ‘In The Life Of’ on p.73, which we hope you’ll love! For our first one, we uncover a typical day in the life of consultant dermatologist Dr Anjali Mahto. With a successful career in both aesthetics and dermatology, Dr Mahto dedicates much of her time to educating the public on the science behind dermatologic conditions and treatments that can help. With a huge social media following and a best-selling book to her name, this article is certainly one to read! If you haven’t already, I must remind you to register for ACE 2020 on March 13 and 14. We will be hosting some really exciting free educational sessions by top industry companies, but spaces are limited. Please note that some sessions are only open to doctors, dentists and nurses, who will need to submit evidence of their qualifications via DocCheck in advance of the event. More information can be found on www.aestheticsconference.com

Clinical Advisory Board

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

WE WANT TO HEAR FROM YOU!

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with more than 20 years’ experience and is director of P&D Surgery. He is an international presenter, as well as the medical director and lead tutor of the multi-award-winning Dalvi Humzah Aesthetic Training courses. Mr Humzah is founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow. Mr Dalvi Humzah, Clinical Lead

Do you have any techniques to share, case studies to showcase or knowledge to impart?

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

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

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

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

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

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

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

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

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© Copyright 2020 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184 ABC accredited publication DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


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Lasers

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

#Training S-Thetics @MissBalaratnam A pleasure to welcome colleagues from @Allergan to the clinic today. Discussing ways we can continue to improve patient results, satisfaction & education as part of their UK Faculty, I’m looking forward to an exciting 2020 ahead #Antiageing Francesca White @francesca__white With this superstar panel at last night’s @the_beauty_triangle event, where we discussed new routes to feeling “Forever Young”, from stem cells to muscle strengthening to intermittent fasting #SkinHealth Blair Stevens @blairsinclairpharma Great evening last night at our “From treatments to tweakments” event hosted by @cosmesurgeuk. A big thank you to @alicehartdavis and Sinclair product experts @river_aesthetics @drvix.manning @charleseastfrcs and @drpam.aesthetics #NutraceuticalsAgostina @agostinaskinade What an amazing team! @tessastevensbeauty Today training on new Skinade TargetedSolutions #skinadets #skinade. A pleasure and certainly fulfilling

#Mentor Lee Walker @leewalker_academy Congratulations to this beautiful lot. Finished their 10 month mentorship programme... So proud to watch them develop #leewalkeracademy

Association launches to raise plume awareness The potential danger of surgical smoke or diathermy plumes generated by electrosurgical, laser or ultrasonic devices has been highlighted with the launch of a new association. The UK Council for Surgical Plumes aims to raise awareness to both patients and practitioners of the importance of measures to protect human health. Vapours, smoke, and particulate debris produced during laser and IPL procedures to vaporise, coagulate, and cut tissue are called plumes. According to association founders, physicist and bioengineer Mike Murphy and Dr Zambia Kader, the evidence linking surgical smoke and harm to the human body should not be ignored by practitioners. Murphy said, “We started this association to inform laser/IPL users about plumes – many users have no idea that they are potentially hazardous. It’s important for non-surgical aesthetic practitioners to understand that plumes can still exist outside of surgery when you are using high energy machines, and the real problem is that people don’t know about this. This is an important issue now, especially given that new research from the US has found that some laser generated plumes can contain quite nasty contaminants.” Skincare

AestheticSource launches new Peel2Glow treatments Aesthetic distributor AestheticSource is launching two new Peel2Glow products by SkinTech this spring; the Beauty & Boost and the Sleep & Repair. Both treatments feature an adapted peel formula, which utilises lactic acid. The company explains that the ingredients lactobionic acid, glycolic acid, citric acid, as well as an antioxidant complex, are all used to target visible signs of photoageing. The Beauty & Boost glow formula consists of four antiageing peptides: acetyl hexapeptide-38, acetylhexapeptide-8, pentapeptide-18 and acetyl octapeptide-3, and hyaluronic acid. AestheticSource states that this is designed to protect and repair the skin as well smooth fine lines and wrinkles. The Sleep & Repair glow formula contains hyaluronic acid, probiotics, melatonin and aloe vera. These ingredients aim to help stimulate the skin’s antioxidant enzymes to defend against free radicals caused by UV radiation and pollution. According to the company, the SkinTech Peel2Glow range provides practitioners with an easy-to-use peel which can be incorporated into an existing treatment portfolio, as well for regular home use.

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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ACE 2020

Updates to the ACE 2020 clinical agenda New educational content from the UK’s leading medical aesthetic companies has been confirmed for the Aesthetics Conference and Exhibition (ACE) on March 13 and 14. In addition to the Galderma Takeover and Teoxane Approach Symposium taking place across the two days, as well as the Allergan Experience scheduled for Saturday 14, renowned speakers from other aesthetic providers will present unmissable workshops on the latest treatments, techniques and technologies due to be released in 2020. Church Pharmacy will host two Masterclasses, while AestheticSource, SkinCeuticals and HA-Derma will host one each on Friday 13. Expert Clinics taking place on the Friday will be led by AesthetiCare, Celluma, BTL Aesthetics, Teleta and Erchonia Lasers, before Cutera, Laboratories Vivacy, Teleta and Venus Concept each lead half-hour Expert Clinics on the Saturday. Informative business talks will cover a huge range of topics; including advertising, marketing, regulation, sales tactics, events, team management, VAT, training and budgeting. All educational sessions are free to attend, however some clinical workshops are only open to doctors, dentists and nurses. Those interested must have provided evidence of their qualifications via DocCheck in advance of attending. Please check the session description and website for more information. REGISTER NOW WITH CODE 10201 VIA AESTHETICSCONFERENCE.COM

Industry

Cutera announces new KOL Aesthetic practitioner Dr Victoria Manning has been confirmed as a key opinion leader for laser and lightbased provider Cutera Medical Ltd. Dr Manning is currently a national trainer and global key opinion leader for Silhouette Soft and Ellansé, as well as being the founder of River Aesthetics, alongside Dr Charlotte Woodward. Last month Cutera Medical Ltd released the truSculpt Flex, a muscle sculpting device, which offers personalised treatments based on patient fitness level and body shape. Dr Manning said, “I wanted to work with a company that aligned with my own core values and ethics, a company that puts patients first and works alongside its brand ambassadors to ensure they are successful in their own right. Having recently met the COO of Cutera, Jason Richey, I know I have made the right decision in this collaboration and Charlotte and I look forward to launching The Flex into the UK and for the ongoing growth of River Aesthetics.”

Vital Statistics Occupations with the highest rates of work-related contact dermatitis are florists, beauticians, cooks, hairdressers and barbers, and certain manufacturing and healthcare related occupations (Work-related Skin Disease report, Health and Safety Executive, 2019)

Online searches for lymphatic drainage treatments have increased by 36% in the past year (YELP, 2019)

64% of marketers either have or are planning to incorporate Instagram Stories into their marketing strategy

(Social Media Trends 2019, Hootsuite)

According to a 2019 audit of UK dermatology coverage, there are 699 consultant dermatologists in England, 71 in Scotland, 38 in Wales and 23 in Northern Ireland (APPGS, 2019)

53% of consumers worldwide would consider a non-invasive body contouring treatment (Allergan 360 Aesthetics Report, 2019)

In a survey of 1,200 male workers, 44% said they had struggled with anxiety at work (Men’s Health magazine, 2019)

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Events Diary 3rd-4th April 2020 18th Aesthetics & Anti-aging Medicine World Congress, Monte Carlo www.euromedicom.com 5th-7th May 2020 British Medical Laser Association Conference www.bmla.co.uk 19th May 2020 British Association of Sclerotherapy (BAS) Conference www.bassclerotherapy.com/events

13 & 14 MARCH 2020 / LONDON

March 13 & 14

The Aesthetics Conference and Exhibition www.aestheticsconference.com 1 & 2 October CCR www.ccrlondon.com

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Injectables

Warning issued against discounted injectable treatments Specialist law firm Cosmetic Surgery Solicitors has teamed up with governmentapproved register of accredited practitioners, Save Face, to caution would-be patients about discounted injectable treatments. The warning has been issued following research by Cosmetic Surgery Solicitors indicating a seasonal spike in Google searches for ‘dermal fillers’, ‘cheek fillers’ and ‘lip fillers’ at the beginning of the calendar year. Michael Saul, partner at Cosmetic Surgery Solicitors, said, “January is traditionally the time when all retailers slash their prices to clear their stock and encourage customers to start shopping again following the expensive festive season, and the cosmetic beauty industry is no different.” He continued, “However, cut-price deals can encourage people to make a snap decision and undergo a procedure that they are not necessarily ready for, from a practitioner who may not have their best interests at heart. As dermal fillers carry risks such as vascular occlusion, nerve damage and even permanent loss of vision, this January we decided to team up with Save Face to help raise awareness of this issue and encourage customers to resist January-sale offers.” Ashton Collins, director of Save Face, said, “Botulinum toxin and dermal fillers are often advertised on social media as risk-free beauty treatments by unscrupulous practitioners, which leads to an increase in demand and consequently an increase in the number of people who suffer botched procedures.” Collins added, “Sadly, the number of unethical social media posts advertising these procedures increases significantly in the new year and are designed specifically to target vulnerable people into making snap decisions.”

Beauty

Medik8 releases new lip balm UK skincare manufacturer Medik8 has launched its first lip balm called Mutiny. The key ingredients of the balm are squalane, sea buckthorn oil and multiweight hyaluronic acid. Medik8 explains that these plant-sourced oils support the skin’s natural healing, restore the skin’s natural barrier and keep the skin hydrated. The company adds that it is an alternative to occlusivepetroleum lip balm, which blocks moisture loss short term. According to Medik8, the balm should be applied as a thick layer every evening, to work as an overnight sleep mask. Aesthetic practitioner Dr Pamela Benito said, “I’m so excited by this new lip balm launch from Medik8 and was thrilled to be one of the first practitioners to try it. Often lip balms are formulated with occlusives such as petrolatum, but Mutiny has been cleverly formulated with squalane – an almost skin-identical lipid that provides long-term hydration and actually nourishes the lips.”

Complications

Survey highlights issues with reporting of complications A survey of 461 aesthetic practitioners conducted by insurance provider Hamilton Fraser Cosmetic Insurance has revealed that more than half of aesthetic practitioners did not report their complications in 2019. A total of 107 practitioners stated that they had experienced a complication following an aesthetic procedure, however most did not report the complication to their insurer, product manufacturer, or the Medicines and Healthcare products Regulatory Agency via the Yellow Card reporting scheme. Professor David Sines, executive chair of the Joint Council for Cosmetic Practitioners (JCCP) commented, “The JCCP and CPSA would remind all healthcare professionals of their professional responsibility to report such incidents in order to develop and produce an evidence-related database to enable effective patient risk management, continuous service improvement and enhanced standard and performance setting within the sector. It is every practitioner’s responsibility to ensure compliance with such reporting procedures.” According to the respondents, the majority of complications were minor (67%), while 24% said they were moderate and 5% found them to be serious or life-threatening. The most common complications experienced were prolonged swelling, allergic reactions and infections. While 96.91% of respondents were able to manage the complication themselves, some participants had sought guidance elsewhere, from nurse colleagues or aesthetic doctors. In addition to complication statistics, other notable results of the survey indicated that 75% of respondents admitted that aesthetics was not their sole source of income, and 72% of people working in aesthetics spent their time alone. Aesthetic practitioner, Dr Sophie Shotter, commented, “I think it’s crucial to build a support network of colleagues and other professionals with whom you can discuss problems should they arise. Just because we leave the NHS environment doesn’t mean we should stop working as a team. There are various professional groups which offer this support, and I think that is an invaluable resource.”

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Skincare

SkinCeuticals releases Glycolic Renewal Cleanser 13 & 14 MARCH 2020 / LONDON

Cosmeceutical company SkinCeuticals has released a new cleanser, which aims to exfoliate skin and remove oil, dirt and debris to brighten complexion. The company explains that the Glycolic Renewal Cleanser contains 11.75% glycolic acid at a pH of 3.5, which delivers a free acid value of 8%. This promotes cellular turnover, which improves skin texture and tone, according to SkinCeuticals. Other ingredients include phytic acid for gentle skin exfoliation, glycerine which aims to attract water to the skin and retain moisture, and aloe barbadensis leaf extract to moisturise skin. The company states that the cleanser should be used twice a day for best results. Training

DHAT to provide Level 7 award in facial anatomy Dalvi Humzah Aesthetic Training (DHAT) is now offering a Level 7 award for its facial anatomy course, which launched on January 20. According to consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah, DHAT lead tutor, the training will offer Level 7 (postgraduate) awards in both its Anatomy and Complications courses, with the option to get a Level 7 qualification if both awards are taken. The course has been developed with a recognised quality assurance through OFQUAL-recognised organisation industry Qualifications (IQ) Ltd and will feature 3D and virtual-reality learning environments. Mr Humzah said, “This is an exciting development following multiple award wins and our experience in delivering facial anatomy teaching over the last nine years. This Level 7 award will provide a standard for medical practitioners in aesthetics. We have also appointed new faculty tutors who will be helping in the further development of this course, which will make it novel, exciting and educational.” Teaching

PCA Skin launches educational skin series UK skincare company PCA Skin has announced that it will be launching four educational training sessions taking place across the UK in 2020. According to the company, the sessions will explore common skin concerns such as acne, ageing and sensitive skin. Sessions will be taking place on May 3, May 4 and November 2 in locations across the UK, between 9:30am and 4pm. Lizzie Shaw, brand manager at PCA Skin, said, “We are excited to bring medical professionals these national training sessions that are grounded on our brand’s three core pillars: product innovation, excellence in education and unparalleled customer support!”

COU N T DOWN TO ACE 20 2 0 – ONE M ON T H TO GO!

On March 13 and 14, the Aesthetics Conference and Exhibition will play host to over 50 clinical and business educational sessions for medical aesthetic professionals, all of which are completely free to attend! Headline Sponsor Galderma will host the 2-day Galderma Takeover featuring expert talks on dermatology, anatomy, injection techniques, complications and more. The conference also features the Teoxane Approach Symposium and the Allergan Experience, bringing you exclusive, free education from the leading aesthetic providers.* The Business Track returns for 2020 and will feature new speakers and a myriad of topics to help you keep your business up-to-date and ahead of the competition. Big industry names will reveal their secrets to success and experts in key areas of business expertise will impart their insight to ensure you stay on track with the latest best practice. In addition to all this free education, the exhibition hosts over 80 companies showcasing the very latest innovations in aesthetics – giving you the opportunity to discover the newest treatments, technologies and equipment for your clinic, under one roof.

REGISTRATION IS COMPLETELY FREE Register now at aestheticsconference.com using code 10201 *Please note that these sessions are only open to doctors, dentists and nurses and access is limited. See programme online for more information. HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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

EDUCATION AND TRAINING UPDATE Board members Mel Recchia and Anna Baker led the BACN Education and Training Committee to focus on updating the Competency Framework, due to be drafted April 2020, which will then undergo a peer review and be presented to members later in the year.

COMPETENCY FRAMEWORK UPDATES As well as a general update of the competency framework, the BACN will also set out a ‘Career Framework for Aesthetic Nurses’. The original Competency Framework for aesthetic nurses was produced in 2013 and updated in 2015, which was accredited by the RCN. The framework consists of Core and Specialist Competences: Core Competences – best practice general competences updated to be relevant for an aesthetic nurse Specialist Competences – competences related to the treatments undertaken by an aesthetic nurse: • Injectables • Fillers • Skin peels and rejuvenation • Laser and light-based treatments The committee is also looking at guidance over new ‘Orphan Treatments’ and the impact of the updated framework on aesthetic nurses who are at different levels of competence. This then leads to a discussion about categories of aesthetic nurses, assessment methodologies, qualifications and equivalency. More specific information will be sent to members later in the year.

BACN REGIONAL MEETINGS The next round of regional meetings are now available to book. We now operate a more structured format for the meetings – mornings are tailored to those members who are relatively inexperienced within aesthetics. At lunch, all members are encouraged to attend to meet and network with each other. After lunch, the sessions are focused on more advanced issues and techniques and the mentoring/case study reviews. Members can attend all sessions. BACN partners will focus presentations according to this categorisation. For more information please contact BACN events manager Tara Glover at tglover@bacn.org.uk. This column is written and supported by the BACN

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Skin

Alma Lasers releases advanced version of Harmony XL Energy device manufacturer Alma Lasers has launched a special edition of the Harmony XL, a multi-application platform that aims to treat common skin concerns such as vascular lesions, pigmented lesions, hair removal and acne. The company explains that the new Harmony XL Pro will feature depth control capabilities, allowing practitioners to direct the precise depth of treatment depending on the area being treated, skin type or indication. Alma states that the Harmony XL Pro will deliver up to 3,000mJ of effective energy, compared to the 1,500mJ in the previous model. The other modules included in the device are the Dye VL Pro, Alma ClearLift, the Pixel Er:YAG, Dye-SR (550-650 nm) and Dye VL (450-600 nm). Alma Lasers is distributed in the UK by ABC Lasers. Industry

S-Thetics wins iS Clinical award Skincare company iS Clinical has announced that surgeon, aesthetic practitioner and medical director of S-Thetics clinic, Miss Sherina Balaratnam, has won its world star contest for the second year running. The competition is based on revenue, and S-Thetics was awarded clinic of the year. Miss Balaratnam said, “It is an honour to receive this award for the second year running from such a globally respected brand. Our patients continue to benefit from exceptional results using the iS Clinical range of skincare and we extend our thanks to the whole iS Clinical family.” Alana Chalmers, director of Harpar Grace, the exclusive UK distributor for iS Clinical, said, “It is an inspiration to see a clinic work so consistently to achieve the level of efficacy they have.” Business

Dr Aamer Khan announces clinic franchise operation The Harley Street Skin Clinic has launched a new franchise model, allowing other businesses to become part of its brand. The clinic explains that partners of The Harley Street Skin Clinic will receive comprehensive training, brand support, guidance with site selection and access to operational software. Aesthetic practitioner Dr Aamer Khan, co-founder of The Harley Street Skin Clinic, said, “The aesthetics industry is experiencing an incredible boom at the present time and shows no sign of abating as the market for both non-invasive and invasive treatments expands across all ages and demographics. Many of our patients travel long distances to us for their treatments and procedures so we recognised the opportunity to establish aesthetics clinic outside of London via the franchise model. Franchising is the most effective scalable solution for us as it enables us to ensure that our branded clinics are run by the most experienced cosmetic doctors and surgeons who will safeguard the reputation of The Harley Street Skin Clinic.”

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Sclerotherapy

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Industry

BAS releases 2020 event programme The British Association of Sclerotherapists (BAS) has released its speakers and topics for its 2020 conference, which will take place on May 19 at the Dorney Lake Conference Centre near Windsor. The conference is open to sclerotherapy specialists, aesthetic doctors, nurses and vascular surgeons, and will include presentations from a line-up of industry specialists, live foam and microsclerotherapy demonstrations, as well as poster presentations. It will also include an optional basic life support refresher and a sponsor exhibition. Speakers will include vascular surgeon Professor Bruce Campbell and consultant vascular surgeons Dr Manj Gohel and Dr Zola Mzimba, with more to be announced. The topics covered will include a debate on compression after sclerotherapy, management of pelvic congestion syndrome and tips on how to take good before and after photographs. Aesthetic practitioner Dr Martyn King, BAS board member and chair of the Aesthetics Complications Expert Group, said, “We hope delegates from throughout the UK and Ireland will enjoy this unique opportunity to update their sclerotherapy skills and network with peers. Our aim is to provide relevant and up to the minute information and, with fewer than 100 delegates, we can accommodate everyone’s questions and discussions. We look forward to a very full, varied and enlightening programme.”

Vivacy laboratory expands French injectable manufacturer Laboratoires Vivacy has increased its production space for its laboratory in Archamps. Vivacy’s laboratory extension increased by 2,000m2, making it a 5,000m2 facility today. According to the company, this extension has doubled the production capacity from three million to six million syringes a year. As well as providing more factory and office space for the development, distribution and production, the extension has also provided a VIP floor dedicated to training. Terina Denny, national sales manager at Vivacy UK, said, “We are excited to constantly welcome UK delegates to our facility in Archamps so they can see the quality and innovation of our products.” Clinical Study

Study suggests positive effects of Emepelle A clinical study evaluating the efficacy and safety of skincare line Emepelle has suggested positive improvements on menopausal skin. The 20-week open label study was led by US dermatologist Dr Joel Cohen and involved 14 female subjects aged 53-68. Results indicated that 100% of participants saw improvements in their skin by week 14, and 86% stated that Emepelle helped alleviate some or all the skin issues they had developed since entering menopause. Emepelle features a patented, non-hormonal ingredient called methyl estradiolpropanoate (MEP), which the company states is a non-hormonal oestrogen receptor agonist that is clinically proven to reinvigorate parts of the skin affected by low oestrogen levels during the menopause. Consultant dermatologist Dr Emma Wedgeworth commented, “Emepelle is a new category of skincare. MEP technology is fascinating because it’s a way of directly targeting the skin cells, helping to boost the effects of an oestrogen-like molecule, which is not actually a hormone. I’m very excited about the use of Emepelle and I think it’s really going to be an area that totally takes off because it’s really helping to target the sorts of changes we see in menopausal skin in a very intelligent way.” Emepelle is available in the UK through skincare and device distributor AesthetiCare.

Research

Study argues there is a lack of evidence to connect sunbeds and melanoma A study conducted by Reichrath et al, and published in Anticancer Research, has suggested that there is no evidence to demonstrate a relationship between moderate solarium use and melanoma. The study comes in response to recent demand for the debate to be closed. The analysis suggests that cohort and case control studies published to date, including recent invetigations, do not prove causality, and randomised controlled trials providing proof are

lacking. The findings were a result of a systematic literature search, identifying publications investigating the topic throughout June 2019. Consultant dermatologist, Dr Susan Mayou, said, “This publication seriously challenges conventional wisdom... until we have conclusive evidence to the contrary, I would still advise my patients to limit exposure to both natural UV light and sunbeds to avoid both skin cancer and photoageing.”

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Skincare

New anti-pollution cream launches Aesthetic product supplier 4T Medical has introduced the new Comfort Cream to the Cebelia skincare range. According to 4T Medical, the new anti-pollution cream is designed to protect sensitive skin against environmental stress such as pollution, cigarette smoke, harsh climatic conditions and temperature variations. The key active ingredient in the Comfort Cream is physcomitrella patens moss, which, according to the company, aims to create a protective barrier for the skin. Other ingredients include allantoin and beeswax, which aim to sooth the skin and calm redness; natural oils including coconut oil, olive oil and sweet almond oil for lipid delivery to the skin, and gycerin, which is an humectant that aims to hydrate the skin. Julien Tordjmann, managing director at 4T Medical, said, “The Cebelia Comfort Cream is an excellent addition to the Cebelia range and is highly effective in protecting the skin from environmental damage and the first signs of ageing.” Weight loss

ZENii launches new supplement Skincare and supplement company ZENii has launched a new supplement called ProLean. The company explains that the supplement is specifically formulated for weight loss, portion control and slimming support. ProLean contains natural glucomannan (konjac root) in a 3,000mg daily dose and zinc, which contributes to normal carbohydrate metabolism and the normal metabolism of fatty acids, states ZENii. Aesthetic practitioner Dr Johanna Ward, founder of ZENii, said, “The launch of ProLean takes ZENii firmly into the weight loss market. For aesthetic clinicians, ProLean is a safe and natural supplement that will complement any weight loss, body contouring or fat freezing treatment. Body contouring results will always look more dramatic and satisfactory when coupled with natural weight loss.” She added, “ProLean doesn’t interfere with the body’s endocrine, thermal or immune systems like lots of other weight loss products. Instead, it simply gives mechanistic portion control in a safe and effective way. We see ProLean as a total game changer and a very helpful clinically evidenced tool for those who overeat.” LED

Dermalux Flex to be distributed through Wigmore Medical Medical device manufacturer Aesthetic Technology Ltd has teamed up with distribution company Wigmore Medical to supply its Dermalux Flex device in the UK. The Flex is a portable LED phototherapy device, which features protocols for a wide range of indications and is medically CE-certified for acne, wound healing, psoriasis and musculoskeletal pain, according to the company. Louise Taylor, director of Aesthetic Technology Ltd, said, “Wigmore Medical are one of the longest established aesthetic distribution companies in the UK with a prestigious portfolio of brands and we are excited to be working with Raffi Eghiayan and his team. We are introducing protocols to incorporate the Flex and ZO Skin Health to extend the treatment options.” The partnership will also be supported through education and training workshops.

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News in Brief BCAM requests medical features The British College of Aesthetic Medicine (BCAM) is looking for speakers for its 2020 conference, taking place on Saturday September 19. This year’s theme is ‘The Leading Edge of Aesthetic Medicine’. The BCAM require abstracts from different papers to encourage discussion and share expertise. This can include sharing of clinical breakthroughs, advances in international aesthetic medicine, showcasing high quality research and making cases with policy makers. The submission deadline for applications is February 29. Black Skin Directory to host CPD workshop on March 12 The online resource for patients with skin of colour, Black Skin Directory, is holding a CPD-certified workshop on March 12 for practitioners to learn how to address concerns from patients with skin of colour. The workshop will cover aesthetic complication management and how to recognise common conditions such as acne, keloid scars, traction alopecia and melasma. Speakers will include oral and maxillofacial surgeon Ms Natasha Berridge, aesthetician Andy Millward, aesthetic practitioner Dr Ifeoma Ejikeme and consultant dermatologist Dr Sandeep Cliff. Dr Steven Land becomes iRejuvenation ambassador Aesthetic practitioner and owner of Novellus Aesthetics, Dr Steven Land, has been confirmed as an ambassador for the aesthetics note-taking and charting app, iRejuvenation. In his role, Dr Land will promote the brand across social media platforms and at aesthetic conferences, as well as help with the ongoing development of the product. Having used the app in his clinic for the last three years, Dr Land said, “I’m so excited to be working closely with a company who have introduced such a useful innovative product that makes running my clinic so much easier.” Dr Firas Al-Niaimi wins global excellence award Consultant dermatologist Dr Firas Al-Niaimi, has received a Global Excellence Award from LUX Life Magazine. Dr Al-Niaimi said, “I am absolutely thrilled, delighted and humbled to hear about my Global Excellence Award. It is a recognition of my tireless efforts in dermatology and laser services, most importantly to my patients and contribution to the high standards of British dermatology. With more than 160 scientific publications and over 200 presentations throughout the world, I am finally seeing the fruits of my hard work.”

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Training

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Business

Cosmetic Courses launches cadaver training

3D-Lipo Ltd extends business to Scotland

Aesthetic training provider Cosmetic Courses is now offering a one-day cadaver facial anatomy course. The course will start with a lecture covering 3D anatomy of the full face, accompanied by a video demonstration looking at dermal filler treatment to the upper, mid and lower facial areas. Following the lecture delegates will be given the chance to administer advanced dermal filler techniques on fresh cadaver heads. Consultant plastic and reconstructive surgeon Mr Adrian Richards, clinical director of Cosmetic Courses, said, “Attending our cadaver course is an excellent way to really understand the placement of the filler and delve deeper into possible complications. Having a good understanding of this will help our delegates provide the best treatment for their patients.” The course will also demonstrate the use of hyaluronidase, looking at how to administer it for different indications.

Aesthetic device manufacturer 3D-Lipo Ltd is expanding its business development initiative into Scotland for 2020, following the success of its launch last May. As part of the brands support services, the initiative was launched exclusively to its clients, designed to provide them with extra advice and support. Strategic client manager Mandy McCulloch will be joining 3D-lipo Ltd’s team of business development managers, working throughout Scotland. The company explains that she will be available for dedicated on-site appointments with both new and existing clients. Scott Julian, national sales manager at 3D-Lipo Ltd, said, “We are delighted to have Mandy representing 3D-Lipo Ltd in Scotland and Northern England. As business development manager, Mandy will be utilising her industry experience and business acumen to further support our customers to maximise their return on investment and treatment revenues.” Nurses

BACN appoints new board member The British Association of Aesthetic Nurses (BACN) has appointed aesthetic nurse prescriber Linda Mather as a new member of its board. Mather was the consultant expert for the Northumbria University Master’s programme in non-surgical aesthetics, and is the practice placement facilitator/educator for aesthetic practice on this course. She also runs her own clinic and is an emergency call handler for the ACE Group. Sharon Bennett, chair of the BACN and aesthetic nurse prescriber, said, “I am delighted that Linda Mather is joining us on the BACN board. She brings with her a huge amount of experience, skills and knowledge to strengthen and future proof our existing committee of incredible and committed nurses. I cannot wait to work more closely with her as we drive the BACN forward.”

On the Scene

Business of Hair, Solihull On January 18, aesthetic practitioners, trichologists and hair surgeons came together to learn how to successfully run a hair restoration practice. The event opened with a welcome from organiser Danny Large of DSL Consulting, in which he outlined the value of coming together to network and learn from each other’s unique skillsets and experience. Alex Bugg of Web Marketing Clinic then opened the talks, with an informative discussion of how to best utilise social media. Key advice for delegates included ‘being social’ and engaging with followers regularly, as well as creating posts that offer added value through education and entertainment. This correlated well with advice from Chloé Gronow, Aesthetics editor and content manager, who emphasised the importance of writing to educate prospective patients through content marketing, rather than utilising direct sales tactics. Gronow also shared her top tips for improving the quality of your writing and how to generate ideas for content. Mark Bugg then

detailed how best to use video marketing in a cost effective and smart way. In addition, editor Vicky Eldridge shared her recommendations for improving mental health in the workplace, while representatives from Rosmetics and Farjo-Saks gave delegates an overview of hair restoration products that could be added to a clinic offering. Key note presentations were delivered by Dr Sophie Shotter and trichologist, Eva Proudman who spoke on working as a team. Dr Shotter shared her experiences of introducing hair restoration procedures to an aesthetic clinic. She recommended introducing TrichoTest, which analyses DNA to suggest which treatments will work best for individual patients, while also emphasising the importance of working collaboratively with other professions to offer the best results to patients. Following her talk, Dr Shotter said, “I think hair is such a big area of development; it’s an untapped market and I really want people to work more collaboratively. I shared my journey which has changed from me trying to do everything, to me sharing my business with other professionals so we can give patients best results. It’s been a great day!” Large concluded, “We’ve had a fantastic time at the Business of Hair event. Everyone’s been interacting really well and I hope it continues to grow... just like hair!”

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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awareness of the issue. Advertisers not following the rules run the risk of being referred to the MHRA or their professional regulatory body. Professor David Sines, executive chair of the JCCP commented, “The JCCP supports codes and standards set out by the MHRA and CAP and their endeavours to protect the public from potentially misleading and harmful advertising. We will continue to work alongside the CAP and ASA in identifying unacceptable and misleading promotion within non-surgical cosmetics and encourage the discussion of POMs responsibly within the confines of the codes set out within CAP.”

Industry support

Regulators Tighten Rules on Toxin Advertising Details of the Enforcement Notice relevant to all aesthetic clinics offering prescription-only medicines New technology was put in place on January 31 to monitor advertisements on social media relating to the promotion of prescription-only medicines (POMs) such as botulinum toxin. The Committees of Advertising Practice (CAP) and Medicines and Healthcare products Regulatory Agency (MHRA) issued an Enforcement Notice to the beauty and cosmetic services industry compelling businesses to review ads and make immediate changes. This is the furthestreaching Enforcement Notice ever issued by CAP, targeting more than 130,000 of the wide-ranging businesses within the cosmetics services industry. ASA chief executive, Guy Parker said, “We’re taking action to tackle botulinum toxin ads on social media using brand new monitoring technology. This tool helps us to be more efficient and effective in identifying and removing problem ads.” This is the second Enforcement Notice in recent months relating directly to the aesthetic industry. In December 2019, an Enforcement Notice was sent to aesthetic training providers highlighting issues with advertising courses to prospective students.1,2

The CAP code The Enforcement Notice draws upon existing policies written in both the Human Medicines Regulations 2012 (HMRs) and Rule 12.12 of the CAP Code and includes paid-for ads,

non-paid for posts and influencer marketing on social media platforms.3 It is illegal to advertise a POM to the general public in the UK, but recent months have seen an ongoing practice of ads of this kind appearing on social media, according to the CAP and the Joint Council for Cosmetic Practitioners (JCCP). Aesthetic practitioner Dr Tapan Patel, owner of PHI clinic in London, said, “Every day I see people advertising botulinum toxin online, as well as on shop windows, magazines and public advertising boards.”

Actions clinics must take The CAP Enforcement Notice advises businesses to remove direct references to botulinum toxin or other POMs, which includes hashtags and names such as ‘beautytox’ or ‘beautox’ where it is an obvious a reference to botulinum toxin. It also states not to use a substitute that directly references to POMs with indirect phrases that can only refer to a POM, such as ‘wrinkle relaxing injections’. Practitioners should also be aware that the Advertising Standards Authority (ASA) considers that a reference to ‘anti-wrinkle injections’ alongside a price that relates to a POM will be seen as an ad for that POM. Practitioners should avoid references to treating medical conditions in a way that could indicate the promotion of a POM, for example ‘injections for excessive sweating’. CAP will also be running a targeted ad campaign across Facebook to raise

The ASA and MHRA announcement came about following pressure from the JCCP and has been supported by a range of associations and practitioners in the field. Aesthetic nurse prescriber Sharon Bennett, chair of the British Association of Cosmetic Nurses (BACN), stated, “The notice to enforce existing legislation on the advertising and social media posts of Botox and botulinum toxin injections is a most welcome and significant step forward in the medical aesthetic sector’s bid to protect the public. Myself, the BACN board, and all of our members have supported this campaign and I applaud the persistence and hard work of those who were integral to the notice and ensured it to be realised, particularly the JCCP and Professor Sines.” Dr Patel added that he supports any positive initiatives in the unregulated field of aesthetics. He said, “I look forward to seeing how the technology works to identify the problem ads. My concerns, at the moment, are that those found to break the rules will be referred to the MHRA or their professional regulatory body, however many toxin injectors are not medical professionals so are not regulated. As always, I welcome more stringent practice, but I do only feel like it could be a small step in the right direction as we do need more legislation and industry regulation.” REFERENCES 1. Advertising regulators warn training providers, Aesthetics journal, December 2019. <https://aestheticsjournal.com/news/ advertising-regulators-warn-training-providers> 2. ASA, Enforcement Notice: Training Courses, December 2019. <https://www.asa.org.uk/resource/enforcement-noticetraining-courses.html> 3. ASA, Enforcement Notice: Advertising Botox and other botulinum toxin injections on social media, January 2020. <https://www.asa.org.uk/resource/enforcement-notice-botoxsocial-media.html>

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Case Study: A Warning to Toxin Providers Dr John Curran and nurse prescriber Hayley Jordan review a recent medical legal case As a medical professional, you MUST be open and honest with patients – it’s in within our code of practice.1 ‘Botox’ has become an everyday word, often used by the public incorrectly to describe any number of treatments and outcomes. However, many practitioners will be using brands of botulinum toxin other than Botox to treat lines and wrinkles, so how many are effectively communicating this to patients? And what are the repercussions if you don’t? In this article, we highlight the real case of a practitioner facing legal action as a result of not communicating the different types of toxin appropriately.

Defence The defence team accepted that diplopia, although rare, is a known side effect of periocular botulinum treatment and was noted in the consent sheet, which was signed after a long consultation. Dr X believed he had exercised a reasonable duty of care in the examination, selection of treatment, administration and consenting. The doctor was honest about the problem at the review appointment and organised an appropriate expert referral. The medical records were excellent, setting out why the patient sought treatment and exactly what was given (another type of botulinum toxin, which was not Botox) and in what dose.

The case

X could be required to pay considerable sums to the patient. These may include a refund of the price of the treatment, as well as compensation to cover the patient’s lost earnings, any financial loss she suffered due to the sale of her car, and any medical expenses she has incurred (apart from the ophthalmologist that Dr X paid for). The patient may also be entitled to compensation for non-monetary losses such as mental distress. In addition, Dr X may be ordered to contribute to the legal fees the patient has incurred in bringing her claim. Outside the current court proceedings, Dr X could face further consequences. These might include criminal sanctions imposed by Trading Standards and/or disciplinary action by the General Medical Council.2 Dr X’s clinic might also be required to take corrective action (through amending its advertising) by the Medicines and Healthcare Products Regulatory Agency on the basis that it has been promoting prescription-only medicines (in this case, botulinum toxins), in breach of the Human Medicines Regulations 2012.3

Be aware

A 42-year-old patient who was feeling low about herself decided to look into ‘Botox’ treatment. She was wary, but felt reassured as several friends said they had undergone ‘Botox’ treatment. After some online research the patient saw that a local clinic mentioned ‘Botox’ on its website, so decided to give the team a call. She was delighted when the receptionist confirmed that the practitioner, Dr X, gave ‘Botox’ treatment and booked her an appointment. On the day of the appointment, the patient explained to Dr X that she had come for ‘Botox’ and, after a long consultation process, was given a consent form for botulinum toxin type A, which she signed, and subsequently had treatment. Two weeks later, the patient presented with double vision and an inability to drive. On examination, Dr X confirmed diplopia and referred her to an ophthalmologist who advised that the problem was caused by diffusion of the botulinum toxin to her intraocular muscles and that it may take three to six months to clear. Unfortunately, being unable to drive, the patient had to give up her job as a taxi driver and lost her car. Her partner was angry that she had treatment, leading to a breakdown in her relationship resulting in separation and mortgage arrears. Dr X subsequently received a letter from the patient’s lawyer. What ensues is a salient lesson about being honest with patients, particularly regarding which medicine is used.

Prosecution The prosecution presented evidence from Dr X’s website that mentioned ‘Botox’ by name and brand and there were no references to any other toxin being used or substituted. There was an entry in the medical record in Dr X’s handwriting, stating, ‘Patient presents feeling low about her appearance, wishes Botox’. The patient was also able to make a statement that she had mentioned ‘Botox’ by name to the receptionist who confirmed the doctor gave that treatment. She further stated that at no time was there a discussion of any other medicine being used. Expert opinion confirmed that all botulinum toxins were not exactly the same, with each having its own characteristics and often with differing dilution and diffusion characteristics. The expert also conceded that the outcome may have been different if a different toxin was used. The expert further suggested that it would be a reasonable conclusion that the reason for using the name of ‘Botox’ in marketing but giving a different medication would likely be commercial.

Legal opinion While the case hasn’t concluded yet, the legal advice Dr X has received indicates that there is a strong case for prosecution. Dr X could be liable to the patient under several legal principles based on the arguments she has advanced in court. As a result, Dr

This case is an example of how your medical legal defence can be weakened, leaving you vulnerable, when you mislead patients. There is strong safety data for all the main toxins but they are not the same and you need to let patients know what they are getting. Practitioners should abide by our professional bodies and not cynically use a trademarked name to promote business, solicit patients and deliberately omit to tell them the truth. Note: Dr X has provided consent for this article to be published as a warning to others. Dr John Curran is the lead practitioner at the Aesthetic Skin Clinic Group and chief medical officer at the Healthxchange Group. Hayley Jordan is an aesthetic nurse prescriber and the with a Level 7 qualification in aesthetic medicine. She is head of clinical governance at the Aesthetic Skin Clinic Group. REFERENCES 1. General Medical Council, Openness and honesty when things go wrong: the professional duty of candour (UK: GMC, 2020) <https://www.gmc-uk.org/ethical-guidance/ethical-guidancefor-doctors/candour---openness-and-honesty-when-things-gowrong> 2. National Trading Standards, How we work (UK: National Trading Standards, 2020) <https://www.nationaltradingstandards.uk/ what-we-do/> 3. MHRA, The Blue Guide (UK: MHRA, 2019) <https://assets. publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/824778/Blue_Guide.pdf>

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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The Rise of Influencer Injectors The industry expresses concern regarding the rise of non-medic ‘influencer injectors’ Medical aesthetic practitioners have been raising safety and regulation concerns in both the mainstream press and social media following recent reports of nonmedical ‘influencers’ training in injectable procedures.1-5 Some of these influencers and celebrities include ex-Love Island star and personal trainer Rykard Jenkins,1,2,3 former TOWIE star Lauren Goodger4,5,6 and glamour model and TV personality Danielle Lloyd.5,7 All have between 70-759k followers on Instagram and none have a medical background. As aesthetics is an unregulated market, it is legal for any individual to inject botulinum toxin and dermal filler treatments following a short training course.8 Aesthetic practitioner Dr Shirin Lakhani told Aesthetics that she was disappointed and shocked to hear that celebrities and influencers were turning their attention to the aesthetics field. “I find it terrifying that people who don’t even hold beauty therapy qualifications are legally able to go on a short training course and be ‘qualified’ to perform treatments like botulinum toxin and dermal fillers,” Dr Lakhani says. Aesthetic practitioner Dr Sophie Shotter adds, “To be in an era where someone can go from an untrained reality TV star to delivering injectable treatments is very, very concerning – I think this is utterly ridiculous.”

treatment and cannot be held accountable as they have no oversight by a professional body such as the GMC, NMC and GDC. However, Dr Shotter is particularly concerned with the rise of ‘influencer injectors’ due to their high social media reach and “young and easily influenced” following. She says, “For example, as part of Love Island, Jenkins’ has presented an ‘aspirational’ image to millions of young people, who will now be exposed to him marketing his aesthetic services. He isn’t bound by the same ethical codes of conduct as medical professionals with regards to his practice and his marketing, and I think this is particularly dangerous for his 350k followers.” Dr Lakhani adds, “Injectable treatments such as botulinum toxin and dermal fillers have very real medical risks associated with them, which require medical interventions from trained medical professionals and prescribers. This is why I believe the treatments should not only be prescribed by a medical professional, but also administered by a medical professional, as they will be the ones who will need to act fast to ensure there is no long-term damage to the patient.” She continues, “I am also outraged that medical professionals are prescribing botulinum toxin to these non-medics, which goes against our code of conduct.”

The concerns

The debate

The non-medic injector debate in aesthetics is long standing.9,10 Many healthcare professionals believe that non-medical professionals are not equipped to recognise and deal with potentially life-threatening complications that may occur following

Aesthetics approached various influencers who have trained in injectables for comment, but they either declined or did not respond. Maxine Hopley, CEO of Cosmetic Couture, which openly trains non-medics, and trained Rykard Jenkins, disagrees that non-medics

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cannot be taught how to perform safe treatments. She highlights that there are many medics who agree with her, stating that Cosmetic Couture has trained countless medical professionals who have gone on to train non-medics. Hopley says, “They would tell you they train non-medics because as long as the individual is competent and capable, the training is thorough and includes first aid and adverse effects, with clinical oversight and ongoing support available, the processes and procedures are not that complicated and not really that dangerous. Which bit of a nurse’s training, for example, makes them more suitable for aesthetics training than a lay person who undertakes a specialist first aid and injectables adverse effects course as part of their training? Shouldn’t this be about the quality of the training and the further support and realistic regulation, rather than the individual?” However, Dr Shotter strongly disagrees that these procedures are safe for lay people to perform. She explains, “Aesthetic procedures carry risks. It’s vital to be able to mitigate that risk through thorough in-depth knowledge of anatomy – something which medical professionals learn over several years – to recognise these problems when they happen (being able to clinically diagnose), and finally to be able to treat these problems (prescribing and administering prescription only medications).” She adds, “These are skills which are entirely additional to the artistic expertise needed to get beautiful results from injectables. These are medical skills which are essential to practising injectables safely. I would argue it’s impossible to learn all of this in such a short course. This takes years of medical training and time spent in medical environments.” Conversely, Hopley believes that many medical aesthetic practitioners are more concerned about money rather than patient safety. “Medical professionals in the aesthetics industry know the value of the business and that’s why so many leave the NHS and set up aesthetic practices. Let’s be clear here – this is a fabulously lucrative industry and it’s not a coincidence that some medics want to keep the business for themselves,” she says. Dr Lakhani told Aesthetics that she does not consider non-medics or even her neighbouring medical professionals as competition. “Non-medical professionals don’t know how to recognise a complication or deal with it and don’t have the support of medical professionals to fall back on. There is enough work for everyone and my concerns are entirely about safeguarding patients,” she explains.

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


SE E US AT

Industry views In recent months the British Association of Aesthetic Nurses updated its Code of Conduct to make it clear that it does not support the training and prescribing of beauty therapists and non-medics,11 which also reflects the stance of the British College of Aesthetic Medicine. The training and prescribing of beauty therapists in injectable treatments such as botulinum toxin and dermal fillers is also not supported by the UK’s voluntarily registers, the Joint Council for Cosmetic Practitioners (JCCP) and Save Face. Ashton Collins, the director of Save Face states, “It is terrifying that a lay person can undertake a training course and emerge a few days later offering a range of complex and advanced non-surgical treatments. What is scarier still is that the training course itself is being legitimised and promoted via social media to an audience that has been accrued because of a reality TV appearance, an audience that has been conditioned to think that having cosmetic procedures is normal and risk-free because of programmes like Love Island.” Professor David Sines, executive chair of the JCCP comments, “The idea that non-medical practitioners can be seen to be competent to provide injectable and filler treatments after a few days’ training and be able to fully diagnose a person’s needs and deal with any complications that occur is ridiculous. The JCCP operates a Professional Standards Authority-government approved register for non-surgical practitioners and maintains a register of approved education and training providers in this area. The JCCP’s position is that it will not register any non-medical practitioners delivering advanced treatments such as injectables. It would also not give approval to any training body offering training to non-medical practitioners to deliver injectable and filler treatments.” Dr Shotter concluded, “As medical professionals we have a duty to protect public safety, and as such we must speak out when we have concerns to this degree. I am not afraid of local ‘competition’ as insinuated – I suspect these influencers’ patient base will be very different from my patients, but I am very concerned about the possible impact on public health from someone with minimal qualifications performing treatments which could require expert medical help to correct.” REFERENCES 1. Kilgariff, S, Industry responds to non-medic Love Island star training in injectable treatments,, Aesthetics journal, November 2019. <https://aestheticsjournal.com/news/industry-responds-tonon-medic-love-island-star-training-in-injectable-treatments> 2. Instagram, Rykard Jenkins. <https://www.instagram.com/p/B5Dl2MWBp6y/> 3. Tweedy, J,, Doctor slams Government’s ‘Wild West’ regulation of Botox and fillers after an exLove Island star qualified to offer treatments with a company that gives two DAYS of training, Mail Online, 2019. <https://www.dailymail.co.uk/femail/article-7711009/GP-slams-Wild-Westapproach-Botox-Love-Island-star-qualifies-treatments.html> 4. Save Face, Lauren Goodger’s filler scandal: ‘You could BLIND someone!’ <https://www. saveface.co.uk/lauren-goodgers-filler-scandal-you-could-blind-someone/> 5. Empire Institute of Beauty and Aesthetics, Facebook. <https://www.facebook.com/ EmpireBeautyAesthetics/videos/2911173008935151/> 6. Mclure, D, Lauren Goodger’s filler scandal: ‘You could BLIND someone!’ Closer Magazine, January 2020. <https://closeronline.co.uk/celebrity/news/lauren-goodger-slammedunqualified-filler/> 7. Novak, K, Lauren Goodger trains to administer lip and facial fillers and shares videos injecting people’s faces, Metro, . December 2019. <https://metro.co.uk/2019/12/13/lauren-goodgertrains-administer-lip-facial-fillers-shares-videos-injecting-peoples-faces-11880089/> 8. Save Face, Laws and Regulations for the Non-Surgical Cosmetic Industry. <https://www. saveface.co.uk/laws-regulations-non-surgical-cosmetic-industry/> 9. Kilgariff, S, News Special: Westminster Regulation Debate, Aesthetics journal, March 2019. <https://aestheticsjournal.com/feature/news-special-westminster-regulation-debate> 10. Kilgariff, S, Prime Minister addresses regulation issues of non-surgical treatments, Aesthetics journal, January 2019. <https://aestheticsjournal.com/news/prime-minister-addressesregulation-issue-of-non-surgical-treatments> 11. Gronow, C, BACN to update Code of Conduct on the training of beauty therapists, Aesthetics journal, November 2019. <https://aestheticsjournal.com/news/bacn-members-unanimouslyagree-to-update-code-of-conduct-on-the-training-of-beauty-therapists>

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Develop Your Business Skills at ACE 2020 Learn from industry experts on March 13 and 14 The Aesthetics Conference and Exhibition provides 33 clinical sessions and 19 business workshops for aesthetic practitioners, delivered by leading brands, trainers and experts. The extensive exhibition plays host to 80+ exhibiting companies showcasing the very latest in medical aesthetics and helping delegates to keep their clinics up to date. There are also numerous networking opportunities for delegates to catch up with peers and colleagues across the specialty. All this makes ACE a mustattend event for every medical aesthetic practitioner.

What can you expect from the Business Track? The Business Track has an all new agenda for ACE 2020, with new speakers and exciting new sessions covering a myriad of topics to help you keep your business stand out from the crowd. Big industry names will reveal their secrets to success and experts in key areas will impart their insight to ensure you stay on track with the latest regulations and business best practice. The Business Track is open to all professionals, so bring your whole team to learn! 2020

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Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Highlights from the Business Track, sponsored by

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Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


Advertorial Sterimedix

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ensuring a secure connection between cannula and syringe. Some syringes from filler manufacturers have a different thread on them to other manufacturers. Silkann® aesthetic cannulas are the only cannulas available which can be screwed on securely to every syringe.

Introducing the GTI Cannula®

Innovations in Cannulas The only UK manufacturer of aesthetic cannulas leads the way in design and innovation Sterimedix has led the way in the manufacture of cannula products for over 30 years. Based in Redditch, Sterimedix draws on the local history of needle making in the area which can be traced back to the 16th Century. Originally focussed on ophthalmic surgery, with the requirement for accuracy and quality, Sterimedix was encouraged to enter the aesthetic field through its long-standing collaborations with companies making hyaluronic acid based products for both eye surgery and then aesthetic procedures.

Introducing Silkann® cannulas By bringing its skills to bear, Sterimedix was able to create and introduce the Silkann® range of aesthetic cannulas. The products were designed to meet the safety and quality needs of practitioners. Medical device manufacturers operate in a highly regulated and controlled environment. Full regulatory and quality systems are in place to support the products, allowing them to be sold in all the markets around the world. Products are 22

manufactured in clean environments to the tightest of tolerances and tested thoroughly before release to the market. The Silkann® range is no different and is made to the highest possible standards in full compliance with local and international standards. Silkann® aesthetic cannulas pass through 14 different processes before they finally make it into a box. They are tested for consistency to levels you might find astonishing. For example, the inner diameter of the cannula cannot vary by more than 0.03mm from the exact specification. Why so strict you may ask? Because the ID of the cannula directly affects the force required to inject the filler, which in turn affects the performance of the filler. Consistency means that every time you use a cannula it should feel the same. What else? The size of the port; same size every time. In the same position relative to the tip – every time. It’s smooth, with no sharp edges, which could compromise your procedure. The surface finish is critical to help the cannula slide easily so you can manipulate it exactly where you want it. The hub design has a unique screw thread which is compatible with all types of syringes,

Not content with producing products that meet the current needs of the profession, Sterimedix has sought to work with innovators to advance the technology. This is something Sterimedix is uniquely capable of doing as it has total control of its own manufacturing and design in its research and development department, as well as full regulatory oversight of new products. As a result, the first GTI Cannula®, which is designed to treat surface defects and small scars, has been launched. The cannula, designed in conjunction with Dr Olivier Amar of the Cadogan Clinic in London, removes the need for the use of sharp instruments and provides for a highly successful and safe

treatment. Clinical studies have confirmed the results to be highly favourable. The device opens the opportunity for all trained injectors to safely treat scarring. Two more GTI Cannula® products are planned for 2020 to allow abdominal treatments of larger and denser defects.

The future of Sterimedix Sterimedix is committed to a positive contribution to the aesthetic profession by bringing high quality, locally made and innovative products to market. The company’s commitment resulted in the move to a new state-of-the-art manufacturing facility in 2019, allowing for further investment in production equipment and staff, expanding the manufacturing capabilities and capacity to continue to grow in support of it’s customers.

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Understanding Dermatology Conditions Journalist Allie Anderson speaks to dermatologists about the procedures and methods they have successfully used to treat dermatology cases The skin is the largest organ of the body, so treatment of dermatological conditions is a vast area. Moreover, when the skin is not at its best it can significantly impact the quality of life of patients. Many minor, everyday skin complaints can be successfully addressed in a conventional aesthetic clinic, while others – like many discussed in this article – are referred to a consultant dermatologist. This article delves into some interesting dermatology cases that have been successfully treated, educating practitioners about the skin condition and how patients are managed. Note that when it comes to dermatology, practitioners need to recognise when the case is outside their remit and refer to an appropriate consultant.

Folliculitis Consultant dermatologist Dr Daron Seukeran specialises in laser surgery. He has successfully used lasers to treat folliculitis in amputees. Folliculitis is a condition in which the hair follicles become inflamed, resulting in clusters of small, red bumps or white pimples around hair follicles. These can develop into pusfilled blisters and can be itchy and painful.1 It is frequently caused by bacterial or fungal infection or physical irritation, for example in patients who shave their beards, with skin occlusion being a risk factor.2 According to Dr Seukeran, this makes it a common complaint among amputees – particularly lower-limb amputees – who wear a prosthesis. It is estimated that around 70-75% of lower-limb amputees experience skin problems related to using a prosthesis.3,4 “Patients often still get hair growth around their stump, particularly on the leg,” explains Dr Seukeran. However, he says, “The occlusive effect of the prosthesis, where it comes into contact with the skin of the stump, can cause irritation, which leads to inflammation of the hair follicles. The problem can be exacerbated with constant use of the prosthesis, with the stump subject to pressure and rubbing against the weight-bearing prosthesis, resulting in discomfort that can be severe. Therefore, patients can’t wear their prosthesis for the length of time they might want to, and, for these people, it can have a major impact on their day-to-day life.” Laser hair removal therapy has been demonstrated to yield a marked improvement in folliculitis,5 with a significant decrease in hair density (and thus, gravity of symptoms). Exacerbations of the disease at follow-up are also reduced after

treatment with an alexandrite laser6 – Dr Seukeran’s tool of choice in this patient cohort. During the initial consultation, he establishes the severity, frequency and factors that worsen the patient’s symptoms, and what treatments they have tried. “Often, they’ll have used remedies like shaving and depilatory creams, which can themselves cause irritation and the hair grows back quickly,” Dr Seukeran comments. “The advantage of lasers is that, even though sometimes the hair may come back, you get long periods with no hair growth and if the hair returns, it’s thinner and less prone to folliculitis,” he explains. In this case study (Figure 1), Dr Seukeran used an alexandrite laser with a wavelength of 755 nanometres (nm) and fluence of 16-22 joules per square centimetre (J/cm2). An 18mm spot size enabled each pulse to target a relatively large area, with fewer pulses needed to treat the whole area of affected skin, meaning each session was just 15 minutes long. Performed at four-to-six-week intervals, the treatment was completed over a four-month period. Dr Seukeran adds, “In general, it’s fast, comfortable and welltolerated; and, because there is no breaking of the skin, there’s no wound care. Although, we do recommend patients use a little moisturiser or aloe vera gel immediately after the treatment.” Some patients, Dr Seukeran says, experience slight redness, but it’s typically asymptomatic and transient at the time of the treatment, so patients can wear their prosthesis straight away. Longer-term risks include pain, tenderness, crusting, blistering, swelling, scarring and infection, although all are rare.7 Before

After

Figure 1: Patient presenting with folliculitis before and four months after four laser hair removal treatments using Candela Gentlelase alexandrite laser.

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Pilonidal sinus Dr Seukeran also treats patients with the very rare and complex skin condition, pilonidal sinus. Again, laser hair removal has yielded positive results. Pilonidal describes a chronic skin disease of the natal cleft; the deep crease between the buttocks that runs between just below the sacrum to the perineum. Dr Seukeran explains it is thought to be caused by inflammation and infection of the hair follicles in the cleft, where skin debris can accumulate and worsen the problem. Men are more commonly affected than women.8 Dr Before

After

with darker or tanned skin, owing to its longer wavelength (1064 nm).11,12 While no specific pre- or post-procedural care is required, the pilonidal sinus must be free from infection for laser treatment to take place Dr Seukeran states. “If there was any concern about infection, we would take wound swabs beforehand and treat accordingly,” he says, adding, “The most important thing is to reassure the patient that it can be treated successfully, but it’s going to take multiple treatments to heal.” For this case study, seven treatments over several months were necessary. He says, “The patient is still undergoing treatment, but they are now asymptomatic with no discharge of pain. It should be noted that there is always risk of recurrence.” Post-procedural effects can include blistering, crusting and localised pain, which can be minimised with topical or local anaesthetic. Generally, lasers are an effective and well-tolerated treatment for pilonidal sinus, according to Dr Seukeran, resulting in healing of problematic and treatmentresistant cases, and improved quality of life for patients.5

Acne

Figure 2: Patient presenting with pilonidal sinus before and approximately seven months after seven laser hair removal treatments using the Candela Gentlelase alexandrite laser.

Seukeran says most patients will develop a pilonidal sinus where a narrow cavity (known as a sinus tract) extends from beneath the skin where there is inflammation and infection, through the soft tissue to the skin’s surface around the coccyx. A painful abscess with foulsmelling discharge can form, he explains.9 “Patients will often have had multiple courses of antibiotics to treat a pilonidal sinus and that may lead to partial improvement, but the tissue quickly breaks down again,” notes Dr Seukeran. He adds that some patients have surgery to remove the abscess and cut out the sinus tract, with the area being allowed to heal by secondary intention – where the wound is left open. However, he highlights that surgical intervention is associated with a 40-60% recurrence rate, and secondary intention carries a risk of post-operative infection and healing time of up to 10 weeks.10 Where hair continues to grow in the natal cleft, it can trap faeces and other debris and proliferate bacteria spread. Thus, he says, “The need to eliminate a nidus of inflammation/infection and provide hair-free wound and peri-wound skin cannot be overstated.”10 Dr Seukeran explains that, “Because persistent hair growth in this area contributes to the development of the problem, permanent hair removal with lasers, often in addition to surgery, can be helpful.”5 The initial consultation would comprise a full medical history, examination of the area and discussion of the symptoms and their impact on the patient’s life in terms of pain and discomfort. “I would also ask whether they’ve had previous treatments and how effective they were,” Dr Seukeran says. To treat the patient in Figure 2, Dr Seukeran used the same parameters as with the folliculitis patient: an alexandrite laser at 16-20 J/cm2 fluence with an 18mm spot size, in order to cover the affected area quickly. “If the hairs are stubborn and a patient doesn’t respond to the standard laser, or if we don’t achieve the results we want, then we can use a different type of laser, such as a long-pulsed Nd:YAG laser, which gives a deeper penetration to impact the hair more effectively,” Dr Seukeran comments. According to Dr Seukeran, this laser type is also considered the most effective for patients

Among other specialties, consultant dermatologist Dr Nicole Chiang offers comprehensive and personalised treatment plans for patients with acne. For those with persistent and scarring acne, her approach is to use oral isotretinoin. Dr Chiang says acne is a skin condition driven by three main factors:13 1. Overactive sebaceous glands, which are usually triggered by hormones – hence acne usually begins at puberty. 2. Follicular hyperkeratosis, whereby the pores become clogged by a build-up of dead skin cells that aren’t shed properly. 3. Overgrowth of Propionibacterium acne (P-acne) bacteria on the skin, which multiply due to excess oil production caused by over activity of the sebaceous glands. “Acne can present as blackheads and whiteheads, red spots known as papules, and yellow spots known as pustules, or large, painful nodules or cysts,” Dr Chiang explains. “When patients have severe acne, they often have scarring too. But before carrying out any Before

After

Figure 3: Patient presenting with acne before and 10 months after treatment using oral isotretinoin.

aesthetic treatments for the scarring, we need to address the acne itself,” she states. The patient in Figure 3 had experienced severe acne for 10 years, and in that time, he had tried numerous topical treatments and several courses of oral antibiotics that had limited long-term success. As a result, the patient had also begun to develop scarring. As well as a full clinical assessment, Dr Chiang’s consultation entails establishing the impact the patient’s acne has on their quality of life, which – as is common with severe dermatological conditions – was significant. “In this patient, I recommended a course of oral isotretinoin. This is the most effective treatment for severe acne accompanied by scarring and in many cases, it’s the only treatment option unless there are contraindications,” Dr Chiang says. A 2019

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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literature review suggested that the use of isotretinoin in patients with acne might increase the risk of depression,14 so Dr Chiang advises clinicians to exercise caution in patients with active or historical depression. Dr Chiang explains that isotretinoin works by targeting the pilosebaceous unit, a structure of the skin comprising hair; the hair follicle, small muscles attached to the hair follicles; and the sebaceous gland. It shrinks the sebaceous glands, reduces sebum production, limits follicular occlusion and inhibits the growth of bacteria, as well as having anti-inflammatory properties.15 “This leads to a reduction in blackheads, whiteheads and clogged pores,” adds Dr Chiang. The treatment course length and doses are determined by the severity of the patient’s condition at baseline and how they respond over time. This patient took one isotretinoin tablet each day for 10 months, beginning with a low dose of 20mg and gradually increasing to 60mg a day. “His acne cleared to a level he was happy with in around eight months, but because it was so severe to begin with, we continued with the treatment for two more months to reduce the risk of relapse,” Dr Chiang comments. Most cases of acne clear in a single course or treatment, and long-term remission can be achieved in 70-80% of cases,16 Dr Chiang says. Blood tests are taken before starting treatment and at regular intervals throughout to check kidney and liver function, to ensure the patient can metabolise and excrete the isotretinoin, says Dr Chiang. Because the medication is teratogenic, she highlights that treatment must be stopped if a female patient falls pregnant. “This is a very effective treatment for acne, but it’s important to manage a patient’s expectations from the beginning,” Dr Chiang concludes, adding, “We must establish the end point the patient hopes to reach in terms of skin clearance, and make sure they understand how long the treatment is likely to last.”

Acne scarring Dr Firas Al-Niaimi is a consultant dermatologist who regularly treats patients with scarring caused by acne. He offers a number of different treatments for this condition and his approach is determined on a case-by-case basis. Acne scarring is a relatively common problem that often results from very aggressive acne, or less severe acne that isn’t properly treated. “It mostly presents on the face and it can have a huge impact on the psychological wellbeing of patients, who tend to be very self-conscious of their scars,” explains Dr Al-Niaimi. “Successful treatment is dependent on accurately describing the type and the severity of the scarring – that will dictate the type of treatment and the prognosis,” he adds. Before

After

Figure 4: Patient presenting with acne scarring before and four months after treatment using subcutaneous surgical subcision and Sculptra poly-L-lactic acid filler.

Dr Al-Niaimi explains that acne scarring can be classed as either atrophic, where there is loss of tissue or damage to the collagen; or hypertrophic, in which there is thickening of the tissue. Acne scarring on the face normally has an indented appearance, and

is thus atrophic in nature. He says that this type of scarring can be subcategorised as:17 • Boxcar scars – broad indentations with sharply defined edges • Ice-pick scars – deep, narrow, pitted scars • Rolling scars – broad indentations with sloping edges Dr Al-Niaimi points out that grading the severity of acne scarring is subjective, with different clinicians using different scales. “In general, the more extensive the scars are, the deeper and more visible they are from a social distance and the more shadows you see, the higher the severity grading,” he comments, emphasising, “The less visible the scars, and the closer you have to come for the scarring to be visible, the milder the severity.” This particular case study in question (Figure 3) had severe, atrophic rolling scars, and on that basis and following a full medical consultation, Dr Al-Niaimi recommended surgical subcision in the first instance, followed by volume replacement with injectable fillers to correct the collagen loss. With this type of scarring, Dr Al-Niaimi explains that the scars are tethered to the underlying subcutaneous layer by strands of tissue, which pull on the dermis and give each scar its dipped, hollow appearance. Surgical subcision entails inserting a needle through a puncture in the skin and cutting the fibrous strands underneath the skin’s surface. In doing so, the tether is released, and the indentation is lifted.18 “I use an advanced technique, where through a single needle entry point, I inject tumescent anaesthesia to expand the subcutaneous layer between the dermis and the fascia. This creates an inflated area that allows for enhanced safety and erects the strands of the scars to keep them under tension,” says Dr Al-Niaimi. At this point, Dr Al-Niaimi makes a 4-5mm incision in the side of the cheek and inserts a long surgical cutting instrument underneath the skin, to subcise the strands of the scars in the entire affected area. He highlights, “It’s a complex procedure that requires skill and thorough understanding of the anatomy to ensure you don’t go too deep or too superficial, but rather along the right plane.” The technique usually takes around an hour and is performed under light sedation. Some transient post-procedure swelling, bruising and pain can be expected, and most patients report significant improvement of the appearance of scarring.19 However, it’s not uncommon for a degree of dipping to remain, Dr Al-Niaimi states. For this reason, Dr Al-Niaimi explains surgical subcision is often combined with other treatments for maximum efficacy.18,20 In this patient, Dr Al-Niaimi recommended an injectable poly-L-lactic acid filler (Sculptra) to stimulate collagen production and restore volume. “I know from experience that subcision alone is not sufficient for severe rolling acne scars, but together with this filler, it can give very good results,” he says. The patient underwent both treatments on the same day, requiring a single anaesthetic and just one trip to the clinic. Alternatively, Dr Al-Niaimi explains that the filler treatment can be performed six-to-eight weeks after the subcision, and follow-up treatments at six-to-eight-week intervals as required; although, this particular patient did not need any subsequent injectables. Dr AlNiaimi highlights that swelling, bruising, redness, pain and tenderness can occur,21 following surgical subcision, and a small minority of patients can develop nodules after the filler,22 which can be prevented or managed with gentle massage of the area.

Psoriasis Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon. Among the various treatments he prescribes for patients with psoriasis is a topical agent that combines corticosteroids and vitamin D analogue, called Enstilar. The inflammatory skin condition

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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psoriasis often presents from young adulthood and affects around 2.2% of the UK population.23 “It’s a symmetrical rash that presents equally on both sides of the body, typically on the elbows and knees,” Dr Cliff explains, adding, “It can also affect individual parts of the skin like the scalp, nails, face and chest, and it can be extremely itchy and sore because the skin cracks. It can sometimes bleed, and it can be very embarrassing and affect a patient’s personal life.” Dr Cliff says that typically, psoriasis is marked by patches of red, thick scaly skin that has a silvery appearance. If it’s correctly diagnosed and appropriately treated, patients very often respond well. In order to confirm psoriasis, Dr Cliff explains that it’s important to examine all of the skin – not just the affected areas – to identify the pattern and distribution of the rash and rule out other conditions. “Quite often, patients will have tried other treatments that haven’t worked, so it’s important to ask them to score the severity of the condition, with zero being very clear and 10 being awful,” Dr Cliff says. “While I may score it a one or two, they might score it an eight or nine because, although it may not be very severe or affect a large area, it might stop them from doing certain things and affect them quite badly,” he adds. So, the consultation should ascertain the patient’s hopes for treatment and what they would like to be able to do – for example, go swimming or wear dark clothes without the skin flaking. He describes a case which demonstrates that not only is it essential to find the right treatment, but the regime must be followed to the letter in order for it to be effective, highlights Dr Cliff. The patient had previously been prescribed Enstilar, a topical foam that combines the active ingredients calcipotriene (a vitamin D analogue) and the corticosteroid betamethasone dipropionate.24 “This is very effective if it’s used properly, but this patient had used it very sparingly and not regularly enough,” Dr Cliff recalls. So, he explains, the medication was restarted. The patient was instructed to apply the foam liberally to the affected areas of skin before going to bed, and to leave it to absorb overnight. After a four-week course, the psoriasis had cleared considerably; the thick, scaly patches had flattened and smoothed and the redness had subsided. In cases where the first-line treatments don’t yield satisfactory results, Dr Cliff says the next steps might be a course of medical sunbeds, whereby the skin is exposed to controlled doses of ultraviolet light for 10-minute sessions a few times a week. Other options are methotrexate, a medication that binds to and inhibits an enzyme involved in the rapid growth of skin cells, and cyclosporine, which stops the growth of immune cells.25 According to Dr Cliff, it’s essential to address lifestyle and (where applicable) to advise patients to avoid excessive alcohol consumption, give up smoking, maintain a healthy weight, take part in physical activity and have their cardiovascular risk assessed.22 “Managing expectations is important,” says Dr Cliff, adding, “We can’t cure psoriasis, but for most patients it’s a question of management and achieving clearance to the point they are happy with. As clinicians, our job is to try and match those aspirations realistically and pragmatically.”

Board-certified dermatologist and Aesthetics journal Clinical Advisory Board member Dr Stefanie Williams highlights, “Dermatology patients may present to aesthetic clinics. However, it is essential to acknowledge that these skin conditions are in fact medical issues that should be referred for prescription treatment. The acne patient mentioned in this article who was successfully treated with oral isotretinoin and the psoriasis patient treated with a prescription combination of a topical vitamin D analogue and corticosteroid are perfect examples of this. My recommendation is to refer patients with dermatological conditions to a dermatologist, rather than delaying their treatment by attempting aesthetic procedures.” REFERENCES 1. Oakley, A, Folliculitis Derm Net NZ, 2014. <https://dermnetnz.org/topics/folliculitis/> 2. Knott, L. Folliculitis. December 2017. Accessed at www.patient.info/doctor/folliculitis-pro 17 January 2020 3. Baars, EC et al. Skin problems of the stump and hand function in lower limb amputees: A historic cohort study. Prosthet Orthot Int. 2008 Jun;32(2):179-85. 4. Highsmith, MJ et al. Identifying and Managing Skin Issues With Lower-Limb Prosthetic Use. In Motion, Volume 21, Issue 1 January/February 2011. 5. Aleem S, Majid I. Unconventional Uses of Laser Hair Removal: A Review. J Cutan Aesthet Surg. 2019;12(1):8–16. 6. Koch D, Pratsou P, Szczecinska W, Lanigan S, Abdullah A. The diverse application of laser hair removal therapy: a tertiary laser unit’s experience with less common indications and a literature overview. Lasers Med Sci. 2015;30:453–67. 7. NHS.uk, Laser hair removal, September 2019. <www.nhs.uk/conditions/cosmetic-procedures/laserhair-removal/> 8. Webdale M et al, Department of Colorectal Surgery Pilonidal Sinus Operation, Norfolk and Norwich University Hospitals NHS Trust, August 2017. 9. ASCRS, Pilonidal Disease, American Society of Colon and Rectal Surgeons. <www.fascrs.org/ patients/disease-condition/pilonidal-disease> 10. Harris CL et al, Twelve Common Mistakes in Pilonidal Sinus Care, Advances in Skin & Wound Care: July 2012 - Volume 25 - Issue 7 - p 324–332. 11. Lorenz S et al, Hair removal with the long pulsed Nd:YAG laser: a prospective study with one year follow-up. Lasers Surg Med. 2002;30(2):127-34. 12. Mittal R et al, Evaluation of Long-pulsed 1064 nm Nd:YAG Laser-assisted Hair Removal vs Multiple Treatment Sessions and Different Hair Types in Indian Patients. J Cutan Aesthet Surg. 2008;1(2):75–79. 13. Oakley A, What causes acne? June 2014, DermNET NZ. <www.dermnetnz.org/topics/what-causesacne/> 14. Li C et al, Use of isotretinoin and risk of depression in patients with acne: a systematic review and meta-analysis. BMJ Open 2019;9:e021549. 15. Oakley A et al, Isotretinoin, February 2016, DermNET NZ. <www.dermnetnz.org/topics/isotretinoin/> 16. Rademaker M, Isotretinoin: dose, duration and relapse. What does 30 years of usage tell us? Australas J Dermatol. 2013 Aug;54(3):157-62. 17. Oakley A, Acne scarring, June 2014, DermNET NZ, <www.dermnetnz.org/topics/acne-scarring/> 18. Chandrashekar B et al. Acne scar subcision. J Cutan Aesthet Surg. 2010;3(2):125–126. 19. Alam M et al, Subcision for Acne Scarring: Technique and Outcomes in 40 Patients. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 31. 310-7; discussion 317. 20. Bayat A et al. Skin scarring. BMJ. 2003;326(7380):88–92. 21. Santos-Longhurst A, Will Sculptra Effectively Rejuvenate My Skin? Healthline, June 2018. <www. healthline.com/health/sculptra#risks-and-side-effects> 22. Chen H et al. Quantitative Assessment of the Longevity of Poly-L-Lactic Acid as a Volumizing Filler Using 3-Dimensional Photography. JAMA Facial Plast Surg. 2015;17(1):39–43. Accessed at www. jamanetwork.com/journals/jamafacialplasticsurgery/fullarticle/1917535 17 January 2020 23. National Institute of Health and Care Excellence, Psoriasis: assessment and management, Clinical guideline [CG153], September 2017. <www.nice.org.uk/guidance/cg153/chapter/Introduction> 24. Leavitt M, New topical foam reduces itch, improves skin, National Psoriasis Foundation, December 2015. <www.psoriasis.org/advance/topical-foam-improves-itch-clears-skin> 25. National Psoriasis Foundation, Systemic Medications: Methotrexate. <www.psoriasis.org/aboutpsoriasis/treatments/systemics/methotrexate>

Summary People with skin conditions will often present in the first instance to an aesthetic clinic, sometimes seeking help for complaints that have resisted treatment. It’s essential to acknowledge the limitations of aesthetic treatments, and to refer on to a consultant dermatologist for medical care where required. Interviewees highlight that the success of any dermatological treatment should be measured according to the hoped-for end goal – and that must be determined by the patient, with guidance from their clinician.

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Treating the Neck with Toxin Dr Souphiyeh Samizadeh explores the ageing of the neck and its treatment using botulinum toxin A lean and tight neck is an important contributor to the appearance of youthfulness and attractiveness. Smooth skin texture with an even tone, a well-defined cervicomental angle, distinct mandibular border and appropriate fullness are all considered to be visual aspects of a youthful neck.1 Multiple underlying physiological processes contribute to ageing of the facial and neck skin. These include chronological ageing (which leads to thinning and reduction in the elasticity of the skin), accumulated tissue damage from environmental factors such as photodamage from sunlight exposure, downward tension from the platysma muscle complex, increased submental fat and the effects of gravity on ageing skin.1,2 An already existing recessed chin and 3D changes of the mandible and the chin contribute to characteristic signs of ageing.3-5 An interplay of these underlying processes leads to the visual signs of ageing of the face and neck such as volume loss, the formation of marionette area hollowness, jowls, wrinkles and folds, as well as the loss of mandibular contouring.1-3 For the medical aesthetic practitioner, it is highly important to understand each individual patient’s complaints and offer treatments that result in maximum outcomes for that patient. In this regard, it is critical to understand the ageing processes of the neck, carry out a correct and complete assessment and analysis for each patient, understand their goals and expectations, and correctly offer treatment options that help to correct the individual patient’s underlying pathology. Various injectables can be used for neck rejuvenation targeting various indications. Examples include botulinum toxin A, dermal fillers, platelet-rich plasma and platelet-rich fibrin, mesotherapy, bioremodelling and biorevitalising agents, thread lifting and fatdissolving agents. Of course, there are other modalities that can be used such as lasers, other energy devices and topical skincare. The role of topical creams and growth factors that are becoming available in the market should not be underestimated. Some clinical studies report rejuvenating effects with topical creams, including significant firming and smoothing effects with reduced appearance of hyperpigmentation.6-8 It is beyond the scope of this article to explain each treatment option. This article therefore outlines some the pathophysiological processes underlying the ageing of the neck, evaluates clinical criteria commonly used to assess neck ageing and explores the administration of botulinum toxin A.

Pathophysiology of the ageing neck Like all human organs, the skin undergoes a process of intrinsic chronological ageing. The decreased elasticity and increased laxity of skin associated with natural ageing are thought to be caused by reductions in the proliferative ability of skin cells, reduced collagen matrix synthesis in the dermis, increased expression of enzymes that degrade the collagenous matrix, a reduction in elastin gene expression and oxidative damage.9-12

These factors contribute to a reduced capacity for the skin to regenerate itself and cause a reduction in collagen content of the skin and a change in the structure of skin collagen fibres from fine and homogeneously ordered to thick and randomly ordered.9-12 In combination with intrinsic ageing, extrinsic factors can accelerate the ageing of the skin, primarily photodamage from sunlight exposure.13 Exposure to ultraviolet radiation from the sun has been shown to cause additional degradation of the dermal matrix and reduce the effectiveness of dermal repair mechanisms.9 This is very clearly observed with athletes who mainly practice outdoors.14,15 With time, the downward pull on the neck and face exerted by the platysma muscle complex and loss of tone in the platysma muscle leads to reduced definition of the chin and jawline and the development of jowls.16 Enlargement and ptosis of the submandibular gland are reported to be part of the ageing process, notably in those who are thin.17 These factors, in combination with the descent of the hyoid bone and larynx, causes the cervicomandibular angle to be altered and the radial and horizontal neck lines become emphasised.4,16 Loss of muscle tone and changes of the skin with ageing have previously been thought to cause platysma bands.18-20 However, Trévidic and Criollo-Lamilla examined patients with unilateral facial palsy and observed visible platysma bands on the healthy side and not on the paralysed side (also no skin ptosis) and therefore, concluded that these lines are produced by the activity of platysma.21 The skin follows the muscle and hence the vertical fibrous bands associated with neck ageing are the result of hyperkinetic platysma muscles attempting to support the structures of the neck and floor of the mouth as they lose structural integrity during ageing.4 In addition, loss of tone in the platysma muscles allows the subplatysmal fat pad to herniate and results in a central fullness of the neck.22 The large submental fat pad protrudes from behind or between the two free borders of the platysma muscle.4 During ageing, the platysma muscle fibres themselves detach from deep planes and become attenuated, also contributing to the appearance of ageing.23 The retaining ligaments that ensure the close proximity of the platysma muscle to the hyoid and mandible also undergo changes and they weaken over time.24 In general, vertical and horizontal neck lines appear at around 40 years of age, or even younger in individuals who are active and have low levels of body fat.25 It’s been reported by the media that the horizontal necklines, or ‘tech neck lines’ in younger individuals are becoming more noticeable and more prevalent due to constant use of devices and bending of the neck.26,27

Clinical assessment of the ageing neck The following five visual criteria to assess the youthfulness of the neck were proposed by Ellenbogen in 1980 and are still used:28 1. A clear jawline (inferior mandibular border clearly well-defined from mentum to angle and no jowl overhang)

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2. Subhyoid depression (gives an appearance of a long and thin neck) 3. Visible thyroid cartilage contour 4. Visible anterior border of the sternocleidomastoid muscle 5. Cervicomental angle between 105° and 120° The classical appearance of an ageing neck includes vertical fibrous bands, horizontal bands and central neck fullness due to subplatysmal fat pad herniation (Figure 1).

Botulinum toxin A Botulinum toxin A (BoNT-A) has emerged as one of the primary means of facial and neck rejuvenation. As we know, BoNT-A is a neurotoxin produced by the bacterium clostridium botulinum and has a paralysing

B C A

Figure 1: Classical signs of an ageing neck, including a) vertical fibrous bands b) horizontal bands and c) central neck fullness due to subplatysmal fat pad herniation

effect on muscles.29 The various preparations of BoNT-A are not interchangeable and this should be considered prior to treatment planning and according to desired treatment outcomes.29 BoNT-A has been shown to change the tone in the muscles that are directly involved in facial shape and animation, and hence can lead to improvement in skin tone and texture based on changes in the underlying muscles.30-32 With correct patient selection, necklines (vertical bands and horizontal lines), in addition to loss of lower face contour, can all be effectively treated with BoNT-A.30,31,33-35 A recent systematic review has found BoNT-A to be a highly effective treatment for isolated platysma bands.36 The rationale for the use of BoNT-A for the rejuvenation of the neck area originates from the idea that the platysma muscle plays a key role in the ageing mechanism of the cervical region by pulling the skin and lower facial structures caudally.2 Chemical denervation or neuromodulation of this muscle with BoNT-A will help reduce some of the exerted tension and hence reduce some of the lines and bands seen in ageing, resulting in improvement of the appearance of vertical, horizontal necklines.2 This was first reported by Brant and Bellman in 1998 with an additional observed effect of improved jawline contour.34 The downward pull of the platysma muscle, in combination with the depressive effect of the depressor anguli oris muscles also results in downward (inferior) pull of the oral commissures.23 Administration of BoNT-A to change the tone of other depressor muscles in the lower face can help reduce wrinkles and lines, and improve the definition of the jawline.31 Various authors have published their own techniques for treating the platysma muscle, some of which are discussed in this article. The primary indication for the use of BoNT-A in the neck area is muscle hyperactivity.23 Therefore, BoNT-A works best on patients with hyperactive muscle and minimal to no skin laxity.35,36 Similarly, in the following cases, injection of BoNT-A will not be effective in rejuvenation:21,35,37

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• Redundant cutaneous laxity • Excessive lipodystrophy • Hypertrophic submandibular glands Aggressive and over treatment of the platysma muscle should be avoided. As with any muscle that is weakened/paralysed, muscle atrophy will take place and this inevitably could result in a lack of support the platysma provides for the lower face and neck. As Dr Michael Kane also mentioned in his 1999 paper, this results in premature ageing of the patients in the long term.35 Studies examining long term effect of BoNT-A for treating necklines would be beneficial. Various BoNT-A injection reports have been published. Treatment of neck using BoNT-A was first reported by Brant and Bellman in 1998 targeting the platysmal bands with an observed effect of improved jawline contour.34 Levy described the ‘Nefertiti lift’ to improve the contours of the jawline, named after the Egyptian queen who had a strongly defined jawline.33 The injection points are placed along the mandible and the technique aims to:33 • Lift and improve the definition of the mandibular border and angle • Elevate the corners of the mouth • Drape the skin of the jawline contour This technique described treating a horizontal line under the mandible and upper part of the posterior platysmal band.33 It is important to keep the anterior platysma fibres in mind as the untreated fibres may result in compensation contraction of the muscle and hence result in local wrinkling and loss of anterior facial contour or the herniated fat may look worse.31 The microbotox technique, shown in Figure 3, was introduced by plastic surgeon Mr Woffles Wu from Singapore. This technique uses many droplets of diluted BoNT-A (Botox) superficially (intradermal or the interface between the dermis and the superficial facial muscle), delivering 100-120 injections, resulting in superficial muscle weakening. This technique is reported to improve skin texture, reduce vertical bands of the neck, smoothen horizontal creases, and better apposition of the platysma to the jawline and neck, improving contouring of the cervicomental angle.30 Al Media et al. examined the anatomy of platysma muscle and its role in lower face dynamics and contouring.31 They highlighted the three insertion points of the platysma muscle and hence the functional anatomy of the upper platysma:31,38 • Platysma pars labialis: interdigitates and blends to orbicularis oris, depressor labii inferioris, mentalis muscles • Platysma pars mandibularis with insertion onto: the periosteum of the ramus of the mandible, the skin, subcutaneous plane of the lower face, and some fibres interdigitating with the DAO • Platysma pars modiolaris: all of the remaining fibres of upper platysma, and posterolateral to the depressor anguli oris

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020

Figure 2: Nefertiti technique with injection points along the mandible and posterior platysma band introduced by Dr Levy from France33


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Dr Souphiyeh Samizadeh is a dental surgeon and clinical director of Revivify London clinic. She is the founder of the Great British Academy of Aesthetic Medicine, is an honorary clinical teacher at King’s College London and Queen Mary University of London and is the visiting associate professor for Shanghai Jiao Tong University. Dr Samizadeh has multiple published papers in peer-reviewed journals and frequently presents at national and international conferences. She trains aesthetic doctors, nurses, dermatologists and surgeons worldwide and is involved in research in the field of aesthetic medicine. Figure 3: Microbotox technique introduced by plastic surgeon Dr Woffles Wu from Singapore.30

The complex anatomy, interdigitation and blending of this muscle results in the formation of various lines and wrinkles upon contraction of different sections of the muscle with its interdigitation. With having an understanding and appreciation of anatomy of this muscle, the correct diagnosis can be made and hence correct treatment administration towards the underlying target muscles involved.31 Potential complications of BoNT-A are technique dependent, but they typically include muscle soreness or neck discomfort, difficulty lifting the head from a pillow from the decubital position, and headaches. Other rare complications include hoarseness and difficulty swallowing, dry mouth and masticatory and speech disturbances.30 A recently published systematic review on the use of BoNT-A for treatment of mild-moderate platysma bands reported that no described complication required further intervention and that the most common complication of treating this area was haematoma/ecchymosis.36 However, the importance of correct technique and the use of small doses are emphasised to reduce the occurrence of complications including dysphagia.36,38,40 Platysma pars mandibularis Platysma pars labialis

Platysma pars modiolaris

Figure 4: Al Media et al. examined the anatomy of platysma muscle and its role in lower face dynamics and contouring.31 They highlighted the three insertion points of the platysma muscle and hence the functional anatomy of the upper platysma.31,37

Conclusion Injectable approaches can help our patients to achieve their desired aesthetic outcomes. Due to multifactorial and multi-layered ageing of the neck, multiple modalities and treatments may be required to achieve the optimal non-surgical rejuvenation so practitioners shouldn’t just look at injectable options alone. It’s important to note that there are currently no published studies that examine the long term effect of the use of BoNT-A for treating the neck area, so this would be welcomed.

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REFERENCES 1. Dayan, S.H., J.P. Arkins, and R. Chaudhry, Minimally invasive neck lifts: have they replaced neck lift surgery? Facial Plast Surg Clin North Am, 2013. 21(2): p. 265-70. 2. Brandt, F.S. and A. Boker, Botulinum toxin for rejuvenation of the neck. Clinics in dermatology, 2003. 21(6): p. 513-520. 3. Rohrich, R.J., et al., Neck rejuvenation revisited. Plastic and reconstructive surgery, 2006. 118(5): p. 1251-1263. 4. Coleman, S.R. and R. Grover, The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthetic surgery journal, 2006. 26(1_Supplement): p. S4-S9. 5. Ramirez, O.M. and K.M. Robertson, Comprehensive approach to rejuvenation of the neck. Facial Plast Surg, 2001. 17(2): p. 129-40. 6. Schlessinger, J., et al., A Firming Neck Cream Containing N-Acetyl Glucosamine Significantly Improves Signs of Aging on the Challenging Neck and Decolletage. J Drugs Dermatol, 2016. 15(1): p. 47-52. 7. Saxena, S.J., D. Duque, and M.J. Schirripa, Assessment of a Comprehensive Anti-Aging Neck Cream. J Drugs Dermatol, 2015. 14(9): p. 997-1002. 8. Chajchir, I., P. Modi, and A. Chajchir, Novel topical BoNTA (CosmeTox, toxin type A) cream used to treat hyperfunctional wrinkles of the face, mouth, and neck. Aesthetic Plast Surg, 2008. 32(5): p. 715-22; discussion 723. 9. Suwabe, H., et al., Degenerative processes of elastic fibers in sun-protected and sun-exposed skin: immunoelectron microscopic observation of elastin, fibrillin-1, amyloid P component, lysozyme and alpha1-antitrypsin. Pathol Int, 1999. 49(5): p. 391-402. 10. Uitto, J., Connective tissue biochemistry of the aging dermis. Age-related alterations in collagen and elastin. Dermatol Clin, 1986. 4(3): p. 433-46. 11. Newton, V.L., et al., Skin aging: molecular pathology, dermal remodelling and the imaging revolution. G Ital Dermatol Venereol, 2015. 150(6): p. 665-74. 12. Jenkins, G., Molecular mechanisms of skin ageing. Mech Ageing Dev, 2002. 123(7): p. 801-10. 13. Kohl, E., et al., Skin ageing. J Eur Acad Dermatol Venereol, 2011. 25(8): p. 873-84. 14. Harrison, S.C. and W.F. Bergfeld, Ultraviolet light and skin cancer in athletes. Sports Health, 2009. 1(4): p. 335-340. 15. Moehrle, M., Outdoor sports and skin cancer. Clinics in dermatology, 2008. 26(1): p. 12-15. 16. Zimbler, M.S., M.S. Kokoska, and J.R. Thomas, Anatomy and pathophysiology of facial aging. Facial Plast Surg Clin North Am, 2001. 9(2): p. 179-87, vii. 17. Ilankovan, V., Anatomy of ageing face. British Journal of Oral and Maxillofacial Surgery, 2014. 52(3): p. 195-202. 18. McKinney, P., The management of platysma bands. Plastic and reconstructive surgery, 1996. 98(6): p. 999-1006. 19. Barbarino, S.C., A.Y. Wu, and D.M. Morrow, Isolated neck-lifting procedure: Isolated stork lift. Aesthetic plastic surgery, 2013. 37(2): p. 205-209. 20. Henley, J.L., D.J. Lesnik, and A.R. Terk, Contralateral platysma suspension: An adjunct to rhytidectomy. Archives of facial plastic surgery, 2005. 7(2): p. 119-123. 21. Trévidic, P. and G. Criollo-Lamilla, Platysma Bands: Is a Change Needed in the Surgical Paradigm? Plastic and reconstructive surgery, 2017. 139(1): p. 41-47. 22. Vistnes, L.M. and S.G. Souther, The anatomical basis for common cosmetic anterior neck deformities. Ann Plast Surg, 1979. 2(5): p. 381-8. 23. Jabbour, S.F., et al., Botulinum toxin for neck rejuvenation: Assessing efficacy and redefining patient selection. Plastic and reconstructive surgery, 2017. 140(1): p. 9e-17e. 24. Le Louarn, C., A new approach to functional anatomy of the lower face: Role of the hyoplatysmal ligament, of the platysma and of the depressor labii lateralis. Ann Chir Plast Esthet, 2016. 61(2): p. 101-9. 25. Daher, J.C., Closed platysmotomy: a new procedure for the treatment of platysma bands without skin dissection. Aesthetic Plast Surg, 2011. 35(5): p. 866-77. 26. Derm-Approved Ways to Treat Neck Wrinkles and Sagging, Harpars Bazaar, <https://www. harpersbazaar.com/beauty/skin-care/a28871836/neck-wrinkles-sagging/> 27. Bunker, A, Your Smartphone Might Be Giving You Neck Wrinkles, Elle, <https://www.elle.com/beauty/ news/a43443/neck-wrinkles-phone-posture/> 28. Ellenbogen, R. and J.V. Karlin, Visual criteria for success in restoring the youthful neck. Plastic and reconstructive surgery, 1980. 66(6): p. 826-837. 29. Samizadeh, S. and K. De Boulle, Botulinum neurotoxin formulations: overcoming the confusion. Clinical, cosmetic and investigational dermatology, 2018. 11: p. 273-287. 30. Wu, W.T., Microbotox of the lower face and neck: evolution of a personal technique and its clinical effects. Plastic and reconstructive surgery, 2015. 136(5): p. 92S-100S. 31. de Almeida, A.R., A. Romiti, and J.D. Carruthers, The facial platysma and its underappreciated role in lower face dynamics and contour. Dermatologic Surgery, 2017. 43(8): p. 1042-1049. 32. De Maio, M. and B. Rzany, Botulinum toxin in aesthetic medicine. 2007: Springer Science & Business Media. 33. Levy, P.M., The ‘Nefertiti lift’: a new technique for specific re-contouring of the jawline. J Cosmet Laser Ther, 2007. 9(4): p. 249-52. 34. Brandt, F.S. and B. Bellman, Cosmetic use of botulinum A exotoxin for the aging neck. Dermatologic surgery, 1998. 24(11): p. 1232-1234. 35. Kane, M.A., Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast Reconstr Surg, 1999. 103(2): p. 656-63; discussion 664-5. 36. Sugrue, C.M., J.L. Kelly, and N. McInerney, Botulinum toxin treatment for mild to moderate platysma bands: a systematic review of efficacy, safety, and injection technique. Aesthetic surgery journal, 2018. 39(2): p. 201-206. 37. Matarasso, A., et al., Botulinum A exotoxin for the management of platysma bands. Plastic and reconstructive surgery, 1999. 103(2): p. 645-52; discussion 653-5. 38. Fagien, S. and H. Raspaldo, Facial rejuvenation with botulinum neurotoxin: an anatomical and experiential perspective. Journal of Cosmetic and Laser Therapy, 2007. 9(sup1): p. 23-31. 39. Obagi, S. and K. Golubets, Mild to Moderate Dysphagia Following Very Low-dose Abobotulinumtoxin A for Platysmal Bands. Journal of drugs in dermatology: JDD, 2017. 16(9): p. 929-930. 40. Phothong, W., et al., A case of dysphagia following botulinum toxin injection for neck rejuvenation. Journal of cosmetic dermatology, 2017. 16(1): p. 15-17.

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We know that one of the drawbacks of IPL treatments is the relatively large area of the output couplers (glass tips). These can be up to around 6cm squared, while many targets may be significantly smaller. This results in large areas of skin surrounding the targets also receiving high energy bursts, leading to potential tissue damage. This article explores a new masking technique, which I have trialled, that allows for higher fluence and longer pulse widths in the treatment of angiomas and small pigmented lesions – I have called it the ‘hole in a stick’ technique.

Masking technique overview I sought to find a way to minimise the adjacent tissue damage that occurs during IPL treatment by masking off those areas during treatments. To do this, I chose standard wooden spatulas, typically found in many clinical facilities, and drilled a hole near one end. I thought wooden spatulas would be safe to use, are easily accessible, and would mask the required area well. Originally the hole was 3mm in diameter, however this proved to be too small for locating targets and clinical outcomes, so I tried 4mm (Figure 1). This size proved more successful. Physicist and bioengineer Mike Murphy Firstly, as standard protocol, a small amount of cold water-based gel was applied to the target area for skin presents a new masking technique for cooling. The spatula was then positioned over each treatment of angiomas and small pigmented lesion individually. The IPL glass tip was then placed lesions using IPL on the wooden spatula, so that most of the glass is touching the wood (Figure 1). A single shot was then Photothermal treatments using intense pulsed light (IPL) fired. In my 20 years of experience in IPLs, I have found that you can systems may be used to effectively remove hair, vascular and achieve better results using higher fluences and longer pulses than pigmented lesions without damaging surrounding tissues.1,2,3 described in manufacturer guidelines. Therefore, I decided to apply However, I have noticed that many IPL users do not utilise a fluence of 41J/cm2 with an envelope pulse width of 94 milliseconds sufficient energy densities or pulse widths to successfully destroy over the wavelength range 500 nm to 1200 nm. The aim of this was the target tissues. Consequently, these practitioners then achieve poor clinical results and conclude that IPL isn’t as effective at treating these concerns as lasers.

Treating Pigmented Lesions

In my 20 years of experience in IPLs, I have found that you can achieve better results using higher fluences and longer pulses than described in manufacturer guidelines Figure 1: A 4mm hole is drilled onto the spatula, which is placed against the skin. The IPL output tip is positioned on the wood so that only the skin under the hole is exposed to the light energy.

Figure 2: After only a few shots (typically around five to eight) the water content of the wood is greatly reduced by the heat energy, resulting in carbonisation of the wood.

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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to maximise absorption by haemoglobin and melanin.4,5 It should be noted that such high energy densities will inevitably cause the wood to carbonise within just a few pulses. This is quite evident with a burning smell and obvious marks on the wood surface (Figure 2). Therefore, to minimise this issue, I decided to soak each stick in water for at least 30 minutes prior to use. I find this allows for a few more shots on the wood before carbonisation begins. These pulse trains were distributed over five sub-pulses with a duration of 10ms each and a gap of 11ms between each sub-pulse. This pulse train was chosen to generate the required fluence while minimising thermal losses during the pulse envelope. Both the fluence and pulse width were measured using an IPL meter designed for this purpose.

Results

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Before

After

Figure 3: Brown pigmented spots and angiomas treated with IPL light energy at 41 J/cm2 and 94ms. The smaller angiomas and pigmented spots cleared after only one session, while the larger lesions required two. No unwanted side effects were reported by the patient. Before

After

Figure 4: A number of pigmented and vascular lesions on the stomach area, before and after one treatment

I have carried out a small amount of tests on sessions at 41 J/cm2 and 94ms. a number of body areas using this masking technique on a Fitzpatrick skin type II Caucasian 55-year-old female Disclaimer: As the fluence and pulsewidth used in this technique are patient, where small benign pigmented lesions and angiomas were greater than most manufacturer guidelines, practitioners’ should use treated (Figure 3 & 4). The patient noticed a ‘slight nipping sensation’ their clinical expertise and judgement. This procedure should only be with each energy pulse, but reported no long term or undesirable performed by experienced practitioners. effects. A small amount of oedema and erythema were noted shortly Mike Murphy is a physicist and bioengineer with 34 after, as would be expected following such a treatment.6 These years’ experience in medical lasers. He started Dermalase typically subsided within 24 hours. Other skin areas were also tested Ltd in 1989 to launch the QS ruby laser into medical and yielded similar results with no unwanted side effects. If such markets in the US, EU and Asia. Murphy is currently the general secretary of the Association of Laser Safety a masking technique is not employed in these treatments, then Professionals, is a Certificated Laser Protection Adviser and is registered unwanted tissue damage is likely in the adjacent skin areas including as an LPA with Healthcare Improvement Scotland. He has published blistering, bruising and swelling.1,6,7 I find that the level of pain is also more than 25 articles, reports and papers in peer-reviewed medical laser significantly higher since many more nerve receptors are stimulated journals and trade publications. by the heat energy. REFERENCES In my experience, the masking technique has allowed for the 1. Barikbin B, Ayatollahi A, Hejazi S, Saffarian Z, Zamani S. The Use of Intense Pulsed Light (IPL) for the Treatment of Vascular Lesions. Rev Artic J Lasers Med Sci. 2011;2(2). higher than ‘standard’ fluence to be used without any unwanted 2. Victor Ross E, Smirnov M, Pankratov M, Altshuler G. Intense Pulsed Light and Laser Treatment of side effects. It also reduces the likelihood of unwanted damage Facial Telangiectasias and Dyspigmentation: Some Theoretical and Practical Comparisons. 3. Grillo E, Rita Travassos A, Boixeda P, et al. Histochemical Evaluation of the Vessel Wall Destruction due to poor skin cooling, since smaller areas are exposed to the and Selectivity after Treatment with Intense Pulsed Light in Capillary Malformations. Actas light energy. In my experience, using higher fluences coupled with Dermosifiliogr. 2015. doi:10.1016/j.ad.2015.10.006 longer pulse widths, the probability of a successful clinical outcome 4. Anderson RR, Parrish JA. Selective Photothermolysis : Precise Microsurgery by Selective Absorption of Pulsed Radiation. Science (80). 1983;220(4596):524-527. is enhanced.7 5. Babilas P, Shafirstein G, Bäumler W, et al. Selective photothermolysis of blood vessels following

Summary The ‘hole in a stick’ technique allows for a higher level of energy input into the skin without inducing excess damage. It’s a very useful and inexpensive way to mask off unwanted IPL light energy when treating skin conditions. My trials have allowed for a much more targeted treatment of small, discrete lesions with higher fluences and longer pulse widths than might normally be used. Applying such fluence/pulse width combinations, without a mask, may likely damage the adjacent skin, with no benefit. It’s important to note that the fluence and pulse width needs to be higher and longer than standard manufacturer protocols. If standard protocols are used, then practitioners are unlikely to see good results. Clinicians should be highly experienced in the use if IPL devices before attempting. Comparative clinical studies would be useful to confirm these initial findings.

flashlamp-pumped pulsed dye laser irradiation: In vivo results and mathematical modelling are in agreement. J Invest Dermatol. 2005;125(2):343-352. doi:10.1111/j.0022-202X.2005.23773.x 6. Moreno-Arias GA, Castelo-Branco C, Ferrando J. Side-effects after IPL photodepilation. Dermatologic Surg. 2002;28(12):1131-1134. 7. Marayiannis KB, Vlachos SP, Savva MP, Kontoes PP. Efficacy of long- and short pulse alexandrite lasers compared with an intense pulsed light source for epilation: A study on 532 sites in 389 patients. J Cosmet Laser Ther. 2003;5(3-4):140-145.

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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and elastin synthesis in the dermis.11,12,13 Extrinsic photoageing causes inflammation, which stimulates elastases to degrade elastin and causes dermal matrix degradation via disruption to the collagen fibre network.14 The production of reactive oxygen species secondary to UVA and UVB exposure exacerbate this degradation14 and also the Dr Amiee Vyas presents a case study on treating visible signs of ageing. Glycolic acid has antiageing and pigmentation with topical skincare inflammatory and antioxidant properties to mitigate these processes.3 Furthermore, it is This is a case of a 73-year-old, Fitzpatrick skin type IV female of safe to use in all Fitzpatrick skin types2,15,16 and, in my experience, is well Indian origin who presented with visible signs of ageing. Her main tolerated if used in a stepwise, controlled manner. Lactic acid has well concerns were uneven skin tone and hyperpigmentation, as well as documented benefits of moisture retention to increase epidermal and an overall tired appearance. The hyperpigmentation was moderate in dermal volume, thereby reducing fine lines and wrinkles and improving severity, consistent with her Fitzpatrick type and a significant history overall skin luminosity.2,17 By selecting products with these multiof unprotected sun exposure in her younger years. On examination mechanistic ingredients, I aimed to provide an effective regime for the with a Wood’s Light, the pigmentation was predominantly epidermal patient that was simple to use without numerous steps. with some dermal patches. The patient had previous history of With my patient being of South Asian descent, it was important cosmeceutical use, but no history of aesthetic injectables or chemical to consider the differences in her ageing process compared to peels and no past medical history or allergies to note. Her main aim Caucasian and other skin types. Asian and Indian subjects are was to improve her skin quality with non-invasive treatments, minimal more susceptible to pigmentation disorders,18 which often manifest downtime and no obvious skin shedding. before visible rhytides in this patient group.19 To specifically target pigmentation and, in line with my patient’s requirement to avoid Treatment visible peeling, I sought to introduce a second non-retinoid, nonThe skin barrier is inevitably weakened with increased age due hydroquinone product to correct the skin tone. to intrinsic factors1 including slower cell turnover, reduced type I Melanogenesis occurs in melanocyte organelles called melanosomes collagen production, hormonal changes, and reduced oil production within the epidermis. It involves a cascade of events in which tyrosine by sebaceous glands, melanocyte changes and elastosis causing a is oxidised to dopa and then dopa is oxidised to melanin by the disorganised connective tissue structure.2,3 This results in fine lines enzyme tyrosinase.7,20,23 This cascade, as well as the subsequent and wrinkles, dryness, skin laxity, uneven texture and tone, as well as processes of melanin transport and distribution, all affect skin enlarged, more visible pores, all of which are further exacerbated by coloration.20 I aimed to target multiple pathways of melanogenesis and 2,3 extrinsic photodamage. I chose to address this patient’s concerns melanin distribution23 with novel ingredients to complement the effects purely with topical skincare because her consultation revealed of the topical retinoid and achieve the best outcome for my patient. that she wanted a homecare regime without frequent clinic visits. The most obvious difference between skin of colour and Caucasian She understood the benefit of combining homecare with in-clinic skin types is the higher concentration of melanin in melanosomes.19 treatments such as chemical peels or medical microneedling, but Furthermore, on a molecular level, specific pigmentation genes she was not keen to proceed with these treatments because of the including some members of tyrosinase-related protein (TRP) family and associated downtime. The patient was not worried about the speed melanocyte-stimulating hormone (MSH) also contribute to variations of the result and was happy to see a gradual improvement over in pigmentation.19,24 Specifically, TRP-1 increases tyrosinase activity, time. She understood that this could take three months or longer to melanin production and melanosome size.19,24 Arbutin is a naturally visualise. She had realistic expectations and was aware that whilst occurring derivative of hydroquinone without the melanotoxic effects; we were working towards the best improvement for her skin, there it inhibits both tyrosinase activity and melanosome maturation and its would be no guarantee of resolution of her hyperpigmentation with effects are dose dependant.27 The synthetic form alpha-arbutin has homecare alone. The ‘gold standard’ topical treatment of skin ageing widely replaced the use of arbutin in topical products due to stronger with retinol/retinoids (namely prescription strength tretinoin) and alpha tyrosinase inhibition and increased efficacy of depigmentation.27 hydroxy acids is well established in clinical practice through effects Hexylresorcinol (HR), is another naturally-occurring agent affecting of exfoliation and promotion of skin turnover.4 Hence, these were the melanogenesis on multiple levels. It is an inhibitor of the tyrosinase,20,23 first ingredients I considered for my patient’s regime. Retinoids applied and peroxidase enzymes in the melanin cascade.20 HR has a at night normalise skin structure by increasing cellular mitosis, thus stimulatory effect on glutathione,20 which is lost in the presence of UVA stimulating collagen production, and can offer excellent benefits to irradiation.28 Depletion of glutathione has been shown to increase pigmentation through tyrosinase inhibition and improved melanocyte tyroinsase activity29 and glutathione is also thought to have a dose 2,5-8 function. However, compliance is often an issue due to irritation dependant inhibition on melanin synthesis.20 and shedding, particularly in darker Fitzpatrick skin types who can Gallic acid is a naturally-occurring plant polyphenol antioxidant experience dermatitis in response to topical retinoids.9,10 which has been shown in vitro to decrease melanin production by I considered alpha hydroxy acids such as glycolic acid and lactic downregulating tyrosinase activity through down regulation of MITF acid because of their ability to modulate both epidermal and dermal and other melanogenesis-related proteins.26 It has also been found to 11,12 changes at high concentrations. This facilitates skin turnover and be protective against UVB-induced hyperpigmentation.27 renewal of the stratum corneum, improving skin texture, fine lines, Finally, vitamin C was a key ingredient I looked for in product wrinkles and pigmentation,2,11 as well as directly accelerating collagen formulations because of its anti-pigmentary, antioxidative,

Case Study: Ageing and Pigmentation

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Summary

Figure 1: Patient at baseline and nine months after treatment

photoprotective and overall antiageing effects30 through reducing matrix metalloproteinases production and collagen damage.30,31 It reduces pigment production by interacting with copper at tyrosinase active sites and inhibiting the action of tyrosinase.30,32-34 The oxidative effect of UV radiation has been suggested to contribute to melanogenesis,35,36 and vitamin C also neutralises oxidative stress by scavenging free radicals in a process of electron transfer.37 The Kakadu Plum has been shown to have the richest source of ascorbic acid and antioxidant potential.38,39 I therefore sought a formulation that could take advantage of this whilst remaining mindful that the benefits of topical vitamin C rest on its stabilisation from oxidation30 and hence looked for a product that utilised an appropriate delivery system. The line I chose to use, which featured the ingredients I was looking for, was a skincare regime by skinbetter science. This included the AlphaRet Overnight Cream, Oxygen Infusion Wash and Even Tone Correcting Serum. I have found that fewer products are required in this home regime, which in turn helps to improve compliance, expedite results and enhance patient satisfaction. This was particularly important for my patient, who had previously used retinol and high strength alpha hydroxy acid-containing products, but found compliance difficult due to the number of steps in her regime. I instructed that the patient apply the Intensive AlphaRet formulation (containing a higher concentration of 18% glycolic acid for enhanced re-texturisation compared to the standard 10% formulation) at night. This was teamed with twice daily use of the Oxygen Infusion Wash and Even Tone Correcting Serum. The patient also used a sunscreen with SPF 50 daily to prevent development of new pigmentation or exacerbation of existing areas via UV radiation mediated melanogenesis.18 She was advised to reapply this two hourly when exposed to the sun for long durations. Despite her experience with active ingredients, I initially advised my patient to use the AlpharRet product alternate nightly for the first week and then increase to every night in order to increase tolerance and reduce irritation. The Even Tone Correcting Serum was used twice daily from the start, before the AlphaRet and before sunscreen.

Results After nine months of using the skincare regime, a visible improvement was noted. The patient’s skin tone appeared brighter and more even, there was a significant reduction of pigmentation particularly noted on the cheeks and a global reduction of visible pores and wrinkles – particularly perioral lines, and softer nasolabial folds. The patient was extremely satisfied with the results, commenting, “I look younger than my youngest sister and I am six years older!” The patient reported that she tolerated the products with no irritation and found that the products could be used as advised from the outset without the need for more gradual use. This could be due to her previous experience of retinol and alpha hydroxy acid use, but could also be associated with the product’s technology, which allows for controlled gradual release of retinoid and lactic acid to minimise irritation potential.

Hyperpigmentation treatment is often challenging because of patient reluctance to accept the downtime associated with many procedures. Improvements can be made by topical skincare use and does not necessarily require irritating retinol and hydroquinone products or in-clinic procedures. Practitioners should choose a skincare line that includes active ingredients to best target their patient’s concerns and ensure maximum compliance. Patient selection is key and appropriate counselling regarding outcome is vital before commencing treatment plans based on homecare regimens alone. Dr Amiee Vyas is the founder of Doctor Amiee Facial Aesthetics & Skin, Mayfair. She specialises in natural enhancements that deliver positive change focussing on skin health and wellness. She is accredited by Save Face, a trainer in injectables for Acquisition Aesthetics and a trainer and KOL for AestheticSource. REFERENCES 1. Lee T, Friedman A. Skin barrier health: regulation and repair of the stratum corneum and the role of over the counter skin care. J Drugs Dermatol. 2017;16(1 Suppl 2): 1047 1051. 2. Mc Daniel DH, Mazur C, Wortzman MS, Nelson DB. Efficacy and tolerability of a double-conjugated retinoid cream vs 1.0% retinol cream or 0.025% tretinoin cream in subjects with mild to severe photoaging. J Cosmetic Dermatol. 2017;16(4) 3. Mayoral FA, Kenner JR, Draelos ZD. The skin health and beauty pyramid: a clinically based guide to selecting topical skincare products. J Drugs Dermatol. 2014;13:414 421 4. Bruce S. Cosmeceuticals for the attenuation of extrinsic and intrinsic dermal aging. J Drugs Dermatol. 2008; 7( 2 Suppl): s17 s22. 5. Kang S. Photoaging and tretinoin. Clin Dermatol. 1998;16:357-364. 6. Kligman LH. Topical retinoic acid enhances repair of ultraviolet damaged dermal connective tissue. Connect Tissue Res. 1984;12:139-150. 7. Kligman AM, et. al. Topical tretinoin for photoaged skin. J Am Acad Dermatol. 1986;15:836-859. 8. Zelickson AS, et. al. Topical tretinoin in photoaging: an ultrastructural study. J Cutaneous Aging Cosmet Dermatol. 1988;1:41-47. 9. Callender VD. Acne in ethnic Skin: Special considerations for therapy. Dermtol. Ther 2004;17-184-195 10. Lawson CN, et. al. Updates in the understanding and treatments of skin and hair disorders in women of color. Int J Women Dermatol, 3 (1) (2017), pp S21-S37 11. Smith WP. Epidermal and dermal effects of topical lactic acid. J Am Acad Dermatol. 1996;35:388-391. 12. Rendon MI, et.al. Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesthetic. 2010;3:32-43. 13. Okano, Y et.al. Biological effects of glycolic acid on dermal matrix metabolism mediated by dermal fibroblasts and epidermal keratinocytes. Exp Dermatol. 2003; 12 (Suppl 2): 57–63 14. Rinnerthaler M, Bischof J, Streubel MK, Trost A, Richter K. Oxidative stress in aging human skin. Biomolecules. 2015;5:545–589 15. Cao X, et.al. Intracellular proton-mediated activation of TRPV3 channels accounts for the exfoliation effect of a-hydroxyl acids on keratinocytes. J Biolog Chem. 2012;287:25905-25916. 16. Sharad J. Glycolic acid peel therapy – current review. Clin Cosmet Investig Dermatol. 2013;6:281-288 17. Grove G, Zerweck C. An evaluation of the moisturizing and anti itch effects of a lactic acid and pramoxine hydrochloride cream. Cutis. 2004;73:135 139. 18. Nouveau S et. al. Hyperpigmentation in Indian Population: Insights and Best Practice. Indian J Dermatol. 2016 Sep-Oct; 61(5):487-495 19. Vashi NA et. al. Aging Differences in Ethnic Skin, Journal of Clinical Dermatology, 9 (2016) 20. Chaudhuri R, Hexylresorcinol: Providing Skin Benefits by Modulating Multiple Molecular Targets. Cosmeceuticals and Active Cosmetics, third Efition, pp.71-82 21. Hearing VJ. Regulating melanosome transfer: Who’s driving the bus. Pig Cell Res 2007;20:334–5 22. Chen QX, Ke LN, Song KK et.al. Inhibitory effects of hexylresorcinol and dodecylresorcinol on mushroom (Agaricus bisporus) tyrosinase. Protein J 2004:23(2):135–41 23. Makino ET et. al. Evaluation of a hydroquinone-free skin brightening product using in vitro inhibition of melanogenesis and clinical reduction of ultraviolet-induced hyperpigmentation. J Drugs Dermatol. 2013 Mar;12(3):s16-20. 24. Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin Cutan Med Surg. 2009;28(2):115-129 25. Zhu W, Gao J. The use of botanical extracts as topical skin-lightening agents for the improvement of skin pigmentation disorders. J Investig Dermatol Symp Proc. 2008 Apr 13(1):20-4 26. Tzu-Rong Su, Jen Jie Lin, Chi-Chu Tsai et. al. Inhibition of Melanogenesis by Gallic Acid: Possible involvement of the PI3K/Akt, MEK/ERK and WWnt/β-Catenin Signaling Pathways in B16F10 Cells. 2013 Int. J. Mol. Sci. 2013, 14(10), 20443-20458 27. Kumar KJ et. al. In vitro and in vivo studies disclosed the depigmenting effects of gallic acid: a novel skin lightening agent for hyperpigmentary skin diseases. Biofactors. 2013 May-Jun;39(3):259-70 28. Larsson P, et.al. Ultraviolet A and B affect human melanocytes and keratinocytes differently. A study of oxidative alterations and apoptosis. Exp Dermatol 2005;14(2):117–23 29. Del Mamol V et.al. Glutathione depletion increases tyrosinase activity in human cells. J Invest Dermatol. 1993:101:871-4 30. Al-Niaimi and Yi Zhen Chiang N. Topical Vitamin C and the Skin: Mechanisms of Action and Clinical Applications. J Clin Aesthet Dermatol. 2017 Jul; 10(7): 14–17 31. Chen L, Hu JY, Wang SQ. The role of antioxidants in photoprotection: a critical review. J Am Acad Dermatol. 2012 Nov; 67(5):1013-24. 32. Pullar JM, Carr AC, Vissers MCM. The role of Vitamin C in Skin Health Nutrients. 2017 Aug; 9(8): 866. 33. Ando H et. al. Approaches to identify inhibitors of melanin biosynthesis via the quality control of tyrosinase. J Invest Dermatol. 2007 Apr; 127(4):751-61. 34. Kameyama K et. al. Inhibitory effect of magnesium L-ascorbyl-2-phosphate (VC-PMG) on melanogenesis in vitro and in vivo.J Am Acad Dermatol. 1996 Jan; 34(1):29-33. 35. D’Mello SA et. al. Review: Signalling Pathways in Melanogenesis. Int. J. Mol. Sci.2016;17(7), 1144 36. Gillbro JM, Olsson MJ. The melanogenesis and mechanisms of skin-lightening agents – esisting and new approaches. Int J Cosmet Sci. 2011 Jun;33(3):210-21 37. Farris PK. Cosmetical vitamins: vitamin C. Cosmoceuticals. Procedures in Cosmetic Dermatology. 2nd ed. New York: Saunders Elsevier; 2009. pp. 51–56. 38. Tan A. C. et. al. Antioxidant and cytoprotective activities of native Australian fruit polyphenols.Food Reasearch International 2011. 44(5) 2034-2040 39. Netzel M. et.al. Native Australian fruits—A novel source of antioxidants for food. Innov. Food Sci. Emerg. Technol. 2007;8:339–346.

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Considerations for Cheeks

bony structure may also have positively selected the appropriate bone structure to compete for female partners, food and other resources, acting as a protective buttress from physical blows.4

Dr Tino Solomon explores the attractiveness of cheeks and shares advice for augmentation

Understanding the anatomy of the mid-face and the changes that occur is crucial when augmenting the cheek and cheekbone area. When considering the anatomy of the cheeks, the adjacent areas must also be taken into account to ensure proportional facial metrics and maintaining beauty standards. Beauty and restoration of the structure of youth are the concepts here. The cheekbone region consists of both the zygomatic (malar) bone and the zygomatic arch. The zygomatic bone is adjoined, via four processes, to the maxilla, temporal, sphenoid and frontal bones, and is responsible for creating the cheek prominence. The zygomatic arch is formed by the zygomatic process of the temporal bone and the temporal process of the zygomatic bone. Nerves and vessels arising from this area include:5 • The zygomatic nerve, a branch of the trigeminal maxillary nerve that emerges from the zygomaticofacial foramen • The zygomatic artery, which emerges alongside the zygomatic nerve • The zygomatic branches of the facial nerve, which travels along the zygomatic bone to the lateral margin of the orbit

Mid-face anatomy

Objective standards of beauty are observed across many cultures. Be it plump lips to certain ratios, symmetrical faces or a particular face shape. It has never been fully understood why some of these features are ‘standard attractive’, despite various hypotheses proposing evolutionary advantages and involving facial metrics, which attempt to explain this.1,2,3 High cheekbones are a facial trait that is universally valued in terms of attractiveness. When our subconscious is assessing one’s character, higher cheekbones have been shown to be considered more trustworthy than individuals with shallower cheekbones.1 In the field of aesthetics, as practitioners, we facilitate augmentation of the cheekbones. Various non-surgical techniques are available and utilised to achieve this aesthetic ideal. This article will explore what it is about the mid-face that people find facially attractive, anatomical considerations, and what modalities we have available to augment and achieve the desired aesthetic outcome.

The beauty of cheeks Recent evidence suggests we naturally judge faces in a fraction of second.2 A functional MRI study has demonstrated an association of high cheekbones with trustworthiness and approachability, together with large eyes and a broad smile, which also indicate attractiveness. Conversely, lower inner eyebrows and shallow cheekbones were seen as untrustworthy.2 Facial metrics, often cited as the mathematical explanation for attractiveness, are particularly relevant here, with cheekbones playing a significant part in shaping and volumising the mid-face longitudinally and laterally.3 A neurophysiological study utilising functional MRI on subjects viewing a multitude of faces of varying proportions showed the attraction response to different facial ratios, noting the importance of facial width to length with evidence for the hypothesis that human faces with variable proportions have differential attractiveness.3 A more detailed mathematical approach was taken in a study of facial metrics, which was assessed on a scale of beauty and attractiveness. Whole face length and width measurements, symmetrical division of the face into vertical thirds and horizontal fifths were also measured and rated (Figure 1). The importance of the cheekbone, with its contribution to width in all these measurements was determinant in facial ratio calculations.2 Prominent cheekbones are a marker of sexual maturity. The rounded child face elongates as puberty sets in and the development of the zygomatic bone correlates with maturation into adults. Men’s cheekbone growth is directly linked to the testosterone surge in puberty. A theory put forward by evolutionary biologists suggests that selection of sexual partners historically preferred strong features, such as prominent cheekbones. Evolution of our

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Figure 1: Depiction of facial fifths and ‘ideal’ vertical to horizontal ratios.2

When considering the anatomy of the cheeks, the adjacent areas must also be taken into account to ensure proportional facial metrics and maintain beauty standards

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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It is the zygomatic arches that are predominantly responsible for the ‘high cheekbone’ look. One study using computed tomography (CT) indicated that as we age, posterior retrusion of the bony maxilla leads to a flattened mid-face and loss of support for the surrounding soft tissues.6 Facial fat loss is also contributory to the remodelling of ageing.6 The mid-face extending to the zygomatic (malar) facial area can be dissected into six main layers: skin, subcutaneous fat tissue, superficial musculoaponeurotic system (SMAS), deep fat tissue, deep fascia and bone.6 As well as bony resorption, deep fat compartments undergo hypotrophic changes, causing a flattening and downward shift in the prominence of the mid-face.6

Supraorbital notch Temporal fossa

Zygomaticoorbital foramen

Ethmoid air cells Infraorbital groove Infraorbital nerve

Zygomaticofacial foramen and nerve Infraorbital foramen

Figure 2: The zygomatic (malar) bone, zygomatic arch and relevant foramen.5

Danger zones to be aware of in the mid-face area include the angular artery (a terminating branch of the facial artery) with awareness of its variations, the transverse facial artery that runs across the submalar region, and the infraorbital foramen, through which the infraorbital neurovascular bundle emerges. The zygomaticofacial foramen (Figure 1), through which a neurovascular bundle perforates, is located laterally on the zygomatic arch and is often not considered when injecting the area, despite it being a terminal branch of the ophthalmic artery, with the risk of retrograde flow of filler and obstruction.5 An imaging study accurately determined that the average distance from the intra-orbital foramen (IOF) to the infraorbital margin is 8.61mm, and 17.43mm to the piriform. Therefore, this allows for safe injection in the region.7 When augmenting the cheekbone region, the mid-face must be considered for augmentation to balance the volume of soft tissue and contours of the entire malar area, while maintaining alignment with the rest of the face.

Contouring the mid-face Makeup artists apply the concept of working with shadow and light when contouring the face. Working to individualised face shape, including oval, square, round, heart-shaped and long, highlights are selectively applied to the central more prominent parts, with shadows outlining the edged. Photographers, myself included, similarly apply this concept to complement an individual’s shape or elongate/ shorten faces and ratios. The aesthetic treatment approach should similarly respect the balance between shadow and light on the face for contouring.8 When treating the cheekbone area, a layered approach should be

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considered, from supraperiosteal deep augmentation to superficial beautification of the skin. A number of treatment options are available to the practitioner to facilitate this process, including dermal filler, fat grafting, energy-based devices, threads, neuromuscular toxin, skin peels, among others. For cheek augmentation using dermal fillers, it’s well known that a filler with lifting capacity should be selected. Cheek augmentation is not exclusively about volumisation, but also reshaping. Augmentation of the cheeks can aid in lifting the lower third of the face by supporting the more superficial soft tissue layers from anchor points in the deeper tissue. I find that this approach creates structure in the zygomatic bone area and replaces volume loss in the malar region by filling the deep medial cheek fat (DMCF) and the suborbicularis oculi fat compartments (SOOF). Anecdotal reports suggest it is common practice to aspirate before supraperiosteal injections to minimise intra-arterial injection, although this is unreliable and varies based on syringe, needle and tissue depth.9 In my experience, when injecting more superficially in the sub dermis, if deemed necessary to improve skin texture, the injection of filler should remain in the same depth plane for uniformity. Concurrent treatment of the temples and lateral part of the face (parotid region) may be added for creating the mid-face contours and convexity desired. Injection of filler in the mid-face can be performed using a needle or cannula; one cadaver study indicated that the use of a cannula was more precise in placement of product.10 The sharp needle technique also showed a higher complication risk with intra-arterial injection occurring, however personal preference and experience dictates here.10 As alluded, facial shadows are as important as the light on the face when shape is considered. Contouring the cheekbone area should respect the balance between shadow and light on the face. Facial highlights can be enhanced by lighting the areas that have lost volume and deflated. Areas of shadow that complement the facial contours are best left untreated to maintain the ‘trough’. I find that

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Figure 3: Hinderer’s (A), Wilkinson’s (B) and Powell’s (C) techniques for locating the malar eminence11

adding volume more towards the forward facing part of the face, supraperiosteally, does not widen the face but allows light to fall on the prominence. If volume is added more laterally on the zygomatic bone and superficially, the face will widen, either bringing the ratio of length to width closer towards the aesthetic ideal or shortening the face. The area of maximal malar prominence can be identified using four reliable and reproducible methods.11 The clinically relevant ones are Hinderer’s, Wilkinson’s and Powell’s methods (Figure 3).11 Others require specialist devices to measure. The most commonly utilised is Hinderer’s lines, which involves

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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locating symmetrical points due to the use of superficial landmarks when compared to the ‘direct palpation’ method.11 This is another cruder method where the soft and bony contours of the malar eminence are palpated, but where a high percentage of facial asymmetry was noted.11 Augmenting the middle third and posterior third of the zygomatic arch will broaden the bi-zygomatic width, so caution should be exercised here to not distort facial proportions. Aesthetic ideals, individual preferences, ethnic variation and cultural trends should also be respected; one template does not fit all.11

Addressing skin on the mid-face

Figure 4: Patient before and after filler augmentation of cheekbone alone. Hinderer’s lines were used as a guide and 0.5ml filler was injected on each side supraperiosteally at two points in the superolateral quadrant. Treatment performed at DrMedispa.

overlaying two intersecting lines from the lateral canthus to the oral commissure and the tragus to the ala wing (Figure 4). The area immediately superolateral to this intersection is the most prominent point that should be augmented for projections.11 Wilkinson’s line involves dropping a vertical line from the lateral canthus to the mandibular edge with the malar prominence located at one third the distance. Powell’s method, a more complicated and less applicable clinically, involves drawing two parallel lines, one from the ala to lateral canthus and one from the oral commissure in parallel; a third line bisecting the nasion to nasal tip, drawn horizontally across both parallel lines, forms an intersection with the second parallel line where the malar eminence is likely located.11 These lines are all there to triangulate the malar eminence, so where these meet is where the best point to inject is for the ideal projection.11 These ‘triangulation’ methods have been shown to be consistent in Before

After

Skin overlying the cheekbones must also be considered and addressed to optimise results with injectable treatments. Laxity here can result in the appearance of a flatter malar bone due to a poor light reflex and irregular tenting of the skin over the underlying periosteum.12 To address this, tightening the skin can be performed using threads to lift the skin at the dermal layer or radiofrequency energy delivered through microneedles. The main physiological effect of radiofrequency treatment is to stimulate collagen formation, tightening the skin and aiding in lifting – this has been shown to be effective in a review of numerous studies.12 Fat contraction when the energy is delivered at a deeper level can aid in shaping the lower third of the face to contour and shape to the desired aesthetics. Noninvasive means include the use of skin peels and pharmaceutical grade skincare to stimulate collagen formation and to hydrate the dermal/epidermal layers.

Summary Strong and contoured cheekbones are a proven attractive feature based on their perceived representation of physical capabilities and personality. As aesthetic practitioners, we have a toolbox of modalities we can utilise to augment the cheekbones and create the aesthetic or personalised ideal. Understanding that these ideals and perceived beauty is a marriage of art and science, but also beauty, is very individual. It is important to note that quantifying the proportions that result in most people perceiving a face as beautiful takes nothing away from its uniqueness. Dr Tino Solomon practises at the DrMediSpa clinic on Chiltern Street, London. A graduate of UCL medical school, he initially underwent speciality training in general and laparoscopic surgery before making the move to primary care, alongside a niche speciality in wilderness and mountain medicine. Dr Solomon has completed advanced courses in injectables and is currently undertaking his Level 7 qualification.

After

Figure 5: Example of cheek contouring treatment. After photos of a patient who has had dermal fillers and a beautification treatment performed using skin peels and finished with makeup contouring to highlight the cheekbones. Treatment performed at DrMedispa.

REFERENCES 1. Freeman et al, Amygdala Responsivity to High-Level Social Information from Unseen Faces, Journal of Neuroscience 6 August 2014, 34 (32) 10573-10581 2. Milutinovic, J, Evaluation of Facial Beauty Using Anthropometric Proportions, The Scientific World Journal, Volume 2014 Article ID 428250, 3. Shen, H, et al., Brain responses to facial attractiveness induced by facial proportions: evidence from an fMRI study, Sci Rep, 2016; 6: 35905. 4. Carrier DR et al., Protective buttressing of the hominin face. Biol Rev Camb Philos Soc. 2015 Feb;90(1):330-46. 5. Kumar S et al, Incidence and location of Zygomatico facial foramen, International Journal of Medical Research and Health Sciences. Volume 3 Issue 1 Jan-Mar. 6. Wan et al, Fat Compartments in MidFacial ageing, Plas Reconstr Surg Glob Open, 2013;1;e92, 2013 7. Raschke, H, Identifying a Safe Zone for Midface Augmentation using Anatomic Landmarks for the Infraorbital Foramen, Aesthetic Surgery Journal 33(1) 13-18. 8. Aucoin, K, Making faces, ISBN-13:978-0316286855 9. Van Loghem et al, J Cosmet Dermatol. 2018 Feb;17(1):39-46 Sensitivity of aspiration as a safety test before injection of soft tissue fillers. 10. Jani A J van Loghem et al, Cannula Versus Sharp Needle for Placement of Soft Tissue Fillers: An Observational Cadaver Study Aesthetic Surgery Journal, Volume 38, Issue 1, January 2018, Pages 73–88 11. P Nechala et al, Comparison of techniques to locate the malar eminence. Can J Plast Surg. 2000;(8)1:21-24 12. Angélica Rodrigues de Araújo et al, Radiofrequency for the treatment of skin laxity: mith[sic] or truth, AnBras Dermatol. 2015 Sep-Oct; 90(5): 707–721.

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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particular are outperforming g heavily in in-house markets in aesthetic medicine. In elopment of new Advertorial May 2017, the Dermalfiller Princess the company’s @aestheticsgroup @aestheticsjournaluk Aesthetics aestheticsjournal.com Croma VOLUME was approved in China through innovation. by the CFDA. Croma-Pharma was roma also promotes the first European company to do maceutical research so. Almost at the same time, the more than 90% of company signed with Sihuan Pharma ed from products Becoming a global player with minimally invasive aesthetic medicine. ch.

Croma-Pharma: Made in Austria

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New headquarters and production ntler Croma-Pharma GmbH, is an international pharmaceutical company based in plant as a clear commitment to free Leobendorf, Austria. For over 40 years, expansion and location ures Croma has been developing and producing Due to the dynamic development of the are so innovative drugs and medicalLtd. a for long-standing licenseand and devices company, the construction expansion of hat they can be distribution agreement. the fields of ophthalmology, orthopedics the headquarters andThis anotherjoint fully automatic a lunch venture the third-largest and break) aesthetic dermatology. Croma is very withproduction facility at the Leobendorf site was proud to have made such an important initiated in 2015. The new headquarters was ive the patient Chinese pharmaceutical company contribution to improving health and inaugurated in September ance. The expert is aimed at the approval of 2017. further quality of life for more than four decades. ferent technologies products and the nationwide Founded in 1976 by pharmacist Gerhard Innovations as a result of intensive and creates a longdistribution of these products in Prinz, Croma is now managed by his sons research and development or relationship. mainland Martin and Andreas Prinz. Since 2005, the China. Croma is investing heavily in in-house aesthetic medicine company has been driven forward through research and development of new products ge growth potential In 2014, Sustainability and social rapid internationalisation. the to drive the company’s long-term growth strategic sale of the Ophthalmology and through innovation. In this context, Croma uty market. In responsibility Orthopedics divisions took place, since then also promotes medical and pharmaceutical offers a steadily the company has specialised in minimally research in Austria. Today, more than 90% dinated portfolio As a family business, Croma invasive aesthetic medicine. Currently, of sales are generated from products of our goal is a “full-face pursues a corporate policy based Croma has 12 international offices in Brazil, own research. r doctors and on ecological, economic and social European Union and Switzerland and nearly solutions for allworldwide. sustainability. For many years, Croma 500 employees Aesthetic dermatology as a a single source in dynamic future market is sponsor of the international Leading HA expert in Europe aesthetic medicine, the trend ble quality. organizationIn modern “Light for the World”. Today Croma is a global player in the is moving from large, irreversible surgical With generous product donations dynamically growing segment of minimally lifts to smaller but more frequent, shorter Croma makes an important e course for invasive aesthetic medicine and is a leading and, above all, gentler treatments. Pain-free contributionlunchtime to the eye care in the S market European processor of hyaluronic acid. The procedures (treatments that are so poorest regions of the company sells nearly six million hyaluronic straightforward thatworld. they can be performed 8 Croma-Pharma acid syringes (injectables) annually through during a lunch break) are designed to affiliates and a network of strategic give the patient a relaxed appearance. stablishing a joint partnerships and distributors in more than 70 The expert combination of different with its long-time countries. Production takes place exclusively technologies optimises results and creates c. to develop and at the company headquarters in Leobendorf a long-term patient-doctor relationship. ulinum toxin, HA near Vienna, Austria. Besides a broad Minimally invasive aesthetic medicine has ead products in US, Contact above-average growth potential in the range of HA fillers from the own production a and New Zealand. site, Croma markets PDO lifting threads, global beauty market. In this area, Croma s its development GmbH a Platelet Rich Plasma (PRP) CROMA-PHARMA system and a offers a steadily growing, well coordinated in its coreHöhn portfolio of products. The goal is a ‘full-face tivitiespersonalised with a skincare technology Stefanie markets. orderstrategic to prepare Cromazeile 2approach’ to offer doctors and patients the e successful market A-2100 Leobendorf gic partnership Phone: +43 676 846868 190 Aesthetics | February 2020 ntinue Croma‘s Mail: stefanie.hoehn@croma.at

best solutions for all indications from a single source in familiar and reliable quality.

Croma sets the course for entering the US market In September 2019 Croma-Pharma GmbH (Croma) establishded a joint venture company with its long-time partner Hugel, Inc. to develop and commercialise botulinum toxin, HA filler and PDO thread products in US, Canada, Australia and New Zealand. Thus Croma unites its development and marketing activities with a strong partner in order to prepare and implement the successful market entry. The strategic partnership with Hugel will continue Croma‘s international expansion efforts and further strengthen Croma‘s market position.

Milestones product approval and joint venture in China Asia in general and China in particular are outperforming markets in aesthetic medicine. In May 2017, the dermal filler Princess VOLUME was approved in China by the CFDA. Croma-Pharma was the first European company to do so. Almost at the same time, the company signed with Sihuan Pharma Ltd. a long-standing license and distribution agreement. This joint venture with the thirdlargest Chinese pharmaceutical company is aimed at the approval of further products and the nationwide distribution of these products in mainland China.

Sustainability and social responsibility As a family business, Croma pursues a corporate policy based on ecological, economic and social sustainability. For many years, Croma has been the sponsor of the international organisation “Light for the World”. With generous product donations Croma makes an important contribution to eye care in the poorest regions of the world. Learn more about Croma’s products and services at croma.at Croma-Pharma GmbH Julian Popple: Country Manager UK Phone: +44 (0) 7442341 227 Email: julian.popple@cromapharma.com Orders: customerservice.uk@croma.at Website: www.croma.at This article is written and supported by Croma-Pharma 49


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Treating Acne and Scarring

Oral therapy should be considered where first line treatment with retinoid +/- antimicrobial fails. It relies on patients complying with their treatment regime and has a high side effect profile, including peeling and irritation. There is also the risk of antibiotic resistance; therefore topical medication has been considered as Nurse prescriber Amanda Wilson shares an the mainstay of treatment in patients with introductory overview of treatment options mild to moderate acne – nodular and cystic acne is excluded from this.2 It is essential for for acne concerns practitioners to counsel patients effectively Acne is a very common skin disease seen in aesthetic medicine on the use of these products and the side effects that can be which affects up to 80% of young adults and adolescents, associated with them. Topical retinoids work by expelling mature although it can be seen across all age groups.1 It affects the comedones, reducing the microcomedone formation and exerting pilosebaceous unit of the skin and, if not well managed, it can leave anti-inflammatory effects. They can be prescribed alongside the patient with severe acne scarring. It may also have significant topical or oral antibiotics if inflammatory acne is present.6 As the psychological impact on the patient, sometimes leading to loss of topical retinoids are able to target the hyperproliferation and self-esteem and depression, as well as physical symptoms such as hyperseborrhea, they can prevent the central precursor to lesson soreness and pain.1,2 Several factors contribute to the pathogenesis formation of inflammatory comedones, papules and pustular nodules. of acne, including follicular epidermal proliferation, excess sebum As they exert a very good safety profile and have no antibiotic production, inflammation and the presence of Propionibacterium resistance, they are safe as long-term medications. Combination (p.acne) bacteria (Figure 1).2 Early treatment intervention for these therapies using benzoyl peroxides (BPO) or antibiotics can treat patients is key to reduce the risk of acne scarring, which can be existing acne lesions faster than individual use (see diagram below difficult to manage, often needing multiple modalities to treat, some for types of acne and treatment options).4 of which will be discussed later in this article. Sinott et al, 2016 and Walsh, 2016, showed that there were high levels of antibiotic resistance to certain antibiotic groups, namely the Acne macrolides and clindamycin, which have been commonly resistant In aesthetics, a number of different treatment modalities have in studies carried out across the globe.4,7 Antibiotic resistance has been developed to treat acne; a full patient assessment is crucial been shown by Walsh to be as high as 50%.4 As antibiotics can be in order for them to have appropriate treatment options prescribed added into treatments for patients, the choice of antibiotic should be to help improve the acne and reduce the risk of scarring. Many carefully considered to reduce the risk. In the case of the decision to clinical papers look at the use of different topical and oral treatment use long-term antibiotics, there should always be a BPO in addition.4,8 1-4 modalities, the main treatment options being: Adding BPO product kills the bacteria and reduces the risk of • Topical prescriptions: retinoids +/- benzoyl peroxide product developing antibiotic resistance. A case study using Obagi Nuderm (usually for mild-moderate acne) MD System which contains 5% BPO is demonstrated in Figure 7. • Systemic (retinoids, antibiotics and hormonal control) As antibiotic resistance is a major increasing concern, practitioners • Oral antibiotics (tetracyclines such as lymecycline or doxycycline) should, where possible, avoid the use of macrolides and tetracyclines as these have a corresponding rate of antibiotic resistance of 65% According to the 2018 National Institute for Health and Care and 20%.2,4 Cyclines (such as lymecycline and doxycycline) have Excellence (NICE) guidelines for the management of patients with shown to be preferable for use in the treatment of acne patients mild to moderate acne, a topical retinoid is the first-line treatment due to their reduced antibiotic resistance.2 Other antibiotics should 5 option used alone or in combination with topical benzyol peroxide. only be used where there is no other option due to allergies/ contraindications. Before the use of isotretinoin, there is often a trial of antibiotics to see if this can control the acne; if ineffective patients Pore Accumilation can then be referred to secondary care. There is clearly a need for of dead cells Epidermis and sebum further guidance due to conflicting information from various sources, Androgens

Sebum

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Inflammation Figure 1: Pathogenic factors contributing to the normal development of acne1

Figure 2: Pathogenesis of acne resulting in inflammation1

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Acne severity

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Alternative oral antibiotic + alternative topical retinoid +/- BPO

Oral isotretinoin or alternative oral antibiotic + alternative topical retinoid +/-BPO or azealic acid

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Oral Antiandrogen + topical retinoid/azelaic acid +/- topical antimicrobial

Oral antiandrogen + topical retinoid +/- oral antibiotic +/- alternative topical antimicrobial

High-dose oral antiandrogen + topical retinoid +/- alternative topical antimicrobial

Aleternatives for females

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Figure 3: Algorithm to improve outcomes in acne treatment4

for example, the NICE guidelines state that antibiotics can be continued for up to six months,5 whereas the American Academy of Dermatology and other authors3-6 agree that antibiotic usage should be limited to three months. Given the global increase in antibiotic resistance there is a perceived need for greater evidence around antibiotic usage for acne patients.

Scarring Facial scarring as a complication from acne can occur in up to 95% of patients and affects both sexes equally.9 The high incidents highlight the need for early intervention to prevent acne scarring, which requires multimodalities for treatment and can be frustrating for patients. For acne scarring, the treatment decided upon will depend on the type of acne scar. The types commonly encountered are ice pick scars, rolling scars and box

pick scars (Figure 4).8 The most common type of scar seen on the face is atrophic, while keloid and hypertrophic are more often seen on the trunk.9 Treatment options include laser resurfacing (CO2 and YAG), microneedling, TCA peels, dermal fillers and autologous fat transfer. Acne scars result from an altered woundhealing response to cutaneous inflammation with inflammatory cell infiltrates found in 77% of atrophic scar tissue.8 Severity of the formation of acne is down to the phylotypes; these differentially activate epidermal innate immunity.8 Generalised, atrophic scars are the most common, seen in 80-90% of patients. A multimodality approach is often needed using a combination of lasers, chemical peels, dermabrasion, microneedling and radiofrequency.8 Caution needs to be taken in patients with Fitzpatrick IV-VI as these patients can develop erythema, transient or permanent dyschromias and hypertrophic scarring in all of the above procedures.9

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Lasers: ablative & nonablative Microneedling +/- PRP Radiofrequenncy: microneedle or fractional biploar If shallow: • Dermabrasion • Chemical peel

Individual • • • • •

Injectable fillers Punch elevation Punch excision Cross technique If narrow: • Cross technique

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Individual • •

Injectable fillers Subcision

Figure 4: Types of acne scars8

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020

Microneedling is an effective and well-researched treatment option for acne scarring. It works most effectively for rolling scars and box pick scarring; however, when combined with radiofrequency it can also work well for ice pick scar tissue. Harris et al., 2015, showed significant improvement of scar tissue with microneedling treatment of up to 31% as scored by the patient groups.10 Fabbrocini et al., 2014, looked at microneedling for all skin types Fitzpatrick I-VI and found there were variations in the side effects


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Figure 5: Effectiveness of treatments for acne scarring8

following on from treatment. Phototypes I-II showed more posttreatment erythema than phototypes III-VI; regardless of the intensity, this did disappear after 24-48 hours in all groups. There were also no hyper or hypo-pigmentation changes in any of the groups, or hypertrophic scar formation, making the complication rate very low.9 The skin needling triggers a cascade of growth factors that then stimulate wound healing; these include inflammatory, proliferative and the remodeling phase. This causes a release of growth factors including platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), epidermal growth factor (EGF), transforming growth factor and alpha and beta (TGF-a and TGF-b). The histology of fibroblast cells are shown to proliferate within 48 hours of needling, particularly collagen type 3, which is gradually replaced with Before

After

Figure 6: Before and after one treatment of Intracel microneedling with RF for ice pick acne scarring. A course of three treatments was recommended. Before

After

Figure 7: Before and after 25 weeks of using Clenziderm MD system with 5% BPO, from the Obagi Medical range, for treatment of an active acne patient.

collagen type 1.8,9 The major advantages of this type of procedure over chemical peels and laser resurfacing is that it is minimallyinvasive with rapid healing and low downtime. The results can be observed eight to 12 months postoperatively and as the epidermis regenerates quickly, this can avoid some of the negative side effects of a chemical peel, dermabrasion or laser skin resurfacing. The procedure can safely be performed on Fitzpatrick I-VI, with pigment complications low to nil.8,9 Chemical peels Peels can be used to effectively treat scar tissue. The depth of the peel selected will be dependent on the depth of the scar tissue to be treated. Peels vary according to their chemical ingredient; medium to deep depth peels are often required for treatment of scar tissue and solutions for this include TCA peels. These peels can reach the papillary dermis, whereas deep peels (phenol) can go as deep as the mid to reticular dermis in the skin. These peels do, however, carry a higher level of risk with prolonged erythema, infection, PIH, scarring, as well as cardiac toxicity related to the systemic absorption of the peels.8 Therefore the medium depth peels are sometimes preferred by both practitioners and patients due to their lower complication risks.

Summary Acne scarring is a common problem facing a significant number of patients and many seek treatment for cosmetic improvement. Treating acne early needs to be a priority for practitioners to avoid the complications of acne scarring. Treatment options need to be tailored depending on the type of scars the patients present with and then a patient-centered, multi-step approach that takes into account the type of acne scarring and patient goals will achieve the highest satisfaction and good cosmetic results. Amanda Wilson is a nurse prescriber with a BSc (Hons) in Adult Nursing. She has been in aesthetics for six years and has worked at a number of London clinics, including The Clinic by Dr Mayoni. Wilson has a specialist interest in dermatological diseases, in particular acne, and treats a high number of acne patients. She is one of the lead trainers at Healthxchange Pharmacy, where she runs training and manages courses for botulinum toxins, Obagi Nuderm and the SmartMed equipment portfolio. REFERENCES 1. Fox, L (2016) “Treatment Modalities for Acne.” Molecules 21(8): pp. 1063-083. 2. Yeasmin, Monira, and Azm Maidul Islam (2017) “Comparative Study of Evaluation of Efficacy and Safety of Combination of Erythromycin and Benzyl Peroxide with Benzyl Peroxide Alone in the Treatment of Acne Vulgaris.” Journal of Bangladesh College of Physicians and Surgeons 35(4): pp:174-78. 3. Sardana, K, Tanvi G, Bipul K, Gautam HK, and Garg VK. (2016) “Cross-sectional Pilot Study of Antibiotic Resistance in Propionibacterium Acnes Strains in Indian Acne Patients Using 16S-RNA Polymerase Chain Reaction: A Comparison Among Treatment Modalities Including Antibiotics, Benzoyl Peroxide, and Isotretinoin.” Indian Journal of Dermatology 61(1): pp:45-52. 4. Walsh TR (2016) “Systematic Review of Antibiotic Resistance in Acne: An Increasing Topical and Oral Threat.” The Lancet. Infectious Diseases 16(7). (Online). Available at: https://www-sciencedirect-com.ergo.southwales.ac.uk/search/advanced?docId=10.1016/S1473-3099(15)00527-7 (accessed 20/12/19) 5. National Institute for Health and Care Excellence (2018) Management of Acne in Primary Care. Available at: https://cks.nice.org.uk/acne-vulgaris (accessed 08/09/2019) 6. Thielitz A, Gollnick H (2008). “Topical Retinoids in Acne Vulgaris.” American Journal of Clinical Dermatology 9(6): pp: 369-82. 7. Sinnott, S.J., K. Bhate, D.J. Margolis, and S.M. Langan (2016). “Antibiotics and Acne: An Emerging Iceberg of Antibiotic Resistance?” British Journal of Dermatology. 175(6) (Online). Available at: https:// onlinelibrary-wiley-com.ergo.southwales.ac.uk/doi/epdf/10.1111/bjd.15129 8. Connolly, Deirdre L., Ha Linh Vu, Nazanin Saedi, and Kavita Mariwalla (2017). “Acne Scarring- Pathogenesis, Evaluation, and Treatment Options.” Journal of Clinical and Aesthetic Dermatology 10(9): pp. 12-23. 9. Fabbrocini, Gabriella, Valerio De Vita, Ambra Monfrecola, Maria Pia De Padova, Benedetta Brazzini, Fernanda Teixeira, and Anthony Chu (2014). “Percutaneous Collagen Induction: An Effective and Safe Treatment for Post-acne Scarring in Different Skin Phototypes.” Journal of Dermatological Treatment 25(2): pp. 147-52. 10. Harris, Adam G, Catherine Naidoo, and Dedee F Murrell (2015) “Skin Needling as a Treatment for Acne Scarring: An Up-to-date Review of the Literature.” International Journal of Women’s Dermatology 1(2): pp. 77-81.

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Regulation of skin barrier The skin barrier is a balanced system of many functions localised in the SC. Out of all functions, the epidermal permeability barrier appears to be the most important; genetic defects in the barrier function underlie some common skin diseases such as AD and psoriasis.10 Barrier homeostasis is controlled by a number of factors, discussed below.

Understanding Moisturisers Dr Benjamin Chun-Man Lee explains why and how skin can benefit from moisturisers, listing key factors to look out for when selecting appropriate products for patients Not all moisturisers are the same and they have very different effects on the skin barrier depending on formulation. Effective moisturisers contain bioactive ingredients that strengthen and potentially repair skin barrier homeostasis,1-3 while others can be hydrating without effecting the skin barrier and some have even been found to be damaging. Individuals with impaired skin barrier functions such as atopic dermatitis (AD), also known as eczema, are the most likely to notice the difference; therefore, the choice of moisturiser has significant implications for the treatment and longterm control of dry skin and skin sensitivity. The Eczema Priority Setting Partnership, a collaboration between patients, clinicians and researchers in England and Wales, has set out the priority of identifying the most effective and safe emollients for treating AD, and differentiating moisturising cream based on mechanism of action.4,5

The skin barrier The epidermis is the outer layer of skin which is rich in skin cells, known as keratinocytes, that are arranged in stratified layers. The epidermis is continuously

regenerated by the process of terminal differentiation of keratinocytes, in which plump cells in the basal layer of epidermis multiply, undergoing morphological changes and rise through the layers to the stratum corneum (SC), the outermost layer of the epidermis.6 Lipids are released during terminal differentiation to form the ‘mortar’ into which keratinocytes are laid. Each keratinocyte forms a tough, chemicallyresistant ‘cornified enveloped (CE)’ by cross-linking proteins.7 The epidermis is completely renewed every 28 days.8 The epidermal barrier has many important functions, such as regulating loss of water and electrolytes, antimicrobial barrier and immune protection, skin hydration and moisturisation, protection from chemicals and toxin penetration, as well as acting as a barrier to terrestrial UV radiation and oxidative stress from air pollution.9 The physical skin barrier is mainly localised to the outermost, protein-rich SC, in which keratinocytes adopt a flattened shape enclosed in a cornified cell envelope.9 The epidermal barrier is constantly under threat from the environment. Therefore, it requires full functionality to protect and maintain health of the body.

Skin pH Skin surface pH is maintained in a value between 4.5 and 5.5 (slightly acidic) in humans by the endogenous processes of fatty acids from phospholipids and urocanic acid from natural-moisturising factors (NMF) in SC, as well as exogenous sources of free fatty acids from sweat glands and lactic acid derived from sebaceous glands by the action of bacterial lipase.11 Furthermore, a lot of protein-degrading enzymes (proteases) in SC are pH dependent, activated by alkaline pH to induce desquamation.12 The use of soap can result in a disruption of skin pH, leading to skin barrier dysfunction and ultimately dry skin. Gel formulations on the other hand, which are commonly used and often a preferred choice for oily or acneprone skin types, may raise the skin’s pH, ultimately leading to weakening skin barrier and its innate immunity against infections.13 Doublebase gel is an example of a gelbased moisturiser. Epidermal lipids The studies of skin barrier dysfunction in AD have found insufficient levels of intercellular lipids, in particular ceramide 1 (CER EOS) in AD skin.14 In normal skin, ceramide is synthesised from a particular form of cell membrane phospholipids called sphingomyelin. In AD, upregulation of a converting enzyme that depletes sphingomyelin in turn depletes a reserve of ceramides.15 In recent years, Cork et al. have reported an emollient mixture containing a pseudoceramide, which showed structural resemblance to human intercellular lipids in SC, promoting superior effect on epidermal permeability barrier function in comparison with a control emollient without the additives.1 Niacinamide, also known as vitamin B3, induced up to a five-fold increase in ceramide synthesis by cultured skin cells.16 Environmental and physiological factors The effect of environmental humidity and temperature on skin barrier function is huge. Absolute humidity (AH) is a measure of water content in a given volume of air. AH

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Application Moisturisers ought to be applied thinly in the same direction of hair growth to avoid clogging hair follicles; for example, in downward strokes over the body in the direction towards hands and feet over the arms and legs, and from the mid-line of face to the outside.32 This is particularly important when moisturising acne-prone skin or using thicker and greasier products.

is independent of temperature, but studies on mice and humans have concluded that cold temperatures have a negative effect on skin barrier function, regardless of epidermal water content.17,18 Relative humidity (RH), on the other hand, is defined as a percentage of the amount of water vapour divided by the moistureholding capacity of air. Therefore, it is a much more reliable measure in clinical studies on the effect of climate on skin barrier function.19 Exposure of human skin to low RH (32% and below) renders skin more susceptible to contact sensitivities, increased transepidermal water loss (TEWL) and dryness, and a longer recovery period to regain normal permeability barrier function.19 Human skin has the ability to adopt to a new environment. However, at low temperatures the adaptability to low humidity appears impeded, causing dry skin and breakdown of skin barrier. The effect of low RH seems to be more significant in the first two days of exposure, after which period, skin gradually adopts to a dry environment and restore integrity and barrier functions.19 Population studies found that individuals working in particular environments, such as the airline industry, fish factories and plumbing, are most susceptible to contact allergies and skin complaints relevant to dry and sensitive skin.19

Choosing the right moisturiser Moisturising fulfils an important need by providing skin comfort and alleviating dryness. A systematic review of clinical studies looking at the effect of moisturisers on eczema development conclude that regular moisturising restores skin homeostasis and defence against microbial penetration, correcting microbial dysbiosis, as well as reducing TEWL in humans.10 A moisturiser is a topically-applied substance or product that overcomes the signs and symptoms of dry skin. Cosmetic creams and lotions are emulsions, either in oil-in-water (O/W) which are non-greasy or waterin-oil (W/O), which are more occlusive.20 Moisturisers are typically made of O/W emulsions.

Composition of moisturising cream Moisturiser composition can vary, mostly in a base, actives and choice of preservatives. They will generally feature a mix or all of the following: • Emulsifiers: preserve the composition of an emulsion, O/W or W/O, and help delivery of active ingredients into the skin, through its protective skin barrier, whilst avoiding disturbance to its barrier properties.21 The choice of emulsifier will determine the constructive or disruptive nature of the emulsion, as well as pH and stability when applied. • Surfactants: added to ‘active’ moisturisers (that have some scientific basis of clinical effect) to boost penetration of water-soluble active ingredients such as vitamin C, by solubilising them into SC. Surfactants are potent irritants but the damaging effect on human skin barrier may vary.22 Sodium lauryl sulphate (SLS) is found in aqueous cream BP, whilst sorbitan laurate, isopropyl myristate and cetostearyl alcohol are surfactants commonly used in moisturisers without noticeable side effects to human skin such as Diprobase cream and Doublebase gel.13 • Emollients: the terms ‘emollient’ and ‘moisturiser’ are often used interchangeably and lack consistency in their use in the literature. An emollient is classically an oil-phase ingredient of a moisturiser that softens skin to improve

feel and delivery of active ingredients.23 Silicones such as dimethicone and cyclomethicones have increased in popularity in this decade. They are added to produce a water-in-silicone emulsion (gelée) that is similar in texture to gels, offering improved skin feel and the perception of a youthful, hydrated skin.24 • Humectants: able to absorb and retain moisture, and are added to counteract with some dehydrating ingredients such as alcohols in gel formulation. Humectant properties confer a moisturising effect on skin, but not necessarily the restoration of permeability barrier function.13 Furthermore, from my knowledge, they play a role as a solvent for some active ingredients, such as salicylic acid in acne-treatment products. Glycerol, butylene glycol, and urea have humectant properties. • Occlusives: humectants offer an artificial and transient moisturising effect to dry skin. For a more sustain maintenance of hydration and preserved barrier function of SC, occlusive agents are added to complement the water-absorbent nature of humectants. Traditional occlusives such as petrolatum and lanolin form a waterproof barrier over the skin surface, and compounds such as silicone derivatives and behenyl alcohol, confer an emollient effect.20,24 Lanolin (wool fat) is recognised as an important sensitiser based on the analysis of patients with eczema;25 anecdotal evidence has suggested that dermatologists have generally advised that occlusive such as E45 cream should be avoided for the treatment of atopic eczema. • Fragrances: with the development of vigorous protocols to assess tolerance of formulations on human skin models and ensure product safety,26 in

The effect of environmental humidity and temperature on skin barrier function is huge

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Individuals working in particular environments, such as the airline industry, fish factories and plumbing, are most susceptible to contact allergies and skin complaints relevant to dry and sensitive skin addition to realistic in-vivo screening by manufacturers in both normal and sensitive populations, the fear of irritation and induction of contact allergy is, in my opinion, no longer substantial as manufacturers are extra careful in their creation. Fragrances improve the overall aesthetic qualities of a moisturiser, added at the minimum concentration required to mask the unpleasant smell of certain ingredients. • Preservatives: crucial components in moisturisers as they confer a cosmetic product a shelf life. With the exception of ointments, moisturisers have preservatives to protect organic ingredients and their moisture content from rancidity. There is no such thing as a preservative-free formulation. Ingredients that are ‘natural’, such as botanicals and creams, require the additional preservative to completely inhibit bacterial growth and oxidation – preservatives are sometimes, quite inappropriately, labelled as antioxidants.27 Manufacturing protocols are developed, and ingredients are formulated to minimise sensitisation and irritation of skin, but common preservatives such as propolis (beewax), formaldehyde-release agents, and methylisothiazolinone to name but a few, continue to make headlines for allergic contact dermatitis.28-30

Conclusion Dry skin is a common problem affecting a lot of people. The development of dry skin is associated with a skin barrier defect in conditions such as atopic dermatitis in the young, asteatotic eczema and winter xerosis in older people.31 Skin barrier homeostasis

maintains integrity and permeability barrier function by regulation and control of pH, microbiome, and desquamation; it can be affected by environmental and health factors including stress. Moisturisers have very different effects on the skin barrier depending on their formulation. An evidencebased approach is always recommended for selecting moisturisers, as not all formulations are the same. Dr Benjamin Chun-Man Lee is a specialty doctor in dermatology (SAS). He is is an honorary teaching fellow at the University of Surrey and a former clinical tutor for PGDip and MSc in Clinical Dermatology at the University of South Wales. In 2018, Dr Lee was awarded SCE dermatology (MRCP Derm UK) and MSc in Skin Ageing and Aesthetic Medicine. REFERENCES 1. Danby SG, Brown K, Higgs-Bayliss T, Chittock J, Albenali L, Cork MJ. The effect of an emollient containing urea, Ceramide NP, and lactate on skin barrier structure and function in older people with dry skin. Skin Pharmacol Physiol. 2016; 2. Buraczewska I, Berne B, Lindberg M, Lodén M, Törmä H. Moisturizers change the mRNA expression of enzymes synthesizing skin barrier lipids. Arch Dermatol Res. 2009; 3. Åkerström U, Reitamo S, Langeland T, Berg M, Rustad L, Korhonen L, et al. Comparison of moisturizing creams for the prevention of atopic dermatitis relapse: A randomized doubleblind controlled multicentre clinical trial. Acta Derm Venereol. 2015; 4. Batchelor JM, Ridd MJ, Clarke T, Ahmed A, Cox M, Crowe S, et al. The eczema Priority Setting Partnership: A collaboration between patients, carers, clinicians and researchers to identify and prioritize important research questions for the treatment of Eczema. Br J Dermatol. 2013; 5. Moncrieff G, Cork M, Lawton S, Kokiet S, Daly C, Clark C. Use of emollients in dry-skin conditions: Consensus statement. Clinical and Experimental Dermatology. 2013. 6. Watt FM. Terminal differentiation of epidermal keratinocytes. Curr Opin Cell Biol. 1989; 7. Downing DT. Lipid and protein structures in the permeability barrier of mammalian epidermis. Journal of Lipid Research. 1992. 8. Potten CS. Cell Replacement in Epidermis (Keratopoiesis) via Discrete Units of Proliferation. Int Rev Cytol. 1981; 9. Wickett RR, Visscher MO. Structure and function of the epidermal barrier. Am J Infect Control. 2006; 10. Kim BE, Leung DYM. Significance of skin barrier dysfunction in atopic dermatitis. Allergy, Asthma and Immunology Research.

2018. 11. Thueson DO, Chan EK, Oechsli LM, Hahn GS. The roles of pH and concentration in lactic acid-induced stimulation of epidermal turnover. Dermatologic Surg. 1998; 12. Caubet C, Jonca N, Brattsand M, Guerrin M, Bernard D, Schmidt R, et al. Degradation of corneodesmosome proteins by two serine proteases of the kallikrein family, SCTE/KLK5/hK5 and SCCE/KLK7/hK7. J Invest Dermatol. 2004; 13. Schmid-Wendtner, M-H., and Hans Christian Korting. “The pH of the skin surface and its impact on the barrier function.” Skin pharmacology and physiology 19.6 (2006): 296-302. 14. 14. Cork MJ, Danby SG, Vasilopoulos Y, Hadgraft J, Lane ME, Moustafa M, et al. Epidermal barrier dysfunction in atopic dermatitis. J Invest Dermatol. 2009; 15. Hara J, Higuchi K, Okamoto R, Kawashima M, Imokawa G. High-expression of sphingomyelin deacylase is an important determinant of ceramide deficiency leading to barrier disruption in atopic dermatitis. J Invest Dermatol. 2000; 16. Matts PJ, Oblong JE, Bissett DL. A review of the range of effects of niacinamide in human skin. Ifscc. 2002; 17. MIDDLETON JD. THE EFFECT OF TEMPERATURE ON EXTENSIBILITY OF ISOLATD CORNEUM AND ITS RELATION TO SKIN CHAPING. Br J Dermatol. 1969; 18. SPENCER TS, LINAMEN CE, AKERS WA, JONES HE. Temperature dependence of water content of stratum corneum. Br J Dermatol. 1975; 19. Engebretsen KA, Johansen JD, Kezic S, Linneberg A, Thyssen JP. The effect of environmental humidity and temperature on skin barrier function and dermatitis. Journal of the European Academy of Dermatology and Venereology. 2016. 20. Rawlings A V., Canestrari DA, Dobkowski B. Moisturizer technology versus clinical performance. Dermatol Ther. 2004; 21. Azeem A, Rizwan M, Ahmad F, Khan Z, Khar R, Aqil M, et al. Emerging Role of Microemulsions in Cosmetics. Recent Pat Drug Deliv Formul. 2008; 22. Vikas S, Seema S, Gurpreet S, Baibhav J. Penetration Enhancers: a Novel Strategy for Enhancing Transdermal Drug Delivery. Res J Pharm. 2011; 23. Lodén M. Role of Topical Emollients and Moisturizers in the Treatment of Dry Skin Barrier Disorders. American Journal of Clinical Dermatology. 2003. 24. Savary G, Grisel M, Picard C. Impact of emollients on the spreading properties of cosmetic products: A combined sensory and instrumental characterization. Colloids Surfaces B Biointerfaces. 2013; 25. Lee B, Warshaw E. Lanolin allergy: History, epidemiology, responsible allergens, and management. Dermatitis. 2008. 26. Roguet R. The use of standardized human skin models for cutaneous pharmacotoxicology studies. Skin Pharmacology and Applied Skin Physiology. 2002. 27. Baines D, Seal R. Natural Food Additives, Ingredients and Flavourings. Natural Food Additives, Ingredients and Flavourings. 2012. 28. De Groot AC. Propolis: A review of properties, applications, chemical composition, contact allergy, and other adverse effects. Dermatitis. 2013. 29. Urwin R, Wilkinson M. Methylchloroisothiazolinone and methylisothiazolinone contact allergy: A new “epidemic.” Contact Dermatitis. 2013; 30. De Groot AC, Flyvholm MA, Lensen G, Menné T, Coenraads PJ. Formaldehyde-releasers: Relationship to formaldehyde contact allergy. Contact allergy to formaldehyde and inventory of formaldehyde-releasers. Contact Dermatitis. 2009. 31. What is asteatotic eczema? (NZ: DermNet, 2019) <https:// dermnetnz.org/topics/asteatotic-eczema/> 32. Greig, Lynn. “Counselling in practice: Dry skin problems in the elderly.” Australian Pharmacist 35.8 (2016): 40.

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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StimSure® The Next Evolution of Body Contouring State-of-the-art muscle toning within a fast, innovative and painless treatment CynoSure is proud to unveil StimSure® – the latest addition to its industry-leading body contouring portfolio, alongside SculpSure® and TempSure®. StimSure is a state-of-the-art, non-invasive electromagnetic muscle building and toning treatment, which can be used to strengthen and tighten muscles for a ‘beyond fat’ approach to holistic body shaping.

Beyond fat… The majority of current body-shaping technologies on the aesthetic market focus primarily on fat reduction; however, around 30% of body composition is muscle, which can have a significant impact on the desired overall slim, toned and healthy look. StimSure® offers practitioners a full body solution which can be used seamlessly in conjunction with existing fat reduction treatments to deliver muscle building and toning for a truly holistic contouring approach.

“I’m proud to be the first in the UK to offer the full suite of CynoSure body-shaping technologies as part of my Body 360 approach. We begin our patient’s transformation with SculpSure® for fat reduction, interspersed with StimSure® sessions to deliver improved muscle tone and posture, before smoothing and tightening the skin using TempSure®. So far, patient feedback on this methodology has been outstanding!” Dr Joney de Souza

How does StimSure work? CE marked for muscular atrophy, StimSure® uses electromagnetic technology to strengthen and tighten the abdominal, gluteal and thigh muscles by delivering up to 24,000 muscle contractions in just 20 to 30 minutes for natural-looking results. The StimSure® applicators generate an electromagnetic field that stimulates the motor neuron cells of the body’s muscles, causing the muscle to contract as it would during movement or exercise. A prolonged contraction, made by a series of individual twitch contractions back to back, creates a ‘maximal

StimSure® offers practitioners a full body solution which can be used seamlessly in conjunction with existing fat reduction treatments 60

Aesthetics | February 2020

tetanic contraction’ that results in more efficient growth of muscle fibres. StimSure® uses 1.0 Tesla per applicator, providing an electromagnetic field that can engage the entire target muscle group.

Who can have StimSure? With four pre-set programs and the ability to create personalised programs on StimSure®, practitioners can tailor treatments for the individual. StimSure® is suitable for a wide range of people, but is not intended for weight loss, nor is it suitable for obese patients. StimSure® is simple to operate, with a secure fixing belt, and can be used through light clothing. Either one or two applicators can be used, and an applicator arm is available. For optimum results, six to eight treatments (twice a week) are recommended.

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A summary of the latest clinical studies Title: A Split-face Comparative Study to Evaluate the Efficacy of 50% Pyruvic Acid Against a Mixture of Glycolic and Salicylic Acids in the Treatment of Acne Vulgaris Authors: Zdrada J, et al. Published: Journal of Cosmetic Dermatology, January 2020 Keywords: acne vulgaris, alpha hydroxy acids, moisturising, salicylic acid, sebum Abstract: One of the ways to treat acne is by using chemical peels. Salicylic, glycolic and pyruvic acids due to their keratolytic and antibacterial properties are often recommended for acne patients. The aim of the study was to compare the effect of a preparation containing glycolic and salicylic acids with pyruvic acid. 14 women diagnosed with acne took part in the study. The facial treatment area was divided into two parts: right (a preparation containing 50% pyruvic acid) and left side (a preparation containing glycolic and salicylic acids.) Skin parameters, namely hydration, sebum secretion and skin colour were measured. As a result of using 50% pyruvic acid, the hydration of the right side of the face increased statistically and there was a decrease in the amount of melanin in the epidermis. On the left side of the face, there was an increase in skin hydration after using a mixture of glycolic and salicylic acids. Chemical peels affect a wide range of pathological factors of acne. A mixture of acids yields fewer side effects than a single acid used in high concentration, but the therapeutic effects are comparable.

Title: Vasculitis Beyond the Areas of Botulinum Toxin-A Injection, Increasing Concerns? Authors: Namazi N and Najar Nobari N Published: Journal of Cosmetic Dermatology, January 2020 Keywords: botulinum toxin-A, vasculitis, injectables Abstract: Botulinum toxins-A, as the most common nonsurgical method for facial rejuvenation, have been used broadly. Despite its significant aesthetic aspects, particular undesirable adverse effects could occur. The aim of this case report is to present the most serious side effects of botulinum toxin injections. This is a case report of a middle age woman with side effects of botulinum toxin injection with presentation of erythema and edema on the sites of injection and more further on the face and neck. On the skin biopsy the small vessel vasculitis on the site on injection and more further on the face and neck was performed as a result of injections. Following Botulinum toxin-A injection, various cutaneous reactions could occur. Some of these reactions such as edema and erythema may be self-limited and has no serious impact on patients’ life but also some severe reactions like this case may occur which may alarm the life threatening side effects of injections. Using the unapproved Botulinum toxin-A should be discouraged due to their hazard of systemic reactions and clinicians should avoid administering the unlicensed products even by patients’ request or lack of the allergic reactions from previous injections.

Title: Fat Grafting to Improve Results of Facelift: Systematic Review of Safety and Effectiveness of Current Treatment Paradigms Authors: Molina-Burbano, et al. Published: Aesthetic Surgery Journal, January 2020 Keywords: facelift, surgery, fat-grafting, lipofilling Abstract: Autologous fat grafting is a helpful supplement to facelift surgery that helps to combat age-related volume loss of facial structures. Despite the widespread prevalence of combined facelift and fat-grafting, there exists significant procedural variation between providers. The primary purpose of this systematic review is to study the efficacy and complication rates of facelift with lipofilling compared with facelift alone. A systematic review of the Cochrane Library and MEDLINE databases as completed to identify all clinical reports of fat grafting combined with facelift surgery using the following key terms: (‘fat grafting’ OR ‘lipotransfer’ OR ‘lipofilling’ OR ‘fat transfer’) AND (‘facelift’ OR ‘rhytidectomy’ OR ‘SMASectomy’ OR ‘facial rejuvenation’). Data on techniques, outcomes, complications, and patient satisfaction were collected. The most common locations of fat graft injection included the nasolabial folds, tear troughs, temporal regions, midface/cheek/malar eminence, marionette groove, lips, and ear lobes. The addition of fat grafting to facelift surgery resulted in significant improvement in facial volume and aesthetic assessments. Combined facelift and fat grafting is a safe and efficacious means to simultaneously address agerelated ptosis and volume loss. Further research is required to validate and improve existing treatment modalities.

Title: Topical Stabilized Hypochlorous Acid: The Future Gold Standard for Wound Care and Scar Management in Dermatologic and Plastic Surgery Procedures Authors: Gold MH, et al. Published: Journal of Cosmetic Dermatology, January 2020 Keywords: hypertrophic scars, keloid scars, scar management, stabilised hypochlorous acid, wound care Abstract: Hypochlorous acid (HOCl), a naturally occurring molecule produced by the immune system, is highly active against bacterial, viral, and fungal microorganisms. Moreover, HOCl is active against biofilm and increases oxygenation of the wound site to improve healing. Natural HOCl is unstable; through technology, it can be stabilized into an effective topical antiseptic agent. This paper focuses on the use of topical stabilized HOCl in wound and scar management for pre-, peri-, and post-procedures – including its ability to reduce the occurrence hypertrophic scars and keloids. The role of the product in other skin conditions is beyond the scope of this article. A panel comprising clinicians with experience in cosmetic and surgical procedures met late 2018 to discuss literature search results and their own current clinical experience regarding topical stabilized HOCl. Topical stabilized HOCl provides an optimal wound healing environment and, when combined with silicone, may be ideal for reducing scarring. For wound care and scar management, topical stabilized HOCl conveys powerful microbicidal and antibiofilm properties, in addition to potency as a topical wound healing agent. It may offer physicians an alternative to other less desirable wound care measures.

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any other digital platform you direct them to) whilst the enthusiasm is there; we live in an age of instant gratification. I believe we could be missing a trick if we don’t tap into the need for instant gratification and potential patients could go with a competitor who can satisfy this need.

Considerations

Utilising Radio Marketing Clinic manager Kerri Lewis explores how radio marketing can be beneficial for your business Radio may not be the first platform that springs to mind when you think of advertising your business, especially in an age where social media seems to reign supreme allowing you to showcase your company with little or no cost. In this fastpaced world, radio can seem old-school and, potentially, expensive as a promotional tool. However, there are several very valid reasons why you shouldn’t write off marketing through radio. This article will explore the marketing concepts and key considerations when deliberating the opportunities that radio marketing can offer.

Advert avoidance

The rule of seven

The digital world

Let’s first look at ‘the rule of seven’. This is a marketing principle that tells us that prospects must come across your offering a minimum of seven times before they even notice your brand and maybe take action.1 This is a concept which has been around for decades and is based on the human brain’s reticular activating system (RAS).1 It sounds complicated but simply put, your RAS acts like a filter to keep what is relevant in your conscious and the not so helpful in your subconscious. Everyday your potential patients are being overwhelmed with marketing messages and there’s a huge amount of competition out there. Getting your message through the data smog at least seven times to your desired audience is a herculean task. But the important takeaway is that you do need to do this, and you need to review and experiment with the marketing channels that you use.

Audio has always been a strong call-toaction medium and even more so in a world where listeners can access brands online.4 In fact, a study conducted by industry body Radiocentre found that exposure to radio advertising boosts brand browsing power by an average of 52%.5 As well as this, more than half of browsing that was identified as having been stimulated by radio takes place within 24 hours of exposure to advertising.5 Other research suggests that 66% of the UK’s population tune in to digital radio each week, which means that listeners literally have your brand at their fingertips.4 You can take advantage of this by directing listeners to your website and/or visually with display ads that they can click on through listening to the radio via an app. This means that prospects can access your website (or

Radio (along with TV), has the lowest level of advertising avoidance according to market research company Sifo Research.2 This is because it’s rare that people switch between stations and so are more likely to hear your advert. Advertising company On Advertising states, ‘Listeners use radio for emotional reasons – to keep their spirits up, to stop themselves from feeling bored in a car or isolated while doing daily chores. This leads to them seeing radio as a kind of friend, and this is a valuable context for an advertiser to appear in’.3

Radio marketing isn’t something that you should jump into without serious consideration as, in my experience, it’s likely that you will be asked to sign a contract with the station for a minimum of six months or up to a year. Shorter term contracts may increase the price of your adverts.5 Like any marketing platform, if you don’t do it well, you could waste your money and, unlike social media, you can’t be reactive and change your advert overnight. 1. Research Consider, what will your target audience be listening to? Who better to ask than your existing customer base as, presumably, you’d like more people who are similar to them through your doors. It’s worth the effort of sending out a simple survey asking what, if any, radio stations they currently tune into. The radio station should be able to offer you their listener figures which will allow you to make an informed choice, alongside your own surveys/research on the station you choose. 2. Multi-channel marketing Multi-channel marketing (multiple touch points) means that you can reach prospects no matter where they are or what their marketing preferences are. For example, if you restrict yourself to Instagram (a mobile channel) you’ll be missing the opportunity for your message to reach those using Facebook (both a mobile and computer channel), or potential patients who listen to the radio (radio/mobile/computer channels). We also mustn’t forget the retail shopfront, which is a physical touch point. When we first opened our clinic, The Skin to Love Clinic, we were approached by a sales representative for a nationwide radio network with a county-based station. I made the mistake of taking up that advertising opportunity because we wanted to get our name out there and we were lured by the station’s large audience numbers. In hindsight, I don’t believe at that stage we had enough supporting touch points to expose our message to our prospects.

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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3. What will you get for your money? Each station will offer different packages so it’s worth researching what’s on offer and whether you can create a bespoke package to suit your budget and needs. Drawing from my own experience, given our first attempt at radio advertising and the learning points mentioned above, I had a good understanding of why that station didn’t work for the clinic. But, I knew that as a medium, radio had great potential. So, we approached another local radio station which had a target audience more suited to our brand. We discussed budgets and together built a sponsorship package that included an advert, sponsorship of a specific lifestyle show and monthly on-air interview slots which allow us to educate listeners. Personally, I listen to a radio station that doesn’t have advertising, but I realise that I am subconsciously influenced by comment, discussion and ideas. So, for me, the most valuable part of our deal is the opportunity to inform prospects about the clinic’s offering and break down any barriers they may have about coming in to see us. In my experience, no two radio stations have offered me a like-for-like package and therefore the price has been variable. Workspace gives us a very generalised idea of costs, by stating, ‘As a rule of thumb, radio advertising is charged at a rate of approximately £2 per thousand listeners at one time. If a show has 100,000 listeners at 10am, then buying a 30-second spot at that time will cost you £200. The late show’s 10,000 listeners at 11pm would only cost £20’.7 No matter your choice on station, if you have a budget in mind, it would be worth approaching them and asking what package they can offer you within your price range. 4. Decide who should represent you Stations should provide the option of producing your radio advert as part of your package and naturally you will have input into the content. You should be able to discuss the type of actor you think should be right for your advert; for example, male, female, age and tone of voice. All of this proved particularly valuable in the success of our advert as the voice actress represented our desired target demographic; a middle-aged female with an accent similar to the broadcast area.8 If the package that you select presents the opportunity to speak on a show as part of an interview or discussion, you need to think carefully about the topics you want to discuss and, egos aside, who is going to best represent you. In my opinion, presuming you have a background in the industry, the best

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person is probably going to be you unless, of course, the subject matter is outside of your speciality; a carefully selected practitioner would be a good alternative if they’re required to talk about medical or specialist topics. Remember, this type of interview is not going to be a frightening display of investigative journalism from your interviewer, it’s a conversation much like the ones you have on a daily basis with your patients. The interviewer will be wanting to get the best from you and not try to trip you up on purpose. That said, if you’re asked to offer specialist opinion for a radio debate, it may be more intense than an interview that is part of your advertising package. If this is the case, or if you simply feel you need some help with any radio interviews, it may be worth investing in some media training. 5. Don’t forget your call to action It may sound obvious, but don’t forget to direct listeners to your business, otherwise it’s a wasted opportunity. Radioworks.co.uk, an independent radio advertising agency, states that, ‘Audio has always been a strong-call toaction medium. We can do this with traditional radio campaigns by running promotions that drive listeners online or with digital audio campaigns by using numerous methods such as audio adverts with clickable display banners’. Don’t beat around the push with your call to action, you should be direct. For example, what do you think is going to be more persuasive in getting the listener to do what you want them to do: ‘You can visit our website for more information’ or ‘Visit our website today to start your journey to better skin’. The latter example is giving the listener a reason to take the desired action and tell them exactly what to so. It’s down to you to enthuse the listener.9 6. Adhere to the ASA guidelines The Advertising Standards Agency (ASA) monitor adverts and give guidance on how to keep advertising in the UK legal, decent, honest and truthful.10 Use this resource to make sure that your advert complies with their standards. Personally, I wouldn’t rely on your station checking your wording; after all, it’s unlikely that they’ll be experts in your industry. ASA displays the UK code of broadcast advertising which is free to download from its website and gives you comprehensive guidance for the copy of your radio advert.11

Return on investment The goal with any advertising is generating leads. Measuring this return on investment

(ROI) can be tricky when there is no ‘evidence’ of click-through to the website, which can be easily measured with digital marketing. To gauge where our leads come from, I ensure that our reception team asks patients where they heard about us at the time of booking their first appointment and again at their first visit. This is recorded on our diary booking system which easily allows me to run a report on sources of new patients. This is valuable as it saves me time collating the information myself, however if your diary management system doesn’t allow you to do this, a simple excel sheet could also work to record this data. You can also set up a website landing page, for example yourwebsite. co.uk/BBCradio1, and have your advert or interviewer direct listeners to that page so that you can monitor the number of prospects who have followed your call to action. Regardless of the difficulties in monitoring more traditional marketing there is much evidence to show that it can generate a good ROI.

Conclusion Radio marketing can form part of a successful, multi-channel marketing plan. Implement methods to ensure that your radio marketing is well choreographed to work in synergy with your other marketing channels for a worthy ROI. Kerri Lewis opened her clinic, The Skin to Love Clinic, in St. Albans in 2013. She also won the SME Young Business Person of The Year award in 2017 and the Business Woman of the Year award in 2018. REFERENCES 1. Storybistro.com, Your brand the marketing rule of 7, November 2019 <http://storybistro.com/your-brand-and-the-marketingrule-of-7/> 2. Media Vision Interactive, Ad avoidance in the age of the internet of things, February 2016 <https://www.mediavisioninteractive. com/advertising-2/ad-avoidance-in-the-age-of-the-internet-ofthings/> 3. On Advertising, Radio Advertising Benefits <http://www. onadvertising.co.uk/radio-advertising-benefits.html> 4. Radio works, Why audio? <https://radioworks.co.uk/why-audio/> 5. Radio Centre, Radio the online multiplier <https://www. radiocentre.org/our-research/radio-the-online-multiplier/> 6. Lohrey J, Radioa Advertising Agreements, Chron <https:// smallbusiness.chron.com/radio-advertising-agreements-73999. html> 7. Workspace.co.uk, Guide to radio advertising <https://www. workspace.co.uk/community/homework/marketing/guide-toradio-advertising#KuKG6ptIzvRyssg0.99> 8. Inc., 6 psychological tricks that will make people buy anything <https://www.inc.com/magazine/201703/kate-rockwood/readyto-sell.html> 9. McCaffrey B, Hook, Line and Slinker: 7 Tips for a Killer Call-toaction, Wordstream, November 2018 <https://www.wordstream. com/blog/ws/2014/10/09/call-to-action> 10. Advertising Standards Authority <https://www.asa.org.uk/> 11. Advertising Standards Authority, Broadcast code <https://www. asa.org.uk/codes-and-rulings/advertising-codes/broadcastcode.html> 12. Oxford Economics, The value of commercil radio to the UK economy, May 2016 <https://www.radiocentre.org/wp-content/ uploads/2018/04/The-economic-impact-of-commercial-radio. pdf>

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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2. Ensure all images allow for a direct likefor-like comparison of treatment effect Consistency is key (Figure 1). Firstly, utilise an appropriate high quality/DSLR camera or purchase an imaging device and ensure all images are taken with the same device/ platform. Watch out for image inconsistencies, such as bad or differing angles, poor lighting, different backgrounds or clothes, allowing makeup in either shot, different hairstyles or not held back from the face, and unnatural or inconsistent facial expressions.

Capitalising Patient Imagery Mr Benji Dhillon presents key considerations for using patient images in case studies A picture is worth a thousand words – so the adage goes – and in a highly visual industry like aesthetics, patient imagery is an extremely valuable tool to showcase clinical expertise, grow your reputation and underpin both educational and clinic marketing initiatives. However, I have found that despite the growing industry knowledge of the importance of good imagery, I am still regularly seeing lowquality pictures shared by clinics. In this article, I will outline my best practice tips for creating powerful patient imagery for the purpose of clinic case studies, and how to maximise these within your clinic PR and marketing.

Why imagery for case studies? The usage of imagery – particularly patient before and afters and case studies – can support a variety of clinic activities including clinical research, marketing materials, educational or training materials and PR/social media assets. However, they can also be used to showcase your results at conferences to your peers or as part of a submission to a medical journal. Strong before/after imagery is often a key deciding factor for patients considering treatment and by leveraging these on your website and social channels, you can optimise the decision-making process. Including such imagery in your clinic marketing approach helps expand your existing customer base while attracting those all-important new patients.

Top three tips for creating strong case study images In order to gain the business and reputational benefits from strong patient imagery, it’s critical to follow some simple guidelines to ensure the images are of a high standard and achieve what you need. 1. Make sure case studies reflect your desired patient demographic Think about how this would be best achieved for your business; with male or female patients? What age range would work best? Are you trying to attract a certain ethnicity or are you accidentally excluding potential patients by not having case studies that represent them? Consider how to tap into not just your current demographic, but your desired target patients too. Before

3. Ensure images reflect the ‘average’ result or patient response Although you might want to shout about your fabulous results, selectively using ‘above average’ case studies can result in unrealistic expectations of your treatments (and subsequent patient complaints). This would obviously damage your trust and credibility among patients. If you still want to share these results, I advise you to make a separate note of the ‘best’ results achieved so far.

Case study recruitment It is industry standard to photograph patients before, during and after aesthetic treatment and have a tick box in the consent form informing patients of this. Many will also include a tick box in the initial medical questionnaire about consent to internal or external marketing use of images or use for educational purposes, but, in my view, the progression to proper case study status requires a specific and considerate approach. I advise working with existing patients at first, as you have already established a rapport and trusting relationship. Raise the topic at the end of their next consultation or appointment and highlight that you would like to use their treatment journey as a more in-depth case study. A useful way to inform and reassure After

Figure 1: Before and after image showcasing consistent photography parameters

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Using imagery in PR Julia Kendrick, founder & director of Kendrick PR Images are powerful, but don’t tell the whole story. The biggest ‘convincer’ for patients considering treatment will be rooted in emotion. Pairing strong imagery with a testimonial or treatment experience will help bring to life the emotion behind a treatment decision. Testimonials help us imagine how we’d feel after having treatment ourselves – this is why they are a powerful conversion tool. Work with your case studies to capture their story and condense this down to a bite-size format (250 words or a one to two minute video) which takes the audience on the journey with them – before, during and after treatment. Be smart with usage across channels. Maximise imagery and testimonials by regularly including across your website and social channels. Utilise multiple formats – photos, videos and text – to ensure a mix of content; don’t just use wall-to-wall before and afters as this isn’t very engaging. Use your assets across all approved PR, marketing and educational channels, including clinic marketing materials, patient newsletters, clinical posters/podium presentations, website and blog, PR materials, social media channels and waiting room materials/videos.

potential case studies is to show them examples of what this could look like. Outline which aspects of treatment you would like to capture and why they are particularly suitable to be a case study, as well as giving a brief overview of the planned imagery usage. I would always recommend being upfront from the start about the intended usage for marketing purposes (especially PR and social media) and if they raise a concern about being identified, you can explore options which obscure their identity – either by showing a close-up of the treatment area, or by obscuring the eyes/identifying characteristics. Once they are clear and aligned with what you want them to do, provide a written consent form, detailing everything you have discussed, for them to sign. Some clinics offer incentives to patients for agreeing to be case studies – such as a reduced treatment cost, or discount of their next chosen treatment. Whilst this can be a useful way to help generate some initial case studies, my guidance is to be cautious and ensure the terms are proportionate and reasonable so that there can be no suggestion of patients being incentivised to treat. In addition, this could be off-putting for some patients, many of whom look for clinics which has a discreet approach.

Consent Consent is the lynchpin on which all this activity depends and can result in potential legal implications if mishandled.1 Once an image has been used online or on social media, it becomes virtually impossible to withdraw or eradicate (even if removed

from the initial source page or channel), thanks to re-sharing or screenshotting actions. It is critical that the patient has a full understanding of how their image will be used and that they sign a comprehensive consent form which gives you the right to use the materials as stipulated.1 My consent form includes: • Consent to photograph/record the patient before and after the treatment • Consent to use the patient’s name (first, last or both) and age • Permission to use and publish photographs/videos/testimonials both in print and digitally, for any lawful purposes such as clinical training or educational materials, marketing materials, or within other printed, online or broadcast media • The length of time that the photographs will be used for (in perpetuity, for up to one year, etc.) • That the patient waives their rights to any royalties or compensation for the use of the photo (if appropriate) • Clinic and patient signature and date boxes Another important step to avoiding legal issues is data protection – firstly, by controlling which devices patient photos are taken on. It’s important to note that clinical photographs form part of the patient’s medical records and so they are regarded as ‘data’.2 Any photos should be taken using clinic-owned devices as this prevents any problems that could arise from staff members having work images on their personal devices. Secondly, the data storage must be compliant with General Data Protection

Regulations (GDPR)3 and should be stored securely,2 and this should be made clear to the patient within the consent form. The device must be password protected and without risk of it being stored on online ‘cloud’ storage accounts.2,3 Have in writing that under no circumstances will you share this information with a third party without expressed consent and that the patient has the right to access, amend or withdraw the information at any time and for any reason.

Conclusion Patient imagery and testimonials are valuable assets for your aesthetic business. In this article, I have outlined why you should invest time and effort into creating your own powerful patient imagery and how to create the best possible tools to support patient education and clinic marketing activities. By taking a considered approach to case study recruitment, you can create tools which target, educate and convert both new and existing patients across a whole host of online and offline channels. Finally, by ensuring a comprehensive consent process, you will be able to advance your marketing plans with confidence, knowing that your reputation and business are protected moving forward. Mr Benji Dhillon is the cosmetic director and co-owner of Define Clinic in Beaconsfield. Mr Dhillon trained in plastic surgery and worked for Allergan on its clinical trials, following which he switched to full-time aesthetic practice. He is part of the international faculty for Teoxane. REFERENCES 1. Advertising Standards Agency – CAP Guidance on the marketing of surgical and non-surgical cosmetic procedures. <https://www.asa.org.uk/resource/cosmetic-interventions.html> 2. Swan M, ‘Patient Photography and Data’, Aesthetics journal, 2018. <https://aestheticsjournal.com/feature/patientphotography-and-data> 3. General Data Protection Regulation <https://gdpr-info.eu/>

13 & 14 MARCH 2020 / LONDON

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Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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If the aesthetic practitioner has doubts about the diagnosis, there are a range of practitioners working in the private or public sector that are suitable for referral. However, it is very unlikely that all the above issues can be addressed by one type of practitioner. It is therefore important practitioners understand the professional background of each group to ensure that the patient gets the opportunity for correct diagnosis and management.

General practice

Referring for Hair Concerns Dr Ingrid Wilson explores the referral options available for aesthetic practitioners confronted with a patient seeking help for hair loss A full head of hair contributes significantly to the perception of image. Consequently, patients experiencing hair loss can often experience psychological distress impacting significantly on their quality of life.1 Due to strains on the NHS, patients suffering with hair loss may present to aesthetic practitioners seeking a solution, or perhaps they are being treated for other cosmetic concerns but point out their hair loss to their aesthetic practitioner for guidance. The majority of aesthetic practitioners will be able to recognise the common conditions of male and female pattern balding. If the cause is known, and it is not associated with underlying medical conditions, the aesthetic practitioner may be in the ideal position to offer advice, as some hair loss approaches available are also used in skin rejuvenation. However, there may sometimes be uncertainties in the diagnosis of other causes of hair loss. If the cause of the hair loss is not correctly identified, there is a potential to make the condition worse.2 The underlying causes could range from genetics, nutritional deficiency, disease process, or hair care practices, for example.3,4 Only a minority of aesthetic practitioners are likely to have received detailed training in

the diagnosis and management of hair loss, so a point may therefore come when it is necessary to refer to another practitioner. In an ideal world, this practitioner could: • Confirm the diagnosis, recognising normal variations and variations by hair texture (including afro-textured hair) • Give practical advice about the optimal hair care practices and cosmetic products needed to retain hair • Give practical advice on hiding hair loss such as cosmetic products, wigs, hairpieces or scalp micropigmentation • Provide evidence-based medical or nonmedical treatment • Provide more experimental treatment once conventional options have been explored • Assess suitability for hair transplantation

The GP is in the best position to diagnose common causes of hair loss and should be considered first if you are in doubt about diagnosis. A GP can request investigations (blood tests and mycology for tinea capitis, for example) and diagnose and advise on the likely course of conditions, without a significant financial cost to the patient. They can also refer to dermatologists in the NHS or privately, particularly in cases of severe alopecia areata and potentially scarring (permanent) hair loss conditions. A crucial role of the GP is recognising and responding to signs and symptoms of possible serious illness. As patients with hair loss are rarely acutely ill, unfortunately hair loss concerns may be considered cosmetic in the context of other diseases. In UK general practice, a typical consultation is scheduled for 10 minutes, and the emphasis would need to be on diagnosis, investigation if needed or referral to a dermatologist. There would simply not be enough time to cover all the practical advice that a patient may be seeking such as nutrition, psychological impact, how to cosmetically camouflage hair loss, what to think about when choosing a wig or discussing hair transplants (which is not routinely available on the NHS). It’s important to note that although GPs are usually the first point of call, they receive very little training in diagnosing skin and hair loss conditions before they qualify.5,6 Within the current Royal College of General Practitioners’ curriculum for GPs in training, the hair loss competency is described as follows: ‘As a GP you should: identify symptoms that are within the range of normal and require no medical intervention, e.g.

In the UK, a consultant dermatologist is best placed to diagnose and treat hair loss that is due to medical causes

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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Payments for referral Remember it goes against guidance to accept payment for referrals. The GMC has published guidance on referrals by doctors, irrespective of whether the intervention can be described as ‘healthcare’ or ‘cosmetic’ or whether the doctor is in private or NHS practice. It states that any payment for a referral will give rise to conflicts of interest.18 Similar standards apply for nurses21 and dentists.22 The Nolan principles apply to anyone who works in public health, education, social and care services and give guidance on transparency on avoiding, declaring and managing any conflicts of interest in healthcare settings.23 As trichologists are not regulated, some develop relationships with hair transplant surgeons for referrals and may receive a fee.

age-related changes such as dry skin/hair loss and innocent moles’.7 The curriculum does not refer to the recognition of potentially permanent or scarring forms of hair loss, which need urgent referral to a dermatologist. Can GPwERs help? At present, there is no subspecialty for hair accreditation for GPs with an extended role in dermatology (GPwER). Hair loss is specifically referred to in guidance for GPwERs as the recognition and holistic management of common dermatoses and their symptoms, including common hair and scalp conditions and recognising when to refer to a dermatologist.8 So, the key difference in basic competency between GPwERs and GPs appears to be recognition of scarring alopecias. GPs and GPwERs may find themselves seeing hair loss patients and as part of reflective practice that is required for appraisal and revalidation, may seek opportunities to learn more about diagnosing and treating hair loss conditions after they qualify.

Consultant dermatologists In the UK, a consultant dermatologist is best placed to diagnose and treat hair loss that is due to medical causes. In the NHS, they receive referrals from GPs. In the private sector, paying patients can be referred to a private dermatologist. Dermatologists have the additional skills of dermoscopy and biopsy (for dermatohistopathology), which is particularly useful in the diagnosis of potentially permanent hair loss conditions (scarring). They are also in a position to prescribe potent medication for some forms of scarring hair loss such as hydroxychloroquine, which GPs are not able to.9 Dermatologists in the UK will treat cases of hair loss within their clinics, but there are currently only a handful of dedicated NHS hair loss clinics, so consequently waiting times can be long. Wigs may also be available from dermatologists, but provision

can vary, according to an Alopecia UK report.10 Some of the NHS dermatologists specialising in hair loss can be found on the British Hair and Nail Society website.11 It should be noted that there is some evidence of a lack of confidence in managing ethnic hair among the dermatology community,12 and of delays in seeking the services of a dermatologist in this cohort.13 As waiting times for dermatologists (and GPs in some areas) can be long, patients can become anxious for explanations or solutions, so they may seek consultations with trichologists or other hair loss specialists like hair transplant surgeons.

Trichologists Trichologists assess, diagnose and treat patients with common hair and scalp problems. These include alopecia (hair loss), dry or excessively greasy hair, head lice, hair breakage and scaly, flaking, greasy or itching scalps. The majority of trichologists in the UK do not have a medical or clinical background with the ability to prescribe, and are therefore not able to prescribe. Many trichologists supply patients with hair and scalp-care products such as medicated shampoos and conditioners as part of the treatment process. However, some controversies exist about the exact remit of their role.14 Some trichologists will also offer additional services such as advice on camouflaging hair loss cosmetically, wigs and hairpieces, or scalp micropigmentation to provide an overall service. Methods such as the use of ultraviolet light, infrared light, or high frequency electrotherapy may be used to assist in treatments. Many trichologists will have experience in hairdressing or wig making and others will even arrange for blood tests as part of their assessment. The introduction of DNA testing for some forms of hair loss may be available to some trichologists, and this gives the potential to specifically tailor advice – some of which can be lifestyle related and not require a

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prescription.15 Trichology is also not currently statutorily regulated in the UK.16 That said, these professionals can be a useful resource for patients experiencing hair and scalp problems who may not be able to access a doctor, and importantly they are able to offer more time to discuss how the problem is impacting on the patient and offer clinicbased treatments in some circumstances. In the UK, trichology training is available from a variety of institutions including The Institute of Trichologists, International Association of Trichologists, The Trichological Society, and Trichocare. Each has its own curriculum and varies in the amount of face-to-face exposure with patients.

Hair transplant surgeons A market has developed for hair transplant surgery as an instant solution for hair loss, although it should be noted that not all patients are suitable. Hair transplant surgeons can come from a variety of backgrounds including general practice, general surgery and plastic surgery, for example. It is usually assumed that a hair transplant in the UK will be undertaken by a GMC-registered doctor. However, sometimes it is not always the case. It is always wise to check whether the doctor associated with a hair transplant clinic is on the GMC register before referring. It appears that there are a variety of private providers for hair transplant training and there is not one standardised training route. As with the cosmetic surgery and nonsurgery fields, there is little regulation and oversight of the hair restoration surgery field in the UK.17 In England, hair restoration surgery (hair transplant surgery and prosthetic hair fibre implantation) is within the scope of the Care Quality Commission.18 However, this may not always mean that a medicallyqualified doctor is performing the surgery on a registered premises. In Wales, Scotland and Northern Ireland a clinic can be registered but not yet inspected. I would suggest that practitioners refer to a hair transplant surgeon who is a member of associations such as the British Association of Hair Restoration Surgery (BAHRS) or the International Society of Hair Restoration Surgery (ISHRS). Even though being trained as a plastic surgeon isn’t required to be a hair transplant surgeon, the NHS website suggests that people interested should also check the British Association of Plastic Reconstruction and Aesthetic Surgeons (BAPRAS) website to see if the surgeon is a ‘full member’ on the specialist register for plastic surgery.19 Hair transplant surgery also

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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falls under the remit of the Joint Council for Cosmetic Practitioners (JCCP), which has strict training requirements to join its register.20 They may also be registered with the British Association of Dermatologists (BAD) and the Royal College of Surgeons (RCS).

Conclusion There are a range of partners to refer your patients to for diagnosing and treating hair loss conditions. It is important when choosing a referral partner to be aware of the nature of their training and their limitations to ensure the best care for your patients. Aesthetic practitioners should always refer if they are not trained or skilled in treating hair concerns, and refer before treating if they are not certain of the clinical diagnosis. Dr Ingrid Wilson became a GP in 1999, is on the specialist register for Public Health Medicine and is a Fellow of the Faculty of Public Health. She trained in trichology with the Institute of Trichologists, gaining the John Mason Memorial Prize. She is a member of the British Hair and Nail Society, The International Association of Trichologists, The Trichological Society, an affiliate Trichologist Member of the British Association of Hair Restoration Surgeons and is the director for Crewe Hair & Skin Clinic. REFERENCES 1. Cartwright T, Endean N, Porter A. Illness perceptions, coping and quality of life in patients with alopecia. Br J Dermatol. 2009;160(5):1034 1039. 2. Almohanna HM; Perper M; Tosti A. Safety concerns when using novel medications to treat alopecia, Expert Opin Drug Saf. 2018 Nov;17(11):1115-1128. 3. Primary Care Dermatology Society, Alopecia – An Overview, <http://www.pcds.org.uk/clinical-guidance/ alopecia-an-overview> 4. Tosti, A. (Miami, FL). Editor(s): Ioannides, D. (Thessaloniki) Alopecias - Practical Evaluation and Management Current Problems in Dermatology,Vol.47. ISBN: 978-3-318-02774-7 e-ISBN: 978-3-318-

02775-4 DOI: 10.1159/isbn.978-3-318-02775-4 5. The King’s Fund, How Can Dermatology Services Meet Current And Future Patient Needs While Ensuring That Quality Of Care Is Not Compromised And That Access Is Equitable Across The UK?, 2015. <https://kingsfund.blogs.com/health_management/2015/05/how-can-dermatology-services-meetcurrent-and-future-patient-needs-while-ensuring-that-quality-of-ca.html> 6. RCP Consultant Physicians Working for Patients –Dermatology Section. Available at: www.rcplondon. ac.uk/resources/series/consultant-physicians-working-patients (accessed 27 October 2019). 7. RCGP, The RCGP Curriculum: Professional & Clinical Modules 2.01–3.21 Curriculum Modules, 2016. <https://www.gmc-uk.org/-/media/documents/RCGP_Curriculum_modules_jan2016.pdf_68839814.pdf> 8. RCGP, Guidance and competences for GPs with Extended Roles in dermatology and skin surgery, <https://www.rcgp.org.uk/training-exams/practice/guidance-and-competences-for-gps-with-extendedroles-in-dermatology-and-skin-surgery.aspx> 9. BAD, Hydroxychloroquine. <http://www.bad.org.uk/for-the-public/patient-information-leaflets/ hydroxychloroquine> 10. Johnson A, Montgomery K NHS Wig Provision in England A report into NHS England’s provision of wigs to Alopecia patients, 2017. <https://www.alopecia.org.uk/nhs-england-wig-report> 11. Find a Specialist - British Hair and Nail Society. https://bhns.org.uk/index.php?/find_a_specialist.html/ 12. Salam A, Dadzie OE. Dermatology training in the U.K.: Does it reflect the changing demographics of our population? British Journal of Dermatology169(6)·July 2013 13. Akintilo L, Hahn EA, Yu JMA, Patterson SSL.Health care barriers and quality of life in central centrifugal cicatricial alopecia patients. Cutis. 2018 Dec;102(6):427-432. 14. Trueb RM, et al., Trichologist, Dermatotrichologist, or Trichiatrist? A Global Perspective on a Strictly Medical Discipline. Skin Appendage Disorders. 4(4):202-207, 2018 Oct. 15. Genetic test for hair loss launches, Aesthetics journal, 2019. <https://aestheticsjournal.com/news/ genetic-test-for-hair-loss-launches> 16. The Institute of Tricholoigsts, Frequently Asked Questions. <https://www.trichologists.org.uk/about-us/ faq-s/> 17. BHRS, Regulation. <https://www.bahrs.co.uk/patient-advice/regulation/> 18. GMC, Competing interests and incentives, <https://www.gmc-uk.org/ethical-guidance/learning-materials/ competing-interests-and-incentives> 19. NHS, Hair transplant. <https://www.nhs.uk/conditions/cosmetic-procedures/hair-transplant/> 20. CPSA, Hair Transplant Surgery. <http://www.cosmeticstandards.org.uk/hair-restoration-surgery.html> 21. <https://www.gmc-uk.org/ethical-guidance/learning-materials/competing-interests-and-incentives> 22. NMC, Conflicts of interest joint statement, 2017. <https://www.nmc.org.uk/news/news-and-updates/ conflicts-of-interest-joint-statement/> 23. GDC, Standards and guidance. <https://www.gdc-uk.org/information-standards-guidance/standardsand-guidance> 24. Gov.UK, The 7 principles of public life, 1995. <https://www.gov.uk/government/publications/the-7principles-of-public-life>

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In The Life of Dr Anjali Mahto

An insight into the daily life of a consultant dermatologist passionate about patient education My mornings consist of… I know I’m not good in the morning, so I structure my days to start later and finish later. In summer, I’ll start clinic at 10am while in winter I start at 11am. Mondays and Fridays are non-clinical days, so I’ll start the morning in the gym. I really enjoy HIIT, fitting in about three session a week, as well as strength training with a personal trainer twice a week. I will usually have a big breakfast and work through lunch. My go-to is a white-egg omelette and a flat white! Having control over how I organise my week was one of the reasons I left my NHS post. I now have time to exercise, write and say yes to exciting opportunities that come my way, rather than having to book annual leave six weeks in advance!

A typical work day includes… It depends on whether I’m in clinic or not. Non-clinic days will be filled with admin, so answering emails, requesting blood tests for patients and potentially catching up on committee work. As part of the British Cosmetic Dermatology Group (BCDG) faculty, I take part in speaking at meetings and putting together agendas for conferences such as CCR. I really enjoy the work with the association as I’m keen to encourage more dermatologists to learn about aesthetics. Dermatologists are in a unique position to be able to advise not just on skin disease, but skin health too. After leaving the NHS, I really wanted to give something back, so I do pro bono press work for the British Skin Foundation; an amazing skin charity which donates significant amounts of money to skin research. Tasks range from reviewing patient blogs, giving advice on dermatology, providing press quotes or takinge part in radio or television interviews. I was recently on Radio 1 talking about acne, which was a really exciting experience! On the first Monday of every month I will download all the articles that catch my interest in the new journals that are out, before reading them on each subsequent Monday. This ensures I am continually learning and also helps form my Instagram posts. If I see something I know my patients

In another life I’d be… A journalist! I studied English at A-level and thought that if medicine didn’t work out, I’d like to be fiction writer. Now, though, I really enjoy sharing factual information and love writing papers and sharing knowledge without the jargon. The most difficult part of my job is… Being on speaking panels with presenters who say something that’s incorrect. As a doctor, I can’t let that go if it’s going to be detrimental to someone’s health, while as a human being I don’t want to be confrontational. It can be really challenging, especially for women who often get labelled negatively if they disagree with other women. I’m still learning how to do this well. The best part of my job is… Seeing people who’ve been made to feel stigmatised their entire life because of their skin and then being able to offer them a solution. It’s rewarding to see the sense of relief they get from learning they don’t have to live with it. I also really appreciate the privilege of being able to construct my working week in the way that works for me. will be interested in or ask me about, I will summarise the content, making it digestible for my 62k followers. I’m passionate about public health education and, the reality is, in a day I can reach more than 5,000 people with a good health message through an Instagram story, rather than the 30 patients I’d see in one day in clinic. One of the key things for me about being a good doctor is making health messages more accessible, minus the jargon. I work at the Cadogan Clinic in Chelsea on Tuesdays, while on

Wednesdays and Thursdays I’m based at 55 Harley Street. I love how varied my work is – I can be advising someone on acne treatment, treating rosacea with IPL, administering dermal fillers, cutting out a mole and removing a skin cancer all in one day. Working in private practice, it’s lovely to take someone through the entire journey of treatment to see the end result. I talk a lot about mental health around skin and am in the habit of referring patients to clinical psychologists, as I believe treatment does involve their help. In general, we should all work with a network of different professions and always refer for procedures outside of our skillset.

After work… I’m working on a few projects involving distance learning, so I’m likely to be studying. Recently, I have been having chemistry tutorials on Wednesdays to support this, but other evenings could involve press work, such as Instagram takeovers, panel events or simply meeting friends for dinner. My perfect evening consists of eating a delicious seafood linguine, followed by watching Netflix and drinking a glass of dry white burgundy with my husband, Nik. I eat and drink everything – I don’t food restrict – everything in moderation works for me!

My most memorable day is… There’s two! One is walking into my first post as a consultant. I’d spent my entire career working towards becoming a consultant and it always seemed like such a long way off. It was very strange when it became a reality – I was very proud to get through the process and it felt like all the tiredness, exams and missing out on life enjoyments were finally worth it! The second was the launch of my book, The Skincare Bible. I never planned to write a book – I was approached by publisher Penguin after they read my posts about skincare – yet it has been such a rewarding experience. I strongly believe that opportunities bring opportunities, so I always advise people to say yes when they come your way – you never know what they’re going to bring!

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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The Last Word Dr Ruth Harker argues why she believes dermatology training is essential in aesthetic practice and why many practitioners need to become better educated Dermatology is the study of the structure and the functions of the skin, the diseases that can affect it and their management. It includes topics from skin cancer to skin ageing and common diseases such as acne, eczema, rosacea, psoriasis and rashes, as well as psychology. It is a vast area of medicine and one that many dermatologists devote their lives to. Non-surgical aesthetic nurses, dentists and doctors are looking, touching, feeling, assessing and treating the skin on a daily basis; however, many don’t have training in dermatology; in other words, skin. Here I am going to explain why I believe this is a problem, and what we can do to solve it.

The issue The skin is the largest organ in the body with a complex, five layer structure that performs many functions. It has a barrier function; literally keeping the outside world out and being waterproof so the body tissues do not become waterlogged. It has a protective function and covers the body’s contents, a defence action to cold, controls sebum production, contains various types of nerve sensors for pain, pressure, heat and cold, and has an immune function, amongst other important roles. Many rashes and lesions, for example, are manifestations of occult systemic disease and genetic disorders.1,2 However, if an aesthetic practitioner does not have training in this area, then it can put patients at risk. For example, if the practitioner cannot diagnose a skin cancer, is this satisfactory for patient care? Some aesthetic practitioners are consultant dermatologists or dermatologists in the hospital training grades, while a number of GPs perform extra study and practice to become GPERs (GPs with extended range).3 These doctors will have had a minimum of nine years’ training, with others having a lot more. Some nurses may work in a dermatology department of an NHS hospital, privately for dermatologists or in a mole clinic, so have learnt much during their work. Other nurses and doctors may have a postgraduate Diploma or Master’s in clinical dermatology. Obviously, these practitioners are in a good position to diagnose and treat the skin. However, the fact is that the majority

of aesthetic practitioners are injectors; some with only a day or two of group injectable training. The standard of the training courses may vary and, very often, they do not include much dermatology education. The concern is that while these practitioners may be skilled injectors, they may miss an important diagnosis relating to the patient’s skin health. I believe that the rationale that aesthetic practitioners should have dermatology training is undeniable; there is no possible reasoning for us not to have it. Medical students do receive some education in dermatology; between two to six weeks depending on the medical school, and perhaps may perceive that this is adequate to specialise in dermatology and treat dermatologic conditions. However, only a small percentage of doctors will have a post-graduate qualification in dermatology or a hospital post in dermatology. Some doctors now aren’t committing to the usual three-year hospital training after medical school and want to go straight on to become an aesthetic practitioner. So, although they will have the title ‘Dr’, they may have practised little medicine or dermatology. Similarly, it’s common for many nurses and dental students, unless they have independently sought additional training, to gain little dermatology training. I don’t believe this is enough to work in aesthetics and more is needed. Alongside this, as injectable treatments are inserted under the skin, many practitioners may believe that dermatology knowledge isn’t important. However, as mentioned dermatology is vast and includes treatments that are performed under the skin.

The solution Seek to gain a Diploma or Master’s in dermatology. There are also various Level 7 courses in aesthetic medicine, which include dermatology, so I recommend that practitioners pursue a course that includes this. I also believe that the ultimate aim is that all aesthetic practitioners – doctors, dentists and nurses – will achieve a Level 7 qualification. Associations such as the British College of Aesthetic Medicine (BCAM) or

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the British Association of Cosmetic Nurses (BACN) offer good guidance to direct candidates to the best accredited courses. BCAM has a new exam for full membership for dentists and doctors and will have a detailed module on dermatology.4 There are also specialist dermatology groups such as the British Association of Dermatologists (BAD) and The British Dermatological Nursing Group (BDNG) which can assist practitioners looking to educate themselves in dermatology. In addition, there are many good textbooks for further reading1,2 and some aesthetic training providers that have specialist courses in cosmetic dermatology, which I believe can also be useful for aesthetic practitioners.5

Summary My views are endorsed by the BCAM, which promotes thorough further training of fully qualified doctors and dentists to ensure that they are the correct practitioners to treat the general public for cosmetic procedures. The Joint Council for Cosmetic Practitioners (JCCP) is composed of representatives from BCAM, the BAD, BAPRAS, BAAPS and the BACN and is striving to achieve agreement on clinical standards for patient safety, acceptable to the relevant regulatory bodies.6 If aesthetic practitioners are educated in dermatology, then I believe they are providing a better and safer service to their patients. It should of course be emphasised that practitioners should never treat outside of their skillset – always refer to a suitable professional. Dr Ruth Harker has been a GP and has been a dermatology hospital practitioner performing minor surgery for many years. She has a diploma in practical dermatology and is medical director of the Erme Clinic. Dr Harker is the conference and finance director for the British College of Aesthetic Medicine. REFERENCES 1. Baran R & Mailback H, Textbook of Cosmetic Dermatology, Fifth Edition (Series in Cosmetic and Laser Therapy) 2017. 2. Gawkrodger D & R Ardern-Jones M, Dermatology: An Illustrated Colour Text, 6e Paperback – Illustrated, 2016. 3. British Association of Dermatologists, Diplomas and Courses for General Practitioners. <http://www.bad.org.uk/healthcare-professionals/education/gps/ diplomas--courses-for-general-practitioners> 4. BCAM to implement exam for Full membership, Aesthetics journal. <https://aestheticsjournal.com/news/bcam-toimplement-exam-for-full-membership> 5. Harley Academy, Cosmetic Dermatology. <https://www. harleyacademy.com/training-courses/cosmetic-dermatology/> 6. Joint Council for Cosmetic Practitioners (JCCP) and Clinical Standards Authority. <https://www.bacn.org.uk/ documents/jccp/JointCouncilforCosmeticPractitionersJCCPCSAGenericPresentationV1.pdf>

Reproduced from Aesthetics | Volume 7/Issue 3 - February 2020


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