Aesthetics January 2018

w ! om no 18 e.c er 0 c st 2 ren gi CE fe Re A on r fo icsc t he st ae

VOLUME 5/ISSUE 2 - JANUARY 2018

OWN YOUR BEAUTY Let your patients show their emotions with confidence

Susanne, actual BeloteroÂŽ patient, 46

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

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

www.belotero.co.uk

M-BEL-UKI-0272 Date of Preparation December 2017

Botulinum Neurotoxin CPD MZ486 OYB FC Advert for AJ.indd 1

Dr Souphiyeh Samizadeh explores different botulinum toxin formulations

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Special Feature: Submental Area

Practitioners reveal their chosen methods for reducing submental fullness

Using Cryolipolysis

Mr Geoffrey Mullan details his technique for body contouring with cryolipolysis

18/12/2017 09:31 Utilising Your Awards Win

Emma Bracey-Wright advises on how to make the most out of winning an award

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Contents • January 2018 06 News The latest product and industry news 16 On the Scene

Out and about in the specialty this month

18 News Special: Banning Under-18 Injectables

Aesthetics investigates a new petition that calls for a ban on treating under-18s with injectables

20 ACE Preview: Expert Clinic

A look at the FREE Expert Clinic agenda at ACE 2018

22 Advertorial: Meet the Trainer with Dr Rikin Parekh

Learn about Avanti Aesthetics Academy on Harley Street from Dr Rikin Parekh

CLINICAL PRACTICE 25 Special Feature: Fat Reduction on the Chin

Practitioners discuss the treatment methods for the submental area

30 CPD: Botulinum Neurotoxin Formations

Dr Souphiyeh Samizadeh analyses the science and pharmacological differences of botulinum neurotoxin formulations

35 Treating Psoriasis

Dr Priya Patel assesses topical treatments available for psoriasis

41 Revolumising the Male Face

Dr Vincent Wong and Dr Pamela Benito provide a step-by-step guide for revolumising the male face with dermal filler

46 An Overview of Cellulite Treatment Options

Dr Bryan Mayou details different approaches for treating cellulite

48 Case Study: Dissolution of HA Filler in the Lower Eyelid

Dr Christine Cowpland shares a case study where she used hyaluronidase to remove filler in the lower eyelid

54 Case Study: Correcting Mid-facial Volume Loss

Nurse prescriber Victoria Parsons details her technique for correcting mid- face volume loss using HA dermal filler

57 Body Contouring Using Cryolipolysis

Mr Geoffrey Mullan presents a case study using cryolipolysis for body contouring

61 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 62 Utilising your Awards Win

PR consultant Emma Bracey-Wright highlights how to make the most of an award recognition

65 Introducing New Staff to Clinic

Surgery manager Sara Roberts provides tips on integrating new staff in clinic

68 The Role of an LPA

Special Feature: Fat Reduction on the Chin Page 25

Clinical Contributors Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in medical aesthetics. She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic.

Dr Priya Patel is a core medical trainee at East Surrey Hospital. She is an aspiring dermatologist, and takes an active interest in topics involving allergy and immunology.

Dr Vincent Wong is an advanced medical aesthetics practitioner and the founder of Harley Street clinic, La Maison de l’Esthétique. He is a fully qualified doctor with extensive research experience in plastic surgery and dermatology.

Dr Pamela Benito received her DDS degree at Madrid University in 2006 and practised general dentistry in the UK for two years while training in the field of facial aesthetics. Dr Benito also lectures and trains other practitioners.

Dr Bryan Mayou is a plastic surgeon and the founder of the Cadogan Clinic. He is renowned for his pioneering work in liposuction, having introduced it to the UK more than 30 years ago, Mr Mayou also specialises in face lifts and breast surgery.

Dr Christine Cowpland graduated from the University of Birmingham with a degree in medicine.

Dr Cowpland established CMedical Aesthetic Clinic in Bristol and has acted as a mentor and examiner at the Harley Academy in London.

Victoria Parsons is a registered nurse and an independent nurse prescriber. She has been qualified for 10 years and works solely in aesthetics.

She teaches foundation botulinum toxin and fillers with Cosmetic Courses.

Mr Geoffrey Mullan is a cosmetic surgeon and medical director at Medicetics Clinics and Training Academy. He has taught anatomy at Guy’s Hospital and has an advanced understanding of the deep structures of the face.

Laser protection advisor Rob Knowles explains the importance of his role

71 In Profile: Dr Ravi Jain

Dr Ravi Jain reflects on his career and details his love for body contouring

73 The Last Word

Cosmetic surgery specialist lawyer Michael Saul questions whether time- limited deals should be used in the aesthetic specialty

Register free for ACE 2018! www.aestheticsconference.com

NEXT MONTH • IN FOCUS: • Dermatology • Pigmentation during pregnancy • Acne management

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Editor’s letter What does everyone think about in January after the indulgences of the festive season?

Many of us make resolutions to become fitter and healthier. I’m sure there is an increase in online searches for gyms with good intentions – but how long does it last? Even if we find the gym Amanda Cameron we want and increase exercise levels, there are Editor still those unwanted, exercise-resistant areas of fat that just won’t go away! In fact this is a common concern for many patients and, in the past, liposuction was the only option. More recently, however, non-surgical alternatives have gained popularity because of their lack of downtime. This month we focus on fat loss and body contouring. We have some great articles for you, including a case study on cryolipolysis by Mr Geoff Mulan on p.57 and a fascinating piece on treating cellulite (p.46) by consultant plastic surgeon and one of the pioneers of liposuction in the UK, Mr Brian Mayou. Other case studies we have this month include a step-by-step guide to treating a male patient for volume loss by Dr Vincent Wong

on p.41, an overview of a cheek enhancement by nurse prescriber Victoria Parsons on p.54 and a discussion of using hyaluronidase to dissolve hyaluronic acid in the lower eyelid by Dr Christine Cowpland on p.48. Remember the Awards, way back in December?! The event may now seem like a distant memory, but hopefully a fond one. With more than 800 of you there, it was the biggest and best Aesthetics Awards yet! Many congratulations to all the Winners, those Highly Commended and Commended, as well as all Finalists. Open the Aesthetics Awards supplement that came with this issue for the highlights and read how to make the most of your recognition in PR consultant Emma Bracey-Wright’s article on p.62. Now, it’s time to get down to work for the Aesthetics Conference and Exhibition 2018. Read more about what’s in store at the Expert Clinic on p.20 and register for free now at www.aestheticsconference.com, so we can see you there on April 27 and 28! The team and I always welcome new contributions to the journal, so if you would like to see your name in print in 2018, email editorial@aestheticsjournal.com to find out more about the exciting opportunities available!

Editorial advisory board

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

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

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

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

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

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

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

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

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multiaward winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts. Dr Williams is also author of Amazon-No-1 Bestseller ‘Future Proof Your Skin’.

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

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

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

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

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

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

15th May 2018 British Association of Sclerotherapists 2018 Conference, Dorney www.bassclerotherapy.com

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Dentists

Dentists now accepted into BCAM The British College of Aesthetic Medicine (BCAM) has opened its doors to allow dentists to become members of its association. Since its inception in 2000, BCAM has only allowed aesthetic doctors to join its association to become associates or full members. However, according to BCAM, allowing dentists to join will be a huge benefit to the association, because it will widen its expert base and provide new and different experiences for members to learn from. Dentists who are new to aesthetics will enter through the new BCAM Academy, while those who can display previous experience will be assessed on a case-by-case basis and may enter as an associate. After two years, associates may then be considered to become a full member. BCAM president, Dr Paul Charlson said, “I am absolutely delighted that BCAM is now an organisation for doctors and dentists. I think it’s important to include dentists because they currently don’t have a body to represent them in aesthetics. Also, there is a huge number of dentists practising out there so it’s a good opportunity for them to really work with us and increase their skills and knowledge.” He continued, “From our point of view, as an organisation, it will strengthen our association, not just in terms of numbers but also in expertise. It gives us another way of looking at how we do things because dentists are a great asset to aesthetics.” BCAM is encouraging all new members to join them at the BCAM 2018 Conference, which will be held on September 22 at the Church House Conference Centre in Westminster, London.

Fillers

FDA approves Teoxane dermal fillers

Global aesthetic manufacturer Teoxane Laboratories has announced that the US Food and Drug Administration (FDA) has approved three of its dermal fillers. The RHA 2, RHA 3 and RHA 4 dermal fillers are now indicated by the Administration for the correction of moderate to severe dynamic facial wrinkles and folds in adults aged 22 years or older. Teoxane’s founder and CEO Valerie Taupin, said, “Since its inception in 2003, the foundations of the company have been based on integrated research and development. Today, we are delighted with the news of the FDA approval of RHA 2, RHA 3 and RHA 4 for sale in the US market.

This further reinforces our commitment to delivering science-based, high-quality HA dermal fillers to the global market.”

Training

Dalvi Humzah Aesthetic Training releases 2018 course dates Aesthetic training provider Dalvi Humzah Aesthetic Training (DHAT) has released course dates for the first half of 2018. The Beginner Cannula Masterclass will take place on January 12 at Wigmore Medical in London and the Facial Anatomy Teaching – Head & Neck course will be on January 24 at the University of Amsterdam. Other courses taking place at Wigmore Medical include: Complications Management Workshop on February 6, Intermediate & Advanced Cannula Masterclass on March 28, Upper Face Injectable Training on May 11, and Mid & Lower Face Injectable Training on June 29. The company has also welcomed two new assistant tutors, Dr Maryam Zamani and Dr Gibrani Eykyn, to work alongside their team. They will be involved in delivering the course content and developing the courses that are provided. Course lead Mr Dalvi Humzah said, “We are delighted to release our initial 2018 dates for the DHAT courses. Delegates will be able to choose from a wide portfolio of courses to enhance their personal and clinical development in the specialty of facial aesthetics. We will be expanding our courses through 2018 to include European venues and be providing a ‘mobile’ Complications Management Workshop at specially selected clinical centres throughout the UK.”

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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Partnerships

Med-fx announces new partners Aesthetic supplier Med-fx has partnered with three companies; aesthetic distributor BioActiveAesthetics, skincare manufacturer SWISSCODE and aesthetic medical supplier Medica Forte. Med-fx will be BioActiveAesthetics’ pharmacy-based supplier for its CEregistered SkinPen Microneedling device and will also be the supplier for The Pefect Peel from Medica Forte. In addition, Med-fx has become Pure Swiss Aesthetics’ exclusive partner for its SWISSCODE range. Chief executive at Pure Swiss Aesthetics, Teresa Da Graça, said, “We are thrilled that Med-fx is our exclusive partner for the SWISSCODE range. Med-fx is a leading UK distributor that shares the same core values with Pure Swiss Aesthetics, such as patient safety, product traceability, innovation as well as training and clinic support.”

She added, “We believe that Med-fx will provide the most efficient service for new and existing SWISSCODE customers. We have full trust in the Med-fx sales representatives, both of whom received acknowledgment at the recent Aesthetics Awards.”

Conference

The countdown to ACE 2018

With the start of the new year and the launch of even more sponsors and sessions, now is the time to register for the free Aesthetics Conference and Exhibition (ACE) 2018. ACE 2018 will bring together more than 2,000 medical aesthetic professionals, companies, manufacturers and suppliers, as well as expert speakers from around the UK and Europe. The agenda is beginning to fill up, with new sponsored sessions announced. Global pharmaceutical company Almirall, in conjunction with multi-platform technology company, Thermi, will be hosting a Masterclass. Beamwave Technologies will also be holding a Masterclass, while medical supplier Church Pharmacy will organise a session within the Expert Clinic agenda. Church Pharmacy will also be broadcasting interviews of their company key opinion leaders during the course of the exhibition, allowing for all to hear their latest tips and techniques. These interviews will also be sent to registered delegates following the event. Also announced is the lanyard sponsor, aesthetic supplier Med-fx. Dr Tapan Patel, who is a regular speaker at ACE and also attends as a delegate, said ACE is not to be missed, “ACE is the one congress I can think of that has a great balance between the trade and exhibition side and a very targeted medical education – I think it’s for practitioners of all experiences and it provides a very valuable learning opportunity.” ACE 2018 will take place on April 27-28 at the Business Design Centre, Islington. You can register free by going to www.aestheticsconference.com.

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Achievement Dr Nestor @DrNestorD Dr Nestor has been inducted as a full member of the British College of Aesthetic Medicine @BCAM01 #member #bcam #proud #Sclerotherapy Dr Joney De Souza @DrJoneyDeSouza Great day teaching other doctors yesterday, sclerotherapy treatment for leg thread veins @wigmoremedical #sclerotherapy #legs #Lecture Dr Uliana Gout @UlianaGout Thanks everyone for your wonderful feedback – loved lecturing and sharing personal tips on how to optimise skin health and discuss the latest paradigm on prevention medicine – in beautiful Russia – great hospitality! #martinex

#AestheticsAwards Profhilo @profhilo_uk HA-Derma team had a blast! Thank you @aestheticsgroup for an amazing evening #AestheticsAwards2017 #Clinic S-Thetics @MissBalaratnam Looking forward to our Saturday clinic today. Thank you @aestheticgroup, @AesthetiCareUK and to our gorgeous patient yesterday for our cards, flowers and for your kind wishes #Dermatology EADV @eadv Many thanks to Prof Richert, all speakers & participants for a lovely 2nd edition of the #EADV Resident course on #Cosmetic #Dermatology

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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Vital Statistics The top surgical procedure in the US, for both men and women in 2016 was liposuction, with 369,323 recorded procedures for women and 45,012 for men

(Grant Thornton, 2017)

In a survey of 618 men in the US, 44% revealed they would have facial cosmetic surgery to feel better about themselves (American Academy of Facial Plastic and Reconstructive Surgery, 2017)

A study by nail art company SensatioNail suggested that the average British woman’s make-up kit is worth £111 (SensatioNail, 2016)

Aesthetics aestheticsjournal.com

Plasma

Crystal Clear introduces The Plasma Lift Skincare company Crystal Clear has introduced its new laser device, The Plasma Lift. According to the company, the Crystal Clear Plasma Lift works by delivering millisecond pulses of plasma energy, which is produced through a combination of nitrogen gas and high frequency radio waves, to the skin via a handpiece.

The thermal energy then triggers the body to regenerate and produce more collagen to the damaged structural elements of the skin. The company states that the new treatment works both on and below the surface of the skin, aiming to improve fine lines and wrinkles, skin tone and texture, as well as pigmentation and acne.

(The American Society for Aesthetic Plastic Surgery, 2017)

A study has suggested that the sales value for vitamins, minerals and supplements in the UK is expected to hit £457 million by 2021

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Recruitment

SJ Partnership launches A new aesthetic sales optimisation and recruitment consultancy, SJ Partnership, has opened for business. The consultancy, led by industry commercial specialists Sue Thomson and Jean Johnston, aims to change the way the aesthetics specialty approaches recruitment, retention and development of its sales and marketing function. It hopes to deliver highcalibre strategic support and unique industry expertise, maximising the success of existing team members, as well as finding, recruiting and retaining new members. According to the consultancy, by connecting clients with the right people, or by upskilling existing teams with enhanced skillsets, they will be enabled to achieve their commercial goals.

Co-founder Sue Thomson said, “We created SJ Partnership in response to overwhelming demand from our contacts within the aesthetics industry, who are currently struggling to find and develop the right sales support to deliver against challenging business objectives.” She added, “By combining our wealth of expertise in the industry along with a highly personalised, efficient approach, we can offer a trusted, effective client service which will help both new and existing aesthetic businesses to achieve sales and growth targets in a faster and more cost-effective manner.”

Skincare

Melanoma in Caucasian women younger than 44 has increased by 6.1% annually in the US (American Academy of Dermatology, 2017)

According to customer engagement company Revoo, customer reviews produce an average 18% uplift in sales (Revoo, 2017)

Exuviance serum capsules released by AestheticSource UK distributor AestheticSource has launched the new AF 20% Vitamin C20 Serum Capsules by Exuviance in the UK. The new capsules contain 20% maximum strength vitamin C (l-ascorbic acid) and the company’s patented AminoFil, an amino acid (tyrosine) compound.

These ingredients aim to transform the skin by brightening the appearance of dark spots and leaving the skin feeling smooth, as well as creating plumper and firmer skin by volumising and reducing the appearance of deep wrinkles. The company also states that the capsules are free of oil and fragrances, and are non-irrigating, as well as non-comedogenic.

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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Fundraising

Healthxchange vow to raise £15k for Tumaini fund UK distributor Healthxchange Pharmacy has set up a fundraising page, aiming to raise £15,000 for The Tumaini Fund.

The fund, which was the Aesthetics Awards’ chosen charity for 2017, is a charity that supports HIV/AIDS widows and orphans in the Kagera region of Tanzania. At the Aesthetics Awards 2017 on December 2, £3,000 was raised, and Healthxchange are hoping to increase this to £15,000. Group chairmen Dr John Curran and Dr Robbie Hannah have also offered to match all donations £1 for £1 until the target is reached. Money raised will go towards building a dispensary and cottage hospital in Kagera. To donate, visit: uk.virginmoneygiving.com/healthxchange.

Body contouring

Juvea Medical first UK clinic to offer SculpSure submental treatment Juvea Medical on Harley Street has become the first clinic in the UK to offer the body contouring laser treatment SculpSure for the submental area. SculpSure is a non-invasive body contouring treatment which uses a laser to raise the temperature of body fat, aiming to disrupt and destroy fat cells under the skin. The fat cells are then said to be naturally eliminated over time. Each treatment lasts approximately 25 minutes and requires no surgery or downtime. “As we age and our metabolism slows down, the skin around our chin and neck area loses its elasticity – which can lead to sagging skin and an accumulation of stubborn fat,” said Mr Faizeen Zavahir, medical director at Juvea Medical. He added, “This is a problem for many patients who visit my clinic looking for a long-term and noninvasive solution.”

Appointment

Dermalux appoints new managing director Aesthetic Technology Ltd (ATL), manufacturers of Dermalux LED Phototherapy systems, has moved into a new, larger manufacturing plant as part of its development and expansion programme.

The site in Warrington, Cheshire also includes new offices and training facilities, bringing the operational, production and warehousing under one roof. Additionally, according to the company, the new facility will allow customers to visit and see how the Dermalux systems are manufactured.

The move coincides with the recent appointment of Dale Needham as the new managing director for ATL. Dale brings over ten years of knowledge and experience in the LED sector, including next generation materials and technologies. According to ATL, his appointment will lead the company forward into the next stage development from a business, technology and regulatory perspective. Of his new appointment, Needham said, “I am delighted to have joined ATL in this capacity and look forward to exciting times ahead for the expansion of the business. The move is part of a longterm strategy with ground-breaking developments planned in the future.”

27 & 28 APR 2018 / LONDON

COUNTDOWN TO ACE 2018 BUSINESS TRACK The Business Track at ACE 2018, sponsored by Enhance Insurance, will host 18 CPD-verified sessions, providing you with vital commercial skills to grow your clinic’s revenue, improve patient retention and stand out from the competition.

No matter what your level of experience, sessions are designed to suit all delegates working in different areas of the specialty. The Business Track will cover areas including: PR, marketing, VAT, insurance, training, business growth, regulation and patient experience, among others. Upon registration, entry is free and you can gain 0.5 CPD points for each session attended.

SPEAKER INSIGHT Dr Tristan Mehta will speak on the future of regulation at the Business Track, providing an update on the Joint Council for Cosmetic Practitioners (JCCP) and advising how to future-proof your training. He says, “Attending ACE, and most definitely the Business Track, can improve the growth of your career and practice a huge amount, as it will offer the chance to ask questions to speakers, create relationships with other aesthetic professionals, and ultimately build your brand. It’s important to think of new ways you can expand your business, and whether you want to learn about industry developments, patient satisfaction, or how to utilise different business service; there’s something for everyone at ACE. I recommend practitioners across the country to attend these sessions to improve the success of their business.”

WHAT DELEGATES SAY “The sessions were very informative and all speakers were willing to answer any questions!”

AESTHETIC DOCTOR, LONDON “ACE presents the perfect opportunity to update our clinical and business knowledge, as well as learn about important regulation, revalidation and consent updates for the year ahead.”

AESTHETIC NURSE, NORTH ENGLAND ACE HEADLINE SPONSOR

BUSINESS TRACK SPONSOR

Enhance Insurance

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Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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Law workshop

La Belle Forme to run Dissection of a Lawsuit training course

Environ introduces handheld skincare device Global skincare brand Environ has introduced the new Focus Care Skin Tech+ Electro-Sonic DF Mobile Skincare Device to its product portfolio.

According to the company, the handheld device, which patients can use at home, is designed to make a lasting difference to the skin’s overall appearance with its dual electro-sonic technology.

This technology aims to stimulate the skin, creating tiny cavitations through low frequency sonophoresis (sound waves) to deliver essential nutrients to the skin, by ionising active molecules and diffusing them into the skin through pulsed iontophoresis (electric current).

The device targets frown lines on the forehead, smile lines, wrinkles around the eyes and upper lip lines, hyperpigmentation from sun damage, as well as submental fullness and minor scars.

Founder and scientific director of Environ, Dr Des Fernandes, said, “As part of my personal mission to future-proof skin around the globe, I wanted people to be able to harness the power of Environ’s DF Technology from the comfort of their home.” Environ skin products are available through UK distributor, the International Institute for Anti-Ageing (iiaa).

What are the major factors that have contributed towards the enormous success of the 3D-lipo brand?

There are several key factors to our successful growth. Firstly, as a brand and as a device we are fundamentally different.

When I designed our first device, and created the branding, I never wanted to follow a single technology route as the market required change and I had no desire to go head-to-head with other equipment manufacturers. From the beginning I strove to develop a machine that contained several technologies which would enable clinics to target multiple indications and deliver the best patient outcomes for fat removal, skin tightening and the treatment of cellulite. The results have always been the foundation of the company’s success. However, the sparkle of our national PR campaign was the key. This has promoted our brand’s USP, which has ensured that our unique treatment is the most sought after body treatment in the UK and offers a significant benefit directly to our clients’ businesses.

Do you have anything new launching to the market anytime soon?

We have three key launches scheduled for 2018, based in the arena of lasers. Watch this space as the first adverts and announcements will be hitting trade publications in February.

Apart from product launches, what new developments are expected from 3D-lipo in 2018?

At 3D-lipo, we pride ourselves on our customer service, ensuring that our clinics make money from day one. In the industry, we are known for providing unprecedented PR support and, in 2018, we are taking it one huge step further by introducing the industry’s first complete business support campaign of its kind. We are investing more than £1 million in national newspaper and TV advertising alone as part of this support package, placing the 3D-lipo brand in front of nine million consumers each month, using controlled advertising to reach a measured level of consumers with one aim – to drive customers directly through our clients’ clinic doors.

This column is written and supported by duction Fat Re

Skincare device

Roy Cowley, managing director of 3D-lipo

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La Belle Forme clinic is set to launch its new training course entitled ‘Dissection of a Lawsuit’ in Glasgow on February 19. The course, developed by specialist consultant plastic surgeon Mr Taimur Shoaib and managing director of aesthetic business consultancy Cobalt-Panacea Associates, Sue Thomson, aims to improve patient and clinic outcomes in terms of medical negligence. The workshop will aim to advise delegates on the challenges of potential litigation within the aesthetics industry, providing real case study examples, to help prevent and best prepare practitioners for potential medical negligence claims in the future. The company states that the ‘Dissection of a Lawsuit’ course will review current legal and insurance statistics, whilst discussing considerations when working not only with the patient, but the wider clinic team. Delegates will hear from a variety of experienced medical speakers including Dr Cormac Convery of the Aesthetics Complications Expert (ACE) Group, general secretary of the Association of Laser Safety Professionals, Mike Murphy, as well as Mr Shoaib, among others.

Mr Shoaib said, “One thing we all fear is receiving a lawyer’s letter telling us a patient is pursuing a claim against us. In this course, we will discuss how to recognise and manage complications, and will be going through real-life examples of successful and unsuccessful claims for negligent treatment.” He added, “This course would benefit every practitioner and manager that works in the specialty of medical aesthetics and we’re very excited about bringing something totally new to our friends and colleagues from all over Britain.”

No other system offers this advanced combination of technologies designed to target fat removal, cellulite and skin tightening without the need to exercise

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• A complete approach to the problem • Prescriptive • Multi-functional • Inch loss • Contouring • Cellulite • Face and Body skin tightening • Highly profitable • No exercise required

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018 Complete start up and support package available from under

Cavitation is a natural phenomenon based on low frequency ultrasound. The Ultrasound produces a strong wave of pressure to fat cell membranes. A fat cell membrane cannot withstand this pressure and therefore disintegrates into a liquid state. The result is natural, permanent fat loss.

Cryolipolysis Using the unique combination of electro and cryo therapy 20-40% of the fat cells in the treated area die in a natural way and dissolve over the course of several months.

Radio Frequency Skin Tightening Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable

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Device

Baldan Group launches HydraLift FX Italian aesthetic distributor and manufacturer Baldan Group has released a new deep cleansing device. The HydraLift FX combines three different handpieces to give a water-based peel, transdermal delivery of cosmetic ingredients and microdermabrasion.

The Infuser handpiece gives a water-based peel containing mandelic, salicylic and hyaluronic acid, which the company claims allows for deep cleansing of the face and a longlasting, moisturising effect. The Mesoporation handpiece aims to make treatment more effective through the transdermal delivery of active substances. It is said by the company to allow the practitioner to restructure the patient’s skin from within, using hyaluronic acid and the Baldan Group’s skincare range, Dermakléb serums. The third handpiece, the DiamondGrain, uses the properties of diamond grains to exfoliate and rejuvenate skin, to treat stretch marks, acne scarring and thickened skin. This handpiece has nine different heads to treat critical areas such as the T-Zone. Together, the three technologies aim to cleanse, moisturise and rejuvenate.

Skincare

NeoStrata releases new serum Skincare company NeoStrata has added the Skin Active Tri-Therapy Lifting Serum to its product portfolio. Among the active ingredients are AminoFil, a tyrosine amino acid derivative, as well as gluconolactone and hyaluronic acid, which, NeoStrata claims, work together to improve skin tone, laxity and texture.

Dermatologist Dr Patricia Farris, who has been using the product, said, “Skin Active Tri-Therapy Lifting Serum with AminoFil represents a cosmeceutical paradigm shift with a novel molecule designed as a treatment for sagging skin, fine lines and wrinkles.

Studies show that patients see visible lifting and firming in difficult to treat areas with continued use of this product as part of their daily homecare”. NeoStrata is distributed in the UK exclusively through AestheticSource.

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

LAUNCH OF THE BACN SHADOWING PROGRAMME Our first Shadowing Project took place in November 2017. Feedback from our host clinic/mentor and our first participant was positive! This programme, put together

by Jane Laferla, the regional leader for Wales and the South West, and her team, will really take off in 2018.

We now have more than 15 Shadowing Clinics on our register and are looking for more. Pease contact Gareth Lewis to sign up to be both a host clinic and to participate – glewis@bacn.org.uk

BACN START UP PROGRAMME This new programme will be launched early in 2018 and led by BACN partners. It is aimed at practitioners who are new to the aesthetic specialty and will comprise three one-day modules: 1. Basic introduction to aesthetics 2. Aesthetics as a business 3. Case study from a BACN practitioner The details of the Start Up Programme are currently being developed and will be revealed by the BACN later in the year.

BACN REGIONAL LEADER CONFERENCE, JANUARY 2018 We will be holding a meeting of the BACN regional leaders on 22nd January in London to discuss the following: 1. Role of regional leaders 2. Role of regional meetings 3. Best practice in the regions 4. Communication with the regions 5. New ideas Please feel free to contact us prior to the meeting if you have anything you’d like us to discuss. The regions are a critical and important part of the Association and we are looking to build on the excellent activity that took place in 2017.

NEW ACTIVITIES FOR 2018

Industry

Dr Tijion Esho announced as KOL for Naturastudios Medical aesthetic supplier Naturastudios has confirmed aesthetic practitioner Dr Tijion Esho as its new key opinion leader for the Dermapen microneedling device. According to the company, Dr Esho is an award-winning doctor and is the founder of the ESHO Clinics in London and Newcastle. He is also the resident doctor on E4 reality TV show, Body Fixers. The company states that Dr Esho was chosen for his expertise in non-surgical aesthetic medicine and will help educate practitioners on effective, non-invasive procedures. Dr Esho said, “Microneedling has played a crucial part of my skin rejuvenation protocols at the ESHO Clinic, so I have seen and used many devices currently on the market. Out of these, the Dermapen stood out as one of the best, not just in its sleek design but ultimately its superior function. I’m truly humbled and excited by this project and my focus will be on development of new technology, teaching and developing new protocols.”

Look out for the following activities planned for 2018: • Presentation skills for nurses • Cadaver training for nurses – beginner and advanced programmes • BACN nurses – case studies • Using machines in your clinic

BACN HQ The BACN is looking to upgrade its website in 2018 and introduce a new CRM system to improve services to members. Watch this space!

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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Training

Advanced practitioners invited to Ellansé training workshops Pharmaceutical company Sinclair Pharma is to run advanced-level Ellansé collagen stimulating dermal filler training workshops for experienced hyaluronic acid injectors.

Training will be delivered by a globally-accredited Sinclair Pharma trainer throughout 2018 at Wigmore Medical in London. The day-long workshops will provide delegates with a solid foundation in the use of Ellansé to achieve full face rejuvenation. They will first observe a live demonstration of the procedure by one of Sinclair’s trainers, which will showcase the latest and most effective techniques. They will then actively participate themselves. On completion of the course, delegates will be able to determine indications between the ideal and non-ideal patient, where to use needle vs cannula, how to manage postoperative care, and how to use Ellansé in conjunction with other aesthetic treatments. The course dates are as follows: January 15, February 28, March 12, May 8, June 18, July 2, September 5, October 3 and 23, and November 19.

Dermatology

Black Skin Directory to launch in February A new online resource for patients with skin of colour is launching in February, aiming to connect patients to skincare professionals specialising in their particular skin type. The website was created by aesthetician Dija Ayodele, who claims that she has heard many patients reporting that they had been turned away from treatment because the clinic ‘doesn’t treat black skin’. In a survey conducted by Ayodele in Spring 2017, out of 125 women of colour who have attempted to find a skincare professional, 92% said they found it challenging, very difficult or they have never been able to find a professional. Ayodele has since created the Black Skin Directory, which she calls ‘the first of its kind directory’ that women of colour can use to locate skincare professionals who are experienced in treating darker skin tones. Consultant dermatologist Dr Sandeep Cliff said of the idea, “The Black Skin Directory at last gives the patient some guidance and confidence in knowing that they will be seeing someone with both expertise and knowledge – I would strongly recommend it and wish it every success.” To be listed on the directory, practitioners must visit the Black Skin Directory website and choose either a monthly or annual plan.

KOL

Dr Maryam Zamani chosen as KOL for BioActiveAesthetics Aesthetic distributor BioActiveAesthetics has named oculoplastic surgeon and aesthetic practitioner Dr Maryam Zamani as its new key opinion leader for the SkinPen Precision device. The SkinPen Precision is a CE registered mechanical medical microneedling device, which is designed and engineered by US manufacturer Bellus Medical. According to the company, it has recently changed the way the cartridge attaches to the pen, which now has ‘ingress protection’, providing risk free procedures including PRP. The company states that, Dr Zamani has used many microneedling pens over the years and is particularly interested in the SkinPen Precision design because, according to the company, it addresses the cross-contamination issues that the FDA raised with all microneedling pens in the USA in 2015. As part of her role, Dr Zamani will be helping to raise awareness of the prevention of cross-contamination with mechanical needling devices to patients and practitioners within the aesthetics specialty.

Aesthetics aestheticsjournal.com

News in Brief BAS announces free ticket for conference competition The British Association of Sclerotherapists (BAS) is giving practitioners the opportunity to win a free ticket to its 2018 conference.

The conference, which will be held on May 15 at the Dorney Lake Conference Centre, aims to help educate practitioners offering microsclerotherapy or foam treatments.

To enter the competition, practitioners must go to the BAS website and answer the following question by March 15: which international sporting event is the BAS 2018 conference venue most famous for?

Wimpole Street Dental launches new website Dental and non-surgical aesthetic clinic Wimpole Street Dental has upgraded its website to increase engagement and entice new patients. According to dentist and owner Dr Richard Marques, the website revamp, which was arranged by design and marketing agency Top Left Design has already allowed for many new referrals.

Dr Marques said, “Before engaging in any kind of marketing activity, we had a very basic website. As a cosmetic dentist, an aesthetically pleasing website is absolutely key to bringing in new clients.”

Bristol-based Déjà Vu Training Academy to relocate Déjà Vu Aesthetic Training Academy will be relocating due to the company’s expansion. The training academy has been established for three years and is founded by clinical director and aesthetic nurse Rita Ogden and business director Jane Blakey.

The academy will stay in the same region of Bristol but will move to historic Clifton venue, Engineers’ House.

Antiageing carbohydrate blocker launches in aesthetic market Research and development company Marmar Investment has launched Tribitor 3-phase carbohydrate blockers into the aesthetics market. Tribitor is dissolved in a glass of water and taken 15 minutes before the consumption of high GI foods such as bread, sweets, rice, pasta and fizzy drinks and aims to inhibit both digestion and absorption of carbohydrates.

Endocrinology and diabetes specialist Dr Theodora Mantzourani said, “By reducing simple sugars in the diet and having a lowglycaemic diet, it can help to slow down the ageing process in our skin, as well as other organs.”

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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Industry

3D-Lipo releases national advertising campaign Aesthetic device manufacturer 3D-Lipo is launching a nationwide newspaper and television advertising campaign as part of its business support programme for both the existing 900 clinics and new clients of the company. £1 million is being invested into the advertising campaign, which aims to drive more patients into clinics that use 3D-Lipo devices.

The business support programme also includes monthly consumable allowances, training and technical support, as well as over the phone business and marketing advice.

Managing director of 3D-Lipo, Roy Cowley, said, “This campaign will present an unprecedented level of support for clinics on a whole new level by providing a significant investment into the industry, using controlled advertising to reach a measured level of consumers. The campaign will directly filter the interest and demand for treatments, where patients can also use a dedicated clinic finder, leading business for clinics selling 3D-Lipo devices nationwide.”

Product launch

endoSPHÈRES to launch new treatment at EF MEDISPA endoSPHÈRES Therapy will be launching for the first time in the UK at EF MEDISPA’s Richmond clinic. The treatment, from Italian manufacturer Fenix Group, is a non-invasive lymphatic drainage treatment and aims to simulate the body’s natural mechanisms to break down, remove and re-shape fat and adipose tissues, whilst also stimulating elastin and collagen production. EF MEDISPA, founded by Esther Fieldgrass, launched almost ten years ago and, according to the clinic, offers a range of aesthetic treatments for anti-ageing therapies, preventative health and aims to provide the latest in cosmetic procedures. UK brand manager of endoSPHÈRES, Chantal Merighi, said, “EF MEDISPA have an incredible reputation in the industry and we are delighted that they will be using endoSPHÈRES. We feel the therapy aligns perfectly with their approach of complete treatment for the face and body. We look forward to working with Esther and her team by bringing the therapy to their exclusive clientele.”

Institute Hyalual appoints new staff Aesthetic product developer Institute Hyalual has filled two roles within its UK business. Katie Bennett has been promoted from her role in sales and marketing, to head of marketing and PR. Bennett has been working for Hyalual since April 2016, but due to recent growth and the launch of the WOW facial, she has acquired a fulltime marketing position.

Bennett is responsible for marketing Hyalual’s entire portfolio and will work on social media campaigns to create strong brand awareness to drive the end consumer to products, campaigns and events.

The company has also welcomed Samantha Phillips to the sales team. Phillips is said, by the company, to come with a wealth of knowledge in aesthetics and her sole focus will be to drive sales within the Greater London territory.

Phillips will be selling across the Hyalual portfolio, including the WOW facial and Rederm.

Claire Williams, UK sales director for Institute Hyalual said, “I am delighted to be able to move Katie into a full-time marketing role as this is where her strengths truly lie. She has a great creative edge and her knowledge of marketing via multiple social media platforms is impressive. Her hard work and dedication to the brand is very apparent and she deserves her new position.” She continued, “I am also delighted to welcome Samantha to the team – her knowledge of customers and aesthetics is well documented as she has been in aesthetics for over 20 years.”

Threads

MAG launches new V Soft PDO Arte thread A new V Soft Lift PDO thread will soon be available through UK aesthetic product supplier Medical Aesthetic Group (MAG).

According to MAG, the Arte thread is a strong PDO lifting thread with press sculpted barbs, a diameter almost double the size of the thread and a thin layer of medical silicone lubrication with a diamond polished tip. MAG states that the Arte thread has been specially designed for use when a strong lifting power is needed.

Aesthetic practitioner Dr Elisabeth Dancey said of the range, “V Soft has revolutionised my practice. The V Soft lifts the face, creates new volume and improves skin quality. No other treatment does so much for the patient, lasts so long and is such a pleasure to perform.” Practitioners can learn more about the new thread, as well as others within the V Soft Lift range at a training session with Dr Martyn King and Dr Hassan Soueid on February 11 at the Royal Society of Medicine.

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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On the Scene

Out and about in the aesthetic specialty

The Aesthetics Awards 2017, London On December 2, aesthetic practitioners, clinics, product manufacturers, distributors and training companies joined together to attend the most prestigious awards ceremony in the specialty, the Aesthetics Awards 2017. Taking place at the Park Plaza Westminster Bridge Hotel in central London, the event, which recognises the very best in aesthetics, was bigger and better than before, seating a record 800 guests, in comparison to 624 guests in 2016. Guests were greeted with a glamorous drinks reception, which was followed by a delicious three-course meal and a comedy set by international stand-up performer, Stewart Francis, who is known for featuring on TV programmes including panel show, Mock the Week. Following a welcome speech from the editor of Aesthetics, Amanda Cameron, Winners, Highly Commended and Commended Finalists were recognised. Expressing his delight after winning The Med-fx Award for Best Clinic North, Dr Miguel Montero said, “It is fantastic to win the Award, it means a lot to me personally, and to my team, that all these years of hard work have been recognised by our colleagues. This award motivates us to work even harder to keep offering the highest standards of patient care in the years to come.”

The 2017 Winner of the SkinCeuticals Award for Medical Practitioner of the Year was Dr Beatriz Molina, who was praised for her work to improve the specialty as whole, in addition to running a successful clinic. She said, “I never expected to win as there was such strong competition and everyone is so good. It’s so important to raise the standards in the industry, as aesthetics is a highly specialised area.

I’m thrilled to win.” Taking home the final award of the night, The Schuco Award for Outstanding Achievement, was laser specialist Dr Elizabeth Raymond Brown, who was acknowledged for her dedication to the specialty through her teaching, speaking and

writing. She said, “It’s a fantastic honour to be recognised. I think the Aesthetics Awards is about showing that it’s a serious specialism and, at a time where we haven’t got a whole lot of regulation, it’s important to come together and show that patients should be at the heart of what we do. If I have helped in any way to raise standards and highlight the importance of training and education, then that’s a fantastic thing.” David Gower, director of Medical Aesthetic Group and Aesthetics Awards category sponsor, said, “I love being at the Aesthetics Awards, events like this bring the specialty together.

Practitioners are here, suppliers are here, it’s such a magical atmosphere!” To read more about the highlights of the event, and to view the full list of Winners, Highly Commended and Commended Finalists, read the Aesthetics Awards supplement that arrived with this issue, or visit www.aestheticsawards.com.

The Aesthetics Awards 2018 will take place on Saturday December 1 at the Park Plaza Westminster Bridge Hotel. Entry will be open from May 1 until June 29, and the 2018 Finalists will be announced in September. After this year’s quick sell-out, tickets are already available for 2018. Contact support@aestheticsjournal.com to secure your prime positioning.

Lumenis 2018 Trends in Aesthetics, London

Aesthetic device company Lumenis invited medical aesthetic practitioners to The Royal College of Physicians on December 4 for its 2018 Trends in Aesthetics event.

The agenda began with talks on efficacy and complications in laser hair removal on Asian Skin by Lumenis trainer and founder of MBA Clinics, Petrina Nugawela, which was followed by a presentation on non-invasive body contouring by Dr Imtiaz Yusuf, who discussed

a four-dimensional approach for fat cell destruction. This was followed by a business presentation by Nugawela, who explained how delegates can expand their practice using advanced laser technologies, and a clinical talk by Dr Benji Dhillon on the current and future applications for ablative and nonablative devices. Linda Blahr, the education and science manager from SkinCeuticals, discussed how practitioners can combine skincare with laser treatments, while laser specialist for Lumenis, Kevin Williams, explained how the company can provide support to its clients.

The event was drawn to a close after health and beauty journalist Samantha Freedman discussed consumer trends to do with lasers and devices. “I thought the event went very well, with excellent feedback from participants and several orders from new and existing

clinics. I hope practitioners and clinic owners understood the opportunities that our company, products and support offers them to expand their clinic for 2018,” Williams said following the event. He added, “The highlights included the lectures by Petrina from MBA clinics and Benji from PHI Clinic. Petrina was not only knowledgeable on treating darker skin types but also shared her very successful clinic expansion programme, all on the back of good equipment from Lumenis.

Benji presented the new and exciting photo fractional technique or the ‘Hollywood facial’, as it’s referred to in the USA.” Nugawela added, “As one of Lumenis’ international trainers, I think holding these kinds of events is very important. It is an excellent way to stay up to date with the industry a great way to support people new to the specialty, helping them get off to the best start possible.”

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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high number of non-medics who will treat patients under the age of 18, without carrying out a full consultation and assessment of their suitability for the procedure.” He adds, “Consultation is absolutely essential to look for red flags which may indicate underlying BDD. Due to the lack of regulation in the industry, it concerns me that people of all ages, particularly those under 18 who are young and impressionable, may not be being educated in the right way or given the correct care.”

Banning Under-18 Injectables Aesthetics examines the premise behind a new petition calling for a ban on botulinum toxin and dermal filler treatments to those under 18 On November 17, 2017, a petition was submitted to the UK Government and Parliament that seeks to ‘stop Botox [sic] and dermal fillers on minors by making it illegal for those under 18’.1 The person responsible for creating the petition is aesthetic practitioner Dr Tijion Esho, of The ESHO Clinics in London and Newcastle, who states in the petition: ‘Cosmetic doctors, nurses, dentists and surgeons have been calling for tougher regulations for injectables. In the UK, it’s almost entirely unregulated with no minimum age for those seeking out Botox [sic] or dermal fillers. Without enforcement of any laws there has been an increase in botched treatments, some of which have been very dangerous, leaving the vulnerable millennial generation at most risk’.1 Although Dr Esho and many other aesthetic practitioners believe that the banning of botulinum toxin and dermal fillers for those under 18 would have a positive outcome, there is debate on the suggestion among the medical aesthetic community.

What is the concern?

“There are a number of things that concern me in relation to people under the age of 18 seeking aesthetic treatments,” explains Dr Esho. “From an anatomical point of view, there’s evidence to support the fact that the face is still developing at this stage of life.2 Although non-surgical, these treatments are still medical and carry significant risks,” he adds. Nurse prescriber Claudia McGloin,

who has been active in presenting her views on this topic over social media, agrees with Dr Esho, and adds that in her experience, younger patients are more prone to seeking cosmetic treatment due to the impact of young celebrity influencers such as Kylie Jenner. She explains, “Under-18s really don’t need these treatments and we are seeing that more and more young girls want to imitate celebrities. We also have the concern of body dysmorphic disorder (BDD). I think any age group could have BDD, but I’ve seen it a lot more in teenagers who have been looking at the unrealistic ideals shown in magazines, TV and social media. They think that having an injectable procedure is more of a ‘beauty treatment’ than a cosmetic medical procedure.” A report released in June last year by The Nuffield Council on Bioethics, which was reported on in the August issue of Aesthetics, highlighted the impact of pressure from social media and advertising on the psychological wellbeing of young patients. It mentioned that young patients are at a high risk of feeling anxious over unachievable appearance ideals, which may prompt them to seek cosmetic treatments at a young age.3,4 It states, ‘We suggest that there are strong justifications for limiting access to cosmetic procedures to people over the age of 18, other than in exceptional cases’. A particular concern of Dr Esho’s is his belief that many practitioners, who are treating patients under the age of 18, are not medically trained. He explains, “I am aware that there is an increasingly

Is this a proposed ‘blanket ban’?

Plastic reconstructive and aesthetic surgeon Ms Éilís Fitzgerald, who is passionate about pushing for tighter regulation in Ireland, explains that when she first read the petition she was concerned that it was proposing a ‘blanket ban’. “I think putting a blanket ban on under 18s having treatments is just too simple, because botulinum toxin and dermal fillers have a place in the medical treatment of those under 18, in particular for the treatment of patients with strabismus, cerebral palsy, brachial plexus injuries, as well as those who need reconstructive work.

A ban could have quite a significant knockon effect to these patients and limit their access to these treatments.”

However, Dr Esho explains that his petition has been created to fundamentally drive awareness around the ‘cosmetic’ treatment of under-18s, rather than the ‘medical’. He instead hopes that, in a specialty where there are no legal minimum training requirements, a ban on procedures for under 18s that are not deemed as ‘medical’ will prevent nonmedics from injecting this age group.

“It is not illegal for non-medics to administer these treatments to those under 18, which is putting young people in danger of adverse reactions. I would like to see action by the government – I would like to see a formal law put in place rather than just guidance.

The introduction of a legal age limit for nonsurgical cosmetic treatments needs to be the first step for other changes to follow and to protect the public,” Dr Esho says.

Although McGloin is in favour of the petition, she acknowledges that it is not entirely clear that it is not a ‘blanket ban’. “I know some colleagues have said that the wording of this petition is a bit of an issue. I think maybe the wording needs to be slightly amended so that we can say that treatment should be decided upon on a case-by-case basis. This would be with regards to certain conditions, which experienced medical practitioners can treat – what we are basically saying is

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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we don’t agree with injecting under 18s for cosmetic treatments, as opposed to medical conditions.”

Will a ban solve the issue?

Ms Fitzgerald believes that a ban of any kind won’t solve the issue of non-medically trained practitioners, or those who lack specialist training, injecting patients under 18 and may actually do more harm than good.

She explains, “I understand where Dr Esho is coming from and I completely agree that the cosmetic use of botulinum toxin and fillers for patients under 18 is crazy. The problem is not with the product; you have to regulate who’s using the product. If you are a practitioner who is properly trained, you are not going to be doing cosmetic procedures on people under 18 as you’d know better. It comes down to just regulating the practitioners; all medical practitioners should be properly trained and regulated and I do not believe anyone without medical training should be permitted to do these procedures.” Ms Fitzgerald says that in the long run, a ban could result in other issues, “What if we discover new indications for these products

Aesthetics Journal

Aesthetics

for under-18s? What do we do with the ban then?” Conversely, McGloin says, “I think it’s a really good idea and it’s certainly a start.”

McGloin adds, “I think myself and many of my colleagues are seeing a lot of underage patients being treated with toxin and fillers so I think Dr Esho is on the right track. It’s highlighting the potential dangers and complications in the aesthetics field.”

In the meantime…

Dr Esho is currently promoting his petition via social media and has received some media news coverage from a letter he wrote in November to the Secretary of State for Health, Jeremy Hunt, as part of his campaign.5 As well as proposing a minimum age for all non-surgical cosmetic procedures, the letter also requested to only allow medical professionals to carry out these types of procedures. There has not yet been a response to this letter. The petition will run until May 17, 2018, and, at the time of publishing this article, it has received 256 signatures. If it were to reach 10,000 signatures by the cut-off date, the UK Government must respond and, at 100,000

signatures, the contents of the petition will be considered for debate in parliament.6 Dr Esho concludes, “It’s part of the whole picture to the solution which I don’t assume is an easy one. I am determined to make a difference and make this a government issue that is addressed by our MPs and key decision makers.”

REFERENCES 1. UK Government and Parliament, Stop Botox & Dermal fillers on minors by making it illegal for those under 18, 2017, <https:// petition.parliament.uk/petitions/205043> 2. Manavpreet Kaur, Rakesh K.Garg, Sanjeev Singla, Analysis of facial soft tissue changes with aging and their effects on facial morphology: A forensic perspective, Volume 5, Issue 2, June 2015, P 46-56.

3. Nuffield Council on Bioethics, Cosmetic procedures: ethical issues, (June 2017) http://nuffieldbioethics.org/wp-content/ uploads/Cosmetic-procedures-full-report.pdf 4. Kat Cooke, Social Media and Appearance Anxiety, Aesthetics, August 2017. <https://aestheticsjournal.com/feature/socialmedia-and-appearance-anxiety> 5. Victoria Hall, ‘Why this doctor is calling for Jeremy Hunt to change cosmetic procedure regulations’, November 8 2017, The Telegraph. <http://www.telegraph.co.uk/beauty/skin/ doctor-calling-jeremy-hunt-change-cosmetic-procedureregulations/> 6. UK Government and Parliament, How petitions work, 2017, <https://petition.parliament.uk/help>

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The second session will focus on volume replacement in the ageing face, led by internationally renowned aesthetic expert and KOL Dr Wolfgang Redka-Swoboda. He will share his top tips on how to achieve fantastic results by using sculpting techniques and will also provide delegates with a demonstration, so you can see his techniques first-hand using the Teosyal Pen and Teosyal RHA 4/Ultra-Deep. Rounding off the trio of injectable teaching sessions is internationally renowned expert Dr Kieren Bong, who will present his approach for effective correction of the under eye. Dr Bong will discuss the fundamental aspects to explore when approaching a tear trough treatment, including the ageing process and anatomical considerations, whilst showcasing his unique technique, the ‘Two Point Eye Lift’, using Teosyal Redensity 2.

New approach to peels Trichloroacetic acid (TCA) peels are a popular treatment to repair and rejuvenate damaged and aged skin, and, at this session with UK skincare distributor UniqueSkin, you can learn how to utilise brand new peel formations. TCA peels traditionally have a reputation of being uncomfortable for the patient, but consultant dermatologist Dr Jean-Luc Vigneron will demonstrate how to use TCA peels of high strength, that can be pain-free and produce greater results for the patient.

Learn invaluable aesthetic skills and watch step-by-step procedures at ACE 2018 The excellence of an aesthetic clinic very much depends on the calibre of practitioners who practise in it. Although you may already have had a first-rate education, been awarded valuable qualifications and attended in-depth training courses, earnest practitioners will know how vital it is to keep learning. In a specialty such as aesthetics, which is extremely fast-moving and continually evolving, it is especially important to keep yourself up-to-date with the latest innovations, treatments and techniques.

At the Aesthetics Conference and Exhibition (ACE) 2018 on April 27 and 28, you can spend two full days updating that vital knowledge and learning about the newest treatments, to keep up with your competitors and ensure best practice. There will be 17 sessions, open to all delegates, within the Expert Clinic taking place at the Business Design Centre, London, led by some of the UK’s most knowledgeable practitioners. Each 30-minute session is worth 0.5 CPD points and will include in-depth analysis, live demonstrations and practical advice. Here’s just some of what you will learn, with more to be announced soon:

Volumising and lifting Global manufacturer Teoxane UK will be hosting three sessions in total, providing delegates with expert advice and demonstrations on their range of injectables. Aesthetic facial specialist Dr Lee Walker will offer expert advice for treating the lips in the session Safe and Predictable Lip Augmentation. He will present the anatomical considerations to be aware of, while sharing new techniques and tools to augment safely and successfully, before conducting a live demonstration, using the Teosyal Pen and Teosyal RHA 2 or 3.

Slimming the face Learn how to help your patients achieve a slimmer, more defined face using the injectable biorevitalisation RRS range of products at the AestheticSource session. Led by Dr Jane Ranneva, dermatologist and specialist in rehabilitative and reconstructive medicine, the session will provide an overview on how you can offer patients supreme biorevitalisation treatments that are highly effective and safe to use for the face and body. AestheticSource will also hold a second session at ACE 2018, with details to be announced soon.

Skin resurfacing Injectables may be the mainstay of many aesthetic clinics, but every practice benefits from offering a range of treatment options, such as devices for skin resurfacing. Aesthetic technology company Cutera Medical will hold an Expert Clinic on the PICO Genesis, led by Dr Sach Mohan. This two-in-one aesthetic laser aims to treat pigmentation, skin tone, sun spots and more.

Tightening skin Sagging and loose skin is a real concern for patients, so skincare and device manufacturer AesthetiCare will educate delegates on the ENDYMED radiofrequency system and its fractional treatments. The session will explain the device’s flexibility to treat key skin rejuvenation indications, as well as body contouring and tightening treatments.

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

And so much more…

With more exciting details to be announced, you can expect to also gain expert advice and guidance from the following companies: Medical supplier Church Pharmacy Laser developer and manufacturer Cynosure Aesthetic distributor HA-Derma Medical device company NeedleConcept Aesthetic supplier Rosmetics To register for FREE today, visit www.aestheticsconference.com

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What the experts say “ACE is the one conference I can think of that has a great balance between the exhibition and very targeted medical education.” Aesthetic practitioner, Dr Tapan Patel “We need to be constantly thinking about ways that we can update our knowledge. We are working in one of the most evolving and exciting specialties out there, so my advice would be to come to conferences – it’s very good for networking and to share experience with other peers. It’s also great to see the latest treatments and technologies.”

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Tell us about your experience.

How did you become an aesthetic trainer?

Meet the Trainer Cosmetic dentist and aesthetic practitioner Dr Rikin Parekh leads the Avanti Aesthetics Academy in Harley Street. He talks comprehensive training and continual support The Avanti Aesthetics Academy has been running for almost four years. How did you get started?

I began by teaching small groups of doctors, dentists and nurses basic and advanced toxin and filler procedures. Over the years, the company has grown and grown through word-of-mouth referrals and very little â&#x20AC;&#x2DC;marketingâ&#x20AC;&#x2122;, which we are very proud of.

In February 2017, we opened our dedicated training premises and clinic at 96 Harley Street where we treat our patients, hold our own training, as well as host some of the biggest companies in aesthetics for their training.

I studied at The University of Manchester and completed my Bachelor of Dental Surgery in 2003. I have been in the aesthetics industry now for close to 12 Dr Rikin Parekh years. After gaining extensive training and experience over the years, I started to train for some of the major aesthetic companies in the market delivering their own training. I am a Key Opinion Leader and trainer for Sinclair, Galderma, Regenyal Laboratories, Endoret PRGF, SF HIFU and ZO Skin Health. In 2014 I established The Avanti Aesthetics Academy after noticing a demand for more comprehensive hands-on training in the market with a real need for ongoing post-training support; as most practitioners know, the speciality can potentially be a very lonely place without support, guidance and a community to share your experiences with, so I decided to address this through my training.

Our intention is to cultivate conscientious practitioners who are sufficiently supported, knowledgeable and skilled not only to deliver clinical excellence but also to put their patientsâ&#x20AC;&#x2122; safety and wellbeing first.

What can delegates learn on your training courses?

We teach our delegates foundation and advanced level botulinum toxin and dermal filler treatments. Our delegates learn the safest and most effective techniques from the outset, for example the use of cannulas. Our advanced level dermal filler courses include full-face volumisation, tear trough and non-surgical rhinoplasty. In 2018, we will be expanding our training offering to include training in platelet rich plasma (PRP), polydioxanone (PDO) threads, mesotherapy/biorevitilisation, medical microneedling, medical skincare and chemical peeling. We will also be providing cadaver and business development workshops. As soon as our delegates sign up to our courses, we send out all the theory notes so that they can prepare in advance for the theory to be covered on the day. Marketing packs containing leaflets and consent forms etc. get sent out to them before they even attend. Our courses are very hands-on, with delegates treating their own models, which we provide, in all the treatments being covered from start to finish. From consultation, medical history, consent, analysis, marking up, taking photos, preparation of materials, providing treatment to giving

post-procedure instructions. As well as performing their own treatments, trainees observe all the other delegates treating their models to maximise retention of information so everything becomes integrated and second nature. We cover anatomy relevant to injectables in detail together, with in-depth prevention and management of complications on our foundation course. We also assist all our delegates to open pharmacy accounts to take advantage of our excellent discounts on products, together with appropriate insurance. In addition, delegates will receive extensive information on how to maximise incorporating aesthetics into their existing businesses or how to start an aesthetic business from scratch.

What experience/qualifications do practitioners need to attend the advanced courses?

There is a natural progression from our foundation toxin and filler courses to our advanced courses.

Our intention for all of our delegates is that they leave our foundation courses confident to be treating patients straight after the course. We are there for them via our online forum, where they 22

Aesthetics | January 2018

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Advertorial Meet the Trainer

support and advice whilst injecting. Delegates are free to move around and witness all injecting taking place to maximise learning and exposure to treatments.

TESTIMONIALS More than 80 Facebook ratings worth 5 Stars!

“I really can’t fault the Academy or Rikin as a trainer, teacher and a mentor! He was supportive and thorough, and his passion for teaching and training is shown through the enthusiasm of the delegates.”

What do delegates receive upon completion of training?

On completion of each course our delegates will receive constructive feedback and a certificate of “Efficient. Brilliant. Fountain of knowledge. Recently completed the attendance, which is valid for insurance purposes foundation botulinum toxin and dermal fillers course which was well from all the major aesthetic insurers. At the moment, structured and relevant.” we are working closely with Industry Qualifications (IQ) to develop longer-term pathways for our delegates I came out of the foundation course with such confidence and started treating patients right away. Not only do you get such great teaching and broaden the scope of training in various popular on the actual course days, there is FULL support after from Rikin and treatments common to aesthetic practice. his team.”

All delegates have access to our online support forum, where they can send any questions, get assistance in treatment planning for difficult cases can ask any questions or get assistance in treatment planning if they and network with other delegates trained by us, forming a close need it and network with the rest of our delegates. We monitor their community of like-minded individuals with a common goal. They also progress closely and, when they have treated and demonstrated have 24-hour access to the Academy by telephone or email if they enough cases to feel confident in their knowledge and skills, they need us in an emergency. may embark on training in more advanced procedures. We do take account of prior learning from potential delegates who have not Is there anything else practitioners should know done our foundation courses on an individual basis. A lot of medical before booking training? professionals who have trained elsewhere in basic toxin and fillers Setting a good foundation is essential when starting out in aesthetics often decide to start at the beginning of our pathway and do our and it is important to choose the right course for you. Key things to foundation courses to set a solid foundation, which we often find to look out for is how much hands-on experience you will get on the be deficient. In particular, we find that the major elements requiring course and the degree of support after the course is done. At the more training are facial analysis, knowledge of anatomy, needle and Avanti Aesthetics Academy we will teach you all the knowledge cannula proficiency, and dealing with complications, which often and skills required to be confident in performing treatments and we leads to lack of confidence. We teach our delegates how to use safe pride ourselves in giving you all the support you need once you’ve needle techniques and cannulas from day one, together with how to completed our training. manage complications; hence they are able to treat certain treatmentsensitive zones, such as nasolabial folds, safely and predictability.

Tell us about a typical training course. What can delegates expect each day?

Our course days are quite intensive. They start at 9am and can run until 7 or 8pm each day. The foundation course is three days; the first day is focused on botulinum toxin, the second on using filler to treat marionette lines with needle and cannula and nasolabial folds with cannula only, and we dedicate another whole day to the artistry of lip augmentation with the most effective needle and cannula techniques.

Our advanced courses are three days also, including full face volumisation, tear trough and non-surgical rhinoplasty courses. The morning of all courses will consist of going through all the theory in detail, which they would have already read prior to attending. They will then practise preparation of materials and inject life-like mannequins to practise injection techniques and positioning. The afternoons are then dedicated to delegates injecting live models after one of the trainers or I inject a live demonstration model. We want to maximise delegates’ hands-on experience, so they will each treat a model each day from start to finish, taking them through the whole patient journey.

Each course has a maximum of 12 delegates, who are split between two beds where myself and another one of our expert trainers will be supervising. All delegates receive unhurried one-to-one attention,

UP COMING TR A INING DATES • Foundation combined course (botulinum toxin, dermal filler and lip augmentation): 20th/21st/27th January • Advanced botulinum toxin and dermal filler volumisation course: 17th/18th January • Foundation combined course (botulinum toxin, dermal filler and lip augmentation): 17th/18th February and 3rd March • Advanced botulinum toxin and dermal filler volumisation course: 6th/7th February • Foundation combined course (botulinum toxin, dermal filler and lip augmentation): 17th/18th/24th March • Advanced botulinum toxin and dermal filler volumisation course: 27th/28th March www.avantiaestheticsacademy.co.uk Tel 020 7935 5803 / 07876 803126 Email : info@avantiaestheticsacademy.co.uk www.facebook.com/avantiaesthetics/

For a comprehensive range of facial aesthetics training, look out for the new Med-fx training portal – at medfx.co.uk Aesthetics | January 2018

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uses light energy to destroy the fat cells found under the chin.

The SculpSure submental applicator is designed for the precise treatment of the chin and neck area for a contoured profile.” The device, which recently received a CE mark for this indication,3 uses a wavelength of 1060 nm, which raises the temperature of the adipose cells between 42-47°C, damaging the structural integrity of the fat cell. Over the next three months, the body Aesthetics speaks to practitioners about naturally eliminates the disrupted fat cells.2 a 25-minute treatment, with no downtime needed,” says their different approaches for reducing “It’s Mr Zavahir, adding, “There are no noted side effects except the appearance of a double chin perhaps a little soreness and redness immediately afterwards.

It is, however, a comfortable treatment which involves no A study published in 2017 suggested that 47% of adults are recovery time so the patient can go back to work straight away.” bothered by the appearance of the area under their chin. Of the Approximately one to three treatments, scheduled six weeks 1,996 survey respondents, 35% said they shy away from photos apart, are needed to see a noticeable difference, according to Mr because of their double chin and 29% of men claimed to have grown Zavahir. He says that, because the fat cells are destroyed during a beard to hide the region.1 the treatments, patients who are maintaining a heathy weight and It is an area of concern for many, and one that cannot be easily hidden lifestyle will see permanent results. While most US Food and Drug or camouflaged. The five practitioners interviewed for this feature Administration (FDA) approved body contouring treatments only all agree it is one of the most common complaints patients have have approval for patients with a BMI of 30 or lower, this is not the regarding their appearance and one that is also on the rise. case for SculpSure, Mr Zavahir points out. “SculpSure submental In this feature, practitioners share their preferred approach to treating treatments are FDA approved for patients with a BMI of up to 43.4 submental fullness, from cryolipolysis to fat dissolving injections.

Although, prior to treating the patient, it is important to discuss their goals and review medical history to determine if this is a suitable Assessment treatment,” he notes, as some patients may be more suited to According to aesthetic practitioner Dr Galyna Selezneva, before any surgical treatment if they require a substantial reduction. treatment options are discussed, the practitioner must distinguish if the Aesthetic practitioner Dr David Jack uses an array of heat-based submental fullness is caused by fat or skin laxity. She explains, “Some devices in his clinic for treating the submental area for skin laxity. patients have skin laxity which they perceive as a ‘double chin’, and He says, “If the patient has the appearance of a double chin due for that I would do a skin tightening treatment. However, if my analysis to skin laxity, then there are a number of different treatments which shows me it is fat, then I will discuss treatment options for addressing work well. I use Fractora, which is a fractional radiofrequency (RF) the fat.” She stresses the importance of checking the patient’s medical device that causes injury to the skin to stimulate bioremodelling.” history, as this gives a good insight as to whether the double chin has Fractora delivers RF energy to the skin through an array of pins been there since the patient was young, despite an otherwise healthy which produce localised heat and small micro-lesion dots in weight, or if it’s new. “I always use a 3D image device to take a photo, the treatment area. The heat, generated by the Fractora pins in so, together with the patient, we can view the submental area from all the sub-dermal tissue, promotes collagen restructuring for skin angles,” she says. rejuvenation and an improved appearance in the skin.5 “I have also Aesthetic practitioner Dr Darren McKeown says it’s also important started to use Profhilo a lot in combination with Fractora, which is to recognise when the patient may require surgery. He explains, “I a 1,4-butanediol diglycidyl ether (BDDE)-free stabilised hyaluronic assess the degree of the problem and the amount of loose skin, fatty acid injectable for treating skin laxity. I find it helps with skin quality, tissue, underlying musculature, as well as the degree of improvement to improve the surface of the skin in that area. I always believe they are hoping to achieve. If they are looking for a really sharp, that combination treatments deliver the best overall results.” As defined jawline and a significant improvement, I advise that the only Fractora is a fractional treatment, there is a risk of redness and way to do that is with a surgical approach and will refer them to a scabbing afterwards, and possibly some swelling. “There is a very surgeon.” If a patient does not want surgery and is willing to accept low risk of burns because it is a controlled treatment; you are not a less significant improvement, then Dr McKeown states that he will heating the skin permanently in one area,” says Dr Jack. “It all begin discussing the non-surgical treatments available. depends on the patient’s skin type, too, as the darker the skin, the more risk of pigmentation changes. So, I would really only use it for Treating the submental region Fitzpatrick skin types I to IV.” Aesthetic devices which lower or raise body temperature, to target Dr McKeown’s device of choice is the Profound microneedling unwanted fat and skin laxity, are becoming more present in aesthetic and radiofrequency device, which he explains can be used for clinics as technology evolves and becomes more effective. So, what both skin tightening and fat reduction in the submental region. devices are practitioners using for the submental region?

He says, “Profound is an energy-based device that uses heat to stimulate collagen contractions. It heats the dermis to 67 degrees Heating and works by inserting microneedles 4mm deep into the dermis, Using targeted heat to destroy fat cells is one way to eliminate which then delivers RF energy with accurate control.” He says that submental fullness. One device that does this is body contouring the practitioner can control the length of time the tissue is held at laser device SculpSure.2 Mr Faz Zavahir, medical director and plastic that temperature for, with the optimal time being four seconds. He surgeon, has been one of the first practitioners to use the device explains that Profound has two handpieces – the Dermal and the for the submental region in the UK. He explains, “This treatment SubQ head. “The SubQ head is specifically designed for melting

Treating the Submental Area

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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After

has undergone a thorough medical assessment with the patient and ruled out any contraindications, such as Raynaud disease (a medical condition in which spasm of arteries causes episodes of reduced blood flow), she will discuss the best time for treatment. “There is very little downtime,” she explains, but in some cases, there is swelling, mild bruising and redness for an hour or so straight after treatment, so it’s best to make sure the patient has no big social events coming up.”

Most patients will need just one applicator placed under the chin, but depending on the size and position of the problem area, patients might need two or even three applications in one session. “If the patient needs two applications, I would Figure 1: Patient treated for skin laxity using the Profound device. Before and six months after treatment do one after another, overlapping the central area, as that is predominately where we carry the majority of the fat. In fat in the submental region,” says Dr McKeown. “It goes a little one session the treatment takes 45 minutes and, once the first bit deeper to treat the subcutaneous fat; so, if I’m treating a ‘fatty application is complete, we remove the applicator, massage the neck’, I use the SubQ first, melt the fat, and then use the Dermal area, and straight away put the second applicator on.” head to tighten the skin.”

The moulded cup uses suction to draw tissue into it to cool it The treatment is performed under local anaesthetic and each down. “The cool temperature crystallises the fat cell,” Dr Selezneva handpiece has ten microneedles, which are then inserted into the explains. “The fat cell becomes a dead fat cell and the body no skin, via a finger trigger, with the standard protocol for a dermal longer recognises it and instead sees it as debris. The body then treatment being 150 insertions. “Throughout treatment, the needles sends scavenger cells to secrete it.”6 come out of the applicator head and treat one section at a time,” During the treatment, patients may feel discomfort, but Dr Selezneva explains Dr McKeown. “The treatment takes around 40 minutes says it shouldn’t be painful. “When the temperature drops, the nerve in total and there is a little bit of downtime as, because of the endings go to sleep and go numb, so no additional numbing is temperature, there can be a lot of swelling afterwards.” He advises required.” She adds, “Some of my patients sleep whilst having the patients to have the treatment on a Friday, have the weekend to treatment, but the majority read a book or look on their phones.” recover and then go back to work on the Monday. However, there Dr Selezneva will review the patient four weeks post treatment and, can be subtle swelling for two weeks after. at that point, it will be decided whether or not the patient will benefit Like any energy-based device, there is the possibility of burns, from a second treatment, although she says that one treatment is scarring and changes to pigmentation – either hyper or hypo – but enough for most patients and very rarely would a patient need a Dr McKeown has never experienced these issues first-hand. “To third. The patient should be made aware of the possibility they may avoid complications such as these, you have to be careful when need extra treatments during the initial consultation. inserting the needles and check they are in the skin at the right “In the submental area, patients start to notice the difference after angle. The tip of the needle, the part that is delivering the energy, two weeks, and then results progressively get better over four to six needs to be fully in the skin before application,” he says. weeks, although in some cases I have seen progression up to two Dr McKeown says patients are usually pleased with their results, months afterwards.” On average, Dr Selezneva says her patients but stresses the importance of managing patient expectations. usually see a 25% reduction in fat and that, as long as they don’t have To explain the results that can be achieved with Profound, he any significant weight gain in the future, results should be permanent. tells patients to imagine what they might get from a facelift and When asked what the main side effects or complications are, the main then imagine a third of that improvement. He explains, “Syneron concern for Dr Selezneva is poor application. “I have unfortunately Candela conducted a study where they compared the outcome seen some wrong applications, where dents have occurred and the of Profound to the outcome of a surgical facelift and the patients results are uneven,” explains Dr Selezneva. “That can be avoided in the study achieved approximately one third of the improvement with proper placement.” She notes that to resolve this issue can be of the patients who have had surgical facelifts. So, this is how I a complicated manner, and possibly can be corrected with further describe it to my patients.”10 Three month’s post treatment with cryolipolysis treatment, but this is decided on a patient-by-patient Profound, Dr McKeown says that approximately 80% of his patients basis. Other reported side effects include temporary redness, swelling, are satisfied, and, after six months, around 90% are satisfied. bruising and skin sensitivity.7 For just skin tightening, there is no definitive answer as to how long results will last using the Profound, explains Dr McKeown, but he Carbon dioxide therapy tends to tell patients to expect two years, as that was the longest As well as heat-based devices, Dr Jack uses carbon dioxide (CO2) outcome portrayed in a study.10 “My suspicion is that after you have therapy, also known as carboxytherapy, to target and destroy fat cells generated new collagen, patients’ skin will always be better than under the chin and tighten loose skin. “There are two applications if they hadn’t had the treatment done. But we haven’t proven that for carboxytherapy,” he explains. “It can be used in the skin for the scientifically yet,” he adds. treatment of stretch marks, fine lines and wrinkles, where you inject into the dermis with a tiny needle, it passes pure carbon dioxide Cooling under the skin and it is heated to body temperature. The second, Devices that use a low temperature to target fat cells are also is that you can inject it into the subcutaneous fat, which is a slightly effective at reducing submental fullness. Dr Selezneva’s treatment deeper injection, and the high CO2 levels are toxic to the fat cells. This of choice for fat under the chin is a cryolipolysis device. Once she induces cell death so you get a reduction of fat cell volume.”

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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Kybella Expected to launch in the UK in 2018 is a new fat dissolving injection, Kybella. After receiving FDA approval in 2015 for the treatment of moderate to severe fat, the product is already available to practitioners in the US. The FDA explains that Kybella is a cytolytic drug, which aims to destroy fat cells when injected into submental fat. Like Aqualyx, it is administered by injection into the fat under the chin.9 Practitioners in the UK have voiced their enthusiasm over its arrival; Dr Selezneva has received training for Kybella in the US and says she is looking forward to the launch in the UK, whilst Dr Jack adds that he believes it will ‘bring in more demand for treatment of the submental region from patients’.

Patients will need to have one treatment a week for ten weeks, but Dr Jack says in his experience they can expect to see a 20-30% reduction in fat. He explains that for superior results, he offers a combination of treatments. “You can do a cryolipolysis treatment, leave for a few weeks, then do carboxytherapy or radiofrequency, and again, do a series of treatments,” he says. “Or, you can do carboxytherapy, reduce fat cell number gently, then do cryolipolysis to really top it off.

Using combination treatments, particularly for fat reduction, can get really good results,” he notes.

Aesthetics

She says, “Patients frequently misjudge how long they will be swollen for. It doesn’t matter how many times you tell them ‘from my experience you’re going to be swollen for up to three weeks’ – and I’ve seen it happen for longer – people presume they will have the best-case scenario. So, patient management can be tricky.” As with the energy devices that target fat, once the fat’s been dissolved, it shouldn’t come back. “Once it’s gone it’s gone,” says Dr Tonks, adding, “But you do sometimes have to do more than one treatment session, depending on how much fat the patient has.” The treatment doesn’t take long to perform, and Dr Tonks will allow for half an hour to consult with the patient and perform the treatment.

The main complication to be aware of for Aqualyx is tissue necrosis, Dr Tonks says, “If you inject too much, too superficially, and you’re not spreading the product out enough, there will be tissue breakdown.

This can be avoided by making sure you are spreading the product evenly under the skin when you are injecting – you can’t put too much in one area and don’t go too superficially.”

Within three to six weeks, patients will start to see results, according to Dr Tonks, adding that ‘patients tend to get a mild to moderate improvement, as well as some skin contraction’.

Keeping up with demand

The practitioners interviewed agree that the demand for non-surgical treatment of the submental region will only increase, and Dr Selezneva believes this could be related to a rise in the ‘selfie’ culture. “I notice more and more that patients bring photos of themselves, as it’s something Before After they have noticed more in photos. I absolutely believe the demand will continue to grow and the industry will carry on aiming to make treatments less invasive for this area,” she explains.

Dr McKeown concludes, “I think when it comes to the face, we can manage pretty much most concerns nonsurgically, but the submental region Figure 2: Patient before and 12 weeks after second cryolipolysis treatment. Photos courtesy of A. Jay Burns, MD is the one area we still struggle with in terms of non-surgical treatments.

Fat dissolving injections However, with the technology improving in the way that it is, and if we For practitioners who prefer using needles to devices, another way continue to make improvements, I think we will see more of a shift to tackle fat in the submental area is with deoxycholic acid. Aesthetic from surgical to non-surgical treatments for the neck and submental practitioner Dr Sarah Tonks has carried out this procedure on many region.” patients. She explains, “The product I use is Aqualyx, which I mix with REFERENCES lidocaine, and then inject at least 10ml of fluid into the tissue. The 1. Survey indicates impact of double chins, Aesthetics (2017) <https://aestheticsjournal.com/news/ survey-indicates-impact-of-double-chins-on-self-perception-and-behaviour?authed> product makes the fat cells lyse and release the fat, before the body 2. Juvea Medical first UK clinic to offer Sculpsure submental treatment, Aesthetics, (2017) <https:// 8 naturally disposes of them.” aestheticsjournal.com/news/juvea-medical-first-uk-clinic-to-offer-sculpsure-submental-treatment> 3. Hologic, Hologic Recieves CE mark to market SculpSure for non-invasive body contouring lipolysis Treating patients with a small pocket of fat is ideal, according to Dr of the submental area under the chin, (2017) <http://investors.hologic.com/2017-10-17-HologicTonks, rather than someone who has a very large double chin. She Receives-CE-Mark-to-Market-SculpSure-R-for-Non-Invasive-Body-Contouring-Lipolysis-of-theSubmental-Area-Under-the-Chin> explains that the recommended method for under the chin, from the 4. Macaela Mackenzie, Laser Treatment SculpSure Is Now Cleared by the FDA for Use on Double manufacturers of Aqualyx, is one injection point and then a fanning Chins (2017) <https://www.allure.com/story/sculpsure-fda-approved-for-chin> 5. Invasix, Fractora, (2017) <https://www.invasix.com/Fractora_7/> technique.

6. CoolSculpting, How it works, (2017) <http://www.coolsculpting.com/what-is-coolsculpting/how-itDr Tonks advises that patients have quite a lot of swelling afterwards works/> 7. Healthline, Understanding the Risks of CoolSculpting, (2017) <https://www.healthline.com/health/ due to the amount of fluid injected. “When patients leave the clinic, coolsculpting-risks#risks-and-side-effects> they do look reasonably swollen,” she says. “Then, a tissue response 8. Roberto amore, Hernan Pinto, Kostas Gritzalaz et al. Intralipotherapy, the State of the Art, <https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC5096534/> occurs, and they get swelling that becomes hard and quite ‘woody’ 9. Kythera Biopharmaceuticals, Kythera Biopharmaceuticals Announces FDA Approval of Kybella (also due to inflammation. I’d say they have that large swelling for maybe known as ATX-101)– First and Only Submental Contouring Injectable Drug, (California: MyKybella. com, 2015) https://mykybella.com/wpcontent/uploads/2015/04/KYTHERA-FDA-Approval-Pressfive days and then it starts to dissipate over a couple of weeks,” she Release-4.29.15-FINAL_.pdf adds.

10. Alexiades et al. Blinded, Randomized, Quantitative Grading Comparison of Minimally Invasive, Fractional Radiofrequency and Surgical Face-lift to Treat Skin Laxity, Arch Dermatology, Vol This swelling, Dr Tonks explains, tends to be underestimated by a lot 146 (No.4) of patients, who are informed of it occurring during the consultation.

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Botulinum Neurotoxin Formulations Dr Souphiyeh Samizadeh explores the science and pharmacological differences of botulinum neurotoxin formulations There are different botulinum toxin A (BT-A) products/formulations available on the market that are used for both therapeutic and cosmetic purposes. They vary in terms of composition, units, chemical properties, biologic activities and weight; hence, they are not interchangeable.1 Like many other aesthetic and therapeutic treatments, poor understanding of the clinical pharmacology of BT-A may result in poor product choice for a given indication, patient consent, inadequate treatment planning and a lack of understanding of potential complications. In this paper, I will discuss the basic clinical pharmacology of BT-A and detail some of the differences presented in the literature between three popular formulations.

Overview of botulinum neurotoxin Botulinum toxin (BT) is a neurotoxic protein that consists of botulinum neurotoxin (BoNT) and non-toxic proteins (also known as complexing proteins).2 It is produced by anaerobic spore-forming bacteria, bacterium Clostridium botulinum and related species, including some strains of Clostridium butyricum and Clostridium baratii.3 BoNT can cause botulism and is one of the most potent toxins known to mankind.4 BT serotypes include A, B, C, D, E, F and G, which are produced by different strains of Clostridium botulinum.4,5 BoNT consists of a heavy and a light chain, which are linked together by a disulfide bond.2 The toxin enters peripheral cholinergic nerve terminals and causes temporary and reversible inhibition of neurotransmitter release.2

Clinical uses The specificity of action of BoNTs has made it a useful, practical and popular therapeutic agent. The popular use of BoNT is because of:6 • Potency – amount of drug needed to produce a given effect • Complete reversibility – does not cause neuronal death

• Neurospecificity – high specificity for peripheral cholinergic nerve terminals There are three well-known BT-A formulations that have been approved by the US Food and Drug Administration, which are currently commercially available in the UK. These are onabotulinum toxin A (Botox/Vistabel), abobotulinum toxin A (Dysport/Azzalure) and incobotulinum toxin A (Bocouture/Xeomin).7 These products have cosmetic product names that differ depending on the country (stated in the brackets above) and a nonproprietary name (the chemical or generic name of a drug, distinguished from a brand name or trademark). Despite having similar efficacies, there is an ongoing debate in the literature and among practitioners regarding the comparability of these various preparations.7 Each of these products is formulated differently, has a different manufacturing process and demonstrates unique characteristics.

They have all been approved for various and limited indications in different countries and these indications are still evolving. However, they are used for many on-label and off-label purposes.8 Practitioners need to understand clinical issues of potency, conversion ratio, and safety issues such as toxin spread and immunogenicity, prior to prescribing and administering any of these products. All contributing factors, including efficacy, diffusion, spread, properties of the preparation, muscle characteristic and injection technique, should be considered when comparing different toxin formulations.8

Composition In nature, BoNT-A, is synthesised as a macromolecular protein complex, consisting of non-toxic accessory proteins (NAPs), bonded

Botulinum toxin type A

Abobotulinum toxin A

Onabotulinum toxin A

Incobotulinum toxin A

Brand name in the UK

Azzalure, Dysport

Botox

Bocouture

Manufacturer

Ipsen Ltd for Galderma

Allergan Inc

Merz Aesthetics (Merz Pharma)

Country of production

UK

Ireland

Germany

Presentation

Freeze-dried (lyophilised) powder for reconstitution

Vacuum-dried powder for reconstitution

Freeze-dried (lyophilised) powder for reconstitution

Excipients

Human serum albumin, Lactose

Human serum albumin, NaCl

Human serum albumin, sucrose

Molecular weight (neurotoxin) kD

Not published

900

150

Shelf-life

2-8 °C 2 years

2-8 °C 2-3 years

Room temperature 3 years

Storage (post-reconstitution)

2-8 °C (Refrigerated) 24 h

2-8 °C (Refrigerated) 24 h

2-8 °C (Refrigerated) 24 h

Figure 1: Comparison of botulinum neurotoxin type A formulations7,10

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to the active neurotoxin. The neurotoxin has a molecular weight of 150kD.9 The therapeutic preparations of BT consist of botulinum neurotoxin, complexing proteins and excipients (Figure 1).9 Various BoNT-A products have different NAP compositions.7 Hence, the molecular weight of the BoNT-A progenitor toxins vary and are determined by the composition of NAPs and the manufacturing process.9 The neurotoxin (150kD) dissociates from NAPs prior to exerting its pharmacologic effects.7 The role of NAPs, in potentially increasing the immunogenic risk, has been debated in the literature, however, there is no consensus that they may modify the immunogenicity of the active toxin.7 BoNT consists of a light amino acid chain with a molecular weight of 50kD and a heavy amino acid chain of 100kD, which are bonded together by a disulphide bond (Figure 2). Both chains are important – they have a different function in the action mechanism of the neurotoxin and the disulphide bond, playing a key role in the biological activity of BT.8,9 The molecular weight of the BoNT-A progenitor toxins varies between 300-900kD.9 IncobotulinumtoxinA contains only 150kD neurotoxin with no complexing proteins.9-11 OnabotulinumtoxinA and abobotulinumtoxinA contain the 150kD neurotoxin as part of a complex with other proteins.11 OnabotulinumtoxinA is composed of a 900kD complex,12 and the size of the abobotulinumtoxinA complex is unknown as it is undisclosed by the manufacturer.13 The neurotoxin has been reported to rapidly dissociate from the complexing proteins after dilution, resulting in drying and reconstitution of the product. Therefore, it has been debated that the molecular weight (protein complex size) does not affect the biological activity and pharmacological properties of BoNT.10,14

Mode of action on the striated muscle All botulinum toxin serotypes disturb the neural transmission by blocking the release of acetylcholine (the principal neurotransmitter at the neuromuscular junction).6,15 Inhibition of the release of acetylcholine, from presynaptic motor neurons, results in muscle paralysis and can be achieved by intramuscular administration of botulinum toxins. This can, in addition, result in muscle atrophy.2 This could be desirable, in the case of masseter and/or temporalis muscle hypertrophy, or could alternatively be an unwanted outcome, depending on the treatment aims and objectives.16,17 The inhibition of neuroexocytosis varies depending on the following:6,15 • Toxin serotype used • The dose injected • The type of cholinergic nerve terminal affected • The animal species Duration of action Paresis occurs after two to five days post injection of BT into a striated muscle and lasts two to three months, prior to wearing off gradually.2 The extent of paresis is associated to the amount of BT injected.

For optimisation of BT treatment, the dose-effect correlation can be taken into consideration.2,18 It has been reported that when lower doses of BT are used, the duration of its action is correlated to the amount injected. However, the duration of action is thought to saturate at approximately three months, when higher BT doses are used.2 Patients treated with BoNT-A, for aesthetic purposes, can expect their results to last at least three months.19 The results, however, can last four to five months, depending on various factors including the area treated, the dose, and the formulation used.19 It has been also reported that the results may last longer for some patients, especially after repeated treatment. The mechanism for this is not fully understood.9

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Potency Potency of a given drug is the measure of drug activity, i.e. the amount required to produce an effect of given intensity. The biological potency of BoNT formulations is based on the median lethal dose of the neurotoxin, after intraperitoneal injection in female Swiss-Webster mice. It is known as median lethal dose (LD50) assay.10,20,21 The dose of product for treating patients (discussed further below) is determined by each manufacturer’s result of LD50 potency or, nowadays, cell-based assay. This is dependent on multiple variables, is not standardised, and is different for each manufacturer. The unit of measurement is the proprietary of each manufacturer. As such, the direct comparisons of potency between products is invalid.10,20,21 From a clinical point of view for practitioners, this means that, despite the same active molecule, BoNT-A, the potency of different preparations varies.7

Reconstitution As all three mentioned products are in powder form, they need to be reconstituted prior to injection. The manufacturer’s suggested diluent is normal saline with no preservatives for all three products.

However, there is debate in regards to reconstitution with saline with no preservatives, and preserved saline. Although some authors debate whether the preservatives in the saline deactivate the toxin partially, other authors have reported equivalent clinical effectiveness with BoNT-A diluted with preserved saline.22-24 Measures can be taken to avoid reducing the efficacy of the toxins. These were previously thought to include not shaking, bubbling, and storing the vial for a long period of time. However, reduction of efficacy due to shaking, bubbling or storage has been refuted by other studies.25-27 It is paramount to remember that suboptimal reconstitution of BoNT preparations can reduce or diminish their efficacy. Similarly, inaccurate reconstitution could result in inaccuracy of actual units injected and therefore compromise treatment.28,29 One author has reported that improper reconstitution of incobotulinumtoxinA, for example swirling without inversion of the vial of this product following saline injection, can result in substantial loss of units of the neurotoxin.28

Dosage There are different amounts of the 150kD toxin (and NAPs)/LD50 unit for different formulations of BoNT-A. Therefore, it is important for practitioners to understand the equivalence ratio of the dose.

The clinical conversion ratio between onabotulinumtoxinA and incobotulinumtoxinA has been shown by clinical and preclinical analysis to be very close to 1:1.30,31 OnabotulinumtoxinA / incobotulinumtoxinA / abobotulinumtoxinA dose conversion is a topic of debate. The available clinical and preclinical data suggests a conversion ratio of 1:3 or lower, 1:2.5.7,32,33

Toxin spread BoNT’s effect on areas away from the injection site is known as toxin spread, or diffusion, and/or field of effect.34 However, there is lack of consistency34 and much confusion about the terminology used; clarity is best described below.34 • Spread – physical movement of toxin from original injection site

S–S

Light Chain

Heavy Chain Figure 2: BoNT consists of two amino acids, heavy and light, which are connected by a disulphide bridge.17

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• Diffusion – kinetic dispersion of toxin beyond original injection site • Migration – distal effect Toxin spread, or diffusion, and/or increased field of effect may increase the risk of adverse effects and complications. For example, treatment of the periorbital area with BT injection can result in eyelid ptosis due to accidental spread of the product to the levator palpebrae superioris muscle and its temporary reduced/diminished activity.22,35 Factors thought to affect the potential for spread of BoNT include: clinical dose, solution, concentration, injection technique, target site, location within the muscle, muscle hyperactivity, depth of injection and post-injection massage.13,36,37 It is thought that incobotulinumtoxinA and onabotulinumtoxinA have comparable spread, however, abobotulinumtoxinA was reported in one study to have significantly greater spread than incobotulinumtoxinA.35 Kerscher, compared the condition anhidrosis, produced by the three products mentioned. They reported that the mean difference in the maximal area of anhidrosis from incobotulinumtoxinA was 135.2mm2 for abobotulinumtoxinA, and therefore suggested an increased risk of side effects due to migration/diffusion of the toxin.35

Storage Each manufacturer recommends optimal storage conditions for their products. As shown in Figure 1, onabotulinumtoxinA and abobotulinumtoxinA need to be stored at 2-8°C while incobotulinumtoxinA can be stored at room temperature.10 Studies have suggested that there is no alteration in potency of onabotulinumtoxinA after reconstitution, even when it is refrigerated or refrozen for up to two weeks after reconstitution.38 No significant alterations or clinical response were reported by other studies that stored onabotulinumtoxinA two to six weeks after reconstitution and prior to injection, however, the question of sterility was raised.39-41

Conclusion There are different BT-A products available on the market and they vary in terms of composition, units, chemical properties, biologic activities and weight. As such, they are not interchangeable.

The conversion ratio of onabotulinum toxin A and incobotulinum toxin A are comparable and reported to be 1:1 and 1:2.5 for abobotulinumtoxinA. The products’ regional approved indications, dilution and reconstitution, storage and field of effect need to be understood prior to prescription and administration. Such differences may cause practical challenges for the clinicians if not understood. The key factors affecting the clinical response to BoNT injections are toxin preparation, reconstitution, dose injected, storage prior and after reconstitution, individual anatomy, and immunogenicity. An understanding of clinical pharmacology of BT-A therapy will be useful for standardising techniques used, and achieving consistent and optimal therapeutic results.

Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in aesthetic medicine. She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic. She has presented at both national and international conferences, and is actively involved with research into aesthetic medicine.

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REFERENCES 1. Brin, M.F., C. James, and J. Maltman, Botulinum toxin type A products are not interchangeable: a review of the evidence. Biologics, 2014. 8: p. 227-41.

2. Dressler, D., F.A. Saberi, and E.R. Barbosa, Botulinum toxin: mechanisms of action. Arq Neuropsiquiatr, 2005. 63(1): p. 180-5.

3. Peck, M.W., Biology and genomic analysis of Clostridium botulinum. Advances in microbial physiology, 2009. 55: p. 183-320.

4. Huang, W., J.A. Foster, and A.S. Rogachefsky, Pharmacology of botulinum toxin. Journal of the American Academy of Dermatology, 2000. 43(2): p. 249-259.

5. Coffield, J., et al., In vitro characterization of botulinum toxin types A, C and D action on human tissues: combined electrophysiologic, pharmacologic and molecular biologic approaches. Journal of Pharmacology and Experimental Therapeutics, 1997. 280(3): p. 1489-1498.

6. Montecucco, C. and J. Molgó, Botulinal neurotoxins: revival of an old killer. Current opinion in pharmacology, 2005. 5(3): p. 274-279.

7. Scaglione, F., Conversion Ratio between Botox®, Dysport®, and Xeomin® in Clinical Practice. Toxins, 2016. 8(3): p. 65.

8. Rosales, R.L., H. Bigalke, and D. Dressler, Pharmacology of botulinum toxin: differences between type A preparations. Eur J Neurol, 2006. 13 Suppl 1: p. 2-10.

9. Dressler, D. and R. Benecke, Pharmacology of therapeutic botulinum toxin preparations. Disabil Rehabil, 2007. 29(23): p. 1761-8.

10. Frevert, J., Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type A products. Drugs in R&d, 2015. 15(1): p. 1-9.

11. Frevert, J., Content of botulinum neurotoxin in botox®/vistabel®, dysport®/azzalure®, and xeomin®/ bocouture®. Drugs in R&d, 2010. 10(2): p. 67.

12. Schantz, E.J. and E.A. Johnson, Properties and use of botulinum toxin and other microbial neurotoxins in medicine. Microbiological reviews, 1992. 56(1): p. 80-99.

13. Pickett, A., Dysport®: pharmacological properties and factors that influence toxin action. Toxicon, 2009. 54(5): p. 683-689.

14. Eisele, K.-H., et al., Studies on the dissociation of botulinum neurotoxin type A complexes. Toxicon, 2011. 57(4): p. 555-565.

15. Foran, P.G., et al., Evaluation of the therapeutic usefulness of botulinum neurotoxin B, C1, E, and F compared with the long lasting type A basis for distinct durations of inhibition of exocytosis in central neurons. Journal of biological chemistry, 2003. 278(2): p. 1363-1371.

16. von Lindern, J.J., et al., Type A botulinum toxin for the treatment of hypertrophy of the masseter and temporal muscles: an alternative treatment. Plastic and reconstructive surgery, 2001. 107(2): p.

327-332.

17. Guyuron, B., et al., Hourglass deformity after botulinum toxin type A injection. Headache: The Journal of Head and Face Pain, 2004. 44(3): p. 262-264.

18. Dressler, D. and J. Rothwell, Electromyographic quantification of the paralysing effect of botulinum toxin in the sternocleidomastoid muscle. European neurology, 2000. 43(1): p. 13.

19. Flynn, T.C., Botulinum Toxin. American journal of clinical dermatology, 2010. 11(3): p. 183-199.

20. Pickett, A., Consistent biochemical data are essential for comparability of botulinum toxin type A products. Drugs in R & D, 2011. 11(1): p. 97-98.

21. Hambleton, P. and A. Pickett, Potency equivalence of botulinum toxin preparations. Journal of the Royal Society of Medicine, 1994. 87(11): p. 719.

22. Carruthers, J.D. and J.A. Carruthers, Treatment of glabellar frown lines with C. botulinum‐A exotoxin.

The Journal of dermatologic surgery and oncology, 1992. 18(1): p. 17-21.

23. Klein, A.W., Dilution and storage of botulinum toxin. Dermatologic surgery, 1998. 24(11): p. 1179-1180.

24. Carruthers, J., S. Fagien, and S. Matarasso, Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Ophthalmic Plastic & Reconstructive Surgery, 2005. 21(2): p. 165.

25. Trindade de Almeida, A.R., et al., Foam during reconstitution does not affect the potency of botulinum toxin type A. Dermatologic surgery, 2003. 29(5): p. 530-532.

26. Trindade de Almeida, A.R., L.C. Secco, and A. Carruthers, Handling botulinum toxins: an updated literature review. Dermatologic Surgery, 2011. 37(11): p. 1553-1565.

27. Kazim, N.A. and E.H. Black, Botox: shaken, not stirred. Ophthalmic Plastic & Reconstructive Surgery, 2008. 24(1): p. 10-12.

28. Carey, W.D., Incorrect reconstitution of incobotulinumtoxinA leads to loss of neurotoxin. Journal of drugs in dermatology: JDD, 2014. 13(6): p. 735-738.

29. Niamtu III, J., Neurotoxin waste from drawing product through the vial stopper. The Journal of clinical and aesthetic dermatology, 2014. 7(6): p. 33.

30. Prager, W., et al., Comparison of Two Botulinum Toxin Type A Preparations for Treating Crow’s Feet: A Split‐Face, Double‐Blind, Proof‐of‐Concept Study. Dermatologic Surgery, 2010. 36(s4): p. 2155-2160.

31. Dressler, D., G. Mander, and K. Fink, Measuring the potency labelling of onabotulinumtoxinA (Botox®) and incobotulinumtoxinA (Xeomin®) in an LD50 assay. Journal of neural transmission, 2012. 119(1): p.

13-15.

32. Yun, J.Y., et al., Dysport and Botox at a Ratio of 2.5:1 Units in Cervical Dystonia: A Double-Blind, Randomized Study. Movement Disorders, 2015. 30(2): p. 206-213.

33. Wohlfarth, K., et al., Botulinum A toxins: units versus units. Naunyn Schmiedebergs Arch Pharmacol, 1997. 355(3): p. 335-40.

34. Pickett, A., S. Dodd, and B. Rzany, Confusion about diffusion and the art of misinterpreting data when comparing different botulinum toxins used in aesthetic applications. Journal of Cosmetic and Laser Therapy, 2008. 10(3): p. 181-183.

35. Kerscher, M., et al., Comparison of the spread of three botulinum toxin type A preparations. Archives of dermatological research, 2012. 304(2): p. 155-161.

36. Brodsky, M.A., D.M. Swope, and D. Grimes, Diffusion of botulinum toxins. Tremor and Other Hyperkinetic Movements, 2012. 2.

37. Roche, N., et al., Undesirable distant effects following botulinum toxin type a injection. Clin Neuropharmacol, 2008. 31(5): p. 272-80.

38. Sloop, R.R., B.A. Cole, and R.O. Escutin, Reconstituted botulinum toxin type A does not lose potency in humans if it is refrozen or refrigerated for 2 weeks before use. Neurology, 1997. 48(1): p. 249-253.

39. Park, M.Y. and K.Y. Ahn, Effect of the Refrigerator Storage Time on the Potency of Botox for Human Extensor Digitorum Brevis Muscle Paralysis. Journal of Clinical Neurology (Seoul, Korea), 2013. 9(3): p. 157-164.

40. Yang, G.C., R.J. Chiu, and G.S. Gillman, Questioning the need to use Botox within 4 hours of reconstitution: a study of fresh vs 2-week-old Botox. Arch Facial Plast Surg, 2008. 10(4): p. 273-9.

41. Hexsel, D.M., et al., Multicenter, double‐blind study of the efficacy of injections with botulinum toxin type A reconstituted up to six consecutive weeks before application. Dermatologic surgery, 2003.

29(5): p. 523-529.

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AVAILABLE IN 4 PACK SIZES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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treated with topical therapies alone.1,3 However, as disease severity increases, treatment can be escalated to systemic modalities, either in isolation or in combination with topicals.2 Psoriasis is typically assessed by the psoriasis area severity index (PASI), which measures the clinical severity and extent of psoriasis, and the dermatology life quality index (DLQI), which determines the functional and psychological impact on patients.3 These scores help categorise psoriasis into mild, moderate, and severe, which helps to steer therapy options. No current standardised guidelines exist for psoriasis management, although some European countries such as Italy or Germany have a general consensus, which are based on trials and expert opinions.2 However, treatment is largely left to the discretion of the clinician based on individualised holistic patient care.

Lifestyle modifications Given that psoriasis is a multisystem disorder, patient education regarding their condition is essential to manage not only the visible effects of psoriasis, but also the metabolic and psychosocial aspects.3 Patients should maintain healthy lifestyles via regular exercise, healthy diets, smoking cessation and reduced alcohol intake. As In the first of a two-part article on treating the above contribute to atherosclerotic process, altering psoriasis, Dr Priya Patel reviews the topical these factors will help to prevent the vascular risks treatment options available for the disorder associated with psoriasis.3 Living a healthier lifestyle also helps positive wellbeing and decreases stress, which Psoriasis is a chronic inflammatory disorder of the skin, but overall has a positive effect on patients and can independently it also affects other organs and joints.1 In addition, psoriasis reduce the rate of psoriatic flares.4,5 These lifestyle modifications can have devastating effects on psychological, emotional and must be addressed alongside medicated therapies as they, in social wellbeing, as it can be a stigmatising condition. Psoriasis isolation, do not improve psoriasis to an effective degree.5 independently contributes to other co-morbidities such as the metabolic syndrome, gastrointestinal disease, malignancy and Topical treatments arthritis.1 Consideration of these comorbidities is important when Alongside medicated topical therapies, described below, emollients deciding on the most appropriate therapy for an individual so that and moisturisers are recommended as they help improve skin good holistic care can be provided for every individual patient. function and provide an effective barrier.3,6,7 Many patients Largely, psoriasis is a clinical diagnosis; however, blood tests for find topical therapies challenging as they are time-consuming inflammatory and rheumatological markers, such as HLA-B27, or and can feel greasy or unpleasant due to smells or staining; skin biopsies, can be performed in clinically challenging cases, therefore compliance is often low.7 However, there are almost no 1 although these are rarely executed. Many different treatment options contraindications to using topical therapies and their side-effect exist, and their use depends on clinical severity and the distribution profile is lower compared to systemic agents, so these should of disease.1 Largely, topical therapies form first-line management always be used as a first-line treatment.3 Currently, no clinical trials and these will be discussed in this article. However, patients with have demonstrated one topical therapy to be markedly superior to more severe, or refractory, symptoms may need dermatological the other and options are based on individualsâ&#x20AC;&#x2122; disease severity and assessment and systemic treatment but this is beyond the scope of personal preference on discussion with a clinician.3,6-7 All topicals this article and will be discussed in Part Two. reviewed have shown efficacy but have their own side-effect profiles. Further long-term trials with larger patient numbers, clear Background measurable and comparable outcomes are needed for all topicals to Psoriasis affects 1-3% of the worldâ&#x20AC;&#x2122;s population,2 with both determine superiority. genders equally affected.2,3 Primarily, the skin is affected, but the impact of disease on quality of life and its burden should not be Corticosteroids underestimated.2 Psoriasis comes in many different forms. The Corticosteroids are topical steroids used to decrease local most common is chronic plaque psoriasis, which will be discussed inflammation.3 They have shown efficacy in psoriasis, particularly in this article in the most detail; however, others subtypes such as for scalp psoriasis. Pooled data from five trials of 646 patients guttate, pustular, palmoplantar, flexural/inverse, erythrodermic and demonstrated statistically significant difference in psoriasis with a psoriatic arthropathy also exist.3 Psoriasis can also be subdivided by 3-point improvement on a 12-point scale when comparing very potent site, such as the scalp or nails, as these areas are often refractory formulations of steroids against placebo.6 Additionally, 12 trials with 2,3 to treatment. The subtype, site, distribution and severity help 1,040 patients demonstrated even potent steroids had a 1.6-point determine the therapeutic options. Mild to moderate cases could be improvement on a 12-point scale which was also statistically significant

Treating Psoriasis

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(95% CI: -0.99 to -0.68).6 However, many patients are reluctant to use steroids in the long-term due to the side effects of skin thinning, easy bruising, vessel dilatation, striae and pigmentary changes.3 Steroids can be combined with almost all other topical or systemic agents, thus lowering the sideeffect profile of both therapies as they work synergistically.

Dithranol Dithranol, or anthralin, are hydroxyanthrones, which interfere with mitochondria and DNA replication, resulting in decreased skin turnover.3 They are slower acting compared to steroids, as they work on changing DNA replication, but they have fewer rebound or withdrawal effects. Their main disadvantages include: skin irritation and staining of the skin and surrounding objects, thus patients must be warned about this. It can be combined with phototherapy, topical tazarotene or steroids to enhance compliance as these therapies are fast acting so patients will see a clinical response, allowing the slower acting dithranol to take effect for long-term management.3 Vitamin D3 Vitamin D3 analogues can be natural or synthetic and work by reducing skin turnover, but it can also cause drying or pruritus.

They may be used in isolation or in combination with steroids, phototherapy or systemic therapies like ciclosporin or acitretin.3 Generally, when combined with steroids, there is less skin irritation, which is a noted side effect.8 Vitamin D analogues, e.g. calcipotriol (Dovonex), are used as one of the mainstay topical treatments for psoriasis, particularly in combination with steroids e.g. Dovobet.3,8 Patients find these preparations easy to use and less irritating to the skin.8 Pooled data from 14 trials reported significant improvement versus placebo with a 1.6-point improvement on a 12-point scale.7 Additionally, when directly compared with corticosteroids, there was no statistical difference in clinical efficacy, withdrawal or adverse events; with the best results from combination of topical Vitamin D analogues and corticosteroids.6 They also demonstrated greater efficacy when compared with dithranol.6 Vitamin A Vitamin A derivatives, or retinoids such as tazarotene, can also be used to slow skin growth, but have a common side-effect profile of skin irritation, dryness and photosensitivity, and cannot be used in pregnancy as they are teratogenic.3 A placebo-controlled trial with 318 patients suggested a clinical benefit of tazarotene by -0.77 (95% CI:-1.01 to -0.53).6 However, many other trials have smaller patient numbers and short follow-up periods, making it difficult to draw meaningful conclusions.6 Salicylic acids Salicylic acids are types of hydroxy acids and help to remove hyperkeratotic scale and plaques.3 Salicylic acid can sometimes be used prior to phototherapy as they reduce the hyperkeratosis associated with psoriasis allowing for better UV penetration.3 It can also be used in combination with steroids, coal tar or anthralin but does cause skin irritation.3 It tends to be combined with topical steroids to reduce skin irritation rather than in isolation as it doesnâ&#x20AC;&#x2122;t treat the underlying inflammatory process of psoriasis when used in isolation.3 Trials comparing Calcipotriol with combination therapy of potent steroid and salicylic acid in two trials with 320 patients found no difference in clinical effect between therapies (-0.04, 95%CI -0.26 to 0.18).6

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Given that psoriasis is a multi-system disorder, patient education regarding their condition is essential to manage not only the visible effects of psoriasis but also the metabolic and psychosocial aspects Coal tar Crude coal tar mixed with paraffin is an older therapy which has been used for centuries to treat psoriasis.3 It slows skin growth and has anti-inflammatory properties. It can be applied directly onto the skin, via a bath or in combination with phototherapy. However, it causes skin irritation, redness, dryness and stains, and in high doses it can be carcinogenic.

Urea Urea works as a keratolytic agent, but can cause skin irritation.3 Urea-based agents provide good skin care by moisturising the skin and forming a barrier, and acts as an antipruritic and antimicrobial agent. However, it has less effect on psoriasis overall as it doesnâ&#x20AC;&#x2122;t actively treat the inflammation associated with psoriasis but rather the hyperkeratotic by-products of the inflammatory process.6-7 Calcineurin inhibitors Calcineurin inhibitors, for example, tacrolimus or pimecrolimus, are used for eczema but have shown some success in psoriasis, although it remains unlicensed. Using pooled data from nine doubleblind and 13 open studies, efficacy was demonstrated for psoriasis, especially facial, flexural and genital psoriasis.9

Phototherapy Light therapy is generally offered when topicals have failed.2,3 This encompasses either phototherapy or chemo-phototherapy, which uses psoralen. Some smaller studies have also suggested blue-light to be effective, however these are only case reports so will not be covered.10 Both forms of light therapy have unclear mechanisms of action, but appear to have anti-inflammatory, immunosuppressive and antiproliferative effects.10-11 Psoralen can be administered topically or orally in addition to UVA light (wavelengths 320-400 nm),10,12 known collectively as PUVA. The advantage of systemic PUVA is it allows for widespread disease to be treated in one setting. However, systemic PUVA leaves patients susceptible to sun damage; therefore, sunprotection must be advised.11 PUVA (either topical or systemic psoralens) can also be combined with topicals (steroids or vitamin D analogues), with combinations

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of topical retinoids and PUVA demonstrating the best results.13 Comparatively, narrow band UVB (NBUVB) has similar efficacies, although is slightly less efficacious than PUVA, with the advantage of not requiring psoralen. NBUVB has shown safer profiles in children and pregnancy, whereas PUVA is contraindicated in these groups.13,14-15 NBUVB uses wavelengths of 311-312 nm, compared with broad-based UVB (BBUVB) ranging from 300-313 nm. Previously, BBUVB was used, but now NBUVB is preferred as there are fewer side effects and better remission rates.14 The exact mechanism of action remains unclear, but phototherapy has shown inhibition of DNA synthesis and keratinocyte hyperproliferation.2 It also induces immunosuppression, T-cell apoptosis and antiinflammatory cytokines.2 In the UK, the British Association of Dermatology (BAD) and the National Institute for Health and Care Excellence (NICE) recommend pre-testing to calculate the minimum erythema dose (MED) needed to initiate phototherapy, as all individuals respond differently; thus, the dose will vary based on skin type and photosensitivity.16-17 Treatment is then initiated at 50% minimum erythema dose, with 10-20% increments until a maximum dose is achieved or skin clears.14 Currently, the number of cumulative doses is limitless; however, both guidelines recommend that after 150-200 PUVA or 200-300 NBUVB sessions the risk of skin cancer is significant, and therapy should only be given in exceptional circumstances by clinicians balancing the patients risks and benefits from phototherapy.16,17 The majority of patients undergo five to 20 treatments before 50% clearance is achieved, with 63-80% achieving total clearance.14,18 Comparatively, PUVA achieves partial/complete clearance in 7090%.11,19 The disadvantages of phototherapy include short-term side effects such as erythema, burning, pruritus, blistering and dry skin.14,18 Long-term skin ageing, photo-damage, irregular pigmentation, actinic keratoses and skin cancers are more common and more prevalent with higher cumulative doses.10,11,20,21 Hence, the minimal dose of phototherapy should be used and only in patients with moderate to severe disease refractory to topicals. Additionally, facial and genital protection is recommended to protect sensitive areas from sun damage.2 Caution should also be taken with patients who have a history of skin cancer and Fitzpatrick skin type I-II skin.14 Furthermore, patients on calcium channel antagonists, phenothiazine or nonsteroidal anti-inflammatories (NSAIDs) have shown photosensitivity, although this is not common; if this occurs, these medications should be discontinued.2 Phototherapy is contraindicated in patients with xeroderma pigmentosa and lupus as these are photosensitive conditions.2 With PUVA there are additional contraindications to patients with immunosuppression, aphakia or allergic reactions to psoralens.10,20 Of note, patients will often experience relapses after treatment cessation, therefore they should be warned of this during consultation.

Another disadvantage is that this therapy can be time-consuming at two to three sessions per week.14,15 Phototherapy can be combined with topicals, although corticosteroids are not recommended as this potentially increases the risk of psoriasis reactivation after discontinuation of phototherapy.22 Systemic retinoids combined with phototherapy results in reduced cumulative UV exposure as fewer sessions are needed.2 However, as retinoids cause skin thinning, this can lead to increased phototoxicity.2 Overall, the risk/benefit balance must be individually considered as patients may willingly accept side effect profiles in preference of disease.10 Patients with darker skin (Fitzpatrick type V-VI) and elderly populations may benefit more from phototherapy as the long-term cancer risk is lower in these groups.19

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Conclusion Psoriasis is a multisystem disorder that requires good holistic care by clinicians to encompass both the skin disorder, the psychosocial aspect and the systemic comorbidities associated with the disease.

The psychosocial impact of this disease should not be overlooked and these burdens must be addressed for patients to feel valued and treated as a person not a disease. Generally, for mild to moderate psoriasis, emollients and topical therapies should be administered and can be managed in the community by primary care physicians. Complex cases will likely need dermatological assessment and review for possible systemics either in isolation or combination with topicals. From the literature there is no one topical therapy that is superior to the other, with all showing efficacy particularly when active agents are combined with keratolytic agents.

Overall, therapy must ultimately be individualised, based on the patient’s site severity and functional impairment of psoriasis, as well as any additional medications and comorbidities that could interact with their disease and treatment options.

Dr Priya Patel is a core medical trainee at East Surrey Hospital. She is an aspiring dermatologist, and takes an active interest in topics involving allergy and immunology.

REFERENCES: 1. Kim WB; Jerome D; Yeung J. Diagnosis and management of psoriasis. Canadian family physician Medecin de famille canadien; 2017; 63(4): 278-285 2. Naldi L; Griffiths CEM. Traditional Therapies in the Management of Moderate to Severe Chronic Plaque Psoriasis: An Assessment of the Benefits and Risks. British Journal of Dermatology. 2005; 152(4): 597-615.

3. Young M; Aldredge L; Parker P. Psoriasis for the primary care practitioner. Journal of the American Association of Nurse Practitioners; 2017; 29(3): 157-178.

4. Barrea L; Nappi F; Di Somma C; Savanelli MC; Falco A; Balato A; Balato N; Savastano S. Environmental Risk Factors in Psoriasis: The Point of View of the Nutritionist. International journal of environmental research and public health. 2016; 13( 5).

5. M J Kaplan. Cardiometabolic risk in psoriasis: differential effects of biologic agents. Vascular health risk management. 2008.4(6):1229-1235.

6. Mason J; Mason AR; Cork MJ. Topical preparations for the treatment of psoriasis: a systematic review. The British journal of dermatology; 2002; 146(3): 351-364.

7. Thaçi D; Augustin M; Krutmann J; Luger T. Importance of basic therapy in psoriasis. Journal of the German Society of Dermatology. 2015; 13(5): 415-418.

8. Stein Gold LF. Topical Therapies for Psoriasis: Improving Management Strategies and Patient Adherence. Seminars in cutaneous medicine and surgery; 2016; 35(2) supplement 2: 36-44; quiz S45 9. Wang C, Lin A. Efficacy of topical calcineurin inhibitors in psoriasis. Journal of Cutanous Medicine and Surgery. 2014;18(1):8-14.

10. Lowe NJ; Chizhevsky V; Gabriel H. Photo(chemo)therapy: general principles. Clinical Dermatology.

1997;15:745-52.

11. Lauharanta J. Photochemotherapy. Clinical Dermatology. 1997; 15: 769-80 12. Lebwohl M; Menter A; Koo J et al. Combination therapy to treat moderate to severe psoriasis.

Journal of American Academy of Dermatology. 2004; 50: 416-30.

13. Griffiths CEM; Clark CM; Chalmers RJG et al. A systematic review of treatments for severe psoriasis. Health Technology Assessment. 2000; 4:1-125.

14. Ibbotson SH; Bilsland D; Cox NH et al. An update and guidance on narrowband ultraviolet B phototherapy: a British Photodermatology Group Workshop Report. British Journal of Dermatology.

2004; 151: 283-97.

15. Gawkrodger DJ, on behalf of the Therapy Guidelines and Audit Subcommittee of the British Association of Dermatologists. Current management of psoriasis. Journal of Dermatological Treatment. 1997; 8: 27-55 16. National Institute for Health and Care Excellence (NICE) (2012): Psoriasis: assessment and management Clinical guideline [CG153]. <https://www.nice.org.uk/guidance/cg153> 17. British association of Dermatologists (BAD) (2016), British Photodermatology Group (BPG): Phototherapy service guidance. <http://www.bad.org.uk/shared/get-file. ashx?itemtype=document&id=4151> 18. Zanolli M. Phototherapy treatment of psoriasis today. Journal of American Academy of Dermatology. 2003; 49:78-86 19. Morison WL; Baughman RD; Day RM et al. Consensus workshop on the toxic effects of long-term PUVA therapy. Archives of Dermatology 1998; 134: 595-8.

20. ICN Pharmaceuticals Inc. Oxsoralen-Ultra® capsules (methoxsalen capsules, USP 10 mg).

Prescribing information, March 2003.

21. Stern RS; Lange R. Non-melanoma skin cancer occurring in patients treated with PUVA five to ten years after first treatment. J Invest Dermatology. 1988; 91:120-124.

22. Honigsmann H. Phototherapy for psoriasis. Clinical Experimental Dermatology. 2001; 26: 343-50.

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Male Facial Revolumisation with Dermal Fillers Dr Vincent Wong and Dr Pamela Benito present a step-by-step guide to rejuvenating the male face after volume loss Sexual dimorphism – the phenotypic differences between the sexes of the same species – in some ways may be less obvious when it comes to facial structure. However, the approach to male aesthetics is different from that of a female. As more men come forward for non-surgical enhancements, it is important that we understand sexual dimorphism and have a profound appreciation of both male and female beauty. This would prevent unwanted feminisation of the male face, which, from our experience, remains one of the main concerns amongst male patients seeking aesthetic treatment.

In this article, we detail the step-by-step treatment of a 40-year-old male patient who presented to us with facial volume loss after losing weight. Due to his job as a personal trainer and fitness model, his body weight fluctuates frequently. Upon presentation, he had lost 1.5 stone through intensive exercise and was worried about the ‘sunken appearance’ of his visage. The patient had never had any dermal filler procedures before the treatment. At the first consultation, we had a long and thorough discussion with the patient to identify his concerns, needs, worries and expectations. Benefits, risks and side effects, were also discussed, and alternative treatments including surgery were explored. The upper, middle, and lower thirds of the patient’s face were analysed for volume loss and the estimated volume of dermal filler required was also discussed. The patient was given a coolingoff period of two weeks before the procedure and was advised to carefully consider all the options. Photographs were taken before and after treatment, and consent forms were signed.

Step by step guide Our experience in treating male patients has led to the development of the ‘23XY Lift’, which describes the injection techniques of dermal fillers into the seven zones of the male face, where volume deficiencies are commonly found. 23XY is the genetic makeup of a male human (X and Y chromosome on chromosome number 23). This technique comprises seven single techniques, one for each zone, which are:

1. Temple 2. Cheek 3. Infraorbital region 4. Alar base 5. Corner of mouth 6. Chin 7. Angle of the jaw When it comes to male facial aesthetics, the 23XY Lift can help enhance the masculinity of the visage, and in our experience of performing 25 treatments using this technique, it also minimises the risks of complications and feminisation of the face. Here, we discuss the seven regions of the male face that can be treated using a step-by-step approach. These techniques are used widely within the aesthetics specialty and are considered safe. However, it is important to bear in mind that this is purely a guide, and there are various other techniques available for the same regions. The patient was treated using the following guide:

Facial analysis: male vs. female Facial attractiveness is characterised by a combination of factors that involve symmetry and proportions that are deemed aesthetically pleasing, according to a number of sources listed in the table below.

Before performing any facial enhancing procedures with dermal fillers, it is vital to analyse the patient’s face so that we: 1. Correctly identify the areas that need volumising 2. Respect the symmetry and proportions of the face

Facial attractiveness is characterised by a combination of factors that involve symmetry

Upper third ideals

Forehead

Eyebrows Glabella

Men

Women

• Greater height and width1,2 • Extensive supraorbital bossing (physical prominence of the supraorbital rim)3 • Flat area above bossing, before the convex curvature of upper forehead4

• Shorter and narrower forehead1,4 • Less or absent bossing4 • Entire forehead is a continuous mild curvature4

• Pronounced and projected1

• Less pronounced and less projected1

• Sit along orbital rim3 • Flat in contour3

• Sit above orbital rim3 • Arched at an angle of 10 to 20 degrees – peak in the lateral third3

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Middle third ideals

Eyes

Nose

Men

Women

• Proportionally smaller in relation to skull size2 • Low eyelid crease5 • Upper eyelids are fuller and more redundant5

• Proportionally bigger in relation to skull size2 • Higher eyelid crease5 • Less upper eyelid tissue5

• Flatter and more angular1,5 • Uniform distribution of subcutaneous fat6 • Apex is low, more medial and subtly defined6

• Rounder and fuller1,5 • Thicker subcutaneous fat compartment medially at a ratio of 1.5:1 7 • Apex is located higher on the mid-face, below and lateral to the lateral canthus and well defined7

• • • • •

Cheeks

Wide and straight Straight contour from radix to tip5 Radix position: at the level of tarsal fold5 Nasofrontal angle: approximately 130 degrees1 Nasolabial angle: 90 to 95 degrees1

Lower third ideals

Narrow and laterally concave Subtle 2mm concavity along contour of nose5 Radix position: at the level of lash line5 Presence of supra tip break (inflection point before the tip starts to elevate)5 • Nasofrontal angle: approximately 138 degrees1 • Nasolabial angle: 95 to 100 degrees, resulting in upward rotation of the tip1 • • • •

Men

Women

Lips

• More volume loss in the lower lip than upper lip with age5

• More volume loss in upper lip than lower lip with age5

Chin

• Larger and more protruding with well-developed lateral tubercles1

• Smaller, narrower and more pointed with less prominent lateral tubercles1

Jawline

• Wide and well-defined (square appearance) with large masseter muscle • Prominent angulation of the mandibular ramis5 • Lower gonial angle1

• Narrower and less prominent (V-shape) • Less prominent angulation of the mandibular ramis5 • Higher gonial angle1

Zone 1: Temple

arteries lie in the periosteal and muscular layers respectively in the inferior medial quadrant.8

Summary • Location: Superior medial quadrant of the temple • Depth: Periosteum • Volume: 0.5-0.6ml (bolus)

1. Palpate the superior medial quadrant of the temple for any vessels and identify a vessel-free area as the needle insertion point.

2. Insert the needle perpendicularly to reach the periosteum.

3. Aspirate to ensure that the needle tip is not in a vessel.

4. Slowly inject a bolus of 0.5-0.6ml.

5. Upon completion of the injection, apply firm pressure to the area to distribute the product evenly.

6. Further treatments in this area should be repeated until sufficient revolumisation is achieved.

Note The inferior half of the temporal fossa has a higher vascular density, hence a higher vascular risk, compared to the upper half.

Practitioners must note that the superficial temporal artery runs in the lateral third of the temporal fossa in the subcutaneous/ superficial muscular aponeurotic system (SMAS) layer. They should also be aware, that the anterior and posterior deep temporal

Zone 2: Cheeks – lateral cheek Summary • Location: Lateral cheek • Depth: Periosteum • Volume: 0.2ml per injection (bolus)

1. Draw a triangle connecting the lateral canthus, ipsilateral oral commissure and ipsilateral tragus (Figure 1).

2. Within the triangle, draw an oval with three points contacting the lines of the triangle tangentially.

3. Divide the oval into lateral, middle and medial thirds.

4. In the lateral third of the oval, pull the lateral cheek taut along

the zygoma. While maintaining the tissue in taut position, inject a single depot of 0.2ml supraperiosteally using a needle (perpendicular approach).

5. Apply pressure on the depot post injection to distribute it evenly.

6. Further injections should be repeated in the middle and medial third of the oval until sufficient revolumisation in the lateral cheek is achieved.

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Note The infraorbital foramen marks the location of the emergence of the infraorbital neurovascular bundle. Also, injections around the eye area have to be done supraperiosteally to prevent damage to the lymphatic drainage system.8 Figure 1: Marking for lateral cheek enhancement in a male face.

Zone 2: Cheeks – medial cheek Summary • Location: Medial cheek • Depth: Subcutaneous • Volume: 0.2-0.3ml per side (retrograde fan-shaped technique using a 25G cannula)

1. At the intersection of the alar-tragal line and the line dropping

vertically down from the lateral canthus, insert a 25G cannula into the subcutaneous layer and inject the medial cheek in a fan-shaped retrograde manner until sufficient revolumisation is achieved (on average 0.2-0.3ml per side in a male face).

Note Whereas the female cheek has a thicker fat compartment in the medial cheek, the male cheek is flatter, with a uniform distribution of fat and hence conforming more to the underlying structures. Therefore, the subcutaneous should be filled uniformly in a male face, replacing lost volume and maintaining the flatter and more angular cheek contour at the same time. Filling of the cheek also provides structural support to the tear trough and palpebral malar groove.

Zone 3: Infraorbital region Summary • Location: Infraorbital region • Depth: Periosteum • Volume: 0.3-0.4ml (retrograde) per side

1. Palpate and mark out the orbital rim. Injections in this area are

safe as long as they are below the orbital rim.

2. Locate and mark the infraorbital foramen by applying pressure using a cotton bud at a point 6-8mm below the orbital rim, slightly medial to the mid-pupillary line. The patient will feel a discomfort when the right spot is located. Avoid injecting into this high-risk area.

3. Identify the first injection site by placing the needle along the tear trough so that the tip of the needle is below the medial canthus.

4. Insert the needle perpendicularly to reach the periosteum and advance the needle along the tear trough on the orbital rim.

5. Aspirate to ensure that the needle tip is not in a vessel.

6. Inject slowly along the tear tough using a retrograde technique (approximately 0.1ml per injection) supraperiosteally.

7. Upon completion of the injection, apply gentle pressure to the area to distribute the product evenly.

8. Further injections should be repeated over the palpebral malar groove and the lateral lid-cheek junction.

Zone 4: Alar base Summary • Location: Alar base • Depth: Periosteum • Volume: 0.2ml per injection (bolus)

1. Insert needle perpendicularly onto the periosteum immediately lateral to the base of the nostril.

2. Aspirate to ensure that the needle tip is not in a vessel.

3. Slowly, inject a bolus of approximately 0.2ml.

4. Post injection, mould the depot accordingly.

Note The piriform becomes wider as the nose ages and alar base treatment will help define and restore a youthful appearance.

Note that the facial artery usually lies lateral to the buccal-maxillary ligament, and hence it is important to position the needle correctly, in the right depth and to aspirate before injection.8 Injections in the alar base come with a risk of vascular compression.8 Patients should be made aware of this and report any skin changes to the nose after the procedure. Also, filling of the nasolabial lines can be carried out in the same session if required.

Zone 5: Corner of mouth Summary • Location: Corner of the mouth • Depth: Deep dermis/superficial subcutaneous • Volume: 0.1-0.15ml (retrograde fan-shaped technique) per side

1. Identify a point 5mm lateral to the corner of the mouth.

2. Insert the needle superficially into the deep dermis/superficial subcutaneous layer, running parallel to the vermillion border.

3. Inject in a retrograde fan-shaped manner (approximately 0.10.15ml per side).

4. Mould the product accordingly.

Note Superficial injections in this region will help support the structure and skin texture of the corners of the mouth. This treatment can be supported with deeper injections inferiorly towards the chin if required; dermal fillers should be injected medial to the mandibular retaining ligament.

Zone 6: Chin Summary • Location: Chin • Depth: Periosteum • Volume: Approximately 0.2ml per injection (bolus)

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1. Identify the area of weakness in the lateral border of the chin

by pinching it horizontally.

2. Insert needle perpendicularly onto the periosteum, medial to the mandibular retaining ligament.

3. Aspirate to ensure that the needle tip is not in a vessel.

4. Slowly, inject a bolus of approximately 0.2ml per side.

5. Mould the depot accordingly post injection.

6. Repeat until sufficient revolumisation is achieved.

7. Stress the chin to identify the point of weakness in the pogonion (Riedel line) by pinching the chin horizontally.

8. Insert the needle perpendicularly onto the periosteum.

9. Aspirate to ensure that the needle tip is not in a vessel.

10. Slowly, inject a bolus of approximately 0.2ml.

11. Mould the depot accordingly post injection. This treatment will increase anterior projection of the chin.

12. Repeat until sufficient revolumisation is achieved.

13. To elongate the chin, inject a slow depot of 0.2ml supraperiosteally at the most inferior point of the chin on each side using an inferior perpendicular approach (aspirate before injecting). Further injections should be repeated until the desired result is achieved.

Note In a male, the lateral border of the chin should correlate with a vertical line dropped from the corner of the mouth.9 For men with a chin cleft requesting anterior projection/elongation, fillers should be injected lateral to the cleft in order to preserve it. Increasing the forward projection of the chin will also tighten the skin around the jawline area. Treatment of the lateral borders of the chin alone will result in a squarer chin, as well as a sharper and well-defined jawline. A line connecting the most prominent portion of the upper and lower lip should touch the pogonion.9 The lower lip should be 2-3mm posterior to the upper lip and the pogonion should never project beyond this line; if this was disrupted, the overall facial harmony would be disrupted too. Treatment of the mental crease can also be carried out in the same session (superficial injections).

Zone 7: Angle of the jaw Summary • Location: Angle of the jaw • Depth: Periosteum • Volume: Approximately 0.3ml per side (bolus)

1. Pinch the angle of the jaw and lift the tissue with the thumb and index finger of the non-injecting hand.

2. Insert needle perpendicularly onto the periosteum.

3. Aspirate to ensure that the needle tip is not in a vessel.

4. Slowly, inject a bolus of approximately 0.3ml per side.

5. Mould the depot accordingly post injection.

6. Further injections should be repeated until the desired result is achieved.

Note Most males are blunt at the angle of the jaw, partially due to thinning of the temporal-buccal fat pad, and this treatment will project the jaw laterally and strengthen the jawline, resulting in

Aesthetics Journal

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a square jaw, which is usually desirable in a man. Dermal fillers must be injected supraperiosteally to avoid damage to important structures (e.g. parotid gland and ducts).

Results The patient was seen three times in total – consultation, treatment, and review at three-weeks post treatment. He was quite swollen and bruised, but that resolved spontaneously without any interventions.

As seen in Figure 2, the patient’s results were immediately visible.

Significant improvements to his concerns were observed. He looked more youthful, energetic and well-rested after treatment. To further optimise his results, skin resurfacing treatments were recommended, for example skin peels and laser treatments.

Before

After

Figure 2: The patient before and after treatment using the 23XY Lift with dermal fillers.

Conclusion The aesthetic approach to treating a male face differs significantly to that of a female face. As aesthetic medicine predominantly focuses on the female face, characteristics of the male face must be fully understood and appreciated before being applied in our practice. This case study demonstrated that the male face can be successfully rejuvenated without risk of feminisation.

Dr Vincent Wong is an advanced medical aesthetics practitioner and the founder of Harley Street clinic, La Maison de l’Esthetique. He is a fully qualified doctor with extensive research experience in plastic surgery and dermatology.

Dr Pamela Benito received her DDS degree at Madrid University in 2006, and then moved to the UK and practised general dentistry for two years while starting training in the field of facial aesthetics.

REFERENCES 1. Ravichandran E, Ravichandran S. Male vs. Female Facial Rejuvenation. Aesthetics Journal 2015;2(11) 2. Snow CC, Gatliff BP, McWilliams KR. Reconstruction of facial features from the skull: An evaluation of its usefulness in forensic anthropology. American Journal of Physical Anthropology 1970;33(2):221-7.

3. Goldstein SM, Katowitz JA. The male eyebrow: A topographic anatomic analysis. Ophthalmic Plastic & Reconstructive Surgery 2005;21(4):285-91.

4. Ousterhout DK. Feminization of the forehead: Contour changing to improve female aesthetics.

Plast Reconstr Surg 1987, May;79(5):701-13.

5. Farhadian JA, Bloom BS, Brauer JA. Male aesthetics: A review of facial anatomy and pertinent clinical implications. Journal of Drugs in Dermatology: JDD 2015;14(9):1029-34.

6. Wysong A, Kim D, Joseph T, MacFarlane DF, Tang JY, Gladstone HB. Quantifying soft tissue loss in the aging male face using magnetic resonance imaging. Dermatologic Surgery 2014;40(7):786-93.

7. Wysong A, Joseph T, Kim D, Tang JY, Gladstone HB. Quantifying soft tissue loss in facial aging: A study in women using magnetic resonance imaging. Dermatol Surg 2013, Dec;39(12):1895-902.

8. Andre, P. and Garcia, P. (2012). Anatomy and volumising injections. [UK]: E2e Medical Pub. 9. Marquardt Beauty Analysis, Face Variations by Sex (2014) <http://www.beautyanalysis.com/ beauty-and-you/face-variations/face-variations-sex/>

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Improving the Appearance of Cellulite

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are themselves grouped into larger pearls and sections, and these are all held together with connective tissue. There are two layers; the deeper layer has larger sections arranged like segments of an orange, which is separated from the superficial fat layer; this is made of smaller palisading columnar fatty pearls. Adults have a fixed number and distribution of fat cells, which determine body shape and type.4 They do not increase in number with weight gain, but they do get bigger, bulging out from the connective tissue restraint, to give the effect of quilting of a mattress (Figure 2). Another cause of increased tension, causing bulging of the connective tissue, is an increase in tissue fluid, as in lymphoedema. This is an accumulation of tissue fluid due to a deficiency in the lymphatic drainage system.5,6

What factors make cellulite worse?

A large percentage of females are thought to have cellulite, and it is normal. It is rare in men and this is thought to be because there Dr Bryan Mayou shares his knowledge on the is less fat in the areas where we see cellulite. different approaches to treating cellulite Additionally, there is a different arrangement of the fatty pearls in the superficial layer, which What is cellulite? are arranged flatter, rather than as vertical columns.7 The influence Put simply, cellulite is the appearance of dimpled skin, which presents of female hormones is mainly on the fat distribution in the areas of mainly on the outer thighs (Figure 1). Its most minor manifestation is secondary sexual development. It is at puberty that girls develop fat dimpling, which can be induced by grasping the skin and underlying over the buttocks, hips and lower abdomen and this is where cellulite tissue between two hands and pushing them together or, alternatively, most commonly occurs. by voluntarily clamping the underlying muscle. This is grade I, In my clinic, I rarely see cellulite in dark skin types and I believe there according to the Nürnberger and Müller scale.1 Nürnberger and Müller are two reasons for this. The first is that the stratum corneum is much proposed the first clinical grading scale for cellulite, dividing the more compact and more elastic,8 which also is a reason that, apart condition into three grades, as described in the table below (Figure from the pigmentation, we see less effects from ageing. The second, 2). At this point I should point out that cellulitis is of course nothing is that the subcutaneous tissue contains much more connective to do with cellulite and is inflammation and infection of the skin and tissue.8 As surgeons, we are aware of this, as performing liposuction 2 underlying fat. procedures in dark skinned patients is generally much harder work, requiring more time due to this connective tissue.

Anatomy Clearly, the more fat a patient has, the more obvious cellulite will To understand the appearance, we need to understand the anatomy become, as tension rises within the subcutaneous fatty pearls. of the skin and underlying fat. There are two layers of fat under the skin constrained in compartments by strands of connective tissue, Treatments made up of collagen, which gives it structure so that the fat does not Treatments can clearly be directed at reducing tension within the ‘flop about’. The most supportive strands occur in the palms and soles, subcutaneous fatty pearls and by tightening the elasticity of the skin. where no movement of the soft tissue can be tolerated.3 As a surgeon who specialises in liposuction, I will focus this article on The fat cells are grouped into lobules by connective tissue, which the surgical treatment of fat, as well as the surgical and non-surgical approach to skin tightening.

Figure 1: Cellulite affecting anterior and posterior thighs

Fat reduction – liposuction Immediately after I introduced liposuction into the UK 35 years ago, I was besieged by patients asking for treatment of their cellulite.

Cellulite is more common in overlying localised fatty deposits of the hips, buttocks and abdomen, however, I was also getting requests from slim patients with just a little bulge of fat. At this point, it looked possible that by reducing the tension in the fat, the mattress effect would also be reduced. However, this turned out not to be the case, because we were reducing the deeper layers of fat, rather than the superficial. Liposuction is used to improve the general shape and a proportion of fat removed is processed

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and reinjected immediately under the dimples, as close as possible to the skin. The superficial reinjection of some of this processed fat is counter intuitive, but nevertheless, can be very helpful in the treatment of big dimples and contour defects which I come across all too frequently from the inexpert use of liposuction. I think it does improve cellulite to a small degree, but I have no evidence to support this.

Improving the shape does make patients very happy and often the problem of cellulite becomes less acute. Although the contour of the body can be improved with liposuction, the quality of the skin will remain unchanged. For practitioners who are not trained in liposuction, it’s worth knowing someone who you can refer liposuction cases to in your local area.

Aesthetics

Non-surgical treatments

Figure 2: Nürnberger and Müller Scale

Less invasive treatments are popular, and logically the skin tightening of radiofrequency techniques, ultrasound and non-ablative lasers are currently the most promising. Radiofrequency in its various forms gives a minor, but for many, worthwhile improvement.

A more sophisticated technique is the use of the Nd-YAG 4410-nm wavelength device. A thin laser fibre is threaded under the skin and, firing sideways, divides these same connective bands, releasing skin that was being pulled downwards, creating the dimples. In addition, the heat stimulates collagen and elastin production to thicken and tighten the skin. This gives consistently moderate, but worthwhile improvements, even though the very long-term results have yet to be assessed. It is difficult to prove if the even less invasive lymphatic massage and endomology (a mechanical massaging, rolling and sucking of the skin’s surface) makes a difference as there are not enough studies to support it, but this does not mean that patients are not content. Zerini et al., from Sienna, reviewed 73 articles and found that many of the topical treatments showed surprisingly good results at the end of treatment time, but as with so many of these studies, the follow-up was short.11 These applications were a combination of many ingredients including tetrahydroxy, propyl, ethylene, diamine, caffeine, carnitene, forskolin and retinol. After 12 weeks, 79% of patients showed improvement in their skin condition. Caffeine was probably the most potent compound preventing excess accumulation of fat in cells. It also has potent antioxidant properties and protects cells against UV radiation and slowing down the process of photoageing of the skin. It also increases the microcirculation of blood and stimulates the growth of hair.12

Surgical skin tightening

Conclusion

Surgical skin tightening is highly effective, but only suitable in a limited number of cases where there is a large laxity of skin. This surplus skin is simply excised, removing the worst of the dimples, allowing the remaining skin to be sutured up much tighter, making the dimples less obvious. This is most effective for the buttocks, outer thighs and inner thighs, however the effect is limited in its extent. During consultation, patients typically pull up the skin of their thighs to show how all the dimples down to the knees are improved, but in practice, the improvement will be limited to the upper part of the thigh. This is because the subcutaneous fat and skin of the thigh is heavy and have been mobilised by liposuction and then pulled upwards against gravity. One is trying to hide the scars high up in the groin and under the buttock fold. If the outer thigh is also treated, then the scar needs to be extended up in the line of a G-string, where it will be more visible. For many people, the improvement is well worth a scar, which will eventually fade after a year or so.

The division of the connective tissue bands, causing the mattress effect, is logical and perhaps can be termed minimally invasive. In its simplest form, it is subcision, which has been used on and off for many years. In a study by Hexsel, 232 women were treated using this technique with subjectively favourable results in 79% of patients who stated they were satisfied.9 However, there was a certain amount of reported pain, bruising and haemasiderosis in most patients. Recently, subcision has been standardised and marketed as Cellfina and has produced similar good results.10 From speaking to exponents of Cellulaze, a laser device that uses heat energy to cut the connective bands, they make an interesting point that these lasers introduced immediately under the skin are doing the same subcision but in addition can cause contraction of the connective tissue support and therefore may give an even better improvement.

No single treatment has shown to be significantly effective. It may be that the answer is in a combination of treatments to achieve the optimum result. We do, however, need much better randomised, controlled studies before we can make fully justified recommendations.

0

No alteration to the skin surface

I

The skin of the affected area is smooth while the subject is standing or lying, but the alterations to the skin surface can be seen by pinching the skin or with muscle contraction

II

The orange skin or mattress appearance is evident when standing, without the use of manipulation (skin pinching or muscle contraction)

III

The alterations described in degree or stage II are present together with raised areas and nodules

Mr Bryan Mayou is a plastic surgeon and the founder of the Cadogan Clinic. Renowned for his pioneering work in liposuction, having introduced it to the UK more than 30 years ago, Mr Mayou is also highly-regarded for specialising in face lifts, breast surgery and fat transfer procedures.

REFERENCES 1. Nürnberger F, Müller G. So-called cellulite: an invented disease. J Dermatol Surg Oncol. 1978 Mar;4(3):221-9 2. NHS, Cellulitis, (2017) <https://www.nhs.uk/conditions/cellulitis/> 3. OpenStax, Anatomy & Physiology. OpenStax CNX. Feb 26, 2016 http://cnx.org/contents/14fb4ad739a1-4eee-ab6e-3ef2482e3e22@8.24.

4. Pool, Robert (2001). Fat: fighting the obesity epidemic. Oxford [Oxfordshire]: Oxford University Press. p. 68. ISBN 0-19-511853-7.

5. Nicole J. Achenbach and Len Kravitz, Cellulite: A Review of Its Anatomy, Physiology and Treatment, IDEA Fitness Journal, (2010) 6. NHS, Lymphoedema, (2017) <https://www.nhs.uk/conditions/lymphoedema/> 7. Barry E. DiBernardo & Jason N. Pozner, Lasers and Non-surgical Rejuvenation, Non-invasive body contouring, p.139 8. Nikki Tang , Candrice Heath , and Nanette B. Silverberg, Developmental Biology of Black Skin, Hair, and Nails, Pediatric Skin of Color, Springer Science+Business Media New York 2015 9. Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite. Int J Dermatol. 2000 Jul;39(7):539-44.

10. Kaminer, M.S., Coleman WP 3rd, Weiss RA et al., A Multicenter Pivotal Study to Evaluate Tissue Stabilized-Guided Subcision Using the Cellfina Device for the Treatment of Cellulite With 3-Year Follow-up. Dermatol Surg, 2017 Jun 28 11. Zerini I, Sisti A, Cuomo R1 et al. Cellulite treatment: a complete literature review. J Cosmet Dermatol.

2015 Sep;14(3):224-40 12. Herman A1, Herman AP, Caffeine’s mechanisms of action and its cosmetic use, Skin Pharmacol Physiol, (2013)

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Background

Case Study: Dissolution of HA Filler in the Lower Eyelid Dr Christine Cowpland discusses the use of HA dermal fillers to treat the lower eyelid in Asian patients and shares a case study where she used hyaluronidase to remove filler in this area Historically, hyaluronic acid (HA) fillers have been used to address folds and wrinkles and correct soft tissue loss.1 With the arrival of new products on the market, and as patient awareness and expectation has increased, the demand for newer and more novel dermal filler procedures has risen.2 Since 2015, an upward trend of injecting dermal filler into the lower eyelid has been seen, principally in Asian patients.3 The ‘under-eye-bands’, formed with HA, are believed to create the illusion of ‘youthful

innocence’, with the appearance of a larger eye aperture, resulting in a more ‘bright-eyed appearance’.3 I was recently contacted by a Korean patient who was unhappy with the cosmetic result of a lower eyelid dermal filler augmentation which had been performed overseas.

This article will share a case study that describes the management of this patient with hyaluronidase. It will also detail the dilution process of a very small amount of hyaluronidase (1.5 IU) and discuss its efficacy.

To treat the lower lids, two 1ml syringes of hyaluronidase were used, one syringe for each eye, from which 0.1ml of product was injected

Within the past decade, there has been a tremendous increase in the number of patients who request and receive facial injectable treatments in Asia.4 Much of the published recommendations reference Western populations,4 but Asians differ in terms of attitudes to beauty and structural facial anatomy. An appreciation of the key aesthetic concerns and requirements for the Asian face is vital to planning appropriate facial aesthetic treatments with HA fillers.4 A 2016 consensus on changing trends and attitudes of Asian beauty reported that attractiveness is achieved by aiming to create an oval facial shape, increasing the vertical height of the face and narrowing the lower face.4 The three-dimensionality of the face is improved by brow, nose, chin and medial cheek projection, and the appearance of the eyes is enlarged by double eyelid augmentation.4 Here, Asians are defined as the diverse groups of ethnicities from East Asia (e.g. China, Korea, Japan, Hong Kong, Taiwan) and Southeast Asia (e.g. Thailand, Singapore, Indonesia, Philippines); those from the Indian subcontinent are not included.

Aegyo-sal In ancient times, the Chinese favoured the appearance of almond-shaped eyes,4 however today, large rounded eyes are considered to be the benchmark of beauty and attractiveness.3 A recent trend in Korea is to enhance lower eyelid protrusion, in order to achieve a more rounded, wide-eyed look.

This ‘Korean-style eye bag’ is also known as ‘aegyo-sal’, which translates to ‘cute skin’ or ‘beautiful/winsome skin’ in Korean or ‘love band’, and is compared to the rolls that are found under the lower eyelashes of a young child. Aegyo-sal is meant to mimic the orbicularis roll, a sphincter that goes all the way around the eye and when voluntarily tightened, closes the eye. The aegyo-sal is often lacking in East Asians. It is important to note that aegyo-sal is not the same as an under-eye bag, caused by bulging lower

Region Nasal and perioral skin

Hyaluronidase (IU) 15-30

Periorbital

30

Infraorbital

10-15

Lower lid

1.5

Figure 1: The use of hyaluronidase in aesthetic practice in line with ACE Group guidelines9

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Aesthetics Dilution of hyaluronidase

Step

Test patch dilution procedure

Dilution strength

1

1,500 IU dissolved into 10ml syringe of 0.9% saline

10ml: 1,500 IU

2

Draw off 1ml into a 1ml syringe (a male to male adaptor was used)

1ml: 150 IU

3

0.1ml of this dilution was used for the 15 IU test patch

0.1ml: 15 IU

Injection of 1.5 IU dilution procedure (author’s protocol)

Dilution strength

4

Draw 0.1ml of solution from the 1ml test patch syringe into a second 1ml syringe* (a male-to-male adaptor was used)

0.1ml = 15 IU or 0.01ml = 1.5 IU**

5

Draw up 0.9ml of 0.9% saline into this second syringe to form 1ml of solution

1ml = 15 IU or 0.1ml = 1.5 IU

6

Inject up to 0.1ml into each eye

0.1ml = 1.5 IU

Figure 2: Dilution process of hyaluronidase *This procedure was performed twice; one syringe for each eye* **Cannot inject 0.01ml as the volume is too small, therefore need to re-dilute as mentioned in Steps 4 and 5** 10

eyelid fat.5 The result of aegyo-sal treatment may be temporary or permanent, depending on the technique used. Autologous fat transfer or dermal filler can be employed for a short to medium-term effect. HA filler is injected medially, centrally and laterally, with a cotton-tip applicator used to even the injection and enhance projection.5 A permanent solution includes acellular dermal matrix (ADM) strips inserted below the eyes, composed of a collagen matrix made from foetal bovine dermis, which acts as a scaffold for native cell growth and promotes localised fullness to create aegyosal.3 There are also many online tutorials documenting how to achieve the ‘aegyo-sal effect’ effect using makeup or tape.6,7,8

Case study I was contacted by a female in her 30s who was looking for a practitioner to dissolve a dermal filler which had been injected

Rather than creating a more youthful and fresh appearance, the patient felt that the dermal filler placed under her eyes had resulted in shadowing, leaving her looking tired into her lower eyelids. The treatment had been performed ten days prior, whilst visiting China. The quantity and consistency of product used was not known. Rather than creating a more youthful and fresh appearance, the patient felt that the dermal filler placed under her eyes had resulted in shadowing, leaving her looking tired. In

addition, the HA was very discrete and firm in texture, with a slightly pointed rather than rounded shape, so she was keen to have this removed as soon as possible.

This case will document the successful injection of hyaluronidase to dissolve lower eyelid dermal filler. It will also describe the dilution process and injection technique

Figure 3: Before, immediately after and 10 days’ post injection of hyaluronidase.

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Learning points • Practice going through the hyaluronidase protocol in case of emergency10 • Keep an emergency hyaluronidase box containing glyceryl trinitrate (GTN), aspirin, heating pads, syringes, tips, male to male adaptor, etc.

• Refer to guidelines before injecting hyaluronidase9,10 • Perform a test patch prior to injection of hyaluronidase where possible • The effects of hyaluronidase may not be apparent for days to weeks, so it is important not to over-treat • Social norms change, as learnt from this case study, so it is important to stay up to date with trends

for administering a very small amount of hyaluronidase. The treatment protocol is based on the Aesthetic Complications Expert (ACE) Group guidelines (Figure 1)9, as well as a hyaluronidase protocol by aesthetic nurse prescriber Lee Rowe, as published in the Aesthetics journal.10 Reconstitution of hyaluronidase Following an initial phone conversation, the patient was seen in clinic for a consultation.

Written consent was obtained, and she was advised to return the following week in order to allow time for any bruising or swelling from the original HA treatment to settle. On the day of treatment, a test patch for hyaluronidase was performed with no reaction. The amount of hyaluronidase recommended for an intradermal test patch varies between four-to-eight units and 20 units; higher doses are suggested by some authors, in order to reduce the likelihood of a false negative reaction to the test.9,11 I therefore elected to stay within these limits and administered 15 IU for the test patch. The dilution process is described in Figure 2. To treat the lower lids, two 1ml syringes of hyaluronidase were used, one syringe for each eye, from which 0.1ml of product was injected. According to the ACE Group guidelines, the recommended hyaluronidase units for treating the lower lid is 1.5 IU (Figure 1).9 In order to achieve a dilution which was appropriate, but with a volume big enough to be able to inject accurately, the hyaluronidase required an extra step of dilution (Figure 2).

Administration of hyaluronidase Initially, 0.5ml of solution (0.75 IU) was injected into each lower eyelid, three boluses per eye; one medial, one lateral, and one central with the patient reclining slightly from vertical, whilst looking upwards. The areas were then gently massaged using the tip of a swab.

Around 30 minutes later the result was

assessed, and it was decided to inject the remaining 0.5ml into each side. The patient was comfortable throughout. As expected there was some mild post-treatment swelling, however, there was some immediate effect and the patient was pleased. She was given a ‘Hyalase Injection Aftercare’ leaflet, as recommended by the ACE Group guidelines, when she departed the clinic.9 Results can be seen in Figure 3.

During the follow-up visit 14 days later, the patient was very satisfied and it was mutually agreed not to treat any further.

Discussion After the test patch, a practical difficulty arose when it came time to administer ‘1.5 IU in 0.01ml of solution’, since a volume of 0.01ml in a 1ml syringe is not large enough to inject (Figure 2). It was therefore necessary to redilute in order to get a large enough volume, to be able to inject accurately. Using a maleto-male adaptor to transfer solutions between the syringes during the dilution was helpful, as it enables you to transfer from a day-today 10ml syringe to a 1ml syringe easily. I have since added one of these adaptors to the clinic ‘emergency hyaluronidase box’ to ensure that in a situation when time is short, time is not wasted transferring solutions between syringes. Doses of up to 30 IU or more of hyaluronidase are often used (Figure 1), with significanatly higher doses in emergency situations,12 so it was interesting to observe the potency of just 1.5 IU. Although it is recommended to use clinical judgement rather than absolute doses when administering hyaluronidase, in my experience with this case, the guidelines appear to have been quite accurate in suggesting 1.5 IU for the lower lid area.

Hyaluronidase starts to work immediately, however it is important to under-treat where possible as the full effect may not be apparent for one to two days afterwards or longer, depending on the concentration of

HA filler, level of cross-linking and amount of HA deposit.10 Although there weren’t any complications in this case study, complications can occur, with an allergic reaction to hyaluronidase being the most common.9 Allergic reaction signs include oedema, erythema, pain and itching.

Following the use of hyaluronidase, the patient should be observed for 30 minutes to avoid complications occurring.9

Summary The uses for HA dermal fillers continue to expand and injection techniques may vary in different countries according to local aesthetic aspirations and norms. Aegyo-sal is a beauty trend becoming more popular, particularly in Asian populations, and can be achieved through dermal filler injection.

In the event of an undesirable result, from my experience, 1.5 IU of hyaluronidase appears to be a reasonable amount to treat this area, in keeping with recent ACE Group guidelines.9 Dr Christine Cowpland graduated from the University of Birmingham with a degree in medicine, and a Bachelor of Science (Honours) degree from the University of Guelph in Ontario, Canada.

Dr Cowpland established CMedical Aesthetic Clinic in Bristol and has acted as a mentor and examiner at the Harley Academy in London.

REFERENCES 1. Rzany B, Hilton S, Prager W, ‘Expert guideline on the use of porcine collagen in aesthetic medicine.’ J Dtsch Dermatol Ges (2010);8 (3): 210- 217 2. Funt DK: ‘Avoiding malar enema during midface/ cheek augmentation with dermal fillers.’ J Clin Aesthet Dermatol.

(2011);4(12):32–36.)

3. Abdulla Fakhro, Hyung Woo Yim, Long Kuy Kim et al. Semin Plast Surg, ‘The Evolution of looks and expectations of asian eyelid and eye appearance.’ (2015) Aug;29(3): 135-144.

4. Lieu S, Wu WT, Chan HH et al. ‘Consensus on changing trends, attitudes, and concepts of Asian beauty.’ Aesthetic Plast Surg.

2016; 40: 193-201.

5. What is aegyo sal? (Brett Kotlus MD) < https://drkotlus.com/ love-band/> 6. How To: Aegyo Sal (Elle Jess, 2016) <https://www.youtube.com/ watch?v=45l3bgSXsX8&t=53s> 7. How to Create Korean Style Eye Bag (Stayoung Seoul, 2016) <https://www.youtube.com/watch?v=THRc6vGPp30> 8. Aegyo Sal Make Up (Mariya Lee, 2014) <https://www.youtube. com/watch?v=dXZWUAQMXjg> 9. King M. ‘The Use of Hyaluronidse in Aesthetic Practice.’ Aesthetic Complications Expert Group (2016) Feb: 1-9.

10. Rowe, L. ‘Hyaluronidase Protocol’ Aesthetics Journal. 2015 <https://aestheticsjournal.com/feature/hyaluronidase-protocol> 11. Vartanian, J, Frankel, A, et al. ‘Injected Hyaluronidase Reduces Restylane-Mediated Cutaneous Augmentation.’ Arch Facial Plast Surg. 2005;7:231-237.

12. Ozturk CN, Li Y, Tung R, et al. ‘Complications following injection of soft-tissue fillers’ Aesthet Surg J. 2013;33(6):862-877.2.

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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Case Study Mid-face and Jowls

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process before carrying out these treatments.

If the patient’s nasolabial folds were to be injected, the buccal fat pads would appear to thicken, which would add to the heaviness.

This is the opposite of the look we are trying to achieve. It is important to always look where the cause of the symptom is and correct Nurse prescriber Victoria Parsons presents a case this rather than the result of the cause. The shape of this patient’s face is typical of many study of correcting jowl heaviness as a result of women in their late 40s, where we can see the face changing from a V-shape, to a square, mid-face volume loss using HA dermal filler bottom-heavy shape. This can be reversed, to A 50-year-old female patient who I have treated many times a degree, by restoring volume to the mid-face, as this will impact on before with toxin, fillers and high-intensity ultrasound came into the appearance of the lower face. my clinic complaining that, after going through the menopause, she felt her face was changing shape and becoming almost Product selection masculine. From performing an assessment, I could see that her Choosing the correct filler is very important, especially when you jawline appeared to be ‘squaring off’ and her cheek area, although are restoring volume to a patient’s face, as you need a filler that not completely flat, had definitely dropped, giving the appearance is going to retain its form, but is still flexible on movement. It must of a heaviness to the jowl area. The buccal fat pads were also support the tissue and integrate well so the patient cannot feel a accentuated due to loss of volume and separation to the malar pads. hard bolus of product.

The patient presented with the typical appearance of mid-face fat In my clinic, I tend to stick with using hyaluronic acid (HA) filler. This is a loss which was affecting the lower face. personal preference as, if there is a problem, we can dissolve the filler Although the patient initially came to me requesting filler to add immediately using hyaluronidase. One of the prime considerations volume to the nasoloabial folds, I decided that restoring lost volume to make when choosing which product to use is the thickness of the within the cheek area would be more beneficial. I knew that, by patient’s skin. If the skin is thin, then a softer product is generally better. injecting the lower face with dermal filler, I might accentuate the As such, I usually use thinner products for older patients. If a patient heaviness that she was already experiencing. I had to explain this to has adequate soft tissue coverage, like the patient in this case did, my patient and assure her that by lifting the cheeks, the lower areas then a thicker filler may be used. For this patient, we chose Juvéderm would be improved and lifted, and that we needed to look at what was Voluma as it is a thick, viscous product and gives shape and volume causing the heaviness, not add to the thickening of the lower face. to an area. We also used Juvéderm Volift to give support beneath the Once this was explained, my patient was happy to proceed. cheek area. Volift has a good lifting effect but has a medium viscosity and less extrusion force is needed when injecting.

Facial ageing For this patient, I chose a thick, viscous product that gave shape and The process of facial ageing starts with structural changes on the volume to the area. I also used a medium viscosity product which had surface and subsurface on multiple tissue layers, including skin, fat a good lifting effect and needed less extrusion force is when injecting. and muscle, as well as changes to the bone structure itself. Volume loss occurs due to fat redistribution, bones become thinner and Treatment method flatter in places and muscles and ligaments loosen, which underpin As well as the product, the correct technique of injection is also the skin. All of these factors contribute to an overall aged facial important; if you are not injecting in the right plane or depth you will appearance.1 not get the desired result from the product.

As with this patient, the menopause also has an effect on facial I marked where I wanted to inject on the patient’s face after ageing. Oestrogen is responsible for stimulating the deposition of fat cleansing thoroughly. By doing this, I was able to note the danger evenly throughout the female body but, following the menopause, areas I intended to avoid, such as the zygomatic facial artery, there is a reduction of oestrogen levels, resulting in fat being infraorbital artery, parotid gland, buccal nerve and the facial artery deposited in a high concentration on the abdomen, buttocks and and vein. thighs, and less so on the face and neck.2 I also marked the point on the zygomatic arch, where the patient Changes in one area due to ageing will affect the surrounding areas, used to have the most protrusion or width. Some of this had been as seen in this patient, so it is important to understand the ageing lost due to the ageing process with bone structural changes and

Case Study: Treating the Mid-face and Jowls

Before

Before

During

After

Figure 1: Case study patient before and after treatment

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

After

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loss of fat pads. I used topical anaesthesia, although I always tell patients that cheek fillers are more ‘uncomfortable’ than painful due to the depth of the injection and they tend to feel more of a pressure than any real pain. I injected using a needle at the highest point on the zygomatic arch, going down to the periosteum, aspirating, then depositing approximately 0.1ml of Juvéderm Voluma, which gave a visible lift.

I then moved down to the second injection point, which was approximately 1cm away from the first injection site. This second bolus of approximately 0.1ml continued to build on the cheek structure to give the patient a lift, which was noticed due to the softening of the nasolabial folds. I added another point to restore the malar pad which had dropped, causing quite a heavy fold. This patient did not show signs of separation, usually seen as a dip between the middle cheek fat pad and the nasolabial fold, instead she just looked heavy and square in the lower face. The cheek had now lifted and the two sides of her face were clearly different due to the lift achieved with the added volume. At this point I showed the patient the difference between the two sides and took photographs of the side view to demonstrate the difference.

I then moved lower down the face to address the lateral lower cheek and parotid area. By treating this area, I was able to lift the jawline. I used a cannula, injecting midway between the nostril and the tragus to vector the product; this helped to support the area I had treated above, as well as to lift the lower face. By injecting slight volume into the lower cheek and the submental, the jawline was improved and a lower lift was created, which slimmed the patient’s face. In this area I used a total of 0.7ml filler; this was more than was used on the other side, where only 0.5ml was needed.

Results There was no bruising and the patient’s results were subtle, as requested. The patient was given aftercare advice and an emergency number to call just in case. She was advised that bruising and swelling can occur, but will quickly resolve. I also mentioned that redness and a tenderness is normal, but I advise patients that if they are experiencing pain or throbbing to call the clinic immediately as this may be an allergic reaction or a possible infection. In addition, I told the patient to get in touch immediately if she noticed any discoloration to the skin near the injection sites, as this could mean a possible occlusion.

The results obtained from creating mid-face volume on this patient impacted the lower face, lifting the nasolabial folds and improving the heaviness she had presented with. By treating the cheeks, we were able to soften the patient’s face and took away some of the heaviness that she had been unhappy about. The patient was reviewed after two weeks and remained happy with the results.

Victoria Parsons is a registered nurse and an independent nurse prescriber, who has been qualified for 10 years, working solely in aesthetics. Her clinic is in the town of Westerham, Kent. Aside from running her own clinic, she teaches foundation botulinum toxin and fillers with Cosmetic Courses in Buckinghamshire.

REFERENCES 1. Morris E. Hartstein, Allan E. Wulc, David EE, ‘Anatomy of the Midface’, Midfacial Rejuvenation, Springer, (2012).

2. C J Ley, B Lees, and J C Stevenson, ‘Sex- and menopause-associated changes in body-fat distribution’, Am J Clin Nutr. (1992) May;55(5):950-4.

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Body Contouring Using Cryolipolysis

How does cryolipolysis work?

The exact mechanism is a combination of immediate fat cell apoptosis with gradual apoptosis associated with lipid-ice crystallisation, inflammatory panniculitis and a phagocytic process that continues for up to 12 weeks.12,13 One study by Preciado et al used thermo-electric cooling plates on Yucatan pigs to cool the skin’s tissue to -7°C and thermocouple Mr Geoffrey Mullan provides an overview of to measure the adipose tissue temperature. cryolipolysis for body contouring and presents probes It demonstrated that the adipose tissue dropped to a case study of a successful treatment 9.5-13.5°C during treatment. As fat cells are more susceptible to cold than other types of tissues,13 Patients’ desire to improve their silhouette has led to a demand for controlled cold exposure of adipocytes induces apoptosis with treatments that improve the body’s contours. There is also a desire minor effects on surrounding structures.8 Other factors suggest the 1,2 to improve the laxity and/or tone of the skin, reduce lymphoedema, formation of intracellular ‘lipid ice’, that forms at +10°C (compared to and alter the appearance of cellulite.3 It is important to note that the water ice at 0°C), may contribute to the death or delayed apoptosis of most popular treatments to contour the body are directed at removing fat cells. It may also affect a number of cellular mechanisms, reducing deposits of adipocytes.4,5 Surgical approaches to target the body’s adenosine triphosphate (ATP) levels and Na-K-ATPase enzyme activity, fat are invasive treatments that involve breaching the skin or excision which leads to intracellular lactic acidosis.12 of the skin with the subcutaneous fat, such as in abdominoplasty.

However, it’s not just freezing that can destroy the cells, but the Liposuction has long been regarded as an effective way to remove process of warming up the tissues can also have an effect. Warming fat from the face and body, and was reported to be the most popular cooled adipose tissue through massage – detailed below – after cosmetic surgical treatment in the US in 2016.4,5 cryolipolysis may promote additional injury to the adipocytes by However, nowadays a large group of patients seek treatments that ischaemia reperfusion (tissue damage caused when blood supply are less invasive, with low recovery time, so may wish to receive nonreturns to tissue), similar to the reperfusion of cooled transplanted invasive treatments instead. Numerous non-surgical devices work on organer enhance the result.14,15 various levels, and target fat removal, skin tightening and lymphatic massage. These devices utilise many modalities such as: low power How is it performed? laser,6 radiofrequency,1,2 high-intensity focused ultrasound,7 mechanical There are a number of cryolipolysis devices available, such vacuum massage to improve lymphatic drainage along with the as CoolSculpting, MOCOOL-A and 3d-lipo, which also utilise appearance of cellulite,3 and more recently, cryolipolysis.8,9 radiofrequency and ultrasound. However, my experience lies with the In my opinion, body contouring treatments should not be aimed at CoolSculpting device so I will be discussing this in more detail. weight loss but, rather, the correction of asymmetries or areas of lipodystrophy that are stubborn to shift, to attain an improvement of After careful assessment, the area to be treated is marked out and the silhouette in individuals with a healthy body mass index (BMI). a thin cotton gel-impregnated pad is placed on the skin to protect it For the purpose of this article, I shall be focusing on body contouring from direct contact with the cold plates and to work as a conducting using cryolipolysis. agent in removing heat from the skin. The device utilises vacuumpressure applicators that draw skin and adipose tissue into an Cryolipolysis applicator cup, which are specific to the part of the area being treated.

Controlled cold lipolysis (cryolipolysis) is used for the breakdown If multiple devices are available, more than one area can be treated of adipocytes by immediate and delayed-induced apoptosis. The simultaneously. These ‘cups’ have thermistors and thermo-electric technology utilises localised cooling, to extract heat from adipocytes8 and is generally accepted as an effective and safe non-surgical procedure for reducing subcutaneous fat. Practitioners have performed the procedure on various body regions, such as the abdomen, flanks, inner thighs, outer thighs, and submental areas. Most commonly treated are the flanks and abdomen, and some practices now safely treat both during a single visit.10 Literature has reviewed the effectiveness of cryolipolysis technology.

A retrospective study by Dierick et al reviewed 518 patients (73% female, 27% male with a mean age of 42.7 and 22.6). The majority of subjects had Fitzpatrick skin types II (n=200, 38%) and III (n=207, 40%).

There were no subjects with Fitzpatrick skin type I, 78 with type IV (15%), and 33 with types V and VI (6%). There were 891 total areas treated, comprising the flanks (59%), abdomen (28%), back (12%), inner thighs and knees (1%), and buttocks (1%). The majority of sites were treated once (86.5%), although some areas were treated two (13%) or three (0.5%) times. The authors reported that 86% showed improvement, 73% were satisfied and only six were dissatisfied after initial treatment, which dropped to two (0.4%) after a second treatment.11

The technology utilises localised cooling, to extract heat from adipocytes and is generally accepted as an effective and safe nonsurgical procedure for reducing subcutaneous fat

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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cooling plates that slowly reduce the temperature. This cooling at the skin level correlates to a temperature drop down to 7-10°C in the fat layer, and blood flow is reduced via tissue compression and coldinduced vasoconstriction.

For this particular device, the temperature reduction is automated and the practitioner does not have any control over the cooling settings, which removes the risk of accidental burns. The device has thermistors that constantly measure the skin temperature and it is believed that the skin is cooled to -5°C during the 60-minute period and this duration avoids frostbite. The company does not actually reveal the exact temperature at which their devices are set.16

Case study A 37-year-old mother of three, the youngest being 12 months, presented at our clinic with growing frustration that, despite leading a healthy lifestyle, she was struggling with her ‘muffin top’ stomach. The patient claimed that she exercised three to four times a week, and since her third child had not been able to lose fat in the lower abdomen region and flanks. She had a BMI of 25.

In the consultation, we discussed both surgical and non-surgical options, and she decided that, given her busy work and family schedule, she did not want the downtime associated with surgery. Furthermore, the thought of wearing a compression garment for more than two weeks was out of the question.

On examination, she had fat in the lower abdomen but minimal fat in the upper abdomen. There was no ptotic skin or skin aprons, skin quality and elasticity were good and there were no extended stretch marks or muscle diastasis. There was no marked visceral fat, however the small fat pockets did affect her silhouette when in tighter clothing. Due to the localised fat pockets and good skin quality, a treatment plan was discussed and agreed upon.

We agreed to the treat the lower abdomen on each side and to treat the upper and lower flanks using cryolipolysis. This meant a total of six treatment cycles in one session, each cycle took one hour with a ten-minute break between treatments. The total treatment time including a lunch break took eight hours; although,

Figure 1: The 37-year-old patient before cryolipolysis treatment.

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The treatment usually lasts for 30-60 minutes per area. This is followed by vigorous tissue massage when the applicator is removed, before moving on to the next region to be treated, which may take a further 30-60 minutes. Treatments can be performed on the same day and a single treatment is performed per area. Tissue culture research has suggested that adipocytes cooled to below 7°C demonstrate necrotic injury, so practitioners may ask, ‘Will low temperatures not burn the skin or cause necrotic damage?’

However, although the outer periphery skin is being cooled by cooling plates at -5°C, over the course of an hour the inner fat tissue does not reach such low levels and, as long as adipocytes are kept above this

we often split long treatments into two sessions, depending on the patient’s choice. The treatment was performed at our clinic and the patient had no medical contraindications to cryolipolysis.

As most of the patient’s fat was superficial subcutaneous fat, it was straightforward to treat the area with minimal risk of leaving uneven skin contours. This is due to the homogenous way that the heat is extracted, avoiding the risk that can be left when liposuction is performed too superficially.18 The cryolipolysis treatment device used was CoolSculpting.

CoolCore applicators were also used on the lower abdomen, and CoolCurve Plus was used on each flank. The varying applicator cups are shaped in different ways to allow for the contours of the body and therefore maintain a constant vacuum to hold the tissue in place. The device used a mild suction to draw the tissue in to the applicator, where thermoelectric cooling cells extracted heat for 60 minutes per application, and thermistors registered the skin temperature.

At the end of the treatment, a pneumatic massage was delivered using the device and, when the tissue was removed from the applicator cup, a deep tissue massage was performed for five minutes by an aesthetician to speed up the rate of tissue warmth. Sasaki et al demonstrated an increase of 21% in fat reduction in treatments that used post-massage compared to a control. One hypothesis for potentially improved efficacy with manual massage is that manual massage causes an additional mechanism of damage to the targeted adipose tissue immediately after treatment, perhaps from tissue-reperfusion injury.14 All the patient’s treatments were performed on the same day and the skin erythema returned to a normal colour within 15 minutes.

Her recovery followed a normal pattern of numb skin for eight days, that fully recovered, and slight swelling on the treatment area. Her follow-up was organised for 14 weeks post-procedure (Figure 2) where I observed a significant reduction in the lower abdomen, and the flanks were significantly improved. The patient was very happy with the results.

Figure 2: Images of the patient at 14 week’s post cryotherapy treatment using CoolSculpting, during this time she had lost 2lbs.

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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A search of the literature does not bring up any reported cases where sensation has not recovered nor is there any evidence of any lasting damage on any of the peripheral nerves ‘therapeutic window’, it is possible to attain the breakdown of fat cells whilst avoiding tissue necrosis and the inflammatory response that this entails. Adipose tissue cooled to 14°C, 21°C, and 28°C result in no necrotic injury, but had the same degree of apoptotic injury as those cooled to 7°C after 48 hours.8

Do results last?

Like any treatment that destroys fat cells, the results are permanent if a stable weight is maintained. For example, in a longitudinal case study, long-term durability was demonstrated in two male patients, who were followed up over a five-year period after the unilateral treatment of one flank. The untreated flank acted as a control for fluctuations in weight. Although both sides increased in size when weight was gained, the difference in the two sides remained. The increase in the treated size was still demonstrably smaller.17

Possible complications and side effects Minor complications During the post-treatment phase, the treated area remains numb for seven to 14 days. A search of the literature does not bring up any reported cases where sensation has not recovered nor is there any evidence of any lasting damage on any of the peripheral nerves.19 Common side effects are temporary erythema and minor bruising. The most common complaint reported is late-onset pain, occurring two week’s post procedure, which generally resolves without intervention.11 As the process involves selective apoptosis leading to the breakdown of adipocytes, there has understandably been concerns that this may affect lipid and triglyceride levels, especially as many clinics now treat multiple areas simultaneously, or in sequence, on the same day. However, a study of 40 patients with fat bulges in their flanks by Coleman et al showed that in the post-treatment period, levels were not affected.21 Serious complications Cryolipolysis has a low incidence of serious adverse effects, however 33 cases of paradoxical adipose hyperplasia (PAH), have been reported22 and practitioners should discuss this whilst obtaining informed consent as it is a serious potential complication.

In paradoxical hyperplasia, the adipose tissue at the treatment site is reported to increase in mass to a degree that is clearly visible and is a permanent change that does not resolve on its own. It requires further intervention such as liposuction lipectomy to treat the reactive tissue.

The cause of PAH is still speculative and is also seen in other lipolysis interventions such as injection lipolysis.22

Aesthetics

Practitioners should be aware of copycat cryolipolysis devices. There has been a well-documented case in the press of a severe skin burn performed by a device in a hairdressing salon in Liverpool.23 It is assumed that the device did not cool the skin in a safe way – either the heat extraction was too fast or the cooling plates continued to extract, even when the optimum temperature was attained, and did not cut out when this critical temperature was reached. The earlier named manufacturers were very clear that it was not one of their devices and an online search will show many overseas companies offering fat-freezing devices that do not have safety approvals.

Conclusion Liposuction remains the most popular cosmetic surgical treatment for body sculpting; however, there is a large group of patients who wish to find a less invasive alternative. In my experience cryolipolysis is a suitable, safe option for patients who do not wish to have the risks and downtime associated with surgery and my patients have shown a high level of satisfaction.

Mr Geoffrey Mullan is a cosmetic surgeon and medical director at Medicetics Clinics and Training Academy. He has taught anatomy at Guy’s Hospital and worked at the Royal Marsden Head and Neck Unit, with an advanced understanding of the deep structures of the face. He has been a dermal filler trainer in the past and offers workshops in a number of treatments in central London.

REFERENCES 1. Narins RS, Tope WD, Pope K, et al. Overtreatment effects associated with a radiofrequency tissuetightening device: rare, preventable, and correctable with subcision and autologous fat transfer.

Dermatol Surg. 2006;32(1):115- 124.

2. Sasaki et al, Goldberg DJ, Fazeli A, Berlin AL. Clinical, laboratory, and MRI analysis of cellulite treatment with a unipolar radiofrequency device. Dermatol Surg. 2008;34:204-209.

3. Gulec AT. Teitelbaum SA, Burns JL, Kubota J, et al. Treatment of cellulite with LPG endermologie. Int J Dermatol. 2009;48:265-270. 12.

4. American Society for Aesthetic Plastic Surgery (ASAPS) 2015 Cosmetic Surgery National Data Bank Statistics. <www.surgery.org/sites/default/files/ASAPS-Stats2015.pdf> 5. Fodor PB. Reflection on lipoplasty: history and personal experience. Aesth Surg J 2009;29:226-231.

6. Lach, E, Reduction of subcutaneous fat and improvement in cellulite appearance by dual-wavelength, lowlevel laser energy combined with vacuum and massage. J Cosmet Laser Ther. 2008;10:202-209.

1. Teitelbaum SA, Burns JL, et al, Noninvasive body contouring by focused ultrasound: safety and efficacy of the Contour I device in a multicenter, controlled, clinical study. Plast Reconstr Surg.

2007;120(3):779-789.

7. Preciado J, Allison J. The effect of cold exposure on adipocytes: examining a novel method for the noninvasive removal of fat. Cryobiology. 2008;57:327.

8. Zelickson B, Egbert BM, Preciado J, et al. Cryolipolysis for noninvasive fat cell destruction: initial results from a pig model. Dermatol Surg. 2009;35:1-9.

9. Stevens WG, Pietrzak LK, Spring MA. Broad overview of a clinical and commercial experience with CoolSculpting. Aesthet Surg J 2013;33:835–846.

10. Dierick CC, Mazer JM, S and M, Koenig S , Arigon V . Safety,tolerance, and patient satisfaction with noninvasive cryolipolysis. Dermatol Surg. 2013;39(8):1209–1216. <http://www.coolini.de/sites/default/ files/studien/Safety_Tolerance_and_Patient_Satisfaction_With_Noninvasive.pdf> 11. Karow AM Jr, Webb WR. Tissue freezing: a theory for injury and survival. Cryobiology. 1965;2:99-108.

12. Gage AA, Baust J. Review: mechanisms of tissue injury in cryosurgery. Cryobiology. 1998;37:171-186.

13. Preciado J, Allison J. The effect of cold exposure on adipocytes: examining a novel method for the noninvasive removal of fat. Cryobiology. 2008;57:327.

14. Coban YK, Kurutas EB, Ciralik H. Ischemia-reperfusion injury of adipofascial tissue: an experimental study evaluating early histologic and biochemical alterations in rats. Mediators Inflamm. 2005;(5):304308.

15. Ingargiola M. J., Motakef S., Chung M. T.,Vasconez H. C., and Sasaki G. H., ‘Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms,’ Plastic and Reconstructive Surgery, vol. 135, no. 6, pp. 1581–1590, 2015.

16. Boey GE, Wasilenchuk JL. Enhanced clinical outcome with manual massage following cryolipolysis treatment: A 4-month study of safety and efficacy. Lasers Surg Med. 2014;46:20–26 17. Bernstein EF, Longtidunal evaluation of cryolipolysis efficacy; two case studies. J Cosmetic Derm 2013; 12:149-52.

18. Hughes C.E. 3rd Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthet. Surg.

J. 2001;21:120–127.

19. Coleman SR, Sachdeva K, Egbert BM. Clinical efficacy of noninvasive cryolipolysis and its effects on peripheral nerves. Aesthetic Plast Surg. 2009;33:482-488.

20. Coleman et al Non-invasive cryolipolysis for subcutaneous fat reduction does not affect serum lipid levels or liver function tests. Lasers Surg Med. 2009;41:785-790.

21. Seaman S., Tannan S et al PAradoxical adipose hyperplasia and cellular effects after cryolipolysis: A Case Report Aes Surg J. 2016 Jan; 36(1).

22. Saskia Murphy, New mum ‘gets second degree burns and permanent scarring’ from fat-freezing treatment that left her wearing maternity clothes, 2015. <http://www.mirror.co.uk/news/uk-news/newmum-gets-second-degree-5820041>

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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A summary of the latest clinical studies Title: Immediate Effect and Safety of HIFU Single Treatment for Male Subcutaneous Fat Reduction Authors: Bitencourt S, Guth F, et al.

Published: Journal of Cosmetic Dermatology, December 2017 Keywords: Adipocytes, body contouring, localised fat Abstract: The increasing search for procedures for fat reduction is related to dissatisfaction with body shape. High-intensity focused ultrasound (HIFU) has been proven effective in body sculpting when used noninvasively to reduce subcutaneous fat and improve body contour. This study aimed to evaluate the immediate effect and safety of HIFU single treatment for male localised fat and body remodeling. Twenty-four male subjects (18 to 59 years old) with BMI ≤ 30 kg/cm² and at least 2 cm of abdominal fat received a single HIFU treatment session.

Individuals were subjected to abdominal measurements before and after procedure. In addition, biochemical analyses of blood samples were performed to assess possible inflammatory effects or oxidative stress induction by the treatment. HIFU was found to be an effective treatment in reducing localized adiposities in the abdominal region. A significant decrease (0.6%) was observed in infraumbilical circumference of subjects submitted to HIFU single treatment when compared with control subjects. The laboratory parameters did not present any appreciable changes. This study further strengthens the current view that HIFU is an effective and safe tool for localised fat reduction.

Title: The Efficacy and Safety of Early Postoperative Botulinum Toxin A Injection for Facial Scars Authors: Lee SH, Min HJ, et al.

Published: Aesthetic Plastic Surgery, December 2017 Keywords: Botulinum toxin A, facial scarring, scar hyperpigmentation Abstract: Scars widen when the underlying musculature pulls apart suture lines, and scars oriented against relaxed skin tension lines are especially susceptible to these distraction forces. Because botulinum toxin A (BTA) induces complete muscle paralysis, the purpose of the current study was to evaluate the effects of BTA using both observer-dependent qualitative assessments and quantitative measurements to verify its beneficial effects on facial scarring. Patients with vertical forehead lacerations, treated by primary closure, were randomly assigned to two groups: one (n = 15) received BTA injections within 5 days of primary closure and the other (n = 15) received no further treatment. Vancouver scar scale (VSS) scores and wound width were determined at the 1-month and 6-month follow-up visits. Quantitative color differences between the scar and surrounding normal skin, using the Commission International d’Eclairage L*a*b* color coordinates, were measured and compared by analyzing photographs. Improved VSS scores, less increase in wound width, and less scar discoloration were noted among patients treated with BTA injections compared with the control group. These differences were observed at the 6-month visit, but not at the 1-month visit.

BTA injection improves scar quality when injected during the early postoperative days.

Title: Hybrid Complexes of High and Low Molecular Weight Hyaluronans Highly Enhance HASCs Differentiation: Implication for Facial Bioremodelling Authors: Stellavato, A, La Noce M, et al.

Published: Cellular Physiology and Biochemistry, November 2017 Keywords: Adipogenic differentiation, adipose stem cells, antiageing, hyaluronic acid Abstract: Adipose-derived Stem Cells (ASCs) are used in regenerative medicine, including fat grafting, recovery from local tissue ischemia and scar remodeling. The aim of this study was to evaluate hyaluronan based gel effects on ASCs differentiation and proliferation. Comparative analyses using high (H) and low (L) molecular weight hyaluronans (HA), hyaluronan hybrid cooperative complexes (HCCs), and high and medium crosslinked hyaluronan based dermal fillers were performed. Human ASCs were characterized by flow cytometry using CD90, CD34, CD105, CD29, CD31, CD45 and CD14 markers. Then, cells were treated for 7, 14 and 21 days with hyaluronans. Adipogenic differentiation was evaluated using Oil red-O staining and expression of leptin, PPAR-γ, LPL and adiponectin using qRTPCR. Adiponectin was analyzed by immunofluorescence, PPAR-γ and adiponectin were analyzed using western blotting. ELISA assays for adiponectin and leptin were performed. Results: HCCs highly affected ASCs differentiation by up-regulating adipogenic genes and related proteins, that were also secreted in the culture medium. H-HA and L-HA induced a lower level of ASCs differentiation. HCCs-based formulations clearly enhance adipogenic differentiation and proliferation, when compared with linear HA and cross-linked hyaluronans. Injection of HCCs in subdermal fat compartment may recruit and differentiate stem cells in adipocytes, and considerably improving fat tissue renewal.

Title: Facial Thread Lifting with Suture Suspension Authors: Tavares JP, Oliveira CACP, et al.

Published: Brazilian Journal of Otorhinolaryngol, December 2017 Keywords: Barbed suture, thread lifting, suture Abstract: The increased interest in minimally-invasive treatments, such as thread lifting, with lower risk of complications, minimum length of time away from work and effectiveness in correcting ptosis and aging characteristics, has led many specialists to adopt this technique, but many doubt its safety and effectiveness. The objective was to analyse data published in the literature on the durability of results, their effectiveness, safety, and risk of serious adverse events associated with procedures using several types of threading sutures. The method was a literature review using the key words “thread lift”, “barbed suture”, “suture suspension” and “APTOS”. Due to the scarcity of literature, recent reports of facial lifting using threads were also selected, complemented with bibliographical references. The first outcomes of facial lifting with barbed sutures remain inconclusive.

Adverse events may occur, although they are mostly minor, selflimiting, and short-lived. The data on the maximum effect of the correction, the durability of results, and the consequences of the long-term suture stay are yet to be clarified.

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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Utilising Your Awards Win Public relations consultant Emma Bracey-Wright explains how you can make the most out of an award recognition Every year the lucky winners of the coveted Aesthetics Awards leave the ceremony smiling and armed with their beautiful accolade; but what happens next? Once the news sinks in that your clinic, or a product that your clinic offers, has won an Aesthetics Award, or another award of high prestige, do you activate a plan of action to turn that award win into sales for your business? Or does the award just sit in an office or on top of the mantelpiece gathering dust? If it is the latter, I hope the following might help you to make the most out of your award win this year, because whether you are a Winner, received a Highly Commended or Commended recognition, or even a Finalist, it is something to shout about. You should take pride in any recognition you have received and communicate this news throughout your business. You should make sure you are singing about it from the roof tops and use this prestigious recognition to help you generate more sales. To do this, you can use the following playlist so that you can sing your own praises. The following are familiar songs that might help you remember these top tips.

‘We are the champions‘ Make sure you are communicating that you are the champion instantly on all your business social media channels and perhaps ask your team to do the same on their own social media channels. This should include Instagram, Twitter, LinkedIn and Facebook. I’d encourage using social media stories, which was examined in more detail in the December issue of Aesthetics,1 to film the win on the night. This allows you

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to broadcast to your audience live. You should also be taking pictures while at the event – think about posting pictures that are eye-catching and fun. These will generate the most likes and it will advertise your brand and your success sufficiently; however, at events such as the Aesthetics Awards, there will also be a press board, where you can get great professional images taken of your team. Make the most of this! If you do not receive the organiser’s professional photos within a couple of days after the event, you should contact them to request these.

You can then post the best images on social media, such as those that are of high-quality, to make sure they get the most comments. I advise to post at peak times such as 6-7pm on weekdays and 10am on weekends (although I have found that this is becoming less important as many posts are now seen due to the individual social media site’s algorithms, rather than posting schedules). Try to make the text and images in your posts motivational, unique and they must be relatable to your proposed viewers.

Authenticity is key.3 Also, if it is an award that had a voting element, it is nice to thank the people who voted for you. Often people will tell you if they voted for you, so to show your appreciation you may like to tag them in your post thanking them. This might help build loyalty with them and help to keep them as a long-term customer. Even if you just do a general post and don’t tag individuals, the chances are that those who voted for you are following you on social media and will see the post and will appreciate the thanks.

When doing any social media posting about your award, be sure to tag the awards organiser and use their designated hashtag so that they can re-share your posts to their social media platforms, broadening your social media reach even more.

From the moment you win an award, the messaging used throughout the promotion of your business must include the fact that you are an award-winning clinic, brand or offer an award-winning treatment

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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‘Simply the best’ You must let your local press know about your win. Local newspapers and magazines love to support local businesses and so they must be told that your clinic, team member or a service at your clinic has received an award. Some awards organisers, such as the Aesthetics Awards, will supply you with a winner’s ‘tool kit’, which will include a press release ready for you to send out to your local press that highlights why you are simply the best. If you have a PR agency or representative, make sure they are writing a press release as soon as possible following the event so that it is still newsworthy, ideally the next morning. If the awards event was held on the weekend, in the ideal world, by the Monday the news should be distributed to the local press. If you don’t have PR representation you can distribute your press releases yourself by searching for the contact details of your local publication’s editors and emailing them a press release.

If you have sent your press release to a publication and they don’t want to include the news of the win, it might be of benefit to invite a journalist to review your services.

Although it still does not guarantee coverage, it can result in positive editorial, that may drive new bookings and increase your revenue. If the person you approach is not interested, do offer it to another member of their team.

In my opinion, press treatments always need to be complimentary. If the journalists decide they want a package for their own purposes, perhaps offer a generous 50% discount for further treatments.

‘Ain’t no stopping us now’ Don’t stop at press. Contact local influencers or those who are ‘on brand’ for you and invite them in to try an award-winning treatment or product in your, perhaps, award-winning clinic. These people could be bloggers, vloggers, socialites, celebrities, models or simply people who have lifestyles or platforms that influence your patients.

Look out for ‘micro-influencers’, who are people that may not have millions of followers as they often have very specific posts that don’t appeal to a large audience, but they can often be more influential than those who speak to the masses.3 When searching for influencers to contact, make sure they have the right ethos and messaging on their social media channels by searching the kind of content they produce. Most influencers are very happy to hear from brands and companies, so don’t be shy. Their contact details or their agent’s

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contact details are usually on their social channels. If they are not interested to work with you, they will let you know politely.

Influencers can be hard to engage with, unless you have a relationship with them; however, if you suddenly have something that is award-winning for them to try, it might whet their appetite and they may be more likely to accept your offer.

If an influencer posts on their blog, vlog or social channels that your award-winning treatment is worth having, or that your award-winning clinic has impressed them, you might get a surge of bookings. Of course, there is always a small risk that they won’t like the treatment; however, most bloggers take no pleasure in posting terrible reviews, so your biggest risk tends to be not getting a review at all. Nevertheless, if you won an award, you must be doing something right, so you can probably be quite confident that they will have a good experience. Just make sure you give them the VIP treatment when they visit. Offer them your very best therapist teamed with an unsurpassed professional service. You can easily tell if a blogger is the type of blogger who enjoys being negative by looking at their posts, if they are like that, avoid working with them.

newsletter, brochures, adverts, social media profiles, press material, conference or trade show stands, postcards that are in your patients’ deliveries, business cards, email signature, the windows of your clinic and all your point-of-sale material. This is ideally what you will do for all wins, but of course prioritise to suit your budget.

Being associated with a prestigious awards ceremony, whether you were a finalist or a winner, might be the reason why a person chooses your clinic, treatment or brand over another.

‘Take it to the limit’

Conclusion

Awards are a seal of approval and a recognition of excellence, so you MUST communicate this wherever possible – there is no limit! From the moment you win an award, the messaging used throughout the promotion of your business must include the fact that you are an award-winning clinic, brand or offer an award-winning treatment.

If you have won more than one award, you can also call yourself a multi-award-winning clinic! Don’t be afraid to use this term throughout your business communications.

It might be that one treatment you offer has won an award, but you can still state that your clinic offers ‘award-winning treatments’ without misleading anyone. Also, award wins don’t just last for one year, if you won an award, you are ‘award-winning’ and you can use that term for as long as you are in the business. Just ensure you do not amend the year you won in any marketing, as this would be advertising false information.

Being recognised at an awards ceremony means updating your marketing. This can either be done yourself, or you can delegate this to your design/website/marketing team.

You need to include ‘award-winning’ and add the award badges to your website,

Being recognised at an awards ceremony is a fantastic opportunity. If you promote this through social media, PR, local influencers, and other business communications as well as word of mouth, you will more than likely find yourself gaining additional business.

Don’t be humble, if you are good enough to be lauded as the best in your specialty, then make sure you sing it out loud for all to hear!

‘Word of mouth’ You should never underestimate the power of word of mouth. Tell everyone. Make sure all your staff tell their family and friends that you, your clinic or the treatments you offer are award-winning so that they can spread the word. This goes for your clinic staff too!

Patients can be told about the award over the phone, or you can get staff to format their email signatures so that each of their emails feature your award win. Do have a meeting with your team and highlight the key messages that you want to get across to make sure that the messaging is communicated correctly. Make sure they are all singing from the same hymn sheet.

Emma Bracey-Wright is a PR consultant specialising in the health, skincare and aesthetics arenas and is the founder and director of EBWPR. Her PR agency represents a global range of clients including NeoStrata, Exuviance, Oxygenetix, Skin Tech, Clinisept+, RADARA, Fillerina, Eudelo, MZ Skin, Dr Maryam Zamani, D.Thomas Clinic, Barrecore, Tribitor and MiraDry. REFERENCES 1. Utilising Social Media Stories, Aesthetics, December 2017.

2. Christa Donovan, ‘5 Things the Most Liked Instagram Photos Include’, Maximize Social Businesses. <https:// maximizesocialbusiness.com/most-liked-instagramphotos-23966/> 3. IZEA, ‘What are micro-influences?, ZEA, 2017. <https://izea. com/2017/06/12/micro-influencers-101/>

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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journal and Aesthetic Professionals. It’s important to be specific in the job description and express what qualities you are looking for in a candidate, so they understand exactly what sort of person you are looking for. In my clinic, our recruitment process is thorough, involving interviews with me and around two to three other clinical members of staff, a tour of the clinic, and a variety of competency-based questions. Examples of these include, ‘Provide an example of how you have successfully handled a difficult situation’ or ‘How do you ensure patients are calm and assured?’ A good way of getting to know the candidate is by showing them around the building and having an informal chat, to get a feel for how they behave in a non-formal scenario.

Ask for direct examples of their personal experiences and be clear about what you will expect of them and when milestones should be reached.

We’re open and upfront about the way we run the practice and what we will expect of the candidate, if they are successful. This approach has worked well for us – the successful candidate enters the practice fully prepared for the role they need to do, and is receptive to our direction and way of working.

Surgery manager Sara Roberts advises on how Putting the time and effort into recruiting properly will pay dividends for any clinic when it comes to to successfully integrate new staff in clinic introducing new staff, because it is much easier to Having the right team in place is vital to the successful running of integrate a person who’s the right fit for the role. any clinic. Whether clinical or not, every member of the team needs to be fulfilling a specific role to the highest standard in order to allow Induction your clinic to perform at its best. However, finding the ideal person As it’s so important that any staff transition results in a seamless for each role and teaching them the ways of your practice can often experience for your patients; it’s vital that new starters are properly be challenging. As a registered nurse and surgery manager at the briefed on your clinic’s processes. I recommend preparing an Farjo Hair Institute, I have recruited and trained many employees. I’ve induction programme to guide new staff through their probationary learnt, from my own role, that it’s important to take responsibility for period, which for my clinic usually lasts three months, outlining key both clinical staff and non-clinical team members. Ensuring staff fit in deliverables with achievable dates, so they know exactly what is with your clinic’s ethos is hugely important, so it’s crucial you recruit the required of them. right person and nurture them into your working environment.

A thorough induction needs to go further than simply covering the usual policies and procedures of hygiene, health and safety, company Finding the right person statements, etc. To enable the new starter to have a clear idea of what When recruiting, although the candidate’s experience is obviously is expected of them, I advise to include the following in their induction: important, it’s also crucial to consider the individual’s personal attributes and their alignment with your clinic’s values. Recruiting • A history of the clinic, outlining its ethos and approach to work someone on experience alone may restrict you and your clinic, and • Descriptions of the full team’s roles create a barrier to finding the perfect candidate.

• A schedule for four, eight, 12 and 24-week reviews – these time We know that good communication, particularly from clinical staff frames allow enough time for the new starter to acquire new skills during patient consultation for example, can be key in reducing and work on their targets discussed in reviews a patient’s anxiety.1 While that’s just one of the skills to look for in • A personalised training action plan to identify key areas to work on a new team member; a warm, personable manner and the ability to keep patients calm and relaxed should always be required in I recommend supplying each staff member with a workbook and an staff. To find out if a candidate has these qualities, I advise to ask evidence-of-training document. Giving them autonomy over their own them not only competency-based questions during their interview, development, as well as personal responsibility to ensure training is mentioned in further detail below, but also questions about them being done, allows staff the freedom to take some control over their as a person, for example, ‘Can you tell us a bit about yourself?’ We future. We deliver our own training initially, working closely with all new want our patients to feel at ease and well-cared for during every clinical staff, to teach techniques for medical procedures as well as aspect of their treatment – and each member of staff has a part to customer-focused training and statutory requirements such as lifting play in aiding this. and handling.

I advise to post the job advertisement online, both directly on your In my clinic, we train new staff in clinical techniques and provide website and on external job sites such as Indeed and CV Library, improvement targets; detailing precisely what constitutes failing or on sites which specialise in aesthetics, such as the Aesthetics to meet expectations, meeting expectations and exceeding

Introducing New Staff to Clinic

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

In faIrness

The professIonal’s vIew of TreaTIng skIn pIgmenTaTIon Pigmentation sPotlight Skin hyperpigmentation is a common complaint, takes many forms and is caused by a number of factors – exposure to the sun, hormonal changes, use of photo-sensitising medications or it can be hereditary. In its most common form, it presents itself as freckles caused by the sun, and may not pose a problem to the individual. At its worst it can be life-altering brown patches of skin on the face and neck that simply won’t go away without treatment.

What the exPerts say Practitioners are already realising the benefits that a blended, medium depth peel containing Glutathione can achieve when treating clients with hyperpigmentation.

Before

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90% of those affected by skin pigmentation issues are women, just 10% are men. an individual aPProach Kelly Saynor, Clinical Director, Medica Forte says: “When looking to address skin pigmentation issues, it’s imperative that we determine what’s caused it in the first place, so it’s possible to treat it correctly and to set the right expectations with the client.”

“As a practitioner it’s crucial to understand that there may be no permanent cure for an individual’s pigmentation issue, it may reoccur due to exposure to the original stimuli that caused it. However treatment will help to considerably reduce, temporarily eradicate or completely remove it, lessening the impact upon everyday life.”

“Determining the route cause of pigmentations also allows us to better manage the level of treatment and further intervention required. The most obvious examples of re-occurrence would be further exposure to the sun or, in the case of melasma in pregnant women, hormonal changes brought on by further pregnancies.”

“The Perfect Peel® offers measurable results for Fitzpatrick 1-6 skin types when improving hyperpigmentation issues, and is extremely effective in delivering a vast improvement for most individuals, often in just one treatment.”

Dr Esho, Esho The Clinic “Peels are perfect for alleviating one of the most prevalent skin issues – hyperpigmentation. I’ve found that using The Perfect Peel® as part of a long-term process where the client returns for repeat applications over a period of time whilst keeping sun exposure to a minimum can reduce or completely eliminate pigmentation issues. The results are some of the best I’ve seen compared with other leading peels in the market. In a short time it’s become my top recommended product.”

Dr David Jack, Harley Street “In my own experience, this is one of the most effective peels for hyperpigmentation that I have used so far – it is extremely simple to use and the results I have seen are relatively impressive.”

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Become a practitioner now: 1. Visit theperfectpeel.co.uk 2. Register as a professional 3. Await your approval 4. Log in and book training To use The Perfect Peel®, you must be a Doctor, Dentist or NMC registered Nurse. theperfectpeel.co.uk

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Giving new starters control over their own development and progression creates an empowered and proactive workforce which drives the clinic forward expectations across a range of areas, including communication, health and safety, and technical skills. These skills must be met before we will allow them to work unsupervised. Depending on their previous experience, new starters are generally supervised for six to 12 months in our clinic.

If the new starter has their own preferred techniques they have learnt elsewhere, that is generally accepted in my clinic, so long as the quality mirrors ours. That noted however, we do prefer to keep things uniform by having clinical staff using similar techniques.

Overall, the key elements any clinic needs to consider are the quality of the induction, the frequency of training, and deciding at what stage a new starter is allowed to be more hands-on with patients. It’s a good idea to assign an existing member of staff as a mentor – a practitioner or a clinic manager for example – to oversee every new starter’s progression.

Transferring existing patients to a new team member Hair transplant surgery requires a number of team members, therefore patients at our clinic will see a number of different members of staff during their treatment, so transferring patients from one staff member to another is generally not a great concern. It is still something to be mindful of however, especially in an aesthetic clinic where patients may not be transferred to different practitioners often. All staff, including front-of-house, are encouraged to introduce themselves fully the first time the patient comes in for a treatment, and they are identifiable by their name badge.

In my experience, honesty is the best policy when it comes to introducing new staff to patients. We are open about new starters and will proactively tell patients when we have changes in the team.

However, it’s important to be respectful of your patient’s journey. If you have performed your internal training well, then patients should not notice a difference in the quality of, or approach to care. New starters should slot into your existing clinical structure seamlessly.

One way of helping patients feel more secure under the care of a new team member is to invest in the new starter’s public profile. We work with our marketing team to create public awareness about new team members, which could include anything from blogs or website stories, to news articles and press profiles. I recommend sending a press release to industry publications and local newspapers about your clinic’s new addition, including a background of the new employer, as

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well as a comment about the clinic, stating the reason for its growth.

This can help patients feel reassured by the quality of the team handling their treatment and can also boost the confidence of the new staff member.

Making new staff feel welcome It’s important to create a welcoming atmosphere and make new starters feel at ease. I personally greet and guide every new starter through communication and support during their first days and weeks to ensure they feel looked after and a part of the clinic. I suggest also running a mentoring system alongside a training programme, to offer all staff, not just new starters, a dedicated person who they can speak to about any issues or concerns at work, as well as their own professional development.

Regular social events can be highly beneficial to strengthen staff relationships within the clinic, in a refreshing, non-clinical setting. Going out for drinks, dinner or holding a movie/games night, for example, can help foster a sense of belonging in a fun, stress-free environment. This helps staff to have a good rapport and relationship with each other – which, in turn, creates a friendly, welcoming atmosphere in-clinic and positively impacts upon patient experience.

Giving new starters control over their own development and progression creates an empowered and proactive workforce which drives the clinic forward. Remember to prioritise regular communication and one-to-ones with every team member, and encourage them to attend external workshops and training to further their development. In my clinic, one-to-ones are less formal than reviews and are more of a quick chat to ensure everything is okay and see if they need any additional support.

Conclusion The most important thing for any clinic to consider at all times is patient experience. Creating positive patient experience is mostly down to the team you have in place; finding, training and retaining the right staff is of utmost importance.

Focus on recruitment first. Put thought into exactly what kind of person you are trying to find and then craft interview questions which will reflect this. Ensure you ask for direct examples of their personal experience and be clear about what you will expect of them and when milestones should be reached. By doing this, you’re more likely to recruit the right person for the role – which, in turn, makes introducing them to your clinic and patients much easier.

Sara Roberts is a registered nurse and has worked at the Farjo Hair Institute for more than 20 years, becoming surgery manager in 2012. In October 2016, she became the first European hair transplant nurse to chair the Surgical Assistants’ Programme at the International Society of Hair Restoration Surgery 24th World Congress in Las Vegas.

REFERENCES 1. Michael John Pritchard, Reducing Anxiety in Elective Surgical Patients (London: Nursing Times, 2011) [https://www.nursingtimes.net/clinical-archive/perioperative-care/reducing-anxiety-in-elective-surgicalpatients/5024376.article]

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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The Role of an LPA Biomedical engineer and laser protection advisor (LPA) Rob Knowles explains why you need an LPA and how to make an appropriate selection A large and growing number of clinics in the UK now work with high power lasers or intense pulsed light (IPL) systems, and are required by law to employ the services of a laser protection advisor (LPA) as an external consultant to oversee laser safety.1 Those performing aesthetic treatments, such as hair and tattoo removal, will presumably be operating a class 3B/4 laser or IPL system, which, without professional LPA support, would be in violation of the Control of Artificial Optical Radiation (AOR) at Work Regulations 2010.1 Consequently, their business would be exposed to the potential for significant financial and commercial damage. This could be through the loss of their treatment licence, a claim as result of an adverse incident that could have been avoided, or a fine.1 The role of the LPA is to provide advice on matters relating to the evaluation of optical radiation equipment hazards, and have responsibility for advising on their control. This includes guiding on laser safety training, the suitability of personal protective equipment, and producing a risk assessment with a corresponding document outlining day-to-day laser safety management and procedures know as the ‘Local Rules’.2 As the legal responsibility for ensuring compliance with AOR regulations ultimately

lies with the business owner or manager,1 an elemental knowledge of the level of competency and service to expect from an LPA is essential.

LPA competency and certification The employment of a certified LPA to oversee laser safety is now a mandatory requirement of local authorities.3 It is also a condition of the special treatment licence that many local authorities have implemented and now issue to compliant businesses operating laser and IPL systems for aesthetic and therapeutic applications.

Guidelines published by the Medicines and Healthcare Products Regulatory Agency (MHRA) give no defined criteria for LPA competence, but instruct that it is for the employer to judge what level of competency they require.4 However, a scope of essential LPA duties is provided by the MHRA, accompanied by details of LPA certification schemes. One such scheme is run by the Association of Laser Safety Professionals (ALSP); a member-based organisation of laser safety professionals.

Nationally recognised LPA certification is awarded by the ALSP to those who demonstrate the necessary standard of knowledge and expertise in laser safety through relevant qualifications, evidence of practical experience, and an assessment interview. A similar scheme is run by RPA

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2000, which awards LPA certification and is also recognised and listed within the MHRA guidelines.

Considering that there is no defined criteria for competence, but instead a seemingly common-sense guide to the LPA role and duties, one may question the need for certification and associated schemes. However, the expertise of a certified LPA in areas such as the current legislative framework and optical radiation exposure evaluation is unique and certainly invaluable in the event of an adverse incident. In such circumstances, the LPA would be informed of the adverse incident and proceed to oversee a thorough and objective investigation into the incident and the surrounding conditions that may have enabled it. The LPA would examine whether controls and protocols were correctly adhered to and, if so, decide where new controls should be implemented to avoid a repeat incident.2 Of course, the knowledge of the LPA often extends much further, with members of certification schemes holding relevant qualifications in the fields of physics, medical science, or biomedical engineering.

Level of service The role and responsibilities of the LPA are outlined in the MHRA guidelines,4 which identifies the LPA’s key duties, and includes: • Undertaking a risk assessment to identify potential hazards associated with the laser/IPL system and the area in which it is to be used.

• Producing suitable Local Rules of working practices, which implement controls to eliminate and/or minimise the identified hazards of the corresponding risk assessment.

• Ensuring that the laser/IPL equipment, room, and personal protective equipment are fit for purpose and compliant with relevant standards.

• Delivering expert advice on safety training of relevant personnel.

• Designating a Laser Protection Supervisor (LPS) within the business to ensure safe working practices are being consistently adhered to, and to liaise with the LPA in the event of an adverse incident, or when reviewing proposed changes to current protocols.

• Investigating any adverse incidents, and reporting the incident to the employer and appropriate external body if necessary.

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The employment of a certified LPA and implementation of their laser safety guidance is a mandatory practice Beyond these elementary duties, there are some lesser-known requirements of the LPA, such as evidence to demonstrate the LPA has carried out an initial on-site visit and inspection as part of the practical risk assessment procedure for each laser/ IPL system in use. This practical obligation is outlined in the British Medical Laser Association (BMLA) essential standards document, which was produced in May 2017 with the intention of providing a comprehensive set of industry standards to be implemented across the entire aesthetic laser/IPL sector.5 The BMLA is a scientific society for medical and aesthetic lasers, and promotes safe operation of laser and lightbased technology throughout the industry.

From my knowledge, local authorities have subsequently adopted the BMLA essential standards and its noted practical inspection requirement into their respective licensing conditions, thus making it crucial that the licensee/employer ensures that a practical inspection is carried out by any perspective or currently employed LPA. As an exception, some class 3b lasers designed for low level laser therapy (LLLT) may not require an onsite visit or restriction to a controlled area, depending on the laser’s intended purpose and technical specification.

The means by which an employer is able to contact their LPA may vary between services of individual LPAs. For some employers, an email-only support service is preferred, whereas others may offer direct phone support in the event of an adverse incident, such as accidental exposure of the eye to the laser beam.

Laser safety training The national minimum requirement, as set by the MHRA, for operating a higher power laser or IPL system is the laser safety ‘Core of Knowledge’ course. This attendance-based course defines the minimum competency level for a laser operator.2

Although there is no statutory approval body for Core of Knowledge courses, the MHRA has defined a course syllabus, and instructs that the course should be delivered by an individual – with a high level of knowledge and understanding of different optical radiation devices, optical radiation safety and the hazards associated with the equipment – such as a certified LPA, to ensure quality and consistency.4 In many cases, local authorities now require that before being registered as authorised users; laser operators attend a Core of Knowledge course that is delivered specifically by a certified LPA. With course completion awarded primarily on the basis of attendance, an online course that might easily be ‘flicked through’ to attain the certificate without involvement or retention may not be accepted. A course delivered by an LPA with the discrepancy to decline inappropriate course completion, enables a degree of regulation of the award’s representative level of competency.

Most LPAs offer the Core of Knowledge course as an additional element to their support services, which may be required at the time of employment, or later when new untrained staff are taken on.

Key requirements Subsequent to making the sizeable investment in laser or IPL equipment, it is understandable that a business may be price-focused when it comes to the additional, but necessary expense of employing an LPA. However, when determining value for money and a service that best meets the needs or the employer, the following points should be considered: • Certification: Make sure the LPA is certified by an official organisation such as the ALSP or RPA 2000. A certified LPA will be glad to provide a copy of their certification upon request.

• Industry expertise: Be sure to find an LPA with expertise and certification in medical and aesthetic applications. Some LPAs hold certification for industrial laser applications not suited to aesthetic lasers.

• Pricing structure: Some LPAs will charge per laser device in use, whereas others charge per clinic. The latter option generally being the cheaper option.

• Means of contact: Find out the means by which the LPA can be contacted, and what kind of response times you should expect.

• On-site visits: Ensure the LPA will perform an initial on-site visit and inspection of the laser room, and that this is included in their fee.

• Training: If you require Core of Knowledge training, find an LPA that offers this service.

This optional extra may be offered at a discount when purchased with LPA support services.

Summary The employment of a certified LPA and implementation of their laser safety guidance is a mandatory practice to ensure regulatory compliance and safe working procedures; protecting patients, employees, equipment, and the respective business. Accordingly, as the employer maintains ultimate responsibility for regulatory compliance, an elemental knowledge of the key requirements of the LPA is essential in assuring an appropriate level of competence and service.

Disclosure: Rob Knowles is a member of the Association of Laser Safety Professionals (ALSP), which offers LPA certification.

Rob Knowles holds a BSc (hons) in biomedical engineering and is a member of the Association of Laser Safety Professionals (ALSP) with LPA certification in Medical and Aesthetic Laser applications.

Knowles is also a member of the BMLA and provides LPA support and laser safety training to establishments across the UK. REFERENCES 1. The Control of Artificial Optical Radiation at Work Regulations. 2010. <http://www.legislation.gov.uk/ uksi/2010/1140/contents/made> 2. Association of Laser Safety Professionals, Laser Protection Advisor, (2014) <http://www.laserprotectionadviser.com/index. php/laser-protection-advisor> 3. Laser Protection, Laser Protection Advisor, (2017) <http://www. laserprotection.co.uk> 4. Medicines and Healthcare Products Regulatory Agency.

‘Lasers, intense light source systems and LEDs – guidance for safe use in medical, surgical, dental and aesthetic practices’.

September 2015.

5. British Medical Laser Association. ‘Essential standards regarding class 3b and class 4 lasers and intense light sources in non-surgical applications’. May 2017.

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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“To make a person feel great and better in themselves is a gift” Dr Ravi Jain reflects on his journey into aesthetics and details his love for body sculpting There are not many areas of medical aesthetics that Dr Ravi Jain hasn’t had experience in. After initial training in gynaecological laparoscopic surgery at The Royal London, Barts and St Mary’s hospitals from 1995 and 1998, and having a successful career as a GP from 2000, Dr Ravi Jain began his aesthetics career in 2006, working as a dermatology clinical assistant at Luton & Dunstable Hospital. Since then, Dr Jain has become a respected speaker and key opinion leader, and has emerged as one of the most successful VASER practitioners in the UK. After making the decision to move to aesthetics full-time, Dr Jain worked under Dr Patrick Bowler, who he considers as one of the UK’s leading aesthetic pioneers, at Courthouse Clinics from 2007-2008. There, he performed a range of aesthetic treatments including toxin and filler injections and body contouring, before opening his own clinic, Riverbanks Wellness, in 2008.

Dr Jain says, “The reason aesthetics really started to appeal to me was because I became enjoyed the high levels of patient satisfaction I was achieving. It was also one of the first specialties where patients said thank you frequently! To make a person feel great and better in themselves is a gift.”

It was in the early days of establishing his own clinic that Dr Jain was introduced to the liposuction technology, VASER, which uses ultrasound technology to remove fat. Dr Jain explains, “When I set up my own practice, VASER seemed like a revolution for body contouring. I wanted to be a part of it, so I established it in my clinic and because of its safe, effective, treatments, with high levels of patient satisfaction, we made a name for ourselves with both patients and practitioners.” Dr Jain attended courses in South America, Italy and the UK to further his knowledge in VASER and its technology, to ensure safe and successful treatments for his patients.

Explaining why body sculpting is an area of particular interest to him, Dr Jain says, “I don’t like body fat on myself and I just feel that if you can get rid of it, then why not? I understand how hard it can be for people to lose weight and, although I advocate trying to lose weight naturally through diet and exercise, people may need a helping hand.” He adds, “I love getting positive results and feedback from patients who have body sculpting procedures. It’s great to be able to give people their confidence and self-esteem back.”

Body sculpting isn’t the only thing Dr Jain is passionate about – speaking about other non-surgical aesthetic treatments including dermal fillers and injections, and training practitioners at conferences, is also an area of huge interest to him. Dr Jain was introduced to this when he became a key opinion leader for Galderma in 2010. He says, “I really enjoy advising, training and working with Galderma, and showing other practitioners how to achieve the best results with their products. I now frequently hold workshops for Galderma and a few other companies, in Australia, New Zealand, Asia, Europe and the Middle East – it’s just fantastic!”

Dr Jain is a firm believer of creating natural-looking results for his

patients, which was the reason why he introduced his concept, ‘Invisible Aesthetics’, which he uses in his clinic. According to Dr Jain, “The approach highlights the importance of ethical care for patients. The majority of my patients seek results that are subtle, almost invisible, as well as gradual, which is what we aim to provide in my clinic.” This also led Dr Jain to introduce his trademarked R-Lift procedure – which aims to give patients a similar effect to a face-lift, without any surgery. Dr Jain says, “The R-Lift uses small amounts of dermal filler, injected into as few as two points on either side of the face. It shows how effective using few needles can actually be, and it creates a natural looking appearance.”

When asked if there is anything he would have done differently in his career, Dr Jain speaks honestly, saying, “I wouldn’t have invested in as much equipment and devices when opening my practice as I did, I would have let it grow organically. Just because you have the machinery available, it doesn’t mean the clientele will come to you.” He advises, “I think new practitioners and practices should focus on having one or two pieces of technology and become known for it, I definitely should have invested in only the VASER to begin with, instead of multiple other machines, as it was, and still is, my pride and joy.”

So, what has 2018 got in store for Dr Jain? “I recently developed a consultation tool that will be launched in 2018, which we hope will support clinicians all over the world to perform consistently high quality patient consultations with excellent outcomes.” He adds, “I can’t say too much at the moment – but patient consultations are vital to a clinic’s success and I really want to highlight their importance. I can’t wait for it to launch!”

What is your motto?

My life and work motto is ‘treat people as you would like to be treated yourself’. Ask yourself, would you be happy with the same service that you have delivered to your patients?

What do you think is the most important thing to be aware of as a practitioner today?

Don’t believe the hype – there’s a lot of marketing hype in both the consumer and trade media about many technologies and treatments, but it’s important to look at clinical evidence and consult with other industry professionals before deciding which new treatments to take on.

What is the best career advice you’ve been given?

Dr Patrick Bowler once said to me during the recession, ‘When you’re running a business, you’ve got to be prepared for quiet periods. Have you got the systems in place and enough cash flow to ride that storm? Because if you do, you’ll come out stronger’. This really resonated with me.

Reproduced from Aesthetics | Volume 5/Issue 2 - January 2018

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deals, it could bring into question the quality of the goods and service on offer.

The Last Word Cosmetic surgery specialist lawyer Michael Saul argues why time-limited deals should be stopped in the aesthetic specialty The poor regulation of the non-invasive aesthetic specialty is an issue of great concern, and the question of using financial incentives to further encourage spending in this field brings with it its own ethical and moral dilemmas. As someone who has acted for patients who have been an unfortunate recipient of unsatisfactory or negligent procedures, I know all too well that the combination of the two could be a dangerous concoction, both for the patient and to the industry at large.

In addition, the Keogh report – a 2013 government-sanctioned, independent review of the regulation of cosmetic interventions – described the advertising of time-limited offers as hazardous, and called for tighter controls to ensure reliability of these kinds of adverts in order to provide the public with safer choices.1 For those currently working in private cosmetic healthcare, the temptation to compete against other businesses by offering discounts can be strong. From a purely commercial standpoint, why should a company not be allowed to employ the

same sales tactics that are used successfully in other industries?

The argument against providing time-limited offers comes in two parts. The first is to argue that these deals do more harm than good to private healthcare as a specialty.

The second is to argue that these deals do more harm than good to the patient, in a sector that is beholden to a duty of care.

The provider Any cosmetic procedure should come with a basic minimum cost that sets the standard for the quality of the service delivered.

The patient is paying for the experience, expertise and quality of the provider, which covers the practitioner, the materials used and the establishment where they conduct their procedures. As such, advertising discounted prices on cosmetic procedures through time-limited deals, or buy-one-getone-free offers, should raise more than a few concerned eyebrows. A large practice may be able to absorb some of the costs lost through such heavy discounts, yet if a smaller or independent company also offers these

Time-limited deals, in particular, can prey on people’s vulnerabilities, either emotionally, physically or financially

The patient A cosmetic procedure, of any kind, is subject to risks and potential complications, and can have long-term, if not permanent, side effects.

It is not a decision that should be rushed into or taken lightly. As such, according to Keogh, it is entirely inappropriate for a private healthcare provider to offer time-limited financial incentives to patients for cosmetic intervention treatments.

Time-limited deals, in particular, can prey on people’s vulnerabilities, either emotionally, physically or financially, and could push these individuals into committing to a procedure before they have done the necessary research to find a safe, qualified and reputable practitioner. Time-limited deals could also force the patient into undergoing a treatment well before the industry-advised 14-day cooling-off period.2 Can time-limited deals be appropriate?

The treatment in which is been offered on a time-limited deal is key; there is unlikely to be any ethical issues if promoting skincare and facial treatments, whereby patients do not need a cooling-off period before purchase.

It could also be said that the availability of otherwise cost-prohibitive procedures should not be taken away from the consumer who has done their research and is aware of the associated risks and potential complications.

Procedures such as botulinum toxin injections or dermal fillers can cost hundreds of pounds per session and require ‘topping up’ over time, and so it can become an expensive exercise. Due to this, loyalty discount schemes could be seen as a good thing, removing the obstacles that prevent those from lower income backgrounds accessing a service that those from higher incomes can better afford. In addition, reputable businesses that wish to use these schemes should, perhaps, not be discriminated against by taking away their opportunity to promote their company or boost sales. However, the public’s health should be first and foremost at the top of the list of priorities. Physically and emotionally, any individual who is considering a cosmetic procedure should be able to fully research their options and prepare themselves mentally for what is to come. A time-sensitive offer could cause an otherwise cautious patient to commit too soon.

What can be done?

While the industry itself is showing signs of

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improving, with the arrival of more organisations aimed at encouraging best practice, such as the Joint Council of Cosmetic Practitioners (JCCP), there are still many steps that can be taken to ensure patient safety and encourage high standards among quality private healthcare providers.

The practitioner should insist that the patient takes a cooling-off period before committing to a procedure, and resist taking deposits or partial-payment in advance of the procedure, as this could also put patients under pressure to commit to a treatment.

In addition, private clinics should not utilise any offers or discounts in promoting their services that could negatively apply pressure to a potential patient. A reward scheme whereby the sixth cosmetic injection is complimentary in a course of six, for example, could be an appropriate way to reward patient loyalty without the patient feeling obliged to pay out for unnecessary treatments. In my opinion, time-limited offers, or discounts off a second cosmetic procedure, are not appropriate and should be tightly restricted.

Lastly, private healthcare providers should make themselves aware of the rules established by the Advertising Standards Authority (ASA) and Committee of Advertising Practice (CAP) to ensure that they are advertising their services in a responsible and legal way. For example, it is prohibited to advertise prescription-only medicines, such as botulinum toxin, to the public, and price lists included on a website shouldn’t encourage viewers to choose a POM based on the price. Those found to be violating ASA rules face sanctions that range from on-the-spot fines, seizure of goods, negative publicity, such as having an ASA warning appear in

Aesthetics

search engine results, referral to Ofcom or Trading Standards, and imprisonment.

Duty of care Patients trust those who work in the medical profession and claim to be experts in their field. With this trust comes an enhanced responsibility to look after those patients and give them sound and objective advice, and to ensure that no patient is ever under any induced pressure – financial or otherwise – to commit to a procedure that they do not need or are not ready for.

Until regulation of the non-surgical aesthetic specialty improves as a whole, it is the private healthcare industry’s duty to first and foremost protect their patients, and then seek to lift the standard of the industry by not pandering to inappropriate marketing tools to drive sales.

Michael Saul is a partner at Cosmetic Surgery Solicitors, the first legal team set up in 2005 to deal with substandard treatment as a result of negligent cosmetic surgery, and is a passionate advocate for ensuring patients are fully informed before undertaking cosmetic surgery. Saul is aware of the negative consequences of the lack of regulation in the industry, and takes issue with the practice of profits before patients and commerce before ethics.

REFERENCES 1. Gov.UK, Review of the Regulation of Cosmetic Interventions, (2013) <https://www.gov.uk/ government/publications/review-of-the-regulation-of-cosmetic-interventions> 2. Royal College of Surgeons, Professional Standards for Cosmetic Surgery (April 2016) <bit.ly/ RCScosmeticstandards> 3. Advertising Standards Authority (ASA), (2017), http://bit.ly/2BS0AY8

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Medical Aesthetic Group Contact: Jenny Claridge +44 02380 676733 info@magroup.co.uk www.magroup.co.uk

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