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VOLUME 2/ISSUE 8 - JULY 2015

Clinically proven Obagi - Skin care for everyone The UK’s Best Cosmeceutical, recognised for the fourth year in a row by the aesthetic medical profession.

N 1 O

In the world

www.obagi.uk.com Treating the Forehead CPD Mr Dalvi Humzah and Anna Baker offer their insight into forehead rejuvenation

Hyperpigmentation

Mesotherapy

Online Reviews

Practitioners discuss the issue of hyperpigmentation and detail their treatment approaches

Juan Lopez shares his treatment protocol for optimising skin hydration

Emily Ross highlights the best ways to utilise online reviews for clinic marketing


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Contents • July 2015 06 News

The latest product and industry news

14 News Special: Consumer Health Reporting

We explore the representation of aesthetics in mainstream media

19 On the Scene

Out and about in the industry this month

Special Feature Hyperpigmentation Page 21

CLINICAL PRACTICE 21 Special Feature: Hyperpigmentation

We ask practitioners to share their best tips for treating hyperpigmentation

27 CPD Clinical Article

Mr Dalvi Humzah and Anna Baker detail the anatomy of the forehead area for aesthetic rejuvenation

33 Eye Rejuvenation

Dr Maryam Zamani provides an overview of aesthetic treatments for rejuvenating the eyes, and details her ‘Tri Eye’ technique

36 Aesthetics Awards 2015

We look at why you should be attending the Aesthetics Awards 2015

38 Hyaluronidase Protocol

Lee Rowe details the importance of hyaluronidase and how to use it

41 Treating Acne Scars with Fillers

Dr Renée Hoenderkamp shares her technique for treating acne scars with dermal fillers

44 Case Study: Liposuction

Dr Amanda Wong Powell discusses the evolution of liposuction and her own experience of performing VASER Liposuction in clinic

49 Mesotherapy for Facial Skin Hydration

Juan Lopez explores the use of mesotherapy to rejuvenate and moisturise the face

53 Spotlight On: Kybella

We investigate the newly FDA-approved fat reducing injection for the chin

55 Abstracts

57 Handling Online Reviews Emily Ross outlines key ways to manage online clinic reviews

60 Supporting Your Patient

Clinical Contributors Mr Dalvi Humzah is a consultant plastic reconstructive and aesthetic surgeon, with a BSc in anatomy. He is the lead tutor for the award-winning anatomy teaching programme, Facial Anatomy Teaching. Anna Baker is a dermatology and cosmetic nurse practitioner. She runs the nurse-led Medicos Rx Skin Clinic at The Nuffield Health Hospital in Cheltenham, and is the coordinator for Facial Anatomy Teaching. Dr Maryam Zamani is an ophthalmologist, oculoplastic surgeon and aesthetic doctor. She qualified at the George Washington University School of Medicine, later completing her training at the imperial College London. Dr Renée Hoenderkamp is a GP registrar in London. With a special interest in aesthetics and women’s health, she founded The Non Surgical Clinic in 2011, focusing on natural looking solutions for facial ageing and deformity. Dr Amanda Wong Powell is a VASER liposuction surgeon, founder of Dr. W on Harley Street and a member of the Royal College of Surgeons (Edinburgh). She is also medical director of medical training platform Meducatus. Lee Rowe is an independent nurse prescriber and aesthetic nurse. Leaving the NHS some years ago, she set up Innersense Aesthetics with fellow nurse Lorraine O’brien and now works full time at her York-based clinic.

A round-up and summary of useful clinical papers

IN PRACTICE

Patient Relations Handling Online Reviews Page 57

Deborah Vine highlights the importance of working as a team to enhance patient care

Juan Lopez is an aesthetic nurse and independent prescriber, with a special interest in skin health and mesotherapy. Owner of DermaTops.com, he is now launching his clinic, Skin Medico, in London.

NEXT MONTH • IN FOCUS: Augmentation • Filler Retrospective • CPD: Lower Eyelid Rejuvenation • Building Your Media Profile

63 Social Media Etiquette

Paul Jackson addresses what practitioners should be aware of when communicating with patients online

66 In Profile: Dr Zein Obagi

Wendy Lewis talks to Dr Zein Obagi about his journey into aesthetics

68 The Last Word: Titles and Qualifications

Dr Sam Robson argues for better clarification of titles and qualifications in medical aesthetics

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Editor’s letter Finally, some sunshine! It feels deceptively like summer has arrived as I sit here in the journal office with the sun beating down on our backs through the windows. Personally I love the sun, as those of you who know me will testify. However, the sun has not been as Amanda Cameron kind to me, and my regrettably sun-damaged Editor skin is the result of summers of abuse in the 70s with little or no SPF. In those days, factor 2 was considered high, and olive oil gave a much better result in terms of tanning. If only I knew then what I know now! These days there is no excuse for having sun-damaged skin, with increased awareness and high SPF, as well as the improvement in fake tan for those of our patients who want to be darker. Aside from the obvious risk of skin cancer, hyperpigmentation is also a very prevalent area of concern in aesthetics, a subject that we explore in this month’s Special Feature (p. 21). One thing is clear, and that is that we do live in a strange and complex world where half the population want to look darker, and the other half want to look lighter. Regardless of cultural preferences, safety in the sun is key, and this message was reinforced with the recent launch of a new UV app from the British

Association of Dermatologists and MET office. The app provides the public with a free daily UV-forecast and suggestions on how best to protect specific skin types. Will you be sharing this new technology with your aesthetic patients? It’s not only skin tone and texture that we’ll be exploring in this issue. Our CPD article this month focuses on the rejuvenation of the forehead, and provides an extensive overview of this area of the face, looking at the anatomy in detail (p. 27). Dr Maryam Zamani presents her technique for rejuvenating the eye area (p.33), and Dr Renée Hoenderkamp looks at the treatment of acne scarring using dermal filler (p. 39). This month we also profile the infamous Dr Zein Obagi, tracing his journey into aesthetics, and his subsequent brand expansion (p. 66). As you will all know by now, entries for the Aesthetics Awards are now closed. We have been overwhelmed by the quality of the written entries, and we look forward to announcing the finalists in September. In the meantime, we want to hear your thoughts about this month’s issue. What are your methods for communicating sun safety to your patients? Do you have your own technique for eye rejuvenation? Let’s keep up the conversation. Email editorial@aestheticsjournal or tweet us @aestheticsgroup #talkaesthetics

Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined 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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic surgeon in the NHS for 15 years, and is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally.

experience in facial aesthetic medicine. UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers, in 2012 he was named Speaker of the Year at the UK Aesthetic Awards. He is actively involved in scientific audit, research and development of pioneering products and techniques.

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Cosmetic Nurses (BACN) and also the UK lead on the BSI committee for aesthetic non-surgical medical standard. Sharon has been developing her practice in aesthetics for 25 years and has recently taken up a board position with the UK Academy of Aesthetic Practitioners (UKAAP).

and PHI Clinic. He has over 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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.

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 Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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.

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Standards

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Psoriasis Psoriasis Foundation @NPF People w/mild #psoriasis are just as likely to develop psoriatic #arthritis as those w/ moderate to severe forms of the disease. #health

#SPF Dr Anjali Mahto @DrAnjaliMahto Physical #sunscreens reflect UV, chemical sunscreens absorb it #sunprotection #SunSafety #healthyskin

#Training Andy Millward @AndyMillward_ Passed assessment & doing my @MARSTE_ACADEMY Dermagen training with @Marie_Reynolds on June 1st. Needle-ss to say I am extremely excited!!

#NeckLift River Aesthetics @riveraesthetics Watching the Neck lift with Dr Dorinda Donici from Russia #aesthetics @Rosmetics @ RealYouClinic

#Learning Sue Ibrahim @SkinSpecialist With 17 years experience in cosmetic dermatology I have performed thousands of injectable treatments, but I am still developing my skills.

#Training Clare McLoughlin @appearancebased I’m at the Allergan Master Class 2015 today and tomorrow, with Mauricio de Maio! Look forward to seeing some of you there too! #allergan

#Success Dr Tijion Esho @DrTijionEsho Failure is needed at times of success, it keeps you humble, and that is a quality to maintain while progressing in life

GMC to develop guidance for doctors carrying out cosmetic procedures The General Medical Council (GMC) has launched a public consultation on the guidance available to UK-based doctors offering cosmetic procedures. The final guidance, expected to be published in early 2016, will aim to set ethical standards that will be expected of both surgical and non-surgical UK doctors. The GMC hopes the guidance will help patients understand what to expect from their doctor and ensure that they undergo cosmetic treatments in a safe environment. Key points in the new guidance will address, amongst others, the need for doctors to be honest with patients, ensure doctors market their services responsibly, and give patients enough time and information before they decide to undergo a procedure. The GMC is also working with the Royal College of Surgeons (RCS) of England to publish information about which surgeons have the right skills to carry out cosmetic surgery. As the vast majority of cosmetic surgery is currently performed within the private sector, the law currently allows any qualified doctor to perform the operations, whether or not they are a trained surgeon, without any additional qualifications or training. The RCS has already drafted new standards of training and practice in an attempt to correct this following the PIP scandal and subsequent Keogh Review. Without a law in place to give the GMC powers to formally recognise these qualifications, however, the RCS claim the standards will have limited effect on the industry. The proposed legislation would give the GMC the power to inform both members of the public and prospective employers which surgeons are qualified to perform cosmetic surgery. Mr David Ward, consultant plastic surgeon and vice president of the Royal College of Surgeons, said, “It is very important that the newly elected government seizes this opportunity to improve patient safety. A simple change in the law will allow the General Medical Council to detail whether an individual has the appropriate skills and training to carry out cosmetic surgery.” Professor Sir Bruce Keogh, NHS England’s medical director, added, “This consultation is a step in the right direction to tighten standards and protect people from potential risks.” Both the public and practitioners are invited to take part in the consultation, which runs until September 1. Those interested in participating can find more information on the GMC website. Skin cancer

Suggested increase in melanoma cases New research has indicated that melanoma rates are increasing among children and young adults. The research indicated that melanoma has increased by more than 250% among children, adolescents and young adults since 1973. However, the results also suggest an increase in survival rates – from 80% between 1973 and 1980, to 95% in 2011. The surveillance, epidemiology and end results (SEER) data analysed 35,762 of melanoma cases, looking at individuals of less than 40 years of age from 1973 to 2011.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Aesthetics Awards

Dermal filler

FDA approves dermal filler for hand treatment The Food and Drug Administration (FDA) has approved the use of dermal filler Radiesse for volume correction in hand augmentation. Earlier this year, the FDA Medical Devices Advisory Committee announced a majority vote of 11 to three in recommending the expanded use of Radiesse within hand augmentation. Now, the dermal filler, produced by Merz Aesthetics, is the first to be approved for use in the hand area. Jim Hartman, vice president and head of US Aesthetics/OTC for Merz North America told BusinessWire, “Merz is proud to be able to provide patients and physicians with the first and only dermal filler approved by the FDA for use in the hand.” He added, “This new indication for Radiesse is a result of our focus on meeting unmet needs in the US aesthetics market, and we are excited to provide our physician customers with this new option to better fulfil the aesthetic desires of their patients.” Radiesse has been previously FDA approved for the correction of moderate to severe facial wrinkles and folds. Side effects may include bruising, swelling and redness, which the company state are generally mild and short term. Skincare

New products launched by NeoStrata Specialist skincare developer NeoStrata has released new products to join its advanced skincare portfolio.The new products include Skin Active Dermal Replenishment, and Smooth Surface Daily Peel. Skin Active Dermal Replenishment is a night cream, which aims to deliver optimal hydration and anti-ageing effects for patients with dry skin, using NeoStrata patented technologies that aim to plump, firm and protect the skin. Smooth Surface Daily Peel is a peel for daily home use, specifically directed at smoothing fine lines and improving skin texture. It uses glycolic acid and NeoStrata’s patented Aminofil, a tyrosine amino acid derivative (N-Acetyl Tyrosinamide) that creates a rapid volumising effect, aiming to visibly reduce deep facial lines and wrinkles. NeoStrata products are available in the UK via AestheticSource.

T H E A R T O F FA C I A L R E J U V E N AT I O N

New sponsors announced for Aesthetics Awards

New sponsors have been announced for the Aesthetics Awards 2015. Medical device company Schuco International will now sponsor the Award for Special Achievement, which recognises the outstanding achievements and significant contribution to the aesthetics profession made by a particular individual. Previously won by pioneering aesthetic practitioner Dr Roy Saleh, this year’s award will once again celebrate a renowned figure in the industry for their dedication to aesthetics. It has further been announced that Swiss-based skincare company Pure Swiss Aesthetics will sponsor the award for Best Clinic Group UK & Ireland (10 clinics or more). This award category will judge entrants on commitment to excellence in customer services, patient care and patient safety. Teresa Da Graça, chief executive of Pure Swiss Aesthetics, said, “Last year’s Aesthetic Awards was Pure Swiss Aesthetics’ introduction to the UK market and that makes our sponsoring this year that bit more special.” She added, “We are very proud and extremely pleased to be launching and sponsoring the Best Clinic Group Award with our Swisscode brand.” Entry for the Aesthetics Awards 2015 closed on June 30, with the voting process commencing from September 1. The awards ceremony will be held on December 5 at the Park Plaza Westminster Bridge Hotel in London. To find out more about the awards, or to book, visit www.aestheticsawards.com

Why are Doctors and Nurses switching to VARIODERM HA Dermal Fillers?

• Made in Germany to the highest of standards • Clinical trials show that it outperforms other major brands for elasticity, longevity and performance • Dynamic product range for various indications • Very competitive pricing • Very high level of patient satisfaction Contact info@adareaesthetics.com for further info and pricing. Adare Aesthetics Ltd, 26 Fitzwilliam Square South, Dublin 2, Ireland. Mob: +353 (0)85 711 7166 | Tel: +353 (0)1 676 9810 Email: info@adareaesthetics.com | Skype: ivanlawlor | Web: www.adareaesthetics.com

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Lips

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Body contouring

SkinCeuticals introduces new lip product Advanced skincare company SkinCeuticals has announced the launch of its new lip product, Antioxidant (AOX) Lip Complex. The product, to be released later this month, is the latest addition to the company’s ‘Correct’ product range. It aims to treat damaged or ageing lips, with a combination of pure antioxidants, vitamin E, silymarin and active ingredients. To be incorporated into a daily care routine, SkinCeuticals claims the AOX Lip Complex delivers three key benefits: restores hydration, refines and smoothes the appearance of the lip tissue, and protects against environmental damage. It also claims to offer significant benefits when offered as part of pre- and post-procedure care following lip filler augmentation, providing relief from common after-effects such as dryness, tightness and swelling. “This is a fantastic treatment which I believe will quickly become an integral part of my patients’ skincare routine because of how it rejuvenates and replenishes lip tissue,” said aesthetic practitioner Dr Sarah Tonks. “AOX Lip Complex delivers an anti-ageing, protective treatment which I will use in my clinic both as a preventative option and as an advanced lip therapy for patients with premature lip damage.”

Eden Aesthetics to distribute new skin tightening system Eden Aesthetics has acquired the UK distribution rights to the Novaestetyc Lift-Shape system. The skin tightening and fractional resurfacing system aims to improve the appearance of skin through the use of Dynamic Quadripolar radiofrequency. According to the company, this new concept allows the practitioner to focus the radiofrequency energy where it is needed most for optimum results. Erika Galtarossa, training manager for Novaestetyc, said, “This system is based on radio frequency (RF) technology, but it is a dynamic quadrapolar radiofrequency, which is something specific from us. It means that it is very effective, but, at the same time, very comfortable to be received, and very safe.” Additional handpieces are available to treat larger areas of the body such as the abdomen, buttocks and thighs.

Botulinum toxin

Regular Botox may reduce number of treatments needed A study carried out by Dr Alastair Carruthers and his team has revealed that in patients who regularly received Botox treatments for more than five years, the time between treatments increased over 22 treatments for glabellar and crow’s feet lines. The retrospective study looked at data received from multiple centres internationally, covering 194 patients who had received a total of 5,112 Botox treatments. Researchers further found that the average annual dose used to treat glabellar lines decreased by 9% as years of treatment increased, with the biggest change happening in the first three years. The number of days between Botox injections for glabellar lines went up from 129 days to 176 days over the course of 22 treatments. For crow’s feet lines, the number of days between treatments also increased from 136 to 209 over the same period. Patients further reported positive outcomes, with 98.3% of those aged under 50 being very satisfied or mostly satisfied with the result of Botox treatment, and 86.9% of all patients treated reported looking younger than their actual age. Dr Carruthers is a consultant for Allergan and has received research grants from the company. The full study, with a full list of disclosures, was published in volume 41, issue 6 of Dermatologic Surgery, in June 2015.

Technology

Consumer gadgets launched to promote sun safety The general public are being encouraged to use gadgets such as mobile apps to protect their skin from sun. Alongside the Met Office, the British Association of Dermatologists (BAD) has produced a mobile app called WORLD UV, which uses GPS technology to calculate local UV levels, and suggest how best users can protect their skin type. In addition, Swedish company Smartsun has developed paper wristbands that measure a user’s UV exposure and changes colour when they need to reapply sunscreen, while Electronic device developer Netatmo has released a bracelet called JUNE. It communicates with a user’s phone to recommend adequate SPF and alert users when they have reached their daily UV limit.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Industry

Allergan set to acquire Kybella manufacturer Global pharmaceutical company Allergan has announced that it will acquire Kythera Biopharmaceuticals for $2.1 billion. The news comes following the recent Food and Drug Administration’s approval of Kybella, a non-surgical treatment aimed at reducing the appearance of submental fat, manufactured by Kythera. The acquisition has been agreed as a case and equity transaction valued at $75 per Kythera share, to be received as 80% in cash and 20% in Allergan shares, subject to certain customary conditions which include the need for approval from Kythera’s stakeholders. Brent Saunders, CEO and president of Allergan, said of the news, “The acquisition of Kythera is a strategic investment that strengthens our leading global position in aesthetics and continues to position us for long-term growth.” The acquisition is subject to expiration or termination of the waiting period under the Hart-Scott-Rodino Antitrust Improvements Act 1976. This states that parties must not complete certain mergers, acquisitions or transfers of assets until a detailed filing has been made with the US Federal Trade Commission and the Department of Justice, in order to ensure the transaction will not adversely affect US commerce under the antitrust laws. Keith Leonard, CEO and president of Kythera, said, “Allergan’s worldclass medical aesthetics, global footprint, history and commitment to developing leading aesthetic products makes them ideally suited to realise the maximum commercial potential of Kybella.” He continued, “We look forward to working with Allergan to ensure a successful US launch of Kybella, as well as to secure additional approvals globally.”

Aesthetics

Vital Statistics

46% of patients use social media to look for information about a treatment prior to a consultation (Aesthetic Plastic Surgery)

Each year, 54% of the UK population is affected by skin disease (British Association of Dermatologists)

125 million

An estimated 125 million people worldwide live with psoriasis (National Psoriasis Foundation)

Skin cancer

Trial suggests positive outcome of treating skin cancer with herpes-based drug A phase three trial has indicated positive results after a new herpes-based drug was used to treat skin cancer patients. Dubbed ‘virotherapy’, the new drug, called T-VEC, works by using ‘neutered’ virus cells to attack the cancer cells, and could become more widely available to cancer patients by next year. More than 400 patients with aggressive melanoma undertook the trial, which showed one in four had responded to treatment. The trial found that 16% were still in remission after six months, and 10% of patients treated had ‘complete remission’ with no detectable cancer remaining. Members of the control group were treated with a protein designed to stimulate the immune response against cancer, but did not include the virus component of the treatment. All patients were treated by injection and received a dose every two weeks for up to 18 months. The trial indicated that side effects remained mild compared to those experienced with chemotherapy drugs, and patients typically experienced mild flu-like symptoms. Regarding the promising outcome of the trial, the authors of the study hope the new drug will offer an alternative to those with few options. Kevin Harrington, professor of biological cancer therapies at the Institute of Cancer Research London, who led the research, told the Guardian, “This is the big promise of this treatment. It’s the first time a virotherapy has been shown to be successful in a phase 3 trial.”

45,506 surgical

procedures were carried out in 2014 (British Association of Aesthetic Plastic Surgeons)

72% of British people admitted to being sunburned in 2014 (British Association of Dermatologists)

44%

Last year, of UK men took steps to lose weight

44%

(Mintel)

Women under 24 years of age show 45% more interest in rhinoplasty than those between 25 and 34 (RealSelf)

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Events diary 7th – 9th July 2015 British Association of Dermatologists (BAD) Meeting, Manchester www.bad.org.uk/events/annualmeeting

31st July – 2nd August 2015 International Master Course on Aging Skin (IMCAS), Asia www.imcas.com/en/asia2015/congress

Aesthetics Journal

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Fat reduction

SculpSure receives FDA 510(k) clearance for non-invasive fat reduction

25th – 26th September 2015

Medical device manufacturer Cynosure has announced that its hyperthermic laser treatment device, SculpSure, has received 510(k) clearance from the Food and Drug Administration for non-invasive fat reduction. The 510(k) clearance means that the company will now be able to market the device for the non-invasive treatment of fat. Using a 1060 nm laser with a flexible applicator system to treat multiple areas of the body, Cynosure claims the SculpSure system works by disrupting subcutaneous fat cells. “SculpSure represents an entirely new approach to non-invasive lipolysis, one that is safe and highly effective in reducing adipose tissue and does so in significantly less time than other current treatments,” said Cynosure chairman and CEO Michael Davin.

F.A.C.E2F@ce conference 2015, Cannes www.face2facecongress.com/en

Body countouring

19th – 23rd August 2015 American Academy of Dermatology (AAD) Summer Meeting, New York www.aad.org/meetings/2015-annualmeeting/general-information

26th September 2015 British College of Aesthetic Medicine Conference, London www.bcam.ac.uk

3rd October 2015 British Association of Cosmetic Nurses Conference, Birmingham www.bacn.org.uk/events/bacn-annualconference-exhibition

5th December 2015 The Aesthetics Awards 2015, London www.aestheticsawards.com

Skincare

DMK to introduce new product range

Invasix launches new MiniFX application Israeli-based medical device company Invasix Limited has launched its new MiniFX application to expand its multitreatment platform, InMode. The new application, now available in the UK, will be added to the range of applications for the InMode system, which aims to allow practitioners to treat a number of indications on one device. Invasix claim the new application will allow practitioners to treat smaller and harder to reach areas, such as the neck and arms. Like its larger counterpart, BodyFX, MiniFX is a non-invasive contouring and cellulite treatment which uses four technologies; radiofrequency, high amplitude, vacuum and skin temperature. Other applications for the InMode platform include FRACTORA (for fractional resurfacing and rejuvenation), FORMA PLUS (for face and body remodelling), LUMECCA (for internsed pulsed light rejuvenation) and DIOLAZE (for laser hair removal). Industry

BACN appoints new vice chair Skincare manufacturer Danné Montague-King (DMK) has announced it will be introducing a new skincare range to its product portfolio. The new range, DMK Fundamentals, will include three skincare kits: Acne Control, Age Management and Pigment Balancing. According to the company, the products in each kit work to support the skin’s own natural function. Presented in ‘Home Prescriptive’ packs, each kit includes a 30-day supply with initial treatment starting in-clinic. Packs include premium DMK products such as Enzyme masques, Quick peels and Fibromax C, with specific products to treat acne, ageing and pigmentation.

The British Association of Cosmetic Nurses (BACN) has appointed a new vice chair, as aesthetic nurse prescriber Lou Sommereux steps down from the position. The BACN has announced that Andrew Rankin, aesthetic practitioner and trainer, will now take over the vice chair position. BACN chair Sharon Bennett said, “Andrew has given enormous amounts of his time working with HEE and with education. He is sensible and balanced, has been on the board for a number of years and so understands the business and the input required from this demanding, time-consuming position.” On taking up his new position, Rankin said, “I am proud to be given this opportunity, as I am to support Sharon as chair, to work alongside my peers and to represent our members so that we can make a difference, which we surely can.”

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Skin cancer

Trial suggests cancer drug combination could shrink nearly 60% of melanomas An international trial of 945 people has indicated that taking a combination of two cancer drugs can have a significant impact on shrinking tumours in patients with advanced melanoma. The results of the trial have suggested that treating patients with both ipilimumab and nivolumab stopped the cancer from advancing for nearly a year in 58% of cases, with tumours either stable or shrinking over a period of 11.5 months. For ipilimumab alone – a product that was approved by the NHS last year as an advanced melanoma treatment – the figures were 19% and 2.5 months. Dr James Larkin, a consultant at the Royal Marsden Hospital and one of the UK’s lead investigators, said, “By giving these drugs together you are effectively taking two brakes off the immune system, rather than one, so the immune system is able to recognise tumours it wasn’t previously recognising and react to that and destroy them.” He continued, “For immunotherapies, we’ve never seen tumour shrinkage rates over 50% so that’s very significant to see. This is a treatment modality that I think is going to have a big future for the treatment of cancer.” Dermal fillers

FDA releases safety notice on filler injections The Food and Drug Administration (FDA) has published a safety communication in relation to the unintentional injection of soft tissue fillers into facial blood vessels. After reviewing information that suggests unintentional injection of soft tissue fillers into blood vessels in the face can result in rare, but serious, side effects, the FDA are now urging practitioners, and those contemplating filler treatment, to be aware of the risks. Risks can include blocking of blood vessels, resulting in embolisation, visual impairment, strokes and necrosis. It can also cause damage to underlying facial structures. The FDA has advised practitioners to thoroughly warn patients of the risks associated with treatment, and to ensure that they are aware of any signs and symptoms associated with injection into blood vessels, with a detailed plan for adverse reactions. Following the review, the FDA is working with manufacturers to update their labelling with additional warnings, precautions and other statements about the risk of unintentional injection into blood vessels. Industry

Ferndale Pharmaceuticals and Aesthetic Technology strengthen collaboration Ferndale Pharmaceuticals has acquired 30% of Aesthetic Technology shares in a joint commercial venture. Aesthetic Technology is the developer and manufacturer of the Dermalux LED phototherapy systems, whilst Ferndale Pharmaceuticals is a specialty dermatology company. Upon the collaboration, Dermalux will be integrated into AesthetiCare, Ferndale’s aesthetic division, with the aim of Aesthetic Technology expanding into the professional beauty and spa sectors. The companies hope that Ferndale can provide Aesthetic Technology with enhanced financial strength and operational infrastructures, particularly with its developing international presence.

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Roger Bloxham, Managing Director at AesthetiCare The new AesthetiCare adverts talk about being ‘Together on the journey to better looking skin’ and say, ‘Let’s do things differently’. What does all this mean? We are saying that we want to develop a long-term partnership plan with clinics and practitioners that will really make a difference to their clinical and business results, not just in the short term, but for years to come. We are also saying that we have the means to do this with the comprehensive product range, skin devices and treatments that make up the AesthetiCare ‘Aesthetic System Portfolio’, and through the superior clinical and business support we provide. ‘Let’s do things differently’ is a way of summarising this approach. ‘Together on the journey to better looking skin’ describes and defines our collective passion and focus for better looking and healthier skin, and reflects our strong dermatology and clinical heritage. What is the AesthetiCare ‘Aesthetic System Portfolio’, mentioned above? This is the portfolio of medigrade skincare and skin devices and treatments that we are constantly working on developing and assembling. The AesthetiCare focus is always on evidence base and technologies and formulations that deliver high-level clinical results. When it comes to skin the portfolio addresses the majority of the needs of an aesthetic skin clinic, and crucially, the products and devices all complement each other, and can be used in evidence-based synergistic combinations to deliver fantastic results. What’s the main focus and which indications does the portfolio combat? The focus is always better looking and healthier skin. The indications are rejuvenation of aged and photo-damaged skin, prevention of the acceleration of skin ageing and providing resolution to skin problems such as acne, acne scars, pigmentation, rosacea / red and flushed skin. We also, through individual technologies and combinations, provide great enhancement to lax and sagging skin, including body shaping and inch loss. This breadth and synergy enables us to truly consult and build long-term clinical and business partnership. This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Skincare

AesthetiCare launches new product range

Skincare and device manufacturer AesthetiCare has launched BiRetix, a new cosmetic range geared at treating spot-prone skin. Included in the range is BiRetix Duo, which contains RetinSphere Technology, (a combination of cosmetic retinoids that aim to clear pores and clarify skin. It also contains BOIPEP.15, a botanical complex with Oligopeptide 10, a bioactive peptide containing naturally occurring amino acids to fight P. acnes, and salicylic acid. According to the company, clinical studies have indicated that each ingredient works to improve the appearance of comedones, spots and redness. The BiRetix Micropeel and BiRetix Mask are also included in the skincare range. The Micropeel contains a clarifying and exfoliating cleanser with botanical extracts and exfoliants that aim to clear pores and stimulate cell renewal, while the clay mask contains mineral, anti-oxidants and RetinSphere technology, which aim to control sebum and reduce shine. The new range is part of the Resolve category of AesthetiCare’s SKINSYNERGY medi-grade skincare portfolio, which also includes products for treating pigmentation and redness. Skincare

AestheticSource announced as headline sponsor for ACE 2016 Skincare distributor AestheticSource has been announced as the official headline sponsor for the Aesthetics Conference and Exhibition (ACE) 2016. Following its success as the headline sponsor at ACE 2015, the company is now looking forward to next year’s premium UK aesthetic conference event. “AestheticSource are proud to be the headline sponsor at the Aesthetics Conference and Exhibition 2016,” said Lorna Bowes, director of AestheticSource. “This year’s conference was a real success for our team, and we look forward to returning in 2016 as we take on the headline sponsorship once again.” She added, “The conference always provides fantastic exposure for AestheticSource, and the extensive agenda really supports our view of the importance of ongoing education within the aesthetic industry. We can’t wait to see what next year’s event will bring to the educational table!” ACE 2016 will feature a broad agenda, with in-depth clinical content on the latest innovations, best practice, advice and demonstrations from leading professionals in the aesthetics industry. To keep up to date with all the latest announcements regarding Aesthetics events, sign up to receive our weekly e-newsletter at www.aestheticsjournal.com

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News in Brief Harley Street doctor offers eighthour lip filler treatment Aesthetic practitioner Dr David Jack is offering patients a lip-plumping procedure that lasts six to eight hours. Instead of injecting traditional filler, Dr Jack injects saline solution to the surrounding area of the lips to produce shorter-term results. According to reports, the treatment, dubbed ‘Cinderella Lips’, is becoming popular amongst people seeking temporary lip enhancements before committing to traditional lip fillers. Waterhouse Young appoints new doctor to join team Aesthetic practitioner Dr Saira Vasev has joined the team of clinical staff at the nonsurgical aesthetic practice, Waterhouse Young. Previously, Dr Vasdev has worked for the NHS where she studied recovery procedures for facial injuries. A spokesperson for Waterhouse Young stated that Dr Vasdev has proven to be a valuable member of the team and feedback from her first clients has been exceptional. EF MEDISPA opens in Canary Wharf Aesthetic clinic chain EF MEDISPA is set to open its fourth London clinic in Canary Wharf later this year. The new clinic, which will be situated on Admiral’s Way, will open in August and aim to offer patients the latest advances in medical aesthetics, with a particular ethos to cater to Canary Wharf’s time-short executives. The company’s current clinic portfolio includes clinics in Kensington, Chelsea and St John’s Wood. Irwin Mitchell launches new cosmetic tracker app Specialist cosmetic surgery lawyers at Irwin Mitchell have developed an app that assists those going through cosmetic procedures to track their journey. The new app, ‘BeautyTracker’, allows patients to track their journey with practitioners and clinics in an attempt to improve safety in the industry, following a rise in patients affected by negligent treatments. Allowing patients to keep a log of treatments and details of practitioners, the app will further provide access to expert advice if a treatment goes wrong. Users will also be able to access independent sources of help and advice if they have an unsatisfactory outcome following treatment.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Botched Bodies and Cosmetic Surgery Cowboys: The representation of aesthetics in mainstream media Aesthetics explores the prevalence of negative reporting on our industry, and talks to media professionals about how it can be improved Introduction ‘Trout pout’, ‘pillow face’ and the ‘Bride of Wildenstein’ are all terms synonymous with the representation of medical aesthetics in the media. Type ‘cosmetic surgery’ into any search engine and results generate news of celebrity treatments, botched procedures and, at worst, death following surgery. While ‘scare stories’ can of course encourage the public to think carefully about the risks of procedures and the importance of seeking treatment from a safe practitioner, some aesthetic professionals argue that they can have a negative impact on the industry. Many practitioners are also quick to criticise the reporting of potentially unsafe treatments and procedures, which often have little to no safety data supporting their use as aesthetic treatments. Stories derived from clinical studies can be exaggerated and sensationalised, claiming new cures and promising immediate, pain-free aesthetic results. So who is to blame for these hyped-up stories? Many are quick to point the finger at newspapers, competing for sales figures and desperate to win the widest readership. Yet the two journalists interviewed for this report highlight the challenges of deciphering scientific jargon and the need for more support from the aesthetics and cosmetic surgery industries to secure accurate reporting. In this, public relations officers (PRs) and the academics approving scientific press releases have an important role to play. Research published in the British Medical Journal suggests that exaggeration in news is strongly associated with exaggeration in press releases. The study has indicated that 40% of press releases on biomedical and health-related science contain exaggerated advice, 33% contain exaggerated casual claims, and 36% contain exaggerated inference to humans from animal research.1 Mr Rajiv Grover, plastic surgeon, former president of the British Association of Aesthetic Plastic Surgeons (BAAPS) and member of the BAAPS press committee, also notes that it is important that practitioners take some of the responsibility for the amount of undesirable stories in the media. He says, “Those negative stories didn’t just come out by accident – there have been negative things happening. It’s important that we have high standards everywhere so there’s less negativity to report.” As such, it seems apparent that aesthetic professionals, PRs and media representatives need to work together to improve the representation of aesthetics and cosmetic surgery in the media, but how can this be done effectively? The Public Interest ‘If it bleeds, it leads’ is an old adage adopted by many media outlets to explain the sales value of a negative news story in comparison to a positive one. Despite many people’s objection to this approach, it does provide an explanation as to why so much aesthetic and cosmetic surgery news focuses on the undesirable results and negative connotations associated with the industry. Along with this, journalists are obliged to report stories that are ‘within the public interest’. The Editors’ Code of Practice, which all members of the press have a duty

to maintain, defines the public interest as including, but not being confined to:2 • Detecting or exposing crime or serious impropriety. • Protecting public health and safety. • Preventing the public from being misled by an action or statement of an individual or organisation. With such a prominent lack of regulation and a high prevalence of un-qualified practice taking place in the UK, it is inevitable that the aesthetic and cosmetic industry ticks the ‘public interest’ box, and captures the attention of the media. Misreporting “We are contacted by PRs on a daily basis,” explains Barney Calman, health editor of the Mail on Sunday. “We have to treat everything with caution – our journalists always request studies, safety data and the proof that something works before writing about it,” he says. Calman exemplifies one case in which a journalist on his team was sent a press release announcing that a particular brand of lip filler could now be used for vaginal rejuvenation. “The reporter had done her due diligence and asked for safety data, which they had sent to her. The filler had received a CE mark based on the fact it is safe to be used in the body, however there was certainly nothing to note that it was indicated for use in that area,” he explains. “It turned out there was nothing to support its safety for vaginal rejuvenation.” Calman notes that following 11 years of reporting healthcare news, he is now adept at spotting anything untoward. “But obviously, if we are lied to or misled then incorrect or unsafe information can get out there,” he says. The Value of PR It is common practice for both aesthetic organisations and individual practitioners to employ the support of PR officers to promote their services and spread their messages within the media. Julia Kendrick has recently established her self-titled PR consultancy business following years of representing large pharmaceutical companies. To minimise the risk of sharing misleading press releases, Kendrick ensures anything she sends out is to a pharmaceutical standard. “The companies I work with are focused on ensuring that all material they send out is extremely accurate, well referenced, and adheres to the standards set out by the ABPI,” she explains. The Association of the British Pharmaceutical Industry (ABPI) Code of Practice sets standards for promoting appropriate use of medicine to the public. It states that, “Companies must ensure that their materials are appropriate, factual, fair and capable of substantiation and that all other activities are appropriate and reasonable.”3 Kendrick encourages her clients and other PR companies to adopt

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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this approach and suggests that, “If you’re conducting yourself and your business to the highest possible standards in the industry, you’re setting yourself up in a way that’s going to be successful, credible and ethical.” While ensuring the accuracy of the content you share is essential, it is sometimes beneficial to inject some fun into press releases, suggests Tingy Simoes, especially when fighting for news space amongst negative reports. Mr Grover agrees, “Journalists in mainstream media are getting hundreds of press releases per day. Unless you make it interesting for them and stand out, there’s no reason for them to read it because they have no time.” As the managing director of Wavelength Marketing Communications and Cacique Public Relations, Simoes is known amongst journalists and practitioners for her eye-catching email subject lines and inventive treatment captions. She’s coined phrases such as, ‘The Miami Thong Lift’, which she says generated international press coverage, and ‘The Smile Transplant’, which refers to the treatment available to facial palsy sufferers. Associating the phrase with the news that the NHS wasn’t routinely funding ‘smile transplants’4 garnered a hugely positive response from the UK media, according to Simoes. “If you give something a name that people can automatically understand and tie it to something current, you’ll get something that’s very well respected and sometimes makes global news,” she explains. From a journalist’s perspective, Calman adds, “There’s certainly a harmonious respect to be had – if PRs come up with fun ways of selling things, and can project a treatment onto a fun theme, then it can often work really well in terms of selling a page.” Simoes also highlights the importance of PR officers understanding the topic they are trying to promote to the media. “I find it sad that some PR agencies are cheapening aesthetics by not understanding it,” she says, adding, “I work so hard on our press releases, ensuring all the information is in there; statistics, detail, layman’s terms – we’re trying to educate people and find the things that are fascinating about the industry.” Freelance journalist Beatrice Aidin agrees, noting that she deletes any ambiguous press releases she receives. “PRs have a tough job to do, especially in terms of medical PR. I think, though, that if the PRs haven’t understood the story, how will I? If they don’t know what they’re talking about I have no faith I’m going to get something accurate.” Calman adds, “I wouldn’t like to blame PR officers because they’re simply working with the information that they’re given. Their job is to have connections with journalists, not to be medical experts.” Improvement Strategies Mr Grover explains that the BAAPS has recently formed an organisation called the National Institute of Aesthetic Research (NIAR) to address the lack of data on the efficacy and safety of aesthetic and cosmetic surgery treatments. Working in association with the Healing Foundation, a charity that supports people living with disfigurement and visible loss of function, Mr Grover explains that the BAAPS hopes the NIAR can investigate areas lacking research and produce reliable data to be shared with the public. He says, “Although the institute’s in its infancy, it will hopefully gain the trust of the media and inform the public of aesthetic developments in an appropriate way.” The fast-paced nature of news also means that the industry needs to act quickly to comment on breaking stories and provide knowledgeable and reliable explanations or opinion. As Calman explains, even journalists who specialise in healthcare reporting are not likely to be medically trained, let alone journalists working within a different specialty, leaving clinical studies and press releases open to interpretation. Being able to help journalists in their enquiries as soon as possible is beneficial to the industry as a whole, as well as for

Aesthetics Journal

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individual practitioners looking to enhance their public profile. Kendrick shares some of her best tips for talking to journalists: • Don’t get drawn into sensationalism; avoid commenting on rumours, you’ll only fuel the fire. • Use your own expertise to provide a balanced perspective on the topic in question. • Research the journalist’s background and publication prior to interview; consider who they are, their specialty, who the publication’s audience is, the tone of the publication, and what you expect the journalist is looking for. • Avoid talking in jargon and acronyms – Albert Einstein once said, “If you can’t explain it simply, you don’t understand it well enough”. Modify your response so that it’s appropriate to the journalist, the media outlet and the readership. Kendrick explains that she hopes these methods will improve the standard of communication needed between the aesthetics world and the media. Aidin adds that a practitioner who can explain things well is invaluable to her reporting. She says, “I’ve learnt a lot from certain practitioners who are intelligent and great communicators; it’s very important.” Looking Forward While the aesthetic industry remains severely lacking in regulation, and manufacturing companies continue to innovate and create, it seems unlikely that the media storm surrounding our industry will die down any time soon. As a journalist, Calman argues that it is not the job of media professionals to police the industry. “We’re not medical experts,” he says. “We’re reporters, and our job is to translate information we receive into a format the can be readily understood by our readers.” In addition, any journalist can be taken to the Independent Press Standards Organisation (IPSO), an independent regulator of the newspaper and magazine industry, and reprimanded for a breach of the Editors’ Code.5 Calman says, “We take the code very seriously and make all of our journalists attend IPSO seminars on their responsibilities of reporting accurately and not distorting the facts.” Kendrick notes that you’re never going to be able to chase down and correct every sensationalist story. As a press officer, she says the importance lies in communicating at the highest possible standard with the aim of minimising the risk of inaccurate reporting. “It’s about having the trust and relationship to follow up with journalists if there’s anything majorly wrong – it ultimately benefits their reputation, as well as provides consumers with accurate information.” Mr Grover highlights the work of associations such as the British College of Aesthetic Medicine and the British Association of Cosmetic Nurses, which are regularly campaigning for higher standards of regulation within the industry. To conclude, he reiterates his first point; “It’s important that we have high standards everywhere, so there’s less negativity to report.” REFERENCES 1. The association between exaggeration in health related science news and academic press releases: retrospective observational study (UK: British Medical Journal, 2014) <http://www.bmj. com/content/349/bmj.g7015> 2. Editors’ Code of Practice (UK: Independent Press Standards Organisation, 2015) <https://www. ipso.co.uk/IPSO/cop.html> 3. Code of Practice for the Pharmaceutical Industry (UK: Association of the British Pharmaceutical Industry, 2015) <http://www.abpi.org.uk/our-work/library/guidelines/Documents/code_of_ 4. practice_2015.pdf4> 5. Rebecca Smith, Smile transplants for stroke sufferers ‘not routinely funded’ by NHS (UK: The Telegraph, 2012) <http://www.telegraph.co.uk/news/health/news/9683290/Smile-transplant-forstroke-sufferers-not-routinely-funded-by-NHS.html> 6. About IPSO (UK: Independent Press Standards Association, 2015) <https://www.ipso.co.uk/ IPSO/index.html>

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Now approved for crow’s feet lines Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x 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: Intramuscular injection (50units/1.25mL). 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. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. 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 observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema,

dry eye. General disorders and administration site conditions; Common: injection site haemotoma. Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. 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 medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1183/BOC/DEC/2014/DS Date of preparation: December 2014

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Meet the Experts Evening, London

Expert to Expert Day, London

Skincare distributor AestheticSource hosted a ‘Meet the Experts Evening’, chaired by dermatologist Dr Sandeep Cliff, at the Royal Society of Medicine in London on June 3. Professor Beth Briden, medical director and CEO of the Advanced Dermatology and Cosmetic Institute in Minnesota, began the sessions by detailing new active ingredients in skincare, and introduced new products from skincare specialists NeoStrata. Dr Uliana Gout, chairperson of the International Chemical Peel Society, then addressed the need for evidence-based skincare, which was followed by dermatologist Dr Mukta Sachdev’s presentation on the importance of pre-peel preparation in order to avoid pigmentation issues in skin of colour. To conclude the presentations, Dr Stefanie Williams discussed the effects of sugar on skin. She advised practitioners to urge patients to monitor their starch intake – a major contributor of sugar in food – and highlighted that those with diabetes appear to age quicker. “It was a very, very good evening,” said attendee and aesthetic practitioner Dr Jamshed Masani, following the final Q&A session. “Especially Dr Mukta Sachdev’s lecture on skin of colour, how she handles peels with pre-peel regimes, and then doing the peels and still getting good results. We in Britain are so frightened to treat skin of colour for the reasons of hypopigmentation and hyperpigmentation.”

FACE, London

The Facial Anti-Ageing Conference and Exhibition (FACE) was held from June 4-6 at the Queen Elizabeth II Centre, London. Throughout the weekend, attendees were invited to lectures on anti-ageing concerns of the face. Topics covered the likes of sun protection, treating blonde/white hair and pigmentation. The event also incorporated the annual BODY Conference into its programme, with one session by aesthetic practitioner Dr Uliana Gout discussing hand rejuvenation procedures and the importance of careful injecting for this area. On Saturday afternoon, Dr Stefanie Williams joined the programme to demonstrate medical needling with PRP, offering key advice on procedure protocol to ensure optimal results. Andrew Morris, country operations manager for Sinclair Pharma, said, “The FACE conference was very busy for Sinclair with lots of interest in Silhouette Soft and ELLANSÉ, particularly in their combination use. There was standing room only at our training workshops which reinforces Sinclair’s commitment to quality training.”

Featuring live demonstrations, lectures and Q&A sessions, Lifestyle Aesthetics hosted its Expert to Expert day at the Royal Society of Medicine in London on May 30. Delegates were invited to a variety of talks with aesthetics practitioners from across the industry, discussing techniques for facial rejuvenation. Aesthetic practitioner Dr Fabio Ingallina began the sessions with a discussion on understanding anatomical landmarks for facial rejuvenation, which was then followed by dental surgeon Dr Lee Walker, who demonstrated effective ways of contouring the lips and perioral area with Teoxane’s Teosyal Pen. Later in the afternoon, delegates were able to question the expert panel, with renowned practitioner Dr Tracy Mountford acting as moderator for the event. Of the day, Sue Wales, co-founder of Lifestyle Aesthetics, said, “It is inspiring to see so many experienced practitioners turning out on a Saturday to gain more tips from our experts.”

Proof in Real Life Reveal, Berlin The treatment of 10 identical twins was announced as the secret behind Galderma’s Proof In Real Life campaign at the Reveal event in Berlin on May 28. One sibling from each pair of twins had been treated with both Restylane and Restylane Skinboosters, or just one of the products, with the aim of demonstrating natural-looking results achieved through aesthetic treatment. Global pharmaceutical company Galderma created the Proof In Real Life campaign with the hope of challenging misconceptions that aesthetic treatments create extreme results. Actress Sharon Stone was announced as the global ambassador for the campaign at the Aesthetic & Anti-Aging Medicine World Congress in March, and later hosted the Reveal event alongside plastic surgeon Mr Per Hedén, who detailed how the patients had been treated. In her opening speech, Stone said, “Tonight’s a very special night, not just for Galderma, but for the world of beauty. We all know that the aesthetic world is famous for showing extreme looks and images of aesthetic treatments, which, as many of us know, are not true. The only way to change this perception is to be bold and to be honest.” The sets of twins were welcomed to the stage to showcase their results and, following the Reveal, mingled with guests to discuss their experiences. Dr Kuldeep Minocha, lead aesthetic practitioner at Absolute Aesthetics in London, treated all but two sets of the twins. He said, “We worked with the individuals as I would in a normal consultation – it was important to me to treat the participants like any other patient. It’s a very unique campaign and it’s been quite amazing to see the results.”

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Colour me youthful: the problem with hyperpigmentation Sun damage, hormones, inflammation – the causes of hyper-pigmented skin are almost as numerous numerousas asthe thetreatments treatmentson onoffer offerto tocorrect correctit. it. Allie Anderson talks to practitioners to find out how to todeal dealwith withthe thecommon commonaesthetic aestheticconcern concern If there’s one presentation in the world of medical aesthetics that continues to challenge practitioners, it’s hyperpigmentation. Yet, evidence suggests that patients are increasingly seeking consultation and treatment for the problem. “Whether that’s because it’s become a bigger issue, or that it’s always been there but people haven’t been seeking advice from private medical professionals before, I’m not sure,” remarks Dr Simon Ravichandran, founder of the Clinetix Medispa group. Whatever the reason, he reports that pigmentation treatments account for around 10-15% of his clinics’ patient cohort.

associate hyperpigmentation with the health of their skin. “Patients come to see me because they’ve reached a point in their lives when they’re bothered by hyperpigmentation,” Miss Balaratnam adds. For example, someone with many freckles on their face (caused by increased melanin) may perceive them to be attractive in youth, but less appealing with age. Similarly, dark liver spots on the face may be no cause for concern for one person, and be very distressing for someone else. Many practitioners, therefore, assess hyperpigmentation not in terms of how severe it is, but the degree to which it affects the patient.

Cause and effect Hyperpigmentation – or hyperpigmentation disorders – are caused by overproduction of melanin by the pigment cells, called melanocytes, and less commonly, by a greater number of melanocytes.1 The umbrella term ‘melasma’ is often broadly used to describe hyperpigmentation disorders of unknown aetiology, associated with hormonal changes (including pregnancy), certain medications and sun exposure. Additionally, increased pigment can be caused by post-inflammatory hyperpigmentation (PIH), such as that left by acne scarring, psoriasis, and previous aesthetic treatments. Exposure to sunlight triggers melanin production in order to protect the skin from harmful ultraviolet (UV) rays.2 Excessive sun exposure results in increased melanin production, making sun exposure a major cause of hyperpigmentation. Accordingly, practitioners report that patients presenting with UV-induced hyperpigmentation tend to be in their 40s and 50s, having spent many years tanning, much of that time ill-informed about the risks associated with sun exposure and sunbeds. Patients seeking treatment for hyperpigmentation more generally range in age from early 30s to late 50s, with more than 90% of cases occurring in women.3

Measures of severity can be useful, though. Dr Ravichandran uses the Melasma Area and Severity Index (MASI), which uses a formula to calculate an overall score of severity based on the practitioner’s assessment of:

Subjective assessment Miss Sherina Balaratnam, medical director of S-Thetics clinic and a former NHS trainee plastic surgeon, comments, “Younger patients – even in their 20s – have less advanced skin damage, but they’re more conscious of it from an appearance point of view.” That, she says, is owing to greater appreciation among younger patients of the dangers of UV damage, which in turn leads them to

1. The extent of coverage on four areas of the face (forehead, left cheek region, right cheek region and chin), each given a score of 0 to 6 based on percentage coverage. 2. Darkness of the hyperpigmentation, where 0 is absent and 4 is maximum. 3. Homogeneity of the hyperpigmentation, using the same scale as the darkness measure.4 The usefulness of the MASI score has been disputed on the basis that it is wholly subjective, but a 2009 study published in the Journal of the American Academy of Dermatology found it to be a reliable and valid measure of melasma severity.5 It also serves as a useful evaluation of treatment outcomes and improvements, says Dr Ravichandran. According to Aysha Awwad, director of Medico Beauty, many patients are concerned specifically about premature ageing, focusing on the appearance of wrinkles rather than uneven pigment. She uses the Glogau Photo-damage and Ageing Skin Scale (also known as the Glogau Wrinkle Scale) to determine a patient’s ‘ageing skin type’. This is determined by the grade of photo-ageing, which is skin damage primarily visible in the form of discolouration and wrinkles, and which develops at different ages depending on the degree of exposure to UV light.6 The scale is used to ascertain which treatments and products match the patient’s skin type and needs.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Figure 1: Glogau Photo-damage and Ageing Skin Scale7 Type

Description

Patient age

Indicators

Type 1

Early wrinkles

20s to 30s

• • • •

Early photo-ageing Mild pigment changes Minimal wrinkles No age spots

Type 2

Wrinkles in motion

30s to 40s

• • • • •

Early to moderate photo-ageing Appearance of smile lines Early brown age spots Skin pores more prominent Early changes in skin texture

Type 3

Wrinkles at rest

50s and older

• • • •

Advanced photo-ageing Prominent brown pigmentation Visible brown age spots Small blood vessels and wrinkles, even at rest

Type 4

Only wrinkles

60s and 70s

• • • •

Severe photo-ageing Yellow-grey skin colour Prior skin cancers Pre-cancerous skin changes (actinic keratosis)

Treatments and techniques Hyperpigmentation treatments fall into three main groups: topical agents, peels and lasers. Triple-combination topical therapy comprising hydroquinone, tretinoin (a prescription-strength retinoic acid) and a corticosteroid has been found in a number of studies to be most effective in treating melasma.8,9 Indeed, Dr Ravichandran describes this as “the gold standard”, and it is his preferred first-line treatment. Miss Balaratnam also opts for hydroquinone to inhibit tyrosinase (which causes melanin cells to become more active), along with tretinoin “to help drive the product deeper into the cellular layers in order to target deeper discoloration.” This follows a Visia Skin Consultation imaging session to analyse a number of contributors’ complexion health and appearance, including UV spots that indicate sun damage, skin tone variation, pore size and wrinkles. The results may also indicate exfoliation with a cosmeceutical such as alpha hydroxyl acid (AHA), forms of which are beneficial in treating PIH and melasma.10 Retinoids, such as retinoic acid, have been shown to be effective in treating PIH,11 but can cause skin irritation. A kinder alternative is the non-prescription vitamin A derivative retinaldehyde, which is well tolerated.12 Awwad chooses this in a topical formulation, claiming it’s gentler than skin-bleaching agents like hydroquinone. “We don’t want to bleach the pigment out of the skin [with hydroquinone]; we want to understand why the melanocytes are behaving in the way they are, and regulate their behaviour,” she says. Her clinic’s treatment protocol also incorporates layered topical treatments applied after deep cleansing of the skin, using a Forao sonic cleansing device to stimulate blood flow and maximise penetration of the active ingredients. Chemical peels in various formulations are employed by some practitioners and there is evidence to support their use as a second-line treatment in some patient groups.9,13 Common options include alpha hydroxyl acid (such as glycolic and mandelic acids) and Jessner’s peel (a medium-depth peel containing salicylic acid, lactic acid and resorcinol). These are typically applied in the clinic setting, and used in combination with longer-term topical therapies that the patient uses at home.

Laser therapy for hyperpigmentation Lasers are commonly the last line of defence against hyperpigmentation, but some practitioners offer laser/lightbased treatment routinely. At River Medical in Ireland, the Fraxel Dual 1550/1927 laser is used in patients with prematurely aged and sun-damaged skin. After a topical anaesthetic cream has been left on the skin for 45 minutes, the laser is applied, with treatment taking just 20-40 minutes. “The melanocytes down on the epidermal/dermal junction grow out like branches of a tree, which appear as freckles or pigmentation on the skin’s surface,” business manager Aileen Gillic explains. “So the source of the problem is not always directly beneath the area of pigmentation – it might be 5-6cm away. For that reason, a full treatment to the whole area (the entire face, décolletage or hand) – rather than just to the pigmented spots – is absolutely necessary.” Side effects of the 1550 and 1927 nanometre light wavelengths include redness and swelling immediately after treatment, with a dry and flaky skin appearance for up to 14 days. “It’s not proper clinical downtime, but it’s social downtime,” Ms Gillic adds.

Chemical peels in various formulations are employed by some practitioners and there is evidence to support their use as a second-line treatment in some patient groups

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Developments will likely continue to be aimed at minimising side effects, which – paradoxically – include increased hyperpigmentation. Dr Ravichandran believes that advancements in topical products like liquorice extract will lead the way, as well as mandelic acid, which “are showing some promise in the management of pigmentation”. There is some emerging evidence of the efficacy of combination salicylic and mandelic acid peels in treating melasma and PIH,14 with more research needed.

The laser that has been at the forefront of removing skin pigment for several years is the Q-switched laser, which uses selective photothermolysis to target specific areas of hyperpigmentation. Dermatologist Dr Maria Gonzalez from the Specialist Skin Clinic uses the ND:Yag (neodymium-doped yttrium aluminium garnet crystal) 1042 nm laser to treat darker skin, while the 532 nm laser is indicated in fairer-skinned patients. She chooses laser for photo-damaged skin in patients who present with solar lentigos, seborrheic warts and dark freckles, and to treat very extensive or resistant melasma. “We focus the laser on the area of pigmentation, but patients are often happier if we treat the whole face as they feel they’ve got a more even result,” Dr Gonzalez comments. Although pre-treatment skin preparation does not significantly improve outcomes, she adds, post-treatment care will usually incorporate an emollient-based moisturising regime. Sun protection Whatever the cause of hyperpigmentation – be it UV damage, idiopathic melasma, or PIH – exposure to UV radiation generally exacerbates the condition. Consequently, patients should take extreme care with sun exposure following treatment for hyperpigmentation. The primary method of both optimising the outcomes of the treatment and preventing further photo-damage and pigmentation is use of a high sun protection factor (SPF) of at least 30 (some practitioners recommend SPF 50+), applied liberally throughout the year. “For anybody who embarks on [hyperpigmentation] treatment, we insist on a homecare regime, because without that, patients are wasting our time and their money,” comments Gillic. “As well as year-round SPF 50, I almost always suggest some vitamin C in the regime to help the sun protection to work that bit harder.” Dr Ravichandran promotes sun avoidance. “It’s an absolute must for all groups of pigmentation disorder,” he says. “I advise patients against sun beds and sun exposure, and recommend a high SPF that covers both UVA and UVB, along with a hat and dark glasses, and covering up in the sun.” The development of treatment and techniques In darker-skinned individuals, an almost-ghostly white complexion with very clear demarcation lines was once a tell-tale sign of hyperpigmentation treatment. “The only solutions years ago were harsh chemicals that bleached the skin, and fully ablative laser treatment,” explains Miss Balaratnam. “Now, we have skin-lightening agents that are so much kinder to the skin, and they’re becoming increasingly more sophisticated. From fully ablative to fractionally ablative lasers, it’s interesting to see how this will develop in the coming years.”

Dr Gonzalez, however, cites more advanced and targeted lasers as the panacea in pigmentation solutions. “Lasers have to be seen as the pinnacle in treating hyperpigmentation. The technology has improved over the last decade or so and is improving all the time,” she remarks. The biggest development in recent years has arguably been the picosecond laser, which effectively delivers a high-energy, very short-wave pulse of light to a highly targeted area with minimal collateral damage to the surrounding skin. “I believe there is an advancement of that already waiting in the wings, so strategic and precise use of lasers is very much the treatment of the future.” Greater understanding of the mechanisms that cause melasma may help to channel future research into effective remedies for this condition. In general, however, a wider acceptance of the damaging effects of the sun’s UV radiation – and importantly, adequately protecting ourselves against the risks of damage – remains the first defence in staving off and dealing with this ever-challenging complaint.  REFERENCES 1. C.B. Lynde; J.N. Kraft; C.W. Lynde, ‘Topical Treatments for Melasma and Postinflammatory Hyperpigmentation’, Skin Therapy Letter, 11(9) (2006), pp. 1-6  2. World Health Organization, The known health effects of UV (www.who.int, 2015) <http://www.who.int/ uv/faq/uvhealtfac/en/index2.html> 3. Rendon M, Berneburg M, Arellano I, Picardo M., ‘Treatment of melasma’, J Am Acad Dermatol, 54 (2006), pp. 272-81 4. BMJ Best Practice, Melasma Classification (London: BMJ Best Practice, 2015) <http://bestpractice.bmj. com/best-practice/monograph/627/basics/classification.html> 5. Pandya AG et al. ‘Reliability assessment and validation of the Melasma Area and Severity Index (MASI) and a new modified MASI scoring method’, Journal of the American Academy of Dermatology, 64(1) (2011), pp. 78-83. 6. Richard G. Glogau, MD, & Associates, Glogau Wrinkle Scale (San Francisco: SFDerm, 2015) <http:// www.sfderm.com/glogau-wrinkle-scale/> 7. Table adapted from ref. 6. 8. Rivas S and Pandya AG, ‘Treatment of melasma with topical agents, peels and lasers: and evidence- based review’, American Journal of Clinical Dermatology, 14(5) (2013), pp. 359-76. 9. Shankar K et al, ‘Evidence-based treatment for melasma: expert opinion and a review’. Dermatology and therapy, 4(2) (2014), pp. 165-86. 10. Van Scott EJ, Yu RJ., ‘Alpha hydroxy acids: Procedures for use in clinical practice’, Cutis, 43 (1989), pp. 222–8; Van Scott EJ, Yu RJ., ‘Hyperkeratinization, corneocyte cohesion, and alpha hydroxy acids’, J Am Acad Dermatol, 11 (1984), pp. 867–79; Goodman GJ, Baron JA., ‘Postacne scarring: A qualitative global scarring grading system’, Dermatol Surg, 32 (2206), pp. 1458–66. Cited in BS Chandrashekar et al, ‘Retinoic acid and glycolic acid combination in the treatment of acne scars’, Indian Dermatology Online Journal, 6(2) (2015), pp 84–88. 11. Schmidt JB, Donath P, Hannes J, Perl S, Neumayer R, Reiner A. ‘Tretinoin-iontophoresis in atrophic acne scars’, Int J Dermatol, 38 (1999), pp. 149–53; Rossi AB, Leyden JJ, Pappert AS, Ramaswamy A, Nkengne A, Ramaswamy R, et al. ‘A pilot methodology study for the photographic assessment of post-inflammatory hyperpigmentation in patients treated with tretinoin’. J Eur Acad Dermatol Venereol. 25 (2011), pp. 398–402. Cited in BS Chandrashekar et al, ‘Retinoic acid and glycolic acid combination in the treatment of acne scars’, Indian Dermatology Online Journal, 6(2) (2015), pp. 84–88. 12. Saurat JH et al, ‘Topical retinaldehyde on human skin: biological effects and tolerance’, Journal of Investigative Dermatology, 103(6) (1994), pp. 770-4. 13. Rashmi S et al, ‘Chemical Peels for Melasma in Dark-skinned Patients’, Journal of cutaneous and aesthetic surgery, 5(4) (2012): 247–253. 14. Garg VK, Sinha S, Sarkar R. ‘Glycolic acid peels versus salicylic-mandelic acid peels in active acne vulgaris and post-acne scarring and hyperpigmentation: A comparative study’. Dermatol Surg. 2009;35:59–65, cited in Rashmi S et al, ‘Chemical Peels for Melasma in Dark-skinned Patients’, Journal of cutaneous and aesthetic surgery, 5(4) (2012), pp. 247–253.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Forehead rejuvenation and contouring strategies Mr Dalvi Humzah and Anna Baker discuss anatomically-sound approaches to treating and re-contouring the forehead The aesthetic practitioner is able to address and successfully treat many of the senescent changes of the upper face, in particular the forehead and glabellar, through a variety of nonsurgical injectable modalities. To achieve an effective result, a current and accurate anatomical awareness, as well as a detailed understanding of product suitability is imperative in order to reduce complications and yield an excellent cosmesis. In this article, a variety of techniques will be analysed in terms of their suitability to refine skin texture and re-contour this region. Key Words Dermal filler, botulinum toxin A, anatomy, forehead, re-contouring Introduction When considering a â&#x20AC;&#x2DC;beautifulâ&#x20AC;&#x2122; face, the forehead, in terms of height, contour and appearance, is accepted as one of the seven keystone areas to acknowledge.1 In this article, the anatomy of the forehead and glabellar will be reviewed with regard to the application of specific non-surgical cosmetic treatments. It is acknowledged that botulinum toxin is used to effectively reduce and soften the appearance of static and dynamic rhytides at the forehead and glabellar.2 The use of dermal fillers to re-contour this region can provide exceptional results.3 The current literature covers varied injection techniques to treat the upper face using botulinum toxin, Figure 1: SCALP Layer one: Skin Layer two: Subcutaneous layer Layer three: Aponeurotic layer, commonly referred to as the SMAS layer; a strong musculo-aponeurotic sheet, encasing the whole face Layer four: Loose areolar tissue; a gliding plane to allow for mimetic expression Layer five: Periosteum/ deep tissue (muscle/fascia)

but little is available in the context of forehead re-contouring. In this article, the authors will share their specialised techniques, underpinned by regional anatomy, with discussion of approaches described within the current literature available. The acronym in Figure 1 (used by many medical students) will be alluded to throughout the article, to allow the reader to clearly visualise the anatomical planes described for product placement.4 The Forehead Topographically the forehead may be defined as the area bounded laterally by the superior temporal septum which arises from the temporal crest, inferiorly by the orbital rims with the supra orbital adhesion and nasion and superiorly the hairline (a variable which is difficult in those who are follicularly challenged).5 When describing the regional anatomy, many texts will address the course and details of individual structures, which while correct, fails to provide a three-dimensional description of the areas of interest for a nonsurgical practitioner. A different view is required when treating an area with what is essentially a blind approach, as the practitioner can not see the structures under the skin whether using a needle or cannula. The five-layered approach outlined above will enable a practitioner to quickly determine the position of product placement, and also understand where important structures are in relation to the approach utilised. It is, however, imperative when using this approach that the practitioner has an in-depth knowledge of the named structures in each area. Layer One: Skin A lot of vital anatomical information can be learnt by examination of this important structure. Apart from the overall appearance of the skin and the ageing changes, superficial arterial and venous structures may be visible that will alert the injector to avoid puncturing these â&#x20AC;&#x201C; and, in doing so, avoid adverse events. The dynamic lines in the glabellar region define the underlying median/

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


@aestheticsgroup Forehead 1

Aesthetics Journal

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Forehead 2

MF

ST SOM

SOL

ST

LT M

M: Median forehead ST: Supratrochlear vessels MF: Middle forehead fat pad LT: Lateral temporal cheek compartment

central fat compartment (see layer two). The glabella line also indicates the line of the supratrochlear vessels located near the subdermis, and the deep insertion of the medial portion of the corrugator. The lateral dermal attachments of the corrugator are often seen as a semicircular depression laterally.6 The horizontal forehead lines represent septal dermal attachments to the underlying frontalis, and when running horizontally indicate the contiguous nature of the frontalis muscle.7 The midline dip and lateral appearance of the forehead lines indicate the point of separation and lateral position of the muscle. This approach to injection, named the â&#x20AC;&#x2DC;objective-muscle-identification approachâ&#x20AC;&#x2122;, will help the injector to accurately and effectively tailor toxin placement.8 Layer Two: Subcutaneous This is an important layer as many structures are located here and understanding this area in detail will allow a practitioner to reduce adverse events. Prior to the seminal work by Rohrich and Pessa, the subcutaneous fat was viewed as an amorphous structure under the skin. However, these authors identified three compartments.7 The (median) central compartment is located in the midline region of the forehead. It has a consistent location that abuts the middle temporal compartments on either side with an inferior border at the nasal dorsum (supratrochlear artery). The lateral boundary is possibly a septal barrier and could be referred to as the central temporal septum. The middle temporal fat compartments lie on either side of the central forehead, the inferior border is the orbicularis retaining ligament, and the lateral border corresponds to the superior temporal septum. The lateral temporal-cheek compartment connects the lateral forehead fat to the lateral cheek and cervical fat. The separation between the middle temporal compartment and lateral temporal compartment may occasionally be seen as an oblique depression on the skin in some patients. While these are important anatomic concepts, it is interesting to note that we are unclear as yet what their role is in the ageing of the forehead, unlike other regions that have been examined, for example, the mid-face fat compartments as described by Gierloff et al.9 Other important structures are the nerves and vessels. The Trigeminal nerve (Cranial nerve V) branches supply the sensory innervation to the forehead.5 Lateral to the medial end of the upper margin of the orbit, the supraorbital nerve indents the bone into a foramen. The nerve passes superiorly and penetrates the frontalis around the superior orbital adhesion and runs superiorly in the forehead fat supratrochlear to supply the scalp and vertex. The smaller supratrochlear nerve passes up on the medial side of the supraorbital nerve penetrating frontalis similarly to innervate the

ROOF

P

P: Procerus ST: Supratrochlear SOM: Supratrochlear medial SOL: Supratrochlear lateral ROOF: Retro orbicularis orbital fat

medial forehead and the infratrochlear nerve supplies skin on the medial eyelid(s), passing above the medial palpebral ligament.10 Frontal branches of the facial nerve transition subcutaneously in the temple to innervate the frontalis segmentally in the subcutaneous plane (layer two).11 Accompanying the nerves, the arteries follow a similar course. The skin of the glabellar and forehead region is mainly supplied by branches from the bilateral supratrochlear, supraorbital and superficial temporal arteries.12 The supratrochlear artery branches from the ophthalmic artery in the orbit and emerges by piercing the orbital septum above the medial canthal tendon.10 It runs in the vicinity of the procerus and corrugator muscles in the nasal root and the glabellar area, passing subcutaneously in level two on its superior path. The artery has several branches during its course and anastomoses with the supraorbital artery and supratrochlear artery.10 Within the corrugator complex, the artery is vulnerable to injury from needle puncture from toxin needle placement and caution is advised here due to its superficial path. The main artery runs in the glabellar line often just under the subdermis in layer two.12 The supraorbital artery is the larger of the two; it divides into a superficial and deep branch, and the former penetrates the frontalis and enters layer two; then anastomosing with the superficial temporal artery and lacrimal artery. It thus connects the internal and external carotid systems.12 Due to these anastomoses within this layer, the injector must approach layer two with a high degree of caution to reduce potentially irreversible complications. The deep branch runs on the deep surface of the frontalis and runs obliquely laterally â&#x20AC;&#x201C; often leaving an indentation on the bone. Occasionally the deep branch will separate in the orbital cavity and enters the forehead through a separate bony canal approximately one cm above the midportion of the orbital rim.13 Deep injections of toxin in this region may spread down this canal and enter the orbital contents, resulting in ptosis.13 The venous return from the face is usually superficial; the supraorbital and supratrochlear veins traverse to the medial canthus where they unite to form the angular vein.14 This becomes the facial vein, which pursues a straight course behind the facial artery, just below the border of the mandible. Blood from the upper lateral forehead is also collected into the tributaries of the superficial temporal vein.14 Layer Three: Frontalis The occipito-frontalis is an exceptionally thin muscle, fusing with the galea aponeurotica from the lateral two thirds of the highest nuchal line of the occipital bone, extending its fine fibres anteriorly to fuse with the procerus muscle at the nasal bone.15 It is part of

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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a group of musculoaponeurotic muscles, which elevate the brow with medial fibres blending inferiorly with the corrugator supercilli and orbicularis oculi muscles blending laterally with orbicularis oculi over the external frontal bone. The occiptofrontalis muscle represents the third layer in the scalp, which equates to the superficial musculoaponeurotic system (SMAS) layer in the face. Spiegel et al established that superiorly to the nasion, the frontalis fibres are contiguous for a variable distance before an aponeurosis is apparent in the space between the bilateral muscles, which may vary considerably between individuals.16 Male subjects may display a wide variation in the medial muscle border as a ‘W’ shape with a variable attenuation point. Female subjects demonstrate a less irregular central dehiscence shape with a continuous frontalis and ‘V’ shape dehiscence. The dynamic forehead lines may indicate the muscle configuration (see layer one). These findings are key in analysing the frontalis muscle activity accurately, to treat effectively and administer botulinum toxin judiciously. Appropriate patient selection for botulinum toxin is crucial. Patients with brow ptosis are poor candidates for correction of forehead ryhtides with toxin.1 This needs to be assessed prior to considering treatment. If present, in the authors’ experience, dermal fillers (including skin boosting or intradermal blanching) may provide superior results, and may additionally subtly enhance the position of the brows. Layer Four: Loose Areolar Tissue This layer represents a gliding plane – essentially an avascular plane. The frontalis glides over this layer and is a safe plane to place dermal fillers for deep forehead contouring (see below), as an avascular plane does not comprise any vessels or structures to compromise. Layer Five: Periosteum The final layer is anatomically the point where the ligaments that define the forehead arise. Moss et al5 describe the following arrangement of ligamentous attachments in the upper face: the temporal ligamentous adhesion supports the region immediately superior to the eyebrow at the junction of its middle and lateral thirds. Located at the intersection of the temporal, frontal and Figure 2: Principle retaining ligament defining the forehead and temporal boundary Superior temporal septum

Inferior temporal septum

Aesthetics

periorbital regions are the superior temporal septum, the inferior temporal septum and the supraorbital adhesion. The temporal ligament arises from the frontal bone as an expansion at the anterior end of the superior temporal septum, inserting into the superficial fascia at the junction of the superficial temporal fascia and galea, on the deep surface of the frontalis muscle. The base is located parallel to the arcus marginalis of the orbital rim at a distance of 10mm above it. The superior temporal septum arises from the periosteum along the superior temporal line of the skull and inserts into the line of junction between the superficial temporal fascia and the galea. Anteriorly, this line of junction occurs between the superficial temporal fascia and the galea, lining the deep surface of the lateral border of the frontalis muscle; the expanded end is the temporal ligamentous adhesion. The supraorbital ligamentous adhesion arises from the frontal bone above the orbital rim, extending between the temporal ligament and the origin of the corrugator muscle. The inferior border is located approximately 6mm above the deep attachment of the periorbital septum; the ligament is condensed around the branches of the supra-orbital nerve and corrugator muscle origin. The periorbital septum originates from three-quarters of the circumference of the orbital rim, extending from the corrugator origin around to the inferomedial boney origin of the orbicularis oculi. The origin and boundaries of these attachments are significant in terms of re-contouring the forehead with dermal fillers within the supraperiosteal plane; placement with a blunt cannula does not permit dissection of these fixed attachments, thus, product remains safely enclosed within the desired plane and anatomical boundary (Figure 1). Anaesthesia For optimum patient comfort when re-contouring the forehead, it may be preferable to block the supratrochlear and supraorbital nerves respectively. 3% mepivicaine or 2% lidocaine may utilised for this purpose, with small volumes used to specifically block these nerves low in the supraorbital region.17 Lidocaine mixed with the dermal filler may also be used, although the injection technique is slower and may still be uncomfortable for the patient. Topical anaesthesia is insufficient for this advanced deep technique, despite the use of a blunt cannula as the supraorbital nerves innervate the underside of the frontalis and periosteum.17 Deep Correction Re-contouring the forehead using a supraperiosteal approach is gaining popularity.13 Redefining this anatomical region provides a youthful contour, and facilitates deep support in counteracting the morphological age-related bone resorbtion noted in both male and female individuals at the glabellar angle.15 Restoring the boney support to the frontal eminence, as well as the lateral brow, achieves a subtle redraping of the overlying tissues and the procedure is popular within certain ethnic populations who strive achieve a rounded, convex appearance to the forehead.3 Facial mapping prior to treatment, along with baseline photography, is key for practitioner and patient to agree on the expected outcome from treatment. Once the full face has been thoroughly cleaned with chlorhexidine and hair tied back, re-contouring may be achieved by commencing an entry point medial to the

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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A male patient may favour augmentation of the supraciliary arch to enhance a masculine brow in conjunction with the frontal eminence, with threads placed supraperiosteally temporal fusion line, utilising a 25g needle entry point to the depth of the supraperiosteal plane (layer four). Calcium hydroxylapatite with its highly viscous, elastic and cohesive properties without additional lidocaine provides an ideal product to use in this layer. A 25g cannula is inserted along the supraperiosteal plane to deposit linear threads of product to augment the right and left frontal eminences from the lateral entry points. The volume of product required to achieve the desired result will vary between individuals, depending upon the degree of correction required. A cannula length of 38mm or 50mm is preferable, depending on the dimensions of the frontal bone; within the supraperiosteal plane, the cannula will glide with ease without risk of injury to nerves or vascular compromise. Busso and Howell describe this technique as ‘horse shoe’ placement of product, which achieves a subtle lift across the length of the brow. 3 A male patient may favour augmentation of the supraciliary arch to enhance a masculine brow in conjunction with the frontal eminence, with threads placed supraperiosteally. Following correction, the product is then moulded into the desired contour, and the patient advised to withhold from applying makeup for 48 hours. Loghem et al concur that a cannula approach is preferable, and also advocate an entry point from the temporal crest.18 The ligamentous attachments in the upper face aid in retaining the product supraperiosteally, facilitated further by cannula placement.18 Superficial Correction To further enhance the result of the deep correction, it is possible to combine the use of botulinum toxin A to soften dynamic ryhtides across the forehead and glabellar complex. For more established ryhtides, a cohesive, polydensified matrix hyaluronic acid dermal filler may be combined through a ‘blanching’ technique using a 30g needle, described by Micheels et al, who postulate that blanching is not caused by vasoconstriction, but instead by the transparent and transient appearance of the gel in close proximity to the skin’s surface.19 A superficial or intradermal depth may be established by ‘tenting’ the needle to visualise the outline in the skin, with the bevel placed downwards, depositing multiple bead-like punctures, just under the skin until the rhytide has been eliminated. The product is gently massaged following correction, providing exceptional levels of correction for static and/or superficial rhytides.

Aesthetics Journal

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Conclusion The content of this paper has been compiled to equip the clinician with current evidence and knowledge pertaining to non-surgical forehead re-contouring. The key to successfully and safely treating this region is a current and accurate anatomical knowledge and in particular an understanding of the layered concept in relation to the forehead (SCALP). Anatomy is a dynamic and three dimensional subject; as anatomical awareness develops, it is imperative that practitioners keep abreast of this specialist subject. Didactic and interactive practical teaching courses will enable an in-depth analysis in respect to important facial structures. Once this view is appreciated, it will enable practitioners to develop safe and effective techniques in treating facial zones. Mr Dalvi Humzah is a consultant plastic reconstructive and aesthetic surgeon, with a BSc in anatomy. He has been a tutor for the Royal College of Surgeons of England and is an examiner for the Intercollegiate MRCS for the Royal College of Surgeons of Glasgow. He is the lead tutor for the award-winning teaching programme, Facial Anatomy Teaching, and actively teaches and lectures internationally. Anna Baker is a dermatology and cosmetic nurse practitioner. She runs the nurse-led Medicos Rx Skin Clinic at The Nuffield Health Hospital in Cheltenham, and is the coordinator for Facial Anatomy Teaching. Baker runs nurse-led photodynamic therapy clinics for non-melanoma skin cancer and is currently studying post-graduate Applied Clinical Anatomy at Keele University. REFERENCES 1. Little A.C., Jones B.C., DeBruine L.M., ‘Facial attractiveness: evolutionary based research’, Trans P., Soc B., 366 (2011), pp. 1638-1659. 2. Dubina M., Tung R., Bolotin D., Mahoney A.M., Tayebi B., Sato M., Mulinari-Brenner F., Jones T., West D.P., Poon E., Nodzenski M., Alam M., ‘Treatment of forehead/glabellar rhytide complex with combination botulinum toxin a and hylaruronic acid versus botulinum toxin A injection alone: a split-face, rater-blinded, randomized control trial’, Journal of Cosmetic Dermatology, 12(4) (2013), pp. 261-6. 3. Busso M., Howel J.D., ‘Forehead Recontouring Using Calcium Hydroxylapatite’, Dermatologic Surgery, 36 (2010), pp. 1910-1913. 4. Smith A.G., Irving’s Anatomy (4th Ed.) (Churchill Livingstone, 1972) 5. Moss J.C., Mendelson B.C., Taylor G.I. ‘Surgical Anatomy of the Ligamentous Attachments in the Temple and Periorbital Regions’, Plastic And Reconstructive Surgery, 105 (4) (2000), pp. 1475-1489. 6. Weider J.M., Moy L.R, ‘Understanding botulinum toxin surgical anatomy of the frown, forehead and periocular region’, Dermatological Surgery, 24 (1998), pp. 1172-1174. 7. Rohrich R.J., Pessa J.E. ‘The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery’, Plastic And Reconstructive Surgery. 119(7):2219-2227. 8. Guerrerosantos J., Eduardo P.G.C., Arriola J.M., Manzano A.I.V.,Villarian-Munoz B., Benavides L.G., Vazquez M.G., ‘Effectiveness of Botulinum Toxin (Type A) administered by the fixed-site dosing approach versus the muscle area identification’, Aesthetic Plastic Surgery, 39 (2015), pp. 243-251. 9. Gierloff M., Stohring C., Buder T., Gassling V., Acil Y., Wiltfang J., ‘Aging Changes of the Midfacial Fat Compartments: A Computed Tomographic Study’, Plastic And Reconstructive Surgery, 129(1) (2012), pp. 263-273. 10. Sinnatamby C.S. (2006) Lasts Anatomy Regional & Applied. 11th Edition. Churchill Livingstone Elsevier. 11. Agarwal C.A., Mendenhall S.D., Foreman K.B., Owsley J.Q., ‘The Course of the Frontal Branch of the Facial Nerve in Relation to Facial Planes: An Anatomic Study’, Plastic And Reconstructive Surgery, 125(2) (2010), pp. 532-537. 12. Shimizu, Y., Imanishi N., Nakajima T., Nakajima H., Aiso A., Kishi K., ‘Venous Architecture of the Glabellar to the Forehead Region’, Clinical Anatomy, 26(2) (2013), pp. 183-195. 13. Carruthers J.D.A., Fagien S., Rohrich., R.J., Weinkle S., Carruthers A. (2014). Blindness Caused by Cosmetic Filler Injection: A Review of Cause and Therapy. Plast Reconstr Surg 134(6):1197-1201. 14. Imanishi N., Najajima H., Minabe T., Chang H., Aiso S., ‘Venous Drainage Architecture of the Temporal and Parietal Regiosn: Anatomy of the Superficial Temporal Artery and Vein’, Plastic And Reconstructive Surgery, 109(7) (2002), pp. 2197-2203. 15. Lorenc Z.P., Smith S., Nestor M., Moradi A. ‘Understanding the functional anatomy of the frontalis and glabellar complex for optimal aesthetic botulinum toxin type A therapy’, Aesthetic Plastic Surgery, 37(5) (2013), pp. 975-83. 16. Spiegel J.H., Goerig R.C., Lufler R.S., Hoagland T.M., ‘Frontalis midline dehiscence: An anatomical study and discussion of clinical relevance’, Journal of Plastic, Reconstructive & Aesthetic Surgery, 62 (2009), pp. 950-954. 17. Zide B.M., Swift R., ‘How to block and tackle the face’, Plast Reconstr Surg, 101(3) (1998), pp. 840-51. 18. Loghem J., Yutskovskaya Y.A., Werschler W.P., ‘Calcium Hydroxylapatite: Over a Decade of Clinical Experience’, The Journal of Clinical and Aesthetic Dermatology, 8(11) (2015), pp. 38-49. 19. Micheels P., Sarazin D., Besse S., Sundaram H., Flynn T.C. ‘A Blanching Technique for Intradermal Injection of the Hylauronic Acid Belotero’, Plastic And Reconstructive Surgery, 132(4S-2) (2013), pp. 59S-68S.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


LIFT, CONTOUR & REJUVENATE with long-term collagen stimulation

The Lifting Filler

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RAD144/0215/LD Date of preparation: February 2015

LESS INTACT COLLAGEN

S TO

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LACK OF STRUCTURAL SUPPORT

REDUCED COLLAGEN SYNTHESIS

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LOSS OF FIBROBLAST ACTIVITY

The Lifting Filler


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move away from removal of excess skin and towards a trend to replace volume and induce collagen stimulation. Restoration of the periorbita is multifaceted and entails smoothing of the lower eyelid, often using a combination of different modalities, such as botulinum toxin, fillers, lasers, radiofrequency and ultrasound technology, to achieve the best aesthetic outcome. Increased collagen degradation and decreased collagen synthesis means the adult skin loses approximately 1% of its dermal collagen content on an annual basis.5,6

Tri Eye Treatment Dr Maryam Zamani provides an overview of the aesthetic treatments available for rejuvenation of the eye, and details her ‘Tri Eye Rejuventation’ and ‘Tri Eye Transformation’ techniques The eyes are the aesthetic centre of the face and are often referred to as the ‘window to the soul’. The periorbita is an area where we can often see the first signs of ageing and is cause for common requests for rejuvenation in aesthetic practices. Complaints include excess skin, fine lines and wrinkles, puffiness around the eyes and pigmentation issues. To understand these issues we need to understand the process by which they occur. Starting in the third decade of life, redundancy of upper eyelid skin begins and continues to progress until that skin rests on the upper eyelid lashes. This results in a hooded appearance that can also be accentuated by the descension of the brow and underlying fat pads. In the fourth decade of life, the lateral canthal rhytids and accentuation of the lower eyelid folds are apparent at rest. This is followed by the herniation of fat pads in the upper and lower eyelids (Figure 1).1 With age, the cheek, periorbita and subobicularis fat atrophy while the orbital retaining ligament relaxes. The process results in a downward displacement of the lid-cheek junction and an indentation between the lower eyelid and the cheek, also known as the tear trough.2 Other factors can influence the appearance of the tear trough as well. Volume loss accentuates the nasojugal grove and the inferior orbital rim creating a hollow appearance (Figure 1).3 Some individuals are predisposed to having lower eyelid fat prolapse that can further accentuate the loss of volume directly inferior.4 Bone resorption in facial ageing in conjunction with soft tissue atrophy has created a

Treatment Options Technological advancements have been made to increase collagen synthesis. Skin rejuvenation can be categorised into two main categories: invasive and non invasive. In the last decade, there has been increased demand for noninvasive procedures for skin rejuvenation and a simultaneous explosion of new non-surgical techniques and combinations of such treatments to improve and rejuvenate the skin around the peri-orbita. These modalities include Intense Pulsed Light (IPL), fractionated laser treatments, radiofrequency and ultrasound technology. The evolving list of nonablative lasers and light systems also includes broadband infrared light, dual yellow laser, pulsed dye (585, 595 nm), Nd: Yag (1064, 1320nm), Diode (910, 1450 nm) and Er: Glass (1540 nm lasers).7 IPL is a non-coherent light that covers a large wavelength to be absorbed by the desired chromophores. It works by causing reversible thermal damage to collagen in the dermal layer and helps fibre remodeling without ablation to the epidermis.8 Regia et al showed improvement in flaccid skin related to the increase of collagen in the deep reticular dermis, promoting a skin tightening effect with IPL.8 Periorbital and facial treatment with IPL may help those patients with Fitzpatrick Skin types I-IV with pigmentation and vascular issues with secondary benefits of mild collagen induction.9 Radiofrequency is another nonablative skin rejuvenation modality used to cause shrinkage of dermal collagen and promote the formation Figure 1

f g

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Lid cheek segment Malar segment Nasolabial segment

a b c d e f

Dermatochalasis Pelpebromalar groove Malar mound Mid cheek groove Tear trough (Nasojugal groove) Medial fat pad

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g Central fat pad h Lacrimal gland i Fat herniation • Lower medial fat pad • Lower central fat pad • Lower lateral fat pad j Malar fat pad (descent)


@aestheticsgroup Figure 2: Reticular vessels treated with Nd: Yag 1064

Figure 3: Tri Eye Rejuvenation:

Before

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Figure 4: Tri Eye Transformation

Before

After Before and two weeks following treatment

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Before

After Before and three months after treatment with Botulinum toxin A, Volbella and Ultherapy

of new collagen through controlled neocollagenesis without integumental injury. Radiofrequency devices are able to achieve greater depths of thermal injury with tissue penetration to the level of the dermis and subcutaneous layer without producing thermal burns.5 Such treatments are generally a succession of four to eight treatments depending on the particular device used. Nd: YAG 1064 laser and the Norseld Dual Yellow Laser are nonablative lasers used for aesthetic rejuvenation of the face. Nd: YAG 1064 can be used successfully and selectively to target haemoglobin in reticular vessels seen in the peri-orbita and temples (Figure 2).10 Norseld Dual Yellow Laser also uses the 578 nm yellow wavelength to target chromphores associated with oxyhaemoglobin in red telangectatic vessels. The Norseld laser is highly successful in treating small red telangectatic vessels along the eyelid margin.11 Fractional resurfacing for aesthetic enhancement continues to evolve using ablative, non-ablative and fractional technologies because of their improved safety profile. These three approaches mainly differ in the mode of thermal damage, degrees of efficacy and downtime.12 Fractional laser technology has gained increased popularity in improving scars, fine lines, dyspigmentation, and wrinkles because of its favourable side effect profile, recovery time and outcome.12,13 Common indications for both non-ablative and ablative resurfacing are for periorbital wrinkles, photo ageing and dyschromias. Laser resurfacing is used to help remove a specific layer of skin down to a specific depth of skin. In doing so, fine lines and wrinkles can be softened, pigmentation improved and skin tightened. Ablative lasers have the advantage of predictable depth of tissue ablation. Erbium; YAG lasers such as the iPixel by Alma can represent an improvement over CO2 lasers in producing less downtime.12,14,15 Fractional resurfacing produces specific microthermal zones of photothermolysis creating columns of injury whereas ablative skin resurfacing creates a confluent area of epidermal and dermal injury.16 Fractional thermolysis leaves intervening areas of normal skin untouched whereby re-epithelialisation and repair can occur rapidly. These treated zones compromise 15-25% of the skin surface per treatment depending on the machine, wavelength, fluency and stacking application of the laser. From my experience, generally two to six sessions are needed to complete a treatment. Similar to ablative resurfacing, the thermally ablated tissue is repopulated by fibroblast-derived neocollagenosis and epidermal stem cell production.12 The advantages of the fractionated laser treatment

After Before and one month following treatment

include reduced erythema, oedema, downtime and dyschromic changes, particularly important in treating Fitzpatrick skin types V and VI.12 Such treatment modalities have an important role in treating the delicate lower eyelid skin, particularly in patients that are not yet candidates for lower eyelid blepharoplasty. In a comparative split-face trial with fractional Er:YAG and microfractional CO2 laser resurfacing showed greater efficacy and patient satisfaction for the fractional CO2 laser,17 however recovery time and risks for CO2 laser were higher. The spectrum of adverse sequel range from mild (prolonged erythema, milia) to moderate (transient to permanent dyspigmentation, local infection) to severe (hypertrophic scarring, ectropian, systemic infection).1 Ultherapy is another non-invasive treatment modality using microfocused ultrasound (MFU) with visualisation to create thermal micro-injuries also known as thermal coagulation points (TCP) in the dermis and subdermal tissue. Despite its lower energy, MFU is capable of heating tissue to greater than 60C to a depth of 5mm within the mid to deep reticular layer of the dermis and subdermis, while sparing the overlying papillary dermal and epidermal layers of the skin.18,19 MFU causes collagen fibres in the superficial musculoaponeurotoic system and deep reticular dermis to contract and stimulate de novo collagen.18 An ultimate lift is created in the healing of the TVP resulting in firming, tightening and shrinking of the dermis and subdermal tissues. The efficacies of Ultherapy treatments vary on the vector direction of treatment and the total energy supplied. Off label, Ultherapy has been used for improving the infraorbital skin laxity by both tightening the obicularis oculi muscle and the orbital septum.18,20,21 Ultherapy has a reputation of being painful; however with proper pre-treatment analgesics, this is well controlled.22 Pain, oedema, headache, numbness, paresis, PIH, bruising and welts are potential transient risk profiles that need to be discussed with the patient.23 Botulinum toxin is an effective neuromodulator used in aesthetic rejuvenation to temporarily paralyse the muscles of facial expression thereby decreasing wrinkle lines created by muscle activity. In the periorbita, botulinum toxin has FDA approval for treatment of the crowâ&#x20AC;&#x2122;s feet and glabellar lines and can be effective in treating the lower eyelid lines and elevating the tail of the eyebrow. As a low risk procedure, botulinum toxin is considered a relatively safe treatment to help diminish the lines created by facial expression.24 Hyaluronic acid (HA) fillers are now playing an even bigger role in treating the ageing eye and face as a three dimensional approach

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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to rejuvenation with particular attention to proportional ideals. In determining the HA to use in the periorbita it is essential to look at the viscosity (how the gel flows from the needle) and elastic modulus (gel stiffness) of the product. In treating the periorbita, I prefer using products from the Juvéderm Vycross family, particularly Volbella in the anatomical tear trough because of its lower HA concentration of 15 mg/ml. A lower HA concentration means the gel is less hydrophilic and will absorb less water from surrounding tissue, causing less oedema.25 HA can be injected into the peri-orbita and malar region with both deep (pre-periosteal and submuscular) and dermal injections in order to temporarily help reduce the appearance of lines and wrinkles. While techniques vary, most incorporate serial depots of HA along the inferior orbital rim, into the subobicularis oculi muscle either in a ‘haystacking’ or injection-withdrawal technique to layer support. An often undertreated and neglected area for HA treatment is temporal hollowing and can have a significant impact on overall facial rejuvenation. All HA injections in the periorbita carry significant risk and great care to understand and respect the underlying anatomy must be taken to minimise potential pitfalls.

Aesthetics

of the appearance of the skin around the eyes but who are not yet surgical candidates or do not feel ready or willing to have surgery. The ‘Tri Eye Rejuvenation’ combines botulinum toxin, HA fillers and Ultherapy in two sessions, ten to 14 days apart, to treat brow ptosis, crow’s feet and the tear trough in a younger patient generally aged 30-50. In the first visit, Ultherapy is used to treat the brow and the lower eyelid and to promote lifting and tightening of the periorbita. 10-14 days later patients return for treatment of the tear trough and temples with HA fillers and toxin to the crow’s feet (Figure 3). All patients are educated about waiting three to six months to observe the final improvement from Ultherapy and that botulinum toxin and HA treatments require maintenance. Alternatively ‘Tri Eye Transformation’ combines HA filler, laser and the iPixel to treat patients that suffer more from periorbital volume loss resulting in fine lines, wrinkles and prominence of vasculature. This treatment has approximately three to six days of downtime. In the first visit, Norseld or Nd: Yag is used to target telangectactic and reticular vessels in the periorbita. On the same visit, iPixel is used to fractionally ablate the periorbital skin. Three more sessions of iPixel are completed monthly and upon satisfaction of this resurfacing, HA filler is injected to help augment the volume loss in the temples and periorbita, which includes the tear trough and mid cheek segments.

Tri Eye Rejuvenation and Transformation In treating the periorbita, there is a vast array of combination treatments that can be implemented. I find that often the most successful aesthetic results come from combining different modalities together to create a more unified approach to rejuvenation and improve overall patient satisfaction. Creating a patient specific treatment plan to combat specific issues is needed for a complete rejuvenation. The combination of botulinum toxin type A and hyaluronic acid appear to rejuvenate the periorbital and temporal areas, glabella, and crow’s feet areas with minimal adverse effects and with higher rate of patient satisfaction.26 In my practice, I have created a triad of treatments in two specific non-surgical protocols called the ‘Tri Eye Rejuvenation’ and ‘Tri Eye Transformation’ to address the ageing periorbita. I have a significant number of patients who present in my clinic complaining

Dr Maryam Zamani is an oculoplastic surgeon and aesthetic doctor. Dr Zamani specialises in surgical and non-surgical aesthetic procedures at the Cadogan Clinic. A graduate from Georgetown University and George Washington University School of Medicine, USA, Dr Zamani completed her studies at Imperial College and Cardiff University.

REFERENCES 1. Scarborough, D., Herron, J., Khan, A., Bisaccia, E., ‘Periorbital Rejuvenation for Early Signs of Aging: Exploring Aesthetic Interventions Part 2’, The Dermatologist, (1) (2003) 2. Rebecca Tung, R., Ruiz de Luzuriaga, A., Park, K., Mauricio Sato, M., Dubina, M., Alam, M., ‘Brighter Eyes: Combined Upper Cheek and Tear Trough Augmentation: A Systematic Approach Utilizing Two Complementary Hyaluronic Acid Fillers’, Journal of drugs in Dermatology, 11 (9) (2012) 3. Hamman, MS., Fabi, S.,  Goldman, M., ‘Comparison of Two Techniques Using Hyaluronic Acid to Correct the Tear Trough Deformity’, Journal of Drugs in Dermatology, 11 (12) (2012). 4. S M Salvi, S Akhtar, and Z Currie, ‘Ageing changes in the eye’, Postgrad Med J., 82(971) (2006), pp. 581–587. 5. Elsaie ML., ‘Cutaneous remodelling and photorejuvenation using radiofrequency devices’, Indian J Dermatol, 54 (2009), pp. 201-5. 6. Chung J, Cho S, Kang S. ‘Why does the skin age? Intrinsic aging, photoaging and their pathophysiology’, In : Photoaging, Rigel Ds, Weiss RA, Lim HW, Dover JS, editors. (New York: Marcel Dekker Inc, 2004), p. 13. 7. Choi YJ, Lee JY, Ahn JY, Kim MN, Park MY., ‘The safety and efficacy of a combined diode laser and bipolar radiofrequency compared with combined infrared light and bipolar radiofrequency for skin rejuvenation’, Indian J Dermatol Venereol Leprol, 78 (2012), pp. 146-52. 8. Patriota RC, Rodrigues CJ, Cucé LC., ‘Intense pulsed light in photoaging: a clinical, histopathological and immunohistochemical evaluation’, An. Bras. Dermatol, 86 (2011) 9. Goldberg DJ., ‘New collagen formation after dermal remodeling with an intense pulsed light source’, J Cutan Laser Ther., 2 (2000), pp. 59–61. 10. Ozyurt, K., Colgecen E., Baykan, H., Ozturk, P., Ozkose, O.,‘Treatment of Superficial Cutaneous Vascular Lesions: Experience with the Long-Pulsed 1064 nm Nd:YAG Laser’, ScientificWorldJournal, 197139 (2012) 11. Norseld, Laser Treatments: Vascular Lesions (norseld.com, 2014) <http://norseld.com/index.php/ laser-treatments/#tabs-2> 12. Goel A, Krupashankar DS, Aurangabadkar S, Nischal KC, Omprakash HM, Mysore V., ‘Fractional lasers in dermatology- Current status and recommendations’, Dermatosurgery Specials 77 (3) (2011), pp. 369-379. 13. Brightman LA, Brauer JA, Anolik R, Weiss E, Karen J, Chapas A, et al., ‘Ablative and fractional ablative lasers’, Dermatol Clin, 27 (2009), pp. 479-89. 14. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD., ‘Pulsed carbon dioxide laser resurfacing of photoaged facial skin’, Arch Dermatol, 132 (1996), pp. 395-40.

15. Alexiades-Armenakas MR, Dover JS, Arndt KA., ‘The spectrum of laser skin resurfacing: Nonablative, fractional, and ablative laser resurfacing’. J Am Acad Dermatol, 58 (2008), pp. 719-37. 16. Hantash BM, Bedi VP, Sudireddy V, Struck SK, Herron GS, Chan KF., ‘Laser-induced transepidermal elimination of dermal content by fractional photothermolysis,’ J Biomed Opt, 11 (2006). 17. Lomeo G, Cassuto D, Scrimali L, Sirago P. Er: YAG versus CO2 ablative fractional resurfacing: A split face study. Abstract presented at American Society for Laser Medicine and Surgery Conference, April 2008, Kissimmee, FL. 18. Fabi SG., ‘Noninvasive skin tightening: focus on new ultrasound techniques’, Clinical, Cosmetic and Investigational Dermatology, 8 (2015), pp. 47-52. 19. Kim YS, Rhim H, Choi MJ, Lim HK, Choi D., ‘High-intensity focused ultrasound therapy: an overview for radiologists’, Korean J Radiol, 2008;9 (2008), pp. 291–302. 20. Suh DH, Oh YJ, Lee SJ, et al., ‘A intense-focused ultrasound tightening for the treatment of infraorbital laxity’, J Cosmet Laser Ther, 14 (2012), pp. 290–295. 21. Pak CS, Lee YK, Jeong JH, Kim JH, Seo JD, Heo CY., ‘Safety and efficacy of Ulthera in the rejuvenation of aging lower eyelids: a pivotal clinical trial’, Aesthetic Plast Surg, 38(5) (2014), pp. 861–868. 22. Fabi, SG., ‘Noninvasive skin tightening: focus on new ultrasound techniques’, Clin Cosmet Investig Dermatol, 8 (2015), pp. 47–52. 23. Hitchcock, T., Dobke, M., ‘Review of the safety profile for microfocused ultrasound with visualization’, Journal of Cosmetic Dermatology, 13 (4) (2014), pp. 329–335. 24. De Boulle, K., Fagien S.,, Sommer, B., Glogau, R., ‘Treating glabellar lines with botulinum toxin type A-hemagglutinin complex: A review of the science, the clinical data, and patient satisfaction’, Clin Interv Aging, 5 (2010), pp. 101–118. 25. Eccelston D., Murphy, DK. , ‘Juvederm Volbella in the perioral area: a 12-month prospective, multicenter, open-label study’, Clinical, Cosmetic and Investigational Dermatology (2012), pp. 167-172. 26. Beer KR, Julius H., Dunn M., Wilson F. , ‘Remodeling of periorbital, temporal, glabellar, and crow’s feet areas with hyaluronic acid and botulinum toxin’, J Cosmet Dermatol, 13 (2) (2014), pp. 143-50. 27. Kearney C, Brew D., ‘Single-session combination treatment with intense pulsed light and nonablative fractional photothermolysis: a split-face study’, Dermatol Surg, 38(7 Pt 1) (2012), pp. 1002-9. 28. Choi YJ, Lee JY, Ahn JY, Kim MN, Park MY., ‘The safety and efficacy of a combined diode laser and bipolar radiofrequency compared with combined infrared light and bipolar radiofrequency for skin rejuvenation’, Indian J Dermatol Venereol Leprol, 2012 78(2) (2012), pp. 146-52.

Conclusion Both these and other combination treatments used for rejuvenation of the periorbital region have been tested to show relatively long-lastingefficacy and high patient satisfaction.27, 28 Integrated treatments for the eye area using variant procedures creates a greater understanding of the multifaceted changes that occur in the ageing face.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


Aesthetics Awards Special Focus

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Booking now open for th

Book Now www.aest With entry closed and the finalists being chosen, booking is open for the most esteemed celebration in medical aesthetics. The Aesthetics Awards will be held on Saturday 5th December at the four star Park Plaza Westminster Bridge Hotel in Central London. Playing host to 500 members of the medical aesthetics community and leaders of the industry, the Awards will honour Winners in all 24 categories, as well as Commended and Highly Commended finalists. The evening will begin with a drinks reception, followed by a formal

Cosmeceutical Range/Product of the Year 2014 “Obagi winning cosmeceutical of the year at the prestigious Aesthetic Awards, the fourth year in a row that Obagi has been honoured, was a simply fantastic achievement and validation that Obagi is still the UK’s leading medical skincare brand, trusted by clinics nationwide. As the award is voted for by those actively involved in the aesthetics industry, it’s an honour to have won this significant category and just reward for the hard work of all involved. We were thrilled to be short-listed and gobsmacked to win, it was an amazing night of celebration with our friends and colleagues; the aesthetic awards is definitely a highlight of the year!” Steve Joyce, Healthxchange Pharmacy

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stheticsawards.com sit down dinner and entertainment from professional comedian Simon Evans, who will also present the Awards ceremony, before guests are invited to enjoy music and dancing late into the night with friends, colleagues and peers. The Awards present the perfect opportunity to meet with key contacts and network with industry leaders, whilst celebrating the best of our industry. Finalists for each category will be announced in the September issue of Aesthetics journal. For the full list of categories and to book tickets visit www.aestheticsawards.com

Best Clinic North England 2014 “The award for us was like a stamp of approval from our peers, because it was judged by a panel of industry experts. We have an incredibly motivated and enthusiastic team here at Good Skin Days, but a ‘pat on the back’ and some recognition for all their hard work is always welcome. At first, the award win generated lots of positive feedback from our existing patient base, but in the longer term, new customers have mentioned it as a factor in their choice to come to our clinic – so it’s been great exposure all round. The evening was a great experience, well organised and well hosted and was enjoyed immensely by the whole team. Our favourite part was definitely hearing our name being read out as the winner and the pride that we felt going on stage to collect our award. Fantastic!” Chris Gill, Good Skin Days This year the Award for Best Clinic North England is sponsored by Epionce

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Aesthetics | July 2015

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Hyaluronidase Protocol Aesthetic nurse Lee Rowe outlines the protocol for administering hyaluronidase and highlights the importance of understanding its use in aesthetics Introduction The aesthetic community is expanding, with non-surgical treatments now contributing to 75% of the market, making the industry worth an estimated £3.6 billion in 2015, in the UK alone.1 Numerous training days are held across the UK, qualifying delegates to obtain and use hyaluronic acid (HA) dermal fillers for their patients’ anti-ageing concerns. However, as we know, the art of injecting is just one aspect of this treatment; other aspects include knowledge and understanding of anatomy and physiology, consenting issues, aftercare and, more importantly, complication management. I find practitioners are frequently raising the issue of how to treat complications on support forums, networking groups and during study days. It is a worrying sight to see how many practitioners do not feel confident nor hold the experience to deal with the adverse reactions that can be so detrimental to a patient. The aim of this article is to give the reader a valuable insight into the use of hyaluronidase; how it works and, crucially, when to administer it. What is hyaluronidase? Hyaluronidases are a family of injectable enzymes that act as dispersion agents. These help speed up the natural breakdown of hyaluronic acid through hydrolysis.2 Licensed for therapeutic indications, such as increasing tissue permeability to enhance the delivery of drugs or to increase the uptake of subcutaneous fluids, in aesthetics, it is widely used ‘off license’.3 Off license does not necessarily mean it is unsafe to use, but that it is being prescribed and administered in a way that is different to its licensed use. The license is obtained from the Medicines and Healthcare products Regulatory Agency4 (MHRA) and will state what the drug can be used for, how much to give and the age of patients suitable to be treated with it. As long as the practitioner is acting in the patient’s best interests, their autonomy is respected and the patient has fully consented, then hyaluronidase can be administered in the event of an adverse reaction.5 Due to this ‘off license’ use of hyaluronidase, practitioners can only seek guidance from other professionals (as well as use their own expertise) in order to judge how much hyaluronidase to use and how to reconstitute it, which can be limiting if one has little experience of using it. Various factors will influence the administration and dosage – for example, the concentration of HA filler, level of cross-linking and amount of HA deposit. Recognising complications with HA fillers There are, of course, several complications associated with having a HA dermal filler treatment, such as bruising, mild swelling and tenderness at the injection site6, which can be easily managed through observation and support on the patient’s behalf. It is the more serious complications, such as when filler is injected into a vein or an artery, that will require medical intervention and the administration of hyaluronidase as part of its management. If HA is injected into an artery this can cause a clot formation around the filler, or the filler itself may cause the blockage. If the vessel is significant in supplying blood to the skin, this can lead to necrosis, an irreversible complication that results in the death of

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the skin tissue.7,8 This occurs when the skin region cannot access enough blood and oxygen.8 When injected into a vein, HA can also cause a blockage, resulting in blood flowing back into the tissues and therefore increasing pressure and causing low grade ischaemia.8 The nose is one of the most feared sites for necrosis following HA procedures, with the tip being the most affected.9 To give an example of how serious a vascular complication can be, injecting dermal filler into the angular vessels around the nose can potentially lead to blockage and skin necrosis or, in extremely rare cases, blindness.10 Fillers injected into an artery in the face can travel proximally to the internal carotid system whereby, on release of pressure, the product travels into the central retinal artery resulting in possible visual loss or blindness.11 It is therefore imperative that practitioners are able recognise the signs of an impending necrosis and have the skills to be able to act quickly, thus lowering the risk of harm to the patient. Not only must a policy be in place which allows the practitioner to deal with the situation, but they must also be fully competent and confident in what to do. When should it be used? Over injection can be a potential risk when injecting HA fillers, leaving the patient with unsightly lumpiness or looking ‘pillow-faced’, with large volumes of filler visible in the mid face.11 Nodules can also occur following HA anywhere on the face, and those that start within 48 hours of injection may be inflammatory – however, those occurring sub-acutely (up to two weeks post-treatment) or late (after two weeks) are more likely to involve infection.12 Large haematomas can also be treated with hyaluronidase.6 The use of hyaluronidase can improve absorption via hypodermoclysis, the process of interstitial infusion or subcutaneous infusion of fluids into the body.13 It is important to stress that if the practitioner suspects infection then hyaluronidase shouldn’t be used14 and antibiotics should be prescribed. However, another side effect that can be resolved with hyaluronidase is when the Tyndall effect presents itself. This is when the HA is too superficially placed and creates a bluish discoloration of the skin.8 Throughout the procedure the practitioner must observe for signs of blanching of the skin, a change in appearance that may appear dusky or mottled.6 In this instance, the patient may complain of pain and the area might begin to feel cool to touch. If these signs are ignored then the area may turn blue and tissue necrosis can occur.8 Hyaluronidase should be administered as soon as this complication occurs, and there is good evidence that tissue necrosis can be prevented or be less severe the sooner the hyaluronidase is injected.8 Hyaluronidase must be used early, as its effectiveness in dissolving HA fillers is reduced after approximately four hours.8 Whether the situation is an emergency or not, it is imperative

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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that the patient fully understands the implications of why it is being prescribed, how it will be administered and a consent form should be signed. Patients must also be made aware of the impending risks involved with the use of hyaluronidase and that it is being used off license.

How to use hyaluronidase A common preparation of hyaluronidase in the UK is made up of 1500 IU of hyaluronidase in a powder for Solution for Injection / Infusion.14 This comes as a freeze-dried white powder in small glass vials or ampoules. As a prescription only medication (POM), it should only be administered following a face-to-face consultation with the prescriber. Below is my technique for preparing hyaluronidase 1500IU: 1. Draw up 10ml of water for injection or 0.9% normal saline in a syringe. 2. Reconstitute the hyaluronidase 1500IU with 1ml of the 10ml of normal saline or water for injection. 3. Rotate the vial to ensure the powder is fully dissolved. 4. Draw up the 1ml of hyaluronidase back into the syringe with the remaining 9ml saline or water for injection thus giving a concentration of 150IU/ml. Each 0.01ml will then be 1.5IU of hyaluronidase. Once the solution is prepared, using a clean non-touch procedure, inject the hyaluronidase into the affected area in small aliquots using a 30 gauge needle for superficial injections and 27 gauge for deeper deposits. Administration should be extremely accurate and limited to the affected area. In the case of nodules, they should be injected directly, and for product that has been injected into the superficial dermis, injections should be placed immediately into and below the product.10 For vascular compromise, serial puncture should be used to inject hyaluronidase along the course of the vessel. The needle should be perpendicular to the skin and several injections are often necessary. During and after the procedure, I recommend massaging the treated area quite vigorously to optimise the result and aid mechanical breakdown.

What are the risks of administrating hyaluronidase? One complication following the administration of hyaluronidase is allergic reactions,11 and, according to clinical studies, occur at a frequency of approximately 0.05% to 0.69%.1 There appears to be conflicting evidence as to whether a patch test of hyaluronidase should be carried out to rule out evidence of allergic reaction, with several practitioners suggesting that when it is used for elective treatments a patch test should be carried to minimise the risk.8 The patch test should be done intradermally (within or between the skin) and I would advise the practitioner to look for signs of inflammation, erythma and persistent itching. However, if the patient is showing signs of a vascular compromise then it could be justifiable to use the hyaluronidase as soon as possible to lower the risk of further harm. Another possible side effect of hyaluronidase is its potential to degrade the body’s natural hyaluronic acid in preference to the

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foreign hyaluronic acid filler that has been injected.15 I would therefore recommend treating the effect rather than absolute dosage, to go slow and to bring the patient back for additional treatments. Following the use of hyaluronidase, I would suggest observing the patient for 30 minutes in a clinical environment and making sure they have appropriate aftercare information. Results are often seen almost immediately, although I have found for denser, more cross-linked products it may take 48 hours for the effects to be seen. A review appointment at two to three weeks should be booked and further treatment offered at this point if needed. Conclusion Hyaluronidase plays an important role in the management of treating complications with HA dermal fillers, however, it should not be a substitute for good technique. Practitioners who deem themselves qualified to inject and treat patients with HA fillers must also be capable and confident to treat and manage complications. Having some knowledge into the use hyaluronidase is not enough to keep and patients safe, and so it is imperative that a policy is in place that all injectors can follow, justify and administer hyaluronidase without delay in an emergency situation. The policy must provide a set of guiding principles to help with decision-making. This doesn’t have to be complicated but understood by all injectors and reviewed regularly. The need for patch testing doesn’t appear mandatory yet but is often recommended, especially if the situation is not urgent. Lee Rowe is an independent nurse prescriber and aesthetic nurse with more than five years of aesthetic experience. Lee set up Innersense Aesthetics with her friend and fellow nurse Lorraine O’brien, after leaving the NHS some years ago, and now works full time in aesthetics in her clinic in York. REFERENCES 1. Dr Maurizio Cavallini, Dr Riccardo Gazzola, Dr Marco Metalla, and Dr Luca Vaienti, ‘The Role of Hyaluronidase in the Treatment of Complications From Hyaluronic Acid Dermal Fillers’, Aesthetic Surgery Journal 33(8) (2013), 1167–1174 2. Hyaluronidase, (US: Drugs.com, 2015) <http://www.drugs.com/cdi/hyaluronidase.html> 3. Hyaluronidase Enzyme (UK: Clinica London, 2013) <http://www.clinicalondon.co.uk/hyaluronidaseenzyme/> 4. Medicines and Healthcare Products Regulatory Agency, (UK: Gov.uk, 2015) <https://www.gov.uk/ government/organisations/medicines-and-healthcare-products-regulatory-agency> 5. Off-label or unlicensed use of medicines: prescribers’ responsibilities, (UK: Gov.uk, 2009) <https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribersresponsibilities> 6. P Lafaille, A Benedotto, ‘Fillers: Contraindications, Side Effects and Precautions’, Journal of Cutan Aesthetic Surgery 3(1) (2010), 16-19. 7. Necrosis, (US: National Library of Medicine, 2013) <http://www.nlm.nih.gov/medlineplus/ency/ article/002266.htm> 8. Inglefield C, Collins F, Duckett M, Goldie K, Huss G, Paun S, Williams S, Expert consensus of Botulinum Toxin and Dermal Filler Treatment second edition (UK: Aesthetic Medical Expert Group, 2014) 9. Dr Lisa Danielle Grunebaum, Dr Inja Bogdan Allemann, Dr Steven Dayan, Dr Stephen Mandy and Dr Lesley Baumann, The Risk of Alar Necrosis Associated with Dermal Filler Injection, (US: Denova Research, 2009) <http://www.denovaresearch.com/sites/default/files/2009-%20The%20risk%20 of%20alar%20necrosis%20assocaited%20with%20dermal%20filler%20injections.pdf> 10. Berthold Rzany, Petra Becker-Wegerich, Frank Bachmann, Ricardo Erdmann and Uwe Wollina, ‘Hyaluronidase in the correction of hyaluronic acid-based fillers: a review and a recommendation for use’, Journal of Cosmetic Dermatology, 8 (2009), 317–32 11. David Funt and Tatjana Pavicic, ‘Dermal fillers in aesthetics: an overview of adverse events and treatment approaches’, Journal of Clinical, Cosmetic and investigational Dermatology, 6 (2013), 295-316 12. Jessica A. Savas, Steven Yang, Katlein Franca, Ivan Camacho, Keyvan Nouri, ‘Inflammatory Nodules Following Soft Tissue Filler Use: A Review of Causative Agents Pathology and Treatment Options’, American Journal of Clinical Dermatology, 14(5) (2013), 401-411. 13. Dr Menahem Sasson and Dr Pesach Shvartzman, Hypodermoclysis: An Alternative Infusion Technique, (US: American Academy of Family Physicians, 2001) <http://www.aafp.org/afp/2001/1101/ p1575.html> 14. Package Leaflet: Information for the User, (UK: MHRA.gov.uk, 2014) <http://www.mhra.gov.uk/home/ groups/spcpil/documents/spcpil/con1424670915822.pdf> 15. Claudio DeLorenzi, ‘Complications of Injectable Fillers, Part I’, Aesthetic Surgery Journal, 33(2013), 561.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Treating acne scarring with fillers Dr RenĂŠe Hoenderkamp discusses the treatment of acne scarring with dermal fillers Introduction Acne scarring can be distressing and stigmatising, especially when affecting the face. Whilst there are a multitude of treatment options available, I do see patients who have tried everything including combinations of lasers, peels, retinoids and needling, but are still searching for a solution. I therefore decided to try and treat some atrophic scars with hyaluronic acid (HA) fillers and witnessed some excellent results. When treating acne scarring with fillers, I use one of two techniques depending on the scar type and number. Injecting filler carefully into the dermis/epidermis underneath atrophic scars lifts them and improves the overall look of skin blighted by acne scarring. This can be done by either individually targeting pitted scars with a plumping filler or approaching an entire area with a lighter filler, used mainly as a skin booster for hydration and skin conditioning. Having said this, all filler types are being used to treat acne scarring.1 Anatomy of acne scarring Acne scars occur when pustules go on to form nodules and cysts. Scarring is the result of skin damage during the healing of active acne. This process produces two typical scar types; atrophic and hypertrophic scars, depending on whether there is a net gain or loss of collagen in the healing process.2 A net loss forms an atrophic scar (80-90%) and a net gain a hypertrophic or keloid scar (10-20%).2 Both processes arise from the same pathophysiology, involving a transition through three stages of damage and healing. The damage caused initially by inflammation of a blocked sebaceous gland causes blanching and vasoconstriction. The immune response floods the area with granulocytes, macrophages, neutrophils, lymphocytes, fibroblasts, and platelets, preparing for granulation via immune mediator release. As granulation progresses the final stage is seen: matrix remodelling. The area is then flooded with enzymes, released from fibroblasts and keratinocytes, which determine the final structure of the extracellular matrix (ECM). Any imbalance in the enzymatic breakdown and rebuild of tissue results in scarring.2 When using fillers to treat acne scarring, only atrophic scars can be treated, because they are the only scars which are depressed, and these are generally classified into three types; boxcar, ice-pick and rolling (Figure 1):

Pros and cons Procedurally, the biggest consultation discussion point is permanence. Using semi-permanent fillers means improvement will gradually wear off and need repeating. My experience is that scars rarely return to their previous state due to a degree of subscision that occurs (and can be actively carried out) during administration. Filler type will dictate longevity, but I use HA fillers, so six to 12 months is the norm.3 Results are instant and improve over the following weeks. I often address specific scars for patients preparing for a big event, so timing is key and having the treatment a few weeks before the event, and not a few days, is always advisable. The procedure is painful but bearable. Some practitioners use lidocaine cream, but I find the associated local oedema is detrimental to scar visualisation, so I avoid using anaesthesia. Anecdotally, it appears to be less painful than lip fillers and these patients have often had many painful procedures to treat the indication previously, so may be more tolerant than other filler patients. Injection site redness and bruising is a possibility, as with all filler procedures, so careful consenting is key to managing expectations and guiding patients on how long potential side effects may last. Is it effective? Certainly my experience suggests the use of fillers is an effective solution for atrophic scar reduction. Results are seen instantly and improve over weeks as there is a double effect from the procedure: physical lifting up and out of the scar, and collagen development that often follows from fibroblast stimulation in the dermis by the needle. Not all scars respond equally, and response is governed by type and depth of scar and how disrupted the underlying tissue is; this dictates filler placement and canâ&#x20AC;&#x2122;t be predicted. I have found broad rolling scars that are distensible when the skin is stretched respond best to fillers, but I have also had success with box car and ice pick scars that are not too narrow. The improvement, whilst varied, is always in my experience evident, and, however slight, is of psychological benefit. These patients have often struggled for years to improve their scars, and resulting expectations are lower than the usual filler patient. They are often so appreciative of small improvements that it is humbling and a useful reminder of the stigma suffered.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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What filler? Essentially, any proven safe and efficacious dermal filler could potentially be used and selection is governed by the experience and expertise of the practitioner. There are more than 120 fillers on the market in the UK but HAs are the most commonly used.4 I prefer them for acne scars and, whilst I turn to both Galderma and Allergan, I tend mainly to use Emervel Classic for direct lifting out of scars, and Restylane Vital/Vital Light for an all over skin improvement approach. This is because Emervel is firm enough to lift out deep scars but malleable enough to mould if necessary. Restylane Skin Boosters provide an excellent extra string to the bow when looking at skin in poor condition with additional acne scarring, rehydrating rather than volumising to improve overall skin texture. As these are resorbable fillers, the effects are not permanent, although longevity varies. Whilst there are permanent fillers on the market, it would be inadvisable to use them on acne scarring where the option to reverse any unwanted side effects is not available. As well as HA, potential compatible filler types include poly-l-lactic acids (Sculptra), bovine collagen gel, polymethylmethacrylate (Bellafill) and calcium hydroxylapatite (Radiesse).1 Interestingly, Bellafill is the first filler with FDA approval and is licensed for acne scar treatment in the US.5 Poly-l-lactic acids (Sculptra): Designed to stimulate collagen synthesis over and above that achieved by needle entry, which could give a long-term result if substantial. Can last several years. Requires a series of injection applications over a few months to get results and results are not reversible.1 Bovine collagen gel: An older solution and not so readily used at clinic level any longer. Bovine in origin rules it out on diet and religious grounds for some patients. Results for depressed rolling scars can be good but only last two to four months. Too soft for any fibrotic scars.6,7 Polymethylmethacrylate (Bellafill): The only filler to have a licence for acne scar treatment in the US, although only for shallow distensible (rolling) scars. Not yet readily available in the UK.5 Calcium hydroxylapatite (Radiesse): A cellulose like water-based gel that contains calcium hydroxyapatite in microscopic particles designed to create volume. Not as malleable as HAs but can last up to a year.1 Treatment The ideal patient for demonstrating this technique would have scattered deep scars. Figures 2, 3, 4 and 5 show one of the first patients that I treated for acne scarring using dermal fillers. Here I used JuvĂŠderm Ultra to treat the deepest scars seen. The after photos (Figure 3 and 5), taken immediately post procedure, show marked initial improvement which will develop with time. When the needle marks and oedema subside the results are often remarkable. Although JuvĂŠderm Ultra is an excellent choice for many filler procedures, I now tend to use Emervel Classic due to it being more malleable and versatile. Complications Complication risks are as for any fillers and the patient must be consented in exactly the same way. Risks specific to this treatment appear to be nodules/

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Technique The procedure is relatively straightforward, but it takes longer than other filler procedures. It is intricate and the local oedema is substantial, so being methodical about how to inject the area is crucial. Lifting out individual scars: 1. Clean the area and photograph well. The photographs are an important record and procedure tool. I use an iPad to display them and discuss the scars with the patient, identifying areas/scars causing most distress. Only after this discussion do I start. 2. Begin at the very furthest edge of the treatment area and work methodically into the area scar by scar. 3. Insert the needle, bevel up under the scar and, when directly under the pitted/dipped area, begin injecting. You should see immediate lifting out of the area. Withdraw and examine. You may need to repeat several times until you have achieved the desired effect. 4. Refer to photography as necessary; some scars will become visible only at certain angles. If there is a scar on the photograph that you canâ&#x20AC;&#x2122;t see on the patient, change your angle or reposition the patient. 5. Some scars have such tortuous tissue sitting under them that when the needle is extruded the filler moves to the side. If this happens, withdraw and massage the filler ensuring that it is not noticeable. Then, use the needle to subcise the scar tissue by moving the needle back and forth in different directions. When you feel that you have broken down some of the scar tissue, attempt to re-site the filler. 6. Continue across the area, massaging the filler under each scar as necessary. Working methodically across the area is crucial because local oedema will grow and individual scars will become difficult to isolate. You will reach a point where local oedema/entry points make any further procedure impossible. Recognise this point and stop. It may mean that when the oedema has settled there is more that you can achieve, but results will already be evident and my experience is that a happy patient is prepared to undertake future treatments. For using skin boosters, this is my approach: 1. Prepare as above. 2. Use the normal multi-injection point technique and shallow placement as for standard skin booster treatment. 3. A  t individual scars, concentrate several product placements directly under the scar as you would when using a standard HA for lifting a scar. 4. Massage the entire area afterwards, checking the individual scars are not raised.

Fig 2: Left cheek before HA filler

Fig 3: Left cheek after HA filler

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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lumps/visible filler caused by too superficial a placement. Avoid this by careful examination and massaging the area posttreatment. I always give the patient careful instructions for when their oedema has settled. I tell them not to worry about filler that they can feel, only that which they can see and don’t like. I show them how to massage any such areas, but tell them that in an ideal world I will have done a good enough job that they won’t need to touch it. I always add to the consent that when treating very shallow scars a balance has to be found between placing the filler superficially enough to lift the scar but deep enough not to be seen. Ultimately, any stubborn superficial filler could be dissolved with hyaluronidase, but thus far I have not had to do this. You should always warn the patient that they will probably look worse on finishing, but explain that this is temporary. The procedure involves so many needle-points that the combination of this with oedema and potential bruising can be visually displeasing. Conclusion Acne scarring is a debilitating and stigmatising condition, which drives patients to seek out and spend vast amounts of money in their quest to improve the situation. By the time they reach the point of fillers, they have already tried almost all other modes of treatment and have spent thousands of pounds. This is both good and bad. It is positive because they will appreciate small improvements, but could be negative because they can be vulnerable and sometimes have unrealistic expectations. Fillers

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offer a good solution for many patients but it is important to be realistic; select your patient carefully and guide them as to the improvement that may be achieved. Show them which scars you believe will benefit from treatment and those which may not, and make sure they are happy with the proposed improvement before starting by conducting a thorough consultation. Take good, clear photos and always warn the patient about how they will look at the end of the treatment. As with all cosmetic procedures, managing expectation is key to happy patients. Dr Renée Hoenderkamp is a GP registrar based in London, having qualified in April 2010. With a special interest in aesthetics and women’s health, she founded The Non Surgical Clinic in 2011, developing a reputation for natural-looking solutions for facial ageing and deformity. REFERENCES 1. Treatment Options: Fillers (Canada: A Scar Free Me, 2014) <www.ascarfreeme.com/resources/> 2. Gabriella Fabbrocini, M C Annunziata, V D’Arco, V De Vita, G Lodi, M C Mauriello, F Pastore, G Monfrecola. ‘Acne Scars: Pathogenesis, Classification and Treatment’, Dermatology and Practice, October (2010) 3. Michael H Gold, ‘Use of Hyaluronic acid fillers for the treatment of the aging face’, Journal of Clinical Interventions in Aging, 2(3) (2007), 396-376. 4. Dermal Fillers (UK: Doctors Makeover, 2015) <http://www.cosmeticsurgeryuk.com/dermal-fillers.php> 5. What is Bellafill? (US: Suneva Medical Inc, 2015) <www.bellafill.com/physician/acne-scar> 6.  Varnavides CK, Forster RA, Cunliffe WJ, ‘The role of bovine collagen in the treatment of acne scars’, British Journal of Dermatology, 116(2) (1987), 199-206. 7. Lisa Sefcik, Collagen Treatment for Acne Scars (US: Live Strong Foundation, 2015) <www. livestrong.com/article/74155-collagen-treatment-acne-scars/>

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Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Liposuction Dr Amanda Wong-Powell discusses the evolution of liposuction and presents the case study of a patient who underwent VASER Liposuction in her clinic Background Liposuction has long been a common procedure in the aesthetic industry. As early as the 1920s, a French surgeon called Charles Dujarrier first attempted liposuction by sculpting a ballet dancer’s calves and knee. Due to an arterial injury, however, the leg was subsequently amputated, which put a halt on the development of liposuction for more than 50 years.1,2 It was not until the late 1970s that Arpad Fischer, Giorgio Fischer, Yves-Gerard Ilouz and Pierre Fournier developed modern liposuction techniques in France and Italy. By the 1980s, the techniques had become popular in the United States, and, in 1985, Jeffrey Klein revolutionised liposuction by perfecting the tumescent technique.1,2 Prior to this, all liposuction procedures were performed under general anaesthetic. This meant that they were associated with significant surgical blood loss and a longer recovery time.3 The tumescent technique, however, permitted liposuction to be performed under local anaesthetic, which significantly reduced the level of blood loss, haematoma, recovery time and discomfort post procedure.3,4 The tumescent, meaning ‘swollen’, technique involves the use of a tumescent solution. The solution comprises a low concentration of lidocaine and adrenaline, which causes the targeted tissue to become swollen and firm, permitting liposuction

The tumescent technique permitted liposuction to be performed under local anaesthetic which significantly reduced the level of blood loss, haematoma, recovery time and discomfort post procedure

procedures to be performed with a reduced risk of blood loss.5 Since then, there has clearly been an increase in the uptake of liposuction procedures, something that has continued into the 21st century. Today, there are many different types of liposuction available, including suction-assisted liposuction (SAL), powerassisted liposuction (PAL), ultrasound-assisted liposuction (UAL), twin cannula-assisted liposuction (TCAL), external ultrasoundassisted liposuction (EUAL), water-assisted liposuction (WAL), and laser-assisted liposuction (LAL).6,7 In my practice, however, I tend to specialise in Vibration Amplification of Sound Energy at Resonance (VASER) Liposuction. I find the VASER technology helps to preserve the connective tissues in the body, which ultimately lowers down time for patients as it is a less invasive treatment. It also maintains fat cells’ viability for fat grafting purposes and, in my opinion, gives very precise body contouring results to enable better high definition sculpting. VASER Liposuction VASER Liposuction is fast becoming one of the most popular variants of liposuction,6 and was invented by Dr William W Cimino when he first began developing VASER systems in 1998. The procedure involves three major steps: 7,8,9 • Firstly, infiltration with tumescent fluid is carried out by injection into the fatty tissue layer. • The fat tissues are then emulsified by ultrasound energy delivered by a small multi-ringed probe. The high frequency vibrations of the system cause gas bubbles within the tumescent fluid to expand and collapse, thus dislodging the fat cells and mixing them into the infiltration fluid. This is known as ‘acoustic streaming’. • Finally the fluid and emulsified fat is subsequently removed by the suction cannula. VASER Liposuction is also gaining popularity with patients as it is the only recognised technology for mid-definition and high-definition body sculpting techniques, which aim to deliver muscular definition and a finer athletic finish to patients.10

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Case study Patient A is a 28-year-old female postgraduate student who had gained approximately 10kg within the last couple of years whilst studying for her master’s degree. She was stress eating, had no time for exercise and had adopted some unhealthy lifestyle habits. Prior to seeing me, she had started an exercise regime, started to eat regularly and had followed a good diet plan – as a result she had lost approximately 3kg. She found that there were certain areas where the fat was proving rather more difficult to shift. At that point she decided to seek help and after some research was interested in having VASER Liposuction. Her first consultation was a general chat about the procedure, her suitability, her motivation, and her expectations from the procedure. A thorough medical history was also taken and an examination performed. We also discussed the benefits and risks of the treatment. She was then sent home to consider her options and decide whether she wanted to have a further consultation, if she was still keen to go ahead. She was seen two weeks later; when we went through the consent process, the risks and the benefits again. We then looked at the areas of concern and worked out what was possible to achieve with her procedure. It was decided that she would have liposuction to her upper and lower abdomen as well as her flanks. We discussed the pre-operative plan, logistics, the procedure itself and post-operative advice. We also discussed how she was going to maintain her new body shape. She was started on prophylactic oral antibiotics two days prior to her procedure. In my practice, routine prophylactic antibiotics (co-amoxiclav) are prescribed to prevent infection. The liposuction procedure was performed under local anaesthetic. On the morning of the procedure, she was re-consented routinely for her procedure. I answered all of her final questions and queries and then marked her body for the areas where I would perform the VASER Liposuction. Important structures such as the xiphisternum, rib cage, other important landmarks and incision areas for portholes are marked whilst the patient is standing upright. Patient marking is similar to drawing a topographic map with the contour lines representing the elevation on the surface and, in this case, the fat tissues. Frontal, bilateral and back view photographs were taken to help with photographic documentation and for before and after comparison. It is also important to point out any asymmetry or scarring the patient may have prior to surgery, as well as checking for any hernias. Routine observations are taken prior to starting and every 15 minutes during the procedure if the patient remains stable. As we are infiltrating Before a significant amount of fluid into the patient, it is important to ensure that the patient empties their bladder prior to starting. Standard sterile preparation and draping is used. Local anaesthetic is then injected into the marked porthole areas. In this case, we used five portholes, which is average for this procedure, although sometimes we may use more or less portholes depending on the size of the

patient and the accessibility of the area to be treated. Once the local anaesthetic started working, a small incision of approximately 0.8mm was made. Tumescent solution is injected into the fatty tissues to achieve infiltration. The formula used in the tumescent was; in each litre of normal saline (0.9%), to add: - 1mg of Adrenaline - 12.5ml Sodium Bicarbonate - 800mg Lidocaine 2% (a total maximum average of 35-45mg/kg of Lidocaine in the tumescent fluid) The tumescent fluid acts as a local anaesthetic as well as a buffer for liposuction. After approximately 20 minutes, the VASER probe was introduced and the fat emulsification process started. For each 100ml of infiltration, VASER is applied for a maximum of one minute. The ultrasound energy causes the bubbles of the infiltration fluid to expand and collapse, thus dislodging the fat cells from the tissue matrix. The ‘acoustic streaming’ then further separates the fatty tissue into small packets of fat cells that subsequently mix into the infiltration fluid ready for suction. The suction was performed using a specialised VentX cannula, which helps to remove the emulsified fluids and fat while preserving the tissue matrix. With Patient A, specific suction techniques were used to give her better definition of her abdomen and to enhance some musculature and lines. A total of 2.5 litres was aspirated, of which 1.5 litres was pure fat. A suitable surgical compression garment was applied immediately post operation. Patient A was able to get up immediately and walked to the recovery room. After a short recovery period and further observations, take-home medications were prepared comprising further antibiotics and analgesia, and Patient A’s relative escorted her home. She had MLD massages on the third day post procedure and underwent a total of 10 sessions in the following two weeks. She wore her compression garment consistently for four weeks, day and night. I saw Patient A for a routine follow-up at two weeks, six weeks and twelve weeks. Patient A’s recovery was uneventful. She was very pleased with her results and she continued with her exercise, healthy diet and lifestyle to maintain her new body shape. Patient A is a good case example of a very compliant, highly motivated and suitable patient with good results. As such, this case particularly highlights the importance of patient selection. Eight weeks after VASER Liposuction

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Patient selection, safety and post-operative care Patient selection is key in most procedures in aesthetic practice. In procedures such as liposuction this holds particularly true in order to ensure good and sustainable results. Patients with unrealistic expectations, who are extremely overweight, have poor skin laxity, poor compliance, or multiple medical problems would not be suitable candidates. If patients have unrealistic expectations, it is likely that they will not be entirely satisfied with the results of the procedure, while overweight patients who are not compliant with the aftercare may need other interventions such as bariatric surgery to achieve long-term successful results. In addition, patients suffering from skin laxity may need an abdominoplasty following liposuction treatment to remove any excess skin. As for any surgical procedure, taking a good medical history and performing a thorough examination is of vital importance. Explaining the procedure in basic layman terms to the patient, and discussing the associated benefits and risks, are equally important. Risks discussed should include asymmetry, bleeding, bruising, haematoma, swelling, pain, chronic pain, infection, neurovascular damage, lipodystrophy, unevenness, change in skin and skin sensation, skin burn, skin laxity, Lidocaine toxicity, seroma and scarring. Other rare risks include perforation, surgical shock, organ damage and death.11,12,13,14,15 Managing the patient’s expectations is paramount. It is important to ensure that the patient is aware of the entire process of the liposuction procedure from pre-operative preparation through to peri-operative and post-operative management. It is crucial that patients are made aware that results are often only visible six weeks post procedure, and best results around 12 weeks post procedure, to ensure they are not initially disappointed with the outcome. Patients also need to understand the risk of bruising, swelling, pain and ‘leakage’ post procedure. They need to be compliant with the post-operative care requirement of wearing a surgical compression garment for approximately two to four weeks, as well as having manual lymphatic drainage (MLD) massage for the first couple of weeks.12 The surgical compression garment helps the skin contract smoothly to the body’s new contours. The MLD massage is aimed at decreasing

Patients with unrealistic expectations, who are extremely overweight, have poor skin laxity, poor compliance, or multiple medical problems would not be suitable candidates

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swelling and lymph drainage. It is a very efficacious massage that helps to improve the lymphatic system as well as stimulating and increasing the rate of removal of waste products, toxins and excess fluid from the body’s tissues.11,12 A short period of rest (typically 12 hours) is recommended directly after the procedure, followed by two to three weeks of general recovery when strenuous activities should be avoided. Simple analgesia post procedure will help keep patients comfortable and relieve their initial pain in the first few days. Patients should be able to return to sedentary work in about a week and more strenuous work within two to three weeks. Light exercises are encouraged two weeks after the procedure and more strenuous ones around four to six weeks after the procedure are often recommended. It is essential that patients are able to commit themselves to a healthy lifestyle, comprising a balanced diet and a post-operative exercise regime to achieve the best possible result and maintain their new body shape. Conclusion VASER Liposuction is now often coupled with fat grafting.16 In my opinion, this technique will be the new frontier of aesthetic medicine and surgery, along with the practise of harvesting stem cells and the use of platelet rich plasma (PRP). These can be mixed with the harvested fat to enhance the viability and longevity of the fat graft, as well as to improve skin rejuvenation. The harvested autologous fat can be re-injected into the breasts, buttocks, face, décolletage, hands and wherever necessary for volumising and revivifying purposes.17 Liposuction is the second most popular aesthetic procedure performed in the world today.6 Given careful patient selection and appropriate procedure design, diligent pre- and post-operative care, along with effective operative techniques, I have found VASER Liposuction to offer highly satisfactory outcomes to a range of patients. Dr Amanda Wong-Powell is the founder and medical director of Dr. W on Harley Street. She has completed her basic surgical training, and is a member of the Royal College of Surgeons (Edinburgh). She is a VASER liposuction surgeon, and also has an interest in weight loss management. She is also medical director of Meducatus, the medical training platform for doctors and surgeons. REFERENCES 1. Flynn TC, ‘History of Liposuction’, Dermatologic Surgery, 26(6) (2000), pp.515-520. 2. Coleman III, William. P. ‘The History of Liposculpture’, Journal of Dermatologic Surgery & Oncology, 16 (12) (1990), p.1086. 3. KleinLipo, Dr Jeffrey Klein M.D (US: KleinLipo, 2013) <http://kleinlipo.com/staff/dr-jeffrey-klein/> 4. Klein JA, ‘Post-tumescent liposuction care: Open drainage and bimodal compression’, Dermatol Clin, 17 (1999) pp.881–90. 5. Rudolph H, De Jong M, ‘Tumescent Anesthesia: lidocaine Dosing Dichotomy’, International Journal of Cosmetic Surgery and Aesthetic Dermatology’, 4 (1) (2004), p.1. <http://online.liebertpub.com/doi/abs/10.1089/153082002320007412> 6. Liposuction 2nd most popular aesthetic surgery procedure in the world (ISAPS, 2013) <http:// www.isaps.org/Media/Default/Current News/ISAPS 2013 Statistic Release FINAL (2).pdf> 7. Shiffman MA, Di Giuseppe A, ‘Liposuction Principles and Practice’, Springer (2006). 8. Shiffman MA, Di Giuseppe A, ‘Body Contouring’, Springer (2010). 9. VASERlipo Science (VASER from Solta Medical, a division of Valeant Pharmaceuticals North America, LLC) <http://www.vaser.com/vaserphysician/vaser-science/vaserlipo-science> 10. Hoyos EH, Prendegast PM, ‘High Definition Body Sculpting’, Springer (2014). 11. Housman TS, Lawrence N, Mellen BG, George MN, Filippo JS, Cerveny KA, et al, ‘The safety of liposuction: Results of a national survey’, Dermatol Surg, 28 (2002), pp.971-8. 12. Coleman WP, 3rd, Glogau RG, Klein JA, Moy RL, Narins RS, Chuang TY, et al., ‘Guidelines of care for liposuction’, J Am Acad Dermatol, 45 (2001), pp.438-47. 13. Lawrence N, Coleman WP, ‘Liposuction’, J Am Acad Dermatol, 47 (2002) pp.105-8. 14. Coleman WP, ‘Powered liposuction’, Dermatol Surg, 26 (2000) pp.315-8. 15. Venkataram J, ‘Tumescent Liposuction: A Review’, J Cutan Aesthet Surg, 1(2) (2008) pp.49-57. 16. Schafer ME, et al., ‘Acute Adipocyte Viability After Third-Generation Ultrasound-Assisted Liposuction’, Aesthetic Surgery Journal, 33(5) (2013) pp.698-704. 17. Fisher C, et al., ‘Comparison of Harvest and Processing Techniques for Fat Grafting and Adipose Stem Cell Isolation’, Plastic Reconstructive Surgery, 132(2) (2013) pp.351-61.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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in the superficial dermis.2 It is also claimed that the injection of mesotherapy products promote skin rejuvenation by increasing both hydration and fibroblast activation, and re-establishing skin tone and elasticity.3 At present, mesotherapy is used to treat a variety of conditions such as acne, rosacea, cellulite, localised adipocytes, stretch marks and hair loss, as well as for skin rejuvenation. In this article I will highlight the case study of a patient with dry skin below the eyes and the mid cheek area. Treatment Protocol The mesotherapy for hydration protocol consists of four sessions. These four sessions are carried out weekly or fortnightly depending on the availability of the patient. To ensure efficacy and even delivery of product to the skin, the treatment is performed with an automated mesogun, ensuring that each individual injection perforates the skin at the same depth and with the same amount of product.

Mesotherapy for Facial Skin Hydration Aesthetic nurse Juan Lopez highlights the benefits of using mesotherapy for facial skin rejuvenation Too often we focus our efforts on treating what patients request, without recommending or suggesting other treatments that would improve their general appearance. In this manner, I believe that we are not working hard enough to care for our canvas. For us, as aesthetic practitioners, the canvas is our patients’ skin, and therefore treatment of this organ should always be our first recommendation. Good skin health makes our patients look better, and will also help to improve the results of any other treatments implemented in the future, such as dermal fillers and botulinum toxin. If the skin looks better, the results of other treatments will be greater. This is comparable to an artist’s masterpiece – undoubtedly, any distinguished artist would ensure that their canvas was of the best quality, to assist them in creating equally high-quality work. Likewise is true of caring for our patients’ skin. For the purpose of improving the skin, I believe in following in the footsteps of the French doctor Michel Pistor. In 1976, Dr Pistor first described a technique involving injections of medications directly into the skin, also known as mesotherapy.1 The aim of mesotherapy in skin rejuvenation is to maintain and restore a healthy and youthful texture. The desired final effect is to firm, brighten and moisturise the skin by injecting suitable products that are biocompatible and absorbable

Session 1 Each session utilises the same protocol of products – in my practice I use a cocktail of products to improve different aspects of the skin. For skin hydration I use the following products and ingredients shown in Table 1. This protocol can be individually tailored depending on the requirement of the patient and their age. Generally, the mesolift cocktail can be changed for other cocktails, such as an anti-ageing cocktail or a firming cocktail. For example, if you have an older patient you can change the mesolift cocktail for the regeneration cocktail, which is better suited for older skin. The type of cocktail that I deploy for this effect contains centella asiatica as the main ingredient, believed to heal the skin, acting alongside dermal regenerative actives dexpanthenol, elastin and organic silicium, working to improve collagen fibres. If you have a younger patient, you can change to the radiance cocktail to help achieve glowing skin, which is what younger patients generally request. This protocol has been adapted from Dr Britta Knoll.4 Pre-treatment Considerations Before considering any form of treatment it is crucial to take a thorough medical history, thereby ensuring mesotherapy is not contraindicated for any patient. This should be followed by a full explanation of what the patient can expect, the length of time that the treatment will take and the maintenance required to maintain the effects on the patient’s skin. The patient will need to be aware of the latter’s implications, commitment and potential cost in the long term. Following consent, and as part of the protocol, it is necessary to take photographs of the patient and the skin condition at the first visit as a baseline, before commencement of treatment. This is also crucial in each session before the treatment in order to be able to monitor and document the progress of the results.2

Table 1: Mesotherapy Protocol for Skin Hydration Product

Composition

Percentage of total mixture

Hyaluronic acid medium molecular weight Non-cross-linked hyaluronic acid MW 2%

30%

Nutritive complex for poly revitalising

Hyaluronic acid, 10 vitamins, 25 amino-acids, 2 co-enzymes, 4 nucleic acids, 2 reducing agents

30%

Mesolift cocktail

Hyaluronic acid, sodium DNA, multivitamins BCAE, organic silicium, DMAE

32%

Procaine

Procaine 2% 20mg/ml

8%

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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My protocol for mesotherapy for hydration is to repeat this treatment every two to three months, depending on the condition of the skin The Mesogun As previously mentioned, it is important to distribute the same amount of product at the same depth in each injection. For that reason, we set up the mesogun to inject at 1mm depth and at a rate of 300 injections per minute. In my experience, patients find the treatment with the mesogun more confortable than manual injections. A study by Duncan and Chubaty5 describes how some practitioners reported that use of a mesogun improved the patient’s experience and lowered the perceived pain sensation. Case Study Patient One is a 37-year-old female, who had visited my clinic previously to have treatment with botulinum toxin type A for facial dynamic lines, hyaluronic acid (HA) fillers for volume replacement and a hydrating HA product for hydration of the skin. Previous skin hydration with the HA product had had a positive effect but the patient found that by the end of the day the skin was suffering and very dry. On previous occasions we had discussed the use of a course of mesotherapy treatment for skin hydration in the area of concern. Following consultation, the patient agreed to undergo four sessions of mesotherapy for the whole face, as is the protocol used in my clinic. First Treatment Once Patient One’s skin was cleansed with chlorhexidine solution and the mesogun preloaded, 5ml of the protocol mixture was injected for a full facial treatment. It is always necessary to make sure that the patient is getting the product at the right skin depth. However, excess product will remain on the skin, which will be absorbed if enough time is allowed before cleaning the skin. According to Patient One, the treatment was not painful with the exception of the top lip area where the treatment was slightly uncomfortable. The Injection Technique The technique used during this facial treatment was ‘Nappage’. ElDomyati et al6 describe this technique as quick and linear injections at superficial or mid dermis (1-4mm). 6 The volume injected should be 0.1ml for each single droplet, at a distance of a few millimetres apart. Post Treatment The treatment was finalised with the application of a recovery cream and a broad-spectrum sunscreen (SPF 50). No bruising was observed immediately post-procedure or in the days following the session. Once the treatment was finished, Patient One was advised not to wash her face for a few hours.

Aesthetics

Further Treatments As per protocol, the treatment continued for a total of four sessions. All sessions followed the same preparation, technique, dosage and post treatment care as the first treatment. The sessions were booked every two weeks, and photographs were taken before each session. Feedback and Outcome Patient One reported after the first session that her skin had improved, exceeding her expectations, and she claimed she felt her skin was more hydrated. The greatest changes observed by both Patient One and myself were after the third and fourth sessions. Patient One described her skin as looking fresh and rested. The last review session was four weeks following the final treatment. At this session Patient One reported that previously her skin used to feel fresh in the mornings, but due to the stress and nature of her job, her skin would start to feel dehydrated again by mid-afternoon; with the mesotherapy she was noticing a fresher look lasting all the way to the evening. For her this was a very positive outcome and one that she wanted to maintain. Treatment Maintenance Patient One was keen to maintain the results. My protocol for mesotherapy for hydration is to repeat this treatment every two to three months, depending on the condition of the skin. The skin is reviewed after two months, after which a treatment is scheduled accordingly, but generally is booked for the following month or earlier if required. Conclusion In my experience, the use of mesotherapy for skin rejuvenation and hydration is a highly effective treatment. This kind of approach will benefit the long-term health and look of the patient’s skin. Other advantages cited by Tosti and De Padova7 include minimal pain and very reduced incidence of complications, and the treatment can be performed on every skin type with less downtime compared with other aesthetic treatments (e.g. microneedling). Both the patient and I agreed the results on her skin had been favourable, consequently improving the patient-practitioner relationship/trust. With this in mind, aesthetic practitioners can confidently offer this treatment in clinic to maintain patient satisfaction. Juan Lopez is an aesthetic nurse and independent prescriber with more than five years of experience. His special interests are skin health and mesotherapy. He is the owner of DermaTops.com and is preparing the launch of his new clinic, Skin Medico, in London. Juan is also a training consultant for Vida Aesthetics Ltd. REFERENCES 1. Pistor, M., ‘What is mesotherapy?’, Le Chirurgien-dentiste de France, 46 288 (1976), p. 59. 2. Savoia, A., Landi, S., & Baldi, A., ‘A new minimally invasive mesotherapy technique for facial rejuvenation’,Dermatology and therapy, 3(1) (2013), 83-93. 3. Lacarrubba, F., Tedeschi, A., Nardone, B., & Micali, G., ‘Mesotherapy for skin rejuvenation: assessment of the subepidermal low-echogenic band by ultrasound evaluation with crosssectional B-mode scanning’, Dermatologic Therapy, 21(s3) (2008), S1-S5. 4. Knoll, B. & Sattler, G., Illustrated Atlas of Esthetic Mesotherapy. (London: Quintessence Publishing Company, 2012) 5. Duncan, D. I., & Chubaty, R., ‘Clinical safety data and standards of practice for injection lipolysis: a retrospective study’, Aesthetic Surgery Journal, 26(5) (2006), 575-585. 6. El-Domyati, M., El-Ammawi, T. S., Moawad, O., El-Fakahany, H., Medhat, W., Mahoney, M. G., & Uitto, J., ‘Efficacy of mesotherapy in facial rejuvenation: a histological and immunohistochemical evaluation’, International journal of dermatology, 51(8) (2012), 913-919. 7. Tosti, A. & Pia De Padova, M., Atlas of Mesotherapy in Skin Rejuvenation, (London: Informa Healthcare, 2007)

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Spotlight On: Kybella Following Kybella’s recent FDA approval for treating submental fat, Aesthetics investigates the drug’s efficacy and how it should be used in practice Double chins have long been associated with a displeasing aesthetic appearance, with many consumers resorting to surgery to remove unwanted submental fat. Now, however, a non-surgical alternative is expected to cause a stir in the US aesthetic market.1 In 2014, the American Society for Dermatologic Surgery (ASDS) reported that 68% of consumers are bothered by submental fullness.2 This notably high statistic is unsurprising says Dr Heidi Waldorf, director of laser and cosmetic dermatology at Mount Sinai Medical Center in New York and a lead clinical investigator in the Kybella study. “Many of my patients, both women and men, are looking for non-surgical options to help treat their double chin,” she explains, adding, “the statistic is almost as much as those who say they are bothered by the lines and wrinkles around their eyes [71%2].” Yet there seems to have been a distinct lack of non-surgical options for treating this ‘problem’ area – until now. Kybella, manufactured by US-based company Kythera Biopharmaceuticals, is expected to become available to US-based practitioners who have completed training in its administration this summer. As of yet, however, no filings have been submitted for the product to launch in Europe. Despite this, the Food and Drug Administration (FDA) approval of the drug has generated global news headlines. The Telegraph reported that Kythera’s shares jumped by almost 8% following the announcement,3 whilst business analysts have suggested that Kybella could bring in more than $300 million a year.1 Of course this is not only significant news for investors in Kythera, it represents to many a new treatment option for those who are unhappy with the amount of fat below their chin. Submental fullness can affect both men and women – of any age or weight – and is often resistant to diet and exercise.4 “The FDA approval of Kybella fills an unmet need for physicians and patients,” explains Dr Waldorf. “Before this, there was an empty spot in our therapeutic toolbox.” Also know as ATX-101, Kybella is identical to the deoxycholic acid that is produced in the

body, which works to help the body absorb fat.5 The FDA explains that Kybella is a cytolytic drug, which aims to destroy fat cells when injected into submental fat. Kythera claims that once destroyed, those cells cannot store or accumulate fat.4 Kybella is administered by injection into the fat under the chin, which can be tailored to individual patient requirements. Patients can receive up to 50 injections in a single treatment, with up to six single treatments administered no less than one month apart. Dr Waldorf says, “Personally, I’m excited about the opportunity to offer my patients a clinically-proven, non-surgical option that I can customise to the patient and their treatment goals.” Research into the efficacy of Kybella was supported by a global development programme, which included more than 20 clinical trials and 2,600 participants worldwide. More than 1,600 participants were treated with the drug, of which 68.2% responded to Kybella in the final phase III trials, compared to just 20.5% who were treated with the placebo drug.6 Significantly, patients noted not only an improvement in the amount of fat under their chin, but also an improvement in the emotional impact of receiving treatment. For Dr Waldorf, this was very satisfying to hear; “As a cosmetic dermatologist, I want my patients to feel better about themselves both physically and emotionally,” she explains. The FDA enrolled 1,022 adult participants with moderate or severe submental fat in its two clinical trials into the safety and efficacy of Kybella. Participants underwent treatment with either Kybella or a placebo for up to six treatments and results indicated that a reduction in the fat was observed more frequently in those who were treated with Kybella.5 Each treatment takes approximately 15 to 20 minutes and, according to Kythera, patients experience visible results after two to four treatments.4 Up to six treatments may be administered and once aesthetic response is achieved, re-treatment is not expected.4 The drug does, however, come with reported side effects. In the clinical trials, 72%

of subjects treated with Kybella experienced injection site hematoma/bruising, and cases of marginal mandibular nerve injury were reported.4 These manifested as an asymmetric smile or facial muscle weakness and resolved spontaneously from 1-298 days, with a median of 44 days.4 In addition, dysphagia (difficulty swallowing) occurred in patients during the trials, with subjects experiencing pain, swelling, and induration of the submental area. Again, cases of dysphagia resolved spontaneously, ranging from 1-81 days, with a median of three days.4 Kythera advises practitioners to avoid injecting into or in close proximity to the marginal mandibular branch of the facial nerve, avoid using Kybella in patients with a current or prior history of dysphagia, and take caution when treating patients with bleeding abnormalities, or those who are currently being treated with antiplatelet or anticoagulant therapy.4 The company also notes that in order to avoid potential tissue damage, Kybella should not be injected into or in close proximity (1-1.5cm) to salivary glands, lymph nodes or muscles.4 It is further advised that the drug should not be injected outside the submental area or in the presence of infection at the injection site.7 Upon reflection of the research discussed, it seems likely that Kybella will have a substantial impact on the way in which aesthetic practitioners approach submental fat treatment in the future. And whilst there may be no plans to launch the drug in the UK in the near future, UK-based practitioners can take this as an opportunity to follow Kybella’s overseas’ development and learn more from our US-based colleagues administering the treatment. REFERENCES 1. Damian Grade, Kythera FDA approval for its double-chin- shrinking shot, (US: Fierce Biotech, 2015) <http://www. fiercebiotech.com/story/kythera-bags-fda-approval-its-double- chin-shrinking-shot/2015-04-29> 2. American Society for Dermatologic Surgery, 2014 ASDS Consumer Survey on Cosmetic Dermatologic Procedures, (US: ASDS, 2014) <https://www.asds.net/uploadedImages/2014%20 Infographic%20FINAL.jpg> 3. Gregory Walton, New cure for double chin approved, (UK: The Telegraph, 2015) <http://www.telegraph.co.uk/news/health/ news/11572510/New-cure-for-double-chin-approved.html> 4. Kythera Biopharmaceuticals, Kythera Biopharmaceuticals Announces FDA Approval of Kybella (also known as ATX-101)– First and Only Submental Contouring Injectable Drug, (California: MyKybella.com, 2015) <https://mykybella.com/wp- content/uploads/2015/04/KYTHERA-FDA-Approval-Press- Release-4.29.15-FINAL_.pdf> 5. Food and Drug Administration, FDA approves treatment for fat below the chin, (US: FDA, 2015) <http://www.fda.gov/ NewsEvents/Newsroom/PressAnnouncements/ucm444978.htm> 6. Kythera Biopharmaceuticals, Fact Sheet Kybella (deoxycholic acid) injection (US: Kythera, 2015) <http://media.globenewswire.com/cache/23392/file/33701.pdf> 7. Kythera Biopharmaceuticals, Full Prescribing Information, (US: Kythera, 2015) <https://mykybella.com/wp-content/ uploads/2015/04/KYBELLA-Combined-FINAL-Labeling.pdf>

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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A summary of the latest clinical studies Title: Outcomes of polydioxanone knotless thread lifting for facial rejuvenation Authors: DH Suh, HW Jang, SJ Lee, WS Lee, HJ Ryu Published: Dermatologic Surgery, June 2015 Keywords: Thread lifting, non-invasive, facial rejuvenation Abstract: Thread lifting is a minimally invasive technique for facial rejuvenation. Various devices for thread lifting using polydioxanone (PDO) are popular in aesthetic clinics in Korea, but there have been a few studies regarding its use. The objective was to describe PDO thread and techniques adopted to counteract the descent and laxity of the face. A retrospective chart review was conducted over a 24-month period. A total of 31 thread lifting procedures were performed. On each side, 5 bidirectional cog threads were used in the procedure for the flabby skin of the nasolabial folds. And, the procedure was performed on the marionette line using 2 twin threads. In most patients (87%), the results obtained were considered satisfactory. Consensus ratings by 2 physicians found that objective outcomes were divided among “excellent,” “good,” “fair,” and “poor.” Texture wise, the outcome ratings were 13 as excellent and 9 as good. Lifting wise, ratings were 11 as excellent and 6 as good. The incidence of complications was low and not serious. In conlusion, facial rejuvenation using PDO thread is a safe and effective procedure associated with only minor complications when performed on patients with modest face sagging, fine wrinkles, and marked facial pores. Title: A novel non-invasive radiofrequency dermal heating device for skin tightening of the face and neck Authors: AA Nelson, D Beynet, GP Lask Published: Journal of Cosmetic and Laser Therapy, May 2015 Keywords: Non-invasive, radiofrequency, rejuvenation, skin tightening Abstract: Loose, lax skin is a common cosmetic complaint. Previous non-invasive skin tightening devices had modest efficacy and were associated with pain or downtime. New technologies may allow for effective skin tightening with a series of no downtime, radiofrequency treatments. The objective was to evaluate the efficacy and safety of a novel bipolar radiofrequency device for skin tightening. 15 consecutive female patients were enrolled in the case series; 14 completed the study and were included in the analysis. The device under investigation is a novel, bipolar radiofrequency device allowing for achievement and maintenance of optimal dermal temperatures to stimulate collagen remodeling and skin tightening. Patients underwent a series of 4-6 weekly treatments. Three blinded, experienced cosmetic physicians evaluated paired blinded pretreatment and post-treatment photographs and determined the associated improvement, if any. All patients (14/14) were determined to have a clinical improvement, as the pre-treatment and posttreatment photos were correctly identified by the evaluators. 21% (3/14) patients were observed to have significant improvement, 50% (7/14) observed to have moderate improvement, and 29% (4/14) had mild improvement. No pain, side effects or adverse events were observed. This novel bipolar radiofrequency device represents a safe, effective treatment option for non-invasive skin tightening.

Title: A comprehensive health impact assessment and determinants of quality of life, health and psychological status in acne patients Authors: C Pagliarello, C Di Pietro, S Tabolli Published: Giornale Italiano di Dermatologia e Venereologia, June 2015 Keywords: Acne, health, psychological impact, effects Abstract: Acne adversely affects all aspects of quality of life (QoL). Although many papers assessed acne-specific QoL impairment, there are few data on its impact on general health and psychological status. Apart from acne severity, little is known about determinants of a worse QoL. The aims of this paper were to measure acne impact on QoL, health and psychological status and to analyse the relationship between socio-demographic variables, disease severity and mental status on QoL of acne sufferers. Acne cases were selected from a survey conducted in 2010. The Short-Form 12-Item Health Survey and the Skindex-29 were used to assess health status and QoL. The 12-Items General Health Questionnaire was used to identify individuals at risk for non-psychotic psychiatric disorders (GHQ-positive). Physician (PhGA) and patient global assessments were obtained. We investigated the variables involved in the QoL through a logistic regression analysis. One hundred ninety-five cases were analysed. Twenty-six percent were GHQ-positive; acne’s impact on health status was worse compared to other chronic diseases. A GHQ-positive status (Skindex-29 overall: OR 2.6; 95% CI 1.20-5.60, P<0.05, functioning: OR 2.5; 95% CI 1.17-5.44, P<0.05, symptoms: OR 3.0; 95% CI 1.36-6.53, P<0.01; emotions: OR 2.55; 95% CI 1.19-5.46, P<0.05) and having a severe/ very severe PhGA (Skindex-29 overall: OR 3.4; 95% CI 1.20-10.38, P<0.05) were associated with a poor QoL. Age of onset >25 was linked to being GHQ-positive (OR 2.92; 95% CI 1.2-7.1, P<0.05) controlling for gender, marital status and educational level. Acne is not a minor disease in comparison with other chronic conditions. Age of onset is capable to influence GHQ status which in turn affects QoL. Title: Effective protection of biological membranes against photooxidative damage: Polymeric antioxidant forming a protecting shield over the membrane Authors: O Mertins, PD Mathews, AB Gomide, MS Baptista, R Itri Published: Biochimica et Biophysica Acta (BBA), June 2015 Keywords: Gallic acid, photodamage, biological membranes, oxidative stress Abstract: We have prepared a chitosan polymer modified with gallic acid in order to develop an efficient protection strategy for biological membranes against photodamage. Lipid bilayers were challenged with photoinduced damage by photosensitisation with methylene blue, which usually causes formation of hydroperoxides, increasing area per lipid, and afterwards allowing leakage of internal materials. The damage was delayed by a solution of gallic acid in a concentration dependent manner, but further suppressed by the polymer at very low concentrations. The membrane of giant unilamellar vesicles was covered with this modified macromolecule leading to a powerful shield against singlet oxygen and thus effectively protecting the lipid membrane from oxidative stress. The results have proven the discovery of a promising strategy for photo protection of biological membranes.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Why you shouldn’t ignore online clinic reviews Emily Ross, director of communications at WhatClinic.com, helps you to make the most of online reviews in order to acquire and retain new patients The internet has completely disrupted the ‘rules’ of traditional marketing. Whilst emphasis was previously, for the most part, placed on the interaction between the business and the consumer, the dialogue between consumers themselves is gaining increasing importance, with online review sites at the forefront of this ‘consumer to consumer’ (C2C) marketing revolution. With more online review sites popping up every day, understanding how they work – and how to maximise them for your business – is essential. Clinics can either spend time reacting to the fall out or, at best, spend time turning this disruption to their advantage. What they cannot do is simply ignore them. Access to this new world of C2C marketing is never far away. With the touch of a screen on a smartphone, consumers can access a number of platforms where they can gripe, moan and criticise via words, photos and even high definition video. Let’s take a look at some of the review platforms available in the UK. In recent years, Google has added Google Reviews to its portfolio.1 With both Google Maps and the colossal brand power behind this product, it’s not to be ignored. Now your clinic is just as likely to be listed on here as in the phone book. Once you have verified your business on Google+, you can then respond to these reviews. Google has also made it particularly easy for people to leave Google reviews via their smart phones. WhatClinic.com Reviews launched in 2008. The site lists more than 100,000 clinics, including medical aesthetic, plastic surgery and private hospitals in more than 120 countries.2 It has also recently added photos and videos to its review content. It provides clinics with tools and apps to get the most out of patient reviews. Facebook Pages3 also provides a review feature for businesses, as launched in 2013.4 This is proving more and more popular, with the number of small businesses using Facebook Pages rising by 10 million in just one year.5 It is enabled for pages

that are categorised as ‘Local Businesses’, allowing people to post reviews and ratings onto your page. Although you don’t get to decide which reviews are published, you can, however, complain to Facebook if a review doesn’t meet its community guidelines.6 These guidelines stipulate that content may be removed if of a threatening or violent nature, or if activity constitutes bullying or harassment. Users can choose to switch off reviews if it’s more than they can handle. The best approach to Facebook online reviews, indeed to all online reviews, is to handle them appropriately. Here I’ll share some simple guidelines for effective review management.

Seven steps for handling a bad review No matter what business you’re in, if you deal with members of the public you’ll probably agree that most people are quite reasonable. But there are some exceptions, and, unfortunately, it’s the exceptions that tend to make the most noise. While online review sites can be a great space for people to share and read positive opinions, it’s also the perfect forum for a small number of people to cause business owners a real headache. So, how should you deal with negative comments? 1. Actually read the review Try and be impartial. Remember that every review is written by a real person, who came to you seeking help. Criticism is always hard to take, but is there anything you can learn from this review? Is there a grain of truth or more in what was said? Irrespective of the medium in which the complaint is made, it is incredibly bad practice to disregard feedback from a paying customer. 2. Respond – the sooner, the better We’re all human, and we can sometimes let our natural defensiveness play out. If you feel very strongly about a review, think before you respond. Wait until the next morning, and try and reply in a professional manner, and as calmly as possible. Or, if you can’t trust yourself to be calm, get someone else to sense-check your response before you post it online. A moment of anger may damage your reputation, and can leave a lifetime of regret. 3. Never, ever include private patient data in your response An obvious one, you’d think, but most clinics are caught out by what is actually classified as ‘private’. Any information relating to an individual’s visit, including the date, time, gender, and treatment choice might be considered confidential information. Essentially, anything that is specific to that patient. ‘When you visited our clinic last Tuesday’ is an excellent example. This very general sentence is personal, because it refers to the individual. Speak only on general policy and practice in your public answers.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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4. Handle it offline This is the first recommended action for managing any disgruntled patient review. There are times when email conversation can make a bad situation worse. Email has a dehumanising effect, and, because of this, it’s easier to be irate in email dialogue. By picking up the phone and making the effort to speak to the customer, and with the effort of simply listening to them, many frustrations and miscommunications can easily blow away. 5. Take time to listen As we all know, in any complaints process, having someone listen to us and empathise is the first step to resolving any dispute. In your online comments show that you are really listening and empathising with the patient who has taken the time to provide feedback, before inviting the person to contact you directly. 6. Don’t ‘fob them off’ Referring the user to information on your website or brochure page is a good idea only if the specific issue is clearly and succinctly dealt with in your website or brochure. But, let’s face it, very few websites are as well laid out as they should be, and it may be harder than you’d imagine to find the one little nugget of information that is relevant or important. Making the user feel as though it’s their fault that they haven’t been able to find the relevant information might only fuel their irritation. 7. Don’t be surprised if… People publicly post your private responses to them. That’s okay – they have the right to broadcast your responses. Unfortunately, you don’t have the same privilege. Don’t be surprised if irate customers say things that aren’t true, frame responses negatively, or are downright offensive. Also, don’t be surprised if someone who is very angry doesn’t bother responding to your carefully crafted comments, or polite invitations to discuss the issue. In these cases, let your last words be the ones to remember. Remain calm, be pleasant, utterly professional and always well-mannered. This is what will last in the mind of the reader – no matter what the initial complaint.

Dealing with malicious reviews and trolling Negative comments and complaints are one thing, but there’s a fine line that can be crossed. Have you heard of internet trolls? This is the term I would use for a person who starts online arguments or upsets people by posting inflammatory or off-topic messages in an online community, in order to provoke an emotional reaction from fellow contributors and readers. The very best advice is: do not feed the trolls. Some people are so provocative, and so clearly driven by malice, that their own comments are enough to ensure that no-one takes them seriously. By engaging in an online back-and-forth you are simply playing into their hands, and potentially causing more trouble than it’s worth. It’s also incredibly difficult to engage with people who are purely out to stir and cause argument without losing your cool, which sends out the wrong message on a public space, and can damage your brand. Check to see if their content warrants a complaint to the host of the review site (if their comments are clearly untrue, for example) and in the meantime, leave well alone. Most review sites provide you with means to flag malicious content, such as the report button on Facebook,6 and many companies will have their own guidelines that must be adhered to. WhatClinic.com is based in Ireland where defamation law is extremely stringent,

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as outlined in the Defamation Act 2009 (which came into effect in 2010).7 No matter where the location of the clinic that is being reviewed is, as the publisher, WhatClinic.com must adhere to Irish law. This means all of these reviews are verified, both by phone and by email, to confirm they come from real patients. Then, a moderator actually reads the review to ensure that it’s not offensive, malicious or defamatory. It means a considerable number of reviews don’t make the grade and cannot be published, but we work hard to engage with patients to help them get their point across in a frank and honest manner, which meets our review guidelines.

Negative reviews only have power if they stand alone When you think about it, one or two poor reviews beside a hundred great ones are actually not that bad. In fact, they can be quite reassuring to the consumer, because it shows that these are indeed genuine reviews from real patients. Realistically, if no one provided any constructive criticism, would you really trust the forum? Many would argue not. How you handle a bad review is often of more interest to other readers than the actual complaint. Every poor review is an opportunity for you to show off your customer care, your patience and your empathy, and you shouldn’t lose sight of that. On our site, we have found that clinic listings with lots of reviews are more popular than those without. There are lots of ways you can encourage patients to leave reviews: 1. Put a link to a review site in the bottom of your emails or on your website 2. Email customers and ask them politely if they would like to review your clinic 3. Add suggestions to receipts and in promotional material that you welcome patient reviews It’s also a great idea to maximise the value of online reviews and market them to your benefit. Why not share your favourite reviews on your social media platforms, or to add them to your website, brochures and point of sale? As a means to really get to understand your patients as consumers, reviews can give you a window into how real patients view your business. That information can often be worth its weight in gold. Whilst online reviews have led to an increased power of C2C marketing,8 remember that it’s a conversation that you too can very easily, and effectively, engage in. Emily Ross is the marketing and communications director of WhatClinic.com – a search engine that lists more than 100,000 private clinics worldwide. She is a regular speaker and lecturer on social media and digital marketing. REFERENCES 1. Get Reviews on Google (US: Google, 2015) <https://support.google.com/business/ answer/3474122?hl=en-GB> 2. About (Ireland: WhatClinic.com, 2015) <http://about.whatclinic.com> 3. Josha Sophy, Facebook enables starred reviews for some businesses (US: Small Business Trends, 2013) <http://smallbiztrends.com/2013/11/facebook-starred-reviews.html> 4. Anthony Ha, Facebook Says There Are Now 40m Active Small Business Page (US: Tech Crunch, 2015) <http://techcrunch.com/2015/04/29/facebook-40-million/#.eqpw5y:74fl> 5. What Happens After You Click “Report” (US: Facebook, 2015) <www.facebook.com/notes/ facebook-safety/what-happens-after-you-click-report/432670926753695> 6. Defamation Act 2009 (Ireland: Houses of Oireachtas, 2009) <www.irishstatutebook.ie/pdf/2009/ en.act.2009.0031.pdf> 7.  Myles Anderson, Local Consumer Survey 2014 (US: BrightLocal, 2014) <www.brightlocal. com/2014/07/01/local-consumer-review-survey-2014/>

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Enhancing the patient journey Clinic operations director Deborah Vine outlines how her team works to provide the best experience for patients on their treatment journey The regulation of cosmetic surgery and associated treatments has been under the spotlight for a good few years. Press coverage has sparked conversation at all levels, especially online via social media and forums, and, in turn, this has heightened awareness surrounding aesthetic treatments. The demand for clearer information is now huge, and this demand has been answered by an increase in information on television, online and through media coverage. Perhaps due to this scrutiny, patients are now more informed, and ask more questions. However, despite this growing confidence, we must not lose sight of their primary reason for visiting us – often this is because something about their body is causing them concern, embarrassment, frustration, or worse. Making that first enquiry will have taken courage and will not have been taken lightly. Throughout this entire experience, each patient may feel completely outside of the realms of comfort, and we must consider this at every point of their journey and craft our responses to their queries carefully. The Journey There are numerous feelings and considerations which affect the decision process in our potential patient’s mind. Our role is to carefully de-construct this, identifying and stripping back any potential barriers, whilst always ensuring that the patient’s best interests remain at the centre of everything we do. Our objective is to make each experience along the way as simple as possible, allowing the patient to focus on getting all of the information that he or she needs in order to help them make an informed decision about treatment with a clear mind. The patient journey begins with the patient identifying their concern and taking the decision to act. This must be where our journey also begins. As a team, we must make things as easy as possible for them and should consider some key questions. Where might they hear about us? How might they find us? How are we represented and, more importantly, how much can they learn about us? Are we encouraging them enough to take a further step?

Going Digital Today, clinics must ensure that they convey a clear, consistent and informative message across all mediums. Attention to detail in all areas has become vital as businesses have several ‘windows to the world’, and each should reflect the consistent service level that the patient can expect throughout their experience. Digitally, video and blogging have become very useful ways to prepare the patient for what they can expect. One very popular project we commissioned at Karidis Cosmetic Surgery London was a video of our customer journey. We wanted people to feel comfortable with where they would be coming to take away any uncertainty. During the video, they pass through the doors of our clinic, where our reception desk is situated, then see other patients sitting in our waiting area, followed by clips of a consultation. Later in the video, the viewer will see what the hospital room would look like on the morning of a surgical procedure, with a patient in a gown and robe discussing their procedure pre-operatively. We believe all of this will help to break down barriers and make the patient feel at home, and the beauty is that they can experience this in their own home where they are already at ease. Although the video is an effective visual aid, some patients would rather read hard facts. In this case, we found that some information was easier to document in a written format, so to reflect this, we created a surgical and non-surgical patient journey guide which is featured on our website. It gives a step-by-step guide of how to get to us, where to park, and what to consider, in order to resolve any uncertainty. Interaction Each time there is interaction with a patient, be it digitally, via email, telephone, letter or personally, it triggers a touch point. Each one should be considered carefully, ensuring that clarity, simplicity, information and business identity have been considered and well represented at all times. In giving patients consistency we nurture their trust, and the patient will feel reassured that they are in safe hands if our message and service remains the same throughout their experience. Any doubt can lead to a lack of confidence and make things difficult. Of course, some patients would prefer to approach the clinic by more traditional methods such as calling or dropping by. My entire team mystery shop other clinics at least once annually with the objective of putting themselves into the patient’s shoes. They look at presentation, information and cleanliness. However, what is more important is that they truly feel what our patients feel. There are some great clinics out there and it is so good to hear when my team return full of inspiration. The exercise is about more than information gathering as it forces the team to examine how they talk to people and react to situations; they also feel the nervous anxiety when they are waiting to explain to someone what they least like about themselves, and how the attitude of those they come into contact with can influence this experience. The ambience in waiting areas varies hugely, and trying to reflect your brand image and showcase your offering whilst creating a comfortable and inviting area can be challenging. Patients can also be waiting a considerable amount of time, so essentials like cleanliness and comfort are basic but vital things to get right in order to avoid a bumpy first meeting. Interaction and information are also

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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key considerations here. We feel it is important that the reception team do not use the reception desk as a barrier. When a patient arrives the receptionist should come around from behind the desk to welcome them, and, if needed, put the patient at ease. They also must ensure they keep patients abreast of any changes, as time is precious to us all. Little touches are always the icing on the cake; they do not have to cost much but do make a huge difference. Detailed follow-up calls, skincare tips, a personal visit from our own surgeon, Mr Karidis, following their surgery – these things all add to the experience. Within our clinic, Mr Karidis sends each of his surgical patients flowers, which are waiting for them in their room when they return from theatre. This is just a small gesture, but one that is always well received. Striving For Improvement Receiving feedback, whether positive or otherwise, is always a blessing. Through our patient satisfaction surveys, we are able to nip dissatisfaction in the bud and formulate plans to make future experiences even better. Making time to listen to our patients is crucial to giving our clinic heart. Although feedback may occasionally not be as positive as you had hoped, it is also a starting point to help you overcome future situations and build upon solid foundations. Any patient dissatisfaction is discussed at our weekly meetings and, as a team, we work out how to resolve them with the best possible outcome for all. One question I have asked my team is to imagine they were considering surgery; what are the questions that they would want to ask, but feel too embarrassed (or too foolish) to ask? Their questions were sometimes personal and sometimes so obvious that we have never addressed them in our patient journey information. Results from these sessions have formed the basis of how we plan to move forward. It is a very good exercise and has really got the team to think like our patients. Clinical Consultation Once a patient gets to the stage of consultation and treatment, Mr Karidis, supported by our clinical and admin teams, works hard to ensure that each detail is addressed and that outcomes are discussed to make sure there are no surprises. Only once the patient has been fully consulted do they meet with an administrator to discuss logistics and pricing. This is a major part of the customer journey and a huge step for each patient, which is why it is absolutely vital that each patient meets Mr Karidis so he can assess and advise them as individuals, based on his knowledge and experience. Patients invest a lot in this process, not just financially but also with trust, with the added potential of exposing a plethora of feelings including guilt, fear and anxiety. A patient meeting their surgeon and the supporting team with whom they are investing is integral to the journey within our clinic. Results of our mystery shop also allow us to gauge follow up after a consultation. However, there is no industry formula here – we all want patients to feel cared for, but not harassed. In our experience, many clinics do not appear to follow up at all. From their mystery shops, members of my team reported that they liked a clinic who sent a well constructed personal email which thanked them for coming and sign-posted that a call would be made in a week’s time to discuss matters further, but that also gave an option to decline this call. This ensures there are no surprises and that patients have the choice to opt out easily. Following their procedures, our clinic has many patients who want to share their positive results with others. What is fantastic for us is that these people become ambassadors for our clinic and at prearranged times will talk to prospective patients, with a view to providing reassurance and answering any questions they might have.

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Moving On Keeping in touch with our patients is key to the success of our business. The team are instrumental in how often people are contacted and, again, this can be through various methods including social media, online forums, newsletters and emails to keep people informed. One of our main ways to engage with patients is through our events and gatherings. We host information evenings for our patients and potential patients with speakers well-established in the aesthetic field to discuss topics and treatments, and to answer any questions. Mr Karidis is always on hand at these events to offer new, insightful information, but, most importantly, will utilise the opportunity to interact with each attendee. We believe this is vital to help people see that he respects and understands how important these social events are, as well as the private consultation. We strive to ensure that our events offer an ‘open door’ policy; where nothing is hidden from attendees who wish to learn more. Participation and excellent communication make the journey through our clinic smoother for the patient. Keeping patients informed and making them feel comfortable and reassured at every point, increasing their confidence in the practice and allowing them to break down their barriers and communicate effectively is key. Surveying our patients about what they like and getting them involved in our future choices and the way we do things has formed a huge part of our plans for 2015, and will be evident in the direction our business takes in the coming years. Our goal is to continue to make it easy for people to glean all the information that they need for making informed decisions, with a very good idea of the agreed potential outcome. With increasing demands and ever changing expectations there will always be room for improvement, however by actively engaging our team and keeping things simple, approachable and accessible, the patient journey becomes a harmonious experience for all. In Practice “Surgery is a big step for most people, and making this decision is associated with a host of different emotions, such as fear and anxiety. We always try to reassure patients as best we can, keeping open channels of communication even after the consultation, so in the event of any uncertainty they can quickly get their questions answered. We hope that this all leads to a very reassured atmosphere for the patient, which makes them feel safe in our hands. When armed with proper information, patients can make a properly informed decision about whether or not surgery is for them. From the moment a patient begins to contemplate possible surgery, that’s when the journey begins. We as a practice and collective team have the ability to favourably influence this patient journey at various points in order to make it as seamless, painless and comfortable as possible. If we can end that journey with a happy and satisfied patient, then we can consider that we have done our job well. Many return for other treatments, and this is a testament to our skills in being able to offer a great patient journey, which in turn gives our team great job satisfaction.” Mr Alex Karidis, founder of Karidis Cosmetic Surgery London Deborah Vine is director of operations at Karidis. She has a wealth of experience creating comfortable environments for people to recognise and achieve their personal goals. With a career spanning across a plethora of industries and high profile brands, Deborah has worked to develop a deep understanding of the emotional decision-making process.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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Social Media Etiquette Paul Jackson aims to eliminate the possibility of committing a social media faux pas with his guide to communicating concisely and effectively online Social media is forming an increasingly important part of aesthetics clinics’ marketing and customer relations. It is a valuable way to convey your personality, to converse and increase awareness of your services with potential and existing patients, as well as to encourage feedback and word of mouth recommendations. With so many businesses seeing the potential of social media, there is a great deal of competition in terms of clinics vying for patients’ attention. Social media users are therefore becoming more and more picky about who they follow and who they engage with online. So whilst social media presents huge opportunities to build and interact with your audience, it can also be a swift way of alienating them if you’re not doing it effectively. In everyday face-to-face interactions if somebody is self-centred, waffling, moaning, talking too much, or talking about things you’re not interested in, you’re unlikely to give them too much of your time, and it’s exactly the same scenario online. Establishing good social media etiquette is crucial, and falling short in this respect can cause you to lose followers faster than you are gaining them. This article aims to ensure that you are not only meeting expectations, but standing out as a glowing example of how to behave and succeed on social media. It’s Not About You A common misconception regarding social media is that it is a platform for voicing your thoughts, detailing the events of your dayto-day life, and promoting your products and services. This is what a large proportion of businesses on social media are doing, but this completely disregards its ‘social’ element. Instead, think of social media as a platform for engaging with your audience, learning about them, and offering them genuinely valuable content and insights. It’s all about your target audience and what they want to read about or view. A good rule to follow is the 80:20 rule – for every two posts that are directly about you or your businesses, eight should not be and should instead be conversing directly with people, providing useful resources, or commenting on relevant topics. Pace Yourself We all want our posts and content to be seen by our audience, and the more we post, the more visible we’ll be. However, over-posting

on social media is one of main reasons that social media users stop following or engaging with people or businesses.1 A clever trick to use here is to determine the days of the week and the times of the day that your social media posts are generally seen the most and receive the best response. Facebook, Twitter and Pinterest all make this data available to you for free via their analytics sections, and free online tools such as Hootsuite and Pagemodo can be used to help you schedule your posting on other social media sites. Use your analytics data to schedule your posts for these times, keeping in mind that quality always beats quantity on social media. Through analysing this data you will also learn about your audience and you’ll start to see trends developing. For example, from my experience of the aesthetics industry, it is common to see social media engagement peaking at lunchtime, during end of school time whilst people are waiting to pick up their children, and in the early evening when people might be making their train journeys home, as well as later in the evening (perhaps when people are browsing online in bed). It’s Not What You Said… As well as considering what to say and when to say it, tone of voice is critical to your social media success. One of the limitations of communicating online is that it can be difficult to understand the intended tone of a post, and tone can often be misinterpreted. Take time to determine exactly how you want to be perceived. As an aesthetic clinic or practitioner you are likely to want to come across as friendly and approachable, understanding and caring, and knowledgeable and trustworthy. This can go a long way to securing your first bookings from potential customers, or further bookings from existing customers. Think about whether your post could be misinterpreted, especially if you are making a light-hearted comment, and take steps to make the intent clear. Knowing Where to Draw the Line There have been a number of well-publicised news stories of incidents where people have said things they shouldn’t have on social media, such as celebrities commenting on stories that were under superinjunctions.2 In the aesthetics industry, two potential minefields are

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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patient confidentiality and giving medical advice online. In the informal and conversational setting of social media it can be easy to feel like you are in ‘off the record’ discussions, but professionalism and ethics should always be at the forefront of your mind. Whether it’s a quick mention of a celebrity patient who has just been in for an appointment, or making treatment or procedure recommendations without a face-to-face consultation, give these topics a wide berth and err on the side of caution when in doubt. Social media is also a place to show sensitivity and awareness. Many people who are considering an aesthetic treatment, and even those who have them regularly, are shy, embarrassed or wary about publicising that fact. Following and initiating contact with your patient and customers online can bring the relationship to the attention of others when they would prefer it was kept private. Instead, encourage them as much as possible to follow and contact you via messaging on your website, in emails, in your clinic and in person.

and schedule posts in advance, such as the ones mentioned previously. These tools typically offer you the option to type out a post and then send it out across all your different social media profiles in one go. Despite being an effective time-saver in many cases, bear in mind that different types of posts and different wording are more effective on different social media sites. For example, short and snappy posts typically perform well on Twitter, whilst image posts tend to perform strongest on Google+, and more insightful and professional content is usually better on LinkedIn. A less formal approach normally has greater appeal on Facebook.3 Social media management tools are a valuable asset and allow you to save time and improve the quality of your activity – the key is to remember to keep tailoring and personalising what you are doing. It’s better to focus on hitting the mark on one social media channel than missing it on several channels.

Professional vs Personal Another area where social media’s blurred lines can limit your success is when it comes to deciding whether you are posting personal or professional content, and this is a particularly tricky issue in aesthetics. Many clinics and practices are built on the skills, reputation and brand of an individual, whilst some practitioners are connected with multiple clinics or practices. When people decide to follow a clinic or a professional they don’t expect to see posts that are far removed from the aesthetics industry. On sites such as Twitter, it is better to have a professional or clinic profile and a separate personal profile in order to separate the two and ensure the right types of content are being posted on each.

Avoid the Hard Sell At the end of the day, businesses and professionals are using social media to build or retain their patient base, or to achieve other goals that will contribute to that, such as building their reputation, status and visibility. Social media really is a marathon and not a sprint so it is important to avoid jumping to the end goal, whether that is convincing a new patient to book a consultation or generating repeat business from an existing customer. In a faceto-face meeting, it would be too abrupt to meet somebody for the first time and to start pushing your products and services to them, and the same applies on social media. Play the long game, build a relationship, get to know your audience, let them get to know you and trust you, and naturally they will make their decisions about you and your services. Sure, you can help them along the way, but continually painting the best picture of yourself and your business is the key, rather than promoting a sales pitch.

Speak Their Language Your target audience is likely to have a range of knowledge levels, from those who are new to aesthetic treatments through to those who have experience of a range of procedures. In technical and medical industries it is easy to fall into the trap of using acronyms, niche phrases and little-known brand names in your social media content. If a user does not understand your posts, they are unlikely to engage with you or share the post. It also gives the impression that your business is not in sync with customer needs. Keep in mind that your target audience is not likely to consist of other aesthetic professionals, so post content that will appeal to your potential and existing customers, rather than other people in the industry. #Overuse #of #Hashtags There are numerous bad habits that you’ll come across online, and overuse of hashtags is a common sight along with people creating their own hashtags unnecessarily. Hashtags are designed for categorising social media posts. If somebody is interested in a certain topic, a certain news story, or a certain person, hashtags allow them to see all the posts that related to what they are interested in. My recommendation would be to have no more than two hashtags in a post. When deciding on a hashtag to use, consider what it is that people will be searching for when they might like to see your post. When a post has too many hashtags it suggests that there is no real value in the post itself and it can cause them to be overlooked and ignored. Be Wary of Shortcuts There is an array of free and premium social media tools available online to help you to manage your social media presence

The Key Takeaways Meeting and exceeding expectations for social media etiquette essentially boils down to a very simple set of considerations. • It’s not about you or what you are interested in talking about, it’s about your audience and what they are interested in you talking about. • Before posting anything on social media sites, ask yourself: should I be posting this, who would want to see this post, what value does it offer them, and what response do I want? • Social media is just like an offline conversation or friendship. Nobody wants to stay and talk to the person who talks too much and only about themselves, so be the listener, the helper, the expert – the person everyone wants to talk to. Paul Jackson is senior marketing consultant at Reload Digital and specialises in social media and online marketing for the aesthetics, beauty, cosmetics and fashion industries. As a chartered marketer and Google certified partner, Paul can be seen speaking at marketing events across the country. REFERENCES 1. Carr, D, Why do people unfollow you on Twitter (www.marketingtechblog.com, 2012) <www.marketingtechblog.com/twitter-unfollow/> 2. BBC News, Alan Davies pays Lord McAlpine damages over tweet (UK, www.bbc.co.uk, 2013) <http://www.bbc.co.uk/news/uk-24654289> 3. Betancourt, L, How to optimise content for social media (engage.scribblelive.com, 2014) <http://engage.scribblelive.com/Article/704594-How-to-Optimize-Content-for-Social-Media)>

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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“You are never too good or too old to learn something new” Beverly Hills dermatologist Dr Zein Obagi has been an outspoken figure in the skincare world for more than three decades. Wendy Lewis talks to him about his considerable achievements in skin health Researcher, lecturer, author and board-certified dermatologist, Dr Zein Obagi is considered by many to be a pioneer in advanced skincare, and one who has broken new ground at every stage of his career. His innovations in pigmentation disorders and chemical peels in particular are widely respected throughout the specialty. Dr Obagi’s interest in skin health began early on. He took a circuitous route into dermatology, having started out as a pathologist dealing with diseased tissues. “I found my true calling when I embraced dermatology as my specialty,” he says. “A baby’s skin always fascinated me. Microscopically, each cell is fulfilling its precise function, which corresponds to its flawless appearance. As a physician, I wanted to offer this possibility to all patients. The fundamental principle driving my approach is that skin must be holistically restored at the cellular level. If the focus is limited to treating only the disease or its symptoms, the results will be limited and short-lived,” he says. In 1983, Dr Obagi was instrumental in pioneering the concept of skin health for the mass market, and developed a line of medical skincare products – the original Obagi Nu-Derm System – that aimed to transform ageing skin. Of that time, he says, “My intention was to challenge the norms of traditional skincare.” His goal was to take the confusion out of skincare for patients by maintaining the stature of physicians, nurses and aestheticians as the true skin care experts. “Who better to know how to maintain healthy skin and treat disease?” he asserts. Today many of his ideas about skin health have become mainstream. Dr Obagi founded the Obagi Skin Health Institute in Beverly Hills in 1985 as a comprehensive dermatology practice exclusively dedicated to advanced skin treatments, where he still sees patients from all over the world. The Institute has since expanded to three additional locations; Laguna Niguel, San Gabriel and Pasadena, California. The trio of Obagi Skin Health Institutes in Southern California are stunningly modern facilities. These state-of-the-art clinics offer a full programme of cosmetic and medical treatments, as well as luxurious spa therapies. After his original company, WorldWide Products, was sold in 2007, he started a new chapter with ZO Skin Health. In keeping with his original vision, ZO markets products exclusively to medical professionals in more than 100 countries. In fact, the company is not afraid to target any business or individual that violates their strict anti-diversion policy. A high functioning integrated team has been crucial to the success of ZO Skin Health, and under the direction of CEO Jim Headley, the ZO Skin Health brand has flourished Dr Obagi serves as the ZO Skin Health, Inc. medical director, where he drives the development of new products, protocols and treatments. “I make sure that each new formulation delivers the level of results our physician partners have come to expect and that their patients want,” he says. 2014 was a significant year for Dr Obagi, with the launch of the second edition of his original best selling textbook,

The Art of Skin Health Restoration and Rejuvenation: The Science of Clinical Practice. To carry on his legacy, he has handpicked a special group of physicians from the US and all over the world to join the ZO Faculty. This elite group of skincare experts, including plastic surgeons, dermatologists and cosmetic doctors, lecture and conduct research on skin health, based on Dr Obagi’s experience and teachings. In May 2015, the first of many planned ZO Skin Centres opened in the Fashion Island shopping centre in Newport Beach, California. The model, which is the culmination of his vision, incorporates all of Dr Obagi’s current thinking about skin health and features an integrated offering of facials, peels, and advanced antiageing treatments with his signature products. Despite all of his major achievements, for Dr Obagi family will always come first, having raised nine children with his partner Samar. Now in his seventh decade, Dr Obagi has the energy and sharp intellect of a man half his age, and shows no signs of slowing down. What is your core philosophy for educating healthcare professionals? I want to get the message across that skin health restoration can’t be accomplished by products alone; the physician needs to know how to use them in the most effective way, through stepby-step treatment protocols. What is the biggest mistake patients make with their skin? They get bad advice, use the wrong products, and over moisturise their skin which makes the skin weaker instead of strengthening the skin. The skin cells get lazy and it actually makes them look older. When they come to us, we take them off moisturisers and put them on a regimen of products to restore skin health. Who is the driving force behind your great success? Without a doubt, my wonderful wife Samar is my biggest fan. She is a very talented businesswoman and has helped me exceed my potential. She runs the business side of Obagi Skin Health Institutes, and oversees public relations and marketing, among other ventures. I don’t know how she does it all. What is the best advice you can offer practitioners today? To not just accept the status quo. Challenge yourself, do your own research, experimentation, and clinical studies. You are never too good or too old to learn something new. Wendy Lewis president of Wendy Lewis & Co, a global aesthetic consultancy business. Lewis is an international figure in the field of medical aesthetics, and is a frequent presenter at international conferences. In 2008, she founded Beautyinthebag.com and serves as editor in chief.

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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The Last Word Dr Sam Robson argues for greater clarity in the use of professional titles What’s in a name? Does it matter what we call ourselves when it comes to our patients? I think it does. Aesthetic medicine can provide an important medical service to patients, having a positive impact on their self-esteem and quality of life. Our job title will convey a certain sense of experience, expertise and ability to both prospective and current patients. The field is already considered to be a slightly grey area ethically. As it comprises completely private medicine, it could be considered by some to be exploiting patients’ desperation for remedies to treat their aesthetic concerns, or even perhaps of selling ‘snake oil’ – a term used to describe fraudulent health products or, more likely in our case, unproven medicine. To improve this negative association, practitioners should strive to put patient care above financial gain. To this end, it is imperative that practitioners portray their capabilities and qualifications honestly to the public and their patients. In 2015, the Care Quality Commission (CQC) published an update to its Regulation of Candour which stated that, ‘Providers [of healthcare] must promote a culture that encourages candour, openness and honesty at all levels. This should be an integral part of a culture of safety that supports organisational and personal learning.’ Surely we should be advocating this culture in our medical aesthetic clinics and complying with the CQC’s notion of openness and honesty? Across the board, however, individuals claim to be “advanced” practitioners and yet where is the evidence from their practice? To my mind, at every step of our interaction with patients we must be open and credible in how we present ourselves. Simply put, we should first declare whether we are surgeons, doctors, dentists or nurses and stand behind the recommendations that only practitioners with the appropriate qualifications be permitted to perform aesthetic treatments. We should then be clear on our individual claims within each of these four practitioner categories. I have some concerns, however, about how individual practitioners prefer to portray themselves:

Surely it is a fundamental expectation to be honest from the outset about who we actually are and our true level of qualifications and expertise

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Surgeons Under this title practitioners should obviously be surgically trained and have completed specialist training, and therefore be on the GMC specialist register. Each individual is in no doubt as to whether or not they fulfil this criterion. Within the individual professions, we understand the significance of being on the GMC register as a doctor, and take this to be a mark of excellence, having achieved a certificate of completion. If we are not surgically trained or have not completed our training, however, should we be calling ourselves a plastic surgeon, aesthetic surgeon or an ENT surgeon? To me, the answer is a clear no – and I believe that only those who have received their FRCS (Plast) status should be referred to as plastic surgeons. The lay public may presume that we have a level of expertise and seniority that we have not actually earned. Is it really appropriate to allow a perception that we are more qualified than we are? Should we be undertaking facial cosmetic surgery procedures if our expertise is in orthopaedics – unless, of course, we have formal qualifications, experience and certification in these areas? Doctors Are we General Practitioners (GPs) or General Practitioners with Special Interest (GPwSI)? Should we use the term dermatologist if we do not have a certificate of completion of training in dermatology? Although cosmetic dermatology is recognised as a sub specialty within dermatology,1 as far as I am aware there is no real qualification of ‘cosmetic dermatologist’ and yet so many doctors with no formal qualification in dermatology claim this title. Would it not be more transparent to declare ourselves as GPs with an interest and some expertise in cosmetic dermatology? (Although bear in mind the scope of this is yet to be defined.)1 Dentists Unless a dentist has a medical qualification too, should they be calling themselves a ‘doctor’? It would appear that many dentists still call themselves ‘doctor’, despite patients being confused by this and even expressing in blogs a desire to have some clarity.2,3 In 2010, the General Dental Council (GDC) published a report on patient and public attitudes to standards for dental professionals.4 It stated that, “The current GDC proposal is that the use of the term ‘doctor’ (or the abbreviation Dr) by dentists should be limited to practitioners who have a PhD or who are medically qualified and registered doctors. The document continued, “It is against the law, for a dentist or DCP to use any title or description ‘reasonably calculated’ to suggest that (s)he has a professional status or qualification other than one which is indicated against his/her name in the register; however, cases alleging misuse of titles, descriptions or qualifications by dentists or DCPs can be dealt with through GDC fitness to practise investigatory/ disciplinary processes.” The document further stated

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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that, ‘Dentists and practices should not advertise themselves as specialists where no such specialist list exists.’5 Despite these points, it seems many dentists continue to use the term ‘doctor’, which, in my opinion, has the potential to confuse and mislead patients. Nurses There seems to be many varieties of nurses practising aesthetics; my understanding is that there are aesthetic nurses, independent nurse prescribers, nurse practitioners, advanced nurse practitioners (ANPs) and aesthetic nurse specialists. There are nurses who call themselves ‘medical directors’, which, to me, suggests they are portraying themselves as doctors. Apart from independent nurse prescribers and ANPs, none of these titles require different or additional qualifications to one another and are merely selfappointed titles. Nurse prescribers are an exception as they do require a prescribing qualification, however, this does not indicate that a nurse is aesthetically trained – just that he or she has completed a prescribing course.6 In 2007, the Nursing and Midwifery Council (NMC) explained that the plethora of titles used by nurses is of concern, as they do not help the public understand the level of care that they can expect. In addition, the Royal College of Nurses stated in 2012 that, “Both the RCN and NMC oppose nurses and/or employers using the title of ANP where a nurse has not completed the appropriate education and preparation.”7 Surely, we should be using one title for all aesthetic nurses or setting levels of qualification where their title will change upon completion? It is confusing enough for those of us within the profession to decipher any level

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of expertise, qualification or experience – without bamboozling the layman with a cacophony of terms designed to impress as well. Is it not a fundamental expectation to be honest from the outset about who we actually are and our true level of qualifications and expertise, before we subject a potentially vulnerable patient to aesthetic treatment? We should be aiming to reassure the public that not only are we transparent about our ability and level of expertise; we are also aware of our limitations and will ultimately put the care of our patients first. I believe that the job titles that we claim for ourselves are the first step in establishing ourselves as a credible and trustworthy body of professionals. Dr Sam Robson trained as a GP before beginning her career in aesthetics in 2004. She is the medical director of Temple Medical in Aberdeen, an appraiser for the British College of Aesthetic Medicine and a voluntary medical advisor for the Royal National Lifeboat Institution. REFERENCES 1. Care Quality Commission, Regulation 20: Duty of Candour, (UK: Care Quality Commission, 2015) <http://www.cqc.org.uk/sites/default/files/20150327_duty_of_candour_guidance_final.pdf> 2. Yusef I et al, A career in dermatology (UK: British Medical Journal, 2010) <http://careers.bmj.com/ careers/advice/view-article.html?id=20001048> 3. Hareyan A, Dentists are not doctors: It’s official now (UK, EmaxHealth, 2008) <http://www. emaxhealth.com/1/79/25802/dentists-are-not-doctors-it-039-s-official-now.html> 4. Jackson L, Surgeon, Doctor, Dentist – are they really who they say they are? (UK, Consulting Room, 2012) <http://www.consultingroom.com/blog/309/surgeon,-doctor,-dentist---are-they- really-who-they-say-they-are?> 5. http://www.gdc-uk.org/Newsandpublications/research/Documents/GDC%20Public%20 Attitudes%20to%20Standards%20for%20Dental%20Professionals.pdf 6. Information available via the British Association of Cosmetic Nurse 7. Advanced nurse practitioners (UK: Royal College of Nursing, 2012) <https://www.rcn.org.uk/__data/ assets/pdf_file/0003/146478/003207.pdf>

Annual British College of Aesthetic Medicine Conference Registration for the annual BCAM conference is now open!

This year’s event will be held at the Church House Conference Centre on Saturday 26th September 2015 BCAM is the responsible body for aesthetic medicine and manages appraisals for aesthetic doctors. BCAM is essential for you as an aesthetic doctor and so the annual conference on 26th September is not to be missed – be there to ensure you don’t get left behind! This year’s rich lineup includes speakers from the cutting edge of aesthetic medicine including Mr Rajiv Grover, Dr Nick Lowe, Mr Paul Banwell, and Dr Ravi Jain. Our conferences are always educational, informative and inspiring; an event where you can acquire new knowledge and expand your development whilst networking with colleagues.

Register via the events page on our brand new website www.bcam.ac.uk/membership/events NETWORKING SESSIONS WITH YOUR COLLEAGUES FUN CHAMPAGNE RECEPTION BOOK YOUR PLACE TODAY

Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015


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EMERVEL – MORE CHOICE AND CONFIDENCE IN MID-FACE FILLER SOLUTIONS Volume is key to maintain facial balance and restore the faces natural contours. Emervel has gel textures especially designed for lifting capacity and volume restoration, optimised especially for the mid-face regions.

EMERVEL DEEP FOR SHAPE REDEFINITION

EMERVEL VOLUME FOR VOLUME RESTORATION

Emervel Deep for patients who require mid-face shape redefinition due to flat zygomatic bones or mild-to-moderate facial asymmetry.

Emervel Volume for patients who require midface volume restoration due to volume loss caused by ageing.

INTRODUCING EMERVEL VOLUME 1ML SMOOTHER FLOW • Optimized gel texture: Homogenous gel particle calibration enables smooth and regular extrusion • 27 G Ultra-thin-wall needles improve flow rate and reduce extrusion force

GREATER WORKING COMFORT • Lightweight, ergonomic syringe for more comfortable handling • Lower extrusion force for reduced fatigue

OPTIMISED CHOICE • Emervel Volume available in 1ml or 2ml - Your choice of comfort and flexibility depending on your patients’ needs.

Galderma (UK) Ltd Meridien House, 69-71 Clarendon Road, Watford, Hertfordshire WD17 1DS Tel: 01923 208950 Email: info.uk@galderma.com For more information visit www.galderma-alliance.co.uk EME/030/0714 Date of prep: July 2014

You can sign up to receive email & text message alerts through Galderma (UK) Ltd’s A&C subscription service for Healthcare Professionals and Non-Medical Aesthetic Clinic Staff.  Scan here, or visit www.galderma-mail.co.uk


Experience all the benefits of VYCROSSâ&#x201E;˘ technology. Treat various areas of the face using only 3 products. Itâ&#x20AC;&#x2122;s that versatile.

Instructions and directions for use are available on request. Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK Date of Preparation: August 2014 UK/0880/2014


Aesthetics July 2015