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VOLUME 5/ISSUE 8 - JULY 2018

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Characteristics of HA Fillers CPD Dr Souphiyeh Samizadeh discusses the characteristics of hyaluronic acid fillers

Special Feature: Marketing Injectables

Professionals explore marketing strategies for injectable procedures

Volumising the Face Using PRF

Dr Vincent Wong and Dr Maria Toncheva detail the combination of PRP and PRF

Presenting Skills

Public speakers and trainers share their top tips for being a good presenter


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Contents • July 2018 06 News The latest product and industry news 14 On the Scene

Out and about in the specialty

16 BAS Annual Conference

Aesthetics reports on the British Association of Sclerotherapists’ Annual Conference

19 News Special: Attitudes to Ageing Aesthetics explores the results of a new survey on perceptions of ageing

Special Feature Marketing Injectables Page 23

CLINICAL PRACTICE 23 Special Feature: Marketing Injectables Professionals share advice on how to avoid the pitfalls of regulatory

non-compliance for marketing injectables

29 CPD: Characteristics of HA Dermal Fillers

Dr Souphiyeh Samizadeh explains the characteristics of hyaluronic acid fillers to aid product selection

32 Advertorial: Introducing Cellfina

An introduction to the minimally-invasive cellulite treatment

34 Spotlight On: Calecim Professional

Aesthetics examines a new skincare range containing umbilical cord lining stem cells

36 Case Study: Dissolving Dermal Filler in the Lips

Aesthetic nurse prescriber Kay Greveson explains how she used hyaluronidase to dissolve a patient’s lip filler

39 Introducing Psychodermatology

Dr Alia Ahmed outlines psychodermatology and its use in an aesthetic clinic

43 Volumising the Face Using PRF

Dr Vincent Wong and Dr Maria Toncheva discuss the combination of PRP and PRF as an alternative to dermal fillers

49 Treating a Cleft Chin

Dr Gabriel Siquier Dameto explores the various treatment methods for a cleft chin

53 Minor Surgery in an Aesthetic Clinic

Dr Ruth Harker provides her advice on minor surgery in aesthetic practice

58 Advertorial: Managing Summer Skin Concerns

Addressing hyperpigmentation with SkinCeuticals Pigment Balancing Peel

59 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 60 Presenting Skills

Public speakers and trainers in the specialty share their top tips for being a good presenter

64 Mobile-optimised Websites

Adam Hampson discusses how to ensure the best user experience for mobile-optimised websites

67 In Profile: Anna Baker

Aesthetic nurse prescriber Anna Baker talks about her passion for learning and what she loves most about the specialty

68 Last Word: Pathway into Aesthetics

Miss Mayoni Gooneratne highlights the trend for newly-qualified medical practitioners entering aesthetics

NEXT MONTH

In Practice Mobile-optimised Websites Page 64

Clinical Contributors Dr Souphiyeh Samizadeh is the founder of the Great British Academy of Aesthetic Medicine and the clinical director of Revivify London clinic. She is an honorary clinical teacher at King’s College London and Queen Mary University of London. Kay Greveson is an award-winning aesthetic nurse prescriber with 14 years’ experience. She is the owner of Regents Park Aesthetics and splits her time between working in the NHS and running her clinic. Dr Alia Ahmed is a consultant dermatologist working for Frimley Health NHS Trust. She graduated from St Bartholomew’s Hospital and the Royal London School of Medicine in 2008 and completed her dermatology training in London, becoming a consultant in 2017. Dr Vincent Wong is an award-winning aesthetic practitioner at the Bader Medical Institute of London. Dr Wong runs regular training courses and workshops for healthcare professionals and mentors junior colleagues. Dr Maria Toncheva specialised in dermatology after graduating as a doctor and now practises in the US, UK and Bulgaria. Dr Toncheva has developed and pioneered a protocol for combining PRP and PRF as an alternative to dermal fillers. Dr Gabriel Siquier Dameto is the founder of Dameto Clinics International and an instructor of the International Threads Academy. He is also a certified member of the Dutch Society of Aesthetic Medicine. Dr Ruth Harker is the conference and finance director for the British College of Aesthetic Medicine. She has been a GP with special interest in dermatology, as well as a dermatology hospital practitioner performing minor surgery for many years.

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Editor’s letter Welcome to the latest issue of the best aesthetics publication in the UK! We have some great articles for you to read this month; whether you are in your clinic, on the beach or relaxing anywhere in the world! The focus is Amanda Cameron on injectables, and whilst we now have many Editor technologies and new products coming onto the market, injectables still make up the bulk of medical aesthetic procedures. They deliver effective results with little downtime, in the right hands, and are the life blood of most clinics. As such, we have a fabulous CPD article by Dr Souphiyeh Samizadeh for you to read on p.29, which provides an overview of dermal fillers and explains in detail the differences in the properties and manufacturing of widely-used products. You may know a lot already, but there is always something new to learn, especially when it comes to cross-linking and rheology. How should injectables be marketed? We take a look at the what to

do and what not to do when promoting injectables to your potential patients in our Special Feature on p.23. We ask what are the rules, how do you best promote yourself and how do you get the results you need legally and safely? In addition, digital marketing consultant Adam Hampson looks at how to optimise your website for use with mobile devices; with some very useful tips here on p.64! Being a good practitioner is one thing, but being a good speaker is another! Just because we can do something, it does not mean it is simple to speak about it – some people are naturals and others have to work at it. We have an article on how you can improve your presenting skills with advice from some well-known practitioners in the specialty on p.60. My favourite articles this month are the fascinating psychodermatology piece by Dr Alia Ahmed on p.39 and the Last Word on p.68, which offers some interesting thoughts on newly-qualified practitioners entering aesthetics by Miss Mayoni Gooneratne. All-in-all a great read this month – enjoy!

Editorial advisory board

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

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

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. She is a registered university mentor in cosmetic medicine and currently a second year student on the Northumbria University Masters course in non-surgical cosmetic interventions. Bennett has been developing her practice in aesthetics for 25 years.

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

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

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

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

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

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

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

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Training

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #ProfessionalWomen Sabrina Shah-Desai @perfecteyesltd This week I was empowered spending time with some amazing female role models who educate and light up a scientific conference with their knowledge, passion and support #ILookLikeASurgeon #WomenWhoTeach #ProfessionalWomen #WomenSupportingWomen #Sunscreen Skin Cancer Foundation @SkinCancerOrg The terms ‘water-resistant’ and ‘sweat-resistant’ indicate whether a sunscreen remains effective for 40 minutes or 80 minutes when you are swimming or sweating. Since no sunscreen is fully ‘waterproof’ or ‘sweatproof’, the FDA prohibits these terms. #Conference Dr Uliana Gout @UlianaGout Loved lecturing on fillers for lips and hands in Japan - #JAAM2018 Conference! #Education #Osaka #Japan #Motivation #Safety DHAesthetic Training @mdhtraining @mdhtraining are proud of our lead tutor @pdsurgery for co-authoring the #ConsensusGuideline on #blindness just published in the Journal of Cosmetic Dermatology #Safety #Complications #ExpertAuthors #PublishedAuthors #Shelfie Dr Mayoni @drmayoni_clinic What’s on your shelfie? Look at all the loveliness on ours including our @aestheticsgroup commendation! #DrMayoni #TheClinic #MedicalSkincare #London #PlasticSurgery Nora Nugent @NugentNora The @BAAPSMedia team at @CongresSofcep in Lyon! #PlasticSurgery #Aesthetics #AestheticSurgery

Cosmetic Courses to move premises Aesthetic training provider Cosmetic Courses is moving its premises to a larger, bespoke clinic in Princes Risborough, Buckinghamshire. According to the company, the new premises will enable Cosmetic Courses to grow further and offer additional training days to new and existing delegates. The new clinic holds six clinic rooms alongside a presentation room and reception area. The company is continuing to offer 21 courses and a Level 7 qualification. Cosmetic Courses claims that moving to a bespoke clinic has meant that the premises are designed and tailored to meet the needs of its models and delegates. Mr Adrian Richards, consultant plastic surgeon and founder of Cosmetic Courses, said, “We are very excited by this move, as a growing company it is something that we’ve needed to do for a number of years. Finding somewhere that we were able to design to meet the needs of our delegates and models has been fantastic and the feedback we have received so far has been great.” Skincare

SkinCeuticals launches new retinols Cosmeceutical company SkinCeuticals has launched two new retinol products, Retinol 0.5 and Retinol 1.0. Retinol 0.5 contains 0.5% pure retinol and Retinol 1.0 contains 1% pure retinol, which is currently the highest concentration that SkinCeuticals offers. According to SkinCeuticals, the new formulations have been developed to enhance the appearance of the skin by reducing the appearance of wrinkles, age spots, fine lines and blemishes. The company recommends that Retinol 1.0 is used as an advanced treatment for photo-damaged and problematic skin on patients who have previously used a lower level retinol. The new formulas contain botanical actives which aim to lessen inflammation associated with the use of some retinols. SkinCeuticals advises the products should be introduced gradually into patients’ skincare routines, beginning with once or twice a week, working up to every other night and then each evening. Speaking about the new products at the Aesthetics Conference and Exhibition, aesthetic practitioner Dr Uliana Gout, founder of London Aesthetic Medicine Clinic and Academy, said, “Retinols can help to stimulate cellular turnover and collagen production; they are great wrinkle treatments. Suitable for use on face and body, retinols can form an essential component of pre- and post-procedural at-home advanced skincare to ensure optimum in-clinic treatment results and ongoing skin health benefits.”

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Events diary 21st September 2018 International Association for Prevention of Complications in Aesthetic Medicine Symposium, London www.iapcam.co.uk

22nd September 2018 British College of Aesthetic Medicine Annual Conference 2018, London www.bcam.ac.uk

4th – 5th October 2018 British Association of Aesthetic Plastic Surgeons Annual International Conference, London www.baaps.org.uk

8th – 9th November 2018 British Association of Cosmetic Nurses Autumn Aesthetic Conference, Birmingham www.bacn.org.uk

1st December 2018 The Aesthetics Awards 2018, London www.aestheticsawards.com

Fat reduction

3D-lipo Ltd introduces 3D-HIFU

Aesthetics

Distribution

Med-fx to distribute in Ireland From this month Med-fx will distribute up to 200 products, including fillers and toxins, to customers within Ireland. This announcement is a result of a new partnership with Ireland-based dental supplier BF Mulholland Ltd, something which Med-fx states will now enable them to ‘provide a premium service to the Irish market’. David Tweedale, head of Med-fx, explained, “The stock will be kept locally, meaning that we will be able to offer a range of benefits such as next day delivery on all qualifying orders and the ability for customers to shop for essential consumable products all in one location at the time of order.” He added, “This is another step to show that being able to deliver a premium service to our customers is important to us and over the coming months we will continue to add new resources and additions to our offering to make sure that the standard we aspire to deliver is achieved.” Appointment

Enhance Insurance hires new team member Sarah-Jayne Senior has joined the Enhance Insurance team as account handler. Senior has experience working within the aesthetic sector and is currently studying for her Certificate in Insurance qualification. Her main responsibilities will be supporting the existing team with the day-to-day management of existing clients, as well as building relationships with potential new clients. Business development executive, Sharon Allen said of the appointment, “Sarah-Jayne is a fantastic and valued addition to the Enhance team. She has more than four years’ experience in medical malpractice and brings with her a wealth of knowledge. In the short time that SarahJayne has been with us she has demonstrated her commitment to customer service and eagerness to continue to develop her knowledge of the industry and products. We are very pleased to have her on board.” Skincare

Aesthetic device manufacturer 3D-lipo has launched its latest skin lifting and fat reduction device, the 3D-HIFU. The non-surgical, dual combination platform for skin lifting and targeted fat reduction uses high intensity focused ultrasound (HIFU) technology to treat face and body concerns. According to 3D-lipo, HIFU is a safe and effective non-surgical technology that improves the appearance of fine lines and wrinkles. The highlyfocused acoustic energy does this by creating a wound-healing response, which results in the formation of new collagen, the company claims. The device can be used on the face to perform brow and jowl-line lifting, nasolabial fold reduction and overall skin tightening. For body sculpting, 3D-lipo claims that the focused energy from the 3D-HIFU device penetrates into the targeted fat tissue and noninvasively destroys the subcutaneous fat. According to 3D-lipo, the benefits of this are faster treatment times and no downtime.

Profhilo Haenkenium launches IBSA Italia has added a new topical product to its offering; Profhilo Haenkenium. The product combines hyaluronic acid (HA) complex with salvia haenkei patented extract, Haenkenium, which aims to provide an antioxidant effect, protect the skin form premature ageing, contrast photoageing, restore barrier function and skin hydration and alleviate skin irritation. According to IBSA Italia, it combines two different molecular weights; the high molecular weight HA creating a protective effect and the low molecular weight contributing to optimal skin hydration. The salvia haenkei, also known as prawn sage, helps to provide protection from free radicals, the company claims. IBSA Italia also states that the product is suitable for use after aesthetic treatments including bioremodelling, dermal fillers and peels and can be incorporated into a patient’s everyday skincare routine. Iveta Vinklerova, sales and marketing director said, “This new discovery may have a bright future in both beauty and medicine. Clinical research revealed prawn sage extract’s ability to slow down cellular ageing.” HA-Derma is the exclusive distributor for the UK and Ireland. Profhilo Haenkenium will be available from October 2018.

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Vital Statistics Out of 1,000 people interviewed aged 15-19, 51% said social media makes having acne harder

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Eczema

Epionce announces new eczema relief cream Skincare company Epionce has launched the Renewal Calming Cream aiming to restore hydration to the skin barrier and relieve symptoms associated with eczema and dry skin. In a study where 22 subjects suffering from moderate or severe eczema were treated three times daily, Epionce claims the product reduced itching by 81%. The cream is designed to soothe and calm the skin as it is formulated with colloidal oatmeal. The product can be used on the face or body and is paraben and fragrance-free. The Renewal Calming Cream is supplied by aesthetic distributor and training provider Eden Aesthetics.

(Cutanea Life Sciences, 2017)

Injectable sales increased by 5% in the US in 2017 and have risen by 40% over the past five years (ASAPS, 2017)

Aesthetics Journal

Genetics

Out of 89 brands studied, Instagram stories were used twice as often as Snapchat stories for marketing (Adweek, 2017)

The popularity of blepharoplasty has increased in the US by 26% from 2017 (ASAPS, 2018)

Global mobile video ad spending grew 142% in the second quarter of 2017, making video the fastest-growing ad format (Smaato, 2017)

In a US study of 40,000 people, 35% of millennials were active to a healthy level, while a quarter remained sedentary (Physical Activity Council, 2018)

Study identifies genes that link tanning and skin cancer A recent UK study suggests that there are 20 genetic markers that appear to be linked with tanning of the skin. Six markers have previously been confirmed, however ten of the remaining 14 have never been associated with pigmentation-related phenotypes. This data, the researchers note, could assist in understanding the genetics of skin cancer. The study, which was published in the journal of Nature Communications and led by senior lecturer Dr Mario Falchi, used data taken from the UK Biobank (UKBB) of 176,678 people of European ancestry, making it the largest of its kind, according to the authors. Dr Falchi, amongst the other researchers involved, concluded that, “We identified five novel associations between ease of skin tanning and genes previously suggested to be involved in the melanin synthesis pathway.” He added, “Our analysis showed genetic correlation between nonmelanoma skin cancer and ease of skin tanning in the UKBB data set.” Awards

Attend the Aesthetics Awards With entry now closed for the Aesthetics Awards 2018, those who wish to attend the most prestigious awards night in the aesthetics specialty are encouraged to secure a place by booking individual tickets or tables of 12. On December 1, guests will be part of a dazzling ceremony and treated to a delicious three course meal and live entertainment. Amanda Cameron, editor of the Aesthetics journal said, “The Aesthetics Awards are back and we are ready to reward and recognise leading players in the aesthetic specialty for their hard work, commitment and achievements. It is also the perfect occasion to kick-start the festive season too!” As well as this, a new sponsor has been confirmed for the following category; The IAPCAM Award for Distributor of the Year. The Aesthetics Awards will take place at the Park Plaza Westminster Bridge Hotel in central London. To book, visit www.aestheticsawards.com.

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Radiofrequency

INDIBA Deep Care launches 
 UK distributor Belle is now supplying the Deep Care device by INDIBA to clinics within the UK. INDIBA Deep Care is an electrical transfer radiofrequency device that offers both thermal and sub-thermal effects for cellulite treatments, lipolysis, skin tightening and vaginal rejuvenation treatments, as well as being used to optimise other aesthetic procedures. It targets the cell membrane by activating specific receptors to help repolarise the membrane’s electric potential, according to Belle. The company states that treatment will cause biostimulation without heating or increasing any tissue temperature. According to the company, the technology can be used both pre and post plastic surgery, medical aesthetic treatments, aesthetic gynaecology treatments, and dermatology treatments. “The inclusion of the Deep Care by INDIBA system to Belle’s already strong portfolio of products in both the surgical and medical aesthetic fields will help to place Belle at the forefront of these very competitive markets,” said Ben Sharples, Belle director. Suncare

iS Clinical releases Extreme Protect SPF30 Skincare brand iS Clinical has introduced a new suncare product, the Extreme Protect SPF30. According to the company, the product helps protect against skin damage and repairs solar damage by reducing redness and inflammation associated with sunburn. It also provides broad spectrum UVA and UVB protection, repairs collagen and cell DNA, reduces the appearance of fine lines and wrinkles, provides an antioxidant barrier and hydrates and softens the skin, the company claims. This is, in part, due to Extremozyme technology – exclusive to the company – that helps to protect and repair the skin through the use of specialised enzymes and micro-organisms. iS Clinical Extreme Protect SPF30 is distributed in the UK by Med-fx and Harpar Grace International.

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

BACN AUTUMN AESTHETIC CONFERENCE Now in its 9th year, the BACN Autumn Aesthetic Conference, set to take place on November 8-9, has grown from strength to strength from its humble beginnings. For the first time, the annual conference will be held over two days; with masterclasses, workshops, and an evening dinner reception held on the first day, followed by the traditional day of expert speakers and presentations on the second day. In addition, both days will hold the BACN exhibition area, with a large number of exhibitors already confirmed. This year, the BACN is leading the way in ensuring we have a majority of nurse speakers covering a wide range of topics relevant to nurses working in aesthetics today. This is something that came out of feedback from our previous conference, and also guarantees that we stay relevant to nurses in this ever-changing environment. The full agenda can be found on the conference page of the BACN website and booking is now open, which includes options for discounted hotel/ conference ticket packages.

BACN TASK AND FINISH GROUPS The BACN is looking for a few highly experienced aesthetic nurses, able to research and evidence, and apply best practice, who would be happy to give some voluntary time to the BACN. Those BACN members who are interested can email Sharon Bennett, BACN Chair at chair@bacn. org.uk. In addition, the BACN is also looking for longer-term commitment for educational support, reporting to the BACN Board. Again, those interested can email Sharon to find out more.

BACN REGIONAL MEETINGS

Pre & post procedure

TSK introduces Ice Mask Aesthetic needle manufacturer TSK Laboratory has launched a sheet mask containing an antimicrobial agent (benzalkonium chloride) to disinfect the skin and a cooling agent that aims to desensitise the nerves. The Antimicrobial Ice Mask is designed to be used both pre and post procedure. TSK Laboratory explains that using the product before an injection treatment will disinfect the skin whilst following the procedure it works to reduce the risk of bruising and infection. Marketing manager, Pieter Versteeg said, “The antimicrobial benzalkonium chloride disinfects the skin, while the Ice Mask cooling method relaxes and reduces sensitivity of the facial nerve sensors to pain.” 

Following on from the success of the Spring/ Summer round of BACN meetings, the next round will be taking place in September/October throughout the UK. There are a fantastic selection of sponsors, demonstrations and expert speakers, with all meetings also providing CPD points. For more information go to the events page of the BACN website or contact Tara Glover, BACN Events Manager. This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Dr Beatriz Molina, medical aesthetic practitioner How have aesthetic innovations improved patient outcomes? Patient outcomes have improved dramatically because we better understand how the face ages. The different technologies allow us to treat areas which were very difficult or risky previously. Also, the products we use are getting better. We now have sophisticated products and more understanding of their properties, allowing us to inject at different levels and achieve a much more natural result. Why is it important to tailor your treatment approach to each individual patient? We are individual and all require different things; every face is different. What is obviously the right product or technique for one patient doesn’t necessarily mean it will be good for another. Patients come to see us because we’re experts; we understand not only the concept of beautification and proportion, but also have a deep knowledge of the products that we use. We need to listen to the concerns of the patient to understand what their motivations are, what they really want to get from the treatment and offer the best advice for each patient. What are your experiences of using the Restylane range of fillers? I personally believe that Restylane is the largest range of products for different types of skin and results. You can choose from the very high G prime of NASHA, to the softness and integration in the tissue of OBT. You can tailor to what patients need and you can mix and match. If you compare it to being an artist, if you have a palette of colours you are going to create a much more beautiful picture than if you only have one or two colours. What key points do you consider achieve a natural-looking summer glow for patients? For me, the age of the patient doesn’t matter. To achieve a ‘summer glow’ it is all about hydrating the skin and fine-tuning to improve its quality. As such, Skinboosters are a must-do for the summer – they should be on everyone’s agenda. RES18-04-0261 DOP: April 2018 This column is written and supported by

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Aesthetics Journal

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Bodycare

Obagi Medical releases first body product Global skincare range Obagi Medical has released the KèraPhine Body Smoothing Lotion, making it the first product from Obagi Medical designed to be used on the body. UK distributor Healthxchange Pharmacy, claims that the the lotion works to restore healthy looking skin by addressing the appearance and texture of rough skin conditions such as keratosis pilaris. It contains glycerin, glycolic acid and ammonium lactate to help keep the skin hydrated. Steve Joyce, marketing and technology director of Healthxchange said, “Obagi’s KèraPhine Body Smoothing Lotion offers a new solution for patients with dry skin. The combination of glycolic acid and lactic acid is extremely effective and KèraPhine is clinically proven to help smooth rough and bumpy skin, exfoliate and remove dead skin cells from the epidermis and reduce dryness on the arms. We are really excited to further extend the Obagi Medical range with the addition of KèraPhine to support daily body care routines.” Loyalty scheme

Oappso launches new clinic loyalty system Mobile app company Oappso, which provides services for several aesthetic clinics, has launched a new digital loyalty stamp scheme. Oappso Loyalty aims to move clinics and other businesses from paper loyalty stamp cards, to digital. The company states that this provides a way to market to customers through its loyalty cards, as well as other benefits and features to increase sales. According to the company, unlike other digital loyalty systems, Oappso Loyalty uses the customers’ existing digital wallet to store loyalty cards. Other more similar systems usually require the customer to download a separate app, the company claims. Clinic owners can create custom loyalty cards online and share a link given to them with their patients in store and online. Patients simply click or scan the link on their phone and the loyalty card is downloaded to their Apple Wallet or Android Passes for Wallet, stored with their other cards such as credit and boarding cards. Feminine health

Speakers announced for IAAGSW second world congress The International Association of Aesthetic Gynaecology and Sexual Wellbeing (IAAGSW) has confirmed international speakers for its second world congress and exhibition. The speakers include Dr Sherif Wakil, IAAGSW president; Dr Jack Pardo, leader of the gynaecology unit at Clínica MEDS in Santiago; Mr Roberto Viel, co-founder of the London Centre for Aesthetic Surgery, and Dr Süleyman Eserdağ, founder of Hera Women’s Health Center in Turkey. The IAAGSW 2018 will concentrate on four areas surrounding sexual wellbeing: aesthetic gynaecology, male sexual rejuvenation, bio-identical hormones and regenerative medicine. Dr Wakil said, “I am very much looking forward to the event because of the opportunities it presents to fellow practitioners in this new and growing sector.” The IAAGSW world congress will take place at the Royal Society of Medicine on October 12, 13 and 14.

Reproduced from Aesthetics Aesthetics || Volume July 20185/Issue 8 - July 2018


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Ambassador

Exclusive distributor of Byonik laser announced Aesthetic distributor Pure Swiss Aesthetics has become the exclusive UK supplier for the new Byonik laser. Byonik is a pulse-triggered laser that aims to works at a cellular level to stimulate cell functions that are essential for optimal skin health. According to Pure Swiss Aesthetics, visible signs of ageing can be reversed by this cellular rejuvenation process and the Byonik laser can be used year-round to treat sensitised, red and stressed skin. The Byonik laser was launched at the Aesthetics Conference and Exhibition in April this year and combines two wavelengths, 658 nm and 806 nm, for a noninvasive and non-ablative treatment to the skin. Teresa Da Graça, chief executive of Pure Swiss Aesthetics, said, “We are very happy about the addition of the Byonik Laser to our portfolio of brands as it strengthens our scope and reach of activity and it totally matches the philosophy of Pure Swiss Aesthetics’ premium and personalised skincare. It is a unique and innovative technology that focuses on long-term skin health.” Collaboration

ZO Skin Health partners with HydraFacial Aesthetic skincare provider ZO Skin Health and skincare treatment brand HydraFacial have collaborated to create a combination treatment called the HydraFacial Brightalive Booster Serum. A new serum was created to be used in conjunction with the HydraFacial machine, which uses patented technology to cleanse, extract, and hydrate the skin. The HydraFacial Brightalive Booster Serum is indicated for hyperpigmentation and sun damaged skin, and has been designed with the aim of enhancing and maintaining the results of a Hydrafacial. ZO Skin Health claims the benefits of the product are that it helps to reduce the appearance of brown spots, even skin tone and hydrate, while preventing new pigmentation formation. According to ZO Skin Health, the serum’s key ingredients include oligopeptide-68, which aims to down regulate MITF pathways; nonapeptide-1, which attempts to reduce melanin synthesis; diglucosyl gallic acid for melanogenesis inhibition; glycerin for hydration retention; and n-Acetyl glucosamine, which aims to inhibit pigment formation, provide anti-inflammatory benefits and induce hyaluronic acid production for improved hydration.

Dr Selena Langdon announced as KOL for BTL Aesthetics Aesthetic device manufacturer BTL Aesthetics has announced that Dr Selena Langdon will be a key opinion leader (KOL) for its range of energy-based devices that treat skin, cellulite and gynaecological concerns. Dr Langdon, founder of Berkshire Aesthetics, has previously introduced several BTL devices into her clinic, including the Exilis Ultra, Ultra Femme 360 and the Unison, confirming her fondness for the brand. She said, “I am pleased to partner with BTL who have developed aesthetic devices which deliver the highest standard of patient safety and treatment efficacy. I am particularly impressed by their recent developments, which combine formerly standalone treatment modalities thereby improving treatment outcomes. Having researched the options available to treat skin laxity, gynaecological issues and cellulite, the range of devices offered by BTL stood out as a clear choice.” Matthew Hubball, territory sales manager at BTL Aesthetics, added, “Dr Langdon has impressed us in terms of her approach to patient care and the treatment outcomes she is able to achieve with our devices. BTL Aesthetics is excited to work with Dr Langdon and are pleased she will represent us.”

Device

Cutera Medical Ltd releases Enlighten SR laser Laser manufacturer Cutera Medical Ltd has released a new facial rejuvenation laser, the Enlighten SR. The device is a dual-wavelength laser with picosecond pulse durations and can cover large spot sizes of up to 8mm in diameter. According to the company, it aims to reduce the appearance of benign pigmented lesions such as moles, age or liver spots and sun damage, while improving skin texture and tone. It is also for those who are looking for a non-invasive, minimal downtime facial rejuvenation option for

brighter, healthier and more youthful looking skin, the company claims. Ben Walsh, Cutera Medical Ltd marketing manager for Europe, the Middle East and Africa region said, “We know that pigmentation is a concern for the majority of the population and people are more frequently seeking help for concerns such as melasma. The introduction of picosecond platforms like Enlighten SR allow us to treat more patients for pigmentary concerns, in fewer treatments and with no downtime.”

Reproduced from Aesthetics Aesthetics || Volume July 20185/Issue 8 - July 2018

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Combination treatment

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Dermatology

The Baldan Group launches Aqua3 Italian-based manufacturer and distributor, The Baldan Group has introduced a new device, the Aqua3. The device combines three technologies including a water-based peel, which contains sequential acids, microdermabrasion and transdermal delivery of cosmetic ingredients. It aims to deeply cleanse the skin, remove dead skin cells, rebalance sebum, deeply moisturise and restructure skin tissue. According to The Baldan Group, the device can be used anywhere on the body, however results are most noticeable on the face and on skin that is affected by stretch marks or scarring. It features three handpieces; the first being an infuser/aspirating handpiece that provides the water-based peel, the second is a Diamond-Grain handpiece, which uses properties of diamond grains to exfoliate the skin and the third, a mesoporation handpiece that aids with transdermal delivery. The Baldan Group recommends combining all three to help create a new type of hydrodermabrasion treatment to cleanse, moisturise and rejuvenate. Recruitment

Med-fx appoints regional sales manager for Ireland The winner of last year’s Healthxchange Award for Sales Representative of the Year, at the Aesthetics Awards 2017, Deirdre (Dee) MacMahon, has been appointed Med-fx’s regional sales manager for Ireland. MacMahon has 11 years of experience within the aesthetics industry, previously working for Merz Aesthetics and Johnson & Johnson. She will be responsible for the marketing and sales of the distribution partnership between Med-fx and dental supplier, BF Mulholland Ltd. MacMahon commented on her new appointment, “Excellence and passion for ‘best in class’ will be at the heart of everything we do and I can’t wait to get started.” David Tweedale, head of Med-fx, also stated, “When we knew we were going to be launching a full Irish distribution service, there was only ever one candidate we wanted to join our team and that was Dee. She will bring so much experience and knowledge to our team and will only help us further to grow our brand and partner with our customers. Dee is a fantastic addition.” Industry

John Bannon Ltd to supply new brands in Ireland Medical device and aesthetic supplier, John Bannon Ltd has been appointed the official wholesaler in Ireland for three brands; aesthetic product developer, Institute Hyalual, anaesthetic device Coolsense and LFL PDO Threads. According to the company, the partnership with these brands compliments the current offering and expands the portfolio of products they offer. Geoff Duffy, product specialist at John Bannon Ltd said, “This is the first of several exciting announcements that the company will be making over the next few months. We are thrilled to have partnered with three great brands and look forward to working with them in the future.”

BAD introduces new acne resource The British Association of Dermatologists (BAD) has launched a new online resource, Acne Support. The website has been developed by dermatologists to provide advice on acne, features more than 40 videos and includes information on acne types, causes, treatments, scarring, prevention and emotional support. Consultant dermatologists Dr Anjali Mahto, Dr Bav Shergill and Dr Nick Lowe, among others, are involved with this new resource as well as professional makeup artist Phil Briggs and members of the British Association of Skin Camouflage. Dr Mahto said, “I am thrilled to be working with such a talented team on the launch of Acne Support. This resource aims to help not only practitioners but patients too. We understand how much of an affect skin conditions can have on people’s lives and are pleased we can offer this service to help them.” Anti-pollution

Exuviance adds new product to range Skincare brand Exuviance, developed by the makers of NeoStrata, is set to launch its new Probiotic Lysate AntiPollution Essence in August. AestheticSource, distributor of the product in the UK, claims the product combines key ingredients that include 10% probiotic lysate, which aims to rebalance the skin; 8% polyhydroxy acid that delivers antioxidant benefits by neutralising damaging pollution factors; and hyaluronic acid to hydrate. Marisa Dufort, director of speciality beauty new product development and ingredient innovation for Johnson & Johnson, which acquired NeoStrata in 2016, said, “This unique anti-pollution essence combines a probiotic lysate to target skin’s microbiome plus our potent polyhydroxy acid to strengthen the skin’s protective barrier, restore radiance and provide antioxidant benefits.”

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Anniversary

Profhilo celebrates second birthday Injectable product Profhilo by IBSA Italia is celebrating its second year of being available in the UK and Ireland. The product is the first BDDE-free stabilised injectable hyaluronic acid-based product that aims to improve tissue quality and treat skin laxity, the company claims. Iveta Vinklerova, sales and marketing director at HA-Derma, the official distributor and training provider said, “The pace of growth for Profhilo is really exciting and we see it as confirmation that the market understands the need for this type of injectable.” She added, “We’re pleased to report that we have had our highest number of booking for our training courses for June 2018. Furthermore, we are finding that some of these bookings are being driven by consumers requesting the treatment in clinic – this is a great indication of increasing levels of consumer awareness for the brand.” Qualification

CIBTAC launches laser tattoo removal qualification The Confederation of International Beauty Therapy and Cosmetology (CIBTAC) has introduced a new laser tattoo removal qualification in partnership with the Medical Aesthetic Training Academy (MATA). According to CIBTAC, the Level 5 course was launched after it noticed an increase in consumer demand for tattoo removal, with more than 90% of CIBTAC members reporting the need for an appropriate qualification. The company claims that the qualification’s combination of online theory and practical training is designed to aid aesthetic professionals in delivering safe tattoo removal when treating a range of tattoo types and colours. CIBTAC’s course entails assessing skin types and conditions, identifying the most appropriate laser to use and the best-suited pre- and post-treatment care. According to CIBTAC, it has been designed to meet the recommendations of the Clinical Practice Standards Authority (CPSA) and the Joint Council for Cosmetic Practitioners (JCCP). Lesley Blair, chair at CIBTAC said, “High quality training is essential, and laser is no exception. We are delighted to be working with MATA to develop a partnership qualification for practitioners that will enable them to train to Level 5 in laser tattoo removal.” Mr Faz Zavahir, surgeon and founder of MATA, said, “Only by developing qualifications and courses that offer competence-based training and education will this sector see an improvement in standards of care and patient safety.” Vaginal rejuvenation

Advanced Esthetics Solutions releases She-Lase Aesthetic device company Advanced Esthetics Solutions (AES) has introduced its new She-Lase mixed modality laser. The aim of the device is to use CO2 and two wavelengths to perform vaginal atrophy, stress urinary incontinence, vulvar remodelling and vaginal rejuvenation treatments. According to AES the laser does this by using both 1540 nm and 10600 nm in sequential emission to ablate the superficial dermis and stimulate the mucosa’s collagen production. The company claims the thermal diffusion under the ablated areas using CO2 is minimal and that this technology produces more hydration, less post-treatment bruising and risk of infection.

News in Brief Dalvi Humzah Aesthetic Training offers threads course Dalvi Humzah Aesthetic Training (DHAT) has announced the first of several new courses, with the initial course focusing on threads. On July 31, DHAT will be running a Silhouette Soft and V-Soft PDO Thread Training course at Wigmore Medical facilitated by DHAT lead tutor and director, Mr Dalvi Humzah, aesthetic practitioner Dr Roberto Pizzamiglio, clinical director of Skin Excellence Clinics Dr Ian Strawford and consultant plastic surgeon Mr Hassan Soueid. The course aims to provide delegates with the opportunity to learn the theoretical and practical use of threads. This training is open to registered doctors and dentists, and each delegate is required to provide two models. NatraSan Skin releases 100ml bottle     Following the release of NatraSan Skin earlier this year, product supplier Medical Aesthetic Group (MAG) has released a new 100ml bottle to use in addition to the original 500ml bottle. The company claims that the hypochlorous acid skin disinfectant is non-irritant and nonsensitising, even to sensitive skin, and delivers ultimate levels of skin and tissue disinfection. Consentz updates software Clinic management software company Consentz has launched new updates for its existing software. The new updates include online booking options, patient sharing, allowing groups of the same clinic to access patient records; MailChimp integration, suitable for those looking to send marketing emails; and a VAT management tool, which, according to Consentz, make it easy for clinics to record if a treatment is medical or cosmetic to indicate whether or not VAT should be paid. Director of Consentz, Michael Geary, said, “Our recent updates come from our deep understanding of medical practice management and the need to keep up with the pressures of a fast-changing marketplace.” SmartMed launches new website Medical systems distributer, SmartMed, a subsidiary of Healthxchange Group, has launched a new website. According to the company, the purpose of the website is to bring together SmartMed’s technologies and key messages under a single brand proposition. Pierre Le Page, marketing manager, commented, “We’re really pleased to announce our new website launch. It comes off the back of considerable success for our technologies – in particular ULTRAcel and the recently launched LIPOcel.”

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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On the Scene

Out and about in the specialty

2nd NeoStrata European Symposium, London On May 18 and 19, aesthetic practitioners from all over the UK and Europe came together to listen to experts and network with colleagues at the second NeoStrata Symposium held at The Royal College of Physicians in London. The first day looked at the science of cosmeceuticals and was followed by a number of patient protocols aiming to educate and inspire delegates, while informing them of what can practically be achieved in clinic and at home. Day two then incorporated combination therapies and chemical peeling with specialist practical advice on techniques that can be used in clinic. This included a primary focus on the NeoStrata Retinol Peel and post-peel healing. Lorna McDonnell-Bowes, director of AestheticSource, the exclusive UK distributor of NeoStrata, spoke after the event, “We had more than 150 practitioners attend from the UK and Europe with multiple lectures and demonstrations carried out across the two days, as well as celebrating 30 years of innovation with NeoStrata Company.” She added, “Our multi-disciplinary team of experts included, Professor Beth Briden from the US, Dr Mukta Sachdev from India, UK practitioners Dr Stefanie Williams, Dr Sandeep Cliff, nurse prescriber Anna Baker, Dr Sophie Shotter and Dr Uliana Gout, as well as the NeoStrata Company team and consumer insights from US aesthetic business consultant Wendy Lewis and beauty director Sarah Jossel. Delegates were able to learn from their peers, see and share real in-clinic results with NeoStrata products, as well as hear about combination therapies and review new clinical data to support their practitioner-topatient relationships. We look forward to hosting our third Symposium in 2019.”

In True Swiss Style, Manchester On June 7, Yuva Medispa in Manchester officially launched the Yuva Swisscode Stem Cell Facial alongside the first Pure Swiss make-up and care brand, Chado, into their clinic. Distributor of the products, Pure Swiss Aesthetics has confirmed that the brands are exclusive to Yuva Medispa, which is its premium partner for the north of England. Guests were treated to a personalised skin health and styling tutorial whilst they learnt how the Chado makeup care range was created from founder Slyvia Rossel. The Yuva Swisscode Stem Cell Facial consists of seven steps incorporating a double cleanse, peel, LED treatment, vitamin F, serum applied with an applicator to increase blood flow, a skin specific serum and finishing with application of products from the Chado range. Teresa Da Graça, Pure Swiss Aesthetics’ chief executive said, “We are delighted to have Yuva Medispa as our Premium Partner in the North. This clinic’s vision is the perfect match to our brands’ positioning and philosophy. Swisscode and Chado are a perfect fit to YUVA’s intelligent and discerning clients who are looking for personalised quality with effective results.” Dr Raj Acquilla, founder of Yuva Medispa added, “To have premium, internationally-recognised brands available within our clinic, really is our philosophy. Bringing the finest and safest ingredients exclusively to our clinic is what we specialise in. Our aim is to enhance natural beauty and provide bespoke optimal and continued skin health.”

S-Thetics Summer Aesthetic Event, Stoke Green

Surgeon, cosmetic doctor and medical director of S-Thetics clinic, Miss Sherina Balaratnam held a patient educational event at Stoke Place Country House in Stoke Green on June 13. The aim of the event was to bring aesthetic companies and patients together to educate them about the latest aesthetic technologies, how they work and how patients can benefit from them, as well as to celebrate the clinic’s three year anniversary. The Town Crier of Beaconsfiled, Dick Smith, opened the event, welcoming guests. Miss Balaratnam then introduced guest speaker Dr Charlene DeHaven, global clinical director of iS Clinical skincare. Dr DeHaven presented an overview of ageing, providing guests with an insight of the main factors that contribute towards it, such as free radical damage, inflammation, glycation and DNA damage and epigenetics. Miss Balaratnam then spoke to the audience about how to use treatments in a combination approach to treat common skin conditions and promote overall skin wellness. Representatives from a range of aesthetic companies also exhibited and performed live treatment demonstrations, including those from Harpar Grace International, UK distributor of iS Clinical and the Déesse LED technology; Surface Imaging, VISIA; Consulting Room, HydraFacial; Cynosure, SculpSure and Icon Laser; AesthetiCare, Endymed; Alma Lasers, Femilift; Medical Aesthetic Group, Oxygenetix. Following the event, Miss Balaratnam said, “Just as medical practitioners evolve through education, our patients now have access to a vast array of information, both online and offline. The aim of the event was to communicate our approach in an easy to understand manner, in a relaxed atmosphere and delivered by experts in their respective fields. The event was very well received with over 95 guests.” Alison Havercroft, a patient of Miss Balaratnam’s, said that she enjoyed the event and left feeling more educated about the procedures offered at the clinic. “The event was very informative, it was really nice to hear some science behind these cosmetic procedures and products. I especially liked seeing the before and after photos. This event has made me think about trying something different.”

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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On June 15 laser developer and manufacturer Cynosure held an event to introduce its new TempSure Envi monopolar radiofrequency (RF) device at the Bulgari Hotel in Knightsbridge, London. The evening began with a welcome presentation for guests by Ben Savigar-Jones, UK country manager for Cynosure, which detailed the company’s milestones and aims for the future with the introduction of the TempSure Envi. Following this, German-based dermatologist Dr Kai Rezai gave a lecture on the RF technology behind the device, its use for multiple treatments including wrinkles, lateral canthal lines and cellulite on the body, and his preferred techniques for treating patients with it. He explained that the aim of the TempSure Envi is to non-invasively tighten the skin using RF technology where the deep layer of the dermis is heated up to 46°C. Dr Rezai said that this treatment triggers two rejuvenation processes: shrinking of the elastic fibres in the dermis and the stimulation of fibroblasts that in turn stimulate collagen production. There was then a question and answer session for attendees before Dr Rezai performed a live demonstration with the TempSure Envi. Savigar-Jones said following the launch, “I’m really pleased with how the event has gone today. There was a lot of questions from the audience, which is great. It’s a key sign that people are engaged in the new technology and we’re really excited to bring this technology to the market.”

Aesthetic practitioners visited Euston Square in London on June 9 to attend non-surgical workshops, watch live demonstrations and attend seminars with the aim of increasing their knowledge within the specialty. The conference, held by aesthetic training provider Cosmetic Courses, welcomed speakers including Dr Olha Vorodukhina, Dr Fiona Durban, aesthetic insurance and claims manager Naomi Di-Scala and senior business developer Marcus Haycock. Speakers presented on a number of topics such as lip augmentation, facial contouring, managing claims and delivering a patient consultation. As well as this, chair of the Joint Council for Cosmetic Practitioners (JCCP), Professor David Sines, also hosted a question and answer session on the update of the status of the JCCP, which was followed by other topics. Mr Adrian Richards, clinical director of Cosmetic Courses and The Private Clinic commented on the event, “Our first conference last year was a great success and this one has been even better! We had a great line-up of speakers sharing their industry knowledge through demonstrations, workshops and seminars. We were also incredibly pleased to have Professor David Sines come along and give an update on the JCCP, whilst also commending us on the courses and facilities we offer to our delegates. Overall it was a fantastic day bringing together industry experts and those starting off. At Cosmetic Courses we believe that learning never stops, offering these conferences alongside our courses allows our delegates to stay up to date with industry trends and continue to refresh their knowledge in the fast-paced and exciting world of aesthetics!”

BAS Conference, Windsor

look after your legs’. During the day, delegates also enjoyed a trade exhibition and poster presentations. Companies showcasing their products included Q Medical Technologies, Hamilton Fraser Cosmetic Insurance, STD Pharmaceutical Products, Credenhill, Sigvaris, and Ultrasound Technologies. BAS president and consultant vascular surgeon Mr Philip Coleridge Smith said he was thrilled that the event was a huge success. “With its focus on practical rather than purely academic presentations and on sharing tried and tested techniques, this meeting has achieved its aim of giving all sclerotherapy practitioners useful information they can take away and implement in their practices, whatever their role or level of experience. We’re gratified to see that the event has attracted a number of new faces in addition to the many who support us year after year,” he said.

Aesthetics reports on the British Association of Sclerotherapists’ (BAS) Annual Conference On May 15, 60 sclerotherapy specialists, aesthetic doctors, nurses and vascular surgeons met at the Dorney Lake Eton College Rowing Centre in Dorney, Windsor for the British Association of Sclerotherapists’ (BAS) annual conference. Consultant vascular surgeon Mr Jonothan Earnshaw kicked off the day by comparing foam sclerotherapy with alternative treatments for varicose veins, perforating veins and leg ulcers. Later in the morning, aesthetic practitioner Dr Martyn King shared his ideas on additional therapies that aesthetic practices might offer sclerotherapy patients. He suggested that practitioners ‘think outside the box’ to identify other needs alongside the presenting problem – for example lipolysis, mesotherapy, skincare products and laser hair removal. As part of the afternoon sessions, chairman of the BAS, Dr Stephen Tristram, associate vascular physician at The Hampshire Clinic, then presented on how to avoid complications of sclerotherapy for telangiectasia and detailed risks and discussed compression, pain and treatment failure. Dr Tristram shared his advice for managing patient expectations, saying that practitioners should avoid the use of the words ‘disappear’, ‘gone’, ‘cure’ ‘never’ or ‘always’. Instead, he suggested to use ‘improve’, ‘much better’, ‘more comfortable’, ‘usually’ and ‘we can

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Attitudes to Ageing Aesthetic professionals discuss the results of a new survey on public perceptions of appearance in older age In June this year the Royal Society for Public Health (RSPH) published a report that examines how attitudes to ageing can affect health and wellbeing. That Age Old Question detailed the responses of 2,000 people using focus groups and a national survey, before making policy recommendations based on the results.1 While part of the report looked at ageism in general; for example, negative stereotypes of older people as lonely, vulnerable, in poor health and an economic burden, it is also explored the public’s perception of appearance in older age. One of the most striking results suggested that nearly half (49%) of women and a quarter (23%) of men said they feel pressured to stay looking young. Other results found that three in five respondents (58%) believe that they will become less attractive as they get older, one in four 18 to 34-year-olds (24%) agreed ‘older people can never really be thought of as attractive’ and only 12% of older women said they were satisfied with their body size. Aesthetics speaks to two practitioners to find out if these related to their patients and how they approach similar negative attitudes in their clinics. Aesthetic business consultant Wendy Lewis also shares her views on how clinicians can focus their marketing to help reduce this pressure amongst the public and potential patients. The pressure to look young Aesthetic practitioner Dr Beatriz Molina says, “It’s true that you hear from older women that when you get to a certain age, you begin to feel invisible. They definitely feel more pressure and feel as though they’re seen as less attractive.” Nurse prescriber Sharon Bennett agrees that women, more than men, feel the pressure to look younger. She says, “With the negative hormonal changes associated with female menopause, it’s no surprise that a lot of men look better with age than women and are therefore more confident with their looks.” She notes, however, that most women don’t want to look drastically younger, explaining, “They generally want to look no more than 10 years younger; good for their age, not half their age.”

Younger expectations In regards to the suggestion that 18 to 34-year-olds think older people can’t be thought of as attractive, Bennett comments, “I don’t believe that really. I find that a lot of younger people think older men and women look gorgeous. Of course, a lot of younger people are frightened by wrinkles, yet when they actually look at older people they don’t necessarily think they’re unattractive; they appreciate their attractiveness for their age.” On the other hand, Bennett explains that she has found the younger generation are a lot more conscious of the ageing process and, thus, are more concerned with taking care of their skin early on. Dr Molina adds, “I think in general we need to be careful with the younger generation as they are becoming too focused on their looks.” She notes TV programmes such as Keeping Up With The Kardashians and Love Island do increase the pressure on young people to look a certain way, which is likely to then have a direct impact on their attitudes to ageing. She continues, “Everyone likes to look at beautiful things and there’s nothing wrong with that as long as you’re doing it from a healthy perspective.” For her, recognising when a patient may be more seriously affected by the ageing process is key. “If I’m treating someone with insecurities then I’m not helping them; the treatment isn’t going to make them feel any better. Sometimes it’s better to say no, give them advice and refer them to counselling. If we don’t take time to understand our patients’ needs, then we are not doing our job properly.” Lewis concurs with both practitioners, explaining, “We can point to the advent of social media as one of the contributing factors. Everyone wants to look ‘selfie good’.” She notes, “The new challenge for practitioners is to manage patient expectations and breakdown the mystique of Instagram and other social channels that are a hotbed of images, which can be misleading when it comes to aesthetic treatment results.” Body image Bennett says she is not surprised that only 12% of women are happy with their body size. “I don’t know many women who love their

body so it sounds like a feasible percentage,” she says, explaining, “If I think of my friends and my patients, many are concerned about individual areas of their body, even though size may not be an issue.” From Lewis’s US-based perspective, she says, “Women’s dissatisfaction with their bodies is not frontpage news. However, it has historically been less pervasive in Europe than in the US where body dysmorphia reigns supreme. It would appear that the UK and Europe and Asia are catching up with the US in this regard.” Marketing One of the recommendations made by the RSPH in its report was for companies to stop using terminology such as ‘antiageing’. It said, ‘Many everyday conversations, informed by the media, are rife with examples of language that either trivialise, vilify, or catastrophise the ageing process. Chief amongst these is the persistent use of the term ‘antiageing’ within the cosmetics and beauty industry’. The report makes reference to US magazine Allure’s decision to stop using the word, which Aesthetics explored in more detail in October 2017.2 Lewis says that many brands in the skincare and aesthetics space are already moving away from this concept in their marketing. She notes that the wellness and fitness industries are doing well through their promotion of ageing better, living longer and being healthier. “That sounds so much more positive and appealing to consumers,” she says. In that respect, Dr Molina highlights how her key message is to ‘holistically help the body to age better – we’re not going to stop ageing, but we’re making it go at a lesser speed’. As a result of treatment, patients are likely to feel more energetic and confident, she says. “Antiageing is a concept of a lot of things; not just lines and wrinkles,” says Dr Molina. “There’s nothing wrong with having treatment if it’s going to make you feel better. It’s about educating patients on overall wellbeing,” she adds. Lewis agrees, concluding, “We are selling wellbeing, optimism and health, looking as good as you feel at every age, which are all true positive sentiments. So, instead of focusing on what needs fixing, look at how to improve your patient’s self-esteem and confidence level, which everyone can relate to.” REFERENCES 1. That Age Old Question (UK: Royal Society for Public Health, 2018) < https://www.rsph.org.uk/our-work/policy/older-people/ that-age-old-question.html> 2. Chloé Gronow, News Special: Language in Aesthetics (UK, Aesthetics, 2017) <https://aestheticsjournal.com/feature/ language-in-aesthetics>

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Marketing Injectable Procedures Allie Anderson explores the importance of a good marketing strategy when it comes to injectables, and shares professionals’ advice on how to avoid the pitfalls of regulatory non-compliance Non-surgical procedures comprise 90% of all cosmetic surgery treatments in the UK, and are worth more than £2.75 billion.1 Two of the most popular are dermal fillers and botulinum toxin, thanks in large to celebrity endorsements, high patient satisfaction and low downtime associated with the treatments. The fact that minimallyinvasive procedures such as fillers remain mostly unregulated means consumers can find a practitioner performing injectables on almost every high street – and a saturated market makes it harder than ever to stand out from the crowd. So, it’s increasingly important that aesthetic practitioners promote themselves, their services and products in the best and most effective way. When it comes to marketing dermal fillers and botulinum toxin injections, doing so involves a certain amount of due diligence to ensure practitioners comply with a series of standards that are in line with General Data Protection Regulation (GDPR), as well as advertising guidelines. This article will focus primarily on best practice guidance for content marketing, however to find out more about compliance with GDPR, regulation around data you hold and who you can market to, readers should visit aestheticsjournal.com/hub/GDPR.

any advertisement wholly or mainly directed to the general public which is likely to lead to the use of a prescription-only medicine (POM)’.2 Thus, advertising botulinum toxin – a prescription injectable – to patients is against the law. “Yet, some practitioners are very overt about promoting botulinum toxin, and even advertise deals like three areas of toxin for a certain price – and that directly contravenes the advertising regulations,” Kendrick adds. “The term ‘Botox’ has slipped into the collective conscious, and people fall into the trap of talking about botulinum toxin in the same way they talk about non-prescription fillers.” Sanctions for breaching this rule can include a fine and even a custodial sentence for severe breaches.2 No such stringent advertising regulation is in place for non-prescription injectables, which is arguably both a blessing and a curse. The risk of an advertising transgression is significantly reduced, but there exists a host of more general statutory, regulatory and ethical requirements practitioners must adhere to.

Background reading

When planning a marketing strategy for injectable procedures, the professionals interviewed for this article agree that practitioners should first read up on all available guidance. “I would advise people to read the Blue Guide in the first instance, as well as guidelines set out by the relevant professional bodies,” suggests Steve Joyce, marketing and technology director at Healthxchange Pharmacy. The latter is the General Medical Council’s Guidance for doctors who offer cosmetic interventions3 (for doctors); a series of best practice guidance published by the Nursing and Midwifery Council4 (for nurses); and the Guidance on advertising5 from the General Dental Council (for cosmetic dentists). In addition, Joyce recommends that practitioners familiarise themselves with the UK Code of Non-Broadcast Advertising and Direct and Promotional Marketing, known as the Committee of Advertising Practice (CAP) Code,6 which outlines rules for marketing communications and is enforced by the Advertising Standards Authority (ASA). Undoubtedly, this is a lot of information to take in, but according to Kendrick, it largely comes down to a simple principle. “The rule of thumb is that, as practitioners, it’s important to strike the fine balance between education and promotion,” she says.

Different channels Legal minefield “There is governmental guidance and there is also guidance published by individual professional bodies,” says director of Kendrick PR, Julia Kendrick, adding, “This is one of the things that makes marketing injectables a bit overwhelming when you’re starting out.” The governmental guidance to which Kendrick refers is the Blue Guide: advertising and promotion of medicines in the UK, published by the Medicines and Healthcare products Regulatory Agency (MHRA). The most salient aspect of marketing injectable procedures is laid out in this guidance; namely, the prohibition of ‘the issue of

A successful strategy for marketing injectable procedures will most likely incorporate a number of different platforms, including direct mail and print advertising, but for most practitioners, it will focus on digital marketing. “You have to adopt a multi-channel approach to communications and marketing and that usually includes website and social media, most commonly Facebook, Twitter and Instagram,” says Kendrick. “It’s practical for practitioners to be active on those sites because that’s where their target customers are most likely to be looking for them.” Maintaining a consistent profile across all channels is crucial to get your name and your services out in the

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public domain, she adds. For some clinics, developing a strong social media following and using it strategically to showcase the injectables they offer can directly drive custom. But for Dr Bhavjit Kaur, medical director at the Health and Aesthetic Clinic, the benefits are generally further reaching. “It might not bring people into your clinic but it does help to create brand awareness, and that’s why it’s important to invest time, however busy you are, to build a following,” she says. Social media is a good platform to market injectables, not least because you can showcase products and procedures in an easily accessible format – and for free – to a potentially unlimited audience. The drawback is that, unlike marketing to your own database of patients, you don’t know who is viewing the material. “With social media, you need to be aware of the breadth of the audience, which means giving consideration to the fact that it may include vulnerable people,” Joyce points out. In the same way, Joyce advises, practitioners should avoid marketing fillers and other injectables with the use of offers and deals, and avoid selling procedures on deal sites like Groupon because of the risk of trivialising such treatments. In fact, Sir Bruce Keogh, in his Review of the Regulation of Cosmetic Interventions back in 2013, said, “The use of financial inducements and time-limited deals to promote cosmetic interventions should be prohibited to avoid inappropriate influencing of vulnerable consumers.”7 Promoting time-limited offers is also in direct contravention of the CAP Code,6 because, as Joyce highlights, “It may well encourage an ill-considered decision to proceed with treatment or otherwise be seen as targeting vulnerable people.”

More than words The language of advertising and marketing is crucial in any industry. The words and phrases you use must not only get across the message you want to convey, but do so in a responsible way that makes you as a practitioner stand out from the crowd. “In marketing, it’s not about what you want to say; it’s about what your audience wants to hear,” says Dr Kaur. “With injectables, it should be educational rather than salesy. The criteria for advertising should always be to give people information so they can make an informed decision.” Importantly, consumers don’t want to get bogged down in technical language and jargon – and that’s where some marketeers may be going wrong, Kendrick says. “A lot of practitioners are very good at providing that clinical element – the function of the product – but in fact that’s not what consumers want to hear,” she points out. “Most people don’t want to know details about the depth and size of the needle, and neither do they want a product that will ‘banish wrinkles’ or ‘turn back the clock’. More and more these days, patients are not looking for those extreme results; they want a more subtle look.” The language used in marketing injectable procedures ought to reflect that, Kendrick says. She recommends using softer, more aspirational language that describes, for example, a ‘well-rested’ and ‘refreshed’ look. Moreover, she says, by the time a patient walks through the clinic doors for a consultation, they will have already chosen the practitioner they want to use, based on the marketing they’ve been exposed to in the lead up to that point. “All of the language they will have seen before they actually get to talk to the practitioner is the important thing, because that’s what makes them decide to choose one over another,” Kendrick says. “So the language people use in their marketing is really important; if it’s not tailored in their

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Marketing POMs As botulinum toxin is a POM, it is vital that aesthetic practitioners remember that it must not be discussed in marketing material such as such as a sponsored advertisement, website homepage, in logos or testimonials. In addition, any small print at the bottom of a homepage should not refer to POMs or directly link consumers to a page where they are referenced. Other POMs to consider include hyaluronidase and lidocaine. Advertising or promotion of POMs to the public is strictly prohibited: UK law states that ‘any advertisement wholly or mainly directed to the general public which is likely to lead to the use of a prescriptiononly medicine are prohibited’. So what CAN be done when marketing POMs?11 • Raise awareness of the ‘conditions’ treated, such as signs of ageing around the eyes, or frown lines • Talk in broad terms such as ‘anti-wrinkle’ injections or ‘cosmetic injections’ as these are non-specific to POMs and could also be deemed to include fillers, which are medical devices • To get more specific, information about a POM should only be provided in the context of a possible treatment option following a consultation

marketing and it’s not applied consistently across the channels, it won’t have the impact with people who are at the stage of thinking about the treatment.” Joyce’s advice is to keep it simple. “Use of clear English is important. Avoid jargon, exaggeration and hyperbole, and be very factual,” he says, adding, “If there is clinical data, it’s good practice to present that as graphs and images, as they can be helpful in that regard.”

Picture this Undoubtedly, one of the best methods of marketing procedures like dermal fillers and botulinum toxin injections is to visually demonstrate the results they can achieve. Use of before and after images is the perfect way to do this. But there are a number of precautions to bear in mind to avoid falling foul of advertising regulations. The CAP, the ASA’s sister organisation that is responsible for writing the Advertising Codes, has an online advice section dedicated to appropriate use of before and after photos in advertising.8 On the issue of consent, it’s essential that you hold signed, dated proof that the patient agrees to you using their photographs for the purposes and under the terms set out in the agreement.8 As of May 2018, any data you hold on a patient, including photographs, must also comply with the General Data Protection Regulations (GDPR).9 Once consent has been dealt with, first and foremost practitioners should ensure that photographs do not exaggerate the efficacy of a product. As Kendrick points out, a set of photos doesn’t have to be deliberately or maliciously deceptive to be misleading: it could be that the lighting or angle of one image is subtly different or that the patient is wearing makeup in one photo and not the other. “It’s crucial that you take the time to ensure the before and after photos are as similar as possible, and that includes making sure they’re properly aligned and consistent,” she says. While editing of photos to enhance the results of a procedure is prohibited,8 some digital manipulation is acceptable, Joyce says. “You

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can use Photoshop to anonymise a photo, for example to block out the eyes, but you should always make it clear that it has been altered to protect the anonymity of the patient,” he comments. It is also permissible to edit some elements of a photograph to make before and after images consistent, so long as it does not in any way overstate the results of the treatment; an example might be to edit out a necklace. In terms of production techniques, CAP counsels against ‘re-touching related to any characteristics directly relevant to the apparent performance of the product, for example, removing or reducing the appearance of lines and wrinkles around the eyes for an eye cream advertisement’.8 The professionals interviewed agree that the same would hold true of an injectable treatment. They emphasise that it’s crucial to make clear that every patient is different; while the images you use in marketing injectables can demonstrate the results in one patient, those results might not be replicated in all patients. Similarly, Kendrick advises that practitioners should give careful consideration to the end result they want to convey in an ‘after’ image and says it’s a good idea to think about your audience. “You often see Instagram awash with images of over-inflated, glossy lips taken straight after they’ve been injected, for example,” she says. “If your patient demographic tends to prefer a subtle look, then you’d probably want to avoid using photographs taken immediately after the treatment, when there might be initial post-procedural swelling.” Instead, opt for follow-up photographs taken a week or two later, and captioned as such, when the swelling and bruising has gone down, to give a realistic expectation of the longer-term result, she adds. Dr Tom van Eijk, who runs an aesthetic clinic in the Netherlands and teaches courses on injectables internationally, agrees and says that the simple rule of thumb is to ensure before and after images strike a chord with the audience. “I think the best before and after examples are the ones that patients can relate to,” he says. “Most of my patients are looking for natural results. They’re of real people – nothing dramatic – but faces you can relate to and results that are discreet.”

Using videos Some practitioners choose to include video footage of injectable procedures in their marketing materials. “In my experience, video creates a lot more engagement on social media and generates a lot more clicks and views than still images,” Kendrick says, adding, “So if they’re done in the right way videos can be very effective marketing tools.” As well as giving consent to having their procedure filmed, and to the practitioner using the footage for the purposes of marketing, Dr Kaur suggests the patient should be able to view the video themselves before it’s uploaded. “It’s good practise to make sure the patient is happy with the video and what is shown, and having them give consent after seeing the film gives another layer of protection,” she says. Moreover, practitioners should take appropriate steps to maintain the patient’s dignity. This extends beyond simply ensuring that intimate areas are covered and patients cannot be identified, and includes behaving in a professional manner while being filmed. In the US, a medical practitioner is facing complaints from more than 100 women, after she uploaded videos to promote her procedures and clinic to YouTube showing her dancing and rapping during surgical procedures. At least three women have claimed they suffered complications because Dr Windell Boutte did not pay appropriate attention while they were on the operating table.10 “Videos must be within the bounds of education; they should not

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be used as entertainment,” Kendrick says. “Practitioners must give due clinical deference to the content of the video, and remember first and foremost that they are clinicians,” she adds. Similarly, it’s good practice to avoid using videos that are gratuitously graphic, adds Joyce. “Videos are useful to help convey what will actually happen during a treatment, so they should be factual in nature and not sensationalise the procedure,” he says. If a filmed procedure is graphic in nature, it’s important to include warnings on the video. Putting yourself in the shoes of the patient viewing the video can help give you perspective on what you’re sharing, says Dr van Eijk. “As normal as it seems to us as doctors, remember it is perceived as creepy to put a needle in someone’s face by the general public,” he comments. “For that reason, I personally limit the intensity of the procedure footage within marketing in order not to scare anyone,” he adds.

Top tips for marketing success These days, injectable procedures are common, so when it comes to marketing, it’s not sufficient to simply focus on the product, according to Kendrick. She says, “That is not enough to differentiate you or your clinic; you need an educational and informative piece about which products you use and why, but I would always counsel practitioners to put time and effort into developing messages that truly set them apart from the competition.” According to Dr Kaur, it all boils down to marketing yourself as well as the products and procedures. “If you are able to instil confidence in the public that you are properly educated and trained, take appropriate precautions and can manage complications if they happen, your patients will then know they can trust you,” she says, concluding, “Your accreditation, reputation, passion, awards and reviews – they are all more important than good photos and a strong social media following, because that is what makes you different from everybody else.” REFERENCES 1. BBC.co.uk. Botox and fillers: Are these ‘tweakments’ all they’re cracked up to be? (BBC, 12 January 2017) www.bbc.co.uk/bbcthree/article/075551b0-d866-45db-ab6a-149ce182d741 [accessed 14 June 2018] 2. Medicines and Healthcare Products Regulatory Agency. Blue Guide: advertising and promotion of medicines in the UK. Third Edition, First revision (September 2014) www.assets.publishing.service.gov. uk/government/uploads/system/uploads/attachment_data/file/376398/Blue_Guide.pdf [accessed 14 June 2018] 3. General Medical Council. Guidance for doctors who offer cosmetic interventions (GMC, 12 April 2016) www.gmc-uk.org/-/media/documents/guidance-for-doctors-who-offer-cosmetic-interventions-210316_ pdf-65254111.pdf [accessed 14 June 2018) 4. Nursing and Midwifery Council. Guidance (2018) www.nmc.org.uk/standards/guidance/ [accessed 14 June 2018] 5. General Dental Council. Guidance on advertising (September 2013) www.gdc-uk.org/ [accessed 14 June 2018] 6. Committee of Advertising Practice. The CAP Code; The UK Code of Non-Broadcast Advertising and Direct and Promotional Marketing (2014) www.asa.org.uk/uploads/assets/uploaded/cacc4b1f-51714ba4-8679bb383a25aa2a.pdf [accessed 14 June 2018] 7. Professor Sir Bruce Keogh KBE, Review of the Regulation of Cosmetic Interventions; Final Report (April 2013) www.assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/192028/Review_of_the_Regulation_of_Cosmetic_Interventions.pdf [accessed 14 June 2018] 8. Committee of Advertising Practice, Before and after photos (December 2014) www.asa.org.uk/adviceonline/before-and-after-photos.html [accessed 14 June 2018] 9. Chloé Gronow, ‘Are you Ready for GDPR?’ (UK: Aesthetics, 2018) <https://aestheticsjournal.com/ feature/are-you-ready-for-gdpr?authed> 10. Oliver Wheaton, Dancing doctor who made rap videos during surgery faces nearly 100 complaints from women, Independent.co.uk (3 June 2018) www.independent.co.uk/news/world/americas/ dancing-rapping-doctor-windell-boutte-surgery-atlanta-unconscious-women-lawsuits-a8381371.html [accessed 14 June 2018] 11. Julia Kendrick, Maintaining Compliant Marketing in Aesthetics (UK: Aesthetics, February 2017). < https://aestheticsjournal.com/cpd/module/maintaining-compliant-marketing-in-aesthetics>

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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oint

Characteristics of HA Dermal Fillers

In the first of a two-part article, Dr Souphiyeh Samizadeh discusses the basic characteristics of hyaluronic acid fillers to aid product selection Abstract Hyaluronic acid (HA) dermal fillers have become very popular agents for facial rejuvenation. There are a number of HA fillers available on the market with continuous evolution of products and product ranges, technology and injection strategies and approaches. The choice of product can become confusing for practitioners with so many different brands, characteristics and strongly marketed unique selling points of each product. In this paper, basic characteristics and rheology of the HA fillers are discussed to aid selection of appropriate products for the correct indications, taking into consideration patient factors.

Introduction HA is found in nearly all biological fluids and tissues, including synovial fluid and extracellular matrix. Both vertebrates and the capsule of some bacteria contain HA.1 It has a high molecular mass and has unique biological, viscoelastic and rheological properties, making it an attractive biomaterial for various medical applications. It is used in clinical medicine, therapeutics and aesthetic medicine. Examples of use in clinical medicine include use as a diagnostic marker for many diseases (e.g. cancer), as a drug delivery agent, as a gene therapy vector, and in rheumatoid arthritis and liver pathologies. Its other clinical uses include, but are not limited to, use in arthritic patients (intra-articular injection of HA to supplement impaired synovial fluid), neurosurgery, ophthalmological surgeries, reconstruction of soft tissue, otological surgeries, cosmetic regeneration and wound healing.2-5 The highest content of HA in the human body is found in synovial fluid, followed by the umbilical cords, and the eye. The highest concentrations are found in the skin. The HA acts as a matrix and has critical functions that include: increasing dermal volume and compressibility, scavenger of free radicals, protective, structure stabilising and shock absorption, and it also influences cell proliferation, differentiation, and tissue repair.1,6 In medical aesthetics, HA dermal fillers are highly popular as an immediate, predictable, and natural-looking result can be achieved with the use of correct products and correct techniques. In addition, their reversibility via enzymatic digestion with hyaluronidase makes them a favourable product. This makes HA products relatively safer than non-HA dermal fillers with improved tolerability profile.7 With the evolution of the products, readily available scientific information regarding both products and ageing changes, the technique and approaches for the clinical use of HA dermal fillers have also changed. The face has a complex anatomy and is a dynamic structure. Hence, any product that is implanted in the face would be subjected to intrinsic and extrinsic forces that vary in terms of intensity and frequency. Therefore, the characteristics of dermal fillers for various

indications and facial regions vary. These characteristics should be taken into consideration when treating other areas such as hands and décolletage.7 There is no general filler that is suitable for every treatment, every facial or body area, or for every individual. There are many factors that may influence HA filler performance and need to be understood by practitioners. Some of these include the total HA concentration (cross-linked and uncross-linked), particle size, the cross-linking method/agent, modulus, swelling/water resorption, and extrusion force.7-10 Prior to being able to compare various available dermal fillers, it is important to understand what various terms used to describe characteristics of HA dermal fillers mean. In this paper, the focus is understanding these terms and in a following paper, these characteristics for commonly available products in the UK will be compared.

Figure 1: A polymer (polysaccharide) that is linear. The building blocks are disaccharide units containing N-acetyl-d-glucosamine and glucuronic acid. These are units that combined together to make a HA molecule, the repeat of these units make a polymer.1

Product architecture Hyaluronic acid (also known as hyaluronan, sodium hyaluronate, HA), is a glycosaminoglycan (a linear water soluble polysaccharide, made up of polymeric carbohydrate molecules – long chains of monosaccharide) that is formed from disaccharide units containing N-acetyl-d-glucosamine and glucuronic acid (Figure 1).1 Properties and characteristics Rheological properties of dermal fillers may help in understanding the differences between HA products in terms of their physical properties which are correlated to their performance. The basic definition of properties and characteristics used to describe dermal fillers can be found on the next page.7,8

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Viscoelastic Viscoelastic properties can be described by four main rheological parameters:11 • G*: overall viscoelastic properties or ‘hardness’ – resistance to distortion • G′: elastic properties • G″: viscous properties • δ: the ratio between the two above characteristics (viscous and elastic) Elastic (solid) and viscous (liquid) components of a gel makes the gel/product viscoelastic (G*). Viscoelasticity of a product is determined during the design and manufacturing of the product.8,11

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HA fillers in the UK Some of the most common HA dermal fillers available in the UK are: • Restylane range: Q-Med/Galderma • Juvéderm range: Allergan • Belotero range: Merz Aesthetics • Teosyal range: Teoxane Laboratories • Perfectha: Sinclair Pharma plc • Aliaxin range: IBSA Farmaceutici Italia In the next paper the rheological properties of some of the above mentioned products will be discussed and suggestions for clinical use made.

Elastic modulus This is the measure of the gel’s ability to resist distortion under pressure applied.7,10 • Known as G prime • Abbreviation: G′ • A quantitative measurement of stiffness/firmness of the gel • Ability to resist distortion under applied pressure • Affected by cross-linking (discussed below) and gel concentration As the G’ increases, the gel deforms less under pressure. Therefore, a product with a high G’ can resist deformation under pressure and external forces much better than those with a low G’. It will also have a higher tissue-lifting capacity.7,10 Viscous modulus/loss modulus Viscous modulus is the measure of the flow properties of a gel. It is a function of concentration of cross-linked HA.12 • Known as G double prime • Abbreviation: G″ • Flow properties This property is an indication of how a product is affected by shear forces during extrusion through the needle, injection and post implantation.7

HA fillers with higher cohesivity can resist deformation and maintain shape of injected gel deposit, while HA fillers that have lower cohesivity but the same G’ lose projection easier than those with higher cohesivity

Viscosity/Complex viscosity This is the capability of the fluid phase to resist shearing forces.7,10 A gel with high viscosity is more resistant to flow, or movement, and is more difficult to spread, meaning that it is likely to stay at the site of implantation.10 • Symbolised as η* Cohesive Cohesivity is the degree of attraction between cross-linked HA units. It characterises behaviour of a product as a gel post implantation.11 Dermal fillers, in particular those injected to the face, are subjected to constant internal and external forces including compressive forces, for example lying on a pillow. HA fillers with higher cohesivity can resist deformation and maintain shape of implanted gel deposit. HA fillers that have lower cohesivity but the same G’ lose projection easier than those with higher cohesivity.11 Cross-linking Cross-linking refers to the action of creating a bond between two strands of HA. HA is a water soluble polymer and therefore needs to be modified to improve its mechanical properties, prevent rapid degradation and improve longevity.8,13 Non-cross-linked and unmodified HA has a short half-life. Following intradermal injection, the half-life is only a few weeks.7 Various cross-linking strategies aim to improve biomechanical properties without changing the biocompatibility and also the biological activity of HA;8 dialdehydes and disulphides, and diglycidyl ethers are examples of cross-linkers used.14 Diglycidyl ethers are one of the most common cross-linkers (used in Restylane, Juvéderm, and Belotero).8,15 At times, one end of the polymer will not be cross-linked. This results in one end being cross-linked and the other end being a pendant. The pendant groups are more likely to influence and contribute to gel water absorption and swelling than to the longevity of the product.8 Increasing the cross-link density of HA makes the overall polymer network stronger and hence, enhances the gel hardness/stiffness and longevity.8 HA concentration HA concentration is expressed in mg/ml and it consists of insoluble HA, soluble-free HA (unmodified and modified soluble HA). The soluble-free HA does not contribute towards longevity. It is added as a lubricant that facilitates the extrusion of the gel through fine-bore needles.8 Therefore, the concentration of cross-linked and free HA is important to be understood. Higher concentration of HA means a higher volume expansion capacity, and also may be linked with increased longevity.9

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Water absorption HA is a water-loving molecule (strongly hydrophilic).16 Water absorption abilities of HA molecules are dependent on the 3D structure. Therefore, more water gets bound as the length of HA molecules increases. This is clinically relevant as this means the dermal fillers can absorb water and hence swell post injection. This ability is dependent on factors including the HA concentration and amount of cross-linked HA. In addition, the process for HA gel hydration employed by companies has an effect. This should be taken into account, as more water will be absorbed and undercorrection maybe needed for dermal fillers that have not been fully hydrated during manufacturing.8 Particle size and particle size distribution The particle size is one of the factors that influence the extrusion force. The higher average particle size means extrusion of the gel through fine-bore needles becomes more difficult. Distribution of particles is also important. It can result in sporadic flow or an interrupted flow of the product through the needle and less control over product placement can occur. The uniformity of the size of the particles is preferred to avoid the mentioned problems.8 Biphasic gels Biphasic gels contain cross-linked HA of selectively sized particles and non-cross-linked free HA used as a carrier. The Restylane range is an example of a biphasic product.16,17 Monophasic gels The molecular weight of HA varies in these gels. They contain high-molecular-weight HA and low-molecular-weight HA in varying amounts and, in some cases, varying degrees of cross-linkage. Monophasic gels contain a single phase of HA with a single density. An example of monophasic gel is the Juvéderm range. This range of products consists of smooth hydrogenous gels produced through the Hylacross technology.16 The proprietary Hylacross technology refers to the fact that the ‘sizing’ process is not part of the Juvéderm technology. The sizing process is where cross-linked HA is pushed through a screen that is specially sized and is broken into pieces which are sorted into various dermal fillers.18 Monodensified dermal fillers are cross-linked once. Different ranges and families of monophasic monodensified fillers are available depending on their manufacturing technology. Examples include the Hylacross technology (e.g. Juvéderm Ultra),20 or the Vycross technology (e.g. Juvéderm Volbella), containing mainly low molecular weight HA, some high molecular weight HA with improved crosslinking20 and the cohesive monophasic polydensified gels (Belotero range) with a matrix that contains higher and lower cross-linking concentrations of HA.21 Polydensified dermal fillers comprise a single phase of HA that is cross-linked continuously. The cohesive polydensified matrix (CPM) technology is used for their production, which produces a gel with non-uniform cross-linking and molecular weight and lower viscosity (Belotero products).16,22

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will result in the correct choice of product, for the correct indication for each individual patient and hence optimal aesthetic results. No single property or parameter can be used for the choice of a dermal filler, a careful consideration of all gel properties is essential for the correct choice of product, understanding the product’s performance and for helping set and manage patients’ expectations. It should be kept in mind that the clinical results are directly dependant on the HA dermal filler characteristics, patient factors and the response of the patient. Patient satisfaction and the final outcome depends on the product properties, placement technique, and the biological patient response. Dr Souphiyeh Samizadeh is a visiting associate professor, the founder of the Great British Academy of Aesthetic Medicine and the clinical director of Revivify London clinic. The focus of her clinical work, academia and research is aesthetic medicine. She frequently presents at national and international conferences and trains aesthetic practitioners worldwide. REFERENCES 1. Kogan, G., et al., Hyaluronic acid: a natural biopolymer with a broad range of biomedical and industrial applications. Biotechnology letters, 2007. 29(1): p. 17-25. 2. Bagga, H., et al., Longterm effects of intraarticular hyaluronan on synovial fluid in osteoarthritis of the knee. J Rheumatol, 2006. 33(5): p. 946-50. 3. Vincent, H.K., et al., Hyaluronic Acid (HA) Viscosupplementation on Synovial Fluid Inflammation in Knee Osteoarthritis: A Pilot Study. The Open Orthopaedics Journal, 2013. 7: p. 378-384. 4. Apaolaza, P.S., et al., A novel gene therapy vector based on hyaluronic acid and solid lipid nanoparticles for ocular diseases. International journal of pharmaceutics, 2014. 465(1): p. 413-426. 5. Chen, W.J. and G. Abatangelo, Functions of hyaluronan in wound repair. Wound Repair and Regeneration, 1999. 7(2): p. 79-89. 6. Brown, M.B. and S.A. Jones, Hyaluronic acid: a unique topical vehicle for the localized delivery of drugs to the skin. Journal of the European Academy of Dermatology and Venereology, 2005. 19(3): p. 308-318. 7. Sundaram, H. and D. Cassuto, Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications. Plastic and reconstructive surgery, 2013. 132(4S-2): p. 5S-21S. 8. Kablik, J., et al., Comparative physical properties of hyaluronic acid dermal fillers. Dermatologic Surgery, 2009. 35(s1): p. 302-312. 9. Falcone, S.J. and R.A. Berg, Crosslinked hyaluronic acid dermal fillers: a comparison of rheological properties. Journal of biomedical materials research Part A, 2008. 87(1): p. 264-271. 10. Sundaram, H., et al., Comparison of the rheological properties of viscosity and elasticity in two categories of soft tissue fillers: calcium hydroxylapatite and hyaluronic acid. Dermatologic Surgery, 2010. 36(s3): p. 1859-1865. 11. 1Pierre, S., S. Liew, and A. Bernardin, Basics of dermal filler rheology. Dermatologic surgery, 2015. 41: p. S120-S126. 12. Chun, C., et al., Effect of molecular weight of hyaluronic acid (HA) on viscoelasticity and particle texturing feel of HA dermal biphasic fillers. Biomaterials Research, 2016. 20(1): p. 24. 13. Wollina, U. and A. Goldman, Hyaluronic acid dermal fillers: safety and efficacy for the treatment of wrinkles, aging skin, body sculpturing and medical conditions. Clinical Medicine Reviews in Therapeutics, 2011. 2011(3): p. 107-121. 14. Lapčík, L., et al., Hyaluronan: preparation, structure, properties, and applications. Chemical reviews, 1998. 98(8): p. 2663-2684. 15. Tezel, A. and G.H. Fredrickson, The science of hyaluronic acid dermal fillers. Journal of Cosmetic and Laser Therapy, 2008. 10(1): p. 35-42. 16. Flynn, T.C., et al., Comparative histology of intradermal implantation of mono and biphasic hyaluronic acid fillers. Dermatologic Surgery, 2011. 37(5): p. 637-643. 17. Verpaele, A. and A. Strand, Restylane SubQ, a non-animal stabilized hyaluronic acid gel for soft tissue augmentation of the mid-and lower face. Aesthetic surgery journal, 2006. 26(1_Supplement): p. S10-S17. 18. Allemann, I.B. and L. Baumann, Hyaluronic acid gel ( Juvéderm(™)) preparations in the treatment of facial wrinkles and folds. Clinical Interventions in Aging, 2008. 3(4): p. 629-634. 19. Allemann, I.B. and L. Baumann, Hyaluronic acid gel (Juvéderm™) preparations in the treatment of facial wrinkles and folds. Clinical interventions in aging, 2008. 3(4): p. 629. 20. Philipp‐Dormston, W.G., S. Hilton, and M. Nathan, A prospective, open‐label, multicenter, observational, postmarket study of the use of a 15 mg/mL hyaluronic acid dermal filler in the lips. Journal of cosmetic dermatology, 2014. 13(2): p. 125-134. 21. Prasetyo, A.D., et al., Hyaluronic acid fillers with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature review. Clinical, cosmetic and investigational dermatology, 2016. 9: p. 257. 22. Santoro, S., et al., Rheological properties of cross-linked hyaluronic acid dermal fillers. Journal of Applied Biomaterials & Biomechanics, 2011. 9(2).

Conclusion There are numerous HA-based dermal fillers available in the UK. These have a wide variety of properties which independently or in combination have direct, indirect and extensive effect on their use, indications, contraindications and clinical outcomes. An understanding of these properties, in addition to clinical experience,

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


Say goodbye to cellulite dimples • Results seen in 14 days1

• 93% patient

satisfaction even at 3 years1

Visit www.cellfina.co.uk or www.cellfina.ie Contact 020 8236 3516 Email customerservices@merz.com The Cellfina® System is CE-marked with the intended use for long-term reduction of cellulite, maintained at three years, by precise release of targeted structural tissue (fibrous septae). The most common side effects were soreness, tenderness and bruising. The Cellfina® System is only available through a licensed aesthetic practitioner. For full product and safety information, refer to the Instructions for Use. Reference: 1. Kaminer, M.S., et al., A Multicenter Pivotal Study to Evaluate Tissue Stabilized-Guided Subcision Using the Cellfina Device for the Treatment of Cellulite With 3-Year Follow-up. Dermatol Surg, 2017(0): p. 1–9

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. © 2018 Merz Aesthetics. All trademarks are the property of their respective owners.

M-CEL-UKI-0244 Date of Preparation May 2018


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What is Cellfina®?

Introducing Cellfina® Global pharmaceutical company Merz Pharma UK Ltd details the minimally invasive cellulite treatment, Cellfina® It’s no secret that cellulite is a common concern for women throughout the world, 1.4 billion to be precise1,2* but with characteristics including dimpling and uneven skin texture, commonly on the buttocks and thighs, what really causes cellulite? There are multiple factors that influence the development of cellulite dimples including hormones, genetics, a sedentary or stressful lifestyle, and diet or weight gain.3 However, what many people are unaware of, is that the structural cause of cellulite is anatomical and a result of tethered fibrous septae bands, found under the skin, woven throughout fat in the thighs and buttocks which connect the skin to underlying tissue at select points.4,5 (Figure 1). These tight bands pull down the skin creating the common puckering effect seen on the surface of the skin.4,5

C

B A

Advertorial Merz

Figure 1: A: Fibrous septae connect the skin to underlying tissue at select points B: Fibrous septae orientated perpendicular to the skin surface pull down on the dermis C: This structural cause of cellulite results in dimpled, bumpy skin

It seems to be that more and more patients are looking to do something about it – which is where clinically proven cellulite procedure, Cellfina® is introduced.

What presence does Cellfina® have nationally? The treatment was named ‘Best Cellulite Treatment’ in the 2018 Tatler Cosmetic Surgery Guide and has featured in a number of consumer publications including Vogue, Sunday Mirror, Daily Mail and Get the Gloss from January this year. Not only that, but Cellfina® has also invested heavily in social and digital advertising, including Google AdWords, Facebook, LinkedIn and Instagram adverts and now has its own dedicated website, www.cellfina.co.uk and www.cellfina.ie. Merz Pharma UK Ltd aims to provide complete training and customised marketing strategies tailored to its customers. The company has experience in staff training, marketing aesthetic treatments and patient relations. With this in mind, the Merz team offers a marketing and business personalised development partnership plan to meet the unique needs of a practice.

Cellfina® is a minimally-invasive cellulite treatment that offers precise results in a single in-clinic 45-60 minute treatment.5,8 Unlike other procedures, it treats the structural cause of cellulite dimples.5 A small needle-sized device is used to treat the cellulite-causing bands just beneath the surface of the skin. The needle breaks the bands up and releases them, like releasing a rubber band under tension, in turn allowing the skin to bounce back and smooth itself out, alleviating the dimpled appearance.4,5 What makes Cellfina® unique is that it hits cellulite at its core.4,5 It is the only EU CE-marked6 and US FDA-cleared7 procedure clinically proven to treat the primary structural cause of cellulite dimples.5 Cellfina® is seen as a simple yet effective treatment by Healthcare Professionals. It is now available in a number of clinics across the UK and Ireland.

Results A non-randomised open-label pivotal study was held across 45 subjects treated with Cellfina®.5 It demonstrated that patients noticed a smoother appearance on their thighs and buttocks in as little as 14 days.5 These results improved over time, and were maintained even at three years, with a 93% patient satisfaction rate.5 Figure 2 shows a patient who underwent one treatment of Cellfina®. The patient was concerned about the visible dimples on her buttock area and the ‘orange peel’ effect on the top of her legs and thighs. She explained, “I removed the dressings the next day and my husband could not believe the difference. The cellulite had completely gone, it is amazing.” When discussing the treatment, she added, “I did encounter bruising, which lasted two weeks and some tenderness but nothing to complain about. It is now four weeks since I had the treatment and the skin continues to improve. I am absolutely thrilled with the results.” Before

After

Figure 2: Female patient before and three months after one treatment of Cellfina®.

*1.7 billion is the total amount of post-pubertal females aged 25-60 worldwide. 85% of women (1.4 billion) are estimated to suffer from cellulite, based on projection figures collected through market research. For more information about Cellfina®, contact 0208 236 3516, or customerservices@merz.com REFERENCES 1. Worldometers, Population by gender, age, fertility rate, immigration <http://www.worldometers.info/ world-population/world-population-gender-age.php> 2. CEL-DOF1-001_01 Cellfina – Global cellulite market research, October 2016 3. Avram MM. Cellulite: a review of its physiology and treatment. J Cosmet Laser Ther. 2004; 6:181-185. 4. Green J, Cohen J, Kaufman J, Metelitsa A, Kaminer M, Therapeutic approaches to cellulite, Semin Cutan Med and Surg. 2015;34:140-143 5. Kaminer, M.S., et al., A Multicenter Pivotal Study to Evaluate Tissue Stabilized-Guided Subcision Using the Cellfina Device for the Treatment of Cellulite With 3-Year Follow-up. Dermatol Surg, 2017(0): p. 1–9. 6. Cellfina CE Mark Approval, July 2016 7. US Food & Drug Administartion, Cellfina, <https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/ pmn.cfm?ID=K161885> 8. Kaminer et al., Multicenter pivotal study of vacuum-assisted precise tissue release for treatment of cellulite. Dermatol Surg 2015;41:336-347

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Aesthetics | July 2018

Date of preparation June 2018

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Spotlight on: Calecim Professional Aesthetics examines the science and the uses of a new skincare range that is formulated using the stem cells from the umbilical cord lining of New Zealand red deer It is without a doubt that stem cells are an exciting innovation that is showing promise across the field of medicine.1 Due to their regeneration properties, the use of stem cells has become more common in the skincare arena. Calecim Professional is the latest stem cell innovation to hit the UK skincare market. Recently launched at the Aesthetics Conference and Exhibition (ACE) 2018, the three products within the range are formulated using stem cells that have been ethically and harmlessly harvested from the umbilical cord lining of New Zealand red deer. The Singaporebased biotech company behind the brand, CellResearch Corporation, claims that this is the first time that umbilical cord lining stem cells have been used in topical skincare to promote skin health.2

The science Calecim Professional was developed after scientists from CellResearch Corporation isolated two types of stem cell strains, epithelial and mesenchymal, from the umbilical cord lining membrane. Both stem cell strains actively produce proteins when they are grown in culture media. This protein mix in culture media is called Cord Lining Conditioned Media (CLCM), which, according to New York dermatologist Dr Doris Day, who has no affiliation with the company and started using the products after a recommendation from a colleague, can be used to direct skin cells to behave in a

‘youthful’ manner.2 She explains, “The cord lining stem cells secrete a mix of proteins, growth factors and cytokines and this helps skin repair, rejuvenate and behave in a more youthful way. It helps increase glycoproteins like hyaluronic acid (HA) in the skin, it encourages cell mobility in a specific direction, for example towards a wound for wound healing, it activates cells to help them divide or even self-destruct and that helps restore and work on epidermal cell turnover.”3,4 According to Dr Day, as well as the type of stem cells, their origin is also important. “These are infant stem cells, which gives greater longevity and there is also a very high yield. We are looking at six billion epithelial and six billion mesenchymal stem cells that are harvested from a single umbilical cord in one growth generation and you can get 30 generations of growth on top of that; so, the immense number of cells that you can harvest is incredible.”4 She adds that the next highest source is bone marrow at two million stem cells and the yield continues to decrease for other sources of stem cells such as fat and those that are plant-derived.5 There are three products within the Calecim Professional range: Serum, with 80% CLCM, Multi-Action Cream, with 50% CLCM and Restorative Hydration Cream, with 40% CLCM. Each contains a different concentration of hyaluronic acid, consolidated peptides or glycoproteins, fibronectin, albumin and soluble collagen.2

Aesthetics aestheticsjournal.com

Studies As Dr Day points out, CLCM was first developed and used for wound healing and other medical applications before aesthetics. “I think it’s the proper way to do things, to see if you can improve burns, chronic wounds, scars and other conditions and then see if there are aesthetic applications as well,” she states. US Food and Drug Administration (FDA) trials for wound healing are currently underway and plans are for Phase 1 to take place in the second half of 2018. Calecim Professional has been used in several clinical studies for aesthetic indications.6,7,8 One single-blinded split-face trial followed the recovery of 14 patients who underwent a full face carbon dioxide fractional laser resurfacing treatment. Immediately after the procedure the right side of the patients’ face was treated with 5cc of basal media, while the left was treated with 5cc of Calecim Serum; patients continued treatment at home for 30 days. Patients (14%) reported more warmth on the non-Calecim treated side at day one, at day seven (50%), and at day 30 (64%). They also reported more pain on the non-Calecim treated side at day one (21%), day seven (43%) and day 30 (71%). Redness reduction was also assessed, with perceived redness greater by 50% on day one, 57% on day seven and 65% on day 30 for the basal media treated side.7 Another study of 15 healthy subjects who applied Calecim Multi-Action Cream over their full face twice a day for four weeks showed positive results, with all patients reporting improvements in complexion with better-quality facial skin tone and definition. Assessment by a blinded plastic surgeon meanwhile noted an improvement in the appearance of eyebrow elevation with greater exposure of the eyelid folds, improved jawline contour, improved tone of nasolabial folds, decreased eye bag puffiness, lifted cheeks, and decreased jowling.8

Using Calecim in clinic According to Dr Day, Calecim can be used both as an in-clinic application after aesthetic procedures and at home. “I use this routinely after both ablative and nonablative laser treatments. I use the Serum immediately after the treatment and then I give patients the remaining product to use at home. Then I give them one of the Calecim creams to take home as part of their treatment regime,” she explains. Dr Day states that she has had especially

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Figure 1: A 28-year-old patient four days following a C02 laser treatment treated with Calecim Professional Serum on their left and basal media on their right. Patient’s left side shows decreased oedema.

good patient feedback after ablative treatments, she says, “Patients have told me that it feels soothing because it takes away the heat and the burning sensation and gives them instant relief.” As well as this, Dr Day also uses Calecim in other areas within her clinic. “I use the Serum for microneedling because it contains HA. In

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my hands, I find that this works as well as platelet rich plasma so can therefore save a lot of money for patients,” she explains. Dr Day has not noted any reactions to the products after using it for more than six months in her clinic, however says that as the Restorative Hydration Cream contains fragrance, reactions could be possible. Because of this, she states, “I use the Serum and then the Multi-Action Cream without the fragrance immediately after treatment for a week.” For maintenance, she notes that patients can choose to use the Hydration Cream which has fragrance in it. “The Serum and Multi-Action Cream have a little bit of a protein smell because they are so highly protein derived and not everyone likes that smell, so you have to take that into account,” she explains.

a priority for me. These stem cells are powerful, reliable and this range is a great asset to use along with other products in my practice.” REFERENCES 1. Explore Stem Cells, ‘Uses for Stem Cells, <http://www. explorestemcells.co.uk/UsesForStemCellsCategory.html> 2. Calecim Professional, <https://calecimprofessional.com/ calecims-technology.html> 3. Rivka C. Stone, Irena Pastar, Nkemcho Ojeh, Vivien Chen, et al, Epithelial-Mesenchymal Transition in Tissue Repair and Fibrosis, Cell Tissue Res, 2016 Sep; 365(3): 495–506. 4. Lim, IJ & Phan TT, ‘Epithelial and Mesanchymal Stem Cells From the Umbilical Cord Lining Membrane’, Cell Transplantation, Vol 23, 2014 pp.497-503. 5. Vangsness CT, Sternberg H, Harris L, ‘Umbilical Cord Tissue Offers the Greatest Number of Harvestable Mesenchymal Stem Cells for Research and Clinical Application: A Literature Review of Different Harvest Sites’, Arthroscopy. 2015 Sep;31(9):1836-43. 6. W. Olaya, Kate Kim, D. Kim, ‘CALECIM® Serum Reduces CO2 Laser Treatment Erythema & 7. Edema: a Randomized Controlled Double-blind Split-face Trial’, Mission Viejo, California, U.S.A. 8. Cheryl L Effron, Reduction of Pain and Discomfort post CO2 Fractional Laser resurfacing after the application of umbilical cord lining extract: A cingle-Blinded Split-Face Trail 9. Dr Ziv peled, ‘Improvements in Skin Tone and Cosmesis with Umbilical Cord Lining Extract Calecim: A Same Patient Control Study’, San Francisco, California.

An additional tool to the kit Dr Day concludes that Calecim Professional has been a welcome addition to her clinic. She says, “I think that having scientificallydriven, well-tested products that are well produced, which have consistent quality control and substance behind them, is

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Discover the finer points of skin rejuvenation Radara – Crow’s Feet focuses on the ‘crow’s feet’ area

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Radara patches use a unique, patented micro-channelling system to deliver high purity HA serum to the skin around the eyes. This innovative treatment repairs, rejuvenates and replenishes, diminishing fine lines for a smoother, firmer appearance. Radara can be used alone or in combination with other aesthetic treatments.

To order, please contact Customer Service: 03301 331135 Radara is exclusively provided through approved medical aesthetic or cosmetic skin clinics. Visit radara.co.uk for more information.

J000070 180x125mm.indd 1

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018

15/05/2018 16:00


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Case Study: Case Study: Dissolving Dermal Dissolving Filler Filler in the Lips

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to say no. Following explanation of the indication, benefits and risks of hyaluronidase, photographs were of hyaluronidase that it was may obtained. not dissolve all the taken and writtenand consent I particularly filler evenly, or it may in fact dissolve his own natural discussed his expectations from treatment, the effects hyaluronic acid. A standard protocol recommended by of hyaluronidase and that it may not dissolve all the the ACE group4 was followed. Hyaluronidase 15000iu filler evenly, or it may in fact dissolve his own natural ampoule was diluted with 5ml 0.9% sodium chloride hyaluronic acid. A standard protocol recommended by resulting in a 300 iu/ml solution. An intradermal patch the ACE group4 was followed. Hyaluronidase 15000iu test of 0.02ml/6iu was performed in the forearm, which ampoule was diluted with 5ml 0.9% sodium chloride Aesthetic nurse prescriber Kay Greveson was negative after a period of 30 minutes and the in a 300 iu/ml solution. An intradermal patch dissolves lip filler in a patient’s over-treated lips resulting procedure therefore deemed safe to proceed. The test of 0.02ml/6iu was performed in the forearm, Aesthetic nurse prescriber Kay Greveson treatment area was marked out and hyaluronidase was which was negative after a period of 30 minutes and There has been much media attention recently regarding injected into the upper lip under the skin using a 30g insulin syringe, explains how she used hyaluronidase to the procedure therefore deemed safe to proceed. complications arising from dermal fillers, particularly those due to the superficial area. The patient was monitored following dissolve filler intrained a patient’s over-treated lipsfor 30The treatment was appointment marked out (Figure 2) and administered bylip non-medically individuals. It is important to treatment minutes and aarea follow-up was arranged hyaluronidase was injected into the upper lip under 1 2 consider lip anatomy, patient expectations and product choice when in two days’ time. The patient was then reviewed in the clinic 48 hours the skin using a 30g insulin syringe, due to the superficial area. There has been much media attention recently regarding undertaking lip enhancement treatments and also to resist over-filling later, the lips were examined and photographs were taken (Figure 2). The patient was monitored following treatment for 30 minutes and a complications arising from dermal fillers, particularly those the lips. Dr Lee Walker advises in an Aesthetics journal article that The patient reported that the dermal filler had appeared to successfully follow-up appointment arranged in two days’ time. The patient administered by non-medically trained individuals. It is important practitioners should use no more than 1ml in the first clinic visit, in order dissolve within 12 hours of treatment with the hyaluronidase and the was 1 2 thenlip reviewed in thetoclinic 48 hours lips werewith examined and to considerover lip anatomy, expectations andtoproduct to prevent filling, andpatient states the ratio of upper lower lipchoice should upper had returned its normal size later, and inthe proportion the photographs werethat taken. patient reported dermalhe filler when undertaking andwhere also to be 40:60, except in lip theenhancement Afro-Caribbeantreatments ethnic group theresist ratio bottom lip. I advised if heThe wanted further dermalthat fillerthe treatment, 3 Dr Lee Walker advises in an Aesthetics journal had appeared to successfully within 12 hours of treatment over-filling the lips. should be 50:50. should wait two weeks to give thedissolve lip chance to heal and ensure the with the hyaluronidase and theby upper lip had returned to ititscame normal article that practitioners should use no more than 1ml in the first clinic hyaluronidase had been excreted the body. Unfortunately, to and inone proportion withviathe bottom lip. that I advised that ifhad he wanted visit, order to prevent over filling, and states the ratio of upper to Caseinstudy mysize attention week later, social media, the patient gone filler treatment,run heby should wait two weeks to give lower lip should bepatient, 40:60,who except in the ethnic group tofurther A 28-year-old male works as aAfro-Caribbean makeup artist and YouTube/ anotherdermal clinic, predominantly non-medical aestheticians, to the lip chance and ensure the hyaluronidase had been where theblogger, ratio should 50:50. Instagram camebe to my clinic3 requesting a more natural look for undergo a furtherto lipheal enhancement treatment. Rather dishearteningly, excreted by the body. Unfortunately, came to my attention one his lips, which had been treated elsewhere. He had no reported past from the photographs I saw on his posts,ithis lips appeared to have medical history, no known allergies and was not taking any long-term been filled to the were when had he first presented at my week later, via same socialvolume media, they that the patient gone to another Case study medication. Hismale aesthetic history hyaluronic acid-based clinic. I contacted the patient andnon-medical asked why he had done thistoagainst clinic, predominantly run by aestheticians, undergo a A 28-year-old patient, whoincluded works as a makeup artist and(HA) You dermal filler of unknown theclinic lips, on possibly two to three advicelip and he replied that he ‘did notI contacted feel like himself anymore’ enhancement treatment. the patient and asked Tube/Instagram blogger,amounts came totomy requesting a more natural myfurther occasions, 12-month at another clinic overseas. and realised hedone preferred fuller lips.my I believe my initial why he had this against advicethat andthis hesupports replied that he ‘did look for hisover lips, awhich had period been treated elsewhere. He hadHe nohad no reported complications from treatment, however, even though he suspicion of body dysmorphia. In retrospect, I believe the decision not feel like himself anymore’ and realised he preferred fuller lips. I reported past medical history, no known allergies and was not taking initially wanted medication. to achieve a His fulleraesthetic look in his lips, he now felthyaluronic he had tobelieve dissolvethat the dermal filler was correct one as of they did dysmorphia. look this supports mythe initial suspicion body In any long-term history included disproportionate volume. The patient could not remember which disproportionate to his face. Since this experience, I have started to was use the retrospect, I believe the decision to dissolve the dermal filler acid-based (HA) dermal filler of unknown amounts to the lips, on 5 particulartwo typetoofthree dermal filler was used but knew it was HA-based. a modified body scale as part of my consultation. correct one asdysmorphia they did look disproportionate to his face. Since this possibly occasions, over a 12-month period at another On examination, the had upper was visibly larger (Figure 1) with an experience, I have started to use a modified body dysmorphia scale clinic overseas. He nolipreported complications from treatment, approximate ratio of 60:40. Dermal filler was palpable in the lip as part of my consultation.6 however, although he initially wanted to achieve a fuller lookand in his lips, Conclusion had also infiltrated to the cutaneous upper lip. The lip felt very hard This was a case of overcorrection of the lips with hyaluronic acid filler, he now felt he had disproportionate volume. The patient could not to touch and in my opinion, the dermal filler that had been used was possibly secondary to poor choice of dermal filler, although this cannot remember which particular type of dermal filler was used but knew Conclusion ‘too thick’ for the area injected. The upper lip was protruding and it felt be proven. need to be mindful patient expectations it was HA-based. On examination, the upper lip was visibly larger This was Practitioners a case of overcorrection of theoflips with hyaluronic acid filler, appropriate to use hyaluronidase to dissolve the excess filler. Upon and motives for seeking treatment. They must also practice withinthis cannot (Figure 1) with an approximate ratio of 60:40 – the opposite of Dr possibly secondary to poor choice of dermal filler, although evaluation I aimed to get the ratios to the recommended 50:50 ratio, their competence and use products that they are familiar with to get Walker’s recommendations. Dermal filler was palpable in the lip and be proven. Practitioners need to be mindful of patient expectations suitable for the case study’s ethnicity. I was concerned that the patient the best outcomes. Social media can influence a patient’s decision to had also infiltrated to the cutaneous upper lip. The lip felt very hard and motives for seeking treatment. They must also practice within had a degree of body dysmorphia. Although I did not formally assess undergo treatment and can also give false images of ‘normal’. This may to touch and in my opinion, the dermal filler that had been used was their competence and use products that they are familiar with to get this using a validated scale, I did discuss this with him and asked why he have been the motivating factor for this particular patient to undergo ‘too thick’ for the area injected. The upper lip was protruding and it the best outcomes. Social media can influence a patient’s decision had so many treatments on his lips. He acknowledged that in his work treatment in the first place, as he has a substantial social media following felt appropriate to use hyaluronidase to dissolve the excess filler. I to undergo treatment and can also give false images of ‘normal’. as a blogger and social media influencer he gets offered a lot of free as a makeup artist. It is practitioners’ responsibility to assess patients’ was concerned that the patient had a degree of body dysmorphia. This may have been the motivating factor for this particular patient treatments and finds it suitability to undergo treatment and to advise them accordingly. Refusal Before Although I did not to undergo treatment in the first place, as he has a substantial social difficult to say no. He did of treatment may be necessary in some cases. formally assess this media following as a makeup artist. It is practitioners’ responsibility to seem to understand that Kay Greveson award-winning nurse them using a validated assess patients’ suitability is toan undergo treatmentaesthetic and to advise this has had an adverse prescriber with 14 years’may experience. She is in the owner scale, I did discuss this accordingly. Refusal of treatment be necessary some cases. effect on his appearance of Regents Park Aesthetics and splits her time between with him and asked and that he had ‘gone too REFERENCES working in the NHS and running her clinic. why he had so many 1. Robson, S (2016). Managing expectations associated with cosmetic interventions. ACE group far’. Following explanation guidance. Accessed online 14/1/18 Figure 1: Image taken before treatment treatments on his lips. of the indication, benefits 2. San Miguel Morgas et al (2015) Systematic review of “filling” procedures for lip augmentation REFERENCES regarding types of material, outcomes and complications. J Craniomaxillofac Surg. 2015 After and He risksacknowledged of hyaluronidase, 1. Robson, S (2016). Managing expectations associated with cosmetic interventions. ACE group guidance. Jul;43(6):883-906 Accessed online 14/1/18 that in hiswere work as a photographs Aesthetics Journal. Accessed online Https://aestheticsjournal.com/feature/lip2. 3.SanWalker MiguelL,Morgas et al (2015) Systematic review of “filling” procedures for lip augmentation regarding and social augmentation takenblogger and written types of material, outcomes and complications. J Craniomaxillofac Surg. 2015 Jul;43(6):883-906 King,L,M The UseJournal. of Hyaluronidase in Aesthetic Practice.; 2017, ACE group guidance. 3. 4.Walker Aesthetics Accessed online Https://aestheticsjournal.com/feature/lip-augmentation media consent wasinfluencer obtained.he Accessed online 14/1/18 4. King, M The Use of Hyaluronidase in Aesthetic Practice.; 2017, ACE group guidance. Accessed online does get offered a 5.14/1/18 David Veale, Nell Ellison, Tom Werner, Rupa Dodhia, Marc Serfaty and Alex Clarke I particularly discussed (2012) Development of a Werner, cosmetic procedure screening (COPS) Body 5. David Veale, Nell Ellison, Tom Rupa Dodhia, Marc Serfatyquestionnaire and Alex Clarke (2012)for Development lot of free treatments his expectations from Disorder.screening Journal of Plastic Reconstructive and Dysmorphic Aesthetic Surgery, (4), of of aDysmorphic cosmetic procedure questionnaire (COPS) for Body Disorder.65 Journal Figure 2: Image taken 48 hours after treatment and finds it difficult 530-532. www.dx.doi.org/10.1016 treatment, the effects Plastic Reconstructive and Aesthetic Surgery, 65 (4), 530-532. www.dx.doi.org/10.1016 32

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Psychodermatology is an emerging

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psoriasis or eczema that present with

Introducing Psychodermatology Dr Alia Ahmed outlines psychodermatology and introducing the service in clinic Psychodermatology is an emerging subspecialty that is geared to considering both the mind and the skin to provide holistic care to patients with dermatological diagnoses.1 Early texts, dating back to Hipprocrates (460-377 BC), recognised the effect of psychological states on the skin. However it was only really in the 1950s that the psychodermatology movement started, under its widely acknowledged founding by Dr Herman Musaph (1915-1992)1 and the first international conference was held in 1987. Recognising patients that may benefit from a psychodermatological approach is important to ensure good clinical outcomes and improve patient experiences. In this article I will discuss what exactly psychodermatology is and how you can introduce it into your own practice.

What is psychodermatology? Psychodermatology (also known as psychocutaneous medicine) is an umbrella term encompassing conditions that link the brain with the skin. It is an interface subspecialty that combines dermatology, psychology and psychiatry. The effect of the brain on the skin is mediated by the Hypothalamic-Pituitary-Adrenal (HPA) axis, which is activated by stress to up/ dysregulate inflammatory pathways and cellular processes to cause or exacerbate skin disease.2 Patients with psychodermatological diagnoses fall into three main categories:5 â&#x20AC;˘ Primary dermatological disorders caused by or associated with psychiatric comorbidity. For example, patients with

secondary psychiatric comorbidities like anxiety or depression secondary psychiatric comorbidities like anxiety or depression â&#x20AC;˘ Primary psychiatric disorders that present with skin disease. These include delusional infestation, body dysmorphia, obsessive compulsive tendencies (e.g. trichotillomania) â&#x20AC;˘ Dermatological conditions that require psychosocial support. For example, vitiligo, alopecia, urticarial, rosacea and acne There is increasing evidence to suggest that patients with dermatological disease have higher levels of psychological and psychiatric comorbidities than controls.3 According to the British Association of Dermatology (BAD), 85% of dermatology patients feel the psychosocial aspects of their skin disease are a major component of their illness, with 17% needing psychological support to cope; this was based on 127 responses from consultant dermatologists.4 Despite this, the number of dedicated psychodermatology services in the UK are falling.5

psychodermatology for up to a year, or through working in a specialised clinic on a regular basis. Other training resources include conferences and courses in psychodermatology. Dermatologists with a special interest in the topic can see and manage patients with psychological/ psychiatric comorbidity, and this may involve support from allied services like psychology. On a tertiary level, psychodermatology clinics can be jointly led by a dermatologist and psychiatrist seeing patients together to manage patients holistically. I believe that psychodermatological conditions are best managed by a dedicated psychodermatology multidisciplinary team (pMDT).5 This typically consists of dermatologists, psychiatrists, and specialist dermatology nurses (who may be trained in forms of psychotherapy, such as habit reversal). In addition, other healthcare professionals can form part of the pMDT to ensure patients are safely monitored in the community setting, for example child and adolescent mental health specialists (CAMHS), paediatricians, social workers, child/vulnerable adult safeguarding teams, and general practitioners/physicians.4 In order to establish a pMDT, access to clinical and social services is required. In the private setting, establishing the community links is just as important.

Psychodermatological recognition in patients Patients with psychodermatological conditions can present in a multitude of ways. One of the main presentations is body dysmorphic disorder (BDD) which has been covered comprehensively in previous articles in the Aesthetics journal by Dr Anthony Bewley, Dr Dimitre Dimitrov6 and Dr Sangita Singh.7 Other conditions that are common in this category and pertinent to aesthetic dermatology are acne, rosacea, alopecia, and obsessive compulsive tendencies, for example acne excoriee, trichotillomania, and skin picking.

Incorporating it in clinic

Assessing psychological impact of dermatological disease

Establishing psychodermatology services within the NHS is difficult due to lack of expertise in the area, as well as higher associated costs of a specialised service. General dermatologists may not be keen to initiate or monitor psychiatric medications, therefore a special interest and further training in this area is often required. This is typically as a subspecialty fellowship in

The crux of the psychodermatological consultation is to make adequate assessments of both objective and subjective impact of dermatological disease on the psyche of the patient. This assessment can be made using objective measures such as the Dermatology Life Quality Index (DLQI),10 Hospital Anxiety and Depression Scale (HADS),11 Patient Health

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Case Study One A 32-year-old Caucasian female presents with a facial rash. She occasionally develops spots on and around her nose. She feels the rash is made worse in heat and after alcohol. Her GP tried antibiotics, which help the spots, but the redness remains, which is her main concern. She has stopped socialising and feels people are always noticing her skin. Clinically she has fixed erythema in a centrofacial distribution. There are no pustules evident on first examination. Your clinical impression is that she has rosacea. As well as medical management of her diagnosis, it is important to let this patient know about the link between stress and rosacea and acknowledge the psychological impact. Rosacea is often aggravated by stress and patients may benefit from addressing stress management. It can also have a severe impact on quality of life, causing depression, anxiety, low confidence and self esteem.8 Patients who identify a negative impact on their quality of life will benefit from a holistic psychodermatological assessment and appropriate management. This may include direction to patient support platforms, psychological support, stress management, and formal assessment for psychiatric comorbidities like depression and anxiety that need treatment with systemic agents under supervision.

Case Study Two A 28-year-old Asian male presents with a history of acne since his teens. It mainly affects his face and back. He tells you although he now only develops a new spot weekly, he is concerned about the scarring on his skin. He feels self-conscious, especially at the gym and in front of his partner. He tells you he feels low about the way he looks. Clinically he does have evidence of moderate to severe acne scarring affecting his face and back, including both box and rolling scars. He has a number of hypertrophic scars on his shoulders. There are few inflammatory acneiform lesions on his forehead and back. He is keen to pursue cosmetic treatments for his scarring. In addition to aesthetic treatments for acne, this patient requires a thorough assessment of the impact of his skin on his quality of life. Acne is known to affect emotions, activities of daily living, social activity, study/work and interpersonal relationships.9 Early assessment of impact and timely management of psychological sequelae (e.g. through psychotherapy) can improve the experience of patients with acne independently of acne severity.

Questionnaire (PHQ),12 Cutaneous Body Index (CBI).13 These patient-reported outcome measures (PROMs) are increasingly important as this is a chance for patients to provide feedback on how they feel about their skin on a day-to-day basis. Serial measurements across consultations are helpful to assess improvement or deterioration and can be used as a basis for referral to psychodermatology services. There are a number of important questions healthcare professionals should all be asking patients with dermatological diagnoses, particularly if they are chronic. In-depth assessment can help identify psychological/psychiatric morbidity and thus facilitate better care and onward specialist referral. I believe that examples of appropriate questions are: • Are you able to concentrate? • Is your sleep affected? • Do you feel low in mood? • Do you feel tearful or anxious? • Does your skin stop you doing the things you want to in life?

• Are your relationships/physical relationships affected by your skin? • Is your social life affected by your skin? • How do you think your skin is affecting your loved ones?

Conclusion Dermatological conditions require holistic management, thus assessment of impact on quality of life of patients using either the questions suggested or objective measures is valuable. This can guide the need for specialty referral to psychodermatology services. If psychiatric comorbidities are identified such as depression or anxiety, adequate monitoring and further medical management via psychodermatology may be indicated. By providing a platform for both medical management of cutaneous disease and concurrent psychological assessment and support, psychodermatology services are ideally placed to manage patients who have been significantly affected by their skin. Such

holistic services are in demand by both patients and clinicians, and empower both to achieve better clinical outcomes. By acknowledging the adverse effect of skin disease on the mind, it is possible to directly impact the quality of life of our patients. Establishing psychodermatology services is a key target when thinking about promoting patient wellbeing in the dermatology setting, it requires specialist management and adequate training. I believe, these clinician-led services are the new face of dermatology in the 21st century. Dr Alia Ahmed is a consultant dermatologist working for Frimley Health NHS Trust. She graduated from St Bartholomew’s Hospital and the Royal London School of Medicine in 2008 and completed her dermatology training in London, becoming a consultant in 2017. REFERENCES 1. Arenas-Guzmán R. Psychodermatology: past, present and future. Open Dermatology Journal. 2011;5:21-7 2. Kim JE et al. Expression of Hypothalamic-Pituitary-Adrenal Axis in Common Skin Diseases: Evidence of its Association with Stress-related Disease Activity. Acta Derm Venereol 2013; 93: 387-393 3. Sampogna F et al. Living with psoriasis: prevalence of shame, anger, worry and problems in daily activities and social life. Acta Derm Venereol 2012; 92(3):299-303. 4. Lowry CL, Shah R, Fleming C et al, Clinical and Experimental Dermatology, A study of service provision in psychocutaneous medicine, 2014 5. Bewley AP et al. Introduction. In:Bewley AP, Taylor RE, editors. Practical psychodermatology. Oxford:Wiley Blackwell; 2014. p3-11. 6. Aesthetics journal, Recognising body dysmorphic disorder in aesthetic practice <https://aestheticsjournal.com/feature/ recognising-body-dysmorphic-disorder-in-aesthetic-practice> 7. Aesthetics journal, The red flag patient <https:// aestheticsjournal.com/feature/the-red-flag-patient> 8. Cardwell LA et al. Psychological disorders associated with rosacea: analysis of unscripted comments. Journal of Dermatology and Dermatological surgery 2015; 19(2):99-103. 9. Hazarika N, Archana M. The psychosocial impact of acne vulgaris. Indian Journal of Dermatology 2016; 61(5):515-520. 10. British Association of Dermatology, Dermatology Life Quality Index <http://www.bad.org.uk/shared/get-file. ashx?id=1653&itemtype=document> 11. Svri.org, Hospital anxiety depression scale <http://www.svri.org/ sites/default/files/attachments/2016-01-13/HADS.pdf> 12. Medical Care, Patient Health Questionnaire, https://journals. lww.com/lww-medicalcare/Abstract/2003/11000/The_Patient_ Health_Questionnaire_2__Validity_of_a.8.aspx 13. National Center for Biotechnology Information, Use of a Cutaneous Body Image (CBI) scale to evaluate self perceptionof body image in acne vulgaris <https://www.ncbi.nlm.nih.gov/ pubmed/25230060>

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Volumising the Face using PRF

occurs, platelet activation begins. Platelets transform from biconcave disks to fully spread cells.3 Tissue factor is released into the bloodstream and binds to VWF to initiate the extrinsic coagulation cascade, thus increasing thrombin production, which activates the molecule that forms blood clots.4 Apart from being a potent platelet activator, thrombin also converts soluble fibrinogen into tough, Dr Vincent Wong and Dr Maria Toncheva insoluble strands of fibrin through polymerisation.4 With the presence of VWF, the cross-linked fibrin mesh contracts discuss the combination of platelet-rich and hardens, forming a mesh atop the platelet plug and plasma and platelet-rich fibrin treatments completes the clot.3,4 After haemostasis, the woundas an alternative to dermal fillers healing process can be divided into three stages. In the inflammatory phase, platelet-derived growth factors are Since its introduction into the field of aesthetic medicine, we believe released into the wound site, resulting in the migration and division that platelet-rich plasma (PRP) has revolutionised the industry with of a variety of cells, ready for the proliferative stage. The proliferation the concept of non-surgical autologous facial rejuvenation. Patients stage is characterised by angiogenesis, collagen deposition, who are against traditional non-surgical treatments with fears of having granulation tissue formation, epithelialisation and wound contraction. â&#x20AC;&#x2DC;foreign bodiesâ&#x20AC;&#x2122; injected into them are now able to improve their With the variety of growth factors secreted by the platelets, visage using their own cells. With increasing demand, the indications fibroblasts are signalled to grow and form a new extracellular matrix; and uses of PRP are ever-growing. Apart from having great healing vascular endothelial cells form new blood vessels to supply the area and rejuvenation properties, recent histology studies have also shown and myofibroblasts decrease the size of the wound by gripping that PRP helps with neocollagenesis.1,2 A concern with PRP, however, is the wound edges and contracting. Once the roles are completed, early washout.3 In addition, traditional PRP (as a standalone treatment) unneeded cells undergo programmed cell death (apoptosis). During does not address volume loss that comes with facial ageing, instead wound maturation and remodelling, newly-formed collagen is addressing skin conditioning and skin health. In this article, we discuss realigned along tension lines to provide strength and elasticity.4 a way of using PRP and liquid fibrin, known as platelet-rich fibrin (PRF), to prevent the initial washout and to revolumise the face. Combining PRP and PRF Despite having the ability to stimulate cellular proliferation and tissue Understanding coagulation and wound healing growth, PRP is still limited when it comes to revolumisation and dermal In order to understand how PRF works, we must first understand the augmentation due to fluidity of plasma and early washout5-8 where clotting process and wound healing. When the endothelial layer is it only stays in the tissue for approximately 48 hours.9 However, disrupted, platelets are anchored to the subendothelium by collagen when PRF is formed by mixing PRP with liquid fibrin, the presence of and von Willebrand factor (VWF), which plays an important role in a fibrin mesh means that the platelets are held in place for longer.9 3 haemostasis following vascular injury. Within seconds after adhesion Furthermore, the cross-linking of the fibrin network adds viscosity to the mixture, making it an ideal alternative to dermal fillers Difference between PRP and PRF for restoring lost volume. As a second generation platelet Platelet-rich plasma concentrate, PRF has been The platelet-rich plasma (PRP) consists of high concentration of autologous platelets suspended used in bone grafting, bone in a small amount of plasma after centrifugation of the blood of the patient. The PRP is a product growth, graft stabilisation, wound derived from blood. Its characteristic is due to the fact that the platelets present in the PRP release healing and various other dental numerous substances that promote tissue repair and affect the behaviour of other cells. surgical indications with excellent results.10,11,12 Indeed, a recent study Platelet-rich fibrin of 15 patients with an average The platelet-rich fibrin (PRF) is a modern platelet concentrate and it is achieved with a simplified age of 54 has suggested that preparation, with no biochemical manipulation of blood. This technique does not require PRF is effective in providing anticoagulants or bovine thrombin (or any other gelling agent). This feature makes the product significant long-term diminution easily usable, with a low rate of mistakes during the preparation stage. The fibrinogen is initially of deep nasolabial folds, with concentrated in the upper part of the tube but, upon the contact with thrombin, normally present in results lasting more than 12 the blood, it is converted into fibrin. The platelets are retained into the meshes of fibrin.13, 14 weeks from one treatment session.9 Additionally, there were PPP PRP PRF no reports of fibrosis, irregularity, Platelet counts low high high hardness, restricted movement or lumpiness.9 Platelet-released low high high As part of our training protocol, to growth factors achieve the best results, platelets Fibrin low, weak low, weak high, strong must be harvested and mixed with Figure 1: Table highlighting the differences between platelet poor plasma, platelet rich plasma and the fibrin matrix correctly. Dr Maria platelet rich fibrin.1,15 Toncheva has pioneered a simple

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yet effective protocol for combining PRP and PRF as an alternative to traditional fillers. In this protocol, whole blood is collected into two PRP tubes and one PRF tube. After centrifugation, PRP is extracted from the PRP tubes. In the PRF tube two components will be present: a plasma clot and liquid thrombin serum (LTS). The extracted LST is mixed thoroughly with PRP into the syringe. This mixture must be injected into the desired treatment areas using dermal filler techniques, in a timely fashion. The treated area can then be massaged and moulded accordingly. PRF provides a 3D structured scaffold for revolumisation.9,10,11 As the platelets are held in place by the fibrin mesh, PRF provides gradual growth factor release, thus making it an effective treatment for rejuvenation with a longer-lasting result than regular PRP.11 The platelet concentration is also higher compared to standalone PRP, allowing PRF treatments to produce superior results. As the regeneration process involves all soft tissue layers from skin to bone, the results are very natural with no risk of over-filling as the treatment stimulates natural revolumisation and there is a natural limit to the rate of tissue or cell replication. Excess cells will undergo apoptosis and the volume from the fibrin will gradually wear off like dermal filler.9 By harnessing the power of platelets, PRF also has strong natural healing properties â&#x20AC;&#x201C; we find this is particularly useful in younger patients who would like to prevent the first signs of ageing. As with PRP treatments, PRF is 100% autologous, making it a safe treatment choice with no risks of allergies.1

Aesthetics Journal

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12 weeks. This is due to the fact that the treatment relies heavily on platelet count and the quality of the platelets. Hence, patient selection plays a vital role in having a successful PRF treatment. Ideal candidates should be fit and healthy and not pregnant or breastfeeding at the time of the treatment. Other exclusion criteria should include patients with clotting disorders (or medications affecting blood clotting, such as aspirin), liver pathology, and those suffering from or battling with cancer.

Case Study A 43-year-old female patient presented with mid-facial volume loss. After the initial consultation, treatable areas were identified. The patientâ&#x20AC;&#x2122;s expectations were discussed and they seemed realistic and achievable. We presented the patient with a list of treatment options, including dermal fillers and surgical interventions, with the pros and cons explained in detail. As this was the patientâ&#x20AC;&#x2122;s first aesthetic treatment, she opted for PRF, as she perceived this to be the most natural option. Photos were taken before Before

After

Complications and patient selection The side effects of PRF treatments are minimal and transient when done correctly. These include bruising, swelling, erythema and discomfort, which are common for all injectable treatments. However, due to the nature of the treatment, good knowledge of facial anatomy is extremely important. As the treatment involves injecting a viscous material into the face, it is crucial that we do not obstruct or occlude any vessels. Unlike hyaluronic acid dermal fillers, there are no straightforward methods of dissolving PRF. For safety reasons, it is recommended not to inject PRF in highly vascular areas such as the temple region, tear trough and lips. As with PRP treatment, the results can vary from patient to patient and some patients may require more than one treatment session after

The cross-linking of the fibrin network adds viscosity to the mixture, making it an ideal alternative to dermal fillers for restoring lost volume

Figure 2: Images depicting before the increase in volume (left) and immediately after PRF treatment (right). Before

After

Figure 3: Volume comparison immediately after PRF (left) and eight weeks after PRF treatment (right). Before

After

Figure 4: Changes in volume before (left) and eight weeks after PRF treatment (right).

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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treatment using a facial volume and skin complexion analysis system and all consent forms and medical questionnaires were signed. During treatment, whole blood was collected, centrifuged and platelets were harvested and mixed with liquid fibrin as per the PRP manufacturer’s protocol. For patient comfort, we applied topical numbing agent (EMLA) for thirty minutes prior to treatment. A total of 5ml of PRF was injected using a needle as the injection has to be done quickly before the PRF becomes too viscous to inject. The PRF was then distributed between the cheeks and nasolabial areas. The patient tolerated the treatment well. Overall the treatment took 45 minutes; 30 minutes for numbing and 15 minutes of injection time. Photos were taken again immediately after the treatment.16 We reviewed the patient eight weeks after the treatment. She was very pleased with the outcome. Apart from small bruises, she did not experience any other side effects. More photos were taken during this visit, and we analysed all photos for volume differences using our imaging system software. As seen in Figure 2, there was a significant change in volume immediately after the treatment. Figure 3 compares the photo taken at followup with the photo taken immediately after treatment. Although the volume was less at the follow-up visit, this change was not significant and the difference was probably due to swelling immediately post procedure. Figure 4 compares the change in volume before the treatment and at follow-up. There were no significant changes in overall facial volume between immediately after the treatment and eight weeks after, meaning that the volume lasted eight weeks. To maintain results, we recommend that patients have another treatment after 12 weeks as the skin quality and texture will improve each time. However, this varies from patient to patient as some can wait longer between treatments. As the tissues naturally limit how much revolumisation a patient receives, there is no risk of overfilling.

Aesthetics Dr Vincent Wong is an award-winning cosmetic doctor at Bader Medical Institute of London. Dr Wong runs regular training courses and workshops for healthcare professionals and mentors junior colleagues. He has also presented his work at numerous national and internal conferences. Dr Wong has also been featured in press on TV and radio. Dr Maria Toncheva specialised in dermatology after graduating as a doctor and now practises in the US, UK and Bulgaria. Dr Toncheva has developed and pioneered a protocol for combining PRP and PRF as an alternative to dermal fillers. She regularly practises from Harley Street in London and trains medical professional from all over the world. REFERENCES 1. Sclafani AP1, Azzi J. Platelet Preparations for Use in Facial Rejuvenation and Wound Healing: A Critical Review of Current Literature. Aesthetic Plast Surg. 2015 Aug;39(4):495-505. doi: 10.1007/ s00266-015-0504-x. Epub 2015 Jun 5. 2. Ozlem et al. Histologic Evidence of New Collagen Formulation Using Platelet Rich Plasma in Skin Rejuvenation: A Prospective Controlled Clinical Study: Authors’ ReplyAnn Dermatol. 2018 Feb; 30(1): 111. 3. Sadler JE. Biochemistry and Genetics of von Willebrand Factor. Annual Review of Biochemistry. 1998 July; 67:395-424. doi: 10.1146/annurev.biochem.67.1.395 4. Brummel S. Butenas S. Mann KG. What is all that thrombin for?: The Journal of Thrombosis and Haemostasis. 2003 June; 1(7): 1504-1514. doi: 10.1046/j.1538-7836.2003.00298.x 5. Matz et al. Safety and feasibility of platelet rich fibrin matrix injections for treatment of common urologic conditions. Investig Clin Urol. 2018 Jan;59(1):61-65. doi: 10.4111/icu.2018.59.1.61. Epub 2017 Dec 21. 6. Conde Montero E et al. Platelet-rich plasma: applications in dermatology. Actas Dermosifiliogr. 2015 Mar;106(2):104-11. doi: 10.1016/j.ad.2013.12.021. Epub 2014 May 1. 7. Leo et al. Systematic review of the use of platelet-rich plasma in aesthetic dermatology. J Cosmet Dermatol. 2015 Dec;14(4):315-23. doi: 10.1111/jocd.12167. Epub 2015 Jul 23. 8. Gawdat et al. Autologous platelet-rich plasma versus readymade growth factors in skin rejuvenation: A split face study. J Cosmet Dermatol. 2017 Jun;16(2):258-264. doi: 10.1111/jocd.12341. Epub 2017 Apr 5. 9. Sclafani AP Safety, efficacy, and utility of platelet-rich fibrin matrix in facial plastic surgery. Arch Facial Plast Surg. 2011 Jul-Aug;13(4):247-51. doi: 10.1001/archfacial.2011.3. Epub 2011 Feb 21. 10. Saltzman et al. The Effect of Platelet-Rich Fibrin Matrix at the Time of Gluteus Medius Repair: A Retrospective Comparative Study. Arthroscopy. 2018 Mar;34(3):832-841. doi: 10.1016/j. arthro.2017.09.032. Epub 2017 Dec 26. 11. Di Liddo et al. Leucocyte and Platelet-rich Fibrin: a carrier of autologous multipotent cells for regenerative medicine. J Cell Mol Med. 2018 Mar;22(3):1840-1854. doi: 10.1111/jcmm.13468. Epub 2018 Jan 5. 12. Sclafani AP. Platelet-rich fibrin matrix for improvement of deep nasolabial folds. J Cosmet Dermatol. 2010 Mar;9(1):66-71. doi: 10.1111/j.1473-2165.2010.00486.x. 13. Giannini et al. Comparison between PRP, PRGF and PRF: lights and shadows in three similar but different protocols. European Review for Medical and Pharmacological Sciences. 2015 Mar; 19 (6):927-930. 14. Marukawa E. Hatakeyama I. Takahashi Y. Omura K. The effects of autogenous plasma and platelet-released growth factors in bone regeneration. Tissue Engineering. Part A. 2014 Feb; 20 (3-4):874-882. doi: 10.1089/ten.tea.2013.0058 15. Dohan et. al. Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends in Biotechnology. 2009 Mar;27(3):158-67. doi: 10.1016/j.tibtech.2008.11.009. Epub 2009 Jan 31. 16. Data on file

Conclusion PRF is a safe and reliable treatment option for soft tissue rejuvenation and dermal augmentation. With the ability to restore lost volume, it adds to the ever-expanding list of aesthetic indications for PRP. Although it will not replace dermal fillers in aesthetic practice, it is an effective alternative for patients who might feel they are too young for dermal fillers and those who would prefer a more natural treatment. Disclosure: Dr Vincent Wong and Dr Maria Toncheva are both ambassadors for PRP Lab UK.

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Treating a Cleft Chin Dr Gabriel Siquier Dameto discusses the attractiveness, characteristics and various treatment methods for a cleft chin What is a cleft chin? A cleft chin refers to a chin with a Y-shaped dimple in the middle.1 It’s usually a dominant genetic trait. Cleft chins form during embryological development and are caused by one of the following issues; either the mandibular processes have not fused properly at the level of the mandibular symphysis which created an indentation,2 or the chin muscles, known as the mentalis muscles, on both sides of the dimple are further apart than normal, effectively pulling in the skin around the chin area. In the vast majority of instances, chin clefting is caused by how the mentalis muscles are situated. The mentalis is a paired central muscle of the lower lip, situated at the tip of the chin. It originates from the mentum and inserts into the chin soft tissue. The mentalis is located in the triangular space that delimits the depressor muscle of the lower lip on both sides of the midline; between the upper part of the symphysis and the mental eminence. It is even, small and conoid. The mentalis is inserted on the upper part in the lower maxilla below the incisive eminences and the canine, below the gums; and in the lower part, at the skin of the chin.3 In the case of a cleft chin, there is either a wide space between the two mentalis muscles or they are particularly large, creating a ‘valley’ of sorts between them.

Attractiveness of a cleft chin Cleft chins are often considered a sign of attractiveness and beauty, as well as a sign of power. In Persian literature, the chin dimple is metaphorically referred to as ‘the chin pit’ or ‘the chin well’; a well in which the poor lover is fallen and trapped.4 But the appreciation of beauty is, most of the time, dependent on personal preferences and fashion. As such, there are individuals

who don’t like the cleft chin as it can be seen as a rude feature in men or as a masculinising feature in women; in this way a cleft chin can sometimes be referred to as a ‘butt chin’ with derogatory connotations.

Differences in cleft chins between men and women

There are some differences regarding how the cleft chin presents in men and women. Generally, the dimple in men is deeper and wider, forming vertical and Y-shaped furrows. In women however, the dimple commonly appears less deep, softer and centered, forming round dimples. This is due to the fact that usually the inferior maxilla of a women is smaller than in men.

Treatment methods Before performing a treatment to enhance or to remove a cleft chin it is important to consider the risks associated with the treatment, to be explained hereafter. Different treatment options are offered, largely depending on whether the patient wants to have a temporary or permanent result. Temporary results can be achieved with various fillers and injectables, if the patient is willing to undergo surgical options then the result will of course be permanent. This article will focus on removing the cleft chin rather than enhancing, which is a less popular treatment, usually to help with the appearance of ageing. Chin fillers The easiest and most direct way to remove a cleft chin is simply by placing hyaluronic acid (HA) filler into the chin area. HA fillers can be injected directly into the dimple, effectively raising the skin in the dimple area to bring it into proportion with the rest of the chin. To achieve this lifting effect and to replenish the deficit of tissue volume in the chin, a high viscosity filler must be used. This will guarantee a longer lasting result and enough lifting capacity. The HA filler is injected with a needle directly onto the maxillary bone where the dimple is located. Filler must be injected with the bolus technique. I would recommend practitioners inject 0.1 ml while counting to ten, this is mainly to avoid complications as slow injections

Syringe

Skin

Pyramidal bolus

Some extra product can be placed subdermally with a cannula and fanning technique. In this way the surface gets smoothened for having a more natural final look.

Combination pyramidal bolus and fanning technique

Combination pyramidal bolus and fanning technique, if necessary more pyramidal bolus can be added along the Y-shape.

Intramuscular injection points for botulinum toxine on the mentalis muscle

Bone The HA filler I use is Aliaxin GP or EV and is injected with a needle directly on to the maxillary bone where the dimple is located. Filler must be injected with bolus technique. I would recommend you inject 0.1 ml while counting to ten. Then while retracting the needle, continuously inject the product in order to create a sort of pyramidal bolus.

Figure 1: Summary of different techniques used for treating a cleft chin

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


aestheticsjournal.com Before

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Six months after

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Personally, my preferred treatment is a combination of HA filler with botulinum toxin. In my opinion this is less invasive, with reduced or no downtime for the patient and immediate results.

Preventing complications

Figure 2: Images demonstrate before and six months after a cleft chin treatment using Aliaxin EV.

and small boluses tend to be safer. Then, while retracting the needle, continuously inject the product in order to create a sort of pyramidal bolus. Two further injections can be administered to the lower corner of the mandible at a 1cm distance from the medial facial line to lengthen the face or visually expand the chin.5 The insertion point is at the lower jaw corner directly inferior to the corner of the mouth. If necessary, some extra product can be placed subdermally with a cannula and fanning technique. In this way, the surface is smoothened to achieve a more natural final look. The quantity of product normally needed for a cleft chin treatment can vary between 1 to 3ml of HA filler. Sometimes, if the dimple is very deep, or in case of mentalis hyperactivity, I believe it is be better to conduct the treatment in two sessions with a one month interval. In clinic, I prefer to do a dosage control of botulinum toxin, which I go on to discuss in more detail below, after one month to see if a top up is even necessary. It also helps to monitor any swelling or complications. Although HA fillers are a quick and generally safe option, the results will not be permanent and the effects will last for around 12 months. It is wise to advise the patient to have a top-up session every eight months in order to achieve continuous results. Botulinum toxin injections Botulinum toxin is a purified toxin that blocks the nerve signals from the brain to the muscle;6 this results in the relaxation of the muscles. As previously mentioned the cleft chin can be formed because of the depression between the two mentalis muscles and botulinum toxin can paralyse these muscles, consequently reducing the appearance of the cleft. The effects of botulinum toxin, however, only last for around three to six months depending on the individual and it will not have the filling capacity. On the other hand however, it is a good ally to complement the HA filler treatment. Surgical options There are also other options to treat the cleft chin such as fat grafting or surgery. These treatments can have a longer lasting effect but they also need more recovery time and they can have more serious complications such as infection, excessive bleeding, scarring, swelling or undesirable results. When performing fat grafting it has to be considered that the size of the chin will be increased and some patients will not be happy with this new appearance. Surgical solutions to correct a cleft chin can involve chin implants, modifying the chin bone itself and addressing the placement of the mentalis muscles, or a combination of these last two options. Whichever treatment the patient may choose, surgical or non-surgical, it is important to keep in mind that it is nearly impossible to reverse a particularly prominent cleft chin by only one type of treatment.

As with all kinds of filler treatments, understanding and respecting the anatomy of the treated area is very important. Early and late complications with varying levels of severity otherwise may otherwise occur. For example, an intravascular injection can cause the development of local skin necrosis, a massive microcirculatory embolism and/or external compression of the chin skin microvasculature. Another complication recently published is a vascular compromise in the tongue.7 This occurred after chin augmentation with HA. The filler was possibly injected into the sub-mental artery or its branches, which then was most likely to have travelled to the deep lingual artery, before causing the vascular compromise. In the case of suspecting a sign or presence of vascular compromise, hyaluronidase must be injected immediately to the treated area and the compromised area. To avoid vascular events, my professional opinion is that injection techniques such as use of a blunt cannula, slow injection, low-pressure injection, moving the needle while injecting, and use of a small bolus per injection should be applied.

Conclusion Although more permanent results for treating the cleft chin can be achieved through surgical options, I believe that a combination treatment of HA filler and botulinum toxin will have a much more positive, less invasive approach. I think it is also important to make patients aware that cleft chins are often perceived as a sign of beauty throughout the world, which is another reason to recommend filler treatments as they don’t last forever. Every aspect of the treatment should be discussed in the consultation to ensure the patient is suitable, it may also be worthwhile to carry out a body dysmorphic disorder (BDD) test if you are initially concerned. Possible complications that could occur should also be discussed. Dr Gabriel Siquier Dameto is the founder of Dameto Clinics International, as well as member and instructor of the International Threads Academy. He is also a certified member of the Dutch Society of Aesthetic Medicine, the President of PeruEsthetic International and HA-Derma’s UK key opinion leader. Dr Siquier Dameto has recently been awarded the International prize ‘Manos de Oro’ (Golden Hands) 2017 in Lima, Peru for his scientific and academic contribution to the growth and research of responsible aesthetic medicine. REFERENCES 1. Healthline, What causes a cleft chin? 2017, < https://www.healthline.com/health/cleft-chin#causes > 2. Krarup, S et al. “Three-Dimensional Analysis of Mandibular Growth and Tooth Eruption.” Journal of Anatomy 207.5 (2005): 669–682. PMC. Web. 26 May 2018. 3. Henry F.R.S. Gray, Anatomy of The Human Body (Philadelphia and New York: Lea & Febiger, 1918), p. 338. 4. Persian Dictionary Dehkhoda, Wells, 2017 < https://web.archive.org/web/20140808065350/http:// www.loghatnaameh.org/dehkhodaworddetail-37e7cdd30d8843bf88822f21885bc505-fa.html> 5. Gabriel Siquier and Natalia Mikhaylova, Correcting Aging Face in Men with HA Fillers, Anti-Age Magazine 26 (2017), 104-105 (p.105). 6. Ornella Rossetto, ‘The binding of botulinum neurotoxins to different peripheral neurons’, Toxicon, 147 (2018), 27-31. 7. Qianwen Wang and others, Vascular Complications After Chin Augmentation Using Hyaluronic Acid, Aesth Plast Surg, 42 (2018), 553–559 (p. 553)

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Minor Surgery in an Aesthetic Clinic Dr Ruth Harker provides her advice to doctors and nurses involved in minor surgery in aesthetic practice, explaining ‘the good, the bad and the ugly’ I don’t know if you’ve tried to get anything removed on the NHS recently? Well, unless it’s suspicious for malignancy – the Bad – it is unlikely to be done. The strain on the NHS means that non-life-threatening procedures go to the bottom of the waiting list or, in many cases relating to cosmetic appearance, patients are refused treatment altogether. I believe this has caused an increase in demand for private treatment for concerns such as compound or intradermal naevi (ordinary moles) as patients simply dislike having them – the Good! – and skin tags, warts, seborrhoeic keratoses, epidermoid cysts and lentigines that are unsightly – the Ugly! Seborrhoeic keratoses are common, and some people’s torso is covered in them, so they are very grateful for treatment. Pilar or epidermoid cysts are often in conspicuous positions on the scalp, forehead, and neck or back and, again, it is a real service to the patient to remove them. Often patients

can have a large collection of skin tags around the neck, the axillae and the groins that they report makes them feel ‘dirty’ and unconfident. This article aims to provide tips to doctors and nurses who have a background in surgery/minor surgery and knowledge and training in dermatology, who are involved in or considering incorporating minor surgery into their aesthetic clinic. The operating room should be fit for purpose and ideally be within a clinic that is accredited by the Care Quality Commission (CQC).1 The practitioner must be registered with the General Medical Council (GMC) or the Nursing and Midwifery Council (NMC), have adequate and correct medical indemnity to cover minor surgery. For any procedures involving incision of the skin (scalpel, punch biopsy) the practitioner will need to be CQC registered as an individual. Curettage, cautery, cryotherapy are below the remit of CQC. must be adhered to and an assistant is required.

Diagnosis tip These days, a common tool used by dermatologists is dermoscopy. This is used to diagnose skin lesions and differentiate the benign – the Good – from the malignant – the Bad.3 A dermoscope (also called dermatoscope) is a hand-held instrument with an intense light source to look at the deep layers on the skin. Once proficient, practitioners can use this tool on every patient they see. In experienced hands, dermoscopy increases the specificity of diagnosing melanoma approximately 15 fold,3 and saves many wasted referrals and patient anxiety with referrals to the skin cancer clinic for benign lesions. I would encourage all aesthetic practitioners to get training in dermoscopy and integrate it into all skin consultations.

Aesthetics vs. NHS In aesthetic practice, the usual lesions we are dealing with are seborrheic keratosis, viral warts, skin tags, benign papillomas, benign naevi (common moles) and benign cysts/boils.2 We have a different scenario to that commonly seen in the NHS. In a skin cancer clinic on the NHS, a biopsy is taken from a suspicious lesion to confirm diagnosis and plan treatment. However, in an aesthetic clinic, the practitioner should be confident that they are dealing with a benign lesion. If there is any doubt that it is not benign, the practitioner should refer the case to a consultant dermatologist with a full history, examination of the findings and photographs with their differential diagnosis for excision at hospital. There is no place for monitoring a suspicious lesion; if in doubt cut it out! Comparatively, in aesthetic practice, minor surgery is performed and the whole specimen is sent to a hospital pathology laboratory, with details of exact site, size, duration and provisional diagnosis for confirmation that it is benign. It is explained to the patient that the specimen will be checked at the laboratory by a histopathologist as a routine standard measure and the result will be back in a few weeks. In the rare circumstance the specimen reveals a cancer, then the practitioner must refer the patient to a skin cancer clinic. Consulting patients During the consultation, a full medical history should be taken. The common patient question, “Can you have a quick look at this?” is correctly answered by saying, “No; I’ll have a careful and thorough look at the whole problem.” This is important as some skin problems are the result of a systemic disease that affects the whole patient, for example rheumatoid nodules, gouty tophi or the butterfly rash of systemic lupus erythematosus.4 The patient must be examined carefully and the practitioner should identify and detail how long the lesion has been present for, and if there has been any change over time. A blemish or mole that has been life-long or present for many years and not changed is highly likely to be benign.5 It is important to ask if the patient has any other similar lesions and examine the whole body. The dermatological examination findings should be accurately recorded and photos should be taken using a ruler in good light. This is important for comparing the scar in later days, should there be a scar.

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Scar formation should also be discussed, explaining that you will do your best to minimise scarring but cannot guarantee that there will be no scar at all. I always say to patients that they currently have a lump/lesion that they know well, but after minor surgery they will end up with a new scar they don’t know – even though the scar may be minimal – and so they need to be really sure it’s worth it for them. Practitioners should also emphasise that patience is needed as the final result cannot be seen for some weeks and that the appearance should continue to improve. As healthcare professionals know, for the first four weeks or so, the operated area will be red, then fade to pink, then fade to its natural colour and merge in completely with the surrounding skin some months later. This simple explanation during the consultation can save a lot of questions post treatment. Practitioners should identify if the patient has any rare risks, such as haemorrhage, nerve damage, wound infection, dehiscence, inadequate closure or removal, diabetes (infection and slow healing is common), poor healing, a history or family history of keloid or hypertrophic scars, drug history, any illness, recent surgery, allergies and, importantly, is taking anticoagulants (risk of bleeding in surgery).2 In my opinion, skin surgery in pregnancy is best avoided and patients with pacemakers and implantable defibrillators require special precautions.5 If the patient is taking psychotropic drugs, anxiolytics or antidepressants, then the practitioner should consider whether the operation is appropriate, whether the patient’s mental state has influenced their decision to have the lesion removed and if they will cope with the local anaesthetic procedure. It is worth asking the patient how they fare at the dentist, whether they tolerate the local anaesthetic or have had any side effects from it. These days it’s common practice for aesthetic practitioners to go through a body dysmorphic disorder (BDD) questionnaire to check the patient is suitable for treatment so I would also recommend this for minor surgery.6 Only when all the above has been discussed and all patient queries answered, should an informed consent be obtained for an agreed fee and a date arranged for the procedure. A ‘cooling-off’ period is where the patient having received all the possible information about the operation can go home and reflect upon it and decide whether they still wish to go ahead with the procedure.7 Likewise, the practitioner may also decide that due to risks

they do not wish to operate on this patient. In particular, this applies to substantial general anaesthetic procedures. If the patient is not in good health, is frail, is on any medication causing increased risk (for example is taking anticoagulants), has BDD or has not thought about the decision carefully, the operation should be postponed, however trivial.

Aesthetics Journal

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Safety tip I believe that it is unsafe for practitioners to operate alone. In case of adverse events such as haemorrhage, vasovagal episode, epileptic fit, anaphylactic reaction or, myocardial infarction, the practitioner should work with a trained assistant. Sterile technique must be adhered to, and it is very hard to maintain a sterile field without an assistant, otherwise one must re-glove every time you need to find or open an item.

Treatment options Details of each type of minor surgery for lesions is beyond the remit of this article, but they include the use of radiofrequency, excision, or cryotherapy. These days, minimally-invasive techniques such as radiofrequency surgery are common in aesthetic clinics.8 In my experience, radiofrequency is particularly successful for actinic lentigines, which are commonly referred to as ‘liver spots’ on the backs of the hands or ‘tea stains’ on the cheeks. Radiofrequency surgery uses no physical effort from the practitioner, but uses part of the electromagnetic spectrum between a laser and a microwave. The operative result is achieved with less tissue damage than conventional excision or curettage and cautery and the wound healing is usually quicker with less scarring. It also has a very high safety profile with less postoperative side effects. Also, fatty eyelid streaks (xanthelasma), spider naevi and telangectasiae (dilated blood vessels) can be dealt with radiofrequency ablation or point hyfrecation9 (focused and insulated electrocautery) can be used for these. Curettage or shave excision are very commonly used methods with excellent wound healing in the right hands. Curettage is used to scrape off raised skin lesions using a sharp cup or ring-shaped tool, whereas shave excision is performed by drawing the flat blade of a scalpel through a raised lesion, across the skin, to remove it.5 Excision of large cysts can be challenging, especially if previously infected, and caution must be exercised as to what cases the practitioner accepts to operate on.5 Cryotherapy (freezing treatment) appeals to the public as it is a ‘quick fix’. However, it can be painful and, in my experience, blisters and atrophic scars are frequent and incomplete removal is common. There is also no histological diagnosis.6 Needless to say, all the previously

mentioned techniques need to be learnt through repeated practical training under the supervision of a surgeon. A different technique is used depending on the nature of the lesion; for example, a crumbly soft seborrheic keratosis can easily be curetted, whereas a macular lesion (completely flat) may need to be excised. Patient comfort In my clinic, the patient journey is made as pleasant as possible with relaxing music, a stress ball for local anaesthetic injections and an empathic nurse at hand. One needs to explain to the patient that they only have to be brave for a few seconds for the local anaesthetic injection, after that they will feel cool antiseptic being applied and should suffer no pain. Extra local anaesthetic can easily be added at the slightest sign of pain. Some patients are very anxious by nature and offering a sedative anti-histamine such as chlorphenamine can be useful to avoid swelling and can also calm the patient down (providing they have a companion to take them home as it causes drowsiness).10 Post-procedure care Following the procedure, the aftercare should be explained verbally and a patient leaflet given with the practitioner’s contact number in case of infection. Wound care varies as to whether it is a shave excision (heals like a graze and wound should be kept moist) or a wound with surface stitches (must be kept dry until stitches removed). This is explained carefully to the patient at the time. After minor surgery, the new skin may be tender for a few weeks and so patients should be advised to avoid sun exposure on the area by keeping the scar covered with clothing or if the skin must be exposed they should use a high SPF sunscreen (30 or greater) on the area for approximately six months. This is because the area will be more sensitive to sunlight. Remember, sun avoidance is always more effective than sun protection cream.

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


Clinical Practice News A deferred prescription for antibiotics may be wise in some cases of increased infection risk such as diabetes, or if the patient lives far away.11 First-aid measures of how to deal with infection and bleeding should also be mentioned to the patient. From recent lectures on surgical technique, with best practice, wound infection should be 1% or under in uncomplicated cases; poor practice can lead to infection rates reaching 10% or more.11 It is well recognised that using a drying, alcohol-based antiseptic such as TCP or witch hazel can be a good preventative in the healing phase. During the post-operative days, if the wound becomes more painful, red and raised than before, pussy or weepy, this suggests infection so review and antibiotics are required. If a wound bleeds, the patient should be advised to apply a firm pressure for 10 minutes without interruption and apply a clean dressing or tissue. If there is still bleeding after this, medical help should be sought.

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Conclusion Minor skin operations performed carefully by an adequately trained practitioner in an aesthetic clinic offers a worthwhile and much appreciated service to the patient. In most cases the patient is unable to obtain treatment for these low priority conditions on the NHS. The practitioner must always acknowledge their limitations and refer to a plastic surgeon if the benign lesion is large, complex or in a difficult site, or refer to a dermatologist if they have any suspicion the lesion is not benign. Dr Ruth Harker is the conference and finance director for the British College of Aesthetic Medicine. She has been a GP with special interest in dermatology and has been a dermatology hospital practitioner performing minor surgery for many years. She is medical director of the Erme Clinic. REFERENCES 1. CQC, ‘Surgical procedures’, 2013. <https://www.cqc.org.uk/sites/default/files/documents/ra_7_ surgical_procedures_0.pdf> 2. T.P Cunliffe & Dr C. Chou, ‘Primary Care Dermatology Society - Skin Surgery Guidelines’, Primary Care Skin Service, 2007. < http://www.pcds.org.uk/images/downloads/skin_surgery_guidelines. pdf> 3. Jonathan Bowling, Diagnostic Dermoscopy: The Illustrated Guide, Wiley-Blackwell 2011 4. Thomas P. Habif MD Clinical Dermatology: A Color Guide to Diagnosis and Therapy, May 2015 ch 26 Cutaneous Manifestations of Internal Diseases 5. Clifford Lawrence, An introduction to Dermatological Surgery, 2002. 6. Eric Hollander, Lisa J Cohen, Daphne Simeon, ‘Body Dysmorphic Disorder’, Psychiatric Annals, 1993;23(7):359-364. 7. GMC, Guidance for doctors who offer cosmetic interventions, 2016. <https://www.gmc-uk.org/-/media/documents/Guidance_for_doctors_who_offer_cosmetic_ interventions_210316.pdf_65254111.pdf> 8. Joe Niamtu, Esthetic Removal of Head and Neck Nevi and Lesions with 4.0MHz radio-wave Surgery: a 30 Year Experience III, J of Oral and Maxillofacial Surgery, 2014. 9. R Scott Boughton, Steven K Spencer, ‘Electrosurgical fundamentals’, Journal of the American Academy of Dermatology 16(4),862-867,1987. 10. Walker KJ, Smith AF, ‘Premedication for anxiety in adult day surgery does not delay discharge of patients’, Cochrane Database of Systematic Reviews: Plain Language Summaries (Internet), John Wiley & Sons, Ltd.Version: October 7, 2009. 11. Global Guidelines for the Prevention of Surgical Site Infection Geneva: Geneva: World Health Organization; 2016.

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Managing summer skin concerns Hyperpigmentation is high on the list of skin concerns affecting most people and in the summer UVA and UVB rays aggravate hyperpigmentation causing patches to become darker. Patients will look to you as experts to provide advice and practical ways to help them manage their pigmentation problems and reduce the risk of further sun spots developing. Using clinically effective skincare, in combination with carefully selected aesthetic procedures such as peels, tackles pigmentation effectively to bestow healthier, younger looking skin.

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A summary of the latest clinical studies Title: The treatment of hyaluronic acid aesthetic interventional induced visual loss (AIIVL): A consensus on practical guidance Authors: Humzah D, Ataullah S, Chiang C, Malhotra R, Goldberg R Published: Journal of Cosmetic Dermatology, June 2018 Keywords: Visual loss, Soft tissue filler, Aesthetic protocol Abstract: Visual loss (blindness) caused by injection of soft tissue fillers is a rare but devastating issue to both patient and practitioner. There is a lack of any structured protocol in the management of this problem. The aim of the study was to produce a pathway for the management of hyaluronic acid aesthetic interventional induced visual loss that was based on the current available literature and guidelines. Evidence proposed guidance for the practical management of this problem was evaluated and a pathway has been developed for patient management and specialist advice. A consensus group experts involved in aesthetic intervention, visual loss research and with experience in dealing with visual loss assessed the current literature and proposed guidelines available. Using the protocols available a pathway for the treatment of aesthetic interventional induced visual loss was proposed. The group produced a set of guidelines for the practitioner to use as an emergency situation and for use in a delayed presentation. The group also produced guidelines for specialists to use in a secondary care setting. These recommendations are based on current publications and or consensus view as there is still a lack of robust Level 1 data to support any particular intervention therapy. Title: The Evaluation of Contact Sensitivity with Standard and Cosmetic Patch Test Series in Rosacea Patients Authors: Erdogan HK, Bulur I, Saracoglu ZN, Bilgin M Published: Annals of Dermatology, June 2018 Keywords: Dermatology, rosacea, contact sensitivity Abstract: Rosacea is a common dermatosis characterized by erythema, telangiectasia, papules and pustules. We aimed to evaluate contact sensitivity in the rosacea patients. We included 65 rosacea patients and 60 healthy volunteers in the study. The patient and control groups were patch tested with European baseline series and cosmetic series. A positive reaction to at least one allergen in the European standard series was found in 32.3% of rosacea patients and 20.0% of subjects in the control group while the relevant numbers were 30.8% of rosacea patients and 10% of controls with the cosmetic series (p=0.08). In total, we found a positive reaction to at least one allergen in 38.5% of patients and 25.0% of controls (p=0.15). We did not find a statistically significant relationship between a positive reaction to one allergen in total and the gender, skin type, rosacea type, ocular involvement, age and disease duration. There were more symptoms in patients with a positive reaction to allergens (p<0.001). Contact sensitivity was detected more common in rosacea patients. Patch testing may be useful in the treatment and follow up of rosacea patients especially if symptoms such as itching, burning and stinging are present. Title: Social Media Ratings of Minimally Invasive Fat Reduction Procedures: Benchmarking Against Traditional Liposuction

Authors: Talasila S, Evers-Meltzer R, Xu S Published: Dermatologic Surgery, June 2018 Keywords: Fat reduction, cryolipolysis, patient satisfaction, liposuction Abstract: Minimally invasive fat reduction procedures are rapidly growing in popularity. The objective was to evaluate online patient reviews to inform practice management. Data from RealSelf.com, a popular online aesthetics platform, were reviewed for all minimally invasive fat reduction procedures. Reviews were also aggregated based on the primary method of action (e.g. laser, radiofrequency, ultrasound, etc.) and compared with liposuction. A chi-square test was used to assess for differences with the Marascuilo procedure for pairwise comparisons. A total of 13 minimally invasive fat reduction procedures were identified encompassing 11,871 total reviews. Liposuction had 4,645 total reviews and a 66% patient satisfaction rate. Minimally invasive fat reduction procedures had 7,170 aggregate reviews and a global patient satisfaction of 58%. Liposuction had statistically significantly higher patient satisfaction than cryolipolysis (55% satisfied, n = 2,707 reviews), laser therapies (61% satisfied, n = 3,565 reviews), and injectables (49% satisfied, n = 319 reviews) (p < .05). Injectables and cryolipolysis had statistically significantly lower patient satisfaction than radiofrequency therapies (63% satisfied, n = 314 reviews) and laser therapies. Ultrasound therapies had 275 reviews and a 73% patient satisfaction rate. A large number of patient reviews suggest that minimally invasive fat reduction procedures have high patient satisfaction, although liposuction still had the highest total patient satisfaction score. However, there are significant pitfalls in interpreting patient reviews, as they do not provide important data such as a patient’s medical history or physician experience and skill. Title: An objective method to assess the improvements of skin texture roughness after botulinum toxin type A treatment of crow’s feet Authors: Cavallini M, Papagni M, Gazzola R Published: Skin Research and Technology, June 2018 Keywords: Botulinum toxin, crow’s feet, texture Abstract: Photo-numeric scales could lack precision and objectivity on evaluating the improvements on wrinkles after a treatment with botulinum toxin type A. The authors suggest a new digital evaluation method to analyze its effectiveness. This study aims to investigate retrospectively the effect of intramuscular injection of botulinum toxin type A on skin texture in the lateral peri-orbital region with a new objective method. Skin texture roughness (STR) in the lateral peri-orbital region is evaluated with a multi-directional light beam by light emitting diodes of different wavelengths (Antera 3D), before and after injections of 12 units of botulinum toxin type A. The wrinkles and lines deeper than 0.5mm are filtered to measure accurately skin texture. We observed an improvement of STR in all cases treated with botulinum toxin type A. A significant decrease of STR was recorded as follows: 17.08% (P < .0001) at 4 weeks and 12.14% at 4 months (P = .001). Botulinum toxin type A treatment of crow’s feet was able to improve STR. The Antera device and software are a valuable, objective, easy and reproducible method to assess the effects of the toxin.

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Money should be no motivator

Presenting Skills Aesthetics talks to recognised public speakers and trainers within the specialty to learn their top tips for being a good presenter ‘Just picture the audience in their underwear’ is common advice given to those less comfortable at taking the spotlight and speaking in front of a crowd. However, is this tactic realistically going to help you present? Even if you are the most experienced medical professional in your field, public speaking doesn’t come naturally to everyone and there are many difficulties associated with standing upon a podium and voicing your expertise, clinical techniques and performing live treatment demonstrations. Presenting to a medical aesthetics audience has its own set of challenges, explains CEO and founder of Harley Academy, Dr Tristan Mehta, who regularly speaks on training and regulation at conferences and other industry events. This is especially true if you are new to presenting to your aesthetic colleagues. “I remember the first time I presented at a conference; even though I was very confident in what I was delivering, I was nervous. I felt like an imposter because there is a sense that the aesthetics specialty is quite insular and often it’s the same people presenting every time,” Dr Mehta says. Being a ‘newbie’ in the aesthetics presenting arena can definitely be intimidating or even terrifying, according to ENT surgeon Mr Simon Ravichandran and aesthetic dentist Dr Emma Ravichandran, founders of Aesthetics Training Academy. Each have been presenting for more than 10 years;

however, say that even experienced and skilled presenters have challenges and can improve or refine their skills. “Many advanced practitioners can overthink and over anticipate what the audience really know and have the tendency to pitch the presentation a little too high, so I think it really is important to know your audience and select what you want to be most impactful to that audience,” Dr Ravichandran states. So how can aesthetic practitioners who are new to presenting learn the ropes, or how can those with experience refine their skills? What should every presenter take into account when they are asked to speak at a conference or trade event? Or even when they are speaking at a patient educational session?

The practitioners interviewed all agree that one of the most important things presenters in aesthetics should do is ask themselves ‘What is motivating me to present on this particular topic in the first place?’ They all note that in aesthetics, this is especially important if you have been asked to speak on behalf of a company with the offer of financial reward. Dr Mehta states, “Good presenting comes down to motivation and why you are doing it. I think there are almost certainly going to be people in aesthetics who love to be on stage for the wrong reasons, like money and fame. You need to be passionate and should be motivated by the genuine impact that you can have on people that are listening.” Consultant plastic reconstructive and aesthetic surgeon, and lead tutor and director of Dalvi Humzah Aesthetic Training, Mr Dalvi Humzah, adds, “It’s not about money or getting people to give you a standing ovation. You should have a drive and ambition for teaching and engaging people. The best presenters will light a spark in the audience and make them want to learn more, and that’s the beauty of a good presenter.” Dr Ravichandran adds, “Make sure you choose to talk about something that you are passionate about, are skilful at, and understand well.” So, how can you present your points in the most effective way?

Know your audience As mentioned, this is a challenge for even the most experienced presenters. According to the practitioners interviewed, first and foremost, every presenter should ask the event organiser who their audience is, every time. Dr Mehta explains, “You’ve got to truly understand why it is people have come to see you. A presenter is like a sales person

“For presenting, the bottom line is self-awareness. You need to be aware of yourself, know how you are acting and be able to pick up on how the audience is reacting to you” Mr Dalvi Humzah

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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who has a message to sell and you must understand why your customer – who is your audience – is interested in receiving that message. You can then target your message accordingly to make it as engaging as possible.” Mr Humzah explains that the biggest challenge in aesthetics is knowing what level to pitch your talk. He says, “You will have novices and experts in the same room and it can be challenging for anyone presenting to grab the attention of the whole audience so that everyone is engaged. What I normally do is acknowledge when something might be quite simple and straightforward or when something might be quite complicated.”

Plan and practise Although it may look easy, a huge amount of preparation, effort and practise goes into a good presentation. When planning, Dr Mehta says that simplicity is key, “Get three learning points together that you think are important about a certain topic and build your conversation around those.” Mr Ravichandran also advocates this technique, and recommends preparing an explanation of why you are best suited to talk on a particular topic. “Always start by telling the audience why you are here, what your skill set is and what the audience is going to get out of your presentation,” he advises. Dr Ravichandran adds that this honesty also helps your confidence, “If you don’t set the benchmark and tell the audience what level of experience you are speaking at from the beginning, then they will assess this during your presentation and, for me, that can cause a bit of anxiety.” She adds, “I often get anxious about speaking. One thing that works well for me is to have the first three sentences in place. This helps me get over the first 15 seconds and I am comfortable to go from there.” Some people find it useful to have their whole presentation written as a script, especially as a beginner. “I used to memorise my whole presentation word for word, down to my stage movements and gestures,” Mr Ravichandran states. Others, Dr Mehta explains, use lecture notes and spend lots of time rehearsing. “This is what I did for my first two years of presenting and teaching. Now I have got to the stage where I almost prefer to just go and see what comes out; I think this can make you appear more authentic,” he says. Dr Ravichandran and Mr Humzah add that they also find practising on the go, such as in the car or in the gym, useful to fit it into a busy

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Speaking for companies Have you ever been asked by a company to speak about its products, techniques or services? Some practitioners will be paid to share their expertise, whilst for others it may be voluntary. However, it’s important to note that often in aesthetics the presentation may have an agenda that’s purpose is more than educating the audience. First and foremost, Dr Mehta advises to consider whether your values align with the company. He says, “You’ve got to love the company’s products and their services.” Dr Ravichandran adds, “Only speak for companies that have products which get you good results. If you don’t already, go and learn everything about it because the most important lesson is that you know your subject inside out.” When presenting for companies, you need to be explicit in what your role is, Mr Ravichandran says, explaining that you have an obligation to let the audience know when you are speaking on behalf of a company, especially because delegates sometimes won’t know the talk might have some promotional elements to it. Mr Humzah adds, “Be open and honest; don’t try and fool people in regards to why you are there. Acknowledge that you are there on behalf of the company and explain what that means and what you’re trying to achieve from that. You should also explain why you are limiting the talk to that product and not discussing any competitors.” Presenting for companies means that you may have restrictions on what you can say and do, explains Dr Ravichandran, explaining, “You have to know what you can and can’t talk about, especially if you are speaking for a pharmaceutical company.” Mr Ravichandran adds, “You need to familiarise yourself with the Association of the British Pharmaceutical Industry1 and you have to talk about their pharmaceutical products only in relationship to their licences in the UK. For example, I might not be able to talk about some types of toxin injections, other than using the correct doses for that particular product and injecting in the correct areas for which you have prescribed. You have to be careful with your language and your slides to ensure you do not make any unsubstantiated claims about a product or device.” This is in accordance with Medicines and Healthcare products Regulatory Agency (MHRA) regulations, so Mr Ravichandran advises to use terminology such as, “Using this technique may reduce the risk of a complication,” as opposed to, “This technique is safer.”2 Not doing so, Mr Ravichandran explains, may have potential repercussions for breach of guidelines.

schedule. “A good rule of thumb is that for every minute of a presentation that you do, you need to spend an hour of preparation – I don’t think you should sit down for a whole day for one presentation, but I will prepare and practise whilst I’m doing other things,” Mr Humzah says. Mr Ravichandran agrees that practise makes perfect, saying, “In the early days, Emma and I would have a recording spot in our kitchen and we would record ourselves and watch it over. It wouldn’t be unusual for us to practise something 30 times before a presentation.”

Read the audience and seek engagement However, a good presenter, Mr Humzah says, is one who has the ability to deviate from their planned presentation, read the audience and assess whether or not the content is being accepted well. He explains, “For presenting, the bottom line is self-awareness. You need to be aware of yourself, know how you are acting and be able to pick up on how the audience is

reacting to you. You might think that you will be speaking to a novice audience so have planned a really simple talk, but suddenly you get in there and you realise it’s not the case or the agenda has changed and you have to change your approach and pitch at a higher level.” Mr Ravichandran describes this as ‘a really advanced and good skill to have’. He believes you can identify whether your audience is accepting your presentation well if they are doing things like maintaining eye contact with you, nodding and sitting on the edge of their chair. Of course, if you can’t get your audience to listen to what you are saying, what’s the point? Mr Humzah explains, “Someone who is sitting in the audience must be engaged, otherwise they will just fall asleep.” He advises that one way to promote engagement is to be dynamic and keep moving. “Instead of standing behind a lectern, try to stand to its side so that people can see all of you, especially if you are short. I always think it’s good to be expressive with your hands and

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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I walk around the stage. This engages you and it engages the audience – it makes their heads and eyes move, which helps them stay alert and listening.” Dr Mehta agrees that body language impacts engagement; he says, “You should open and expose your body, don’t cross your arms and make sure to stand in a fluid and natural way. You’ve got to portray your body language as if you are a leader with interesting things to share.” He adds, “I also think clarity and voice are important for engagement; making eye contact with the audience and asking if there are any questions as you go along can also be useful.” Another tool is humour, which Mr Humzah believes is a good aspect of teaching and presenting. However, he notes that it’s not for every audience, particularly for international delegates who may not have the same sense of humour.

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inside-out and be ready to present at any medium and in any format,” he advises. Although for many it could be obvious, Mr Humzah also states that some presenters get their clothing wrong. “Presenters need to dress accordingly; I recommend smart formal business attire – it’s not a fashion show. For live demonstrations, wearing scrubs shows that it’s a clinical setting. If someone is presenting on stage then going backstage to do a live demonstration, then I think a white coat can be a good idea so you can easily take it on and off.” Another element of professionalism is time keeping, as presenters that run over can cause frustration for both the audience and other presenters. “This is a pet hate of mine,” Mr Humzah declares, adding, “It is very important to keep to time. Find out what your timeframe is and always prepare a presentation that’s a little bit shorter than

“Always start by telling the audience why you are here, what your skill set is and what the audience is going to get out of your presentation” Mr Simon Ravichandran Dr Ravichandran points out that something that even experienced presenters sometimes forget is that delegates at conferences will often see you present several times, so she advises to to never present the same thing. “Care about your audience. If you have a presentation that you may use several times, make regular changes. Keep your content fresh and up-todate; aesthetics changes constantly so your talk has to change too,” she advises.

Stay professional “I think it’s very important to be professional in all aspects of presenting,” explains Mr Humzah, adding, “Unpredictable things do happen, technology issues are very common and I have seen people shout at others when this happens. Keep your cool; people will remember if you don’t.” Mr Ravichandran explains that there can be all kinds of last-minute circumstances that will affect your presentation. “I once left my computer on a train and was lucky that I had emailed a PDF to someone, but this meant that I had to present from a PDF, which wasn’t ideal. Make sure you know your subject

expected – if you have been given 20 minutes, prepare a 15-minute presentation.” He advises presenters always keep an eye on the clock or chairperson, if there is one. He says, “Too many people get engrossed in their presentation and have a chairperson waving their hands at them saying they are running over but don’t notice them.”

Presenting live demos Presenting live treatment demonstrations, practitioners agree, is another separate challenge. Dr Ravichandran’s top tip is not to change what you do in clinic every day to impress a crowd. “It’s easy to tell when a presenter is doing something for the first time or if they are doing something they are not used to. If you use needles in clinic, don’t demonstrate with a cannula just because it might be the fashion at the time. Do what you are confident doing, it’s the best and safest way to do it.” Both Dr and Mr Ravichandran will always bring their own clinical supplies with them. Mr Ravichandran explains, “We always bring things like needles, cannulas and emergency medication so we can ensure we are familiar with the devices and

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drugs we may be using.” Mr Ravichandran also advises all presenters who are performing live demonstrations to check they are adequately insured. Mr Humzah’s advice is for presenters to make clear in their live demonstrations to aesthetic professionals what its aim is and what you are trying to achieve. “You need to be clear to your audience that it’s just a short demonstration and that you are not a presenting a technique that will allow them to leave the presentation and do it tomorrow,” he explains.

Continue to learn As most aesthetic practitioners know, there is never an end to learning and even the best presenters can improve or discover new techniques. To learn to become a better presenter, Mr Ravichandran and Dr Ravichandran encourage practitioners to attend courses. “They don’t have to be specific to aesthetics, there are so many courses available to teach or refine presenting skills. Just search presentation skill courses online and go on as many as you can because they will each teach you something different – there is no right way of doing it.” Mr Humzah adds that you should watch and critique recordings of yourself, as well as asking other people to give you constructive criticism. Mr Ravichandran, notes that he regularly gets told that he speaks too fast. To help with this, he says, “I ask someone to stand at the back of the lecture theatre and use hand signals to to slow me down.”

Find your own voice Practitioners agree that when successful, presenting at aesthetic conferences and events can be extremely rewarding. Dr Ravichandran’s final advice is to, “Stay honest, find a style that works for you and don’t try and replicate something that’s not natural to you,” while Mr Ravichandran adds, “Never agree to talk about something that you are not interested in or won’t learn about.” Dr Mehta concludes, “The tip is to find your authentic voice and to accept that it won’t please everyone. If you believe in what you are talking about and present it in an effective way, you will eventually be heard.” REFERENCES 1. The Association of the British Pharmaceutical Industry, 2018. <https://www.abpi.org.uk/> 2. MHRA, The Blue Guide ADVERTISING AND PROMOTION OF MEDICINES IN THE UK, 2014. <https://assets.publishing.service. gov.uk/government/uploads/system/uploads/attachment_data/ file/376398/Blue_Guide.pdf>

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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website. Considering your traffic’s browsing limitations on different mobile devices is important, because their journey around your site is either helped or hindered by your design.

Mobile-optimised Websites Digital marketing consultant Adam Hampson divulges how to ensure the best user experience for patients viewing your mobile-optimised website, and why this is vital to your digital marketing strategy Moving with the times means moving with the technology, and more and more online searching is being conducted on portable devices. Adults accessing the internet via their smartphone increased to 73% in 2017,1 more than double the rate of 2011. As of May 2018, the way Google determines which sites are more prominent on its search page (search engine optimisation) is also beginning to favour mobile websites over desktop,2 so a mobile device-optimised site will positively affect your Google search rankings. This is why it’s never been more important for you and your business to have a website optimised for mobile device use. Following the trends of online traffic should lead you straight to mobile browsing if you want to remain relevant and be seen by your potential patients on the world

wide web. A correctly designed mobileoptimised website can lower your bounce rate, increase your traffic, and provide the valuable streamlined content needed to push you up the search engine rankings and onto the screens of more potential patients. In this article, I’ll discuss not only why a mobile-optimised website is important for your business, but how best to design it for your patients’ best user experience. Although many aesthetic practitioners will not be designing a mobile-optimised site themselves, it is important that they have a basic understanding of their components and how they work.

Consider your users’ limitations For your patients to have an exceptional user experience, you need to consider what you yourself look for when browsing a

Your desktop website may contain a lot of dynamic design that works well when the user has a scrolling curser, but this won’t work on a mobile device

Your desktop website may contain a lot of dynamic design that works well when the user has a tracking or scrolling cursor, but this won’t work on a mobile device or tablet. Consider how you display certain pieces of information that may be vital to prompting an enquiry and whether they’re accessible on a mobile and portable device. For example, does your desktop website incorporate pop-ups, hover-states that reveal a mirage of information once rolled over, or design using Flash Media Player? These elements won’t translate to your mobile site and will frustrate anyone trying to use it. A clunky user experience can frustrate your traffic, heightening your potential bounce rate (the number of visitors leaving your site). Your mobile site also lacks a cursor and a scroll bar. On portable devices, the scroll and the click are the same motion, so it’s important to consider this when designing your mobile-optimised site and space your clickable links accordingly. There is no user experience without usability, so it’s important to ensure your mobile site can work before you think about jazzing it up.

Considerations for the best possible user experience Readability When designing for the optimum user experience, your mobile-optimised site should consider screen resolution. The size of the tablet itself isn’t as important here; resolution refers to the number of horizontal and vertical pixels on the display screen where your user will interact with your site. The more pixels there are, the more information is visible without scrolling. The iPad can range from 768 by 1024 pixels, to 2048 by 2732,3 with the same sort of disparity between iPhones and Androids. The most used screen resolution falls at 720 by 1280 pixels,4 so it’s best to aim for this kind of compatibility in lieu of designing for every variant on the market. Link buttons Links that are placed within text can be difficult to navigate (or avoid) with the all-purpose finger click. Mobile and portable devices are almost exclusively touchscreen so, as mentioned above,

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Data compiled from Google Analytics by the search engines themselves showed that sites that load in five seconds or less see 70% longer viewing session duration the scroll and the click are the exact same motion. This is why I recommend swapping links in your body of copy, which should be selective anyway, with clickable buttons. These buttons can be eye-catching and use imperatives such as ‘Book Your Consultation Now!’ These interesting, engaging, yet simple buttons create simplicity and guide your traffic through the important stages of the enquiry process.5 Contact functionality Mobile optimisation for portable devices can have excellent functionality and contact capabilities when implicated correctly. For example, command function buttons such as one that states ‘click to contact’ can be linked straight through to a call with your contact number or can be designed to open a new email to your enquiry address. This can be useful as it allows for patients to not have to copy and paste or remember a number or email address to contact you, they can just press the button on your site and it’s done for them. Designing properly for mobile optimisation opens a vast world of real-time communication in which your traffic is interested and so can immediately initiate contact. This can also be useful when incorporating location tools that sync with map applications on the device, showing how a user can travel to your premises. Combine these streamlined communication portals with clickable icons mentioned above and you have a well-oiled mobileoptimised website. Condense your design As I discussed earlier, dynamic design is anything but on a mobile website. FlashPlayer graphics, instantly playable videos, and animations aren’t supported and will appear clumsy if they appear at all. Instead, consider condensing your design

into statement content that both captures your audience, yet doesn’t overwhelm your potential patients.6 Statement content includes photography, graphics, and information that helps your user discern your services in a bite-size snapshot. Content overload can delineate your entire landing page, losing your users’ interest so just incorporate the necessities such as your brand colours, logo, and carefully selected written content to keep your traffic engaged and motivated to find out more. Try to capture the most engaging information and content you can before the user feels the need to scroll,7 which includes but isn’t limited to a service you offer, a photo of your team, or an enticing unique selling point. If you offer free consultations or are hosting an event day, this is a great way to introduce new traffic. Reduce the size of your navigation bar, menu, or photo banner to free up available pixels that are better used to engage and inspire. A great way to reduce menu size, yet still allow for easy functionality, is to adopt a collapsible dropdown menu with shelved parent pages. This means your information can be carefully categorised and will guide your traffic through their own client journey or funnel. Content size and load times The less complex the content, the less time it will take your mobile-optimised website to load. Load times have a huge impact on your users’ experience, a 2016 Google study found.8 Data compiled from Google Analytics by the search engines themselves showed that sites that load in five seconds or less see 70% longer viewing session duration. Of more than 10,000+ mobile web domains analysed, Google found that the average load time for mobile sites was 19 seconds, which can greatly impact your bounce rate. This means that the faster your site can load, the more likely your traffic

is going to stick around and peruse your content and services.9 Lessening your load times means condensing your content. Stripped-back design that is easy to navigate and doesn’t include videos or too many images decreases your load time. Consider which content is your absolute priority, and which content you think your patients look for when choosing an aesthetics provider.

Conclusion Ensuring the best user experience for your mobile-optimised website is a careful mosaic of different considerations and attributions. Your choice of content, functionality, and how you combine the two can either take your patients by the hand or push them away, so a careful balance between the two needs to be established and maintained. If you haven’t considered optimising your site for mobile use, then you could be missing out on vital conversion and alienating far too much traffic to ignore. Adam Hampson is the founder and director of Cosmetic Digital, a web design and digital marketing agency in Nottingham that works with clients in the cosmetic medical sector. He has recently launched 13 Digital Training and offers digital marketing training courses for dentists, doctors, and nurses of all abilities. REFERENCES 1. Office for National Statistics, ‘Home internet and social media usage’, <https://www.ons.gov.uk/ peoplepopulationandcommunity/householdcharacteristics/ homeinternetandsocialmediausage> 2. Search Engine Land, ‘Google to move more sites to mobilefirst index in coming weeks’, 21 February 2018. <https:// searchengineland.com/google-move-sites-mobile-first-indexwithin-next-several-weeks-292660> 3. Media Genesis, ‘Popular Screen Resolutions: Designing for All’, 25 March 2018. <http://mediag.com/news/popular-screenresolutions-designing-for-all/> 4. Device Atlas, ‘Most used phone screen sizes to design websites for in 2017’, 17 January 2017. 5. <https://deviceatlas.com/blog/most-used-phone-screen-sizes-todesign-websites-2017 > 6. Google Developers, ‘What Makes a Good Mobile Site?’ September 2016. <https://developers.google.com/web/ fundamentals/design-and-ux/principles/#keep_calls_to_action_ front_and_center> 7. Adobe Blog, ’10 Do’s and Don’ts of Mobile UX Design’, 1 February 2018. <https://theblog.adobe.com/10-dos-dontsmobile-ux-design/?origref=https%3A%2F%2Fwww.google. co.uk%2F> 8. Digital Marketing Institute, ‘3 Ways to Create Mobile-Friendly Content’, <https://digitalmarketinginstitute.com/en-gb/blog/20177-20-3-ways-to-create-mobile-friendly-content> 9. Double Click by Google, ‘The need for mobile speed: How mobile latency impacts publisher revenue’, 2017. <https://www. doubleclickbygoogle.com/articles/mobile-speed-matters/>

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“I was interested in aesthetics because of the role, the recognition and level of autonomy that nurses have” Aesthetic nurse prescriber Anna Baker talks to us about her passion for learning and details what she loves most about the specialty She holds an impressive five qualifications to her name, works as a lead trainer for distribution companies HA-Derma and AestheticSource, and spends the majority of her time tutoring on the Dalvi Humzah Aesthetic Training (DHAT) courses. Hard work has enabled nurse prescriber Anna Baker to speak at many UK conferences, present in Poland, gain an official teaching qualification on the Nursing and Midwifery Council (NMC), sit on the board for the British Association of Cosmetic Nurses (BACN) and win an Aesthetics Award last year for The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year. With this wealth of experience and clear passion to continuously learn, where did it all begin for this Sussexborn nurse? “When I first qualified in 2003, I was working in A&E, and about a year later I decided to specialise in dermatology as I found that area most interesting,” explains Baker, continuing, “It was when I was working in the dermatology department at a hospital in Manchester in 2007 that I was first introduced to aesthetics by a colleague who was working in the sector at the time. I had never really contemplated it before; I wouldn’t say it was accidental, more circumstantial.” Baker explains that once she became aware of the platform nurses were given within aesthetics, she was more drawn to it than ever before. She says, “I was interested in aesthetics because of the role, the recognition and level of autonomy that nurses have. I believe that the role of nurses has really come to the fore and we are very lucky

Both expertise and training need to be treated with a great deal of respect to have that here in the UK; it’s not like that anywhere else.” This recognition has helped Baker attain her biggest achievement to date. She explains, “It’s an honour to work alongside a consultant surgical and international faculty to facilitate clinical dissection, principally on areas which I participate in demonstrating on our cadaveric training courses. In addition, I have been very privileged to present at European conferences. Another one of my biggest achievements was winning the Aesthetics Award last year, it was such an honour to have won such a prestigious award. We have so many phenomenal nurses 2003

2011

2015

in the UK aesthetics specialty, so I feel extremely humbled.” Education and hard work has become a key part in Baker’s career, and she believes that there is no room for complacency in this specialty so is constantly looking for ways in which she can improve. She explains, “There is still so much we don’t know, especially about anatomy. I have attained many qualifications and still feel like I have so much to learn, hence why I decided to commence my MA at King’s College London, which I am currently half way through. I believe that both expertise and training need to be treated with a great deal of respect.” For specialty newcomers, she insists passion is what will get you through, “I am firm believer that a trainer or presenter should know their subject inside out, firstly to instil conviction to the audience, and secondly to be able to discuss and teach content in the event of any technical problems with slides, or other AV material. During a session, for example, if slides fail; technical knowledge matters. To do well in aesthetics, you not only need the skill with your hands or your eye, you really do need technical knowledge to back it up. Is it ever a bad thing to be as well qualified as you can be? Of course it isn’t.” She concludes, “The great thing about this industry, particularly in the UK, is that you can be whoever you want to be. No matter if you are a nurse, a clinic manager, a doctor; if you want to have the most successful clinic, become a recognised trainer, speak at conferences, you can. You have the power to be a champion in any area you choose.” What is your motto? I truly believe that you are never the best you can be, and there is always room to strive for more. What treatment do you enjoy giving the most? I will always have a passion for dermatology, I really love performing superficial and medium depth peels, being able to use potent ingredients that have been well formulated, meaning there is little to no downtime. I think people want to know more about skin and it’s being taken much more seriously as a discussion point in initial consultation. We are going to see a real shift in skin trends over the next few years. What is the best piece of career advice you have been given? Never stop learning. As well as that, you should always be humble and grateful for any opportunity that comes your way!

2016 – current

2017 NMC Teacher Award-Practice Educator Qualification

University of Southampton

De Montfort University

Keele University

King’s College London

Bachelor of Nursing

Independent Nurse Prescriber

PGCert-Applied Clinical Anatomy (Head & Neck)

Commenced MA Clinical Education-with a triple accreditation to: Nursing & Midwifery Council (NMC), Academy of Medical Educators (AoME), Higher Education Academy (HEA)

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


@aestheticsgroup

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practice, which help ground the success of business endeavours. I’m talking about that connection, ability to listen and get a feel for what your patient is all about. These skills simply cannot be encapsulated in a two-day course, after which a practitioner is directly responsible for patient outcomes.

The Last Word: Pathway into Aesthetics Miss Mayoni Gooneratne highlights the growing trend for newly-qualified medical practitioners entering aesthetics, examining whether more industry support and mentoring is needed to ensure proper patient care We know aesthetics is a highly dynamic and fast-paced specialty, driven by innovation, new science and an evergrowing patient demand. Once, it was the exclusive domain of a specialised few – primarily surgeons1 – but the last few decades have seen a wider variety of medical practitioners entering the field, including nurses, dentists, dermatologists and GPs to name but a few. Whilst I heartily believe that aesthetics should only be practised by medical professionals, I have grown concerned about the training, support and expertise of many of the new entrants coming into the specialty. My own observations as a trainer and interaction with delegates at conferences indicate there is an increasing number of medical practitioners jumping almost directly from their foundation qualifications straight into aesthetics – virtually bypassing the NHS to fast-track towards what they see as the promise of a lucrative cash-pay business. My question is whether, without a solid foundation of practical, clinical experiences, are these ‘fast-track’ industry entrants going to end up putting patient safety at risk?

The ‘shiny’ world of aesthetics With the public sector pay cap of 1% a year having been implemented in 2013, following pay freezes for the two years prior to this,2 it is understandable why so many practitioners are leaving the NHS in search of more financially-rewarding careers. The current strains placed on healthcare professionals within the NHS also continue to grow. For many, the booming aesthetics specialty offers a way to utilise clinical skills and provide patient care within what can be a highly lucrative and in-demand cash-pay business model. Whilst this move is obviously a free choice, my belief is that individuals who are switching into aesthetics very early in their careers are missing a host of invaluable skills for patient management and care, which can only be achieved having spent a few years undertaking hands-on clinical practice. The ability, for example, to recognise and manage complications, I believe, comes with clinical exposure and time. Don’t get me wrong – I’m not against younger practitioners entering the aesthetic specialty; in fact, youth often brings a new way of thinking and practising. However, there’s a lot to be said for the hands-on experience and independent skills that are acquired in clinical

Training and mentoring My career began in the NHS more than 18 years ago, when I studied medical surgery at St George’s Hospital Medical School before specialising in colorectal surgery. When I decided to make the transition into aesthetics, I undertook extensive training with Cosmetic Courses at Aurora Clinics, as this was the only UK training academy led by a plastic surgeon at the time. This was important to me as I felt a surgeon could best help me understand and respect tissue layers of the skin to achieve optimum aesthetic results. Yet, even after this training and with all my years of surgical training and clinical experience, I still felt completely out of my depth and pursued several other courses alongside one-to-one training and mentoring before truly starting my business. The rigorous training, constant reviews and check-ups and a clear hierarchy of teachers and mentors you receive in medicine is not as clear-cut in aesthetics – there is nobody ‘checking up on you’ in the early days and I feel this is a potential danger zone, particularly with the increased number of new aesthetic practitioners who only have minimal NHS experience under their belts. Conversely, I’m not advocating for a ‘nannying’ approach in aesthetics, just consideration of a supportive way to help new practitioners find their feet and learn how to manage patients (and complications) on their own, but have the option of senior support when they need it. When I was a house officer, I remember my senior house officer saying, “Please don’t phone me until you get the patient as far as you can get them.” This really stretched my capabilities, but rather than phoning at the first hurdle, I built my confidence and capabilities with that lifeline still available. I feel this kind of approach is currently lacking in aesthetics. This absence of a ‘foundation’ of clinical experience can manifest in some new practitioners feeling very nervous and unsure about putting their aesthetic training into practice. As with surgery, in aesthetics there is an element of learning by doing – yet often I see practitioners on my training courses who feel unable to treat patients despite several sessions of training. Often, they are looking for ‘fool proof’ and absolute textbook methodologies for patient assessment and

Reproduced from Aesthetics | Volume 5/Issue 8 - July 2018


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Aesthetics Journal

treatment, and struggle to grasp the concept that you can’t adopt the exact same approach with every patient, or even with the same patients at different time-points. The lack of on-the-job mentoring for many aesthetics practitioners can leave them feeling unable to trust their own skills – or worse, to treat patients without feeling fully confident or able to review and manage any complications. The solution Rather than being quite so damning about this new generation of aesthetic practitioner, I think other experienced aesthetic professionals should support them. As long as the NHS is allowing their vital staff to leave in droves, we will need to put in place something to support these medical professionals. The old adage of ‘see one, do one, teach one’ is something that I think could be adopted to a degree in aesthetics. I would propose a mentoring system whereby new practitioners are allocated a mentor to refer and report to. Maybe something for the myriad of new training courses to adopt to make them more discerning? Some voluntary associations, bodies and training academies are taking the lead on this; for example, the British Association of Cosmetic Nurses offer a mentoring programme,3 while the British College of Aesthetic Medicine have just launched an Academy which aims to mentor and train its members.4 The Joint Council for Cosmetic Practitioners meanwhile have adopted the role of a ‘supervisor’, who has oversight and is accountable for their delegated practitioner.5 I think every patient should be an opportunity to assess, analyse, reflect and learn from. This is ongoing and we must remember ‘train hard, fight easy’ to ensure that our patients, and indeed us as a profession, stay safe.

Aesthetics

Conclusion The immense strain on our NHS is unlikely to resolve in the next few years, and with the aesthetics specialty continuing to demonstrate significant growth this will represent a highly attractive alternative for many newly-qualified medical practitioners. With no mandatory training and qualification pathway in aesthetics, it is primarily up to the individual to decide how rigorously to pursue training and support before engaging with patients. I believe this offers significant scope for future concerns on patient safety and care, and there should be a greater focus on training and mentorship within the industry. This could help support new practitioners and give them the tools and confidence to deliver the best possible experience for their patients. Miss Mayoni Gooneratne is a London-based general surgeon with over 18 years of medical and surgical experience. She is a graduate of St George’s Hospital and has been a member of the Royal College of Surgeons since 2002. Miss Gooneratne has completed extensive training in aesthetic techniques over the last few years which has culminated in the creation of private aesthetic clinic The Clinic by Dr Mayoni in 2016. REFERENCES 1. British Association of Aesthetic Plastic Surgeons, History of BAAPS, 2017. <https://baaps.org.uk/about/ history_of_baaps.aspx> 2. Doug Pyper, Feargal McGuinness and Philip Brien, Public Sector Pay Briefing Paper CBP8037, House of Commons, 3 May 2018, pp.3. <researchbriefings.files.parliament.uk/documents/CBP-8037/CBP8037.pdf> 3. BACN, BACN launches new ‘Reviladation Mentor’ programme in Southhanpton, 2016. <http://www. bacn.org.uk/content/56a8effe9cf496.17009580.pdf> 4. BCAM Academy, The Academy, 2018. <https://www.bcamacademy.co.uk/the-academy/> 5. CPSA Supervision Matrix, 2018. <http://www.cosmeticstandards.org.uk/supervision-matrix.html>

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96% of patients showed aesthetic improvement one month after treatment with Restylane® Skinboosters™ Vital1* *Results shown for investigator-reported Global Aesthetic Improvement Scale (GAIS) at one month after the second treatment session. Patients received Restylane Skinboosters Vital over two treatment sessions scheduled four weeks apart. 2 mL of product was administered at the first treatment session and 1 mL at the second session. In addition, a single maintenance treatment (1 mL of product) was given at six months (n=27).

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Reference: 1. Kerscher M et al. Restylane Skinboosters for improved facial skin quality using two treatment sessions. Poster presented at IMCAS, 26 – 29 January 2017, Paris, France.

Date of preparation: January 2018 RES18-01-0031c

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