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VOLUME 3/ISSUE 7 - JUNE 2016

HENTIC AUT Micro-Focused Ultrasound with Visualisation

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ULT/182/2016/MAY/2016/SS Date of preparation May 2016

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Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com *stimulates new collagen and elastin which can reverse the signs of ageing References: 1. Ulthera System Instructions for Use, 1001393IFU Rev H. 2. Sasaki GH & Tevez A. JCDSA. 2012; 2: 108-116. 3. Alam M, et al. J Am Acad Dermatol. 2010;62:262-269. 4. Lee HS, et al. Dermatol Surg. 2011;1-8. 5. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202. 6. ULT-DOF-003 Ultherapy Treatment Duration. Merz - July 2015. 7. http://www.accessdata.fda.gov/ cdrh_docs/pdf13/k134032.pdf Accessed May 2016. 8. CE Certificate 3808396CE01, DEKRA April 2012. Adverse incidents must be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents must also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143

Botulinum Toxin for Men CPD Dr David Jack details what to be aware of when treating men with botulinum toxin

Before

www.ultherapy.co.uk After

Tightening the Neck

Understanding Ultrasound

Practitioners discuss their preferred skin tightening methods for the jowls and neck

Dr Sarah Tonks explains the science behind ultrasound and its aesthetic indications

Cyber Crime Holly Markham outlines changes to data protection laws and advises how to stay safe online


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Contents • June 2016 06 News

The latest product and industry news

14 On the Scene

Out and about in the industry this month

17 Conference Reports

Reports on the GAA educational day, ASAP meeting and FEN conference

20 News Special: Acne

Aesthetics investigates recent concerns regarding the psychological implications that acne can have on patients

CLINICAL PRACTICE

Special Feature Tightening the Neck Page 23

23 Special Feature: Tightening the Neck

Practitioners discuss their preferred skin tightening methods for the lower face, jowls and neck

29 CPD: Treating Men with Botulinum Toxin

Dr David Jack details the relevant anatomy to be aware of when treating men with botulinum toxin

33 Gynaecomastia

Mr Demetrius Evriviades explains how to correctly diagnose gynaecomastia and how to effectively treat male patients with the concern

36 Aesthetics Awards 2016

Why you should enter the prestigious industry awards

38 Managing Alopecia with Mesotherapy and Botulinum Toxin

Dr Philippe Hamida-Pisal presents a pilot study on a new protocol for treating alopecia

41 Case Study: Acne Scarring

Dr Jasmeet Baxi details how she successfully managed a patient’s acne using chemical peels and topical skincare

45 Understanding Ultrasound

Dr Sarah Tonks outlines the science behind ultrasound and explains how it can be used for skin tightening

50 Advertorial: Radara

A micro-revolution in non invasive anti-ageing skincare

51 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 53 Managing Cybercrime Threats in Healthcare

Holly Markham discusses changes to data protection laws and advises how to protect your patients’ privacy

59 Training Courses in Medical Aesthetics

Dr Tristan Mehta outlines how to successfully create and run a training course in medical aesthetics

63 Improving Industry Supplier Support

Sales representative Caroline Gwilliam shares advice on how to the make the most of aesthetic suppliers to benefit your business

Data Protection Cyber Crime Page 53

Clinical Contributors Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. He graduated from the University of Glasgow and later became a member of the Royal College of Surgeons of Edinburgh. Mr Demetrius Evriviades is a consultant plastic and reconstructive surgeon with healthcare platform Medstars. He is an NHS Consultant at the New QE and BMI Priory Hospitals in Birmingham and also runs a private practice. Dr Philippe Hamida-Pisal is an aesthetic practitioner working in London and Paris. He is the president of the Society of Mesotherapy UK, the society partner of Euromedicom and IMCAS Paris and is a keynote speaker at major industry events. Dr Jasmeet Baxi graduated with an MBChB from the University of Leeds in 2008. She also has a BSc Hons in Chemistry with Management from King’s College London. Dr Baxi is an experienced aesthetic practitioner and the founder of NaturaSKIN Ltd. Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry; based at the Chelsea Private Clinic she practises cosmetic injectables and hormonal based therapies.

67 In Profile: Dr Patrick Bowler

Dr Patrick Bowler reminisces on the development of the aesthetics industry in the UK

68 The Last Word

Sharon Bennett discusses the rise in lip filler treatments for young people and debates the associated ethical and legal dilemmas

NEXT MONTH

One month left to enter the Aesthetics Awards 2016 www.aestheticsawards.com

• IN FOCUS: The Sun • PRFG Case Study • Suncare • Audio Branding

Subscribe Free to Aesthetics

Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228


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Editor’s letter As I write this month’s Editor’s Letter, I have just finished giving a talk at the Face Eyes and Nose conference in Coventry. It’s an interesting conference with delegates from the world of plastic surgery at different stages Amanda Cameron of their careers, mixed with some nonEditor surgical practitioners – well done to Mr Dalvi Humzah and Anna Baker for their great organisation. May also saw the Galderma Aesthetics Academy day and the Association of Scottish Aesthetic Practitioners conference take place. We are delighted that aesthetic nurse prescriber Lou Sommereux and Dr Simon Ravichandran have taken the time to write up their experiences for this month’s journal on p.19. Hopefully you know by now that entry to the Aesthetics Awards 2016 is open! Make sure you look at the categories closely to decide which you are going to enter. Each category’s winner will be decided upon by either a combination of votes and scores from an independent judging panel, or by the judging panel alone. We really take the judging process very seriously and are as objective as possible in choosing the most appropriate judges for each category. Read p.36

to find out how to enter and learn more about the most prestigious awards ceremony in the aesthetic calendar. Our special focus this month is skin tightening – in the past it has been so difficult to get good results, however as technology improves so do the results. Turn to p.23 to discover how practitioners have achieved success in treating the lower face and neck using radiofrequency, ultrasound and botulinum toxin. Acne is a widespread problem amongst adults as well as teenagers, so June’s News Special (p.20) examines the psychological impact that the condition may have on patients. We talk to a number of dermatologists, aesthetic practitioners and GPs about how the private sector can do more to ensure patients don’t suffer unnecessarily. What I love about this industry is that it never stands still – as evidenced by the number of new product launches taking place this month and last, which is very exciting. We love attending launch events and discovering new products, technologies and treatments, so if you have something exciting planned please do let us know by emailing editorial@aestheticsjournal.com or tweeting @aestheticsgroup

Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Mr Dalvi Humzah is a consultant plastic, reconstructive and

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

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

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

Dr Tapan Patel is the founder and medical director of VIVA

Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015.

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

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Elise Payne; support@aestheticsjournal.com © Copyright 2016 Aesthetics. All rights reserved. Aesthetics Journal is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

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Regulation

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Clinic Dr Stefanie Williams @DrStefanieW Our new bar stools for the working bar in the Eudelo clinic waiting room arrived. Pink! I like them, but my husband doesn’t… What do you think?

#GAA2016 Dr Ravi Jain @DrRaviJain On my way to #GAA2016 in London for a day’s education & learning – they are two different things!! #lifeofanaestheticdoctor #Learning Lorna Bowes @LornaBowes Ready to work, really! Inside all day at Clinica Hera, Spain. Learning. #skincare #peeling #beauty @AestheticSource

#Presentation Dr David Eccleston @DavidEccleston Sitting in #Heathrow #T5 awaiting flight to Bucharest ready to deliver a presentation on the #Allergan portfolio and the #MDCodes #ASAP2016 Julia Kendrick @JRKendrick Great day with @AsapSc and the @ABNExperts1 – helping Scottish clinics prepare for new aesthetic regulations!

#PostGrad Sharon Bennett @sharonbennettuk Aghhhh, applied to do non surgical aesthetic post grad course @NorthumbriaUni September! #BACN #FEN2016 Shanks T K Sanker @Estheticsurgeon Absolutely amazing presentation: facial FengShui by Andy Chiang @FaceEyesNose

Cosmetic associations join forces aiming to ensure patient safety Prominent aesthetic and cosmetic associations have come together with the aim of improving safety for patients undergoing non-surgical cosmetic interventions. The five organisations: The British Association of Aesthetic Plastic Surgeons (BAAPS), The British Association of Cosmetic Nurses (BACN), The British Association of Dermatologists (BAD), The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) and The British College of Aesthetic Medicine (BCAM), have created two groups with the support of the Department of Health; the Clinical Standards Authority for Non-Surgical Cosmetic Intervention (CSA) and the Joint Council for Cosmetic Practitioners (JCCP). The CSA and the JCCP will collaborate to ensure patient safety in the specific area of non-surgical intervention, including dermal fillers, botulinum toxin injections and cosmetic laser therapies. The bodies will also aim to protect patients by improving and enforcing clinical standards and training, and by maintaining a register of practitioners – tasks they say they have already begun working on. Interim chair of the JCCP, Professor David Sines CBE, said, “Sections of the non-surgical cosmetic interventions industry remain largely unregulated, however healthcare professionals have made important strides in improving patient safety. The formation of the CSA and the JCCP is an important step forward.” The organisations are planning to fully launch in April 2017. Innovation

US scientists create ‘second skin’ that aims to conceal wrinkles Scientists from the US have developed an elastic, wearable cross-linked polymer layer (XPL) that aims to mimic the properties of normal, youthful skin. According to the developers from the Massachusetts Institute of Technology (MIT) and Harvard Medical School, XPL can be topically applied to the skin to smooth the appearance of wrinkles. XPL is currently applied in a twostep process. The first involves applying an invisible cream to the skin, which has the polysiloxane components in it, followed by a second cream that contains a platinum catalyst that causes the polymer to form a strong cross-linked film that remains on the skin for up to 24 hours. The layer is designed to be applied in the morning and disposed of at night by ‘peeling’ off. According to studies conducted by the developers, the material can also withstand normal daily wear as well as exposure to moisture without falling off. Daniel Anderson, who helped develop the material at the MIT said it can be used for several purposes, “It’s an invisible layer that can provide a barrier, provide cosmetic improvement, and potentially deliver a drug locally to the area that’s being treated. Those three things together could really make it ideal for use in humans.”

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Acquisition

Aesthetics

Laser

Allergan acquires Topokine Therapeutics Global pharmaceutical company Allergan has acquired Topokine Therapeutics and its product portfolio that includes the potential first topical treatment for steatoblepharon. The topical treatment, XAF5, aims to penetrate the skin under the eyes and act on fat cells to shrink under-eye bags. “The acquisition of Topokine and its XAF5 technology adds an innovative technology to Allergan’s industry leading mid-to-late stage pipeline of more than 70 programmes and bolsters our leadership in medical aesthetics,” said David Nicholson, executive vice president and president of global brands research and development at Allergan. He continued, “XAF5 has the potential to be the first topical fat reduction product for the treatment of steatoblepharon, a condition with no current therapeutic options available for patients. We look forward to continuing the outstanding development work conducted by the Topokine team to bring this innovative medical aesthetic treatment to market.”

Alma Lasers launches Soprano ICE Platinum Device manufacturer Alma Lasers has launched the new Soprano ICE platinum, a three-wavelength platform for hair removal. The device combines three laser wavelengths into one applicator, which aims to treat different tissue depths and anatomical structures within the hair follicles, allowing all varieties of hair to be treated with a single shot. The three different wavelengths include the Alex Technology, a 755nm wavelength that according to Alma Lasers can be used on a wide range of hair types and colours; the Speed Technology, a 810nm laser that aims to provide deep penetration to the follicle with a high repetition rate and 2cm spot size for fast treatments; and the YAG Technology, a 1064nm wavelength that aims to treat dark skin types. Alma Lasers’ CEO Dr Ziv Karni said, “The new Soprano ICE Platinum, with 10 years of clinically-proven effectiveness, revolutionises the way in which laser hair removal is performed.” Alma Lasers devices are distributed in the UK and Ireland by ABC Lasers.

Ultrasound

Sun Safety

VENN Healthcare launches new ultrasound devices Aesthetic distributor VENN Healthcare has launched the ULTRAFORMER II and III to the UK for face and neck treatment and body contouring. According to manufacturer Classys, the devices treat various layers of the superficial dermis, deep dermis, fat layers and the superficial muscular aponeurotic system. The ULTRAFORMER II is a multi-functional high intensity focused ultrasound device that aims to treat the face and neck by stimulating collagen synthesis and regeneration resulting in lifting and tightening. According to VENN Healthcare, treatment can take between 20-30 minutes and results are typical seen two to three months after treatment without the need for any downtime. The ULTRAFORMER III is based on micro- and macro-focused ultrasound technology and aims to treat any part of the body including the face, neck, abdomen, buttock, upper arm and knee. The treatment lasts around 30 minutes, depending on the size of the target area and aims to have minimal side effects. Cosmetic practitioner Dr Tapan Patel, who has been using the device at his practice, PHI Clinic, said, “ULTRAFORMER is a game changer for providing the face and neck with a rejuvenation uplift.” The ULTRAFORMER devices are manufactured by Classys in South Korea and are distributed in the UK by VENN Healthcare.

The BAD conducts Sun Awareness Week survey The British Association of Dermatologists (BAD) conducted a survey to promote its Sun Awareness Week in May, which suggested that 80% of people are failing to apply sunscreen before being exposed to the sun. The BAD urged people to take sun protection seriously due to the risks of developing melanoma, which according to the organisation, more than doubles in people with a history of sunburn compared with people who have never been sunburned. The poll also indicated that 70% of people fail to reapply sunscreen every two hours as recommended and 35% of people would only seek shade if they were hot rather than to avoid burning. “These results show just how widely sunscreens are not being used properly by the British public, and highlight an important area for sun awareness campaigns to target,” said Johnathon Major from the BAD. He continued, “While we have succeeded in making people aware of the link between sunburn and skin cancer, we have more work to do in teaching people how to use sunscreen properly. Education is key if we are going to improve sun safety habits and prevent the public from putting themselves at risk.” The organisation also suggests that people should spend time in the shade between 11am and 3pm and wear covered clothing such as a shirt, hat, and sunglasses.

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Aesthetics Journal

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Skincare

Johnson & Johnson to acquire NeoStrata

The Murad Method Facial System launches

Antiageing skincare company NeoStrata is to be acquired by Johnson & Johnson Consumer Inc. The acquisition will include NeoStrata’s affiliates and parent company TriStrata Incorporated. Lorna Bowes, director of AestheticSource, distributors of NeoStrata in the UK, said, “The combined clinical and commercial know-how of these two companies will only strengthen the NeoStrata and Exuviance brands globally, and in Great Britain, AestheticSource will continue to support customers and increase consumer awareness of the results-driven ranges, with exciting times ahead for both brands – it’s business as usual!”

Skincare company Murad is to release a new facial system aimed at promoting whole-person wellness. The personalised concept aims to target multiple skin concerns while delivering relaxation with touch-point massage. The Murad Method Facial begins with an in-depth, segmented, five-zone analysis of the skin that aims to reveal its true health. This allows the practitioner to treat multiple skin concerns at different levels of severity in one prescriptive treatment, using professional-strength products. Upon completion of the treatment, a personalised at-home product prescription is provided, and practitioners are encouraged to share skin health recipes, at-home skincare advice and an inspiration card, which features a motivating quote from Dr Murad to encourage emotional self-care.

Digital

Dermal Fillers

Complications management app launches A mobile application that aims to assist practitioners on managing complications has been launched in the UK. InjectSOS was developed by a group of experienced aesthetic practitioners including consultant plastic surgeon Mr Christopher Inglefield, who created the app to provide practitioners with a tool to ask for advice when complications arise. The app features instant messaging and phone call requests to receive immediate help with complications between 9am and 8pm in the UK. According to the manufacturer, the app is also confidential and comes with encryption and security software so that photos can be securely uploaded to help describe the complication. The photos, messages and phone calls will be directed to the panel of UK specialists, who are all plastic surgeons, cosmetic doctors and experience aesthetic practitioners.

Wellness Trading launches mesoestetic mesofillers

Aesthetic distributor Wellness Trading has introduced the mesofiller by mesoestetic pharma group to its product offering. The mesofiller is a dermal implant based on reticulated hyaluronic acid that aims to smooth and correct wrinkles and restore facial volume to achieve natural, immediate and long-lasting results. According to mesoestetic, the filler is a monophasic transparent gel that is cross-linked with 100% hyaluronic acid chains to ensure better resistance to enzymatic degradation. The company also says the product is non-animal derived and is completely absorbable. Two types are available, including the mesofiller global, which aims to treat medium depth wrinkles and lips and mesofiller intense, which aims to treat deep wrinkles and facial remodelling. mesofiller has been CE mark approved and is distributed in the UK by Wellness Trading.

Regulation

Cynosure to hold regulation seminar in June Laser and light-based aesthetic treatment and manufacturing company Cynosure will discuss the changes in training requirements at a regulation seminar. The seminar will consist of a training overview by Cynosure clinical manager Kelly Harding, as well as presentations from Mr Faz Zavahir, founder of medical and aesthetic training academy (MATA) and consultant for MATA Dr Elizabeth Raymond Brown. The lectures will feature topics on

regulation, health and safety, insurance and training, and will present delegates with opportunities to discuss individual requirements. Harding said, “The Regulation Seminar is an informative day to reassure and guide Cynosure customers through the potential changes in training requirements from 2016.” The event will take place at Chandos House Conference Centre in Central London on June 15.

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Dermal Fillers

MedivaPharma launches Decoria dermal fillers to UK

Aesthetics

Vital Statistics The optimum length of time to shower is 5 minutes to avoid washing away the body’s natural oils (Eucerin, 2015)

UK pharmaceutical supplier of facial aesthetic products, MedivaPharma, has introduced Decoria dermal fillers to its product portfolio. According to MedivaPharma, Decoria is a non-animal, minimally cross-linked hyaluronic acid gel that includes two types of products, the Decoria Essence and the Decoria Intense. The Decoria Essence aims to correct and shape superficial to moderately deep wrinkles and folds, and can also increase the lip’s fullness. The Decoria Intense aims to enhance the lips, contour the face and smooth out wrinkles that are moderate to severe. The Decoria dermal fillers are available to medical professionals in the UK from MedivaPharma and are manufactured by Bohus Biotech in Sweden. Awards

Judges confirmed for the Aesthetics Awards 2016 The judging panel for this year’s prestigious Aesthetics Awards has been announced. The panel includes an array of industry experts and professionals who will study each entry carefully to decide the most worthy winners. The panel comprises consultant plastic surgeon Mr Dalvi Humzah, PR consultant Julia Kendrick, aesthetic nurse prescriber Lorna Bowes, president of the British College of Aesthetic Medicine Dr Paul Charlson and consultant plastic surgeon and president of the British Association of Plastic, Reconstructive and Aesthetic Surgeons Mr Nigel Mercer. All categories will be judged by the panel, with the exception of The Schuco International Award for Special Achievement, which will be decided upon by the Aesthetics journal team. Nine categories will have their winners decided by a combination of voting and judges scores. The Awards ceremony, which will take place in London on December 3 at the Park Plaza Hotel, Westminster Bridge, will see 600 members of the medical aesthetics specialty celebrate their achievements in 24 different categories. Kendrick said, “The Aesthetics Awards represent the crème de la crème of this industry, and I am thrilled to be among the prestigious judging panel this year. I am sure all the categories will be hotly contested so I can’t wait to see the entries!” The Aesthetics Awards 2016 will cover all aspects of the specialty, recognising professionals in an array of categories including, The Dermalux Award for Aesthetic Medical Practitioner of the Year, Treatment of the Year, The Hamilton Fraser Award for Association/Industry Body of the Year and Best Customer Service by a Manufacturer or Supplier. With entry for the Awards due to close on June 30, practitioners, clinics and companies are urged to enter as soon as possible. For more information on categories and entry details for this year’s awards, visit www.aestheticsawards.com

9% of cosmetic print advertisements were found to be in breach of one or more of all relevant advertising codes/laws in 2015 (EASA, 2015)

Respondents to a study who got their first tattoo before their 21st birthday are far more likely to have a tattoo they regret than those who got it after (38% versus 7%) (YouGov, 2015)

41% of rosacea sufferers have cancelled social engagements due to the condition (Rosacea.org, 2016)

Since 2000, the demand for botulinum toxin procedures has increased by 748% (Yahoo! Finance, 2015)

Nearly two in five (38%) Americans would consider not going on a second date with someone who has misaligned teeth (Invisalign, 2012) Studies have indicated that a product’s branding colour influences 60 to 80% of a customer’s purchasing decision (Entrepreneur.com, 2012)

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Events diary 29th June – 1st July 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting 2016, Bristol www.bapras.org.uk

5th – 7th July 2016 British Association of Dermatologists Annual Meeting, Birmingham www.bad.org.uk

17th September 2016 British Association of Cosmetic Nurses Annual Conference and Exhibition, Birmingham www.bacn.org.uk

24th September 2016 British College of Aesthetic Medicine Conference 2016, London www.bcam.ac.uk

3rd December 2016 Aesthetics Awards, London www.aestheticsawards.com

Skincare

UNIVERSKIN launches consumer range Skincare company UNIVERSKIN has released a new serum for consumers aimed at treating an array of skin conditions. A number of active ingredients can be added to the base serum to create a specially formulated product to target specific patient issues, such as acne, ageing, rosacea and pigmentation. The base serum contains 11 ingredients including biomimetic peptides, which mimic the natural regenerative process of the skin and pure skin boosters such as vitamin E, omega 3, hyaluronic acid, melitane, kollaren vegf, thymullen and ECM-Protect enzyme. According to UNIVERSKIN, there are more than 1,500 possible combinations of ingredients. UNIVERSKIN, distributed by Schuco International, is developed by dermatologists, plastic surgeons, biologists and pharmacists and aims to provide patients with a unique treatment, which can be tailored to each individual’s concerns. The formulas aim to target: oxidative stress, loss of volume, acne, ageing, sun damage, rosacea, tone, inflamed skin, dry skin, and skin texture.

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Industry

Dr Stefanie Williams opens new clinic in London Dermatologist Dr Stefanie Williams has opened a new clinic, eudelo, short for European Dermatology London, with fresh branding in Bondway, London. The facility includes medical dermatological services and non-surgical aesthetic services that take place in eight treatment rooms. Currently it houses three dermatologists, three medical aestheticians and one aesthetic doctor. Dr Williams said the move has made it easier for patients to access the clinic for treatments. “It was a brave decision to move to this area but it’s working so well. Patients like the new place and last month we had a record number of new patients. It is really interesting to see what a difference being accessible makes.” She continued, “It’s slightly different from the old-school Harley Street, but we wanted to do something completely different, something fresh; create an oasis.” Awards

Galderma SkinPact Awards to recognise dermatologists in Latin America Galderma is holding the SkinPact Awards in October to recognise the initiatives of dermatologists in Latin America. The aim of the awards is to appreciate the work of international dermatologists and to encourage them to help improve skin health in their communities. The SkinPact Awards began last year in collaboration with the International League of Dermatological Societies with the worldwide launch of the programme, which focuses on a different region of the world every year. The awards has two categories recognising community leadership and excellence in education, which each hold two awards, one judged by community peers and the other by an expert panel of judges. International dermatologists are encouraged to vote for the best entries, which will take place between July 1 to September 30. Laser

Alma Lasers launches Accent Prime Alma Lasers has launched a new skin tightening and body contouring device. The new platform, Accent Prime, combines ultrasound and radiofrequency technologies with the aim of delivering fast, effective, highly-customised treatments with long-lasting results. Accent Prime features the new UltraSpeed handpiece, based on ultrasound technology that aims to create local, superficial dermal heating in delicate areas with real-time monitoring of skin temperature. The platform also features three new highly-powered stationary applicators: Tune Large, Tune Face and Tune Periorbital. These applications utilise RF energy, vacuum and contact cooling. “We are thrilled to introduce the next generation body contouring and skin tightening solution,” said Dr Ziv Karni, CEO of Alma, adding, “Accent Prime will undoubtedly change the paradigm allowing practitioners to offer a tailored solution for different skin types with superior results at unprecedented time.”

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Insurance

All Med Pro releases new indemnity policy Medical insurance provider All Med Pro has partnered with Hiscox Insurance to launch a new indemnity policy for dental practitioners offering aesthetic treatments. The policy aims to provide flexible coverage for dentists to enable their dental practices and aesthetic treatments to be insured under one policy. The policy includes up to £10 million of indemnity insurance, reputation protection, data protection cover, loss of documents cover, legal support and advice line and 12 months of interest free direct debit. Adam O’Keeffe, a director at All Med Pro, said, “All dentists should have indemnity arrangements which are transparent, accountable and in the best interest of the public. Our product provides a dentist with the peace of mind that they have a contract-certain policy with Hiscox, who are one of the leading UK insurers.” Rejuvenation

CACI International launches antiageing eye products Aesthetic device supplier CACI International has introduced the CACI Eye Revive serum and Hydro Eye Mask to its product offering, aiming to address concerns in the periorbital area. The CACI Eye Revive serum is applied using an eye roller to gently move over the surface of the skin. The serum aims to reduce puffiness and dark circles around the eye. It features hyaluronic acid for hydration and moisture and seaweed extract to detoxify and improve skin inflammation. The formulation also includes a paraben-free complex called REGU-AGE PF, which aims to protect and strengthen the eye area whilst reducing the appearance of under-eye circles and puffiness. The Hydro Eye Mask is designed to apply after the CACI EYE Revive serum and aims to revive dull and puffy eyes. It incorporates hyaluronic acid, cucumber extract, green tea, and collagen to hydrate, moisturise, and plump the skin to reduce the appearance of fine lines and wrinkles. Industry

New report predicts global facial aesthetics market to exceed US $5.5 billion by 2020 The latest research by global technology research and advisory company Technavio predicts the global facial aesthetics market will be worth more than US $5.5 billion by 2020. The reported titled, Global Facial Aesthetics Market 20162020 looks at the market in the Americas, Europe, the Middle East and Africa (EMEA) and Asia-Pacific (APAC) and estimates that the market will grow at a compound annual growth rate of around 10% in five years. Technavio health and wellness analyst Amber Chourasia said, “The global facial aesthetics market is growing at a steady rate due to the rising beauty consciousness among consumers and a shift in preference from invasive to minimally or non-invasive procedures.” According to the research, the market in the Americas is expected to grow at a rate of 8%, the EMEA is expected to grow at 10% and in the APAC a 13% growth is expected. According to the research, during 2015, botulinum toxin was the most popular treatment in the facial aesthetics market and accounted for approximately 52% of the total market share. Technavio develops more than 2,000 global research pieces per year, covering more than 500 technologies across 80 countries.

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Ronnie McFarlane, Chief Executive and Joint Founder of Sterimedix Limited When and why was Sterimedix founded? Sterimedix was founded in Redditch, Worcestershire, in 1989 to manufacture and sell ophthalmic single-use devices, namely cannulas and needles for cataract surgery. This was because the founders had significant experience in the ophthalmic specialty and had identified a niche market opportunity for a new business. This business has continued to grow and has developed into a leading brand through innovation, quality, regulatory compliance, and customer service, and we now supply to more than 50 countries worldwide. Why did Sterimedix start making products for the aesthetic sector? Sterimedix is a major supplier of cannulas and needles for manufacturers of viscoelastic fluids for use in ophthalmic surgery, and when these manufacturers modified their products to be used as aesthetic fillers, they identified Sterimedix as the ideal partner for their new delivery systems. Our unique ability to develop new products for specific procedures placed us in an ideal position to engineer the new range of Silkann® aesthetic needles and cannulas for these requirements. We have incorporated specific product improvements in our range, which were previously not on offer from existing suppliers, and we genuinely believe that we have raised the standards and quality of cannulas and needles on sale in the aesthetic marketplace today. What are the latest developments at Sterimedix? Sterimedix continues to develop and expand its range, and will seek to meet the challenges that customers continually set us. For example we have just launched our e-commerce website, www.AestheticCannula.com. Many of our customers worldwide wanted to purchase online, so we have responded to their requests. However, our current wholesale and distribution partners remain very important to us and it is purely a matter of choice for the customer where they choose to buy our products. We are sponsoring the Aesthetics Awards for the second year running in 2016. We are delighted to support our home market and help to recognise the outstanding work of the entire industry at the awards ceremony. This column is written and supported by

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Advanced Esthetics Solutions launches REFORM Skincare Aesthetic distributor Advanced Esthetics Solutions has introduced REFORM Skincare to its product offering. REFORM Skincare is a cosmeceutical brand that aims to protect and create an antiageing effect by helping with pigmentation, blemishes, fine lines and wrinkles, general redness and assisting in a good overall skin complexion. The formulation uses antioxidants including vitamin C and E, and acids including ferulic, kojic and hyaluronic. The eight REFORM Skincare products include the Vitamin B5 Gel for dry, damaged and dehydrated skin, HYAL Vitamin C + E Serum for skin brightening and toning, Hyaluronic Acid Serum to support the skin’s firmness and elasticity and to soften lines and wrinkles, the Everyday Moisturiser for soothing and protecting the skin, the Phyto Botanical Gel, for hydration and anti-inflammation, the Retinol 1% Crème to help reduce the signs of fine lines, wrinkles and blemishes and the SPF 30 Advanced Formula Sunscreen, which protects the skin from UV and harmful sun exposure. Industry

Premier Laser Clinic rebrands Premier Laser Clinic has changed its name to Premier Laser and Skin, involving a new website and branding. The rebrand is due to the clinic’s developments and expansions into skin rejuvenation and antiageing treatments and includes a new website, logo, colour scheme and point of sale. The clinic is led by managing director Lucy Xu, with dermatologist Dr Eric Huang, plastic surgeon Mr Jean Nehme and ENT specialist Mr Deniz Kanliada. “It’s sending the right message and image to the market,” said Xu. “We have always had a high standard of service, the top in technology options and are of a reasonable price point to our consumers; however it was difficult to portray this. By changing the branding we have positioned ourselves as experts in the laser and skin field, which has had a fantastic impact on the business,” she said.

Skincare

True North Cosmetics releases new product range Skincare company True North Cosmetics has launched its ‘futuristic’ Biometric Skin Analysis system and new product range. The company claims the new system uses the same measuring tool as the FBI when investigating the way a criminal would look in the future. It is claimed that the advanced technology analyses the face as in depth and as detailed as it would a fingerprint, which then gives valuable insight into the skin’s needs, such as its moisture level, oil production, sensitivity and the number and depth of lines and wrinkles. “The True North philosophy is to offer high-quality products for women who desire a straightforward skincare programme that delivers impressive results regardless of age or gender,” said company founder, Jan Repholtz Behrens, adding, “we truly care about our customers’ skin condition and offer them a detailed skin analysis using our biometric measuring tool, which gives us valuable insights into their skin’s need.”

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News in Brief Survey suggests patients want the ‘natural look’ A survey of 2,000 American men and women, conducted by dermatology company Galderma, suggests 74% would be more interested in treatments if they produced natural as opposed to frozen results. Other results in the survey indicated that less than 40% of people would be comfortable talking about treatment with a healthcare specialist. The research included online responses from 1,001 US women and 1,000 US men aged between 30-50 and was conducted on behalf of Galderma by Wakefield Research. CACI International launches Synergy system Aesthetic device supplier CACI International has launched the CACI Synergy system for non-surgical antiageing and skin rejuvenation treatments. The CACI Synergy system incorporates the new S.P.E.D (Simultaneous Photo Electrical Delivery) technology, which aims to deliver LED light therapy at the same time as microcurrent facial toning. Elizabeth Arden PRO releases new SPF30 lip balm Skincare company Elizabeth Arden PRO has introduced the Triple Protection Factor Lip Balm SPF30 to its product offering. The product is formulated using DNA enzyme complex, which include photolayse, endonuclease, 8-oxoguanine glycosylase, and antioxidants, which include L-carnosine, L-ergothioneine and Arazine. According to Elizabeth Arden, the product is clinically and dermatologically tested, is noncomedogenic and does not contain any fragrances or parabens. US dermatologists perform 10 million procedures in 2015 According to research released by the American Society of Dermatologic Surgery (ASDS), dermatologic surgeons performed almost 10 million necessary and cosmetic procedures in 2015. Skin cancer treatments were ranked the most common procedure (3.17 million), a figure that according to ASDS has increased by 18% since 2012. The ASDS also claims that, the number of total procedures are up 5% more than the previous year, and have increased 27% since 2012.

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VENN Healthcare Advanced Antiageing Seminar, London The latest developments in VENN’s antiageing devices were presented to doctors, nurses, clinic owners and aestheticians at the VENN Healthcare Advanced Antiageing Seminar at PHI Clinic, London on April 25. After a drinks reception, Chris Schiel, CEO of aesthetic distributor VENN Healthcare, opened the event and introduced cosmetic practitioner and PHI Clinic director Dr Tapan Patel and aesthetic surgeon Dr Benji Dhillon, who spoke about the Lutronic INFINI and the new Classys ULTRAFORMER III device. The Lutronic INFINI is a high intensity focused radiofrequency device that aims to deliver enhanced wrinkle reduction, skin tightening and volumisation results throughout the whole body using microneedles. Dr Patel said PHI Clinic had been using the Lutronic INFINI device for almost five years and noted that the device is precise, has minimal downtime, can be delivered at a low-cost and usually only one to three treatments are needed. Most importantly, he added, “We can treat all skin types; it’s impossible now to be in aesthetic medicine and stick to treating patients with only one skin type.” Dr Patel also discussed the science behind the device, how it compares to other

IBSA International Anatomy Masterclass, Paris

International delegates congregated in Paris for the International Anatomy Masterclass by IBSA Farmaceutici Italia on April 28. The masterclass was the first of its kind organised by IBSA and involved anatomy training for the use of hyaluronic dermal filler injections. The event featured a full day of training led by Dr Benjamin Ascher, Professor Daniel Cassuto, Dr Bernard Mole, Dr Cecile Winter and Professor Raphael Sina. The range of topics presented included an understanding of anatomy to optimise injection techniques, danger zones to be aware of, live dissections, and a discussion of techniques for the face, hands and décolletage. The day also featured a presentation of IBSA’s Aliaxin fillers. The delegates had the unique opportunity to undergo hands-on training under the supervision of the trainers, for better understanding and to improve their skills. IBSA’s products are distributed in the UK by HA-DERMA.

similar products, showed before and after photos and case studies, and explained how to use the device through a live demonstration. Dr Dhillon then went on to discuss his experiences using the new Classys ULTRAFORMER III device, a high intensity focused ultrasound system, which aims to provide a lifting and tightening effect on the face and neck. After the close of the session Dr Patel said, “I was delighted to work in collaboration with VENN Healthcare because we have two of their systems and it gave myself and Dr Dhillon the chance to describe how we are incorporating new technologies into our full antiageing programme. It was a fantastic session, full of interaction, and allowed us to share experiences and I hope the delegates enjoyed it.”

The Association of PDO Threads UK conference, London The Association of PDO Threads UK hosted its first conference at the Royal Society of Medicine on Saturday May 7. The conference began with a canapé and drinks reception, followed by presentations from association chair Professor Syed Haq, board member Dr Jaques Otto, and independent nurse prescriber Yvonne Senior. A neck lift live demonstration with Professor Haq showed delegates how to use polydioxanone (PDO) threads in this area, while Dr Otto demonstrated his techniques on the face. Senior presented a business session discussing educational standards, and London underwriter Lisa Matthews spoke about medical insurance and clauses. The afternoon offered delegates more workshops led by Professor Haq and Dr Otto and the day concluded with a question and answer networking session. “The conference was very informative, and a massive step in the right direction to ensure PDO threads are correctly used, ensuring the best possible outcome for our patients,” said Dr Irfan Mian, who, along with Mr Bassim Matti, was a guest of honour at the event. He continued, “The networking possibilities and feedback from other doctors and members was invaluable, I would like to congratulate everyone concerned!” Alongside the conference, delegates were able to enjoy the exhibition, which comprised many product and distributor stalls including NeoPharmaUK Ltd, IntraVita Ltd, Cosmetic Insure, Facethetics Ltd and HA-Derma. The Association of PDO Threads is a new group that aims to ensure the best possible practices are used when conducting procedures involving polydioxanone threads.

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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International Launch of UltraShape Power, London Attendees from across Europe gathered at Dr Haus Dermatology on Harley Street, London, for the launch of the new noninvasive body contouring treatment, UltraShape Power from Syneron Candela. Delegates were presented with a selection of healthy breakfast options on the morning of May 10, before a presentation from Syneron Candela, public relations company True Grace PR and dermatologist and cosmetic practitioner Dr Ariel Haus. Marjolijn Benthem, director of marketing in Europe, Middle East and Africa at Syneron Candela, began the presentation with an overview of the company and the UltraShape Power device. Managing director of True Grace PR, Charlotte Moreso, followed this presentation, informing the audience on why the event was themed on superheroes; explaining that they believe 2016 is ‘the year of the power players’ and that the device aims to help consumers feel empowered with their body. Moreso displayed survey results of 1,000 respondents on their views of powerful people and what makes

one. The results indicated that the majority (37%) of people felt that being healthy made them feel powerful and 21% said being content with their body made them feel powerful. Dr Haus, who uses the device in his practice, then presented the audience with a more in-depth analysis of how the focused ultrasound device aims to destroy fat cells without using heat. He showed a selection of before and after images to demonstrate the results as well as a clinical study on the device. The results of the study, which included 43 participants who had the recommended three treatments, indicated a circumference reduction of 2.62cm at a 12-week follow-up. It also indicated that 80% of participants reported an improvement twoweeks post treatment. Attendees were then invited to have their photo taken by UK cartoonist Neil Kerber, who would turn the delegates into their own ‘cartoon superhero’. The event concluded with a live demonstration of a patient being treated with the device on her abdomen. She claimed to be a physically active and a healthy-eating individual, but struggled to lose smaller pockets of fat. This was the first time the patient had been treated with the device and she reported no feelings of discomfort. Dr Haus said, “I was very honoured to be the first one to have the new UltraShape Power device, and for me, Syneron Candela is the RollsRoyce of aesthetic devices.”

Face Eyes Nose Conference, Coventry Aesthetics reports on the highlights of the annual FEN conference The non-surgical-focused opening day of the Face Eyes Nose Conference saw plastic surgeons from across the world come together to learn how to maximise their practice with aesthetic treatments. The conference, which took place at University Hospital Coventry on May 1115, began its first day with a masterclass in aesthetic treatment of the face. The agenda presented delegates with a clear overview of how aesthetic treatments can complement surgical ones and provided detail on different modalities of treatments. In the morning, Aesthetics journal editor and sales and marketing professional Amanda

Cameron informed delegates how to use their brand to enhance their practice. She spoke about how to create a USP and what to avoid when creating a brand. Aesthetic nurse prescriber Lorna Bowes also spoke in the morning, answering questions on whether cosmeceuticals really work. Bowes identified the main ingredients in certain products and explained what their functions are, highlighting an abundance of studies that supported the ingredients’ uses in skincare. Before the attendees broke for lunch, consultant plastic surgeon and course convenor Mr Dalvi Humzah delivered a presentation on ‘Cannula or Needle: Assessing the Safety of the Techniques’. He asked the audience which they thought was better; cannula or needle? The majority of the audience raised their hands in support of the needle. Mr Humzah then highlighted the pros and cons of each delivery system and took an in-depth look at the anatomy, stressing the importance of ‘knowing where you’re injecting’, Mr Humzah said, “If you

know where your tip is then you’ll always be safe.” He concluded his presentation with a video of himself and a colleague injecting a cadaver and comparing the results between the cannula and needle. Professor Andy Pickett began the afternoon and re-engaged the audience with an update on botulinum toxin. He explored the abundance of its uses, including latest research that indicates botulinum toxin may be effective in treating obesity; although he acknowledged it would still be ‘a few years’ before it might be licenced for the indication. Professor Pickett claimed that toxin had turned back the anatomy clock and that ‘although botulinum toxin had never saved a life, it had improved the quality’ of the lives of many. He also touched upon the treatment’s effectiveness in skin conditions such as rosacea and the need to be wary of counterfeit products. The Face Eyes Nose Conference also featured an array of international speakers who provided interesting experiences from overseas; Dr Matt White (New York) Dr Bernard Mole (France), Dr Roberto Pizzamiglio (Italy) and Dr Andy Chiang (China). Dr Chang intrigued delegates with his talk on ethical facial contouring, focusing on the desired facial features of Chinese women. The day concluded with a panel Q&A discussion and a drinks and canapé reception.

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


Preserve the identity of your patients with natural-looking results.1 Azzalure is proven to reduce the severity of glabellar lines.2 It provides fast onset of action (median 2-3 days)2 and long-lasting efficacy (up to 5 months)2, and almost 90% of patients felt the results “surpassed” or “met” their expectation.1 References: 1. Molina B et al. J Eur Acad Dermatol Venereol. 2015;29(7):1382-1388. 2. Azzalure Summary of Product Characteristics.

Actual Azzalure user. Fictional model name. Results may vary. Azzalure Abbreviated Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection) Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Galderma (UK) Ltd. Azzalure and Galderma are trademarks owned by Galderma S.A Date of preparation: February 2016 AZZ/003/0216

intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation.Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE) Legal Category: POM Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: March 2013


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Galderma Aesthetics Academy 2016, London

interesting presentation describing how studies have shown that long-term use of dermal fillers stimulate changes in the soft tissue (SMAS) by creating a Velcro effect in the retaining facial ligaments, therefore giving more support to the Independent nurse prescriber Lou lower face. This was followed by an interactive live injectable Sommereux reports on the highlights of demonstration, ‘Treating through the Generation’, the Galderma educational day on a mother and daughter, led by aesthetic nurse prescriber Jackie Partridge and Dr Kuldeep The Galderma Aesthetic Academy (GAA) day, which took Minocha, and chaired by Dr Beatriz Molina. They demonstrated place on April 22 in central London, is an annual educational temple techniques and a range of treatments for concerns including highlight in the plethora of conferences taking place in the UK. mid-face volume loss and tear trough deformities. Dr Juan Sopena This 13th event produced exceptional content and was enjoyed by and Dr Philippe Kestemont then performed another live demonstration all who attended. I was personally delighted to learn that of the of treating a male patient, highlighting the important differences when 300 delegates present, 60% were nurses. Alexandra Tretiakova, treating male versus female patients. Galderma general manager UK and Ireland, opened the day with The afternoon sessions continued to highlight the value of creating a warm welcome, as did Toby Cooper, head of Galderma UK. They a customised portfolio and ensuring patient safety. Dr Sopena and informed the audience that in the past 20 years Galderma products Dr Minocha each treated a female patient, looking at the full-face have been used in 28 million treatments; an impressive statistic that approach to rejuvenation. Whilst they injected and showed varying reflects the high levels of patient satisfaction and retention that the techniques, Dr Kestemont used cadaver videos to demonstrate company implements. To begin the day, Galderma unveiled a new where to place products and danger zones to avoid; this was patient-based approach, simplifying the filler portfolio for healthcare acclaimed as exceptional teaching at the highest level. The last professionals and consumers. Emervel is now positioned under lecture of the day was conducted by the unique Jez Rose, known as the Restylane megabrand, therefore providing an extensive and The Behaviour Expert, who presented a very humorous, inspirational broad portfolio offering individualised treatments for every patient and informative key note lecture on how to achieve a high level of need. Galderma also announced the launch of a new digital era for patient satisfaction and retain customers in your business. This was both patients and healthcare professionals with a new consumer followed by the annual donation to Operation Smile and a networking website, patient app and a comprehensive resource centre. Mr reception of refreshments and canapés. Andrea Allan, who attended Rajiv Grover who has presented and/or chaired at each of the from her clinic in Suffolk, concluded, “I thought the meeting finished on 13 yearly meeting days, began the educational agenda with an a high, reflecting the positive feeling throughout the day.”

ASAP 2016, Scotland Founder and chairman Dr Simon Ravichandran outlines the highlights of the Association of Scottish Aesthetic Practitioners meeting in Glasgow

May 6 and 7 saw the 5th annual conference of the Association of Scottish Aesthetic Practitioners (ASAP), and it’s return to the Royal College of Physicians and Surgeons in Glasgow. This conference has been growing year on year and has established itself as a vital source of education and networking for practitioners in Scotland and the North of England. Friday consisted of a series of business workshops hosted by the Aesthetic Business Network. The topics on the agenda included how to develop USPs, how to market and use social media, the value of brand development and compliance issues in aesthetic businesses. All of the talks were aimed specifically to help the delegates understand how to view the new Scottish Regulations as an opportunity to grow and differentiate themselves from their competitors, rather than be faced with hurdles and restrictions. One delegate said that initially she was disheartened and overwhelmed by the regulatory process, but after the seminars felt positive about moving forward and using the system to develop her business and brand. Running alongside the business workshop was a series of clinical masterclasses hosted by Merz Aesthetics, Intraline, Invasix,

Renaissance Skincare and Rosmetics that were well received, giving the delegates the chance to get up close and personal with high-profile speakers. Saturday was the exhibition and plenary session day with four sessions featured in the programme. Mr Dalvi Humzah and Dr Vincent Wong led the first session of the day, and discussed the anatomy relevant to aesthetic treatments and the male consultation process. The second session was based on complications and involved an insightful presentation by aesthetic nurse prescriber Linda Mather on the effect a complication can have on a practitioner. Each panel member then presented a complication that they have dealt with and an informative discussion took place regarding the avoidance and management of complications that can occur. The third session focused on introducing new technologies into the clinic and the final session was the ASAP injectable masterclass, featuring live demonstrations in thread lifting with Dr Aamer Khan, and dermal filler demonstrations with Mr Dalvi Humzah and Dr Vincent Wong. The turn out for the event was great and sitting at the back meant it was easy to see how informative the delegates found the event, with a great many delegates furiously writing notes through the presentations. Planning is already underway for 2017 with plans for a new venue and an expanded agenda to make sure everyone gets as much value as possible from the event!

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Are practitioners taking acne seriously enough? Aesthetics investigates the recent concerns with the psychological implications that acne can have on patients Charities worried about the potential psychological implications of skin conditions on patients have recently voiced concerns in the media about the way acne is perceived in society by not only the public, but by medical practitioners as well.1,2 According to statistics from research conducted in 2015 by the British Skin Foundation (BSF), a charity that aims to help people living with skin diseases in the UK, 95% of people say acne has an impact on their daily lives, with 63% reporting a decrease in self-confidence.3 The BSF and Changing Faces, a charity that represents and supports people with disfigurements to the face and body, including skin conditions, argue that statistics like these highlight the psychological implications that could present in patients suffering from acne. The charities also stress that, due to the potential underlying psychological effects, the condition is not taken seriously enough by some medical practitioners. Approximately 85% of people between the ages of 12 and 24 experience at least minor acne,4 and the condition can expand far into adulthood with studies indicating around 70% of people over 20 experience acne at one time or another.5 So what implications does acne have on a patient’s mental health, confidence and self-worth, and are aesthetic practitioners taking these implications seriously enough? How acne psychologically affects patients Studies have suggested that acne can cause a number of psychological abnormalities, including depression, anxiety, embarrassment, and lack of self-confidence.6 “People with acne can feel unsupported, socially isolated and become withdrawn, which can affect all aspects of their life including

“I have come across some people who have gone to the extreme to self harm and attempt to end their lives because of the effect scarring has had” Dr Vishal Madan

relationships at work, with family and friends,” says Dr Anjali Mahto, consultant dermatologist and BSF spokesperson. Psychological effects of acne can result from two possible areas, according to consultant dermatologist Dr Vishal Madan; the visible disease itself, which includes painful acne lesions, papules, pustules and nodules, and the scarring that may be a result of the improper treatment of acne. Cosmetic dermatologist Dr Sam Bunting says that the level of psychological impact acne has depends very much on the patient, “With any dermatological condition you always need to factor in the individual’s subjective response to the condition, at the same time as objectively assessing its severity – it can be surprising how diverse the impact of skin disease can be.” Dr Madan has seen how severe the psychological long-term affects of acne scarring can be, explaining, “People who develop scars on their faces get deeper scars on the psyche somewhere. I see people experiencing subclinical and clinical depression as a result of acne scarring; I have come across some people who have gone to the extreme to self harm and attempt to end their lives because of the effect scarring has had on their lives.” The concerns Ivon Van Heugten, policy adviser in health at Changing Faces, says the charity often sees acne sufferers feeling as though they have not been taken seriously enough, which can be concerning. “Acne is often a temporary condition and only sometimes a lifelong condition, and because of that people think that it’s just a stage that you go through – this is a common attitude not only amongst the public but also amongst health professionals – skin conditions are often underestimated in terms of the treatment and the psychological care that is needed.” Dr Mahto agrees with these concerns, and says, “In a health system that is bursting at the seams, often conditions that are not life-threatening do not get the priority that they need. The growing field of psychodermatology recognises this and places emphasis on the often-unmet need for patients with skin disease to get the psychological support they require. Dr Mahto explains that the results from studies such as the one from the BSF do not surprise her, “People do underestimate acne and the impact it has on those suffering with it; I think these results highlight that acne should be taken far more seriously.” Dr Bunting suggests that the main issues lie at the general practice level where, due to the limitation of resources, many patients who need the next level of help are not being referred to a dermatologist. “Almost everyone that I have seen with acne has had the experience of not being taken as seriously as they would like to

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be by the medical profession, in terms of how their skin condition are affecting them,” she explains, adding that, in her experience, patients are only being referred by the GP if their acne is severe enough to warrant Roaccutane. Dr Jane Leonard is a GP and an aesthetic practitioner who believes that GPs probably do not get the sufficient dermatological training that patients may need. She says, “At the end of the day we are generalists, in some areas, particularly related to skin. People only know the basics, so even simple things like making the differentiation between mild, moderate and severe acne can be challenging and some practitioners may not have had that experience or insight to know what they need to do.” Education is key Dr Madan believes that non-specialist medical professionals need more education to not only recognise the severity of acne on the outside, but to deal with the emotional factors that surround acne, “There’s a lack of education, and a lack of awareness of the long-term sequela of acne. You cannot address this issue if there is not enough education to the clinicians who are diagnosing the condition.”     Dr Bunting agrees, “GPs face a big challenge when it comes to managing dermatological patients. Skin disease is terribly common and many of them won’t have had a huge amount of dermatology exposure during their GP training. It’s important to keep dialogue with patients suffering from common conditions like acne as open as possible to ensure the best possible standard of care and seek secondary care input in complex cases.” Dr Mahto says it is crucial that GPs and medical professionals know

Aesthetics

when to treat acne and the deeper issues that surround the condition, as well as when to refer, “Healthcare and allied professionals need to be trained in recognising acne, assessing severity adequately and knowing when a specialist opinion from a dermatologist is required. Otherwise, patients will always be done a disservice.” Dr Leonard suggests that skin specialists and dermatologists can do more to support other medical professionals who might not have as much experience, and recommends a multidisciplinary approach, saying that they, “Need to pick up the phone and ask for advice if necessary, rather than relying on a watch and wait approach.” She says this can go both ways, and practitioners with strong dermatology experience can help GPs, nurses and other medical professionals by letting them know their knowledge is available if they need it, or letting them know that if the GP’s patients are interested in going private, then they are there to help. Dr Leonard concludes, “At the end of the day everybody is good at the things they are good at, but sharing information and sharing support is always a good thing.” REFERENCES 1. Morse, F, ‘Acne needs to be taken more seriously, say charities,’ BBC Newsbeat, (April 2016) <http:// www.bbc.co.uk/newsbeat/article/36081736/acne-needs-to-be-taken-more-seriously-say-charities> 2. Worley, W, ‘Acne must be taken more seriously, charities say.’ The Independent, (April 2016), <http:// www.independent.co.uk/life-style/health-and-families/health-news/acne-skin-dermatology-seriouslycharities-a6993576.html> 3. British Skin Foundation Acne Survey of 2,299 acne suffers, (2014-2015), <http://www. britishskinfoundation.org.uk/LinkClick.aspx?fileticket=i2bE2n4c8m0=&tabid=172> 4. Bhate K, Williams HC, ‘Epidemiology of acne vulgaris,’ The British journal of dermatology, 168(2013) pp.474-85. 5. Collier, C, Harper J et al.,‘The prevalence of acne in adults 20 years and older,’ Journal of the American Academy of Dermatology, (2008) 6. Tan, FKL, ‘Psychosocial Impact of Acne Vulgaris: Evaluating the Evidence, Skin Therapy Letter, (2004).

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Tightening the Neck Practitioners discuss their preferred skin tightening methods for the lower face, jowls and neck Most aesthetic practitioners talk of a ‘full-face approach’ to rejuvenation, but what about those areas beyond the face? Sagging necks and jawlines, as well as wrinkled hands and knees, are often regarded as the ‘telltale signs of ageing’, indicating the maturity of a person despite how youthful their face may look. We know of a plethora of treatments available to offer patients seeking facial rejuvenation, but what can aesthetic practitioners do to improve the appearance of the neck non-surgically?

Ageing and anatomy Scarborough et al explain that senescent changes of the mature neck include accumulation of fat, laxity of muscular support, and the cumulative effects of photodamage and gravity. These contribute to the loss of definition of the cervicomental angle (Figure 1), submental fullness, sagging of the jowls, inelasticity and redundancy of the skin, along with platysmal band formation.1 As a result of these developments, the lower facial third may appear fuller, which can diminish the ‘heart-shaped’ facial shape that is so widely associated with a youthful appearance. According to practitioners interviewed for this article, treatment should therefore aim to tighten the lower face and neck, as well as improve the appearance of platysmal bands.

i

ii

iii

iv

Figure 1: Depiction of the loss of definition of the cervicomental angle1

Consultation Understanding a patient’s concern is key to successful treatment, as is being aware of their general health, diet and lifestyle factors, explains Dr Anita Sturnham, founder and director of the Nuriss Skincare and Wellness Centre. Dr Sturnham comments that, regardless of the type of aesthetic concern a patient might present with, she asks all patients to bring their current skincare products and makeup to the first consultation so that she can establish what may be working and what may be causing concerns. “Getting the skincare right is essential if we are going to make progress and fight the ageing process,” she explains,

adding, “We need hydrating, collagenboosting, pigmentation-stablising active ingredients in the serums and night creams to really boost the skin’s health and prepare it for advanced treatments.” Dr Johanna Ward, founder and director of The Skin & Body Clinic, explains that the first question she asks all patients is whether or not they would consider cosmetic surgery. “I find that this question makes people confront the question of ‘How much does this problem bother me?’,” she says, which can help to establish what type of treatments to offer the patient. Dr Ward also notes that all non-surgical skin tightening and uplift treatments require the patient to understand about skin health and be able to commit to a consistent skincare regime in order to enhance and maintain results. “Patients should know why they should wear a daily SPF and why their smoking habit might be impending their results. Once we have the basic education in place the rest of the dialogue is easy,” she explains.

Treatment Next, a decision should be made on what treatment to offer. Dr Victoria Dobbie, founder and medical director of the Face & Body clinic, explains that in her practice, this is often dependent on the patient’s budget. “If they’re not seeing enough sagging to invest in a more expensive treatment, they may prefer to undergo botulinum toxin treatment for the early signs of sagging of the jawline and neck,” she says. Dr Ward notes that botulinum toxin alone may not be enough for some patients, as it does not have an impact on skin health and collagen. She does, however, offer injectable treatments in combination with other procedures, explaining, “With skin tightening, we can treat virtually every centimeter of the face and neck, and, when combined with botulinum toxin and fillers, they can help patients achieve dramatic non-surgical results.” Botulinum toxin Often described in consumer media as the ‘Nefertiti Lift’ after the Egyptian queen famous for her defined jawline, some practitioners offer patients botulinum toxin injections in the neck. Dr Dobbie says she offers this treatment to patients with mild jowling, a down-turned mouth or the early signs of platysmal bands. “Botulinum toxin is an excellent way of preventing this from getting any worse,” she explains. For optimum results, Dr Dobbie asks patients to bite on their back

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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teeth to contract their platysmal bands. “I get hold of a band between two fingers and inject intradermally, pulling the band away from the neck. Doing so ensures that you are only injecting the platysmal band; you don’t want to inject the deeper muscles in the neck as they could effect swallowing – although I think it would be quite difficult to actually get them. It’s easily avoidable.” Dr Sturnham also advocates the use of botulinum toxin for platysmal bands. She says the downside is that patients may have to wait up to 14 days to see results, and, like any injectable treatment, there is a risk of redness, swelling, bruising and infection. Ultrasound There is a wide range of ultrasound devices on the market, which have all demonstrated successful results. Consultant plastic surgeon Mr Paul Banwell, founder and medical director of The Banwell Clinic, says, “The technology is expanding and there’s a wealth of evidence supporting the use of focused ultrasound for skin tightening. All of the devices are good; they’re all slightly different which allows practitioners a choice in what they use.” In his clinic, Mr Banwell has been trialling the 3D-skinmed (Figure 2). The device uses highintensity focused ultrasound (HIFU) and radiofrequency energy, which aim to target the subcutaneous tissues, causing fibroblastic stimulation that then increases collagen production. “Secondary to that, the temperature effect causes collagen fragmentation, contraction and denaturisation of the protein and collagen, which influences a tightening effect as a result,” explains Mr Banwell. The final stage of the treatment delivers cosmeceutical products to the skin using a sonotrode, which emits acoustic waves and air pressure that aim to help the topical products reach the targeted tissue depth as quickly as possible.2 According to the manufacturer, results become visible within a four-week period, whilst further improvement in facial skin tightening and wrinkles is seen up to six weeks post treatment.2 Mr Banwell explains that pain is minimal, with patients reporting the feeling is similar to having an elastic band flicked against your skin. He adds, “What’s interesting is, as you get more experienced, you can titrate the settings according to discomfort in each individual patient – that’s half the skill and artistry of using any machine really – you get a better feel for what a machine can do for certain patients over time.” Dr Dobbie chooses to offer Ultherapy (Figure 3) in her clinic. She explains, “It’s a single, one-off treatment and can give tightening between 2-5cm after six months. And it lasts; I’m reviewing patients after two years at the moment, 50% are deciding to have a top-up treatment and 50% are deciding they’re absolutely fine.” The FDA-approved device uses ultrasound imaging, to allow the

Figure 2: Before and after treatment with 3D-skinmed. Images courtesy of Mr Paul Banwell.

Aesthetics

practitioner to see down to 8mm below the skin on a screen.3 Dr Dobbie advises that practitioners should make use of this and Figure 3: Before and 90 days after treatment with Ultherapy. Images courtesy of Dr Leslie Baumann learn how to successfully identify and Ultherapy. the different layers of the skin to determine optimal placement of the treatment energy. She also notes that practitioners should recognise the differences in individual patients’ skin and know how and when to treat accordingly. The Ultherapy transducers offer three different treatment depths; 4.55mm to the SMAS/platysma, 3mm to the deep dermis and 1.5mm to the superficial dermis.3 Dr Dobbie explains, “Some people have very thin skin, particularly in the neck, so we use the transducer at 3mm instead of 4.5mm, as the 4.5mm would be below your target.” For Dr Ward, ULTRAcel is her ultrasound treatment of choice. Similarly to other ultrasound devices, the treatment uses HIFU technology to reach a depth of 3-4.5mm to target the SMAS, fascia, fibrous tissue of fat layer, dermal layer and the dermis.4 The main difference, however, is that ULTRAcel incorporates grid radiofrequency that aims to promote the production and remodelling of collagen prior to the ultrasound lifting and tightening

“The technology is expanding and there’s a wealth of evidence supporting the use of focused ultrasound for skin tightening” Mr Paul Banwell effect. The main skin tightening and lifting effect develops over two to three months, although some patients report seeing an effect immediately. According to Dr Ward, patients present at all ages and stages in their lives for skin tightening. She does note, however, that it is much easier to get results on skin that still has healthy collagen and elastin levels, and skin that has not been damaged by chronic sun exposure. Radiofrequency Dr Ward explains that for optimum results, she uses ULTRAcel in combination with the INTRAcel radiofrequency-needling device (Figure 4). “This will combine monopolar and bipolar radiofrequency with focused ultrasound,” she says, explaiwning, “The ULTRAcel treatment will help tighten the SMAS layer and the INTRAcel treatment will help tighten the overlying skin, improve skin texture and reduce fine lines and wrinkles.” She suggests that the combination can achieve everything a surgeon would do through a facelift procedure, but non-surgically and without the same level of risk. “In terms of

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to ensure appropriate placement of the needles in the dermis, because if they are placed superficially, skin damage such as scarring could occur. Overall, Dr Proebstle says Profound is an effective treatment that offers superior results for tightening compared to other products he has tried. He comments, “We can obtain tightening that we have been unable to achieve so far, without hurting the superficial skin layer like with ablative lasers.” Laser For ultimate skin rejuvenation, Dr Sturnham offers her patients non-ablative laser treatments with the Figure 4: Before and four months after one ULTRAcel treatment and two INTRAcel ClearLift in combination with treatment with the treatments undergone over a three-month period. Images courtesy of Dr Johanna Ward and Exilis Elite system. She explains that the device Healthxchange Pharmacy. uses 1064 Q-switched laser technology and works by delivering short bursts of light energy, which aim to reach underneath the skin’s surface and create microscopic holes under the skin. These holes aim to stimulate a collagen remodelling process as the skin tries to repair itself. “The laser also breaks down unwanted pigmentation and even regulates sebum production – it’s a great multi-tasking laser,” says Dr Sturnham. She explains that the FDA-approved Exilis uses radiofrequency and ultrasound energy to stimulate the breakdown of old damaged collagen stores and elastin fibres, and improve the skin’s firmness and elasticity by enhancing collagen production. “It is a dual technology that accesses the deeper layers of the skin, making it an extremely effective and popular non-surgical treatment,” she says, adding, “The ClearLift complications, the nice thing with the INTRAcel/ULTRAcel is that it is a works to improve the skin at a cellular level, whilst the Exilis Elite really universal treatment,” she says, explaining, “It is safe for virtually intensely focuses on skin tightening and collagen remodelling.” everyone and every skin type, and avoids any of the pigmentation Dr Sturnham recommends that patients undergo a total of four complications associated with laser.” According to Dr Ward there is sessions, one every 7-10 days, with maintenance treatments once or a 24-hour downtime period following INTRAcel treatments, but it is twice a year. She adds that the treatment is not suitable for patients generally well tolerated. “We have done more than 200 treatments who are pregnant, breastfeeding or are taking medication that is a now with INTRAcel/ULTRAcel and the only complication we have seen contradiction to laser. so far is one post-treatment outbreak of folliculitis,” she says. Radiofrequency is also the treatment of choice for Dr Thomas Conclusion Proebstle, founder and medical director of the Proebstle Private As with any aesthetic treatment, appropriate patient selection and Clinic. He uses the Profound device; a bipolar radiofrequencythe skill of the practitioner are key to successful results. “As with any needling system which, he explains, aims to define the maxillary machine, it’s only as good as the user,” says Mr Banwell. “You have bone, the mandibular and the jawline, as well as tighten the neck to choose the right patients and whoever’s using the machine has and improve the appearance of a double chin and chin/neck angle to be competent,” he adds. Dr Ward agrees, highlighting the need (Figure 5). “All patients with skin laxity in the lower half of the face for continued learning when adopting new treatments, explaining and upper neck are suitable,” he comments, adding that patients that she is part of a group that meets regularly to exchange tips, techniques and learning. She says, “I love being part of the learning phase with the new equipment and I find it exciting to be part of a team of people who are exploring new science and technologies. The group is really helpful and helps drive results and patient satisfaction, which is great.” Mr Banwell concludes by offering advice to practitioners looking to add a skin-tightening device to their product portfolio, “Research your choice of machine carefully – there are a variety to choose from on the market and there’s one to suit every clinic according to patient requests and budget.”

As with any aesthetic treatment, appropriate patient selection and the skill of the practitioner are key to successful results

Figure 5: Before and 11 days after treatment with Profound. Images courtesy of Dr David Kent and Syneron Candela.

usually only require one treatment, although a second may be considered if the sagging is severe. According to Dr Proebstle, patients can expect to see results within two to three weeks – much less time than with some other heatbased treatments. He advises that practitioners should take care

REFERENCES 1. Scarborough et al, ‘Exploring Aesthetic Interventions: Treating the Sagging Jawline and Platysmal Banding: A Simplified Technique’, The Dermatologist, 15 1 (2007) <http://www.the-dermatologist.com/ article/6765> 2. 3D-skinmed (UK: 3D-lipo, 2016) <http://www.3d-skinmed.co.uk/3d-skinmed/> 3. Ultherapy, Harness the power of sound to non-invasively list skin, (US: Ultherapy, 2016) <http://www. ultherapy.com/Physicians/Science-Of-How-Ultrasound-Skin-Lift-Works> 4. Ultracel, FAQs, (UK: Ultracel UK, 2016) <http://ultraceluk.com/faq/#1453065890713-25e4a607-4b6e>

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Botulinum Toxin for Men: Treating the ‘Brotox’ Boom Dr David Jack examines the increase in male aesthetic treatments and details the relevant anatomy to be aware of when treating men with botulinum toxin Since the conceptualisation of botulinum toxins types A and B (BTX-A/BTX-B) as treatments for cosmetic enhancement in 1990,1 their use has grown exponentially making botulinum toxin one of the most requested and accessible cosmetic treatments available around the world.1 As in the realms of beauty and fashion, the male market for aesthetic treatments was traditionally seen as an afterthought, lagging behind in terms of revenue and importance when compared with that of the female. Between 2000 and 2014 however, the American Association of Plastic Surgeons reported an increase of 67% of men undergoing minimally invasive non-surgical cosmetic procedures and, within this, an increase of 337% of men undergoing botulinum toxin treatments.2 This significant statistic highlights and supports the recent observations in the media that male patients are gaining significant interest in these treatments. Indeed, more than 400,000 men underwent botulinum toxin treatments in 2014 in the US alone. Interestingly, over the same time period, the report found a substantial decrease of 48% of men undergoing surgical cosmetic procedures.2 In my clinic I personally have noticed a change in the number of males enquiring about and undergoing botulinum toxin treatments in the last few years, in line with this recent statistical data. Although there is yet to be a significant demographic study on this, in my observation, the majority of these patients are high performing professionals aged between 35-60 who are choosing to invest in themselves, but are not keen on the idea of surgical interventions to maintain their appearance. Given the increase in uptake of these cosmetic non-surgical interventions by men in recent years, it is important for any aesthetic practitioner to have a good understanding of the specific treatment goals and aesthetic anatomical nuances when treating male patients with botulinum toxin treatments. In this article, I will outline the gross anatomical differences when comparing male and female faces, the different treatment goals, and I will also suggest ways to optimise neurotoxin treatment of the male

In general, the higher muscle bulk in males results in a higher dosage requirement than their female counterparts

face. In addition, I will outline the treatment of axillary and palmar hyperhidrosis, an important secondary usage of botulinum toxin by aesthetic medicine providers.

Male facial anatomy Regardless of gender, less than 15% of human faces are considered to be symmetrical,3 and all faces can be considered to have ‘imperfections’ in one or more feature if viewed from an idealistic standpoint. Regardless of this, ideal ‘attractiveness’ in males when compared to females can be associated with certain specific facial features,4,5 thus allowing targeted aesthetic interventions to enhance these features without resulting in feminisation. Developmentally, all faces begin as female. During development and puberty, aside from facial hair growth, higher androgen levels in males stimulate masculinisation of the facial soft tissues and bony structures, with development of bulkier mid-face components and squarer jawlines synonymous with a masculine appearance. Dr Mauricio de Maio, an acclaimed plastic surgeon, considered by many to be the authority on non-surgical facial treatments, described a hierarchy of three groups of facial features that confer masculinity on a face.5 The first and most important features in men include the nose, the chin and jawline, and the zygomatic arches. In males, attractiveness is associated with a strong chin, which may even over-project the lower lip, in contrast to females, where higher cheekbones and a chin slightly posterior to the lower lip, are desirable features. The second group of masculinising characteristics includes the supraorbital ridges, premaxilla and the contours of the temporal region. Frontal bossing and prominent supraorbital ridges give the male eyes a deeper appearance compared to females. According to Dr de Maio, the eyes, eyebrows, lips, perioral and nasolabial areas form the third group of characteristics. These features confer individuality and dynamic harmony to the face. Whilst each of the individual features in each group are important targets for any treatment, it is of course essential to consider the face as a whole when planning any aesthetic intervention. Treating one area without considering the others, and indeed the impact of one treated area on another area, can upset the overall harmony of the face as a whole.

Botulinum toxin-A Botulinum toxin-A is one of eight-genetically distinct cytoplasmic exotoxins produced by the gram-positive obligate anaerobic bacillus Clostridium botulinum. This toxin acts at the level of the cholinergic neuromuscular junctions and nicotinic/muscarinic receptors of the sympathetic and parasympathetic nervous systems to block the release of acetylcholine, and, thus, block the stimulation of the targets of motor and other autonomic nerves. In low doses, the BTX-A does not exhibit systemic effects so can be safely injected for local effects including blocking of muscle action

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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potentials and reduction in local sweat production. The US Food and Drug Administration approved BTX-A in 2002 for the temporary treatment of dynamic glabellar lines for cosmetic purposes, and in 2013 for the treatment of lateral canthal lines.6 This was followed in 2006 by approval in the UK for treatment of glabellar lines and in 2014 for lateral canthal lines by the MRHA.7 Off label use of BTX-A for other dynamic facial lines has also been well documented over the last 20 years and has allowed specific informal guidelines to be developed for treatment of a variety of aesthetic and functional purposes. Anecdotally, males presenting to clinics tend to seek botulinum toxin treatments for two main purposes: treatment of upper face static lines, and treatment of axillary and palmar hyperhidrosis. Treatment of dynamic lines, when static lines are not present, does not seem to be a particular concern in male patients.

Applied anatomy: the use of botulinum toxin in male patients Ideal facial anatomy in males In men, the aesthetically ideal face has a muscular and overhanging horizontal brow. Male eyes are generally narrower and less open than females. Hypertrophy of the orbicularis oculi pars palpebris is also a common feature, together with some upper lid skin excess and slight closure of the eyelids.4,5 The latter feature is generally compensated for by excessive frontalis contraction at an earlier stage than in females, making the development of horizontal forehead lines generally an earlier feature in males.4,5 Often, the male frontalis contains strong central muscle fibres where often an aponeurosis exists in females. The treatment of the male upper face with BTX-A therefore needs to be carefully performed in order to maintain the expected low brow position without over-relaxing or high arching of the lateral brow, but also to prevent excessive eyelid heaviness. Lateral canthal treatments should also not be overdone, which could risk feminising the male eye area by excessive opening and flatness. In addition, the higher male muscle bulk may result in an increased dosage requirement when compared to females and differences in skin quality will also affect this. Patients with thick, deeply furrowed sebaceous skin require generally much higher doses than those with thinner, dryer skin.8 Injection techniques Dosing for male facial treatments using botulinum toxin can be more difficult than female patients, particularly for practitioners with less experience of treating males than females. Most experienced practitioners therefore advocate an approach of using a standard

The first and most important features in men include the nose, the chin and jawline, and the zygomatic arches

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Hyperhidrosis In addition to its cosmetic uses, primary axillary and palmoplantar hyperhidrosis may be safely and effectively treated with botulinum toxin via its inhibition of acetylcholinergic transmission at postganglionic sympathetic presynaptic nerve terminals. This troublesome condition is estimated to affect around 3% of men15 and can cause significant psychological distress and expense to individuals affected as a result of soiling of clothing, loss of work and loss of confidence. The use of botulinum toxin A has been shown to be effective for a mean duration of 6.7 months in patients treated in the axillary region,16 with some patients reporting symptom control for up to 12 months from a single treatment.17 In my clinic hyperhidrosis treatments with botulinum toxin are the second most requested treatment by males, and given the simplicity and effectiveness of this treatment, patients usually have good levels of satisfaction as a result of the treatment. Generally a slightly lower concentration of dilution can be used to increase the diffusion of botulinum toxin in the area when compared to treatments in the face11 and a suggested dose of 50-75 units per axilla is recommended. The incidence of adverse effects in the treatment of hyperhidrosis is extremely low but could include bruising and eczema with high doses.17 In palmar hyperhidrosis I tend to use 50 units per palm, injected intradermally following topical local anaesthesia. In patients with low pain thresholds, median and ulnar nerve blocks may sometimes be required for anaesthesia in this area, although this should only be performed by those experienced in administering these blocks. Grip weakness has been reported in patients undergoing botulinum toxin treatments for palmar hyperhidrosis but this is rare and transient17 in those affected, usually lasting only for a few weeks post treatment.

recommended dose (as recommended by the manufacturers) and then â&#x20AC;&#x2DC;topping-upâ&#x20AC;&#x2122; as necessary with additional small doses, ten days to two weeks post treatment, should the results not be satisfactory. In general, the higher muscle bulk in males results in a higher dosage requirement than their female counterparts. Suggested recommendations for doses of botulinum toxin for the upper face are 10-40 Speywood units for the glabella complex, 10-30 units for the lateral canthal area and 6-15 units for the frontalis.9 The higher the concentration of dilution used, the less risk of diffusion of product and therefore more accurate placement of injections.10 A suggested dilution of 1.25ml 0.9% saline for 50U Allergan Botox (botulinum toxin type A) or 2.5ml for 100U is the generally accepted standard for the upper face.11 In men particularly, the aim of botulinum toxin treatments should be to relax static facial lines, without complete paralysis of the treated areas, which in itself is a decidedly feminising feature. Botulinum toxin treatments to the glabellar region involve three to five dosage points placed along the corrugator supercilli and procereus muscles. I personally inject this area using deep injections to the medial part of corrugators at the level of the supercilliary arch with a higher dose than the lateral part, which is injected superficially with a lower dose approximately 1cm above the medial supraorbital rim. The location of the injection can be

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Lateral orbital injections sometimes require much higher doses in males than females, given the significant strength of the male orbicularis oculi judged in the individual by asking the patient to frown and the lateral extent of the superficial insertion of the corrugator can be demonstrated. The procereus is injected in either one or two places (two if it is a very long procereus) in a mid-depth injection (not to bone) into the belly of this muscle. Some practitioners advocate the upward direction of the needle point away from the globe of the eye when injecting the corrugator muscles12 to avoid downward diffusion of neurotoxin, decreasing the risk of lid ptosis. Treatment of the forehead is generally simple with six to eight injection sites placed in the frontalis muscle spaced 1.5-2cm apart across the forehead, 1.5cm or more above the level of the supraorbital ridge, including the lateral part of frontalis at the level of the hairline to prevent overarching of the lateral eyebrows. Overtreatment of this area may result in brow ptosis so the standard dose and top up at two weeks approach is strongly advocated for this area. Lateral orbital injections sometimes require much higher doses in males than females, given the significant strength of the male orbicularis oculi. Injections are placed in the lateral parts of the muscle, at a distance of 1cm lateral to the orbital rim, generally in three sites, avoiding injection of the zygomaticus muscle (which could result in smile asymmetry if treated). The landmarks to restrict inadvertent treatment of these lateral oral levators are to avoid injecting in the area medial to an imaginary vertical line running through the lateral canthus and below the level of the superior zygomatic arch.13 Injections in the lateral canthal area should be superficial, just deep to the dermis. Elongated and deep crow’s feet may also be treated by additional injections in the temporal area.14 Lower face treatments in males Treatment of the lower face with botulinum toxin is increasing in popularity, particularly in females with strong platysmal bands to perform a ‘Nefertiti lift’ and for jawline reduction. In males, these treatments can also improve the appearance of the lower face in patients with strong platysmal bands. Male treatments, similar to the upper face, have a higher dosage requirement generally, especially in those with high muscle bulk. Masseteric debulking for jawline reduction and bruxism treatments with botulinum toxin, involving injections into the body and insertion of the bilateral masseter muscles, are popular in female patients as they can improve the silhouette of the face and result in a more tapered feminine

Aesthetics

jawline. In men seeking treatments for bruxism, it is important to consider the effect such treatments will have on the jawline, as over treatment may result in narrowing and therefore feminisation of the lower face.

Summary The male market for aesthetic non-surgical treatments is increasingly important in the world of medical aesthetics. Indeed, demand for non-surgical interventions has increased exponentially over the past decade with botulinum toxin treatments dominating this trend.2 It is important for practitioners in this field to understand the gross anatomical differences in male and female facial anatomy to tailor these cosmetic treatments to the male face to provide enhancement without feminisation (unless this is required). A number of key anatomical features contribute to the ‘ideal’ masculine face and judicious placement and dosage of botulinum toxin injections are important to maintain this masculinity. The treatment of hyperhidrosis with botulinum toxin is an additional important aspect of treatment of the male patient in the treatment range of the modern aesthetic clinic. In the coming years, it is likely that an increasing number of treatments designed specifically for men will appear in the field of medical aesthetics so understanding not only the anatomical, but also the aspirations, of this patient group is of utmost importance to maintaining a sustainable patient base. Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. He graduated from the University of Glasgow and later became a member of the Royal College of Surgeons of Edinburgh. Dr Jack trained in the NHS until 2014, mostly in plastic surgery, before leaving to establish his nonsurgical aesthetic practice, having worked in this sector part-time for almost seven years. REFERENCES 1. Carruthers A, Carruthers J., ‘The treatment of glabellar furrows with botulinum A exotoxin’, J Dermatol Surg Oncol, 16 83 (1990). 2. 2014 Cosmetic Surgery Gender Distribution, American Association of Plastic Surgeons 2014 Plastic Surgery Statistics Report 3. Adamson PA, Zavod MB., ‘Changing perceptions of beauty: A surgeon’s perspective’, Facial Plast Surg, 22 (2006), pp.188-93. 4. De Maio M, Rzany B., ‘Facial aesthetics in male patients. In The Male Patient in Aesthetic Medicine’, Berlin Heidelberg: Springer-Verlag (2009), pp.1-18. 5. de Maio, M., ‘Ethnic and Gender Considerations in the Use of Facial Injectables: Male Patients’, Plastic & Reconstructive Surgery, 136 (2015), 40S–43S. 6. FDA approves Botox Cosmetic to improve the appearance of crow’s feet lines, (US: FDA, 2013) <http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm367662.htm> 7. Botox (Botulinum toxin type A), (UK, MHRA, 2010) <http://www.mhra.gov.uk/home/groups/par/ documents/websiteresources/con108643.pdf> 8. Pribitkin EA, Greco TM, Goode RL, Keane WM., ‘Patient selection in the treatment of glabellar wrinkles with botulinum toxin type A injection’, Arch Otolaryngol Head Neck Surg, 123 (1997), pp.321-26. 9. Ascher B, Talarico S, Cassuto D, Escobar S, Hexsel D, Jaen P, et al., ‘International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood unit) - part I: Upper facial wrinkles’, J Eur Acad Dermatol Venereol, 24 (2010), pp.1278-84. 10. Klein AW., ‘Complications, Adverse Reactions, and Insights with the use of botulinum toxin’, Dermatol Surg, 29 (2003), pp.549-56. 11. Highlights of Prescribing Information, (US, Allergan, 2016) <http://www.allergan.com/assets/pdf/ botox_cosmetic_pi.pdf> 12. Hankins CL, Strimling R, Rogers GS., ‘Botulinum toxin for glabellar wrinkles’, Dermatol Surg, 24 (1998), pp.1181-83. 13. Klein AW., ‘Contraindications and complications with the use of botulinum toxin’, Clin Dermatol, 22 (2004), pp.66-75. 14. Kadunc BV., ‘Periorbital wrinkles’, In: D Hexsel, AT Almeida, editors., Cosmetic Use of Botulinum Toxin, Porto Alegre, Brazil: AGE Editora, (2002), pp.149-50. 15. Hyperhidrosis, (US: American Academy of Dermatology, 2015) <https://www.aad.org/public/ diseases/dry-sweaty-skin/hyperhidrosis> 16. Solish N, Bertucci V, Dansereau A, et al., ‘A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee’, Dermatol Surg, 33 8 (2007), pp.908-923. 17. Shelley, W.B., N.Y. Talanin, E.D. Shelley., ‘Botulinum toxin therapy for palmar hyperhidrosis’, Journal of the American Academy of Dermatology, 38 2 (1998), pp.227-29.

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can be painful or tender to touch.7 Characteristics of gynaecomastia can often be seen in adolescent males. This is common around the age of 14, but will usually resolve spontaneously within one to two years. It may be due to the relatively delayed testosterone surge with relation to oestrogen at puberty, or due to a temporary increase in aromatase activity.8 If the symptoms are still obvious once adulthood has been reached, it could be a genuine case of gynaecomastia and advice could then be sought if required.

Treating Gynaecomastia Mr Demetrius Evriviades explains how to correctly diagnose gynaecomastia and effectively treat male patients with the concern An article released by The British Association of Aesthetic and Plastic Surgeons (BAAPS)1 on the excessive development of male breasts, known as gynaecomastia, reports that the condition is thought to affect 40% of men. According to a separate article by BAAPS, male surgery continues to account for nearly 10% of all cosmetic surgery treatments2 and gynaecomastia procedures have increased in popularity as the third most common procedure for men.3 The condition can be very distressing to some men and can affect confidence and body image, making it difficult to carry out everyday activities such as going to the gym, swimming or even just removing one’s shirt. It is often assumed that ‘man boobs’ are simply linked to obesity, however, there are a number of possible causes. What is gynaecomastia? In Greek, ‘gynae’ means ‘woman’ and ‘mastos’ means ‘breast’. Gynaecomastia is caused by glandular proliferation (the firm and dense tissue) and fat deposition (soft tissue). The ratio of glandular to fatty tissue in any breast varies between individuals, but in gynaecomastia cases there may be an excess of both.4 The condition can be provoked by an imbalance of the hormones oestrogen and testosterone, and can also be triggered by certain medication such as antidepressants and heart and liver

treatments. It has been linked to some cancer drugs, which cut levels of male hormones, and research5 also indicates that anabolic steroids can cause further breast tissue growth. Unfortunately, some men are genetically predisposed to gynaecomastia in the same way that some women can have larger breasts than others.6 What are the symptoms of gynaecomastia? The main characteristics of gynaecomastia are breast swelling, increased areolar diameter, presence of an anomalous inframammary fold, glandular ptosis and skin redundancy.7 To touch, the area can vary from small, firm enlargement of breast tissue just behind the nipple to a larger, more female-looking breast. It can affect the breast unilaterally or bilaterally and the area

Consultation A medical questionnaire will be completed so patients should be prepared to discuss any existing medical conditions, medications being taken and any previous surgeries carried out. I will usually show prospective patients case studies from previous gynaecomastia surgeries and we will discuss any risks or complications that the patient should be aware of when undergoing surgery. I will then carry out a physical assessment of the breasts, looking for glandular or fat predominance by doing the ‘pinch test’ – if a hard lump can be felt when you pinch the breast, then that signals the condition. I also look at the degree of glandular ptosis, skin excess, nodules/masses, and nipple abnormalities or discharge. I will then grade the condition using the Rohrich grading system outlined below (Figure 1). This ranges from Grade I: an increased diameter and slight protrusion limited to the areola, to Grade IV: severe hypertrophy with skin redundancy, severe ptosis and the nipple area complex (NAC) positioned more than 1cm below the inframammary fold. At this stage I will usually take preoperative photographs for the patient’s medical records. The ideal candidate for gynaecomastia surgery10 would fit the

Rohrich grading system9 Grade I

Minimal hypertrophy (250g of breast tissue) without ptosis A. Primarily glandular B. Primarily fibrous

Grade II

Moderate hypertrophy (250–500g of breast tissue) without ptosis A. Primarily glandular B. Primarily fibrous

Grade III

Severe hypertrophy (500 g of breast tissue) with Grade I ptosis Glandular or fibrous

Grade IV

Severe hypertrophy with Grade II or III ptosis Glandular or fibrous

Figure 1: The Rohrich grading system

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criteria below, however providing that the patient fits the admission policy of the operating facility, patients with Grade I to IV are suitable: • A healthy individual who does not have a life-threatening illness or medical conditions that can impair healing • A non-smoker and non-drug user • Men who are physically healthy and of relatively normal weight • Men who have realistic expectations • Men whose breast development has stabilised In preparation for gynaecomastia surgery, patients may be asked to stop smoking and to avoid taking aspirin, anti-inflammatory drugs11 and herbal supplements12 as they can increase bleeding. The success and safety of any cosmetic procedure depends very much on complete candidness during consultation. How surgery can correct gynaecomastia The aims of surgical treatment are to restore normal chest contours, eliminate the inframammary fold, correct the NAC position, remove redundant skin, create symmetry between the two halves of the chest and minimise scarring. If there is predominantly a diffuse fatty enlargement of the breast, liposuction is the usual treatment. This involves a small incision on each side of the chest depending on the result required. Incisions may be located along a portion of the edge of the areola or within the armpit. Through these incisions excess fat and/or glandular tissue is removed and, at the same time, a new chest contour is sculpted that looks natural to the patient’s body shape. If excess glandular tissue is the primary cause of breast enlargement, it may need to be excised, which will leave a scar, usually around the nipple edge. Tissue excision allows the surgeon to remove a

Figure 1: 28-year-old male who presented with Grade 1 gynaecomastia six weeks before treatment and three months post-operation

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The success and safety of any cosmetic procedure depends very much on complete candidness during consultation greater amount of glandular tissue and/ or skin that cannot be successfully treated with liposuction alone. This excision can be performed alone or in conjunction with liposuction. The location and length of the incisions depends on the extent of surgery needed, but they are typically located around the edge of the areola (periareolar incision) or within the natural creases of the chest. Major reductions that involve the removal of a significant amount of tissue and skin may require larger incisions that result in more obvious scars and, in this case, suction drains will usually be in place for a minimum of 24 hours or until fluid has ceased to drain. As a surgeon, it is always important to take care when placing the incision to ensure that the resulting scars are as inconspicuous as possible; however, the patient’s wellbeing must always be the priority. The procedure is usually carried out under general anaesthetic, although in minor cases (liposuction alone) local anaesthesia and sedation can be used – this is usually in a Grade I case. Depending on the technique used to correct gynaecomastia, an overnight stay in hospital is usually required, although in minor cases this can be carried out as a day case. This will usually be decided during consultation based on diagnosis.

taken to aide healing and reduce the potential for infection. Contact numbers will also be given should the patient have post-operative questions or in case of emergency. Patients will usually be seen five to seven days post operatively by a nurse who will carry out a wound check to remove any stitches if required and ensure the operation site is clean, dry and healing well. This is also an opportunity ask questions or seek advice. If the nurse is happy with the healing process, at this stage an appointment will usually be arranged to return to see me within the next three months. It is important that the surgical incisions are not subjected to excessive force, swelling, abrasion, or motion during the time of healing, normal healing may be resumed at six weeks. Those who choose to undergo surgery do so in the hope that the result is permanent, but there is no 100% guarantee. If gynaecomastia resulted from the use of certain prescription medications, I would advise having a conversation with the patient’s GP regarding alternative prescriptive drugs in order to retain the aesthetic result. Patients should avoid drugs (including steroids), or weight gain and remain at a stable weight in order to maintain results.

Recovery During surgery, dressings or bandages will be applied to the incisions and drains placed in situ if appropriate. This will drain excess blood or fluid that may collect at the site. Following surgery, the area will be swollen and bruised for a while and it can be difficult to assess the full effect of the procedure immediately. To help reduce swelling, patients are instructed to wear an elastic pressure garment continuously for at least a week. This will help minimise swelling and will support the new chest contour. Patients will be given specific instructions that will include how to care for the surgical site and any medication that should be

Risks As with all surgical procedures, there are risks. While in most cases these are rare, it is important to ensure the patient is aware of all the possible complications before undergoing surgery. The possible risks can include infection, excessive bleeding, injury to the skin, extreme fluid loss, an accumulation of fluid or an unfavourable reaction to the anaesthesia used. If an excision has been performed, rather than liposuction, then a blood clot can form that may need to be drained in theatre.13 This form of surgery can leave obvious scars that can take time to lighten and fade. Scarring is very individual in nature and no two people heal in exactly

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the same fashion and at exactly the same rate. It is impossible to predict how well a patient will heal although there are silicone based scar treatments available on the market that aim to aid the healing process and reduce the redness of scarring. Other risks of this surgery can include an uneven contour to the chest or breasts and nipples that do not heal equal in size or shape. Therefore, when asymmetry is present, it is sometimes necessary to carry out a second correctional surgery to remove more tissue. It is common to experience numbness or a loss of sensation in the breasts on a temporary basis. For some individuals this loss of sensation could last anywhere from a few months to a year.14 Results Surgery can be, and in most cases is, life changing.15 Suffering with gynaecomastia can affect body image and deter men from carrying out normal day-to-day activities where the condition is noticeable. Once recovery is complete, patients experience an enhanced quality of life and increased confidence, whereby going to the gym, playing sport and wearing more fitted clothes become an option, choices that they may have never considered pre-surgery. Mr Demetrius Evriviades is a consultant plastic and reconstructive surgeon with healthcare platform Medstars. He is an NHS Consultant at the New QE and BMI Priory Hospitals in Birmingham and also runs a private practice. He is a full member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons and is a member of the Midlands Regional Training Committee. REFERENCES 1. BAAPS, Gynecomastia, The British Association of Aesthetic Plastic Surgeons, (2016) <baaps.org. uk/docs/procedures/Gynecomastia.pdf> 2. BAAPS, Britain sucks, The British Association of Aesthetic Plastic Surgeons, (2014) <http://baaps. org.uk/about-us/press-releases/1833-britain-sucks> 3. Gynecomastia treatment, What is gynaecomastia? (2016) <http://www. gynecomastiatreatment.org.uk/> 4. NHS, What is gynaecomastia, NHS choices (2008) <http://www.nhs.uk/chq/Pages/885. aspx?CategoryID=61> 5. Jay. R Hoffman & Nicholas A. Ratamess, Medical Issues Associated with Anabolic Steroid Use: Are They Exaggerated? Journal of Sports & Medicine, (2006) <http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3827559/> 6. Kamilla Porter, GP management of gynaecomastia, GP Online, (2012) <http://www.gponline.com/ gp-management-gynaecomastia/cancer/womens/article/1118276> 7. Ruth E Johnson & M. Hassan Murad, Gynecomastia: Pathophysiology, Evaluation, and Management, Mayo Clinic Proceedings, <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770912/> 8. Gynecoma, Gynecomastia in Teenagers: A Teen’s Guide to Gynecomastia, (2016) <http://www. gynecoma.com/gynecomastia-in-teenagers/> 9. Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr, Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction, Plastic Reconstructive Surgery, (2003) <http:// www.ncbi.nlm.nih.gov/pubmed/12560721> 10. NHS Modernisations Agency, Information for Commissioners of Plastic Surgery Services, Action on Plastic Surgery, <http://www.bapras.org.uk/docs/default-source/commissioning-and-policy/ information-for-commissioners-of-plastic-surgery-services.pdf?sfvrsn=2> 11. Lawrence C, Sakuntabhai A, Tiling-Grosse S, Effect of aspirin and nonsteroidal antiinflammatory drug therapy on bleeding complications in dermatologic surgical patients, Journal of the American Academy of Dermatology, (1994) <http://www.ncbi.nlm.nih.gov/pubmed/7962782> 12. Wong WW, Gabriel A, Maxwell GP, Gupta SC, Bleeding risks of herbal, homeopathic, and dietary supplements: a hidden nightmare for plastic surgeons? Aesthetic Surgery Journal, (2012) <http:// www.ncbi.nlm.nih.gov/pubmed/22395325> 13. American Society of Plastic Surgeons, Gynecomastia Surgery, ASPS, (2016) <http://www.plasticsurgery.org/cosmetic-procedures/gynecomastia-surgery. html?sub=Gynecomastia+surgery+risks+and+safety> 14. Dr Mordcai Blau, Recovering from Gynecomastia Surgery, Cosmetic MD, (2016) <http://www. cosmetic-md.com/gynecomastia/information/recovering-from-gynecomastia-surgery/> 15. Shakespeare V, Cole RP. Measuring patient-based outcomes in a plastic surgery service: breast reduction surgical patients. British Journal of Plastic Surgery. 50: 24-8, 1997

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Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


Aesthetics Awards Special Feature

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WWW.AESTHETICSAWARDS.COM

Don’t miss your chance to win a prestigious Aesthetics Award in 2016 Following the success of last year’s ceremony, the Aesthetics Awards 2016 promises to be bigger and better than ever. On Saturday December 3, the Park Plaza Hotel in Westminster will play host to the very best in medical aesthetics to celebrate the achievements of the past year. Around 600 guests will enjoy a drinks reception, a performance from a top comedian and a formal sit-down dinner before the awards presentation begins. Winners of the 24 entry

categories will be announced and invited to the stage to accept their award before commemorating the evening by enjoying music and dancing late into the night. The Aesthetics Awards 2016 promises to be a night to remember. With just one month to go before entry closes, don’t miss this opportunity to be recognised for your achievements in the aesthetics specialty.

Hear from some of last year’s winners on the value of being recognised with an Aesthetics Award... The Epionce Award for Best Clinic North England 2015 “When we won, it was the first time in my life I’d ever been genuinely speechless. To win two years in a row is an absolute privilege. The first year you win – it’s great, the second year – you can call yourselves a multi-award winning clinic! For the past year we’ve had countless members of the public come to the clinic saying ‘I came to you because you’re an award-winning clinic’.” Chris Gill, Good Skin Days This year the Best Clinic North England category is sponsored by Wigmore Medical

Best Customer Service by a Manufacturer or Supplier 2015 “We’re delighted to win the award because it’s a real stamp of credibility for us.” Hayley Hutchings, Lynton Lasers Ltd

The Janeé Parsons Award for Sales Representative of the Year, supported by Healthxchange Pharmacy 2015 “It’s really important to be recognised and I never thought I’d win in a million years! I didn’t even think I’d get ‘Commended’ so when I won, I was completely shocked and really happy. What an amazing night!” Caroline Gwilliam, AestheticSource sales representative This year the Sales Representative of the Year category is sponsored by Healthxchange Pharmacy

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Categories Each category has been designed specifically to recognise the finalists and winners for their services to the profession. Awards are presented to those who have truly excelled in the field of medical aesthetics, from clinics and individual practitioners to manufacturers and suppliers. Highlighting both individuals and companies who work hard to raise standards and promote best practice in our industry provides an uplifting and aspirational event for the profession, which is so important to entrants, finalists and winners.

How to enter Visit www.aestheticsawards.com today to check the entry criteria for each category and download the questions. You can enter as many categories as you wish but may only enter yourself, a company you work for as an employee, contractor or agency, an employee who works for your company or a product made or distributed by your company. Entries made on behalf of a third party will not be accepted. You can only enter each category once and multiple entries for the same clinic, company, individual, treatment or product will be disregarded. All entries must be accompanied by the supporting evidence requested in the entry form. This information will be used to select the finalists and by the judges when deciding on Winners and those who should receive Commendations and High Commendations. The list of finalists will be announced in the September issue of the Aesthetics journal, after which the voting and final judging process will begin.

ENTER NOW! Entries close 30th June www.aestheticsawards.com Enhance Insurance

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Aesthetics Awards Special Feature

Find your categories and enter now: • The Barry Knapp Award for Product Innovation of the Year, supported by Oxygenetix • Cosmeceutical Range/Product of the Year
 • The Sterimedix Award for Injectable Product of the Year 
 • Treatment of the Year 
 • Best Treatment Partner 
 • Equipment Supplier of the Year 
 • The Healthxchange Academy Award for Sales Representative of the Year 
 • Best Customer Service by a Manufacturer, Supplier or Distributor 
 • Distributor of the Year 
 • The Enhance Insurance Award for Training Initiative of the Year 
 • The 3D-lipo Award for Best New Clinic, UK and Ireland 
 • Best Clinic Scotland 
 • The Wigmore Medical Award for Best Clinic North England 
 • The Lynton Lasers Award for Best Clinic South England 
 • The Med-fx Award for Best Clinic London 
 • Best Clinic Wales 
 • The SkinCeuticals Award for Best Clinic Ireland 
 • The AestheticSource Award for Best Clinic Group, UK & Ireland (3 clinics or more) 
 • The Swisscode Award for Best Clinic Group, UK & Ireland (10 clinics or more) 
 • The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year 
 • The Dermalux Award for Aesthetic Medical Practitioner of the Year 
 • Clinic Reception Team of the Year 
 • The Hamilton Fraser Award for Association / Industry Body of the Year • The Schuco International Award for Special Achievement – the winner of this category will be selected by the Aesthetics judges from within the profession. Individual entries are not accepted for this category.

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Entries must be completed on the Aesthetics Awards website no later than June 30. Late entries will be charged with an administration fee at £100 plus VAT per entry. Amendments to existing entries will also be subject to a charge of £100 plus VAT. If you have any questions regarding the entry process call our support team on 0203 096 1228 or email support@aestheticsawards.com

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Aesthetics | June 2016

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Treating Alopecia with Mesotherapy and Botulinum Toxin Dr Philippe Hamida-Pisal presents a pilot study on a new protocol for treating alopecia, created with Pam Cushing, Dr Michelle Westcott and Dr Jan Nel Hair possesses a symbolic connotation of strength and seduction that dates back to Egyptian times and to which we still attach great importance. The appearance of hair can be interpreted in very different ways, in concepts that rank from sexuality to religion. As a result, hair loss can have a significant psychological impact that varies depending on culture, age and sex.

Numbers to remember In an adult, these are the average numbers for:1 • Hair density: 200 follicles / cm2 • Number of hairs: 100-150,000 • Diameter: 0.1mm • Growth per month: 1-1.5cm • Hair life: 2-7 years • Number of cycles: 15-20 • Hair resistance: 100gr

Alopecia and the hair cycle There are different types of hair loss that can appear as defined patches or as more widespread and diffuse areas. We know that the incidence of alopecia increases dramatically with age and androgenic alopecia is the most common type of hair loss in both men and women. In the Caucasian population, 70 to 80% of men and 42% of women between 50 and 70 years old show signs of hair loss.1,2 The hair cycle is divided into three phases:1,2 1. First, we have the active growth phase of hair follicles known as anagen. A hair is formed by a bulb with a vessel in its centre that brings nutrients to it. This phase lasts between two to four years and, if a hair is torn during this phase, it will never grow back. 2. Then we have the resting phase, called catagen, when a hair stops growing. It gradually detaches from the bulb and rises to the surface of the skin. The dermal papilla begins to separate itself from the hair follicle and the vessels it contains disappear gradually. 3. Finally, we have the falling phase, called telogen, during which the hair is detached from the follicle. The residual bulb disappears and another is formed to give birth to a new hair. The dermal papilla, which contains vessels, migrates to the new bulb to provide it with the nutrients it needs for a new growth phase.

hair loss by speeding up the hair renewal process. After 25 cycles, the follicle becomes exhausted and the hair becomes finer, until it dies and disappears. Treatment is directed towards this hormonal transformation in order to prevent the conversion of testosterone into DHT.1,2,3

Therapeutic approach

Dr Michelle Westcott, Dr Jan Nel (from the Society of Mesotherapy [SoMZA] South Africa), Pam Cushing and I (from SoMUK), who are all key members of the Societies of Mesotherapy, have devised a treatment protocol for androgen alopecia using a combination of mesotherapy and botulinum toxin. The purpose of the treatment is to prevent the catagen phase and extend the anagen phase through the use of antioxidant and cytoprotective molecules, which will aim to induce the stimulation of cellular metabolism and hydration. These molecules are present in cocktails such as NCTF 135 HA from Filorga Laboratory, NCTC 109 from mesoestetic or Cytocare 516 from Revitacare. We already understand the role of polyrevitalising solutions and their effect in terms of regrowth, quality, moisture, thickness and hair shine.4 By combining different types of vitamins in one solution, practitioners are able to offer patients tailored treatments for their individual concerns. Similarly, we also know the action of botulinum toxin on the sebaceous glands, keratin and therefore its effect on the quality and stiffness of hair.5 Injecting botulinum toxin into the peripheral muscle increases the decompression of vessels through muscle relaxation, thus causing an augmentation in oxygen to the frontal and coronal scalp.6 The metabolism of Before

After

The role of hormones Baldness depends on certain hormones, called androgens, hence the scientific name of androgenic alopecia. Androgens are converted into dihydrotestosterone (DHT) by the 5-alpha reductase enzyme, which makes them active and encourages

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016

Figure 1: Before and after six weeks of treatment with botulinum toxin and mesotherapy


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Aesthetics Journal Figure 2: Before and after eight weeks of treatment with botulinum toxin and mesotherapy

After

testosterone to DHT is favoured by low oxygen, but an oxygen-rich environment in the hormone oestradiol activates a transformation in which this hormone (in a similar way to the process of skin ageing) has a significant impact on improving hair quality, and therefore decreasing hair loss.3,6

Aesthetics

This combined technique offers truly encouraging results in preventing alopecia, improving the quality of hair, implants and regrowth

Method For this study, the main requests of patients were for softer, smoother, less dry, firmer, easier to style hair, which is more resistant to chemicals, and also to treat hair loss while improving alopecia. To begin, we diluted botulinum toxin with CE-marked polyrevitalising solutions. For this study, we used an ampoule of Azzalure diluted in 1.25ml saline and mixed directly with 3ml of the polyrevitalising solution NCTF 135 HA (by Laboratoires Filorga). The purpose of this mix is ​​not to block, but to reduce the action of the sebaceous glands. The study also allowed us to verify the mixing efficiency in treating seborrhoea and its effect on the quality and flexibility of the hair. In addition, we worked on identifying the profile of patients who responded to treatment, to define the criteria of inclusions and exclusions for further research and future trials. Inclusion criteria: all of the patients who took part in the study (five men and 15 women of all ethnicities, with Fitzpatrick skin types ranging from I to VI) had concerns relating to seborrhoea, thin, damaged and dry hair and one suffered from Type 2 allergies to products dyes. Exclusion criteria: • Pregnant women • Postpartum telogen effluvium • Patients with hair loss caused by an illness or a nutritional disorder • Patients with muscle pathologies First clinical results Five criteria were chosen by patients in agreement with the practitioner, and measured on a scale from 0 (no effect) to 10 (results beyond expectations). The criteria were hydration, thickness, strength, flexibility and shine. An observation time of four weeks was implemented to monitor potential adverse effects and results can be seen in Figure 1. Patient Results Hydration

Thickness

Strength

Flexibility

Shine

Week 1

6

0

0

0

6

Week 2

8

0

3

2

8

Week 3

10

3

7

5

10

Week 4

10

5

8

7

10

We can also report that the patient allergic to colouring products had a sharp decrease in the itching she previously had on the scalp and the line marking the irritation completely disappeared after the treatment.

Conclusion In summary, the results of this pilot study of a single treatment have, after four weeks, exceeded our expectations, with the patients involved reporting a 100% satisfaction rate. Injections of polyrevitalising solutions, through use of conventional injection techniques or using a meso-gun, combined with botulinum toxin, are indicated as effective and positive in all parameters of ageing, oxidative stress, nutritional deficiencies, seborrhoea and improving hair quality. This combined technique offers truly encouraging results in preventing alopecia, improving the quality of hair, implants and regrowth. Patients also reported that following treatment their hair-drying time was reduced, meaning that it created much less heat-based damage to the hair and scalp. The main limitation of the treatment is that it is only effective where the hair follicle is still present. To enhance the results of the study, it would be beneficial to trial the treatment on a larger patient base (ideally 100 patients) to present a wider range of results to analyse. In addition, we are currently working on a creating a different dilution for a longer lasting effect. Dr Philippe Hamida-Pisal is an aesthetic practitioner working in London and Paris. As well as being the president of the Society of Mesotherapy of the UK, the society partner of Euromedicom and IMCAS Paris, Dr Hamida-Pisal is a key note speaker at major industry events around the world; discussing the concept of beauty, the ageing process and ethnic skin. REFERENCES 1. Fisher TW., ‘Alopecia- Diagnostic and Therapeutic Management’, Akt Drmatol, 34 (2008), pp.209-25. 2. Hoffmann R, Happle R., ‘Current understanding of androgenetic alopecia. Part I: Etiopathogenesis’, Eur J dermatol, 10 (2000), pp.319-27. 3. McElwee KJ, Shapiro J., ‘Promising therapies for treating and/or preventing androgenic alopecia’, Skin letter Therapy, 17 (6) (2012). 4. Hamida-Pisal, P, ‘The Science Behind Mesotherapy’, Aesthetics, 2, 11 (2015), p.29. 5. Freund BJ. Schwartz M. Treatment of male pattern baldness with botulinum toxin; a pilot study. Plast Reconstr Surg 2010; 126-246e-8. 6. Trueb RM., ‘Oxidative stress in Ageing of Hair’, Int J Trichol, 9 (2009), pp.6-14. FURTHER READING • Quan QD, Sinclair R., ‘Female pattern hair loss: current treatment concepts’, Clin Interv Aging, 2007 2(2), pp.189-199.

Figure 1: Results based on all patients’ answers four weeks after a single treatment

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Case Study: Treating Acne Dr Jasmeet Baxi details how she successfully managed a patient’s acne using chemical peels and topical skincare As an aesthetic clinician, I have been treating and assessing patients with both acne and acne scarring for the past five years. In February 2015, I met a 23-year-old woman (Patient A) who has been suffering with acne for several years. Her skin tone on a Fitzpatrick scale was II.1 During the initial consultation it became obvious that she had tried several overthe-counter preparations with no resolve. She was rather frustrated with her skin and noted that this was affecting her psychologically. As a result she had developed low self-esteem and was keen to have her skin treated to help resolve the acne and improve her confidence. A full medical history was taken which clarified that she had no past medical problems, no allergies and was not taking any current medication to note. Upon review of her skin, it was evident that she was suffering from mild to moderate acne vulgaris with some inflammation. The acne vulgaris was mainly localised to her cheeks and there was also some on her chin. There were evident inflammatory papules, with a few pustules in places. There was also evidence of some scarring left over from previous acne lesions.

Treatment: first peel Prior to treatment Patient A was using a face wash system she had bought online, which contained small amounts of salicylic acid as its main active ingredient to help resolve acne. However, she felt this was not really helping. Following a review of her skin and discussing the results with her, it was evident that she was keen to try using topical treatments such as chemical peels first, which she had heard could help, rather

Figure 1: Patient A before treatment

than taking any form of oral medication. Following this discussion, and given that studies regarding acne and chemical peels have indicated that a course of four to six peels can result in an approximate 45-50% reduction in acne lesions present,2-4 I decided to initially treat Patient A with one chemical peel and determine if she would require further treatments following this. Based on the patient’s skin type, and also upon reviewing the mild to moderate acne present, a medium depth chemical peel was used that contained a combination of acids. Due to the severity of Patient A’s skin (Figure 1), a series of superficial peels would be needed to achieve the same result as a couple of medium depth peels. It was therefore more efficient to offer two medium depth peels. The peel used was The Perfect Peel, which is a 5-acid blended peel with glutathione, vitamins and minerals. This peel was chosen due to the fact that it was not only easy to apply and use, but also provided Patient A with a mix of acids to help treat the skin for both the erythema, acne and elements of uneven skin tone and texture. The main ingredients included:5 • • • • • • • •

Trichloroacetic acid Salicylic acid Retinoic acid Glutathione Kojic acid Phenol Vitamin C Minerals

The peel was applied to a cleansed face and Patient A was given an aftercare advice leaflet that stated, amongst other points,

that the patient should not touch, rub, wash or apply makeup to the treated area for the first day. It also gave instructions on how to appropriately use the products included in the post-peel aftercare home kit and advised that patients should always wear sunscreen of at least SPF 30 from the third day post peel. Patient A was contacted regularly during the week following treatment as the skin peeled. During the peeling process, no complications occurred. A week after the treatment, I reviewed her skin (Figure 2).

Figure 2: After one medium depth chemical peel

Skincare Studies have suggested that the effect of chemical peels generally tends to last for one to two months and results are reported as ‘fair’ to ‘good’.3-8 As such, during Patient A’s review, we also discussed the possibility of a good skincare regimen to try and enhance the effects of the peel that had just been applied. A week after treatment I started Patient A on the Obagi Nu-Derm skincare routine, as it provided good but gentle exfoliation of the skin and also provided products to help not only brighten the skin, but also promote skin cell rejuvenation and prevent hyperpigmention. Thus creating a brighter, lighter and even toned complexion. It is not necessary to use these particular products. Similar products from other skincare ranges can also be used in a similar way post peel to help treat acne and acne scarring. Patient A was using the following: 9 Morning • Face wash – 2% salicylic acid based • Toner • Vitamin C serum – 15% • Clear – a topical treatment that contains

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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4% hydroquinone to correct slight pigmentation and improve overall skin tone • Exfoderm – a topical treatment that contains a plant acid (3% phytic acid), which removes old skin cells while promoting new skin cells for a lighter, brighter complexion • Hydrating moisturiser • Sun protection cream SPF 50 Evening • Face wash – 2% salicylic acid based • Toner • Clear – a topical treatment which contains 4% hydroquinone to correct slight pigmentation and improve overall skin tone • Blender – a topical treatment that contains 4% hydroquinone to target hyperpigmented (discolored) areas • Hydrating moisturiser • Obagi Tretinoin 0.25% cream These products were started a week post treatment and continued for eight weeks. Patient A was compliant with the products and found them quite easy to use. I reviewed Patient A again in the clinic eight weeks after the first chemical peel (Figure 3). There was a reduction in the erythema and inflammation of the skin and also in the number of breakouts that had occurred. The skin had improved and she was also noticing that people were complimenting her on the overall appearance of her skin, which was also improving her self-esteem and confidence. The skincare products were stopped for a week prior to the next chemical peel treatment except for the cleanser, hydrating moisturiser and sun protection cream.

Figure 3: Eight weeks after first peel

Treatment: second peel The same 5-acid blend chemical peel was then applied as previously and I monitored Patient A’s skin’s progression closely. During the peeling of the second peel there were no complications and the skin

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Figure 4: One week after the second medium depth chemical peel

peeled over the course of a week after it had been applied. Once the peeling had resolved, Patient A was again reviewed a week later in the clinic. A week after the second peel (Figure 4), I provided Patient A with a protocol to reintroduce the products she had been using to her skincare routine. I reviewed her skin again six weeks later and was pleased to learn that her skin had continued to remain breakout-free and was no longer as red and inflamed as it once was. However, she still had some acne scarring left on the cheeks, and we discussed the possibility of doing a further chemical peel to help with this. Due to financial reasons, this suggestion has currently been postponed. She continued with the current skincare routine for up to six months and then reduced it gradually to:

has created. It is extremely rewarding to be able to improve a patient’s lifestyle as well as their skin concerns. Acne and acne scarring are very common problems faced by many patients who present to aesthetic clinics. Helping a patient improve their overall skin tone, texture and complexion will improve and enhance other treatments within that area. Chemical peels are not only used to treat acne but can also be used for antiageing and skin rejuvenation. As such, I believe peels are a good treatment to offer aesthetic patients either for the purpose of acne or as a basic add-on to their current treatments. Clinicians who would like to add peeling to their treatment list should only do so once they have attended a chemical peels course and received the appropriate training for the peel or set of peels they wish to use.

Figure 5: 12 months since the first treatment

Morning • Face wash – 2% salicylic acid based • Toner • Vitamin C serum – 15% • Hydrating moisturiser • Sun protection cream SPF 50 Evening • Face wash – 2% salicylic acid based • Toner • Hydrating moisturiser

Moving forward I have arranged follow-up consultations with Patient A several times over the course of the past 12 months and am delighted that her skin is much better; the acne vulgaris has improved immensely (Figure 5). She has the odd spot but nothing as bad as it once was. Currently, Patient A’s skin is acne free but she still has a few scars left from previous acne vulgaris episodes, which we will aim to treat later this year using a combination of microneedling sessions with a dermaroller and a course of microinjections of hyaluronic acid, alongside regular treatment reviews. The best part of the treatment process has been the level of confidence and improved self-esteem that treating Patient A’s acne

Dr Jasmeet Baxi graduated with an MBChB from the University of Leeds in 2008. She also has a BSc Hons in Chemistry with Management from King’s College London. Dr Baxi is an experienced aesthetic practitioner and is the founder of the aesthetic company NaturaSKIN Ltd. REFERENCES 1. Fitzpatrick Skin Type (Australia: Australian Radiation Protection and Nuclear Safety Agency, 1988) <http://www.arpansa.gov.au/ pubs/RadiationProtection/FitzpatrickSkinType.pdf> 2. Kempiak SJ and Uebelhoer N., ‘Superficial chemical peels and microdermabrasion for acne vulgaris’, Seminars in Cutaneous Medicine and Surgery, 27 (3) (2008), pp.212-220. 3. Kessler E, et al., ‘Coparison of α- and β-hydroxy acid chemical peels in the treatment of mild to moderately severe facial acne vulgaris’, Dermatologic Surgery, 34(1) (2008), pp.45-50. 4. Ilknur T, et al., ‘Glycolic acid peels versus amino fruit acid peels for acne’, Journal of Cosmetic and Laser Therapy, 12(5) (2010), pp.242-245. 5. The Perfect Peel: 5-acid blended peel with glutathione, vitamins and minerals (UK: The Perfect Peel, 2016) <http:// theperfectpeel.co.uk/the-perfect-peel/> 6. Raone B, et al., ‘Salicylic Acid peel incorporating triethyl citrate and ethyl linoleate in the treatment of moderate acne: a new therapeutic approach’, Dermatologic Surgery, 39(8) (2013), pp.1243-51. 7. Bae BG, et al., ‘Salicylic acid peels versus Jessner’s solution for acne vulgarism: a comparative study’, Dermatologic Surgery, 39(2)(2013), pp.248-53. 8. Peric S, et al., ‘Side effects assessment in glycolic acid peelings in patients with acne type I’, Bosnian Journal of Basic Medical Sciences, 11(1) (2011), pp.52-57. 9. Correct & transform your skin (US: Obaji Medical, 2010) <http:// obagi.uk.com/Consumer/Products/Nu_Derm.htm>

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Understanding Ultrasound Dr Sarah Tonks details the science behind ultrasound and explains how it can be used for skin tightening Focused ultrasound has recently been developed to meet the growing demand for achieving significant non-invasive skin lifting and tightening. Photoageing of the facial tissues follows a semi-predictable progression of textural, pigmentary, skeletal, and adipose changes.1 Initially, dynamic rhytids are present which evolve to static rhytids with time. The tissues develop laxity, often seen in the jowls and in the submental region. Traditionally the energy delivery devices used to treat ageing skin would include ablative carbon dioxide or erbium:ytterium-aluminum-garnet (YAG) devices, or treatments such as deep chemical peels and dermabrasion. These methods rely on ablation of the dermis and reepithelialisation, whilst causing a significant enough thermal injury to the dermis in order to stimulate a wound-healing response and therefore collagen remodelling and contraction of the tissues.1 Unfortunately most of these treatments require significant patient downtime. More recently, other devices have become available such as infrared and LED devices, and energy-based procedures such as radiofrequency. Radiofrequency ablation allows the use of thermal energy to the reticular dermis to cause tissue contraction and remodelling whilst minimising downtime. In addition, these have the added benefit of being a safer treatment than those listed above, for a wider range of skin types.1 Unfortunately the results are often more modest than more invasive procedures and there is considerable individual variation in responsiveness to treatment.

What is ultrasound? Ultrasound is an energy modality that can be focused and penetrates deeply into the tissues to cause thermal coagulation. There are several terms used for ultrasound, such as intense focused ultrasound (IFUS), high intensity focused ultrasound (HIFU), microfocused ultrasound (MFU) and focused ultrasound (FUS). HIFU uses high-energy ultrasound and is used mainly in medical applications such as ablating tumours or adipose tissue for body

Aesthetics

contouring. MFU uses lower energy to treat the superficial layers of the skin. HIFU involves thermal and cavitation to cause cell disruption and death, whereas MFU relies on heat to achieve tissue effects.2 For the remainder of this article the energy modality referred to will be FUS as this is the type most commonly used in aesthetic treatments. FUS is similar to the ultrasound used in medical imaging but it is highly convergent and used to form different frequencies of energy. Transducers direct the ultrasound energy to a small focal point where the elevated temperatures are capable of causing tissue coagulation. Like medical imaging, the beam of ultrasound energy can pass harmlessly through the skin allowing the focal point to target the subcutaneous tissues.2 Ultrasound is the sound wave frequencies in the range of 18-20 kHz, which is above the range of human hearing. Inducible energy is delivered to specific foci in the dermis and subcutis leading to generation of heat, initiating the tissue repair cascade. Thermal coagulation points are placed at prescribed depths creating microcoagulation zones of 1 to 1.5mm.3 The thermal injury is confined by keeping the pulse duration short â&#x20AC;&#x201C; the epidermis is unaffected if the energy delivered is not excessive, so there is no need for epidermal cooling.3 As the tissue only has smaller zones of focal damage, rapid healing can occur from tissue immediately adjacent to the lesions. The ultrasound vibrates tissue and creates friction between molecules, which absorb the mechanical energy leading to heat. Coagulation only occurs in the focal range of the beam. Energy is deposited in short pulses of 50-200 milliseconds. The energy delivered at each site is around 0.5-10J.4 It is estimated that the tissue is heated to 65-75â °C, which is the temperature at which collagen denaturation occurs and tissue repair cascade begins. The intermolecular hydrogen bonds are broken causing the chains of collagen to fold and assume a more stable configuration resulting in shorter, thicker collagen.4 De novo collagen formation occurs in the areas of thermal tissue coagulation and new viscoelastic collagen forms causing the lifting and tightening of the skin. FUS targets the SMAS which is a fan-shaped structure covering the face and connects the facial muscles with the dermis.4 The tightening seen occurs due to the heating of specific zones of tissue. Histologic evidence suggests that dermal collagen and elastic fibres were increased in number, causing thickening of the reticular dermis.5 The onset of collagen remodelling occurs up to around three months and persists for around one year, which is similar to radiofrequency or laser energy sources.2

FUS is similar to the ultrasound used in medical imaging but it is highly convergent and used to form different frequencies of energy

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Cadaver studies have shown that penetration depth is determined by frequency â&#x20AC;&#x201C; higher frequency waves produce a shallow focal injury zone and low frequency waves penetrate more deeply. They have also demonstrated consistency in depth, size and orientation of the thermal coagulation points in the subdermal soft tissue and deeper SMAS layers while preserving adjacent soft tissue.1,3,6 Apart from ionising radiation, ultrasound is the only type of inducible energy that can be delivered into deep tissue selectively.1

Patient selection Those who wish to avoid a surgical facelift but would like an improvement in skin laxity are ideal candidates. The patient should have mild to moderate skin and soft tissue laxity. Smokers and those with excessive photoageing are not ideal candidates as their ability to create collagen may be inadequate. Those with severe ageing, heavy and full tissues may have their result impaired by the inability of the collagen to shorten. Younger patients are more suited for the procedure as they generally have a more robust wound-healing response. Relative contraindications are medical conditions that impair wound healing and those who have a keloid response. Absolute contraindications include an open wound at the treatment site, cystic acne, a metallic implant at the site of treatment and pregnancy. Safety has been demonstrated across all skin types as absorption of ultrasound energy is independent of the melanin content of skin; the microscopic and bulk mechanical properties of the tissue determine the absorption in the skin.7 It is important that the patient has realistic expectations of the procedure. Clinical improvements are often subtle, unlike surgical procedures. There is also the potential for no appreciable clinical improvement.

Specific devices Several devices that have FUS are available in the UK such as Ulthera, Ultracel and Doublo. Some of these allow the direct visualisation of the dermis and subcutaneous tissues prior to treatment with a display, which allows identification of key

The onset of collagen remodelling occurs up to around three months and persists for around one year, which is similar to radiofrequency or laser energy source

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Areas with thinner skin should be treated with superficial depth and the cheek and submentum should be treated with both the deeper and superficial transducers anatomic structures and the depths allowing precise energy deposition into the dermis, although it is not clear that being able to visualise the tissues in this way makes a clinical improvement in treatment outcome. Ulthera received FDA approval for eyebrow lifting in 2009 and then gained approval for skin lifting of the neck and submental tissue in 2012.8 The device consists of a computer, central power unit and interchangeable transducers. Multiple output settings can be controlled such as power output, exposure time, length of exposure time and time delay between each exposure. The device has four available transducers: super superficial 19MHz at 1.5mm focus depth, superficial 7.5MHz at 3mm focus depth, intermediate 7.5MHz at 4.5mm focus depth, deep 4.4MHz at 4.5mm focus depth. The Ultracel is a similar device that has a 3 and 4mm transducer available in the UK. In a recent Korean study two devices were compared for facial skin tightening in 20 patients (Ulthera and Ultra-Skin). The two devices had similar efficacy in blinded clinician and quantitative assessment, although there were some differences with patient satisfaction and degree of pain. Interestingly, the patients reported more pain but a higher degree of satisfaction with Ulthera, despite there being no significant difference in the blinded assessors evaluation of the results.9

Protocol The depth of treatment is dictated by the thickness of the skin at that site. Areas with thinner skin should be treated with superficial depth and the cheek and submentum should be treated with both the deeper and superficial transducers. In dual-plane treatment the deeper plane is treated first. The efficacy of treatment is increased when multiple treatment passes are used. In one study, areas of the face and neck were treated with a 4MHz and 4.5mm transducer followed by a 7MHz and 3mm transducer. Two blinded clinicians determined that 8 of 10 patients showed clinical improvement 90 days after treatment while nine subjects reported improvement.10 If the vector is varied, further improvements have been demonstrated in treatment outcome. Using the same energy output one study reported that 15 vertically orientated treatment lines in 3 and 4.5mm tissue depths produced

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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The amount of pain experienced varies from mild to severe and the type of pain control used varies according to physician preference

significantly greater lifting than 15 horizontally placed lines in the opposing brows and marionette lines.11 Overall treatment sites receiving more treatment lines and higher energy at dual depths produced significantly greater lifting. Despite concerns about lipoatrophy with FUS, this phenomenon has not been reported in the literature so far. Although FUS typically results in microscopic coagulation, staking of pulses should be avoided and repeat treatments with some time interval would be better in terms of safety to avoid cavitation.12 The patient should be advised to refrain from applying facial foundation, powders and lotions on the day of treatment if possible. All metal jewellery on the face should be removed. Those with a history of herpes simplex infection should take prophylactic anti-virals for two days before and six days after treatment. The skin is cleansed of any facial makeup or product prior to treatment and some practitioners mark the number of target columns. An ultrasound gel is applied to the treatment site and the probe is placed on the skin and activated. The entire surface area of the transducer should be applied to the skin. It may be necessary to reapply ultrasound gel during the procedure to ensure proper coupling. In some machines it is possible to visualise focal depth on the monitor in the ultrasound image, which can be aligned with the corresponding layer of the deep dermis to SMAS. Parallel arrays of ultrasound pulses are delivered. The number of lines depends on the size of treatment area. Treatment should be avoided over the thyroid gland, inside the orbital rim and over implants. Post procedure the ultrasound gel is removed and the patient is free to return immediately to their usual activities. Pain The amount of pain experienced varies from mild to severe and the type of pain control used varies according to physician preference. The use of 5-10mg diazepam and 50-75mg meperidine 20-30 minutes prior to the procedure has been described.13 Others have described topical or local anaesthesia, conscious sedation, cold compresses, high-dose non-steroidal anti-inflammatories, oral or intravenous narcotics and massage.14

Aesthetics Journal

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Most patients having treatment to the mid-face and neck do not require any pain control, whereas those treated to the brow may require some due the thin tissue overlaying the frontal bone.11 It is my preference not to use any pain relief methods, as I am aware that the patient won’t be able to notice if you are damaging a nerve when anaesthetised. Safety This treatment has a good side effect profile and most side effects are temporary. Possible side effects include pain, erythema, oedema and purpura. The most distressing complication which may occur is motor nerve paralysis. Areas where the facial nerve branches are superficial are at the greatest risk such as the temporal branch of the trigeminal nerve at the temple and the marginal mandibular nerve at the jawline. Symptoms can be seen one to two hours after treatment, secondary to nerve inflammation. Resolution is seen within two to six weeks.13 Three of the patients studied have developed transient dysaethesia to the deep branch of the supraorbital nerve lasting three to seven days and four patients developed numbness along the mandible after cheek treatment that resolved after two to three weeks.11

Summary Focused ultrasound delivers ultrasound energy to predetermined depths to the deep dermis and subdermal tissue. Neocollagenesis and tissue contraction occurs in the months after treatment. As the energy delivered is focused precisely and adjacent tissue is spared it has a very good safety profile. More recent treatment developments have included the use of this technology on other body sites including the décolletage. Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, based at the Chelsea Private Clinic she practises cosmetic injectables and hormonal based therapies.  REFERENCES 1. Minkis, K. & Alam, M. Ultrasound skin tightening. Dermatol. Clin. 32, 71–7 (2014). 2. Fabi, S. G. Noninvasive skin tightening: focus on new ultrasound techniques. Clin. Cosmet. Investig. Dermatol. 8, 47–52 (2015). 3. Laubach, H. J., Makin, I. R. S., Barthe, P. G., Slayton, M. H. & Manstein, D. Intense focused ultrasound: evaluation of a new treatment modality for precise microcoagulation within the skin. Dermatol. Surg. 34, 727–34 (2008). 4. Ghassemi, A., Prescher, A., Riediger, D. & Axer, H. Anatomy of the SMAS revisited. Aesthetic Plast. Surg. 27, 258–64 5. Suh, D.-H. et al. A intense-focused ultrasound tightening for the treatment of infraorbital laxity. J. Cosmet. Laser Ther. 14, 290–5 (2012). 6. White, W. M., Makin, I. R. S., Slayton, M. H., Barthe, P. G. & Gliklich, R. Selective transcutaneous delivery of energy to porcine soft tissues using Intense Ultrasound (IUS). Lasers Surg. Med. 40, 67–75 (2008). 7. Suh, D. H. et al. Intense focused ultrasound tightening in Asian skin: clinical and pathologic results. Dermatol. Surg. 37, 1595–602 (2011). 8. No Title. Available at: http://www.marketwired.com/press-release/ultherar-system-receivesthird-fda-clearance-1874112.htm. 9. Jung, H. J., Min, J., Seo, H.-M. & Kim, W.-S. Comparison of effect between high intense focused ultrasound devices for facial tightening: Evaluator-blinded, split-face study. J. Cosmet. Laser Ther. 1–5 (2016). doi:10.3109/14764172.2016.1157359 10. Lee, H. S. et al. Multiple pass ultrasound tightening of skin laxity of the lower face and neck. Dermatol. Surg. 38, 20–7 (2012). 11. Sasaki, G. H. & Tevez, A. Clinical efficacy and safety of focused-image ultrasonography: a 2-year experience. Aesthet. Surg. J. 32, 601–12 (2012). 12. Suh, D. H., So, B. J., Lee, S. J., Song, K.-Y. & Ryu, H. J. Intense focused ultrasound for facial tightening: histologic changes in 11 Patients. J. Cosmet. Laser Ther. 17, 200–3 (2015). 13. MacGregor, J. L. & Tanzi, E. L. Microfocused ultrasound for skin tightening. Semin. Cutan. Med. Surg. 32, 18–25 (2013). 14. Brobst, R. W., Ferguson, M. & Perkins, S. W. Ulthera: initial and six month results. Facial Plast. Surg. Clin. North Am. 20, 163–76, vi (2012).

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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A Micro-Revolution in Non Invasive Anti-Ageing Skincare Mr Paul Banwell is an internationally-known, fully accredited Plastic & Cosmetic Surgeon who runs a modern cosmetic surgery practice in the South East of England and London. Here, Mr Banwell is interviewed and gives his insights into Radara – the latest innovation in micro-channelling skincare: What is Radara and what new technology does it bring to the industry? Whilst botulinum toxin remains the gold standard treatment for periocular wrinkles, many prospective patients still seek an alternative approach; we believe that Radara represents an innovative solution for such patients. Micro-needling (collagen induction therapy) is a wellestablished method for skin rejuvenation, resulting in neo-collagenesis, neo-vascularisation and stimulation of elastin. Where Radara stands apart is that it’s a non-invasive micro-channelling regime, not a traditional micro-needling product, using a combination of rejuvenating micro-channelling patches and a topically-applied, high purity, naturallyderived hyaluronic acid serum. The unique, flexible periocular adhesive patches are coated with microscopic plastic projections less than 0.5mm in length which painlessly create two-thousand micro-channels within the skin, thus allowing deeper penetration of the HA serum to restore natural elasticity, hydration and support. Can an at-home topical treatment truly deliver significant skin benefits? Radara underwent independent testing (n=32 patients) at the renowned Dermatest facility in Germany, where results demonstrated a significant reduction in fine lines and wrinkles of up to 35% in just four weeks. Their results also revealed that the patches almost doubled the anti-wrinkle efficacy versus the serum alone. No adverse effects were reported and the treatment was well tolerated by all participants.

normal skincare routine especially if they are nervous about more advanced or invasive treatments such as injectables. As a home-use product, Radara gives patients a sense of control and the non-invasive, quick and easy application means that it can be easily added into an existing daily skincare regime. There are also those more ‘experienced’ aesthetic patients who may look to enhance and maintain the results of their other treatments from home – they tend to be very excited about new advanced treatment innovations and are often keen to try the ‘next big thing.’ Furthermore the Radara treatment regime allows the clinic team team a chance to review patients at regular intervals to evaluate their results and discuss their on-going needs (thus providing ample opportunity to connect with them). Is this just another technical gimmick or does Radara technology truly deliver? Based on the available trial results, Radara has been a fantastic treatment in patients looking for a non-invasive approach to periocular rejuvenation and we have had some great feedback from our patients. With a five-minute nightly application over the course of a month, patients can expect to see smoother, firmer skin and a significant reduction in fine lines and wrinkles, with no pain or downtime.1 A wealth of clinical experience has been leveraged in the development of the product and it has certainly been recognised as an innovative solution within the industry over the past year. Importantly, and despite not being a medical device, Radara has delivered compelling safety and efficacy results through independent testing.

Which patients are suitable for Radara? The beauty of Radara is that it can integrate seamlessly into your clinic offerings – without detracting from your existing portfolio of treatments. It is a great option for those patients who are looking to ‘step up’ their Radara One-Month Supply - Trade price: £100 (RRP £240) For stockist enquiries, please contact Wigmore Medical on 020 7491 0150 www.wigmoremedical.com For further information, contact: info@radara.co.uk | www.radara.co.uk | @radaraUK REFERENCES 1. Innoture Aesthetics – Data on File. Specialist dermatological report on the optical 3D-Measurement of the surface of the skin Quantitative evaluation of the roughness of the surface of the skin with the calculation of standardized skin roughness parameters according to DIN 4768ff. Dermatest® GmbH I Engelstrasse 37 I 48143 Münster

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A summary of the latest clinical studies Title: Nasal appearance after secondary cleft rhinoplasty: comparison of professional rating with patient satisfaction Authors: Pausch NC, Unger C, Pitak-Arnnop P, Subbalekha K Published: Journal of Oral and Maxillofacial Surgery, April 2016 Keywords: Cleft lip and palate, facial perception, patient satisfaction, secondary rhinoplasty Abstract: The purpose of this study was to compare professional rating and patient satisfaction of nasal appearance after secondary cleft rhinoplasty. We used a cross-sectional study design and enrolled German adults with nonsyndromic unilateral or bilateral cleft lip and/or palate (UCLP and BCLP, respectively) undergoing secondary cleft rhinoplasty from January 2001 to December 2013. The predictor variable was professional rating. The outcome variable was patient satisfaction with postoperative nasal aesthetics. Other study variables included patient age and gender, type of surgery, and patient rating of nasal function. Appropriate descriptive and univariate statistics were computed, and a P value of <0.05 was regarded as statistically significant. Inter-rater reliability was assessed by the use of Cohen’s kappa coefficient. The study sample consisted of 242 adult cleft patients of mean age of 22.1 ± 9.2 years (range 14-64), including 97 females (40 %) and 176 unilateral clefts (73 %). Most of the patients reported good function (82 %) and good aesthetics (74 %). The main professional rating was good aesthetics (65 %). Analysis of interobserver reliability revealed significant differences between patient satisfaction and professional assessment (κ = 0.385; P < 0.0001). Although most of the patients were satisfied with the functional and aesthetic results of secondary cleft rhinoplasty, patient self-assessment of nasal appearance differed from professional assessment. Title: Reduction of post-surgical scarring with the use of ablative fractional CO2 lasers: A pilot study using a porcine model Authors: Baca ME, Neaman KC, Rapp DA, Burton ME, Mann RJ, Renucci JD Published: Lasers in Surgery and Medicine, April 2016 Keywords: Fractional photothermolysis, wound healing Abstract: Wound healing inevitably leads to scarring, which leads to functional and cosmetic defects. It is the goal of this study to investigate the immediate use of ablative fractional CO2 lasers to reduce post-operative scarring secondary to surgical wounds. In this prospective controlled study, 20 surgical incisions were created on each of three pigs. Fifteen of the incisions were treated with an ablative fractional CO2 laser at one of three laser settings. The remaining five incisions served as a control. Punch biopsies were taken post-operatively over time. Digital photographs were taken of each incisional scar at each time period. Blinded evaluators used a previously verified scoring system to score photographs of the incisional scars taken at the 6 month time period. With regards to the comparison between the three individual laser treatment groups and the control, there were no statistically significant effects for treatment (P = 0.40), time (P = 0.48), or for the interaction of time and treatment (P = 0.57). With regards to the visual assessment tool, there were no statistically significant differences between treatments for Overall Appearance (P = 0.21) or for Total Score (P = 0.24). In the limited setting of this pilot study, treatment of surgical incisions with ablative

fractional CO2 lasers does not significantly lessen scar formation. In addition, photographic analysis was not able to demonstrate a significant difference. Future studies on this topic will need a larger sample size to better answer whether a statistically significant difference may exist. Title: Vein imaging laser reduces bruising in bruise-prone botulinum toxin injected patients Authors: Lowe NJ, Halliday D Published: Journal of Cosmetic and Laser Therapy, March 2016 Keywords: Vein imaging, reduced bruising with botulinum toxin injections Abstract: Injection-related bruising is a common complication of many injectable treatments including facial injections of botulinum toxin (BTX) for aesthetic use. We have investigated the use of a vein imaging laser (VIL) to observe otherwise non-visible subcutaneous blood vessels in 40 patients who had a history of bruising with past BTX injections to the face during the previous 12 months. Over a 4-month period 40 patients, who previously had developed bruising after injectable BTX to the face, were treated with further BTX to the same areas as previously, but using a VIL during the injections. Patients were evaluated for their severity of bruising. 40 patients out of 2400 patients had experienced bruising with a severity score total of 92 (mean per patient 2.3) with BTX injections before VIL use. On injection using the VIL 6 of the 40 patients had bruising with severity score total of 7 (mean 1.16). The use of a VIL significantly reduced the frequency and severity of bruising associated with BTX injections. Title: Treatment of striae distensae with needling therapy versus microdermabrasion with sonophoresis Authors: Nassar A, Ghonemy S, EI Gohary Y, EL-Desoky F Published: Journal of Cosmetic and Laser Therapy, April 2016 Keywords: Striae distensae, histopathology, microdermabrasion with sonophoresis, needling therapy Abstract: Striae distensae (SD) is a challenging cosmetic problem for which various treatment modalities have been applied. Our aim was to evaluate the efficacy and tolerability of needling therapy versus microdermabrasion with sonophoresis in the treatment of SD. Forty female patients with SD (mean duration 2.98± 2.66) were enrolled in this study. Patients were assigned to two groups, group 1 treated with needling therapy and group 2 treated by microdermabrasion with sonophoresis. In group 1, three sessions of needling therapy were carried out for each patient with four weeks interval between the sessions, while in group 2, ten sessions of combined microdermabrasion and sonophoresis were carried out for each patient. Skin biopsies were taken from the most atrophic site stained with hematoxylin and eosin stain, Masson trichrome stains to study of histopathological changes and efficacy of treatment. There was significant clinical improvement of SD in group 1 compared with group 2. Amount of collagen, number of fibroblasts and epidermal thickness were increased in the dermis at the end of treatment sessions (90% in group 1 compared to 50% in group 2). Needling therapy is easy, safe, economic method and considered as a suitable modality in management of striae.

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


Silkann. Aesthetic cannula innovations from Sterimedix. A world leader in single-use surgical products Silkann is a comprehensive range of twin-packed Sterimedix flexible aesthetic cannulas and sharp needles - designed for operational efficiency and with your patients’ comfort in mind. Each cannula with screw thread polycarbonate hub, is supplied with a slightly larger sharp pre-hole needle, giving practitioners the perfect match between cannula and needle to ensure maximium accuracy whilst maintaining optimum patient comfort.

• A new and unique screw type hub manufactured using polycarbonate to reduce the risk of cannula detachment. • Indicator on the hub to show orientation of the port during injection. Aest hetic Cann ula a nd Sh arp N eedle Sets Fat T ransf er Ca nnula s

• The best port quality and consistency of port position, to remove risks during procedures. • Ports designed to optimise the flow and performance of fillers whilst reducing injection forces. • The highest quality of packaging to maintain the integrity of the cannulas at all times.

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Managing Cybercrime Threats in Healthcare Insurance and risk management consultant Holly Markham discusses changes to data protection laws and advises how to protect your patients’ privacy According to a study carried out by the Information Commissioner’s Office (ICO), the healthcare sector is the most vulnerable industry when it comes to cyber-attacks and data breaches.1 Breaches in the healthcare sector exceeded any other industry in the UK in 20152016, including local government, finance and retail institutes (Figure 1).1 With new EU data privacy laws looming, an increased integration of technology and the current vulnerability of the healthcare sector, medical professionals and aesthetic businesses need to take a proactive approach to mitigating their exposure to cybercrime and data breaches to protect the highly sensitive information of their patients and to act in accordance with the law.

What do we perceive as cybercrime or data breaches? Traditionally when we think of cybercrime or data breaches, our thoughts are drawn to the vision of criminals hacking into a website to obtain financial information or take control of personal data. We also tend to think that our business has some sort of immunity to these risks and it will never happen to us. Cybercrime and data breaches can take a variety of forms. The mainstream media has highlighted how even the biggest institutes can fall foul. Some of the most prolific examples that would have Health 278 been brought to your Local Government 60 attention over the past Education 43 decade include: Finance, insurance and credit 31 • The Nationwide Building Justice 24 Society, which was fined Legal 21 £980,000 in 2007 when Charitable and voluntary 17 an unencrypted laptop was stolen from an General business 15 employee and risked the Legal and property services 15 personal data of near 11 Other 55 million customers.2 0 60 120 180 240 300 • The infamous data Number of incidents breach of Sony PlayStation in 2011, Figure 1: Data security breaches by sector 1

where hackers intercepted personal information of more than 77 million users.3 • TalkTalk was recently involved in an incident where two teenage hackers exploited the weakness of their website and compromised more than 157,000 customer records, including more than 15,000 bank account details in November 2015.4 • In healthcare, the most notable case relates to the Brighton & Sussex NHS Trust which was fined £325,000 by the ICO for the loss of highly sensitive personal data belonging to tens of thousands of people including HIV and genitourinary medicine patients, as well as personal data such as National Insurance numbers, addresses and hospital IDs of medical staff.5

Data breaches and how to avoid them Data breaches can easily occur within the medical aesthetics sector. It is important to be aware that it could happen to you; understanding where your business’s weakness might be is vital. The following list comprises some of the most common ways data is breached and how to prevent them. Loss or theft of paper work It is no secret that some healthcare providers have still not yet moved into the 21st century and are living in a paper-based society. Paper is easily lost, could potentially get left on a commute to and from your clinic, or stolen from your premises. To prevent this, implement a clear desk policy; classify documentation; shred all confidential waste (if in doubt, shred it) and/or engage an accredited organisation to collect and shred documentation for you. It is also a good idea to increase your premise’s security. If using paper-filing systems, ensure that patient records are safely secured in a locked cabinet ideally within a locked office area and remove all keys from the premises. This is one of the processes that your chosen data protection officer should review (explained on the next page). There are several data leakage prevention solutions to prevent data incorrectly leaving an organisation whether by mistake or malicious intent. Posting or emailing information to an incorrect recipient A simple clerical error such as emailing the wrong patient or sending a letter with the wrong patient details enclosed is classed as a data breach.6 As a healthcare provider you hold highly sensitive confidential data which,

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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if it falls into the wrong hands, could cause severe damage and distress to those individuals. This is difficult to prevent so add disclaimers to your post and email. To lower your cyber risk when sending sensitive documents, only email using password protected files.

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140 Loss or theft of paperwork

120 Number of incidents

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Loss or theft of unencrypted device

100 80

Data posted or faxed to incorrect recipient

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Data sent by email to

40 Loss of an unencrypted device incorrect recipient How many practitioners use their 20 own iPad, iPhone or tablet device Insecure webpage to take patient before and after (including hacking) 0 photographs? Some of which may well be celebrities or those with a Oct-Dec ‘14 Jan-Mar ‘15 Apr-Jun ‘15 Jul-Sep ‘15 high profile. If that device is lost or Figure 2: Comparison of the number of data security breaches stolen, this is a breach, no matter what patient the photos are of. What would the ramifications be to your reputation and finances if Failure to redact data such data got into the wrong hands? To prevent this, ensure that all Improper redaction most often occurs when text or images are of your devices are encrypted by default (available on most mobile covered instead of being completely purged from a document. devices – to encrypt is to code information to prevent unauthorised For example, if you use a case study or post before and after access). Also implement mobile device management so that you photographs on your website and have simply blackened out can remotely wipe devices that are lost. sensitive information or not fully concealed the identity of the patient, then you are at risk of breach. As discussed, the way to Hacking an insecure webpage prevent this is insuring that you implement all of the processes The first mistake is to think ‘my website is not interesting to hackers, outlined above. For more information you can visit the ICO’s guide we don’t transact any financial information so we’re fine, it will to data protection.7 never happen to us’. You may be surprised to know that as many of you read this, hackers are attempting to break into websites just So why is data privacy such a hot topic? like yours. It is not exactly your website per se that the average In January 2012 the European Commission proposed a reform hacker wants, it’s the power that the webserver is running on. Your of the EU data protection rules to make them fit for an ever website can be used as a valuable tool to conceal a hacker’s identity increasing, technology-driven society and to create uniformity whilst they perform illegal tasks, or to send millions of spam emails across the 28 member states.9 Four years on, and with data from your server to your patients asking for payments, or to serve breaches continually on the rise, the implementation of the reform vulnerable visitors to your website with viruses. A hacker may also is imminent and it is important that businesses are a readily encrypt your server with specially-developed ransomware to commit prepared to meet the requirements of the new legislation. cyber extortion demanding payment. To manage this, regularly carry The changes to law require more rigorous processes to obtain out penetration and vulnerability scans to test the effectiveness of explicit consent on the collection of data and also a ‘right to your firewalls and data security. The aim of this is to identify browser be forgotten’ requiring companies controlling data to delete exploits, unpatched software, unsecure coding practices and weak information upon their client’s request. In addition, individuals will encryption algorithms. A penetration test must be conducted by also be allowed access to their own personal data and be given a certified ethical penetration tester, who will use their expertise the right of data portability, meaning patients could request a to identify specific weaknesses within an organisation’s security copy of their data and move it to another company. The new EU arrangements. This involves simulating a malicious attack on an rules could potentially drive a safer patient journey by allowing a organisation’s information security arrangements, often using a more open form of practitioner-patient communication, providing combination of methods and tools. As well as this, do not use free patients with a set of their own records that they could transfer if WiFi access or hotspots as it is easy for unscrupulous cyber criminals visiting a new clinic for further or different treatments.10 to intercept your data. Any access to your business or home network In addition to empowering all EU citizens with more control should also be encrypted and password protected. over their own data, the new legislation will affect businesses regardless of whether you are an individual practitioner or a large Inadequate processes for removal of old documentation/records chain of clinics. One of the most prevalent changes that will make Highly sensitive patient information, records, hard drives and an impact is the requirement to notify the ICO of any serious business recycling, if not discarded safely, can significantly increase breaches as soon as your business has been made aware; a the risks of a security breach if it falls into the wrong hands. To serious breach could involve some of the examples detailed prevent this, ensure that all old paper documents are shredded and where highly sensitive data such as patient records are involved. get your data protection officer to review current data protection Breaches must be notified as soon as reasonably possible, ideally processes and run a programme to bring the organisation into line within 24 hours, and clinic owners should notify any affected with the ICO guidelines. individuals without delay. 8

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


Consultant Plastic, Reconstructive & Aesthetic Surgeon Mr Dalvi Humzah provides award winning bespoke facial anatomy, complications management and advanced injectable training. Facial Anatomy Teaching explores the current concepts and literature pertaining to treating age-related changes, with a practical dissection for delegates to analyze the current injection techniques using needle & cannula approaches The Management of Non-Surgical Complications Through Anatomy Teaching incorporates a detailed theoretical component on the recognition, diagnosis and current management strategies of toxin and dermal fillers. This includes a dissection and practical hyalase workshop. Advanced Toxin & Dermal Filler Training provides bespoke advanced injectable teaching using cannula and needle approaches. These sessions incorporate facial analysis using 3D camera technology.

Mr Dalvi Humzah is an internationally recognised tutor who has been performing injectable treatments for more than 25 years. He has been closely involved in the research and development of many injectable products and devices, as well as holding consultancy roles in the management of complications. 

Forthcoming Training Dates Advanced Injectable Training 8th June & 6th July Wigmore Medical London

Facial Anatomy Teaching 12th September The Royal College of Surgeons England

The Management of Non-Surgical Complications Through Anatomy Teaching 13thSeptember The Royal College of Surgeons England

W: www.facialanatomy.co.uk T: 07592 268 490 E: facialanatomyteaching@gmail.com

Cyber Crime Cyber Risks are a real threat to your business The real value and benefits of Cyber Insurance become very clear when your system is breached. Find out how Cyber Insurance can protect your business when criminals get in.

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Top tips for protecting your data 1. Only use encrypted devices to take before and after photographs and to store patient information

2. Increase your premise’s security 3. Ensure that paper filing systems and patient records are 4. 5. 6. 7. 8.

secured in a locked cabinet – remove all keys from the premises Encrypt all your digital patient files Do not use free WiFi access or hotspots Encrypt and password protect any access to your business or home internet network Scan and test the effectiveness of firewalls and data security Password protect sensitive documents when sending

What is the Information Commissioner’s Office? The ICO is a non-departmental public body that reports directly to the British parliament as an independent regulatory office. The ICO is tasked with enforcing a range of regulations such as the Data Protection Act 199810 and the Privacy and Electronic Communications (EC Directive) Regulations11 in the UK. The ICO is also responsible for making guidelines for legislation and has the power to enforce these laws and issue fines to those who breach these regulations.

Prevention is better than cure The good news is the new law will not be introduced until 2018, however all healthcare professionals and businesses should utilise this time to proactively ensure their business is readily prepared to act in accordance with legislation.

Consequences of a data breach As well as severe reputational damage there will be significant fines for individuals, clinics and businesses that do not comply with the proposed regulation, with the possibility of individuals and associations acting in the public interest to bring claims for noncompliance. The imposed fines could be anywhere up to 4% of your global turnover.13 Businesses need to carefully review the new laws to ensure they comply.

How to mitigate your risk of data breaches Businesses will need to put in place written security and privacy policies and procedures, which include the process of reporting breaches. If you hold highly sensitive data such as healthcare information, then you will need to appoint a data protection officer. This person can be an existing member of staff, but they must be competent and have extensive knowledge of data protection. Businesses can obtain cyber and data training from specialist providers, which will provide practical guidance on how to mitigate risk and protect themselves from cyber and data crime. Alternatively, the data protection officer can also be an outsourced consultant who can act on behalf of your business to ensure you meet the legislation standards. As well as this, it is a good idea to consider computer software and insurance, explained below, to safeguard you and your clinic.

Aesthetics

software system. These systems are encrypted to protect the highly sensitive patient information you record throughout the consultation process. The companies that create such systems are often engaged with the ICO during the design to ensure best practice and consider future EU legislation, which enables patients to have access and transport information held about them.

Cyber and data insurance One solution that all medical and aesthetic businesses should consider is cyber and data insurance protection. Cyber and data insurance not only provides financial protection for businesses from regulatory awards, fines or penalties imposed against you for data breaches, it also covers the third party damages and the costs associated with an investigation brought from the ICO in relation to a potential breach or notification. As well as the financial protection provided by cyber and data insurance, the cover extends to provide your business with full support from a team of IT forensic, legal and PR experts who are on your side to protect your reputation from a media frenzy, investigate and diagnose the route of the attack and the rectification costs to get your systems secure and safely up and running again.

It can happen to you No one is immune from data breaches or the risks of cybercrime. It’s not just a hacker, but also human error that can give rise to a claim and, as mentioned, the ICO has highlighted the healthcare sector as the most vulnerable in the UK.1 The best way to protect your business from cyber and data breaches is through creating a robust risk management strategy to prevent them occurring in the first place. However, it is not always possible and even the most data secure businesses suffer losses, so it is imperative to ensure you and your business are prepared for the implications of a potential data breach. Holly Markham is the business development executive at Enhance Insurance, which specifically covers medical professionals. She has more than 10 years’ experience working in providing risk management advice and implementing high-level insurance programmes to mitigate and protect businesses. In 2013, Allianz highlighted Markham as one of the UK’s top five young brokers. REFERENCES 1. ICO (Information Commissioner’s Office), Action We’ve Taken, ‘Data security incident trends,’ 2016 <https://ico.org.uk/action-weve-taken/data-security-incident-trends/>  2. BBC News, Nationwide fine for stolen laptop, 2007, <http://news.bbc.co.uk/1/hi/business/6360715. stm> 3. Quinn, B & Arthur, C, PlayStation Network hackers access data of 77 million users, (2011), <http://www. theguardian.com/technology/2011/apr/26/playstation-network-hackers-data> 4. Farrell, S, Nearly 157,000 had data breached in TalkTalk cyber-attack (2015) <http://www.theguardian. com/business/2015/nov/06/nearly-157000-had-data-breached-in-talktalk-cyber-attack> 5. BBC News, Brighton hospital fined record £325,000 over data theft, (2012), <http://www.bbc.co.uk/ news/uk-england-sussex-18293565> 6. Information Security (Principle 7) ICO (Information Commissioners Office) Guide to Data Protection 7. ICO (Information Commissioner’s Office), ‘About the Guide to data protection’, 2016, <www.ico.org.uk/ for-organisations/guide-to-data-protection> 8. Data security incident statistics and trends,  ICO (Information Commissioner’s Office) Action We’ve Taken ‘Data security incident trends’ 3rd March 2016 9. European Commission, ‘Protection of personal data,’ <http://ec.europa.eu/justice/data-protection/> 10. European Commission, ‘Data Protection Day 2015: Concluding the EU Data Protection Reform essential for the Digital Single Market,’ Brussels, 2015. 11. Gov.UK, Data Protection, 2015, <https://www.gov.uk/data-protection/the-data-protection-act> 12. Legislation.gov.uk, The Privacy and Electronic Communications (EC Directive) Regulations 2003, <http://www.legislation.gov.uk/uksi/2003/2426/contents/made> 13. BBC News, EU data laws threaten huge fines, 2015 <http://www.bbc.co.uk/news/ technology-35110909>

Software to prevent cybercrime One way practitioners can mitigate their risk and exposure to cyber and data breaches is by introducing a compliant medical consultation

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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• Are there any regulatory frameworks that should be considered? • What are the relevant recommendations from professional councils, e.g. the General Medical Council, General Dental Council, Nursing and Midwifery Council, General Pharmaceutical Council? • What will be the mode(s) of delivery and duration of the course? How will this differ from what is currently on offer? • Can you obtain approval from an insurance company to run your course?

Training Courses in Medical Aesthetics Dr Tristan Mehta discusses how to successfully create and run a training course in medical aesthetics How to improve training standards is probably one of the most important issues facing the medical aesthetics specialty to date. As with any medical field, high quality education is necessary to ensure that evidence-based knowledge ingrains into our practice. Training should challenge attendees to continuously advance their own knowledge and understanding, and keep the influence of manufacturers at an academic distance.

Non-surgical aesthetic treatments can be split into four main categories: 1. Injectable treatments 2. Energy-based treatments 3. Skin and tissue rejuvenation 4. Emerging and novel treatments, e.g. thread-lifts

Given the exponential growth of aesthetics (£2.3 billion in 2010, and estimated at £3.6 billion in 2015)1 – with new technologies and changing regulations being announced every year – education is more important than ever. However, rapid expansion also brings with it inherent challenges. How do we keep training both relevant and impartial in such a fast-paced specialty? In this article I will look at how to deal with the greatest opportunities and challenges facing aesthetics training today.

Within each of these categories, we are seeing various types of course providers. The recent popularity of devices and machines is maligned more than any other field by the fact that training is almost exclusively run by manufacturers for their own devices. Pharmaceutical companies initially ran their own training courses for injectables, but as the industry grew, there became an emerging market for independent, or semi-independent ‘weekend courses’. Several universities now run much lengthier and more formal postgraduate qualifications, which aim to give practitioners a wide scope of knowledge in the various aesthetic modalities – for a considerable cost.

The landscape

Entering the market

Medical practitioners are comfortable with formal training programmes, learning outcomes and assessments. We often crave this format of learning because this is how we learnt at university. As we are all aware, however, there is currently no standardised formal training programme in medical aesthetics. So what framework can we use to further our education?

The decision to launch a new training course in aesthetic medicine should be influenced by a few important factors: • What is your area of expertise? • Where is the current market need? • Where might the market need be in the future? • What competition is there? Which locations do they cover?

Let us take the example of injectables training (botulinum toxin and dermal fillers). When searching online for ‘Botox training,’ more than 80 courses show up. What might make yours unique? Given the prevalence of one or two-day courses, you might focus on making the duration of your course different. Perhaps you are able to produce a more rigorous, or a better value course by offering more time with delegates. Alternatively, you might want to focus on a specific healthcare group, such as pharmacists, who have different educational requirements from doctors, for example. As our sector rapidly changes, the training course launched must remain congruent with emerging trends and treatments. Some examples of change-resistant training initiatives do not focus on specific treatments; for example, anatomy courses or business support/marketing courses are relatively well ‘future-proofed’.

Regulation and accreditation Regulation is an increasingly hot topic in medical aesthetics – and for good reason: there is no other field in healthcare with so few legal or regulatory restrictions on who may perform treatments.1 Following the controversial 2013 review by Sir Bruce Keogh,1 Health Education England (HEE) conducted a consultation with an expert reference group in 20152 and 2016.3 The key outputs from HEE for training courses are: • Training providers should offer postgraduate-accredited training courses, with higher-education standard theoretical learning content and a set number of treatments required under supervision • The new qualification requirements apply to all practitioners, regardless of previous training and professional background • Practitioners who have already completed training will be able to apply for formal

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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recognition of this from an accredited cosmetic training provider, preventing the need to undertake any unnecessary further education • Very short courses, e.g. one-to-two days in duration, will not meet the requirements for Recognition of Prior Learning. This poses a dilemma for the majority of practitioners in our industry, given that the vast majority of training has been delivered over a weekend • A joint council is to be formed, which will take ownership of cosmetic industry standards for education and training HEE offers recommendations, not regulation, however they are just as important. Its 2016 report states, “Although adoption of the new requirements will be voluntary at this stage, it is recommended that the qualification requirements be adopted as best practice and accepted as the standard that the industry should adopt improve public safety and raise standards of practice and professionalism.”3 Running ‘basic’ and ‘advanced’ versions of the same course has also taken some criticism, often seen as an excuse for course providers to make further money from their customers. The GMC has published draft guidelines for doctors offering cosmetic procedures,4 which state that supervised practice is required before entering aesthetics as a doctor. In the same guidelines, the GMC supports the HEE recommendations for training and qualification requirements. Ultimately (and perhaps unfortunately), insurance companies are currently effectively the only regulators of training in our industry. Any course must be approved by an insurance company if it is to engender new skills to the practitioners.6 Accreditation Given that nurses are now required to revalidate each year,5 CPD points are an increasingly valuable asset. Application for CPD accreditation can be made through the CPD Certification Service website or other CPD accreditation providers. Having your course CPD accredited can make it more appealing to those practitioners who seek funding to attend your course. Ofqual (Office of Qualifications and Examinations Regulation) regulates qualifications, examinations and assessments in England. Most recognised qualification e.g. A Levels and NVQs are regulated by Ofqual. Training centres can

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work with awarding bodies to directly accredit their qualifications with Ofqual, although this process is typically lengthy and will require months of qualification development.

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in question. Each patient or ‘model’ as some courses call them – will need to be screened prior to the training day, to ensure there are no medical contraindications. 

Spread the word Costs There are several costs associated with setting up a training course that need to be considered. These include: • Medical malpractice insurance and product liability insurance (around £2,000) • Marketing (variable cost) • Venue hire (variable cost) • Clinical equipment e.g. product, consumables and a sharps bin/clinical waste bin (variable cost) • Trainer hire (variable cost) • Handouts and associated printing costs (variable cost) – note: pharmaceutical companies and manufacturers may be willing to team up with your course, if they can market their products and devices to your students • Refreshments and lunch (roughly £15-20 per delegate) Initial setting up costs will vary mostly on the venue used and the modality, which is being trained, but on average, running your first training day may require an initial investment of more than £4,000. In order to make a profit margin of 20%, fees must cover 120% of the cost of running a course. For example, if your course costs £6,000 to run, then revenues of £7,200 must be made. Assuming you are taking eight students, this would require a student fee of £900 each. This is a fairly typical price for a training day in aesthetics. Recruitment of ‘models’ can actually be a source of revenue for a training day, but come at the expense of a logistical headache. HEE Part 12 explains how it is acceptable to offer promotional discounts on aesthetic treatments on the basis of medical education. The difficulty is not gathering the volume of patients; but in fact ensuring they are appropriate for the aesthetic treatment

In a highly competitive market, how can we get the attention of our customers? Our digital connectivity has significantly reduced the cost of marketing – any course can reach out to thousands of practitioners with a website and social media. Trust and transparency As a result of this online accessibility, the playing field is now level, so what matters the most? Trust, leadership and transparency. Success now is not dependent on being the low price leader, but the high trust leader. Price is no longer our strongest negotiating tactic – we are drawn to transparency. Reviews and referrals are of utmost value so ensure you ask all students to write a short testimonial or fill in a feedback form that can be used in future marketing upon completion of your course. Ensure the students have given permission for you to use their name and/or feedback for this purpose prior to sharing any information. For the first course, it may be worthwhile asking a couple of colleagues or industry peers to provide a written or filmed recommendation to aid your marketing tactics. In a professional arena, it is important to resist making meaningless claims such as ‘The UK’s Number 1 Course’. Claims like this are patently unfounded, and trust is our most valuable commodity in business right now. Instead, think of creative and honest USPs to promote your training course. Targeted marketing Training courses have the luxury of plenty of targeted advertising opportunities. Of particular value are the targeted monthly magazines and journals to specific healthcare groups. Direct paid advertising can be taken advantage of, alongside editorial opportunities. Google Adwords is

What makes a good training course? • • • • • • •

Value for money Accreditation (CPD or Ofqual) Relevance in terms of technology or regulation Small group sizes for practical sessions Credible medical academic faculty with relevant training faculty Centrally located or in a major city Formal collaboration with recognised institutions

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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A one-day course schematic 09:00 Ice-breakers 09:10 Agenda 09:15 Learning outcomes 09:20 Initial theory 10:30 Coffee break 10:45 Further theory 12:30 Hot lunch

13:30 Practical session 14:45 Coffee break 15:00 Examination 16:00 Certificates 16:15 Feedback 16:30 Up-sell further courses and training

another common paid-for tool for targeted marketing based on search keywords. Be aware that prescription-only medications such as botulinum toxin are disallowed from this.8 Social media marketing can also be highly effective in targeting specific healthcare groups, often requiring minimal amounts of investment. Letting the audience know that you are up-to-date will engender trust – and Twitter is the best option we have for this. Are you regularly Tweeting original content? It is also important to note that you should never buy Twitter or Facebook followers – it is often obvious that you have done so and, ultimately, you want to develop an engaged loyal audience over time. Industry conferences and exhibitions are also a great place to market your training course. We have more than five national industry exhibitions each year. These events are the perfect opportunity to build trust amongst your profession through networking, alongside marketing to new practitioners entering the specialty. Practicalities and pitfalls In my opinion, the future of theoretical learning is distance-learning via online education. The vast majority of practitioners enrolling onto your course will therefore be more excited about the practical elements as this is not something easily taught online – as such, the practical elements should be where your emphasis is. Furthermore, HEE recommends that at least 50% of a course should be dedicated to practical experience.2,3

Name Basing the name of your training course (or clinic, for that matter) around your own name or reputation is a double-edged sword. On one hand, your credibility may bring in customers, especially if you have carved out a niche for yourself in a certain field or technique. However, you are exposing your personal brand to a large degree. Businesses are inherently risky and the unfortunate truth is that most

businesses do not succeed, which may have an impact on the other business ventures you are running under your personal brand name.

Venue The venue for your course is an important decision. Will it be part of your existing clinic? What capacity do you require? Do you need to hire a Care Quality Commission (CQC) registered premises for the specific procedures you are offering training in?6 According to the CQC’s regulations, the premises where care and treatment is given must be clean, suitable and appropriately located; the equipment must also be clean and suitable for the purpose of the procedure and must be maintained, stored securely and used properly.7 Hiring premises can be difficult when starting out – the venue needs to be booked in advance, but you can’t guarantee that you will fill the space. As your course becomes more popular this becomes less of an issue. But when starting out, it is advisable to run with smaller group numbers and run the course through your existing clinic.

Delegate experience Taking into account various practitioner backgrounds and experiences can be challenging. An experienced trainer will notice which delegates have more experience and tailor the teaching session accordingly. Some practitioners may need additional support and are usually not shy to get their money’s worth through taking the trainer aside when necessary. Trainers are encouraged to regularly ask learners whether they are keeping up and happy with the pace of learning. Another inherent challenge to offering training to a wide multidisciplinary team is factoring in the undergraduate experience each group will have already had. Common undergraduate areas covered by all healthcare groups should include the patient consultation, health and safety, and ethics. HEE Part 12 breaks down the requirements

for learning for each professional group, for example, clinical healthcare professionals such as doctors, dentists and nurses are not required to study certain areas already covered during their undergraduate years - for example, clinical governance and accountability and professionalism.

Conclusion Running a training course in medical aesthetics is a very rewarding experience. The ultimate rewards lie in challenging yourself to stay up-to-date, whilst in the process making connections with, and leading, the next generation of practitioners. Of critical importance is ensuring your training course is future-proof, and right now this requires taking a serious look at the regulatory frameworks emerging in 2016. Dr Tristan Mehta is a medical doctor, entrepreneur and founder of Harley Academy. He is studying for an MSc in Skin Ageing and Aesthetic Medicine and is passionate about developing better standards in medical education through novel approaches and the implementation of stateof-the-art technology.

Disclosure Dr Tristan Mehta is the founder of Harley Academy, a training centre, which awards accredited qualifications in aesthetics in-line with HEE guidelines. REFERENCES 1. Keogh et al. Review of the Regulation of Cosmetic Interventions’ Department of Health, (2013), <https://www.gov.uk/government/ publications/review-of-the-regulation-of-cosmetic-interventions> 2. Health Education England, ‘PART ONE: Qualification requirements for delivery of cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery’; (2015) <https://hee.nhs.uk/sites/default/files/documents/HEE%20 Cosmetic%20publication%20part%20one%20update%20 v1%20final%20version.pdf> 3. Health Education England (2016) ‘PART TWO: Report on implementation of qualification requirements for cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery,’ <https://hee.nhs.uk/sites/default/files/ documents/HEE%20Cosmetic%20publication%20part%20 two%20update%20v1%20final%20version.pdf > 4. General Medical Council (2015) ‘Draft Guidance for all doctors who offer cosmetic interventions’ <http://www.gmc-uk.org/ Guidance_for_all_doctors_who_offer_cosmetic_interventions_ consultation_english__2__distributed.pdf_61281552.pdf> 1. NMC, Revalidation: Your step-by-step guide through the process, The Nursing and Midwifery Council (2016) <http://www. cosmetic-insurance.com/training/> 2. Care Quality Commission: Quick reference guide to regulated activities by type of service (2015) <http://www.cqc.org.uk/ file/4792> 3. Care Quality Commission, ‘Health and Social Care Act 2008 (Regulated Activities) Regulations 2014,’ Regulation 15: Premises and equipment, <http://www.cqc.org.uk/content/regulation-15premises-and-equipment> 4. ‘Healthcare and medicines,’ Google Advertising Policies, 2016 <https://support.google.com/adwordspolicy/answer/176031>

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Improving Industry Supplier Support Sales representative Caroline Gwilliam shares advice on how to the make the most of aesthetic suppliers to benefit your business There are many resources available to new aesthetic clinics that offer to increase footfall and retention of business. For example, you could pay for a business consultant, website designer, marketing executive or take an online course; all of these would help to improve your business and thus retain and expand your patient base. However, often overlooked and under-used are the aesthetic suppliers or company representatives. They can provide invaluable help and advice at no cost, particularly when these resources are built into the support you receive as a valued partner. Suppliers should have in-depth specialist knowledge of their market and products. They also usually have a great network of contacts and, if experienced enough, know what works and what doesn’t work in the clinical aesthetic setting, drawing upon their wealth of knowledge which can help you reach your business goals.  

Getting started It is beneficial to set up business planning and review meetings with your suppliers at the outset. As business professionals, confidentiality and discretion is assumed, however, it doesn’t hurt to start a meeting with a respectful reminder for confidentiality as you begin a collaborative relationship. Outline your business plan, along with short, medium and long-term goals. You can then work together to set a time frame of achievement targets and align the kind of support you need.  Of course, you will have your own ideas

about what you need from your suppliers, however acquiring other experienced aesthetic professionals’ advice and perspectives on your objectives can reveal new and different approaches and ideas. As a starting point, look at how your suppliers might provide some collaborative support across three areas of the business – the owner, the clinic staff and the patients. Of course these areas are not mutually exclusive, there are overlaps and adaptations and the below list is a guide that will help you with your decisions. Financial • Products will have an RRP but when it comes to treatments and services, a supplier should have knowledge of the local area’s pricing range. Utilise their experience to help you set realistic, yet rewarding, prices for your products and services. • Consult your supplier on pricing, discounts and treatment packages, as they will usually have good ideas to help repeat business and increase footfall. Suppliers can often provide price per dose/per treatment and are able to give profit margins based on the number of patients undergoing a procedure.   • Consider and discuss suppliers’ terms and conditions of business, which usually include contractual agreements, payment terms and any delivery charges. It is also worthwhile discussing minimum order requirements, as these can vary amongst suppliers. In terms of cash flow, minimum orders can be tricky

for a new business. You will, however, find that if you choose the right products for your customer base, and market them effectively, the stock will sell to satisfied patients who will continue to order and your cash flow will start to increase. • Consult your supplier on appropriate insurance cover. If the goods that the company supplies require specialist insurance, your supplier will be able to put you in touch with suitable insurance companies. Some of your suppliers may have encountered some of the same initial financial challenges when working with other clinics, so there will be common ground and mutual understanding, which can potentially lead to some great contacts and advice.  

Reputation  Online presence Social media and internet presence should be considered a high priority for your clinic, whether this is to raise the profile of the owner, clinic practitioners or the clinic itself. Most aesthetic businesses use social media to promote their products and services, so it is likely your supplier or their colleagues will have a good understanding of how to use it to your benefit. Take advantage of this knowledge and link with your supplier’s existing presence. This can be anything as simple as asking to be featured in their e-newsletters, social media or blog posts, or being involved in filming for their various media channels. Getting your name or your clinic’s name featured in association with a reputable and respected brand, such as your supplier’s, will enhance your reputation and online presence. Conference presentations Another way a supplier can help with raising your profile is by increasing podium presence, providing you with opportunities to present at industry meetings and conferences. This is especially true when their company is sponsoring a workshop or presentation at an exhibition. This exposes clinic staff to a new audience and further opportunities, such as meeting other industry professionals with experience in various fields, sharing best practice techniques and enhancing their knowledge of the industry. In addition, it is a great way to show local patients that you are a nationally or internationally recognised authority, which can increase footfall and customer loyalty through credibility and trust. 

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Site visits A clinic owner and their staff may also benefit from a factory or manufacturing site visit, which can be set up via the supplier, to help them fully understand the ethos of the company and its products. This can be useful as staff then have the reassurance of knowing the manufacturing and safety regulations of a product or device are of a high standard. Offering this reassurance to patients should ultimately build trust and enhance reputation, leading to positive results and patient satisfaction. Open events Open events are a great way to engage existing and potential patients with your products and services to increase footfall and generate new business. Suppliers can help run demonstrations during these events, organise raffle prizes or offer mini consultations on their specific technologies, as well as provide gift bags and literature for the attendees. Suppliers are always happy to showcase their technology, and running ‘Meet the Expert’ sessions during an open event will educate attendees on how the technology works.

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all your staff members understand the key messages for each treatment in your offering and retail products on display, so it is worth requesting training for your reception team, as well as your clinical team. Being able to communicate key messages clearly and simply will create a positive impression and will underpin your position as a practitioner, which in turn will build customer credibility and product turnover.

Product displays In regards to marketing, product displays and advertising, suppliers have great knowledge about best-selling products and how to display them for maximum attention and promotion. Suppliers can help with lighting ideas and positioning of products, promotional posters and display information. Sometimes it is more beneficial to focus on one or two products for maximum impact; too many leaflets on display can be confusing to the patient and look untidy in a reception area – your supplier can help you decide what literature is most relevant to your target audience and recommend where they should be displayed.

Training and technology  Developing relationships When considering other new products or technology coming to market, it is a good idea to discuss these with your suppliers because they spend time learning about the new technologies that dovetail their own; when mutually beneficial, introductions to other suitable suppliers can sometimes be made.  It’s also worth considering that smaller entrepreneurial companies are able to partner and connect flexibly and quickly with clinics. The benefit of working with a distributor enterprise is that they are entrepreneurial in spirit and are often able to develop personalised solutions for your business needs.  

Key messages First impressions can have a significant impact on a patient’s view of your clinic, so remind your reception team, who are often the first people to greet patients, of the importance of creating a good first impression. It’s important that the clinic team are well informed when it comes to products, treatments and services available, as they may be approached and questioned by patients sitting in the waiting area. The information needs to be clear, correct and consistent. Suppliers should be able to help

Product training should include product history, context and the story behind the brand to create an in-depth understanding of your stock. This is where ‘little and often’ sessions come in useful with your supplier; ideally they should initially take place monthly, or more frequently if need be, to help staff understand the product’s aims and outcomes, and how they can advise patients looking to make a purchase. Initial training courses should be tailored to your business needs and followed up with short recap sessions. Inhouse recap training or refresher courses are essential to keep in touch and up-to-date with the brand and any new developments. Some technology can be difficult to understand, especially for non-medical staff, so your supplier should be able to package the terminology in such a way that it is easy to digest and communicate. Likewise, safety issues with new technology should be covered and understood by all clinic staff so that patients can be reassured if necessary.  Treatment plans Good product training and understanding also makes an impact on sales skills. It may be a good idea to use treatment plans to document products used so that clinic staff can always recommend a step-up treatment or product, thereby keeping

patients interested and engaged. When building treatment plans for skincare, it is important to keep in mind that suppliers often have protocols and a number of templates and standard forms to cover consultation, medical history, consent and treatment planning. You can use and adapt these forms to make them suitable for your own patient base. Product champions Your supplier can help develop a ‘product champion’ within your team and spend more time with this person, developing their understanding and knowledge, thus freeing up the rest of the clinic team. Product champions can share knowledge to the rest of the team later, as appropriate. Try ‘product of the week/month’ promotions to help increase trade, with staff given a little extra training so that they are confident in communicating the product’s key qualities to patients. Centres of excellence Centres of excellence are sometimes developed by suppliers in order to provide a learning and educational resource in a workshop setting. Held in a positive mentoring atmosphere, these workshops can be enlightening for the newly set-up aesthetic clinic owner, as they will highlight any challenges associated with running a clinic as well as provide the opportunity to learn trade secrets on how to run a successful aesthetics business. Speak to your supplier about the opportunities on offer or, if they don’t hold such workshops, suggest setting one up to meet and communicate with your clinical peers.

Summary  You can accelerate your business success by identifying your clinic objectives and aligning them with various supporting resources offered to you by your suppliers. Engaged and supportive suppliers will be a great asset to you, your team, your business and your patients. Caroline Gwilliam left Bath University in 2000 and has worked in the pharmaceutical and medical devices industry, across diverse therapy areas within the NHS and private sectors. Gwilliam has spent the last seven years in medical aesthetics in London and the South East. Within the past 18 months she has specialised in skincare.

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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“Once you have an idea in your mind, you need to pursue it and stay focused” Dr Patrick Bowler reminisces about the beginning of the aesthetics industry, its development in the UK, and how he proudly formed the British College of Aesthetic Medicine When Dr Patrick Bowler began his journey into the virtually nonexistent aesthetic industry almost 28 years ago he had no idea where the future would take him. He explains, “I trained at the Royal London Hospital in White Chapel and eventually became a GP in Brentwood in Essex for about 15 years, where my main interest was dermatology.” At the time, Dr Bowler says, the NHS was in a crisis because patients were receiving favourable treatments depending on their postcode and he felt that he didn’t want to continue to explain government policy to patients. “My lovely wife had a magazine and it was talking about collagen injections in the US. She said, ‘I think this might be interesting,’ so I went on a collagen training course which was run by an American company in the UK.” The training involved using collagen fillers that were derived from the skin of cattle (bovine). “It was the first training in the UK that related to aesthetics. It was only me and a few other doctors, there weren’t many of us.” After the training, Dr Bowler bought the necessary material and, unlike marketing typically used in today’s practices, he says, “I put an advert in the local paper and the phone started ringing – it was ridiculous, it just kept ringing.” Dr Bowler was the first in his area to offer these kinds of non-surgical treatments and found there was a huge market for women who didn’t want to have surgery. “There was a very restricted menu of treatments available – the fact that these women kept phoning was an eyeopener for me; that was why I decided I was interested in aesthetics.” Gradually, Dr Bowler built up his practice to the point where he was able to leave the NHS and in 1987 set up his first private practice. In 1998 he opened a clinic in an old Victorian courthouse in Brentwood, naming it Courthouse Clinics, which has grown to encompass 11 branches nationwide, winning The Swisscode Award for Best Clinic Group UK and Ireland at the Aesthetics Awards in 2015. He explains, “In the beginning it was a very isolated existence. For practitioners that were involved in aesthetics, there was nobody really to speak to if you wanted some advice or if you had any problems; it was a very lonely path to begin with.” One big industry change was the increase in the number of practitioners of various backgrounds who now perform aesthetic treatments, which Dr Bowler says was seen from around 2005 onwards. This was mainly due to the increase in media interest, driving more public awareness of the non-surgical approaches for looking younger. “One of the things I was quite pleased about was when Dr Rita Rakus and I were feeling lonely 16 years ago so we got together to talk about the industry and formed the British Association of Cosmetic Doctors.” The association, now known as the British College of Aesthetic Medicine, began with around 26 members in 2000 and has grown to more than 350 members. This has been one of Dr Bowler’s proudest achievements. “Of course you have to be

modest about these things but I think the thing I am most proud of is getting the association going to provide education and the possibility to network for doctors in the UK; I am very pleased with how its turned out. When I go to meetings now, and sit at the back, I look at two or three hundred people and remember that was a result of some early thinking and deciding to get something happening.” At its early inception, the main issue the association was facing was revalidation for cosmetic doctors. Today, with the lack of regulation still regarded as a major concern in the aesthetics industry, Dr Bowler wishes he did more about it earlier. “Looking back at my career now, this is one of my regrets – that I didn’t force that issue more with the authorities. The market is basically unregulated and I think why or how did that happen?” Dr Bowler has recently retired from clinical practice, but is still the director of Courthouse Clinics and works hard to ensure that treatments on offer are as safe as possible for the patient through conducting regular audits and monitoring patient case studies. “I hung my needles and lasers up in June 2015 and there wasn’t any regrets because I had been doing it for a long time. Other than my work at Courthouse, I have a big family – I have a house in France and I enjoy art, I like to paint a bit,” he says. For newcomers to aesthetics Dr Bowler recommends, “Under promise and over deliver. Give people realistic expectations of what the outcome is likely to be because if you are promising the earth and you can’t produce it, you’re going to get many disappointed patients. If you can do that little bit extra then they are delighted.” What treatment or technology do you most enjoy? Combination treatments – I always liked using lasers for skin rejuvenation combined with botulinum toxin and fillers. Do you have an industry pet hate? Terrible lip jobs particularly in older women with the top lip being bigger than the bottom – I think who the heck did that? Why would you want to look like that? What is your best advice to give others? There is always going to be winds that push you off course but once you have an idea in your mind, you need to pursue it and stay focused. What do you think the industry will be like in 10 years? Bigger lips. Bigger Cheeks. Bigger breasts. Everything bigger! I think it’s going to change pretty dramatically mainly because of cellular medicine – altering genes, stem cells – I think in 10 years time maybe we won’t be doing botulinum toxin or filler but instead using genetic cellular methods to improve the way we look.

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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The Last Word Independent nurse prescriber and chair of the BACN Sharon Bennett discusses the rise in lip filler treatments for young people and debates the associated ethical and legal dilemmas With so many teens requesting lip treatments, or those wanting something outside of what we understand as attractive and normal, it may be an ethical practitioner’s natural instinct to refuse treatment. We can emphasise the potential complications and try to persuade the patient that they don’t need a treatment to look better, but we may have to accept that the patient may well go to someone less ethical or professional who will agree to treat. As such, some might question if we as medical professionals have a responsibility to consider treating in these circumstances to ensure that the patient undergoes safe practices. This article will outline the important points to consider when treating lips in young people who are under 18, or in my opinion ‘underage’, and the ethical and legal approaches practitioners should be taking. Underage and too big The lips of TV personality Kylie Jenner have been an increasing topic of conversation amongst teens and young women across the UK. At first Jenner denied she had lip fillers at all, and claimed that skillful makeup alone had morphed her slim lips into luscious shapely ones at the age of 17. Jenner finally went public in May 2015, admitting her lips had been injected with a filler to achieve the look.1 According to some UK clinics,2 this initiated a deluge of young girls wanting to replicate

Lip fillers seem to have become a fashion accessory rather than an age-defying treatment

Aesthetics Journal

Aesthetics aestheticsjournal.com

her lips. Since then, this has increased the debate amongst aesthetic practitioners as to the ethical/legal dilemma on whether to treat or not in these circumstances. Lip fillers seem to have become a fashion accessory rather than an age-defying treatment and, although I don’t think there is anything necessarily wrong with that, we are now faced with the issue of size, mainly stemming from reality TV shows where participants such as Holly Hagan from Geordie Shore and, more recently, the women in the Channel 5 show ‘My Mum’s Hotter Than Me’, seek to continually enhance the size of their lips. With many of the younger age group wanting much larger and sometimes an ‘extreme’ lip look, the potential problems associated with lip injecting may be exacerbated due to inappropriate product choice and delivery. Manufacturers do not recommend the highly cross-linked molecule fillers (indicated to give facial volume) in the lips, however when I see photos in the press and on social media it often looks like this is what is being injected, or alternatively, far too many syringes of a less volumising filler seem to be used. Some fillers are more hydrophilic than others, but, either way, with a large volume, they can give rise to increased swelling and bruising, so the chances of necrosis and deformities also increase. Lack of product understanding coupled with the inability to understand and medically manage the complications by non-medical practitioners is of concern.3 I spoke to the Safety in Beauty campaign, which says that it has received an alarming number of complaints relating to lip fillers from young adults, with the most popular age group reporting complications being 18-34. The British Association of Cosmetic Nurses (BACN) has also received a number of enquiries regarding policy and legality of treating under 18s. The BACN’s closed Facebook forum has also seen a rise of discussions on the subject, with anecdotal reports of an increase in enquiries for treatment from this age group. A growing number of BACN members are also consulting patients who are seeking corrective procedures after poor treatment elsewhere. Is it illegal to inject an under 18 with lip fillers? Having spoken to both insurers and legal experts the answer is NO it is not illegal. However, aside from the ethics, there are a number of important points to consider before that answer has you reaching to open a box of lip filler for the excited 16-year-old sitting in your clinic. Eddie Hooker, CEO and founder of Hamilton Fraser Cosmetic Insurance, was quick to inform me that the company does not include under 18s in their cosmetic malpractice insurance policies. One cannot ban treatments to the under 18s, as from a medical position the treatment may be required, but they would generally decline cover unless there are clear medical reasons/evidence provided to demonstrate the treatment is in the best interest of the patient. Janine Revill, director of Cosmetic Insure, informed me that her company has different types of cosmetic policies. Some exclude under 18s and others are not specific. However, they would expect practitioners to adhere to their Code of Practice that highlights the importance of requiring identity and consent before administering a lip treatment, which Hamilton Fraser also advocates. Checking identity Checking identity is the responsibility of the practitioner offering treatment. Apart from the insurance issue, being unware of a patient’s age is unlikely to stand up against an ethics committee, and teens may lie about their age when seeking a treatment. Onus is on the practitioner during consultation to ask the correct questions and gather all relevant information before administering treatment. There are many ways to verify a patient’s age; with a

Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Aesthetics Journal

passport, birth certificate or driving licence being the most obvious. Hooker explains that Hamilton Fraser sees many claims rejected due to incorrect information or lack of verification, which may render any consent invalid. In the media Interestingly, in my clinic, Harrogate Aesthetics, we had a whatclinic.com email request from a 15-year-old wanting a lip filler. She was declined treatment and politely emailed with a host of reasons as to why lip filler would be unsuitable for her. In retrospect, I wondered if it was a hoax and sent to test whether we would offer treatment, as a number of media sources have been performing undercover investigations of clinics around this issue. Recently The Sun sent two undercover, underage teenagers to clinics across the UK to see if they would be happy to treat them with botulinum toxin and fillers and six considered to treat.4 The practitioners were a mix of doctors, a podiatrist, a prescribing pharmacist, a paediatrician and a nurse. In response, a spokesman for the British Association of Aesthetic Plastic Surgeons (BAAPS), described giving an under-18 fillers (or botulinum toxin) as ‘completely unethical’ and added, “At such a young age, a patient does not require any ‘anti-ageing’ treatment. To suggest otherwise is irresponsible, especially given that younger people are likely to be more psychologically vulnerable and may not fully understand the long-term consequences or risks.” Mr Rajiv Grover, consultant plastic surgeon and former president of BAAPS, agreed, and told The Sun that, “An ethical practitioner should reassure them

Aesthetics

(an underage patient) nothing needs to be done and build their confidence in a positive way.” What should be happening My personal belief is that treating patients who are under 18 with lip filler is fundamentally wrong. These ‘children’ – and they still are children in my view – have yet to suffer the vagaries of ageing, and the management of these patients brings a host of potential problems to consider including the psychological/psychosocial aspect and consent. It is a difficult balance to maintain, but the important thing is to stay true to yourself as a medical professional and to follow your ethical compass when it comes to treating the lips of underage patients. 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. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015 at the Aesthetics Awards. REFERENCES 1. BBC Newsbeat, ‘Kylie Jenner admits what many had suspected - she’s had lip fillers,’ (2015) <http:// www.bbc.co.uk/newsbeat/article/32620344/kylie-jenner-admits-what-many-had-suspected---sheshad-lip-fillers> 2. Emma Akbareian, ‘Kylie Jenner lip filler confession leads to 70% increase in enquiries for the procedure’, Independent, (2015) <http://www.independent.co.uk/life-style/fashion/news/kylie-jennerlip-filler-confession-leads-to-70-rise-in-enquiries-for-the-procedure-10232716.html> 3. Juvéderm, About JUVÉDERM VOLUMA, (2013) <https://hcp.juvederm.com/voluma/> 4. Cherry Wilson, ‘Nippers ‘n tuck: Six clinics offered Botox or filler to 15-year-olds’ The Sun, (2016) <http://www.thesun.co.uk/sol/homepage/news/6899336/Shock-Sun-probe-in-to-our-deregulatedbeauty-industry.html>

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Reproduced from Aesthetics | Volume 3/Issue 7 - June 2016


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Aesthetics June 2016