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E C m AN ! co H ER s. C T ard N ST E aw LA TO ics t he st ae

VOLUME 5/ISSUE 7 - JUNE 2018

! r e m m u s for

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RES18-02-0113d Date of preparation: February 2018

Treating Vaginal Laxity CPD Dr Mayoni Gooneratne details the efficacy of treatments for vaginal rejuvenation

Special Feature: Ingredients in Suncare Practitioners discuss their sunscreen preferences

Healing the Skin Post Procedure Dr Sophie Shotter explains the importance of good hygiene for quality healing

Setting Up Your Business Dr Qian Xu looks at the differences between sole traders and limited companies


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Contents • June 2018 06 News

The latest product and industry news

16 ASAPS 2018

Aesthetic business consultant Wendy Lewis reports on the 21st American Society for Aesthetic Plastic Surgery meeting

17 Promoting Education with AlumierMD

A report on the charitable activities of this skincare company

18 News Special: Scotland-based Nurses to Stock POMs

Aesthetics investigates how nurse clinic owners in Scotland can now legally stock prescription-only medicines

21 ACE 2018: The Highlights

A recap on the best bits of the Aesthetics Conference and Exhibition 2018

Special Feature Ingredients in Suncare Page 27

CLINICAL PRACTICE 27 Special Feature: Ingredients in Suncare

Practitioners discuss their sunscreen preferences

32 CPD: Vaginal Rejuvenation

Dr Mayoni Gooneratne presents the treatments available for vaginal laxity

36 Aesthetics Awards 2018

Details of the awards categories and entry process

39 Advertorial: Introducing TempSure Envi

An introduction to the new radiofrequency device from Cynosure

40 Advertorial: Efficacy and Tolerance of Sunekos® 200

Med-fx summarises a clinical study on a new injectable product

43 The Impact of Sun on Skin

Dr Jorge Zafra discusses the different ways the body is affected by sunlight

In Practice Patient Educational Events Page 57

47 Healing the Skin

Dr Sophie Shotter explains the importance of hygiene for skin healing

51 Lower Face Aesthetics

Dr Zohaib Ullah explores the use of injectable treatments in the area

54 Advertorial: Introducing the Motus AY

Lynton presents its new alexandrite laser

A round-up and summary of useful clinical papers

IN PRACTICE 57 Planning Patient Educational Events

Miss Sherina Balaratnam looks at how to plan and deliver educational events

62 Understanding Video Marketing

Adam Hampson details why video is vital to your digital marketing content

64 Sole Traders vs. Limited Companies

Dr Qian Xu examines the differences between setting up your business as a sole trader or a limited company

67 In Profile: Dr Christopher Rowland Payne

Consultant dermatologist Dr Christopher Rowland Payne explains why it’s crucial that aesthetic practitioners are experts in sun protection

68 The Last Word

Dr Mayoni Gooneratne is a graduate of St George’s Hospital and has been a member of the Royal College of Surgeons since 2002. Dr Gooneratne opened The Clinic by Dr Mayoni in 2016. She is an associate member of BCAM. Dr Jorge Zafra has a Master’s degree in Aesthetic and Anti-ageing Medicine from the Universitat de Barcelona, Spain. His private medical practice, Zafra Medical, is based in Clifton Village in Bristol.

55 Abstracts

Clinical Contributors

Dr Selena Langdon discusses her concerns with the regulation and marketing of body contouring treatments in the UK

NEXT MONTH

Dr Sophie Shotter is an aesthetic practitioner with a practice in Kent called Illuminate Skin Clinic. Dr Shotter has a special interest in holistic approaches to antiageing and wellness, with combination treatments at the core of this. Dr Zohaib Ullah is the clinical director at My Skin Clinic and also a trainer at My Skin Clinic Training Academy. He specialises in non-surgical facial aesthetics, skin rejuvenation and antiageing treatments.

Last month to enter the Aesthetics Awards! Don’t miss out!

• Special Feature: Injectables • Defensive strategies for lasers • Overview of dermal fillers

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


AVAILABLE IN 4 PACK SIZES

Bocouture® (botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information: M-BOC-UK-0134. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of botulinum toxin. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Total recommended standard dose is 20 units. 4 units into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 4 units injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 10 units to 20 units is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 2 units, 3 units or 4 units is applied per injection point, respectively. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with

ageing or photo damage). In this case, patients may not respond to botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with botulinum toxin hypersensitivity, amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with botulinum toxin products. Glabellar Frown Lines: Common: headache, muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: eyelid oedema, dry eye, injection site haematoma. Upper Facial Lines: Very common: headache. Common: hypoaesthesia, injection site haematoma, application site pain, application site erythema, discomfort (heavy feeling of frontal area), eyelid ptosis, dry eye, facial asymmetry, nausea. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90, 100 U twin pack £459.80. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany.

Date of Preparation: April 2018. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. 1. Bocouture® 50 units Summary of Product Characteristics (SmPC). January 2018. Available from: https://www.medicines.org.uk/emc/ medicine/23251. 2. Bocouture® 100 units Summary of Product Characteristics (SmPC). January 2018. Available from: https://www.medicines.org.uk/ emc/medicine/32426. 3. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomized, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157. Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0129 Date of Preparation April 2018


Editor’s letter Finally, the sunshine has started to make an appearance. The first May bank holiday, for example, was the hottest on record since the bank holiday was introduced in 1978! As Brits I think it is safe to say that we are quick to get out Amanda Cameron in the sun the moment that it appears, and those Editor of you who know me will testify that I was once one of them. My sundamaged skin is a result of summers of abuse in the 70s with little or no SPF. In those days, factor two was considered high and olive oil and lemon juice gave a much better result in terms of tanning. If only I had the knowledge then that I have now… Statistics from Sun Awareness Week in May stated that, ‘Everyone is affected by damage to the skin from the sun, in fact last year, 35% of people in the UK were burnt at least once, with 28% of those being burnt more than three times during the year.’ In this issue, we take a look at the sun in quite some depth; we can all agree that we have no excuse to be sun damaged with countless high SPF products available

and the improvement in artificial tanning products. We discuss ingredients you should be looking for in your suncare products in our Special Feature on p.27 and Dr Jorge Zafra explores the way in which sunlight can affect our bodies on p.43. Also this month we report on the news that prescribing nurses with clinics in Scotland can now hold stock for prescriptions on p.18; I am sure they will be the envy of nurses in the rest of the UK as it allows them so be safer in practice and adds reassurance for patients. Then on p.64 there’s a review on how to progress in business from being a sole trader to a limited company by Dr Qian Xu. In this month’s issue we have also rounded up the best bits from our Aesthetics Conference and Exhibition (ACE) on p.21 and turn our attention towards our next event, which is set to be bigger and better than ever before; the Aesthetics Awards. Head to p.36 to decide which of the 25 categories is right for you and enter via our website www.aestheticawards.com by June 29 to be in with a chance of being recognised for your hard work in 2018.

Editorial advisory board

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

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

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

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

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

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

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

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

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

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

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Marketing

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Complications BACN @BACNurses Nurses who are new to #aesthetics may not know the full extent of injectable complications. It’s worth reading this fantastic in-depth article on the @aestheticsgroup website so you can increase your knowledge on the subject. #Networking Sabrina Shah-Desai @perfecteyesltd Making new friends with some lovely Aussie colleagues at my 3 Periorbital & full face rejuvenation Galderma masterclasses (200 new friends) #restylane #5facets #anatomy #TIPS #Perfecteyesltd #Aestheticsjournal S-Thetics @MissBalaratnam Enjoying a relaxing Sunday and keeping up to date with trends in #aestheticmedicine with @aestheticsgroup #AestheticsJournal #Aesthetics #reading #uptodate Thank you to the contributors for sharing their #knowledge and expertise. #Sunscreen Dr Doris Day @drdorisday Discussing the ban on certain sunscreen ingredients being considered by Hawaii and other states… #dermatology #ASDSskinMD #ASDSskinexperts #sunscreen #skincancerawareness #Dermatology Olivier Branford @OlivierBranford Great to catch up with @DrAnjaliMahto author of the #skincarebible and brilliant #dermatology colleague #London #Chelsea #Environment Dr Uliana Gout @UlianaGout Thanks @aestheticsgroup for quoting my views of face and body wet-wipe use… Worthwhile topic to debate in terms of skin health and environment protection. @bcamacademy @britishcollegeofaestheticmed #ACE2018 #wetwipes #enviroment #UK

Galderma launches summer campaign International pharmaceutical company Galderma has launched its new ‘Summer You – What’s Your Secret?’ dermal filler social media campaign. The campaign aims to support Galderma’s customers in promoting their business to existing and potential new patients throughout the summer by providing a series of visual communication materials to help aesthetic clinics engage multiple audiences. The suite of branded and unbranded content includes key messaging, images, Twitter cards and video GIFs for customers to include in their existing marketing campaigns. “In my patient population, summer is the most popular season to seek aesthetic treatments. Social media is one of the key platforms we use to communicate with our existing and potential new patients and is essential in helping us to secure new business,” said Jackie Partridge, nurse independent prescriber and founding board member of the British Association of Cosmetic Nurses. Alexandra Tretiakova, Galderma general manager, UK and Ireland, said, “We are delighted to provide our customers with engaging communications to help them promote the excellent work they do during the busy summer season.” Industry

Schuco Aesthetics appoints new head of sales Karen Esson is the new head of sales for UK distributor Schuco Aesthetics. As part of her new role, Esson will primarily focus on stakeholder and relationship building, helping to look after those who support the business as well as seeking new opportunities for investment. Commercial director, Chris Littlejohn said, “We are delighted to welcome Karen into the Schuco Aesthetics team. Her wealth of expertise and relationships in the aesthetic industry are renowned and we are looking forward to working alongside her to deliver important strategic developments that will help realise our commercial ambitions within aesthetics.” Suncare

Hawaii to ban sunscreen products to save coral reefs Sunscreens containing oxybenzone and octinoxate may soon be prohibited in Hawaii. A study held by international scientists suggested that the ingredients are ‘highly toxic’ to corals and marine life and could not only cause deformities in baby coral but also be contributing to coral bleaching. If the bill is approved by David Ige, the state’s democratic governor, the ban could come into place as soon as 2021. State senator Mike Gabbard, who proposed the ban, told the Honolulu Star Adviser, “Hawaii is definitely on the cutting edge by banning these dangerous chemicals in sunscreens, our island paradise, surrounded by coral reefs, is the perfect place to set the gold standard for the world to follow.”

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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Events diary 14 – 16 June 2018 th

th

British Medical Laser Association Laser Skin & Body Conference 2018, Rotterdam www.lasereurope2018.com

Aesthetics

Skincare

AestheticSource introduces skinbetter science to UK

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

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

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

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

Compression

macom Medical introduces new technology in garment range Compression garment manufacturer macom Medical has introduced a new technology within the material used in its compression garment range. The new fabric will have a velvety feel and a cooling sensation when in contact with the skin. According to macom, the compression level remains the same, however it will have a smoother finish which will follow the wearers’ movements more closely, allowing for more flexibility. It aims to enhance post-treatment outcomes by compressing the area, reducing the swelling and the associated risks, boosting lymphatic flow and speeding up the recovery time. Nadia Collin, head of sales, said, “The surgical and aesthetic market is continually evolving, it is our duty to keep abreast of changes and make sure that our products continue to enhance the outcome of new treatments and protocols.”

Aesthetic distributor AestheticSource has added the skinbetter science cosmeceutical range to its portfolio. The range is new to the UK and contains patented technologies; InterFuse, a transdermal delivery system that transports topical skincare faster and deeper to where they are most effective; Alpharet, an alpha hydroxyl acid and retinoid combination; and WEL, which includes 19 antioxidant ingredients. According to skinbetter science, the formulations are data driven and aim to create a new paradigm in clinical skincare. Executive chairman of the company, Jonah Shacknai explained, “With the launch of skinbetter science, we are bringing world-class antiageing technology into the offices of the professionals who can make the largest impact on skin health nationwide – aesthetic physicians. We are committed to developing and bringing to market cutting-edge skincare products with unsurpassed effectiveness, safety and elegance and a luxury consumer experience.” Lorna Bowes, founder of AestheticSource added, “We are delighted to add skinbetter science to the AestheticSource portfolio of technologically advanced, clinically-proven products – especially in the contemporary aesthetic industry. AestheticSource strives to identify and bring to market clinically proven innovation and skincare technology, and skinbetter science fills a new niche gap in the market.” Expansion

3D-lipo opens new head office and training centre Due to expansion of the company, aesthetic device manufacturer 3D-lipo has opened a brand new 6,000 square foot head office and training centre. It is situated on the outskirts of Rugby in Warwickshire and will cater training for up to 50 practitioners per week, as well as hosting a number of free business opportunity seminars in the company’s new showroom as part of their newly launched business initiative. The location will also house the company’s head office and will aim to improve customer service, training and warehouse facilities. Managing director of 3D-lipo, Roy Cowley said, “I am delighted to announce the move of our head office, training centre and warehousing facilities to our brand new, company-owned premises which will secure the future of the business. All aspects of the business have now been brought together ensuring better customer service going forward and a much larger premises to cater for an increase in numbers attending training.” He continued, “The move now positions 3D-lipo Ltd to proceed with our ISO 13485 quality assurance certificate ahead of our medical certification of all 3D devices.” In order to help raise the brand’s profile and patient awareness for the demand of its three dimensional treatments, Cowley has also recently appeared on ITV’s Lorraine programme. He concluded, “As a business purely offering 3D-lipo, publicity and support like being on the show is such amazing help, making a big difference to my company.”

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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

ACE 2018 The BACN had a fantastic time exhibiting at ACE this year in London; meeting new members and catching up with familiar faces. These events are always a great opportunity to speak to members about concerns, queries, or anything they want to know about the BACN. It was also great to meet nurses new to aesthetics to offer advice and guidance to them. We are already looking forward to next year!

RENEWALS The BACN renewals period has now come to a close, and we are pleased that retention rates have been matched year on year, securing our association going forward for the rest of the membership year, ensuring we can offer more services, and deliver a strong voice in the industry. Thank you to every member who renewed, and for those who still wish to rejoin, get in touch with the BACN HQ team via admin@bacn.org.uk.

CALL FOR POSTERS This year the annual BACN conference is sending out a call for posters. This is an ideal opportunity for members to showcase their knowledge and potential solutions to support, inform and educate their fellow peers. It is time for BACN members to display and share their wealth of experience and professional development within the speciality of aesthetics. Abstract contents can either be research-based using established scientific methods, or demonstrate experience and information from individuals or collaborations i.e. from clinics or an institution. All posters submitted will be peer reviewed by the programme committee and those who have submitted will be informed of the outcome by email. Posters will be on display during the conference lunch break and at a dedicated poster session which will enable all the delegates to have a chance to view those on display. All we ask is that you or one of your collaborating authors stand by your poster at the conference so you are available for delegates to discuss your work. There will be acknowledgement for the most innovative and/ or educational posters. For more information regarding this, along with suggested topics get in touch with BACN Operations Manager Sarah Greenan at sgreenan@bacn.org.uk. This column is written and supported by the BACN

Entry for the Aesthetics Awards 2018 closes this month With the most prestigious awards event in the specialty set to take place on December 1, practitioners, clinics, trainers, suppliers, distributors and other companies in aesthetics are encouraged to enter within the next few weeks as entry officially closes on June 29. With 26 categories covering all aspects of the aesthetics specialty, there is a suitable category for everyone. Not only is it completely free to enter, but the recognition for just being a finalist give companies and practitioners great PR and marketing exposure. Dr Miguel Montero, medical director at Discover Laser and last year’s winner of the Med-fx Award for Best Clinic North England explained, “It was great to be nominated, and just to be there felt in itself an achievement. We are grateful to all the patients, business partners and colleagues who have been supporting us through the years. This award motivates us to work even harder to keep offering the highest standards of patient care in the years to come.” As well as this, a new sponsor has also been confirmed for the following category; The Sinclair Pharma Award for Best Independent Training Provider. The Aesthetics Awards will take place at the Park Plaza Westminster Bridge Hotel in central London. To enter and to book tickets for the event, visit www.aestheticsawards.com. Finalists will be announced September 3. Threads

Sinclair Pharma launches Silhouette XLift after pilot study Pharmaceutical company Sinclair Pharma has launched a new protocol named Silhouette XLift after a successful pilot study, which trialled a new way of treating patients using Silhouette Soft threads. The Silhouette Soft treatment aims to lift and regenerate skin through the use of bidirectional cones on sutures inserted into the subcutaneous layer. In the pilot study, Dr Ian Strawford, Dr Victoria Manning, Dr Ayad Harb and Dr Kuldeep Minocha each treated four patients using the new Silhouette Soft XLift protocol. Following the study, the company now recommends that practitioners use 10 sutures per patient to improve the aesthetic outcomes and stimulate more collagenesis. Dr Strawford said, “A significant advantage of treating patients with this number of sutures are fewer complications – results have shown an immediate lift, without any puckering or dimpling. Additionally, recovery time has also been much less.” Dr Manning added, “Feedback from patients so far has been extremely positive with improved initial results and eight out of ten patients stating they would have the procedure again. These pioneering techniques will enhance results and increase satisfaction of patients.”

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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Appointment

Enhance Insurance announces new employee Jennifer Mitchell has joined the Enhance Insurance team as claims handler. She has 16 years’ experience managing claims across various insurance classes including liability, personal injury and negligence. Martin Swann, divisional director at Enhance said, “Jennifer will work with the Enhance team to support our clients with any claims and circumstances that may arise. She will be liaising with insurers and their claims’ teams on behalf of Enhance clients to ensure that any notifications and subsequent claims are dealt with swiftly and professionally to achieve the best outcome for our valued clients.” Mitchell added, “I am looking forward to building relationships with my new colleagues and getting to know the clients and responding to their needs. With my years of experience, I am quite used to all sorts of circumstances and situations being reported – the more unusual the better!” Skincare

mesoestetic launches new home treatment ampoules Pharmaceutical and skincare manufacturer mesoestetic has introduced new products to its home ampoules line and reformulated some of its treatments. mesoestetic launched its first ampoules more than 30 years ago and according to the company, the new optimised formulas provide better results for at-home use. The company has released five formulas, each contained within individual, sterile, sealed glass ampoules. The five ampoules include: proteoglycans, for both mature and dry skins; antiaging flash, designed to treat all skin types with antiageing action; glycolic + E + F, devised to accelerate epidermal renewal; topical melatonin, which aims to stimulate the production of endogenous antioxidant defences in the skin; and pollution defence, designed to provide daytime protection to all skin types. According to mesoestetic, the ampoules have been dermatologically tested and supported by in vitro and in vivo studies on cell cultures. Development

Lynton opens manufacturing and training facilities UK laser and IPL manufacturer, Lynton, has invested close to half a million pounds in a brand new manufacturing and training facility based in Cheshire. The decision was made so the business can meet growing demand for aesthetic equipment and so it can invest further into expansion. “At Lynton, we pride ourselves on the quality, reliability and clinical capabilities of our UK-manufactured aesthetic equipment,” said Lynton managing director, Jonathon Exley. He added, “Due to record-high demand year-on-year for our products and training courses, it became apparent that we would need to invest further in our manufacturing and training facilities, ensuring sustainable growth for Lynton.”

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Sharon Allen, business development executive at Enhance Insurance Tell us about your experience? I joined Enhance just over a year ago and it’s been great! I’ve been really well supported by the team and, as a brand, Enhance is doing excellently. What I love about my role is that you never know who you’re going to pick up the phone to. We receive a whole range of enquiries and I ensure that I give the same level of service to everyone I speak to; be it someone just starting out in aesthetics or a well-established multi-clinic owner – my job is to make sure practitioners understand insurance and help them as much as I can. A lot of my referrals have been through word-of-mouth, which you just can’t beat. It’s allowed me to build really good relationships with clients, as well as training schools and other suppliers in the specialty. What are the key pieces of advice you give practitioners seeking insurance? I ask all my clients which treatments they’re looking to provide in the future. It’s important that they consider all the costs incurred of adopting new procedures, as some of the more invasive treatments may involve additional charges and excesses. Before practitioners commit themselves to training, I advise them to carefully consider all the associated costs. We’ve also had a lot of calls from people going into panic-mode over GDPR lately. I recommend cyber and data cover, while advising practitioners of the importance of consent processes and ensuring their privacy statements are up to date. We work with law firm Hill Dickinson to help ensure that consent forms include everything they need to protect both practitioners and patients. What do you have planned for the rest of 2018? The Enhance team and I will be attending the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) conference on September 21 and the British College of Aesthetic Medicine (BCAM) conference on September 22 in London. We’re also sponsoring The Enhance Insurance Award for Best Clinic Group UK & Ireland (3 clinics or more) at the Aesthetics Awards on December 1, so are looking forward to catching up with clients and meeting new ones at the ceremony! This column is written and supported by

Enhance Insurance

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018

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Vital Statistics In a study of over 2,000 Brits, 16% of women and 10% of men have actively posted a picture online in which a friend looked terrible, because they looked good in it themselves

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Awards

Aesthetics Awards wins silver at Awards Awards 2018

(Huawei, 2018)

In 2017, Facebook accounted for 20% of the global online advertising market (Statista, 2018)

71% of almost 2,000 internet users aged 18 and over agree that people should be psychologically assessed before they are allowed to have cosmetic surgery (Mintel, 2018)

Aesthetics Media Ltd’s event, the Aesthetics Awards, has been presented with a silver accolade for the Best Awards Event by a Publisher at the Awards Awards. The Awards Awards aims to acknowledge and celebrate the behind-the-scenes commitment of companies who are part of coordinating industry award ceremonies. Organised by Global Conference Network (GCN) Events, the second annual Awards Awards took place on April 17 at The Wardorf Hilton hotel in London. With winners in 14 categories, more than 270 awards professionals attended the ceremony that was hosted by writer and comedian, Russell Kane. Guests were treated to entertainment from magician Nick Reade and comedian Rachel Parris. Inside Housing was named the Best Awards Event by a Publisher with Aesthetics Media’s Aesthetics Awards winning Silver in the same category. Suzy Allinson, brand director for Aesthetics Media, said, “We are absolutely thrilled to have won a silver award for the Aesthetics Awards where we celebrate and reward those who uphold the highest standards across the specialty. This accolade is so important to us as it demonstrates that the Aesthetics Awards is among the top award ceremonies in the UK.” Entries are now open for the Aesthetics Awards 2018 and will close on June 29. Hair removal

In a poll of 1,000 women, 21% blamed a lack of sleep as having a detrimental impact on their looks and ageing

(Health & Aesthetics clinic, 2017)

In a survey of almost 2,000 people, 69% agreed that visibly damaged teeth can impact people’s emotional wellbeing (Mintel, 2018)

There are currently an estimated 16,000 people in the UK with skin problems they regard as caused or made worse by work (Health & Safety Executive, 2017)

Lynton to launch Motus AY Laser manufacturer Lynton has paired with Italian counterpart, DEKA to launch the Motus AY hair removal laser. The company claims that the laser is pain free, using an Alexandrite laser that has been FDA-cleared for use on all skin types. According to Lynton, the Alexandrite laser has traditionally only been safe to use on Fitzpatrick skin types I-III due to its melanin absorption capabilities, making it unsafe to use on any skin of colour. However, the Motus AY aims to overcome these restrictions by combining Moveo technology with the Alexandralite laser and the Nd:YAG laser. Lynton claims that Moveo technology stops the laser from losing energy by using light circular movements at a reduced power, avoiding wasted energy, making the process much less painful. Jonathon Exley, managing director at Lynton said, “I am delighted to announce this new partnership with DEKA lasers, it opens the necessary channels for UK clinics to introduce revolutionary new technology like the Motus AY, but with the added reassurance of purchasing with Lynton.”

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Training

Sinclair Pharma introduces online training portal Pharmaceutical company Sinclair Pharma has launched its new online training portal, Sinclair College. According to Sinclair Pharma, the new resource intends to aid healthcare professionals by providing them with free and unlimited access to learning resources. These include medical-themed courses, webinars, a comprehensive library of published papers on the application of Sinclair Pharma’s aesthetic treatments, and biographies of experts in minimally-invasive treatments, science, biology, digital marketing and communication skills. Sinclair College also aims to make learning opportunities, such as presentations from its World Expert Meeting (WEM), an experience that is restricted to its attendees, accessible via the portal. Dr Ian Hallam, dental surgeon and trainer, said, “WEM focused on clinical advancements in aesthetic treatments and product development. Providing us with webinars and access to information through Sinclair College, I think is a wonderful addition to the training it provides to physicians.” Hyaluronic acid

Profhilo wins award for best injectable product in Europe Injectable product Profhilo by IBSA Italia has won the award for the best injectable product in Europe in the Aesthetic Industry Awards, in which results were published in the European Aesthetic Guide. According to the manufacturer, Profhilo is the first BDDEfree stabilised injectable hyaluronic acid-based product that aims to improve tissue quality and treat skin laxity. Iveta Vinklerova, sales and marketing manager at HA-Derma, the UK distributor of IBSA products, said, “It’s an absolute honour to be recognised, especially in such a competitive category. IBSA has set a new paradigm in treating tissue quality to help counteract ageing. This has confirmed Profhilo’s position amongst the dermal fillers and toxins, as a third staple injectable treatment. It is becoming a ‘must have’ treatment on offer in every clinic in the UK and Ireland.” HA-Derma is the exclusive distributor and training provider for the UK and Ireland. The awards are supported by the European Aesthetic Guide. Appointment

Harper Grace expands team Distributor Harper Grace International has added two new members to the team; Susan McConnell and Victoria Hempstock. McConnell will be responsible for developing brand awareness, new partnerships and generating sales across the north of England, whereas Hempstock will be undertaking training and business development for the clinic and spa division. Having both worked within aesthetics for companies including AestheticSource, Transform Medical Group and RA Academy prior to this move, Alana Chalmers director and founder of Harper Grace is looking forward to what the pair can bring to the team. “We are delighted to welcome Susan McConnell and Victoria Hempstock to our team. Their combined skills and experience will heavily support the growth and new initiatives planned for iS Clinical over the forthcoming 18 months.”

News in Brief SkinMed hires marketing assistant Dermatological research and distribution company SkinMed has expanded and hired a new marketing assistant. Charlie Hope, who has a degree in English literature and creative writing, will provide support to the growing marketing team and will work closely with SkinMed’s clinical customers. Hope said, “I’m really excited to be working with SkinMed. I’ve seen firsthand the effect that living with rosacea can have on a person and knowing that I could be helping in any way to make a difference to sufferers is an amazing opportunity. It’s also a great way to put my creative writing skills to good use.” Oxygenetix launches new foundation bottle Foundation and treatment recovery brand Oxygenetix has introduced a new bottle for both its original and acne control foundations. According to Oxygenetix, the bottle has a transparent design that is more practical for judging how much product is left. The company has also launched new sampler cards, allowing for patients to test one of the 12 shades before purchasing the foundation. Oxygenetix is distributed in the UK by Medical Aesthetic Group. BCAM supports the ban of wet wipes It has been revealed that wet wipes could be non-existent over the next few decades as part of the UK government’s plan to eliminate plastic waste. Following this, the British College of Aesthetic Medicine (BCAM) spokesperson Dr Uliana Gout explained why why she believes that wet wipes could be responsible for skin conditions as well as having a negative effect on the environment. She said, “I believe there is definitely a link between certain skin conditions being aggravated when using certain wet wipes, particularly in patients with rosacea and eczema. I would advise we review our daily practices and take note of the concerns arising from the use of wet wipes which have become the norm for much of the global population.” RevitaLash launches Micellar Water Lash Wash RevitaLash Cosmetics has added the Micellar Water Lash Wash to its collection. The product aims to remove dirt, oil and makeup whilst conditioning lashes, brows and eyelids. According to the company, it is an oil-free formula containing panthenol, aloe and chamomile, making it safe to use with lash extensions. The Micellar Water Lash Wash is available through Skinbrands.

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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Distribution

Rebrand

Medik8 updates brand to be more eco-friendly

Global skincare company Medik8 has updated its brand with the launch of a refreshed identity and regime. The update to the packaging has seen more than 300,000 plastic parts being replaced with recycled paper, making every paper-based packaging recyclable or certified by international forest management organisation, the Forest Stewardship Council (FSC). According to the company, the update has helped to emphasise the brand’s core values of simplicity and sustainability. As well as this, Medik8 has launched a new antiageing regime named CSA, standing for vitamin C plus Sunscreen by day, vitamin A by night, in the hope to make the concept simple to navigate for users. Medik8 founder, Elliot Isaacs said, “This is the ultimate prescription for younger, healthy-looking skin. There’s no need to complicate things because this straightforward strategy is clinically proven to deliver results you can see, as well as feel. That’s why we are dedicated to refining this simple philosophy – developing ever-increasingly advanced CSA formulas.” Hair restoration

Theradome receives FDA clearance for LH80 PRO Medical device company, Theradome Inc, has received clearance from the Food and Drug Administration (FDA) for its LH80 PRO hair restoration device for men. The Theradome for female use had already been approved by the FDA in 2013. It aims to stimulate weak hair follicles and provide them with targeted laser energy. According to Theradome, this increases microcirculation bringing nutrients and oxygen to stimulate hair growth and to stop or slow hair loss. Founder and CEO of Theradome, Tamim Hamid, said, “After endless attempts to try to regain my own hair, I decided to combine my experience as a NASA scientist along with my doctoral work in biomedical engineering, to create a solution that actually worked.” He added, “We are pleased that we can help the millions of men around the globe who suffer from hair loss. This new level of clearance grants a broader audience access to an effective, less-expensive therapy that can be used in the comfort of their home.”

Harpar Grace announces Med-fx as distribution partner Aesthetic distributor Harpar Grace International has partnered with Med-fx in order to increase access to its aesthetic brands, iS Clinical and the Déesse Pro LED Light Therapy Mask. Commenting on the new partnership, founder and director of Harpar Grace, Alana Chalmers said, “We are delighted to partner with Med-fx as we share a common vision and aspiration for the UK market. The combination of our resources and joint focus on the brands will enable us to meet the growing demand of both iS Clinical and Déesse Pro LED Light Therapy Mask in the UK without compromising quality of service or training standards.” Skincare

DMK launches Biogen C Crème Skincare manufacturer Danné MontagueKing (DMK) has launched the Biogen C Crème. According to the company, the product stimulates, tones and tightens dull, tired and stressed skin whilst smoothing fine lines and wrinkles. DMK has stated that the new product is also effective both pre and post surgery due to the antibacterial and anti-inflammatory wound healing eucalyptus leaf oil, krameria triandra root and safflower oil. Managing director, Peter Williams said, “We are delighted to announce the launch of new DMK Biogen Crème. This firming moisture crème has been reformulated to boost tired and stressed skin. It is a particular favourite of our founder and innovator Danné Montague-King.” E-commerce

ClinicSoftware.com adds online shop to its platform Clinic management software company ClinicSoftware.com now has functions to sell products online, as well as deliver and track orders while also taking and managing online appointments. According to the company, these online appointments, products sales, and payments can be managed through. ClinicSoftware.com to give clinics greater access to the insights about their patients’ journey. The company’s CEO Alexandru Stefan said, “We’ve always been about meaningful selling online and taking bookings 24/7 at ClinicSoftware.com and this can accelerate sales in incredible ways.”

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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On the Scene

Out and about in the specialty

Cosmecoin VIP launch, London

On Thursday May 10 an exclusive selection of aesthetic practitioners, clinic owners and technology officers were invited to the Eight Members Club in London to celebrate the VIP launch of the new Cosmecoin loyalty scheme, which works in conjunction with existing client management system iConsult. The evening featured presentations from a panel consisting of founder and CEO of iConsult and Cosmecoin, Richard Crawford-Small, chief technology officer, Chris Barber, digital marketing advisor, Rick O’Neill, medical practitioner, Dr Ravi Jain and iConsult user, nurse prescriber Nikki Zanna. Crawford-Small said of the event, “I am delighted with how this evening has gone. We are aiming to revolutionise the aesthetic industry, by using a ‘Token of Trust’ – aka a ‘Cosmecoin’ – and innovative technologies, to build a safe, trusting and profitable community, based on the existing iConsult system.”

Intimate Wellness Workshop, London On April 30, medical professionals were invited to Church House conference centre in Westminster, London to learn about treatments for women’s intimate wellness with device company, Syneron Candela. The session, held by gynaecologist Dr Andreas Lenhard and clinical training manager Patricia Homar, saw advice being given on treatments available for women’s intimate wellness, with the Syneron Candela Core Intima device being a main focus. Scott Julian, sales manager for Syneron Candela UK and Ireland said, “With the increasing interest in this area of treatment, both from medical professionals and consumers, we thought it was the perfect opportunity to bring an independent expert over from Europe, to share his knowledge and the experiences he has had in his own practice.”

Secrets to Success: Obagi Medical, London

Scottish Medical Cosmetic Awards, Glasgow On Friday April 20 the Scottish aesthetics industry joined together to attend a business conference followed by an evening celebrating the Scottish Medical Cosmetic Awards, held at the Crowne Plaza Hotel in Glasgow. For the first time ever, the conference, which focused on non-clinical business issues, was held on the same day as the awards. The awards ceremony was hosted by television presenter, Kaye Adams and former Miss Great Britain, Deone Robertson. The night saw Dr Nestor Demosthenous of Dr Nestor’s Medical & Cosmetic Centre win Cosmetic Doctor of the Year and the Most Innovative Clinic award whilst Jackie Partridge, aesthetic nurse prescriber and owner of dermalclinic, won Best Clinic in Scotland and was highly commended Best Nurse in Scotland. BeamWave Technologies won the award for Best Equipment Supplier and Linda Strachan won Nurse of the Year, just to mention a few. Director of Medical Cosmetic Events Ltd, Frances Turner Traill said, “The awards and the business conference that we ran during the day was a huge success. I am really looking forward to next year!”

On April 30, delegates were invited to the Bloomsbury Hotel in London to celebrate 30 years of Obagi Medical and discover new brand developments. The event was also held in Manchester on May 2 and Dublin on May 3. It was hosted by Obagi Medical’s vice president of development and research, Dr Laurence Dryer and international director Aimee DeMarais, who discussed the use of combination treatments, incorporating the use of Obagi products with non-invasive procedures. Dr Dryer and DeMarais also introduced two new products in the UK range; Obagi Professional-C Peptide Complex and Obagi Professional-C Suncare SPF 30. Karen Hill, managing director at Healthxchange, the official distributor of Obagi, concluded the trio of events stating, “Over 250 delegates heard about Obagi’s re-launch plans following the sale to medical sciences leader at China Regenerative Medicine International Ltd, from Aimee DeMarais, which included access to new clinical data regarding the classic Obagi Nu-Derm system and an exciting suite of new product innovations. The feedback was extremely positive with something new for everyone.”

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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ASAPS 2018, New York

surgeon Mr Stephen Ronan, and Secret RF from Cutera. In the new device category, Cytrellis Fractional Coring Skin Tightening Technology designed to remove sagging skin without surgery or scarring, was introduced and is currently undergoing clinical trials, according to Mr Pozner. He said the technology utilises a fractional laser with a 22 gauge needle, making micro-excisions aiming to promote skin tightening Aesthetic business consultant Wendy Lewis and improvement in wrinkles with minimal downtime. A session by plastic surgeon Mr Brian Kinney which reports on the 21st American Society for featured the launch of the new EmSculpt system from BTL Aesthetics gained particular attention; the device Aesthetic Plastic Surgery meeting aims to build muscle and reduce fat using the companyâ&#x20AC;&#x2122;s The American Society for Aesthetic Plastic proprietary HIFEM (High-Intensity Focused Electromagnetic) Surgery (ASAPS) is the worldâ&#x20AC;&#x2122;s leading technology that induces supramaximal muscle contractions. In organisation devoted entirely to aesthetic the topical skincare category, growth factors, peptides and alpha plastic surgery and cosmetic medicine of and beta defensins attracted major interest and debate. Data was the face and body with more than 2,600 presented by leading plastic surgeons on two patent-pending plastic surgeon members. New York City technologies used in age-reversing topical formulations, Mr Alan was host to this international congress of Widgerow discussed TriHex technology from Alastin Skincare and aesthetic plastic surgeons who came to Mr Barry DiBernardo spoke on Age-Repair Defensins from Defenage learn, listen and share their techniques with colleagues from all over Skincare, both available only in the US to date. the world. Aesthetic surgery has evolved from purely a surgical specialty to include a vast array of non-surgical procedures, including lasers, energy-based devices, injectable fillers and neuromodulators. At the congress there was a lot of excitement about the future introduction of several new toxins. RT002 from Revance Therapeutics, daxibotulinumtoxinA, has been shown in clinical trials to have a longer duration of efficacy according to oculoplastic surgeon Mr Brian Biesman; while plastic surgeon Mr Alan Matarasso explained that EB-001 botulinum neurotoxin serotype E (BoNT/E) from Bonti is said to has a fast onset of action (within 24 hours) and a short duration of effect (about three to four weeks) making it potentially suitable for pain management. Emerging uses for PRP was a recurring theme of the conference, in addition to fat grafting; in particular gluteal fat graft that Among the new developments in business management was the has become a controversial topic among plastic surgeons due to the introduction of a new subscription service for practices to improve rise in complications and patient deaths that have been reported. patient retention. Called HintMD, the cloud-based model offers a unique patient engagement and commerce platform for aesthetic Other popular topics were the Motiva breast implants and the practitioners that features personalised treatment plan subscription expanding category of vaginal rejuvenation systems. As discussed solutions to drive repeat treatments, patient compliance and by plastic surgeon Mr Jason Pozner, a new entry in this category is satisfaction. Social media and digital marketing took centre stage, the first home-use vaginal device, the vFit system (called vSculpt in with a number of panels and courses devoted to new strategies for the EU) from Joylux, Inc. that uses a patented combination of low promoting aesthetic procedures online. Among the presenters were level light, gentle heat, and sonic technology to aim to help women plastic surgeons Mr Anthony Youn, Miss Heather Furnas, Miss Jennifer improve sensation, pleasure, and intimacy. New radiofrequencyWalden, Mr Matthew Schulman and Mr Christopher Khorsandi. Key based microneedling launches include the Vivace Fractional learnings included the consensus of opinion that Instagram has Microneedle RF from Aesthetics Biomedical, presented by plastic emerged as the leading platform for aesthetic patients and has underscored the advancement of live streaming video content as a must-have marketing tactic for 2018. Among the key strategies for social media success presented included best practice for using Facebook Live, Instagram Live and Instagram Stories, and Snapchat to convert fans and followers to new patients, as well as the advent of Facebook messenger and text messaging for patient communications. There was also an emphasis on the recent Facebook privacy issue that has raised concerns among aesthetic surgeons over the potential breaches of patient privacy data. Finally, Mr Grant Stevens, board-certified plastic surgeon from California, took over the helm as the new ASAPS President. ASAPS will take place in New Orleans next year on 16-21 May.

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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a member of the local community, who made them aware of the very basic learning conditions of students at the nearby Nhlengelo Primary School, situated in White City, a very Aesthetics discovers the premises behind Alumier MD’s poor area in Mpumalanga, South Africa. The school was set up by the funding for education and conservation in South Africa community and couldn’t accomodate Skincare company AlumierMD recently invited Aesthetics to spend the high number of students attending every day. It comprised just a week at the Timbavati Game reserve in South Africa to learn about two single classrooms, which lacked fundamental facilities such the company’s efforts towards helping to facilitate education and as toilets, accessible water or a kitchen. The classroom couldn’t fit conservation in the region. The company’s founders are passionate the high number of students attending every day, which resulted in about making a difference as they have close connections with the many studying under a tree outdoors. “We were asked if we could locals in the area and they believe their efforts can go a long way. help build another classroom for the children, but when we went there we realised that we couldn’t let the kids who were attending the school learn in those conditions,” said Jackaman, who managed the Nhlengelo Primary School project. He explained, “In White City and the surrounding areas, education is very important for these little children, especially good education. There is a drive to create awareness of animal, vegetation and water conservation in the whole area so they can grow up and conserve the whole ecosystem and become guardians of the community in the future.” Together, Levey and Jackaman provided funding and resources to establish essential facilities, including eight classrooms, safety fencing and security, toilets, a kitchen, a small health clinic, and most importantly, a running water “One of the reasons AlumierMD was built was to fund the work that supply. Their colleague Leslie Rigali from North America was integral myself, my friends and colleagues have been doing to promote to the support and administration of this funding. education and environmental conservation in South Africa,” said one Principal Lyson Ndlui explained, “When we started I would work from of the company’s founders, Paul Levey, who grew up in the country. my car and the children would drink water from a 20 litre container With a background in dermatology, he created AlumierMD as he that I would bring. When we received funding, we saw a lot of believed there was a gap in the market for skincare that used safe and changes and even now they are still assisting us. The funding brought clean science which was extremely difficult to counterfeit. He hopes light to this community, where poverty is something that we see every that the profits from the company can eventually fund the learning of 300 children, which would in turn help promote conservation. “It all started in believing in the importance of education and believing that it’s the only way that we are going to save the planet,” Levey stated. In 2011, before AlumierMD was formed, Levey and his good friend and colleague Dave Jackaman were approached by

Promoting Education and Conservation with AlumierMD

“One of the reasons AlumierMD was built was to fund the work that myself, my friends and colleagues have been doing to promote education and environmental conservation in South Africa” AlumierMD co-founder, Paul Levey

day.” He added that although the school has come a long way, it still requires requiring more funding for reliable water, new classrooms, more toilets and a library. AlumierMD is hoping to help further by setting up what the company hopes to call the Alumier Foundation, a non-for-profit charity which aims to assist this school, as well as other organisations, to continue to promote education and conservation in South Africa. Other educational and conservation organisations AlumierMD is hoping to support through this initiative include; The Greater Kruger Environmental Protection Foundation (GKEPF), The Timbavati Foundation, Elephants Alive, and Wild Shots Outreach. The charity will launch later this year.

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Scotland-based Nurses to Stock POMs Aesthetics investigates how nurse clinic owners in Scotland are now legally allowed to stock prescription-only medicines in their practice Healthcare Improvement Scotland (HIS), the regulator for independent healthcare services in Scotland, has confirmed in a recent Stakeholder meeting that independent clinic owners who are registered with HIS can now legally stock prescription-only medicines (POMs) on premises. This, as Scottish independent nurse prescriber and clinic owner Frances Turner Traill has pointed out, is a welcoming change for many aesthetic nurse prescribers that own private clinics, who otherwise have not had immediate access to POMs such as hyaluronidase, botulinum toxin and lidocaine. So, how exactly has this change come about and what does it mean for nurses in Scotland?

Why do nurses want to stock POMs? Historically, nurse prescribers, despite having much of the same prescribing capabilities as a doctor,1 have not been permitted by the Medicines and Healthcare products Regulatory Agency (MHRA) to hold POMs on premises without the presence of an on-site doctor.2 This is currently still the case in the rest of the UK.

Aesthetics aestheticsjournal.com

According to Turner Traill, this had not been an issue until the growth of nurses working within the aesthetics specialty. “20 years ago, nurses didn’t prescribe and they certainly didn’t own clinics.1,3 Now, the landscape has changed and in Scotland especially we have prescribing nurses who own large clinics, employ many people and carry out thousands of treatments every year. However, we still can’t hold stock,” she states, adding, “It was out of sync that nurses who are big players in the aesthetic arena couldn’t hold emergency stock legally.” Having emergency medications like hyaluronidase on premises, Turner Traill says, is essential in every aesthetic clinic that has practitioners performing dermal filler treatments. She explains, “It’s all about safety. The window of opportunity to have a successful outcome of a serious complication like vascular occlusion is quite short; therefore, you must be able to immediately respond to it with hyaluronidase to get the best clinical outcome. It’s important that all practitioners can treat potential aesthetic complications and access the correct medication in an emergency situation.”

How did change come about?

According to HIS, legislation that came into force in Scotland in April 20164,5 which requires all independent clinics to be registered with HIS in Scotland was the key catalyst for this change. Turner Traill, who represents the BACN for HIS, and is also on the HIS advisory board, said the BACN has been in discussions with HIS and the MHRA for several years to lobby for change. “It was a discussion that we kept having with HIS and I thought that we had to sort this out because it was going to look at odds on the regulatory side of things in Scotland if HIS-registered clinics couldn’t hold stock legally, particularly in an emergency. Finally, the penny dropped and HIS negotiated on behalf of the BACN and all nurses who own a HIS regulated clinic. They realised that the stock issue had to be rectified with the MHRA to protect patient safety above all else.” After communications with the MHRA, a spokesperson for HIS confirmed with Aesthetics, “The MHRA has advised us that a nurse or a nurse independent prescriber cannot order and stock prescription-only medicines or pharmacy medicines in their own right. However, any ‘persons carrying on the business of an independent clinic’ are able to order and stock prescription-only and pharmacy medicines in connection with the running of the clinic.”6 Turner Traill adds, “Essentially, from a nursing point of view, nurses cannot hold stock legally unless they also own a HIS-registered clinic. Basically, it’s a slight change in the interpretation, not the law, which has huge benefits for us as nurses. But, we do have to have checks, balances and management protocols in place that will satisfy our regulators, HIS and the MHRA.” Such protocols include ensuring medicine storage is secure and correct, which may include a designated refrigerator approved for the storage of temperature-controlled

“HIS negotiated on behalf of the BACN and all nurses who own a HIS regulated clinic that the stock issue had to be rectified with the MHRA to protect patient safety above all else” Frances Turner Traill, nurse prescriber

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medicines, according to a medicine’s legal category.7,8 As for the rest of the UK, nurses are still not permitted to stock POMs.2 Aesthetics contacted the MHRA to ask if change was on the horizon, but a spokesperson simply stated, “We are not aware of any plans to widen the definition in England.”9 Turner Traill said, “Our friends in the other three countries of the UK are keen to be able to hold stock too, so the BACN board is leading the way with discussions and negotiations.” BACN vice chair and registered nurse prescriber Andrew Rankin, adds that this will only occur with either a change in the law or a significant reinterpretation of the law. He explains, “There is nothing the BACN can do directly, but fortunately we are in the position where we can at least discuss the matter with the MHRA and explain the problems that come from this inability to hold stock. I believe we can evidence that nurses really do provide best practice in prescribing that justifies holding stock and I think ultimately it will be a case of the MHRA directing how best to move forward with this.”

The future for nurses in Scotland As well as the safety perspective, this change has many other benefits to HIS-registered Scottish nurse prescribers who are clinic owners, as they can also stock other common POMs such as botulinum toxin and lidocaine. Nurse prescriber and clinic owner Michelle McLean, who is also the Scottish regional leader for the BACN, explains that this change will have a very positive impact on her clinic and patients. “It will make our business run more seamlessly. Nurse-led clinics will now be able to run in the same way as a doctor-led clinic. This means

Aesthetics

nurse practitioners won’t have to employ a doctor just so they can stock medication when we have the same prescribing rights. It is also beneficial from a financial aspect. For example, previously if someone only needed one area of botulinum toxin treated you would have to order them a full vial and discharge the rest as the vial was patient specific, but now this is not the case,” she says. Rankin adds, “I think it is quite an exciting time for nurses in Scotland, the ability to hold stock really does open up your practice to serve your patients better.” McLean concludes that she believes it’s a time in history for nurses. “This is where things are going to move forward for nurses to become more empowered and independent; it’s just a really good thing for both nurses and patients. The regulation has caught up with the times and it’s great that we can run an independent practice and know that we are doing everything correctly,” she states. REFERENCES 1. RCN Fact Sheet, Nurse Prescribing in the UK, 2014. <https://www.rcn.org.uk/about-us/policy-briefings/ pol-1512> 2. Legislation.gov.uk, The Human Medicines Regulations 2012. <http://www.legislation.gov.uk/ uksi/2012/1916/made> 3. Angela Dowden, The expanding role of nurse prescribers, Prescriber, 2016. <https://onlinelibrary. wiley.com/doi/pdf/10.1002/psb.1469> 4. HIS, Leading the way in ensuring that cosmetic interventions in Scotland are carried out safely – Kevin Freeman-Ferguson, Head of Service Review, Healthcare Improvement Scotland, 2017. <https:// blog.healthcareimprovementscotland.org/> 5. Kilgariff, S, HIS Registration Launch, 2017, Aesthetics. <https://aestheticsjournal.com/feature/hisregistration-launch> 6. Statement obtained from HIS. Record on file. 7. HIS, Independent Healthcare Medicines Governance Audit Tool, 2017. <http://www. healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/independent_ healthcare/information_for_providers.aspx.> 8. HIS, Independent Clinics Additional guidance for providing a service in your own home. <http://healthcareimprovementscotland.org/his/idoc.ashx?docid=5a58ec6f-bd31-4675-9649a86f58187bc9&version=-1> 9. Statement obtained from MHRA. Record on file.

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Face Up To It Patient photographs form part of a patient’s medical record and should be treated with the utmost confidentiality. If you don’t have the patient’s specific consent to use their images outside of their medical records, you could run the risk of legal action even if the images are anonymised. At Enhance we can protect you against any alleged breach of confidentiality whether founded or otherwise. If you require any further guidance regarding data protection issues call us today and we’ll help you implement the tools to mitigate future problems and help with compliance.

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Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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Exclusive Education at the Elite Training Experience For the first time ever, four of the UK’s leading aesthetic trainers held three-hour taster sessions of their courses at ACE. Delegates were invited to book on to one or more of the courses which included; Dalvi Humzah Aesthetic Training led by consultant plastic and aesthetic surgeon Mr Dalvi Humzah, Academy 102 led by Dr Tapan Patel, Medics Direct Training led by Dr Kate Goldie and RA Academy led by Dr Raj Acquilla. Dedicated to upskilling techniques, improving anatomy knowledge and supporting patient retention rates, the Elite Training Experience sessions impressed delegates who took part. One attendee summarised their experience by saying, “Interesting, good pace, good theory helping “Excellent trainers, with assessment and lots of knowledge managing complications, and experience. and fantastic practical Good live demos” demonstrations,” while another enthused, “Kate Goldie is an exceptional injector and easy to listen to. Always inspirational!”

ACE 2018: The Highlights The Aesthetics Conference and Exhibition (ACE) 2018 took place on April 27 and 28 at the Business Design Centre in London. The two days featured a fantastic line-up of educational sessions providing both clinical and business advice to support practitioners build a successful aesthetic clinic. At the end of the first day, a networking reception, sponsored by Dr Harry Singh’s new book Let Go of the Handbrake, brought delegates together to discuss their day’s learning, meet top speakers and interact with leading suppliers in the specialty. Feedback for the event was excellent, with 88% of delegates rating ACE 2018 overall as good to excellent. 80% said they would recommend the event to their friends and colleagues, while 75% said they were likely, very likely or definitely going to attend next year. One delegate said, “I’m very glad I attended and “ACE has the took away a host a very specialty’s needs valuable literature and covered and is contacts”, while another added, “Thoroughly brilliant at introducing enjoyed the two days at my new technologies” first experience of ACE and will definitely be coming again – have enjoyed my time and learned a lot.”

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Live demonstrations at the Expert Clinic Huge crowds gathered at the Expert Clinic over the course of the two days to watch 17 interactive clinical workshops on topics that included injectables, lasers, skincare, peels and energy devices. The valuable sessions featured expert live demonstrations and discussions of all the latest aesthetic trends. One delegate praised the “Great variety and interesting topics” while another said they, “Picked up lots of tips that motivated me.” The half-hour sponsored sessions were led by top aesthetic companies AesthetiCare, AestheticSource, Church Pharmacy, Cutera Medical Ltd, Cynosure UK Ltd, Fusion GT, HA-Derma, Naturastudios Ltd, Needle Concept, Rosmetics, Teoxane UK, ThermaVein, Unique Skin Ltd and Venus Concept.

KOL Insights at the Masterclasses Best practice use of some of the UK’s top aesthetic products and treatments was the focus of the 12 Masterclasses held at ACE. The 60-minute sessions introduced delegates to new treatment strategies and shared valuable advice on how to maximise patients’ results. Recognition from delegates included, “Good practical sessions performed by excellent practitioners with good visual screening of

practice.” Another simply said, “Brilliant!!!” Masterclasses were held by AestheticSource, BeamWave Technologies, BTL Aesthetics, CALECIM Professional, Galderma (UK) Ltd, Innoture: Radara®, Lumenis, Naturastudios Ltd, Rosmetics, Schuco Aesthetics and SkinCeuticals.

Practice Advice at the Business Track The 12 workshops on everything you need to know about running a successful clinic was a huge success with great delegate feedback. One emphasised that the quality of talks was, “High and practical”, while others said the Business Track, which was sponsored by Enhance Insurance, featured,

“The session I attended with Dr Shah-Desai was excellent. I was lucky to be in the front row; she was a great speaker”

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018

“The session I attended about setting up a clinic was really helpful”


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“Great variety of trade stands, presentations and show special offers”

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“Very knowledge speakers” with, “Informative and helpful” advice. Sessions focused on an array of topics, which included PR, marketing, digital activities, training, regulation, management, insurance, VAT and consent processes.

Product Launches at the Exhibition The 2,500m2 Exhibition Floor played host to more than 80 top aesthetic suppliers. At the stands delegates were able to watch live demonstrations, build new connections and discover all the latest products and treatments. One delegate said of the Exhibition, “Good mix of exhibitors, friendly atmosphere, nice venue”, while another added, “Plenty of stands with good variety of products displayed. Excellent selection of presentations. Something for EVERYBODY.”

#ACE2018 DHAesthetic Training @mdhtraining

The #EliteTraining in action at #ACE2018 Thank you to all faculty and those who attended @mdhtraining @pdsurgery @CosmeticDigita1 @DrHema @Anna32Baker @tsklaboratory @AgostinaSkinade @SKINTECH_peel @aestheticsgroup aesthetics.medical @aesthetica.medical

A great weekend at the Aesthetics Conference in London with many highly prestigious colleagues. Always learning and keeping up to date with new techniques and treatments to provide the best, most effective and safest treatments to our patients! The best practitioner is one who never stops learning #ace2018 #london LMC Aesthetics @lmc_aesthetics

Some exciting new ideas for the clinic #ACE2018

AesthetiCare Team @AesthetiCareUK

A showstopper of a weekend at ACE 2018! A fantastic ENDYMED Expert Clinic session and full stand! Thanks to everyone who came visited us! Dr Jessica Prior @drjessicaprior

I had a great day at the Aesthetic Conference & Exhibition in London! I discovered some amazing new products and treatments focussing on skin rejuvenation and skin concerns such as acne scarring and pigmentation. I’m excited to do some further training to offer these treatments! #ace2018 #london #aesthetics #theperfectpeel #dermapen #sunekos #prpfacial #skinrejuvenation #antiageing #skincare #neostrata

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Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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Unravelling sunscreen

Ingredients in Suncare Allie Anderson speaks to practitioners about their go-to sun care products and how they work to safeguard the skin from damage Non-melanoma skin cancer has the highest incidence of all cancers in the UK, with more than 130,000 cases diagnosed every year.1 This doesn’t even factor in unreported cases, of which there are likely to be many, according to Cancer Research UK. Melanoma, on the other hand, is the fifth most common cancer in the UK, accounting for 13,500 new cancer diagnoses annually.2 While non-melanoma skin cancers tend to be curable and easily treated – most cases are surgically excised and require no further treatment3 – melanoma is often less straightforward and survival rates are dependent on many factors, such as the specific type of melanoma, the stage at which it is diagnosed, the patient’s age and overall health.4 What both cancer types have in common is that exposure to ultraviolet light from both the sun and sunbeds is a major cause and risk factor.5

How UV light affects the skin According to the British Association of Dermatologists (BAD), ultraviolet A (UVA) and ultraviolet B (UVB) rays are the two main types of harmful radiation and damage the skin in a number of ways. UVA affects the elastin in the skin, which leads to wrinkles and sun-induced skin ageing such as coarse wrinkles, leathery skin and brown pigmentation, as well as skin cancer. UVB is most responsible for sunburn and has strong links to malignant melanoma and basal cell carcinoma.1 The mechanism by which this damage occurs is cellular death: the ultraviolet radiation kills off skin cells by breaking down their DNA. This can happen indirectly – the UV rays cause proliferation of free radicals leading to oxidative stress, which in turn attacks cellular DNA – and directly, by initiating a reaction between two thiamine molecules in the DNA strand and, thus, altering its structure.6,7 Dr Laurence Dryer, research scientist and skincare professional, and vice president of research and development at Obagi Medical, notes that not only does UV radiation damage skin cell DNA, but it also impairs the biological processes that are designed to restore it. “Once the sun rays denature the DNA, it in turn causes the way the DNA is put together to unravel, and the rays also damage the enzymes that are normally there to repair the DNA should there be a problem with it. When the DNA is prevented from repairing itself, it’s not going to make enough collagen and elastin – the components that make the skin resilient, strong and young,” she explains. “Moreover, the sun stimulates additional enzymes that will degrade the collagen and elastin that are already there. So, the sun attacks and breaks down elements in the skin that are already present, and slows down the synthesis of elements that you need.”

Regularly using a broad-spectrum sunscreen that protects the skin from UVA and UVB radiation has been demonstrated to help prevent photoageing and reduce incidence of skin cancer.8,9 Practitioners interviewed concurred that clinicians must therefore make effective sun protection an integral part of their package of care for patients, not only because they are proponents of healthy, youthful skin, but also because the success of the treatments and procedures they perform depend upon preventing further damage. “Sun protection is the aesthetician’s insurance policy,” Dr Dryer states, “Because if a practitioner is repairing something, and the patient is not using sun protection every single day, they’re fighting a losing battle.” With manifold sunscreens on the market and a surfeit of potentially confusing and conflicting information about which is best, aesthetics practitioners are well placed to guide patients. Physical vs. chemical At the most basic level, sunscreens are categorised as either physical or chemical – but they can also be a combination of the two. Miss Sherina Balaratnam, surgeon and founder of S-Thetics, explains that the two work in fundamentally different ways. “Physical sunscreen provides the skin with protection by reflecting and scattering the UVA and UVB rays away from the skin’s surface,” she says. “Chemical sunscreen works differently: it absorbs the UVA rays and UVB rays, converts it to heat and then releases it from the skin.” Physical and chemical sunscreens can also be differentiated according to the types of UV filters they contain – the active ingredients that protect against radiation. Table 1 summarises some of the common UV filters found in physical and chemical sunscreen, as well as the properties of both. Focus on ingredients When recommending sun protection to patients, Miss Balaratnam chooses the “multitasking” iS Clinical products that she says are suitable for a number of indications. Among the range she recommends to patients are the iS Clinical Extreme Protect SPF30, and Eclipse SPF50+, both containing titanium dioxide and micronised zinc oxide, as well as extremozymes that repair cellular damage and reduce DNA breakdown.10 “These ingredients work intrinsically by doing three things,” she says. “They repair the cellular DNA, contain antioxidants to

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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for on sunscreens, 44% didn’t know what SPF meant.14 Practitioners, therefore, should Octolcrylene Common UV filters Titanium dioxide (TiO2) make sure their patients are informed Zinc oxide (ZnO) Avobenzone about the dangers of UVA as well as UVB Octinoxate Octisalate radiation. This includes understanding that Oxybenzone a product’s UVA star rating indicates the Homosalate Helioplex percentage of UVA radiation absorbed by 4-MBC the sunscreen only in comparison to the Mexoryl SX and XL UVB protection it affords – or, the ratio of Generally stable Variable stability (avobenzone is known Properties the level of UVA to UVB protection.15 In to be unstable but can be stabilised if combined with other ingredients) other words, a sunscreen with SPF15 and TiO2 protects against UVB rays Chemical filters provide more a UVA rating of five stars does not offer as and some of UVA rays protection, depending on stability and much defence against UVA radiation as an ZnO protects against the entire specific UV filter SPF30 with a five-star UVA rating. As such, spectrum of UVB and UVA rays the British Association of Dermatologists Provides protection immediately Provides protection 20 minutes recommends a high SPF of at least 30 after application after application (must be applied in coupled with a four or five star UVA rating is advance of sun exposure) the optimum choice.16 Patient tolerance TiO2 isn’t tolerated by everyone UV filters can irritate some skin and ZnO is well tolerated cause allergic reactions But as Dr Dryer points out, even an SPF30 with a high level of UVA protection will not block all of the sun’s UV radiation, leaving Table 1: Sunscreen ingredients and properties21 the skin still vulnerable to damage. That’s repair oxidative stress caused by sun damage, and give the skin why, she says, it’s important to consider all of a product’s ingredients. hydration because they have vitamin E, olive leaf extract and centella “The Obagi Professional-C Suncare SPF features avobenzone, asiatica, so they have excellent anti-inflammatory properties.” homosalate, octisalate, octocrylene, and oxybenzones, which are It’s not just UV light that patients need to be aware of. In recent years, the five cornerstones that will ensure protection against UVA and evidence has suggested that infrared (IR) rays can be damaging to UVB, but it will not protect against 100% of the sun rays, so some the skin. Although IR rays comprise around 50% of radiation emitted of those rays will go through,” she explains. “In order for the body from the sun – in comparison to UV rays, which account for just and the skin to be protected from the rays that still go through, the 2-3% – they are less potent and hence, have not received much product contains 10% L-ascorbic acid, which I believe is the best and attention.11 Notwithstanding, IR rays have been shown to cause most efficacious form of vitamin C.”17 The L-ascorbic acid fights free the proliferation of free radicals and decrease collagen synthesis, radicals and protects against oxidation,18 offsetting the deleterious 12 resulting in photoaged skin. Furthermore, dose-dependent higheffect of the unfiltered radiation, Dr Dryer adds. energy visible (HEV) light – or blue light, such as that emitted from The practitioners interviewed agree that UK patients remain computer, TV and smartphone screens – can degrade antioxidants somewhat nonchalant about the dangers of sun exposure and in the epidermis and cause similar damage over time.13 sunbed use, many still ascribing to the idea that a tan is a sign of For the founder of EF Medispa, Esther Fieldgrass, this is evidence good health.19 As long as societal norms dictate that a suntan is that sunscreens should protect against the full spectrum of light, desirable and attractive, healthcare professionals may continue and she recommends patients use products from mesoestetic. to face an uphill struggle to engage patients in sun protection. “This sun protection covers the skin from UVA, UVB, HEV and IR Independent nurse prescriber Anna Baker claims that pigmented light – giving patients optimal combination of physical, biological and sunscreens that contain a sunless tanning element are the solution. chemical filters to provide maximum effectiveness,” she comments. “Products that can tick all of the boxes mean people don’t have to In addition, she adds that the mesoprotech range includes products go and bake themselves in the sun,” she says, adding, “Patients can containing different active ingredients – physical and chemical and now use SPF50 with antioxidant protection and still get a tan.” biological – for different skin requirements. “Each product includes To this end, Baker recommends two products to her patients; the the addition of collagen pro-47, a chaperone protein that protects first being Neostrata Sheer Physical Protection. Suggesting that this and enhances collagen,” Fieldgrass says. “The melan 130+ also is ideal for use on the face, neck and décolletage, Baker describes contains azeloglicine to regulate hyperpigmentation by inhibiting this as, “A powerhouse of antioxidants and antiageing ingredients,” tyrosinase activation. This combination combines intensive treatment which also includes a mineral-based pigment that blends to suit a active principles with sun protection, so they are working to improve range of skin tones. Containing physical UV filters titanium dioxide the skin – not just to protect it.” Since HEV and IR protection is a and zinc oxide, it has SPF50 and a maximum UVA protection grade fairly new concept, relatively few sunscreens – particularly high of PA ++++ (the Japanese system of rating UVA protection based on street brands – include filters to prevent these rays from penetrating the ‘persistent pigment darkening’ process – i.e. the extent to which the skin. So, as practitioners interviewed attest, a broad-spectrum UVA radiation causes the skin to brown and remain brown).20 sunscreen to guard against UVA and UVB is the very minimum “It also contains lactobionic acid, which gives antioxidant benefits, patients should use. It’s important, however, that patients are hydrates and nourishes the skin, and preserves against detrimental educated in regards to the level of UV protection products offer – in effects of other nasty enzymes associated with sun exposure,” Baker a 2017 survey, 60% of UK adults thought that SPF ratings indicated adds. “Two other potent antioxidants in this SPF are EGCG green tea the degree of protection from all of the sun’s harmful rays, and while extract, which works to protect the skin’s cellular DNA, and vitamin almost two-thirds said that SPF is the most important thing to look E. It’s non-irritating, non-sensitising, and you could use it on rosacea, Physical sunscreen

Chemical sunscreen

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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In a 2017 survey, 60% of UK adults thought that SPF ratings indicated the degree of protection from all of the sun’s harmful rays, and while almost two-thirds said that SPF is the most important thing to look for on sunscreens, 44% didn’t know what SPF meant and post procedurally on intact skin, for example after superficial chemical peels,” she explains. Baker’s second go-to product for patients wanting a healthy glow is Tancream – a topical sunless tanning lotion that provides SPF 50 and five-star UVA protection alongside an instant bronzer and gradual self-tan. “This is a new concept – it has a colour corrector component to it, which means it can even out skin tone,” Baker says. “It’s also paraben-free, odour-free, has an antioxidant complex and can be applied just like a moisturiser without any residual staining.” Although the high defence against UV radiation makes Tancream a robust sunscreen, Baker notes that over-application can result in the development of a deep brown colour due to the gradual tanning agent. Thus, she advises patients to use it as they would a sunless tanner, rather than as a sunscreen to be reapplied regularly throughout the day. “It is dermatologically tested and is very forgiving and safe, but I would suggest that patients who are taking prescription emollients like topical steroids to check with their dermatologist that there are no contraindications,” Baker adds.

Encouraging compliance These practitioners concur that a strict approach to sun protection is necessary, such that sunscreen must form an integral part of a patient’s skincare regime. “As practitioners, we have to remember to first do no harm,” Miss Balaratnam comments. “So, if patients don’t want to use an SPF then we’re unwilling to carry out treatments; it’s as stringent as that.” For patients who need persuading, skin analysis techniques and digital imaging to visibly demonstrate skin damage – and the improvement using sun protection – is a convincing strategy says Miss Balaratnam. She carries out a Visia digital skin analysis on all new patients to assess their skin health on the surface and 2mm underneath, and repeats the analysis six weeks later following adherence to a comprehensive skincare regime that compulsorily includes a broad-spectrum SPF. “When we can measure patients’ results, we can effectively demonstrate the efficacy of sunscreens and that they work, and this encourages patients to remain motivated to continue using them,” she says.

Aesthetics

Compliance is further encouraged if patients are offered products that are pleasant to use, says Baker. “People are put off using a lot of high street products because many are thick and cakey, and often give a greasy and chalky appearance – they’re simply not very nice to apply,” she comments. “In the aesthetics industry, we have access to advanced, very sophisticated, cosmetically elegant formulations that patients like to wear because they feel nice. That means they are more likely to engage in conversations and adopt good skincare regimes.” Offering a range of such products that patients enjoy using can also generate upselling opportunities, says Fieldgrass. “Our practitioners at EF Medispa will always finish facial treatments with sun protection before the patient leaves the clinic. These sun protection products can be incorporated into skincare regimes, so this can be included as part of a regular skincare purchase,” she says. For example, the mesoestetic melan 130+ sunscreen can be included as part of a chemical peel package, so that patients derive optimal benefits from the treatment, Fieldgrass states, adding, “This is a fantastic way to upsell a particular product.”

Conclusion Aesthetic practitioners are in the business of retaining youth, treating photoaged skin to reverse the effects of cumulative, long-term exposure to the sun. They are also dutybound to prevent such damage from occurring. Good-quality sun protection must therefore be a fundamental part of their offering in order to safeguard patients’ overall health. REFERENCES 1. Sunscreen Fact Sheet, (UK: British Association of Dermatologists, 2018) <http://www.bad.org.uk/forthe-public/skin-cancer/sunscreen-fact-sheet#uva-and-uvb> 2. Skin cancer (melanoma) (UK: NHS Choices, 2018) <https://www.nhs.uk/conditions/melanoma-skincancer/> 3. Making decisions about your treatment (UK: Cancer Research UK, 2018) <http://www. cancerresearchuk.org/about-cancer/skin-cancer/treatment/treatment-decisions> 4. Survival (UK: Cancer Research UK, 2018) <http://about-cancer.cancerresearchuk.org/about-cancer/ melanoma/survival> 5. How ultraviolet (UV) radiation causes skin cancer (Aus: Cancer Council, 2018) <https://www. cancercouncil.com.au/63295/cancer-prevention/sun-protection/sun-protection-sport-and-recreation/ sun-protection-information-for-sporting-groups/how-ultraviolet-uv-radiation-causes-skin-cancer/> 6. Rinnerthaler M, Bischof J et al., ‘Oxidative Stress in Aging Human Skin’, Biomolecules, <https://www. ncbi.nlm.nih.gov/pmc/articles/PMC4496685/> 7. Csanyi C, How Does UV Light Damage the DNA Strand? (US: Sciencing, 2017) <https://sciencing.com/ uv-light-damage-dna-strand-12687.html> 8. Study: Regular Suncreen Use Can Prevent Wrinkles (US: Skin Cancer Foundation, 2013) <https://www. skincancer.org/prevention/sun-protection/sunscreen/aging> 9. Green A et al., ‘Reduced melanoma after regular sunscreen use: randomised trial follow-up’, Journal of Clinical Oncology <https://www.ncbi.nlm.nih.gov/pubmed/21135266> 10. Physical vs. Chemical Suncreen (US: Skinacea, 2015) <http://www.skinacea.com/sunscreen/physicalvs-chemical-sunscreen.html#.Wv2RXIiUu00> 11. Hartmann M, The Rise of Extremophiles (US: Dermascope, 2018) <https://www.dermascope.com/ ingredients/the-rise-of-extremophiles> 12. Barolet D et al., ‘Infrared and Skin: Friend or Foe’ J Photochem Photobiol <https://www.ncbi.nlm.nih. gov/pmc/articles/PMC4745411/> 13. Infrared light and skin ageing: UV shielding is not enough (US: Smart Skincare, 2017) <http://www. smartskincare.com/skinprotection/infrared-skin-aging.html> 14. Vandersee S, ‘Blue-Violet Light Irradiation Dose Dependently Decreases Carotenoids in Human Skin, Which Indicates the Generation of Free Radicals’, Oxid Med Cell Longev <https://www.ncbi.nlm.nih. gov/pmc/articles/PMC4337113/> 15. Smithers R, ‘Suncreen label congusion putting Britons at risk, say experts’ The Guardian <https:// www.theguardian.com/uk-news/2017/may/27/britons-risk-sunburn-skin-damage> 16. Sunscreen Fact Sheet, (UK: British Association of Dermatologists, 2018) <http://www.bad.org.uk/ for-the-public/skin-cancer/sunscreen-fact-sheet#uva-and-uvb><http://www.bad.org.uk/for-the-public/ skin-cancer/sunscreen-fact-sheet> 17. Sunscreen Fact Sheet, (UK: British Association of Dermatologists, 2018) http://www.bad.org.uk/for-thepublic/skin-cancer/sunscreen-fact-sheet> 18. Vitamin C and Skin Health, (US: Oregon State University, 2018) <http://lpi.oregonstate.edu/mic/healthdisease/skin-health/vitamin-C> 19. Vitamin C and Skin Health, (US: Oregon State University, 2018) <http://lpi.oregonstate.edu/mic/healthdisease/skin-health/vitamin-C> 20. Press Association, ‘Four in 10 UK parents wrongly believe a sun tan is healthy, says poll (UK: The Guardian, 2017) <https://www.theguardian.com/society/2017/jun/27/four-in-10-uk-parents-wronglybelieve-a-sun-tan-is-healthy-says-poll> 21. What does the PA+ Suncreen Symbol Mean? (US: Paula’s Choice Skincare, 2018) <https://www. paulaschoice.com/expert-advice/skincare-advice/sun-care/what-does-pa-sunscreen-symbol-mean. html>

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Vaginal Rejuvenation Dr Mayoni Gooneratne presents the treatments available to address vaginal laxity and discusses their efficacy Abstract Vaginal rejuvenation, an umbrella term which, for the purposes of the article, includes all treatments that aim to address both the aesthetic and functional problems caused by vaginal laxity, has a range of possible treatments. These treatments range from noninvasive topical gels and lotions to invasive surgical procedures. This article will define the term vaginal laxity, explore its aetiology and symptoms, before discussing the range of treatment options available, alongside the latest research into their efficacy. Vaginal laxity is strongly associated with childbirth, but is also associated with other conditions including, but not limited to, diabetes, connective tissue disorders and obesity. The symptoms may be acute or chronic in nature. Although statistics on vaginal laxity are few and far between, it is believed by many practitioners to be an under-reported condition, due in part to the reluctance of women to seek help, affecting a significant minority of pre- and post-menopausal women.1 In recent years, a number of new energy-based treatments for vaginal laxity have become available, using radiofrequency (RF) or laser energy to treat the condition. Many use techniques pioneered in rejuvenation skincare. This article explores the various devices available, which are non-invasive and generally pain free. Please note that this article does not discuss vulvar laxity, which relates to asymmetrical or irregularly shaped labia majora and minora.

What is vaginal rejuvenation? For the purposes of this article, vaginal rejuvenation encompasses all treatments which aim to treat the problem of vaginal laxity, from topical creams and gels through to pelvic floor exercises, energybased devices and surgical procedures.

What is vaginal laxity?

Vaginal laxity, or genitopelvic vaginal laxity, means simply a loosening of the vaginal entrance or canal. It has symptoms which include (but are not limited to) stress urinary incontinence, decreased sensation during sexual intercourse, loss of sexual satisfaction, a decrease in hydration of the vaginal mucosa, and vaginal flatulence.2 Aetiology: what causes vaginal laxity? Genitopelvic vaginal laxity is strongly associated with a history of childbirth3 but can also be caused by other conditions, including but not limited to; nerve damage due to diabetes,4 obesity5 and genetic disorders that affect collagen metabolism (e.g. EhlersDanlos).6 During childbirth, damage can occur due to trauma such as tearing, or an instrumented delivery. In cases where this damage does not heal fully, women can be left with chronic results.7

There are two types of vaginal laxity: 1. Vaginal Introital Laxity (VIL)1 refers to the introitus, or entrance, of the vagina. This region also includes the clitoral complex – the clitoris and the urethra. Laxity in this area can lead to a change in sexual sensation, and is a functional rather than an aesthetic condition. The changes in sensation can cause a decline in sexual satisfaction and lead to sexual dysfunction. 2. Vaginal Canal Laxity (VCL)2 can be both a functional and an aesthetic problem. For example, women may complain of changes in urinary continence, the passing of ‘vaginal wind’, faecal incontinence, and/or flatal incontinence (leaking of gas). Severe cases may also involve prolapse, where a bulge is visible at the introital opening. Women may suffer from either or both forms of vaginal laxity, which can have a significant impact on their quality of life, sexual relationships and self-esteem. These problems can extend into menopause and beyond, as hormonal changes further affect vulvovaginal health.8 This topic is of growing interest to the medical aesthetic community as women seek solutions and treatments that do not involve surgery. A study published in 2017 found that, among 920 women who reported vaginal laxity, 43% stated that it is ‘quite a problem’ or ‘a serious problem’ to them.9 In order to better understand vaginal laxity, it is helpful to understand the structure and anatomy of the vagina at a microscopic level. The vagina is a fibromuscular tube, and its wall has three layers:10,11 1. The internal mucosal layer is composed of the epithelium and the lamina propria. The epithelium is made up of non-keratinised stratified squamous cells. Beneath this is the lamina propria, a thin layer of connective tissue with a vast amount of elastic fibres and a dense network of blood vessels. 2. The intermediate muscularis layer is composed mainly of smooth muscle. 3. The external adventitial layer is rich in collagen and elastin. The adventitia provides structural support to the vagina and allows it to expand during childbirth.

The physical and psychological impact of vaginal laxity As discussed, vaginal laxity can cause both functional and aesthetic problems for the sufferer. Vaginal laxity can be a cause of sexual dysfunction, which is defined by the World Health Organisation as ‘the various ways in which a woman is unable to participates in a sexual relationship as she would wish’.12

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Damage to the genitopelvic region may change sexual sensation and can reduce lubrication. Problems with vaginal dryness can also lead to pain or discomfort during intercourse (dyspareunia).13 Vaginal laxity can also cause stress urinary incontinence (SUI). SUI occurs due to damage to the pelvic floor and/or the urethra. Weakness in this area means that the urethra does not stay closed as pressure builds within the bladder. Coughing, laughing or sneezing all put extra pressure on the bladder, which can also cause urine to leak.14 These physical effects can cause sufferers great psychological distress, impacting a woman’s sense of self, confidence, self-esteem and sexual relationships. The problem is particularly difficult to address as women are often very reluctant to seek help due to the sensitive nature of the condition. Embarrassment, fear, and a belief that there is little that can be done to help, are all factors that can prevent a woman from seeking help and advice for vaginal laxity problems.15 It must also be acknowledged that lack of training and understanding from some medical professionals can be a barrier to a woman receiving the appropriate help and advice.

The prevalence of vaginal laxity Unfortunately, there are very few published statistics on the prevalence of vaginal laxity among the female population. An Australian study16 published in 2000 used data from a 1998 crosssectional population survey among 3,010 adults aged between 15 and 97 years. Of the sample, 51.3% were women and 48.7% were men. It found that pelvic floor disorders (including urinary incontinence, anal incontinence and prolapse among others) are ‘very common, and strongly associated with female gender, ageing, pregnancy, parity and instrumental delivery’. The study found that 5.2% of women self-reported vaginal laxity, and 20.8% reported stress urinary incontinence (SUI). Incidence of SUI rose to 40.8% among women who had a spontaneous vaginal delivery, and 43.5% among those who had had instrumental vaginal delivery. It is interesting to note that mothers who have had caesarean deliveries are also at increased risk of pelvic problems, compared to women who have not given birth.17 Although this data were analysed 20 years ago, the study begins to reveal the scale of the problem for women. Societal changes since then, such as increased rates of obesity and diabetes, and the increasing age of mothers at birth, would suggest that the incidence of pelvic floor disorders will increase. Indeed, a US study published in 2009 projected that the number of American women with at least one pelvic floor disorder will increase from 28.1 million in 2010 to 43.8 million in 2050.18 Further research in this area is needed to full quantify and understand the problem in the UK. When it comes to sexual dysfunction specifically, a 2004 study collated data from 27,500 men and women aged 40 to 80 in 29 countries. The analysis suggests that only 16% of women have discussed this problem with a healthcare provider.19 A 2012 online survey of 563 physician members of the International Urogynecological Association (IUGA) found that nearly 83% agree that vaginal laxity is ‘underreported by my patient’.20

How diagnosis is reached

At present, there are no standardised objective measurements to assess vaginal laxity, and it remains a subjective patient-reported symptom.21 As symptoms may be transient and improve spontaneously (particularly following childbirth), diagnosis would not usually be confirmed until symptoms have been experienced for three to six months. Diagnosis is initially reached by description of symptoms

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by the patient (such as a decline in sexual sensation, problems with urinary and/or faecal continence, a feeling of looseness and so on). A clinical assessment of the perineum may also be conducted. Assessment for treatment: factors to consider Please note that invasive treatment procedures should be delayed for at least six months’ post-pregnancy to allow time for the restoration of hormonal levels and the resolution of anatomical changes caused by pregnancy.22 A woman should also have ceased breast-feeding at least three months prior to evaluation for any treatment, as this can also impact uterine positioning and hormonal levels.22 Some cancer treatments can cause damage to the pelvic area.23 Any incidence of breast, ovarian or other gynaecological cancers should be explored in-depth with the patient, including how these diagnoses were associated with the timing or development of vaginal laxity symptoms, before treatment is embarked upon. It is also important to assess the degree of distress that the symptoms cause, and this should be factored into any treatment plan. Validated questionnaires such as the Female Sexual Distress Scale-Revised (FSDS-R)24 can be useful, as they provide a measure of the psychological and emotional components of distress, in addition to the physical symptoms. Sexual dysfunction can also be assessed using measures such as the Female Sexual Function Index (FSFI).25 A recent cross-sectional study into vaginal laxity, sexual distress and sexual dysfunction used both the FSDS-R and FSFI questionnaires to measure sexual health issues among 239 patients, for example.26 Finally, it is important that practitioners take steps to ensure that the patient is seeking treatment voluntarily. As with all treatments, the patient must give informed consent. For further reading in this area, consult the General Medical Council’s (GMC’s) Good Medical Practice guidelines,27 and its Consent guidelines,28 which can be found at the GMC website. It is also important to take steps to ensure that patients are not being coerced into seeking treatment by their partner or spouse. For this reason, a private one-to-one consultation with the patient is recommended. Patients should also have a ‘cooling-off’ period between the consultation and treatment. Treatment should never be given on the same day as the consultation.

Treatment options There are a variety of treatment options for vaginal laxity, including both non-invasive and invasive techniques. Topical creams Creams that aim to treat vaginal laxity and dryness have been available for many years. Oestrogen-based gels are effective in treating vaginal atrophy, and have been shown to increase blood flow and the thickness of the epithelium.15 However, there is no peer-reviewed evidence in support of over-the-counter vaginal tightening products. Exercises Physical therapy and exercises, such as those devised by Kegel in the 1940s,29 aim to re-condition the vaginal wall by strengthening and toning the muscle layer.30 However, studies into the effectiveness of these exercises have focused on continence and prolapse, rather than vaginal laxity.31 Physical therapy and exercise approaches of this type also involve a level of commitment from the patient to achieve results – regular practice over a period of weeks and months – which could be a barrier to success for some patients.30

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technologies Vaginal rejuvenation using energy-based devices.2 Giussy et al’s 2017 narrative review is also helpful, discussing a variety of energy-based treatments alongside surgical options.32

It is important to take steps to ensure that patients are not being coerced into seeking treatment by their partner or spouse. For this reason, a private one-to-one consultation with the patient is recommended Surgery Vaginal laxity can be addressed with surgery, which aims to decrease the diameter of the vaginal canal and its opening. Also known as vaginoplasty, this can involve the excision of excess tissue, muscular tightening, remodelling of the perineal body and the excision of surplus skin.32 This is the most invasive option for treatment of vaginal laxity, requiring full anaesthesia and a recovery period, and, as with all surgery, involves many possible complications. A narrative review of articles32 revealed mixed outcomes for patients, and concluded that there is little evidence to support this kind of surgery to increase sexual satisfaction. Energy-based treatments There are two energy-based treatment options for vaginal laxity: laser and radiofrequency (RF) devices. Both are non-ablative, meaning that they target lower layers of the skin, but not the surface. These non-invasive devices use energy targeted at specific levels within the vaginal wall to increase collagen production, encourage the contracture of elastin fibers, prompt neovascularisation, and hence improve lubrication.2 Treatments usually last for between 15 and 30 minutes, with some devices requiring just one treatment, whilst others require a course of treatments. Treatment is given via a hand-held probe inserted into the vagina. These devices do not require anaesthesia.2 As relatively recent inventions, research into their long-term results for vaginal laxity is limited. Although the concept of photothermolysis arrived in 1983, and the first low-dose nonablative RF treatment was introduced in 2002,42 these techniques were initially for facial rejuvenation. The distal effect of the laser energy on proximal organs such as rectum, urethra, and bladder is unknown, as yet.32 However, studies published so far into their efficacy have shown promising results. A 2010 study among 24 women aged 25-44, for example, showed an excellent six-month safety profile and subjective improvement in vaginal tightness and sexual function.33 While there is not time within this article to cover each treatment device in detail, a good starting point is Karcher and Sadick’s 2016 review of available

CO2 and Er:Yag lasers These devices operate at different wavelengths, but each uses fractional photothermolysis. This is a process whereby the light energy from the laser creates thermal necrosis (heat damage) at multiple microscopic areas within the skin. This process has gained acceptance as a safe and effective method for resurfacing and restoring the skin in dermatology.34 The thermal necrosis triggers a wound-healing cascade (the inflammation cascade) that results in the formation of new elastin and collagen fibres, firming and tightening the tissue. Treatment is quick, taking between 10 and 30 minutes to conduct, and requires no anaesthetic. There is no downtime post treatment, and women can get back into their normal routine the same day.2 A study in 2014 aimed to assess the efficacy and feasibility of fractional CO2 laser in the treatment of vulvovaginal atrophy in postmenopausal women. 50 women aged 54-66 years were assessed before and after three applications of treatment. The study showed a significant improvement at 12 weeks’ post treatment using a CO2 laser, which was targeted at the vaginal wall in small 200-micron dots, affecting only a small percentage of the tissue.35 A separate study published in 2017 assessed fractional CO2 laser treatment in perimenopausal women. The study included 21 women, who each received three treatments. At 12 weeks’ follow-up, 82% of patients shows a statistically significant improvement in vaginal health, 81% reported improvement in sexual gratification and 94% reported improvement in vaginal rejuvenation. There were no adverse effects, with itching being the most commonly reported side-effect (20%).36 Erbium:YAG Lasers operate at a lower wavelength than C02 lasers, but treatment works on the same principles. A comparative study in which one group received CO2 laser therapy and another Er:YAG laser therapy found that there was improvement in vaginal tightening in both groups.2 A 2014 study into the use of Er:YAG laser for the treatment of vaginal relaxation looked at 30 post-partum females aged 33-56 years, who each received four sessions of treatment. No adverse events or side effects were recorded, and significant improvement in vaginal wall relaxation (laxity) was seen in all subjects at two months’ post procedure.37 Radiofrequency Like laser treatment, RF treatments work by generating volumetric heating in the tissue, promoting collagen and elastin production.38 RF treatments emit focused electromagnetic waves and have been used in a variety of aesthetic applications such as facial rejuvenation.38 Nonablative RF has more recently been used in the treatment of vaginal laxity. As with laser treatment, no anaesthesia is required and patients report a tolerable sensation of warmth. Treatments take 30 minutes or less to administer. A 2015 study among 23 patients that underwent three treatments at 30 minutes each found that all experienced a tightening result, and significant improvement in urinary continence and sexual satisfaction.39 There were no adverse effects reported. A 2017 randomised, singleblinded and sham-controlled study of a different radiofrequency device found that a single treatment was associated with both improved vaginal laxity and improved sexual function.40

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Complications As a non-invasive and non-surgical technique, there are few complications or side-effects with RF treatments. This article discussed non-ablative techniques; it should be noted that treatments which are based on the ablation of mucosal tissue have a longer recovery time than non-ablative techniques.41 One study of ablative fractional CO2 laser treatment found that some patients experienced a burning sensation, which lasted up to five days’ post treatment.41 Non-ablative treatments have been found to have a lower complication rate and shorter recovery time.41 A 2011 histological study looked at ovine tissue treated with ablative and non-ablative low-energy RF.. The study concluded that the non-ablative treatment delivers RF at levels insufficient to result in thermal cellular necrosis.42 In contrast to the low-dose ablative therapies, non-ablative applications preserved cellular viability and a functional tissue framework, and the tissue changes did not cause scar formation, inflammation or angiogenesis (the formation of new blood vessels). Non-ablative laser and RF treatments have been found to be well tolerated with no adverse effects.

Summary Vaginal laxity is a common problem for women, especially after pregnancy and birth, and into menopause. However, due to embarrassment and lack of knowledge, it remains under-diagnosed. As women gain knowledge and confidence in this area, and seek effective treatments, we can expect continued development in the non-invasive energy-based devices. Initial studies suggest that they can be effective treatments for vaginal laxity with mild to moderate symptoms, for women of all ages, both pre- and post-menopause.43 Disclosure: Dr Mayoni Gooneratne is an ambassador for Geneveve by Viveve Medical, an energy-based treatment for vaginal laxity and stress urinary incontinence. Dr Mayoni Gooneratne is a graduate of St George’s Hospital, is registered with the GMC and has been a member of the Royal College of Surgeons since 2002. She has completed extensive training in aesthetic techniques over the last few years which has culminated in the creation of private aesthetic clinic The Clinic by Dr Mayoni in 2016. She is accredited by Save Face and is an associate member of BCAM. REFERENCES 1. Michael L. Krychman, ‘Vaginal Laxity Issues, Answers and Implications for Female Sexual Function’ The Journal of Sexual Medicine, (2016) Volume 13 https://www.jsm.jsexmed.org/article/S17436095(16)30353-8/pdf [30/04/18] 2. Cheryl Karcher, Neil Sadick, ‘Vaginal rejuvenation using energy-based devices’, International Journal of Women’s Dermatology, Volume 2, Issue 3 (2016) https://www.sciencedirect.com/science/ article/pii/S2352647516300107 [30/03/18] (pp 85-88) 3. S Lalji, P Lozanova, ‘Evaluation of the safety and efficacy of a monopolar nonablative radiofrequency device for the improvement of vulvo-vaginal laxity and urinary incontinence’, Journal of Cosmetic Dermatology, (2017) Volume 16 https://www.ncbi.nlm.nih.gov/pubmed/28556393 (pp230-234) 4. M Baldassarre et al, ‘Changes in vaginal physiology of menopausal women with type 2 diabetes’, The Journal of Sexual Medicine, (2015), Volume 12, https://www.ncbi.nlm.nih.gov/pubmed/25974321 (pp1346-55) 5. A Pomian et al, ‘Obesity and Pelvic Floor Disorders: A Review of the Literature’, Medical Science Monitor, (2016) Volume 22, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907402/, (pp1880-1886) 6. D. Egging et al, ‘Analysis of obstetric complications and uterine connective tissue in tenascin-Xdeficient humans and mice’, Cell and Tissue Research, (2008) Volume 332, https://www.ncbi.nlm. nih.gov/pmc/articles/PMC2386751/ (pp523-532) 7. H. Memon, V. Handa, ‘Vaginal childbirth and pelvic floor disorders’ Womens Health (2013) Volume 9, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3877300/ 8. A. Parish et al ‘Impact of vulvovaginal health on postmenopausal women: a review of surveys on symptoms of vulvovaginal atrophy’ International Journal of Women’s Health, Volume 5 (2013) https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3735281/ (pp 437-337) 9. Dr. Patrick Campbell, Vaginal laxity – prevalence, impact and associated symptoms in women attending a urogynaecology clinic (IUGA Academy, 2017) https://academy.iuga.org/ iuga/2017/42nd/175235/patrick.campbell.vaginal.laxity.-.prevalence.impact.and.associated. symptoms.in.html?f=media=3 10. Aurora Miranda, MD, Vaginal Anatomy (Medscape, 2017) https://emedicine.medscape.com/ article/1949237-overview#a2

Aesthetics 11. Female Genital Anatomy (Boston University School of Medicine, Sexual Medicine) http://www.bumc. bu.edu/sexualmedicine/physicianinformation/female-genital-anatomy/ [Accessed 20 March 2018] 12. Defining Sexual Health (World Health Organisation, 2010) http://www.who.int/reproductivehealth/ topics/sexual_health/sh_definitions/en/ [accessed 16 March 2018] 13. SM Yount, ‘The Impact of Pelvic Floor Disorders and Pelvic Surgery on Women’s Sexual Satisfaction and Function’ Journal of Midwifery and Women’s Health, Volume 58 (2013) https://www.ncbi.nlm.nih. gov/pubmed/26055700 (p538) 14. Urinary Incontinence (NHS Choices, 2016) https://www.nhs.uk/conditions/urinary-incontinence/causes/ 15. S. Reiter, ‘Barriers to effective treatment of vaginal atrophy with local oestrogen therapy’, International Journal of General Medicine, Volume 6 (2013) https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3603331/ (pp153-58) 16. A. MacLennan et al, ‘The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery’, BJOG An International Journal of Obstetrics and Gynaecology, Volume 107 (2000) https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.2000.tb11669.x (pp1460-70) 17. H. Memon, ‘Pelvic floor disorders following vaginal or caesarean delivery’, Current Opinions in Obstetrics and Gynecology’ Volume 24 (2012) https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3681820/ (pp 349-354) 18. JM Wu et al, ‘Forecasting the prevalence of pelvic floor disorders in US Women: 2010 to 2050’, Obstetrics and Gynecology, Volume 114 (2009) https://www.ncbi.nlm.nih.gov/pubmed/19935030 (p 1278) 19. A. Nicolosi et al, ‘Sexual behaviour and sexual dysfunctions after age 40: The global study of sexual attitudes and behaviors’, Urology, Volume 64 (2004) https://www.sciencedirect.com/science/article/ pii/S0090429504008234 (pp991-997) 20. RN Pauls et al, ‘Vaginal laxity: a poorly understood quality of life problem; a survey of physician members of the International Urogynecological Association (IUGA)’, International Urogynecological Journal, Volume 23 (2012) https://www.ncbi.nlm.nih.gov/pubmed/22669419 (pp 1435-48) 21. Ali A. Qureshi, MD, Vaginal Laxity: Issues, Answers and Treatment Considerations’, unpublished White Paper, Marina Plastic Surgery, Marina del Rey, 2018), pp19-23 22. li A. Qureshi, MD, Vaginal Laxity: Issues, Answers and Treatment Considerations’, unpublished White Paper, Marina Plastic Surgery, Marina del Rey, 2018), p5 23. L. Morris et al, ‘Radiation-induced vaginal stenosis: current perspectives’ International Journal of Women’s Health, Volume 9 (2017) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5422455/ (pp273279) 24. The FSDS-R Screening Questionnaire, Obgynalliance.com http://www.obgynalliance.com/files/fsd/ FSDS-R_Pocketcard.pdf 25. The FSFI Screening Questionnaire, Obgynalliance.com http://www.obgynalliance.com/files/fsd/ FSFI_Pocketcard.pdf 26. AA. Qureshi et al, ‘Vaginal Laxity, Sexual Distress, and Sexual Dysfunction: A Cross-Sectional Study in a Plastic Surgery Practice’ Aesthetic Surgery Journal, Volume 23 (2018) https://www.ncbi.nlm.nih. gov/pubmed/29370358 (Epub ahead of print) 27. Good Medical Practice (General Medical Council, 2014) https://www.gmc-uk.org/ethical-guidance/ ethical-guidance-for-doctors/good-medical-practice 28. Consent: patients and doctors making decisions together (General Medical Council, 2008) https:// www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/consent 29. Kegel Exercise, ScienceDirect.com, https://www.sciencedirect.com/topics/medicine-and-dentistry/ kegel-exercise 30. N Golmakani et al, ‘The effect of pelvic floor muscle exercises program on sexual self-efficacy in primiparous women after delivery’ Iranian Journal of Nursing and Midwifery Research, Volume 20 (2015) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462060/ (pp347-353) 31. A. Marques, ‘The status of pelvic floor muscle training for women’ Canadian Urological Association Journal, Volume 4 (2010) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997838/ pp419-424) 32. G. Barbara et al, ‘Vaginal rejuvenation: current perspectives’, International Journal of Women’s Health, Volume 9 (2017) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5560421/ (pp513-519) 33. LS Millheiser, Radiofrequency treatment of vaginal laxity after vaginal delivery: nonsurgical vaginal tightening, Journal of Sexual Medicine, Volume 7 (2010) https://www.ncbi.nlm.nih.gov/ pubmed/20584127 (p3088) 34. SR Cohen et al, ‘Fractional photothermolysis for skin rejuvenation’ Plastic Reconstructive Surgery, Volume 124 (2009) https://www.ncbi.nlm.nih.gov/pubmed/19568091 (pp281-90) 35. S. Salvatore et al, ‘A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: A pilot study’, Climacteric, Volume 17 (2014) https://www.scopus.com/record/display.uri?eid=2-s2.084904327368&origin=inward&txGid=9f5a783c177ce3043ab9c7e59d38c3ae (pp363-369) 36. C. Arroyo, ‘Fractional CO2 laser treatment for vulvovaginal atrophy symptoms and vaginal rejuvenation in perimenopausal women’, International Journal of Women’s Health, Volume 9 (2017) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584900/ p591 37. Lee M.S., ‘Treatment of Vaginal Relaxation Syndrome with an Erbium:YAG Laser Using 90° and 360° Scanning Scopes: A Pilot Study & Short-term Results’, Laser Therapy, Volume 23 (2014) https://www. ncbi.nlm.nih.gov/pmc/articles/PMC4112282/ (p129) 38. M. Paul et al, ‘Three-Dimensional Radiofrequency Tissue Tightening: A Proposed Mechanism and Applications for Body Contouring’ Aesthetic Plastic Surgery, Volume 35 (2010) https://www.ncbi.nlm. nih.gov/pmc/articles/PMC3036829/ (pp 87-95) 39. R.M Alinsod, ‘Temperature controlled radiofrequency for vulvovaginal laxity’ Prime Journal, (2015) https://www.prime-journal.com/temperature-controlled-radiofrequency-for-vulvovaginal-laxity/ 40. M Krychman et al, ‘Effect of Single-Treatment, Surface-Cooled Radiofrequency Therapy on Vaginal Laxity and Female Sexual Function: The VIVEVE I Randomized Controlled Trial’. Journal of Sexual Medicine, Volume 14 (2017) https://www.ncbi.nlm.nih.gov/pubmed/28161079 (pp215-225) 41. J. Pardo, V Sola Dalenz, ‘Laser Vaginal Tightening with Non-ablative Er:YAG for Vaginal Relaxation Syndrome. Evaluation of Patient Satisfaction.’ Journal of the Laser and Health Academy, (2016) https://www.laserandhealthacademy.com/media/objave/academy/priponke/pardo_laha_2016_ onlinefirst.pdf (pp 1-2) 42. J. Vos et al, ‘Non-ablative hyperthermic mesenchymal regeneration: A proposed mechanism of action based on the ViveveTM model’ (Viveve.com, 2011) http://www.viveve.com/wp-content/ uploads/2017/10/Vos-2011_SPIE.pdf (pp1-8) 43. M. Gold et al, ‘Review and clinical experience exploring evidence, clinical efficacy, and safety regarding nonsurgical treatment of feminine rejuvenation’ Journal of Cosmetic Dermatology (2018) https://onlinelibrary.wiley.com/doi/abs/10.1111/jocd.12524 (Epub only)

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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DON’T MISS Y TO BE RECOGN

June is the final month you have to enter the largest U you become a Winner, Highly Commended, Commen Aesthetics Awards will ensure your patients

HOW TO E N T E R VISIT aestheticsawards.com and click ‘Categories’ to view the wide range of categories you can enter! READ the entry criteria of your chosen category carefully to submit the most valuable information DRAFT your answers and ask a friend/colleague to proof read to check their readability and accuracy

COMPANIES > > > > > >

PRODUCTS

SUBMIT your answers with supporting documents and images to provide a thorough application by June 29

> > >

CHECK the September issue or visit aestheticsawards.com on September 3 to see if you’re a finalist!

>

Late entries and/or amendments to entries will be charged an administration fee of £100 +VAT per entry. If you have any questions please call 0203 096 1228 or email support@aestheticsjournal.com.

Distributor of the Year Wholesaler of the Year Best Manufacturer in the UK Best UK Subsidiary of a Global Manufacturer The Healthxchange Pharmacy Award for Sales Representative of the Year Best Clinic Support Partner

Injectable Product of the Year Energy Treatment of the Year The Barry Knapp Award for Product Innovation of the Year, supported by Medical Aesthetic Group Skin Treatment of the Year

OTHER CLINICS > > > >

The AestheticSource Award for Best New Clinic, UK & Ireland The Consentz Award for Clinic Reception Team of the Year The MATA Award for Best Clinic Group UK & Ireland (10 clinics or more) The Enhance Insurance Award for Best Clinic Group UK & Ireland (3 clinics or more)

T > >

R > > > > > >

C O >

S PON S O

Enhance Insurance

|

Advice

|

Support


YOUR CHANCE NISED IN 2018!

UK-based awards ceremony in the specialty! Whether nded or a Finalist, being associated with the prestigious s and clients know you are one of the best!

TRAINING PROVIDERS The Dalvi Humzah Aesthetic Training Award for Best Supplier Training Provider The Sinclair Pharma Award for Best Independent Training Provider

REGIONAL CLINICS Best Clinic Scotland The John Bannon Award for Best Clinic Ireland The iS Clinical Award for Best Clinic South England The AesthetiCare Award for Best Clinic North England The John Bannon UK Award for Best Clinic Midlands & Wales The Dermalux LED Award for Best Clinic London

CLINIC, COMPANY OR ORGANISATION The PHI Clinic Award for Professional Initiative of the Year

O R ED BY

INDIVIDUAL PRACTITIONERS > > >

Aesthetic Nurse Practitioner of the Year The ABC Lasers Award for Medical Aesthetic Practitioner of the Year The Schuco Aesthetics Award for Outstanding Medical Achievement in Medical Aesthetics (There will be no finalists in this category and the winner will be selected on the night of the Aesthetics Awards)

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Beautifully Intelligent RF Technology TM

For more information email Fiona.comport@cynosure.com or visit cynosureuk.com/tempsure


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Advertorial Cynosure

Introducing TempSure Envi – Beautifully Intelligent™ RF Technology Want the Secret to Consistent, Reliable Treatment Results? With any radiofrequency (RF) technology, there is the inherent challenge of delivering consistent, reliable results every time, across every patient. Maintaining critical therapeutic tissue temperatures is vital for achieving the desired collagen activation and skin rejuvenation results, however many current technologies limit practitioners to a virtual guessing game. TempSure™ – the new state-of-the-art 300w monopolar radiofrequency platform from market leaders, Cynosure – is making inconsistent RF results a thing of the past. Re-booting Collagen Production – Every Time TempSure™ is a multi-modal treatment platform which uses RF energy to minimise fine lines and wrinkles, tighten skin through soft tissue coagulation and improve the appearance of cellulite. The RF technology can also be applied in additional specialist treatment modes for vaginal rejuvenation and surgical applications. The Therapeutic Logic Control (TLC) feature guarantees consistent treatments time after time: this unique time and temperature monitor only activates the treatment timer when the tissue reaches therapeutic temperature. The real-time temperature sensing technology is up to 100x faster than the competition,1 with a light alert to indicate when the target tissue is at therapeutic temperature, thereby delivering repeatable treatment results, procedure after procedure. TempSure™ Envi – For Face, Body & Beyond TempSure™ Envi is the face and body application mode of this new platform system, intended for treating forehead lines, frown lines, crow’s feet, smile lines, wrinkles and cellulite on the body. TempSure™ Envi works by delivering radiofrequency technology to non-invasively heat the deep layers of the dermis without damaging the epidermis. By increasing skin temperature for a defined therapeutic time, neo-

collagenesis is triggered resulting in tighter, younger looking skin. The powerful 300W generator allows for more consistent bulk heating during body treatments and the expandable TempSure™ platform can support additional treatment modalities as your practice grows. There are five handpieces available, ranging from 10mm-30mm, with an addon feature for cellulite treatment.

About Cynosure Cynosure Inc leads the world in aesthetic laser technologies and research, creating innovative, safe and efficacious procedures for the treatments patients want most. These include hair removal, treatment of vascular and pigmented lesions, skin revitalisation, tattoo removal, laser lipolysis to liquefy and remove unwanted fat and the temporary reduction in the appearance of cellulite. Established in 1991, Cynosure has expanded its family of products through acquisitions including Palomar, a pioneer in cosmetic laser and IPL systems. Cynosure’s product portfolio encompasses a broad range of energy sources, including Alexandrite, diode, Nd: YAG, picosecond, pulse dye, Q-switched lasers and intense pulsed light.

Safe, Powerful & Expandable TempSure™ Envi is safe for all skin types and levels of sun exposure and is minimally invasive for patients – with no surgery, no needles and no downtime. Most treatments can be performed in around 45 minutes, which makes a quick and convenient option for patients. With TempSure™ Envi, you can give your patients an easy, gentle way to maintain tighter, younger-looking skin without invasive procedures or downtime, no matter what their skin type or the time of year. The platform has a high patient satisfaction level, with 99% of patients describing the treatment as comfortable or relaxing.1 With four soothing treatment tones to choose from, your patients will look forward to returning for follow-up visits. For more information, please contact: Fiona.Comport@hologic.com +44 (0)1628 522252 REFERENCES 1. In-house study

Aesthetics | June 2018

39


Advertorial Med-fx

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Efficacy and Tolerance of Sunekos® 200 Aesthetic supplier Med-fx summarises a clinical study on a new injectable product that aims to promote neocollagenesis and elastogenesis In July 2017, Efficacy and Tolerance of an Injectable Medical Device Containing Hyaluronic Acid and Amino acids: A Monocentric Six-Month Open-Label Evaluation was published in the Journal of Clinical Trials.1 This study was conducted by researcher Adele Sparavigna from the Clinical Research and Bioengineering Institute in Milan and Alessandro Orlandini who is based at Professional Dietetics in Milan, which specialises in patented amino acid formulas. Together, Sparavigna and Orlandini investigated the results that can be achieved with Sunekos® 200; a class III medical device comprising small bottles containing 100mg of sterile and apyrogenous lyophilised of Glycine, L-Proline, L-Lysine HCP, L-Valine, L-Alanine and sterile vials containing sodium hyaluronate (30mg in 3ml of distilled water). The product, manufactured by Professional Dietetics and available through Med-fx in the UK, is designed to be used for the correction of photoageing/ageing of the face and body. The injectable solution contains low molecular hyaluronic acid (HA) and a specific amino acids mixture, which has been formulated to physiologically promote local neocollagenesis and elastogenesis through fibroblasts chemotaxis migration into the injected area.

aesthetic treatment 12 months prior to the start of the study or been administered permanent fillers in the past. The injectable solution was prepared ex tempore, mixing the amino acids powder with the HA solution. The first intradermal treatment (T1i) was performed during the first visit (T0), after basal evaluations and repeated after 10 (T2i), 20 (T3i) and 30 (T4i) days. Treatments were performed with a 30G, 13mm needle, with a microinjection technique by a specialised dermatologist, bilaterally on the face (zygomatic protuberance, nostril’s angle, inferior margin of tragus, lip-marionette lines, mandibular angle). The injected volume selected for the four implants was 3ml (1.5ml for each side) for each session performed. Subjects were evaluated in basal conditions and after 4, 8, 12 and 24 weeks, using validated clinical scales, subjective evaluations and objective quantitative outcome measures. Assessment of aesthetic results included photographic documentation. Before

Two months after

Method

Type of Improvement

Sum of medium, marked and very marked judgements

Improvement of cheeks volume

57%

Reshaping of face silhouette

62%

Reduction of deep wrinkles

57%

Reduction of superficial wrinkles

76.2%

Lifting effect

76%

Improvement of skin suppleness

67%

Improvement of skin smoothness

71.4%

Improvement of skin brightness

81%

Improvement of skin hydration

71.4%

FACIAL VOLUME LOSS (FVLS reference photographic scale) 5

4 3.8 3

2 2.0 -47.4%

1

2.2

2.0 -47.4% -42.1%

0 T0

Figure 1: Subjects’ judgements on the treatment efficacy (sum of subject % who expressed a medium, marked and very marked judgements).

40

Figure 2: Before and two months after the first injection.

Visual score (mean value)

The open single-centre study was conducted under dermatological control in Milan. It included 25 healthy female subjects aged 48-65 years, with a mean age of 57. Each had mild-moderate cutaneous photoageing, with Fitzpatrick Skin Type I-III. The subjects were instructed to avoid strong UV irradiation on the face during the study period and not to change habits regarding food, physical activity, make-up use and facial cleansing products. None of the subjects had undergone

T2M

T3M

T6M

T0: baseline T2M: 2 months after the 1st injection procedure T3M: 3 months after the 1st injection procedure T6M: 6 months after the 1st injection procedure

Aesthetics | June 2018


Results Four subjects dropped out of the study due to personal decisions. No other important events occurred that may have interfered with the results during the study period. Obtained results showed an improvement of all the clinical and subjective assessments and on the majority of objective instrumental parameters. These were already significant 10 days after the first injection procedure and were still significant and still improving after six months (at follow up). Global judgment on tolerability was good/excellent, both in the investigators’ opinion and volunteers’ self-evaluation.

Safety Results A total of nine light/moderate bruises on some injection points occurred during the protocol following injections. They totally disappeared within five to 10 days. One subject complained 48 hours after the second treatment of the appearance of a moderate bruise associated with a light oedema to the left periocular area; the event was treated with lactoferrin cosmetic cream (two times a day for five days) and followed until complete resolution. Since all these reactions represent expected events imputable to the injection procedure, the investigator judged the product tolerance as good-excellent in 100% of subjects, which was also confirmed by the subjects’ self-assessment (38% as good and 62% as excellent).

Conclusion Obtained results confirm the aesthetic performance of Sunekos® 200 on the main signs of facial skin photoageing. In particular, it was demonstrated to have an impact on the biovolumetric effect, the antiwrinkle efficacy, as well as superficial and deep moisturising activity and elasticising properties. This study supports the definition of extracellular matrix targeting for this product. The experimental work confirm that all objective and subjective outcomes achieved in the clinical study over time are comparable to those obtained with filler, despite the fact that this medical device is based on a non-cross-linked hyaluronic acid. It has been demonstrated that a simultaneous and ordered activation of collagen and elastin in the matrix is possible. This activation has proved to be capable of counteracting elastosis. The efficacy of the product is not limited to the period of treatment, but has been verified in follow-up, where a significant increase of the parameters of rejuvenation of the extracellular matrix are still present after six months. The majority of volunteers noticed the treatment efficacy and underlined, in particular, the product’s anti-wrinkle, filling and biorevitalising activity, as well as the lifting effect and the reshaping of the facial silhouette.

Next Generation Skin Regeneration Restores the naturally youthful look of the skin through deep regeneration, stimulating production of new collagen and elastin in the face, neck, arms and hands. Sunekos. Better because… • Restoring the biological functions of the derma through effective deep hydration • Patent protected combination of Hyaluronic Acid and Amino Acids • Noticeable and lasting improvement for over 6 months*

REFERENCES 1. Sparavigna A, Orlandini A, ‘Efficacy and Tolerance of an Injectable Medical Device Containing Hyaluronic Acid and Amino acids: A Monocentric Six-Month Open-Label Evaluation’, J Clin Trials, (2017), 7: 316.

Exclusively from Med-fx - with complete support & training from our specialist team. Visit training.medfx.co.uk *Sparavigna A and Orlandini A Efficacy and Tolerance of an Injectable Medical Device Containing Hyaluronic Acid and Amino acids: A Monocentric Six-Month Open-Label Evaluation J Clin Trials, an open access journal ISSN:2167-0870 Volume 7 • Issue 4 • 1000316

MED4113-Sunekos-Campaign-HP.indd 1

17/04/2018 13


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The Impact of Sun on Skin Dr Jorge Zafra discusses the different ways the body is affected by sunlight Now that the days are becoming sunnier in the UK and holiday season has begun, the importance of understanding the impact of sunlight exposure and vitamin D is crucial to be able to recommend appropriate skincare and assess our patients’ health from an antiageing perspective. Ageing is a multifactorial process, which depends on both intrinsic and extrinsic factors. The main extrinsic factor is sun exposure; ultraviolet (UV) rays have positive effects on our body predominantly through the activation of vitamin D.1,2,3,4 However, UV rays also have negative effects on the skin, increasing the risk of skin cancers and photoageing. Healthy lifestyle recommendations are key to minimising the signs of ageing and maximising the outcome of aesthetic treatments.

Vitamin D Living organisms began to evolve in the oceans more than one billion years ago. Emiliania huxleyi, which is a type of photosynthetic plankton that forms the basis of virtually all marine food webs, has existed unchanged for millions of years. When exposed to sunlight, not only does it photosynthesise glucose, but it also produces vitamin D2, which is essential for their exoskeleton. Since life on earth has evolved from these type of organisms this could explain why vertebrates, including humans, have depended on sun exposure for the maintenance of their calcium metabolism.5 UV rays emitted by the sun are divided into three major subtypes: UVA (320-400 nm), UVB (290-320 nm), and UVC (200-290 nm). UVA and UVB reach the earth and penetrate the skin; UVA makes up approximately 95% of the total UV rays, while UVB only makes up about 5%. UVC meanwhile is effectively absorbed in the upper atmosphere, preventing it from reaching the earth.1,6 Only UVB has a role in vitamin production and it mainly acts on the epidermal basal layer of the skin. It has a beneficial and essential impact in humans due to the production of Vitamin D3. UVB acts on subcutaneous 7-dehydrocholestrol (7-DHC) to convert it into pre-vitamin

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D3, after which it is thermally converted into 25-hydroxycholecalciferol (25(OH)D3) (calcifediol).2 Calcifediol is then converted primarily in the kidneys and liver into its most hormonally-active form, 1α,25dihydroxvitamin D3 or calcitriol. Calcitriol, the active form of vitamin D3, regulates nearly 60 genes, through which it can down-regulate protooncogenes such as c-myc, c-fos and c-jun, as well as up-regulate genes responsible for cell cycle arrest. Calcitriol can also stimulate DNA repair, affect the immune system and is found to be implicated in regulating our mood. The increase in serum 25(OH)D attained from exposure to UVB radiation is often more effective than ingesting 1000 IU vitamin D. Exposing 20% of the body surface to sunlight is equivalent to ingesting approximately 1400-2000 IUs of vitamin D3.6 Although UVB has positive effects on vitamin D production, it is also thought to be most responsible for skin cancers as it is the typical source of sunburn, inflammation, DNA damage, oxidative stress, free radical production, immunosuppression and photoageing.2,6 Vitamin D deficiency The degree of skin pigmentation and age influences vitamin D production as larger amounts of melanin on the epidermal layer protect from the UV rays, however reduce the skin’s ability to produce vitamin D and the production also decreases with age.6,7,8,9 The definition of vitamin D deficiency, based on 25 (OH) D serum levels, is a motive for controversy in literature. Levels above 30 ng/ml (> 75 nmol/l) are considered satisfactory by a number of authors like Trummer et al.10 in their review of beneficial effects of UV radiation. Levels lower than 20 ng/ml (< 50 nmol/l) may be consensually considered as vitamin D deficiency, since 97.5% of the population is above this level.7,10 The following are considered as risk factors for the development of vitamin D deficiency:9 • Infants receiving prolonged exclusive breastfeeding (significant cause of rickets) • The elderly (older skin produces less vitamin D) • Individuals with low sun exposure • Extreme climate conditions or in high latitudes • Rigorous use of photoprotective measures • Covering the skin for religious practice reasons • People with dark skin (Fitzpatrick phototypes V and VI) as they have higher melanin in the epidermal layer, reducing the skin’s ability to produce vitamin D from sunlight • Patients with malabsorption syndrome • Patients with a BMI over 30 as greater amounts of subcutaneous fat can sequester more of the vitamin and alter its release into circulation Daily doses of vitamin D recommended by the Food and Nutrition Board for deficiency prevention in individuals at risk are:9,11 • 0-12 months: 400 IU/day
 • 1 to 70 years of age: 600 IU/day
 • > 70 years of age: 800 IU/day Intoxication by vitamin D, associated with hypercalcemia and hyperphosphatemia, is extremely rare and may be caused by doses greater than 50,000 UI per day and a level of (25 (OH) D) above 150 ng/mL. Photodegradation of vitamin D3 produced by the skin avoids intoxication by vitamin D through sun exposure.9,10

Sun exposure and skin cancer Our skin is the first line of defense against environmental toxicants and consequently suffers directly from the deleterious effects of UV radiation. UV radiation is the primary source for the development of

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


The active ingredient of NatraSan Skin is HOCI or hypochlorous acid, a highly effective weak acid that is naturally present in the human immune system. Ingredients are water, salt and hypochlorous only. NatraSan Skin contains no sodium hypochlorite, Phosphoric Acid or Alcohol. The shelf life is 18 months (even after opening) NatraSan Skin delivers ultimate levels of skin and tissue disinfection and is powerfully bactericidal, virucidal, fungicidal and sporicidal. NatraSan Skin is also fast acting and kills pathogens on contact. Available in 500ml for clinic use and 100ml for patient use.

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cutaneous cancers, which affects the Caucasian population more frequently.4,6 Most skin cancers diagnosed are non-melanoma skin cancers, consisting of squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs), accounting for around 96% of all skin cancers, while cutaneous malignant melanoma (CMM) for the remaining 4%.6 Most skin cancers develop on sun-exposed areas of the skin. The non-melanoma skin cancers are more easily treatable as they are diagnosed earlier whereas melanoma, the least common form of skin cancer, is often lethal.6 The lifetime risk assessments demonstrate that those with lower exposures rates to UV rays, like the average UK holiday maker, have an increased risk for developing CMM. The pattern of SCCs is the accumulated UV exposure that determines the risk for development. Studies demonstrate that around 83% of children have sunburn in the summer, a percentage that drops to 36% among teenagers.6 The incidence of melanoma and non-melanoma skin cancer in patients with sunburn history is well documented in meta-analysis; this was the base for a mathematical model by Schalka et al. in 2014 that concluded that the habit of applying sunscreen in the first 18 years of life reduced the incidence of skin cancer by 78% during lifetime, attributing this possibility due to the number of sunburn episodes in childhood and adolescence.3

Sun exposure and photoageing Practically, ageing signs can be classified into four main categories: wrinkles/texture, loss of firmness of cutaneous tissues (ptosis), vascular disorders, and pigmentation heterogeneities. Kligman and Kligman introduced the term ‘photoageing’ in 1986 so to differentiate intrinsic from extrinsic ageing of the skin.1,12 Intrinsic ageing is the ‘natural’ process, caused by the accumulation of reactive oxygen species (ROS), resulting from oxidative cellular metabolism and influenced by genetic factors (ethnicity), anatomic variations and hormonal changes (natural decline of hormone and growth factor levels). Despite the identification and understanding of the causes of chronological ageing, this process is considered incontrollable.1,2,3,4 Extrinsic ageing is responsible for 80% of the visible signs of skin ageing, which include the aesthetic signs of ageing and the clinical injuries like the non-melanoma skin cancers. It is a result of chronic exposure to various environmental elements, such as sun and UV exposure (the main extrinsic factor),1,2,3,4 pollution, smoking, diet, repetitive muscle movements (squinting, frowning, pursing, etc), sleeping position and cutaneous or general diseases.1 This type of ageing is mediated by two processes that disrupts the skin collagen matrix: decreased collagen synthesis and increased collagen degradation. The main traits of photoaged skin is the accumulation of damage to the extracellular matrix fibres of collagen and elastin, by accumulation of elastotic material composed of aggregated elastin fibres.4 Photoageing ultimately simulates a typical wound-healing response with deposition of collagen type I, which is seen in scars, rather than the usual mixture of collagen type III and I that gives skin resilience and pliability.13

Solar protection The most important products used for skincare are sunscreens (physical or chemical) because of their ability to prevent photoageing.14 The elements present in sunscreens are called UV filters. These interfere directly with the incident solar radiation through absorption, reflection or dispersion of energy. From the structural viewpoint, UV filters can be organic/chemical or inorganic/physical.14 The chemical filters absorb UV ray photons, promoting an alteration in their molecular structure. The physical filters have a mineral origin and promote the reflection of UV radiation to the external part of the tissue.6,15 An SPF15 sunscreen filters out 93% of UV radiation, SPF30 a 96% and

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SPF50 a 98%.15 The general guideline for sunscreen application is to use 2mg of sunscreen per cm2 of skin surface.16 Evidence suggests that most users apply insufficient amounts of sunscreen; moreover, individuals may overestimate the amount of time that they can stay in the sun after applying sunscreen relative to their skin type.6,15 It is therefore important to advise patients accordingly. Patients should be advised to avoid sun exposure without adequate protection, especially in the period of greater risk between 10:00am and 3:00pm.3,9 Children younger than six months of age should not be directly exposed to the sun and should not make regular use of sunscreen to allow adequate synthesis of vitamin D.3,9

Conclusion Knowledge about vitamin D, skin cancer risk and motivation to prevent sunburn does not seem to play a role on the perceived importance of tanning, while implementing sun-safe practices have been viewed as interfering with people’s recreational experiences. UVB exposure is necessary for maintaining a healthy lifestyle due to its important role in the synthesis of vitamin D3. However, UVB also causes a number of adverse health effects ranging from sunburn to skin cancer. The use of sunscreen with SPF higher than 30 is recommended to everyone older than six months when exposed to the sun, it should be applied in recommended amount and reapplied accordingly.3,15 Oral supplementation of vitamin D is indicated for all the population with risk factors to develop vitamin D deficiency.9 Dr Jorge Zafra has a Master’s degree in Aesthetic and Anti-ageing Medicine from the Universitat de Barcelona, Spain. He has worked as a GP and has had a vast international and multicultural experience throughout his medical career. His private medical practice, Zafra Medical, is based in Clifton Village in Bristol. REFERENCES 1. Clatici, V. et al. Perceived Age and Life Style. The Specific Contributions of Seven Factors Involved in Health and Beauty. MAEDICA – a Journal of Clinical Medicine 2017; 12(3): 191-201 2. Parrado C, Mascaraque M, Gilaberte Y, Juarranz A, Gonzalez S. Fernblock (Polypodium leucotomos Extract): Molecular Mechanisms and Pleiotropic Effects in Light-Related Skin Conditions, Photoaging and Skin Cancers, a Review. IJMS. 2016 Jul;17(7):1026–21. 3. Schalka S, Steiner D, Ravelli FN, Steiner T, Terena AC, Marçon CR, et al. Brazilian Consensus on Photoprotection. An Bras Dermatol. 2014;89(6 Suppl 1):S6-73. 4. Vierkötter, Andrea . Environmental in uences on skin aging and ethnic-specific manifestations. Dermato-Endocrinology 4:3, 227–231; July–December 2012; © 2012 Landes Bioscience 5. Wacker, Matthias and Holick Michael F. Sunlight and Vitamin D; A global perspective for health. Dermato Endocrinology 5:1, 51–108;January 2013. 6. Parrado C, Mascaraque M, Gilaberte Y, Juarranz A, Gonzalez S. Fernblock (Polypodium leucotomos Extract): Molecular Mechanisms and Pleiotropic Effects in Light-Related Skin Conditions, Photoaging and Skin Cancers, a Review. IJMS. 2016 Jul;17(7):1026–21. 7. Hossein-nezhad A, Holick MF. Vitamin D for Health: A Global Perspective. Mayo Clinic Proceedings. 2013 Jul;88(7):720–55. 8. D’Orazio J, Jarrett S, Amaro-Ortiz A, Scott T. UV Radiation and the Skin. IJMS. 2013 Jun;14(6):12222–48. 9. National Institute of Health, Fact sheets for Health professionals Vitamin D. Revised March 2 2018. <https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/> 10. Trummer C, Pandis M, Verheyen N, Grübler M, Gaksch M, Obermayer-Pietsch B, et al. Beneficial Effects of UV-Radiation: Vitamin D and beyond. IJERPH. 2016 Oct;13(10):1028–16. 11. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010. 12. Kligman LH, Kligman AM. The nature of photoageing: its prevention and repair. Photodermatology. 1986;3:215–227. 13. Papakonstantinou E, Roth M, Karakiulakis G. Hyaluronic acid: A key molecule in skin aging. DermatoEndocrinology. 2014 Oct 27;4(3):253–8. 14. Kostyuk V, Potapovich A, Albuhaydar AR, Mayer W, De Luca C, Korkina L. Natural Substances for Prevention of Skin Photoaging: Screening Systems in the Development of Sunscreen and Rejuvenation Cosmetics. Rejuvenation Research. 2018 Apr;21(2):91–101. 15. Rodrigues AM, Sniehotta FF, Birch-Machin MA, Araujo-Soares V. Aware, motivated and striving for a “safe tan”: an exploratory mixed-method study of sun-protection during holidays. Health Psychology and Behavioral Medicine. Taylor & Francis; 2017 Jun 5;5(1):276–98. 16. British Association of Dermatologists, Sunscreen Fact Sheet, 2013. <http://www.bad.org.uk/for-thepublic/skin-cancer/sunscreen-fact-sheet

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


Skin Protection - not just sun protection.

Protect, Smooth, Repair This lightweight, transparent fluid offers physical broad spectrum sun protection with a virtually invisible universal tint and ultrasheer mattifying texture that is ideal for all skin types, including sensitive skin.

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this is the phase that can cause itching, swelling and redness. 3. Proliferation is the ‘rebuilding’ phase where new tissue and blood vessels are being created. By this stage the skin should be a healthy pink colour and should be sufficiently stable, so as to not bleed if disturbed. 4. Maturation commences once the wound has closed and the dermal tissue begins to mature and strengthen.1

Healing the Skin Dr Sophie Shotter explains how the skin repairs itself and the importance of good hygiene for quality healing In my experience, the way the skin is cared for following an aesthetic procedure can have as much influence on the outcome of a treatment as the procedure itself. The term aesthetics is applied to a very broad range of procedures, including noninvasive treatments such as light therapy, peels or injectables, right the way through to surgical facelifts and implants. Whatever the procedure, they all, to a varying degree, involve causing a level of disruption or trauma to the skin. Generally speaking, the more invasive the procedure, the more skin trauma caused; however, there are also many non-invasive procedures such as dermal needling, facial peels or lasering, which involve causing deliberate trauma in order to stimulate the process of cell regeneration and therefore skin healing. Managing the healing process is consequently an intrinsic aspect of all aesthetic procedures and, without exception, the better the quality of skin healing, the better the end result.

How skin heals A four-stage model is typically used to describe the skin healing process.1 Although initially developed to describe wound healing in medical environments, the same process takes place following an aesthetic procedure – whether this be on a micro-scale following injectables or after a more invasive procedure such as a surgical face lift. 1. Hemostasis is the stemming of blood flow. This involves the constricting of damaged blood vessels and the production of platelets to thicken the blood and coagulate the wound. 2. Inflammation is the symptom of antibodies, nutrients and white blood cells travelling to the site of the injury. The predominant cells at work are the phagocytic cells – neutrophils and macrophages – which mount a host response and break down any devitalised necrotic/sloughy tissue. Although a natural part of the process,

Irrespective of whether the wound is of a medical or aesthetic nature, the most desirable outcome is for the skin to heal as quickly and effectively as possible. Healthy, smooth and attractive skin is, after all, the goal of all aesthetic procedures and the quicker that redness, swelling, and bruising subsides and broken skin heals, the sooner the patient will be able to enjoy the results of their procedure. Rapid healing also gives protection against infection; all the while the dermal layer is ‘unzipped’ we are susceptible to the ingress of pathogens, which not only presents the risk of infection, but will slow the healing process. Fortunately, the incidence of severe infections in aesthetics is low; however, this is no reason to be complacent.2 The type of procedures being conducted in aesthetic clinics often entail similar skin incisions to that undertaken in medical surgery where methicillin-resistant Staphylococcus aureus (MRSA) and sepsis are prevalent concerns. For example, lesion removals and onestitch facelifts all require bigger incisions. In addition to speed, the quality of skin healing is just as important. It is the quality of healing that determines how well the skin knits together whether there will be any lasting discoloration or scarring. In medical environments, scars are often the tell-tale sign to a patient having undergone surgery. In aesthetics, this would somewhat undermine the purpose of having a procedure conducted in the first place. Doing what we can to optimise the quality

Figure 1: The wound healing process1 Hemostasis

Inflammation

Proliferation

Maturation

Scab Freshly healed epidermis Fibroplast

Blood clot

Macrophage

Freshly healed dermis Blood vessel

Fibroblasts proliferating

Subcutaneous fat

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of skin recovery is therefore part and parcel of delivering the results our patients seek.

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Hypochlorous use

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Soap and water use

Promoting good skin healing through hygiene As part of post-procedure care, we all give patients strict advice on many aspects to improve their healing and their outcomes, including not touching their face or applying makeup, avoiding intense exercise and avoiding any substances that may increase bruising. One of the most important contributors to skin healing is hygiene, as microbial load is implicated as causative in many aesthetic complications.3 Whilst it is impossible to achieve wound sterility, (our skin is constantly shedding dead cells and excreting natural oils and sweat),4 it is important to do all we can to manage the level of bacterial contamination the recovering skin competes against. It is widely acknowledged that high microbial loads, high levels of microbial diversity and, of course, the presence of pathogenic organisms, have a significant negative impact on speed and quality of wound healing.5 Ultimately, where contamination is too high, infections will result. Keeping a treated area clean after a procedure is therefore paramount. One of the biggest hygiene challenges following a procedure is to ensure the patient doesn’t touch the treated area with anything other than cleanly washed hands. However, even ambient contamination from the air, the clothes we wear and the bed sheets we sleep on, can slow recovery.6 As can of course, the application of makeup, which will not only contaminate a recovery site, but will also prevent the wound from ‘breathing’, which again will inhibit the healing process.7 However, overzealous attempts to keep a wound clean can also slow its progress.8 Typically, when a wound occurs a lot of the surrounding tissue is harmed and therefore dies, even if it looks ‘ok’ at the time of the initial injury. To optimise healing this then needs to be removed so that non-viable tissue doesn’t impair healing of healthy tissue. In aesthetics, it would most likely be the unintentional debridement of a wound resulting from it getting too wet from daily hygiene routines such as showering. Whilst keeping the area clean is good, it can be detrimental if the wound gets too wet and maceration and tissue breakdown occurs.7 It is also worth noting that the needle punctures from the likes of fillers and toxin seal so quickly that it would be less relevant for this. So, what is needed is a protective layer

Figure 2: Patient healing 10 days post surgical facelift. The patient used Clinisept+ hypochlorous solution on their right side and gentle soap and water on their left. Images courtesy of Mr Paul Baguley. Soap and water use

Hypochlorous use

Figure 3: Patient healing 10 days post surgical facelift. The patient used gentle soap and water on their right side and Clinisept+ hypochlorous solution on their left. Images courtesy of Mr Paul Baguley.

that shields the wound from contamination and yet allows it to breath and regenerate cleanly – hence the use of dressings for more serious wounds. However, it is still highly desirable to keep the area clean whilst the wound continues through the latter, ‘proliferation’ and ‘maturation’ stages of its recovery and the same applies to any aesthetic procedure, particularly resurfacing treatments. Achieving this during the process of cell regeneration is difficult; re-growing skin cells that are highly susceptible to any external chemistries and even the slightest levels of toxicity will hamper the healing process in exactly the same way that external pathogens do.9

Types of skin disinfectants and their efficacy Providing the ideal environment for postprocedure skin recovery requires a careful balance to be struck between applying an agent that is strong enough to remove the microbial load, but that is not so strong that it creates a toxic environment that slows the growth and damages the re-growing skin.10 The majority of skin disinfectants are based upon chlorhexidine, iodine or alcohol. However, although effective in killing bacteria, are also cytotoxic to the skin. Cytotoxicity can cause a degree of chemical burden, stinging and irritating the skin, which hampers and slows the recovery process.11 There are alternatives that are gentle on the skin, such as witch hazel, or a mild soap and water dilution is sometimes used for aftercare, despite only having a modest disinfecting performance. However these

are not sufficiently antimicrobial to deliver the microbiologically clean environment that re-growing skin cells need for optimum regeneration.12 To put this into context, even clean drinking water contains millions of organisms. Hypochlorous acid solutions are a newer skin disinfectant, which combines highly effective disinfecting ability with excellent skin compatibility.13-18 Although well proven in antimicrobial efficacy, hypochlorous solutions have only recently been produced in a sufficiently stable format to retain its purity and therefore skin compatibility. Hypochlorous is the same solution produced by the body’s own immune system during the inflammatory stage of wound healing – the previously mentioned stage two.19 This hypochlorous solution is produced by neutrophils in the white blood cells to fight invading pathogens when the skin is damaged. Being able to replicate this enables the same chemistry to be applied on the outside of the skin as is being produced naturally on the inside. Because of it being ‘host natural’, it is non-cytotoxic to re-growing cells, causing no inflammatory response or irritation and is also non-sensitising when applied. As a result of using this technology, the skin is quickly calmed with significant reductions in erythema, oedema and patient discomfort.16 Results are also optimised; skin rapidly recovers from procedures at its own natural pace, which is typically significantly faster than occurs with traditional aftercare regimes.20 Practitioners should note that there are different formulations of hypochlorous solutions. I suggest that when choosing between solutions that

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practitioners choose one that is of very high purity to ensure maximum hygiene and protection against infection.

Conclusion Ways to promote good skin healing through hygiene should be considered by every aesthetic professional. Many chemistries are actually cytotoxic and can cause a degree of chemical burden to the skin which disrupts the skin’s recovery process. In my opinion, they are therefore useful for skin preparation on intact skin before an aesthetic procedure, but should not be used as aftercare. Hypochlorous acid solution enables pre-procedure levels of hygiene to be maintained as the skin heals and, crucially, without the chemical burden that compromises most skin cleansing chemistries.

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Disclosure: Dr Sophie Shotter is a trainer for UK aesthetic distributor AestheticSource, which distributes a hypochlorous solution. Dr Sophie Shotter is an aesthetic doctor with a practice in Kent called Illuminate Skin Clinic. Dr Shotter has a special interest in holistic approaches to antiageing and wellness, with combination treatments at the core of this. She is a key opinion leader for several leading aesthetic companies, and is regularly called on to speak and teach. REFERENCES 1. Leaper DJ & Harding KG, Wounds: Biology & Management, Oxford Medical Publications, 1998. 2. Bailey SH, Cohen JL, Kenkel JM. Etiology, Prevention and Treatment of Dermal Filler Complications. Aesthet Surg J 2011;31(1):110-21. 3. Helena Collier, ‘The role of bacterial biofilms in aesthetic medicine’, Journal of Aesthetic Nursing (December 2014). 4. Yamini Durani, MD May 2013 5. M. Tuttle et al. Association Between Microbial Bioburden and Healing Outcomes in Venous Leg Ulcers: A Review of the Evidence, Adv Wound Care (New Rochelle). 2015 Jan 1; 4(1): 1–11. 6. John Fallon, Contamination of Bed Linen: Factors in Microbial and Allergen Accumulation, ICT Infection Control Today, 2018. <http://www.infectioncontroltoday.com/transmission-prevention/ contamination-bed-linen-factors-microbial-and-allergen-accumulation> 7. R. Campana, C. Scesa, V. Patrone, E. Vittoria and W. Baffone, Microbiological study of cosmetic products during their use by consumers: health risk and efficacy of preservative systems, stituto di Scienze Tossicologiche, Igienistiche ed Ambientali, Universita` di Urbino ‘Carlo Bo’, Urbino, Italy, 2016. 8. Bale S, V Jones (1997) Wound Care Nursing: A patient-centred approach. Baillière Tindall Published in association with the RCN, London Black D (1982) Inequalities in Health (Black report). Penguin, Harmondsworth 9. Antiseptics (US: Encyclopedia.com, 2004) <http://www.encyclopedia.com/medicine/drugs/ pharmacology/antiseptics> 10. Sandle, Tim. (2016). Standards and controls for skin disinfection. The Clinical Services Journal. 15. 25-28. 11. Khan S, Khan AU, Hasan S. Genotoxic assessment of chlorhexidine mouthwash on exfoliated buccal epithelial cells in chronic gingivitis patients. J Indian Soc Periodontol 2016;20(6):584-591 12. Friedman M, Wolf R (1996). Chemistry of soaps and detergents: various types of commercial products and their ingredients. Clin. Dermatol. 14: 7-13. 13. Lorrain Smith, A. Murray Drennan, Theodore Rettie and William Campbell, ‘Experimental Observations on the antiseptic action of Hypochlorous Acid and its application to wound treatment,’ Br Med J, Jul 1915; 2:129 – 136. 14. L. Wang et al. ‘Hypochlorous Acid as a Potential Wound Care Agent: Part I. Stabilized Hypochlorous Acid: A Component of the Inorganic Armamentarium of Innate Immunity, Journal of Burns and Wounds, April 2007. 15. Martin C, Robson et al, ‘Hypochlorous Acid as a Potential Wound Care Agent: Part 2. Stabilized Hypochlorous Acid: Its Role in Decreasing Tissue Bacterial Bioburden and Overcoming the Inhibition of Infection on Wound Healing’, Journal of Burns and Wounds, April 2007. 16. Selkon JB, Cherry GW, Wilson JM, Hughes MA., ‘Evaluation of hypochlorous acid washes in the treatment of chronic venous leg ulcers’, J Wound Care, 2006 Jan;15(1):33-7. 17. Serhan Sakarya, Necati Gunay, Meltem Karakulak, Barcin Ozturk, Bulent Ertugrul, ‘Hypochlorous Acid: An Ideal Wound Care Agent With Powerful Microbicidal, Antibiofilm, and Wound Healing Potency’, Wounds, 2014;26(12):342-350. 18. Mimi Mekkawy & Ahmed Kamal, ‘A Randomized Clinical Trial: The Efficacy of Hypochlorous Acid on Septic Traumatic Wound’, Journal of Education and Practice, 2014, 5:16. 19. L. Wang et al. ‘Hypochlorous Acid as a Potential Wound Care Agent: Part I. Stabilized Hypochlorous Acid: A Component of the Inorganic Armamentarium of Innate Immunity, Journal of Burns and Wounds, April 2007. 20. Dr Paul Baguley MB ChB BSc LMCC MD FRCPC FRCSC FRCSEd Plas “with Clinisept+, I am seeing levels of skin recovery in 10 days that I would normally expect to see in three weeks”.

“This book is for ALL medical practitioners practising or wishing to practise in medical aesthetics. Whether you’re a learner driver or someone who has got a bit jaded and is stuck in the middle lane, this book will pump you so full of fuel and ambition that you will want to push your business to Formula One levels” Lorna Jackson

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An innovative product portfolio to give a lift to your patients and your business For more information on the Sinclair aesthetic products and training support visit: www.sinclair.com Sinclair Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. Date of preparation: May 2018


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only our skin, but the underlying muscles/fat pads and bone structure alters. As with the effect of gravity, any loss of volume or laxity to the mid-face will produce a pronounced loss of lower face structure and aesthetic appeal. For purposes of this article, we will be focusing on the lower face; however, it is still key to assess the patient using the three-zone approach to achieve a truly satisfactory aesthetic outcome. The lower face can be broken up into the perioral, the jawline and the chin, which each have their own subsection, as demonstrated in Figure 2.3

Treating the lower face Botulinum toxin and HA fillers can be used to treat the lower face for a variety of indications. Botulinum toxin treatment is performed for the relaxation and restriction of movement of the underlying muscles, and dermal fillers are used for restoring volume and support for deeper soft tissues. For each area and subsection, we will try to evaluate the safety and efficacy of both botulinum injections and dermal fillers with the objective of providing a complete aesthetic outcome. Dr Zohaib Ullah provides an introduction In general, both botulinum toxin and dermal fillers, in to lower facial aesthetics and explores the experienced and knowledgeable hands, are very safe. use of injectable treatments in the area Procedural awareness, injection technique and skill is key, as well as a sound understanding of the patient’s Facial aesthetic treatments with the use of botulinum toxin anatomy and a good, careful, medical and treatment history will and hyaluronic acid (HA) soft tissue fillers have come a long help to ensure good patient selection. way since they were first introduced. Main indications related to facial aesthetics continue to be localised to the use on the Perioral area upper face.1,2 However, treating the lower face with botulinum Given the perioral area is the region used for speaking, eating toxin and dermal fillers is now common practice among medical and breathing, amongst other things, it is an area which should aesthetic professionals. To undergo safe and successful treatment, always be considered when assessing the lower face for practitioners must consider the structure and function of the lower rejuvenation. The lips are the main feature of this region and are face, and understand how to approach each anatomical region. more commonly associated with purely dermal filler treatment. This is because, as we age, we lose both shape and volume. Latest fashion trends have suggested that plumper, fuller lips with good definition are popular and deemed to be more aesthetically pleasing, as evidenced on social media by popular celebrities and ‘influencers’. The lips are a truly delicate area and when using dermal fillers, the margins for error are comparatively small. This is because the plane in which the product is placed is, at best, only 1-2mm in width,4 so it can be very easy to inject into the underlying musculature rather than the correct plane. Given the properties of dermal fillers, and the added tendancy to involve anaesthesia, they have a hydroscopic effecy and draw in fluid, which will almost always result in a more Figure 1: The three main areas of the face3 swollen appearance, so good counselling on post-procedure visual outcomes is a must to manage Assessing the face expectations. Inadequate experience, as well as injecting into the When assessing the patient, practitioners can use a three-zone lips, can also lead to extensive bruising, and can present ‘lumps’ approach to the face, which comprises three main areas – the of the product forming if not carefully administered. Long-term upper, the mid and the lower face (Figure 1).3 reactions, including granulomas, are rare but not unheard of, with Any changes to the mid-face (ie: cheek volume) subsequently also many level 4 evidence case series documenting this.5 influence changes to the lower part of the face. As we age, not There is also a role for toxin to be used in the surrounding radial/

Lower Face Aesthetics

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used in the volumisation of the cheeks to try to raise this region.8 I have found that using dermal fillers just anterior to the jowls can D help to reshape and define the jowl borders in isolation. More commonly however, it is B at this point where radiofrequency/PDO threads, and ultimately surgical lifts are C A required if all above methods to stabilise G E the mid-face fail, but as we are focusing on toxin and fillers, these will not be discussed F in detail. H Masseter hypertrophy is an aesthetic concern for many as it gives the look of a widened Perioral: lips (A), radial lip lines (B), oral commissure (C), nasolabial lines (D), marionette lines (E) mandible. This is not only an aesthetic but Jawline: mandibular loss of definition, which relates to masseters (G) the jowls (F) also a medical concern, given that some Chin: mentalis (H) patients complain of troubles with mastication, lips lines. By applying toxin to the perioral lines superficially, as well as subsequently painful jaws due to teeth grinding (which practitioners can smooth out, soften and often remove lines, theoretically causes the hypertrophy in the first place). The use of providing a much more complete perioral aesthetic outcome. toxin in the masseter allows for relaxation of the muscle and, over Large amounts, or incorrectly placed toxin, can result in lip paralysis time, reduction of the masseter muscle itself.9 Many case studies have and so care needs to be taken. Level 2 evidence has suggested shown the beneficial effect of toxin use in this area, with statistically that injections are therefore best done using small amounts with significant mean masseteric volume reduction, including when regular top ups in the first instance.6 The increase in depth of the performed in comparison trials with photographic confirmation.10,11,12 oral commissure with age can result in the typical ‘sad’ smile. Again, One level 4 study comprising 22 participants reported up to 30% affected by surrounding tissue droop and skin laxity, it is an area reduction in mean masseteric volume.13 Complications, however, do 8 also directly controlled by the depressor anguli oris. By injecting the include possible damage to the mandibular branch of the facial nerve, depressor anguli oris with botulinum toxin, we can help improve the change in mastication forces, speech disturbance due to overdosing commissure’s shape, giving a lift, also improving marionette lines. and occasionally muscle pain, facial asymmetry, and prominent Adding dermal filler into this region will help to not only stabilise the zygoma, demonstrated in a study with level 4 evidence.14 oral commissure, but also to add volume to the marionette lines that so readily form in this area, due to the ageing process.9 Chin It is generally accepted that there are two main issues when Jawline it comes to the chin. One is the dimpling effect caused by the A combination of mid-facial changes, including skin laxity, soft tissue mentalis muscle, and the other is no chin volume secondary to volume loss and structural bone changes, can make the jowl area hereditary bone definition. The chin is a good example of where difficult to treat. This is especially if the practitioner is only focusing toxin and fillers can both work hand in hand. Chin rhytides are on the lower face. A combined approach should always be used caused by the dermal atrophy of the mentalis. This can cause an with the mid-face to help improve this area. Dermal fillers can be unsightly dimpling effect when facial expressions are made.15 Toxin injected into the rhytides superficially is of great use as it helps to not only smooth out wrinkles, but also to improve facial expression, thus resulting in a more uniform and levelled chin.16 When it comes to adding volume and prominence to the chin, the use of a dermal filler will always help to contour the chin and provide a great aesthetic outcome.17 The injection sites need to be accurate; product should be placed between tissue and bone, to avoid the neurovascular bundle that runs close by.15 This not only limits complications, but also provides a firm base by which to stabilise the mentalis and provide good lift and definition.18 Figure 2: The areas within the periorial, jawline and the chin in the lower face

When assessing the patient, practitioners can use a three-zone approach to the face, which comprises three main areas – the upper, the mid and the lower face

Side effects Both botulinum toxin and HA fillers have potential side effects, some of which have been discussed in the relevant sections above. Although infrequent, attention to detail in injecting safely and correctly, added with good clinical knowledge, are key to minimising risks involved. Botulinum toxin side effects can range from simple headaches, which are more common,19 to more serious side effects such as eyelid disorders and the absolute worst case scenario, eyelid ptosis.20 Vascular compromise is known to be the major adverse event to look for when injecting HA fillers, although others can include local inflammatory reactions, inappropriate placement and technique-

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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related issues. Although these side effects are possible, they are relatively rare, especially the most catastrophic – blindness due to vascular occlusion.21,22

Conclusion The lower face is frequently treated with varying techniques, doses and outcomes. Both HA fillers and botulinum toxin have a relatively safe profile and, in experienced and knowledgeable hands, can provide fantastic results. However, it is always good to be aware of complications as when they do occur as they can be life changing. Combining treatments, of course, helps to provide much more superior aesthetic outcomes rather than if treated in isolation.23 Dr Zohaib Ullah is the clinical director at My Skin Clinic and also a trainer at My Skin Clinic Training Academy, educating other medical practitioners in the field of aesthetic medicine. He specialises in non-surgical facial aesthetics, skin rejuvenation and antiageing treatments. He is a member of the BCAM and is procuring his Master’s degree in aesthetics. REFERENCES 1. Patricia T Ting and Anatoli Freiman ‘The story of Clostridium Botulinum from food poisoning to Botox’, 2004. <https://www.ncbi.nlm.nih.gov/pubmed/15244362> 2. Kontis TC1, Rivkin A., ‘The history of injectable facial fillers’, Facial Plast Surg. (2009) 25 (2), pp.67-72. 3. Introduction to Facial Musicles for the Botox Training (2014) <https://botoxcourses.wordpress. com/2014/08/12/introduction-to-facial-muscles-for-the-botox-training/> 4. Gerard J. Tortora, Sandra R Grabowski, ‘Principles of Anatomy and Physiology’, 10th Edition. 5. El-Khalawany M1, Fawzy S2, Saied A3, Al Said M4, Amer A5, Eassa B6., ‘Dermal filler complications: a clinicopathologic study with a spectrum of histologic reaction patterns’, AnnDiagn Pathol., (2015) 19(1), pp.10-5. 6. Carruthers A1, Carruthers J, Monheit GD, Davis PG, Tardie G., ‘Multicenter, randomized, parallelgroup study of the safety and effectiveness of onabotulinumtoxinA and hyaluronic acid dermal

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fillers (24-mg/ml smooth, cohesive gel) alone and in combination for lower facial rejuvenation’, Dermatol Surg. (2010) 36 Suppl 4, pp.2121-34. 7. Alberto Goldman and Uwe Wollina, ‘Elevation of the Corner of the Mouth Using Botulinum Toxin Type A’, J Cutan Aesthet Surg., (2010) 3(3), pp.145-150. 8. William J.Lipham, Jill S. Melicher, ‘Cosmetic and Clinical Applications of Botox and Dermal Fillers’, 3rd Revised edition. 9. Wanitphakdeedecha R1, Ungaksornpairote C1., ‘The efficacy of two formulations of botulinumtoxin type A for masseter reduction: a split-face comparison study’, J Dermatolog Treat., (2016), pp.1-4. 10. 1Wanitphakdeedecha R et al. The efficacy of two formulations of botulinum toxin type A for masseter reduction: a split-face comparison study. J Dermatolog Treat. 2017 Aug;28(5):443-446. 11. Shaoping Cheng, Yong Miao and Zhiqi Hu. Analysis of effectiveness and complications of botulinum toxin A masseter injection and hyaluronic acid chin injection related to lower third of facial contour remodeling. Biomedical Research (2017) Volume 28, Issue 15 12. Lee SH, et al. Abobotulinum toxin A and onabotulinum toxin A for masseteric hypertrophy: a splitface study in 25 Korean patients. J Dermatolog Treat. 2013 Apr;24(2):133-6. 13. Choe SW1, Cho WI, Lee CK, Seo SJ., ‘Effects of botulinum toxin type A on contouring of the lower face’, Dermatol Surg. (2005) 31(5):502-7 14. EW, Ahuja AT, Ho WS., ‘A prospective study of the effect of botulinum toxin A on masseteric muscle hypertrophy with ultrasonographic and electromyographic measurement’, Br J Plast Surg., (2001) 54, pp.197-200. 15. Rebecca Small, ‘A Practical Guide to Botulinum Toxin Procedures (Cosmetic Procedures)’,1st Edition. 16. Carruthers, J. Carruthers, ‘A. Practical Cosmetic Botox Techniques. Journal of CutaneousMedicine and Surgery’, Volume 3, Supplement 4, (1999). 17. Perkins SW1, Balikian R. ‘Treatment of perioral rhytids’, Perioral Facial Plast Surg Clin North Am., (2007) 15(4), pp.409-14. 18. Richard N. Sherman., ‘Avoiding dermal filler complications’, <http://dx.doi.org/10.1016/j. clindermatol.2008.12.002> 19. Botox OnabotulinumtoxinA injection <http://www.botox.com/> 20. Jia Z1, Lu H1 et al., ‘Adverse Events of Botulinum Toxin Type A in Facial Rejuvenation: A Systematic Review and Meta-Analysis’, Aesthetic Plast Surg., (2016) 40(5), pp.769-77. 21. Signorini M, et al., ‘Global Aesthetics Consensus: Avoidance and Management of Complications from HA Fillers - Evidence- and Opinion-Based Review and Consensus Recommendations’, PRS, 2016. 22. Cemile Nurdan Ozturk, MD, Yumeng Li, BS., ‘Complications Following Injection of Soft-Tissue Fillers’, Aesthet Surg J (2013) 33 (6), pp.862-877. 23. Carruthers A1, Carruthers J, Monheit GD, Davis PG, Tardie G., ‘Multicenter, randomized, parallelgroup study of the safety and effectiveness of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/ml smooth, cohesive gel) alone and in combination for lower facial rejuvenation’, Dermatol Surg. (2010).

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A summary of the latest clinical studies Title: Sebo-Pharmacokinetics: A Proposed Percutaneous Sebum Egression Method Authors: Reddy R, Cary JH, Elmahdy A, Maibach H Published: Journal of Dermatological Treatment, May 2018 Keywords: Acne vulgaris, drug delivery, sebaceous gland, sebum Abstract: The sebaceous gland is widely believed a critical factor in the pathogenesis of acne vulgaris. Although extensive studies document the ability of oral and topical treatments to improve acne, little is known about the quantification and mechanism of drug delivery via the sebaceous gland. A percutaneous egression method presents a way to study how drugs reaching the bloodstream can enter the skin. A literature search was performed across databases (PubMed, Embase, and Google Scholar) and the University of California, San Francisco (UCSF) textbook library with relevant search terms. This search failed to reveal data on sebo-pharmacokinetics (PK); however, many articles center on pharmacodynamics (PD) ie functional improvement instigated by oral or topical treatments. Experiments on humans and hamsters – representative sebaceous gland models – demonstrate indirect pharmacodynamic measures of sebaceous gland function. Here, we summarize the current available data on drug delivery via the sebaceous gland and suggest a practical method to directly document sebo-pharmacokinetics in man and animal.

Title: Elimination of Aesthetic Deformations of the Midface Area Our Experience Authors: Sulamanidze M, Sulamanidze G, Sulamanidze C Published: Aesthetic Plastic Surgery, June 2018 Keywords: Thread lifting, midface, nasolacrimal furrow, rejuvenation Abstract: The aesthetic manifestations of the aging process in the cheekbone, cheek and infraorbital areas are especially concerning for patients, so rejuvenating interventions in these areas are most in demand. To introduce the experience of our clinic for aesthetic manipulation using Aptos (anti-ptosis) thread lifting methods in the midface area. Among the surgical interventions that we used were Aptos thread lifting methods both in combination with lower blepharoplasty, and without it. At the same time, special attention was paid to the individual approach, trying to minimize invasiveness and, most importantly, trying to achieve the effect of moving subcutaneous soft tissues to a new, more advantageous position from an aesthetic point of view, with their fixation to dense structures. The results of application of the presented methods to lift the cheek-zygomatic and infraorbital regions using Aptos methods were studied. In the overwhelming majority of cases, the results satisfied both surgeons and patients. Aptos methods for lifting the midface soft tissues, which we used, are quite effective for rejuvenating the aging face.

Title: Effectiveness and Safety of Hyaluronic Acid Gel with Lidocaine for the Treatment of Nasolabial Folds: A Systematic Review and Meta-analysis Authors: Wang C, Luan S, Panayi AC, Xin M, Mi B, Luan J Published: Aesthetic Plastic Surgery, May 2018 Keywords: Hyaluronic acid, lidocaine, nasolabial folds, treatment outcome Abstract: Hyaluronic acid (HA) gel is a widely used dermal filler for the correction of facial volume loss. The incorporation of lidocaine with HA provides a pain-relieving alternative for individuals considering facial rejuvenation. The aim of this systematic review and meta-analysis is to compare the effectiveness and safety of HA with lidocaine (HAL) with that of HA without lidocaine for the treatment of nasolabial folds (NLFs). Studies were identified using the electronic databases PubMed, Embase, Cochrane Central Register of Controlled Trials and Web of Science from inception up to January 2018. Randomized controlled trials (RCTs) were selected based on the inclusion criteria. Outcomes included 100-mm Visual Analogue Scale (VAS) score, Wrinkle Severity Rating Scale score and adverse events. A total of 908 patients from 12 RCTs were included in the meta-analysis. VAS score within 30 min after injection in the HAL group was much lower than that with just HA group (MD = - 28.83, 95% CI - 36.38 to - 21.28). There was no significant difference in effectiveness between the two products 24 months post-injection (MD = 0.13, 95% CI - 0.15 to 0.41). The main adverse events, such as swelling, erythema, bruising, itching and induration, also showed no significant difference. HAL is more effective for pain relief than HA alone, but both display similar effectiveness and safety for the correction of NLFs.

Title: Contemporary Laser and Light-Based Rejuvenation Techniques Authors: Hamilton M, Campbell A, Holcomb JD Published: Facial Plastic Surgery Clinics of North America, May 2018 Keywords: Ablative, CO2 laser, laser resurfacing Abstract: Laser and light skin rejuvenation have changed dramatically in the last 10 years. CO2 and erbium:YAG remain the main wavelengths, but fractional, nonablative, and combination devices have been added. For those patients with lighter skin types and extensive photodamage and rhytids, full-field ablative laser resurfacing remains the procedure of choice. For those seeking less downtime and risks, fractional devices offer an excellent and growing alternative, although multiple treatments may be required for optimal results. A new generation of hybrid and nonablative devices offer many advantages, yet many of these results may be duplicated with well-proven intense pulsed light. Title: Soft Tissue Contraction in Body Contouring With Radiofrequency-Assisted Liposuction: A Treatment Gap Solution Authors: Theodorou SJ, Del Vecchio D, Chia CT Published: Aesthetic Surgery Journal, May 2018 Keywords: Liposuction, body contouring, radiofrequency Abstract: Radiofrequency-assisted liposuction is a relatively new concept in energy-assisted body contouring techniques and has received instrument approval. This supplemental article reviews the clinical application of electromagnetic energy via the BodyTite (InMode Corporation, Toronto, Canada) device on soft tissues during suction lipectomy, its effect on soft tissue contraction, and its use in aesthetic body contouring in various clinical scenarios.

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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a level of education and support on any treatments they may be considering. The consultation and assessment enables us to identify key areas of concern and formulate treatment plans for our patients. Following on from this, we can then guide patients toward our selected topics within our educational events, so that they can ask further questions and observe live treatment demonstrations in a comfortable environment in small group sessions.

Planning Patient Educational Events Miss Sherina Balaratnam discusses how to plan and deliver successful in-clinic educational events Running an aesthetic clinic brings many challenges to medical practitioners. From practice management and staff training to maintaining high patient satisfaction, through to business development and marketing, the end point is to continuously and successfully grow our practices. Focusing on new patient acquisitions, whilst maintaining a strong existing patient retention rate, is key to achieving this. An integral part of achieving patient retention and acquisition in my clinical practice is by hosting regular educational events. In this article, I will cover the key strategies behind hosting these events, how to maximise each opportunity to benefit your patients and deliver a high return on investment for your time.

The paradox of choice As American psychologist and author of The Paradox of Choice: Why More is Less, Barry Schwartz stated, “Learning to choose is hard. Learning to choose well is harder. And learning to choose well in a world of unlimited possibilities is harder still, perhaps too hard.”1 In aesthetics, this couldn’t be more true. With such a large amount of information facing today’s patients, the decision-making process can be somewhat overwhelming. Patients need to choose the right products, practitioner, practice and suitable price, so are increasingly being faced with the challenge of the ‘too much choice’ scenario. Schwartz argues that eliminating consumer choices can greatly reduce anxiety for shoppers; autonomy and freedom of choice are critical to our wellbeing, and choice is

critical to freedom and autonomy.1 At the very beginning of a new practice, it is easy to focus on continually acquiring new patients. This, however, often overlooks the existing patients within your practice whom you may already have spent a considerable amount of time with. These patients have formed a level of trust in you and your practice, likely undertaken a significant amount of research in the treatments they are receiving and have built a strong faith in what you and your team deliver. The Pareto principle of marketing identifies that 80% of business is generated by 20% of existing customers.1 So it is no wonder why we need to focus our attention on empowering our existing patients with knowledge, whilst simultaneously acquiring and educating new patients coming into our practices. I have found that educational events are an ideal way to achieve this. Introducing existing patients to new technologies or treatments they may not have been aware of, whilst attracting new patients to the clinic, has been a key method of growing my practice.

Why patient education is important Medical aesthetics can be a minefield for patients. With an ever increasing number of technologies and treatments, all claiming exceptional results, it is no surprise that patients can present to our clinics confused, with unrealistic expectations of the results they can achieve. Similar to how aesthetic practitioners need guided training on the treatments we deliver to patients, patients too can benefit from

The types of events The educational events I hold in my clinic are broadly categorised into: • Dedicated new treatment launches: These are generally focused sessions, based on a specific technology or product, for example, lasers for skin rejuvenation • Clinic anniversary events: An ideal opportunity to thank your existing patients for their loyalty and support, whilst also educating them about your services • Single topic or technology focused: We have previously run patient sessions on topics such as dermal fillers and how they work, the anatomy of the ageing process as well as all about laser technology These events are an ideal opportunity for existing and prospective patients to meet your clinic team, understand more about your ethos and learn more about the treatments and technologies you offer and how these may benefit them. Having direct access to you and your team in an informal yet professional environment is key as I find that it encourages trust and relationship development. I believe this is important in establishing long-term patients. In this environment, patients gain further knowledge and are provided with access to focused information delivered by a team they trust. A general guide on how we carry out our events are as follows: 1. Welcome and presentation on the topic 2. Live treatment demonstration carried out by the key distributor, or a member of the team 3. Summary of the topic and Q & A session by a team member and the distributor 4. Opportunity for mini consultations

Your target audience Broadly, event attendees could be classified into two distinct categories: 1. Those who have been having medical aesthetic treatments on multiple occasions and therefore are likely to be more at ease with the clinic environment

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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My 10 top tips for creating successful events 1. Always plan at least three months in advance 2. Ensure each team member has a clearly defined role at the day of the event so as to ensure all bases are covered 3. Aim for a target number of attendees and adopt a dynamic approach to ensure you reach your target 4. Avoid school holiday periods 5. Plan mid-week events, either at lunchtime of early evening, as they tend to work best for all types of patient categories 6. Provide information packs on both the product/s you are educating them about, as well as your clinic and yourself 7. Seek and welcome feedback in order to continuously improve your events. We use patient feedback questionnaires to obtain this as well as encourage patients to provide verbal and email feedback 8. Send all guests a post event thank you via email, and follow up a week later to see if you can assist with any further enquiries or appointments 9. Provide refreshments 10. Prepare an introductory speech to help set the agenda and expectations for the event

2. Those who may not have set foot in such a clinic previously and consequently could be more apprehensive It is essential to take our target audience into consideration in order to shape the event accordingly. Existing patients who are comfortable within the environment and team often require a more directional approach to decision-making, based on the close rapport and trust that they have already established with their practitioner. For new patients who have never set foot in a clinic before, this may be an intimidating experience and may require more guidance during an event as this would be considered part of an ‘induction’ process into medical aesthetics. Bearing in mind, they are likely not to have had a consultation at the clinic as yet. We adopt a multidisciplinary team approach to our patient care, which is highly beneficial during this new patient induction.

to a focused and interested patient base, with clear call to action to ‘bring a friend who may be interested’ • Secure any supplier support • Establish advertising plan: in-clinic brochures and invitations, emailers, social media, your clinic website Six weeks prior • Finalise event agenda and brief patients on what they can expect, including whether you are holding live treatment demonstrations • Continue distributing invitations to internal patients • Determine what promotional offers you will include Two weeks prior • Send a reminder email to invite attendees that have not RSVPd • Personally call invitees to follow up on invitations

Planning Pre-event preparation is key and in my experience, scheduling three months in advance for event planning is essential to allow ample time to cover this. Below is my framework, which I use on a session-tosession basis on creating the ideal event.

Two days prior • Call RSVPs to remind them of the event • Brief team on structure and timings of the event and any promotional offers • Ensure everyone is aligned on roles and responsibilities

Three months prior • Decide on topic and key objectives: choose location, date and time • Determine target audience and set your ideal attendee number • Formalise your budget: catering, staffing, marketing • Send invitations and personally reach out

On the day • Preparation of the clinic with branding, information leaflets, marketing materials and banners • Set up refreshments area • Ensure attendees are registered and subscribe to marketing communications that are relevant to them so you can better

manage follow-up conversations • Set up spaces for presentations, live treatment demonstrations and on-site mini consultations • Book appointments for attendees that are unable to have consultations on the day • Establish a leaving process where attendees are thanked and handed a goody bag and further information on how to contact your team for more information or to book a treatment • Encourage feedback using patient feedback questionnaires

The day after the event • Send ‘Thank You’ notes and emails to attendees • Contact any no-shows to invite back for a complimentary consultation A well planned and executed event enables you to have a two-way conversation with attendees. This feedback is vital to ensuring your treatment portfolio is aligned and evolves with patient expectations and demand. It also enables your patients to become more knowledgeable in the area of aesthetics, which can increase their trust in you and your services, and increase your patient base.

Conclusion Hosting events is a great way to introduce new treatment offerings to your existing patients as well as attracting new patients to your practice. Following three years of successful events and collaborations with our partner suppliers, we now have a streamlined approach to hosting effective, informative and educational events with clear objectives and goals, which sets us apart from other businesses. As business blogger Seth Godin says, “In a crowded marketplace, fitting in is a failure. In a busy marketplace, not standing out is the same as being invisible.”3 Miss Sherina Balaratnam is a surgeon with a background in plastic surgery training and now specialises in the latest nonsurgical cosmetic treatment innovations. Miss Balaratnam practises from her clinic in Beaconsfield and regularly trains other healthcare professionals on advanced injectable techniques and the consultation process. REFERENCES 1. Barry Schwartz, ‘The Paradox of Choice’, 2004. 2. Richard Koch, ‘The 80/20 Principle’, 1997. 3. Seth Godin, ‘Purple Cow: Transform Your Business by Being Remarkable’, 2003.

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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site higher up the search engine results.5 Adding a video to your websites also sees your traffic spend as much as 88% more time on it,6 meaning that patients will spend more time on a website with video than a website without. This, of course, gives your patients far more time to learn about your brand and services, thereby increasing the chance of them contacting you for a consultation.

Understanding Video Marketing Digital marketing consultant Adam Hampson discusses why video is vital to your clinic’s digital marketing content and how it can positively impact search engine optimisation, social media engagement, and buying behaviours Did you know that 300 hours of video are being uploaded onto YouTube every minute?1 Businesses that are not adapting their content marketing to include video aren’t reaping the digital engagement benefits it offers and could be missing out on potential patients. Static content, such as images and text, is useful for static views, such as on an Instagram grid overview or a thumbnail. But video, or dynamic content, as an active media on websites and Facebook feeds can be extremely useful to an aesthetic clinic. Video can positively affect your search engine optimisation (SEO) and your social media engagement and reach.2 It can also positively impact your patient’s buying behaviours that influence conversion, when implemented correctly. In this article, I’ll not only discuss the why, but the how of video marketing and what your clinic or business can gain by planning it into your content strategy.

Impact of video marketing on buying behaviours There is no denying that videos affect patients’ buying habits and trust levels in your clinic or practice.3 Video content shows a certain pride, investment, and effort made in your business and it helps to craft a wellrounded brand image that will keep your patients engaged, placing value in your services. Interestingly, 81% of people have been convinced to buy a product or service

by watching a video.3 By publishing a video of your products, services, or treatments and sharing your professionalism in an engaging format, you greatly increase your chance of gaining patient interest and enquiries. The way this works is that our brains enjoy narratives and puzzles and the stimulation of imagery and audio cues – we are actually turned off by the ‘hard sell’ technique.4 Your main aim should be to create engaging video content that your patients want to see, such as offering your patients answers and solutions to commonly shared problems. Examples of this can be tailored to your business – take a frequently asked question on a treatment and answer it in a video. By adopting video content into your digital strategy, you can shape and predict your patients’ buying and viewing habits, leaving a trail for them to follow that leads directly to your clinic. Video marketing for Google SEO Your SEO has no doubt been carefully formulated and maintained for some time, but without video you are not achieving its full potential. Google’s searching algorithm now looks for what is deemed ‘quality content’, for example videos and other engaging landing page composition, over relevant search term use.5 If you publish videos on your website, Google will identify the pages with video and favour them above other factors such as keywords, pushing your

Video marketing for Facebook’s algorithm The social media platform that many businesses use to share their videos is Facebook. Interestingly, social media platforms like Facebook are moving away from their initial algorithm that placed a high importance upon the presence of video on the news feed. Instead, they now favour discussion and interaction which, rather fittingly, can still be accomplished with video.7 Recently, Mark Zuckerberg himself took to the platform to inform the public that the company was shifting ‘from focusing on helping you find relevant content, to helping you have more meaningful social interactions’.8 However, despite this, videos on your business’ Facebook page still have a positive impact on buying behaviours and are still entertaining, informative, and persuasive. This change actually leaves room for videos to still engage, as long as actively seek this engagement. For your video to be successful, you need to encourage engagement of the video, rather than focusing on likes and general acceptance of your video posting. Do this in the video content and in the Facebook caption with direct calls to action, questions prompting answers, and opinion-sharing. Comments and shares are far preferable to likes because this kind of social engagement pushes your content onto the friends’ newsfeed of the participating audience. Seeking to engage and communicate rather than just be present, can not only alter your content marketing, but your brand. Using a combination approach To be successful though, you need to upload your video to multiple platforms, including Facebook, YouTube, as well as your website, as this will positively affect your SEO. This, in turn, will help increase the number of times potential patients will see your brand and therefore can increase the chances of them contacting you for a consultation. The more times you upload your video, the more times Google will recognise it as dynamic content, leading it to feature your content sources higher in its search rankings.

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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Video formatting tips It’s important to note that your video needs to be mobile optimised, because 42% of Britons use their smartphone or other mobile devices to watch clips online.9 Also, dodge the duplicate content when uploading; by this we mean using differing titles and descriptions for each upload to keep your video marketing performing perfectly. This is because when Google indexes your website, social platforms, and web assets associated with your business, it looks for unique content. By changing the captions, titles, and descriptions on your videos slightly, you placate Google’s need for diverse content but are still fully utilising your video creation.

How to use video in your marketing strategy Video marketing is not only great for building your brand, but it is also extremely effective at showcasing products, treatments, and services. Doing this effectively and correctly, however, is crucial. While simple informational videos that explain a product aren’t the most engaging, videos that take their viewers on a journey are. For example, if you post a video of you simply talking

because those considering treatment want to know more about you, your services, and your ethos. By personalising the proposed experience, you cater to their curiosity and to their trust. Videos of one of your employees talking through a treatment as they administer it or detailing their own use of one of your products, such as skincare, for social proof can help to add a certain tangibility to your clinic. Social proof creates the image of a community that your patient wants to be

81% of people have been convinced to buy a product or service by watching a video about how great a certain skincare system is, you’re demonstrating nothing more than the ‘hard sell’. If you post a video of how to use this skincare routine, demonstrate its steps, and talk your patients through its benefits, you’re demonstrating an active engagement and involvement. By giving viewers this three-dimensional insight into the product, you’re imparting some knowledge or value on them. Videos can be centred around any topic, but we recommended a simple threestep formula: present a problem, offer the solution, propose the call the action. By taking your patients on this journey and guiding them into questioning their own related target area, you immediately plant the seed that leads to an enquiry. If you add value to a service by presenting it as something worth investing viewership in, then you’re prompting your traffic to see it as valuable. However, you don’t necessarily have to always centre your video content strategy around products and services. Video marketing is a great way to humanise your business and build your brand. This is important when seeking new patients

involved in, so by inviting them to share this experience you increase the likelihood of their interest.10 Social media as social proof works incredibly well, purely because of its user-generated nature. It invites the everyday people around you and your business to gain an insight into your workings and contribute with their own reviews and interactions. As we’ve previously explored, video encourages engagement, which is why they are particularly effective at informing and persuading. This medium works exceptionally well with a video tour of your premises, behind the scenes style shooting, or video testimonials. Word of mouth is powerful, and today, word of mouth doesn’t happen face to face,11 so utilise video content for your digital marketing and social media to gain the trust of your traffic. Even real-time video updates can demonstrate your brand in action. With the addition of a ‘Story’ on Instagram and Facebook, you can now post content that lasts for 24 hours before erasing. This allows you to document the day-to-day character building of your brand and business without disrupting your main content strategy on your social media. Videos and Boomerangs12

(looping, soundless videos that capture just a few seconds) can be added to these with simple messages such as ‘good morning’ to add a personal and invested touch to your brand. Of course, it’s important you get your video strategy right. The best way to do this is to plan in the long-term. Consider running a campaign where once a week you focus on a treatment in a video, and plan this ahead of time. By creating a schedule and script, your content will continue to look professional and engaging. Include your own branding, a call to action, and a uniform formatting to ensure that your videos run seamlessly into the same campaign.

Conclusion Video marketing is a valuable addition to your digital marketing and content strategy; influencing not only your social media and search engine optimisation, but also your traffic’s behaviour. If you haven’t considered implementing effective and comprehensive video content, then you could be drastically affecting your conversion rates and missing out on exactly what your patient base wants to see. Adam Hampson is the founder and director of Cosmetic Digital, a web design and digital marketing agency in Nottingham that works with clients in the cosmetic medical sector. He is also a public speaker on aesthetics marketing and branding. REFERENCES 1. Fortune Lords, YouTube Statistics 2018, <https://fortunelords. com/youtube-statistics/> 2. Vertical Leap, SEO best practices for images and video content, <https://www.vertical-leap.uk/blog/seo-best-practice-for-images-and-video-content/> 3. Wyz Owl, Video Marketing Statistics 2018, <https://www. wyzowl.com/video-marketing-statistics-2018/> 4. NRG Digital, The Psychology Behind Video, <http://nrg-digital.co.uk/psychology-behind-video> 5. Advanced Web Ranking, 13 SEO Tips for Videos That Only the Experts Know, <https://www.advancedwebranking.com/ blog/seo-tips-for-videos/> 6. Impact, 19 Intriguing Video Marketing Stats (& Proving Why You Should Implement It), <https://www.impactbnd.com/ blog/6-intriguing-stats-why-you-should-implement-videomarketing> 7. Hootsuite, How the Facebook Algorithm Works and How to Make it Work for You, <https://blog.hootsuite.com/facebook-algorithm/> 8. Facebook, Mark Zuckerberg’s Official Page, <https://www. facebook.com/zuck/posts/10104413015393571> 9. Statista, Penetration of online video watching in Great Britain as of November 2017, by device, <https://www. statista.com/statistics/289079/online-video-watching-penetration-in-great-britain-by-device/> 10. Kissmetrics Blog, 7 Things You MUST Understand When Leveraging Social Proof in Your Marketing Efforts, <https:// blog.kissmetrics.com/social-proof-factors-2/> 11. Big Commerce, The 19 Ecommerce Trends + 147 Online Shopping Stats Fueling Sales Growth in 2018, <https://www. bigcommerce.com/blog/ecommerce-trends/> 12. iTunes Store, Boomerang App, </,https://itunes.apple.com/ gb/app/boomerang-from-instagram/id1041596399?platform=iphone&preserveScrollPosition=true#platform/ iphone/>

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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Sole Traders vs. Limited Companies Dr Qian Xu discusses the differences between setting up your business as a sole trader or a limited company In my experience, I have found that most aesthetic practitioners have very limited business and accounting knowledge when they first start their aesthetic journey. I certainly don’t remember any lectures on these topics in medical school. After attending an injectables foundation day, students often leave the training room full of excitement; however, as soon as they arrive home, their minds are filled with hundreds of questions about how they actually get started. I often carry out one-to-one clinical mentoring sessions as part of an aesthetics injectables Level 7 qualification course, and one of the things I get asked a lot by my students is, ‘When should I consider changing to a limited company?’. As there is a lot of information out there on this topic, it can be overwhelming for those who are not entirely familiar with it. In this article, I have summarised all of the important points that I believe are essential for aesthetic practitioners to know when they are starting their business.

From employee to self-employed The majority of aesthetic practitioners would have come from a National Health Service (NHS) background and as an employee of the NHS, you would be on the payroll and receive a monthly salary. If you have a look at your payslip, you will notice that the amount

you receive in your bank account is only about 60-70% of your gross or total pay. This is because the income tax, national insurance, pension contributions, and any student loans are all taken by your employer and paid for you on your behalf. So as an employee, you work and you get paid; it’s pretty hassle-free. This changes when you start your own business in aesthetics as you become selfemployed; among your responsibilities you will be sorting out your own, and possibly your employees’ taxes. Being self-employed can be in one of three forms: sole trader, limited company and partnership.1 The latter is rarely seen in the world of aesthetics in my experience, therefore, I will focus on sole trader and limited company. The sole trader The simplest way to start your business is to operate as a sole trader. Sole trader simply means that you receive payments directly from customers for your products or services, as opposed to being paid by an employer. If you want to operate as a sole trader, you just need to declare to Her Majesty’s Revenue & Customs (HMRC) as self-employed.2 Being a sole trader means that there is no distinction between you and your business. You don’t need a separate bank account or an accountant, so maintenance costs are

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relatively low. However, it is a good idea to keep track of your business sales and expenses on a spreadsheet, because you will need to file this information with the selfassessment tax return every year, and then pay the amount of tax that is due.3 The selfassessment can be filed online and is fairly straightforward.4 I would say that the main advantage of doing this is that it is low cost and low maintenance. When you are first starting, you may only have a few patients every couple of months, so it doesn’t make sense to pay for an accountant. Furthermore, you may be practising aesthetics alongside a part-time or even a full-time NHS job, so it’s unlikely that you will build your patient base very quickly. The sole trader route can give you more flexibility, especially if you just want to ‘test the waters’ and see if aesthetics is something you want to do long-term. So if it’s so easy being a sole trader, why do so many practitioners form limited companies? Can you keep trading as a sole trader forever? The limited company Let’s start by understanding what a limited company actually is. It is a legal entity that is completely separate from your personal affairs.5 As a sole trader, if your business went into debt, you would be personally liable to repay the debt, so in theory, you could lose your house. As a limited company, any debts are limited to the company, so your personal assets are protected. A limited company is owned by its shareholders and is run by its officers. An officer is simply someone who is appointed to take a particular role in the company. In your case, you can appoint yourself to be the director of your company, and allocate 100% of the company’s shares to yourself. Alternatively, if you have business partners, you can have more than one company director, and you can decide how to split the shares. Your limited company would have its own bank account, so business transactions are separate from your personal ones. It is registered with Companies House, which is a government organisation that incorporates and dissolves limited companies, and makes company information available to the public.6 Every year, you are required to submit a confirmation statement to update them on your address, company officers and shareholder information. In addition to that, you will need an accountant to help you submit annual accounts to Companies House and HMRC.7 If you know what you are doing, it is possible to do this yourself, however, if you miss a deadline or get something wrong, you could be

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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penalised for it later. There are many advantages to having a limited company. As well as protecting your personal assets, a limited company looks more professional and will instantly add some credibility to your business. However, the most important reason that independent practitioners choose to form a limited company is the tax advantages that it can bring.

Be more tax efficient In order to understand why a limited company can be more tax efficient, you must first understand how tax is applied to sole traders and limited companies. When you are a sole trader, your business income is treated the same as way as your personal income, and therefore you have to pay national insurance contributions (NIC) as well as income tax. If your annual income is over £45,000, then you will have to pay 40% tax on the amount you earn, which is applied to all of your income.8 With a limited company, your company would need to pay a 19% corporation tax on the profit it makes.8 After the tax is paid, the net profit can be taken out as a dividend (an amount of the net profit typically paid to shareholders annually) or be kept in the company. Your gross profit is the turnover minus the expenses. Any expenses related to the business can be claimed as a business expense, such as aesthetics training courses, networking or travelling to and from business meetings. It is common practise for a director to take out a salary which is equal to the personal allowance. This is the tax-free income allowance set by the government, which is currently £11,850 per year. If your salary is less than the personal allowance, then you do not need to pay the NIC. If you were to do this, you would then take out dividends to top up your income. The tax on dividends is a bit lower than on your normal income.8 So this is a very tax-efficient way to draw your income. If you don’t need so much money, you can just leave the money in the company. You will only pay tax on it if you want to draw it out as dividend. Another benefit of a limited company compared to a sole trader is that any losses can be carried over to the next financial year to offset the profit in the following year.9 This is really useful because in the first couple of years, you are likely to be spending much more than you will be bringing in. In terms of planning for the future, your company can contribute towards your pensions, you can sell your shares to others (e.g. family members), and you can employ other people. So if you have big plans about

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opening your own clinic one day, it might be worth forming a limited company sooner rather than later.

Incorporate a limited company Before incorporating a limited company, it is always a good idea to speak to an accountant to make sure it is appropriate for your situation. If you are going to go ahead with it, then you can either go through Companies House directly,6 or use a third-party company formations website to help you through the process. The registered address of the company is public information, and is searchable from Companies House. If you do not want to use your home address for this, you can pay for a service address and set up mail forwarding to your home address. The service address will be the official address where HMRC and Companies House will send letters to.10 It’s also worth thinking about who you want the shareholders to be. You might want to give some shares to your spouse, for example, if they are unemployed or in a low income bracket because you can make use of their personal allowance and maximise your household income.11 If you want to do this, it’s much easier to do it while you are forming the company.

VAT Value-added tax is currently 20% of the price of your product or service, and you are required to become VAT-registered and pay this to the HMRC if your annual turnover exceeds £85,000, unless you are only offering VAT-exempt services. You can be VAT-registered as a sole trader or a limited company.12 The HMRC states, ‘We will generally accept that cosmetic services are exempt where they are undertaken as an element of a healthcare treatment programme. Where services are undertaken purely for cosmetic reasons, they will be standard rated’.12 This is a grey area with no clear guidance that needs further clarification. But I have found that the current general consensus is that the cosmetic procedures are performed to improve the psychological well-being of our patients, and therefore counts as a medical intervention, thus would be VAT-exempt. However, there may be other reasons why you might want to register for VAT,13 so it would be a good idea to have a discussion with your accountant.

overwhelming it can be. There are a number of organisations and communities out there that can advise you on what is right for you. Most training academies have their own Facebook groups, which tend to be useful for clinical discussions. I have also created a closed Facebook group open to all aesthetic practitioners from a healthcare background, the Aesthetics Practitioners Community to offer support and guidance on all aspects of the aesthetics business. There are pros and cons to both working as sole trader and limited company. In my opinion, the deciding factor should be how serious and sure you are about going into and staying in the aesthetics business. If you have no doubts about it, then I would form a limited company from the beginning. It looks a lot more professional, and it’s good to get into good habits early. If you have just done an injectables foundation course, then the legal structures of your business shouldn’t be your first concern and going down the sole trader route is absolutely fine, this also works well if you are currently employed too. Dr Qian Xu is the founder and medical director of Skin Aesthetics. She has a background in surgery and emergency medicine, before specialising in aesthetic medicine in 2012. Dr Xu has been a lead trainer and mentor at Harley Academy, and she is now setting up her own Aesthetics Business Training Academy. REFERENCES 1. Gov.uk, Working For Yourself <https://www.gov.uk/working-foryourself> 2. Gov.uk, Set Up a Sole Trader <https://www.gov.uk/set-up-soletrader> 3. Gov.uk, Self Assessment Tax Returns <https://www.gov.uk/selfassessment-tax-returns> 4. Bytestart.co.uk, Sole Trader Tax – A Guide for start-ups and the newly self employed <http://www.bytestart.co.uk/sole-tradertax-guide.html> 5. Gov.uk, Set up a Private Limited Company <https://www.gov.uk/ limited-company-formation> 6. Gov.uk, Companies House <https://www.gov.uk/government/ organisations/companies-house> 7. Gov.uk, Running a Limited Company <https://www.gov.uk/ running-a-limited-company> 8. Contractorcalculator.co.uk, Contractor tax: limited company and personal taxes explained <https://www.contractorcalculator. co.uk/limited_company_personal_taxes.aspx> 9. Taxation.co.uk, Loss relief options available to business <https:// www.taxation.co.uk/Articles/2017/07/18/336697/loss-reliefoptions-available-business> 10. Your Company Formations, The difference between a service address and a registered office address <https://www. yourcompanyformations.co.uk/blog/the-difference-between-aservice-address-and-a-registered-office-address> 11. Contractorcalculator.co.uk, Contractor guide to splitting dividends <https://www.contractorcalculator.co.uk/contractor_ guide_splitting_dividends.aspx> 12. Gov.uk, VAT Notice 701/57: health professionals and pharmaceutical products <https://www.gov.uk/government/ publications/vat-notice-70157-health-professionals-andpharmaceutical-products/vat-notice-70157-health-professionalsand-pharmaceutical-products> 13. Gov.uk, VAT Registration <https://www.gov.uk/vat-registration>

Conclusion Personally, I have been through all the stages of the business myself, and know how

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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“Aesthetic practitioners need to be experts in sun protection and skin cancer vigilance” Allie Anderson speaks to Dr Christopher Rowland Payne about why it’s crucial that aesthetic practitioners are experts in sun protection and skincare, and how working with others has helped to shape his career Consultant dermatologist Dr Christopher Rowland Payne has been treating various sun-related skin complaints for his entire career, which spans more than three decades. It was through his work with skin cancer patients that he became interested in aesthetics. “I was treating a lot of skin cancers in the NHS, such as melanoma, basal cell and squamous cell cancer, and when carrying out procedures one is always trying to find a good cosmetic result,” he explains, noting, “Sometimes, that result is better than the untreated side of the face, and bit by bit you realise that rather than just making better a problem, you can improve a person’s appearance. So you become focused not just on illness, but also on wellness.” At the same time, the aesthetics specialty was expanding rapidly: the explosion of new treatments and procedures that practitioners could offer patients to combat a greater number of complaints really piqued Dr Rowland Payne’s interest, so he decided to branch out into aesthetic practice. “Of all the specialties, dermatology is most intimately linked with aesthetics, and the natural evolution of one to the other is obvious,” he says. Having completed his medical training at St Bartholomew’s Hospital, and subsequently working in Edinburgh before finding his way back to London to train in dermatology at St Thomas’ and Westminster Hospitals, Dr Rowland Payne began seeing private patients when he was appointed consultant in 1990. Three years ago he opened his own private clinic, where he works each day, as well as working as a consultant to The London Hospital across the road. Treating sundamaged skin, including skin cancer, still forms a large part of his day-to-day practice. Many of the skin cancers he finds are discovered on routine total skin examination of patients who have been referred for other reasons. “I studied this systematically by looking at 200 consecutive patients, and this included new patients and those I’d seen before,” Dr

Rowland Payne says. “In 41 of the 200, there were 117 skin malignancies, six of which were melanomas, which neither the patient nor the referring doctor had noticed.” This, he says, is a good reason for all aesthetic practitioners to be aware of moles, melanomas and other skin cancers and to understand the physiology and anatomy of the skin, the effects of sun exposure and how to prevent the sun from damaging the skin. “Aesthetic practitioners need to be experts in suncare and how to live with the sun in a healthy way,” he comments. “Of course, using sunscreen from Easter to October is an important part of that, but we must also teach patients the importance of wearing hats, covering up and seeking shade. Very often, patients don’t tell you that they’ve been using sunbeds, but there is a giveaway called the Sunbed Suntan SacroScapular Sparing Sign, or the six S’s” he says. This term, coined by Dr Rowland Payne, describes three areas of the body – the sacrum and each of the scapulae – where the patient’s weight is concentrated as they lie on a sunbed, and thus, which are blanched. Since tanning is an oxygen-dependent process, and these blanched areas aren’t exposed to oxygen as the patient lies on the sunbed, the three areas do not tan while the rest of the body does. Dr Rowland Payne says, “Practitioners can use the six S’s to look for evidence of frequent sunbed use, and to educate patients about its dangers.” Dr Rowland Payne is enjoying a fairly illustrious career, some of the highlights of which include delivering the 2017 Royal Society of Medicine’s Stevens Lecture on skin cancer and sun addiction, being President of the European Society of Cosmetic and Aesthetic Dermatology and President of the Royal Society of Medicine’s Aesthetic Faculty Council, and holding editorship of the Journal of Cosmetic Dermatology, as well as being on the Aesthetics editorial board. “Those were extremely satisfying because it meant that I could be involved in educating and teaching, as well as learning, and it’s important to be able

to share one’s knowledge,” he says. But equally gratifying, he notes, is having the opportunity to continue to work with and learn from peers. Dr Rowland Payne believes his most notable achievement was working on the 2016 800-page textbook, Cosmetic Medicine and Surgery, with three international colleagues. “It was a very hard but rewarding thing to have done,” he says. “Every day we’re lucky to see people we can help, so the thing I appreciate most about my job is that every day, I’m happy to come to work. I love my job, and that’s a great privilege.” What about your job gives you the greatest satisfaction? When a patient comes in for one thing and, on examining them, you find something more concerning that they didn’t know they had, such as melanoma. You can help them to avoid the suffering that would have gone with later diagnosis. Is there anything you would have done differently in your career, given the chance? I would have worked harder as a medical student because I was very lazy! But now I work harder and harder every year. There’s that old thing you were told at school: the more you put in, the more you get out, and it’s so true. When you have some spare time, what do you do to wind down? I love cycling, and I’m very interested in history. In May I combined the two and cycled down the Valley of the Meuse in France, running into Belgium. What would you tell someone starting out in aesthetics? Try and work with many people; visit people and see how they work, and if possible get them to visit you too so they can work alongside you with your patients. You learn such a lot that way.

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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surveillance, monitoring or reporting of complications.9,10 Even if body contouring devices were classed as medical, the requirements for a Class II medical device only differs in that a Notified Body is required to carry out a conformity assessment to approve the manufacturerâ&#x20AC;&#x2122;s declaration.11 While medical device distributors are required to report adverse events to a competent authority (MHRA), there is no obligation for clinical investigation data to be provided as part of the approval submission for body contouring devices.11

The Last Word Dr Selena Langdon discusses her concerns with the regulation and marketing of body contouring treatments in the UK and what she believes needs to change to ensure patient safety The global market for body contouring treatments was estimated by market research company IMARC Group to be valued at US $5.3 billion in 2016 and is forecast to grow at a compound annual growth rate (CAGR) of around 7% during 2017-2022 to reach US $8 billion.1 Many practitioners will notice the number and type of devices available is growing to meet this demand. I believe that like many other aesthetic treatments and devices in the UK, there is a lack of appropriate regulation in regards to product safety and pre-market testing. This has led to a growing number of devices being marketed to the public, many of which have little or no evidence of either efficacy or safety. As well as this, many users are implementing misleading marketing messages and using devices, whether they are appropriately regulated and tested or not, in settings with no medical oversight. An unregulated device market â&#x20AC;&#x201C; the root of the issue The Medicines and Healthcare Products Regulatory Agency (MHRA) is charged with regulating medical devices in the UK to ensure they work and are acceptably safe.2 If aesthetic devices make no medical claim, they are currently outside the current scope of regulation.3 The Care Quality Commission (CQC) as the healthcare regulator for England, only licenses and regulates

cosmetic treatments that involve surgical procedures and does not regulate the nonsurgical sector.4 This leaves body contouring devices and their operation currently outside the scope of any direct regulation. In my own practice, I rely on Food and Drug Administration (FDA) clearance as it requires evidence of both safety and efficacy before a device can be marketed in the US.5,6 In contrast, the current European equivalent for medical devices is the CE Mark, which does not subject the device to a comparable level of scrutiny.7 As body contouring devices are not, at present, classed as medical devices in Europe and instead are classed as electrical devices,8 the CE Mark applied to these devices only relates to the Low Voltage Directive (LVD) 2014/35/ EU9 and the Electromagnetic Compatibility (EMC) Directive 2014/30/EU.10 Both of these require no certification or testing of patient safety, treatment efficacy or post-market

Non-medical operators compound the risks I believe there is an issue with non-medical professionals performing body contouring treatments without the oversight of a medically trained and regulated practitioner. While side effects, complications and other problems can potentially arise from most treatments, the ability to properly assess contraindications such as male gynaecomastia, hernias, tumours, diastasis recti, lymph node enlargement or lipomas is extremely important. Offering body contouring treatments with devices which have not been subject to sufficient scrutiny in a setting where no medical oversight is available only compounds the risks and using such devices when the patient has a contraindication can lead to serious posttreatment complications. As an example, in 2017 the Journal of Wound Care (JWC) reported a complication case that involved a 53-year-old woman. She sustained a significant frostbite injury following a 60-minute unnamed cryolipolysis treatment performed by a beauty therapist in a beauty salon. A few hours after the treatment, it was reported that two painful skin blisters developed with progressive associated erythema. The salon owner did not recommend the patient seek immediate medical attention and the injury progressed to full-thickness frostbite injuries after one week.12 Unlike non-medics, who do not have

I believe there is an issue with nonmedical professionals performing body contouring treatments without the oversight of a medically trained and regulated practitioner

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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any professional guidelines to follow, medical operators of body contouring devices have a responsibility to follow professional guidelines and are subject to professional standards such as those laid down by the General Medical Council in its ‘Guidance for doctors who offer cosmetic interventions’.13 From my personal experience, I am aware that several major body contouring manufacturers and their distributors carry out a process of due diligence on those seeking to purchase and operate their devices. I am told by the manufacturers that the reason for this is to ensure that a medical practitioner is sufficiently engaged in the consultation and treatment process, as they believe that outcomes and safety of the treatment is, in part, operator dependent. Holding professionals to a higher standard does not guard the public against those not subject to oversight by a professional body. While professional oversight helps to raise standards within a professional setting, it does not capture all operators of the devices. Without sufficient regulations being in place to control the sale and use of the devices, or make medical oversight compulsory, then risks to the public remain. Marketing I believe the marketing of body contouring devices is also an issue. The marketing of body contouring treatments is subject to certain standards such as the Cosmetic Interventions Advertising Guidance, and monitoring of compliance with this guidance is the responsibility of the Advertising Standards Authority (ASA).14,15,16 The ASA’s Cosmetic Interventions Advertising Guidance states, among other requirements: • advertisements must not mislead by exaggerating the capability or performance of a product or service • objective claims must be backed by evidence, if relevant, consisting of trials conducted on people For the ASA to pursue an advertiser for a false claim, it is likely that a patient would need to raise an issue with the ASA and will probably only do so once they become aware that the claims made in the advertising are false. This would occur most likely after a failed treatment or having sustained injury. Advertisers who fail to remove misleading or inaccurate advertisements can be referred by the ASA to the National Trading Standards (NTS). The NTS is the legal backstop for the

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ASA and can prosecute an advertiser to an unlimited fine or up to two years in prison.17,18 However, such penalties are used as a last resort and, in most instances, the ads are amended or withdrawn, with more severe penalties applied only to repeat offenders. The incentives for advertisers to make false or misleading claims are therefore high and consumers are afforded only modest protection from false or misleading claims about treatment efficacy and safety.19

to a competent authority (the MHRA in the UK),21 I expect the market for body contouring treatments to develop in a positive way post 2020. In the meantime, I believe it is necessary for medical practitioners to help patients understand the treatment choices and risks associated with the various methods for body contouring available, provide effective oversight of the treatment and to advertise treatments in line with professional standards and ASA guidance.

A change to regulation An important change in regulation took place on 25 May 2017, with the introduction of EU Regulation 2017/745, which becomes applicable from 25 May 2020.21 This specifically includes equipment intended to be used to reduce, remove or destroy adipose tissue. The devices will need to undergo clinical evaluations which shall be based on relevant data concerning safety, including data from post-market surveillance, post-market clinical follow-up, and, where applicable, specific clinical investigation. Manufacturers will also have to report serious incidents and other reportable events, as well as supporting the coordination of the evaluation of such incidents and events by competent authorities.21 The reporting of adverse incidents is important because adverse incidents can occur due to a malfunction, unclear instructions, poor user practises or servicing and maintenance issues. This change in regulation will bring the EU more in line with the standards and practices of the FDA in terms of regulation, monitoring and consumer protection. Although the extent to which the UK regulations will reflect the EU Regulations post-Brexit is difficult to ascertain; I believe this is an extremely positive step forward for aesthetics in the UK.

Dr Selena Langdon is the founder and medical director of Berkshire Aesthetics. Dr Langdon completed her MRCS while training in plastic surgery in London. She now specialises full time in aesthetic medicine with a special interest in non-surgical body contouring.

Where to from here? The demand for body contouring treatments is growing and the new EU Regulation will increase oversight of body contouring devices. The question is the extent to which the UK will incorporate the new regulation into its own, post-Brexit. I am hopeful that the UK chooses to harmonise with the EU on medical device regulation, which will improve patient safety by providing more oversight, better pre-market testing and more control over the body contouring devices available in the market. Assuming an improved regulatory framework for these devices, clinical evaluation prior to certification and mandatory reporting of adverse incidents

REFERENCES 1. IMARC, Body Contouring Market: Global Industry Trends, Share, Size, Growth, Opportunity and Forecast 2018-2023 <https:// www.imarcgroup.com/body-contouring-market> 2. MHRA, Services and information. <https://www.gov.uk/ government/organisations/medicines-and-healthcare-productsregulatory-agency> 3. Gov.uk, Decide if your product is a medicine or a medical device, MHRA, 2013 <https://www.gov.uk/guidance/decide-ifyour-product-is-a-medicine-or-a-medical-device> 4. CQC, Regulated activities. <http://www.cqc.org.uk/guidanceproviders/registration/regulated-activities> 5. US FDA, Step 3: Pathway to Approval. <https://www.fda.gov/ ForPatients/Approvals/Devices/ucm405381.htm> 6. US FDA, Information Sheet Guidance For IRBs, Clinical Investigators, and Sponsors Frequently Asked Questions About Medical Devices, 2006. <https://www.fda.gov/downloads/ RegulatoryInformation/Guidances/UCM127067.pdf> 7. Gov.uk, Guidance CE marking, 2012. <https://www.gov.uk/ guidance/ce-marking> 8. Council Directive 93/42/EEC of 14 June 1993 concerning medical devices, 1993. <http://eur-lex.europa.eu/legal-content/ EN/TXT/HTML/?uri=CELEX:31993L0042&from=EN> 9. European Commission, The Low Voltage Directive (LVD), 2016. <http://ec.europa.eu/growth/sectors/electrical-engineering/ lvd-directive_en> 10. Official Journal of the European Union, DIRECTIVE 2014/30/ EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL, 2014. <http://eur-lex.europa.eu/legal-content/EN/TXT/ PDF/?uri=CELEX:32014L0030&from=EN> 11. Gov.uk, Guidance Medical devices: conformity assessment and the CE mark, 2015. <https://www.gov.uk/guidance/medicaldevices-conformity-assessment-and-the-ce-mark> 12. Choong, W.L., Wohlgemut, H.S. & Hallam, M.J., Frostbite following cryolipolysis treatment in a beauty salon: a case study, Journal of Wound Care, Volume 26, NO 4, APRIL 2017, pg. 188 to 190 13. GMC, Guidance for doctors who offer cosmetic interventions, 2016. <https://www.gmc-uk.org/-/media/documents/Guidance_ for_doctors_who_offer_cosmetic_interventions_210316. pdf_65254111.pdf> 14. American Society fo Dermatologic Surgery, ASDS SURVEY: SEVEN OUT OF TEN CONSUMERS CONSIDERING COSMETIC PROCEDURES, 2017. <https://www.asds.net/Skin-Experts/ News-Room/Press-Releases/ASDS-survey-Seven-out-of-tenconsumers-considering-cosmetic-procedures> 15. CAP, Cosmetic interventions Advertising Guidance (non-broadcast and broadcast) <https://www.asa.org.uk/ asset/06D92630-75DE-4DDC-81F365D94E7BA21C/> 16. ASA, Our Funding, 2018. <https://www.asa.org.uk/about-asaand-cap/about-regulation/our-funding.html> 17. ASA, Sanctions, 2018. <https://www.asa.org.uk/codes-andrulings/sanctions.html> 18. National Trading Standards, Protecting Consumers & Safeguarding Businesses, 2018. <http://www. nationaltradingstandards.uk/> 19. ASA, Who complains about ads? A regional breakdown, 2016, <https://www.asa.org.uk/news/who-complains-about-ads-aregional-breakdown.html> 20. Regulation (EU) 2017/745 of the European Parliament and of the Council of 5 April 2017 on medical devices, EU Publications <https://publications.europa.eu/en/publication-detail/-/ publication/83bdc18f-315d-11e7-9412-01aa75ed71a1> 21. REGULATION (EU) 2017/745 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 5 April 2017, Official Journal of the European Union. <http://eur-lex.europa.eu/legal-content/EN/ TXT/HTML/?uri=CELEX:32017R0745&from=EN>

Reproduced from Aesthetics | Volume 5/Issue 7 - June 2018


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

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

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

Aesthetics June 2018  

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Aesthetics June 2018  

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