Aesthetics March 2016

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VOLUME 3/ISSUE 4 - MARCH 2016

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Granuloma Management CPD Dr Beata Cybulska discusses granuloma formation and treatment

Eyelash Transplants Mr Asim Shahmalak shares his techniques for successful eyelash transplants

Treating Facial Thread Veins with Lasers Mary White examines how to use lasers to treat thread veins

The Benefits of Bloggers Mike Nolan explains how to engage with bloggers for marketing opportunities

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Contents • March 2016 06 News

The latest product and industry news 16 Conference and R&D Reports

Aesthetics reports on IMCAS Paris, the Neauvia ‘New Art Aesthetics’ World

Congress and research and development at mesoestetic 18 On the Scene

Out and about in the industry this month 22 News Special: Cosmetic Surgery on the Rise

Aesthetics reports on the latest BAAPS annual audit figures and examines

why cosmetic treatments are on the rise 24 Aesthetics Conference and Exhibition 2016

A look at the free clinical content available at ACE 2016

Special Feature Treating Hair Loss Page 27

CLINICAL PRACTICE 27 Special Feature: Managing Hair Loss

Practitioners discuss their preferred treatment options for thinning and

declining hair 32 CPD: Granuloma Management

Dr Beata Cybulska discusses the treatment of granulomas following

dermal filler injections 38 Treating the Post-pregnancy Body

Mr Taimur Shoaib shares treatment options for aesthetic concerns

following childbirth 43 Eyelash Transplants

Mr Asim Shahmalak examines the history of eyelash transplants and

provides treatment advice 49 Peri-ocular Ageing

Mrs Sabrina Shah-Desai explains how to treat peri-ocular ageing in

different ethnicities 53 Treating Facial Thread Veins with Lasers

Aesthetic nurse prescriber Mary White describes laser functions and

thread vein treatments 57 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 58 The Benefits of Bloggers

Mike Nolan explains how to attract patients through partnering with

online bloggers 61 The Big Brand Theory

Roydon Cowley discusses branding strategies and how to separate

yourself from the competition 64 How Google Influences New Patients

Jay Cruiz examines Google’s impact on clinic reputation and advises

practitioners on how to manage online reviews 67 In Profile: Dr Beatriz Molina

Dr Beatriz Molina reflects on her journey into medical aesthetics and

shares her passion for making it a recognised specialty 68 The Last Word

Dr Joney De Souza debates the use of voucher websites as a portal for

selling cosmetic treatments

NEXT MONTH • IN FOCUS: Combination Treatments • Mid-facial Rejuvenation • PDO Threadlifting • Benefits of 3D Imaging

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

In Practice How Google Influences New Patients Page 64

Clinical Contributors Dr Beata Cybulska is a board-registered dermatovenereologist (Poland) and an aesthetic practitioner with more than 20 years of experience of working in teaching hospitals in London and Bristol as an associate specialist.

Mr Taimur Shoaib is a consultant plastic surgeon with more than 20 years’ medical experience. He qualified from the University of Glasgow in 1992, before establishing his cosmetic surgery practice, La Belle Forme, in 2009.

Mr Asim Shahmalak is a hair transplant surgeon and gained his medical degree from the University of Karachi, Pakistan in 1988. He founded the Crown Clinic in Manchester eight years ago and also has consulting rooms in Harley Street.

Mrs Sabrina Shah-Desai is a consultant oculoplastic surgeon with experience in non-surgical aesthetic peri-orbital rejuvenation with botulinum toxin and dermal fillers. She is a keen educator and runs surgical training wet labs and regularly speaks at national conferences.

Mary White is an aesthetic nurse prescriber and specialises in dermatology laser and aesthetic injectable treatments. White owns an award-winning clinic in Worcestershire and has been a clinical trainer for two leading suppliers of medical lasers in the UK.

Register for the Aesthetics Conference and Exhibition 2016 15-16 April www.aestheticsconference.com

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Editor’s letter The month in which we turn the clocks forward and spring arrives is finally here. Personally I can’t wait for the equinox, when the sun crosses the celestial equator – that imaginary line in the sky, and we are on the summer countdown!

Amanda Cameron Before we focus on what’s to come in summer, Editor we have a conference to attend. All is nearly ready for the biggest and best aesthetic congress of the year, the Aesthetics Conference and Exhibition (ACE) 2016, taking place on April 15 and 16. We now have a fantastic line-up of expert speakers and hot topics to engage everyone, whatever your speciality. This year, we have created eight Conference sessions, each dedicated to key anatomical facial and body areas. Book either a 1-day or a 2-day Pass to update your knowledge and understanding of full facial rejuvenation, treating the neck, breasts, buttock and thighs, and vaginal rejuvenation. Alternatively, with free registration, you have access to the Expert Clinics, Masterclasses, Treatments on Trial and Business Track agendas, where you can discover new treatments and techniques, learn about the use and efficacy of new products, and enhance your business skills, with comprehensive advice from the UK’s most

knowledgeable aesthetic professionals. We have also introduced innovative and exciting technology to enhance the sound and viewing of sessions to ensure you don’t miss out on anything taking place.

Read more about ACE 2016 on p.24.

So what articles do we have for you this month? Dr Beata Cybulska’s CPD article (p.32) on the management of granulomas will be relevant to all aesthetic practitioners offering dermal filler injections, so I urge everyone to read it carefully to aid your understanding of the formation, pathophysiology and treatment of this delayed complication.

Hair loss can be a significant aesthetic concern for both men and women, and, thankfully, there is range of treatment options available, which are increasingly being performed in aesthetic clinics. Turn to p.27 to learn more about successful procedures and how you can expand your offerings. Hair loss doesn’t solely occur on the scalp, it can also affect eyebrows and eyelashes, as I found out in Mr Asim Shahmalak’s fascinating eyelash transplant article. Turn to p.43 to enhance your understanding of this complex procedure.

Please do let us know what you enjoyed reading this month and the sessions you’re looking forward to attending at ACE 2016 by tweeting us @aestheticsgroup or emailing editorial@aestheticsjournal.com

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

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

and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years.

Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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Audit

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Moles Dr Anjali Mahto @DrAnjaliMahto #Skincancer clinic done this morning. Learn to examine your moles #WorldCancerDay #melonoma #Confrence Dr Askari Townshend @Dr_AskariT Back in the UK after a great weekend catching up with & learning from fellow experts #imcas2016. You can never know too much! #Conference Dr Uliana Gout @UlianaGout A pleasure to lecture at the E3 Summit and the Ukranian Aesthetic Consilium Conference 2016 @Media_Consilium #Regulation SkinLizzie @LPALimited My #Skin & #aesthetics #service is regularly inspected & audited via #saveface & #CQC #standards

#Presenter Dr Raj Acquilla @RajAcquilla Very honoured to present at the @RoySocMed #London with #KoenDeBoulle and friends. #Survey Gary Ross @ukaesthetic Cosmetic surgery with BAAPS surgeons increasing.

Great to be part of the safety audit. Thanks @BAAPSmedia. #Genetics Dr Doris Day @DrDorisDay Opening the conversation re: genetics and beauty, starting with my daughter! #mumgenes #happymama #workispleasure

New data suggests cosmetic procedures in Britain have risen by 13% The annual audit released by the British Association of Aesthetic Plastic Surgeons (BAAPS) suggests a ‘record number’ of Britons underwent cosmetic surgery in 2015.

The data, collected by BAAPS, states that 51,000 Britons underwent procedures last year – a 13% rise since 2014. Women’s cosmetic surgery is said to have risen by 12.5% from 2014, with breast augmentation remaining the most popular procedure, rising a further 12% from 2014. A rise in men having cosmetic surgery is also noted in the report, with face/neck lifts climbing 14%, eyelid surgery up 15% and brow lifts 15.5%. The most significant rise in male cosmetic surgery was liposuction, which rose by 20% from the previous year.

Consultant plastic surgeon and BAAPS president, Mr Michael Cadier, said, “There’s no doubt that we are seeing an increase in demand for cosmetic surgery from both men and women. Whether this is inspired by celebrity culture and a recognition that the results of modern aesthetic procedures in the right hands can be subtle, natural-looking and attractive, what is most important is for patients to remember that surgery is, on the whole, life-changing and irreversible – far from a trivial ‘status symbol’ beauty treatment.”

The report suggests that a trend in celebrities openly confessing to having procedures could be helping to de-stigmatise cosmetic surgery and fuel growth. Mr Rajiv Grover, consultant plastic surgeon and former president of BAAPS said, “The 2015 BAAPS audit has shown that demand for cosmetic surgery continues to increase following the quieter period in 2014 which mirrored the British economy. Perhaps the decline of the ‘hyper-masculine’ look fashionable last year, which has given way to a sharper, more slimline shape, has influenced men – and it certainly appears both genders seem encouraged by a new openness in glamorous celebrities admitting they have had ‘a little surgical help’ to enhance their looks.”

Suncare

AesthetiCare launches new mineral formulation Skincare manufacturer AesthetiCare has introduced a new sun protectant mineral formulation to its Heliocare 360˚ range.

The Heliocare 360˚ Mineral is designed to provide the skin with a hydrating, antiageing layer that aims to protect the skin from harsh UVA and UVB rays.

The Heliocare 360˚ range contains formulations of antioxidant activity with the polypodium leucotomos extract fortified with ferulic acid and caffeic acid, combined with, amongst others, an antioxidant complex of vitamins C and E, and green tea extract. AesthetiCare claims the product can be used under makeup and is suitable for all skin types.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Conference

Meet the experts at ACE 2016 Delegates will have the special opportunity to meet leading aesthetic nurses, doctors, surgeons and other industry experts at the Aesthetics Conference and Exhibition (ACE) on April 15 and 16. Prominent practitioners will be present at the Aesthetics stand throughout the two days, to meet and greet delegates and to answer any industry questions they may have.

In attendance will be consultant plastic and reconstructive aesthetic surgeon, Mr Dalvi Humzah, cosmetic dermatologist Dr Raj Acquilla, consultant plastic surgeon Mr Taimur Shoaib, cosmetic practitioner, Dr Tapan Patel, consultant plastic and cosmetic surgeon, Mr Adrian Richards and dermatologist Dr Maria Gonzalez. Aesthetics journal editor and ACE programme organiser Amanda Cameron said she is looking forwarding to introducing the experts to attending delegates. “This is the first time at ACE where we will have some of the industry’s top practitioners available for delegates to speak to at the Aesthetics stand.

I am so glad we can give attendees this unique opportunity. They can ask their individual questions face to face in a more personal environment, whilst networking with their peers.” For more information and to register for ACE 2016, please visit www.aestheticsconference.com

Countdown to ACE 2016 Latest programme updates Professor Andy Pickett will discuss the risks associated with fake and counterfeit aesthetic products at his Business Track session.

Dr Julian De Silva’s Expert Clinic session will include details of his techniques for non-invasive nose reshaping using fillers.

Mr Paul Banwell’s Expert Clinic session, sponsored by 3D-lipo Ltd, will discuss the benefits of the latest developments in non-surgical facial rejuvenation using HIFU technology.

Skincare

SkinCeuticals launches addition to Correct range Skincare company SkinCeuticals has added the Triple Lipid Restore 2:4:2 to its Correct skincare range. The Triple Lipid Restore is an antiageing lipid replenishment cream that aims to stimulate lipid replenishment, barrier protection, hydration and repair in ageing or dry skin. According to SkinCeuticals, the Triple Lipid Restore is the first product to effectively harness potent lipid combinations. It combines a ratio of lipids in a concentration of 2% ceramides, 4% cholesterol and 2% omega-fatty acids to correct and nourish skin by replenishing the lipid ratio and restoring natural hydration and skin barrier function.

The product is part of the Correct portfolio, which aims to prevent further skin damage due to collagen breakdown, closer cell turnover and loss of moisture, as well as correct and restore the skin for a healthier and youthful appearance.

Investigation

Clinics found to be offering under-18s cosmetic procedures An investigation by The Sun claims that 12 clinics across five major UK cities considered treating children as young as 15 years old. Doctors, nurses and a paediatric surgeon are said to have discussed treatment with the under-18s, with the surgeon apparently telling a 15-year-old he could “100% convince” her mother to allow her to have botulinum toxin and lip fillers. An undercover reporter took the 15-year-old girl to consultations at clinics across the UK where she asked for dermal fillers to make her lips bigger, botulinum toxin to smooth forehead wrinkles or semipermanent makeup. Each clinic was given the girl’s date of birth. Twelve clinics were found to consider treating the girl and six booked her in to have lip filler or botulinum toxin. Mr Nilesh Sojitra, consultant plastic surgeon said, “At such a young age, a patient does not require any ‘antiageing’ treatment. To suggest otherwise is irresponsible.”

Insight Cosmetic practitioner and international speaker Dr Tapan Patel says: “Year on year there has been an increasing attendance at ACE and I think this conference will only get bigger over time. As a regular speaker, I can say we are incredibly well-looked after, the organisation is top-notch, the audio-visual team is fantastic, and it’s always a real privilege to be part of the show.

As an advanced practitioner, I attend conferences to continually progress my learning, and I would advise any injector, no matter how experienced, to do the same. The learning process is a dynamic one, techniques are constantly evolving and our knowledge of anatomy is constantly expanding; I believe investing in continuous medical education is vital.”

What delegates say “Excellent range of exhibitors and speakers, with a variety of topics covered.”

Aesthetic nurse prescriber, Ireland

“Good exhibitors, friendly environment, easy to get to. Excellent variety of lecturers and great value for money.”

Cosmetic doctor, Swansea

www.aestheticsconference.com HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Suncare

Industry

Pfizer and Allergan announce new division and leaderships US global biopharmaceutical company Pfizer will create a new division following the completion of its merge with Allergan, scheduled for the second half of this year. The new operating segment, named Global Specialty and Consumer Brands, will include Pfizer’s Consumer Healthcare unit and Allergan’s ophthalmology and aesthetics businesses. The current executive vice president at Allergan, Bill Meury, has been announced as the group’s president. Pfizer also stated that after the closing of the transaction, the company’s Global Innovative Pharma and its Vaccines, Oncology and Consumer (VOC) business will be combined, under the leadership of Albert Bourla, who is currently group president of VOC. At this time, the company also said it will continue to manage the combined company’s commercial operations through two distinct businesses; Innovative Products and Established Products. Ian Read, chairman and chief executive officer of Pfizer, said, “We are designing the combined company to preserve and enhance our option to potentially separate the innovative and established businesses into separate companies in the future, and continue to expect to make a decision about any potential separation by no later than the end of 2018.”

Vaginal rejuvenation

Lumenis launches FemTouch for intimate area Laser device manufacturer Lumenis has launched a fractional CO2 laser for an in-clinic treatment of health-related vaginal conditions. The FemTouch aims to help post-menopausal women suffering from symptoms such as vaginal atrophy and stress urinary incontinence, and works by promoting the remodeling of the vaginal mucous epithelium layer. The fractional laser is applied along the vaginal wall, without the need of anaesthesia, resulting in a gentle controlled ablation and coagulation of the vaginal lining. According to Lumenis, the treatment requires two to four sessions of around two minutes each to reach optimal outcomes. “FemTouch is an effective, safe and fast treatment for women who want to improve their vaginal health,” said gynaecologist, Dr Massimiliano Marziali. He continued, “I am excited to add this treatment to my practice as the patients I have treated so far are satisfied with the clinical outcomes and with the overall procedure, which takes only a few minutes and is generally comfortable for them. I believe that FemTouch is the future of vaginal health as its simplicity of usage also leads to good clinical outcomes and it could also be effective for additional gynaecological indications.”

New NICE guidelines uncover the risks and benefits of sunlight exposure The National Institute for Health and Care Excellence (NICE) has released new guidelines that outline the risks and benefits of sunlight exposure. The guidelines, Sunlight exposure: risks and benefits, urges practitioners to communicate the risks of excessive sun exposure to their patients, as well as inform them of the increased risk of low vitamin D status due to underexposure. NICE has made 18 recommendations in the guidance, including suggestions to practitioners which include offering one-to-one tailored advice to individual patients, communicating the risks and benefits of sun exposure to their patients and supporting community health programmes to raise awareness of under and overexposure to sunlight.

Deputy chief executive and director of health and social care at NICE, Professor Gillian Leng, said, “We need to better identify groups at risk of over or underexposure to sunlight and give them better understanding of why they may need to modify their behaviour and how. Our new recommendations will help tailor public health activities focused on those groups most at risk from over or underexposure to sunlight. They will ensure that all activities and campaigns take a balanced, consistent and effective approach, and ultimately make the sun more friend than foe.”

Education

Dr Beatriz Molina and Mrs Sabrina Shah-Desai launch new training course Consultant ophthalmic plastic and reconstructive surgeon Mrs Sabrina Shah-Desai and aesthetic practitioner Dr Beatriz Molina will hold a facial rejuvenation course together in Coventry on April 11.

The course, titled, ‘Anatomical Basis of Facial Rejuvenation with Dermal Fillers and Management of Complications Wet Lab,’ will provide delegates with a unique, hands-on experience in how to avoid and treat complications from non-surgical filler treatments.

“Industry comments have indicated that there is a growing need for expert training in the management of acute and chronic complications of dermal fillers – particularly the use of hyalase, the doses and how to manage vascular complications,” said Mrs Shah-Desai. “Delegates can expect a highly interactive day, where the training is not didactic and theoretical, but practical, evidence-based, hands-on and relevant to clinical practice,” she said.

Attendees will have the opportunity to obtain an understanding of facial anatomical layers using cadaver pro-sections and will be able to practice anatomical surface marking on frozen cadavers.

The ‘wet lab’ will cover basic, intermediate and advanced safe reproducible filler injection techniques for the forehead, temple, tear trough, superior sulcus, perioral and jawline, as well as practical sessions using hyaluronidase. Mrs Shah-Desai and Dr Molina will also discuss common dermal filler complications, such as the Tyndall effect and overfilling, and will provide their advice on the management of these complications.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Skincare

Teoxane adds UV protectant to skincare range Aesthetic manufacturer Teoxane Laboratories has introduced the Advanced Perfecting Shield to its Teoxane Cosmeceutical range. The Advanced Perfecting Shield is an SPF 30 day cream that aims to hydrate, revitalise and restore the skin while offering advanced UVA/UVB protection.

The formula consists of Teoxane Cosmeceutical’s Resilient Hyaluronic Acid, which aims to provide optimal hydration to visibly smooth, plump and strengthen the skin. Dermo-Restructuring Complex is also included, which contains antioxidants, amino acids, glutathione, alpha lipoic acid and minerals, as well as vitamin B6 to revitalise and protect the skin from oxidative stress.

NovHyal (N-acetyl glucosamine-6-phosphate enzyme) is also a part of this formula, which aims to restructure the skin by stimulating HA production.

The Advanced Perfecting Shield comprises solar filters with ingredients that aim to inhibit hyaluronidase reaction, have an anti-glycation effect and SPF 30 daily sun protection from UVA/UVB rays. The cream has been designed to be a makeup base and is lightly tinted so can be used both as a tinted cream and for mixing with foundation.

Aesthetics

Vital Statistics 2,006

In a survey of respondents, nearly a third of UK adults would have aesthetic treatment for a change in job or career (Intraline Medical Aesthetics survey)

41%

It is estimated that 41% of women over the age of 50 have varicose veins (Chicago Vein Institute)

In a survey of 2,104 people, 88% said they trust online reviews as much as personal recommendations (Local Consumer Review Survey 2014

Awards

by Bright Local)

New sponsor announced for Aesthetics Awards 2016 Enhance Insurance will sponsor the Training Initiative of the Year category at the Aesthetics Awards in December this year. The category recognises high quality aesthetic training programmes that deliver engaging, relevant content with a continuous development and improvement platform, resulting in measurable outcomes for delegates.

“Enhance are proud to be sponsoring the Aesthetics Award for Training Initiative of The Year in 2016, in order to highlight the gold standard industry training courses,” said Holly Markham, business development executive at Enhance Insurance. She continued, “It is imperative that high quality training is available to practitioners wanting to pursue a career or continue to develop and improve their knowledge and skills in aesthetics. From an insurance perspective, practitioners involved in aesthetics should be looking to continually up-skill, positioning themselves with continued comprehensive technical ability, a solid understanding of anatomical theory, as well as education, which encompasses consultation skills and knowledge surrounding health, safety and clinical compliance.”

Enhance Insurance is part of Vantage Professional Risks, a London-based independent insurance and risk management broker. The company has more than 30 years’ experience in providing insurance services for professionals in the medical and aesthetics sector.

The Aesthetics Awards 2016 will be held at the Park Plaza Westminster Bridge Hotel in London on December 3. To see last year’s winners and a gallery of images visit www.aestheticsawards.com

The global dermal facial fillers market is forecast to grow at a rate of 13.07% during 2014-2019 (Global Dermal Facial Fillers Market 2015-2019 Report)

In a study of 3 million user interactions, results showed that Instagram has 58 times more engagement per follower than Facebook (Forrester report)

40% of men will have noticeable hair loss by the time they are 35 (International Society of Hair Restoration Surgery)

In a survey of 7,000 mothers, one to two years after giving birth, 86% of women say their stomach still hasn’t returned to normal (BabyCenter survey 2008)

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Events diary 4th – 8th March 2016 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org/meetings/2016-annual-meeting

31st March – 2nd April 2016 Aesthetic & Anti-aging Medicine World Congress 2016, Monte Carlo www.euromedicom.com

4th – 6th April 2016 British Society for Investigative Dermatology Annual Meeting 2016, Dundee www.bad.org.uk

15th – 16th April 2016 Aesthetics Conference & Exhibition, London www.aestheticsconference.com

28th April 2016 British Association of Sclerotherapists 2016 Annual Meeting, Basingstoke www.bassclerotherapy.com

11th – 15th May 2016 Face Eyes Nose Conference, Coventry www.faceeyesnose.co.uk

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

ACE 2016 registrations and consumables partner announced Facial aesthetic product supplying company, Med-fx will be the registrations and consumables partner of the Aesthetics Conference and Exhibition 2016 on April 15 and 16. Med-fx is a market-leading provider of aesthetic products and business support services supplying a wide range of products from botulinum toxins, dermal fillers and cosmeceuticals to surgery consumable products. Sales manager Dyan Williams said, “Med-fx are ideally placed to support the huge clinical agenda for 2016, which features an array of interesting and relevant content such as the Expert Clinics and Masterclasses from the UK’s top practitioners.” To register for ACE visit www.aestheticsconference.com

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Advertising

BAAPS condemns timesensitive discount deals The British Association of Aesthetic Plastic Surgeons has criticised time-sensitive deals in cosmetic treatments that ‘continue to flourish unchecked’.

Despite the Government enquiry into cosmetic surgery condemning time-linked offers for treatments such as facial injectables as unethical, BAAPS has expressed its concern over Valentine’s Day-themed offers that appeared on the internet, with one clinic offering breast implants as a ‘Valentine’s Day prize’.

“If despite Government directives, providers can continue to advertise timesensitive deals and prizes for what should be deemed as medical treatments, what message does that send about our sector?” said Mr Rajiv Grover. He continued, “It is outrageous that despite the warnings in the Keogh Review and the Government’s response, clinics continue to behave without a conscience by putting their profits before common sense. A warning from the Advertising Standards Agency in response to aggressive marketing and advertising is a bark without any bite, and clinics repeatedly flout this token slap on the wrist – yet will gain a database of patients who have not considered any risk.”

Dermal filler

IBSA launches new hyaluronic acid hybrid Profhilo Profhilo, a new hyaluronic acid (HA) stable hybrid cooperative complex for bioremodeling skin laxity, launched globally at the International Master Course on Aging Skin (IMCAS) on January 31 in Paris. The new product is manufactured by pharmaceutical company IBSA Farmaceutici Italia and is a BDDE-free, thermally cross-linked HA hybrid that aims to remodel and restore firmness to the skin and nourish cells. According to IBSA, Profhilo is biocompatible as it is composed of a pure HA produced by biofermentation and has a reduced risk of side effects, as it is absent of additives.

Aesthetic distributor HA-Derma will officially launch Profhilo in the UK in June, however practitioners can attend the company’s stand at ACE 2016 on April 15 and 16 for more information on the product. ACE 2016 will take place at the Business Design Centre in London on April 15 and 16. For more information and to register visit www.aestheticsconference.com Dermal filler

DERMAFILL now available in more than 350 UK clinics The DERMAFILL product range, which was launched into the UK at the Aesthetics Conference and Exhibition last year, is now available in more than 350 clinics. Managing Director of Breit Aesthetics, Jazz Dhariwal, said, “Within the first 12 months of launch we have had a tremendous response to our UK launch of DERMAFILL with more than 350 UK clinics now using the DERMAFILL range ahead of conventional HA technologies. We have chosen Cosmedic Pharmacy as our exclusive provider for all prescription requests.”

The distributor Breit Aesthetics claims DERMAFILL is the first of a new fourth generation of safer, more effective, pure monophasic injectable dermal fillers.

The company also claims the product exceeds the stricter standards of the FDA’s very low level of 1,4-Butanediol Diglycidyl Ether (BDDE) controls.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Aesthetics

Skin rejuvenation

Naturastudios launches the Jet Peel 3V Naturastudios has released multi-platform system Jet Peel 3V for skin rejuvenation. The Jet Peel 3V uses air pressure to deliver saline or medical gas to stimulate biorejuvenation of the skin. The high velocity of the treatment is said to allow for transdermal delivery without the use of needles or heat. The machine’s three patented handpieces, powered by medical grade gas, connects to the machine and injects water, saline or vitamin infusion into the epidermis.

The company claims that the high velocity air breaks down water, saline or vitamin infusions into micro-droplets, creating a kinetic energy, allowing deeper penetration with little or no downtime. The jet-stream of micro-droplets aims to gently and painlessly cleanse and exfoliate the skin, resulting in skin rejuvenation. The Jet Peel 3V treatment also aims to leave skin feeling fresher, fade blemishes and imperfections, fine lines and wrinkles, and improve the appearance of scars and stretch marks.

Appointment

Swisscode UK announces Dr Shirin Lakhani as new brand ambassador Cosmeceutical skincare manufacturer, Swisscode UK, has appointed aesthetic practitioner Dr Shirin Lakhani to represent its brand in Kent and Guernsey.

Dr Lakhani has worked as an NHS practitioner with experience in general medicine, general surgery, urology, and accident and emergency. She later trained as an anaesthetist, where she became skilled at injection techniques and practical procedures. Dr Lakhani now consults for a number of London and Guernsey aesthetic clinics and runs her own clinic in Kent, Elite Aesthetics, which she opened in 2013. Swisscode UK CEO, Teresa Da Graca, said, “We are delighted to have the expert skincare knowledge of Dr Shirin Lakhani to support our brand as we continue on our successful growth in the UK aesthetic clinic market place.” Swisscode is a skincare line that consists of concentrates and serums, which aim to deliver products that boost the skin’s rejuvenation process.

Antiageing

Sterex relaunches wrinkle reduction treatment

Roydon Cowley, founder and managing director of 3D-lipo What’s your primary focus and key to your success?

We focus on supplying treatments to the majority of patients, not the minority. What we have done is taken high quality, expensive technologies and managed to bring them all together into one device – bringing down the price and therefore allowing the majority of patients to have access to these treatments. This new idea, along with successful branding and national awareness campaigns, as well as associations with key industry figures such as leading consultant plastic and cosmetic surgeon Mr Paul Banwell, has built a brand that has been a success for the patients of more than 450 UK clinics.

How are your products different and unique?

We don’t stand behind trends. We developed a three-dimensional platform that uses different technologies that work best on the individual indications. Therefore, with our equipment, practitioners can be very bespoke in their approach, as they don’t need to have four or five different machines in their clinic in order to address the needs of each individual patient. With our platform, you can put together a very tailored programme to make sure you get the best possible treatment outcomes for every patient.

Building on the success of 3D-lipo, what are your plans for the future?

Following the success of the 3D-lipomed, which was a multi-technology body platform, it was inevitable that we would want to replicate that achievement with a non-surgical device for the face. We have developed the 3D-skinmed, which has become an extremely popular platform for treating the face. It’s again, three-dimensional, offering HIFU and radiofrequency technology, plus impact infusion. The fact that this device is affordable and three-dimensional, means that the future brings these treatments to the majority of patients, not the minority.

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Cellulite

Aesthetic manufacturing company Sterex Electrolysis International Ltd has relaunched BioSkinJetting, a treatment used in conjunction with the radiofrequency BioSkinSmoothing machine to treat wrinkles, scars and imperfections. Sterex managing director Laurie Cartmell said the relaunch was a necessary move to re-introduce the treatments to the aesthetic industry. She explained, “This time around, treatments based on subcision are accepted and embraced. BioSkinJetting is built upon the same principle as dermarolling and stamping, but when we launched previously, were simply before our time.” According to Sterex, the treatment aims to stimulate the skin underneath the wrinkle to form new tissue containing regenerated collagen and elastin fibres, which the company claims results in long-lasting, natural and visibly less-deep wrinkles and blemishes.

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Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016 Cavitation

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Injectables

‘Thinnest needle in the world’ introduced to the UK Consultant plastic and aesthetic surgeon Mr Dalvi Humzah and cosmetic nurse practitioner Anna Baker have been chosen as part of a select few in the UK to use the THE INViSIBLE NEEDLE. TSK Laboratory, manufacturer of THE INViSIBLE NEEDLE, claims its the first needle of its kind and the thinnest needle available to date. Technological advancements have made it possible to make the needle 33% thinner than the needle used in insulin syringes (30G) – usually used for botulinum toxin injection – and 14% thinner than the 33G needles currently used at Mr Humzah’s practice, the AMP Clinic. Mr Humzah said, “The extremely thin diameter of THE INViSIBLE NEEDLE results in a nearly painless experience for patients and is ideal for botulinum toxin injections. One of the biggest fears patients have when it comes to having these injections is a painful needle injection, but THE INViSIBLE NEEDLE may relieve this fear and greatly improve the overall patient experience.” The needle was launched on January 28 at IMCAS in Paris, which was attended by Mr Humzah and Baker, who shared their experience of using the needle with delegates.

Device

3D-lipo to launch new shockwave therapy device Aesthetic device manufacturer 3D-lipo has announced it will launch its latest product, the 3D-shockwave, at the Aesthetics Conference and Exhibition on April 15 and 16.

The three-dimensional device is designed to stimulate skin tightening, reduce cellulite and improve stretch marks.

It uses a probe against the skin to emit radial waves, which works by stimulating the breakdown of fat, collagen synthesis and lymphatic drainage. According to 3D-lipo, a course of 8-10 individual, 45-minute treatments, twice per week will achieve the best results, which will be seen within the first four treatments.

To achieve accelerated results, the company suggests combining 3D-shockwave treatments such as cryolipolysis.

Cosmeceuticals

5 Squirrels launches new edition to Your Signature Range Private label cosmeceutical supplier, 5 Squirrels, has introduced a foaming cleanser to its Your Signature Range. Reveal is a foaming clinical strength glycolic wash, which the company claims has been developed and tested in consultation with aesthetic clinic patients. Director of 5 Squirrels, Gary Conroy believes this product will help practitioners extend their own brand of skincare to their patients. “The feedback on the quality of our products and offering has seen us grow enormously in the past 12 months, both from number of patients repeat purchasing the range, and in the number of clinics adopting our solution as a means of improving client retention, increasing brand awareness and staving off competition from online discounters for skincare.” Reveal is the ninth product in the range, and additional products are scheduled to be released later in the year.

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News in Brief New medical insurance platform launches Insurance company Vantage Professional Risks has introduced a specialist medical and aesthetics platform, Enhance Insurance.

Divisional director of Enhance Insurance, Martin Swann, said, “Having listened to the frustrations of the industry surrounding insurance, we felt it was time to draw upon our expertise to put in place a new offering specifically designed for the medical aesthetic sector.”

Teoxane releases photo app for clinical practice Teoxane Laboratories has launched a photo application to assist practitioners in their day-to-day treatments. Teoxane Aesthepic can be used to store patient data, treatment information, before and after photographs and relevant reminders. The new app aims to organise, optimise and improve the clinic’s day-to-day activity. The app is available for download from iTunes and Play Store and can be used on a mobile, tablet or via a desktop device.

Classys launches new fat freezing device Aesthetic medical device manufacturer Classys has released new fat freezing machine, CLATUU. The product, which aims to remodel the shape of the body with no downtime or pain, features a 360-degree cooling panel and a dual handpiece, which aims to work simultaneously over the treatment area to increase coverage and reduce treatment time. The controlled cooling system aims to have long-lasting results, improving the skin’s firmness and texture, reshaping the body and reducing fat deposits.

HA-Derma appoints new product specialist Aesthetic distributor HA-Derma has announced Hana Te Reo as its new product specialist. Te Reo has worked in the aesthetic industry for 11 years, previously working at the Boston Medical Group and Harley Street Treatments. HA-Derma is hoping her past experience will play a key role in the launch of new products, such as Aliaxin, which will officially launch at the Aesthetic Conference and Exhibition 2016 in April, and Profhilo, which will launch in June.

“I’m really excited to be working with the team at HA-Derma,” Te Reo said, adding “I share the same goals of supplying safe, cutting-edge products that are clinically proven and science-based.”

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

BOOK YOUR FREE DEMONSTRATION Skincare

DERMEDICS launches in the UK International skincare and treatment company DERMEDICS has launched in the UK. DERMEDICS products aim to offer solutions to overcome common skin problems for people of all ages and skin types through professional therapies and take-home treatments.

“I am so pleased to introduce DERMEDICS Paramedical Skincare range,” said UK director for DERMEDICS, Kate Lovland. “We combine superior product formulations with aesthetic medical treatments to give our customers incredible results. With skincare heritage in 32 worldwide markets we are able to bring truly international expertise to the UK, which is fully supported with training and ongoing customer service.” Practitioners who are new to using DERMEDICS products are eligible for complimentary one-day training sessions and starter packs. DERMEDICS is also offering extensive training programmes for facials and weight loss, skin peels, microdermabrasion, nappage mesotherapy, derma roller, skin needling and dermaplanning, and contour body wraps. The courses will be available to attend in Manchester and can also be accessed online.

Melanoma

Study indicates melanoma rates are higher in younger women A new study examining associations between indoor tanning and melanoma has suggested a melanoma diagnosis is more common in younger women.

The population-based case-controlled study conducted by DeAnne Lazovich et al in the US, studied 681 patients who were diagnosed as having melanoma between 2004 and 2007, of which 68.3% were women. It compared this with 654 control patients who hadn’t had the disease, of which 68.2% were women. All participants in the study were aged between 25 and 49 years old. Researchers looked at how often the participants used indoor tanning and how old they were when they first started doing it. Nearly 80% of the women surveyed said they had been indoor tanning, in contrast to 44% of men. Compared to women aged 40 to 49 years old who on average initiated tanning aged 25 years, women younger than 40 years initiated indoor tanning at a younger age, 16 years, and reported more frequent indoor tanning sessions. The study reported that women under 30 years old were six times more likely to be in the case group than the control group if they tanned indoors. “That almost all of the risk of melanoma relating to indoor tanning was among women was surprising, as was the very strong association among the youngest women,” said Lazovich.

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Antiageing

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Research

Mesoestetic launches Beauty Bar nutraceutical cocktails International pharmaceutical manufacturer, mesoestetic Pharma Group, has introduced its new range of Beauty Bar drinkable antiageing cocktails to the UK. The company explains that the Beauty Bar cocktails are a way for clinics to incorporate nutraceuticals, natural products made from plant extracts, oligo elements and vitamins that aim to enhance the beauty of the skin. It’s claimed by mesoestetic that the products are quickly absorbed by the body and prevent skin ageing by fighting flaccidity and cellulite to improve the skin’s structure and appearance.

Three cocktails are available in the range, the Collagen 360 Elixir, which aims to firm the skin, the Radiance DNA elixir, which aims to provide antiageing treatments and Whitening Elixir, which aims to even out skin tone. The cocktails are composed of collagen, hyaluronic acid or grape extract and are served with mixtures of either ginger, lemon, strawberry or pineapple juice.

Cosmetic surgery industry delivers the best customer service A new report published by Intently indicates that the cosmetic surgery industry is among the best businesses for customer service. Researchers analysed the email response rate from more than 16,000 service providers around the world. The research indicated that cosmetic surgery is in the top five businesses that deliver the best customer service, with an email response rate of 32%, compared to the worst rated business – technology services – which was 5%. Neil Harris, CEO at Intently – a platform for connecting consumers to service providers, said, “Given that cosmetic surgery is such a personal matter, it’s been amazing to see how often these procedures have been requested on Intently.

Even more pleasing is that this service group came third out of 160 categories. It’s a growing industry and the service providers have a strong grasp of the need for outstanding customer service.”

Sclerotherapy

BAS to hold CPD accredited meeting in April The British Association of Sclerotherapists (BAS) will hold its annual meeting at the Ark Conference Centre in Basingstoke on April 28. Dr Martyn King, a BAS board member, said, “This promises to be a lively and highly informative CPD event, unmissable for anyone wishing to broaden or update their sclerotherapy skills.” The day will include a full programme of stimulating presentations by distinguished vascular surgeons and leading aesthetic doctors and nurses, as well as offering live demonstrations of foam and microsclerotherapy, and ultrasound assessment.

Confirmed speakers include consultant vascular surgeon Mr Philip Coleridge Smith and associate specialist in vascular surgery Dr Stephen Tristram; topics will include complications and how to avoid them, compression after sclerotherapy, and marketing your clinic effectively.

In addition to increasing their skills and knowledge, delegates will have the opportunity during the live demonstrations to question leading professionals on their techniques, and there will be ample time for networking with peers.

The evening before the meeting, delegates can choose to attend the BAS dinner, another opportunity to meet and get to know industry peers. An aesthetic nurse who attended last year said of the event, “Great up-to-date info, well presented, varied and entertaining; I learnt a lot. It was great to meet other professionals.”

Skincare

iS Clinical launches new face cream Cosmeceutical skincare brand iS Clinical has launched a new daily face cream. The Youth Intensive Crème is said to show skin improvement from the first day of use, revealing smoother, firmer skin and a more radiant youthful complexion – according to iS Clinical. Ingredients in the face cream include: superoxide dimutase (SOD), which aims to safely absorb free radicals to combat photoageing and cell damage; botanically derived hyaluronic acid microspheres, which aim to act like tiny sponges and expand, filling in wrinkles; vitamin C, which aims to lighten skin by inhibiting melanin synthesis; and copper tripeptide-1 growth factor, which aims to stimulate the synthesis of collagen in skin fibroblasts.

An independent clinical study by Bioscreen Testing Services looked at 35 female participants, ranging from 42 to 68 years old, who used the Youth Intensive Crème twice daily for four weeks. The testers evaluated skin hydration, skin firmness, skin tone and skin texture using instrument measurements, clinical grading and subject questionnaires. From the study, 77% of participants noticed an increase in skin firmness, 91% said their skin was more volumised and 100% said they saw an improvement in skin hydration. The Youth Intensive Crème is suitable for dry and sensitive skin types.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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R&D at mesoestetic

Aesthetics visits the production site and research and development headquarters for mesoestetic Pharma Group’s dermatological and cosmetic medicines mesoestetic Pharma Group is a pharmaceutical laboratory founded in 1984. A family business, currently employing 90 people at its headquarters in Barcelona, Spain, its aim is to provide aesthetic professionals with complete and effective solutions through its consistent efforts in research, development and innovation.

The company develops, manufacturers and markets advanced medical and aesthetic products, which includes a consumer range, a professional range, a medical range and medical-aesthetic devices. The facility prides itself on its ability to produce products from the research stage, to production, to the clinical trial stage, to the marketing and distribution stage, all at one location. The facility is home to mesoestetic’s head office, production plant, biotechnology unit, monitoring and follow-up

Neauvia ‘New Art Aesthetics’ World Congress 2015, Warsaw Aesthetics reports on the highlights from Neauvia’s international training seminar in Warsaw Around 170 aesthetic practitioners, nurses, doctors and distributors from more than 30 countries gathered in Warsaw to attend the Neauvia Organic dermal filler ‘New Art Aesthetics’ World Congress on January 29 and 30.

The event began with an introduction to Neauvia Organic, a new line of Swiss dermal fillers developed by Matex Lab SA and manufactured in Italy. The talk discussed how the fillers use a new cross-linker polyethylene glycol (PEG) polymer, which is nontoxic and completely degradable in the tissue, instead of BDDE. According to the company, this makes Neauvia Organic the most biocompatible filler on the market. This PEG polymer aims to reduce the risk of immunological reaction, reduce inflammation and granuloma formation, and delay the degradation and the bioabsorption of the implant. Dermatologist Dr Nicola Zerbinati, who ran the event, started working with Neauvia three years ago.

“We have created a new concept of filler; we use a new crosslinker that gives us an incredible new hyaluronic acid matrix. It is

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unit, and the logistics platform, which serves more than 60 distribution partners in more than 90 different countries. Carles Font, son of mesoestetic founder Joan Carlos Font, is currently involved in the export and business developments. He said mesoestetic’s involvement and commitment to further development makes it stand out. “We consider that if we have a good reputation and are well-known in the market, it’s because of our products and the results that we are providing to all of our clients,” he said. “So in order to keep providing the best products to our customers, we reinvest 40% of our benefits into the research and development department and have been doing this since the beginning.” The company starts its development process by testing different kinds of human cells with raw materials to determine the most effective ingredients. These results are used to produce products, which are then used in clinical trials and subsequently distributed all over the world. Independent nurse prescriber, and manager of facethefuture clinic, Kate Bancroft, visited the mesoestetic site and was impressed with the company’s research and development efforts. She said, “This visit was a really nice way of understanding how much R&D goes into mesoestetic products and how it comes to the end user in a perfectly packaged form.” Deputy chairman of Absolute Aesthetics, Victoria Smith also journeyed to the laboratory and said the experience confirmed the company’s scientific philosophy. “The mesoestetic facilities were extremely impressive and reflected a true scientific ethos. Absolute Aesthetics has been using the Dermamelan peel in our practice for some time. The trip gave us the opportunity to find out more about the range of products available and the results that can be achieved,” she said.

the only filler in the market with this PEG cross-linker,” he said. Eight international aesthetic practitioners presented their views of the four different dermal fillers available for various anatomical areas and treatments, including rhinoplasty, nasolabial fold, lips, jowl line, hand rejuvenation, zygomatic area, periocular area and vaginal rejuvenation. Highlights of the session included Dr Dawid Serafin’s presentation on using Neauvia for vaginal rejuvenation. The theory presentations were complemented with a second day of live demonstrations on 55 different models. Dr Katrina Felberg shared advice on peri-ocular treatment techniques, while Dr Peter Caspari demonstrated the use of Neauvia on the nasolabial area. After the live demonstrations, delegates were presented with the before and after images of the models to determine their opinions on the product’s results. Aesthetic practitioner Dr Kathryn Taylor Barnes, founder of The Real You Clinic said, “I am really excited about the formulation of this product being organic, that appeals to a lot of the modern day men and women.”

Neauvia sales director for the UK and Ireland, Kevin Eley introduced the products to practitioners in January, and said, “Physicians have commented on the superior filling ability of the products and have also been surprised at the smaller levels of pain and swelling with the Neauvia line.” Facial plastic and laser surgeon Dr Ayham AlAyoubi, who has already started using Neauvia in his clinic on Harley Street said, “It’s definitely an additional product which each cosmetic doctor has to add into their portfolio.”

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Wigmore Medical Open Day, London Practitioners attended the launch of the latest antiageing skincare technology created by Innoture, as well as mini thread lift demonstrations, at the Royal Society of Medicine on.

Korean aesthetic dermatologist and surgeon Dr Kwon Han Jin performed the mini thread lift demonstrations while providing attendees with helpful technique advice and engaging in a question and answer session. The Radara seminar provided delegates with an introduction to the Radara skincare system that consists of rejuvenating micro-channelling patches and hyaluronic acid serum, which aims to reduce fine lines and wrinkles. Leading the seminar was aesthetic surgeon Dr Benji Dhillon, who explained the technology behind Radara, gave an overview of clinical data, and explained how to treat patients with the product and how to incorporate it into a clinic. “My belief is that this is a new product that bridges the gap between topical treatments and injectables and serves as a first-step for someone who doesn’t want to have injectables yet,” said Dr Dhillon. “The feedback we have had so far has been really positive and supports the fact that it works. Users like that it’s a once-nightly treatment and, by using it, reminds them to do other things, so their nightly beauty regime becomes more consistent.”

Also speaking at the seminar was Ryan Bamsey, who was involved in the commercialisation of the Radara microneedling platform, and Sue Thomson, the aesthetic sales director of the manufacturing company Innoture. “I think the day has been really good, we have been able to attract the attention of people who have seen Radara in the media so it has been really exciting,” said Thomson. Radara is owned and manufactured by Innoture Aesthetics, a medical technology company based in Chelsea, London.

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SculpSure pre-launch, London

Laser and light-based aesthetic treatment and manufacturing company, Cynosure, introduced its new laser treatment SculpSure to practitioners at the Home House in London.

Practitioners were invited to learn about the new body-sculpting laser technology through live demonstrations and discussions. Delegates who attended included Dr Tapan Patel, founder and director of PHI Clinic, which is the first clinic to treat patients with the SculpSure laser. Also in attendance was Lisa Littlehouse, managing director of Cavendish Clinic, Dr Nicholas Lowe, consultant dermatologist and founder of Cranley Clinic, Dr Faizeen Zavahir, medical director of Juvea Clinic, Ms Lena Andersson, founder of Anelca Clinic, and dermatologist Dr Beata Cybulska. SculpSure, which has been approved by the Food and Drug Administration, aims to offer convenient, comfortable, non-invasive fat reduction for any body and skin type. Cynosure spokesperson, Bill Kelley, said, “SculpSure is a revolutionary, highly advanced procedure, comprising a clever combination of the science of laser technology with the art of body contouring.”

SkinCeuticals Triple Lipid Restore 2:4:2 Medical Preview Event, London SkinCeuticals welcomed aesthetic practitioners, nurses, dermatologists and medical professionals to Somerset House for a preview of the new Triple Lipid Restore 2:4:2 on February 2.

Guests were greeted with a drinks and canapés reception, before taking their seats in the main room to hear from a panel of UK and international aesthetic practitioners and scientists.

Hosted by beauty journalist Alice Hart-Davis, the evening began with a talk on skin ageing and clinical challenges presented by Dr Hema Sundaram, a US dermatologist, who explained the roles of lipids in the skin and how they deplete with age. Dr Sundaram revealed that 12.9 billion dollars was spent on cosmetic procedures in the US in 2014. Next, Jim Krol, global scientific director of SkinCeuticals, unveiled the science behind the lipid replenishment cream and the results of two years of research. In an eight-week clinical study on 55 patients, who applied the product twice daily, Triple Lipid Restore 2:4:2 was said to ‘significantly improve’ the appearance of key signs of accelerated ageing: clarity, evenness, radiance, smoothness, laxity and pore appearance. The female-only participants recorded a 40%

improvement in the texture and smoothness of their skin and an 18% improvement in pore appearance, compared to baseline.

Finally, aesthetic practitioner Dr Tapan Patel spoke on how to integrate the product into clinical practice and identify the correct patients for the treatment. Dr Patel explained the importance of treating the condition of the skin first, and stated, “If the skin isn’t right, then the treatment won’t be quite right either.” Speaking after the event, Dr Sundaram said, “Having worked behind the scenes with the SkinCeuticals R&D team in developing Triple Lipid Restore 2:4:2, it was a pleasure to present this unique product to our UK practitioners and discuss the benefits that our science-led approach to skincare can have for their everyday clinical practice.”

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Dr Kieren Bong London Two Point Eye Lift Masterclass, London Ten delegates attended a training day with aesthetic doctor Dr Kieren Bong who demonstrated his Two Point Eye Lift technique at the Wigmore training facility at the Royal Society of Medicine. The session focused on the anatomy of the eye area, how to choose the right patient for the Two Point Eye Lift, a technique for rejuvenating hollow eyes with dermal fillers, and a discussion of how to prevent possible complications.

Dr Bong uses Teosyal Redensity II for the lift, a dermal filler product with semicross-linked hyaluronic acid that aims to specifically treat the under eye hollows and tear trough. Dr Lina Strachan, a dentist and facial aesthetic consultant from A & L Clinics in Ipswich, who attended the masterclass, said, “The workshop was great and Dr Bong is an outstanding specialist and an artist in the aesthetics field. I have been to several of his courses before, and after every one of them I felt confident that I learned something new that will take me and my practice to the next level. The day was well structured and a perfect working environment.”

Dr Bong also provided a one-on-one practical session where delegates were able to treat a model under his direction and supervision. The Two Point Eye Lift technique is used in more than 20 countries and, according to Dr Bong, is internationally recognised as one of the safest and most effective techniques for rejuvenating under eye hollows with dermal fillers.

Algeness launch, London Practitioners attended an information seminar by aesthetic distribution company, Wigmore Medical to learn about the new natural dermal filler derived from red algae, Algeness, at the Royal Society of Medicine on February 9. The evening began with an introduction to Algeness from the executive chairman at Advanced Aesthetic Technologies, which markets the products, and Algeness Europe, Richard Brutt, who explained that the product is the UK’s first natural dermal filler composed of agarose (polysaccharide) gel. A presentation followed by Dr Giorgio Maullu from Italy, who discussed the science and technology behind the product.

He explained that the product is composed of an agarose gel or sugar, which is natural to the human body and does not contain the cross-linked synthetic chemical, BDDE, associated with other hyaluronic acid (HA) fillers.

He explained that because of this, there is high patient tolerability and biocompatibility, and the product is safer as it does not induce allergic or foreign body reactions. “Since its debut, I have been using the agarose gel with amazing results,” said Dr Maullu, adding, “its molecular characteristic of three-dimensional mesh allows me to go deep, in order to gain a volumising effect, as well as work on the surface where, besides giving a smoothing effect on the epidermis, it has given proof of biostimulant properties on fibroblasts, in regards to collagen and elastin production.” KOL Dr TaylorBarnes also presented, and said, “Algeness is attractive to my clinic patients.

They like the association with red algae and being naturally sourced. It is versatile and suitable for smoothing and volumising with the three varieties of Algeness HD (mid Dermis), VL (deep Dermis and sub cutaneous) and DF (Deep Volumizer). I have had great results with lip enhancement using HD, nasolabial with VL and cheek sculpting with DF,” she said.

Cosmetic Redress Scheme inaugural meeting, Hamilton Fraser, Hertfordshire On February 10, aesthetic practitioners and representatives of aesthetic bodies attended a roundtable meeting to discuss how new Alternative Dispute Resolution (ADR) regulations could impact the cosmetic and aesthetic industry. New legislation, the Consumer Rights Act 2015, came into force on October 1, which brought into UK law the requirements from a European Union ADR Directive. This means that all traders are required to signpost their consumers to a government authorised consumer redress scheme – a set of rules under which a firm is required to take one or more of the following steps: investigate whether, on or after a specific date, it has failed to comply with particular requirements that are applicable to an activity it has been carrying on; determine whether the failure has caused, or may cause, loss or damage to consumers; determine what the redress should be in respect of the failure, and make the redress to the consumers. If the trader operates online then they must provide a link to the new Online Dispute Resolution website, which provides information about authorised consumer redress schemes; and if a trader does not do either, they could be subject to an unlimited fine or even a custodial sentence. The meeting posed the question, ‘Is a Cosmetic Redress Scheme something that should be introduced into the market and if yes, how can we make this work?’ Tim Frome, associate director of Hamilton Fraser, explained the Consumer Rights Act 2015 to the group. For the health sector, membership of the redress scheme is not compulsory, however consumers must be signposted to a scheme they feel is responsible for them.

According to the Department for Business Innovation and Skills, ADR is quicker than a court and the costs are lower.

It is also less confrontational, but the outcome is taken into consideration by courts if taken further.

The attendees agreed that incorporating ADR would be a good way of ensuring traders had an internal complaints procedure in place. Paul Burgess, CEO of the British Association of Cosmetic Nurses (BACN), suggested there should be a mandatory membership of a redress scheme before anybody can join the BACN or other trade bodies.

The attendees agreed on the creation of a new scheme and all agreed that Hamilton Fraser would be a good industry player to start the new cosmetic redress scheme and provide a valuable service. Everyone agreed on a name: the Consumer Redress Scheme, as well as a logo, and agreed that beauticians should also be able to join if they wish to. Eddie Hooker, CEO of Hamilton Fraser, said, “Raising standards and educating practitioners is a core value of Hamilton Fraser Cosmetic Insurance and the scheme would fit in well with what we do.”

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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18th International Master Course on Aging Skin, Paris Aesthetics reports on the highlights from Paris’ international aesthetics conference More than 6,500 doctors, nurses, surgeons, manufacturers and aesthetic professionals attended the 18th International Master Course on Aging Science (IMCAS) in Paris between January 28 and 31. Professionals from 85 countries around the world gathered at the Palais Des Congrès in Paris for four days of learning, educating and networking.

The diverse agenda comprised 127 scientific sessions, 1,050 lectures, 520 expert speakers and 180 exhibitors. Many delegates noticed the increase in attendees at this year’s congress, as well as an upsurge in the amount of international sessions.

“The conference was busy on all four days,” said consultant plastic surgeon Mr Dalvi Humzah. “IMCAS has grown considerably and you need to plan before you go to ensure you don’t miss anything.” On the first day of the conference, the ‘Minimally Invasive Cadaver Workshop’ proved to be popular with a packed-out audience. The full-day workshop looked at facial anatomy and how to avoid vascular complications, with live links streamed from Tokyo and Taipei.

On the same day, a new agenda, ‘Middle Eastern Masterclass’, organised in part by dermatologist Dr Sahar Douad Ghannam, took place. The panel explored the patient-doctor communication in consultation with Middle Eastern patients and how to properly handle the cultural values of the region when dealing with patients.

Aesthetic business consultant Wendy Lewis, who was part of the ‘Middle Eastern Masterclass’ and ‘Tips to Avoid Psychological Pitfalls in Aesthetic Procedures’ panels, was impressed by the versatility of this year’s congress, “As a veteran of IMCAS, having been going for 15 out of 18 years in Paris, and one of the first Americans to embrace the importance of this global congress, 2016 did not disappoint! I participated in two important panels that generated a lot of interest.”

The ‘Tips to Avoid Psychological Pitfalls in Aesthetic Procedures’ panel discussion, led by Dallas plastic surgeon Dr Rod Rohrich and Mayo Clinic facial plastic surgeon Dr Eugene Kern, highlighted important signs for practitioners to look out for when treating patients. The international panel, including Dr Jonathan Sykes, Dr Richard Abs and Dr Milos Kovacevic, explored how to properly screen aesthetic patients, the red flags to look out for and signs of body dysmorphia.

Cosmeceuticals took centre stage on Friday with a full-day programme covering important topics for attendees, including the consumer interest in natural products, probiotics, prebiotics, and nutraceuticals, as well as innovative delivery systems for active ingredients. US dermatologist Dr Hema Sundaram delivered a particularly helpful talk, ‘What’s New Concerning Cosmeceuticals Combined with Procedures: A Literature Review of Recent Updates’, in which she talked about combing topical products with procedures. Dr Sundaram argued that doing so can address signs of ageing that singular procedures cannot easily treat, and advised delegates on how to

achieve improved post-procedure recovery time with reduced side effects. Arguing that dysfunction of the skin barrier is the ‘cardinal sin of the ageing process’, she explained how it is essential to use ingredients that improve transepidermal water loss (TEWL), and increase the H2O content of the skin.

Independent nurse prescriber Lorna Bowes was impressed by the one-day cosmeceutical agenda, “These sessions were packed throughout most of that day and it was very interesting. The main theme running through these sessions was that cosmeceuticals and nutraceuticals actually can be evidence-based and it was interesting to see a resurge of interest in skin peels.”

Friday also saw Dr Arthur Swift present a 3D experience on facial restoring and enhancement, drawing special attention to facial anatomy, product placement and depth considerations. Mr Humzah said the ‘audience reacted well to the novel experience’ and it was a ‘very engaging session’. To complete the symposium, Dr Kuldeep Minocha looked at a ‘fresh approach to skin rejuvenation’ using new techniques and skin boosters.

Dr Swift also presented on ‘Combined Treatments with Filler and Toxin for the Upper Face’ on Saturday.

Dr Tapan Patel followed Dr Swift on the agenda, speaking on combination treatment for full-face rejuvenation; combination treatment was a popular theme throughout the whole weekend, particularly non-surgical and minimally invasive options, and novel drug delivery systems.

The IMCAS Industry Tribune highlighted some interesting trends, including a desire for ‘instant beauty’. A fairly new advancement also made its way onto the agenda at IMCAS in the form of topical botulinum toxin. A talk comparing two types of topical toxins influenced an intriguing discussion led by plastic surgeon, Dr Michael Kane.

Feedback from the weekend was particularly positive.

US dermatologist Dr Gary Monheit said, “This was the most outstanding IMCAS, as well as multi-speciality cosmetic meeting I have ever attended. The panels were successful and all the talks I was involved with were objective, relevant and unbiased.”

Dr Benjamin Ascher, plastic surgeon and IMCAS scientific director, said, “We are delighted with the feedback that we have received from this year’s congress. The Minimally Invasive Cadaver Workshop, spread over an entire day, proved to be incredibly popular, and we were delighted to see that the day dedicated to cosmeceuticals also attracted a large audience, confirming our belief that this sector is set to explode in popularity over the coming years. The exhibition, this year spread over two levels for the first time, was also a great success, with exhibitors coming from all four corners of the world to display their latest products and devices. We are now looking at how we can utilise the feedback that we have received to build upon this year’s success and to develop an even more comprehensive scientific programme in 2017.”

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Cosmetic surgery on the rise The latest figures from the British Association of Aesthetic Plastic Surgeons’ annual audit indicated a significant rise in the number of Britons having cosmetic surgery. Aesthetics investigates why it appears that more people are prepared to opt for a surgical treatment The rise in the number of people having non-invasive procedures over the past few years has been well documented. Consumer media has been saturated with headlines on the rise of treatments such as dermal fillers and botulinum toxin;1 news of Kylie Jenner having lip fillers caused a surge of enquiries in some clinics, with one London practice reporting a 70% rise in lip filler enquiries in the 24-hours following the news.2 But now, according to the 2015 BAAPS annual audit, cosmetic surgery is also accelerating, following a 9% dip in 2014.3 The data collected by the body of surgeons suggests 51,000 Britons underwent cosmetic procedures last year and the amount of women having surgery increased by 12.5%, whilst the amount of men going under the knife increased by 13.5%. So why are more people looking to cosmetic surgery as a viable option to enhance their body? And, does this spell the end to the stigma surrounding the specialty?

The facts The most noteworthy increases in the published results include a 20% rise in both men and women having liposuction, a 15% increase in otoplasty and a 12% rise in breast augmentation – which remains the most popular procedure in women. In men, eyelid surgery is the most common treatment, which rose by 15% last year, while a previously less common procedure in men, brow lifts, also increased by 15.5%.

Mr Rajiv Grover, consultant plastic surgeon and former president of BAAPS, said, “The double digit rise in surgical procedures suggests that the public are choosing to spend on treatments with a proven track record such as facelifts and liposuction, which remain the gold standard for facial rejuvenation and body contouring.

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The plethora of new non-invasive methods for skin tightening and cellulite that are here today and gone tomorrow, often appear too good to be true and fail to make the cut.”

Consultant oral and maxillofacial surgeon, Miss Katherine George, also believes that alternative nonsurgical options don’t always deliver, “By the time I see my patients for the first time, a lot of them have already tried non-surgical treatments. Although these types of treatments have minimal downsides, surgery is still the benchmark and will deliver natural-looking results.” Having non-surgical treatments can be a long-term commitment for many patients. The average duration of results for a treatment such as botulinum toxin on facial lines ranges between three to six months,4 meaning patients have to keep going back for more to keep up their new appearance. This isn’t an issue with a lot of surgical procedures. Consultant maxillofacial and facial plastic surgeon, Miss Caroline Mills, believes people are becoming more informed of the potential downsides of treatments such as dermal fillers, “Fillers aren’t the be all and end all and people are starting to see the possible negative side effects of having dermal filler. Surgery can be a nicer way of doing things and will actually cost less money in the long term. I also think people are finding surgery is more acceptable than it used to be.”

On the other hand, aesthetic practitioner Dr Kuldeep Minocha believes that non-invasive procedures still very much have a place in antiageing treatments, “Timely intervention on appropriate patients by an experienced aesthetic practitioner can lead to excellent, natural-looking results. Advances in our understanding of the evidence-based use of hyaluronic acid dermal fillers, collagen stimulators, toxins, suspension threads, medical devices and topical skincare over the last two decades has hugely benefited our increasing patient base.”

The stigma According to author Deborah Mitchell in the book Botox: is it for you? People were more likely to make up an elaborate excuse as to why they were disappearing from work for a few weeks than admit to having a facelift or eyelid surgery.5 Nowadays,

“Having nonsurgical procedures can be a long-term commitment for many patients” Miss Katherine George, consultant oral and maxillofacial surgeon

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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“The double digit rise in surgical procedures suggests that the public are choosing to spend on treatments with a proven track record such as facelifts and liposuction, which remain the gold standard for facial rejuvenation and body contouring” Mr Rajiv Grover, consultant plastic surgeon

more and more people are happy to admit to having cosmetic procedures and this is reflected in celebrity culture. “Celebrities such as Jane Fonda and Sharon Stone have admitted to having cosmetic procedures and I think people notice how much better they look for it,” said Mr Grover, adding, “There is definitely less stigma attached now.” Mr Bryan Mayou, consultant plastic surgeon and founder of Cadogan Cosmetics believes there is also less shame attached to cosmetic surgery for men, “There’s much less of a taboo now for men undergoing cosmetic surgery. They’ll all talk about it; it’s not a secret and they don’t creep in to a clinic quietly hoping no one sees them. Men are prepared to talk about it with their wives, friends and even the men they work with.”

More men Between 2011 and 2013, the number of men having botulinum toxin treatments rose by 200% at Courthouse Clinics,6 and cosmetic surgery also seems to be gaining popularity with men. “Having non-invasive treatments is almost a gateway to surgical procedures,” notes Miss George, adding, “The number of people who come to me for surgery have already tried botulinum toxin and thread lifts, and this includes men.”

The most popular cosmetic surgery procedures men are opting for include rhinoplasty, ear correction, face/neck lifts and fat transfer, according to BAAPS.7 Mr Grover said, “Media figures such as David Beckham and David Gandy are seen all over men’s magazines and they have this very chiseled, masculine appearance. Men are looking to them, wanting to achieve that look.”

But Miss Mills believes men’s expectations need to be better managed, “Men are a more difficult group to handle. Some men are looking to surgery for lifestyle reasons; they think it’s a way to get a girlfriend, and it’s not. Some men I treat say they like the results to begin with, but later on, complain that it hasn’t made them feel any better.”

Gynaecomastia has seen a 13% jump over the last ten years, rising

Aesthetics

to an average of 796 operations per annum.8 Consultant plastic surgeon Mr Adrian Richards has seen an increase in men coming to his clinic for the procedure, “Having gynaecomastia can be very upsetting for some men and they don’t necessarily have this condition because they’re overweight. These men tend to have a low body mass index, but due to a hormonal imbalance, have developed gynaecomastia. In the past, men might have been more likely to try and cover it up and hide it under loose clothing, but now they’re more open to having surgery.”

A change in trends for women Although the amount of women having breast augmentation continues to rise, patients are said to be requesting a more naturallook and Mr Richards has also noticed this change, “In France, the trend has always been to have smaller, more natural-looking breasts, whereas for a while in the UK, the trend was ‘bigger is better’. That’s not the case anymore. I’d say women now want the ‘Parisian look’ and actually say to me ‘I don’t want to look big’.”

Mr Richards believes that women are also more willing to have procedures they may have been too afraid to have previously, “I treated a woman for an inverted nipple which she’d had for 15 years. It’d had a big impact on her life and she’d found it difficult to have a relationship because of it. She came in to the clinic and within 20 minutes I had corrected it. I think more people are realising the potential with cosmetic surgery.”

The future With BAAPS’s figures suggesting that cosmetic surgery is gaining popularity, is there still room for non-invasive treatments to grow alongside? “I think that non-surgical treatment is good at prevention and slowing down ageing,” said Mr Grover, “Think about a remote control; non-surgical treatments are like pressing the slow-motion button or pressing pause, but surgery is the rewind.”

Mr Richards adds, “There has definitely been a swing back to surgery. Whenever there is something new there is a hype surrounding it, whether it’s the ‘vampire face-lift’, or the latest dermal filler. But then the excitement dies down and people eventually realise it’s not the answer to everything. But surgery keeps getting better and achieves the greatest results.”

Dr Minocha concludes, “For some patients, surgery may be a step too far with its potential downtime and complications, and an injectable option is preferred. As aesthetic practitioners we must also recognise our limitations and refer to our surgical colleagues when the patient has reached their injectable threshold.”

REFERENCES 1. WhatClinic, (2015) Enquiries into non-surgical cosmetic treatments rise by more than half (55%) in just six months, <http://www.whatclinic.com/about/press/pdfs/Medical%20Aesthetics%20UK%20 Roundup%20-%20June%202015.pdf> 2. Akbarein, E. (2015) Kylie Jenner lip filler confession leads to 70% increase in enquiries for the procedure, The Independent, <http://www.independent.co.uk/life-style/fashion/news/kylie-jenner-lipfiller-confession-leads-to-70-rise-in-enquiries-for-the-procedure-10232716.html> 3. BAAPS, (2015) Annual Audit, <http://baaps.org.uk/about-us/audit/2040-auto-generate-from-title> 4. Rice, F. (2015) Botox Vs Fillers: Here’s Everything You Need To Know, Marie Claire, <http://www. marieclaire.co.uk/blogs/548418/botox-vs-fillers-the-lowdown.html> 5. Mitchell, D. (2002) Botox: is it for you? The Botox Miracle, Gallery Books; USA, p.15 6. Aidin, B. (2014) Botox treatments for men grow in popularity, FT, <http://www.ft.com/cms/ s/2/25e82892-b69b-11e3-905b-00144feabdc0.html#axzz3zgEKnzFb> 7. BAAPS, (2016) SUPER CUTS ‘Daddy Makeovers’ and the Celeb Confessions: Cosmetic Surgery Procedures Soar in Britain, <http://baaps.org.uk/about-us/press-releases/2202-super-cuts-daddymakeovers-and-celeb-confessions-cosmetic-surgery-procedures-soar-in-britain> 8. Wells, J. (2016) Rise of the ‘moob job’? UK men opting for plastic surgery doubles, The Telegraph, <http://www.telegraph.co.uk/men/the-filter/rise-of-the-moob-job-uk-men-opting-for-plastic-surgerydoubles/>w

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Free Clinical Agenda at ACE 2016 With free CPD points available and 2,000 delegates expected to attend ACE 2016, we look at the comprehensive free clinical agenda and describe what’s in store on April 15 and 16 Delegates will have access to a comprehensive free clinical agenda consisting of professional speakers and high-quality content at the Aesthetics Conference and Exhibition (ACE) 2016 on April 15 and 16. Alongside the premium Conference programme, which comprises eight sessions on key anatomical areas, the free clinical agenda will allow professionals to enhance their practice clinical skills and gain CPD accreditation within the Expert Clinics, Masterclasses and Treatments on Trial agendas.

Expert Clinics Two dedicated workshop areas in the Exhibition hall will host the Expert Clinic agenda, which will encompass free practical sessions run by top aesthetic experts, demonstrating their best techniques in order to maximise treatment outcomes.

With a new layout and improved audio system for an optimal learning experience, the Expert Clinics are the perfect place to strengthen clinical knowledge and ensure you’re up-to-date with everything that’s happening in the industry. Special sponsored sessions will take place over the two days and will include presentations from industry specialists supported by Rosmetics, Naturastudios, AestheticSource, AesthetiCare, 3d-lipo, Fusion GT, BTL Aesthetics, Healthxchange, Syneron Candela, Medico Beauty, SkinCeuticals and Lynton Lasers. AestheticSource will host cosmetic

and dermatology nurse practitioner, Anna Baker and dermatologist Dr Sandeep Cliff, who will be presenting on how to boost sales of cosmeceutical products with multitasking, in-clinic techniques. AesthetiCare will sponsor a unique session on how to get natural results through non-surgical face and eye lifts using radiofrequency by surgeon and aesthetic practitioner Miss Sherina Balaratnam. 3D-lipo Ltd will be sponsoring a stimulating presentation by consultant cosmetic surgeon, Mr Paul Banwell on the benefits of the latest developments in non-surgical facial rejuvenation and lifting using high intensity focussed ultrasound (HIFU) multi-technology devices. Fusion GT will sponsor two sessions by aesthetic surgeon Vanessa Patrizi, who will discuss thought-provoking concepts on non-surgical blepharoplasty and non-invasive face lifting.

Delegates will be able to hear from aesthetic practitioner, Dr Galyna Selezneva, sponsored

by BTL Aesthetics, and SkinCeuticals will support discussions by dermatologist, Dr Firas Al-Niaimi. Healthxchange will also sponsor an in-depth session by cosmetic doctor, Dr Johanna Ward, on technology for non-surgical face-lifts and collagen remodeling. As well as this, Medico Beauty will sponsor interesting discussions by its managing director Aysha Awwad. Through the Expert Clinics, delegates can benefit from in-depth presentations and thoughtprovoking discussions from other leading aesthetic professionals and experts. A talk on facial lifting and slimming with botulinum toxin will be led by dental surgeon and aesthetic practitioner Dr Victoria Dobbie, who will provide top tips for patient selection and technique, as well as consent advice in her facial beautification and rejuvenation dedicated session. A discussion on optimising facial harmony will be

Aesthetics aestheticsjournal.com

delivered by dental surgeon and aesthetic practitioner, Dr Souphiyeh Samizadeh, who will highlight different skeletal patterns and explain how to treat the face, respecting proportions and patterns to obtain a natural effect. A presentation on surgical versus non-surgical options for the face will be delivered by consultant plastic surgeon, Mr Adrian Richards, who explained delegates will get an insight into facial ageing, how and when this occurs and the possible treatment options during his session, where he will be supported by aesthetic nurse prescriber, Mel Recchia. “I will be discussing the MACS facelift procedure as a surgical solution to facial ageing,” said Mr Richards, adding. “Most notably who is suitable, the specifics of the procedure and the expected results following surgery. Mel Recchia will be discussing nonsurgical treatment options, specifically the use of botulinum toxin and dermal fillers, as well as discussing new techniques and effects on the ageing face.” The session will also include an unmissable live demonstration, which Mr Richards said is extremely important to aid learning and understanding of the theory. “The demonstrations show practice in action and enable delegates to put questions to presenters as they are administering treatments. It also allows delegates to gain a greater understanding of facial assessment which we consider an important aspect of our own training courses,” he said. “There is a wealth of experience, knowledge and information available at the Expert Clinics for delegates to pick and choose which is most relevant to them. It is also an excellent opportunity to network with like-minded professionals and share learning experiences,” he concluded. Delegates will have the opportunity to gain in-depth knowledge on non-surgical nose reshaping from facial cosmetic surgeon Dr Julian De Silva, who will demonstrate the latest techniques and beautification treatments to establish facial proportions and aesthetics.

How to optimise patient results using a multidisciplinary approach will be examined in an Expert Clinic session by Miss Balaratnam.

Attendees can expect to be presented with a selection of clinical case studies to illustrate the role of topical skincare, radiofrequency technology, botulinum toxin injections and full-face revolumising using dermal fillers, followed by a live demonstration using the Juvéderm Vycross range of dermal fillers.

“ACE 2016 is a valuable opportunity for practitioners to gain knowledge and skills about different aesthetic treatments and techniques,” said Miss Balaratnam. “Our

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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“I come to ACE specifically to see doctors that I respect, to see certain lecturers, and I’ve also come here as an opportunity to network.”

Cosmetic doctor

profession is all about continued learning, and I am looking forward to presenting and sharing my approach to facial rejuvenation, hopefully helping delegates to learn something new.”

Practitioners can attend aesthetic practitioner Dr Lee Walker’s presentation on lip augmentation, which will include a demonstration and talk about the first motorised cordless HA injection device.

Aesthetic practitioner Dr Sangita Singh, who hopes to provide insight on how to recognise the warning signs of patients not to treat, will lead interesting discussions on managing ‘red flag patients’. An overview of the extensive range of laser treatments available for the skin will be presented by consultant dermatologist Dr Daron Seukeran, who will discuss the use of lasers for hair and tattoo removal, acne, scars, rosacea, skin resurfacing and laser skin rejuvenation. Talks on hair transplant techniques, anatomy and physiology will be conducted by cosmetic surgeon Dr Sotirios Foutsizoglou, who will describe the hair cycle and follicular anatomy, with a focus on common hair restoration techniques, the traditional strip surgery and the follicular unit extraction technique.

Senior researcher in skin biochemistry and physiopathology, Dr Chiara de Luca, will lead a presentation focusing the power of non-aggressive ingredients to ignite the skin’s natural immune system and Baker and Dr Cliff will present a second Expert Clinic session in collaboration with Dr Mustafa Varcin on the future of cosmeceuticals. As well as this, delegates can expect a comprehensive presentation by Dr Sarah Tonks, Dr David Jack and Dr Kishan Raichura on the multiple approaches to lower face treatments.

Masterclasses The Masterclass presentations are to be showcased in dedicated rooms in the gallery and will demonstrate the best practice methods with the latest products, providing delegates with invaluable product guidance.

Galderma will host a Masterclass on periorbital rejuvenation with hyaluronic acid fillers.

During the session, consultant oculoplastic surgeon, Mrs Sabrina Shah-Dasai, will discuss the anatomical basis of peri-orbital

rejuvenation and will highlight the importance of choosing appropriate fillers, correct injection techniques and how to maximise aesthetic outcomes. HA-Derma will also be supporting a Masterclass session led by plastic and aesthetic surgeon, Professor Daniel Cassuto, along with dermatologist, Professor Hema Sundaram and HA-Derma’s UK lead trainer and aesthetic practitioner and dental surgeon, Dr Irfan Mian. Sales and marketing manager, Iveta Vinklerova, said HA-Derma was delighted to be featuring a Masterclass session at ACE for the first time.

“ACE is giving us a fantastic opportunity to position our products amongst the leading brands within the industry. We are equally excited to sponsor our Masterclass, which will complement the conference programme and provide important educational content for the delegates.” Other top medical aesthetic companies, including Zeltiq, who will support cosmetic practitioner, Dr Sach Mohan, will host a number of other leading professionals demonstrating how to use the most popular products and treatments, while discussing the best ways to incorporate them in to daily practice. Each 90-minute Masterclass will allow practitioners to build on their skills and understanding through informative and focused guidance. Practitioners are encouraged to take advantage of this free, innovative content.

Treatments on Trial Delegates are sure to benefit from attending the Treatments on Trial on Saturday April 16 in the gallery, where engaging debates and discussions on the latest products will take place. The event, which is an exciting new feature of ACE, is supported by BTL Aesthetics, Lumenis and Syneron Candela, and will focus on body contouring and weight loss. Delegates will also have the opportunity to learn how and when to use the latest treatment offerings and directly compare these to discover the best options for their practice. “ACE is an important event in our conference diary and gives us the ideal opportunity to meet with medical practitioners and showcase our technology,” said Syneron Candela marketing manager, Dianne Burkhill.

“This year, we have chosen to sponsor the

Treatments on Trial session as we believe it’s important that delegates attending the event have the opportunity to hear about the latest treatments available, so that they can make informed decisions about what will best suit their business needs,” she said. Director of BTL Aesthetics, Lee Boulderstone, said he is thrilled to be a part of this new agenda at ACE 2016. “BTL Aesthetics are delighted to sponsor Treatments on Trial at ACE this year. With such a huge amount of products available and the deregulation of some aesthetic devices in 2010, it can be difficult for practitioners and business owners to make informed decisions as to what devices to invest in. As a company, we are committed to providing superior technology to practitioners, and the introduction of Treatments on Trial means that all companies who are involved can provide their own clinical data and results to the aesthetic market, and delegates can be confident that the products on show are proven to be both safe and efficacious,” he said.

Free CPD accreditation Practitioners are urged to make the most of the free, informative clinical content offering at ACE 2016, and utilise this opportunity to gain more product and industry knowledge, as well as CPD accreditation. To access the free Expert Clinics, Masterclass and Treatments on Trial agendas, practitioners can register online. Once registered, they can also choose to purchase the premium Conference Pass for a full and comprehensive learning experience.

Through this free registration, delegates can also attend the Business Track, to learn the latest in business industry knowledge. The Aesthetics Conference and Exhibition 2016 is expected to attract 2,000 practitioners and industry personnel from across all areas of the aesthetics field. There are 50 CPD points available over the two-days, so be sure not to miss out on this key event in the professional calendar.

To gain access to the free clinical sessions, including the Expert Clinics, Masterclasses and Treatments on Trial, as well as the Business Track, practitioners can register online for free at www.aestheticsconference.com HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Managing Hair Loss There are numerous techniques and procedures available to restore thinning and declining hair. Allie Anderson speaks to practitioners about some of the options available and details how they work Many people seek aesthetic treatment for hair loss that has occurred either as a result of ageing or an underlying condition.

Various treatments are available, however unnatural-looking results have made some of them unappealing. Even with the development of more advanced technology, according to the practitioners interviewed for this article, the market for male hair loss treatments remained comparatively small until around five years ago, when there came a steady rise in demand, particularly among younger men. “I see a large proportion of men in their 20s, and that’s doubled in the last few years. I put that down to celebrities,” explains Dr Edward Ball, medical director of The Maitland Clinic. He is, of course, alluding to the likes of Wayne Rooney, who at the age of 25 famously (and openly) underwent hair transplant surgery in 2011,1 demonstrating impressive results. Such well-publicised successful treatments, revealing fuller-looking hair and restored hairlines, have helped generate interest among the general public. In fact, research conducted by The Maitland Clinic found that one fifth of 2,000 men polled think hair transplants are more acceptable thanks to these high-profile endorsements.2 This is perhaps borne out in the numbers of people – both men and women – having treatment, with numbers of surgical treatments carried out in Europe increasing by 45% between 2008 and 2014.3 Dr Ball adds that, in his opinion, the rise of social media and ‘selfie’ culture is, in part, responsible for society’s increasing preoccupation with hair.

Causes of hair loss Anecdotal evidence from those interviews suggests that the most common cause of hair loss in men who seek treatment is androgenic alopecia (male pattern hair loss). It is caused by oversensitivity of the hair follicles to dihydrotestosterone, a converted form of the testosterone hormone.4 Male pattern baldness also runs in families, most strongly in the mother’s side.4 This form of hair loss typically follows a predictable pattern, such that patients’ hair usually begin to recede at the temples or notice a thinning patch on the crown, followed by gradually increasing thinning and sometimes complete loss of hair on the top of the head.5 Women, too, can present with androgenic alopecia (female pattern hair loss). “Some women have hair that thins more as they age,” says Natasha Borciani, owner of Borciani London. “They tend to get a strip (of thinning hair) down the centre along the parting, which will widen over the years.” This diffuse thinning makes the scalp more visible and worsens with time. Androgenic hair loss in women is associated with the presence of testosterone, and, post-menopause, with a reduction in oestrogen levels.5 The most common problem in women with regards to hair loss is telogen effluvium, which presents as widespread yet gradual diffuse shedding or thinning of the hair, rather than in clumps or patches.6

Other types of hair loss include:5,6 • Alopecia areata – where coin-sized bald patches appear on the scalp • Scarring alopecia – also known as cicatricial alopecia, usually caused by complications from another condition (and consequently, hair won’t grow back) • Anagen effluvium – commonly a side effect of chemotherapy and other cancer treatments • Trichotillomania – self-inflicted hair loss caused by obsessivecompulsive pulling of the hair

Forms of treatment Medication Medical interventions can be effective to slow or halt the progression of androgenic hair loss in men and women, and is often the first line of treatment. “There are two FDA-approved medications for hair loss, the first of which is minoxidil,” says Dr Munir Somji, clinical director at Priors Clinic. He adds, “Although we’re not completely sure of its mechanism of action, it causes vasodilation, which could help hair growth.”7 The vasodilatory effects of minoxidil could, it is suggested, open potassium channels and thereby allow more oxygen, blood and nutrients to the hair follicle.7 Indeed, topical minoxidil has been indicated to generate ‘superior’ results compared with placebo controls in trials among both men and women, with 5% concentrations appearing to be more effective than 2% and eliciting no significant adverse effects.8,9 The second FDA-approved medication, says Dr Somji, is finasteride. “It is prescribed in 1mg doses for male pattern hair loss, and we see that it actually stops hair loss in about 65% of individuals,” he says. It works by blocking the conversion of testosterone to dihydrotestosterone, and it has been indicated to promote hair growth and prevent further loss, with improvements noted in 66% of male recipients after two years of treatment, with a good tolerability profile.10 Before

After

Figure 1: Patient with traumatic alopecia treated with minoxidil and tailored, topical solutions over a period of seven months. Images courtesy of Mandy Baldwin.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Mesotherapy Before After Six months after Mesotherapy is used in aesthetics to combat a number of concerns, including cellulite and signs of ageing skin,11 and its application in hair loss is gaining in popularity.

“The science is limited, but essentially, mesotherapy Left side Right side Left side Right side is a term that describes a technique as opposed to a specific treatment,” explains Pam Cushing, aesthetic Figure 2: Images following treatment with the Athrex ACP PRP system from Biotherapy nurse prescriber and vice president of the Society of Services Ltd Windsor. Images courtesy of Pam Cushing.

Mesotherapy UK. “You can do mesotherapy with different types of products; for example, we could use platelet-rich plasma is different for everybody. People of Indian origin have longer hair (PRP), pure hyaluronic acid, or cocktails that combine natural products follicles than Caucasian people, for example,” he says. As a result, that would stimulate the hair to thicken by feeding the bulb of the hair injection depth should be determined by the length of the individual follicle.” patient’s hair follicle. “I surgically remove one follicle and look at These ‘hair cocktails’ contain different pre-mixed ingredients that it under the microscope to measure how far it goes down to the can be injected into the scalp. “Using very small, microinjections just papillary dermis, which is where the PRP is injected. That gives me underneath the scalp, small deposits of the product are delivered an accurate measurement of how deep to set the needle,” explains and evenly spaced out, to stimulate collagen production, but also Dr Somji, adding, that this is typically between 1.5 and 2.5mm, with to feed, nourish and hydrate the hair bulb,” says Cushing. “If you 0.5ml of PRP injected per cm squared, but, crucially, the depth is increase the nutrients, vitamins, trace elements and amino acids that varied from patient to patient, where other practitioners may use the the hair requires for growth, it stands to reason that the bulb will grow same depth across the board. According to consultant trichologist thicker.” She points out that different manufacturers will use different Mandy Baldwin from the Hair and Scalp Clinic, dormant hair follicles preparations, but an example cocktail might include: start to become fortified and reinvigorated almost immediately.

• Drugs – buflomedil, pentoxifylline, minoxidil, finasteride “You can’t see anything straight away but there is lots happening • Vitamins – dexpanthenol (B5), biotin (vitamin H), L-ascorbic acid underneath, just like when you plant a seed that eventually grows (vitamin C), vitamins A, E, B1, B2, B6, B complex, and D into a flower,” she says. “Patients normally begin to see a change at • Trace elements – cobalt, copper, ginkgo biloba, lithium, around three to six months post treatment.” Moreover, Baldwin adds, magnesium, manganese, phosphorous, selenium, sulphur, zinc PRP can be used in combination with hair transplantation to help • Nutritional drugs – Centella asiatica, silicon the implanted follicles to prosper, reduce inflammation, erythema, • Hormone – calcitonin trauma, and the formation of scabs, and to aid healing.

• Anaesthetic – procaine Hair transplantation This type of therapy has been the subject of comparatively few When one thinks of hair loss treatments, transplantation might be the scientific studies, but some have demonstrated that mesotherapy can first thing that springs to mind. Dr Ball explains, “Hair transplant surgery elicit good results in the treatment of acute diffuse hair loss, such as is based around a principle known as ‘donor dominance’. That means telogen effluvium, stress alopecia, androgenetic hair loss and alopecia the donor hair is dominant in its characteristics. So, you take hair from areata.14 Patients typically undergo one treatment per month over a donor area – that usually being the back and sides of the head – three months, at which point Cushing would expect to see results. and the hair will retain the characteristic from that area regardless of “The greatest limitation is patient expectation,” she says. “You have where you put it.” Hair transplant surgery is said to produce ‘excellent’ to be realistic, and some patients can be dissatisfied purely because results in the treatment of many forms of male and female hair loss, the change has not been as rapid as they anticipated. Managing particularly androgenic alopecia.15 expectations is important.”

There are two methods of removing the donor hair: follicular unit transplantation (FUT) and follicular unit extraction (FUE). The former Platelet-rich plasma involves taking a strip of skin from the back of the head, usually Dr Somji offers PRP treatment, in which the patient’s own blood is around 1- 2cm wide, with the length dependent on both how much re-injected into the scalp via multiple, tiny injections around 1cm hair you need and the density of the donor hair. “You have to apart. This involves withdrawing blood – usually from the patient’s carefully dissect in between each hair follicle to maximise the donor arm – and processing it through a machine to centrifuge it and yield, and the skin is then stitched up,” Dr Ball comments. “This can separate out plasma containing a high concentration of platelets. leave a scar, which although is usually barely noticeable and is easily This PRP is rich in growth factors – naturally occurring substances covered by hair, can be a concern for some patients, particularly that stimulate cell growth and proliferation, and thereby promote men who like to keep their hair short.” In such patients, the latter tissue regeneration.12 Studies have demonstrated that injecting PRP (and more advanced) technique – FUE – is advised. Dr Ball explains, preparations has a ‘positive therapeutic effect on male androgenic “Here, instead of taking the whole piece of skin and stitching it up, alopecia without major side effects’.13 “First, we do a trichoscopy, you remove each hair individually using a device that makes tiny looking at the scalp under a microscope for areas of miniaturised punches of around 0.8 to 1mm. From that point on, both techniques follicles,” Dr Somji comments, adding, “We count the number are the same.” of follicles per cm squared, so we have a quantitative analysis The donor hair is examined under the microscope and separated before treatment.” This gives both the patient and the practitioner into individual grafts of one or two hairs, which must be delicately a measurable assessment of the success of the treatment. An handled and placed in a preservative solution to maintain their important factor, according to Dr Somji, is the depth to which you viability. The area of the scalp receiving the donor hair is then inject the scalp. “The length of the hair follicle underneath the skin prepared: the practitioner makes a series of tiny incisions, into which

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similar to a very fine tattoo pen, which allows me to blend into any remaining hair, and achieve a natural-looking hairline.”

Patients normally undergo two or three treatments, each four Before After weeks apart, to get optimum results, but the nature of the technique – placing pigment into the skin – means that you can see a distinct difference Figure 3: Patient in his 20s who underwent a single hair transplant surgery at The Maitland Clinic using the FUT method straight away. Borciani reports to the frontal half, following seven months on oral finasteride (1mg daily). Images courtesy of Dr Edward Ball. that anecdotally, the effect can the grafts will be positioned. “The placing of the hair takes a long last up to two or three years, with a maintenance session often time. Each graft must be laid out to match the angle, direction, and required around 15 months post procedure. “There are factors that the density of the hair you want to create,” says Dr Ball. “It has to be affect the longevity, such as sun exposure, lifestyle and general natural-looking, in keeping with the patient’s age, face shape and skin condition – oily skin doesn’t retain the pigment as well – but if hair line, and the whole procedure can take up to 10 hours.” People patients look after their scalp, they should be happy for more than can, anecdotally, return to normal daily routine within one week, with a year,” she says. no evidence of having had surgery, Dr Ball adds. Post-treatment care involves not touching the hair for the first six days, while the Conclusion skin heals over to root the follicles into place, then washing, styling Hair loss for both sexes can be an emotional event and a source of and treating the hair as normal thereafter. “The hair graft sits dormant great insecurity. The manifold treatments available can offer a solution, waiting for new hair to grow, and that happens in stages very and as techniques become more sophisticated, they will undoubtedly gradually. It’s subtle, and it normally starts about four to six months produce increasingly better results. Scientists have been researching after surgery. Patients get most of the growth by 10 to 12 months. the potential to grow human hair using stem cells, whereby stem Beyond that, while they won’t get new hair growth, the quality, cells can turn dead hair follicles into healthy ones, and consequently calibre and thickness of the hair tends to get better and better.” promote new hair growth.18 The point in time when not only human hair can be grown in human tissue, but also when the science is Hair follicle stimulation routinely applied in clinics, may be closer than we think.

Most solutions are aimed at restoring hair, but an alternative REFERENCES option is to conceal instead of ‘treat’ hair loss, by way of scalp 1. Harley Street Hair Clinic, Wayne Rooney’s hair transplant, (London, 2013). <www.hshairclinic.co.uk/ patients-gallery/wayne-rooney/> micropigmentation (SMP). Borciani offers this ‘follicle simulation’ for 2. The Maitland Clinic, Balding truth about hair loss in the UK, 2015. Data on file via The Maitland Clinic. men and women experiencing all types of hair loss. She says, “We 3. International Society of Hair Restoration Surgery, 2015 Practice Census Results, (USA, 2015) <http:// webcache.googleusercontent.com/search?q=cache:NxGrEwaoTNYJ:www.ishrs.org/sites/default/files/ create micro dots of pigment underneath the skin in the dermal layer, users/user3/report_2015_practice_census-final.pdf+&cd=1&hl=en&ct=clnk&gl=uk&client=safari> which mimics the appearance of real hair follicles or strands. It’s a 4. Men’s Health Forum, Hair loss FAQs, (London, 2014) <www.menshealthforum.org.uk/hair-loss-faqs> 5. The Institute of Trichologists, Hair conditions (London) <www.trichologists.org.uk/index.php/ more affordable and natural alternative to hair restoration.” While conditions/hair-conditions> SMP can be an effective application for balding or thinning hair and 6. NHS Choices, Hair loss (London, 2015) <www.nhs.uk/Conditions/Hair-loss/Pages/Introduction. aspx#telogen> can yield extremely pleasing results,16 Figure 4 7. Rossi A, Cantisani C, Melis L, Iorio A, Scali E, Calvieri S., ‘Minoxidil use in dermatology, side effects and this is largely reliant on the technical recent patents’, Recent Pat Inflamm Allergy Drug Discov, 2 (2012), pp.130-6.

8. Lucky AW, Piacquadio DJ, Ditre CM, Dunlap F, Kantor I, Pandya AG, Savin RC, Tharp MD., ‘A and artistic skills of the practitioner, randomized, placebo-controlled trial of 5% and 2% topical minoxidil solutions in the treatment of whose careful selection of pigments female pattern hair loss’, J Am Acad Dermatol, 50 (2004), pp.541-53.

9. Olsen EA, Dunlap FE, Funicella T, Koperski JA, Swinehart JM, Tschen EH, Trancik RJ., ‘A randomized and understanding of the hair loss clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of process is crucial to the procedure’s androgenetic alopecia in men’, J Am Acad Dermatol, 47 (2002), pp.377-85.

10. McClellan KJ, Markham A., ‘Finasteride: a review of its use in male pattern hair loss’, Drugs, 57 (1999), success.17 “I draw on a hairline pp.111-26. template with a liner to get an idea 11. Mesotherapy and Estetik, FAQ, testimonials, patient warning, (New York, 2006) <www.mesotherapy.

Before and after two sessions com/faq/> of hair follicle stimulation of the shape we can work with and 12. El-Sharkawy H, Kantarci A, Deady J, Hasturk H, Liu H, Alshahat M, Van Dyke TE., ‘Platelet-rich plasma: over four weeks. Images what the likely result will be,” Borciani growth factors and pro- and anti-inflammatory properties’, J Periodontol, 78 (2007), pp.661-9. courtesy of Natasha Borciani.

13. Gentile, P et al, ‘The Effect of Platelet-Rich Plasma in Hair Regrowth: A Randomized Placeboexplains. “Then we do some colour Controlled Trial’, Stem Cells Translational Medicine, 4 (2015), pp.1317–1323. matching; we work with a large range of pigments that we blend 14. Kutlubay Z, Karakuş Ö, ‘Hair Mesotherapy’, Hair Ther Transplant (2012) 2:e102. <www.omicsgroup.org/ journals/2167-0951/2167-0951-2-e102.pdf> together to find an exact match that’s as natural looking as possible.”

15. Paul T Rose, ‘Hair restoration surgery: challenges and solutions’, Clin Cosmet Investig Dermatol, 8 After numbing the scalp for 20 to 30 minutes, the treatment is (2015), pp.361-370.

16. William R Rassman, Jae P Pak, Jino Kim, ‘Scalp Micropigmentation: A Useful Treatment for Hair Loss’, performed using one of two systems – or a combination of both – Facial Plastic Surgery Clinics of North America, 21 3 (2013), pp.497-503. depending on the extent of the hair loss and the desired outcome.

17. William R Rassman, Jae P Pak, Jino Kim, Norman Estrin., ‘Scalp Micropigmentation – A Concealer for Hair and Scalp Deformities’, J Clin Aesthet Dermatol, 8(3) (2015), pp. 35-42.

“The first is a roller system, which allows you to put in far more 18. Medic8, Future Treatment Hair Loss – Hair Loss treatments, <http://www.medic8.com/healthguide/ pigment far more quickly. It reduces the length of time the patient hair-loss/treatments/future-treatment-hair-loss.html> has to be in the chair, which, for a full head, could be from up to five hours down to about 60 minutes.” This roller is applied to large sections of the scalp, and around the front and sides the second system will usually be used. “This is a manual dotting technique, Before

After

Before

After

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Granuloma Management Dr Beata Cybulska details the formation, pathophysiology and treatment of granulomas following dermal filler injections Abstract Granulomas are a delayed, poorly understood and distressing complication of dermal filler injections. Histologically, they represent a foreign body type of reaction with giant cells and macrophages infiltrating tissues. Granulomas are classified into three types: cystic, nodular and sclerosing, which clinically present as red, firm papules, nodules or plaques occurring months or years after filler injections.

Filler dependent factors such as volume and particle size, as well as the presence of biofilm, have been suggested as possible causes.

Treatment is often empirical, hence good differential diagnosis is essential in choosing the right treatment pathway. Overcorrection using dermal fillers, hypersensitivity reaction and infections ought to be considered before embarking on treatment, which consists of antibiotics and hyaluronidase in the first instance, followed by intralesional or systemic steroids. Surgical excision is recommended as the last resort. Investigations that may be of assistance in making the diagnosis and assist with the management include blood tests such as: white blood count (WBC) and C-reactive protein (CRP). Out of the imaging methods available, the use of ultrasound (USS) is most useful. Biopsy and histology offer confirmatory diagnosis. Culture is often unhelpful as a negative result does not exclude possibility of the presence of biofilm. Counselling the patient and adopting preventative measures such appropriate filler choice and prevention of infection should be part of every case of dermal filler injections.

Introduction Granulomas following dermal filler injections are challenging for aesthetic practitioners to manage and can be distressing to the individuals affected by them.1,2 Granulomas can develop months or years after deposition of the dermal filler in the dermis and may occur after both permanent and semi-permanent dermal filler use, including hyaluronic acid (HA), bovine collagen, silicone, paraffin, polyacrylamide gel, poly-lactic acid microspheres and calcium hydroxyapatite.1-8 Frequency of granuloma occurrence has been reported as 0.02-0.4% after HA and 0.04%-0.3% after bovine collagen injections.3,4,5

Pathophysiology of granuloma Granuloma formation is a non-allergic, chronic inflammatory response, characterised by foreign body types of reaction in the dermis following injection of dermal filler or other foreign material.3,4 A granuloma is defined as a tumour composed of immune cells such as macrophages, activated and fused into multinucleated giant cells, consisting of more than 20 nuclei and arranged in an irregular and random way.9,10 Formation of granuloma occurs in stages involving: 1) Protein absorption 2) Macrophage adhesion 3) Macrophage fusion 4) Crosstalk As the neutrophil infiltration and adsorption of host proteins to the foreign material occur, monocytes circulating in the blood migrate

to the surrounding tissues and differentiate into macrophages.

Where the particle volume is greater than the macrophage volume, macrophages aggregate, forming giant cells and secrete factors, which activate fibroblasts, influencing the development of fibrous capsule around the foreign body material and formation of the foreign body giant cell (FBGC). 3,9,10 It is not fully understood why small filler particles or silicone fluid trigger granuloma formation, both of which are easily phagocytosed by macrophages.11 One hypothesis that was put forward by Lemperle et al in 2006 suggests that macrophages act as memory cells and remember small phagocytosed particles. Triggered by systemic infection, they initiate FBGC formation and the development of granuloma.12 The authors were of the opinion that volume, purity and physical characteristics of the injected dermal filler such as particle size, smoothness, charge and hydrophilicity play a role in this process.

Bentkover hypothesised that the main cause of FBGC reaction is the size of the filler particles, which prevents them from being phagocytosed.13 Granulomas have been linked to biofilms, which are defined as a structured community of microorganisms encapsulated within a self-developed, polymeric matrix, irreversibly adherent to a living or inert surface.14 In 2007, Christiansen hypothesised that biofilms form when bacteria is introduced during filler injections or are seeded in the filler during bacteriaemic episodes.14 Once present, they remain dormant for months or years on the surface of the filler and become a target of a delayed immune response, resulting in granuloma formulation. Many biofilms are almost impossible to culture using current microbiology culture technology.15 They live in a quiescent state, resulting in a low-grade infection associated with low-grade host response. Activation of biofilms may be triggered by dental manipulation, trauma or other factors, leading to local or systemic infection, as well as granulomatous, inflammatory response. Biofilm populations can shift from active to dormant depending on exogenous threats. When bacterial proteins turn off cell metabolism and the cell becomes dormant, it becomes antibiotic resistant, as well as difficult, if not impossible, to culture.3,15,16,17 Patients with chronic sinusitis, chronic dental problems, or other infections may have a greater tendency to develop an infection after a filler is injected in the periorbital area or central face. These patients may also be prone to formation of a biofilm around or in the implant, caused by injection trauma around the site of a previous filler injection.

Many problems that were previously assumed to be foreign body granulomas or allergic reactions, on the basis of negative bacterial cultures, are now thought to be due to biofilms.3,15,16,17

Diagnosis and treatment of dermal filler granulomas Diagnosis and management of dermal filler granulomas is complex. In order to offer satisfactory treatment and resolution, it is very important to take good medical and aesthetic history and thoroughly examine the patient. Investigations may assist with making correct diagnosis although, in reality, they are rarely carried out and treatment is empirical. It is therefore essential to understand the pathophysiology

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Granuloma

Presentation and symptoms

Causes

Onset

Aesthetics Delayed hypersensitivity

Filler nodule

Infection

Cystic, nodular, bluish, indurated plaques with congested capillaries that are bigger than the injected volume of filler and develop simultaneously at different sites.

Evenly sized, whiter in colour and harder than granulomatous nodules.

Erythema, oedema, indurated papule, nodule with or without itching.

Erythema, swelling, oedema, induration and/or tenderness.

Filler dependent: type and volume of filler used.

Injector dependent: poor injection technique (overcorrection or too superficial injection), lack of massage.

Filler dependent: HA or bovine type collagen.

Subject dependent: bacterial, viral, fungal, parasitic infections.

Subject dependent: infection and biofilm.

Injector dependent: attention to skin cleanliness and patient selection.

Subject dependent: lack of massage (L-polylactic acid).

Delayed by months or years after filler injection.

Early – up to two weeks after filler injection.

Injector dependent: poor patient selection, poor skin cleansing.

One month after filler injection with spontaneous resolution after one year.

Early or delayed.

Figure 1: Differential diagnosis of granuloma3,16

of granulomas and differentiate them from other causes of nodular lesions caused by dermal fillers, as their management differs depending on the presence or absence of inflammatory features.

abscesses, dermal fillers should not be injected. There is evidence that these infections might invade the implanted filler and may result in biofilm formation, which in turn may trigger hypersensitivity reaction.16

Patient history Medical history should constitute part of every aesthetic consultation.

In cases of delayed complications such as suspected granuloma formation, more specific questions about onset, presence of inflammatory features such as pain and redness, history of dermal filler injections, type and volume of injected filler and sites, presence of skin infections, as well as skin conditions or immunocompromised state should be enquired for. Pre-existing skin infection in or close to the injected area may worsen and result in complications. Patients with ongoing skin infections caused by bacteria like streptococci and staphylococci resulting in impetigo; those with excessive Propionibacterium acnes or parasitic mite infection such as demodex folliculorum associated with rosacea; yeast infections; extensive pityrosporum folliculitis; viral infections such as herpes virus simplex (HSV) or perioral human papilloma virus infection (HPV); should not have dermal filler injections until the infection is treated. In the presence of sinusitis, periodontal disease, ear, nose or throat infections, or dental

Clinical and histological features of dermal filler granulomas

Patients with chronic sinusitis, chronic dental problems, or other infections may have a greater tendency to develop an infection after a filler is injected in the periorbital area or central face

Dermal filler granulomas have been classified into three types based on their histological features: cystic (HA, bovine collagen), nodular lipogranuloma with ‘Swiss cheese pattern’ (silicone, polyacrylamide) and sclerosing.11 Mixed pattern granulomas have also been identified.1 Clinically, granulomas present as red, firm papules, nodules or plaques, which may occur months or years after filler injection.16 Intralesional injections Corticosteroids (triamcinolone acetate – Kenalog) Bleomycin 5-Fluorouracil

Systemic treatment23,24,25 Antibiotics Prednisolone Allopurinol Colchicine Cyclosporine

Surgery Melting with laser Incision and drainage Excision plus fat grafting or flaps

Figure 2: Treatment options for granulomas

Differential diagnosis of granulomas It is sometimes difficult to distinguish between granulomas and nodules due to other causes or an abscess. Diagnosis of nodules complicating dermal filler injections is complex and difficult in those with no clear history of dermal filler injection. It is, however, very important to get the correct diagnosis in order to achieve a successful outcome. Granulomas ought to be differentiated from nodules caused by poor injection technique, an infection or delayed hypersensitivity reaction (Figure 1). Establishing possible causes of dermal filler nodules impacts on treatment options and outcomes. Investigations which may assist in diagnosis include: blood tests: C-reactive protein, white blood count (WBC), erythrocyte sedimentation rate (ESR), microscopy and culture, in situ hybridisation, computerised tomography (CT scan), magnetic resonance imaging (MRI), skin biopsy and histology.11,18 Cassuto and Sundaram (2013) advocate the use of ultrasound (USS) imaging in cases of persistent nodules to assist with location of the implanted material.19

Treatment of granulomas Treatment of dermal filler nodules is often empiric without full evaluation of possible causes and variable satisfaction rates

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Non-inflammatory dermal filler nodules Palpable, visible, nodules appearing two to four weeks after injection

Early onset

Delayed onset

HA filler

Non HA filler

Hyaluronidase

Massage Lidocaine + Saline

Small amounts of intralesional steroids 5 FU 0.5ml of 50mg/ml + 0.3ml of 10 mg/ml triamcinolone + 0.2 ml of 2% lidocaine with adrenalin Fractional laser (eyelids and lips) Surgical excision

Prevention of non-inflammatory nodules formation Avoid: overcorrection, superficial filler placement; use appropriate filler for tissue site, massage for even distribution Figure 3: Management of non-inflammatory dermal filler nodules

due to a misunderstanding of the pathophysiology. A problemfocused approach in the diagnosis and treatment has been recommended.17,19-21 Common causes such as infection, before rare causes such as hypersensitivity to filler material, ought to be considered, as should poor injection technique, before filler dependent factors are blamed (Figure 1). Painful nodular lesions with inflammatory features ought to be treated promptly with broad spectrum antibiotics in spite of negative culture when biofilm is suspected (Figure 2). If HA filler was injected, intralesional hyaluronidase and extraction of the nodule content using a 16G needle and negative pressure, followed by administration of intralesional 5 fluorouracil (5 FU), laser lysis and, as a last resort, surgical excision can be carried out. Antibiotic therapy is the first step in the management of cases suspected of infection origin, in spite of negative culture. Intralesional steroids used before antibiotics can prolong the problem.

Intralesional injections Painless granuloma with no inflammatory response can be treated with intralesional steroids in the first instance, followed by 5 FU and surgical excision21 (Figure 2). Such lesions are not urgent and the patient can be reviewed in two weeks. Polymethylmethacrylate fillers can be melted with laser energy first, before pouring them out of the area as demonstrated by Cassuto et al.22 In some cases it may be necessary to use intralesional steroids to reduce the lump whilst continuing to administer antibiotics. Injections of steroids ought to be performed carefully due to the risk of localised atrophy. High dose triamcinolone (35-40mg) mixed with 2% lidocaine is recommended using a 0.5mlto 1ml insulin syringe with

a 30G needle for intralesional injections. Smaller needle diameter helps to avoid steroid-induced atrophy. As granulomas spread in a finger-like pattern, best injection technique involves injecting small amounts on the periphery, moving towards the centre. Other agents include bleomycin, colchicine, cyclosporine, immiquimod or etanercept, which is traditionally used to treat rheumatoid arthritis and psoriasis.23-26 Isotretinon can be used alone or in combination with steroids.27 Systemic treatment Systemic treatment is recommended in recurrent granulomas when localised treatment is not effective. Higher doses of steroids are used in such cases, e.g. oral prednisolone 30mg/day starting dose followed by 60mg/day of maintenance dose has been suggested to prevent recurrence of granulomas.1 Oral antibiotic minocycline alone or combined with oral or intralesional steroids has been indicated as effective in the treatment of inflammatory granulomas and silicone granulomas.20 Surgical treatment Surgical excision offers a cure by removing the foreign body, as well as biofilm, however it is not without complications. In particular, scarring and deformities can occur because of potential invasive growth of granulomas and irregular borders making their complete removal impossible.4 In addition, in silicone-induced granulomas, surgery carries a risk of abscess or a fistula. Localised sclerosing granulomas can be excised with subsequent correction of deformities using fat grafts or flaps.3 Incision and drainage of a sterile abscess has been indicated as effective.6

Inflammatory nodules Granuloma

Biofilm Red, indurated area occurring any time after filler injection Broad spectrum antibiotics:

Sterile abscess, red, indurated area occurring several months to years after filler injection Intralesional or systemic steroids: triamcinolone, betamethasone or prednisolone.

Ciprofloxacin or clarithromycin 500mg bd PO + moxifloxacin 400mg od PO x four weeks.

If poor response switch to clindamycin 600mg bd P.O. + tetracycline 500mg bd PO.

If no response add: 5 FU, bleomycin, colchicine, cyclosporine.

If still no response, consider surgical excision using flap technique or fat grafting.

If good response, extract nodule material using 16G needle and negative pressure. Consider: injections of 0.5 cc of 5FU monthly x 4; laser lysis, incision and washing out cavity with antibiotics or surgical excision.

Prevention of inflammatory nodules formation Clean skin thoroughly before injection, avoid injecting through oral or nasal mucosa, use prophylactic antibiotics if facial infection present two weeks prior to treatment.

Limit filler volume, avoid intramuscular injection, select microspheres with smooth surfaces for use in patients with multiple filler injections.

Figure 4: Management of inflammatory dermal filler nodules28

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Clean surfaces >> Clean surfaces with disinfectant wipes >> Discard contaminated material >> Clean cold packs with antiseptic wipes and wrap them in gauze before procedure

Aesthetics Journal

Clean patient’s skin >> Find out about history of local or systemic infections >> Remove makeup >> Clean skin with an antiseptic >> Tell patients not to touch cleaned areas >> Clean the skin after procedure >> Consider topical antibiotic treatment

Aesthetics Clean hands >> Disinfect hands prior to using clean gloves >> Do not touch surfaces, lights, nonclean areas before injecting

Clean instruments >> Use single-use dressing pack per patient >> Keep syringes/ needles in clean area before and during treatment >> Use a ‘no touch’ technique at all times, restricting any contact to clean areas

Figure 5: Aseptic technique

Case study Figures 6 and 7 show the before and after images of a female patient who self-referred for treatment of a nodular, inflammatory lesion which appeared several weeks after hyaluronic acid injection to treat the tear trough. The lesion was preceded by non-inflammatory, tender nodules. Culture was positive for coagulase-negative Staphylococcus aureous. The patient was treated with hyaluronidase injections, antibiotic ciprofloxacin 500 bd for two weeks, followed by surgical incision and drainage, as well as LED lamp treatment.

Before

After

Prevention of dermal filler granulomas Dermal filler related granulomas may be prevented by meticulous cleansing and disinfecting the skin, sterile injection technique, prophylactic antibiotics, as well as using smaller gauge needles to minimise trauma and access for bacteria. Patients should be advised to avoid makeup immediately before and after injection.

Overcorrection with dermal filler, injecting too large a volume of the wrong type of filler for the tissue type, and lack of even redistribution of the filler due to lack of massage, should be avoided. Correct injection technique with placement of needle at the appropriate depth before injecting and discontinuing injecting before retraction of the needle is recommended.

Conclusion Granulomas are rare, however they are complex and difficult to manage delayed complications of dermal filler injections.

Understanding their pathophysiology is essential in differential diagnosis and appropriate management. Use of a sterile and correct injection technique, as well as high quality dermal filler that is appropriate for the tissue type, are important factors in the prevention of these challenging, and often distressing for the patient, filler complications.

Figure 6

Figure 7

Images courtesy of Dr Ewa Kaniowska, MD, dermatologist, founder of Derma Pulse – aesthetic dermatology and laser center in Wroclaw, Poland.

REFERENCES 1. Lemperle G, Gauthier-Hazan N, Wolters M, et al., ‘Foreign body granulomas after all injectable dermal fillers: part1: Possible causes’, Plast Reconstr Surg, 123 (2009), pp.1842-63.

2. Requena C, Izquierdo MJ, Navarro M, et al., ‘Adverse reactions to injectable aesthetic microimplants’, Am J Dermatopathol, 23 (2001), pp.197-202.

3. Lee JM, Kim YJ., ‘Foreign Body Granulomas after the use of dermal fillers: pathophysiology, clinical appearance, histologic features, and treatment’, Arch of Plast Surg, 42 (2015), pp.232-239.

4. Alijotas-Reig J, Garcia-Gimenez V., ‘Delayed immune-mediated adverse effects related to hyaluronic acid and acrylic hydrogel dermal fillers: clinical findings, long-term follow up and review of literature’, J Eur Acad Dermatol Venerol, 22 (2008), pp.150-61.

5. Ko CJ, Glusac EJ, Shapiro PE., ‘Non-infectious granulomas’, In: Lever WF, Elder DE, editors. Lever’s histopathology of the skin., Wolters Kluwer Health/Lippincott Williams & Wilkons, (2009), pp.373-87.

6. Lemperle G, Gauthier-Hazan N., ‘Foreign body granulomas after all injectable dermal fillers: part 2.

Treatment options’, Plast Reconstr Surg, 123 (2009), pp.1864-73.

7. Mukta Sachdev, YN Anantheswar, BC Ashok, Sunaina Hameed, and Sanjay A Pai, ‘Facial Granulomas Secondary to Injection of Semi-Permanent Cosmetic Dermal Filler Containing Acrylic Hydrogel Particles’, J Cutan Aesthet Surg, 3(3), (2010), pp.162-166.

8. Lowe NJ, Maxwell CA, Patnaik R., ‘Adverse reactions to dermal fillers: review’, Dermatol Surg, 31 (2005), pp.1616-25.

9. Murphy KM, Traves P, Walport M, ‘Janeway’s immunology’, Garland Science (2008).

10. Rubin E, Faber JL., ‘Pathology’, Lippincott-Ra-ven, (1999).

11. Zimmermann US, Clerici TJ., ‘The histological aspects of filler complications’, Semin Cutan Med Surg, 23 (2004), pp.241-50.

12. Lemperle G, Rullan PP, Gauthier –Hazan N., ‘Avoiding and treating dermal filler complications’, Plast Reconstr Surg, 118, (2006), 92S-107S. 13. Bentkover SH., ‘The biology of facial fillers’, Facial Plast Surg, 25 (2009), pp.73-85.

14. Christiansen L., ‘Normal and pathologic tissue reactions to soft tissue gel fillers’, Dermatol Surg, 33 (2007) pp.168-75.

15. Dayan SH, Arkins JP, Brindise R., ‘Soft tissue fillers and biofilm’, Fac Plast Surg, 27 (2011), pp.23-28.

16. De Boulle K, Heydenrych I., ‘Patient factors influencing dermal filler complications: prevention,

Dr Beata Cybulska is a board-registered dermatovenereologist (Poland) and an aesthetic practitioner with more than 20 years of experience of working in teaching hospitals in London and Bristol as an associate specialist.

She trained in aesthetic medicine in the UK and Poland, graduating with distinction from Queen Mary University of London and the International Foundation of Anti-ageing and Aesthetic Medicine in Warsaw. assessment and treatment’, Clin Cosm and Inestigat Dermatol, 8 (2015) pp.201-214.

17. Nairns RS, Coleman WP, Glogau RG., ‘Recommendations and treatment options for nodules and other filler complications’, Dermatol Surg, 35 (2009), pp.1667-1671.

18. Lemperle G, Morhenn V, Charrier U., ‘Human histology and persistence of various injectable filler substances for soft tissue augmentation’, Aesthetic Plast Surg 27 (2003), pp.354-66.

19. Cassuto D, Sundaram H., ‘A problem-oriented approach to nodular complications from hyaluronic acid and calcium hydroxylapatite fillers: classification and recommendations for treatment’, Plast Reconstr Surg. 132 (2013) 48S-58S. 20. Lemperle G, Duffy DM., ‘Treatment options for dermal filler complications’, J Am Acad Dermatol, 26 (2006), pp.356-64.

21. Conejo-Mir JS, Sanz Guirado S, Angel Munoz M., ‘Adverse granulomatous reaction to Artecall treated by intralesional 5-Fluorouracil and triamcinolone injection’, Dermatol Surg. 32 (8) (2006), pp.1079-81.

22. Cassuto D, Marangoni O, De Santis G, Christiansen L., ‘Advanced laser techniques for filler – induced complications’, Dermatol Surg, 35 (2009), pp.1689-16-95.

23. De Barros Silveira LK, de Oliveira FL, Alves T de B et al. ‘The therapeutic benefit of allopurinol in the treatment of foreign body granulomas caused by Polymethylmethacrylate microspheres’, Case Rep Dermatol Med, (2012) 945205.

24. Aivaliotis M, Kontochristopulos G, Hatziolu E et al. ‘Successful colchicine administration in facial granulomas caused by cosmetic implants: report of a case’, J Dermatol Treat, 18 (2007), pp.112-4.

25. Bauman LS, Kerdel F., ‘The treatment of bovine collagen allergy with cyclosporine’, Dermatol Surg 25 (1999), pp.247-9.

26. Desai AM, Browning J, Rosen T., ‘Etanercept therapy for silicone granuloma’, J Drugs Dermatol, 5 (9) (2006), pp.894-6.

27. Lloret P, España A, Leache A, Bauzá A, Fernández-Galar M et al. ‘Successful treatment of granulomatous reactions secondary to injection of esthetic implants’, Dermatol Surg. 31(4) (2005), pp.486-90.

28. Funt D, Pavicic T., ‘Dermal Fillers in aesthetics: an overview of adverse events and treatment approaches’, Clin Cosm and Interven Dermatol, 6 (2013), pp.295-315.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Treating the Postpregnancy Body Mr Taimur Shoaib details the options available to treat womenâ&#x20AC;&#x2122;s aesthetic concerns following childbirth Pregnancy is a physiological process, resulting in changes to a womanâ&#x20AC;&#x2122;s body during and after the pregnancy. As the NHS sees the condition as a normal physiological process, rather than one that leads to a medical condition, it does not offer funded treatment. Many of the changes that we see post-pregnancy are related to hormonal changes and the development in the body shape and size that take place during pregnancy, as well as subsequent breastfeeding. In this article I will highlight some of the more common conditions that affect women, and the changes they see that are sometimes considered unfavourable, which lead to a consultation at a medical aesthetic clinic.

The article will specifically not discuss the gynaecological changes that occur during and following pregnancy.

Skin physiology and pathophysiology In order to understand what happens after pregnancy, it is important to understand some of the inherent properties of the skin. These properties change and are affected during pregnancy, and so a level of understanding of the normal anatomy and physiology of the skin is vital to understand what happens, and why it happens, when pregnancy occurs. In the skin, the elastic and collagen fibres are arranged in a springlike manner.1 When a spring is stretched to a certain level, it springs back to its usual configuration and returns to the same state

that it was in, prior to the stretching process. If a spring is stretched beyond the point where it has the ability to return to its pre-sprung state, it remains permanently stretched, which is a state known as hysteresis.

Accordingly, it will permanently enlarge and become loose and stretched. For this reason, we see loose skin around structures that have stretched, such as the abdomen, the breasts and any other areas where weight gain has taken place. Permanent loose skin after pregnancy appears because the tightly-wound collagen and elastic fibres have unwound beyond their ability to return to their pre-sprung state, and they have thus exhibited the characteristics of hysteresis.2 Collagen and elastic fibres can also tear and split. Therefore, when these fibres are stretched quickly, the collagen and elastic fibres cannot only unwind but can also tear.

When they do so, the thickness of the dermis is reduced, an injury response takes place increasing blood supply to the area, and the quantity of elastic fibres and collagen in the skin decreases, forming stretch marks.

Stretch marks are initially purple and thin due to the increased blood supply following the injury response. Afterwards, when the blood supply reduces, the stretch marks become pale and wide. In skin prone to postinflammatory hyperpigmentation, the skin may become hyperpigmented and thinned.3 Increased pigmentation is a normal part of pregnancy. During pregnancy there are increased levels of the adrenocorticotropic

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hormone (ACTH), which is very similar to melanocyte-stimulating hormone (MSH).4 One of the hallmarks of pregnancy is the linea nigricans, the dark line of skin that runs from the umbilicus to the pubic region. This area of skin becomes hyperpigmented and, due to the increased levels of ACTH during pregnancy, women are prone to melasma and other disorders of hyperpigmentation.5 Lastly, the breasts increase in size in preparation for lactating, and the abdomen increases in size to accommodate the growing foetus. During pregnancy there is inevitable weight gain and an increase in fat stores in areas that may be resistant to subsequent diet and exercise, thereby leading to permanent pockets of unwanted fat. Now that we understand some of the changes that occur during pregnancy, we can appreciate some of the concerns that women will have when they attend medical aesthetic clinics.

Stretch marks Stretch marks may be pale, purple or pigmented, depending on the individual and what stage the stretch mark is at. Examination of an area of skin where there are stretch marks should note the number, colour, length, width and location of the marks. Accurate records, including high-quality photographs taken under standardised conditions, with a ruler scale, will allow comparisons before and after treatment. Purple stretch marks manifest themselves as a result of increased vascularity in the dermis of the stretch-marked skin, and recommended treatment for this would generally be a light-based procedure that reduces vascularity, for example a green or yellow intense pulsed light (IPL) or laser.

With these wavelengths of light, IPL will target haemoglobin as a chromophore, thereby reducing the prominence of blood vessels.

Stretch marks that are pale can have treatment to increase pigmentation within the skin. Treatments such as micropigmentation can add colour to pale skin, as it is a method by which skin-coloured tattoos are carefully created in areas of pale skin, in order to darken it to match the colour of the surrounding skin.

Stretch marks are characterised by thinned skin and, unfortunately, it is not possible to completely eliminate the reduced depth of the dermis. Since that is the case, it is important to advise patients that the stretch marks will still be present, but we should be able to reduce their size and prominence.

There are several non-surgical treatments that can thicken the skin: laser, microneedling,

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ACTH levels increase during pregnancy and this results in melanocyte stimulation, melasma and darkening of the skin in certain areas platelet rich plasma (PRP) injections and radiofrequency. All of these methods can be used to help thicken the skin to a mild degree. The laser treatment of choice for thickening the skin is a fractionated ablative laser, such as an Erbium:YAG laser, CO2 laser, or YSGG laser.6 This technology drills small holes into the skin and the injury elicits a repair response. As a result, the skin thickens to varying degrees, causing a reduction in the prominence of the stretch mark. Multiple treatments are required to reduce the stretch marks and a suitable time period is required to allow skin healing in between successive treatments. Microneedling includes treatments such as dermaroller, Dermapen, and the Dermastamp. These devices create needle-point entry micro-injuries in the skin. The skin heals quickly, but the injury elicits a repair and regeneration process, which thickens the dermis and creates a collagenesis response. Microneedling devices are available in different needle lengths, and the required length of the needle is one that will penetrate through the full thickness of the dermis, in view of the full thickness depth of the actual stretch mark. As with the laser, multiple treatments are required to reduce, not eliminate, stretch marks. PRP has been used to reduce stretch marks and there is anecdotal evidence of its efficacy. PRP involves taking a blood sample from the patient, separating the blood into its components in a centrifuge, extracting the platelets from the centrifuge and injecting the platelets into the dermis, using something similar to the Nappage technique, in which the injection is targeted at the junction between the dermis and epidermis. Platelets are involved in repair and regeneration of injuries and release growth factors. The release of these growth factors also elicits a collagenesis response, hence reducing the prominence of stretch marks.

As mentioned, radiofrequency energy can also be used to treat stretch marks. The technology works by passing an electric current through the tissues. Those tissues

that have high resistance absorb the energy converted to heat and again elicit a collagenesis response. There are devices available that combine microneedling with radiofrequency and, as with all treatments that have a mild to moderate effect, combination treatments are often used to give the best possible results.

Pigmentation As we know, ACTH levels increase during pregnancy and this results in melanocyte stimulation, melasma and darkening of the skin in certain areas. After pregnancy and the normalisation of ACTH levels, the melanocytes no longer undergo hyperstimulation. Accordingly, the level of melanin production normalises but, sometimes, patchy pigmentation remains.5 In such cases, hyperpigmentation can be treated with a number of different treatment options. Melanocyte stimulation can be downgraded with prescription and overthe-counter medicines such as kojic acid, tretinoin and hydroquinone. Lasers, such as the Alexandrite or Nd:YAG laser, can be used to reduce pigmentation and on-going use of cosmeceutical products also help in suppressing the overproduction of melanin.

Body fat changes During pregnancy, body fat distribution changes. In some cases, the distribution of fat remains altered even after parturition and some women will have a desire to restore their body shape back to the pre-pregnancy state. For pockets of fat that are resistant to diet and exercise there are non-surgical and surgical treatment options available.

Non-surgical treatments include cryolipolysis, contact radiofrequency and non-contact radiofrequency devices. These give a mild to moderate reduction in the fat that is treated, for example cryolipolysis reduces pinch thickness by approximately 15-28% in the area treated.7 All treatment options must always be discussed with patients, even though the healthcare professional

Aesthetics aestheticsjournal.com

may not actually deliver those treatments.

In my opinion, liposuction remains the gold standard for fat reduction and body contouring. Liposuction consists of three main phases: fluid infiltration, fat energy delivery and fat extraction. Fluid infiltration can be considered to be absent (in dry liposuction), and with increasing volumes of fluid infiltrated into the area treated. The terms used for the amount of volume of fluid are: wet liposuction, superwet liposuction and tumescent liposuction. The next step, in which energy is delivered to the fat, is one of three options: laser, ultrasound or radiofrequency. Each energy-based system has its advantages and disadvantages (for example, some RF systems can be bulky) and different surgeons will have their preference based on a number of criteria. The energy-based delivery systems disrupt the fat cells, increase the amount of fat removed in relation to blood removal, tighten the overlying skin and sometimes emulsify and target the fat cells.

Finally, the practitioner will remove the fat, which may be performed through standard liposuction or through a power-assisted liposuction device. Power-assisted liposuction transfers the repetitive mechanical force from the surgeon to a surgical device, reducing mechanical strain and stress for the surgeon.

Changes in the breast size and shape One of the major changes that takes place during pregnancy is the size and shape of the breasts as they prepare for lactation. After pregnancy and lactation, breast glandular hypertrophy reduces and often women are left with lost volume in the upper pole of the breast, glandular ptosis, nipple ptosis and excess skin. In such cases, breast surgery for reshaping may be an option. In women who have simply lost volume, particularly in the upper pole of the breast, augmentation with breast implants is the treatment of choice for those looking to increase volume.

If there is concomitant ptosis of the nipple, this may be combined with a mastopexy, in which the breast tissue is elevated off the pectoral fascia to secure it in a more cranial position, while simultaneously elevating the nipple-areolar-complex on a vascular pedicle to raise its position. This will be conducted either as a one-stage or twostage procedure, particularly when the skin of the breast undergoes hysteresis. When this happens the skin will not retract back to its original state, leaving some redundant skin.

Sometimes the breast tissue enlarges and remains enlarged, and a breast reduction may be indicated.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Overhanging skin in the abdomen As a result of the developing foetus, the abdominal region stretches to accommodate the growth. The skin may develop stretch marks and these are often seen in the lower abdomen, between the umbilicus and the pubic region. The skin will usually show signs of failing to shrink back to its pre-pregnancy state, as a result of hysteresis, and an abdominal apron of skin may ensue. Sometimes the patient may have had a caesarean section, with a lower abdominal Pfannenstiel incision. If the skin at the site of such an incision is tethered down to the underlying tissues, an abdominal overhang develops. The treatment of choice to reduce excess skin, particularly when there is a significant abdominal pannus, is an abdominoplasty. As part of the abdominoplasty procedure, any divarication of the rectus muscles may also be addressed with muscle suturing. In such cases, a preoperative assessment is made of the position of the rectus abdominus muscle. If the surgeon determines there is an increased width of the muscles in the midline, with reduced muscle function in this area, a decision with the patient may be made to bring the muscles closer together. In these cases, the lateralised anterior wall of the rectus fascia is medialised with an appropriately strong suture. The excess skin is excised and the abdomen is inevitably flatter.

Summary In conclusion, there are several changes that happen as a result of pregnancy, and many of these changes can be addressed in a medical and surgical aesthetic clinic. These changes are normal and physiological and are all to be expected during pregnancy. If the

Aesthetics

changes concern a woman, then there are procedures that we can perform that may improve symptoms and improve their quality of life.

Mr Taimur Shoaib is a consultant plastic surgeon with more than 20 years’ medical experience. He qualified from the University of Glasgow in 1992, before establishing his cosmetic surgery practice, La Belle Forme, in 2009. Mr Shoaib is an honorary senior clinical lecturer at the University of Glasgow and a faculty member of the Allergan Medical Institute.

Mr Taimur Shoaib will discuss surgical and non-surgical methods for fat reduction and enlargement at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/programme to find out more.

REFERENCES 1. Tatsuo USHIKI., ‘Collagen Fibers, Reticular Fibers and Elastic Fibers. A Comprehensive Understanding from a Morphological Viewpoint’, Archives of Histology and Cytology, 65 (2002), p.109-126.

2. Hussain, Sadaf Hashim, Boonyapat Limthongkul, and Tatyana R. Humphreys., ‘The biomechanical properties of the skin’, Dermatologic Surgery, 39.2 (2013), pp.193-203.

3. Arem, Arnold J., and C. Ward Kischer., ‘Analysis of striae’, Plástic and reconstructive surgery, 65.1 (1980), pp.22-29.

4. Schwyzer, Robert., ‘ACTH: a short introductory review*’, Annals of the New York Academy of Sciences, 297.1 (1977), pp.3-26.

5. Melmed et al., ‘Williams Textbook of Endocrinology’, 12th Edition, ISBN: 978-1-4377-0324-5.

6. Elsaie, Mohamed L., Leslie S. Baumann, and Lotfy T. Elsaaiee., ‘Striae distensae (stretch marks) and different modalities of therapy: an update’, Dermatologic Surgery, 35.4 (2009), pp.563-573.

7. Ingargiola, Michael J., et al, ‘Cryolipolysis for Fat Reduction and Body Contouring: Safety and Efficacy of Current Treatment Paradigms’, Plastic and reconstructive surgery, 135.6 (2015), pp.1581-1590.

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Aesthetics

• Radiotherapy or chemotherapy for cancer that has resulted in loss of hair.

• Trichotillomania.

• Permanent damage to the eyelashes during a beauty routine – possibly by accidentally ripping them out or by over-plucking.

Fashion dictates, to a large degree, the way people use their eyelashes. There is a range of cosmetic aids that can help eyelashes appear longer, thicker or of a different colour. In recent times, I have witnessed more and more people looking to eyelash transplantation in order to get the eyelashes they want. Such transplants are relatively new developments, however they are becoming increasingly popular as women covet the fuller eyelashes popular with celebrities.

Eyelash Transplants Mr Asim Shahmalak details the history of eyelash transplants and shares his technique for treatment Eyelash transplants were originally developed to help victims of accidents and traumas who had subsequently damaged their lashes permanently. Burns victims, for instance, can often be left with no eyelashes at all – damaging their facial symmetry and selfesteem. The first eyelash transplant was carried out 17 years ago in Brazil,1 and once surgeons at a hospital in San Paulo first began performing the procedure, word spread quickly around the world about its possible life-changing benefits.

Over time, surgeons have begun to realise that eyelash transplants can also be performed for aesthetic reasons; patients with naturally thin eyelashes could benefit, particularly those who have permanently damaged their eyelashes using glue-on false eyelashes. Wearing these false lashes can sometimes rip out natural follicles, leaving patients with virtually bald eyelids.

There are only a few surgeons in the world currently carrying out eyelash transplants today. I performed the very first eyelash transplant in the UK in 2009,2 on a young woman who suffered from trichotillomania,3 a condition where a person feels compelled to pull their hair out. It received a lot of publicity and was one of the most fulfilling moments of my career; the patient told me afterwards that it had changed her life.

In this article I shall explain how to assess patients for the procedure, and detail the treatment process and expectant results.

Indications for an eyelash transplant Eyelashes make an important contribution to facial symmetry and presentation of oneself to others. A person without eyelashes may feel very self-conscious about his/her appearance. Like general hair transplant surgery, eyelash surgery can be required due to a number of reasons: • Physical trauma/facial injury and scarring, resulting from events such as: road accidents, industrial accidents, thermal and chemical burns, eyelid tattoos and the use of false eyelashes.

• Surgical treatment of an injury or tumour that resulted in removal of eyelash follicles and tissue scarring.

The consultation The key questions I consider from the outset of the consultation are: does the patient really need an eyelash transplant, and are they suitable for the procedure? It must be noted that eyelash transplants can only be carried out on the upper eyelid, as the hair does not grow as well on the lower lid. From my experience, hairs on the lower lid grow very straight and are difficult to curl and trim.

During the consultation, I am looking for gaps in the eyelid where hair, harvested from the scalp, can be transplanted. This is not always possible with an accident victim as their eyelids can be badly damaged. In these cases, I may have to wait for a plastic or ophthalmic surgeon to rebuild the eyelid so there is an area where the transplant can take place.

It is also important to make sure that the patient can close their eyes completely. Some trauma victims cannot close the full lid and this makes a transplant impossible because the new transplanted lashes could damage the eye.

Many eyelash transplant patients have suffered from trichotillomania and it is imperative you are satisfied that they have been cured of the condition for at least two years before performing a procedure. In my opinion, the risk of them relapsing and ripping out the transplanted hair is too great prior to two years as trichotillomania can be a challenging condition to treat.4 I often perform eyelash transplants on women who have damaged their eyelids by gluing on false eyelashes. With these patients you need to be sure that there is a healthy upper eyelid where new eyelashes can be transplanted. If the procedure is being performed for aesthetic reasons, you need to be sure that the patient genuinely needs the operation; I tend not to treat patients who simply want longer eyelashes. In these cases, I prefer to recommend an eyelash conditioner such as RevitaLash or Latisse, which can help lashes to grow longer.

I need to make sure there is a decent gap of approximately 1-2mm in

Wearing false lashes can sometimes rip out natural follicles, leaving patients with virtually bald eyelids

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Case study one: Patient A One of my successful eyelash transplant patients was a 42-yearold woman who had an eyelash transplant at my clinic two years ago.5 The patient had damaged her natural eyelashes from becoming addicted to wearing false lashes for 20 years.

The patient was left with just three eyelashes on her upper right lid and 19 on her upper left lid. The damage was made worse when she got an eye infection which caused itching and she rubbed off many of her already weakened natural lashes.

With almost completely bald upper lids, the patient was too embarrassed to leave her house or even let her family, boyfriend or friends see her without her false eyelashes.

Patient A’s eyelash transplant was carried out over a single day at Crown Clinic. She had 70 eyelashes transplanted into Before

Before

After

After

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her eyelids in a three-hour operation. A strip of hair was taken from the back of her scalp and the individual hair follicles removed. I then threaded each hair into the skin at the bottom of her upper eyelids. Patient A felt some mild discomfort in the harvesting area at the back of her head, however this passed after a couple of days. She had swelling in both upper eyelids for two or three days following the operation, which eventually resided. It took around six months for the new eyelashes to fully bed into her eyelids. I assessed the patient six months after the operation and found that 95% of the transplanted follicles were now growing healthily in her upper eyelids. Patient A reported that she first noticed positive results two months after the operation, however the new lashes did not look their best until six months after the operation.

After

Case Study Two: Patient B I travelled to my home city of Karachi in January 2013 to perform hair, eyebrow and eyelash transplants on seven women who had been horrifically scarred in acid attacks.6 I helped a 24-year-old woman (Patient B) by giving her two new eyebrows and eyelashes on her right eye with hair transplanted from the back of her head in a series of intricate operations performed over three days.

As Patient B was the victim of an acid attack, it made the procedure slightly more complicated because you have to assess the eyelid very carefully to ensure that it is will be receptive to the transplanted hair. In this case, the patient’s eyelids were receptive, despite extensive damage to the lids from the attack. The operation had a success rate of around 85% when Patient B was assessed a year after the procedure. Patient B had no complications, however there was mild pain in the harvesting area for two days following the operation. She felt no pain in her eyelids either during or after the operation, though there was some gentle swelling which went down after two days.

the eyelid for me to insert the new follicles. Without sufficient gaps to fill, I run the risk of damaging the existing healthy follicles in the lid.

Eyelash transplant procedure The process starts by removing a section of hair from the patient, typically from the back of the head where hairs tend to be longer, making it easier to thread them through the upper eyelid. An area (1 x 1cm) of scalp is numbed with a local anaesthetic and a small strip of hair is removed and the scalp sewn back with stitches. Harvesting is fairly quick, usually taking no more than 10 minutes to surgically remove the strip. As there would be from any mild surgical treatment, patients will experience some mild discomfort from the harvesting area, however they don’t tend to experience any pain at all in their upper eyelid following the threading of the new lashes – either during or after the procedure. There will be a small amount of scarring, though it only tends to be visible on patients with very short hair.

Following the harvesting, the scalp strip is given to a technician who separates the hair tissue into single hair follicular grafts under a

microscope. I will choose the hair grafts for the transplant individually – I am always looking to use longer hair, about 3-4 inches long, so these strands can be easily threaded into the donor area. Once I have the donor grafts, the upper eyelid is anaesthetised and I insert the grafts by threading with a curved needle. It is a long and painstaking job because each graft has to be individually threaded. Surgical loupes are used which are magnified to six times their normal size to assist with this process and ensure the hairs are placed in exactly the right position on the lid. A normal eyelid will have between 100 and 150 lashes per eye. In an eyelash transplant, I look to add between 25 and 60 new lashes to the upper lid. The operation normally takes around three to four hours and the success rate is very good – between 80 and 90%.

To arrive at this success rate I assess patients from six months to a year after their operation. I then count the number of follicles that have been transplanted and check how many of these new hairs have survived.

Post-operative care and complications The patient will need between three to five days to recover, while

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there will be bruising and swelling around the eyelid. We advise that they do not wash their face for the first couple of days following the operation to allow the new follicles to settle in. It takes around six months for the new lashes to grow to their full length and be seen at their best.

As with any surgery, there can occasionally be complications such as an infection, which can usually be remedied with antibiotics. Also, there is a chance the new follicles will grow into the eyelid – these would need to be removed either by plucking them out or via surgery if they become embedded inside the eyelid. There can also be swelling at the base of the follicle, which again can be treated with antibiotics. As the donor hair is taken from the scalp, it grows just as hair on the head does. This means it will need trimming every week and curling, too, so that the new lashes blend with the existing natural lashes. At Crown Clinic we provide all patients with a cutting and curling kit so they can do this at home, though some prefer to get this done at a beauty salon.

We have found that with some patients, over several years, the donor hair has taken some of the properties of the natural eyelashes – growing more slowly than scalp hair and also curling naturally. In these cases, the transplanted hair may only need trimming once every three weeks.

Conclusion Eyelash transplants are an increasingly common cosmetic procedure, which are performed for both medical and aesthetic reasons. In my experience the success rate of this treatment has

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been very high and complications are rare. Patients who have lost their eyelashes can suffer severe damage to their self-esteem. At Crown Clinic we have treated patients who are so embarrassed by their bald eyelids that they refuse to leave the house without wearing false eyelashes. Eyelash transplants can, however, provide profound benefits to patients, increasing their confidence and allowing them to lead normal lives in the years after a procedure.

It must be noted that eyelash transplantation is an extremely complicated procedure and only a handful of surgeons in the world currently carry out this operation. Only a qualified surgeon should carry out an eyelash transplant and thorough training is essential.

Dr Asim Shahmalak is a hair transplant surgeon and gained his medical degree from the University of Karachi, Pakistan in 1988. He founded the Crown Clinic in Manchester eight years ago and also has consulting rooms in Harley Street. He is a hair loss expert on Channel 4 show Embarrassing Bodies.

REFERENCES 1. Eyelash transplant or surgery to solve alopecia (US: Hairtransplantsurgery.com, 2009) <http://www. hairtransplantsurgery.co.uk/eyelash-hair-loss-alopecia-eyelashes-transplant.html> 2. Peter Bainbridge, (2013) Manchester Evening News, Salford woman spends £4,000 on EYELASH transplant <http://www.manchestereveningnews.co.uk/news/greater-manchester-news/salfordwoman-spends-4000-eyelash-5840036> 3. ITV News, (2014), Manchester surgeon helps acid attack victims in Pakistan, <http://www.itv.com/ news/granada/2014-02-25/manchester-surgeon-helps-acid-attack-victims-in-pakistan/> 4. Trichotillomania – Treatment (UK, NHS Choices, 2015) <http://www.nhs.uk/Conditions/trichotillomania/ Pages/treatment.aspx> 5. Peter Bainbridge, (2013) Manchester Evening News, Salford woman spends £4,000 on EYELASH transplant <http://www.manchestereveningnews.co.uk/news/greater-manchester-news/salfordwoman-spends-4000-eyelash-5840036> 6. ITV News, (2014), Manchester surgeon helps acid attack victims in Pakistan, <http://www.itv.com/ news/granada/2014-02-25/manchester-surgeon-helps-acid-attack-victims-in-pakistan/>

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Peri-ocular Ageing Mrs Sabrina Shah-Desai explains the variations in ageing of the peri-ocular region in different ethnicities and how to treat the area appropriately In my research, I have found that world literature on cosmetic facial rejuvenation is commonly centered on Caucasian aesthetic ideals and tends to ignore the larger ethnic groups such as African, Asian (Oriental and Indian) and Hispanic, despite darker skinned people (tan, olive, brown and black) constituting the majority of the global population.1 Of the 5,000 ethnic groups in the world, the largest are the Chinese followed by the Indians.1 The obvious difference in individuals of varying ethnicities is the skin colour, although there is a wide variation of the facial dimensions between ethnicity, gender, and age. When assessing the anatomical aspects, it is apparent that key angles and proportions do vary in different ethnicities.2 Photoageing affects all skin types, regardless of ethnicity. As eyelid skin is one of the thinnest in the human body, the periorbital area is the first to demonstrate visible signs of ageing.3

Rawlings’ analysis of the effects of photoageing due to sun exposure4 concluded that although all ethnic groups are subject to the process of photoageing, Caucasian skin usually ages faster than any other ethnic group. The main reason is that this skin type contains low levels of melanin and is thinner, making factors such as upper eyelid hooding, eye bags and crow’s feet more visible (as early as the third decade), whereas hyperpigmented macules and seborrhoeic keratosis are more common with the darker skin types.4 Studies have confirmed that racial differences in skin physiology are mainly related to the protective role of melanin present in races with darker skin, differences in stratum corneum (SC) thickness, water content, rate of transepidermal water loss (TEWL) and in skin characteristics like extensibility, recovery and elastic modulus.4,5 Typically in the skull, the nose area, eye orbits, and brow ridges, significant racial differences are apparent.6

Peri-orbital features of the African American, Asian and Hispanic patient African American peri-orbital area: Characteristics • Brow ptosis • Forehead and glabella furrows • Upper eye lid > lower lid tissue laxity with lateral upper lid fullness due to lacrimal gland herniation • Lower supra tarsal fold of skin – due to shorter tarsus • Lateral canthal (outer corner of eye) rounding • Malar hypoplasia causes increased inferior scleral show, malar flattening, submalar hollowing • Proptosis (bulgy eye) • Periorbital hyperpigmentation – progress to melanoma, papillomas and keratoses 7

Not only does African American skin contain the most amount of melanin, which protects its complexion from the ageing-affects of the sun, 4,5 but the skin is also thicker, therefore wrinkles show up much later in life (generally the sixth decade). However, African American skin is much more likely to develop a scar after an incision and has a higher risk of pigmentation.4,5 The eye orbits of African Americans tend to be of a more rectangular shape, with small brow ridges, high brows and lateral brow hair thinning. When it comes to the eye area, the main concerns for African Americans are droopy eyelids (ptosis), bulgy-looking eyes and rounding at the outer corner due to soft tissue atrophy and bony remodelling of the eye socket.7

Asian peri-orbital area:8 Characteristics • Weaker facial skeletal support • Malar fat pad ptosis • Tear trough deformity • Descent of thick juxtabrow tissues of lower orbit (oriental) • Single eyelid (oriental) • Epicanthic folds (oriental) Asian skin is made up of higher levels of melanin, and, as a result, signs of ageing around the eye zone show up much later in life. However, melanin also makes skin more prone to pigmentation and it is common to see hyperpigmented macules and seborrhoeic keratosis. Nearly half of Oriental Asians are born with no upper eyelid crease (single eyelid), which can cause the lashes to droop in the visual axis (lash ptosis) or give rise to a sleepy appearance.10 The eye orbits of Asians tend to be of a more rounded shape, with small brow ridges, high brows with a shorter tail. Weaker skeletal support and loss of elasticity leads to under eye hollows and cheek flattening.8

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Hispanic and Latino peri-orbital area:7 Characteristics • Minimal skin elastosis • Eyelid ptosis • Infraorbital shadows • Loss of soft tissue bulk in infra brow region, malar, submalar and infraorbital region • In Hispanics, the brow tends to be set lower on the supraorbital rim than Caucasians Hispanic and Latino skin tones can range from light to very dark. The skin of these ethnic groups contains a fair amount of melanin, making them less likely to show signs of ageing until they hit their 40s.7 Like Oriental and African American skin, it is more prone to developing skin discolorations. Hispanics tend to have a lower brow position compared to Caucasians, which can sag relatively early and cause brow drooping. Dark circles under the eyes are also common, which is due to volume loss along the eye socket (tear trough area).7

Treatment Whilst the darker-skinned ethnic groups tend to have less periorbital wrinkling, they are all prone to pigmentation issues and practitioners should bear in mind that any skin rejuvenating treatment may respond unpredictably to chemical peeling in different ethnicities. Asian (Indian) skin may be more sensitive to topical therapies and develop allergic reactions.9 An individual patient history of post-inflammatory hyperpigmentation (PIH) is very important to take into account. In this subpopulation, peels may be considered as a second-line therapy after topical therapies fail.9 I use botulinum toxin in African Americans and Hispanic patients to improve brow ptosis and glabellar furrows. African Americans need dermal fillers to support their lateral canthus and cheek, as these areas are prone to early ageing. I would normally inject three points (similar to points 1,2 and 3 of the 8-point lift)11 to correct the malar hypoplasia and the lateral canthal rounding. Surgical correction is performed without cutting the skin, where possible, to avoid keloid formation.

Asian (Oriental) patients require upper eyelid rejuvenation (double eyelid blepharoplasty), which I perform surgically and non-surgically (suture Asian blepharoplasty). From my experience, Asian (Indian) and Hispanic patients tend to require tear trough rejuvenation earlier than other ethnicities. Asian (Indian) dark circles often have

As eyelid skin is one of the thinnest in the human body, the periorbital area is the first to demonstrate visible signs of ageing

a hereditary pigmentation component, which make their dark circles more challenging to treat. For dark circle rejuvenation in Asian (Indian) ethnicities, I use a combination of topical creams that contain vitamin C, Kojic acid and arbutin. I also use a skin plumping filler in the lower eyelid skin, such as Restylane Vital Light, in addition to a deep filler in the central and lateral trough.

Recognising ethnic differences in skeletal support and skin can hugely impact our ability to better target rejuvenation efforts for different ethnic groups.

Mrs Sabrina Shah-Desai is an oculoplastic surgeon well known for cosmetic eyelid lifts, scar-less droopy eyelid correction and revision eyelid surgery. She is highly experienced in non-surgical aesthetic periorbital rejuvenation with botulinum toxin and dermal fillers. Mrs Shah-Desai is a keen educator and runs surgical training wet labs.

Mrs Sabrina Shah-Desai will discuss periorbital rejuvenation with hyaluronic acid fillers at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/ programme to find out more.

REFERENCES 1. Levinson, D (1998), Ethnic Groups Worldwide: A Ready Reference Handbook, Greenwood Publishing Group 2. Farkas LG, Katic MJ, Forrest CR et al, International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg, 2005;16:615–46.

3. Chopra K, Calva D, Sosin M et al, (2015) A comprehensive examination of topographic thickness of skin in the human face. Aesthet Surg J Nov;35(8):1007-13 4. Rawlings AV, (2006) Ethnic skin types: are there differences in skin structure and function? Int J Cosmet Sci, Apr;28(2):79-93 5. Voegeli R, Rawlings AV, et al, (2015) A novel continuous colour mapping approach for visualization of facial skin hydration and transepidermal water loss for four ethnic groups, Int J Cosmet Sci, Dec;37(6):595-605 6. Jagadish Chandra H, Ravi MS, et al, (2012) Standards of facial esthetics: An anthropometric study. J Maxillofac Oral Surg,11:384–9.

7. Grimes, P.E (eds), (2008) Aesthetics and Cosmetic Surgery for Darker Skin Types, Lippincott Williams & Wilkins; Philadelphia 8. Liew S, (2015) Ethnic and Gender Considerations in the Use of Facial Injectables: Asian Patients.

Plast Reconstr Surg, Nov;136(5 Suppl):22S-27S. 9. Marta I. Rendon, Diane S. Berson et al, (2010) Evidence and Considerations in the Application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing, J Clin Aesthet Dermatol, 3(7): 32–43 10. Chen, W.P, (2015) Asian Blepharoplasty and the eyelid crease, Elsevier; China 11. De Maio, M, Treatment planning, Injectable fillers in aesthetic medicine, 2014: pp52-58

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Treating Facial Thread Veins with Lasers Aesthetic nurse prescriber Mary White takes an in-depth look at how lasers function and explains how to use them to effectively treat thread veins The last decade has brought about big advances in medical laser technology, which have assisted aesthetic practitioners in providing a more effective treatment of thread veins. Broken veins, telangiectasia or thread veins are the small red or blue veins that can appear anywhere on the body and are very common on the face. Thread veins can appear as single veins, widely dispersed, or as a collection of broken veins close together. They can also appear as a collection of vessels arising from a single point, known as spider naevi. Thread veins are caused by a variety of factors including exposure to ultraviolet light, wind and extreme temperatures.

Steroid creams and the hormonal changes that occur during pregnancy can also cause thread veins.8 In addition, there is a belief generally amongst practitioners that some individuals are genetically more prone to develop thread veins than others, and some people are more at risk because of old injuries. To understand how to safely and effectively treat facial thread veins using lasers, it is necessary to go back to some basic physics in order to appreciate the principles of how laser light interacts with tissue to achieve the desired result.

All lasers have unique characteristics, which determine the outcome of treatment, and what condition a specific laser can effectively treat.

Back to basics: physics of lasers in dermatology All lasers have unique characteristics, which determine the outcome of treatment, and what condition a specific laser can effectively treat. Laser light is nonionising, which means that unlike X-rays or cosmic radiation, it does not affect cellular DNA.1 Many lasers that are used in dermatology fall within the visible part of the electromagnetic spectrum, and

wavelengths of these lasers are typically measured in nanometres (nm).

Lasers have certain characteristics that make them unique. Laser light is monochromatic (one colour, or one wavelength), coherent (all the photons are in phase) and collimated (it can be precisely directed). For example, ordinary light from a light bulb or a torch is polychromatic (has several colours) with all wavelengths of visible light present (remember splitting sunlight using prisms in science lessons to show the colours of the rainbow?) and is not coherent or collimated, which means it is scattered in many directions.1 When standing in front of a wall with a torch, the circular light from the torch would be small whilst close to the wall and would get dimmer and more scattered as it retreats from the wall. Compare that with a laser pointer being used at a conference in a large auditorium; the laser spot does not change size or get bigger as the speaker moves around and it can travel a long way around a room. Laser light interacts with targets in many ways, such as reflection, scattering and transmission.

However, from my experience when using lasers in dermatology applications, the tissue interaction that is most utilised is absorption. Lasers have a variety of indications, such as cutting, vaporising and coagulation, and they can do this because the target tissue absorbs the laser light.

The theory of selective photothermolysis2 states that in order to destroy a selected target, while sparing the surrounding tissue, three basic parameters are necessary. First of all, the colour of the chosen laser light (wavelength) must be one that is absorbed by the target and poorly absorbed by the surrounding tissue. This spares the surrounding tissue from being damaged at the same time by the laser. Secondly, the length of time that the laser beam interacts with the target, that is the pulse duration, must be long enough to destroy the target and is determined by the size of the target.

The pulse duration will vary depending on the application you are using the laser for. Finally, in order to destroy or alter the target, it must be heated to a high enough temperature to cause permanent damage to that target.2 Therefore, enough energy must be applied and absorbed for an effective temperature rise.

When treating facial thread veins, the target for absorbing the energy of the laser is haemoglobin or oxyhaemaglobin.

A laser would be selected on the basis that it would absorb well into these chromophores (targets), while at the same time not affecting surrounding structures such as melanin or water. Haemoglobin and oxyhaemaglobin are well absorbed by wavelengths of 585-595nm,4 which are the wavelengths of Pulsed Dye Lasers (PDL).

Another influencing factor when choosing

Another influencing factor when choosing a laser to treat facial thread veins is the depth of penetration of the laser into tissue

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a laser to treat facial thread veins is the depth of penetration of the laser into tissue.

This is dependent upon the wavelength of the laser and also the spot size, with larger spot sizes penetrating deeper than smaller ones. Facial thread veins are fairly superficial and will require smaller spot sizes than, for example, a hair follicle for laser hair removal, which will be more deeply rooted.

Another important parameter to consider when carrying out laser treatment is pulse duration. Pulse duration is the amount of time over which the laser pulse is delivered into the target, in this case the haemoglobin in the blood cells. In order for laser treatment to be effective, the pulse duration must be selected in consideration with the thermal relaxation time (TRT) of the target. The pulse duration must be shorter than the TRT of haemoglobin, but not too short that it causes unwanted side effects, such as hyper/hypo pigmentation or scarring.2 TRT is defined as the time required for the targeted chromophore/structure to cool to half its peak temperature immediately after the laser exposure. Simply put, smaller objects cool faster than larger objects of the same material and it is important to consider how long the haemoglobin will take to cool down, and then choose an appropriate pulse duration.

Finally the energy density that is delivered during laser treatment must be considered, which would vary depending on a number of factors including spot size, wave length and laser manufacturer, and is referred to as fluence and measured in joules/cm2. Fluence takes into account the energy used as well as the area being treated or spot size.

Lasers vs. Intense Pulsed Light (IPL) Once the physics is understood, it is easier to see the fundamental difference between

Aesthetics Journal

lasers and IPL sources. Both technologies can reduce thread veins, but that’s where the similarity ends.

Lasers have the properties described earlier: monochromatic, collimated and coherent light. Lasers target a single chromophore; haemoglobin in the case of thread vein removal and the surrounding tissue is spared by the principle of Selective Photothermolysis.1 IPL is simply a very bright light or lamp and is polychromatic, not collimated, and exposes the patient to a broader spectrum of light energy defined by cut-off filters, typically in the range of 6001200nm. The use of filters in front of the light source can exclude certain wavelengths by blocking them, but it is impossible to filter every wavelength and be left with just one.3 The multiple wavelengths IPL produces target multiple chromophores and can therefore be absorbed by surrounding tissue that is an unintentional target, such as melanin. This can increase the risk of unwanted side effects of treatment and limits the safe use of IPL to fairer skin types, usually I-III on the Fitzpatrick Scale.3 I believe IPL to be is far less effective than laser for thread vein removal as it is more diffuse and less powerful. Figure 1 demonstrates how IPL diffuses into target tissues more than laser light and how the many colours or wavelengths affect competing chromophores.

Treating facial thread veins with Nd:YAG laser The Nd:YAG laser delivers a burst of energy using long pulse durations in the remit of milliseconds. Using longer pulse durations delivers the energy in a more controlled and gentle manner than very short durations, such as the acoustic type nanosecond pulse durations delivered during tattoo removal. Nd:Yag laser at

IPL vs LASER

IPL • Polychromatic (many colours) • Diffuses and scatters in tissue • Poor depth of penetration

LASER • Nd:YAG laser penetrates deeply to reach target • Is a single colour to target the structure • Not diffusing or scattering • Is focused

Figure 1: IPL diffuses into target tissues more than laser light and how the many colours or wavelengths affect competing chromophores

Aesthetics aestheticsjournal.com

1064nm is delivered deeply into the skin to target vessels lying in the deeper dermis.

Energy from the laser is absorbed by the vessels and the haemoglobin therein and causes a reaction, usually either intravascular coagulation or collapsing of the vessel wall by damaging the endothelial lining.5 In either case, the damaged veins are gradually dissolved and removed by the body’s immune system over several weeks after treatment, during a process called phagocytosis.6 The Nd:YAG laser in my clinic effectively treats facial thread veins in one to three treatments sessions, lasting approximately five to 15 minutes, with treatments spaced at six to eight week intervals. The treatment sensation is hot, however this is reduced by epidermal cooling, delivered with a cryogen device built into the laser I use.

Freezing cryogen gas is delivered onto the treatment area and can be controlled by three parameters: how long to freeze for (in milliseconds), the delay between the cryogen delivery and the laser beam delivery (again milliseconds) and how long to freeze after the laser beam delivery (also in milliseconds). This effectively cools and protects the epidermis and reduces the risk of thermal damage and scarring. With Nd:YAG laser therapy, the thread veins are immediately less visible than before treatment. There may be some skin reaction in the form of intravascular coagulation, which appears as a grey-hued tiny bruise on some larger vessels, particularly around the nose.

Other acceptable clinical end points include vasospasm, vessel swelling and ‘sticky’ vessels, which are caused by the microscopic damage to the endothelial cells of the vessel walls, causing them to collapse and then ‘stick’ together, preventing further blood flow through the vessels.7 The latter is probably the best clinical endpoint in my opinion, and when tested with a blanche test, these vessels will not refill and an excellent outcome can usually be predicted. From my extensive experience in treating thread veins, normal sequelae of treatment include erythema, oedema and occasional micro-crusting.

These side effects usually disappear after 24-48 hours, but can occasionally last up to seven days.

Complications of laser therapy using Nd:YAG lasers In general, and in experienced hands, laser therapy is safe and effective. Complications

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Before

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Figure 2: Facial thread veins treated with Nd:YAG laser in my clinic and the results after just one session. Treatment parameters were: 1064nm, 1.5mm spot size, 40ms pulse duration and fluence of 360J/cm.2 Cryogen cooling was delivered at 10ms pre spray, 20ms delivery delay and 10ms post spray.

Figure 3: Treating a patient for thread veins using Nd:YAG laser

do sometimes occur but the risk of scarring is very low due to the sparing of surrounding tissues.2 Overtreatment indicators are usually seen as: • • • • •

Blistering Pain Whitening of skin or vessels Indentations ‘Popping’ of blood vessels during treatment

A common error when administering laser treatment for facial thread veins is the incorrect selection of which laser parameter to alter first. It is often believed that increasing the fluence is the best approach when a clinical endpoint is not achieved. Unfortunately, this usually leads to thermal damage of the treated area and non-selective damage to tissues and, thus, increases the risk of scarring.2 When treating facial thread veins with Nd:YAG laser, the first parameter to alter when clinical endpoints are not achieved is the pulse duration. Larger blood vessels will require heating for longer than smaller

ones and when the correct pulse duration is used, selective damage will occur.

Because larger objects and structures take longer to cool down than smaller ones with a smaller surface area, larger blood vessels take longer to cool down than smaller ones. Therefore, a longer pulse duration would be selected for wider vessels and a shorter pulse duration for narrower ones.

Using pulse durations that are too short can cause unwanted side effects and carry more risk. A fixed fluence of energy is being delivered over a fixed period of time. If this energy is delivered over a short period of time, e.g. pulse duration 3ms, it comes as a short, strong pulse.

However, if this energy is delivered over a longer period such as 30-60ms, it is more gently delivered. It can be confusing to think of pulse duration as being ‘stronger’ when the number is higher but, in fact, it should be considered as gently ‘simmering’ the target with the same energy, just over a longer period of time, rather than delivering a short burst of energy in a short time. The safest way to

The damaged veins are gradually dissolved and removed by the body’s immune system over several weeks after treatment, during a process called phagocytosis

treat is to adjust the pulse duration first, until a desired endpoint is seen. Only then should the fluence be increased in stages until either intravascular coagulation, or ‘sticky’ vessels are seen.

Conclusion Facial thread veins can be safely and effectively treated using Nd:YAG laser therapy. The treatment is cost effective as, in my experience, it usually takes under three sessions to clear most unwanted veins.

The incidence of recurrence is low with this treatment and side effects are minimal.

Mary White has been an aesthetic nurse since 1993 and specialises in dermatology laser treatments and aesthetic injectable treatments. Mary owns and runs a busy full time CQC Registered aesthetic clinic in Worcestershire and is passionate about providing an environment of clinical excellence for her patients.

REFERENCES 1. Lanigan, S.W, (2000) Lasers in Dermatology, Springer-Verlag Ltd, pp.2-8 2. Anderson RR, Parrish JA, (1983) Selective Photothermolysis: Precise microsurgery by selective absorption of pulse irradiation, Science 220, pp.524-527 3. Randeberg L, Daae Hagen A., Svaasand L, (2002) ‘Optical Properties of Human Blood as a function of temperature’, Lasers in Surgery: Advanced Characterization, Therapeutics and Systems XII, pp.20-28.

4. Kauvar, A. & Hruza G, (2005) 5. DermNet, (2014) Nd:YAG laser treatment http://www.dermnetnz. org/procedures/nd-yag-laser.html 6. Britannica, (2015) Phagocytosis, http://www.britannica.com/ science/phagocytosis 7. Dover, J.S, Sadik, N.S, Goldman MP, (1999) The role of laser and light sources in the treatment of leg veins, Dermatol Surg, 25:328-336 8. Stearn, M. Tread veins, Embarrassing Problems, <http://www. embarrassingproblems.com/problem/thread-veins>

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Cholesterol – the new ‘wonder’ ingredient for mature skin?

Leading Washington DC-based dermatologist and cosmetic surgeon, Dr Hema Sundaram, unveils the latest research insights for mature skincare, and how this has underpinned the development of Triple Lipid Restore 2:4:2 – the latest addition to SkinCeuticals’ Correct range.

We know that older skin has different physiological needs versus young skin, but what are these exactly?

When skin is young and healthy, it’s in perfect balance – there is a constant turnover of the structural components. The rate of cellular breakdown is equal to the rate of regeneration and, most importantly, the barrier function is intact.

However, as we age, the degradation cycle outweighs the skin’s ability to form essential components - in particular, lipids such as ceramides and cholesterol leading to disrupted barrier function and increased trans-epidermal water loss (TEWL). Research from dry skin conditions such as atopic dermatitis has shown that ceramide deficiency is a core, underlying factor in these conditions and, as a result, topical formulations for dry skin and ageing skin are primarily ceramide-dominant.

However, our latest research shows that it is in fact cholesterol deficiency that plays the most significant role in ageing skin. Triple Lipid Restore 2:4:2 is the first product to have a cholesterol-dominant formula specifically tailored to restore the exact ratio of lipids that are deficient in chronologically aged skin. I believe this will be a complete game-changer for skin specialists and their patients.

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What is the connection between lipid loss and accelerated ageing? What does this look like for the patient?

Aged skin is chronically water-deprived and unable to protect itself due to the loss of lipid protection. Associated barrier abnormalities result in skin becoming more vulnerable against external aggressors and irritants, causing effects such as reduced desquamation. This results in uneven texture and dry patches; weakening of the skin barrier integrity that is required for ongoing self-repair; and lower levels of moisture, which is required for healthy skin fullness. Patients notice that their skin is dull, rough, and uncomfortably tight, with a loss of firmness and radiance.

2

What is Triple Lipid 2:4:2 and how is it different to other mature skin creams?

Triple Lipid is a unique anti-ageing lipid replenishment cream to address the specific challenges of accelerated ageing and skin barrier repair. It is founded on SkinCeuticals’ two-year research programme, in which I was honoured to be directly involved, highlighting the role of cholesterol to accelerate barrier recovery.

Triple Lipid Restore 2:4:2 is the first and only cosmeceutical product to combine a proprietary ratio of lipids in a maximised concentration of 2% ceramides, 4% cholesterol and 2% omega-fatty acids. This specialised ingredient combination is designed to restore healthy skin function and self-repair by replenishing the essential skin lipid ratio, as well as restoring natural hydration and skin barrier function. With its lightweight and fast-absorbing texture, this cosmetically elegant

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cream is scientifically proven to stimulate lipid replenishment, barrier protection, hydration and repair ageing or dry skin.

What have been the clinical results?

Our eight-week clinical study demonstrated statistically significant improvements in the key signs of accelerated ageing, such as skin clarity, evenness, radiance, smoothness, laxity, and pore appearance (p<0.05). Treatment with Triple Lipid Restore 2:4:2 more than doubled levels of ceramides (57%) and cholesterol (52%) after eight weeks, refilling those essential lipids in the skin. The skin barrier was restored, with a 39% improvement in hydration after just 24 hours, and eight times faster barrier recovery following an external injury (tape stripping). Barrier quality was also improved, shown by a doubling of mature corneocytes, thus reducing susceptibility to external aggressors.

4

How can Triple Lipid Restore 2:4:2 be integrated within clinical practice?

As clinicians, we’re evolving towards patient-tailored treatments – this is what we’re looking to deliver in our practices through a combination of products, treatments and procedures. Skin ageing is multifactorial and multi-level, so it makes sense to address this with a variety of topical actives and procedures.

However, a pre-requisite for the most successful outcomes from these procedures and from topical treatments is a fully-functioning skin barrier. If the barrier is compromised, we’re not going to get the results we’re looking for– no matter the quality of the other treatments we’re offering. Triple Lipid Restore 2:4:2 therefore forms the foundation or cornerstone of our patients’ skincare. Once we’ve repaired the skin barrier function, we can layer all the other treatment benefits on top.

5

Triple Lipid Restore 2:4:2 from SkinCeuticals.

Available Nationwide.

• TRL242 Retail size 48ml | Trade Price: £51.25 • TRL242 PRO size 120ml | Trade Price: £65

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A summary of the latest clinical studies Title: The long-term effect of 1550nm erbium:glass fractional laser in acne vulgaris Authors: Liu Y, Zeng W, Hu D, Jha S, Ge Q, Geng S, Xiao S, Hu G, Wang X Published: Lasers Medical Science, January 2016 Keywords: Fractional laser, acne, laser, lesions Abstract: We evaluated the short-term and long-term effects of the 1550nm erbium:glass (Er:glass) fractional laser in the treatment of facial acne vulgaris. Forty-five (9 male and 36 female) acne patients were treated 4 times at 4-week intervals with the following parameters: 169 spot density and 15-30mJ/cm(2) fluence. There was no control group. The laser spots were adjustable (maximum overlap: 20 %) according to the treatment area, and delivered in rows in order to cover all the face. The IGA scores and lesion counts were performed for each treatment. Their current state was obtained by phone call follow-up to determine the long-term effect and photographs were offered by themselves or taken in hospital.

After four treatments, all patients had an obvious reduction of lesion counts and IGA score and the peak lesion counts decreased to 67.7% after the initial four treatment sessions. For long-term effect, 8 patients lost follow-up, hence 37 patients were followed-up.

8 patients were 2-year follow up, 27 at the 1-year follow-up, and all patients at the half-year follow-up. The mean percent reduction was 72% at the half-year follow-up, 79% at the 1-year follow-up and 75% at the 2-year follow-up. All patients responded that their skin was less prone to oiliness. In conclusion, acne can be successfully treated by 1550nm Er:glass fractional laser, with few side effects and prolonged acne clearing.

Title: Combined autologous platelet-rich plasma with microneedling verses microneedling with distilled water in the treatment of atrophic acne scars: a concurrent split-face study Authors: Asif M, Kanodia S, Singh K Published: Journal of Cosmetic Dermatology, January 2016 Keywords: Acne, scar, plasma, microneedling, injections, distilled water Abstract: Acne scarring causes cosmetic discomfort, depression, low self-esteem and reduced quality of life. Microneedling is an established treatment for scars, although the efficacy of plateletrich plasma (PRP) has not been explored much. The objective of this study was to evaluate the efficacy and safety of platelet-rich plasma (PRP) combined with microneedling for the treatment of atrophic acne scars. Fifty patients of 17-32 years of age with atrophic acne scars were enrolled. Microneedling was performed on both halves of the face. Intradermal injections as well as topical application of PRP was given on the right half of the face, while the left half of the face was treated with intradermal administration of distilled water. Right and left halves showed 62.20% and 45.84% improvement, respectively, on Goodman’s Quantitative scale.

Goodman’s Qualitative scale showed excellent response in 20 (40%) patients and good response in 30 (60%) patients over right half of the face, while the left half of the face showed excellent response in 5 (10%) patients, good response in 42 (6%) patients and poor response in three patients. We conclude that PRP has efficacy in the management of atrophic acne scars. It can be combined with microneedling to enhance the final clinical outcomes in comparison with microneedling alone.

Title: Perioral wrinkles are associated with female gender, aging, and smoking: Development of a gender-specific photonumeric scale Authors: Chien AL, Qi J, Cheng N, Do TT, Mesfin M, Egbers R, Xie W, Chow C, Chubb H, Sachs D, Voorhees J, Kang S Published: Journal of the American Academy of Dermatology, January 2016 Keywords: Wrinkles, photonumeric scale, photoageing Abstract: Perioral wrinkling is commonly reported among older adults, but its objective evaluation and causes remain poorly understood. We sought to develop a photonumeric scale for perioral wrinkling and to elucidate contributory lifestyle factors.

In this cross-sectional study, we recruited participants for facial photographs and a survey. A gender-specific photonumeric scale for perioral wrinkling was developed and used by 3 graders to evaluate participant photographs. Scores and survey responses were used to create a multiple regression model to predict perioral wrinkling.

In all, 143 participants aged 21 to 91 years were enrolled. Intraclass correlation coefficient values for interrater and intrarater reliability were high (>0.8) across 2 trials and 3 graders. A multiple regression model for prediction of perioral wrinkling severity included age, gender, and years of smoking as variables. The study was limited by sample size and a predominantly Caucasian study population. We created a photonumeric scale that accounts for gender differences in perioral wrinkling and highlighted contributory variables to photoaging in this anatomical location.

Title: Target-oriented therapy: Emerging drugs for atopic dermatitis Authors: Lauffer F, Ring J Published: Expert Opinion on Emerging Drugs, January 2016 Keywords: Dermatitis, eczema, atopic dermatitis, skin disease Abstract: Atopic dermatitis (AD) is a chronic inflammatory skin disease with a life-time prevalence of 10-20% in western countries. Patients suffer from stigmatizing eczematous skin lesions, persisting itch and sleep disorders. Starting usually in early childhood the course of AD is heterogeneous. While most frequently AD disappears before adolescence, about 30% of patients show a chronic persisting course. There is an urgent need for new therapeutic options as until now, specific drugs are missing. Areas covered: Over the last years research has made enormous progress in understanding mechanisms involved in AD pathogenesis. Th2 cells and their key cytokines IL-4 and IL-13 as well as TSLP, CRTH2 and IgE are targets for new compounds currently being tested in clinical trials. This review highlights new drugs for AD at all stages of development as well as current promising scientific approaches. Expert opinion: After decades of silence the market for AD drugs has recently become highly active. Amongst all new compounds, dupilumab – an antibody directed against IL-4 and IL-13 receptors – is the most advanced candidate showing convincing efficacy in several phase III studies.

The availability of specific drugs for AD will open up a new era in dermatological therapy.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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blogger likes what you do, they could tell their 50,000 followers that your product or service is simply the best, dramatically increasing the chance of a referral.

Often, mainstream media will follow these bloggers, meaning your blogger may also be able to open an Aladdin’s cave of opportunities. She or he may tell all their followers about you, and then the high street glossy magazines may pick it up, further building the publicity trail. In my opinion, word-of-mouth endorsement is far more powerful than advertising. An endorsement from a blogger or the media is a third party, without an agenda, vocalising that your business is the best at what you do.

How do I find a blogger?

The Benefits of Bloggers PR consultant Mike Nolan shares advice on how aesthetic professionals can build successful relationships with bloggers to improve their online marketing and increase their customer base A decade ago, barely anyone knew what a blogger was. Thanks to the great tidal wave of digital communication in recent years, however, these ‘internet writers’, for want of a better term, have become an integral part of modern communication.

Working in public relations (PR), I now recommend that most of my clients make blogger outreach an essential part of their marketing plan. I also advise that for certain industries, in particular aesthetics, clients do their utmost to look for what I call the ‘professional bloggers’, and go out of their way to ‘make friends’ with them. In my opinion, this might be the wisest marketing decision they will ever make.

Why use bloggers?

Certainly in the beauty and aesthetics industry, bloggers have a very loyal following, so getting to know them could be hugely beneficial for increasing your patient base and future business development.

The best bloggers can have millions of followers and be extremely influential people.

For example, 25-year-old Zoella has more than 10 million YouTube followers1 and, while some adults may not have heard of her, my 11-year-old daughter will listen to Zoella more than she will her mother.

Zoella is certainly one of the UK’s blogging stars and, while getting her on board would now likely be a big ask, consider if you got hold of her four years ago – where would someone with Zoella’s reach and influence have taken your business?

It used to be the case that magazines, newspapers and the rest of traditional media held the key to the best PR opportunities, however bloggers are now considered as valuable as some of the best beauty magazines in terms of sharing powerful endorsements. I believe this is evident by the sheer number of followers they have.2 As most business owners know, the best way to find new customers is through a recommendation. That recommendation could be from Patient A, who was so delighted with her treatment results at your clinic that she tells her best friend, Patient B, who in turn gets in touch with you and books an appointment. If a popular beauty

The savviest businesses are increasingly recognising the important role that bloggers can play in their marketing plan. But who are these bloggers, and how do you reach them? Bloggers are often a PR professional, journalist, photographer, videographer, search engine expert and social media specialist all rolled into one. Luckily for you, finding bloggers is relatively easy. If your budget is limited, then the first port of call should be Google.

It’s free and it’s easy to use. For example, put in your search term, ‘beauty bloggers’ and see what comes up. Generally, somebody will have pulled together a list of the best beauty bloggers and, very helpfully, will often rate them for you, so you can see instantly which blogger would be most appropriate for your business growth goals.

One such website, Blow Ltd, lists the 27 most powerful beauty bloggers in the UK and, while the stats presented are a year old, it gives you a good idea of how many followers a blogger can reach.2 If you don’t have time to search through Google listings, you can take some shortcuts. Two of my favourite tools are Buzzsumo3 and Authority Spy.4 Buzzsumo is a great platform for discovering interesting content and finding those influential bloggers who are hopefully going to talk about your clinic. You can search based on topics/keywords or Twitter usernames, filter by type of user (e.g. bloggers, influencers, journalists) and then sort your results by various metrics. Usefully, it can also help you identify which posts are getting the most shares for your competitors. Buzzsumo allows a free trial, but then depending on the amount of use, starts at £55 per month.

Authority Spy is a simple and easy to use influencer research tool that also has helpful features for those starting out, and, if you are feeling creative, you can also source guest blogging opportunities. Simply enter a search term and the system does the rest, pulling together hundreds of influential bloggers in a matter of seconds. Once you have reviewed the results, the platform provides a direct link to their social media profiles, so it’s easy to access your potential bloggers. This service starts at around £20 for a basic package.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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with any business clients, the most important thing is to treat them with respect and this will likely be reciprocated.

If a popular beauty blogger likes what you do, they could tell their 50,000 followers that your product or service is simply the best, dramatically increasing the chance of a referral Working with bloggers Once you find the kind of bloggers that you want to make contact with, spend some time exploring the content of their blog posts and make sure that their audience and your target market are in harmony. Bear in mind, that when it comes to a blog audience, bigger isn’t always better. It’s better to go where there’s a small audience who may be your exact target market. For example, if you’re trying to promote your post-pregnancy weight loss treatment, telling an audience of teenage girls seeking acne treatments won’t have much of an impact.

Some bloggers have a PR page, which means they are interested in partnering with brands and will be open to you contacting them.

When making contact, the first thing to remember is that they are human just like me and you, and most respond positively to the personal bespoke approach, so no bulk emailing! Ensure you have done your research and understand what your potential blogger is interested in, then tell them a little bit about your business and how you could work together.

It’s not easy capturing the attention of the right kind of bloggers, and all blogs are not equal. Some blogs might look the part, however they may not have a great following. This means that even if the blogger agrees to talk about you, enough of, or even the right people may not hear the messages they subsequently share. Ensure you have thoroughly researched not only the blogger’s blog, but also their social media accounts and the responses from their followers to the content they share. Important questions to ask include: • How often do they post online?

• What social networks do they use?

• Can they present any audience data such as average age, sex and location?

You should then consider whether the responses are in-line with your needs and appropriate to the audience you are trying to attract. If, for some reason, you don’t feel that a relationship will work after you’ve approached a blogger, don’t be afraid to walk away. Be aware, however, that if you treat bloggers with disregard, there is a chance that they won’t be slow in telling their audience, which could negatively impact on your business. Remember, as

Payment It may also be advisable to offer bloggers some kind of compensation for helping promote your product or service. Newer bloggers who are hoping to make a name for themselves may be willing to help promote your products or services in exchange for free products to review, or a ‘shout out’ via your social media channels. While these emerging bloggers do not necessarily rely on their blog as their main income, it doesn’t mean they shouldn’t be compensated for the value that they can offer your brand.

With established bloggers, who produce blogs for a living, you should ensure that you offer them a fair rate of compensation. If the rates aren’t clear from the blogger’s media kit, which is usually on their website, ask about this. Many bloggers will have rates for working with brands, but are usually open to negotiation depending on the project. They may also be open to ‘payment’ in the form of products or services – this is a case of common sense – only do something that you feel is right and at all times bear in mind that this, like all relationships is about nurturing and trust.

Content Be specific about your campaign goals and let the blogger know what these are. It is important, however, that you are not controlling what the blogger can and can’t do. Bloggers are usually very creative people and could dream up better promotional ideas than you would have ever thought of. The promotional formats that bloggers are now using are wide-ranging and may include, amongst others, written blogs, videos, photography, graphic design and social media. Let the blogger feel free to decide how they communicate with their audience.

Conclusion Hopefully this article has equipped you with the knowledge to approach bloggers with confidence and got you excited to explore this particular form of digital marketing further. If you’re still a little hesitant then talk to a media professional who should be able to help point you in the right direction and find appropriate bloggers for you. Remember, just as you would in other business arrangements, if you like how the blogger has worked, show your appreciation. If you nurture the relationship, the blogger will, in all likelihood, become a brand advocate and keep promoting your business, even if you aren’t passing money to them. And remember, bloggers are the new stars of the digital age, so embrace them – they aren’t about to go anywhere soon.

Mike Nolan has been involved in PR for more than a decade and is the founder and director of Nolan PR. Since he started his company in 2009 he has helped a broad range of clients from many industries design and implement successful social media marketing campaigns. Nolan also has news editing and journalistic experience at a daily newspaper.

REFERENCES 1. Zoella, (UK, YouTube, 2016) <https://www.youtube.com/user/zoella280390?feature=mhee> 2. Emma Cooke, 27 Most Powerful Beauty Bloggers (UK, Blow Ltd, 2015) <http://www.blowltd.com/ magazine/magazine/27-most-powerful-uk-beauty-bloggers-weve-crunched-the-numbers.html#.

VqfP-PmLTIU> 3. Buzzsumo (2016) <http://buzzsumo.com/> 4. Authority Spy (2016) <http://authorityspy.com>

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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The Big Brand Theory Aesthetic business founder Roydon Cowley discusses branding strategies and how you can separate yourself from the competition As small business owners, our expertise will often lie in only a few specific areas of our business’s total operational requirements. As an aesthetic practice/clinic owner, this is likely to be the hands-on element and day-to-day running of the clinic and treatment application. The thought of accounting, legal requirements and other peripheral duties can fill some business owners with dread. These individuals may choose to delegate these responsibilities to qualified third parties, however there is a risk they might totally neglect these areas of running a business. From my experience of working with aesthetic businesses, I have noticed that branding is one of the areas that is often significantly lacking. Have you considered the importance and relevance of branding when planning your business strategy?

When discussing my brand I am often told how lucky I am, as if it has in some way stumbled into success. I generally answer, “Yes it’s strange, the harder I work the luckier I seem to become!” In truth, using many years of experience, good and bad, my brand was more likely to succeed from day one as I had a very specific plan and branding strategy. It is this I would like to share with you, as I believe it can be applied to significantly improve any company’s performance in the increasingly competitive market of aesthetics.

What is branding?

Firstly, we need to appreciate what branding is and why it is so important to our businesses. Branding goes way beyond just a logo or graphic element. When you think about your brand, you really need to think about your entire customer experience. This is everything from your logo, website, social media experiences and treatments, to the way you answer the phone, and the way your customers experience your staff. When you look at this broad definition of branding, it can be overwhelming to think about. In short, however, your brand is the way that your customer perceives you. It is critical to be aware of your brand experience and have a plan to create the experience that you want to allow your customers/ patients to have – a good brand doesn’t just happen – it is a well thought out and strategic plan. Many small organisations and startups neglect spending necessary time thinking about their brand in this broad sense, as well as the impact it has on their business.

10 reasons why focusing on your brand is important: 1. Promotes recognition 2. Sets you apart from the competition 3. Tells people about your business ‘DNA’ 4. Provides motivation, structure and direction for your staff 5. Generates referrals as customers love to tell others about brands they like 6. Helps customers know what to expect 7. Represents you and your promise to your customer 8. Helps you to create clarity and stay focused 9. Helps you to connect with your customers emotionally 10. Provides your business with value

All of the above is relatively basic stuff when assessing how important branding is and what I would regard as the solid foundations of any strategy. The best branding is built on a strong idea; one which you and your staff can hold on to, commit to, and deliver upon.

More importantly, you need to be different if you want to swim alone in the big blue ocean!

Blue Ocean vs. Red Ocean strategy In business, we use the ‘Blue Ocean’ and ‘Red Ocean’ strategies, which are analogies that define what sort of market you are in. The ‘Red Ocean’ represents all of the industries in existence today – the known market space. In this ocean, boundaries are defined and accepted and the competitive rules of the game are well known. Here, companies try to outperform their rivals to achieve a greater share of the product or service demand or, as this space becomes more crowded, prospects for profits and growth are reduced through price wars. A product becomes a simple commodity, and cutthroat competition turns the ocean bloody; hence, the term ‘Red Ocean’.1,2 Our ‘Red Ocean’ is the business of aesthetics, which we all know is becoming a more crowded space with plenty of sharks circling in the bloodied waters. ‘Blue Ocean’ on the other hand, is defined in contrast of the industries not in existence today – the unknown market space, untainted by competition.1,2 In the ‘Blue Ocean’, competition is irrelevant because the rules of the game are yet to be set. ‘Blue Ocean’ is an analogy to describe the wider, deeper potential of a market space that is not yet explored and where you swim alone (Figure 1).2 How to use the ‘Blue Ocean’ strategy So what is the relevance of this strategy and how can you benefit from it? As an aesthetic practice, you are likely to have a price list of services that is accepted as standard within the industry. This positions you firmly in the ‘Red Ocean’, swimming with the rest of the sharks and fighting for market share in an increasingly competitive environment. I am making the assumption that you are striving to be the best and have already looked at some or all of the 10 reasons why focussing on your brand is important; making a concerted effort to implement these ideas in your practice. You might also have stunning premises, excellent techniques and treatments and other successful elements of

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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means you are non-comparable to the high street and seek to make the competition irrelevant. You need to create and capture new demand and break the value to cost trade off – meaning that differentiation AND low cost should be persued simultaneously to create a ‘Blue Ocean’ instead of differentiation OR low cost.

You too can create bespoke treatments that not only Create uncontested market space Compete in existing market space improve your patient’s outcomes, but also make you Beat the competition Make the competition irrelevant non-comparable to your direct competitors.

You are the expert in your field and through research of Exploit existing demand Create and capture new demand the excellent devices and products now available, you Make the value-cost trade off Break the value-cost trade off are best positioned to create the best treatments, for a Align the whole system of a firm’s Align the whole system of a firms variety of indications. activities with it’s startegic choice activities in pursuit of differentiation As an example, your antiageing facial might be of differentitation or low cost and low cost microdermabrasion layered with radiofrequency “Defend Current Position” “Innovate & Pursue New Opportunities” and LED, combined with peels following a course of Perspective Perspective treatments. For a more curative approach your package Figure 1: Blue Ocean vs. Red Ocean.2 may include dermal fillers and/or botulinum toxin. your aesthetic practice, which puts you in good stead against your You could create a programme/course and give it a name such as competition. However, I guarantee that your price list will be full of the ‘Hollywood Bespoke Facial’ and, once you have decided upon services that can be compared to your competitors, and decisions to a brand name and direction, market it effectively to demonstrate come to your clinic could be made purely on price before a patient how unique and ground-breaking it is. Alternatively, you might want even comes through your door. to brand it in your name to promote your innovation, such as ‘The Dr Jones Age Defying Facial’. Like me, you will get a great deal of Finding my ‘Blue Ocean’ enjoyment out of creating your treatments and a lot of pride whilst For many years I chased the next technology trend as a distributor. selling them. No longer are you that clinic selling a generic treatment, I had to fight for a sale based on why ours was better than but a passionate individual and bespoke organisation that spreads the another’s and, in some instances, it wasn’t. I even instigated a huge word about their differences, not their similarities to others.

PR campaign to support one of our brands, which worked well but Some good examples of those who have adopted this strategy are, created a popular platform for others to jump onto. Not only will the ‘60 Minute Bespoke Facial’ by Antonia Burrell Holistic Skincare, other companies follow your lead, they might actually do a better the ‘Made To Measure Facial’ by Anne Semonin and the ‘Dr Leah job or sell the product or service at a better price. I didn’t realise it Bespoke Facial’ by Dr Leah Totton. These are great examples of at the time but I was drowning in the ‘Red Ocean’ with a group of individuals who stand alone with their strategy and whose services sharks circling in anticipation. cannot be compared to others. Many create bespoke facials that are Learning from these lessons, I set out to do something fundamentally tailored to the individual patient’s needs. Not only does the patient feel different. My passion is for the development of effective non-surgical special – they cannot compare this service to any other provider. technology for the face and body. Over the years, I realised that no The final point is that you align the whole system of your company’s one technology or trend treats all indications for the face or body. activities in pursuit of promoting these differences. Ways to achieve Therefore, I developed multi-technology affordable devices, aiming this could include celebrity PR campaigns, local editorial coverage to give the best possible patient outcomes on the face and body. through editors and journalists experiencing your unique offering, This philosophy was to treat the whole problem by adopting a threesocial media and advertising. Sometimes it is really effective if you dimensional approach to treat fat removal, tighten skin and improve seek individuals or personalities who have large social media or blog cellulite, hence the name of the company. We strongly market this following to spread the word. Diving into the ‘Blue Ocean’ is much philosophy ensuring that only my company and clients benefit from more rewarding than simply selling what everyone else is selling or our specific treatments and services. relying on short-lived trends to boost your income; I urge you to give This approach has also worked for some of the most respected it a try. brands like Bloomberg Business, Canon, and Apple.2 Apple created Roydon Cowley is the founder and managing future profits and growth not by exploiting existing demand, but by director of 3D-lipo Ltd and he has been involved in reconstructing industry boundaries to create new market space the beauty/aesthetics industry for the past 25 years.

After seeing a gap in the market, he established his and unlock latent demand. As a result, the company’s value grew own manufacturing company specialising in multiexponentially as the total market value of a firm reflects not only technology platform devices and developed his company through today’s performance but also its future profitability. Apple adopted powerful branding and marketing campaigns. a number of blue ocean strategic moves that transformed the REFERENCES company from a computer manufacturer into a consumer electronics 1. Chan Kim W & Mauborgne R, ‘Blue Ocean Strategy: How to Create Uncontested Market Space and 3 powerhouse. This philosophy can work for you too.

Make the Competition Irrelevant, (Harvard Business Review Press; Expanded edition 2015), <http:// How to find your own ‘Blue Ocean’ In this increasingly competitive environment, as a business, you now have to be smart in order to win. As the saying goes, ‘work smarter not harder’. You need to stand alone; create a business strategy that

thepersonalcoach.ca/userContent/documents/BookReport,BlueOceanStrategy.pdf> 2. What is Blue Ocean Strategy, (2015), <https://www.blueoceanstrategy.com/what-is-blue-ocean-strategy/> 3. Blue Ocean Strategic Moves, (2015), <https://www.blueoceanstrategy.com/bos-moves/> 4. Chan Kim W, Mauborgne R & Oh Young Ko, How Apple’s Corporate Strategy Drove High Growth, (2015) <https://www.blueoceanstrategy.com/teaching-materials/apple/>

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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reputation may significantly suffer now, as Google displays this bad review and negative rating prominently in its search results.

Google, of course, is left unscathed. The fate of the clinic has no bearing on Google’s success. Google is constantly looking for ways to enhance the ‘user’ experience (that’s the ‘user’ experience and not your clinic’s bottom line). Its mission is to understand exactly what its users are searching for, and return exactly what they are looking for. Today, when someone searches for a clinic, Google knows that person probably wants to find the most trusted and reliable clinic in their area. They want to know they will be in safe hands and they want to feel confident that their results will be excellent. In most cases, this matters even more than cost.

How Google influences new patients PR and reputation management consultant Jay Cruiz discusses Google’s impact on your clinic’s reputation and offers advice on how to successfully manage online reviews For the better part of a decade, leveraging Google’s search engine has been a very effective way to market a clinic and bring in a wealth of new patients. Unfortunately, some of Google’s recent innovations can hurt the reputation of many clinics. Google is now one of the primary determinants of your clinic’s overall reputation – and the way you manage your online reputation determines whether this is good news, or bad news, for your clinic.

Your clients are likely to use Google Google is the internet’s leading search engine and the world’s most visited website, equating to around two fifths of the world’s internet traffic, beyond sites like YouTube and even Facebook. In fact, in 2013 when Google went down for just two-to-five minutes; worldwide internet traffic plummeted by approximately 40%.2 In the modern era, when someone is considering an aesthetic treatment or procedure, they will usually open their computer or tap on their smart phones, searching for the best clinic in their area. Nine times out of 10 they are using Google,3 because people TRUST Google.

Google doesn’t consider your business Imagine a clinic that’s extremely well trusted and adored by its patients. It has a gorgeous website, professionally created and presented. The staff are efficient, friendly and great at what they do, however, they never encouraged their patients to rate and review the clinic online. Then one day, this stellar clinic treats a person who is just having a bad day. A horrible day in fact, not to mention that they are a rather ‘difficult’ patient at the best of times. The clinic may have fallen temporarily short of their usual standard (perhaps through no fault of their own). Regardless, the patient, in a rage, decides to log in to their favourite review site and display their dissatisfaction online. Consequently, this otherwise excellent clinic is now represented entirely by that single negative review online. The clinic now appears to be one of the worst rated in the region. The clinic’s

The effect of Google reviews Google is often where your clinic makes its first impression online, and with a competing clinic just pixels away, your first impression really counts. To provide the user with a better experience and ‘return exactly what they are looking for,’ Google now gathers reviews, star ratings and testimonials from past patients across the web. In Google Maps and local results, for example, they will prominently display reviews submitted by people via their own Google accounts. Anyone can leave reviews this way and Google prompts its users to do so. In regular Google Search results, Google gives these reviews priority placement and it will then also show the average rating, right there in the results, individually from other sites that use rating schema. These sites include Yelp, Facebook Pages, GlassDoor.com and many others. When people search for your clinic, they may well also add the word ‘review’ to the search to see what other people say about you as demonstrated by Google Suggest. These eye-catching features draw the user’s attention and often supersede the regular search results, in terms of user focus.

So it’s now the clinic with the ‘5-star reputation’ winning the business.

A clinic with no reviews also has no positive feedback to reassure potential clients. Consequentially, if your online reputation is not carefully managed, one bad review can destroy your chances of bringing in new patients via the internet, since there is no buffer or counterpoint. More than ever, people are looking to Google to help them choose a clinic. That one star rating could mean all your other investment in marketing and promotion, print ads, radio spots etc. are severely hindered.

The 5-star reputation and your clinic A 5-star reputation is the gold standard of trust and credibility online and encourages new and potential patients to choose your clinic over another. No matter how far technology develops, social proof is likely to always be one of the primary deciding factors as to whether a patient chooses one clinic over another. If enough people say Clinic B is better than Clinic A, with all other factors being equal, Clinic B gets the business. If your aim is to leverage the internet to attract new patients, your focus should be on forging a 5-star reputation for them to clearly see when searching online for aesthetic treatment.

Priming: the deciding factor you can control There is a psychological concept known as ‘priming’, whereby a person’s pre-conceived expectations ‘prime’ them either positively or negatively, towards how they ultimately feel about a given experience.

One of the best examples of ‘perception dictating experience’ is wine tasting – and how if a person expects a wine to taste better... the wine tastes better to them.4 This explains why a bad review has such a severe knock-on effect for the rest of your potential patients.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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Negative priming occurs when a person is influenced to expect bad things.5 This tends to occur when reading a critical review online, for example. A negatively primed patient is far more attuned to ‘nitpicking’.

They are on the lookout for things that bother them, inconvenience them, or could be done better. Bad reviews online ‘negatively prime’ as much as 50-75% of potential patients.6 Conversely, positive priming occurs when a person is influenced to expect good things. 7 When a person expects good things, they pay more attention to the things they like and enjoy. This is where their mind is focused, so any mild negatives tend to be marginalised or ignored completely. For these reasons, online reputation management should form a critical part of your overall marketing strategy. Akin to ‘confirmation bias’, people pay far more attention to evidence that confirms their perspective as being correct, while more readily ignoring evidence that challenges their perspective and proving them to be misguided or completely wrong.8 As such, no matter how many reviews you may currently have, managing your online reputation is critical for minimising damage caused by bad reviews.

Of course, creating a 5-star reputation can actually have the reverse effect, in that more patients will seek you out, tell their friends, be primed to enjoy a more positive experience, leave better reviews AND spend more with you in the future through follow up treatments – not to mention referral business!

Putting your clinic on the map Another innovation of Google’s has been the inclusion of ‘Google Maps’ in the search results as well as the coinciding star ratings and reviews. It takes up a lot of space on the results page too, so your appearance here (or lack thereof) has an exponentially greater impact. This is yet another instance where you can display and benefit from a strong 5-star reputation, or suffer and become crippled by a scathing one star review. The fact is, most people nowadays find a clinic by using Google Maps9,10 and pay attention to the reviews that appear alongside the map and location points.

This makes your presence in Google Maps and your clinic’s reviews exponentially more important. There are three major factors to focus on when improving your Google Maps presence: • Address and telephone number citations • Review generation and management • Mobile friendly websites These elements have the biggest impact11 and mobile optimisation is especially important, because Google has actually gone as far to tell its human website analysts to rate any web page, which is not ‘mobile-friendly’12 (i.e. a page that becomes unusable on a mobile device) with the lowest rating. Simply having a mobile version of your site does not make it mobile-friendly. A ‘mobile site’ allows you to access the site on a smartphone without having to view it like a normal website which helps usability as it prevents the need of zooming in. A ‘mobile friendly’ site however, is designed to give the best and easiest user experience while getting more people to contact the business by providing a contact number, easy review system and location map.

Never fake it ‘til you make it’ Most clinics already understand the gravity and opportunity that goes with having a solid reputation. Unfortunately, some clinics (or the marketing companies they employ) also opt to take shortcuts, which only serve to hurt them in the long run. For some, the temptation is

Aesthetics

there to implement ‘fake’ reviews. Forget about the penalties your site eventually receives from Google, this can land you in serious legal trouble as well,13 and nothing hurts your reputation quite like a court hearing. Amazon recently began a law suit against more than 1,114 fake reviewers as it undermines consumer trust14 and Yelp joined a series of law suits known as ‘Operation Green Turf’ in 2013 with damages being awarded $350,000 from 19 separate companies.15 The funny thing here is; fake reviews all tend to sound the same. The language used is often unconvincing, which inspires a level of scepticism from potential patients, so those reviews could have the opposite effect. Not to mention there are algorithms, which effectively pick out these fake reviews due to the predictable wording. My advice is to avoid this practice altogether.

The most cost-effective way to a 5-star reputation If you run a good clinic, you should already have a plentiful supply of patients willing to sing your praises. If you genuinely enhance their lives and make an effort to help them feel good (with a healthy dose of ‘positive priming’ working in your favour too), you should have no trouble gathering positive reviews. You simply need to ask for them to post on your chosen site (and be sure to direct them to various top review sites, to get the most visibility in Google Search). Do not underestimate the rising power of online reviews for your clinic’s success. If you decide to work with a marketing company to handle this side of your business, make sure they focus on real reviews, strong branding, and appreciate the importance of a good patient satisfaction strategy and the impact of online presence.

Jay Cruiz is the sales and research director at Fountain PR, an online PR and reputation management company set up to help aesthetic clinics develop their own 5-star reputations. For several years before helping clinics with their online reputation and visibility, Cruiz worked in the field of sales and client acquisition, from event sales, to medical equipment, to the aesthetics industry.

REFERENCES 1. Worstall Tim, Fascinating Number: Google Is Now 40% Of The Internet (Forbes, 2013) <http://www. forbes.com/sites/timworstall/2013/08/17/fascinating-number-google-is-now-40-of-the-internet/> 2. Statista, Inc, Worldwide market share of leading search engines from January 2010 to October 2015, (Statista.com, 2015) <http://www.statista.com/statistics/216573/worldwide-market-share-of-searchengines/> 3. Mayyasi A, The Price of Wine (Priceonomics.com, 2013) <http://blog.priceonomics.com/ post/46618070248/the-price-of-wine> 4. Plassmann et al, Marketing actions can modulate neural representations of experienced pleasantness, (California Institute of Technology, 2007) <http://www.pnas.org/content/105/3/1050.full.pdf> 5. Anderson M, Study: 72% Of Consumers Trust Online Reviews As Much As Personal Recommendations, (SearchEngineLand.com, 2012) <http://searchengineland.com/study-72-of-consumers-trust-onlinereviews-as-much-as-personal-recommendations-114152> 6. Plous S, The Psychology of Judgment and Decision Making (McGraw-Hill Higher Education, 1993) p.233.

7. Ariely D et al, ‘Tom Sawyer and the Construction of Value,’ Journal of Economic Behavior and Organization’, 2006 <https://www.bostonfed.org/economic/wp/wp2005/wp0510.pdf> 8. Smith CS, Google Trends: Yellow Pages Will Be Toast In Four Years (SearchEngineLand.com, 2007) <http://searchengineland.com/google-trends-yellow-pages-will-be-toast-in-four-years-12256> 9. Smith, Chris Silver, Are Yellow Pages Toast? Four Years Later We Review Ad Value (SearchEngineLand. com, 2012) <http://searchengineland.com/are-yellow-pages-toast-four-years-later-we-review-advalue-116199> 10. Moz.com, The 2015 Local Search Ranking Factors (SEOMoz, Inc, 2015) <https://moz.com/local-searchranking-factors> 11. Slegg J, 30+ Important Takeaways from Google’s Search Quality Rater’s Guidelines (SEOMoz, Inc, 2015) <https://moz.com/blog/google-search-quality-raters-guidelines> 12. Paresh D, Edmunds.com settles lawsuit against alleged fake reviewer Humankind (Los Angeles Times, 2013), <http://articles.latimes.com/2013/aug/29/business/la-fi-tn-edmunds-lawsuit-humankind-20130829> 13. Tuttle B, Amazon Lawsuit Shows That Fake Online Reviews Are a Big Problem (Time Inc, 2015) <http:// time.com/money/4078632/amazon-fake-online-reviews/> 14. Schneiderman, ET et al, Schneiderman Announces Agreement With 19 Companies To Stop Writing Fake Online Reviews And Pay More Than $350,000 In Fines (New York State Office of the Attorney General, 2013) <http://www.ag.ny.gov/press-release/ag-schneiderman-announces-agreement-19companies-stop-writing-fake-online-reviews-and>

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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

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complications “wet lab” aestheticsjournal.com

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“All practitioners should take a step back and say ‘how can I make myself proud of what I do?’”

Dr Beatriz Molina details her route into aesthetics and her constant strive to make it a recognised specialty Coming to the UK was supposed to be a temporary move for “Being part of the committee for BCAM, I was talking to nurses, aesthetic practitioner Dr Beatriz Molina, who initially moved here to dermatologists and surgeons, trying to get everybody together to train as a surgeon, gain some experience within the NHS and learn work with HEE. At the time, we were at opposite ends of the table, but English. But after falling in love with her now-husband and the British having been in the industry for a very long time and knowing people This one-day simulation “wet-lab” provide "Anatomical basiscareer of Facial rejuvenation way of life, Dr Molina’s took an unexpected turn. quite well personally, it waswill easier for me to speak to people and say small group, hands on practical training, so that “Iwith attended medical school at the University of Malaga and then ‘look, we have a common aim here, we need to join forces’ and that Dermal Fillers and management of delegates will be confident in how to avoid and came to England in 1994 to start my surgical training.

But after five was a big achievement.”

Dr Molina advises anyone looking to get complications wet lab" on 11th April 2016 treat complications from non-surgical fillercourses extremely carefully. Work years of learning I woke up one morning and decided that I didn’t into the industry to, “Choose your treatments,with based on a thorough anatomical want do it anymore,” explains Dr Molina.wet-lab Her sudden someone closely and if you can, have a mentor and get properly This to unique "hands on" fresh -cadaver is a change-ofknowledge. scientific, evidence-based course run by heart left her family and friends in shock, “I had a bit of a breakdown trained. Do it very slowly, carefully and don’t take it as a side job. If internationally recognized andmy anatomical and thought ‘what am I goingclinical to do with life?’ and then some you want to do it because you love it, go for it, but it is going to take Course Directors : trainers, with the that aim Iof aesthetic friends suggested gopromoting into generalsafe practice temporarily, whilst a lot of your time.” Although Dr Molina is proud of her achievements, Mrs. Sabrina Shah-Desai (MS, FRCS), one of Ipractice made myamongst mind upmedical on what professionals.

I wanted to do.” Becoming a general she continues to strive for better, “We need to stop people from UK’s leading Oculoplastic Surgeons specializing in Delegates will a comprehensive practitioner was get a new adventure for Drunderstanding Molina and, as she explains, doing asurgical half-a-day course andrejuvenation. then going out there thinking they can surgical and non periorbital of facial anatomical layers usingsurgeon, cadaverhowever the problem less stressful than being a trainee do the treatments.

Things are improving, Dr. Beatriz Molina, one of the world’s leading but very slowly. Our next prosections and‘inwill anatomical surface was, she wasn’t lovepractice with it’. “It wasn’t enough to keep me excited is to make aesthetic and cosmetic medicine an approved authoritiesbig andgoal opinion leaders on aesthetics marking on fresh with everyday – but thenfrozen I foundcadavers, cosmetics.”

Dr an Molina heard about speciality.

It’s going to take time, I think by carrying on with the medicine and vice president of the Britishbut College emphasis on avoidingwith critical neurovascular treating hyperhidrosis botulinum toxin and wanted to learn hard work, we’ll be able to achieve it.” of Aesthetic Medicine. anatomy in upper, mid and lower face. more, “I did a course and found out you could also use botulinum The “wet-lab” will cover basic, intermediate and toxin to treat lines and wrinkles – it was like a wake-up call!” This course will place at Whattake treatment dothe youWest enjoyMidlands giving the most? advanced safe reproducible filler injection Dr Molina had been practising medicine for 11 years when she Surgical finally Training Centre, Coventry on 11th April I love using dermal fillers and feel like an artist when I’m treating techniques for the most clinically relevant facial discovered her passion for aesthetics. “I got really excited and2016. patients with them. I combine my medical knowledge with my areas (forehead, temple, tear trough, superior booked myself onto courses in botulinum toxin for lines and wrinkles, artistic flair and I love how you can transform someone’s face. You sulcus, peri-oral and jawline).

Course Fee : £895 , includes lunch and all and then for dermal fillers, and then that’s when see the changesheadsets straight away Delegates will be confident in thelasers; management of my journey refreshments, can teaching materials, & a and it’s just incredible. really started.”

Afterfiller two years of training(Tyndall in aesthetic treatments, common dermal complications Certificate of attendance.

What technological tool do you think best compliments your Dr Molina decided toand open own clinic, and, in expert 2005, Medikas effect, overfilling) beher updated on current work? in Somerset was launched, followed by her Bristol establishment protocols for the management of vascular To learn more the courses to book Atabout the moment, it’s theor cannulas foryour my dermal filler. I can achieve a in 2014.

“In those days, in Somerset, where I was working as a GP, complications. The wet-lab includes practical place, email lot and I think it’s enabled me to develop my own techniques and there wasn’t really anyone offering aesthetic services and I realised sessions using Hyaluronidase. infodermalfillercomplications@gmail.com give better results with fewer traumas. there was a gap in the market.” Dr Molina wanted to make sure her

or drbmolina@gmail.com

clinic offered a variety of treatments and that she had the knowledge and expertise she needed in order to deliver this. She explains, “If you want to offer a service, you have to know everything about it.

Sometimes we think ‘we’re doctors and we know it all’ – but we don’t!

It is a very specialised industry; you have to study a lot, you have to learn and I took it very seriously.” In 2015, Dr Molina was appointed vice president of the British College of Aesthetic Medicine (BCAM), by the committee board. As vice president, she is a firm believer in keeping yourself as up-to-date as possible within the industry. “It’s fast evolving and there are new techniques coming in everyday, a lot more new products, and you need to have a solid understanding to know what looks good and will work and what sounds a bit crazy. You have to be very selective and that’s important for your patients.”

BCAM and the British Association of Cosmetic Nurses have been working together with Health Education England (HEE) to establish a new regulatory body for the cosmetic sector in England – the Joint Council for Cosmetic Practitioners (JCCP); a venture Dr Molina is particularly excited about and proud of.

Do you have an industry pet hate?

I don’t like how anybody in this country can perform aesthetic treatments. You see a lot of people traumatised because they’ve had a really bad experience or a bad result and that’s why we are trying to change it. All practitioners should take a step back and say ‘how can I, from the heart, make myself proud of what I do?’

What aspects of the industry do you enjoy the most?

The conferences! It’s great to have these big meetings where you get to see your colleagues and share experiences. You get to talk to people and learn all about different treatments and procedures.

It’s nice because you can trust your colleagues and ask, ‘what do you think about that product? What do you think about that treatment?’ and they give you their honest opinion. It’s fantastic!

Dr Beatriz Molina will discuss treating the buttock and thigh area at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/programme to find out more.

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

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the suggested financial benefits of the deal, as well as being left with poor treatment results.

The Last Word Dr Joney De Souza discusses the use of voucher websites as a portal for selling cosmetic treatments From my professional standpoint, and many other practitioners I know, the presence of e-commerce voucher sites within the cosmetic aesthetic arena is a complex minefield. Whilst discount sites can highlight some attractive deals in medical aesthetics, I believe it to be immensely important for both consumers and practitioners to exercise severe caution before buying or selling through such portals.

The use and benefits of voucher sites Voucher sites such as Groupon, LivingSocial and Wowcher have an incredibly successful business model and a vast multi-national customer base. On entering the discount site arena in 2008, Groupon became the second fastest online company to reach a billion dollar valuation,1 thereby cementing itself as a popular business model with proven credentials for potential businesses and consumers alike. Selling invasive and non-invasive cosmetic treatments on these e-commerce platforms could initially seem to have many advantages. First and foremost, they can be an invaluable way to increase footfall and promotion of a brand, clinician or establishment. Unlike classified advertising, the vendor doesn’t have to pay any upfront costs to participate on these sites. This thereby, might make it an attractive concept for retailers looking to build brand loyalty and promote themselves on an internationally recognised platform, while, at the same time, potentially gaining more customers and selling surplus inventory. The most common types of treatments that clinics advertise through these sites tend to be laser treatments, dermal filler treatment for lips and nose reshaping and microdermabrasion.

Disadvantages for patients However, on deeper inspection, concerns arise over the financial viability for businesses and, even more importantly, the sub-standard ethics for which some businesses operate within this field. The aesthetics arena is an incredibly poorly regulated industry and consumer desire for discounted treatments, matched with the need for practitioners to ‘survive’ in such a competitive market, can lead to some serious compromises being made. These not only include poor choice and cheaper variations of products being used, but also the sub-standard investment a practitioner might be tempted to make in their own and staff training, leading to a direct impact on skills. Consumers may think that they are purchasing a great deal, whereas they could have actually signed up for an aesthetic service carried out by an unqualified and non-medically trained practitioner, in a field that already has very little regulation in place to protect consumers. In addition, the majority of deals advertised on such platforms offer limited product availability with a plethora of terms and conditions that can confuse the consumer with complicated timing or redemption structures not primarily visible in the original advert. As a result, the consumer may not experience

Disadvantages for practitioners Businesses also have to understand that the use of these sites is very rarely a means of generating profit, with some sites taking more than 50% commission of the total sale price,2,3 effectively making the deals offered ‘loss leaders’. The promise of attracting loyal and returning customers is also widely revoked due to the nature of customers who purchase such deals being classed as ‘price-sensitive deal-seekers’ who are therefore unlikely to return to the practitioner in the future, without similar substantial promotions and discounts being applied to services. The popular practice of compromising on treatment quality to drive down price can mean an increase in the risk of potential complications,4,5 which will have a direct negative impact on treatment results and on the practitioners’ reputation. This could therefore actually drive business away from a practice and hinder your primary goal for advertising on such sites in the first place. One incredibly important question to factor in is if the voucher deal will have a negative impact on your business by damaging your brand, especially if you have formerly marketed yourself within the luxury sector. Once patients start to consider you as a discount provider of treatments, you will probably never be able to increase prices to their original state and, unfortunately, that reputation will be difficult to regain.

Think long, not short term!

Regulation Furthermore, an important point for any practitioner to consider is the notable restrictions by regulatory bodies like the General Medical Council (GMC), Nursing and Midwifery Council (NMC) and General Dental Council (GDC) on advertising treatments that use prescription medications, such as botulinum toxin (or the generalised use of Botox). As a prescription-only medicine, botulinum toxin is banned from any promotion incentives or marketing and this would be applicable to voucher websites. These sites also need to be careful what they are promoting botulinum toxin can treat. As stated on the Advertising Standards Agency website: “The only cosmetic use for which Botox is licensed is the ‘glabellar’ lines, which are the vertical lines on the forehead between the eyes. This means that although Botox is commonly used to treat other lines and wrinkles, it is not licensed for that sort of use. Any claims, therefore, that go beyond factual information representative of the licence are likely to automatically breach the Advertising Code.”6 The GMC advises against the use of botulinum toxin advertising7 and I’ve known some practitioners get around this by using the terms ‘muscle relaxing treatments’ on promotional deal sites. Sites such as Google also now bans ‘Adwords’ containing the use of the word ‘Botox’ and also penalise users who openly advertise it on websites.8 Although these sites are merely a purchasing platform

Reproduced from Aesthetics | Volume 3/Issue 4 - March 2016

aestheticsjournal.com

@aestheticsgroup

for prospective customers to browse deals, I believe a significant percentage of clinics and practitioners using these sites and carrying out these discounted treatments are indeed breaching their ethical and moral duty. Ethics are breached if these procedures are carried out by non-medically trained aestheticians that may have had sub-standard training and potentially use cheaper and poor variations of the products, something I believe happens through these sites.

The Keogh report – the Review of the Regulation of Cosmetic Interventions – considered time-limited deals to be ‘socially irresponsible and should be prohibited by the professional registers’ codes of practice’.9 It also pointed out that financial inducements and package deals were negligent. Patients should have adequate time to consider the information before agreeing to any cosmetic procedure – something that time-limited deals on voucher websites do not allow for, meaning people aren’t properly consenting.

Conclusion As a general ethos, I believe the use of discount sites for promotion of aesthetic

Aesthetics Journal

Aesthetics

medicine has more negatives than positives for a practitioner and clinic. From a consumer’s standpoint, if you do some detailed groundwork, you can attain a very good deal with an astute practitioner, without voucher websites, however this can be hard to find. I would advise my peers that we tell all potential consumers to approach selected practitioners with caution, checking practitioners’ credentials and registration with leading bodies such as the GMC, NMC and GDC, as well as direct customer reviews. I would also advise practitioners to tell anyone looking for cosmetic aesthetic treatments in the UK to look beyond the financial aspect of the deal and consider all risks and implications, given the poorly regulated sphere which these services are part of.

Usually, when patients come to me saying they have found an ‘unbelievable’ low price for a treatment, I tell them that more often than not, there will be a distinct reason behind this seemingly plausible offer and that, if they choose to go ahead, they should do even more to ensure all the prior points discussed have been checked. As the old adage says, you get what you pay for!

Dr Joney De Souza gained his medical degree in Brazil and has more than 15 years’ experience in aesthetic and antiageing medicine. A GMC-registered aesthetic doctor and member of the British College of Aesthetic Medicine, Dr De Souza relocated to London in 2007 and has a skin and laser clinic on Wigmore Street.

REFERENCES 1. Steiner, C. (2010) Meet The Fastest Growing Company Ever, Forbes Magazine, August 30 issue 2. Christie, (2012) Online daily deals: good for the customer but bad for business? Attacat Brain, http://www.attacat.co.uk/brain/ online-daily-deals-good-for-the-customer-but-bad-for-business> 3. Brignall, M. (2011) Groupon: cut-price deals… and customer service, The Guardian <http://www.theguardian.com/ money/2011/nov/18/groupon-vouchers-readers-experiencessecond-class-service> 4. Casewell, L. (2013) Cut price cosmetic surgery: Why online voucher sites aren’t offering you the best deal, Huffington Post, <http://www.huffingtonpost.co.uk/laura-casewell/cut-pricecosmetic-surgery_b_3712075.html> 5. NHS, (2009) Cosmetic surgery ‘needs regulation’, <http://www. nhs.uk/news/2009/11November/Pages/plastic-cosmetic-surgerybotox-filler-warning.aspx> 6. ASA, (2014) Taking a firm line – ASA rulings on Botox ads <https://www.asa.org.uk/News-resources/Media-Centre/2014/ ASA-rulings-on-Botox.aspx#.Vqt7mFOLS34> 7. CAP, (2015) Marketing of cosmetic interventions, https:// www.cap.org.uk/~/media/Files/CAP/Help%20notes%20new/ CosmeticSurgeryMarketingHelpNote.ashx 8. Custwin, (2010) No more Botox in adwords – How will this affect Google? <http://www.custwin.co.uk/custwin-blog/2010/06/nomore-botox-in-adwords-–-how-this-will-affect-google/> 9. Department of Health, (2013) Review of the Regulation of Cosmetic Interventions, <https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/192028/Review_ of_the_Regulation_of_Cosmetic_Interventions.pdf>

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Reproduced from Aesthetics | Volume 3/Issue 4 - Marchinfodermalfillercomplications@gmail.com 2016 or drbmolina@gmail.com

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UK/0721/2015

Date of Preparation: October 2015