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Adipose Tissue and Ageing CPD Dr Sotirios Foutsizoglou explains how fat tissue affects ageing of the face
Special Feature: Hair Removal Practitioners share their advice on using lasers for effectively removing hair
Nose and Chin Augmentation Dr Yusra Al-Mukhtar outlines treatments for non-surgical profiloplasty
Managing Workload
Business coach Alan Adams details ways to manage your time efficiently
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All treatments were carried out by The Cosmetic Skin Clinic. Disclaimer: Please be aware that results and benefits may vary from patient to patient taking into consideration factors such as age, lifestyle and medical history. M-ULT-UKI-0398 Date of Preparation September 2018
References: 1. http://www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed August 2018. 2. CE Certificate 3808396CE01, DEKRA March 2017. 3. Ulthera System Instructions for Use, 1001393IFU Rev L. 4. Sasaki GH & Tevez A. Journal of Cosmetics, Dermatological Sciences and _Applications. 2012; 2: 108-116. 5. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202. 6. Fabi SG and Goldman MP. Dermatol Surg. 2014;40;569.
Contents • November 2018 08 News
The latest product and industry news
16 Conference Reports
Overviews of the IAGSAW, BCAM and IAPCAM annual events
20 Sinclair Pharma World Experts Meeting Report
A look at the Sinclair Pharma conference held in Barcelona
22 News Special: The Brazilian Butt Lift
Aesthetics reports on the recent recommendation for BAAPS members
Special Feature Hair Removal Page 27
24 ACE Preview: The Elite Training Experience
Key details of the elite training available and discount on offer
CLINICAL PRACTICE 27 Special Feature: Effective Laser Hair Removal
Practitioners discuss their methods for using lasers for hair removal
32 CPD: Understanding Adipose Tissue
Mr Sotirios Foutsizoglou explains how fat tissue affects facial ageing
37 Spotlight On: EMsculpt
Aesthetics explores the new device for building muscle and reducing fat
In Practice Hiring Staff for a Second Clinic Page 66
41 Identifying and Classifying Hair Loss
Dr Martin Wade presents his algorithm to help classify types of hair loss
44 Offering Profiloplasty
Dr Yusra Al-Mukhtar details how to enhance a patient’s profile
48 Using Stem Cells for Hair Restoration
Consultant plastic surgeon Mr Ali Juma explores the use of stem cells for treating hair loss in men and women
50 Advertorial: AestheticSource
Discover RRS XL Hair for treating alopecia
53 Case Study: Treating Hair Loss
Independent nurse prescribers Frances Turner Traill and Lyndsey Loughery describe how they treated a young patient with alopecia
59 Abstracts
60 Implementing a Creative Strategy
Marketing and PR professional James Dempster explores exercises to help practitioners produce innovative content for their marketing
64 Managing Your Clinic’s Workload
Business coach and author Alan Adams discusses how to successfully prioritise tasks and manage time efficiently
66 Hiring Staff for a Second Clinic
Nurse prescriber Jodie Grove advises her recruitment approach
71 In Profile: Dr Greg Williams
Plastic surgeon Dr Greg Williams shares his passion for hair restoration and details his journey to becoming a leading hair transplant surgeon
72 The Last Word
Mr Nigel Mercer argues for the ban of cosmetic surgery adverts
NEXT MONTH • IN FOCUS: Evolution • Pain management in aesthetics • Seasons and skin changes
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Mr Sotirios Foutsizoglou is completing his last year of training in plastic and reconstructive surgery at Evangelismos General Hospital of Athens. Since 2012 he has been training medical aesthetic practitioners in facial anatomy and advanced non-surgical treatments. Dr Martin Wade is a consultant dermatologist specialising in the medical diagnosis and treatment of hair loss and scalp disorders. He practises at The London Skin and Hair Clinic and presents regularly to those interested in hair loss and scalp conditions. Dr Yusra Al-Mukhtar is a dental surgeon with experience in head and neck surgery and facial aesthetics. She is a lead trainer for injectable courses with Oris Medical and works in private clinics in London and Liverpool. Frances Turner Traill is an independent nurse prescriber and clinical director of FTT Skin Clinics in Inverness and Hamilton. She is the Scottish board member of the BACN representing new regulation changes with the Scottish government and HIS.
A round-up and summary of useful clinical papers
IN PRACTICE
Clinical Contributors
Lyndsey Loughery in an independent nurse prescriber at FTT Skin Clinics. She is currently working towards her PgDip in Dermatology in Clinical Practice, as well as her PG Cert in medical aesthetics. Loughery is a member of the BACN. Mr Ali Juma practises privately in London and Wirral, following a 12-year career as a consultant plastic surgeon in the NHS. He offers a range of cosmetic and plastic surgery procedures, along with aesthetic treatments.
Aesthetics Awards 2018
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Editor’s letter Many of you may be delighted at the prospect of Christmas approaching, while others may be a bit ‘Bah Humbug’, but either way it’s time to get your festive offers and promotions planned for the period to maximise clinic success. We have some great business articles this month Amanda Cameron to help with your preparations, such as creative Editor strategies to improve your reach, by marketing and PR professional James Dempster on p.60, and business coach Alan Adams’ piece on managing your clinic’s workload on p.64 – especially useful during the busy Christmas period! I often hear myself complain that there is not much new in aesthetics, however this month we focus on hair, a topic that can get forgotten by some, yet there does appear to be some interesting new technology coming to market. Nurse prescribers Frances Turner Traill and Lyndsey Loughery share a case study in which they successfully treated a patient for hair loss with plasma technology on p.53, while Dr Ali Juma discusses the use of stem cells on p.48. Dr Martin Wade also shares
his hair loss classification system on p.41 and we interview Dr Greg Williams to find out more about his interesting journey to becoming a leading and well-respected hair transplant surgeon on p.71. It’s a busy time again for conferences and this month you will read our BCAM, IAPCAM and IAGSAW reports on p.16, with the BACN following next month. It is important to support these professional bodies and the security they can offer in an ever changing world of aesthetics. The social event of the aesthetic year, The Aesthetics Awards, is now less than a month away! I hope the hair, makeup, shoes and outfits are prepared and planned. It promises to be one special night with a few exciting updates and award-winning comedian Russel Kane set to delight and entertain. If you haven’t already, book your tickets by visiting www.aestheticsawards.com. ACE is next in March, which will be here before we know it! Keep your registrations coming in – the fact we have so many already is some indication that many of you are planning ahead. You can read more about what to expect from the Elite Training Experience on p.24 and register to attend by visiting www.aestheticsconference.com.
Editorial advisory board
We are honoured that a number of leading figures from the medical aesthetic community have joined the Aesthetics journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with over 20 years’ experience. He is an international presenter, as well as the medical director and lead tutor of Medicos Rx. Mr Humzah also runs the multi-award winning Dalvi Humzah Aesthetic Training courses. He is a founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow.
Dr Raj Acquilla is a cosmetic dermatologist with more than 12 years' experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers.
Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. She is a registered university mentor in cosmetic medicine and currently a second year student on the Northumbria University Masters course in non-surgical cosmetic interventions. Bennett has been developing her practice in aesthetics for 25 years.
Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.
Mr Adrian Richards is a plastic and cosmetic surgeon with 12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook.
Dr Maria Gonzalez has worked in the field of dermatology for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.
Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She is currently undertaking her Masters in Aesthetic Medicine, for which she is also a course mentor. Partridge is a founding board member of the British Association of Cosmetic Nurses and has represented the association for Health Improvement Scotland.
Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multiaward winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts. Dr Williams is also author of Amazon-No-1 Bestseller ‘Future Proof Your Skin’.
Dr Christopher Rowland Payne is a consultant dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.
Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University. Dr Samizadeh frequently presents at international conferences and is passionate about raising industry standards.
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Awards
Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Hairloss Zoë Passam @ZoePassam Such a great day @getaheadofhairloss which I’m proud to have been a part of, and kudos to this lady @DrSharonWong for making it all happen! #trichology #alopecia #PHIlanthropy Dr Tapan Patel @drtapanp PHI-lanthropy Ball 2018! Thrilled to have raised over £60,000 on Saturday to help fund the Yezidi Emergency Support founded by the Incredible Anne Norona. A massive thank you to all who attended and contributed too generously! @phiclinic #charity #giving #PLEXR Dr Dev Patel @drdevpatel1 Can’t believe it’s already been a week since my first trip to #China as a #trainer. It was a packed 2 days of teaching 60 Chinese doctors on #PLEXR and also advanced #dermalfiller techniques, focussing on the lower face. #BACN Sharon Bennett @sharonbennettskin Ready to leave home for BACN board meeting today in London. Focus on education, training and safety in injectables. Annual conference Nov 8/9! #DermalFillers #LipFillers #Aesthetics Miss Sherina Balaratnam @MissBalaratnam Great to meet up with @nancyghattas and Nick Spicer of @Allergan in beautiful Istanbul this morning. Always enjoy our discussions on #medical #aesthetics and look forward to exciting times ahead! #Career Mr Adrian Richards @mradrian.richards If you do what you love, you’ll never work a day in your life #NaturalImplants #BreastAugmentation #PlasticSurgery #London
Last chance to book the Aesthetics Awards 2018 The long-awaited Aesthetics Awards will take place next month at the Park Plaza Westminster Bridge Hotel in London and there are limited places available to join the celebrations. The 63 expert judges have submitted their verdicts and voting for the Awards closed on October 31. The ceremony will present Winner trophies, as well as Highly Commended and Commended recognition in 26 clinic, practitioner and company categories. The very best clinics, products, training providers, distributors and other aesthetic companies will be recognised for their continued hard work and effort over the past year. Aesthetics journal editor, Amanda Cameron, said, “This year we are expecting more than 850 guests to join us at our prestigious central London venue, the Park Plaza Westminster Bridge Hotel. I have been in the aesthetics specialty for nearly 30 years and it delights me every time to see the industry flourish with new and emerging talent and innovation. If you haven’t already, book your place to join us in celebrating another successful year and don’t miss our talented host and comedian Russell Kane!” The Aesthetics Awards takes place on Saturday December 1. Each ticket costs £290 +VAT or a table of 12 is £3,300 +VAT. To book, visit www.aestheticsawards.com while seats are still available. Fat
CoolSculpting receives FDA clearance for submandibular area CoolSculpting, owned by global pharmaceutical company Allergan, has received FDA clearance to treat the submandibular area. In December 2017, CoolSculpting was approved for improving the appearance of lax tissue in conjunction with submental fat. According to Allergan, the FDA clearance has now also expanded to include patients with a body mass index of up to 46.2 when treating the submental and submandibular areas. This clearance makes CoolSculpting the first and only non-surgical fat reduction treatment to contour the area below the jawline and improve the appearance of lax tissue in conjunction with submental fat treatments, the company claims. David Nicholson, chief research and development officer at Allergan said, “This new indication to treat the submandibular area underscores Allergan’s dedication to research and innovation within the body contouring category.” According to Allergan, CoolSculpting has had an 85% average patient satisfaction rate reported across three studies, while a 22-week study demonstrated an average of 33% reduction in fat layer thickness after two treatments.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Appointment
Events diary
New commercial director for Aesthetics Media Ltd
8th – 9th November 2018
Aesthetics Media Ltd, publisher of the Aesthetics journal and organiser of the Aesthetics Conference and Exhibition and the Aesthetics Awards, has appointed Jenny Claridge to the role of commercial director. In this newly created role, Claridge will work closely with the business development and support teams to enhance the customer experience as well as focus on commercial planning to develop the Aesthetics Media Ltd product portfolio. Previously the director of sales at Medical Aesthetic Group for the past three years, Claridge has also held senior sales and marketing roles with global life sciences company, Johnson & Johnson, in their consumer, pharmaceutical, surgery and vision care divisions. Chris Edmonds, chairman of Aesthetics Media said, “We are delighted that Jenny with be joining the team at this exciting time. Her background will add significant additional depth to the management team. We are at an important development stage in the Aesthetics brand journey and putting the customer experience at the forefront is key as we add new products to the portfolio that will better serve medical aesthetics professionals.”
British Association of Cosmetic Nurses Autumn Aesthetic Conference, Birmingham www.bacn.org.uk
28th – 30th November 2018 British Association of Plastic Reconstructive and Aesthetic Surgeons Winter Scientific Meeting 2018, London www.bapras.org.uk
31st Jan – 2nd Feb 2019 IMCAS Annual World Congress 2019, Paris www.imcas.com
Cosmeceutical
Teoxane introduces RHA topical skin booster
1st December 2018 The Aesthetics Awards, London www.aestheticsawards.com
Swiss aesthetic manufacturer Teoxane has launched a sterile RHA topical skin booster. The RHA topical skin booster is a cross-linked resilient hyaluronic acid (RHA) gel that can be administered between skin rejuvenation procedures such as microneedling and fractional laser. Included in the formulation is the company’s new Boosted DermoRestructuring Complex, which the company states is 100 times more concentrated in the RHA topical skin booster than in previous Teoxane cosmeceuticals. The company explains this complex strengthens the dermis and provides powerful antioxidant protection, leaving skin on the face, neck and décolleté looking naturally more radiant and bright. Regulation
1 –2
March 2019
1 & st2 M A Rnd CH 2019 / LONDON
The Aesthetics Conference and Exhibition, London www.aestheticsconference.com
Acquisition
JCCP announces first approved training providers The Joint Council for Cosmetic Practitioners (JCCP) has announced the first wave of approved education and training providers. In January this year, the JCCP said it was working with three education and training providers as ‘test sites’ to pilot the implementation of a review process. This process aimed to provide assurance to the Council that its proposed standards and process for the approval of education and training organisations were fit for purpose. The approval has been awarded to Harley Academy in London, for the delivery of the IQ approved Level 7 certificate in Injectables for Aesthetic Medicine; to Northumbria University in Newcastle Upon Tyne, for the delivery of a post graduate certificate in Professional Non-Surgical Aesthetic Practice; and to Sally Durant Aesthetic Education and Training in the West Midlands, for the delivery of the CIBTAC Level 4 certificate in Microneedling. These education and training organisations have now been added to the JCCP register of ‘Approved Education and Training Provider Organisations’ for the named programmes and qualifications.
Candela acquires Lasertronic Aesthetic device company, Candela, previously known as Syneron Candela, has acquired its existing UK technical service partner, Lasertronic. The laser service organisation based in Birmingham and Dublin, repairs medical lasers in both hospital and clinic settings. According to Candela, this new acquisition will provide direct technical service and support to its existing and future customer base. The company states that by utilising its own team of manufacturer-trained, certified engineers, they can build a high level of support and a good technical service. Robert Fielitz, executive vice president and managing director for Candela said, “This acquisition will allow us to focus even more on our valued customers. Having a direct service team furthers our commitment to deliver on our motto of science, results, trust and enhances our one team, one company, one vision approach.”
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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ACE 2019
BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses
ACE 2019 to host the Elite Training Experience
REGIONAL MEETINGS Our latest round of Super Group Regional Meetings took place throughout September and October, with all meetings featuring our specialist VAT Roadshow aimed at providing advice for small businesses in aesthetics. The roadshow was led by Jonathan Bardolph, BACN treasurer, who often assists medical professionals with tax compliance matters within aesthetics. Previous roadshows have included nurse revalidation and GDPR compliance. We were joined at our meetings by a number of BACN partners who showcased demonstrations and education talks directly to nurse members. All demonstrations and presentations also come with CPD points that members can access via their online member’s area and they can complete their reflective learning statements.
PEER REVIEW Within our meetings members also have the provision to engage in peer-to-peer reviews and hear from other members about issues facing them in their own clinics, along with group discussions led by regional leaders. Whilst the BACN has a successful and active Facebook group, the importance of face-to-face conversation with peers cannot be forgotten.
TRAINING
After such a successful debut at the Aesthetics Conference and Exhibition (ACE) last year, the Elite Training Experience is back for 2019, showcasing four of the most reputable and sought-after training providers in the specialty. This year, two new training providers will showcase their clinical expertise and outstanding anatomical knowledge in three-hour CPD certified sessions: Aesthetic Training Academy, with Dr Simon Ravichandran and Dr Emma Ravichandran, and Dr Bob Khanna Training Institute, with Professor Bob Khanna. Delegates will also see the return of Dalvi Humzah Aesthetic Training, with key speakers Mr Dalvi Humzah and nurse prescriber Anna Baker, and Medics Direct Training, with Dr Kate Goldie. Dr Simon Ravichandran said he is thrilled to present at the Elite Training Experience. “Over the whole three hours, continuous live demonstrations will be overlaid with theoretical descriptions and presentations, encapsulating those totally new to aesthetics, as well as those who want to reform advanced injectable treatments.” Each Elite Training Experience session is priced at £195 +VAT, a fraction of the usual cost for education with these training providers. By booking to attend any Elite Training Experience session at ACE 2019 delegates will receive an exclusive 10% discount on a future full course booking delivered by that particular trainer. Note that access to these sessions are restricted so check each training provider’s restrictions before booking. Visit www.aestheticsconference.com and book before December 31 for a 10% early booking discount. Hyaluronic acid
Many regional meetings also come with basic life support and anaphylaxis training, which for many members who longer work in the NHS, this is vitally important. All regional meetings are included in BACN membership, and members are able to attend any meetings throughout the UK. BACN events manager, Tara Glover, works directly with BACN Regional Leaders to improve existing meeting structure and develop agendas and content. BACN members are also always welcome to feedback on issues they would like raised at meetings, and topics of interest to them. Tara can be contacted at tglover@bacn.org.uk. This column is written and supported by the BACN
HA-Derma launches Viscoderm Hydrobooster HA-Derma, the UK and Ireland distributor of IBSA Italia products, has added the Viscoderm Hydrobooster to its portfolio. This new product is a stabilised hyaluronic acid that, the company states, offers a dual function; biological process of hydration and tissue restructuring, as well as a mechanical action to stretch superficial wrinkles. This causes an action that IBSA Italia has named ‘hydrostretch’, which is designed to improve skin elasticity, radiance and smoothness, as well as treat superficial wrinkles for advanced signs of ageing. IBSA Italia states that this action is made possible by the product’s rheological properties. It is recommended that Viscoderm Hydrobooster is used on the perioral, periocular and forehead areas of the face for particularly effective results. HA-Derma recommends undergoing training, which they provide, to achieve best results.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Appointment
AestheticSource appoints new operations manager Medical aesthetics distributor, AestheticSource, has welcomed Archie Tashjian as its new operations manager. Tashjian joins the team with more than 25 years’ experience in specialist information technology and 12 years’ industry experience at Wigmore Medical Ltd where he worked across customer services, training and operational management. According to AestheticSource, Tashjian will be closely involved with the customer service and training departments and will also be working with the directors on international projects. Director of AestheticSource, Lorna McDonnell-Bowes said, “We are delighted to welcome Archie to the AestheticSource family. Archie brings with him a wealth of knowledge and experience built up over many years of IT and operational experience, which will help us move forward to the next stage of business growth.” Hyperpigmentation
mesoestetic introduces tran3x Pharmaceutical and skincare manufacturer mesoestetic has launched its tran3x programme, which aims to provide a multidimensional approach to skin pigmentation. The new treatment programme is based on the active ingredient tranexamic acid, which, according to mesoestetic, complements the effectiveness of depigmenting active ingredients present in the trans3x formula by acting on keratinocytes, inhibiting the release of melanocyte stimulating factors. The company claims that by doing this, the product offers greater efficacy by acting on the inflammatory and vascular component that characterises resistant hyperpigmentation. In addition, it can be used as a modular treatment to address various indications including solar lentigines and freckles, as well as to use postlaser and to complement the mesoestetic cosmelan/dermamelan depigmentation method. Wellness Trading is the exclusive distributor for mesoestetic. Masterclass
SkinViva Training launches new course Training provider SkinViva Training will host the Cadaveric Master Class in Facial Anatomy and Vascular Complications Avoidance course at Keele University in Staffordshire on November 18. The company states that the course aims to give delegates an advanced understanding of facial anatomy in 3D, through theory-based and hands-on learning in the dissection lab. Attendees will leave being able to evaluate faces and understand the physiology of ageing, break down the injecting sites and understand the risks within each area, plus much more. Medical director and founder of SkinViva Ltd and SkinViva Training, Dr Tim Pearce, will be leading the course with trauma and consultant orthopaedic surgeon Mr Ansar Mahmood. Dr Pearce described the course as, “A rare learning experience which will stay with you throughout your aesthetics career.” SkinViva Training has confirmed that there will be more dates scheduled for next year.
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Mme Valerie Taupin, founder and CEO of Teoxane Laboratories What filler trends have you seen develop over your career? A few years ago, fillers were used to volumise, which caused the infamous ‘big cheeks’ look. Now, fillers are placed carefully for lift rather than volume, creating a subtler appearance. Fillers are now also applied in the jaw, chin and temple to accentuate the natural structure of the face, which we lose as we age. For this, I would recommend Teosyal RHA 4, which can be injected more superficially than other fillers to help create a lifting effect without over volumising. Are there any filler innovations we can look forward to? In the future, there will be more products with less BDDE, which will help increase the natural behaviour of the filler in the skin. It will also improve the safety of the filler, as the treatment won’t alter the natural state of the skin. This has already been implemented in Teosyal RHA, which uses 50% less BDDE. Injecting filler superficially for smaller wrinkles is also on the rise, although this necessitates a more flexible, dynamic filler. RHA 1 is undetectable in the skin, meaning it is perfect for use in the upper dermis, where you shouldn’t be able to feel any added filler. Why should younger people be concerned about antiageing? HEV light emits from phones, computers and tablets, penetrating deeply into layers of skin, thus accelerating ageing. This means antiageing solutions are more significant than ever for younger people. What influence do you think social media has had on the filler industry? Social media has allowed consumers to be more informed than ever – in particular I have noticed an increased understanding around the importance of hyaluronic acid in skin health. Perceptions are changing around lip fillers, with a massive increase in interest from younger people. My guess? We’ll all be after more subtly plumped lips in 2019. This column is written and supported by
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Application
Healthxchange Group to launch Clever Clinic app 1 & 2 MARCH 2019 / LONDON
COUNTDOWN TO ACE 2019 ELITE TRAINING EXPERIENCE After its hugely successful debut at ACE 2018, the Elite Training Experience is set to return for 2019 with the latest clinical updates and best practice advice in comprehensive three-hour training sessions. Back by popular demand is Dalvi Humzah Aesthetic Training led by consultant plastic surgeon Mr Dalvi Humzah, as well as Medics Direct Training with Dr Kate Goldie. New to this exciting agenda are Drs Emma and Simon Ravichandran who will host their Aesthetic Training Academy, and Professor Bob Khanna of the Dr Bob Khanna Training Institute. Delegates can attend as many training experiences as they wish, with a 10% discount available on each until December 31. All attendees will also get 10% off a full course booked with the trainers following the Experience. SPEAKER INSIGHT Professor Khanna said, “I am so excited to be joining the Elite Training Experience this year! Those who attend my session will benefit from an in-depth anatomy overview, as well as discussion of full facial assessment, combination treatments and clinical photography. The Elite Training Experience is a fantastic opportunity to update your skills, learn new approaches and network with your peers – with a 10% discount too, there’s no reason not to book now!” WHAT DELEGATES SAY “I’ve just been to the Elite Training Experience and it doesn’t matter how many times I come to these things and how long I’ve been in the trade, I learn a dozen new things every time. What I do know is that there’s an awful lot that I don’t know and I love carrying on learning.” Aesthetic doctor, Norwich E L I T E
Healthxchange Group will launch a new app that has been designed to ‘transform how doctors and nurses interact with their patients’. Available to Healthxchange Group customers in 2019, this electronic medical record app includes a calendar booking system and notification system that monitors the progress of a patient appointment. A prescription generator which links to the Healthxchange e-pharmacy is also included, aiming to ‘create a seamless pathway for prescribing’. The practitioner is also able to take notes during consultations using Clever Clinic, which automatically generates product and treatment options. Dr John Curran, chairman of Healthxchange Group said, “The intelligent and intuitive application has features we believe can make a difference to aesthetic practitioners and businesses.” Clever Clinic will be available for iOS devices as well as on desktop for clinic administration staff. Industry
BCAM to implement exam for full membership Doctors and dentists wishing to become a full member of the British College of Aesthetic Medicine (BCAM) will be required to complete assessments to test their clinical knowledge and skills. Currently, to become a full BCAM member, doctors or dentists must meet the criteria and be an associate member for a minimum of two years, after which they can apply to become a full member. However, new plans from BCAM aim for it be a mandatory requirement for those wishing to become full members to pass an assessment that covers a broad range of aesthetic treatments and modalities. According to BCAM, current full members who have sat a previous assessment by the University of Leicester will not need to re-sit the new exam, but it is still undecided exactly what will be required. Consultant plastic and aesthetic surgeon Mr Dalvi Humzah, who is not a full member of BCAM, but has been asked to be the chair of the Educational Committee and to contribute to the assessments, believes the move is a positive one for the association. “As an industry, we need to make sure that aesthetic practitioners are able to give patients the full remit of the specialism and show that they are competent in the whole aspect of aesthetics,” he stated. BCAM hopes that the exam will be finalised and implemented by October next year. Full details will be published on the BCAM website when confirmed. Conference
New sponsors for ACE 2019
T R A I N I N G E X P E R I E N C E
2019
*Access to the Elite Training Experience is restricted to medical-qualified professionals. Visit aestheticsconference.com for more details. www.aestheticsconference.com
New sponsors have been confirmed for the Aesthetics Conference and Exhibition (ACE) 2019, due to take place on March 1 and 2. HA-Derma is holding a Symposium session, Fusion GT, Thermavein and AesthetiCare will sponsor Expert Clinic sessions, and Lumenis and BTL Aesthetics are each holding a Masterclass session. The Lanyard sponsor has been announced as SlimFit Aesthetics. Free registration for ACE 2019 is now open, go to www.aestheticsconference.com to register to attend.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Clinic launch
Harley Academy launches first clinic Aesthetic training company Harley Academy has launched its first clinic, GILD Clinic, which is based in Moorgate, London. The clinic will offer non-surgical aesthetic treatments including injectables, mesotherapy, microneedling and chemical peels. Patients will be given the option to choose between treatments with Harley Academy students or those experienced in skin and injectables. Dr Tristan Mehta, CEO of Harley Academy stated, “This project involves providing an extended treatment menu with different price points and more availability to our patients. GILD Clinic will also be a route to market for Harley Academy alumni providing employment to the best graduates.” According to aesthetic practitioner and clinical director at GILD Clinic Dr Emily MacGregor, patients are becoming more interested in learning about their treatments, and many value the educational component they receive from attending a clinic within a training academy.
Aesthetics
Vital Statistics In 2017, brow lift surgeries in men in the UK rose by 27%, while facelifts rose by 16% (BAAPS, 2018)
In the UK 8 million women experience some form of hair loss (Wimpole Clinic, 2018)
40% of adults aged 18-34 in the UK have had a non-surgical or surgical cosmetic treatment (Realself, 2018)
Botulinum toxin
Study indicates positive results for higher dose of onabotulinumtoxinA A study conducted by Allergan suggests that higher doses of Botox Cosmetic (onabotulinumtoxinA) to treat moderate to severe glabella lines produces greater duration of treatment effect. Allergan conducted the trial using Botox Cosmetic 40, 60 and 80 unit doses versus Botox Cosmetic 20 unit dose in 226 patients. In the trial, 32% of patients were responders at week 24 in the Botox Cosmetic 40 unit group, 30.6% in the 60 unit group, and 38.5% in the 80 unit group, compared to 16% in the 20 unit group. “These study results help us better understand the dose duration of effect and confirm that higher doses of botulinum toxin produce a longer duration of treatment effect for the treatment of glabellar lines,” said David Nicholson, chief research and development officer at Allergan. Trainers
Galderma expands Aesthetics Academy Faculty International pharmaceutical company Galderma has expanded the Galderma Aesthetics Academy Faculty with more key opinion leaders joining the team. The Faculty will also be refining a series of masterclasses with a focus on treatment selection for both the full face and individual features. The Galderma Faculty now includes aesthetic practitioners Dr Patrick Treacy, Dr Ryan Hamdy, Dr Heather Muir, Dr Donna Mills, Dr Max Malik and aesthetic nurse Andie McLean. Dr Muir said, “I am delighted to have joined Galderma’s UK Training Faculty and to be involved in their Train the Trainer Programme. Peer-to-peer learning is such an important way to enable trainers to share their knowledge and experience to help upskill others.”
In a survey of 2,000 people, 56% of men in the US said they prefer to keep health concerns to themselves (Cleveland Clinic, 2018)
15,745 non-surgical tattoo removal treatments took place in the US in 2017 (ASAPS, 2018)
Alopecia areata, which causes bald patches on the scalp, affects one or two in every 1,000 people in the UK (NHS, 2018)
In 2017, Allergan’s botulinum toxin, Botox, generated nearly $3.2 billion US of revenue worldwide (Statista, 2018)
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Jackie Partridge joins Aesthetics Editorial Board Aesthetic nurse prescriber Jackie Partridge has joined the prestigious Aesthetics journal Editorial Board. Partridge, who runs the dermalclinic in Edinburgh and is a global ambassador for Galderma, has a BSc in Professional Practice (Dermatology) and is currently undertaking her Master’s in Aesthetic Medicine, for which she is also a course mentor. She is a founding board member of the BACN and has represented the association for Health Improvement Scotland. In 2015, Partridge won the Scottish Cosmetic Nurse of the Year, was Highly Commended for Aesthetic Nurse Practitioner of the Year in 2017 at the Aesthetics Awards, as well as being Commended in 2015 and 2016. She won Best Independent Nurse Prescriber at the Look Awards 2017 and Best Scottish Clinic at the MAC Awards 2017. As a valued member of the Aesthetics journal Editorial Board, Partridge will share her experience and expertise to assist with the continuing development of the journal, steering the direction of educational clinical and business content. She said, “I am absolutely delighted to have been asked to join this professional faculty, it’s a true honour.” Eyes
Fillerina unveils product for periorbital treatments The formula for the needleless topical gel filler, Fillerina, has been revised to treat two new skin zones; the eyes and the eyelids. The topical gel encompasses eight types of hyaluronic acid with a low molecular weight and three molecules of collagen and is designed to address fine lines and dark circles. The treatment is available in two dosages; grade 4, which is designed to treat deep crow’s feet, wrinkles and sagging, and grade 5, which aims to treat very deep crow’s feet, wrinkles and severe sagging of the eyelids. Metro Health Distribution, which distributes Fillerina in the UK, recommends that the product is applied twice daily for at least one month. Recognition
Teoxane UK recognises Skintique Clinic with award Aesthetic manufacturer Teoxane UK has awarded the Skintique Clinic, led by aesthetic practitioner Dr Natalia Hancock, with an ‘Outstanding Clinic Award’. The UK division of Texoane developed the Outstanding Clinic Award as a way of recognising clinics that ‘go the extra mile’ and showcase excellence in business practice, patient safety, exceptional results and commitment to developing the aesthetics market. Jordan Sheals, head of marketing and medical education at Teoxane UK commented, “Teoxane UK is delighted to award Natalia Hancock with the Outstanding Clinic Award. Natalia has been a brand ambassador for Teosyal products for several years and continues to deliver a patient journey, which is second to none from her clinic in Leicester. Natalia is a valued member of the Teoxane extended family and is recognised for her experience within the field of aesthetics, it is a great pleasure to present her with this award.”
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News in Brief Sinclair Pharma increases product shelf life The Silhouette Soft sutures by pharmaceutical company Sinclair Pharma will now have an 18-month shelf life as opposed to 12; an increase of 50%. The company states that all packs of the Silhouette Soft with the new 18-month shelf life will be dispatched to affiliates and partners immediately as previous 12 months stocks run low. According to Sinclair Pharma, the first batch with the longer shelf life will be Lot369. SkinVital rebrands Dermatological company SkinMed has rebranded its 20% vitamin C serum, SkinVital. According to the company, SkinVital has exceeded expectations and had overwhelmingly positive feedback from its customers. The product now has a 30ml blue bottle with a white dropper lid for a more enhanced clinical and professional appearance. SkinVital contains 20% vitamin C, vitamins E, B3 and B5 as well as hyaluronic and ferulic acid. Camille Morrison, aesthetician at The Cadogan Clinic, stated, “I absolutely love this product – I have noticed that my patients’ skin is much more radiant and I can see a glow on the skin that was not there before.” Kendrick PR takes on EBWPR Aesthetic PR and communications consultancy Kendrick PR has acquired PR agency EBWPR. According to Kendrick PR, the two business offerings will combine to create a ‘unique, full-service PR and marketing consultancy service’ focused on the medical aesthetic, wellbeing and beauty industries. Now supported by a team of eight staff, Kendrick PR will also leverage the EBWPR network and strategic support in Los Angeles and New York, aiming to add further scope and capability for its clients who are looking to expand their brands in the US. Aesthetic Response meets QG-GDPR Standards Clinic support company Aesthetic Response has been certified by Quality Guild (QG) Management Standards after passing the company’s General Data Protection Regulation (GPDR) requirements. Having previously secured QG Management Standards’ Cyber Essentials accreditation, Aesthetic Response has now gained certification in compliance with the requirements of the QG-GDPR Management Standard. They are one of only 15 companies to be currently listed on the company’s list of ‘GDPR Certified Companies’.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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IMCAS world congress preview The International Master Course on Aging Science (IMCAS) is returning home to Paris from January 31 to February 2 to host the 21st edition of IMCAS Annual World Congress at the Palais des Congrès. With an expected 10,000 delegates from over 100 different countries and more than 700 world-renowned speakers leading 265 sessions, the conference aims to deliver three intensive days of 310 learning hours. The scientific programme is constructed upon 15 key themes including lasers and EBD, injectables, clinical dermatology, cosmeceuticals, face surgery, breast and body surgery, regenerative surgery and cell therapy, genital treatments, hair restoration, as well as business development. The full day or half-day modules will be focused on the key themes, exploring the newest developments and how they apply to practice. According to IMCAS, the full day Cadaver Workshop will return for 2019, where it will integrate cutting-edge imaging technologies for an extensive look at the anatomy behind injections. The 21st edition will introduce for the first time, IMCAS Surgery, an ensemble of courses focused on plastic surgery, taking place across all three days of the congress. This module will highlight the Live Aesthetic Surgery Workshop, taking place on the second day, with a dynamic format that features simultaneous transmissions of live dissection with live surgery. Also taking place will be the Global Market Day on the Friday. Comprising three parts, the day will begin with the Innovation Shark Tank, which will consist of presentations from international start-ups, followed by the Investors’ Forum of high-profile On the Scene
analysts and investors, before concluding with the Economic Tribune, which will feature analyses of the various market segments in the field. A networking cocktail reception will take place to conclude the first day of IMCAS, while the annual Gala Dinner will be held to close the event on the final night and allow delegates to network with their peers. Those interested can subscribe to IMCAS Academy and gain access to all the presentations from congresses past and present. This aims to allow users to progress at their own pace in their own time. Subscribers can also download the app for mobile devices to further enhance their experience. On the Scene
sk:n clinic launch, Cardiff On October 4, medical skincare clinic group sk:n opened its 49th clinic on Charles Street in the centre of Cardiff. This clinic is a merger between its existing operation at the David Lloyd Health Club on Ipswich Road and Cellite clinic, an established aesthetic clinic that has been in the area for more than 20 years and was owned by Dr Harryono Judodihardjo. Guests were able to drop in throughout the day to see the refreshed facilities, meet the staff and enquire about treatments. Live demonstrations were performed throughout the day and Dr Judodihardjo was interviewed for a local a radio station about the new launch. The clinic will offer a range of body treatments that have never before been available in a sk:n clinic, including the Pure Tumescent Liposculpture and Endermologie cellulite treatment. Dr Judodihardjo said, “We are all very excited to join an established, leading medical clinic group and I believe that our joint expertise brings a new dimension to what we can offer. The award-winning quality of our service and treatments will by no means be compromised, but can only improve and grow as we embark on this journey with sk:n. We look forward to welcoming back our existing patients, as well as new ones.”
PHI-Lanthropy ball, London On October 13, aesthetic practitioner and owner of London’s PHI clinic, Dr Tapan Patel and his wife Gudiya Patel, who founded the PHI-Lanthropy charity together, held a gala ball for colleagues, patients and friends at the Montcalm Hotel in Marble Arch, London. In its second year, the event aimed to raise funds for the Yezidi Emergency Support charity, which was founded by NHS nurse and Woman of the Year 2018 winner, Anne Norona, and supports victims of SIS genocide. The charity’s support ranges from health and antenatal care, rehabilitation and wellbeing services to survivors, as well as building houses and providing education to the Yezidi children. The ball raised £60,000 in which Dr Patel said he was ‘blown away’ by, “I’m completely overwhelmed by the love and support we have received from everyone. The amount we have raised has blown me away and 100% of every contribution goes directly to those in need. I’d like to thank everyone who attended the PHI-Lanthropy event and a special thanks to the companies that also sponsored the fantastic goody bags including Skinade, iS Clinical, Zenii Skincare and many more!” There was also live entertainment throughout the event, including a gospel choir, Indian drummers and a live band.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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On the Scene
On the Scene
The Best of Hyaluronic Acid, hosted by HA-Derma and IBSA, London On Wednesday October 3, aesthetic practitioners were invited to attend aesthetic distributor HA-Derma and pharmaceutical company IBSA Italia’s first educational event titled ‘The Best of Hyaluronic Acid’. The event, which took place at King’s Fund in London, was held to support the UK charity for children with facial disfigurement, Facing the World, and raised £4,000. To kick off the event, director of HA-Derma Iveta Vinklerova welcomed guests, introducing the topics and speakers as well as sharing background information on both HA-Derma and IBSA. Speakers throughout the day included IBSA’s dermo esthetic business unit manager, Tania Pirazzini; Professor Chiara Schiraldi from the University of Naples; UK and Ireland national sales manager for HA-Derma Frank Ward; HA-Derma medical director Dr Fab Equizi; IBSA international KOL Dr Gabriel Siquier Dameto; aesthetic practitioner Dr Beatriz Molina and independent nurse prescriber Sharon Gilshenan. Many of the speakers also performed live demonstrations. HA-Derma’s operations director, Hana Te Reo said of the day, “The primary objective behind our very first HA-Derma event was to recognise industry practitioners and ‘give back’ by sharing knowledge and insight into the background and collaboration between IBSA and HA-Derma. Furthermore, we have also been able to offer practitioners the chance to meet with Professor Chiara and support the Facing The World charity, a cause very close to our hearts.”
Teoxane Expert Day, London On September 18, practitioners were invited to learn about the latest innovations and techniques by aesthetic manufacturer Teoxane UK in London. Around 250 delegates attended the fifth Teoxane Expert Day (TED), which featured scientific and anatomical lectures and live demonstrations from leading UK and international speakers. The day focused on new techniques and key anatomical areas including the tear trough, lips and contouring of the mid and lower face. After a welcome breakfast and a greeting from director of Teoxane UK Sandra Fishlock, who shared the achievements of Teoxane over the last 15 years, delegates heard from Dr Philippe Faraut, Dr Lee Walker, Dr Patrick Trevidic, Dr Wolfgang Redka-Swoboda, Dr Tahera BhojaniLynch, Dr Raul Cetto and Dr Ayad Harb. Dr Bhojani-Lynch, who is a cosmetic doctor and ophthalmologist, said of the day, “It was one of the most interesting and informative educational days I’ve attended in a long time. My highlight was Dr Trevidic, who showed anatomy dissections corresponding to the live injections on every part of the face.” Jordan Sheals, brand manager at Teoxane UK said the day was a complete success, “We aim to share medical education at the highest standard, delivering scientific innovation and excellence in facial aesthetics and our fifth TED certainly delivered this – it was a real success.”
2nd IAAGSW World Congress, London Aesthetics reports on the highlights of the International Association of Aesthetic Gynaecology and Sexual Wellbeing (IAAGSW) World Congress On October 12, 13 and 14 the second IAAGSW World Congress was held at the Royal Society of Medicine in London. Aesthetic practitioners, gynaecologists and surgeons were in attendance to learn more about the new aesthetic gynaecology and andrology subspecialty. The first two days consisted of live demonstrations and
videos focusing on aesthetic gynaecology, andrology, regenerative medicine and bioidentical hormones, whilst the third was a full day of live procedures. IAAGSW president, aesthetic practitioner Dr Sherif Wakil, perfomed a demonstration of vaginal rejuvenation with dermal fillers, carboxytherapy was showcased by aesthetic
practitioner Dr Isabella Ermenegildo and gynaecologist Dr Jack Pardo used lasers. Urologist Dr Dimitrios Borousas and surgeon Mr Gary Horn both performed penis enlargement treatments using dermal fillers. Dr Pardo said of the conference, “The event was extremely well organised with a lot of knowledge and experience shared with a highly scientific agenda.” Dr Wakil added, “I am very happy that the congress was another great success following the first last year; the feedback was outstanding from the speakers, delegates and sponsoring companies. There was a vast amount of scientific knowledge and cutting-edge treatments from all over the world, I believe this event has benefitted not only the UK doctors but all of the international doctors who travelled from 40 countries including Taiwan and China to attend. I feel very honoured that I am continuing to build the foundation of these specialities in the UK, it was very hard work but it’s absolutely worth it.”
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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BCAM Conference 2018, London Aesthetics reports on the British College of Aesthetics Medicine’s annual conference On Saturday September 22, 250 medical aesthetic doctors and dentists attended BCAM’s annual conference at the Church House Conference Centre in Westminster, London. Conference director and aesthetic practitioner Dr Ruth Harker started the day with her welcome speech, which outlined BCAM’s vision to become a renowned academic institute and fraternity for doctors and dentists in the medical aesthetic specialty. The conference provided two comprehensive agendas alongside an exhibition. The Main Lecture Programme focused on clinical presentations and live demonstrations. Delegates learnt about the anatomy of the jawline and neck, alongside strategies for rejuvenation from consultant plastic surgeon Mr Rajiv Grover, while consultant dermatologist Dr James Britton discussed dermatological infections and how to manage them. General practitioner and TV presenter Dr Hilary Jones chaired a forum on infections and complications, in which aesthetic practitioners Dr Patrick Treacy and Dr Tapan Patel, consultant plastic surgeon Mr Nigel Mercer and Mr Grover discussed the number of infections practitioners are experiencing and the importance
Aesthetics Journal
of ensuring the appropriate training has been completed before attempting new procedures. Dr Patel noted, “ I feel that the quality of training courses is much better now, there’s structure and more involvement of the anatomy. Make sure that you get the adequate training and avoid experimentation.” Other subjects covered in the main lecture programme were nonsurgical rhinoplasty, when to say ‘no’ in aesthetics, complications with fillers and botulinum toxin, as well as treating lax periorbital skin non-surgically. In the second programme, the Business and Clinical Forum, topics such as appraisals, and producing profit and litigation in aesthetics were covered. Psychotherapist Norman Wright, and aesthetic practitioners Dr Max Malik and Dr Steven Harris all presented individually on the mental wellbeing of aesthetic patients and how to recognise body dysmorphic disorder. As the event drew to a close, Dr Harker shared her final thoughts on the conference, “I think today has been absolutely fabulous and more than I could have dreamed of. It’s been busy, with a real buzz circulating the event. Everyone who attended has been exhilarated and inspired by the speakers as they have been so interesting and covered a plethora of different topics.” The BCAM Conference for 2019 will take place at the Church House Conference Centre in Westminster on Saturday September 21.
IAPCAM Symposium, London Aesthetics reports on the second International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) symposium Held at Church House Conference Centre in London on September 21, the IAPCAM symposium hosted 120 delegates to advance their knowledge on complication management. Conference director and aesthetic practitioner Dr Beatriz Molina introduced the meeting agenda alongside facial plastic surgeon Mr Frank Rosengaus Leizgold, who helped co-host the day. Kicking off the talks was dermatologist and aesthetic practitioner Dr Harryono Judodihardjo, who discussed considerations of complications and differential diagnosis techniques. Then, aesthetic practitioner Dr Philippe Hamida-Pisal presented a talk on prevention and management of complications in mesotherapy. Following this, physician Professor Syed Haq performed a live demonstration of a full-face polydioxanone (PDO) thread lift. This was later followed by aesthetic practitioner Dr Nestor
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Demosthenous, who showcased a full-face thread lift with poly-L-lactic acid (PLLA) threads which provided an alternative option to the previous variant of threads shown. Following the thread theme, aesthetic practitioner Dr Kuldeep Minocha discussed the most common complications when treating the neck with fillers and threads. His tip was to, “Always advise patients to disinfect their hands before the procedure as usually the first thing they do afterwards is touch their face.” Partner at law firm Hill Dickinson Emma Galland talked on mitigating the cost of a complication and best practice before and after a treatment, in which the key message was to ‘document everything’. Ending a busy morning was dental surgeon Mr Andrew Greenwood who performed a live demonstration on using hyaluronidase for dermal filler complications. During the afternoon, maxilloplastic surgeon
Mr Jeff Downie and aesthetic practitioner Dr Gabriel Siquier Dameto co-hosted a session on understanding anatomy. Medical device specialists Feza Haque and Salma Husain from the Medicines and Healthcare products Regulatory Agency, then presented on current regulatory considerations of medical devices. This was followed by presentations of successful case studies from consultant dermatologist Dr Sandeep Cliff, aesthetic practitioner Dr Sophie Shotter and Dr Molina. To round up the day, a live panel discussion took place featuring Dr Cliff, Dr Rosengaus Leizgold, Dr Shotter, Dr Siquier, Dr Demosthenous, Mr Greenwood, Dr Minocha and Dr Molina. Delegates were able to ask questions to the panel, which included regulation, product recommendations and case-by-case advice. Dr Molina concluded, “It’s been another great day for all involved. Great speakers, an innovative agenda and fantastic support from all our sponsors helped us to provide a very educational day for our delegates. We have been able to hold an open, honest forum, allowing all to share their experiences with the difficult topic of complications within the aesthetic specialty. We look forward to seeing everyone back for next years’ IAPCAM symposium.”
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Sinclair Pharma’s World Experts Meeting, Barcelona Aesthetics reports on the annual World Experts Meeting (WEM) held by Sinclair Pharma in Barcelona on October 19 and 20 Pharmaceutical company Sinclair Pharma hosted its sixth WEM at the Palau de Congressos de Catalunya in the cosmopolitan city of Barcelona. In attendance were more than 1,300 delegates from across 49 countries, primarily made up of aesthetic practitioners. There were also 44 speakers from across the globe taking part in the event. Spanish surgeon and Sinclair brand ambassador Mr Javier De Benito introduced the two-day meeting by welcoming those in attendance to the three Sinclair pillars; dermal fillers Ellansé and Perfectha and suture Silhouette Soft. He discussed how each product can be used in practice, both alone and in combination. Using the products in combination was a primary focus across both days. Day one’s agenda focused on upper, midface and lower face treatments. Speakers presented on the anatomy of all of these areas, exploring considerations for different ethnicities and how to get the best treatment results. A number of live demonstrations were performed, presented by aesthetic practitioners Dr Saleena Zimri, Dr Kyungkook Hong, Dr Shang-Li Lin and Dr Gabriel Aribi. Dentist and aesthetic practitioner Dr Tim Eldridge from the UK also presented on the technology behind Ellansé and Silhouette Soft, before a roundtable discussion on preventing complications took place. The day drew to a close with a live demonstration of a full-face combination treatment using all
three pillars, performed by plastic surgeon Mr Alieksiéi Carrijo. Consultant plastic surgeon and delegate, Mr Geoff Wilson said of the day, “This is a great opportunity to see how techniques are evolving and I am looking forward to being able to take this information and replicate it in my own clinic.” All guests were invited to a gala cocktail party on the Friday evening with the opportunity to network and meet with colleagues and peers. During the event a ‘before and after competition’ took place, in which customers of Sinclair Pharma from across the world shared their best cases. It was a fantastic night for the UK practitioners, as coming in at second place was aesthetic nurse prescriber Patricia Goodwin and in first place, aesthetic practitioner Dr Victoria Manning. National sales manager of UK and Ireland, Simon Ofei, said, “I am thrilled that two of our UK practitioners have been recognised
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for their excellence in a global competition. I think this just shows how forward-thinking and innovative we are as a country.” The second and final day of WEM saw talks on creating the perfect profile, hand rejuvenation and treating the neck, all of which were supported by live demonstrations from plastic surgeon Mr Franco Vercesi, consultant plastic surgeon Mr Francisco De Melo, aesthetics practitioners Dr Kyungkook Hong and Dr Rosalba Russo. Presentations and a roundtable discussion also took place on the technology and different uses of Perfectha. The final session looked at unique cases in which the three products had been used for various other indications such as treating cellulite, vaginal rejuvenation, presented by GP and aesthetic practitioner Dr Kathryn Taylor Barnes, and buttock contouring; all of which suggested that the products have the potential to be used in a number of ways and that more studies into these areas should be encouraged. Dr Manning, who is a brand advocate for Sinclair Pharma and was also one of the 44 speakers at the event, said the opportunity was a career highlight, “It’s been an amazing opportunity to speak in front of 1,300 people about an area I am extremely passionate about. To be able to share my experience in front of some of the world’s best injectors is an honour.” Sinclair Pharma’s brand manager, Joanna Neal, concluded, “It has been a fantastic few days here in Barcelona. Not only have we had the largest UK attendance than ever before, but the quality of the talks and live demonstrations continue to improve year on year. We have seen a number of treatments during the event that have combined all three of our products and we hope that our delegates see the fantastic results that this can have, providing them with the knowledge to practise this in their own clinic.”
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Why was the advice given? According to consultant plastic surgeon and president of the BAAPS Mr Paul Harris, this advisory was to be expected and he states that it is, in part, due to the lack of suitable data to show the procedure is safe, paired with the high reported complication and death rate. In August this year, the Task Force for Safety in Gluteal Fat Grafting (which represents plastic surgeons worldwide and aims to promote patient safety and conducts studies to develop specific safety guidelines), issued a warning against the procedure. It also provided additional recommendations to surgeons for patient safety and urged them to thoroughly discuss the risks with patients.7 Mr Harris says, “This advisory is a natural progression of the Task Force’s warning, conversations within the association and reported UK deaths. We had to make the decision whether we take a register and report all deaths and complications, but by doing this you are not saving lives; a death is still a death whether it’s on a register or not.” Mr Harris says that although this isn’t a blanket ban, the BAAPS will be monitoring UK treatments closely, and if more deaths do occur, they may enforce a complete ban for their members by amending the association’s Code of Conduct. Aesthetics explores the recent advisory “In the past, if members have continued to work outside of the from the BAAPS to their members against Code of Conduct we have asked them to leave. It may be in future that we change the ‘recommend’ to ‘must not’ but, at the performing the Brazilian Butt Lift moment, there is no suggestion we will be doing that. Although At the Annual Scientific Meeting of the British Association of this is not a threat, it is not something we are taking lightly,” Mr Harris Aesthetic Plastic Surgeons (BAAPS) in October all members explains. Consultant plastic, reconstructive and aesthetic surgeon, were advised by the association to stop performing Brazilian Mr Dalvi Humzah who isn’t a member of the BAAPS, questions if the Butt Lift (BBL) procedures until more data is collated. The primary advisory was necessary as it could potentially prevent surgeons from reason BAAPS has given this advice to its members is because of reporting complications from the procedure. However, he recognises high complication reports related to this procedure.1 According to that it highlights the severity of the surgery to both patients and BAAPS, the BBL has the highest death rate of all cosmetic surgery surgeons. “I would have thought a more tempered approach would procedures, with one in 3,000 treatments resulting in fatality.2 This be to detail the risks and advise how it needs to be mitigated. Any announcement came the day after a second UK woman died procedure to the buttock is extremely high risk and those performing following the procedure abroad;3 however, BAAPS confirms they these treatments should be highly-qualified, carefully mentored and have been monitoring the issue for many months and the statement able to act quickly should a complication arise,” he says. Mr Humzah was not in light of this death. agrees that these procedures are very high risk and should have Since the announcement, the British Association of Plastic parameters around them; it is for this reason that, around five years Reconstructive and Aesthetic Surgeons (BAPRAS) has also stated ago, he made the decision not to perform any buttock procedures. that they are ‘fully supportive of the BAAPS decision’ on this.4 The This is because he noticed he only had a handful of patients and UK Association of Aesthetic Plastic Surgeons (UKAAPS) has agreed felt he couldn’t keep his competency to a high standard with low with the BAAPS concerns over the safety record of the treatment numbers. Mr Harris recognises this, stating, “There are some surgeons although Professor Frame, president of UKAAPS stated that it is around the world that are doing five or ten cases a day and that gives acceptable to perform this procedure in some circumstances and them significant experience. However, we don’t think that there are with adequate training. At the time of going to print UKAAPS has not any surgeons, or they are in a small minority, in this country that are released a formal advisory for its members. doing that sort of quantity, so they don’t have that sort of experience.
The BAAPS’ advisory on Brazilian Butt Lift
Understanding the BBL
The BBL is a marketing term, referring to the process of contouring and augmenting the lower back and loins through liposuction, and reinjecting this fat into the buttocks to create a larger, lifted effect.2 The treatment became particularly popular globally in 2015 and the American Society of Plastic Surgeons reported that there was a buttock procedure in the US (including BBL and implants) every 30 minutes, every
day during 2015.5 The BAAPS suggests that the procedure has become popular due to ‘aggressive marketing campaigns’ and celebrities showcasing a more voluptuous posterior on social media channels.1 Possible complications specific to this surgery include severe bacterial infections, including MRSA and pseudomonas, necrosis, scarring, wound ruptures and abscesses, amongst others.1 Usually, fatalities are caused by injection of fat
into large veins or nerves (such as the superior or inferior gluteal vein or sciatic nerve) causing a fat embolism, where the fat enters the bloodstream and blocks a blood vessel or stops oxygen getting to the lungs.2 A survey conducted in 2017 by the Aesthetic Surgery Journal showed that 692 surgeons from across the world reported 32 cases of death and 103 non-fatal complications from BBL procedures over their careers.6
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
That’s why we are saying, if you are only doing a few a year, that’s probably not the right thing to do.” Mr Humzah adds to this, stating that there are more considerations than just the surgeon. He explains, “It’s not only about the competency of the surgeon but also the facility. If performing these treatments, I believe they should be carried out in facilities where all eventualities can be catered for. I know patients who have had a serious complication in the recovery room from BBLs’ and had to be blue-lighted into an intensive care unit. This should be onsite if we are willing to take on such high-risk procedures and have evidence that complications are likely.”
Is health tourism the issue? It has been highlighted by the BAAPS that most BBL treatments are taking place abroad. Although Mr Harris recognises that this advisory to UK practitioners may encourage patients to continue to go abroad, he explains that the issue isn’t about where they are getting the procedure done, it’s about raising awareness of the dangers. He adds, “We need to raise awareness to our patients and make them think twice, whether they go abroad or not. There are also huge cost implications to our NHS. Mr Humzah agrees with Mr Harris, but also states that health tourism can be a good thing, although not for this particular procedure. “I often wrestle with the health tourism issue as it works both ways. A lot of my patients travel from abroad to see me.” He suggests tighter regulation from the UK government on aftercare following procedures that are conducted abroad could help, “I would say there needs to be a focus on continuity of care if a patient does have a treatment abroad. Patients that decide to do this need to be provided with appropriate insurance and adequate information on what happens after.”
Moving forward Mr Humzah says that in his experience it is uncommon for associations to put advisories such as these in place for its members, but Mr Harris reiterates that he believes it is ‘the right thing to do’. He adds, “We have been keeping an eye on this issue for some time now. All associations have a Code of Conduct and although this hasn’t reached ours as of yet, there is clearly a problem here. We need to do everything we can to protect the public.” Although Mr Harris and Mr Humzah believe this is a big issue today, they highlight that the BBL could simply be another trend. Mr Harris concludes, “Isn’t it dreadful that people lose their lives over a trend? It may well be that when the Task Force collates all data, which is something they are working on, guidelines will be put in place on how much or where to inject. This would mean that we are able to provide safe care. But, until we have that information, for which a date isn’t secured, we shouldn’t be doing it.” REFERENCES 1. BAAPS, The Bottom Line, 2018 <https://baaps.org.uk/media/press_releases/1630/the_bottom_line> 2. BAAPS, BAAPS statement on Brazilian Buttock Lifts, 2018 <https://baaps.org.uk/media/press_releases/1621/baaps_statement_on_brazilian_buttock_lifts 3. BBC, Second Brit dies after ‘Brazilian butt lift’ surgery, 2018<https://www.bbc.co.uk/news/ health-45731191> 4. BAPRAS, Statement on Brazilian Butt Lift, 2018 <http://www.bapras.org.uk/media-government/ news-and-views/view/bapras-statement-on-’brazillian-butt-lift’-surgery> 5. Plasticsurgery.org, American Society of Plastic Surgeons, New statistics reflect the changing face of plastic surgery, 2016 <https://www.plasticsurgery.org/news/press-releases/new-statistics-reflectthe-changing-face-of-plastic-surgery> 6. Mofid M, Teitelbaum et al, Aesthetic Surgery Journal, Report on Mortality from Gluteal Fat Grafting: Recommendations from the ASERF Task Force, 2017<https://academic.oup.com/asj/ article/37/7/796/3075249> 7. Surgery.org, Multi-society Gluteal Fat Grafting Task Force issues safety advisory urging practitioners to reevaluate technique, 2018<https://www.surgery.org/sites/default/files/Gluteal-Fat-Grafting-02-06-18_0.pdf>
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Meet Your Elite Training Providers Develop your practical and clinical skills by attending training from the best providers in the UK at the Elite Training Experience Do you want to brush up on the latest aesthetic techniques, products and clinical skills? Or perhaps you have just joined the aesthetic specialty and are looking to progress your knowledge? No matter what stage you are at in your medical aesthetic career, you will learn something new at the Elite Training Experience, showcased at the Aesthetics Conference and Exhibition (ACE)
in London on March 1-2. Never before has any other event brought together four of the UK’s most sought-after training providers. Conference organiser and Aesthetics journal editor, Amanda Cameron, said that each provider will bring their own unique training style. She said, “After an extremely successful agenda last year, we decided to bring the Elite Training Experience back for 2019. We
have introduced two, fresh new training providers, which are sure to create a stir with delegates. Remember that seating is limited and to reserve your place before the end of this year for a 10% discount. I can’t wait for delegates to see just how much they will gain from attending these clinical sessions, which are jam-packed with live demonstrations from the best UK injectors!”
AESTHETIC TRAINING ACADEMY
DALVI HUMZAH AESTHETIC TRAINING
Friday March 1 – 10:00-13:00
Friday March 1 – 14:00-17:00
Kicking off the Elite Training Experience agenda will be the team from Aesthetic Training Academy, presented by industry-renowned KOL and aesthetic practitioner Dr Simon Ravichandran and experienced aesthetic medicine specialist and dentist Dr Emma Ravichandran. This practical Elite Training Experience session will showcase a mastery of techniques, taking delegates through the methods learnt from beginner level, all the way to sophisticated procedures achieved by the most advanced practitioners. In this session, continuous live demonstrations will be overlaid with theoretical descriptions and presentations covering:
The award-winning education provided by Dalvi Humzah Aesthetic Training (DHAT) is back for another year, incorporating the latest treatment tips and techniques from consultant plastic, reconstructive and aesthetic surgeon and lead tutor Mr Dalvi Humzah, and cosmetic and dermatology nurse practitioner and DHAT tutor Anna Baker. The DHAT content this year will be brand new to the Elite Training Experience and will drive your anatomy knowledge forward, whilst providing you with the latest tips and techniques for successful and safe injectable treatments. Among the content will be:
• Patient assessment: ethics, methods for responsibly selecting the right patient, assessment skills for appropriate treatment tactics • Anatomy and injection techniques: anatomical presentations and live demonstrations on all areas of the face • Complications: preventing injection mistakes, avoiding danger zones and discovering how to ensure safe and successful results
• Treatment of the neck: a multimodal approach for successful neck treatments, including dermal fillers, botulinum toxin and threads
• 3D facial anatomy: facial anatomy considerations through the launch of a brand new 3D virtual reality training suite
• The secret Ps of a powerful presentation: impress your
colleagues and patients with the art of effective delivery and presentation
BOOK YOUR EXPERIENCE So, which trainer will you choose? The best thing about the Elite Training Experience is that you don’t have to! You can attend every session and learn something new to help improve or refine your clinical or business skills, ensuring you progress in the ever-evolving field of medical aesthetics. What’s more, by attending, you will receive free access to ACE 2019 and all the complimentary content within the Expert Clinic,
Masterclass, Symposium and Business Track agendas, as well as access to the 2500m2 Exhibition Floor, featuring more than 80 aesthetic companies. Remember, by booking to attend any Elite Training Experience session at ACE 2019, delegates will receive three CPD points, as well as an exclusive 10% discount on a future full course with their chosen training provider. Each Elite
Training Experience is priced at £195 +VAT, a fraction of the usual cost for education with these training providers. Book before December 31 for a 10% discount. Sessions within the Elite Training Experience are restricted to certain medical professionals and delegates will be required to provide their medical professional numbers to book. See you at the Elite Training Experience!
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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MEDICS DIRECT TRAINING
DR BOB KHANNA TRAINING INSTITUTE
Saturday March 2 – 10:00-13:00
Saturday March 2 – 14:00-17:00
Returning for another successful training event will be internationally renowned aesthetic practitioner Dr Kate Goldie and her team from Medics Direct Training. For 10 years, Medics Direct Training has been at the forefront of aesthetic education, both in the UK and internationally. This lively and dynamic session, arising from Dr Goldie’s years of experience, will provide valuable insights for everyone from expert practitioners to those starting in practice. This year, Dr Goldie’s session will draw upon her latest skills and techniques to explore how to incorporate traditional aesthetic injectable treatments with regenerative and rejuvenating methods. Amongst the content will be:
• Regenerative aesthetics: produce exceptional results through platelet-rich plasma and other new technologies
• Debunking cannulas: improve your use of cannulas for successful dermal filler placement for mid-face sculpting and shaping
• Introducing new modalities: tailor your treatments to your individual skills and patients to achieve maximum patient satisfaction
Making its debut at the Elite Training Experience agenda will be Dr Bob Khanna Training Institute (DrBKTI), presented by cosmetic and reconstructive dental surgeon Professor Bob Khanna. Professor Khanna was one of the first dental surgeons in the world to venture into dermal filler and botulinum toxin aesthetic procedures for non-surgical facial rejuvenation, and over the last 22 years has trained thousands of practitioners. Drawing upon his international training and presenting experience, Professor Khanna will explore the following: • Anatomy and assessment: comprehensive lectures covering the anatomical considerations for successful facial analysis, consultation, diagnose and treatment • Combination treatments for the face: combination of different non-surgical modalities for upper, mid and lower face treatment • Clinical photography: the essentials for clinical photography to produce accurate and reproducible before and after images
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Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Effective Laser Hair Removal Practitioners discuss their treatment methods and technology preferences for successful long-term laser hair removal While many topics in the November hair issue of the Aesthetics journal focus on stimulating and regenerating hair growth, we cannot ignore the popularity of the opposing treatment, the removal of unwanted hair. Hair removal dates back to, and potentially pre-dates, ancient Egyptian times, where both men and women shaved their body and head hair for hygienic and fashion reasons.1 While researchers state that waxing using caramelised sugar and shaving using razors were the common means for removal in those times, today there are more modern methods.1 Although shaving, tweezing, epilating, waxing, chemical depilation, and other such methods are still widely used to remove hair, many people are now looking for more long-term solutions.
Why laser? Generally speaking, aesthetic practitioners have three options for long-term hair reduction. Electrolysis, intense pulsed light (IPL) and laser hair removal (LHR).2 All practitioners interviewed for this article prefer to use LHR over IPL and electrolysis. The main reasons stated were that electrolysis can be very slow and painful,3,4 while the practitioners believe laser is more suitable, safer and more efficient for treating a wider variety of skin types, compared to IPL. Independent nurse prescriber and owner of Cosmex clinic in Cambridge, Lou Sommereux, explains, “Lasers have more fluence, or more power, but laser is also a concentrated, single wavelength, which means that we can choose specific wavelengths that will have better absorption by the melanin in the hair follicle. Comparatively, IPL has thousands of wavelengths; it’s a wide spectrum of light and it doesn’t focus its energy with that light for optimum wavelength – meaning that it’s not quite as powerful.”4,5,10 Dr Neil Sadick, clinical professor for dermatology at Weill Cornell
Medical College and the head of Sadick dermatology and Sadick Research Group in the US, adds, “I think LHR is the most efficient way to safely remove hair for the long-term. IPL is also safe but I find that laser is the least painful, is more effective and has the best safety profile. I would assume that LHR is still the most popular aesthetic treatment performed on a global basis in 2018.” Consultant dermatologist Dr Firas Al-Niaimi, who practises privately in London’s Harley Street and is group medical director at sk:n clinic, agrees, “We exclusively use lasers because we believe that lasers are better in the long-term and have more consistent results. These results vary between individuals, but following treatment most people will need one to two sessions of maintenance a year, depending on their factors such as hair growth, initial response and hormone status.”5 Consultant dermatologist Dr Maria Gonzalez, owner of Specialist Skin Clinic in Cardiff, notes that although she hasn’t used IPL for hair removal for many years, it shouldn’t necessarily be ruled out. “I think IPL is more of a starter system. I find you can get good results using modern IPL systems in patients with skin types I-III, but you can’t effectively and safely treat type IV skin and above, so if you don’t have a very cosmopolitan population you can get away with IPL.” But, she adds, “If you are really serious about getting good results for a variety of patients I think you need to invest in lasers, specifically the 755 nm and 1064 nm long pulse wavelengths.” Dr Gonzalez’s reasoning behind this is that these wavelengths can treat patients from skin type I-VI.
Choosing a device Sommereux states that practitioners often feel overwhelmed by the sheer number of devices available to choose from. Sommereux states, “It’s a bit like when patients come in and say that they are overwhelmed about skincare and they just don’t know what to go for. I think choosing a laser device is about talking to the companies, getting a feel for what’s out there and building a relationship with that company. Ensure that the technology ticks all the boxes that you are
Laser lingo6 Light amplification by the stimulated emission of radiation (laser): device with single wavelength that produces a beam of light with the properties of coherence, collimation and monochromaticity Intense pulsed light (IPL): device with a broad spectrum of light energy that is defined by filters that cut off this light8 Pulse: The time for which the laser beam interacts with a given point on the skin (usually in milliseconds, nanoseconds)7 Spot size: the diameter of the laser beam Wavelength: a shorter wavelength is safer for lighter skin types and a longer wavelength is better for darker or tanned skin types Fluence: the energy delivered per unit area Alexandrite Laser Wavelength: 755 nm, long pulsed, can treat skin types I-IV and rarely and carefully type V using longer pulse widths Diode Laser Wavelength: 800-810 nm, long pulsed, can treat skin types I-V Neodymium: Yttrium-Aluminium-Garnet (Nd:YAG): 1064 nm, long pulsed, can treat skin types I-VI
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
FINALIST 2018
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looking for.” Dr Al-Niaimi suggests that practitioners need to assess the device’s wavelength, spot size, power and cooling. “What practitioners need to look for is, firstly, a suitable wavelength for the type of hair – I think for the lower skin types I-III you preferably you want an alexandrite [755 nm] or a diode [800-810 nm] laser. For the higher skin types, you should look at a Nd:YAG 1064 nm,” he explains, adding, “Also you would want to look at a system that is reliable, with enough energy and enough power, a spot size that will allow you to get depth of penetration and speed. Efficient cooling is important Figure 1: Patient before and five treatments on the back using Candela GentleMax Pro. Spot size: as it increases the device’s safety profile. If you require 15mm, fluence: 14 J/cm2, cooling DCD: 80-50. Images courtesy of Dr Marcelle Kutun. additional cooling, depending on the area, you can use cold air or ice packs before and after.”8 can be quite chunky and ugly and this is quite nice and slender.” All practitioners interviewed each have individual preference for LHR Sommereux also notes that practitioners should consider the weight devices. Dr Sadick’s lasers of choice are the Venus Velocity 800 of the handpiece, as some can be quite heavy, which can tire the nm diode and Cutera Xeo 1064 nm Nd:YAG machines. He states, user after extended use. “Many companies produce excellent technologies, but these are the To complement laser treatment, Dr Al-Niaimi and Dr Gonzalez ones I have researched and have had the most experience in. I am consider combining laser treatments with eflornithine hydrochloride particularly excited by the Venus Velocity as it’s a high-powered diode 13.9% cream, sold under the brand name Vaniqa, for particularly laser, is very fast, has very little discomfort and has a very high hair challenging facial cases.9 Dr Gonzalez states, “Some patients, who removal efficiency.” need a bit of extra assistance and take a bit longer to respond to Dr Al-Niaimi uses the Candela GentleMax Pro, which is a dual treatment get improvement because it slows down the hair growth, wavelength system, with 755 nm and 1064 nm, and the Cynosure so can be used in combination with laser treatment.” Apogee Elite laser systems. To him, the clinical studies regarding For patients with red, white or grey hair, all practitioners interviewed safety and efficacy matter the most. He explains, “These systems note that the best approach is to recommend alternative short-term are very well established in the market in terms of studies and safety hair removal methods, or to refer for electrolysis.3,4 This is because, profile and they have the right wavelengths. They also have different despite technological developments, it is still not possible to treat spot sizes and we are very happy with the results that we are these hair colours using LHR or even IPL. Dr Al-Niaimi explains, getting.” Speaking specifically about the GentleMax Pro, Dr Al-Niaimi “It’s because laser and IPL needs a chromophore, or target, to be states, “I like this device because of its dual wavelengths, multiple absorbed and white, red or blonde hairs lack this target.”4,5 spot sizes, which are large, high power and its dynamic cooling device, which increases safety.” Laser treatment tips and considerations Senior aesthetician Musharraf (Mo) Ashraf, managing director of New Dr Gonzalez claims that the majority of patients are easy to treat. “I Life Medical Aesthetics, adds, “I have had a few lasers but my absolute would say about 70% of people get very good results, but around 30% favourite is the Cynosure Apogee Elite. I use it because it’s got two of patients will be more challenging,” she says, adding, “Three factors wavelengths, an alexandrite 755 nm wavelength and a 1064 nm contribute to successful results: skin colour, hair colour and hair calibre, Nd:YAG. I use the alexandrite to treat light skin types and the Nd:YAG which is the thickness of the hair. These factors will determine how for darker. That means that we can treat almost every skin type and it challenging the patient is and what you will use to treat them.” gives fantastic results.” Dr Gonzalez says patients with dark brown or black hair will get Dr Gonzalez also uses the Apogee Elite, stating that she thinks these the best results, while those with lighter and thinner hair are more two wavelengths are usually all that most practitioners will need. She challenging. Although patients with pigmented skin can get good adds, “I also have the ABC Soprano ICE Platinum diode system with results, they can also be challenging to treat because they are more an 810 nm wavelength. This device has technology that is slightly likely to result in complications, discussed below.5 different from the Elite laser as you are treating a field, rather than one Ashraf highlights that one must assess a patient’s tan and sun spot at a time. This theoretically means you are using lower energy exposure. She explains, “If I am in doubt about the patient’s skin type, I for a wider area and so it should be less painful.” Dr Gonzalez says will always assess an area that has not been exposed, for example the she will therefore choose this laser when patients have a low pain buttock or bikini area. I make it very clear in the consultation that they threshold and when treating larger areas like the legs and back. She can’t have any sun exposure before or after the treatment to prevent also notes that she uses this to treat difficult cases, such as fine facial pigmentation. We send out a pre-care treatment form and an aftercare hair in Asian patients, and if a patient comes back from holiday with a treatment form to remind patients.” Ashraf advises patients to avoid slight tan, because she says the technology used in this device is less sun exposure for three weeks before and after treatment, although likely to cause complications. there are differing recommendations. The NHS recommends one Sommereux’s laser of choice is the Aluna Supreme dual wavelength week, while some authors recommend six or 12 weeks.5,6,10 810 nm diode and 1064 Nd:YAG laser from Cambridge Stratum. She Ashraf states that because the UK summer was so hot this year, she says, “I choose this because of its safety, efficacy, reliability and delayed many treatments. “I postponed about 70% of my facial laser price – an affordable price is very important to me. It’s also very treatments because even though people say they’re wearing SPF, I easy to use – it’s got great pictures of different areas of the body find that most don’t reapply every two hours. Even for patients who and you just programme that area so it’s very user-friendly and feels wear scarfs around their face, the lip area could still be exposed, for very safe. I think it’s also nice to look at – some of the machines example, so I refused treatment.”
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Reiterating the importance of skin colour, the biggest tip Sommereux gives is to never guess patients’ skin type. “Always use the Fitzpatrick skin scale and always make sure that it’s documented,” she advises. Dr Sadick notes the importance of ensuring the patient’s expectations are not too high, reiterating that results are ‘partial permanent’ rather than ‘permanent’ and each patient is likely to have different outcomes. “Results vary between patients and I find that it takes between four to 10 treatments to give a significant amount of long-term hair removal. I also advise patients not to shave immediately before they come in – you don’t want long hairs, but you don’t want it totally shaved – so I advise they shave a day before,” he says.
Adverse events Complications and side effects caused by experienced, appropriately trained aestheticians or medical professionals are rare, according to the interviewees. However, most commonly erythema, hyper and hypopigmentation, and burns can occur, among others.11,12 Dr Sadick adds, “There is also an entity called paradoxical hyperplasia, which needs to be discussed with the patient. This is where hair will increase in length – it is a rare side effect of the procedure.”8 As mentioned, the darker the skin, the higher the risk of complications. Dr Gonzalez states, “I have never had any complications in Caucasian skin, and that tells you where all your complications lie – in pigmented skin.” She adds, “You need to be particularly careful with Asian patients as some are darker skinned than others. If you are unsure where they fit, always go with the safer 1064 nm wavelength first. There are also patients of nebular skin types, meaning they look very fair but if you saw them tan you will be shocked at how easily they colour and they can get serious inflammatory hyperpigmentation following laser treatments.” To prevent complications, Sommereux highlights the importance of a patch test 48 hours before the first treatment to check for unwanted skin responses. Dr Sadick adds that if someone doesn’t respond to the patch test or even a treatment as one would expect, they may need to be referred to their GP or a gynaecologist. He says, “They might have some androgen problems or polycystic ovary syndrome. This needs to be treated prior for efficient hair removal.” Dr Gonzalez states that out of all the treatments she offers, most of her complications arise following LHR. “It’s not that we have many complications, but they stand out next to everything else that we do,” she says. Therefore, practitioners note that choosing the right device and technology is paramount, as is training in each new device you acquire.
Marketing LHR in clinic According to Sommereux, now is a good time of year to market LHR treatments. She says, “From autumn into the winter is the best time to treat patients so that the skin is ready for summer. LHR is usually a course of around six to eight treatments so it’s really important to plan ahead and think about summer holidays and market accordingly.” Interestingly, while Dr Gonzalez notes that LHR is the most popular treatment in her clinic, she puts a lot more effort into marketing other treatments. She says, “Even if I do no marketing we find that at the end of the year it’s still the most popular treatment. I don’t tend to market LHR because I don’t want to try and compete with large clinics. Instead, I just ride the crest that they have created because they are pushing it so much that people just assume that it’s offered anywhere.” If Dr Gonzalez does decide to do any LHR marketing, she targets her current patients rather than attempt to bring in new ones. She says, “The market is very consumed by the biggest
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players so I find this approach works best for my clinic.” Dr Sadick agrees that in-clinic marketing is a good approach, stating, “Let your own patients know you have the technology by holding evening workshops and always have some kind of professional information available in your clinic to let your patients know you have it available.” LHR is actually the only treatment Dr Gonzalez offers a ‘package’ for, as she is generally against marketing discounts, and doesn’t use this term. She says, “I think discounts or packages can make the treatment very retail-like. I think discounts can undervalue the medical importance of the treatment – it might be a cosmetic treatment, but the complications are certainly very medical.” She adds, “We let patients ask us about pricing for packages. We explain the treatment in detail and then when they bring up the price we say they can get a discount if they book several treatments.” All practitioners interviewed state that they do not market on discount websites such as Groupon, despite its popularity. For example, when typing in ‘laser hair removal London’ more than 200 results are generated.13 Ashraf says, “We never go through sites like Groupon. This is because when you get somebody who is coming in for a cheap treatment they are just going to go somewhere else later for a cheap treatment. Apart from not being able to keep the patient, you also don’t know where they have gone for their last laser and when.”
Summary Practitioners interviewed reiterate the importance of training, knowing each device’s parameters and knowing which patients need extra care. As Dr Gonzalez states, the highest risk of LHR complications is with patients of darker skin types so take even more care with these patients. She reiterates, “Don’t take skin types for granted, especially if there is pigmentation.” As with many other non-surgical aesthetic treatments, managing patient expectations is also critical, and practitioners stress the importance of informing patients that LHR is not ‘permanent’, despite the marketing of such by some clinics. REFERENCES 1. Illumin, Beauty and the Geek: The Engineering Behind Laser Hair Removal, University of Southern California, 2012, <https://illumin.usc.edu/beauty-and-the-geek-the-engineering-behind-laser-hairremoval/> 2. Vanessa Ngan, Hair Removal Techniues, DermNetNZ, 2005. <https://www.dermnetnz.org/topics/ hair-removal-techniques/ 3. Vanessa Ngan, Electrolysis, DermNet NZ, 2003. <https://www.dermnetnz.org/topics/electrolysis/> 4. Keyvan Nouri, Handbook of Lasers in Dermatology, 2014. <https://books.google.co.uk/books?id=YbZjBAAAQBAJ&printsec=frontcover&dq=laser+vs+IPL+hair+removal&hl=en&sa=X&ved=0ahUKEwi9w-_ ErY3eAhVH3KQKHclHA18Q6AEILTAB#v=onepage&q=hair%20removal&f=false> 5. Barry DiBernardo, & Jason Pozner, ‘Lasers and Non-surgical Rejuvenation’, Elsevier Health Sciences, 2009. <https://books.google.co.uk/books?id=WxLfU4QX2dEC&pg=PA76&dq=Repeat+sessions+for+laser+hair+removal&hl=en&sa=X&ved=0ahUKEwjy2aWa2ZneAhWGWsAKHS1FCB8Q6AEILjAB#v=onepage&q=Repeat%20sessions%20for%20laser%20hair%20removal&f=false> 6. Koushik Lahiri, Textbook of Lasers in Dermatology, 2016. <https://books.google.co.uk/books?id=-HKJDAAAQBAJ&pg=PA72&dq=laser+hair+removal&hl=en&sa=X&ved=0ahUKEwjv1ufEvo3eAhVS3aQKHeCkD2gQ6AEINDAC#v=snippet&q=intense%20pulsed%20light&f=false> 7. Rabindra Kumar Yadav, Definitions in Laser Technology, J Cutan Aesthet Surg. 2009 Jan-Jun; 2(1): 45–46. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840918/> 8. Sanjeev J Aurangabadkar, Venkataram Mysore, & E Suhail Ahmed, Buying a Laser - Tips and Pearls, J Cutan Aesthet Surg. 2014 Apr-Jun; 7(2): 124–130. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4134647/> 9. Vanessa Ngan, Eflornithine hydrochloride, 2005 <https://www.dermnetnz.org/topics/eflornithine-hydrochloride/> 10. NHS, Laser Hair Removal, 2016. <https://www.nhs.uk/conditions/cosmetic-treatments/laser-hair-removal/> 11. Ophelia E. Dadzie, Antoine Petit, Andrew F. Alexis, Ethnic Dermatology: Principles and Practice, 2013. <https://books.google.co.uk/books?id=XAlFDwAAQBAJ&pg=PA269&dq=laser+hair+removal+complications+and+side+effects&hl=en&sa=X&ved=0ahUKEwiW4t-e0o_eAhUHJcAKHcmJDXQQ6AEIOTAD#v=onepage&q=laser%20hair%20removal%20complications%20and%20side%20 effects&f=false> 12. The Joint Documents Working Group of The Federal Provincial Territorial Radiation Protection Committee, Laser Hair Removal Safety Guidelines for Facility Owners & Operators, 2011. <http://www. bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/EH/RPS/LaserHairRemovalGuidelinesforFacilityOwnersandOperatorsFINALDRAFTtrs.pdf> 13. Groupon, results for ‘laser hair removal’, 2018. <https://www.groupon.co.uk/browse/london?lat=51.502&lng=-0.141&query=laser+hair+removal&address=London&division=london&locale=en_GB>
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Adipose in the Ageing Face Mr Sotirios Foutsizoglou explains how fat tissue in ageing affects the appearance of the face Fat is a ubiquitous component of the subcutaneous tissues. We used to think of fat as the equivalent to a ‘savings account’ of nutrients when metabolic expenditure exceeds caloric intake.1 However, as our understanding of the dynamics of ageing evolves, a complex interplay in multiple tissue layers is emerging. Adipose tissue and the age-related changes in its distribution throughout the body has attracted enormous attention over the last decade as it is now a known fact that fat distribution patterns affect the appearance of our body as we age.2-4 Treating increased focal adiposities or selective loss of fat as seen in lipoatrophy has become a large component of cosmetic surgery and aesthetic medicine. Numerous surgical techniques and non-invasive technologies exist that can successfully improve either focal accumulation of fat or volume loss and shift. For instance, facial volume loss can now be effectively treated with various soft tissue augmentation and volumetric filling agents. To successfully and safely perform cosmetic procedures involving subcutaneous fat tissue, it is essential to understand the complex physiology and intricate interplay of fat as it relates to human health.1 Thus, it is important to gain a basic knowledge of adipogenesis, anatomy, and the physiology and diverse function of adipose tissue.
Anatomy, physiology and function of adipose tissue Fat is composed of cells known as adipocytes. These cells have manifold effects on the body, including energy expenditure, temperature, homeostasis, and innate and adaptive immunity. Taken together, adipocytes are organised and distributed as a multi-depot organ known as adipose tissue.5 Adipose tissue should be thought of as a complex organ with a variety of important metabolic functions. In fact, it is composed of mature adipocytes, blood vessels, nerves, fibroblasts, and adipocyte precursor cells known as preadipocytes.1 Among mature adipocytes, two cytotypes can be distinguished by differences in their colour and function: white adipose tissue (WAT) and brown adipose tissue (BAT). These two types of adipocyte receive a vascular and nerve supply,6 but are histologically distinct, differing in their physiological function, size and distribution of lipid droplets and organelles.7 White adipocytes are spherical in shape and have a single, unilocular lipid droplet occupying the cytoplasm, with a relatively small, eccentric nuclei boarding the periphery.8 Brown adipocytes, in contrast, are polygonal cells with multiple smaller, ‘multilocular’ lipid droplets, with a centrally placed nuclei, and a high mitochondrial content.9,10 WAT and BAT also differ in their distribution and function. WAT is distributed in depots in two main anatomic subdivisions, intraabdominal visceral fat and subcutaneous fat. The subcutaneous fat is further divided into superficial and deep subcutaneous tissue.11
BAT, conversely, can be found in characteristic locations in neonates, including the interscapular region, neck, axilla, and around the great vessels. Although it was earlier accepted that BAT was found only in neonates, while in adults BAT was either absent or at least of no relevance,12 it has been convincingly demonstrated that BAT is indeed present in most adults, where it has a thermogenic function.13 White adipose tissue White adipose tissue (WAT) is composed of white adipocytes and macroscopically has an ivory or yellow appearance. The function of WAT can be largely grouped into: 1. Storage of energy in the form of lipids 2. Glucose metabolism 3. Autocrine and paracrine functions on various organs by the secretion of bioactive peptides such as leptin, which influences the hypothalamus by regulating appetite.14 Major depots of WAT reside in the subcutaneous region as well as in the visceral region. The distribution of subcutaneous WAT is genetically determined (e.g. android vs. gynaecoid distribution of subcutaneous fat in men and women respectively15) and environmentally modulated (e.g. excess consumption of calories), contributing to the appearance of our face and body.16 Compared with subcutaneous WAT depots, visceral WAT depots, in general, display a more pro-inflammatory profile with greater secretory capacity.17 WAT also plays an important role in the pathophysiology of obesity. As with other areas of the body, obesity can significantly affect the appearance of the face, so it is interesting to understand the role of WAT. In obesity, WAT depots experience abnormal and excess expansion, either by an increase in adipocyte number or adipocyte size.16 WAT in obese individuals becomes inflamed and releases an increased amount of pro-inflammatory cytokines, including monocyte attractant protein 1, tumour necrosis factor α (TNF-α), interleukin 6 (IL-6) and adipocyte FABP (A-FABP), and a reduced amount of antiinflammatory adiponectin into the circulation.18 Brown adipose tissue BAT, or brown fat, is composed predominantly of brown adipocytes. BAT is a small, but highly specialised tissue, the main function of which is to produce heat (thermogenesis). This function requires a good blood supply and a dense population of mitochondria – two features that account for its reddish-brown colour and distinguish it from WAT.6 BAT is characterised by the expression of uncoupling protein-1 gene (UCP-1), also known as thermogenin, a mitochondrial protein unique to brown fat.19 UCP-1 is essential for utilisation of fatty acids for the generation of heat.19 UCP-1 is upregulated during episodes of cold exposure, including in the immediate postnatal period in which a neonate is forced to rapidly acclimate from physiological temperatures to ambient room temperature. Thermogenesis in BAT is controlled
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Figure 1: Normal healthy brown adipose tissue (left) compared to normal healthy white adipose tissue (right).6-8,11-13
by the hypothalamus through the sympathetic nervous system.20 The rapid onset of thermogenesis in BAT is essential for survival in newborn infants. In fact, newborns use 50% of caloric intake for nonshivering thermogenesis in BAT.21
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to maintain adipose dynamics in adults, proliferative adipocyte precursor cells (APCs) must exist to accommodate metabolic demands.29 Committed subcutaneous preadipocytes are reduced in human obesity. Furthermore, a recent study by Spalding et al. suggests that approximately 10% of the body’s adipocytes are regenerated each year.30 In addition, adipocyte number can increase during the development of obesity, despite a higher rate of apoptosis.31 Therefore, an adipocyte precursor pool is thought to remain present in adipose tissue during adult life and contribute to the renewal of new, mature adipocytes. Very few studies are available regarding the nature of APCs, including commitment to the preadipocyte, as well as the processes that control adipose conversion and formation of new adipocytes in human adult adipose tissue. Adipocyte loss can also occur during adulthood.32 Weight loss studies demonstrate a reduction in the volume and number of mature adipocytes.33,35 Two mechanisms are hypothesised to be responsible for this phenomenon: programmed cell death, known as apoptosis; or dedifferentiation, the process by which mature cells revert to less committed precursor cells.35,36
Adipogenesis: from stem cell to adipocyte New developments such as the use of adipose-derived stem cells or preadipocytes may lead to targeted treatments aimed at addressing the underlying causes of fat-related disorders as well as age-related volumetric changes in the topography of adipose tissue in the face. Human adipogenesis begins in embryos and continues into the early neonatal period.22 Adipocyte development is essential as it enables neonates to cope more efficiently with intervals between food intake.23 Mature adipocytes are derived from precursor cells known as the preadipocyte. In humans, a predetermined number of preadipocytes are programmed at an early point of embryonic development. The preadipocytes are derived from mesenchymal stem cells (MSCs) of mesoderm origin that have the potential to become adipose tissue, smooth muscle, bone, or cartilage.1 A complex process drives adipocyte development. Essentially this can be broken down into a two-step sequence of events: recruitment and proliferation of preadipocytes and differentiation to mature adipocytes.24 In the first stage, there is an increased number of cells, followed by differentiation marked by a change in morphology and function of the cell. Numerous regulatory signals are involved in the complex cascade.25 Transition from proliferation to differentiation in cell culture involves expression of collagen VI and disappearance of inhibitory proteins.26 Although most adipose development occurs during prenatal and early postnatal life, adipogenesis and fat accumulation can happen over one’s lifetime as WAT retains the ability to expand during adult life, especially to accommodate energy surplus.27 Adipose tissue expansion occurs in two ways – by increase of existing adipocytes’ size (hypertrophy) or by recruiting new fat cells (hyperplasia). Obesity, for example, results from an energy surplus and is characterised by an increased storage of lipid and expansion of adipose tissue. Accumulating evidence in human subjects suggests that obesityrelated complications such as diabetes result from the inability of subcutaneous adipose tissue to expand and safely store lipids, which leads to ectopic deposition in other tissues and insulin resistance due to lipotoxicity. This impaired expandability is due to the limited ability of adipose tissue progenitor cells to supply new adipocytes through their differentiation into specialised cells.28 Hence, in order to support expansion of adipose tissue mass and
Implications of facial fat in ageing Without regard for facial anatomy, which includes knowledge of facial fat and its change with ageing, cosmetic treatments, such as injectable dermal fillers, will produce incomplete and unnatural results.1 Young faces have a well-defined cheek mass composed primarily of fat within fine fascial septae. With age, fascia-retaining ligaments weaken to varying degrees, causing the cheek to succumb to the effects of gravity.37 The result of this is that individuals in their late 40s and above have a paucity of soft tissue in the infraorbital region and accentuated nasolabial folds due to an anterior and inferior projection of the cheek mass. In the ageing face, redistribution and loss of subcutaneous fat is a significant contributor to flat, hollow contours, particularly in the infraorbital regions, cheeks, and around the mouth. The mid-face, which extends from the lower eyelid to the oral commissure, demonstrates changes that are predominantly volume dependent. Ageing leads to an overall change in facial shape as volume shifts from the upper mid-face to the lower face, transitioning the youthful, heart-shaped face into a more aged, rectangular shape.38 Advancing age is associated with a generalised deflation of the midface. The combination of volume loss and the effect of the underlying retaining ligaments, in particular the orbital retaining ligament, malar septum, and McGregor’s patch, contribute to the hallmarks of midfacial ageing.2 Volume loss at the inferior orbital rim creates a concavity and overlying shadow, separating the lower eyelid from the cheek. Volume loss and tethering of the malar septum create the mid-cheek furrow that runs parallel to the nasolabial fold and is the hallmark of mid-face ageing. Lateral cheek volume loss diminishes the dominance of mid-face volume and skeletonises the zygomatic arch, creating a harsh sublimar shadow.1 In addition, buccal volume loss accentuates an aged appearance. Therefore, facial rejuvenation of the mid-face should focus on restoring the dominance of mid-face volume to give a more heart-shaped face and minimising the segmenting shadows seen with age. Facial fat compartments Facial adipose tissue consists of superficial and deep subcutaneous WAT and exists in discrete, independent anatomical subunits that are referred to as fat pads.11 In 2007, a study from Rohrich and Pessa at the University of Texas Southwestern Medical Center revolutionised
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Sub-orbicularis oculi fat (lateral part)
Superior orbital fat Inferior orbital fat
Sub-orbicularis oculi fat (medial part)
Lateral orbital fat
Nasolabial fat
Deep medial cheek fat (lateral part)
Medial cheek fat Lateral temporal cheek fat
Buccal extension of the buccal fat
Middle cheek fat
Buccal extension of the buccal fat
Figure 2: Superficial fat compartments of the face. Adapted from Gierloff et al.38,39
our understanding of facial fat anatomy by showing that facial subcutaneous fat is highly compartmentalised (Figure 2 & 3).2 Agerelated differential loss of volume within these fat compartments contributes to change in facial topography and appearance. Areas prone to fat loss include the buccal fat pads, malar fat pads, perioral fat, chin, temporal fossa, and periorbital area, which all give roundness and shape to a youthful-appearing face.41 Rohrich and Pessa’s work initiated the delineation of the structural anatomy of the facial fat compartments with direct implications in facial revolumisation techniques. For instance, site-specific volumisation of the underlying deep medial cheek fat compartment immediately manifests as increased anterior projection of the superficial fat compartments of the medial cheek, with subsequent improvement in the nasolabial fold, as well as improvement in the nasojugal fold, or ‘tear trough’.2 The thinning and shifting of facial subcutaneous superficial and deep WAT compartments can be restored using injectable dermal fillers of high G prime in targeted areas. Additionally, unwanted body fat deposits can be treated with non-invasive lipolytic means or body contouring procedures such as liposuction.
Conclusion Subcutaneous adipose tissue is an integral component of the integumentary system, functioning to store energy and provide insulation. However, adipose tissue has a limited capacity for self-renewal. Current reconstructive and cosmetic procedures for soft tissue augmentation include the use of dermal fillers and fat grafting; however, these are associated with poor long-term retention and results, high costs, and the potential for complications. This is particularly evident when used by practitioners without comprehension of the ageing process, the anatomy of the area to be treated, and the complex physiological and age-related changes of the adipose tissue. Adipose-derived stem cells or preadipocytes may be a promising future alternative, furthering our ability to restore a more youthful and attractive appearance in a safer, longer-lasting and more natural fashion.
Ristow’s space
Figure 3: Deep fat compartments of the face. Adapted from Gierloff et al.38,39
Muscle and facial ageing In addition to the redistribution and loss of subcutaneous fat, there is a gradual weakening of the superficial musculoaponeurotic system (SMAS) beginning in the late 30s and early 40s. This causes further ptosis of the lateral and mid-face regions. Along with these changes comes an accumulation of submandibular and submental fat, sagging of the submandibular gland, and weakening of the platysma muscle, all of which obscure the smooth contour of a youthful-appearing jaw line and a sharp cervicomental angle.40 Mr Sotirios Foutsizoglou is currently completing his last year of training in plastic and reconstructive surgery at Evangelismos General Hospital of Athens. Since 2012, in his role as the lead trainer of KT Medical Aesthetics Group, he has been training medical aesthetic practitioners in facial anatomy and advanced non-surgical treatments and procedures. He has written and lectured on facial anatomy and complications associated with injectables both nationally and internationally. REFERENCES 1. Avram M.M. Fat Removal: Invasive and noninvasive body contouring. John Wiley & Sons Ltd, 2015. 2. Rohrich, R.J. & Pessa, J.E. (2007) The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plastic and Reconstructive Surgery, 119 (7), 2219–2227; discussion 2228–2231. 3. Gierloff M, Stöhring C, Buder T, Gassling V, Açil Y, Wiltfang J. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012 129(1): 263-273. 4. Daniel Dal’Asta Coimbra, Natalia Caballero Uribe, Betina Stefanello de Oliveira, “Facial squaring” in the aging process, Surg Cosmet Dermatol 2014;6(1):6571. 5. Cinti, S. (2002) Adipocyte differentiation and transdifferentiation: plasticity of the adipose organ. Journal of Endocrinological Investigation, 25 (10), 823–835. 6. Cinti, S. (2005) The adipose organ. Prostaglandins, Leukotrienes, and Essential Fatty Acids, 73(1), 9–15. 7. Fawcett, D. (1952) A comparison of the histological organization and cytochemical reactions of brown and white adipose tissues. Journal of Morphology, 90, 363–405. 8. Napolitano, L. (1963) The differentiation of white adipose cells. An electron microscope study. Journal of Cell Biology, 18, 663–679. 9. Afzelius, B.A. (1970) Brown adipose tissues: its gross anatomy, histology, and cytology. In: Lindberg, O. Brown Adipose Tissue. Elsevier, Amsterdam, pp. 1–31. 10. Geloen, A. et al. (1990) In vivo differentiation of brown adipocytes in adult mice: an electron microscopic study. The American Journal of Anatomy, 188 (4), 366–372. 11. Smith, S.R. et al. (2001) Contributions of total body fat, abdominal subcutaneous adipose tissue compartments, and visceral adipose tissue to the metabolic complications of obesity. Metabolism, 50 (4), 425–435. 12. Saely CH, Geiger K, Drexel H. Brown versus white adipose tissue: a mini-review. Gerontology.
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2012;58(1):15-23. doi: 10.1159/000321319. Epub 2010 Dec 7), 13. Nedergaard J. Cannon B. Brown Adipose Tissue: Development and Function. Fetal and Neonatal Physiology (Fifth Edition). Volume 1, 2017, Pages 354-363.e4). 14. Kim, S. & Moustaid-Moussa, N. (2000) Secretory, endocrine and autocrine/paracrine function of the adipocyte. Journal of Nutrition, 130 (12), 3110S–3115S. 15. Karastergiou K, et al. Sex differences in human adipose tissues – the biology of pear shape. Biol Sex Differ. 2012; 3: 13.) 16. Tchoukalova YD, Votruba SB, Tchkonia T, Giorgadze N, Kirkland JL, Jensen MD. Regional differences in cellular mechanisms of adipose tissue gain with overfeeding. Proc Natl Acad Sci USA 2010; 107: 18226–18231. 17. Hocking SL, Wu LE, Guilhaus M, Chisholm DJ, James DE. Intrinsic depot-specific differences in the secretome of adipose tissue, preadipocytes, and adipose tissue-derived microvascular endothelial cells. Diabetes 2010; 59: 3008–3016. 18. Gregor MF, Hotamisligil GS. Inflammatory mechanisms in obesity. Annu Rev Immunol 2011; 29: 415–445. 19. Cinti, S. et al. (1997) Immunohistochemical localization of leptin and uncoupling protein in white and brown adipose tissue. Endocrinology, 138 (2), 797–804. 20. Lafontan, M. & Berlan, M. (1993) Fat cell adrenergic receptors and the control of white and brown fat cell function. Journal of Lipid Research, 34 (7), 1057–1091. 21. Hey, E.N. (1969) The relation between environmental temperature and oxygen consumption in the new-born baby. Journal of Physiology, 200 (3), 589–603. 22. Burdi, A.R. et al. (1985) Adipose tissue growth patterns during human gestation: a histometric comparison of buccal and gluteal fat depots. International Journal of Obesity, 9 (4), 247–256. 23. MacDougald, O.A. & Lane, M.D. (1995) Transcriptional regulation of gene expression during adipocyte differentiation. Annual Review of Biochemistry, 64, 345–373. 24. Gregoire, F.M., Smas, C.M. & Sul, H.S. (1998) Understanding adipocyte differentiation. Physiological Reviews,78 (3), 783–809. 25. Smas, C.M. & Sul, H.S. (1995) Control of adipocyte differentiation. Biochemical Journal, 309, 697–710. 26. Ntambi, J.M. & Young-Cheul, K. (2000) Adipocyte differentiation and gene expression. Journal of Nutrition, 130 (12), 3122S–3126S. 27. Poulos SP, Hausman DB, Hausman GJ. The development and endocrine functions of adipose tissue. Mol Cell Endocrinol. 2010;323(1):20–34. 28. Isakson P, Hammarstedt A, Gustafson B, Smith U. Impaired preadipocyte differentiation in human abdominal obesity: role of Wnt, tumor necrosis factor-alpha, and infl ammation. Diabetes. 2009;58(7):1550–7. 29. T choukalova Y, Koutsari C, Jensen M. Committed subcutaneous preadipocytes are reduced in human obesity. Diabetologia. 2007;50(1):151–7. 30. Spalding KL, Arner E, Westermark PO, Bernard S, Buchholz BA, Bergmann O, et al. Dynamics of fat cell turnover in humans. Nature. 2008;453(7196):783–7.
Aesthetics 31. Strissel KJ, Stancheva Z, Miyoshi H, Perfi eld 2nd JW, DeFuria J, Jick Z, et al. Adipocyte death, adipose tissue remodeling, and obesity complications. Diabetes. 2007;56(12):2910–8. Epub 2007/09/13. 32. Ailhaud, G. et al. (1991) Growth and differentiation of regional adipose tissue: molecular and hormonal mechanisms. International Journal of Obesity, 15 (Suppl. 2), 87–90. 33. Miller, W.H. Jr., et al. (1983) Effects of severe long-term food deprivation and refeeding on adipose tissue cells in the rat. American Journal of Physiology, 245 (1), E74–E80. 34. Zhou, Y.T. et al. (1999) Reversing adipocyte differentiation: implications for treatment of obesity. Proceedings of the National Academy of Sciences of the United States of America, 96 (5), 2391–2395. 35. Van, R.L., Bayliss, C.E. & Roncari, D.A. (1976) Cytological and enzymological characterization of adult human adipocyte precursors in culture. Journal of Clinical Investigation, 58 (3), 699–704. 36. Van, R.L. & Roncari, D.A. (1978) Complete differentiation of adipocyte precursors. A culture system for studying the cellular nature of adipose tissue. Cell and Tissue Research, 195 (2),317–329. 37. Gierloff M, Stöhring C, Buder T, Gassling V, Açil Y, Wiltfang J. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012 129(1): 263-273. 38. Daniel Dal’Asta Coimbra, Natalia Caballero Uribe, Betina Stefanello de Oliveira, “Facial squaring” in the aging process, Surg Cosmet Dermatol 2014;6(1):6571. 39. Park DM. Total Facelift: Forehead Lift, Midface Lift, and Neck Lift.Arch Plast Surg. 2015 Mar; 42(2): 111–125. 40. Harstein ME et al. Midfacial Rejuvenation. Springer 2012.
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Spotlight On: EMsculpt Aesthetics explores the use of a new energy-based device that aims to build muscle and reduce fat simultaneously As a practitioner, it is not uncommon for a patient to come into your clinic and say, ‘I want a toned tummy’ or ‘I’d like a more lifted, perkier bottom’. And whilst fat reduction and skin laxity treatments may well be something you can offer, the toning of the muscles may prove difficult to achieve due to the lack of technology available. Last month, however, saw the launch of the world’s only non-invasive device that aims to simultaneously build muscle and reduce fat on both the abdominal area and the buttocks; the EMsculpt.
The science According to manufacturer BTL Aesthetics, the EMsculpt was developed after the technology was shown to have positive results for treating sports’ teams for muscle regeneration.1 The device uses high-intensity focused electro-magnetic (HIFEM) technology. HIFEM uses a focused electro-magnetic field that interacts with motor neurons, which subsequently triggers supramaximal contractions to the striated muscle.2 Dr Rosh Ravindran, one of four practitioners in the UK chosen to Before
After
FIGURE 2: A 27-year-old patient, before and immediately after her fourth 30-minute treatment to the glutes. Images courtesy of Dr Rosh Ravindran at KLNIK.
trial the device before its launch explains, “The technology only acts upon striated muscle hence why there’s no impact on the bladder or bowels because they’re smooth muscle.” According to the manufacturer, HIFEM technology is also non-ionising, nonradiating, non-thermal and does not affect sensory nerves as it is designed to only stimulate motor neurons.2
By activating the supramaximal contractions, hyperplasia and hypertrophy of the muscles takes place. The voluntary contractions cause an adrenaline release, which signals the fat cells to initiate lipolysis (the breakdown of fats).1 The rapid stimulation is excessive, and the free fatty acids start over-accumulating in the fat cells; this overflow causes cell dysfunction and the start of apoptosis (cell death).2 Research indicates that this technology can force approximately 20,000 muscle contractions per half an hour session, something which the body would not be able to do alone.2
Clinical trials The EMsculpt has been subject to seven clinical trials; four focusing on the abdomen which involved a computer tomography (CT) scan, magnetic resonance imaging (MRI) scan, an ultrasonography study and a waist circumference reduction study, whilst two assessed buttock lifting; an initial study and a large-scale multicentric study. A histological in-vivo study also took place to evaluate fat cell death and supramaximal contractions.3-9 A histological in-vivo study involved one EMsculpt treatment of two porcine models where changes were evaluated in programmed cell death of adipocytes. UNEL assay was put in place to detect biochemical and haematological parameters and punch biopsy specimens of fat tissue and blood samples were taken before the treatment, after
Research indicates that this technology can force approximately 20,000 muscle contractions per half an hour session one hour and eight hours post treatment. Researchers noted, on average, a 92% increase in apoptotic levels in fat cells from 18.75% at baseline to 35.95% eight hours after one treatment. Blood analysis confirmed a rapid metabolic reaction after treatment as supporting evidence of changes in the subcutaneous fat; no safety risks were identified.4 The MRI scan study involved 22 patients who were treated with four 30 minute sessions and were evaluated through an MRI scan after two months. Researchers concluded that abdominal fat thickness was reduced on average by 18.6% or 4.3mm and abdominal muscle mass increased by 15.4%, partnered with a
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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for the practitioner based on the patients tolerance and is slowly increased.” Dr Rosh says that in his experience, the patients that achieve the best results are those with lower body fat. “For these patients you can see results straight away because there is less fat to target. However, if I had a patient with high body fat, they still get a result but it is more related to their circumferential waist reduction. I find that abdominal patients Figure 1: A 32 year old patient before and immediately after her fourth 30-minute treatment to the abdominal area. get immediate improvement, while usually, Images courtesy of Dr Rosh Ravindran and KLNIK. results are seen after the second and third 10.4% average reduction in diastasis recti. There were no adverse treatment for the glutes. Sporty people may see it straight away events; however, several patients reported mild muscle fatigue because of previous muscle memory,” he explains. which resolved within 12-48 hours.3 The ultrasound study, which In regards to pain after treatment, Dr Ravindran says that although evaluated 33 patients one month after receiving four 30 minute patients have a higher muscular response than a typical gym workout, treatments showed an average of 19% reduction of fat. 21 out of they feel it less. He explains, “You don’t get the lactic acid build up that 33 patients had greater than 15% fat reduction and there were no you get from going to the gym where you can’t walk for a few days ‘non-responders’. There was also a 91% satisfaction rate and no because EMsculpt has a different mechanism of action. I would say complications were reported.9 Combined, all seven trials show an that after each treatment for the tummy, patients will feel an ache for overall outcome of 19% reduction in subcutaneous abdominal fat, around 48 hours and with the buttocks it is even less.” Dr Ravindran 16% increase in muscle mass, a 44cm reduction in thickness of has not noted any complications but he emphasises that a detailed subcutaneous abdominal fat and an average waist circumference consultation is key to prevention. “The technology is magnetic so reduction of 4.4cm.2 you can’t have metal pacemakers of any kind in the body. I also The EMsculpt has also been cleared by the US Food and Drug personally prefer not to perform the treatment when women are on Administration for the improvement of abdominal tone and their period; there is already a lot of muscle contraction happening at strengthening of the abdominal muscles and has obtained a CE this time so it could potentially increase bleeding, although this is not mark for medical devices.10,11 clinically proven,” he explains, adding, “I also prefer not to treat anyone Dr Ravindran says the positive clinical trial results were what sparked until they are at least three months’ post-partum.” To summarise, Dr his interest in the device. He explains, “Data is hugely important to Ravindran says that he looking forward to seeing the results he can me when it comes to new treatments and devices. I want to see achieve in the future with the EMsculpt device. He says, “I believe it is three things: safety, imaging and histology. The unique thing that I the best in class and the first of its kind.” found about the EMsculpt trial results were that they were robust and REFERENCES consistent across all seven of the studies.” 1. BTL Aesthetics, About Us <https://www.btlaesthetics.com/en/about-us>
In practice So, how does this device work in practice and who would be the ‘perfect patient’? According to Dr Ravindran, this procedure can work for most patients, with the exception of those morbidly obese, pregnant or breastfeeding. It is advised by the company that a protocol of four 30-minute treatment sessions over the course of a two-week period is suitable and best results will be seen after three months, with continued improvement over a six month time period.12 For the procedure itself, two Tesla magnetic paddles are secured to the targeted area by a fixation belt and the relevant setting is selected. Dr Rosh explains, “The settings go from 1-100 in intensity, for the buttocks you use two paddles and for the abdomen it is usually just one. This is reactionary
All seven trials show an overall outcome of 19% reduction in subcutaneous abdominal fat
2. Data on file (obtained from Impress PR and BTL Aesthetics) 3. Kinney B, Lozanova P, High Intensity Focused Electro-magnetic therapy (HIFEM) evaluated by magnetic resonance imaging (MRI): Safety and efficacy study of a dual tissue effect based noninvasive abdominal body shaping , presented at the Annual Meeting of the American Society for Laser Medicine and Surgery, 2018 Dallas <https://www.dropbox.com/sh/ztnbzrboiz9y64u/AAA2KmFA6Ym_qNgf7TWWjgra?dl=0&preview=Emsculpt_CLIN_Study-3_Summary_EN100.pdf> 4. Weiss R, Bernardy J, Induction of fat apoptosis by a non-thermal device: safety and mechanism of an action of non-invasive HIFEM technology evaluated in a histological porcine model, presented at the Annual Meeting of the American Society for Laser Medicine and Surgery, 2018 Dallas <https://www. dropbox.com/sh/ztnbzrboiz9y64u/AAA2Km-FA6Ym_qNgf7TWWjgra?dl=0&preview=Emsculpt_CLIN_ Study-1_Summary_EN100.pdf> 5. Kent D, Jacob C, Computed Tomography (CT) based evidence of simultaneous changes in human adipose and muscle tissues following a high intensity focused electro-magnetic field (HIFEM) application: a new method for non-invasive body sculpting, presented at the Annual Meeting of the American Society for Laser Medicine and Surgery, 2018 Dallas < https://www.dropbox.com/ sh/ztnbzrboiz9y64u/AAA2Km-FA6Ym_qNgf7TWWjgra?dl=0&preview=Emsculpt_CLIN_Study-4_ Summary_EN100.pdf> 6. Jacob C, Paskova K, A novel non-invasive technology based on simultaneous induction of changed in adipose and muscle tissues: safety and efficacy of a high intensity focused electro-magnetic field device used for abdominal body shaping, presented at the Annual Meeting of the American Society for Laser Medicine and Surgery, 2018 Dallas <https://www.dropbox.com/sh/ztnbzrboiz9y64u/ AAA2Km-FA6Ym_qNgf7TWWjgra?dl=0&preview=Emsculpt_CLIN_Study-5_Summary_EN100.pdf> 7. Busso M, Denkova R, Efficacy of high intensity focused electro-magnetic field therapy when used for non-invasive buttocks augmentation and lifting: a clinical study, presented at the Annual Meeting of the American Society for Laser Medicine and Surgery, 2018 Dallas <https://www.dropbox.com/ sh/ztnbzrboiz9y64u/AAA2Km-FA6Ym_qNgf7TWWjgra?dl=0&preview=Emsculpt_CLIN_Study-6_ Summary_EN100.pdf> 8. Jacob C, Kinney B, Busso M et al, 2018, High intensity focused electro-magnetic technology (HIFEM) for non-invasive buttocks lifting and toning of gluteal muscles: a multi-center efficacy and safety study <https://www.dropbox.com/sh/ztnbzrboiz9y64u/AAA2Km-FA6Ym_ qNgf7TWWjgra?dl=0&preview=Emsculpt_CLIN_Study-7_Summary_EN100.pdf> 9. Katz B, Bard R, Goldfarb R et al, Changes in subcutaneous abdominal thickness following highintensity focused electro-magnetic (HIFEM) field treatments: a multicentre ultrasound study, presented at the Annual Meeting of the American Society for Laser Medicine and Surgery, 2018 Dallas <https:// www.dropbox.com/sh/ztnbzrboiz9y64u/AAA2Km-FA6Ym_qNgf7TWWjgra?dl=0&preview=Emsculpt_ CLIN_Study-2_Summary_EN100.pdf> 10. Data on file (obtained from BTL Aesthetics) 11. Data on file (obtained from BTL Aesthetics)
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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dermatologist who specialises in hair loss and scalp conditions, I have developed a hair loss algorithm to help aesthetic practitioners navigate diagnosing hair loss conditions in a more systematic manner (Figure 1). I find that this algorithm helps distinguish patterns and potential causes of hair loss, while enabling practitioners to identify when they can help their patients. It also proves useful to help recognise where practitioners may need to refer to someone who specialises in specific hair and scalp conditions.
Forms of hair loss The first step in diagnosing hair loss is to take a thorough history, including the length of time that the hair loss has been present, and also whether any other scalp symptoms exist. Through examining the scalp, an experienced practitioner will be able to identify the forms of hair loss that may be present in aesthetic patients. A dermatoscope (a type of microscope used by dermatologists) or magnifier can aid in examining the scalp closely to identify inflammation on the scalp or the presence of miniaturisation of the hair shafts (which would suggest androgenetic alopecia). When examining the scalp, I am looking to identify the form of hair loss that is present and to classify it as either diffuse or patchy.
Identifying and Classifying Hair Loss Dr Martin Wade presents his diagnosis algorithm to help aesthetic practitioners classify different types of hair loss Hair loss and scalp conditions are common amongst aesthetic patients in the UK. Hair is an intrinsic part of who we are as a person and so it is not uncommon for patients to place a lot of value on their hair. The most prevalent types of hair loss are androgenetic alopecia, in the form of male pattern baldness (MPB) or female pattern hair loss (FPHL), alopecia areata and frontal fibrosing alopecia (FFA).1,2,3 Around 50% of men have some degree of MPB by age 501 and alopecia areata can affect up to 2% of the population at some stage of their life.2 This article presents my algorithm for identifying hair loss, aiming to provide practitioners with a structured approach to help their aesthetic patients deal with hair loss and to help them identify when they may need to refer to a specialist.
Utilising an algorithm Due to the broad range of hair loss and scalp conditions that exist, diagnosing the underlying causes of hair loss can be complex. As a
Diffuse I categorise diffuse hair loss as an even reduction in hair density. I find that it is seen in patients with either androgenetic alopecia (patterned) or telogen effluvium (global), which are both explained below. Within diffuse hair loss, practitioners should look to identify if there is patterned hair loss or global hair loss. Patterned Patterned hair loss, with thinning of hair on the vertex of the scalp, is seen in androgenetic alopecia, otherwise known as MPB or FPHL. In men, MPB is caused by androgens and genetics, hence its name androgenetic alopecia.1,4 Although all men and women have a tendency to develop thinning hair as they age, the causes in women can vary according to age, which can make the condition more complicated. If the onset is in the teens and 20s, then it is
HAIR LOSS DIAG NO SIS ALG O RITHM
DIFFUSE
PATCHY
PATTERNED
GLOBAL
AGA: MPB / FPHL (LPP)
ATE CTE (LPP)
NON-SCARRING
SCARRING
NON-INFLAMED
INFLAMED
A.A. TTM
TINEA CAPITIS
LPP FFA DLE FDC CCCA/FDS
Figure 1: Hair loss algorithm to help practitioners navigate diagnosing hair loss conditions. Image courtesy of The London Skin and Hair Clinic. AGA - androgenetic alopecia MPB - male pattern baldness FPHL - female pattern hair loss
LPP - lichen planopilaris ATE - acute telogen effluvium CTE - chronic telogen effluvium
AA - alopecia areata TTM - trichotillomania FFA - frontal fibrosing alopecia
DLE - discoid lupus erythematosus FDC - folliculitis decalvans CCCA - central centrifugal cicatricial alopecia
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
FDS - follicular degeneration syndrome
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Lichen planopilaris Lichen planopilaris is a complicated condition. Although one of the scarring alopecias, it can also present in a diffuse pattern and can therefore mimic other conditions such as telogen effluvium or FPHL. Clues to the diagnosis of this condition are inflammation on the scalp and symptoms of burning or tenderness in the scalp; if this is suspected then a biopsy it is usually necessary to confirm the diagnosis. Therefore, if the patient is experiencing pain or a burning sensation, then it’s likely to have an inflammatory causes, so don’t assume the hair loss is telogen effluvium or FPHL.10 Lichen planopilaris can also present as patchy hair loss where, I find, it is easier to diagnose.
more likely to be related to hormones and genetics.4 Occurring after 60, researchers believe that the main cause is simply the ageing process.5 Women aged between 30-60 usually have hair loss due to a combination of genetics, hormone levels and other non-hormonal factors such as thyroid, iron status and nutrition.5 I find this is the most complex group to diagnose because of the combination of various elements contributing to the cause of hair loss. Global Global hair loss is characterised by reduced hair density throughout the entire scalp, with the archetypical condition being telogen effluvium. Telogen effluvium is an alteration of the hair cycle, where there is an increase in the number of hairs entering the resting phase (telogen). In a normal scalp, usually 12% of the hairs are in the resting phase.6 If this number increases even up to 15% or 16%, then patients become aware of increased hair shedding. Acute telogen effluvium can involve a rapid onset and is often quite dramatic with a telogen count of up to 25% of hairs. It usually lasts for under three months and if the condition lasts longer than this, it tends to be an ongoing concern and is then called chronic telogen effluvium.6
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Non-scarring With non-scarring hair loss, alopecia areata is by far the most common. This usually presents as randomly occurring patches of hair loss affecting the scalp hair, but it can also affect eyebrows, eyelashes and men’s beards. A history of patchy hair loss with spontaneous regrowth usually confirms the diagnosis. Hair loss with this condition can be dramatic and it can lead to complete hair loss from the scalp, which is called alopecia areata totalis.7 The non-scarring patchy forms of hair loss can be further divided into noninflamed or inflamed. • Non-inflamed forms: refers to the loss of hair without erythema, scaling or symptoms of itching or pain. The non-inflamed forms of patchy hair loss include alopecia areata and trichotillomania. With alopecia areata, there are well demarcated patches of hair loss that often have exclamation mark hairs, which is a pathognomonic sign. Exclamation mark hairs are short hairs that are broken off and are narrower as they become closer to the scalp.7 • Inflamed forms: refers mainly to capitis, a fungal infection on the scalp. This is seen much more commonly in children but can occasionally occur in adults. Once again, erythema and scale are seen on the scalp and pustules can sometimes be present. If this process continues untreated it can begin to scar, destroying the hair follicles.8 Scarring The most commonly seen scarring alopecia is lichen planopilaris, where perifollicular erythema (redness) and perifollicular hyperkeratosis (roughness) present around the hair follicles. The centre of the patches is usually paler and shiny, taking on a scarred appearance as they are devoid of any remaining hair follicles.9 Discoid lupus erythematosus can also look similar to lichen planopilaris, however it usually presents as larger, more inflamed patches of hair loss. Folliculitis decalvans usually presents as a
Patchy Patchy hair loss is when discrete areas that contain no hair are interspersed amongst areas on the scalp with a normal hair density. It is common in patients with alopecia areata or those that have the scarring alopecias. The patchy forms of hair loss can be classified as either non-scarring or scarring.7
Tips for managing patients Temporary or permanent hair loss can be very distressing and I find that these patients are often anxious. Furthermore, the support they have previously received may have been minimal or even negative. In my experience, it is not uncommon to meet patients who say that their GP has told them their hair loss is simply a ‘cosmetic issue’ or that there is nothing that can be done. As well as medical treatment options, I suggest practitioners consider recommending camouflage options such as hair fibres or hair pieces that can help patients disguise their hair loss. In some cases, I may recommend talking to a psychologist who specialises in hair loss, who can aid patients with tools and techniques to cope with the emotional burden of loss of hair.
Figure 2: Patient presenting with lichen planopilaris scalp. Image courtesy of The London Skin and Hair Clinic.
Figure 3: Patient presenting with folliculitis decalvans scalp. Image courtesy of The London Skin and Hair Clinic.
Figure 4: Patient presenting with frontal fibrosing alopecia scalp. Image courtesy of The London Skin and Hair Clinic.
Figure 5: Patient presenting with androgenetic alopecia scalp. Image courtesy of The London Skin and Hair Clinic.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
‘boggy scalp’ where pustules are present and may be seen with associated crusting. Multiple hairs emerging from one follicular orifice is often seen in this condition and is called tufting or pili multigemini. Central centrifugal cicatricial alopecia (CCCA) is a unique condition, seen almost exclusively in black women and is manifest by an enlarging patch of scarring hair loss originating on the posterior to mid-vertex, expanding outwards.9 In clinic, I have also seen an increasing number of women present with FFA. This should be considered in women who are reporting hair loss from the frontal hairline. The classic signs are a receding hairline with redness around the hair follicles and also the presence of lonely hairs stranded in front of the receded frontal hairline. This pattern can extend down to the ears and usually also involves eyebrow loss, while being considered a variant of lichen planopilaris.9
Conclusion The prospect of a patient complaining of hair loss can be overwhelming. There are many causes of hair loss and the treatment is certainly not the same for all conditions. Being able to take a methodical approach to at least categorising, if not diagnosing, the type of hair loss will allow aesthetic practitioners to know when they are able to manage the situation or when a referral to a specialist may be required. The hair loss algorithm I have presented should help with this task and can be used as a reference point. If a practitioner can’t personally help the patient, then it is vital they are able to recognise the problem and point them in the right direction of someone who can. Dr Martin Wade is a consultant dermatologist specialising in the medical diagnosis and treatment of hair loss and scalp disorders. He practises at The London Skin and Hair Clinic, a private medical dermatology centre. Dr Wade presents regularly to GPs and specialists interested in hair loss and scalp conditions. REFERENCES 1. Cranwell W, Sinclair R. Male Androgenetic Alopecia. 2016 Feb 29 <https://www.ncbi.nlm.nih.gov/ pubmed/25905192> 2. Villasante FAC, Miteva M. Epidemiology and burden of alopecia areata: A systematic review. Clin. Cosmet Investig Dermatol 2015;8:397-403. 3. Rudnika L, Rakowska A. The increasing incidence of frontal fibrosing alopecia. In search of triggering factors. J Eur Acad Dermatol Venereol. 2017 Oct;31(10) 1579-1580 4. Price VH. Androgenetic Alopecia in women. J Investig Dermatol Symp Proc. 2003 Jun;8(1):24-7 5. Price VH Female Hair Loss Differs By Age. Dermatology 2013, Sep 12 6. Giriffith G, Barker J, Bleiker T, Chalmers R, Creamer D. Rook’s Textbook of Dermatology. Wiley Blackwell. 2015 Chapter 89.24-28 7. Giriffith G, Barker J, Bleiker T, Chalmers R, Creamer D. Rook’s Textbook of Dermatology. Wiley Blackwell 2015 Chapter 89.28-33 8. Giriffith G, Barker J, Bleiker T, Chalmers R, Creamer D. Rook’s Textbook of Dermatology. Wiley Blackwell 2015 Chapter 32.38-41 9. Giriffith G, Barker J, Bleiker T, Chalmers R, Creamer D. Rook’s Textbook of Dermatology. Wiley Blackwell 2015 Chapter 89.37-41 10. Soares VC, Mulinari-Brenner F, Souza TE. Lichen planopilaris epidemiology: a retrospective study of 80 cases. An Bras Dermatol. 2015 Sep-Oct;90(5):666-70
FURTHER READING • British Association of Dermatology, patient information leaflets. <http://www.bad.org.uk/for-thepublic/patient-information-leaflets> • DermnetNZ, Skin topics A-Z. <https://www.dermnetnz.org/topics/>
DERMAFILL is the first of a new 4th generation of safer and more effective pure Monophasic injectable dermal fillers which exceed the stricter standards of the FDA very low level BDDE controls. This new advancement of cleaner manufactured homogenised viscoelastic Hyaluronic gels comes pre-purified to a new unseen standard. The final product arrives as a threedimensional pure gel made of very strong chains of HA. Utilising the innovation of the unique Time-X technology, which results in a product that is easier to use. DERMAFILL allows improved tissue control whilst creating immediate visible and safe results that are more consistent and longer-lasting without the drawbacks of conventional HA technologies. The DERMAFILL range is presented as 4 products, each specific to the indications being treated. • DERMAFILL Global Xtra - For fine lines and wrinkles. • DERMAFILL Volume Ultra - For the correction of deep wrinkles and restoration of facial volume. • DERMAFILL Lips - To redraw the lip contour and enhance volume. • DERMAFILL Regen - For optimal hydration of cutaneous skin tissue. The UK DERMAFILL distribution is being headed up by Mr. Jazz Dhariwal E.E.M.E (medical) and his team at Breit Aesthetics. Jazz is a well known face within the aesthetics community and is respected for his string of award winning achievements and innovative product launches within the medial aesthetic sector over the past 12 years. Exclusively through
info@breitaesthetics.com www.dermafill.eu | 020 7193 2128 43
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Offering Profiloplasty Dr Yusra Al-Mukhtar discusses how she uses nonsurgical profiloplasty to successfully enhance the profile of her patients and presents three case studies showcasing her results A non-surgical â&#x20AC;&#x2DC;profiloplastyâ&#x20AC;&#x2122; refers to any treatment performed to enhance the profile of a patient, making them appear more harmonious and balanced. The procedure typically involves a non-surgical rhinoplasty (NSR), chin augmentation, and sometimes lip enhancement using a suitable dermal filler to create better overall balance and proportion to the face. The purpose of this article is to demonstrate various profiloplasty treatments and present case studies to showcase how it can be used in clinical practice. In an aesthetic clinic, patients rarely come in asking for a profiloplasty and typically will come in for a non-surgical rhinoplasty (NSR) without realising the impact their other facial features have on the appearance of their nose and face in general. I find that patients often fail to recognise a small or retrusive facial feature, as their focus is often on the dominant aesthetic feature such as a dorsal hump on their nose. Failure to address the relationship between the nose and the chin is a common error in the pre-treatment evaluation of a NSR. It is the responsibility of the astute clinician to assess, recognise and educate their patient about the aesthetic proportions of their features and how to safely and optimally create a pleasing aesthetic outcome. Consequently, an incorrect analysis leads to inappropriate conclusions.1,2 The ideal chin-nose relationship has been researched and theorised over. One of the most popular standards is that described by plastic surgeon Mr Mario Gonzalez-Ulloa in 2014 (Figure 1).3 He traced a line perpendicular to the horizontal line shown on the Frankfort horizontal plane (a plane passing through the inferior margin of the orbit and the upper margin of the external auditory meatus) and tangential to the nasion, which is in the midline and the point of the deepest nasal root, called the zero meridian. He proposed that, in a face with ideal proportions, the pogonion (the most projecting point of the chin) should be on that line or immediately posterior to it. In a patient presenting with a skeletal discrepancy such as a retrognathic mandible, often referred to as a class II skeletal base (where the lower jaw is set further back than the upper jaw), a low gonial angle, creating shorter lower third face height, or a small chin relative to the rest of the face, it is possible for a chin augmentation to create protrusion anteriorly and elongation of the chin.
Treatment As with all procedures, it is imperative that a full-face assessment of the patient is undertaken. A NSR involves injections of dermal filler into strategic points in the nose and is often, but not always, to mask a dorsal hump; thus straightening the bridge of the nose, and elevating the tip, creating a lifted and shortened appearance. In respect to a NSR, particular assessment of the relationship of the nose to the chin must be undertaken. Patients who have had previous surgical rhinoplasty pose greater risk of arterial complications due to the altered anatomy and these cases must be approached with care and only performed by experienced advanced injectors.4
Profiloplasty can enhance the profile whilst avoiding the trauma, potential scarring and costs associated with surgery
Correct chin size and posture, including anterior projection, length and symmetry, is essential to achieving an aesthetically pleasing result after a NSR procedure. In particular, a reduced chin projection can make the nose appear abnormally large.2 Achieving a balanced proportion between the chin and nose is therefore fundamental to facial harmony.1,5 As mentioned, profiloplasty involves changing the static and dynamic appearance of the face, often to mimic skeletal structures. As such, I opt for a dermal filler that has volumising capacity with a high G prime and cross-linked to provide longevity. The dermal filler of choice should have a high safety profile and a low risk profile. In my experience, a product that contains local anaesthetic makes treatment more tolerable Figure 1: Ideal chin-nose relationship according to Gonzallez-Ulloa. The chin point aligns with a line dropped perpendicular to the Frankfort horizontal plane. in these otherwise sensitive areas. 3
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Side effects and complications Contraindications for profiloplasty are the same as any other dermal filler treatment, and include pregnancy, breastfeeding, immune suppression and keloid scarring.6 Patients’ expectations must be managed and those that have particularly large noses, very deep dorsal humps or severe class II skeletal bases,10 maybe best treated surgically and should be counselled accordingly. Side effects of dermal fillers in these areas include swelling and bruising, which generally take between one to four weeks to fully settle. Chin augmentation can be particularly tender after treatment, with swelling impacting the surrounding muscles and creating a feeling of stiffness. The patient should be counselled that this is normal and will subside; meanwhile normal analgesics can be used for pain management.
Case Study 1 Before
After
Before
After
Complications of dermal fillers can include infection and necrosis.7 An aseptic technique must be employed to reduce the risk of infection and patients should be advised not to touch the area or apply makeup for at least 12 hours. Necrosis further to a vascular
2 - supraperichondrium
3 - supraperichondrium
1 - supraperiosteum
Figure 2: Figure demonstrating depth of recommended filler placement to the nose and the order in which to make the injections
occlusion, although rare, is a serious complication and the risk will be reduced by a thorough understanding of the local anatomy and employing safe injecting techniques. I believe practitioners should always aspirate to check if the needle is in a blood vessel prior to injecting as a safety measure and ensure that injections are deep to the bone or supraperichondrium (cartilage). I also advise injecting slowly and in small increments, always keeping an eye on the skin to check for any blanching which would indicate a vascular occlusion. Any signs of an occlusion must be treated promptly by dissolving the filler with hyaluronidase. It is important that patients are advised that if they experience any changes in skin colour, note ulceration or blistering of the skin, or experience white spots, which could indicate an impending necrosis, they must return for urgent treatment. The risk of blindness following dermal filler treatment should also be discussed. Although this is rare, there have now been more than 150 reported cases worldwide, with the nose been one of the highest risk areas, and thus this should always be included in the consent process.7
Figure 3: A 22-year-old patient treated with a HA dermal filler to the nose and chin. Images taken before and immediately after treatment. Both sides of the face are shown.
This 22-year-old female patient attended my clinic complaining of a ‘big’ nose which she felt self-conscious of and had considered surgical rhinoplasty. On the profile assessment, I noticed that the patient had a dorsal hump on the nose, but the nose itself was not ‘big’. Her chin appeared flat in profile and the pogonion of the chin sat further back than the ideal chin-nose relationship as described by Gonzallez-Ulloa. She could also be described as having a moderately weak chin or a skeletal class II base. In this case, the smaller chin in proportion to the nose created the appearance of an oversized or prominent nose and compromised the facial balance. Following assessment, discussion and planning, I felt this patient would benefit from non-surgical profiloplasty including a NSR and chin augmentation to correct and enhance the facial proportions. Following appropriate cleaning and disinfection, the NSR was performed using hyaluronic acid (HA) dermal filler injections at the radix, directly above and below the dorsal hump, and at the tip using a fine needle to these specific points to reduce trauma. Every injection of dermal filler was delivered slowly, at the supraperiosteal plane or supraperichondrial plane and after aspirating in small 0.1ml boluses. The total volume of HA injected into the nose was 0.6ml. The chin was then augmented with the same volumising HA. Dermal filler was injected supraperiosteally in boluses of 0.2ml per injection after careful aspiration. Filler was placed to enhance the anterior projection of the pogonion, and to increase the chin height at the menton (the most inferior point on the chin). A total of 2ml was placed in the chin underneath the mentalis muscle. The whole procedure took 15 minutes of injecting time. The result shows an improved nose to chin relationship and a more feminine, aesthetically-pleasing profile.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Case Study 2 This 25-year-old patient presented to clinic complaining that her nose was large, her lips were small and her face was disproportionate. On assessment, I noted a small dorsal hump on the bridge of the nose, a shortened lower third Figure 4: A 25-year-old patient treated with face height, a class II dermal filler to the nose, chin and lips. Images skeletal base with deep taken before and immediately after treatment. labiomental crease and an upwards rotating chin. Treatment in this case was aimed at reducing the deep labiomental angle and improving the balance of the facial profile through primarily softening the deep crease, reducing the upwards rotation of the chin and lengthening the chin. I firstly elevated the radix of the nose using 0.2ml of a high G prime Before
Before
After
After
Aesthetics
dermal filler injected supraperiosteally after aspirating, followed by an injection into the tip of the nose, again injecting deep and on the supraperichondrial plane after aspirating, delivering a bolus of 0.05ml to elevate the tip. The upper and lower lips were then augmented to enhance projection using a total of 1ml of a softer dermal filler suitable for lip augmentation. In this case I used a 27 gauge needle to deliver the product at the supra muscular plane in thin linear threads of 0.05ml per aliquot to enhance the projection and volume of the lips, keeping in mind the recommended PHI proportion of upper lip to lower lip width of 1:1.6.10 Lastly, I injected the labiomental crease with the same type of dermal filler that was used in the lips to reduce the deep indentation here using a 25 gauge cannula, augmenting the area with a total of 1ml (0.5ml per side) to reduce the upwards rotation of the mentalis. I then used 0.6ml of the same product used in the nose to augment the chin using three injection points, one at the menton and two either side of the menton, depositing a bolus of 0.2ml after aspirating using a 27 gauge needle. The photos shown were taken before and immediately after treatment.
Conclusion Case Study 3
This 26-year-old female patient attended my clinic complaining that she felt her nose was drooping and long, her lips were small and that she felt she looked ‘goofy’. On assessment, I noted a class II division dental occlusion, resulting Figure 5: A 26-year-old patient treated with dermal filler to the nose, chin and lips. Images in a marked dental taken before and immediately after treatment. overjet (the distance between the upper and lower teeth) creating this appearance. She had a class II skeletal base. The treatment plan in this case included a NSR, lip and chin augmentation. The nose was treated at four points: the radix using 0.2ml of product after aspirating onto periosteum to elevate the depression, then 0.1ml was injected immediately below the dorsal hump supraperichondrially, followed by 0.1ml injection into the tip of the nose on the supraperichondrium to create an upwards turning tip. The last injected point was at the subnasale, depositing 0.1ml of product anterior to the nasal spine to extend the nasolabial angle. A dense dermal filler with lifting capacity and integrated local anaesthetic was used to perform the NSR and chin augmentation. I injected the chin using 1.5ml of product to enhance the projection of the chin, placed in small bolus points of 0.2ml per bolus and lateral to the pogonion. The lips were enhanced with 1ml of dermal filler, with a focus on the lower lip fullness and downwards rotation, in order to mask and minimise the appearance of the class II dental occlusion. The photos shown were taken before and immediately after treatment.
Profiloplasty can enhance the profile whilst avoiding the trauma, potential scarring and costs associated with surgery. This is a suitable treatment particularly for class II skeletal patients who wish to enhance the appearance of their facial profile without undergoing surgery. Patients must be appropriately counselled about the risks, have their expectations managed to ensure they are realistic, and informed that the results are expected to last on average 12-18 months depending on filler used. The vasculature of the nose in particular deems it a high risk area to inject. The experienced injector must always remain conscious of this fact and employ safe injecting techniques to reduce the risk of an occlusion. Dr Yusra Al-Muktar is a dental surgeon with several years’ experience in head and neck surgery and facial aesthetics. She is a lead trainer for injectable courses with Oris Medical, based at the Royal College of General Practitioners. Dr Al-Muktar has worked as an advanced injector for Destination Skin and works in private clinics in London and Liverpool, performing a range of advanced facial aesthetic procedures. REFERENCES 1. E Lee, ‘Aesthetic Alteration of the Chin’, Semin Plast Surg., (2013), pp.155-160. 2. ME Tardy, S Dayan, D Hecht, ‘Preoperative rhinoplasty’, Otlaryngol Clin North Am, (2002), pp.1-27. 3. GONZÁLEZ-ULLOA MARIO M.D.STEVENS, EDUARDO M.D. ‘THE ROLE OF CHIN CORRECTION IN PROFILEPLASTY’ Plastic and Reconstructive Surgery: May 1968 - Volume 41 - Issue 5 - ppg 477-486 4. Non-surgical minimally invasive rhinoplasty: tips and tricks from the perspective of a dermatologist Ali Sahan1 , Funda Tamer2 Acta Dermatovenerologica 2017;26:101-103 5. D Shaye et al., ‘Chin Augmentation Surgery’, Rhinplasty Archive, (2013) https://www.rhinoplastyarchive. com/articles/chin-augmentation-surgery 6. J Cutan Aesthet Surg. 2010 Jan-Apr; 3(1): 16–19. Fillers: Contraindications, Side Effects and Precautions Philippe Lafaille and Anthony Benedetto 7. Mohammed H.Abduljabbar, Mohammad A.Basendwh, Journal of Dermatology & Dermatologic Surgery, July 2016, Complications of hyaluronic acid fillers and their managements 8. Swift, A, Remington K, Clinics in Plastic Surgery, July 2011, Volume 38, BeautiPHIcation™: A Global Approach to Facial Beauty 9. Stephen S. Park, Clin Exp Otorhinolaryngol. 2011 Jun; 4(2): 55–66. Fundamental Principles in Aesthetic Rhinoplasty 10. Aesthetic Surgery Journal, The Origin of the Zero-Degree Meridian Used in Facial Aesthetic Analysis, 2014 < https://academic.oup.com/asj/article/34/7/NP72/257045>
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Stem cell treatment for genetic early baldness Assessment of all patients with hair loss is paramount prior to commencing any form of treatment. The assessment considerations should include, but are not limited to, diet, anaemia, stress, hormonal imbalance, post-cancer treatments, trauma and burns, as these can contribute to the cause of the hair loss.5 The degree of hair loss in males can be classified using the Norwood Hamilton classification and in females the classification is based on the Savin scale.6 The first line treatment of MPB and FPHL is medical, which includes topical minoxidil, and for males only, finasteride.5,6 Low-level laser treatment can also be utilised,7 while micronutrients can be considered. Plateletrich plasma (PRP) is another method for treating genetic alopecia, although more scientific evidence is needed to support its efficacy.8 It is generally accepted that the gold standard for treating MPB and FPHL alopecia is follicular unit transplantation. It is not, however, offered in either male or female patients with early alopecia consisting of diffuse thinning, poor donor availability, and scarring alopecia.9 In addition, some patients may not wish to continue with medical treatment even after a hair transplant, which I believe leaves a gap Consultant plastic surgeon Mr Ali Juma for treatment using adipose tissue that is enriched with explores the use of stem cells for treating regenerative stem cells.9 Fat loss correlates to hair loss as ASCs secrete various hair loss in men and women growth factors, which can promote hair growth. A 2016 Stem cells are more frequently being discussed for uses in study that examined the effects of ASCs conditioned medium on 11 regenerative medicine and there are new developments in their men and 11 women with alopecia found that stem cell conditioned use for hair restoration. This article will explore a treatment option medium appears highly effective for alopecia and that the treatment that is relativity new to the UK to help patients with male patterned represents a new therapy for hair regeneration after hair numbers baldness (MPB) and female patterned hair loss (FPHL), explaining its were significantly increased.10 mechanism of action and how to obtain successful results. ASCs conditioned medium is rich in growth factors such as vascular endothelial growth factor, which can control hair growth and follicle Stem cells size through angiogenesis.10 Other factors like hepatocytes, plateletStem cells originate from different sources, which include derived growth factors, as well as the maintenance and induction of embryonic, pluripotent, adipose tissue (fat) and muscles.1 the anagen and the hair follicle growth phase, are also present and Mesenchymal stem cells, particularly those of adipose tissue origin influence cyclic growth of the hair follicle.11,12,13 Injecting autologous (adipose-derived mesenchymal stromal/stem cells or ASCs) appear fat subcutaneously, which is enriched with regenerative stem cells to be an ideal and more practical source to use in regenerative in both males and females may represent a promising alternative medicine. This is because adult human adipose tissue is in approach to treating this condition.9 I believe for best results it should 1 abundance in males and females. This abundance means ASCs be considered as an option for hair regeneration in patients with early are the most common source with minimal donor site morbidity, MPB and FPHL â&#x20AC;&#x201C; Norwood Hamilton type I-III A male baldness, and limited discomfort and outpatient surgery. Stem cells are also Savin type I-II (sub-classification 1-4) of female baldness.15 2 multipotent and have a good potential for regeneration of tissues. Adipose tissue is composed of >90% fat globules by volume and stromal vascular fraction (SVF), which is a component of the lipoaspirate obtained from liposuction of excess adipose tissue and contains a large number of regenerative cells. SVF includes preadipocytes, fibroblasts, vascular smooth muscles, endothelial cells, monocytes, lymphocytes, macrophages and stem cells.3 The donor site of the ASCs influences their behaviour; for example, the ASCs derived from the superficial abdominal wall are more resistant to apoptosis than those derived from the inner arm, medial thigh, trochanteric area and deep abdomen.4 The technique used to harvest ASCs influences the way they behave due to the variation in the cell subtypes which accompany them. For example, the use of lower pressure fat aspiration will reduce damage to fat cells.4
Using Stem Cells for Hair Restoration
Injecting autologous fat subcutaneously, which is enriched with regenerative stem cells, may represent a promising alternative
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Figure 3: Male baldness at baseline, six months and 12 months following Kerastem treatment. Image courtesy of Belle UK from US clinical STYLE trial.15
Figure 4: Female baldness at baseline, six months and 12 months following Kerastem treatment. Image courtesy of Belle UK from US STYLE clinical trial.15
Treatment pathway
and complications, including the risks and potential complications associated with liposuction.16 The recovery period is usually two to three weeks following the treatment. It is a one-off treatment, and the results may continue to improve even 12 months later. Another benefit of this treatment is contouring of the fat donor sites.
The single treatment involves liposuction and the transfer of autologous fat that has been enriched with adipose-derived regenerative cells (SVF stem cells). To achieve this, two different systems must be used to purify fat, remove contaminates and to process the SVF stem cells.9 I use the Kerastem system for processing the SVF stem cells as it appears to be the only system available in the UK to provide high quality cells. The protocol for Kerastem uses the Puregraft system for obtaining a purified autologous fat graft. The treatment requires appropriate patient selection, following a clinical history and examination, which includes assessment of donor sites for fat. The fat donor sites commonly include the abdomen and flanks. Treatment of alopecia with ASCs has contraindications including local skin disease, inflammation, infection, allergic conditions, autoimmune disease, pregnancy, cancer and current anticoagulant therapy.10 When the clinical presentation and the options of treatment available match the patient’s request, a full discussion of the benefits, scars, including their extent and location, potential risks, in addition to the surgical and medical complications, are discussed. Upon agreement with the patient and allowing for the appropriate twoweek cooling-off period, the patient is scheduled for treatment. The patient is administered an intravenous dose of antibiotics one hour before surgery. The treatment pathway includes liposuction, which can be performed under general anaesthetic or twilight anaesthesia. Tumescent local anaesthetic is infused into the donor sites for fat, while liposuction is performed using handheld 2.4mm cannulas; however, a micro-air mechanically-assisted system can also be used to aspirate the fat.9 The procedure uses enzymatic treatment of the fat to release the regenerative stem cells, which according to the literature makes it more effective.9 All patients are covered prophylactically with pneumatic compression mechanical boots and compression stockings for deep vein thrombosis prophylaxis. The liposuction donor sites are dressed and a liposuction compression garment is applied for a period of four to six weeks. The amount of fat aspirated is 250cc. The first 50ccs is processed through the Puregraft system to obtain a purified autologous fat graft. The remaining 200cc is processed through a the Kerastem system to obtain a 5cc cell suspension of regenerative stem cells. This latter process takes 75-90 minutes.9 The SVF yield per 1ml of fat input is between 5.48 x 105 - 7.31 x 105 of stem cells and progenitor cells.14 A scalp ring with 1% Lidocaine and 1:200,000 adrenaline is administered first. The area to be treated is planned and a grid of 1cm squares is mapped. 0.1ml of purified fat is injected into the subcutaneous fatty layer of the scalp in each 1cm square of the grid with a 1.2mm cannula. Each cm2 of treatment area is then injected with 500,000 stem cells. These cells are injected into the dermis on withdrawal of the needle.15 Patients are discharged one to two hours following completion of the treatment.9 The treatment process takes two and half hours from start to end. The treatment has minimal risks
Conclusion Genetic early alopecia treatment commences after a thorough clinical assessment and a first-line conservative medical approach. Hair transplant is still the gold standard for treatment; however, treatment with adipose tissue derived stem cells, which is relatively new to our shores in the UK, could be considered as an alternative. Early research shows it to be an efficient one-off method in the majority of patients in treating Norwood Hamilton type I-III A male baldness, and female hair loss Savin type I (sub-classification 1-4), and II (sub-classification 1-2). More research will follow in due course from continued research in the US15 and through continued data collection and effective research in the UK. Mr Ali Juma privately in London and Wirral and previously held a 12-year career as a consultant plastic surgeon in the NHS. He offers a range of cosmetic and plastic surgery procedures, along with aesthetic treatments. Mr Juma is registered with the General Medical Council. He is a member of BAAPS and BAPRAS. REFERENCES 1. Mizuno H, Tobita M, Uysal C Concise Review: Adipose-Derived Stem Cells as a Novel Tool for Future Regenerative Medicine. Stem Cells, 2012; 30: 804-810. 2. Gimble JM, Katz AJ, Bunnell BA. Adipose-derived stem cells for regenerative medicine. Circ Res. 2007; 100:1249–60. 3. Boquest AC, Shahdadfar A, Brinchmann JE et al. Isolation of stromal stem cells from human adipose tissue. Methods Mol Biol 2006; 325:35–46. 4. Prunet-Marcassus B, Cousin B, Caton D, Andre M, Penicaud L, Casteilla L. From heterogeneity to plasticity in adipose tissues: site- specific differences. Exp Cell Res. 2006; 312:727–736. 5. Krupa Shankar DS, Chakravarthi M, Shilpakar R. Male androgenetic alopecia: population base study in 1,005 subjects. Int J Trichology. 2009; 1(2): 131–133. 6. Gan DCC, Sinclair RD. Prevalence of male and female pattern hair loss in Maryborough. J Investig Dermatol Symp Proc. 2005; 10:184–189. 7. Magerl M, Paus R, Farjo N, Muller-Rover S, Peters EM, Foitzik K, Tobin DJ. Limitations of human occipital scalp hair follicle organ culture for studying the effects of minoxidil as a hair growth enhancer. Exp Dermatol. 2004; 13(10): 535–542. 8. Khatu A S, More Y E, Gokhale N R, Chavhan D C, Bendsure N. Platelet-rich plasma in androgenic alopecia: myth or effective tool. J Cutan Aesthet Surg. 2014 Apr-Jun 7(2): 107-110. 9. Perex-Meza D, Ziering C, Sforza M, Krishman G, Ball E, Daniels E. Hair follicle growth by stromal vascular fraction enhanced adipose transplantation in baldness. Stem Cells and Cloning: Advances and Applications. 2017: 1-10. 10. Fukuoka H, Suga H. Hair regeneration treatment using adipose derived stem cell condition medium: follow-up with trichgrams. EPlasty 2015; 15: e10, March 2016. 11. Yano K, Brown L F, Detmar M. Control of hair growth and follicle size by VEGF-mediated angiogenesis. J Clin Invest. 2001: 107: 409-417. 12. Jindo T, Tsuboi R, Takamori K, Ogawa H. Local injection of hepatocyte growth factor/scatter factor (HGF/SF) alters cyclic growth of murine hair follicles. J Invest Dermatol. 1998; 110: 338-42. 13. Lindner G, Menrad A, Gherardi E, et al. Involvement of hepatocyte growth factor/scatter factor and met receptor signalling in hair follicle morphogenesis and cycling. FASEB J. 2000; 14:319–32. 14. CLINICAL EVALUATION (Alopecia). Cytori Celution. 800 System (Celution 800 Device & associated. Celution 805 Consumable Set). Reference available upon request from BELLE UK. 15. Kerastem Technologies, A Trial of Cell Enriched Adipose For Androgenetic Alopecia (STYLE), <https:// clinicaltrials.gov/ct2/show/NCT02503852> 16. Christodoulos Kaoutzanis, Varun Gupta, et al., ‘Cosmetic Liposuction: Preoperative Risk Factors, Major Complication Rates, and Safety of Combined Procedures’, Aesthetic Surgery Journal, Volume 37, Issue 6, 1 June 2017, Pages 680–694.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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DISCOVER The next generation non-cross linked Hyaluronic Acid to treat alopecia
RRS®SUCCESS CASE STUDY GALLERY BEFORE
AFTER
Images courtesy of Frances Turner Traill, FTT Skin Clinics Showcasing the versality and diversity of RRS XL Hair® with different application technology and device modalities, here three leading industry practitioners share their successful case studies and how you can optimise treatment outcome by utilising the benefits of combination therapy...
BEFORE
WHAT IS RRS XL HAIR®?
RRS XL Hair® is a dermal filler containing non cross-linked Hyaluronic Acid solubilised in a solution to treat alopecia. A dermal implant for alopecia areata, telogen effluvium, anagen effluvium, pattern alopecia, RRS XL Hair® is formulated to activate hair restoration by increasing proliferation of human papilla cells. When alopecia takes place there is insufficient ‘cross talk’ between the scalp cells and skin matrix. The restructurising and moisturising capacity of Hyaluronic Acid in RRS XL Hair® provides the scalp with exceptional hydration and biostimulation. Hyaluronic Acid is known for its ability to restructure the intercellular matrix and allow more efficient physiologicol ‘cross talk’ between hair root cells and the intercellular matrix. Following an in vitro study, XL Hair increased cells proliferation by 23%. Featuring Fibroblast Growth Factors, terpenes, vitamins, flavonoids, organic silicium, amino acids and non-cross-linked HA, XL Hair is one of the few successful non-surgical treatments for hair loss. 50
Aesthetics | November 2018
AFTER
Images courtesy of Jan Birch, Blemish Clinic
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Modality #1
Modality #2
RRS XL HAIR® MESO GUN
PLASMA PORATION RRS XL HAIR® THERAPY
DURATION OF TREATMENT: 30 mins once per week for 12 weeks Reduce treatment time and stimulate dermal activity with meso gun application - the multiple needle penetrations in this treatment protocol stimulates hair growth, combined with injection delivery of the RRS XL Hair® formulation.
DURATION OF TREATMENT: 30 mins per session per week for 6-12 weeks as necessary Utilise the cellular regeneration technology of Plasma Poration, which enables the delivery of the product into the scalp without the need for needle discomfort with effective results.
“Using a meso gun for this application makes the treatment much more comfortable for the patient and also much quicker. It is also my go-to for treating any larger areas of the face or body as well. RRS is like my little apothecary. I love being able to blend and mix different vials to achieve utterly bespoke results for my patients, but also knowing that picking one vial off the shelf will also do an incredible job. The safety profile, extensive testing and fantastic results mean it is my go-to for skin biorevitalisation.”
“We are at early stages in trialing plasma and RRS therapy for hair loss and already from two clinical cases we are experiencing great results. One 26 year old female patient with first presentation of a solitary area of alopecia showed remarkable results after only 2 treatments but continued to have 6 treatments and has full hair growth restored. One male patient is in the early stages of treatment for male pattern baldness also having had only 2 treatments to date. He is showing signs of new hair growth which is promising. Any type of hair loss can be of great distress to the patient and to find an innovative treatment which is showing promising results is fantastic.”
Dr Sophie Shotter, Illuminate Skin Clinic
Frances Turner Traill, FTT Skin Clinics
Modality #3 RRS XL HAIR® THERAPY NAPAGE, REJUVEPEN & OMNILUX™ RED LIGHT THERAPY DURATION OF TREATMENT: 60 mins per session every other week for 12 weeks (Omnilux™ red light therapy weekly) Utilising Napage and Microneedling enables delivery of RRS XL Hair® directly into the scalp combining the benefits of microtrauma and the formulation. Patients cleanse and prepare their scalp with a chlorhexidine pre-treatment shampoo which is used on the day before coming in for treatment. The practitioner injects the affected areas of
hair loss as well as microneedling with excess RRS XL Hair and between treatments patients are supplied with a daily home use stimulating shampoo and serum to help boost hair growth. Patients are treated every other week and require the Omnilux™ red light therapy weekly. Results can be seen in as little as 6 weeks with optimal outcome after 12. “We have been combining injecting, microneedling and Omnilux™ red light therapy and patients have been experiencing successful results. It is important to educate patients about the hair growth and resting phases as this treatment needs to stimulate hair folicles and it can take a number of months before the new hair growth can be seen.” Jan Birch Consultant Nurse, Blemish Clinic
For more information, expert quotes, images and press samples please contact the in-house press office: Vikki Baker e: vikki@aestheticsource.com t: 01234 313130
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Injecting is optional with cold plasma “From concept to reality Plasma Shower is the latest break-through in aesthetic medical technology” Plasma BTTM with Plasma ShowerTM offers unique applications of, digitally precise pulse durations and single shot modes at various energy levels. The skin depth varies in different areas of the face and body and also in patient age, Plasma BTTM will offer a truly bespoke treatment to address each individual area. Plasma ShowerTM is a unique delivery system of non-ablative plasma which has many positive effects to the skin, causing regeneration and is fatal to bacteria, having a profound effect on the treatment of acne. Plasma ShowerTM also relaxes the cell adhesion proteins in the skin so Trans Dermal Delivery of products can occur at astonishing levels. Products can be topically applied such as Mesotherapy serums, PRP, Vitamin solutions and even Hyalase for compilications management. Plasma ShowerTM is also available on the PlaSonTM device. Please email: hello@beamwave.co.uk for more information or to book a demonstration.
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Case Study: Treating Hair Loss Nurse prescribers Frances Turner Traill and Lyndsey Loughery treat alopecia areata Hair in many individuals can represent beauty, youth and health and, in women, hair often represents femininity.1 Alopecia is a dermatologic condition that affects the pilosebaceous unit in both genders. It can be extremely distressing for the individual and can impact greatly on their quality of life, often influencing negative body image, low self-esteem, depression, introversion and feelings of unattractiveness.2
Case study Our patient, a 26-year-old female, initially presented to FTT Skin Clinics with skin issues mainly on her neck area, which we diagnosed as atopic dermatitis caused by an autoimmune problem, so we referred her back to her GP for further investigation. During the indepth consultation with the patient, however, she divulged that she also suffered from an area of baldness on the crown of her head. The patient has long, glossy, auburn hair and over a period of several months prior to our visit she had noticed a distinct patch of baldness emerging when running her fingers through her hair. We measured this area to be 5x5cm, which she managed to cover up most of the time by brushing her hair over the area. The patient didn’t know who to turn to in order to resolve this issue as she was unsure of the treatment possibilities. While we explained that we do offer treatment for hair loss, we recommended that she have a routine blood test when she visited her GP to aim to diagnose the cause of the hair loss before we offered any treatment. When the patient visited her GP, she discussed additional concerns of non-specific tiredness, describing that she had been feeling run down, was presenting with skin issues (aforementioned atopic dermatitis), as well as her hair loss. The patient’s blood test indicated that she was mildly anaemic with low B12 and was consequently treated by her GP with a course of B12 injections (hydroxycobalamin), which resulted in improvement in her tiredness and fatigue. The GP believed the cause of her hair loss was the B12 deficiency, and a lowered autoimmune system.
PL A S MA • Plasma kills the germs and bacteria by breaking the bacterial molecular structure11 • Increases the skin absorption rate by temporarily breaking the cell adhesion molecules (CAMs)10 • Tightens the aged skin by balancing the membrane potential12 • Stimulates the generation of collagen and fibroblasts12 Figure 1: The effect of plasma on human skin
The patient was also treated with first line emollients and a mild potency topical steroid (hydrocortisone 2%) for her atopic dermatitis. In addition, the GP recommended the patient started using over the counter hair treatment shampoo Nioxin for her thinning hair. The following week, as her hair patch had not resolved, she came back to our clinic for us to assist her with her hair loss concerns.
Hair loss diagnosis Diagnosis is usually based on history and examination with the clinician, exploring a history of atopy or other autoimmune disorders and family history of alopecia. We diagnose our female patients based on clinical presentation and severity, using the Ludwig Classification.3 This severity classification includes: Type 1: hair loss is considered to be mild Type 2: hair loss is considered moderate Type 3: hair loss is considered most extreme Our patient was diagnosed as Type 1 on the Ludwig Classification, as it was a solitary patch of hair loss with no other thinning areas. We diagnosed her with patchy alopecia areata, which is a recurrent nonscarring type of alopecia that can affect both sexes with approximately 50% of cases presenting in childhood and 80% starting before the age of 40.4 Alopecia areata has no known race or sex preponderance5 and can manifest in many different patterns and affect any hair bearing areas. Although a medically benign condition, it can cause a great deal of psychosocial and emotional distress.6 Characteristically, the initial lesion is a circumscribed, bald, smooth patch which may be completely devoid of hair or have scattered exclamation mark hairs with the skin being normal or slightly reddened. It is most often asymptomatic, although some patients may complain of trichodynia in the affected area.6 It is classified as an autoimmune disorder with approximately 20% of patients known to have a family history.5 Onset or recurrence of hair loss can be triggered by viral infection, trauma, hormonal change and emotional and physical stressors.7 Treatment options Treatment options for hair loss are variable and are dependent on the type. Many hair loss treatments can produce regrowth of hair, although it has been reported in the British Medical Journal that complete reversal is never achieved.8 For this patient, the options we gave her were that she could either do nothing, as it may resolve on its own, or try over the counter minoxidil 5% shampoo. Although, in practice, we find that this is a variable treatment and is unlikely to completely resolve the issue. We also told her about a treatment that is new to the clinic, cold atmospheric plasma combined with mesotherapy, which we had not used for hair loss before, but thought may help. We have had considerable experience with cold atmospheric plasma for nonsurgical lesion removal and acne treatment, however the concept of using cold atmospheric plasma with mesotherapy was relatively new. The patient was attracted to this option because it is a non-invasive treatment with no downtime or pain. After an in-depth consultation, she decided that she would try a six-week course of this combination treatment as her hair loss was causing her great distress. Combining cold atmospheric plasma and mesotherapy For this treatment, we used the Plasma BT Shower handpiece with RRS XL Hair mesotherapy. We also offer RRS mesotherapy through microneedling, however most of our patients prefer to use
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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3 sessions after
Aesthetics 6 sessions after
Results The patient had noticeable results from the third session, going from a smooth bald patch on week one, with soft vellus hair on week three. This continued to improve over the following three sessions and, at week six, although the hair was short in this area, there were normal terminal hairs at full hair thickness. We reviewed the patient after a further four weeks, where there was noticeable hair Figure 2: Patient before and after treatment using Plasma BT with RRS XL Hair mesotherapy. growth and no evidence of any further hair loss. We advised the it with Plasma BT as we find it to be quicker and more efficient. The patient that although the results may be permanent, due to the nature treatment is also pain-free as you can treat deep into the dermis of alopecia areata, this patch may reoccur, not necessarily in the same using transdermal delivery from the Plasma BT to biorevitalise the area. If there was further hair loss in the future, then a full six-week skin, without needles. Plasma is the fourth state of matter, following treatment using the same protocol would be advised. the state of solid, liquid and gas, whereby the gaseous state has been ionised by the high temperature and high electricity in everyday Conclusion environment. Plasma works differently in bacteria than in a human cell. Although alopecia is considered a benign disorder and viewed as a It kills bacteria, but it provides stimulation to a human cell and helps cosmetic concern in many patients, it can have a huge psychological with its regeneration.9,10 In aesthetics, plasma devices can be useful impact on the individual’s quality of life. We believe mesotherapy because they can dramatically increase the skin’s absorption rate by offers a good treatment option for patients suffering from nontemporarily breaking the cell adhesion molecules (CAMs).11 Because scarring alopecia and, in our experience, combining it with cold of the change in CAMs, we can get volumes of several millilitres of atmospheric plasma is revolutionary as it can lead to faster and mesotherapy products into the skin that would have previously had more effective results, without any downtime, and the treatment is to been injected. This is why I believe it is a good option to use to completely pain free. enhance the effects of mesotherapy hair loss, as injecting superficially Frances Turner Traill is an independent nurse into the scalp is particularly painful and difficult to anaesthetise in the prescriber who is the clinical director of FTT Skin Clinics 9,10 usual way with topical creams. Mesotherapy is a hugely popular with clinics in Inverness and Hamilton, Scotland. She is the Scottish board member of the British Association treatment, which is traditionally injected into the skin as a solution of Cosmetic Nurses (BACN) representing BACN on loaded with amino acids, antioxidants, peptides and hyaluronic acid. new regulation changes with Scottish government and Health RRS is our mesotherapy product of choice as we have found it offers Improvement Scotland. Her credentials are: RGN RMN MA (Hons) NIP, our patients safe, highly effective results for the face and body. BSc (Derm), PG Cert (Medical Aesthetics). Treatment of patient There are no contraindications to this treatment, however at FTT Skin Clinics we ask our patients to see their GP before beginning to rule out any underlying issues. As the patient reported being systemically unwell, as well as her atopic dermatitis, we felt it was best to work in conjunction with her GP. We treated the symptoms of her hair loss, whilst he investigated and treated the causes, explained above. We treated the patient with cold atmospheric plasma and mesotherapy every seven to 10 days, as per the patient’s schedule, which we found was long enough to monitor any growth/changes. We performed six treatments and recommended three hair products to enhance the results. We firstly advised the patient use an adequate scalp preparation shampoo two to four hours before each treatment. Other products are available, but we recommended Aesthetic Dermal Daily Care Scalpfit shampoo, which is designed to be used before procedures like mesotherapy or hair transplant. We instructed the patient to leave this product on the hair for two minutes before rinsing off. We also recommended Aesthetic Dermal Hair Energizer spray, which was to be applied to the scalp twice daily and gently massaged to ensure distribution the affected area, as well as Revitalix post-treatment scalp and hair hydration revitalising shampoo, to be used after every treatment and in between treatment sessions as maintenance.
Lyndsey Loughery in an independent nurse prescriber at FTT Skin Clinics. She is currently working towards her PgDip in Dermatology In Clinical Practice and She is also working towards her PG Cert (medical Aesthetics) and is a member of BACN. REFERENCES 1. Davis, D. S. Callender, V. D. (2018). Review of quality of life studies in women with alopecia. International Journal of Women’s Dermatology. 2. Phillips, G. Slomiany, P. Allison, R. (2017). Hair Loss: Common Causes and Treatment. American Family Physician: 2017;96(6):371-378. Online. <https://www.medscape.com/viewarticle/886852_1> 3. Hair Transplant Institute, Ludwig Classification: Diagnosing Female Hair Loss, 2013 <http://www. miamihair.com/blog/hair-loss/ludwig-classification-diagnosing-female-hair-loss/> 4. Oakley, A. Alopecia areata, DermNet NZ, 2015. <https://www.dermnetnz.org/topics/alopecia-areata/> 5. Cunliffe, T. Alopecia – an overview. 2018. <http://www.pcds.org.uk/clinical-guidance/alopecia-anoverview> 6. Bolduc, C. Alopecia Areata. 2018 <https://emedicine.medscape.com/article/1069931-overview> 7. BMJ, Alopecia areata, (2018). <https://bestpractice.bmj.com/topics/en-gb/222> 8. Plasma the Forth State of Matter, Plasma Treat, 2018. <https://www.plasmatreat.com/plasmatechnology/what-is-plasma.html> 9. Emmert, S, Brehmer, F et al, Atmospheric pressure plasma in dermatology: Ulcus treatment and much more, Clinical Plasma Medicine, 2012. 10. Lademann, O, Richter H, et al., ‘Drug delivery through the skin barrier enhanced by treatment with tissue-tolerable plasma’, Exp Dermatol. 2011 Jun;20(6):488-90. 11. J Heinlin, et al., Plasma applications in medicine with a special focus on dermatology, Journal of the European Academy of Dermatology and Venereology, 2011, 25, 1–11. 12. Choi, JH, et al., ‘Treatment with low-temperature atmospheric pressure plasma enhances cutaneous delivery of epidermal growth factor by regulating E-cadherin-mediated cell junctions’, Arch Dermatol Res. 2014 Sep;306(7):635-43.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
FINALIST 2018
Working with you to deliver natural-looking results FINALIST 2018
A lifting and regenerating suture treatment for the mid-face, jowls and neck.
A bioresorbable collagen stimulator for facial correction and volumisation.
A tailor-made range of HA dermal fillers for wrinkle correction, facial contouring and volume restoration.
An innovative product portfolio to give a lift to your patients and your business For more information on the Sinclair aesthetic products and training support visit: www.sinclairpharma.com Sinclair Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. Date of preparation: July 2018
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A summary of the latest clinical studies Title: Treatment of Male Pattern Alopecia with Platelet-Rich Plasma: A Double Blind Controlled Study with Analysis of Platelet Number and Growth Factor Levels Authors: Rodrigues B, Montalvão S, Cancela R, et al. Published: Journal of the American Academy of Dermatology, October 2018 Keywords: Platelet-rich plasma, alopecia, hair loss Abstract: Promising results were described with platelet-rich plasma (PRP) in androgenetic alopecia that could be associated to platelet number and growth factor levels. The objective of the study was to analyse the platelet number and growth factor levels in PRP and its correlation with hair growth parameters evaluated by TrichoScan. Twenty-six patients randomized to receive four subcutaneous injections of PRP or saline. Hair growth, hair density, and percentage of anagen hairs were evaluated before, after and three months after the last injection using TrichoScan method. Growth factors (PDGF, EGF and VEGF) were measured by Luminex method. We demonstrated a significant increase in hair count (p = 0.0016), hair density (p = 0.012) and percentage of anagen hairs (p = 0.007) in PRP group when compared to control group, without correlation with platelet counts or quantification of the growth factors in PRP. Our data favours the use of PRP as therapeutic alternative in the treatment of androgenetic alopecia. The lack of association between platelet count, PDGF, EGF and VEGF levels and clinical improvement suggest that other mechanisms could be involved in this response.
Title: Google Trends as a Tool for Evaluating Public Interest in Facial Cosmetic Procedures Authors: Tijerina J, Morrison S et al. Published: Aesthetic Surgery Journal, October 2018 Keywords: Google trends, patient interest, procedures Abstract: The utility of Google Trends (GT) in analyzing worldwide and regional patient interest for plastic surgery procedures is becoming invaluable to plastic surgery practices. GT data may offer practical information to plastic surgeons pertaining to seasonal and geographic trends in interest in facial cosmetic procedures. The authors sought to analyze geographic and temporal trends between GT search volumes and US surgery volumes using univariate analysis. The “related queries” feature of GT generated potential search terms. GT data were compiled for cheek implants, mentoplasty, otoplasty, blepharoplasty, rhytidectomy, forehead lift, hair transplantation, lip augmentation, lip reduction, platysmaplasty, and rhinoplasty from January 2004 to December 2017. Annual volumes for respective procedures were obtained from annual statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017. Geographical and temporal variations in search volume were detected during the study. Several search terms demonstrated no significant relationships or were significant with only one database. GT may provide a high utility for informing plastic surgeons about the interest expressed by our patient population regarding certain cosmetic search terms and procedures.
Title: Self-esteem is Related to Anxiety in Psoriasis Patients: A Case Control Study Authors: Słomian A, Łakuta P et al. Published: Journal of Psychosomatic Research, November 2018 Keywords: Psoriasis, self-esteem, anxiety Abstract: In psoriasis, taking steps to improve emotional health is important to bring lasting benefits to patients’ physical health and overall well-being. We aimed to identify factors that relate to anxiety in psoriasis and are potentially modifiable and that thus qualify as targets for future planned interventions for improving mental health. In this study, the importance of coping strategies and self-esteem as potential targets were tested. A total of 102 patients diagnosed with psoriasis, aged 26-65 years (M = 43.39 years, SD = 10.56) and 98 healthy controls (with an overall age, gender, educational attainment distribution similar to that of the cases) completed the Rosenberg’s Self-Esteem Scale, the Coping Inventory for Stressful Situations, and the State-Trait Anxiety Inventory. Patients with psoriasis compared to healthy controls reported significantly higher rates of anxiety and emotion- and avoidance-oriented coping strategies, presented lower rates of task-oriented coping strategies, and significantly lower levels of self-esteem. Importantly, our results revealed that self-esteem in psoriasis patients was strongly related to anxiety. Moreover, the increased rates of anxiety in psoriasis were not significantly associated with the coping strategies, suggesting that in patients with psoriasis coping strategies are secondary to other factors such as selfimage and self-esteem. The results identify self-esteem as a target to adopt in further interventions for psoriasis patients.
Title: Hyaluronic Acid, a Promising Skin Rejuvenating Biomedicine: A Review of Recent Updates and Pre-clinical and Clinical Investigations on Cosmetic and Nutricosmetic Effects Authors: Bukhari S, Roswandi N, Waqas M, et al. Published: International Journal of Biological Macromolecules, October 2018 Keywords: Hyaluronic acid, skin rejuvenation, dermal filler Abstract: Owing to its remarkable biomedical and tissue regeneration potential, hyaluronic acid (HA) has been numerously employed as one of the imperative components of the cosmetic and nutricosmetic products. The present review aims to summarize and critically appraise recent developments and clinical investigations on cosmetic and nutricosmetic efficacy of HA for skin rejuvenation. A thorough analysis of the literature revealed that HA based formulations (i.e. gels, creams, intra-dermal filler injections, dermal fillers, facial fillers, autologous fat gels, lotion, serum, and implants, etc.) exhibit remarkable anti-wrinkle, anti-nasolabial fold, antiaging, space-filling, and face rejuvenating properties. This has been achieved via soft tissue augmentation, improved skin hydration, collagen and elastin stimulation, and face volume restoration. HA, alone or in combination with lidocaine and other co-agents, showed promising efficacy in skin tightness and elasticity, face rejuvenation, improving aesthetic scores, reducing the wrinkle scars, longevity, and tear trough rejuvenation. Our critical analysis evidenced that application/administration of HA exhibits outstanding nutricosmetic efficacy and thus is warranted to be used as a prime component of cosmetic products.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Write a list of your values
Implementing a Creative Strategy Marketing and PR professional James Dempster explores the importance of creative exercises to help practitioners produce innovative content for their marketing As the business aspect of aesthetics can be such a competitive field, practitioners and clinics have a need to show their patients that they stand out and are providers of safe, effective, quality treatments. To send the right messages to patients in an effective way, you need to do more than provide basic information on your website and create an attractive advertisement or printed marketing materials. But with so many clinics trying to get your potential patients’ attention, how can you come up with unique, interesting messaging? The answer, I believe, is through creative strategy exercises. These exercises are more than just an opportunity to generate ideas for creative campaigns; they provide the opportunity to re-evaluate your brand’s mission and values to underpin your marketing output and communicate meaningfully with your audience (and yes, if you are a practitioner you are still a brand). Creative strategy exercises can also help
you to assess the appropriate marketing channels that you should utilise in order to deliver these campaigns to your audience, ensuring your message is heard by the right people at the right time. In this article, I’m going to break down one creative strategy exercise (I call it a creative workshop) that I use time and time again with clients in the healthcare and aesthetics industries to help shape a long-term creative strategy. If you would like to try this exercise to help you come up with creative ideas for your marketing strategy, I suggest that you find private environment and set aside a day or so with your clinic manager, marketing manager, shareholders and other relevant team members. You could do this exercise any time, whether you are just opening your first clinic, or if you currently have a clinic and want to revise your marketing strategy. I recommend doing this twice a year, although after the first time you may not need an entire day.
No matter how long you’ve been in practice, a creative strategy is best achieved by stripping your business back to its very foundation. Ask yourself, ‘Why am I doing this?’ The majority of professionals I meet within the aesthetics specialty started their practice to provide patients with safe and effective results that are natural in appearance, predominantly to help restore confidence and improve quality of life. So, think about the reasons for your brand or clinic’s existence and write a list of your values. What do you want to be known for? I recommend that your team individually write a list as large as possible and then come together and whittle this down to three or four that you want to concentrate on. For example, do you want people to think you and your procedures are: Trustworthy? Safe? Professional? Effective? Authoritative? Compliant? Caring?
State your unique selling points A key factor for achieving an engaged audience is by being unique in your offering. So, your next step in this exercise is to ask yourself, what is it that makes your clinic or practice unique? What is it about you that makes your patients come back? Within the aesthetics specialty, this will almost certainly run deeper than monetary value or convenience alone, as your patients are buying into a service that, whilst not as invasive as a cosmetic procedure, is nonetheless crossing a particular personal boundary. By asking yourself the above questions, you can write another list, but this time you will uncover what your unique selling points (USPs) are. If you’re still stuck, ask your key clients why they come back to you, look at competitors or think about your favourite (non-industry) brands. For example, maybe your USPs are: • Clinician led service • Latest techniques and products • Rated as ‘Outstanding’ by the Care Quality Commission
Demographic
Geographic area
Key traits and values
Motivations
Other defining factors
Women between the ages of 45-54.
London, affluent suburban counties – e.g. Surrey, Sussex, Dorset.
Interested in outcomes, rather than price. Want ‘best in class’ treatment.
Friends, family and relationships (peers), Facebook, TV, film and on demand media, celebrity influence, social culture (dining out, bars), consumer publications (i.e. Red magazine, Woman & Home, Women’s Health), word of mouth, reviews and recommendations.
Women that have had children, may be approaching or going through menopause.
Figure 1: A table you can use to determine who your audience is, or who you aspire it to be
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
IN THE LEADER1 BOTOX® is the original* and #1 selling toxin in the world†1,2
*First licensed Botulinum Toxin Type A. † Therapeutic and aesthetic use.2 Based on market share in 16 countries.1 1. Allergan. Data on file. INT/0827/2017 September 2017. 2. Allergan. Data on file. INT/0681/2017a. BOTOX® is indicated for the temporary improvement in the appearance of the following facial lines, when the severity of these lines has an important psychological impact in adult patients: moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines), moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile, moderate to severe crow’s feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously. Prescribing Information can be found overleaf. UK/0187/2018e Date of preparation: October 2018
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TM
BOTOX® (botulinum toxin type A) Glabellar and Crow’s Feet Lines Abbreviated Prescribing Information Presentation: Botulinum toxin type A (from clostridium botulinum), 50 or 100 or 200 Allergan Units/vial. Indications: Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines); moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile; moderate to severe crow’s feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously in adults, when the severity of these lines has an important psychological impact for the patient. Dosage and Administration: See Summary of Product Characteristics for full information. Do not inject into blood vessels. Botulinum toxin units are not interchangeable from one product to another. Not recommended for patients <18 years. The recommended injection volume per muscle site is 0.1 ml (4 Units). Glabellar Lines: Five injection sites: 2 in each corrugator muscle and 1 in the procerus muscle: total dose 20 Units. Crow’s Feet Lines: Six injection sites: 3 in each lateral orbicularis oculi muscle: total dose 24 Units. In the event of treatment failure or diminished effect following repeat injections alternative treatment methods should be employed. Contraindications: Known hypersensitivity to any constituent. Infection at proposed injection site(s). Warnings/Precautions: Use not recommended in women who are pregnant, breast-feeding and/or women of childbearing potential not using contraception. The recommended dosages and frequencies of administration of BOTOX should not be exceeded due to the potential for overdose, exaggerated muscle weakness, distant spread of toxin and the formation of neutralising antibodies. Initial dosing in treatment naïve patients should begin with the lowest recommended dose for the specific indication. Prescribers and patients should be aware that side effects can occur despite previous injections being well tolerated. Caution should be exercised on the occasion of each administration. There are reports of side effects related to spread of toxin distant from injection site, sometimes resulting in death. BOTOX should only be used with extreme caution and under close supervision in patients with subclinical or clinical evidence of defective neuromuscular transmission and in patients with underlying neurological disorders. Caution in patients with underlying neurological disorder and history of dysphagia and aspiration. Patients should seek medical help if swallowing, speech or respiratory disorders arise. Previously sedentary patients should resume activities gradually. Relevant anatomy and changes due to prior surgical procedures must be understood prior to administration and injection into vulnerable anatomic structures must be avoided. Pneumothorax associated with injection procedure has been reported. Caution is warranted when injecting in proximity to the lung, particularly the apices or other vulnerable structures. Serious adverse events including fatal outcomes have been reported in patients who had received off-label injections directly into salivary glands, the oro-lingual-pharyngeal region, oesophagus and stomach. If serious and/or immediate hypersensitivity reactions occur (in rare cases), injection of toxin should be discontinued and appropriate medical therapy, such as epinephrine, immediately instituted. Procedure related injury could occur. Caution in the presence of inflammation at injection site(s), ptosis or when excessive weakness/atrophy is present in target muscle. Reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. New onset or recurrent seizure occurred rarely in predisposed patients, however relationship to botulinum toxin has not been established. Clinical fluctuations may occur during repeated use. Too frequent or excessive dosing can lead to antibody formation and treatment resistance. It is mandatory that BOTOX is used for one single patient treatment only during a single session. May cause asthenia, muscle weakness, somnolence, dizziness and visual disturbance which could affect driving and operation of machinery. Interactions: Theoretically, the effect may be potentiated by aminoglycoside antibiotics or other drugs that interfere with neuromuscular transmission. Adverse Effects: See Summary of Product Characteristics for full information on side effects. Based on controlled clinical trial data, the proportion of patients treated for glabellar lines that would be expected
to experience an adverse reaction after treatment is 23% (placebo 19%). In pivotal controlled clinical trials for crow’s feet lines, such events were reported in 8% (24 Units for crow’s feet lines alone) and 6% (44 Units: 24 Units for crow’s feet lines administered simultaneously with 20 Units for glabellar lines) of patients compared to 5% for placebo. Adverse reactions may be related to treatment, injection technique or both. In general, adverse reactions occur within the first few days following injection and are transient, but rarely persist for several months or longer. Local muscle weakness represents the expected pharmacological action. Localised pain, tenderness and/or bruising may be associated with the injection. Fever and flu syndrome have been reported. Frequency By Indication: Defined as follows: Common (≥1/100 to <1/10), Uncommon (≥1/1,000 to <1/100). Glabellar Lines (20 Units): Infections and infestations. Uncommon: Infection. Psychiatric disorders. Uncommon: Anxiety. Nervous system disorders. Common: Headache. Uncommon: Paraesthesia, dizziness. Eye disorders. Common: Eyelid ptosis. Uncommon: Blepharitis, eye pain, visual disturbance. Gastrointestinal disorders. Uncommon: Nausea, oral dryness. Skin and subcutaneous tissue disorders. Common: Erythema. Uncommon: Skin tightness, oedema (face, eyelid, periorbital), photosensitivity reaction, pruritus, dry skin. Musculoskeletal and connective tissue disorders. Common: Localised muscle weakness. Uncommon: Muscle twitching. General disorders and administration site conditions. Common: Face pain. Uncommon: Flu syndrome, asthenia, fever. Crow’s Feet Lines (24 Units): Eye disorders. Common: Eyelid oedema. General disorders and administration site conditions. Common: Injection site haemorrhage*, injection site haematoma*. Uncommon: Injection site pain*, injection site paraesthesia (*procedurerelated adverse reactions). Crow’s Feet Lines and Glabellar Lines (44 Units): General disorders and administration site conditions. Common: Injection site haematoma*. Uncommon: Injection site haemorrhage, injection site pain* (*procedure-related adverse reactions). The following adverse events have been reported since the drug has been marketed for glabellar lines, crow’s feet lines and other indications: Cardiac disorders: Arrhythmia, myocardial infarction. Ear and labyrinth disorders: Hypoacusis, tinnitus, vertigo. Eye disorders: Angle-closure glaucoma (for treatment of blepharospasm), strabismus, blurred vision, visual disturbance, lagopthalmos. Gastrointestinal disorders: Abdominal pain, diarrhoea, constipation, dry mouth, dysphagia, nausea, vomiting. General disorders and administration site conditions: Denervation atrophy, malaise, pyrexia. Immune system disorders: Anaphylaxis, angioedema, serum sickness, urticaria. Metabolism and nutrition disorders: Anorexia. Muscoskeletal and connective tissue disorders: Muscle atrophy, myalgia. Nervous system disorders: Bronchial plexopathy, dysphonia, dysarthria, facial paresis, hypoaesthesia, muscle weakness, myasthenia gravis, peripheral neuropathy, paraesthesia, radiculopathy, seizures, syncope, facial palsy. Respiratory, thoracic and mediastinal disorders: Aspiration pneumonia (some with fatal outcome), dyspnea, respiratory depression, respiratory failure. Skin and subcutaneous tissue disorders: Alopecia, dermatitis psoriasiform, erythema multiforme, hyperhidrosis, madarosis, pruritus, rash. NHS Price: 50 Units: £77.50, 100 Units: £138.20, 200 Units £276.40. Marketing Authorization Number: 50 Units: 426/0118, 100 Units: 426/0074, 200 Units 426/0119. Marketing Authorization Holder: Allergan Ltd, Marlow International, The Parkway, Marlow, Bucks, SL7 1YL, UK. Legal Category: POM. Date of preparation: June 2015. Further information is available from: Allergan Limited, Marlow International, The Parkway, Marlow, Bucks SL7 1YL
Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.
UK/0187/2018e Date of preparation: October 2018
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During this exercise, my clients often find that some of their USPs link directly to the values that underpin the reason for being in business. Try to aim for between three and five.
Discover who your target patient is Who is your target patient? It sounds like the most basic question; shouldn’t it be everyone? The simple answer is no. Even the biggest businesses simply cannot choose ‘everyone’ as their target audience; you cannot be everything to everyone. Moreover, whilst ‘everyone’ and ‘anyone’ seems like a wide pool of potential patients to reach, how can you possibly begin to target your messaging to speak to them individually? The key to effective marketing and devising a creative strategy is to understand your key patient segments, not just in terms of their demographics, but their own values, behaviour and interests. Don’t be afraid to be bold – sometimes turning the wrong audience away is needed, especially in this specialty. Even if you feel confident that your offering appeals to several broad audiences, it’s important to note that these groups will be interested in very different things and, similarly, motivated in different ways. This should help clarify which messages you deliver to each of the target groups – messages should be personal and clear. For this part of the exercise, I advise that you create a table such as Figure 1 that you can use to create separate lists to help you understand who your current patients are, or who you aspire them to be. You can use a combination of mind maps to help do this. You need to determine the following: • Demographic: what is their age group, gender? • Geographical area: are they county specific, city-based or nationwide? • Key traits and values: what do these people care about? • Motivations: what media drives them? • Are there any other defining factors? If stuck, look at your clinic’s data to see how much of the above data you have. If you’re still stuck, consider a survey. Figure 1 is an example of something that you might produce for one type of audience – ideally you want between one and three. By identifying this group of women as a primary audience and analysing their values and interests, this provides a steer on the tone of voice used within content and gives you a clue as to what marketing channels would be most effective at targeting this group, which is discussed below.
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Determine suitable marketing channels and how to use them Utilising various channels for marketing purposes is worthless without the insight gleaned from audience analysis, and ineffective if you haven’t established – or even just realigned yourself with – your values and USPs. How do you know what to say if you don’t know what your audience is looking for, and how do you know where to say it if you don’t know where they spend their time? Something I tell my clients is to ‘follow the data’. Even as a professional in your field, you cannot instinctively know everything about your primary audience. Take the assumption that older demographics consume mostly print materials, for instance. Despite many thinking that social media platforms are a grey area for marketing to mature audiences, Facebook has recently experienced a surge in users over 50, soon to make them the second largest demographic using the platform.1 The type of channels you might consider could include Facebook, Instagram, Google – paid and organic, email; and don’t forget word of mouth. I advise to use post-it notes for this section of the exercise. Give everyone a different colour and ask individuals to write down their ideas of a channel they could use on their post-its, as well as an idea of how to utilise it well. Make it clear to them that these can be both online or offline marketing channels. The rules for this part of the exercise are simple; number one is that no answer is a bad answer, and number two is there are no budget limitations so not to restrict creative flare. Use your clinic’s values, USPs and target audience lists, as well as your imagination, to generate ideas on how these channels could be used. For example, you may come up with types of channels and ideas of how to use them like the below: • Wouldn’t it be great to create an exciting social media campaign with renowned patients acting as brand ambassadors? • We could encourage patients to share experiences on their own social media profiles to raise awareness of our treatments by reminding them how important it is to us through emails. By demonstrating how important patient experience is to your clinic, and asking them to help, you will get more feedback. You might not have the budget or the know-how to make a lot of these ideas happen, but the exercise aims to help you understand how you can utilise your most important channels to engage your audience. Additionally, you can select a couple of the
best ideas and start to whittle them into something that is more realistic, measurable and that aligns with your budget.
Pull everything together to form a creative strategy So how do you formulate everything you have learnt about your values, USPs, target patients and their most effective marketing channels into a creative strategy? Following a branding or creative workshop, you should take these findings away and convey them into a more digestible format that you can use to refer to and build upon this in future. This can be a simple brand guideline document; first outlining your business’s vision, mission and values to determine a brand tone, then progressing into short analyses for each key target audience. Take your defined channels and create a short description as to why you will use them, how you will use them and what activity this will achieve. Think carefully about what it is that you want your audience to do. Is it to book a consultation? Or read more about a certain treatment? Set clear calls to action so you have an idea of what you are measuring, whether that is an increase in calls or emails to your clinic, or a higher volume of traffic to your website.
Summary You don’t have to be a marketing expert to know your business, audience and goals, and there are hundreds of different creative strategy exercises that you can use to streamline your marketing, which will help you to reach your target patients and effectively get you more business. Hopefully, you now understand why these kinds of basic exercises are so important for determining a strategic approach to your marketing and how to go about doing one effectively. As long as you have reinforced the fundamentals of your brand and your creative ideas are underpinned by a sense of rationality, there is no reason why you cannot formulate a sound creative strategy. James Dempster has worked in marketing and PR for more than 10 years. Previously a commercial director for a private hospital, in 2013 he formed a business partnership to found Cobb Healthcare, a full-service marketing and PR agency for healthcare professionals, and Cobb Digital, a digital marketing agency aimed at helping all sectors create powerful online campaigns. REFERENCES 1. Guardian, 2018. <https://www.theguardian.com/ technology/2018/feb/12/is-facebook-for-old-people-over-55sflock-in-as-the-young-leave>
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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Managing Your Clinic’s Workload Business coach and author Alan Adams discusses how to successfully prioritise tasks in an aesthetic clinic and details ways to manage your time efficiently Let me start by saying that there is no such thing as ‘time saving’. We cannot store time and, generally speaking, nor do we have any more or less than anyone in a day. The amount of time we have in a day is not negotiable, and an increased demand in your time does not mean increased supply. In this article, I share guidance on how to best manage your clinic’s workload to avoid you and your team feeling overwhelmed, so that you get the very most from the time you have available and reap the rewards of a business that’s running effectively and, ultimately, more profitably.
Multitasking is a lie People are inherently prone to distractions. In a thriving clinic with a fast-paced environment, which can require you to take phone calls, manage emails and social media, and deal with unexpected patient visits, it’s easier than ever to have your mind and focus taken off elsewhere. An observational study by Professor of Informatics, Gloria Mark, from the University of California found that a typical office worker is interrupted every 11 minutes, while it takes a subsequent 25 minutes to get back into the flow of their work.1,2 A total of 48 subjects participated and were asked to take part in an email task in which they would be faced with interruptions every two minutes. The results showed that any interruption introduced a change in work pattern and is not necessarily related to the context.
It is possible to do more than one job at a time of course, but I believe it’s not effective for getting through your workload and making the business run more smoothly. One of my favourite studies that showcases just how ineffective multitasking is was undertaken amongst 1,100 workers by the University of London’s Institute of Psychiatry and found that doing many things at once caused a greater decrease in IQ than smoking marijuana or having a poor night’s sleep.³ Remember, it takes you much longer to do the job when you’re distracted by other things, and you’ll always feel ‘busy’ by responding to urgent but non-important work. The sweet spot for any clinic owner is to work on things that are not urgent, but are really important. For example, setting aside time to create compelling and engaging marketing content that can then be distributed across multiple channels can be hugely valuable to any clinic owner in ensuring that he or she has a consistent and continual flow of communications being shared with both prospective, and existing, patients. Nigel Botterill, a British entrepreneur who has built eight separate million-pound companies, uses a very unique technique to make sure he isn’t distracted and focuses on the important tasks. He is extremely protective of his first 90 minutes of the day; in fact, he has a ‘Do Not Disturb Unless There’s a Fire’ sign on his door and his team know not to bother him during this time. Putting this into context, if, as a clinic owner,
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you spend this first 90 minutes of the day, developing a process that could save you nine minutes a day, whether that be automating an element of your practice or refining a set system, after just 10 days this can really start having an impact on your time. Many clinics I speak to struggle with the marketing of their business, and so another way to use this precious 90 minutes is to solely focus on a particular area for that allocated time. So creating content such as advice and guidance pieces, top tips guides, developing video showreels, and undertaking online courses that cover the varying sales and marketing methods and tools available, can ultimately help you to drive your business forward. In any business, it’s important to remember to work on your business and not be engrossed with what’s going on in it. That’s why, in order to grow and flourish, I believe your time as a clinic owner needs to be spent wisely, and you need to consider your time to be absolutely sacrosanct. Of course, everyone is different, but you might find yourself to be one of many business owners who procrastinate. Either because you know a certain job will take up a large amount of your time, you know it’s going to be hard work, or you simply just don’t like doing it. My advice with tasks such as these would be to break each one of them down into smaller chunks, making them far less daunting and much more manageable.
Outsource, outsource, outsource Procrastination and distractions are two of the biggest time wasters. So, if you fall into one or both of these, what’s the solution? You could outsource. For example, if you manage your own accounts and dread that time of the month which sees you having to numbercrunch, really re-evaluate how valuable you are to your business and whether undertaking this particular task is the best use of your time. Are you really doing yourself justice by using time you could be spending with patients and providing profitable treatments, just to save spending £100 once a month on a bookkeeper? If, like many people, you struggle to let go of certain jobs because you believe that no one else can do it, ask yourself this, ‘If my business was turning over £10,000,000, would I really be doing this? And if the answer is no, then it’s certainly something you should be outsourcing. If your financial situation negates you from outsourcing the big things, then look at some of the smaller tasks that you currently undertake and consider training someone else in the team to do them.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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I would advise that you make a list of every single job that you currently do and identify every one of those that you personally don’t need to; it can be anything from taking clinic phone calls to creating a PR plan. Remember, your business is ultimately a commercial and profitable enterprise that should operate even when you’re not there. Make your time the most productive by outsourcing, so that you have the freedom to focus on what really matters.
Review your workload A growing to-do list can make you feel like you’re not making any progress, no matter how hard you’ve worked. Be sure to do the work that will make the biggest impact. Think about the Pareto Principle2 which encompasses the 80/20 divide. This applies to task prioritising and scheduling. The rule suggests that 20% of your activities will account for 80% of your results. For example, if you have a list of 10 tasks, it’s likely two them will be worth more than the other eight items put together. The ideal patients will typically pay more and take up less of your time, whilst those who continually try to knock you down on price and complain the most will subsequently take up more of your time, energy, and head space. So, focus your efforts on identifying and securing the great patients, and freeing those patients who aren’t worthy of your time. At the start of each week or even each day, write the list of things you need to do in order, and be realistic. This helps to clear things out of your mind so that you can focus on the job at hand even more effectively. If you have one job that just isn’t getting done, think about whether someone else in your team can do it. Delegation is very helpful in getting more done and helping you to feel less like it’s all on you. Depending on the size of your clinic, simply tracking what your team is spending its time doing can also be critical. You may be using one of the industry-specific time management tools or even a paperbased one, but if you’ve not really started tracking exactly where your clinic’s overall time is being spent, start now. Your CRM system should be able to identify just what it is your team members are spending their time on, but there are also specialist time-tracking software programmes (which are often free), such as Toggl, which can support you and your staff.
Blocking your time It’s always a good idea to think about planning out your perfect week; when you’re seeing patients, when you’re working on the development of the business, and how you’re
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coordinating marketing and sales. And if you stick to your schedule, you go home each day feeling like you’ve accomplished exactly what you set out to, instead of thinking about the 101 things you haven’t done, which only exacerbates the problem of procrastination and stress. In this specialty, patients are hugely important; but, what’s urgent to them is not necessarily what’s urgent to you. Plus, if your patients think that they should be able to get hold of you at any time they call, email or text it shows that you’ve been too easily interruptible for too long. Of course, you should be there for your patients. But I believe that in order to manage your workload efficiently, there has to be boundaries and limits, and very rarely do issues or enquiries need your immediate response. For example, has anyone ever emailed you to say there’s a fire in the building and you should probably escape? As long as you’ve reverted back to the patient in the same day or even within a few hours, you’re doing great – and are much more in control of your own time. For example, you could block out one hour in the morning, one at midday, and one in the afternoon to solely respond to your phone calls and emails, closing the applications down outside of this time so you can plan your time effectively.
Planning for perfection I would say that one of the things you have to really get good at when it comes to maximising your time is planning. It’s about understanding what really matters to your business’s growth and its end goal and focusing on that each and every day. The really important tasks that need sorting urgently are always around, and you’ll know when you’ve had one of those days because you’ll look back and feel like you’ve achieved nothing. That isn’t the case – you’ve just been busy ‘doing’ the doing within your business like the day-to-day operations of the business like answering the phone and filling out paperwork. Goal setting is also hugely powerful in any business. Many clinic owners I work with have set up their business with their own end destination in mind. Whether that’s having financial security to achieve their personal goals, to grow their business so that it no longer needs them to work in it full time, or to simply not work for someone else. Whatever their reason may be, many of them have found that their end goal feels like a lifetime away and feel disillusioned because they aren’t getting any closer to achieving it. As a result, they lose their sense of direction and purpose, and they fall out of love with
the job they’re doing because it’s not yielding the return they’d hoped for. It is important to rekindle your passion for the reason you set up in the first place by focusing again on your aspirations and goals. I would advise setting your goals for one, three, five and 10 years’ time and then work backwards from this so that you end up at today. What things do you need to achieve today, this week, this month, and this quarter that will take you even closer to your goal? It’ll soon become clear again why you’re doing what you’re doing. From there, you can make a plan. List out your weekly, monthly, and yearly action priorities. Getting into this practice will soon become habit, and something you’ll need to get your team involved in too so that they understand what’s important and why you or they are doing it. Ultimately, make sure that you’re still doing what you love – and remember why you started out in the first place – reminding yourself that it’s all about the journey. If you’re doing this for your family, arrange to spend more time with them so that they’re always at the forefront of your mind (and business objectives).
Conclusion One of the easiest ways to experience burn-out and fall out of love for what you’re doing is by focusing on all the wrong things. Workloads can feel ever-growing and everurgent, but if you really do practice the art of prioritising, planning, and delegating or outsourcing where it’s warranted, a lot of your time can be freed up to focus on what’s really important to you and your clinic. None of us have an unlimited amount of time, but the most successful people in any business know how valuable their time is and are hugely precious about how they use it. Alan Adams is an awardwinning business coach and bestselling author and has helped hundreds of businesses across the UK. The publication of his third book, The Beautiful Business: Secrets to Sculpting Your Ultimate Clinic, sees him focus specifically on the medical, cosmetic and aesthetic clinic sector, sharing advice and guidance with the aim to revolutionise clinic turnover, patient retention and overall growth. REFERENCES 1. The New York Times, Brain Interrupted, 2013 <https://www. nytimes.com/2013/05/05/opinion/sunday/a-focus-on-distraction. html> 2. Research Gate, The cost of interrupted work: More speed and stress, 2008 <https://www.researchgate.net/ publication/221518077_The_cost_of_interrupted_work_More_ speed_and_stress> 3. Forbes, Why Multitasking is Worse Than Marijuana <https://www. forbes.com/sites/vanessaloder/2014/06/11/why-multi-tasking-isworse-than-marijuana-for-your-iq/#556afbdf7c11> 4. WhatIs.com, Pareto Principle <https://whatis.techtarget.com/ definition/Pareto-principle>
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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initial scheme launched in 2012, the first six months of wages were completely covered; now it’s 50%, which is still a huge help in the expansion process. The scheme is for young people aged 16 to 24 who are not already in full time employment or in full time education. In return for the scheme’s contribution to wages, employers are required to employ the candidate for 25 to 40 hours a week with a minimum contract of six months.2
Clinic culture
Hiring Staff for a Second Clinic Independent nurse prescriber Jodie Grove shares her approach to recruitment in aesthetics After five years of successfully building my aesthetic business, I recently took the plunge to expand and open a second clinic. During the process of finding great staff to work alongside me, I have learnt a thing or two about recruiting. These learnings have made me be better prepared to deal with numerous challenging situations, should they arise. This article will explore various elements of recruitment that I came to understand the importance of while embarking on the journey of expanding and opening a second clinic.
Stocktake your skills Before beginning any recruitment process, I highly recommend completing an audit of what you have, what you want, and what you need – a skills stocktake, if you will. If you are responsible for running another clinic or business, it’s likely that you will have a pretty good idea of what skills, competencies and level of cover you need to keep it running smoothly. Firstly, you need to think, what do you have? Look at the skills that already exist in your clinic. Do you understand the capabilities and aspirations of your team? This is where having a robust performance review process and carving out time to regularly talk with your employees can be extremely beneficial. My experience has shown that, in a small business with limited career paths, it can be challenging to motivate and retain ambitious staff. If there is someone already working in your initial clinic who is ready for a challenge,
this is the perfect chance to develop your staff member by promoting them into a new, and perhaps more advanced role, while supporting them during this process. This was the case with my receptionist; she had been with me for six months and wasn’t really enjoying the position, however, I was keen to retain her as she had a good work ethic. She has a huge interest in beauty and I decided to enrol her on a Level 2 beauty therapy course. Following this, I recruited a new, more experienced receptionist who could also act as front of house manager for my first clinic. Then, you need to consider, what do you want? Think about how this new role will add to your business. Will it give you a competitive advantage, allow you to introduce a new service, or just support you in keeping things running smoothly on a day-to-day basis? Gauge whether you could stretch your budget to attract someone with a more diverse skillset or higher level of expertise that may cost a little more, but will ultimately allow you to deliver a better or more unique service to your patients. Finally, what do you need? Evaluate what the impact would be if you compromised on what you want by hiring someone with less experience into a more affordable role, with room to grow. You could look into whether there are any apprenticeship or subsidised employment schemes running in your area. In Wales, where my clinic is based, there are many supportive schemes for businesses. I have used the Jobs Growth Wales scheme with several staff members.2 When the
Cultural fit is the likelihood that someone will reflect and/or be able to adapt to the core beliefs, attitudes and behaviours that make up your organisation.3 A 2005 analysis revealed that employees who fit well with their organisation, colleagues and manager had greater job satisfaction, were more likely to remain with their organisation and showed superior job performance.3 Brent Gleeson, keynote speaker and author of the book Talking Point, argues that culture fit is the single most important aspect of retaining great employees.4 I find that having a good grasp of what you want your organisational culture to be is particularly relevant when opening a second clinic. This is because it’s a unique opportunity to define and shape your clinic’s culture from scratch. Detailing your clinic’s values throughout the recruitment process will give you a better chance of recognising and engaging with candidates who align with your clinic culture and will play a proactive role in developing and supporting the culture you want to see in your new business.5
Cast your net Good candidates who have the capability to demonstrate great patient care skills and more general business competencies are in high demand within the aesthetic specialty, so think of your advert as an extension of your marketing approach. It’s the first impression a potential candidate will get and it’s an opportunity to promote the ethos of your workplace. Therefore the wording and tone of your advert should reflect this. In recent job adverts, I have included the company mission statement and directed candidates to the website to explore our ethos and values. The way I attract most of my candidates is through social media platforms and word of mouth; these both allow me to be agile in engaging with and responding to candidates. However, it’s still vital to have an advertising process in place. For me,
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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that means asking all candidates for a CV and outlining clear criteria that allows me to sift through applications based on essential skills and experience before delving into interviewing. The type of criteria I look for is whether they have made a conscious effort to provide a good covering letter and if they have a consistent work history; in my opinion, having employment from a young age shows their work ethic and drive.
The interview I choose to conduct interviews with my senior therapist and also my business manager as we all have a different angle to assessing the suitability of a candidate. Consider the competencies needed for the post and devise a combination of competency-based questions and practical exercises that will give a clear insight into whether the person has the necessary capabilities for the position. Competency-based questions should be open-ended and ask a person to describe a real-life situation and how they deal with it, as opposed to closed or hypothetical questions.6 It’s good practice to use the same set of questions for every candidate, take notes and score their response to each question;7 I have found that a simple ‘marks out of five’ system works well. This allows you to get a feel for a candidate’s experience levels, how they handle challenging situations, and importantly, enables you to subjectively compare how different candidates stack up against each other.
Example interview questions There is a variety of competency questions that you may ask but here is an example of the type of questions I use in relation to delivering quality service. As customer care is a focus of my clinic, this element of the interview is really important to me. • Give me an example of how you’ve demonstrated an understanding of patient needs? • How do you respond to patient feedback? • Can you describe a time when you’ve been proactive in finding a solution to a problem encountered by your patient? • How would you respond to a patient who was disappointed in their treatment?
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Make the first day count I have implemented a thorough and comprehensive policy within both of my clinics about the induction arrangements on the employee’s first day. For me, it is important to be present to greet new staff and to clearly set out in writing all the things the new employee will need to learn. The challenges of having businesses across multiple sites means you can’t always be there in person. In that case, I find delegating the responsibility to another senior member of staff can work well.
The importance of a contract
Continuing the journey
Having conducted a poll amongst my employees at my initial clinic, based on their previous experiences, I have been amazed at the number of businesses in the aesthetics specialty that don’t issue written contracts. Under UK law, as soon as someone accepts a job offer, a legal contract is in place whether or not it’s written down – a verbal agreement counts as a legal contract.8 However, having a well-written contract is beneficial for both employer and employee as it ensures the terms of the contract are clear to both parties and reduces the likelihood of misunderstanding or misrepresentation that could easily occur with a verbal agreement alone. It forms the basis of your employment relationship, manages expectations of both parties, and is a way of providing clarity in the event of a legal dispute. At the very least, a basic contract of employment should include details about pay, holidays and working hours, and refer to any relevant policies such as maternity leave, time off for emergencies and paid training arrangements.9
While having a clear recruitment plan in place and taking the above points into consideration will aid in the task of recruiting new staff for your expanding business, there will almost always be some challenges that arise along the way. When it comes to recruiting staff for a second clinic, as with any business process, the key thing is to continuously evaluate the effectiveness of what you are doing, assess what works well and identify room for improvement.
Understand your legal obligations On the subject of legal disputes, it’s vital that you understand your obligations as an employer under UK employment law. Your clinic’s recruitment process should be fair and non-discriminatory so it doesn’t disadvantage anyone with a protected characteristic; such as race, gender or sexuality.10 Understanding how to handle applications under the new General Data Protection Regulation (GDPR) is imperative. Some key GDPR principles to bear in mind when recruiting for your clinic include:11 • Personal data should be processed fairly, lawfully and in a transparent manner • Data should be obtained for specified and lawful purposes and not further processed in a manner that is incompatible with those purposes • Data should be kept secure and for no longer than necessary As an employer, GDPR legislation applies to any personal data that you hold on individuals, including applicants, employees and ex-employees.12
Jodie Grove is an independent nurse prescriber and founder of The Grove Skin & Laser Clinic in Swansea, South Wales. She has worked alongside leading plastic surgeons and is a member of the British Association of Cosmetic Nurses and the Royal College of Nurses. Grove takes a holistic approach to her practice and aims to offer a bespoke and personal service to her patients. REFERENCES 1. Gifford J. Performance Appraisa. CIPD. 2017. <https://www. cipd.co.uk/knowledge/fundamentals/people/performance/ appraisals-factsheet> 2. Jobs Growth Wales. Careers Wales. 2018. <https://www. careerswales.com/employers/server.php?show=nav.9830> 3. Bouton K. Recruiting for Cultural Fit, Harvard Business Review. 2015. <https://hbr.org/2015/07/recruiting-for-cultural-fit> 4. Gleeson B. The 1 Thing All Great Bosses Think About During Job Interviews, Inc. 2017. <https://www.inc.com/brent-gleeson/ how-important-is-culture-fit-for-employee-retention.html> 5. Webrecruit. 5 Way to Communicate Your Company Culture in Your Recruitment Advert. 2018. <https://www.webrecruit.co.uk/ tools/5-ways-to-communicate-your-company-culture-in-yourrecruitment-advert/> 6. ISC Professional. Competency Based Interviews. 2016. <https:// www.interview-skills.co.uk/free-information/interview-guide/ competency-based-interviews> 7. ACAS. Recruiting an employee: A step by step guide. 2018. <http://www.acas.org.uk/index.aspx?articleid=4221> 8. Gov.UK. Employment Contracts. <https://www.gov.uk/workreference> 9. ACAS. Contracts of Employment. 2018 <http://www.acas.org.uk/ index.aspx?articleid=1577> 10. Gov.UK. Employers: preventing discrimination. https://www.gov. uk/employer-preventing-discrimination/recruitment?step-bystep-nav=47bcdf4c-9df9-48ff-b1ad-2381ca819464 11. Information Commissioner’s Office. Guide to the GDPR: The principles. <https://ico.org.uk/for-organisations/guide-to-thegeneral-data-protection-regulation-gdpr/principles/> 12. ACAS. Guidance – Recruiting Staff. 2018. <http://www.acas.org. uk/media/pdf/m/j/Recruiting-staff.pdf>
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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“Hair restoration surgery is not difficult to learn but can be very hard to do well” Dr Greg Williams talks about his passion for hair transplant surgery and patient interaction Dr Greg Williams is one of the few plastic surgeons in the UK who has dedicated his practice to hair restoration. So, where did his interest in the field begin and what is it he enjoys most about this intricate line of ‘extremely rewarding’ work? After graduating in 1990 from medical school in Kingston, Jamaica, where he was born and raised, Dr Williams moved to the UK in 1992 to pursue a career in surgery and qualified as a plastic surgeon from the Royal College of Surgeons of England in 2003. He undertook an Aesthetics Surgery Fellowship at The Wellington Hospital in London, a Burns Fellowship in Galveston, Texas and spent time in both Brazil and Toronto learning about hair transplant surgery before taking up his NHS burns and plastic surgery consultant post at the Chelsea and Westminster Hospital in central London. Dr Williams was one of the few doctors in the UK who performed follicular unit hair transplant surgery in the NHS, doing so as part of the reconstructive procedures offered to burn survivors. “I moved into hair restoration surgery as part of my burns practice in the NHS, where I worked at some of the well-known burns services in the South East of England. I would work with patients who had scarring to their hair-bearing areas and would be looking to restore this through modern follicular unit transplantation,” explains Dr Williams. Now he is a Fellow of the Royal College of Surgeons of England, a member of the British Association of Aesthetic Plastic Surgeons, president of the British Association of Hair Restoration Surgery (BAHRS) and a Fellow of the International Society of Hair Restoration Surgery (ISHRS). He also works as the lead hair restoration surgeon at Farjo Hair Institute’s Harley Street practice, and although the clinic offers non-surgical treatments, it is the surgical options available that Dr Williams enjoys carrying out the most. Training and continued education has been a fundamental part of Dr Williams’ career and is something that still remains extremely important to him, especially in a specialty, which he says, has no specific regulation or
training requirement in the UK or Europe. He emphasises, “Unfortunately, there is little training available for hair restoration in the UK and there are currently no specific qualifications required, so it is possible for any doctor to start doing this surgery and that is quite a big problem.” Dr Williams adds, “In different European countries there are opposing laws and standards to do with hair restoration surgery and some countries have no specific guidance at all. I chair the ISHRS SubCommittee on European Standards which advises on this.” Dr Williams suggests any practitioners looking to get into this line of work do their research, go to conferences, take time to learn the skills, be critical of their work and make sure that what they are offering is of an acceptable standard. However, in a specialism that has no set standards this can prove difficult. So, when performing hair transplant procedures Dr Williams suggests, “I think the acceptable standard is that about 90% of transplanted hairs should grow, the hair growth direction and angle should be correct, and the transplant result should look completely natural. Patients should be appropriately counselled about the risks of significant on-going hair loss and the pharmacological and non-surgical treatments available for this. The key outcome is subjective patient satisfaction, which is determined, in part, by setting realistic expectations and then delivering them.” He adds, “A great way to learn is to shadow a hair transplant surgeon who is receptive and willing to host you so you can see what is involved. Hair restoration surgery is not difficult to learn but can be very hard to do well. For any doctors that are already practising, it is essential they are carrying out procedures in a Care Quality Commission (CQC) registered facility and that all service providers of hair restoration surgery are CQC registered; both of which are legal requirements. They should also know their limitations. If it’s too much for you, refer it to someone who can handle it.”
Reflecting on his work, Dr Williams says that although he enjoys managing all different types of hair loss concerns, he finds treating transgender patients particularly rewarding, “I find the female hairline creation in male to female transgender patients very rewarding because, as a group, these patients tend to be very happy and very satisfied with the results I can provide them.” Is there anything you would have done differently? The philosophy that I teach my children is that life is a series of paths, there are forks in the path and you end up where you are because of the decisions you make. There is nothing I would change as I wouldn’t be where I am now. Are there any specific treatment techniques you like to use? When doing follicular unit excision I utilise a range of tools including manual punches, automated drills and robotic devices depending on the patient’s hair and scalp skin characteristics, to ensure that I extract the best quality follicular unit grafts with the least amount of damage to the hairs. What’s the best piece of career advice you have been given? I was told by a mentor very early on in my career that one can try to have an NHS practice, a private practice and a family life and you will fail at all three; but, you can perhaps do reasonably well at two. I have found that true and although I am where I am today because of the NHS, I found it to be a natural progression to focus on my private practice and family life. What aspect of your work do you enjoy the most? I’ll always most enjoy the clinical side of my job and having patient interaction, but I am also particularly interested in regulation of this field, promoting high standards and good ethical practice.
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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The Last Word Consultant plastic surgeon Mr Nigel Mercer argues for the ban of cosmetic surgery adverts The concern We are all familiar with the pressure many people feel to look ‘perfect’. With the growth in social media and the rise of ‘influencers’ portraying their filtered lifestyle through their Instagram feed, the public are increasingly exposed to pressures to look and act a certain way. It seems that this pressure is frequently being fuelled by plastic surgery companies that target a very specific demographic via television adverts, in magazines and through social media’s clever algorithms. They are able to directly reach a young and impressionable audience of women, who follow celebrities and social influencers, and are reality TV viewers. This, in my opinion, is completely irresponsible when research has shown a significant proportion of the patients who go on to seek treatment have significant psychological issues with their appearance.1 Essentially, an advert is a sales pitch. It does not offer balanced, personalised and in-depth information on the risks or side effects of what it is promoting, and it certainly doesn’t discuss more suitable alternatives. Upon viewing a cosmetic surgery advert, many women will opt for a procedure with the impression that it is straightforward and completely safe – they treat it as a commodity. And as we know, both surgical and non-surgical treatments are not commodities; they are medical procedures and should be treated as so. In accordance with the Montgomery ruling,2 we should take time to educate our patients on the risks of undergoing any procedure for them to make an informed decision. We should be confident that our patients have taken time to carefully consider their options and are undergoing treatment for the right reasons.
The solution A ban on the advertising of cosmetic surgery was previously called for following the Poly Implant Prothese (PIP) scandal in 2010,3 however this was not approved by the Advertising Standards Authority (ASA)5 which stated that, instead, adverts relating to cosmetic surgery could continue to run as long as they were legal, honest, truthful and socially responsible.4 It is my belief, however, that adverts are
frequently crossing the line of being ‘socially responsible’. The Committee of Advertising Practice (CAP) states that ‘socially responsible’ is classed as those that do not put customers under an undue pressure to purchase because of a time-limited deal and suggest that a procedure should be undertaken lightheartedly.4 I would recommend that the ASA looks at the evidence from countries such as France where advertising for cosmetic surgery is banned.3 If we followed this lead, companies would save their marketing revenue stream and we could be more confident that patients are not unduly pressured into undergoing a procedure that they have little understanding of and are not fully prepared for. I think we could also learn a lot from the advertising changes that took place in 2017 which made it illegal to sell branded cigarette packets and instead had to include numerous health warnings.7
The opposing view I appreciate that it could be argued that practitioners’ websites advertise cosmetic surgery. And yes, I agree, that this is a form of advertising; however, if someone logs onto your website, they are actively looking for you and a website allows for more detailed information to be outlined. This allows users to take time to absorb the information and make an informed decision. Companies will also say, ‘But we need to advertise our brand within the market’. But my argument is, why? Their market share is stable and if you’re that good then you don’t need adverts to maintain it. Happy patients will do that for you. Advertisers may also believe that if they include disclosures such as ‘the procedure is subject to a consultation’, at the end of the advertisement, or in small print throughout, then that is ethical and the viewer is making an informed decision. However, I don’t believe many viewers actually take notice of these and they are often so small that they go unnoticed. This summer we saw blatant targeted advertising towards young women with ads for cosmetic surgery appearing in the breaks between Love Island on ITV. Largely, the response was negative, with social media and national news sites awash with criticism of the decision.3 The British Association of
Aesthetics aestheticsjournal.com
Aesthetic Plastic Surgeons (BAAPS) called for a full ban on advertising plastic surgery, which is something I very much support.6 Following the broadcast of the adverts seen during Love Island, UK TV and radio communications regulator Ofcom received more than 650 complaints. They investigated and ITV advised that there were no more adverts of this nature scheduled and accepted that they had made a mistake in broadcasting them, stating they ‘take its responsibility to viewers very seriously’.8 As a result of this, on October 17, the ASA upheld the complaints about the advert deeming it ‘irresponsible and harmful’ and said it should not be shown again in its current form.9
Moving forward Traditionally, the advertising that a plastic surgeon or aesthetic practitioner would do would mostly be word of mouth. And, to me, this is how it should be. If you provide a good service and a safe service, then your practice will grow. As practitioners, we should report any unethical advertising to the ASA if we have concerns that it could put patients at risk. And most importantly, we should continue to deliver in-depth consultations with our patients, ensuring that they are making an informed decision in regards to any type of treatment they choose to undergo. Mr Nigel Mercer is a consultant plastic surgeon who practises in Bristol. Presidencies of BAPRAS, BAAPS and EASAPS have allowed Mr Mercer to be at the heart of the public discussion about regulation of aesthetic surgery and medicine.
Read the full version of this article at www.aestheticsjournal.com REFERENCES 1. Sansone R, Sansone L, Psychiatry Edgmont, Cosmetic surgery and psychological issues, 2007 <https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2861519/> 2. Praiss.co.uk, Implications of the Supreme Court’s decision in Montgomery v Lanarkshire health board < http://prasis.co.uk/ support_guidance/reducing_risk/consent/montgomery_law. aspx> 3. British Medical Journal, Head to Head Should all advertising of cosmetic surgery be banned? <https://www.bmj.com/bmj/sectionpdf/187677?path=/bmj/345/7882/Head_to_Head.full.pdf> 4. ASA.org.uk, Cosmetic Interventions: Social Responsibility, 2015 <https://www.asa.org.uk/advice-online/cosmetic-interventionssocial-responsibility.html> 5. ASA.org.uk, Is the ASA good for advertising? 2017 <https://www. asa.org.uk/news/is-the-asa-good-for-advertising.html> 6. BAAPS.org.uk, BAAPS statement on cosmetic surgery adverts targeting vulnerablr people, 2018 <https://baaps.org.uk/media/ press_releases/1591/baaps_statement_on_cosmetic_surgery_ adverts_targeting_vulnerable_people> 7. Cancer Research UK, This is the end of tobacco advertising <https://scienceblog.cancerresearchuk.org/2017/05/19/this-isthe-end-of-tobacco-advertising/> 8. Independent.co.uk, Love Island: ITV admits it was wrong to air cosmetic surgery and diet ads during breaks <https://www. independent.co.uk/life-style/love-island-itv2-ads-cosmeticsurgery-weight-loss-diet-apology-a8464646.html> 9. ASA.org.uk, ASA ruling on MYA Cosmetic Surgery Ltd, 2018 < https://www.asa.org.uk/rulings/mya-cosmetic-surgeryltd-a18-459775.html>
Reproduced from Aesthetics | Volume 5/Issue 12 - November 2018
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96% of patients showed aesthetic improvement one month after treatment with Restylane® Skinboosters™ Vital1* *Results shown for investigator-reported Global Aesthetic Improvement Scale (GAIS) at one month after the second treatment session. Patients received Restylane Skinboosters Vital over two treatment sessions scheduled four weeks apart. 2 mL of product was administered at the first treatment session and 1 mL at the second session. In addition, a single maintenance treatment (1 mL of product) was given at six months (n=27).
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Reference: 1. Kerscher M et al. Restylane Skinboosters for improved facial skin quality using two treatment sessions. Poster presented at IMCAS, 26 – 29 January 2017, Paris, France.
Date of preparation: January 2018 RES18-01-0031c