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VOLUME 6/ISSUE 11 - OCTOBER 2019

NEW

DISCOLORATION DEFENSE SERUM H I G H- POT EN C Y F O R M ULA TO H E L P RE DU CE T HE A P P EA R A N C E O F KE Y TYPE S OF D IS C O LO UR AT IO N

41

%

IMP R OVEM ENT IN T HE A P PEARANCE O F ST UBBORN BR OWN PATCH ES*

*Average results. Clinical assessment visual grading at 12 weeks, 63 subjects

Laser for Fat Reduction CPD Dr Miguel Montero reviews how laser technology works for fat reduction

Special Feature: Skin of Colour & Lasers Practitioners discuss rejuvenating darker skin with lasers

Understanding Laser Tattoo Removal Dr Peter Hughes explores laser tattoo removal technologies

Maintaining Devices

Dr Samantha Hills provides ways to ensure the longevity of your equipment


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Contents • October 2019 06 News The latest product and industry news 15 On the Scene

Out and about in aesthetics

17 Advertorial: Merz Aesthetics Exploring the special partnership between two distributors 18 News Special: Celebrating Skin Imperfections

Aesthetics explores the stigma surrounding skin conditions

20 Judging the Aesthetics Awards

Learn about the prestigious role of the Aesthetics Awards judges

Special Feature: Treating Skin of Colour with Lasers Page 23

CLINICAL PRACTICE 23 Special Feature: Treating Skin of Colour with Lasers

Practitioners discuss the key considerations around treating darker skin types with lasers for skin rejuvenation

29 CPD: Understanding Laser for Fat Reduction

Dr Miguel Montero reviews literature for lasers in fat reduction

32 Advertorial: SkinCeuticals Discoloration Defense Serum

Breaking the cycle of discolouration with the new SkinCeuticals Discoloration Defense Serum

35 Managing Delayed Onset Nodules

Dr Fiona Durban shares advice for delayed onset nodules

41 Laser Tattoo Removal

Dr Peter Hughes explores the technologies available for laser tattoo removal

46 Understanding Growth Factors: Part 1

Dr Anna Hemming discusses the science behind growth factors

50 Case Study: Treating a Burn

Dr Ifeoma Ejikeme shares a case study of a burn that was treated using oxygen and low-level light therapy

53 Abstracts

A round-up and summary of useful clinical papers

54 Advertorial: Croma-Pharma

Becoming a global player with minimally-invasive aesthetic medicine

57 Tips for Maintaining Devices

Laser specialist Dr Samantha Hills provides tips for equipment longevity

61 Building a Successful Business Culture

Aesthetic nurse Lorna McDonnell Bowes explores how to build trust, passion and authenticity in a business

67 Reflecting on Aesthetic Practice

Clinical Contributors Dr Miguel Montero completed medical school in Spain and started using LLLT in 1992. He has a Postgraduate Diploma in Clinical Dermatology and has been the lead clinician at Discover Laser Clinic in Lancashire for the last 12 years. Dr Peter Hughes is the scientific director and co-owner of Quayside Medical Aesthetics. He has a PhD from the University of Sydney, earning him his Dr title, whereby his research interests involved laser spectroscopy and instrumental design and development. Dr Fiona Durban qualified from St Mary’s Hospital Medical School in 2000. She attained the MRCGP (merit) in 2005 and was then a partner in general practice for seven years, specialising in women’s health. Dr Durban is the Cosmetic Courses clinical lead for Buckinghamshire.

IN PRACTICE

Aesthetics Awards: Judging the Aesthetics Awards Page 20

Dr Kalpna Pindolia explores the concept of reflection in aesthetic medicine

Dr Anna Hemming is an aesthetic practitioner with more than 11 years’ experience in medical aesthetics. She is the owner and medical director of Thames Skin Clinic in Twickenham and associate doctor at Cranley Clinic on London’s Harley Street. Dr Ifeoma Ejikeme is an NHS medical consultant. She trained at Bristol University, and holds a post-doctoral fellowship in head and neck surgery from Columbia University. She is board certified in internal medicine and has a master’s degree in aesthetic medicine.

71 In Profile: Mary White

Nurse prescriber Mary White shares her love for lasers and injectables

73 The Last Word

Dr Alex Parys argues the need for emergency department staff to be trained in aesthetic complications

NEXT MONTH • IN FOCUS: Upper Face • Treating Static Lines • Forehead Anatomy • Tips for CQC Registration

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Free ACE 2020 registration is Open! Turn to page 38 for more info!

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


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Editor’s letter Well, what a busy month September was! Filled with celebrations of Aesthetics Awards Finalists (get voting by the way!), product launches, education days and of course the IAPCAM and BCAM conferences which, at the time of print, we’re still yet to attend. Chloé Gronow We’ve included event reports in our On the Editor & Content Scene pages on p.15, with more to showcase Manager in our November issue. We hear many readers comment that medical aesthetics can often be an isolating profession, with many of you working as sole practitioners. That’s why we really champion all the fantastic events that do take place. As well as being excellent places to catch up with your suppliers and meet new ones, you can also network with fellow aesthetic professionals and learn from their expertise and experiences. If you’re reading this in the first week of October, there’s still time to register for CCR, which takes place on October 10 and 11. Held at Olympia in London, CCR has seven conferences taking place and up to 80 CPD points available. There’ll also be eight hours of live

injectable content and exclusive brand takeovers, not forgetting more than 200 suppliers to meet and learn about their exciting innovations. And if you’re reading this after the 10th and 11th, don’t worry, registration for ACE 2020 is now open! On March 13 and 14, more than 2,000 aesthetic professionals will again meet in London for even more unmissable education, product launches and updates that you will want to be a part of. Both CCR and ACE offer unrivalled education and networking opportunities, so I do really encourage you to attend. Now, time to read our energy issue! We have worked hard to include great content on a variety of energy-based devices and treatments. Want more advice on considerations for treating darker skin with laser? Turn to p.23. Want to learn more about the science behind tattoo removal? Dr Peter Hughes has you covered on p.41. Want to gain a CPD point for your knowledge on fat reduction with laser? Read Dr Miguel Montero’s article on p.29. Want to learn from Dr Ifeoma Ejikeme’s experience on using LED to treat a scar? Check out her case study on p.50. Finally, why not brush up on your knowledge of taking care of your light-based devices with advice from Dr Samantha Hill on p.57!

Clinical Advisory Board

Leading figures from the medical aesthetic community have joined the Aesthetics Advisory Board to help steer the direction of our educational, clinical and business content

WE WANT TO HEAR FROM YOU!

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with more than 20 years’ experience and is director of P&D Surgery. He is an international presenter, as well as the medical director and lead tutor of the multi-award-winning Dalvi Humzah Aesthetic Training courses. Mr Humzah is founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow. Mr Dalvi Humzah, Clinical Lead

Do you have any techniques to share, case studies to showcase or knowledge to impart?

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic nonsurgical medical standards. She is a registered university mentor in cosmetic medicine and has completed the Northumbria University Master’s course in non-surgical cosmetic interventions.

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.

Mr Adrian Richards is a plastic and cosmetic surgeon with 18 years’ experience. He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

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 for botulinum toxin and dermal fillers.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multi-award 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.

Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She has recently completed her Master’s 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 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 AntiAgeing Experts. Dr Patel is passionate about standards in aesthetic medicine.

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.

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© Copyright 2019 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184 ABC accredited publication DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


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Fillers

Talk #Aesthetics Follow us on Twitter @aestheticsgroup and Instagram @aestheticsjournaluk

#AlwaysLearning Dr Liesel Holler @drlieselholler Just finished a LIVE injection webinar of chin and jawline contouring with the famous plastic surgeon Mr Mauricio De Maio together with Allergan faculty members from 14 countries! Our specialty is constantly evolving so it is of paramount importance to always keep updated with latest techniques! #AlwaysLearning #CPD #Allergan #Anatomy Dr Lee Walker @leewalker_academy Mid face augmentation today with a fantastic group! Anatomy packed day, respect to Gill for attempting to name all the branches of the maxillary artery – close! #LeeWalkerAcademy #Anatomy #BodyShaping Julia Kendrick @juliarosekendrick Had a great day in Brussels today at the @hologic education centre with @cynosureuk – learning more about #LaserSkinRejuvenation and #BodyShaping – so interesting! #Ambassador Miss Sherina Balaratnam @MissBalaratnam I am hugely honoured to announce that I am the first doctor, outside of the USA, to be invited as a brand ambassador for @iSCLINICAL at the personal invitation of the company founders, announced at the 2019 iS Clinical global distributors meeting! #Aesthetics #SoProud #Ambassador #Teaching Dr Victoria Manning @drvix.manning A fabulous day training with some talented doctors with @vivacylab.uk thanks for having me! #Teaching #Menopause #Desirial

VOLUMA XC receives FDA approval for mid-face via cannula Global pharmaceutical company Allergan has received US Food and Drug Administration (FDA) approval for the use of Juvéderm VOLUMA XC with a TSK STERiGLIDE cannula for cheek augmentation to correct age-related volume definition in the midface in adults over 21. The approval is the first for the use of cannula using Juvéderm VOLUMA XC, which Allergan has confirmed is the equivalent of Juvéderm VOLUMA in the UK. According to a 12-week multicentre, split-face, investigator-blinded, non-inferiority study with 60 subjects, results demonstrated comparable performance, safety profile and patient satisfaction between cannula and needle injection. “As a physician, I have used the Juvéderm collection of fillers for 13 years, so I am thrilled that the FDA has approved the use of cannula with Juvéderm VOLUMA XC for mid-face volume deficit. With this latest approval, I have another effective option to provide volume and contour in the mid-face area,” said board-certified dermatologist and clinical trial investigator Dr Dee Anna Glaser. “At Allergan, we are committed to driving innovation in medical aesthetics as well as providing best-in-class injector training to our customers,” said senior vice president of US Allergan Medical Aesthetics, Carrie Strom. She added, “With this approval, Allergan will be able to educate on facial anatomy and injection techniques that will help healthcare providers administer treatment with Juvéderm VOLUMA XC safely to achieve optimal patient satisfaction.” Education

Last chance to register for Galderma webinar

Pharmaceutical company Galderma UK will be supporting the next webinar hosted by Aesthetics Media on October 14. However, those wishing to take part must have registered with DocCheck by Thursday October 10 to join. The webinar, titled Abobotulinum toxin type A in Action: Marketing Guidance & Treatment for Lateral Canthal Lines will give practitioners sound advertising and marketing guidance from aesthetic practitioners Dr Lara Watson and Dr Priyanka Chadha, whilst nurse prescriber Sharon Bennett will be performing a demonstration on treating the lateral canthal lines. This webinar is only for doctors, surgeons, nurses and dentists with a valid professional licence. You must submit your licence (GMC/NMC/GDC certificate) and proof of identity certificates (e.g. driving licence/passport) to DocCheck in advance of the webinar. For those who registered for the previous webinar, you will not be required to do this again. You will just need to confirm your attendance on the Aesthetics website.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Lips

Teoxane launches new products in LipUnique Collection Swiss aesthetic manufacturer Teoxane has added the Teosyal RHA KISS hyaluronic acid dermal filler (0.7ml) and the [3D] Lip cosmeceutical to its LipUnique Collection. The LipUnique Collection consists of six products aiming to provide a flexible toolkit for practitioners to create bespoke, natural and dynamic results. The range includes Teosyal RHA 1, Teosyal RHA 2, the new Teosyal RHA KISS, Teosyal RHA 3, Teosyal PURESENSE KISS, and the new [3D] Lip cosmeceutical. According to Teoxane, the new Teosyal RHA KISS has high stretch and medium strength and is designed for subtle, dynamic lip reshaping using a small amount of gel. Teoxane states that it offers the same composition and rheological properties of RHA 2, but with the added benefit of a smaller volume of 0.7ml. The [3D] Lip aims to nourish and hydrate lips to maintain glow and natural plumpness between in-clinic treatments. Jordan Sheals, deputy general manager at Teoxane UK commented, “Because every smile is unique, every treatment should be personalised. With the addition of our NEW Teosyal RHA KISS and the [3D] Lip cosmeceutical, the Teoxane LipUnique Collection offers a truly flexible portfolio of HA products to achieve the safe, effective outcome that the patient desires, whatever that may be.”

Vital Statistics Laser, light and energy-based treatments have increased 74% since 2012, last year a total of 3.49 million procedures were performed in the US (ASDS, 2019)

In Europe, there are currently 393.4 million active mobile social media users (Hootsuite, 2019)

63% of 21-35-year olds around the world said that they think overall appearance impacts how successful they are in life (Allergan, 2019)

Devices

MHRA bans certain Dermapen devices The Medicines and Healthcare products Regulatory Agency (MHRA) has released an alert for practitioners to stop using the Dermapen 3 device, the Dermapen 3 needle tips and the Dermapen Cryo device due to potential risk of injury or infection. The alert is relevant to products with an affected serial number/batch number, which, according to the MHRA, do not have a valid CE mark so their safety can no longer be assured. Affected devices include: the Dermapen 3 device with serial numbers 3MD1605456 to 3MD1702134 inclusive, Dermapen 3 needle tips with batch numbers DP164278, DP180226 and DP180109 and all Dermapen Cryo devices. The MHRA spokesperson advised practitioners that if they have affected devices, they should contact their supplier for further advice. Dermapen is manufactured by Equipmed and distributed in the UK by Naturastudios. Naturastudios has confirmed that it stopped marketing the Dermapen Cryo two years ago when they decided to distribute the CryoPen instead, which they say is approved by the Food and Drug Administration and is medically CE marked. Sales director of Naturastudios, Simon Ringer commented regarding the recent safety notice relating to the Dermapen 3 microneedling device. He said, “As a company who prides itself on safety, training and customer service, Naturastudios has sourced the Dermapen-approved DPM8 device, which does have a CE certificate, as a contingency plan to allow our customers to carry on offering the leading microneedling treatments in conjunction with Dermapen Dermaceuticals.”

There are an estimated 24 million Instagram users in the UK, which is 42% of the UK’s population (Avocado Social, 2019)

The American Society for Dermatologic Surgery reported that in 2018 there were 623,000 body sculpting treatments performed in the US alone

(ASDS, 2019)

In a patient-focused survey of more than 1,000 mothers, 72% said that they struggle to refine their stomach post-partum (Cynosure, 2019)

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Events Diary 10 -11 October CCR Expo & BAAPS Annual International Conference www.easyfairs.com/ccr-expo-2019 www.baaps.org.uk th

th

2nd November WACS Annual Conference www.welshaesthetics.com 7th-8th November British Association of Cosmetic Nurses Conference www.bacn.org.uk 12th November AestheticSource and Aesthetics Webinar

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Entertainment

Tom Allen to host the Aesthetics Awards 2019 Comedian, actor and writer Tom Allen has been confirmed as the host and entertainment for the Aesthetics Awards taking place on December 7 at the Park Plaza Westminster Bridge Hotel in London. In 2005, Allen won So You Think You’re Funny in Edinburgh and the BBC New Comedy Awards and has since appeared on the BBC’s Live at the Apollo, 8 Out of 10 Cats Does Countdown, The Great British Bake Off’s Extra Slice and Channel 4’s Comedy Gala. Voting for the Awards is open in 12 categories until October 31, so readers are encouraged to vote for their preferred winners before the closing date. The votes count for 30% of the entrant’s final score in the applicable categories while the other 70% will be judges’ scores. A new sponsor has also been confirmed for this year; Clinetix clinic based in Scotland run by Dr Simon and Dr Emma Ravichandran is supporting the Award for Professional Initiative of the Year. Book tickets via the Aesthetics Awards website, www.aestheticsawards.com. Partnership

7 December th

The Aesthetics Awards 2019 www.aestheticsawards.com

13 & 14 MARCH 2020 / LONDON

13th-14th March

The Aesthetics Conference and Exhibition www.aestheticsconference.com Pigmentation

Cysteamine relaunches as Cyspera Aesthetic distributor AestheticSource has announced that the topical designed to treat pigmentation, currently known as Cysteamine Cream, has rebranded to Cyspera. The brand strategy comes after in-depth research by scientists and market analysis that suggested that Cyspera would resonate better with clients and patients to represent the benefits of the treatment of pigmentation, AestheticSource states. The name was created from a combination of the two words ‘cysteamine’ and ‘sperare’ with the latter meaning belief, patients and confidence in Latin.

Merz reinforces partnerships Aesthetic distributor Merz Aesthetics has announced that it has reinforced its partnership with distributors Church Pharmacy and Wigmore Medical. The company has confirmed, that as a family-owned business established for over 110 years, they are delighted to be partnering with similarly long-established, family-owned, customer-focused businesses. “Merz Aesthetics operates to a strict set of working practice standards and we have two underlying mantras for our business: we will never compromise patient safety and never mislead healthcare professionals. This means that aesthetic practitioners can be sure that when they order Merz Aesthetics brands from either Church Pharmacy or Wigmore Medical they will benefit from knowing that their product is genuinely sourced from Merz in the UK, has been properly managed through its supply chain and can benefit from access to Merz Aesthetics as partners,” said Stuart Rose, managing director of Merz in the UK. He continued, “In addition, they will be getting excellent value and arguably the best customer service available from an aesthetic pharmacy partner. Our sales and customer services teams are working in close partnership with the Church and Wigmore teams to ensure practitioners get great value and excellent service and the response that we have had has been overwhelming. We look forward to our continued partnership working and welcoming new customers to the Merz portfolio every day.” Hair

Genetic test for hair loss launches A test that analyses a patient’s DNA and lifestyle factors has been launched that aims to determine the cause of a patient’s hair loss to assist practitioners in recommending the most appropriate treatment approaches. The Fagron TrichoTest by Fagron UK, part of the Fagron Group, is performed by taking a saliva test and analysing three polymorphisms within 16 DNA mutations (SNPs), examining a total of 48 genetic variations. Medication, pathologies, emotional state, physical activity, habits and family history are also taken into consideration through a patient questionnaire to propose an individualised treatment that will be the most effective to the particular patient, according to the company.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Digital

FVCE launches at CCR Following a soft launch at the Aesthetics Conference and Exhibition (ACE) earlier this year, online platform FVCE will be officially released at CCR on October 10-11. FVCE.co.uk is an online marketplace for non-surgical aesthetics designed to connect patients with qualified practitioners through its website and app. The company explains that a practitioner signing up to the online platform would be able to dictate their own working hours, choose between working remotely or at a clinic, access new patients in the area, manage a booking and secure payment system, have access to e-consultations and a digitalised consent process. FVCE is founded by Dr Hussain Cheema and Cameron Roddha, who has a background in business development. Dr Cheema commented, “We wish to own our niche and be the one-stop-shop for consumers desiring facial aesthetic procedures. Our market research shows that customers do not want to get their treatments from a platform that also offers a breadth of other beauty treatments such as nails or makeup. We stand apart by specialising, which gives the patient reassurance that FVCE focuses on quality and safely practised procedures.” FVCE only includes qualified doctors, dentists and nurse practitioners. Skincare

MAG to distribute FILLMED

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

REGIONAL MEETINGS September was a fantastic month for the BACN, with regional meetings being held throughout the country. Attendance was high, and it was great to see new and older members discuss the future of aesthetics and their place in the arena. The BACN is primarily a support network for nurses in aesthetics, and the association comes into its own during these events. Throughout October, the BACN will also be at Birmingham, Glasgow, and Belfast to wrap up the Autumn regional events. Booking is still available through the BACN website.

CCR The BACN is extremely excited to be at CCR on October 10 and 11. With a number of nurse speakers, and the BACN Nursing Lounge at stand J12, it’s a brilliant two days of engaging with those new to the association and also catching up with familiar faces. The BACN team will be there over the two days so do say hello.

AUTUMN AESTHETIC CONFERENCE

Aesthetic product supplier Medical Aesthetic Group (MAG) will now be distributing injectable and skincare range, FILLMED. FILLMED explains that the new partnership will see MAG manage all aspects of stock, payment processing, dispatch and customer support, and is designed to complement existing distribution within the medical and beauty sectors. David Gower, managing director of MAG said, ‘We believe firmly in the highest standards of product support and only supply our professional products to those who are fully knowledgeable about the treatment and protocol, so we are delighted to be working with FILLMED. Our role, as well as fulfilling the sales transaction, is to add value with dedicated customer support and information regarding training.”

The full agenda of the two-day conference is now on the BACN website, with a number of exciting new speakers and announcements. Spaces on the Professional Sessions Symposium on the November 7 are now very limited, but there are places left on the main conference day, which is included as part of the BACN membership. As the biggest event that the BACN holds, the Autumn Aesthetic Conference is where BACN members gather and network on a national level. The exhibition has a number of suppliers and BACN partners providing offers and information throughout the main conference day on November 8 so it will be a full day of speakers, demonstrations, and exhibition opportunities.

Survey results

AESTHETICS AWARDS

Female surgeons highlight motivations for career in surgery Almost 50% of female members of the British Association of Plastic and Reconstructive Aesthetic Surgeons (BAPRAS) agree that role models working within plastic surgery had motivated them to build a career in the specialty, according to a recent survey. The survey analysed 132 members (95 male and 35 female) on why they chose a career in plastic surgery, as well what they like and dislike about working in the specialty. It also found that female members made the decision to go into plastic surgery earlier than their male counterparts – with 62% of women saying they had chosen their specialism before they left medical school, compared to 38% of men. More than a quarter (27%) of female members noted that plastic surgery offers a more supportive working environment than other specialties, however only 15% said the specialty allows the flexibility to balance work and personal life successfully.

The BACN wants to congratulate all the Finalists of the Aesthetics Awards 2019 – and especially those who are BACN members. Last year, BACN Chair Sharon Bennett won The Schuco Aesthetics Award for Outstanding Achievement in Medical Aesthetics and there were a number of members who won awards for their individual achievements. 2019 has been another year to celebrate nurses in aesthetics, and the Awards really reflect the hard work that nurses have made in the specialty. This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Digital

Wigmore founder launches new digital platform 13 & 14 MARCH 2020 / LONDON

Find out about the latest technologies and best practice from industry-leading practitioners, plus interactive workshops and live demonstrations. ACE is your chance to develop your own personal learning and increase your CPD points. For 2020 we are delighted to have Galderma as our Headline Sponsor, delivering two days of exclusive educational content in the Main Auditorium. You can expect to learn about the latest products and innovations, as well as trends predicted for 2020 and beyond. There will also be highly anticipated sessions from Teoxane and Allergan which you do not want to miss!

K E Y STATS FRO M AC E 201 9

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SP EA K ER S

W H AT DEL EGAT ES SAY “The fact that we can attend this for free is fantastic and something we should be taking advantage of!” AESTHETIC PLASTIC SURGEON, LONDON

“The industry can be quite isolating if you work alone, so it’s really important to come to ACE so that you meet like-minded people and learn new things” NURSE PRESCRIBER, COVENTRY

HEADLINE SPONSOR

Digital platform etresvous.com, referred to as EV, is launching at CCR on October 14 and 15. According to the company, EV puts bookings, consultations, marketing and CRM all in one place to assist practitioners with their business. The platform enables users to accept appointments, host virtual consultations and use in conjunction or as a standalone CRM system. EV explains that it will include editorial features about aesthetic treatments and products and is designed to engage and educate a large, targeted audience and convert them into informed customers. Those signed up with EV will have the opportunity to be included in articles with the aim to raise the practitioner’s profile. Founder and director Raffi Eghiayan says, “EV is the solution that experts working in the aesthetics industry have been waiting for and I’m delighted to be able to announce its launch.” Skin Rejuvenation

Eden Aesthetics release DermaFrac C Distributor Eden Aesthetics has introduced DermaFrac C handpiece, which is a compact, portable system combining microneedling with simultaneous infusion and microdermabrasion. The company explains that the handpiece operates under vacuum occlusion whilst the microneedles create pathways of uniform depth to allow better penetration of topicals. There are also seven proprietary formulations which have been specifically designed for delivery through the DermaFrac C handpiece. Titled rejuvenate, lighten, hydrate, clarify, vitamin c, custom and GF-R, the formulations address a variety of skin concerns to provide a targeted treatment for every patient, Eden Aesthetics states. Relaunch

Medik8 updates professional range Skincare manufacturer Medik8 has updated its professional range to offer enhanced results to practitioners and patients. Medik8 Professional now includes six Combination Lifestyle Peels, which are formulated to target different skin concerns, aiming to deliver visible results with less discomfort and downtime. The peels include REWIND, which aims to help promote collagen production and reduce the appearance of fine lines and wrinkles; EVEN, which targets sun damage, hyperpigmentation and dull, uneven skin; CLARITY that aims to decongest the complexion and keep blemishes under control; UNIVERSAL AHA to brighten, smooth, decongest and revitalise all skin types; SENSITIVE PHA which is targeted to sensitive or redness-prone skin to smooth skin texture and EYE REVEAL, which aims to reduce the signs of ageing around the eyes. Also included in the Medik8 Professional range are Mono Peels, which contain one type of acid – glycolic, lactic or mandelic – in varying concentrations. According to the company, these peels can be layered over any of Medik8’s stronger peels to intensify results, as well as being layered on concentrated areas of concern.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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ACE 2020

Education

Teoxane UK to host free education at ACE Aesthetic manufacturer Teoxane UK will host two full days of free clinical education at the Aesthetics Conference and Exhibition (ACE) on March 13-14 next year. The move reinforces the company’s dedication to providing exceptional world-class clinical education to aesthetic practitioners, Teoxane states. There will be four two-hour Teoxane Takeover Symposiums across the two days, which will only be available to doctors, dentists, nurses and pharmacists. “With Teoxane’s dedication to high quality world class medical education we are delighted to have secured two full days of events at ACE 2020. Our symposiums will feature a range of topics each with a focus on anatomy, techniques and product rheology for safe and effective practice,” commented Jordan Sheals, deputy general manager at Teoxane UK. Sheals added, “Teoxane’s Symposiums will see a range of speakers from the UK and abroad discussing the Teoxane Approach to dermal filler beautification, rejuvenation and restoration in all areas of the face. Following on from the success of ACE 2019 medical education events, we are looking forward to continue to build on our strong Medical Education Platform at ACE 2020.” ACE 2020 will take place at the Business Design Centre in Islington, London and free registration is now open via www.aestheticsconference.com Education

Second TAMC event to take place this month The Aesthetic Medicine Congress (TAMC), in association with the British College of Aesthetic Medicine, will take place in Dubrovnik on October 12 and 13. Renowned UK-based key opinion leaders (KOLs) will travel to the Croatian city to present on a wide range of aesthetic topics, including injectable treatments for facial rejuvenation, skincare, body contouring, vaginal rejuvenation and business development. Speakers include Dr Tapan Patel, Dr Rita Rakus, Dr Tracy Mountford, Dr Patrick Treacy, Dr Sherif el Wakil, Professor Bob Khanna and Dr David Eccleston. Organising and scientific committee president is Dr Nikola Milojevic, who said, “We have two parallel lecture theatres packed with the who’s who of British, European, and world KOLs. We are sure that anyone attending will learn a lot, refine their skills, make valuable professional connections and return home happy.” Following the success of last year’s event, he added, “We are looking forward to our second year of TAMC and repeating the big success of last year which, to wide acclaim, was one of the best aesthetic conferences of the year! We can’t wait for beautiful Dubrovnik, and this is a fun congress too, so we can’t wait to repeat the excellent vibe from last year, and learn a lot in the process!” According to TAMC, practitioners who are allowed to administer botulinum toxin and dermal fillers in their respective countries are eligible to attend.

SkinViva launches new training programme Aesthetic training company SkinViva Training will launch a new CPD-accredited programme designed to create ‘Master Clinicians’ on October 28. According to the company, The Mastery Programme adheres to Level 7 standards and criteria and will cover five core clinical, as well as three core business domains. Domain One will include anatomy, physiology and product science; Domain Two will outline how to identify and communicate aesthetic goals on the face in terms of rules, ratios and principles of beauty; Domain Three will detail technique strategies; Domain Four covers complication prevention and management, while Domain Five aims to teach clinicians essential communication skills and principles to aid consultations. The three business domains will cover business mastery, innovation, marketing and administration. SkinViva advises that training will be delivered by founder and clinical director Dr Tim Pearce, who will use a combination of small group practical sessions, e-learning and coaching. Training materials, peer support and testing will be available via a dedicated online learning platform. Trainees must be a degree-level qualified professional with an active professional pin and able to undertake a V300 independent prescriber course. Topical

Elénzia launches post-laser cream Skincare distributor Elénzia has released the Lasergen aftercare cream mask for use following ablative laser treatments. According to the company, the product enhances the results of ablative laser treatments by reducing redness and irritation by 5%, further reducing acne scarring by 8.5% and reducing hyperpigmentation by 32%. In addition, it has also been shown to reduce pigmentation by 17%. Lasergen uses nano gold technology which, Elénzia explains, is made by uniting tiny fragments of hyaluronic acid with tiny particles of gold. These are able to enter the dermis and activate multiple cell receptors, stimulating the natural production of hyaluronic acid, collagen and elastin, as well as inducing cell migration and proliferation, Elénzia states. High percentages of shea butter and aloe vera have also been added to Lasergen, which aim to reduce redness and irritation while the skin regenerates.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Laser

The Baldan Group launches new body contouring device Aesthetic product manufacturer and distributor The Baldan Group will launch a 1060 nm diode laser for nonsurgical body contouring at CCR on October 10-11, called Le Shape. According to the company, the device generates hyperthermic energy, variable between 42°C and 47°C, which causes the breakdown of the lipid cells, avoiding damaging the surrounding tissues and, at the same time, stimulating the production of collagen. During the treatment, the cooling system aims to protect the surface of the skin and prevent any damage. The Baldan Group advises that Le Shape is indicated for treating the upper and lower part of the abdomen, inner and outer thighs, arms and hips. The company also notes that in some cases, it can also be used to treat the buttocks and knees. Skincare

New plant-derived rejuvenation product launches A plant-derived solution named Fraxin has been launched into the aesthetics market aiming to address signs of ageing. According to the company, the solution took eight years of research to perfect and can be administered topically, via microneedle or hydra stamp. Fraxin is classified as a herbal remedy and is available in a powder form containing a 100% mixture of spilanthol extract and toosendanin extract that are dissolved in saline or distilled water. The company states that spilanthol has well documented myorelaxant properties and is used in a number of anti-wrinkle products, while toosendanin is a highly effective acetylcholine blocker at both the neuromuscular junction and the central synapses, the same process of botulinum toxin. The company notes that currently Fraxin should not be administered thorugh subcutaneous injection and should only be offered after a face-to-face consultation and must be prepared at the premises of the practitioner. Industry

JCCP publishes social media guidelines The Joint Council for Cosmetic Practitioners (JCCP) has released new guidelines for its registrants to promote appropriate use of social media. According to the JCCP, the move follows a rapidly increasing number of aesthetic practitioners using social media sites and platforms, some of which are using the sites unsuitably. To create the ‘Ethical Use of Social Media Code of Conduct’ guidelines, the JCCP has re-visited the social media guidelines issued by the key healthcare sector regulators to devise its own set for its registrants. “The JCCP encourages the use of social media but believes this should be undertaken in a courteous and professional way that upholds public trust and confidence and in such a manner as to demonstrate respect for fellow practitioners,” executive chair of the JCCP, Professor David Sines, said. Within the guidelines is a ‘Social Media Posting Protocol’, which states that registrants need to be professional, respectful, maintain confidentiality and privacy, respect third party content, always permit the subject matter experts to respond and add value, know that the internet is permanent and keep personal views separate. It also explains that individuals are personally responsible for their words and actions and advises that when in doubt, do not post.

News in Brief Proto-col Clinical releases new vegan supplement British skincare company Proto-col Clinical has introduced the No. 15 Red Superfruits product to its offering. According to the company, the formulation blends 15 naturally-sourced ingredients that are high in polyphenols and antioxidant compounds such as blueberry, cranberry, grape and added vitamin C. Proto-col Clinical states that the product can help slow down the ageing process by combating free radical activity, protecting skin from damage and inflammatory skin conditions such as eczema. Postgraduate course launches The University of Salford has partnered with the ICE Postgraduate Dental Institute and Hospital to introduce a new PG Cert in Non-surgical Facial Aesthetics. The training programme is aimed towards doctors, dentists and nurses who want to obtain a Level 7 qualification in botulinum toxin and dermal filler treatments. Run by dental and aesthetic practitioner Dr Tracey Bell, the course aims to enhance students’ knowledge on facial aesthetic treatments. According to Dr Bell, students will also learn about evidence-based treatment planning, patient communication, legal and ethical considerations and related human factor concepts. New oxygen therapy device launches The patented OXYjet GO device that uses oxygen therapy for at-home or ‘on the go’ use has been launched by distributor OXYjet UK Ltd. According to the company, OXYjet GO uses the same technology as its in-clinic OXYjet platform, which uses pulsed pressure to allow for microencapsulated oxygen to be delivered to deep layers of the dermis along with the concentrated active ingredients found within its OXYjet serum formulas. Clinical image app released A new app that aims to allow healthcare professionals to take clinical pictures safely and securely has launched in the UK. Clinical CAM was released by consultant colorectal surgeon Mr Rakesh Bhardwaj and is designed to store patient photographs and consent documents securely on the app. Mr Bhardwaj said, “This app allows the clinician to take pictures safely, in line with regulatory guidance. The images do not go to the cloud – they stay within the app and are automatically deleted off the phone.” Clinical CAM will officially launch at CCR on October 10 and 11.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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On the Scene

Out and about in the specialty

Pigmentation un-covered Symposium, London On Friday September 6, 130 aesthetic practitioners met at the headquarters of the Royal College of General Practitioners at Euston Square for the Pigmentation uncovered Symposium. The event was organised by AestheticSource, the distributor of the NeoStrata, Skinbetter Science, Exuviance, Skin Tech, RRS, Clinisept+, Tancream, Cyspera (the newly launched rebrand of cysteamine cream) and Peel2Glow products. The day was opened by Lorna McDonnell Bowes, director of AestheticSource, who discussed the company’s journey, its commitment to providing skincare solutions, and gave an overview of its portfolio. The clinical sessions then begun with consultant dermatologist Dr Jinah Yoo, who explored the causes, symptoms and diagnosis of pigmentation. Nurse prescriber Anna Baker mentioned that practitioners are seeing an influx of patients after the summer months so now is a critical time to address their pigmentation concerns. She explored the ingredients found in effective topical formulations, including those found in Bene Bellum – a product range currently being developed by Skin Tech Pharma Group. The day also covered talks on treating skin of colour, combination therapies, chemical peels, homecare, and maintaining results. Presentations were performed by consultant dermatologist in India Dr Mukta Sachdev, aesthetic practitioners Dr Amiee Vyas and Dr Mayoni Gooneratne, Black Skin Directory founder Dija Ayodele and aesthetic practitioner Dr Xavier Goodarzian, who performed a chemical peel demonstration via video. The day ended with Daksha Patel, a life coach and trainer and director of Your Mind at Work, who explained techniques for building resilience.

BTC Graduation Party, London Graduates of the BTC Training course run by Dr Harry Singh met at the Amba Hotel in London on September 7 to celebrate their successes and network with fellow aesthetic professionals. Guests enjoyed drinks and canapés while sharing their experiences of launching a facial aesthetic clinic with the support of BTC. The training company aims to provide students with practical and theoretical clinical support, as well as business education. According to Dr Singh, the evening was a great success enjoyed by all. He said, “I wanted to appreciate all our past delegates by celebrating with them and we definitely achieved that at the BTC Graduation Party until the early hours of Sunday morning! They have all achieved a lot in a short space of time and we wanted to reward all their efforts.” Guests also took away a goody bag with vouchers and offers from BTC Training and its partners.

Academic Aesthetics Mastermind Group, London On September 4, the fourth Academic Aesthetics Mastermind Group was hosted by co-owners of Trikwan Aesthetics clinic Dr Zoya Diwan and Dr Sanjay Trikha in Mayfair. The meeting had a primary focus on rare complications and practitioners presented and discussed case studies they had managed. Dr Diwan shared a case on abscesses, aesthetic practitioner Dr Zunaid Ali discussed vascular occlusion and dentist and aesthetic practitioner Dr Sepideh Etemad-Shahidi shared her case on granulomas. Following this, aesthetic practitioner Dr Chris Rennie critically reviewed an existing paper, titled Effectiveness of Retrobulbar Hyaluronidase Injection in an Iatrogenic Blindness Rabbit Model Using Hyaluronic Acid Filler Injection. Attendees were then asked to share their thoughts on the study, which they had been sent prior to the event. The cofounders then proposed a series of case studies to be collated with the aim to be published on the treatment of abscesses, due to the lack of literature currently available. Dr Diwan said, “We’ve had a really engaged group this evening and it’s fantastic to see returning and new members every month. It’s clear that there are flaws in the many current studies in this field and even the one we critically appraised today, and that is why I believe it is important for us to come together and create papers that will hopefully assist the future of aesthetic practitioners.”

Allergan Spark Exhibition, Marlow On September 14 and 15, global pharmaceutical company Allergan hosted its first Spark exhibition at its international hub in Marlow, Buckinghamshire. The day was designed to help support and educate Allergan customers at all stages of their medical aesthetics journey through live demonstrations and talks on branding and social media to clinical practice and product supply. As well as an educational agenda taking place, there was also an exhibition with stands from the Allergan customer service team, a Juvéderm sensory booth (where delegates could touch and feel the products), Hamilton Fraser, Harley Academy, Healthxchange and Cosmetic Courses. John Campbell, Spark Innovations manager and organiser of the event says, “The weekend was a huge success! To be able to put this event on and showcase our newly refurbished office in Marlow, had a real impact for our Spark customers. Spark is all about making it easier for our customers to make connections with us and find all the trusted information in one place. There was a real buzz on the days from the customers and the feedback from them, was that they were really pleased to be invited and they valued the talks and demos provided.”

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Alma Academy European Meeting, Greece On September 12-15, more than 250 delegates from 35 countries attend the first ever Alma Academy meeting hosted at the Sheraton Rhodes resort in Greece. The event was led by dermatologists Dr Lehavit Akerman, Dr Iva Stoilova, Dr Ilan Karavani, Dr Pablo Naranjo, Dr Assi Levi and Dr Fernando Urdiales. Throughout the agenda, delegates learnt about topics including laser hair removal, skin rejuvenation and body contouring. The primary focus however was on learning to use a combination of technologies, fillers as well as business and marketing tools. The event included live demonstrations, workshops and panel discussions on varying topics. Delegates also enjoyed access to a social media lab with Alma’s digital team to assist those new to the specialty with their marketing plans going forward.

11th 5-ContinentCongress, Barcelona

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Allergan Immersive Digital Tutorial Two new MD Codes were launched by plastic surgeon Mr Mauricio de Maio on September 12 at the very first immersive digital tutorial held by the Allergan Medical Institute (AMI). Advanced Allergan practitioners from around the world were invited to learn the latest injection techniques for effective mid and lower face treatments using the Juvéderm product range. Mr de Maio highlighted the importance of continued learning during the webinar, stating, “The field of medical aesthetics is constantly involving so the education of injectors is a never-ending task. We must take the time to reflect how we can improve our practice and deliver better outcomes to our patients.” He then introduced best practice for patient assessment and the new MD Codes – the 7-POINT SHAPE for women and 9-POINT SHAPE for men. The 7-POINT SHAPE for women involves seven points, which include Ck1, Ck4, Jw1, C1 and C2, and Jw4 and Jw5. The 9-POINT SHAPE for men involves injection of Ck1, Ck4, Jw1, Jw2, C1, C2, Jw4, Jw5 and C5 points. During the webinar, Mr de Maio performed the 7-POINT SHAPE injection techniques using Juvéderm Volux and Juvéderm Voluma, and encouraged viewers to perform the treatments on their own patients in their clinics.

Lynton Customer Workshop, Manchester From August 29 to September 1, 1,250 delegates from across 79 countries and five continents attended the 5-ContinentCongress in Barcelona. Speakers across the event included consultant dermatologist and Aesthetics clinical advisory board member Dr Christopher RowlandPayne, aesthetic practitioner Dr Uliana Gout, plastic surgeon Mr Olivier Amar, consultant dermatologist Dr Firas Al-Niaimi, plus many more. Topics covered included medical and aesthetic dermatology, current and emerging injectables, aesthetic gynaecology, medicines for the skin and chemical peels. As well as this, the conference also housed an exhibition featuring 80 companies including Allergan, Merz, Galderma, mesoestetic, SkinCeuticals, Croma, amongst others. Congress president, Dr Michael Gold said of the event, “The 5CC has become one of the most respected scientific aesthetic, cosmetic and medical dermatology meetings found anywhere in the world. Every year we continue to expand the programme to feature something for everyone – injectables, lasers and energy-based devices, skincare, practice management – with experts from all over the world teaching and sharing their knowledge in a beautiful forum. We look forward to another great conference in 2020!”

On September 16, Lynton customers were invited to attend a workshop hosted at the Hilton Hotel in Deansgate, Manchester to meet with the company’s staff and discuss the latest innovation in the aesthetics industry. The company explains that it decided to host the workshop in Manchester, where the company first began, to celebrate its 25th year in the development of advanced laser and light technologies. The day started with complementary drinks and canapés on arrival followed by an introductory welcome from managing director of Lynton, Dr Jonathan Exley. This was then followed with a talk from sales and marketing director Hayley Jones, discussing Lynton’s product portfolio and expansion plans. The agenda also saw talks from clinical trainer Rhiannon Smith, who discussed the latest technologies and research, and business owner Richard Crawford Small explored ways to strengthen your clinical marketing strategy. Throughout the event, there were a range of talks, as well as a live demonstration with the Onda device. “We were so proud to share our 25 years anniversary with our customers exploring the future of Lynton and technologies of light. It has been a great event!” said Dr Exley.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Advertorial Merz Aesthetics

Keeping it in the Family and Protecting Patients

the UK and have remained dedicated and focused on the aesthetic market. Both have fully registered and compliant premises and source their product exclusively through Merz Pharma UK who receive it direct from the manufacturing and distribution in Germany. This guarantee on the supply Merz Aesthetics explores its special partnership centre chain means that aesthetic practitioners can rest between two leading aesthetic distributors assured that the products are both genuine and have not been subject to any non-compliant distribution Merz Pharma UK and Ireland is pleased to confirm its special practices, such as out-of-range temperature excursions, particularly partnership with two of the UK’s leading aesthetics distributors, high risk in some of the summer temperatures seen across Europe Church Pharmacy and Wigmore Medical. As a family-owned recently,” Rose added. There has been a recent flood of very low business, established for over 110 years, Merz are delighted to priced dermal fillers entering the market. Practitioners need to be be partnering with these similarly long-established, family-owned, aware that where prices seem too good to be true there is a very real customer-focused businesses. chance that some corners have been cut. Good Distribution Practice 2019 has seen much change in the UK and Irish aesthetics market, requires investment and diligence and this costs money. But it is with the introduction of EU-wide legislation around the Falsified there for a reason – to assure customers that the product that they Medicines Directive, the ongoing saga of Brexit, growing influence of ultimately inject into their patients – and possibly themselves – are the JCCP in establishing a register of practitioners and seeking to raise both genuine i.e. not counterfeit, and are in the same condition as standards for safe and effective aesthetic medicine and, latterly, the when they left the factory. For example, any product shipped over the significant distribution changes in the aesthetic injectables market. fiercely hot summer seen in Europe, where temperatures reached All of this flux can cause uncertainty and so Merz Aesthetics has 40°C, that did not go in refrigerated containers will almost certainly moved to reinforce and underline its special partnership with Church have breached the maximum upper storage temperature for quality. Pharmacy and Wigmore Medical, both of whom share many of the Merz uses temperature logging devices and any product which has underlying values of Merz. exceeded 25°C in transit is quarantined and destroyed. Many of the highly discounted products are unlikely to have had this safeguard and may remain on the market, posing a potential risk to patient safety and practitioners’ businesses. Rose reiterates, “This summer has seen an unprecedented demand for Merz UK with our partners, with one product running out of over a year’s supply of medicinal samples in less than one month. Practitioners seem to really appreciate the benefits of partnering with two of the best pharmacy distributors in the UK and the only global pharmaceutical company whose primary focus is aesthetic medicine.” Rose, continued, “Our sales and customer services teams are working in close partnership with the Church and Wigmore teams to ensure practitioners get great value and excellent service and the response that we have had has been overwhelming. We look forward to continued partnership working and welcoming new customers to the Merz portfolio every day.”

“This guarantee on the supply chain means that aesthetic practitioners can rest assured that the products are both genuine and have not been subject to any noncompliant distribution practices, such as out-of-range temperature excursions, particularly high risk in some of the summer temperatures seen across Europe recently” Stuart Rose, managing director of Merz in the UK

“Merz Aesthetics operates to a strict set of working practice standards and we have two underlying mantras for our business: we will never compromise patient safety and never mislead healthcare professionals. This means that aesthetic practitioners can be sure that when they order Merz Aesthetics brands from either Church Pharmacy or Wigmore Medical they will benefit from knowing that their product is genuinely sourced from Merz in the UK, has been properly managed through its supply chain and can benefit from access to Merz Aesthetics as partners,” said Stuart Rose, managing director of Merz in the UK. “In addition they will be getting excellent value and arguably the best customer service available from an aesthetic pharmacy partner. Both Church and Wigmore have a long-established presence in

About Merz With approximately 3,000 employees and a direct presence in 28 countries, Merz is a global, family-owned medical aesthetics and neurotoxin company based in Frankfurt, Germany. Privately held for 110 years, the company is distinguished by its commitment to innovation, solid financial strength and continuous growth. In addition to its comprehensive portfolio of medical aesthetic products in the device, injectable and skincare categories, Merz also focuses on the treatment of neurologically-induced movement disorders. More information is available at merzpharma.co.uk.

Merz Pharma UK Ltd. 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire, WD6 3SR Phone: 0208 236 0000 Email: customerservices@merz.com

Aesthetics | October 2019

M-MA-UKI-0623 Date of Preparation September 2019

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Celebrating Skin Imperfections Aesthetics explores the stigma surrounding skin conditions and how they are slowly becoming more accepted and normalised in today’s society As you gaze upon the large, powerful images of 20 women it’s hard to imagine what it must feel like to suffer from a severe or persistent skin condition; or perhaps you can relate? In September, photographer Sophie Harris-Taylor and the Francesca Maffeo Gallery presented an exhibition in London called ‘Epidermis’.1 Harris-Taylor told Aesthetics that her aim was to interview and photograph 20 bare-faced women across the UK to help normalise natural beauty and celebrate the imperfections so commonly seen those suffering from conditions like acne, rosacea and eczema. “I suffered from severe acne throughout my teens and twenties and there were no images or role models in the media to relate to. This can make you feel isolated and as though you are the only one suffering,” Harris-Taylor says, adding, “In my photographs, I wanted to create a series of work that empowers women and allows them to love the skin they’re in, regardless of what condition they have and do so in a way to show that they are still incredibly beautiful. Normality is defined by the images we see all around us. We are led to believe all women have perfect flawless skin – they don’t – and there are still so many stigmas surrounding skin conditions.” While the aesthetics specialty is fuelled by those wanting to improve their appearance, it’s important for practitioners to understand the stigmas that patients may face and how they can help them become more confident in their own skin. Consultant dermatologist Dr Anjali Mahto, emphasises, “In an industry where we as practitioners correct people’s ‘imperfections’ I think we need to be very conscious of what our patients’ motivations are for treatment, such as their psychological impacts and that we are not pushing an idea of unrealistic beauty. The important thing for practitioners I think is identifying if something is actually an ‘imperfection’ or not.”

suffers are embarrassed and hide or cover up their skin conditions, and don’t talk to anyone about it,” she explains. Harris-Taylor reiterates this, explaining that although some individuals she photographed had a skin-positive attitude and were confident in their own skin, others were not. “Some were really insecure, and self-conscious, never leaving the house without makeup and the photoshoot was a really big deal for them as their conditions have affected them in so many ways throughout their life,” she explains. Dr Mahto, who actively shares her own acne journey on social media, adds, “Skin can really affect an individual’s mental health and people can feel very unattractive and unworthy due to the way they look. Unfortunately, I do think society still has a very narrow view of beauty – which is clear glowing skin – and this won’t change until people see that not showcasing all kinds of diversity is a problem.”

The stigmas of skin According to The British Skin Foundation, 60% of the population currently suffer from, or have suffered with a skin disease at some point during their lifetime.2 Statistics from the British Association of Dermatologists (BAD) state that 24% of the population consult a GP each year because of a skin complaint and it is one of the most common reasons for a new consultation with GPs.3 However, even though skin conditions are relatively common, consultant dermatologist Dr Helen Robertshaw agrees that there is still a huge social stigma surrounding skin issues. “There are a lot of misunderstandings from both the public and people suffering from skin conditions. For example, it’s commonly thought that people with acne have dirty skin or a poor diet, rosacea patients drink too much alcohol, or that people with hand eczema are contagious. Because of these beliefs,

“In my photographs, I wanted to create a series of work that empowers women and allows them to love the skin they’re in, regardless of what condition they have” Photographer Sophie Harris-Taylor

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Images of Lex, Joice and Izzy taken by Sophie Harris-Taylor showcased at the Epidermis exhibition presented by Francesca Maffeo Gallery. Image at article head is Louisa.

Changing the face of normality Some brands have started to acknowledge diversity and encourage body and skin positivity and 2018 seemed like it was the year to do so. Early last year skincare brand Dove hired models with skin conditions for its ‘Make Peace with Dry Skin’ campaign to promote its DermaSeries collection,4 while a campaign by makeup brand CoverGirl titled ‘I Am What I Make Up’ featured a model with vitiligo.5 A few months later, retailer Missguided launched the #InYourOwnSkin campaign to celebrate female imperfections and flaws. It featured models with an array of skin conditions that the label felt authentically reflected its audience.6 Harris-Taylor, Dr Robertshaw and Dr Mahto all acknowledge that these campaigns are good steps towards promoting the beauty in skin diversity, but Harris-Taylor says that sometimes they have a large focus on extreme cases. She says, “Sometimes I feel like the skin condition has to be really apparent or even ‘extreme’ for it to be acknowledged, like model Winnie Harlow’s vitiligo,7 and I think people like the ‘shock’ of that. We rarely see the in-between and I think that needs to be shown more – it’s something that I wanted to portray in my photographs.” Both Dr Robertshaw and Dr Mahto applaud Harris-Taylor for shining a positive light on skin through this exhibition. Dr Mahto says, “I think what Sophie is doing is absolutely amazing, the amount of stigma that is still attached to skin disorders is immense and I agree that until we start normalising it, it won’t go away.” To achieve this, Dr Robertshaw says the media, celebrities and advertisers need

“We need to be conscious of what our patients’ motivations are for treatment and that we are not pushing an idea of unrealistic beauty” Consultant dermatologist Dr Anjali Mahto

to show more ‘normal’ skin such as minor birth marks, scars, stretch marks, psoriasis, moles and even hyperhidrosis. Harris-Taylor adds, “I think we just need to keep pushing for companies to show people with real skin more and bring more diversity into advertising, magazines and even on TV. The more this is done, the more I think people will feel like they can talk about their conditions, and will have less of a need to cover themselves in a mask and be more confident in the skin they are in.” Dr Mahto suggests that aesthetic practitioners can also help by supporting patients the best way they can when they present to clinic. “I advise practitioners to always show empathy and discuss the option of referring to a clinical psychologist if they think their patient will benefit from this. Practitioners can also help patients and prospective patients become more familiar and educated when it comes to skin conditions, and share accurate resources such as the BAD patient information leaflets for acne as there is a lot of misinformation on the internet,” Dr Mahto says. Harris-Taylor concludes, “Over the past 10 years I think we have seen a shift in people talking about mental health, so I would really

love to see people opening up more and talking about their skin and I think this will help make skin conditions less taboo.” REFERENCES 1. Francesca Maffeo Gallery, ‘Sophie Harris-Taylor Epidermis’ 2019. <https://www.francescamaffeogallery.com/epidermissophie-harris-taylor> 2. The British Skin Foundation, About Us. <https:// www.britishskinfoundation.org.uk/who-weare#targetText=The%20British%20Skin%20Foundation%20 is,some%20point%20during%20their%20lifetime.> 3. Parliament.UK, Health CommitteeWritten evidence from the British Association of Dermatologists (LTC 89). <https://publications.parliament.uk/pa/cm201415/ cmselect/cmhealth/401/401vw78.htm#targetText=Skin%20 disorders%20are%20amongst%20the,more%20than%20 2%>2C000%20different%20diseases.&targetText=It%20 is%20estimated%20that%20several,cell%20skin%20 cancers%20a%20year.> 4. Becky Bargh, ‘Dove hires models with skin conditions to promote new DermaSeries collection’, Cosmetics Business, February 2018. <https://www.cosmeticsbusiness.com/news/ article_page/Dove_hires_models_with_skin_conditions_ to_promote_new_DermaSeries_collection/139117> 5. Sabrina Barr, Overgirl Campaign Features Model With Vitiligo For First Time, Independent, February 2018. <https:// www.independent.co.uk/life-style/fashion/covergirlcampaign-vitiligo-model-makeup-foundation-america-amydeanna-a8221116.html> 6. Olivia Petter, ‘Missguided Celebrates Female ‘Flaws’ In Latest Campaign’, May 2018. <https://www.independent. co.uk/life-style/fashion/missguided-female-flawsimperfections-celebration-campaign-body-positivityfashion-a8345176.html> 7. Bibby Sowray, Winnie Harlow, the model changing the face of fashion, August 2015 <https://www.telegraph.co.uk/ fashion/people/winnie-harlow-model-with-vitiligo/>

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


Aesthetics Awards Judging

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been given appropriate categories for judging and I believe the rigour of the whole process means everyone can feel justifiably confident and proud of being named a Finalist, Commended, Highly Commended or Winner!”

Does each judge review all the categories?

Judging the Aesthetics Awards Find out more about the prestigious role of the Aesthetics Awards judges On October 31, voting and judging for the Aesthetics Awards will come to a close. Scores will then be carefully collated before the 2019 Winners, along with Commended and Highly Commended finalists, will be revealed at the glamorous ceremony in the Park Plaza Westminster Bridge ballroom on December 7. More than 800 guests who work across the specialty are expected to attend for an evening filled with excitement, entertainment and, of course, celebration! But before all that, the 60+ judges supporting the Aesthetics Awards have an extremely difficult job in carefully considering numerous entries in their assigned categories. So how does it work? And how is a fair process guaranteed? Aesthetics answers the most commonly asked questions…

Who are the Aesthetics Awards judges? There are more than 60 Aesthetics Awards judges in total, who are mainly medical practitioners working within aesthetics. As the Aesthetics Awards is a ceremony for professionals, judged by those who are experts in their field, it’s important that doctors, dentists, nurses and surgeons all take part in the judging. Other judges comprise company specialists, including business consultant, author and marketing specialist Wendy Lewis and PR consultant Julia Kendrick. Kendrick, who has been on the panel for four years. She said, “For me, the Aesthetics Awards really is the pinnacle of industry awards because the application and judging process is so thorough and really tailored to each entry. In such a closely-knit industry where many of us have worked together, the judges’ declarations and vetting to ensure impartiality is really important. I have always

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Aesthetics | October 2019

No! Judges usually assess between one and two categories each. One reason for this is they simply wouldn’t have time – with 26 categories and hundreds of entries, it would be a very busy few months for them! The main reason, however, is to avoid any conflicts of interest. Every judge must sign a declaration form before access to the entries is given. On this declaration, they must detail any categories they, or a colleague, has entered or plan to enter, any relevant financial disclosures and any reasons they would not be able to judge a particular category objectively. They must also sign to confirm that they will:

Voting Voting is open for 12 categories. As the Aesthetics Awards is an awards ceremony for aesthetic professionals, judged by aesthetic professionals, with the aim of justly rewarding best practice and the highest standards within the specialty, it wouldn’t make sense for the general public or patients to take part in voting. Therefore, the 12 voteable categories are all those which aesthetic professionals will have had experience of and be able to fairly assess who they think should win! So, if you’ve worked with or been influenced by any of the finalists in the voted-for categories listed on the website, then support them by submitting your vote before October 31! >> Topical Skin Product/Range of the Year >> Injectable Product of the Year >> Energy Device of the Year >> Best Clinic Support Partner >> Best UK Subsidiary of a Global Manufacturer >> Best Manufacturer in the UK >> The Healthxchange Award for Sales Representative of the Year >> The ClinicSoftware.com Award for Aesthetic Product Distributor of the Year >> Pharmacy Distributor of the Year >> The Clinetix Award for Professional Initiative of the Year >> The Sinclair Pharma Award for Best Independent Training Provider >> The Dalvi Humzah Aesthetic Training Award for Best Supplier Training Provider


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• Endeavour to score fairly based on the merit of each entry • Treat any information contained within the entries sent in a confidential manner • Not share the details of the categories they are judging or scores awarded with any external parties • Not use the information contained within any entries judged for their own commercial or personal purposes

Aesthetics Awards Judging

and score based on sound evidence, along with a demonstration of commitment to clinical excellence, rather than choosing the most wellknown or biggest brand, company or individual.

What happens next for finalists?

Before assigning categories, the Aesthetics team spends time researching the judge and judges are instructed to notify the team immediately if any further conflicts of interest arise after signing their declaration.

How do judges score entries? Entries are scored on a special portal on the Aesthetics Awards website. Judges are provided with access to a page dedicated to their assigned categories, which they can log into, save scores and come back to it later, if necessary. The easy-to-use system means judges are able to really concentrate on the content of the entries. The entry is presented in the exact format it is submitted by the entrants and, of course, if entrants have provided supporting evidence, judges can view images and download any documents provided. For each question, scores are given out of 10 and judges can make further comments at the bottom of each entry. Judges are advised that, although background knowledge of an entrant may inform judgement to a certain extent, they should base their decisions primarily on the entry that has been submitted. Aesthetics specifically asks them to consider the entry holistically

Once all of the judges have submitted their scores, the Aesthetics team will gather results and very carefully total the numbers. If a category also has a voted-for element, then the number of votes will be measured alongside the judges’ scores in a 30-70 ratio, respectively. This all gets checked thoroughly by the team to ensure there are no mistakes, anomalies or outliers before the Winner trophies are engraved, certificates printed and those successful are announced on the night! If you haven’t booked your ticket yet, do so fast! Visit aestheticsawards.com to purchase individual tickets or tables of 10. See you on December 7!

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Skin rejuvenation and lasers

Treating Skin of Colour with Lasers Practitioners discuss the key considerations around treating darker skin types with lasers for skin rejuvenation Whether you attend conferences, talk amongst colleagues or scour social media, it’s safe to say that lasers are a hot topic. We have seen a significant rise in their usage over the last five years1 and some practitioners believe lasers are the ‘holy grail’ for many a skin concern. However, there seems to be one area that some still shy away from; treating skin of colour. The UK is one of the most multicultural and diverse countries in the world2 but despite this, there still seems to be apprehension amongst practitioners when treating patients darker than Fitzpatrick Type III. As well as anecdotal evidence, a study published in the Journal of Drugs in Dermatology in July this year concluded that knowledge gaps and myths concerning facial aesthetic treatment in individuals with skin of colour do still exist.3 The following month, a study was published in JAMA Dermatology, reporting that if a clinic has a dermatologist with specific expertise in skin of colour then it improves the experience of black patients seeking dermatology solutions.4 To further support this, founder of the Black Skin Directory and aesthetician Dija Ayodele told Aesthetics, “Whilst awareness is improving, laser treatments are still poorly misunderstood within the skin of colour demographic. The main confusion is around its suitability and safety for darker skin tones. Communication and education from brands and practitioners alike should be clearer and be more inclusive by featuring pictures of patients with these skin types so that skin of colour patients are aware of the benefits of laser treatment. It’s not just the patients that are apprehensive, it’s the practitioners too, and I think there needs to be a lot more support and training out there for those who are looking to treat skin of colour.” This article will explore the key considerations of treating skin of colour for skin rejuvenation purposes using lasers. It will discuss common complications, detail treatment techniques, and discuss why, when used appropriately and in conjunction with other modalities, it can be a strong addition to any clinic with a diverse patient base.

Why are practitioners apprehensive?

“Practitioners are mainly cautious in treating ethnic patients with lasers primarily due to the risks associated with the procedures, and rightly so. There are much higher risks of scarring and hyper and hypopigmentation in darker skin types due to the increased melanin content.5,6 Practitioners need to be particularly wary of this,” explains Dr Vishal Madan, consultant dermatologist and a laser and Mohs micrographic surgeon. “This is despite the advent of newer devices and technologies which claim the risks are lower when treating patients of colour. Although technology has gotten better, there are still natural risks with treating skin with high melanin. The higher the skin’s melanin, the higher the chance of complications and pigmentary alteration that can arise as a result of heating it,” he adds. Consultant dermatologist Dr Justine Hextall reiterates this point, noting, “I think practitioners’ apprehensions are entirely appropriate. There are few published studies in the treatment of skin types V and VI with laser therapies and these are obviously the groups most at risk for post-inflammatory hypo or hyperpigmentation.”

Whilst skin rejuvenation using lasers amongst Caucasian patients is a common offering, the practitioners interviewed agree that often in darker skinned patients, rejuvenation falls under textural and dermatological concerns, as opposed to fine lines and wrinkles. Dr Madan explains, “Generally speaking, skin of colour patients don’t come into clinic with requests of treating fine lines and wrinkles. They age in a different way to Caucasian patients and they don’t have as many deep rhytids. It’s usually dermatologic concerns such as pigmentation and scarring that they want to address.” Consultant dermatologist, Dr Mukta Sachdev, who is currently practising in India, adds, “Everyone’s concept of skin rejuvenation is very different. Some may consider it to be treating wrinkles, whilst others may be looking for textural improvement. It’s important to find out what the patient’s motives are as that will help guide the practitioner for the most suitable treatment options.” So, when would lasers be suitable for patients of colour looking to improve the skin? Dr Madan believes that lasers are often the last resort when other modalities have failed. He says, “I personally would not advise someone to have laser as the first option, particularly in skin of colour. You have to build a patient’s tolerance to laser and first explore other treatments out there that are less invasive.” Dr Hextall says that she would caution any practitioner trying to treat pigmentary issues in skin of colour without carefully looking at the alternative options, considering pretreatment regimes and patch testing the skin. Dr Sachdev agrees, “No one does just one treatment anymore. If the patient is suffering with pigmentation, for example, and they aren’t pleased with the topical results, then we would make the decision to move them onto a laser, something like the Q-switched Nd:YAG laser, as there are studies to suggest that it is generally safer in skin of colour.”7,8 Whilst aesthetic practitioner Dr Ifeoma Ejikeme would opt for chemical peels, dermal fillers and botulinum toxin for generic skin rejuvenation in patients with darker skin, she says lasers absolutely have a place when treating more uncommon skin conditions. “I choose not to treat general ageing concerns with laser because there are much less invasive modalities out there. However, I believe they are very beneficial for treating keloid scars, ochronosis and deep acne scarring,” she explains. Dr Madan adds, “My expertise is in treating acne scarring and this actually doubles as a

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rejuvenation treatment because the scarring will respond to fractional CO2 laser, which then gives skin tightening as a byproduct. It’s really important to examine the skin and the patient’s history. For example, if a patient comes in with boxcar scarring due to acne which they have said has not responded to microneedling, I would then decide to offer fractional ablative laser. The rejuvenation can sometimes come as a secondary option to a larger underlying condition.” All practitioners interviewed highlight that a multi-modal approach is preferable for skin rejuvenation and sometimes safer amongst the darker Fitzpatrick types. Dr Sachdev says, “Nowadays, practitioners are aware of utilising a combination approach but when done effectively laser can offer extremely good results for many indications that topicals cannot treat alone.”

Common complications

Dr Madan explains that he likes to divide the complications associated with laser in skin of colour into two categories; immediate and long-term. “The immediate complications are generally expected and reversible, these include hyperpigmentation, erythema, milia formation or folliculitis as a result of using occlusive topicals after treatment.9 The long-term complications are the ones that can be much more difficult to manage. These primarily include scarring and hypopigmentation. Prolonged hyperpigmentation is uncommon, especially if you use suitable protocols, but does still exist. There is also the risk of the activation of herpes simplex virus (HSV), which is also fairly rare but should not be overlooked.”10 Dr Hextall adds, “Skin of colour is prone to post inflammatory pigmentary change, be that an increase or decrease in pigmentation. The problem with inducing this change is it can take months to settle and sometimes can be permanent. Remember that many treatments such as intense pulsed light target melanin. The darker the skin, the more melanin and therefore the greater the absorption of the light, therefore energy levels have to be reduced. I cannot overstate the importance of a patch test before any laser treatment in any skin type.” Dr Ejikeme also reiterates that whilst post-inflammatory hyperpigmentation is often an adverse event that patients will express concern about, it is relatively easy to prevent in most cases. She says, “The key thing is to have a good protocol in place, to recognise it quickly and begin a treatment effectively. The most concerning is hypopigmentation.” Dr Ejikeme further

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explains, “The laser needs a chromophore, or end point, to be absorbed. If the end point is something that looks very similar to a melanocyte, then the laser will put a signal through to that point and will consequently penetrate heat at a level that will damage and sometimes destroy the melanocyte, thus, causing pigmentary change.” Dr Madan advises to not perform such treatments on mild acne scarring, active acne, or if someone has very dark skin with a history of keloid scarring.5,9

Learn your patient’s skin type

To aid in prevention of the aforementioned complications and understand when to recommend laser treatment, both Dr Sachdev and Dr Ejikeme agree that there are lots of other classification scales that can be more beneficial than the common Fitzpatrick scale. “The problem with the Fitzpatrick scale,” Dr Ejikeme explains, “is that that it focuses primarily on skin colour. In actual fact we need to take into account genetic makeup and heritage to truly understand how a patient may react to a laser treatment.” Dr Sachdev adds, “There is the Taylor Hyperpigmentation Scale,11 the Obagi Skin Classification12 and the Roberts Skin Type Classification System,13 all of which have applications for darker skin types. The most recent, published in 2011, is the Genetico-Racial Skin Classification14 and this encompasses all races, from Nordic to African. It incorporates the concept of interracial marriages too for those patients who have mixed racial descent – helping to predict how a particular patient will react to a treatment can give us warning signs that one needs to be extra careful when treating.” Dr Ejikeme adds, “You need to ask your patients, no matter what their skin colour is, about their family history. Find out where their parents are from and where their grandparents are from. We need to know how the skin is going to react to the treatments. For example, a Japanese woman who appears to be a Fitzpatrick type II, could tan as dark as a type IV. Not being aware of this could be calamitous for her.” Dr Ejikeme continues, “Finding out information such as this can then help determine how long you should pre-treat the patient for and what strength of products you should be using. In the example mentioned above, you would treat this patient as a type IV to account for any eventuality.”

Treatment advice “Before treatment, if the patient is potentially a risk for post-inflammatory hyperpigmentation,

I always perform a patch test on a small area of the body, usually the inner arm or behind the ear and assess the response in a couple of weeks,” says Dr Sachdev. “You need to make sure that you test in a place that has some exposure to the sun as testing an area that doesn’t have any exposure can be misleading when you come to do the treatment. For example, you could come to treat the whole face and then realise that sun exposure provokes a completely different response,” she explains. Dr Madan also believes that patch tests are a good way to manage patients’ expectations. He says, “Whilst it is important to understand that a patch test does not always guarantee a safe treatment, it will help to set the patient’s expectations as they will be able to see the associated downtime and that they may also get a bronzing effect after treatment. If the patient is concerned with the results of the patch test, it’s generally a good indicator that they may not be suitable for treatment.” As well as this, all practitioners advise to incorporate a pre-treatment plan using topicals for up to eight weeks prior to laser treatment, regardless of the concern being targeted. Dr Madan adds that SPF is also incredibly important for treatment success. “It’s so important to start patients of colour on a strict sun care regime six to eight weeks prior to treatment. I would also start them on a pigment-lightening regime and would slowly build the use from twice weekly to three times per week then every day. The use should then stop one week before treatment, however sunblock use should be continued. This would be suitable for any indication on darker skin when using ablative lasers. If there is a history of HSV the prophylaxis should be used to reduce risk of reactivation,”10 he explains. In regards to the treatment itself, Dr Sachdev believes that it’s not a case of having the best laser, it’s more the experience of the operator. “The practitioner should be comfortable in using different techniques, just as they would when administering filler,” she explains, adding, “Practitioners should identify what technique is most suitable for the patient – for example a stamping or in motion technique. They should ensure that they are not too aggressive with the treatment and the settings should not be too high. It’s not a cookbook recipe, it needs to be patient dependent and that’s where experience kicks in.” Dr Sachdev recommends to start 10-20% lower fluency in darker skin than the company

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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recommendation. “This is simply from a safety standpoint until you get comfortable with the device. Then you can up the settings,” she says. Dr Madan agrees with this advice, and adds, “Lowering the fluence is very important. Generally, I would say that if you offer your Caucasian patients the same treatment in three sessions, you should do it in six for the darker skin types. But saying this, don’t ever sell a package. You may do just one session and get the results that you are happy with. The patient can then choose if they want to come back for another one or not.” Dr Hextall adds, “At the time of treatment skin cooling before, during and after the procedure is incredibly important. You can do this with cold gel packs, by spraying the skin with cooled mineral water after a procedure and you can also apply a cold mask that contains antioxidants and hyaluronic acid, taking advantage of increased absorption of topical products. As well as this, long pulse durations facilitate efficient epidermal cooling and are therefore associated with fewer adverse events in darker skin types. You should look out for unwanted skin reactions as you treat. Listen to the patient, if they say it is more painful than usual, don’t plough on, stop. I frequently stop during treatment and observe the skin. If I am at all concerned, I will immediately cool the skin and reconsider my settings. If in doubt, stop. If there is an issue, cool the skin, consider topical anti-inflammatory creams and if necessary, bring the patient back daily.” As well as this, Dr Hextall says that postprocedure treatments and support is just as important as the treatment itself. She shares, “In my experience, it isn’t the complication that is the issue for most patients, it is the lack of support afterwards that usually triggers the complaint. This is about being contactable, making sure the patient can be seen daily if needed and has a very clear monitored treatment plan in place to reduce further damage.”

Know your device Whilst all practitioners agree that it comes down to the knowledge and experience of the handler, they reiterate the importance of checking studies and efficacies of the devices used on skin of colour. Dr Sachdev uses a number of devices and technologies in her clinic, including the eTwo by Candela Medical, a selection of Alma devices, amongst many others. She says, “I think that all of the companies today

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are very clued up and very aware of the concerns amongst skin of colour patients. Now it is common for each company to give recommendations of the setting that can be used for each skin type. But it’s important that you have proof that your device works for that indication, so ask the company for any clinical trials or supporting literature. In pigmentation for example, you need to know the absorption spectrum. This all works on the theory of selective photothermolysis.” Dr Hextall uses the M22 platform by Lumenis with the erbium-doped nonablative fractionated laser, ResurFX. She says, “This is my device of preference because it emits energy in a customisable train of pulses, allowing for tissue cooling between pulses. It delivers peak energy safely to the target, while protecting vital epidermal structures like melanocytes, thus reducing the risk of post-inflammatory pigmentation. The multiple filters allow for very specific targeted treatment.16 Because the fractional laser in ResurFX is not targeting melanin, it is able to deliver the heat required to stimulate mild collagen production and improve pigmentation.” Dr Madan is the only practitioner interviewed that prefers to use a fractional CO2 laser – his choice is the KLS Martin surgical laser – and this he explains is down to personal preference and experience. He says, “Fractionated Erbium:YAG (Er:YAG) lasers are generally considered safer, but if you are experienced in CO2 resurfacing I think the results you get are far superior. If you are new to the field, however, I would choose the Er:YAG over CO2. It is more suitable for those who are less experienced because of the favourable safety profile.” Dr Madan adds, “Fractional non-ablative lasers are appropriate in types V and VI, although the results have not been to mine or my patients’ satisfaction. I believe that you need to explain to the patient that because you are not doing a treatment that is ablating the skin, you may not see the results that you want. The main advantage with the CO2 laser is that you can be as superficial or as deep as you like.”

Meet your patients’ expectations Both Dr Sachdev and Dr Madan recommend to always under-promise and over-deliver to help manage patient expectations. Dr Madan shares, “My practice is primarily surgical so often, by the time patients have come to me, they have explored all of their options. They come

with high hopes and unfortunately their hopes have to be brought down. Explain to them that you can achieve 20-30% improvement but never promise more than 50% improvement. Then if you achieve 60% improvement, that’s fantastic!” Dr Sachdev suggests, “Continuously reevaluate results with images throughout. Often patients will forget what their concerns looked like before, so this is a really important tip. Also remember that every patient is an individual and each case needs to be evaluated as so. There really is no gold-standard approach or a superior device.” Being honest when a treatment is beyond your remit is also a key factor, Dr Ejikeme highlights. She states, “Know when not to treat. I think practitioners are getting better at saying no, but you should also explain this to patients sensitively.” Dr Ejikeme concludes, “The patient shouldn’t be made to feel as though it is their fault you are unable to treat them. Simply state the treatments that are available for their presented concern and outline would be the best, even if you don’t offer it. Your patient will come back to you for the treatments that you do well and respect you more for referring them to someone who can treat them.” REFERENCES 1. ASDS, ASDS Survey on Dermatologic Procedures, 2019 <https:// www.asds.net/medical-professionals/practice-resources/asdssurvey-on-dermatologic-procedures> 2. Migiro G, The Most Diverse Cities in the World, WorldAtlas, March 2019 3. Alexis A, Few J et al., Myths and knowledge gaps in the aesthetic treatment of patients with skin of colour, Journal of Drugs in Dermatology, July 2019  4. Reuters, Many dermatologists need more training on African American skin and hair, August 2019 <https://uk.reuters. com/article/us-health-dermatology-black-perceptions/manydermatologists-need-more-training-on-african-american-skinand-hair-idUKKCN1VB2IG> 5. Prohaska J, Badri T, Laser complications, Stat Pearls, April 2019 <https://www.ncbi.nlm.nih.gov/books/NBK532248/> 6. Davis E, Callender V, Postinflammatory hyperpigmentation, Journal of Clinical and Aesthetic Dermatology, July 2010  7. Pai GS, Pai AH, Q-Switched Laser Treatment for Individuals with Skin Type V, Aesthetics in Dermatology and Surgery, 2017  8. Levin MK, Ng E et al., Treatment of pigmentary disorders in patients with skin of color with a novel 755 nm picosecond, Q-switched ruby, and Q-switched Nd:YAG nanosecond lasers: A retrospective photographic review, Lasers in Surgey and Medicine, February 2016 9. AlNomair N, Nazarian R, Marmur E, Complications in lasers,lights and radiofrequency devices, Facial Plast Surg, 2012 10. Convery C, Aesthetic Treatments and Herpes Simplex Virus, Aesthetics journal, July 2017  11. Taylor S et al., The Taylor Hyperpigmentation Scale, Journal of the American Academy of Dermatology, March 2005 12. ZO Skin Health, Obagi Skin Classification <https://zo-skinhealth. co.uk/skin-classification-skin-type/#targetText=The%20 Fitzpatrick%20Scale%20was%20the,the%20chances%20of%20 developing%20melanoma.> 13. Roberts E, The Roberts Skin Type Classification System, Journal of Drugs in Dermatology, May 2008  14. Fanous N et al., The new Genetico-Racial Skin Classification, Canadian Journal of Plastic Surgery, 2011 15. Ping C, Xueliang D et al., A retrospective study on the clinical efficacy of the intense pulsed light source for photodamage and skin rejuvenation, Journal of Cosmetic and Laser Therapy, March 2016

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Understanding Laser for Fat Reduction

Dr Miguel Montero reviews the current literature and explores how laser technology works for fat reduction Non-invasive body contouring has become one of the fastestgrowing areas of aesthetic medicine as patients prefer lessinvasive but still effective procedures.1 Low-level laser therapy (LLLT) is a proven, effective treatment in the reduction of overall body circumference measurements.2,3 In this article, literature regarding mechanism of action, treatment protocols and efficacy of LLLT is reviewed.

Definitions The study of diseases caused by light and the use of it to detect, diagnose and treat disease is known as photomedicine. A part of photomedicine is the scientific study of LLLT, which began in the 1970s and continues to the present day.4 The impact LLLT has on the tissue and its beneficial clinical effects is called photobiomodulation, which is a term that has been known since the invention of lasers.5 LLLT is used widely in dentistry, neurology, pain management, physical therapies and other branches of medicine.6-10 The effect of LLLT is not fully understood by the medical community; however, we do know that besides the activation of cell metabolism through respiratory chain stimulation (primary mode of action), there is also cell signalling (secondary mode of action). The research continues as we lack information of some key steps.11 There are multiple modalities of body contouring using energybased devices where thermogenesis and other mechanisms of action are used to produce adipocyte death, variable degrees of neocollagenesis and skin tightening. Originally, LLLT emerged as an effective adjunct therapy for lipoplasty, improving the ease of extraction during liposuction as well as reducing postsurgical pain.12,13 Following several multisite, randomised, controlled, double-blinded studies, LLLT has become a substantial therapeutic option for circumferential reduction of the waist, hips, thighs, and upper arms on its own accord.2,12,14,15

Mechanism of action

LLLT has an effect on the adipose tissue, related to the absorption of red and near-infrared photons by chromophores in the mitochondria (particularly cytochrome c oxidase).16 This is followed by a chain of events, including rises in mitochondrial membrane potential, oxygen consumption,17 adenosine triphosphate (ATP),17 a transient increase in reactive oxygen species (ROS)18 and a release of nitric oxide (NO).16,17 The mechanism of action of LLLT on fat remains, to some extent, controversial. Applying LLLT for fat removal has no observable consequence on surrounding tissues and does not increase tissue temperature,19,20 contrary to the procedure called laser-assisted liposuction or laser-lipo. It takes time (one to two weeks) to show its own effect on the treated zone.21 Evidence has existed for a long time that wavelengths between 630 and 640 nm are optimum for biomodulation22,23,24 and these wavelengths were therefore used for LLLT-assisted lipoplasty

in 2000.13 Neira R et al. presented findings at a conference using a device on 250 patients that emits 10mW of 635 nm light. It was applied to the surface of the skin before liposuction, with the intent to emulsify the fat, thereby softening the area prior to aspiration.13 Following this, a placebo-controlled, randomised, double-blind, multicentre clinical study on 700 patients was performed to evaluate the clinical utility of this application as an adjunct to liposuction.25 The results by Neira et al. suggested that laser therapy decreased operating room times, increased the volume of fat extracted, less force was required by the physician to break up fat, and the recovery for patients was significantly improved.25 This was confirmed in 2004 in a study designed to evaluate the above parameters.26 Neira et al. attributed the effects of LLLT on adipocytes to the formation of transitory micro-pores, which were visualised on scanning electron microscopy. In this study, LLLT was used in vitro on adipose cells and researchers found a transitory pore in the adipocyte membrane through which fat leaked from the inside of the cell into the interstitial space outside.27 One possible explanation might be that increased ROS levels following LLLT initiate a process known as lipid peroxidation, where ROS reacts with lipids found within the cellular membranes, and temporarily damages them by creating pores.28 Further studies trying to replicate these results have failed to identify any pores,29 didnâ&#x20AC;&#x2122;t get any significant results,30 or found that most changes were restricted to the brown fatty tissue only and yellow tissue preserved its appearance with no signs of lipolysis observed.31 However, the experimental parameters and protocols used in these studies were not the same as the original. Another proposed mechanism is that the increased levels of cAMP could activate a protein kinase, which could stimulate a cytoplasmic lipase that converts triglycerides into fatty acids and glycerol, which can both pass through pores formed in the cell membrane.32 It doesnâ&#x20AC;&#x2122;t offer any explanation to the appearance of the observed pores. One in vitro study demonstrated no increase of glycerol and fatty acids, suggesting that fat loss from the adipocytes in response to laser treatment was not due to a stimulation of lipolysis.14 However, they did detect increased triglyceride levels, which further supported the formation of pores in adipocytes leaking the intact contents.14 LLLT provokes a move of the intracellular redox state towards an oxidative state, initiating redoxsensitive transcription factors such as NF-kBand AP-1, upregulating the expression of genes.33 Perhaps the activation or suppression of specific transcription factors can influence membrane proteins, which in turn will modify the permeability of adipocytes (Figure 1).28 It is not known what cellular components of the adipocyte allow for this unique laser induced endpoint, which appears to be exclusive to adipocytes.34 We donâ&#x20AC;&#x2122;t know whether the transitory pore caused by LLLT is a direct result of upregulated gene expression via transcription factor activation, lipid peroxidation by increased superoxide production, or a simpler exocytosis-like process. Therefore, more studies are needed to ascertain the actual mechanisms which underpin the clinical effects that have been observed.

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LLLT does not destroy the adipocyte when it mobilises the fat from the inside to the outside of the membrane, keeping the cell alive and in good condition. This is a very important fact which needs to be discussed with the patients undergoing treatment, as the potential for the re-accumulation of fat in the tissue remains intact if the lifestyle doesn’t change.2

LLLT for non-invasive body contouring

LLLT is currently widely established as effective for reducing circumference of areas such as the waist, hip, thigh, and upper arms in individuals who are overweight, but non-obese (body mass index <30kg/m2).35 As it is a completely non-invasive procedure, the use of LLLT for body contouring is not associated with severe adverse effects, such as pain or infection, and there are no adverse changes in serum lipids. LLLT has no adverse effects on the skin or underlying musculo-fascial system and there is no required recovery period following treatment.35 The clinical study which was used to obtain the first FDA market clearance in the US for circumferential reduction of the waist, hips, and thighs used an LLLT device with five rotating independent diode laser heads, each emitting 17mW of light at 635 nm. This was a placebocontrolled, randomised, double-blind, multisite trial evaluating 67 study participants.2 The results obtained from that study demonstrated an average reduction of 8.91cm across patients’ waist, hips, and thighs after six treatments over two weeks. The trial was planned and carried out exemplarily, with no changes in lifestyle, absence of diet restrictions, exercise requirements, or any other adjunctive components. The authors also hypothesised that the circumferential reduction was not likely related to fluid nor fat relocation since the measurement points included non-treated regions which achieved a 2.54cm loss on their own.2 A different randomised study used a 635-680 nm 10mW LLLT device for 30 minutes twice a week for four weeks on 40 healthy young men and women who were asked not to change their diet or exercise habits.14 Researchers achieved a girth loss of 2.54cm at the waist.14 However, it is worthwhile to note that this device was only approved by the FDA for hand and wrist pain associated with carpal tunnel syndrome. Another randomised controlled trial looked at the effect of a 635 nm laser on a different area; the upper arm.36 Researchers studied 62 patients – 31 in each group. Long-term efficacy was assessed at

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a follow-up visit between five and 10 months. The combined results showed that 58% of patients achieved study success criteria, defined as a combined reduction in arm circumference of 1.25cm measured at three equally spaced points between the elbow and shoulder. The results were maintained after more than seven months. One of the larger randomised controlled trials sought to determine whether the results of LLLT therapy with a 635 nm laser are based on simple fluid redistribution.15 Data were used from 689 participants to evaluate the circumferential reduction of the waist, hips, and thighs, as well as non-treated systemic regions and significant differences were found (P<0001). The authors reported that the circumferential reduction represented intracellular lipids permeated from the treated area. The question was whether the liberated material and subsequent body slimming could arise due to simple fluid redistribution. If this were the case, the remote non-treated regions would show an increase in circumferential measurements after LLLT treatment. The results showed a mean total circumferential loss, in both treated and remote regions, of 13.13cm, demonstrating that fluid redistribution is not the likely cause for the reduction. The authors proposed that the slimming induced by LLLT is secondary to lipid mobilisation and subsequent lipid metabolism.15 Abdominal fat is not the only target for LLLT. Cellulite has been the subject of research as well.37 In one double-blind randomised controlled trial, 68 patients were allocated to treatment with a 532 nm device or control, three weekly for two weeks. There were 19 patients in the LLLT group which achieved a decrease of one or more stages on the Nurnberger-Muller grading scale (55.88%) versus three patients (8.82%) in the sham-treated group. Patients treated with LLLT achieved a significant decrease in combined baseline thigh circumference at the two-week study endpoint and six-week follow-up evaluation versus no change for sham-treated patients. In contrast with other technologies, LLLT was shown in one study to be effective as a stand-alone procedure without requiring massage or mechanical manipulation.37 There have been attempts to change the protocol. In one study, 54 patients received a weekly treatment with a 635 nm laser for six weeks.35 The results were that the mean reduction in combined circumference was 13.7cm, with 72.2% of the patients achieving >11.43cm reductio, and overall satisfaction with the treatment >80%. The conclusion was that maybe the weekly treatments are more effective than the previous six treatments over two weeks.35

Cell membrane

Respitory chain

Cytochrome c oxidase

ROS

Ca2+, K+ cAMP, ApH

NO

ATP

Ca2/Na+ Antiporter Na+/K+ Antiporter Na+/K+ ATPase Ca2+ Pump

Figure 1: The potential mechanism of action of LLLT in fat reduction. LLLT stimulates the cytochrome c within the mitochondria in the adipocytes. This will lead to increases in ROS, NO and other processes. The specific increase in ATP synthesis will in turn induce a rise in cAMP.28

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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One previous study demonstrated the effectiveness of LLLT to reduce body circumference in the hips, thighs, and abdomen of non-obese individuals with a BMI <30kg/m2, so research turned its attention to assess the effectiveness of LLLT to reduce hip, thigh, and abdomen circumference of obese individuals with BMI between 30 and 40 kg/m2. In this randomised, double-blind placebo-controlled study, 28 obese, but otherwise healthy individuals, were randomised to undergo 30-minute LLLT or pretend treatments (n=25) three times weekly for four weeks.19 The device was a 532 nm laser, with 10x17mW diodes. After four weeks, 20 LLLT-treated patients (71.43%) achieved 7.2cm decrease in combined measurements versus three sham-treated patients (12%), the mean total decrease two weeks’ post-treatment was 15.21cm. There were no adverse events.19 Based on these results, the device was cleared by the US FDA as a noninvasive aesthetic treatment for reduction of circumference of hips, waist, and upper abdomen when applied to individuals with a BMI between 30-40kg/m2.38

LLLT effect on serum lipid levels Although authors hypothesised that fat released following LLLT treatment may appear in the bloodstream where it might have a negative effect in the lipid profile, a non-randomised, uncontrolled pilot study demonstrated an actual reduction in serum cholesterol and leptin levels following LLLT.39 This effect has been confirmed in other studies, which demonstrated similar effects in blood lipid profiles following LLLT treatments using different lasers.40,41 The clinical implication of this is that we can reassure our patients that we are not going to cause any adverse effect related to increases of cholesterol and triglycerides. The evidence suggests that the levels actually drop following the treatment.39,40,41

Conclusion LLLT is an effective and safe tool for body contouring due to the circumferential reduction in multiple body measurements and the absence of any side effects. Future lines of research should involve the combination of LLLT with lymphatic drainage, vibration therapy, lifestyle interventions and other interventions which are often associated with LLLT in clinical practice. Dr Miguel Montero completed medical school in Spain and started using LLLT in 1992. He has a Postgraduate Diploma in Clinical Dermatology and has been the leading clinician at Discover Laser Clinic in Lancashire for the last 12 years, where he has successfully treated more than 50 patients with LLLT.

Visit our website to test your knowledge and complete our Multiple Choice Questions based on this article. You will then receive a certificate confirmation of your CPD point.

REFERENCES 1. Mazzoni, D., Lin, M.J., Dubin, D.P. and Khorasani, H., Review of non-invasive body contouring devices for fat reduction, skin tightening and muscle definition. Australasian Journal of Dermatology, 2019. 2. Jackson RF, Dedo DD, Roche GC, Turok DI, Maloney RJ. “Low-level laser therapy as a non-invasive approach for body contouring: a randomized, controlled study.” Lasers Surg Med. 41.10 (2009): 799–809. 3. Nestor, M.S., Newburger, J. and Zarraga, M.B., 2013. Body contouring using 635-nm low level laser therapy. Semin Cutan Med Surg, 32(1), pp.35-40. 4. Hamblin, M.R. and Huang, Y. eds., 2013. Handbook of photomedicine. Taylor & Francis. 5. Mester, A. and Mester, A., 2017. The history of photobiomodulation: Endre Mester (1903–1984).

6. Stonecipher KG, Kezirian GM. Wavefront-optimized versus wavefront-guided LASIK for myopic astigmatism with the ALLEGRETTO WAVE: Three-month results of a prospective FDA trial. J Refract Surg 2008;24(4):424–430. 7. Zins JE, Alghoul M, Gonzalez AM, Strumble P. Self-reported outcome after diode laser hair removal. Ann Plast Surg 2008;60(3):233–238. 8. Katz B, McBean. J. The new laser liposuction for men. Dermatol Ther 2007;20(6):448–451. 9. Zouari L, Bousson V, Hamze B, Roulot E, Roqueplan F, Laredo JD. CT-guided percutaneous laser photocoagulation of osteoid osteomas of the hands and feet. Eur Radiol 2008; May 24. 10. Posten W, Wrone DA, Dover JS, Arndt KA, Silapunt S, Alam M. Low-level laser therapy for wound healing: Mechanism and efficacy. Dermatol Surg 2005;31(3):334–340. 11. Karu, T.I. “Cellular mechanisms of low-power laser therapy.” Laser Applications in Medicine, Biology, and Environmental Science 5149 (2003): 60-66. 12. Jackson, FR., Roche G., Kimberly JB., Douglas DD., T KS. “Low level laser-assisted liposuction: A 2004 clinical study of its effectiveness for enhancing ease of liposuction procedures and facilitating the recovery process for patients undergoing thigh, hip and stomach countouring.” Am J Cosmet Surg 21.4 (2004): 291-4. 13. Neira R, Solarte E, Reyes MA, et al. “Low level assisted lipoplasty: A new techique.” Proceedings of the World Congress on Lipoplasty. Dearborn, MI., 2000. 14. Caruso-Davis MK, Guillot TS, Podichetty VK, Mashtalir N, Dhurandhar NV, Dubuisson O, Yu Y, Greenway FL. “Efficacy of low-level laser therapy for body contouring and spot fat reduction.” Obes Surg 21.6 (2011): 722–729. 15. Jackson RF, Stern FA, Neira R, et al. “Application of low-level laser therapy for non-invasive body contouring .” Lasers Surg Med 44 (2012): 211-217. 16. Karu TI, Pyatibrat LV, Kalendo GS. “Photobiological modulation of cell attachment via cytochrome C oxidase.” Photochem Photobiol Sci 3.2 (2004): 211-6. 17. Karu TI, Piatibrat LV, Kalendo GS, et al. “Changes in the amount of ATP in HeLa cells under the action of He-Ne laser radiation.” Biull Eksp Biol Med 115.6 (1993): 617-8. 18. Rosenbaum M, Prieto V, Hellmer J, Boschmann M, Krueger J, Leibel RL, Ship AG. “An exploratory investigation of the morphology and biochemistry of cellulite.” Plast Reconstr Surg 101.7 (1998): 1934–1939. 19. Roche G. C., Shanks S., Jackson R., Holsey L. J. “Low-level laser therapy for reducing the hip, waist, and upper abdomen circumference of individuals with obesity.” Photomedicine and laser surgery. 35.3 (2017): 142–149. 20. Neira R, Arroyave J, Ramirez H, et al. “Fat liquefaction: effect of low-level laser energy on adipose tissue.” Plast Reconstr Surg 110.3 (2002): 912-22. 21. Alizadeh, Z., Halabchi, F., Mazaheri, R., Abolhasani, M. and Tabesh, M., 2016. Review of the mechanisms and effects of noninvasive body contouring devices on cellulite and subcutaneous fat. International journal of endocrinology and metabolism, 14(4). 22. Fröhlich H. “Long range coherence and energy storage in biological systems.” Int J Quantum Chem 2.5 (1968): 641-9. 23. Van Breugel HH, Bar PR. “Power density and exposure time of He–Ne laser irradiation are more important than total energy dose in photobiomodulation of human fibroblasts in vitro.” Lasers Surg Med 12.5 (1992): 528-537. 24. Al-Watban F, Zang X. “Comparison of the effects of laser therapy on wound healing using different laser wavelengths.” Laser Ther 8.2 (1996): 127-135. 25. Neira R, Ortiz-Neira C. “ Low-level laser-assisted liposculpture: Clinical report of 700 cases.” Aesthet Surg J 22.5 (2002): 451-5. 26. Jackson R, Roche G, Butterwick JK, et al. “Low level laser assisted liposuction: 2004 clinical trial of its effectiveness for enhancing ease of liposuction procedures and facilitating the recovery process for patients undergoing thigh, hip and stomach contouring.” Am J Cosmet Surg 21 (2004): 191-198. 27. Neira, R., Jackson, R., Dedo, D., Ortiz, C.L. and Arroyave, J.A., 2001. Low-level laser-assisted lipoplasty appearance of fat demonstrated by MRI on abdominal tissue. The American Journal of Cosmetic Surgery, 18(3), pp.133-140. 28. Avci, P., Nyame, T.T., Gupta, G.K., Sadasivam, M. and Hamblin, M.R.,. “Low level laser therapy for fat layer reduction: A comprehensive review.” Lasers in surgery and medicine 45.6 (2013): 349-357. 29. Brown SA, Rohrich RJ, Kenkel J, Young VL, Hoopman J, Coimbra M. “Effect of low-level laser therapy on abdominal adipocytes before lipoplasty procedures.” Plast Reconstr Surg 113.6 (2004): 1796–1804. 30. Elm, C.M., Wallander, I.D., et al,. “Efficacy of a multiple diode laser system for body contouring.” Lasers in surgery and medicine 43.2 (2011): 114-121. 31. Medrado AP, Trindade E, Reis SR, Andrade ZA. “Action of lowlevel laser therapy on living fatty tissue of rats.” Lasers Med Sci 21.1 (2006): 19-23. 32. Honnor RC, Dhillon GS, Londos C. “cAMP-dependent protein kinase and lipolysis in rat adipocytes. II. Definition of steady state relationship with lipolytic and antilipolytic modulators.” J Biol Chem 260.28 (1985): 15130–15138. 33. Zhang Q, Piston DW, Goodman RH. “Regulation of corepressor function by nuclear NADH.” Science 295 (2002): 1895– 1897. 34. Mulholland, R.S., Paul, M.D. and Chalfoun, C., 2011. Noninvasive body contouring with radiofrequency, ultrasound, cryolipolysis, and low-level laser therapy. Clinics in plastic surgery, 38(3), pp.503-520. 35. Thornfeldt, C.R., Thaxton, P.M. and Hornfeldt, C.S. “ A six-week low-level laser therapy protocol is effective for reducing waist, hip, thigh, and upper abdomen circumference.” The Journal of clinical and aesthetic dermatology 9.6 (2016.): 31-35. 36. Nestor MS, Zarraga MB, Park H. “ Effect of 635 nm low-level laser therapy on upper arm circumference reduction: A double-blind, randomized, Sham-controlled Trial.” J Clin Aesthet Dermatol 5.2 (2012): 42–48. 37. Jackson, R.F., Roche, G.C. and Shanks, S.C. “A double blind, placebo controlled randomized trial evaluating the ability of low level laser therapy to improve the appearance of cellulite.” Lasers in surgery and medicine 45.3 (2013) 38. FDA, 510(k) Premarket Notification. <https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn. cfm?ID=K142042> 39. Maloney RJ, Shanks SC, Jenney E. “The reduction in cholesterol and triglyceride serum levels following low-level laser irradiation: A non-controlled, non-randomized pilot study.” Lasers Surg Med 21 (2009): 66. 40. Rushdi AT. “Effect of low-level laser therapy on cholesterol and triglyceride serum levels in ICU patients: A controlled, randomized study.” EJCTA 4 (2010): 96–99. 41. Jackson FR, Roche GC, Wisler K. “Reduction in cholesterol and triglyceride serum levels following low-level laser irradiation: A noncontrolled, nonrandomized pilot study.” Am J Cosmet Surg 27.4 (2010): 177–184.

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Discoloration Defense: Expert Q&A with Dr Alexis Granite Breaking the cycle of discolouration with the new SkinCeuticals Discoloration Defense Serum Discoloration Defense Serum is a new multi-phase serum targeting visible discolouration and is clinically proven to deliver a brighter, more even skin tone. It is formulated to address visible pigmentation which can be triggered by inflammatory processes in the skin such as melasma caused by hormonal changes and blemish-scarring. Hero ingredient tranexamic acid minimises the

reoccurrence of discolouration and stubborn brown patches, thus breaking the cycle of discolouration with continued use. In a 12week study,1 twice-daily application of Discoloration Defense Serum demonstrated a statistically significant reduction in the appearance of post-inflammatory discolouration and uneven skin tone including 41% average reduction in the appearance of stubborn brown patches.

Table 1: Results of 12-week study of twice-daily application of Discoloration Defense Serum1

We asked Dr Alexis Granite, a consultant dermatologist practising at the Cadogan Clinic and Mallucci London, to explain how Discoloration Defense Serum helps improve the appearance of skin discolouration and promote exfoliation to reduce pigmentation.

1. What is skin discolouration and why do we get it? Skin discolouration may refer to either an excess of pigment (hyperpigmentation) or a lack of pigment (hypopigmentation). Generally speaking, discolouration products are targeted towards hyperpigmentation as this form is more amenable to treatment. Hyperpigmentation is caused by the overproduction of melanin within our skin and may be caused by a variety of factors including sun exposure, ageing, hormonal changes, inflammation or trauma to the skin. 32

2. What are the treatment options? There are a multitude of therapeutic options for hyperpigmentation including at-home skincare products, prescription topicals, and inclinic treatments such as chemical peels, microneedling and laser. Typically, when it comes to treating discolouration, a combination approach is most effective. When shopping for skincare to help combat discolouration ingredients to look for include vitamin C, niacinamide and retinol. There are a multitude of topical acids that may be used to treat hyperpigmentation such as tranexemic, azelaic, kojic and glycolic.

3. So how does Discoloration Defense Serum improve pigmentation? Why does it work? Discoloration Defense Serum works to improve the look of pigmentation by incorporating three key ingredients: 1.8% tranexamic acid, 5% niacinamide (a form of vitamin B3) and 5% HEPES. Both tranexamic acid and niacinamide target key types of discolouration. HEPES is derived from sulfonic acid and aids

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in epidermal skin cell turnover, helping to minimise the appearance of pigmentation and allowing other ingredients to penetrate more effectively. Continued use of Discoloration Defense Serum helps even skin tone and reduce the appearance of stubborn forms of discoloration.

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The regimen for using Discoloration Defense Serum at home Ideally three to five drops of Discoloration Defense Serum should be applied twice daily to the face. A sample regimen for skin discolouration and overall anti-ageing might include the following: AM:

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1. Cleanse 2. Phloretin CF 3. Discoloration Defense Serum 4. Moisturiser/SPF

Discoloration Defense Serum is an optimised formula of anti-discolouration ingredients which work together to reduce the appearance of uneven skin tone and pigmentation. Its lightweight formulation makes it suitable for nearly all skin types and is easy to use.

PM: 1. Cleanse 2. Retinol on alternate nights as tolerated 3. Discoloration Defense Serum 4. Moisturiser

5. How do you use Discoloration Defense Serum in conjunction with other in-clinic treatments? Discoloration Defense Serum can be used in conjunction with other in-clinic treatments as well as prescription topical therapies such as hydroquinone. Typically, I recommend starting Discoloration Defense Serum once or twice daily two weeks prior to intense pulsed light (IPL) then continuing Discoloration Defense Serum for at least two weeks following the procedure as tolerated. I also use post-peel to sustain the benefits when all signs of irritation have disappeared and the skin has fully recovered.

Discoloration Defense Serum is an optimised formula of antidiscolouration ingredients which work together to reduce the appearance of uneven skin tone and pigmentation

6. Can it be used as a stand-alone treatment? Absolutely, especially for those with mild hyperpigmentation. Of course, the judicious use of sunscreen is also necessary in any skincare regimen when tackling discolouration. Once appearance of pigmentation has faded, it is best to continue with Discoloration Defense Serum to help continue targeting any potential discolouration.

7. Describe the ideal patient profile for treatment with Discoloration Defense Serum The ideal patient for treatment with Discoloration Defense Serum is someone with mild-moderate pigmentation of more recent onset. They may be looking for an at-home skincare product that complements a prescription topical treatment or in-clinic therapy for pigmentation.

8. How have your patients responded to Discoloration Defense Serum? My patients have been pleased with Discoloration Defense Serum. The majority have found the product easy to incorporate into their routine with its elegant, lightweight formulation. Most have reported improved skin brightness and more even skin tone. REFERENCES 1. DOF: A 12-week, single-centre, clinical study was conducted on 63 females, ages 26 to 60, Fitzpatrick I-IV, with mild to moderate facial pigmentation, including melasma, post-inflammatory hyperpigmentation and hyperpigmentation. Discoloration Defense Serum was applied to the face twice a day in conjunction with a sunscreen. Efficacy and tolerability evaluations were conducted at baseline and at weeks 2, 4, 8, and 12.

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Managing Delayed Onset Nodules

the patient’s immune response has been activated, such as hay fever or eczema. For a diagnosis of DONs, this will occur months to years after initial treatment. If, however, the patient is presenting within only a few days of filler treatment, then infection should be suspected, and treatment should follow Dr Fiona Durban discusses avoidance, recognition appropriate management guidelines, for example, such as those provided by the ACE and management of delayed onset nodules Group.1 following hyaluronic acid filler treatment and If clinical signs of inflammation are absent, then the cause is most likely due to incorrect shares a successful case study placement of product or even filler migration, As aesthetic practitioners, it is important to have the knowledge therefore a non-inflammatory nodule. In this case, mechanical and skills required to manage the complications that may occur displacement by massage or diffusion with either saline or following the treatments we deliver. With a growing number of lidocaine may be attempted.4 practitioners providing filler treatments, the development of products designed for increasing longevity and patient demand, there is a Treatment heightened risk of being faced with managing a complication either The mainstay of management for inflammatory nodules will initially immediately or sometime after a treatment is given. be antibiotics. This may be with either a macrolide or tetracycline and Delayed onset nodules (DONs) can cause the patient discomfort initially a two-week course should be given.1 There is still debate as and distress due to their unsightly appearance and require a long to whether bacterial contamination5 is a cause of development of a course of treatment with multiple reviews or follow-ups. It is therefore nodule and it may be the anti-inflammatory or immunomodulatory important to follow best practice and techniques to be able to effect of the antibiotic that plays a role in resolution.6 It has been recognise nodules should they occur, manage them in an appropriate demonstrated by plastic surgeon Mr David Funt and dermatologist and timely fashion, and ultimately avoid the development of them. Dr Tatjana Pavicic in a study in 2013 that treatment with non-steroidal anti-inflammatory medication or steroids without antibiotics may lead What are delayed onset nodules? to a worse prognosis than if antibiotics are used initially;4 therefore, The term DONs as adopted by the Aesthetic Complications Expert these treatments should be an adjunct, rather than alternative, (ACE) Group1 is defined as ‘a visible or palpable unintended mass where necessary. In the cases I have managed, I have also advised which occurs at or close to the injection site of dermal filler’. It is antihistamine medication as a further way of down-regulating any difficult to define what causes DONs as it is a non-specific term with immune response. a number of possible pathologies. They are commonly categorised If antibiotics alone are not resolving the nodule, then dual antibiotic as inflammatory or non-inflammatory in nature. Inflammatory nodules therapy4 and/or treatment with hyaluronidase should be considered.7,8 may occur months to years after treatment, whereas non-inflammatory The cases I have managed have all successfully resolved after use of nodules typically occur shortly (usually within days) after filler hyaluronidase, although repeat treatment may be necessary. Other administration and can mostly be attributed to incorrect placement treatment modalities beyond this include the use of intralesional of the product. As they appear shortly after, they are therefore not steroids or allopurinol.1 These treatments must all be performed by 1,2 ‘delayed’ in nature. experienced and competent practitioners. Incidence of visible nodules following hyaluronic acid (HA) filler injection is still relatively uncommon with an estimated incidence of Avoiding development of DONs 0.01-1%.1 The specific incidence of foreign body granuloma, which is a The key considerations can be divided into factors relating to either subtype of a DON and can only be confirmed histologically after HA the patient or the practitioner. Consultation prior to treatment is filler injection, has been reported as 0.02% to 0.4%.2,3 However it is my therefore key to determine which is most suitable. belief that DONs are underreported so it is difficult to indicate a true reflection to date. Patient considerations Providing the opportunity to address patient expectations, assess How to recognise and treat DONs competence to consent, and assess risks of treatment or of managing From my own clinical observation of an inflammatory nodule, the a complication, should it arise, is essential. If the patient is under the patient will present with a lump or swelling alongside clinical care of another medical speciality, I also believe it to be good practice features suggestive of inflammation – namely erythema, warmth to ensure they have no objections to the patient receiving treatment. and tenderness. This may follow an infection or a process where For example, if a patient has been treated for an autoimmune disease by a rheumatology team, I would either directly liaise with the team in question (with the patient’s consent) or ask the patient to provide a letter stating this. DONs are more common in patients with an active immune response, especially autoimmune diseases.6 Therefore, consideration should be given before treating patients with illnesses such as rheumatoid arthritis, systemic

DONs are more common in patients with an active immune response, especially autoimmune diseases

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Case study This 38-year-old female was fit and well with a past medical history of scalp psoriasis, which was well controlled using topical treatment. She was also allergic to penicillin. Prior to 2017, her treatment history with myself had included upper face toxin and skin peels for rejuvenation. In October 2017, after consultation, she underwent filler treatment to the tear trough area, having a good result that she was pleased with. A 25-gauge cannula was used for administration of a low-concentration HA filler, with low G prime and cohesivity.

Figure 1: Patient before treatment using hyaluronidase

Figure 2: Patient after two weeks following treatment using hyaluronidase

In November 2017 she went on to receive an 8-point lift,7 then received additional filler to the cheek area in May 2018. In August 2018, which was 10 months after the initial treatment, the patient noted a red, hard lump under her left eye. She contacted me directly after noticing the lump and an appointment was made in the same week. It should be noted that this had appeared 10 days after she had a viral upper respiratory tract infection. This may have activated her immune system – leading to recognition of the filler product as ‘foreign’. Upon examination, she generally felt well with no temperature. She presented with an erythematous, 10mm firm, mobile lump. This was not tender and no lymphadenopathy was evident. Clinical signs suggested that this was an inflammatory nodule and she was prescribed clarithromycin 500mg twice daily and also advised that she could take a regular antihistamine. She was reviewed 10 days later, when there was noted to be less erythema, although it was still visible, and there was also a palpable lump (Figure 1). Antibiotics were continued, as well as non-steroidal anti-inflammatory medication. A further week later there was no clinical change to symptoms or signs and so the decision was made to use hyaluronidase to dissolve the filler present. An intradermal skin patch test was performed to the forearm. Following this, a total of 450 units of hyaluronidase was used (a dilution of 1500 units/5ml saline). The nodule itself was targeted using a 30 gauge needle. An immediate improvement was seen with flattening and softening of the nodule (Figure 2). The patient was then reviewed two weeks later. The nodule under the left eye had settled but there was a new development of a non-visible lump palpated over the right anterior cheek of 10x15mm. It was not tender or red therefore I diagnosed this as a second nodule, non-inflammatory in nature. A watch and wait policy was implemented as the lump was not visible or causing concern to the patient. She was advised to seek review if any symptoms changed. One month later all symptoms had completely resolved with no lumps evident.

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lupus, or even severe eczema or hay fever. These patients should at least be stable on immunomodulatory medication before treatment is considered.6 With regard to past medical history, previous history of allergies or reaction to dermal fillers would be significant grounds not to perform the treatment, as would polypharmacy, which may make management of any complication more difficult. Practitioner considerations It’s generally accepted that the risk of complication is greater with practitioners who are less experienced, so there needs to be a focus on quality of training provided to those seeking it. There should be an emphasis on knowledge of anatomy and correct injection of product, including using an aseptic technique. The correct product should also be selected, which should have evidence of safety and use of the area to be treated. If the filler is placed too superficially for example, it is therefore more likely to cause future complications such as palpable nodules, as explained above. The area to be treated is also relevant. For example, injection to the lips and periorbital area is at higher risk of DON development due to thinner skin, surrounding lymphatics and constant movement.1 Therefore, in my opinion, these areas should only be treated by more advanced practitioners. It is also particularly important to see patients in a timely manner so as any unnecessary worry is avoided, and treatment can be commenced as soon as possible. Whilst there are no studies to suggest an optimum time frame it is needless to say that speedy resolutions are more desirable for the patient.

Summary Thorough consultation and consideration of all aspects of treatment, including medical history, area to be treated, product selection and injection technique should be considered. If a complication such as DONs occurs, the patient should be seen promptly and managed appropriately, also taking into account the psychological impact this may have. It is also my belief that we should not think that we work in isolation and communication with other medical professionals who may be treating the patient or an awareness of when to seek help and advice is fundamental. Dr Fiona Durban qualified from St Mary’s Hospital Medical School in 2000. She attained the MRCGP (merit) in 2005 and was then a partner in general practice for seven years, specialising in women’s health. Dr Durban decided to move into aesthetic medicine in 2013 and is currently clinical lead for Cosmetic Courses based in Buckinghamshire. Dr Durban trains in a variety of courses including Level 7. She is a full member of BCAM. REFERENCES 1. Aesthetic Complications Expert Group. Authors; M King, S Bassett, E Davies, S King. Management of Delayed Onset Nodules. Review date 2017. 2. Lemperle G, Gauthier-Hazan N, Wolters M, Eisemann-Klein M, Zimmermann U, Duffy D M. Foreign body granulomas after all injectable dermal fillers: part 1. Possible causes Plast Reconstr. Surg., 123 (6) (2009), pp. 1842-1863 3. Lee JM, Kim Y J. Foreign body granulomas after the use of dermal fillers: pathophysiology, clinical appearance, histologic features, and treatment. Arch. Plast. Surg., 42 (2) (2015), pp. 232-239 4. Funt DK, Pavicic T. Dermal fillers in aesthetics:an overview of adverse events and treatment approaches.Clin,Cosmetic and Investigational Derm 2013;6:295-316 5. Christensen L, Breiting V, Bjarnsholt T et al. Bacterial Infection as a likely cause of adverse reactions to polyacrylamide hydrogel fillers in cosmetic surgery. Clinical Infectious Diseases 2013;56: 1438-1444 6. Ledon JA, Savas JA, Yang S, Franca K, Camocho I, Nouri K. Inflammatory nodules following soft tissue filler use: A review of causative agents, pathology and treatment options. Am J Clin Dermatology 2013;14 (5):401-411 7. Chantrey J, 8 point lift: achieveing the liquid face lift, Aesthetics journal, March 2014, <https:// aestheticsjournal.com/feature/8-point-lift-achieving-the-liquid-face-lift> FURTHER READING • Cavallini M, Gazzola R, Mettala M, Valenti L. The role of hyaluronidase in the treatment of complications for hyaluronic acid fillers. Aesthetic Surgery Journal, Vol 33, Issue *, Nov 2013 p1167-1174 • Brody HJ. Use of hyaluronidase in the treatment of granulomatous hyaluronic reactions or unwanted hyaluroniic acid placement. Dermatol Surg 2005;31:893-897

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Laser tattoo removal The advent of laser brought new options for tattoo removal. In the 1970s, laser tattoo removal was typically performed with either an argon or CO2 laser. During this time, laser tattoo removal worked via a non-selective heat and destruction process that also often resulted in prominent scarring.3 It wasn’t until Anderson et al. first reported their theory on selective photothermolysis in 1983 that lasers were able to be used more safely and effectively for the removal of tattoo pigmentation.4 With an understanding of this theory, practitioners were able to safely and effectively target and destroy their desired chromophore (ink pigmentation) in the skin as a function of its affinity to absorb a distinct wavelength of light. This theory also postulated that the chromophore will be selectively damaged or destroyed if the laser fluence, in terms of energy per area (J/cm2), is sufficiently high and the laser pulse duration sufficiently short. Consequently, the initial argon and CO2 lasers have been replaced with short pulsed Q-switched lasers for laser tattoo removal treatments. Q-switched lasers are now considered the gold standard for tattoo removal.5

Laser Tattoo Removal

Q-switched lasers Q-switching (QS) of a laser – sometimes known as giant pulse formation, or quality switching – is a technique by which a laser can be made to produce intense short pulsed durations on the order of nanosecond (ns) and picosecond (ps) with extremely high peak powers (MW – megawatt).5-9 The three short pulsed QS lasers widely available today for tattoo removal include:8,10 • Q-switched ruby laser (QSRL) – emits a wavelength 694 nm • Q-switched alexandrite laser (QSAL) – has a near infrared wavelength of 755 nm • Q-switched neodymium-doped yttrium aluminium garnet (QS Nd:YAG) laser – emits infrared light of 1064 nm

Dr Peter Hughes explores the technologies available for laser tattoo removal Advances in laser tattoo removal technology over the past 60 years have resulted in devices that provide more effective tattoo removal than were achievable in the past, while reducing complications. This article will discuss such developments with an emphasis on laser specifications and their importance with regards to patient safety and treatment efficacy. The content will be of interest to existing laser practitioners, and aim to serve as a useful guide for those new to laser tattoo removal who may be considering introducing such a treatment into their clinic.

The QS Nd:YAG wavelength can be changed by passing it through a potassium titanyl phosphate (KTP) crystal. Due to the optical Throughout the years, many methods for tattoo removal have properties of this crystal it is possible to halve the fundamental been explored. These include dermabrasion, shaving, excision and wavelength to yield 532 nm light (frequency is doubled) via a process direct suture, or excision with graft, salabrasion, cryosurgery and known as second harmonic generation. A typical Nd:YAG laser with trichloroacetic acid.1,2 All of these methods can cause non-selective a KTP crystal can provide both 1064 nm and 532 nm light.10 The destruction of the tattoo and surrounding skin, often resulting in laser of choice often depends on the colour of the target pigment or unwanted scarring.1,2 tattoo ink. Table 1 depicts the relationship between pigment colour, corresponding treatment wavelength and Colour QS Nd:YAG QSRL QSAL QS Nd:YAG the corresponding QS laser.5,7,8 In addition to 532 nm 694 nm 755 nm 1064 nm selecting the appropriate laser wavelength, a Black X X Ideal Ideal laser must be able to deliver a laser pulse that India Ink X X Ideal X is fast, whilst also having a large peak power output (maximum power during a pulse) and Brown X X X Used* a uniform beam profile for the safest and Blue X X Ideal Ideal most effective treatment.12 Numerous studies Green X Used* Ideal Used* have demonstrated treatment efficacy using Orange Used X X X QS lasers for tattoo removal,6-10 although Yellow Used** X X X it should be noted that complications and Red Ideal X X X side effects have also been reported. These include oedema, erythema, purpura, pinpoint Purple X Used* X X bleeding, transient hyperpigmentation, Table 1: Ideal QS laser for various tattoo pigments.5,7,8 *With variable results. **Effective and consistent persistent hypopigmentation, blister formation reduction of yellow tattoo ink using a frequency doubled Nd:YAG 532 nm laser with a picosecond and scarring.5,7,9,13 pulse duration has been reported.11

History of tattoo removal

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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version 1.0 – July 2019

1. Sito G, et al. Aesthet Surg J. 2019. doi: 10.1093/asj/sjz026. 2. Micheels P et al. J Drugs Dermatol 2017;16(2):154–61.


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Laser pulse duration When performing laser treatments, ideally the pulse duration of the laser should be faster than, or equal to, the target chromophore thermal relaxation time (TRT),6 as defined as the time that it takes for the central temperature in a structure to decrease by 50%.14 If this is achieved, and the pulse duration is less than the TRT of a particle, the heat will be confined within its structure and heat diffusion to the surrounding tissue avoided. Short pulse, high energy laser output is therefore effective for tattoo removal for it confines its energy to the target chromophore with little to no diffusion to surrounding tissue.9 Consequently, collateral damage and trauma to surrounding tissue is avoided. The estimated TRT of tattoo ink particles is 0.1-10ns,15 although some newer estimates are in the range of 10-100ps.6 Therefore, for effective tattoo removal it has been suggested that the laser pulse duration should be less than 10ns.5,7,15 The actual pulse duration of a laser will depend on the type of QS laser and the hardware and electronics used by the manufacturer. The laser pulse duration is typically a set parameter as specified by the manufacturer. Traditionally, pulse durations for QS lasers were of the order of nanosecond pulse widths; however, more recently, picosecond lasers are becoming more readily available.7,9,16 Picosecond lasers are considerably faster than the TRT for an ink chromophore, and as a result are considered safer due to their reduced likelihood of skin trauma.7,9,13,16 They are also considered to be more efficient, for some ink colours,7,9,13,16 due to their enhanced ability to disrupt the tattoo ink granules relative to a nanosecond laser. Consequently, treatment with a picosecond laser may require fewer laser sessions overall for tattoo removal.7,9,13,16 Laser pulse duration has an inverse relationship with the laser pulse peak power and can be calculated according to this equation:22 Peak Power (Watts) = Energy per pulse (joules) / Pulse duration (seconds)

According to this equation, as the laser pulse duration decreases, while maintaining the same pulse energy, the peak power for the laser pulse must increase. This means that a picosecond laser will require less laser pulse energy to achieve the same peak power as a nanosecond laser. Or conversely, a picosecond laser, with a similar available energy output range as a nanosecond laser, will have considerably greater laser peak power available. This relationship can be illustrated by calculating the peak power for three typical laser pulses, each with a different pulse duration (viz. 10ns, 750ps and 450ps) but with the same pulse energy (350mJ). The resultant peak power calculated for each of the different laser pulse durations is presented in Table 2. The calculated results depicted in Table 2 clearly illustrate the impact pulse duration has with regards to the laser peak power. In my example, reducing the laser pulse duration from 10ns to 450ps, while maintaining the same pulse energy, increased the laser peak power by more than 20 times. This relationship is something a practitioner must take into consideration in the event of changing from a nanosecond laser to a picosecond laser and transitioning treatment protocols to the new laser.

Laser fluence Laser fluence is a measure of the laser pulse energy per unit of area (joules/cm2) and is typically what most practitioners would adjust during a treatment plan. In practice, the typical laser fluence operating range will be somewhere between 2-9J/cm2 and will depend on many factors, including: the type of laser, pulse duration, selected wavelength, type of tattoo, and the patientâ&#x20AC;&#x2122;s response to the patch test (to name a few).9,17,18 The laser fluence can be increased by manually

In addition to selecting the appropriate laser wavelength, a laser must be able to deliver a laser pulse that is fast, whilst also having a large peak power output and a uniform beam profile for the safest and most effective treatment

adjusting the laserâ&#x20AC;&#x2122;s power (within the laser software) or by reducing the laser beam diameter to a smaller spot size. Increasing the laser fluence by reducing the beam diameter will increase the treatment time, but more importantly, it will reduce the effective laser fluence due to scattering of the beam.8

Scattering As a laser beam propagates into the skin, light scattering occurs due to interactions with the skin. This scattering spreads the beam radially outward on each side, thereby reducing the beamâ&#x20AC;&#x2122;s effective fluence as it penetrates into the skin. As a result, energy is lost from the beam before it reaches the chromophore.8,19 Scattering losses are more significant for smaller beams where the spreading/scattering of the beam is relatively large compared to the original incoming beam spot size. Conversely, the impact of scattering from a large beam, compared to a smaller spot size of same initial laser fluence will have a lesser impact and thus have a greater effective fluence. A larger beam size will therefore propagate deeper into the skin and provide more energy to the site of the chromophore for more effective tattoo removal.8 Cencic et al. reported the impact of scattering as a measure of effective laser fluence for an Nd:YAG laser 1064 nm for two beams with the same initial fluence, Pulse Duration (time) Peak Power (Watts) but with different beam 10 ns 35 MW diameters.8 They found 750 ps 470 MW that an 8mm beam diameter will have 450 ps 780 MW approximately double Pulse Energy 350mJ the effective laser fluence compared to a Table 2: Increasing peak power as a function beam of 2mm with the of decreasing pulse duration for a laser pulse same initial fluence. of 350mJ.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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TOP HAT PROFILE

GAUSSIAN PROFILE Beam Axis

Peak Power

Peak Power

Beam Axis

0

0

Distance (x)

Distance (x)

Figure 1: Energy distribution for a ‘top hat’ beam profile and a Gaussian beam profile. 12

The extent of scattering is dependent on the laser wavelength and has been found to decrease with increasing wavelength.8,20 For example, an Nd:YAG (1064 nm) has a relatively small scattering coefficient compared to alexandrite (755 nm), ruby (694 nm) or Nd:YAG (532 nm) laser wavelengths. The use of skin optical clearing agents injected into the skin have been reported to improve laser tattoo removal by reducing the extent of scattering.19,21 The use of such agents reduce scattering by temporarily increasing the skin’s transparency via two main mechanisms – tissue dehydration and refractive index (RI) matching between tissue components.22

A larger beam size will propagate deeper into the skin and provide more energy to the site of the chromophore for more effective tattoo removal Beam profile Another important specification of the laser is the beam energy profile itself. The beam profile is a cross sectional depiction of the beam’s intensity (peak power) as a function of the beam’s diameter. The cross section is taken from the plane perpendicular to the beam’s axis. Beam profiles are typically described as being either a ‘top hat’ or a ‘Gaussian’ shaped profile.12 Figure 1 illustrates how the beam peak power changes for both beam profiles as a function of the radial distance from the beam axis.12 As depicted in Figure 1, a ‘top hat’ beam profile provides a homogenous peak power throughout the entire beam cross section. This is in contrast to a Gaussian beam profile, whereby the peak power smoothly decays from its maximum on the beam axis to zero.12 Homogeneity of the laser beam profile, such as with a ‘top hat’ profile, is of great importance with regards to treatment safety and efficacy.12 Lasers with a Gaussian beam profile on the other hand have a power ‘hot spot’ that can increase the risk of overexposure to parts of the treated area, potentially resulting in skin trauma. The average radiant exposure for a Gaussian beam profile at the ‘hot spot’ can be several times higher when compared to the average fluence for the same beam.20 Therefore, it is important for a practitioner to take this into consideration when performing a treatment with a Gaussian beam profiled laser.

Conclusion

For effective laser tattoo removal, it is important for the practitioner to have a good understanding of the performance characteristics and specifications of their own laser. They should consider the pulse duration, laser fluence, beam diameter (spot size) and beam profile, and be aware of how such characteristics can have an impact on treatment efficacy and safety. Dr Peter Hughes is the scientific director and co-owner of Quayside Medical Aesthetics. He has a PhD from the University of Sydney, earning him his Dr title, whereby his research interests involved laser spectroscopy and instrumental design and development. Dr Hughes is also the laser protection supervisor and senior laser practitioner at Quayside Medical Aesthetics. REFERENCES 1. Mirko Campisi, “Complications of tattoos and tattoos removal: state-of-the-art in Italy”, Journal of Health and Social Sciences, 1 (2016); 105-112 (p.107) 2. TA Piggot, RW Norris, “ The treatment of tattoos with trichloroacetic acid: experience with 670 patients”, British Journal of Plastic Surgery, 41 (1988), 112-117 (p.112) 3. Apfelberg DB, Maser MR, Lash H. “Aron laser treatment of decorative tattoos” British Journal of Plastic Surgery, 32 (1979); 141-144 (p. 141) 4. Richard Rox Anderson, John A Parrish, “Selective Photothermolysis: Precise Microsurgery by Selective Absorption of Pulsed Radiation” , Science, 220 (1983) 524-527 5. Eric F. Berntein et al. “A Novel Dual-Wavelength, Nd:YAG, Picosecond-Domain Laser Safely and Effectively Removes Multicolor Tattoos”, 47 (2015) 542-548 (p.542) 6. Shymanta Barua, “Laser Interaction in Tattoo Removal by Q-Switched Lasers”, Journal of Cutaneous and Aesthetic Surgery, 8,1 (2015): 5-8, (p.6) 7. Victor Ross, George Naseef, Charles Lin, et al. Comparison of Responses of Tattoos to Picosecond and Nanosecond Q-Switched Neodymium:YAG Lasers. Arch Dermatol. 1998;134(2):167–171 (p.167) 8. Boris Cencic, et al. “High Fluence, High Beam Quality Q-Switched Nd:YAG Laser with optoflex Delivery System for Treating Benign Pigmented Lesions and Tattoos”, 1 (2010) 9-18 9. Richard Torbeck, Richard Bankowski, Sarah Henize, Nazanin Saedi, “Lasers in tattoo and pigmentation control: role of Picosure laser system” 9 (2016) 63- 67 10. Carla Gregorio, Simao Cohen, Valter Alves, “ Laser assisted tattoo removal: a literature review” Surgical Cosmetic Dermatology, 5 (2013) 289-296 11. Alabdulrazzaq H, Brauer JA, Bae YS, Geronemus RG, “Clearance of yellow tattoo ink with a novel 532-nm picosecond laser” Lasers Surg Med., 47, 4, (2015) 285-288 12. Syrus Karsai, Gudrum Pfirrmann, Stefan Hammes, Christian Raulin, “ Treatment of Resistant Tattoos Using a New Generation Q-Switched Nd:YAG Laser: Influence of Beam Profile and Spot Size on Clearance Success” 40 (2008) 139-145 13. Freedman JR, Kauf,man J, Metelitsa AI, “Picosecond lasers: the next generation of short-pulsed lasers” Seminars in Cutaneous Medicine and Surgery, 33, (2014) 164-168 14. Yadav, Rabindra Kumar. “Definitions in laser technology.” Journal of cutaneous and aesthetic surgery vol. 2,1 (2009): 15. Ho DD, London R, Zimmerman GB, Young DA, “Laser tattoo removal a study of the mechanism and the optimal treatment strategy via computer simulations” Lasers Surgery Medicine, 30 (2002) 389- 397 16. Mi Soo Choi et al. “Effects of Picosecond laser on the multi-colored tattoo removal using Hartley guinea pig: A preliminary study” PLOS One, (2018) 1-12 17. Uros G Ahcan et al. “Q-switched laser tattoo removal” Zdrav Vestn, (2013) 552-563 18. Syrus Karsai, Gudrum Pfirrmann, Stefan Hammes, Christian Raulin, “Treatment of Resistant Tattoos Using a New Generation Q-Switched Nd:YAG Laser: Influence of Beam Profile and Spot Size on Clearance Success” 40 (2008) 139-145 19. Caihua Liu, Rui Shi, Min Chen, Dan Zhu, “Quantitative evaluation of enhanced laser tattoo removal by skin optical clearing” Journal of Innovative Optical Health Sciences, 8 (2015) 1-8. 20. Ladislav Grad, Tom Sult, Robin Sult, “Scientific Evaluation of VSP Nd:YAG Lasers for Hair Removal” Journal of the Laser and Health Academy, Vol 2007, 1-4 <www.laserandhealth.com> 21. Xinyi Liu, Bin Chen, “In Vivo Experimental Study on the Enhancement of Optical Clearing Effect by Laser Irradiation in Conjunction with a Chemical Penetration Enhancer” Applied Science, 9, 542 (2019) 1-9. 22. Luis Oliveira et al. “Optical clearing mechanisms characterization in muscle” Journal of Innovative Optical Health Sciences, 9 (2016) 1650035 (19 pages) <www.worldscientific.com>

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Understanding Growth Factors In the first of a two-part article, Dr Anna Hemming discusses the science behind growth factors The science and research behind medical aesthetic treatments continues to develop with new products, therapies and procedures emerging and the boundaries are being pushed continuously. In the late 1990s, during the research dissertation for my anatomy degree, I studied the effect of growth factors, specifically insulin-like growth factors (IGFs) and tumour necrosis factor (TNF), and their potential to kill breast cancer cells. Little did I realise that my laboratory research would feature in my aesthetic medicine career. Several years ago, I attended a session at the CCR conference where Singapore surgeon Mr Ivor Lim reignited my interest in the world of growth factors and the body’s ability to regenerate and heal from within. By understanding and using our natural ability to mend, we can learn and reproduce some key elements to help speed up healing and increase stimulation to benefit our aesthetic procedures and use them as stand-alone treatments. In this article, I want to immerse you in the world of molecular biology. You will gain a greater understanding of what growth factors are, the different types and gain an understanding of where they come from.

The science A growth factor is a signalling molecule; a natural substance with the capability to control cell activities in an autocrine, paracrine and endocrine manner.1 Growth factors can be a protein or hormone and are important for regulating a variety of cellular processes by acting as signalling molecules inside and between cells. They exert their biological functions by binding to specific receptors and activating signalling pathways which, in turn, regulate gene transcription in the nucleus and ultimately stimulate a biological response, shown in Figure 1.2 The term ‘growth factor’ can be interchangeable with ‘cytokine’.3 It was initially thought that the two molecules had different affects; growth factors focused on cell growth and proliferation while cytokines linked to immunological or hematopoietic response. However, it has been found that they both have similar functions and therefore the terms are now used interchangeably. Similar to hormones, they bind to specific receptors on the surface of their target cell.3 A growth factor can have various functions on different cell types and affect a wide variety of physiological processes to stimulate cell growth, cell proliferation, wound healing, cellular differentiation, apoptosis, immunological or haematopoietic responses, angiogenesis or metabolism.1 The activity can be productive as well as destructive and the abnormal production or regulation of growth factors can cause a variety of diseases including cancer,4 liver fibrosis5 and bronchopulmonary dysplasia.6 These properties were the instigation of my initial research in the potential use of growth factors to target and kill breast cancer cells in 1998.3

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There are family (simple groups) and super family (a group with lots of members, like IGF) classifications of growth factors based on structural and functional characteristics.7 The family groups often regulate specific responses and can help target their use within aesthetic medicine.

The history In 1867, stem cells became of interest to scientists when research evidenced their ability to migrate to a site of injury8 and participate in tissue regeneration.9 The first growth factor, the nerve growth factor, was discovered by neurobiologist Rita Levi-Montalcini and sociologist Stanley Cohen in 1952.10 They succeeded in isolating the nerve growth factor, after transferring pieces of cancer tumours from mice into chicken embryos and observing the rapid growth of nerves around the tumour, proving the tumour was secreting a substance causing nerve growth. They won the Nobel prize in 1986 for the discovery of growth factors, before Cohen then went on to discover epidermal growth factor (EGF), discussed more below.10 There was a breakthrough in 1962 whereby biologist John Gurdon discovered that the specialisation of cells is reversible and researcher Shinya Yamanaka reprogrammed a mature cell in mice to become immature in 2006.11-13 Gurdon and Yamanaka14 won the Nobel Prize for this in 2012. Considering that stem cells were only isolated from embryonic mice in 1981, the research has shown huge potential for future therapeutic treatments. There is now an extensive list of growth factors isolated with the ability to stimulate different signals on cells and control many cellular activities. Many will be familiar with some of the larger families of growth factors, which include transforming growth factor (TGF), epidermal growth factor (EGF), fibroblast growth factor (FGF), and insulin-like

Growth factors signal by different mechanisms:3 1. Paracrine signalling between neighbouring cells to elicit a quick response for a brief duration due to degradation of the paracrine ligands 2. Autocrine signalling within the cell through synthesis leading to a biological response within the same cell. Typically, within the cell cytoplasm or by secreting a growth factor which interacts with receptors on the surface of the same cell 3. Endocrine signalling through the secretion of growth factors into the blood which are transported to the target cells where the response is triggered

Activation of gene expression Signalling molecules

Signal transduction

Producer cell Receptor binding

Biological response Target cell Figure 1: The communication between neighbour cells using signalling molecules2

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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This article is the first of two on growth factors by Dr Anna Hemming. Her next article will detail the use of growth factors within regenerative and aesthetic medicine.

1/10,000

BONE MARROW CELLS

• • •

Lots of stem cells Rapid healing Youthful skin • • •

1/100,000

Less stem cells Slow healing Ageing, damaged skin

1/250,000

1/400,000

Dr Anna Hemming has more than 11 years’ experience in medical aesthetics. She is the owner and medical director of Thames Skin Clinic in Twickenham and associate doctor at Cranley Clinic on Harley Street. Dr Hemming is a GP who has worked at Buckingham Palace and spent five years as an army doctor. She speaks at aesthetic conferences worldwide about growth factors.

1/2, 000,000

Newborn

Teenager

Age 30

Age 50

Age 80

Figure 2: The number of stem cells during an adult life21

growth factor (IGF).7 Different growth factors promote different activities. For example, EGF enhances osteogenic differentiation,15 while fibroblast growth factors and vascular endothelial growth factors stimulate blood vessel differentiation (angiogenesis).

Understanding cells Growth factors are created by and act on stem cells as well as other cells in the body. In order to understand growth factors, we need to understand how cells are regenerated, their origin and how they can be stimulated for their specific use within aesthetic medicine.16 Stem cells are the cell factories of the body, providing the new cells the body needs after they die or are damaged. Stem cells have a remarkable potential to develop into many different cell types and are fundamental in the body’s regeneration and repair process.16 There are two broad types of stem cell; the embryonic stem cell (present in the early blastocyst in the developing foetus – these are ethically and physically difficult to isolate and seldom used) and the specialised cells in the foetus (ectoderm, endoderm and mesoderm).17,18 All stem cells after this phase of foetal development are adult stem cells, including those found in the umbilical cord lining cells. The adult stem cell is an undifferentiated cell, found in most differentiated tissues and organs. The three most accessible sources of autologous adult stem cells in humans are bone marrow, adipose tissue and blood. Adult stem cells can also be taken from the umbilical cord immediately after birth and stored for future use.18

Acting as a repair system for the body, the adult stem cell divides and differentiates without limit to replenish other cells as long as the person or animal is alive, maintaining the normal turn-over of regenerative organs such as blood, skin and intestinal tissue. The number of stems cells we have in our body decreases with time, slowing our ability to heal and maintain our body’s demands for repair, contributing to ageing. By the time we are 50 years old we have 1/400000 of the stem cells present at birth (Figure 2).21 The direct use of human growth factors in medical treatments is forbidden under EU law,20 however growth factors can now be engineered by inserting the human genetic code into a non-human host cell (single cell bacteria).19 The host cell produces the particular growth factor which can be harvested. Creating recombinant growth factors of a human nature, but not from a human origin, allows treatment products to be created with known concentrations of selected growth factors (and their use is allowed under EU law).20

Conclusion The depth of history and award-winning research behind the humble growth factor indicates how important these small molecules are. Aesthetic medicine is becoming more focused on regenerative medicine where the use of stem cell science aids the repair process of our skin and decreases the down time following aggressive treatments. By understanding how growth factors work enables us to use specific targeted actions of individual selected growth factors within medical treatments.

REFERENCES 1. Alberts B, Johnson A, Lewis J et al., Molecular Biology of the Cell, Garland Science, 2002 <https://www.ncbi.nlm.nih.gov/ books/NBK26813/> 2. Nicola N, Guidebook to cytokines and their receptors, Oxford ; New York: Oxford University Press; 1994. 3. Yorio T, Clark AF, Wax MB, Ocular Therapeutics: Eye on New Discoveries, Academic Press,(15 October 2007). 4. Sporn MB, Roberts AB, Peptide growth factors and inflammation, tissue repair, and cancer, The Journal of clinical investigation 1986 5. Milani S, Herbst H, Schuppan D, Stein H, Surrenti C, Transforming growth factors beta 1 and beta 2 are differentially expressed in fibrotic liver disease, The American journal of pathology, 1991 6. Thebaud B, Abman SH, Bronchopulmonary dysplasia: where have all the vessels gone? Roles of angiogenic growth factors in chronic lung disease, American journal of respiratory and critical care medicine 2007 7. Bafinco A, Aaronson S, Classification of growth factors and their receptors, Cancer Medicine, 1993 <https://www.ncbi.nlm.nih.gov/ books/NBK12423/> 8. Cohnheim J, Cohnheim’s Vorlesungen über allgemeine Pathologie, vol. 2, Lectures on general pathology, 1880 9. Afanasyev BV, Elstner E, Zander AR, Friedenstein AJ, Founder of the mesenchymal stem cell concept, Cell Therapy Transplantation, June 2009 10. NobelPrize.org, Stanley Cohen – Facts, Nobel Media AB 2019, Aug 2019 <https://www.nobelprize.org/prizes/medicine/1986/ cohen/facts/> 11. Goujon E, Recherches expérimentales sur les propriétés physiologiques de la moelle des os, J Anat Physiol, 1869 12. Gurdon J.B, The developmental capacity of nuclei taken from intestinal epithelium cells of feeding tadpoles, Journal of Embryology and Experimental Morphology, 1962 13. Gurdon JB, The egg and the nucleus: a battle for supremacy. Development, 2013 14. Takahashi, K., Yamanaka, S, Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors, Cell, 2006 15. Del Angel-Mosqueda C, Gutiérrez-Puente Y, López-Lozano AP, Romero-Zavaleta RE, Mendiola-Jiménez A, Medina-De la Garza CE, Márquez-M M, De la Garza-Ramos MA, “Epidermal growth factor enhances osteogenic differentiation of dental pulp stem cells in vitro”, Head & Face Medicine, September 2015 16. Mao A S, and Mooney, D. J, Regenerative medicine: Current therapies and future directions. Proc. Natl. Acad. Sci. U. S. A, 2015 17. National Institute of Health, Stem Cell Basis, 2016, <https://web. archive.org/web/20160831113614/http:/stemcells.nih.gov/info/ basics/pages/basics3.aspx> 18. Mahla RS, “Stem cells application in regenerative medicine and disease threpeutics”, International Journal of Cell Biology. 2016  19. Schuldiner M, Yanuka O, Itskovitz-Eldor J et al., Effects of eight growth factors on the differentiation of cells derived from human embryonic stem cells, PNAS, October 10, 2000  20. Hilling C, Human growth factors as natural healers: current literature application, April 2013 <https://www. cosmeticsandtoiletries.com/formulating/function/active/ premium-Human-Growth-Factors-as-Natural-Healers-CurrentLiterature-and-Application-204553091.html#targetText=The%20 FDA%20allows%20the%20use,cosmetics%20in%20the%20 European%20Union.> 21. Brusahan SK, McGuire TR et al., Human blood and marrow side population stem cell and Stro-1 positive bone marrow stromal cell numbers decline with age, with an increase in quality of surviving stem cells: correlation with cytokines, November 2010 <https://www.ncbi.nlm.nih.gov/pubmed/21035480>

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Case Study: Treating a Burn Dr Ifeoma Ejikeme shares a case study of a burn that was treated using oxygen and low-level light therapy As reputable aesthetic practitioners, we are often sought out by patients who have had treatments elsewhere and present with aesthetic complications that require immediate attention. Delays in starting treatment can lead to a poor aesthetic result and permanent damage. In order to reduce the likelihood of this we must diagnose early and start appropriate treatments to improve healing. In this article, I share a case study whereby I reviewed a patient with a burn and used oxygen and low-level light therapy to improve wound healing and reduce scar formation. Prompt treatment and sound clinical judgement prevented complications such as delayed wound healing, post-inflammatory hyperpigmentation, infection and scarring.

Case study Background A 20-year-old female noticed a pimple on the middle of her forehead. She had normal to oily skin with no history of acne and had no other skin concerns; it was a relatively rare occurrence for her to have pimples. She went to a routine eyebrow threading appointment the same day as noticing the pimple and was advised by the beautician to apply garlic to the pimple and then put a plaster over the top, as this was a measure the beautician used to remove her own pimples. That evening the patient applied

a halved garlic clove, held it in place with a plaster and went to sleep. When she awoke, she was alarmed to feel pain on her forehead and observed a lesion (Figure 1). She initially went to see her GP who advised her to go to A&E for a review. In A&E, the area was cleaned and fusidic acid ointment was prescribed to be applied daily. The patient was advised that the lesion would heal, but that it was possible that she may get a scar, which they said should fade with time. However, distraught by the thought of being left with a large scar in the middle of the forehead, the patient contacted me the following day to see what else could be done.

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performed and she was otherwise fit and well with no comorbidities. The area was assessed and cleaned with 0.9% normal saline. I concluded that she had a 4cm partial thickness second-degree burn with a central blister on the forehead. I informed her that the burn may be chemical due to the garlic placed on the forehead overnight. Garlic has been used for thousands of years for its antibacterial and antiviral properties, however it has been described that topical placement of fresh garlic on the skin for long periods of time can lead to chemical burns and type IV hypersensitivity reactions.9 The effects of the garlic may have been exacerbated by the placement of the plaster sealing it in place. Treatment options The options of treatment were discussed with the patient. These included: 1. Do nothing and wait and see, as a proportion of second-degree burns can heal with mild irregularities or minimal pigmentary changes.1,2,3 2. Watch and wait and start 4% hydroquinone as hyperpigmentation develops.2 The negative of this would be that we would have to wait for the hyperpigment to develop. Our primary aim is to prevent this from happening. She already has evidence of what the watch and wait method does on other areas of her body. 3. Start low-level light treatment using a combination of red, blue and near infrared4,5,6 with the aim of improving wound healing, reducing the risk of hyperpigmentation and reducing the risk of infection.4-7 4. Start 70% oxygen therapy with the goal of increasing oxygenation to improve wound healing.8

Consultation Treatment plan The patient has Fitzpatrick skin type IV and After discussing the pros and cons of the explained to me that previous minor injuries above treatment options, together we had healed with hyperpigmentation and, decided on a plan to best reduce the risk because of these experiences, she was of a scar. All treatments were recommend concerned that she Before would be left with a pigmented scar on the forehead. The fact that she suffered from hyperpigmentation was a concern to me and I needed to consider our treatment options carefully. A full history and Figure 1: Patient presenting with burn on forehead examination was

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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After

surprising given her Fitzpatrick skin type2,3 and past history of hyperpigmentation from minor injuries. She was delighted with the result and had no further issues.

Conclusion

Figure 2: Three weeks after treatment plan

based on the observations of the burn at that given time. The patient understood that even with a treatment plan she may still have a scar. We decided to perform a combination of oxygen treatments and low-level light therapy with red, blue and near infrared twice a week for three weeks. Each treatment consisted of 20 minutes of oxygen therapy followed by 20 minutes of lowlevel light treatment. At home, the patient cleaned her face with a gentle non-foaming cleanser taking care not to agitate the burn. Fusidic acid was continued for the first 48 hours to reduce the risk of infection. Whilst burns are often initially sterile, the presence of blisters greatly increase the risk of infection.1 The forehead was kept out of direct sunlight and covered with Mederma scar gel after the first 48 hours for the duration of the treatment plan. The active ingredients in this specific topical include onion extract and allantoin. Onion extract has been shown to have powerful antioxidant and anti-inflammatory properties and is used for superficial and partial thickness burns.10 Allantoin has been shown to be helpful in wound healing and scar modulation.10 Then, 24 hours after the first session, the forehead was reviewed with the aim to debride the blister if it had not resolved, however it had resolved overnight. Treatments were continued and the patient showed steady improvement over the next three weeks. Result At the three-week follow-up, the burn had completely resolved without any textural or pigmentary changes. This was particularly

The degree of the burn was not medically skin threatening, however could have left a lasting aesthetic defect on the patient’s forehead. It was important that I presented a variety of treatment options to the patient, whilst also advising her using my experience in dealing with complications. A protocol of low-level light and oxygen therapy can be started immediately after chemical and pressure burns to improve the aesthetic outcomes, as showcased in this case study. In cases such as these, where the condition wasn’t considered an emergency, it’s also important to offer different treatment options to ensure that the patient feels well-informed of the choices available to them and isn’t pressured into one particular treatment. Dr Ifeoma Ejikeme is an NHS medical consultant. She trained at Bristol University, and holds a postdoctoral fellowship in head and neck surgery from Columbia University. She is board certified in internal medicine and has a master’s degree with distinction in aesthetic medicine. She is currently a senior lecturer in aesthetic medicine at Queen Mary’s university and the medical director of Adonia Medical Clinic. REFERENCES 1. Gupta S.M Chittoria R. K., Subbarao E., et al ‘Low level laser as an adjunct therapy for second degree superficial burns’ Plat Aesthet Res 2018 (5) 41 2. Sorg H., Tilkorn D., Hager S. et al ‘Skin wound healing: An update on the current knowledge and concepts’ Eur Surg Res 2017 (58)81-94 3. Davis E., Callendar V.D. ‘Post inflammatory hyperpigmentation, a review of the epidemiology, clinical features and treatment options in skin of colour’ J Clin Aesthet Dermatol 2010 (3):7:20-31 4. Adamskaya N., Dungel P., Mittermayr R., ‘Light therapy by blue LED improves would healing in an excision model in rate’ Injury 2011(42):9:917-921 5. Terrell S., Aires D., Scheiger E.S. ‘Treatment of acne vulgarus using blue light photodynamic therapy in an African-American Patient’ Journal of Drugs in Dermatology209(8):7: 669-671 6. MacCormack MA. ‘Photodynamic therapy in dermatology: An update on applications and outcomes.’ Semin Cutan Med Surg. 2008(27):1:52-62 7. Avci P., Gupta A., Sadasivam M., ‘Low-Level Laser (light) therapy (LLT) in skin: stimulating, healing, restoring’ Semin Cutan Med Surg 2013 32 (1): 41-52 8. Sen C.H.’Wound healing essentials: let there be oxygen’ Wound Rep Reg 2009 (17) 1-18 9. Sharp O., Waseem S., Wong K.Y. ‘A garlic burn’ BMJ 2018:1-2 10. Sidgwick G.P., McGeorge D. Bayat A., ‘A comprehensive evidence-based review on the role of topicals and dressings in the management of skin scarring’ Arch Dermatol Res 2015 (307): 461-477

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Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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A summary of the latest clinical studies Title: Minimizing Tissue Damage due to Filler Injection with Systemic Hyperbaric Oxygen Therapy Authors: Hong WT, Kim J, Kim SW Published: Archives of Craniofacial Surgery, August 2019 Keywords: Hyaluronic acid, filler complication, necrosis, dermal filler, oxygen therapy Abstract: Recently, there is a growing interest of hyperbaric oxygen therapy in many fields of medicine. We had a 43-year-old female patient presented with severe necrosis of the nose, philtrum, and upper lip due to retrograde arterial occlusion after nasolabial fold hyaluronic acid filler injection. Our patient went through 43 sessions of systemic hyperbaric oxygen therapy from December 2, 2017 to January 18, 2018. We administered 2.8 atmosphere absolute (ATA) for 135 minutes in the first session and the remaining sessions consisted of 2.0 ATA for 110 minutes. In reporting this case, we wish to provide a warning regarding the latent risk of filler injections and share our experience about minimizing soft tissue damage in the early stages with systemic hyperbaric oxygen therapy. Title: Fractional Ablative Laser Therapy is an Effective Treatment for Hypertrophic Burn Scars: A Prospective Study of Objective and Subjective Outcomes Authors: Miletta Net al. Published: Dermatologic Surgery, August 2019 Keywords: Scars, burns, ablative laser Abstract: Objective: the aim of this study is to determine objective and subjective changes in mature hypertrophic burn scars treated with a fractional ablative carbon dioxide (CO2) laser. Background: fractional CO2 laser treatment has been reported to improve burn scars, with increasing clinical use despite a paucity of controlled, prospective clinical studies using objective measures of improvement. Methods: a multicenter, site-controlled, prospective open-label study was conducted from 2013 to 2016. Objective and patient-reported outcome measures were documented at baseline, at each monthly laser treatment, and 6 months after treatment. Objective measurements employed were: mechanical skin torque to measure viscoelastic properties; ultrasonic imaging to measure scar thickness; and reflectometry to measure erythema and pigmentation. Subjective measures included health-related quality of life, patient and investigator scar assessment scales, and blinded scoring of before and after photographs. Subjects aged 11 years or older with hypertrophic burn scars were recruited. Each subject received 3 monthly treatment sessions with an ablative fractionated CO2 laser. Results: twenty-nine subjects were enrolled, of whom 26 received at least 1 fractional CO2 laser treatment and 22 received 3 treatments. Mean age of those completing all 3 treatments was 28 years. Statistically significant objective improvements in elastic stretch (P < 0.01), elastic recovery (P < 0.01), extensibility (P < 0.01), and thickness (P < 0.01) were noted. Patient- and physician-reported scar appearance and pain/pruritus were significantly improved (P < 0.01). There was no regression of improvement for at least 6 months after treatment. Conclusions: fractional ablative laser treatment provides significant, sustained improvement of elasticity, thickness, appearance, and symptoms of mature hypertrophic burn scars.

Title: A Study Protocol of Vaginal Laser Therapy in Gynecological Cancer Survivors Authors: Athanasiou S et al. Published: Climacteric, September 2019 Keywords: Laser, vaginal rejuvenation, sexual dysfunction Abstract: Objectives: sexual dysfunction and radiation cystitis are common adverse events following radiotherapy for gynecological cancer (GC). This study aims to assess the efficacy of intravaginal CO2 laser on GC survivors with dyspareunia following pelvic radiation and/or brachytherapy. Methods: this is the study protocol of a randomized double-blind placebocontrolled trial. All participants will receive five therapies (active or placebo) at monthly intervals. Differences between groups will be assessed at baseline and 1, 3, 6, 9, and 12 mohs following the five laser therapies. Results: as this is a study protocol, the study is ongoing with an expected end of recruitment and analysis date of 2021. Conclusion: pelvic radiotherapy for GC increases the 5-year survival rate but with a negative impact on women’s quality of life due to sexual dysfunction and radiation cystitis onset. With this study, CO2 laser therapy will be evaluated for the first time in GC survivors treated with radiotherapy. ClinicalTrials.gov registration number: NCT03714581. Title: Pain and Bruising Levels After Lip Augmentation: A Comparison of Anterograde and Retrograde Techniques Using an Automated Motorized Injection Device. A Blinded, Prospective, Randomized, Parallel Within-Subject Trial Authors: Galadari H, Mariwalla K, et al. Published: Dermatologic Surgery, August 2019 Keywords: Dermal filler, lips, augmentation, technique Abstract: Background: dermal fillers for lip augmentation can be injected using various techniques. Although all seem to provide acceptable results, it is not clear which technique is safer, less painful, and provides greater patient comfort. Objective: to compare patients’ self-reported pain intensity during the injection of hyaluronic acid dermal filler for lip augmentation, with 2 different techniques, anterograde versus retrograde. Methods and Materials: prospective, single-center, within-subject, single-blinded, randomized controlled trial. All subjects received injections in the lip with hyaluronic acid-based filler, each side using the anterograde or retrograde injection technique. An automated motorized injection device was used to ensure a homogeneous deposition flow of the product injected and reduce operator bias. Pain intensity was self-assessed using a 100-mm visual analog scale. Presence and severity of bruising were recorded. Results: forty-four women (mean age 30.3 years) were randomized. Mean self-reported pain score was 53.1% lower with the anterograde technique than with the retrograde (p < .0001). The anterograde technique had lower rates of site reactions, showed a faster recovery time, and 68.2% of patients favored this technique. Conclusion: this study demonstrated that the anterograde technique was less painful, and led to fewer bruising and site reactions than the retrograde technique when using an automated device.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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ntler Leobendorf, August 2019 – Croma-Pharma New headquarters and production plant as a clear commitment to free GmbH, is an international pharmaceutical company based in Leobendorf, Austria. For expansion and location ures over 40 years, Croma has been developing Due to the dynamic development of the are so and producing innovative drugs Ltd. long-standing licenseand and andamedical company, the construction expansion of hat they can befields of ophthalmology, distribution the agreement. devices for the headquarters andThis anotherjoint fully automatic a lunch break) venture withproduction the third-largest orthopedics and aesthetic dermatology. facility at the Leobendorf site was Croma is very proud to have made such initiated in 2015. The new headquarters was ive the patient Chinese pharmaceutical company an important contribution to improving inaugurated in September ance. The expert is aimed at the approval of 2017. further health and quality of life for more than four ferent technologies products and the nationwide decades. Founded in 1976 by pharmacist Innovations as a result of intensive and creates a longdistribution of these products in Gerhard Prinz, Croma is now managed by research and development or relationship. his sons Martin and Andreasmainland Prinz. Since China. Croma is investing heavily in in-house aesthetic medicine 2005, the company has been driven forward research and development of new products ge growth potential Sustainability and social through rapid internationalisation. In 2014, to drive the company’s long-term growth the strategic sale of the Ophthalmology and through innovation. In this context, Croma uty market. In responsibility Orthopedics divisions took place, since then also promotes medical and pharmaceutical offers a steadily the company has specialised in minimally research in Austria. Today, more than 90% dinated portfolio As a family business, Croma invasive aesthetic medicine. Currently, of sales are generated from products of our goal is a “full-face pursues a corporate policy based Croma has 12 international offices in Brazil, own research. r doctors and on ecological, economic and social European Union and Switzerland and nearly solutions for allworldwide. sustainability. For many years, Croma 500 employees Aesthetic dermatology as a a single source in dynamic future market is sponsor of the international Leading HA expert in Europe aesthetic medicine, the trend ble quality. organizationIn modern “Light for the World”. Today Croma is a global player in the is moving from large, irreversible surgical With generous product donations dynamically growing segment of minimally lifts to smaller but more frequent, shorter Croma makes an important e course for invasive aesthetic medicine and is a leading and, above all, gentler treatments. Pain-free contributionlunchtime to the eye care in the S market European processor of hyaluronic acid. The procedures (treatments that are so poorest regions of the company sells nearly six million hyaluronic straightforward thatworld. they can be performed 8 Croma-Pharma acid syringes (injectables) annually through during a lunch break) are designed to affiliates and a network of strategic give the patient a relaxed appearance. stablishing a joint partnerships and distributors in more than 70 The expert combination of different with its long-time countries. Production takes place exclusively technologies optimises results and creates c. to develop and at the company headquarters in Leobendorf a long-term patient-doctor relationship. ulinum toxin, HA near Vienna, Austria. Besides a broad Minimally invasive aesthetic medicine has ead products in US, Contact above-average growth potential in the range of HA fillers from the own production a and New Zealand. site, Croma markets PDO lifting threads, global beauty market. In this area, Croma s its development GmbH a Platelet Rich Plasma (PRP) CROMA-PHARMA system and a offers a steadily growing, well coordinated in its coreHöhn portfolio of products. The goal is a ‘full-face tivitiespersonalised with a skincare technology Stefanie markets. orderstrategic to prepare Cromazeile 2approach’ to offer doctors and patients the e successful market A-2100 Leobendorf gic partnership Phone: +43 676 846868 Aesthetics | 190 October 2019 ntinue Croma‘s Mail: stefanie.hoehn@croma.at

best solutions for all indications from a single source in familiar and reliable quality.

Croma sets the course for entering the US market In September 2019 Croma-Pharma GmbH (Croma) is establishing a joint venture company with its long-time partner Hugel, Inc. to develop and commercialise botulinum toxin, HA filler and PDO thread products in US, Canada, Australia and New Zealand. Thus Croma unites its development and marketing activities with a strong partner in order to prepare and implement the successful market entry. The strategic partnership with Hugel will continue Croma‘s international expansion efforts and further strengthen Croma‘s market position.

Milestones product approval and joint venture in China Asia in general and China in particular are outperforming markets in aesthetic medicine. In May 2017, the dermal filler Princess VOLUME was approved in China by the CFDA. Croma-Pharma was the first European company to do so. Almost at the same time, the company signed with Sihuan Pharma Ltd. a long-standing license and distribution agreement. This joint venture with the third-largest Chinese pharmaceutical company is aimed at the approval of further products and the nationwide distribution of these products in mainland China.

Sustainability and social responsibility As a family business, Croma pursues a corporate policy based on ecological, economic and social sustainability. For many years, Croma has been the sponsor of the international organisation “Light for the World”. With generous product donations Croma makes an important contribution to eye care in the poorest regions of the world. Learn more about Croma’s products and services at croma.at Croma-Pharma GmbH Julian Popple: Country Manager UK Phone: +44 (0) 7442341 227 Email: julian.popple@cromapharma.com Orders: customerservice.uk@croma.at Website: www.croma.at 55


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Tips for Maintaining Devices Laser specialist Dr Samantha Hills outlines ways to ensure the longevity of your lasers and other energy-based equipment In aesthetics, other than buying a property, purchasing lasers or other energy-based devices is often the single biggest investment practitioners will make. High quality devices can be a high cost transaction for practitioners, so when you go to make this investment, longevity of your equipment is key. Anyone who owns a car or combiboiler knows that there are certain types of equipment that need a bit more tender loving care than others. The better your system is maintained, the longer you can expect it to be making money for you – lasers can expect to last up to 25 years when well maintained and looked after. However, if you begin to neglect your equipment, then this longevity will certainly not last. It is also essential that your device is maintained in line with your manufacturer’s unique guidelines to ensure you are operating safely and delivering the optimum treatment and results to your patients. This article will provide my top tips for making sure that whatever energy-based device you choose to have in your clinic, it has the best chance of a long and healthy life.

Servicing The most important thing to note when maintaining your laser/energy-based device is that a regular service will give you longevity and a good return on your initial investment. Much like a car, with all systems, you should adhere to regular servicing. Each laser or light device requires different servicing intervals. Intense pulsed light (IPL) systems,

for example, usually have fewer delicate optical components and generally just require one service per year, but most laser systems require two to three services.1,2 Some very high precision lasers, such as those used for corrective eye surgery, are serviced every two months – be sure to check what is applicable to your machine with your supplier.2,3 Regular servicing will usually pick up any issues with a system that might be putting stress on delicate components, which means that they will likely last longer and avoid costly repairs later down the line. For example, it’s essential that optical components found within lasers and IPLs are regularly checked because over time, even tiny specks of dirt or debris can damage the coating on the lenses and mirrors.2 Regular servicing also ensures a constant and calibrated output, enabling you to deliver safe and effective treatments for your patients.4 Regular servicing will not only ensure that your device is working safely and appropriately, but you may also need evidence to retain

valid insurance cover. 5-8 This is especially important should a claim occur because it serves as proof of adhering to manufacturer safety guidelines. Servicing usually involves an engineer checking all the components in your system, including the flow tubes, light guides, IPL lamps, O-rings, flash lamps, diodes and recalibrating your equipment. I recommend to always get your device serviced through your device supplier. This is because every system is different and aesthetic engineers from your supplier will know what to look for and how to run your individual system and handpieces through thorough inspections, designed to catch any issues before they could cause a major problem. It’s then less likely that you’ll experience an unexpected device problem and you can be confident that your aesthetic operations will continue at peak efficiency. Alongside this, should you ever need an emergency service, your supplier will be able to support you for a quick resolution. Some device suppliers will offer their clients annual service plans or packages. This usually involves a representative from the company who will keep track of your routine maintenance schedule and contact you when action is needed, which can help to avoid missed services, and therefore prolonged disruption, or avoid unexpected bills. I recommend to never wait until the service is needed and to work in advance to perform it earlier than required. This is because you may require new parts for your machine that need to be ordered in, so you should never be a device down without notice. Doing so benefits the business by avoiding lost revenue or reputation, alongside disappointed patients, as the systems are kept maintained and regularly serviced.

Calibration Calibration is another key part of taking care of your device. Much like servicing, calibration is most commonly done by a technician either during the service, or between servicing if necessary, but it does depend on the device.

Calibration is imperative to make sure outputs are correct, so the device is working within the accurate parameters to ensure a safe and effective treatment

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Calibration is imperative to make sure outputs are correct, so the device is working within the accurate parameters to ensure a safe and effective treatment. As a practitioner, you should check the below functions to determine if a technician is needed. Do not ignore messages on your device for regular calibration This is vitally important to ensure a constant and calibrated output, enabling you to deliver safe and effective treatments for your patients, and retain valid insurance cover. If your aesthetic device asks for a full calibration to verify energy output, this could be a sign that something internally or in the delivery system has been affected since the last calibration. Contact your service provider to help troubleshoot the issue. Cooling system check Check your cooling system levels before you start the day. Water filters may need topping up with de-ionized water, which has chemical and electrical properties for optimal cooling, or additional coolants.9 Make sure you are familiar with what your device requires. If you are doing this yourself, take care not to overfill the fluid as it could spill onto the electronic components and cause major damage. If you do not check your cooling system regularly, it will allow your system to overheat, which can result in heat damage to internal and external components, which could then result in your system to stop working. Many devices feature a warning message when coolant is needed, however this function may not work if you are not servicing your device regularly, further reinforcing the importance of this check. Inspect and clean handpieces and their accessories To get the best out of your equipment, check your handpieces and accessories daily. With IPLs, make sure to check the filters are not damaged check for blemishes and marks – this is imperative to prevent burning. If you see blemishes or marks on your IPL filters do not attempt to fix them yourself; a qualified engineer should sort them. Again with IPLs, also check for chips on your light guides; if you notice any contact your service provider. The main day-to-day management is to keep the system clean and store away laser pens or IPL light guides and handpieces when not in use. With lasers, make sure there is no debris on the lens before use. Clean all areas of your handpieces, laser lenses and IPL blocks using sterile alcohol wipes between patients; it’s not just good clinical practice, but it will

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also ensure they last longer. Dust and debris are the number one reason for electrical and optical failures as they prevent your aesthetic laser from properly cooling, which can lead to potential component and electrical damage.10 You can do this with IPLs using a blanking plate to protect the internal filter and by placing all handpieces back in their holders when not in use. Check flash lamp shot count Most lasers and IPLs are limited by shot count, which is the number of shots available in your handpiece. When used, your device will likely present the amount of shots done. When your shots get low, this tells you when your handpiece will need servicing or replacing. An error code will often be displayed if a shot count has been reached; therefore, checking the shot count before you start your day will prevent any problems or delays during a treatment. Even if your equipment continues to work after exceeding the shot count, don’t be fooled that the machine is working properly. The clinical effectiveness of it will almost certainly be affected and can deteriorate if you continue to use it, maybe even causing irreversible damage to the equipment.3,11 If you receive an error regarding the shot count, then the handpiece will need servicing or replacing so you should contact your supplier or servicer to check all the components and recalibrate your equipment. When errors with your system occur, consulting your device user manual can help provide guidance to solve the problem. Be wary of knocks, drops or bangs Another thing that will help prolong your devices is to treat it with care and don’t drop, knock or bang your handpieces. Aesthetic energy-based devices are made of complex components that need to be aligned properly. If you drop your handpiece or bang it too hard, you can easily knock the components out of alignment. You may not notice if this has occurred, but it could cause a change in the output or performance. If you do knock or drop your handpiece, it’s advisable to contact your service provider to complete a check. Keep your treatment room cool Room temperature is essential in helping keep the device cool and to prevent overheating, especially in summer months. Air-conditioned rooms are the best option to keep the device operational; I would recommend an operating temperature of 1025°.12,13 To easily and accurately measure your temperature and humidity it might be a good

idea to get a thermometer for the room. Also ensure your treatment room is large enough so that the device is well ventilated and not covered or blocked to allow its internal fans to efficiently cool it. I always advise to consider your room size and ventilation prior to purchasing a system.

Conclusion

Let’s face it, today’s aesthetic energy-based devices aren’t cheap. Making sure your system is properly maintained is the best way to protect your investment. Your devices require continued, day-to-day attention and regular servicing to retain valid insurance cover and ensure it operates at peak performance for years to come. Dr Samantha Hills has a degree in physics and a PhD in Physics and Pharmaceutical Sciences, working in light responsive drug delivery, earning her ‘Dr’ title. She is the clinical director of Lynton Lasers and was recently appointed as an Honorary Lecturer at the University of Manchester. REFERENCES 1. Babilas, P., Schreml, S., Szeimies, R. and Landthaler, M. (2010). Intense pulsed light (IPL): A review. Lasers in Surgery and Medicine, 42(2), pp.93-104. 2. BMLA, Essential Standards Regarding Class 3B and Class 4 Lasers and Intense Light Sources in Non-surgical Applications, 2017. <http://www.bmla.co.uk/wp-content/uploads/BMLA%20 Essential%20Standards%20May%202017.pdf> 3. George J Hruza, Elizabeth L Tanzi, Procedures in Cosmetic Dermatology: Lasers and Lights: Volume 4, 2017. 4. Regulation (EU) 2017/745 of the European Parliament and of the Council of 5 April 2017 on medical devices, amending Directive 2001/83/EC, Regulation (EC) No 178/2002 and Regulation (EC) No 1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC, Article 2: Definitions (1) <http://eur-lex.europa.eu/ legal-content/EN/TXT/?uri=CELEX:32017R0745> 5. Nanni CA, Alster TS. Complications of cutaneous laser surgery. A review. Dermatol Surg. 1998; 24:209-19. 6. Greve B. Raulin C. Professional errors caused by lasers and intense pulsed light technology in dermatology and aesthetic medicine: preventive strategies and case studies. Dermatol Surg. 2002; 28(2):156-61. 7. Willey A, Anderson RR, Azpiazu JL et al. Complications of Laser Dermatologic Surgery. Lasers Surg Med. 2006; 38:1-15. 8. Haedersdal M. Cutaneous side effects from laser treatment of the skin: skin cancer, scars, wounds, pigmentary changes, and purpura – use of pulsed dye laser, copper vapour laser and argon laser. Acta Derm Venereol 1999; 78(suppl 207):1-32. 9. Medicines and Healthcare products Regulatory Agency, ‘Lasers, intense light source systems and LEDs – guidance for safe use in medical, surgical, dental and aesthetic practices’, MHRA; 2015, <https://assets.publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/474136/Laser_guidance_ Oct_2015.pdf> 10. Alster TS. Getting started: Setting up a laser practice. In: Alster TS, editor. Manual of cutaneous laser techniques. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2000. pp. 2–4. Ch 1.  11. British Standards Institution. BS EN 60601-2022:2013. Medical electrical equipment. Particular requirements for basic safety and essential performance of surgical, cosmetic, therapeutic and diagnostic laser equipment. London: British Standards Institution; 2013 <https://shop.bsigroup.com/ ProductDetail/?pid=000000000030085294> 12. Dhepe N. Minimum standard guidelines of care on requirements for setting up a laser room. Indian J Dermator Venereol Leprol, 2009; 75, Suppl S2:101-10. Available from: http://www.ijdvl.com/text.asp?2009/75/8/101/54978 13. Aurangabadkar, S., Mysore, V. and Ahmed, E. (2014). Buying a laser - Tips and pearls. Journal of Cutaneous and Aesthetic Surgery, 7(2), p.124. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4134647/#ref9>

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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is always open, but that our home is where the heart of the business is. For example, at sales meetings David used to cook dinner and everyone would join us around our dining table – we can’t do this anymore as there are too many of us, but we maintain that spirit. However, truly building this culture is more than just involving people in our home life, it is involving the team in decisions on how the business will grow and evolve. Selecting, communicating and sticking to the right culture is, in my opinion, a pivotal element of developing a successful business. This article will explore my tips on how you can do this effectively.

Defining culture

Building a Successful Business Culture Aesthetic nurse Lorna McDonnell Bowes explores how to build trust, passion and authenticity in an aesthetic business As a nurse working in the NHS, I never expected to become an entrepreneur and run my own business. One thing I have learnt since doing so, though, is that each business has its own culture and way of doing things that work best for its unique structure and the employees within it. However, building a successful culture can be both challenging and gratifying. In building our aesthetic distribution company, AestheticSource, my business partner and now husband, David McDonnell, and I, set out purposefully to build a team based on three core values of trust, passion and authenticity. We wanted to create a ‘family feel’, to empower each person to be brave, to be different and to be their best self. But, most of all, we wanted every individual to feel supported and cared for. Achieving this family feel has been a collaboration between, at first, just the two of us, but then through our growing teams. We have always run an open-house culture, not just that our door Stories

Rituals and Routines Management meetings Sales meetings Conferences Symposia

Control Systems Records/CRM Clinical compliance Cosmetic compliance Fiscal compliance Commercial compliance

History of company Pedigree of brands Key team member stories Reputation

The Paradigm Authenticity Trust Passion

Symbols Logo Job titles Offices Marketing

Power Structures Collaborative decision making Strong leadership at all levels

Organisational Structures Flat leadership structure Leadership by example

Figure 1: The cultural web taking from Fundamentals of Strategy. The text below these headings are AestheticSource’s version and can be replaced with your own values and strategies.

There are many recognised ways to define company culture. We have believed in and use Hofstede Insights,1 which is a resource built on approaches developed by Professor Geert Hofstede, a Dutch social psychologist. He has studied and written about how values in the workplace are influenced by culture and has written many books on the topic; I suggest reading Cultures and Organizations: Software of the Mind.2,3 The most recent definition of culture by Hofstede Insights is ‘the way in which the members of an organisation relate to each other, their work and the outside world in comparison to other organisations’.2,3 Put simply, Professor Hofstede’s ideology allows conversation internally around how the culture can best be developed to enable, rather than hinder, company strategy and goals. One of the most valuable tools we have used is ‘the cultural web’ (Figure 1). This is a tool taken from Fundamentals of Strategy that allows us to dispassionately review how we are perceived by our team (our internal customers) and by the clients in the businesses we sell to (our external customers).4 Businesses can note down their strategies under each heading of the cultural web, for example, at the core of our cultural plan are authenticity trust and passion, shown in Figure 1. In the next section, I will explain, with examples, how this plays out in a growing business. To reinforce these tools, I advise that your management team meet regularly to discuss how your organisational culture is fairing, what work you might need to do to improve the culture, and how your staff, customers and team understand your culture. This can be time consuming, but has proven extremely valuable to us.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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employee’s hands and gains their trust when they are listened DECIDE to. Based on the responses, a DO Schedule a time Do it now business might indeed need to do it to restructure, such as your leadership team, or maybe you need to move to new offices, DELEGATE DELETE which has happened in our case. Who can do it Eliminate it for you? There are many tools available to help decide which decisions Figure 2: The Eisenhower matrix, which was first described by Dwight will bring the best results, I favour Eisenhower, the 34 President of the US. simplicity and like to use an Eisenhower matrix (Figure 2) to prioritise. The Trust results of this exercise can be further growth In the development of our culture, we firstly and a re-energised team that works with set out to create a team of creative leaders collective enthusiasm and drive. who were willing to have a voice in the business. This runs throughout the business, Passion and the trust we have in each other grows as I have worked for several great employers; the company expands. all of which were extremely passionate, There are many ways you can build trust in not only about their field, but for honesty, a business. One exercise we have done to relationships, individuals and to succeed. not only encourage trust, but to also facilitate This struck a chord with me, and enabled any change in the business, is to ask our me to see the value of this in a workplace employees a series of open questions at a and to lead by example – if you want your team meeting, which we hold regularly. We team members to be passionate, you have monthly management meetings, and must first be passionate yourself. So why quarterly full team meetings. For example, is passion so important? In entrepreneur we ask: Richard Branson’s blog, he states, “Passion • Why are we here? I mean, each of us at is one of the most effective motivators this company? when it comes to launching a business – • What do we want from the days we work? and often one of the strongest predictors • What changes do you want to see here at of whether an idea will lead to success.”5 the company? It is important that the whole team are passionate about not only the business, These questions are often complemented but also about each other. Creating and with a quote, that aims to help inspire them. maintaining passion and enthusiasm One I chose recently was, “Sometimes the starts with careful recruitment; employing questions are complicated and the answers people who already have these qualities. are simple” by Dr Seuss. I also recommend to take chances when This kind of activity puts some power into the strangers present themselves to you and Not urgent

Not important

Important

Urgent

th

8

As well as being engaged with your business, you should ensure that your staff members are fully engaged with one another

announce that they want to work for the business and allow them to prove their value to you. You should focus on developing the passions of each and every team member and allow them the freedoms to develop in the areas they have particular interests in, whilst holding the balance of ensuring that this does not deviate too far from the overall business strategy. I recommend that you watch out for habitualised patterns, and gently examine the root causes should you find them. Where necessary or beneficial, encourage people to change their embedded habits to develop new, more productive strategies – this, I find, helps develop passion. As well as being engaged with your business, you should ensure that your staff members are fully engaged with one another. To do this, you can hold team building days to build relationships, or arrange ‘away days’ together, for example a spa day. It may well be the most basic of tools, but in my experience, it can be very effective. Putting people in a new environment to see each other in another light often allows more creative thought by removing any restraints so often felt in the enclosed and sterile surrounds of a meeting room, as well as making them feel appreciated and valued. You could also run a voucher scheme that rewards short term, achievable targets that focuses the team on specific objectives and at the same time creates real excitement and passion to do well. Another way to help your staff be passionate about one another is for them to truly understand each other, beyond knowing each others’ birthdays and pet’s names. An exercise we are currently undertaking is sharing our top 10 personal goals, with the aim of really getting to understand each other’s potential dreams and aspirations. Measuring the effects of this are simple, we notice increased productivity as well as a team that ‘gels’ and who will laugh together, be silly together, share together and grow together.

Authenticity The importance of authenticity in building a business cannot be underestimated. In 2017 Stackla, a marketing and research firm, published research suggesting that 86% of 2,000 people surveyed felt authenticity was a key factor when deciding which brands to support.6 Creating a culture of authenticity means ensuring that words are consistent

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Y

It’s WORKING!

Give up the good for the great

I’m good. I don’t know what I get so down on myself

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Wait a second, my life is great!

I’m excited!

Ugh! This is hard!

I think I’m going bankrupt

I messed up

I was wrong. I suck! X

Figure 3: ‘A day in the life as an entrepreneur’ concept by Derek Halpern. Sometimes in life, everything goes smoothly, and sometimes unexpected happens. The important thing is knowing how to turn problems into opportunities and having a team that can get you through. 5

with deeds, and being relatable. This creates some significant challenges in running a small business. You run the risk of being ‘all things to all people’. An article on authenticity published in the Harvard Business Review states, “To attract followers, a leader has to be many things to many people. The trick is to pull that off while remaining true to yourself.”7 This makes clear the case that authenticity is not an innate quality; it does not ‘belong’ to an individual. It is a quality that others must attribute to an individual, or a group of individuals or a whole company. For me personally, authenticity has meant aligning my passion for skin, my vocational need to care for people, and my business drive alongside the ever-present juggle of family life and business life. Being true to each component has allowed me to form a team that relies on me to be ‘real’. Simply put, the way I ensure my employees have faith in the business’s authenticity is leading by example, and by being a ‘real’ person that my employees can relate to. What does this look like? In part, it involves sharing my thoughts, about admitting when I am scared, nervous, unsure; talking about the challenges of balancing business and family life; sharing in failures as much as in successes. But more, it is about sharing the exact same when anyone in the team feels scared, nervous, unsure or challenged by work/life balance.

So why is this important?

For you to really understand why it has been vital for me to create a successful business culture that is based on trust, passion and authenticity to create a family feel, you need to know a little about my personal journey. In my early nursing career, I was thrown into management. The clinical lead of my department advised me that although I was a good nurse he felt I was capable of leadership, and that the NHS would not provide any support or training. He therefore recommended I explored working in industry instead and learn management skills in a different environment. Since then, I have worked for many great employers; including previous Aesthetics journal editor Amanda Cameron, whose passion for great leadership and encouragement inspired me to study for an MBA, and who continues to inspire me today. Chairman of Wigmore Medical, David Hicks, was my last boss before myself and David McDonnell set up our own distributing company; his

consummate networking skills, also based firmly on authenticity, fired my drive to build another successful business. Now, every business owner has their challenges (Figure 3), but in summer 2018, I went from seemingly fit and healthy to going between Moorfields Eye Hospital and Bedford Hospital Stroke Clinic. My diagnosis was inferior homonymous quadrantanopia associated to probable stroke; likely as a result of years of ‘life’ with the inevitable stresses of divorce, business and, possibly, perfectionism. This turned my life upside down, resulting in an inability to drive, and a decision not to continue my nursing practice. I was required to take a lot of unplanned time off but the response from my family at the company was beautiful. In adversity, the AestheticSource family stepped in, pulled together and took over my entire role. They even changed my email password to force me to rest! We talked together about the trust we needed in each other for them to do this; the confidence they knew I had in them that they would take care of all my responsibilities with care and authenticity; their confidence that I would be comfortable with their decisions. Without trust, passion and authenticity in my business culture, none of this would have been possible and the business would have sure enough failed. I am now back full time, and it’s thanks to my team, and our strong culture, that the business continues to expand, and is stronger with more energy and passion than ever. This is, despite my absence for most of the summer, autumn and into the winter of 2018.

Summary

My business is a family built up over many years and it is achievable to create this feel in your business too. Remember, have authenticity in everything that you do. Trust each other, your brands and services, and any partners you have. Finally, have passion for your ethos, brands and your customers/patients. If ever you need to take a step back from your business, your team need to be there to take over, ensuring your business maintains its success and continues to allow you to excel. Lorna McDonnell Bowes undertook her first staff nurse role in dermatology in 1987 and moved to medical aesthetics in the early 1990s. As well as many years of running The Bowes Clinics, she was a founder committee member of the BACN, consultant editor of the Journal of Aesthetic Nursing and is a regular speaker at conferences. She then went on to set up AestheticSource in 2012, a medical aesthetics distributor and training provider. REFERENCES 1. Hofsted Insights <www.hofstede-insights.com> 2. Cultures and Organizations: Software of the Mind. 1st edition, McGraw-Hill USA, 1997. 3. Geert Hofstede, ‘Why is culture so important? <https://geerthofstede.com/> 4. Johnson, G et al., Fundamentals of Strategy, Pearson UK, 2017 5. Natalie Clarkson, Richard Branson: The importance of passion in business, 2015. <https://www. virgin.com/entrepreneur/richard-branson-the-importance-of-passion-in-business> 6. Peter Cassidy, Survey Finds Consumers Crave Authenticity - and User-Generated Content Delivers, 2017. <https://www.socialmediatoday.com/news/survey-finds-consumers-crave-authenticity-anduser-generated-content-deli/511360/> 7. Goffee R, Jones G. Managing Authenticity; The Paradox of Great Leadership. Harvard Business Review 2015, <www.hbr.org> 8. Chris Winfield, What a Day In the Life of an Entrepreneur Actually Looks Like, Entrepreneur Europe, 2016. <https://www.entrepreneur.com/article/274831> 9. James Clear, ‘Use the ‘Eisenhower Box’ to Stop Wasting Time and Be More Productive’, Entrepreneur Europe, 2014. <https://www.entrepreneur.com/article/233054>

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Reflecting on Aesthetic Practice Dr Kalpna Pindolia explores the concept of reflection in aesthetic medicine to improve clinical practice Just like any other clinical speciality, lifelong learning is the foundation of excellent patient care in aesthetic medicine. As a central foundation of the process of appraisal for revalidation, reflection has become a formal tool to enhance and strengthen quality outcomes for our patients. This article discusses the concept of reflection within aesthetic medicine and how you can use it to evaluate your knowledge, experience and skills to improve your clinical practice.

Revalidation Medical revalidation is the process by which a medical practitioner’s regulatory body confirms the continuation of a practitioner’s licence to practise in the UK.1 It is performed every five years for a doctor2 and three years for a nurse,3 while dentists perform an annual renewal where they need to undertake continuing professional development to maintain their registration.4 Revalidation, as a central part of the clinical governance process, is recognised as a valuable means of driving change in clinical practice to keep patients safe. Reflection is a fundamental tool in stimulating learning and provides essential supporting information at appraisal for a medical practitioner’s revalidation.

What is reflection? It has been said that amateur golfers mostly remember their successes, whereas professional golfers never forget their mistakes. Each golfer, amateur or professional, is reflecting on their experience of successes or mistakes, as fuel for learning to improve their performance and the same can be said for aesthetic practitioners. Reflective practice in medicine is defined by the Academy of Medical Royal Colleges as ‘The process whereby an individual thinks analytically about anything relating to their professional practice with the intention of gaining insight and using the lessons learnt to maintain good practice or make improvements where possible’.5 It engages our metacognitive processes, which are the processes of using our

intellectual and personal qualities to explore our experiences and evolve our understanding of the outcomes.6

The advantages of reflection It has become the consensus opinion of healthcare education and regulators that reflective practice stimulates self-regulation and lifelong experiential learning. On June 18 this year, the GMC, and eight other healthcare regulators, which included the NMC and GDC, published a joint statement on the importance and benefits of being a reflective practitioner.7 It states that being a reflective practitioner is beneficial because: • It supports individual professionals in multidisciplinary teamwork • It fosters improvements in practice and services • It assures the public that health and care professionals are continuously learning and seeking to improve Reflecting on positive experiences can lead to reinforcement and replication of actions that can help our patients. It can lead to future resilience, awareness of your own core values and encourages self-regulation of behaviour with future clinical and personal encounters. As well as this, considering strengths of practice can be rewarding and motivating. Reflection on negative experiences or outcomes can lead to isolation of the contributing factors. This is where opportunities to improve care can be identified. For instance, with a complication occurring from an injecting technique, reflection upon the circumstances may reveal the need for more knowledge of the procedure. Reflective practice also aids insightful strategies to close the gaps in our potential areas of weakness, should similar circumstances occur again. For instance, the second time a patient complains may be managed quite differently after applying strategies evolving from reflective learning from a first complaint. Discussing reflections with colleagues can foster team learning, communication

and positive dynamics. It also encourages creative strategical approaches within teams to modify healthcare systems in the interest of patient safety.

The challenges of reflection Many medical professionals can be anxious about their appraisals due to their paramount significance in licensing. In order to develop the important introspective components of reflection, an understanding of one’s emotional ‘self’ is central to becoming a selfregulated, lifelong learner. Understandably, some practitioners will find this process more comfortable than others. Responses from almost 8,000 British Medical Association (BMA) members showed that 26% felt comfortable with reflective practice, while 74% felt some level of concern that it could be used against them.8 Some practitioners also question whether the benefits of documented reflection balance the potential legal implications. With the recent Dr Bawa-Garba case, involving a junior doctor who was convicted of manslaughter by gross negligence and removed from the medical register,9 many practitioners feel they are no longer able to reflect without fear of recrimination. This is because a reflective document from her e-portfolio, which was thought to be used at her trial, suggested reflective practice in the UK may not be inherently safe.10 However, Dr Bawa-Garba’s medical defence organisation confirmed that her appraisal portfolio did not form part of the evidence before the court and jury.9 After this, the GMC went on to confirm that they will never ask for reflective statements as part of an investigation. However, reflective notes can, though rarely, be required by a court in context of litigation.11,12 Although this is the case, we as practitioners should not fear this as documentation for reflection purposes requires little identifiable data. Documentation should focus on reflective analysis, which captures learning outcomes and future plans, rather than detailed circumstances. Anonymising reflective notes means they will still be valuable to you for reflection purposes, but can avoid difficulties should the notes be disclosed.12 It is worth noting that reflection also demonstrates remediation and current safe practice,9 and can be used as defence in fitness to practise hearings.9

How to demonstrate reflection The GMC’s Reflective Practitioner Guidance for Doctors and Medical Students advises how to demonstrate reflection.12,13 Reflection can be stimulated from many sources,

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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Reflecting in aesthetic medicine There are plenty of opportunities to demonstrate your commitment to reflective practice. These include: • Case or event reviews informing knowledge advancement and amendments to future treatment plans • Seeking advice on cases with a peer or mentor demonstrates learning from others • Working in teams where reflection has led to collaborative change, refining practice • If establishing your own aesthetic practice, development of documents, protocols and policy to protect patients • A log of treatments conducted to monitor outcomes of new treatments and complications informing professional development plans • Involvement in teaching or mentoring where reflection has led to evolving content and education of others in the sector • Professional relationships with colleagues, perhaps dealing with conflict or establishing consensus groups optimising care • Performance against defined standards like those of the Care Quality Commission (CQC) • Learning from the success or mistake of another • Management of a dissatisfied or challenging patient • Managing complex cases well • Attendance to industry events and conferences stimulating positive or more challenging thoughts • Maintenance of improvements you have implemented previously • Research or content writing for any industry magazines or journals • Explore how continuing professional development material has helped to develop your knowledge or understanding in a certain topic

including clinical events, complaints or compliments and feedback, reading resources, meetings and discussing outcomes with teams. Documentation can be of a single event or a summary of the reflective approach developed on several different types of experience. They can be a situation the healthcare practitioner observed, or was directly involved with. When you are reflecting on unfavourable experiences, like a clinical mistake, it is best to approach this with calm balance. This includes refraining from writing defensively and blaming others. You should also avoid being excessively judgemental of yourself and others in these situations with negative outcomes. This is usually achieved by taking some time to step back, discussing the situation with colleagues and evaluating after the initial emotions of the experience have settled. There are many reflective models than can help facilitate reflection. Kolb14 and Gibbs15 have been central in creating healthcare reflective models which are supported by Academy of Medical Royal Colleges.6 Simply put, the fundamental approach is: 1. Explore what happened. This is an anonymised narrative of actions and the experience that you have had.

2. Ask yourself, so what? This leads to the practitioner to question why this is important, addressing the feelings generated with the significance of reflection. 3. Determine what to do next. This is an evaluation of what was positive or negative. Consider this from your perspective as well as the perspective of others. Think of the bigger picture and other factors that may have had an impact, as well as your own actions. You can then analyse what could have been done differently and think of strategies to actively address this in future learning or behaviour. Reflection can be documented as a single event or a summary of their reflective approach based on several different types of experience.6 You do not need to document all of your learning activities, but just provide enough balanced evidence to give assurance that reflection is taking place in all domains of practice. So quality of the appraisal documentation is the focus rather than quantity. It is also worth bearing in mind that the reflection experience is as a continuum of constant refinement of practice linking

past, present and future experiences. By reinforcing changes in the future, you are also demonstrating a commitment to safety for patients.

Conclusion Through the process of reflection, as healthcare professionals, we can become masters of evaluating our knowledge, experience and skills. Formal logging of the process encourages the habit of reflection and reinforces mental strategies that can be quickly mobilised to effectively address situations in day-to-day clinical practice and life. Reflection is effectively a catalyst to realise your own emerging potential as you evolve as a healthcare practitioner, demonstrating that safety is at the heart of your medical professionalism. Dr Kalpna Pindolia graduated from the University of Wales, College of Medicine, and is an experienced emergency medicine and maritime medicine doctor. She has dedicated her career to aesthetic medicine. She has her own clinic in West London and is a GMC Appraiser at Harley Academy. REFERENCES 1. NHS England, What is revalidation? <https://www.england.nhs. uk/medical-revalidation/about-us/what-is-revalidation/> 2. GMC, What is revalidation? <https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/revalidation/ introduction-to-revalidation> 3. NMC, Revalidation. <http://revalidation.nmc.org.uk/welcome-to-revalidation.1.html> 4. GDC, Annual renewal and fees. <https://www.gdc-uk.org/ registration/annual-renewal-and-fees> 5. Academy of Medical Royal Colleges, Academy and COPMeD Reflective Practice Toolkit Guidance Note. <http://www.aomrc. org.uk/wp-content/uploads/2018/08/Reflective_Practice_Toolkit_AoMRC_CoPMED_0818.pdf> 6. The use of reflection in medical education: AMEE Guide No. 44 <https://medicine.usask.ca/documents/faculty-affairs/workshops/ReflectionMEdicalEducation.pdf> 7. GMC, Each regulators requirements for reflection. <https:// www.gmc-uk.org/education/standards-guidance-and-curricula/ guidance/reflective-practice/benefits-of-becoming-a-reflective-practitioner/each-regulators-requirements-for-reflection> 8. Nick Bostock, Just one in four doctors comfortable with reflective practice, huge BMA poll reveals, GP, 2018. <https://www. gponline.com/just-one-four-doctors-comfortable-reflectivepractice-huge-bma-poll-reveals/article/1486273> 9. BMA, Reflective Practice, 2018. <https://www.bma.org.uk/ collective-voice/influence/key-negotiations/training-and-workforce/the-case-of-dr-bawa-garba/reflective-practice> 10. GMC, Factsheet: Dr Bawa-Garba’s case. <https://www.gmc-uk. org/-/media/documents/20180419-factsheet---dr-bawa-garbacase-final_pdf-74385491.pdf> 11. GMC, The reflective practitioner - guidance for doctors and medical students. <https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice/ the-reflective-practitioner---guidance-for-doctors-and-medicalstudents> 12. The Reflective Practitioner Guidance for doctors and medical students. <https://www.gmc-uk.org/-/media/education/downloads/guidance/the-reflective-practioner-guidance.pdf> 13. Kolb, D.A. (1984). Experiential learning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall. 14. Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit, Oxford Brookes University, Oxford.

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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“If you put patients at the forefront, then success does follow” Aesthetic nurse prescriber Mary White shares her love for lasers and injectables and explores how technology has developed over the years As a Midlands girl born and bred in Solihull, aesthetic nurse prescriber Mary White says she is proud to not have ventured too far from home, running and owning an aesthetic clinic in Droitwich Spa since 2001. “I have always been interested in science and medicine so expected I would have a career with a medical background. I did my nursing training in Redditch and graduated in 1991, before working for a while as a paediatric nurse. I also went to nurse in Germany as I spoke German and was interested in travelling whilst I was young,” White reflects. When she returned to the UK in early 1993 she wanted a change from nursing. She explains, “I had no job and I spotted an advert in the paper that was looking for a nurse to run a laser clinic in Birmingham. There was no experience necessary and full training was provided so I applied and miraculously got the job, which was a surprise because I had no experience in laser dermatology and was only about 23 years old. This really was the epiphany of my career developing into laser and dermatology treatments, which I’ve specialised in ever since.” White says that the nineties was an exciting time to be entering the aesthetics field. She recalls, “It was the very early stages of laser being introduced into the UK for treatments like tattoo removal. I used the very first Q-switched Nd:YAG lasers to come to the UK, which was a turning point for tattoo removal because, before this, removal was impossibly difficult. It was very exciting and nobody else was doing it – it was very much a ‘learn on the job’ kind of thing. When I started using lasers there was also no such thing as laser hair removal – in about 1995 I was involved in clinical trials at our clinic using an old ruby laser, which was painstakingly slow. Then I did trials using Candela lasers, which were much faster, before we also started using them for thread veins; it was all very exciting and very new.” In 1996, White learnt how to inject dermal fillers, which at the time were made of bovine collagen. She says, “We used to have to do skin tests beforehand because about 3-4%

of patients were allergic. The big turning point for dermal fillers was Restylane, as this was made of hyaluronic acid, which I started using in about 1998.” White worked in several clinics, including Lasercare Clinics (now sk:n) and Harley Medical Group performing laser and facial aesthetics treatments. In 2001 she became a laser trainer for Cynosure and Candela, as well as opening Outline Clinic in Droitwich Spa. “I wanted to work for myself because I thought it would suit my family life and enable me to work less with more flexible hours. Of course, I was kidding myself because I have worked more owning my own business than I would have ever done for anybody else, but I have loved it,” she says. The challenges of owning your own aesthetic practice in the early 2000s were very different to those of today, White acknowledges. “The main one was that there was no patient awareness about the industry, the treatments or the possibilities. If you told people what you did they would raise their eyebrow at you – back in the day when people could raise their eyebrows! – and they would have no clue what you were talking about. Now, everybody has heard of fillers, for example, so it can be much easier to get patients,” she explains.

When asked what her greatest achievements are, White says, “I’m very proud to be an employer – I have a fantastic team and together we all strive to keep the clinic progressing and I’m very proud of that. Our clinic is also registered with the Care Quality Commission, which I think is important to illustrate commitment to patient safety and helps staff to understand the importance of good care. I am also extremely proud to have won The John Bannon Pharmacy Award for Best Clinic Midlands and Wales at the Aesthetics Awards last year. This was absolutely incredible, probably one of the highlights of my career as it was great to be recognised even though there are so many other and much bigger clinics out there – I was hugely proud.” White adds that she is thrilled to be an Aesthetics Awards Finalist once again this year for her region, and her team are in the running for the Clinic Reception Team of the Year Award. White’s word of advice for others getting into aesthetics is, “Play ‘the long game’ – it’s not going to be a get rich quick overnight scheme – which I think a lot of people believe. If you treat people properly, act ethically and put your patients at the forefront of everything that you do, then success does follow.”

Do you have an interesting hobby? I used to breed and show cats and one of my Siamese cats once won best variety at the Supreme Cat Show; I am very proud of that! What’s your favourite treatment to perform? Although I started off in lasers, I now really love doing a full facial rejuvenation using fillers. I do multiple syringes of filler usually over three-week intervals, which gives incredible transformations. I usually use the Juvéderm’s Vycross range as my go-to product for this. What’s your top business tip? Never discount your prices and never enter a price war with a competitor. There will always be patients at every aspect of the market – for example, there will always be people who shop at John Lewis and those that choose Primark.  What’s exciting you at the moment? We are just starting to branch out into body treatments and have recently introduced a CoolSculpting machine. Fat loss is a new concept for our clinic and we have had a huge amount of interest in it so I’m very excited for the future of this!

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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The Last Word Dr Alex Parys argues the need for emergency department staff to be trained in complications caused by private aesthetic treatments With an increasing number of non-surgical aesthetic treatments being performed each year, there is inevitably an associated increase in the number of complications.1,2 These can range from minor complications, such as temporary swelling and bruising, to the serious – vascular occlusion or necrosis. A recent complaints report conducted and published by independent accreditation body Save Face found that out of 613 adverse filler outcomes, nearly 4.5% were due to infection, and approximately 1% represented vascular occlusion or impending necrosis.3 With the ongoing regulation debate that this specialty is all too familiar with, we find ourselves left with a heterogenous market of mixed skills and mixed backgrounds. One would hope that those undertaking such procedures have the insight to learn how to recognise and treat any complications that may arise from their treatments. Sadly, this does not appear to be the case, as demonstrated by the complaints report, which found 83% of complications were caused by non-medics.3 But, where do patients with these complications go? Often it is their original aesthetic practitioner, but as mentioned, this relies on their ability to both prevent, recognise and treat complications. If the patient is unhappy with the conclusion of their practitioner, still concerned, it is out of hours, or they are simply scared and anxious, they will often seek assistance elsewhere.

The aforementioned report found that, whilst the majority of patients with complications were either ignored by the practitioner who had treated them or sought out corrective procedures by other practitioners, nearly 6% of those attended either their GP or Accident and Emergency department, which I will refer to as the Emergency Department (ED) for the rest of the article.3

The argument A 2013 Department of Health review found that, over a 15-month period at the Chelsea and Westminster Hospital in London, 12 patients presented to the ED needing treatment for complications following cosmetic procedures, incurring a cost of £43,000.4,5 For one individual, their adverse reaction to facial filler resulted in a five-night hospital stay and a reported cost to the NHS of £4,028.4,5 As the NHS does not recover funds from private healthcare providers following treatments, it could be argued that it should not have to bear responsibility for providing care for procedures that have gone wrong.6 Additionally, the NHS is already under considerable strain, both financially and in terms of workforce. The four-hour target, which expects 95% of patients to be seen within that timeframe, has not been met since July 2015.7 Clinical staff remain stretched to deliver safe, effective care due to the mismatch in supply and demand.8 The total number of ED attendances exceeded

2.2 million in July 2019 – the highest number ever recorded. The average number of ED attendances per day reached over 73,000.7 With this in mind, many argue that it should primarily be the original injector who manages the adverse event and refers to if necessary. However, the reality is that patients will still present to the ED, and in my opinion, the ED therefore needs to be able to deal with the wide variety of presentations that walk through that door. However, it is important to note that emergency doctors or advanced clinical practitioners may not know which product has been used, or be aware that in some unfortunate cases the practitioner has used unofficial sources. Compounding this is the rise of those self-injecting filler, using substances ranging from hyaluronic acid to cooking oil. These patients will have no other care pathway apart from their GP or ED for their self-inflicted complications. The Department of Oral and Maxillofacial Surgery (OMFS) in London recently published an article detailing such a case, where a 24-yearold female presented with a four-week history of suspicious upper lip swelling.9 She was referred by her GP on the urgent head and neck cancer referral pathway. It was only when they reviewed her electronic patient records in more detail that they discovered she had presented to the ED four weeks prior complaining of lip swelling post self-injection of dermal filler purchased over the internet. She was unable to name the product used, or the website she ordered from, and as a result it was unknown whether the filler was permanent or non-permanent. Fortunately, the swelling self-resolved with conservative management, but this still cost the NHS £323.17 for one ED attendance and two OMFS clinic appointments. She did not undergo any imaging or further investigations once they discovered her previous presentation, but had this not been available, the costs incurred could have been significantly higher. It also meant this patient inappropriately took up an urgent cancer slot.9

My experience Having been an emergency department registrar in my previous NHS life, I would not have felt adequately equipped to correctly deal with complications from fillers – dissolving lip filler certainly wasn’t covered by my specialist training syllabus! Burn victims, anaphylactic shock, sepsis – yes; visual loss secondary to filler-related retinal artery occlusion – no. Even now,

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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I believe the issue lies more in a lack of exposure and education for the emergency staff, as this is something that is out of their usual scope of presentations working full time in aesthetics, differentiating a true complication from something benign can still be challenging. This is highlighted by the fact that some aesthetic-related complications have a very small window before tissue necrosis or even visual loss can occur.10 Failure to recognise and commence treatment within these timeframes can lead to devastating consequences for the patient, who may already have presented late to the ED. Not to mention, likely cause further costs to the NHS in the future. Whilst I did not encounter any filler-related complications during my years in the ED, having spoken with colleagues across Manchester, where I practised, the overwhelming response has been that, although the number of filler-related complications presenting to the department may be very low, there is a definite lack of education regarding management in this area. One of my colleagues working within ED has experienced ‘a few lip disasters’ over the past few months, with the majority of cases presenting as infection, although there have also been several with anaphylaxis from either a substance in/used with the filler or from hyaluronidase. She noted that there appears to be an increasing number of these presentations, and the majority have been from non-medic injectors, which perhaps explains their presentations to the ED – especially when you combine that with the data from Save Face where 35% of patients with complications were ignored by the person who treated them. The majority of these are something ED staff can manage and refer on as part of standard training. However, it’s possible for some ‘infections’ to be secondary to underlying occlusion, and therefore the underlying cause may be missed and further damage may occur if this is not something staff are aware is a possibility. This was recently highlighted in a case where a beauty therapist used a needle-free device to administer lip filler. The patient (who was also a nurse) experienced immediate pain and knew something was wrong, but the practitioner did not know

what to do, even though she recognised something was wrong. The patient therefore self-presented to ED, only to be discharged with a diagnosis of lip haematoma. The following morning, symptoms worsened with discolouration tracking up the nose – clear signs of a vascular occlusion. Fortunately, she found an aesthetic nurse prescriber who was able to administer hyaluronidase and antibiotics with a successful outcome.11 I believe the ED staff were not unreasonable in their diagnosis, as the number of cases presenting remains low currently, and it is not something that they receive training on as part of their core competences. As aesthetic practitioners, we should be far more aware of signs and symptoms of potential complications in our daily treatments. I believe the issue lies more in a lack of exposure and education for the emergency staff, as this is something that is out of their usual scope of presentations. However, this case demonstrates that, whilst it should ideally be the treating practitioner who provides the majority of complication management, ED should at the very least have an awareness of filler complications, as well as algorithms for management to ensure prompt treatment and better outcomes.

The solution

It is for this reason that I have started to undertake teaching sessions with doctors in the various Manchester emergency departments, with the aim of increasing awareness of the various presentations of filler complications, and providing them with a treatment algorithm, which is outside the scope of this article. There have also been similar sessions provided in other parts of the country, and this is something I would encourage other practitioners to provide throughout the rest of the UK. I should also mention the work that the Aesthetic Complications Expert Group has been achieving in order to help support registered practitioners who may encounter a complication.12 Another important factor to consider is the initial treatment consultation,

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where patients need to be adequately educated on possible side effects, how to recognise them, as well as emergency contact details. This would help to reduce inappropriate ED presentations, whilst hopefully reducing the time someone with a complication takes to get in touch, as every minute counts. I would argue that a rushed consultation without a detailed discussion of possible adverse events, no matter how concerning or off-putting they might sound to the patient, results in them being unable to provide valid informed consent for the treatment – something that may result in legal implications for the practitioner should such a complication arise. To conclude, emergency care and the work of emergency departments is one of the pillars on which our NHS is built.8 Whether patients present with minor or life-threatening conditions, staff aim to deliver high-quality patient care for all. It is my belief that medicine as a whole is a multidisciplinary modality, and it is just as important for private practitioners to support their NHS colleagues as well as each other in providing the best patient-centred care possible. Dr Alex Parys is an aesthetic practitioner in Manchester with nearly a decade of NHS service as both an emergency medicine and clinical radiology specialist registrar. He is an associate member of BCAM, and member of the ACE Group. His special interests include complication management/education and non-surgical body sculpting. Dr Parys has a second clinic opening this month in Bolton offering a 360 body solution programme. REFERENCES 1. Kilgariff S, News Special: Aesthetic Complications, Aesthetics journal, September 2019 <https://aestheticsjournal.com/feature/ aesthetic-complications?authed> 2. Close M, News Special: Lip Filler Complications, Aesthetics journal, January 2019 < https://aestheticsjournal.com/feature/ news-special-lip-filler-complications> 3. Save Face, Consumer Complaints Report 2017-2018 < https:// www.saveface.co.uk/complaints-report/> 4. Gov.uk, Review of the Regulation of Cosmetic Interventions, April 2013 5. J Collier, R Young, N Kirkpatrick, M Gregori, N Hachach-Haram, Complications of facial fillers: resource implications for NHS hospitals, BMJ Case Reports, 2013 6. Creative Research, Regulation of Cosmetic Interventions: Research among the General Public and Practitioners, and Teenagers, Creative Research Limited, March 2013 7. NHS England, A&E Attendances and Emergency Admissions July 2019 Statistical Commentary <https://www.england.nhs. uk/statistics/wp-content/uploads/sites/2/2019/08/Statisticalcommentary-July-2019-ntSgq-1.pdf> 8. The Royal College of Emergency Medicine, Securing the future workforce for emergency departments in England, October 2017 <https://improvement.nhs.uk/documents/1826/ Emergency_department_workforce_plan_-_111017_Final.3.pdf> 9. Blanchard J, Palmer J, Ali E, and Cheng L, Complications of SelfInjected Facial Fillers: A Treatment Conundrum in the UK, Case Reports in Surgery, 2019 <https://doi.org/10.1155/2019/2041839> 10. L Walker, M King, This month’s guideline: Visual Loss Secondary to Cosmetic Filler Injection, J Clin Aesthet Dermatol, 2018 May 11. FTT Skin Clinic, Instagram post <https://www.instagram.com/p/ B1teGcJBrFu/> 12. ACE Group <http://acegroup.online/>

Reproduced from Aesthetics | Volume 6/Issue 11 - October 2019


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