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VOLUME 5/ISSUE 5 - APRIL 2018

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Treating the Neck CPD

Mr Dalvi Humzah and aesthetic nurse Anna Baker explore treatments for the neck

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schucoaesthetics schucoaesthetics

Special Feature: Complication Processes

Case Study: Lip Filler Complication

Publishing Laws

Practitioners discuss how to report complications

Dr Beatriz Molina presents an adverse event with a HA filler

09/03/2018 09/03/2018 16:39 16:39

Journalist Fiona Clark looks at how to avoid breaching publishing legislation


HAS SHE GOT

A SECRET?

r e h n i s ’ It w o l g l a natur

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

restylane.co.uk/saj

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

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


Contents • April 2018 06 News

The latest product and industry news

17 News Special: The Launch of the Joint Council

Aesthetics asks how the practitioner register aims to promote patient safety

20 ACE Preview: Make the Most of ACE

A look at what you will gain from attending ACE 2018

CLINICAL PRACTICE

Special Feature Adopting a Complication Process Page 21

25 Special Feature: Adopting a Complication Process Practitioners discuss what processes to follow when faced with an aesthetic complication

30 CPD: Treating the Neck

Mr Dalvi Humzah and nurse prescriber Anna Baker detail the anatomical features of the neck and how it can be successfully treated

35 Case Study: Lip Filler Complication

Dr Beatriz Molina shares her technique for correcting a lip filler complication

In Practice Using Trust Indicators Page 67

40 Advertorial: Treating the Cheeks

Dr Harry Singh discusses the use of Restylane fillers for facial aesthetics

42 Lips Through the Decades

Aesthetic nurse prescriber Jackie Partridge explains perioral ageing

44 An Introduction to Injectable Complications

Dr Catherine Fairris analyses complications that may occur after toxin and filler injections

48 Advertorial: Introducing Princess Volume Plus

Schuco Aesthetics announces the launch of its latest HA dermal filler

51 Avoiding Needlestick Injuries

Technical manager Luke Rutterford explains how to implement best practice to avoid injury from sharps

56 Advertorial: SkinCeuticals: Integrating skincare Practitioners discuss how to highlight the importance of skincare in clinics 57 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 59 Patient Photography and Data

Risk specialist Martin Swann highlights the misuse of clinical photographs

62 How to Avoid Breaching Publishing Laws

Journalist Fiona Clark details how to avoid breaching publishing legislation

67 Using Trust Indicators

Aesthetic practitioner Tersea Kis discusses how to achieve natural looking lips

71 In Profile: Dr Hema Sundaram

Dermatologist Dr Hema Sundaram reflects on her passion for teaching, science and patient safety

73 The Last Word

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and runs the award-winning Dalvi Humzah Aesthetic Training. Mr Humzah worked as a consultant plastic surgeon in the NHS for 10 years and teaches internationally. Anna Baker is a qualified tutor, cosmetic and dermatology nurse prescriber who has been involved in developing Dalvi Humzah Aesthetic Training since 2012. She is the coordinator and a faculty member for this teaching.  Dr Beatriz Molina is the medical director and owner of Medikas clinics and a KOL for Galderma UK. Dr Molina is also the founder of the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM).  Jackie Partridge is an aesthetic nurse prescriber and completed her BSc in Professional Practice (Dermatology) in 2014. Partridge is an honorary board member of the BACN and a global ambassador for Galderma. Dr Catherine Fairris qualified from Bristol University in 2008 and is an associate member of BCAM. She is now the director of Wessex Skin LTD in Winchester, specialising in minimally invasive cosmetic procedures and cosmeceuticals. Luke Rutterford is technical manager for the Initial Medical and Specialist Hygiene divisions of Retonkil Initial in the UK, with responsibility for training, service development, innovation, quality and compliance.

Marketing consultant Adam Hampson shares advice how your clinic’s use of online trust indicators can drive higher conversion rates

70 Advertorial: The Secret to Natural Looking Lips

Clinical Contributors

Aesthetic nurse prescriber Eve Bird explains why she believes using social media at conferences is essential

NEXT MONTH

Don’t miss ACE 2018 on April 27 and 28. There is still time to register!

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Editor’s letter April brings the ACE issue and we are all set for yet another brilliant event. I always look forward to seeing that sunshine stream through the beautiful glass roof at the Business Design Centre. Did you know that the building was Amanda Cameron originally opened as the Royal Agricultural Hall Editor in 1862 for holding agricultural shows? It was the home of the Smithfield show from 1862 to 1938 and hosted the Royal Tournament from its inauguration in 1880, until the event became too large for the venue. We are in an auspicious building steeped in history, so very appropriate that it should have been the site for ACE – we will create our own place in history on April 27 and 28. At a time in medical aesthetics where we seem to be united in wanting to keep the speciality under the control of medical practitioners only, but are very divided in how best to do that, it would be very satisfying and rewarding for us to come together at ACE. We should focus on learning together and positively take our education forward, so that the main winners are

our patients. In the pursuit of that goal, in this month’s issue we are examining complications and how to manage them. Now, if anything divides those who can, from those who cannot, it is the management of complications where an in-depth knowledge of anatomy, physiology, product properties, treatment technique and pharmacology is a necessity. I am sure we can all agree on that! This month we have a fascinating case study that is a real eye opener on a lip complication (p.35) by Dr Beatriz Molina, as well as an introductory article on the complications most commonly encountered with botulinum toxin and fillers by Dr Catherine Fairris on p.44. Reporting complications is as equally important as managing them, so our Special Feature on p.25 takes a detailed look at the process by talking to some key players in this arena who are working hard to help facilitate the process. Please do come and say hello if you spot us at ACE – we’re always keen to learn more about your clinic lives and hear your ideas for topics to cover in the journal. If you haven’t already registered for ACE, visit aestheticsconference.com to do it for free today!

Editorial advisory board

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

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

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

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

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

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

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

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

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

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

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Dermal fillers

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Legacy Dr Raul Cetto @DrRaulCetto Deeply saddened by the loss of Professor Hawking. A warm, funny and unique individual who will be remembered with affection and admiration all over the world. His exceptional contributions to scientific knowledge have left an indelible legacy #StephenHawking #CouncilMeetings Nora Nugent @NugentNora Busy day ahead with @BAAPSMedia Council meetings! #PlasticSurgery #aesthetics #patientsafety #Training Mr Dalvi Humzah @mdhtraining We are all about #anatomy at the first AnEW Conference in Singapore @pdsurgery sharing #multiawardwinning #facialanatomy knowledge with #internationalanatomists #Education Dr Greg Williams @Drgregwilliams Lecturing in Dubai @ISHRS #WorldLiveSurgeryWorkshop on ‘Long term planning & patient selection in hair transplant surgery’ – critical subject where understanding comes with experience. A good professional reputation comes with satisfied patient #TeamAesthetics Mr Adrian Richards @mradrian.richards #HappyMonday here’s a throwback from the JCCP & CPSA launch at the House of Lords with the talented @aestheticsjournaluk team: Shannon Kilgariff, Chloé Gronow & Amanda Cameron. #RSM Dr Patrick J Treacy  @ptreacy  Some memories of the 10th Royal Society of Medicine Aesthetic Congress 2018 @EUROMEDICOM @RoySocMed

Schuco Aesthetics launches Princess Volume Plus Schuco Aesthetics, the newly launched division of UK distributor Schuco International, has released the latest addition to the Princess dermal filler range to the UK. Princess Volume Plus is said by Schuco Aesthetics to be the most robust formulation in the Princess portfolio. It is a soft, versatile gel with a high G prime and can be used for subcutaneous or deep dermis injection, and aims to provide structure, lift and support for correcting and restoring facial volume, alongside facial contouring. The high G prime formulation means the product can, according to the manufacturer, be used for reconstructive purposes in the treatment of facial lipoatrophy, scars or morphological asymmetry. The official launch is being hosted by aesthetic practitioners Dr Rita Rakus, Mr Kambiz Golchin and aesthetic nurse prescriber Lee Garrett at a Masterclass at ACE 2018, on Friday 27 April at 4-5pm. Please note this session is for medically-qualified professionals only and you will be required to provide a GMC, NMC, or GDC number in order to attend. Complications

Save Face releases new complication statistics Independent accreditation body Save Face has announced that in the last twelve months reports regarding unsafe procedures and rogue practitioners have almost trebled, with a total of 934 reported cases. It claims that more than 83% of the cases were of treatments that were administered by beauticians, hairdressers and other non-healthcare professionals. Upon further investigation, 30% of all complaints received were performed by people who had ‘set themselves up with no relevant training and were believed to be purchasing their products, including dermal fillers and botulinum toxin, over the internet’. It also stated that 84% of patients who reported the complaints had no idea what products were used and how they were sourced, and 39% did not have a consultation at all. Botulinum toxin, laser treatments and PDO thread lifts were amongst some of the most popular procedures that were complained about; however, it was dermal fillers that came out on top with 76% of the complaints being related to this procedure. The most common complaints were associated with lip fillers being uneven, having unsightly lumps and nodules, unusual swelling and bruising, infections, vascular occlusion or a compromise of healthy tissue. The report concluded that Save Face had identified and exposed seven practitioners who were either masquerading as doctors and nurses, or who continued to practice despite being struck off by the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC).

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Chemical peels

AestheticSource launches Skin Tech EPVL Peel The new Easy Phen Very Light (EPVL) Peel by Skin Tech Pharma Group is now available in the UK from aesthetic distributor AestheticSource. Developed by Dr Philippe Deprez, the EPVL Peel combines 15% phenol, 8% TCA and 0.5% croton oil, which, the company claims, offers a unique peel formulation to specifically target photoageing, fine lines, wrinkles, resistant pigmentation and lentigines with minimal downtime. The peel aims to work between the grenz zone and papillary dermis, and can be tailored to offer light to deep penetration ranging from the basal layer to the grenz zone, and deeper to the papillary dermis. The company claims that the formulation is suitable for Fitzpatrick types I-IV and has limited treatment downtime and minimal to no post-peel erythema. Lorna Bowes, AestheticSource founder and director, said, “This exciting innovation allows easy application, consistent results, as well as the significant patient benefit of a one-off medium depth peel.” The EPVL Peel launches April 27, 11-12pm at a free Masterclass hosted by AestheticSource (stand 24) at ACE 2018. The session is restricted to those with a GMC, NMC, or GDC number. Marketing

Dr Harry Singh releases Let Go Of The Handbrake Aesthetic dentist Dr Harry Singh will release his new book, Let Go Of The Handbrake, at an event in London on April 5. The book aims to teach aesthetic practitioners how to get started in aesthetics, how to market their business, manage the patient journey, retain patients, manage finances and make good profits. Dr Singh said, “Let Go Of The Handbrake is a resource which will help you discover your passions, your visions, create your goals, and how to manage your time effectively to reach your business aims. You’ll learn about regulation, effective training, staffing, leadership, marketing strategies and targeted spend, social media, effective consultation practices and building patient relationships, key performance indicators and referral programmes, as well as basic accountancy and partnering with other local businesses.” Practitioners can purchase the resource via the company’s website or at ACE 2018 on April 27-28. Let Go Of The Handbrake is also sponsoring the ACE 2018 Networking Event on the evening of Friday April 27, which will take place at the catering area on the lower level of the Village Green.

Aesthetics

Vital Statistics 62% of people aged between 50-64 think that businesses are trying ‘too hard’ when it comes to using emojis (Statista, 2016)

Breast augmentation remains the most popular cosmetic surgery procedure in the UK with a total of 8,251 cases, which is a 6% increase from 2016 to 2017 (BAAPS, 2017)

In a worldwide study, India is the most popular country to have a tattoo removal procedure with 22,860 cases. Japan came in second with 20,159 (Statista, 2016)

In a study on the use of mobile technology being used in healthcare, 77% of patients said they felt positive about clinicians using mobile devices in their care (Zebra Healthcare, 2018)

38% of women admitted they wanted a ‘fuss-free’ skincare routine whilst 30% said they use more skincare products than they used to (Statista, 2018)

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Learning

Med-fx announces aesthetics seminar dates for April Aesthetic supplier Med-fx has confirmed dates for its CPD-accredited non-commercial education sessions. The sessions aim to bring together the best industry speakers to maximise knowledge sharing and networking in the specialty. They include topics such as dermatology, and complication management, as well as business advice. The sessions will take place in Sheffield on April 12, Bury on April 15, Birmingham on April 17, London on April 19, and Glasgow on April 20. According to Med-fx there are limited places available, so interested practitioners should contact the company for more information and to book.  Tattoo removal

3D-lipo releases the 3D-NanoSure Aesthetic device manufacturer 3D-lipo has launched the 3D-NanoSure multi-platform machine for tattoo removal. According to the company, the 3D-NanoSure is a fast, dual wavelength Q-switched Nd:YAG technology that can remove unwanted dark and multi-coloured tattoos safely and effectively. The device uses 1064 nm wavelength for treating black, blue and other dark colours, while the 532 nm wavelength aims to effectively remove red, orange, pink and other bright colours. The company claims that in combination, the wavelengths can remove 95% of tattoos. The company states that the benefits to patients include: affordability, minimal pain, no downtime and fast results; while practitioners can benefit from a competitively priced system that can also perform pigmentation and melasma removal and skin lightening. For more information, visit 3D-lipo at stand 28 at ACE 2018 on April 27-28. To register free, visit www.aestheticsconference.com. Society

Aesthetic society for Wales A new society for aesthetic practitioners practising in Wales is set to officially launch in June 2018. The Welsh Aesthetic and Cosmetic Society (WACS) is a not-for-profit society that aims to provide an educational and best practice forum for professionals delivering aesthetic and cosmetic services to patients in Wales. Membership is open to doctors, surgeons, dentists, nurses and pharmacists registered with their professional body. According to WACS, members of the association will be supported with free online education, advanced notice of training courses, business advice workshops, an annual conference, peer group networking, referral pathways, and discounts and offers.

27 & 28 APR 2018 / LONDON

ACE OVERVIEW FREE CONTENT On April 27 and 28, more than 2,000 aesthetic professionals from across the country will meet at the Business Design Centre in London for two days filled with unmissable education and networking opportunities. The 17 Expert Clinic sessions, 12 Masterclasses and 12 Business Track workshops are all FREE to attend, and delegates will also have access to the huge Exhibition Floor, featuring live demos and new products from almost 80 top aesthetic suppliers. ELITE TRAINING EXPERIENCE For those looking to enhance their training in 2018, then the Elite Training Experience taster sessions are perfect for you. For just £195 +VAT per session, delegates can attend up to four three-hour training experiences from Dalvi Humzah Aesthetic Training, Academy 102, Medics Direct Training and RA Academy. In each, you will learn new techniques, enhance your anatomy knowledge and watch live demos. Attendees also receive 10% off a future training course with their chosen provider, as well as other discounts exclusive to each Experience. Please note that some access restrictions apply to the Masterclasses and Elite Training Experience, so it’s advised to check the session description in advance! SPEAKER INSIGHT Dr Tristan Mehta, aesthetic practitioner and founder of training company, Harley Academy, will present on The Future of Regulation – JCCP Update. In his talk, Dr Mehta will delve into the state of regulation in the medical aesthetic specialty today and address some hot topics surrounding the JCCP. He says, “ACE is one of my favourite conferences to attend and speak at, as the quality of education is always so high. In times of uncertainty surrounding regulation within the profession, I aim to dispel some myths surrounding the JCCP and give practitioners an unbiased summary of the options available to them.”

ACE HEADLINE SPONSOR

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Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Cellulite

Deleo adds the Diamond applicator to Cristal range Device manufacturer Deleo has added cellulite reduction applicator Diamond to its existing Cristal line. The new applicator aims to reduce cellulite and improve skin tightening to create a smoother texture of the targeted area. It uses an IR light that is absorbed by the targeted tissue and converted into thermal energy in order to heat the fat cells. The vacuum then stimulates fibroblasts by mechanical stress stretches septa, a mesh or net-like fibrous connective tissue forming a network of compartments, by pulsed suction. Export manager, Herbet Samson said, “We are very excited to be launching this new applicator. What makes the Diamond applicator so different to other products on the market is that it combines high intensity focused diode (HIFD) technology with a pulsed suction to have a synergic effect on different skin layers.” He continued, “It’s also ergonomic with a very lightweight and morphological conception for easy use.” For more information, visit Deleo at stand 72 at ACE 2018 on April 27-28. To register free, visit www.aestheticsconference.com.  Appointment

New clinic lead for Harley Academy course Aesthetic practitioner Dr Marcus Mehta is to become the clinic lead for the new Skin Rejuvenation in Aesthetic Medicine course, healthcare professional entry route, run by Harley Academy. Dr Tristan Mehta, CEO of Harley Academy, said, “Our forthcoming qualifications will be available to two main groups; healthcare professionals and aestheticians who have a minimum NVQ Level 3.” He continued, “The course will have a split entry to each group of candidates depending on their background. Dr Marcus Mehta has a research degree in biomedical science, focused on human anatomy and stem cell therapy, alongside his medical degree, which makes him ideally placed for this role.” Dr Marcus Mehta also holds a postgraduate diploma in Clinical Dermatology and works at the Dr Rita Rakus Clinic in Knightsbridge. Harley Academy will be exhibiting on stand 16 at ACE 2018. Stem cells

Calecim launches in UK Singapore-based biotech company CellResearch Corporation will officially launch its cord-lining stem cell-based cosmeceutical, Calecim Professional in the UK at the end of April. According to the company, Calecim Professional reduces post-procedure downtime and enhances treatment results, while also acting as an antiageing homecare product. The formula contains Cord Lining Conditioned Media (CLCM), a protein mix derived from two types of potent stem cell strains (epithelial and mesenchymal) which are ethically and harmlessly harvested from the umbilical cord lining of New Zealand deer. The company states that Calecim Professional has been clinically observed to visibly improve skin fullness, addressing skin laxity and restoring youthful radiance, in as little as two weeks. Calecim Professional will hold its official UK launch at a Masterclass held by Dr Doris Day at ACE 2018 on Saturday April 28 at 10-11am. Please note: this session is available to healthcare professionals only, with a valid professional body number. To register free for this Masterclass, visit www.aestheticsconference.com. 

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

The BACN Membership year runs from April 1 to March 31 so the big focus for our members is on renewing to remain part of the largest professional association for aesthetic nurses in the UK.

BACN BUSINESS SUPPORT PROGRAMME The original ‘Startup’ programme has now been redesigned to include modules for both new entrants to aesthetics and to existing practitioners wishing to grow and expand their businesses. The new programme will be in three stages as follows: Module 1: Introduction to aesthetics as a business • Nurses who are considering entering aesthetics as a career or business. • Nurses who have just started providing aesthetic treatments, either independently or as an employee of an aesthetics provider, and are considering establishing their own business. Module 2: Keys to success in operating an aesthetics business • Nurses who have been self-employed or working part-time and wish to formalise their business arrangements. • Nurses who have been operating an aesthetics business for a while and now wish to expand and/or open a new clinic. Module 3: Business Planning for Your Business – Practitioner and Expert Advice Sessions • Nurses who have been through the business planning process and wish to seek advice from experts and existing practitioners. • Existing nurse practitioners who wish to update and upgrade business practice. • Nurses seeking specific advice in a key element of running their business. Contact Gareth Lewis, BACN Membership and Marketing Manager at HQ for more information and how to book for this programme or any of the modules. This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Events diary 4 – 7 April 2018 th

th

Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc2018.org

27th – 28th April 2018 The Aesthetics Conference and Exhibition 2018, London www.aestheticsconference.com

15th May 2018 British Association of Sclerotherapists 2018 Conference, Dorney www.bassclerotherapy.com

14th – 16th June 2018 BMLA Laser Skin & Body Conference 2018, Rotterdam www.lasereurope2018.com

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

Th13teen Training to launch in May Cosmetic Digital is set to launch a range of courses under a new company, Th13teen Training. The new training academy aims to deliver training and support for clinics that need strategic digital marketing knowledge and practical skills to launch or grow their business. Set to open on May 4, the Nottingham-based courses will include Digital Marketing for Beginners, Advanced Digital Marketing, Google SEO, Google Adwords and Social Media, as well as bespoke tailored courses for clinics that want to focus on specific areas of their marketing and business. “What works for one clinic doesn’t work for another,” said director Adam Hampson, adding, “Their location, number of competitors, range of treatments, types of treatments, and educational background all play a huge factor in their marketing plan.” He added, “There are many training companies, but none with expertise in digital marketing for aesthetics and medical cosmetics, which operate alongside an established digital agency with expertise in the sector. We will share our expertise and knowledge – not from textbooks but from practical skills and knowledge gained and developed from more than 13 years’ working with hundreds of practitioners, clinics, practices and businesses.” Cosmetic Digital will exhibit at ACE 2018 on stand 52.

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Digital

Church Pharmacy launches DigitRx app Medical supplier Church Pharmacy has released a mobile app for its bespoke e-prescribing website DigitRx. According to Church Pharmacy co-director, Zain Bhojani, the app is easy to use and allows for customers to create prescriptions and online orders in a much simpler mobile interface. “DigitRx was launched in October 2014 and we have found that the vast majority of our customers were using it on their mobile devices, so it was a natural step to develop the application for their phones, Bhojani said, adding, “We have seen a lot of downloads very quickly and the feedback has been fantastic. You can prescribe from anywhere while on the go.” Church Pharmacy will exhibit at ACE 2018 on Stand 12. Skin rejuvenation

Lumenis introduces the Photofacial treatment Lumenis has launched the Photofacial that combines existing M22, IPL and ResurFX treatments. The M22 is designed to minimise downtime and aims to help with skin rejuvenation, collagen stimulation, pigmented and vascular lesions, active acne treatment, scarring and stretch mark removal. Lumenis claims the ResurFX can resurface the skin and still protect deeper, vulnerable elements. The laser is a nonablative treatment, that stimulates the production of collagen and elastic fibers. According to the company, the aim of combining the M22, IPL and ResurFX treatments is to significantly improve the tone and texture of the skin, tackle fine lines and wrinkles, acne, pigmentation, scarring and thread veins. The multiple functions in one treatment means that the treatment takes less time, with minimal downtime and is completely bespoke dependent on the skin conditions and skin type. Aesthetic practitioner Dr Benji Dhillon, who performs the treatments at PHI Clinic, said, “Treatments like Lumenis M22, ResurFX and IPL ensure the skin is functioning optimally, increasing the skin’s luminosity and radiance. This improves the health of the skin for a natural rejuvenation. There is minimal downtime to these treatments ensuring they suit patients’ lifestyle choices.” Lumenis (stand 37) will hold a Masterclass on Friday April 27 at 3-4pm. To register free for this Masterclass, visit www.aestheticsconference.com. Conference

New details announced for ACE 2018 With less than one month to go until the Aesthetics Conference and Exhibition (ACE) 2018, more sessions and sponsors have been confirmed. HA-Derma is confirmed as lunch bag sponsor and Healthxchange Pharmacy has been confirmed as the registration sponsor and is also set to launch two new products at the exhibition. The first is the Envy Facial, a skin resurfacing treatment that combines exfoliation, extraction and the infusion of condition rich serums, as well as new products from skincare experts, Obagi Medical. New Expert Clinic sessions have been annouced for aesthetic wholesaler Rosmetics, distributor Fusion GT and equipment supplier Naturastudios, who will also hold a Masterclass, along with manufacturer of antiageing skincare technology Radara, Innoture, Rosmetics and device manufacturer BTL Aesthetics, which is holding a female health workshop on the BTL Ultrafemme 360 with Dr Tracey Sims. To register for ACE on April 27-28, visit www.aestheticsconference.com.

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Aesthetics

Plasma

Beamwave releases new device PlaSon Beamwave Technologies has launched the PlaSon, a new device that combines plasma and ultrasonic technology that aims to bring multiple benefits to the skin. The PlasmaPoration handpiece aims to remove the bacteria and help absorb essential drugs into the skin tissue, as well as aid with skin regeneration by stimulating generation of collagen and fibroblasts, in addition to anti-pigmentation by suppressing melanin pigment. Similarly, the SonoPortaion handpiece aims to increase the cell absorption and drug delivery into the cells, strengthen skin elasticity by stimulating blood circulation, as well as purify the skin by facilitating the emission of melanin in the dermis and epidermis. The device can be used alone with either the PlasmaPoration or SonoPortaion functions, or it can use a combination of both. When both treatments are merged the device can be used for transdermal drug absorption, treating wrinkles, scars, inflammation and wound healing. Visit Beamwave at stand 43 at ACE 2018 on April 27-28. Complications

Speakers announced for IAPCAM 2nd Symposium The director of the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM), Dr Beatriz Molina, has announced the organisation’s second symposium. Taking place on Friday September 21, the IAPCAM 2nd Symposium aims to help the aesthetics specialty provide annual consensus updates on complications as well as practical, evidence-based hands-on training, collaborating with pharmaceutical and aesthetic companies within the UK. “Last year’s symposium went extremely well and I am thrilled that we already have the majority of our complications-focused agenda confirmed,” said Dr Molina, adding, “The agenda will include anatomy education; common complication diagnosis from Dr Harryono Judodihardjo, mesotherapy complication prevention and management by Dr Philippe Hamida-Pisal; thread complications, and a live demonstration on how to use hyaluronidase. Also speaking will be Professor Daniel Cassuto, Dr Kuldeep Minocha, Dr Sandeep Cliff and a spokesperson from Enhance Insurance. I look forward to seeing everyone there!” The IAPCAM 2nd Symposium will take place at the Church House Conference Centre in London and tickets are now available. Finance

Pretty Face Finance new website goes live Aesthetics finance company Pretty Face Finance has launched a new and improved website with multiple features for both clinic owners and patients applying for finance. Clinics can now manage their own price lists/information amendments and view all finance applications made for the clinic. For patients, they can apply for finance and spread the cost between one to nine months, and if they do not already have a preferred clinic, they can use the postcode finder to search for local clinics. “We are so excited to launch our new site which we have been working on for almost 12 months,” said aesthetic nurse prescriber and company founder Rebecca McDermott. For more information, visit stand 76 at ACE 2018 on April 27-28.

60

Teresa Kis, independent nurse prescriber and facial aesthetician Tell us about your experience? I have been carrying out facial aesthetics since 2003 and am a senior nurse trainer; training other doctors, dentists and nurses in basic and advanced dermal filler techniques. Lip augmentation is a big part of my practice. It’s the next most popular treatment after botulinum toxin treatments. I have built my experience over many years and am still adding to my expertise by attending lectures, conferences and watching many others online. I have demonstrated dermal filler techniques at aesthetic conferences and am a member of the British Association of Cosmetic Nurses and the Royal College of Nurses. What advice do you have for clinicians planning to treat patients’ lips? When consulting for lip treatments, I firstly listen to what the patients want, before advising them if their requests are achievable and will look aesthetically pleasing. The ratio should be one third in top lip to two thirds in bottom lip, whilst paying attention to treating the mouth corners and the philtrum ridge. Why are the lips so important aesthetically? Lips are part of the facial triangle that we focus on when we look at a person’s face and, therefore, need to be aesthetically pleasing. Treating an ageing lip can knock years off a person, whilst treating a young person with thin lips can give them a real confidence boost. What are the benefits of the Restylane range? The Restylane range fulfils all my needs – whatever the patient’s age or desired look. Restylane Kysse is great for those first timers who are worrying about the swelling afterwards, as it gives good volume but swells minimally. Restylane Lyps is great for the younger patient who wants a fuller look, whilst still appearing natural. Restylane Refyne is great for the older patients who want a small enhancement with minimal swelling. I also sometimes use Restylane Classic and Skinboosters in the lips to provide different desired looks. RES18-02-0131 Date of Preparation: February 2018 This column is written and supported by

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Body contouring

News in Brief

mesoestetic launches stretch mark and cellulite spray Pharmaceutical and skincare manufacturer mesoestetic Pharma Group has formulated a new topical product that aims to eliminate localised fat and cellulite, while re-sculpting the contours of the body. The ‘bodyshock reduce & go’ comes in a spray format, and, according to the company, is a non-greasy absorbable formula, which makes it quick and easy for patients to apply. The new treatment is formulated with L-carnitine, caffeine, niacinamide and a slimming and anti-cellulite concentrate that is rich in silybin, a polyphenol derived from the milk thistle plant. The company states that this ingredient gives the formulation a slimming and lipolytic action that helps reduce localised fat and drain fluids by reactivating cutaneous micro-circulation. The ingredient also aims to encourage the use of fatty acids for energy, which the company says makes it ideal to use both before and after exercise. The launch of bodyshock reduce & go completes the current range of home treatments in the mesoestetic bodyshock family, complementing the other specific solutions for body contouring. mesoestetic will exhibit at ACE 2018 on stand 31. Microneedling

SkinPen Precision receives FDA approval Microneedling device, SkinPen Precision, by Bellus Medical has been approved by the Food and Drug Administration (FDA), which, according to the company, is the first device of its kind to have received the clearance. Joe Proctor, President and CEO of Bellus Medical said, “FDA clearance for SkinPen Precision demonstrates our unwavering commitment to the safety, quality and excellence needed to elevate the standards in the microneedling industry.” He continued, “With this recognition by the highest organisation in the US, the FDA, providers and consumers know they Restores the naturally youthful look of healthcare the skin through deep regeneration, stimulating can trust SkinPen Precision and Bellus Medical to create, develop and manufacture the production of new collagen and elastin safest and most cutting-edge solutions on the market.” SkinPen is distributed in the UK by in the face, neck, arms and hands. BioActiveAesthetics. For more information, visit stand 6 at ACE 2018 on April 27-27.

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Med-fx will distribute a new cellulite cream from skin689 as well as a new injectable product from Sunekos. Creme Anti-Cellulite aims to structurally improve the appearance of cellulite using patentpending active ingredient CHacoll. The ingredient is said to penetrate the skin deeply and stimulate the collagen synthesis. As a result, collagen fibers build up and the collagen fiber network fortifies. Sunekos is produced by Professional Dietetics, a privately owned Itaiian company that specialises in patented amino acid formulas. The Sunekos 200 is training an injectable aimsorder, to restore dermal tissue and biogenesis For expert or treatment to placethat your talk to andoffithe ndExtra outCellular more today. through theMed-fx regenertion Matrix (ECM). The product uses patentprotected technology using a combination of hyaluronic acid and amino acids. Tiziano Cameroni, owner of ProfessionalKelly Dietetics, said, “Sunekos is totally safe and easy to Zara Vickers Tobin Lorraine McLoughlin Regional Sales Manager:the South Regional Sales Manager: Regional Sales Manager: London use. It aims to restore naturally youthful look of theNorth skin through deep regeneration, 07834 160 785 07525 615 334 07764 803 855 stimulating the production of new collagen andelastin in the face, neck, arms and hands.” *Sparavigna A and Orlandini A Efficacy and Tolerance of an Injectable Medical Device Containing Hyaluronic Acid and Amino acids: A Monocentric Six-Month Open-Label Evaluation J Clin Trials, access journal ISSN:2167-0870 Visit Med-fx atan open ACE 2018 at standVolume 27.7 • Issue 4 • 1000316 MED4113-Sunekos-Campaign-FP-v3.indd 3

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Archidemia to release new resources Medical scientific book and resource provider, Archidemia, will be launching two new products at ACE 2018. The first book, titled Anatomy & Filler Complications, will look at serious vascular embolic complications that may occur with dermal fillers. It discusses the importance of training and educating practitioners as well as preventing adverse events. The second resource, Centrofacial Rejuvenation examines the effects of volume loss and reduced skin surface quality in the ageing process of the face and the restorative power of volume replacement. Archidemia will be exhibiting at stand 73 at ACE 2018. New Endocare CELLPRO Regime Kit The new CELLPRO Regime Kit has been added to the Endocare CELLPRO skincare product range. The new CELLPRO Regime Kit contains the complete CELLPRO daily regime, which includes a day cream, night cream and an eye product. The company claims the kit provides excellent value for both clinics and patients and acts as a good introduction to the CELLPRO daily regime. Skincare distributor AesthetiCare is the UK distributors of Endocare CELLPRO. AesthetiCare is exhibiting at stand 20 at ACE 2018. SculpSure Submental launches Cynosure has officially launched SculpSure Submental for non-invasive body contouring of the submental area. The treatment aims to help patients achieve a slimmer and more sculpted jawline, without surgery or downtime. SculpSure is available as a stand alone device for treating the chin, as well as a hardware and software upgrade for existing users. The treatment indication has a recently certified CE Mark for use in the European Union (EU) and its member states. Skin Collagen Plus released Skincare supplement brand the Advanced Nutrition Programme has released a new product that aims to help support optimum collagen production. The product contains two packs of 60 capsules; the Skin Collagen Support pack and Skin Vit C. The Skin Collagen Support combines plant nutrient antioxidants such as hesperidin, rutin and grape seed extract, with a synergistic complex of vitamins including vitamins A, C and D, which aim to promote healthy collagen, elastin and hyaluronic acid production. The Skin Vit C pack combines vitamin C with bioflavonoids and aims to support collagen formation, even skin tone and promote good skin health.

20/03/2018 12:32

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Conference report

SkinCeuticals Glycolic 10 Renew Overnight Masterclass, London Skincare company SkinCeuticals held an evening masterclass on March 6 to introduce the Glycolic 10 Renew Overnight. The event, which was held at the Bulgari Hotel in London, was led by aesthetic practitioner Dr Uliana Gout. She began by introducing the panel and the schedule for the evening, before discussing the benefits of SkinCeuticals’ latest launch. Dermatologist Dr Stefanie Williams then looked at the importance of skincare in aesthetic practice and provided tips on how to get the best compliance for patients, as well as using the right language and concepts when consulting with them. Dr Williams explained, “I usually explain the success of my clinic using three concepts. One of the concepts is the foundation principle. If you think about your face as the ‘house’, over time things may begin to collapse and that is because something is missing. Our skin needs a foundation just like our houses do and, for me, that foundation is skincare.” The next part of the session welcomed SkinCeuticals CEO, Leslie Harris who introduced the Glycolic 10 Renew Overnight. This was then followed by a live patient assessment with Dr Benji Dhillon, which focused on incorporating in-clinic procedures and cosmeceutical skincare. Dr Gout said, “It has been an excellent evening catching up with colleagues, whilst sharing the latest tips and recommendations for optimising skincare within our clinical practice. It’s a pleasure to be involved in the latest launch of the novel Glycolic 10 Renew Overnight treatment.” On the Scene

Galderma Training Academy Official Opening, Watford Aesthetic trainers were invited to an exclusive guided tour of Galderma’s new training centre at its UK head office in Watford, on February 24. Upon arrival, guests were offered the opportunity to take part in a behind-the-scenes tour of the training centre, which includes a spacious classroom and adjoining sterile treatment room that boasts the latest AV technology. Toby Cooper, head of medical solutions at Galderma, delivered a short presentation discussing the company’s success. He said, “We’re excited that our training faculty has joined us today to celebrate the official opening of our Training Academy. At Galderma, we are committed to the future of aesthetics and dermatology through which educational support has always been a key element to all aspects of provision for our aesthetic customers.” He continued, “Over the last year we’ve created a leading global aesthetic curriculum and we hope our innovative training centre will offer a unique learning space for our award-winning training programmes and continuing education sessions.” To conclude the event, Jemma Cooke, medical education manager, cut a ribbon to mark the official opening of the Training Academy.

RSM Aesthetics 10, London Aesthetics reports on the highlights of the 10th RSM Aesthetics conference Medical practitioners attended the RSM Aesthetics 10 conference on Friday February 23 at the Royal Society of Medicine in hope to review the current best practice of clinical care for medical aesthetic procedures. The main agenda began with a welcome address and introduction by consultant vascular surgeon and RSM associate dean Miss Kaji Sritharan, and consultant plastic surgeon and meeting organiser Mr Jonathan Britto. At the event, delegates learnt about a variety of marketing topics, including ethical marketing from consultant plastic surgeon Mr Jonathan Staiano and content marketing from content producing agency StoryCode founder Laura Peek. Clinical topics included a talk by Singapore-based plastic surgeon Mr Ivor Lim, on how umbilical stem cell technology has had positive results on wound healing and skincare, while aesthetic practitioner Dr Uliana Gout also presented on the latest concepts of ageing prevention. Dr Gout discussed the use of botulinum toxin for younger patients with static lines, hyperkinetic expressions and strong active muscles for line prevention. She concluded, “Prevention and early intervention is a very interesting area and one that we should study further.” Other noteworthy presentations included talks from consultant ophthalmic plastic and reconstructive surgeon Mrs Sabrina Shah-Desai on filler approaches to the eyelids; combination approaches to the face and neck by Dr Souphiyeh Samizadeh; and surgical hair restoration by hair transplant surgeon Dr Greg Williams. Running alongside this agenda were optional small workshops with eight delegates in each. The agenda included beginner’s sessions on fillers and threads, as well as a demonstration of botulinum toxin therapies for the brow, face and neck by Dr Samizadeh. Dermatologist Dr Harryono Judodihardjo, who is president elect designate on the RSM Aesthetic Conference committee, said he enjoyed the talks at the conference. He explained, “I particularly enjoyed the morning symposium on umbilical stem cell technology in the aesthetics of skin and the additional talk about it during the main session by Mr Lim. I learnt something new!” Aesthetic nurse prescriber Liz Bardolph added, “I attended the RSM Aesthetic 10 conference as I was keen to have an update of botulinum toxin for cosmetic use and to learn from others’ techniques. In addition, it is an excellent conference away from sales biases with highly regarded speakers. I felt it was a very worthwhile conference and I was able to do some useful networking.” Delegates were also able to meet aesthetic businesses at the small exhibition, which included Galderma, AestheticSource, Harley Academy, SkinCeuticals, Calecim Professional and AZTEC Services, among others.

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The Launch of the Joint Council

with representatives from the wider sector. These will help to improve patient safety, raise standards and standardise practice across the aesthetics specialty.” In addition, the CPSA has a specific group focused on ‘horizon scanning’. The Authority will monitor new devices and treatments to assess whether they require inclusion After the official launch of the Joint Council for in their guidelines. “Horizon scanning is important because in this industry, new Cosmetic Practitioners, Aesthetics asks how the things come out almost every week. So, practitioner register aims to promote patient safety even if we produce the standards today, next week there could be new treatments On January 8, 2016, the concept of the Joint Council for Cosmetic that are not included as they don’t yet exist,” he says. Data gathering, Practitioners (JCCP) was announced. From the start, its aim was to such as adverse events, and product safety and efficacy, is also a provide credible regulation, protection and guidance for the public stated priority for the CPSA. Mr Woollard explains, “Scientific data in an unregulated sector.1 in the cosmetic world is dismal. We will gather reports on adverse It followed training qualification recommendations published by incidents and near misses as well as patient-reported outcomes. Health Education England in October 2015 that outlined different This will provide data on treatments that are associated with poor levels of learning (Levels 4-7) for practitioners delivering aesthetic outcomes or higher risk. The idea is that practitioners and patients treatment. HEE also acknowledged that the specialty needed a will report to the CPSA information and data on products, devices, joint professional council to assume ownership of the cosmetic treatments and adverse events so that we can raise the standards industry standards for education and training.2 This guidance was across the board and protect patient safety. The CPSA would then commissioned by the Department of Health in response to the 2013 feed this data regarding concerning products, devices or practices Keogh report, which stated, ‘It is our view that dermal fillers are a on to the Medicines and Healthcare products Regulatory Agency crisis waiting to happen… In fact, a person having a non-surgical (MHRA) or the regulatory bodies.”4,7 cosmetic intervention has no more protection and redress than someone buying a ballpoint pen or a toothbrush.’3 The structure of the Joint Council Two years later, on March 1 of this year, the JCCP’s voluntary registers The JCCP has two separate registers, one for practitioners who can for approved practitioners and education and training providers demonstrate that they have met the appropriate education, clinical launched. This was alongside the launch of the Cosmetic Practice and practice standards as outlined by the JCCP and the CPSA; and a Standards Authority (CPSA), a group of specialists who set the practice separate register of approved education and training providers.8 Standards for the JCCP.4 The JCCP Practitioner Register is divided into two parts. The first is The official unveiling took place on February 22 at the House of for those registered with a professional statutory regulatory body Lords in London. On the evening, consultant plastic surgeon and (PSRB), including the General Medical Council (GMC), the Nursing and chair of the CPSA, Mr Simon Withey, said, “If practitioners abide by Midwifery Council (NMC), the General Dental Council (GDC), the Health the code of conduct and follow the CPSA’s standards, then this will and Care Professions Council (HCPC) or the General Pharmaceutical hopefully avert the crisis that Sir Bruce Keogh anticipated when Council (GPhC). The second is for practitioners who are not in current he wrote his report.”4 Professor David Sines, chair of the JCCP, membership with, or are not eligible to join a PSRB, for example, added that the JCCP now has charitable status, and is currently aestheticians and beauty therapists.9 awaiting formal accreditation by the Professional Standards Authority (PSA).4,5 They have also signed an agreement with Ofqual for training standards and signed a memorandum with the Advertising Standards Authority (ASA) to ensure that the public receive honest declarations of practitioner and treatment information.4,5 The registers are now open to join. However, there is disagreement amongst the medical aesthetics community about how exactly the voluntary register for practitioners will work to promote patient safety.

Creating guidance Before the JCCP could launch, it needed a clear set of standards that could be used as a benchmark for education and training. These standards have now been developed by the JCCP. In addition, practice standards have been developed by the CPSA, which have now been adopted by the JCCP as a benchmark of practice proficiency for practitioners in each of the modalities that they recognise.6 Consultant plastic surgeon Mr Alex Woollard, CPSA board member and trustee, explains, “The CPSA’s first role has been to create practice standards based on clinical risk, which have been produced by a number of experienced practitioners in consultation

“The idea is that practitioners and patients will report to the CPSA information and data on products, devices, treatments and adverse events so that we can raise the standards across the board and protect patient safety” Mr Alex Woollard

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Beauty therapists and injectables Many medically qualified practitioners have expressed concern regarding the JCCP allowing beauty therapists who perform dermal filler and botulinum toxin treatments onto the register. In response to this, Professor Sines has said that the JCCP is trying to make patients as safe as it is feasibly possible in the absence of statutory regulation. “Legally, there is nothing to prevent a therapist injecting into the head, neck or face,” he explains, adding, “We have made it clear in our standards that any beauty therapist administering botulinum toxin and dermal filler injections can only do so under the supervision of a JCCP-registered clinical prescriber who must remain personally accountable.13 It’s clear that until there is change the legislative framework, then we must do our absolute best to regulate and to bring people to account.” When asked about therapists who simply choose not to join the JCCP register, Professor Sines states, “It is a voluntary register and I will always argue that nothing less than statutory regulation will protect the public. At present, all we can do is make the register as accessible as possible to all individuals, without diluting the standard or the supervision level that we require for patient and public safety.”

Professor Sines says that joining the JCCP register involves a straightforward online application. He states, “It costs £450 per annum. For PSRBs, applicants must provide evidence of their PSRB PIN number, declare they are of good character and willing to abide by the JCCP and CPSA Joint Code of Practice,10,11 agree that their premises of operation are named and meet the JCCP Premises Standards, evidence of indemnity, and confirm that they meet all the CPSA’s standards for education and training.” Professor Sines says that the same process will be followed by all registrants, although nonPSRB registered practitioners will not provide a PSRB PIN number. Mr Woollard also notes that only practitioners who have trained with a JCCP-accredited training provider, or who are able to demonstrate that they have undertaken an equivalent standard of education and training with another provider, will be accepted onto the JCCP register.6 He states, “The standards have been written for both experienced practitioners and to guide those who have just come out of a training establishment and want to set up a practice. At present, we are in a transition period that requires a complex grandfathering process. In in a few years’ time, once this has been established and hopefully the landscape has evolved, I would be questioning why someone had gone to a trainer who was not JCCP-accredited.”

“It is a voluntary register and I will always argue that nothing less than statutory regulation will protect the public” Professor David Sines

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For those already on the Treatments You Can Trust (TYCT) register, a voluntary register which lists practitioners tested against published guidelines, Professor Sines explains that registrants will be invited to transfer to the JCCP Register as provisional members of the JCCP. However, he states, “No TYCT registrant is being automatically accepted onto the JCCP register and they still have to meet all of our standards in exactly the same way as any other registrant. At their next renewal date, they will be invoiced by the JCCP and go through the formal process, should they choose.”12 Professor Sines doesn’t yet know how long the registration process may take, but estimates that most applicants should hear back within four to six weeks. Registration lasts three years, but Professor Sines says, “There will be an annual subscription fee, and practitioners must provide an updated copy of indemnity insurance, as well as perform several other declarations, including advising the Council of any untoward or adverse incidents that have occurred during the previous twelve months.”

Responsibilities of members All practitioners on the register will be responsible for continuing to maintain the high standards as outlined by the JCCP and the CPSA. However, Professor Sines says there are several key notable responsibilities that should also be mentioned. He explains, “What is crucial is that every year practitioners must disclose the adverse events they have come across over the past year. If we find that a practitioner on our register hasn’t been declaring such incidents, this could well be a reason for us to seek their removal from the register because it’s a condition of best practice to be open and transparent in the interests of patient safety.” As well as this, once registered, practitioners must abide by the CPSA’s Supervision Matrix (Figure 1).13 This is a document that outlines the requirements for supervision for different types of practitioners. The document is too complex to detail in this article, but the level and nature of supervision varies according to the procedure risk, HEE level, background of practitioner and the discretion of the supervisor. Practitioners should visit the CPSA’s website to find out more.13 One purpose of the Supervision Matrix, Mr Woollard notes, is to discourage ‘lone practitioners’ and ‘ghost supervision’ and instead encourage the development of geographically local support networks. This is to ensure support for practitioners at all levels and provide a clear process of accountability, as well as encourage shared learning and quality improvement. He explains, “People have in their heads that supervision means they are never able to have an independent practice. But, for any healthcare professional, supervision is something that should be part and parcel of their working life. Everyone, no matter how senior they are, will have a supervisor – someone who oversees and looks at your practice. It’s part of appraisal as recognised by the GMC, and it is part of a network of support.” As an example, a practitioner performing microneedling treatments at Level 4 must have a supervisor who is at least Level 5 for microneedling. If a practitioner is a Level 7 for a particular treatment, they will need to be supervised by one of their peers who is also at Level 7 for that procedure. Mr Woollard says that a supervision register will be set up in the future, and encourages potential supervisors to get involved.

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


Aesthetics

Irresponsibility will have consequences If the practitioner does not abide by the JCCP and CPSA’s requirements, they may be subject to investigation and potentially be removed from the register.14 Professor Sines adds, “We have made it very clear to the PSRBs and have agreed that if we discover a complaint, or investigate one of our members, we will also notify their professional regulator. The JCCP has now signed a memorandum of understanding with the CEO of the GMC in this regard with plans to extend to other PSRBs. Registrants will be advised that the JCCP will always refer to their respective PSRB if there have been any concerns or complaints about their proficiency or fitness to practise.”13

B O O K L A U N C H P A R T Y

Spreading the word The JCCP register will open to the public in early April 2018, allowing them to view practitioners who have met the requirements. ​ However, Professor Sines acknowledges that creating awareness and getting patients to search the register is a challenge. “I think a major challenge now is both practitioner and patient adoption, so marketing and promoting the JCCP is going to be key. We are already working with a major social media company and we have been on the radio to disseminate the message. We also have celebrity Leslie Ash supporting both the CPSA and JCCP, which is helping our campaign,” he says. Professor Sines concludes by arguing that if they can achieve public awareness, it will help promote patient safety. He states, “We are seeking to become a thoughtful organisation. An organisation that encourages the pursuit of trustworthiness and effective collaboration amongst its partners to protect the public and provide excellence in practice. It’s not easy – we’ve had many pushbacks – but we are resilient.” Mr Woollard adds, “This is a voluntary register; we hope that it eventually becomes statutory, but at this point in time it is voluntary. The big message is that we have a real opportunity here to radically change the status of the industry and tighten up loopholes. I hope that people see this in a positive light. This is an attempt to lift things up, to give credibility to the sector and raise the bar. Above all, to protect our patients. It’s gaining real momentum.” REFERENCES 1. Kilgariff, S, ‘The Future of the JCCP’, Aesthetics, July 2016 <https://aestheticsjournal.com/feature/ the-future-of-the-jccp> 2. Health Education England, PART TWO: Report on implementation of qualification requirements for cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, The Department of Health, (2015) pp.15- 22. 3. Gov.UK, Review of the Regulation of Cosmetic Interventions, (2013) <https://www.gov.uk/ government/publications/review-of-the-regulation-of-cosmetic-interventions > 4. Aesthetics, On the Scene: JCCP Launch, House of Lords, Aesthetics, February 2018. <https:// aestheticsjournal.com/news/on-the-scene-jccp-launch-house-of-lords> 5. JCCP, About Us - Mission Statement & Values, 2018 <http://www.jccp.org.uk/AboutUs/JCCPConstitution> 6. CPSA, CPSA Clinical and Practice Standards Overarching Principles, <http://www. cosmeticstandards.org.uk/uploads/1/0/6/2/106271141/20180303_cpsa_overarching_principles_ final.pdf> 7. JCCP, JCCP and CPSA Guidance for Practitioners Who Provide Cosmetic Interventions. <http:// www.jccp.org.uk/ckfinder/userfiles/files/JCCP%26CPSA%20Code%20of%20Practice.pdf> 8. JCCP, Membership Type, 2018. <http://www.jccp.org.uk/JoinNow#> 9. JCCP, Structure of the Register, 2018 <http://www.jccp.org.uk/PractitionersAndClinics/structure-ofthe-register> 10. JCCP, Appendix 7: JCCP and CPSA Guidance for Practitioners Who Provide Cosmetic Interventions. <http://www.cosmeticstandards.org.uk/uploads/1/0/6/2/106271141/jccp_cpsa_code_ of_practice.pdf> 11. JCCP, JCCP/CPSA Code of Practise, 2018 http://www.jccp.org.uk/PractitionersAndClinics/jccpcpsa-code-of-practise 12. TYCT, Transfer of TYCT Register to JCCP Register What you need to know, 2018, <https:// treatmentsyoucantrust.org.uk/transfer-of-tyct-register-to-jccp-register/download> 13. CPSA, CPSA Supervision Matrix Please consider this Supervision Matrix for a Day 1 Practitioner, 2018. <http://www.cosmeticstandards.org.uk/uploads/1/0/6/2/106271141/20180103_cpsa_ supervision_matrix_final.pdf> 14. JCCP, Joint Council of Cosmetic Practitioners (JCCP) Terms and Conditions of Registration, 2018. <http://www.jccp.org.uk/ckfinder/userfiles/files/JCCP%20Terms%20%26%20Conditions%20of%20 Registration%20V1_13Feb%20.pdf>

To secure your place at this exclusive event, please visit... letgoofthehandbrake.com S E E U S O N S TA N D 5 6

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At the Amba Hotel, Charing Cross, Strand, London WC2N 5HX “This book is for ALL medical practitioners practising or wishing to practise in medical aesthetics. Whether you’re a learner driver or someone who has got a bit jaded and is stuck in the middle lane, this book will pump you so full of fuel and ambition that you will want to push your business to Formula One levels” Lorna Jackson

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Make the Most of ACE 2018 On April 27 and 28, aesthetic professionals from across the UK will join together for two days of education and networking at the Aesthetics Conference and Exhibition. Read on to find out what you will gain from attending! What’s on your learning agenda for 2018? Whether it’s updating your clinical skills or enhancing your business acumen, the vast variety of topics covered at the Aesthetics Conference and Exhibition (ACE) will ensure you’re equipped with the latest techniques and knowledge to maximise patient satisfaction and retention! As well as boosting your learning at ACE, you will have the opportunity to meet fellow aesthetic practitioners, engage with renowned speakers, and discover the latest

products and treatments from the UK’s top suppliers, distributors and manufacturers. With so much going on under one roof, the event is not to be missed! It’s free to attend and you can drop in for just a couple of hours or make the most of the full two days! You can also upgrade your free pass to include up to four Elite Training Experiences, which cost just £195 +VAT per session. Check out what you will see at ACE 2018:

FRIDAY APRIL 27 EXPERT CLINIC

2018

0.5 CPD POINTS PER SESSION

The Expert Clinic is situated at the farthest end of the Exhibition Floor and will present 17 sponsored sessions across the two days. It has a live demonstration stage and high quality AV, making it easy for you to watch the speakers showcasing their techniques in action!

• Radiofrequency with ENDYMED; discover new techniques for performing fractional treatments, hosted by AesthetiCare • Lip augmentation with the Teosyal Pen and Teosyal RHA 2 and 3; country expert for Teoxane UK Dr Lee Walker will outline the theory and practical application of lip treatments, while highlighting the anatomical considerations and danger zones to be aware of when treating this area • Correction of the tear trough using Teosyal Redensity 2; learn more about the Two Point Eye Lift – a unique approach to treating the under-eye area, developed by Teoxane key opinion leader (KOL) Dr Kieren Bong • The latest updates from Fusion GT; discover the latest products from aesthetics equipment supplier Fusion GT • Cannula techniques with Needle Concept; a leading KOL will demonstrate the latest range of cannulas, and how they are used, from this French medical device company • Clinical skills with Church Pharmacy; look forward to this engaging session on injectable techniques from medical supplier Church Pharmacy • Mid-face sculpting with the Teosyal Pen and Teosyal RHA 4/ Ultra-Deep; Teoxane KOL Dr Wolfgang Redka-Swoboda will focus

on volume replacement and achieving fantastic results by using sculpting techniques • Overview of ThermaVein Rapide; Professor Nadey Hakim will talk on this latest device from ThermaVein, which uses thermocoagulation to eliminate thread veins in a safe and permanent treatment • Combining peels and RRS Injectable Biorevitalisation; utilising a combination of TCA peels and RRS, AestheticSource KOLs Dr Evgeniya Ranneva and Dr Philippe Deprez will discuss how to achieve ultimate face and body rejuvenation, targeting photoageing and pigmentation • Laser treatments with PICO Genesis; in Cutera Medical’s session, Dr Sach Mohan will detail how the two-in-one laser can treat a range of aesthetic concerns

MASTERCLASSES The 12 Masterclasses will be held in two private rooms situated on the upper floor. 2018 They comprise practical demonstrations and in-depth discussions of the latest products and treatments from leading KOLs. The 1 CPD P O I N T P E R Masterclasses generally fill up fast, so you’re encouraged to arrive early to guarantee a SESSION seat! Access to several sessions may be restricted to some professionals, so check the programme on the website or in your ACE Guide in advance. • Maximising success with Innoture; learn about microneedlebased solutions using a patented, mass manufacture process • Unique delivery methods with Plasma BT; Dr Beatriz Molina

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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will demonstrate the technology, methodology and application of sublimative and non-ablative plasma, utilising the Plasma BT device from Beamwave Treating common skin concerns with SkinCeuticals; effective management techniques for pigmentation, blemishes and fine lines, using chemical peels in combination with clinically-proven skincare regimens will be discussed by Dr Uliana Gout Lips through the ages with Restylane; Galderma KOL and nurse prescriber Jackie Partridge will present on how lip trends have developed through time, while outlining appropriate treatment methods for the perioral area Using the M22 IPL System; discover the advantages of using this new technology as an alternative to pulse dye lasers, in which Lumenis laser specialist Kevin Williams will present case studies and share his expertise Latest innovations in facial contouring and volumising with Princess dermal fillers; an expert panel will discuss how to maximise your clinic portfolio offering with this new dermal filler from Schuco Aesthetics, featuring live demonstrations and Q&As

Aesthetics

BUSINESS TRACK These 12 innovative workshops from business experts across the aesthetic specialty will provide you with everything 2018 you need to know about how to run a successful practice. All aesthetic 0.5 CPD P O I N T S P E R professionals are encouraged to attend, including practitioners, clinic managers, SESSION marketing teams, brand directory and clinic staff – your whole team can benefit from this varied agenda! • Attracting, converting and retaining patients; Dr Harry Singh will advise how you can master all three to turbo boost profits from facial aesthetics • Avoiding VAT pitfalls; the law surrounding VAT will be presented by specialist Veronica Donnelly, who will give examples of her successful history in dealing with reviews and appeals • Scaling up and/or exiting aesthetics; whether you are planning to maintain your practice or grow it to maximise value for acquisition,

Gary Conroy, sales and marketing professional, will share his advice on how to strategically plan to increase your clinic’s value Top 10 benefits of training and education; how do you identify the training and qualifications to invest in? And can it really make a difference to your bottom line? Education specialist Dr Elizabeth Raymond Brown will help you decide Boosting business performance; business consultant Marcus Heycock will talk on how to identify critical operational KPIs to allow you to gain insight on developing and implementing successful growth strategies Digital marketing; an in-depth discussion on how to gain better results from your marketing budget, increase online conversion rates to attract more enquiries, avoid digital marketing mistakes and improve your Google ranking, from digital marketing specialist Adam Hampson Under promising and over delivering; consultant plastic surgeon Mr Adrian Richards will look at the key elements to building a sustainable business and discuss the concept of under promising and over delivering to meet patient expectations Building clinic success through PR and marketing; whether you’re a newly launched clinic staking your claim in the specialty, or an established clinic looking to head off competitors, PR consultant Julia Kendrick will reveal how to help drive new revenue and growth through your PR and marketing strategies Bringing together clinical excellence and business success; Lorna Bowes, aesthetic nurse and director of a leading distribution company, will share her knowledge on building patient satisfaction, while delivering a positive profit and loss sheet at fiscal year-end Insurance updates; led by Business Track sponsor Enhance Insurance, this session by Martin Swann will update you on key aesthetic insurance news and advice

SATURDAY APRIL 28 EXPERT CLINIC • Venus Concept updates; discover the latest medical aesthetic technology to help grow your practice, expand your patient database and increase your return of investment • Light-based aesthetic treatments with Cynosure; an expert KOL will outline how Cynosure’s products can be used for a diverse range of treatment applications • Incorporating IBSA Farmaceutici Italia’s products into your clinic; Dr Gabriel Siquier Dameto will talk about the products distributed by HA-Derma in the UK, which include Aliaxin, Viscoderm and Profhilo • Gaining successful outcomes with Rosmetics; find out more about the products from this company, including the award-winning

Stylage and Revitacare ranges, as well as VI Peel for Fitzpatrick skin types I-IV, Magic Needle blunt cannula, Regen PRP and the U225 Mesotherapy Gun • Skin treatments with Naturastudios; a discussion of the products and treatments from this equipment supplier, including the Dermapen • New approach to deeper peels; Unique Skin’s KOL Dr Jean-Luc Vigneron will demonstrate how

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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to use TCA peels of a high strength to produce greater results that can be pain-free for the patient and performed without medication • Creating a slim face with RRS Injectable Biorevitalisation; Dr Evgeniya Ranneva will present again on RSS – this time outlining how to help patients achieve a slimmer, more defined face using the range of products distributed by AestheticSource

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You will have the opportunity to meet fellow practitioners, engage with renowned speakers and discover the latest products and treatments

MASTERCLASSES • Stem cells in cosmeceutical skincare with Calecim; New York dermatologist Dr Doris Day will unveil Calecim Professional’s globally-patented cord-lining stem cell technology and showcase how this material can revolutionise both homecare and postprocedure cosmeceuticals • Perfecting the balance of TCA and phenol with SkinTech; the new Easy Pen Very Light Peel will be the focus of this Masterclass, which will help change your deep peeling practice and provide patients with a comfortable treatment with minimal risk of complications, led by Dr Philippe Deprez • Beauty through expressions with Galderma; an in-depth discussion of how practitioners can treat their patient with Restylane dermal fillers to maintain natural beauty • Skin devices with Naturastudios; hear from a leading KOL on the products and devices to support your practice in 2018 • Non-surgical devices with BTL Aesthetics; an overview of the latest technology to add to your clinic with Dr Tracey Sims • Skin support with Rosmetics; learn how to use the products and treatments on offer from this company, such as the award-winning Stylage and RevitaCare ranges

know when starting your clinic journey • The future of regulation – a JCCP update; Dr Tristan Mehta will provide an overview of how the Joint Council for Cosmetic Practitioners will work, while explaining the state of regulation in aesthetics today • Insurance overview; psychotherapist and founder of Pre and Post Procedure Support (PaPPS) Norman Wright will bring his insight to this session, supported by Business Track sponsor, Enhance Insurance • Choosing a training course; nurse prescriber and tutor Anna Baker will detail key considerations when selecting a training course – from the teaching qualifications of the tutor to critical reflection of individual learning needs • Branding in aesthetics; successful London clinic owner Dr Rita Rakus will provide her latest tips for successful business branding • Claim trends for 2017; insurance consultant Naomi Di-Scala will run through an analysis of claim trends seen in 2017, while providing advice on what areas can be improved upon and how practitioners can reduce their risk of a claim

BUSINESS TRACK • Affordable finance options for your patients; nurse prescriber and entrepreneur Rebecca McDermott will explore the current demand for affordable yet ethical payment plans for aesthetic patients, and how practitioners can help them spread the cost of treatment • The dos and dont’s of a website; key actions on maximising visits to your site and encouraging users to book clinic appointments will be discussed by digital specialist Tracey Prior, who will also advise on what to avoid on your website • Building a clinic from scratch; nurse prescriber Jacqueline Naeini will share her experience of opening a new clinic and establishing a returning patient database, while outlining everything you need to

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E L I T E

T R A I N I N G E X P E R I E N C E

2018 3 CPD

POINTS PER SESSION

FRIDAY APRIL 27 Dalvi Humzah Aesthetic Training (DHAT) This unique session, led by multi-award-winning consultant plastic surgeon Mr Dalvi Humzah, comprises an international expert faculty that includes dermatology nurse prescriber Anna Baker, dermatologist Dr Hema Sundaram, general surgeon Dr Wolfgang Redka-Swoboda and founder of Cosmetic Digital, Adam Hampson. The team will share practical and interactive advice on how to enhance your skills using cannulas, as well as how to address specific skin concerns and facial areas. Mr Humzah will demonstrate his new trademarked procedure – the MD Lift – for a medium-depth lift for nasolabial folds. As an attendee, you will receive 10% off a future course with DHAT, 50% off a box of TSK needles of your choice, and 10% off a digital marketing course with Cosmetic Digital, when purchased at ACE. Access to this session is restricted to doctors, dentists and nurses with valid GMC, GDC or NMC numbers. Academy 102 Founder and medical director of the renowned PHI Clinic on Harley Street, Dr Tapan Patel, will feature high definition videos from his new e-MASTR platform and perform live demonstrations of filler and toxin procedures so you can see first-class facial rejuvenation treatments in action. This interactive session will allow you to ask Dr Patel key questions on an array of injectable topics, ensuring you go home equipped with valuable new skills and knowledge to build upon your clinical offering. You will receive 10% off a future course with Academy 102 when you attend this taster session. Access is restricted to doctors, dentists, nurses and pharmacists with valid GMC, GDC, NMC or GPhC numbers.

SATURDAY APRIL 27 Medics Direct Training In this dynamic and engaging session, international speaker Dr Kate Goldie will present interactive live demonstrations on the art of individualised mid-face treatments, discussing how to beautify patients while keeping their uniqueness. She will also explore the art of lip sculpting and outline how to shape a young, dynamic lip and refresh an older lip, while giving specific guidance on combining fillers and toxin to balance the flow and transitions of the facial profile. Periorbital treatments will also be discussed by Dr Goldie, and if you attend you will be invited to discuss your individual cases at the Medics Direct Training stand. After the workshop, you will also receive a complementary e-learning module with the highlights, technique videos and theory of the workshop, as well as 10% off a future training course with Medics Direct Training. Access is restricted to doctors, dentists, nurses and pharmacists with valid GMC, GDC, NMC or GPhC numbers. RA Academy Global key opinion leader Dr Raj Acquilla will be joined by nurse prescriber Jane Wilson to share his injection techniques for a total-face approach to treatment, covering facial aesthetic ideals for male and female patients, treatment planning, facial anatomy for hyaluronic acid and botulinum toxin injection with live demonstrations, as well as risk avoidance and complication management. His talk will use a make-up artist to discuss illumination, show projection and depressions while geometry, ratios, proportion and angles will be discussed. The perception of sadness and anger during ageing and how injectables can create facial serenity will also be covered. Attend this session for 10% off a future training course with RA Academy. Access is restricted to doctors, dentists, nurses and pharmacists with valid professional numbers.

I attended last year, is it worth me attending again this year? Absolutely! There have been so many new products, devices, treatment and techniques launched in the past year that there will be plenty of new things to discover. ACE is also a fantastic place to gain CPD points for your revalidation, so don’t forget to be scanned into sessions you attend. There’s so much on – how can I organise my time at ACE? The ACE website has a fantastic function called ‘Add to My Agenda’. When you click on a session within the programme, you can click the Add to My Agenda to create a personalised timetable that you can print off and bring to the event. I’m a practitioner, can I bring my clinic team along with me? Definitely! ACE is valuable to anyone involved in aesthetics. The Business Track is a great place to learn about the commercial aspects of running a practice, while the Exhibition Floor offers everyone the opportunity to watch live demos, as well as discover all the up and coming products and treatments. Access to Masterclasses and Elite Training Experiences are restricted, so all attendees should check these agendas in advance. How do I get to ACE and where can I stay nearby? ACE is held at the Business Design Centre in Islington, London. It’s within walking distance of Angel tube station, which serves the Northern Line, and is only a short distance from King’s Cross and Euston mainline rail stations, which offer multiple tube services. The venue is conveniently located on the A1 which joins several main roads including the North Circular, M25 and M1. Parking is available. There’s a Hilton hotel right next door to the venue, as well as a range of hotels to suit any budget within walking distance. More information is on our website.

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Adopting a Complications Process Aesthetics looks at the guidance available for practitioners when avoiding and reporting a complication It’s something that no practitioner ever wishes for, yet almost all will experience this during their medical careers: a complication. Complications can occur from all types of non-surgical aesthetic treatments including injectables, lasers and energy devices. Complications range from the mild, such as swelling and bruising, to the very severe and rare, such as vascular compromise. Whilst numerous training providers aim to provide adequate teaching in how to effectively and safely manage complications from a clinical perspective, many practitioners have different ways of ensuring they are prepared for an adverse event, recording the incidence and reporting the complication. In this article, Aesthetics explores the complications guidance available and practitioners provide their advice on recording and reporting adverse events.

Preparation If a patient experiences a complication after leaving the clinic, will they know what to do and where to turn? This is one concern amongst practitioners, as there are many anecdotal instances of patients not informing the original practitioner of an adverse event, and instead, seeing their GP or going to their local A&E. “Patients must be equipped with comprehensive aftercare instructions,” says aesthetic dentist Dr MJ Rowland - Warmann, who completed a dissertation on hyaluronic acid dermal filler complications as part of her Master’s in Aesthetic Medicine. “Aftercare instructions should be given before the patient even has their procedure, as it is part of the initial consent process,”1 she adds. Dr Beatriz Molina, founder of the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM), says, “I have seen a huge increase in people walking into my clinic saying they were treated six or more months ago with a filler, they had a complication and didn’t know what to do, so just ‘put up with it’.” She explains that one patient flew from Glasgow to her Somerset clinic, after the patient’s GP recommended she see her. “The patient had spent nine months with bags under her eyes due to a superficial filler placement, and it was something that was easily corrected; she just didn’t know what to do.” As part of Dr Molina’s work with IAPCAM, she is creating guidelines and instructions for both the patient and practitioner. “For the patient, instructions will say ‘if things go wrong this is what to do’ and the same for the practitioner,” she explains. What about complications that happen in clinic? You may be the most competent practitioner, but Dr Rowland-Warmann emphasises that you should always be prepared for an adverse event, “I’d recommend having an algorithm stuck to the inside of your cupboard door, because you may forget everything at a time of despair; whether it says: ‘call this number for this complication’ or ‘do this, do that’ it will help you stay collected and professional in front of the patient, which will help keep them calm.” Mr Dalvi Humzah, plastic reconstructive and aesthetic surgeon and

founder of the Aesthetics Interventional Induced Visual Loss (AIIVL) Consensus Group, says, “I think practitioners should have an emergency handbook for all types of complications. They should have a step-bystep guide, that is unique to their clinic or clinical environment.” He adds, “And what’s most important, is that you must make sure the patient is fully informed as to what is happening and the pathway that you might be taking to deal with it.”

Support Although all medical professional bodies, such as the General Medical Council (GMC), the Nursing and Midwifery Council (NMC), General Dental Council (GDC) and General Pharmaceutical Council (GPhC) would expect practitioners to know how to deal with a complication, there may be times when you need assistance and support, especially in particularly difficult and unique cases.1,2,3,5 For example, the GPhC standards states, “Medical emergencies can happen at any time. You must make sure that there is at least one other person available within the working environment to deal with medical emergencies when you are treating patients.” Dr Martyn King, chairperson of the Aesthetics Complications Expert (ACE) Group says, “If the complication is out of your depth, then clinically you are obliged to contact a more experienced practitioner or ask for help according to the GMC;1 a lot of people will buddy up with somebody for this purpose.” He adds, “From an ACE Group point of view, practitioners can go on the ACE Facebook forum and ask for some advice; if time’s permitting. They can also contact the ACE Group directly and we will give them help and advice on how to manage it. Often, we can arrange a consultation and see the patient together.” Mr Humzah has concerns over practitioners getting the wrong advice from social media and unendorsed forums, so advises to use these with caution. He explains, “There is a vogue at the moment for going on the internet and talking in unofficial forums and that may not be the best way to deal with a complication as you may get conflicting advice.” Dr King agrees, adding, “It depends how the forum is set up; there are a lot of forums that are quite derogatory. The difference with the ACE Group is that we have a professional forum which only allows discussions on complications, so anyone asking lots of questions on other matters or posting adverts get moderated quickly; we have zero tolerance. If you are going to use a forum it needs to be properly moderated.” Dr King also notes that if you are asking for advice and potentially posting pictures onto a forum, you need to make sure you have the proper consent from the patient.4 Dr Molina says, “All practitioners should know how to deal with a complication, however, there are times where you might not be sure and you need the support of a practitioner, especially those who work on their own.” She adds, “It is best to have a very good network of peers you can call on.” It is also important to build relationships with local hospitals in case of the rare occurance of a vascular compromise, according to Dr Rowland-Warmann. She says, “Firstly, stop, take stock of the situation and reassure the patient as it is going to be just as stressful for them as it is for you. Then, for an emergency such as vascular compromise, have a mentor you can call, have a local hospital number, and know where your local eye hospital is if a patient has suffered vision loss. It’s also imperative to know exactly who to call at the hospital too for

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


Contour & Define

1

Favourable rheological properties to create contours, shape and definition2 RadiesseÂŽ is designed to contour and define fundamental areas that accentuate facial shape, such as the jawline and lower face.2

The Ageing Jawline 4

M-RAD-UKI-0093 Date of Preparation January 2018

s

in

ce

2015

Bony structure of a youthful jawline*

Bony structure of an ageing jawline*

As patients age, their jaw bone becomes narrower through bony resorption, making the angle of the jaw less acute or sharp3. RadiesseÂŽ has high levels of viscosity and elasticity, allowing you to sculpt and define, to create the desired effect of a youthful bony structure1. *Images courtesy of Merz Institute of Advanced Aesthetics.

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://ww.hpra.ie/homepage/ about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143.

Call Merz Aesthetics Customer Services to find out more or to place an order

Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com

1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512. 2. Meland Science Brief:Calcium Hydroxylapatite with Integral Lidocaine Demonstrates a Similar Rheological Profile of Viscosity and Elasticity When Compared to Calcium Hydroxylapatite without Lidocaine and the Highest Among Lidocaine-Based HA Fillers. Melissa Meland and Chris Groppi. Poster # 1821. E-POSTER PRESENTATION Saturday, 3/21/2015 from 11:05:00 AM to 11:10:00 AM. 73rd Annual Meeting of the American Academy of Dermatology. 3. Shaw RB, et al. Plast Reconstr Surg 2007; 119-675-81. 4. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/pmaapprovals/ucm439066.htm


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reactions to products marked with a Black Triangle in the British National Formulary and elsewhere using the Yellow Card Scheme • Adverse incidents involving medical devices, including those caused by human error that put, or have the potential to put, the safety of patients, healthcare professionals or others at risk The NMC,5 GDC2 and GPhC3 also obligate practitioners to report to the MHRA.5 The GDC guidance states, “You must record all patient safety incidents and report them promptly to the appropriate national body.”2 The Yellow Card Scheme is described by the MHRA as vital in monitoring the safety of all healthcare products in the UK, ‘to ensure they are acceptably safe for patients and those that use them’. Reports can be made for all medicines, including all medical devices available on the UK market such as dermal fillers. When reporting, you will need to fill out the short online form and provide the following: • • • • Figure 1: Example of a vascular complication reporting form, created by Dr MJ Rowland-Warmann

emergencies such as these, as not everyone there will know how to specifically deal with aesthetic complications. Also, you should go with the patient to the hospital, to make sure they get the care they need.”

Recording Once the complication has been properly handled and dealt with, it is important for the practitioner to log and report it; minor side effects, such as bruising and minor swelling that resolves on its own, would not necessarily need to be reported, but the practitioner must use his or her discretion. Mr Humzah says, “You must ensure every detail is accurate and clearly recorded in your notes, it is very important for insurance purposes.”1-3,5 Dr Rowland Warmann says that as part of her clinic’s Care Quality Commission (CQC) registration, they have an accident book where they log everything. She says, “You don’t have to overcomplicate matters, just have one book where you can log everything. You need a protocol for reporting and logging so it doesn’t get lost and that way you can audit all adverse events, no matter what they are.” Information must be as detailed as possible, including all products used, batch numbers, any anaesthetic used and how the patient reacted.

Reporting Reporting is essential practice for all medical practitioners and the GMC states that to help keep patients safe, practitioners should routinely monitor patient outcomes, and audit their practice, reporting at least annual data.1 Practitioners are obliged by their governing bodies to report to the MHRA. Dr King adds, “Anyone who is a member of the ACE group can report it on the ACE website and we have a form that mirrors the MHRA one. Once we receive any filled-in forms, we forward them to the MHRA and the manufacturer of the product that was used.” Reporting to the MHRA According to the GMC, you must inform the Medicines and Healthcare products Regulatory Agency (MHRA) about:1 • Serious suspected adverse reactions to all medicines and all

Name, position, organisation Address and contact details Device details Details of the incident

The Scheme collects information on suspected problems or incidents involving: • Side effects (also known as adverse drug reactions or ADRs) • Medical device adverse incidents • Defective medicines (those that are not of an acceptable quality) • Counterfeit or fake medicines or medical devices The MHRA states, ‘It is important for people to report problems experienced with medicines or medical devices as these are used to identify issues which might not have been previously known about. The MHRA will review the product if necessary, and take action to minimise risk and maximise benefit to the patients. The MHRA is also able to investigate counterfeit or fake medicines or devices and, if necessary, take action to protect public health’.6 For products and incidence that cannot be reported to the MHRA, practitioners interviewed for this article advise still to record it internally. Reporting to the manufacturer If it is a product-related complication then also refer it to the manufacturers, Mr Humzah says, “The more you tell manufacturers, the better. They can look at batch numbers, for example, and determine if a particular batch had a problem. But, unless you report it, they won’t be able to tell you that.” Dr King explains that when reporting a complication to the MHRA, practitioners should include the manufacturer in the copy so that “these issues cannot be ‘swept under the carpet’ as the MHRA will issue a report number which cannot be ignored so easily.” Dr King is concerned that some practitioners are not reporting to the manufacturers, due to concerns over repercussions. “People shouldn’t fear reporting; I think some believe that if they report a complication with a certain product to the manufacturer, then the manufacturer will get upset and stop visiting them or inviting them to conferences. But, in the same way as the NHS does, we need to be open and if there are problems we need to report them. The MHRA doesn’t tend to act on single, one-off reports, but if it gets 10-20 reports of the same product, its team will think ‘there is a problem here’ and action it,” he advises. Manufacturers must encourage reporting, and according to Dr King, legally they have to have some mechanism to report, however, he says, “these are often not very transparent, and are

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without a rigorous process.” As for the details that should be included, he says “Sex and age are permitted as non-traceable but a patient identification number is needed in case the reporting leads to legal proceedings whereby a court can request disclosure.” Reporting to insurance providers If you have a complication, do you tell your medical defence/ malpractice insurer, and at what point do you do so? “Thankfully, you see quite a lot of complications that are so well managed, with the patients kept on-board, that very few turn into complaints,” says Dr King; however, he notes, “Still ensure you document everything accordingly in case they do complain as you will need to provide the insurer with this information.” Mr Humzah adds, “If your patient has a complication, you have to consider your insurance company straight away. Check your policy, as insurance providers have different requirements of what to inform them of. Some may say only inform them if it is something that is definitely going to become a legal issue, others say you should inform them of all complications, even if it is not likely to proceed to something legal.” Sharon Allen, business development executive at Enhance Insurance explains in more detail, “When a practitioner comes face-to-face with a situation where their patient isn’t happy with their results or suffers an adverse reaction to a treatment or procedure provided, it can be very daunting and distressing. It is at this time practitioners need to contact their broker, advising them of the situation, who in turn notify insurers.” Allen explains that a majority of incidents are logged for ‘notification purposes only’ and after a while will be closed. Depending on the circumstances, a draft response may initially be issued for the practitioner to send to their patient, to try and minimise the situation and stop the incident escalating into a claim. In some cases, a refund of the treatment cost will also be offered. “Either way,” says Allen, “it is imperative insurers are notified as soon as possible, failure to do so may jeopardise the claim or result in the practitioner not complying with a policy clause, resulting in the insurer not providing indemnity. If unsure, I recommend practitioners contact their broker so that they fully understand their obligations.” Allen advises that the majority of medical malpractice policies are written on a ‘claims made’ basis, meaning that “it is the policy in force at the time the complaint/notification is made who will deal with the matter, regardless of the policy in force at the time of the incident. “She adds, “If the practitioner was aware of a situation within the previous policy period and had not contacted their insurer at the time, then the new or existing insurer will not indemnify them and the practitioner may have to deal with the matter themselves.”

Lack of data Due to a lack of reporting, data on complications in medical aesthetics is minimal, and this is something all the practitioners interviewed want to see change. Dr King acknowledges that reporting is very poor, “On the ACE Facebook forum, we probably get a complication mentioned every day, but officially, there is only one reported on our website every three to four weeks. If you are reporting quite a few complications, then I think the practitioner might be worried there will be repercussions on them. But complications happen.” Mr Humzah adds, “People do get embarrassed but they’ve got to get over that. It is all about the learning process and sharing that complication for other people to learn and prevent it from happening

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to someone else.” This is something Dr Molina wants to ensure, and is currently looking into ways to do this. She says, “I am setting up an audit process with IAPCAM, which will include all medical practitioners who are registered and authorised to perform treatments. They can report complications with us and we will collect the data and share it. At the moment, even if I report a complication to a manufacturer, then no one else will find out about it, only the company. We all need to be able to see the issues.”

Improving the process Each of the practitioners interviewed for this article believe more needs to be done to improve the process of handling, recording and reporting complications. Although aesthetic practitioners would recommend patients return to see them if they have a complication, many patients turn up at their GP surgery or local A&E, thinking that is the best place to go. However Dr Molina argues that the NHS is not the best place for patients to seek a resolve. Dr Molina says, “With IAPCAM, we would like to set up some guidelines and send them to places such as A&E and GP surgeries, as at the moment, when patients turn up there, they are getting lots of different advice.” According to Dr Rowland-Warmann, training providers need to ensure they are equipping practitioners, “Training course providers should think about how they teach trainees on complication management. Practitioners who I mentor have said to me that if a complication occurred they wouldn’t know how to deal with it. They have said that the use of hyaluronidase was ‘glossed over’ and they didn’t know about any other complications except ones with HA filler.” Dr Molina emphasises, “Know your anatomy, then learn complications, then learn to inject. You shouldn’t be injecting unless you know how to deal with the complication, so I think that should be taught first.” Dr King says, “I think there needs to be a lot more done, and it needs to come from the professional bodies, such as the GMC and GDC, or the MHRA. More emphasis should be made on the importance of knowing what to do when faced with a complication. I think manufacturers and suppliers have a duty to help practitioners and make it easy to report to them.” He concludes, “The MHRA forms are so easy to fill out, and take just two minutes. In terms of procedure and policy, I would say make sure you write down as much information as possible, including batch numbers and expiry dates. It is all about documentation; it has to be done at the time, and be completely accurate.” REFERENCES 1. General Medical Council, Guidance for doctors who offer cosmetic interventions (April 2016) <http:// www.gmc-uk.org/guidance/ethical_guidance/28687.asp> 2. GDC, Focus on standards, (2018) <https://standards.gdc-uk.org/pages/principle1/principle1.aspx 3. https://www.pharmacyregulation.org/standards 4. Christopher Cunniff et al. Informed consent for medical photographs, (2000) <https://www.ncbi.nlm. nih.gov/pmc/articles/PMC3111075/> 5. NMC, Standards for Medicines Management, <https://www.nmc.org.uk/globalassets/sitedocuments/ standards/nmc-standards-for-medicines-management.pdf> 6. YellowCard, About YellowCard, <https://yellowcard.mhra.gov.uk>

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Treating the Neck Consultant plastic surgeon Mr Dalvi Humzah and cosmetic and dermatology nurse practitioner Anna Baker detail the anatomical features of the neck and how it can be successfully treated The neck is an area that is not as commonly considered for aesthetic treatment compared to other areas such as the face. However, for our patients, the appearance of the face and neck contributes to the overall aesthetic look that they want to achieve. To understand how to treat this area, practitioners must know the anatomy, consider how the neck is perceived, what defines an attractive neck, as well as the underlying structures that change dynamically with age.

Attractive necks The appearance of the neck may be considered in terms of a youthful neck, an elderly neck and a culturally-defined neck. The neck in youth has a defined structure, which emanates a youthful appearance. This is exemplified by: smooth non-creased skin, visible structures of the medial and lateral borders of the sternocleidomastoid, posteriorly the Figure 1: An example of a youthful, attractive borders of trapezius neck structure with hollows at the suprasternal notch and supraclavicular areas (Figure 1).1 The elderly neck is defined by deterioration of the skin with the appearance of skin lines and loss of elasticity. It may also Figure 2: An example of an elderly neck have a rough, sunstructure damaged appearance. The underlying platysma undergoes hypertonicity (appearance of platysmal bands) and hypertrophy. There is also separation of the platysma resulting in prolapse of the post-platysmal fat. The overall appearance is of deterioration of structure and loss of defined areas with descent of the soft tissues (Figure 2).1 There are also culturallysignificant appearances of the neck that may be specifically defined by ethnic expectations. For example, the Karen tribe (long-neck tribe) in Northern Thailand who are known to use spiral brass coils around their necks to give the illusion of necks that are unusually long.2 In this article, we will consider the youthful and ageing anatomy of the neck.

Dynamic anatomical changes in the neck With ageing, there are several areas that change with the neck, including skin and the underlining anatomy, which includes the fat pads and the platysma.

Skin As we age, the skin undergoes a progressive degree of deterioration with changes in the cellular arrangement of the skin, resulting in a roughened appearance. There is a gradual deterioration to the skin texture and quality, as well as associated loss of thickness of the dermal structures. With ageing, the skin of the neck also becomes more textured with flexural creases around the neck. It loses elasticity, (due to changes in collagen and elastin) which in combination with further descent of soft tissues, causes sagging of the skin â&#x20AC;&#x201C; this is irreversible.3 Therefore, if the sagging of the soft tissues is corrected, either by weight loss or re-positioning of the underlying fatty tissues by excision or repositioning, the skin remains lax due to the loss of elasticity. This contributes to the disproportion in terms of visual measurements and changes the appearance of the neck. The ageing neck was initially examined in detail in 1980 by Ellenborgen and Karlin,1 who described further areas of the neck in terms of youthful appearances. These are described below.1 Inferior mandibular margin The youthful neck has a sharply-defined mandibular margin running from the mandibular angle to the mentum with no evidence of jowling.1 With ageing, the loss of skin elasticity associated with changes in the superficial jowl fat (volume increase, sagging and inferior volume changes) results in the typical jowl formation.4 This is further attenuated by the hypertonic action of the mandibular attachment of the platysma, further blunting the mandibular profile.5 This is also associated with mandibular bone resorption.6 Submandibular gland descent, however, does not appear to be an age-related change.7 Subhyoid depression When viewed in profile, the whole submental area of the neck, from the chin down to the sternal notch, is also different when comparing a youthful and an elderly neck. The youthful neck appears to have a right-angle appearance (inverted L), compared to an elderly neck, where the line between the chin and the sternal notch appears almost continual with loss of the sharp sub-hyoid angle.8 With age, the distance between the chin and sternal notch decreases rather than increases, due to the loss of the subhyoid depression. The loss of this definition related to the first neck skin crease and subhyoid depression may be attributed to laxity of the Cervico-mental suspensory ligament of the neck, which is attached to the under surface of the platysma.8 Thyroid cartilage bulge (Adamâ&#x20AC;&#x2122;s apple) This is of importance in sexual differentiation, and is particularly important when treating the female neck. The thyroid area should not be made prominent in a slim female neck and is often reduced in transgender surgery.9

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Anterior border of the sternocleidomastoid A slim youthful neck has a visible anterior border of the sternocleidomastoid from the mastoid to the sternum. Although this feature was the least important aspect of a youthful neck as viewed by Ellenborg and Karlin.1 Cervico-mental angle An angle between 105-120 degrees was suggested as an indication of a youthful neck, however an angle of greater than 120 degrees gives the visual appearance of a double chin or heavy submental neck.1 These variations made it difficult to measure and define the neck accurately, and in order to define a youthful neck a new, easily visualised term was proposed: sternocleidomastoid-submental line.1

1. 2. 3. 1

4.

2

3

5. 6.

5 6

4

110° degrees

Defined mandible Subhyoid depression Prominent thyroid cartilage Visible anterior border of sternocleidomastoid Cervicomental angle Sternocleidomastoid – submental (SM-SM) angle

90° degrees Figure 3: The sternocleidomastoid-submental line angle1

Sternocleidomastoid-submental (SM-SM) line angle The sternocleidomastoid-submental angle of 90 degrees is easily seen in a slim neck. As the sternocleidomastoid is perpendicular to the submental line, this particular angle does not need to be measured unlike the other angles (Figure 3).1 Underlying anatomy The visual criteria discussed above enables a neck to be assessed in terms of youthful structure and ageing. However, the underlying anatomy is also important to understand, which explains why some of these visual appearances change with the dynamics of the neck. The anatomy of the neck in keeping with the gross anatomical layers of the face may be considered in five layers: the overlying skin (discussed above), cutaneous tissue, the platysma (aponeurotic layer), subplatysmal space (containing fat and loose areolar tissue) and deeper structures as the fifth layer.10 Fat pads The underlying subcutaneous tissue, referred to as the preplatysmal fat pad is subdivided into the suprahyoid and infrahyoid subcompartments.11 The suprahyoid subcompartment lies between the hyoid bone and the mandibular border. The infrahyoid subcompartment lies between the hyoid cartilage and the thyroid cartilage. The subplatysmal fat is a deeper layer and is further subdivided into six subcompartments which are the: central suprahyoid, central infrahyoid, lateral suprahyoid compartments, (one on each side) and lateral infrahyoid compartments (one on each side). The very deep fat compartment in the neck is a negligible layer of fat that is bordered superficially by the anterior belly of the digastric and the submandibular gland. This adheres tightly with the superficial layer of strap muscles and the investing deep fascia of the neck. A dye injection study performed in 2014 demonstrated direct communication between the supraplatysmal fat and the subplatysmal

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fat.11 However, this did not communicate with the very deep fat compartment. Within the subplatysmal fat compartment, the lateral infrahyoid fat did not stain, suggesting that this fat pad may be anatomically distinct within the neck.11 These fat compartments have been looked at by several authors and have been noted as being variable in individuals.12,13,14 Attempts have been made to quantify the amount of fat in the neck by different authors.7,12,13 The overall conclusion is that the volumetric changes associated with the neck is an interplay of the subplatysmal and preplatysmal fat pads – recontouring the neck will require treatment of both fat pads to achieve the desired outcome. Other authors have described three compartments of subplatysmal fat: central, medial and lateral.14 However, how these various fat pads within the neck change with ageing is still not completely elucidated. Platysma The platysma itself has a variable course within the neck and in the face and is slightly different for different individuals. As with the face, variations within the platysma have been described.15 This study, based on an analysis of 50 European necks, demonstrated that the medial fibres of the platysma showed anatomical variations in the submental region. Three different patterns were described in the submental area: Type I – interlacing at about 2cm below the mentum (75%), Type II – fibres decussate at the level of the thyroid cartilage (15%) and Type III – the platysmal medial fibres insert directly at the cutaneous muscle of the chin without interlacing (10%). These patterns also show racial and ethnic variations in terms of percentage variation and relative separation of the medial fibres.16,17 On the other hand, Pogrel et al. described four different configurations of decussation depending on the relationship between the medial margin of the two platysmal bundles with a different cross-over pattern compared to that proposed by de Costro. They studied 20 preserved cadavers and found a complete platysmal diaphragm submentally (15%). In 85% of cases, there was only some degree of midline dehiscence.18 Right and left fibres merged or crossed to form an inverted V or U shape. These different configurations have implications for the ageing neck as a platysma that decussates is more likely to prevent the ‘turkey-gobbler neck’ compared to a platysma that separates (divarication), resulting in prolapse of the subplatysmal fat.12 Subplatysmal structures Underlying the platysma are important venous structures in the paramedian line, namely the anterior jugular veins. Lateral to this and overlying the sternocleidomastoid are the external jugular veins and deep to the sterna-mastoid are the internal jugular and carotid arteries. The investing layer of deep neck fascia may be viewed as the boundary of the deep layers of the neck with the other structures posterior to this, including the strap muscles, the trachea and the oesophagus. In these deeper areas, there are potential spaces for allowing structures to move relative to one another, e.g. retropharyngeal space which are gliding spaces (Figure 4). The final structure that contributes to the volume and shape of the neck is the submandibular gland. The 2014 study by Larson appears to indicate that on average, 25% of the soft tissue component of the neck is comprised of the submandibular gland, and the superficial lobe typically contributes to neck fullness.11 However, the evidence for gland ptosis is not universally accepted. Raveendran et al. considers that true ptosis of this gland is unlikely to occur during the ageing process.7 The submandibular gland is surrounded by a relatively strong capsule, which fuses with the deep investing fascia. In their

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Prevertebral fascia Roof of posterior triangle Carotid sheath and vagus nerve Internal jugular vein

Retropharyngeal space Cervical sympathetic

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sound anatomical awareness, appropriate placement of product, and dosage, can prevent functional complications such as dysphagia, dysphonia and neck weakness.25,26 Microaliquots of low-viscosity hyaluronic acid fillers, as well as mesotherapy and biorevitalisation formulations, can be effective in revitalising the extra-cellular matrix of the dermis.27,28

Photoaged skin The signs of chronic photodamage skin and intrinsic ageing External are often more obvious on the neck than other locations, jugular vein especially if the patient has undergone facial rejuvenation Pretacheal fascia Platysma procedures.29 Aged skin manifests fragmented dermal Thyroid gland collagen, leading to fibroblast dysregulation and decrease Sterno-mastoid in the production of new collagen, which is clinically seen Investing layer Infrahyoid muscles Pretracheal fascia as rhytids and laxity.30 Chronic ultraviolet exposure leads to solar lentigines, telangiectasias, poikiloderma of civatte, Figure 4: Transverse section of the neck and deep structures and a coarse texture.22 A significant body of literature 7 study, this capsule was not weakened with age. When dissected, supports the use of intense pulsed light (IPL) in treating uneven the gland did not appear to be loose, but rather sprang upward and dyspigmentation, poikiloderma of civatte and telangectasias.29,31,32 required tension and sharp dissection to be freed from its attachments. One study of 135 participants reported levels of clearance of more The authors conclude that loss of support and an associated descent than 75% of hyperpigmentation and telangiectasias, as well as of the glands in relation to their natural boundaries is unlikely. The size textural improvements.31 IPL settings used on the neck area are and volume of the digastric muscles also contributes to neck fullness, as usually lower than those used on the face due to the lower number of does the fat overlying the thyroid cartilage which can be significant in the pilosebaceous units and thinner epidermis.32 IPL and QS-alexandrite obese neck.7 Outside of laxity and decussation around the submental lasers can also be combined with an ablative fractionated CO2 laser region, there are other distinct changes with ageing that occur. The to correct established laxity and rhytids.29 Some evidence suggests muscle undergoes hypertonicity, resulting in platysmal bands with loss that ablative fractional CO2 lasers produce significant sustained of the submandibular definition due to contraction of the muscle. This improvement in superficial skin laxity and texture in the neck and jowl results in shortening of the submental skin, as described by Ellenborgen area with low risk of adverse events.33,34 A number of chemical peel and Karlin, with the typical lack of jaw definition and platysmal bands agents are discussed in the literature for treating many of the ageseen in the elderly neck.1 When addressing possible treatments for the related changes described in the neck region. Superficial exfoliating neck, the underlying anatomy and changes associated with ageing must agents such as glycolic and citric acid may be beneficial in correcting be considered. Historically, there is paucity in the literature regarding textural changes and improving superficial pigmentation without aesthetic non-surgical approaches to correct many of the age-related significant downtime post treatment.35 Trichloroacetic acid is described 19 changes discussed in this region. An increasing and recent shift in to successfully treat photoaged and coarse skin of the neck, though focus is directed towards this anatomical region as an emerging area formulations and strengths vary between manufacturers, with some of interest, supported by a growing number of treatments.20 Current peeling reported following treatment.36 This may be combined with treatment options reported in the literature can include, but are not a stabilising agent (hydrogen peroxide) to produce a subdermal â&#x20AC;&#x2DC;nolimited to, radiofrequency and ultrasound therapy for skin tightening/ needleâ&#x20AC;&#x2122; biorevitalisation agent.27 laxity, liposuction, laser lipolysis, techniques/devices and injectable lipolytic drugs for the reduction of submental fat.21 Fractional lasers Neck lines and contour and radiofrequency devices, chemical peels, microneedling, intense Radiofrequency (RF) was the first non-surgical technology pulsed light (IPL), dermal fillers, pigment and vascular lasers can address introduced for skin tightening/laxity of the face.37,38 Using electric superficial dyschromias and rhytids/crepey skin and neuromodulators current, it is able to heat tissue, which produces coagulation that can improve the appearance of platysmal banding.20 stimulates long-term collagen production and immediate tissue contraction.20 As water is the targeted chromophore, RF does not Early intervention and prevention cause epidermal ablation, (or subsequent stimulation of epidermal It is widely recognised in the literature that the daily use of a topical melanocytes), like laser modalities, decreasing the risk of postskincare regimen comprising active ingredients22 can significantly inflammatory hyperpigmentation or scarring for all Fitzpatrick skin improve the appearance of the skin, improve elastin quality, stimulate types.20 Classification of RF devices include monopolar, bipolar, collagen production, lighten areas of superficial pigmentation and multipolar and fractional.39 Each configuration is available with specific 22,23,24 reduce the appearance of fine lines. A broad-spectrum UVA/UVB pulse durations and frequencies,39 with waves ranging from 3kHzsunscreen is recommended to areas, such as the neck, that undergo 300GHz. RF devices deliver energy to subepidermal tissues initiating chronic sunlight exposure.22 Many cosmeceutical formulations contain immediate collagen denaturation and subsequent contraction, which combinations of many different compounds e.g. retinoids, humectants, is followed by delayed neocollagenisis.39 In addition, ultrasoundpeptides, alpha hydroxy acids (AHAs), polyhydroxy acids (PHAs) or assisted technologies have been shown to produce a significant bionic acids, and antioxidants.7 Fabi et al. propose that early intervention fat reduction with complementary skin tightening.40 In a study of 15 in the neck can focus on preventing the formation of prominent female patients (ages 43-75 years) with substantial neck laxity and platysmal banding and suggest BoNT-A as first line treatment.19 A cervicomental angle deformity, Rooijens et al. applied ultrasonic

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energy for an average of two minutes (ranging from 45s-6.5mins), followed by a mean aspiration volume of 125ml of fat. Results showed significant improvements for treatment of all grades of the ageing neck with little morbidity or complications.40 High-intensity focused ultrasound (HIFU) and micro-focused ultrasound (MFU) may be used to treat the neck.41 HIFU involves thermal injury and cavitation to cause cell disruption and cell death. The injury that occurs with HIFU is a thermomechanical process; the ultrasound energy which is absorbed by tissue causes molecular vibrations resulting in heat generation and a rapid rise in temperature and formation of microscopic bubbles.42 On the other hand, MFU relies only on heat to achieve its effects. The local temperature is elevated to at least 65°C, the temperature at which collagen contraction begins to occur at discrete thermal coagulation points while sparing adjacent non-target tissues.42 The net result is non-invasive tightening and lifting of sagging facial and neck skin and improvements in the appearance of wrinkles. This latter treatment may also be combined with calcium hydroxylapatite to produce a synergistic effect on improving neck lines and wrinkles.43 A new deoxycholic acid injection (the first injectable adipocytolytic to be approved by the Food and Drug Administration (FDA) for the reduction of moderate to severe submental fat,3 will soon be available in the UK and be recognised by the Medicines and Healthcare products Regulatory Agency (MHRA). This drug works by localised adipocytolysis; while leaving surrounding tissue mostly unaffected.44 Studies including MRI scans revealed submental fat reduction after these injections; with long-term follow-up showing that the results were maintained over time.45,46

Summary Owing to the multifactorial age-related changes that affect the aesthetic appearance of the neck, a multimodal approach is often required.29 The practitioner approaching neck rejuvenation will need to understand the underlying anatomical and cellular changes, while addressing these with a variety of treatment strategies. Mr Dalvi Humzah and Anna Baker will be presenting at the Elite Training Experience at the Aesthetics Conference and Exhibition (ACE) 2018 on April 27. For more information or to book, visit www.aestheticsconference.com. Disclosure: Mr Dalvi Humzah and Anna Baker run a training course on the multi-modal treatment of the neck and décolletage. Anna Baker is a qualified tutor, cosmetic and dermatology nurse prescriber who has been involved in developing Dalvi Humzah Aesthetic Training with lead tutor, Mr Dalvi Humzah, since 2012. She is the coordinator and a faculty member for this teaching. Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and runs the award-winning Dalvi Humzah Aesthetic Training. Mr Humzah worked as a consultant plastic surgeon in the NHS for 10 years and teaches nationally and internationally.  REFERENCES: 1. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg. 1980;66:826-837. 2. Chawanaputorn D. Patenaporn V. Malikaew P. Khongkhunthian P. Reichart P A. (2007) Facial and dental characteristics of Padaung women (long-neck Karen) wearing brass neck coils in Mae Hong Son Province, Thailand. AJO-DO May 2007 Volume 131, Issue 5, Pages 639–645. 3. Bazin R, Doublet E. Skin Aging Atlas: Volume 1. Caucasian Type. Paris, France: Med’Com Editions; 2007. 4. Gierloff M, Stohring C, Buder T, Wiltfang J. The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides. JPRAS. 2012;65:1292-1297. 5. Jabbour SF, Kechichian EG, Awaida CJ, Tomb RR, Nasr MW. Botulinum Toxin for Neck Rejuvenation: Assessing Efficacy and Redefining Patient Selection. Plast Reconstr Surg. 2017;140:9e-17e.

Aesthetics 6. Shaw, Jr RB, Katzel EB, Koltz PF, Yaremchuk MJ, Girotto JA, Kahn DM, Langstein HN. Aging of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies. Plast Reconstr Surg. 2011; 127(1): 374-383. 7. Raveendran SS, Anthony DJ, Ion L. An Anatomic Basis for Volumetric Evaluation of the Neck. Aesthetic Surgery Journal 2012;32(6): 685 –69. 8. Labbe´ D, Rocha CSM, Rocha FdeS. Cervico-Mental Angle Suspensory Ligament: The Keystone to Understand the Cervico-Mental Angle and the Ageing Process of the Neck. Aesth Plast Surg 2017; 41:832–836. 9. Altman K, Facial feminization surgery: current state of the art. Int J Oral Maxillofac Surg 2012;41(8): 885 -894. 10. Mendelson B.C., Jacobson S.R., ‘Surgical anatomy of the mid-cheek; facial layers, spaces and midcheek segments’, Clin Plast Surg, 35 (2008), pp.395-404. 11. Larson JD, Tierney WS, Ozturk CN, Zins JE. Defining the fat compartments in the neck: A cadaver study. Aesthet Surg J. 2014;34:499–506. 12. Adamson J, Horton C, Crawford H. The surgical correction of the “turkey gobbler” deformity. Plast Reconstr Surg. 1964;34:598-605. 13. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg. 1980;66:826-837. 14. Rohrich RJ, Pessa JE. The subplatysmal supramylohyoid fat. Plast Reconstr Surg. 2010;126:589-595. 15. de Castro CC. The anatomy of the platysma muscle. Plast Reconstr Surg. 1980;66:680-683. 16. Chhaparwal, R, Mittal, PS., Joshi, SS, Joshi, S. Variations in the morphology of platysma muscle in central Indians. J. Morphol. Sci., 2013, 30(4):244-24. 17. Gierloff M, Stohring C, Buder T, Wiltfang J. The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides. JPRAS. 2012;65:1292-1297. 18. Humphrey S, Sykes J, Kantor J, Bertucci V, et al. (2016) ATX-101 for reduction of submental fat: a phase III randomized controlled trial. J Am Acad Dermatol;75(4):788–97. 19. Kim HJ, Hu KS, Kang MK, Hwang K, Chung, IH. Decussation patterns of the platysma in Koreans. Br J Plast Surg, 2001, 54(5): 400-2. 20. Larson JD, Tierney WS, Ozturk CN, Zins JE. Defining the fat compartments in the neck: A cadaver study. Aesthet Surg J. 2014;34:499–506. 21. Jabbour SF, Kechichian EG, Awaida CJ, Tomb RR, Nasr MW. Botulinum Toxin for Neck Rejuvenation: Assessing Efficacy and Redefining Patient Selection. Plast Reconstr Surg. 2017;140:9e-17e. 22. Jones DH, Carruthers J, Joseph JH, Callender VD, et al. (2016) REFINE-1, a multicenter, randomized, double-blind, placebo-controlled, phase 3 trial with ATX-101, an injectable drug for submental fat reduction. Dermatol Surg;42(1):38–49. 23. Yaar M., Gilchrest B.A. (2007) Photoaging: mechanism, prevention and therapy British Association of Dermatologists 157:874-887 24. Lanuti E.L., Kirsner R.S. (2010) Effects of Pollution on Skin Aging Journal of Investigative Dermatology 130:2696 doi:10.1038/jid.2010.323 25. Levy P.M. (2015) Neurotoxins: Current Concepts in Cosmetic Use on the Face and Neck-Jawline Contouring/Platysma Bands/Necklace Lines Plast Reconstr Surg 136(5s):80s-83s. 26. Ascher B., Talarico S., Cassuto D., Escobar S., Hexsel D. Jaèn P., Monheit G.D., Rzany B., Viel M. (2010) International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywoord Unit)-Part II: wrinkles on the middle and lower face, neck and chest Journal of the European Academy of Dermatology and Venereology 24:1285-1295 27. Castellana R , De Sa Viana A C, L.Rizzi L.. (2013) Fibroblast stimulation through the activation of the endocrinal system applying trichloroacetic acid) (La Medicina Estetica Anno 37 N. 3. July – September. 28. Sparavigna A., Tenconi B., De Ponti I. (2015) Antiaging, photoprotective, and brightening activity in biorevitalization: a new solution for aging skin Clinical Cosmetic and Investigational Dermatology 8:57-65 29. Vanaman M., Fabi S.G., Cox S.E. (2016) Neck Rejuvenation Using a Combination Approach: Our Experience and a Review of the Literature Dermatol Surg 42:s94-s100 30. Fisher G.J., Varani J., Voorhees J.J. (2008) Looking older: fibroblast collapse and therapeutic implications. Arch Dermatol 144:666-672 31. Weiss R.A., Goldman M.P., Weiss M.A. (2000) Treatment of poikiloderma of Civatte with an intense pulsed light source Dermatol Surg 26:823-827 32. Weiss R.A., Weiss M.A., Beasley K.L. (2002) Rejuvenation of photoaged skin: 5 years results with intense pulsed light of the face, neck, and chest Dernatol Surg 28(12):1115-1119 33. Oram Y., Akkaya A.D. (2014) Neck rejuvenation with fractional CO2 laser resurfacing for the neck: prospective study and review of the literature J Drugs Dermatol 8:723-729. 34. Tierney E.P., Hanke C.W. (2009) Ablative fractionated CO2, laser resurfacing for the neck: prospective study and review of the literature J Drugs Dermatol 8:723-731Trevidic P, Criollo-Lamilla G. Platysmal Bands: Is a Change Needed in the Surgical Paradigm? Plast Reconstr Surg. 2016; 139:41-47. 35. Landau M (2016) Chemical peels Clinics in Dermatology 26:200-208 36. Baker T.M. (1999) Chemical and lasers for skin resurfacing Aesthetic Surg 19:325-327 37. Nelson A.A., Beynet D., Lask G.P. (2015) A novel non-invasive radiofrequency dermal heating device for skin tightening of the face and neck J Cosmet Laser Ther 17(6):307-312 38. Dendle J., Wu D.C., Fabi S.G., Melo D., Goldman M.P. (2016) A Retrospective Evaluation of Subsurface Monopolar Radiofrequency for Lifting of the Face, Neck, and Jawline Dermatol Surg 42(11): 1261-1265 39. Bloom B.S., Emer J., Goldberg D.J. (2012) Assessment of the safety and efficacy of a bipolar fractionated radiofrequency device in the treatment of photodamaged skin J Cosmet Laser Ther 14(5):208-211 40. Rooijens P.P., Zweep H.P., Beekman W.H. (2008) Combined use of ultrasound-assisted liposuction and limited-incision Platysmaplasty for treatment of the aging neck Facial Plast Surg 32(5);790-794 41. Fabi S G (2015) Noninvasive skin tightening: focus on new ultrasound techniques. Clin Cosmet Investig Dermatol. 8: 47–52. 42. White WM, Makin IR, Barthe PG, Slayton MH, Gliklich RE.(2007) Selective creation of thermal injury zones in the superficial musculoaponeurotic system using intense ultrasound therapy: a new target for noninvasive facial rejuvenation. Arch Facial Plast Surg.;9:22–29. 43. Casabona G, Nogueira Teixeira D. (2018) Microfocused ultrasound in combination with diluted calcium hydroxylapatite for improving skin laxity and the appearance of lines in the neck and decolletage. J Cosmet Dermatol.;17:66–72 44. Humphrey S, Sykes J, Kantor J, Bertucci V, et al. (2016) ATX-101 for reduction of submental fat: a phase III randomized controlled trial. J Am Acad Dermatol;75(4):788–97. 45. Jones DH, Carruthers J, Joseph JH, Callender VD, et al. (2016) REFINE-1, a multicenter, randomized, double-blind, placebo-controlled, phase 3 trial with ATX-101, an injectable drug for submental fat reduction. Dermatol Surg;42(1):38–49. 46. Rotunda AM, Suzuki H, Moy RL, Kolodney MS. Detergent effects of sodium deoxycholate are a major feature of an injectable phosphatidylcholine formulation used for localized fat dissolution. Dermatol Surg 2004;30(7):1001–8.

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Case Study: Lip Filler Complication

She soon developed flaky brown crusts and patches of dryness on the underside of her top and bottom lips (Figure 4). She was concerned as it was not something she had previously experienced after her filler treatment five months ago. Seven days after her initial treatment she went back to see her original practitioner. Dr Beatriz Molina presents a lip filler complication The practitioner was not concerned with the patient’s symptoms and advised her that the and discusses the management of the patient symptoms she was experiencing might have Managing complications is a difficult task. However, it is even harder been the result of dryness or transient sensitivity. A transient reaction when a patient presents to clinic with a complication from another to the filler would mean that it should settle after a couple of weeks.1 practitioner, as most patients do not know what product they had or Straight after this consultation, the patient emailed a plastic surgeon where the product was exactly injected. In this circumstance, what she found through a Google search to get a second opinion. The do you do? The easiest thing is to ask the patient to return to the surgeon advised her that the problem could have arisen because practitioner who treated them. This, I believe, is best practice as the the lips were potentially overfilled. They said this could be causing original practitioner should have all the necessary clinical data to the mucosa, (wet part of the lips) which would otherwise be inside correct the complication. But, sometimes this is not an option because the mouth, to be exposed to the surrounding air, drying them out. the patient may have lost their trust in the practitioner and does not They advised her to use a 100% petroleum ointment (Vaseline) to wish to be treated by them again. Other times, we get referrals from resolve this. The patient had already been using Aquaphor, a skin practitioners who are not sure how to handle a complication, or the ointment containing petroleum (plus other ingredients) to keep her patient is not listening to their advice. At least in these cases, a referral lips moisturised prior to the development of this crust.2 She had used means that we get a full medical history and we know exactly what Aquaphor for at least five years intermittently, with no side effects products were used and in what way. from it. Following the advice of the plastic surgeon, she started to The following case study will discuss the patient journey of a young use more Aquaphor and kept a thin layer of it on her lips constantly. female who was referred to me from another aesthetic doctor after the However, she continued to experience problems; layers of the skin patient experienced a filler complication in the lips. Please note that peeled off, bit by bit, and her lips became increasingly raw. Two the below information is from the patient’s testimony only, not from the weeks’ post treatment, she saw her original practitioner again. They various practitioners involved. reassured her that she was experiencing some normal skin sensitivity issues following treatment and things should clear up soon. Patient journey To be on the safe side, the practitioner suggested to have the filler A 28-year-old female patient was recently referred to me from one removed with hyaluronidase. It is unknown why the patient didn’t of my colleagues and friends who is an aesthetic doctor. agree to this, or why the practitioner didn’t insist upon it. At this stage, The patient was firstly injected by this practitioner with 1ml of a the patient was feeling as though her situation was not normal, but the well-known hyaluronic acid (HA) dermal filler in May 2016. It was patient said that the practitioner advised her that it was. The patient injected into the body of the lips with a cannula in an anterograde raised the possibility that she might be experiencing a hypersensitivity technique and there were no adverse events reported. reaction to the product, as it was a different one used to her previous A following treatment was performed by the same practitioner five treatment, but the practitioner did not believe that this was a concern months later, on October 28, where 1ml of a different HA filler was at this stage. injected in the same area. As the skin on the patient’s lips became increasingly sensitive, As expected, following these second injections, the patient fragile and seemed to rub off when she touched them (Figure 6), experienced slight swelling and bruising, but this went down after she arranged an appointment with the plastic surgeon that she had three days. At this stage, it seemed that there were no concerns emailed previously on November 27. The surgeon advised her that following the treatment and the patient was pleased with the she was experiencing either an inflammatory reaction, or a herpes results (Figure 2). outbreak. They therefore prescribed oral antiviral medication – However, after day three, the patient’s lips were becoming very acyclovir 800mg five times a day for seven days – suggesting that swollen. This was causing her difficulty in speaking and eating as her treating the herpes should be a first line of action before having the lips would split easily, even from a soft touch (Figure 3). The skin on filler removed. the lips became increasingly sensitive and raw. However, her skin got progressively and rapidly worse. The surgeon

Figure 1: Patient before dermal filler treatment

Figure 2: Patient on October 31, three days after her second dermal filler treatment

Figure 3: Patient on November 1, four days post treatment

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Figure 4: Patient on November 4, seven days post treatment

contacted the patient’s original practitioner via email to discuss their concerns, and again suggested that the patient was experiencing a herpes outbreak. After taking the course of acyclovir, the patient’s skin became even more raw, so she sought the advice of her GP, who advised that she was experiencing inflammatory issues in response to the filler treatment. She was prescribed topical steroid medication and Epaderm emollient cream and was told to keep using Aquaphor. As her symptoms continued, the patient went back to the GP several days after. They prescribed oral steroid medication – prednisolone 30mg a day for one week. At this point, the patient described, “It was as if the whole top layer of my lip skin had fallen away, exposing the raw layer underneath. I also developed small blisters. Smiling could cause small tears and abrasions in the skin. I was having a difficult time eating and speaking, and I was drinking everything through a straw. There were times when the skin on my lips looked white or pale." She had been applying Aquaphor to her lips constantly for two weeks at this point, and she assumed that after seeing several different practitioners of different experiences that keeping the lips well moisturised was a reasonable strategy to protect her skin. However, she did eventually notice that the Aquaphor packaging also states to ‘use as often as required’ and provides no further information regarding adverse reactions. The patient said, “However, at this point I felt perhaps my use of Aquaphor had been excessive and I discontinued using it as I felt it may have been contributing to the problem.” After discontinuing the use of Aquaphor, the skin did seem to clear up quite substantially thereafter, with a noticeable improvement after just the first day. However, she gradually developed a very thick, dry crusting on her lips and was still unable to eat or speak normally as a result of this. She was only consuming liquid food through a straw. Unfortunately, she decided to apply gentian

Figure 7: Patient one week before she presented to my clinic

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Figure 5: Patient on November 12, 15 days post treatment

Figure 6: Patient on November 27, 30 days after initial treatment

I concluded that there was a compression to the vascular supply to the lower lip; she aggravated things by using Aquaphor, as this was acting as an occlusion violet to her lips as an antiseptic on December 10. Gentian violet is an antiseptic dye used to treat fungal infections of the skin. She stated, “I didn’t realise that it would stain my lips so severely and that it would be impossible to get off due to the fragility of my skin.” At this point, the patient used the mobile app HealthTap and arranged a virtual consultation using Skype with a board-certified American dermatologist. Their diagnosis was desquamation of the lip and they said that she was likely experiencing hypersensitivity issues due to the filler. They advised her to apply a topical steroid medication and to seek to have the filler dissolved if it didn’t clear up. Subsequently the patient developed small cracks at the corners of her mouth. The skin that healed in the area also started to have a white appearance again and formed crusts. The patient had been doing a lot of her own research online since having issues with her lips and was still concerned that the problem with her skin desquamation, diagnosed by the dermatologist, was partially due to an over application of Aquaphor. She thought this could potentially be due to maceration of her lip skin. She asked the dermatologist on HealthTap explicitly about this, but they suggested that the problem was more likely to be an inflammatory reaction to the filler material. They also stated that it could be due to an Aquaphor allergy. However, the patient researched the potential side effects of Aquaphor on WebMD and found that ‘turning white, wet and soggy from too much wetness’ were possible adverse reactions.2 She stated, “When my lips were at their worst, the skin did indeed look white and soggy.” However, she did not feel that this explained the other issues with her lips. Patient presenting to my clinic On December 19, the patient came to see me after being referred by her original practitioner. Her lower lip was stained with the gentian violet that she has used

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previously. The patient refused to let me examine the lips, as she said they were too painful. She was also very upset as her condition had not improved after two months following her filler treatment, despite seeking advice from several practitioners. After carefully looking through her medical record, her photographs and considering the events related above, I concluded that there was a compression to the vascular supply to the lower lip; she aggravated things by using Aquaphor, as this was acting as an occlusion. This explained the blistering and the desquamation of the lip and why symptoms were not immediately resolved post treatment.3 I knew that the only solution to resolve this was to dissolve the filler. If there is a problem with vascular supply to the tissue, it starts to die. The patient did not get necrosis, likely because there was only a partial vascular compromise, not a full compromise; adding an emollient made things worse.1,4-11 The patient was concerned that having the filler dissolved at this point would cause trauma to her lip, due to the fragility of her skin. I explained, in length, the risks associated with dissolving the filler (allergic reaction, anaphylactic reaction, bruising, swelling) and the pros and cons of using the hyaluronidase, such as the fact that the filler would go, making her lips go back to how they were before any filler treatment. I then asked her to seriously consider the treatment and think about going ahead with it. Following this, I referred her back to her original practitioner. I got in touch with the practitioner and advised them to dissolve the filler using hyaluronidase 1500 units in 10ml of sodium chloride. I also said that if there were concerns of excessive inflammation and swelling in the lips, so to not aggravate the problem, they could start the patient on prednisolone 30mg for five days. After two or three days, the patient would likely be ready for their hyaluronidase treatment. Following this treatment, the original practitioner reported that the patient made a full recovery.

Discussion In my opinion, this patient probably experienced these symptoms as filler was likely injected too deeply, causing the compression. Alternatively, it could have been that too much product was injected in the area. Sometimes I find that practitioners who use cannulas inject deeper than they believe they are, which can cause issues. In my opinion, the original practitioner should have listened to their patient’s concerns and understood that it is not normal to develop new symptoms days after a dermal filler treatment.1 They likely did not have enough knowledge and experience in regards to identifying and managing dermal filler complications. This case did have an unusual presentation, so it is unfair to think that the original practitioner did not know it was a compression at an early stage. However, they should have known that something was not right. The original practitioner most certainly should have asked a colleague for their advice at this stage, rather than the patient feeling that nothing has been done and for her to seek further advice on her own. I believe it’s important that patients stick to their original practitioner, and they need to feel as though their concerns are taken seriously. There was no evidence of infection, so the patient should not have been on prednisolone for so long. As far as I am aware, there was no reason for the surgeon to believe this was herpes and the symptoms did not seem consistent of herpes infection. If I was treating this patient, I would have started her on prednisolone 30mg for one week and seen her after three days just to be sure there was no infection. At that point, I would have seen it was a

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reaction to the filler and I would have injected hyaluronidase. Instead of treating her myself, I referred her back to her original practitioner for treatment. This is because I do not believe in making a practitioner look negligent in the eyes of the patient. Everyone can make a mistake and the practitioner was really concerned about the patient’s wellbeing, which is why she finally referred her to me for an opinion. The practitioner was also fully capable of performing the hyaluronidase treatment as per my advice; however, if they were not, I would have quite happily step in to help.

Conclusion All practitioners must keep good patient records, including before and after photos to manage a patient’s treatment journey. In this case, the symptoms should have been recognised and the filler should absolutely have been dissolved earlier. Practitioners need to take patient concerns seriously and see patients as often as required. They should also establish a good network of colleagues that they can trust for advice when needed. Finally, I recommend that all practitioners complete thorough training in anatomy and complication prevention, diagnosis and management skills. Dr Beatriz Molina will be speaking at the Aesthetics Conference & Exhibition on Friday April 27 at 10:30am on unique delivery methods with plasma. To register for free, go to www.aestheticsconference.com. Dr Beatriz Molina is the medical director and owner of Medikas clinics. She is a KOL for Galderma UK and is also an international speaker and a country mentor leader for Galderma Global. Dr Molina is the founder of the IAPCAM and the winner of The SkinCeuticals Award for Medical Aesthetic Practitioner of the Year at the Aesthetics Awards 2017. REFERENCES: 1. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;6:295-316. 2. WebMed, ‘Aquaphor Topical Ointment’, <https://www.webmd.com/drugs/2/drug-7713/aquaphortopical/details> 1. D.DeLorenzi, Complications of Injectable Fillers, Part 2: Vascular Complications, Aesthetic Surgery Journal 2014, Vol. 34(4) 2. Beleznay K, Humphrey S, Carruthers JDA, et al. Vascular Compromise from Soft Tissue Augmentation. J Clin Aesthet Dermatol. 2014;7(9):37-43. 2. 3. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthet Surg J. 2002;22(6):555-557.  4. Glaich AS, Cohen JL, Goldberg LH. Treatment of Hyaluronic Acid Filler–Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations. Dermatol Surg. 2006;32(2):276-281. 5. Hanke CW, Higley HR, Jolivette DM, et al. Abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen implant. J Am Acad Dermatol. 1991;25(2 Pt 1):319-326. 6. Cohen JL. Dermatol Surg. Understanding, avoiding, and managing dermal filler complications. 2008;34 Suppl 1:S92-S99. 7. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J. 2011;31(1):110-121. 8. Ozturk CN, Li Y, Tung R, et al. Complications following injection of soft-tissue fillers. Aesthet Surg J. 2013;33(6):862-877. 9. Cohen JL, Brown MR. Anatomic considerations for soft tissue augmentation of the face. J Drugs Dermatol 2009;8:13-16.

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Treating the Cheeks Dr Harry Singh discusses the use of Restylane fillers for facial aesthetics, available from Med-fx I started in facial aesthetics back in 2002, and when we saw a line/fold, we filled it – we were the original ‘line chasers’. As our understanding of the ageing process, anatomy and techniques have advanced, we now look at addressing the ‘cause’ of ageing and not the ‘consequence’ of ageing. Anatomy The upper lateral cheek projects anteriorly over the zygomatic arch. Anteriorly the convexity of the cheek and lid-cheek junction are due to the deep cheek fat pads below the eyes and deep-to-the-cheek muscles. Laterally, the buccal fat pad gives the cheek its roundness.1 It tapers into the nasolabial fold and this convexity followed by a slight concavity is known as the ‘Ogee curve’.2 We now know that the ageing process is a multifactorial event that involves changes to; skin, collagen/elastin, fat compartments, muscle, retaining ligaments and bone. In summary, the deep and superficial fat pads deflate and descend, the periorbital and zygoma bones resorb and the retaining ligaments become laxer.3 In reference to the mid-facial fat pads and the cheeks, we are concerned with the deep and superficial fat pads, such as the medial cheek, nasolabial, middle cheek, lateral cheek; deep fat pads – medial and lateral sub-orbicularis oculi, deep medial cheek, buccal. We will pay close attention to the retaining ligaments in this region that become laxer as we age and therefore effect the quality of the skin. The retaining ligaments we are concerned with are; orbital/malar ligaments, zygomatic ligaments and masseter-cutaneous ligaments. Treatment options When assessing any patient for dermal filler treatment in this region, I will categorise them into three outcomes:

Be wary of: • Angular artery and vein • Branches of the trigeminal nerve such as the ophthalmic, maxillary and mandibular • The infraorbital foramen in which the infraorbital nerve, infraorbital artery and infraorbital vein all exit being a perpendicular line joining the lateral infraorbital rim and the extended tear trough. I will use this area as a reference to where I need to add volume to the cheeks. I will place a finger block at the infraorbital rim to prevent any product migrating pass this structure. However, volume replacement is specific to each patient, and you may need to deviate slightly from the area marked. For lifting purposes in female patients, I will want to have a maximum projection at the intersection of the alar-tragal line and the lateral canthus of the eye. As we go laterally, the bolus amounts will decrease incrementally, and I will mark out the upper and lower borders of the zygomatic arch, making sure the bolus is between these two markings. Needle vs. Cannula For volume replacement, I prefer to use a cannula. Due to the larger area we need to cover, I want to reduce the number of insertion points and passes I need to make. I normally use the TSK Cannulas STERiGLIDE™ 25G x 50mm with 23G x13mm needle to make the entry point. When I require lifting, I prefer needles and will inject perpendicularly to the skin and hit bone,5 placing my deposits at the dots marked in the figure.

• Do they need volume replacement? • Do they need lifting? • Do they need contouring? Obviously, some patients will need a combination of all three. As always, the management of patient expectations is critical to any success in the outcome. Where to inject Where we inject will depend on what outcome we want to achieve (as per the classification above). I will first outline the infra-orbital rim (each side may differ) and the infra-orbital foramen (which is normally 3-5mm below the infraorbital rim and in line with the medial limbus).4 I will also use a cotton-tipped applicator to slightly depress this region and ask the patient when they feel a sensation. Next, I will draw a line that extends to the tear trough. This is quite important as we don’t want to inject medially to this (a no-go area) as you will encounter the angular artery and leave an unnatural appearance if you deposit filler here. Then, I will complete this triangle. The upper part is the infraorbital rim, the medial part being the extended tear trough, and the lateral part 40

Figure 1: Image shows the different areas we need to consider

Aesthetics | April 2018


Advertorial ----------Products to use I favour hyaluronic acid fillers due to the non-permanent nature and the opportunity to remove any product by using hyaluronidase. I prefer the Galderma range of products, which are available from Med-fx, as their range allows me to perform a tailored approach to each patient depending on the desired result and the skin quality. For example, the use of softer, less viscous products with a low G prime for a more superficial approach and those patients with poor skin quality. Then, products with more viscous and higher G prime for a deeper approach and lifting for those patients with good skin quality. For volume replacement, I will normally use Restylane Volyme™. This is injected by a cannula in the subcutaneous plane and using a fanning technique.6 You may need anything between 1-4ml dependent on the amount of volume loss. But as always, place a little, sit the patient up, reassess and then decide if you need more. For lifting, I will use Restylane Lyft™ or Restylane Defyne™. The choice of product will depend on the patient’s skin quality. The better the skin quality, the more it can take in lifting, hence the use of the NASHA™ (Non-Animal Stabilised Hyaluronic Acid) range such as Restylane Lyft™, which has a high degree of cross-linking. For those patients with poor skin quality or thin skin, then I prefer a softer product and would look at Restylane’s OBT™ (Optimal Balance Technology) range such as Restylane Defyne™. I would normally use a total of 1ml on both sides for the lifting result. The maximum projection may require 0.5ml and then less as we advance laterally. A word of warning, however, these are only generalisations and amounts will vary for each patient. Risk factors This can be divided into assessment and technique. The incorrect assessment of what the patient needs will result in an unnatural result. A common mistake I see is adding volume where there has been minimal volume loss. This results in a puffy look. Every procedure we carry out will have some risks associated with it.7 Our role as clinicians is to predict and then minimise these risks. When injecting bolus deposits, you want to aspirate to make sure you are not directly injecting into a vessel. You should inject very slowly and while injecting, observe the skin. In addition, I recommend making sure you stay on bone, as this is a relatively safe area. At the end of the procedure, I will gently mould and massage the product to reinforce the desired outcome. Dr Harry Singh has been carrying out facial aesthetics since 2002. He is not only a skilful facial aesthetician but a keen marketer which he feels is vital to attract and retain patients requesting facial aesthetic services. He has published numerous articles on the clinical and non-clinical aspects of facial aesthetics and spoken at dental and facial aesthetics conferences on these topics. REFERENCES 1. Prendergast MP. Facial Proportions. 2. Ko AC, Korn BS, Kikkawa DO. The aging face. Survey Ophthal. 2017;62(2017):190-202. 3. Kahn DM, Shaw RB. Overview of current thoughts on facial volume and ageing. Facial Plast Surg 2010;26(5):350-5. 4. Surek CC, Beut J, Stephens R, Jelks G, Lamb J. ‘Pertinet Anatomy and Analysis for Midface Volumizing Procedures’, Plastic and Reconstructive Surgery, 135(5) (2015), 818e-829e. 5. Brighetti, Filippo. H.A. the Filler. 6. De Maio, Mauricio and Rzany, Berthold. Injectable Fillers in Aesthetic Medicine. 7. Gladstone HB, Cohen JL. Adverse effects when injecting facial fillers.Semin Cutan Med Surg. 2007;26(1):34-39.

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What is happening within this triangle is of great interest to us as aesthetic practitioners, as it forms the canvas for our medical expertise, anatomy understanding and allows our creative abilities to thrive. One of the most aesthetically challenging parts of this triangle is the perioral region, which will be the focus of this article.

Lips Through the Ages Aesthetic nurse prescriber Jackie Partridge explains perioral ageing and discusses the latest anatomical treatment considerations As many of us who work in the field of medical aesthetics are aware, we are often the go-to person for a patient who is unhappy with their general appearance. It is very common, in my opinion, that a patient might not be aware of exactly what it is about their appearance that is resulting in a less than favourable look, whereas some are only too aware of what their problem or area of concern is. The ageing process will affect us all in time, and, in many ways itâ&#x20AC;&#x2122;s an unkind phenomenon. Anatomical changes, which affect the bone reabsorption in a structural way, set the parameters of how the soft tissues above are supported. The effects of dynamic muscle activity, as well as gravity, also play a part in our ever-changing appearance.1

It has been mentioned many times by aesthetic colleagues that facial anatomy in youth appears as a triangle or pyramid. The reason for this is that in youth the bony prominences and fat pads in the mid-face are well volumised, with good cheek projection. In the lower third of the face, the buccal fat pad is well supported by its retaining ligament and the chin projects well. This is the triangle or pyramid with a point at the base and a wider angle at the top. As the ageing process develops, the mid-face becomes flatter, the temples more concave and the jowls have been subjected to gravity, causing the lower face to become heavier than in youth, leading to the apparent inversion of the triangle caused by the anatomical changes of ageing.1,2

A recent 2017 study by Cotofana et al that looked at the anatomy of the perioral area might well change the way many injectors, including myself, treat the lip

Perioral changes with age As we age, there are specific anatomical changes that happen to this area, and according to Gupta et al., these signs of ageing and the inability to conceal them can have an effect on a patientâ&#x20AC;&#x2122;s anxiety and depression levels.3 According to Sarver, the thickness of the female lip reaches its maximum at age 14, whereas boys lips do not maximise their thickness potential until the age of 16.4 Between the ages of 18 and 42, Sarver describes lip thicknesses to be similar for both sexes.4 Factors that affect the ageing appearance of the lip and perioral region include: extrinsic factors such as environmental, UV, smoking and medication such as steroid use; and intrinsic factors such as dental disease, the menopause and general ill health, like the herpes virus or oral tumours.5 Most patients in their twenties will present with good lip projection, sound levels of lip and perioral hydration and no evidence of rhytids in the upper or lower cutaneous white lip. The cupidâ&#x20AC;&#x2122;s bow will project, further exasperating the short appearance of the upper cutaneous white lip. It is expected for there to be evidence of some upper tooth show.5 The fashion for fuller lips is one that is being driven by the millennial market and social media. Patients between the ages of 30 and 40 will have a degree of semblance in the appearance of the perioral and lip region and, in most cases, these changes would be due to environmental and lifestyle choices. According to Landau, smoking and UV damage are two of the most impactful and well appreciated environmental factors of ageing.5, 15 Research gathered between 1973-2003 indicates that tooth loss is more prevalent in older patients and is indicative of less structural support for the perioral region, resulting in the development of even more static rhytids.6 However, in the last 30 years, oral hygiene and periodontal health has improved significantly in the 20-80-year-old age groups. It is therefore expected that

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Lip treatment Lip augmentation is the most frequently sought after procedure for the treatment of facial volumisation, according to The American Society of Plastic Surgeons.11 It is in my opinion that it is important that anyone offering lip augmentation to a patient should have sound After knowledge of anatomy in order to limit the incidence of vascular or arterial occlusion.12 A recent 2017 study by Cotofana et al that looked at the anatomy of the perioral area might well change the way many injectors, including myself, treat the lip. This multiFigure 1: A 71-year-old patient who was experiencing accelerated centred anatomical study ageing due to the menopause. Image shows before and after 1ml of involved 193 anatomical Restylane Kysse injection. head specimens, of which the evidence of perioral ageing will be less 56.5% were female cadavers.13 The study apparent than it has been previously.6 included the use of computed tomographic The menopause however, affects the imaging, which showed the anatomical skin in women greatly, with loss of sebum variances involving the anatomical location production and collagen density during of the superior and inferior labial arteries the post-menopausal period, which in relation to the orbicularis oris muscle. drops by 2% annually on average.7 These The authors’ findings demonstrate that the changes will impact the integrity of the superior labial artery runs at the level of skin surrounding the mouth and therefore the vermilion border, whereas the inferior the aesthetic appearance. The average labial artery is found inferior to the vermillion age of menopausal onset in Europe is border. Both the superior and inferior arteries 50.1-52.8 years,8 and there is literature that located in the midline were identified as demonstrates the effects of this loss of submucosal.12,13 This would therefore indicate collagen and the results that this has on the that the safest depth in which to inject dermal structural strength and quality of the skin.16 fillers into the lips in the medial aspect, would Of course, the menopause is not a factor be deep, rather than superficial. However, in the male patient; however, men are not there are anatomical variances from person without ageing in this area. Montagna notes to person, and this study demonstrated that that follicular growth in the beard region across the 193 cadaver head specimens, slows down with the ageing process.9 the superior and inferior labial arteries Moretti discusses the increased vasculature were identified in three different locations.13 in the male beard region, and this Augmentation of the lip with dermal fillers increased blood profusion will positively delivers a more youthful appearance and, impact good skin quality.17 Likewise, as the according to a study undertaken by Bisson beard density decreases, so will the blood comparing lips of models and non-models, supply and this would then explain the loss the models were more likely to have fuller lips of tensile strength in this area, which could and these were deemed more attractive.18 explain an increase in rhytid development Awareness that the inferior and superior in males of this age group.9,17 labial arteries could be more superficial than The signs of ageing in the 50 years plus perhaps originally thought should impact how individual are much more noticeable and we, as practitioners, deliver our treatments in include, but are not limited to, loss of lip this region. projection, reduction in upper tooth show, increase in cutaneous rhytids, flattening of Conclusion the philtral columns and elongation of the It is extremely important that you consult your cutaneous upper white lip.10 patient carefully and advise appropriately, Before

based on safe medical practice before performing any procedure. Our knowledge of harmony and proportion is critical when assessing and planning a lip augmentation and helps us to deliver what would be aesthetically pleasing for lips of patients within specific decades.14 However, it is always important to discuss with the patient how they would like their treated lips to look; after all, this is an individual matter. Practitioners should also be aware of the latest anatomical advice and studies to ensure they continue to treat safely and successfully. Less is more in my humble opinion! Jackie Partridge is an independent aesthetic nurse prescriber. She is the clinical director and owner of dermalclinic in Edinburgh. As a KOL for Galderma and a member of the Global Nurse Faculty, Partridge is a regular presenter and trainer at facial aesthetic events and conferences. She is also a mentor for Northumbria University where she is undergoing her Master’s. REFERENCES 1. Mendelson B, Wong CH, ‘Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation’, Aesthetic Plast Surg, 2012 36(4): 753–60. 2. Sydney R. Coleman, MD Rajiv Grover, ‘The Anatomy of the Aging Face: Volume Loss and Changes in 3-Dimensional Topography’ Aesthetic Surgery Journal, V 26, Iss1, 2006, pp. S4-S9,  3. Gupta MA, Gilchrest BA, ;Pschosocial aspects of aging ski’, Dermatol Clin, 2005, 23: 643-648. 4. Sarver DM, ‘Understanding Aging Makes Beauty Timeless: How orthodontics, cosmetic and oral surgery enhance beauty,’ DearDoctor.com, 2010. www.deardoctor.com/articles/understanding-aging/page3.php 5. Tobin D, Introduction to skin aging. Journal of Tissue Viability, 2017, 26, pp37-46 6. Hugoson A, Sjo¨din B, Norderyd O, ‘Trends over 30 years, 1973– 2003, in the prevalence and severity of periodontal disease’, J Clin Periodontol, 2008; 35: 405–414 7. Herman J, Rost-Roszkowska M, Skotnicka-Graca U. ‘Skincare during the menopause period: non invasive procedures of beauty studies’, Postepy Dermatol Alergol, 2013, 30(6): 388–395. 8. S. Palacios,V. W. Henderson, N. Siseles,D. Tan & P. Villaseca, ‘Age of menopause and impact of climacteric symptoms by geographical region’, Climacteric. 2010 Oct;13(5):419-28. 9. W. MONTAGNA, K. CARLISLE, ‘Structural changes in ageing skin,’ British Journal of Dermatology Volume 122, Issue s35 61–70 10. Penna, V., Stark, G.B., Voigt, M. et al. Aesth Plast Surg (2015) 39: 1. <https://doi.org/10.1007/s00266-014-0415-2> 11. American society of Plastic Surgeons. (2015) Cosmetic plastic surgery statistics. Accessed online on 11.2.18 12. Distribution Pattern of the Superior and Inferior Labial Arteries: Impact for Safe Upper and Lower Lip Augmentation Procedures 13. Cotofana, Sebastian M.D., Ph.D.; Pretterklieber, Bettina M.D.; Lucius, Runhild; Frank, Konstantin; Haas, Maximilian; Schenck, Thilo L. M.D., Ph.D.; Gleiser, Corinna Ph.D.; Weyers, Imke M.D.; Wedel, Thilo M.D., Ph.D.; Pretterklieber, Michael M.D., Ph.D. Plastic and Reconstructive Surgery (2017) pp 1075-1082 14. Bousquet MT, Agerup B. Restylane lip implantation: European experience. Operative Techniques in Oculoplastic, Orbital, and Reconstructive Surgery. 1999;2:172–6.  15. Landau M. (2007) Environmental Factors in Skin Diseases. Curr Probl Dermatol. Basel, Karger, 2007, vol 35, pp 1-13 16. Raine-Fenning, N.J., Brincat, M.P. & Muscat-Baron, Y. Am J Clin Dermatol (2003) 4: 371. <https://doi.org/10.2165/00128071200304060-00001> 17. Moretti G, Ellis RA, Mescon H. Vascular patterns in the skin of the face. J Invest Dermatol 1959;33:103–12 18. Bisson M, Grobbelaar A (2004) The Esthetic Properties of Lips: A Comparison of Models and Nonmodels. The Angle Orthodontist: April 2004, Vol. 74, No. 2, pp. 162-166.

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An Introduction to Injectable Complications Dr Catherine Fairris provides an introduction to the types of complications that may occur after toxin and filler injections Minimally invasive aesthetic techniques such as botulinum toxin injections and dermal fillers are often seen as a safe and cost effective aesthetic option. If performed by experienced, welltrained practitioners, the probability of complications occurring is relatively small; however, there are complications that patients can experience. This article will discuss the common complications that may occur as a result of botulinum toxin and dermal filler treatments and will briefly state the routine management approaches. As this article is an introduction, it will not go into significant detail, but instead hopes to educate practitioners who are new to aesthetics.

Neurotoxins

Botulinum toxin type A (BoNT-A) injections are the most commonly performed minimally invasive cosmetic procedure.1,2 BoNT-A acts by inhibiting the release of acetylcholine from presynaptic nerves at the neuromuscular junction, thereby hindering muscle contraction of both smooth and striated muscle.3 Although eight serotypes of BoNT exist, only type A is approved by the US Food and Drug Administration (FDA) for cosmetic use.1,3 BoNT-A-related adverse effects are relatively uncommon and the majority tend to be mild and temporary, usually occuring as a result of the effect of the product on unintended muscle groups after injecting.1

dilution, and indication for treatment.1,3,4 A systematic review of 31 clinical studies (with a total of 1,678 participants) of botulinum toxin type A in aesthetic treatments found the incidence of eyelid ptosis (2.5 %), brow ptosis (3.1 %), eye sensory disorders (3%), and lip asymmetries and imbalances of the lower face (6.9%)5 to be relatively low. The most commonly reported toxin adverse effects are injection site pain,1 which can be reduced by reconstitution with 0.9% bacteriostatic saline.6 Other commonly reported complications of BoNT-A are injection site ecchymosis, headaches, and fever/ malaise.1,2,4 Bruising can be significantly reduced by careful assessment of injection sites and placing puncture sites away from superficial blood vessels,1,4,5 especially around the periorbital region, which has a rich vascular network. Pre-treatment with topical anaesthetics and using small gauge needles – such as 30-32G – can minimises pain, whilst ice packs can be useful to reduce swelling and bruising pre and post treatment.1 Patient avoidance of aspirin, non-steroidal anti-inflammatory Does the patient have a severe headache?

No

Yes

No

Adverse effects of BoNT-A Adverse events caused by injection into unintended muscle groups or unexpected diffusion of product to surrounding muscle can lead to focal facial paralysis and muscle weakness, causing eyelid ptosis, diplopia and facial asymmetry.1,3,4 The risk of these adverse events can be reduced if the practitioner has a good understanding of patient anatomy, product dosage and

Reassure and observe

Is there significant ptosis resulting in obstruction of visual fields?

Does it involve the eyelid?

Is there diplopia or loss of voluntary eye closure?

No

drugs (NSAIDS) and vitamin E derivatives for seven days prior to treatment can also help to reduce bruising,1 although comorbidities must be taken into account when recommending this. For example, if the patient has cardiovascular risk factors and is taking prophylactic aspirin, it may not be safe to stop. The occurrence of headaches following injection of BoNT-A has been widely researched. In a study of 264 patients treated with BoNT-A for glabella lines (203 in treatment arm and 61 placebo), 15.3% of the treatment group reported headache, which was the most frequently reported adverse effect.7 However, headache was also reported in 15% of the placebo group. Therefore, the authors concluded that it was likely related to the injection itself rather than the BoNT-A.7 Management is, as with other causes of headaches, conservative or with simple analgesia.4,5,7 Eyelid ptosis can occur if BoNT-A spreads to the levator palpebrae superioris muscle, usually as a result of downward diffusion of BoNT-A when attempting to treat glabellar and forehead rhytides.4 Ptosis can occur up to two weeks’ post treatment, and usually lasts between two to four weeks.4 The incidence is reported to be between 1-5% of glabellar and forehead treatments.4,5 To avoid this, injections should be placed at least 1cm above the brow and should not cross the mid-pupillary line laterally. If ptosis occurs, it can be treated with application of alpha2-adrenergic agonist eye drops to cause contraction of the Müller’s muscle, which elevate the upper eyelid.8 For example, two to three drops daily of apraclonidine 0.5% into the affected eye until symptoms resolve should be effective.2,8 When treating the periocular region, there

Does the patient have facial paralysis in the unintended area?

Yes

Give advice about simple analgesia and reassure that symptoms will settle within 2-4 weeks

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Yes Yes No

Yes

Refer immediately to an ophthalmologist

Reassure and observe

If no contraindication, prescribe an alpha adrenergic agonist e.g. apraclonidine 0.5% 2-3 drops in the affected eye daily for 2-4 weeks (review regularly)

Figure 1: Proposed protocol for the management of complications of botulinum toxin. This table has been created based upon my own clinical experience and what I have read in studies and the literature.1,4,5,7 Note this is not official guidance.

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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This suggests that the filler has been injected too superficially (Tyndall effect) • Incise the area and drain filler material with a sharp needle (LA should be applied for patient comfort) • Alternatively, if no hx of bee sting allergy, infiltrate with hyaluronidase (made as per manufacturer’s guidance)

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Is there a bluish discolouration of the skin overlying where the filler has been injected?

Yes

No

Are there red, painful lumps under the skin <2 weeks following filler injection? No

Is there evidence of granuloma formulation (well defined lumps under the skin >6 weeks following filler injection)?

If non-tender nodules, then likely granuloma. Identify the agent that has been injected, biopsy may be required. If well demarcated and large, refer for surgical excision. Alternatively, injection of corticosteroid and/or triamcinolone acetonide at regular intervals of 4-6 weeks until lumps resolve. 5-florouracil may be used – refer for specialist input early on.

Yes

No

Always consider possibility of biofilm: send samples for culture and refer on for specialist input

Yes

This suggests acute infection. If possible, excise and drain lumps. Samples should be sent for culture. Commence broad spectrum oral antibiotics e.g. macrolide and a tetracycline until culture specificity available. Use antiviral e.g aciclorvir if any suggestion of herpes simplex. Discuss with local microbiologist if any concerns/hx of allergy.

Figure 2: Proposed protocol for the management of late complications of dermal filler. This table has been created based upon my own clinical experience and what I have read in studies and the literature.9,10,11,14 Note this is not official guidance.

does not already contain lidocaine), or by using topical gel packs before and after treatment.9,13 The practitioner’s injection technique can also influence whether the patient develops bruising and swelling. For example, rapid injection of filler, the use of the fanning technique, as well as using large volumes of filler, have all been shown to increase the incidence of bruising, and swelling.4,9,13 These complications can be minimised by using blunt tip cannulas, small gauge needles (as appropriate to the viscosity of the product) and limiting delivery to the smallest volume of filler required to achieve the best aesthetic result.4,9,10,11,13

Adverse effects of dermal fillers is a risk of diplopia and loss of voluntary eye closure, which can be avoided by injecting BoNT-A laterally to the orbital rim, placing injections superficially within the orbicularis oculi muscle and by injecting small doses.5

Dermal fillers There are currently more than 100 dermal filler products available in the European market.9 They can be broadly divided into their duration of action, temporary or permanent.10 Temporary fillers are biodegradable with effects lasting between three to 24 months. Temporary dermal fillers are: hyaluronic acid (HA), poly-l-lactic acid (PLLA), calcium hydroxylapatite (CaHA), and collagen, which is not as common.9,10 Dermal fillers such as polymethylmethacrylate (PMMA) and silicone, are considered permanent as they cannot be absorbed and broken down by the human body.9 Dermal filler use in aesthetic medicine is broad; from addressing fine lines and wrinkles to facial contouring and projection.7,10 The choice of filler is often based on the anatomical area that needs to be treated, the volume that is required to reach the best aesthetic result, longevity of the product and the cost.10 The most popular type of dermal filler is hyaluronic acid (HA), which generally has the best safety profile amongst all nonautologous dermal fillers.10 This is because HA is a naturally occurring molecule that is identical across species, therefore HA fillers are minimally immunogenic and easily dissolved by the enzyme hyaluronidase.11,12 HA molecules are linear polysaccharides which are negatively charged to bind water. Chemical cross-linking stabilises them, although they are broken down gradually,

so they are not permanent. The more cross-linking they contain, the longer it takes to break them down.10 Although the injection of dermal filler is described as minimally invasive, related adverse effects may be more serious, with greater long term sequelae, for example vascular occlusion.10 Injection site reactions tend to be the most common complication reported due to immediate trauma to the skin from the process of injection, irrespective of the type of dermal filler used.10 Complications can be classified as minor and short lived; such as swelling, redness, tenderness, and bruising which tend to last between four to seven days,11 to delayed complications occurring months or even years later, for example, granuloma formation – discussed below.10 Complications of dermal fillers can be broadly divided into technical errors (injection of an inappropriate volume of filler, inaccurate depth of filler injection, injecting in the wrong location and inappropriate filler choice) and inflammatory complications (contamination by infectious agents and immune-mediated reactions).11 When HA complications occur, the fillers can be broken down by hyaluronidase, which is a mucolytic enzyme that hydrolyses the HA in both natural and cross-linked form.11,12 An example of this is if the filler has been injected too superficially, as superficial placement will cause a bluish discolouration of the skin overlying the filler (the Tyndall effect), which does not resolve until the filler has been removed or has been resorbed.9,10,13 As with BoNT-A, injection site pain can be minimised by using topical anaesthetics, by injecting local anaesthetic such as lidocaine (if the dermal filler being used

Hypersensitivity reactions Hypersensitivity reactions – the development of swelling, erythema, and tenderness within a few minutes of dermal filler injections – have also been reported. In 2002, a review article by Friedman et al. stated that the incidence of hypersensitivity reactions reported with HA fillers in the year 2000, was 0.02%.1 The risk of hypersensitivity is thought to be greatest in dermal fillers that contain bovine collagen, however it is a theoretical risk with all types of dermal filler. Therefore, skin testing is recommended in patients with a history of anaphylaxis or allergy to any of the constituents of the filler, for example, lidocaine. Skin testing prior to use of polymethylmethacrylate (PMMA) filler is mandatory as it contains bovine collagen making it highly immunogenic.1,9,13 Granulomas Granuloma formation can occur with any injectable filler. Subclinical granulomatous inflammation is a normal tissue response to the injected material; therefore, it is the degree and severity of granuloma that determines significance.11,14 Granuloma formation is the body’s attempt at removing foreign material. Histologically, they contain inflammatory infiltrate composed of histiocytes and epithelioid cells.14 They are separate from nodules which are isolated single ‘lumps’ of product surrounded by a fibrous capsule, becoming palpable within weeks of treatment.14 Granuloma formation is usually a late complication of filler injection. The risk of granuloma formation is less with resorbable fillers, compared with permanent fillers. Administration of local or systemic steroids

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Bocouture® (Botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information: M-BOCUKI-0051. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Horizontal. Glabellar Frown Lines: Total recommended standard dose is 20 units. 4 units into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 4 units injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 10 units to 20 units is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 2 units, 3 units or 4 units is applied per injection point, respectively. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with

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

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


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Does the patient have respiratory distress (perioral swelling OR angioedema OR RR or O2 sats)?

Aesthetics Journal

No Is there excessive pain OR skin blanching OR levido reticularis OR capillary refill time?

Yes

If high suspicion of anaphylaxis: call immediately for help and commence immediate life support measurers. If available, give: oxygen, adrenaline, antihistamine, corticosteroids (as per ALS)

Aesthetics

Yes

No

Apply a warm compression to the affected area If no hx of bee sting allergy, infiltrate with generous volumes of hyaluronidase 3. Give 75mg of Aspirin 4. Apply nitroglycerin 2% paste generously to affected area to encourage vasodilation 5. Consider commencing prophylactic antibiotics 6. Review patient daily – refer on to specialist centre at earliest opportunity if symptoms not improving/significant area affected/ visual symptoms MONITOR PATIENT CLOSELY THROUGHOUT 1. 2.

Has filler been injected too superficially?

Yes

Stop treatment: consider infiltration with hyaluronidase to remove filler

Figure 3: Proposed protocol for the management of immediate complications of dermal filler. This table has been created based upon my own clinical experience and what I have read in studies and the literature.11,12 Note this is not official guidance.

can be used as treatment; 5-fluorouracil can be injected into the lesions to reduce growth. Surgical excision is recommended for larger, well-defined lesions.9,10,11,13,14 Vascular occlusions The most serious complication of dermal fillers are vascular complications, which are also known as embolia cutis medicamentosa (ECM) or Nicolau syndrome.12 Vascular events usually occur as a result of accidental intravascular injection of dermal filler into an artery, thus leading to obstruction of blood supply to distal tissues.6,9,12 Obstruction of blood supply can cause blindness; for example, inadvertent bolus injection into the angular artery has the potential to cause blindness via retrograde flow of filler into the ophthalmic artery.12 Management of artery occlusion is very difficult, therefore the best method is avoidance. Careful assessment of the patient is strongly advocated and if there is any doubt as to whether an artery is close to the site of injection, then the injection of a small amount of adrenaline into the proposed treatment area can be used to identify and constrict arteries.12 Cannula use has also been shown to reduce the risk of vascular occlusion4 and avoiding small bore needles can reduce the likelihood of the needle entering the lumen of the vessel to deposit filler intravascularly. Although, larger bore needles are more likely to cause bruising.10,12,13 Injecting slowly and using small bolus of product (0.1ml or less) at a time can also reduce the risk of depositing large volumes of product intravascularly.12 If vascular occlusion occurs, having a clear protocol of how to manage the situation to

minimise morbidity is extremely important. The protocol for management is too vast to detail in this article, but it is vital that practitioners can identify the signs and symptom associated. Initially there may be severe pain, blanching of the skin distal to the site of occlusion and livedo reticularis.10,12 However, symptoms may take several hours to present or evolve over a period of a few days, so patients should also be advised to be aware of pain disproportionate to the treatment received, persisting for longer than expected, change in skin colour, and exudate.10,12 Biofilms Biofilms are a living bacterial colony that adhere to a foreign implant and encapsulate it.15 Biofilms evade the host immune system by altering gene expression. They are characterised by recurrence and chronicity. Definitive treatment usually only occurs following removal of the implant as biofilms are notoriously difficult to treat.15

Management Preparing for filler emergencies is paramount, and literature has advocated that injectors have access to a ‘filler crash kit’, which includes hyaluronidase, aspirin and topical nitroglycerin paste. This can be used in the event of vascular occlusion (Figure 3).12 After treatment, close monitoring of the patient should take place and referral should be made, without delay, to a hospital for urgent vascular surgeon input.12

and aesthetic practitioners need to have a very good understanding of the anatomy and the products they are using. Preparedness with a ‘filler crash kit’ and vigilance of the development of complications will ultimately ensure that treatment is started promptly, which should improve outcome. Practitioners should ensure they are adequately trained before attempting any BoNT-A or dermal filler treatments. Dr Catherine Fairris qualified from Bristol University in 2008 and is an associate member of BCAM. She trained under Dr Geoffrey Fairris, consultant dermatologist, and is now the director of Wessex Skin LTD in Winchester, specialising in minimally invasive cosmetic procedures and cosmecauticals. Dr Fairris is currently completing her thesis for her Master’s degree in Aesthetic Medicine. REFERENCES 1. Cox S.E. and Adigun C.G. Complications of injectable fillers and neurotoxins. Dermatologic Therapy. Vol 24, 2011, 524-536 2. Cosmetic surgery national data bank statistics. Aesthetic Surg. J. 2016;36(1); pp1-29 https://academic-oup-com.ezproxy.library. qmul.ac.uk/asj/article/36/suppl_1/1/2474285 3. Botox®Insert: http://www.allergan.com/assets/pdf/botox_ cosmetic_pi.pdf 4. Christiansen D. and Stebbins W. A Guide to Safety in Dermatologic Cosmetic Procedures: Avoidance and management of common Pitfalls and Perils. Curr Derm Rep (2013) 2:125-134 5. Brin MF, Boodhoo TI, Pogoda JM, et al. Safety and tolerability of onabotulinumtoxinA in the treatment of facial lines: A metaanalysis of individual patient data from global clinical registration studies in 1678 participants. J Am Acad Dermatol. 2009;61:961. e1–970.e1. 6. Alam M, Dover JS, Arndt KA. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: A double-blind, randomized controlled trial. Arch Dermatol. 2002;138:510–514. 7. Carruthers JV, Lowe NJ, Menter MA et.al. A multicentre, double blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type Ain the treatment of glabella lines. J AM Acad Dermatol. 2002; 46: 840-9 8. Omoigui S and Irene S. Treatment of Ptosis as a complication of Botulinum Toxin Injection. American Academy of Pain Medicine. 2005; 6(2); 149-151 9. Wollina U., Goldman A. Hyaluronic acid dermal fillers: safety and efficacy for the treatment of wrinkles, aging skin, body sculpting and medical conditions. Clin Med Rev Therapeutics 2011; 3:107-121 10. Luebberding S. Alexiades-Armenakas M. critical Appraisal of the Safety of Dermal Fillers: A primer for Clinicians. Curr Derm Rep (2013) 2:150-157 11. DeLorenzi C. Complications of Injectable Fillers, Part 1. Aesthetic Surgery Journal (2013), Vol. 33(4) 561-575 12. DeLorenzi C. Complications of Injectable Fillers, Part 2: Vascular Complications. Aesthetic Surgery Journal (2014), Vol. 34(4) 584-600 13. Christiansen D., Stebbins W. A Guide to Safety in Dermatologic Cosmetic procedure: avoidance and management of common pitfalls and perils. Current Dermatology Reports. 2013 2(2) pp125-134 14. Foreign Body granulomas after all injectable dermal fillers: Part 1. Possible causes. Plastic and Reconstructive Surgery Vol 123(6), 2009 pp1842-1863 15. Daines SM and Williams EF. Complications Associated with Injectable soft-tissue fillers. A 5-Year Retrospective Review. JAMA Facial Plastic Surg. 2013;15(3): 226-231

Summary Severe adverse reactions to BoNT-A are rare and most complications are usually reversible. Complications of dermal fillers can cause significant morbidity and mortality,

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


Advertorial Schuco Aesthetics

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Introducing Princess® Volume Plus – A New Level of Lift Schuco Aesthetics Announces Launch of Latest HA Dermal Filler Innovation April sees the launch of Princess® Volume Plus – the newest addition to the leading dermal filler range from the experts of hyaluronic acid, Croma-Pharma. The most robust formulation in the Princess® portfolio, Volume Plus is designed for volume enhancement and facial contouring. This soft, versatile gel has a higher G prime than the current top five market leaders, and has been specifically designed for mid-face volumising, reshaping and contouring. Princess® HA dermal fillers are supreme aesthetic injectables created and developed by Croma-Pharma, with over 40 years of expertise. Since 1994, over 45 million syringes of HA dermal fillers have been produced.

UNIQUE PROPERTIES Princess® Volume Plus demonstrates superior elastic properties compared to other volumising dermal fillers as it integrates seamlessly into the surrounding tissue, while providing the ultimate structural support. In vitro enzymatic degradation experiments show that Princess® Volume Plus is considerably more stable than competitor products. It has a higher G Prime compared to the current top five market leading fillers yet can still maintain a consistently a low extrusion force. The unique, durable glass syringe design provides an exceptionally smooth extrusion force for increased injection stability and comfort, coupled with easier recycling.

Temple Region

Cheeks Nasolabial Folds

Marionette Lines

Chin

48

Aesthetics | April 2018


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Advertorial Schuco Aesthetics

TREATMENT INDICATIONS Volume Plus is ideal for subcutaneous or deep dermis injection, to provide structure, lift and support for correcting and restoring facial volume, alongside facial contouring. Thanks to the high G prime formulation, Volume Plus can be used for reconstructive purposes in the treatment of facial lipoatrophy, debilitating scars or morphological asymmetry. Key treatment areas • Temple region • Cheeks and mid-face • Marionette lines • Nasolabial folds • Chin

PATIENT BENEFITS The Princess® HA dermal filler range gives patients instantly visible effects, coupled with long-lasting, natural results. The smooth gels integrate seamlessly within the skin, giving increased hydration, lift and shape to facial contours. The addition of lidocaine minimises patient discomfort both during and after treatment – some products in the range are also available without lidocaine. Ultimately – your patients can have confidence that they are receiving a highquality product with proven safety, efficacy and satisfaction.

USER FEEDBACK

“I’ve been using HA fillers for 25 years and have used many different brands in that time. I’ve been very happy with Princess® – I’ve been using it for around three years because it’s very safe, very natural and I’ve had no adverse events. My team and I have been trying out the new Princess® Volume Plus as the latest step in the portfolio and have been getting some great results. So far in my injectable career, I would say Princess® has been the best!” Dr Rita Rakus, multi award-winning aesthetic expert at the Dr Rita Rakus Clinic, Knightsbridge

“From a patient perspective, the Princess® range gives instantly visible effects, coupled with longlasting, natural results. The smooth gels integrate seamlessly within the skin, giving increased hydration, lift and shape to facial contours. The addition of lidocaine minimises patient discomfort both during and after treatment and, ultimately, my patients can have confidence that they are receiving a high-quality product with proven safety, efficacy and satisfaction.” Mr Kambiz Golchin, consultant ENT and facial plastic surgeon at the Beacon Face & Dermatology Clinic, Dublin

JOIN US AT ACE! Join the Schuco Aesthetics team on Friday 27th April, 4-5PM at the ACE congress for an Expert Masterclass which will exclusively unveil and demonstrate the latest innovations with the Princess® dermal filler portfolio, including the new Volume Plus. Led by an expert panel of Dr Rita Rakus, Mr Kambiz Golchin and Lee Garrett, the Masterclass will feature a mixture of informative presentations, expert panel Q&As and a live injecting demonstration.

Princess® Volume Plus – Cross-Linked Hyaluronic Acid with 0.3% Lidocaine Concentration HA:

2.5% (25mg/ml)

Crosslinking agent:

BDDE

Other ingredients:

Phosphate buffer, NaCl, 0.3% lidocaine hydrochloride

Needle:

2 x 27G ó” thin wall Terumo needles (CE mark 0197)

Packaging:

Box of 1ml syringe

Duration:

Up to 12 months

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Avoiding Needlestick Injuries Clinic waste technical manager Luke Rutterford explains how to implement best practice to avoid injury from sharps and needlesticks Needlestick and sharps injuries are one of the most efficient methods for spreading bloodborne pathogens between patients and healthcare providers, and therefore can pose a substantial risk to health.1 Because of the kinds of treatments conducted in medical aesthetic clinics, there is a risk of needlestick and sharps injuries occurring, so it is crucial that practitioners and other clinic staff are aware of the safe segregation, storage, disposal and management of sharps’ waste. This will ensure the hazards associated with handling these items are significantly reduced, and that there is compliance with the Hazardous Waste Regulations2 (or Special Waste Regulations in Scotland).3 Needlestick and sharps injuries can result in the spread of hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV), while other types of infections can also occur.4 A European directive was made available in 2010 with the aim to create safer working environments by preventing injuries caused by medical sharps. In the UK, The Health and Safety (Sharp Instruments in Healthcare) Regulations 20135 was launched to meet the requirements of the EU Directive 2010/32 and to specifically address the gaps in existing UK legislation at that time.

Instruments of concern Items that are commonly found around the aesthetic clinic classed as ‘sharps’ include syringes, hypodermic needles, scalpels, razors and razor blades, phials, pipettes, microneedling devices, test tubes and glass (whether broken or intact). Some of the most common scenarios where needlestick injuries occur in the healthcare sectors around the world include when recapping or detaching the needle after use on a patient, while taking a blood test or during IV cannulation.6 The risk of needlestick or sharps injury is highest among workers in health and social care environments, including aesthetic clinics, as these professionals directly handle sharps on a daily basis, multiple times a day. It is crucial that all team members that facilitate any type of treatment with needles or other sharp items are fully aware of and trained on this subject, and that this training is regularly updated and reinforced.

What are the risks? As mentioned, the main risks from a sharps injury are the potential exposure to infections, such as bloodborne viruses (BBV). This can occur when a sharp that is contaminated with blood or another bodily fluid from a patient pierces the skin of another person. Of the BBVs that cause the most concern is HBV, which affects the liver, causing inflammation called hepatitis.7 Infections of HBV can either be acute or chronic, the latter being more serious. Individuals can recover from acute infections without medical intervention and many people do not even display any symptoms; they often don’t realise that they have it. Chronic infections remain with the person for life and can affect the liver in the long-term, causing cirrhosis, if treatment such as an anti-viral drug is not administered. HCV is also an infection of the liver that can be acute or chronic and again, many people infected might mistake symptoms as another illness, such as the flu.8 HIV is a lentivirus that causes acquired immunodeficiency syndrome (AIDS) and can be passed on through infected blood and other bodily fluids. It weakens the immune system, which can allow life-threatening infections and cancers to attack the body.9 The rate of diffusion of infection after an infected needlestick injury varies depending upon the bloodborne pathogen. Factors that may increase the risk of contracting an infection, and that influence possible management of its development, include:10

• Percutaneous injury, rather than mucous membrane or broken skin exposure • Injury with a device used to penetrate a patient’s artery or vein • Blood exposure rather than exposure to bloodstained fluid, diluted blood (for example in a local anaesthetic solution) or other bodily fluid • Injury from a hollow bore rather than solid bore needle • Injury from a wide gauge rather than narrow gauge needle • Visible blood on the device • No protective equipment used (such as gloves, double gloves and eye protection) • First aid measures not implemented (not washing wounds or dealing with them in the correct manner) • Hepatitis B e-antigen (HBeAg) detectable in source patient blood • Exposed person not, or inadequately, immunised against hepatitis B • Source patient co-infected with more than one BBV • High viral load of HIV in source patient11 • Deep rather than superficial injury12

Prevention The Health and Safety (Sharps Instruments in Healthcare) Regulations 2013 outline requirements for hospitals and the healthcare sector in general, including cosmetic, medical and dental establishments. The regulations target both employers and employees, showing how important it is for every single person involved in healthcare to take responsibility for their part in needle and sharps safety. They have a duty of care to their colleagues and patients.5 The recent additions taken from the European Directive and included in the 2013 UK Regulation are: • Providing sharps disposal equipment as close as possible to the assessed areas where sharps are being used or found • Prevent the recapping of needles • Use of personal protection equipment (PPE) • Making information available and raising awareness of risks, good practice, recording of incidents/accidents and support on offer. This information may be presented as safe operating systems, safety guides, posters or sections on a dedicated website that covers the potential risks from injuries involving sharps, relevant legal duties of the employer, good practice injury prevention and the pros and cons of vaccination. • Training on the correct use of safer sharps and disposal procedures13 It is acknowledged that the single most important way to help to prevent needlestick injuries is to avoid recapping and re-sheathing.5,14,15 The term ‘safer sharps’ is now commonly used and this refers to medical sharps that incorporate features

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Safe segregation, storage and disposal The segregation, storage and disposal of sharps is determined by the type of contamination. This contamination establishes the correct colour of waste bin required for the waste that is being disposed. The Safe Management of Healthcare Waste Regulations18 set out guidelines on the safe and legal disposal of sharps waste using a colour-coded scheme. Sharps containers provide safe storage and disposal of sharps waste and come colour coded to ensure that the waste is segregated appropriately according to legislation: • An orange lid – sharps not containing or contaminated with medicines, such as sharps used for blood samples and acupuncture • A yellow lid – items contaminated with or containing medicines or anaesthetics • A purple lid – for the disposal of sharps and medicines with cytotoxic or cytotoxic contents or contamination • A blue lid – for the disposal of out-of-date drugs, used drug denaturing kits and discarded items from use in the handling of pharmaceuticals such as bottles or boxes with residues, gloves, masks, connecting tubes, syringe bodies and drug vials Sharps bins should be sourced from a reputable supplier to ensure that they are impact and puncture resistant, as well as being leakage proof, to ensure complete protection of healthcare workers, patients and waste disposal employees. Once sharps containers are full – i.e. they are full to the recommended fill line and no more needles can be easily and safely placed in the container – they should be securely closed and stored in a separate area away from patients. Waste collection should be organised according to the individual clinic’s needs, as it’s important to limit the amount of time full sharps containers and other waste streams are stored on the premises.

or mechanisms to prevent or minimise the risk of an injury.5 It is also advised to keep a rigid, puncture-proof waste container close to hand for used needles, helping to avoid the temptation of recapping. It is equally important to use proper protective clothing, such as gloves, facemasks and goggles to avoid any inadvertent transmission of blood or other bodily fluids. Every healthcare worker at risk from accidental exposure to blood should be trained in infection control and vaccinated against HBV (unfortunately there are not yet any preventive vaccines available for HCV or HIV). Action Action after exposure to potentially contaminated material through a needlestick or sharps injury should be swift and follow the below protocol: 15,16 • If skin is punctured, free bleeding should be gently encouraged, ideally holding it under running water to prevent infection of other areas of the hand/skin • The wound should be washed with soap or disinfecting handwash and water, but not scrubbed or sucked • If there is any possibility of HCV, HBV or HIV exposure, urgent medical advice should be sought for the relative indications for anti-retroviral post-exposure prophylaxis.17 This is the medication

Aesthetics

administered in emergency situations where HIV transmission is possible and must be started within 72 hours of potential exposure. It’s available from healthcare providers on prescription or from emergency health services. • Notification to the employer should be made as soon as is practically possible, with them making an official recording of the incident. Or if you are a sole practitioner/employer then you should record the incident. When the employer is notified, this should initiate an investigation into the event so that any immediate action can be taken, but also so lessons can be learnt for the future; for example, perhaps a change in policy or protocol or the acquisition of a new safety device is required.

Conclusion Through minimising sharps usage, remaining abreast of new regulations and adopting safety devices to prevent injuries, aesthetic clinics can help keep their employees, patients and other members of the public safe. Luke Rutterford is technical manager for the Initial Medical and Specialist Hygiene divisions of Rentokil Initial in the UK, with responsibility for training, service development, innovation, quality and compliance. Rutterford also worked within the documentary industry for the National Geographic show ‘Pests from Hell’ and holds a BSc (Hons) in Forensic Science from Anglia Ruskin University, Cambridge. REFERENCES 1. Science Direct, Needlestick Injury, (2008) <http://www.sciencedirect.com/topics/medicine-anddentistry/needlestick-injury> 2. The Hazardous Waste (England and Wales) (Amendment) Regulations 2005. http://www.legislation. gov.uk/uksi/2005/894/contents/made [Accessed November 2017] 3. The Special Waste Regulations 1996. http://www.legislation.gov.uk/uksi/1996/972/contents/made [Accessed November 2017] 4. Science Direct, Needlestick Injury, (2008) <http://www.sciencedirect.com/topics/medicine-anddentistry/needlestick-injury> 5. Health and Safety Executive. Health and Safety (Sharp Instruments in Healthcare) regulations 2013. http://www.hse.gov.uk/pubns/hsis7.htm [Accessed November 2017] 6. Goel V, Kumar D, Lingaiah R, Singh S. Occurrence of needlestick and injuries among health-care workers of a tertiary care teaching hospital in north India. J Lab Physicians. 2017 Jan-Mar; 9(1): 20–25. doi:  10.4103/0974-2727.187917 7. NHS Choices. Health A-Z. Hepatitis B. https://www.nhs.uk/conditions/hepatitis-b/ [Accessed November 2017] 8. NHS Choices. Health A-Z. Hepatitis C https://www.nhs.uk/conditions/hepatitis-c/ [Accessed November 2017] 9. NHS Choices. Health A-Z. HIV and AIDS. https://www.nhs.uk/conditions/hiv-and-aids/symptoms/ [Accessed November 2017] 10. NHS Employers Needlestick Injury document: http://www.nhsemployers.org/~/media/Employers/ Documents/Retain%20and%20improve/Needlestick20injury.pdf [Accessed November 2017] 11. Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R et al. „A case-control study of HIV seroconversion in healthcare workers after percutaneous exposure‟ (1997). N Engl J Med. 337: 1485-1490 12. Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R et al. „A case-control study of HIV seroconversion in healthcare workers after percutaneous exposure‟ (1997). N Engl J Med. 337: 1485-1490 13. Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 Guidance for employers and employees. http://www.hse.gov.uk/pubns/hsis7.pdf [Accessed November 2017] 14. Royal College of Nursing. Sharps Safety RCN guidance to support the implementation of The Health and Safety (Sharp Instruments in healthcare regulations) 2013. https://www.gla.ac.uk/media/ media_511552_en.pdf [Accessed February 2018] 15. Council Directive 2010/32/EU. Official Journal of the European Union. http://eur-lex.europa.eu/ LexUriServ/LexUriServ.do?uri=OJ:L:2010:134:0066:0072:EN:PDF [Accessed February 2018] 16. Health and Safety Executive. Sharps injuries. What to do if you receive a sharps injury. http://www. hse.gov.uk/healthservices/needlesticks/ [Accessed February 2018] 17. NHS Employers Needlestick Injury, (2017) http://www.nhsemployers.org/~/media/Employers/ Documents/Retain%20and%20improve/Needlestick20injury.pdf [Accessed November 2017] 18. Department of Health. Environment and sustainability health technical memorandum 07-01: safe management of healthcare waste. https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/167976/HTM_07-01_Final.pdf [Accessed November 2017].

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Aesthetics Journal

Aesthetics

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SkinCeuticals Masterclass: Integrating skincare into your practice The recent SkinCeuticals Expert Masterclass, held at the Bulgari Hotel in London, focused on practical ways to integrate cosmeceutical skincare into daily aesthetic practice. The Masterclass, chaired by Dr Uliana Gout, renowned cosmetic physician, combined interactive discussion sessions with live patient assessments. The evening served to highlight the importance of evidence-based skincare in clinical practice to promote healthy skin and to optimise aesthetic treatment outcomes whilst minimising downtime. The event also heralded the latest addition to the SkinCeuticals Correct range: Glycolic 10 Renew Overnight.

NEW Glycolic 10 Renew Overnight Glycolic 10 Renew Overnight is an innovative night cream restoring skin lustre and improving skin texture to bestow a healthy, radiant skin complexion. Leslie Harris, CEO of SkinCeuticals, introduced the research behind Glycolic 10 Renew Overnight. She described how the formula secures the alpha hydroxy acid at the ‘ideal’ 10% active level, which has been demonstrated to promote effective skin cell turnover without causing the irritation and discomfort sometimes associated with topical glycolic acid-based creams. Leslie explained that Glycolic 10 Renew Overnight includes 2% phytic acid to promote brightness, alongside a soothing botanical complex to form a protective, breathable layer to help lock in hydration and provide comfort. Concluding her presentation Leslie said, “Glycolic 10 Renew Overnight meets consumer demand for a long-lasting ‘glow’, as well as prolonging the effects of in-clinic procedures. Finally, it offers a solution to treating dull, photodamaged skin which we know is a common skin concern for many patients today.”

Evidence-based Skincare: a vital cornerstone in aesthetic practice Dr Stefanie Williams, leading dermatologist and medical director of the EUDELO clinic, is passionate about the role clinically effective skincare has in her practice. Outlining her unique stepwise ‘Staircase’ approach, Dr Williams explained how she integrates skincare into her clinical practice to improve overall skin quality and health before eventually progressing her patients to regenerative and corrective procedures. Dr Williams says, “As professional aesthetic practitioners, we should not overlook the benefits of cosmeceutical skincare. Not only does it play a vital role in slowing down skin ageing but it also can help expand your customer base. Research shows that 85% of aesthetic patients want advice about skincare but this need is unmet in many cases, which presents a huge opportunity for business growth.” She added, “Moreover, when evidence-based skincare is used in combination with aesthetic procedures you can optimise treatment results, minimising downtime, to achieve high patient satisfaction and all important word-of-mouth referrals. It is a Win-Win!”

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Aesthetics | April 2018

Patient Assessment and Treatment Planning In the final session Dr Uliana Gout and Dr Williams were joined by Dr Benji Dhillon, aesthetic surgeon at the PHI Clinic in London. Presented with two models, each with differing skin concerns, the experts discussed their best practice approaches and explained how they would integrate cosmeceutical skincare into their respective multimodality treatment plans to improve skin quality and provide skin health benefits pre and post treatment. Dr Dhillon said, “I firmly believe that evidence-based skincare is an essential long term adjunct to aesthetic procedures.”

Optimising patient satisfaction Dr Uliana Gout summed up the evening “Tonight’s SkinCeuticals Masterclass has proved to be an excellent platform, in a friendly and engaging environment, for sharing the latest evidence on the role of cosmeceutical skincare within the Aesthetic Medicine arena. It has been a pleasure to Chair the session, to see so many existing and new colleagues and to exchange ideas and information. Great to see the interest in how to best integrate evidence-based skincare into our clinical practice to optimise patient satisfaction, promote safety and enhance treatment results.” Email: contact@skinceuticals.co.uk Twitter: @SkinCeuticalsUK

Dr Uliana Gout will present at the SkinCeuticals Masterclass at the Aesthetics Conference and Exhibition (ACE) on Friday 27 April, 12-1pm.


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Aesthetics

A summary of the latest clinical studies Title: Assessing the Safety of Superficial Chemical Peels in Darker Skin: A Retrospective Study Authors: Vemula S, Maymone MBC, Secemsky EA et al. Published: Journal of the American Academy of Dermatology, March 2018 Keywords: Chemical peels, ethnic skin, pigmentation Abstract: Chemical peels have shown efficacy in the treatment of acne, photoaging, and pigmentary dyschromias; however, studies evaluating side effects, particularly in patients with skin of color, are limited. We sought to determine the frequency of side effects and complications associated with superficial chemical peels in patients with skin types III-VI. A 5-year single center retrospective analysis was performed. Of 473 chemical peel treatments included in this study, 18 (3.8%) were associated with short-term (≤2 weeks) or longterm (>2 weeks) complications. The most frequent complications were crusting (2.3%), post-inflammatory hyperpigmentation (PIH) (1.9%) and erythema (1.9%). All side effects resolved within 8 months of treatment and were located on the face. When stratified by season, side effects were noted to be less common during the winter. In the adjusted model, Fitzpatrick skin type VI was associated with a higher odds of side effects. Limitations were single center retrospective design. Superficial chemical peels performed in patients with skin types III-VI had a relatively low complication rate, and skin type VI had higher odds of experiencing an adverse event. Side effects were noted to be less frequent during the winter months. Title: A Randomized, Controlled Multicenter Study Evaluating Focused Ultrasound Treatment For Fat Reduction in the Flanks Authors: Gold MH, Coleman WP, Coleman W et al. Published: Journal of Cosmetic and Laser Therapy, March 2018 Keywords: Body contouring, fat reduction, focused ultrasound Abstract: We evaluated focused, pulsed ultrasound treatment to randomized flanks, compared to corresponding non-treated contralateral flanks. Subjects were enrolled at three sites for a series of focused ultrasound treatments to a single flank, with the contralateral flank remaining untreated throughout the study. Success criteria included measureable fat thickness reduction on ultrasound imaging in the treated areas at 16 weeks after the final treatment session, and correct identification of the post-treatment photo and treated flank in at least 80% of evaluated images, as assessed by two blinded evaluators. The post-treatment flank photo and treated flank side were correctly identified in 82% and 93% of cases, respectively. All study subjects demonstrated significant fat reduction in their treated area, as measured by ultrasound and skin caliper. Subjects expressed a high satisfaction from treatment outcomes. There were no complications with treatment. A series of three ultrasound treatments resulted in significant fat reduction in treated flanks. Although treatment results are more modest than with liposuction, non-invasive ultrasound treatment may provide an attractive alternative for patients seeking an in-office, nonsurgical procedure for fat reduction. Title: Demodex Mites Modulate Sebocyte Immune Reaction: Possible Role in the Pathogenesis of Rosacea Authors: Lacey N, Russell-Hallinan A, Zouboulis CC et al.

Published: British Journal of Dermatology, March 2018 Keywords: Rosacea, pathogenesis, dermatology, Demodex mite Abstract: Rosacea is a common facial skin disorder affecting middle-aged adults. Its aetiology is unknown and pathogenesis uncertain. The Demodex mite population in the skin of these patients is significantly higher than in subjects with normal skin suggesting they may be of etiological importance in this disorder. Little is known of the role of these mites in human skin and their potential to interact with the host immune system has not been elucidated. Live Demodex mites were extracted from normal facial skin of control subjects and used in cell stimulation experiments with the immortalised SZ95 sebocyte line. Direct Demodex effects and the effects of medium in which Demodex had been cultured were evaluated on the TLR-signalling pathway on both a gene and protein expression level. Mites modulated TLR signalling events on both mRNA and protein levels in SZ95 sebocytes. An initial trend towards down modulation of genes in this pathway was observed. A subsequent switch to positive gene up-regulation was recorded after 48 hours of co-culture. Demodex secreted bioactive molecules that affected TLR2 receptor expression by sebocytes. High numbers of Demodex induced pro-inflammatory cytokine secretion whereas lower numbers did not. Demodex mites have the capacity to modulate the TLR signalling pathway of an immortalised human sebocyte line. Mites have the capacity to secrete bioactive molecules that affect the immune reactivity of sebocytes. Increasing mite numbers influenced IL8 secretion by these cells. Title: Endoscopic Transaxillary Prepectoral Conversion for Submuscular Breast Implants Authors: Park SH, Sim HB Published: Archives of Plastic Surgery, March 2018 Keywords: Axilla, breast implants, mammaplasty Abstract: During breast augmentation, the transaxillary approach provides the advantage of allowing the mammary prosthesis to be placed through incisions that are remote from the breast itself, thereby reducing the visibility of postoperative scars. This study analyzed 17 patients (34 breasts) with submuscular breast implants with grade III-IV capsular contracture who received treatment from 2010 to 2015. The mean age of the patients was 29 years (range, 2038 years). The inclusion criterion was a pinch test of more than 3 cm at the upper pole of the breast. Previous axillary scars were used to expose the pectoralis fascia, and submuscular breast implants were removed carefully. The dissection underneath the pectoralis fascia was performed with endoscopic assistance, using electrocautery under direct visualization. The mean follow-up period was 14 months (range, 6-24 months). The entire dissection plane was changed from the submuscular plane to the subfascial plane. Round textured gel implants were used, with a mean implant size of 220 mL (range, 160-300 mL). Two patients developed grade II capsular contracture. There were no cases of malposition or asymmetry. Three patients complained of minor implant palpability. None of the patients required additional surgery. Endoscopic subfascial conversion may be an effective technique for treating capsular contracture and avoiding scarring of the breast in selected patients.

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


Advertorial DermaFrac

The DermaGenesis DermaFrac machine takes microneedling to a whole new level DermaFrac is a dermal microneedling system that offers simultaneous delivery of infused ingredients in a pain-free, no downtime treatment. DermaFrac eliminates all the problems associated with traditional microneedling roller treatments where operator technique, variations in pressure applied and skin elasticity can produce uneven, unpredictable results. The absence of the need for anaesthesia with the DermaFrac, the simplicity of use and the lack of any downtime make it an ideal procedure for the aesthetician working in a clinic. DermaFrac is the next generation of treatments, beyond just stand-alone microdermabrasion, and offers an alternative to fractional laser skin resurfacing; without the risk of complications and the associated high cost of the equipment and related treatment costs. How does it work? Crystal-free microdermabrasion relies on constant vacuum pressure to perform an even and effective peel rather than requiring the practitioner to apply pressure. The disposable tip design eliminates cross-contamination. Microneedling regenerates the surface texture and the tone of the skin by creating thousands of tiny micro-injuries and channels that stimulate cell production and repair mechanisms. The vacuum assisted handpiece permits even penetration to the full depth of the needle ranging from 0.25-0.5mm. More importantly, it assists the needle tips to penetrate uniformly to maximise the delivery of the topical infusions solution into the papillary dermis. The microneedles create pathways for the simultaneous infusion of active ingredients such as growth peptides, hyaluronic acid, antioxidants, lightening agents and anti-acne therapy, all of which boost the effect of the needling. The final step of the procedure uses the Coolbreeze™ handpiece, which emits a high energy of LED Light Therapy with the skin kept comfortable with a cool air flow. The LED lights are available in Red (627 nm) and Blue (415 nm) for customisable treatments. This device emits a higher energy than other LED therapies, allowing for fast completion of treatment times. The DermaFrac is light and easily portable. Pre-treatment of the skin with the DermaFrac improves skin health and hydration, making additional combination treatments such as chemical peels and laser treatments safer and more effective. Anyone can benefit from the treatment, even the most sensitive of skin types. Available from Eden Aesthetics E: info@edenaesthetics.com T: 01245 227 752 W: www.dermafrac.co.uk 58

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Patient Photography and Data Medical malpractice and risk specialist Martin Swann highlights the legal, regulatory and insurance problems that can arise from the misuse of clinical photographs Clinical photographs are essential to the practice of medical aesthetics. As patients are seeking a change to their appearance, it is absolutely essential to record in detail their appearance prior to the procedure, immediately afterwards, and at each follow-up appointment while the patient is recovering. These clinical photographs form part of the patient’s medical records, and are therefore regarded as ‘data’. Thus, these photos must be securely retained for a minimum period of time (at least seven years, and in some cases, longer).1

Uses of photographs Such photographs can and should be used in the treatment and review of that particular patient. However, aesthetic practitioners often use these photographs for other purposes, such as: • To illustrate typical outcomes, or known side effects, to show patients during consultations • For training purposes • For research or similar exercises • To be used in articles published in medical journals for the purposes of wider education of the medical community • To publish in marketing literature, websites or social media for promotion No aesthetic practitioner would knowingly misuse photographs of their patients. However, the legal and regulatory context for the use of patient images, which is discussed below, is complex. Therefore, many aesthetic practitioners will, in fact, be breaching their legal duties to their patients and incurring regulatory and insurance problems for themselves. So, what are the pitfalls and how can aesthetic practitioners avoid them?

Legal and regulatory issues It is vital to remember that any data, including photographs, should only be used or processed for the purpose it was provided for. All aesthetic practitioners are subject to

the Data Protection Act 1998.2 From May 2018 they will also be obliged to comply with the General Data Protection Regulation (GDPR).3 Under GDPR, ‘health data’ is a special category of personal data.4 The data protection laws do, of course, allow this sort of data – in this instance the photograph – to be ‘processed’4 for medical purposes, otherwise it would become impossible for practitioners to use or share photographs for the purposes of treating that particular patient. Processing refers to any operation which is performed on personal data.4 As an example, in the absence of any express agreement to the contrary (as opposed to implied), if the data was only ‘provided’ by the patient for the purposes of their personal treatment, then clinical photos should not be used for any other purposes; this is unless you have your patient’s express consent (for example, by having your patient sign a form listing all the uses to which their health data will be put). It is crucial for aesthetic practitioners to understand that even if they are using a patient’s photograph for entirely laudable purposes such as education, if they do not have the patient’s consent to use their photograph for that purpose, they are potentially breaching data protection laws.3,5 The patient must also be told about the purpose of the data collection, or photographs, in advance of the data being processed, and whether it will be transferred to third parties such as other practitioners involved in the patient’s care, or training providers. Where a patient consents to their data (such as a photograph) being used for purposes other than their clinical care (such as the photograph being used to train other clinicians), in order for the practitioner to be able to rely on that consent it must be explicit, specific, freely given and clearly recorded.6,7 In addition, it must be as easy for patients to withdraw consent as it is to give it,7 so careful consideration should be given to the wording of consent forms regarding use of photos. GDPR Article 7 requires that, ‘The request

for consent shall be presented in a manner which is clearly distinguishable from the other matters, in an intelligible and easily accessible form, using clear and plain language.’7 In addition, the Data Protection Act (and also the GDPR) makes it essential to store patient photographs safely and securely.8 Many aesthetic practitioners take digital photographs using a stand-alone digital camera or the camera on a device such as a smartphone or tablet. The practical consequence of this is that copies of that digital photograph can end up in a number of different places, including online ‘cloud’ storage accounts if the device’s settings allow it. However, the law requires that each copy of that photograph is safe from unauthorised access.8 It is not enough to make sure that the patient’s formal medical file is stored securely (whether in hard copy or electronic format). Any copies of the photograph left on the camera device’s memory, transferred to another device such as a laptop, or uploaded to the cloud, must also be kept just as securely (such as by ensuring that all the hardware or accounts are encrypted). Breaches or failure to comply Failure to comply with these regulations could have very serious consequences. Aesthetic practitioners should be registered with the Information Commissioner’s Office (ICO),9 the UK’s independent regulatory office for data protection and electronic communications and anyone holding data should be registered with the ICO by law.10 In cases where there is a breach of data protection which poses a ‘high risk’ to patients, the practitioner will have to notify the ICO within 72 hours of the detection of the breach,9 as well as notifying the patient themselves. GDPR will also bring in significantly higher penalties for data breaches – a maximum fine of 4% of global annual turnover or €20 million (whichever greater) for the most serious of infringements.11 Aesthetic practitioners have always had a duty to strictly maintain patient confidentiality in all medical records, including clinical patient photographs. While this is the case for all photos, it is even more vital when the patient is identifiable from the photograph alone. Therefore, using or sharing patient photographs for any purpose other than the treatment of that particular patient, without express consent from that patient, would be a clear breach of the practitioner’s professional duty to that patient. Serious cases could result in an investigation by the practitioner’s regulator, given that a data breach could also

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Aesthetics Journal

Aesthetics

Case study: posting patient images on social media A very experienced aesthetic doctor carried out an aesthetic procedure on his patient’s face. The procedure went perfectly, and the patient was very pleased. As usual, the practitioner had taken clinical before and after photographs. They explained to the patient that they often posted clinical photographs on their Instagram account to help promote their practice and to demonstrate to prospective patients what their treatments could achieve. The patient agreed that their photos could be posted, but the doctor did not ask them to sign anything to record that in writing. The next day, the patient messaged the doctor to say that they had changed their mind and did not want their photos posted online. The doctor agreed not to publish, but did not get the message to their marketing manager in time. The photographs were posted on Instagram and stayed there for a couple of days. The patient’s friend happened to see the photographs, because the patient had recommended the doctor to her friend. The friend alerted the patient, who complained to the doctor. The practitioner apologised and deleted the posts straight away, thinking that was the end of the matter. However, a couple of weeks later, they received a letter from the patient’s solicitors seeking compensation. The doctor contacted their medical indemnity and public liability insurers, but both of them declined to cover the claim because both policies had an express exclusion in relation to ‘data protection’ breaches. Therefore, the doctor had to pay for legal representation, and then compensation to the patient, out of their own pocket. Unfortunately, in this case, the doctor did not do enough in this instance to protect themselves and the patient. Oral consent is not good enough evidence of consent to properly satisfy the requirements of our data protection laws and should have obtained express written consent.3,5-7 While a ‘cooling off’ period is not required under the legislation, from a risk management point of view, it would have been sensible to wait for at least a week or so before posting the photographs. Bearing in mind that GDPR expressly requires that it should be as easy to withdraw consent as to give it,3,5-7 the doctor also needed a more robust internal policy to make sure that for their marketing manager did not post pictures after a patient’s consent had been withdrawn. All aesthetic practitioners should anticipate that some patients will consent but then change their minds, especially given how important many people’s online profile is to them. If a patient found (possibly unflattering) clinical photographs of themselves online, it may prompt them to complain or sue if they did not expressly consent to that particular use of their image.

be a breach of the practitioner’s professional conduct obligations in respect of patient confidentiality.

Insurance issues If an aesthetic practitioner has inadvertently breached their legal or regulatory duties by inadvertently misusing a patient photograph, or failing to keep them safe from unauthorised access, then they could face a claim from the patient based on breaches of the data protection laws. In such a situation, the aesthetic practitioner might expect that the claim would be covered under their medical indemnity insurance arrangements. But this will not always be the case. Many such policies contain exclusions that mean that claims arising from data protection breaches are not covered. Therefore, aesthetic practitioners should check with their insurance broker whether the medical indemnity policy includes cover

for patient data breaches. This is especially important if the practitioner ever uses patient photographs for purposes other than treating the patients, such as teaching or training obligations, or if it will be desirable to publish photos of patients online for publicity purposes. They should discuss this expressly with their broker so that they can help ensure that their cover will meet that particular aesthetic practitioner’s needs.

Conclusion It may be somewhat counter-intuitive to think of patient photographs as ‘data’, but the data protection legislation makes it clear that it most certainly is. In addition, patient photographs are part of a patient’s medical records in exactly the same way as their medical history form,12 and therefore patient confidentiality considerations apply. To protect yourself from legal and regulatory difficulties, all aesthetic practitioners need

to give careful thought to whether to use patient photographs for purposes other than treating that particular patient. If so, then they need to ensure that they create written consent forms that expressly records all uses for the photograph, and put in place proper procedures to make sure that photographs are never inadvertently used or shared without the patient’s consent. Aesthetic practitioners also need to speak to their indemnity providers or insurance brokers to ensure that their indemnity or insurance arrangements would respond in the event of a complaint or claim based on alleged data protection breaches. Martin Swann will be presenting at the Aesthetics Conference and Exhibition (ACE) 2018 on April 27. To register free, visit www. aestheticsconference.com. Disclosure: Martin Swann is the divisional director of Enhance Insurance. Martin Swann has been insuring medical and healthcare professionals and businesses for more than 15 years. Swann has extensive experience in risk identification, mitigation and management and provides advice on how best to reduce the risks faced by your practice. Swann claims that his focus throughout his career has always been ‘the client’ and he aims to provide businesses with high quality advice and a service that is fully focused on their needs. REFERENCES 1. The Private and Voluntary Health Care (England) Records 2011, Schedule 3 2. As long as they are established in the UK - DPA 1998 sections 1 and 5. 3. Martin Swann, Getting Ready for GDPR, Aesthetics journal, 2017. <https://aestheticsjournal.com/feature/getting-ready-for-gdpr> 4. PrivazyPlan, ‘Article 4 EU GDPR “Definitions”, 2017. <http://www. privacy-regulation.eu/en/article-4-definitions-GDPR.htm> 5. ICO, Guide to the General Data Protection Regulation (GDPR), 2018. <https://ico.org.uk/for-organisations/guide-to-the-generaldata-protection-regulation-gdpr/> 6. PrivazyPlan, Article 9 EU GDPR, “Processing of special categories of personal data” 2017 <http://www.privacyregulation.eu/en/article-9-processing-of-special-categories-ofpersonal-data-GDPR.htm> 7. PrivazyPlan, Article 7 EU GDPR “Conditions for consent”, 2017 <http://www.privacy-regulation.eu/en/article-7-conditions-forconsent-GDPR.htm> 8. Legislation.co.uk, Data Protection Act 1998, <https://www. legislation.gov.uk/ukpga/1998/29/schedule/1> 9. PrivazyPlan, Recital 87 EU GDPR, 2017. <http://www.privacyregulation.eu/en/recital-87-GDPR.htm> 10. IOC, 2018, <https://ico.org.uk/> 11. It Governance, GDPR enforcement and penalties, 2018, <https:// www.itgovernance.co.uk/dpa-and-gdpr-penalties> 12. General Medical Council, Good medical practice (UK: GMC, 2013) <https://www.gmc-uk.org/guidance/ good_medical_ practice.asp>

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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speaking, if you’re not the copyright owner and you do any of these things, then you have breached copyright. As a publisher, it is your responsibility to ensure that you have not published anything you do not have a right to publish or you could find yourself in trouble.

How to Avoid Breaching Publishing Laws Journalist Fiona Clark looks at some of the myths and misconceptions in publishing and how to avoid breaching legislation You've built your website and posted your blogs. Your social media accounts are building a steady following and the bookings are rolling in. Congratulations, you now have a second career – publishing. But before you crack open the champagne to celebrate, the world of publishing comes with a plethora of rules and responsibilities that you need to consider. Copyright infringement and defamation laws are just a couple when it comes to the rules. Breaches of copyright can be costly in terms of fines, with courts able to award fines of up to £5,000.1 And, if you think this doesn’t apply to you, then think again. If you haven’t taken the pictures or written the words that you’re posting, then somebody else has, and it’s your responsibility to ensure you have the right to publish them. ‘I didn’t know’ is not a defence, according to Simon Ewing, copyright and intellectual property lawyer for Russell Cooke solicitors, who I interviewed on this subject. He explains, “Copying and other infringing acts under the legislation are ‘strict liability’ offences. In other words, it does not matter if you had no knowledge or intention to copy someone else’s work – you can still be liable.”

What is copyright?

Copyright, according to the Oxford English Dictionary is, “The exclusive and assignable legal right, given to the originator for a fixed number of years, to print, publish, perform, film, or record literary, artistic, or musical material.” Ewing adds copyright also gives the owner, “Certain moral rights including the right to object to derogatory treatment of the work. And those rights belong to the owner alone unless and until they give permission to a third party.” There are some defences and exceptions2 which we’ll get to later but, generally

Myth 1: I can do what I like with an article I’m quoted in You’re interviewed for an article, maybe along with a few others, and the article is published. The publisher says you can put it on your website. Great; linking content from your site to others and vice versa with a hyperlink, also known as back-linking, is good for search engine optimising (SEO), so it’s a win-win. Then you decide you don’t like other practitioners being quoted in an article on your site, so you cut the other practitioners out. This would be considered adaptation, and unless you have written permission to do it, it is unadvisable. “Even if the publisher has given permission, that licence is likely to be restricted to making it available in its original form. By editing it without consent, you’ve probably breached the terms of the licence and again treated the work in a manner contrary to the author’s moral rights,” Ewing warns.3 Then you decide that since it’s your words that have been used to create this masterpiece, surely you have the right to take the reporter’s name off it, put your name on it and pass it on to a third party as your own work? This is a big ‘no-no’. Someone else took the time to write your words down and link them nicely with words of their own. The journalist may own the copyright themselves but, in most cases, the copyright will lie with the original publisher or employer who paid that person to string your pearls of wisdom together.4 That copyright will remain with them for around 70 years,5 so it’ll will be quite some time before you can make any changes.6 So, how can you make people aware that

As a publisher, it is your responsibility to ensure that you have not published anything you do not have a right to

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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There is software that photographers and agencies can use to trawl the net and see who has published their work, and when they find someone, they aren’t shy about issuing a demand for compensation you’re featured in a particular piece? Make a page on your site that lists the articles you’re in with a brief paragraph at the top saying something along the lines of ‘Proud to be featured in the following articles’. And you can highlight your involvement on social media as well. Articles will often feature more than one ‘expert’ – so consider it an honour to be alongside others who know their stuff. Myth 2: If it’s on the internet I can use it This myth persists, but nothing could be further from the truth. Every so often you may download images of celebrities, such as Kylie Jenner or Courteney Cox, to put on your website/social media. It is understandable why some may think these images are free of copyright. When you upload your own pictures to Instagram or Facebook, and you’ve agreed to the terms and conditions, this gives those platforms the right to publish your work.7 They are ensuring you have given them permission to publish but contrary to popular belief, this does not mean that these platforms own the copyright or that those millions of pictures, including all those celebrity shots on it, are now in the ‘public domain’ and up for grabs. In many cases, photographers retain their own copyright, or it could be held by the magazine that commissioned the pictures, or by an agency such as Getty Images or Shutterstock. These days there is software that photographers and agencies can use to trawl the net and see who has published their work, and when they find someone, they aren’t shy about issuing a demand for compensation. And it’s not a rare event. In fact, there is an entire UK website dedicated to support and advice on letters of demand, and the claims can be for a few hundred pounds to a few thousand.8 Tip: You aren’t legally bound to respond to

a letter of demand but it is important that you don’t ignore them. If it escalates and they decide to sue, the court will look at whether you complied with their demand to remove the picture or responded at all. Your failure to act could result in further damages against you.9 If you can’t justify your right to publish, then remove the offending image and seek legal advice. If you want to publish pictures of celebrities, sign up to a stock photo library and make sure you purchase the right licensing agreement that allows you access to celebrity pictures and the right to publish them on not just your website but also on social media. You must read the licencing agreement. Myth 3: celebrities are public figures and I can say what I like Not content with just saying how much you ‘love their look’, you may decide to go further with the images of Kylie Jenner and Courteney Cox, putting together an older and a more recent picture perhaps, and commenting on the work you think they’ve had done. With a couple of little arrows drawn on to ‘prove your point’ in the appropriate spots you press to publish – and just like Ewing says, you’ve probably committed several infringing acts with one small click: copying, issuing copies and communicating the work to the public.10 Ewing says, “The small tweak may also be contrary to the copyright owner’s moral right, giving them the right to object to derogatory treatment.”11 Speculation over your kitchen table is one thing, but to comment in public on another person’s presumed medical procedure – which they may deny ever having had done, is probably not a great idea as it could leave you open to a defamation12 charge as well. What is defamation? According to legal website Law on the Web, defamation ‘is a spoken or written expression

which is deemed to harm the reputation of an individual and proved to be false’.13 And it can be as simple as causing their reputation to be lowered or being seen to hold them to ridicule. “If you make supposedly factual statements that are in fact untrue and diminish the reputation of the celebrity then you may find yourself on the end of a defamation claim,” Ewing says.12 And if you’ve criticised the work, their doctor may not be too happy either and could take action against you as well. While the General Medical Council isn’t specific about commenting on social media, it does say use your judgement and prepare to be able to explain and justify your comments.14   Public interest or interesting for the public? You may argue that media organisations regularly take images from social media and get away with it, so, why can’t you? Well, there are a variety of things to consider here from an editorial point of view. Accuracy, privacy and ‘public interest’ are among them along with being fair, impartial and accountable. It may be that media organisations use public interest as their defence. The Legal Dictionary defines public interest as ‘a common concern among citizens in the management and affairs of local, state, and national government. It does not mean mere curiosity but is a broad term that refers to the body politic and the public weal’.15 According to the Editors’ Code, which is enforced by regulator the Independent Press Standards Organisation (IPSO), public interest includes, but is not confined to:16 Detecting or exposing crime Protecting public health or safety Protecting the public from being misled Disclosing a person or organisation’s failure or likely failure to comply with any obligation to which they are subject • Disclosing a miscarriage of justice • Raising or contributing to a matter of public debate, including serious cases of impropriety, unethical conduct or incompetence concerning the public • Disclosing concealment, or likely concealment, of any of the above • • • •

So clearly there’s a big difference between ‘public interest’ and what the public may be interested in – and no matter how much we all love Kylie Jenner’s lips, they won’t meet the ‘public interest’ test. And when it comes to accuracy – can you really be sure of exactly what they’ve had done?

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Make sure you know where the pictures you use on your website or social media come from

If you still feel you must indulge in this area, make sure you have the rights to publish the picture, avoid speculation, and take your mother’s advice: if you can’t say anything nice, don’t say anything at all.

When size matters But, you’re just a small fish, not a major media player, why would anyone bother about what you do with their pictures? You’re a commercial organisation that is hoping to drive more patients to your door by using these pictures. That means you’re making money off someone else’s work. So here, size doesn’t matter. But, when it comes to determining a pay-out figure, size does matter. Take the case of the photo agency Xposure who sued Khloe Kardashian for $150,000 for a photo it owned but the celebrity posted on her Instagram feed. According to the Daily Mail, who had the rights to publish the picture, Xposure told the court that Khloe had made the picture 'immediately available to her nearly 67 million followers and others, consumers of entertainment news’. In addition to the $150,000, the agency also demanded $25,000 on top for the alteration of the picture and the removal of copyright information.17 In the end, the case was dismissed with both agreeing to pay their own court fees. While 67 million followers might be out of the reach of most aesthetics practitioners, these days it’s not unusual for members of the aesthetics community to have considerable social media followings of their own. Some have followings that reach from tens of thousands to hundreds of thousands. That can rival some smaller media organisations and could see the copyright owner seeking greater compensation. “As well as ordering that the offending item be removed or deleted, a court can order an infringer to account for profits they have made from it or make an award of damages,”

Ewing says. “Although a claimant typically needs to establish that it has suffered loss18 as a result of the infringement, it also opens to a court to exercise discretion and award additional damages where the defendant’s actions have been flagrant. And ‘flagrancy’ does not automatically imply a deliberate act; courts have exercised their discretion to award additional damages when the actions are merely reckless.” In a nutshell, that means that you have to check where the pictures came from. ‘I didn’t know’ is not a defence and even if you think it’s a genuine mistake, the court may think you weren’t diligent and award extra damages on top, as it sees fit.    How can you protect yourself? Make sure you know where the pictures you use on your website or social media come from. If you have someone running your website or social media channels, then ensure that they have taken the pictures from a reputable library and that the licence they have grants third party publishing rights. If you’re posting pictures of your patients always make sure that you have written consent to use their pictures on all social media and web platforms, as well as permission to share the pictures with third parties such as the media or sites that promote your work. Life is busy enough without having the extra strain of a copyright infringement or defamation case on your plate – not to mention a very unhappy patient who feels they’ve been exploited. It may be an extra cost to subscribe to an official stock photo agency and it might take an extra bit of paper work to consent the patients, but in the end, it could save you a lot of pain and money. To put it simply: don’t share, post or repost pictures unless you know where they came from and you have a paper trail of verifiable permission in place.

Fiona Clark is the director of Harley Street Emporium. She is a journalist with more than 30 years’ experience in television, radio, print and online and has worked for the Australian Broadcasting Corporation, Australian Doctor, Medical Observer, and written for Deutsche Welle and The Lancet. In 2017, she launched Harley Street Emporium, a hub for evidence-based information for consumers on aesthetics and skincare. REFERENCES 1. GOV.UK, Intellectual property offences, Trade mark act 1994, <https://www.gov.uk/government/publications/intellectualproperty-offences/intellectual-property-offences> 2. GOV.UK, Exceptions to copyright, <https://www.gov.uk/ guidance/exceptions-to-copyright> 3. Legislation, Copyright, Designs and Patients Ace 1988, <http:// www.legislation.gov.uk/ukpga/1988/48/contents> 4. British Library, Help for researchers, Copyright, <https://www. bl.uk/reshelp/findhelprestype/news/copynews/index.html> 5. UKCCS, Copyright Law fact sheet, (2004) <https://www. copyrightservice.co.uk/copyright/p10_duration> 6. UKCCS, Copyright Law fact sheet, (2004) <https://www. copyrightservice.co.uk/copyright/p10_duration> 7. Copyright Laws, Instagram and Copyright – what are the tersm of use? (2017) <https://www.copyrightlaws.com/instagramcontent-copyright/> 8. Extortion Letter Info, The ELI Forums, <https://www. extortionletterinfo.com/forum/uk-getty-images-letter-forum/> 9. Lahle Wolfe, What is a settlement Demand Letter? The Balance, (2017) <https://www.thebalance.com/what-is-a-settlementdemand-letter-3514942> 10. Legislation, Copyright, Designs and Patients Act 1988, Part one, Chapter 2 <http://www.legislation.gov.uk/ukpga/1988/48/part/I/ chapter/II?> 11. Legislation, Copyright, Designs and Patients Act 1988, Section 80 <http://www.legislation.gov.uk/ukpga/1988/48/section/80> 12. Legislation, Copyright, Designs and Patients Act 1988, Section 1 <http://www.legislation.gov.uk/ukpga/2013/26/section/1> 13. Law on the Web, What Defamation Means <https://www. lawontheweb.co.uk/legal-help/definition-of-defamatory> 14. GMC, Professionalism in action, https://www.gmc-uk.org/ guidance/good_medical_practice/professionalism_in_action. asp 15. The Free Dictionary, Public Interest <https://legal-dictionary. thefreedictionary.com/Public+Interest> 16. IPSO, About IPSO, <https://www.ipso.co.uk/about-ipso/> 17. Kelly McLaughlin, EXCLUSIVE: Photo agency that sued Khloe Kardashian for more than $175,000 after she shared THIS photo on Instagram agrees to dismiss its case, (2018) <http://www. dailymail.co.uk/news/article-5423741/Photo-agency-agreesdrop-suit-against-Khloe-Kardashian.html#ixzz59eH0HetS> 18. Legislation, Defamation Act 2013, <http://www.legislation.gov.uk/ ukpga/2013/26/section/1>

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Using Trust Indicators Marketing consultant Adam Hampson discusses how your business’s use of online trust indicators can drive higher conversion rates Consider when the last time was that you bought a product or service without doing some research into the business, its track record, or its apparent character. These days, the answer is likely never. Patients, as consumers, place heavy consideration on these kinds of assets, as it is an opportunity for them to build trust in you and your services. Building trust is incredibly important as it forms part of your professional reputation and will indefinitely influence a new client’s decision to seek treatment with you. It takes 0.05 seconds for a patient to form a first impression,1 so we need to ensure it is a good one. One way in which to build trust is by using what we call trust indicators. These are written and visual assets used online to boost confidence in a business and usher customers into making an enquiry. They can

be as simple as photos of your premises or publically accessible reviews, but they make all the difference when patients are deciding whether to book a consultation. This article will outline examples of trust indicators, how they can help gain new patient enquiries and how best to employ them to increase your conversion and clickthrough rates.

Online trust indicators Visual website content First and foremost, your business’s trust indicators should always be exhibited on your website. For many potential patients that aren’t familiar with your clinic and may be considering aesthetic treatment for the first time, they need a myriad of visual and textual

A positive reputation that is visible on your website can boost search rankings, drive more click-throughs and build trust among your patients

content prompts to instil confidence in you and your services. Personalising your website is key, and you can achieve this through photos of the team, accompanied by a short bio of their qualifications and background, and of the clinic itself. By showing the faces behind your business you are humanising your clinic, setting your potential new patient at ease because you are sharing your identity with them. By encouraging this kind of familiarity, your patient will begin to warm to your business and learn that you are not just a brand, but a person behind the brand. Your interior clinic photos should include people in them, either your employees or an interaction with a patient. These can be staged with staff and the photos can be taken yourself, but indicating your clinic is active prompts trust and therefore an increased chance of enquiries. Videos such as a tour of your premises, introducing yourself, products, and services are effective trust indicators because you are actively engaging your patient in your culture. Well maintained and busy premises show both a financial and personal investment, so including photos of such on your website will assure patients of your success and talent, which may help lead to higher conversion rates. Reviews and patient testimonials – the more recent the better – are another essential trust indicator to incorporate into your web content. A positive reputation that is visible on your website can boost search rankings, drive more click-throughs, and build trust among your patients.2 When showcasing reviews by your potential patients’ contemporaries, you will be providing them with examples of people, much like them, who placed trust in your service, increasing your chance of an enquiry.3 You should actively ask your patients to leave a review, should they feel comfortable. Google reviews can be cumbersome as they require pre-existing accounts, whereas most people already use platforms such as Facebook and TrustPilot (an online review website), where it is simple and easy to leave a review, so you should encourage your patients to use these. TrustPilot also provide you with ‘badges’ that show your average rating that you can host on your site, an immediate visual embodiment of trust. A healthy mixture of independent review sites such as TrustPilot in conjunction with social media work effectively in demonstrating a multi-platform and recognised, established business that has increasing web and trust presence.

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Clinic experience content As well as visual prompts, your potential patient needs to be informed and equipped with general service information to increase the chance of an enquiry. Important clinic information such as treatment fees and the patient’s treatment journey combine to create a well-rounded insight, but make sure to stress the importance of individual consultations to increase the likelihood of a new enquiry. It can be difficult to price an aesthetic treatment plan when it depends on individual needs and desires, so providing a base price ‘available from’ provides your patient with enough information to assess for themselves. Again, stress the need of the consultation to determine individual treatment plan and prices. Providing physical evidence, such as hosting your location via Google Maps and contact details, can help instil trust and boost enquiries because it adds a sense of physicality and realness to your business. The key to higher enquiries is to provide a step-by-step guide of what your patient can expect during their treatment journey, from consultation to end results. You can achieve this by creating a separate page, or include it in the treatment page content. By including these trust indicators, your patient has already formulated an idea of the consultation process and possible outcome from before and afters, allowing them enough insight to feel informed, yet to also recognise that they need individualised consultations. Use key information, such as treatment processes, as a trust indicator to introduce your services and entice, but to also allow the opportunity for further engagement. Active content – social media and blogging Social media and blog content can be used as effective trust indicators to increase new enquiries because it allows engagement and constant contact. In fact, 52% of businesses say that social media positively influences sales and revenue.4 Social media is an effective tool for a clinic to utilise to expand their brand awareness across a wider patient base. Here you can post updates, promotions and treatment content, and engage directly with your patient base to create a network to mirror your website. Before and afters of treatments that link to your website will help to create trust and insight into treatment results, accessible practitioners, and a range of treatments carried out with pride. When considering trust indicators and building your brand in a modern and highly competitive industry, social media is fundamental to building trust.5

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By utilising these platforms, you demonstrate a professional knowledge and investment, adding cultural insight and leading your patient to trust your business. An active blog that is updated once a week can form the basis of your content strategy, but it also positively impacts your search engine optimisation. By keeping your blog active and regularly updated, you are adding more pages to your site and providing more keywords, which positively effects your Google listings.6 By utilising content relevant to your business and by allowing your own voice and business ethos to take centre stage, you are showing an active working pride in your services and patients. Write content about a new treatment, an announcement, or answer a frequently asked question to show you are qualified in your profession. This kind of public and personal exposure of your character works incredibly well as a trust indicator because it shows that you yourself place trust and confidence in your business,7 so your potential new patient should too.

The results of trust indicators So, how can utilising trust indicators benefit your business? Return on investment and exposure Your return on investment can be measured through your enquiries and engagement. A higher engagement means your content strategy and trust indicators are working in tandem. The more pages of a decent length (over 300 words) your website has, the higher Google will favour you in its search term rankings.8 Increasing traffic to your website also pushes it higher up search term rankings, so utilising your content strategy effectively not only provides ample opportunity for trust indicators but also can positively impact your search engine optimisation. Your trust indicators may form a healthy portion of your content strategy, which should be fresh and relevant in order for search engine optimisation to work effectively. This can prompt more traffic and ultimately more enquiries when potential patients search for your services. Reputation management and popularity The more you communicate via your website and social media, the higher the initial level of trust and confidence your clinic is providing.9 This will increase both your chance of enquiry and your conversion rate to treatment, because your new patient now has an informed and reliable insight into your

treatment process. You will experience a more relaxed informed patient who is more likely to proceed with their treatment plan after consultation.10 These trust indicators can work well to meet the expectations of new patients, by either realistically informing them of treatment outcomes or exceeding them. Encourage this new patient to consent to before and after photos and leave a review. Both of these components combine to create recent and up-to-date content to form more trust indicators so you can increase your active content to grow your online portfolio of results.

Conclusion Trust indicators are valuable assets worth investing for your clinic or business’s website. If you are not utilising them properly or at all, then this can drastically and negatively affect your conversion rates and reduce your return on investment in digital marketing. Adam Hampson will be speaking at the Elite Training Experience and Business Track at ACE 2018 on April 27. Register at www. aestheticsconference.com. Adam Hampson is founder and director of Cosmetic Digital, a web design and digital marketing agency specialising in aesthetics and medical cosmetics. Hampson delivers a number of keynotes, lectures and seminars on digital marketing and web design. REFERENCES 1. Readz, Online Content: How To Nail A Positive First Impression, <https://www.readz.com/positive-first-impression> viewed 6 March, 2018 2. Bright Local, Impact of Reviews and Ratings on Search ClickThrough Rates <https://www.brightlocal.com/learn/reviewsearch-click-through-study/> published 26 April, 2017 3. TrustPilot, More is better: Why review quantity matters <http:// blog.trustpilot.com/blog/more-is-better-why-review-quantitymatters> published 5 February, 2018 4. Smart Insights, How businesses use social media: 2017 report <https://www.smartinsights.com/social-media-marketing/socialmedia-strategy/businesses-use-social-media-2017-report/> viewed 5 March, 2018 5. OnePageCRM, 5 ways to win your customers trust with content <https://www.onepagecrm.com/blog/win-customers-withcontent> viewed 26 February, 2018 6. LifeLearn, Does Blogging Help with SEO? <https://www.lifelearn. com/2017/03/06/does-blogging-help-with-seo/> published 6 March, 2017 7. Search Engine Journal, 5 Ways a Blog Can Help Your Business Right Now <https://www.searchenginejournal.com/benefits-ofblogging-for-business/195037/> 13 May, 2017 8. Search Engine Land, 8 major Google ranking signals in 2017, <https://searchengineland.com/8-major-google-rankingsignals-2017-278450> viewed 6 March 2018 9. Conversion XL, 13 Ways to Increase Your Conversion Rate Right Now <https://conversionxl.com/ways-to-increase-yourconversion-rate/> viewed 26 February, 2018 10. Up Your Service, Well Informed Customers Are Critical For Customer Service Quality, <https://www.upyourservice.com/ learning-library/customer-service-education/a-well-informedcustomer-is-a-better-customer> viewed 6 March, 2018

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Is there a ‘gold standard’ technique or best practice for administering lip fillers? I use a variety of different techniques depending on what needs to be achieved. The most important thing to consider is your patients’ safety and your understanding of the anatomy of the lips; where blood vessels lie, as well as how to recognise and deal with any complications. I'm always on the lookout for new tips to improve my personal techniques.

The Secret to Natural Looking Lips, with aesthetic nurse Teresa Kis What is the first thing clinicians should consider when reviewing a patient for lip filler treatment? The first thing I always consider is whether the patient’s requests are realistic. I ask myself, ‘Is it achievable and will it enhance their appearance?’ A good treatment result for me is when the patient looks in the mirror and says, ‘I love them’ or when an older patient says, ‘You have given me back my lips’. What are the trends in lip treatments amongst your patients? Young patients want full lips and often bring pictures of celebrities or models. I usually show them several before and after pictures of patients who I have treated, to give them an idea of what to expect and demonstrate the results that can be achieved. I tell them that we have to work with what they have and sometimes it might take a few treatments to achieve their desired look. Older patients usually want some fullness and other concerns addressed, such as lip lines and downturned corners of the mouth. They want to be able to put their lipstick on without it bleeding into the lip lines.

Restylane OBT Optimal Balance Technology (OBT), offers a broad range of gel textures, all containing the same concentration of hyaluronic acid (HA), which means that the products can serve a wide range of functions. Softer gels distribute more evenly to smoothen lines and wrinkles, and firmer gels can deliver more lift and volume. For older patients with thinner tissue coverage, who would benefit from restoration as well as volumisation, OBT will deliver results that provide a more distributed, rather than targeted, tissue integration and give a softer, more even look.
 OBT is used exclusively in Restylane products to achieve diverse effects depending on the treatment area: • Restylane VolymeTM, Restylane DefyneTM and Restylane KysseTM have a larger gel particle size to provide volume and add definition • Restylane FynesseTM and Restylane RefyneTM have a smaller gel particle size, offering a lower lifting capacity to target superficial wrinkles and fine lines • Restylane has the world’s broadest portfolio of fillers, enabling you to tailor treatment to your patients’ needs

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What product qualities do you look for in a lip filler? Clinical data demonstrating the tolerability and efficacy of products is extremely important. There are so many fillers available now, so it is imperative that practitioners use ones that have clinical studies and good support from the manufacturer. The Restylane range fulfils all my needs – whatever the patient’s age or desired look. Restylane Kysse is great for those who are first-timers and worrying about the swelling afterwards, as it gives good volume but swells minimally. Restylane Lyps is great for younger patients who want a fuller look whilst still appearing natural. Restylane Refyne is suited to older patients who want a small enhancement with minimal swelling. I also sometimes use Restylane Classic and Skinboosters in the lips to provide different desired looks. As a general rule: • Optimal Balance Technology (OBT) = less swelling and a more forgiving look • Non-Animal Stabilised Hyaluronic Acid (NASHA) = a firmer look and more pout A lip filler must be smooth to inject and give the required volume. I never promise my patients that results will last more than four to six months when injecting the lips, however I do say that they may be lucky and last longer. I also advise that with more treatments, we will be able to build the volume and extend the life of their augmentation. Swelling post treatment is minimal with the OBT range. What are your top tip for lips? • Safety first • Manage expectations  • Use good products  • Listen to what the patients want to achieve; if they want a significant change and you only give them a small difference they will be disappointed and go somewhere else next time – so work with them and discuss potential outcomes • My lip patients come back to me regularly as I listen to their needs to try to achieve what they want

Teresa Kis has been carrying out facial aesthetic treatments since 2003 and is also a senior nurse trainer, training other doctors, dentists and nurses in basic and advanced dermal filler techniques. She has demonstrated her techniques at aesthetic conferences and is a member of the British Association of Cosmetic Nurses and the Royal College of Nurses.

RES18-02-0135. DoP: February 2018. This article has been funded by Galderma (UK) Ltd.

Aesthetics | April 2018


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“The key to advancing in this specialty is to think like a scientist” US-based dermatologist, researcher and international educator Dr Hema Sundaram discusses her passion for teaching, science and patient safety Notable dates 1985: Completed Bachelors Degree at Cambridge University 1988: Completed Master’s Degree in Genetics at Cambridge University 1989: Completed Medical Degree with Honors at Cambridge University 1989: Moved back to the US 1990-91: Post-doctoral research in molecular biology 1991-93: Dermatology Residency at University of Chicago 1993-95: Medical Staff Fellowship at National Institutes of Health 2001-02: Opened two clinics – Sundaram Dermatology, Cosmetic & Laser Surgery Centre

With two hard-working biochemists as parents, it would have been difficult for young Hema Sundaram to be anything but interested in research and science. “I was born in the US but my parents moved to the UK when I was about two months old and this is where I grew up. My family was continuously focussed on research during my childhood and, as you can imagine, there was a lot of scientific talk at the dinner table! So, from a young age I was surrounded by science and taught to think analytically,” explains Dr Sundaram. Even before she attended medical school at Cambridge University, Dr Sundaram was passionate about this area. “I finished school a little early, took a year off and did full time research in a lab and I continued to do research throughout my undergrad degree, at medical school and thereafter,” she recollects, adding, “For me, research was, and still is, a very important part of what I do.” Dr Sundaram became interested in dermatology while writing a thesis on molecular biology for her degree in genetics. But, it wasn’t until she moved to the US with her husband and undertook a dermatology residency at the University of Chicago that she became interested in minimally-invasive aesthetic procedures. “I realised how aesthetic procedures transformed the way patients felt on the inside, as well as the outside. The difference it made to their self-confidence was a revelation. I also discovered that I like doing things with my hands. I love the idea

of using your intellect for taking a patient history, performing a clinical examination and formulating a treatment plan, while also using your hands as a tool to achieve a positive outcome,” she explains. “As soon as I had this epiphany, I knew that procedural dermatology was what I wanted to do for the rest of my life,” Dr Sundaram says. Dr Sundaram also loves the challenge of determining the best treatment plan for patients. “This field is a wonderful and challenging opportunity. We have to select the most appropriate technologies on an individual basis for each patient and this relates back to science. We need to understand the science in both the ageing process and how the products work. A great part of my research is focussed on eludicating the science of current and emerging aesthetic technologies, and in leveraging scientific understanding to develop new technologies that improve patient results or safety. The key to advancing aesthetic and procedural dermatology is to think like a scientist.” When discussing what treatment modality she appreciates most, Dr Sundaram states, “I think the best approach is to use multiple modalities to treat each patient individually. Since we know that ageing is a multifactorial process, it makes sense logically that we address it with multiple treatment modalities,” she explains. As well as a passion for science, teaching plays a significant role in Dr Sundaram’s professional life. She explains, “I remember my first ever conference talk was on the aesthetic and therapeutic applications of botulinum toxin. I found speaking at conferences to be a very inspiring experience. I have realised since then that to master and understand any concept you must teach it to others. I also find it exhilarating to present; to be able to communicate quite complex concepts to an audience and have them understand is a great experience for us as educators.” Dr Sundaram has since taught and lectured across the globe at universities, academy training courses and international conferences. From her travels, Dr Sundaram has recognised that there is a global need to monitor procedural safety and

practitioner qualifications. “I am involved in initiatives to improve procedural safety and outcomes through the American Society for Dermatologic Surgery (ASDS), and the Global Aesthetics Alliance (GAA), which brings together key opinion leaders from throughout the world,” she explains. When asked about what the future holds for the aesthetic specialty, Dr Sundaram states, “I hope it holds balanced, non-commercialised education. Much of the research and innovation comes from the companies in this specialty, so it makes sense for us practitioners to be partnering with them in education and research, but we need to be doing it in a healthy way. Healthy means that the business considerations of the industry should never override the best interests of our patients. Remember, we are not sales people – our first responsibility is always to our patients.” Dr Sundaram will present at the DHAT session at the Elite Training Experience at ACE 2018 in London on April 27. What are you most proud of? The balance I have in my practice between the aesthetic and therapeutic procedures. As a dermatologist, both aspects of patient care are important. What is the best advice you have ever been given? A wise plastic surgeon once told me that I should not be afraid to say no and not to overextend myself. It’s important to appreciate that we can’t be everywhere. What’s your biggest life achievement? To have balanced my career with my family life. I didn’t accept a single commitment that involved travel until my family and I felt my children were old enough. What is your future aspiration? I hope I have helped a little to create understanding of how relevant science is to what we do every day in our clinics. I always aspire to make science understandable and to make it exciting to those who are not scientific nerds, as I am!

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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The Last Word Aesthetic nurse prescriber Eve Bird expresses why she believes using social media at conferences is essential for aesthetic practitioners As an aesthetic practitioner based in the north of England, I regularly attend conferences all over the UK. This is because I believe it’s vitally important to keep abreast of developments within the industry, to explore new ideas and to network with other aesthetic practitioners. Just as training is an essential part of everyday life as an aesthetic practitioner, so, too, is social media. Our clinic thrives on platforms such as Facebook and Twitter and we like to use them to keep patients in the know, share updates within the industry, along with those of the clinic, while educating them on new and current treatments and products. This is why I’ll always have a smartphone onhand when attending events or aesthetic conferences.

The benefits I’ve always seen updating social media channels during conferences as a mutually beneficial practice. My patients benefit by being brought into the life of the clinic and learn about the aesthetics industry, while the speakers benefit by receiving a whole new audience for the product, treatment or service they are talking about. The conference may also retweet or reply to a tweet, which expands our clinic’s reach further. It cements the speaker’s name as an authority in the specialty, while reassuring my patients that I’m keeping up to date with the latest technology, health and safety, and practices in the aesthetics world. It’s a win-win situation but of course, general rules of etiquette must be followed, as poor manners are inexcusable, as discussed in more detail below.

Why some may disagree Bad etiquette There are some who prefer to share on social media throughout a conference and talk, however, I prefer to tweet and share outside of the presentation. Surely, we cannot ignore the fact that we are attending to learn something new and updating social media incessantly would detract from this objective. Therefore, I think it is best to tweet/update Facebook just before the conference begins, during a break, if there is one, and again at the end. I’ve never thought of this as bad etiquette as many conferences actively encourage sharing on social media and will share the hashtags that they want attendees to use when mentioning the conference. Of course, phones should be set to silent, so as not to interrupt the speaker throughout their presentation. Misleading Thankfully, I’ve never had an issue with tweets being taken out of context as I usually tweet a direct quote, or my own experiences of the conference. I save anything that requires further expansion for my copywriter to use in a blog on my return. I can see how some tweets can be misleading though, if a full explanation isn’t given. It’s always best to check, recheck and if in doubt, don’t post.

Aesthetics

What practitioners should do Although I strongly believe that using social media at conferences is essential, practitioners should go about it in the correct way, as to not cause disruption. The flash should always be off (unless the speaker has finished) and a phone should always be set to silent, in my opinion. It’s difficult enough to speak in public without interruptions from multiple phones. Make sure the conference is social media friendly Many conferences will have signs sharing the hashtags they want you to use and have Wi-Fi available. For example, at the Aesthetics Conference and Exhibition (ACE), it encourages delegates to engage on social media using #ACE2018 but delegates should be considerate of speakers and respect their instructions on what they can/can’t share. Many conferences will also be active on social media in the hours leading up to the conference. These are good indicators that they welcome engagement during their presentations. If there seems to be a social media blackout, and you can’t find details online, ask a conference organiser to ensure you’re practicing good etiquette while sharing with your followers. Check for any guidelines There may be a sign asking you not to tweet or share on social media during a presentation or conference, or a speaker may lay out some rules at the beginning of a talk. This is to protect patient confidentiality and to ensure that any media circulating, with a connection to the conference, is of a professional quality. Make sure you listen carefully and scout the area for any signs to ensure you’re being polite and respectful.

Summary When using social media at events, I believe it is always important to keep good etiquette at the forefront or your mind, ensure you are not in breach of copyright and be careful not to misquote speakers. Basic good manners should be considered, such as keeping your phone on silent, choosing a seat a little further back so as not to distract the speaker, seeking permission if you’re unclear and always crediting the conference and speaker. In summary, I believe tweeting and sharing on social media is an integral part of attending an aesthetic conference to educate your patients, as well as fellow practitioners who are not in attendance, as long as common sense and respect are exerted. Eve Bird is an award-winning aesthetic clinic owner and nurse practitioner. She holds an array of medical qualifications and consistently trains in the latest practices of aesthetics in order to deliver the best possible treatments and results to her valued clients. Bird is the owner of Botastic in Hull, which won the Best Small Clinic Award. Martina Mercer is an award-winning marketer and copywriter working within the aesthetics and beauty industry. She aims to help aesthetic clinics and beauty salons gain excellent search engine optimisations while also expanding their online profile through intelligent search marketing and converting copy. REFERENCES 1. Thomson Reuters, Step-by-step guide to copyright in images online, <https:// uk.practicallaw.thomsonreuters.com/w-003-6889?transitionType=Default&contextData=(sc. Default)&firstPage=true&bhcp=1>

Reproduced from Aesthetics | Volume 5/Issue 5 - April 2018


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Just Eliza

Preserve the identity of your patients with natural-looking results.1 Azzalure® is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines (vertical lines between the eyebrows) seen at frown and/or lateral canthal lines (crow’s feet lines) seen at smile lines, in adult patients under 65 years, when the severity of these lines has an important psychological impact on the patient.2 References: 1. Molina B et al. J Eur Acad Dermatol Venereol 2015;29(7):1382-1388 2. Azzalure Summary of Product Characteristics.

Actual Azzalure user. Fictional model name. Results may vary. Azzalure Abbreviated Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe: • Glabellar lines seen at maximum frown, and/or • lateral canthal lines (crow’s feet lines) seen at maximum smile in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Glabellar lines: recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,; 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. Lateral canthal lines: recommended dose per side is 30 Speywood units (60 Speywood units for both sides, 0.30 ml of reconstituted solution) divided into 3 injection sites; 10 Speywood units (0.05 ml of reconstituted solution) administered intramuscularly into each injection point. All injection points should be at the external part of the orbicularis oculi muscle and sufficiently far from the orbital rim (approximately 1 - 2 cm); (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. The efficacy and safety of repeat injections of Azzalure has been evaluated in Glabellar lines up to 24 months and up to 8 repeat treatment cycles and for Lateral Canthal lines up to 12 months and up to 5 repeat treatment cycles. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis. Special warnings and precautions for use: Care should be taken to ensure that Azzalure is not injected into a blood vessel. Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Galderma (UK) Ltd. Azzalure and Galderma are trademarks owned by Nestlé Skin Health S.A. AZZ17-05-0026 Date of preparation: May 2017

alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy, Lactation & Fertility: Not to be used during pregnancy or lactation. There are no clinical data from the use of Azzalure on fertility. There is no evidence of direct effect of Azzalure on fertility in animal studies Side Effects: Most frequently occurring related reactions are headache and injection site reactions for glabellar lines and; headache, injection site reactions and eyelid oedema for lateral canthal lines.. Generally treatment/injection technique related reactions occur within first week following injection and are transient. Undesirable effects may be related to the active substance, the injection procedure, or a combination of both. For glabellar lines: Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and haematoma). Common (≥ 1/100 to < 1/10): Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites, predominantly describes brow paresis), Asthenopia, Eyelid ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual impairment, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. For lateral canthal lines: Common (≥ 1/100 to < 1/10): Headache, Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites), Eyelid ptosis, Eyelid oedema and Injection site disorders (e.g. haematoma, pruritus and oedema). Adverse reactions resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE) Legal Category: POM Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: January 2017

Keep it natural. Keep it real.

Aesthetics April 2018  

Complication Management

Aesthetics April 2018  

Complication Management